Updates in the Management of Patients With Allergic Rhinitis

In this video, Sarah Wise, MD, MSRC, discusses updates to the International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis 2023, including how the updates should be used to improve clinical practice and what is next for research in the management of patients with allergic rhinitis.  

Additional Resources:

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

Scope it Out. Accessed May 10, 2023. https://www.scopeitoutpodcast.com/

Sarah K. Wise, MD, MSCR, is a professor of otolaryngology and head and neck surgery at Emory University and the lead author of the International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis 2023 (Atlanta, GA). 

TRANSCRIPTION:

Dr Sarah Wise: Hello, I'm Dr Sarah Wise. I am a professor of Otolaryngology Head and Neck Surgery at Emory University in Atlanta, Georgia. And I am the lead author on the International Consensus Statement for Allergy and Rhinology that focuses on allergic rhinitis. And we've just recently done a 2023 update of the document. I think that's what we're going to talk about today.

Consultant360: Please provide an overview of the International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis 2023.

Dr Wise: The international consensus statement on allergy and rhinology or ICAR is what I'll call it for short, is a process that was started initially in 2016, published in the International Forum of Allergy and Rhinology Journal. This methodology of reviewing the literature and providing an evidence-based summary is something that's been published nearly every year in the IFAR Journal on various topics. Our most recent update of allergic rhinitis was just published this year, and it's an update of a prior document that came out in 2018.

The methods that we use for evaluating the literature is an extensive literature search, a coalition of the evidence into a very short text summary for each topic that we address, and then a short evidence table that summarizes each publication in that area. And then, a recommendation summary that takes into account the evidence itself as well as the benefit of the intervention, any harm and cost, and then ultimately makes a recommendation to the clinician as to whether or not they should employ this intervention in their practice. It's really a pretty thorough evaluation of the literature distilled down into a digestible format for the clinician and an easy-to-read recommendation with integral information.

Consultant360: What does this document contain?

Dr Wise: Our ICAR document for allergic rhinitis update for 2023 was a document that we worked on for about two and a half years. We have a total of 127 authors from really around the world. We have authors from many countries, Australia, Canada, China, Germany, Italy, Malaysia, the Netherlands, Singapore, Korea, Spain, Sweden, the UK, US, Thailand, and several others. It's a multidisciplinary effort including otolaryngologists, allergists, immunologists, infectious disease specialists, complimentary and integrative medicine, nursing, pediatrics, primary care, and respiratory medicine, so lots of different folks contributing. And all of these folks have an interest in allergic rhinitis research, evaluation and treatment.

Overall, we addressed 10 broad content areas, and those range anywhere from the definition and classification of allergic rhinitis to differential diagnosis, pathophysiology, epidemiology and disease burden, risk factors in protective factors, evaluation and diagnosis management, pediatric considerations, associated conditions, and then we also had a special section on COVID-19. And within those 10 broad content areas, we actually have a total of 144 individual topics that are related to allergic rhinitis. For example, an individual topic under the broad heading of management would be something like intranasal corticosteroid treatment or tablet-based sublingual immunotherapy. An individual topic under associated conditions would be something like asthma or otitis media or cough.

The document itself is fairly long, it's over 400 pages of text, but in the PDF format, it comes with a navigatable table of contents where you can click a hyperlink and go directly to the topic of interest. It's really intended to be a reference document essentially so that people can just look up a topic that they're interested in, see what the current literature is, if there are any recommendations, and how those recommendations are framed.

Consultant360: What are some of the most compelling updates to the literature?

Dr Wise:  I think it's important to note that the literature really expands very quickly. For example, our literature updates spanned the years of 2016 to 2022. And during that period of time, there was about 5,800 new articles indexed in PubMed under the heading of allergic rhinitis. The amount of literature that there is to go through and the time that it expands is really amazing. Some of the things that I think are interesting updates, if we look at the burden of allergic rhinitis, there's lots of burden clinically, socioeconomically, et cetera. But a couple of the areas where we've seen a lot of literature in the last few years is the effect of allergic rhinitis on quality of life and also the effect on sleep. And this goes for both adults and children. Treatment of allergic rhinitis is recommended both to improve quality of life and sleep.

Another interesting area that we looked at, we looked at several risk factors for allergic rhinitis as well as potential protective factors. Are there things that we can do to potentially protect people from developing allergic rhinitis? One of the areas that we looked at was breastfeeding and I think that we're all probably aware of the benefits of breastfeeding overall.

Some articles in the recent literature that would indicate that breastfeeding potentially can have a protective effect on children to prevent them from developing allergic rhinitis. In contrast, when we think about dietary intake overall, whether that's dietary intake of the mother when the child is in utero or diet in early life, there was a thought for a while that restricting the diet of the mother or restricting the diet of young children may prevent them from developing allergies. At least in recent literature, we've learned that restricting the maternal diet while the child is in utero is not really a contributing factor to developing allergic rhinitis. However, if a child does have food allergies when they're young, that can potentially indicate an overall allergic tendency and a potential risk for allergic rhinitis later.

If we think about diagnostic modalities for allergic rhinitis, things like skin testing, skin prick-testing specifically and serum allergen-specific IgE are classic modalities for evaluating for allergic rhinitis and those are certainly still recommended. But we've also learned in recent years that some of the manifestations of allergy in the nose can occur around the area where the sinuses drain specifically along the middle turbinates, superior turbinates in the back of the nasal septum. One of the options that has been advocated in more recent years is the use of nasal endoscopy to identify these certain findings in the clinic. And this is something that's commonly performed by otolaryngologists and increasingly performed by allergist immunologists, as well.

When we think about treatment, there are really three classic primary treatments for allergic rhinitis. One is avoiding allergens or changing our environment, putting in place environmental controls to reduce allergen exposure. Another avenue is using medications to control symptoms, and then the third would be using allergen immunotherapy to affect a change on the immune system overall so that the patient is not as reactive to allergens.

Some of the new recommendations that we've seen with this document is a recommendation against the use of oral decongestant medications as a sole treatment for allergy. This is primarily related to the fact that there are other better treatments and oral decongestants can have lots of unwanted side effects, and so the use of an oral decongestant alone is not recommended. Also, we've seen as far as intranasal corticosteroid use in the treatment of sinus disease, we've seen a lot of non-traditional application, so non spray application of intranasal corticosteroid use for sinus disease, things like high volume steroid irrigations, but there's not very strong research for this type of application in allergic rhinitis to stick with the intranasal corticosteroid sprays and not really use high-volume irrigations for allergic rhinitis alone.

And then another thing I'll mention is leukotriene receptor antagonists have gained a FDA box warning in the intervening time since our 2018 document. That affects some of the recommendations for the use of leukotriene receptor antagonists in the realm of allergic rhinitis with quite a bit more caution against the use of these medications for allergic rhinitis alone. Our document also considered various types of immunotherapy, both subcutaneous and sublingual immunotherapy, and there's really strong evidence for the use of both types of immunotherapy for allergic rhinitis. So for patients that are not as responsive to pharmacotherapy and avoidance measures, immunotherapy should certainly be considered in the right patient.

Consultant360: What’s next for research on this topic?

Dr Wise: I think that's one of the most exciting things about doing such a large literature search is that it really highlights not only the things that we know, but it identifies the areas where we could use more research and highlights the things that we don't know. I think there are a lot of things that could be investigated in a lot of these different realms and content areas related to allergic rhinitis. I think we need to really understand a little bit more about allergic rhinitis and the differences related to geographic locations around the world. And then tying into that, we need to understand the effect of climate change on the incidents and severity of allergic rhinitis. We certainly could learn more about how genetics and environmental factors can coincide or affect one another in the development of allergic rhinitis.

In the realm of evaluation and diagnosis, one of the things that we've all been made more aware of, especially in the COVID era, is the importance of smell loss and that can potentially be a symptom of allergic rhinitis, but it's not really something that's been studied extensively. Really understanding hyposmia as a symptom of allergic rhinitis is something that could probably be investigated a bit more.

Also, I mentioned some of the intranasal findings of allergic rhinitis. I think we could probably understand a bit more about nasal allergen-specific IgE or the IgE that is present in the nose specific to certain allergens and how we can potentially use that more in the diagnosis of allergic rhinitis. In the management realm, I think we could certainly understand a little bit better about the direct comparison between different immunotherapy modalities, so subcutaneous versus sublingual immunotherapy, and potentially the outcomes of other immunotherapy protocols like rush or cluster immunotherapy. Overall, what is potentially the best immunotherapy method for a given individual with allergic rhinitis.

And then finally, in the realm of associated conditions or comorbid diseases that occur with allergic rhinitis, we certainly could learn more about different types of chronic rhinosinusitis and nasal polyps and how those are associated with allergic rhinitis. The research in this area in the past has been very conflicting. And as we really understand more about chronic sinusitis and nasal polyp subtypes and endotypes, I'm hopeful that we'll be able to identify better where allergy fits into those.

And then finally, although this certainly doesn't cover all the potential research areas, the last thing I'll mention is the relationship of allergic rhinitis to ear disease or otologic disease, and where we can help to identify allergy better in patients with chronic ear conditions and potentially use allergy treatments to help those folks.