Guideline:
Allergic rhinitis
Bibliographic Source(s)
- University of Michigan Health System. Allergic rhinitis. Ann Arbor (MI): University of Michigan Health System (UMHS); 2007 Oct. 12 p. [3 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: University of Michigan Health System. Allergic rhinitis. Ann Arbor (MI): University of Michigan Health System; 2002 Jul. 12 p. [3 references]
Guideline Category
Diagnosis
Management
Treatment
Intended Users
Advanced Practice Nurses
Nurses
Pharmacists
Physician Assistants
Physicians
Guideline Objective(s)
To assist in the diagnosis and cost-effective treatment of allergic rhinitis
Target Population
Adults and children with presumed or confirmed allergic rhinitis
Interventions and Practices Considered
Diagnosis
- History and examination
- Symptom diary
- Medication trial
- Allergy testing (skin tests and radioallergosorbent test [RAST])
Therapy
- Avoidance of allergens
- Over-the-counter non-sedating antihistamine loratadine (Claritin)
- Prescribed medications
- Intranasal corticosteroids such as fluticasone propionate (Flonase); mometasone (Nasonex AQ); flunisolide (Nasarel)
- Oral non-sedating antihistamines such as fexofenadine (Allegra)
- Oral decongestants
- Leukotriene inhibitors
- Intranasal cromolyn
- Intranasal antihistamines (Astelin)
- Ocular preparations
- Immunotherapy
- Referral to an allergist/specialist
- Special considerations in pediatrics pregnancy severe asthma and severe atopic dermatitis patients
Major Outcomes Considered
- Accuracy and sensitivity of diagnostic tools
- Incidence frequency and severity of allergy symptoms such as itching sneezing rhinorrhea
- Medication side effects
- Cost-effectiveness of treatment
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The literature search for this update began with the results of the literature search performed for the 2002 version of this guideline. A search for literature published since that time was performed. The search on Medline was conducted prospectively for literature published from 1/1/99 to 7/31/06 using the major keywords of: allergic rhinitis human (adult and pediatric) English language clinical guidelines avoid clinical trials – phase IV cohort studies controlled clinical trials multicenter studies randomized controlled trials observational trial meta analysis. Separate searches were performed for: history (inciting factors seasonality family history severity & severity scoring) physical exam signs symptoms (nasal exam for changes in mucosa conjunctival changes) laboratory (nasal smear for presence of eosinophyls skin testing; avoid: radioallergosorbent test [RAST]) Diagnosis – other references avoid or control triggers corticosteroids (intra-nasal ocular) antihistamines (intra-nasal oral ocular) leukotriene inhibitors/modulators decongestants (intra-nasal ocular oral) mast cell stabilizers (intra-nasal ocular) nonsteroidal anti-inflammatory (ocular) anticholinergics (intra-nasal) omalizumab saline irrigation to remove allergens (nasal spray eye wash) immunotherapy/allergy shots or inhaler turbinate reduction surgery integrative/alternative/ complementary medicine [9/1/05 – 7/31/06 only] pregnancy & lactation) treatment or management – other references.
The search was conducted in components each keyed to a specific causal link in a formal problem structure (available upon request). The search was supplemented with recent clinical trials known to expert members of the panel. Negative trials were specifically sought. The search was a single cycle.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence
- Randomized controlled trials
- Controlled trials no randomization
- Observational trials
- Opinion of expert panel
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Conclusions were based on prospective randomized clinical trials (RCTs) if available to the exclusion of other data. If RCTs were not available observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation expert opinion was used to estimate effect size.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
Treatment Strategy and Cost
Pharmacologic control of allergic rhinitis is expensive and may carry some long term side effects especially in children. Immunotherapy (allergy shots) may provide significant long-term control of symptoms at a reduced cost and without the risks of medication but requires multiple office visits which compromises patient compliance. These issues must be weighed when considering treatment options.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Drug tables were reviewed by UMHHC Pharmacy Services. The guideline was reviewed at clinical conferences or grand round meetings of divisions and departments to which the content is most relevant. This guideline was reviewed at meetings of Allergy and Immunology Family Medicine General Medicine General Pediatrics and Otolaryngology. The revised document is reviewed by the Guidelines Steering Committee composed of representatives from all primary care specialties. The UMHS Executive Committee on Clinical Affairs performs a final review prior to institutionally endorsing the guideline.
Major Recommendations
Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text for additional information including detailed information on dosing possible side effects and cost of medications; avoidance of allergens; skin testing; immunological therapy; and considerations for special patient populations (i.e. pediatrics pregnant patients patients with severe asthma or severe atopic dermatitis). Definitions for the levels of evidence (A B C D) are provided at the end of the "Major Recommendations" field.
Diagnosis
Allergic rhinitis is an antigen-mediated inflammation of the nasal mucosa that may extend into the paranasal sinuses. Diagnosis is usually made by history and examination ("itchy running sneezy stuffy"). A symptom diary and a trial of medication may be helpful to confirm a diagnosis. Allergy testing is not commonly needed to make the diagnosis but may be helpful for patients with multiple potential allergen sensitivities.
Therapy
The goal of therapy is to relieve symptoms.
- Avoidance of allergens is the first step in this process. (Refer to text in the original guideline document for details.) If avoidance fails:
- The over-the-counter (OTC) non-sedating antihistamine loratadine (Claritin) should be tried initially as it will provide relief in most cases. If symptoms persist consider the following options:
- Prescribed medications
- Intranasal corticosteroids are considered the most potent medications available for treating allergic rhinitis [A]. They control itching sneezing rhinorrhea and stuffiness in most patients but do not alleviate ocular symptoms. They have a relatively good long-term safety profile. University of Michigan Health System (UMHS) preferred intranasal corticosteroids for adults are generics: fluticasone (Flonase) and flunisolide (Nasarel). Mometasone (Nasonex AQ) is preferred for children.
- Oral non-sedating antihistamines prevent and relieve itching sneezing and rhinorrhea but tend to be less effective for nasal congestion [A]. UMHS preferred prescription antihistamine is fexofenadine (Allegra).
- Oral decongestants decrease swelling of the nasal mucosa which in turn alleviates nasal congestion [A]. However they are associated with appreciable side effects especially in geriatric patients and should only be considered when congestion is not controlled by other agents. They are contraindicated with monoamine oxidase inhibitors (MAOIs) in uncontrolled hypertension and in severe coronary artery disease.
- Leukotriene inhibitors are less effective than intranasal corticosteroids [A] but may be considered for patients that cannot tolerate the first line agents or have co-morbid asthma.
- Intranasal cromolyn (OTC) is less effective than intranasal corticosteroids [A]. Cromolyn is a good alternative for patients who are not candidates for corticosteroids. It is most effective when used regularly prior to the onset of allergic symptoms.
- Intranasal antihistamines (Astelin) while effective in treating the nasal symptoms associated with seasonal and perennial rhinitis and nonallergic vasomotor rhinitis offer no therapeutic benefit over conventional treatment [A].
- Ocular preparations should be considered for patients with allergic conjunctivitis who are not adequately controlled with or can not tolerate an oral antihistamine.
Referral
Appropriate criteria for referral to a colleague who specializes in the diagnosis and treatment of allergies may include [D]:
- Consideration of allergy skin/radioallergosorbent test (RAST) testing for better allergen identification for avoidance and/or immunotherapy because of:
- Failure of medical therapy.
- Perennial or seasonal allergic rhinitis that is moderate to severe
- Associated comorbidities (see Table 5 in the original guideline document)
- Any severe allergic reactions causing patient or parental anxiety
Controversial Issues
Medication Versus Immunotherapy
A formal risk/cost-benefit analysis of medication therapy versus immunotherapy (allergy shots) has not been performed; however patients with moderate to severe symptoms that continue year round (seasonal or perennial allergic rhinitis) may benefit most from immunotherapy [D].
Definitions:
Levels of Evidence
Levels of evidence reflect the best available literature in support of an intervention or test.
- Randomized controlled trials
- Controlled trials no randomization
- Observational trials
- Opinion of expert panel
Clinical Algorithm(s)
A clinical algorithm for treatment of allergic rhinitis is available in the original guideline document.
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Conclusions were based on prospective randomized clinical trials if available to the exclusion of other data; if randomized controlled trials were not available observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation expert opinion was used to estimate effect size.
Potential Benefits
- Accurate diagnosis and cost-effective treatment of allergic rhinitis
- Relief of symptoms of allergic rhinitis
Potential Harms
Medication Side Effects
Refer to Table 8 in the original guideline document for details on medication side effects.
Intranasal Corticosteroids
The incidence of adverse effects is between 5 to 10%; local effects most commonly reported include sneezing stinging and burning or irritation.
Oral Antihistamines
First generation agents adversely affect cognition and performance.
Oral Decongestants
- Oral decongestants (including combination products containing a decongestant) should be used with caution in patients with unstable hypertension ischemic heart disease glaucoma prostatic hypertrophy or diabetes mellitus.
- Urinary retention in elderly males is a common side effect.
- Geriatric patients may be more sensitive to the effects of decongestants.
Nasal Cromolyn
- The four times daily dosing can cause compliance problems.
- Adverse effects are minimal and include nasal irritation sneezing and unpleasant taste.
Contraindications
Oral decongestants are contraindicated with monoamine oxidase inhibitors (MAOIs) in uncontrolled hypertension and in severe coronary artery disease.
Qualifying Statements
These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
Patient Resources
Staff Training/Competency Material
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- University of Michigan Health System. Allergic rhinitis. Ann Arbor (MI): University of Michigan Health System (UMHS); 2007 Oct. 12 p. [3 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
University of Michigan Health System
Guideline Committee
Allergic Rhinitis Guideline Team
Composition of Group that Authored the Guideline
Team Leader: David A. DeGuzman MD General Medicine
Team Members: Catherine M. Bettcher MD Family Medicine; R. Van Harrison PhD Medical Education; Christine L. Holland MD Allergy; Cary E. Johnson PharmD Pharmacy; Sharon Kileny MD Pediatrics; Jeffery E. Terrell MD Otolaryngology
UMHS Guidelines Oversight Team: Connie Standiford MD; William E. Chavey MD; Van Harrison PhD
Financial Disclosures/Conflicts of Interest
The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented but is made to provide readers with information that might be of potential importance to their evaluation of the information.
Team Member; Company; Relationship
David DeGuzman MD (None)
Catherine Bettcher MD (None)
R. Van Harrison PhD (None)
Christine Holland MD (None)
Cary Johnson PharmD (None)
Sharon Kileny MD (None)
Jeffery Terrell MD Neilmed Research support (saline solution)
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: University of Michigan Health System. Allergic rhinitis. Ann Arbor (MI): University of Michigan Health System; 2002 Jul. 12 p. [3 references]
Guideline Availability
Electronic copies: Available for download (in Portable Document Format [PDF]) from the University of Michigan Health System Web site.
Availability of Companion Documents
Continuing Medical Education (CME) information is available from the University of Michigan Health System Web site.
Patient Resources
The following are available:
- Allergic rhinitis. University of Michigan Health System; 2007 Jan. Various p. Available from the University of Michigan Health System Web site.
- Saline nasal sprays & irrigation. University of Michigan Health System; 2006 May. Various p. Available from the University of Michigan Health System Web site.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC STATUS
This NGC summary was completed by ECRI on January 7 2003. The information was verified by the guideline developer on February 4 2003. This NGC summary was updated by ECRI Institute on January 22 2008. The updated information was verified by the guideline developer on February 11 2008. This summary was updated by ECRI Institute on November 17 2008 following the U.S. Food and Drug Administration advisory on OTC cough and cold medications.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is copyrighted by the University of Michigan Health System (UMHS).
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