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allergy.allergic-rhinitis.core.v1PRODUCTION
allergy.allergic-rhinitis.core.v1

Allergic rhinitis (seasonal + perennial)

allergychronicsubacuteadultpediatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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.

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Chronic AR framing set; CRS/foreign-body/malignancy ddx noted

Patient inputs (10)

Pollen calendar, dust mite, animal dander, mould — targets avoidance counselling and immunotherapy candidacy (ICAR-AR 2018 PMID 29438602)

Asthma, eczema, food allergy, conjunctivitis — atopic-march burden; uncontrolled asthma is a contraindication to allergen immunotherapy SCIT (ICAR-AR 2018 PMID 29438602)

Red flag — unilateral discharge / blood / facial swelling / vision changes / orbital pain steers away from AR toward CRS, foreign body, malignancy, CSF leak

ARIA classifies intermittent (<4 d/wk OR <4 wk) vs persistent (>=4 d/wk AND >=4 wk) and mild vs moderate-severe (sleep + ADL + work/school impairment) to set pharmacotherapy step (ARIA 2016 PMID 28602936)

True adequacy of prior INCS (correct technique + 2-4 wk + adherence) determines whether to escalate or optimise (JTF 2017 PMID 29181536)

Pediatric agent age cutoffs (cetirizine/loratadine >=6 mo; intranasal fluticasone furoate >=2 y; montelukast >=12 mo with neuropsych warning) (ICAR-AR 2018 PMID 29438602)

Uncontrolled asthma is a contraindication to initiating SCIT and a comorbidity driver for dupilumab in overlapping CRSwNP + AR (ICAR-AR 2018 PMID 29438602)

Targeted aeroallergen sIgE / SPT confirms trigger and gates immunotherapy candidacy; not required to start INCS empirically (JTF 2017 PMID 29181536)

Montelukast FDA boxed warning 2020 — depression, suicidal ideation, behaviour change; screen before and during therapy (ICAR-AR 2018 PMID 29438602)

Pregnancy modifies choice — budesonide is the historically preferred INCS in pregnancy; oral 2nd-gen H1 (loratadine/cetirizine) preferred over 1st-gen; LTRA generally avoided

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationalseverered_flag_unilateral_or_bloody
    Unilateral discharge, blood in nasal discharge, vision change, orbital pain, anosmia, or watery clear discharge post-trauma
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremontelukast_neuropsychiatric_warning
    New or worsening depression / suicidal ideation / behaviour change in patient on montelukast
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateincs_inadequate_at_2_to_4_weeks
    Persistent moderate-severe AR symptoms despite 2-4 wk of correctly used INCS monotherapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterefractory_ar_for_immunotherapy_referral
    Moderate-severe AR refractory to optimised step 3 with identified specific aeroallergen and controlled asthma
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecrswnp_overlap_suspected
    AR + nasal polyps OR + asthma + NSAID-triggered respiratory symptoms (AERD/NERD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildrhinitis_medicamentosa_from_chronic_decongestant
    Worsening rebound congestion in a patient using topical decongestant >5 d
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Allergic rhinitis — ARIA/JTF stepwise INCS-anchored pharmacotherapy with allergen immunotherapy for disease modification
axis: ar_stepwise_incs_anchored_ladderstep 1 - Step 1 — Mild intermittent: oral second-gen H1 PRN + saline irrigation + trigger avoidance
Selected step "Step 1 — Mild intermittent: oral second-gen H1 PRN + saline irrigation + trigger avoidance" — ARIA mild intermittent — symptoms <4 d/wk and <4 wk, no sleep / ADL / work impairment
  • cetirizine
    first line
    second_gen_h1_antihistamine
    10 mg PO (adult); 2.5-10 mg PO peds by weight • PO • once daily PRN (max: 10 mg/day adult)
    triggers: mild_intermittent_ar
    ARIA 2016 (PMID 28602936) + JTF 2017 (PMID 29181536) — second-gen H1 for mild intermittent AR; non-sedating, no anticholinergic burden.
    rxcui 20610
  • loratadine
    first line
    second_gen_h1_antihistamine
    10 mg PO (adult); peds by weight • PO • once daily PRN (max: 10 mg/day adult)
    triggers: mild_intermittent_ar, pregnancy_second_gen_h1_preferred
    ARIA 2016 (PMID 28602936) — alternative second-gen H1; preferred in pregnancy among second-gen.
    rxcui 28889
  • fexofenadine
    first line
    second_gen_h1_antihistamine
    180 mg PO (adult); peds 30-60 mg • PO • once daily PRN (max: 180 mg/day adult)
    triggers: mild_intermittent_ar, least_sedating_preferred
    ARIA 2016 (PMID 28602936) — alternative second-gen H1; consistently least-sedating in head-to-head data.
    rxcui 87636
  • saline_nasal_irrigation
    add on
    mechanical_clearance
    triggers: post_nasal_drip, thick_secretions
    ICAR-AR 2018 (PMID 29438602) — low-volume isotonic saline reduces symptoms and improves clearance; adjunct to pharmacotherapy.
  • trigger_avoidance_and_environmental_control
    first line
    avoidance
    triggers: identified_specific_aeroallergen
    ICAR-AR 2018 (PMID 29438602) — dust-mite covers + HEPA + pollen-window-closure are adjunctive; single-intervention monotherapy is rarely sufficient.

outpatient playbook — drug actions (4)

  1. 1. cetirizine PRN for mild intermittent
    rxcui 20610
    10 mg • PO • daily PRN
    trigger: Mild intermittent AR (ARIA 2016 PMID 28602936)
    Second-gen H1 PRN; non-sedating; pregnancy-acceptable
  2. 2. mometasone INCS for moderate-severe
    rxcui 108118
    100 mcg (2 sprays each nostril) • intranasal • once daily
    trigger: Moderate-severe AR (JTF 2017 PMID 29181536 STRONG)
    INCS monotherapy is superior to INCS + oral H1 combination and to LTRA
  3. 3. azelastine + fluticasone combination if inadequate INCS
    rxcui 18603
    2 sprays each nostril BID • intranasal • BID
    trigger: Inadequate INCS monotherapy at 2-4 wk (JTF 2017 PMID 29181536)
    INCS + intranasal H1 combination for refractory moderate-severe AR
  4. 4. SCIT or SLIT for trigger-specific refractory disease
    3-5 y course • SC or SL • per protocol
    trigger: Refractory moderate-severe AR with controlled asthma (ARIA 2016 PMID 28602936)
    Allergen immunotherapy is disease-modifying

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Rhinorrhoea, nasal congestion, sneezing, nasal or ocular itch — IgE-mediated AR (ARIA 2016 PMID 28602936); Seasonal allergen-driven pattern (pollens) OR perennial pattern (dust mite, animal dander, mould) — ARIA classification entry; Recurrent otitis with effusion in children or co-existing asthma — atopic-march comorbidity surveillance.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Allergic rhinitis (seasonal + perennial)** (allergy.allergic-rhinitis.core.v1).
Phenotype framing: 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).
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Allergic rhinitis — ARIA/JTF stepwise INCS-anchored pharmacotherapy with allergen immunotherapy for disease modification** — step "Step 1 — Mild intermittent: oral second-gen H1 PRN + saline irrigation + trigger avoidance".
1. cetirizine 10 mg PO (adult); 2.5-10 mg PO peds by weight PO once daily PRN (second_gen_h1_antihistamine, first line) — ARIA 2016 (PMID 28602936) + JTF 2017 (PMID 29181536) — second-gen H1 for mild intermittent AR; non-sedating, no anticholinergic burden.
2. loratadine 10 mg PO (adult); peds by weight PO once daily PRN (second_gen_h1_antihistamine, first line) — ARIA 2016 (PMID 28602936) — alternative second-gen H1; preferred in pregnancy among second-gen.
3. fexofenadine 180 mg PO (adult); peds 30-60 mg PO once daily PRN (second_gen_h1_antihistamine, first line) — ARIA 2016 (PMID 28602936) — alternative second-gen H1; consistently least-sedating in head-to-head data.
4. saline_nasal_irrigation (mechanical_clearance, add on) — ICAR-AR 2018 (PMID 29438602) — low-volume isotonic saline reduces symptoms and improves clearance; adjunct to pharmacotherapy.
5. trigger_avoidance_and_environmental_control (avoidance, first line) — ICAR-AR 2018 (PMID 29438602) — dust-mite covers + HEPA + pollen-window-closure are adjunctive; single-intervention monotherapy is rarely sufficient.

Setting playbook (outpatient) — Confirm IgE-mediated AR clinically, classify by ARIA tier, anchor on INCS for moderate-severe disease (JTF 2017 STRONG), and reserve allergen immunotherapy for trigger-specific moderate-severe AR with controlled asthma
6. cetirizine PRN for mild intermittent 10 mg PO daily PRN — Mild intermittent AR (ARIA 2016 PMID 28602936) (Second-gen H1 PRN; non-sedating; pregnancy-acceptable)
7. mometasone INCS for moderate-severe 100 mcg (2 sprays each nostril) intranasal once daily — Moderate-severe AR (JTF 2017 PMID 29181536 STRONG) (INCS monotherapy is superior to INCS + oral H1 combination and to LTRA)
8. azelastine + fluticasone combination if inadequate INCS 2 sprays each nostril BID intranasal BID — Inadequate INCS monotherapy at 2-4 wk (JTF 2017 PMID 29181536) (INCS + intranasal H1 combination for refractory moderate-severe AR)
9. SCIT or SLIT for trigger-specific refractory disease 3-5 y course SC or SL per protocol — Refractory moderate-severe AR with controlled asthma (ARIA 2016 PMID 28602936) (Allergen immunotherapy is disease-modifying)

Non-pharmacologic actions:
- INCS technique demonstration: jet aimed laterally away from septum (ICAR-AR 2018 PMID 29438602)
- Saline nasal irrigation as adjunct (ICAR-AR 2018 PMID 29438602)
- Trigger avoidance counselling: dust-mite covers, HEPA, pollen-window-closure (ICAR-AR 2018 PMID 29438602)
- Pollen-season pre-medication 2 wk before predicted season for seasonal AR

AVOID / contraindication checks:
- Montelukast boxed warning neuropsychiatric (FDA 2020 — depression, suicidal ideation, behavior change; screen pre and during therapy)
- Topical decongestants max 5 days to avoid rhinitis medicamentosa (ICAR AR 2018 PMID 29438602)
- Against routine oral or im systemic corticosteroids for AR (ICAR AR 2018 PMID 29438602)
- Scit systemic reaction risk requires epinephrine available and asthma controlled (ARIA 2016 PMID 28602936)
- Incs jet direction lateral to avoid septal erosion perforation epistaxis (ICAR AR 2018 PMID 29438602)
- Budesonide historically preferred incs in pregnancy (ICAR AR 2018 PMID 29438602)

Monitoring

Regimen monitoring:
- incs response at 2 to 4 weeks then seasonal review (JTF 2017 PMID 29181536)
- incs technique lateral jet at every visit (ICAR-AR 2018 PMID 29438602)
- montelukast neuropsychiatric screen pre and during (FDA 2020 boxed warning)
- scit post injection observation 30 min with epinephrine available (ARIA 2016 PMID 28602936)
- pollen season pre medication 2 weeks before season (ICAR-AR 2018 PMID 29438602)
- asthma control status each visit for immunotherapy eligibility (ARIA 2016 PMID 28602936)

Setting (outpatient) monitoring:
- Reassess at 2-4 wk after step change; INCS technique at every visit (JTF 2017 PMID 29181536)
- Annual atopic-comorbidity review + asthma control + immunotherapy progress
- Montelukast neuropsych screen pre and during therapy (FDA 2020 boxed warning)

Follow-up plan: 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.
- Close-out criterion: Annual review documented; biologic / specialist referral made if step-up criteria met

Monitoring phase: 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.

Disposition

Current setting: outpatient — Confirm IgE-mediated AR clinically, classify by ARIA tier, anchor on INCS for moderate-severe disease (JTF 2017 STRONG), and reserve allergen immunotherapy for trigger-specific moderate-severe AR with controlled asthma

Disposition criteria:
- Continue ladder + annual review
- Allergist referral for immunotherapy candidacy or refractory disease
- ENT referral for red flags or structural ddx

Escalation triggers (move to higher acuity):
- Red-flag features (unilateral, blood, vision, orbital pain, CSF leak) -> route to ENT or CSF-rhinorrhoea workup
- Persistent symptoms despite optimised step 3 -> allergist referral for immunotherapy / biologic
- CRSwNP suspicion -> ent.chronic-rhinosinusitis.core.v1 for nasal endoscopy + CT sinus + dupilumab consideration

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Unilateral discharge, blood in nasal discharge, vision change, orbital pain, anosmia, or watery clear discharge post-trauma
- [SEVERE] New or worsening depression / suicidal ideation / behaviour change in patient on montelukast
- [MODERATE] Persistent moderate-severe AR symptoms despite 2-4 wk of correctly used INCS monotherapy

Citations

- ARIA 2016 revision (Brożek JL et al, J Allergy Clin Immunol 2017-06; PMID 28602936); ICAR-AR 2018 (Wise SK et al, Int Forum Allergy Rhinol 2018-02; full PMID 29438602, exec PMID 29438600); JTF 2017 practice parameter (Wallace DV, Dykewicz MS et al, Ann Intern Med 2017-11; PMID 29181536) [PMID:28602936](https://pubmed.ncbi.nlm.nih.gov/28602936/)
- Cited evidence (PMID 29438602) [PMID:29438602](https://pubmed.ncbi.nlm.nih.gov/29438602/)
- Cited evidence (PMID 29438600) [PMID:29438600](https://pubmed.ncbi.nlm.nih.gov/29438600/)
- Cited evidence (PMID 29181536) [PMID:29181536](https://pubmed.ncbi.nlm.nih.gov/29181536/)

Last reconciled with current guidelines: 2026-05-26.
References
  • ARIA 2016 revision (Brożek JL et al, J Allergy Clin Immunol 2017-06; PMID 28602936); ICAR-AR 2018 (Wise SK et al, Int Forum Allergy Rhinol 2018-02; full PMID 29438602, exec PMID 29438600); JTF 2017 practice parameter (Wallace DV, Dykewicz MS et al, Ann Intern Med 2017-11; PMID 29181536) — PMID:28602936
  • Cited evidence (PMID 29438602) — PMID:29438602
  • Cited evidence (PMID 29438600) — PMID:29438600
  • Cited evidence (PMID 29181536) — PMID:29181536