xRead - September 2022

Wise et al.

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Harm: Financial cost and risk of anaphylactic reactions.

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Cost: Moderate to high.

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Benefits-Harm Assessment: Preponderance of benefit over harm.

• Value Judgments: Combination therapy increases the safety of AIT, with decreased systemic reactions following cluster and rush protocols. Associated treatment costs and likelihood of systemic reactions must be considered, with greater consideration for omalizumab pretreatment prior to higher-risk AIT protocols. While 2 high-quality RCTs have demonstrated improved symptom control with combination therapy over AIT or omalizumab alone, not all patients will require this approach. Rather, an individualized approach to patient management must be considered, with evaluation of alternative causes for persistent symptoms, such as unidentified allergen sensitivity. The current evidence does not support the utilization of combination therapy for all patients failing to benefit from AIT alone. • Policy Level: Option, based on current evidence. However, it is important to note that omalizumab is not currently approved by the FDA for the treatment of AR. • Intervention: Omalizumab may be offered as a premedication prior to induction of cluster or rush AIT protocols. Combination therapy is an option for a carefully selected patient with persistent symptomatic AR following AIT. An individualized approach to patient management must be considered. In addition, as omalizumab is not currently approved by the FDA for AR treatment, in the United States this treatment approach would likely not be performed in routine clinical practice presently. Several medical conditions have been associated with AR, with varying prevalence dependent upon the specific comorbidity. In contrast, certain conditions are often associated with allergy or AR by conjecture, yet the available literature fails to identify a close association. This section examines various medical conditions that have a potential association with AR, specifically examining the evidence that supports or refutes the association X.A.1. Asthma definition— Asthma is a heterogeneous and complex disease, perhaps better characterized as a syndrome with overlapping phenotypes. The definition of asthma has evolved over the past several decades, combining clinical symptoms, examination findings, and functional parameters. When analyzing current international or national asthma guidelines, 1744-1747 all include respiratory symptoms such as cough, shortness of breath, wheezing or chest tightness, and the presence of a variable expiratory airflow limitation that needs to be documented from bronchodilator reversibility testing or bronchial hyperreactivity tests (eg, methacholine test or other tests such as inhaled histamine, mannitol, exercise, or eucapnic hyperventilation). All guidelines also include the statement

X. Associated conditions

X.A. Asthma

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.