Clinical Practice Guideline: Allergic Rhinitis

Michael D. Seidman, MD1, Richard K. Gurgel, MD2, Sandra Y. Lin, MD3, Seth R. Schwartz, MD, MPH4, Fuad M. Baroody, MD5, James R. Bonner, MD6, Douglas E. Dawson, MD7, Mark S. Dykewicz, MD8 , Jesse M. Hackell, MD9, Joseph K. Han, MD10, Stacey L. Ishman, MD, MPH11, Helene J. Krouse, PhD, ANP-BC, CORLN12, Sonya Malekzadeh, MD13, James (Whit) W. Mims, MD14, Folashade S. Omole, MD15, William D. Reddy, LAc, DiplAc16, Dana V. Wallace, MD17, Sandra A. Walsh18, Barbara E. Warren, PsyD, MEd18, Meghan N. Wilson, MD19, Lorraine C. Nnacheta, MPH20

1. ¹Department of Otolaryngology–Head and Neck Surgery, Henry Ford West Bloomfield Hospital West Bloomfield, Michigan, USA
2. ²Department of Surgery Otolaryngology–Head and Neck Surgery University of Utah, Salt Lake City, Utah, USA
3. ³Johns Hopkins School of Medicine, Department of Otolaryngology–Head and Neck Surgery, Baltimore, Maryland, USA
4. ⁴Virginia Mason Medical Center, Seattle, Washington, USA
5. ⁵University of Chicago Medical Center, Department of Otolaryngology, Chicago, Illinois, USA
6. ⁶Birmingham VA Medical Center, Birmingham, Alabama, USA
7. ⁷Otolaryngology, Private Practice, Muscatine, Iowa, USA
8. ⁸Department of Internal Medicine, St Louis University School of Medicine, St Louis, Missouri, USA
9. ⁹Pomona Pediatrics, Pomona, New York, USA
10. ¹⁰Eastern Virginia Medical School, Norfolk, Virginia, USA
11. ¹¹Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
12. ¹²Wayne State University, Philadelphia, Pennsylvania, USA
13. ¹³Georgetown University Hospital, Washington, DC, USA
14. ¹⁴Wake Forest Baptist Health, Winston Salem, North Carolina, USA
15. ¹⁵Morehouse School of Medicine, East Point, Georgia, USA
16. ¹⁶Acupuncture and Oriental Medicine (AAAOM), Annandale, Virginia, USA
17. ¹⁷Florida Atlantic University, Boca Raton, Florida and Nova Southeastern University, Davie, Florida, USA
18. ¹⁸Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
19. ¹⁹Louisiana State University School of Medicine, New Orleans, Louisiana, USA
20. ²⁰Department of Research and Quality, American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria, Virginia, USA

1. Michael D. Seidman, MD, Henry Ford West Bloomfield Hospital, 6777 West Maple Rd, West Bloomfield, MI 48322, USA. Email: mseidma1@hfhs.org

1. Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Abstract

Objective Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

Purpose The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. 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 AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

Action Statements The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls.

The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR.

The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendationregarding the use of herbal therapy for patients with AR.

This Article

1. doi: 10.1177/0194599814561600

   Otolaryngol Head Neck Surg February 2015 vol. 152 no. 1 suppl S1-S43
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