In addition, imaging is not needed to diagnose or treat straightforward AR cases. Instead, Dr. Lin said, imaging should be reserved for patients with comorbidities or those who have another issue such as chronic sinusitis or atypical symptoms that might suggest a nasal tumor or mass.
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April 2015Amber Luong, MD, PhD, associate professor in the department of otorhinolaryngology at The University of Texas Medical School at Houston, who was not involved with the guideline’s creation, found these specific recommendations to be particularly noteworthy. “In straightforward cases, you should empirically treat for AR with an oral antihistamine or possibly a nasal steroid spray,” she said. “Don’t order confirmatory tests unless the patient fails empirical therapy.”
And, while it can be tempting to order a computed tomography (CT) scan, Dr. Luong said the recommendations state that it is not necessary in patients with a clear history of AR. “As a physician, it’s important to remember that a lot of AR symptoms overlap with sinus disease, but a CT scan is not warranted unless the patient doesn’t respond as expected to treatment,” she added. “Then it’s time to explore alternative diagnoses.”
Environmental Controls
The panel recommended that physicians advise that AR patients who have identified allergens that correlate with clinical symptoms avoid known allergens or possibly utilize environmental controls (e.g., remove pets and use air filtration systems, bed covers, and acaricides). The guideline includes a discussion of the literature’s findings.
“It is interesting that some of the environmental controls that reduce allergen levels don’t actually reduce symptoms,” Dr. Lin said. For example, you may recommend that a patient with pet allergies regularly wash his or her pet. “While this reduces the level of pet allergen according to the scientific evidence, it may not impact the patient’s symptoms. So why recommend something that doesn’t change a patient’s symptoms? Critically look at what the literature says and be sure to relay this to patients.”
Sarah Wise, MD, MSCR, associate professor in the department of otolaryngology-head and neck surgery at Atlanta’s Emory University, who was not involved with the guideline’s creation, noted the limited amount of literature that examines the benefits of environmental controls. “Controls can be expensive and difficult for AR patients to execute,” she said. “Although there is some limited data to suggest that extensive environmental control measures may decrease allergen load and provide symptom benefit for patients with house dust mite allergy, similar evidence is lacking for many other allergens like pollen. In general, we tell pollen-allergic patients to keep their windows closed during pollen season and to change their clothes (and possibly shower) if they spend time outdoors during their allergic season, but this is based more on common sense than data.”
Pharmacological Treatments
A variety of pharmacological treatments are discussed in the guideline, with recommendations based on the patient’s symptoms and/or responses to other therapies. Dr. Lin highlighted the fact that clinicians should not offer oral leukotriene receptor antagonists as primary therapy for patients with AR. “The evidence supports more effective agents such as topical steroid sprays, oral second-generation antihistamines, and intranasal antihistamines,” she said. “This may be surprising for some physicians who use this as first-line therapy.” In patients with both asthma and AR, however, oral leukotriene receptor antagonists may be a good choice, because this therapy treats both conditions.