Turkish Guideline for Diagnosis and Treatment of Allergic Rhinitis (ART)

Türk KBB-BBC Derneği + allied societies… · 2021 · Türkiye

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Authors: Mustafa Cenk Ecevit, Müge Özcan, İlknur Haberal Can et al.
Title: Turkish Guideline for Diagnosis and Treatment of Allergic Rhinitis (ART)
Journal: Turkish Archives of Otorhinolaryngology, 2021
DOI: 10.4274/tao.2021.suppl.1
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC8221269

Licence statement of the original publication

Content of this journal is licensed under a Creative Commons Attribution 4.0 International License.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

6.3.3.1.4. Allergen test panel

We suggest you to take pollen map of Turkey into consideration as well as the pollen calendar before planning an inhalant test panel in your center (168).

8.1.2.3. Immunotherapy

Although some case reports described a link between SCIT application and autoimmune disorders, the authors did not find any evidence for that (level of evidence: III). There was no evidence that immunotherapy administration caused more frequent and serious side effects in cases with autoimmune disorders (level of evidence: IV), and there was no evidence that immunotherapy would be less effective in individuals with autoimmune disorders (level of evidence: IV). In line with these results, it has been stated that immunotherapy is considered to be relatively contraindicated in the remission period, and definitely contraindicated in the active period of an autoimmune disease, and immunotherapy should be used carefully in presence of autoimmune disorders since the data are insufficientgrade of recommendation: D
It has been stated that there is no information on the effect of immunotherapy on the course of the malignant diseases (NR), and that immunotherapy application is not expected to cause more frequent and more serious side effects (NR). It has been stated that immunotherapy is not expected to be less effective in presence of a malignant disease (NR). In line with these results, it has been reported that the application of immunotherapy in malignant diseases is considered as a definite contraindicationgrade of recommendation: D
It has been reported that use of beta blockers is a relative contraindication for immunotherapy since they prevent performing an effective treatment in case of anaphylaxis due to inhibition of the effect of epinephrine on beta receptors, and unmet alpha adrenergic effect (level of evidence: III). More serious side effects were observed in those using beta blockers, however an increase was not expected in the frequency of side effects (level of evidence: III). There is no evidence showing that immunotherapy is less effective when the patient is on beta blocker treatment (level of evidence: III). Therefore, the authors pointed out that administration of immunotherapy in individuals using beta blockers must be decided on a profit-loss account, and SIT was considered as relatively contraindicated in the ones that use beta blockersgrade of recommendation: C
In case of use of ACE inhibitors, the authors stated that vasodilation caused due to their effects on the renin-angiotensin system might affect the response in anaphylaxis. Although it has been found that side effects may not occur more frequently, more serious side effects may occur in case of ACE inhibitor use (level of evidence: III). It was stated that there was no evidence for the effectiveness of immunotherapy (level of evidence: IV). In line with these results, the authors reported that there was no contraindication for immunotherapy in the ones that use ACE inhibitorsgrade of recommendation: C
It has been known that epinephrine, which is used in case of an emergency situation can cause serious hypertension and cardiac arrhythmias in patients using monoamine oxidase inhibitors. However, there is no evidence that immunotherapy causes more serious and more frequent side effects in the use of monoamine oxidase inhibitors (level of evidence: IV) or that immunotherapy is less effective (level of evidence: IV). Therefore, immunotherapy is not contraindicated in patients using monoamine oxidase inhibitors. However, caution should be exercised while using epinephrine in these patientsgrade of recommendation: D
There is no evidence that immunotherapy has a negative effect on the course of cardiovascular diseases (level of evidence: IV). There is no evidence that immunotherapy causes more frequent and more serious side effects, or immunotherapy is less effective (level of evidence: IV), however treatment of the side effects may be more difficult in these patients (level of evidence: IV). In the light of these results, the authors stated that the immunotherapy was relatively contraindicated in patients with cardiovascular disorders (grade of recommendation: D), and the decision for SIT should be based on obtaining expert opinion on cardiovascular disorder, careful evaluation of the disease and its treatment, anaphylaxis risk, and profit and loss assessment.
There is insufficient evidence regarding immunotherapy in HIV positive states; the present data are based on the patients without serious symptoms. Immunotherapy has no negative effect on the course of the disease (IV), more frequent and more serious side effects are not expected (level of evidence: IV), and it is not considered that immunotherapy will be less effective (IV), however these remarks cannot be excluded (level of evidence: IV). Therefore, immunotherapy application is accepted as a relative contraindication in HIV positive patients, and it has been stated that the decision should be individually basedgrade of recommendation: D
In general, immunotherapy has been reported to have a negative effect on the course of the disease in patients with immune deficiency or in need of an immunosuppressive therapy (NR), and theoretically it may increase the risk of more serious side effects (NR). In addition, immunotherapy is thought to be less effective in patients with adaptation problems and in patients with an impaired immune systemlevel of evidence: IV

Abstract

Object: To prepare a national guideline for Otorhinolaryngologist who treat allergic rhinitis patients.

Methods: The study was conducted by three authors, namely the writing support team. The support team made the study plan, determined the writing instructions, chose the subgroups including the advisory committee, the advisors for authors and the authors. A workshop was organized at the very beginning to explain the details of the study to the team. Advisors took the chance to meet their coworkers in their subgroups and determined the main headings and subheadings of the guideline, together with the authors. After key words were determined by the authors, literature search was done in various databases. The authors keep in touch with the advisors and the advisors with the advisory committee and the support group at every stage of the study. National and International published articles as well as the abstracts of unpublished studies, imperatively presented in National Congresses, were included in this guideline. Only Guideline and meta-analyses published in last seven years (2013-2017) and randomized controlled studies published in last two years (2015-2017) were included. After all work was completed by the subgroups, support team brought all work together and edited the article.

Results: A detailed guideline about all aspects of allergic rhinitis was created.

Conclusion: The authors believe that this guideline will enable a compact and up-to-date information on allergic rhinitis to healthcare professionals. This guideline is the first in the field of Otolaryngology in Turkey. It should be updated at regular intervals.

Contents of the original publication

The section headings of the original.

1. Why have we composed this guide?
2. Definition and pathogenesis of allergic rhinitis
2.1. IgE sensitization
2.2. Early phase response
2.3. Late phase response
2.4. The effect of innate immune response on allergic rhinitis
2.5. Mast cells
2.6. Basophils
2.7. Group 2 innate lymphoid cells
2.8. Natural killer cells
2.9. Eosinophils
2.10. Antigen presenting cells
2.11. T and B lymphocytes
2.12. Cytokines and chemokines
2.13. The role of local and systemic IgE
2.14. Lipid mediators in allergic rhinitis
2.15. Nasal mucosal epithelial barrier
2.16. Neuroimmune mechanisms in allergic rhinitis
2.17. Nasal hyper-reactivity
3. Classification of allergic rhinitis
3.1. Seasonal allergic rhinitis
3.2. Perennial allergic rhinitis
3.3. Episodic allergic rhinitis
3.4. Seasonal exacerbation of chronic disease
3.5. Intermittent allergic rhinitis
3.6. Persistent allergic rhinitis
3.7. Mild disease
3.8. Moderate-severe disease
3.9. Local allergic rhinitis
4. Epidemiology of allergic rhinitis
4.1. Global epidemiology of allergic rhinitis
4.2. Specification of the epidemiological studies and data in Turkey, and questioning their accuracy
4.2.1. Comparison of epidemiological data in Turkey with other regions of the world
4.2.2. Specification of the regional differences in Turkey (diet, seasonal differences)
4.2.3. Specification of the epidemiological data in relation to age, gender, region, method of diagnosis, occupation, allergens, classification, urban/rural areas, diet (breast milk, lactose, gluten)
5. The influence of allergic rhinitis on quality of life
5.1. Quality of life scales frequently used for allergic rhinitis
5.1.1. Medical Outcome Study, Short-Form 36 (SF-36), Short Form-12 (SF-12), Short Form-20 (SF-20)
5.1.2. Glasgow Benefit Inventory
5.1.3. Sinonasal Outcome Test 20 and Sinonasal Outcome Test 22 (SNOT-22)
5.1.4. Rhinoconjunctivitis Quality of Life Questionnaire
5.1.5. Rhinasthma Quality of Life Questionnaire
5.1.6. General Nasal Patient Inventory
5.1.7. Sinonasal-5 Quality of Life Survey
5.1.8. Rhinitis Control Assessment Test (RCAT)
5.1.9. Nasal Obstruction Symptom Evaluation Scale
5.1.10. Rhinosinusitis Disability Index
5.1.11. Rhinosinusitis Symptom Inventory
6. Diagnosis of allergic rhinitis
6.1 History
6.1.1. Symptoms
6.1.1.1. Nasal symptoms
6.1.1.2. Non-nasal symptoms
6.1.1.3. Symptom characteristics
6.1.2. Personal history
6.1.2.1. Occupation
6.1.2.2. Medications
6.1.2.3. Previous surgery
6.1.2.4. Comorbid diseases
6.1.2.5. Smoking and air pollution
6.1.2.6. Place of living
6.1.2.7. Pets
6.1.2.8. Food allergy
6.1.3. Family history
6.1.3.1. Number of the siblings
6.1.3.2. Household
6.1.3.3. Childhood history
6.1.3.4. Family history of atopy and allergic diseases
6.2. Physical examination
6.2.1. Nasal signs
6.2.2. Ocular signs
6.2.3. Other signs on otorhinolaryngological examination
6.2.4. Complications
6.3. In vivo tests in the diagnosis of allergic rhinitis
6.3.1. Introduction
6.3.2. Evaluation before diagnostic testing
6.3.2.1. Indications for skin prick test
6.3.2.2. Indications for intradermal test
6.3.2.3. Patient selection for skin prick test
6.3.2.3.1. Age
6.3.2.3.2. Contraindications
6.3.2.3.3. Relative contraindications
6.3.2.3.4. Medications that affect skin prick test results
6.3.2.3.5. Patient factors that affect skin prick test results
6.3.2.4. Intradermal skin test
6.3.3. Method
6.3.3.1 Allergens for skin prick test
6.3.3.1.1. Commercial extracts
6.3.3.1.2. The contents of skin prick test extracts
6.3.3.1.3. Cross-reaction
6.3.3.1.4. Allergen test panel
6.3.3.1.5. Food allergens
6.3.3.1.6. Storage of the allergen extracts
6.3.3.2. Positive and negative controls
6.3.3.3. Equipment for skin testing
6.3.3.4. Performing a skin prick test
6.3.3.4.1. Equipment needed for skin prick testing
6.3.3.4.2. The area of the body used for skin prick testing
6.3.3.4.3. Test method
6.3.3.4.4. Waiting period before reading the results
6.3.3.4.5. Measuring erythema and induration
6.3.3.4.6. Recording skin prick test results
6.3.3.4.7. Follow up of the patient after skin prick testing
6.3.3.5. Reporting skin prick test results
6.3.4. Evaluation of skin prick test results
6.3.4.1. The significance of positive and negative results
6.3.4.2. The value of skin prick testing
6.3.5. The team
6.3.5.1. Physician
6.3.5.2. Other medical staff
6.3.6. Safety and risks
6.3.6.1. The safety and risks of skin prick test
6.3.6.2. Safety rules and equipment
6.3.6.3. Informed consent form
6.4. In vitro tests for diagnosis of allergic rhinitis
6.4.1. Serum total IgE level
6.4.2. Serum allergen-specific IgE
6.4.3. Determination of serum specific IgE with microarray method
6.4.4. Basophil activation test
6.4.5. Basophil, histamine and leukotriene release tests
6.4.6. Nasal allergen-specific IgE
6.5 Other tests used in diagnosis of allergic rhinitis
6.5.1. Nasal provocation test
6.5.2. Nasal cytology
6.5.3. Visual analogue scoring
6.5.4. Studies on mucociliary clearance
6.5.5. Rhinomanometry and acoustic rhinometry
6.5.6. Smell tests
6.5.7. Nasal nitric oxide measurement
6.5.8. Microarray tests
6.6. Radiological imaging
6.6.1. Plain X-ray
6.6.2. Computerized tomography
6.6.3. Magnetic resonance imaging
6.7. Differential diagnosis of allergic rhinitis
6.7.1. Introduction
6.7.2. Pathophysiology
6.7.3. Classification of rhinitis
6.7.3.1. Allergic rhinitis
6.7.3.2. Non-allergic rhinitis
6.7.3.2.1. Non-allergic rhinopathy (vasomotor rhinitis, idiopathic rhinitis)
6.7.3.2.2. Non-allergic rhinitis with eosinophilia syndrome
6.7.3.2.3. Gustatory rhinitis
6.7.3.2.4. Medication induced rhinitis (rhinitis medicamentosa)
6.7.3.2.5. Hormonal rhinitis
6.7.3.2.6. Atrophic rhinitis
6.7.3.2.7. Senile rhinitis
6.7.3.2.8. Cerebrospinal fluid rhinorrhea
6.7.4. Differential diagnosis of allergic and non-allergic rhinitis
6.8. Differential diagnosis of allergic rhinitis and comorbid disorders
6.8.1. Differential diagnosis of allergic rhinitis
6.8.1.1. Management of non-allergic rhinitis
6.8.1.1.1. History and symptoms
6.8.1.1.2. Physical examination
6.8.1.1.3. Diagnostic methods
6.8.1.1.4. Further medical workup
6.8.1.1.5. Treatment
6.8.1.2. Disorders other than non-allergic rhinitis in differential diagnosis of allergic rhinitis
6.8.2. Comorbid diseases in allergic rhinitis
6.8.2.1. Asthma
6.8.2.2. Rhinosinusitis
6.8.2.2.1. Nasal polyps
6.8.2.2.2. Relation of acute rhinosinusitis and allergic rhinitis
6.8.2.2.3. Relation of allergic rhinitis with chronic rhinosinusitis without nasal polyps
6.8.2.2.4. Relation of allergic rhinitis with chronic rhinosinusitis with nasal polyps
6.8.2.3. Conjunctivitis
6.8.2.4. Otitis media
6.8.2.5. Gastroesophageal and laryngopharyngeal reflux
6.8.2.6. Adenoid hypertrophy
6.8.2.7. Cough
6.8.2.8. Skin rash
6.8.2.9. Sleep disorders
6.8.2.10. Cognitive disorders and learning disability
6.8.2.11. Sexual dysfunction
7. Treatment of allergic rhinitis
7.1. Environmental control
7.1.1. Control of indoors: methods for avoiding indoor allergens
7.1.2. Control of outdoors: methods for avoiding outdoor allergens
7.2. Pharmacotherapy
7.2.1. Corticosteroids in treatment of allergic rhinitis
7.2.1.1. Systemic corticosteroids
7.2.1.2. Nasal corticosteroids
7.2.2. Oral antihistamines
7.2.2.1. H1 antihistamines
7.2.2.2. Adverse effects
7.2.3. Nasal antihistamines
7.2.3.1. Azelastine
7.2.3.2. Olopatadine
7.2.3.3. Comparison of olopatadine with azelastine
7.2.3.4. Comparison of nasal antihistamines with oral histamines
7.2.3.5. Comparison of nasal antihistamines with nasal corticosteroids
7.2.3.6. Comparison of onset of action of nasal antihistamines with that of nasal corticosteroids
7.2.3.7. Combination of nasal antihistamine and nasal corticosteroid
7.2.4. Antileukotriens
7.2.4.1. Meta-analyses
7.2.4.2. Other international and national publications
7.2.4.3 ARIA reports
7.2.4.4. Adverse effects
7.2.5. Combined preparations
7.2.5.1. Combination of oral antihistamine and leukotriene receptor antagonist
International literature:
National literature:
7.2.5.2. Combination of oral antihistamine and decongestant
International literature:
7.2.5.3. Combination of antihistamine and corticosteroid
International literature:
7.2.5.4. Combination of nasal corticosteroid and antihistamine
International literature:
7.2.5.5. Combination of nasal corticosteroid and decongestant
International literature:
7.2.6. Anti-IgE
7.2.7. Cromolyns
7.2.8. Decongestants
7.2.8.1. Systemic decongestants
7.2.8.2. Nasal decongestants
7.2.8.3. Use of decongestants during pregnancy and in the elderly
7.2.9. Anticholinergics
7.3. Immunotherapy
7.3.1. Introduction
7.3.2. Informing the patient
7.3.2.1. Treatment process
7.3.2.2. The results of treatment
7.3.2.3. Cessation of treatment
7.3.2.4. Immunotherapy in the future
7.3.3. Subcutaneous immunotherapy
7.3.3.1. Initiation of treatment and the dose scheme
International publications
National publications
7.3.3.2. Maintenance and the dose scheme
International publications
When is the treatment schedule changed?
National publications
Adverse effects
7.3.3.3. Adverse effects
International publications
National publications
7.3.4. Sublingual immunotherapy
Application
7.3.4.1. Initiation of treatment and the dose scheme
7.3.4.2. Maintenance and the dose scheme
7.3.4.3. Adverse effects
7.3.5. Oral immunotherapy
7.3.5.1. Initiation of treatment and the dose scheme
7.3.5.1. Maintenance treatment
7.3.5.3. Adverse effects
7.3.6. Informed consent form for immunotherapy
7.3.7. Comparison of immunotherapy methods
7.3.8. Algorithm
7.3.9. Conclusion
8. Special conditions in treatment of allergic rhinitis
8.1. Treatment of allergic rhinitis in special conditions
8.1.1. Treatment of allergic rhinitis in children
8.1.1.1. Epidemiology and risk factors
8.1.1.2. Clinical course and diagnosis of allergic rhinitis in children
8.1.1.3. Treatment of allergic rhinitis in children
8.1.1.3.1. Environmental control and allergen avoidance
8.1.1.3.2. Pharmacotherapy
8.1.1.3.2.1. Corticosteroids
8.1.1.3.2.2. Oral and nasal antihistamines
8.1.1.3.2.3. Leukotriene modifiers
8.1.1.3.2.4. Nasal cromolyn
8.1.1.3.2.5. Nasal anticholinergics
8.1.1.3.2.6. Decongestants
8.1.1.3.2.7. Saline irrigation
8.1.1.3.2.8. Anti-IgE
8.1.1.3.3. Immunotherapy
8.1.2. Treatment of allergic rhinitis in the elderly
8.1.2.1. Allergen avoidance
8.1.2.2. Pharmacotherapy
8.1.2.2.1. Antihistamines
8.1.2.2.2. Corticosteroids
8.1.2.2.3. Decongestants
8.1.2.2.4. Leukotriene receptor antagonists
8.1.2.2.5. Nasal cromolyn sodium
8.1.2.2.6. Nasal anticholinergics
8.1.2.2.7. Anti IgE
8.1.2.3. Immunotherapy
8.1.3. Treatment of allergic rhinitis during pregnancy and lactation
8.1.3.1. Treatment of allergic rhinitis during pregnancy
8.1.3.1.1. Nasal corticosteroids
8.1.3.1.2. Systemic corticosteroids
8.1.3.1.3. Antihistamines
8.1.3.1.4. Nasal antihistamines
8.1.3.1.5. Combination of nasal second generation antihistamine and corticosteroid
8.1.3.1.6. Nasal cromones
8.1.3.1.7. Decongestants
8.1.3.1.8. Nasal anticholinergics
8.1.3.1.9. Leukotriene receptor antagonists
8.1.3.1.10. Specific immunotherapy
8.1.3.2. Treatment of allergic rhinitis during lactation
8.1.4. Allergic rhinitis and its treatment in athletes
8.1.4.1. Allergic rhinitis in athletes
8.1.4.2. Treatment of allergic rhinitis in athletes
8.1.4.2.1. Decongestants
8.1.4.2.2. Antihistamines
8.1.4.2.3. Nasal anticholinergics
8.1.4.2.4. Nasal cromones
8.1.4.2.5. Nasal and systemic corticosteroids
8.1.4.2.6. Specific immunotherapy
8.1.5. Treatment of allergic rhinitis in patient with comorbid endocrine disorders
8.1.5.1. Diabetes
8.1.5.2. Thyroid disorders
8.1.5.3. Cushing’s syndrome
8.1.6. Special occupations (heavy and dangerous jobs)
8.1.7. Treatment of allergic rhinitis in patients with other chronic conditions
8.2. Surgery in allergic rhinitis
8.2.1. Inferior turbinate surgery and septoplasty in patients with allergic rhinitis
8.2.2. Vidian neurectomy in allergic rhinitis
8.2. Other treatment methods in allergic rhinitis
8.2.1. Acupuncture
8.2.1.1. The basics of acupuncture
8.2.1.2. Mechanism of action of acupuncture
8.2.1.3. The effect of acupuncture on pathogenesis of allergy
8.2.1.4. Acupuncture research on allergic rhinitis
8.2.1.5. Conclusions
Action Statement Profile (959).
8.3.2. Probiotic treatment in allergic rhinitis
8.3.3. Phototherapy in allergic rhinitis
8.3.4. Botulinum toxin in treatment of allergic rhinitis
8.3.4.1. Topical application
8.3.4.2. Infiltration
9. Tables for level of evidence

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