A 16 year old boy has his GCSEs coming up and feels his hayfever is stopping him from concentrating. He has tried antihistamines before with some success, but he is worried they might make him drowsy and worsen his focus.
This is a real problem. A case-control study found students were more likely to drop GCSE grades between a mock in winter and the real one in summer if they had allergic rhinitis – https://www.ncbi.nlm.nih.gov/pubmed/17560637
“In this study, young people with reported allergic rhinitis symptoms on an examination day were, in comparison with their fellow students without symptoms, 40% more likely to drop a grade between their practice and final GCSE examinations, and 70% more likely to drop a grade if they reported taking sedating antihistamines at the time of their examinations.”
“The significant effect of sedating medications on examination performance observed in this study should encourage prescribers to recommend the use of non-sedating alternatives in routine practice.”
Q. How far do I have to explore other differentials when someone says its their typical hayfever? I find it a little awkward to keep asking patients ‘what do you mean by hayfever?’ when they clearly have hayfever.
A. Hayfever = seasonal rhinitis +/- conjunctivitis
Rhinitis = nasal discharge +/- nasal obstruction (sneezing and itching too, especially in allergic forms)
Sinusitis = facial pain in sinus area +/- rhinitis
After confirming the patient has rhinitis, the next thing to establish is allergic vs infectious vs obstructive.
The red flags for something nasty are unilateral rhinitis symptoms, especially with obstructive/blood stained/smoker/drinker/Chinese origin/CN III-VII abnormalities. It’s also worth examining for polyps / hypertrophied turbinates if this hasn’t been done before. That’s about as far as I normally go in someone who is known to have to have hayfever with a good seasonal history.
Q. Are the non sedating antihistamines really non sedating? Which one would you pick?
From the BNF:
Drowsiness is a significant side-effect with most of the older antihistamines although paradoxical stimulation may occur rarely, especially with high doses or in children and the elderly. Drowsiness may diminish after a few days of treatment and is considerably less of a problem with the newer antihistamines.
From BMJ Learning:
“Cetirizine has a faster onset of action than loratadine, and a meta analysis found it to be more effective for treating allergic rhinitis compared with loratadine, montelukast, and desloratadine. It has also been shown to be more effective than fexofenadine at relieving the symptoms of SAR at five to 12 hours following administration.”
So, non-sedatings are better for this patient. In terms of the choice of non sedating, our local allergy clinic loves cetirizine first line. That said, fexofenadine does not carry drowsiness warning labels in the US, but cetirizine does carry labels stating may cause drowsiness may occur and to avoid heavy machinery/alcohol. Perhaps in this patient fexofenadine could be second line after cetirizine if drowsiness / impaired concentration is still a problem.
Q. What other non-pharmaceutical treatments would you use?
Allergen avoidance and a saline rinse (like Neil Med). The saline rinse seems to be loved by ENT for pretty much all types of nasal congestion. It’s pretty safe, and you can use it once to three times a day.
Q Anything else?
NICE CKS have the following table:
Oral steroids are occasionally used short term for ridiculously severe symptoms or if something important is coming up, like GCSEs or the Lego Batman movie.
Most of the time I use intranasal corticosteroids next. NICE CKS suggest they can be used for moderate and severe hayfever.
It’s important to demonstrate to the patient how to use them. I’ve often found when I ask a patient to demonstrate how they use the spray, it’s often a deep sniff to the back of the throat preventing oesophageal hayfever. I like this video:
This is how I say it:
To spray the right nostril – a poem by Dr Crunch
Look slightly down.
Hold the spray in your left hand.
Place the spray in the right nostril.
Angle it towards your right ear.
Spray with a gentle inhalation.
Q. They aren’t getting better and now they came back to see me instead of someone else and I have to deal with it and help.
A. According to BMJ Learning (http://learning.bmj.com/learning/module-intro/ask-an-expert-hay-fever.html?moduleId=10056477), it’s probably one of the following three things:
• They are using the spray incorrectly
• They are using the spray only “as needed”
• They are not using the spray for long enough.
What were the patient’s expectations about the nasal spray? It takes 8-12 hours to see an effect from the spray, and really at least two weeks to judge if its working. It needs to be used regularly, not PRN. In fact, if someone is known to have bad hayfever each year, then it’s worth using the spray for 2 weeks prior to the start of hayfever season.
Q. Won’t we stunt his growth?
A. The older nasal corticosteroids did have significant systemic absorbtion, especially beclomethasone, which is the most likely one they would purchase over the counter.
The newer ones, like momentasone and fluticasone, basically have <0.5% systemic absorbtion. Neither you or the patient have to worry about this. The BNF is chilled with momentasone 50mcg/day for children from 6 years up.
Q. So just to summarise, what did you do for this patient?
A. GCSE performance may be worsened by poorly controlled hayfever. It was important to get on top of it.
Nasal corticosteroids were the next line after non sedating antihistamines, allergen avoidance and sinus rinse. The patient responded nicely to this, having been advised about the timeframes for response and the technique.