一方、画像診断はルーチンで行われるべきでなく、そして、LT受容体拮抗剤は少なくとも第一選択とすべきではないとされた。
最下段には、NEJMの記事あるが、やはり、ステロイド点鼻を第一選択とするものである。ガイドラインと異なり、経口剤は代替薬剤のポジションである。
Clinical Practice Guideline: Allergic Rhinitis
Otolaryngology-Head and Neck Surgery. February 2015; 152 (1 suppl)
STATEMENT 1. PATIENT HISTORY AND PHYSICAL EXAMINATION: Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing.
STATEMENT 2. ALLERGY TESTING: Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. Recommendation based on RCTs and systematic reviews, with a preponderance of benefit over harm.
STATEMENT 3. IMAGING: Clinicians should not routinely perform sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR. Recommendation against based on observational studies, with a preponderance of benefit over harm.
STATEMENT 4. ENVIRONMENTAL FACTORS: Clinicians may advise avoidance of known allergens or may advise environmental controls (eg, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents that kill dust mites]) in AR patients who have identified allergens that correlate with clinical symptoms.
STATEMENT 5. CHRONIC CONDITIONS AND COMORBIDITIES: Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. Recommen-dation based on randomized trials with some heterogeneity and a preponderance of benefit over harm.
STATEMENT 6. TOPICAL STEROIDS: Clinicians should recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. Strong recommendation based on RCTs with minor limitations and a preponderance of benefit over harm.
STATEMENT 7. ORAL ANTIHISTAMINES: Clinicians should recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. Strong recommendation based on RCTs with minor limitations and a preponderance of benefit over harm.
STATEMENT 8. INTRANASAL ANTIHISTAMINES: Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. Option based on RCTs with minor limitations and observational studies, with equilibrium of benefit and harm.
STATEMENT 9. ORAL LEUKOTRIENE RECEPTOR ANTAGONISTS (LTRAs):Clinicians should not offer LTRAs as primary therapy for patients with AR. Recommendation against based on RCTs and systematic reviews, with a preponderance of benefit over harm.
STATEMENT 10. COMBINATION THERAPY: Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. Option based on RCTs with minor limitations and observational studies, with equilibrium of benefit and harm.
STATEMENT 11. IMMUNOTHERAPY: Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. Recommendation based on RCTs and systematic reviews, with a preponderance of benefit over harm.
STATEMENT 12. Inferior Turbinate Reduction: Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. Option based on observational studies, with a preponderance of benefit over harm.
STATEMENT 13. ACUPUNCTURE: Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. Option based on RCTs with limitations, observational studies with consistent effects, and a preponderance of benefit over harm.
STATEMENT 14. HERBAL THERAPY: No recommendation regarding the use of herbal therapy for patients with AR. No recommendation based on limited knowledge of herbal medicines and concern about the quality of standardization and safety.
漢方は、鍼治療未満 ・・・
Allergic Rhinitis
Lisa M. Wheatley, M.D., M.P.H., and Alkis Togias, M.D.
N Engl J Med 2015; 372:456-463January 29, 2015DOI: 10.1056/NEJMcp1412282
Allergic Rhinitis An estimated 15 to 30% of patients in the United States have allergic rhinitis, a condition that affects productivity and the quality of life in children and adults.
Allergic rhinitis frequently coexists with asthma and other allergic diseases; most people with asthma have rhinitis.
Intranasal glucocorticoids are generally the most effective therapy; oral and nasal antihistamines and leukotriene-receptor antagonists are alternatives.
However, many patients do not obtain adequate relief with pharmacotherapy.
Allergen immunotherapy should be used in patients with refractory symptoms or in those for whom pharmacotherapy is associated with unacceptable side effects.
Two forms of allergen immunotherapy are now available: subcutaneous injections and rapidly dissolving sublingual tablets, the latter limited in the United States to the treatment of grass and ragweed allergy.
Both forms of therapy generally provide sustained efficacy after the cessation of treatment.
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