What are the guideline sources, guidelines and references for Allergic rhinitis ?
Guideline sources The following summarized guidelines for the evaluation and management of allergic rhinitis are prepared by our editorial team based on guidelines from the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2020), the Allergic Rhinitis and its Impact on Asthma (ARIA 2017), and the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2015). 1 2 3 4 4 4 5 6 7 Definition Allergic rhinitis is an inflammatory disease of the nasal mucosa characterized by symptoms of sneezing, nasal pruritus, airflow obstruction, and clear nasal discharge. 4 Epidemiology Common allergens that are associated with allergic rhinitis include pollen and mites (67%), animal dander and pollutants (23%), and fungal allergens (21%). 6 Pathophysiology The prevalence of physician-diagnosed allergic rhinitis is estimated at 14% in the United States. 5 Disease course https://web.pathway.md/diseases/rec4ETSKQguw0ZOAi 1/7 6/23/23, 2:18 AM Allergic rhinitis Pathway In patients with allergic rhinitis, exposure to allergens triggers an IgE-mediated hypersensitivity reaction, leading to mucosal inflammation and associated nasal symptoms. Type 2 helper T cells play a role in maintaining persistent mucosal inflammation beyond the time of allergen exposure. 4 Prognosis and risk of recurrence Allergic rhinitis can impair quality of life by interrupting sleep. It is associated with work performance impairment and missed work time. 4 7 Pathway Calculator Allergic rhinitis Diagnostic criteria for allergic rhi Diagnosis and management Guidelines 1. Screening and diagnosis Diagnostic criteria: diagnose allergic rhinitis clinically when patients present with 1 typical symptom(s) (nasal congestion, runny nose, itchy nose, or sneezing), and history and physical examination is consistent with an allergic cause. B 2. Classification and risk stratification Severity assessment: consider using a validated instrument (such as scoring system, scale, or questionnaire) to help determine the severity of rhinitis and to monitor the degree of disease control. C 3. Diagnostic investigations Clinical examination: As per AAAAI 2020 guidelines: Elicit a complete detailed history and perform physical examination in patients presenting with symptoms of rhinitis. B Review all current medications in patients presenting with symptoms of rhinitis to assess whether drug-induced rhinitis may be present. A As per AAO-HNSF 2015 guidelines, assess patients with allergic rhinitis for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. B IgE allergy testing: https://web.pathway.md/diseases/rec4ETSKQguw0ZOAi 2/7 6/23/23, 2:18 AM Allergic rhinitis Pathway As per AAAAI 2020 guidelines: Obtain aeroallergen skin prick testing or serum-specific IgE to confirm the diagnosis of allergic rhinitis in patients with a history consistent with allergic rhinitis. A Do not obtain food skin prick testing or serum-specific IgE for foods in the routine evaluation of patients presenting with signs and symptoms compatible with the diagnosis of allergic rhinitis. D As per AAO-HNSF 2015 guidelines, obtain specific IgE allergy testing: in patients in whom there is uncertainty regarding the diagnosis of allergic rhinitis in patients in whom knowledge of the specific causative allergen is needed to target therapy in patients with a lack of response to empiric treatment for allergic rhinitis. B Sinonasal imaging: avoid routine sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of allergic rhinitis. D 4. Medical management Intranasal corticosteroids: As per AAAAI 2020 guidelines: Prefer intranasal corticosteroids when choosing monotherapy in patients with persistent allergic rhinitis. A Prefer intranasal corticosteroids over leukotriene receptor antagonists for the initial treatment of 15 years old patients with moderate or severe seasonal allergic rhinitis. A As per ARIA 2017 guidelines, consider offering intranasal corticosteroids, alone or in combination with oral (conditional recommendation, low certainty of evidence) or intranasal antihistamines, in patients with seasonal allergic rhinitis. C Show 4 more Intranasal antihistamines: As per AAAAI 2020 guidelines: Offer intranasal antihistamines for the initial treatment of patients with seasonal allergic rhinitis. A Offer intranasal antihistamines as first-line therapy in patients with intermittent allergic rhinitis. B As per ARIA 2017 guidelines, consider offering intranasal antihistamines in combination with intranasal corticosteroids rather than intranasal antihistamines alone in patients with seasonal allergic rhinitis. C Show 3 more As per AAO-HNSF 2015 guidelines, consider intranasal antihistamines for patients with seasonal, perennial, or episodic allergic rhinitis. C Intranasal decongestants: https://web.pathway.md/diseases/rec4ETSKQguw0ZOAi 3/7 6/23/23, 2:18 AM Allergic rhinitis Pathway Consider offering intranasal decongestants for short-term and for intermittent or episodic therapy of nasal congestion. C Consider offering intranasal decongestants for up to 5 days in patients with severe mucosal edema impairing the delivery of other intranasal agents. C Intranasal anticholinergics: consider offering intranasal ipratropium in patients with perennial allergic rhinitis having rhinorrhea as their main nasal symptom. C Intranasal cromolyn: consider offering intranasal cromolyn just before allergen exposure to reduce symptoms of allergic rhinitis from episodic allergen exposures. C Systemic corticosteroids: Consider offering a short course (5-7 days) of oral corticosteroids in patients with severe or intractable allergic rhinitis. C Avoid administering depot parenteral corticosteroids in patients with very severe or intractable allergic rhinitis. D Oral antihistamines: As per AAAAI 2020 guidelines, do not use first-generation antihistamines in patients with allergic rhinitis. Prefer second-generation antihistamines over first-generation antihistamines when prescribing oral antihistamines. D As per ARIA 2017 guidelines, consider offering either oral antihistamines or leukotriene receptor antagonists in patients with seasonal allergic rhinitis. C Show 3 more As per AAO-HNSF 2015 guidelines, administer oral second-generation/less sedating antihistamines for patients with primary complaints of sneezing and itching. B Oral leukotriene receptor antagonists: As per AAAAI 2020 guidelines, do not use montelukast for the initial treatment of patients with allergic rhinitis. D Show 2 more As per ARIA 2017 guidelines, consider offering either leukotriene receptor antagonists or oral antihistamines in patients with seasonal allergic rhinitis. C As per AAO-HNSF 2015 guidelines, avoid leukotriene receptor antagonists as primary therapy for patients with allergic rhinitis. D Oral decongestants: Be cautious when using oral decongestants in older adult and < 4 years old pediatric patients, and in patients of any age having a history of cardiac arrhythmia, angina pectoris, cerebrovascular disease, uncontrolled hypertension, bladder outlet obstruction, glaucoma, hyperthyroidism, or Tourette's syndrome. B Avoid using oral decongestants during the first trimester of pregnancy. D Combination therapy: As per AAAAI 2020 guidelines, do not use a combination of oral antihistamines and intranasal corticosteroids in preference to monotherapy with an intranasal corticosteroid for the initial https://web.pathway.md/diseases/rec4ETSKQguw0ZOAi 4/7 6/23/23, 2:18 AM Allergic rhinitis Pathway treatment of > 12 years old patients with symptoms of seasonal allergic rhinitis. D Show 7 more As per AAO-HNSF 2015 guidelines, consider combination pharmacologic therapy in patients with allergic rhinitis who do not respond adequately to monotherapy. C Allergen immunotherapy: As per AAAAI 2020 guidelines: Consider offering allergen immunotherapy (SC or sublingual tablets) through shared decision making in patients with moderate/severe allergic rhinitis: not controlled with allergen avoidance and/or pharmacotherapy choosing immunotherapy as the preferred method of treatment (such as due to the desire to avoid the adverse effects, costs, or long-term use of pharmacotherapy) desiring the potential benefit of immunotherapy to prevent or reduce the severity of comorbid conditions, such as asthma. C Consider offering allergen immunotherapy (SC or sublingual tablets) in patients with controlled mild and moderate asthma with coexisting allergic rhinitis. C As per AAO-HNSF 2015 guidelines, refer patients who do not respond adequately to pharmacologic therapy to a clinician who can offer immunotherapy. B 5. Nonpharmacologic interventions Avoidance of allergens: consider advising avoidance of known allergens or environmental control measures (such as removal of pets, air filtration systems, bed covers, and chemical agents formulated to kill dust mites) in patients with allergic rhinitis who have identified allergens that correlate with clinical symptoms. C Herbal products: As per AAAAI 2020 guidelines, insufficient evidence to recommend for or against the use of specific herbal products for the treatment of patients with allergic rhinitis. I As per AAO-HNSF 2015 guidelines, insufficient evidence to make recommendations regarding the use of herbal therapy for patients with allergic rhinitis. Acupuncture: As per AAAAI 2020 guidelines, insufficient evidence to recommend for or against the use of acupuncture for the treatment of patients with allergic rhinitis. I As per AAO-HNSF 2015 guidelines, consider acupuncture in patients with allergic rhinitis who are interested in nonpharmacologic therapy. C 6. Surgical interventions Inferior turbinate reduction: consider performing surgical inferior turbinate reduction in patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical https://web.pathway.md/diseases/rec4ETSKQguw0ZOAi 5/7 6/23/23, 2:18 AM Allergic rhinitis Pathway management. C References 1. Mark S Dykewicz, Dana V Wallace, David J Amrol et al. Rhinitis 2020 A practice parameter update. J Allergy Clin Immunol. 2020 Oct;146 4 721 767. Open 2. Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg. 2015 Feb;152 1 Suppl):S1 43. Open 3. Jan L Bro ek, Jean Bousquet, Ioana Agache et al. Allergic Rhinitis and its Impact on Asthma ARIA guidelines-2016 revision. J Allergy Clin Immunol. 2017 Oct;140 4 950 958. Open 4. Wheatley LM, Togias A. 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Open 10. Ahmed Al-Digheari, Bassam Mahboub, Hesham Tarraf et al. The clinical burden of allergic rhinitis in five Middle Eastern countries: results of the SNAPSHOT program. Allergy Asthma Clin Immunol. 2018 Nov 19;14 63. Open 11. Eli O Meltzer, Michael S Blaiss, M Jennifer Derebery et al. Burden of allergic rhinitis: results from the Pediatric Allergies in America survey. J Allergy Clin Immunol. 2009 Sep;124 3 Suppl):S43 70. Open 12. M Fr hlich, M Pinart, T Keller et al. Is there a sex-shift in prevalence of allergic rhinitis and comorbid asthma from childhood to adulthood? A meta-analysis. Clin Transl Allergy. 2017 Dec 5;7 44. Open 13. L M Baumann, K M Romero, C L Robinson et al. Prevalence and risk factors for allergic rhinitis in two resource-limited settings in Peru with disparate degrees of urbanization. Clin Exp Allergy. 2015 Jan;45 1 192 9. Open 14. Lia Restimulia, Dwi Reno Pawarti, Haris Mayaguyang Ekorini. The Relationship between Serum Vitamin D Levels with Allergic Rhinitis Incidence and Total Nasal Symptom Score in Allergic Rhinitis Patients. Open Access Maced J Med Sci. 2018 Aug 10;6 8 1405 1409. Open 15. Lisa M Wheatley, Alkis Togias. Clinical practice. Allergic rhinitis. N Engl J Med. 2015 Jan 29;372 5 456 63. Open https://web.pathway.md/diseases/rec4ETSKQguw0ZOAi 6/7 6/23/23, 2:18 AM Allergic rhinitis Pathway 16. Zhisheng Shao, Jonathan A Bernstein. Occupational Rhinitis: Classification, Diagnosis, and Therapeutics. Curr Allergy Asthma Rep. 2019 Nov 27;19 12 54. Open https://web.pathway.md/diseases/rec4ETSKQguw0ZOAi 7/7