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Do allergy shots help seasonal allergies more than antihistamines and nasal steroids?

EVIDENCE-BASED ANSWER

Multiple randomized controlled trials (RCTs) demonstrate the effectiveness of both allergen immunotherapy and antihistamines, with of 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 opinion (1) (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

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 betted Usually you can find an acceptable treatment alternative, one with better symptom control or fewer side effects.

When patients ate 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.

Mary M. Stephens, MD, MPH

East Tennessee State University, Kingsport

* 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)

FAST TRACK

For most patients there is an acceptable alternative to allergy shots, with better symptom control and fewer side effects

REFERENCES

(1.) Rachelefsky GS. National guidelines needed to manage rhinitis and prevent complications. Ann Allergy Asthma Immunol 1999; 82:296-305.

(2.) Long A, et al. Management of allergic and nonallergic rhinitis. Evid Rep Technol Assess (Summ) 2002; 54:1-6.

(3.) Juniper EF, et al. Comparison of the efficacy and side effects of aqueous steroid nasal spray (budesonide) and allergen-injection therapy (Pollinex-R) in the treatment of seasonal allergic rhinoconjunctivitis. J Allergy Clin Immunol 1990; 85:606-611.

(4.) Rak S, et al. A double-blinded, comparative study of the effects of short preseason specific immunotherapy and topical steroids in patients with allergic rhinoconjunctivitis and asthma. J Allergy Clin Immunol 2001; 108:921-928.

(5.) Rak S, Heinrich C, Scheynius A. Comparison of nasal immunohistology in patients with seasonal rhinoconjunctivitis treated with topical steroids or specific allergen immunotherapy. Allergy 2005; 60:643-649.

(6.) Giovannini M, et al. Comparison of allergen immunotherapy and drug treatment in seasonal rhinoconjunctivitis: a 3-years study Allerg Immunol (Paris) 2005; 37:69-71.

(7.) Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998; 317:1624-1629.

(8.) Bousquet J, Lockey R, Malling HJ. Allergen immunotherapy: therapeutic vaccines for allergic diseases. A WHO position paper. J Allergy Clin Immunol 1998; 102:558-562.

(9.) Naclerio R, Solomon W. Rhinitis and inhalant allergens. JAMA 1997; 278:1842-1848.

(10.) American Academy of Allergy; Asthma and Immunology and American College of Allergy, Asthma and Immunology. Allergen immunotherapy: a practice parameter. Ann Allergy Asthma Immunol 2003; 90(1 Suppl 1):1-40.

(11.) Dinakar C, Portnoy JM Allergen immunotherapy in the prevention of asthma. Curr Opin Allergy Clin Immunol 2004; 4:131-136.

(12.) Matloff SM, et al. Systemic reactions to immunotherapy. Allergy Proc 1993; 14:347-350.

L. J. Fagnan, MD, Ariel K. Smits, MD, MPH, Dolores Zegar Judkins, MLS Oregon Health and Sciences University, Portland
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Title Annotation:CLINICAL INQUIRIES: From the Family Physicians Inquiries Network
Author:Fagnan, L.J.; Smits, Ariel K.; Judkins, Dolores Zegar
Publication:Journal of Family Practice
Geographic Code:1U6TN
Date:Oct 1, 2006
Words:852
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