Allergic rhinitis: What’s best for your patient?
The algorithm and recommendations provided here can help you take an evidence-based approach to your patient’s allergic rhinitis.
When a patient’s symptoms are poorly controlled or persist after treatment, consider allergen testing.29 Skin prick testing (SPT) is the best means of eliciting specific allergen sensitization. However, limit testing to allergens most likely causing the patient’s symptoms rather than ordering a random panel; 15% of those with a positive SPT to specific allergens do not have symptoms when exposed to those allergens in their environment.5 And always interpret results of allergy testing in light of the patient’s history.2,15,18
SPT has a high negative predictive value, which can prevent unnecessary lifestyle changes.29 However, keep in mind that SPT results may be suppressed if the patient is using antihistamines, tricyclic antidepressants, or topical steroids.29 If SPT is not feasible or the patient is taking medications that may suppress results, consider arranging for serum-specific IgE testing, also known as radioallergosorbent testing, or RAST.5 RAST and SPT have similar sensitivities for house dust mites, but RAST is not as sensitive as SPT for other inhalants (eg, cat epithelium, mold, grass pollen).5
ASI methods developed to date use subcutaneous, sublingual, or nasal routes of administration. However, the US Food and Drug Administration has yet to approve commercial sublingual or nasal products for use in the United States.16
Subcutaneous immunotherapy may cause local adverse reactions (pruritus and swelling) and systemic reactions that can be severe or life threatening (anaphylaxis) and thus must be given in a doctor’s office prepared to treat anaphylaxis.6,16,30 Adrenaline administration has been necessary in 0.13% of those being treated.9 Subcutaneous immunotherapy must be done for 3 to 5 years for sustained effective treatment.15
ARIA 2010 suggests subcutaneous immunotherapy for adults with seasonal AR and with persistent AR due to house dust mites.4 A 2007 Cochrane review found subcutaneous immunotherapy is efficacious for patients with seasonal AR due to pollens, resulting in decreased symptoms and medication use with few significant severe adverse reactions.9 A meta-analysis showed subcutaneous immunotherapy is as potent as pharmacotherapy in controlling seasonal AR symptoms as early as the first season of treatment.31
What if the patient is pregnant—or a child? BSACI notes that maintenance ASI may be continued in a patient who becomes pregnant, but starting ASI or increasing the dose is contraindicated.5
Based on ARIA 2008 and 2010, consider subcutaneous immunotherapy for children—but not for those <5 years.3,4 Care must be used in selecting patients, as 3 to 5 years of treatment are necessary for sustained benefit.15
Lifestyle changes: Limited benefit may be achievable
ARIA 2010 recommends mold avoidance and animal dander avoidance for patients so affected.4 Allergens from pets can persist in homes for months after pet removal.15 BSACI found that commercially available nasal filters (filters or screens placed over or within both nares) reduced symptoms of AR during ragweed and grass pollen seasons.5 Allergen avoidance for children with persistent AR has not shown consistent benefit.15 A 2010 Cochrane review concluded that allergen avoidance may decrease AR symptoms, but more research is needed.11
House dust mites. The 2010 Cochrane review also reported on 2 trials that assessed high-efficiency particulate air (HEPA) filters specifically for patients allergic to house dust mites.11 The studies, which had methodological limitations (inconsistent randomization, small sample size, and short duration), concluded that HEPA filters alone will not likely reduce symptoms of house dust mite allergy. But HEPA filters may be beneficial as one component of an extensive bedroom-based environmental control program.11
Impermeable bedding has been shown to reduce dust mite load by 50% to 70%, leaving residual allergen that may still trigger symptoms.11 A 2012 Cochrane review concluded that achieving substantial reductions in house dust mite load using a combination approach of multiple interventions, including acaricides and extensive bedroom-based environmental control programs, may decrease AR symptoms.12 However, ARIA 2010 recommends against single chemical or physical preventive methods and against combination preventive methods to reduce house dust mite exposure.4
Total elimination of house dust mites may be impossible, and recommending use of impermeable covers and HEPA filters, removal of rugs and curtains, and frequent cleaning must take into account a patient’s symptoms and a family’s motivation and finances.11,18
Complementary and alternative medicine: Too little evidence
ARIA 2010 suggests against patients using homeopathy, acupuncture, butterbur, herbal medicines, or phototherapy for AR.4 While one systematic review of acupuncture for AR demonstrated mixed results with no specific effects for seasonal AR and some improvement of frequent nonseasonal symptoms,32 another review concluded evidence was insufficient to make any recommendation.32,33 The benefit of ear acupressure is unknown, as supporting studies are of low methodological quality, although it appeared to provide some benefit for AR.34
