Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Discuss the American Academy of Otolaryngology-Head and Neck Surgery’s latest clinical practice guideline on the diagnosis and management of allergic rhinitis.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at http://akhcme.com/akhcme/lessons/36. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Take CME(click to view)
Current estimates show that allergic rhinitis (AR) is the most common chronic disease among children in the United States. Ranking as the fifth most common chronic disease in the U.S. overall, AR has been estimated to generate $2 to $5 billion in direct health expenditures annually. Numerous diagnostic tests and treatments are used to manage patients with AR, but research suggests that there is considerable variation in how they are used by clinicians who care for these patients.
In order to help optimize the care of patients with AR, the American Academy of Otolaryngology-Head and Neck Surgery published a clinical practice guideline on AR in Otolaryngology-Head and Neck Surgery. “The primary goals of the guideline are to address quality improvement opportunities by evaluating the available evidence and assessing the harm-benefit balance of various diagnostic and management options,” says Michael D. Seidman, MD, FACS, lead author of the guideline.
To create the guideline, a diverse group of 20 panel members examined 31 clinical practice guidelines, 390 systematic reviews, and 1,605 randomized controlled trials to develop 14 key action statements, which are summarized below:
- Clinicians should make a clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and one or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing.
- 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.
- Clinicians should not routinely perform sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR.
- Clinicians may advise patients to avoid known allergens or advise them about environmental controls when identified allergens correlate with clinical symptoms.
- Clinicians should assess patients with a clinical diagnosis of AR for the presence of associated conditions, such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. This information should be documented in the medical record.
- Clinicians should recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life.
- Clinicians should recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching.
- Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR.
- Clinicians should not offer oral leukotriene receptor antagonists as primary therapy for patients with AR.
- Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate responses to pharmacologic monotherapy.
- Clinicians should offer, or refer to a clinician who can offer, immunotherapy for patients with AR who have inadequate responses to symptoms with pharmacologic therapy with or without environmental controls.
- 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.
- Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in non-pharmacologic therapy.
- No recommendation is made regarding use of herbal therapy for patients with AR.
Dr. Seidman notes that some clinicians may be inclined to order confirmatory testing for a diagnosis of AR in patients who appear to have allergic symptoms. “Physicians may be surprised by our recommendation to start therapy with a nasal steroid in patients with a strong history of AR or symptoms consistent with a diagnosis of AR before testing them,” he says. “Testing can be expensive. Many physicians also chose to obtain CT scans or x-rays of the sinuses to confirm AR in congested patients. Clinicians may also be surprised by our recommendation against routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR. The rationale behind this recommendation is that limiting imaging can help avoid unnecessary radiation exposure, decrease costs, and reduce variations in care.”
The lack of a recommendation regarding herbal therapy is the result of little evidence on the subject matter, according to Dr. Seidman. “Our literature review showed many herbal remedies had some effect in patients with AR, but the literature wasn’t strong enough to sway the 20-member guideline task force,” he says.
The guideline task force also was unable to agree on a simple algorithm for treating AR. This was due to the fact that patients will vary with regard to preferences, severity of symptoms, duration of symptoms, coexisting conditions, and allergen sensitizations. Instead, the guideline writers provided guidance for clinicians using illustrative clinical scenarios that are consistent with available evidence and expert advice (Figure). “Clinicians should recognize that there’s a strong role for patient preferences in the management of AR,” says Dr. Seidman.
The guidelines are meant to guide appropriate care from a general perspective rather than dictate care on an individual basis, Dr. Seidman notes. “Clinicians should try to adhere to the guidelines within reason and refrain from imaging and testing all patients suspected of having AR,” he says.
Dr. Seidman is the Director of the Division of Otologic/Neurologic Surgery in the Department of Otolaryngology-Head and Neck Surgery at Henry Ford Hospital; the Director of the Otolaryngology Research Laboratory and Medical Director of the Center for Integrative Medicine at Henry Ford Health System; and the Medical Director of Wellness at Henry Ford West Bloomfield Hospital.
Michael D. Seidman, MD, has indicated to Physician’s Weekly that he has no relevant financial interests to disclose.
Readings & Resources (click to view)
Seidman M, Gurgel R, Lin S, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152:197-206. Available at http://oto.sagepub.com/content/152/1_suppl/S1.full.pdf+html.
Min Y. The pathophysiology, diagnosis and treatment of allergic rhinitis. Allergy Asthma Immunol Res. 2010;2:65-76.
Nguyen P, Vickery J, Blaiss M. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res. 2011;3:148-156.
Meltzer E, Bukstein D. The economic impact of allergic rhinitis and current guidelines for treatment. Ann Allergy Asthma Immunol. 2011;106:S12-S16.