Guideline:
Symptom severity assessment of allergic rhinitis
Bibliographic Source(s)
- Spector SL Nicklas RA Chapman JA Bernstein IL Berger WE Blessing-Moore J Dykewicz MS Fineman SM Lee RE Li JT Portnoy JM Schuller DE Lang D Tilles SA. Symptom severity assessment of allergic rhinitis: part 1. Ann Allergy Asthma Immunol 2003 Aug;91(2):105-14. [14 references] PubMed
Guideline Status
This is the current release of the guideline.
Guideline Category
Evaluation
Intended Users
Physicians
Guideline Objective(s)
To provide practice parameters for the symptom severity assessment of allergic rhinitis
Target Population
Adults and children with allergic rhinitis
Interventions and Practices Considered
Evaluation
- Individual assessment of symptom severity using a 7-point visual analog scale
- Identify confounding variables
- Objective measurement of symptoms including:
- Episodes of sneezing
- Number of sneezes per episode
- Amount of nasal tissue used during a given period
- Amount of swelling on physical examination and/or anterior rhinoscopy
- Various rhinometric techniques
- Assessment on non-nasal symptom severity using a 7-point visual analog scale
- Global assessment of symptom severity
- Disease-specific quality-of-life surveys including a visual analog scale
- Evaluation of effectiveness and adverse effects of current and past medications using a visual analog scale
Major Outcomes Considered
Utility of assessment tools and interventions
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
Assessing Nasal Symptom Severity
By asking the patient to evaluate individual symptom severity using a 7-point visual analog scale interval data are generated with lower measurement error and a correspondingly higher precision compared with a 5-point equal interval scale. Figure 1 in the original guideline document is an example of the type of visual analog scale that is recommended to evaluate severity of rhinitis.
Since the duration of allergic rhinitis symptoms is different in every patient each analysis of symptom severity should specify the period during which the evaluation is being made (e.g. more than 24 hours more than 2 weeks or a point-in-time evaluation). It may also be helpful in some patients to distinguish patterns of symptoms (e.g. daytime or nighttime indoor or outdoor). Recognizing these possible confounding variables the further characterization of symptoms is left to the discretion of the physician.
Objective measurement of symptoms should be incorporated into evaluation of rhinitis severity if considered helpful by the health care professional and could include the following: (1) presence or absence of episodes of sneezing; (2) number of sneezes per episode; (3) amount of nasal tissue used during a given period; (4) amount of swelling seen on physical examination and/or anterior rhinoscopy; and (5) various rhinometric techniques.
Assessing Non-Nasal Symptom Severity
Since non-nasal symptoms are not found universally in patients with rhinitis they are not included in the rhinitis severity scale outlined in Figure 1 in the original guideline document which has been specifically designed to permit an evaluation of nasal symptoms. Since they are so frequently associated with rhinitis however they may also be evaluated using a scale similar to that used for nasal symptoms (Figure 2 in the original guideline document). Adjustment in a treatment regimen based on severity of non-nasal symptoms can be made by the health care professional on an individual basis similar to the adjustments recommended for nasal symptoms.
Global Assessment of Nasal and Non-nasal Symptom Severity
A global scale provides additional information about the status of the patient beyond what is found with individual symptoms. It asks the patient to globally rate the combination of the nasal and non-nasal symptoms on a 7-point scale. Unlike the scales for nasal and non-nasal symptoms a score of 7 on the global evaluation scale indicates that the patient is having no symptoms. Overall symptoms can be rated using the scale shown in Figure 3 in the original guideline document.
Quality of Life in the Assessment of Rhinitis Severity
Quality of life is an important consideration in the evaluation and treatment of patients with allergic rhinitis. Disease-specific quality-of-life surveys for allergic rhinitis have been developed and standardized for children and adults. Such surveys facilitate the recognition of individual effects of the disease on the patient's quality of life which may not otherwise be mentioned by patients and may be ignored or trivialized by patients and health care professionals. Use of surveys by physicians at each clinic visit can help to evaluate the effects of treatment interventions on symptom control and the patient's quality of life. In addition patients and families learn to recognize the effects of allergic rhinitis symptoms on the quality of their life.
The visual analog scale shown in Figure 4 in the original guideline document which assesses the patient's quality of life can be used by the physician as adjunctive data to support the initial evaluation of rhinitis severity based on nasal symptoms. It can also be used by the physician as a means of patient follow-up after determining the initial management of the patient. It incorporates activities and functioning during the day and sleeping at night.
The Impact of Current and Past Medications on Assessment of Rhinitis Severity
Determining past responsiveness and adverse effects from medications (including over-the-counter or herbal medications) can help guide the health care practitioner in selection of future therapeutic approaches and directly affects the evaluation of rhinitis severity. It is important therefore to determine the current and past medications that each patient has received including whether a particular medication was either ineffective or had produced a significant adverse effect. Failure of a drug used consistently has a different significance for severity evaluation than failure of the drug due to poor compliance. Nonprescription antihistamines topical alpha1-decongestants and cromolyn and herbal remedies may not necessarily be reported by patients spontaneously. Long-term daily use of topical decongestants is of special concern since they frequently produce rhinitis medicamentosa. Current use of medications for rhinitis or other conditions and their effect on rhinitis severity should be considered. A beneficial therapeutic effect on rhinitis may be seen with the use of medications for non-nasal conditions (e.g. leukotriene modifiers or orally inhaled corticosteroids). If these agents are withdrawn or the dose is decreased an increase in symptoms of rhinitis may occur. These are variables that cannot easily be controlled for unless a sophisticated model is used to explain a large number of comorbidities and their treatment.
Rhinitis Medication Assessment
The visual analog scale shown in Figure 5 in the original guideline document can be used to evaluate medications. This scale includes those medications (including alternative medications) that the patient has used in the past for nasal and non-nasal symptoms and how effective they were (i.e. to what extent they relieved or aggravated nasal symptoms or produced adverse effects). Visual analog scales should be constructed for the effectiveness and side effect profile of each past and current nasal and non-nasal medication used by the patient.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of evidence is not specifically stated for each recommendation.
Potential Benefits
Overall Benefits
Accurate assessment of nasal and non-nasal symptom severity of allergic rhinitis as well as quality of life issues related to allergic rhinitis
Specific Benefits
- Classification of rhinitis severity may be used in adults or children to help determine appropriate pharmacotherapy.
- Use of surveys by physicians at each clinic visit can help to evaluate the effects of treatment interventions on symptoms control and the patient's quality of life.
- Determining past responsiveness and adverse effects from medications can help guide the health care practitioner in selection of future therapeutic approaches and directly affects the evaluation of rhinitis severity.
- The assessment and quantification of severity of symptoms of allergic rhinitis should allow for more consistent patient management and facilitation of research protocols
Potential Harms
Not stated
Qualifying Statements
- This parameter was edited by Dr. Nicklas in his private capacity and not in his capacity as a medical officer with the Food and Drug Administration. No official support or endorsement by the Food and Drug Administration is intended or should be inferred.
- This is a complete and comprehensive document at the current time. The medical environment is a changing environment and not all recommendations will be appropriate for all patients.
- Because this document incorporated the efforts of many participants no single individual including those who served on the Joint Task Force is authorized to provide an official American College of Allergy Asthma and Immunology (AAAAI) or American College of Allergy Asthma and Immunology (ACAAI) interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI the ACAAI and the Joint Council of Allergy Asthma and Immunology.
- These parameters are not designed for use by pharmaceutical companies in drug promotion.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Chart Documentation/Checklists/Forms
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
Bibliographic Source(s)
- Spector SL Nicklas RA Chapman JA Bernstein IL Berger WE Blessing-Moore J Dykewicz MS Fineman SM Lee RE Li JT Portnoy JM Schuller DE Lang D Tilles SA. Symptom severity assessment of allergic rhinitis: part 1. Ann Allergy Asthma Immunol 2003 Aug;91(2):105-14. [14 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Funded exclusively by the American Academy of Allergy Asthma and Immunology (AAAAI) the American College of Allergy Asthma and Immunology (ACAAI) and the Joint Council of Allergy Asthma and Immunology (JCAAI).
Guideline Committee
Joint Task Force on Practice Parameters
Composition of Group that Authored the Guideline
Primary Authors: Sheldon L. Spector MD; Richard A. Nicklas MD; Jean A. Chapman MD; I. Leonard Bernstein MD; William E. Berger MD; Joann Blessing-Moore MD; Mark S. Dykewicz MD; Stanley M. Fineman MD; Rufus E. Lee MD; James T. Li MD PhD; Jay M. Portnoy MD; Diane E. Schuller MD; David Lang MD; and Stephen A. Tilles MD
*This parameter was edited by Dr. Nicklas in his private capacity and not in his capacity as a medical officer with the Food and Drug Administration. No official support or endorsement by the Food and Drug Administration is intended or should be inferred.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available from the Joint Council of Allergy Asthma and Immunology (JCAAI) Web site.
Print copies: Available from JCAAI 50 N. Brockway Ste 3-3 Palatine IL 60067; E-mail: info@jcaai.org.
Availability of Companion Documents
The following is available:
- Forms to be given to the patients. Addendum. Electronic copies: Available from the Joint Council of Allergy Asthma and Immunology (JCAAI) Web site.
Print copies: Available from JCAAI 50 N. Brockway Ste 3-3 Palatine IL 60067; E-mail: info@jcaai.org.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on May 9 2005. The information was verified by the guideline developer on May 23 2005.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. Please contact the Joint Council of Allergy Asthma and Immunology for more information.
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