This protocol applies when patients with severe persistent allergic rhinitis have not achieved symptom resolution — including nasal congestion, rhinorrhea, sneezing, nasal pruritus, and ocular symptoms — despite standard first-line management.
The patient has severe persistent allergic rhinitis: symptoms occur more than four days per week and more than four weeks per year, and their severity is impacting quality of life — affecting asthma control, sleep, sports participation, or school or work performance.
Initial management with allergen avoidance and patient education, combined with an intranasal corticosteroid plus an oral or intranasal antihistamine, an oral leukotriene receptor antagonist, or intranasal cromolyn, was attempted. The goal — resolution of nasal congestion, rhinorrhea, sneezing, nasal pruritus, and ocular symptoms — was not achieved.
For severe persistent symptoms unresponsive to the above, a form of immunotherapy may be considered. The complete regimen — including the specific modality, patient selection criteria, and all clinical considerations — is detailed in the full protocol.
Severity can be divided into mild (symptoms do not interfere with quality of life) or severe (symptoms impact asthma control, sleep, sports participation, or school or work performance).
Frequency can be divided into intermittent or persistent (more than four days per week and more than four weeks per year, respectively).
Consider subcutaneous or sublingual immunotherapy.
Immunotherapy should be considered for moderate or severe persistent allergic rhinitis that is not responsive to usual treatments, in patients who cannot tolerate standard therapies or who want to avoid long-term medication use, and in patients with allergic asthma.
Patients with more severe disease not responding to intranasal corticosteroids with or without second-line therapies should be referred for consideration of immunotherapy.
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