Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology
University Hospital Southampton NHS Foundation Trust1, Boston Children's Hospital2, University of Lisbon3, University Hospital of South Manchester NHS Foundation Trust4, Odense University Hospital5, Catholic University of Leuven6, National and Kapodistrian University of Athens7, Royal Free Hospital8, University of Turku9
TL;DR: Oral and intranasal antihistamines and nasal corticosteroids are both appropriate for first‐line AR treatment although the latter are more effective, and potentially useful add‐on therapies for AR include oral leukotriene receptor antagonists, short bursts of a nasal decongestant, saline douches and nasal anticholinergics.
Abstract: Rhinitis is a common problem in childhood and adolescence and impacts negatively on physical, social and psychological well-being. This position paper, prepared by the European Academy of Allergy and Clinical Immunology Taskforce on Rhinitis in Children, aims to provide evidence-based recommendations for the diagnosis and therapy of paediatric rhinitis. Rhinitis is characterized by at least two nasal symptoms: rhinorrhoea, blockage, sneezing or itching. It is classified as allergic rhinitis, infectious rhinitis and nonallergic, noninfectious rhinitis. Similar symptoms may occur with other conditions such as adenoidal hypertrophy, septal deviation and nasal polyps. Examination by anterior rhinoscopy and allergy tests may help to substantiate a diagnosis of allergic rhinitis. Avoidance of relevant allergens may be helpful for allergic rhinitis (AR). Oral and intranasal antihistamines and nasal corticosteroids are both appropriate for first-line AR treatment although the latter are more effective. Once-daily forms of corticosteroids are preferred given their improved safety profile. Potentially useful add-on therapies for AR include oral leukotriene receptor antagonists, short bursts of a nasal decongestant, saline douches and nasal anticholinergics. Allergen-specific immunotherapy is helpful in IgE-mediated AR and may prevent the progression of allergic disease. There are still a number of areas that need to be clarified in the management of rhinitis in children and adolescents.
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St Mary's Hospital1, University Hospital Southampton NHS Foundation Trust2, University of Southampton3, Heidelberg University4, Swiss Institute of Allergy and Asthma Research5, National Institutes of Health6, Erasmus University Rotterdam7, Odense University Hospital8, Nippon Medical School9, University of Cyprus10, University of Edinburgh11, Charité12, University of Messina13, Eskişehir Osmangazi University14, Boston Children's Hospital15, Katholieke Universiteit Leuven16, Utrecht University17, Johns Hopkins University18, Athens State University19, University Medical Center Groningen20, University of Milan21, University College Hospital22, King's College London23, Medical University of Graz24, European Union25, Capital Medical University26, Transylvania University27, Northern General Hospital28, Hospital Clínico San Carlos29, Wrocław Medical University30, University of Amsterdam31, University of Padua32
TL;DR: In general, broad evidence for the clinical efficacy of AIT for AR exists but a product‐specific evaluation of evidence is recommended, and SCIT and SLIT are recommended for both seasonal and perennial AR for its short‐term benefit.
Abstract: Allergic rhinoconjunctivitis (AR) is an allergic disorder of the nose and eyes affecting about a fifth of the general population. Symptoms of AR can be controlled with allergen avoidance measures and pharmacotherapy. However, many patients continue to have ongoing symptoms and an impaired quality of life; pharmacotherapy may also induce some side-effects. Allergen immunotherapy (AIT) represents the only currently available treatment that targets the underlying pathophysiology, and it may have a disease-modifying effect. Either the subcutaneous (SCIT) or sublingual (SLIT) routes may be used. This Guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on AIT for AR and is part of the EAACI presidential project "EAACI Guidelines on Allergen Immunotherapy." It aims to provide evidence-based clinical recommendations and has been informed by a formal systematic review and meta-analysis. Its generation has followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included involvement of the full range of stakeholders. In general, broad evidence for the clinical efficacy of AIT for AR exists but a product-specific evaluation of evidence is recommended. In general, SCIT and SLIT are recommended for both seasonal and perennial AR for its short-term benefit. The strongest evidence for long-term benefit is documented for grass AIT (especially for the grass tablets) where long-term benefit is seen. To achieve long-term efficacy, it is recommended that a minimum of 3 years of therapy is used. Many gaps in the evidence base exist, particularly around long-term benefit and use in children.
436 citations
Cites background or methods from "Paediatric rhinitis: position paper..."
...Adapted from Roberts et al 2013.(7) Local allergic rhinitis may be seen where there is only evidence of local nasal allergic sensitization....
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...Adapted from Roberts et al 2013.7 Local allergic rhinitis may be seen where there is only evidence of local nasal allergic sensitization.15,16,26 There are numerous other causes of nonallergic, noninfectious rhinitis, an example is nonallergic rhinitis with eosinophilia syndrome (NARES)....
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Emory University1, Johns Hopkins University2, Temple University3, University of Utah4, Swiss Institute of Allergy and Asthma Research5, University of Chicago6, Ghent University7, Humanitas University8, Eskişehir Osmangazi University9, Imperial College London10, University of California, San Diego11, University of North Carolina at Chapel Hill12, Rutgers University13, University of Amsterdam14, University of Missouri15, University of Texas Southwestern Medical Center16, Aarhus University17, Hannover Medical School18, Case Western Reserve University19, Stanford University20, Harvard University21, University of Turku22, University of Colorado Boulder23, University of Texas at Austin24, San Antonio Military Medical Center25, University of Pittsburgh26, University of Texas Health Science Center at Houston27, Ochsner Health System28, Uniformed Services University of the Health Sciences29, Karolinska Institutet30, Wake Forest University31, University of Pavia32, University of Barcelona33, University of Colorado Denver34, Loyola University Chicago35, Nippon Medical School36, Heidelberg University37, Boston University38, Cornell University39, University of Calgary40, Medical University of South Carolina41, Brown University42, George Washington University43, University of Edinburgh44, Oregon Health & Science University45, Mahidol University46, National University of Singapore47, University of Michigan48
TL;DR: To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).
Abstract: BACKGROUND:
Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).
METHODS:
Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.
RESULTS:
The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.
CONCLUSION:
This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.
401 citations
TL;DR: These guidelines have been prepared in line with existing international guidelines to provide evidence-based recommendations for the diagnosis and management of AR in China and have been developed by the Chinese Society of Allergy to be accessible to both national and international medical communities involved in the Management of AR patients.
Abstract: Allergic rhinitis (AR) is a global health problem that causes major illnesses and disabilities worldwide. Epidemiologic studies have demonstrated that the prevalence of AR has increased progressively over the last few decades in more developed countries and currently affects up to 40% of the population worldwide. Likewise, a rising trend of AR has also been observed over the last 2–3 decades in developing countries including China, with the prevalence of AR varying widely in these countries. A survey of self-reported AR over a 6-year period in the general Chinese adult population reported that the standardized prevalence of adult AR increased from 11.1% in 2005 to 17.6% in 2011. An increasing number of original articles and imporclinical trials on the epidemiology, pathophysiologic mechanisms, diagnosis, management and comorbidities of AR in Chinese subjects have been published in international peer-reviewed journals over the past 2 decades, and substantially added to our understanding of this disease as a global problem. Although guidelines for the diagnosis and treatment of AR in Chinese subjects have also been published, they have not been translated into English and therefore not generally accessible for reference to non-Chinese speaking international medical communities. Moreover, methods for the diagnosis and treatment of AR in China have not been standardized entirely and some patients are still treated according to regional preferences. Thus, the present guidelines have been developed by the Chinese Society of Allergy to be accessible to both national and international medical communities involved in the management of AR patients. These guidelines have been prepared in line with existing international guidelines to provide evidence-based recommendations for the diagnosis and management of AR in China.
174 citations
TL;DR: This is an updated guideline for the diagnosis and management of allergic and non‐allergic rhinitis, first published in 2007 and produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods.
Abstract: This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10–15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.
170 citations
TL;DR: Rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed, and the concept of control‐based management is emphasized, which transcends allrhinitis subtypes.
Abstract: Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.
142 citations
Cites background from "Paediatric rhinitis: position paper..."
...Local allergic rhinitis and NARES Local allergic rhinitis (LAR) has recently been suggested to be a distinct rhinitis endotype characterized by symptoms similar to AR associated with local (nasal) allergen-specific Allergy 70 (2015) 474–494 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd476 IgE (sIgE), but with no evidence of systemic sIgE....
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...Nonallergic rhinitis Noninfectious, nonallergic rhinitis (NAR) is a heterogeneous group of nasal conditions with rhinitis symptoms....
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...One study noted an additive effect of co-administration of oral AH with intranasal steroids for the treatment of NARES (177), but further research is required on such a regimen....
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...rhinitis • Symptoms: Obstruction, rhinorrhea, sneezing, and pruritus • Seasonal symptoms (58), preponderance of sneezing and pruritus (48) • Family history of atopy (8) • Early onset (<age 20) • Concurrent allergic conjunctivitis (6), atopic dermatitis, asthma (79, 293), food allergy (58), and obstructive sleep apnea syndrome (OSAS) (153–155) • Allergic shiners: dark discolorations of the periorbital skin • Demie–Morgan lines: folds of the lower eyelid, • Allergic crease: horizontal wrinkle near the tip of the nose • Gothic arch: narrowing of the hard palate • Mucosa: pallor, edema, hyperemia, and clear discharge when patient is symptomatic....
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...These subphenotypes are discussed below: Idiopathic Rhinitis (vasomotor rhinitis) Idiopathic rhinitis (IR) is the most prevalent NAR subphenotype (62), but is still a diagnosis of exclusion (58, 62, 66) and ongoing research is required to define specific endotypes with corresponding usable biomarkers....
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References
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Federal University of Bahia1, McMaster University2, University of Amsterdam3, National Institutes of Health4, Charité5, Catholic University of Cordoba6, University of Genoa7, Radboud University Nijmegen8, Transilvania University of Brașov9, Ghent University10, University of Tennessee Health Science Center11, University of Naples Federico II12, Laval University13, Universidade Federal de Minas Gerais14, University of Oslo15, University of Manchester16, Aarhus University17, Imperial College London18, Erasmus University Rotterdam19, George Washington University20, Seoul National University21, Medical University of Łódź22, Hai phong University Of Medicine and Pharmacy23, Université de Montréal24, Guangzhou Medical University25, University of South Florida26, University of California, San Diego27, University of California28, University of Chicago29, Monash University30, Teikyo University31, National and Kapodistrian University of Athens32, Nippon Medical School33, Sofia Medical University34, Leiden University35, Leiden University Medical Center36, University College London37, University of Manitoba38, University of Helsinki39, Finnish Institute of Occupational Health40, National University of Singapore41, Karolinska Institutet42, University of Minnesota43, Celal Bayar University44, University of Cape Town45, Pierre-and-Marie-Curie University46, Tunis University47, University of Ghana48, University of Wisconsin-Madison49, University of British Columbia50, Georgia Regents University51, Vilnius University52, University of Washington53, University of Dundee54, University of Poitiers55, University of Mississippi56, Federal University of São Paulo57, German Red Cross58, Jagiellonian University Medical College59, Chiba University60, American Pharmacists Association61, University of Aberdeen62, University of Nevada, Reno63, University of North Carolina at Chapel Hill64
TL;DR: The ARIA guidelines for the management of allergic rhinitis and asthma are similar in both the 1999 ARIA workshop report and the 2008 Update as discussed by the authors, but the GRADE approach is not yet available.
Abstract: Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.
In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.
This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.
The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.
Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.
The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.
3,769 citations
TL;DR: The rise in prevalence of symptoms in many centres is concerning, but the absence of increases in prevalence in asthma symptoms for centres with existing high prevalence in the older age-group is reassuring.
3,762 citations
"Paediatric rhinitis: position paper..." refers background in this paper
...Rhinitis is a common problem in childhood and adolescence (1, 2)....
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Journal Article•
TL;DR: The variation in the prevalences of asthma, allergic rhinoconjunctivitis, and atopic-eczema symptoms is striking between different centres throughout the world and will form the basis of further studies to investigate factors that potentially lead to these international patterns.
3,584 citations
TL;DR: In this article, the authors investigated worldwide prevalence of asthma, allergic rhinoconjunctivitis, and atopic disorders in children, and found differences of between 20-fold and 60-fold between centres in the prevalence of symptoms of asthma.
3,019 citations
University of Amsterdam1, Ghent University2, University of Chicago3, University of Pennsylvania4, Lund University5, Auckland City Hospital6, University of Antwerp7, University of New South Wales8, Katholieke Universiteit Leuven9, Guy's and St Thomas' NHS Foundation Trust10, Queen's University11, University of Zagreb12, Northwestern University13, Medical University of Łódź14, University of Aberdeen15, Medical University of South Carolina16, University of North Carolina at Chapel Hill17, University of Southampton18, University of São Paulo19, National University of Singapore20, Flinders University21
TL;DR: The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012 and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery.
Abstract: The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.
2,853 citations