Seasonal Allergic Rhinitis Treatment Guidelines Updated

The guidelines focus on three key clinical statements.

The American College of Allergy, Asthma, and Immunology (ACAAI) has issued updated guidelines on the treatment of seasonal allergic rhinitis (SAR). The guidelines have been published in the journal Annals of Allergy, Asthma and Immunology.

“The Joint Task Force on Practice Parameters (JTFPP) formed a workgroup to develop a focused, systematic review to provide guidance to health care providers for the treatment of seasonal allergic rhinitis in patients over the age of 12,” said allergist Dana Wallace, MD, past ACAAI president and co-author of the guideline.

The main objective of the updated guideline was to highlight opportunities for improvement in the management of allergic rhinitis. As such, the Task Force selected three questions for systematic review. These included the following:


Is there any clinical benefit of using a combination of oral antihistamine + intranasal corticosteroid versus intranasal corticosteroid monotherapy for initial treatment of moderate to severe SAR in patient ≥12yrs old?


Clinicians should routinely prescribe intranasal corticosteroid monotherapy rather than the combination. Based on the studies analyzed, there was no statistically significant superiority for the combination for any of the outcomes. (Strength: Strong).


How does montelukast compare with an intranasal corticosteroid in terms of clinical benefit for the initial treatment of moderate to severe SAR in patients ≥15yrs old?


Clinicians should recommend an intranasal corticosteroid over a leukotriene receptor antagonist for patients ≥15yrs old. Based on the studies analyzed, intranasal corticosteroids have a greater clinical benefit over montelukast with regard to nasal symptom reduction. (Strength: Strong).


Is there any clinical benefit to using an intranasal corticosteroid + an intranasal antihistamine compared with monotherapy with either drug for the initial management of moderate to severe SAR in patients ≥12yrs old?


For patients with moderate to severe symptoms, the combination of intranasal corticosteroid + intranasal antihistamine may be recommended. Based on the studies analyzed, there was a statistically significant clinical benefit with regard to total nasal symptom reduction when using the combination but with potentially increased adverse events (Strength: Weak).

“There is a strong message in the guidelines promoting the importance of shared decision-making with patients,” said St. Louis University allergist Mark Dykewicz, MD, ACAAI member and lead author of the guidelines. “The guideline encourages physicians to make patients aware that taking two medications, e.g., using a combination of drugs, such as an oral antihistamine and [intranasal corticosteroid], is not always better than using a single drug such as an [intranasal corticosteroid].” 

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The updated guidelines do not provide specific recommendations on oral antihistamine monotherapy as initial treatment or about perennial allergic rhinitis or mild SAR, though the Task Force does include a table of questions regarding unmet needs for allergic rhinitis drug therapy and whether current evidence would likely be able to answer them.

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