Allergic Rhinitis

symptoms remain uncontrolled with avoidance measures and appropriate pharmacotherapy in adherent patients. The aim of AIT is to induce tolerance to the allergens and therefore reduce the symptoms of allergic diseases.

By gradually increasing the patient’s exposure to the allergen that causes the allergy, the patient becomes tolerant to it. Immunotherapy is only used in patients with severe symptoms and must be done by a specialist. AIT for the management of allergic disease has entered a new phase. Safe, effective, oral sub-lingual immunotherapy (SLIT) preparations are becoming increasingly available for use in allergy de-sensitisation as opposed to allergy injections. The use of AIT by 'allergy shots/injections' was severely curtailed in Ireland and the UK from 1986 when a number of deaths were reported with its use in general practice, particularly in those patients who had unstable underlying asthma. The situation has changed over the past decade however, with strong evidence that AIT can effectively treat AR , eradicate it and even prevent the development of asthma in allergic children if used early enough. For a sustained effect, AIT should be applied for a minimum of three years, either continuously or pre-seasonally. Benefit may not appear until the end of the first year of treatment, but may persist for many years beyond the course of treatment. Prolonged desensitisation using increasing doses of the culprit allergen both by subcutaneous immunotherapy (SCIT) and SLIT reduces rhinitis symptoms which have been refractory to INGC and oral antihistamines.

Grazax and Oralair are two licenced SLIT preparations available for grass pollen AR in Ireland. If patients have co-existing asthma, it must be recognised and treated and their lung function test must be normal. Patients must be advised to place the tablet under the tongue for one-totwo minutes and then swallow it. Grazax should be commenced two-to-four months before the pollen season starts in late May/ June and continued daily for a total of three years. Oralair is commenced at the same time for a period of six months per year for three successive years if there is an effect seen after the first season.

SLIT is now viewed as a significant advance in the treatment of allergic diseases. It is very effective in the treatment of rhinitis with long-lasting benefits seen after the treatment is discontinued. It is the only treatment that offers the possibility of reducing long-term costs and the burden of allergies by changing the natural course of the disease.

Other emerging therapies

Biological therapies represent a potential step forward in providing individualised care for patients with uncontrolled severe upper airway diseases. Biologics like omalizumab and dupilumab have demonstrated efficacy in patients with chronic AR and with nasal polyps. These monoclonal antibodies target type 2 inflammatory cytokines, including IL-4, IL-5, 1L-13 and IgE and have convincing evidence in proof of concept studies. The immediate goals in biologic therapies for allergies and asthma are to develop biomarkers to identify patients most likely to respond to these therapies and to monitor disease severity. As experience with biological therapies continues to grow, they are expected to move from their current position as add-on therapies for severe allergic disease to play a more prominent role in treatment strategies for many more allergy patients.

House dust allergy tips

 Allergy-proof covers for mattresses, duvets and pillows;

 Choose wood or hard vinyl floor coverings instead of carpet;

 Fit roller blinds that can be easily wiped clean;

 Regularly clean cushions, soft toys, curtains and upholstered furniture, either by washing or vacuuming them;

 Use synthetic pillows and acrylic duvets instead of woollen blankets or feather bedding;

 Using a vacuum cleaner fitted with a high-efficiency particulate air (HEPA) filter can remove more dust than an ordinary vacuum cleaner;

 Use a clean damp cloth to wipe surfaces – dry dusting can spread allergens further.

Pets

If a pet cannot permanently be removed from the house:

 Keep pets outside as much as possible or limit them to one room, preferably without carpet;

 Do not allow pets in bedrooms;

 Wash pets at least once a fortnight;

 Groom dogs regularly outside;

 Regularly wash bedding and soft furnishings a pet has been on;

 Taking an antihistamine one hour before entering a house with a pet can help reduce symptoms.

Pollen

To avoid exposure to pollen:

 Check weather reports for the pollen count and stay indoors when it is high;

 Avoid line-drying clothes and bedding when the pollen count is high;

 Wear wraparound sunglasses to protect eyes from pollen;

 Keep doors and windows shut during mid-morning and early evening, when there's most pollen in the air;

 Shower, wash hair and change clothes after being outside;

 Avoid grassy areas, such as parks and fields, when possible;

 If you have a lawn, consider asking someone else to cut the grass for you.

Mould spores

To help prevent mould spores:

 Keep your home dry and well ventilated;

 When showering or cooking, open windows, but keep internal doors closed to prevent damp air spreading through the house, and use extractor fans;

 Avoid drying clothes indoors, storing clothes in damp cupboards and packing clothes too tightly in wardrobes;

 Prevent damp and condensation in the home.

References on request

Author: Theresa LowryLehnen, CNS, GPN, RNP, PhD, and National PRO, Irish General Practice Nurses Educational Association