How to get right up their nose! Kathryn Powrie allergy nurse specialist

How to get right up their nose!
Kathryn Powrie
allergy nurse specialist
kathryn.powrie@meht.nhs.uk
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