Allergic rhinitis
- Recommendations
1- PATIENT HISTORY AND PHYSICAL EXAMINATION: Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes.
➡️Strong recommendation
Moderate quality evidence (Observational studies) (3-6)
2- ALLERGY TESTING:
Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy.
➡️Strong recommendation
High quality evidence (RCTs and systematic reviews) (7-15)
3- IMAGING:
Clinicians should not routinely perform sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR.
➡️Strong recommendation against
Moderate quality evidence (Observational studies) (16,17)
4- ENVIRONMENTAL FACTORS:
Clinicians may advise avoidance of known allergens or
may advise environmental controls (eg, removal of pets;
the use of air filtration systems, bed covers, and acaricides
[chemical agents that kill dust mites]) in AR patients who
have identified allergens that correlate with clinical symptoms.
➡️Conditional recommendation
Moderate quality evidence (Randomized controlled trials and observational studies) (18-23)
5- CHRONIC CONDITIONS AND COMORBIDITIES:
Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media.
➡️Conditional recommendation
Moderate quality evidence (Randomized controlled trials with some heterogeneity) (24-31)
6- PHARMACOLOGIC THERAPY:
A- TOPICAL STEROIDS:
Clinicians should recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life.
➡️Strong recommendation
High quality evidence (RCTs with minor limitations) (32-39)
B- ORAL ANTIHISTAMINES:
Clinicians should recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching.
➡️Strong recommendation
High quality evidence (RCTs with minor limitations) (40-48)
C- INTRANASAL ANTIHISTAMINES:
Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR.
➡️Conditional recommendation
High quality evidence (RCTs and observational studies) (49-53)
D- ORAL LEUKOTRIENE RECEPTOR ANTAGONISTS (LTRAs):
Clinicians should not offer LTRAs as primary therapy for patients with AR.
➡️Strong recommendation against
High quality evidence (RCTs and systematic reviews) (54-57)
E- SALINE NASAL WASH:
Saline nasal wash is recommended as part of the treatment strategy for AR.
➡️Strong recommendation
High quality evidence (RCTs and systematic reviews) (58-64)
F- ORAL CORTICOSTEROIDS :
Recommendation against the routine use of oral corticosteroids for AR. Although not recommended for routine use in AR, certain clinical scenarios warrant the use of short courses of systemic corticosteroids after a discussion of the risks and benefits with the patient. This may include patients with significant nasal obstruction that would preclude penetration of intranasal agents (INCSs or antihistamines). In these cases, a short course of systemic oral corticosteroids could improve congestion and facilitate access and efficacy of the topical agents.
➡️Conditional recommendation against
Moderate quality evidence (RCTs) (65-68)
G- CROMOLYN :
Disodium chromoglycate (DSCG) may be considered for the treatment of AR, particularly in patients known triggers and who cannot tolerate INCSs.
➡️Conditional recommendation
Low quality evidence (69-72)
H- INTRANASAL ANTICHOLINERGIC :
Ipratropium bromide nasal spray may be considered as an adjunct medication to INCSs in PAR patients with uncontrolled rhinorrhea.
➡️Conditional recommendation
Low quality evidence (73-75)
I- OMALIZUMAB:Stronge recommendation against the use of Omalizumab as monotherapy in the treatment of AR. Omalizumab may be used for patients with clear IgE mediated asthma with cpexistent allergic rhinitis who fail conventional therapy. Omalizumab is not currently approved by the FDA for AR treatment. Also as an expensive treatment, cost should be taken into consideration.
➡️Strong recommendation against use in treatment of allergic rhinitis alone
High quality evidence (RCTs and systematic reviews)(76-78)
7- COMBINATION THERAPY:
Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy.
➡️Conditional recommendation
Moderate quality evidence (RCTs and observational studies)
There is strong evidence supporting the use of some combinations and the ineffectiveness of other combinations:
▪️ Intranasal Steroids and Intranasal Antihistamines
The combination of INS and intranasal antihistamine is more
effective than INS or intranasal antihistamine monotherapy
for AR. (79-81)
▪️ Intranasal Steroids and Oral Antihistamines:
When patients have no response to INS or incomplete control of nasal symptoms with an INS, oral antihistamines should not be routinely used as additive therapy. (82-84)
▪️ Oral Antihistamines and Oral Decongestants:
Oral antihistamines and oral decongestant combinations control AR symptoms better than either oral antihistamine or oral decongestant alone. Oral decongestant use is not recommended for patients under 4 years of age, and the extended release, 120-mg, 12-hour dose is not recommended for patients under 12 years of age. There is recommendation against long-term use given the significant side effect profile of oral decongestants. (85-88)
▪️ Oral Antihistamines and Leukotriene Receptor Antagonists:
There is conflicting evidence as to whether combined treatment with oral antihistamine and LTRA is superior to either as single treatment, and therefore routine use of combined therapy is not recommended. Combination of oral antihistamine and LTRA is either inferior to or less likely equivalent to INS monotherapy in control of AR symptoms.
Combination therapy with LTRA and oral antihistamine is an option for management of AR, particularly in patients with comorbid asthma or those who do not tolerate INCSs and symptoms are not well-controlled on oral antihistamine monotherapy. (89-95)
▪️ Intranasal Steroids and Leukotriene Receptor Antagonists:
LTRAs should not routinely be used as additive therapy for
patients benefiting from INS for AR. (96-100)
▪️ Intranasal Steroids and Intranasal Oxymetazoline:
The combination of INS and intranasal oxymetazoline is more
effective in controlling AR symptoms than either monotherapy. Short-term use (<3 days) of this combination in cases of severe nasal congestion is recommended. (101-103)
8- PHARMACOLOGIC THERAPY OF ALLERGIC RHINITIS ASSOCIATED WITH BRONCHIAL ASTHMA:
Asthma association with AR and nonallergic rhinitis: Most patients with asthma also have rhinitis, and 10%-40% of rhinitis patients have asthma. IgE mediated inflammation may involve both the upper and lower airways, supporting the unified airway concept.
Rhinitis as a risk factor for asthma: Rhinitis, both allergic and nonallergic, is a risk factor for developing asthma. Asthma and AR also share common risk factors, such as allergen sensitization.
Pharmacotherapy: was reviewed in the treatment of AR with coexisting asthma. Recommendations are as follows:
▪️ Use of pharmacotherapy other than systemic steroids: Recommended for optimal control of AR, with potential additional benefit for coexistent asthma, although not recommended for primary intent of asthma treatment.
▪️ Use of systemic corticosteroid is not recommended for routine use in AR with comorbid asthma due to an unfavorable risk-benefit profile, although certain situations may indicate a short course (eg, acute asthma exacerbation).
▪️ Omalizumab: Recommended for those patients with clear IgE-mediated allergic asthma with coexistent AR who fail conventional therapy. The significant additional cost of this therapy should be considered in its evaluation.
➡️Strong recommendation
High quality evidence (RCTs and Systematic reviews) (104-106)
9- IMMUNOTHERAPY:
Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy.
➡️Strong recommendation
High quality evidence (RCTs and observational studies) (107-113)
10- INFERIOR TURBINATE REDUCTION:
Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management.
➡️Conditional recommendation
Moderate quality evidence (Observational studies) (114-117)
11- HERBAL THERAPY:
No recommendation regarding the use of herbal therapy for patients with AR, based on limited knowledge of herbal medicines and concern about the quality of standardization
and safety.
➡️No recommendation
Low quality evidence (118-125)