April 2015, Vol 3, No 4 - Inside Allergies & Asthma
Bradley Pacella, PharmDc

Allergic rhinitis (AR) is the fifth most common chronic disease in the United States, and the most common chronic disease in children.1

Overall, it is estimated THAT AR affects nearly 1 in 6 Americans, which results in $2 billion to $5 billion in direct health expenditures annually, as well as $2 billion to $4 billion in lost productivity annually.1

Rhinitis is an inflammation of the membrane lining in the nose. Associated symptoms include sneezing; itchy eyes, nose, or throat; watery eyes; rhinorrhea; nasal congestion; and postnasal drip.2 It is believed that most of these symptoms can be alleviated as clinicians follow the new AR treatment guidelines.

Treating Allergic Rhinitis

Some of the most well-known methods for managing AR are nonpharmacologic in nature. These include environmental controls, which focus on avoiding exposure to allergens.2 More precisely, these methods center on using devices with high-efficiency particulate air filters; habitual vacuuming of carpets, drapes, and upholstery; and washing bedding in hot water. Moreover, using nasal wetting agents or performing nasal irrigation with warm saline may reduce symptoms. Furthermore, according to the “hygiene hypothesis,” it is also important to not oversanitize so children can build a healthy immune system.3

Updated Treatment Guidelines

Recently, the American Academy of Otolaryngology–Head and Neck Surgery updated their AR treatment guidelines on the quality improvement opportunities deemed most important for clinicians.1

These new guidelines differ from the previous guidelines because they place increased emphasis on what a clinician should, should not, or may do in relation to a patient with AR. Furthermore, the updated guidelines emphasize the importance of nonpharmacologic management, and expand upon the potential role of subcutaneous or sublingual immunotherapy. The hope is that these guidelines will lead to more efficient and optimal treatments for patients with AR. In addition, it is important to note that these guidelines differ from the previous guidelines because they place less emphasis on prescribing specific treatments based solely on symptoms.

The guidelines are segmented into a series of 14 statements. Each statement is followed by an action statement profile that focuses on qualitative and quantitative measures, which, most importantly, include aggregate evidence quality (ie, grade A, B, C, D, or X), which are determined based on the quality of evidence, and policy level (ie, strong recommendation, recommendation, option, or no recommendation).

Guideline Statements

The first statement, Patient History and Physical Examination, focuses on AR diagnosis. According to the guidelines, clinicians should make a clinical diagnosis of AR when a patient presents with a history and physical examination consistent with an allergy in addition to nasal congestion, runny nose, itchy nose, or sneezing (grade C, recommendation). Although a definitive diagnosis is dependent on the finding of an immunoglobulin E (IgE)-mediated response to a specific allergen, the guideline authors suggested that it is generally reasonable to begin therapy based on the patient’s history and physical examination.

In the second statement, which discusses allergy testing, the guidelines more precisely address IgE-specific allergy testing, and recommend that clinicians should perform and interpret this test for patients with a clinical diagnosis of AR who do not respond to empiric therapy (grade B).

The third statement, Imaging, focuses on sinonasal imaging. The guidelines do not recommend the routine use of this type of imaging because of its potential costs and adverse effects (grade C).

Environmental factors are discussed in the fourth statement, including an optional recommendation on the clinician’s role in educating patients on environmental factors associated with AR. In particular, they suggest that clinicians may advise patients to avoid known allergens, or implement environmental controls (grade B).

The fifth statement, Chronic Conditions and Comorbidities, discusses treating patients with other chronic conditions and comorbidities who present with AR. More precisely, this statement recommends that clinicians should assess and document patients with AR who present with related conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media (grade B).

The sixth, seventh, and eighth statements (Topical Steroids, Oral Antihistamines, and Intranasal Antihistamines, respectively) address specific pharmacologic recommendations. The sixth statement strongly recommends the use of intranasal steroids upon the clinical diagnosis of AR in patients whose quality of life is affected by their symptoms (grade A). Similarly, the seventh statement strongly recommends the use of oral second-generation/less sedating antihistamines for patients with AR whose primary concerns are sneezing and itching (grade A). The eighth statement provides an optional recommendation that patients with seasonal, perennial, or episodic AR be offered intranasal antihistamines (grade A).

The ninth statement, Oral Leuko­triene Receptor Antagonists, does not recommend the use of oral leukotriene receptor antagonists for patients with AR as primary therapy (grade A).

The tenth statement, Combination Therapy, addresses whether combination therapy is appropriate for patients with AR. According to this statement, patients with AR who inadequately respond to pharmacologic monotherapy may be offered combination pharmacologic therapy (grade A).

The eleventh statement, Immunotherapy, discusses options for patients who experience an inadequate response to symptoms with pharmacologic therapy, with or without environmental controls. The guidelines recommend that clinicians should offer sublingual or subcutaneous immunotherapy to patients who fall into this category (grade A).

The twelfth statement, Inferior Turbinate Reduction, addresses whether and when inferior turbinate reduction should be offered to patients with AR. This statement details that clinicians may offer—or refer to someone who can offer—such a procedure to patients with AR who also have nasal airway obstruction and enlarged inferior turbinates, and in whom medical management has not succeeded (grade C).

The thirteenth statement, Acupuncture, discusses whether it should be offered to patients with AR. More precisely, the thirteenth statement details that clinicians may offer acupuncture to patients with AR who are interested in therapy that is nonpharmacologic (grade B).

The fourteenth statement, Herbal Therapy, focuses on the use and role of herbal therapy in the treatment of AR; no recommendation is provided because of a lack of evidence associated with their use.

Conclusion

These guidelines were created to provide clinicians with a tool on which to base diagnostic procedures, patient education, and treatment choices for patients with AR. Moreover, although these guidelines are supported by relatively strong evidence, they are not intended to be a sole source of guidance, replace clinical judgment, nor establish protocol. These guidelines can enable pharmacists, nurse practitioners, and physician assistants in retail clinics to assist prescribers in the treatment of patients with AR.

References

  1. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152(suppl 1):S1-S43.
  2. Tran NP, Vickery J, Blaiss MS. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res. 2011;3:148-156.
  3. Okada H, Kuhn C, Feillet H, Bach JF. The “hygiene hypothesis” for autoimmune and allergic diseases: an update. Clin Exp Immunol. 2010;160:1-9.
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