Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR. This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR. This comprehensive practice parameter for allergic and nonallergic rhinitis provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacotherapy options, and allergen immunotherapy. Food allergy testing and parenteral corticosteroids are not recommended. Key new and updated recommendations are emphasized (Table I).Table IWhat is new or newly emphasized in Rhinitis 2020?Four new algorithms based on a combination of evidence and expert opinion can guide the clinician in the treatment of intermittent and persistent AR and NAR.New tables assist in making (1) the differential diagnosis for rhinitis based on patient history and (2) the diagnosis and treatment for rhinitis-associated conditions or conditions that mimic rhinitis.Cough is emphasized as a common symptom present in both AR and NAR.New information is presented about LAR, possibly present in up to 25% of patients with rhinitis, and its response to both SCIT and SLIT, although more research is needed.We recommend that food allergy testing not be performed in the routine evaluation of possible AR (Recommendation 4).We recommend that the oral LTRA montelukast should only be used for AR in patients who have an inadequate response or intolerance to alternative therapies. Serious neuropsychiatric events that may include suicidal thoughts or actions have been reported in patients taking montelukast (Receommendation 7).Either INAH or INCS may be offered as first-line monotherapy for NAR (Recommendations 12, 32).Since the 2008 rhinitis update, additional studies support the use of combination INCS and INAH in AR and NAR (Recommendations 22-24).Oral decongestants should be avoided during the first trimester of pregnancy (Recommendation 19).Additional information is presented as to why first-generation antihistamines should not be used in AR, especially on a chronic basis, due to potential sedation, performance impairment, poor sleep quality, anticholinergic-medicated symptoms, and increased risk of dementia (Receommendation 6).We continue to suggest that the use of intranasal decongestants generally be limited to short-term use to prevent rebound congestion that may occur with longer use. However, in limited circumstances discussed in the document, patients on regimens that include an INCS may be offered combination therapy with addition of an intranasal decongestant for up to 4 wk (Receommendations 16, 26).SCIT and SLIT tablets are both effective for the treatment of AR and may help prevent and/or treat allergic asthma (Receommendation 34).Neither acupuncture nor herbal medications have adequate studies to support a recommendation to use them in the treatment of AR (Receommendations 36, 37). Open table in a new tab