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New Canadian AR guidance supports flexible diagnostic testing, individualized first-line therapy selection, and broader use of SLIT and SCIT while emphasizing patient preferences and shared decision-making.
A newly released Canadian-focused practice parameter is reshaping the clinical approach to allergic rhinitis (AR), emphasizing individualized treatment decisions, broader access to immunotherapy, and flexibility in diagnostic testing.
AR affects millions of children and adults across Canada and remains one of the country’s most common chronic allergic conditions. While international allergy societies have previously issued AR care guidelines, Canadian experts noted that regional prescribing patterns, healthcare practices, and differences in drug approvals required a tailored national update. To address these gaps, a multidisciplinary Canadian Work Group reviewed evidence published since 2016 and developed responses to 6 key research questions focused on diagnosis, pharmacotherapy, and immunotherapy in AR.
Blood Allergy Testing Can Replace Skin Prick Testing (SPT) in Many Patients
One of the most clinically relevant conclusions addressed whether serum-specific IgE (sIgE) testing alone is sufficient to identify candidates for allergen immunotherapy or whether SPT remains mandatory. After reviewing available evidence, the Work Group concluded that both serum-specific IgE testing and SPT are acceptable diagnostic approaches for AR and for guiding immunotherapy decisions. The recommendation may enhance access to allergy evaluation for those who cannot undergo SPT because of medication use, skin disease, limited specialist availability, or logistical barriers.
Intranasal Corticosteroids (INCS) Remain the Preferred First-Line Therapy
The panel also examined whether second-generation oral antihistamines (OAHs) or INCS should be considered first-line treatment when patient and prescriber preferences are taken into account. The experts reported that existing international guidelines consistently support INCS as the preferred first-line therapy because of their superior potency in controlling nasal inflammation and symptoms.
However, the Canadian guidance stresses that real-world treatment decisions often depend on stakeholder engagement, including patient preference, convenience, tolerability, cost, and adherence concerns. As a result, second-generation OAHs may still become the initial treatment choice in many cases.
Combination Intranasal Therapy Shows Superior Symptom Control
The Work Group reviewed evidence comparing combination intranasal antihistamine (INAH)/INCS therapy with the use of INCS + OAH. The panel concluded that combination INAH/INCS formulations are superior to INCS combined with OAHs for symptom relief in AR. The experts also investigated whether prolonged treatment might eventually equalize the two strategies, but they found insufficient evidence to answer that question definitively.
Leukotriene Receptor Antagonists (LTRAs) May Help Patients With Asthma and Nighttime Symptoms
Another research question explored whether LTRAs yield advantages over OAHs in those who cannot tolerate INCS. According to the review, LTRAs generally offer inferior or, at best, equivalent daytime and overall symptom control compared with OAHs.
Nonetheless, the guidance notes that LTRAs may improve nighttime symptoms and may be particularly beneficial for AR accompanied by concomitant asthma, where dual airway benefits may be clinically valuable.
Sublingual Immunotherapy (SLIT) and Subcutaneous Immunotherapy (SCIT) Selection Should Consider More Than Efficacy
The Canadian panel also evaluated whether SLIT tablets should be considered first-line immunotherapy options over SCIT. The experts concluded that efficacy data alone are not sufficient to favor one therapy over the other.
Instead, they emphasized that factors such as patient preference, convenience, safety profile, accessibility, adherence, treatment burden, and healthcare resource use may outweigh modest differences in efficacy when selecting immunotherapy.
Broader Immunotherapy Access Encouraged
In its final research question, the Work Group examined whether all patients evaluated by allergists should routinely be offered SLIT or SCIT as treatment options based on efficacy evidence. The panel stated that current evidence supports the broad use of allergen immunotherapy in AR. However, clinicians should still account for additional clinical considerations, including comorbidities, contraindications, patient suitability, and practical treatment limitations.
Shift Toward Personalized AR Management
Overall, the updated Canadian practice parameter reflects a growing shift toward patient-centered AR care. The recommendations support flexible diagnostic pathways, individualized medication selection, and wider consideration of immunotherapy strategies tailored to patient needs and clinical context.
The guidance also reinforces the criticality of shared decision-making between patients and medical care providers in choosing among oral therapies, intranasal medications, and immunotherapy options.
Allergy, Asthma, and Clinical Immunology
Focused allergic rhinitis practice parameter for Canada
Anne K Ellis et al.
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