Updates Announced for Clinical Practice Guidelines on Inhalant Allergy Treatment

Twelve evidence-based Key Action Statements were provided for clinicians to guide them in the treatment of patients reporting inhalant allergy symptoms.

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An announcement was made by the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) that the organization had updated guidelines for treating patients with inhalant allergy symptoms, published in Otolaryngology–Head and Neck Surgery.¹

Summary of Announcement

Allergen immunotherapy (AIT) aims to reduce allergic symptoms and induce immunologic tolerance by exposing patients to specific allergens.
Inhalant AIT, commonly delivered as subcutaneous or sublingual immunotherapy, is widely used for allergic rhinitis and allergic asthma.
Clinical practice guidelines recommend tailored AIT initiation, evaluation for asthma symptoms, patient education, and individualized treatment duration.

The foundation’s newly-identified clinical practice guideline points to improvements in quality which are deemed necessary, providing physicians with evidence-based recommendations on the use of immunotherapy for management of inhalant allergy symptoms.²

The newly-added guideline included 12 evidenced-based Key Action Statements (KAS) to guide doctors in their addressing of allergy sufferers needs.

"More than 50 million Americans suffer from allergies annually,” Richard Gurgel, MD, MSCI, chair of the AAO-HNSF Guideline Development Group (GDG), said in a statement. “Despite the widespread use of allergen immunotherapy (AIT), there are multiple clinical dilemmas that exist, including patient selection, modes of immunotherapy delivery, and ongoing needs to evaluate and ensure the safety and efficacy of AIT.”²

The GDG panel determining the guideline updates was made up of 17 members set up to represent experts in otolaryngology and allergy, with others having extensive background in the design of clinical practice guidelines.

Update Summary

In their updated guidelines,¹ the team of panelists made the following key action statements for clinicians treating patients with inhalant allergies:

AIT should not be implemented among patients who have uncontrolled asthma, are pregnant, or cannot tolerate use of injectable epinephrine.
There should be an assessment of patients’ symptoms or refer the patient to another doctor who can examine them for signs and symptoms of asthma prior to the initiation of AIT and for signs of uncontrolled asthma prior to administering AIT subsequently.
Physicians should provide a recommendation for another doctor who can offer immunotherapy for patients with allergic rhinitis with or without allergic asthma, assuming the known symptoms are inadequately controlled through medical therapy, allergen avoidance, or both, or the patients have a preference for using immunomodulation.
Physicians should ensure patients who are immunotherapy candidates are educated regarding the distinctions between SCIT and SLIT (aqueous and tablet), with risks, convenience, benefits, and costs being highlighted.
Education for patients should also cover the possible benefits of AIT in (1) the prevention of new allergen sensitization, (2) the reduction of allergic asthma development risk, and (3) the alteration of the natural history of the condition with continued benefit following the termination of treatment.
Doctors prescribing AIT should limit such treatment to only patients with clinically relevant allergens known to correlate with their history and confirmed through the use of testing.
AIT initiation should not be done by physicians for those who have a history of anaphylaxis, are known to implement concomitant beta-blockers, report having systemic immunosuppression, or report having eosinophilic esophagitis (SLIT only).
Pre- and co-seasonal immunotherapy should be provided by physicians who provide SLIT to those with seasonal allergic rhinitis.
The treatment of polysensitized patients may be done by physicians using only a limited number of allergens.
Avoidance of repeated allergy testing should be maintained when used as an evaluation of the efficacy of ongoing AIT, though it may be used if there are changes in patients’ environmental exposures or if there is a loss of control of their symptoms.
Continued escalation or maintenance dosing should be done by physicians using AIT when patients are shown to have local reactions.
Physicians should, for those shown to be experiencing symptomatic control from AIT, treat patients for a minimum 3 years. Ongoing treatment duration should also be based upon the responses observed to treatment.

Impact of the Guideline Updates

The guideline updates were designed to provide support for the provision of enhanced care among patients in the age range of 5 years and older with inhalant allergy symptoms. The foundation gave the example of such allergens as grass, pollen, pet dander, ragweed, and dust mites.²

Steady dose increases during AIT allow patients’ immune systems to become more tolerant of said allergens, and consequently less sensitive. AIT differs from alternative options as it can result in lasting effects even after its termination, leading to diminishes in financial burden due to medication reduction.

The foundation also noted that AIT may be helpful due to its potential for asthma symptom reduction, as well as its use in preventing development of other new allergies. In the announcement, the foundation noted that the full KASs and the guideline, along with additional supplemental materials, are accessible on this website.

References

^{Gurgel, R.K., Baroody, F.M., Damask, C.C., Mims, J.“., Ishman, S.L., Baker, D.P., Contrera, K.J., Farid, F.S., Fornadley, J.A., Gardner, D.D., Henry, L.R., Kim, J., Levy, J.M., Reger, C.M., Ritz, H.J., Stachler, R.J., Valdez, T.A., Reyes, J. and Dhepyasuwan, N. (2024), Executive Summary of Clinical Practice Guideline on Immunotherapy for Inhalant Allergy. Otolaryngol Head Neck Surg, 170: 635-667. https://doi.org/10.1002/ohn.650.}
^{New Clinical Practice Guideline Provides Evidence-based Recommendations for
Immunotherapy for Inhalant Allergy. The American Academy of Otolaryngology–Head and Neck Surgery Foundation. February 26, 2024. https://medicalxpress.com/news/2024-02-clinical-guideline-evidence-based-immunotherapy.html#:~:text=This%20clinical%20practice%20guideline%20identifies,who%20are%20experiencing%20symptoms%20from. Date accessed: February 26, 2024.}