EVIDENCE-BASED ANSWER
Multiple randomized controlled trials (RCTs) demonstrate the effectiveness of both allergen immunotherapy and antihistamines, with or without nasal steroids, in the treatment of seasonal allergic rhinitis (strength of recommendation [SOR]: A). No RCTs directly compare immunotherapy with conservative management. Treatment decisions are driven by the clinical presentation, patient and physician preferences, practice guidelines, and expert opinion1 (SOR: C, based on expert opinion). In standard practice, immunotherapy is not recommended for most patients with seasonal allergic rhinitis.
CLINICAL COMMENTARY
Usually there’s an acceptable treatment alternative with better symptom control or fewer side effects
Mary M. Stephens, MD, MPH
East Tennessee State University, Kingsport
When patients ask me about allergy shots, I ask them to tell me about their concerns about their allergies and experiences with previous treatments. Often I find that they do not really want shots, but just want to feel better! Usually you can find an acceptable treatment alternative, one with better symptom control or fewer side effects.
When patients are referred for immunotherapy, it’s important for them to have realistic expectations. The initial process involves weekly visits, and it may take years to gain adequate symptom control. For patients with the commitment, time, and insurance coverage, however, the outcomes can be very positive.
Evidence summary
A 2002 Agency for Healthcare Research and Quality systematic review on the diagnosis and treatment of allergic rhinitis found no RCTs comparing antihistamines or nasal corticosteroids with immunotherapy.2 Our literature review found 4 studies not included in this report that compared immunotherapy with nasal steroids or oral antihistamines.3-6 Only 2 of these examined patient-oriented outcomes and both are of poor quality.3,6 One study reported that inhaled nasal steroid therapy was superior to a nonstandard immunotherapy for ragweed pollen–induced rhinitis.3 The second study allowed patients to choose a treatment arm; it found that immunotherapy was superior to treatment with antihistamines and nasal steroids for patients who chose it.6
For patients requiring medication, studies comparing antihistamines with nasal corticosteroids have documented the superiority of intranasal steroids for symptom control of allergic rhinitis.2,7
The effectiveness of immunotherapy has been documented in more than 40 placebo-controlled trials. However, the patients involved in these trials were often concurrently treated with allergy medications.8 In standard practice, immunotherapy is not recommended for most patients with seasonal allergic rhinitis unless avoidance measures and symptomatic therapy are ineffective, have adverse effects, or are not feasible.9 Studies indicate that immunotherapy is effective for several years after treatment is discontinued.10
A review of recent placebo-controlled trials indicates that the risk of developing asthma among patients with allergic rhinoconjunctivitis is significantly reduced when patients receive specific immunotherapy.11 However, allergy immunotherapy presents risk of systemic reactions, with one study reporting a 0.5% risk of systemic reactions per year of therapy.12
Recommendations from others
The American College of Allergy, Asthma, and Immunology recommends that effective management of allergic rhinitis may require combinations of medications—antihistamines, decongestants, nasal corticosteroids, and anticholinergic agents as well as aggressive avoidance of rhinitis triggers. Consider allergen immunotherapy in carefully selected patients in consultation with an allergist-immunologist.10