Allergic Rhinitis and its Impact on Asthma - ARIA

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ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA GUIDELINES ● 2010 – V. 9/8/2010 Recommendations In the following six sections we present specific recommendations for: prevention of allergy, allergic rhinitis, <strong>and</strong>/or asthma reducing allergen exposure for treatment of allergic rhinitis <strong>and</strong>/or asthma pharmacological treatment of allergic rhinitis immunotherapy in allergic rhinitis alternative <strong>and</strong> complementary treatment of allergic rhinitis treatment of asthma in patients with concomitant allergic rhinitis Changing information about treatment of allergic rhinitis <strong>and</strong> paucity of up-to-date systematic reviews of available evidence will require a timely update of these guidelines. Future revisions of ARIA will include quality assessment of the individual studies cited in the systematic reviews we applied in making these recommendations. Recommendations that address similar management options should be interpreted together. For instance, the recommendation to use oral H1-antihistamines (Question 11) should be interpreted in the context of other recommendations to use new-generation versus old-generation H1antihistamines (Question 12), to use oral H1-anthistamines in children to prevent development of asthma (Question 13), <strong>and</strong> to use new-generation oral H1-antihistamines versus intranasal H1antihistamines (Question 15), versus leukotriene receptor antagonists (Question 17) or versus intranasal glucocorticosteroids (Question 19). PAGE 28 OF 153
ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA GUIDELINES ● 2010 – V. 9/8/2010 I. Prevention of allergy Question 1 Should exclusive breastfeeding be used in infants to prevent allergy? Summary of findings Seven systematic reviews addressed the question if exclusive breastfeeding prevents development of allergy. Three reviews focused on prevention of the development of atopic dermatitis (47), allergic rhinitis (48), <strong>and</strong> asthma (49) (see accompanying evidence profile). Their findings were summarised in overview of these reviews (50). The fifth systematic review explored if extending the period of exclusive breastfeeding beyond 3 months to up to 7 months influences child’s health (including allergy), growth, <strong>and</strong> development (51) (see accompanying evidence profile). The sixth review summarised the available studies in a narrative form but did not provide any summary estimates (52). All reviews included prospective observational studies. A recent systematic review (53) did not find any new studies investigating the risk of atopic dermatitis that would not be included in the analysis of Gdalevich <strong>and</strong> colleagues (47) <strong>and</strong> it found four more recent studies on the prevention of asthma (54-57). We did not assess the quality of evidence supporting other benef<strong>its</strong> from breastfeeding except for development of allergy <strong>and</strong> asthma. For this revision of the ARIA guidelines we also have not assessed the relative benefit of exclusive breastfeeding compared to other alternative methods of infant nutrition, e.g. formulas containing hydrolysed protein for prevention of allergy <strong>and</strong>/or asthma in infants. Benef<strong>its</strong> There is evidence from observational studies that exclusive breastfeeding for at least 3 months may prevent atopic dermatitis, allergic rhinitis, <strong>and</strong> asthma. Some of the effect estimates are imprecise. Extending exclusive breastfeeding to at least 6 months may provide additional benefit, although the estimates are also imprecise <strong>and</strong> do not exclude no effect. All critical outcomes indicate beneficial effects in the same direction. Harms There were no important risks associated with exclusive breastfeeding reported in the systematic reviews. However, breastfeeding may not always be in the best interest of an infant when contraindications are present (e.g., classic galactosemia, active untreated tuberculosis or human immunodeficiency virus infection in mother, chemotherapeutic agents or radioactive isotopes being used in the mother for diagnostic or therapeutic purposes, some other medications until they clear from the milk, <strong>and</strong> bacterial or viral infection of a breast) (58). Conclusions <strong>and</strong> research needs Given the few specific possible undesirable effects of exclusive breastfeeding in situations that are relatively well described, exclusive breastfeeding for at least three months appears to be of net clinical benefit. However, the available evidence supporting <strong>its</strong> beneficial effect on development of allergy <strong>and</strong> asthma is limited <strong>and</strong> overall of low quality for the critical outcomes. PAGE 29 OF 153
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Allergic Rhinitis and its Impact on Asthma - ARIA

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