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Guideline Summary
Guideline Title
Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 revision.
Bibliographic Source(s)
Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 revision. Geneva: World Health Organization (WHO); 2010 Dec 23. 153 p. [742 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Allergic rhinitis and its impact on asthma. Geneva (Switzerland): World Health Organization (WHO); 2008.

This document will be updated when these reviews are performed, major new research is published, or new treatments become available. This update is planned in 2012.

Scope

Disease/Condition(s)
  • Allergic rhinitis
  • Asthma
  • Allergy

Note: Allergic rhinitis is defined clinically by the symptoms caused by immunologically mediated (most often IgE-dependent) inflammation after the exposure of the nasal mucous membranes to offending allergens. Symptoms of allergic rhinitis include rhinorrhea, nasal obstruction or blockage, nasal itching, sneezing, and postnasal drip that reverse spontaneously or after treatment. Allergic conjunctivitis often accompanies allergic rhinitis.

Guideline Category
Diagnosis
Management
Prevention
Treatment
Clinical Specialty
Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Otolaryngology
Pediatrics
Preventive Medicine
Pulmonary Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Managed Care Organizations
Nurses
Patients
Physician Assistants
Physicians
Public Health Departments
Respiratory Care Practitioners
Guideline Objective(s)

To develop explicit, unambiguous, and transparent clinical recommendations systematically for treatment of allergic rhinitis on the basis of current best evidence

Target Population

Adults and children with allergy, allergic rhinitis, and/or asthma

Interventions and Practices Considered

Prevention of Allergy

  1. Breastfeeding infants
  2. Antigen avoidance diet (considered but not recommended)
  3. Avoidance of environmental tobacco smoke
  4. Avoidance of exposure to house dust mites in infants and preschool children
  5. Avoidance of exposure to pets in infants and preschool children
  6. Avoidance of occupational allergen exposure

Treatment of Allergic Rhinitis

  1. Reduce allergen exposure
    • Avoidance of indoor moulds exposure at home
    • Avoidance of animal dander exposure at home
    • Immediate and total cessation of exposure to an occupational agent or exposure controls
  2. Pharmacological treatment of allergic rhinitis
    • Oral H1-antihistamines (new generation)
    • Intranasal H1-antihistamines
    • Oral leukotriene receptor antagonists
    • Intranasal glucocorticosteroids
    • Oral glucocorticosteroids
    • Intramuscular glucocorticosteroids (considered but not recommended)
    • Intranasal chromones
    • Intranasal ipratropium bromide
    • Intranasal decongestant
    • Oral decongestants
    • Intraocular H-antihistamines
    • Intraocular chromones
  3. Specific allergen immunotherapy
    • Subcutaneous specific immunotherapy
    • Sublingual allergen-specific immunotherapy
    • Intranasal allergen-specific immunotherapy
  4. Alternative and complementary treatment for allergic rhinitis (considered but not recommended)

Treatment of Asthma in Patients with Allergic Rhinitis

  1. Oral H1-antihistamines (considered but not recommended)
  2. Combination of oral H1-antihistamine and an oral decongestant (considered but not recommended)
  3. Intranasal glucocorticosteroids (considered but not recommended)
  4. Inhaled glucocorticosteroids
  5. Subcutaneous specific immunotherapy
  6. Sublingual specific immunotherapy
  7. Monoclonal antibody against IgE
Major Outcomes Considered
  • Side effects of treatment
  • Response of symptoms (sneezing, rhinorrhea, nasal obstruction, nasal itch, eye symptoms) to treatment
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Identifying and Summarizing the Evidence

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to developing guidelines postulates that before grading the quality of evidence and strength of each recommendation, guideline developers should first identify a recently well-done systematic review of the appropriate evidence answering the relevant clinical questions, or conduct one when there is none available. This should be followed by a transparent evidence summary, such as creation of GRADE evidence profiles, on which to base judgements.

For the Allergic Rhinitis and its Impact on Asthma (ARIA) guideline 2008 update, this postulate is partially fulfilled. Members of the ARIA guideline panel, including the GRADE representatives, performed extensive literature searches addressing the clinical questions covered by the guideline. In addition, they identified up-to-date valid systematic reviews by searching the MEDLINE database, Cochrane Library, and in selected cases also reference lists of the most recent narrative views, related systematic reviews, or studies on the topic. They based their judgements on these systematic reviews and, if applicable, on additional randomised trials published afterwards. They developed GRADE evidence profiles (see Figure 1 in the methodology document [see the "Availability of Companion Documents"] field) based on the systematic reviews. These concise evidence profiles allowed panel members to base their judgements on the same and concisely summarised evidence.

When there was no recent systematic review available, the panel did not perform its own systematic reviews, but followed a pragmatic approach and searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar for relevant randomised trials.

For many questions randomised trials were not available, and the panel relied on available observational studies that were identified for a prior ARIA guideline edition, its subsequent updates, or additional non-structured searches for observational studies. Panel members evaluated the original observational studies to inform judgements about the quality of the underlying evidence. In such situations, they based the judgements about the quality of evidence on a crude examination of the most important studies.

For the 2010 Update

The panel used the previous version of the ARIA guidelines as a starting point for the identification of clinical questions.

The panel based the evidence summaries on existing up-to-date well done systematic reviews. Systematic reviews were supplemented, if necessary, with additional recent randomised trials (until August 2007 and for selected clinical questions until January 2009). When there was no recent valid systematic review available, the panel did not perform rigorous systematic reviews, but systematically searched MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant studies. When possible and justified the panel combined the results of identified studies using meta-analysis. The identified original studies were evaluated to inform judgements about the underlying evidence, if they addressed the relevant PICO (population, intervention, comparison, outcomes) question.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

A summary of the GRADE approach to grading the quality of evidence for each outcome.

Source of Body of Evidence Initial Rating of Quality of a Body of Evidence Factors that May Decrease the Quality Factors that May Increase the Quality Final Quality of a Body of Evidence
Randomized trials
Observational studies
High
Low
  1. Risk of bias
  2. Inconsistency
  3. Indirectness
  4. Imprecision
  5. Publication bias
  1. Large effect
  2. Dose-response
  3. All plausible residual confounding would reduce the demonstrated effect or would suggest a spurious effect if no effect was observed
High (++++)
Moderate (+++O)
Low (++OO)
Very low (+OOO)
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Preparation of Evidence Summaries

The panel prepared evidence profiles for each question (originating from the previous edition of the guideline) following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using the GRADEpro© software version 3.1. These concise evidence profiles allowed panel members to base their judgements on the same and concisely summarised evidence. The summaries of evidence were then peer reviewed and corrections and comments incorporated by the expert panel.

The panel based the evidence summaries on existing up-to-date well done systematic reviews. Systematic reviews were supplemented, if necessary, with additional recent randomised trials (until August 2007 and for selected clinical questions until January 2009).

When possible and justified the panel combined the results of identified studies using meta-analysis. The identified original studies were evaluated to inform judgements about the underlying evidence, if they addressed the relevant PICO (population, intervention, comparison, outcomes) question.

The GRADE system classifies the quality of evidence into four categories: high, moderate, low, and very low. The quality of evidence reflects the extent to which a guideline panel's confidence in an estimate of the effect is adequate to support a particular recommendation. When classifying evidence into one of the quality categories one considers the following factors: 1) study design and rigour of its execution or risk of bias (as described above for this revision we did not review all original studies, but rather relied on the judgement of the authors of a systematic review), 2) the extent to which available evidence can be directly applied to the target patients, interventions, and outcomes, 3) the consistency of results, 4) whether the results are precise, and 5) whether there is a likelihood of publication bias (in this publication we grouped the evaluation of selective outcome reporting and typical publication bias – please note that the GRADE working group has since categorised selective outcome reporting bias under limitations in study design and execution and separated it from publication bias based on methods of the Cochrane Collaboration). The following three factors lead to upgrading the quality of evidence: 1) a strong or very strong association, 2) a dose-effect relationship, and 3) all plausible confounding may be working to reduce the demonstrated effect or increase the effect if no effect was observed. The overall quality of evidence is determined by the lowest quality of evidence for each of the critical outcomes. When outcomes point in the same direction (all critical outcomes suggesting benefit) then the overall quality of evidence reflects the quality of the better evidence (e.g., two critical outcomes showing convincing benefit are of low quality and a third of very low quality, the overall quality is not reduced from low to very low).

The following are the definitions of these categories:

  • High: Further research is very unlikely to change confidence in the estimate of effect.
  • Moderate: Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
  • Low: Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.
  • Very low: Any estimate of effect is very uncertain.

Some outcomes in patients with allergic rhinitis are measured on a continuous scale (e.g., symptom scores and quality of life). When they are summarised across studies and combined in meta-analysis, they are often presented as standardised mean difference (SMD) that is expressed in standard deviation (SD) units. Results expressed as a SMD are challenging to interpret by clinicians. To facilitate understanding the panel used interpretation of the effect size suggested by Cohen. According to this interpretation, a SMD of around 0.2 is considered a small effect, around 0.5 – a moderate effect, and around 0.8 or higher – a large effect. The panel used this interpretation throughout this document whenever we referred to effects of interventions as either small, moderate or large.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Group Composition

The Allergic Rhinitis and its Impact on Asthma (ARIA) guideline panel included eight clinicians experienced in treating allergic rhinitis (AR) and asthma in adults and in children and two methodologists who were primarily responsible for collecting the evidence, developing evidence summaries, and drafting the guideline.

Panel Meetings

Two meetings were held to discuss the clinical questions, the results of the evidence reviews, and to agree on recommendations. No recommendation required voting.

Balancing Desirable and Undesirable Consequences of Available Treatment Options and Developing Recommendations

Formulating the recommendations included consideration of the quality of evidence, desirable and undesirable consequences of following the recommended course of action, and values and preferences of those for whom the recommendations are intended. For most recommendations resource utilization (cost) was also taken into account. Recommendations were classified as 'strong' or 'weak' as recommended by the GRADE working group. Statements about the underlying values and preferences as well as the remarks are integral parts of the recommendations and serve to facilitate accurate interpretation.

In this document, the expression "values and preferences" refers to the relative worth or importance of a health state or the consequences of a decision to follow a particular course of action (i.e., a relative weight one attributes to particular benefits, harms, burdens, and costs to determine their balance). Individuals usually assign less value to and have less preference for more impaired health states (e.g., death or impaired social functioning and work productivity due to severe rhinitis symptoms) compared to other health states (e.g., full health or having very mild symptoms that do not interfere with daily life). The panel used the decision framework described previously to determine the strength of recommendations.

Following the GRADE approach, in these guidelines the panel classified recommendations as either strong or conditional (weak). The strength of recommendations depends on a balance between all desirable and all undesirable effects of an intervention (i.e., net clinical benefit), quality of available evidence, values and preferences, and cost (resource utilization). In general, the higher the quality of the supporting evidence, the more likely it is for the recommendation to be strong. Conversely, if the quality is low or very low a conditional recommendation is more likely. Strong recommendations based on low or very low quality evidence are rare, but possible. An alternative, acceptable term for conditional recommendation is weak. For strong recommendations the panel used the words "we recommend" and for conditional recommendations – "we suggest".

Rating Scheme for the Strength of the Recommendations

Interpretation of Strong and Conditional (Weak)* Recommendations

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

*Guideline panels applying GRADE use the term "conditional" and "weak" synonymously.

Cost Analysis

Little information about costs of prevention or treatment of allergic rhinitis was available to the panel and it is very likely that it varies considerably across geographical areas and jurisdictions. Cost, therefore, plays a limited role in these recommendations. However, whenever we considered cost and resource expenditure we used health system perspective. For individual patients cost may not be an issue if the medication is provided at reduced price or free of charge. Clinicians and patients should consider their local resource implications when interpreting these recommendations.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Eighty clinicians involved in the management of patients and/or research of allergic rhinitis (AR) from a variety of countries and 3 members of patient organizations were asked to review the guidelines. As a result, the guideline panel performed additional searches for most recent studies and reassessed the evidence for several questions.

Recommendations

Major Recommendations

Definitions of the strength of the recommendations (High-Low) and an interpretation of strong and conditional (weak) recommendations are provided at the end of the "Major Recommendations" field.

Prevention of Allergy

  1. Should exclusive breastfeeding be used in infants to prevent allergy?

    Recommendation: The guideline panel suggests exclusive breastfeeding for at least the first three months for all infants irrespective of their family history of atopy (conditional recommendation | low quality evidence).

    Values and preferences: This recommendation places a relatively high value on the prevention of allergy and asthma, and a relatively low value on challenges or burden of breastfeeding in certain situations.

    Remarks: The evidence that exclusive breastfeeding for at least the first three months reduces the risk of allergy or asthma is not convincing and the recommendation to exclusively breastfeed is conditional. This recommendation applies to situations in which other reasons do not suggest harm from breastfeeding (e.g., classic galactosemia, active untreated tuberculosis or human immunodeficiency virus infection in the mother, antimetabolites, chemotherapeutic agents or radioactive isotopes used in the mother until they clear from the milk, and bacterial or viral infection of a breast).

  2. Should antigen avoidance diet be used in pregnant or breastfeeding women to prevent development of allergy in children?

    Recommendation: For pregnant or breastfeeding women, the guideline panel suggests no antigen avoidance diet to prevent development of allergy in children (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on adequate nourishment of mothers and children, and a relatively low value on very uncertain effects on the prevention of allergy and asthma in this setting.

  3. Should children and pregnant women avoid environmental tobacco smoke (i.e., passive smoking) to reduce the risk of developing allergy, wheezing, or asthma in children?

    Recommendation: In children and pregnant women, the guideline panel recommends total avoidance of environmental tobacco smoke (i.e., passive smoking) (strong recommendation | very low quality evidence).

    Remarks: Smoking and exposure to second-hand smoke are common health problems around the world causing a substantial burden of disease for children and adults. While it is very rare to make a strong recommendation based on low or very low quality evidence, the Allergic Rhinitis and its Impact on Asthma (ARIA) guideline panel felt that in the absence of important adverse effects associated with smoking cessation or reducing the exposure to second-hand smoke, the balance between the desirable and undesirable effects is clear.

  4. Should infants and preschool children avoid exposure to house dust mites to reduce the risk of developing dust mite allergy and asthma?

    Recommendation: In infants and preschool children, the guideline panel suggests multifaceted interventions to reduce early life exposure to house dust mites (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively low value on the burden and cost of using multiple preventive measures (e.g., encasings to parental and child's bed, washing bedding and soft toys at temperature exceeding 55°C [131°F], use of acaricide, smooth flooring without carpets, etc.), and relatively high value on an uncertain small reduction of the risk of developing wheeze or asthma. For some children at lower risk of developing asthma and in certain circumstances an alternative choice will be equally reasonable.

    Remarks: Children at high risk of developing asthma are those with at least one parent or sibling with asthma or other allergic disease.

  5. Should infants and preschool children avoid exposure to pets at home to reduce the risk of developing allergy and asthma?

    Recommendation: In infants and preschool children, the guideline panel suggests no special avoidance of exposure to pets at home (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on possible psychosocial downsides of not having a pet and relatively low value on potential reduction in the uncertain risk of developing allergy and/or asthma.

    Remarks: Clinicians and patients may reasonably choose an alternative action, considering circumstances that include other sensitized family members.

  6. Should specific measures reducing occupational agent exposure be used to decrease the risk of sensitization and subsequent development of occupational rhinitis and asthma?

    Recommendation: For individuals exposed to occupational agents, the guideline panel recommends specific prevention measures eliminating or reducing occupational allergen exposure (strong recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on reducing the risk of sensitization to occupational allergens and developing occupational rhinitis and/or asthma with the subsequent adverse consequences, and a relatively low value on the feasibility and cost of specific strategies aimed at reducing occupational allergen exposure.

    Remarks: Total allergen avoidance, if possible, seems to be the most effective primary prevention measure.

Treatment of Allergic Rhinitis

Reducing Allergen Exposure

  1. Should methods aimed at reducing exposure to house dust mites be used in patients allergic to dust mite allergens?

    Recommendation: In patients with allergic rhinitis and/or asthma sensitive to house dust mite allergens, the guideline developers recommend that clinicians do not administer and patients do not use currently available single chemical or physical preventive methods aimed at reducing exposure to house dust mites (strong recommendation | low quality evidence) or their combination (conditional recommendation | very low quality evidence), unless this is done in the context of formal clinical research.

    The guideline panel suggests multifaceted environmental control programs be used in inner-city homes to improve symptoms of asthma in children (conditional recommendation | very low quality evidence).

    Underlying values and preferences: The recommendation to use multifaceted environmental control programs in inner-city homes places a relatively high value on possible reduction in the symptoms of asthma in children, and relatively low value on the cost of such programmes.

  2. Should patients allergic to indoor moulds avoid exposure to these allergens at home?

    Recommendation: In patients allergic to indoor moulds, the guideline panel suggests avoiding exposure to these allergens at home (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on possible reduction in the symptoms of rhinitis and asthma, and a relatively low value on the burden and cost of interventions aimed at reducing exposure to household moulds.

  3. Should patients allergic to animal dander avoid exposure to these allergens at home?

    Recommendation: In patients with allergic rhinitis due to animal dander, the guideline panel recommends avoiding exposure to these allergens at home (strong recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on potential reduction of symptoms of allergic rhinitis, and a relatively low value on psychosocial downsides of not having a pet or the inconvenience and cost of environmental control measures.

    Remarks: Based on biological rationale, there is little doubt that total avoidance of animal allergens at home, and probably also marked reduction in their concentration, can improve symptoms, despite paucity of published data to substantiate this statement.

  4. Should immediate and total cessation of exposure to an occupational agent or exposure control be used in patients with occupational rhinitis and asthma?

    Recommendation: In patients with occupational asthma, the guideline panel recommends immediate and total cessation of exposure to occupational allergen (strong recommendation | very low quality evidence). When total cessation of exposure is not possible, the guideline developers suggest specific strategies aimed at minimizing occupational allergen exposure (conditional recommendation | very low quality evidence).

    Underlying values and preferences: The recommendation to immediately and totally cease the exposure to occupational allergen places a relatively high value on reducing the symptoms of asthma and deterioration of lung function, and a relatively low value on the potential socioeconomic downsides (e.g., unemployment).

Pharmacological Treatment of Allergic Rhinitis

  1. Should oral H1-antihistamines be used for the treatment of allergic rhinitis?

    Recommendation: In patients with allergic rhinitis (AR), the guideline panel recommends new generation oral H1-antihistamines that do not cause sedation and do not interact with cytochrome P450 (strong recommendation | low quality evidence). In patients with AR, the guideline panel suggests new generation oral H1-antihistamines that cause some sedation and/or interact with cytochrome P450 (conditional recommendation | low quality evidence).

    Underlying values and preferences: The recommendation to use new generation oral H1-antihistamines that cause some sedation and/or interact with cytochrome P450 places a relatively high value on a reduction of symptoms of AR, and a relatively low value on side effects of these medications.

    Remarks: Astemizole and terfenadine were removed from the market due to cardiotoxic side effects.

  2. Should new generation oral H1-antihistamines versus old generation oral H1-antihistamines be used for the treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel recommends new generation over old generation oral H1-antihistamines (strong recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on the reduction of adverse effects, and a relatively low value on an uncertain comparative efficacy of new versus old generation oral H1-antihistamines.

  3. Should oral H1-antihistamines be used in preschool children with other allergic diseases for the prevention of wheezing or asthma?

    Recommendation: In infants with atopic dermatitis and/or family history of allergy or asthma (at high risk of developing asthma), the guideline panel suggests clinicians do not administer and parents do not use oral H1-antihistamines for the prevention of wheezing or asthma (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding side effects of oral H1-antihistamines in infants, and a lower value on the very uncertain reduction in the risk of developing asthma or wheezing.

    Remarks: The recommendation not to use oral H1-antihistamines in these infants refers only to prevention of asthma or wheezing. The guideline panel did not consider other conditions in which these medications may be commonly used (e.g., urticaria).

  4. Should intranasal H1-antihistamines be used for treatment of allergic rhinitis?

    Recommendation: The guideline panel suggests intranasal H1-antihistamines in adults with seasonal allergic rhinitis (conditional recommendation | low quality evidence) and in children with seasonal allergic rhinitis (conditional recommendation | very low quality evidence). In adults and children with perennial/persistent AR, the guideline panel suggests that clinicians do not administer and patients do not use intranasal H1-antihistamines until more data on their relative efficacy and safety is available (conditional recommendation | very low quality evidence).

    Underlying values and preferences: The recommendation to use intranasal H1-antihistamines in patients with seasonal allergic rhinitis places a relatively high value on reduction of symptoms, and a relatively low value on the risk of rare or mild side effects. The recommendation not to use intranasal H1-antihistamines in patients with perennial/persistent allergic rhinitis places a relatively high value on their uncertain efficacy and possible side effects, and a relatively low value on possible small reduction in symptoms.

  5. Should new generation oral H1-antihistamines versus intranasal H1-antihistamines be used for treatment of allergic rhinitis?

    Recommendation: The guideline panel suggests new generation oral H1-antihistamines rather than intranasal H1-antihistamines in adults with seasonal allergic rhinitis (conditional recommendation | moderate quality evidence) and in adults with perennial/persistent allergic rhinitis (conditional recommendation | very low quality evidence). In children with intermittent or persistent allergic rhinitis the guideline panel also suggests new generation oral H1-antihistamines rather than intranasal H1-antihistamines (conditional recommendation | very low quality evidence).

    Underlying values and preferences: These recommendations place a relatively high value on probable higher patient preference for oral versus intranasal route of administration as well as avoiding the bitter taste of some intranasal H1-antihistamines, and relatively low value on increased somnolence with some new generation oral H1-antihistamines. In many patients with different values and preferences or those who experience adverse effects of new generation oral H1-antihistamines an alternative choice may be equally reasonable.

  6. Should oral leukotriene receptor antagonists be used for treatment of allergic rhinitis?

    Recommendation: The guideline panel suggests oral leukotriene receptor antagonists in adults and children with seasonal allergic rhinitis (conditional recommendation | high quality evidence) and in preschool children with perennial allergic rhinitis (conditional recommendation | low quality evidence). In adults with perennial allergic rhinitis the guideline panel suggests that clinicians do not administer and patients do not use oral leukotriene receptor antagonists (conditional recommendation | high quality evidence).

    Underlying values and preferences: The recommendation to use oral leukotriene receptor antagonists in adults and children with seasonal allergic rhinitis and in preschool children with perennial allergic rhinitis places a relatively high value on their safety and tolerability, and relatively low value on their limited efficacy and high cost.

    The recommendation not to use oral leukotriene receptor antagonists in adults with perennial allergic rhinitis places a relatively high value on their very limited efficacy and high cost, and relatively low value on potential small benefit in few patients.

    Remarks: Evidence is available only for montelukast. This recommendation refers to the treatment of rhinitis, not to the treatment of asthma in patients with concomitant allergic rhinitis (see recommendation 45).

  7. Should oral leukotriene receptor antagonists versus oral H1-antihistamines be used for treatment of allergic rhinitis?

    Recommendation: The guideline panel suggests oral H1-antihistamines over oral leukotriene receptor antagonists in patients with seasonal allergic rhinitis (conditional recommendation | moderate quality evidence) and in preschool children with perennial allergic rhinitis (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding resource expenditure.

  8. Should intranasal glucocorticosteroids be used for treatment of allergic rhinitis?

    Recommendation: The guideline panel recommends intranasal glucocorticosteroids for treatment of allergic rhinitis in adults (strong recommendation | high quality evidence) and suggest intranasal glucocorticosteroids in children with allergic rhinitis (conditional recommendation | moderate quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on the efficacy of intranasal glucocorticosteroids, and a relatively low value on avoiding their possible adverse effects.

  9. Should intranasal glucocorticosteroids versus oral H1-antihistamines be used in patients with allergic rhinitis?

    Recommendation: In patients with seasonal AR, the guideline panel suggests intranasal glucocorticosteroids over oral H1-antihistamines in adults (conditional recommendation | low quality evidence) and in children (conditional recommendation | very low quality evidence). In patients with perennial/persistent AR, the guideline panel suggests intranasal glucocorticosteroids over oral H1-antihistamines in adults (conditional recommendation | moderate quality evidence) and in children (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on the likely higher efficacy of intranasal glucocorticosteroids. In many patients with strong preference for oral versus intranasal route of administration an alternative choice may be reasonable.

  10. Should intranasal glucocorticosteroids versus intranasal H1-antihistamines be used in patients with allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel recommends intranasal glucocorticosteroids rather than intranasal H1-antihistamines (strong recommendation | high quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on efficacy of intranasal glucocorticosteroids, and a relatively low value on their rare adverse effects.

  11. Should intranasal glucocorticosteroids versus oral leukotriene receptor antagonists be used for treatment of allergic rhinitis?

    Recommendation: In patients with seasonal allergic rhinitis the guideline panel recommends intranasal glucocorticosteroids over oral leukotriene receptor antagonists (strong recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a high value on the efficacy of intranasal glucocorticosteroids.

    Remarks: Evidence is available for montelukast only.

  12. Should oral glucocorticosteroids be used for treatment of allergic rhinitis in patients not responding to other therapy?

    Recommendation: In patients with allergic rhinitis and moderate to severe nasal and/or ocular symptoms that are not controlled with other treatments, the guideline panel suggests a short course of oral glucocorticosteroids (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on possible relief of severe symptoms, and a relatively low value on avoiding possible side effects of a short course of oral glucocorticosteroids.

    Remarks: Systemic glucocorticosteroids should not be considered as a first line of treatment for AR. They can be used for few days as a last resort of treatment when combinations of other medications are ineffective. Oral glucocorticosteroids should be avoided in children, pregnant women, and patients with known contraindications.

  13. Should intramuscular glucocorticosteroids be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel recommends that clinicians do not administer intramuscular glucocorticosteroids (strong recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding possible side effects of a single or multiple injections of intramuscular glucocorticosteroids, and relatively low value on their efficacy and convenience of use.

    Remarks: Possible side effects of intramuscular glucocorticosteroids may be far more serious than the condition they are supposed to treat (i.e., AR).

  14. Should intranasal chromones be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests intranasal chromones (conditional recommendation | moderate quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on excellent safety and tolerability of intranasal chromones, and relatively low value on their limited efficacy and on limiting resource expenditure.

    Remarks: The need for administration 4 times daily is likely to reduce patient adherence and reduce efficacy.

  15. Should intranasal H1-antihistamines versus intranasal chromones be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests intranasal H1-antihistamines over intranasal chromones (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on possibly higher efficacy of intranasal H1-antihistamines, and relatively low value on safety and tolerability of intranasal chromones.

    Remarks: Chromones require administration 4 times daily that may limit patient adherence to treatment and reduce efficacy.

  16. Should intranasal ipratropium bromide be used for treatment of allergic rhinitis?

    Recommendation: In patients with perennial AR, the guideline panel suggests intranasal ipratropium bromide for treatment of rhinorrhea (conditional recommendation | moderate quality evidence).

    Remarks: Intranasal ipratropium bromide is effective for rhinorrhea. It is unlikely to be beneficial for other symptoms of AR.

  17. Should intranasal decongestant be used for treatment of allergic rhinitis?

    Recommendation: In adults with allergic rhinitis and severe nasal obstruction, the guideline panel suggests a very short course (not longer than five days and preferably shorter) of intranasal decongestant while co-administering other drugs (conditional recommendation | very low quality evidence). The guideline panel suggests that clinicians do not administer and parents do not use intranasal decongestants in preschool children (conditional recommendation | very low quality evidence).

    Underlying values and preferences: The recommendation for use of a very short course of an intranasal decongestant in adults with allergic rhinitis places a relatively high value on the prompt relief of nasal obstruction, and relatively low value on avoiding the risk of adverse effects with a prolonged use of intranasal decongestant.

    The recommendation against the use of an intranasal decongestant in children and against long-term use in adults places a relatively high value on avoiding the risk of serious adverse effects, and relatively low value on a possible benefit from a reduced nasal blockage.

  18. Should oral decongestant be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests that clinicians do not administer and patients do not use oral decongestants regularly (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding adverse effects of oral decongestants, and a relatively low value on possible small reduction in symptoms of rhinitis.

    Remarks: Oral decongestants may be of benefit for some patients as a rescue or "as needed" medication.

  19. Should combination of oral decongestant and H1-antihistamine versus oral H1-antihistamine alone be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests clinicians do not administer and patients do not use regularly a combination of oral H1-antihistamine and an oral decongestant, compared to oral H1-antihistamine alone (conditional recommendation | moderate quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding adverse effects of oral decongestant, and a relatively low value on small additional reduction in symptoms of rhinitis.

    Remarks: In adults with symptoms not controlled with oral H1-antihistamine alone who are less averse to side effects of oral decongestants an alternative choice may be equally reasonable. Administration of a combined treatment as a rescue medication may also be beneficial to some patients.

  20. Should intraocular H1-antihistamines be used for the treatment of ocular symptoms in patients with allergic rhinitis?

    Recommendation: In patients with allergic rhinitis and symptoms of conjunctivitis, the guideline panel suggests intraocular H1-antihistamines (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on consistent effectiveness of intraocular H1-antihistamines, and relatively low value on their side effects and uncertain effectiveness in patients already using other medications for AR.

    Remarks: Only one study was done in children.

  21. Should intraocular chromones be used for treatment of ocular symptoms in patients with allergic rhinitis?

    Recommendation: In patients with allergic rhinitis and symptoms of conjunctivitis, the guideline panel suggests intraocular chromones (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on excellent safety and tolerability of intraocular chromones and relatively low value on their limited effectiveness.

    Remarks: In adults and children with limited ocular symptoms, chromones may be tried first because of their excellent safety and tolerability. Chromones require administration 4 times daily that may limit patient compliance with treatment and reduce efficacy.

Specific Allergen Immunotherapy for Allergic Rhinitis

  1. Should subcutaneous specific immunotherapy be used for treatment of allergic rhinitis in adults without concomitant asthma?

    Recommendation: The guideline panel suggests subcutaneous allergen specific immunotherapy in adults with seasonal (conditional recommendation | moderate quality evidence) and perennial allergic rhinitis due to house dust mites (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on relieving the symptoms of AR, and a relatively low value on avoiding adverse effects and on resource expenditure.

  2. Should subcutaneous specific immunotherapy be used for treatment of allergic rhinitis in children without concomitant asthma?

    Recommendation: In children with AR, the guideline panel suggests subcutaneous specific immunotherapy (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on probable reduction in symptoms of allergic rhinitis and the potential prevention of the development of asthma, and relatively low value on avoiding adverse effects in children and resource expenditure.

  3. Should sublingual specific immunotherapy be used for treatment of allergic rhinitis in adults without concomitant asthma?

    Recommendation: The guideline panel suggests sublingual allergen specific immunotherapy in adults with rhinitis due to pollen (conditional recommendation | moderate quality evidence) or house dust mites (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on alleviating the symptoms of rhinitis, and relatively low value on avoiding adverse effects and resource expenditure.

    Remarks: Local adverse effects are relatively frequent (~35%). An alternative choice may be equally reasonable, if patients' values or preferences differ from those described here.

  4. Should sublingual specific immunotherapy be used for treatment of allergic rhinitis in children without concomitant asthma?

    Recommendation: In children with allergic rhinitis due to pollens, the guideline panel suggests sublingual allergen-specific immunotherapy (conditional recommendation | moderate quality evidence). In children with allergic rhinitis due to house dust mites, the guideline panel suggests that clinicians do not administer sublingual immunotherapy outside rigorously designed clinical trials (conditional recommendation | very low quality evidence).

    Underlying values and preferences: The recommendation to use sublingual immunotherapy in children with seasonal allergic rhinitis places a relatively high value on small reduction in nasal symptoms, and relatively low value on avoiding adverse effects in children and resource expenditure. The recommendation to use sublingual immunotherapy in children with perennial allergic rhinitis only in the context of clinical research places a relatively high value on avoiding adverse effects and resource expenditure, and relatively low value on possible small reduction in nasal symptoms.

    Remark: Local adverse effects are relatively frequent (~35%). An alternative choice may be equally reasonable, if patients' values or preferences differ from those described here.

  5. Should local nasal specific immunotherapy be used for treatment of allergic rhinitis?

    Recommendation: The guideline panel suggests intranasal allergen specific immunotherapy in adults (conditional recommendation | low quality evidence) and in children with allergic rhinitis due to pollens (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on the reduction of symptoms of allergic rhinitis during pollen season, and a relatively low value on avoiding local side effects and cost. An alternative choice may be equally reasonable.

Alternative and Complementary Treatment for Allergic Rhinitis

  1. Should homeopathy be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests that clinicians do not administer and patients do not use homeopathy (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding possible adverse effects and resource expenditure, and a relatively low value on any possible, but unproven, benefit of these treatments in AR.

  2. Should acupuncture be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests clinicians do not administer and patients do not use acupuncture (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding the potential complications of acupuncture, and a relatively low value on uncertain reduction in symptoms of rhinitis.

    Remarks: In patients who choose to be treated with acupuncture ONLY disposable needles should be used.

  3. Should butterbur be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests clinicians do not administer and patients do not use butterbur (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding the uncertain adverse effects of butterbur, and a relatively low value on equally uncertain reduction in symptoms of rhinitis.

    Remarks: In patients who are less risk averse an alternative may be equally reasonable. However, if one chooses to use butterbur one should consider only commercial preparations in which butterbur extract does not contain toxic pyrrolizidine alkaloids.

  4. Should herbal medicines other than butterbur be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests clinicians do not administer and patients do not use herbal medicines (conditional recommendation | very low quality evidence).

    Underlying values and preferences: The recommendation places a relatively high value on avoiding possible serious adverse events and drug interactions, and a relatively low value on possible reduction in symptoms of rhinitis.

  5. Should physical techniques and other alternative therapies be used for treatment of allergic rhinitis?

    Recommendation: In patients with AR, the guideline panel suggests that clinicians do not administer and patients do not use phototherapy or other physical techniques (conditional recommendation | very low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding potential adverse effects of these therapies, and a relatively low value on their very uncertain effect on symptoms of rhinitis.

Treatment of Asthma in Patients with Allergic Rhinitis and Asthma

  1. Should oral H1-antihistamines be used for treatment of asthma in patients with allergic rhinitis and asthma?

    Recommendation: In patients (both children and adults) with allergic rhinitis and asthma, the guideline panel suggests clinicians do not administer and patients do not use oral H1-antihistamines for the treatment of asthma (conditional recommendation | very low quality evidence).

    Underlying values and preferences: The recommendation not to use oral H1-antihistamines in adults with allergic rhinitis and asthma for the treatment of asthma places a relatively high value on avoiding their adverse effects, and a relatively low value on their very uncertain effect on symptoms of asthma. The recommendation not to use oral H1-antihistamines in children with allergic rhinitis for the treatment of asthma or wheeze, despite the evidence of efficacy of ketotifen when used alone in children with mild to moderate asthma, places a relatively high value on avoiding its side effects, and a relatively low value on its unknown efficacy in children already using inhaled corticosteroids, since inhaled corticosteroids are currently considered medications of first choice in treatment of chronic asthma.

    Remarks: This recommendation suggests that oral H1-antihistamines should not be used to treat symptoms of asthma, but they may still be used in patients with asthma and rhinitis for treatment of rhinitis (recommendations 11 and 12).

  2. Should combination of oral H1-antihistamine and oral decongestant be used for treatment of asthma in patients with allergic rhinitis and asthma?

    Recommendation: In patients with allergic rhinitis and asthma, the guideline panel suggests clinicians do not administer and patients do not use a combination of oral H1-antihistamine and oral decongestant for treatment of asthma (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding adverse effects of combination of oral H1-antihistamine and oral decongestant, and a relatively low value on possible small reduction in asthma symptoms of uncertain clinical significance.

  3. Should intranasal glucocorticosteroids be used for treatment of asthma in patients with allergic rhinitis and asthma?

    Recommendation: In patients with allergic rhinitis and asthma, the guideline panel suggests that clinicians do not administer and patients do not use intranasal glucocorticosteroids for treatment of asthma (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on avoiding adverse effects, albeit minor burden, and cost of intranasal glucocorticosteroids, and a relatively low value on a small clinical benefit.

    Remarks: This recommendation suggests that intranasal glucocorticosteroids are not used to treat symptoms of asthma, but they may still be used in patients with asthma and rhinitis for treatment of rhinitis (recommendations 18–21).

  4. Should leukotriene receptor antagonists be used for treatment of asthma in patients with allergic rhinitis and asthma?

    Recommendation: In patients with allergic rhinitis and asthma, the guideline panel recommends inhaled glucocorticosteroids over oral leukotriene receptor antagonists as a single controlling medication for asthma (strong recommendation | moderate quality evidence).

    In patients with allergic rhinitis and asthma who prefer not to use or cannot use inhaled glucocorticosteroids or in children whose parents do not agree to use inhaled glucocorticosteroids, the guideline panel suggests oral leukotriene receptor antagonists for treatment of asthma (conditional recommendation | moderate quality evidence).

    Underlying values and preferences: These recommendations place a relatively high value on a limited efficacy of leukotriene receptor antagonists (LTRA) and additional cost of treatment. The suggestion to use oral LTRA in patients who do not use inhaled glucocorticosteroids places relatively high value on small reduction in symptoms of asthma and improvement in quality of life, and a relatively low value on limiting the cost of treatment.

    Remarks: These recommendations do not apply to the treatment of rhinitis (recommendations 16, 17, 21).

  5. Should subcutaneous allergen-specific immunotherapy be used in patients with allergic rhinitis and asthma?

    Recommendation: In patients with allergic rhinitis and asthma, the guideline panel suggests subcutaneous specific immunotherapy for treatment of asthma (conditional recommendation | moderate quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on reducing the symptoms of asthma, and a relatively low value on avoiding adverse effects and limiting the cost of subcutaneous specific immunotherapy. In patients who are more averse to the side effects of subcutaneous specific immunotherapy an alternative choice may be equally reasonable.

    Remarks: Subcutaneous specific immunotherapy may also be used in patients with asthma and concomitant allergic rhinitis for treatment of rhinitis. Resource limitations will have stronger implications for the implementation of this recommendation.

  6. Should sublingual specific immunotherapy be used in patients with allergic rhinitis and asthma?

    Recommendation: In patients with allergic rhinitis and asthma, the guideline panel suggests sublingual specific immunotherapy for treatment of asthma (conditional recommendation | low quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on possible reduction of asthma symptoms, and a relatively low value on avoiding adverse effects and limiting the cost of sublingual specific immunotherapy.

    Remarks: Sublingual specific immunotherapy may also be used in patients with asthma and concomitant allergic rhinitis for treatment of rhinitis. Resource limitations will have stronger implications for the implementation of this recommendation.

  7. Should a monoclonal antibody against IgE be used for treatment of asthma in patients with allergic rhinitis and asthma?

    Recommendation: In patients with allergic rhinitis and asthma with a clear IgE-dependent allergic component, uncontrolled despite optimal pharmacologic treatment and appropriate allergen avoidance, the guideline panel suggests monoclonal antibody against IgE for treatment of asthma (conditional recommendation | moderate quality evidence).

    Underlying values and preferences: This recommendation places a relatively high value on reduction of symptoms of asthma and exacerbations in patients with severe asthma, and a relatively low value on avoiding the burden of subcutaneous injections, cost of treatment, small risk of anaphylaxis and some uncertainty about the risk of malignancy.

Definitions:

A summary of the GRADE approach to grading the quality of evidence for each outcome.

Source of Body of Evidence Initial Rating of Quality of a Body of Evidence Factors that May Decrease the Quality Factors that May Increase the Quality Final Quality of a Body of Evidence
Randomized trials
Observational studies
High
Low
  1. Risk of bias
  2. Inconsistency
  3. Indirectness
  4. Imprecision
  5. Publication bias
  1. Large effect
  2. Dose-response
  3. All plausible residual confounding would reduce the demonstrated effect or would suggest a spurious effect if no effect was observed
High (++++)
Moderate (+++O)
Low (++OO)
Very low (+OOO)

Interpretation of Strong and Conditional (Weak)* Recommendations

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

*Guideline panels applying GRADE use the term "conditional" and "weak" synonymously.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate prevention and treatment of allergic rhinitis and its impact on asthma

Potential Harms

The side effects associated with medications for allergic rhinitis and asthma

See the original guideline document for specific "Harms" information for each recommendation.

Contraindications

Contraindications
  • Breastfeeding may not always be in the best interest of an infant when contraindications are present (e.g., classic galactosemia, active untreated tuberculosis or human immunodeficiency virus infection in mother, chemotherapeutic agents or radioactive isotopes being used in the mother for diagnostic or therapeutic purposes, some other medications until they clear from the milk, and bacterial or viral infection of a breast).
  • Oral glucocorticosteroids should be avoided in children, pregnant women, and patients with known contraindications.

Qualifying Statements

Qualifying Statements
  • The methods used to develop the guidelines are transparent. The recommendations have been developed to be as specific and detailed as possible without losing sight of the user-friendliness of this document and the individual recommendations. Since recommendations in Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines are developed as international guidelines, the ARIA guideline panel encourages feedback on all aspects of these guidelines including their applicability in individual countries. This feedback will be considered when revising the document.
  • The ARIA guidelines provide clinicians and their patients with a basis for rational decisions in the management of allergic rhinitis. Clinicians, patients, third-party payers, institutional review committees, other stakeholders, or the courts should never view these recommendations as dictates. No recommendation can take into account all of the often-compelling unique features of individual clinical circumstances. Therefore, nobody charged with evaluating clinicians' actions should attempt to apply the recommendations from these guidelines as rote or in a blanket fashion.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Patient Resources
Quick Reference Guides/Physician Guides
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 revision. Geneva: World Health Organization (WHO); 2010 Dec 23. 153 p. [742 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2001 Nov (revised 2010)
Guideline Developer(s)
Allergic Rhinitis and its Impact on Asthma Workshop Group - Independent Expert Panel
Source(s) of Funding

World Health Organization

Guideline Committee

Allergic Rhinitis and its Impact on Asthma (ARIA) Guideline Panel

Composition of Group That Authored the Guideline

Authors: Jan L. Brożek, MD, PhD; Jean Bousquet, MD, PhD; Carlos E. Baena-Cagnani, MD; Sergio Bonini, MD; G. Walter Canonica, MD; Thomas B. Casale, MD; Roy Gerth van Wijk, MD, PhD; Ken Ohta, MD, PhD; Torsten Zuberbier, MD; Holger J. Schunemann, MD, PhD, MSc

Financial Disclosures/Conflicts of Interest

Disclosure of Potential Conflict of Interest

J.L. Brożek is an editor of a clinical journal where various drugs are advertised, including those that are the subject of this guideline; he received honoraria for speaking at conferences from GlaxoSmithKline and is a member of the GRADE working group.

J. Bousquet received fees and honoraria for lectures, expert panel participation and consultations from Allmiral, AstraZeneca, Centocor, Chiesi Farmaceutici, GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Nycomed-Altana, Pfizer, Roche, Sanofi-Aventis, Stallergenes, Schering Plough, UCB and Uriach.

C. Baena-Cagnani received fees for consultancy, speaker bureau participation, lectures and research grants from Sanofi-Aventis, Novartis, GSK, Schering Plough, ALK and Abello.

S. Bonini has no conflict of interest, but declares membership in the Agenzia Italiana del Farmaco (AIFA) Research & Development panel.

G. Walter Canonica received fees and honoraria for lectures, expert panel participation and consultations and research support from A. Menarini, Alcon, Alk-Abellò, Almirall, Altana, Anallergo, AstraZeneca, Aventis Pharma, Bayer, Biofutura Pharma, Boehringer Ingelheim, Chiesi Farmaceutici, Chiron, Essex, Fujisawa, Genentech, Gentili, GlaxoSmithKline, Lofarma, Merck Sharp & Dohme, Novartis, Pfizer, Pharmacia & Upjohn, Schering Plough, SigmaTau, Stallergenes, Yamanuchi, UCB Pharma and Valeas.

R. Gerth van Wijk received fees for lectures and expert panel participation from Allmiral, Alcon, Merck Sharp & Dohme, Novartis, Stallargenes and UCB.

H. J. Schunemann is co-chair of the GRADE working group and he supports the implementation of the GRADE approach worldwide. From non-profit organizations he has accepted honoraria and consulting fees for activities in which his work with GRADE is relevant. In the past five years, HJS received no personal payments for service from pharmaceutical for profit organizations. No financial support was received for the preparation of the evidence profiles or provided to the evidence synthesis team that HJS led as part of this work.

T. Zuberbier has received fees for consulting with Schering Plough, Novartis, Leti, Stallergenes, Bayer Schering, Ansell, Kryolan, UCB Pharma, Merck Sharp & Dohme, DST and Procter and Gamble.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Allergic rhinitis and its impact on asthma. Geneva (Switzerland): World Health Organization (WHO); 2008.

This document will be updated when these reviews are performed, major new research is published, or new treatments become available. This update is planned in 2012.

Guideline Availability

Electronic copies of Allergic Rhinitis and its Impact on Asthma (ARIA) documents and resources: Available from the ARIA Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • ARIA one airway questionnaires. ARIA pocket guide for your practice. 2011. 4 p. Electronic copies: Available from the Allergic Rhinitis and its Impact on Asthma (ARIA) Web site External Web Site Policy.
  • ARIA teaching slides. Electronic copies: Available from the ARIA Web site External Web Site Policy.
  • ARIA audit tool. Electronic copies: Available from the ARIA Web site External Web Site Policy.
  • Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, van Wijk RG, Ohta K, Zuberbier T, Schünemann HJ. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. J Allergy Clin Immunol. 2010 Sep;126(3):466-76. Electronic copies: Available to subscribers from the Journal of Allergy and Clinical Immunology Web site.
Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on March 19, 2003. This NGC summary was updated by ECRI Institute on April 24, 2008. The updated information was verified by the guideline developer on June 27, 2008. This NGC summary was updated by ECRI Institute on March 2, 2011. The updated information was verified by the guideline developer on March 29, 2011.

Copyright Statement

The name and logo of ARIA are registered trademarks. Permission must be granted by the ARIA Secretariat for the use of ARIA materials.

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