NICE vs BSACI: Management of Allergic Rhinitis (2025)
Allergic rhinitis (AR) is a common condition in primary and secondary care, significantly impacting quality of life and productivity. In the UK, clinicians primarily refer to two key evidence-based guidelines: the National Institute for Health and Care Excellence (NICE) NG79 and the British Society for Allergy & Clinical Immunology (BSACI) guideline. While aligned on core principles, they offer distinct perspectives reflective of their remits. NICE provides a broad, primary-care-focused pathway, whereas BSACI delivers a more detailed, specialist-oriented approach. This comparison highlights these differences to aid clinicians in applying the most appropriate management strategy for their patients.
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Diagnosis and Assessment
NICE NG79 Approach
NICE emphasises a pragmatic, primary-care-led diagnosis. The focus is on a clinical history to identify typical symptoms (sneezing, rhinorrhoea, nasal blockage, itching) and their relationship with allergen exposure.
- Diagnostic Testing: Recommends skin prick testing as the first-line investigation. If skin prick testing is unavailable or contraindicated, serum-specific IgE (immunoCAP) testing is an alternative.
- Focus: On confirming the diagnosis of allergy and guiding allergen avoidance advice. The guideline is less focused on detailed phenotyping.
BSACI Approach
BSACI provides a more comprehensive assessment framework, suitable for both primary and secondary care. It stresses the importance of distinguishing AR from other forms of rhinitis (e.g., local allergic rhinitis, non-allergic rhinitis).
- Diagnostic Testing: Also recommends skin prick testing as primary. However, it gives more weight to the role of nasal allergen challenge as a gold standard for doubtful cases, particularly for local allergic rhinitis.
- Focus: On a detailed diagnostic work-up, including assessment of severity, impact on quality of life, and co-morbidities like asthma, which is crucial for step-up therapy decisions.
Key Difference: BSACI offers greater depth on differential diagnosis and investigation nuances, reflecting its specialist audience. NICE prioritises a quick, accessible diagnostic path for general practice.
Treatment: Pharmacological Management
Both guidelines advocate a stepwise approach, but with notable differences in sequencing and recommendations for newer agents.
Stepwise Therapy: NICE
- Step 1 (Mild, intermittent): Recommend an intranasal antihistamine (e.g., azelastine) or an intranasal corticosteroid (INS).
- Step 2 (Moderate-severe, persistent): A regular INS is the cornerstone of treatment.
- Add-on Therapy: If symptoms persist after 2-4 weeks, add a non-sedating oral antihistamine.
- Step 3 (Severe, persistent): Consider referral for immunotherapy or adding a short course of oral corticosteroids (with caution).
Practical Takeaway: NICE places intranasal antihistamines on par with INS for initial mild/intermittent symptoms, offering an alternative for patients averse to steroids.
Stepwise Therapy: BSACI
- Step 1 (All patients with persistent symptoms): A regular INS is the unequivocal first-line treatment for persistent AR.
- Add-on Therapy: For inadequate response, add an intranasal antihistamine (preferred) or an oral antihistamine. BSACI highlights the evidence for the combination spray (INS + azelastine) as a highly effective option at this stage.
- Step 3: Recommends referral for immunotherapy assessment earlier in the pathway for suitable candidates, before considering oral corticosteroids.
Practical Takeaway: BSACI firmly positions INS as the foundation of treatment for anyone with persistent symptoms, reflecting its superior efficacy. The combination spray is explicitly endorsed as a key add-on.
Key Differences in Treatment
- First-line for mild disease: NICE offers a choice (INS or nasal antihistamine). BSACI recommends INS for any persistent symptoms.
- Combination Spray: BSACI strongly advocates for its use as add-on therapy. NICE NG79 (2019) predates its widespread availability and does not feature it prominently.
- Immunotherapy: BSACI encourages earlier consideration, aligning with its specialist focus on modifying the disease course.
Special Situations
Pregnancy and Breastfeeding
- NICE: Advises that the use of INS (especially beclomethasone and budesonide) and loratadine is considered safe, but to use the lowest effective dose. Recommends consultation with the GP.
- BSACI: Provides more detailed guidance, stating that second-generation antihistamines (loratadine, cetirizine) and INS (budesonide preferred) are safe. Emphasises the importance of controlling AR for the mother's and baby's wellbeing.
Children
- Both guidelines agree on the use of age-appropriate INS (e.g., fluticasone propionate from 4 years, mometasone from 3 years).
- BSACI offers more specific dosing and formulation advice for paediatric populations.
Asthma Co-morbidity
- Both strongly emphasise the link between AR and asthma and the importance of treating AR to improve asthma control.
- BSACI provides a more detailed rationale and evidence base for this crucial connection.
Practical Clinical Flow: A Hybrid Approach
For a UK clinician, integrating both guidelines can create an efficient pathway:
- Diagnosis (NICE-led): Take a clinical history. Confirm allergy via skin prick test or specific IgE blood test in primary care.
- Initial Treatment (BSACI-led for persistence): For patients with persistent symptoms, initiate a regular intranasal corticosteroid (INS) as first-line (BSACI principle). For truly mild, intermittent symptoms, an intranasal antihistamine is a valid option (NICE principle).
- Review at 2-4 Weeks: Assess response.
- Inadequate Response (BSACI-led): Add an intranasal antihistamine, preferably via a combination spray if available and appropriate. Ensure correct technique for INS use.
- Further Inadequate Response/Poorly Controlled Severe AR: Consider referral to secondary care for further assessment, consideration of immunotherapy, and exclusion of other causes (e.g., nasal polyps). This aligns with both guidelines but is a stronger recommendation in BSACI.
Frequently Asked Questions (FAQs) for Clinicians
1. Which guideline should I follow in primary care?
NICE NG79 is designed for you. It offers a straightforward, cost-effective pathway. However, adopting BSACI's strong recommendation of INS as first-line for persistent symptoms is an evidence-based enhancement to the NICE pathway.
2. Is the combination spray (INS + antihistamine) available on the NHS?
Yes. Dymista® (fluticasone propionate and azelastine) is licensed for use in the UK and is available on prescription. It is recommended by BSACI as a highly effective option for patients not fully controlled on INS alone.
3. When should I refer for allergen immunotherapy?
Consider referral for patients with severe AR that remains uncontrolled despite optimal pharmacotherapy (high-dose INS + add-ons) and with a confirmed specific IgE to a relevant allergen. BSACI encourages earlier referral to explore this disease-modifying option.
4. How important is nasal spray technique?
Critical. Both guidelines implicitly highlight that poor technique is a major cause of treatment failure. Clinicians should routinely demonstrate and check technique: head tilted slightly forward, spray directed laterally away from the septum.
5. What about non-pharmacological measures?
Both guidelines agree that allergen avoidance should be advised but is often difficult to achieve and has limited evidence for efficacy alone. House dust mite avoidance measures are generally not recommended due to lack of proven benefit. The mainstay of treatment is pharmacological.
Source Links
- NICE Guideline NG79 (Last updated Feb 2019): Allergic rhinitis | Diagnosis and management | Guidance | NICE
- BSACI Guideline (2025 - Expected Update): (The current BS guideline is Scadding et al. 2017. Clinicians should check the BSACI website for the 2025 publication.)
- Current (2017) Reference: Scadding, G.K. et al. (2017). Clin Exp Allergy. 47(7):856-889. DOI Link
- BSACI Website: British Society for Allergy & Clinical Immunology