Scenario: Resistant hayfever

Adam May comes into the pharmacy with his mum. He is doing his GCSE exams but his hayfever is making it very hard to concentrate...

Parveen can see that Adam does indeed have a severe case of hayfever. His eyes and nose are both streaming and red from constant wiping. She asks him whether he has tried anything. “Normally I can keep it at bay with a nose spray – Flixonase, I think it’s called – but this year it didn’t seem to touch it,” says Adam. “I’m still using it, but I’ve added loratadine tablets as I read somewhere that they are the least likely to make me feel sleepy, which I really don’t need at the moment, and some eye drops too. To be honest, it feels like I’m not doing anything: it has never been this bad.”

Answer

Parveen should recommend that Adam visits his GP, who will be able to prescribe a short course of high dose corticosteroid tablets. These are highly effective at relieving symptoms short-term, and are ideal for an exam-type situation as they should not be taken for more than 10 days because of the risk of side-effects such as mood swings, weight gain and acne.

However, they will suppress the allergic response to such a degree that symptoms are unlikely to return to the same level once Adam stops taking the corticosteroid tablets. He should then be able to keep his hayfever under control using the measures he has already been trying, and may even be able to step them down a bit.

The bigger picture

There is another use for oral steroids in hayfever: as a short course during the beginning of treatment with a corticosteroid spray. This reduces oedema of the nasal mucosa, which can sometimes be sufficiently severe so as to block the passage of a spray, thereby reducing its therapeutic effectiveness. Using oral corticosteroids in this way also helps shrink nasal polyps, again giving a spray formulation of the drug class an opportunity to work.

Individuals with very severe hayfever, despite correct use of medication, may be given immunotherapy treatment. Sometimes referred to as desensitisation, this approach involves exposing the patient to small amounts of the allergen, in either injectable or sublingual form, and – assuming they haven’t had an anaphylactic reaction – slowly increasing the allergen amount administered so that immunity starts to develop. Three years’ treatment is considered necessary for long-term results and it must be initiated under specialist supervision.

Extend your learning

• Allergen avoidance is one of the cornerstones of hayfever management. Read what Allergy UK recommends in the section entitled ‘Avoidance of the allergic trigger’ at allergyuk.org/hayfever-and-allergic-rhinitis/ hay-fever-and-allergic-rhinitis
• Hayfever may be common but it can be very debilitating and is also a risk factor for asthma exacerbations. Find out more at cks.nice.org.uk/allergic-rhinitis

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