The American Academy of Otolaryngology–Head and Neck Surgery Foundation addresses quality improvement opportunities in the diagnosis and management of allergic rhinitis in a new multi-disciplinary, evidence-based clinical practice guideline, published today in Otolaryngology-Head and Neck Surgery.
“Allergic rhinitis occurs when you inhale something that you’re allergic to, like pet dander or pollen, and then the inside lining of your nose becomes inflamed, resulting in congestion, runny nose, sneezing or itching,” explains Sandra Y. Lin, MD, one of the guideline’s authors. “It has a major impact in the U.S., affecting about 1 in every 6 Americans and generating an estimated $2 to $5 billion in expenditures each year.”
As the fifth most common chronic disease in the U.S., there has been considerable variation in the treatments used to manage allergic rhinitis. The guideline’s strongest recommendations are for topical steroids and oral antihistamines. A recommendation is also made on allergy-specific immunotherapy, which modifies how a patient’s immune system responds to allergens, an increasingly popular option given the FDA’s recent approval of under-the-tongue immunotherapy tablets.
“Most importantly, the guideline makes clear what should be and should not be the first lines of treatment for allergic rhinitis,” said Dr. Lin.
The clinical guideline for allergic rhinitis was created by a multi-disciplinary panel of experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced pediatric nursing, and complementary and integrative medicine.
AAO-HNSF Clinical Practice Guideline: Allergic Rhinitis
“Allergic rhinitis occurs when you inhale something that you’re allergic to, like pet dander or pollen, and then the inside lining of your nose becomes inflamed, resulting in congestion, runny nose, sneezing or itching. It has a major impact in the U.S., affecting about 1 in every 6 Americans and generating an estimated $2 to $5 billion in expenditures each year.”
— Sandra Y. Lin, MD, guideline co-author
What is allergic rhinitis?
Allergic rhinitis, often called “hay fever,” is inflammation of the inside lining of the nose. It occurs in response to a person inhaling something to which he or she is allergic.
Allergic rhinitis is characterized by nasal congestion, drainage, sneezing and/or itching.
It is classified by its pattern of exposure to a triggering allergen, such as seasonal (pollen), perennial (dust), or episodic (pets); and by the frequency and severity of symptoms.
Why is the allergic rhinitis guideline important?
Allergic rhinitis is the fifth most common chronic disease in the United States overall, and the most common among children. It is estimated to affect 1 in every 6 Americans.
Allergic rhinitis generates an estimated $2 to $5 billion in direct health expenditures annually, and is responsible for as much as $2 to $4 billion in lost productivity annually.
In children, allergic rhinitis and its associated comorbidities are responsible for 800,000 to 2 million lost school days each year.
What is the purpose of the allergic rhinitis guideline?
The primary purpose of the guideline is to address quality improvement opportunities for all clinicians who manage allergic rhinitis patients as well as to reduce harmful or unnecessary variations in care as identified by the available evidence. This guideline is applicable for both pediatric and adult allergic rhinitis patients, but excludes children under the age of 2 years.
The guideline was created by a multi-disciplinary panel of experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced pediatric nursing, and complementary and integrative medicine to address quality improvement opportunities for clinicians in any setting who are likely to manage allergic rhinitis.
What are significant points made in the guideline?
1. Patient History and Physical Examination — Clinicians should make the clinical diagnosis of allergic rhinitis when patients present with a history and physical exam consistent with an allergic cause and one or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of allergic rhinitis consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, red and watery eyes.
2. Allergy Test — 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 allergic rhinitis 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.
3. Imaging — Clinicians should NOT routinely perform sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of allergic rhinitis.
4. Environmental Factors — Clinicians may advise avoidance of known allergens or may advise environmental controls (i.e. removal of pets, the use of air filtration systems, bed covers, and acaricides [chemical agents that kill dust mites]) in allergic rhinitis patients who have identified allergens that correlate with clinical symptoms.
5. Chronic Condition and Comorbidities — Clinicians should assess patients with a clinical diagnosis of allergic rhinitis 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.
6. Topical Steroids — Clinicians should recommend intranasal steroids for patients with a clinical diagnosis of allergic rhinitis whose symptoms impact their quality of life (QOL).
7. Oral Antihistamines — Clinicians should recommend oral second generation/less sedating antihistamines for patients with allergic rhinitis and primary complaints of sneezing and itching.
8. Intranasal Antihistamines — Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic allergic rhinitis.
9. Oral Leukotriene Receptor Antagonists (LTRAs) — Clinicians should NOT offer oral leukotriene receptor antagonists as primary therapy for patients with allergic rhinitis.
10. Combination Therapy — Clinicians may offer combination pharmacologic therapy in patients with allergic rhinitis who have inadequate response to pharmacologic monotherapy.
11. Immunotherapy — Clinicians should offer or refer to a clinician who can offer immunotherapy (sublingual or subcutaneous) for patients with allergic rhinitis who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls.
12. Inferior Turbinate Reduction — Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with allergic rhinitis with nasal airway obstruction and enlarged inferior turbinates who have failed medical management.
13. Acupuncture — Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with allergic rhinitis who are interested in non-pharmacologic therapy.
14. Herbal Therapy — No recommendation regarding the use of herbal therapy for patients with allergic rhinitis.
The study done by American Academy of Otolaryngology – Head and Neck Surgery.
