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Hay fever management

A concise guide to the causes, avoidance and treatment of seasonal allergic rhinitis.

Hay fever (seasonal allergic rhinitis) affects up to 25% of people in the UK, including 10% of 6-7-year-olds and 15% of 13-14-year-olds

Prevalence can be affected by the following factors: 

  • Gender: More males than females suffer before adolescence, with more females than males suffering post-adolescence
  • Age: Peek prevalence occurs in the third and fourth decades, with some evidence for remission in later adulthood
  • Geography: Prevalence has increased significantly in the last four-to-five decades in the UK. Our country and Sweden have the highest prevalence of hay fever in Europe
  • Other conditions: More than 40% of people with hay fever have asthma and 80% of people with ashtma have hay fever. 


Allergens responsible for hay fever include grass pollens, tree pollens and fungal mould spores. People can be allergic to one type of pollen. Allergic rhinitis on exposure to cats and dogs is also relatively common and sometimes horses, rabbits, pet rats, hamsters and guinea pigs as well.

Types of pollen

Grass pollen

Around 95% of hay fever is triggered by grass pollen, which tends to be highest between mid-May and July although the season can extend from April to September.

Tree pollen

The first pollen to be released during the hay fever season.

Weed pollen

This can also be a trigger for hay fever: highest from the end of June to September.

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Hay fever can be managed using a variety of treatments, the most popular of which are antihistamines. 

Types of antihistamines

Oral antihistamines are considered clinically efficacious for treating mild to moderate as well as intermittent symptoms of allergic rhinitis. 

They are effective in reducing sneezing and runny nose but less so in reducing nasal congestion. They usually work within a day

They should be taken regularly rather than when needed in cases of persistent hay fever

They can be recommended as an addition to intranasal steroids for moderate/severe persistent rhinitis uncontrolled on topical intranasal corticosteroids alone, particularly when eye symptoms are present 

Non-sedating antihistamines available OTC include acrivastine (taken three times daily), cetirizine (taken once daily) and loratadine (taken once daily)

Compared with older antihistamines, non-sedating antihistamines cause less sedation, but some people do experience drowsiness. Anticholinergic effects (e.g. dry mouth, blurred vision, constipation, urinary retention) are very much lower in the newer drugs

Acrivastine has the fastest onset of action but needs to be taken three times daily

For sale OTC, loratadine can be recommended for children over two years, cetirizine over six years and acrivastine over 12 years

Older antihistamines (diphenhydramine, promethazine) have a greater tendency to cause sedation; other older antihistamines (chlorphenamine) are relatively less sedative but sedation can still be a problem

Sedative and anticholinergic effects are increased if the person is taking other medications with anticholinergic (e.g. tricyclic antidepressants, haloperidol, metoclopramide, prochlorperazine) and sedative (e.g. hypnotics, sedatives, anxiolytics) effects respectively Alcohol also increases sedative effects

Antihistamines should not be used by patients with narrow/closed angle glaucoma and should be used with caution in liver disease and prostatic hypertrophy

Nasal antihistamines (azelastine nasal spray) are for mild to moderate, intermittent and mild persistent rhinitis in children over 5 years

They are superior to oral antihistamines in reducing nasal obstruction 

They have a rapid onset of action and can be used as ‘on demand’ rescue therapy for symptom breakthrough. However, continuous treatment is more clinically effective than on demand use 

They can be effective in patients in whom there has been previous failure of oral antihistamines 

They are less effective than an intranasal steroid in relieving the symptoms of allergic rhinitis 

The BNF suggest treatment should begin two-three weeks before the start of the season

Treatment with both an intranasal and oral antihistamine confers no additional advantage in alleviating nasal symptoms

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