Key Points
- Allergic rhinitis (AR) is one of the most common diseases affecting adults. In the United States today it is the most common chronic disease in children and the fifth most common disease overall.
- AR is estimated to affect nearly one in every six Americans and generates $2 to $5 billion dollars in direct health expenditures annually.
- Many diagnostic tests and treatments are used in managing patients with this disorder, yet there is considerable variation in their use.
Definitions
- AR is defined as an immunoglobulin E (IgE)-mediated inflammatory response of the nasal mucous membranes after exposure to inhaled allergens. Symptoms include rhinorrhea (anterior or postnasal drip), nasal congestion, nasal itching, and sneezing. AR can be seasonal, perennial, or episodic with symptoms being intermittent or persistent.
- AR may be classified by
- the temporal pattern of exposure to a triggering allergen as:
- seasonal, (e.g., pollens) or
- perennial/year round, (e.g., dust mites) or
- episodic (environmental from exposures not normally encountered in the patient’s environment, e.g., visiting a home with pets)
- frequency of symptoms
- intermittent (<4 days/week or <4 weeks/year) or
- persistent (>4 days/week and >4 weeks/year)
Note: This classification of symptom frequency has limitations. For example, the patient who has symptoms 3 days/week year round would be classified as “intermittent” even though he or she would more closely resemble a “persistent” patient. It may be best for the patient and the provider to determine which frequency category is most appropriate and would best guide the treatment plan. Based on these definitions, it is possible that a patient may have intermittent symptoms with perennial AR or persistent symptoms with seasonal AR.
- severity of symptoms
- mild (when symptoms are present but are not interfering with quality of life) or
- more severe (when symptoms are bad enough to interfere with quality of life)
- the temporal pattern of exposure to a triggering allergen as:
- Although the FDA uses "seasonal" or "perennial" when approving new medications for AR, classifying a patient’s symptoms by frequency and severity allows for more appropriate treatment selection.
Table 1. Abbreviations and Definitions of Common Terms
| Term | Definition |
|---|---|
| Allergic rhinitis (AR) | An IgE-mediated inflammatory response of the nasal mucous membranes after exposure to inhaled allergens. Symptoms include rhinorrhea (anterior or posterior nasal drainage), nasal congestion, nasal itching, and sneezing. |
| Seasonal allergic rhinitis (SAR) | An IgE-mediated inflammatory response to seasonal aeroallergens. The length of seasonal exposure to these allergens is dependent on geographic location and climatic conditions. |
| Perennial allergic rhinitis (PAR) | An IgE-mediated inflammatory response to year-round environmental aeroallergens. These may include dust mites, mold, animal allergens, or certain occupational allergens. |
| Intermittent allergic rhinitis | An IgE-mediated inflammatory response and is characterized by frequency of exposure or symptoms (<4 days/week or <4 weeks/year). |
| Persistent allergic rhinitis | An IgE-mediated inflammatory response and is characterized by persistent symptoms (>4 days/week and >4 weeks/year). |
| Episodic allergic rhinitis | An IgE-mediated inflammatory response and can occur if an individual is in contact with an exposure that is not normally a part of the individual’s environment (i.e., a cat at a friend’s house). |
Table 2. Summary of Guideline Key Action Statements (KAS)
| Statement | Action | Strength |
|---|---|---|
| 1. Patient History and Physical Examination | Clinicians should make the clinical diagnosis of AR when patients present with a history and physical exam consistent with an allergic cause and one 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, red and watery eyes. | R-C |
| 2. Allergy Testing | 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. | R-B |
| 3. Imaging | Clinicians should NOT routinely perform sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR. | R-C (against) |
| 4. Environmental Factors | Clinicians may advise avoidance of known allergens or may advise environmental controls (i.e., removal of pets, the use of air filtration systems, bed covers, and acaricides [chemical agents that kill dust mites]) in AR patients who have identified allergens that correlate with clinical symptoms. | O-B |
| 5. Chronic Conditions and Comorbidities | Clinicians should assess and document in the medical record patients with a clinical diagnosis of AR for the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis and otitis media. | R-B |
| 6. Topical Steroids | Clinicians should recommend INSs for patients with a clinical diagnosis of AR whose symptoms impact their quality of life. | S-A |
| 7. Oral Antihistamines | Clinicians should recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. | S-A |
| 8. Intranasal Antihistamines | Clinicians may offer INAs for patients with seasonal, perennial, or episodic AR. | O-A |
| 9. Oral Leukotriene Receptor Antagonists (LTRAs) | Clinicians should NOT offer oral LTRAs as primary therapy for patients with AR. | R-A (against) |
| 10. Combination Therapy | Clinicians may offer combination pharmacologic therapy for patients with AR who have inadequate response to pharmacologic monotherapy. | O-A |
| 11. Immunotherapy | 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. | R-A |
| 12. Inferior Turbinate Reduction | Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction for patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. | O-C |
| 13. Acupuncture | Clinicians may offer, or refer to a clinician who can offer, acupuncture for patients with AR who are interested in nonpharmacologic therapy. | O-B |
| 14. Herbal Therapy | No recommendation regarding the use of herbal therapy for patients with AR. | NR |
Diagnosis
Table 3. History and Physical Findings in AR
| Presenting Symptoms | Historical Findings | Physical Findings |
|---|---|---|
|
|
|
Table 4. IgE-Specific Tests
| Recommendation | Advantages | Disadvantages | |
|---|---|---|---|
| Skin Tests - Skin prick or intradermal | Recommend |
|
|
| Blood testing - Allergen specific IgE | Recommend |
|
|
| IgG or total IgE | Recommend against | Does not yield information helpful for management of AR | |
Other nonspecific tests
| No recommendation for or against |