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Wise et al.

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• Aggregate Grade of Evidence: B (Level 1b: 2 studies; Table X.A.4-4). Grade A evidence with multiple 1b RCTs and 1a reviews exist for asthma and AR individually, but only 1 double-blind RCT specifically evaluating omalizumab vs placebo in patients with concurrent conditions. • Benefit: Decreased asthma exacerbations, decreased symptom scores, and improvement in disease-specific QOL in patients with coexisting asthma and AR. • Harm: There is evidence for acceptable safety for use up to 52 weeks. 1821 Potential longer-term harm unknown. Minor events such as mild injection site reactions are reported. Possibility of anaphylaxis. • Cost: Substantially higher cost than conventional therapy for asthma and AR. • Benefits-Harm Assessment: Benefits appear to outweigh potential harm for the treatment of more severe/persistent coexistent AR and asthma. • Value Judgments: Added benefit of omalizumab as therapy for patients with AR and asthma that is uncontrolled despite maximal conventional interventions. However, given the significant increased cost associated with omalizumab, the value of this therapy is likely greatest for patients with severe asthma and symptoms that persist despite usual therapies. • Policy Level: Omalizumab is recommended for those patients with clear IgE mediated allergic asthma with coexistent AR who fail conventional therapy. The significant additional cost of this therapy should be considered in evaluating its value. Allergen immunotherapy.— Both SCIT and SLIT have been shown to improve the control of comorbid AR conditions, such as asthma 1618,1788,1822 (Table X.A.4-5). AIT also appears to prevent the development of asthma. 1678,1797,1798 The efficacy of SLIT for AR has been confirmed by several systematic reviews. 1694,1695,1823 Both SCIT and SLIT have been shown to be efficacious for AR, though there is ongoing debate as to whether 1 form is superior. 1697,1703 AIT is also thought to help halt the progression of allergic disease, including prevention of new allergic sensitivities and the development of asthma. 1624,1626,1678,1797,1798,1824-1826 AIT also appears to have long-lasting effects even after discontinuing treatment, unlike pharmacotherapy. Such promising results have led to a 2010 ARIA update statement recommending both SCIT and SLIT for the treatment of asthma in patients with AR and asthma. 1167 Recent systematic reviews demonstrate that SCIT and SLIT reduce both asthma and rhinitis symptoms, as well as medication use. 1694,1822 These evidence-based reviews also demonstrate strong evidence for the utility of SCIT and SLIT in the treatment of asthma alone in studies that did not specifically address the condition of combined asthma and AR. 1694,1822 Evidence for AIT (SCIT and SLIT) for asthma in context of comorbid asthma and AR, is reviewed in Table X.A.4-5. (See section IX.D. Management – Allergen immunotherapy (AIT) for additional information on this topic.)

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Allergen immunotherapy recommendations for the treatment of AR with coexisting asthma.

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