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Recent updates in guidelines for treatment of Seasonal Allergic Rhinitis

on | Last revised on 27th May 2018

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The 2017 Joint Task Force on Practice Parameters (JTFPP) comprising representatives from the American Academy of Allergy, Asthma, and Immunology (AAAAI), the American College of Allergy, Asthma, and Immunology (ACAAI), and the Joint Council of Allergy, Asthma, and Immunology has provided an update to their 2008 guidelines for treatment of seasonal allergic rhinitis (SAR) in adolescents and adults.

The updated guidelines have been published online on 2nd November 2017, in the journal Annals of Allergy, Asthma and Immunology by JTFPP, headed by Mark Dykewicz, MD, professor of allergy and immunology and of internal medicine, Saint Louis University School of Medicine, Missouri.

This is the first update for seasonal allergic rhinitis management guidelines since 2008. 

The main objective of the updated guideline was to highlight opportunities for improvement in the management of allergic rhinitis.

The current update aims in changing the initial treatment strategies and targets to reduce the unnecessary cost to patients and variations in care.

The working group has systematically reviewed following three clinical scenarios in the current update.

Scenario 1 - Oral antihistamine plus INCS versus INCS monotherapy

Question:
Is there any clinical benefit when comparing combination of oral antihistamine plus an intranasal corticosteroid (INCS) against INCS monotherapy alone for initial treatment of moderate to severe SAR in patients above 12 years of age?

Recommendation:
JTFPP recommends that clinicians should initially prescribe intranasal corticosteroid monotherapy rather than the combination. Based on the literature review, there was no statistically significant advantage for the combination for any of the clinical outcomes. (Strength: Strong).

2008 guideline:
In the old 2008 guidelines, the recommendation simply stated that oral antihistamine and INCS combination may be considered in initial treatment of SAR, even though studies at the time did not suggest that the combination led to greater symptomatic relief than INCS alone.

Scenario 2 - Montelukast versus Intranasal Corticosteroid

Question: 
Is there any clinical benefit when montelukast (a leukotriene receptor antagonist, LTRA) was compared against intranasal corticosteroid monotherapy for initial treatment of moderate to severe SAR in patients who are at least 15 years of age?

Recommendation:
The task force endorsed that, for initial treatment of moderate to severe SAR in patients 15 years and above, clinician should recommend an INCS over an LTRA. Based on the studies analyzed, INCS have a greater clinical benefit over montelukast monotherapy with regard to nasal symptom reduction. (Strength: Strong).

2008 guideline:
In their earlier guidelines, task force did not make any specific recommendation on this point - Dr Dykewicz explained.

Scenario 3 - INCS plus INAH versus monotherapy

Question:
The third question addressed by the task force was whether there is any clinical benefit when combination of INCS with an intranasal antihistamine (INAH) was compared against monotherapy with either drug for the initial management of moderate to severe SAR in patients above 12years old?

Recommendation:
The taskforce recommended that for patients with moderate to severe symptoms, combination of intranasal corticosteroid with intranasal antihistamine may be recommended. Based on the studies analyzed, there was a statistically significant clinical benefit with regard to total nasal symptom reduction when using INCS and INAH combination but with potentially increased adverse events (Strength: Weak).

Still, this is a weak recommendation, given the authors' concerns about potential study biases and the dearth of research into add-on treatment.

2008 guideline:
The group's 2008 guidance said that concomitant administration "could be considered," but studies since then have found a clinically meaningful improvement in nasal symptoms with the addition of an antihistamine.

Also a single device containing both agents was not available in 2008 when earlier recommendations were released and patient had to use two separate nasal spray devices - Dr Dykewicz added.

Other observations made by authors

There is a strong message in the guidelines promoting the importance of shared decision-making with patients.

Health care providers should be encouraged to inform patients that taking two medications , e.g., using a combination of drugs, such as an oral antihistamine and INCS, is not always better than using a single drug such as an INCS.

Although using a combination of an intranasal antihistamine and an intranasal corticosteroid often provides better relief than use of either medication by itself, the combination of the 2 types of drugs will likely be more expensive. Using both medication, either combined or separately, may also increase risk for adverse effects like bad taste.

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

Conclusions

  1. For patients aged 12 years and above, seasonal allergic rhinitis should be initially managed with intranasal corticosteroid monotherapy instead of a corticosteroid plus oral antihistamine.
  2. For patients aged 15 years and above, an intranasal corticosteroid is recommended for initial treatment rather than a leukotriene receptor antagonist.
  3. For initial treatment of moderate to severe SAR in adults, clinicians may recommend the combination of an INCS and an intranasal antihistamine.
  4. When a patient is already taking an INCS, but patient’s condition is not optimally controlled, and is considering the addition of an antihistamine, the best additional therapy is an INAH not an oral antihistamine.

References

  1.  Dykewicz MS, Wallace DV, Baroody F, et al. Treatment of seasonal allergic rhinitis. Annals of Allergy, Asthma & Immunology. 2017.

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Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

He has subspecialty interests in paediatric otorhinolaryngology and received his training from Department of Pediatric ENT, Christian Medical College Hospital, Vellore, Tamilnadu, India.

He did his graduation from Cochin University of Science and Technology (CUSAT) in 2010, and pursued his masters in oto-rhino-laryngology from Sri Siddhartha Academy of Higher Education, Tumkur, Karnataka, India in 2017.

He is passionate about teaching and has an interest in education, in particular free and open access medical education (FOAMed) and e-learning. He has got around 10+ publications in various national and international peer reviewed journals.

He is the founder and Editor in Chief of e4ent.com, which he began in January 2017.

Outside work, he is proud of his role as partner of Dr. Regina M and father of Zia Mohammed, and helps in fixing his broken toys.

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