12-phase flow (12)

1. 1FRAME
   Frame as CHRONIC IgE-mediated nasal inflammation managed on a stepwise pharmacotherapy ladder anchored by INCS (JTF 2017 STRONG), with allergen immunotherapy reserved for trigger-specific moderate-severe disease. Acute systemic allergic reactions route to allergy.anaphylaxis.v1.
   advance: Chronic AR framing set; CRS/foreign-body/malignancy ddx noted
2. 2ENTRY
   Recognise rhinorrhoea + congestion + sneezing + itch with a seasonal or perennial pattern and atopic background; differentiate vasomotor / non-allergic rhinitis (no clear allergen pattern, no atopic features) and atrophic rhinitis (Sjögren, autoimmune).
   inputs: symptom_severity_and_duration
   advance: IgE-mediated AR pattern recognised vs non-allergic alternatives
3. 3CONTEXT
   Establish trigger exposures (pollen calendar, dust mite, dander, mould), atopic comorbidities (asthma, eczema, food allergy, conjunctivitis), asthma control (the immunotherapy gate), and the impact on sleep/ADL/work — the ARIA severity input.
   inputs: trigger_exposures, atopic_comorbidities, asthma_control_status
   advance: Trigger + comorbidity + impact context established
4. 4RED_FLAGS
   Unilateral discharge, blood, vision changes, orbital pain, facial swelling, anosmia, or watery clear discharge after head trauma → route OUT to ent.chronic-rhinosinusitis or to CSF-rhinorrhoea workup. Severe asthma with poor control → optimise asthma BEFORE immunotherapy.
   inputs: unilateral_or_bloody_rhinorrhoea
   advance: Red-flag presentations excluded or routed
5. 5INITIAL_WORKUP
   AR is a CLINICAL diagnosis — no labs required to start empirical INCS. Targeted aeroallergen sIgE OR SPT when (a) immunotherapy is contemplated, (b) trigger uncertainty, (c) avoidance counselling depends on identifying the specific allergen. Avoid broad untargeted IgE panels.
   inputs: aeroallergen_specific_ige_or_spt
   actions: panel.cbc
   advance: Empirical pharmacotherapy started; targeted aeroallergen testing scheduled if immunotherapy planned
6. 6BRANCHING_WORKUP
   Persistent symptoms despite optimised INCS + intranasal H1 combination → reassess diagnosis (CRS with/without nasal polyps via nasal endoscopy + CT sinus; aspirin-exacerbated respiratory disease AERD/NERD if asthma + nasal polyps + NSAID reaction), reassess adherence/technique, then immunotherapy or biologic candidacy (omalizumab off-label; dupilumab for CRSwNP comorbidity).
   advance: Refractory pathway directed: CRS workup, AERD workup, or immunotherapy/biologic decision
7. 7DIFFERENTIAL
   Terminal differential: AR (this engine) vs non-allergic rhinitis (vasomotor, gustatory, hormonal, drug-induced — no atopic features, no allergen pattern) vs CRSwNP / CRSsNP (route ent.chronic-rhinosinusitis.core.v1) vs aspirin-exacerbated respiratory disease (asthma + polyps + NSAID-triggered) vs rhinitis medicamentosa (chronic decongestant overuse) vs CSF rhinorrhoea (clear watery unilateral post-trauma, beta-2 transferrin positive) vs nasopharyngeal mass (unilateral, bleeding, ear fullness).
   advance: Single best diagnosis assigned; alternative routed if AR not the unifying diagnosis
8. 8RISK_STRATIFICATION
   ARIA classification — intermittent vs persistent (frequency + duration) and mild vs moderate-severe (sleep + ADL + work/school impairment + bothersome symptoms). Mild intermittent: oral 2nd-gen H1 PRN. Moderate-severe intermittent or any persistent: INCS first-line. Combination + immunotherapy for refractory disease.
   inputs: symptom_severity_and_duration
   advance: ARIA tier (intermittent/persistent x mild/moderate-severe) assigned
9. 9TREATMENT
   JTF 2017 (PMID 29181536) + ARIA 2016 (PMID 28602936) + ICAR-AR 2018 (PMID 29438602) anchor: (1) Mild intermittent → oral 2nd-gen H1 (cetirizine/loratadine/fexofenadine) PRN ± saline irrigation; (2) Moderate-severe (intermittent or persistent) → INCS MONOTHERAPY (mometasone, fluticasone propionate or furoate, triamcinolone, budesonide) — JTF 2017 STRONG OVER INCS + oral H1 combo and STRONG OVER LTRA; (3) Inadequate INCS response → INCS + INTRANASAL ANTIHISTAMINE combo (azelastine-fluticasone fixed combo) — JTF 2017 WEAK; (4) Allergen immunotherapy (SCIT 3-5 y or SLIT 3-5 y) for trigger-specific moderate-severe AR with controlled asthma — disease-modifying; (5) LTRA (montelukast) is NOT first-line — INCS preferred (JTF 2017 STRONG); FDA boxed warning for neuropsychiatric AEs; reserve for AR + asthma overlap when other agents fail. Topical decongestants (oxymetazoline) <=5 days only to avoid rhinitis medicamentosa. Oral / IM systemic corticosteroids are NOT routinely recommended (ICAR-AR 2018). Omalizumab + dupilumab roles: dupilumab for CRSwNP overlap; omalizumab off-label for severe AR.
   inputs: prior_pharmacotherapy_trial, age, asthma_control_status, pregnancy_status
   advance: Correct step assigned; INCS technique demonstrated; immunotherapy candidacy assessed
10. 10DISPOSITION
    Entirely outpatient. Allergist referral for: trigger uncertainty, immunotherapy candidacy, refractory disease despite optimised step 3, CRSwNP suspicion, severe asthma comorbidity. Otorhinolaryngology referral for red flags or structural ddx.
    advance: Outpatient follow-up arranged; allergist/ENT referral made if criteria met
11. 11MONITORING
    Reassess at 2-4 wk after starting INCS (effect peaks at 2-4 wk) or step change. INCS technique check at every visit (jet aimed laterally away from septum to avoid epistaxis/perforation). Pollen-season pre-medication ~2 wk before predicted season for seasonal AR. Montelukast neuropsych screen pre + during therapy (FDA boxed warning). SCIT/SLIT systemic-reaction surveillance with epinephrine auto-injector for SCIT-naive uptitration.
    inputs: neuropsychiatric_symptoms_on_montelukast
    advance: Response reassessed at 2-4 wk; INCS technique verified; safety screens current
12. 12FOLLOWUP
    Annual review for symptom control + INCS technique + comorbidity update + immunotherapy progress. Persistent symptoms despite optimised step 3 OR new asthma/eczema → re-examine diagnosis (CRSwNP, AERD) and consider biologic / specialist referral.
    inputs: atopic_comorbidities
    advance: Annual review documented; biologic / specialist referral made if step-up criteria met