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Wise et al.

Page 462

Author Manuscript Author Manuscript Author Manuscript Author Manuscript Number of listed studies Aggregate grade of evidence Recommendation

Topic level Interpretation Intranasal antihistamines 44 A Recommendation Intranasal antihistamines many be used as first-line or second-line therapy for the treatment of AR.

Oral corticosteroids 9 B Recommend against Due to the risks of oral steroid use, along with the availability of other pharmacotherapy options, this therapy is not recommended for routine AR management. Injectable corticosteroids 13 B Recommend against Due to the risks of injectable steroid use, along with the availability of other pharmacotherapy options, systemic or intraturbinate injection of corticosteroids is not recommended for the routine treatment of AR.

Intranasal corticosteroids 53 A Strong recommendation INCS should be used as first-line therapy in the treatment of AR. Oral decongestants 9 B Option Option for pseudoephedrine for short-term treatment of AR symptoms. Recommend against Recommend against phenylephrine, as it has not been shown to be superior to placebo.

Topical decongestants 4 B Option Option for topical IND use in the short-term for nasal decongestion. Chronic use carries a risk of RM. Leukotriene receptor antagonists 31 A Recommend against LTRAs should not be used as monotherapy in the treatment of AR. Combination: INCS and intranasal antihistamine

Cromolyn (DSCG) 22 A Option DSCG may be considered in the treatment of AR, particularly for patients with known triggers who cannot tolerate INCS. Intranasal anticholinergic (IPB) 14 B Option IPB nasal spray may be considered as an adjunct to INCS in PAR patients with uncontrolled rhinorrhea. Omalizumab 6 A No indication Omalizumab is not approved by the FDA for the treatment of AR alone.

Nasal saline 12 A Strong recommendation Nasal saline is strongly recommended as part of the treatment strategy for AR. Probiotics 28 A Option Probiotics may be considered in the treatment of AR. Combination: oral antihistamine and oral decongestant 21 A Option Option, particularly for acute exacerbations with a primary symptom of nasal congestion. Combination: oral antihistamine and INCS 5 B Option Combination equivocal over either drug alone. Combination: oral antihistamine and LTRA

13 A Option Combination is an option for AR management, particularly in patients with comorbid asthma who do not tolerate INCS and are not well-controlled on oral antihistamine monotherapy. 12 A Strong recommendation Strong recommendation for combination therapy when monotherapy fails to control AR symptoms. Acupuncture 15 B Option In patients who wish to avoid medications, acupuncture many be suggested as a possible therapeutic adjunct. Honey 3 B No recommendation Studies are inconclusive and heterogeneous. Herbal therapies — — No recommendation Multiple different herbs studied, with few studies for each specific therapy. Results are inconclusive. Surgical treatment 12 C Option Turbinate reduction may be considered in AR patients with nasal obstruction who have failed medical management.

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