Allergy

A journey through the 2017 British

Society for Allergy and Clinical
Immunology (BSACI) rhinitis guideline
Dr Elizabeth Angier
Portfolio GP, Southampton; secretary of the Primary Care and Allied Health Interest Group,
European Academy of Allergy and Clinical Immunology; member of the Standards of Care
Committee Guidelines British Society of Clinical Immunology and Allergy GP and clinical assistant

This session is independent

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Dr Elizabeth Angier
Portfolio GP, Southampton
Secretary, Primary Care and Allied Health
Interest Group, European Academy of
Allergy and Clinical Immunology
Member, Standards of Care Committee
Guidelines British Society of Clinical
Immunology and Allergy

Brought to you by Guidelines and Guidelines in Practice.

A journey through the 2017
British Society for Allergy and
Clinical Immunology (BSACI)
rhinitis guideline
Dr Elizabeth Angier
Portfolio GP
MSc Student, Southampton University
Secretary, Primary Care and Allied Health Interest Group, European Academy of Allergy
and Clinical Immunology

Brought to you by Guidelines and Guidelines in Practice.

 Disclosures
Research Support/P.I. No relevant conflicts of interest to declare

Employee No relevant conflicts of interest to declare

Consultant No relevant conflicts of interest to declare

Major Stockholder No relevant conflicts of interest to declare

Speakers Bureau No relevant conflicts of interest to declare

Honoraria MEDA

Scientific Advisory Board SCHERING-PLOUGH, STALLERGENES, MEDA

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Outline
• Background, definition
• Impact
• Service delivery, history, cases
• Overview of patient journeys
• Paediatrics, tests, treatments, referral
• Immunotherapy

Brought to you by Guidelines and Guidelines in Practice.

 The British Society for
Allergy and Clinical
Immunology (BSACI)

BSACI is the national, professional and

academic society, which represents the
specialty of allergy at all levels

Its aim is to improve the management

of allergies and related diseases of the
immune system in the UK, through
education, training and research

Brought to you by Guidelines and Guidelines in Practice.

BSACI, British Society for Allergy and Clinical Immunology.

Brought to you by Guidelines and Guidelines in Practice.

 Rhinitis: introduction
• Rhinitis is defined as inflammation of nasal epithelium and is
characterised by at least two nasal symptoms (rhinorrhea, blockage,
sneezing or itching)
• Number of different (overlapping) clinical presentations:
1. Allergic rhinitis — symptoms caused by exposure to an allergen to which a
patient is sensitised (allergen-driven) — seasonal vs perennial, intermittent vs
persistent, mild vs moderate/severe
2. Infectious rhinitis — usually secondary to a viral infection — may overlap with
allergic rhinitis
3. Non-allergic, non-infectious — irritants (cigarette smoke), food (sulphites,
spice, alcohol), drugs (NSAID), NARES, rhinitis medicamentosa, vasomotor,
hormonal, emotional or gustatory
NARES, non-allergic rhinitis with eosinophilia; NSAID, non-steroidal anti-inflammatory drug.

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 Causes of rhinitis/rhinosinusitis
Infectious Occupational (allergic/non-allergic) Other causes
• Viral • Intermittent • NARES
• Bacterial • Persistent • Churg–Strauss syndrome
• Other infective • Irritants
agents Drug-induced • Food
• Aspirin • Emotional
Allergic
• Other medications • Atrophic
• Intermittent
• Gastro-oesophageal reflux
• Persistent Hormonal
• Idiopathic
NARES, non-allergic rhinitis with eosinophilia. Bousquet J, van Cauwenberge P. Allergic rhinitis and its impact on asthma (ARIA). Geneva: WHO, 2000.

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 ARIA classification of allergic rhinitis
Intermittent symptoms Persistent symptoms
• <4 days per week • >4 days per week
OR AND
• <4 weeks • >4 weeks

Mild Moderate-severe
• Normal sleep One or more items
• Normal daily activities • Abnormal sleep
• Normal work and school • Impairment of daily activities, sport, leisure
• No troublesome symptoms • Problems caused at school or work
• Troublesome symptoms

ARIA, allergic rhinitis and its impact on asthma. Bousquet J, van Cauwenberge P. Allergic rhinitis and its impact on asthma (ARIA). Geneva: WHO, 2000.

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Rhinitis is still…
• Ignored
• Underdiagnosed
• Misdiagnosed
• Mistreated

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Why treat rhinitis?
• Prevalence
• Comorbidities
• Complications
• Quality of life
• Costs

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 Impact of allergic rhinitis on patients’
daily life
Sleep and tiredness
• 46% of patients feel tired1
• 77% of patients had trouble falling asleep1

Daily activities Learning and cognitive

impaired2,3 Impact of functions disturbed6
allergic
rhinitis
Work and school productivity Embarrassment
• ≤90% effectiveness at work4 • Adolescents embarrassed to use inhalers6
• ≤93% impaired classroom performance3,5

1. Scadding G et al. XXVI EAACI, 2007 (abstract 1408); 2. Reilly M et al. Clin Drug Invest 1996; 11: 278–288;
3. Tanner L et al. Am J Manag Care 1999; 5(Suppl 4): S235–S247; 4. Blanc P et al. J Clin Epidemiol 200; 54:610–618;
5. Juniper E et al. J Allergy Clin Immunol 1994; 93: 413–423; 6. Marshall P, Colon E. Ann Allergy 1993; 71: 251–258.

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 Impact of rhinitis on asthma: one airway
• Rhinitis is a risk factor for asthma: odds ratio >3, >7 farmers,
>40 HDM
• Rhinitis reduces asthma control, = smoking, > poor Rx
compliance
• Most asthma exacerbations start in the nose with a viral URTI
• Rhinitis increases viral URTI effects
• Rhinitis Rx reduces need for emergency treatment and
hospitalisation for asthma

HDM, house dust mite; Rx, treatment; URTI, upper respiratory tract infection. Scadding G, Walker S. Prim Care Respir J 2012; 21: 222–228.

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Asthma and rhinits
• Up to 80% of people with Rhinitis
alone
asthma have rhinitis

Rhinitis
+
asthma
Asthma
alone

Bouscquet J, van Cauwenberge P. Management of allergic rhinitis and its impact on asthma: pocket guide. Brussels: ARIA, 2001.
Bousquet J et al. J Allergy Clin Immunol 2001; 108(5): S147–S334.
Sibbald B, Rink E Thorax 1991; 46: 895–901.
Leynaert B et al Am J Respir Crit Care Med 2000;162:1391–1396.

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 Allergic rhinitis impacts negatively on
patients’ activities: data from Finland

to severe impact (%)

Patients with moderate
• In Sweden, the
cost of rhinitis is
€2.7 billion/year
in terms of lost
productivity

Patient Voice Allergy Survey

Valovirta E et al. Curr Opin Allergy Clin Immunol 2008; 8: 1–9.
Hellgren J et al. Allergy 2010; 65: 776–783.

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 Allergic rhinitis landscape
European survey
Most patients have ‘moderate/severe’ allergic rhinitis • 67.2% = moderate or severe
• 42.5% = persistent disease

Many patients have mixed forms of allergic rhinitis

Many patients are becoming poly-sensitised

Evolution of treatment-resistant phenotypes SCUAD

• SCUAD • Approximately 20% of patients with AR

Canonica G et al. Allergy 2007; 62 (Suppl 85): 17–25.

Pie chart data refer to non-infectious rhinitis. Settipane R. Allergy Asthma Proc 2001; 22(4): 185–189.
Mösges R et al. Allergy 2007; 62(9): 969–975.
AR, allergic rhinitis. SCUAD, severe chronic upper airway disease. Bousquet J et al. J Allergy Clin Immunol 2009; 124(3): 428–433

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Service delivery
• Self-care
• Pharmacists
• Practice nurses
• GPs
• Specialists
• Triple aim

Brought to you by Guidelines and Guidelines in Practice.

Outline
• Background, definition
• Impact
• Service delivery, history, cases
• Overview of patient journeys
• Paediatrics, tests, treatments, referral
• Immunotherapy

Brought to you by Guidelines and Guidelines in Practice.

History
• The cornerstone to diagnosis
• This hasn’t changed
• Right questions to ask
• Importance of good communication

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What can I ask in 10–15 minutes?
• 3 Cs of primary care:

• Contact accessibility

• Continuity

• Coordination

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History
• Worst symptoms — in order • Past history
• When? • Family history
• Where? • Social history — housing
• What increases them? • Associated symptoms?
• What decreases them? • School/work, hobbies, food,
• Treatment? medication and reactions,
smoking, pets, etc

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Allergy more likely if:
• Itching
• Eye involvement
• Allergen exposure provokes symptoms
• Allergen avoidance relieves them
• Personal/family history allergic disease
• Allergy treatment helps

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WARNING symptoms — refer if:
• Unilateral
• Blood-stained discharge
• Pain
• Rhinorrhoea only

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Case 1
• Miles, 17-year-old student, A levels this summer
• Runny and blocked nose and sneezing every June
• Also noticed asthma worse then
• Co-existent nut allergy
• Takes over-the-counter antihistamines
• Books an appointment with triage practice nurse to ask for
advice
• Questions to ask?

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Case history
• History
• Examination
• Advice
• Treatment
• Review

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Check nasal spray technique

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 Moderate/severe
Mild rhinitis
rhinitis

AH INS

Treatment failure

Check use, concordance, dose

* Additional therapies
can be accomplished
using two different Combination treatment with INS and INAH*
medications, or a
combination
treatment in one
device. There is, as Treatment failure
yet, no comparative
evidence on which to
base this choice;
however, Check use, concordance, dose
concordance appears
more likely when the
regimen is simple.

AH, antihistamine Watery rhinorrhoea Itch/sneeze/extranasal itch/rash Catarrh Blockage

BSACI, British
Society for Allergy
and Clinical
Immunology • Add ipratropium • Switch to non-sedating oral AH • Add LTRA if asthmatic • Add (briefly) IN decongestant
IN, intranasal
INAH, intranasal
antihistamine
INS, intranasal
corticosteroids
LTRA, leukotriene
Infection?/structural problem Treatment failure Inflammatory rhinitis
BSACI rhinitis guideline. In:
receptor Hayeem N, editor. Guidelines –
antagonist summarising clinical guidelines
OC, oral for primary care. 64th ed.
corticosteroids Consider immunotherapy if symptoms Course of OC, continue Chesham: MGP Ltd; September
Surgical referral
Rx, treatment predominantly due to one allergen local treatment 2017. pp.298–304.

Brought to you by Guidelines and Guidelines in Practice.

Key point
• Media quote, 2007:

• ‘Hayfever drugs cost students an exam grade’

• Avoid 1st-generation antihistamines!

Walker S et al. J Allergy and Clinical Immunology 2007; 120: 381–387.

Brought to you by Guidelines and Guidelines in Practice.

Outline
• Background, definition
• Impact
• Service delivery, history, cases
• Overview of patient journeys
• Paediatrics, tests, treatments, referral
• Immunotherapy

Brought to you by Guidelines and Guidelines in Practice.

Emma
• 7-year-old brought in by mum
• Runny nose and cough at night tired in the morning
• Sneezing
• Questions to ask?

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Emma
• History
• Examination
• Tests?
• Advice
• Treatment

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 Paediatric rhinitis: presentation
Classic symptoms
• Rhinorrhoea — sniffing
• Pruritus — nose rubbing, sneezing
• Conjunctivitis — red, itchy, watery
eyes
• Congestion — mouth breathing,
snoring, allergic shiners
• Habitual open mouth breathing
Not just a runny nose!
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Potential atypical presentations
• Cough
• Poorly controlled asthma
• Eustachian tube dysfunction eg reduced hearing
• Sleep problems — tired, poor school performance
• Rhinosinusitis — catarrh, headache, facial pain,
halitosis, cough, hyposmia
• Prolonged and frequent respiratory tract
infections
• Oral allergy syndrome
 Being unable to concentrate
Needing to rub eyes
Rashes on your skin

Paediatric Itchy nose

Being unable to remember things learned at school

rhinitis: Sneezing
Blocked nose

impact Needing to rub your nose

Needing to blow your nose
on the Your parents complaining that you don’t listen

patient Runny nose

Being unable to get to sleep
Itchy nose
Sw ollen eyes
Coughing at night

Being Worn out

Coughing
Feeling out of breath

Directly related to rhinitis Coughing w hile playing a game

Potential comorbidity Wheezing w hile running

0 1 2 3 4
Score
Roberts G et al. J Allergy Clin Immunol 2003; 111(3): 491–7..

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Allergic rhinitis:
pharmacotherapy

Approach to therapy
Œ,  and Ž are potential entry
points into therapeutic approach
depending on severity
Reconsider diagnosis if not
controlled, especially if <2 years
Also consider rescue therapy with
short course of decongestant or
low dose prednisolone

Roberts G et al. Allergy 2013; 68(9): 1102–1116.

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 Allergic rhinitis: pharmacotherapy
Reasons for lack of response to therapy Compliance and education
• Poor compliance? • Understudied area in
• Nasal obstruction preventing drug delivery paediatric rhinitis
(decongestant) • Compliance may be
• Additional pathology: deviated septum, particularly problematical
polyps with nasal sprays
• Persistent allergen exposure • Many patients do not use
nasal sprays correctly
• Wrong diagnosis — non-allergic rhinitis?
• Did not start before the pollen season
Hellings P et al. Allergy 2013; 68(1): 1–7.

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 Managing paediatric rhinoconjunctivitis
• Rhinitis is prevalent but underappreciated
• Some children present atypically with comorbidities: asthma, eczema, oral allergy
syndrome, sleep disorders, and hearing problems
• Comprehensive clinical history and thorough examination of nose aids accurate
diagnosis
• Allergy tests may confirm or refute an allergic origin
• With treatment failure, further investigations required to exclude other possible diagnoses
• Therapy: avoidance of relevant allergens; pharmacotherapy (antihistamine and/or nasal
corticosteroids; specific immunotherapy
• Add-on therapies: oral montelukast, intranasal anticholinergics, and decongestants

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Martin
• Pizza delivery man
• No time in the day to see GP
• Runny and blocked nose from February to July/August, some
itchy eyes as well
• Uses over-the-counter antihistamines
• Goes to see his pharmacist, who also works part-time in the
general practice
• Does he need to see his GP?

Brought to you by Guidelines and Guidelines in Practice.

 Moderate/severe
Mild rhinitis
rhinitis

AH INS

Treatment failure

Check use, concordance, dose

* Additional therapies
can be accomplished
using two different Combination treatment with INS and INAH*
medications, or a
combination
treatment in one
device. There is, as Treatment failure
yet, no comparative
evidence on which to
base this choice;
however, Check use, concordance, dose
concordance appears
more likely when the
regimen is simple.

AH, antihistamine Watery rhinorrhoea Itch/sneeze/extranasal itch/rash Catarrh Blockage

BSACI, British
Society for Allergy
and Clinical
Immunology • Add ipratropium • Switch to non-sedating oral AH • Add LTRA if asthmatic • Add (briefly) IN decongestant
IN, intranasal
INAH, intranasal
antihistamine
INS, intranasal
corticosteroids
LTRA, leukotriene
Infection?/structural problem Treatment failure Inflammatory rhinitis
BSACI rhinitis guideline. In:
receptor Hayeem N, editor. Guidelines –
antagonist summarising clinical guidelines
OC, oral for primary care. 64th ed.
corticosteroids Consider immunotherapy if symptoms Course of OC, continue Chesham: MGP Ltd; September
Surgical referral
Rx, treatment predominantly due to one allergen local treatment 2017. pp.298–304.

Brought to you by Guidelines and Guidelines in Practice.

Outline
• Background, definition
• Impact
• Service delivery, history, cases
• Overview of patient journeys
• Paediatrics, tests, treatments, referral
• Immunotherapy

Brought to you by Guidelines and Guidelines in Practice.

 Pollens

Rhinitis:
diagnostic
approaches

Skin prick test Support clinical diagnosis of allergic rhinitis, identify

Serum-specific IgE specific triggers or investigate atypical presentation
IgE, immunoglobuin E.

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 New framework for
interpretation of IgE
sensitisation tests

IgE, immunoglobuin E. Roberts G et al. Allergy 2016; 71: 1540–1551.

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Skin-prick tests

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Causes of false-negative skin-prick tests
• Antihistamines, tricyclic antidepressants
• Topical corticosteroid
• High-dose oral corticosteroid
• Early in disease – local sensitisation in nose

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Allergic rhinitis: treatment
• Allergen avoidance
• Pharmacotherapy
• Immunotherapy
• RARELY surgery
• Education, education, education
• www.whiar.org
• www.bsaci.org
• www.eaaci.org

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Allergen avoidance
• Works — no hayfever in January
• Occupational rhinitis — vital to remove before asthma
develops
• Difficult — travel away or avoid high pollen days
• Evening — close windows, washing in, hair wash
• Put something in nose — petroleum jelly, cellulose, hay balm,
filters

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 Intranasal steroids rule!
• Superior in meta-analyses to:
• Oral antihistamine1
• Topical antihistamine2
• LTRAs3

• Also superior to antihistamine + LTRA4

1. Weiner J et al. BMJ 1998; 317(7173): 1624–1629.

2. Yáñez A, Rodrigo G. Ann Allergy Asthma Immunol 2002; 89(5): 479–484.
3. Wilson A et al. Am J Med 2004; 1165(5): 338–344.
LTRA, leukotriene receptor antagonist. 4. Di Lorenzo G et al. Clin Exp Allergy 2004; 34(2): 259–277.

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Check bioavailability

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What is new in 2017 guideline version?

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 Moderate/severe
Mild rhinitis
rhinitis

AH INS

Treatment failure

Check use, concordance, dose

* Additional therapies
can be accomplished
using two different Combination treatment with INS and INAH*
medications, or a
combination
treatment in one
device. There is, as Treatment failure
yet, no comparative
evidence on which to
base this choice;
however, Check use, concordance, dose
concordance appears
more likely when the
regimen is simple.

AH, antihistamine Watery rhinorrhoea Itch/sneeze/extranasal itch/rash Catarrh Blockage

BSACI, British
Society for Allergy
and Clinical
Immunology • Add ipratropium • Switch to non-sedating oral AH • Add LTRA if asthmatic • Add (briefly) IN decongestant
IN, intranasal
INAH, intranasal
antihistamine
INS, intranasal
corticosteroids
LTRA, leukotriene
Infection?/structural problem Treatment failure Inflammatory rhinitis
BSACI rhinitis guideline. In:
receptor Hayeem N, editor. Guidelines –
antagonist summarising clinical guidelines
OC, oral for primary care. 64th ed.
corticosteroids Consider immunotherapy if symptoms Course of OC, continue Chesham: MGP Ltd; September
Surgical referral
Rx, treatment predominantly due to one allergen local treatment 2017. pp.298–304.

Brought to you by Guidelines and Guidelines in Practice.

 Allergy referral
• Uncontrolled symptoms (SCUAD)
• Investigation of allergens/triggers
• Consideration of immunotherapy
• Occupational allergy
• Multisystem allergy
• Systemically unwell
• Recurrent nasal polyps

SCUAD, severe chronic upper airway disease.

Brought to you by Guidelines and Guidelines in Practice.

 Moderate/severe
Mild rhinitis
rhinitis

AH INS

Treatment failure

Check use, concordance, dose

* Additional therapies
can be accomplished
using two different Combination treatment with INS and INAH*
medications, or a
combination
treatment in one
device. There is, as Treatment failure
yet, no comparative
evidence on which to
base this choice;
however, Check use, concordance, dose
concordance appears
more likely when the
regimen is simple.

AH, antihistamine Watery rhinorrhoea Itch/sneeze/extranasal itch/rash Catarrh Blockage

BSACI, British
Society for Allergy
and Clinical
Immunology • Add ipratropium • Switch to non-sedating oral AH • Add LTRA if asthmatic • Add (briefly) IN decongestant
IN, intranasal
INAH, intranasal
antihistamine
INS, intranasal
corticosteroids
LTRA, leukotriene
Infection?/structural problem Treatment failure Inflammatory rhinitis
BSACI rhinitis guideline. In:
receptor Hayeem N, editor. Guidelines –
antagonist summarising clinical guidelines
OC, oral for primary care. 64th ed.
corticosteroids Consider immunotherapy if symptoms Course of OC, continue Chesham: MGP Ltd; September
Surgical referral
Rx, treatment predominantly due to one allergen local treatment 2017. pp.298–304.

Brought to you by Guidelines and Guidelines in Practice.

 Allergen immunotherapy
‘Allergen-specific immunotherapy is the practice of administering
(gradually increasing) quantities of an allergen product to an
individual with IgE-mediated allergic disease in order to
ameliorate the symptoms associated with subsequent exposure to
the causative allergen’

IgE, immunoglobulin E. Alvarez-Cuesta E et al. Allergy 2006: 61 (Suppl 82): 1–20.

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 Allergen immunotherapy: indications
• Allergic rhinitis/conjunctivitis, (allergic asthma*) and systemic
reactions to wasp/bee venom
• Effective in IgE-mediated disease with limited spectrum
of allergies (1 or 2)
• Should be combined with allergen avoidance,
pharmacotherapy and patient education

*Not currently in UK, except with allergic rhinitis.

IgE, immunoglobulin E. Bousquet J et al. Allergy 1998; 53 (Suppl 44): 1–42.

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 Allergen immunotherapy: contraindications
• Uncontrolled asthma or FEV1 <70% predicted
• Beta-blockers
• Malignancy
• (Systemic) autoimmune/inflammatory disease
• Pregnancy at initiation of treatment
• (Acute) infection/illness

FEV1, forced expiratory volume in 1 second.

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 Immunotherapy for allergic rhinitis
• AIT offers prospect of:
• sustained prevention of
most allergic symptoms
• disease modification
avoiding progression
• disease remission
AIT, allergen-specific immunotherapy
FEV1, forced expiratory volume in 1 second
SCIT, subcutaneous immunotherapy
SLIT, sublingual immunotherapy
Brought to you by Guidelines and Guidelines in Practice.
• SCIT = injection:
• Specialist administration
• Severe side-effects possible
• Contraindicated in chronic asthma
• SLIT = under the tongue:
• Self-adminstered (1st dose
supervised)
• Can be used in patients with mild
asthma (FEV1 >70%)
Bousquet J et al. J Allergy Clin Immunol 2001; 108: S147–S334.
Lost in translation
• Holistic quality care and
seamless service delivery
are key in the context of
allergy care

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 Rhinitis
• Some slides altered and used with permission of BSACI:

• Glenis Scadding, RNTNE Hospital, London

• Guy Scadding, Royal Brompton Hospital, London

BSACI, British Society for Allergy and Clinical Immunology; RNTNE, Royal National Throat, Nose and Ear.

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