2018 Section 5 - Rhinology and Allergic Disorders

ICAR Executive Summary

TABLE III-2. Summary of recommendations for ARS management

Benefit-harm assessment

Policy

Intervention

LOE

Benefit

Harm

Cost

level

Antibiotics (whether to prescribe)

A Potential for shorter duration of

GI complaints greater than observed in placebo for both drugs, more pronounced for amoxicillin-clavulanate. Potential for resistance and for anaphylaxis GI complaints greater than observed in placebo for both drugs, more pronounced for amoxicillin-clavulanate. Potential for resistance and for anaphylaxis Minimal harm with rare mild adverse event

Low to moderate Benefit of

Antibiotic use in suspected ABRS: Option

treatment over placebo is small

symptoms; reduced pathogen carriage

Antibiotics (choosing amoxicillin or

B Potential for shorter duration of

Low to moderate Benefit of

If an antibiotic is chosen, amoxicillin-clavulanate vs amoxicillin: Option

treatment over placebo is small

amoxicillin- clavulanate)

symptoms; reduced pathogen carriage

Corticosteroids (nasal [INCS] and systemic)

A INCS improved patient symptoms as monotherapy or

Low

Benefit of

Use of INCS: Strong

treatment over placebo small, but tangible; minimal harm with INCS, greater risk for prolonged systemic corticosteroids

recommendation. Use of systemic

adjuvant to antibiotics in severe cases, and hastened recovery; Systemic minimal benefit

corticosteroid: No recommendation

Decongestants

N/A

Insufficient evidence for a recommendation Insufficient evidence for a recommendation

Antihistamines

N/A

Nasal saline irrigation

A Possible nasal symptom improvement. Improved saccharin transit times

Occasional patient discomfort

Minimal

Benefit likely to

Option

outweigh harm

ABRS = acute bacterial rhinosinusitis; GI = gastrointestinal; INCS = intranasal corticosteroids; LOE = level of evidence; N/A = not applicable.

uncomplicated ARS. Consider amoxicillin- clavulanate for potentially complicated infection or when resistant organisms are suspected. Intranasal Corticosteroids and Systemic Corticosteroids : With infrequent adverse events and limited systemic up- take, intranasal corticosteroid (INCS) use in ARS is a recommendation with grade A aggregate quality of evidence. Additional studies comparing ideal INCS for- mulation, dose, and timing will provide important in- sight into tailoring INCS treatment in ARS. Studies that have looked at systemic corticosteroid therapy in ARS have used heterogeneous methods and had varying re- sults. Given the lack of clear benefit and substantial risk of harm, systemic corticosteroids in cases of uncompli- cated ARS are not recommended, with a grade B aggre- gate quality of evidence

◦ Aggregate Grade of Evidence: A (Level 1a: 7 studies; Level 1b: 11 studies). ◦ Benefit: INCS improved patient symptoms as monotherapy or adjuvant to antibiotics in severe cases, and hastened recovery; Systemic minimal benefit. ◦ Harm: Minimal harm with rare mild adverse event. ◦ Cost: Low for both interventions. ◦ Benefits-Harm Assessment: Benefit of treatment over placebo small, but tangible; minimal harm with INCS, greater risk for prolonged systemic cor- ticosteroids. ◦ Value Judgments: INCS improved patient symp- toms with low risk for adverse event. ◦ Policy Level: Use of INCS: Strong recommendation. Use of systemic corticosteroid: No recommenda- tion.

International Forum of Allergy & Rhinology, Vol. 6, No. S1, February 2016

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