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Evidence-Based Diagnostic Strategies for Evaluating Suspected Allergic Rhinitis

Karna Gendo, MD; and Eric B. Larson, MD, MPH
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From the Northwest Asthma and Allergy Center and The Center for Health Studies, Group Health Cooperative, University of Washington, Seattle, Washington.

Acknowledgments: The authors thank Gail Shapiro, MD; John Sheffield, MD; and Michael Kennedy, MD, for their thoughtful reviews of the manuscript and helpful suggestions.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Eric B. Larson, MD, MPH, The Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1448.

Current Author Addresses: Dr. Gendo: Northwest Asthma and Allergy Center, 4540 Sand Point Way NE, Seattle, WA 98105-3941.

Dr. Larson: The Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1448.

Ann Intern Med. 2004;140(4):278-289. doi:10.7326/0003-4819-140-4-200402170-00010
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Allergic rhinitis is an increasingly common disease, with a prevalence of at least 10% to 25% in the United States. Diagnostic allergy tests, such as skin tests and in vitro tests, can assist clinicians in determining whether nasal symptoms are allergic in origin. In addition, safe and effective medications are available to treat allergic rhinitis.The initial strategy should be to determine whether patients should undergo diagnostic testing or receive empirical treatment. This paper reviews the test characteristics of the history, skin tests, and in vitro tests in diagnosing allergic rhinitis from the perspective of decision thresholds. A combination of pertinent medical history features in a practice with a high baseline prevalence of allergic rhinitis justifies the common practice of empirical treatment since allergy medication has minimal toxicity and side effects.The situation is more complex when the patient needs a diagnostic test, because reported sensitivities and specificities of skin tests and in vitro tests vary widely. As a result, it is difficult to calculate the post-test probability of allergic rhinitis with any confidence. The decision to initiate diagnostic testing must rely on clinical judgment to select patients who would benefit most from determining their allergic status while minimizing unnecessary testing and medications. Diagnosing allergy to a specific antigen allows patients to avoid the allergen and makes them candidates for allergen immunotherapy, which can decrease the need for medications.


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The effect of prevalence on the predictive values of diagnostic tests using diagnostic test performance data.

To use this graph, estimate the pretest probability of allergic rhinitis and decide whether that probability justifies empirical treatment. Then, note the post-test probabilities corresponding to the pretest probability after positive and negative test results (vertical axis). If both probabilities justify the same action, testing will not change the decision about treatment and a choice (empirical treatment or watchful waiting) based on the pretest probability alone should be made. Data from Wood and colleagues (27) and Eriksson (20), with permission.

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