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More information about allergy

Reactions to stings can cause large local swelling, which settles over a few days. However, if stings cause symptoms away from the site of the sting or make a person feel unwell, a specialist referral should be considered. Read: Insect sting allergy - the facts

Where appropriate, we offer immunotherapy (desensitisation) which is an effective treatment for bee and wasp allergy.  It is a three-year course of injections. Read: UHNM venom patient information leaflet

Hayfever is a common allergic reaction which occurs at particular times of the year. It is also known as seasonal allergic rhinitis occurring as a reaction to pollen from grass, trees and weeds during the early spring and summer months. It can affect both adults and children.

Perennial allergic rhinitis, where symptoms persist all through the year, is usually caused due to allergy to house dust mite.

For patients who suffer with severe symptoms despite the best standard of therapy, we may recommend immunotherapy (desensitisation). This is a three-year treatment programme consisting of either a daily tablet under the tongue or a course of injections. Patient Information on Immunotherapy can be found here.

Patient Information

What is allergic rhinitis?

Rhinitis is inflammation of the nose. Symptoms include sneezing, runny nose, blocked / stuffy nose, itching and 'post-nasal drip' (the sensation of mucus running down the back of the throat). It can occur in association with inflammation of the eyes or sinuses. Rhinitis can have several causes, such as infection, a reaction to medication, irritation by dusts, or allergy. When allergy causes rhinitis, the condition is called ‘allergic rhinitis’.

Allergic rhinitis can be seasonal or all year round:

Allergen Symptoms occur in:
Grass pollen  Summer (Summer hayfever)
Tree pollen  Spring (Spring hayfever)
House dust mite All year round (perennial)
Pets  All year round (perennial)
How can I avoid pollen?
  • Monitor pollen forecasts daily.
  • Rain washes pollen from the air so pollen counts should be lower on cooler, wet days. 
  • Use saline nasal rinses to remove pollen and allergens from the nose. 
  • Apply a barrier/balm e.g. Vaseline®, to the entrance of the nostrils to trap/block allergens.
  • On days when the pollen count is high, when getting home remove your clothing and shower. 
  • Keep windows closed when indoors. Pay particular attention in early mornings when the pollen is released into the air and in the evening when the air cools and pollen begins to fall to the ground. 
  • Wear wraparound sunglasses and a wide brimmed hat. 
  • Avoid drying washing on an outdoor clothes line when the pollen count is high.
  • Wipe a pets’ coat with a damp cloth to remove any pollen particles. 
  • Try and avoid triggers or take an antihistamine before known exposure.
How can I avoid house dust mite (HDM)?

You cannot avoid house dust mite! DM are found mainly in the bed, soft furnishings and carpets.

Only limited benefit can be obtained form HDM avoidance, so try a few basic things:

  • Wash bedding often and at more than 600c if possible. 
  • Cover mattress and pillows in dust mite-proof covers. 
  • HDM like moist warm conditions, so let the bed air during the day and leave the window open to ventilate the room.
What if I am allergic to my pet?

Most pet owners tolerate their own pets and have problems when exposed to other pets. If you have a new pet and have been found allergic, the most effective way to reduce your symptoms will be to rehome your pet.

If this is not possible, try the following: 

  • Avoid close contact with your pet (e.g. cuddling, kissing, allowing to sit in your lap).
  • Keep your pet away from your bedding, sofa and other areas that you frequently use. 
  • Where possible, replace carpets with wooden floors to reduce amount of pet fur/dust mite in the house.
How can I use my medication most effectively?

All rhinitis medication should be taken regularly to gain the maximum benefit. It is more difficult to treat symptoms that are already well established. We recommend starting your treatments at least 2 weeks before your symptoms usually begin.

Nasal washes - Washing the nose with a saline wash can relieve symptoms and clean the nose prior to using a nasal spray. The solution can simply be sniffed up the nose, or if preferred proprietary devices are available e.g. Sinus RinseTM.

Ingredients for saline wash solution:

  • 240 mls previously boiled and cooled water
  • 1/4 teaspoon salt 
  • 1/4 teaspoon bicarbonate of soda

Antihistamines - They are available in liquid, tablet and nasal spray form. There is a large range of antihistamines, but generally daily non-sedating antihistamines are recommended e.g. cetirizine. If one does not suit you it may be worth trying a different one. Antihistamines are available over the counter in pharmacies or on prescription.  
Steroid nasal spray - This is the most effective treatment for allergic rhinitis. 
 
Taking nasal sprays

  • Shake bottle well
  • Look down
  • Using RIGHT hand for LEFT nostril put nozzle just inside nose and aim towards outside wall
  • Squirt once or twice (2 different directions)
  • Change hands and repeat for the other side
  • DO NOT SNIFF HARD

Nasal sprays are available over the counter e.g. Fluticasone or on prescription.

There are several types of nasal spray so you may need to try more than one to find one that works best for you.

Eye drops -Antihistamines and nasal sprays can help to ease eye symptoms.

Sodium cromoglycate eye drops can be obtained over the counter or on prescription and can also help.

Montelukast –This is another drug that blocks chemicals that cause inflammation (like antihistamines).  It can be particularly useful in perennial rhinitis.  It is only available on prescription.

Decongestants –These drugs e.g. Otrivine should be avoided as much as possible.  If these drugs are used frequently then symptoms can get even worse and be difficult to control.

Immunotherapy –This is for patients with very severe allergic rhinitis despite taking maximum conventional medication.

Your allergy consultant or nurse will discuss this treatment with you and provide more information if they feel it is suitable in your case.

Some patients with symptoms of rhinitis do not have an allergy.

What is non-allergic rhinitis?

Non-allergic rhinitis is inflammation of the inside of the nose that isn't caused by an allergy. Rhinitis caused by an allergen, such as pollen, is a separate condition known as allergic rhinitis.

Symptoms of non-allergic rhinitis can include: 

  • a blocked nose 
  • a runny nose – this may be through the nostrils or down the back of the nose (catarrh) 
  • sneezing – although this is generally less severe than in allergic rhinitis
  • mild irritation or discomfort in and around your nose
  • reduced sense of smell

These symptoms can be constant or they may come and go.

While these symptoms are similar to those of allergic rhinitis (hay fever), non allergic rhinitis is different because, unlike an allergy, it doesn't involve the immune system.

What causes non-allergic rhinitis?

There are many different causes and often it is not possible to identify one cause.

There are several factors that can be associated with non-allergic rhinitis:

  • Infection 
  • Irritants e.g. smoke, paint fumes 
  • Change in temperature 
  • Alcohol
  • Spicy food 
  • Stress 

Some medications:

  • Some blood pressure tablets (eg. those ending with a ‘pril’ such as Ramipril)
  • Aspirin, Ibuprofen and other common painkillers
  • Cocaine use
  • Some medication available for treating blocked nose (eg. Otrivine)
  • Hormonal changes e.g. pregnancy, puberty and HRT
Overuse of drugs for ‘blocked nose’

Some sprays (such as Otrivine) unblock your nose by reducing the swelling of the blood vessels in your nose. However, if they are used for longer than five to seven days at a time, they can cause the lining of your nose to swell up again. This can happen even after the original problem has resolved. If you use more decongestants in an attempt to reduce the swelling, it is likely to make the problem worse. The medical term for rhinitis caused by the overuse of nasal decongestants is rhinitis medicamentosa.

Tissue damage

Inside your nose, there are three ridges of bone covered by a layer of tissue. These layers of tissue are called turbinates. A type of rhinitis called atrophic rhinitis can occur if the turbinates become damaged.

Most cases of atrophic rhinitis in the UK occur when the turbinates are damaged or removed during surgery (sometimes it is necessary to surgically remove turbinates if they're obstructing your airflow).

Turbinates play an important role in the functioning of your nose, such as keeping the inside of your nose moist and protecting the body from being infected with bacteria. If they are damaged or removed, the remaining tissue can become inflamed, crusty, and prone to infection.

What investigations do I need?

Sometimes the symptoms will be enough to make the diagnosis clear and no tests will be required.  However it is quite common to have some allergy tests to exclude this common cause of rhinitis.  Rarely blood tests may be carried out.

How can I use my medication most effectively?

All rhinitis medication should be taken regularly to gain the maximum benefit.  It is more difficult to treat symptoms that are already well established.

Nasal washes - Washing the nose with a saline wash can relieve symptoms and clean the nose prior to using a nasal spray. 

The solution can simply be sniffed up the nose, or if preferred proprietary devices are available e.g. Sinus RinseTM.

Ingredients for saline wash solution:

  • 240 mls previously boiled and cooled water 
  • 1/4 teaspoon salt 
  • 1/4 teaspoon bicarbonate of soda 

Antihistamines - Surprisingly antihistamines can sometimes be helpful. 

Antihistamine nasal sprays can be obtained over-the-counter from your pharmacy or on prescription.  

Anticholinergic nasal spray - These are helpful for people with primarily a runny nose.

Steroid nasal spray - This is the most effective treatment for rhinitis. Nasal sprays are available over the counter (e.g. Fluticasone ) or on prescription. There are several types of nasal spray so you may need to try more than one to find one that works best for you.

Taking nasal sprays
  • Shake bottle well
  • Look down
  • Using RIGHT hand for LEFT nostril put nozzle just inside nose and aim towards outside wall
  • Squirt once or twice (2 different directions)
  • Change hands and repeat for the other side
  • DO NOT SNIFF HARD

Decongestants – Some cases of non-allergic rhinitis are caused by overusing nasal decongestant sprays. In these cases, the best treatment is to stop using these sprays. However, this can be difficult, particularly if you've been using them for some time.

Try not using the spray in your least congested nostril first. After seven days this nostril should open up, at which point you should try to stop using the spray in your other nostril.

Food allergies, unlike intolerances, are an immune response to specific food allergens. They are more common in children. Read: Food allergy information from Allergy UK

Occasionally we offer food challenges in clinic to rule out food allergies. Read Patient Information about Food Challenges here

The respiratory specialists in Royal Stoke University Hospital manage asthma. However, some asthma patients with allergies may need to be seen in our clinic. Your GPs or specialists may be able to take this decision where appropriate. 

Most reactions that occur when people take medications are caused by side effects.

Testing for drug allergy may not be straight-forward and often it is better to just avoid the drug.  When this causes a problem, a referral to the allergy clinic may be appropriate. Read the Patient Information on the Drug and Vaccine Challenge here

Anaphylaxis is a severe allergic reaction that can be life-threatening.  All patients who have a reaction like this should be seen by a doctor who can identify a possible cause and will provide a plan including how to manage allergic reactions. For more information, click here:  www.anaphylaxis.org.uk

Emergency Treatment of Allergic Reactions

What is an allergic reaction?

An allergy is the response of the body's immune system to normally harmless substances, such as foods, and insect stings. Whilst in most people these substances (allergens) pose no problem, in allergic individuals their immune system identifies them as a ’threat’ and produces an inappropriate response. Most reactions are mild and easily managed with anti-histamines. This leaflet will explain what to do if you have a reaction.

Mild/moderate reactions

These are very common and symptoms may include: 

  • Itching skin 
  • Rash 
  • tickly throat 
  • swelling (e.g. face or lips)
     
Treatment plan:

Antihistamine e.g. cetirizine. Take 1-2 tablets immediately. Take one further tablet if no improvement. If reaction does not improve or gets worse seek medical attention.

Severe allergic reactions 

These are rare and symptoms may include:

  • Wheeze, difficulty breathing or a choking feeling.
  • Swelling of tongue or throat that is restricting swallowing and/or breathing.
  • Dizziness, collapse or deteriorating consciousness.
     
Treatment plan: 

Call an ambulance (dial 999)

Tell the operator this is an emergency case of anaphylaxis (anna-fill-axis) Lie flat If wheezy and you have an inhaler, give 10 puffs salbutamol (blue inhaler) via spacer  Take antihistamine (e.g.cetirizine)1-2 tablets immediately.

Points to Remember
  • Avoidance is the main management  
  • Don’t be polite -spit out the food causing symptoms 
  • Make sure your anti-histamines are in date 
  • Carry your anti-histamines with you at all times 
  • Take the antihistamine at the first sign of symptoms  
  • If you have asthma, ensure your asthma is well controlled and carry your blue inhaler with you
Further information

The Anaphylaxis Campaign www.anaphylaxis.org.uk 1 Alexandra Road, Farnborough, Hampshire, GU14 6BU. Tel: 01252 542029

AllergyUK www.allergyuk.org Allergy UK, Planwell House, LEFA Business Park, Edgington Way, Sidcup, Kent, DA14 5BH. Tel: 01322 619898

Epipen®

Severe allergic reactions

These are rare and symptoms may include:

  • Wheeze, persistent cough, difficulty breathing or a choking feeling.
  • Swelling of tongue or throat that is restricting swallowing and/or breathing.
  • Dizziness, collapse or deteriorating consciousness.

Treat early, if in doubt use the Epipen® pen Treatment plan:

  • Lie flat.
  • Give the Epipen® pen as shown (see diagrams).
  • Immediately call an ambulance (dial 999)
  • Tell the operator this is an emergency case of anaphylaxis (anna-fill-axis). If wheezy and you have a blue salbutamol inhaler, give 10 puffs via a spacer.
  • Antihistamine e.g. cetirizine.Take 1-2 tablets immediately.
  • A second Epipen® pen may be given after 10 minutes if symptoms return or are no better.

how to give epipen

Points to remember
  • Make sure both your Epipen® pens and antihistamines are in date. 
  • Make sure you know how to use your Epipen® see ‘Further information’ for trainer pens and online videos). 
  • Carry your Epipen® pens and antihistamines with you at all times 
  • Consider carrying a medical ID alert with information about your risk of anaphylaxis.
  • If you have asthma, make sure it is well controlled. 
Further information

Epipen® www.epipen.co.uk You can arrange to be alerted when you need to order a new Epipen®, you can order a trainer pen and there is a video of how to use the Epipen® pen.

The Anaphylaxis Campaign www.anaphylaxis.org.uk 1 Alexandra Road, Farnborough, Hampshire, GU14 6BU. Tel: 01252 542029

AllergyUK www.allergyuk.org Allergy UK, Planwell House, LEFA Business Park, Edgington Way, Sidcup, Kent, DA14 5BH. Tel: 01322 619898

The MedicAlert Foundation www.medicalert.org.uk MedicAlert House, 327 Upper Fourth St, Milton Keynes, MK9 1EH. Tel: 01908 951045 Email: info@medicalert.org.uk Monday to Friday 9am to 5pm & Sat 9am-3pm

Emerade®

Severe allergic reactions

emerade

These are rare and symptoms may include:

  • Wheeze, difficulty breathing or a choking feeling.
  • Swelling of tongue or throat that is restricting swallowing and/or breathing.
  • Dizziness, collapse or deteriorating consciousness.

Treat early, if in doubt use the Emerade® pen

Treatment plan:
  • Lie flat.
  • Give the Emerade® pen as shown (see
    diagrams).
  • Immediately call an ambulance (dial 999)
  • Tell the operator this is an emergency case of
    anaphylaxis (anna-fill-axis).
  • If wheezy and you have a blue salbutamol inhaler, give 10 puffs via a spacer.
  • A second Emerade® pen may be given after 10 minutes if symptoms return or are no better.

How to give an Emerade® pen

How to administer

Points to remember
  • Make sure both your Emerade® pens and antihistamines are in date.
  • Make sure you know how to use your Emerade® (see ‘Further information’ for
    trainer pens and online videos).
  • Carry your Emerade® pens and antihistamines with you at all times
  • Consider carrying a medical ID alert with information about your risk of anaphylaxis.
  • If you have asthma, make sure it is well controlled.
Further information

Emerade®  www.emerade.com You can order a trainer pen and there is a video of how to use the Emerade® pen.
 
The Anaphylaxis Campaign www.anaphylaxis.org.uk  1 Alexandra Road, Farnborough, Hampshire, GU14 6BU. Tel: 01252 542029
 
AllergyUK www.allergyuk.org Allergy UK, Planwell House, LEFA Business Park, Edgington Way, Sidcup, Kent, DA14 5BH. Tel: 01322 619898
 
The MedicAlert Foundation www.medicalert.org.uk  MedicAlert House, 327 Upper Fourth St, Milton Keynes, MK9 1EH. Tel: 01908 951045  Email: info@medicalert.org.uk  Monday to Friday 9am to 5pm & Sat 9am3pm

Patients referred with reactions after local anaesthetic generally bypass the general clinic and are seen in the challenge clinic.  Allergy to local anaesthetic is extremely rare.

Urticaria – also known as hives, wheals, welts or nettle rash – is a raised, itchy rash that appears on the skin. It may appear on one part of the body or be spread across large areas.  Sometimes it is associated with swelling called angioedema.  Less often angioedema may occur on its own.  In the allergy clinic about 1 in 3 patients we see have urticaria.  Chronic urticaria, lasting for more than 6 weeks, is unlikely to be due to allergy.

Occasionally patients on blood pressure tablets called 'ACE inhibitors', for example Ramipril, develop angioedema.  Your own doctor will be able to offer a safe and suitable alternative to these drugs. It is important that you contact them. Read: UHNM CSAU patient information leaflet - 2017

Other sources of useful information:

Information for primary care physicians: UHNM management of CSAU

www.allergy.uk
www.anaphylaxis.org
www.asthma.org.uk
www.bad.org.uk
www.bsaci.org
www.nhs.uk 

Information for patients with urticaria not responding to high dose anti-histamine or monteleukast, we can offer omalizumab treatment:

What is Urticaria?

Urticaria is a red, itchy rash sometimes called hives or nettle rash. It is thought to be caused due to release of excessive histamine from some immune cells, which is why antihistamines are commonly used to treat this condition.

What is Omalizumab and how does it work?

There is probably more than one mechanism or cause for chronic urticaria. Stimulation of some immune cells (called mast cells) causing release of histamine is likely to be one mechanism. Omalizumab is a man-made drug that reduces stimulation of these cells and thus, decreases the release of histamine.

Why am I being offered Omalizumab?

You have been offered this medicine since your urticaria has not improved despite taking high doses of antihistamines and other drugs.

80-90% of people taking Omalizumab get significant benefit and about a third of patients are completely free of symptoms after 12 weeks. 

It suppresses symptoms and is not a cure, so the symptoms can return once the treatment is stopped.

What does the course of Omalizumab involve?

There is a national guideline for the use of Omalizumab. We use a questionnaire that helps us understand how much improvement there has been in your symptoms. It is important that you fill this questionnaire at the correct time points, since it may be difficult for us to justify the use of the drug without this information.

Omalizumab is licensed to be given as a series of injections every month, lasting for 6 months.  In clinic we sometimes find that the injections work just as well given every 6 weeks.  There is a small risk of reaction so you need to stay in the clinic for 1 hour after the first injection and 30 mins after subsequent injections.

We initially provide 4 doses and reassess your symptoms to see if the medicine is working. After 6 injections we will stop the treatment, but if you have a flare up of symptoms and meet the criteria again for another course of treatment, then we will restart the Omalizumab.

What are the risks of taking Omalizumab?

Some people who have had Omalizumab for urticaria have described reactions at the site of the injection, such as swelling and redness. Some patients have had an increased number of  coughs and colds after starting the drug.

Are there any serious risks?

In asthma patients taking this medication, there have been rare cases of  a severe allergic reaction.  Although this has not been seen in patients with urticaria, we will monitor you for an hour after the first injection and for 30 mins after subsequent injections in the clinic.

In our clinic we provide you with an adrenaline autoinjector to carry for the first 24 hours so that in the unlikely event that you had a severe reaction you would be able to treat it quickly and effectively

Remember to bring your adrenaline autoinjector to clinic appointments.

What else do I need to know?

You should not have Omalizumab if you are at risk of a worm infection (e.g. travel to some countries), or if you are pregnant or breast feeding.

Please inform someone from the clinic if there are any changes to your other medication, if you develop any new illness, become pregnant or plan to become pregnant.

Further Information

British Association of Dermatologists www.bad.org.uk Willan House,  4 Fitzroy Square, London W1T 5HQ  Tel: 0207 383 026 
 
Novartis (who make omalizumab) Website to provide information: http://www.xolair.com/