Allergic rhinitis (hay fever): the Australian general practice guide

What allergic rhinitis actually is

Allergic rhinitis is an IgE-mediated inflammatory response of the nasal mucosal lining to inhaled allergens. When a sensitised person breathes in pollen, house dust mite particles, animal dander, or mould spores, mast cells in the nasal lining release histamine, leukotrienes, and prostaglandins. The early-phase response — sneezing, watery rhinorrhoea, nasal itch — occurs within minutes. A late-phase response hours later drives the congestion, post-nasal drip, and sleep disruption that many people find most disabling.

Around 19% of Australians — approximately 5 million people — live with allergic rhinitis, giving Australia one of the highest prevalence rates globally. Contrary to the common assumption that it is a minor inconvenience, ASCIA’s clinical update identifies significant impacts on sleep quality, work and school performance, and quality of life. Around 80% of people with asthma also have allergic rhinitis, and the two conditions share a common inflammatory pathway — treating one meaningfully improves the other.

This article covers the Australian general practice approach to diagnosis, stepwise management, the evidence base for treatment choices, and when to refer.

A. Core clinical — the AU general-practice framework

Classification: intermittent vs persistent, mild vs moderate-severe

The ARIA classification (Allergic Rhinitis and its Impact on Asthma), adopted by ASCIA and eTG Respiratory, uses two axes:

• Frequency: intermittent (<4 days/week OR <4 consecutive weeks) vs persistent (≥4 days/week AND ≥4 consecutive weeks)
• Severity: mild (no impairment to sleep, daily activity, school or work performance) vs moderate-severe (at least one of those impaired)

This classification drives management intensity. Mild intermittent symptoms tolerate antihistamine PRN. Moderate-severe persistent symptoms warrant daily intranasal corticosteroid (INCS).

The triggers: seasonal and perennial

Seasonal (spring-dominant in southeast Australia):

• Grass pollen — the most common trigger; ryegrass, couch, and other grasses peak October–December in Melbourne, Canberra, and regional southeast Australia
• Tree pollen — plane, birch, and native trees peak late winter to early spring
• Weed pollen — late spring to autumn

Perennial (year-round):

• House dust mite — the dominant perennial trigger; found in bedding, soft furnishings, carpets; thrives in humid environments
• Animal dander — cats, dogs, horses; dander is sticky and persists long after the animal is removed
• Mould spores — damp environments, particularly post-flood
• Cockroach allergen — inner-city environments

History and examination

A focused history asks about: symptom pattern (sneezing, watery rhinorrhoea, nasal itch, congestion, post-nasal drip, itchy or watery eyes); seasonal versus perennial timing; specific triggers identified by the patient; atopic comorbidities (asthma, eczema, food allergy, anaphylaxis); family history of atopy; quality-of-life impact on sleep, work, and activity.

Red flags that shift the differential: unilateral persistent nasal symptoms or bleeding (polyp, septal deviation, foreign body in children, or — rarely — tumour); clear unilateral discharge after head trauma (cerebrospinal fluid leak); symptoms with NSAID use combined with anosmia and polyps (AERD/Samter’s triad).

Examination: anterior rhinoscopy or otoscope with wide speculum — pale, boggy, swollen turbinates with watery discharge suggest allergic rhinitis; look for nasal polyps. Allergic stigmata: “allergic shiners” (infraorbital venous congestion), transverse nasal crease from chronic rubbing, cobblestone posterior pharynx. Assess for comorbid asthma.

Investigations

Most typical cases are a clinical diagnosis — testing is reserved for when allergen identification will change management (e.g., planning allergen immunotherapy or needing to confirm occupational exposure).

• Allergen-specific IgE (RAST/ImmunoCAP) — MBS item 71093 for allergen-specific IgE testing (up to 4 specified allergens); item 71095 for mixed allergen panels. Useful when skin prick test is contraindicated (severe eczema, dermatographism, antihistamines that cannot be withheld)
• Skin prick test — gold standard; specialist allergy clinic; more rapid and sensitive than blood testing
• Total IgE — MBS 66818 — supportive only; not diagnostic alone
• Eosinophil count — MBS 65070 — supportive
• CT sinuses / nasendoscopy — ENT referral for structural concerns, recurrent sinusitis, or nasal polyps

Differential diagnosis

Condition	Key discriminator
Non-allergic (vasomotor) rhinitis	Temperature or strong-odour triggers; no atopy; negative testing
Viral rhinitis (cold)	Acute onset, fever, malaise, self-limited 7–10 days
Bacterial sinusitis	Persistent ≥10 days, purulent, facial pain, “double sickening”
Structural (polyps, deviated septum)	Fixed unilateral obstruction; no itch or sneezing
Rhinitis medicamentosa	History of prolonged oxymetazoline or xylometazoline use (>3–5 days)
Drug-induced	ACE inhibitor cough; oestrogen, PDE5 inhibitors, clonidine
CSF rhinorrhoea	Clear unilateral post-traumatic discharge; beta-2-transferrin positive

B. Evidence — why intranasal corticosteroids outperform antihistamines

INCS vs antihistamine: head-to-head data

The Wallace practice parameter (JACI 2008) — a systematic review of head-to-head trials — confirmed that intranasal corticosteroids are more effective than oral antihistamines for all nasal symptoms, including itch and sneezing. The mechanism: INCS reduce the underlying eosinophilic mucosal inflammation, addressing both the early-phase and late-phase response. Oral antihistamines block H1 receptors and help with the immediate itch, sneezing, and rhinorrhoea response but do not adequately address congestion or late-phase inflammation.

The clinical implication: for mild intermittent symptoms, an antihistamine PRN is appropriate. For moderate-severe or persistent symptoms, INCS is first-line — and the patient needs to understand it takes days to weeks for full effect.

Combining INCS with intranasal antihistamine

The Carr trial (JACI 2012) demonstrated that the combination product azelastine plus fluticasone (Dymista) was superior to either component alone in moderate-severe persistent allergic rhinitis. This combination is available in Australia under PBS Authority Required (Streamlined) for moderate-severe AR not controlled on intranasal monotherapy.

Saline nasal irrigation: cheap, effective adjunct

A systematic review by Hermelingmeier (Am J Rhinol Allergy 2012) found that large-volume isotonic or hypotonic saline irrigation 2–3 times daily modestly improves symptoms and reduces medication requirement. Mechanism: physical clearance of allergens, inflammatory mediators, and secretions from the nasal mucosa. It is safe, inexpensive, and relevant at every step of treatment — recommend it universally.

Allergen immunotherapy: the disease-modifying option

A Penagos meta-analysis (JACI 2017) confirmed allergen immunotherapy reduces nasal and ocular symptoms, decreases medication requirement, and — in children — reduces the development of new allergen sensitisations and asthma. Importantly, benefit persists for years after the 3–5 year course completes. This is the critical distinction from pharmacotherapy: immunotherapy changes the underlying immune response rather than suppressing symptoms.

C. Stepwise management — the ASCIA approach

The ASCIA Allergic Rhinitis Treatment Plan 2024 and eTG Respiratory: Allergic rhinitis both use a four-step framework aligned with ARIA severity classification.

Step 1 — all patients: allergen avoidance and saline irrigation

House dust mite reduction:

• Encase mattress, pillow, and quilt in anti-mite covers
• Wash bedding weekly in hot water (at least 55°C)
• Reduce carpets and soft furnishings where possible
• Maintain indoor relative humidity below 50%
• HEPA air filtration has modest additional benefit

Pollen avoidance:

• Close windows during high-pollen periods (mornings in spring)
• Shower and change clothing after outdoor activity during pollen season
• Wear sunglasses outdoors; dry washing indoors during peak season
• Monitor pollen counts via Melbourne Pollen or Canberra Pollen apps

Saline nasal irrigation — large-volume isotonic or hypotonic saline 2–3 times daily as a universal adjunct.

Step 2 — mild intermittent or mild persistent symptoms

Second-generation oral antihistamine PRN or daily per AMH: loratadine 10 mg, cetirizine 10 mg, fexofenadine 180 mg, desloratadine 5 mg, or levocetirizine 5 mg. Avoid first-generation antihistamines — sedation, anticholinergic burden, cognitive impairment, falls in older adults.

Alternatively: intranasal antihistamine (azelastine spray) for faster onset of action, or sodium cromoglycate (intranasal; multiple daily doses required) as a preventive option.

Step 3 — moderate-severe persistent symptoms (or step 2 failure)

Intranasal corticosteroid daily — the most effective single agent. Options per eTG:

• Fluticasone propionate 50 mcg — 2 sprays each nostril daily
• Fluticasone furoate (Avamys) 27.5 mcg — 2 sprays each nostril daily
• Mometasone furoate (Nasonex) 50 mcg — 2 sprays each nostril daily
• Budesonide (Rhinocort) 32–64 mcg — 1–2 sprays each nostril daily
• Ciclesonide 50 mcg — 2 sprays each nostril daily

Technique is critical and should be demonstrated at every visit: head slightly forward, spray angled toward the outer eye (away from the septum), breathe in gently through the nose while spraying, avoid forceful sniffing. Incorrect technique — spraying toward the septum — is the most common cause of epistaxis and treatment failure.

For moderate-severe persistent AR not controlled on INCS alone: add azelastine + fluticasone combination (Dymista) — Authority Required (Streamlined); or add second-generation oral antihistamine for breakthrough itch and sneezing.

Step 4 — refractory severe persistent symptoms

Montelukast 10 mg daily — modest efficacy in allergic rhinitis; most useful when asthma co-exists. However, the TGA issued a Boxed Warning in 2020 for neuropsychiatric events including mood changes, sleep disturbance, and behaviour changes — counsel patients and families before prescribing.

Short course oral corticosteroid — prednisolone 25 mg daily for 3–7 days for a severe acute flare, limited to once or twice yearly.

Refer for allergen immunotherapy — the disease-modifying option for eligible patients (see section C above).

For allergic conjunctivitis: mast-cell stabiliser or antihistamine eye drops — olopatadine 0.1% twice daily or ketotifen 0.025% twice daily. Cool compresses; avoid rubbing. Avoid topical corticosteroid eye drops without ophthalmology supervision (risk of cataract and raised intraocular pressure).

D. Australian operations

MBS items

Standard consults: items 3 / 23 / 36 / 44. Telehealth equivalents under the existing 12-month relationship rule.

Allergen testing: specific IgE item 71093 (up to 4 allergens per episode) and 71095 (mixed panels). Total IgE 66818. FBC and eosinophils 65070.

Chronic and persistent allergic rhinitis with allergen immunotherapy planned qualifies for a GPCCMP (items 965 / 967). Plan elements: allergen identification and avoidance plan, medication regimen and technique, asthma co-management if present, action plan for thunderstorm asthma in spring (for high-risk patients), scheduled 3–6 monthly review. ATSI Health Assessment item 715.

PBS pharmacotherapy

• INCS (fluticasone, mometasone, budesonide, ciclesonide, beclomethasone) — most are general schedule; some are available over the counter
• Combined azelastine + fluticasone (Dymista) — Authority Required (Streamlined) for moderate-severe AR not controlled on monotherapy
• Second-generation oral antihistamines — most available over the counter; general schedule when prescribed
• Montelukast — Authority Required (Streamlined); TGA Boxed Warning 2020 for neuropsychiatric events
• SLIT products (Acarizax, Actair, Oralair, Grazax, Itulazax) — not PBS-subsidised; private prescription approximately $1,500–3,000/year
• Omalizumab, dupilumab, mepolizumab — Authority Required for severe asthma or chronic rhinosinusitis with nasal polyps; specialist initiation

Pseudoephedrine is a Schedule 3 (pharmacist-only) or Schedule 4 agent depending on formulation and quantity. Short-term only; avoid in hypertension, ischaemic heart disease, or BPH. Not recommended for chronic allergic rhinitis management.

Topical decongestants (oxymetazoline, xylometazoline) — rapid relief but rhinitis medicamentosa develops with use beyond 3–5 days. Short courses only, never for chronic management.

Occupational rhinitis

Workplace-triggered allergic rhinitis (flour dust, latex, wood dust, isocyanates, laboratory animals) is compensable under state workers’ compensation legislation. Identify the occupational trigger early — continued exposure accelerates sensitisation. Formal occupational history and specialist allergy referral are warranted for suspected occupational rhinitis.

E. Special populations

Pregnancy. Safe options: saline nasal irrigation, sodium cromoglycate, loratadine or cetirizine (Pregnancy Category B), budesonide INCS (Category A — the best-studied intranasal corticosteroid in pregnancy). Avoid pseudoephedrine in the first trimester. Most other agents should be discussed with the treating GP before use.

Older adults. Second-generation antihistamines only — first-generation agents increase fall risk, cause urinary retention, and worsen cognitive function. INCS are the preferred pharmacotherapy. Review for polypharmacy interactions.

Children. INCS dose-adjusted per product; growth monitoring is appropriate with long-term use, though the effect on final height at standard doses is minimal. SLIT is approved from age 5–12 depending on the product — check current TGA approval for each agent. Paediatric allergen assessment often requires specialist allergy referral.

Athletes. Intranasal corticosteroids are permitted by WADA. Oral corticosteroids are restricted in some sporting contexts. Check the relevant sporting body’s rules before prescribing in competitive athletes.

Thunderstorm asthma risk group — grass-pollen-allergic patients with asthma in southeast Australia should have: a written asthma action plan, a preventer inhaler (ICS-formoterol), regular INCS during spring pollen season, and monitoring of VicEmergency thunderstorm asthma alerts. For highest-risk patients (severe asthma, multiple previous attacks), consider seasonal SLIT or specialist review for omalizumab.

When to escalate

Refer to a clinical immunologist, allergist, or ENT when:

• Anaphylaxis occurs on allergen exposure — immediate emergency (adrenaline IM, call 000); then specialist follow-up for adrenaline autoinjector prescription and written ASCIA Anaphylaxis Action Plan
• Thunderstorm asthma with severe bronchospasm — emergency presentation
• Suspected AERD (Samter’s triad: anosmia + nasal polyps + asthma + NSAID hypersensitivity)
• Persistent unilateral nasal symptoms or unexplained nasal bleeding — ENT for structural assessment
• Moderate-severe persistent symptoms refractory to optimised pharmacotherapy and technique — for allergen immunotherapy assessment
• Children with severe allergic rhinitis and possible benefit from SLIT
• Suspected occupational allergic rhinitis — allergy and occupational medicine

What this article is and is not

This is general health information drawn from ASCIA’s Allergic Rhinitis Clinical Update, ASCIA Allergic Rhinitis Treatment Plan 2024, eTG Respiratory: Allergic rhinitis, and AMH. It reflects Australian general practice as of the review date and does not constitute personal medical advice or create a doctor–patient relationship. Treatment decisions — including choice of medication, referral for allergen testing, and immunotherapy eligibility — require assessment by your own GP and treating clinicians.

Consumer-friendly information: HealthDirect — Hay fever, ASCIA patient information, Allergy & Anaphylaxis Australia, Better Health Channel — Hay fever, Asthma Australia — thunderstorm asthma.

For anaphylaxis: call 000. For thunderstorm asthma alerts in spring: VicEmergency.

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Sources cited

1. ASCIA. Allergic Rhinitis Clinical Update.
2. ASCIA. Allergic Rhinitis Treatment Plan 2024.
3. Therapeutic Guidelines Limited. eTG complete — Respiratory: Allergic rhinitis (subscription).
4. Australian Medicines Handbook. AMH (current edition).
5. ARIA. Allergic Rhinitis and its Impact on Asthma.
6. Allergy & Anaphylaxis Australia. Allergen Immunotherapy.
7. TGA. Montelukast neuropsychiatric Boxed Warning 2020.
8. Australian Department of Health. Thunderstorm asthma.
9. Asthma Australia. Thunderstorm asthma.
10. MBS Online. Items 23 / 65070 / 66818 / 71093 / 71095 / 715 / 965 / 967.
11. PBS. pbs.gov.au — INCS, antihistamine, Dymista, montelukast listings.
12. Wallace DV et al. JACI 2008.
13. Carr WW et al. JACI 2012.
14. Hermelingmeier KE et al. Am J Rhinol Allergy 2012.
15. Penagos M et al. JACI 2017.
16. AIHW. aihw.gov.au.
17. HealthDirect. Hay fever.
18. Better Health Channel. Hay fever.
19. VicEmergency. Thunderstorm asthma alerts.