Allergic rhinitis

- Executive Summary

▪️ 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.

▪️ ALLERGIC 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.

▪️ IMAGING: Clinicians should not routinely perform sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR.

▪️  ENVIRONMENTAL FACTORS: Clinicians may advise avoidance of known allergens or may advise environmental controls in AR patients who have identified allergens that correlate with clinical symptoms.

▪️  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.

▪️  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.

B- ORAL ANTIHISTAMINES: Clinicians should recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching.

C- INTRANASAL ANTIHISTAMINES: Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR.

D- ORAL LEUKOTRIENE RECEPTOR ANTAGONISTS (LTRAs): Clinicians should not offer LTRAs as primary therapy for patients with AR.

E- SALINE NASAL WASH: Saline nasal wash is recommended as part of the treatment strategy for AR.

F- ORAL CORTICOSTEROIDS: Recommendation against the routine use of oral corticosteroids for AR.

G- CROMOLYN: Disodium chromoglycate (DSCG) may be considered for the treatment of AR, particularly in patients known triggers and who cannot tolerate INCSs.

H- INTRANASAL ANTICHOLINERGIC: Ipratropium bromide nasal spray may be considered as an adjunct medication to INCSs in PAR patients with uncontrolled rhinorrhea.

I-  OMALIZUMAB: Strong recommendation against use in treatment of allergic rhinitis alone

▪️  COMBINATION THERAPY: Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy.

▪️  PHARMACOLOGIC THERAPY OF ALLERGIC RHINITIS ASSOCIATED WITH BRONCHIAL ASTHMA:

✔️ Use of systemic corticosteroid is not recommended for routine use in AR with comorbid asthma.

✔️ Omalizumab: Recommended for those patients with clear IgE-mediated allergic asthma with coexistent AR who fail conventional therapy.

▪️  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.

▪️ 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.

▪️  HERBAL THERAPY:  No recommendation regarding the use of herbal therapy for patients with AR.