How should I approach the management of a patient with allergic rhinitis who also has asthma?

To approach the management of a patient with allergic rhinitis who also has asthma, it is important to address both conditions, as they are often co-existing atopic disorders NICE NG245. The management involves a combination of self-management strategies, pharmacological treatments, and appropriate monitoring and referral pathways for each condition.

Self-Management and Allergen Avoidance for Allergic Rhinitis

• Advise the patient on sources of information and support, such as Allergy UK factsheets and NHS patient information leaflets NICE CKS.


• Suggest the use of nasal irrigation with saline, available over-the-counter, to rinse the nasal cavity NICE CKS.


• Provide advice on allergen avoidance techniques if a specific causative allergen is identified NICE CKS. For pollen allergy, this includes avoiding grassy areas during high pollen counts, keeping windows shut, and showering after high pollen exposure NICE CKS. For house dust mite allergy, advise on measures like washing bedding at high temperatures and choosing hard floor surfaces NICE CKS. For animal allergy, ideally advise not allowing the animal in the house, or restricting its presence to the kitchen and regular washing of the animal and surfaces NICE CKS. For occupational allergies, advise avoiding or reducing exposure to allergens in the workplace NICE CKS.

Pharmacological Management for Allergic Rhinitis

• Advise on or prescribe first-line treatment based on patient preference, age, severity, and persistence of symptoms NICE CKS.


• Intranasal corticosteroids are the most effective treatment for allergic rhinitis, though they may take several hours to several days to become effective, with maximal effect potentially seen after two weeks NICE CKS. Options include mometasone furoate, fluticasone furoate, or fluticasone propionate, which have minimal systemic absorption NICE CKS.


• Intranasal antihistamines (e.g., azelastine) have a faster onset of action (within minutes) but are less effective than intranasal corticosteroids NICE CKS.


• For mild, intermittent allergic rhinitis in adolescents and adults, any first-line treatment (intranasal or oral non-sedating antihistamine, intranasal corticosteroid, or a combination) may be offered NICE CKS. In children, an antihistamine (intranasal or oral non-sedating) is suggested NICE CKS.


• For moderate to severe or persistent allergic rhinitis, suggest an intranasal corticosteroid or the combination of an intranasal corticosteroid with an intranasal antihistamine NICE CKS.


• If drug treatment provides adequate symptom control, advise the patient to continue until they are no longer likely to be exposed to the suspected allergen NICE CKS. For recurrent seasonal symptoms, advise restarting treatment two weeks before re-exposure NICE CKS.

Management and Monitoring for Asthma

• Monitor asthma control at every review, checking for symptoms, time off work or school due to asthma, reliever inhaler use, oral corticosteroid courses, and any hospital admissions or emergency department attendances due to asthma NICE NG245.


• Consider using a validated symptom questionnaire (e.g., Asthma Control Questionnaire) at any asthma review NICE NG245.


• Ensure the patient has an annual review by a healthcare professional with appropriate training in asthma management, which should incorporate a written personalised action plan NICE NG245.


• Note that leukotriene receptor antagonists are a type of oral medicine used in the treatment of both asthma and seasonal allergies NICE NG245.

Referral Considerations

• For Allergic Rhinitis: Consider referral to an allergy or ear, nose, and throat (ENT) specialist if there are red flag features (e.g., unilateral symptoms, blood-stained nasal discharge), predominant nasal obstruction or structural abnormality making intranasal treatment difficult, persistent symptoms despite optimal primary care management, or if specialist immunotherapy is being considered NICE CKS.


• For Asthma: Refer for specialist assessment if a child's asthma is not responding to treatment NICE NG245. Refer any preschool child with an admission to hospital, or two or more emergency department admissions with wheeze in a 12-month period, to a specialist respiratory paediatrician NICE NG245. Refer people with suspected occupational asthma to an occupational asthma specialist NICE NG245.