PRACTICE RECOMMENDATIONS
• Use nasal steroids to treat allergic rhinitis (AR) in adults. A
• Recommend nasal saline irrigation to reduce symptoms in children and adults with seasonal rhinitis. A
• Consider immunotherapy for adults and children with severe AR that does not respond to conventional pharmacotherapy or allergen avoidance measures. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A man in his 30s with allergic rhinitis (AR) at predictable times of the year with high pollen counts reports only modest symptom relief with a nasal steroid preparation after 3 weeks of use. He comes to see you because he’s “tired of feeling lousy all of the time.”
What management options would you consider?
There is a plethora of treatment options for patients like this one, and considerable variation in clinical practice when it comes to AR.1 The good news is that there are several recent guidelines for treating AR patients, whose symptoms (and underlying cause) can vary widely.
The following review—and accompanying algorithm—provides evidence-based recommendations that can help you refine your approach to AR.
Two guidelines, and several Cochrane reviews
Allergic Rhinitis and its Impact on Asthma (ARIA), a sentinel rhinitis treatment guideline, was published in 2001 and updated in 2008 and 2010.2-4 The British Society for Allergy and Clinical Immunology Standards of Care Committee (BSACI) published guidelines for rhinitis management in 2008 and guidelines for immunotherapy in 2011.5,6 In addition, several Cochrane reviews have been performed.7-12 The ALGORITHM1-6 combines these recommendations. The TABLE2-12 itemizes the recommendations made by each guideline.
ALGORITHM
An evidence-based approach to treating allergic rhinitis1-6
Based on recommendations from ARIA and BSACI guidelines and Cochrane reviews
ARIA, Allergic Rhinitis and its Impact on Asthma; BSACI, British Society for Allergy and Clinical Immunology Standards of Care Committee.
TABLE
Treatment recommendations/suggestions for allergic rhinitis2-12
| TREATMENT RECOMMENDATIONS/SUGGESTIONS | ARIA 2001 | ARIA 2008 | ARIA 2010 | BSACI 2008 | BSACI 2011 | COCHRANE REVIEWS |
|---|---|---|---|---|---|---|
| General principles of treatment | ||||||
| Maintenance therapy is required for persistent AR as medications have little effect after cessation. | X | |||||
| Patient education | ||||||
| Standardized patient education improves disease-specific quality of life. | X | |||||
| Nasal steroids | ||||||
| NS are the most effective monotherapy for all symptoms of AR, seasonal and perennial,* including nasal congestion. | X | |||||
| NS are recommended for AR treatment in adults and suggested for children. | X | |||||
| NS are the treatment of choice for moderate to severe persistent* AR and for treatment failures with antihistamines alone. | X | |||||
| NS are suggested over oral antihistamines in adults and children for seasonal AR. | X | |||||
| NS are suggested over oral antihistamines for adults and children with persistent AR. | X | |||||
| NS are recommended rather than nasal antihistamines. | X | |||||
| NS are recommended over oral leukotriene receptor antagonists for seasonal AR. | X | |||||
| NS are the most effective treatment of AR for children. | X | |||||
| There is insufficient evidence for or against the use of oral antihistamines plus NS vs NS alone in children with AR. | X (2010) | |||||
| Intermittent* NS use may be beneficial in children. | X | |||||
| Avoid NS with high bioavailability (betamethasone) in children, as regular use for >1 year may decrease growth rate. | X | |||||
| Antihistamines | ||||||
| New-generation oral nonsedating antihistamines that do not affect cytochrome P450 are recommended for the treatment of patients with AR. | X | |||||
| Oral or topical antihistamines are first-line treatment for mild to moderate intermittent and moderate persistent AR. | X | |||||
| When NS alone do not control moderate to severe persistent AR, may add oral or topical antihistamines. | X | |||||
| New-generation oral antihistamines are suggested over nasal antihistamines for children and adults, and for children with seasonal or persistent AR. | X | |||||
| Oral antihistamines are suggested over oral leukotriene receptor antagonists in patients with seasonal AR and in preschool children with persistent AR. | X | |||||
| Nasal antihistamines are suggested over nasal chromones (the need to use chromones 4 times daily may limit adherence). | X | |||||
| Nasal antihistamine use is suggested for children and adults with seasonal AR. | X | |||||
| Patients with persistent AR should avoid using nasal antihistamines until more data on efficacy and safety are available. | X | |||||
| In children, weigh adverse effects of antihistamines against the general malaise caused by AR. | X | |||||
| Treatment with once-daily, long-acting antihistamines rather than multiple daily dosing may improve adherence in children. | X | |||||
| Continuous administration of antihistamines is optimal in children, rather than as needed. | X | |||||
| Intraocular antihistamines or intraocular chromones are suggested for patients with ocular symptoms. | X | |||||
| Oral leukotriene receptor antagonists | ||||||
| Oral leukotriene receptor antagonists are suggested for children and adults with seasonal AR and for preschool children with persistent AR. | X | |||||
| Avoid oral leukotriene receptor antagonists in adults with persistent AR. | X | |||||
| Decongestants | ||||||
| For adults with severe nasal obstruction, a short course (<5 days) of a nasal decongestant, along with other drugs, is suggested. | X | |||||
| Nasal decongestants may be useful for eustachian tube dysfunction when flying, for children with acute otitis media with middle ear pain, to relieve congestion after an upper respiratory infection, and to improve nasal patency prior to NS use. | X | |||||
| Regular oral decongestant use is not suggested. | X | X | ||||
| Avoid decongestants in pregnant patients. | X | |||||
| Avoid using nasal decongestants in preschool children. | X | |||||
| Chromones | ||||||
| Limited use of chromones is recommended for children and adults with mild symptoms. | X | |||||
| Chromones are less effective than NS or antihistamines. | X | |||||
| Nasal antihistamines are suggested over nasal chromones. | X | |||||
| Intraocular antihistamines or intraocular chromones are suggested for ocular symptoms. Due to the excellent safety of these agents, chromones may be tried before antihistamines. | X | |||||
| Nasal saline | ||||||
| Nasal saline irrigation reduces symptoms in children and adults with seasonal rhinitis. | X | |||||
| Oral, intramuscular steroids | ||||||
| A short course of oral glucocorticosteroids is suggested for patients with AR and moderate to severe nasal or ocular symptoms not controlled with other treatments. | X | |||||
| Oral steroids are rarely indicated, but a short course (5-10 days) may be used for severe nasal congestion, uncontrolled symptoms on conventional pharmacotherapy, or important social/work events. | X | |||||
| Avoid intramuscular steroids. | X | X | ||||
| Ipratropium | ||||||
| Nasal ipratropium is suggested for treatment of rhinorrhea for patients with persistent AR. | X | |||||
| Allergen-specific immunotherapy | ||||||
| Immunotherapy is effective for adults and children with severe AR who do not respond to conventional pharmacotherapy or allergen avoidance measures. | X | |||||
| SCIT is suggested for adults with seasonal AR and those with persistent AR due to house dust mites. | X | |||||
| SCIT is efficacious for patients with seasonal AR due to pollens, resulting in decreased symptoms and medication use with few severe adverse reactions. | X (2007) | |||||
| SLIT is suggested for adults with AR due to pollen, although other alternatives may be equally reasonable. | X | |||||
| SLIT is safe and efficacious for AR treatment, decreasing symptoms and medication requirements. | X (2003) | |||||
| Nasal immunotherapy is suggested for adults with AR due to pollens. | X | |||||
| For pregnant patients, maintenance ASI may be continued, but starting ASI or increasing the dose is contraindicated. | X | |||||
| SCIT is suggested for children with AR. | X | |||||
| SCIT should not be started before 5 years of age. | X | |||||
| Based on preliminary studies, SLIT is safe, but more studies are needed in children. | X | |||||
| SLIT and NIT are suggested for children with AR due to pollens, acknowledging that other alternatives may be equally reasonable. SLIT should not be given to children with AR due to HDM unless being done for research. | X | |||||
| Lifestyle changes | ||||||
| Avoid single chemical or physical preventive and combination preventive methods to reduce HDM exposure. | X | |||||
| Allergen avoidance may decrease AR symptoms, but more research is needed. | X (2010) | |||||
| Achieving substantial reductions in HDM load may decrease AR symptoms. | X (2012) | |||||
| Avoidance of mold or animal dander is recommended for patients who are allergic to them. | X | |||||
| Nasal filters can reduce symptoms of AR during ragweed and grass pollen seasons. | X | |||||
| Complementary and alternative medicine | ||||||
| Avoid homeopathy, acupuncture, butterbur, herbal medicines, and phototherapy. | X | |||||
| AR, allergic rhinitis; ARIA, Allergic Rhinitis and its Impact on Asthma; ASI, allergen-specific immunotherapy; BSACI, British Society for Allergy and Clinical Immunology Standards of Care Committee; HDM, house dust mites; NIT, nasal immunotherapy; NS, nasal steroids; SCIT, subcutaneous immunotherapy; SLIT, sublingual immunotherapy. *ARIA 2008 recommended changing the classification of AR from seasonal and perennial (frequent nonseasonal nasal or ocular symptoms) to intermittent (symptoms lasting <4 days per week or <4 weeks per year) or persistent (symptoms >4 days per week and >4 weeks per year).3 AR severity is classified as mild or moderate to severe.2,3 | ||||||