Hayfever Tips

Noelle Madden - Pharmacist, April 2021.

It’s that time of year again…the sun is shining, the sunglasses are back in use ...the misery begins for hay fever sufferers and that’s approximately 1 in 5 people in Ireland! In this blog I am hoping to make the 2021 Hayfever season a better one for our followers! I have undertaken a complete review of the topic and I have learnt some amazing tips which I am excited to share with you here!

• Ideally start your hay fever treatment 2 weeks before the pollen count starts to rise, this gives the treatment a head start compared to waiting until your nose is already stuffy and running but if that ship has sailed, don’t worry all is not lost, better late than never!
• The gold standard treatment for Hay fever or allergic rhinitis is a corticosteroid nasal spray, these steroid nasal sprays work wonderfully by exerting a potent anti-inflammatory effect locally in the nose when they are used correctly, a respiratory consultant once described them in a lecture as “the steroid cream for the skin in your nose”. So, let’s review the best way to use your corticosteroid nasal spray:

1. Steroid nasal sprays only work if they are used regularly so make it a habit e.g. tag it on to brushing your teeth every night. Once the steroid nasal spray is being used correctly once a day at night is often enough for many people, just bear in mind that steroid nasal sprays take about a week to kick in fully so persevere!
2. Shake the nasal spray & prime it as per the leaflet in the pack if it’s your first time using it or if you haven’t used the nasal spray in a while.
3. Blow your nose. If your nose is snotty the steroid nasal spray will just dissolve in the snot and won’t reach the lining of your nose where it needs to work. Some people find it helpful to use a nasal rinse e.g. Neilmed Sinus Rinse half an hour before their steroid nasal spray.
4. Tilt your head slightly forward and place the nozzle of the nasal spray just inside your nose pointing away from the septum. So, using your right hand for your left nostril put the nozzle just inside the nose and aim towards the outside wall of the nose and vice versa for the other nostril. If you spray the nasal spray onto the septum (centre of your nose), the carrier dries out the skin there and it may crack and bleed.
5. Spray the nasal spray into the nose but DON’T SNIFF!! If you sniff you will eat your snot and you’re spray! You want to deposit the medication at the start of your nose and the little hairs in your nose (the cilia) will move it over the next few hours to cover the entire nasal mucosa where it needs to exert it’s anti-inflammatory effect to reduce your hay fever or rhinitis symptoms.
6. Clean the tip of the nasal spray and cover it.

Tips when choosing a steroid nasal spray:
BSACI, The British Society of Allergy and Clinical Immunology suggests using a steroid nasal spray with lower bioavailability if possible to control your hay fever/allergic rhinitis symptoms to reduce the amount of steroid absorbed into your system, it only needs to work locally in the nose to treat your hay fever/allergic rhinitis symptoms. The graphic below shows the comparative bioavailability of the various nasal corticosteroids that are available. Fluticasone and momethasone, both of which are available as nasal sprays OTC have a bioavailability of just 0.5% which means the level of systemic absorption is very low and so they are safe for long term use as will be needed for control of hayfever/allergic rhinitis symptoms. Topical nasal drops containing corticosteroid e.g. Betnesol, are occasionally used short term for very problematic nasal symptoms but there is much greater systemic absorption compared to corticosteroid nasal sprays, see graphic below.

BSACI guideline for the diagnosis and management of allergic and non‐allergic rhinitis (Revised Edition 2017; First edition 2007)

• A key message is that when properly used steroid nasal sprays really help with the itch, sneezing, blocked and runny nose as well as the itchy watery red eyes caused by hay fever/allergic rhinitis.
• Long acting steroid injections e.g. kenalog, are used less frequently nowadays due to the risk of serious side effects e.g. osteoporosis, diabetes, hypertension.
• Oral antihistamines can be added in when needed as they generally exert
  
  their effect within one hour so if you are having a bad hay fever/rhinitis day, the addition of a morning antihistamine to your night time corticosteroid nasal spray routine may work well. It is great to see that another antihistamine that was previously only available on prescription is now available OTC without a prescription from your pharmacist i.e. fexofenadine (Telfast). This is in addition to loratadine, cetirizine and chlorpheniramine which have all been available OTC for some time.
• If your eyes are problematic despite using a steroid nasal spray at the
  
  correct dose for your age consistently and adding in an oral antihistamine there are some topical eye products worth a try. Antihistamine eye drops
  work well but they are short acting so they will need to be used multiple times throughout the day e.g. Otrivine-antistin eye drops. Hylo-Dual eye drops work very well for some people, they contain sodium hyaluronate which moisturizes the eye and ectoin which stabilizes the tear film and reduces the entry of allergens into
  
  the tear film. Another product for the eyes, Optase contains just ectoin. Hylo-Dual and Optase are preservative free and suitable for use in pregnancy. Sodium chromoglycate eye drops e.g. Opticrom act as a mast cell stabiliser in the eye and are useful for some patients with problematic eye symptoms of hay fever.
• Topical antihistamines in a nasal spray e.g. Azelastine can also be useful for some patients. Rhinolast contains azelastine alone and Dymista contains fluticasone, steroid as well as azelastine. Topical nasal antihistamines seem helpful for sneezing, itching, runny and blocked nose symptoms of hay fever/allergic rhinitis. Both of these nasal sprays are only available on prescription.
• Topical decongestant nasal sprays e.g. Otrivine nasal spray help to reduce nasal blockage and so aid penetration of the nasal steroid sprays. If you are commencing treatment with a steroid nasal spray after your symptoms have already begun it may help to use a decongestant nasal spray in the morning to give immediate symptom relief and your steroid nasal spray at night to which will take about a week to kick in fully. Decongestant nasal sprays give relief within 15 minutes, but they cannot be used for more than 7 days continuously or they will block the receptors in the nose and cause rebound nasal congestion which is very difficult to treat.
  
• Oral decongestants don’t cause rebound congestion, but they can cause sleep disturbance and they are not suitable for all patients e.g. Those with hypertension, diabetes and overactive thyroid.
• Leukotriene receptor antagonists e.g. montelucast are not first line treatment but they may be of benefit in some patients who also suffer with asthma.
• Immunotherapy is a newer treatment option for severely symptomatic hay fever sufferers for whom conventional treatments have not worked. They work by exposing the patient’s immune system to controlled doses of the allergen which over time causes the person’s immune system to become less reactive to the allergen e.g. Oralair and Grazex, both of these agents must be started a number of months before the pollen season begins and they require careful monitoring of the patient after initial administration.
• Hayband- this product is based on acupressure and is useful for some patients. However, it is NOT SUITABLE for use during PREGNANCY.
• Sinus Rinses such as Neilmed Sinus Rinse can be useful to clear any pollen and mucous lodged in the nose and can be very helpful when used alone or half an hour before a steroid nasal spray as explained earlier in this blog. It is a drug free solution but it is very important to use boiled cooled water and not tap water when mixing the sachets as you don’t to squirt any bugs that might be in your tap water up your nose into the nasal passages.
• There are also saline nasal sprays e.g. Sterimar nasal sprays which are also drug free and can be useful for children and pregnant and breast feeding ladies to clear the nasal passages of allergen and moisturize the nasal passages.
  
• 
  Barrier type sprays e.g. Becodefence provide a drug free solution and work by coating the mucosa of the nose and stopping allergens attacking it, they become entrapped in the microgel barrier instead. This product also diffuses any pollen that gets into the nose and helps the nose to clear allergens away. Becodefence is suitable for athletes, pregnant and breast feeding women.

1. Dry clothes indoors to avoid pollen lodging in them.
2. Shower after extended periods outdoors to remove pollen from hair and skin.
3. Avoid being outdoors mid-morning and late afternoon when the pollen count tends to be at it’s highest. Keep windows and doors closed when the pollen count is high.
4. Vaccume regularly with a HEPA filter and damp dust to remove pollen and spores from surfaces.
5. Keep furry pets outside during the pollen season to avoid transfer of pollen from their fur.
6. When outdoors, wear wrap around sunglasses to help reduce the amount of pollen entering the eyes and smear Vaseline around the nostrils to help prevent pollen entering the nose.
7. Keep car windows closed and if you need to be near a field of silage being cut or someone mowing a lawn, wear a face mask to reduce the pollen exposure.
8. Commence prophylactic oral antihistamines and corticosteroid nasal spray 4 weeks before the pollen count starts to rise. Many allergy consultants recommend starting hay fever/allergic rhinitis treatment on Easter Sunday each year.
9. For students sitting exams, it is important that contact is made with the school/college to ensure that the student is not put sitting beside an open window during the exams.
10. Asthma sufferers who also suffer from hay fever/allergic rhinitis often find that controlling their hay fever/allergic rhinitis leads to much better control of their asthma, it’s one airway the mucosa of the nose and the lungs are linked closely.

I hope that you found this blog useful and informative and I hope that the tips included will help you to have a better hay fever season in 2021. If you have any questions or need any further advice do contact us in store.

You can follow a link to check the pollen count here on the Asthma.ie website.

Warm regards,
Noelle
Supervising Pharmacist