Based on symptoms alone, distinguishing between flu and AR can be challenging. According to Green et al, a thorough history provides the first step towards an accurate diagnosis.⁴  

Patients who present with symptoms such as sudden episodes of sneezing, both anterior and posterior rhinorrhoea, nasal obstruction, and nasal itch, and a personal history of allergic diseases (such as atopic dermatitis, allergic asthma, or allergic conjunctivitis) most likely have AR and not flu. The complaint of 'itch' is often prominent in acute AR, with patients also frequently reporting itching of the palate and eyes, sometimes accompanied by tearing. ⁴   

Severe AR cases may present with troublesome symptoms such as sleep-disrupting breathing and impairment of daily activities. Children may exhibit behaviours like snorting, sniffing, and tongue clicking due to an itchy palate.⁴ 

Symptoms of viral infections such as fever or a sore throat generally last around two weeks, while some patients living with AR may have year-long symptoms.⁴ 

The next step to confirm an AR diagnosis involves examining external clinical signs and performing an anterior rhinoscopy, otoscopy, and throat examination. Signs supporting a diagnosis of AR include allergic shiners, Dennie–Morgan lines, a transverse nasal crease, allergic facies, and allergic mannerisms.⁴  

Additional indications are swelling of the nasal mucosa, clear secretions, and a pale or pale-bluish color of the nasal mucosa. In contrast, a beefy red mucosa is often associated with viral infections. Serous middle-ear effusions, retracted tympanic membranes, and lymphoid hyperplasia (cobbling) of the posterior pharynx may also suggest an acute exacerbation of AR.⁴ 

Do AR symptoms worsen during winter months? 

Allergic triggers can be differentiated based on the duration of symptoms: Perennial (year-round) or seasonal, and whether they are associated with being indoors or outdoors. Perennial indoor allergens include house dust mites, and cat and dog dander. During winter, exacerbations of AR may occur when indoor living increases and symptoms flare-up as a result of increased exposure.⁴ 

In addition to increased exposure to indoor allergens, a flurry of recent studies has explored the link between meteorological factors and AR. These studies consistently identify cold weather as a significant risk factor for AR, likely due to its effects on the respiratory epithelium and the induction of bronchial hyperresponsiveness.^5,6 

Wang and colleagues set out to explore the specific impact of temperature variability on AR. They studied AR-related emergency room visits, outpatient visits, and weather conditions from 2014 to 2016. They found that there were 53 538 recorded cases of AR during the study period. The average diurnal temperature range was 8.4°C (ranging from 1°C to 21.2°C), and it did not show a significant adverse effect on AR. However, the average two neighbouring days TCN was 0°C (ranging from -12.2°C to 5.9°C) and was significantly associated with an increased risk of AR. A large temperature drop of 3.8°C resulted in a delayed, short-lasting effect on AR, with a relative risk of 1.02. Boys and children >15-years seemed more vulnerable to the effects of TCN.⁵ 

The impact of cold-induced AR 

Hyrkäs-Palmu et al hypothesised that individuals living with AR and/or asthma experience cold weather-related functional disability (FD) and exacerbation of health problems (EH) more frequently than those without these conditions.⁶ 

This population-based study included 7 330 adults with confirmed diagnoses of asthma and AR, as well as outcomes like cold weather-related FD and EH, using a self-administered questionnaire. The prevalences of cold-related FD and EH were found to be 20.3% and 10.3%, respectively.⁶ 

Furthermore, the study found that the risk of FD increased in relation to AR (adjusted prevalence ratio [PR] 1.19 for men vs. 1.26 for women), asthma (1.29 for men vs. 1.36 for women), and their combination (1.16 for men vs. 1.40 for women). Similarly, the risk of cold weather-related EH was associated with AR (1.53 for men vs. 1.78 for women), asthma (4.28 for men vs. 3.77 for women), and their combination (4.02 for men vs. 4.60 for women).⁶  

The authors concluded that their study provides new evidence that individuals living with AR and/or asthma are more susceptible to cold weather-related FD and EH compared to those without pre-existing respiratory diseases.⁶ 

How is cold-induced AR treated? 

AR treatment in general include allergen avoidance and pharmacotherapy. Intranasal corticosteroids (INCS) are the cornerstone of pharmacotherapy, and occasionally, a short course of oral corticosteroids (CS) may be necessary, particularly in cases involving comorbidities such as asthma or nasal polyps, severe symptoms, or intolerance to INCS. When oral CS are used, they should be combined with INCS.⁴  

Intranasal CS (INCS) are superior to AHs and leukotriene receptor antagonists in relieving all symptoms of acute AR, including ocular symptoms and airway hyperresponsiveness when AR and asthma coexist. AHs offer a faster onset of action.⁴ 

AHs, with their relatively fast onset of action, serve as useful adjunctive therapy to INCS. Second-generation AHs are less lipid-soluble, making it difficult for them to cross the blood-brain barrier, thus avoiding the sedative and cognitive effects associated with first-generation agents.⁴  

A topical AH, such as azelastine nasal spray in combination with an INCS, may be beneficial if the response to oral therapy is inadequate, recommend Green et al.⁴ 

The updated Allergic Rhinitis and its Impact on Asthma guidelines recommend either a combination of an INCS with an INAH or an INCS alone.  According to the authors of 2023 International Consensus Statement on Allergy and Rhinology, INCS/INAH combination therapy offers rapid symptom relief and superior efficacy compared to monotherapy.^7,8 

The updated review (2023) of the South African Allergic Rhinitis Working Group (SAARWG) also recommends combination INCS/INAH therapy. According to the group, combination therapy should be considered early in the treatment plan if available for moderate-to-severe AR.  The SAARWG also recommends fixed-dose combination (FDC) INCS/INAH therapy as an alternative therapeutic option for AR management.⁹ 

Viatris recently announced the launch of their new fixed-dose combination (FDC) azelastine/fluticasone nasal spray for the treatment of moderate-to-severe seasonal and perennial AR in adults if the use of either INAH or CS alone are not considered sufficient. This combination is also approved for the treatment seasonal AR in paediatric patients ≥6-years.¹⁰  

Various studies have examined the safety and effectiveness of combination azelastine/fluticasone nasal spray in different scenarios. Ratner et al demonstrated that this combination significantly improved TNSS by 37.9%. Similarly, Hampel et al found that it enhanced TNSS, improving nasal congestion, runny nose, itchy nose, and sneezing, by 28.4%.^11,12 

In a recent systematic review and meta-analysis by Debbaneh et al, the combination azelastine/fluticasone nasal spray was found to outperform placebo in reducing TNSS by 60%. The authors of this study concluded that the existing evidence strongly supports the efficacy and superiority of combination azelastine/fluticasone in alleviating symptom scores reported by patients with AR. Consequently, they advocate for considering combination nasal spray as a second-line therapy for patients whose AR symptoms are not adequately managed with monotherapy.¹³ 

Conclusion 

The overlap of flu and AR symptoms, compounded by cold weather exacerbating AR, presents a significant challenge for diagnosis and management. The introduction of FDC therapy offers a proactive approach to managing moderate-to-severe AR, providing relief for both adult and paediatric populations. With mounting evidence supporting its efficacy and safety profile, combination azelastine/fluticasone nasal spray stands as a compelling second-line therapy for patients whose AR symptoms remain inadequately controlled with monotherapy. 

References 

1. National Institute of Communicable Diseases. Influenza: NICD recommendations for the diagnosis, management, prevention and public health response. Updated April 2024. [Internet]. Available at: www.nicd.ac.za/wp-content/uploads/2024/05/Influenza-guidelines-2024_final.pdf 
2. Esterhuizen N, Berman DM, Neumann FH, et al. The South African Pollen Monitoring Network: Insights from 2 years of national aerospora sampling (2019-2021). Clin Transl Allergy, 2023. 
3. Allergy Foundation of South Africa. Allergic rhinitis. [Internet]. Available at: https://www.allergyfoundation.co.za/allergy-information/allergic-diseases/allergic-rhinitis/  
4. Green RJ, van Niekerk A, McDonald M, et al. Acute allergic rhinitis. SAFP, 2020. 
5. Hyrkäs-Palmu H, Ikäheimo TM, Laatikainen T, et al. Cold weather increases respiratory symptoms and functional disability especially among patients with asthma and allergic rhinitis. Sci Rep, 2018 
6. Wang X, Cheng J, Ling L, et al. Impact of temperature variability on childhood allergic rhinitis in a subtropical city of China. BMC Public Health, 2020. 
7. Brozek JL, Bousquet J, Agache I, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. Journal of Allergy and Clinical Immunology, 2017  
8. Wise SK, Damask C, Roland LT, et al. International Consensus Statement on Allergy and Rhinology: Allergic rhinitis – 2023. International Forum of Allergy and Rhinology, 2023. 
9. Richards GA, McDonald M, Gray CL, et al. Allergic rhinitis: Review of the diagnosis and management: South African Allergic Rhinitis Working Group. S Afr Fam Pract (2004), 2023. 
10. Professional information.  Dymista Nasal Spray. 2024. [Internet]. Available at: https://pi-pil-repository.sahpra.org.za/wp-content/uploads/2024/03/pil_dymista_approved_oct2023.pdf 
11. Ratner PH, Hampel F, Van Bavel J, et al. Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol, 2008. 
12. Hampel FC, Ratner PH, Van Bavel J, et al. Double-blind, placebo-controlled study of azelastine and fluticasone in a single nasal spray delivery device. Ann Allergy Asthma Immunol, 2010.  
13. Debbaneh PM, Bareiss AK, Wise SK, et al. Intranasal Azelastine and Fluticasone as Combination Therapy for Allergic Rhinitis: Systematic Review and Meta-analysis. Otolaryngology-Head and Neck Surgery, 2019.