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Respiratory allergies

Learning objectives

After completing the module, you should be able to:

  • Consolidate your knowledge of the various types of respiratory allergy and their diagnoses
  • Identify the developments in the latest edition of the British Society Allergy Clinical Immunology rhinitis guidelines, and their impact on the management of respiratory allergies in primary care
  • Confidently take an allergy-focused clinical history, carry out risk assessments and provide advice on allergen avoidance for a variety of triggers
  • Know the treatment ladder for allergic rhinitis, including both pharmacological and non-pharmacological approaches
  • Recognise symptoms and causes of non-allergic rhinitis
  • Develop an understanding of the factors affecting patients’ compliance with their allergy medication and ways to promote adherence in your practice

Introduction

Approximately 30–40% of the world’s population is affected by one or more allergic conditions.[1] Allergy is a multi-organ disease that can be caused by dust mites, moulds, animal dander, foods, such as nuts or fruit, and pollen from grass, weeds or trees. Allergy symptoms – sneezing, rhinorrhoea, nasal obstruction, ocular pruritus, tearing and puffy eyes – can be intermittent or persistent, and mild or moderate to severe. Allergic rhinitis affects 10–15% of children and up to 26% of adults and is associated with illness, disability and comorbidities, most notably asthma.[2, 3] Nasal allergies can have a negative effect on patients’ quality of life, daily activities, school performance, work productivity and NHS costs.[4, 5]

While the impact of allergies on daily life is increasingly recognised, allergic rhinitis is currently under-diagnosed in clinical practice.[2] Increased awareness of signs and symptoms, differential diagnoses and allergy testing is needed to better recognise and adequately manage this condition.

Rhinitis is usually divided into allergic, non-allergic and infective forms.[3] Allergic rhinitis is diagnosed by careful history and examination, supported by specific allergy tests. Skin prick tests are generally done in allergy centres, although a number of pilot projects have shown these can be delivered in primary care. Specific IgE tests are accessible to primary care but have to be chosen and interpreted within the context of the patient’s history.

Recent years have seen considerable progress in the understanding of the link between upper and lower airways, from their anatomy to the pathophysiology of inflammation and the need for coordinated disease management. This has been reinforced by the British Society for Allergy and Clinical Immunology (BSACI) guidelines on rhinitis, which recommend assessing lung function and controlling asthma symptoms as an integral part of management for allergic rhinitis.[3]

It is late May and exam preparation time for high school students. Seventeen-year-old Ben comes to see the prescribing triage nurse. He had dropped out of the Friday afternoon football match due to worsening hay fever and asthma symptoms, which were usually well controlled. As well as wanting to be able to play football outside with his friends, Ben is keen to be fit for his A levels which are coming up in a few weeks’ time. He is worried that his hay fever symptoms are disrupting his sleep, which causes him to be drowsy during the daytime.

A case-control analysis conducted by the charity Education for Health examined 1,834 students aged 15 to 17 who were taking their GCSEs. Students’ performances in mock exams and final GCSE exams for the core subjects of mathematics, English and science were examined against their responses to questionnaires on hay fever symptoms.[6] Between 38% and 43% of teenagers reported hay fever symptoms on any one of the examination days. The group showing a drop in GCSE grades was significantly more likely than the control group to have had allergic rhinitis symptoms during the examination period, to have taken any allergic rhinitis medication or to have taken sedating antihistamines.[6] The survey found that 28% of teenagers taking medication were on a sedating antihistamine,[6] and the percentage of students in this group with an unexpected drop in their GCSE grades was 70%. These findings highlight the importance of appropriately assessing and controlling symptoms in teenagers presenting with hay fever and ensuring they are prescribed non-sedating medications, which are less likely to interfere with their school performance at such an important time.

Ben’s main hay fever symptom is nasal blockage, although his eyes and palate are mildly itchy and he occasionally has some sneezing and a runny nose. He has no nasal crusting and his rhinorrhoea is bilateral. He has been taking cetirizine, an over-the-counter (OTC) oral antihistamine, which he says helped somewhat but his symptoms have persisted. He walks to and from school, which means it’s not practical for him to avoid going outside when the pollen count is highest (typically early morning and early evening). [3]

The nurse suggests some barrier measures that might help reduce Ben’s pollen exposure, such as wearing sunglasses, trying a barrier ointment around his nose, and showering when he gets home. [3]She also decides adding an intranasal corticosteroid would help optimise Ben’s treatment. She prescribes a low-bioavailability (i.e. one with limited systemic effects) steroid nasal spray and provides training on how to use it correctly (Figure 1). She explains that it may take some time to work. He can continue with the OTC non-sedating cetirizine or consider another OTC long-acting antihistamine such as loratadine, or a prescription for fexofenadine as an alternative. She explains that most antihistamines have very few side effects but that individual susceptibility varies. In order to be able to deliver the steroid spray she advises him to try a decongestant spray for three days only to relieve some of his nasal congestion, which may make the intranasal steroid more effective.

A combination spray has recently been approved that contains azelastine (an intranasal antihistamine) and fluticasone propionate (a corticosteroid). It leads to greater symptom control than either component used as monotherapy. The BSACI guideline recommends combination intranasal therapy for patients whose symptoms remain uncontrolled on either antihistamine or corticosteroid monotherapy, or on a combination of intranasal corticosteroid and oral antihistamine. As Ben is already taking an oral antihistamine it is not unreasonable for the nurse to add an intranasal corticosteroid to the existing oral therapy, but if following the BSACI treatment algorithm (Figure 2), the combination intranasal spray could also be tried.

Figure 2: BSACI algorithm for the treatment of rhinitis. Source: BSACI Guidelines 2017[3]

 

 

Ben also mentions that he is invited to a friend’s 18th birthday party at the local curry house later that evening. On inspection of Ben’s medical records, the nurse notices that he has nut allergy recorded but has not had a review or a prescription for a self-injectable adrenaline pen over the past three years. When asked about it, Ben says he ‘forgot that it’s important’; he does not carry a pen and he ‘probably lost’ the one he had been given.

Patients with asthma, particularly those with poorly controlled symptoms, are at increased risk of a fatal severe allergic reaction. In these patients, anaphylaxis may sometimes be mistaken for an asthma exacerbation and inappropriately treated solely with asthma inhalers.[7] The nurse explains to Ben that it’s important to carry his adrenaline pen with him at all times and to know when and how to use it. Personalised allergy plans, for example using the template provided by the BSACI, can be useful (Figure 3).[8]

Aware that she has only about 10 minutes left of the appointment, the nurse makes a quick action plan. She will likely cover only three of the topics below:

Given Ben’s symptoms and medical history, the plan of action should focus on prescribing a new adrenaline autoinjector device and checking his knowledge or training him on the appropriate use of the device. Dietary advice such as avoiding nuts and being aware of them in all types of food should be a second priority. The nurse should also signpost the patient to the BSACI website for information,[9] the Anaphylaxis Campaign website[10] and other sources of information or patient support. Recommendations on management, risk assessment and education are provided in the EAACI Guidelines for Food Allergy and Anaphylaxis, which state that patients at risk of anaphylaxis should have access to self-injectable adrenaline for treating future severe reactions.[11] Facilitated access to allergy consultations, counselling by dietitians as  well as coordination among the healthcare professionals dealing with the various clinical manifestations of the disease should all be ideally put in place.[11]

Ben’s asthma control should be reviewed and be optimally controlled and the nurse can check asthma inhaler technique. Optimal control of his rhinitis will also help his asthma control.

If time permits, a comprehensive, allergy-focused clinical history should also be taken.

Two weeks later, Ben is booked for a follow-up appointment with his general practitioner (GP). He is fitter, having fewer problems with his breathing and is able to concentrate on his studies. However, he does not like the bitter taste of the spray so he has only been taking it intermittently. The GP explains that he needs to use the spray every day if it is to be effective. She is pleased to hear however that he has carried his adrenaline autoinjector with him everywhere since the last appointment, and has told his best friend about his allergy and what to do if Ben ever has a serious allergic reaction. This is especially important given that teenagers are a high-risk group for anaphylaxis, and so time in the consultation going over the need to carry adrenaline devices is time well spent.

Martin presents to his GP with hay fever symptoms of runny nose and itchy palate, which he had been experiencing for the past four years at roughly the same time of the year (February/March). He is a 28-year-old bodybuilder who follows a healthy diet, based on raw fruit and vegetables. Martin has noticed lately that his lips start swelling mildly when eating apples, cherries and plums, but he has no other symptoms. He does not experience these symptoms if he has either peeled or cooked the fruit.

Martin is worried about pesticides but his GP suspects pollen food syndrome (PFS), sometimes referred to as oral allergy syndrome (OAS).

PFS, also known as oral allergy syndrome (OAS), is the most common food allergy among adults.[13]Pollens from trees, grasses and weeds contain proteins of similar structure to those present in raw foods such as apples, kiwi, hazelnuts and almonds.[12, 13] The most common pollen involved in PFS in the UK is birch tree pollen, whose main allergen, Bet v1, is highly cross-reactive with many plant foods.[14] Some PFS sufferers are affected by only one or two foods, while others develop symptoms to a wide range of foods. In most cases, the allergens are easily inactivated by cooking, processing and digestion.[12]

Usually the diagnosis of PFS can be made on the basis of a history of symptoms with fruits or vegetables when they are raw but not when they are consumed after cooking in a patient with seasonal allergic rhinitis. Skin prick testing to the trigger fruit or vegetable can support the diagnosis. It should be carried out by a healthcare professional with the relevant training and competencies with the appropriate equipment and facilities. A positive result only confirms a PFS diagnosis when the patient also has symptoms to that raw food as pollen may cross-react with the fruit or vegetable.

What advice might Martin’s GP provide him about his PFS?

Martin’s GP offers him advice on how to manage his PFS while maintaining a healthy diet. Martin is advised to try canned or cooked fruit. If Martin had complained of symptoms with nuts an allergy referral would be advised as it can be difficult to differentiate true nut allergy from oral allergy; the allergy unit may carry out allergen component blood tests and oral supervised challenge on the hospital ward to look at this further.

Ten-year-old Abigail comes to the local practice with her mother. Abigail has a constantly runny nose and an intermittent cough that started to become bothersome around a month before. This is their second visit to the practice; her mother explains that, two weeks ago, Abigail had been diagnosed by another clinician with a viral upper respiratory tract infection. She has no spring time or summer hayfever symptoms. However, despite getting plenty of rest at home, as well as a course of paracetamol, Abigail’s symptoms did not go away. Abigail is the proud owner of Tigger, a three-month-old kitten. Abigail’s mother is not certain whether the kitten is causing Abigail’s symptoms – and if so, might they need to send Tigger away?

The doctor asks whether Abigail has any symptoms on coming into contact with the cat, for example stroking or being licked. Abigail does not get a rash, but does get an itchy and a runny nose after direct contact. The GP is aware that, after prolonged exposure, symptoms may be present all the time not just on contact.

On examination Abigail has an allergic crease in her nose and allergic shiners around her eyes. Knowing that all patients with persistent rhinitis should undergo spirometry according to current BSACI guidelines, the GP performs this test. Allergic rhinitis is a risk factor for the development of asthma, and a personal or family history of an atopic disorder such as eczema or allergic rhinitis may indicate the presence of asthma[15]. Fortunately, Abigail’s chest is clear and her spirometry results are normal.

To investigate further, the GP asks her practice nurse, who has had allergy training, to perform a skin prick test for dust, fungal spores and cat dander, and finds the results are positive only for the cat allergen. The results, together with Abigail’s history and symptoms, suggest these are being triggered by her pet. However, since it is possible this is a false positive, the doctor decides to focus for the time being on providing lifestyle advice to both Abigail and her parents, and recommends an antihistamine syrup. Additionally, the doctor enquires about the possibility of Abigail spending some time away from the house in an animal-free environment, and she is informed that Abigail is planning on spending four weeks with her aunt, who does not own any pets. This could provide further information about the cause of Abigail’s symptoms.

The BSACI guidelines consider that there is limited information from randomised studies on which to base recommendations for pet allergies. The updated rhinitis guidelines from 2017 state that HEPA air filters used alone do not seem to be helpful for cat allergies, although laminar airflow systems may be of some benefit. The other measures are not mentioned by the BSACI, but are recommended by the organisation Allergy UK.[16]

FOLLOW-UP

Abigail returns with her mother two months later. While Abigail’s cough has subsided somewhat since the weather has warmed up, her nose is still bothering her – although when she stayed with her aunt, her symptoms improved considerably. The doctor prescribes nasal steroid spray with a low systemic availability (Figure 4) for Abigail. If other forms of corticosteroid (such as inhaled corticosteroids for asthma, or topical forms for skin conditions) are already being taken by a patient, it is recommended to use a low-bioavailability form of steroid nasal spray to reduce the ‘steroid load’ experienced by the patient. The doctor therefore checks that Abigail is not using steroids by any other route, but ultimately decides to prescribe a low-bioavailability steroid spray anyway as these are considered more suitable for use in children.[3] She demonstrates how the spray should be used, and also discusses the practicalities of treatment with Abigail’s mother and checks neither child nor parent has any concerns. She advises Abigail and her mother that, if the allergy symptoms do not subside over the next three weeks or so, it is time they found a new home for Tigger.

Figure 4: Approach to therapy for paediatric allergic rhinitis[3]

Ear pain on pressure changes (e.g. while flying), reduced hearing and chronic otitis media are possible symptoms in pre-school or school-aged children. Poor asthma control or a cough that may be misdiagnosed as asthma, irritability, tiredness, poor school performance and frequent or prolonged respiratory infections may all indicate rhinitis in children of any age, including adolescents. Gastroesophageal reflux is not associated with allergic rhinitis, but may be a cause of non-allergic non-infectious rhinitis.

Emily is a 40-year-old maths teacher who has been followed by her local GP for five years for her asthma symptoms, which are well controlled. She now comes to the doctor complaining of itchy eyes and a runny nose, which have been bothering her constantly for the past year and are making it hard for her to teach classes or even rest properly. She also coughs after housework such as dusting or changing bed sheets, which she assumes is related to her asthma.

Her rhinitis is bilateral, nasal discharge not blood stained, and there is no nasal crusting. On examination her turbinates are swollen and no polyps are present. There are no pets at home, she has no symptoms with latex or aspirin, no contact with chemicals or plants/moulds, and no seasonal worsening of her symptoms. She is not taking any medications known to cause non-allergic rhinitis. She has tried both a non-sedating oral antihistamine and a steroid nasal spray bought over the counter with no relief. She has taken these regularly and says she has good understanding of how to use the nasal spray.

Figure 5: Triggers for non-allergic rhinitis[3]

 

The case for skin prick testing or blood tests in adult respiratory allergy patients is under debate but the doctor decides this is necessary in Emily’s case.[18] Total IgE alone can be misleading and is not considered worthwhile but may support the interpretation of allergen-specific IgE tests. The GP orders a specific IgE test for house dust mite allergy, (along with a full blood count and thyroid function tests which are normal). He provisionally diagnoses Emily with house dust mite allergy based on her history, and this is confirmed by a positive blood test. He prescribes a combination nasal antihistamine and steroid spray at the maximum dose, as recommended by treatment guidelines.[3] The practice nurse goes over again with Emily how to use nasal sprays correctly and gives her a leaflet to take home. The nurse also discusses some avoidance measures with Emily, such as using anti-allergenic bedding covers, delegating someone to damp-wipe all hard surfaces in her house once a week, and regularly vacuuming carpets and upholstered furniture with a high-filtration vacuum cleaner. She directs Emily to the Allergy UK website for more information on this.[19]

When she comes back to the practice two months later, Emily says she does not feel the spray is effective. Her symptoms are persistent and bothersome, and she does not like the taste of the medication. The doctor is aware that a large proportion of patients with allergic rhinitis are not satisfied with their nasal sprays for a variety of reasons, and as a result stop taking them altogether.

In a study evaluating the burden of allergic rhinitis in the landmark allergy surveys – Allergies in America (AIA), Asia-Pacific (AIAP), Latin America (AILA) and Middle East (AIME) –  incomplete symptom relief, slow onset of action and decreased efficacy with sustained use were all reported as contributing to a treatment change or discontinuation in the patients surveyed.[17] Bothersome effects such as a feeling of dryness, unpleasant taste, headaches and drowsiness, which were also reported by a majority of patients in the landmark surveys, are also an important consideration given their impact on treatment compliance.[20] In the UK, a survey of 124 patients with allergic rhinitis revealed that patients perceived their condition as significantly more severe than did physicians, and reported an impaired health-related quality of life due to their symptoms being uncontrolled despite medication.[21]

In Emily’s case, after ensuring she understands how to use her medication, the GP decides to add montelukast, a leukotriene receptor antagonist that works by blocking the effects of leukotriene molecules released during allergic reactions. Montelukast is licensed for the treatment of rhinitis in asthma patients

At her second follow-up two months later, Emily still comes with persistent symptoms and a general sense of fatigue and discouragement. The GP reviews her treatment options and advises Emily that she might benefit from a course of immunotherapy. He books an appointment with an allergy specialist and makes sure her asthma is well controlled. Emily asks about a possible intramuscular steroid injection but the GP explains that this treatment is not generally recommended. [3] The risk–benefit profile of intramuscular steroids is considered poor, due to the increased risk of complications such as avascular necrosis of the hips, osteoporosis and diabetes.[22,23]

Immunotherapy involves gradually desensitising the immune system to a specific allergen and is only suitable for people suffering from certain types of allergies. It is an effective treatment if the allergen is the specific driver of symptoms[3]. Available guidelines recommend immunotherapy as a second-line option in people with IgE-mediated disease who are suffering from persistent and severe symptoms and are unresponsive to treatments.[3]

Immunotherapy is the only treatment that can modify the natural course of allergic rhinitis and offers the possibility of long-term remission, but risks have to be weighed against benefits. Due to the risk of a systemic reaction, including anaphylaxis, following the procedure, subcutaneous immunotherapy can only be administered under the supervision of a fully trained physician, and patients should be monitored for 30–60 minutes afterwards. Immunotherapy is now available in both sublingual forms and subcutaneous forms. In some areas of the UK where protocols have been agreed, sublingual immunotherapy can be given at home as part of a shared-care agreement between primary care and the allergy department (once the patient has been initially assessed by an allergist and the first dose has been given under supervision in the allergy clinic). The allergy centre will then monitor the patient’s response at subsequent outpatient reviews.

Peter, a busy 40-year old estate agent, suffers from hayfever with itchy eyes, sneezing and bilateral rhinorrhoea every year, mainly from late May until July. His symptoms are worse outside of the house, not triggered by housework, do not occur at work or with aspirin, latex or paints, and are better if he goes abroad to the seaside in the summer months. He has no diagnosis of asthma. He has had hayfever since he was a young child, but it has worsened in the last few years. He used to get ear infections as a child.

He has not seen his GP for help as he can never get an appointment that fits around his long and often erratic working hours, so he self-medicates by buying antihistamines over the internet. He gets the cheapest tablets (chlorphenamine) but they only last a few hours and can make him drowsy particularly after drinking alcohol at the weekends. He hasn’t tried nasal sprays as he prefers the convenience of tablets. He did try some local honey as was told by a relative this was protective, and he has tried avoidance measures including putting Vaseline around his nose, washing his hair at night, not putting clothes to dry outside in the season and closing windows in the house.

On his lunch break one day he drops in to see the pharmacist as the shop is more accessible. The pharmacist has his own consulting room and a 30-minute slot free, so he asks some questions about Peter’s symptoms, triggers, seasonality, and treatments tried so far. The pharmacist says from the history that this sounds like allergic grass pollen rhinitis and can be treated symptomatically without further tests.

Many patients will require a combination of treatments to adequately control all their symptoms. Oral antihistamines are effective against a range of different symptoms, but intranasal medication is generally considered more effective for rhinitis symptoms such as sneezing or rhinorrhoea.

Table 1: Pharmacotherapy effects on individual rhinitis symptoms.[3]

The pharmacist explains the benefits of nasal sprays to Peter.[3] He also suggests that Peter considers eye drops if his ocular symptoms are not controlled on oral or intranasal medication alone, and shows Peter how to use these.

The pharmacist explains the different types of antihistamine and steroid sprays available including which ones are available on prescription, which can be bought without prescription, the known side effects of each and the types of sprays available. He advises it will be cheaper for Peter to buy an OTC antihistamine or steroid than to get a prescription-only medication, and this also avoids the need for a GP appointment. He also shows Peter the equipment the pharmacy sells for saline nasal irrigation, as this is generally well-tolerated and has a small effect on reducing allergic rhinitis symptoms;[3] some patients may prefer this over pharmacological treatments, but Peter thinks he would find it inconvenient.

The pharmacist asks what Peter prefers and they come to a shared decision to try a low‑bioavailability nasal corticosteroid spray. Ideally, this would be best started two weeks before the grass pollen season. If the spray isn’t successful, he could consider adding an oral antihistamine or swap to a combination intranasal antihistamine/corticosteroid, which he would currently need a script for. He then demonstrates how to use the sprays and explains the importance of regular use – and of buying the medication from a reputable pharmacy, especially if purchasing online.

Peter asks about an article he read in the paper about dementia and antihistamines.

First generation, sedating antihistamines with an anticholinergic effect have been associated with an increased risk of dementia in a prospective observational cohort study. In this group of 3,434 participants, a dose-dependent relationship was found, with higher cumulative anticholinergic use associated with a greater risk of dementia.[24]

The pharmacist reassures Peter that he is not recommending anticholinergic antihistamines today and goes through the different types of antihistamine available again should he want to purchase them in future, if the steroid spray he is purchasing now doesn’t provide enough relief. He advises Peter that if the OTC medications don’t adequately control his symptoms, he should see his GP for a further history and examination and go over further treatment options.

Through a series of interactive case studies, this module presents a compelling argument for the importance of timely recognition and accurate diagnosis of respiratory allergies in primary practice. A wide range of aeroallergens can trigger allergic rhinitis, and, while an allergy-focused clinical history can help elucidate the causes and formulate strategies for allergen avoidance, confirmatory diagnosis is achieved by a blood test or skin-prick test and positive history. Occupational causes should not be overlooked.

Some cases of rhinitis can be mixed presentations of both allergic and non-allergic. It’s important to have an awareness of medications and other factors that can cause non-allergic rhinitis symptoms. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidosis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

A range of treatments are available for allergic rhinitis, some of which patients can access themselves online or in their local pharmacy. These include first-line options such as non-sedating oral antihistamines and intranasal corticosteroid sprays. Second-line (and beyond) options include intranasal combination sprays, leukotriene receptor antagonists and immunotherapy.[3] Some patients may benefit from nasal lavage and newer treatments are just emerging although these are still in a research phase.

Testing for and managing uncontrolled asthma in patients presenting with rhinitis symptoms is an integral component of the treatment algorithm. Rhinitis is strongly associated with asthma: 74%-81% of asthmatics report symptoms of rhinitis and both allergic and non-allergic rhinitis are risk factors for new-onset asthma[3] . Uncontrolled asthma is also a risk factor for anaphylaxis in patients with concomitant food allergy, and this should be factored into the holistic patient management.

The role of the primary care physician, nurse and pharmacist in educating patients with respiratory allergies cannot be over-emphasised. Many patients with mild rhinitis can be managed by pharmacists; however, if they are not responding to treatments or have other possible underlying causes they should be reviewed by a GP or specialist nurse.

Healthcare professionals can improve the management of respiratory allergies in primary care by taking a good, allergy-focused history, providing lifestyle advice for allergen avoidance, educating patients on medication choice and – for severe cases not responding to maximal-dose treatment – discussing the pros and cons of immunotherapy. For multi-system allergy patients with rhinitis, asthma and food allergy, using a single consultation as an opportunity to provide training on allergy and asthma control using personalised asthma plans, anaphylaxis plans and training in the use of adrenaline pens, can be an efficient use of time and resources.

  1. World Allergy Organization, White Book on Allergy. 2011.
  2. Bernstein, J.A., Allergic and mixed rhinitis: Epidemiology and natural history. Allergy Asthma Proc, 2010. 31(5): p. 365-9.
  3. Scadding, G.K., et al., BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy, 2017. 47: p. 34.
  4. Blaiss, M.S., Cognitive, social, and economic costs of allergic rhinitis. Allergy Asthma Proc, 2000. 21(1): p. 7-13.
  5. Cockburn, I.M., et al., Loss of work productivity due to illness and medical treatment. J Occup Environ Med, 1999. 41(11): p. 948-53.
  6. Walker, S., et al., Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study. J Allergy Clin Immunol, 2007. 120(2): p. 381-7.
  7. Kim, H. and D. Fischer, Anaphylaxis. Allergy Asthma Clin Immunol, 2011. 7 Suppl 1: p. S6.
  8. British Society for Allergy and Clinical Immunology, Allergy Action Plan (Personal plan for individuals prescribed EpiPen). Available from: http://www.bsaci.org/about/download-paediatric-allergy-action-plans [Last accessed 10 November 2017]
  9. British Society for Allergy and Clinical Immunology. BSACI | Resources for allergy sufferers and carers. 2017 [cited 2017 3 November]; Available from: http://www.bsaci.org/resources/index.htm.
  10. Anaphylaxis Campaign UK. 2017; Available from: https://www.anaphylaxis.org.uk/.
  11. Muraro, A., et al., EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy, 2014. 69(8): p. 1008-25.
  12. Angier, E. and A. Sheikh, 10-Minute consultation: Pollen food syndrome in a teenage student. BMJ, 2010. 340: p. b3405.
  13. Ma, S., S.H. Sicherer, and A. Nowak-Wegrzyn, A survey on the management of pollen-food allergy syndrome in allergy practices. J Allergy Clin Immunol, 2003. 112(4): p. 784-8.
  14. Skypala, I.J., et al., Development and validation of a structured questionnaire for the diagnosis of oral allergy syndrome in subjects with seasonal allergic rhinitis during the UK birch pollen season. Clin Exp Allergy, 2011. 41(7): p. 1001-11.
  15. British Thoracic Society and S.I.G. Network., British guideline on the management of asthma: a national clinical guideline. 2016.
  16. Allergy UK, Your quick guide to… domestic pet avoidance (version 3). 2014.
  17. Meltzer, E.O., et al., Burden of allergic rhinitis: allergies in America, Latin America, and Asia-Pacific adult surveys. Allergy Asthma Proc, 2012. 33 Suppl 1: p. S113-41.
  18. Smith, H., et al., Pragmatic randomized controlled trial of a structured allergy intervention for adults with asthma and rhinitis in general practice. Allergy, 2015. 70(2): p. 203-11.
  19. Allergy UK. Your quick guide to: House dust mite. 2015; Available from: https://www.allergyuk.org/information-and-advice/conditions-and-symptoms/320-in-the-home#downloads
  20. Fromer, L.M., et al., Insights on allergic rhinitis from the patient perspective. J Fam Pract, 2012. 61(2 Suppl): p. S16-22.
  21. Scadding, G.K. and A. Williams, The burden of allergic rhinitis as reported by UK patients compared with their doctors. Rhinology, 2008. 46(2): p. 99-106.
  22. Aasbjerg, K., Torp-Pedersen, C., Vaag, A. and Backer, V., Treating allergic rhinitis with depot-steroid injections increase risk of osteoporosis and diabetes. Resp Med, 2013. 107(12): p.1852-8.
  23. Nasser, S.M.S. and Ewan, P.W., Depot corticosteroid treatment for hay fever causing avascular necrosis of both hips. BMJ, 2001. 322(7022): 1589-91.
  24. Gray, S.L., et al., Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med, 2015. 175(3): p. 401-7.

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