Hay fever: start three weeks before you think you need to

Every year, in the last week of April, a run of people come in miserable, having started an antihistamine four days earlier and concluded it does not work.

It probably does work. It has just been started three weeks late.

Why timing changes the outcome

Allergic rhinitis is an inflammatory process that builds. Once the nasal mucosa is inflamed and the mast cells are primed, you are no longer preventing a reaction — you are trying to suppress one that is already running. That is a harder job and the drugs do it less well.

Steroid nasal sprays in particular take ten to fourteen days to reach full effect. Starting one on a bad day and judging it on Thursday is the single most common reason people decide it was useless.

Start two to three weeks before your usual season. For tree pollen that means late February; for grass, mid-to-late April.

The order of things

A steroid nasal spray is the most effective single treatment for moderate symptoms, and it is consistently under-used. Technique matters more than the product: aim outwards, towards the ear on the same side, not up towards the middle of your head. Do not sniff hard — it takes it straight past where it needs to be. If you taste it, it has gone too far back.

A non-sedating antihistamine daily through the season, not as needed. Cetirizine, loratadine, fexofenadine. There is little between them; if one does nothing after a fortnight, switching is reasonable.

Eye drops separately if the eyes are the main problem, because neither of the above does much for them.

When to come in

If you are doing all three properly and still struggling, there are options — higher-dose combination sprays, a short course of something stronger, and for a small number of people, immunotherapy, which actually modifies the disease rather than suppressing it.

Also come in if what you are calling hay fever lasts all year. Perennial symptoms usually mean dust mite or animal dander, and the management is different.

And if there is wheeze with it, that needs assessing. Allergic rhinitis and asthma are the same airway, and uncontrolled nasal symptoms make asthma harder to control.