-
Awaiting sx severity & frequency assessment
Frequency & severity of sx drives selection of 1st-line tx. Visual analog scores (VAS) correlate well to severity, are used in AAAAI1 & ARIA2 guidelines - Determine frequency of sx: intermittent (<4 days/wk or <4 consecutive wks/yr) of persistent ( ≥4 days/wk or ≥4 consecutive wks/yr)
- Assess severity of sx: “mild” sx = NL daily activities, sports/leisure, work/school, sleep, and no troublesome sx; if any of these are not true, then classify as “moderate/severe”
- Consider use of a validated instrument (scoring system, scale, or questionnaire), such as VAS, below, to help determine the severity of rhinitis & to monitor the degree of sx control
Visual Analog Scale (VAS) for Chronic Rhinitis Footnotes 1 AAAAI 2020. Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
2 ARIA 2020. Bousquet J, 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. Accessed 4/23/21 -
Untreated allergic rhinitis
Intermittent/seasonal rhinitis Start w/ intranasal antihistamine (INAH), 2nd-gen oral antihistamine (OAH), or intranasal steroid (INCS) as mono-tx; individualize med mgmt in light of pt preference;1 avoid triggers, step-down/stop tx if sx controlled & trigger gone - Antihistamines: INAH may be more effective than OAH & rapid onset advantageous for seasonal/episodic/intermittent sx; AAAAI recommends against 1st-gen OAH2
- Add decongestants initially, if edema impairs delivery of intranasal tx: oral2,3 (not rec’d by BSACI) or intranasal;2,4 combo PSE + 2nd gen OAH preferred over INCS by AAAAI; don’t use >5 days & exercise caution in certain pts2
- Intranasal corticosteroid is a 1st-line option, per AAAAI, ARIA, & AAO-HNS; combo w/ INAH more effective than INCS alone & is also 1st-line, per ARIA (reserved for mod/severe dz or tx failure by other societies)
- Nasal saline may reduce pt-reported dz severity,2,4 amount of pharmaco-tx needed,4 & is well-tolerated2,4
- Don’t use montelukast as 1st-line d/t ↓efficacy and serious neuropsych side effects (suicidality)2,3
- If pregnant:2,4 nasal saline, INCS (except triamcinolone), OAH, nedocromil & cromolyn considered safe; avoid decongestants, esp in 1st trimester, per AAAAI
- If ocular sx/allergic conjunctivitis: sx improve w/ OAH, INCS, INAH, but may require ophthalmic med: mast-cell stabilizer, antihistamine, or dual-action drug4,5
- Complementary: BSACI advises against acupuncture,4 while AAO-HNS says it may be offered.3 No evidence for/against homeopathy, herbs, phototherapy, or other complementary tx, per AAAAI, AAO-HNS, & BSACI
Avoid triggers - Avoidance of animals effective for animal allergy;4 highly pollen-allergic pts should stay indoors during high pollen counts; benefit of other environmental measures uncertain3,4
- Avoid irritant triggers (eg, smoke, chemical fumes, temp change, perfumes)4
- Can consider intranasal cromolyn for short term prevention, used <15min prior to episodic environmental allergen exposure2
Footnotes 1 ARIA 2020. Selection of pharmaco-tx for pts w/ allergic rhinitis depends on: (1) pt empowerment, preferences, & age; (2) prominent sx, sx severity, and multimorbidity; (3) efficacy & safety of tx; (4) speed of onset of action of tx; (5) current tx; (6) hx of response to tx; (7) effect on sleep & work productivity; (8) self-management strategies; and (9) resource use.
Bousquet J, 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. Accessed 4/23/21
2 AAAAI 2020. Use oral decongestants w/ caution in older pts, children <4 yo, & pts w/ hx of cardiac arrhythmia, angina pectoris, cerebrovascular dz, uncontrolled HTN, bladder outlet obstruction, glaucoma, hyperthyroidism or Tourette’s syndrome.
Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
3 AAO-HNS 2015. May advise avoidance/environmental control if identified allergens correlate w/ sx.
Pets: Washing dogs 2x/wk ↓allergen exposure; benefit of washing cats unsubstantiated.
Dust mites: Multiple, simultaneous measures more likely to help than single measures (eg, impermeable bed covers, acaricides, HEPA filter).
Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
4 BSACI 2017. Antihistamine/mast-cell stabilizer agents onset <30min; good for acute and long-term use. Reserve ocular steroid for severe cases: risk of ↑IOP, cataracts, infxn; loteprednol has lower risk of ↑IOP. Other topical agents less effective w/ potential drawbacks: Vasoconstrictor (eg, naphazoline) or antihistamine/vasoconstrictor can cause rebound; antihistamines (emedastine, levocabastine), NSAID (ketorolac), mast-cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) have slow onset.
Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
5 ARIA 2020. Bousquet J, 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. Accessed 4/23/21
Start w/ intranasal antihistamine (INAH), 2nd-gen oral antihistamine (OAH), or intranasal steroid (INCS) as mono-tx; combo tx w/ INAH + INCS also 1st-line option & is more effective than INCS alone; individualize med mgmt in light of pt preference;1 avoid triggers, step-down/stop tx if sx controlled & trigger gone - Antihistamines: INAH may be more effective than OAH & rapid onset advantageous for seasonal/episodic/intermittent sx; AAAAI recommends against 1st-gen OAH2
- Intranasal corticosteroid is a 1st-line option, combo w/ INAH more effective than INCS alone & is also 1st-line2
- Add decongestants initially, if edema impairs delivery of intranasal tx: oral2,3 (not rec’d by BSACI) or intranasal;2,4 combo PSE + 2nd-gen OAH is least-favored 1st-line option by AAAAI; don’t use >5 days & exercise caution in certain pts5
- Consider oral steroids (not depot injection)2,4 x5-7 days for very severe sx2
- Nasal saline may reduce pt-reported dz severity,2,4 amount of pharmaco-tx needed,4 & is well-tolerated2,4
- Don’t use montelukast as 1st-line d/t ↓efficacy & serious neuropsych side effects (suicidality); other LTRAs also not recommended as 1st-line option2
- Don’t use combo of 2nd-gen OAH and INCS as 1st-line, per AAAAI
- If pregnant:2,4 nasal saline, INCS (except triamcinolone), OAH, nedocromil & cromolyn considered safe; avoid decongestants, esp in 1st trimester, per AAAAI
- If ocular sx/allergic conjunctivitis: sx improve w/ OAH, INCS, INAH, but may require ophthalmic med: mast-cell stabilizer, antihistamine, or dual-action drug6,7
- Complementary: BSACI advises against acupuncture,4 while AAO-HNS says it may be offered.3 No evidence for/against homeopathy, herbs, phototherapy, or other complementary tx, per AAAAI, AAO-HNS & BSACI
Avoid triggers - Avoidance of animals effective for animal allergy;4 highly pollen-allergic pts should stay indoors during high pollen counts; benefit of other environmental measures uncertain4,8
- Avoid irritant triggers (eg, smoke, chemical fumes, temp change, perfumes)4
- Can consider intranasal cromolyn for short-term prevention, used <15min prior to episodic environmental allergen exposure2
Offer immuno-tx to select pts - Consider immuno-tx in pts w/ mod/severe AR who prefer to avoid pharmaco-tx or desire additional benefit in setting of comorbid conditions (eg, asthma)2
Footnotes 1 ARIA 2020. Selection of pharmaco-tx for pts w/ allergic rhinitis depends on:
(1) pt empowerment, preferences, & age; (2) prominent sx, sx severity, and multimorbidity; (3) efficacy & safety of tx; (4) speed of onset of action of tx; (5) current tx; (6) hx of response to tx; (7) effect on sleep & work productivity;
(8) self-management strategies; and (9) resource use.
Bousquet J, 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. Accessed 4/23/21
2 AAAAI 2020. Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
3 AAO-HNS 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
4 BSACI 2017. Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
5 AAAAI 2020. Use oral decongestants w/ caution in older pts, children <4 yo & pts w/ hx of cardiac arrhythmia, angina pectoris, cerebrovascular dz, uncontrolled HTN, bladder outlet obstruction, glaucoma, hyperthyroidism or Tourette’s syndrome.
6 ARIA 2020. Bousquet J, 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. Accessed 4/23/21
7 BCACI 2017. Antihistamine/mast-cell stabilizer agents onset <30min; good for acute and long-term use. Reserve ocular steroid for severe cases: risk of ↑IOP, cataracts, infxn; loteprednol has lower risk of ↑IOP. Other topical agents less effective w/ potential drawbacks: Vasoconstrictor (eg, naphazoline) or antihistamine/vasoconstrictor can cause rebound; antihistamines (emedastine, levocabastine), NSAID (ketorolac), mast-cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) have slow onset.
Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
8 AAO-HNS 2015. May advise avoidance/environmental control if identified allergens correlate w/ sx.
Pets: Washing dogs 2x/wk ↓allergen exposure; benefit of washing cats unsubstantiated.
Dust mites: Multiple, simultaneous measures more likely to help than single measures (eg, impermeable bed covers, acaricides, HEPA filter).
Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
Start w/ intranasal steroid (INCS), intranasal antihistamine (INAH), 2nd-gen oral antihistamine (OAH), or intranasal cromolyn as mono-tx; individualize med mgmt in light of pt preference;1 avoid triggers, step-down/stop tx if sx controlled & trigger gone - Intranasal corticosteroid is a 1st-line option, per AAAAI, ARIA, & AAO-HNS; combo w/ INAH more effective than INCS alone & is also 1st-line, per ARIA (reserved for mod/severe dz or tx failure by other societies)
- Antihistamines: INAH may be more effective than OAH & rapid onset advantageous for seasonal/episodic/intermittent sx; use OAH daily (not prn), per BSACI; AAAAI recommends against 1st-gen OAH2
- Add decongestants initially, if edema impairs delivery of intranasal tx: oral2,3 (not rec’d by BSACI) or intranasal;2,4 combo PSE + 2nd-gen OAH preferred over intranasal cromolyn by AAAAI; don’t use >5 days & exercise caution in certain pts5
- Intranasal cromolyn is a 1st-line consideration, per AAAAI, but onset is slow (1-2wk) & qid dosing may limit adherence2
- Nasal saline may reduce pt-reported dz severity,2,4 amount of pharmaco-tx needed,4 & is well-tolerated2,4
- Don’t use montelukast as 1st-line d/t ↓efficacy & serious neuropsych side effects (suicidality); other LTRAs also not recommended as 1st-line option2
- If pregnant:2,4 nasal saline, INCS (except triamcinolone), OAH, nedocromil & cromolyn considered safe; avoid decongestants, esp in 1st trimester, per AAAAI
- If ocular sx/allergic conjunctivitis: sx improve w/ OAH, INCS, INAH, but may require ophthalmic med: mast-cell stabilizer, antihistamine, or dual-action drug6,7
- Complementary: BSACI advises against acupuncture,4 while AAO-HNS says it may be offered.3 No evidence for/against homeopathy, herbs, phototherapy, or other complementary tx, per AAAAI, AAO-HNS & BSACI
Avoid triggers - Avoidance of animals effective for animal allergy;4 highly pollen-allergic pts should stay indoors during high pollen counts; benefit of other environmental measures uncertain4,8
- Avoid irritant triggers (eg, smoke, chemical fumes, temp change, perfumes)4
- Can consider intranasal cromolyn for short-term prevention, used <15min prior to episodic environmental allergen exposure2
Footnotes 1 ARIA 2020. Selection of pharmaco-tx for pts w/ allergic rhinitis depends on: (1) pt empowerment, preferences, & age; (2) prominent sx, sx severity, and multimorbidity; (3) efficacy & safety of tx; (4) speed of onset of action of tx; (5) current tx; (6) hx of response to tx; (7) effect on sleep & work productivity; (8) self-management strategies; and (9) resource use.
Bousquet J, 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. Accessed 4/23/21
2 AAAAI 2020. Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
3 AAO-HNS 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
4 BSACI 2017. Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
5 AAAAI 2020. Use oral decongestants w/ caution in older pts, children <4 yo, & pts w/ hx of cardiac arrhythmia, angina pectoris, cerebrovascular dz, uncontrolled HTN, bladder outlet obstruction, glaucoma, hyperthyroidism or Tourette’s syndrome.
Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
6 ARIA 2020. Bousquet J, 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. Accessed 4/23/21
7 BCACI 2017. Antihistamine/mast-cell stabilizer agents onset <30min; good for acute and long-term use. Reserve ocular steroid for severe cases: risk of ↑IOP, cataracts, infxn; loteprednol has lower risk of ↑IOP. Other topical agents less effective w/ potential drawbacks: Vasoconstrictor (eg, naphazoline) or antihistamine/vasoconstrictor can cause rebound; antihistamines (emedastine, levocabastine), NSAID (ketorolac), mast-cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) have slow onset.
Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
8 AAO-HNS 2015. May advise avoidance/environmental control if identified allergens correlate w/ sx.
Pets: Washing dogs 2x/wk ↓allergen exposure; benefit of washing cats unsubstantiated.
Dust mites: Multiple, simultaneous measures more likely to help than single measures (eg, impermeable bed covers, acaricides, HEPA filter).
Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
Start w/ combo intranasal antihistamine (INAH) + intranasal steroid (INCS), which is more effective than INCS alone; mono-tx w/ INCS or INAH also a 1st-line option; individualize med mgmt in light of pt preference;1 avoid triggers, step-down/stop tx if sx controlled & trigger gone - Intranasal corticosteroid mono-tx is a 1st-line option, but combo INCS + INAH more effective than INCS alone2-4 & is preferred 1st-line, per AAAAI
- Antihistamines: INAH is a 1st-line option, per AAAAI, AAO-HNS & may be more effective than oral antihistamine (OAH); AAAAI recommends against 1st-gen OAH2
- Add decongestants initially, if edema impairs delivery of intranasal tx: oral2,3 (not rec’d by BSACI) or intranasal;2,5 don’t use >5 days & exercise caution in certain pts6
- Consider oral steroids (not depot injection)2,5 x5-7 days for very severe sx2
- Nasal saline may reduce pt-reported dz severity,2,5 amount of pharmaco-tx needed,5 & is well-tolerated2,5
- Don’t use montelukast d/t ↓efficacy & serious neuropsych side effects (suicidality); don’t use LTRAs alone or in combo w/ OAH2
- Don’t use combo of 2nd-gen OAH & INCS as 1st-line, per AAAAI
- If pregnant:2,5 nasal saline, INCS (except triamcinolone), OAH, nedocromil & cromolyn considered safe; avoid decongestants, esp in 1st trimester, per AAAAI
- If ocular sx/allergic conjunctivitis: sx improve w/ OAH, INCS, INAH, but may require ophthalmic med: mast-cell stabilizer, antihistamine, or dual-action drug4,7
- Complementary: BSACI advises against acupuncture,5 while AAO-HNS says it may be offered.8 No evidence for/against homeopathy, herbs, phototherapy, or other complementary tx, per AAAAI, AAO-HNS, & BSACI
Avoid triggers - Avoidance of animals effective for animal allergy;5 highly pollen-allergic pts should stay indoors during high pollen counts; benefit of other environmental measures uncertain5,8
- Avoid irritant triggers (eg, smoke, chemical fumes, temp change, perfumes)5
- Can consider intranasal cromolyn for short-term prevention, used <15min prior to episodic environmental allergen exposure2
Offer immuno-tx to select pts - Consider immuno-tx in pts w/ mod/severe AR who prefer to avoid pharmaco-tx or desire additional benefit in setting of comorbid conditions (eg, asthma)2
Footnotes 1 ARIA 2020. Selection of pharmaco-tx for pts w/ allergic rhinitis depends on: (1) pt empowerment, preferences, & age; (2) prominent sx, sx severity, and multimorbidity; (3) efficacy & safety of tx; (4) speed of onset of action of tx; (5) current tx; (6) hx of response to tx; (7) effect on sleep & work productivity; (8) self-management strategies; and (9) resource use.
Bousquet J, 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. Accessed 4/23/21
2 AAAAI 2020. Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
3 AAO-HNS 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
4 ARIA 2020. Bousquet J, 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. Accessed 4/23/21
5 BSACI 2017. Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
6 AAAAI 2020. Use oral decongestants w/ caution in older pts, children <4 yo, & pts w/ hx of cardiac arrhythmia, angina pectoris, cerebrovascular dz, uncontrolled HTN, bladder outlet obstruction, glaucoma, hyperthyroidism or Tourette’s syndrome.
Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
7 BCACI 2017. Antihistamine/mast-cell stabilizer agents onset <30min; good for acute and long-term use. Reserve ocular steroid for severe cases: risk of ↑IOP, cataracts, infection; loteprednol has lower risk of ↑IOP. Other topical agents less effective w/ potential drawbacks: Vasoconstrictor (eg, naphazoline) or antihistamine/vasoconstrictor can cause rebound; antihistamines (emedastine, levocabastine), NSAID (ketorolac), mast-cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) have slow onset.
Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
8 AAO-HNS 2015. May advise avoidance/environmental control if identified allergens correlate w/ sx.
Pets: Washing dogs 2x/wk ↓ allergen exposure; benefit of washing cats unsubstantiated.
Dust mites: Multiple, simultaneous measures more likely to help than single measures (eg, impermeable bed covers, acaricides, HEPA filter).
Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
-
Inadequate response to tx
Check medication use, concordance, dose;1 select other mono-tx option; alternatively, use combo intranasal steroid (INCS) & intranasal antihistamine (INAH), if not used initially;2,3 can also consider adding sx specific agents or referral for turbinate reduction in certain pts; immuno-tx reserved as final option by most societies - Intranasal corticosteroid mono-tx is an option, but combo INCS + INAH more effective than INCS alone2-4 & is preferred 1st-line, per AAAAI
- Antihistamines:1,2,4 INAH may be more effective than oral antihistamine (OAH) & rapid onset advantageous for seasonal/episodic/intermittent sx; use OAH daily (not prn), esp for itch/sneeze/rash sx; AAAAI recommends against 1st-gen OAH2
- Add decongestants, if edema impairs delivery of intranasal tx: oral2,4 (not rec’d by BSACI) or intranasal;1,2 don’t use >5 days & exercise caution in certain pts5
- Consider oral steroids (not depot injection)1,2 x5-7 days for very severe sx,2 or if inflammatory rhinitis is suspected after other tx failures1
- Nasal saline may reduce pt-reported dz severity,1,2 amount of pharmaco-tx needed,1 & is well-tolerated1,2
- If rhinorrhea is dominant: Consider switching to or adding intranasal ipratropium1,2
- Consider structural or infectious problem in setting of repeated tx failure1 or after initial failure w/ congestion as dominant sx4
- Don’t use montelukast d/t ↓efficacy & serious neuropsych side effects (suicidality); don’t use LTRAs in combo w/ OAH; use only in pts not successfully treated w/ other options2
- If pregnant:1,2 nasal saline, INCS (except triamcinolone), OAH, nedocromil & cromolyn considered safe; avoid decongestants, esp in 1st trimester, per AAAAI
- If ocular sx/allergic conjunctivitis: sx improve w/ OAH, INCS, INAH, but may require ophthalmic med: mast-cell stabilizer, antihistamine, or dual-action drug3,6
- Complementary: BSACI advises against acupuncture,1 while AAO-HNS says it may be offered.4 No evidence for/against homeopathy, herbs, phototherapy, or other complementary tx, per AAAAI, AAO-HNS, & BSACI
Avoid triggers - Avoidance of animals effective for animal allergy;1 highly pollen-allergic pts should stay indoors during high pollen counts; benefit of other environmental measures uncertain1,7
- Avoid irritant triggers (eg, smoke, chemical fumes, temp change, perfumes)1
- Can consider intranasal cromolyn for short-term prevention, used <15min prior to episodic environmental allergen exposure2
Offer immuno-tx to select pts - Consider immuno-tx in pts w/ mod/severe AR who have failed allergen avoidance & pharmaco-tx2-4
- May also offer immuno-tx w/ milder dz after tx failure if nasal congestion, itching, sneezing, and/or rhinorrhea are dominant sx,4 or if sx predominantly due to 1 allergen1
- There may be additional benefit in pts w/ comorbid asthma2
Footnotes 1 BSACI 2017. Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
2 AAAAI 2020. Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
3 ARIA 2020. Bousquet J, 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. Accessed 4/23/21
4 AAO-HNS 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
5 AAAAI 2020. Use oral decongestants w/ caution in older pts, children <4 yo, & pts w/ hx of cardiac arrhythmia, angina pectoris, cerebrovascular dz, uncontrolled HTN, bladder outlet obstruction, glaucoma, hyperthyroidism or Tourette’s syndrome.
Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol. 2020. Oct;146(4):721-767. Accessed 4/23/21
6 BCACI 2017. Antihistamine/mast-cell stabilizer agents onset <30min; good for acute and long-term use. Reserve ocular steroid for severe cases: risk of ↑IOP, cataracts, infxn; loteprednol has lower risk of ↑IOP. Other topical agents less effective w/ potential drawbacks: Vasoconstrictor (eg, naphazoline) or antihistamine/vasoconstrictor can cause rebound; antihistamines (emedastine, levocabastine), NSAID (ketorolac), mast-cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) have slow onset.
Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856–889. Accessed 4/23/21
7 AAO-HNS 2015. May advise avoidance/environmental control if identified allergens correlate w/ sx.
Pets: Washing dogs 2x/wk ↓allergen exposure; benefit of washing cats unsubstantiated.
Dust mites: Multiple, simultaneous measures more likely to help than single measures (eg, impermeable bed covers, acaricides, HEPA filter).
Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015. Feb;152(1 Suppl):S1-43. Accessed 4/23/21
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