Highlights & Basics
- Allergic rhinitis is an immunoglobulin E (IgE)-mediated inflammatory nasal condition resulting from allergen introduction in a sensitized individual.
- Presumptive diagnosis of allergic rhinitis is usually clinical and is made if someone experiences one or more of rhinorrhea, sneezing, itching of nose/palate/eyes, or nasal congestion in response to allergen exposure. Cough is also a common symptom.
- The diagnosis is confirmed with demonstration of specific IgE reactive to environmental allergens. Food allergy testing is not recommended in the routine evaluation of rhinitis.
- Treatment includes allergen avoidance (reducing exposure to relevant allergens such as dander, dust mite, and pollen), pharmacotherapy, and immunotherapy.
- Intranasal corticosteroids remain the single most effective class of medications for treating allergic rhinitis.
- Immunotherapy is often recommended for patients with persistent symptoms.
Quick Reference
History & Exam
Key Factors
sneezing
nasal pruritus
Other Factors
palate, throat, ear, and eye itching
eye redness, puffiness, and watery discharge
fatigue and irritability
nasal congestion
rhinorrhea
allergic shiners
conjunctival injection
ocular mucoid discharge
nasal crease
pale nasal mucosa
swelling of the nasal mucosa and turbinates
abundant clear nasal secretions
Dennie-Morgan lines (creases present under the lower eyelids)
Diagnostics Tests
1st Tests to Order
therapeutic trial of antihistamine or intranasal corticosteroid
Other Tests to consider
allergen skin-prick testing
in vitro specific IgE determination
Treatment Options
acute
mild or intermittent symptoms
intranasal corticosteroid
allergen avoidance
oral antihistamine
allergen avoidance
intranasal antihistamine
allergen avoidance
alternative first-line monotherapy or combination therapy
allergen avoidance
Definition
Classifications
Allergic Rhinitis and its Impact on Asthma (ARIA) classification
- <4 days a week or for <4 consecutive weeks/year.
- ≥4 days a week and for ≥4 consecutive weeks/year.
- Sleep disturbance
- Impairment of daily activities, leisure, and/or sport
- Impairment of school or work
- Troublesome symptoms.
- Sleep disturbance
- Impairment of daily activities, leisure, and/or sport
- Impairment of school or work
- Troublesome symptoms.
Classification by symptom severity
Classification by temporal pattern of allergen exposure
Vignette
Common Vignette
Epidemiology
Etiology
Pathophysiology
Diagnostic Approach
Signs and symptoms
- Pruritus
- Sneezing
- Rhinorrhea
- Nasal congestion, often the most bothersome.
- Palate, throat, ear, and eye itching
- Eye redness, puffiness, and watery discharge.
- Fatigue
- Irritability.
Physical exam
Trial of therapy
Allergy testing
- Skin prick testing or in vitro IgE determination usually suffice, although on some occasions both tests are used for optimal management.
- The choice of test often depends on availability. In vitro IgE determination tends to be more readily available but is more expensive, and provides less sensitivity and specificity than skin testing. However, in vitro IgE determination may be preferable in patients with severe eczema affecting the testing area, in patients with significant dermatographism, or for those unwilling or unable to stop their antihistamines or medications with antihistamine properties (e.g., tricyclic antidepressants).
- Most medical laboratories offer a variety of allergen panels that should incorporate the most important perennial allergens such as animal danders and dust mites as well as geographically important local pollens such as grasses, weeds, and trees. However, tests should be ordered judiciously in the context of the patient's symptoms and exposures; the "shotgun approach" - ordering numerous tests to see if any come back positive - is inappropriate.
- Panels including foods have no role in the diagnosis of AR in the absence of systemic symptoms (e.g., urticaria or anaphylaxis) that occur in conjunction with the consumption of certain foods.
- Results may not only confirm the presence of allergic disease but also help in directing environmental control interventions and determining whether a patient may be suitable for immunotherapy.
- Approximately 26% of patients previously considered nonallergic based on negative tests for specific IgE may have positive nasal allergen provocation tests.[54] Although cumbersome, nasal allergen provocation tests might be an option for confirming the diagnosis in patients who have symptoms of AR, and negative specific IgE in vivo or in vitro tests, and who fail empiric therapy for AR based on the characteristics of their symptoms.
Risk Factors
History & Exam
Tests
Differential Diagnosis
Nonallergic rhinitis
Differentiating Signs/Symptoms
- Sporadic or persistent perennial symptoms not resulting from IgE-mediated immunopathologic events.
- Pain/pressure and a postnasal drip sensation are common.
- Presence of nasal itching and sneezing less likely.
- Nonallergic triggers such as strong odors, perfumes, cigarette smoke, and weather-related changes may be present.
Differentiating Tests
- Other than the absence of positive allergy tests, no single, specific differentiating feature exists.
Acute sinusitis
Differentiating Signs/Symptoms
- Acute (<2 weeks), subacute (2 to 6 weeks).
- Acute disease often due to an infectious cause.
- May present with cough, discolored nasal mucus, and facial pressure/pain.[59]
Differentiating Tests
- Diagnosis is usually clinical.
Chronic sinusitis
Differentiating Signs/Symptoms
- Symptoms >12 weeks. Usually diagnosed with the aid of radiologic studies. One of the more common clinical characteristics of chronic sinusitis is the presence of hyposmia or anosmia.
- More commonly characterized by chronic inflammation than a bacterial infection, especially in adults.[59]
- Frequently characterized as chronic sinusitis with nasal polyposis, and chronic sinusitis without nasal polyposis.
Differentiating Tests
- Sinus CT scans are abnormal, by definition, in people with chronic sinusitis.
Infectious rhinosinusitis
Differentiating Signs/Symptoms
- Viral infection may result in acute (<2 weeks) episode of rhinitis presenting with nasal congestion, rhinorrhea, sneezing, and varying degrees of nasal pruritus. May present with a sore throat, myalgias, headaches, discolored mucus, and fever. More common during the fall to spring months.
Differentiating Tests
- Diagnosis is usually clinical.
Criteria
- <4 days a week or for <4 consecutive weeks/year.
- >4 days a week and for ≥4 consecutive weeks/year.
- Sleep disturbance
- Impairment of daily activities, leisure, and/or sport
- Impairment of school or work
- Troublesome symptoms.
Treatment Approach
- Allergen avoidance is one of the guiding principles of treatment. While environmental control measures can sometimes lead to complete symptom control (e.g., by removing a pet), they can at other times be difficult to implement.
- After an initial pharmacologic treatment regimen has been initiated, follow-up should occur within 7-14 days and therapy be stepped up or stepped down, as deemed necessary.[64]
- Second-generation, nonsedating antihistamines are recommended for initial treatment of mild symptoms.[3] They are considered to be safe and relatively free of adverse effects. Sedation associated with the use of first-generation antihistamines diminishes their utility.
- Second-generation antihistamines (e.g., loratadine and cetirizine) are preferred for breast-feeding mothers.[65] Caution is advised if use of first-generation antihistamines is required in breast-feeding mothers.[65] Case reports and studies report somnolence and irritability in breastfed infants when first-generation antihistamines are taken by the mother.[66]
Allergen avoidance and control
- Keep windows of homes and cars closed and employ an air conditioner in the recycling/indoor mode.
- Minimize time spent outdoors during times of high pollen count, when practical.
- Avoid activities known to cause exposure to pollen, such as mowing grass.
- Shower after outdoor activities where exposure to pollen is high.
- Use recirculated air in the car when pollen levels are high.
- Wear sunglasses (to protect eyes from airborne pollen).
- Dry bedding and clothing inside or in a tumble dryer.
- Physical measures include heating ventilation, freezing, washing, and barrier methods.
- Wash bedding weekly in hot water (>140°F [>60°C]) to kill dust mites and denature the allergens they produce. Hot tumble drying of washed items for an additional 10 minutes after they are dry will kill dust mites.
- Cover mattress, pillow, and quilt with dust mite-resistant covers. Wash covers every 2 months.
- Remove all soft toys and woolen bedding from the bedroom. Freezing soft toys overnight kills mites but does not remove the allergen; they can then be tumbled in the dryer to help with this.
- Where possible replace carpets with hard floors.
- Damp dust or use cloths to clean hard surfaces (including hard floors) weekly.
- Vacuum carpets weekly.
- Reduce humidity - have a dry and well ventilated house, and adequate floor and wall insulation.
- Venetian blinds or flat blinds are easier to clean than heavy curtains.
- Consider leather or vinyl sofas instead of fabric.
- Individuals allergic to cats and dogs have few effective ways to reduce their exposure to pet allergens short of ridding themselves of the animals. It is important to counsel patients that pet allergen levels only slowly decline over several months when a pet is removed from the home; therefore, rapid improvement is not expected.[68] Ultimately though, the affected individual willing to part with their cat or dog will frequently experience significant symptom relief.
- Cockroach infestation is associated with AR and asthma, especially in the inner city.[76]
- Control measures are based on eliminating suitable environments and restricting access by sealing, caulking, and controlling the food supply as well as using chemical control and traps.
- While cockroach extermination by professionals may reduce allergen levels by 80% to 90%, the clinical significance of this finding requires further research.[77]
- Reinfestation from adjacent apartments is a frequent problem, and thus extermination efforts will likely need to be repeated and extended beyond the affected space.
- Mold-allergic individuals should carefully inspect their home for mold damage, with special attention to more humid areas of the dwelling.
- Appropriate steps should be taken to mitigate or prevent sources of humidity and/or water ingress associated with indoor mold growth. Ensure adequate natural ventilation, including the use of extractor fans; seal leaks in bathrooms and roofs.
- Clear overflowing gutters and blocked under-floor vents.
- Remove indoor pot plants (which promote mold growth).
- Dry or remove wet carpets.
- Avoid working with garden compost or mulch, or mowing lawns.
- Remove localized mold growth with a dilute bleach solution. More extensive mold damage may require aggressive measures such as replacing the affected surface/material.
Mild or intermittent symptoms
Persistent and moderate or severe symptoms
Usual therapy not effective
- An incomplete response to trial of therapy of environmental and pharmacologic interventions, and a persistent and significant impact on quality of life (interference with hobbies, family life, activities of daily living, sleep, emotional well-being)
- An inability to adequately control associated conditions such as asthma or sinus disease.
Treatment Options
mild or intermittent symptoms
intranasal corticosteroid
Primary Options
- beclomethasone dipropionate nasal
(42 micrograms/spray aqueous) children ≥6 years of age and adults: 42-84 micrograms (1-2 sprays) in each nostril twice daily
- beclomethasone dipropionate nasal
- budesonide nasal
(32 micrograms/spray) children ≥6 years of age: 32-64 micrograms (1-2 sprays) in each nostril once daily; children ≥12 years of age and adults: 32-128 micrograms (1-4 sprays) in each nostril once daily
- budesonide nasal
- fluticasone propionate nasal
(50 micrograms/spray) children ≥4 years of age and adults: 50-100 micrograms (1-2 sprays) in each nostril once daily
- fluticasone propionate nasal
- mometasone nasal
(50 micrograms/spray) children ≥2 years of age: 50 micrograms (1 spray) in each nostril once daily; children ≥12 years of age and adults: 100 micrograms (2 sprays) in each nostril once daily
- mometasone nasal
Comments
- In patients with mild or intermittent symptoms, intranasal corticosteroids are a first-line treatment option.[99]
- Examples of suitable intranasal corticosteroids are provided here; however, this list is not exhaustive and many other options are available.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
oral antihistamine
Primary Options
- cetirizine
children ≥6 months of age: 2.5 to 5 mg orally once daily when required; children ≥6 years of age and adults: 5-10 mg orally once daily when required
- cetirizine
- desloratadine
children ≥6 months of age: 1 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 5 mg orally once daily when required
- desloratadine
- fexofenadine
children ≥2 years of age: 30 mg orally twice daily when required; children ≥12 years of age and adults: 60 mg orally twice daily or 180 mg once daily when required
- fexofenadine
- levocetirizine
children ≥6 months of age: 1.25 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 2.5 to 5 mg orally once daily when required
- levocetirizine
- loratadine
children ≥2 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required
- loratadine
Comments
- In patients with mild or intermittent symptoms, a nonsedating antihistamine is a first-line treatment option.[99]
- Oral antihistamines are effective for rhinorrhea, sneezing, and itching, but have only a modest effect on nasal congestion.[63] Cetirizine, a second-generation antihistamine, has been found to be particularly effective in AR, but may cause some mild sedation.[79] Second-generation oral antihistamines are preferred to first-generation agents because they cause less sedation, dizziness, and incoordination.[3]
- Paradoxical hyperactivity with use of sedating antihistamines has been reported, particularly in children.[80]
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
intranasal antihistamine
Primary Options
- azelastine nasal
(137 micrograms/spray) children ≥5 years of age: 137 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 137-274 micrograms (1-2 sprays) in each nostril twice daily; (205.5 micrograms/spray) children ≥6 years of age: 205.5 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 205.5 to 411 micrograms (1-2 sprays) in each nostril once to twice daily
- azelastine nasal
- olopatadine nasal
(665 micrograms/spray) children ≥6 years of age: 665 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 1330 micrograms (2 sprays) in each nostril twice daily
- olopatadine nasal
Comments
- Intranasal antihistamines (e.g., azelastine, olopatadine) are another first-line option when symptoms are intermittent and do not require daily medication.[3]
- Intranasal antihistamines are particularly effective for rhinorrhea and nasal congestion, but they do not improve symptoms at non-nasal sites.[81] They have a fast onset of action after initial dosing (usually 15-30 minutes, and no later than 3 hours) and are effective over a 12-hour period.[3] [99]
- Intranasal antihistamines may cause sedation.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
alternative first-line monotherapy or combination therapy
Comments
- The patient should be reassessed after a trial of monotherapy with an intranasal corticosteroid or oral antihistamine (ideally within 5-7 days).[3] If the patient remains symptomatic, an alternative first-line monotherapy should be used.[3] Failing this, first-line treatment options (from different drug classes) may be combined. For example, an intranasal corticosteroid or intranasal antihistamine could be added to an oral antihistamine. If symptoms are persistent, an intranasal corticosteroid and intranasal antihistamine may be continued in combination.[99]
- When symptoms improve, decreasing or discontinuing treatment may be considered.[3] [99] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled. If multiple pharmacologic agents are used, discontinuation of the medication added to the intranasal corticosteroid may be considered.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
persistent and moderate to severe symptoms
intranasal corticosteroid
Primary Options
- beclomethasone dipropionate nasal
(42 micrograms/spray aqueous) children ≥6 years of age and adults: 42-84 micrograms (1-2 sprays) in each nostril twice daily
- beclomethasone dipropionate nasal
- budesonide nasal
(32 micrograms/spray) children ≥6 years of age: 32-64 micrograms (1-2 sprays) in each nostril once daily; children ≥12 years of age and adults: 32-128 micrograms (1-4 sprays) in each nostril once daily
- budesonide nasal
- fluticasone propionate nasal
(50 micrograms/spray) children ≥4 years of age and adults: 50-100 micrograms (1-2 sprays) in each nostril once daily
- fluticasone propionate nasal
- mometasone nasal
(50 micrograms/spray) children ≥2 years of age: 50 micrograms (1 spray) in each nostril once daily; children ≥12 years of age and adults: 100 micrograms (2 sprays) in each nostril once daily
- mometasone nasal
Comments
- Examples of suitable intranasal corticosteroids are provided here; however, this list is not exhaustive and many other options are available.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
oral antihistamine
Primary Options
- cetirizine
children ≥6 months of age: 2.5 to 5 mg orally once daily when required; children ≥6 years of age and adults: 5-10 mg orally once daily when required
- cetirizine
- desloratadine
children ≥6 months of age: 1 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 5 mg orally once daily when required
- desloratadine
- fexofenadine
children ≥2 years of age: 30 mg orally twice daily when required; children ≥12 years of age and adults: 60 mg orally twice daily or 180 mg once daily when required
- fexofenadine
- levocetirizine
children ≥6 months of age: 1.25 to 2.5 mg orally once daily when required; children ≥12 years of age and adults: 2.5 to 5 mg orally once daily when required
- levocetirizine
- loratadine
children ≥2 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required
- loratadine
Comments
- Oral antihistamines are a first-line option if symptoms are persistent and moderate or severe.
- Oral antihistamines are effective for rhinorrhea, sneezing, and itching, but have only a modest effect on nasal congestion.[63] Cetirizine, a second-generation antihistamine, has been found to be particularly effective in AR, but may cause some mild sedation.[79] Second-generation oral antihistamines are preferred to first-generation agents because they cause less sedation, dizziness, and incoordination.[3]
- Paradoxical hyperactivity with use of sedating antihistamines has been reported, particularly in children.[80]
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
intranasal antihistamine
Primary Options
- azelastine nasal
(137 micrograms/spray) children ≥5 years of age: 137 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 137-274 micrograms (1-2 sprays) in each nostril twice daily; (205.5 micrograms/spray) children ≥6 years of age: 205.5 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 205.5 to 411 micrograms (1-2 sprays) in each nostril once to twice daily
- azelastine nasal
- olopatadine nasal
(665 micrograms/spray) children ≥6 years of age: 665 micrograms (1 spray) in each nostril twice daily; children ≥12 years of age and adults: 1330 micrograms (2 sprays) in each nostril twice daily
- olopatadine nasal
Comments
- Intranasal antihistamines (e.g., azelastine, olopatadine) are particularly effective for rhinorrhea and nasal congestion, but they do not improve symptoms at non-nasal sites.[81] They have a fast onset of action after initial dosing (usually 15-30 minutes, and no later than 3 hours) and are effective over a 12-hour period.[3] [99]
- Intranasal antihistamines may cause sedation.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
alternative first-line monotherapy or combination therapy
Comments
- The patient should be reassessed after a trial of monotherapy with an intranasal corticosteroid or oral antihistamine (ideally within 5-7 days).[3] If the patient remains symptomatic, an alternative first-line monotherapy should be used.[3] Failing this, first-line treatment options (from different drug classes) may be combined. For example, an intranasal corticosteroid or intranasal antihistamine could be added to an oral antihistamine. If symptoms are persistent, an intranasal corticosteroid and intranasal antihistamine may be continued in combination.[99]
- When symptoms improve, decreasing or discontinuing treatment may be considered.[3] [99] The dose of intranasal sprays can be reduced as long as symptoms continue to be controlled. If multiple pharmacologic agents are used, discontinuation of the medication added to the intranasal corticosteroid may be considered.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT)
Primary Options
- house dust mite allergen extract
consult specialist for guidance on sublingual dose
- house dust mite allergen extract
- mixed grass pollens allergen extract
consult specialist for guidance on sublingual dose
- mixed grass pollens allergen extract
- timothy grass pollen allergen extract
consult specialist for guidance on sublingual dose
- timothy grass pollen allergen extract
- short ragweed pollen allergen extract
consult specialist for guidance on sublingual dose
- short ragweed pollen allergen extract
Comments
- Immunotherapy is the only treatment modality to potentially have a disease-modifying effect.[100] It should be targeted to include allergens that are clinically relevant to both the patient and the geographic locale.
- Immunotherapy may be offered by an allergy specialist (through a shared decision-making model) to a patient who remains symptomatic despite allergen avoidance measures and pharmacotherapy.[3] Immunotherapy is also commonly used by patients either unwilling to take or unable to tolerate medications.[3]
- SLIT is effective in treating AR in both adults and children.[85] [87] [88] [89] [90] [91] It is considered to be safer than SCIT because adverse effects are usually limited to mucosal symptoms, and it is easier to administer (patient self-administers). However, SLIT may be less effective than SCIT.[91]
- SLIT is more appropriately used in monosensitized patients, especially those sensitized to dust mites, grass, or ragweed.[94] [95] [96] [97] [98] For polysensitized patients, SLIT with multiple allergens is sometimes employed, although no commercially available formulation containing more than one allergen currently exists.
- SLIT formulations can be employed in two different manners. One involves taking SLIT for approximately 12 weeks before and throughout the pollen season, stopping thereafter. Alternatively, SLIT can be taken daily for 3 years to provide a sustained effect for a fourth year, even after discontinuation.[100] [101]
- SCIT is used less frequently than SLIT. Improvement requires several months of treatment. It is generally accepted that a 1-year trial will determine who will and who will not respond to SCIT.
- Local and systemic reactions to SCIT may occur.[102] [103] Systemic reactions can vary from mild to life-threatening; fatal reactions after receiving an allergy vaccine are estimated to occur at a rate of 1 in 2 to 2.5 million injections.[104] [105] SCIT may reduce the progression from AR to asthma when given in children ages 6 to 14 years for a minimum of 3 years.[86] Various extract manufacturers and dosing regimens exist for SCIT.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
oral corticosteroid
Primary Options
- prednisone
5-60 mg/day orally
- prednisone
Comments
- If immunotherapy is not available or there is a significant wait, a short course (7 days) of an oral corticosteroid may also be considered if symptoms are severe.[99]
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the relevant allergens of concern for a particular patient.
usual therapy ineffective or poorly tolerated
sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT)
Primary Options
- house dust mite allergen extract
consult specialist for guidance on sublingual dose
- house dust mite allergen extract
- mixed grass pollens allergen extract
consult specialist for guidance on sublingual dose
- mixed grass pollens allergen extract
- timothy grass pollen allergen extract
consult specialist for guidance on sublingual dose
- timothy grass pollen allergen extract
- short ragweed pollen allergen extract
consult specialist for guidance on sublingual dose
- short ragweed pollen allergen extract
Comments
- Immunotherapy is the only treatment modality to potentially have a disease-modifying effect.[100] It should be targeted to include allergens that are clinically relevant to both the patient and the geographic locale.
- Immunotherapy may be offered by an allergy specialist (through a shared decision-making model) to a patient who remains symptomatic despite allergen avoidance measures and pharmacotherapy.[3] Immunotherapy is also commonly used by patients either unwilling to take or unable to tolerate medications.[3]
- SLIT is more appropriately used in monosensitized patients, especially those sensitized to dust mites, grass, or ragweed.[94] [95] [96] [97] [98] For polysensitized patients, SLIT with multiple allergens is sometimes employed, although no commercially available formulation containing more than one allergen currently exists.
- SLIT formulations can be employed in two different manners. One involves taking SLIT for approximately 12 weeks before and throughout the pollen season, stopping thereafter. Alternatively, SLIT can be taken daily for 3 years to provide a sustained effect for a fourth year, even after discontinuation.[100] [101]
- SCIT is used less frequently than SLIT. Improvement requires several months of treatment. It is generally accepted that a 1-year trial will determine who will and who will not respond to SCIT.
- Local and systemic reactions to SCIT may occur.[102] [103] Systemic reactions can vary from mild to life-threatening; fatal reactions after receiving an allergy vaccine are estimated to occur at a rate of 1 in 2 to 2.5 million injections.[104] [105] SCIT may reduce the progression from AR to asthma when given in children ages 6 to 14 years for a minimum of 3 years.[86] Various extract manufacturers and dosing regimens exist for SCIT.
allergen avoidance
Comments
- Allergen avoidance should be attempted by all patients with AR.
- Allergy testing can be helpful in identifying the allergens of concern for a particular patient.
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Natural history of disease
Variability of severity
Immunotherapy outcomes
Complications
Citations
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Scadding GK, Kariyawasam HH, Scadding G, et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (revised edition 2017). Clin Exp Allergy. 2017 July;47(7):856-89.[Abstract][Full Text]
Bousquet J, Schünemann HJ, Togias A, et al. Next-generation Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence. J Allergy Clin Immunol. 2020 Jan;145(1):70-80.e3.[Abstract][Full Text]
Wise SK, Lin SY, Toskala E, et al. International consensus statement on allergy and rhinology: allergic rhinitis. Int Forum Allergy Rhinol. 2018 Feb;8(2):108-352.[Abstract][Full Text]
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Key Articles
Referenced Articles
Guidelines
Diagnostic
Summary
Systematically developed recommendations regarding the diagnosis of allergic rhinitis.Published by
American Academy of Allergy, Asthma, and Immunology
Published
2020
Summary
Recommendations on the evaluation of people with AR.Published by
American Academy of Otolaryngology; Head & Neck Surgery Foundation
Published
2015
Summary
Comprehensive recommendations on the use of skin-prick tests in allergic conditions, including AR.Published by
Global Allergy and Asthma European Network
Published
2012
Summary
Recommendations regarding clinical assessment.Published by
Australasian Society of Clinical Immunology and Allergy
Published
2020
Summary
Includes recommendations regarding diagnosis of AR.Published by
Japanese Society of Allergology
Published
2020
Summary
Updated guideline for the diagnosis of allergic and nonallergic rhinitis.Published by
British Society for Allergy and Clinical Immunology
Published
2017
Treatment
Summary
Recommends stepwise pharmacologic treatment of AR.Published by
American Academy of Allergy, Asthma, and Immunology
Published
2020
Summary
Recommendations on the treatment of people with seasonal AR.Published by
Joint Task Force on Practice; American Academy of Allergy, Asthma & Immunology; American College of Allergy, Asthma and Immunology
Published
2017
Summary
Guidance for effective, safe, and appropriate administration of the Food and Drug Administration-approved sublingual immunotherapy formulations.Published by
American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology
Published
2017
Summary
Includes recommendations for pediatricians.Published by
Committee on Environmental Health, American Academy of Pediatrics
Published
2006 (reaffirmed 2016)
Summary
Next-generation guidelines for the pharmacologic treatment of allergic rhinitis were developed by using existing GRADE-based guidelines.Published by
Centre for Empowering Patients and Communities; European Academy of Allergy and Clinical Immunology; European Institute for Innovation and Technology EIT Health; European Federation of Allergy and Airways Diseases Patients' Associations; European Respiratory Society; European Forum for Research and Education in Allergy and Airways Diseases; Global Allergy and Asthma European Network; Global Alliance against Chronic Respiratory Diseases; Global Initiative for Asthma; Impact of Air Pollution in Asthma and Rhinitis; Société Française d'Allergologie; Societé de Pneumologie de Langue Française; World Allergy Organization
Published
2020
Summary
Recommendations regarding the prevention and management of allergic disease.Published by
Global Allergy and Asthma European Network; Grading of Recommendations Assessment, Development and Evaluation Working Group; American Academy of Allergy, Asthma & Immunology
Published
2016
Summary
Includes an AR treatment plan.Published by
Australasian Society of Clinical Immunology and Allergy
Published
2020
Summary
Includes treatment and prescriptions for children and pregnant women.Published by
Japanese Society of Allergology
Published
2020
Summary
Recommendations on the use of allergen immunotherapy in people with allergic rhinoconjunctivitis.Published by
European Academy of Allergy and Clinical Immunology
Published
2018
Summary
Recommendations regarding the management of allergic and nonallergic rhinitis.Published by
British Society for Allergy and Clinical Immunology
Published
2017
Credits
Patient Instructions
- Information on allergen avoidance (only if allergy testing has been performed - there is no value in discussing avoidance of "typical" allergens without confirming that they are relevant to the patient)
- An action plan detailing various aspects of the chosen pharmacologic agent(s)
- Expected clinical outcomes.
- Appropriate dosing frequency and technique (including teaching on proper administration of nasal sprays)
- Whether treatments should be used on a schedule or as needed
- Expected time to clinical improvement
- Possible adverse effects (e.g., sedation with first-generation antihistamines).