Pharmacists should be aware that consultations are often prompted by inadequate control of symptoms – over a third of GP consultations (35.4 per cent) in SAR are due to dissatisfaction with therapy.15

The 2016 ARIA guidelines focuses on drug treatments for people experiencing moderate to severe AR. Its recommendations are less applicable to people with mild AR who may be more likely to self-manage their condition with OTC medication.1

The 2018 ARIA guideline notes there is “little good quality evidence” for the effectiveness of anticholinergics and decongestants, whether oral or intranasal, in AR on a short-term basis. A familiar concern is the potential for rebound rhinitis (rhinitis medicamentosa) and tachyphylaxis after prolonged use of decongestants for 10 days or more.9

Among OTC treatments, ARIA says that intra-nasal corticosteroids (INCS) are more effective than oral or intranasal H1-antihistamines, but patient preference may be for oral medication. Other OTC or self-care options include leukotriene receptor antagonists (LTRA), nasal washing, vasoconstrictors and cromoglycate.9

In particular, ARIA has attempted to gauge “the relative merits of using oral H1-antihistamines, intranasal H1-antihistamines, intranasal corticosteroids, and leukotriene receptor antagonists either alone or in combination.” It has done this by assessing outcomes it considered important for patients: AR symptoms; quality of life; the impact on work or school performance; and adverse effects.1

However, the recommendations are backed by only a “moderate certainty of evidence” at best and include “low certainty of evidence” and “very low certainty of evidence” recommendations.

Its recommendations can be summarised as follows:1

• An oral H1-antihistamine (OAH) + intranasal corticosteroid (INCS) versus an INCS alone. PAR - an INCS alone rather than the combination. SAR - either option.
• An intranasal H1-antihistamine (INAH) + INCS -vs- an INCS alone. PAR - either. SAR - either.
• An INAH + INCS -vs- an INAH. SAR - INCS + INAH rather than INAH alone.
• A leukotriene receptor antagonist (LTRA) -vs- an OAH. PAR - OAH rather than a LTRA. SAR - either.
• An INAH -vs- an INCS. PAR - INCS rather than INAH. SAR - INCS rather than INAH.
• An INAH -vs- an OAH. PAR - either. SAR - either.

Based on ‘Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines—2016 revision.’