Otolaryngology - Head and Neck Surgery-2015 - Rhinitis Allergic
Otolaryngology - Head and Neck Surgery-2015 - Rhinitis Allergic
Otolaryngology - Head and Neck Surgery-2015 - Rhinitis Allergic
OTOXXX10.1177/0194599814561600Otola
Guideline
Otolaryngology
Head and Neck Surgery
2015, V
ol. 152(1S) S1S43
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2014
Reprints and permission:
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DOI: 10.1177/0194599814561600
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Abstract
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
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Introduction
Allergic rhinitis (AR) is one of the most common diseases
affecting adults.1 It is the most common chronic disease in
children in the United States today2 and is the fifth most common chronic disease in the United States overall.3 AR is estimated to affect nearly 1 in every 6 Americans and generates
$2 to $5 billion in direct health expenditures annually.4,5 It can
impair quality of life and, through loss of work and school
Department of OtolaryngologyHead and Neck Surgery, Henry Ford West Bloomfield Hospital West Bloomfield, Michigan, USA; 2Department of Surgery
OtolaryngologyHead and Neck Surgery University of Utah, Salt Lake City, Utah, USA; 3Johns Hopkins School of Medicine, Department of Otolaryngology
Head and Neck Surgery, Baltimore, Maryland, USA; 4Virginia Mason Medical Center, Seattle, Washington, USA; 5University of Chicago Medical Center,
Department of Otolaryngology, Chicago, Illinois, USA; 6Birmingham VA Medical Center, Birmingham, Alabama, USA; 7Otolaryngology, Private Practice,
Muscatine, Iowa, USA; 8Department of Internal Medicine, St Louis University School of Medicine, St Louis, Missouri, USA; 9Pomona Pediatrics, Pomona, New
York, USA; 10Eastern Virginia Medical School, Norfolk,Virginia, USA; 11Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio, USA; 12Wayne State
University, Philadelphia, Pennsylvania, USA; 13Georgetown University Hospital, Washington, DC, USA; 14Wake Forest Baptist Health, Winston Salem, North
Carolina, USA; 15Morehouse School of Medicine, East Point, Georgia, USA; 16Acupuncture and Oriental Medicine (AAAOM), Annandale,Virginia, USA
17
Florida Atlantic University, Boca Raton, Florida and Nova Southeastern University, Davie, Florida, USA; 18Consumers United for Evidence-based Healthcare,
Fredericton, New Brunswick, Canada; 19Louisiana State University School of Medicine, New Orleans, Louisiana, USA; 20Department of Research and Quality,
American Academy of OtolaryngologyHead and Neck Surgery Foundation, Alexandria,Virginia, USA.
Corresponding Author:
Michael D. Seidman, MD, Henry Ford West Bloomfield Hospital, 6777 West Maple Rd, West Bloomfield, MI 48322, USA.
Email: [email protected]
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Seidman et al
Table 1. Abbreviations and Definitions of Common Terms.
Term
Allergic rhinitis (AR)
Seasonal allergic rhinitis (SAR)
Perennial allergic rhinitis (PAR)
Intermittent allergic rhinitis
Persistent allergic rhinitis
Episodic allergic rhinitis
Definition
Disease caused by 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.
Disease caused by an IgE-mediated inflammatory response to seasonal aeroallergens. The length of
seasonal exposure to these allergens is dependent on geographic location and climatic conditions.
Disease caused by an IgE-mediated inflammatory response to year-round environmental aeroallergens.
These may include dust mites, mold, animal allergens, or certain occupational allergens.
Disease caused by an IgE-mediated inflammatory response and characterized by frequency of exposure or
symptoms (<4 days per week or <4 weeks per year).
Disease caused by an IgE-mediated inflammatory response and characterized by persistent symptoms (>4
days per week and >4 weeks per year).
Disease caused by an IgE-mediated inflammatory response that can occur if an individual is in contact with
an exposure that is not normally a part of the individuals environment. (ie, a cat at a friends house).
Guideline 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 in this 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 select 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 be an all-inclusive
guide for patient management, nor are the recommendations
intended to limit treatment or care provided to individual patients.
The guideline is not intended to replace individualized patient
care or clinical judgment. Its goal is to create a multidisciplinary
guideline with a specific set of focused recommendations based
upon an established and transparent process that considers levels
of evidence, harm-benefit balance, and expert consensus to
resolve gaps in evidence.8 These specific recommendations may
then be used to develop performance measures and identify avenues for quality improvement. Table 2 highlights the topics and
issues considered in the development of this guideline.
Healthcare Burden
Incidence and Prevalence
Allergic rhinitis is a worldwide health problem that affects
adults and children. In the United States, AR is the 16th most
common primary diagnosis for outpatient office visits.9 Large
epidemiologic studies consistently show a significantly higher
percentage of the population with rhinitis symptoms than
those with rhinitis symptoms and positive allergy tests.10 In
the 2005-2006 National Health and Nutritional Examination
Survey (NHANES), a sample of 7398 people (selected to
represent the United States population age 6 years and older)
were surveyed for hay fever, current allergies, and current rhinitis and tested for IgE specific to 19 inhalant allergens. One in 3 participants reported rhinitis symptoms within
the last 12 months not associated with an upper respiratory
infection. Of those with rhinitis, 52.7% demonstrated at least
1 positive allergy test.10 By this standard, IgE-mediated AR
may affect 1 in 6 persons within the United States. The United
States population is most commonly sensitized to grass pollen, dust mites, and ragweed pollen.10
The International Study of Asthma and Allergies in
Childhood (ISAAC), a worldwide study of allergies in
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Table 2. Topics and Issues Considered in Allergic Rhinitis (AR) Guideline Development.a
Diagnosis/Testing
Diagnosis of AR
Differentiating
nonallergic nasal
conditions from AR
When should a patient
be referred to an allergy
specialist?
Differentiating perennial
or seasonal AR
Identifying and treating
comorbidities
When is it acceptable
to test for allergic
component(s), and what
type of test should be
performed?
Accuracy of self
diagnosis
Accuracy of clinician
diagnosis based on
clinical assessment
Children age 2 and
instruments to measure
symptoms/objective
Prevention/Education/
Risk Factors
Treatment
additive vs negative
effects
Self-directed therapy
or over-the-counter
medications vs
physician-directed or
prescription medications
Use and safety of nasal,
oral, topical steroids
When is it acceptable
to add a second or
third medication?
Treatment of allergic
conjunctivitis
Role of surgical
management
Managing chronic
inflammation of lung,
sinus, skin, and ears
Role of immunotherapy
Efficacy of different
antihistamines
Measuring response to
therapy and identifying
further need for therapy
Role of environmental
controls
education
When is it appropriate
to manage symptoms
over the phone (or
internet)?
Role of dietary
modifications
Value of pollen counts
in determining symptom
severity and selfguidance
Role of stress
management in
the creation of, or
exacerbation of, AR
symptoms
Identification of
risk factors for the
development of AR
Other Therapies
Outcomes
Role of acupuncture
This list was created by the Guideline Development Group to refine content and prioritize action statements; not all items listed were ultimately included in
the guideline.
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Seidman et al
in children over time. In the United States, over an 8-year time
period ending in 2002, the prevalence of AR in 2422 children
ages 13 to 14 years increased from 13% to 19%.11 These
results illustrate that AR is both a common and growing global
concern.
Methods
This guideline was developed using an explicit and transparent a priori protocol for creating actionable statements based
on supporting evidence and the associated balance of benefit
and harm.21 The Guideline Development Group consisted of
20 panel members representing experts in otolaryngology,
allergy and immunology, internal medicine, family medicine,
pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine (acupuncture and herbal
therapies), and consumer advocacy.
Literature Search
An information specialist conducted 2 literature searches from
June 2013 through November 2013, using a validated filter
strategy, to identify clinical practice guidelines, systematic
reviews, and randomized controlled trials (RCTs). The search
terms used were ((Nasal Allergy[TW] OR Nasal Allergies[TW]
OR Nose Allergy[TW] OR Pollinosis[TW] OR Pollinoses[TW]
OR Catarrh[TW] OR Catarrhs[TW]) OR (Allergic Rhinitis[TW])
OR (((Rhinitis, Allergic, Perennial[MESH]) OR Rhinitis,
Allergic, Seasonal[MESH]) OR Rhinitis, Atrophic[MESH])
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Systematic review of cross-sectional studies with consistently Well-designed randomized controlled trials performed on a
applied reference standard and blinding
population similar to the guidelines target population
Individual cross-sectional studies with consistently applied
Randomized controlled trials; overwhelmingly consistent
reference standard and blinding
evidence from observational studies
Nonconsecutive studies, case-control studies, or studies with Observational studies (case control and cohort design)
poor, nonindependent, or inconsistently applied reference
standards
Mechanism-based reasoning or case reports
Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit over harm
American Academy of Pediatrics classification scheme25 updated for consistency with current level of evidence definitions.26
needed, with targeted searches to address specific needs identified in writing the guideline through February 2014. After
assessing quality and relevance, we retained 9 of the clinical
practice guidelines, 81 of the systematic reviews, and 177 of
the RCTs.
In a series of conference calls, the working group defined
the scope and objectives of the proposed guideline. During the
12 months devoted to guideline development ending in March
2014, the group met twice, with in-person meetings following
the format previously described,21 using electronic decisionsupport (BRIDGE-Wiz, Yale Center for Medical Informatics,
CT) software to facilitate creating actionable recommendations and evidence profiles.22 Internal electronic review and
feedback on each guideline draft were used to ensure accuracy
of content and consistency with standardized criteria for
reporting clinical practice guidelines.23
American Academy of OtolaryngologyHead and Neck
Surgery Foundation (AAO-HNSF) staff used the Guideline
Implementability Appraisal and Extractor (GLIA) to appraise
adherence of the draft guideline to methodological standards,
to improve clarity of recommendations, and to predict potential obstacles to implementation.24 Guideline panel members
received summary appraisals in April 2014 and modified an
advanced draft of the guideline.
The final guideline draft underwent extensive external peer
review. Comments were compiled and reviewed by the panels chair and co-chairs, and a modified version of the guideline was distributed and approved by the guideline development
panel. The recommendations contained in the guideline are
based on the best available data published through May 2014.
Where data were lacking, a combination of clinical experience
and expert consensus was used. A scheduled review process
will occur at 5 years from publication, or sooner if new compelling evidence warrants earlier consideration.
Classification of Evidence-Based
Statements
Guidelines are intended to produce optimal health outcomes
for patients, to minimize harms, and to reduce inappropriate
variations in clinical care. The evidence-based approach to
guideline development requires that the evidence supporting
a policy be identified, appraised, and summarized and that an
explicit link between evidence and statements be defined.
Evidence-based statements reflect both the quality of evidence and the balance of benefit and harm that is anticipated
when the statement is followed. The definitions for evidencebased statements are listed in Tables 325 and 4.25 Because
much of the guideline dealt with evidence relating to diagnostic tests, Table 3 was adapted to include current recommendations from the Oxford Centre for Evidence-Based
Medicine.26
Guidelines are not intended to supersede professional judgment but rather may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance.
Less frequent variation in practice is expected for a strong
recommendation than might be expected with a recommendation. Options offer the most opportunity for practice
variability.25 Clinicians should always act and decide in a way
that they believe will best serve their patients interests and
needs, regardless of guideline recommendations. Clinicians
must also operate within their scope of practice and according
to their training. Guidelines represent the best judgment of a
team of experienced clinicians and methodologists addressing
the scientific evidence for a particular topic.25
Making recommendations about health practices involves
value judgments on the desirability of various outcomes associated with management options. Values applied by the guideline panel sought to minimize harm and diminish unnecessary
and inappropriate therapy. A major goal of the panel was to be
transparent and explicit about how values were applied and to
document the process.
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Seidman et al
Table 4. Guideline Definitions for Evidence-Based Statements.
Statement
Strong Recommendation
Recommendation
Option
No Recommendation
Definition
Implication
decision making, which in turn leads to better patient adherence and outcomes. For the purposes of this guideline, shared
decision making refers to the exchange of information regarding treatment risks and benefits, as well as the expression of
patient preferences and values, which result in mutual responsibility in decisions regarding treatment and care.29 In cases
where evidence is weak or benefits are unclear, the practice of
shared decision makingagain where the management decision is made by a collaborative effort between the clinician
and an informed patientis extremely useful. Factors related
to patient preference include (but are not limited to) absolute
benefits (numbers needed to treat), adverse effects (number
needed to harm), cost of drugs or procedures, and frequency
and duration of treatment.
STATEMENT 1. PATIENT HISTORY AND PHYSICAL
EXAMINATION: 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. Recommendation based on
observational studies, with a preponderance of benefit over
harm.
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Action
Strength
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. 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.
Clinicians should not routinely perform sinonasal imaging in patients presenting
3.Imaging
with symptoms consistent with a diagnosis of AR.
4.Environmental factors Clinicians may advise avoidance of known allergens or may advise environmental
controls (eg, 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.
5.Chronic conditions and Clinicians should assess patients with a clinical diagnosis of AR for, and document
comorbidities
in the medical record, the presence of associated conditions such as asthma,
atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and
otitis media.
6.Topical steroids
Clinicians should recommend intranasal steroids for patients with a clinical
diagnosis of AR whose symptoms affect their quality of life.
Clinicians should recommend oral second-generation/less sedating antihistamines
7.Oral antihistamines
for patients with AR and primary complaints of sneezing and itching.
8.Intranasal
Clinicians may offer intranasal antihistamines for patients with seasonal, perennial,
antihistamines
or episodic AR.
Clinicians should not offer oral leukotriene receptor antagonists as primary
9.Oral leukotriene
therapy for patients with AR.
receptor antagonists
(LTRAs)
10. Combination therapy Clinicians may offer combination pharmacologic therapy in patients with AR who
have inadequate response to pharmacologic monotherapy.
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.
12.Inferior turbinate
Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate
reduction
reduction in patients with AR with nasal airway obstruction and enlarged inferior
turbinates who have failed medical management.
13.Acupuncture
Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture,
for patients with AR who are interested in nonpharmacologic therapy.
14. Herbal therapy
No recommendation regarding the use of herbal therapy for patients with AR.
Recommendation
Recommendation
Recommendation (against)
Option
Recommendation
Strong recommendation
Strong recommendation
Option
Recommendation (against)
Option
Recommendation
Option
Option
No recommendation
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Seidman et al
Supporting Text
The purpose of this statement is to provide guidance for the
initial clinical diagnosis of AR when a patient first presents to
a health care provider. Since rhinitis is an extremely frequent
complaint, and since this complaint will often be heard first in
the primary care setting, it is important that primary care providers be able to make an initial, if provisional, diagnosis,
especially since first-line, effective, readily available therapies
for AR may differ from those used for nonallergic rhinitis.30
Key elements of the history in patients presenting with AR
include seasonal, perennial or episodic, exposure-associated
itching of the nose, palate, or eyes, sneezing, nasal congestion,
sniffling, clear rhinorrhea, and postnasal drip.31 Children may
only complain of malaise or fatigue, often associated with a
cough, and the history must include specific questions about
rhinorrhea and nasal and ocular itch in order to elicit these complaints.32 Seasonal disease may be caused by exposure to outdoor fungal spores or plant pollens, which vary seasonally in
their appearance; perennial symptoms tend to be associated
with sensitization to indoor allergens, such as dust mites, cockroaches, animal dander, and other molds,33 but may also be
attributed to persistent pollen exposure in some climates.
Associated exposures to specific identifiable allergens, such as
animals, in connection with the sudden appearance and clearing
of symptoms should also be sought. Alternatively, symptoms
that develop on exposure to irritants such as smoke, fumes, and
chemicals are less likely to represent AR. Symptoms of other
sinonasal diseases such as sinusitis, vasomotor rhinitis, and
granulomatous diseases can overlap with AR symptoms and
should be differentiated from AR. Less typical symptoms, such
as epistaxis, unilateral rhinorrhea, unilateral nasal blockage,
severe headache, or anosmia, suggest alternative diagnoses and
should be investigated further. These symptoms could indicate
a more concerning diagnosis, such as cerebrospinal fluid (CSF)
rhinorrhea, sinonasal tumors, or chronic rhinosinusitis. Less
typical symptoms such as epistaxis, unilateral nasal symptoms,
severe headache, or anosmia suggest alternative diagnoses.
Viral upper respiratory infections may produce similar symptoms but tend to be of a shorter duration and often include other
symptoms such as fever and myalgia. Clinicians should pay
attention to a patients medications, such as antihypertensive
drugs, psychotropic agents, and topical decongestants, that may
cause nasal symptoms.34 Moreover, a family history of AR,
asthma, or atopic dermatitis strengthens the diagnosis of AR
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Historical Findings
Seasonal vs perennial nature of symptoms
Symptoms on exposure to particular agent
(animals, particular plants)
Current medications
Family history of atopic or allergic disease
Symptoms on exposure to irritants (makes
allergic origin less likely)
Symptoms of upper respiratory infection
(makes allergic origin less likely)
Supporting Text
The purpose of this statement is to help clinicians decide
when to use IgE-specific allergy testing and to define the
types of testing that may be useful. While a presumptive diagnosis of AR can be made based on a history and physical
Physical Findings
Clear rhinorrhea (clear or colored may
exist, although colored rhinorrhea may
indicate a comorbid disease process with
AR)
Bluish or pale swelling of nasal mucosa
Ocular findings (watery discharge, swollen
conjunctivae, scleral injection)
Frequent throat clearing
Allergic shiners
Nasal crease
Absence of foreign body, tumor, purulence
suggesting infection
Skin Testing
Skin testing is a bioassay performed by introducing a specific
allergen into the patients skin. Skin testing allows for direct
observation of the bodys reaction to a specific antigen. The
antigen rapidly activates cutaneous mast cells by interacting
with IgE antibodies on the surface of those cells. This leads to
the release of chemical substances such as histamine from
mast cell granules and results in the development of a wheal
and flare reaction within 15 to 20 minutes.39,40
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Table 7. Immunoglobulin E (IgE)Specific Tests.
Recommendation
Advantages
Disadvantages
Skin tests
Skin prick, or intradermal
Recommend
Blood
Recommend
No risk of anaphylaxis
Not affected by patients
medications
Can be used for patients
with skin conditions such
as dermatographism or
severe eczema
Can be used for patients on
-blockers or with comorbid
medical conditions that
preclude skin testing
Recommend against
Skin testing is primarily done by either the skin prick/puncture technique or by the intradermal/intracutaneous technique.
Skin prick testing has been shown to be highly sensitive and
specific, typically over 80% for both.38,41,42 Scratch testing, a
form of puncture technique, is rarely done now due to reduced
sensitivity and specificity, poor reproducibility, and greater
patient discomfort.38,43 Intradermal and intradermal dilutional
tests are other forms of skin testing that are used for identifying IgE-specific allergens.44 Intradermal skin tests are particularly helpful when the prick test is negative and there is a high
clinical suspicion for allergic sensitization to a particular allergen or if increased sensitivity is required.38,45 Provocationneutralization testing is a form of intradermal testing that is
primarily of historical interest for inhalant allergy testing, as it
has been shown to produce unreliable results.38
Skin testing can be used in patients of any age. While
infants may have small wheals with both positive controls and
allergens, prick/puncture tests can be performed with a high
degree of reliability. Although the prevalence of positive skin
tests is known to be lower after age 50, significant positive
skin tests can still be detected in the older population.38,42,46,47
Skin testing may be contraindicated when coexistent uncontrolled or severe asthma is present. Skin disease such as
eczema can be a relative contraindication. Other contraindications may include coexisting medical conditions that would
likely compromise survival should skin testing-induced anaphylaxis develop: for example, severe and unstable cardiovascular disease, concurrent use of -blockers.
While adverse reactions such as immediate and delayed
local swelling, redness, pain, and itching have been reported
with skin testing, serious adverse events such as anaphylaxis
and death are extremely rare. There have been no fatalities
reported as a result of prick inhalant testing and 6 fatalities
from intradermal inhalant testing, with 5 of these being asthmatic patients for whom prick testing did not precede intradermal testing.38,48 There is considerable variation in clinical
practice in (1) the number of skin tests performed, (2) the
allergen extract concentration used for testing, (3) selection of
skin testing devices, (4) interpretation and documentation of
results, and (5) quality assurance procedures used.41,49 When
performing prick or intracutaneous skin testing, the clinician
should use standardized allergen extracts when available and
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should record measurements of wheal and erythema for allergen and positive and negative controls at 15 to 20 minutes
after placement. The clinician should also list all medications
the patient has taken within the past week, as many medications, such as antihistamines and some antidepressants (eg,
tricyclics), may suppress the skin test response.38,42,50
Blood Testing
Allergen-specific IgE can be determined by testing the
patients serum with an in vitro test. Using an immunoassay,
allergen-specific IgE in serum is detected by incubating the
serum with the suspected allergen, which has been absorbed
on a solid phase (eg, plastic disc or bead). The bound specific
IgE is then measured by the addition of an anti-IgE antibody
for this specific allergen, which has a label, such as an
enzyme, attached to allow for detection. Anti-IgE antibodies
tagged to radioactive tags, (radioallergosorbent tests, aka
RAST) are seldom used today, making the term RAST an
anachronism.43
Advantages of using immunoassays for allergy testing
include the ability to test for sensitivity to specific antigens
without concern about adverse reactions, including anaphylaxis. Antihistamines and other medications (eg, tricyclic antidepressants and -blockers) do not need to be withheld. Using
blood allergy testing instead of skin testing may be preferred
when special skin conditions, such as dermatographism (skin
writing with reddened and raised skin lines produced by
scratching or stroking) or severe eczema, are present, in that
these conditions may make skin test interpretation very
difficult.38
While both skin prick and serum-specific IgE tests have
similar diagnostic properties, the skin prick test is generally
considered to be more sensitive.38,51,52 Another potential
advantage of skin testing is that it is less expensive than blood
testing,53 and patients are able to see the tangible results of
their testing. Clinicians should use their best judgment when
deciding which method of IgE-specific testing to use for a
given patient. Given the lack of conclusive evidence of superiority of one test over another, in the absence of contraindications to one form of testing, patient preference for and the
availability of skin or blood testing should play a role in deciding which test to use. Clinicians should always be aware that
detection of sensitization to an allergen is not equivalent to a
clinical diagnosis of an allergy to a specific allergen. In the
absence of clinical symptoms, positive skin or blood testing
does not mean that the patient has an allergy to that allergen.
Other Tests
Other diagnostic tests are used to evaluate patients with suspected AR. Those tests include acoustic rhinometry, olfactory
testing, microarray testing, nasal nitric oxide measurements,
testing for food allergy, and nasal allergen challenges. Nasal
smears to evaluate nasal eosinophilia have been used by some
clinicians, although general agreement on their usefulness is
lacking.7,54-56 There is insufficient evidence to make recommendations for or against the use of these tests. As a final
point, the providers knowledge of the patients history, local
Supporting Text
The purpose of this statement is to discourage the routine use
of diagnostic imaging for patients with AR. History, physical
examination, and allergy testing are the key aspects of making
the diagnosis of AR. Specific IgE-mediated allergen diagnostic testing is confirmatory. There are no radiological findings
specifically diagnostic for AR. The utility of imaging procedures in AR is undocumented, and no articles were found
regarding the diagnostic yield of imaging studies with AR.
Radiographic imaging is unwarranted in patients who
already meet clinical criteria for the diagnosis of AR. Potential
significant adverse events and unnecessary costs preclude any
benefits of routine imaging. Plain film radiographs and computed tomography (CT) scans expose patients to ionizing
radiation, which may result in future radiation-induced cancers.57,58 Iodinated contrast carries the risk of allergic anaphylactic reactions and nephrotoxicity.59
Radiographic testing may have a role in the diagnosis if the
clinical presentation points to potential sequelae of AR, such
as rhinosinusitis, nasal polyposis, or concerns of a suspected
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Seidman et al
neoplasm. In contrast to AR, which only affects the nasal
mucosa, rhinosinusitis is defined as inflammation of the nasal
cavity and adjacent paranasal sinuses. Complicated sinusitis
implies spread of infection into adjacent structures, which can
result in orbital or intracranial complications, such as orbital
abscess and meningitis.60 Diagnosis of most cases of uncomplicated acute and subacute rhinosinusitis is based on clinical
findings. Sinonasal imaging, specifically CT scans without
contrast, may be indicated in patients who demonstrate signs
and symptoms of recurrent acute rhinosinusitis, nasal polyposis, chronic rhinosinusitis, or complicated rhinosinusitis or to
define sinus anatomy prior to surgery.61 In patients with a suspected sinonasal neoplasm, sinus CT and magnetic resonance
imaging (MRI) may be indicated for further evaluation. CT
scans will define the bony anatomy of the sinuses and patterns
of bone destruction as well as any formation of cartilaginous
or bone matrix. MRI with and without contrast can differentiate soft-tissue densities from postobstructive secretions and
will delineate evidence of perineural, orbital, skull base, or
intracranial extension of tumor.62,63
In summary, the diagnosis of AR is based on clinical presentation, and there is no role for radiographic imaging.
Potential significant costs and possible side effects of imaging
modalities outweigh their utility in the routine evaluation of a
patient with AR.
Supporting Text
S14
significantly reduced dust mite levels in the bedroom. Additionally, patients in the intervention group reported a significant
improvement in nasal symptoms compared with those in the
control group.
The effectiveness of HEPA filtration in reducing symptoms
of AR and medication use was examined in a randomized
double-blind study.80 Thirty-two patients with positive sensitization to HDM used high air filtration in the bedroom for 8
weeks: 4 weeks with HEPA filtration and 4 weeks with placebo filtration. Comparative analysis between the 2 filtration
periods found a reduction in particulate matter in the bedrooms when HEPA filters were used but no improvement in
allergy symptoms or medication use. However, when the
researchers compared the last 2 weeks of each 4-week period,
there were significant reductions in symptom scores in the
HEPA filtration group, indicating some benefit. In another
study,81 35 patients with perennial allergic rhinoconjunctivitis
sensitized to dust mite, cat, or dog allergens participated in a
randomized, double-blind, placebo-controlled crossover design
to determine the effectiveness of a combined therapy using
dust-mite barrier bed pillow encasings and localized HEPA air
filtration. Participants were assigned to either the active filtration group or the placebo group for 2 weeks followed by a
1-week washout period before switching groups for a second
2-week period. Dust samples collected around and under the
bed showed a reduction of 99% in the active filtration group
compared with a reduction of only 7% in the placebo group.
Overnight nasal and ocular symptoms of AR were significantly
reduced in the active group compared with the placebo group;
however, no changes in daytime symptoms were found.
Use of multiple strategies may help reduce dust mite exposure and nasal symptoms in HDM-sensitive patients, although
a single intervention such as using HDM-impermeable covers
on bedding or HEPA filtration has not been shown to be effective.72,77,82 Based on the limited quality of evidence on dust
mite avoidance measures, further research is needed to better
understand the effectiveness of these approaches. Table 8
lists the environmental control measures that can be used to
possibly reduce allergen levels and symptoms.
STATEMENT 5. CHRONIC CONDITIONS AND
COMORBIDITIES: 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. Recommendation based on randomized trials with some heterogeneity
and a preponderance of benefit over harm.
S15
Seidman et al
Table 8. Environmental Control Measures to Reduce Allergen Levels and Symptoms.
Evidence Supports Reduction
in Allergen Level
Environmental Control Measure
Yes
Removal of pets
Washing pets twice a week
Acaricides to kill dust mites
Impermeable covers for bedding
Air filtration
Combined use of multiple control measures
No
X
X
X
X
X
X
Supporting Text
The purpose of this statement is to increase awareness of the
medical conditions that are associated with AR and emphasize
the importance of diagnosing and treating these comorbidities, which include atopic disorders, sleep-disordered breathing, otitis media, and rhinosinusitis.
There is a well-established epidemiologic association
among the atopic disorders, asthma, eczema, and AR, which
share many pathophysiologic mechanisms. Over half of
patients with asthma have AR,83 and 10% to 40% of patients
with AR have asthma. The association between asthma and
AR is especially strong when asthma is documented to have
an allergic cause, a situation where the absence of AR would
be distinctly unusual.84 In children, the risk of asthma is
related to the severity and duration of the patients rhinitis.85,86
Childhood AR not only predisposes to the development of
asthma in childhood but also increases the risk of asthma persisting into adulthood and the onset of allergic asthma in middle age. In contrast, adult-onset, nonallergic asthma is not
necessarily associated with AR.87 Moreover, the presence of
food-associated atopic dermatitis before age 4 is associated
with the development of asthma and AR later in childhood
(after age 7)88; this is a consistent observation that has been
referred to as the allergic march. In one study, 57.6% of
children with early childhood eczema developed AR, 34.1%
No
X
X
became asthmatic, and the likelihood of developing the respiratory disorders was related to the severity of the dermatitis.89
The connection between the skin inflammation and later
respiratory disease may be due in part to sensitization to airborne allergens by contact with the skin surface.90 Allergic
conjunctivitis can also be seen in conjunction with AR and can
be treated concurrently.
Recognition of the connections among these atopic diseases has implications for both diagnosis and therapy. A history of atopic eczema or asthma makes an allergic origin more
likely in a patient presenting with persistent or recurrent nasal
symptoms. Evaluation of a patient with AR should always
include an assessment for asthma; inquiry about typical symptoms such as difficulty breathing, cough, wheezing, and ability to exercise; and examination of the chest. This evaluation
should be repeated on follow-up visits, particularly in children, and spirometry should be performed whenever asthma is
suspected. Treatment of AR in patients with concurrent asthma
should be individualized; the use of oral antihistamines91,92
and especially INS93,94 has been shown to reduce bronchial
hyperreactivity and improve asthma control.86,95-97 In addition,
leukotriene receptor antagonists may be an appropriate choice
for patients with both asthma and AR98 even though they are
not first-line therapy for independent AR (see Statement 9 on
LTRAs). Immunotherapy can also benefit both conditions,99-102
and there is evidence that treatment of children with AR with
allergen-specific immunotherapy may prevent the development of asthma103 and sensitivity to new allergens.104 There is
also emerging evidence that immunotherapy for AR may
improve control of atopic dermatitis.105
Nasal blockage and impaired mucociliary clearance106 may
predispose patients with AR to sinus infection; however, a
definite relationship between these disorders is not well established. Adenoid hypertrophy must also be considered in children with AR or sinonasal disease.
There may be an association between AR and otitis media
with effusion,107 with reports of comorbidity varying widely from
16.3 to 89%.108 In a review of patients with both conditions,
allergy treatment using INS, with or without antibiotics, was
found to hasten resolution of otitis media with effusion.109 This
effect may be related to reversing underlying Eustachian tube
dysfunction. AR has been associated with sleep-disordered
S16
Supporting Text
The purpose of this statement is to encourage clinicians to use
INS for AR based on their efficacy, superiority over other
therapies, and good safety record.
Intranasal steroids are very effective for the treatment of AR.
With potent anti-inflammatory properties, INS directly modulate the pathophysiology of AR. In nasal allergen challenge
models, pretreatment with INS results in significant reduction
in mediator and cytokine release along with a significant inhibition in the recruitment of basophils, eosinophils, neutrophils,
S17
Seidman et al
secretions, and epistaxis. The incidence of epistaxis with different preparations ranges from 4% to 8% over short treatment
periods ranging from 2 to 12 weeks with no differences
between placebo and active therapy.159,160 Higher incidences
of epistaxis (reaching 20%) are reported in studies carried
over a year.161,162 Epistaxis can be minimized with proper INS
positioning and administration, generally pointed away from
the septum within each side of the nose. Septal perforations,
although rare, have been reported.163 Biopsy specimens from
the nasal mucosa of patients with perennial rhinitis who have
been treated with INS continuously for 1 to 5 years showed no
evidence of atrophy.164-171 Studies in adults and children evaluating the effects of INS on the hypothalamic-pituitary axis using
morning cortisol concentrations, cosyntropin stimulation, and
24-hour urinary free cortisol excretion show no adverse
effects.162,172-183 There is some evidence of hypothalamicpituitary-adrenal axis suppression with betamethasone nasal
spray specifically.184,185 Patients with HIV may absorb INS at
a higher rate and need to use caution when using INS or find
an alternative treatment.186-188 Although there have been
reports of an association between the use of INS and the
development of posterior subcapsular cataracts,189 later work
did not corroborate these concerns.190,191 Studies with INS
given over several months have failed to show development of
posterior subcapsular cataracts, significant increases in intraocular pressure, or glaucoma.162,172,180,192
The effect of INS on growth in children has been investigated in controlled studies using both knemometry (a technique able to measure short-term growth by estimating the
distance between heel and knee of the sitting child with an
accuracy of 0.09-0.16 mm) in short-term studies and stadiometry (the accurate measurement of height using an instrument
that provides a direct digital reading of height that is accurate
to the nearest millimeter) in yearlong, placebo-controlled
studies where height is measured monthly. In knemometry
studies, intranasal budesonide reduced lower leg growth rate
in 2 studies, but the difference was statistically significant in
only one of them.193,194 In placebo-controlled studies, fluticasone furoate, triamcinolone acetonide (in 2 doses), and fluticasone propionate for 2 weeks did not affect lower leg growth
rate compared with placebo.195,196 In the yearlong studies
using stadiometry, intranasal beclomethasone dipropionate, at
twice the recommended daily dosage, resulted in growth suppression, but fluticasone propionate and mometasone furoate
showed no effects on growth compared with placebo.197,198 In
a small, nonrandomized, open-label study, children were followed for 2 years while receiving triamcinolone acetonide
nasal spray, and their height was measured by stadiometry and
compared with predicted values; no significant difference was
shown between measured and predicted heights.199 Therefore,
in clinical practice, it seems prudent to use the intranasal steroid preparations that have not been shown to have any negative impact on growth in children, as detailed above.
Short courses of systemic corticosteroids are often used
clinically for patients with severe AR but have not been shown
to be superior to INS.7,200 In nasal challenge studies, systemic
S18
Name
Formulation
FDA
Indications
Age
Contraindications Approved
Propellant,
Triamcinolone
acetonidea (Nasacort aqueous
Allergy 24HR), 55 g
per spray
Seasonal and
perennial AR
History of
hypersensitivity
to medication
or components
2 y
AR and
nonallergic
rhinitis
History of
hypersensitivity
to medication
or components
6 y
Seasonal and
perennial AR
History of
hypersensitivity
to medication
or components
6 y
Fluticasone
propionateb
(Flonase), 50 g
per spray
History of
hypersensitivity
to medication
or components
4 y
Mometasone furoate
(Nasonex), 50 g
per spray
Aqueous
Seasonal and
perennial AR,
nasal polyps
History of
hypersensitivity
to medication
or components
2 y
Ciclesonide
Aqueous
Seasonal and
(Omnaris), 50 g per suspension perennial AR
spray
History of
hypersensitivity
to medication
or components
6 y
Fluticasone furoate
Suspension
(Veramyst), 27.5 g
per spray
Seasonal and
perennial AR
History of
hypersensitivity
to medication
or components
2 y
HFA
Seasonal and
nonaqueous perennial AR
aerosol
History of
hypersensitivity
to medication
or components
History of
hypersensitivity
to medication
or components
12 y
(Qnasl), 80 g per
spray
Seasonal and
perennial AR
12 y
Dosing
Common Side
Effects
OTC or
Prescription
Abbreviations: AR, allergic rhinitis; HFA, hydrofluoroalkane; OTC, over the counter.
a
Only preparation available OTC.
Downloaded from oto.sagepub.com by guest on March 12, 2015
b
Available in generic form.
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Seidman et al
antihistamines and nasal steroids that will provide
good patient adherence and treatment efficacy.
Exclusions: None
Policy level: Strong recommendation
Differences of opinions: None
Supporting Text
The purpose of this statement is to define the role and encourage the use of oral antihistamines in the treatment of AR.
These agents have been in use since the 1940s, and numerous
controlled clinical studies have established their effectiveness, in both children and adults, for relief of symptoms
including rhinorrhea, sneezing, itching, and nasal blockage as
well as associated ocular complaints.202-206 While these agents
may not be as effective as INS, they are adequate for many
patients with mild to moderate disease and have the advantage
of lower cost, rapid onset of action, and effectiveness for
intermittent symptoms.
Oral antihistamines, which block the action of histamine
on the H1 receptor, have numerous anti-inflammatory effects206
and can be broadly categorized as first- or second-generation
agents. Older first-generation agents, which are lipophilic and
cross the blood-brain barrier, also have antimuscarinic effects.
Newer second-generation agents are highly selective for the
H1 receptor and have limited penetration of the central nervous system. Examples of first-generation medications
include diphenhydramine, chlorpheniramine, and hydroxyzine. The use of first-generation agents is limited by the side
effects of sedation and mucosal dryness. It is important to recognize that performance impairment may occur even when
patients have no obvious perception of drowsiness.207,208
Commonly used second-generation drugs include fexofenadine, cetirizine, levocetirizine, loratadine, and desloratadine.
In almost all situations, second-generation antihistamines are
preferred. There are relatively few comparative studies among
the various compounds of second-generation antihistamines,
but data indicate that cetirizine and its active enantiomer,
levocetirizine, are the most potent209-212 but carry a modest
risk of sedation not seen with other drugs in this class.208,213,214
Advantages of oral antihistamines include rapid onset of
action,215,216 once-daily dosing, maintenance of effectiveness
with regular use, and the availability of some drugs without a
prescription. Some patients who fail to improve with one
agent may respond to an alternative drug in this category.217,218
Maximum benefit is seen with continuous use,219,220 but use
on an as-needed basis can provide significant symptom relief
and is appropriate for some patients, especially those with
intermittent symptoms.221
Although most studies have shown that INS, used on a continuous basis, is superior to oral antihistamines for treatment
of AR, especially for symptoms of nasal congestion,150,222-226
an antihistamine, used as a single agent either intermittently or
continuously, may provide adequate relief for many individuals. Oral antihistamines usually produce no further improvement when added to treatment with INS, although the addition
of as-needed INS to a regularly taken oral antihistamine is a
viable strategy.227,228 The decision to use oral agents rather
Supporting Text
The purpose of this statement is to address the use of intranasal antihistamines for patients with AR. Antihistamine allergy
medications are H1-receptor antagonists, and 2 intranasal
antihistamines are currently approved by the US FDA for
S20
Medication
FDA Indications
(Seasonal,
Perennial)
Contraindications
Approved Ages
Cetirizine
(Zyrtec)
Both
Hypersensitivity
6 months
to cetirizine,
levocetirizine, or
hydroxyzine
Levocetirizine
(Xyzal)
Both
Hypersensitivity
6 months
to levocetirizine,
cetirizine, or
hydroxyzine
Fexofenadine
(Allegra)
Seasonal
Hypersensitivity to 2 years
fexofenadine
Loratadine (Claritin,Both
Alavert)
Desloratadine
(Clarinex)
Both
Hypersensitivity
2 years
to loratadine or
desloratadine
Hypersensitivity to 6 months
desloratadine or
loratadine
Common Side
Effects
Dosing
Occasional
Age 2-5 y: 2.5 mg
sedation, mucosal 1 or 2 times per
dryness, urinary
day
retention
Age 6-12 y: 5-10
mg/d
Age 12-65 y: 10
mg/d
Age 66-76 y: 5-10
mg/d
Age 77 y: 5 mg/d
Occasional
Age 2-5 y, 1.25
sedation, mucosal mg/d
dryness, urinary Age 6-11 y, 2.5
retention
mg/d
Age 12 y, 2.5-5.0
mg/d
Occasional
Age 2-11 y, 30 mg
headache
twice a day
Age 12 y, 60 mg
twice a day or
180 mg/d
Possible sedation Age 2-5 y, 5 mg/d
with higher than Age 6 y, 10 mg/d
usual doses
Possible sedation Age 2-5 y, 1.25
with higher than
mg/d
usual doses
Age 6-11 y, 2.5
mg/d
Age 12 y, 5 mg/d
OTC or
Prescription
OTC
Prescription
OTC
OTC
Prescription
treatment of AR. Azelastine and olopatadine are both secondgeneration H1-receptor antagonists and have equal efficacy in
head-to-head, placebo-controlled comparison studies.229 The
formulations of these 2 antihistamines are listed in Table 11.
One of the benefits of intranasal application is targeted
delivery and increased dosage to nasal tissues while limiting
systemic effects.230 For the treatment of nasal symptoms,
intranasal antihistamines have shown equality or superiority
to oral antihistamines in numerous well-designed randomized,
controlled, and blinded studies.231-233 Intranasal antihistamines
show benefit even in patients who fail oral antihistamine
treatment.233,234 Specifically with regard to nasal congestion,
intranasal antihistamines are more efficacious than oral preparations.232,235,236 Intranasal antihistamines also have the advantage of rapid onset of action in the range of 15 to 30 minutes,
which is much faster than in the oral route (average onset 150
minutes).231,237 Numerous studies have compared INS to intranasal antihistamines. The results are conflicting, with some
showing equality238-240 and some showing superiority of
INS.149,241 Heterogeneity, lack of standardized dosing, lack of
validated outcome metrics, and short-term follow-up limit the
applicability of these comparisons.
S21
Seidman et al
Table 11. Allergic Rhinitis (AR) Intranasal Antihistamines.
Medication
FDA Indications
Contraindications
Approved Ages
Dosing
Olopatadine
Seasonal AR
(Patanase) (as
HCl) 0.6% (665
g per spray);
aqueous nasal
spray
Azelastine (Astelin) Seasonal AR,
0.1% solution
vasomotor
(137 g per
rhinitis
spray)
None
6 y
None
6 y
Azelastine
Seasonal AR,
(Astepro) 0.15% perennial AR
solution (205.5
g per spray)
None
6 y
Azelastine plus
Seasonal AR
fluticasone
(Dymista) (137
g of azelastine,
50 g of
fluticasone per
spray)
None
12 y
Common Side
Effects
OTC or
Prescription
Bitter taste
Epistaxis
somnolence
Headache
Prescription
Bitter taste
Epistaxis
Somnolence
Headache
Prescription
Bitter taste
Epistaxis
Somnolence
Headache
Prescription
Bitter taste
Epistaxis
Somnolence
Headache
Prescription
S22
The plus symbols indicate the relative effectiveness for each medication class for the various symptoms: for example, most effective for congestion (+++) but also effective for each of the other symptoms (+).
One of the intranasal antihistamines available in the United States (Astepro) is indicated for perennial/persistent AR.
b
Low
Not as
monotherapy
Yes
Yes
No
No
+
+
+
+
Large
+
++
+b
++
++
++
++
++
++
+b
++
Large
No
+
+
++
+
+
++
++
+
++
Large
++
++
++
++
+
++
+++
+++
Intranasal
steroids
Oral
antihistamines
Intranasal
antihistamines
Leukotriene
receptor
antagonist
+++
+++
++
Severe
Mild
Persistent
Intermittent
Episodic
Perennial
Seasonal
Nasal Itching
Sneezing
Congestion Rhinorrhea
Medication
Class
Recommendations
for Symptoms
Recommendations for
Exposure to Allergen
Recommendations for
Symptom Frequency
Recommendations for
Symptom Severity
Patient
Preference
Supporting Text
The purpose of this statement is to reduce the use of a more
expensive, less effective agent as first-line treatment of AR.
The LTRA montelukast is FDA-approved for treatment of
symptoms of seasonal AR in adults and pediatric patients 2
years of age and older and perennial AR in adults and pediatric
patients 6 months of age and older. While several other LTRAs
are available in the United States, montelukast is the only LTRA
approved by the FDA for AR. Systematic literature reviews and
meta-analyses (predominantly based on controlled studies of
montelukast in adults with seasonal AR) conclude that LTRAs
are more effective at controlling symptoms and improving quality of life than placebo.245-248 While some studies have shown that
LTRAs are as effective as oral antihistamines,151,245,247,248 others
have shown that LTRAs are less effective246 than oral antihistamines and INS.151,245-248 In a single randomized, double-blind
study, montelukast had a similar effect to pseudoephedrine in
reducing symptoms of AR except the symptom of nasal congestion, for which pseudoephedrine was more effective.249 In patients
having both AR and asthma, montelukast improves both
conditions.250-253
Montelukast is generally well tolerated and is not associated
with drowsiness.254 In placebo-controlled trials, behavior-related
adverse events were infrequent.255 However, some postmarketing
reports have demonstrated rare drug-induced neuropsychiatric
events (including aggression, depression, suicidal thinking, and
behavior).256 Suicidal ideation was reported in 1 of 9929 patients
(0.01%) in clinical trials treated with montelukast.257
Montelukast has traditionally been more expensive than oral
antihistamines,258 although the cost differential has been lessened
with the introduction of generic montelukast. Because montelukast is currently more expensive and equally as effective as or
less effective than oral antihistamines for AR, and because it
is less effective than INS, clinicians should not routinely offer
an LTRA as primary therapy for patients with AR. However,
there may be a subset of patient who have AR and asthma who
may benefit from this medication.
STATEMENT 10. COMBINATION THERAPY: Clinicians
may offer combination pharmacologic therapy in patients
with AR who have inadequate response to pharmacologic
monotherapy. Option based on RCTs with minor limitations and
observational studies, with equilibrium of benefit and harm.
S23
Seidman et al
Benefits: Improved effectiveness and symptom control of combined therapy
Risks, harms, costs: Increased cost, overuse of medication, use of ineffective combinations, multiple
medication side effects, drug interactions
Benefit-harm assessment: Equilibrium
Value judgments: None
Intentional vagueness: The term combination
therapy is nonspecific as there are multiple different combinations. The details are elaborated in the
supporting text. The term inadequate response to
monotherapy also allows for some interpretation by
clinicians and patients.
Role of patient preferences: ModerateShared decision making in consideration of evidence for benefits,
harms and cost of combinations, effective dosing,
and potential medication interactions to assist the
patient in more effective treatment compliance.
Exclusions: Decongestants that are part of some
combined products are not approved for children
under the age of 4 years.
Policy level: Option
Differences of opinion: None
Supporting Text
The purpose of this statement is to promote the use of effective
and decrease the use of ineffective pharmacologic combinations for the treatment of AR. When initial therapy with an INS
does not lead to adequate control of allergic nasal symptoms, or
the patient cannot tolerate INS, the practitioner may choose
combination therapies, of which the most effective additive to
an INS is an intranasal antihistamine. In severe nasal obstruction, adding topical oxymetazoline to INS for a few days has
proven benefit, but due to concerns about nasal rebound, topical oxymetazoline use should be limited to a few days. If nasal
sprays are disliked or not tolerated, combination therapy of an
oral antihistamine and decongestant is the next most effective
pharmacotherapy for AR. The selection of effective pharmacotherapy for AR may be influenced by coexisting conditions of
allergic conjunctivitis or asthma. While oral antihistamines and
INS are common selections for primary monotherapy, their
combination does not offer much clinical benefit.
decongestant alone. This benefit has been consistently demonstrated in multiple randomized, placebo-controlled trials,
each with more than 500 subjects enrolled.262-270 Adding an
oral decongestant to a second-generation antihistamine
increases side effects of insomnia, headache, dry mouth, and
nervousness.263,264,267 Additionally, the potential for tolerance
from chronic use of oral decongestants may be seen.
In one study, 24-hour extended-release pseudoephedrine
(240 mg) caused less insomnia than 12-hour extendedrelease pseudoephedrine (120 mg) taken twice daily (4% vs
15%, P < .01).271 A 2005 meta-analysis concluded that
pseudoephedrine caused a small but significant increase in
systolic blood pressure (0.99 mm Hg; 95% CI, 0.08 to 1.90)
and heart rate (2.83 beats/min; 95% CI, 2.0 to 3.6), with no
effect on diastolic blood pressure (0.63 mm Hg, 95% CI,
0.10 to 1.35).272 Oral decongestant use is not recommended for patients under 4 years of age, and the extendedrelease, 120-mg, 12-hour dose is not recommended for
patients under 12 years of age.
S24
Oral Antihistamine
monotherapy
Intranasal Antihistamine
monotherapy
Add
Intranasal Antihistamine
or
Oxymetazoline (3 days or less)
Add
Oral Decongestant
(increased side effects of
headache, dry mouth,
hypertension, and nervousness.)
Add
Intranasal steroid
Do not add
Oral Antihistamine
or
Leukotriene Receptor Antagonists
Could add
Leukotriene Receptor
Antagonoist (evidence mixed)
Do not add
Intra-Nasal steroid
(Reasonable to change to INS, but
adding not helpful)
Supporting Text
The purpose of this statement is to increase the awareness of
immunotherapy as a treatment for AR, promote its appropriate use, and reduce unnecessary or harmful variation in care.
Allergen-specific immunotherapy (SIT) involves controlled, repetitive dosing of allergen(s) in patients diagnosed
with IgE-mediated AR by history and confirmed with specific
allergy testing in order to increase immune tolerance to the
offending allergen(s). The ultimate goal of SIT is to decrease
S25
Seidman et al
Table 13. Comparison of Features of SCIT and SLIT.
SCIT
SLIT
FDA status
FDA approved
Socioeconomic
Abbreviations: CPT, Current Procedural Terminology; SCIT, subcutaneous immunotherapy; SLIT, sublingual immunotherapy.
S26
Supporting Text
The purpose of this statement is to increase awareness of and
allow for appropriate use of inferior turbinate reduction surgery
as part of the management for AR patients with persistent nasal
symptoms and turbinate hypertrophy despite medical treatment.
The inferior turbinates are tissues located on the lateral
wall of the inside of the nose that consist of bone covered with
tissue that can enlarge and swell in response to inflammation.
S27
Seidman et al
Nasal airway obstruction, secondary to hypertrophic inferior
turbinates, is a common symptom of AR. Several surgical procedures are available for addressing inferior turbinate hypertrophy. These generally involve different methods for
removing either (1) entire portions of the turbinate (turbinectomy) or (2) only the tissues between the mucosal covering
and/or the bone of the turbinate (submucous resection); or
shrinking the volume of the turbinate (tissue ablation). One
prospective randomized study of 382 patients with inferior
turbinate hypertrophy compared turbinectomy, laser cautery,
electrocautery, cryotherapy, submucosal resection, and submucosal resection with inferior turbinate outfracture.326 Of
these methods, submucous resection with outfracture was the
most effective surgical therapy with the fewest complications.
These procedures have been described as being performed
under local anesthetic, sedation, or a general anesthetic.
Currently, the 2 most common techniques for turbinate
reduction are submucous resection and tissue ablation. One
prospective randomized study of 60 patients assessed the
long-term effect of tissue ablation and submucous resection.327
Both techniques reduced subjective nasal obstruction at 3 and
6 months. However, the submucous resection group had
greater nasal patency at 12 months post treatment compared
with the group that underwent tissue ablation.327
A nonblinded randomized trial of 58 perennial AR patients
who had failed oral antihistamines compared inferior turbinate reduction surgery to INS and assessed the outcome of
nasal congestion.328 After 1 year, both groups had reduction in
nasal resistance by acoustic rhinometry. However, the surgical
group had statistically significant improvement in nasal congestion symptoms, while the medical group showed a nonsignificant trend for improvement.
Several uncontrolled studies suggest that inferior turbinate
procedures may also diminish the symptoms of rhinorrhea and
sneezing in patients with AR.329-331 Fukazawa et al330 prospectively evaluated 95 patients who underwent inferior turbinate
reduction for nasal congestion due to AR. The patients had
reduced nasal congestion, rhinorrhea, and sneezing at 1, 3, 6,
and 12 months after the procedure. Another uncontrolled prospective cohort of 60 patients undergoing submucous resection of the inferior turbinates showed a decreased nasal
response to allergy provocation test at 2 and 12 months after
the procedure.329 A second report in this cohort with 3- and
5-year follow-up demonstrated sustained improvement of
symptoms of nasal congestion, sneezing, and rhinorrhea.331
However, patients with persistent symptoms after surgery may
require ongoing medical treatment.
While generally considered to be safe, inferior turbinate
reduction can be complicated by nasal bleeding, synechiae
(scar) formation, or crusting. Rarely atrophic rhinitis (empty
nose syndrome) can be a complication from inferior turbinate
reduction, in which patients have the sensation of nasal
obstruction due to lack of sensations of airflow. Atrophic rhinitis is very rare when only submucous resection, rather than
turbinectomy, is performed. Finally, turbinate reduction is a
surgical procedure with the attendant cost of surgery and the
general risks of anesthesia.
Supporting Text
The purpose of this statement is to enable patient access to
potentially beneficial nontraditional treatment and increase
awareness of the possible benefit of acupuncture in the treatment of patients with AR.
The NIH National Center for Complementary and Alternative
Medicine (NCCAM) defines acupuncture as a family of procedures involving the stimulation of points on the body. The
technique that has been most often studied involves penetrating the skin with thin, solid, metallic needles that are manipulated by hand or by electrical stimulation. There are no
published estimates of the frequency of acupuncture for AR in
the United States, but a nested case-control study of adults
with allergic disease in Germany reported that lifetime acupuncture use was 17% for those with AR.332 A 2006 systematic review of complementary and integrative medicine by the
S28
191 adults with perennial AR reported a significant improvement in Total Nasal Symptom Score at the end of treatment (P
= .029) and 4 weeks after treatment (P = .04), with 3.68 and
3.77 standard deviation, respectively, when compared with
sham acupuncture, and a significant improvement in the Total
Non-Nasal Symptom Score compared with the waitlist group
(P = .0002).347 Throughout the study, 4 nasal symptoms (nasal
obstruction, sneezing, rhinorrhea, and nasal itch) were selfassessed daily and recorded in a diary by participants, using a
5-point scale (0 = no symptom; 1 = mild; 2 = moderate; 3 =
severe; and 4 = very severe). Seven-day individual and Total
Nasal Symptom Scores were determined from the daily symptom scores. No other outcomes were significantly different.347
The use of a placebo control in the medical and immunotherapy treatment trials for AR has shown that placebo effects
are significant and can be greater than 50% for symptom
improvement. For most of the clinical trials reviewed here,
sham acupuncture was used. However, the location, depth,
and manipulation of the sham needles varied widely, and
while some trials report that sham therapy itself might have a
therapeutic effect, several showed no placebo effect from
sham acupuncture.348
The mechanism of action of acupuncture in the treatment
of AR is unknown. Studies suggest that acupuncture inhibits
cytokine synthesis, such as interleukin-10 in patients with AR
and interleukin-6 and interleukin-10 in patients with asthma;
however, it remains unclear whether these findings correlate
with clinical effect.349-352
In summary, one systematic review and several subsequent
large RCTs have found that acupuncture offers some symptom
control and improved quality of life in patients with perennial
AR. Although the systematic reviews of earlier trials did not
find a benefit in seasonal AR, subsequent RCTs found benefit
to acupuncture for symptom control in seasonal AR patients.
Additionally we could find no evidence of significant harms
associated with acupuncture. Accordingly, for patients with an
interest in nonpharmacologic approaches to management of
AR, acupuncture may be offered as an option.
STATEMENT 14. HERBAL THERAPY: No recommendation regarding the use of herbal therapy for patients
with AR. No recommendation based on limited knowledge of
herbal medicines and concern about the quality of standardization and safety.
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Seidman et al
Benefit-harm assessment: Not applicable
Value judgments: There are many herbal therapies,
but there is only evidence for a few that have appropriate studies. There is limited knowledge about
these products among most of the panel members,
and accordingly there was a bias against their use.
There is concern about the quality of standardization
of herbal medicines and their safety,
Intentional vagueness: None
Role of patient preferences: None
Exclusions: None
Policy level: No recommendation
Differences of opinion: None
Supporting Text
The guideline development panel was unable to make a recommendation on the use of herbal therapy for treating patients
with AR due to the lack of English-language translation of the
majority of the literature, the diversity of and lack of standardization of herbal therapies, and a poor understanding by the
panel of the risks and harms of these therapies.
Traditional Chinese herbal medicine has been practiced for
over 80 centuries and continues to evolve. The Chinese pharmacopeia has over 13,000 medicinals and more than 100,000
herbal combinations recorded in ancient literature.353 Although
the prevalence and use of traditional Chinese herbal formulations is on the rise globally,354 there are limited high-quality,
large-scale, multicenter trials validating their safety and effectiveness.355 Studies of traditional Chinese medicine have demonstrated positive benefits in the treatment of AR; however,
many of the studies are small in size, the studies investigate
different medicines, and some of these studies have possible
methodological issues. Therefore, based on the myriad differing herbal therapies, lack of knowledge regarding risks, and
the shortcomings of the existing literature, no recommendation can be made regarding the use of traditional Chinese
medicine in AR.
The ARIA 2006 guideline identified 3 studies of reasonable
quality with an average number of 74 patients evaluating
Butterbur, Biminne, and a Chinese herbal mixture. These all
showed positive results on clinical symptoms and quality of
life for AR, but the ARIA guideline concluded that the studies were too few to make recommendations.333
Many Chinese herbal remedies are commonly prescribed
for AR depending on the traditional Chinese medical diagnosis of the patients signs and symptoms. Various small clinical
trials have reported that those herbal decoctions possess antiallergic, anti-inflammatory, or immunomodulatory actions,
such as inhibition of the release of mast cell mediation, reduction of histamine release, inhibition of inflammation induced
by chemical agents, and modulation of serum IgE levels or of
lymphocyte and/or macrophage activity.356-360 Although progress is ongoing toward global regulation of Chinese herbal
products and improved safety,361,362 currently none of these
herbal remedies are regulated by the FDA.
Implementation Considerations
The clinical practice guideline is published as a supplement to
OtolaryngologyHead and Neck Surgery, which will facilitate reference and distribution. A full-text version of the
guideline will be accessible, free of charge, at http://www.
entnet.org. In addition, all AAO-HNSF guidelines are now
available via the OtolaryngologyHead and Neck Surgery
app for smartphones and tablets. The guideline will be presented to AAO-HNS members as a miniseminar at the 2014
AAO-HNSF Annual Meeting and OTO EXPO. Existing brochures and publication by the AAO-HNSF will be updated to
reflect the guidelines recommendations.
As a supplement to clinicians, an algorithm of the guidelines action statements, Figure 2, and a table with common
allergic rhinitis clinical scenarios, Figure 3, has been provided. The algorithm allows for a more rapid understanding of
the guidelines logic and the sequence of the action statements.
The Guideline Development Group hopes the algorithm can
be adopted as a quick reference guide to support the implementation of the guidelines recommendations.
Research Needs
This guideline was based on the current body of evidence
regarding treatment of AR. While many of the key action
statements were supported by Grade A level evidence, review
of the evidence profile for other statements revealed knowledge gaps and the need for further research. As determined by
the Guideline Development Groups review of the literature,
assessment of current clinical practices, and determination of
evidence gaps, research needs were determined as follows:
1. Research is needed to determine the effect of environmental control strategies on AR. The aggregate
evidence profile for environmental controls was a
Grade B. Controlled trials to identify the efficacy of
environmental controls on measurable AR endpoints
are needed.
2. Research is needed to evaluate the safety and efficacy of SIT, specifically SLIT. There have been
few US-based studies evaluating SLIT, which has
been offered in the United States in an off-label,
non-FDA-approved fashion. With FDA approval of
Oralair, a mixed allergen extract consisting of several pollens (Sweet Vernal, Orchard, Perennial Rye,
Timothy, and Kentucky Blue Grass), Grastek (treatment for Timothy grass pollen) and Ragwitek (treatment for short ragweed pollen) in 2014, prospective
RCTs are needed to properly evaluate the effect of
S30
Physician determines
clinical diagnosis of allergic
rhinis
Environmental
Factors (KAS4):
Clinicians may
advise avoidance of
known or suspected
allergens
Immunotherapy
If Posive Allergy Tesng (KAS11):
Clinicians should offer, or refer to a clinician who
can offer, immunotherapy (sublingual or
subcutaneous) for paents with allergic rhinis who
have inadequate response to pharmacologic
therapy with or without environmental controls
Figure 2. Allergic rhinitis (AR) diagnosis and treatment flow chart for evaluating and managing patients with AR based on this guidelines
recommendations. KAS, key action statement.
5. Research is needed to determine the safety and efficacy of acupuncture for AR. There is a relative paucity
of data in the English-language literature regarding
the use of complementary and integrative medicine
for AR. As such, specific recommendations for or
against these treatments could not be made. Higher
levels of evidence regarding these therapies need to
be obtained through well-designed clinical trials and/
or systematic reviews of existing data.
6. The studies on herbal therapies involve use of preparations that combine numerous herbal extracts in
varying amounts; thus, research needs to be conducted on specific herbal extracts along with standardization of dosing to determine efficacy for AR.
7. Controlled trials are needed comparing surgical versus
medical management of inferior turbinate hypertrophy
S31
Seidman et al
Disclaimer
Figure 3. Common allergic rhinitis clinical scenarios. The
guidelines task force could not agree on a simple algorithm for
treating allergic rhinitis as variations in patient preferences, severity
of symptoms, duration of symptoms, coexisting conditions, and
allergen sensitizations all influenced reasonable recommendations.
Instead, Figure 3 provides guidance for practitioners using
illustrative clinical scenarios that are consistent with available
evidence and expert advice.
Author Contributions
Michael D. Seidman, writer, chair; Richard K. Gurgel, writer,
assistant chair; Sandra Y. Lin, writer, assistant chair; Seth R.
Schwartz, methodologist; Fuad M. Baroody, writer; James R.
S32
Disclosures
Competing interests: Michael D. Seidman, medical director
Scientific Advisory BoardVisalus; founder of Body Language
Vitamin Co; National Institutes of Health grant on simulation; 6
patents but related to supplements, aircraft, and the middle ear and
brain implant; Sandra Y. Lin, consultant for Wellpoint; Fuad M.
Baroody, speaker for Merck, Inc; speaker for GlaxoSmithKline and
speaker/consultant for Acclarent/Johnson/Johnson; Mark S.
Dykewicz, consultant for Merck and research contract support to
Saint Louis University for Novartis; Jesse M. Hackell,
GlaxoSmithKline (Speakers Bureau); Sunovion Pharmaceuticals Inc
(Advisory Board) has had discussions regarding nasal corticosteroids; Transit of Venus (Advisory Board); Joseph K. Han, Medtronic
research grant; PI and consultant on clinical study with Intersect; and
speaker for Merck; Stacey L. Ishman, consultant for First Line
Medical; Dana V. Wallace, TEVA (Speakers Bureau); Sanofi
(Advisory Panel and Speakers Bureau); Mylan (Advisory Board
and Speakers Bureau); Sunovian (Speakers Bureau); MEDA
(Advisory Panel and Speakers Bureau); ACAAI Executive
Committee Chair and Board of Regents, Rhinitis/Sinusitis
Committee; AAAAI/ACAAI/JCAAI Practice Parameter Joint Task
Force.
Sponsorships: American Academy of OtolaryngologyHead and
Neck Surgery Foundation.
Funding Source: American Academy of OtolaryngologyHead
and Neck Surgery Foundation.
References
1. Min YG. The pathophysiology, diagnosis and treatment of allergic rhinitis. Allergy Asthma Immunol Res. 2010;2(2):65-76.
2. Mattos JL, Woodard CR, Payne SC. Trends in common rhinologic illnesses: analysis of U.S. healthcare surveys 1995-2007.
Int Forum Allergy Rhinol. 2011;1:3-12.
3. Nguyen PT, Vickery J, Blaiss MS. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res.
2011;3(3):148-156.
4. Meltzer EO, Bukstein DA. The economic impact of allergic rhinitis and current guidelines for treatment. Ann Allergy Asthma
Immunol. 2011;106(2 suppl):S12-S16.
5. Blaiss MS. Allergic rhinitis: direct and indirect costs. Allergy
Asthma Proc. 2010;31:375-380.
6. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and
its Impact on Asthma (ARIA) 2008 update (in collaboration
with the World Health Organization, GA(2)LEN and AllerGen).
Allergy. 2008;63(suppl 86):8-160.
7. Wallace DV, Dykewicz MS. The diagnosis and management of
rhinitis: an updated practice parameter. J Allergy Clin Immunol.
2008;122:S1-S84.
8. Rosenfeld RM, Shiffman RN, Robertson P. Clinical practice
guideline development manual, third edition: a quality-driven
S33
Seidman et al
26. Oxford Centre for Evidence-Based Medicine. OCEBM Levels of
Evidence Working Group. The Oxford 2011 levels of evidence.
http://www.cebm.net/index.aspx?o=5653. Accessed April 24,
2014.
27. Choudhry NK, Stelfox HT, Detsky AS. Relationships between
authors of clinical practice guidelines and the pharmaceutical
industry. JAMA. 2002;287(5):612-617.
28. Detsky AS. Sources of bias for authors of clinical practice guidelines. CMAJ. 2006;175:1033-1035.
29. Barry MJ, Edgman-Levitan S. Shared decision makingthe pinnacle of patient-centered care. N Engl J Med. 2012;366:780-781.
30. Long A, McFadden C, DeVine D, et al. Management of allergic and non-allergic rhinitis (Evidence Report/Technology
Assessment No. 54). (Prepared by New England Medical Center
Evidence-based Practice Center under Contract No. 290-97-0019).
AHRQ Pub. No. 02-E024. Rockville, MD: Agency for Healthcare Research and Quality; May 2002.
31. Allergic Rhinitis Guideline Team. UMHS clinical guideline on
allergic rhinitis. University of Michigan Health System. October 2013. http://www.med.umich.edu/1info/fhp/practiceguides/
allergic/allergic.pdf. Accessed April 24, 2014.
32. de Groot H, Brand PL, Fokkens WF, et al. Allergic rhinoconjunctivitis in children. BMJ. 2007;335(7627):985-988.
33. McCrory DC, Williams JW, Dolor RJ, et al. Management of
allergic rhinitis in the working-age population. Evid Rep Technol
Assess (Summ). 2003;(67):1-4.
34. Varghese M, Glaum MC, Lockey RF. Drug-induced rhinitis. Clin
Exp Allergy. 2010;40(3):381-384.
35. Dold S, Wjst M, von Mutius E, et al. Genetic risk for asthma, allergic rhinitis and atopic dermatitis. Arch Dis Child. 1992;67:1018.
36. Wang DY. Risk factors of allergic rhinitis: genetic or environmental? Ther Clin Risk Manag. 2005;1(2):115.
37. Blaiss MS. Allergic rhinitis and impairment issues in schoolchildren:
a consensus report. Curr Med Res Opin. 2004;20(12):1937-1952.
38. Bernstein LE, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008;100(3 suppl 3):S1-S148.
39. Anon JB. Introduction to in vivo allergy testing. Otolaryngol
Head Neck Surg. 1993;109(3 pt 2):593-600.
40. Kim BJ, Mun SK. Objective measurements using the skin prick
test in allergic rhinitis. Arch Otolaryngol Head Neck Surg.
2010;136(11):1104-1106.
41. Oppenheimer J, Nelson HS. Skin testing: a survey of allergists.
Ann Allergy Asthma Immunol. 2006;96(1):19-23.
42. Bousquet J, Heinzerling L, Bachert C, et al. Practical guide to skin
prick tests in allergy to aeroallergens. Allergy. 2012;67(1):18-24.
43. Fornadley J, Corey J, Osguthorpe J, et al. Allergic rhini
tis: clinical practice guideline. Otolaryngol Head Neck Surg.
1996;115(1):115-122.
44. Krouse J, Mabry R. Skin testing for inhalant allergy 2003: current
strategies. Otolaryngol Head Neck Surg. 2003;129(4 suppl):S33S49.
45. Sicherer SH, Wood RA. Allergy testing in childhood: using
allergen-specific IgE tests. Pediatrics. 2012;129(1):193-197.
46. Menardo JL, Bousquet J, Rodiere M, et al. Skin test reactivity in
infancy. J Allergy Clin Immunol. 1985;75(6):646-651.
S34
63. Setzen G, Fergurson BJ, Han JK, et al. Clinical consensus statement: appropriate use of computed tomography for paranasal sinus
disease. Otolaryngol Head Neck Surg. 2012;147(5):808-816.
64. Portnoy J, Kennedy K, Sublett J, et al. Environmental assessment and exposure control: a practice parameterfurry animals.
Ann Allergy Asthma Immunol. 2012;108:223.e1-223.e15.
65. Mimouni Bloch A, Mimouni D, Mimouni M, et al. Does breastfeeding protect against allergic rhinitis during childhood? A metaanalysis of prospective studies. Acta Paediatr. 2002;91:275-279.
66. Kramer MS. Breastfeeding and allergy: the evidence. Ann Nutr
Metab. 2011;59(suppl 1):20-26.
67. Matheson MC, Allen KJ, Tang ML. Understanding the evidence
for and against the role of breastfeeding in allergy prevention.
Clin Exp Allergy. 2012;42:827-851.
68. Hodson T, Custovic A, Simpson A, et al. Washing the dog reduces
dog allergen levels, but the dog needs to be washed twice a week.
J Allergy Clin Immunol. 1999;103:581-585.
69. Custovic A, Simpson BM, Simpson A, et al. Effect of environmental manipulation in pregnancy and early life on respiratory
symptoms and atopy during first year of life: a randomized trial.
Lancet. 2001;358:188-193.
70. Lodrup Carlsen KC, Roll S, Carlsen KH, et al. Does pet ownership in infancy lead to asthma or allergy at school age? Pooled
analysis of individual participant data for 11 European birth
cohorts. PLoS One. 2012;7(8):e43214.
71. Fretzayas A, Kotzia D, Moustaki M. Controversial role of
pets in the development of atopy in children. World J Pediatr.
2013;9(2):112-119.
72. Sheikh A, Hurwitz B, Nurmatov U, et al. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database
Syst Rev. 2010;(7):CD001563.
73. Sheikh A, Hurwitz B. House dust mite avoidance measures
for perennial allergic rhinitis. Cochrane Database Syst Rev.
2001;(4):CD001563.
74. Sheikh A, Hurwitz B. House dust mite avoidance measures for
perennial allergic rhinitis: a systematic review of efficacy. Br J
Gen Pract. 2003;53(489):318-322.
75. Sheikh A, Hurwitz B, Shehata VA. House dust mite avoidance
measures for perennial allergic rhinitis. Cochrane Database Syst
Rev. 2007;(1):CD001563.
76. Nurmatov U, van Schayk CP, Hurwitz B, et al. House dust mite
avoidance measures for perennial allergic rhinitis: an updated
Cochrane systematic review. Allergy. 2012;67:158-165.
77. Terreehorst I, Hak E, Oosting AJ, et al. Evaluation of impermeable covers for bedding in patients with allergic rhinitis. N Engl
J Med. 2003;349:237-246.
78. Horak F, Matthews S, Ihorst G, et al. Effect of mite-impermeable
mattress encasings and an educational package on the development of allergies in a multinational randomized, controlled birth
cohort study. Clin Exp Allergy. 2004;34:1220-1225.
79. Moon JS, Choi SO. Environmental controls in reducing house
dust mites and nasal symptoms in patients with allergic rhinitis.
Yonsei Med J. 1999;40(3):238-243.
80. Reisman RE, Mauriello PM, Davis GB, et al. A double-blind
study of the effectiveness of a high-efficiency particulate
air (HEPA) filter in the treatment of patients with perennial
S35
Seidman et al
97. Lohia S, Schlosser RJ, Soler ZM. Impact of intranasal corticosteroids on asthma outcomes in allergic rhinitis: a meta-analysis. Allergy. 2013;68(5):569-579.
98. Nishimura M, Koga T, Kamimura T, et al. Comparison of leukotriene receptor antagonists and antihistamines as an add-on
therapy in patients with asthma complicated by allergic rhinitis.
Kurume Med J. 2011;58(1):9-14.
99. Grembiale RD, Camporota L, Naty S, et al. Effects of specific immunotherapy in allergic rhinitic individuals with
bronchial hyperresponsiveness. Am J Respir Crit Care Med.
2000;162(6):2048-2052.
100. Rak S, Lwhagen O, Venge P. The effect of immunotherapy on
bronchial hyperresponsiveness and eosinophil cationic protein
in pollen allergic patients. J Allergy Clin Immunol. 1988;82(3
pt 1):470-480.
101. Kim JM, Lin SY, Suarez-Cuervo C, et al. Allergen-specific
immunotherapy for pediatric asthma and rhinoconjunctivitis: a
systematic review. Pediatrics. 2013;131:1155-1167.
102. Abramson MJ, Puy RM, Weiner JM. Injection allergen
immunotherapy for asthma. Cochrane Database Syst Rev.
2010;(8):CD001186.
103. Niggemann B, Jacobsen L, Dreborg S, et al. Five-year followup on the PAT study: specific immunotherapy and long-term
prevention of asthma in children. Allergy. 2006;61(7):855-859.
104. Jacobsen L, Valovirta E. How strong in the evidence that
immunotherapy in children prevents the progression of allergy
and asthma? Curr Opin Allergy Clin Immunol. 2007;7(6):556560.
105. Gendelman SR, Lang DM. Specific immunotherapy in
the treatment of atopic dermatitis: a systematic review
using the GRADE system. Ann Allergy Asthma Immunol.
2013;111(6):555-561.
106. Vlastos I, Athanasopoulos I, Mastronikolis NS, et al. Impaired
mucociliary clearance in allergic rhinitis patients is related
to a predisposition to rhinosinusitis. Ear Nose Throat J.
2009;88(4):E17-E19.
107. Kreiner-Moller E, Chawes BL, Caye-Thomasen P, et al. Allergic rhinitis is associated with otitis media with effusion: a birth
cohort study. Clin Exp Allergy. 2012;42(11):1615-1620.
108. Luong A, Roland PS. The link between allergic rhinitis and
chronic otitis media with effusion in atopic patients. Otolaryngol Clin North Am. 2008;41(2):311-323.
109. Lack G, Caulfield H, Penagos M. The link between otitis media
with effusion and allergy: a potential role for intranasal corticosteroids. Pediatr Allergy Immunol. 2011;22(3):258-266.
110. Kimple AJ, Ishman SL. Allergy and sleep disordered breathing.
Curr Opin Otolaryngol Head Neck Surg. 2013;21:277-281.
111. Pratt EL, Craig TJ. Assessing outcomes from the sleep disturbance associated with rhinitis. Curr Opin Allergy Clin Immunol. 2007;7:249-256.
112. Lunn M, Craig T. Rhinitis and sleep. Sleep Med Rev.
2011;15:293-299.
113. Santos CB, Pratt EL, Hanks C, et al. Allergic rhinitis and its
effect on sleep, fatigue and daytime somnolence. Ann Allergy
Immunol. 2006;97(5):579-586.
114. Gurevich F, Glass C, Davies M, et al. The effect of intranasal
steroid budesonide on the congestion related sleep disturbance
and daytime somnolence in patients with perennial allergic rhinitis. Allergy Asthma Proc. 2005;26(4):268-274.
115. Craig T, Mende C, Hughes K, et al. The effect of topical nasal
fluticasone on objective sleep testing and the symptoms of rhinitis, sleep and daytime somnolence in perennial allergic rhinitis. Allergy Asthma Proc. 2003;24(1):53-58.
116. Golden S, Teets SJ, Lehman EB, et al. Effect of topical nasal
azelastine on the symptoms of rhinitis, sleep and daytime
somnolence in perennial allergic rhinitis. Ann Allergy Asthma
Immunol. 2000;85(1):53-57.
117. Mason M, Welsh EJ, Smith I. Drug therapy for obstruc
tive sleep apnoea in adults. Cochrane Database Syst Rev.
2013;(5):CD003002.
118. Bascom R, Wachs M, Naclerio RM, et al. Basophil influx
occurs after nasal antigen challenge: effects of topical corticosteroid pretreatment. J Allergy Clin Immunol. 1988;81:580.
119. Pipkorn U, Proud D, Lichtenstein LM, et al. Inhibition of mediator release in allergic rhinitis by pretreatment with topical glucocorticosteroids. N Engl J Med. 1987;316:1506.
120. Erin EM, Leaker BR, Zacharasiewicz AS, et al. Single dose
topical corticosteroid inhibits IL-5 and IL13 in nasal lavage
following grass pollen challenge. Allergy. 2005;60:1524-1529.
121. Christodoulopoulos P, Cameron L, Durham S, et al. Molecular pathology of allergic disease, II: upper airway disease. J
Allergy Clin Immunol. 2000;105:211.
122. Meltzer EO, Jalowayski AA, Orgel A, et al. Subjective and
objective assessments in patients with seasonal allergic rhinitis: effects of therapy with mometasone furoate nasal spray. J
Allergy Clin Immunol. 1998;102:39-49.
123. Pipkorn U, Proud D, Lichtenstein LM, et al. Effect of short-term
systemic glucocorticoid treatment on human nasal mediator
release after antigen challenge. J Clin Invest. 1987;80(4):957961.
124. Baroody FM, Cruz AA, Lichtenstein LM, et al. Intranasal
beclomethasone inhibits antigen-induced nasal hyperresponsiveness to histamine. J Allergy Clin Immunol. 1992;90:373.
125. Meyer P, Andersson M, Persson CG, et al. Steroid-sensitive
indices of airway inflammation in children with seasonal allergic rhinitis. Pediatr Allergy Immunol. 2003;14:60-65.
126. Herman H. Once-daily administration of intranasal corticosteroids for allergic rhinitis: a comparative review of efficacy,
safety, patient preference, and cost. Am J Rhinol. 2007;21:7079.
127. Rodrigo GJ, Neffen H. Efficacy of fluticasone furoate nasal
spray vs. placebo for the treatment of ocular and nasal symptoms of allergic rhinitis: a systematic review. Clin Exp Allergy.
2011;41:160-170.
128. Penagos M, Compalati E, Tarantini F, et al. Efficacy of
mometasone furoate nasal spray in the treatment of allergic
rhinitis: meta-analysis of randomized, double-blind, placebocontrolled, clinical trials. Allergy. 2008;63:1280-1291.
129. Dibildox J. Safety and efficacy of mometasone furoate nasal
spray in children with allergic rhinitis: results of recent clinical
trials. J Allergy Clin Immunol. 2001;108:S54-S58.
130. Rachelefsky G, Farrar JR. A control model to evaluate pharmacotherapy for allergic rhinitis in children. JAMA Pediatr.
2013;167(4):380-386.
S36
131. Craig TJ, Teets S, Lehman EB, et al. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids. J
Allergy Clin Immunol. 1998;101:633-637.
132. Yamada T, Yamamoto H, Kubo S, et al. Efficacy of mometasone furoate nasal spray for nasal symptoms, quality of life,
rhinitis-disturbed sleep, and nasal nitric oxide in patients with
perennial allergic rhinitis. Allergy Asthma Proc. 2012;33:e9e16.
133. Hughes K, Glass C, Ripchinski M, et al. Efficacy of the topical nasal steroid budesonide on improving sleep and daytime
somnolence in patients with perennial allergic rhinitis. Allergy.
2003;58:380-385.
134. Meltzer EO, Munafo DA, Chung W, et al. Intranasal mometasone furoate therapy for allergic rhinitis symptoms and rhinitisdisturbed sleep. Ann Allergy Asthma Immunol. 2010;105:65-74.
135. Day JH, Briscoe MP, Rafeiro E, et al. Onset of action of intranasal budesonide (Rhinocort aqua) in seasonal allergic rhinitis
studied in a controlled exposure model. J Allergy Clin Immunol. 2000;105:489-494.
136. Fokkens WJ, Cserhati E, dos Santos JM, et al. Budesonide
aqueous nasal spray is an effective treatment in children with
perennial allergic rhinitis, with an onset of action within 12
hours. Ann Allergy Asthma Immunol. 2002;89:279-284.
137. Selner JC, Weber RW, Richmond GW, et al. Onset of action of
aqueous beclomethasone dipropionate nasal spray in seasonal
allergic rhinitis. Clin Ther. 1995;17(6):1099-1109.
138. Kaiser HB, Naclerio RM, Given J, et al. Fluticasone furoate
nasal spray: a single treatment option for the symptoms of seasonal allergic rhinitis. J Allergy Clin Immunol. 2007;119:14301437.
139. Day J, Carrillo T. Comparison of the efficacy of budesonide
and fluticasone propionate aqueous nasal spray for once daily
treatment of perennial allergic rhinitis. J Allergy Clin Immunol.
1998;102:902-908.
140. Juniper EF, Guyatt GH, OByrne PM, et al. Aqueous beclomethasone diproprionate nasal spray: regular versus as
required use in the treatment of seasonal allergic rhinitis. J
Allergy Clin Immunol. 1990;86:380-386.
141. Juniper EF, Guyatt GH, Archer B, et al. Aqueous beclomethasone dipropionate in the treatment of ragweed pollen-induced
rhinitis: further exploration of as needed use. J Allergy Clin
Immunol. 1993;92:66-72.
142. Jen A, Baroody F, de Tineo M, et al. As-needed use of fluticasone propionate nasal spray reduces symptoms of seasonal
allergic rhinitis. J Allergy Clin Immunol. 2000;105:732-738.
143. Dykewicz MS, Kaiser HB, Nathan RA, et al. Fluticasone propionate aqueous nasal spray improves nasal symptoms of seasonal allergic rhinitis when used as needed (prn). Ann Allergy
Asthma Immunol. 2003;91:44-48.
144. DeWester J, Philpot EE, Westlund RE, et al. The efficacy of
intranasal fluticasone propionate in the relief of ocular symptoms associated with seasonal allergic rhinitis. Allergy Asthma
Proc. 2003;24:331-337.
145. Bielory L, Chun Y, Bielory BP, et al. Impact of mometasone
furoate nasal spray on individual ocular symptoms of allergic
rhinitis: a meta-analysis. Allergy. 2011;66:686-693.
S37
Seidman et al
161. Rosenblut A, Bardin PG, Muller B, et al. Long-term safety of
fluticasone furoate nasal spray in adults and adolescents with
perennial allergic rhinitis. Allergy. 2007;62:1071-1077.
162. Ratner PH, Meltzer EO, Teper A. Mometasone furoate nasal
spray is safe and effective for 1-year treatment of children
with perennial allergic rhinitis. Int J Pediatr Otorhinolaryngol.
2009;73:651-657.
163. Lanier B, Kai G, Marple B, et al. Pathophysiology and progression of nasal septal perforation. Ann Allergy Immunol.
2007;99:473-480.
164. Holm AF, Fokkens WJ, Godthelp T, et al. A 1-year placebocontrolled study of intranasal fluticasone propionate aqueous
nasal spray in patients with perennial allergic rhinitis: a safety
and biopsy study. Clin Otolaryngol. 1998;23:69-73.
165. Klosek JM, Laliberte F, Laliberte MF, et al. Local safety of
intranasal triamcinolone acetonide: clinical and histological
aspects of nasal mucosa in the long term treatment of perennial
allergic rhinitis. Rhinology. 2001;39:17-22.
166. Baroody FM, Cheng CC, Moylan B, et al. Absence of nasal
mucosal atrophy with fluticasone aqueous nasal spray. Arch
Otolaryngol Head Neck Surg. 2001;127:193-199.
167. Knight A, Kolin A. Long term efficacy and safety of beclomethasone dipropionate aerosol in perennial rhinitis. Ann
Allergy. 1983;50:81-84.
168. Pipkorn U, Pukander J, Suonp J, et al. Long-term safety
of budesonide nasal aerosol: a 5.5-year follow up study. Clin
Allergy. 1988;18:253-259.
169. Minshall E, Ghaffar O, Cameron L, et al. Assessment by nasal
biopsy of longterm use of mometosone furoate aqueous nasal
spray in the treatment of perennial rhinitis. Otolaryngol Head
Neck Surg. 1998;118:648-654.
170. Laliberte F, Laliberte MF, Lecart S, et al. Clinical and pathologic methods to assess the long-term safety of nasal corticosteroids. Allergy. 2000;55:718-722.
171. Fokkens WJ, Rinia B, van Drunen CM, et al. No mucosal atrophy and reduced inflammatory cells: active-controlled trial
with yearlong fluticasone furoate nasal spray. Am J Rhinol
Allergy. 2012;26:36-44.
172. Van As A, Bronsky EA, Dockhorn RJ, et al. Once daily fluticasone propionate is as effective for perennial allergic rhinitis
as twice daily beclomethasone diproprionate. J Allergy Clin
Immunol. 1993;91:1146-1154.
173. Wihl JA, Andersson KE, Johansson SA. Systemic effects
of two nasally administered glucocorticosteroids. Allergy.
1997;52:620-626.
174. Brannan MD, Herron JM, Reidenberg P, et al. Lack of
hypothalamic-pituitary-adrenal axis suppression with oncedaily or twice-daily beclomethasone dipropionate aqueous
nasal spray administered to patients with allergic rhinitis. Clin
Ther. 1995;17:637-647.
175. Vargas R, Dockhorn RJ, Findlay SR, et al. Effect of fluticasone
propionate aqueous nasal spray versus oral prednisone on the
hypothalamic-pituitary-adrenal axis. J Allergy Clin Immunol.
1998;102:191-197.
176. Howland WC III, Dockhorn R, Gillman S, et al. A comparison of effects of triamcinolone acetonide aqueous nasal spray,
S38
S39
Seidman et al
allergic rhinitis. Int J Pediatr Otorhinolaryngol. 2007;71(6):
843-849.
222. Condemi J, Schulz R, Lim J. Triamcinolone acetonide aqueous nasal spray versus loratadine in seasonal allergic rhinitis:
efficacy and quality of life. Ann Allergy Asthma Immunol.
2000;84(5):533-538.
223. Yamamoto H, Yonekura S, Sakurai D, et al. Comparison of
nasal steroid with antihistamine in prophylactic treatment
against pollinosis using an environmental challenge chamber.
Allergy Asthma Proc. 2012;33(5):397-403.
224. Bender BG, Milgrom H. Comparison of the effects of fluticasone propionate aqueous nasal spray and loratadine on daytime
alertness and performance in children with seasonal allergic
rhinitis. Ann Allergy Asthma Immunol. 2004;92(3):344-349.
225. Rinne J, Simola M, Malmberg H, et al. Early treatment of perennial rhinitis with budesonide or cetirizine and its effect on longterm outcome. J Allergy Clin Immunol. 2002;109(3):426-432.
226. Bhatia S, Baroody FM, deTineo M, et al. Increased nasal
airflow with budesonide compared with desloratadine during the allergy season. Arch Otolaryngol Head Neck Surg.
2005;131(3):223-228.
227. Juniper EF, Guyatt FH, Ferris PJ, et al. First-line treatment of
seasonal (ragweed) rhinoconjunctivitis: a randomized management trial comparing a nasal steroid spray and a nonsedating
antihistamine. CMAJ. 1997;156(8):1123-1131.
228. Hilberg O. Effect of terfenadine and budesonide on nasal
symptoms, olfaction, and nasal airway patency following allergen challenge. Allergy. 1995;50(8):683-688.
229. Shah SR, Nayak A, Ratner P, et al. Effects of Olopatadine
hydrochloride nasal spray 0.6% in the treatment of seasonal
allergic rhinitis: a phase III, multicenter, randomized, doubleblind, active- and placebo-controlled study in adolescents and
adults. Clin Ther. 2009;31:99-107.
230. Nickels AS, Dimov V, Wolf R. Pharmacokinetic evaluation of
Oloptadine for the treatment of allergic rhinitis and conjunctivitis. Expert Opin Drug Metab Toxicol. 2011;7:1593-1599.
231. Horak F, Zieglmayer UP, Zieglmayer R, et al. Azelastine nasal
spray and Desloratadine tablets in pollen-induced seasonal
allergic rhinitis: a pharmacodynamic study of onset of action
and efficacy. Curr Med Res Opin. 2006;22:151-157.
232. Kaliner MA, Berger WE, Ratner PH, et al. The efficacy of
intranasal antihistamines in the treatment of allergic rhinitis.
Ann Allergy Asthma Immunol. 2011;106:S6-S11.
233. LaForce CF, Corren J, Wheeler WJ, et al. Efficacy of Azelastine nasal spray in seasonal allergic rhinitis patients who remain
symptomatic after treatment with Fexofenadine. Ann Allergy
Asthma Immunol. 2004;93:154-159.
234. Berger WE, White MV; Rhinitis Study Group. Efficacy
of Azelastine nasal spray in patients with an unsatisfactory response to loratadine. Ann Allergy Asthma Immunol.
2003;91:205-211.
235. Ratner PH, Findlay SR, Hampel F Jr, et al. A double-blind,
controlled trial to assess the safety and efficacy of azelastine
nasal spray in seasonal allergic rhinitis. J Allergy Clin Immunol. 1994;94(5):818-825.
236. LaForce C, Dockhorn RJ, Prenner BM, et al. Safety and
efficacy of Azelastine nasal spray (Astelin NS) for seasonal
S40
S41
Seidman et al
280. Cingi C, Gunhan K, Gage-White L, et al. Efficacy of leukotriene antagonists as concomitant therapy in allergic rhinitis.
Laryngoscope. 2010;120:1718-1723.
281. Kurowski M, Kuna P, Gorski P. Montelukast plus cetirizine in
the prophylactic treatment of seasonal allergic rhinitis: influence on clinical symptoms and nasal allergic inflammation.
Allergy. 2004;59(3):280-288.
282. Yamamoto H, Yamada T, Sakashita M, et al. Efficacy of prophylactic treatment with montelukast and montelukast plus
add-on loratadine for seasonal allergic rhinitis. Allergy Asthma
Proc. 2012;33(2):e17-e22.
283. Di Lorenzo G, Pacor ML, Pellitteri ME, et al. Randomized
placebo-controlled trial comparing fluticasone aqueous nasal
spray in mono-therapy, fluticasone plus cetirizine, fluticasone
plus montelukast and cetirizine plus montelukast for seasonal
allergic rhinitis. Clin Exp Allergy. 2004;34(2):259-267.
284. Pullerits T, Praks L, Ristioja V, et al. Comparison of a nasal
glucocorticoid, antileukotriene, and a combination of antileukotriene and antihistamine in the treatment of seasonal allergic
rhinitis. J Allergy Clin Immunol. 2002;109(6):949-955.
285. Saengpanich S, deTineo M, Naclerio RM, et al. Fluticasone
nasal spray and the combination of loratadine and montelukast
in seasonal allergic rhinitis. Arch Otolaryngol Head Neck Surg.
2003;129(5):557-562.
286. Modgill V, Badyal DK, Verghese A. Efficacy and safety of
montelukast add-on therapy in allergic rhinitis. Methods Find
Exp Clin Pharmacol. 2010;32(9):669-674.
287. Esteitie R, deTineo M, Naclerio RM, et al. Effect of the addition of montelukast to fluticasone proprionate for the treatment
of perennial allergic rhinitis. Ann Allergy Asthma Immunol.
2010;105:155-161.
288. Badorrek P, Dick M, Schauerte A, et al. A combination of
cetirizine and pseudoephedrine has therapeutic benefits when
compared to single drug treatment in allergic rhinitis. Int J Clin
Pharmacol Ther. 2009;47(2):71-77.
289. Meltzer EO, LaForce C, Ratner P, et al. MP29-02 (a novel
intranasal formulation of azelastine hydrochloride and fluticasone propionate) in the treatment of seasonal allergic rhinitis: a
randomized, double-blind, placebo-controlled trial of efficacy
and safety. Allergy Asthma Proc. 2012;33(4):324-332.
290. Carr W, Bernstein JP, Lieberman P, et al. A novel intranasal
therapy of azelastine with fluticasone for the treatment of allergic rhinitis. J Allergy Clin Immunol. 2012;129:1282-1289.
291. Lau SK, Wei WI, Van Hasselt CA, et al. A clinical comparison of budesonide nasal aerosol, terfenadine and a combined
therapy of budesonide and oxymetazoline in adult patients with
perennial rhinitis. Asian Pac J Allergy Immunol. 1990;8(2):
109-115.
292. Meltzer EO, Bernstein DI, Prenner BM, et al. Mometasone
furoate nasal spray plus oxymetazoline nasal spray: short-term
efficacy and safety in seasonal allergic rhinitis. Am J Rhinol
Allergy. 2013;27(2):102-108.
293. Baroody FM, Brown D, Gavanescu L, et al. Oxymetazoline
adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol.
2011;127:927-934.
S42
standardized Parietaria judaica extract in children with allergic rhinoconjunctivitis. J Allergy Clin Immunol. 1999;104(2 pt
1):425-432.
309. Jacobsen L, Niggemann B, Dreborg S, et al. The PAT Investigator Group. Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up
on the PAT study. Allergy. 2007;62(8):943-948.
310. Marogna M, Spadolini I, Massolo A, et al. Long-lasting effects
of sublingual immunotherapy according to its duration: a 15
year prospective study. J Allergy Clin Immunol. 2010;126:969975.
311. Cox LS, Linnemann DL, Nolte H, et al. Sublingual immunotherapy: a comprehensive review. J Allergy Clin Immunol.
2006;117:1021-1035.
312. Bernstein DL, Wanner M, Borish L, et al. Immunotherapy
Committee, American Academy of Allergy, Asthma and Immunology. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol.
2004;113:1129-1136.
313. Hurst DS, Gordon BR, Fornadley JA, et al. Safety of homebased and office allergy immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg. 1999;121(5):553-561.
314. Calderon MA, Simons FER, Malling HJ, et al. Sublingual
allergen immunotherapy: mode of action and its relationship
with the safety profile. Allergy. 2012;67:302-311.
315. de Groot H, Bijl A. Anaphylactic reaction after the first dose
of sublingual immunotherapy with grass pollen table. Allergy.
2009;62(6):963-964.
316. Food and Drug Administration (FDA) Briefing Document
(Oralair, Grastek and Ragwitek package insert). Biologic
License Application (BLA) for Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens
Allergen Extract Tablet for Sublingual Use (11-December
2013). APAC Briefing document: 1-16. http://www.fda.gov/
downloads/advisorycommittees/committeesmeetingmaterials/
bloodvaccinesandotherbiologics/allergenicproductsadvisory
committee/ucm377852.pdf. Accessed June 10, 2014.
317. Food and Drug Administration. Oralair package insert. 2014.
http://www.fda.gov/downloads/BiologicsBloodVaccines/
Allergenics/UCM391580.pdf. Accessed June 10, 2014.
318. Food and Drug Administration. Grastek package insert. 2014.
http://www.fda.gov/downloads/BiologicsBloodVaccines/Aller
genics/UCM393184.pdf. Accessed June 10, 2014.
319. Food and Drug Administration. Ragwitek package insert. 2014.
http://www.fda.gov/downloads/biologicsbloodvaccines/allergenics/ucm393600.pdf. Accessed June 10, 2014.
320. Dretzke J, Meadows A, Novielli N, et al. Subcutaneous and
sublingual immunotherapy for seasonal allergic rhinitis: a systematic review and indirect comparison. J Allergy Clin Immunol. 2013;131(5):1361-1366.
321. Chelladurai Y, Suarez-Cuervo C, Erekosima N, et al. Effectiveness of subcutaneous versus sublingual immunotherapy for the
treatment of allergic rhinoconjunctivitis and asthma: a systematic
review. J Allergy Clin Immunol Practice. 2013;1(4):361-369.
322. Di Bona D, Plaia A, Leto-Barone MS, et al. Efficacy of subcutaneous and sublingual immunotherapy with grass allergens for
S43
Seidman et al
339. Magnusson AL, Svensson RE, Leirvik C, et al. The effect of
acupuncture on allergic rhinitis: a randomized controlled trial.
Am J Chin Med. 2004;32:105-115.
340. Xue CC, An X, Cheung TP, et al. Acupuncture for persistent
allergic rhinitis: a randomised, sham-controlled trial. Med J
Aust. 2007;187(6):337-341.
341. Petti FB, Liguori A, Ippoliti F. Study on cytokines IL-2, IL-6,
IL-10 in patients of chronic allergic rhinitis treated with acupuncture. J Tradit Chin Med. 2002;22:104-111.
342. Park YC, Jo JH, Hong KE, et al. Effect of acupuncture on nasal
obstruction in patients with persistent allergic rhinitis: a randomized controlled trial. J Kor Acu Mox. 2005;22:229-239.
343. Rao YQ, Han NY. Therapeutic effect of acupuncture on allergic
rhinitis and its effects on immunologic function [in Chinese].
Zhongguo Zhen Jiu. 2006;26:557-560.
344. Li YM, Zhuang LX, Lai SX, et al. Effects of electroacupuncture on allergic plasma vasoactive intestinal peptide and substance P in perennial allergic rhinitis patients. Acupunct Res.
2007;32:136-138.
345. Brinkhaus B, Witt C, Jena S, et al. Acupuncture in patients with
allergic rhinitis: a pragmatic randomized trial. Ann Intern Med.
2008;101:535-543.
346. Brinkhaus B, Ortiz M, Witt CM, et al. Acupuncture in patients
with seasonal allergic rhinitis: a randomized trial. Ann Intern
Med. 2013;158:225-234.
347. Choi SM, Park JE, Li SS, et al. A multicenter, randomized,
controlled trial testing the effects of acupuncture on allergic
rhinitis. Allergy. 2013;68(3):365-374.
348. Dincer F, Linde K. Sham interventions in randomized clinical trials of acupuncturea review. Complement Ther Med.
2003;11:235-242.
349. Dawidson I, Angmar-Mansson B, Blom M, et al. Sensory
stimulation (acupuncture) increases the release of calcitonin
gene-related peptide in the saliva of xerostomia sufferers. Neuropeptides. 1999;33:244-250.
350. Joos S, Schotte C, Zou H, et al. Immunomodulatory effects of
acupuncture in the treatment of allergic asthma: a randomized
controlled study. J Altern Complement Med. 2000;6:519-525.
351. Dawidson I, Angmar-Mansson B, Blom M, et al. The influence of
sensory stimulation (acupuncture) on the release of neuropeptides
in the saliva of healthy subjects. Life Sci. 1998;63:659-674.