Allergy Management Guidelines

General Principles

The American Academy of Allergy, Asthma, and Immunology recommends a stepwise approach for allergy management, focusing on symptom severity, type of allergic condition, and patient response to therapy 1, 2
Treatment goals should focus on reducing morbidity, mortality, and improving quality of life by controlling symptoms and preventing exacerbations 2
Patient education about allergen avoidance, medication use, and recognition of worsening symptoms is essential at every step 3

For mild allergic symptoms, the American Academy of Allergy, Asthma, and Immunology recommends non-sedating second-generation H1 antihistamines as needed for symptom relief 2
For allergic rhinitis, intranasal corticosteroids (INCS) are considered as monotherapy for consistent symptoms 2
For moderate allergic symptoms, daily INCS are the preferred controller medication for allergic rhinitis 2
For severe allergic symptoms, combination therapy with INCS plus oral antihistamine and/or leukotriene receptor antagonist is recommended for allergic rhinitis 2
For allergic asthma, low-dose inhaled corticosteroids are the preferred controller medication 1
For severe allergic asthma, medium to high-dose inhaled corticosteroids plus long-acting beta agonists are recommended 1
Biologics (e.g., omalizumab) may be considered for severe allergic asthma with demonstrated allergic sensitization 1

The American Academy of Allergy, Asthma, and Immunology recommends considering allergen immunotherapy (subcutaneous or sublingual) for patients with persistent symptoms despite optimal pharmacotherapy 1, 4
Immunotherapy is effective for allergic rhinitis, allergic asthma, and insect venom allergies when there is clear evidence of specific IgE sensitization to clinically relevant allergens 4

Epinephrine is the only first-line treatment for anaphylaxis, with no substitute 5
Administer intramuscular epinephrine immediately upon recognition of anaphylaxis 6, 7, 8
H1 antihistamines (e.g., diphenhydramine) may be used as second-line treatment for relieving itching and urticaria 6, 7, 8
Corticosteroids (e.g., prednisone) may be used to prevent biphasic or protracted reactions 6, 7, 8
Bronchodilators (albuterol) may be used for respiratory symptoms 6, 7, 8

Prescribe epinephrine auto-injectors (2 doses) with proper training for patients at risk of recurrent anaphylaxis 6, 7, 8
Develop an emergency action plan for the patient 3
Provide education on allergen avoidance 3
Refer to an allergist for comprehensive evaluation 3

Second-generation antihistamines are generally preferred over first-generation antihistamines for treating allergic reactions due to their improved safety profile and reduced sedative effects, as recommended by the American Academy of Allergy, Asthma, and Immunology 9

Loratadine should be used at a dose of 10 mg once daily, according to the American Academy of Allergy, Asthma, and Immunology 9
Diphenhydramine can be used at a dose of 25-50 mg every 6 hours, with a maximum of 50 mg per dose, but should be used with caution due to significant sedation, performance impairment, and anticholinergic effects, as noted by the American Academy of Allergy, Asthma, and Immunology 10, 11, 12

For anaphylaxis, the first-line treatment is epinephrine IM, and adjunctive antihistamine therapy with diphenhydramine 1-2 mg/kg (maximum 50 mg) IV or oral, or a second-generation antihistamine for less sedation, is recommended by the American Heart Association 10, 11, 13
Intranasal antihistamines, such as azelastine, can be used as first-line treatment for allergic and non-allergic rhinitis, and are equal to or superior to oral second-generation antihistamines for seasonal allergic rhinitis, according to the American Academy of Allergy, Asthma, and Immunology 9

First-generation antihistamines can cause significant sedation, cognitive impairment, and have been associated with accidents and cardiac events, as reported by the National Institute of Health 9
Oral decongestants should be used with caution in patients with cardiovascular disease, hypertension, glaucoma, or hyperthyroidism, as advised by the American Heart Association 9

Saline nasal irrigation is beneficial for chronic rhinorrhea and rhinosinusitis, as recommended by the American Academy of Otolaryngology 9