{"id":996,"date":"2017-07-25T11:39:15","date_gmt":"2017-07-25T11:39:15","guid":{"rendered":"https:\/\/drcrunch.wordpress.com\/?p=996"},"modified":"2017-07-25T11:39:15","modified_gmt":"2017-07-25T11:39:15","slug":"hay-fever-vs-gcses","status":"publish","type":"post","link":"http:\/\/drcrunch.co.uk\/blog\/2017\/07\/25\/hay-fever-vs-gcses\/","title":{"rendered":"Hay Fever vs GCSEs"},"content":{"rendered":"

A 16 year old boy has his GCSEs coming up and feels his hayfever is stopping him from concentrating. He has tried antihistamines before with some success, but he is worried they might make him drowsy and worsen his focus.<\/p>\n

This is a real problem. A case-control study found students were more likely to drop GCSE grades between a mock in winter and the real one in summer if they had allergic rhinitis – https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/17560637<\/a><\/p>\n

\u201cIn this study, young people with reported allergic rhinitis symptoms on an examination day were, in comparison with their fellow students without symptoms, 40% more likely to drop a grade between their practice and final GCSE examinations, and 70% more likely to drop a grade if they reported taking sedating antihistamines at the time of their examinations.\u201d<\/p>\n

\u201cThe significant effect of sedating medications on examination performance observed in this study should encourage prescribers to recommend the use of non-sedating alternatives in routine practice.\u201d<\/p>\n


\nQ. How far do I have to explore other differentials when someone says its their typical hayfever? I find it a little awkward to keep asking patients \u2018what do you mean by hayfever?\u2019 when they clearly have hayfever. <\/strong><\/p>\n

A. Hayfever = seasonal rhinitis +\/- conjunctivitis<\/p>\n

Rhinitis = nasal discharge +\/- nasal obstruction (sneezing and itching too, especially in allergic forms)<\/p>\n

Sinusitis = facial pain in sinus area +\/- rhinitis<\/p>\n

After confirming the patient has rhinitis, the next thing to establish is allergic vs infectious vs obstructive.<\/p>\n

The red flags for something nasty are unilateral rhinitis symptoms, especially with obstructive\/blood stained\/smoker\/drinker\/Chinese origin\/CN III-VII abnormalities. It\u2019s also worth examining for polyps \/ hypertrophied turbinates if this hasn\u2019t been done before. That\u2019s about as far as I normally go in someone who is known to have to have hayfever with a good seasonal history.<\/p>\n

Q. Are the non sedating antihistamines really non sedating? Which one would you pick?<\/strong><\/p>\n

From the BNF:<\/p>\n

Drowsiness is a significant side-effect with most of the older antihistamines although paradoxical stimulation may occur rarely, especially with high doses or in children and the elderly. Drowsiness may diminish after a few days of treatment and is considerably less of a problem with the newer antihistamines.<\/p>\n

From BMJ Learning<\/a>:<\/p>\n

\u201cCetirizine has a faster onset of action than loratadine,\u00a0and a meta analysis found it to be more effective for treating allergic rhinitis compared with loratadine, montelukast, and desloratadine. It has also been shown to be more effective than fexofenadine at relieving the symptoms of SAR at five to 12 hours following administration.\u201d<\/p>\n

So, non-sedatings are better for this patient. In terms of the choice of non sedating, our local allergy clinic loves cetirizine first line. That said, fexofenadine does not carry drowsiness warning labels in the US, but cetirizine does carry labels stating may cause drowsiness may occur and to avoid heavy machinery\/alcohol. Perhaps in this patient fexofenadine could be second line after cetirizine if drowsiness \/ impaired concentration is still a problem.<\/p>\n

Q. What other non-pharmaceutical treatments would you use?<\/strong><\/p>\n

Allergen avoidance and a saline rinse (like Neil Med). The saline rinse seems to be loved by ENT for pretty much all types of nasal congestion. It\u2019s pretty safe, and you can use it once to three times a day.<\/p>\n

Q Anything else?<\/strong><\/p>\n

NICE CKS <\/a>have the following table:<\/p>\n

\"Screen<\/p>\n

Oral steroids are occasionally used short term for ridiculously severe symptoms or if something important is coming up, like GCSEs or the Lego Batman movie.<\/p>\n

Most of the time I use intranasal corticosteroids next. NICE CKS suggest they can be used for moderate and severe hayfever.<\/p>\n

It\u2019s important to demonstrate to the patient how to use them. I\u2019ve often found when I ask a patient to demonstrate how they use the spray, it\u2019s often a deep sniff to the back of the throat preventing oesophageal hayfever. I like this video:<\/p>\n