Clinicians should treat allergic rhinitis (AR) with intranasal steroids when patients' symptoms impair their quality of life, according to clinical practice guidelines published February 2 in Otolaryngology–Head and Neck Surgery. The guidelines further suggest that clinicians should recommend second-generation oral antihistamines, which are less likely to cause drowsiness, for patients complaining primarily of sneezing and itching.
AR is the fifth most common chronic disease in the United States, affecting one in six of all Americans, and is the most common chronic disease among children, the authors write. Medical treatment in the United States costs $2 to $5 billion, with more than half of that amount devoted to prescription medications. AR also accounts for as much as $2 to $4 billion in lost productivity annually, and an estimated 800,000 to 2 million lost school days, according to the work group led by Michael D. Seidman, MD, from the Department of Otolaryngology–Head and Neck Surgery, Henry Ford West Bloomfield Hospital, West Bloomfield, Michigan.
The multidisciplinary panel of 21 experts created a series of actionable statements based on available evidence in the hope of reducing wide variation that now exists in care and promoting effective diagnosis for children older than 2 years and adults. The expert panel defines AR as an inflammatory response of the nasal mucous membranes after inhaling an allergen, such as grass pollen, dust mites, or pet dander, which can trigger symptoms that can include runny nose, nasal congestion, sneezing, and itching.
The panel issued a "strong" recommendation for intranasal steroids and oral antihistamines as first lines of treatment, a rating that indicates clinicians should follow the recommendation unless they have a "clear and compelling" rationale to choose an alternate approach.
However, clinicians should not offer oral leukotriene receptor antagonists as primary therapy for patients with AR, a recommendation that clinicians generally should follow while factoring in patient preferences. Nor should they routinely perform sinonasal imaging in patients with AR symptoms, which can subject people to "unnecessary radiation exposure." Clinicians can diagnose patients with AR on the basis of their history, a physical exam, and allergy testing.
Intranasal steroids, the panel writes, are effective, superior to other therapies, improve quality of life, and have a targeted local effect. "Placebo-controlled clinical trials demonstrate the effectiveness of [intranasal steroids] in the reduction of nasal symptoms including sneezing, itching, rhinorrhea, and congestion in adults and children with AR," write Dr Seidman and colleagues. "By reducing nasal symptoms, [intranasal steroids] significantly improve the quality of life and sleep of patients with AR."
Second-generation oral antihistamines work quickly to tamp down symptoms and, because they are available over the counter and as generics, offer potential cost savings. "Advantages of oral antihistamines include rapid onset of action, once-daily dosing, maintenance of effectiveness with regular use, and the availability of some drugs without a prescription. Some patients who fail to improve with one agent may respond to an alternative drug in this category," the panel writes.
Clinicians should offer sublingual or subcutaneous immunotherapy for patients with AR who are not responding to pharmacologic therapy, the panel recommends, in part to increase awareness of "the only proven treatment for AR that has the potential to change the natural history of the disease."
In its review of the available evidence, the panel identified a number of gaps and suggests additional research, including randomized controlled trials to study the effect of environmental control strategies on AR, such as removing pets and using air filtration systems, and research into the safety and efficacy of allergen-specific immunotherapy and sublingual immunotherapy.
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