Extremely high tree pollen counts have been reported in Pretoria during October. These levels are potentially extremely dangerous for pollen allergy sufferers, especially asthmatics. Outdoor activities should be avoided.1
High counts were reported in Cape Town and Johannesburg. The report cautions that >90% of pollen allergy sufferers will experience symptoms. Very allergic patients and asthmatics should limit outdoor activities and keep indoor areas free from wind exposure.1
What are the tell-tale signs of pollen allergy?
AR is defined as an immunoglobulin E (IgE)-mediated inflammatory nasal condition resulting from allergen introduction in a sensitised individual. The immune response leading to IgE production in AR is often a systemic phenomenon, and patients with AR demonstrate evidence of systemic atopy. One manifestation of systemic atopy in AR is the cutaneous reaction elicited during traditional allergy skin testing.3
The symptoms of AR consist of sneezing, nasal congestion, rhinorrhoea, nasal itching, and airflow obstruction. AR can result in significant disturbances in quality of life (QoL), sleep, exercise tolerance, productivity, and social functioning.2,3
Between 35% to 50% of adult patients report that nasal allergies have at least a moderate effect on their daily life and up to 45% of children experience sleep disruption because of nasal allergy symptoms.4
The total direct medical costs (eg doctors’ visits, medication) of rhinitis are extremely high, therefore effective management and treatment are essential. AR is also a significant cause of lost work and school days and decreased work productivity/presenteeism (work interference) and school performance.4
Up to 10% of workers reported absenteeism because of their nasal allergies, and up to 25% reported presenteeism, with an estimated 23% to 33% decrease in productivity on days when allergies were at their worst compared with days when the respondent experienced no symptoms.4
Classification of AR
Apart from seasonal, AR is classified as perennial (year-long), mixed rhinitis (when both allergic and non-allergic components contribute to symptoms) intermittent and persistent. Intermittent AR symptoms must be present for: <4 days/week and ≤4 consecutive weeks/year). Persistent AR is defined as: ≥4 days/week and ≥4 consecutive weeks/year).4
Treatment is guided by symptoms severity. Mild rhinitis severity is present when symptoms are not interfering with QoL such as impairment of daily activities, work or school performance, leisure activities, and sleep. Moderate/severe rhinitis is present when symptoms are troublesome or there is negative impact on any of these QoL parameters.4
What is the optimal management and treatment approach to AR?
Effective management starts with allergen avoidance (eg pets) and environmental controls(eg use of acaricides in household cleaners to reduce house dust mite concentration). Patient education is an essential component.3
The choice of treatment depends on the severity of the disease. Generally, second-generation antihistamines (AH) are recommended as first-line treatment for mild AR.3
The current ARIA guidelines recommend the following treatment:5,6
Step 1: Nonsedating AH (oral, intranasal, ocular), leukotriene receptor antagonists, or cromones (intranasal, ocular) for mild symptoms
Step 2: Intranasal corticosteroid (INCS) for moderate to severe symptoms and/or persistent AR
Step 3: INCS plus intranasal azelastine for patients with uncontrolled symptoms at step 2 (current or historical). Combination of INCS and intranasal AH (INAH) - depending on the physician’s experience, other therapeutic strategies could be used. Free combination of INAH)/oral AH plus INCS. Fixed combination of INCS plus INAH
Step 4: Oral CS as a short course and an add-on treatment
Step 5: Consider referral to a specialist and allergen immunotherapy.
The 2020 American Academy of Allergy, Asthma & Immunology for patients older than 12-years recommends combination INCS and an INAH for the initial treatment of moderate/severe nasal symptoms of SAR in patients age ≥12 years who are resistant to pharmacologic monotherapy.4
Conclusions
One of the main fallacies about AR is that it is a ‘nuisance’ disease. Over 30% of AR patients suffer debilitating allergic symptoms that can lead to severe disability and life-threatening conditions such as anaphylaxis. In severe cases, intense bronchospasm, laryngeal oedema, cyanosis, hypotension, and shock may occur.7
AR is a growing global healthcare concern. It is projected that the prevalence of the disease will continue to increase as more people migrate to cities, where they are exposed to pollutants and other environmental hazards. Climate change has also been implicated in the increasing prevalence of AR. AR should be treated as a chronic disease.7,8
