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Wise et al.

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II.C. ICAR statement development

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

After the content of each of topic was reviewed and consensus reached among the initial author and 2 iterative reviewers, the principal editor (S.K.W.) compiled all topics into a single ICAR:AR statement. The first draft of each large ICAR:AR portion (ie, Evaluation and Diagnosis, Pharmacotherapy, Immunotherapy, etc.) then underwent additional reviews for consistency and understanding using a group of 6 to 8 authors. Finally, the draft ICAR:AR was circulated to all authors. The final ICAR:AR manuscript was produced when all authors agreed upon the literature and final recommendations. External peer review, with 20 reviewers, was also undertaken for the final ICAR:AR document (Fig. II.A-3). It should be noted that because each topic author individually performed the literature search for his/her assigned topic, search results may demonstrate some inherent variability despite specific and detailed search instructions. Furthermore, while aiming to be as comprehensive as possible, this document may not present every study published on every topic. For certain topics, the literature is extensive and only high-quality studies or systematic reviews are listed. If the aggregate evidence on a topic reached a high evidence grade with only high level studies, an exhaustive list of lower level studies (or all studies ever performed) is not provided. AR is an immunoglobulin E (IgE)-mediated inflammatory nasal condition resulting from allergen introduction in a sensitized individual. 7 AR was defined in 1929 as a process which included 3 cardinal symptoms: sneezing, nasal obstruction, and mucus discharge. 8 Symptoms occur with allergen exposure in the allergic patient. AR is a widely prevalent condition that can result in significant physical sequelae and recurrent or persistent morbidities. 7 The prevalence of AR is approximately 10% to 40%, depending on geographic location, 9 with the highest incidence occurring in children. 10 However, AR is nearly absent in infants, typically not manifesting until the second year of life at the earliest. When AR presents in children, this is likely secondary to the rapidly evolving immune system. AR often results from an overactive response of T helper (Th) 2 lymphocytes that can initiate a systemic, IgE driven reaction which may dominate child’s immune system until it is completely mature. During this time, a skin-prick test (SPT) or in vitro antigen-specific IgE (sIgE) test can be used to confirm the diagnosis of AR. In the atopic individual, exposure to indoor and outdoor allergens may prompt antigen specific IgE production. Reintroduction of the allergen triggers early-stage and late-stage reactions, leading to the clinical manifestations of AR. The early-stage reaction occurs within minutes after reintroduction of the sensitized allergen, producing nasal itching, nasal congestion, and rhinorrhea. 11 The late-stage reaction occurs during the 4-hour to 8-hour period after allergen introduction and results in nasal blockage, hyposmia, increased mucus

II.D. Limitations of methods and data presentation

III. Definition and differential diagnosis III.A. Allergic rhinitis definition

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