Seasonal Allergic Rhinitis
Hay fever/Seasonal Allergic Rhinitis and Conjunctivitis (adults)
When to consider referral
1. Seasonal symptoms that are severe and resistant to treatment (when combination treatment at maximum doses has been attempted throughout the season). Treatment should be initiated at least 2 weeks before the anticipated start of the pollen season.
Primary care management prior to referral
1. Exclude red flag features
a. Unilateral symptoms, polyps, persistent blood stained discharge or persistent purulent discharge – consider referral to ENT.
2. Mild symptoms should be treated with oral non-sedating antihistamines at doses up to twice BNF maximum dosing (cetirizine 10mg, loratadine 10mg, or fexofenadine 180mg up to twice daily).
3. Moderate-severe symptoms should be treated with intranasal corticosteroid (eg Beconase, two sprays into each nostril twice daily; consider trying alternative, eg Nasonex or Avamys) in addition to non-sedating antihistamines. Consistent daily use of intranasal use is vital, given maximal effect may not be apparent for at least two weeks.
a. Start antihistamines and intranasal corticosteroids two weeks before usual symptom onset and continue throughout season
b. Training in appropriate nasal spray technique essential. Guidance is available at
4. Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of 15-20mg for a maximum of 5 days as a one-off treatment can be used for severe symptoms uncontrolled on conventional therapy, to control symptoms during important periods (eg exams or other major events).
5. Topical cromoglicate and nedocromil eyedrops are useful to manage allergic conjunctivitis.
6. Consider a concomitant diagnosis of asthma and manage according to guidelines
- Montelukast can be added to conventional therapy in patients with seasonal allergic rhinitis and concomitant asthma.
Avoid sedating antihistamines, depot corticosteroids, and chronic use of decongestants.
No investigations are recommended prior to referral.
- Perennial rhinoconjunctivitis (non-seasonal)
- Infective rhinosinusitis
- Non-allergic (eg hormonal, drug-induced, vasomotor) rhinitis
For diagnostic algorithm see
Information required with referral
Clinical history, background of treatment tried, any investigations performed.
Clinic options available
We have no Choose and Book slots available – we review and triage all referrals ourselves and allocate clinics appropriately.