Rhinitis 2020: A practice parameter update - 05/10/20

Doi : 10.1016/j.jaci.2020.07.007

Mark S. Dykewicz, MD ^a,^⁎ , Dana V. Wallace, MD ^b, David J. Amrol, MD ^c, Fuad M. Baroody, MD ^d, Jonathan A. Bernstein, MD ^e, Timothy J. Craig, DO ^f, Chitra Dinakar, MD ^g, Anne K. Ellis, MD ^h, Ira Finegold, MD ⁱ, David B.K. Golden, MD ^j, Matthew J. Greenhawt, MD ^k, John B. Hagan, MD ^l, Caroline C. Horner, MD ^m, David A. Khan, MD ⁿ, David M. Lang, MD ^o, Desiree E.S. Larenas-Linnemann, MD ^p, Jay A. Lieberman, MD ^q, Eli O. Meltzer, MD ^r,^s, John J. Oppenheimer, MD ^t,^u, Matthew A. Rank, MD ^v, Marcus S. Shaker, MD ^w, Jeffrey L. Shaw, MD ^x, Gary C. Steven, MD ^y, David R. Stukus, MD ^z,^aa, Julie Wang, MD ^bb
^a Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, School of Medicine, Saint Louis University, St Louis, Mo
^b Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
^c Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
^d Department of Otolaryngology–Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Ill
^e Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
^f Departments of Medicine and Pediatrics, Penn State University, Hershey, Pa
^g Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, Calif
^h Division of Allergy and Immunology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
ⁱ Division of Allergy and Immunology, Department of Medicine, Mount Sinai West, New York, NY
^j Division of Allergy and Clinical Immunology, Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Md
^k Section of Allergy and Immunology, Department of Pediatrics, Children’s Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colo
^l Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
^m Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, School of Medicine, Washington University, St Louis, Mo
ⁿ Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
^o Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
^p Center of Excellence in Asthma and Allergy, Hospital Medica Sur, Mexico City, Mexico
^q Division of Pulmonology Allergy and Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
^r Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, University of California, San Diego, Calif
^s Allergy and Asthma Medical Group and Research Center, San Diego, Calif
^t Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey–Rutgers New Jersey Medical School, New Brunswick, NJ
^u Pulmonary and Allergy Associates, Morristown, NJ
^v Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
^w Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
^x Prevea Health, Green Bay, Wis
^y Allergy, Asthma and Sinus Center, Greenfield, Wis
^z Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio
^aa Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
^bb Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY

^∗Corresponding author: Mark S. Dykewicz, MD, Saint Louis University School of Medicine, Section of Allergy and Immunology, Department of Internal Medicine, 1402 S. Grand Boulevard, M157, St Louis, MO 63104.Saint Louis University School of MedicineSection of Allergy and ImmunologyDepartment of Internal Medicine1402 S. Grand BoulevardM157St LouisMO63104
Chief Editor(s):
Mark S. Dykewicz, Dana V. Wallace

Joint Task Force on Practice Parameters:
Chitra Dinakar, Anne K. Ellis, David B.K. Golden, Matthew J. Greenhawt, Caroline C. Horner, David A. Khan, David M. Lang, Jay A. Lieberman, John J. Oppenheimer, Matthew A. Rank, Marcus S. Shaker, David R. Stukus, Julie Wang

Workgroup Contributors:
Mark S. Dykewicz, Dana V. Wallace, David J. Amrol, Fuad M. Baroody, Jonathan A. Bernstein, Timothy J. Craig, Ira Finegold, John B. Hagan, Desiree E.S. Larenas-Linnemann, Eli O. Meltzer, Jeffrey L. Shaw, Gary C. Steven

Abstract

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.

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Key words : Allergic rhinitis, nonallergic rhinitis, vasomotor rhinitis, local allergic rhinitis, food allergy antihistamines, corticosteroids, ipratropium, allergen immunotherapy, decongestants

Abbreviations used : AH, AIT, AR, CBS, CHM, CRS, CT, DBPC, DP, FDA, GRADE, INAH, INCS, JTFPP, LAR, LTRA, NAPT, NAR, NARES, NSAID, NSD, OAS, PAR, QOL, SAR, SCIT, sIgE, SLIT, SLIT-D, SLIT-T, TRPV1, VAS, VMR, UACS

	Disclosure of potential conflict of interest: The Joint Task Force on Practice Parameters (JTFPP) members’ and work group members’ conflict of interest disclosure forms can be found at www.allergyparameters.org. Mark S. Dykewicz has served as a committee member for the American Academy of Allergy, Asthma, and Immunology (AAAAI) Rhinitis, Rhino-sinusitis, and Ocular Allergy Interest Section and is also a member of the American College of Asthma, Allergy, and Immunology (ACAAI) Rhinitis/Sinusitis Committee. Dana V. Wallace has received financial support from Mylan, Kaleo, Optinose, ALK-Abelló, Bryan, and Sanofi. David J. Amrol has received financial support from CSL Behring; and is a board member for the Southeastern Allergy, Asthma, and Immunology Society. Fuad M. Baroody is a member of the American Rhinologic Society and a member of the American Academy of Otolaryngology–Head and Neck Surgery. Jonathan A. Bernstein has received financial support from Sanofi Regeneron, AstraZeneca, Merck, Optinose, Takeda, CSL Behring, Biocryst, Pharming, the National Institutes of Health, Taylor Francis, INEOS; is Editor-in-Chief of the Journal of Asthma, INEOS medical immunosurveillance director, vice chair, and lectureship chair of the AAAAI Foundation, chairman of AFI, ACAAI Asthma Chair, Scientific Chair, and Young Investigator Award Chair; and serves on the board of directors and scientific committee of Interasma. Timothy J. Craig has received financial support from CSL Behring, Dyax, Takeda, BioCryst, Pharming, Grifols, GlaxoSmithKline, Regeneron, and Novartis/Genentech; is on the medical advisory board for Hereditary Angioedema Asssociation of America; serves of the board of directors for the AAAAI; and is a member of the American Lung Association Mid-Atlantic Board. Chitra Dinakar has received financial support from Propeller Health, ACAAI (stipend for Editorial Board of AllergyWatch), and the American Association of Allergists of Indian Origin; serves on the board of directors of the AAAAI and on the medical advisory board of Food Equity Initiative; and is Assistant Editor of AllergyWatch. Anne K. Ellis has received financial support from ALK-Abelló, AstraZeneca, Green Cross, Merck, Novartis, Nuvo, Pediapharm, Pfizer, Kaleo, Novartis, Sanofi, and Regerneron; and serves on the board of directors of the Canadian Allergy Society of Allergy and Clinical Immunology. Ira Finegold has no competing relationships, organizational interests, or conflicts to disclose. David B. K. Golden has received financial support from Aquestive, Sandoz, ALK-Abelló, Sandoz, Genentech, Stallergenes-Greer, and UpToDate. Matthew J. Greenhawt has received financial support from Aquestive, Merck, Allergenis, Allergy Therapeutics, Sanofi Genzyme, Genentech, Aravax, Prota, Before Brands, the Institute for Clinical and Economic Review, ACAAI, DBV Technologies, and Intrommune; is supported by the Agency of Healthcare Research and Quality; has served on the advisory board of International Food Protein Induced Enterocolitis Syndrome Association, the Asthma and Allergy Foundation of America, and the National Peanut Board; and is Associate Editor of the Annals of Allergy, Asthma, and Immunology. John B. Hagan is member of the Quality, Adherence and Outcomes Committee at the AAAAI; and is chairman of the Rhinitis/Sinusitis/Ocular Committee at the ACAAI. Caroline C. Horner has served as committee chair for the AAAAI Asthma Diagnosis and Treatment Interest Section, Interest Section Coordinating Committee, and In-Training Exam Coordinating Committee. David A. Khan has received financial support from UpToDate and Aimmune; serves on the board of directors of the AAAAI, ACAAI Chair of Literature Review, co-chair of Conjoint Board Review, Texas Allergy, Asthma, and Immunology Society Chair of Meetings Committee; and is Associate Editor of the Journal of Allergy and Clinical Immunology in Practice. David M. Lang is on the Editorial Board for Allergy and Asthma Proceedings, topic editor for DynaMed, Associate Editor for the Journal of Asthma; and delegate to the National Quality Forum representing the AAAAI. Desiree E. S. Larenas-Linnemann has received financial support from AstraZeneca, Mylan, GlaxoSmithKline, Sanofi, Novartis, DBV Technologies, SUMA/Circassia, and Thermo Fisher Scientific; is a board member of the Colegio Mexicano de Inmunologia Clinica y Alergia, member of Immunotherapy Committee of the AAAAI, chair of Information Technology Interest Group and Task Force of European Academy of Allergy and Clinical Immunology (EAACI), and Chair of International Committee for the Latin portfolio of the ACAAI. Jay A. Lieberman has received financial support from the ACAAI, Aquestive, Aimmune, DBV Technologies, Biotest Pharma, and Regerneron; is Associate Editor of the Annals of Allergy, Asthma, and Immunology, vice chair for the ACAAI Food Allergy Committee, and medical director for Food Allergy Alliance of the MidSouth. Eli O. Meltzer has received support from Boehringer-Ingelheim, GlaxoSmithKline, Glenmark, GossamerBio, Merck, Mylan, Optinose, ALK-Abelló, AstraZeneca, and Regeneron/Sanofi. John J. Oppenheimer has received financial support from DBV Technologies, TEVA, GlaxoSmithKline adjudication/data safety monitoring board, AstraZeneca, Novartis, and Sanofi; is Associate Editor of the Annals of Allergy, Asthma, and Immunology and AllergyWatch, an American Board of Internal Medicine Council Member and American Board of Allergy and Immunology Liaison to the American Board of Internal Medicine, UpToDate reviewer, American College of Chest Physicians Cough Guideline Committee Member, and WebMD Editor. Matthew A. Rank has received financial support from the ACAAI, National Institutes of Health, and Levin Family Foundation; has served as chair of the AAAAI Health Care Outcomes, Education Delivery and Quality Interest Section; and is research director of the Phoenix Children’s Hospital Breathmobile. Marcus S. Shaker has received financial support from the Eastern Allergy Conference; and has a family member who is the chief executive officer of Altrix Medical. Jeffrey L. Shaw is a committee member for the Rhinitis, Sinusitis, and Ocular Committee of ACAAI. Gary C. Steven has received financial support from 3M, AstraZeneca, Attenua, Chiesi, Cipla, Glenmark5, GlaxoSmithKline, Lupin, Menlo, Merck, Novartis, Pearl, Sanofi, TEVA, Stallergenes, NeRRe, Watson, Westward, Aimmune, ALK-Abelló, Regeneron, American Academy of Neurology, Boehringer, and Optinose. David R. Stukus has received financial support from Aimmune, Before Brands, Abbott Nutrition, the American Academy of Pediatrics, and ACAAI; has served as committee chair for AAAAI and ACAAI. Julie Wang has received financial support from ALK-Abelló, Regeneron, DBV Technologies, and Aimmune; is an UpToDate author; serves on the executive committee of the American Academy of Pediatrics Section on Allergy and Immunology; and serves as vice chair of the AAAAI Anaphylaxis, Dermatitis, Drug Allergy Interest Section.
	Reprints: Joint Task Force on Practice Parameters Liaison: Rebecca Brandt (American Academy of Allergy, Asthma, and Immunology, 555 E. Wells Street, Suite 1100, Milwaukee, WI 53202. E-mail: rbrandt@aaaai.org); JTFPP.allergy@gmail.com.
	Previously published practice parameters and guidelines of the JTFPP are available at www.allergyparameters.org. www.AAAAI.org, and www.ACAAI.org.
	Resolving conflict of interest: The JTFPP is committed to ensuring that all guidelines are based on the best scientific evidence at the time of publication, and that such evidence is free of commercial bias to the greatest extent possible. Before confirming the selection of the work group chairperson and members, the JTFPP discusses and resolves all relevant potential conflicts of interest (COIs) of each work group member. The JTFPP recognizes that experts in a field are likely to have interests that could come into conflict with the development of a completely unbiased and objective guideline. Therefore, a process has been developed to acknowledge potential COIs when making specific recommendations. To preserve the greatest transparency regarding potential COIs, all members of the JTFPP and work group complete a COI form prior to the development of each document and again prior to the guideline submission for publication.
	During the review process there are additional measures to avoid bias. At the work group level, all the recommendations and discussion sections are reviewed by all work group members to ensure that content is appropriate and without apparent bias. If any recommendation or section is deemed to have apparent bias, it is appropriately revised, without the section author’s involvement, in an attempt to remove potential bias. In addition, the entire document is also reviewed by the JTFPP and any apparent bias is acknowledged and removed at that level. For each and every recommendation, a vote is required by the work group and JTFPP, and any member with any perceived COI is recused from that vote (and so explained in the document). Any dissenting votes that cannot be resolved are described and explained in the document.
	In a final stage of review, the practice parameter is sent to invited expert reviewers for review, selected by the AAAAI and the ACAAI. The document is also posted on the AAAAI and ACAAI websites for general membership and the public-at-large to review and offer comment. All reviewers must provide statements of potential COIs. Although the JTFPP has the final responsibility for the content of the documents submitted for publication, each reviewer’s comments will be discussed and reviewers will receive written responses to comments when appropriate.
	The JTFPP members’ and work group members’ COI disclosure forms can be found at www.allergyparameters.org.
	Disclaimer: The AAAAI and the ACAAI have jointly accepted responsibility for developing “Rhinitis 2020: a practice parameter update.” The medical environment is rapidly changing, and not all recommendations will be appropriate or applicable to all patients and may change over time. Because this document incorporates the efforts of many participants, no single individual, including members serving on the JTFPP, is authorized to provide an official AAAAI or ACAAI interpretation of this guideline. Any request for information or interpretation of this practice parameter by the AAAAI or ACAAI should be directed to the executive offices of the AAAAI and the ACAAI. Practice parameters and guidelines are not designed for use by the pharmaceutical industry in drug development or promotion. The JTFPP understands that the cost of diagnostic tests and therapeutic interventions is an important concern that may appropriately influence the evaluation and treatment selected for a given patient. The JTFPP recognizes that the emphasis of our primary recommendations regarding a medication may vary, for example, depending on third-party payer issues and product patent expiration dates. However, because a given test or a therapeutic intervention’s cost is so widely variable, and there is a relative paucity of pharmacoeconomic data, the JTFPP is not always able to consider cost when formulating recommendations. In extraordinary circumstances, when the cost benefit of an intervention is prohibitive as supported by pharmacoeconomic data, commentary may be provided.
	Contributors: The JTFPP has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the JTFPP will ensure that appropriate recognition is provided.

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