New Guidelines for Allergic Rhinitis Change Treatment

Pam Harrison

November 09, 2017

An update of recommendations for the treatment of seasonal allergic rhinitis (SAR) in adolescents and adults, issued by members of the Joint Task Force on Practice Parameters (JTFPP), changes initial treatment strategies and aims to reduce unnecessary cost to patients and variations in care.

The previous guidelines were issued in 2008 by the JTFPP of the American Academy of Allergy, Asthma, & Immunology; the American College of Allergy, Asthma & Immunology; and the Joint Council of Allergy, Asthma & Immunology.

The guidelines were published online November 2 in the Annals of Allergy, Asthma & Immunology.

"All guidelines should be periodically reviewed to assure they reflect the most up-to-date clinical evidence," lead author, Mark Dykewicz, MD, professor of allergy and immunology and of internal medicine, Saint Louis University School of Medicine, Missouri, told Medscape Medical News in an email.

"And we hope the guideline update will provide guidance to clinicians and patients that will facilitate shared decision-making about choosing between treatment options for seasonal allergic rhinitis and promote cost-effective care," he added.

The 2017 guideline update addressed three clinical scenarios. First, the working group asked whether the combination of an oral antihistamine plus an intranasal corticosteroid (INCS) provides greater symptomatic relief than an INCS alone. "When treating patients with AR, clinicians often use a combination of therapies," the working group writes — most commonly, the combination of an oral antihistamine and an INCS.

However, after a literature review, JTFPP members determined that for patients aged 12 years and older, nasal symptoms of SAR should be treated at least initially with an INCS alone rather than the INCS–oral antihistamine combination.

"This strong, directive recommendation represents a clear shift from the 2008 document, which did not specifically recommend monotherapy with an INCS over combination therapy," Dr Dykewicz said. In 2008, the recommendation simply stated that this combination may be considered, even though studies at the time did not suggest that the combination led to greater symptomatic relief than INCS alone.

The second scenario concerned how the leukotriene receptor antagonist (LTRA) montelukast compares with an INCS for the treatment of moderate to severe SAR in patients who are at least 15 years of age.

Again, earlier recommendations indicated that INCS was the most effective class of medication to control symptoms of AR, but earlier guideline authors did not make a specific recommendation on this point, as Dr Dykewicz explained. In the 2017 document, the working group concluded that "for initial treatment of moderate to severe SAR in patients 15 years and older, the clinician should recommend an INCS over an LTRA."

"A key reason why we felt this question needed to be re-examined in our 2017 update was that in 2013, the Agency for Healthcare Research and Quality concluded that for relief of nasal symptoms, an INCS and a LTRA were 'equivalent' with 'high-quality evidence' [to support their recommendation]," Dr Dykewicz explained.

"We obviously came to a very different conclusion," he added.

The last scenario the working group addressed was whether patients with SAR derive greater clinical benefit if treated with a combination of an INCS plus an intranasal antihistamine (INAH) compared with either agent alone. "The new update states that with high-quality evidence, the clinician may recommend combination therapy with an INCS and an INAH over either monotherapy, albeit with increased cost and some increased risk for side effects," Dr Dykewicz said.

This combination can be delivered with either a single device containing both agents — not available in 2008 when the earlier recommendations were released — or two separate nasal spray devices, he added.

The authors caution that not all patients respond to recommended treatments for SAR, and clinicians may have to modify treatment options to suit individual patient characteristics.

For example, older adults may be taking drugs for conditions other than SAR and may be more susceptible to certain side effects associated with recommended SAR therapies. The working group also emphasizes that even if the therapies recommended in the updated review are approved for children with SAR, the studies reviewed were not done in children and therefore the same medications cannot be recommended for a pediatric population.

Notably, the authors did not address the use of oral antihistamines as an initial treatment for SAR, nor did they make any statements about treatment of mild SAR or perennial allergic rhinitis.

The work was funded by the American Academy of Allergy, Asthma & Immunology  and the American College of Allergy, Asthma & Immunology. Dr Dykewicz  has served as a consultant for Alcon.

Ann Allergy Asthma Immunol. Published online November 2, 2017. Abstract

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