Allergic rhinitis treatments: an interview with Dr Dermot Ryan, GP and allergy expert

Interview conducted by April Cashin-Garbutt, MA (Editor)Jun 5 2013

Please can you give a brief introduction to allergic rhinitis (AR)?

Allergic rhinitis is most commonly recognized as hay fever in the United Kingdom and it is due to the impact of an allergen, in the case of hay fever a pollen, setting off an inflammatory response in the lungs, causing typical symptoms in any combination of:

• runny nose
• itchy nose
• sneezing
• blocked nose
• tearing, and itchy eyes

However, some people also have allergic rhinitis the whole year round, which isn't often as well-recognized, and that's known as perennial or persistent rhinitis.

How does seasonal AR differ from perennial AR and who do the different types affect?

That is a very interesting question! Some people with perennial rhinitis also have seasonal rhinitis, so they have perennial rhinitis the whole year around, and the symptoms of that are predominantly blocking of the nose, and is often due to house dustmites or pet allergens in the home, and they have worsening symptoms during the different pollen seasons, so they can have perennial and seasonal.

People with seasonal rhinitis, more properly known nowadays as intermittent rhinitis, only have symptoms when their particular pollen is around.

The problem is that there are numerous pollen seasons in the UK, so different people may have one or two or three different pollen seasons depending on which pollens they have become sensitized to and are allergic to.

So, people with hay fever may have more than one bout of hay fever, which is why it's now called intermittent rhinitis, to recognize that it's not just the grass pollen which causes hay fever.

Are perennial AR and seasonal AR more common in adults or children?

Perennial AR is more common in adults and intermittent rhinitis is more common in children.

But there are a lot of gaps in our knowledge about the impact of rhinitis particularly in the under-fives because it's often difficult to differentiate what might be an allergic cause of rhinitis, and what is a snotty nose due to a viral infection, given that children under the age of five have so many viral infections.

How do the symptoms of AR vary in severity?

It depends largely on the exposure to the amount of pollen, so in very simple terms, the higher the pollen count for the particular affecting pollen, the greater the symptoms experienced.

Now, we haven't really seen bad hay fever in the United Kingdom for the last three years because of the damp wet weather which has kept the pollen count down. But two previous hay fever seasons were really quite bad with people suffering enormously.

This year, it hasn't really taken hold yet to the extent that it might have done, because of the extended cold period, which means that a lot of early pollinating plants, such as birch, haven't really done so until the last couple of weeks.

Apart from the two or three days of excellent weather we've had, like the early May bank holiday, we haven't seen the temperatures or the weather to permit high pollen counts in the majority of the country.

Why do many people remain symptomatic despite receiving treatment for AR?

There's a variety of reasons for that. Firstly, anybody who suffers from AR every year should take the medication about two weeks before their pollen season is due to begin. That will give them protection before the hay fever season has even started.

It's far better to have everything stabilized before you've been exposed to the pollen, rather to wait to start treatment after you've been exposed and the inflammatory mechanisms have already started kicking off.

Secondly, many people don't take their medicines regularly, in particular they will look on the internet and see that today's going to be a low pollen count day, and they won't take their medication. If you miss the medication for a day, you miss the protection of the medication and the symptoms come back, and it will take two-three days to regain control of the symptoms.

A lot of people mistakenly don't take their medication on a daily basis during their pollen season.

Also a lot of people who are taking topical nasal steroids or nasal sprays don't have the right technique. In particular, they sniff all the medication after spraying it up their nose, this then goes into their tummies where it doesn't have any effect at all.

It needs to stay in the nose for some time, for three or four minutes, before you sniff in order for the medication to penetrate into the nasal passages and sinuses and give it a chance to start working.

What are the main treatments patients use to relieve their AR symptoms?

One of the things patients can use is saline nasal douches, which are available over the counter. These literally rinse out their noses and sinuses, and it's a very effective way of helping to relieve symptoms for many sufferers.

And then we get to medical things, by far and away, up to now, the most effective treatment is topical nasal steroids, and with the newer ones, which need to be used once per day, give substantial relief from symptoms.

Many people also require antihistamines, which are also available over the counter, and if patients are buying antihistamines they should buy the second generation non-sedating antihistamines, because the first generation of sedating antihistamines such as chlorphenamine, are responsible for impaired hand-eye coordination, cognition and intellectual tasks, so they can cause accidents,  including driving accidents.

All antihistamines have the potential to cause sedation but the newer ones are less sedating than the first generation ones.

And if they don't work, topical antihistamines in the nose or in the eyes, you can spread azelastine drops to the eyes, or cromoglycate drops to the nose or for the eye, may also help to supplement treatment.

People shouldn't use topical nasal decongestants for long periods of time as although they can provide rapid relief of symptoms, the nose gets addicted to it, and after ten or twelve days people keep using it more frequently to get the same effect, and eventually it doesn't have any effect at all. And if you stop using it, the symptoms get worse, with increased nasal congestion although this will wear off, generally speaking, with time. So, that sort of treatment is useful for a few days only.

For the very severe people there is immunotherapy for grass pollen, or for birch, but that needs to be accessed largely through an allergist.

Please could you describe the new nasal spray Dymista® that has recently been launched in the UK? How does this differ from other available treatments?

Dymista is a real advance in treatment because it's a combination of a topical nasal steroid with a topical antihistamine, and this means it combats different parts of the pathways.

As a result of which, the studies, which are large, well-conducted studies, demonstrate that Dymista is approximately twice as effective in its actions on both the eyes and the nose as either fluticasone a topical nasal steroid, which is sold over the counter, or azelastine, which is a prescription topical nasal spray.

So, it appears that there are benefits of adding the effects of two different medications, which work on two different pathways, and it also has the advantage of a very rapid on-set action in comparison to Azelastine* on its own or Fluticasone* on its own, and it may well be that the speed of on-set of action encourages patients to take their medication as they can feel a difference very, very rapidly, which encourages one to take medication.  

If you don't feel benefit from medication understandably you stop taking it, thinking "that's no good." So I think the speed, the rapid on-set of action, and the increased effect that it has on the individual components, helps people to recognize that the medication is having an effect, and thus they're more likely to take it regularly, and because they're taking it more regularly, that also leads to the likelihood of a better outcome for the individual patient.

How safe and effective is Dymista®? What studies have been carried out on this?

I haven't seen all the studies, but the year-long studies which have been done for regulatory purposes don't show up any signal of anything to be concerned about.

The greatest thing about Dymista is that because the medication is applied to the lining of the nose and sinuses, there is very little absorption into the body, into the systemic circulation, and the exposure to side effects is very, very small.

If you look at the study in terms of side effects between Dymista, Fluticasone, Azelastine or placebo, the rate of side effects of all medications, including placebo, is essentially similar.

With regard  to potential  long-term side effects of Dymista, particularly if you look at the fluticasone component, there doesn't appear to be any significant signal showing any problems after a year of use.

What are the main reasons why patients don’t adhere to current treatments? Do you think patients will be more likely to adhere to new treatments like Dymista®?

I think that many patients do get significant relief from their symptoms by buying medication over the counter, so more than half of sufferers of hay fever in the UK buy their medication over the counter and don't come to the doctors at all, so they're clearly getting adequate relief from their symptoms.

Most of the people who come to see their GPs have moderate to severe symptoms, and most of those people have tried over-the-counter medications and haven't had the benefit they expected from that.

Some of the reasons they don't have the benefit is because they started the medication after the hay fever season started, and also because they weren't using the nasal medication technique properly, in other words their technique was poor, or they weren't taking their medication every day.

A combination of these reasons mean that the patients won't get the potential benefits of those individual agents, making patients belief it is the medication which is having a poor effect when on reality the way in which it is being used compromises effectiveness.

The reason Dymista is likely to work, or the reason people are more likely to adhere to it, is because it works more effectively than the individual components, so it has a bigger impact, and it has an impact more quickly, and those two factors should encourage the patients to take the medication more regularly and with increased effect.

Where is Dymista® currently available?

It is a prescription-only drug so you can only get it through your GP or by seeing your hospital allergist which very few people in the UK will see because there are only twenty-seven allergists in the whole of the United Kingdom.

So they all need to go to their GP if they are failing to get adequate relief from their existing medication.

If you're getting adequate relief from your existing medication, you can keep on taking that and do not need to do any more.

So, this is for people who aren't getting adequate relief from their existing medication, or a combination of medications, because some people are on three or four medications to control their hay fever.

Why do some people think AR is a trivial disorder?

I think a lot of people just don't understand the effects that allergic rhinitis has upon somebody whose symptoms aren't controlled. We all know how lousy we feel when we have a common cold, when we feel not well for a three or four days and a bit moody and just feel heavy-headed and our concentration goes, so that's what allergic rhinitis feels like - except it goes on for two or three weeks at a time, so I think we need to need to be sympathetic to people who suffer from hay fever.

It doesn't, or rarely, kills people, I'm not aware that it kills anybody at all - but it does have a significant impact on the life of the individual sufferer, and often on the sufferers' families, whose activities are curtailed because they can't do things because it impacts upon the person who has the problem.

I think it's not a trivial disorder. For people with mild disease, you can take one medication a day and it will relieve all symptoms. That's fine, but about fifty percent of sufferers have significant symptoms for a protracted period of time.

Some people also develop symptoms of asthma during the hay fever season, in particular the wheezing, coughing, and tightness of chest on exercise, and if they have those symptoms during hay fever season, they really should see their family doctor and be checked over from the point of view of asthma, because they might require asthma medication as well as the hay fever medication for those six to eight weeks.

But also, people who suffer from asthma will often get a worsening of their asthma due to hay fever. There's no evidence that Dymista has any benefits for somebody who suffers from asthma.

Where can readers find more information?

The clinical papers are published in the Journal of Allergy and Clinical Immunology: http://www.jacionline.org/

About Dr. Dermot Ryan

Dermot Ryan is a GP in Loughborough with a long standing interest in respiratory disease and allergy as managed within primary care.

He was chairman of the Primary Care Respiratory Society during which time he oversaw the establishment of an academic unit of Primary Care Respiratory Medicine at the University of Aberdeen.

Dr. Ryan has been a member of various guideline groups including the British asthma guidelines group (SIGN/BTS), The British Society of Allergy and Clinical Immunology rhinitis guidelines group and the World Allergy Organisation immunotherapy guidelines group.

He has performed research in both asthma and rhinitis and is currently involved in establishing the primary care interest group of the European Academy of allergy and Clinical Immunology.

Dr. Ryan holds and honorary appointment at the University of Edinburgh.