What is allergic rhinitis

Allergic rhinitis is inflammation of the inside of your nose caused by an allergen, such as pollen, dust, mold, or flakes of skin from certain animals. Rhinitis means ‘inflammation of the nose’, whilst the term allergic describes ‘a normal but exaggerated response to a substance’. Allergies are your immune system’s incorrect response to allergens (foreign substances). Exposure to what is normally a harmless substance causes the immune system to react as if the substance is harmful. People may experience a number of allergic symptoms including itchy, watery nose and eyes, asthma symptoms, eczema or hives and allergic shock (also called anaphylaxis or anaphylactic shock). Allergic rhinitis may be perennial allergic rhinitis, which means symptoms are present throughout the year, or seasonal allergic rhinitis, with symptoms peaking during the months of spring and summer when pollen levels are at their highest.

There is also a strong relationship between allergic rhinitis and asthma; patients with allergic rhinitis are three times more likely to develop asthma and effective treatment of allergic rhinitis has beneficial effects on asthma.

Perennial allergic rhinitis is characterized primarily by nasal symptoms including watering or congestion of the nose and sneezing. It occurs due to an exaggerated response to an environmental trigger which results in inflammation of the lining of the nose. Perennial allergic rhinitis is similar to hayfever, however, the substances which cause the allergic reaction are present all year round.

Common causes of allergic rhinitis include the fecal matter of the house dust-mite, animal proteins from domestic pets, and industrial dusts and fumes.

Allergic rhinitis is caused by the immune system reacting to an allergen as if it were harmful.

This results in cells releasing a number of chemicals that cause the inside layer of your nose (the mucous membrane) to become swollen and excessive levels of mucus to be produced.

Common allergens that cause allergic rhinitis include pollen – this type of allergic rhinitis is known as hay fever – as well as mold spores, house dust mites, and flakes of skin or droplets of urine or saliva from certain animals.

Allergic rhinitis is a very common condition affecting many people worldwide, estimated to affect around one in every five people in the US.

Visit your doctor if the symptoms of allergic rhinitis are disrupting your sleep, preventing you carrying out everyday activities, or adversely affecting your performance at work or school.

A diagnosis of allergic rhinitis will usually be based on your symptoms and any possible triggers you may have noticed. If the cause of your condition is uncertain, you may be referred for allergy testing.

If your condition is mild, you can also help reduce the symptoms by taking over-the-counter medications, such as non-sedating antihistamines, and by regularly rinsing your nasal passages with a salt water solution to keep your nose free of irritants.

See your doctor for advice if you’ve tried taking these steps and they haven’t helped. They may prescribe a stronger medication, such as a nasal spray containing corticosteroids.

Further problems

Allergic rhinitis can lead to complications in some cases. These include:

• nasal polyps – abnormal but non-cancerous (benign) sacs of fluid that grow inside the nasal passages and sinuses
• sinusitis – an infection caused by nasal inflammation and swelling that prevents mucus draining from the sinuses
• middle ear infections – infection of part of the ear located directly behind the eardrum

These problems can often be treated with medication, although surgery is sometimes needed in severe or long-term cases.

Who’s most at risk?

It isn’t fully understood why some people become oversensitive to allergens, although you’re more likely to develop an allergy if there’s a history of allergies in your family.

If this is the case, you’re said to be “atopic”, or to have “atopy”. People who are atopic have a genetic tendency to develop allergic conditions. Their increased immune response to allergens results in increased production of IgE antibodies.

Environmental factors may also play a part. Studies have shown certain things may increase the chance of a child developing allergies, such as growing up in a house where people smoke and being exposed to dust mites at a young age.

It’s difficult to completely avoid potential allergens, but you can take steps to reduce exposure to a particular allergen you know or suspect is triggering your allergic rhinitis. This will help improve your symptoms.

Seasonal allergic rhinitis

Seasonal allergic rhinitis is also called hayfever that occurs in late summer or spring. Seasonal allergic rhinitis (hayfever) is characterized by irritation and congestion or watering of the nose, itchy eyes, ears and throat, and sneezing. Seasonal allergic rhinitis (hayfever) occurs due to an exaggerated response to an environmental trigger which results in inflammation of the lining of the nose. In the case of seasonal allergic rhinitis, pollen is the most common trigger, hence symptoms are usually experienced during the spring and summer months when the pollen season is at its peak. Hypersensitivity to ragweed, not hay, is the primary cause of seasonal allergic rhinitis in 75 percent of all Americans who suffer from this seasonal disorder. People with sensitivity to tree pollen have symptoms in late March or early April; an allergic reaction to mold spores occurs in October and November as a consequence of falling leaves.

Allergic rhinitis symptoms

Allergic rhinitis typically causes cold-like symptoms, such as sneezing, itchiness and a blocked or runny nose. These symptoms usually start soon after being exposed to an allergen.

Some people only get allergic rhinitis for a few months at a time because they’re sensitive to seasonal allergens, such as tree or grass pollen. Other people get allergic rhinitis all year round.

Most people with allergic rhinitis have mild symptoms that can be easily and effectively treated. But for some symptoms can be severe and persistent, causing sleep problems and interfering with everyday life.

The symptoms of allergic rhinitis occasionally improve with time, but this can take many years and it’s unlikely that the condition will disappear completely.

Allergic rhinitis complications

If you have allergic rhinitis, there’s a risk you could develop further problems.

A blocked or runny nose can result in difficulty sleeping, drowsiness during the daytime, irritability and problems concentrating. Allergic rhinitis can also make symptoms of asthma worse.

The inflammation associated with allergic rhinitis can also sometimes lead to other conditions, such as nasal polyps, sinusitis and middle ear infections.

Nasal polyps

Nasal polyps are swellings that grow in the lining inside your nose or sinuses, the small cavities above and behind your nose.

They’re caused by inflammation of the membranes of the nose and sometimes develop as a result of rhinitis.

Nasal polyps are shaped like teardrops when they’re growing and look like a grape on a stem when fully grown.

They vary in size and can be yellow, grey or pink. They can grow on their own or in clusters, and usually affect both nostrils.

If nasal polyps grow large enough, or in clusters, they can interfere with your breathing, reduce your sense of smell and block your sinuses, which can lead to sinusitis.

Small nasal polyps can be shrunk using steroid nasal sprays so they don’t cause an obstruction in your nose. Large polyps may need to be surgically removed.

Sinusitis

Sinusitis is a common complication of allergic rhinitis. It’s where the sinuses become inflamed or infected.

The sinuses naturally produce mucus, which usually drains into your nose through small channels.

However, if the drainage channels are inflamed or blocked – for example, because of allergic rhinitis or nasal polyps – the mucus can’t drain away and it may become infected.

Sinusitis is common and usually clears up on its own within 2 to 3 weeks. But medicines can help if it’s taking a long time to go away.

Common symptoms of sinusitis include:

• a blocked nose, making it difficult to breathe through your nose
• a runny nose
• mucus that drips from the back of your nose down your throat (post-nasal drip)
• a reduced sense of smell or taste
• a feeling of fullness, pressure or pain in the face
• snoring
• obstructive sleep apnea (OSA) – your airways become temporarily blocked while you’re asleep, which can disturb your sleep

Over-the-counter painkillers, such as paracetamol, ibuprofen or aspirin, can be used to help reduce any pain and discomfort in your face.

However, these medications aren’t suitable for everyone, so check the leaflet that comes with them before using them.

For example, children under the age of 16 shouldn’t take aspirin, and ibuprofen isn’t recommended for people with asthma or a history of stomach ulcers. Speak to your doctor or pharmacist if you’re unsure.

Antibiotics may also be recommended if your sinuses become infected with bacteria. If you have long-term (chronic) sinusitis, surgery may be needed to improve the drainage of your sinuses.

Sinusitis treatment

How you can treat sinusitis yourself

You can often treat mild sinusitis without seeing a doctor by:

• getting plenty of rest
• drinking plenty of fluids
• taking painkillers, such as paracetamol or ibuprofen – don’t give aspirin to children under 16
• holding a warm clean flannel over your face for a few minutes several times a day
• inhaling steam from a bowl of hot water – don’t let children do this because of the risk of scalding
• cleaning your nose with a salt water solution to ease congestion

How to clean your nose with a salt water solution

1. Boil a pint of water, then leave it to cool
2. Mix a teaspoon of salt and a teaspoon of bicarbonate of soda into the water
3. Wash your hands
4. Stand over a sink, cup the palm of one hand and pour a small amount of the solution into it
5. Sniff the water into one nostril at a time
6. Repeat these steps until your nose feels more comfortable

You don’t need to use all of the solution, but use a fresh one each day.

A pharmacist can advise you about medicines that can help, such as:

• decongestant nasal sprays, drops or tablets to unblock your nose
• salt water nasal sprays or solutions to rinse out the inside of your nose

You can buy nasal sprays without a prescription, but they shouldn’t be used for more than a week.

Some decongestant tablets also contain paracetamol or ibuprofen. If you’re taking painkillers as well as a decongestant, be careful not to take more than the recommended dose.

Treatment from a doctor

Your doctor may be able to recommend other medicines to help with your symptoms, such as:

• steroid nasal sprays or drops – to reduce the swelling in your sinuses
• antihistamines – if an allergy is causing your symptoms
• antibiotics – if a bacterial infection is causing your symptoms and you’re very unwell or at risk of complications (more rare)

You might need to take steroid nasal sprays or drops for a few months. They sometimes cause irritation, sore throats or nosebleeds.

Your doctor may refer you to an ear, nose and throat (ENT) specialist if:

• these medicines don’t help with your sinusitis
• your sinusitis has lasted longer than 3 months (chronic sinusitis)
• you keep getting sinusitis

They may also recommend surgery in some cases.

Surgery for sinusitis

Surgery to treat chronic sinusitis is called functional endoscopic sinus surgery.

Functional endoscopic sinus surgery is carried out under general anaesthetic (where you’re asleep).

The surgeon can widen your sinuses by either:

• removing some of the blocked skin tissue
• inflating a tiny balloon in the blocked sinuses, then removing it

You should be able to have functional endoscopic sinus surgery within 18 weeks of your doctor appointment.

Middle ear infections

Middle ear infections (otitis media) can also develop as a complication of nasal problems, including allergic rhinitis.

These infections can occur if rhinitis causes a problem with the Eustachian tube, which connects the back of the nose and middle ear, at the back of the nose.

If this tube doesn’t function properly, fluid can build up in the middle ear behind the ear drum and can become infected.

There’s also the possibility of infection at the back of the nose spreading to the ear through the Eustachian tube.

The main symptoms of a middle ear infection usually start quickly and include:

• pain inside the ear
• a high temperature of 100.4 °F (38 °C) or above
• being sick
• a lack of energy
• difficulty hearing
• discharge running out of the ear
• feeling of pressure or fullness inside the ear
• itching and irritation in and around the ear
• scaly skin in and around the ear

Young children and babies with a middle ear infection may also:

• rub or pull their ear
• not react to some sounds
• be irritable or restless
• be off their food
• keep losing their balance

Most middle ear infections clear up within 3 days, although sometimes symptoms can last up to a week, but paracetamol (acetaminophen) or ibuprofen can be used to help relieve fever and pain. Antibiotics may also be prescribed if the symptoms persist or are particularly severe.

Middle ear infection treatment

If your child is older than 6 months of age and only has mild symptoms, the best treatment is to let the fluid go away on its own. You can give your child an over-the-counter pain reliever, such as acetaminophen, (one brand: Children’s Tylenol) if he or she is uncomfortable. A warm, moist cloth placed over the ear may also help.

Usually the fluid goes away in 2 to 3 months, and hearing returns to normal. Your doctor may want to check your child again at some point to see if fluid is still present. If it is, he or she may give your child antibiotics.

One treatment your doctor may suggest is a nasal balloon. A nasal balloon can help clear the fluid from the middle ear. You can easily use a nasal balloon at home. Your child will simply insert the balloon nozzle in one nostril while blocking the other nostril with a finger. Then, he or she will inflate the balloon with their nose.

If the fluid does not go away after a certain amount of time and treatment, your child may need ear tubes. These small tubes are inserted through the ear drum. They allow the doctor to suction out the fluid behind the ear. They also allow air to get into the middle ear, which helps prevent fluid build-up. Any hearing loss experienced by your child should be restored after the fluid is drained.

How to treat a middle ear infection yourself

To help relieve any pain and discomfort from a middle ear infection:

DO

• use painkillers such as paracetamol or ibuprofen (children under 16 shouldn’t take aspirin)
• place a warm or cold flannel on the ear

DON’T

• put anything inside your ear to remove earwax, such as cotton buds or your finger
• let water or shampoo get in your ear
• use decongestants or antihistamines – there’s no evidence they help with ear infections

FDA Warning

The. U.S. Food and Drug Administration (FDA) advise against the use of ear candles. Ear candles can cause serious injuries and there is no evidence to support their effectiveness ¹.

Treatment from a doctor

Your doctor may prescribe medicine for your ear infection, depending on what’s caused it.

Antibiotics aren’t usually offered because middle ear infections often clear up on their own, and antibiotics make little difference to symptoms, including pain.

Antibiotics might be prescribed if:

• an ear infection doesn’t start to get better after 3 days
• you or your child has any fluid coming out of their ear
• you or your child has an illness that means there’s a risk of complications, such as cystic fibrosis

They may also be prescribed if your child is less than 2 years old and has an infection in both ears.

Allergic rhinitis causes

Allergic rhinitis is caused by an allergic reaction to an allergen, such as pollen, dust and certain animals.

Figure 1. Development of allergic sensitization in allergic rhinitis

Footnotes: As shown in Panel A, sensitization involves allergen uptake by antigen-presenting cells (dendritic cells) at a mucosal site, leading to activation of antigen-specific T cells, most likely at draining lymph nodes. Simultaneous activation of epithelial cells by nonantigenic pathways (e.g., proteases) can lead to the release of epithelial cytokines (thymic stromal lymphopoietin [TSLP], interleukin-25, and interleukin-33), which can polarize the sensitization process into a type 2 helper T (Th2) cell response. This polarization is directed toward the dendritic cells and probably involves the participation of type 2 innate lymphoid cells (ILC2) and basophils, which release Th2-driving cytokines (interleukin-13 and interleukin-4). The result of this process is the generation of Th2 cells, which, in turn, drive B cells to become allergen-specific IgE-producing plasma cells. MHC denotes major histocompatibility complex. As shown in Panel B, allergen-specific IgE antibodies attach to high-affinity receptors on the surface of tissue-resident mast cells and circulating basophils. On reexposure, the allergen binds to IgE on the surface of those cells and cross-links IgE receptors, resulting in mast-cell and basophil activation and the release of neuroactive and vasoactive mediators such as histamine and the cysteinyl leukotrienes. These substances produce the typical symptoms of allergic rhinitis. In addition, local activation of Th2 lymphocytes by dendritic cells results in the release of chemokines and cytokines that orchestrate the influx of inflammatory cells (eosinophils, basophils, neutrophils, T cells, and B cells) to the mucosa, providing more allergen targets and up-regulating the end organs of the nose (nerves, vasculature, and glands). Th2 inflammation renders the nasal mucosa more sensitive to allergen but also to environmental irritants. In addition, exposure to allergen further stimulates production of IgE. As shown in Panel C, mediators released by mast cells and basophils can directly activate sensory-nerve endings, blood vessels, and glands through specific receptors. Histamine seems to have direct effects on blood vessels (leading to vascular permeability and plasma leakage) and sensory nerves, whereas leukotrienes are more likely to cause vasodilatation. Activation of sensory nerves leads to the generation of pruritus and to various central reflexes. These include a motor reflex leading to sneezing and parasympathetic reflexes that stimulate nasal-gland secretion and produce some vasodilatation. In addition, the sympathetic drive to the erectile venous sinusoids of the nose is suppressed, allowing for vascular engorgement and obstruction of the nasal passages. In the presence of allergic inflammation, these end-organ responses become up-regulated and more pronounced. Sensory-nerve hyperresponsiveness is a common pathophysiological feature of allergic rhinitis.

Oversensitive immune system

If you have allergic rhinitis, your immune system – your natural defence against infection and illness – will react to an allergen as if it were harmful.

If your immune system is oversensitive, it will react to allergens by producing antibodies to fight them off. Antibodies are special proteins in the blood that are usually produced to fight viruses and infections.

Allergic reactions don’t occur the first time you come into contact with an allergen. The immune system has to recognize and “memorize” it before producing antibodies to fight it. This process is known as sensitization.

After you develop sensitivity to an allergen, it will be detected by antibodies called immunoglobulin E (IgE) whenever it comes into contact with the inside of your nose and throat.

These antibodies cause cells to release a number of chemicals, including histamine, which can cause the inside layer of your nose (the mucous membrane) to become inflamed and produce excess mucus. This is what causes the typical symptoms of sneezing and a blocked or runny nose.

Common allergens

Allergic rhinitis is triggered by breathing in tiny particles of allergens. The most common airborne allergens that cause rhinitis are described below.

House dust mites

House dust mites are tiny insects that feed on the dead flakes of human skin. They can be found in mattresses, carpets, soft furniture, pillows and beds.

Rhinitis isn’t caused by the dust mites themselves, but by a chemical found in their excrement. Dust mites are present all year round, although their numbers tend to peak during the winter.

Pollen and spores

Tiny particles of pollen produced by trees and grasses can sometimes cause allergic rhinitis. Most trees pollinate from early to mid-spring, whereas grasses pollinate at the end of spring and beginning of summer.

Rhinitis can also be caused by spores produced by mold and fungi.

Animals

Many people are allergic to animals, such as cats and dogs. The allergic reaction isn’t caused by animal fur, but flakes of dead animal skin and their urine and saliva.

Dogs and cats are the most common culprits, although some people are affected by horses, cattle, rabbits and rodents, such as guinea pigs and hamsters.

However, being around dogs from an early age can help protect against allergies, and there’s some evidence to suggest that this might also be the case with cats.

Work-related allergens

Some people are affected by allergens found in their work environment, such as wood dust, flour dust or latex.

Allergic rhinitis prevention

The best way to prevent allergic rhinitis is to avoid the allergen that causes it.

But this isn’t always easy. Allergens, such as dust mites, aren’t always easy to spot and can breed in even the cleanest house.

It can also be difficult to avoid coming into contact with pets, particularly if they belong to friends and family.

Below is some advice to help you avoid the most common allergens.

House dust mites

Dust mites are one of the biggest causes of allergies. They’re microscopic insects that breed in household dust.

To help limit the number of mites in your house, you should:

• consider buying an air-permeable occlusive mattress and bedding covers – this type of bedding acts as a barrier to dust mites and their droppings
• choose wood or hard vinyl floor coverings instead of carpet
• fit roller blinds that can be easily wiped clean
• regularly clean cushions, soft toys, curtains and upholstered furniture, either by washing or vacuuming them
• use synthetic pillows and acrylic duvets instead of woollen blankets or feather bedding
• use a vacuum cleaner fitted with a high efficiency particulate air (HEPA) filter – it can remove more dust than ordinary vacuum cleaners
• use a clean damp cloth to wipe surfaces – dry dusting can spread allergens further

Concentrate your efforts on controlling dust mites in the areas of your home where you spend most time, such as the bedroom and living room.

Pets

It isn’t pet fur that causes an allergic reaction, but exposure to flakes of their dead skin, saliva and dried urine.

If you can’t permanently remove a pet from the house, you may find the following tips useful:

• keep pets outside as much as possible or limit them to one room, preferably one without carpet
• don’t allow pets in bedrooms
• wash pets at least once a fortnight
• groom dogs regularly outside
• regularly wash bedding and soft furnishings your pet has been on

If you’re visiting a friend or relative with a pet, ask them not to dust or vacuum on the day you’re visiting because it will disturb allergens into the air.

Taking an antihistamine medicine one hour before you enter a house with a pet can help reduce your symptoms.

Pollen

Different plants and trees pollinate at different times of the year, so when you get allergic rhinitis will depend on what sort of pollen(s) you’re allergic to.

Most people are affected during the spring and summer months because this is when most trees and plants pollinate.

To avoid exposure to pollen, you may find the following tips useful:

• check weather reports for the pollen count and stay indoors when it’s high
• avoid line-drying clothes and bedding when the pollen count is high
• wear wraparound sunglasses to protect your eyes from pollen
• keep doors and windows shut during mid-morning and early evening, when there’s most pollen in the air
• shower, wash your hair and change your clothes after being outside
• avoid grassy areas, such as parks and fields, when possible
• if you have a lawn, consider asking someone else to cut the grass for you

Mold spores

Molds can grow on any decaying matter, both in and outside the house. The molds themselves aren’t allergens, but the spores they release are.

Spores are released when there’s a sudden rise in temperature in a moist environment, such as when central heating is turned on in a damp house or wet clothes are dried next to a fireplace.

To help prevent mold spores, you should:

• keep your home dry and well ventilated
• when showering or cooking, open windows but keep internal doors closed to prevent damp air spreading through the house, and use extractor fans
• avoid drying clothes indoors, storing clothes in damp cupboards and packing clothes too tightly in wardrobes
• deal with any damp and condensation in your home.

Allergic rhinitis diagnosis

Your doctor will often be able to diagnose allergic rhinitis from your symptoms and your personal and family medical history.

Your doctor will ask you whether you’ve noticed any triggers that seem to cause a reaction, and whether it happens at a particular place or time.

Your doctor may examine the inside of your nose to check for nasal polyps.

Nasal polyps are fleshy swellings that grow from the lining of your nose or your sinuses, the small cavities inside your nose. They can be caused by the inflammation that occurs as a result of allergic rhinitis.

Allergic rhinitis is usually confirmed when medical treatment starts. If you respond well to antihistamines, it’s almost certain that your symptoms are caused by an allergy.

Allergy testing

If the exact cause of allergic rhinitis is uncertain, your doctor may refer you to a hospital allergy clinic for allergy testing.

The two main allergy tests are:

1. Skin prick test – where the allergen is placed on your arm and the surface of the skin is pricked with a needle to introduce the allergen to your immune system; if you’re allergic to the substance, a small itchy spot (welt) will appear
2. Blood test – to check for the immunoglobulin E (IgE) antibody in your blood; your immune system produces this antibody in response to a suspected allergen

Commercial allergy testing kits aren’t recommended because the testing is often of a lower standard than that provided by the allergy specialist or an accredited private clinic.

It’s also important that the test results are interpreted by a qualified healthcare professional with detailed knowledge of your symptoms and medical history.

Further tests

In some cases further hospital tests may be needed to check for complications, such as nasal polyps or sinusitis.

For example, you may need:

• a nasal endoscopy – where a thin tube with a light source and video camera at one end (endoscope) is inserted up your nose so your doctor can see inside your nose
• a nasal inspiratory flow test – where a small device is placed over your mouth and nose to measure the air flow when you inhale through your nose
• a computerised tomography (CT) scan – a scan that uses X-rays and a computer to create detailed images of the inside of the body.

Allergic rhinitis treatment

Treatment for allergic rhinitis depends on how severe your symptoms are and how much they’re affecting your everyday activities.

In most cases treatment aims to relieve symptoms such as sneezing and a blocked or runny nose.

If you have mild allergic rhinitis, you can often treat the symptoms yourself.

You should visit your doctor if your symptoms are more severe and affecting your quality of life, or if self-help measures haven’t been effective.

Table 1. Pharmacotherapy and Immunotherapy for Allergic Rhinitis

Footnotes:

Allergic rhinitis home remedies

It’s possible to treat the symptoms of mild allergic rhinitis with over-the-counter medications, such as long-acting, non-sedating antihistamines.

If possible, try to reduce exposure to the allergen that triggers the condition. See preventing allergic rhinitis for more information and advice about this.

Cleaning your nasal passages

Regularly cleaning your nasal passages with a salt water solution – known as nasal douching or irrigation – can also help by keeping your nose free of irritants.

You can do this either by using a homemade solution or a solution made with sachets of ingredients bought from a pharmacy. Or you can buy a saline spray at a pharmacy.

Small syringes or pots (Neti pot) that often look like small horns or teapots are also available to help flush the solution around the inside of your nose.

Nasal wash

• To make the solution at home, mix half a teaspoon of salt and half a teaspoon of bicarbonate of soda (baking powder) into a pint (568ml) of boiled water that’s been left to cool to around body temperature – do not attempt to rinse your nose while the water is still hot.

To rinse your nose:

• stand over a sink, cup the palm of one hand and pour a small amount of the solution into it
• sniff the water into one nostril at a time
• repeat this until your nose feels comfortable – you may not need to use all of the solution

While you do this, some solution may pass into your throat through the back of your nose. The solution is harmless if swallowed, but try to spit out as much of it as possible.

Nasal irrigation can be carried out as often as necessary, but a fresh solution should be made each time.

Allergic rhinitis medication

Medication won’t cure your allergy, but it can be used to treat the common symptoms.

If your symptoms are caused by seasonal allergens, such as pollen, you should be able to stop taking your medication after the risk of exposure has passed.

Visit your doctor if your symptoms don’t respond to medication after two weeks.

Antihistamines

Antihistamines (e.g., Cetirizine hydrochloride [Zyrtec], Fexofenadine hydrochloride [Telfast]) relieve symptoms of allergic rhinitis by blocking the action of a chemical called histamine, which the body releases when it thinks it’s under attack from an allergen.

Antihistamines are often used when symptoms do not occur very often or do not last very long.

• Antihistamines can be bought as a pill, capsule, or liquid without a prescription.
• Older antihistamines can cause sleepiness. They may affect a child’s ability to learn and make it unsafe for adults to drive or use machinery.
• Newer antihistamines cause little or no sleepiness or learning problems.
• Antihistamine nasal sprays work well for treating allergic rhinitis. They are only available with a prescription.

You can buy antihistamine tablets over the counter from your pharmacist without a prescription, but antihistamine nasal sprays are only available with a prescription.

Antihistamines can sometimes cause drowsiness. If you’re taking them for the first time, see how you react to them before driving or operating heavy machinery. In particular, antihistamines can cause drowsiness if you drink alcohol while taking them.

Decongestants

Decongestants (e.g., Phenylephrine hydrochloride [Sudafed]) are medicines that help dry up a runny or stuffy nose. They come as pills, liquids, capsules, or nasal sprays. You can buy them over-the-counter (OTC), without a prescription.

• You can use decongestants along with antihistamine pills or liquids.
• DO NOT use nasal spray decongestants for more than 3 days in a row.
• Talk to your child’s health care provider before giving decongestants to your child.

Corticosteroids

If you have frequent or persistent symptoms and you have a nasal blockage or nasal polyps, your doctor may recommend a nasal spray or drops containing corticosteroids.

Nasal corticosteroid sprays (e.g., Budesonide [Rhinocort], Mometasone furoate [Nasonex]) are the most effective treatment. Many brands are available. You can buy some brands without a prescription. For other brands, you need a prescription.

• Nasal corticosteroid sprays work best when you use them every day.
• It may take 2 or more weeks of steady use for your symptoms to improve.
• Nasal corticosteroid sprays are safe for children and adults.

Corticosteroids help reduce inflammation and swelling. They take longer to work than antihistamines, but their effects last longer. Side effects from inhaled corticosteroids are rare, but can include nasal dryness, irritation and nosebleeds.

Intranasal corticosteroids are cheaper than antihistamines and provide better relief of nasal symptoms, however the two can be used together for optimal symptom control.

If you have a particularly severe bout of symptoms and need rapid relief, your doctor may prescribe a short course of oral corticosteroid tablets such as prednisone lasting 5 to 10 days.

Eye drops

Eye drops containing anti-histamine or steroids may be used to control symptoms such as itchy or watery eyes e.g., Ketotifen fumarate (Zaditen), Hydrocortisone acetate (Hycor).

Add-on treatments

If allergic rhinitis doesn’t respond to treatment, your doctor may choose to add to your original treatment.

Your doctor may suggest:

• increasing the dose of your corticosteroid nasal spray
• using a short-term course of a decongestant nasal spray to take with your other medication
• combining antihistamine tablets with corticosteroid nasal sprays, and possibly decongestants
• using a nasal spray that contains a medicine called ipratropium, which will help reduce excessive nasal discharge
• using a leukotriene receptor antagonist medication – medication that blocks the effects of chemicals called leukotrienes, which are released during an allergic reaction

If you don’t respond to the add-on treatments, you may be referred to a specialist for further assessment and treatment.

Immunotherapy

Immunotherapy, also known as hyposensitisation or desensitisation, is another type of treatment used for some allergies.

It’s only suitable for people with certain types of allergies, such as hay fever, and is usually only considered if your symptoms are severe.

Immunotherapy involves gradually introducing more and more of the allergen into your body to make your immune system less sensitive to it.

The allergen is often injected under the skin of your upper arm. Injections are given at weekly intervals, with a slightly increased dose each time.

Immunotherapy can also be carried out using tablets that contain an allergen, such as grass pollen, which are placed under your tongue.

When a dose is reached that’s effective in reducing your allergic reaction (the maintenance dose), you’ll need to continue with the injections or tablets for up to three years.

Immunotherapy should only be carried out under the close supervision of a specially trained doctor as there’s a risk it may cause a serious allergic reaction.

The appropriate use, timing of initiation, and duration of immunotherapy remain uncertain. The general recommendation in the United States has been to start immunotherapy only for patients in whom symptom control is not adequate with pharmacotherapy or those who prefer immunotherapy to pharmacotherapy ³. However, the Preventive Allergy Treatment Study, in which children with allergic rhinitis but without asthma were randomly assigned to subcutaneous immunotherapy or a pharmacotherapy control, showed that fewer children had new allergies or asthma after 3 years of immunotherapy, and this preventive effect persisted 7 years after therapy was discontinued ⁴. A similar large trial using sublingual immunotherapy is ongoing ⁵.

With subcutaneous immunotherapy, the standard practice in the United States is to administer multiple allergens (on average, eight allergens simultaneously in a single injection or multiple injections) because most patients are sensitized and symptomatic on exposure to multiple allergens.49 It is not known whether multi-allergen therapy results in better outcomes than single-allergen therapy. Although some older studies suggest a benefit of multi-allergen immunotherapy, most trials showing the efficacy of immunotherapy involve a single allergen.

The role of allergen avoidance in the prevention of allergic rhinitis is controversial. Avoidance of seasonal inhalant allergens is universally recommended on the basis of empirical evidence, but the efficacy of strategies to avoid exposure to perennial allergens, including dust mites, pest allergens (cockroach and mouse), and molds, has been questioned. For abatement strategies to be successful, allergens need to be reduced to very low levels, which are difficult to achieve. Abatement usually requires a multifaceted and continuous approach, raising feasibility problems. Multifaceted programs have been effective in the management of asthma but have not been studied in allergic rhinitis.50

Allergic rhinitis guidelines

Guidelines for the treatment of allergic rhinitis are available from the international community (Allergic Rhinitis and Its Impact on Asthma [ARIA] guidelines) and jointly from the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology in the United States ⁶. Differences between the two sets of guidelines exist. For example, the ARIA guidelines ⁶ do not recommend oral decongestants, even when combined with antihistamines, except as rescue medications, and they recommend nasal antihistamines only for seasonal use. Whereas the ARIA guidelines do not specifically endorse combinations of medications, the U.S. guidelines recommend a stepped-care approach that can include more than one medication. The U.S. guidelines were written before Food and Drug Administration approval of sublingual immunotherapy, and therefore this treatment is not discussed. The recommendations in this article are largely concordant with both sets of guidelines.

Allergic Rhinitis and its Impact on Asthma (ARIA) Recommendations

I. Prevention of allergy

Recommendation 1:

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest exclusive breastfeeding for at least first three months for all infants irrespective of their family history of atopy (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on the prevention of allergy and asthma, and a relatively low value on challenges or burden of breastfeeding in certain situations.

Remarks

The evidence, that exclusive breastfeeding for at least the first three months reduces the risk of allergy or asthma, is not convincing and, therefore, the recommendation to exclusively breastfeed is conditional. This recommendation applies to situations in which other reasons do not suggest harm from breastfeeding (e.g. classic galactosemia, active untreated tuberculosis or human immunodeficiency virus infection in mother, antimetabolites or chemotherapeutic agents or radioactive isotopes being used in the mother for diagnostic or therapeutic purposes until they clear from the milk, and bacterial or viral infection of a breast).

Recommendation 2:

For pregnant or breastfeeding women, we suggest no antigen avoidance diet to prevent development of allergy in children (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on adequate nourishment of mothers and children, and a relatively low value on very uncertain effects on the prevention of allergy and asthma in this setting.

Recommendation 3:

In children and pregnant women, we recommend total avoidance of environmental tobacco smoke (i.e. passive smoking) (strong recommendation | very low quality evidence).

Remarks

Smoking and exposure to second-hand smoke are common health problems around the world causing a substantial burden of disease for children and adults. While it is very rare to make a strong recommendation based on low or very low quality evidence, the ARIA guideline panel felt that in the absence of important adverse effects associated with smoking cessation or reducing the exposure to second-hand smoke, the balance between the desirable and undesirable effects is clear.

Recommendation 4:

In infants and preschool children, we suggest multifaceted interventions to reduce early life exposure to house dust mite (conditional recommendation | low quality evidence).

This recommendation places a relatively low value on the burden and cost of using multiple preventive measures (e.g. encasings to parental and child’s bed, washing bedding and soft toys at temperature exceeding 55°C [131°F], use of acaricide, smooth flooring without carpets, etc.), and relatively high value on an uncertain small reduction of the risk of developing wheeze or asthma. For some children at lower risk of developing asthma and in certain circumstances an alternative choice will be equally reasonable.

Remarks

Children at high risk of developing asthma are those with at least one parent or sibling with asthma or other allergic disease.

Recommendation 5:

In infants and preschool children, we suggest no special avoidance of exposure to pets at home (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on possible psychosocial downsides of not having a pet, and relatively low value on potential reduction in the uncertain risk of developing allergy and/or asthma.

Remarks

Clinicians and patients may reasonably choose an alternative action, considering circumstances that include other sensitized family members.

Recommendation 6:

For individuals exposed to occupational agents, we recommend specific prevention measures eliminating or reducing occupational allergen exposure (strong recommendation | low quality evidence).

This recommendation places a relatively high value on reducing the risk of sensitization to occupational allergens and developing occupational rhinitis and/or asthma with the subsequent adverse consequences, and a relatively low value on the feasibility and cost of specific strategies aimed at reducing occupational allergen exposure.

Remarks

Total allergen avoidance, if possible, seems to be the most effective primary prevention measure.

II. Treatment of allergic rhinitis

Reducing allergen exposure

Recommendation 7:

In patients with allergic rhinitis and/or asthma sensitive to house dust mite allergens, we recommend that clinicians do not administer and patients do not use currently available single chemical or physical preventive methods aimed at reducing exposure to house dust mites (strong recommendation | low quality evidence) or their combination (conditional recommendation | very low quality evidence), unless this is done in the context of formal clinical research.
We suggest multifaceted environmental control programmes be used in inner-city homes to improve symptoms of asthma in children (conditional recommendation | very low quality evidence).

The recommendation to use multifaceted environmental control programmes in inner-city homes places a relatively high value on possible reduction in the symptoms of asthma in children, and relatively low value on the cost of such programmes.

Recommendation 8:

In patients allergic to indoor moulds, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest avoiding exposure to these allergens at home (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on possible reduction in the symptoms of rhinitis and asthma, and a relatively low value on the burden and cost of interventions aimed at reducing exposure to household moulds.

Recommendation 9:

In patients with allergic rhinitis due to animal dander, we recommend avoiding exposure to these allergens at home (strong recommendation | very low quality evidence).

This recommendation places a relatively high value on potential reduction of symptoms of allergic rhinitis, and a relatively low value on psychosocial downsides of not having a pet or the inconvenience and cost of environmental control measures.

Remarks

Based on biological rationale, there is little doubt that total avoidance of animal allergens at home, and probably also marked reduction in their concentration, can improve symptoms, despite paucity of published data to substantiate this statement.

Recommendation 10:

In patients with occupational asthma, we recommend immediate and total cessation of exposure to occupational allergen (strong recommendation | very low quality evidence). When total cessation of exposure is not possible, we suggest specific strategies aimed at minimizing occupational allergen exposure (conditional recommendation | very low quality evidence).

The recommendation to immediately and totally cease the exposure to occupational allergen places a relatively high value on reducing the symptoms of asthma and deterioration of lung function, and a relatively low value on the potential socioeconomic downsides (e.g. unemployment).

Pharmacological treatment of allergic rhinitis

Recommendation 11:

In patients with allergic rhinitis, we recommend new generation oral H1-antihistamines that do not cause sedation and do not interact with cytochrome P450 (strong recommendation | low quality evidence). In patients with allergic rhinitis, we suggest new generation oral H1-antihistamines that cause some sedation and/or interact with cytochrome P450 (conditional recommendation | low quality evidence).

The recommendation to use new generation oral H1-antihistamines that cause some sedation and/or interact with cytochrome P450 places a relatively high value on a reduction of symptoms of allergic rhinitis, and a relatively low value on side effects of these medications.

Remarks

Astemizole and terfenadine were removed from the market due to cardiotoxic side effects.
See recommendation 12 referring to the comparison of new generation versus old generation agents for the choice of one over the other.

Recommendation 12:

In patients with allergic rhinitis, we recommend new generation over old generation oral H1-antihistamines (strong recommendation | low quality evidence).

This recommendation places a relatively high value on the reduction of adverse effects, and a relatively low value on an uncertain comparative efficacy of new versus old generation oral H1-antihistamines.

Recommendation 13:

In infants with atopic dermatitis and/or family history of allergy or asthma (at high risk of developing asthma), we suggest clinicians do not administer and parents do not use oral H1-antihistamines for the prevention of wheezing or asthma (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on avoiding side effects of oral H1-antihistamines in infants, and a lower value on the very uncertain reduction in the risk of developing asthma or wheezing.

Remarks

The recommendation not to use oral H1-antihistamines in these infants refers only to prevention of asthma or wheezing. The guideline panel did not consider other conditions in which these medications may be commonly used (e.g. urticaria).

Recommendation 14:

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest intranasal H1-antihistamines in adults with seasonal allergic rhinitis (conditional recommendation| low quality evidence) and in children with seasonal allergic rhinitis (conditional recommendation | very low quality evidence). In adults and children with perennial/persistent allergic rhinitis, we suggest that clinicians do not administer and patients do not use intranasal H1-antihistamines until more data on their relative efficacy and safety is available (conditional recommendation | very low quality evidence).

The recommendation to use intranasal H1-antihistamines in patients with seasonal allergic rhinitis places a relatively high value on reduction of symptoms, and a relatively low value on the risk of rare or mild side effects. The recommendation not to use intranasal H1-antihistamines in patients with perennial/persistent allergic rhinitis places a relatively high value on their uncertain efficacy and possible side effects, and a relatively low value on possible small reduction in symptoms.

Recommendation 15:

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest new generation oral H1-antihistamines rather than intranasal H1-antihistamines in adults with seasonal allergic rhinitis (conditional recommendation | moderate quality evidence) and in adults with perennial/persistent allergic rhinitis (conditional recommendation | very low quality evidence). In children with intermittent or persistent allergic rhinitis we also suggest new generation oral H1-antihistamines rather than intranasal H1-antihistamines (conditional recommendation | very low quality evidence).

These recommendations place a relatively high value on probable higher patient preference for oral versus intranasal route of administration as well as avoiding bitter taste of some intranasal H1-antihistamines, and relatively low value on increased somnolence with some new generation oral H1-antihistamines. In many patients with different values and preferences or those who experience adverse effects of new generation oral H1-antihistamines an alternative choice may be equally reasonable.

Recommendation 16:

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest oral leukotriene receptor antagonists in adults and children with seasonal allergic rhinitis (conditional recommendation | high quality evidence) and in preschool children with perennial allergic rhinitis (conditional recommendation | low quality evidence). In adults with perennial allergic rhinitis we suggest that clinicians do not administer and patients do not use oral leukotriene receptor antagonists (conditional recommendation | high quality evidence).

The recommendation to use oral leukotriene receptor antagonists in adults and children with seasonal allergic rhinitis and in preschool children with perennial allergic rhinitis places a relatively high value on their safety and tolerability, and relatively low value on their limited efficacy and high cost.
The recommendation not to use oral leukotriene receptor antagonists in adults with perennial allergic rhinitis places a relatively high value on their very limited efficacy and high cost, and relatively low value on potential small benefit in few patients.

Remarks

Evidence is available only for montelukast. This recommendation refers to the treatment of rhinitis, not to the treatment of asthma in patients with concomitant allergic rhinitis (see recommendation 45).

Recommendation 17:

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest oral H1-antihistamines over oral leukotriene receptor antagonists in patients with seasonal allergic rhinitis (conditional recommendation | moderate quality evidence) and in preschool children with perennial allergic rhinitis (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on avoiding resource expenditure.

Recommendation 18:

Allergic Rhinitis and its Impact on Asthma (ARIA) recommend intranasal glucocorticosteroids for treatment of allergic rhinitis in adults (strong recommendation | high quality evidence) and suggest intranasal glucocorticosteroids in children with allergic rhinitis (conditional recommendation | moderate quality evidence).

This recommendation places a relatively high value on the efficacy of intranasal glucocorticosteroids, and a relatively low value on avoiding their possible adverse effects.

Recommendation 19:

In patients with seasonal allergic rhinitis, we suggest intranasal glucocorticosteroids over oral H1-antihistamines in adults (conditional recommendation | low quality evidence) and in children (conditional recommendation | very low quality evidence). In patients with perennial/persistent allergic rhinitis, we suggest intranasal glucocorticosteroids over oral H1-antihistamines in adults (conditional recommendation | moderate quality evidence) and in children (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on the likely higher efficacy of intranasal glucocorticosteroids. In many patients with strong preference for oral versus intranasal route of administration an alternative choice may be reasonable.

Recommendation 20:

In patients with allergic rhinitis, we recommend intranasal glucocorticosteroids rather than intranasal H1-antihistamines (strong recommendation | high quality evidence).

This recommendation places a relatively high value on efficacy of intranasal glucocorticosteroids, and a relatively low value on their rare adverse effects.

Recommendation 21:

In patients with seasonal allergic rhinitis Allergic Rhinitis and its Impact on Asthma (ARIA) recommend intranasal glucocorticosteroids over oral leukotriene receptor antagonists (strong recommendation | low quality evidence).

This recommendation places a high value on the efficacy of intranasal glucocorticosteroids.

Remarks

Evidence is available for montelukast only.

• Recommendation 22:

In patients with allergic rhinitis and moderate to severe nasal and/or ocular symptoms that are not controlled with other treatments, we suggest short course of oral glucocorticosteroids (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on possible relief of severe symptoms, and a relatively low value on avoiding possible side effects of a short course of oral glucocorticosteroids.

Remarks

Systemic glucocorticosteroids should not be considered as a first line of treatment for allergic rhinitis. They can be used for few days as a last resort of treatment when combinations of other medications are ineffective. Oral glucocorticosteroids should be avoided in children, pregnant women, and patients with known contraindications.

Recommendation 23:

In patients with allergic rhinitis, we recommend that clinicians do not administer intramuscular glucocorticosteroids (strong recommendation | low quality evidence).

This recommendation places a relatively high value on avoiding possible side effects of a single or multiple injections of intramuscular glucocorticosteroids, and relatively low value on their efficacy and convenience of use.

Remarks

Possible side effects of intramuscular glucocorticosteroids may be far more serious than the condition they are supposed to treat (i.e. allergic rhinitis).

Recommendation 24:

In patients with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest intranasal chromones (conditional recommendation | moderate quality evidence).

This recommendation places a relatively high value on excellent safety and tolerability of intranasal chromones, and relatively low value on their limited efficacy and on limiting resource expenditure.

Remarks

The need for administration 4 times daily is likely to reduce patient adherence and reduce efficacy.

Recommendation 25:

In patients with allergic rhinitis, we suggest intranasal H1-antihistamines over intranasal chromones (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on possibly higher efficacy of intranasal H1-antihistamines, and relatively low value on safety and tolerability of intranasal chromones.

Remarks

Chromones require administration 4 times daily that may limit patient adherence to treatment and reduce efficacy.

Recommendation 26:

In patients with perennial allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest intranasal ipratropium bromide for treatment of rhinorrhea (conditional recommendation | moderate quality evidence).

Remarks

Intranasal ipratropium bromide is effective for rhinorrhea. It is unlikely to be beneficial for other symptoms of allergic rhinitis.

Recommendation 27:

In adults with allergic rhinitis and severe nasal obstruction, we suggest very short course (not longer than five days and preferably shorter) of intranasal decongestant while co-administering other drugs (conditional recommendation | very low quality evidence). We suggest that clinicians do not administer and parents do not use intranasal decongestants in preschool children (conditional recommendation | very low quality evidence).

The recommendation for use of a very short course of an intranasal decongestant in adults with allergic rhinitis places a relatively high value on the prompt relief of nasal obstruction, and relatively low value on avoiding the risk of adverse effects with a prolonged use of intranasal decongestant.

The recommendation against the use of an intranasal decongestant in children and against long-term use in adults places a relatively high value on avoiding the risk of serious adverse effects, and relatively low value on a possible benefit from a reduced nasal blockage.

Recommendation 28:

In patients with allergic rhinitis, we suggest that clinicians do not administer and patients do not use oral decongestants regularly (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on avoiding adverse effects of oral decongestants, and a relatively low value on possible small reduction in symptoms of rhinitis.

Remarks

Oral decongestants may be of benefit for some patients as a rescue or “as needed” medication.

Recommendation 29:

In patients with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest clinicians do not administer and patients do not use regularly a combination of oral H1-antihistamine and an oral decongestant, compared to oral H1-antihistamine alone (conditional recommendation | moderate quality evidence).

This recommendation places a relatively high value on avoiding adverse effects of oral decongestant, and a relatively low value on small additional reduction in symptoms of rhinitis.

Remarks

In adults with symptoms not controlled with oral H1-antihistamine alone who are less averse to side effects of oral decongestants an alternative choice may be equally reasonable. Administration of a combined treatment as a rescue medication may also be beneficial to some patients.

Recommendation 30:

In patients with allergic rhinitis and symptoms of conjunctivitis, we suggest intraocular H1-antihistamines (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on consistent effectiveness of intraocular H1-antihistamines, and relatively low value on their side effects and uncertain effectiveness in patients already using other medications for allergic rhinitis.

Remarks

Only one study was done in children.

Recommendation 31:

In patients with allergic rhinitis and symptoms of conjunctivitis, we suggest intraocular chromones (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on excellent safety and tolerability of intraocular chromones and relatively low value on their limited effectiveness.

Remarks

In adults and children with limited ocular symptoms, chromones may be tried first because of their excellent safety and tolerability. Chromones require administration 4 times daily that may limit patient compliance with treatment and reduce efficacy.

Recommendation 32: 

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest subcutaneous allergen specific immunotherapy in adults with seasonal (conditional recommendation | moderate quality evidence) and perennial allergic rhinitis due to house dust mites (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on relieving the symptoms of allergic rhinitis, and a relatively low value on avoiding adverse effects and on resource expenditure.

Recommendation 33:

In children with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest subcutaneous specific immunotherapy (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on probable reduction in symptoms of allergic rhinitis and the potential prevention of the development of asthma, and relatively low value on avoiding adverse effects in children and resource expenditure.

Recommendation 34:

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest sublingual allergen specific immunotherapy in adults with rhinitis due to pollen (conditional recommendation | moderate quality evidence) or house dust mites (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on alleviating the symptoms of rhinitis, and relatively low value on avoiding adverse effects and resource expenditure.

Remarks

Local adverse effects are relatively frequent (~35%). An alternative choice may be equally reasonable, if patients’ values or preferences differ from those described here.

Recommendation 35:

In children with allergic rhinitis due to pollens, we suggest sublingual allergen-specific immunotherapy (conditional recommendation | moderate quality evidence). In children with allergic rhinitis due to house dust mites, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest that clinicians do not administer sublingual immunotherapy outside rigorously designed clinical trials (conditional recommendation | very low quality evidence).

The recommendation to use sublingual immunotherapy in children with seasonal allergic rhinitis places a relatively high value on small reduction in nasal symptoms, and relatively low value on avoiding adverse effects in children and resource expenditure. The recommendation to use sublingual immunotherapy in children with perennial allergic rhinitis only in the context of clinical research places a relatively high value on avoiding adverse effects and resource expenditure, and relatively low value on possible small reduction in nasal symptoms.

Remark

Local adverse effects are relatively frequent (~35%). An alternative choice may be equally reasonable, if patients’ values or preferences differ from those described here.

Recommendation 36:

Allergic Rhinitis and its Impact on Asthma (ARIA) suggest intranasal allergen specific immunotherapy in adults (conditional recommendation | low quality evidence) and in children with allergic rhinitis due to pollens (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on the reduction of symptoms of allergic rhinitis during pollen season, and a relatively low value on avoiding local side effects and cost. An alternative choice may be equally reasonable.

Alternative and complementary treatment for allergic rhinitis

Recommendation 37:

In patients with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest that clinicians do not administer and patients do not use homeopathy (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on avoiding possible adverse effects and resource expenditure, and a relatively low value on any possible, but unproven, benefit of these treatments in allergic rhinitis.

Recommendation 38:

In patients with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest clinicians do not administer and patients do not use acupuncture (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on avoiding the potential complications of acupuncture, and a relatively low value on uncertain reduction in symptoms of rhinitis.

Remarks

In patients who choose to be treated with acupuncture ONLY disposable needles should be used.

Recommendation 39:

In patients with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest clinicians do not administer and patients do not use butterbur (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on avoiding the uncertain adverse effects of butterbur, and a relatively low value on equally uncertain reduction in symptoms of rhinitis.

Remarks

In patients who are less risk averse an alternative may be equally reasonable. However, if one chooses to use butterbur one should consider only commercial preparations in which butterbur extract does not contain toxic pyrrolizidine alkaloids.

Recommendation 40:

In patients with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest clinicians do not administer and patients do not use herbal medicines (conditional recommendation | very low quality evidence).

The recommendation places a relatively high value on avoiding possible serious adverse events and drug interactions, and a relatively low value on possible reduction in symptoms of rhinitis.

Recommendation 41:

In patients with allergic rhinitis, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest that clinicians do not administer and patients do not use phototherapy or other physical techniques (conditional recommendation | very low quality evidence).

This recommendation places a relatively high value on avoiding potential adverse effects of these therapies, and a relatively low value on their very uncertain effect on symptoms of rhinitis.

III. Treatment of asthma in patients with allergic rhinitis and asthma

Recommendation 42:

In patients (both children and adults) with allergic rhinitis and asthma, we suggest clinicians do not administer and patients do not use oral H1-antihistamines for the treatment of asthma (conditional recommendation | very low quality evidence).

The recommendation not to use oral H1-antihistamines in adults with allergic rhinitis and asthma for the treatment of asthma places a relatively high value on avoiding their adverse effects, and a relatively low value on their very uncertain effect on symptoms of asthma.

The recommendation not to use oral H1-antihistamines in children with allergic rhinitis for the treatment of asthma or wheeze, despite the evidence of efficacy of ketotifen when used alone in children with mild to moderate asthma, places a relatively high value on avoiding its side effects, and a relatively low value on its unknown efficacy in children already using inhaled corticosteroids, since inhaled corticosteroids are currently considered medications of first choice in treatment of chronic asthma.

Remarks

This recommendation suggests that oral H1-antihistamines should not be used to treat symptoms of asthma, but they may still be used in patients with asthma and rhinitis for treatment of rhinitis (recommendations 11, 12, 15, and 17).

Recommendation 43:

In patients with allergic rhinitis and asthma, we suggest clinicians do not administer and patients do not use a combination of oral H1-antihistamine and oral decongestant for treatment of asthma (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on avoiding adverse effects of combination of oral H1-antihistamine and oral decongestant, and a relatively low value on possible small reduction in asthma symptoms of uncertain clinical significance.

Recommendation 44:

In patients with allergic rhinitis and asthma, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest that clinicians do not administer and patients do not use intranasal glucocorticosteroids for treatment of asthma (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on avoiding adverse effects, burden, and cost of intranasal glucocorticosteroids, and a relatively low value on unlikely clinical benefit.

Remarks

This recommendation suggests that intranasal glucocorticosteroids are not used to treat symptoms of asthma, but they may still be used in patients with asthma and rhinitis for treatment of rhinitis (see recommendations 18, 19, 20, and 21).

Recommendation 45:

In patients with allergic rhinitis and asthma, Allergic Rhinitis and its Impact on Asthma (ARIA) recommend inhaled glucocorticosteroids over oral leukotriene receptor antagonists as a single controlling medication for asthma (strong recommendation | moderate quality evidence).

In patients with allergic rhinitis and asthma who prefer not to use or cannot use inhaled glucocorticosteroids or in children whose parents do not agree to use inhaled glucocorticosteroids, we suggest oral leukotriene receptor antagonists for treatment of asthma (conditional recommendation | moderate quality evidence).

These recommendations place a relatively high value on a limited efficacy of LTRA and additional cost of treatment. The suggestion to use oral LTRA in patients who do not use inhaled glucocorticosteroids places relatively high value on small reduction in symptoms of asthma and improvement in quality of life, and a relatively low value on limiting the cost of treatment.

Remarks

These recommendations do not apply to the treatment of rhinitis (see recommendation 16, 17, 21).

Recommendation 46:

In patients with allergic rhinitis and asthma, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest subcutaneous specific immunotherapy for treatment of asthma (conditional recommendation | moderate quality evidence).

This recommendation places a relatively high value on reducing the symptoms of asthma, and a relatively low value on avoiding adverse effects and limiting the cost of subcutaneous specific immunotherapy. In patients who are more averse to the side effects of subcutaneous specific immunotherapy an alternative choice may be equally reasonable.

Remarks

Subcutaneous specific immunotherapy may also be used in patients with asthma and concomitant allergic rhinitis for treatment of rhinitis (see recommendations 32 and 33). Resource limitations will have stronger implications for the implementation of this recommendation.

Recommendation 47:

In patients with allergic rhinitis and asthma, Allergic Rhinitis and its Impact on Asthma (ARIA) suggest sublingual specific immunotherapy for treatment of asthma (conditional recommendation | low quality evidence).

This recommendation places a relatively high value on possible reduction of asthma symptoms, and a relatively low value on avoiding adverse effects and limiting the cost of sublingual specific immunotherapy.

Remarks

Sublingual specific immunotherapy may also be used in patients with asthma and concomitant allergic rhinitis for treatment of rhinitis (see recommendations 34 and 35). Resource limitations will have stronger implications for the implementation of this recommendation.

Recommendation 48:

In patients with allergic rhinitis and asthma with a clear IgE-dependent allergic component, uncontrolled despite optimal pharmacologic treatment and appropriate allergen avoidance, we suggest monoclonal antibody against IgE for treatment of asthma (conditional recommendation | moderate quality evidence).

This recommendation places a relatively high value on reduction of symptoms of asthma and exacerbations in patients with severe asthma, and a relatively low value on avoiding the burden of subcutaneous injections, cost of treatment, small risk of anaphylaxis and some uncertainty about the risk of malignancy.

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