Lecture Notes: International Consensus on Allergic Rhinitis

Introduction

Speaker: Professor Sarah Wise, Professor of Otolaryngology and Ethnic Surgery, Emory University, Atlanta.
Topic: Allergic Rhinitis and the International Consensus Statement on Allergy and Rhinology.
Document Reference: Published in 2018, involved over 100 authors from various specialties.
Main Focus: Methods, findings, and future research on allergic rhinitis (AR).

Introduction: Large document meant to serve as a reference with 250 pages, involving 18 months of collaborative effort.
Eight Broad Content Areas:
- Definition and differential diagnosis of AR.
- Pathophysiology and mechanisms.
- Epidemiology and risk factors.
- Disease burden (socioeconomics, sleep, quality of life).
- Evaluation and diagnosis methods.
- Management (environmental controls, pharmacotherapy, alternative therapies, immunotherapy).
- Associated conditions (rhinosinusitis, nasal polyps, etc).

Evidence-Based Review: Developed by Rudnick and Smith, used for reviewing high-quality evidence.
- Types of Evidence: Systematic reviews, meta-analyses, clinical practice guidelines, randomized controlled trials (RCTs).
- Process: Evidence is summarized, graded, and recommendations are formed considering benefit, harm, and cost.
- Iterative Review: Drafts are reviewed by additional authors blindly to reach consensus.
Evidence Summary Table: Lists study details, level of evidence, and research conclusions.
Policy Level: Based on the aggregate grade of evidence and the balance of benefit/harm.

Antihistamines:
- Oral Antihistamines: Strong evidence, low cost, over the counter.
- Intranasal Antihistamines: Strong evidence, prescription needed, good for sneezing, itching, rhinorrhea, ocular symptoms but has a foul taste.
Intranasal Corticosteroids: Strong evidence, over the counter, first-line therapy for AR.
Combination Therapy: Intranasal corticosteroids plus antihistamines offer synergistic benefits.
Nasal Saline: Effective in managing AR.
Immunotherapy: Subcutaneous and sublingual immunotherapy are effective with potential long-term benefits.
- Concerns: Safety (anaphylaxis), cost, and patient selection.

Challenges: Weaker evidence compared to pharmacotherapy and immunotherapy; many studies focus on allergen levels rather than respiratory symptoms.
Combination Approach: Better than single intervention.
Cost: Varies depending on the intervention.

Intralymphatic Immunotherapy: Allergen injected into lymph nodes, involves less allergen, and shows potential benefits; needs more research.
Local Allergic Rhinitis and Nasal Specific IgE: Assessed via nasal provocation tests or nasal washings.

Acupuncture: Mixed evidence; recent meta-analysis shows some benefit.
Probiotics: Found to be an option, but more research needed involving specific products.

Genetics of AR: Understanding genetic and environmental interactions.
Climate Change: Effects on allergen prevalence and geographic patterns.
Diagnosis: Better understanding of nasal specific IgE and skin testing techniques.
Treatment: Economic comparisons of immunotherapy, and exploring intra lymphatic immunotherapy.
Environmental Controls: More research on the efficacy of environmental controls on respiratory symptoms.

Validity of Documents: Documents are still valid but must be adapted as new evidence emerges.
Pregnancy and AR: Addressed the impact and advisable medications during pregnancy.
Nasal Spray vs. Nasal Douche: Depends on the anatomy, disease, and treatment goals.
Empty Nose Syndrome: Importance of saline and potential use of steroids when treating combined with AR.
Access Constraints in Africa: Focus on pharmacotherapy and environmental controls as alternatives to expensive immunotherapy.
Combination Intranasal Sprays: Usage and alternatives when costs are high.

Advisory: Encouragement to download the detailed document for in-depth understanding and practical application.
Future Participation and Conferences: Attendance and participation in future events like the European Rhinologic Society meeting.

Thank you for participating and hope to see you at future sessions!