Chinese Society of Allergy Guidelines for Diagnosis and Treatment of Allergic Rhinitis (English Version, 2018)
Core Overview
This is China’s first official English guideline on allergic rhinitis (AR), published in Allergy Asthma & Immunology Research (2018) (IF≈3.809), led by Prof. Zhang Luo (Beijing Tongren Hospital) and developed by 47 experts from 19 Chinese institutions. It integrates Chinese epidemiologic/clinical evidence (198 Chinese references, 112 in English journals) and aligns with international standards, covering epidemiology, classification, diagnosis, treatment, efficacy evaluation, patient education, and future directions.
1. Key Background & Epidemiology
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Prevalence in China: Adult AR standardized prevalence rose from 11.1% (2005) to 17.6% (2011); pediatric prevalence is also high, with regional variation (higher in northern/coastal areas).
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Major allergens in China: House dust mites (Dermatophagoides pteronyssinus/farinae), pollen (Artemisia, ragweed, birch), mold, pet dander, and cockroach; seasonal AR is common in northern China (Artemisia pollen in autumn).
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Burden: Impairs quality of life (sleep, work/school performance), increases comorbidities (asthma, sinusitis, conjunctivitis, otitis media), and imposes heavy socioeconomic costs.
2. Classification of AR
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Classification Criterion |
Types |
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Onset & Duration |
- Seasonal AR (SAR): Intermittent, triggered by seasonal pollen/mold
- Perennial AR (PAR): Persistent, triggered by indoor allergens (mites, pets, cockroaches)
- Mixed AR: Combination of SAR + PAR
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Severity (based on symptoms & impact) |
- Mild: No sleep disturbance, no impact on daily activities/work/school
- Moderate-Severe: ≥1 of: sleep disturbance, impaired daily activities/work/school, bothersome symptoms
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Frequency |
- Intermittent: Symptoms <4 days/week OR <4 consecutive weeks
- Persistent: Symptoms ≥4 days/week AND ≥4 consecutive weeks
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3. Diagnosis (Evidence-Based, Stepwise)
3.1 Clinical Diagnosis (Core)
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Typical symptoms: Nasal itching, sneezing (≥3 consecutive), rhinorrhea (clear, watery), nasal congestion; often with ocular symptoms (itching, redness, tearing) or asthma comorbidity.
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Physical exam: Pale/edematous nasal mucosa, clear watery secretions, turbinates hypertrophy; conjunctival hyperemia/edema (allergic conjunctivitis).
3.2 Allergen Testing (Confirmatory)
|
Test |
Indications |
Notes |
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Skin Prick Test (SPT, first-line) |
Suspected AR; identify culprit allergens |
Positive: wheal ≥3mm (vs negative control); avoid antihistamines 3–7 days prior |
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Specific IgE (sIgE) Blood Test |
SPT contraindicated (severe dermatitis, antihistamine non-compliant, pediatric/elderly) |
Correlates with SPT; less sensitive than SPT for local allergens |
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Nasal Provocation Test (NPT) |
Diagnostic dilemma (symptoms + negative SPT/sIgE); confirm local AR |
Gold standard for causal allergen; performed in specialized centers |
3.3 Differential Diagnosis
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Non-allergic rhinitis (vasomotor, infectious, hormonal, drug-induced), sinusitis, nasal polyps, adenoid hypertrophy (pediatric), systemic diseases (e.g., GPA).
4. Management (Stepwise, Individualized, Prevention + Treatment)
4.1 Allergen Avoidance (Foundation)
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House dust mites: Encase mattresses/pillows in allergen-impermeable covers; wash bedding in ≥55℃ water; reduce humidity (<50%); avoid carpets/soft toys.
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Pollen: Limit outdoor exposure during peak pollen seasons; wear masks/sunglasses; air purifiers with HEPA filters.
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Pets: Remove pets from home (ideal); restrict to non-bedroom areas; frequent grooming.
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Mold/Cockroach: Fix water leaks; clean damp areas; use mold inhibitors; bait traps for cockroaches.
4.2 Pharmacological Treatment (Stepwise, Based on Severity/Frequency)
4.2.1 First-Line Medications (Strong Recommendation)
|
Medication Class |
Agents |
Indications |
Key Notes |
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Intranasal Corticosteroids (INCS) |
Fluticasone propionate, mometasone furoate, budesonide |
Moderate-Severe SAR/PAR; first-line for persistent AR |
Once-daily, long-term use safe; start 1–2 weeks before pollen season; avoid nasal irritation (correct administration) |
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Oral/Intranasal Antihistamines (2nd-gen) |
Loratadine, cetirizine, levocetirizine, bilastine; olopatadine nasal spray |
Mild AR; intermittent SAR; adjuvant to INCS |
2nd-gen: minimal sedation/anticholinergic effects; intranasal: faster onset (15–30min) |
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Leukotriene Receptor Antagonists (LTRAs) |
Montelukast |
AR + asthma; aspirin-exacerbated respiratory disease (AERD); adjuvant to INCS/antihistamines |
Oral, once-daily; good for nighttime symptoms |
4.2.2 Second-Line/Adjuvant Medications
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Intranasal Decongestants: Oxymetazoline, xylometazoline (short-term <7 days) for severe nasal congestion; avoid rebound congestion.
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Oral Decongestants: Pseudoephedrine (caution in hypertension/hyperthyroidism/prostate hyperplasia).
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Intranasal Anticholinergics: Ipratropium bromide for severe rhinorrhea.
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Combination Preparations: INCS + antihistamine (e.g., fluticasone + azelastine) for moderate-severe AR (improved compliance).
4.3 Allergen Immunotherapy (AIT, Curative Potential)
4.3.1 Indications
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Confirmed AR (SAR/PAR) with positive SPT/sIgE to a single/multiple relevant allergens (mites, pollen).
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Inadequate control with pharmacotherapy + avoidance; young patients (preferable <18yo); AR + asthma (prevent asthma progression).
4.3.2 Types & Administration
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Type |
Route |
Protocol |
Notes |
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Subcutaneous Immunotherapy (SCIT) |
Subcutaneous injection |
Up-dosing phase (12–16 weeks) + maintenance phase (3–5 years) |
Gold standard; high efficacy; monitor for anaphylaxis (30min observation post-injection) |
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Sublingual Immunotherapy (SLIT) |
Sublingual drops/tablets |
Daily home administration; maintenance 3–5 years |
Safer (rare anaphylaxis); better compliance; lower efficacy than SCIT (mitigate with longer duration) |
4.3.3 Contraindications
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Severe/uncontrolled asthma (FEV1 <70% predicted); active autoimmune diseases; malignancies; pregnancy (initiation not recommended; continuation if already on AIT).
4.4 Surgical Treatment (Adjuvant, Not Curative)
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Indications: Severe nasal obstruction (turbinate hypertrophy, deviated nasal septum) refractory to medical therapy; comorbid nasal polyps/sinusitis.
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Procedures: Inferior turbinate reduction (radiofrequency, coblation), septoplasty; endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps (CRSwNP).
5. Efficacy Evaluation
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Subjective: Visual Analogue Scale (VAS, 0–10) for nasal/ocular symptoms; Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ).
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Objective: Nasal peak inspiratory flow (NPIF); nasal endoscopy (mucosa edema/secretions); NPT (reduced reactivity post-AIT).
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Treatment Success: ≥50% reduction in symptom score + improved quality of life; AIT: long-term remission (≥2 years post-discontinuation).
6. Patient Education & Follow-Up
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Education: Allergen avoidance, correct medication use (INCS administration, AIT compliance), recognition of severe reactions (anaphylaxis, asthma exacerbation).
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Follow-Up:
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Pharmacotherapy: 2–4 weeks after initiation, then every 3–6 months.
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AIT: SCIT (weekly up-dosing, monthly maintenance); SLIT (3 months, then 6–12 months).
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Long-term: Annual reassessment of symptoms, comorbidities, and treatment response.
7. Special Populations
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Pediatric AR: Prioritize avoidance + 2nd-gen antihistamines/SLIT; INCS (low-dose, age-appropriate); avoid oral decongestants in <6yo.
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Elderly AR: Caution with sedating antihistamines/decongestants; prefer INCS + non-sedating antihistamines; AIT (SCIT) with close monitoring.
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Pregnant/Lactating: Avoid AIT initiation; INCS (budesonide/fluticasone, category B) + 2nd-gen antihistamines (loratadine/cetirizine) as first-line.
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AR + Asthma: Stepwise treatment for both conditions; AIT (mites/pollen) to reduce asthma exacerbations.