Allergic rhinitis (AR) is increasingly recognized as a chronic inflammatory airway disease rather than a benign nasal condition. With rising prevalence and persistent gaps in diagnosis and treatment, Indian otorhinolaryngology experts have issued a national expert consensus offering detailed and practical recommendations for AR management.
The consensus, issued in "Asia Pacific Allergy", was developed through a modified Delphi process involving senior ENT specialists across India, ensuring strong agreement and real-world applicability.
DIAGNOSTIC RECOMMENDATIONS
- AR must be detected primarily on clinical grounds, on the basis of the presence of typical nasal symptoms and patient history.
- AR should be suspected when at least two of the following symptoms are present: sneezing or nasal itching, rhinorrhea, and nasal obstruction.
- A detailed history of allergen exposure, symptom triggers, seasonality, and family history of atopy should be routinely procured.
- Physical examination should encompass assessment for pale or bluish nasal mucosa, watery nasal secretions, inferior turbinate hypertrophy, and associated ocular signs.
- Routine radiological imaging is not required for those with uncomplicated AR.
- Routine allergy testing is not needed for initial diagnosis and must be reserved for those with diagnostic uncertainty or poor response to standard therapy.
- All patients with AR must be evaluated for comorbid conditions, including asthma, chronic rhinosinusitis, otitis media, conjunctivitis, and sleep-disordered breathing.
PATIENT CLASSIFICATION RECOMMENDATIONS
- Traditional classification alone may not adequately guide therapy in patients.
- AR patients should additionally be categorized based on predominant symptom profile to optimize treatment selection.
- Those with predominant sneezing, rhinorrhea, nasal itching, and ocular symptoms should be classified as “sneeze-runners.”
- Those with predominant nasal blockage, thick nasal discharge, postnasal drip, and breathing difficulty should be classified as “blockers.”
- The consensus recognizes that blocker-type AR is more prevalent in India and is often linked with persistent and moderate-to-severe disease.
TREATMENT GOALS
- The primary goal of AR treatment is rapid and sustained control of ocular and nasal symptoms.
- Treatment must aim to improve sleep quality, daily functioning, school or work productivity, and overall quality of life.
- Long-term management must focus on preventing disease progression and minimizing complications.
FIRST-LINE TREATMENT RECOMMENDATIONS
- Intranasal corticosteroids (INCS) are advocated as the first-line option for moderate-to-severe or persistent AR.
- Intranasal corticosteroids should be preferred over oral antihistamines for successful control of nasal obstruction.
- Fluticasone furoate (110 mcg once daily) is advocated owing to its proven efficacy, safety profile, and patient acceptability.
- Once-daily dosing is preferred to improve treatment adherence.
PHENOTYPE-BASED PHARMACOTHERAPY RECOMMENDATIONS
1. For Sneeze-Runners
- Those with mild symptoms may be managed with second-generation oral antihistamines.
- Intranasal antihistamines are preferred over oral antihistamines for faster onset of action and better symptom control.
- Combination therapy with INCS and intranasal antihistamines may be used in moderate-to-severe disease.
2. For Blockers
- Those with mild persistent nasal obstruction should receive INC monotherapy.
- Those with moderate-to-severe nasal blockage should receive early combination therapy rather than stepwise escalation.
- Early aggressive control of nasal congestion is suggested to prevent complications and improve adherence.
RECOMMENDATIONS ON FIXED-DOSE COMBINATION (FDC) THERAPY
- The FDC of fluticasone furoate and oxymetazoline (27.5/50 mcg) is advocated for those with significant nasal obstruction.
- This combination offers faster relief of nasal blockage compared to INC monotherapy.
- Short-term use of intranasal decongestants is considered safe when combined with INCS.
- The combination therapy can be used for up to 28 days without significant risk of rebound congestion when used as directed.
- This strategy is particularly valuable for blocker-type AR, which is common in Indian patients.
RECOMMENDATIONS ON ADD-ON AND SUPPORTIVE THERAPIES
- Leukotriene receptor antagonists (LTRAs) should not be used as first-line therapy in AR.
- LTRAs may be considered only in patients with coexisting asthma.
- Intranasal saline irrigation is recommended for all sufferers as an auxiliary component to pharmacological intervention.
- Allergen immunotherapy (sublingual or subcutaneous) should be considered in those with persistent symptoms despite optimal pharmacotherapy.
- Immunotherapy may provide long-term disease modification and symptom reduction.
RECOMMENDATIONS ON ADHERENCE AND PATIENT EDUCATION
- Poor adherence is a significant cause of therapeutic failure in AR.
- Patients should be educated that AR is a chronic inflammatory condition requiring regular treatment.
- Misconceptions regarding INC safety should be actively addressed.
- Clinicians should demonstrate and periodically review correct nasal spray technique.
- Written treatment plans should be provided to improve long-term compliance.
Comments (0)