AAO-HNSF Publishes Clinical Practice Guidelines for Allergen Immunotherapy


AAO-HNSF guideline development group included 17 panel members, including experts from otolaryngology and allergy, those who have knowledge in clinical practice guideline development, and patient representatives.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) published clinical practice guidelines for immunotherapy for inhalant allergy, according to a press release from the organization. The guideline provides opportunities for quality improvement and evidence-based recommendations on the management of inhalant allergies with immunotherapy. The guidelines cover patients aged 5 years and older who have symptoms of inhalant allergies and were published in Otolaryngology–Head and Neck Surgery.1,2

People giving flowers and dog to young woman suffering from allergy on light background | Image Credit: Pixel-Shot - stock.adobe.com

Image Credit: Pixel-Shot - stock.adobe.com

“More than 50 million Americans suffer from allergies annually. Despite the widespread use of allergen immunotherapy (AIT), there are multiple clinical dilemmas that exist, including patient selection, modes of immunotherapy delivery, and ongoing needs to evaluate and ensure the safety and efficacy of AIT,” Richard K. Gurgel, MD, MSCI, chair of the AAO-HNSF Guideline Development Group, said in the press release.1

3 Key Takeaways

  1. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published clinical practice guidelines for allergen immunotherapy for inhalant allergies.
  2. Allergen immunotherapy (AIT) works by gradually increasing exposure to allergens, allowing the immune system to build tolerance and reducing allergy symptoms.
  3. The guidelines highlight the widespread use of AIT despite ongoing challenges, including patient selection, modes of delivery, and ensuring safety and efficacy

AIT is a treatment intended to reduce allergy symptoms and improve quality of life, with evidence that shows it can reduce asthma symptoms and prevent asthma and new allergies from developing. It works by patients inhaling regular and repeated doses of an allergen, including dander, pollen, ragweed, grass, and dust mites. When gradually increasing exposure, the immune system can build tolerance, causing the patient to be less sensitive to common allergens, according to the press release.1

The guidelines can help inform care decisions with an evidence-based framework for assessing patients’ needs for AIT, if needed. There are 12 key action statements including:1,2

  1. Candidacy for AIT: The guideline authors stated that physicians should offer or refer a health care provider who can offer immunotherapy for those with allergic rhinitis, who either have or do not have allergic asthma, if symptoms are inadequately controlled with previous interventions, such as medical therapy or allergy avoidance.
  2. Who Are Not Eligible For AIT:
    1. Patients Who Should Not Receive AIT: Patients who are pregnant, have uncontrolled asthma, or cannot tolerate injectable epinephrine should not get ATI.
    2. Who May Not Get AIT: Physicians can choose to not give AIT to individuals who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (sublingual immunotherapy (SLIT) patients only).
  3. Asthma Assessment: Physicians should evaluate or have another health care provider evaluate the patient for signs and symptoms of asthma before starting therapy. They should also evaluate for uncontrolled asthma.
  4. Education on Treatment: Physicians should also educate individuals on the differences of subcutaneous immunotherapy and SLIT, including risks, benefits, convenience, and costs.
  5. Education on Preventative Aspects of Treatment: Physicians should also inform patients on the potential benefits of AIT, including preventing new allergen sensitizations, reducing risk of allergic asthma, and altering history of the disease even after discontinuing therapy.
  6. Pre- and Co-Therapy: When SLIT is administered for seasonal allergic rhinitis, physicians should offer pre- and co-seasonal immunotherapy.
  7. Selecting Allergens: Allergens included for AIT should be limited to those that are clinically relevant to the patient’s history and are confirmed via testing.
  8. Polysensitized Patients With Limited Allergens: Patients who have a limited number of allergens and are polysensitized may be treated with AIT.
  9. Local Reaction and Escalation of Therapy: Escalation should continue or maintenance dose given even with a local reaction to the AIT.
  10. Anaphylaxis Identification and Management: The physician who administers AIT should be able to administer allergy skin testing and should be able to diagnose and manage anaphylaxis.
  11. Retesting During AIT: Physicians should not repeat allergy testing as efficacy assessment during ongoing AIT, unless there is a change in exposure or a loss of control of the patient’s symptoms.
  12. Duration of Treatment: Physicians should treat patients who experience symptom control with AIT for a minimum of 3 years, but should assess ongoing treatment duration based on the patient’s response.

“The guideline development group used the AAO-HNSF's rigorous, evidence-based methodology to create high-quality recommendations on immunotherapy. We hope this [clinical practice guideline] will be a valuable resource to optimize patient care and reduce unnecessary and costly variation in AIT management,” Gurgel said in the press release.1

The guideline development group included 17 panel members, including experts from otolaryngology and allergy, those who have knowledge in clinical practice guideline development, and patient representatives, according to the press release.1

  1. New Clinical Practice Guideline Provides Evidence-based Recommendations for Immunotherapy for Inhalant Allergy. News release. American Academy of Otolaryngology–Head and Neck Surgery Foundation. February 26, 2024. Accessed March 4, 2024. https://www.entnet.org/resource/new-clinical-practice-guideline-provides-evidence-based-recommendations-for-immunotherapy-for-inhalant-allergy/
  2. Gurgel RK, Baroody FM, Damask CC, et al. Clinical Practice Guideline: Immunotherapy for Inhalant Allergy. Otolaryngol Head Neck Surg. 2024;170 Suppl 1:S1-S42. doi:10.1002/ohn.648
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