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Pharmacologic Tx of Seasonal Allergic Rhinitis

Ann Intern Med; ePub 2017 Nov 28; Wallace, et al

The Joint Task Force on Practice Parameters, which comprises representatives of the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), has provided guidance to healthcare providers on the initial pharmacologic treatment of seasonal allergic rhinitis in patients aged ≥12 years. The recommendations include:

  • For initial treatment of seasonal allergic rhinitis in persons aged ≥12 years, routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine.
  • For initial treatment of seasonal allergic rhinitis in persons aged ≥15 years, recommend an intranasal corticosteroid over a leukotriene receptor antagonist.
  • For treatment of moderate to severe seasonal allergic rhinitis in persons aged ≥12 years, the clinician may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment.

Citation:

Wallace DV, Dykewicz MS, Oppenheimer J, Portnoy JM, Lang DM. Pharmacologic treatment of seasonal allergic rhinitis: Synopsis of guidance from the 2017 Joint Task Force on Practice Parameters. [Published online ahead of print November 28, 2017]. Ann Intern Med. doi:10.7326/M17-2203.

Commentary:

Allergic rhinitis affects about 1 in 6 people in the US and is a source of much discomfort, as well as loss of sleep and productivity. Often, antihistamines are the first line of treatment used by both patients and physicians. These guidelines provide much needed, straightforward guidance. Based on both efficacy and side effect profile, intranasal corticosteroids are the first line of approach. When studied alone and in combination with oral antihistamines, there is no improvement in symptoms when oral antihistamines are added to intranasal corticosteroids and first line treatment. It is important to note that adding an oral antihistamine to an intranasal corticosteroid is still a reasonable choice for patients who have persistent symptoms while on an intranasal corticosteroid. For patients with severe allergic rhinitis, initial treatment with both an intranasal corticosteroid and an intranasal antihistamine (azelastine) has greater efficacy than either agent alone. In one study, there was a 40% relative improvement with fluticasone propionate plus azelastine than with either agent alone.1 For patients with severe allergic rhinitis, the combination is worth considering. —Neil Skolnik, MD

  1. Ratner PH, Hampel F, Van Bavel J, et al. Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2008;100:74-81. doi:10.1016/S1081-1206(10)60408-5.

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