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## Complete Summary

#### GUIDELINE TITLE

Symptom severity assessment of allergic rhinitis: part 1.

#### BIBLIOGRAPHIC SOURCE(S)

Spector SL, Nicklas RA, Chapman JA, Bernstein IL, Berger WE,
Blessing-Moore J, Dykewicz MS, Fineman SM, Lee RE, Li JT, Portnoy JM,
Schuller DE, Lang D, Tilles SA. Symptom severity assessment of allergic
rhinitis: part 1. Ann Allergy Asthma Immunol 2003 Aug;91(2):105-14. \[14
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12952100)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Allergic rhinitis

#### GUIDELINE CATEGORY

Evaluation

#### CLINICAL SPECIALTY

Allergy and Immunology\
Family Practice\
Internal Medicine\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide practice parameters for the symptom severity assessment of
allergic rhinitis

#### TARGET POPULATION

Adults and children with allergic rhinitis

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Individual assessment of symptom severity using a 7-point visual
    analog scale

2.  Identify confounding variables

3.  Objective measurement of symptoms including:

    -   Episodes of sneezing

    -   Number of sneezes per episode

    -   Amount of nasal tissue used during a given period

    -   Amount of swelling on physical examination and/or anterior
        rhinoscopy

    -   Various rhinometric techniques

4.  Assessment on non-nasal symptom severity using a 7-point visual
    analog scale

5.  Global assessment of symptom severity

6.  Disease-specific quality-of-life surveys including a visual analog
    scale

7.  Evaluation of effectiveness and adverse effects of current and past
    medications using a visual analog scale

#### MAJOR OUTCOMES CONSIDERED

Utility of assessment tools and interventions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Assessing Nasal Symptom Severity**

By asking the patient to evaluate individual symptom severity using a
7-point visual analog scale, interval data are generated with lower
measurement error and a correspondingly higher precision compared with a
5-point equal interval scale. Figure 1 in the original guideline
document is an example of the type of visual analog scale that is
recommended to evaluate severity of rhinitis.

Since the duration of allergic rhinitis symptoms is different in every
patient, each analysis of symptom severity should specify the period
during which the evaluation is being made (e.g., more than 24 hours,
more than 2 weeks, or a point-in-time evaluation). It may also be
helpful in some patients to distinguish patterns of symptoms (e.g.,
daytime or nighttime, indoor or outdoor). Recognizing these possible
confounding variables, the further characterization of symptoms is left
to the discretion of the physician.

Objective measurement of symptoms should be incorporated into evaluation
of rhinitis severity if considered helpful by the health care
professional and could include the following: (1) presence or absence of
episodes of sneezing; (2) number of sneezes per episode; (3) amount of
nasal tissue used during a given period; (4) amount of swelling seen on
physical examination and/or anterior rhinoscopy; and (5) various
rhinometric techniques.

**Assessing Non-Nasal Symptom Severity**

Since non-nasal symptoms are not found universally in patients with
rhinitis, they are not included in the rhinitis severity scale outlined
in Figure 1 in the original guideline document, which has been
specifically designed to permit an evaluation of nasal symptoms. Since
they are so frequently associated with rhinitis, however, they may also
be evaluated, using a scale similar to that used for nasal symptoms
(Figure 2 in the original guideline document). Adjustment in a treatment
regimen based on severity of non-nasal symptoms can be made by the
health care professional on an individual basis, similar to the
adjustments recommended for nasal symptoms.

**Global Assessment of Nasal and Non-nasal Symptom Severity**

A global scale provides additional information about the status of the
patient beyond what is found with individual symptoms. It asks the
patient to globally rate the combination of the nasal and non-nasal
symptoms on a 7-point scale. Unlike the scales for nasal and non-nasal
symptoms, a score of 7 on the global evaluation scale indicates that the
patient is having no symptoms. Overall symptoms can be rated using the
scale shown in Figure 3 in the original guideline document.

**Quality of Life in the Assessment of Rhinitis Severity**

Quality of life is an important consideration in the evaluation and
treatment of patients with allergic rhinitis. Disease-specific
quality-of-life surveys for allergic rhinitis have been developed and
standardized for children and adults. Such surveys facilitate the
recognition of individual effects of the disease on the patient\'s
quality of life, which may not otherwise be mentioned by patients and
may be ignored or trivialized by patients and health care professionals.
Use of surveys by physicians at each clinic visit can help to evaluate
the effects of treatment interventions on symptom control and the
patient\'s quality of life. In addition, patients and families learn to
recognize the effects of allergic rhinitis symptoms on the quality of
their life.

The visual analog scale shown in Figure 4 in the original guideline
document, which assesses the patient\'s quality of life, can be used by
the physician as adjunctive data to support the initial evaluation of
rhinitis severity based on nasal symptoms. It can also be used by the
physician as a means of patient follow-up after determining the initial
management of the patient. It incorporates activities and functioning
during the day and sleeping at night.

**The Impact of Current and Past Medications on Assessment of Rhinitis
Severity**

Determining past responsiveness and adverse effects from medications
(including over-the-counter or herbal medications) can help guide the
health care practitioner in selection of future therapeutic approaches
and directly affects the evaluation of rhinitis severity. It is
important therefore to determine the current and past medications that
each patient has received, including whether a particular medication was
either ineffective or had produced a significant adverse effect. Failure
of a drug used consistently has a different significance for severity
evaluation than failure of the drug due to poor compliance.
Nonprescription antihistamines, topical alpha1-decongestants and
cromolyn, and herbal remedies may not necessarily be reported by
patients spontaneously. Long-term daily use of topical decongestants is
of special concern, since they frequently produce rhinitis
medicamentosa. Current use of medications for rhinitis or other
conditions and their effect on rhinitis severity should be considered. A
beneficial therapeutic effect on rhinitis may be seen with the use of
medications for non-nasal conditions (e.g., leukotriene modifiers or
orally inhaled corticosteroids). If these agents are withdrawn or the
dose is decreased, an increase in symptoms of rhinitis may occur. These
are variables that cannot easily be controlled for unless a
sophisticated model is used to explain a large number of comorbidities
and their treatment.

**Rhinitis Medication Assessment**

The visual analog scale shown in Figure 5 in the original guideline
document can be used to evaluate medications. This scale includes those
medications (including alternative medications) that the patient has
used in the past for nasal and non-nasal symptoms and how effective they
were (i.e., to what extent they relieved or aggravated nasal symptoms or
produced adverse effects). Visual analog scales should be constructed
for the effectiveness and side effect profile of each past and current
nasal and non-nasal medication used by the patient.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is not specifically stated for each recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Overall Benefits**

Accurate assessment of nasal and non-nasal symptom severity of allergic
rhinitis as well as quality of life issues related to allergic rhinitis

**Specific Benefits**

-   Classification of rhinitis severity may be used in adults or
    children to help determine appropriate pharmacotherapy.

-   Use of surveys by physicians at each clinic visit can help to
    evaluate the effects of treatment interventions on symptoms control
    and the patient\'s quality of life.

-   Determining past responsiveness and adverse effects from medications
    can help guide the health care practitioner in selection of future
    therapeutic approaches and directly affects the evaluation of
    rhinitis severity.

-   The assessment and quantification of severity of symptoms of
    allergic rhinitis should allow for more consistent patient
    management and facilitation of research protocols

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This parameter was edited by Dr. Nicklas in his private capacity and
    not in his capacity as a medical officer with the Food and Drug
    Administration. No official support or endorsement by the Food and
    Drug Administration is intended or should be inferred.

-   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 American College of
    Allergy, Asthma, and Immunology (AAAAI) or American College of
    Allergy, Asthma, and Immunology (ACAAI) interpretation of these
    practice parameters. Any request for information about or an
    interpretation of these practice parameters by the AAAAI or the
    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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Spector SL, Nicklas RA, Chapman JA, Bernstein IL, Berger WE,
Blessing-Moore J, Dykewicz MS, Fineman SM, Lee RE, Li JT, Portnoy JM,
Schuller DE, Lang D, Tilles SA. Symptom severity assessment of allergic
rhinitis: part 1. Ann Allergy Asthma Immunol 2003 Aug;91(2):105-14. \[14
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12952100)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Aug

#### GUIDELINE DEVELOPER(S)

American Academy of Allergy, Asthma and Immunology - Medical Specialty
Society\
American College of Allergy, Asthma and Immunology - Medical Specialty
Society\
Joint Council of Allergy, Asthma and Immunology - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Funded exclusively by the American Academy of Allergy, Asthma, and
Immunology (AAAAI), the American College of Allergy, Asthma, and
Immunology (ACAAI), and the Joint Council of Allergy, Asthma, and
Immunology (JCAAI).

#### GUIDELINE COMMITTEE

Joint Task Force on Practice Parameters

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Sheldon L. Spector, MD; Richard A. Nicklas, MD; Jean
A. Chapman, MD; I. Leonard Bernstein, MD; William E. Berger, MD; Joann
Blessing-Moore, MD; Mark S. Dykewicz, MD; Stanley M. Fineman, MD; Rufus
E. Lee, MD; James T. Li, MD, PhD; Jay M. Portnoy, MD; Diane E. Schuller,
MD; David Lang, MD; and Stephen A. Tilles, MD

\*This parameter was edited by Dr. Nicklas in his private capacity and
not in his capacity as a medical officer with the Food and Drug
Administration. No official support or endorsement by the Food and Drug
Administration is intended or should be inferred.

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Joint Council of Allergy, Asthma,
and Immunology (JCAAI) Web
site](http://www.jcaai.readyportal.net/file_depot/0-10000000/20000-30000/27387/folder/63948/AllerRhin_PT12003.pdf).

Print copies: Available from JCAAI, 50 N. Brockway, Ste 3-3 Palatine, IL
60067; E-mail: <info@jcaai.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Forms to be given to the patients. Addendum. Electronic copies:
    Available from the [Joint Council of Allergy, Asthma, and Immunology
    (JCAAI) Web site](http://www.jcaai.org/pp/ssaar_11_addendum.asp).

Print copies: Available from JCAAI, 50 N. Brockway, Ste 3-3 Palatine, IL
60067; E-mail: <info@jcaai.org>.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 9, 2005. The information
was verified by the guideline developer on May 23, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Joint Council of Allergy, Asthma, and Immunology for more information.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008