How to get right up their nose! Kathryn Powrie allergy nurse specialist [email protected] Incidence of allergic disease Asthma Seasonal Allergic Rhinitis Perennial Allergic Rhinitis Atopic eczema Cows milk allergy Adult food allergy 10-15% 10-12% 10% 10-12% 3% (infancy) 1-2% (but 20% think they have food allergy) Drug allergy (ADR account for 6.5% hospital admissions) ? Management of allergic disease 1. Allergen avoidance (& identify alternatives) 2. Symptom control 3. Desensitisation / immunotherapy Aeroallergen Avoidance     Important intervention in allergy management. Sometimes impractical. Problems associated with accidental exposure. Combine with symptom management Symptom Targeted Treatment  Antihistamines – topical, ocular, oral. (caution about side effects)  Corticosteroids – inhaled, nasal, topical, oral.  Bronchodilators as required. Efficacy of Treatments for Allergic Rhinitis Treatment Sneezing Rhinorrhoea Blockage Itch Eye symptoms Antihistamine (oral) ++ ++ + +++ ++ Cromolyn (nasal) + + + + - Decongestant (nasal) - - +++ - - Ipratropium (nasal) - ++ - - - Leukotrine anatgonist (oral) - + ++ - ++ Steroids (nasal) +++ +++ +++ ++ ++ BSACI Guidelines for allergic & non-allergic rhinitis http://onlinelibrary.wiley.com/doi/10.1111/j.13652222.2007.02888.x/abstract Key Questions when choosing an intra-nasal steroid  Duration of action (doses per day)  Systemic side effects  Choice of preparation (preservative/ease of use/patient acceptability)  When to use (long term / pre-seasonally)  Does patient have troublesome eye symptoms? Intra-nasal steroid sprays Drug Age licence Dosing frequency Benzalkonium Preservative? Benefit for Eye Symptoms Onset of action Systemic Bioavailability Beclometasone (Beconase) 6+ Bd Yes No 2-3 days 44% £2.19 Budesonide (Rhinocort) 12+ od / bd No No 1-2 weeks 31% £3.49 Fluticasone propionate (Flixonase) 4+ Od Yes No 3-4 days <1% £11.01 Fluticasone furoate (Avamys) 6+ Od Yes Yes 8-36 hours <1% £6.44 Mometasone (Nasonex) 6+ od Yes Some benefit 12-48 hours <1% £7.68 Triamcinolone (Nasocort) 6+ od Yes No 3-4 days 46% £7.39 Fluticasone propionate & azelastine HCL (Dymista) 12+ BD Yes Yes 1.86% £18.91 Side effects of INS Common (10% of users) Epistaxis Nasal burning / irritation Rare Raised intraocular pressure/glaucoma Smell/taste disturbance Good practice point monitor height of children receiving long term treatment with nasal steroid sprays DIY without clear instructions…. Can lead to an unexpected result!! How to use your nasal spray 1. 2. 3. 4. 5. 6. 7. Saline douching Blow nose Look down, chin to chest Use opposite hand to nostril Direct spray away from septum Do not sniff Repeat for opposite side. Case Study “I’ve tried everything…” History 26 year old referred by GP as requesting steroid injection Hx – lifelong hayfever, April – July Sx – blocked & runny nose, itchy & watery eyes, itchy palate & ears, no wheeze/cough. PMH – eczema as a baby, NKDA FH - mother has asthma SH - non smoker, dog, works as a tennis coach DH - OTC antihistamines, beconase twice daily, eye drops, sudafed Ix - skin tests positive to tree & grass pollen Management  STOP sudafed!  Pre-seasonal and then daily triple therapy with; Potent nasal steroid + Non sedative antihistamine + Antihistamine eye drops +  Avoidance Review  In season with symptom score & spirometry.  Immunotherapy if still symptomatic. Summary  Nasal corticosteroids are the most effective treatment for allergic rhinitis.  Strong safety evidence for Fluticasone & Mometasone.  Start 2 weeks prior to pollen season.  Teach technique.  Combine with antihistamines and eye drops  Refer if uncontrolled for consideration of immunotherapy Specialist Allergy Services Specialist allergy service details can be found on the BSACI website; www.bsaci.org Patient websites; www.allergyuk.org www.nhs.uk/conditions/Allergies www.patient.co.uk www.asthma.org.uk