After a long, hard winter many people look forward to the arrival of spring, but for those who suffer from hayfever it means pollen is just around the corner – along with their own particular symptoms...

Introduction

For some hayfever sufferers the symptoms of sneezing, a runny or blocked nose and itchy red eyes are just a minor inconvenience. For many, however, the condition can lead to complications such as blocked sinuses, headaches, asthma flare-ups and insomnia — all of which can affect significantly a person’s quality of life.

For such a common allergy there is still much confusion among sufferers about the causes and treatments available for hayfever — so how can you best help customers deal with its debilitating effects? The following case studies, based on everyday scenarios encountered in pharmacy, provide some helpful guidance and explore some of the management approaches you can take:

1. Case study: pregnant woman

Meghan Walker, a woman in her mid-30s, asks for some advice. She tells you that she has hayfever with a blocked nose and her eyes are itchy and streaming. She is not sleeping well and is struggling to do her work as a librarian. Meghan is five-and-a-half months pregnant.

Meghan has had mild hayfever most summers since she was 15 years of age but it does not normally impact hugely on her quality of life. The hayfever is usually controlled by taking chlorphenamine tablets whenever her symptoms become more troublesome (as she finds they make her a little drowsy) but Meghan tells you the tablets are not working as well as usual. On questioning further you discover she suffered from eczema as a child and is concerned about the risk of allergy in her infant.

Pregnancy with its associated hormonal changes can make the symptoms of hayfever worse – although some women’s symptoms may improve or remain unchanged. Pregnancy can induce inflammation and swelling of the nasal mucosa, which can lead to ‘pregnancy rhinitis’ or nasal congestion and a runny nose. Although the cause of pregnancy rhinitis is related to hormonal changes rather than allergens, this condition may make seasonal allergic rhinitis worse.  

With regards to chlorphenamine, most manufacturers advise avoiding antihistamines during pregnancy although the BNF states there is no evidence of teratogenicity. Only a small number of women have been studied taking chlorphenamine during pregnancy and, as with all medicines, it is not possible to state with certainty that antihistamines do no harm in pregnancy. 

Although Meghan’s worsening symptoms are likely to be linked to her pregnancy, there is plenty she can do to try an avoid the allergen, such as closing windows in the evening as this is when the pollen count is at its highest, closing car windows when driving to work, and if possible, keeping
windows closed at work. 

The National Childbirth Trust (NCT) has put together some useful information for easing symptoms of hayfever during pregnancy that include the following:

• Stay indoors where possible, with windows and doors shut
• Try and avoid parks/fields/grassy spaces
• Wear wrap-around sunglasses when outside
• Keep an eye on the pollen count via the Met Office website to avoid going out when the pollen count is at its highest
• Know what you are allergic to (the grass pollen count is highest April-July; weed pollen count is highest June-September)
• Avoid mowing the grass in the garden
• Wash hands and face regularly
• Put petroleum jelly around nostrils to trap pollen before it enters the nasal passage
• Try to avoid hanging laundry outside. This stops pollen being caught up in clothes/towels/bed sheets  
• Wash and brush pets’ hair as often as possible
• Avoid contact with other irritants such as smoke, dust and sprays. 

Medication?

If Meghan wants to medicate her hayfever, she should consult her GP. Loratadine and cetirizine are the medications most often prescribed for hayfever during pregnancy, even though they are not licensed for OTC use in this way. 

Other options include intranasal corticosteroids but these should not be recommended OTC during pregnancy. If her GP considers there is a real need, Meghan could be advised to try sodium cromoglicate nasal drops or spray, and for eye symptoms to consider antihistamine or sodium cromoglicate eye drops. 

Ideally, sodium cromoglicate nasal preparations should be started one week before the hayfever season is likely to begin and then used continuously. There seem to be no significant side-effects although nasal irritation may occasionally occur. Cromoglicate eye drops are usually highly effective for the treatment of eye symptoms and generally work within the hour. 

If prescribed, Meghan should use the eye drops four times daily and continuously to obtain full benefit. Check when dispensing whether she wears contact lenses as the eye drops contain the preservative benzalkonium chloride, which can be deposited in soft contact lenses.

Oral and topical decongestants are not advised during pregnancy as they cause vasoconstriction and could theoretically compromise blood supply to the placenta. Manufacturers advise avoiding the use of intranasal ephedrine and xylometazoline during pregnancy.

With regards to allergy in the offspring, there is no way to predict whether this will occur or not. About half of babies born to a mother with a history of allergies develop an allergic condition (hayfever, eczema or asthma). To reduce the risk of allergy in her child, Meghan should be encouraged to avoid smoking and smoke exposure as this is associated with a higher incidence of allergy in the child and worse symptoms if an allergy occurs.

Advise Meghan to eat a healthy diet with plenty of fruit and vegetables. Remind her to follow the Government advice to limit oily fish intake to two portions a week. Restricting the diet during pregnancy has not been proven to be effective in allergy prevention. For example, there is little evidence that avoiding milk, eggs or other potential allergens reduces the risk of eczema or asthma in infants and may negatively impact upon the mother’s and/or the baby’s nutrition. 

Current Government advice states that if mothers would like to eat peanuts or foods containing peanuts during pregnancy or breastfeeding, they can choose to do so as part of a healthy balanced diet unless they are allergic to peanuts. In fact, there is some evidence to suggest that exposure to common allergens while in the womb or through breastmilk may reduce the risk of a child developing an allergy.

Vitamin D, omega-3 polyunsaturated fatty acids (PUFAs) and folic acid have important roles in the development of the growing foetus – so it is important to include them in recommended intakes but further evidence is required to clarify whether increased intake of these nutrients during pregnancy helps to reduce the risk of the baby developing an allergy. 

There has also been a suggestion that consuming probiotics during pregnancy may reduce the risk of the baby developing a food allergy but the evidence to support this is of low quality. Most guidelines make no specific recommendations about their use in pregnant women.

2. Case study: student teenager

Laal Patel is a 17-year-old girl with a tickly cough in the throat that is keeping her awake at night and causing drowsiness during the day. Her nose is constantly running and she is  sneezing during the day and then her nose is blocked at night, making her sleep disturbance worse. She is not wheezing and has no shortness of breath. 

Laal is preparing for some A-level assessments and says she is finding it hard to stay awake. Her eyes are mildly red, itchy and discharging clear tears. On questioning, you discover there is a strong family history of atopy (both parents have asthma; her mother had eczema as a child) but Laal herself has no history of asthma, eczema or hayfever. This is the first time she has had these symptoms, she tells you. 

Laal’s symptoms suggest hayfever. Seasonal asthma is also a possibility as the cough is persistent, although Laal is not wheezing or experiencing shortness of breath. A consultation with her GP would be wise but Laal’s hayfever symptoms could be treated by the pharmacy team pending her visit to the doctor. 

It is important to control Laal’s symptoms as they are having a significant impact on her ability to work and she is worried about her assessments. 

Laal may also benefit from some lifestyle measures. These include washing her hair before going to bed to remove pollens, drying laundry away from areas where pollen can build up, using petroleum jelly or balms to prevent pollens entering the nasal airways, wearing allergy masks, using air conditioning in the car, and not allowing any pets into her bedroom at night.

OTC treatment could also be helpful. Laal’s night-time nasal congestion bothers her the most and this would suggest the benefit of a corticosteroid nasal spray. However, Laal is 17 years old and these medications are only licensed for OTC use in those 18 years and over. 

An oral or topical antihistamine could be recommended but these tend to be more effective for itchy or runny nose and less effective for nasal congestion. Antihistamines such as diphenhydramine and chlorphenamine are sedating and would not be appropriate in this case as Laal is trying to prepare for assessments and is already drowsy during the day. 

It is important to be aware, however, that not everyone is affected in this way or they may benefit from getting a good night’s sleep if they take the antihistamine in the evening – but it is best not to try a sedating antihistamine during the A-level study/assessment period. Loratadine and cetirizine are theoretically non-sedating, but the effect also varies from patient to patient. 

3. Case study: truck driver

Tadeusz Kozlowski is a 42-year-old long distance truck driver who suffers from a severe allergy to birch pollen. It is April and Tadeusz is worried about a two-week trip to and round the Baltic states where birch is ubiquitous.

Based on past experience, Tadeusz expects that his eyes will become extremely itchy, red and watery. He wears contact lenses. Currently he also has a blocked nose for which he uses oxymetazoline nasal spray and pseudoephedrine tablets. Tadeusz doesn’t want to take antihistamines as he is afraid of falling asleep while driving. He has also developed a mildly sore mouth. Tadeusz is overweight and is trying to eat more fruit and nuts rather than chocolate for snacks.

Tadeusz is probably right that his symptoms are due to birch pollen allergy as this tends to peak between April and May. The fact that he has nasal congestion suggests that the oxymetazoline and pseudoephedrine (both decongestants) are contributing to the problem due to a rebound effect. Suggest that he stops both and recommend a once-a-day non-sedating antihistamine, such as cetirizine or loratadine.

Advise him to try it for a week or so to see if he feels drowsy because people can react to these drugs in different ways.

To ease the expected redness, irritation and watering of his eyes, Tadeusz can try eye drops containing an antihistamine (e.g. azelastine) or sodium cromoglicate – the latter tends to be effective in most people. Both are relatively well tolerated but Tadeusz may find azelastine more convenient when away on a trip as it only needs to be administered twice daily (compared to four times daily for sodium cromoglicate). 

Another OTC eye drop contains a combination of the antihistamine antazoline with the vasoconstrictor xylometazoline, which acts to narrow tiny blood vessels in the surface of the eye and stop allergens being transported to the site of irritation. 

Combination anti-allergy eye drops are not suitable for customers with narrow angle glaucoma or patients on monoamine oxidase inhibitors (or within 14 days of stopping such treatment). Reassure Tadeusz that ocular hayfever symptoms do not affect vision.

Tadeusz should be advised to stop wearing his contact lenses while using eye drops (the presence of benzalkonium chloride preservative, which deposits on the lenses, can cause allergy in its own right) and until his symptoms subside. 

Additionally, contact lenses can be uncomfortable when eye symptoms occur. However, if Tadeusz is unwilling to stop wearing his contact lenses, a nasal corticosteroid may be an option as intranasal corticosteroids are effective in reducing ocular as well as nasal symptoms. The mechanism of action is unclear but it may be due in part to a systemic effect resulting from local absorption, although systemically related adverse effects are uncommon.  

Symptoms of mouth soreness alongside pollen allergy could indicate that Tadeusz may be suffering from a food-related allergy. Birch pollen allergy can trigger several symptoms including the lesser-known oral allergy syndrome (OAS). 

With OAS the mouth may tingle or itch after eating certain raw fruits or nuts. This is known as cross reactivity in which the immune system is confused and cannot tell the difference between the pollen and certain proteins in foods. Foods that cross react to birch pollen include almonds, apples, apricots, carrots, celery, cherry, hazelnut, kiwi, parsley, peanut, peach, pear, plum and soya bean. 

Some people allergic to birch pollen can tolerate these foods but if Tadeusz suspects allergy to nuts this could become serious. Depending on the severity of the OAS, Tadeusz should be referred to his GP for allergy testing.

General lifestyle recommendations for Tadeusz also include:

• Avoiding rubbing his eyes as this can exacerbate the inflammatory effect
• Bathing his eyes either with a flannel soaked in cold water or by using an OTC eye bath
• Minimising contact with the causative pollen by wearing wraparound sunglasses while driving, keeping the windows of his lorry shut and using internal air circulation. In most modern vehicles, this will include an inbuilt pollen filter.