Stirling expert panel consensus algorithm for the pharmacological management of allergic rhinitis3

In 2015, a multi-professional group of clinicians met in Stirling, Scotland, to development a simplified allergic rhinitis (AR) treatment algorithm for use in primary and secondary care, incorporating current knowledge and recently available treatments.

Promoting AR management in primary care

The primary objective of the panel was to promote better management of AR patients, improve diagnosis and treatment in primary care and to facilitate transition of difficult-to-treat patients into secondary care. Adherence to this care pathway has the potential to reduce AR management costs in the UK by avoiding unnecessary treatments and investigations, and avoiding the need for costly referrals to secondary care for the majority of AR cases.


The combination of intranasal azelastine hydrochloride and fluticasone propionate in a single device (Dymista® [AZ/FP]) may be used second line after failure of topical intranasal corticosteroids (INCS) after checking for correct use and compliance with the medication. If incorrect use or non-compliance is found, re-education followed by repeat trial of topical INCS is recommended before AZ/FP (single device) prescription.

AZ/FP (single device) may be used first line in certain cases in which the GP considers that monotherapy is more likely to fail, if they consider it warranted in their professional opinion, in accordance with the labelled product indication.

In the event of treatment failure on second-line AZ/FP (single device) in primary care, and correct use of medication and compliance have been checked, along with confirmation of the diagnosis, referral to secondary care is recommended for further investigations.

In secondary care, the consensus group considers that AZ/FP (single device) could be used as a first-line alternative to topical INCS in patients with moderate-severe symptoms (see figure below).

Dymista®’s place in therapy in A: primary care, and B: secondary care, is indicated
in the following treatment algorithms1


AH: anti-histamine; AZE: azelastine; IgE: immunoglobulin E; INCS: intranasal corticosteroid; LTRA: leukotriene receptor antagonist; OAH: oral antihistamine; OC: oral corticosteroid; Rx: treatment; SPT: skin prick test; Sx: symptoms.

*You may consider the addition of an OAH to INCS. However, scientific evidence shows that adding an OAH to INCS provides no additional benefit over INCS alone.

Adapted from Lipworth B, et al. 2017.3


  • Scadding GK, et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy 2017; 47(7): 856‑889.
  • Scottish Medicine Consortium (SMC). Available at Last accessed: November 2018.
  • Lipworth B, et al. An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK: a consensus statement from an expert panel. NPJ Prim Care Respir Med. 2017; 27(1): 3.
  • Dymista®. Summary of Product Characteristics. Available at:
    Last accessed: November 2018.

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