 nasal antihistamine, include local irritation and taste disturbance.
Topical corticosteroids
Topical corticosteroids include fluticasone propionate, mometasone furoate, budesonide, and beclomethasone diproprionate. Systemically bioavailable absorption is very low with mometasone and fluticasone, and modest for the others but systemic absorption is high for betamethasone and dexamethasone. Although these agents have a fast onset of action (within 6–8 hours), maximal improvement in symptoms may not occur for at least 2 weeks.
Topical corticosteroids may be used as follows:1
- if symptoms are moderate or severe, or antihistamines (oral or topical) provide inadequate relief then topical nasal steroids are recommended
- intranasal corticosteroids are beneficial for sneezing, rhinorrhoea, and nasal obstruction (with some activity against allergic conjunctivitis).
Hypothalamic-pituitary axis suppression may occur with long-term use of topical corticosteroids and the guideline advises monitoring of growth in children. More common side effects include nasal irritation, sore throat, and epistaxis. Some of these side effects can be reduced by judicious use of the spray, aiming the nozzle towards the lateral wall of the nostril when placed just inside the nose.
Combination therapy
If symptoms of rhinitis persist despite the use of antihistamines or topical intranasal corticosteroids, and maximal doses have been used with good nasal spray technique and compliance, combined treatment with both agents is recommended (see Figure 1).
Other treatment options
Other treatment options that can be used are:1
- for nasal blockage, the short-term use (i.e. <10 days) of an intranasal decongestant (e.g. ephedrine, xylometazoline, or oxymetazoline) may be beneficial, although it should be borne in mind that regular use leads to tachyphylaxis and chronic nasal obstruction—oral decongestants are not recommended1
- in patients with co-morbid asthma, oral anti-leukotrienes (montelukast and zafirlukast) have been used, although more evidence of benefit for rhinitis is required when these agents are used alone or in combination with antihistamines
- topical anticholinergic preparations such as ipratropium bromide may be beneficial in reducing rhinorrhoea, particularly in the treatment of autonomic (previously called vasomotor) or allergic rhinitis
- sodium cromoglicate has some effect on nasal obstruction
- systemic corticosteroids should be used rarely but have a role in severe nasal obstruction as short-term rescue of symptoms, particularly for important life events. The guideline recommends a dose of 0.5 mg/kg orally for 5–10 days in combination with a topical nasal corticosteroid taken in the morning with food.
Treatment in pregnancy
Pregnancy-associated rhinitis is a self-limiting condition and treatment should only be initiated if the benefit of treatment outweighs the risk to the foetus. Saline nasal douching may be beneficial, although the potential sodium load requires blood pressure monitoring. Intranasal corticosteroids such as beclometasone, fluticasone, and budesonide have been used by pregnant women, as have antihistamines such as chlorphenamine, loratidine and cetirizine. The guideline advises against the use of decongestants in pregnancy because of the potential for teratogenic effects, for example with pseudoephedrine.
Treatment in children
Therapy for children includes the use of long-acting antihistamines and nasal corticosteroids. Growth monitoring may be required if the child remains on long-term treatment with nasal corticosteroids and in these circumstances the child should be switched to a preparation with the lowest systemic bioavailability and at the lowest possible dose.
Treatment failure should prompt a check for compliance and, if necessary, referral to either an allergy clinic or ENT department as discussed above.
Education and prevention
The BSACI guideline emphasises the importance of allergy education, particularly with regard to the (negative) effect rhinitis may have on quality of life. The patient should be provided with information about the potential complications of rhinitis. A review of drug therapy should be carried out to assess efficacy of and compliance with treatment, and this should also include an assessment of technique in the use of nasal therapy.
The guideline also makes recommendations on allergen avoidance, both within the home and at work. For example, there is lack of evidence to recommend the use of mite-proof bed covers as a single intervention in sensitised patients. However the guideline recommends that multiple measures to reduce house dust mite exposure, including the use of mite-proof bed covers, hot washing bed linen, removing soft toys, and so on, are most likely to be successful. In individuals who have sensitivity to domestic pets such as cats, measures to reduce allergen exposure include shampooing carpets, washing the cat on a weekly basis and replacing carpets with hardwood floors.
A number of pollen avoidance measures such as using nasal filters, wearing wraparound glasses, and minimising early morning outdoor activity when the greatest pollen is emitted, are sensible although not always practical. Occupational rhinitis is considered a risk factor for occupational asthma and usually predates the onset of asthma. Of particular relevance to the workplace is primary prevention, particularly through the use of non-powdered or non-latex gloves, and avoidance of other occupational allergens known to cause allergic sensitisation.9
Co-morbidities
Over 80% of patients with asthma may have co-existing rhinitis, and rhinitis is also a risk factor for development of asthma.9 Asthma tends to be more severe in patients with perennial rhinitis, and bronchial hyperreactivity can be reduced by using nasal corticosteroids. Patients with asthma whose rhinitis is well treated have been shown to have fewer emergency visits to hospital.10
Implications for primary care
The BSACI guideline emphasises the importance of skin prick testing to differentiate between allergic and non-allergic rhinitis. With training and education it is possible for primary care to offer skin prick testing to aeroallergens in the community. The importance of close collaboration between primary care and allergy specialists is important, particularly in the interpretation of skin prick testing.
Local referral pathways are important in dealing with patients where treatment has not worked or where co-morbidities complicate management.
In a study of a general practice population of patients with moderate-to-severe rhinitis, more than 80% of patients reported impaired activities, as opposed to only 40% with mild rhinitis.11 A randomised controlled trial to evaluate the effectiveness of standardised allergy training for healthcare professionals in patients suffering from perennial rhinitis showed modest improvements in disease-specific quality of life.12
Summary
Rhinitis can be subdivided into allergic, non-allergic, or infective subtypes and recognition of the subtype can be particularly important in patients whose rhinitis has proved refractory to standard therapy. Rhinitis often remains unrecognised, particularly when symptoms accompany co-morbid conditions such as asthma or sinusitis.
Primary care has an important role in the identification and management of this condition, and practice-based commissioning may allow development of speedy referral pathways, particularly to allergy and ENT services, for the management of rhinitis.
- Rhinitis is a common condition affecting up to 20% of the UK population
- Skin prick testing is necessary to make an accurate diagnosis
- The House of Lords Science and Technology Committee 2007 report on allergy recommends the establishment of at least one specialist allergy centre per SHAa
- Tariff pricesb (2008/09 outpatient indicative tariff):
- Allergy clinic = £178 (new), £94 (follow up)—includes skin prick testing where required
- ENT = £121 (new), £63 (follow up) for adults and £130 (new), £72 for children
- Scadding G, Durham, S, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38 (1): 19–42.
-.
- Kaiser H. Risk factors in allergy/asthma. Allergy Asthma Proc 2004; 25 (1): 7–10.
- Standards of Care Committee, The British Society for Allergy and Clinical Immunology. Rhinitis management guidelines. In: Foord-Kelcey G, editor. Guidelines – summarising clinical guidelines for primary care. 34th ed. Berkhamsted: MGP Ltd; February 2008, pp 371–376.
-.
- Corren J, Manning B, Thompson S et al. Rhinitis therapy and the prevention of hospital care for asthma: a case-control study. J Allergy Clin Immunol 2004; 113 (3): 415–419.
- Bousquet J, Neukirch F, Bousquet P et al. Severity and impairment of allergic rhinitis in patients consulting in primary care. J Allergy Clin Immunol 2006; 117 (1): 158–162.
- Sheikh A, Khan-Wasti S, Price D. Standardized training for healthcare professionals and its impact on patients with perennial rhinitis: a multi-centre randomized controlled trial. Clin Exp Allergy 2007; 37 (1): 90–99.GThe way its currently set up (in my market) is it just uses total time online.  The other requirements still stand (min. trips/hr, 90% accept).

So to use my market rates as an example, Friday night 9pm-3am I'm guaranteed $20 gross fares ($16 net) per hour, if I meet/exceed 2 trips/hour average

If I'm online 9-11:30 (2.5 hours) I have to 1. accept 90