CPG: Allergic Rhinitis – Research Needs

Research Needs section from Allergic Rhinitis CPG

This guideline was based on the current body of evidence regarding treatment of AR. While many of the key action statements were supported by Grade A level evidence, review of the evidence profile for other statements revealed knowledge gaps and the need for further research. As determined by the Guideline Development Group’s review of the literature, assessment of current clinical practices, and determination of evidence gaps, research needs were determined as follows:

1. Research is needed to determine the effect of environmental control strategies on AR. The aggregate evidence profile for environmental controls was a Grade B. Controlled trials to identify the efficacy of environmental controls on measurable AR endpoints are needed.
2. Research is needed to evaluate the safety and efficacy of SIT, specifically SLIT. There have been few US-based studies evaluating SLIT, which has been offered in the United States in an off-label, non-FDA-approved fashion. With FDA approval of Oralair, a mixed allergen extract consisting of several pollens (Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass), Grastek (treatment for Timothy grass pollen) and Ragwitek (treatment for short ragweed pollen) in 2014, prospective RCTs are needed to properly evaluate the effect of the office-sold, physician-diluted, nonstandardized products and other SLIT preparations.
3. Cost-effectiveness research (including direct and indirect costs) of SCIT compared with SLIT is needed. Also needed are better comparisons of SLIT versus SCIT; such comparisons are very few and far between, and there are none in the United States.
4. Research is needed to determine the molecular effects of first-line therapies for AR target end-organ immune responses (ie, topical steroids and antihistamines for nasal symptoms). Basic mechanistic research in the fields of allergy and immunology addressing the underlying triggers for specific patients is needed, as well as other immune-modulating treatments that alter the pathophysiology of AR and its comorbid conditions.
5. Research is needed to determine the safety and efficacy of acupuncture for AR. There is a relative paucity of data in the English-language literature regarding the use of complementary and integrative medicine for AR. As such, specific recommendations for or against these treatments could not be made. Higher levels of evidence regarding these therapies need to be obtained through well-designed clinical trials and/or systematic reviews of existing data.
6. The studies on herbal therapies involve use of preparations that combine numerous herbal extracts in varying amounts; thus, research needs to be conducted on specific herbal extracts along with standardization of dosing to determine efficacy for AR.
7. Controlled trials are needed comparing surgical versus medical management of inferior turbinate hypertrophy with nasal congestion in patients with AR. In addition, there is a need for further research regarding the role of septoplasty in the treatment of AR.
8. Research is needed to determine the relationship between AR and comorbid conditions such as otitis media and sinusitis. In addition, research is needed to determine the effect of AR treatment on comorbid conditions and the effect of treatment for comorbid
   conditions on AR.
9. Research is needed regarding the impact of patient adherence to different treatments, and treatment outcomes, which often is neglected in establishing the evidence base for AR or other treatments in trials. There is a need for increased diversity in trial subjects and the examination of other factors influencing treatment outcomes such as ease or utility of treatment administrations, as well as the impact of patient education aids on patient adherence and subsequent outcomes.
10. More research, including basic and/or translational trials, is needed to evaluate novel forms of immunotherapy such as peptide vaccines, DNA conjugated vaccines, intradermal injections, and intralymphatic injections. These are all strategies that are hypothesized to reduce the allergenicity of extracts while maintaining or enhancing the beneficial effects on the immune system.
11. Analysis is needed of the impact of immunomodulatory agents for the treatment of asthma on AR.
12. The relationship between AR and comorbid conditions such as otitis media and sinusitis should be
    determined. In addition, research is needed to determine the effect of AR on comorbid conditions.
13. It should be determined whether different forms of allergy testing can provide clinically meaningful
    information. It is still unclear whether one form of testing is superior to the other in identifying clinically relevant allergens.
14. Studies are needed to determine the effect of combined allergen formulations for AR that are standardized, tolerable, and effectively dosed.
15. Outcome measures are needed using SN-5 or other tools to measure and compare efficacy of medical and surgical treatments for nasal congestion/AR in both children and adults.