CPG Presentation Transcript Paper

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AR is an IgE-mediated inflammatory illness that causes nasal congestion, rhinorrhea (nasal discharge), sneezing, and/or itching. Stuffy nose, sneezing, post nasal drip, post nasal drip and itchy nose are some of the symptoms of AR. It is also defined as inflammation of the interior lining of the nose that occurs when a person inhales anything that they are allergic to, such as animal pollen or dander. There are three major classifications of AR. These include (1) those triggered by allergens, such as seasonal, perennial, or episodic; (2) how often symptoms occur; and (3) how severe symptoms are. When choosing the most appropriate treatment strategies for an individual patient, identifying AR as a class may help.

CPG Presentation Transcript Paper

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The AR classification system that the Food and Drug Administration (FDA) uses is that which categorizes AR as being either perennial or seasonal. Nonetheless, it is accepted that this classification system has some inherent limitations, as geographic location and climatic conditions determine the length of the aeroallergen pollen season. It can be very difficult to tell if someone has an allergic reaction to pollen from an allergic reaction caused by allergens that are perennial in temperate zones because in the warmer parts of the world, pollen is present year-round (eg, dust mites).  It is also well recognized that people with AR often have perennial AR (usually worse in the fall and spring) worsened by seasonal pollen exposure, and this is why it is not always clear if seasonal versus perennial AR patients experience similar issues.

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The purpose of this CPG statement is to provide guidelines for the initial clinical diagnosis of AR when a patient first appears to a health care professional.  This is simply because  rhinitis is a common complaint and is commonly quoted first in primary care. Primary care providers must be able to make an initial, if provisional, diagnosis, especially one that is effective. It also important to keep in mind that readily available therapies for AR may differ from those used for nonallergic rhinitis.

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Healthcare providers should confirm the clinical diagnosis of AR when patients show an history upon undergoing a physical examination whose results shows consistency with an allergic etiology and one or more of the following symptoms: nasal congestion, itchy nose, runny nose, or sneezing. AR signs such as fluid rhinorrhea, pale nasal mucosa staining, and red watery eyes are symptoms that show an allergic origin. Recommendations based on a benefit-to-harm should be made based on empirical data. CPG Presentation Transcript Paper

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The AR classification system that the Food and Drug Administration (FDA) uses is that which categorizes AR as being either perennial or seasonal. Nonetheless, it is accepted that this classification system has some inherent limitations, as geographic location and climatic conditions determine the length of the aeroallergen pollen season. It can be very difficult to tell if someone has an allergic reaction to pollen from an allergic reaction caused by allergens that are perennial in temperate zones because in the warmer parts of the world, pollen is present year-round (eg, dust mites).  It is also well recognized that people with AR often have perennial AR (usually worse in the fall and spring) worsened by seasonal pollen exposure, and this is why it is not always clear if seasonal versus perennial AR patients experience similar issues.

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This clinical guideline isn’t meant to be a comprehensive reference for diagnosing and treating AR; instead, it’s meant to focus on a small number of quality improvement opportunities that healthcare groups deem most relevant. The recommendations in the guideline are not meant to be an all-encompassing guide to patient management, nor are they meant to limit the therapy or care offered to specific patients. The recommendations are not meant to take the place of custom patient care or clinical judgment. Its purpose is to provide a multidisciplinary guideline with a precise set of targeted recommendations based on a well-established and transparent approach that takes into account levels of evidence, cost-benefit balance, and expert consensus to close evidence gaps.

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The presence of prominent rhinorrhea and pale pink or bluish edema of the nasal turbinate mucosa are two classic physical examination findings that confirm the diagnosis of AR. Common ocular symptoms include watery eye discharge, swelling of the conjunctivae, and the “allergic shiner,” which includes darkening and puffiness of the lower eyelids, as well as venous pooling in the lid capillaries. Persistent adenoids can cause nasal symptoms and should be evaluated, particularly in children. The presence of postnasal drip, as well as regular throat clearing, is common. Keeping in mind that these symptoms aren’t exclusive to AR, clinicians should rule out other causes such as laryngopharyngeal reflux if a patient exhibits them. Chronic AR symptoms can result in nose rubbing (the “allergic salute”) and the creation of an “allergic crease” over the nose’s bridge. Individuals, particularly youngsters, may develop “adenoid facies” as a result of persistent mouth breathing when AR develops nasal blockage. While many of these symptoms are in and of themselves nonspecific, their occurrence in a patient with the correct history strengthens the case for AR.

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Many people with AR symptoms can be successfully treated empirically based solely on their history and physical examination if there is no indication of IgE allergy. Empiric treatment is defined as treatment that begins before IgE-specific testing and may involve environmental controls, allergen avoidance, or medicinal care. Confirmation testing, on the other hand, is essential in specific clinical conditions. These are some of the scenarios: when patients do not respond to empiric treatment, when the diagnosis of AR is in questionable, when the diagnosis of the specific allergen could change therapeutic decisions, or to aid in medication titration.

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If the clinical presentation reveals possible AR sequelae such as rhinozone, nasal polyposis, or suspected neoplasmic issues, radiographic testing may be used as a diagnostic tool. In contrast to AR, which solely affects the nasal mucosa, rhino-inusitis is described as inflammation of the nasal cavity and neighboring paranasal sinuses. Infection spreading to surrounding structures complicates sinusitis, which can lead to cerebral or orbital problems such as abscess or meningitis. The clinical presentation is used to diagnose AR, and radiographic imaging is not used. The potential high costs and side effects of imaging modalities outweigh their utility in regular evaluation of individuals with AR… CPG Presentation Transcript Paper

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