New Canadian guidance on allergic rhinitis management

Allergic rhinitis is a common condition in children and adults in Canada, affecting up to 20% of the general population. It can negatively impact daily activities, sleep, work, school performance and overall health-related quality of life. Three key measures to reduce the burden of allergic rhinitis are allergen avoidance, allergen immunotherapy and the use of symptom-relieving pharmacotherapies.Although previous practice statements have been published on allergic rhinitis, the Allergic Rhinitis Working Group in Canada created a focused practice parameter by identifying six unanswered questions and/or unmet needs specific to the treatment of allergic rhinitis in Canada. The six research questions and answers are summarized below. Consult the article for further details and a discussion of the evidence.In patients with symptoms indicative of allergic rhinitis, is serum-specific IgE (sIgE) sufficient to identify candidates for immunotherapy or is a skin prick test (SPT) mandatory? Evidence suggests that either sIgE testing or SPT can be used to support the final diagnosis of allergic rhinitis and guide allergen immunotherapy. While sIgE testing was used much more routinely than SPT in during the COVID-19 pandemic, sIgE should continue to be accepted as a sufficient approach for guiding the use of immunotherapy in allergic rhinitis.When taking into account the preferences of the patient and the prescriber, should a second-generation oral antihistamine or an intranasal corticosteroid be first line? Existing guidelines generally agree on the use of an intranasal corticosteroid as first-line therapy; however, patient and provider preferences and considerations can easily shift the first choice to a second-generation oral antihistamine. Second-generation oral antihistamines are widely supported as a treatment option, with evidence of their efficacy in symptom control. Is a combination intranasal antihistamine/corticosteroid formulation superior to an intranasal corticosteroid plus oral antihistamine? Do they become equivalent after prolonged use? Combination intranasal antihistamine/corticosteroid products (e.g., olopatadine/mometasone, azelastine/fluticasone) are superior to an intranasal corticosteroid plus oral antihistamine. However, evidence is insufficient to determine whether these therapies become equivalent after prolonged use. Do leukotriene receptor antagonists have a greater benefit than oral antihistamines in allergic rhinitis for some symptoms to justify a therapeutic trial in those who cannot tolerate intranasal corticosteroids? Leukotriene receptor antagonists (e.g., montelukast) have inferior, or at best equivalent, daytime or overall symptom control compared with oral antihistamines. However, leukotriene receptor antagonists may improve nighttime symptom control and provide benefits in patients with allergic rhinitis and concomitant asthma.Should sublingual immunotherapy (SLIT) tablets be considered first-line immunotherapeutic options over subcutaneous immunotherapy (SCIT) based on evidence of efficacy? The choice between SLIT or SCIT cannot be made on efficacy alone, and differences in other factors (e.g., costs, risks, practical considerations for administration, patient preference) outweigh any differences in efficacy.Based on efficacy data, should all patients seen by an allergist be offered SLIT or SCIT as a treatment option? Efficacy data suggest that SLIT or SCIT should be used broadly in patients with allergic rhinitis, but other clinical concerns also need to be taken into consideration. These include the potential side effects (both SLIT and SCIT), the need to identify the particular allergen(s) causing allergic rhinitis symptoms (both), the need for office visits (SCIT), provider expertise for preparation and delivery (SCIT), cost (both), and sustained adherence to modify the immune response (both).The Allergic Rhinitis Working Group concluded that implementation of these recommendations, in conjunction with shared decision-making, may improve outcomes in Canadian patients with allergic rhinitis.Reference:Ellis AK, Cook V, Keith PK, et al. Focused allergic rhinitis practice parameter for Canada. Allergy Asthma Clin Immunol 2024;20(1):45. (accessed August 20, 2024).

New Canadian guidance on allergic rhinitis management

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