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This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Adherence to subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) requires both consistency with scheduled administration and persistence of therapy for a minimum of 3 years to achieve sustained long-term benefit. Reported adherence rates for both forms of allergen immunotherapy (AIT) have, in general, been low but have varied widely based on type of study, population, age, and setting. This chapter reviews adherence to AIT in “real life,” emphasizing studies that directly compare SCIT to SLIT. While nonpersistence for AIT varies from 11% to 97%, the mean for SCIT (54%) and SLIT (58%) is similar. Reported major reasons for discontinuation of SCIT include inconvenience, excessive time commitment, medical comorbidities, and financial concerns, while for SLIT they include lack of efficacy, adverse effects, inability to be compliant, and financial concerns. A multifaceted strategy involving shared decision-making, motivational interviewing, close follow-up, and engagement of the entire healthcare system is required to achieve adherence. Although there have been limited studies on cost-effectiveness, the data available on AIT in the United States demonstrate that reduced resource use and costs have improved in as little as 6 months; however, sustained cost-effectiveness depends on sustained adherence.

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.

The review compares and contrasts seven major United States and international allergic rhinitis guidelines from 2008 to 2017.Despite many treatment options for allergic rhinitis, patients often report lack of therapeutic control and a reduced quality of life. Guidelines intended to improve allergic rhinitis care have been evolving into evidence based, systematic reviews, with less reliance on consensus of expert opinion characteristic of more traditional guidelines. The first Grading of Recommendations Assessment, Development, and Evaluation-based guideline developed in the United States for seasonal allergic rhinitis was first published in 2017.When critically analyzing the allergic rhinitis guidelines that use the rigorous Grading of Recommendations Assessment, Development, and Evaluation methodology, different groups of expert authors, using the same reference articles, will, at times, reach different conclusions regarding the quality of the evidence and the strength of the recommendation. Factors potentially contributing to these divergent determinations include: lack of objective primary outcome measures in allergic rhinitis, poorly defined Minimal Clinically Important Difference, failure to include all interested parties in guideline development, for example, patients, and subjectivity inherent in the expert panel.

I. Leonard Bernstein, MD; James T. Li, MD, PhD; David I. Bernstein, MD; Robert Hamilton, PhD, DABMLI; Sheldon L. Spector, MD; Ricardo Tan, MD; Scott Sicherer, MD; David B. K. Golden, MD; David A. Khan, MD; Richard A. Nicklas, MD; Jay M. Portnoy, MD; Joann Blessing-Moore, MD; Linda Cox, MD; David M. Lang, MD; John Oppenheimer, MD; Christopher C. Randolph, MD; Diane E. Schuller, MD; Stephen A. Tilles, MD; Dana V. Wallace, MD; Estelle Levetin, PhD; and Richard Weber, MD

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Rodents (Rodentia) are the largest order of mammals in the world, with estimates ranging from 1,500 to 2,000 different documented species. The order includes commonly known mammals, such as rats, mice, guinea pigs, hamsters, and gerbils. The order Rodentia also includes beavers, muskrats, porcupines, woodchucks, chipmunks, squirrels, prairie dogs, marmots, chinchillas, voles, lemmings, and many others, although significant human exposure to these rodents is uncommon. The presence of 2 sets of incisors (top and bottom), used for chewing, is the common characteristic of rodent species. Incidentally, rabbits, hares, and a few other species make up the Lagomorpha order and therefore are not classified as rodents. Figure 1 shows an abbreviated taxonomy of the order Rodentia.2 Figure 1 Taxonomy of the order Rodentia. Adapted from Taxonomy of Common Rodent and Rodent-like pets.2 The common house mouse (Mus musculus) is a small, primarily nocturnal mammal. Although usually considered to be pests, mice also are popular pets. Mice are known to invade and establish residence in homes and other buildings, including schools, to obtain food and can at times be harmful, causing structural damage. Certain rodents, such as the deer mouse, can also spread diseases such as hantavirus through their feces and possibly also through their urine and saliva.3,4 Mice also are commonly used in research laboratories, where laboratory animal handlers come into contact with their allergens. Mice tend to have litter sizes of 4 to 8 pups and can have 6 to 8 litters per year, depending on the availability of food. Their life span in the wild is less than 1 year because of predation, although under laboratory conditions they can live as long as 2 years.5 Mice have the ability to jump 12 inches up and down 8 feet to the floor. They can run up almost any vertical surface, including wood, brick, metal pipes, wire mesh, and cables, and can run along suspended electric wires and ropes. They can squeeze through a 1/4-inchdiameter hole, travel upside down, cling from 1/4-inch hardware mesh, swim well, and survive at 24 °F for many generations.6 Rats are long-tailed mammals also of the order Rodentia. The most important rats from a human perspective are the black or roof rat, Rattus rattus, and the brown or Norway rat, Rattus norvegicus. The Norway rat is found in every state of the United States, whereas the roof rat tends to be found in coastal states. Rats usually can be distinguished from mice by their larger size. Rats also can serve as vectors for certain pathogens, such as Lassa fever. They are popular as pets but also are commonly used in research laboratories, where laboratory animal handlers come into contact with their allergens.6 Rats tend to be nocturnal and search for food and water between dusk and dawn; however, they will come out in daylight if their habitat is overcrowded or food is lacking. They require daily water; prefer traveling along edges, pipes, and rafters; and can even travel along overhead utility lines. They prefer to not cross open spaces to avoid predation, and although they have poor visual acuity, they have acute senses of smell, taste, hearing, and touch using their whiskers. Rats tend to have litter sizes of 5 to 12, and they can have up to 9 litters per year, depending on food supplies. Their life span generally is less than 1 year. Rats can pass through openings as small as 3/4 inch, theycan climb up vertical surfaces and even inside vertical pipes, and they can crawl horizontally on any type of pipe or conduit. They can jump vertically 24 inches and fall more than 50 feet and survive. They are able to swim under water for up to 30 seconds, tread water for up to 3 days, and swim up to ½ mile in open water. This permits them to enter buildings through drains and toilets.7 Although guinea pigs (Cavia porcellus), hamsters (Mesocritecus auratus), and gerbils (Gerbillus jerboa) also are rodents, they usually are kept as pets in a confined area and usually are not considered to be pests. Patients who keep such pets clearly can develop allergic symptoms after sensitization; however, other than in the case of laboratory animal workers, exposure to such rodents can usually be contained, and complete abatement, should it become necessary, is easily accomplished with removal of the offending animal.

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing "The diagnosis and Management of Rhinitis: An Updated Practice Parameter." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.