TABLE XI.

Aggregate grades of evidence and recommendation levels

Topic	Number of listed studies	Aggregate grade of evidence	Recommendation level	Interpretation
Risk factors for AR
Genetics	5 (GWAS)	C	—	Some genes have been associated with development of AR and other atopic diseases.
In utero or early exposure (mites)	6	C	—	Data inconclusive.
In utero or early exposure (pollen)	2	C	—	Data inconclusive.
In utero or early exposure (animal dander)	39	C	—	Data inconclusive.
In utero or early exposure (fungal allergens)	13	C	—	Data inconclusive.
Restricted diet (during pregnancy and early childhood)	5	A	—	Maternal diet restriction while the child is in utero does not influence the development of AR. Food allergy during childhood is a risk factor for AR.
Pollution	14	C	—	Data inconclusive.
Tobacco smoke	9	A	—	Most studies found no association between active or passive tobacco smoke exposure and AR. Specific patient populations and temporal variations (ie, length of exposure) should be further evaluated.
Socioeconomic status	10	C	—	Most studies show an association between high SES and AR, but this is not a consistent finding across all studies.
Potential protective effect on the development of AR
Breastfeeding	2 (SRs)	C	Option	Option for breastfeeding for the specific purpose of AR prevention. In general, breastfeeding has been strongly recommended due to its multiple beneficial effects.
Pet exposure	6	C	—	No evidence that pet avoidance in childhood prevents AR later in life. Early pet exposure, especially dog exposure in non-allergic families early in childhood, may be protective.
Microbial diversity (“hygiene hypothesis”)	15	B	—	Microbial diversity of the skin, airways, and gut is important for the prevention of sensitization and allergic disease in populations.
Disease burden
QOL	33	B	Recommendation	AR has significant effects on general and disease-specific. QOL Treatment of AR is recommended to improve QOL.
Effect on sleep	46	B	Recommendation	AR has significant negative effects on sleep. Treatment of AR is recommended to decrease sleep disturbance.
Evaluation and diagnosis
Clinical examination (history and physical)	4	D	Recommendation	Despite the lack of studies to address clinical examination in the diagnosis of AR, history taking is essential and physical examination is recommended. Multiple prior guideline documents support this recommendation.
Nasal endoscopy	5	D	Option	Evidence does not support the routine use of nasal endoscopy for diagnosing AR. However, it may be helpful in ruling out other causes of symptoms.
Radiologic imaging	0	N/A	Recommend against	Radiologic imaging is not recommended for the diagnosis of AR.
Use of validated survey instruments	10	A	Strong recommendation	Validated survey instruments can be used to screen for AR, follow treatment outcomes, and as an outcome measure for clinical trials.
Skin-prick testing	8	B	Recommendation	SPT is recommended for evaluation of allergen sensitivities in appropriately selected patients. The practitioner may decide whether skin or in vitro sIgE testing is best in an individual patient.
Skin intradermal testing	17	B	Option	Intradermal testing may be used to determine specific airborne allergen sensitization for individuals suspected of having AR.
Blended skin testing techniques	5	D	Option	MQT is a skin testing technique that may be used to determine a safe starting dose for AIT.
Serum total IgE (tIgE)	15	C	Option	Serum tIgE is an option to assess atopic status.
Serum antigen-specific IgE (sIgE)	7	B	Recommendation	Serum sIgE testing is recommended for evaluation of allergen sensitivities in appropriately selected patients. The practitioner may decide whether skin or in vitro sIgE testing is best in an individual patient.
Correlation between skin and in vitro testing	19	B	—	Studies differ regarding the concordance of various allergy testing methods.
Nasal sIgE	24	C	Option	Nasal sIgE is an option in patients with suspected or known LAR to aid in diagnosis or guide therapy.
Basophil activation test	12	B	Option	BAT may be used for diagnosis when first-line tests are discordant, and for monitoring response to AIT.
Nasal provocation testing	4	C	—	NPT has been employed for diagnosis of occupational rhinitis and LAR.
Nasal cytology	4	C	—	Nasal cytology is an investigational tool, rather than diagnostic.
Nasal histology	11	B	—	Nasal histology is used for research on the pathophysiology of AR but is not routinely used in clinical practice for the diagnosis of AR.
Management-avoidance measures and environmental controls
House dust mite	12	B	Option	Concomitant use of acaricides and EC measures is an option for the treatment of AR.
Cockroach	11	B	Option	Combination of physical measures (bait traps, house cleaning) and education is an option for AR management related to cockroach exposure.
Pets	3	B	Option	Pet avoidances and EC strategies are an option for AR related to pets.
Pollen and occupational allergens	3	B	Option	Pollen and occupational allergen avoidance by EC strategies are an option for the treatment of AR.
Management-pharmacotherapy
Oral H1 antihistamines	21	A	Strong recommendation	Newer-generation oral H1 antihistamines are strongly recommended for the treatment of AR.
Oral H2 antihistamines	6	B	No recommendation	Available data does not adequately address the question of benefit in the treatment of AR.
Intranasal antihistamines	44	A	Recommendation	Intranasal antihistamines many be used as first-line or second-line therapy for the treatment of AR.
Oral corticosteroids	9	B	Recommend against	Due to the risks of oral steroid use, along with the availability of other pharmacotherapy options, this therapy is not recommended for routine AR management.
Injectable corticosteroids	13	B	Recommend against	Due to the risks of injectable steroid use, along with the availability of other pharmacotherapy options, systemic or intraturbinate injection of corticosteroids is not recommended for the routine treatment of AR.
Intranasal corticosteroids	53	A	Strong recommendation	INCS should be used as first-line therapy in the treatment of AR.
Oral decongestants	9	B	Option	Option for pseudoephedrine for short-term treatment of AR symptoms.
			Recommend against	Recommend against phenylephrine, as it has not been shown to be superior to placebo.
Topical decongestants	4	B	Option	Option for topical IND use in the short-term for nasal decongestion. Chronic use carries a risk of RM.
Leukotriene receptor antagonists	31	A	Recommend against	LTRAs should not be used as monotherapy in the treatment of AR.
Cromolyn (DSCG)	22	A	Option	DSCG may be considered in the treatment of AR, particularly for patients with known triggers who cannot tolerate INCS.
Intranasal anticholinergic (IPB)	14	B	Option	IPB nasal spray may be considered as an adjunct to INCS in PAR patients with uncontrolled rhinorrhea.
Omalizumab	6	A	No indication	Omalizumab is not approved by the FDA for the treatment of AR alone.
Nasal saline	12	A	Strong recommendation	Nasal saline is strongly recommended as part of the treatment strategy for AR.
Probiotics	28	A	Option	Probiotics may be considered in the treatment of AR.
Combination: oral antihistamine and oral decongestant	21	A	Option	Option, particularly for acute exacerbations with a primary symptom of nasal congestion.
Combination: oral antihistamine and INCS	5	B	Option	Combination equivocal over either drug alone.
Combination: oral antihistamine and LTRA	13	A	Option	Combination is an option for AR management, particularly in patients with comorbid asthma who do not tolerate INCS and are not well-controlled on oral antihistamine monotherapy.
Combination: INCS and intranasal antihistamine	12	A	Strong recommendation	Strong recommendation for combination therapy when monotherapy fails to control AR symptoms.
Acupuncture	15	B	Option	In patients who wish to avoid medications, acupuncture many be suggested as a possible therapeutic adjunct.
Honey	3	B	No recommendation	Studies are inconclusive and heterogeneous.
Herbal therapies	—	—	No recommendation	Multiple different herbs studied, with few studies for each specific therapy. Results are inconclusive.
Surgical treatment	12	C	Option	Turbinate reduction may be considered in AR patients with nasal obstruction who have failed medical management.
Management–allergen immunotherapy
Subcutaneous immunotherapy	8	A	Strong recommendation	Strong recommendation for SCIT in patients unable to obtain adequate relief from pharmacotherapy and those who would benefit from secondary disease-modifying effects.
Sublingual immunotherapy	25	A	Strong recommendationa	Strong recommendation for SLIT in patients unable to obtain adequate relief from pharmacotherapy.
Trans/epicutaneous immunotherapy	4	B	Recommend against	Limited studies show variable effectiveness, along with adverse reactions. Trans/epicutaneous immunotherapy is not recommended for AR treatment.
Intralymphatic immunotherapy	7	B	Option	Pending additional studies, ILIT may be a viable option for AR treatment in the clinical population.
Associated conditions
Asthma-association with rhinitis	7	C	—	Asthma is associated with AR and NAR.
Asthma–rhinitis as a risk factor	13	C	—	AR and NAR are risk factors for developing asthma.
Asthma–benefit of AR treatment	—	—	—	See section X.A.4 for specific recommendations.
Acute rhinosinusitis	5	C	—	AR is thought to be a disease-modifying factor for ARS.
Recurrent acute rhinosinusitis	2	D	—	Data inconclusive.
Chronic rhinosinusitis without nasal polyps	10	D	—	Conflicting evidence for/against an association.
Chronic rhinosinusitis with nasal polyps	21	D	—	Conflicting evidence for/against an association.
Conjunctivitis	7	C	—	AC is a frequently occurring comorbidity of AR.
Atopic dermatitis	20	C	—	There is evidence for an association between AR and AD.
Food allergy and PFAS	12	B	—	There is evidence for a link between pollen allergy and PFAS.
Adenoid hypertrophy	11	C	—	Data inconclusive.
Otologic conditions–Eustachian tube dysfunction	7	C	—	There is a causal role for AR in some cases of ETD.
Otologic conditions–otitis media	16	C	—	Relationship between AR and OTE is unclear.
Otologic conditions–Meniere’s disease	8	C	—	Evidence for an association is of low grade, with substantial defects in study design.
Cough	9	C	—	Low level evidence for an association between AR and cough.
Laryngeal disease	18	C	—	There is some evidence for an association between AR and laryngeal disease.
Eosinophilic esophagitis	13	C	—	Limited observational data suggests a potential association between aeroallergens and EoE pathogenesis.
Sleep disturbance and OSA	20	B	—	Sleep disturbance is associated with AR.

^aSpecific recommendations for various SLIT preparations and treatment effects are given in section IX.D.4.

AC = allergic conjunctivitis; AD = atopic dermatitis; AIT = allergen immunotherapy; AR = allergic rhinitis; ARS = acute rhinosinusitis; BAT = basophil activation test; DSCG = disodium cromoglycate; EC = environmental controls; EoE = eosinophilic esophagitis; ETD = Eustachian tube dysfunction; FDA = Food and Drug Administration; GWAS = genome-wide association study; ILIT = intralymphatic immunotherapy; INCS = intranasal corticosteroids; IND = intranasal decongestants; IPB = ipratropium bromide; LAR = local allergic rhinitis; LTRA = leukotriene receptor antagonist; MQT = Modified Quantitative Testing; NAR = non-allergic rhinitis; NPT = nasal provocation testing; OSA = obstructive sleep apnea; OTE = otitis media with effusion; PAR = perennial allergic rhinitis; PFAS = pollen-food allergy syndrome; QOL = quality of life; RM = rhinitis medicamentosa; SCIT = subcutaneous immunotherapy; SES = socioeconomic status; sIgE = antigen-specific immunoglobulin E; SLIT = sublingual immunotherapy; SPT = skin-prick test; SR = systematic review; tIgE = total immunoglobulin E.