Guideline clarifies 1st-line treatment for allergic rhinitis

First-line treatment for allergic rhinitis should include intranasal steroids, as well as less-sedating second-generation oral antihistamines for patients whose primary complaints are sneezing and itching, according to a new clinical practice guideline published online in Otolaryngology-Head and Neck Surgery.

In contrast, sinonasal imaging should not be routine when patients first present with symptoms consistent with allergic rhinitis, and oral leukotriene receptor antagonists are not recommended as first-line therapy, said Henry Ford, West Bloomfield Hospital and chair of the guideline working group and his associates.

A panel of 20 experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine, and consumer advocacy developed the new practice guideline to enable clinicians in all settings to improve patient care and reduce harmful or unnecessary variations in care for allergic rhinitis.

The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing allergic rhinitis.

During the course of one year, the working group reviewed 60 randomized, controlled trials, 31 existing clinical practice guidelines, and 390 systematic reviews of the literature regarding allergic rhinitis in adults and children older than age 2 years. They then compiled 14 key recommendations that underwent extensive peer review, which have been published online and as a supplement to the February issue.

In addition to the recommendation noted above, the guideline advises:

• Clinicians should diagnose allergic rhinitis when patients present with a history and physical exam consistent with the disorder (including clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red, watery eyes) plus symptoms of nasal congestion, runny nose, itchy nose, or sneezing.

• Clinicians should perform and interpret (or refer patients for) specific IgE allergy testing for allergic rhinitis that doesn’t respond to empiric treatment, or when the diagnosis is uncertain, or when identifying the specific causative allergen would allow targeted therapy.

• Clinicians should assess diagnosed patients for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhino sinusitis, and otitis media, and should document that in the medical record.

• Clinicians should offer (or refer patients for) sublingual or subcutaneous immunotherapy when allergic rhinitis doesn’t respond adequately to pharmacologic therapy.

• Clinicians may advise avoidance of known allergens or controlling the patient’s environment by such measures as removing pets, using air filtration systems, using dust mite-reducing covers for bedding, and using acaricides.

• Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic allergic rhinitis.

• Clinicians may offer (or refer patients for) reduction of the inferior turbinates for patients who have nasal airway obstruction or enlarged turbinates.

• Clinicians may offer (or refer patient for) acupuncture if they are interested in nonpharmacologic therapy.

The working group offered no recommendations concerning herbal therapy for allergic rhinitis, because of the limited literature on those substances and concern about their safety.