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Rhinitis Indication Review Update 2024

This document serves as an addendum to the CHI Original Rhinitis Clinical Guidance, updating clinical practice guidelines and drug therapies for allergic rhinitis as of January 2024. It summarizes the latest evidence and recommendations from various international guidelines, highlighting the management strategies for allergic rhinitis, including environmental control, pharmacologic management, and immunotherapy. The report also notes changes in the CHI formulary, including the removal of certain drugs and the lack of new registered drugs by the SFDA.

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Rhinitis Indication Review Update 2024

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RHINITIS

CHI Formulary Indication Review

INDICATION UPDATE

ADDENDUM- January 2024

To the CHI Original Rhinitis Clinical

Guidance- Issued January 2020

1|Page
Contents

CBS: We recommend that when

A practice parameter
choosing monotherapy for persistent
Strong, High update, [2020]
AR, INCS be the preferred medication.

CBS: We suggest that the use of

intranasal decongestants to be short A practice parameter
Conditional, Low
term and used for intermittent or update, [2020]
episodic therapy of nasal congestion.
CBS: We recommend that oral
A practice parameter
decongestants to be avoided during Strong, Low
update, [2020]
the first trimester of pregnancy.
CBS: We suggest that intranasal
cromolyn to be offered as an option
Conditional, Very A practice parameter
to be taken just prior to allergen
low update, [2020]
exposure to reduce symptoms of AR
from episodic allergen exposures.
GRADE: We suggest that the clinician
consider the combination of an INCS
A practice parameter
and an INAH for the initial treatment Conditional, High
update, [2020]
of moderate/severe nasal symptoms
of SAR in patients ≥12 y old.
CBS: We suggest that for patients
taking an INCS who have persistent
Conditional, A practice parameter
rhinorrhea, the clinician may consider
Moderate update, [2020]
the addition of intranasal
ipratropium.
CBS: We suggest that for patients
with AR and nasal congestion
uncontrolled with an oral Conditional, A practice parameter
antihistamine, the clinician consider Moderate update, [2020]
the addition of pseudoephedrine,
when tolerated.

12 | P a g e
CBS: We suggest that AIT
(subcutaneous or sublingual tablets)
Conditional, A practice parameter
to be considered for patients with
Moderate update, [2020]
controlled mild/moderate asthma
with coexisting AR.
Acupuncture. CBS: We cannot make
a recommendation for or against the A practice parameter
N/A, Very low
use of acupuncture for the treatment update, [2020]
of AR.

At the end of the report, a key recommendation synthesis section is added

highlighting the latest updates in the clinical and therapeutic management of
rhinitis.

Section 1.0 Summary of Reviewed Clinical Guidelines &

Evidence

This section is divided into two parts: the first includes recommendations from
updated versions of guidelines mentioned in the previous CHI Rhinitis report, and
the second includes newly added guidelines that have helped generate this report.

1.1 Revised Guidelines

This section contains the updated versions of the guidelines mentioned in the
January 2020 CHI Rhinitis Report and the corresponding recommendations:

Table 2. Guidelines Requiring Revision

Guidelines Requiring Revision

Old Versions Updated versions
Section 1.1 American Academy of
Otolaryngology—Head and Neck
N/A*
Surgery Clinical Practice Guideline:
Allergic Rhinitis [2015}
Section 1.2 International Consensus Section 1.1.1. International Consensus
Statement on Allergy and Rhinology: Statement on Allergy and Rhinology:
Allergic Rhinitis [2018] Allergic Rhinitis [2023]5
Section 1.3 British Society of Allergy and
N/A*
Clinical Immunology (BSACI) Guideline

13 | P a g e
for the Diagnosis and Management of
Allergic and Non-Allergic Rhinitis
(Revised Edition 2017; First edition 2007)
Section 1.4 Pediatric Rhinitis: Position
Paper of the European Academy of N/A*
Allergy and Clinical Immunology [2013]

*: No updated versions available

1.1.1 International Consensus Statement on Allergy and Rhinology: Allergic

Rhinitis [2023]

Please refer to Section 1.2 of CHI Rhinitis original clinical guidance.

In the 5 years that have passed since the publication of the 2018 International
Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic
Rhinitis 2018), the literature has expanded substantially. ICAR-Allergic Rhinitis 2023 is
not intended to be a clinical practice guideline, meta-analysis, or expert panel report.
The ICAR authors have carefully reviewed all relevant literature and determined the
strength of the available evidence. Based upon this evidence, where applicable,
recommendations are made for various diagnostic and treatment options in the
realm of AR5. ICAR-Allergic Rhinitis 2023 employed established evidence-based
review with recommendation (EBRR) methodology to individually evaluate each
topic, based on the work of Rudmik and Smith (table 3)6.

Table 3. American Academy of Pediatrics (AAP) Defined Strategy for

Recommendation Development

Level of
Diagnosis Therapy/Prevention/Etiology
Evidence
Systematic review of cross-
sectional studies with consistently Systematic review of randomized
1
applied reference standard and trials or n-of-1 trials
blinding
Individual cross-sectional studies Randomized trial or observational
2 with consistently applied study with dramatic
reference standard and blinding effect
Cohort study or control arm of Non-randomized controlled
3
randomized trial cohort/follow-up study
Case-series or case control Case-series, case-control studies,
4
studies, or poor quality or historically controlled studies*

14 | P a g e
prognostic cohort study
5 Not applicable Mechanism-based reasoning
*Level may be graded down on the basis of study design, inconsistency between
studies, indirectness of evidence, imprecision, or because the absolute effect size is
very small; level may be graded up if there is a large or very large effect size or if a
significant dose-response relationship is demonstrated. **As always, a systematic
review is generally better than an individual study
Aggregate grade of evidence
Grade Research Quality
A Well-designed RCTs
RCTs with minor limitations Overwhelming consistent evidence from
B
observational studies
C Observational studies (case control and cohort design)
D Expert opinion Case reports Reasoning from first principle
AAP (American Academy of Pediatrics) defined strategy for recommendation
development

Preponderance of Balance of Benefit Preponderance of

Evidence Quality
Benefit over Harm and Harm Harm over Benefit

Strong
A. Well-designed Strong
Recommendation
RCT’s recommendation
Against

B. RCT’s with minor

limitations;
Overwhelmingly
consistent evidence Option
from observational Recommendation
studies Recommendation
Against
C. Observational
studies (case
control and cohort
design)
D. Expert opinion,
Case reports, No Recommendation
Option
Reasoning from Recommendation Against
first principles

15 | P a g e
Evaluation and Diagnosis
History and physical examination
• Despite low level evidence specifically addressing this area, history is essential
in the diagnosis of AR. Policy level: Recommendation.
• When possible, physical examination should be performed with appropriate
personal protective equipment to aid in the diagnosis of AR and exclusion of
other conditions. When combined with patient history, it increases diagnostic
accuracy and may exclude alternative causes of symptoms. Policy level:
Recommendation.
• Nasal endoscopy: Nasal endoscopy may be considered as a diagnostic
adjunct in the evaluation of patients with suspected AR. Policy level: Option.
• Radiologic studies: Routine use of imaging is not recommended for the
diagnosis of AR. Policy level: Recommendation against.
• Skin testing: Regular use of the same SPT device type will allow clinicians to
familiarize themselves with it and interpretation of results may therefore be
more consistent. The use of standardized allergen extracts can further
improve consistency of interpretation. Policy level: Recommendation.
• Serum IgE: Intervention: Assessment of tIgE may be useful to assess overall
atopic status; furthermore, in selected cases it might help guide therapy (i.e.,
monitor efficacy of AIT). Policy level: Option
• Nasal provocation testing: Measurement of nasal sIgE is an option in
patients with non-allergic rhinitis suspected of having LAR to support this
diagnosis and guide AIT if pharmacologic therapies are inadequate. A
consensus for levels of nasal sIgE indicating AR needs to be established. Policy
level: Option
Diagnostic modalities for evaluation of allergic rhinitis
Use of validated survey instruments: Validated surveys may be used to screen for
AR, follow treatment outcomes and as a primary outcome measure for clinical trials.
Specific tests are optimized for various clinicopathological scenarios. Policy level:
Recommendation.
Component resolved diagnostic testing: Component resolved diagnostic testing is
an option for diagnosis of AR by specialists. Policy level: Option
Nasal provocation testing: Application of nasal provocation testing is useful in local
AR and to confirm occupational rhinitis. Policy level: Option for diagnosis of AR when
skin or in vitro tests are equivocal or unreliable. Recommendation for diagnosis of
local AR and occupational rhinitis

16 | P a g e
Nasal cytology: Nasal cytology could help in cases of non-allergic rhinitis to suspect
local AR or in cases of AR to diagnose a mixed rhinitis. It could be considered an
option in cases of negative SPT and/or serum sIgE to evaluate the presence of
mucosal eosinophils and consideration of local AR or type 2 inflammation. The cut-
off values for determining non-allergic rhinitis with eosinophilia syndrome (NARES)
are not yet clear. Policy level: Option
Nasal histology: Nasal histology may be helpful in clinical research or selected cases
(e.g., evaluation of tissue eosinophils during surgery). Recommendation against
routine clinical practice for AR evaluation due to invasive nature of obtaining a
specimen. Policy level: Recommendation against
Rhinomanometry: Rhinomanometry is useful in distinguishing between structural
and soft tissue causes of obstruction, when history and examination findings are not
congruent, as well as a research tool. Better with individual nasal cavity assessment
and four-phase rhinomanometry. Policy level: Option
Acoustic rhinometry: Acoustic rhinometry is most useful in research setting as
opposed to as a clinical diagnostic tool. Policy level: Option.
Peak nasal inspiratory flow: Use in conjunction with patient reported outcome
measures to improve utility. Policy level: Option.
Fractional exhaled nitric oxide (FeNO), Nasal nitric oxide (nNO): History and
physical, diagnostic skin testing, or sIgE testing should be the first-line evaluation of
AR. FeNO or nasal NO testing may provide additional diagnostic information if
necessary but should not be routinely employed for AR diagnosis. Policy level: FeNO:
Recommend against for routine diagnosis of AR. nNO: Recommend against for
routine diagnosis of AR.

Pharmacotherapy and procedural options

➢ Pharmacologic treatments are frequently employed to control AR symptoms.
Depending on the specific therapy and geographic region, these may be
available by prescription or over the counter. The evidence for pharmacologic
options for AR has been reviewed.
Oral H1 antihistamines: Newer-generation oral antihistamines can be considered in
the treatment of AR. Policy level: Strong recommendation for the use of newer-
generation oral antihistamines for AR.
Intranasal antihistamines: Intranasal antihistamines may be used as first- or
second-line therapy in the treatment of AR. Policy level: Strong recommendation.
Oral corticosteroids: Although not recommended for routine use in AR, certain
clinical scenarios may warrant the use of short courses of systemic corticosteroids,
following a discussion of the risks and benefits with the patient. For example, oral

17 | P a g e
steroids could be considered in selecting patients with significant nasal obstruction
that precludes adequate penetration of intranasal agents (corticosteroids or
antihistamines). In these cases, a short course of systemic corticosteroids may
improve congestion and facilitate access of topical medications. No evidence
supports this suggestion, and thus careful clinical judgment and risk discussion are
advocated. Policy level: Strong recommendation against routine use.
Intranasal corticosteroids: non-traditional application: No evidence for non-
traditional application of intranasal steroids for AR. Policy level: Recommendation
against.
Intranasal saline: Nasal saline is strongly recommended as part of the treatment
strategy for AR. Policy level: Strong recommendation.
Oral decongestants: Although not recommended for routine use in AR,
pseudoephedrine can be effective in reducing nasal congestion in patients with AR;
however, it should only be used as short-term/rescue therapy after a discussion of
the risks and benefits with the patient (comorbidities) and consideration of
alternative intranasal therapy options. Policy level: Strong recommendation against
routine use in AR. In certain cases, combination therapy with an oral antihistamine
may be beneficial to alleviate severe nasal congestion in short courses.
Intranasal cromolyn: DSCG (Disodium cromoglycate) may be used as a second-line
treatment for AR in patients who fail INCS or intranasal antihistamines, or for short-
term preventative benefit prior to allergen exposures. Policy level: Recommendation
as a second-line treatment in AR.
Biologic therapies: Monoclonal antibody (Biologic) therapies are not currently
approved for the treatment of AR. Policy level: Option based upon published
evidence, although not currently approved for this indication.
Combination oral antihistamine and intranasal corticosteroid: Current evidence is
mixed to support antihistamines as an additive therapy to INCS, as several
randomized trials have not demonstrated a benefit over INCS alone for symptoms of
AR. Policy level: Option.
Combination oral antihistamine and leukotriene receptor antagonist:
Combination LTRA and oral antihistamines should not be used as first line therapy
for AR but can be considered in patients with contraindications to other alternatives.
This combination should be used judiciously after carefully weighing potential risks
and benefits. Policy level: Recommendation against first line therapy.
Combination intranasal corticosteroid and leukotriene receptor antagonist
(LTRA): Consider use in patients with AR and asthma, after weighing therapeutic
benefits against risks of mental health adverse effects. Policy level: Option as
combination therapy if comorbid asthma is present and mental health risks are
considered. Not recommended for AR alone.
18 | P a g e
Combination intranasal corticosteroid (INCS) and intranasal decongestant: Short-
term combination therapy with INCS and intranasal decongestant may be
considered in patients with AR refractory to combination therapy with INCS and
intranasal antihistamine prior to consideration of inferior turbinate reduction or in
patients declining surgery. Policy level: Option
Combination intranasal corticosteroid and intranasal ipratropium bromide:
Combining IPB with beclomethasone dipropionate can be more effective than
either agent alone for the treatment of rhinorrhea in refractory AR in children and
adults. Although multiple consensus guidelines have recommended, and there is
evidence to support this recommendation, it is important to note that there has only
been one randomized controlled trial (RCT) to study the efficacy of combined INCS
and IPB therapy compared to either agent alone, and this study was performed in a
combined population of patients with AR and non-allergic rhinitis. Policy level:
Option.

Allergen immunotherapy for the treatment of allergic rhinitis:

Conventional subcutaneous immunotherapy (SCIT): SCIT is an appropriate
treatment consideration for patients who have not obtained adequate relief with
symptomatic therapy or who prefer this therapy as a primary management option,
require prolonged weeks of treatment during the year, and/or wish to start
treatment for the benefit of the potential secondary disease modifying effects of
SCIT. Policy level: Strong recommendation for SCIT as a patient preference-sensitive
option for the treatment of AR. Strong recommendation for SCIT over no therapy for
the treatment of AR. Option for SCIT over sublingual immunotherapy (SLIT) for the
treatment of AR.
Rush subcutaneous immunotherapy: Aeroallergen rush SCIT is an option for AR in
appropriately selected patients that do not have adequate control of their symptoms
with symptomatic therapies. If available at practice location, the use of
depigmented-polymerized allergen extracts for rush SCIT has a better safety profile
compared with standard extracts. Policy level: Option
Cluster subcutaneous immunotherapy: Cluster SCIT can be safely implemented in
clinical practice and offered to those patients eligible for SCIT that may prefer this.
Policy level: Option
Sublingual immunotherapy (SLIT): general considerations: Recommend tablet or
aqueous SLIT in patients (adults and children) with seasonal and/or perennial AR
who wish to reduce their symptoms and medication use, as well as possibly reduce
the propensity to develop asthma or new allergen sensitizations. Policy level: Strong
recommendation for the use of SLIT grass pollen tablet, ragweed tablet, HDM tablet,
and tree pollen aqueous solution. Recommendation for SLIT for Alternaria allergy.

19 | P a g e
Option for SLIT for animal allergy. Recommendation for dual-therapy SLIT in bi-
allergic patients.
Sublingual immunotherapy tablets: SLIT tablets are recommended for patients
with severe or refractory AR. Epinephrine auto-injector is recommended in the FDA
labeling for approved tablets due to the rare but serious risk of anaphylaxis. Tablets
for selecting antigens are available in various countries. Policy level: Strong
recommendation.
Aqueous sublingual immunotherapy: High-dose aqueous SLIT is recommended
for those patients who wish to reduce their symptoms and rescue medication use.
Policy level: Recommendation.
Epicutaneous/transcutaneous immunotherapy: While epicutaneous AIT may
potentially have a future clinical application in the treatment of AR, at this juncture
there are limited studies that show variable and limited effectiveness, and a
significant rate of adverse reactions. Given the above and the availability of
alternative treatments, epicutaneous AIT is not recommended at this time. Policy
level: Recommendation against
Intralymphatic immunotherapy: More studies are essential to establish the long-
term effects of ILIT. Policy level: Option
Combination subcutaneous immunotherapy and biologics: Current evidence
supports that anti-IgE may be beneficial as a premedication prior to induction of
cluster or rush SCIT protocols, and combination therapy may be advantageous as an
option for carefully selected patients with persistent symptomatic AR following AIT.
However, at the time of this writing, biologic therapies are not approved by the US
FDA for AR alone. An individualized approach to patient management must be
considered. Policy level: Option.

1.2 Additional Guidelines

This part includes the added guidelines to the previous CHI Rhinitis report, along
with their recommendations.

Table 4. List of Additional Guidelines

Additional Guidelines
Section 1.2.1 Saudi guidelines on Allergic Rhinitis in Asthma [2014]7
Section 1.2.2 Japanese guidelines for allergic rhinitis [2020]8
Section 1.2.3 ASCIA: Australasian Society of Clinical Immunology and Allergy,
Allergic Rhinitis Clinical Update [2022]9

20 | P a g e
Section 1.2.4 Ashford and St. Peter’s Hospitals NHS Foundation Trust Pediatric
Allergic Rhinitis guidelines [2023]10
Section 1.2.5 Current treatment options for allergic rhinitis: a review [2023]11
Section 1.2.6 Rhinitis [2020]: A practice parameter update12

1.2.1 Saudi Clinical Practice Guideline on Allergic Rhinitis in Asthma [2014]

The Ministry of Health (MoH) of Saudi Arabia with the methodological support of the
McMaster University working group produced clinical practice guidelines to assist
health care providers in evidence-based clinical decision-making. This guideline
evaluates the role of inhaled corticosteroids, inhaled antihistamines, and sublingual
immunotherapy in the management of allergic rhinitis in this population7.
The guideline working group developed and graded the recommendations and
assessed the quality of the supporting evidence according to the GRADE approach.
Quality of evidence (confidence in the available estimates of treatment effects) is
categorized as: high, moderate, low, or very low based on consideration of risk of
bias, directness, consistency, and precision of the estimates. The strength of
recommendations is expressed as either strong (‘guideline panel recommends…’) or
conditional (‘guideline panel suggests…’) and has explicit implications (table 5).

Table 5. Interpretation of Strong and Conditional (Weak) Recommendations

Conditional (weak)
Implications Strong recommendation
recommendation
Most individuals in this situation
would want the recommended
course of action and only a small The majority of individuals in this
proportion would not. Formal situation would want the
For patients
decision aids are not likely to be suggested course of action, but
needed to help individuals make many would not
decisions consistent with their
values and preferences.
Recognize that different choices
Most individuals should receive will be appropriate for individual
intervention. Adherence to this patients and that you must help
For recommendation according to each patient arrive at a
clinicians the guideline could be used as a management decision
quality criterion or performance consistent with his or her values
indicator. and preferences. Decision aids
may be useful helping

21 | P a g e
individuals making decisions
consistent with their values and
preferences
Policy making will require
The recommendation can be
For policy substantial debate and
adapted as policy in most
makers involvement of various
situations
stakeholders.
Quality of evidence is classified as “high”, “moderate”, “low”, or “very low”
based on decisions about methodological characteristics of the available
evidence for a specific health care problem.
High Moderate Low Very low
We are moderately
confident in the Our confidence in We have very little
We are very effect estimate: the effect estimate confidence in the
confident that the The true effect is is limited: The true effect estimate:
true effect lies likely to be close to effect may be The true effect is
close to that of the the estimate of the substantially likely to be
estimate of the effect, but there is different from the substantially
effect. a possibility that it estimate of the different from the
is substantially effect. estimate of effect
different.

The Saudi guidelines’ recommendations are assigned the class of recommendations

defined in the preceding table:
• The KSA MoH panel recommends intranasal corticosteroids for treatment of
adults with seasonal or intermittent allergic rhinitis (Strong recommendation;
Moderate-quality evidence).
• The KSA MoH panel suggests intranasal corticosteroids for treatment of adults
with perennial or persistent allergic rhinitis (Conditional recommendation;
Low-quality evidence).
• The KSA MoH panel recommends intranasal corticosteroids rather than
intranasal H1- antihistamines for treatment of adults with seasonal or
intermittent allergic rhinitis (Strong recommendation; High-quality evidence).
• The KSA MoH panel suggests intranasal corticosteroids rather than intranasal
H1- antihistamines for treatment of adults with perennial or persistent allergic
rhinitis (Conditional recommendation; Very low-quality evidence).

22 | P a g e
• The KSA MoH panel suggests sublingual immunotherapy for treatment of
adults with seasonal or intermittent allergic rhinitis (conditional
recommendation; Moderate-quality evidence).
• The KSA MoH panel suggests sublingual immunotherapy for treatment of
adults with perennial/persistent allergic rhinitis (conditional recommendation;
very low-quality evidence).
• The KSA MoH panel suggests sublingual immunotherapy for treatment of
children younger than 18 years old with seasonal or intermittent allergic
rhinitis (Conditional recommendation; Moderate-quality evidence).
• The KSA MoH panel suggests sublingual immunotherapy be not used for
treatment of children younger than 18 years old with perennial or persistent
allergic rhinitis (Conditional recommendation; very low-quality evidence

1.2.2 Japanese Society of Allergology Guidelines for Allergic Rhinitis [2020]

The revised guideline published in 2020 by the Japanese Society of Allergology

includes assessment of diagnosis/treatment and prescriptions for children and
pregnant women, for broad clinical applications. An evidence-based step-by-step
strategy for treatment is also described. No grades of recommendations were
outlined8.
• The aim of treatment is to alleviate symptoms and remove difficulties with
everyday life. Choose a treatment based on severity, disease type, and lifestyle.
1. Natural courses and communication with patients: Combinations of
pharmacotherapies based on severity and disease types and
communication with patients improve patients' satisfaction and QOL.
2. Elimination and avoidance of antigens: In addition to cleaning,
lowering humidity with dehumidifier is effective in reducing mites. For
Japanese cedar pollinosis, refer to pollen dispersal information to
consider measures to prevent pollen inhalation. For pet allergies, avoid
contact with causative pets and keep dogs and cats clean.
3. Pharmacotherapy: Therapeutic agents for allergic rhinitis, with
different mechanisms of action, are classified as shown in the following
(figure 1). Alpha-sympathomimetics (vasoconstrictor nose drops), which
temporarily alleviate nasal blockage, are also used.

23 | P a g e
Table 6. Therapeutic Agents for Allergic Rhinitis. Adapted from the Japanese Society
of Allergology 2020 Guideline.

Mast cell stabilizer

Disodium cromoglycate, tranilast, amlexanox, pemirolast potassium
Chemical mediator receptor antagonists
d-chlorpheniramine maleate,
1st generation
clemastine fumarate
Ketotifen fumarate, azelastine
hydrochloride, oxatomide,
mequitazine, emedastine
Histamine H1 receptor difumarate, epinastine
antagonists hydrochloride, ebastine, cetirizine
(antihistamine) 2nd generation hydrochloride, levocabastine
hydrochloride, bepotastine
besilate, fexofenadine
hydrochloride, olopatadine
hydrochloride, loratadine,
fexofenadine & pseudoephedrine
Leukotriene receptor
Pranlukast hydrate, montelukast sodium
antagonists
Prostaglandin
D2/thromboxane A2
receptor antagonists
Ramatroban
(anti-prostaglandin
D2/thromboxane A2
agents)
Th2 cytokine inhibitor
Suplatast tosilate
Steroids
Beclomethasone propionate, fluticasone propionate,
Nasal mometasone furoate hydrate, dexamethasone
cipecilate capsule for external use
Compounding agent of betamethasone/d-
Oral
chlorpheniramine maleate
Others
Nonspecific thallassotherapy agents, biological preparations, and herbal
medicines

24 | P a g e
Mast cell stabilizers
Since the development of disodium cromoglicate (DSCG), local agents (eye drops
and nasal spray) and oral agents, such as tranilast, amlexanox, and pemirolast
potassium, have been on the market. They have mild effects. To achieve sufficient
clinical effects, 2-week prolonged administration is required. Amelioration rates are
increased by continuous administration. Adverse effects, such as sleepiness and dry
mouth, do not occur.

Chemical mediator receptor antagonists

Histamine H1 receptor antagonists (antihistamines)
• First-generation antihistamine: First-generation antihistamine often causes
adverse effects, such as sleepiness, impaired performance, and dry mouth, but
have immediate effects on sneezing and watery rhinorrhea. First-generation
antihistamines are contraindicated for patients with glaucoma, prostatic
hyperplasia, and asthma because of their potent anticholinergic effects. They
have less central nervous system depressant actions in children than in adults.
Caution should be exercised for excitatory effects, such as convulsions. Most
first-generation antihistamine are marketed as OTC.
• Second-generation antihistamine: Second-generation antihistamine, such as
ketotifen fumarate, oxatomide, azelastine hydrochloride, emedastine
difumarate, and mequitazine, are effective to some extent for nasal blockage
aside from sneezing and watery rhinorrhea. However, they may cause adverse
effects, such as sleepiness and impaired performance, in early versions. Thus,
caution should be exercised in administering them. The adverse effects of late
versions, such as epinastine hydrochloride, ebastine, cetiridine, fexofenadine,
loratadine, olopatadine hydrochloride, bepotastine besilate, and levocetirizine,
have been reduced. Priority indications are mild to moderate sneezing and
rhinorrhea type. Combine them with topical steroids depending on severity. A
combination drug containing an antihistamine (fexofenadine) and an oral
decongestant (pseudoephedrine) is now available. However, the priority
indication for this combination drug is limited to the moderate to severe nasal
blockage type of pollinosis and the severe nasal blockage type of perennial
allergic rhinitis.

Leukotriene receptor antagonists (antileukotrienes)

Peptide leukotrienes, produced and released by mast cells, eosinophils, and
macrophages, have potent relaxing effects on the vascular smooth muscles of the
nasal mucosa, enhancing effects on vascular permeability, and stimulating effects
on eosinophil migration. Pranlukast and montelukast are available. They are
effective for nasal blockage. Their effects are increased by prolonged administration.

25 | P a g e
Comparable effects with those of antihistamines can be achieved for sneezing and
rhinorrhea within 4 weeks. Primary indications are treatment of symptoms of the
moderate or milder nasal blockage type and those of intermediate type with nasal
blockage as the chief complaint. No adverse effects of sleepiness occur.

Prostaglandin D2 and thromboxane A2 receptor antagonist

Ramatroban enhances vascular permeability in the nasal mucosa and suppresses
eosinophil migration by blocking thromboxane receptors and suppresses eosinophil
migration by blocking CRTh2 (chemoattractant receptor-homologous receptor
expressed on Th2 cell), a part of the prostaglandin D2 receptor. They have strong
delayed effects on nasal blockage. Primary indications are treatment of symptoms of
nasal blockage type and those of combined type with nasal blockage as a chief
complaint. The agents interact with some other medicines but cause no adverse
effects of sleepiness.

Th2 cytokine inhibitors

IPD inhibits the production of Th2 cytokines, such as IL-4 and IL-5, in T lymphocytes
to alleviate allergic inflammation. No adverse effects of sleepiness occur.

Steroids
• Nasal steroids: Beclomethasone propionate, fluticasone propionate,
mometasone furoate, fluticasone furoate, and dexamethasone cipecilate
are available. All agents have strong local effects in small amounts and are
poorly absorbed and readily degraded. Thus, they have few systemic adverse
effects. They are highly effective for sneezing, watery rhinorrhea, and nasal
mucosal swelling, and exert their effects within 1e3 days. A slight feeling of
nasal irritation, feeling of dryness, and epistaxis may occur.
• Steroids for internal use: Only for intractable cases with severe nasal blockage
and laryngopharynx symptoms, uncontrollable with nasal spray steroids,
prednisolone (20-40 mg/day) can be administered for 4-7 days at the start of
treatment. Caution should be exercised for adverse effects.

Alpha-sympathomimetics (nasal topical vasoconstrictor [decongestant])

Alpha-sympathomimetics act on the a-receptors of vascular smooth muscles to
cause vasoconstriction and temporarily alleviate nasal mucosal swelling. Long-term
continuous administration causes medicament rhinitis. For the most severe
pollinosis, they can be administered 2-3 times a day for 1-2 weeks.

26 | P a g e
Other pharmacotherapeutic agents
Nonspecific thalassotherapy agents, biological preparation, and herbal medicines
can be used.
Adverse effects and drug interactions of therapeutic agents for allergic rhinitis.
Therapeutic agents for allergic rhinitis are those for symptomatic treatment, used to
alleviate symptoms. Caution should be exercised for harmful adverse effects and
drug interactions during treatment. If they occur, take immediate measures and
switch to a different treatment.

Specific immunotherapy
Subcutaneous specific immunotherapy (SCIT) has been used over the past century.
Its demonstrated effects may be exerted via immunological mechanisms. Of note,
local mast cells are decreased, the Th1/Th2 balance is altered, and regulatory T cells
are increased. It takes several months to develop effects, requiring routine injection
for ≥3 years. Furthermore, a systemic anaphylaxis response may develop in a small
number of cases.
Indications: This therapy is indicated for the treatment of patients aged 6 years,
without severe systemic symptoms, to whom emergency adrenaline may be
administered. Exclude patients on b-blocker therapy or with severe asthma. While
this therapy has no harmful effects on pregnant women, it should not be started
during pregnancy.
Implementation:
• Specialists should prescribe antigen extracts and take measures against
systemic reactions, such as anaphylactic shock.
• In patients with asthma complications, avoid this therapy during a paroxysmal
period. In patients with pollinosis, avoid starting this therapy during dispersal
of causative pollen.
• For initial injection, reduce the threshold concentration for intradermal
reaction to 1/10. Before injection, ask more than one physician or health care
professional about concentration and dosage.
• Before increasing an aqueous solution, concentration or changing lots,
conduct an intradermal test. For patients with erythema of ≥50 mm diameter,
carefully conduct the test and follow-up the patients for 20-30 min after
injection.
• Perform therapy for at least 3 years. Therapeutic effects often continue for
several years after discontinuation of administration.
• Instruct patients to continue the therapy.

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Sublingual immunotherapy (SLIT):
Presently, SLIT is permitted in Japan for reactions to the allergens, Japanese cedar
pollen and dust mites. The current indication for SLIT is confirmation of a positive
allergen to Japanese cedar pollen or dust mites by a skin reaction or a specific IgE in
a patient 5 years of age or older. The allergen is administered as a liquid or tablet
every day in a dose escalation manner for at least 2 or 3 years.
The contraindications are serious illnesses that require the use of a b blocker,
unstable asthma in which a systemic steroid may be required, treatment with an
anti-cancer drug, severe autoimmune disease, or cases in which it is assumed the
treatment should not be used in the patient because of the side effects. It cannot be
begun from the dispersion period. Sublingual inoculation should be suspended in
the case of pregnancy, mouth injury or ulcer, or if severe odonto-therapy is required.
However, if pregnancy occurs while this therapy is being administered, allergen
immunotherapy, including subcutaneous injection, is generally thought to be safe.

Surgical treatment
Nasal blockage in allergic rhinitis is often caused by nasal deformities, such as
deviated septum, hypertrophic rhinitis, and nasal polyps. In this case, corrective
surgery of nasal cavity can be performed to improve nasal ventilation. Before pollen
season, laser surgery is also performed for Japanese cedar pollinosis, but the effects
of this surgery do not continue in the following year. The main purpose is to alleviate
nasal blockage. For intractable rhinorrhea, perform posterior nasal neurectomy.

1.2.3 Australasian Society of Clinical Immunology and Allergy (ASCIA) Allergic

Rhinitis Clinical Update [2022]

This document published by ASCIA in 2022 is aimed to complement the knowledge

of medical practitioners (including general practitioners, pediatricians, and
physicians), pharmacists, nurse practitioners and nurses, dietitians and other allied
healthcare professionals with information on allergic rhinitis9. Grades of
recommendations were not outlined.

Aeroallergen minimization
• Avoidance or minimization of confirmed allergens may assist some people in
reducing the severity of their allergic rhinitis symptoms.
• This can be difficult to achieve for house dust mite and pollens.
• Avoidance strategies must only be developed if the allergens are clinically
significant.

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• Realistic consideration must also be given to the family’s ability to act in
strategies.

Pharmacotherapy and other treatment options

The duration and severity of allergic rhinitis symptoms are useful in guiding therapy,
as shown in the table below.

Table 7. Pharmacotherapy and Treatment Options for Allergic Rhinitis. Adapted

from the ASCIA 2022 Guideline.

Persistent and Intermittent and Persistent and

mild moderate-severe moderate-severe
Intranasal corticosteroid sprays*
Intermittent and Combination treatments (intranasal corticosteroid and
mild antihistamine sprays)*
+/- Other therapies (intranasal antihistamines, intranasal
chromones, intranasal anticholinergic sprays, leukotriene
antagonists)
Oral non-sedating or intranasal antihistamines*
+/- Nasal saline irrigation
Allergen avoidance
*Typical first-line treatments
Allergen immunotherapy
recommended

Definitions: Intermittent: 4 days/week or >4 weeks • Mild: Normal sleep, no

impairment of daily activities, normal work, or school performance. • Moderate-
severe: One or more of abnormal sleep, impairment of activities, abnormal work or
school performance, troublesome symptoms.

Table 8. Allergic Rhinitis Pharmacotherapy Options. Adapted from the ASCIA 2022
Guideline.

First line treatment Other possible Short term treatment

options treatments options
Antihistamines (non-
Decongestants (oral or
sedating oral or Saline treatments
intranasal)
intranasal)
Intranasal corticosteroid Systemic oral
Intranasal chromones
sprays corticosteroids

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Combination treatments Combination treatments
Intranasal anticholinergic
(intranasal corticosteroid (intranasal decongestant
sprays
and antihistamine sprays) and antihistamine sprays)
Oral leukotriene
antagonists

When symptoms improve, pharmacotherapy doses may be reduced.

A trial of pharmacotherapy initiated by primary care physicians and maintained for
at least 4 weeks is recommended before considering referral to a specialist if no
improvement.
If a patient is a competitive athlete, it is important to ensure medications suggested
are permitted. For example, pseudoephedrine used in some decongestants is
subject to certain restrictions.

Non-sedating antihistamines

Table 9. Non-Sedating Antihistamines. Adapted from the ASCIA 2022 Guideline.

First line treatment for intermittent mild
Place in therapy allergic rhinitis or used in conjunction with
other therapies.
Rapid onset action (1-2 hours)
Route
Very rapid onset action (within 30 minutes).
• Oral
May be used as a rescue medication to
• Intranasal
provide immediate relief of symptoms.
Availability Over the counter
Non-sedating antihistamines are
Type recommended. Sedating antihistamines are
not recommended.
Frequency of use Once or twice a day.
Benefits
↓ itchy, watery eyes
• Ocular symptoms
↓ sneezing, itchy, runny nose
• Nasal sneeze/itch/runny nose
Limited decrease in symptoms
• Nasal congestion

Whilst some nasal antihistamines can reduce nasal congestion, intranasal

corticosteroids (INCS) are more effective in reducing nasal congestion. Combination
treatments containing an antihistamine and INCS spray offer the combined
advantages of both medications.

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Intranasal corticosteroids (INCS)

Table 10. Intranasal Corticosteroids (INCS). Adapted from the ASCIA 2022 Guideline.
First line treatment for persistent and/or
Place in therapy moderate to severe allergic rhinitis and
treatment failures with antihistamines alone
Availability Over the counter
Different intranasal corticosteroids often
Age restriction
have different minimum age restrictions
Continuous (more effective; a few days to
take effect; maximal effect by 2 weeks)
Frequency of use Long-term use if recommended where
effective
As-needed basis (less effective)
Benefits
• Ocular symptoms
↓ itchy, watery eyes
• Nasal sneeze/itch/runny nose
↓ sneezing, itchy, runny nose
• Nasal congestion
↓ nasal congestion
• Cost effective reduction of
symptoms

Different brands of INCS vary in strength and efficacy. Combination treatments

containing an antihistamine and INCS spray offer the combined advantages of both
medications.

Other treatment options

• Saline nasal irrigation
o Clears aeroallergens and inflammatory mucus.
o Well tolerated and effective in reducing rhinitis symptoms.
o Safe and inexpensive.
o Large volume (>60 mL) and positive pressure devices appear to be
more effective than simple sprays.
o Is not a replacement for pharmacotherapy.
• Intranasal chromones such as sodium cromoglycate
o Are typically used for intermittent rhinitis.

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o Predominantly used for the immediate treatment of itch, sneeze,
rhinorrhea.
o Are more useful for episodic treatment than regular prophylaxis.
o Duration of action is approximately 4 hours.
o Are less effective than intranasal corticosteroids
• Intranasal ipratropium
o Anticholinergic sprays are useful in non-allergic rhinitis.
o Only decreases watery rhinorrhea.
o May be used in allergic rhinitis as adjunct treatment for rhinorrhea
persisting despite antihistamines or intranasal corticosteroid use.
• Oral leukotriene antagonists
o Used in children/adolescents with asthma and allergic rhinitis.
o No additional benefit if used in combination with antihistamines for
treatment of allergic rhinitis.
o The combination of leukotriene antagonists (e.g., Montelukast) and
antihistamines are no more effective than intranasal corticosteroids
alone for allergic rhinitis.
• Decongestants
o Oral or nasal decongestants may be used short term (3-5 days) to
reduce nasal congestion if severe. This allows more effective
administration of intranasal corticosteroids if turbinates are very
swollen.
o Chronic use of intranasal decongestants may lead to rebound nasal
obstruction, called rhinitis medicamentosa.
o Decongestants should not be used in patients with hypertension,
coronary artery disease, prostatism or glaucoma. • Decongestants
should not be used in pregnancy
• Systemic steroids
o Brief courses of oral corticosteroids (3-7 days) are rarely indicated but
may be considered: If there is severe nasal obstruction. As short-term
rescue medication if symptoms are severe, despite conventional
therapy, but only up to a maximum limit of 2 or 3 short courses in a 12-
month period.

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o Depocorticosteroids are NOT recommended due to short duration of
benefit and potential for local (subdermal and dermal atrophy) and
systemic side effects.
o Patients requiring oral corticosteroids for allergic rhinitis should be
referred to a clinical immunology/allergy/specialist for assessment.

Ocular management
• Non-pharmacological therapy: Flush allergen from eyes (saline washes, liquid-
tear preparations), Cool compresses.
• Ocular or oral antihistamines or topical mast cell stabilizers may be used to
control itchy/watery eyes.
• Intranasal corticosteroids can reduce ocular symptoms of allergic rhinitis.
• Ocular corticosteroids should only be prescribed in consultation with, and
regular review by an Ophthalmologist.

Management of allergic rhinitis in pregnancy

• Up to 20% of pregnant women develop symptoms of rhinitis, typically in
second trimester, improving 2 weeks after delivery.
• Medications for allergic rhinitis should only be used during pregnancy if the
benefit to the mother justifies the potential risk to the fetus.
• There are few well-controlled clinical studies in pregnant women examining
the safety of many of the medications used in allergic rhinitis.
• Ideally pharmacotherapy should be avoided in the first trimester of
pregnancy. However, there are some oral antihistamines and intranasal
corticosteroid sprays with an “A” category used by many pregnant women
without any proven increase in harmful effects on fetus.
• Saline nasal irrigation and intranasal chromones are safe in pregnancy.

Management of allergic rhinitis during lactation:

Recommend taking medication after feeding the infant to minimize any potential
infant exposure.
➔ Considered safe: Saline nasal treatments, Intranasal sodium cromoglycate
(chromone), Intranasal ipratropium (anti-cholinergic), non-sedating oral
antihistamines Intranasal corticosteroids.
➔ Evidence for safety lacking (recommend not use): Intranasal azelastine
hydrochloride (antihistamine) Intranasal lodoxamide trometamol (chromone).

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➔ Crosses into breast milk (recommend not use): Oral or intranasal
decongestants Intranasal levocabastine hydrochloride (antihistamine).

Dietary restrictions are not recommended

• There is no evidence that allergic rhinitis is due to food allergies, although
conditions may coexist.
• Food elimination is not recommended unless there is a confirmed allergy, and
has potential for serious nutritional consequences, especially in young
children.
• Restricting cow’s milk (dairy) products is often popular, even if there is no
confirmed food allergy, but studies do not show any change in mucus
production following dietary modification.

Allergen immunotherapy
• Also known as desensitization.
• Involves the regular administration of commercially available allergen
preparations to promote clinical tolerance to the allergen/s, administered by
subcutaneous injections or sublingual preparations.
• Is usually administered for 3-5 years in order to produce durable effects, to
reduce the frequency and severity of allergic rhinitis symptoms.
• Should only be initiated by medical specialists with training in allergy,
following a confirmed diagnosis.

Surgery
Surgery plays a limited role in the management of rhinitis.

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

• Nasal irrigation is a widespread first line treatment.
• Intranasal corticosteroids are safe and effective for long term use.
• If short courses of oral corticosteroids are prescribed, both patients and
practitioners must remain vigilant to avoid side effects.
• A short course of antibiotics may have a role to play in non-Type 2 CRSwNP,
but patient selection is important and side effects need to be managed.
• The effectiveness of allergen immunotherapy in the treatment of CRSwNP
remains unclear.
• A few Types 2 targeted biologics have been trialed with positive outcomes.

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• These treatments are high cost and need to be used in a cost-effective
manner.
• Endoscopic sinus surgery plays a significant role in the management of
CRSwNP.
• Surgery is safe, reduces symptom burden, and improves quality of life.
• Refer to an ENT or clinical immunology/allergy specialist for treatment.

1.2.4 National Health Service (NHS) Pediatric Allergic Rhinitis Guideline [2023]

This guideline has been developed by the Ashford and St. Peter’s Hospitals to
support all clinicians, both allergy specialists and general pediatricians, in managing
allergic rhinitis, as well as to guide in decision making as to when to investigate or
refer into specialist clinics10. No grades of recommendations were outlined.
Step up and down to achieve symptom control. Allow 8-12 weeks at each step.
➔ Step 1, allergen avoidance: nasal rinsing - with saline solution
➔ Step 2, regular long-acting non-sedating antihistamine: cetirizine or
loratadine OR regular nasal corticosteroid spray: fluticasone furoate,
mometasone furoate, or fluticasone.
Start with antihistamine if pruritus dominant or nasal corticosteroid if congestion
dominant:
➔ Step 3, regular oral antihistamine, and nasal corticosteroid
➔ Step 4, switch to 2nd line oral antihistamine: fexofenadine (from 6yrs)
➔ Step 5, regular nasal antihistamine + corticosteroid spray and oral
antihistamine: azelastine and fluticasone nasal spray (from 12yrs) +
fexofenadine
➔ Step 6, add in leukotriene receptor antagonist: montelukast.
➔ Step 7, allergen specific immunotherapy
If eye symptoms – consider sodium cromoglicate eye drops.
Refer for skin prick testing to aid in allergen avoidance and diagnostic uncertainty.
Refer to ENT in case of failed nasal corticosteroid spray + antihistamine for
assessment of adenoidal hypertrophy/ consideration of turbinate surgery, or
suspected obstructive sleep apnea.

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1.2.5 American Academy of Allergy, Asthma & Immunology (AAAAI) Rhinitis
Practice Parameter Update [2020]

This comprehensive practice parameter for allergic and nonallergic rhinitis provides
updated guidance on diagnosis, assessment, selection of monotherapy and
combination pharmacotherapy options, and allergen immunotherapy12.

Table 11. AAAAI Strength Grading and Certainty of Evidence

Grading the Strength of the Consensus Based Statements (CBSs)

Strong CBS The work group and JTFPP are confident that the desirable effects of
adherence to the statement outweigh the undesirable effects. This
CBS may be appropriate to be used as a practice standard indicator.
When making a strong CBS, the wording is ‘‘We recommend,’
implying that the clinician ‘‘should’ follow the recommendation.
The implications of a strong CBS are:
• For patients—most people in your situation would want the
recommended course of action and only a small proportion would
not; request discussion if the intervention is not offered.
• For clinicians—most patients should receive the recommended
course of action.
• For policy makers—the recommendation can be adopted as a
policy in most situations.
Conditional The work group and JTFPP reached a decision that the desirable
CBS effects of adherence to CBS probably outweigh the undesirable effect.
When making a conditional CBS, the wording is ‘‘We suggest,’
implying that the clinician ‘‘may’ follow the recommendation.
The implications of a conditional CBS are:
• For patients—most people in your situation would want the
recommended course of action, but many would not.
• For clinicians—you should recognize that different choices will be
appropriate for different patients and that you must help each
patient to arrive at a management decision consistent with her or
his values and preferences. It is likely that shared decision making
will play a major role in arriving at the management decision.
• For policy makers—policy making will require substantial debate
and involvement of many stakeholders.
Grading the Certainty of Evidence for Each CBS

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High Further research is very unlikely to change our confidence in the
estimate of effect. The recommendation is based on high-quality
evidence, such as multiple highly rated randomized controlled trials,
systematic reviews, or meta-analyses.
Moderate Further research is likely to have an important impact on our
confidence in the estimate of effect and may change the estimate.
The recommendation would likely be based on somewhat limited
evidence, such as reduced number or quality of randomized
controlled trials or controlled trials without randomization.
Low Further research is very likely to have an important impact on our
confidence in the estimate of effect and is likely to change the
estimate. The recommendation would likely be based on very weak
evidence, such as nonexperimental studies, registries, or comparative
studies.
Very Low Any estimate of the effect is very uncertain. The recommendation is
based largely on very low-quality studies and/or on expert opinion.
CBS without determination of certainty.
When there are either no published studies, or very limited and/or very weak
evidence, a consensus statement without any category of certainty of evidence was
developed. The degree of agreement by all JTFPP and work group members is
indicated, with voting details provided if there were dissenting votes.

This guideline contains systematically developed recommendations intended to

optimize care of adult and adolescent patients (≥ 12-15 years of age) and to assist
physicians and/or other health care practitioners and patients to make decisions
regarding diagnosis and therapy for rhinitis. Even though many treatments are
approved for younger children, the application of recommendations to children
would be partially based on data extrapolation from adult studies and would
therefore be less certain.

Clinical history and physical examination

1. CBS: We recommend that the clinician complete a detailed history and a
physical examination in a patient presenting with symptoms of rhinitis.
Strong Low
2. CBS: We recommend that for patients presenting with rhinitis symptoms, a
review of all current medications should be completed to assess whether
drug-induced rhinitis may be present. Strong Ungraded

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Vasculitis, sarcoidosis, and other systemic diseases
3. CBS: We recommend that aeroallergen skin prick testing or sIgE testing be
completed to confirm the diagnosis of AR in a patient with a history
consistent with AR. Strong High
4. CBS: We recommend that the clinician not perform food skin prick testing or
sIgE for foods in their routine evaluation of a patient presenting with the signs
and symptoms compatible with the diagnosis of AR. Strong Ungraded

Severity assessment including QOL by survey instruments and questionnaires

5. CBS: We suggest that the use of a validated instrument (e.g., scoring system,
scale, or questionnaire) be considered to help determine the severity of
rhinitis and to monitor the degree of disease control. Conditional Low
6. CBS: We recommend against prescribing a first-generation antihistamine and
are in favor of a second-generation antihistamine when prescribing an oral
antihistamine for the treatment of AR. Strong High

PHARMACOTHERAPY
Oral leukotriene receptor antagonists
7. CBS: We suggest that the clinician not select the oral LTRA montelukast for
the initial treatment of AR due to reduced efficacy when compared with that
of other agents. Furthermore, serious neuropsychiatric events that may
include suicidal thoughts or actions have been reported in some patients
taking montelukast. As advised by the FDA, montelukast should be used to
treat AR only in patients who are not treated effectively with or cannot
tolerate other alternative therapies. Conditional Very low
8. CBS: We recommend that the clinician not select an oral LTRA for the
treatment of NAR. Conditional Ungraded
Systemic corticosteroids
9. CBS: We suggest that for the treatment of very severe or intractable AR, the
clinician may consider a short course (5-7 d) of oral corticosteroids. Conditional
Very low
10. CBS: We suggest that for the treatment of very severe or intractable AR, the
clinician not prescribe a depot parenteral corticosteroid for AR due to the
potential risks of systemic and local corticosteroid side effects. Conditional
Low .

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INTRANASAL AGENTS
Intranasal antihistamines
11. CBS: We recommend that the clinician offer INAH as an initial treatment
option for patients with SAR. Strong High
12. CBS: We recommend that the clinician offer INAH as a first-line monotherapy
option for patients with NAR. Strong High
13. CBS: We recommend that the clinician offer INAH as a first-line option for
patients with intermittent AR. Conditional Ungraded
Intranasal corticosteroids
14. CBS: We recommend that when choosing monotherapy for persistent AR,
INCS be the preferred medication. Strong High
15. GRADE: We recommend that for the initial treatment of moderate/severe SAR
in patients ≥15 y of age, the clinician use an INCS over an LTRA. (Also see
Recommendation 7.) Strong High
Intranasal decongestants
16. CBS: We suggest that the use of intranasal decongestants be short term and
used for intermittent or episodic therapy of nasal congestion. (However, see
also Recommendation 26.) Conditional Low
17. CBS: We suggest that in patients having severe mucosal edema, which
impairs the delivery of other intranasal agents, an intranasal decongestant be
considered for up to 5 d of use. Conditional Ungraded
Oral decongestants
18. CBS: We suggest that oral decongestant agents be used with caution in older
adults and children younger than 4 y old, and in patients of any age who have
a history of cardiac arrhythmia, angina pectoris, cerebrovascular disease,
uncontrolled hypertension, bladder outlet obstruction, glaucoma,
hyperthyroidism, or Tourette syndrome. Conditional Low
19. CBS: We recommend that oral decongestants be avoided during the first
trimester of pregnancy. Strong Low
Intranasal ipratropium
20. CBS: We suggest that patients with PAR and NAR who have rhinorrhea as
their main nasal symptom be offered intranasal ipratropium. Conditional Low
for PAR; moderate for NAR .

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Intranasal cromolyn
21. CBS: We suggest that intranasal cromolyn be offered as an option to be taken
just prior to allergen exposure to reduce symptoms of AR from episodic
allergen exposures. Conditional Very low
INCS and INAH combined.
22. GRADE: We suggest that the clinician consider the combination of an INCS
and an INAH for the initial treatment of moderate/severe nasal symptoms of
SAR in patients ≥12 y old. Conditional High
23. CBS: We suggest that the clinician consider the combination of an INCS and
an INAH for moderate/severe SAR and PAR that is resistant to pharmacologic
monotherapy. * Conditional Moderate
24. CBS: We suggest that the clinician consider the combination of an INCS and
an INAH for moderate/severe NAR that is resistant to pharmacologic
monotherapy. * Conditional Low
INCS with intranasal ipratropium for control of rhinorrhea
25. CBS: We suggest that for patients taking an INCS who have persistent
rhinorrhea, the clinician may consider the addition of intranasal ipratropium.
Conditional Moderate
INCS with intranasal decongestant
26. CBS: We suggest that patients with persistent nasal congestion unresponsive
to an INCS or to an INCS-INAH combination be offered combination therapy
with addition of an intranasal decongestant for up to 4 wk. Conditional Low
Oral antihistamine with oral decongestant
27. CBS: We suggest that for patients with AR and nasal congestion uncontrolled
with an oral antihistamine, the clinician consider the addition of
pseudoephedrine, when tolerated. (See Recommendation 18.) Conditional
Moderate
Oral antihistamines with oral LTRAs
28. CBS: We suggest that for SAR the clinician not combine the oral LTRA
montelukast with an oral antihistamine for symptoms not controlled with an
oral antihistamine. (See Recommendation 7.) Conditional Moderate

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COMBINATION THERAPIES THAT HAVE NOT BEEN SHOWN TO BE
CONVINCINGLY SUPERIOR TO MONOTHERAPY
Oral antihistamine with INCS
29. GRADE: We recommend that the clinician not prescribe, as initial treatment, a
combination of an oral antihistamine and an intranasal steroid in preference
to monotherapy with an intranasal steroid in patients ≥ 12 y of age with
symptoms of SAR. Strong Moderate
30. CBS: We suggest that the clinician not prescribe the combination of an oral
antihistamine and an INCS in preference to monotherapy with an intranasal
steroid in all patients with SAR and PAR. Conditional Very low.
Oral LTRAs with INCS
31. CBS: We suggest against the addition of the oral LTRA montelukast to an
INCS for AR, due to the lack of adequate evidence of improved efficacy and
concerns for serious neuropsychiatric events from montelukast. (See
Recommendation 7.) Conditional Very low
Pharmacotherapy for NAR
32. CBS: We suggest that the clinician offer an INCS as a first-line therapy for NAR.
Conditional Low
33. CBS: We suggest that the clinician offer an INAH as a first-line therapy for
NAR. Conditional Very low
AIT and AR
34. CBS: We suggest that AIT (subcutaneous or sublingual tablets) be offered
through shared decision making to patients with moderate/severe AR who (1)
are not controlled with allergen avoidance and/or pharmacotherapy or (2)
choose immunotherapy as the preferred method of treatment (e.g., due to
the desire to avoid the adverse effects, costs, or long-term use of
pharmacotherapy) and/or (3) desire the potential benefit of immunotherapy
to prevent or reduce the severity of comorbid conditions, such as asthma.
Conditional Moderate
35. CBS: We suggest that AIT (subcutaneous or sublingual tablets) be considered
for patients with controlled mild/moderate asthma with coexisting AR.
Conditional Moderate

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Acupuncture
36. CBS: We cannot make a recommendation for or against the use of
acupuncture for the treatment of AR. N/A Very low.
Herbal medications
37. CBS: We cannot make a recommendation for or against the use of specific
herbal products for the treatment of AR.

1.2.6 Review Article: Current Treatment Options for Allergic Rhinitis

[International Journal of Research in Medical Sciences, 2023]

This review article published by Swain et al. in the International Journal of Research
in Medical Sciences in July 2023 discusses details of current treatment options for
AR11.

TREATMENT OPTIONS
There are several treatment options for AR such as non-pharmacologic and
pharmacologic. The goal of the treatment is to eliminate or reduce the present
symptoms and prevent future attacks and complications. Appropriate treatment
selection should have minimal adverse effects and enable the patient to maintain a
normal lifestyle. The treatment options include allergen avoidance,
pharmacotherapy, and immunotherapy.

NON-PHARMACOLOGIC INTERVENTIONS
➔ Allergen Avoidance: Patients can take measures to reduce exposure to
triggers based on specific allergens, whether it is pollen, mold, or animal
dander. Allergen avoidance should be part of an overall treatment strategy
that includes pharmacotherapy. Pet avoidance shows a clear benefit.

PHARMACOTHERAPY
• The treatment options are usually administered orally or intranasally.
• The treatment options available include antihistamines, corticosteroids,
decongestants, leukotriene receptor antagonists, and anticholinergics.
• Immunotherapy is also an important treatment option for patients who are
refractory to pharmacotherapy.
The most common pharmacologic treatment options include intranasal
corticosteroids, H1 receptor inverse agonists (antihistamines), and leukotriene
receptor antagonists. These medications are effective in the case of seasonal AR and
in perineal AR.

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Intranasal corticosteroids
• Intranasal corticosteroid sprays are the first-line treatment for moderate to
severe AR and are considered the most effective medication for controlling
the symptoms of AR.
• Intranasal corticosteroids are highly effective in reducing nasal obstruction
and congestion. Intranasal corticosteroids are preferred over all other agents
for mild or moderate to severe symptoms of AR.
• The intranasal corticosteroids are beclomethasone propionate, fluticasone
propionate, mometasone furoate, fluticasone furoate, and dexamethasone
cipecilate.
• Intranasal corticosteroids rarely show systemic effects of oral corticosteroids-
adrenal suppression, bone fractures (particularly in elderly age), growth
suppression, and ocular effects.
• All available intranasal corticosteroids are efficacious in controlling AR
symptoms. The product differentiation involves factors like cost, ease of
dosing, and sensory issues such as aroma and taste, which can affect patient
preference.

Antihistamines
• Antihistamines are most effective against symptoms that are primarily
mediated by histamines such as sneezing, pruritus, and ocular symptoms.1
Antihistamines are less effective for nasal congestion and may require a
combination with a decongestant or intranasal corticosteroid.
• Oral antihistamines are considered a first-line treatment option for patients
with mild to moderate intermittent symptoms of AR.
• First-generation oral forms of antihistamines are usually well tolerated but
have sedative, cognitive, and anticholinergic effects that can lead to
challenges for some patients.
• Second-generation oral antihistamines usually have no sedative effects and
are well tolerated. Second-generation oral antihistamines such as
fexofenadine, loratadine, and desloratadine do not cause sedation at
recommended doses. Cetirizine and intranasal azelastine can cause sedation
at recommended doses.

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Nasal decongestants
• Use of intranasal decongestants should be limited to no more than three
days in a row, as overuse can result in dependence and the patient can
experience rebound nasal congestion due to α-receptor downregulation, or
rhinitis medicamentosa.

Leukotrienes receptor antagonists (LTRAs)

• These can be used alone or in combination with antihistamines or intranasal
corticosteroids and may be helpful in patients who have comorbid asthma.
• LTRAs have shown efficacy in asthma.
• Montelukast provides statistically significant improvement for nasal
symptoms; however, topical corticosteroids and oral antihistamines give a
greater reduction in nasal symptom scores.
• Montelukast is considered a safe medication as prophylaxis and treatment for
airway allergy including in pediatric age.

Combination of antihistamines and LTRAs

• Anticholinergics: These can be used in combination with an antihistamine or
intranasal corticosteroid in patients who have primary symptom is rhinorrhea
or is refractory to other treatment.
• Saline douching: Isotonic solutions are well tolerated, inexpensive, easy to use,
and have no side effects.
• Immunotherapy: Subcutaneous immunotherapy is effective in decreasing the
symptoms and minimizes the medication requirement in long term. It is
reserved for patients with a severe type of AR whose symptoms are not
sufficiently treated by pharmacotherapy.
• Probiotics: Study has shown that probiotics may be very helpful for the
treatment or prevention of AR in the pediatric age group. Probiotics promote
an improvement to the immune response of the human body and there is
satisfactory action on the modulation of the allergic response more as
compared to conventional treatment.

AR in pregnancy
• Intranasal corticosteroids are not associated with an increased chance of
congenital malformations in humans. These should be considered as first-line
therapy in treating AR based on their superiority to oral antihistamines,
decongestants, and mast cell stabilizers with respect to efficacy.

44 | P a g e
• The first-generation antihistamines have not been incriminated as human
teratogens. The teratogenicity of second-generation antihistamines has not
been studied completely. The fetal safety of loratadine and fexofenadine has
not been established in controlled trials and so, their use for AR cannot be
used unless first-line therapies have been tried and have failed.

AR in children
• Mometasone furoate and fluticasone propionate have been studied in
children and found no adverse effects on cortisol levels, the hypothalamic-
pituitary-adrenal axis, or growth.
• Nasal douching with isotonic saline solution can reduce the symptoms of
children and adults with seasonal rhinitis and is safe and inexpensive.
Ipratropium bromide nasal spray reduces rhinorrhea but does not affect
another nasal symptom.

Surgical treatment
• Nasal blockage in AR is often caused by deviated nasal septum, hypertrophic
rhinitis, and nasal polyps. In this case corrective surgery of the nasal cavity can
be performed to relieve nasal obstruction. Corrective surgery to relieve nasal
obstruction includes submucosal turbinectomy, septoplasty, inferior
turbinectomy, and nasal polypectomy. Vidian neurectomy is helpful to control
rhinorrhea.

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Section 2.0 Drug Therapy in Rhinitis
This section comprises three subsections: the first contains the newly recommended
drugs, the second covers drug modifications, and the third outlines the drugs that
have been withdrawn from the market.

2.1 Additions

Since the publication of the previous CHI report in January 2020, no new drugs for
the management of rhinitis have been registered by the SFDA.

2.2 Modifications

• Modifications that have been made since January 2020: Removed PA for
LEVOCABASTINE 0.5 mg/ml eye drops suspension- PHENIRAMINE,
NAPHAZOLINE HYDROCHLORIDE-ANTAZOLINE SULFATE, NAPHAZOLINE
NITRATE- NAPHAZOLINE HYDROCHLORIDE- ANTAZOLINE PHOSPHATE,
NAPHAZOLINE HYDROCHLORIDE- SODIUM CROMOGLICATE,
TETRAHYDROZOLINE- FLUOROMETHOLONE, SODIUM CROMOGLICATE; All the
eye/nose drops, ophthalmic solutions are given over the counter. No need for PA.

2.3 Delisting

The medications below are no longer SFDA registered13, therefore, it is advisable to

delist the following drugs from CHI formulary. Please refer to Drugs in the disease -
section 2 of CHI Rhinitis original clinical guidance
• Ebastine
• Cetirizine HCL/Pseudoephedrine

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Section 3.0 Key Recommendations Synthesis
History and physical examination
• Despite low level evidence specifically addressing this area, history is essential
in the diagnosis of AR. Policy level: Recommendation.5
• When possible, physical examination should be performed with appropriate
personal protective equipment to aid in the diagnosis of AR and exclusion of
other conditions. When combined with patient history, it increases diagnostic
accuracy. Policy level: Recommendation.5
Diagnostic modalities for evaluation of allergic rhinitis
• Use of validated survey instruments: Validated surveys may be used to
screen for AR, follow treatment outcomes and as a primary outcome measure
for clinical trials. Specific tests are optimized for various clinicopathological
scenarios. Policy level: Recommendation.5
Pharmacotherapy and procedural options
• Oral H1 antihistamines: Newer-generation oral antihistamines can be
considered in the treatment of AR. Policy level: Strong recommendation for
the use of newer-generation oral antihistamines for AR.5
• Intranasal antihistamines may be used as first- or second-line therapy in the
treatment of AR. Policy level: Strong recommendation.5
• Intranasal cromolyn: DSCG (Disodium cromoglycate) may be used as a
second-line treatment for AR in patients who fail INCS or intranasal
antihistamines, or for short-term preventative benefit prior to allergen
exposures. Policy level: Recommendation as a second-line treatment in AR.5
• Intranasal corticosteroids: non-traditional application: No evidence for non-
traditional application of intranasal steroids for AR. Policy level:
Recommendation against. 5
• Oral corticosteroids: Although not recommended for routine use in AR,
certain clinical scenarios may warrant the use of short courses of systemic
corticosteroids, following a discussion of the risks and benefits with the
patient. For example, oral steroids could be considered in selecting patients
with significant nasal obstruction that precludes adequate penetration of
intranasal agents (corticosteroids or antihistamines). In these cases, a short
course of systemic corticosteroids may improve congestion and facilitate
access of topical medications. No evidence supports this suggestion, and thus
careful clinical judgment and risk discussion are advocated. Policy level:
Strong recommendation against routine use. 5

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• Oral decongestants: Although not recommended for routine use in AR,
pseudoephedrine can be effective in reducing nasal congestion in patients
with AR; however, it should only be used as short-term/rescue therapy after a
discussion of the risks and benefits with the patient (comorbidities) and
consideration of alternative intranasal therapy options. Policy level: Strong
recommendation against routine use in AR. In certain cases, combination
therapy with an oral antihistamine may be beneficial to alleviate severe nasal
congestion in short courses. 5
• Biologic therapies: Monoclonal antibody (Biologic) therapies are not currently
approved for the treatment of AR. Policy level: Option based upon published
evidence, although not currently approved for this indication.5
• Combination oral antihistamine and leukotriene receptor antagonist:
Combination LTRA and oral antihistamines should not be used as first line
therapy for AR but can be considered in patients with contraindications to
other alternatives. This combination should be used judiciously after carefully
weighing potential risks and benefits. Policy level: Recommendation against
first line therapy. 5
Allergen immunotherapy for the treatment of allergic rhinitis:
• Sublingual immunotherapy tablets: SLIT tablets are recommended for
patients with severe or refractory AR. Epinephrine auto-injector is
recommended in the FDA labeling for approved tablets due to the rare but
serious risk of anaphylaxis. Tablets for selecting antigens are available in
various countries. Policy level: Strong recommendation.5
• Depocorticosteroids are NOT recommended due to short duration of benefit
and potential for local (subdermal/dermal atrophy) and systemic side effects.9
• Patients requiring oral corticosteroids for allergic rhinitis should be referred to
a clinical immunology/allergy/specialist for assessment.9
• Herbal medications: CBS: We cannot make a recommendation for or against
the use of specific herbal products for the treatment of AR. 12

Section 4.0 Conclusion

This report serves as an annex to the previous CHI Rhinitis report and aims to
provide recommendations to aid in the management of Rhinitis. It is important to
note that these recommendations should be utilized to support clinical decision-
making and not replace it in the management of individual patients with Rhinitis.
Health professionals are expected to consider this guidance alongside the specific
needs, preferences, and values of their patients when exercising their judgment.

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Section 5.0 References
1. Tiffany Jean M, Ahdad Ziyar M. Allergic Rhinitis: Practice Essentials,
Background, Pathophysiology. Published February 14, 2023. Accessed
November 3, 2023. [Link]
overview
2. Liva GA, Karatzanis AD, Prokopakis EP. Review of Rhinitis: Classification,
Types, Pathophysiology. J Clin Med. 2021;10(14):3183.
doi:10.3390/JCM10143183
3. Nur Husna SM, Tan HTT, Md Shukri N, Mohd Ashari NS, Wong KK. Allergic
Rhinitis: A Clinical and Pathophysiological Overview. Front Med
(Lausanne). 2022;9:874114. doi:10.3389/FMED.2022.874114/BIBTEX
4. Aburiziza A, Almatrafi MA, Alonazi AS, et al. The Prevalence, Clinical Picture,
and Triggers of Allergic Rhinitis in Saudi Population: A Systematic Review
and Meta-Analysis. J Asthma Allergy. 2022;15:1831. doi:10.2147/JAA.S391142
5. Wise SK, Damask C, Roland LT, et al. International consensus statement on
allergy and rhinology: Allergic rhinitis – 2023. Int Forum Allergy Rhinol.
2023;13(4):293-859. doi:10.1002/alr.23090
6. Rudmik L, Smith TL. Development of an evidence‐based review with
recommendations using an online iterative process. Int Forum Allergy
Rhinol. 2011;1(6):431-437. doi:10.1002/alr.20095
7. Gazlan S, Alenazi F, Almohsen S. Allergic Rhinitis. Ministry of Health of
Saudi Arabia and McMaster University Clinical Practice Guidelines on the
Allergic Rhinitis.; 2014.
[Link]
8. Okubo K, Kurono Y, Ichimura K, et al. Japanese guidelines for allergic
rhinitis 2020. Allergology International. 2020;69(3):331-345.
doi:10.1016/[Link].2020.04.001
9. ASCIA Clinical Update Allergic Rhinitis - Australasian Society of Clinical
Immunology and Allergy (ASCIA). Published 2022. Accessed November 3,
2023. [Link]
10. Dr Bethany Smith. Paediatric Department NHS Ashford and St. Peter’s
Hospitals - Paediatric Allergic Rhinitis.; 2023.
11. Swain SK, Singh V. Current treatment options for allergic rhinitis: a review.
Int J Res Med Sci. 2023;11(7):2750-2755. doi:10.18203/2320-6012.ijrms20232139
12. Dykewicz MS, Wallace D V., Amrol DJ, et al. Rhinitis 2020: A practice
parameter update. Journal of Allergy and Clinical Immunology.
2020;146(4):721-767. doi:10.1016/[Link].2020.07.007

49 | P a g e
13. SFDA Drug List J. SFDA Drug List . Published 2023. Accessed June 20, 2023.
[Link]

Section 6.0 Appendices

Appendix A. Prescribing Edits Definition

I. Prescribing Edits (ensure consistent use of abbreviations, e.g., CU, ST)

Some covered drugs may have additional requirements, rules, or limits on coverage.
These requirements and limits may include:

Prescribing edits Tools Description

AGE (Age): Coverage may depend on patient age
CU (Concurrent Use): Coverage may depend upon concurrent
use of another drug
G (Gender): Coverage may depend on patient
gender
MD (Physician Specialty): Coverage may depend on prescribing
physician’s specialty or board
certification
PA (Prior Authorization): Requires specific physician request
process
QL (Quantity Limits): Coverage may be limited to specific
quantities per prescription and/or time
period
ST (Step Therapy): Coverage may depend on previous use
of another drug
EU (Emergency Use only): This drug status on Formulary is only for
emergency use
PE (Protocol Edit): Use of drug is dependent on protocol
combination, doses, and sequence of
therapy

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Appendix B. Rhinitis Scope

Section Rationale/updates
Section 1.1 N/A
American
Academy of
Otolaryngology—
Head and Neck
Surgery
Foundation
Clinical Practice
Guideline:
Allergic Rhinitis
[2015}
Section 1.2 The Section 1.1.1. International consensus statement on allergy and rhinology: Allergic rhinitis
American [2023]5
Treatment Diagnostic modalities for evaluation of allergic rhinitis
International Changes in the recommendations related to: Use of validated survey instruments, Component
Consensus resolved diagnostic testing, Nasal provocation testing, Nasal cytology, Nasal histology,
Statement on Rhinomanometry, Acoustic rhinometry, Peak nasal inspiratory flow, FeNO, NnO.
Allergy and
Use of validated survey instruments: Validated surveys may be used to screen for AR, follow
Rhinology:
treatment outcomes and as a primary outcome measure for clinical trials. Specific tests are
Allergic Rhinitis
optimized for various clinicopathological scenarios. Policy level: Recommendation.
[2018]
Component resolved diagnostic testing: Component resolved diagnostic testing is an option
for diagnosis of AR by specialists. Policy level: Option
Nasal provocation testing: Application of nasal provocation testing is useful in local AR and to
confirm occupational rhinitis. Policy level: Option for diagnosis of AR when skin or in vitro tests
are equivocal or unreliable. Recommendation for diagnosis of local AR and occupational rhinitis

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Nasal cytology: Nasal cytology could help in cases of non-allergic rhinitis to suspect local AR or
in cases of AR to diagnose a mixed rhinitis. It could be considered an option in cases of negative
SPT and/or serum sIgE to evaluate the presence of mucosal eosinophils and consideration of
local AR or type 2 inflammation. The cut-off values for determining non-allergic rhinitis with
eosinophilia syndrome (NARES) are not yet clear. Policy level: Option
Nasal histology: Nasal histology may be helpful in clinical research or selected cases (e.g.,
evaluation of tissue eosinophils during surgery). Recommendation against in routine clinical
practice for AR evaluation due to invasive nature of obtaining a specimen. Policy level:
Recommendation against
Rhinomanometry: Rhinomanometry is useful in distinguishing between structural and soft
tissue causes of obstruction, when history and examination findings are not congruent, as well
as a research tool. Better with individual nasal cavity assessment and four-phase
rhinomanometry. Policy level: Option
Acoustic rhinometry: Acoustic rhinometry is most useful in research setting as opposed to as a
clinical diagnostic tool. Policy level: Option.
Peak nasal inspiratory flow: Use in conjunction with patient reported outcome measures to
improve utility. Policy level: Option.
Fractional exhaled nitric oxide (FeNO), Nasal nitric oxide (nNO): History and physical,
diagnostic skin testing, or sIgE testing should be the first-line evaluation of AR. FeNO or nasal NO
testing may provide additional diagnostic information if necessary but should not be routinely
employed for AR diagnosis. Policy level: FeNO: Recommend against for routine diagnosis of AR.
nNO: Recommend against for routine diagnosis of AR.
Pharmacotherapy and procedural options
➢ Pharmacologic treatments are frequently employed to control AR symptoms. Depending on
the specific therapy and geographic region, these may be available by prescription or over
the counter. The evidence for pharmacologic options for AR has been reviewed.
Oral H1 antihistamines: Newer-generation oral antihistamines can be considered in the
treatment of AR. Policy level: Strong recommendation for the use of newer-generation oral
antihistamines for AR.

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Oral corticosteroids: Although not recommended for routine use in AR, certain clinical scenarios
may warrant the use of short courses of systemic corticosteroids, following a discussion of the
risks and benefits with the patient. For example, oral steroids could be considered in select
patients with significant nasal obstruction that precludes adequate penetration of intranasal
agents (corticosteroids or antihistamines). In these cases, a short course of systemic
corticosteroids may improve congestion and facilitate access of topical medications. No
evidence supports this suggestion, and thus careful clinical judgment and risk discussion are
advocated. Policy level: Strong recommendation against routine use.
Intranasal corticosteroids: non-traditional application: No evidence for non-traditional
application of intranasal steroids for AR. Policy level: Recommendation against.
Oral decongestants: Although not recommended for routine use in AR, pseudoephedrine can
be effective in reducing nasal congestion in patients with AR; however, it should only be used as
short-term/rescue therapy after a discussion of the risks and benefits with the patient
(comorbidities) and consideration of alternative intranasal therapy options. Policy level: Strong
recommendation against for routine use in AR. In certain cases, combination therapy with an
oral antihistamine may be beneficial to alleviate severe nasal congestion in short courses.
Intranasal cromolyn: DSCG (Disodium cromoglycate) may be used as a second-line treatment
for AR in patients who fail INCS or intranasal antihistamines, or for short-term preventative
benefit prior to allergen exposures. Policy level: Recommendation as a second-line treatment in
AR.
Biologic therapies: Monoclonal antibody (biologic) therapies are not currently approved for the
treatment of AR. Policy level: Option based upon published evidence, although not currently
approved for this indication.
Combination oral antihistamine and intranasal corticosteroid: Current evidence is mixed to
support antihistamines as an additive therapy to INCS, as several randomized trials have not
demonstrated a benefit over INCS alone for symptoms of AR. Policy level: Option.
Combination oral antihistamine and leukotriene receptor antagonist: Combination LTRA and
oral antihistamines should not be used as first line therapy for AR but can be considered in
patients with contraindications to other alternatives. This combination should be used

53 | P a g e
judiciously after carefully weighing potential risks and benefits. Policy level: Recommendation
against as first line therapy.
Combination intranasal corticosteroid and leukotriene receptor antagonist (LTRA): Consider
use in patients with AR and asthma, after weighing therapeutic benefits against risks of mental
health adverse effects. Policy level: Option as combination therapy if comorbid asthma present
and mental health risks are considered. Not recommended for AR alone.
Combination intranasal corticosteroid (INCS) and intranasal decongestant: Short-term
combination therapy with INCS and intranasal decongestant may be considered in patients with
AR refractory to combination therapy with INCS and intranasal antihistamine prior to
consideration of inferior turbinate reduction or in patients declining surgery. Policy level: Option
Combination intranasal corticosteroid and intranasal ipratropium bromide: Combining IPB
with beclomethasone dipropionate can be more effective than either agent alone for the
treatment of rhinorrhea in refractory AR in children and adults. Although multiple consensus
guidelines have recommended, and there is evidence to support this recommendation, it is
important to note that there has only been one randomized controlled trial (RCT) to study the
efficacy of combined INCS and IPB therapy compared to either agent alone, and this study was
performed in a combined population of patients with AR and non-allergic rhinitis. Policy level:
Option.
Allergen immunotherapy for the treatment of allergic rhinitis:
Conventional subcutaneous immunotherapy (SCIT): SCIT is an appropriate treatment
consideration for patients who have not obtained adequate relief with symptomatic therapy or
who prefer this therapy as a primary management option, require prolonged weeks of
treatment during the year, and/or wish to start treatment for the benefit of the potential
secondary diseasemodifying effects of SCIT. Policy level: Strong recommendation for SCIT as a
patient preference-sensitive option for the treatment of AR. Strong recommendation for SCIT
over no therapy for the treatment of AR. Option for SCIT over sublingual immunotherapy (SLIT)
for the treatment of AR.
Rush subcutaneous immunotherapy: Aeroallergen rush SCIT is an option for AR in
appropriately selected patients that do not have adequate control of their symptoms with

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symptomatic therapies. If available at practice location, the use of depigmented-polymerized
allergen extracts for rush SCIT has a better safety profile compared with standard extracts. Policy
level: Option
Cluster subcutaneous immunotherapy: Cluster SCIT can be safely implemented in clinical
practice and offered to those patients eligible for SCIT that may prefer this. Policy level: Option
Sublingual immunotherapy (SLIT): general considerations: Recommend tablet or aqueous SLIT
in patients (adults and children) with seasonal and/or perennial AR who wish to reduce their
symptoms and medication use, as well as possibly reduce the propensity to develop asthma or
new allergen sensitizations. Policy level: Strong recommendation for the use of SLIT grass pollen
tablet, ragweed tablet, HDM tablet, and tree pollen aqueous solution. Recommendation for SLIT
for Alternaria allergy. Option for SLIT for animal allergy. Recommendation for dual-therapy SLIT
in bi-allergic patients.
Sublingual immunotherapy tablets: SLIT tablets are recommended for patients with severe or
refractory AR. Epinephrine auto-injector is recommended in the FDA labeling for approved
tablets due to the rare but serious risk of anaphylaxis. Tablets for select antigens are available in
various countries. Policy level: Strong recommendation.
Aqueous sublingual immunotherapy: High-dose aqueous SLIT is recommended for those
patients who wish to reduce their symptoms and rescue medication use. Policy level:
Recommendation.
Epicutaneous/transcutaneous immunotherapy: While epicutaneous AIT may potentially have
a future clinical application in the treatment of AR, at this juncture there are limited studies that
show variable and limited effectiveness, and a significant rate of adverse reactions. Given the
above and the availability of alternative treatments, epicutaneous AIT is not recommended at
this time. Policy level: Recommendation against
Intralymphatic immunotherapy: More studies are essential to establish the long-term effects of
ILIT. Policy level: Option
Combination subcutaneous immunotherapy and biologics: Current evidence supports that
anti-IgE may be beneficial as a premedication prior to induction of cluster or rush SCIT protocols,
and combination therapy may be advantageous as an option for carefully selected patients with

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persistent symptomatic AR following AIT. However, at the time of this writing, biologic therapies
are not approved by the US FDA for AR alone. An individualized approach to patient
management must be considered. Policy level: Option.
Section 1.3 N/A
BSACI guideline
for the diagnosis
and
management of
allergic and non-
allergic rhinitis
(Revised Edition
2017; First edition
2007)
Section 1.4 N/A
American
Pediatric rhinitis:
position paper of
the European
Academy of
Allergy and
Clinical
Immunology
[2013]
N/A Section 1.2.1. Saudi guidelines on Allergic Rhinitis in Asthma [2014]7
• The KSA MoH panel recommends intranasal corticosteroids for treatment of adults with
seasonal or intermittent allergic rhinitis (Strong recommendation; Moderate-quality
evidence).
• The KSA MoH panel suggests intranasal corticosteroids for treatment of adults with perennial

56 | P a g e
or persistent allergic rhinitis (Conditional recommendation; Low-quality evidence).
• The KSA MoH panel recommends intranasal corticosteroids rather than intranasal H1-
antihistamines for treatment of adults with seasonal or intermittent allergic rhinitis (Strong
recommendation; High-quality evidence).
• The KSA MoH panel suggests intranasal corticosteroids rather than intranasal H1-
antihistamines for treatment of adults with perennial or persistent allergic rhinitis
(Conditional recommendation; Very low-quality evidence).
• The KSA MoH panel suggests sublingual immunotherapy for treatment of adults with
seasonal or intermittent allergic rhinitis (conditional recommendation; Moderate-quality
evidence).
• The KSA MoH panel suggests sublingual immunotherapy for treatment of adults with
perennial/persistent allergic rhinitis (conditional recommendation; very low-quality evidence).
• The KSA MoH panel suggests sublingual immunotherapy for treatment of children younger
than 18 years old with seasonal or intermittent allergic rhinitis (Conditional recommendation;
Moderate-quality evidence).
• The KSA MoH panel suggests sublingual immunotherapy be not used for treatment of
children younger than 18 years old with perennial or persistent allergic rhinitis (Conditional
recommendation; very low-quality evidence
N/A Section 1.2.2. Japanese guidelines for allergic rhinitis [2020]8
Step-by-step approach for treatment by ARIA. Modified from ARIA 2008, Japanese version.
The aim of treatment is to alleviate symptoms and remove difficulties with everyday life. Choose
a treatment based on severity, disease type, and lifestyle.
• Natural courses and communication with patients (Table 3) Combinations of
pharmacotherapies based on severity and disease types and communication with patients
improve patients' satisfaction and QOL. Japanese cedar pollinosis, which developed during
childhood or early or late Middle Ages, should be treated in view of a prolonged course.
• Elimination and avoidance of antigens (Table 4) In addition to cleaning, lowering humidity
with dehumidifier is effective in reducing mites. For Japanese cedar pollinosis, refer to pollen

57 | P a g e
dispersal information to consider measures to prevent pollen inhalation. For pet allergies,
avoid contact with causative pets and keep dogs and cats clean.
• Pharmacotherapy (Table 5): Therapeutic agents for allergic rhinitis, with different
mechanisms of action, are classified. Alpha- sympathomimetics (vasoconstrictor nose
drops), which temporarily alleviate nasal blockage, are also used.
Mast cell stabilizer: Since the development of disodium cromoglicate (DSCG), local agents (eye
drops and nasal spray) and oral agents, such as tranilast, amlexanox, and pemirolast
potassium, have been on the market. They have mild effects. To achieve sufficient clinical
effects, 2-week prolonged administration is required. Amelioration rates are increased by
continuous administration. Adverse effects, such as sleepiness and dry mouth, do not occur.
Chemical mediator receptor antagonists a) Histamine H1 receptor antagonists (antihistamine)
(i) First-generation antihistamine: First-generation antihistamine often causes adverse
effects, such as sleepiness, impaired performance, and dry mouth, but have immediate
effects on sneezing and watery rhinorrhea. First-generation antihistamines are
contraindicated for patients with glaucoma, prostatic hyperplasia, and asthma because of
their potent anticholinergic effects. They have less central nervous system depressant actions
in children than in adults. Caution should be exercised for excitatory effects, such as
convulsions. Most first-generation antihistamine are marketed as OTC.
(ii) Second-generation antihistamine (Table 6): Second-generation antihistamine, such as
ketotifen fumarate, oxatomide, azelastine hydrochloride, emedastine difumarate, and
mequitazine, are effective to some extent for nasal blockage aside from sneezing and watery
rhinorrhea. However, they may cause adverse effects, such as sleepiness and impaired
performance, in early versions. Thus, caution should be exercised in administering them. The
adverse effects of late versions, such as epinastine hydrochloride, ebastine, cetiridine,
fexofenadine, loratadine, olopatadine hydrochloride, bepotastine besilate, and levocetirizine,
have been reduced. Priority indications are mild to moderate sneezing and rhinorrhea type.
Combine them with topical steroids depending on severity. A combination drug containing
an antihistamine (fexofenadine) and an oral decongestant (pseudoephedrine) is now
available. However, the priority indication for this combination drug is limited to the

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moderate to severe nasal blockage type of pollinosis and the severe nasal blockage type of
perennial allergic rhinitis.
• Leukotriene receptor antagonists (antileukotrienes) (Table 7): Peptide leukotrienes,
produced and released by mast cells, eosinophils, and macrophages, have potent relaxing
effects on the vascular smooth muscles of the nasal mucosa, enhancing effects on vascular
permeability, and stimulating effects on eosinophil migration. Pranlukast and montelukast
are available. They are effective for nasal blockage. Their effects are increased by prolonged
administration. Comparable effects with those of antihistamines can be achieved for
sneezing and rhinorrhea within 4 weeks. Primary indications are treatment of symptoms of
the moderate or milder nasal blockage type and those of intermediate type with nasal
blockage as the chief complaint. No adverse effects of sleepiness, occur.
• Prostaglandin D2 and thromboxane A2 receptor antagonist (Table 8): Ramatroban enhances
vascular permeability in the nasal mucosa and suppresses eosinophil migration by blocking
thromboxane receptors and suppresses eosinophil migration by blocking CRTh2
(chemoattractant receptor-homologous receptor expressed on Th2 cell), a part of the
prostaglandin D2 receptor. They have strong delayed effects on nasal blockage. Primary
indications are treatment of symptoms of nasal blockage type and those of combined type
with nasal blockage as a chief complaint. The agents interact with some other medicines but
cause no adverse effects of sleepiness.
Th2 cytokine inhibitors: IPD inhibits the production of Th2 cytokines, such as IL-4 and IL-5, in T
lymphocytes to alleviate allergic inflammation. No adverse effects of sleepiness occur.
Steroids
a) Nasal steroids (Table 9): Beclomethasone propionate, fluticasone propionate, mometasone
furoate, fluticasone furoate, and dexamethasone cipecilate are available. All agents have
strong local effects in small amounts and are poorly absorbed and readily degraded. Thus, they
have few systemic adverse effects. They are highly effective for sneezing, watery rhinorrhea, and
nasal mucosal swelling, and exert their effects within 1e3 days. A slight feeling of nasal irritation,
feeling of dryness, and epistaxis may occur.
b) Steroids for internal use: Only for intractable cases with severe nasal blockage and

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laryngopharynx symptoms, uncontrollable with nasal spray steroids, prednisolone (20-40
mg/day) can be administered for 4-7 days at the start of treatment. Caution should be exercised
for adverse effects.
Alpha-sympathomimetics (nasal topical vasoconstrictor [decongestant]): Alpha-
sympathomimetics act on the a-receptors of vascular smooth muscles to cause vasoconstriction
and temporarily alleviate nasal mucosal swelling. Long-term continuous administration causes
medicament rhinitis. For the most severe pollinosis, they can be administered 2-3 times a day for
1-2 weeks.
Other pharmacotherapy: Nonspecific thalassotherapy agents, biological preparation, and herbal
medicines can be used.
Adverse effects and drug interactions of therapeutic agents for allergic rhinitis (Table 11, 12):
Therapeutic agents for allergic rhinitis are those for symptomatic treatment, used to alleviate
symptoms. Caution should be exercised for harmful adverse effects and drug interactions during
treatment. If they occur, take immediate measures and switch to a different treatment.
• Specific immunotherapy:
Subcutaneous specific immunotherapy (SCIT) has been used over the past century. Its
demonstrated effects may be exerted via immunological mechanisms. Of note, local mast cells
are decreased, the Th1/Th2 balance is altered, and regulatory T cells are increased. It takes several
months to develop effects, requiring routine injection for ≥3 years. Furthermore, a systemic
anaphylaxis response may develop in a small number of cases.16 The characteristics of this
method are shown in Table 13.
(1) Indications: This therapy is indicated for the treatment of patients aged 6 years, without
severe systemic symptoms, to whom emergency adrenaline may be administered. Exclude
patients on b-blocker therapy or with severe asthma. While this therapy has no harmful effects
on pregnant women, it should not be started during pregnancy.
(2) Implementation
- Specialists should prescribe antigen extracts and take measures against systemic reactions,
such as anaphylactic shock.
- In patients with asthma complications, avoid this therapy during a paroxysmal period. In

60 | P a g e
patients with pollinosis, avoid starting this therapy during dispersal of causative pollen.
- For initial injection, reduce the threshold concentration for intradermal reaction to 1/10. Before
injection, ask more than one physician or health care professional about concentration and
dosage.
- Before increasing an aqueous solution concentration or changing lots, conduct an intradermal
test. For patients with erythema of ≥50 mm diameter, carefully conduct the test and follow-up
the patients for 20-30 min after injection.
- Perform therapy for at least 3 years. Therapeutic effects often continue for several years after
discontinuation of administration.
- Instruct patients to continue the therapy.
• Sublingual immunotherapy (SLIT) Presently, SLIT is permitted in Japan for reactions to the
allergens, Japanese cedar pollen and dust mites. The current indication for SLIT is
confirmation of a positive allergen to Japanese cedar pollen or dust mites by a skin reaction
or a specific IgE in a patient 5 years of age or older. The allergen is administered as a liquid or
tablet every day in a dose escalation manner for at least 2 or 3 years.
• The contraindications are serious illnesses that require the use of a b blocker, unstable
asthma in which a systemic steroid may be required, treatment with an anti-cancer drug,
severe autoimmune disease, or cases in which it is assumed the treatment should not be
used in the patient because of the side effects. It cannot be begun from the dispersion
period. Sublingual inoculation should be suspended in the case of pregnancy, mouth injury
or ulcer, or if severe odonto-therapy is required. However, if pregnancy occurs while this
therapy is being administered, allergen immunotherapy, including subcutaneous injection, is
generally thought to be safe.
• Surgical treatment Nasal blockage in allergic rhinitis is often caused by nasal deformities,
such as deviated septum, hypertrophic rhinitis, and nasal polyps. In this case, perform
corrective surgery of nasal cavity to improve nasal ventilation. Before pollen season, laser
surgery is also performed for Japanese cedar pollinosis, but the effects of this surgery do not
continue in the following year. The main purpose is to alleviate nasal blockage. Various
techniques shown in Table 14 are used. For intractable rhinorrhea, perform posterior nasal

61 | P a g e
neurectomy.
Choice of therapy
• Perennial allergic rhinitis
Select a therapy based on severity and disease type. Selection criteria are shown in Table 15.
➢ For mild symptoms, second-generation antihistamines, mast cell stabilizers, Th2 cytokine
inhibitors, or nasal topical steroids are the first-line agents.
➢ For moderate symptoms of sneezing and rhinorrhea type, choose one of the following: (i)
second-generation antihistamine, (ii) mast cell stabilizer, and (iii) nasal topical steroids. Add (i)
or (ii) with (iii) as needed. For symptoms of nasal blockage or combined type, choose an agent
from (i) leukotriene receptor antagonists, (ii) prostaglandin D2/thromboxane A2 receptor
antagonist, (iii) Th2 cytokine inhibitor, (iv) nasal topical steroids. Combine (i) or (ii) or (iii) with
(iv) as needed.
➢ For severe cases with severe sneezing and rhinorrhea, combine second-generation
antihistamine with nasal spray steroids. For symptoms of nasal blockage or combined type,
add nasal topical steroids with leukotriene receptor antagonists or prostaglandin
D2/thromboxane A2 receptor antagonists. Additionally, a combination drug containing an
antihistamine and an oral decongestant is suitable for this type.
➢ For all cases, eliminate and avoid antigens. For cases in which treatment can be continued,
specific immunotherapy can also be chosen. For cases of nasal blockage type, in which the
effects of pharmacotherapy are insufficient, surgical treatment can also be chosen.
• Pollinosis: Therapy is chosen based on severity and disease type. However, the severity of
pollinosis markedly changes with the amount of pollen dispersal.
• The table below summarizes the choice of therapy for pollinosis based on severity.

62 | P a g e
N/A Section 1.2.3. ASCIA: Australasian Society of Clinical Immunology and Allergy, Allergic Rhinitis
Clinical Update [2022]11
Aeroallergen minimization
• Avoidance or minimization of confirmed allergens may assist some people in reducing the
severity of their allergic rhinitis symptoms.
• This can be difficult to achieve for house dust mite and pollens.
• Avoidance strategies must only be developed if the allergens are clinically significant.
• Realistic consideration must also be given to the family’s ability to act in strategies.
Pharmacotherapy and other treatment options
The duration and severity of allergic rhinitis symptoms are useful in guiding therapy, as shown in
the table below.

63 | P a g e
Definitions: Intermittent: 4 days/week or >4 weeks • Mild: Normal sleep, no impairment of daily
activities, normal work, or school performance. • Moderate-severe: One or more of abnormal
sleep, impairment of activities, abnormal work or school performance, troublesome symptoms.
• Allergic rhinitis pharmacotherapy options table.
• Allergic rhinitis pharmacotherapy principles.:
➔ When symptoms improve, pharmacotherapy doses may be reduced.
➔ A trial of pharmacotherapy initiated by primary care physicians and maintained for at
least 4 weeks is recommended before considering referral to a specialist if no
improvement.
➔ If a patient is a competitive athlete, it is important to ensure medications suggested are
permitted. For example, pseudoephedrine used in some decongestants is subject to
certain restrictions.
• Non-sedating antihistamines, Intranasal corticosteroids (INCS)
• Other treatment options: Saline nasal irrigation, Intranasal chromones such as sodium
cromoglycate, Intranasal ipratropium, Oral leukotriene antagonists, Decongestants, Systemic
steroids.
• Ocular management:
➔ Non-pharmacological therapy: Flush allergen from eyes (saline washes, liquid-tear
preparations), Cool compresses.

64 | P a g e
➔ Ocular or oral antihistamines or topical mast cell stabilizers may be used to control
itchy/watery eyes.
➔ Intranasal corticosteroids can reduce ocular symptoms of allergic rhinitis.
➔ Ocular corticosteroids should only be prescribed in consultation with, and regular review
by an Ophthalmologist.
• Management of allergic rhinitis in pregnancy
• Up to 20% of pregnant women develop symptoms of rhinitis, typically in second trimester,
improving 2 weeks after delivery.
• Medications for allergic rhinitis should only be used during pregnancy if the benefit to the
mother justifies the potential risk to the fetus.
• There are few well-controlled clinical studies in pregnant women examining the safety of
many of the medications used in allergic rhinitis.
• Ideally pharmacotherapy should be avoided in the first trimester of pregnancy. However,
there are some oral antihistamines and intranasal corticosteroid sprays with an “A”
category used by many pregnant women without any proven increase in harmful effects
on fetus.
• Saline nasal irrigation and intranasal chromones are safe in pregnancy.
• Management of allergic rhinitis during lactation: Recommend taking medication after
feeding the infant to minimize any potential infant exposure. (table)
Dietary restrictions are not recommended.
• There is no evidence that allergic rhinitis is due to food allergies, although conditions may
coexist.
• Food elimination is not recommended unless there is a confirmed allergy, and has potential
for serious nutritional consequences, especially in young children.
• Restricting cow’s milk (dairy) products is often popular, even if there is no confirmed food
allergy, but studies do not show any change in mucus production following dietary
modification.
• Allergen immunotherapy

65 | P a g e
• Surgery
• Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)
N/A Section 1.2.4. Ashford and St. Peter’s Hospitals NHS Foundation Trust Pediatric Allergic Rhinitis
guidelines [2023]10
Step up and down to achieve symptom control. Allow 8-12 weeks at each step.
➔ Step 1, Allergen Avoidance: Nasal rinsing - with saline solution
➔ Step 2, Regular long-acting non-sedating antihistamine: Cetirizine or Loratadine OR
Regular nasal corticosteroid spray: Avamys or Mometasone Furoate or Flixonase
Start with antihistamine if pruritus dominant or nasal corticosteroid if congestion dominant:
➔ Step 3, Regular oral antihistamine, and nasal corticosteroid
➔ Step 4, Switch to 2nd line oral antihistamine: Fexofenadine (from 6yrs)
➔ Step 5, Regular nasal antihistamine + corticosteroid spray and oral antihistamine:
Dymista nasal spray (from 12yrs) + Fexofenadine
➔ Step 6, Add in Leukotriene receptor antagonist: Montelukast.
➔ Step 7, Allergen specific immunotherapy
If eye symptoms – consider sodium cromoglicate eye drops.
Who to refer for Skin prick testing: To aid allergen avoidance, Diagnostic uncertainty.
Who to refer to ENT: Failed nasal corticosteroid spray + antihistamine for assessment of
adenoidal hypertrophy/ consideration of turbinate surgery, Suspected Obstructive Sleep Apnoea.
N/A Section 1.2.5. Rhinitis 2020: A practice parameter update12
This guideline contains systematically developed recommendations intended to optimize care of
adult and adolescent patients (>_12-15 years of age) and to assist physicians and/or other health
care practitioners and patients to make decisions regarding diagnosis and therapy for rhinitis.
Even though many treatments are approved for younger children, the application of
recommendations to children would be partially based on data extrapolation from adult studies
and would therefore be less certain.
38. CBS: We recommend that the clinician complete a detailed history and a physical

66 | P a g e
examination in a patient presenting with symptoms of rhinitis. Strong Low
39. CBS: We recommend that for patients presenting with rhinitis symptoms, a review of all
current medications should be completed to assess whether drug-induced rhinitis may be
present. Strong Ungraded
40. CBS: We recommend that aeroallergen skin prick testing or sIgE testing be completed to
confirm the diagnosis of AR in a patient with a history consistent with AR. Strong High
41. CBS: We recommend that the clinician not perform food skin prick testing or sIgE for foods in
their routine evaluation of a patient presenting with the signs and symptoms compatible
with the diagnosis of AR. Strong Ungraded
42. CBS: We suggest that the use of a validated instrument (e.g., scoring system, scale, or
questionnaire) be considered to help determine the severity of rhinitis and to monitor the
degree of disease control. Conditional Low
43. CBS: We recommend against prescribing a first-generation antihistamine and are in favor of
a second-generation antihistamine when prescribing an oral antihistamine for the treatment
of AR. Strong High
44. CBS: We suggest that the clinician not select the oral LTRA montelukast for the initial
treatment of AR due to reduced efficacy when compared with that of other agents.
Furthermore, serious neuropsychiatric events that may include suicidal thoughts or actions
have been reported in some patients taking montelukast. As advised by the FDA,
montelukast should be used to treat AR only in patients who are not treated effectively with
or cannot tolerate other alternative therapies. Conditional Very low
45. CBS: We recommend that the clinician not select an oral LTRA for the treatment of NAR.
Conditional Ungraded
46. CBS: We suggest that for the treatment of very severe or intractable AR, the clinician may
consider a short course (5-7 d) of oral corticosteroids. Conditional Very low
47. CBS: We suggest that for the treatment of very severe or intractable AR, the clinician not
prescribe a depot parenteral corticosteroid for AR due to the potential risks of systemic and
local corticosteroid side effects. Conditional Low

67 | P a g e
48. CBS: We recommend that the clinician offer INAH as an initial treatment option for patients
with SAR. Strong High
49. CBS: We recommend that the clinician offer INAH as a first-line monotherapy option for
patients with NAR. Strong High
50. CBS: We recommend that the clinician offer INAH as a first-line option for patients with
intermittent AR. Conditional Ungraded
51. CBS: We recommend that when choosing monotherapy for persistent AR, INCS be the
preferred medication. Strong High
52. GRADE: We recommend that for the initial treatment of moderate/severe SAR in patients ≥15
y of age, the clinician use an INCS over an LTRA. (Also see Recomendation 7.) Strong High
53. CBS: We suggest that the use of intranasal decongestants be short term and used for
intermittent or episodic therapy of nasal congestion. (However, see also Recommendation
26.) Conditional Low
54. CBS: We suggest that in patients having severe mucosal edema, which impairs the delivery
of other intranasal agents, an intranasal decongestant be considered for up to 5 d of use.
Conditional Ungraded
55. CBS: We suggest that oral decongestant agents be used with caution in older adults and
children younger than 4 y old, and in patients of any age who have a history of cardiac
arrhythmia, angina pectoris, cerebrovascular disease, uncontrolled hypertension, bladder
outlet obstruction, glaucoma, hyperthyroidism, or Tourette syndrome. Conditional Low
56. CBS: We recommend that oral decongestants be avoided during the first trimester of
pregnancy. Strong Low
57. CBS: We suggest that patients with PAR and NAR who have rhinorrhea as their main nasal
symptom be offered intranasal ipratropium. Conditional Low for PAR; moderate for NAR
58. CBS: We suggest that intranasal cromolyn be offered as an option to be taken just prior to
allergen exposure to reduce symptoms of AR from episodic allergen exposures. Conditional
Very low
59. GRADE: We suggest that the clinician consider the combination of an INCS and an INAH for

68 | P a g e
the initial treatment of moderate/severe nasal symptoms of SAR in patients ≥12 y old.
Conditional High
60. CBS: We suggest that the clinician consider the combination of an INCS and an INAH for
moderate/severe SAR and PAR that is resistant to pharmacologic monotherapy. * Conditional
Moderate
61. CBS: We suggest that the clinician consider the combination of an INCS and an INAH for
moderate/severe NAR that is resistant to pharmacologic monotherapy. * Conditional Low
62. CBS: We suggest that for patients taking an INCS who have persistent rhinorrhea, the
clinician may consider the addition of intranasal ipratropium. Conditional Moderate
63. CBS: We suggest that patients with persistent nasal congestion unresponsive to an INCS or
to an INCS-INAH combination be offered combination therapy with addition of an intranasal
decongestant for up to 4 wk. Conditional Low
64. CBS: We suggest that for patients with AR and nasal congestion uncontrolled with an oral
antihistamine, the clinician consider the addition of pseudoephedrine, when tolerated. (See
Recommendation 18.) Conditional Moderate
65. CBS: We suggest that for SAR the clinician not combine the oral LTRA montelukast with an
oral antihistamine for symptoms not controlled with an oral antihistamine. (See
Recommendation 7.) Conditional Moderate
66. GRADE: We recommend that the clinician not prescribe, as initial treatment, a combination
of an oral antihistamine and an intranasal steroid in preference to monotherapy with an
intranasal steroid in patients ≥ 12 y of age with symptoms of SAR. Strong Moderate
67. CBS: We suggest that the clinician not prescribe the combination of an oral antihistamine
and an INCS in preference to monotherapy with an intranasal steroid in all patients with SAR
and PAR. Conditional Very low.
68. CBS: We suggest against the addition of the oral LTRA montelukast to an INCS for AR, due to
the lack of adequate evidence of improved efficacy and concerns for serious neuropsychiatric
events from montelukast. (See Recommendation 7.) Conditional Very low
69. CBS: We suggest that the clinician offer an INCS as a first-line therapy for NAR. Conditional

69 | P a g e
Low
70. CBS: We suggest that the clinician offer an INAH as a first-line therapy for NAR. Conditional
Very low
71. CBS: We suggest that AIT (subcutaneous or sublingual tablets) be offered through shared
decision making to patients with moderate/severe AR who (1) are not controlled with allergen
avoidance and/or pharmacotherapy or (2) choose immunotherapy as the preferred method
of treatment (e.g., due to the desire to avoid the adverse effects, costs, or long-term use of
pharmacotherapy) and/or (3) desire the potential benefit of immunotherapy to prevent or
reduce the severity of comorbid conditions, such as asthma. Conditional Moderate
72. CBS: We suggest that AIT (subcutaneous or sublingual tablets) be considered for patients
with controlled mild/moderate asthma with coexisting AR. Conditional Moderate
73. CBS: We cannot make a recommendation for or against the use of acupuncture for the
treatment of AR. N/A Very low.
74. CBS: We cannot make a recommendation for or against the use of specific herbal products
for the treatment of AR
N/A Section 1.2.6. Current treatment options for allergic rhinitis: a review [2023]11

70 | P a g e
Appendix C. MeSH Terms PubMed

C.1 PubMed Search for Rhinitis:

Query Filters Search Details Results

(("Rhinitis"[MeSH Terms] AND

"Rhinitis"[Title/Abstract]) OR
"Rhinitides"[Title/Abstract]
OR "nasal
catarrh"[Title/Abstract] OR
((((((Rhinitis[MeS "catarrh nasal"[Title/Abstract]
H Terms]) AND OR (("catarrhal"[All Fields] OR
(Rhinitis[Title/Abs "common cold"[MeSH Terms]
tract])) OR OR ("common"[All Fields]
(Rhinitides[Title/ AND "cold"[All Fields]) OR
Abstract])) OR "common cold"[All Fields] OR
(Nasal "Catarrh"[All Fields] OR
Catarrh[Title/Abst Guideline, in the "Catarrhs"[All Fields]) AND
5
ract])) OR last 5 years "Nasal"[Title/Abstract]) OR
(Catarrh, (("nasalance"[All Fields] OR
Nasal[Title/Abstra "nasality"[All Fields] OR
ct])) OR (Catarrhs, "nasalization"[All Fields] OR
Nasal[Title/Abstra "nasalized"[All Fields] OR
ct])) OR (Nasal "nasally"[All Fields] OR
Catarrhs[Title/Ab "nose"[MeSH Terms] OR
stract]) "nose"[All Fields] OR
"Nasal"[All Fields] OR
"nasals"[All Fields]) AND
"Catarrhs"[Title/Abstract]))
AND ((y_5[Filter]) AND
(guideline[Filter]))

71 | P a g e
Appendix D. Treatment Algorithm

Diagnosis of allergic rhinitis

(History: prick test or serum Persistent symptoms
specific IgE antibody)

Avoidance of antigens Mild Moderate/Severe

Intermittent symptoms Mild Moderate/Severe Nasal Steroids

Oral histamine Hi antagonists Oral histamine H1 antagonists Reexamined at 2-4 weeks.

Nasal histamine H1 Nasal histamine H1

antagonists and/or antagonists and/or Improved: Gradually reduce
vasoconstrictors/ leukotriene vasoconstrictors/nasal the dose and continue
receptor antagonists (in steroids/leukotriene receptor administration for 1 month
random order) antagonists (in random order)

No effects: Reconsider
For perennial rhinitis, revisit a diagnosis. Reconfirm
hospital at 2-4 weeks compliance. Suspect infection
and others causes.

No effects: Gradually reduce

Addition or dose increase of
the dose and continue
nasal steroids
administration for 1 month.

Improved: Continue the For itching/sneezing, add

administration for 1 month histamine H1 antagonists

For conjunctivitis, add the following For rhinorrhea, add

agents: ipratropium

• Oral histamine H1 antagonists, or

intraocular histamine H1 antagonists,
or intraocular disodium cromoglycate For blockage, add
vasoconstrictors or oral
(or eye irrigation with physiological corticosteroids (for a short
time)
saline)
• Consider specific immunotherapy.

No effects: Surgery is
recommended.

Figure 1. Step by step approach for the treatment of allergic rhinitis (AR)

72 | P a g e

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Rhinitis Indication Review Update 2024

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Rhinitis Indication Review Update 2024

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RHINITIS

CHI Formulary Indication Review

ADDENDUM- January 2024

To the CHI Original Rhinitis Clinical

Related Documents ................................................................................................................................................. 3

CBS: We recommend that when

CBS: We suggest that the use of

At the end of the report, a key recommendation synthesis section is added

Section 1.0 Summary of Reviewed Clinical Guidelines &

1.1 Revised Guidelines

Table 2. Guidelines Requiring Revision

Guidelines Requiring Revision

*: No updated versions available

1.1.1 International Consensus Statement on Allergy and Rhinology: Allergic

Please refer to Section 1.2 of CHI Rhinitis original clinical guidance.

Table 3. American Academy of Pediatrics (AAP) Defined Strategy for

Preponderance of Balance of Benefit Preponderance of

B. RCT’s with minor

Pharmacotherapy and procedural options

Allergen immunotherapy for the treatment of allergic rhinitis:

1.2 Additional Guidelines

Table 4. List of Additional Guidelines

1.2.1 Saudi Clinical Practice Guideline on Allergic Rhinitis in Asthma [2014]

Table 5. Interpretation of Strong and Conditional (Weak) Recommendations

The Saudi guidelines’ recommendations are assigned the class of recommendations

1.2.2 Japanese Society of Allergology Guidelines for Allergic Rhinitis [2020]

The revised guideline published in 2020 by the Japanese Society of Allergology

Mast cell stabilizer

Chemical mediator receptor antagonists

Leukotriene receptor antagonists (antileukotrienes)

Prostaglandin D2 and thromboxane A2 receptor antagonist

Th2 cytokine inhibitors

Alpha-sympathomimetics (nasal topical vasoconstrictor [decongestant])

1.2.3 Australasian Society of Clinical Immunology and Allergy (ASCIA) Allergic

This document published by ASCIA in 2022 is aimed to complement the knowledge

Pharmacotherapy and other treatment options

Table 7. Pharmacotherapy and Treatment Options for Allergic Rhinitis. Adapted

Persistent and Intermittent and Persistent and

Definitions: Intermittent: 4 days/week or >4 weeks • Mild: Normal sleep, no

First line treatment Other possible Short term treatment

When symptoms improve, pharmacotherapy doses may be reduced.

Table 9. Non-Sedating Antihistamines. Adapted from the ASCIA 2022 Guideline.

Whilst some nasal antihistamines can reduce nasal congestion, intranasal

Different brands of INCS vary in strength and efficacy. Combination treatments

Other treatment options

Management of allergic rhinitis in pregnancy

Management of allergic rhinitis during lactation:

Dietary restrictions are not recommended

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

Table 11. AAAAI Strength Grading and Certainty of Evidence

Grading the Strength of the Consensus Based Statements (CBSs)

This guideline contains systematically developed recommendations intended to

Clinical history and physical examination

Severity assessment including QOL by survey instruments and questionnaires

1.2.6 Review Article: Current Treatment Options for Allergic Rhinitis

Leukotrienes receptor antagonists (LTRAs)

Combination of antihistamines and LTRAs

The medications below are no longer SFDA registered13, therefore, it is advisable to

Section 4.0 Conclusion

Section 6.0 Appendices

Appendix A. Prescribing Edits Definition

I. Prescribing Edits (ensure consistent use of abbreviations, e.g., CU, ST)

Prescribing edits Tools Description

C.1 PubMed Search for Rhinitis:

Query Filters Search Details Results

(("Rhinitis"[MeSH Terms] AND

Diagnosis of allergic rhinitis

Avoidance of antigens Mild Moderate/Severe

Intermittent symptoms Mild Moderate/Severe Nasal Steroids

Oral histamine Hi antagonists Oral histamine H1 antagonists Reexamined at 2-4 weeks.

Nasal histamine H1 Nasal histamine H1

No effects: Gradually reduce

Improved: Continue the For itching/sneezing, add

For conjunctivitis, add the following For rhinorrhea, add

• Oral histamine H1 antagonists, or

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