Managing Allergic Rhinitis: Effective Strategies (Recording)

This webinar was recorded on March 13, 2025

Allergic rhinitis, or hay fever, affects millions of people worldwide, leading to symptoms like sneezing, nasal congestion, itching, and watery eyes. While it may seem like just an inconvenience to some, for many, it can significantly impact quality of life—interfering with work, sleep, and daily activities. In today’s webinar, we’ll discuss evidence-based strategies for managing allergic rhinitis, including the latest pharmacological treatments, non-pharmacological approaches, and emerging therapies.

Speaker:

Andrew White, MD, FAAAAI, FACAAI

As an allergist and immunologist, Dr. Andrew White treats all types of allergic conditions, as well as those arising from immune system deficiencies. He frequently sees patients with asthma, hay fever, eczema, food allergies, skin allergies, and hives. Additionally, he diagnoses and treats immune deficiencies such as common variable immunodeficiency (CVID) and various other conditions that may increase the risk of infection. He also treats patients with chronic sinusitis and nasal polyposis. Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s Syndrome, is another key area of focus. He has a particular interest in vocal cord dysfunction, mastocytosis, and mast cell activation syndromes. Dr. White believes in fostering a partnership with his patients. He emphasizes the importance of listening closely to the concerns of his patients to guide them to the best treatment options available. Alongside his clinical practice, he conducts research on aspirin-exacerbated respiratory disease, a subject on which he has authored multiple publications and ongoing research protocols. Outside of work, he enjoys adventures with his wife and children, mountain biking, reading, and making music.

This Advances webinar is in partnership with the American College of Allergy, Asthma & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for Advances webinars.

All attendees will be offered a certificate of attendance. No other continuing education credit is provided.

CME is available through ACAAI for this webinar.

Sponsored by the American College of Allergy, Asthma and Immunology

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

we have an exciting session and I am delighted to introduce you to today’s speaker. We are in for an engaging and informative session. With his extensive knowledge and experience. We have a few housekeeping items. Before we start. Our participants must remain on mute during the webinar. We will record today’s session and upload it in our website within a few days. Can fall — find all of our recorded webinars. Please scroll to the bottom of the page to access our recorded webinars and any upcoming events. We do have an AA staff member monitoring the chat if you need assistance. This webinar will last one hour including time for questions. Can submit your questions in the Q&A box located at the bottom of your screen any time the webinar. We will answer as many questions as we can before concluding’s today’s webinar. This webinar is sponsored in partnership with the American College of allergy asthma and immunology. The college offers CME for physicians. No other continuing education credit is provided. For today’s webinar, all nonphysician attendees will receive attendance credits and a certificate of attendance. If you would like him you can create a free college account on their website and obtain CME or attendance credits through the member portal for these advanced webinars. A few days after today’s webinar we will receive — you will receive an email with supplemental information and a link to download the certificate of attendance. We will also have the link to the certificate in the chat today. Let’s get started. Today’s topic is managing allergic rhinitis effective strategies. Allergic rhinitis or hayfever affects millions of people leading to symptoms like sneezing, itchy and watery eyes. It may seem like just an inconvenience to some, for many a can significantly impact quality of life interfering with work, sleep, and daily activities. In today’s webinar we will discuss evidence raised strategies including the latest pharmacological treatments and nonpharmacological approaches and emerging therapies. It is my pleasure to introduce our speaker today. Dr. Andrew wedding is an immunologist who commonly sees patients with asthma, eczema, food allergies and other skin allergies. He diagnoses and treats common variable immunodeficiency and several other conditions that can lead to an increased risk of infection. After white does conduct research and as published on respiratory disease. And chronic sinusitis. Dr. White believes in building a partnership with his patients and believes it is important to listen carefully to the patient. Outside of work Dr. Weick — after white enjoys going on adventures with his wife and children, mountain biking, biking, reading and making music. Thank you for being here today.

Dr. White: thank you so much and thank you to the Allergy & Asthma Network for setting this up. I hope you will find it valuable. I look forward to the questions at the end. You see on the slide the disclosures for myself and for our moderator. And for the learning objectives, we are going to talk about the impact of allergic rhinitis on quality of life. We will spend some time talking about the evidence behind some of the pharmacological and nonpharmacological strategies for managing allergic rhinitis and we will touch on some of the advances and emerging therapies for allergic rhinitis. I want to start by taking one step back from allergic rhinitis because for allergists, the thought of nasal symptoms is something we see in pretty much 50% of the patients that come into our practice. They are complaining of some kind of nasal complaint. A lot of times they are ready on treatment for allergic rhinitis and it isn’t working and potentially does because it is not allergic rhinitis in the first place. A lot of what we see and that being nonallergic rhinitis. Listed on the right with the bullet points you can see a variety of different subtypes of nonallergic rhinitis. By definition that is not being triggered by the typical pathway. There is something called non— nonallergic rhinitis also known as NAR. We also have infectious rhinitis. They are repeatedly assaulted by that. The vasomotor and gustatory rhinitis are things that we see quite a bit. Especially with watery rhinorrhea, these are the patients that will say — they sit down to eat in the moment they sit down there nose begins to run. That is gustatory rhinitis. Vasomotor rhinitis is triggered by different things like changing posture. As soon as they sit up in the morning there nose runs like a faucet. Could happen with temperature changes. Drug-induced rhinitis, certain medications can cause this especially in older men on prostate medicines. Those are well known to cause nasal congestion. And the very difficult to treat condition known as atrophic rhinitis. The normal humidification apparatus of the nose becomes nonfunctional. There may be some alterations in the micro Byam — micro biome so the nasal passages become dry, crusted and painful and it is difficult to treat. And finally her mood over right I — and finally hormonal rhinitis. Women that go through pregnancies or other situations. The take-home is when patients come into the clinic with symptoms they make call it “allergy” but it may not necessarily be allergic rhinitis. As we step through the treatment it is important. And these are common conditions and can coexist in the same patient. We are going to move on and talk and focus the rest of the talk on allergic rhinitis.

We are talking about allergic rhinitis which is specifically the nose. That condition coexists with allergic conjunctivitis. We should be asking them if they are here for nasal symptoms and ocular symptoms. Many patients will experience both. Any patients will have one part of this that dominates, that bothers them the most. And we will focus our treatment towards that particular organ whether it is the eyes or the nose remember these are — I have another slide that hits on this in a little bit. From a burden of illness, we will talk for a few slides about how this affects us as humans. It is a super common problem. Many of you on the call no doubt have allergic rhinitis. It is thought to affect about 400 million folks throughout the world. I put this triangle here to share that there is a wide spectrum of how it affects us. Some patients may have mild and intermittent symptoms and it is a nuisance that bothers them occasionally. At the other end you have patients that are miserable, constantly affected by this. We will especially talk more about that group. The prevalence is estimated to be around 10.7% of children and that includes physician diagnosed and up to 20% of people throughout their life will report having allergic rhinitis. And we have known this also for quite some time that there is a discrepancy that seems to be stratified raised on the income level of the country. Allergic disorders, atopic disorders seem to be more common in patients that are more developed, high income countries rates are as high as 80%. They are significantly lower in middle or low income countries. When we think about male versus female. It is a little more common in boys in childhood which flip-flops during adolescence. It is more likely to be females then. And roughly will in adulthood, male to female. I wanted my talk to include some recent articles that are important to be aware of. And then, a lot of the talk will be more of an overview. This was an important paper to review. A cool study. They look at a technology called mask air which is an apt that the users would have on their phone. What it would do is prompt the user with allergic rhinitis to enter in answers to questions that both related to the control of allergic rhinitis — rhinitis and the effect where the effects that the patient was having related work. It all comes down to the fact that when you have allergic rhinitis you don’t tend to miss work from it but you do tend to go to work and not function like you should and that is called present he is him as opposed to absenteeism.

This study was designed to look at the effect of allergic rhinitis particularly poorly controlled allergic rhinitis. This study occurred in 22 countries around the world. The individuals that participated would go through for several months reaching their symptoms and how it affected their work. You can see that the patients were stratified on a weekly basis to whether that week was well-controlled, partially controlled or poorly controlled. And the app and the analysis was able to look at the effect on work productivity. And this was all normalized to U.S. dollars with the purchasing power. The dollars we will talk about were based on U.S. dollars. Not a big surprise here I’m sure you saw this coming. If you have poorly controlled allergic rhinitis it has a significant impact on work productivity. And much more so for patients where it was poorly controlled versus well-controlled. Red is the poorly controlled and the opposite is the green, the well-controlled poorly controlled allergic rhinitis had up to a 60% affect on productivity. What that means is — in a dollar amount is $500 per week per patient and lost productivity in U.S. dollars. This is huge I think — large companies probably recognize this when they think through the productivity of their workforce. That is why there is often a lot of programs to help promote wellness oath physical and psychological — both physical and psychological wellness. We would do well as physicians to recognize that this poorly controlled condition can have a significant effect on society at large and on our patient specifically. A couple take-home points — no surprise to you on the line but allergic rhinitis is not just about the nose. We think about a variety of other components of this disease. We know that it can really affect sleep. And so, in a study that demonstrated that about one out of five patients had excessive daytime sleepiness and over half had poor sleep quality associated with allergic rhinitis. And when we think about up her airway cough syndrome, our patients can be more prone to prolonged cough or chronic cough. This study looked at cap season which is a way that you can trigger the cough and you can — you can find the exact level that triggers a specific cough reflex. These patients, if you did the challenge during the pollen season more — were more sensitive to cap season. Clearly, and there are more studies we can go over, but this is not just a syndrome of nose and I allergy symptoms. It has far-reaching consequences. This is one more study I wanted to share. This is an interesting observation.

The authors were looking at something called — which is an elongation in abnormal shape of the cornea. It is thought to possibly be because of chronic eye rubbing and what ends up happening is the cornea becomes then you — becomes then and because it has an abnormal shape it may have an impact on vision acuity. They may be much more frequently needing to get a prescription change. This has been associated with allergic disease in the past specifically atopic –. This was a big analysis that looked at a huge number of patients and they were looking at the rate of this in patients with allergic rhinitis. You can see there is a significant association with the odds ratio of 1.7 for having this condition. I think as allergists we tend to be a little more uncomfortable with ocular symptoms especially anything outside of the typical allergic conjunctivitis symptoms. But we really need to understand that this is associated with our disease that we treat both allergic rhinitis and some of the other conditions that we treat. There may be a component of this being triggered by chronic eye rubbing which has big consequences for our patients. If we have any suspicion that this could be going on, we should consult ophthalmology for an evaluation. And if the patient’s not thinking to ask us about this, we should ask questions if they have noticed any change in visual acuity. A couple more introductory slides. If you are not familiar with this paper it looks at the rise of allergic disease over the last 150 years. Everyone has a lot of interest in this. Why are we seeing rapid changes in our atopic conditions. Around 1870 is where a lot of the modern thought about the beginning of allergic rhinitis. There are reports of it going on before that. That is when this epidemic of allergic rhinitis began. In the early 1900s it was mostly just about allergic rhinitis and following that we saw increasing rates of asthma, food allergy and newer syndromes. And there are a lot of interesting theories about how this happens. This is a great article that talks about a variety of different changes to our environment like the coronation of water, ragweed eradication and things like that that are interesting from a historical standpoint. We will get into the meat of it here. For allergists, you should be intimately familiar with this concept. This cartoon uses food allergen but the premise is the same for an airborne allergies so we will switch that out to read dust mite. You initially encounter the allergen on your meat kit — mucosal service. That will be met with and and read Excel which has to understand the allergen, the specific context, is something that is abnormal and merits a response. In this situation, what is — when it is an allergy, the allergen will be introduced to the AFT cell and that will lead to the development of a Th2 cell .

Those are defined by the cytokines that they produce. Why the — why this happens is still an area of research. If you could shut that often prevent the development of an allergy at the beginning would be a big advance. What we end up with important cytokines that are produced including IL nine and IL-13. The T cell will interact with the other B cell in the lymph node and again with the specific context of these cytokines, the B cell will differentiate into a plasma cell that makes ige, in this case and ige against dust mite. The antibodies will circulate and find the cell where they will predominantly cluster on the surface of the mast cell. The mast cells are interfacing with the external environment. So at a later date with the allergen being introduced again to the mucosal surface, now the mast cell is primed and will cross-link ige and release an immediate response. This is the classic allergic pathway. It is a sophisticated loop from an immune standpoint. We will circle back to this at the end when we talk about immunotherapy. We will talk about treatment. When we go through with our patients the ways to treat, I try to make it clear to them that everything is going to fall into one of these three categories. We can help them identify and potentially avoid the allergen. We have a variety of medications that I will talk about. And we have ways that we can modify the immune response called immunotherapy. Everything will fit into one of these categories. It is important to go over with the patients at the main goal. Are they interested in avoidance, medication or immunotherapy. Each one of these slides could be a top in and of itself so I’m giving you a lot of this as just some broad overview. One of the main allergens that we encounter is dust mite allergen. It is a huge driver of allergic disease. There is a variety of ways that we can control dust mites. Bokeh Singh mostly on the beds, mattress encasements. These are tightly woven encasements that can prevent passage of the dust mite allergen through them so we are able to dramatically decrease the amount that will be exposed to the nose or in breathing. HEPA filters on air purifiers can potentially be helpful. There are opportunities to address the carpeting. When vacuuming and you could use a HEPA filter. And humidity control. The more humidity could foster more dust mites so a dehumidifier could potentially be helpful. There are pros and cons and it is justifiable, just because you can do an intervention and you can do a decrease and dust mite doesn’t necessarily lead to a reduction in symptoms.

We need to caution our patients to not do everything but we want to give them some tools to make a difference in their home environment especially where there are dust mites where there is evidence that controls can improve the situation. Some of the other allergens — cockroach is another one and many of us test for this. Unfortunately it is unclear how much benefit there is for avoidance measures. If someone has a cockroach infestation they will be interested in getting it mediated but whether that will lead to an improvement in symptoms as less clear. Interesting statistics about pet allergies. Only 4% of sensitized individuals will remove pets from their homes. This is not a popular answer when we tell them that you are allergic to cats, how do you feel about removing that cat. Unlikely that will change their approach. And I honestly think that sometimes that is why patients come in — they are having symptoms, they have a pet that is part of the family and they are unwilling to consider the removal of the patch. Because a lot of the allergen with pets is pretty sticky, it is more on surfaces and less so in the ambient air, it is a little less clear that HEPA filters will have a huge effect. If one of the plans is the wash the pet, there are studies that show you need to wash it at least twice a week to minimize the allergens significantly. I think that is a harder thing to do on a regular basis with that goal in mind. And what about pollen? this is interesting. We don’t have a ton of evidence from many of the things that could be done for a pollen allergy. Some of the things that can be done are special filters that you can put in your car or the homes or you are filtering the air keeping the windows and doors shut so you are able to potentially decrease the pollen count somewhat inside the house. Some other recommendations that I think are interesting is washing your hair and clothing before entering the bedroom during heavy pollen seasons. And — this is not what the photograph is here, but there are some special glasses that are wraparound and even nasal filters that have been study that have been shown to be somewhat effective. There are some interesting potential advancements in that. I’m not sure exactly the appetite of patients to be doing that but at least they are out there and you can be aware of that.

So, those are the avoidance measures and now we focus on medication. This is a really challenging area for us as physicians. A lot of these are available over-the-counter. The patients will have already intentionally tried these things. They may not show up on the medical record and they may not remember — they will say, I took a nose spray, the green one. And the physician won’t know what it was. That is a big challenge. There is also the possibility that patients can be on combination medicines. They are doing a lot of this on their own or based on the advice of friends. That is the challenge. Here is the lay of the land. We have pills, oral agents will be the antihistamines. The other drugs that could be used that are easily available are the Monta Lou casts. We have ocular products. Antihistamines, stabilizers. And corridor Co. steroids — cortico steroids. And we have nasal products. The nasal corticosteroids. And there are some products that are combination — steroid and histamine products. When we see a patient, we will try to sort out whether this is more of an intermittent issue and also whether it is severe or mild. Or persistent. A lot of times the patients will have a little bit of both. They may have a season that is particularly bad but they are congested all year long. The point of this slide was to show that there are a lot of options and they are all pretty fair in terms of your first try one of the treatments that can be effective for all of these is the intranasal steroids. When you compare these two other treatments, it is a good place to start. There are pros and cons to all of these. Our job is to go through with the patient and try to understand, what are you looking for out of a medication? do you want something that is more of a long-term way to control this? or are you just looking for what you can take twice a week or twice a month when you’re having a bad day? this review went through a lot of the evidence for the various products that are available. And I wanted to highlight — I don’t like to include big block tables. It is hard to get oriented. I just want you to scroll down with the onset of action of the medications. These are really important as we give advice to our patients. You can see the products that really seem to have the fastest onset of action, within five-15 minutes, are going to be the topical antihistamines.

Though oral pills tended to be more delayed, over the course of a couple of hours. The other thing to pay attention to is the nasal steroids have a relatively quick affect. I think we tell our patients, if you start a nasal steroid spray, you will use it for a week or two to get Max benefit but there is benefit in the different challenge studies even over the course of a few hours. You can see here that, down here at the bottom, there is evidence of the nasal steroid sprays can work over the course of 6-8 hours, even within the first day of use. This really speaks I think to how we can counsel our patients. If they are wanting something that works immediately and something to take occasionally, that will be a different recommendation that we can give them versus if they are using something more regularly. This was a network meta analysis that compared the nasal products alter themselves. This is a way to look at the magnitude of affect. The way these are structured is the size of the circle is the number of patients. You can see how big the studies were. And the intensity of the Green versus the red is the magnitude of the benefits. You can see that when you compare these all to themselves, the flu sicasone products seemed to do well. The nasal products seemed to what — to do well. The nasal and histamine products had less strength of the response. You can see more orange than red. And the combination products, it makes sense that they also did well. The point is that the nasal steroid spray probably are superior in terms of the benefit you will get compared directly against the nasal into histamine sprays. A lot of our patients are going to be using combination products . And so this is a summary that came from a very large review of all of the treatment options for allergic rhinitis. These are some statements that came from this. For oral decongestants, the recommendation is not to use routinely. The combination of using an oral antihistamine and an antagonist — we need to be careful about this because of the blocker. They have a black box warning now related to mood.

We need to be really careful about having that be part of first-line therapy. At would not be a combination for first-line therapy. The recommendation is that if you are using a new soul steroid and in so antihistamine combination, it is a strong recommendation to use them when the nasal steroid alone fails. It is a good addition. There is strong evidence that the nasal version is better than the nasal steroid than the oral antihistamines. If you are stacking them against each other better to go with nasal and histamine. When you are thinking about nasal steroid antagonist, you are dealing with a black box warning. And intranasal steroid and nasal decongestants. This is interesting. There is a big concern with nasal decongestants and it is tacky fright taxes. I think it is an option. It is probably superior to the nasal steroid alone but you have to counsel your patient about the potential risk. And finally for patients that have strong rhinorrhea component , there is not much evidence for combination with nasal steroid — just one study. This comes up a lot for natural treatments. A lot of our patients are interested in something other than medication. We can tell them that for acupuncture, there does seem to be some benefit to the quality of life. The other very common things that people are interested like local honey or herbal therapies — we don’t have evidence to support them. We cannot give a recommendation that is evidence-based it would be good to have more studies to see if there is really something there. At the end of all of this, we have a lot of treatments and many of them are over-the-counter. The patients are often left to their own devices. And I think for a lot of patients if they are going to any other doctor rather — other than an allergist this might be a 22nd part — 20 second part of the visit. These are some interesting summary statements.

This is coming out of an evidence-based review article of allergic rhinitis. Patients are poorly at here in. There is no doubt in my mind that that is true based on my clinical experience. The number three is that most patients with rhinitis use on-demand treatment when their symptoms are suboptimally controlled. That means that despite having symptoms they are just taking medication when they are having a particularly bad day. And only when they are really uncontrolled they change their medications to daily. So they are living with symptoms that they could do better with. Number four, the vast majority of patients do not follow guidelines or physicians prescriptions. And the next one is my favorite — when physicians are allergic, they behave like patients. Even though we know better, we know how best to manage this, we still end up doing the same thing. We wait until we are particularly symptomatic, take medication for a few days and then we stop and never satisfactorily achieve control. This suggests that we need to overhaul the way we even think about this in terms of educating patients because the way we are doing this if we cannot even do it ourselves as physicians we are hard-pressed to expect our patients to do it. Those are the Met of — medications. There is more to go over in that area. I tell patients that for most people we can get the bulk of their symptoms under control with medication but not everybody. And some patients, the bulk of the medications that would work buyer them to be under control is not a satisfactory option. And they are not willing to do that. There are a lot of reasons that patients are interested in moving towards immunotherapy. This would be the treatment we can offer that would modify the immune response. Immunotherapy was — is something that has been done for decades. And for a long time, although it was clear it work, it was not clear if it would have a disease modifying affect. Ultimately, what we would hope for for a treatment is you would deploy it for a certain amount of time and the modification to the immune system becomes permanent.

This was one of the main landmark studies that looked at this. Dr. Steve Durham published this in the New England Journal of medicine in 1990 nine and all allergists should be aware of the paper. There was a group of patients that got placebo shots. Placebo immunotherapy. And a group that got active treatment. You can see on the far left column the pollen count on top is in green. Below that are the patient’s’– patients’symptoms. Those on placebo had a lot of symptoms and those on active immunotherapy had a lot of improvement. The study was designed to follow what came next. So now, in this particular trial, they then changed the patient’s in the active group, the patient’s getting the immunotherapy in yellow. They were randomized to discontinue shots or continue their maintenance shots. And the big question was — what would happen if you discontinued your shots? would you start to have symptoms again or would you continue to do well? when you look across the subsequent years, 1993, 94, 95, you can see the red and the blue groups really are superimposed with each other. There was no advantage to continuing the immunotherapy at that point C might as well stop. The great message is with immunotherapy, at least the way they did it in this study, there was a permanent affect that you could modify the immune response so you would be able to stop your immunotherapy. This is why we have the recommendation for our patients that our goal for treatment will be a repeat five year timeframe — a 3-5 year timeframe and then we would consider discontinuing the treatment. How does immunotherapy work? we are still trying to figure that out after all of this time. This is the same path I showed you before with the cell talking to the T cell and the T cell was differentiating ultimately making ige. That is across the top. Across the bottom is potentially what is happening with immunotherapies. You are stimulating the immune system. There is a variety of effects that, measured over the years, that the cumulative effect is still unclear but there is the development of regulatory T cells.

There is the proliferation of some anti-inflammatory cytokines like IL-10 and TGF-beta that you see at the bottom. You will also change the antibodies that you produce to an ige four and that potentially can have an effect on sopping up some of the allergens. There are a lot of effects that are interesting that we are still learning about. The more we understand about this the better we can hijack the process and make it safer and more convenient for patients. But this is the rationale for why immunotherapy works. There is several ways to do immunotherapy. I have outlined the three most universally used. At the top we have subcutaneous immunotherapy. There are tabular — there are tablets available as prescription and drops. I will go through the differences. For the shops, the subcutaneous across the top, we have good data for a lot of the allergens. Not all of them. But what the therapeutic dose should be. There is a risk of anaphylaxis. That shots have to be given in the office. And there is a different cost structure. Immunotherapy given as a shot does not come from a pharmacy so there will not be a pharmacy related co-pay. There will be different codes that go through — that deal with the costs. The tablets — these are FDA approved, each one of these went through rigorous double-blind placebo controlled trial so we have great evidence of the effect of these. These are safe and can be given at home. These are daily treatments. The first dose is usually observed in the office. There is a theoretical risk of allergic reaction but because of the relative safety, these are given at home. You start off with the first dose — sorry, used — you start with the top does so there is no top dosing. Because these come from the pharmacy benefit, there could be co-pays and sometimes challenges getting it approved. Some of the other difficulties — we don’t have many options for these. We have grass, pollen, ragweed. We have some limitations in patients with multiple allergies. And there are some questions about using these together in terms of the logistics of treating both grass pollen and dust mite together in the same person. And finally, there are slit drops. These are really used by using the allergen extracts.

These are created for a patient based on what they are allergic to and they can be administered as a drop. They are not FDA approved. And generally they will not be covered by insurance. There is a lower systemic reaction risk. There is less certainty of the clinical benefit of these. As in subcutaneous immunotherapy there is a wide range of what can be put in the dose. In terms of the amount of allergen. That leaves some uncertainty in terms of what we can tell our patients regarding the clinical benefit. OK. These are met analyses looking at the two main options. Subcutaneous immunotherapy versus sublingual immunotherapy. The main point is if a patient asks us which one is better — they both work. Subcutaneous works, sublingual works. These are looking at medication scores. These analyses favor either one of these options. It gives us as physicians of the luxury of also going through some of the logistics in patient preference as we decide what we are going to deploy for the patient. Don’t try to read this. I wanted you to see the table exists. This is from a very large review of treatment options for allergic rhinitis published in the Journal hi far in 2023. I will scroll down and show you the bottom line related immunotherapy. These are recommendations from the authors after going through all the evidence trying to come up with general recommendations. Under strongly recommended treatment options are subcutaneous, sublingual immunotherapy is with slit tablets and specifically, because there is better evidence for tree pollen, the slit drops recommended would be high dose slit drops. Drops frets — drops for something else, mold. And using two tablet immunotherapies. And some options, we have different ways to get patients to maintenance. Rush versus cluster. Because there is a little less evidence that slit drops for animals. There are innovative ways to administer the allergens. They are still undergoing the study but there are some places that offer this.

The allergen is injected directly into the lymph node or a therapy, inter-mucosal therapy . There are potential ways to administer immunotherapy and none of these are standard and not recommended. You see them listed there and I won’t spend more time talking about that. If you treat allergic rhinitis or see patients with this, you really need to be comfortable with this concept of pollen food allergy syndrome. A lot of patients may have this and come in as their primary complaint as a food allergy. There is an array of foods that cross reacts with the pollen and when you ingest the food especially in the raw form you could end up with oral new coastal — mucosal syndrome. Birch pollen patients — Birch pollen — patients will have this with Apple and carrots. We see bananas, cucumbers, melons and grasses have a lot of the same foods. Mugwort — mugwort celery spice syndrome and there are a lot of spaces there. If patients are complaining about a variety of food allergies and there are foods listed here, you would do well to actually do a bunch of Pollard — pollen allergen testing. For most patients, these foods only cause problems if they are in the raw form. If they are cooked, they are well-tolerated. For example, patient may be able to eat carrot cake but not have a raw carrot or have apple pie not be able to eat a fresh apple. This is an evolving area that as allergists we need to be aware of. Can you have allergic rhinitis with negative tests? this is a concept called local allergic rhinitis. You have a patient who has is suspected that who has suspected — who has suspected allergic rhinitis. You have the same tests. For either test come if you go down and make it to the bottom and you have negative skin testing and negative zero ige, maybe you have a strong suspicion based on clinical history, dog or cat where it is clear. You could do a nasal provocation test. There are protocols for how to do this. This is important because there is a subgroup of patients that clearly have this condition where they have reproducible allergen positive provocation tests. They have negative testing. And we know that in this group, they can respond to immunotherapy and avoidance measures. In terms of thinking about patience that may be interested in immunotherapy, if you can prove the allergen with a nasal provocation test, that is something that is an option for them. If you are interested in this, there are some articles in the literature that describe how to do this.

And so just be aware this is out there for patients have a strong history we should consider doing this a bit more. I will finally finish with this slide. When patients come to the office with allergic rhinitis, once we have diagnosed them with allergic rhinitis we have clearly defined they have an allergic condition. These are conditions that often coexists with other allergic problems. And so we should be asking questions or thinking about some of the other things that go along with allergic rhinitis. Chronic rhino sign new situs is one important one. Patients can have overlapping symptoms. They may still have a lot of postnasal drip or nasal congestion. If you just approach it from the standpoint of allergic rhinitis and you don’t ask Russians about sense and smell, discharge, you might miss the fact that they also have chronic right you write — write new sinusitis where the treatment would be different. We should be asking if they have reactions to aspirin. Patients with a specific form of — with nasal polyps will describe having nasal congestion and sneezing. And that would be treated differently. It usually signals they have underlying nasal polyps. Patients very commonly have comorbidity dermatitis especially for those that have a lot of ocular symptoms. There could be a component of air your brittle dermatitis that could be affecting their vision and their ocular symptoms and coexists with allergic rhinitis. Especially when patients are having G.I. symptoms, especially if they are having dysphasia symptoms, we want to ask about this and consider working them up for that. Up to a quarter of these patients have pollen food allergy syndrome.

That should be another thing that raises that in the back of your mind to ask a few questions about whether the patients feel like they have trouble swallowing or if food gets stuck. Asking questions about food allergy, prompting questions about foods that make their mouth which. We know from the unified airway theory that what happens in the upper airway can go into the lower airway so asking about cough, asking patients how they do with a viral illness are all really important. And remember, like I said in the beginning, a lot of patients may have a component of nonallergic rhinitis and could do well with a nasal spray for the rhinorrhea component of their nonallergic rhinitis while you are also treating simultaneously there allergic rhinitis. And so, the summary here — I think a couple things. Number one, probably we don’t need to tell allergists that they need to take the condition seriously but we do need to properly educate our peers and other specialties that these patients can have a significant effect on their quality of life. And there is more to this than just telling them in 30 seconds to go take some over-the-counter medicines. This can be affecting their sleep, it can be causing them to have a cough, it can have effects on visual acuity later in life. You can have a lot of issues with present tea-ism. The second point is we have a lot of different treatments. This is a classic scenario for shared decision-making. Sitting down with the patient — what exactly do you want? may be taking something daily is not a good treatment if you won’t do it. Giving patients good information about their sub lingual — about their immunotherapy options whether it is sub lingual or subcutaneous. And don’t forget, we have an opportunity when we are talking about their nose to ask about the other comorbidities and see if there are other ways we can tune up what the patients are experiencing. And with that, I will pause and I’m happy to take some questions.

De De: perfect timing. We have a couple of questions. People are interested in treatments for children or adolescents. Do you have suggestions or recommendations that you have seen or based on your experience and research that would be more beneficial for children or for adolescents?

Dr. White: almost everything we have talked about is available for children and adolescents. The sub lingual immunotherapy, subcutaneous immunotherapy, pretty much all of the nasal treatments, the oral treatments — it is all options for treatment — for children and adolescents. The issues with adolescence is they are slowly developing their own personality and there is often a bit of conflict with what the patient wants and what the parent wants. Often really try to engage the team themselves –the teenager themselves. What do want out of this visit? and encouraging them to do something regularly like a nasal spray. If you look at all of the data, these sprays are usually going to be the winner. If I can convince someone to do that, even if it is just a couple times per year when they are really bad and they do it for a couple of weeks to quiet things down, I still feel like it is a win. A lot of people are taking oral antihistamines and will not get a lot of benefits. It is real opportunity to try to switch them to the nasal treatments. For younger kids it is more challenging because getting a nose spray in can be challenging. Trying to get a little engagement with the child at that visit with their parent or get them on board with the fact that this will help you the most. The story is the same. The nasal steroid spray — if you can do them regularly, those are probably the winner.

De De: we also have questions, couple B will have asked questions specific to nasal saline and nasal washes. Do you have recommendations?

Dr. White: that is a great treatment option. I think we tend to use that or for patients with chronic right you sign new situs. The difference is that a nasal saline spray is a small volume spray. But the rents is a large volume. You are instilling a large enough amount of saline into one nostril that it actually goes around the back and comes out the other side. We are all familiar with the concept. It is great for patients that are prone to reoccurring infections and they have thick drainage they cannot clear out. Many patients that use this really like this with a natural decongestant effect. I think it is a really great treatment if it works. For a patient with simple allergic rhinitis. The problem is that true nasal rinses are pretty messy. You have to have clean water. It is not superfast. There is a nuisance factor to it. Absolutely I would tell a patient that if you are interested in trying this, let’s do it and if you like it, it is a great treatment to consider.

De De: the next question is dealing with immunotherapy. Could you speak to the intervals for retesting after starting immunotherapy or over time using immunotherapy?

Dr. White: if you’re going to go on immunotherapy, we are expecting some changes in your allergy profile. The truth is we are not going to base decision-making on stopping the immunotherapy based on the size of the test. Many people won’t repeat testing simply with the purpose of telling the patient that they can now stop. I think the evidence is really strongest that you do it for a 3-5 year period and then you stop. I think the reasons — sometimes patients are interested in repeat testing. It is reasonable. And also reasonable if there is a change in symptoms and you wonder if they have developed a new allergen. But I don’t think it is really necessary to de facto test everyone at the five year mark in order to determine if they can stop their shots.

De De: patient education for immunotherapy — the commitment definitely needs to be discussed. With the patience to get them to the finish line.

Dr. White: there is definitely — probably a 20% or 30% of patients do not complete therapy and it could be higher in different groups. That is a huge problem. A lot of times patients will come in and they have had a bad few months. They willing to do anything. I think we need to really say that you really need to think through this. I understand you have had a bad couple of months but this is a big commitment. Let’s talk about what that means in real life.

De De: exactly. We thank you Dr. Ebright for your exceptional presentation today. We have learned a ton. For the attendees, remember the zoom will be mailed to you in a few days with a link to the recording and evaluation was supplemental resources. It is on the horizon is we are thrilled to share we will have two exciting webinars coming up that we hope you will join us. One is on March 27 at 4:00 p.m. And join us — we welcome you to enjoy — to join us for a webinar series in Spanish. In this special session our guest will share her journey living with eczema offering a heartfelt look at the challenges that she faces and the impact of the disease on her life. Her story will be sure to inspire and resonate providing valuable insights into the emotional and physical aspects of managing this condition. We hope you will be able to join and connect with us during that conversation. The second is on April 10 at noon. Join us for another advanced webinar and this one is entitled basics and Biologics presented by Jared Devereaux Hill will provide a comprehensive overview of Biologics. Don’t miss the opportunity to enter college and stay current on the latest advancements and our field. Thank you again from all of us at Allergy & Asthma Network. We strive daily to be your resource. Thank you.