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Greater Knox Pharmacy

43 Boronia Road, Boronia VIC 3155
Tel: 03-9739-8951
Email: admin@greaterknoxpharmacy.com.au
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Hay Fever

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1. Symptom Frequency

Classification




First choice Treatment Options




1. Overview

Hay fever, also called allergic rhinitis, is caused by an allergic response to outdoor or indoor allergens, such as pollen, dust mites, or tiny flecks of skin and saliva shed by cats, dogs, and other animals with fur or feathers (pet dander).

When you have hay fever, your immune system identifies a harmless airborne substance as harmful. Your immune system then produces antibodies to this harmless substance.

In Australia, up to 21% of the population is affected by hay fever, most commonly between the ages of 25 and 44 years.

Rhinitis is a major risk factor for developing asthma; effective management of rhinitis is associated with better asthma control. Patients with rhinitis due to pollen allergy have an increased risk of asthma exacerbations during thunderstorms coinciding with high pollen season.

1.1 Risk Factors

The following can increase your risk of developing hay fever:

  • Having other allergies or asthma
  • Having atopic dermatitis (eczema)
  • Having a blood relative (such as a parent or sibling) with allergies or asthma
  • Living or working in an environment that constantly exposes you to allergens — such as animal dander or dust mites
  • Having a mother who smoked during your first year of life

2. Symptoms

Hay fever signs and symptoms can include:

  • Runny nose and nasal congestion
  • Watery, itchy, red eyes (allergic conjunctivitis)
  • Sneezing
  • Itchy nose, roof of mouth or throat
  • Swollen, blue-colored skin under the eyes (allergic shiners)
  • Post-nasal drip
  • Fatigue
  • Occasional cough

2.1 Hay Fever vs Common Cold

Signs and Symptoms Onset Duration
Hay Fever Runny nose with thin, watery discharge; no fever Immediately after exposure to allergens As long as you're exposed to allergens
Common Cold Runny nose with watery or thick yellow discharge; body aches; low-grade fever One to three days after exposure to a cold virus Three to seven days

3. Classification

Hay fever can be classified by severity and chronicity and is usually described by both adjectives, for example 'intermittent, severe' or 'persistent, mild'. This classification is useful for choosing management options.

Intermittent
  • < 4 days / week or
  • < 4 weeks
Persistent
  • > 4 days / week and
  • > 4 weeks
Mild
Normal sleep and:
  • No impairment of daily activity
  • Normal school or work performance
  • No troublesome symptoms
Moderate or Severe
One or more of:
  • Abnormal sleep
  • Impairment of daily activities
  • Abnormal school or work performance
  • Troublesome symptoms

4. Reducing Allergen Exposure

It is extremely hard to avoid getting hay fever. The best thing to do is to lessen your exposure to the allergens that cause your symptoms and take allergy medications before you are exposed to allergens.

Reducing allergen exposure can be often difficult especially for house dust mites and outside pollen, but it can be beneficial to reduce the severity of hay fever symptoms.

4.1 General Prevention Measures

  • Check out the pollen calendar to help you identify plants that may trigger hay fever and when they’re most likely to be flowering. You can find out what they look like too, so you can avoid locations where these plants might be growing.
  • Reduce the amount of pollen that can enter the house by shutting windows at night and first thing in the morning.
  • Smear petroleum jelly (like Vaseline) inside your nose when you are outdoors. This helps trap pollen and stops it reaching the inner lining of your nose.
  • Stay indoors as much as possible in spring when the pollen count forecast is high, and on windy days or after thunderstorms.
  • Wear wrap-around sunglasses and frequently splash your eyes with water. This will help protect your eyes from irritation and flush out any pollen.
  • Stay away from parks and gardens while lawns are being mowed. If you can’t avoid this, wearing a mask may help, if practical.
  • Don’t mow the lawn, or sit or stand on grass.
  • Shower after playing sport and other outdoor activities to rinse off any pollen you’ve been exposed to.
  • Use recirculated air in the car, especially when pollen levels are high, or keep the windows closed.
  • Avoid hanging clothes outside so they don’t come into contact with pollen.
  • If you have pets, bathe and brush their hair regularly.

4.2 House Dust Mites

  • Bedding
    • Wash sheets, blankets, pillowcases and other bedding weekly in hot water.
    • Tumble drying for 10 minutes will kill mites
    • Use allergen proof and dust mite impermeable covers on pillows and matrices
    • Use commercial products containing tea tree oil for cold washing
  • Reduce Humidity:
    • Use dehumidifier
    • Use air conditioning
  • Carpets:
    • Vacuum weekly with small particle or HEPA filter
    • Consider removing (especially where you sleep) if highly sensitive
    • Some insecticides that kill mites and are approved for indoor use
  • Other:
    • Damp dusting
    • Remove soft toys or wash in eucalyptus oil or place them in freezer overnight
    • Remove sheepskin and woollen underlay from bedrooms

4.3 Pollen

  • Avoid outdoor activities especially in the early morning and activities known to cause allergen exposure (e.g. grass cutting)
  • Remain indoors on dry, windy days or after thunderstorms
  • Shower after outdoor activities
  • Close doors and windows during pollen season
  • Don't hang laundry outside — pollen can stick to sheets and towels.
  • Use recirculated air conditioning in house and car
  • Wear sunglasses and a mask to minimise the amount of pollen exposure.

4.4 Pet Dander

  • Keep pets out of your home, if possible. However, it can take a while for allergen levels to decrease.
  • Washing pets regularly may or may not help
  • Keep pets outside the bedroom and off furniture

4.5 Moulds

  • Remove visible mould (e.g. using bleach or other mould removing cleaners)
  • Use a dehumidifier to reduce indoor humidity.
  • Ensure adequate ventilation
  • Dry or remove wet carpets
  • Fix any leaks
  • Remove indoor pot plants

5. Treatment

Many people only find relief when using a combination of hay fever medications. This depends on severity, frequency and type of symptoms.

When symptoms improve doses may be reduced.

Itch/Sneeze Nasal discharge Nasal blockage Eye symptoms
Intranasal corticosteroids +++ +++ ++ ++
Oral/intranasal antihistamines ++ ++ +/- ++ (oral)
- (intranasal)
Antihistamine eye drops - - - ++
Oral/intranasal decongestants - - + (oral)
+++ (intranasal)
-
Decongestant eye drops - - - +/-
Intranasal Chromones + + +/- -
Cromoglycate eye drops - - - +
Ipratropium - +++ - -
Montelukast* - + ++ ++
+++ very effective, ++ moderately effective, + marginally effective, +/– little or no effect, – ineffective
* Requires prescription

5.1 Intranasal Saline/Irrigation

Should be used 10-15 minutes before other medicated nasal sprays. They help to clear nasal congestion, wash away dust, pollen and other irritants.

5.2 Intranasal Corticosteroids (INCS)

For many people these are often the most effective medication, and should be the option to try first. They are most effective to relieve itch, sneeze, and nasal discharge, and have good efficacy to relieve nasal blockage and eye symptoms.

The maximum benefit can take up to 2 weeks, and they are best started before the allergy season and continued throughout. Some symptoms can improve within hours however.

There are several you can buy without a prescription, including:

  • Nasonex (mometasone)
  • Rhinocort (budesonide)
  • Beconase (beclomethasone) and
  • Flixonase (fluticasone)
  • Dymista (fluticasone, azelastine)
  • Other prescription options also available

Pregnancy Breastfeeding Children
Budesonide (e.g. Rhinocort) A - safe safe > 2 years
Mometasone (e.g. Nasonex) B3 - probably safe safe > 3 years
Beclomethasone (Beconase) B3 - probably safe safe > 12 years
Fluticasone (Flixonase) B3 - probably safe safe > 2 years

5.3 Antihistamines

Individual response to an antihistamine varies widely; it may be necessary to try a number to see which is best tolerated and most effective. Even though they are typically tried first, they may not offer the best results. They can improve most symptoms of hay fever, and they can be used along with other options for better symptom control.

5.3.1 Newer Less Sedating Antihistamines

Advantages

  • Once daily dosing
  • Available without prescription
  • Effective against a wide range of symptoms
  • Can be used long term

^ Indicated for chronic urticaria only for children below 2 years of age
* Indicated for chronic urticaria only for children below 1 year of age
Pregnancy Breastfeeding Children
Loratadine (e.g. Claratyne) B1 - probably safe safe > 1 year
Fexofenadine (e.g. Telfast) B2 - probably safe safe > 6 months^
Cetirizine (e.g. Zyrtec) B2 - probably safe safe > 1 year
Desloratadine (e.g. Aerius) B1 - probably safe safe > 6 months*
Bilastine (e.g. Allertine) B3 - consider alternative consider alternative > 12 years

5.3.2 Older Sedating Antihistamines

Usually require multiple daily doses. More likely to cause side effects than the less sedating options. Examples include:

  • Dexchlorpheniramine (e.g. Polaramine)
  • Promethazine (e.g. Phenergan, Avomine)

5.3.3 Antihistamine Nasal Sprays

They have similar efficacy to oral antihistamines (except on eye symptoms). Examples include:

  • Azelastine (e.g. Azep)
  • Levocabastine (e.g. Livostin, Zyrtec)
  • Azelastine is also available in combination with INCS

5.3.4 Antihistamines Eye Drops

Work quite quickly, usually within 15 minutes. Can be used alongside other medications for symptoms of itchy and watery eyes. Examples include:

  • Ketotifen (e.g. Zaditen)
  • Levocabastine (e.g. Livostin, Zyrtec)
  • Azelastine (e.g. Eyezep)
  • Other prescription options also available.

5.4 Decongestants

Rarely used on their own for hay fever, and have limited benefit when used with other medications. Benefit is mostly restricted to relieving nasal blockage when nasal sprays are used.

5.4.1 Oral Decongestants

Offer only a slight benefit in improving nasal blockage, compared to their potential side effects. They do not feature in any hay fever treatment guidelines.

5.4.2 Nasal Sprays

Very effective for relieving nasal blockage, but are not recommended to be used for more than 3-5 days in a row. If prolonged use is required, take a break every 3-5 days to avoid rebound congestion.

  • Oxymetazoline (e.g. Demazin, Dimetapp, Vicks, Drixine, Logicin)
  • Phenylephrine (e.g. Nyal)
  • Tramazoline (e.g. Spray-Tish)
  • Xylometazoline (e.g. Otrivin, Flo)

5.4.3 Decongestant Eye Drops

Not recommended for the following reasons:

  • their benefit is doubtful
  • rebound hyperaemia leads to overuse
  • although advertised as being useful for relieving eye redness due to minor irritants such as dust, smoke and contact lens wear, a cool compress is as beneficial and is safer; ocular lubricants may also relieve irritation due to dry eyes
Do not use these drops regularly for more than 5 days as using them for too long can cause symptoms similar to red eyes.
Seek medical attention if symptoms do not improve within 48 hours. 🚩🚩🚩

5.5 Ipratropium

May be an option when a runny nose is the dominant problem. Examples include:

  • Ipratropium (e.g. Atrovent, Atrovent Forte)

5.6 Cromoglycates

Only available in eye drops. They are not as effective as other options and take longer to work.

  • Sodium cromoglycate (e.g. Cromo Fresh)

5.7 Montelukast

May be beneficial for patients who suffer from both hay fever and asthma. However, it is less effective than intranasal corticosteroids and requires a doctor’s prescription.

5.8 Immunotherapy

Link1
If medications don't relieve your hay fever symptoms or cause too many side effects, your doctor may recommend allergy shots (immunotherapy or desensitisation therapy). Usually started by an allergy specialist.2

6. References

  1. australasian society of clinical immunology and allergy
  2. australasian society of clinical immunology and allergy
  3. Australian Medical Handbook, July 2020
  4. Mayo Clinic
  5. Asthma Australia