Question

Is hay fever more common in people with ME? I’m in my midthirties and never had hay fever before being diagnosed with ME several years ago. Every summer and autumn I now have the full list of hay fever symptoms – runny nose, blocked nose and red itching eyes. This year it has been worse than ever and my chest has been wheezy as well. MY GP thinks it may have triggered mild asthma. And is it safe to use a steroid nasal spray for hay fever if you have ME?

Answer

There is quite a lot of anecdotal patient evidence, and some research evidence, to indicate that allergic conditions like Hay Fever are more common in people with ME/CFS. The reasons are uncertain but it could involve both genetics and immune system dysfunction. Hay Fever was actually quite rare two hundred years ago, but it’s now very common and affects around a quarter of the population. A similar increase has occurred in other allergic disorders – something that may be due to a lack of early exposure to infections, growing up in a very clean environment, or overdiagnosis and a growth in unconventional testing.

Also known as seasonal allergic rhinitis, Hay Fever is often trivialised but it can cause severe symptoms and progress to, or worsen, asthma. Symptoms are caused by an overactive response in the body’s immune system to a wide range of plant and tree pollens. This triggers the release of chemicals such as histamine – which cause sneezing, itching, blockage in the nose, often with itching, watering and redness in the eyes. It can sometimes be difficult to distinguish a cold from Hay Fever. Colds usually start with a sore throat, only last a few days and do not tend to cause itching or eye symptoms. Hay Fever might also be confused with Covid-19 because some people with Covid have nasal symptoms. Fever, cough, malaise, myalgia, diarrhoea, or sudden complete loss of smell are all far more suggestive of Covid-19. Eye symptoms and itching are more likely in Hay Fever and symptoms usually occur at specific seasonal times of year (spring for tree pollens; summer for grass pollens; autumn for weed pollens and mould spores).

Diagnosis and management can be aided by the identification of specific (IgE) antibodies to the various triggers. This can be done by skin prick testing or by a blood test but false positive results can occur. A screening test using IgE to multiple allergens is inadvisable. Instead, specific pollens suggested by patient history should be tested.

Management

1. Allergen avoidance: Hay fever does not usually occur outside of the relevant pollen season. Taking a holiday during the time of highest pollen peaks (e.g., the last fortnight in June for grass pollen) to a place further south where the pollen season has already finished can be helpful, but might not be practical if you have ME/CFS.
   • Plan outdoor activities for the middle of the day when pollen grains have risen into the atmosphere.
   • Try to avoid being outside in the evening when pollen descends as the air cools.
   • Bring in any washing that is drying outside before the evening for the same reason.
   • Hair washing helps to remove pollen and prevents deposition on pillows.
   • Wrap-around sunglasses reduce eye contact with pollen.
   • Nasal douching with salt water after pollen exposure can reduce symptoms.
2. Steroid nasal sprays effective than antihistamines are more and should be considered for anyone with symptoms that are more than a mild nuisance. Regular daily use, starting a week or two before expected symptom onset, gives optimal results. Corticosteroids in nasal sprays are safe for people with ME/CFS and are not associated with the problems of high-dose oral steroids. Correct use of a spray, avoiding the nasal septum (the fleshy bit between the nostrils), is important.
3. Oral antihistamine tablets be purchased in pharmacies can and are often used as a first-choice treatment. However, they tend to be less effective than steroid nasal sprays and slower in onset. They improve eye symptoms and itchy skin as well as reducing nasal itching, running, and sneezing but have little effect on nasal blockage. Intranasal antihistamines are twice as effective on nasal symptoms as oral ones and act within 15 minutes. Some patients dislike the bitter taste of intranasal azelastine.
4. A prescription combination spray containing a corticosteroid (fluticasone propionate) and a nasal antihistamine (azelastine) is now available. This is superior to either drug used alone and provides more rapid relief than a steroid nasal spray used alone, which can take several days to reach maximal effect.
5. Topical decongestant formulations constrict tiny blood vessels and relieve obstruction within minutes and are very popular. However, they are best avoided, or only used occasionally for a few days, because they can make things worse if use more often.
6. Alternative remedies: butterbur was a herb shown to be effective as an antihistamine in one study. However, herbal preparations are not often produced to good standards and have been associated with liver disease. Homeopathic preparations and acupuncture also have a very weak and even non-existent scientific evidence base.
7. Allergen-specific immunotherapy can alter the course of disease and may also reduce asthma and new sensitisations. Dissolvable tablets of grass pollen allergen are available and are effective.
8. More complicated treatment requires four to six pre-seasonal injections or year-round immunisation, initially weekly, then monthly. All forms of immunotherapy require referral, usually to a hospital allergist or immunologist for assessment of suitability.
9. People with uncontrolled and severe hay fever are prime candidates for referral. Doctors should also consider referring patients who cannot tolerate drug treatments or whose futures may be impaired by their symptoms – such as teenagers with important examinations.

More information

• The NHS: Hay Fever: Causes, Symptoms, Treatments | February 2021