New guideline released on allergic rhinitis

The American Academy of Otolaryngology-Head and Neck Surgery Foundation released a new clinical guideline last week on allergic rhinitis.

The guideline was developed by experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced pediatric nursing, and complementary and integrative medicine, with the goal of optimizing care of adults and children age 2 and older with allergic rhinitis. The guideline was based on evidence from 9 clinical practice guidelines, 81 systematic reviews, and 177 randomized, controlled trials published between June 2013 and February 2014.

The expert panel strongly recommended intranasal steroids for patients whose allergic rhinitis is affecting their quality of life. It also strongly recommended oral second-generation or less sedating antihistamines for patients with allergic rhinitis whose primary symptoms are sneezing and itching. The panel also made the following recommendations:

• Clinicians should make a clinical diagnosis of allergic rhinitis when patients present with a history and physical exam consistent with an allergic cause (including but not limited to clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes) and 1 or more of the following: nasal congestion, runny nose, itchy nose, or sneezing.
• Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing when patients with a clinical diagnosis of allergic rhinitis do not respond to empiric treatment, when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy.
• Clinicians should assess for and document in the medical record associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media in patients with a clinical diagnosis of allergic rhinitis.
• Clinicians should offer or refer to a clinician who can offer sublingual or subcutaneous immunotherapy for patients with allergic rhinitis who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls.

The expert panel recommended against routine sinonasal imaging in patients presenting with symptoms consistent with an allergic rhinitis diagnosis, as well as against oral leukotriene receptor antagonists as primary therapy for patients with allergic rhinitis. The panel made no recommendation on use of herbal therapy but noted that physicians may offer acupuncture or a referral for acupuncture to patients who are interested in nonpharmacologic therapy.

The expert panel also recommended that clinicians may offer combination pharmacologic therapy to patients with inadequate response to pharmacologic monotherapy, as well as intranasal antihistamines for patients with seasonal, perennial, or episodic allergic rhinitis.

The full guideline, which was published Feb. 2 by Otolaryngology-Head and Neck Surgery, is available free of charge online.