Updated Guidelines on Allergic Rhinitis—Anything New?

Allergic rhinitis is a common disorder in children, and rhinitis symptoms can adversely affect a child's well-being, with effects on sleep quality, concentration, school attendance and performance, and family dynamics.^1,2 Data from the National Health Interview Survey 2009–2011 reported a prevalence rate of 11% in children younger than 5 years old and up to 21% in children aged 10–18 years old. ³ These data are consistent with the worldwide pediatric prevalence of 14.6% from the International Study of Asthma and Allergies in Children (ISAAC). ⁴ Fortunately, the prevalence of respiratory allergy in children has remained constant for the last 15 years in the United States. ³ However, allergic rhinitis in the pediatric patient and their family exerts significant society costs with 800,000–2,000,000 lost school days annually.^5,6

Evidenced-based guidelines have been published from multiple organizations such as the global Allergic Rhinitis and its Impact on Asthma (ARIA) in 2010, ⁷ the British Society of Allergy and Clinical Immunology (BSACI) in 2008, ⁸ International Primary Care Respiratory Group (IPPCRG), ⁹ and the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology (AAAAI report) in 2008. ¹⁰ However, these guidelines are now several years old, and new advancements in the management of allergic rhinitis have occurred in recent years. The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) published evidenced-based guidelines in 2015. ¹¹ The purpose of this article is to highlight the new information in the AAO-HNS guideline and contrast the information with the AAAAI report guidelines in order to identify the usefulness of each.

The AAO-HNS guidelines were developed from a panel of experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advance practice nursing, complementary and alternative medicine, and consumer advocacy. The costs for developing the guidelines were fully borne by the American Academy of Otolaryngology—Head and Neck Surgery, and conflicts of interest were disclosed prior to relevant discussion or panelists were recused. The guidelines were developed for use in children aged 2 years and older, as data in younger children was sparse and considered to be significantly different from that of older children and adults. The AAO-HNS guidelines are specific for allergic rhinitis, whereas the AAAAI report covers diagnosis and management of nonallergic rhinitis syndromes such as vasomotor rhinitis, nonallergic rhinitis with eosinophilia syndrome (NARES), and occupational, hormonal, and drug-induced rhinitis. The definitions for intermittent and persistent allergic rhinitis in the AAO-HNS guidelines are consistent with the AAAAI report as well as with other international guidelines.^7–9

The AAO-HNS guidelines considered issues on accuracy of self-diagnosis and self-directed therapy with nonprescription products. These are important issues now that intranasal steroids (triamcinolone and fluticasone) are available without a prescription and there is a growing trend for retail medical care. ¹² The AAO-HNS guidelines are divided into 14 key action statements that provide a useful approach to integrating the information into clinical practice. Each of the key action statements is supported by evidenced-based data. Each key action statement includes a remark in these areas: quality improvement opportunity; aggregate evidence quality; level of confidence in the evidence; benefits; risks, harms, costs; benefit–harm assessment; value judgments; intentional vagueness; role of patient preferences; exclusions; policy level; and differences of opinions. Each is followed by supporting data.

Two of the key action statements in the AAO-HNS guidelines recommend against performing sinonasal imaging in patients with a symptom history consistent with allergic rhinitis and against using leukotriene receptor antagonists as primary therapy.

The AAO-HNS guidelines do not state risk factors for the development of allergic rhinitis (family history of atopy, serum IgE>100 IU/mL before the age of 6 years, higher socioeconomic class, presence of a positive allergy skin-prick test), ¹⁰ which would seem a surprising omission, as the guidelines were written, in part, to appeal to nonallergist providers. In addition, the AAO-HNS guidelines give equal preference to skin-prick testing and IgE blood testing, whereas the AAAAI clearly state skin-prick testing is preferable.

The section on environmental control (Statement 4) provides a helpful update over the AAAAI guidelines. Many of the references in this section are from 2011 or later and cover the latest findings on breast-feeding and pet ownership in preschool-aged children on the development of allergic rhinitis, and on house dust mite avoidance measures for symptom control.^13–17 Briefly, despite several systematic reviews and meta-analyses, the data on breast-feeding remains inconclusive for reducing the risk of developing allergic rhinitis. ¹⁸ This is in part due to the difficulty of designing a methodologically sound prospective clinical trial due to maternal preferences, duration of follow-up, and misclassification of infant feeding methods that confound the data. ¹⁴ Similarly, a meta-analysis of 11 birth cohorts ¹⁵ and literature review ¹⁶ failed to find conclusive evidence of pet ownership in early life either contributing to or protecting against sensitization. A 2012 Cochrane review of house dust mite avoidance measures determined that acaricides were the most effective agent used alone or in combination with other control measures in improving allergic rhinitis symptoms. ¹⁷

The AAO-HNS guidelines contain a helpful table on comparison of intranasal steroids that includes Food and Drug Administration (FDA) indications and dose. This latter information could be helpful, as at least one state Medicaid program (Florida) issued an alert that it is adhering to the FDA-labeled indications for inhaled corticosteroids for asthma as of May 1, 2015, which has particular consequences for prescribing drugs in children. The AAAAI report table on intranasal steroids includes which products have alcohol or benzalkonium chloride as preservative. The two over-the-counter products (triamcinolone and fluticasone) have benzalkonium chloride and no alcohol; the latter may cause drying of the mucus membranes. The sections on the supporting evidence for combination therapy are mostly from older studies prior to 2010. The AAO-HNS guidelines lack any discussion of oral or topical decongestants, oral corticosteroids, intranasal anticholinergics, omalizumab, intranasal cromolyn, or saline in the management of allergic rhinitis.

Sublingual immunotherapy was approved by the FDA in 2014, and this section of the AAO-HNS guidelines contains discussion of the latest evidence from 2011 forward that is not in the AAAAI report. The recent literature on this topic for children is discussed in a previous issue of this journal. ¹⁹

The only discussion of surgical treatment in the AAO-HNS guidelines is inferior turbinate reduction, whereas the AAAAI guidelines also include discussion of septoplasty, sinus surgery, nasal polypectomy, and adenoidectomy.

The AAO-HNS guidelines also include discussion of the evidence for acupuncture and Chinese herbal therapy, which is absent in the AAAAI report. Studies of acupuncture are particularly difficult to perform due to the need for a comparator arm of sham acupuncture, and studies are virtually nonexistent in children. Nonetheless, two recent well-designed studies published in peer-reviewed journals showed some benefit on symptom control compared to sham acupuncture.^20,21 At present, the guidelines state that there is sufficient evidence to recommend acupuncture in patients who express an interest. The AAO-HNS guidelines, however, make no recommendation on the use of Chinese herbal therapy due to limited knowledge and concern about standardization and safety of these medicines.

In summary, the AAO-HNS clinical practice guidelines for allergic rhinitis provide evidence-based recommendations for treatment in an easy-to-read format. Other rhinitis guidelines tend to be dense and are geared toward allergy specialists. These guidelines include 14 key recommendations and are well suited for nonspecialist practitioners.