This blog on the evidence behind the hayfever injection is written by Dr Randhawa, a GP in the Birmingham area. She also works as the skincare lead for The Aesthetics Doctors in our Harborne and Quinton clinics.
What is hayfever?
Hay fever, also known as allergic rhinitis, is an allergic condition characterized by an immune system reaction to allergens such as pollen, dust mites, animal dander, or mold spores. In hay fever, the immune system mistakenly identifies these allergens as harmful and releases chemicals, such as histamine, triggering symptoms. Common symptoms include sneezing, a runny or congested nose, itchy or watery eyes, itching in the throat or ears, coughing, fatigue, headache, and sinus pressure or pain. It can significantly impact an individual’s quality of life if left untreated. Hay fever is different from a common cold, as it is caused by an allergic response rather than a viral infection. Treatment options include avoiding allergens, using over-the-counter antihistamines, nasal sprays, eye drops and in some cases, prescribed medications or allergen immunotherapy.
What is the hayfever injection?
The hayfever injection is a steroid injection; Kenalog (triamcinolone) is injected into a large muscle of the body such as the buttocks.
How does the hayfever injection work?
For approximately 1 in 10 people, at home or over the counter remedies for hayfever aren’t enough to relieve their symptoms. The hayfever injection, Kenalog (triamcinolone), works by administering a corticosteroid medication into a large muscle in the body, usually the gluteal muscle (buttocks). The kenalog injection contains triamcinolone, which is a synthetic corticosteroid. When injected, Kenalog functions by suppressing the immune system’s abnormal reaction to pollen and reducing inflammation in the body.
Specifically, in the context of hay fever, it helps alleviate symptoms by reducing the inflammation and sensitivity in the nasal passages and airways caused by the allergic response to pollen or other allergens. By reducing the immune system’s response to allergens, Kenalog can help relieve symptoms such as sneezing, congestion, itching, and runny nose associated with hay fever. Patients who receive hay fever injections generally require only one every hay fever season. However, it is not for patients who have ordinary hayfever symptoms which respond to over the counter medications. It should only be considered for those that have tried the usual remedies but they have been unsuccessful.
What are steroids?
Steroids are synthetic versions of hormones that the adrenal glands in the body naturally produce. These hormones regulate various bodily functions, including metabolism, immune response, inflammation, and stress. As doctors we prescribe steroids to treat conditions such as inflammatory diseases, autoimmune disorders, organ transplantation, skin conditions, and hormone deficiencies. It is crucial to use steroids under professional guidance due to their potential side effects. Gradual tapering off is necessary to avoid withdrawal symptoms.
What are the UK guidelines on the hayfever injection Kenalog?
The hayfever injection is no longer available on the NHS. However, some private clinics do still offer Kenalog injections. In October 2019, the drug license for kenalog to be used for hayfever was withdrawn due to concerns about its safety profile. Allergy UK support this stance. A doctor (or any other qualified prescriber) working in a private clinic can still prescribe a medication which is no longer licensed for an indication but this is done ‘off label’ and prescribers must have a very good reason for not following the standard, widely accepted guidelines.
Following several high profile rulings, the Advertising Standards Authority (ASA), the Medicines and Healthcare products Regulatory Agency (MHRA) and the Committees of Advertising Practice (CAP) have issued a joint enforcement notice about the advertising of Kenalog injections. The enforcement notice advises all businesses that are offering kenalog injections as a treatment for hayfever to stop advertising it; this includes their websites and social media platforms. It also said patients must be made aware of the risks of using unlicensed treatments such as Kenalog (triamcinolone) during the consultation.
What are the risks of kenalog?
Kenalog injections deliver a high dose of steroids into the buttocks. However, the steroids do not stay here, they leak out of the muscle and travel throughout the body over three to eight weeks, affecting every body system. This is in contrast to steroid inhalers which are a smaller dose and locally delivered to the lungs. They therefore do not affect other body systems and have minimal side effects.
As kenalog injections work by suppressing your immune system, you can become more susceptible to infections and side effects. You may end up picking up infections such as the flu, chickenpox and shingles much more readily. The infections are also more likely to be severe and present atypically e.g septicaemia and tuberculosis (TB) may already be very advanced before they are recognised. Other common side effects include:
- Increased blood pressure
- Irregular heart beat
- Nausea
- Headache
- Dizziness
- Fluid retention
- Electrolyte imbalance
- Fatigue
- Skin rashes
- Increased weight
- Muscle weakness
- Breathing difficulties
- Abdominal pain
- Insomnia
- Taste disturbance
- Osteoporosis – see below
- Mental health problems – see below
How can steroids affect your mind?
Systemic steroids which affect the whole body, in high doses i.e kenalog are linked to psychiatric reactions such as euphoria, insomnia, irritability, mood lability, suicidal thoughts, psychotic reactions, and behavioural disturbances. Systemic corticosteroids should be prescribed with care in those predisposed to psychiatric reactions, including those who have previously suffered corticosteroid–induced psychosis, or who have a personal or family history of psychiatric disorders.
How can steroids affect your bones?
High doses of steroids can also weaken your bones, leading to osteoporosis and an increased risk of broken bones. They accelerate bone breakdown by increasing the activity of osteoclasts, the cells responsible for bone resorption. This excessive bone breakdown surpasses the rate at which new bone is formed by osteoblasts, leading to a net loss of bone density. As a result, bones become more fragile and prone to fractures.
What’s the bottom line?
The kenalog steroid injection may be tempting as a quick fix for hayfever symptoms but there are many concerns regarding its safety profile. It is certainly not for patients who have ordinary hayfever symptoms which respond to over the counter medications and should only be considered in rare cases where patients are resistant to usual measures. Even in these cases, the pros and cons need to weighed up carefully with a medical practitioner. It is no longer licensed to be used for hayfever and has been withdrawn by the NHS with good reason.
So how do you manage hayfever?
Managing hay fever according to the NICE (National Institute for Health and Care Excellence) guidelines involves several approaches. Here are some recommendations:
Self-care measures
Adopt self-help strategies like wearing wrap-around sunglasses outdoors, avoiding freshly cut grass, using petroleum jelly around the nostrils to trap pollen, and taking a shower after being outside to remove pollen from your body and hair.
Avoidance of allergens
If there are known causative allergens, try and minimize exposure to them. For people with a grass pollen allergy, avoid walking in grassy, open spaces and keep windows shut. For those with confirmed house dust mite allergy, it is recommended to wash all bedding at a high temperature at least once a week and use synthetic pillows anc acrylic duvets. Those that have an occupational allergy should eliminate the allergen where possible. If not, employers should ensure adequate ventilation.
Medications
Take over-the-counter antihistamines, nasal sprays, or eye drops to alleviate hay fever symptoms. Follow the recommended dosages and usage instructions. This can be discussed with the pharmacist if you are not sure.
Intranasal anti-histamines: intranasal antihistamines (azelastine) have a faster onset of action and are more effective than oral preparations.
Oral anti-histamines
Non-sedating anti-histamines such as loratadine and cetirizine are good first line choices.
Intranasal corticosteroids
Use intranasal corticosteroid sprays as a first-line treatment for moderate to severe hay fever symptoms. These sprays help reduce inflammation in the nasal passages, improving congestion and overall symptoms.
Combination therapy
If symptoms are not well controlled these treatments may need to be combined.
Allergen immunotherapy
For severe hay fever that doesn’t respond to a combination of these treatments, allergen immunotherapy may be considered. This involves gradual exposure to allergens to reduce sensitivity over time.
The kenalog injection is not in the NICE guidelines for the management of hayfever. If the above measures are not working, please consult your GP for up-to-date guidance, they can tailor the management plan to your needs to hopefully achieve good control of your symptoms. For more information on how to manage your symptoms, see the NHS website https://www.nhs.uk/conditions/hay-fever/ and patient.co.uk information leaflet https://patient.info/allergies-blood-immune/hay-fever-leaflet. The Allergy UK factsheets on Hay fever (Allergic Rhinitis) and Improving your indoor air quality are also helpful.