Allergic rhinitis 2

Nathan Hare MD
2/19/13
Allergic Rhinitis

Outline
 Epidemiology
 Description
 Pathophysiology
 Triggers
 Co-morbidities
 Local Allergic Rhinitis
 Treatment
 Environmental Modifications
 Medications
 Subcutaneous Immunotherapy
 Sublingual Immunotherapy

Allergic Rhinitis (AR)
 Affects 10-40% of children world-wide 1
 Affects up to 40% of children in the U.S.
 Affects 10-30% of adults in the U.S.2
1. Jamal J Al Sayyad1,*, Zbys Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Editorial Group: Topical nasal steroids for
intermittent and persistent allergic rhinitis in children Cochrane Ear, Nose and Throat Disorders Group, Published Online:
21 JAN 2009
2. http://www.aaaai.org/conditions-and-treatments/library/allergy-library/rhinitis.aspx

Symptoms of Allergic Rhinitis
 Nasal Congestion
 Nasal Pruritus
 Sneezing
 Rhinorrhea
 Post Nasal Drainage
 Daytime inattention
 Irritability
 Hyperactivity

Bischoff Nature Reviews Immunology 7, 93–104 (February 2007) | doi:10.1038/nri2018
Pathophysiology

Common Triggers for Allergic Rhinitis
Seasonal Perennial
 Tree Pollen
 Grass Pollen
 Weed Pollen
 Mold Spores
 Dust Mites
 Cockroaches
 Cat
 Dog
 Mouse (inner city
schools) *
Permaul P, Hoffman E, Fu C, Sheehan W, Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D, Phipatanakul W.
Allergens in urban schools and homes of children with asthma.
Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi: 10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6.
•Exposure is to airborne allergens
•Have to think of indoor exposure beyond the home

Inner City School Allergen Exposures
 Settled dust and airborne allergen levels
 12 schools, vs homes
 Mouse levels were “substantial”
 Cat and Dog levels low, but were higher at school
 Dust mite and cockroach levels were low
Permaul P, Hoffman E, Fu C, Sheehan W, Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D, Phipatanakul W.
Allergens in urban schools and homes of children with asthma.
Pediatr Allergy Immunol. 2012 Sep;23(6):543-9. doi: 10.1111/j.1399-3038.2012.01327.x. Epub 2012 Jun 6.

Allergic Rhinitis: Comorbidities
 Important to remember impacts on children
beyond the nose
 Asthma , eczema, food allergy
(28%, 50%, 38% of 108 4 yo pts w AR1)
 Oral Allergy Syndrome (25% of 8 year olds 1)
 Sleep Disordered Breathing
 ADHD (?)
 Daytime inattention
 Irritability
 Hyperactivity
1. Westman M, Stjärne P, Asarnoj A, Kull I, van Hage M, Wickman M, Toskala E.
Natural course and comorbidities of allergic and nonallergic rhinitis in children.
J Allergy Clin Immunol. 2012 Feb;129(2):403-8. doi: 10.1016/j.jaci.2011.09.036. Epub 2011 Nov 5.

AR & Sleep Disordered Breathing in
Children
 Jan 2013 Review, covered last 25 years
 Ages 7-17
 Case-series or Case-Control articles
 10 articles studied habitual snoring
 6 articles studied OSA
 12/18 articles: statistically significant association
between AR and SDB
 Evidence grade B
Lin SY, Melvin TA, Boss EF, Ishman SL.
The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review.
Int Forum Allergy Rhinol. 2013 Jan 10. doi: 10.1002/alr.21123. [Epub ahead of print]

ADHD & Allergic Rhinitis
 Taiwan
 Cross-sectional study: increased prevalence of AR in
ADHD pts 1
 Second study: Significant association among ADHD, tic
disorder, and AR 2
 Third study: increased prevalence of ADHD in AR
patients (≥226,000 pediatric patients) 3
1. Chou PH, Lin CC, Lin CH, Loh EW, Chan CH, Lan TH.
Prevalence of allergic rhinitis in patients with attention-deficit/hyperactivity disorder: a population-based study.
Eur Child Adolesc Psychiatry. 2012 Dec 30. [Epub ahead of print]
2. Chen MH, Su TP, Chen YS, Hsu JW, Huang KL, Chang WH, Bai YM.
Attention deficit hyperactivity disorder, tic disorder, and allergy: Is there a link? A nationwide population-based study.
J Child Psychol Psychiatry. 2012 Nov 12. doi: 10.1111/jcpp.12018. [Epub ahead of print]
3.. Tsai MC, Lin HK, Lin CH, Fu LS.
Prevalence of attention deficit/hyperactivity disorder in pediatric allergic rhinitis: a nationwide population-based study.
Allergy Asthma Proc. 2011 Nov-Dec;32(6):41-6. doi: 10.2500/aap.2011.32.3489

Local Allergic Rhinitis
 Negative prick skin tests, negative intradermal
skin tests, negative allergen-specific serum IgE
 Symptoms after nasal challenge with allergen
 Local allergen-specific IgE produced after
challenge with allergen
 47-62.5% prevalence in European studies
Rondón C, Campo P, Togias A, Fokkens WJ, Durham SR, Powe DG, Mullol J, Blanca M.
Local allergic rhinitis: concept, pathophysiology, and management.
J Allergy Clin Immunol. 2012 Jun;129(6):1460-7. doi: 10.1016/j.jaci.2012.02.032. Epub 2012 Apr 18. Review.

Allergic Rhinitis: Treatment
 Can we change the environment to reduce the
patient‟s exposure to triggers?
 Can we modify the patient‟s symptoms?
 Can we modify the patient‟s immune system?

Environmental Modifications
 Does pet ownership make a difference in the
development of AR?
 Dust Mite Avoidance Measures
 Getting Rid of Pets if the patient is allergic
 Washing the pet
 Keep windows closed and run the AC during
pollen and mold seasons
 Clean any visible mold

Does Pet Ownership in Children
Change Anything?
 2012 International Survey
 “Early-life exposure to cats is a risk factor for …
rhinoconjunctivitis … in 6- to 7-year-old
children, especially in less-affluent countries. “
Brunekreef B, Von Mutius E, Wong G, Odhiambo J, García-Marcos L, Foliaki S; ISAAC Phase Three Study Group.
Exposure to cats and dogs, and symptoms of asthma, rhinoconjunctivitis, and eczema.
Epidemiology. 2012 Sep;23(5):742-50.

Change Anything?
 Australian Birth Cohort
 Followed 620 infants for first 12 yrs of life
 “Pets at birth either decreased or had no effect on
allergic disease up to age 12. “
 “We found no evidence that exposure to cats or
dogs at birth increases the risk of allergic disease
in high-risk children.”
Lodge CJ, Lowe AJ, Gurrin LC, Matheson MC, Balloch A, Axelrad C, Hill DJ, Hosking CS, Rodrigues S, Svanes C, Abramson MJ, Allen KJ, Dharmage S
Pets at birth do not increase allergic disease in at-risk children.
Clin Exp Allergy. 2012 Sep;42(9):1377-85. doi: 10.1111/j.1365-2222.2012.04032.x.

Change Anything?
 2012 Meta-analysis
 Children ages 6-10
 ≥22,000 children from 11 European Birth Cohorts
from 1990s
 Owning a furry pet or bird during the first 2 years
of life did not affect the risk of developing allergic
rhinitis.
Lødrup Carlsen KC, Roll S, Carlsen KH, Mowinckel P, Wijga AH, Brunekreef B, Torrent M, Roberts G, Arshad SH, Kull I, Krämer U, von Berg A, Eller E, H
Kuehni C, Spycher B, Sunyer J, Chen CM, Reich A, Asarnoj A, Puig C, Herbarth O, Mahachie John JM, Van Steen K, Willich SN, Wahn U, Lau S, Keil T;
GALEN WP 1.5 „Birth Cohorts‟ working group.
Does pet ownership in infancy lead to asthma or allergy at school age? Pooled analysis of Individual participant data from 11 European birth co
PLoS One. 2012;7(8):e43214. doi: 10.1371/journal.pone.0043214. Epub 2012 Aug 29.

House dust mite avoidance
measures for perennial Allergic
Rhinitis
 2010 Cochrane Review, assessed as up to date end
of 2009.1
 9 trials (501 participants satisfied criteria)
 Mite-impermeable bedding covers (2 studies were
good quality)
 Acaricides (2 studies)
 HEPA filters (2 studies)
 Acaricides +/- covers (1 study)
1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group:
House dust mite avoidance measures for perennial allergic rhinitis
Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009

House dust mite avoidance
measures for perennial Allergic
Rhinitis
 Conclusions:
 Trials to date … small and of poor methodological quality…difficult
to offer any definitive recommendations on the role … of house
dust mite avoidance measures in the management of house dust
mite sensitive perennial allergic rhinitis.
 Use of acaricides and extensive bedroom-based environmental
control programmes may be of some benefit in reducing rhinitis
symptoms and, if considered appropriate, these should be the
interventions of choice.
 Isolated use of house dust mite impermeable bedding is unlikely to
prove effective.
1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group:
House dust mite avoidance measures for perennial allergic rhinitis
Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009

Washing the Pet
Dogs:
Hodson T, Custovic A, Simpson A, Chapman M, Woodcock A, Green R.
Washing the dog reduces dog allergen levels, but the dog needs to be washed twice a week
J Allergy Clin Immunol. 1999 Apr;103(4):581-5.
Cats:
Nageotte C, Park M, Havstad S, Zoratti E, Ownby D.
Duration of airborne Fel d 1 reduction after cat washing.
J Allergy Clin Immunol. 2006 Aug;118(2):521-2. Epub 2006 Jun 27.
Drop in Cat allergen levels lasted only 1 day after washing. But, it was pointed out that
Goetz DW.
Washing the cat requires shampoo.
J Allergy Clin Immunol. 2007 Mar;119(3):758; author reply 758-9. Epub 2007 Jan 19.

What about Hypoallergenic
Dogs?
 Hypoallergenic Breeds do not exist.
 In this study, dogs from “hypoallergenic breeds”
had higher allergen levels in hair and coat
samples than control dogs.
 Differences between breeds were small.
Vredegoor DW, Willemse T, Chapman MD, Heederik DJ, Krop EJ.
Can f 1 levels in hair and homes of different dog breeds: lack of evidence to describe any dog breed as hypoallergen
J Allergy Clin Immunol. 2012 Oct;130(4):904-9.e7. doi: 10.1016/j.jaci.2012.05.013. Epub 2012 Jun 22.

Treating Symptoms
 Nasal Saline Irrigation
 Medications

Nasal Saline Irrigation (SNI)
 “Meta-analysis”: 50 trials, >400 participants
 Performed regularly up to 7 weeks
 27.66% improvement in nasal symptoms
 62.1% reduction in medicine consumption
 31.19% acceleration of mucociliary clearance
time
 27.88% improvement in quality of life.
 “no evidence showing that regular, daily SNI
adversely affects the patient's health or causes
unexpected side effects.”Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Mösges R.
Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis.
Am J Rhinol Allergy. 2012 Sep-Oct;26(5):e119-25. doi: 10.2500/ajra.2012.26.3787.

Nasal Saline Irrigation in Children
 4 week RCT, investigator blinded
 220 children aged 5-9 yrs with seasonal AR
 80 used hypertonic saline (2.7%), 80 used normal
saline, 60 control subjects (no treatment)
 Evaluated effect on Nasal symptoms
(rhinorrhea, itching, sneezing, nasal
obstruction), swelling of turbinates, adenoid
hypertrophy or middle ear effusion
Marchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito S, Principi N
Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children.
Int J Immunopathol Pharmacol. 2012 Jul-Sep;25(3):721-30.

Nasal Saline Irrigation in Children
 Hypertonic Saline: “significant reduction” in all
areas
 Normal Saline: “significant reduction” in
rhinorrhea and sneezing
 Control: no significant change
Marchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito S, Principi N
Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children.
Int J Immunopathol Pharmacol. 2012 Jul-Sep;25(3):721-30.

Medications
 Anti-histamines
 Oral, Intranasal
 Leukotriene-modifying
agents
 Oral
 Steroids
 Oral, Intranasal
 Mast-cell stabilizers
 Intranasal

Antihistamines
1st Generation 2nd Generation
 Diphenhydramine
 Hydroxyzine
 Chlorpheniramine
 Brompheniramine
 Loratadine, Deslorata
dine
 Cetirizine, Levocetirizi
ne
 Fexofenadine
 Azelastine (Astelin, ≥5
yrs, Astepro, ≥12
yrs, intranasal)
 Olopatadine
(Patanase, ≥6*Also thought to work as a mast cell stabilizer
(http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021545s013lbl.pdf)

Leukotriene-Modifiers
 Montelukast (Singulair, ≥6 mo)
 Zafirlukast (Accolate, ≥5 yrs)
 Zileuton (Zyflo, ≥ 12 yrs)

Intranasal Steroids
Liquid Dry Powder
 Fluticasone
(Flonase, ≥4 yrs)
 Mometasone
(Nasonex, ≥2yrs)
 Ciclesonide
(Omnaris, ≥6 yrs)
 Triamcinolone
(Nasacort AQ, ≥2 yrs)
 Beclomethasone
(Qnasl, ≥12 yrs old)
 Ciclesonide
(Zetonna, ≥12 yrs old)

Intranasal Steroids
 6 week study of beclomethasone, placebo, and
placebo/prednisone:
 beclomethasone NOT INFERIOR to placebo in
regards to suppression of hypothalamic-pituitary-
adrenal axis function
Ratner PH, Miller SD, Hampel FC Jr, Melchior A, Dunbar SA, Tantry SK.
Once-daily treatment with beclomethasone dipropionate nasal aerosol does not affect hypothalamic-pituitary-adrenal axis
Ann Allergy Asthma Immunol. 2012 Nov;109(5):336-41. doi: 10.1016/j.anai.2012.08.005.

Intranasal Steroids in Children
 Cochrane Review published online 2009, assessed
as up to date 2006
 3 trials, total 79 children
 Beclomethasone or flunisolide vs. placebo
 Weak or unreliable evidence for effectiveness.1
1. Jamal J Al Sayyad1,*, Zbys Fedorowicz2, Dunia Alhashimi3, Ahmed Jamal4, Topical nasal steroids for intermittent and
persistent allergic rhinitis in children Editorial Group: Cochrane Ear, Nose and Throat Disorders Group, Published Online:
21 JAN 2009

Intranasal Steroids with add-on oral
Antihistamine therapy in children
 2010 Cochrane Review found only 1 RCT with 24
children (defined as under age 18).1
 Sufficient data not provided to answer question
 Conclusion: no evidence available for benefit of add-on
antihistamine treatment to intranasal steroids for children with
intermittent or persistent allergic rhinitis.
 Take-away message: don‟t forget potential side effects of
antihistamines, and keep in mind costs of adding a second
medication.
1. Mona Nasser1,*, Zbys Fedorowicz2, Hamad Aljufairi3, William McKerrow4
Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children
Editorial Group: Cochrane Ear, Nose and Throat Disorders Group
Published Online: 7 JUL 2010 Assessed as up-to-date: 20 SEP 2009

Total Nasal Symptom Score
 Intensity of nasal symptoms
 Rhinorrhea, Nasal itching, Nasal
Obstruction, Sneezing
0 = No symptoms
1 = Mild
2= Moderate
3= Severe
 Total Possible Score ranges from 0 (no symptoms) to
12 (maximum symptom intensity)
Valero A, Izquierdo I, Giralt J, Bartra J, del Cuvillo A, Mullol J.
Rupatadine improves nasal symptoms, quality of life (ESPRINT-15) and severity in a subanalysis of a cohort of Spanish
allergic rhinitis patients.
J Investig Allergol Clin Immunol. 2011;21(3):229-35.

Combination Therapy: Intranasal
steroid & Intranasal antihistamine
 TNSS: Total Nasal Symptom Score
 The TNSS improved 27.1% with fluticasone nasal
spray, 24.8% with azelastine nasal spray, and
37.9% with the 2 agents in combination
Ratner PH, Hampel F, Van Bavel J, Amar NJ, Daftary P, Wheeler W, Sacks H.
Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray
in the treatment of patients with seasonal allergic rhinitis.
Ann Allergy Asthma Immunol. 2008 Jan;100(1):74-81. doi: 10.1016/S1081-1206(10)60408-5.

Combination Intranasal steroid and
Antihistamine
 Fluticasone and azelastine in the same
delivery device
 Meta-analysis of 3 separate
multicenter, randomized, double-
blind, placebo- and active-
controlled, parallel-group trials
 Each trial conducted for 14 days during
different allergy seasons
 3398 patients (>11 yrs old)
 Moderate to severe seasonal allergic
rhinitisCarr W, Bernstein J, Lieberman P, Meltzer E, Bachert C, Price D, Munzel U, Bousquet J.
A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis.
J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10. doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13.

Combination Intranasal steroid and
Antihistamine
 Combination reduced mean reflective
total nasal symptom score from baseline
(-5.7 [SD, 5.3])
 Fluticasone (-5.1 [SD, 4.9], P < .001)
 Azelastine (-4.4 [SD, 4.8], P < .001)
 Placebo (-3.0 [SD, 4.2], P < .001).
 Available now as Dymista (≥12 yrs)
Carr W, Bernstein J, Lieberman P, Meltzer E, Bachert C, Price D, Munzel U, Bousquet J.
A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis.
J Allergy Clin Immunol. 2012 May;129(5):1282-1289.e10. doi: 10.1016/j.jaci.2012.01.077. Epub 2012 Mar 13.

Fig E1
Source: Journal of Allergy and Clinical Immunology 2012; 129:1282-1289.e10 (DOI:10.1016/j.jaci.2012.01.077 )
Copyright © 2012 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Inferior Turbinate Surgery after failed
Medical Treatment of Allergic Rhinitis
 2010 Cochrane review was unable to find any
randomized controlled trials comparing this surgery to
continued medical treatment.1
1. Jemy Jose1,*, Andrew P Coatesworth2, Inferior turbinate surgery for nasal obstruction in allergic rhinitis after failed
medical treatment Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 8 DEC 2010
Assessed as up-to-date: 5 JUL 2010

Altering the Immune Response
 Helminths (Worms)
 Subcutaneous Immunotherapy (Allergy Shots)
 Sublingual Immunotherapy

Worms
• Why look? Helminths modulate the natural
immune responses of their human hosts, and
may prevent or cure immune-mediated or allergic
diseases (e.g. allergic rhinitis) in the host. Non-
randomized studies support this hypothesis.1
 “Trials using helminths like hookworm (Necator
americanus) or porcine whipworm (Trichuris suis)
show that they are safe and may be effective
therapies for the control of the aberrant intestinal
inflammation seen in Crohn's disease and
ulcerative colitis.”2
1. Ashley M Croft1,*, Peter Bager2, Sushil Kumar3 Helminth therapy (worms) for allergic rhinitis
Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 18 APR 2012 Assessed as up-to-date: 24 JUN 2011
2. Elliott DE, Weinstock JV. Where are we on worms? Curr Opin Gastroenterol. 2012 Nov;28(6):551-6. doi: 10.1097/MOG.0b013e3283572f73.

Helminth therapy (worms) for
Allergic Rhinitis
 2012 Cochrane Review, assessed as up to date
2011.1
 They found 130 people…
 1.8 to 7.7x increase in GI side effects vs placebo
 Insufficient evidence, appears to be safe
1. Ashley M Croft1,*, Peter Bager2, Sushil Kumar3 Helminth therapy (worms) for allergic rhinitis
Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 18 APR 2012 Assessed as up-to-date:
24 JUN 2011

Allergy Injection Immunotherapy (IT)
for Seasonal Allergic Rhinitis
 2009 Cochrane Review1, assessed as up to date
2006
 51 of 1111 publications met criteria
 2871 participants (1645 active, 1226 placebo)
 Averaged 18 injections per participant
 Duration of IT 3 days to 3 years
1. Moises A Calderon1,*, Bernadette Alves2, Mikila Jacobson3, Brian Hurwitz4, Aziz Sheikh5, Stephen Durham6
Allergen injection immunotherapy for seasonal allergic rhinitis
Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 21 JAN 2009 Assessed as up-to-date: 13
NOV 2006

 Symptom Scores from 15 trials
 an overall reduction in the immunotherapy group
(SMD -0.73 (95% CI -0.97 to -0.50, P < 0.00001)).
 Medication score data from 13 trials
 an overall reduction in the immunotherapy group
(SMD of -0.57 (95% CI -0.82 to -0.33, p<0.00001)).
NOV 2006

 Epinephrine (adrenaline)
 given in 0.13% (19 of 14085 injections) of those on active
treatment
 given in 0.01% (1 of 8278 injections) of the placebo group
for treatment of adverse events.
 Fatalities: None
NOV 2006

 Authors‟ Conclusions:
 Specific allergen injection immunotherapy in
suitably selected patients with seasonal allergic
rhinitis results in a significant reduction in symptom
scores and medication use.
 Injection immunotherapy has a known and relatively
low risk of severe adverse events.
 We found no long-term consequences from adverse
events.1
NOV 2006

Sublingual immunotherapy (SLIT) for
Allergic Rhinitis
 2011 Cochrane Review, assessed as up to date
2009.1
 49/60 RCTs suitable for meta-analysis pooling
 2333 SLIT, 2256 placebo participants
 Significant reduction in symptoms
 (SMD -0.49; 95% confidence interval (CI) -0.64 to -0.34, P <
0.00001)
 Significant reduction in medication requirements
 (SMD -0.32; 95% CI -0.43 to -0.21, P < 0.00001)
1. Suzana Radulovic1,*, Moises A Calderon2, Duncan Wilson3, Stephen Durham2 Sublingual immunotherapy for allergic
rhinitis
Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 16 FEB 2011 Assessed as up-to-date:
13 AUG 2009

Sublingual immunotherapy (SLIT) for
Allergic Rhinitis
 SLIT appears to be safe
 None of the trials in this review reported
 Severe systemic reactions
 Anaphylaxis
 Use of epinephrine
1. Suzana Radulovic1,*, Moises A Calderon2, Duncan Wilson3, Stephen Durham2 Sublingual immunotherapy for allergic
rhinitis
Editorial Group: Cochrane Ear, Nose and Throat Disorders Group Published Online: 16 FEB 2011 Assessed as up-to-date:
13 AUG 2009

Subcutaneous (SCIT) vs Sublingual
(SLIT) Immunotherapy
SCIT SLIT
 Symptoms
(SMD -0.73 (95% CI -0.97 to -
0.50, P < 0.00001)).
 Medication need
(SMD of -0.57 (95% CI -0.82 to
-0.33, p<0.00001)).
 Epinephrine: 0.13% of
treatment injections, vs. 0.01%
of placebo
 Fatalities: None
 Symptoms
(SMD -0.49; 95%
confidence interval (CI) -
0.64 to -0.34, P <
0.00001)
 Medication need
(SMD -0.32; 95% CI -0.43 to
-0.21, P < 0.00001)
 Epinephrine: No use
 Severe systemic reactions:
None
 Anaphylaxis: None

When to consider Allergy
Immunotherapy
 Symptoms are not well controlled with
medication.
 Patient prefers to avoid medication
 Patient is unable to tolerate medication
 Possible decreased long-term cost of treatment
 Co-existing Allergic Rhinitis and Asthma
 Possible prevention of asthma

Subcutaneous immunotherapy for allergic
rhinitis: an evidence based review of the
recent literature with recommendations.
 Safe when administered to carefully selected
patients and in settings capable of responding to
systemic reactions.
 Recommended for patients with seasonal or
perennial allergic rhinitis not responsive to
conservative medical therapy, and whose
symptoms significantly affect quality of life.
Purkey MT, Smith TL, Ferguson BJ, Luong A, Reisacher WR, Pillsbury HC 3rd, Toskala E.
Subcutaneous immunotherapy for allergic rhinitis: an evidence based review of the recent literature with recommendatio
Int Forum Allergy Rhinol. 2013 Jan 11. doi: 10.1002/alr.21141. [Epub ahead of print]

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