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Patient and physician perspectives on the impact and management of perennial and seasonal allergic rhinitis
Abstract
Patient and physician perspectives on the impact and management of perennial (PAR) and seasonal allergic rhinitis (SAR) were studied. In all, 2139 subjects were questioned about their medical conditions, severity and frequency of symptoms and satisfaction with treatment. A group of general practitioners (GPs) were also invited to discuss their experiences in the management of rhinitis. In this UK survey, allergic rhinitis was more common than asthma, hypertension, skin rashes, eczema and diabetes. The prevalence of SAR and PAR was 15% and 2%, respectively. Sneezing and runny nose were the most common symptoms and GPs were the main contact for advice and treatment (54% of patients). Symptoms were well-controlled in 32% of patients. Allergic rhinitis affected work, home and social life in 29%, 34% and 30% of patients, respectively. The GPs considered PAR to be more difficult to treat than SAR, and GP and patient level of satisfaction in the treatment of PAR was low. This suggests that education of patients and physicians on the benefits of allergen avoidance, and the selective use of the highly effective therapies available on prescription could improve the level of satisfaction with therapy. Adherence to current guidelines on the management of rhinitis could lead to an effective, structured treatment plan for patients.
... Allergic rhinitis is the most common of all allergic disorders (Sly, 1999;Scadding, Richards, & Price, 2000). The word rhinitis means inflammation of the lining of the nose. ...
... The most common symptoms in allergic rhinitis include violent, prolonged sneezing; watery, clear nasal discharge; nasal congestion, nose itching or rubbing, reduction in the sense of smell, breathing through the mouth, constant clearing of the throat; and itching, tearing eyes (ALAAAG & Edelman, 1997;NIAID, 1998). The findings from a United Kingdom survey (Scadding et al., 2000) show that sneezing and runny nose were the most common symptoms in patients both with seasonal rhinitis and in patients with perennial rhinitis. Other common symptoms in patients with seasonal rhinitis were itchy eyes, watery eyes, and itchy nose. ...
... Having allergies can be a critical issue for well-being and quality of life. Around 30 % of British patients reported that allergic rhinitis had impacts on their work, home, and social life (Scadding et al., 2000). A study from France (Bousquet et al., 1994) and a study from the United States confirmed that allergic rhinitis adversely affected the physical and mental health status of sufferers. ...
The purpose of this research was to examine home conditions, housing satisfaction, and allergen avoidance practices of people with allergic rhinitis, focusing on female patients who lived in an urban area in a hot, humid climate. The Morris and Winter theory of housing adjustment provided the theoretical base. A sample of 41 female allergy patients aged 20 to 77 years completed a screening questionnaire and an in-depth questionnaire. Dwellings were visited to conduct home observations and to take photos. Dust mite allergens were reported as the most common allergy triggers. Presence of cockroaches, furry pets, molds in bathrooms, and molds in kitchens were the most common problematic home conditions. Allergen avoidance practices were not followed regularly, such as using allergen-proof pillowcases and sheets, washing bedding in hot water, and using an exhaust fan. Respondents who received recommendations from doctors were most likely to follow allergen avoidance practices. There was a significant negative relationship between problematic home conditions and housing satisfaction in terms of health issues. A significant negative relationship between age and allergen avoidance practices was also found. Obstacles that prevented respondents from improving their homes in order to avoid allergens included the cost of products and emotional attachment to pets.
... When symptomatic, patients feel the impact of AR on all areas of their daily lives, at home, socially and at work/school. [5][6][7] Indeed, in the UK children with symptomatic AR are more likely to unexpectedly drop an exam grade during summer tests than their non-AR counterparts, and are even more at risk of so doing if taking sedating anti-histamines. 8 Poorly controlled AR also has a negative impact on asthma control, equivalent to that induced by smoking. ...
... When symptomatic, patients feel the impact 76 of AR on all areas of their daily lives, at home, socially and at work/school. [5][6][7] Indeed, in the 77 UK children with symptomatic AR are more likely to unexpectedly drop an exam grade 78 during summer tests than their non-AR counterparts, and are even more at risk of so doing 79 if taking sedating anti-histamines. 8 Poorly controlled AR also has a negative impact on 80 asthma control, equivalent to that induced by smoking. ...
... About 68% of those with PAR complained of sleep interference compared to 48% of patients with SAR [24]. Additionally, up to 40% of PAR patients complain of headache, fatigue, low productivity and inability to concentrate at work, leading to impairment of professional activities [26]. PAR patients also frequently suffer from olfactory dysfunction (particularly hyposmia) [27]. ...
... US$162 for SAR) [34]. Additionally, a survey in the UK showed that general practitioners (GPs) considered PAR more difficult to treat than SAR, with both GP and patient satisfaction with PAR treatment lower than its seasonal counterpart [26]. PAR patients also used a greater number of concomitant medications (multiple second-generation antihistamines, intranasal corticosteroids (INS), other asthma medications and decongestants) and immunotherapy regimens [34] than those with SAR. ...
Introduction:
Allergic rhinitis (AR) has a major negative impact on patients' quality of life (QoL) and carries a high socio-economic burden. This is particularly the case for patients who experience symptoms for extended periods of time (i.e. those with perennial (PAR) or persistent AR (PER), depending on the classification system used). This review covers available pharmacological advances and recent developments in the treatment of PAR or PER. Areas covered: Pharmacological AR treatment is used to reduce symptom burden and help restore patients' normal daily routine. Traditionally, non-sedating antihistamines and intranasal corticosteroids (INS) were the two drug classes recommended for use first line. These, along with anti-leukotrienes, decongestants, mast cell stabilizers and anti-cholinergics, constituted the bulk of the AR treatment arsenal. MP29-02 (Dymista(®), Meda, Solna, Sweden) is the most recent addition to that arsenal. It is a novel intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP) delivered in a single spray and has surpassed available therapies in terms of symptom control and treatment response. Other relatively new treatments for PAR or PER include H3 antihistamines, toll-like receptor (TLR) agonists, cellulose powders and micro-emulsions, novel biomolecular formulations and omalizumab. Each of these new additions is reviewed here. Expert opinion: A new AR drug class has recently been introduced (i.e. RO1AD58). Currently MP29-02 is the only treatment option within this drug class. It can be estimated that combination treatments like MP29-02 will become the mainstay of PAR and PER therapy since use will result in better compliance, improved efficacy over INS and a faster response together with good levels of tolerability. The challenge is to find other equally, or more effective, combination treatments, as has been the therapeutic standard in bronchial asthma for decades. The potential of biologics, as well as TLR-agonists and other new treatment options needs to be further evaluated.
... 1 It is estimated that allergic rhinitis affects over 20 per cent of the UK population 2 and up to 40 per cent of children. 3 Most patients with allergic rhinitis can be easily and effectively managed in the community but both patients and GPs describe low levels of satisfaction when treating allergic rhinitis. 4 Studies suggest that patients are undertreated, with only 32 per cent of patients reporting good symptom control in UK primary care. 4 Affected patients sometimes turn to complementary treatment because of a poor clinical response to treatment and fear that prolonged use of conventional medications may be related to potential adverse effects. ...
... 4 Studies suggest that patients are undertreated, with only 32 per cent of patients reporting good symptom control in UK primary care. 4 Affected patients sometimes turn to complementary treatment because of a poor clinical response to treatment and fear that prolonged use of conventional medications may be related to potential adverse effects. ...
Allergic rhinitis is a common and undertreated condition and is often a precursor to asthma in children. Our Drug review discusses diagnosis, recommended management and recent advances in treatment, followed by sources of further information and an analysis of the prescription data.
... Surpreendentemente, alguns estudos demonstram, por exemplo, que a intensidade dos sintomas não se correlaciona necessariamente com o nível de prejuízo à qualidade de vida, um aspecto que salienta mais uma vez a relevância da individualidade de cada paciente. (3,4) ...
... (24) Graus variáveis de prejuízo às atividades profissionais podem ser vivenciados por até 60% dos pacientes com RA sazonal e por até 40% dos com RA perene. (3) Os pacientes queixam-se de cefaleia, fadiga, baixo rendimento e baixa concentração no trabalho. Vale lembrar que a conjuntivite, comumente associada à RA, pode prejudicar a acuidade visual e as atividades relacionadas à visão. ...
The objective of this review was to present evidence of the relationship between allergic rhinitis and impairment of quality of life. The data sources were original articles, reviews and consensus statements entered into the Medline and LILACS databases between 1997 and 2008. The following search terms were used: "allergic rhinitis"; "quality of life"; and "sleep disorders". Quality of life is often impaired in patients with allergic rhinitis, due to the classic symptoms of the disease (sneezing, pruritus, rhinorrhea and nasal obstruction). In addition, the pathophysiology of allergic rhinitis often disrupts sleep, leading to fatigue, irritability, memory deficits, daytime sleepiness and depression. The total burden of this disease goes beyond impairment of physical and social functioning. It has also a financial impact, which becomes greater when we consider the evidence that allergic rhinitis is a possible causal factor of comorbidities, such as asthma and sinusitis. Nasal obstruction, the most prominent symptom, is associated with sleep disorders, which can have a profound effect on mental health, learning, behavior and attention. Finally, allergic rhinitis-a chronic condition that affects adults, adolescents and children-is often underdiagnosed or inadequately treated. The deleterious impact that allergic rhinitis-related sleep disorders have on patient capacity to perform activities of daily living is an important component of the morbidity of the disease. With an accurate diagnosis, there are various available treatments that can reduce the burden of allergic rhinitis.
... Persistent disease involves symptoms that occur more than 4 days per week and are present for longer than 4 weeks. [4][5][6][7][8][9][10][11] Numerous types of drugs are available for this purpose and each has unique characteristics. The physician must tailor the regimen according to the patient symptoms and circumstances. ...
Allergic rhinitis is the most common form of rhinitis, worldwide, affecting close to 10% to 30% of the global population. Heredity and environmental exposures may contribute to a predisposition to allergies. Pharmacotherapy along with effective allergen avoidance measures forms the mainstay of management of Allergic Rhinitis. The evidence indicates that intranasal corticosteroids are more efficacious than are antihistamines in the control of Allergic Rhinitis symptoms. This "superiority" is principally related to their effect on nasal obstruction. The numbers of studies done to know the efficacy of combination sprays over steroidal sprays alone are very few and provide insufficient insight.
The purpose of this study was to ascertain whether the combination nasal sprays should be prescribed as a standard medical management for allergic rhinitis or not, as to achieve better quality of life after treatment with maximum improvement in Total Nasal Symptom Score (TNSS).
100 subjects were taken up for this study, 50 in each group after fulfilling the inclusion and exclusion criteria. Subjects were allocated in two groups according to consultant’s preference. Subjects were evaluated for Total Nasal Symptom Score (TNSS) and score of Mini Rhino conjunctivitis Quality of Life Questionnaire (MiniRQLQ) before and after the treatment initiation
The study was conducted in two groups based on drug given and both the groups were evaluated after 2 weeks and 4 weeks of medication on the basis of TNSS and MiniRQLQ score.
Allergic Rhinitis was found to be more common in younger age group. Both the drugs were effective in reducing the Total nasal symptom scores (TNSS) and score of MiniRQLQ significantly (p<0.001). However, Combination Nasal Sprays (Intra-nasal corticosteroids with intranasal antihistamines) were found to be statistically superior when compared to only intranasal steroid sprays.
Combination Nasal Sprays are highly efficacious and statistically better to steroid nasal sprays hence this study confirms the superiority of combination nasal sprays and recommends combination nasal sprays as first line of treatment for allergic rhinitis.
... Evidence suggested that in seasonal allergic rhinitis, ocular symptoms are more frequent than in perennial allergic rhinitis [14]. ...
Allergic rhinitis and allergic conjunctivitis are so frequently associated that the need to coin a new name to describe the simultaneous manifestations generated the term allergic rhinoconjunctivitis. The significant impact of rhinoconjunctivitis on the quality of life and the wellbeing of the patients is the reason why the medical community shows a great interest to this disease. Another aspect is the financial burden that is not negligible. The anatomical connection between the organs involved facilitates the propagation of the disease. The allergic pathophysiological mechanisms implicated in allergic rhinitis and conjunctivitis also share common features. The diagnosis of rhinoconjunctivitis is based on the concordance between the symptoms, the clinical examination, and the diagnostic tests that should reveal the existence of an allergen specific IgE in vivo or in vitro. Whilst the nasal smear for eosinophils is considered a reliable diagnostic test for allergic rhinitis, the occurrence of eosinophils in the conjunctive is not a trustworthy indicator of allergy. The therapy of allergic rhinoconjunctivitis is based on patient education, pharmacotherapy, and allergen-specific immunotherapy. The local treatment for the allergic rhinitis is primarily based on topical corticosteroids that also manage the ocular symptoms. The first line of treatment of the ocular manifestations is represented by topical antihistamines and mast-cell stabilizers or double action drugs.
... A memória e o aprendizado são características funcionais que podem ser prejudicadas em pacientes com rinite alérgica ocasionando impacto crucial sobre seu desempenho intelectual 12 , aprendizado 13 , queda na produtividade do trabalho e ser causa frequente de absenteísmo 14 . Não somente a doença, mas também a medicação empregada para alívio dos sintomas pode influenciar a produtividade no trabalho 15,16 . ...
Objective: To assess the impairment of quality of life of children with allergic rhinitis (AR) followed in a specialized clinic. Methods: After admission patients/guardians answered a questionnaire (Allergies in America) being obtained personal data, duration of disease, most bothersome symptoms, treatment given, treatment response, among others. Results: 88.2% patients (n=74; aged 5y9m to 18y9m) have intermittent AR. Familial history of nasal allergy was reported by 64.0%. Allergic rhinitis was confirmed by skin prick test in 86.5% and by serum specific IgE in 66.2%. Moderate/extreme discomfort symptoms were identified as: nasal congestion (64.9%), sneezing (60.8%), nasal itching (59.5%), and redness/itching eyes (58.1%). Dust (83.8%), climate/ humidity (25.7%) and perfume (19.9%) were the main symptom trigger agents. Acute attacks determined loss of school (56.9%) and interference in playing with animals (66.2%). Nevertheless, more than 70.0% report being satisfied with the treatment received. Conclusion: This study confirms the high nuisance that cause RA symptoms in patients and proves how they committed quality of life of RA patients. Rev. bras. alerg. imunopatol. 2011; 34(5):203-208: Allergic rhinitis, impact, quality of life, children, adolescents. Resumo Objetivo: Avaliar o grau de comprometimento da qualidade de vida de crianças rinite alérgica (RA) há pelo menos um ano seguidas em ambulatório especializado. Métodos: Após admissão, pacientes responderam questionário (Allergies in America) sendo obtidos dados pessoais, tempo de doença, sintomas mais incômodos, tratamento realizado, resposta terapêutica, entre outros. Resultados: Participaram 74 pacientes (5 anos e 9 meses a 18 anos e 9 meses) com RA (intermitente em 66,2%). Alergia nasal em outro membro da família foi apontada por 64,9%. A etiologia alérgica da rinite 86,5% foi documentada por testes cutâneos de hipersensibilidade imediata e em 66,2% pela pesquisa de IgE sérica específica. Desconforto moderado ou extremo pelos sintomas foi apontado: congestão nasal (64,9%); espirros repetidos (60,8%); prurido nasal (59,5%); hiperemia/prurido ocular (58,1%). Sendo a congestão a que mais causou incômodo por 20,3%. Exposição ao pó (83,8%); clima/umidade (25,7%); perfume (19,9%); animais (18,9%) e poluição (13,5%) foram os agentes desencadeantes de sintomas. Crises agudas determinaram perda escolar (56,9%) e interferência em brincar com animais (66,2%). Apesar disso, mais de 70,0% referem estar satisfeitos com o tratamento utilizado. Conclusão: Este estudo confirma o elevado incômodo que os sintomas de RA acarretam aos doentes e comprova o quanto a RA compromete a vida desses pacientes. Rev. bras. alerg. imunopatol. 2011; 34(5):203-208: Rinite alérgica, impacto, qualidade de vida, crianças, adolescentes. Impacto sobre a qualidade de vida e o nível de satisfação com o tratamento da rinite alérgica por crianças e adolescentes acompanhados em serviço de referência* The impact on quality of life and satisfaction with the treatment of allergic rhinitis among children and adolescents followed in a reference center*
... 25% of the population 4 while in the United States and the United Kingdom, SAR affects 20% of adults and 40% of children. 2,[4][5][6][7] SAR symptoms pose as a major clinical problem and socioeconomic burden that impair quality of life of the patients due to sleep disturbance, poorer work performance and school grades. 8,9 Allergic inflammation can be classified into 2 phases, early and late phase. ...
Allergen immunotherapy (AIT) is an effective treatment for allergic rhinitis, inducing long-term clinical tolerance to the sensitising allergen. Clinical tolerance induction can be achieved when AIT is administered for at least three years. AIT is associated with the modulation of innate and adaptive immune systems. This comprises of inhibiting of IgE-dependent activation of mast cells and basophils in the local target organ, suppression of Th2 cells, immune deviation towards Th1 cells, induction of T and B regulatory cells and production of allergen neutralising antibodies. However, recent developments in our understanding of underpinning mechanisms of AIT have revealed that immunotherapy administered either by SCIT or SLIT induces immune regulation through novel cell targets and molecular mechanisms. This comprehensive review discusses how immune tolerance driven by SCIT and SLIT is associated with the induction of a novel regulatory subset of innate lymphoid cells, suppression of pro-inflammatory Th2, Th2A and T follicular helper cells, drive Th2 cell exhaustion and differential expression of nasal and systemic antibodies IgA. Uncovering the underpinning mechanisms of successful AIT and immune tolerance will allow the development of targeted therapeutics for allergic rhinitis with and without asthma.
... As a result, healthcare professionals are reorienting and becoming more attentive, with an interest in assessing the quality of life and patient satisfaction, along with evaluating other aspects of the disease or treatment. 6,7 The extent of quality-of-life impairment varies mainly depending on the individual's standards of "personal wellbeing", the perception of the outside world, and expectations from the treatment. Interestingly, the intensity of symptoms does not necessarily correspond to the degree of impairment of quality of life, an aspect that again emphasises the individuality of each patient. ...
Introduction: Chronic nasal congestion in patients with allergic rhinitis can lead to sleep disorders and to sleep apnoea which, in combination with fatigue, can induce systemic effects, including irritability, weakness, malaise, and decreased appetite, growth retardation in adolescents, resulting in severe worsening of quality of life. Also, allergic rhinitis can affect social life, school performance, and productivity, especially in patients with severe disease.
Aim: The aim of the present case-control study was to investigate the impact of quality-of-life impairment and the main contributing symptoms in patients with allergic rhinosinusitis.Materials and methods: During the survey from January to December 2018, 139 participants (111 with allergic rhinitis and 28 controls) were enrolled in the study. Participants in the clinical and control groups were invited to complete a quality-of-life questionnaire for patients with sino-nasal pathology (SNOT-22). For results, a comparison in terms of eye affecting itching, burning, redness, and tearing sensation, a 10-grade visual analogue scale table was presented.
Results: Comparing the clinical and control groups of healthy patients in the first SNOT-22, the value was significantly elevated as expected. The mean score (SNOT-22 total score) of the twenty-two symptom scores in patients was 2.52±0.93 (0-5); by comparison, the value in the control group was only 0.64±0.11, with the difference being statistically significant (p=0.001). The results of the visual analogue scale for which the patients were asked to note the level of eye impairment: redness, burning, itching, and tearing that contributed to their negative sense of the quality of life, were eloquent. A statistically significant difference was found between participants with intermittent and persistent forms (6.06±0.20 vs. 3.00±0.25, p=0.001), and between the entire clinical group with AR and the healthy controls included in the study (4.48±0.22 versus 0.21±0.03, p=0.000).
Conclusions: Summarising the results of our study and the available literature, we have concluded that nasal congestion and the abundance of secretions are symptoms that disrupt mostly the quality of life in AR patients and significantly affect the quality of sleep and are inevitable consequences of both daytime tone and productivity.The rich palette of symptoms that lead to deterioration of the mental and physical well-being of those affected by AR necessitates the need to sharpen the attention of professionals working for this type of pathology in order to strive to detail and differentiate the specific complaint and degree of quality of life deterioration.
... Seasonal AR (SAR) is usually caused by pollens, whereas perennial AR (PAR) is often associated with sensitization to indoor allergens. PAR is generally considered more challenging to treat than SAR, and symptoms often persist despite best care [217].Indeed, comorbid AR is a marker of poor control or more severe asthma [218][219][220]. ...
Recent advances in understanding T2 inflammation have broadened the diseases in which T2 inflammation can be involved. Dupilumab is a recently developed monoclonal antibody blocking the signaling of both IL-4 and IL13, two crucial cytokines of the T2 responses. New possible indications are increasingly exploring. Among them are skin diseases, such as prurigo nodularis, nummular eczema, allergic contact dermatitis, chronic hand eczema, spontaneous chronic urticaria, bullous pemphigoid, alopecia areata, and Netherton syndrome, among other several cutaneous diseases. Also, respiratory diseases, such as allergic bronchopulmonary aspergillosis, chronic eosinophilic pneumonia, and allergic rhinitis. In addition, eosinophilic gastrointestinal disorders, particularly eosinophilic esophagitis, and food allergy are two more research fields. Here we review the published data and clinical trials about the use of dupilumab in these disorders.
... Recent evidence shows that patients with AR have a low level of satisfaction with their therapy 22 . 58% of our patients reported minimal or no improvement of nasal symptoms despite use of nasal sprays. ...
Nasal corticosteroid sprays are the recommended, first-line treatment in the management of allergic rhinitis. Patient compliance and spray technique appear to be significant issues. There is a paucity of information in medical literature, regarding patient knowledge, perception, and satisfaction of the use of nasal corticosteroid sprays. A prospective, questionnaire-based study was performed, Patient knowledge, perception, and technique of using nasal corticosteroid sprays was assessed. One hundred patients completed the questionnaire. Ages ranged from 16 to 68 years. 89%(n=89) had no knowledge of the required duration of treatment. 60%(n=60) were not shown how to administer the spray. 55%(n=55) did not know their spray contained steroids. 39%(n=39) gave up their treatment in under two weeks, primarily because they reported minimal or no improvement in nasal symptoms. 80%(n=80) of patients had poor spray technique. All patients complained of one or more side effects. Patients administering corticosteroid intranasal sprays possess limited knowledge and awareness of the treatment for allergic rhinitis. They do not receive sufficient instruction regarding administering the spray or duration of use, and subsequently achieve suboptimal satisfaction with their management. A knowledge gap exists that could be bridged by better patient education.
... Allergic rhinitis (AR) is one of the most common types of atopic comorbidity in patients with uncontrolled, persistent asthma. 1 Perennial allergic rhinitis (PAR), which is often associated with sensitization to indoor allergens, such as dust mites and animal dander, 2 is generally considered more difficult to treat than seasonal allergic rhinitis (SAR), and symptoms of PAR often persist despite available treatment. 3 Individuals sensitized to mites or other indoor aeroallergens are more likely to have severe asthma than patients with seasonal allergies, 4,5 which adds to the disease burden in patients with asthma. 5,6 Indeed, comorbid AR is a marker of more severe asthma and contributes to poor asthma control. ...
Background
Comorbid perennial allergic rhinitis (PAR), or year-round aeroallergen sensitivity, significantly contributes to disease burden in asthma patients. Dupilumab blocks the shared receptor for interleukin (IL)-4 and IL-13, key drivers of type 2 inflammation that play important roles in asthma and PAR. In LIBERTY ASTHMA QUEST (NCT02414854), dupilumab reduced severe asthma exacerbations and improved forced expiratory volume in 1 second (FEV1) in patients with uncontrolled, moderate-to-severe asthma, with greater efficacy observed in patients with elevated type 2 inflammatory biomarkers at baseline (blood eosinophils and fractional exhaled nitric oxide [FeNO]).
Objective
We assessed dupilumab efficacy in QUEST patients with comorbid PAR (allergic rhinitis history and ≥1 perennial aeroallergen-specific IgE ≥0.35 kU/L at baseline).
Methods
Severe asthma exacerbation rates, FEV1, asthma control (ACQ-5), rhinoconjunctivitis-specific health-related quality of life (HRQoL) (RQLQ[S]+12), and type 2 inflammatory biomarkers during the 52-week treatment period were assessed. RESULTS: 814/1902 (42.8%) patients had comorbid PAR. Dupilumab 200 and 300 mg q2w versus placebo reduced severe exacerbations rates by 32.2% and 34.6% (both P<.05), and improved FEV1 at Week 12 by 0.14 L and 0.18 L (both P<.01); greater efficacy was observed in patients with elevated baseline blood eosinophils (≥300 cells/μL) and FeNO. Dupilumab treatment also numerically improved ACQ-5 and RQLQ(s)+12 scores, and suppressed type 2 inflammatory biomarkers.
Conclusion
Dupilumab improved key asthma-related outcomes, asthma control and rhinoconjunctivitis-specific HRQoL, while suppressing type 2 inflammatory biomarkers and perennial allergen specific IgE in patients with moderate-to-severe asthma and comorbid PAR, highlighting its dual inhibitory effects on IL-4/IL-13 and its role in managing both asthma and PAR.
... [10] In the contemporary classification of AR under ARIA, the burden of the ailment is determined not by the burden of the symptoms themselves but by the manner in which they influence the patient's life: whether they hamper their day-to-day activities, work, education, further emphasises the relativity of individual assessment. [17] The integrated and comprehensive approach to the patient, the ailment symptoms, the quality of life and satisfaction provide for a comprehensive assessment of the AR burden and the success of its treatment. ...
Allergic rhinitis (AR) is the most common allergic ailment in which the combination of symptoms and accompanying complaints can lead to severe deterioration of patients' quality of life. It is a known fact that AR disturbs the patients' daily physical and emotional condition and their social activities; it limits the cognitive capacity and can cause depression and anxiety. The purpose of this study is to assess the impact of the seasonal allergic rhinitis on the quality of life in patients who apply self-treatment and do not follow a physician-prescribed therapy. Seventy-one patients of AR symptoms who do not follow a physician-prescribed therapy but seek advice in pharmacies have been monitored during the pollen season. Their quality of life has been studied with the help of a generic questionnaire SF-12V2 validated for Bulgaria; it studies patients' physical, mental and psychosocial functions and offers summarized assessments of their physical and mental health. The research established that the respondents do not perceive AR as a factor that impacts their overall physical health in a significant way. They assess their physical condition to be slightly above the norm measured against the scale of the applied tool. All indices concerning the patients' mental health are below the norm, which is an indicator that seasonal AR creates
... Allergic rhinitis (AR) is a very common allergic disease that affects over 30% of populations over the world [1]. AR generally develops during childhood, and it is the most common chronic allergic disorder in children [2]. ...
Allergic rhinitis (AR) is an allergic disease characterized as (immunoglobulin E)-mediated type I hypersensitivity disorder. The interleukin-13 (IL-13) signaling pathway has been implicated in the pathogenesis of AR. In the present study, we investigated the regulatory role and mechanism of long noncoding RNA Linc00632 in IL-13-induced inflammatory cytokine and mucus production in nasal epithelial cells (NECs) from AR patients. We evaluated the expression of Linc00632 in nasal tissues from AR patients and in IL-13-treated NECs. We explored the role of Linc00632 in granulocyte-macrophage colony-stimulating factor (GM-CSF), eotaxin, and MUAC5AC production in IL-13-treated NECs. We searched for the potential target of Linc00632. Downregulation of Linc00632 was identified in nasal tissues of AR patients and in IL-13-treated NECs. Linc00632 inhibited IL-13-induced GM-CSF, eotaxin, and MUAC5AC production. Linc00632 targeted miR-498 and negatively regulated its expression. MiR-498 targeted IL1RN and inhibition of miR-498 suppressed IL-13-induced GM-CSF, eotaxin, and MUC5AC expression. The regulation of IL-13-induced dysfunction of NECs by Linc00632 depended on miR-498. Linc00632 inhibited IL-13-induced GM-CSF, eotaxin, and MUAC5AC production in IL-13-treated NECs by targeting miR-498.
... However, when patients do consult, GPs can be dismissive or underestimate the impact of the symptoms. A study of 100 physicians in the USA similarly found that ~30% underestimated the impact of allergic rhinitis on patients' ability to work, 17 although it could not be established whether this affected treatment decisions. ...
Objectives
To explore patient views and perspectives of current management of chronic rhinosinusitis (CRS) in primary and secondary care.
Design
Semistructured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic RhinOsinusitis).
Setting
Primary care and secondary care ear, nose and throat outpatient clinics in the UK.
Participants
Twenty-five patients consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis.
Results
CRS has a significant impact on patients’ quality of life, affecting their ability to work effectively, their social interactions and daily living. Patients seek help when symptoms become unmanageable, but can become frustrated with the primary care system with difficulties obtaining an appointment, and lack of continuity of care. Patients perceive that general practitioners can be dismissive of CRS symptoms, and patients often prioritise other concerns when they consult. Health system barriers and poor communication can result in delays in accessing appropriate treatment and referral. Adherence to intranasal steroids is a problem and patients are uncertain about correct technique. Nasal irrigation can be time-consuming and difficult for patients to use. Secondary care consultations can appear rushed, and patients would like specialists to take a more ‘holistic’ approach to their management. Surgery is often considered a temporary solution, appropriate when medical options have been explored.
Conclusions
Patients are frustrated with the management of their CRS, and poor communication can result in delays in receiving appropriate treatment and timely referral. Patients seek better understanding of their condition and guidance to support treatments decisions in light of uncertainties around the different medical and surgical options. Better coordinated care between general practice and specialist settings and consistency of advice has the potential to increase patient satisfaction and improve outcomes.
... The importance of this criterion was appreciated by the bodies which formulate recommendations regarding the treatment of patients with both AR (ARIA 2010) and urtica-physical functioning, uncontrolled AR can significantly change the quality of life of patients, as well as their performance and learning ability [37][38][39]. The intensity of symptoms does not necessarily correlate with the degree of impairment of quality of life, so the choice of effective treatment requires an individual approach to each patient [39][40][41]. ...
Allergic rhinitis (AR) is the most common form of allergy, which - as epidemiological research has shown - applies to nearly 25% of the population. AR significantly affects the quality of life of the patient, and the more severe the disease, the greater the risk of developing bronchial asthma. One of the factors affecting the severity of symptoms and the degree of their control is air pollution. In some patients, despite proper treatment, persistence or only partial remission of symptoms (uncontrolled allergic rhinitis) is observed. This can lead to an increase in comorbidities - inflammation of the paranasal sinuses, otitis media and asthma - both in children and in adults. The treatment of allergic rhinitis, in accordance with the standards, consists in: education of the patient, elimination of the allergen from the environment and factors intensifying the course of the disease, selection of proper pharmacotherapy and specific allergen immunotherapy. Many factors influence the selection of the antihistamine used, e.g., the opportunity of safe increase of the dosage.
... [26][27][28] While this has been explored in the related field of asthma, in which patient medication self-management has been shown to play a significant role in overall treatment success; 29 our understanding of medication self management in AR is limited. While large-scale studies in Europe and the Americas have provided us with detailed information about patient medication preferences along with the co-existence of bothersome symptoms and loss of productivity, 3,[22][23][24][25]30,31 they fail to explain why patients chose to self-medicate in the way they do, despite often living with suboptimally managed AR. ...
Allergic rhinitis (AR) is sub-optimally managed in the community and is responsible for a significant health and economic burden. Uncontrolled AR increases the risk of poorly controlled asthma and presents an increased susceptibility to thunderstorm asthma. With the availability of treatments over-the-counter, bypassing the health care professional (HCP), the role of the patient is paramount. Research on the role of the patient in AR management in the current environment is limited. This study aims to explore the patient perspective of AR management and understand why it is sub-optimally managed in the community. Patient perspectives of AR management were explored utilizing a qualitative, phenomenological approach. Adults with AR were included in the study and interviewed. Transcripts were analyzed for recurrent themes and emergent concepts. Forty-seven participants with AR were interviewed about their experiences. Patient reports of delayed diagnosis, treatment fatigue and confidence in the ability to manage their AR themselves, heavily influenced their management preferences. Patients also described barriers associated with AR management including financial expense as well as being mistaken for having an infectious disease. Patients described examples of the impact on their quality of life caused by their AR, yet they strongly believed they could manage it themselves. This belief that AR is a condition that should be entirely self-managed, contributes to its burden. It amplifies patients' separation from HCPs and having access to guidelines aimed at optimizing their AR control.
... 6 Of the 2, PAR is generally considered more difficult to treat and, despite best care, patients often remain symptomatic. 10 Patients with PAR also have an increased risk of developing asthma, and epidemiological evidence suggests that comorbid AR is a marker for more difficult-to-control or severe asthma. 8,[11][12][13] The cooccurrence of the 2 conditions is also associated with increased asthma-related hospitalizations, impaired quality of life, and higher total annual medical costs. ...
Background:
Dupilumab, an anti-IL-4Rα monoclonal antibody, inhibits IL-4/IL-13 signaling, key drivers of type 2/Th2 immune diseases (e.g. atopic/allergic disease). In a pivotal, phase 2b study (NCT01854047), dupilumab reduced severe exacerbations, improved lung function and quality of life, and was generally well tolerated in patients with uncontrolled persistent asthma despite using medium-to-high-dose inhaled corticosteroids plus long-acting β2-agonists.
Objective:
To examine dupilumab's effect on the 22-item Sino-Nasal Outcome Test (SNOT-22) total score and its allergic rhinitis (AR)-associated items in asthma patients with comorbid perennial allergic rhinitis (PAR).
Methods:
Post-hoc analysis reporting data from the phase 2b study for the 200 and 300 mg q2w doses under investigation in phase 3 (NCT02414854). PAR was defined at study entry as a specific response to typical perennial antigens (immunoglobulin E [IgE]≥0.35 Ku/L).
Results:
Overall, 241 (61%) patients had PAR. In asthma patients with PAR, dupilumab 300 mg q2w vs placebo significantly improved SNOT-22 total score (LS mean difference -5.98 [95% CI, -10.45, -1.51], P = 0.009) and all 4 AR-associated symptoms evaluated (nasal blockage: -0.60 [-0.96, -0.25]; runny nose: -0.67 [-1.04, -0.31]; sneezing: -0.55 [-0.89, -0.21]; post-nasal discharge: -0.49 [-0.83, -0.16]; all P < 0.01]. Dupilumab 200 mg q2w demonstrated numerical, but not statistically significant decreases in SNOT-22 total score (-1.82 [-6.46, 2.83], P = 0.443 vs placebo] and in each AR-associated symptom. In non-PAR patients, no differences were observed for these measures vs placebo.
Conclusion:
Dupilumab 300 mg q2w significantly improved AR-associated nasal symptoms in patients with uncontrolled persistent asthma and comorbid PAR.
... Recently, several largescale surveys (e.g., Allergies in American Survey, Allergies in Latin America, and Allergies in Asia Pacific) have attempted to further clarify the prevalence of diagnosed AR, its impact on QOL, and current treatment gaps in several regions of the world. 8,[20][21][22][23] Unfortunately, no such studies or surveys have addressed the true burden of AR in the Middle East. Therefore, the Allergies in Middle East Survey (AIMES) was undertaken in an attempt to further clarify the prevalence of AR, its impact on QOL, existing treatment paradigms and treatment gaps associated with AR, and the medications currently used to treat this disease. ...
Background:
Chronic respiratory diseases such as asthma and allergic rhinitis (AR) are a major public health problem in developing countries including those in the Middle East. However, to date, there is a paucity of information related to physician-diagnosed AR in this region. The Allergies in Middle East Survey was undertaken to help clarify and broaden the understanding of physician-diagnosed AR across Egypt, Iran, Lebanon, Saudi Arabia, and the United Arab Emirates. The survey explores the frequency of physician-diagnosed AR, prevalence and types of associated symptoms, the impact on quality of life (QOL), current treatment practices, and therapy expectations.
Methods:
In total, 7411 households in five countries (Egypt, Lebanon, Saudi Arabia, Iran and the United Arab Emirates) were screened to identify individuals that were ≥4 years old with a physician diagnosis of AR and either symptoms and/or treatment in the past 12 months. A total of 501 respondents from the five countries completed the survey. Standardized questionnaires were used to make comparisons across the regions; however, the data collection procedures were tailored for each country. The sample was probability based to ensure valid statistical inference to the population.
Results:
Ten percent of the Middle East population surveyed had a physician diagnosis of AR, with 65% of respondents stating that their allergies were intermittent in nature. An otolaryngologist or allergist diagnosed the majority of the individuals surveyed. Runny nose, nasal and throat itching, postnasal drip, and nasal congestion or stuffed up nose were the most common and bothersome symptoms of AR. The majority of survey participants (58% of the overall survey population) with AR reported that the condition had an impact on their daily private and professional life. Seventy-two percent of adults reported that their AR symptoms limited their work/school activities and 35% reported that their AR interfered with and caused them to miss work or school within the past 12 months. One factor, in addition to the outward AR symptoms, that could have contributed to these function impairments may have been sleep disturbances. Although a secondary symptom to AR, sleep disturbances (difficulty getting to sleep, waking up during the night or lack of a good night's sleep) were shown in this survey to be extremely troubling in ∼15% of AR sufferers. In the past year >90% of patients reported taking a medication of any type for their AR, with nearly a 4:1 ratio of patients taking a prescription medication versus an over-the-counter (OTC) medication in the past 4 weeks. Over 75% of survey respondents reported taking an intranasal corticosteroid (INCS) in the last 4 weeks and the satisfaction rate of INCS medications was similar to that reported for OTC medications. The most common reasons cited for dissatisfaction with INCS medications were inadequate effectiveness, bothersome side effects (e.g., unpleasant taste and retrograde drainage into the pharynx), decreased effectiveness with chronic use, and failure to provide 24-hour relief.
Conclusion:
These data show that AR is common in the Middle East region as elsewhere in the world. Many patients with AR in Middle East region suffer from their symptoms (e.g., runny nose, nasal itching, nasal congestion, postnasal drip, and other symptoms) on all or most days during the times of the year that their allergies are worst. These symptoms have been shown to reduce QOL and performance at work/school to a significant degree. Additionally, the survey data underscore a considerable treatment gap with current therapies for AR and that many AR patients still have not found adequate effectiveness with currently available medications. Thus, through identification of disease impact on the Middle East population and highlighting treatment gaps, clinicians in the Middle East may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.
... eine gezielte, individuell auf den einzelnen Patienten zugeschnittene Therapieplanung gelegt werden. Dies erfordert vom Therapeuten jedoch eine eingehende Auseinandersetzung mit dem Krankheitserleben und den Krankheitsvorstellungen jedes einzelnen Patienten.Prinzipiell zeigte sich für alle untersuchten Lebensbereiche, dass sich in dieser Studie prozentuell weitaus mehr Patienten beeinträchtigt fühlen als beispielsweise beiScadding et al. (2000). Einerseits könnte dies an den unterschiedlichen Messinstrumenten liegen, andererseits spielen hier sicherlich auch Unterschiede in der Stichprobenzusammensetzung eine Rolle. ...
Zusammenfassung Auf der Grundlage eines biopsychosozialen Verständnisses von Krankheit und Gesundheit sollten verschiedene Aspekte des subjekti-ven Krankheitserlebens von Patienten mit chronischen Nasenbe-schwerden untersucht und in Bezug zu medizinischen Befunden betrachtet werden. 66 Personen mit chronisch behinderter Nasenat-mung, die in Behandlung eines HNO-Arztes stehen, machten Anga-ben zu ihrer Symptomwahrnehmung, ihrem persönlichen Umgang mit den Nasenbeschwerden sowie den dadurch erlebten Beeinträchti-gungen. Des weiteren wurden ihre subjektiven Theorien zur Krank-heitsverursachung (Patiententheoriefragebogen, PATEF), das Aus-maß der Somatisierung und die Unsicherheit im Sozialkontakt (Symptom-Checkliste, SCL-90-R) erfasst. In Beruf, Freizeitgestal-tung und Sozialkontakt fühlen sich jeweils etwa 40% der Befragten durch die Nasenbeschwerden beeinträchtigt. 36% beurteilen alle bis-her in Auseinandersetzung mit den Symptomen unternommenen Maßnahmen als nicht oder kaum hilfreich. Die untersuchten Patienten mit chronisch behinderter Nasenatmung haben eine mit anderen Krankheitsgruppen vergleichbar stark ausgeprägte Tendenz krank-heitsbezogene Ursachentheorien auszubilden, wobei sie neben schäd-lichen Umwelteinflüssen und ihrer körperlichen Konstitution vor allem ihr eigenes ungünstiges Gesundheitsverhalten für die Auslö-sung der Symptome verantwortlich machen. Patienten mit unter-schiedlich stark ausgeprägten klinischen Befunden unterscheiden sich in der Beurteilung der erhobenen subjektiven Parameter nicht signifi-kant voneinander. Allerdings übt die Somatisierung einen modulie-renden Einfluss auf die Beziehung zwischen objektivem und subjek-tivem Schweregrad aus. Den Ergebnissen der vorliegenden klinischen Untersuchung zufolge erscheint ein biopsychosoziales Verständnis und in dessen Folge eine verstärkte Berücksichtigung von psycho-sozialen Aspekten in Diagnostik und Therapie chronischer Nasen-beschwerden sinnvoll. Schlüsselwörter Chronische Nasenbeschwerden, biopsychosoziales Krankheitsmo-dell, subjektive Krankheitstheorien, Ursachenzuschreibungen, Krank-heitserleben. Abstract Chronic nasal obstruction – a bio-psycho-social understanding of nasal symptoms Based on a biopsychosocial understanding of illness and health, this study dealt with subjective illness experience and its relationship to clinical findings among patients with chronic nasal symptoms. 66 ENT outpatients suffering from chronic nasal obstruction gave information about their symptom perception, illness behaviour and impairment in life caused by the nasal symptoms. Furthermore causal illness attributions (PATEF), somatization and interpersonal sensitivity (SCL-90-R) were investigated. Nasal symptoms affect working life, recreational activities and social life in approximately 40% of patients , respectively. 36% consider all action taken in relation to the disease as " not " or " hardly " helpful. The extent of causal illness theories of subjects with chronic nasal obstruction is comparable to that of patients with other diseases. Beside environmental influences and physical constitution the subjects of this study consider their own harmful behaviour to be mainly responsible for their nasal disease. Concerning symptom perception, no significant difference is found in patients with different clinical findings. Tendency of somatization has a modulating effect on the relation between objective and subjective symptom severity. According to the results of this study, adequate consideration of psychosocial aspects in diagnostical and therapeutical procedures of chronic nasal diseases seems to be reasonable.
... When symptomatic, patients feel the impact of AR on all areas of their daily lives, at home, socially and at work/school. [5][6][7] Indeed, in Strengths and limitations of this study ▪ Sufficiently large patient numbers to draw general conclusion on use of MP-AzeFlu in routine clinical practice in the UK. ▪ Low amount of missing data. ...
Objective
The aims of this study were (1) to characterise the type of patient prescribed MP-AzeFlu (Dymista, a novel formulation of azelastine hydrochloride, fluticasone propionate and excipients in a single spray) in real life in the UK and physicians' reasons for prescribing it and (2) to quantify the personal and societal burden of allergic rhinitis (AR) in the UK prior to MP-AzeFlu prescription.
Design, setting and participants
This multicentre, non-interventional study enrolled patients (n=193) with moderate-to-severe AR and acute symptoms who were eligible to receive treatment with MP-AzeFlu according to its licensed indications. Information was gathered on patient demographics, AR history and symptom severity, symptomatology and AR treatments in the previous calendar year (prior to MP-AzeFlu prescription). Physicians also recorded the number of previous AR visits, specific reasons for these visits and their reason for prescribing MP-AzeFlu.
Results
Most patients had seasonal AR either alone (10.4%) or in combination with perennial AR (35.2%), but many had AR of unknown origin (35.8%). Prior to MP-AzeFlu prescription, patients reported troublesome symptoms (78.2%) and sleep disturbance (64.8%), with congestion considered the most bothersome (54.4%) and ocular symptoms reported by 68.4% of patients. The most frequent reason for MP-AzeFlu prescription was that other therapies were not sufficient in the past (78.8%) or not sufficient to treat acute symptoms (16.1%). 79.3% of patients reported using ≥2 AR therapies in the past year. An average of 1.6 (SD 1.9) doctor visits due to AR were reported prior to MP-AzeFlu prescription.
Conclusions
In the UK, MP-AzeFlu was prescribed for individuals (≥12 years) with moderate/severe AR irrespective of (1) previous AR treatment (mono or multiple), (2) previous or likely treatment failure, (3) phenotype, (4) number of previous physician visits for AR and (5) for the relief of both acute symptoms and in anticipation of allergen exposure.
... Traditionally, allergy investigations have focused on nasal symptoms, but recent studies have highlighted the prevalence and significance of OS. Evidence suggests that OS are particularly prevalent in seasonal AR sufferers (37) who were sensitised to outdoor aeroallergens (9). Despite previous opinions, OS are not only common but also distressing for sufferers (36). ...
The aim of this study was to determine the frequency of ocular symptoms and compare the demographic and clinical characteristics in AR patients depending on sensitisation to various types of aeroallergens.
Allergic rhinitis is defined as an IgE-mediated inflammation of the lining of the nose that is characterized by nasal symptoms, including nasal congestion, sneezing, itching of nose and runny nose. Patients suffering from allergic rhinitis frequently experience ocular symptoms such as ocular redness, eye itching and tears. The frequency of ocular symptoms in our study population was 27,6%. No statistical significance was found in the mean ages of the patients who did or did not experience ocular symptoms p>0,05 (p=0,243). Our results indicated that there were no statistical differences (p>0,05) among the groups of allergic rhinitis patients based on experiencing nasal symptoms according to the types of aeroallergens. Our results indicated that there were significant experiences of ocular symptoms in patients who were sensitised to outdoor aeroallergens (p
... This finding represents one of the main drivers of the increasing spread of over-thecounter (OTC) medications for AR. Data for recent European and American surveys confirmed an increasing shift in the transfer of prescription AR products to OTC status, not only due to physicians' prescription but also as a consequence of the ready availability of these products, whose diffusion is constantly changing and not easily quantifiable [31,[35][36][37]. On the other side, the launch of novel AIT for treating moderate-to-severe AR over the forecast period is expected to start dominating the AR therapeutics space, given the emerging evidence for the cost-effectiveness of AIT over symptomatic drug treatment [38,39]. ...
Introduction:
Allergic rhinitis is a worldwide health problem, currently affecting up to 40% of the general population, and characterized by the following symptoms in a variable degree of severity and duration: nasal congestion/obstruction, rhinorrhea, itchy nose and/or eyes, and/or sneezing. General symptoms like fatigue, reduced quality of sleep, impaired concentration and reduced productivity, if left untreated, may significantly affect quality of life. In addition, of being associated to various comorbidities, allergic rhinitis is also an independent risk factor for the development and worsening of asthma. Perennial allergic rhinitis is caused by allergens present around the year. Areas covered: Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines currently recommend a stepwise therapeutic approach that combines patient education with specific allergen avoidance, symptomatic pharmacotherapy and allergen immunotherapy. The available treatment strategies provide suboptimal symptom relief in patients with moderate-to-severe disease who continue to experience symptoms while treated, even on multiple therapies. Expert opinion: New insights into current therapy have been provided with the development of new symptomatic drugs with improved pharmacokinetics and safety. However, the ultimate research goal is beyond symptomatic treatment, and is mainly directed at modifying the immune response to allergens and prevent the progression of allergic rhinitis towards asthma. In this direction, promising advances are expected in the fields of allergen immunotherapy and biological drugs, such as omalizumab. Finally, significant research efforts are also focused on the growing number of new specific molecular targets involved in the Th2 pathway inflammation of allergic diseases.
... The importance of this criterion was appreciated by the bodies which formulate recommendations regarding the treatment of patients with both AR (ARIA 2010) and urtica-physical functioning, uncontrolled AR can significantly change the quality of life of patients, as well as their performance and learning ability [37][38][39]. The intensity of symptoms does not necessarily correlate with the degree of impairment of quality of life, so the choice of effective treatment requires an individual approach to each patient [39][40][41]. ...
... TAYS:n potilaista osalla allerginen nuha oli todennäköisesti alihoidettu, kun tarkastellaan nenäoireisten (61,8 %) ja mahdollisesti oireisten (tieto kirjaamatta, 31,5 %) suurta osuutta ja lääkkeiden käyttöä. Sitä paitsi lääkityksen käyttö ei välttämättä poista oireita (20,28). ...
Background
Allergic rhinitis (AR) and asthma are nowadays
considered as manifestations of the same disease
entity. Most asthma patients have allergic rhinitis. This
study aimed to investigate the diagnosis and treatment
of AR in asthmatic school-aged children in paediatric
practice.
Methods
The study population consisted of a random sample
(n = 400) of 903 asthmatic children aged 7–15 years
who were followed up by a Tampere University
Hospital paediatrician over a defined study period
between 2000 and 2002. Two forms were used to collect
the data retrospectively from patient records.
Results
The patient records showed that 21.5% (95%CI
17.6–26.0%) of the patients were diagnosed with
allergic rhinitis. Rhinitis symptoms were present in
61.8% (95%CI 56.8–66.7%). 44.6% (95%CI 39.7–49.7%)
of the patients had not had a nasal examination.
Medication for allergy was used by 47% (95%CI
42.0–52.1%). Some of the patients whose nose had not
been examined or who had negative findings in the
nasal examination, used intranasal corticosteroids.
Conclusions
Allergic rhinitis in asthmatic school-aged children is
underdiagnosed and the principles of the treatment are
unclear. Proper diagnosis and recommended treatment
options should be emphasized in all health care
services.
... junctivitis, 17 which reported a score of 6.3. This suggests that ocular symptoms in patients with persistent allergic rhinoconjunctivitis tend to be less severe 18 and less prevalent than seasonal allergic rhinitis. 19 Additional studies on ocular symptoms and their relation to other atopies would be useful to understand the mech- anism of ocular allergies and its best option of treatment. ...
Allergic rhinoconjunctivitis denotes both nasal and ocular manifestation of allergy, which may be solely treated with intranasal steroid. This study compares the efficacy of mometasone furoate nasal spray (NS) and fluticasone furoate NS in treatment of allergic rhinoconjunctivitis. The secondary objective is to study the severity of baseline ocular symptoms in allergic rhinoconjunctivitis. Seventy-eight patients with allergic rhinoconjunctivitis were assessed subjectively and objectively using twice-daily symptom scores for nasal (reflective total nasal symptom score [rTNSS] and instantaneous TNSS [iTNSS]) and ocular (reflective total ocular symptom score [rTOSS] and instantaneous TOSS [iTOSS]) symptoms, rhinoconjunctivitis quality-of-life questionnaires (RQOLQs), and acoustic rhinometry. All measurements were taken at baseline and at 4 and 8 weeks of treatment. Sixty-three patients who were randomized into the mometasone furoate group (n = 36) and the fluticasone furoate group (n = 27) completed the study. Seventy-six percent of patients had mild ocular symptoms, 20.5% had moderate symptoms, and only 2.6% had severe symptoms at baseline based on the iTOSS; 65.1% had mild nasal symptoms and 3% had severe nasal symptoms. There was significant reduction in the symptom scores after 1 week (p < 0.05). Both groups had significant improvement in RQOLQ scores after 1 month, which further improved at 2 months (p < 0.05). The nasal dimensions also improved in both groups (p < 0.05) but there was no statistically significant difference between groups. Both mometasone furoate and fluticasone furoate are effective as single-modality treatment of allergic rhinoconjunctivitis. The majority of patients manifest mild ocular symptoms that may be solely treated with intranasal steroids.
Allergic rhinitis (AR) is a disease that is difficult to cure and accompanies the patient's life. Proinflammatory cytokines (GM-CSF and eotaxin) and MUC5AC are key mediators promoting AR progression. Herein, the function of lncRNA ZFAS1 in AR was investigated. Nasal epithelial cells (NECs) were subjected to 50 ng/mL IL-13 for 24 h to construct an AR cell model. The mRNA and protein expressions were assessed using qRT-PCR and western blot. The levels of GM-CSF, eotaxin, IL-1β, IL-6, TNF-α and MUC5AC in cell supernatant were examined by ELISA. The binding relationships between HDAC3, ZFAS1, miR-7-5p and SIRT1 were analysed using dual luciferase reporter or ChIP assays. Herein, our results displayed that ZFAS1 and SIRT1 were lowly expressed in AR, while miR-7-5p and HDAC3 were highly expressed. Functional experiments displayed that ZFAS1 overexpression suppressed IL-13-induced proinflammatory cytokines and mucin production in NECs. The highly expressed HDAC3 in AR inhibited ZFAS1 expression by binding with ZFAS1 promoter. In addition, our experiments revealed that ZFAS1 targeted miR-7-5p, and miR-7-5p targeted SIRT1. As expected, miR-7-5p overexpression or SIRT1 silencing abrogated ZFAS1 upregulation's repression on IL-13-induced proinflammatory cytokines and MUC5AC secretory levels in NECs. ZFAS1 suppressed proinflammatory cytokines, inflammatory cytokines, and MUC5AC secretory levels in AR by regulating the miR-7-5p/SIRT1 axis. Thus, our work suggested that ZFAS1 might serve as a novel target for AR treatment and prevention.
Background:
Allergic rhinitis induced by house dust mites (HDMs) is a highly prevalent but often underdiagnosed and undertreated/untreated chronic disease. It often has a negative impact on sleep, work, leisure activities, and health-related quality of life. Allergen immunotherapy is a proven, safe treatment for respiratory allergies.
Objective:
We sought to assess the efficacy and safety of a 300 index of reactivity (IR) sublingual tablet formulation of Dermatophagoides pteronyssinus:Dermatophagoides farinae 1:1 extract in adolescents (aged ≥12) and adults with moderate to severe HDM-induced allergic rhinitis.
Methods:
In a phase III, international, double-blind, placebo-controlled, randomized clinical trial, participants received approximately 12 months of treatment with placebo or the 300 IR tablet. The primary end point was the average total combined score during 4 weeks at the end of the treatment period.
Results:
A total of 1607 participants were randomized, and 1476 (including 555 [37.6%] with concomitant mild controlled asthma at inclusion) comprised the full analysis set. Over the primary evaluation period, the least squares mean average total combined score in the 300 IR group (3.62) was significantly lower (P < .0001) than in the placebo group (4.35), with a relative least squares mean difference of -16.9% (95% CI, -24.0% to -9.2%). All prespecified secondary end points were consistently improved in the 300 IR group, relative to placebo. The 300 IR tablet was generally well tolerated. Treatment-related adverse events (mainly mild or moderate local reactions) were reported for 51.0% of the patients in the 300 IR group and 14.9% in the placebo group.
Conclusions:
The 300 IR sublingual HDM tablet is an effective, safe treatment for HDM-induced allergic rhinitis.
Allergic rhinitis (AR) is among the most prevalent chronic conditions in children. As with many other atopic conditions, the rate of AR diagnosis in children is increasing. AR typically first occurs early in life, emerging with symptoms such as rhinorrhea, congestion, itching, and sneezing. Although previously classified as seasonal and perennial rhinitis according to the type of allergen triggering symptoms, recently the World Health Organization has developed guidelines that classify AR as either persistent or intermittent based on the persistence of symptoms. Mold, household dust, pollen, and pet dander are all considered typical allergens contributing to AR. AR can occur despite the absence of systemic immune sensitization as a result of entropy or localized IgE production in children. Perennial or seasonal AR is largely determined by geographic location and local antigen exposure. AR is highly prevalent among children, affecting 15% of 6-year-olds and 40% of 13-year-olds. Boys are more commonly affected than girls; gender distribution is equal in adulthood. Approximately 80% of patients that develop AR do so before the age of 20 years and the ocular symptoms of allergic conjunctivitis (AC) are frequently associated with AR. Twin studies suggest a significant genetic factor in AR, though no genes have been conclusively identified. In this chapter, allergic rhinitis in pediatric patients is discussed.
Background:
House dust mite (HDM) sublingual immunotherapy tablet (SLIT-tablet; MK-8237; Merck/ALK) has demonstrated beneficial effects on allergic rhinoconjunctivitis and asthma outcomes in European trials.
Objective:
This is the first trial to assess the efficacy/safety of HDM SLIT-tablets in North American subjects with HDM allergic rhinitis with/without conjunctivitis (AR/C).
Methods:
In this double-blinded, multicenter trial (NCT01700192), 1,482 subjects (aged ≥12 years) with HDM AR/C with or without asthma were randomized to daily SQ HDM SLIT-tablet (12 SQ-HDM dose) or placebo for up to ≈52 weeks. A rhinitis daily-symptom score (DSS, 4 nasal symptoms, maximum=12) of ≥6, or ≥5 with 1 symptom being severe, on 5 of 7 consecutive days before randomization was required. The primary endpoint was average total combined rhinitis score (TCRS), defined as rhinitis DSS plus rhinitis daily-medication score (DMS), during the last 8 treatment weeks.
Results:
12 SQ-HDM treatment improved TCRS 17% vs placebo (95% CI: 10%, 25%). Improvements vs placebo in the secondary endpoints average rhinitis DSS, rhinitis DMS, total combined rhinoconjunctivitis score, and visual analogue scale-assessed ARC symptoms were 16%, 18%, 17%, and 16%, respectively. All nominal P-values were <0.001 vs placebo except rhinitis DMS (P=0.15). No treatment-related AEs meeting the ICH definition of serious were reported; 1 non-serious treatment-related systemic allergic reaction occurred (assessed as moderate intensity) at first administration under medical supervision and was treated with epinephrine.
Conclusions:
In the first North American trial of a SLIT-tablet for HDM allergy, 12 SQ-HDM was well tolerated and improved HDM rhinitis symptoms in adults and adolescents.
• Objective: To provide an overview of the approach to diagnosis and management of allergic rhinitis. • Methods: Review of the literature. • Results: Allergic rhinitis affects 20% to 40% of the U.S. population and has a significant impact on patients, their families, and society. The diagnosis can often be ascertained from a history that points to a specific, often seasonal or environmental, trigger. Treatment is often begun without the aid of any testing and based on a diagnosis made on history and physical examination alone. The mainstays of first-line treatment are nonsedating oral antihistamines, nasal corticosteroids, and nasal antihistamine sprays. As an adjunct, mast cell stabilizing antihistamine eye drops may be used. First-line pharmacotherapy should be based on the nature and severity of the patient's symptoms. Allergy testing should be considered when a patient's symptoms are not controlled by routine medical therapies. • Conclusion: Allergy is a significant burden to society. A symptom-based approach to the pharmacologic treatment of allergic rhinitis will yield the most satisfactory control of the patient's major symptoms.
Allergic rhinitis is a common and often debilitating condition representing significant health-related quality-of-life (HRQoL) burdens, leading to detrimental effects on the physical, psychological and social aspects ofpatients' lives and on healthcare systems. Allergic rhinitis is regarded as a trivial disorder by many and consequently given a low priority by some healthcare providers; failure to identify, diagnose and manage the disease appropriately, coupled with non-adherence to treatment and undertreatment, all lead to a significant disease burden. These issues highlight the requirement for both patient education as to the benefits of treatment and the application of evidence-based guidelines for management by healthcare professionals. Older treatments are often inadequate or have undesired side effects. More recent treatments are emerging that have improved antihistamine effects and are well tolerated. An example is rupatadine, a histamine H1 receptor antagonist and platelet activating factor (PAF) receptor inhibitor, which provides rapid-onset symptom relief and extended clinical activity. In trials and in clinical use, rupatadine has shown similar efficacy to other antihistamines while demonstrating no cardiovascular, cognitive or psychomotor effects.
Allergic rhinitis is commonly seen in general practice. This article looks at diagnosis and management, and how health professionals can make a positive difference to the lives of people with allergic rhinitis
To explore the experience of CRS and its management from the perspective of patients with CRS. To our knowledge this is the first qualitative study exploring sinus disease.
Semi-structured qualitative interviews.
ENT outpatient clinic.
21 adult patients with CRS: 11 male, 10 female. Patients suffered from a range of types of CRS (including polyps and fungal disease) and differing durations of symptoms (1.5- 47 years). Participants were purposively selected. Thematic analysis was used.
Patient experience of CRS and its management.
Patients had concerns regarding management of their symptoms by both healthcare professionals and themselves, including delays to referral and repeated medications. They reported reduced quality of life and high financial and psychosocial costs associated with living with CRS.
Despite guidelines for CRS treatment, outcomes remain variable leading to dissatisfaction with treatment. Adherence to existing guidelines may result in fewer repeated consultations in primary care and earlier referrals to secondary care. This article is protected by copyright. All rights reserved.
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This article provides a summary of some of the issues associated with the prescribing of antihistamines for seasonal allergic rhinitis. There is a consideration of their pharmacological mode of action and a brief overview of sedating and non-sedating antihistamines. A pre-reading self assessment provides the opportunity for the reader to assess prior knowledge of this area. There is a discussion of some of the more important prescribing issues including adverse effects and drug interactions.
Allergic rhinitis is a common problem that affects around 20% of the UK population and is caused by the sensitization of the mucous membranes to allergens. This causes sneezing, itching, discharge and blockage of the nasal passages. It often co-exists with asthma and if it is not treated, it can cause poor asthma control. After a diagnosis is made, management may entail lifestyle changes and medication, which should be personalized to the patient. The choice of medication will vary according to the severity of the symptoms, the need for rapid relief and contraindications in pregnancy or breastfeeding. This article looks at diagnosis and management, and how health professionals can make a positive difference to the lives of people with allergic rhinitis.
Seasonal rhinoconjunctivitis affects around 20% of the population, explain Steve Holmes and Jane Scullion
Allergic rhinitis can impact on patients' quality of life, sleep, work and education, write Dr Steve Holmes and Jane Scullion
The estimated incidence of hay fever (seasonal allergic rhinitis) is 10-25% worldwide. Although it is considered by some to be a trivial complaint, this is not always the case, with some individuals affected severely, to the extent that their choice of career or summer activities is restricted. This article focuses on the current thinking on hay fever, its diagnosis, and its practical everyday management.
Stuart Wood evaluates what is known so far about the potential of NeoClarityn, a new antihistamine treatment for hay fever and other allergic symptoms.
Objective:
The aim of this analysis is to explore views of patients with chronic rhinosinusitis (CRS) about of the aetiology of their respiratory symptoms and the relationship between upper and lower respiratory symptoms.
Methods:
This study is part of a larger mixed methods study investigating the epidemiology of CRS, which comprises a questionnaire study of patients with CRS and controls and a qualitative study of 21 patients with CRS. Semi structured qualitative interviews were undertaken with these patients; 11 males and 10 females. Twelve patients had asthma. Patients were recruited with a tertiary outpatient rhinology clinic. Interviews were transcribed verbatim and analysed using thematic analysis, using Nvivo software (QSR International, Melbourne, Australia). Several important and recurring themes were highlighted.
Results:
Patients described many perceived triggering factors and an interaction between upper and lower respiratory tract symptoms. They felt that their symptoms could be managed more holistically.
Conclusions:
Concerns about triggers of respiratory symptoms and interactions between upper and lower respiratory symptoms are of significant concern to patients. These should be appropriately managed and acknowledged in formal treatment pathways, for example, through the use of combined ENT/respiratory clinics.
Background
Many asthmatic patients have coexisting allergic rhinitis (AR). This study aims to investigate the compliance of physicians with respiratory medicine specialty (PRMs) to Global Initiative for Asthma (GINA) and Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines during the management of their asthma-AR patients.Methods
This cross-sectional questionnaire study surveyed the diagnostic methods and treatment patterns for asthma-AR comorbidity by PRMs from 98 hospitals across China.ResultsPRMs reported an estimated prevalence of asthma-AR comorbidity of >30% at their clinics. PRMs with greater work experience and a higher professional title estimated treating a significantly higher proportion of patients with AR within the previous month (p = 0.002 and p < 0.001, respectively); they also estimated a higher incidence of patients with AR in the autumn (p < 0.001 and p < 0.001). A higher percentage of PRMs with ≥11 years work experience prescribed nasal steroids for AR as compared to those with 1 to 10 years experience (56.9% vs 44.7%, p = 0.002). A greater proportion of chief physicians used leukotriene modifiers and a lower proportion used antihistamine H1-receptor blockers for AR as compared to residents (resident vs assistant chief: 27.5% vs 11.6%, p = 0.002; and resident vs chief PRMs: 27.5% vs 9.5%, p = 0.001).ConclusionPRMs in China demonstrated an up-to-date comprehension of asthma management (>90%); however, knowledge gaps existed in their concepts of AR and asthma-AR comorbidity. Thus, further education is warranted for PRMs regarding the importance of AR in asthma patients, definitive diagnosis (allergy tests), classifications of AR, and treatment guidelines for the asthma-AR comorbidity.
Background:
300IR 5-grass pollen sublingual immunotherapy tablets have been approved for the treatment of allergic rhinitis (AR) with or without conjunctivitis in adults and children >5 years with grass pollen allergy. This study was designed to review data on nasal symptoms with 300IR 5-grass pollen sublingual tablets in adults and children.
Methods:
We reviewed data from four double-blind, placebo-controlled, randomized clinical trials. Two groups of patients who received a daily dose of either placebo or 300IR 5-grass pollen sublingual tablets starting 4 months before the expected start of the pollen season and continuing through the season were compared (analysis of covariance) for scores of sneezing, rhinorrhea, nasal pruritus, nasal congestion, total nasal symptom score (TNSS), and adult Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores.
Results:
Data for 266 children (one pediatric trial) and 1036 adults (three trials) were analyzed. Compared with the placebo groups, mean TNSS in the 300IR groups was lower by 22% in children and 19-36% in adults. Among the four nasal symptoms, the lowest scores relative to placebo were for nasal congestion in children (31%) and adults (43%). Mean adult RQLQ scores were 21-31% lower in the 300IR group than in the placebo group.
Conclusion:
Allergen immunotherapy with 300IR 5-grass pollen sublingual tablets was consistently associated with AR symptom relief in adults and children and provided a clinically meaningful improvement in quality of life.
According to the Federal Institution of Health Insurance, ENT doctors perform more skin prick tests for the diagnosis of allergic rhinitis (AR) than other medical specialties in Belgium. However, immunotherapy (IT) is not practiced by all. This study aims to obtain insight into IT practice by ENT doctors, the type of IT performed and the reasons not to perform IT.
A questionnaire was sent to all registered ENT doctors of Belgium (n=648), involving questions on type and duration of ENT practice, geography and gender. In addition, the questionnaire informed about diagnosis of AR, indication for IT, type of IT performed, and reasons not to perform IT and referral pattern.
The response rate among ENT doctors was 54%, with 7% of responders being excluded as they do not diagnose AR. 81% of Belgian ENT doctors make the indication for IT in AR patients, with 19% neglecting the indication for IT in AR patients. The two main reasons for not indicating IT are lack of expertise and the perception of high costs associated with IT. 70% of ENT specialists are practicing IT themselves, with sublingual IT being mostly performed. Interestingly, IT is mostly frequently performed by those ENT doctors with long-standing ENT practice, in private practice and in Wallonia.
Despite the high prevalence of AR in ENT practice, IT is most frequently performed by ENT doctors with longstanding practice, working in private practice and/or in the French speaking part of Belgium. Among the different types of IT, sublingual IT is the most frequently performed means of IT by ENT doctors.
Asthma is a chronic disease in which social life is altered. The importance of restrictions on social life may be greater in severe asthma or when symptoms are not adequately controlled. General scales of quality-of-life (QOL) may be used to detect the importance of social life impairment, but it is not yet known whether the scores of such QOL measures are reliable and valid in asthmatic patients. A study was carried out in 252 patients with asthma of variable severity (FEV1 ranging from 25 to 131% of predicted) to assess the validity of a general QOL scale, the first French version of the SF-36 health status questionnaire (SF-36). This is based on 36 items selected to represent nine health concepts (physical, social, and role functioning; mental health; health perceptions; energy or fatigue; pain; and general health). All nine SF-36 category scores were highly significantly correlated with the severity of asthma assessed by the clinical score of Aas (p < 0.0007 to p < 0.0001). Eight SF-36 category scores were highly significantly correlated with FEV1 (p < 0.003 to p < 0.0001). A high internal reliability of SF-36 was found using the alpha coefficient of Cronbach (0.91 for the whole questionnaire). The SF-36 questionnaire is valid and reliable in asthma and can therefore be used to examine QOL in asthmatic and nonasthmatic patients and to determine to what extent asthma impairs social life.
To determine whether intranasal corticosteroids are superior to oral H1 receptor antagonists (antihistamines) in the treatment of allergic rhinitis.
Meta-analysis of randomised controlled trials comparing intranasal corticosteroids with oral antihistamines.
Randomised controlled trials conducted worldwide and published between 1966 and 1997.
2267 subjects with allergic rhinitis in 16 randomised controlled trials.
Nasal blockage, nasal discharge, sneezing, nasal itch, postnasal drip, nasal discomfort, total nasal symptoms, nasal resistance, and eye symptoms and global ratings. Outcomes measured on different scales were combined to determine pooled odds ratios (categorical outcomes) or standardised mean differences (continuous outcomes). Assessment of heterogeneity between studies, and subgroup analyses of eye symptoms, were undertaken.
Intranasal corticosteroids produced significantly greater relief than oral antihistamines of nasal blockage (standardised mean difference 0.63, 95% confidence interval - 0.73 to - 0.53), nasal discharge (-0.5, - 0.6 to - 0.4), sneezing (- 0.49, - 0.59 to - 0.39), nasal itch (- 0.38,- 0.49 to - 0.21), postnasal drip (- 0.24,- 0.42 to - 0.06), and total nasal symptoms (- 0.42,- 0.53 to - 0.32), and global ratings gave an odds ratio for deterioration of symptoms of 0.26 (0.08 to 0.8). There were no significant differences between treatments for nasal discomfort, nasal resistance, or eye symptoms. The effects on sneezing, total nasal symptoms, and eye symptoms were significantly heterogeneous between studies. Other combined outcomes were homogeneous between studies. Subgroup analysis of the outcome of eye symptoms suggested that the duration of assessment (averaged mean score over the study period versus mean score at end of study period) might have accounted for the heterogeneity.
The results of this systematic review, together with data on safety and cost effectiveness, support the use of intranasal corticosteroids over oral antihistamines as first line treatment for allergic rhinitis.
Rhinitis falls into three main groups: allergic, infective and a third group which is poorly understood and amorphous. Allergic rhinitis may be seasonal (e.g. pollinosis), or perennial (e.g. house dust mite allergy). Acute infective rhinitis is usually viral and quickly self-limiting. Secondary bacterial infection may occur, and at times this may lead to severe acute sinusitis with a potential for serious orbital and intracranial complications. 'Vasomotor rhinitis' has been used to describe the third group, but the mechanisms involved are not fully understood. This condition is usually multifactorial, and precise determination of any one aetiology is impracticable and often impossible. These agents include dietary, hormonal, environmental and emotional factors. Diagnosis depends on history and examination, together with special investigations that will vary according to the patient's symptoms. Skin prick tests remain a simple and useful investigation for allergy. Blood tests for specific and total immunoglobulin E (IgE) and other immunoglobulin levels may be indicated. Nasal mucociliary clearance may be investigated using the saccharin clearance test and nasal mucosa brushed for ciliary beat frequency. Nasal smears can also be helpful. Nasal endoscopy allows accurate assessment of disease and anatomical abnormalities. Plain X-rays of the sinuses can be misleading, particularly when assessing the anatomy and pathology of the ethmoids and ostiomeatal complex. It is this area, however, which is of most importance in terms of drainage and aeration of the maxillary, frontal, anterior and middle ethmoidal sinuses. Computed tomographic (CT) scanning of the sinuses in the coronal plane provides excellent visualization of this area.
Background:
A clinical test that could inform the clinician about the severity of a patient's nasal symptoms and health-related quality of life (QOL) would be very useful.
Objective:
We attempted to determine whether, in patients with perennial allergic rhinitis, nasal challenge with histamine could be used to estimate daily symptoms and QOL.
Methods:
Forty-eight patients with perennial allergic rhinitis were challenged with histamine to determine nasal hyperreactivity. Nasal response was monitored by the number of sneezes, the amount of secretion, and a symptom score. Daily nasal symptoms were recorded during the 2 preceding weeks. Patients also completed a rhinitis QOL questionnaire.
Results:
Responsiveness to histamine and total daily nasal symptoms were moderately correlated (r = 0.51, p = 0.001). Comparison of total daily nasal symptoms with the overall QOL score showed a moderate correlation (r = 0.59, p < 0.001). Nasal response to histamine and overall QOL score were also correlated (r = 0.43, p = 0.002). However, overall QOL and daily nasal symptoms could be predicted by wide 95% confidence intervals only for each decade of nasal responsiveness to histamine (expressed as a composite symptom score).
Conclusion:
In patients with perennial allergic rhinitis nasal hyperreactivity as determined by histamine challenge, QOL, and daily nasal symptoms are moderately correlated. Therefore nasal histamine challenge can be used as a tool for estimating the severity of daily nasal symptoms and QOL, although it cannot predict nasal symptoms and QOL very accurately.
Seasonal allergic rhinitis is often regarded as a trivial condition which patients should treat themselves. However, a significant proportion of sufferers are not fully controlled on standard hay fever medication, either because they do not use it properly or because their symptoms are resistant to standard therapy. The latter group may be suitable for allergen immunotherapy, which was once widely available in UK general practice but is now only available through specialist centres.
To describe the symptom control of patients with hay fever, to assess concordance with prescribed medication, and to estimate the number of patients who may benefit from referral for allergen immunotherapy.
General practices in Hampshire and Dorset, UK.
Survey of adult hay fever sufferers prescribed a non-sedating antihistamine and nasal steroid spray by their general practitioner. A postal questionnaire was sent to all eligible patients aged 16-64 registered with 16 general practices. Self-assessment of symptom control and reported compliance with medication were used to identify those patients who were suboptimally controlled and might therefore benefit from immunotherapy.
Eight hundred and forty-six out of 62500 registered patients aged 16-64 (1.4%) were receiving both drugs, and responses were received from 627 (74.1%); 526 of these met the full entry criteria. One hundred and forty-two patients (27.0%) were using both types of drug regularly. Of the 142 patients using optimum pharmacotherapy, 54 (38.0%) reported good control of their hay fever symptoms. The remaining 62.0% experienced troublesome residual symptoms and described symptom control as partial or poor. Among those using suboptimal pharmacotherapy, 181/376 (48.1%) reported good control.
Many patients are using treatment inappropriately. Current guidelines need to be applied better but there is also a significant burden of residual symptoms, even among those receiving current optimal therapy. This indicates a need for patients with severe summer hay fever to receive specialist assessment.
Drug therapy for allergic rhinitis is used either to prevent symptoms from occurring by short-circuiting the reaction and thus inhibiting the production of chemical mediators or to control symptoms after the target organs have been stimulated by these mediators. Antihistamines, the mainstay treatment of allergic rhinitis, are H1-receptor antagonists that bind competitively to histamine receptors. The older, classic antihistamines are effective in treating the symptoms of allergic rhinitis, but most are sedating because they cross the blood-brain barrier. They also have anticholinergic activity, which further restricts their use. The new, nonsedating antihistamines have overcome most of these limitations, and because they are long-acting, they require fewer daily dosages. Many still under development are quite potent and may be used for indications other than allergic rhinitis. Decongestants, sympathomimetic amines, are available both orally and topically as either short- or long-acting preparations. Topical decongestants should be used only for a short time to prevent rebound and ensuring overusage. These drugs interact with numerous antihypertensive medications and tricyclic antidepressants. Often combined with antihistamines, decongestants help offset their sedative effect.
Little is known about the epidemiology of rhinitis, particularly the perennial and non-allergic forms. The aim of this study was to compare the symptoms, atopic state, and medical history of individuals with seasonal and perennial rhinitis.
Of 7702 adults aged 16-65 years registered with a London general practice, 2969 (30%) were screened by postal questionnaire. Samples of 113 subjects without rhinitis, 51 with seasonal symptoms alone, 128 with perennial symptoms and seasonal exacerbations were then interviewed. Atopic and non-atopic subjects were distinguished by skinprick testing with five common allergens.
The estimated minimum prevalence of rhinitis was 24%: 3% had seasonal symptoms only, of whom 78% were atopic; 13% had perennial symptoms only, of whom 50% were atopic; and 8% had perennial symptoms with seasonal exacerbations, of whom 68% were atopic. Seasonal rhinitis was characterised by sneezing, itching, and a high prevalence of diurnal variation in symptoms. The most common provoking factors were dust, pollens, and infections. By comparison, perennial rhinitis was characterised by a higher prevalence of nasal blockage and catarrh, and a lower prevalence of diurnal variation and provocation by pollen. There were no significant differences among the groups in the sociodemographic characteristics examined. Subjects with seasonal rhinitis were more likely to be atopic and to have eczema and a family history of hayfever than those without rhinitis. Those with perennial rhinitis were more likely to have past or current eczema or migraine, be wheezy or labelled asthmatic, or have a family history of nose trouble other than hayfever. Subjects with both seasonal and perennial symptoms presented an intermediate clinical picture.
Seasonal and perennial rhinitis differ in their atopic state, clinical presentation, and medical history. The extent to which these differences are genetically or environmentally determined requires further investigation.
The objective of this study was to develop and test a health-related quality of life questionnaire for clinical trials in rhinoconjunctivitis. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was developed by asking patients to identify areas of their lives affected by rhinoconjunctivitis. The resultant RQLQ was tested for reproducibility, responsiveness and validity in a randomized, double-blind trial of regular versus 'as required' aqueous beclomethasone dipropionate (BDP) nasal spray in ragweed pollen-induced rhinoconjunctivitis. Eighty-five patients from previous rhinoconjunctivitis studies participated in the developmental survey. Sixty ragweed-sensitive patients, from previous trials and media notices, were enrolled in the clinical trial. Aqueous BDP (800 micrograms) nasal spray was administered regularly or 'as required' throughout the ragweed pollen season. The survey revealed that, in addition to local symptoms of rhinoconjunctivitis, patients experienced impairment of quality of life through systemic symptoms, sleep disturbance, practical problems, activity limitations and emotional problems. The RQLQ includes 28 questions related to these dimensions. Repeated administration of the RQLQ demonstrated good reproducibility. During the clinical trial, the RQLQ proved responsive in its ability to distinguish between regular and 'as required' medication use. Validity was shown by moderate to strong relations between changes in symptom diary scores and changes in RQLQ scores. In conclusion the RQLQ is likely to prove useful as a measure of health-related quality of life in clinical trials in both rhinoconjunctivitis and rhinitis.
The computer records of Swedish conscript examinations in 1971 and 1981 were analysed regarding the prevalence of asthma and allergic rhinitis. The material comprised approximately 55,000 18-year-old males in each cohort. During the 10-year period the prevalence of asthma increased from 1.9 to 2.8% and of allergic rhinitis from 4.4 to 8.4%. The prevalence of allergic rhinitis was already higher in the northern than in the southern part of the country in 1971. The increase in both diseases was higher in the northern parts of Sweden, giving double prevalence figures in the northern part of the country compared to the southern part in 1981. The distribution of the prevalence was similar to the temperature pattern in the country, the higher prevalence being associated with a colder outdoor climate. Both diseases were more prevalent in urban than in rural areas.
Both first-generation and second-generation antihistamines effectively reduce symptoms of sneezing, rhinorrhea, and nasal pruritus in individuals with allergic disease. These agents act as competitive inhibitors of histamine (a principal mediator of the allergic response) at various target-organ sites. Although the classic, first-generation antihistamines are unable to halt the allergic reaction once it has begun, emerging evidence has suggested that newer, second-generation agents may interfere with the release of inflammatory mediators from mast cells or may inhibit eosinophil chemotaxis. These effects may confer additional clinical benefit. Also, the second-generation agents produce fewer adverse reactions, including a marked reduction in sedation. Contrary to previous recommendations, recent findings have suggested that antihistamines may not necessarily be contraindicated in patients who have both asthma and allergic rhinitis. A greater understanding of the mechanisms of action and clinical effects of both older-generation and newer-generation antihistamines should help define optimal therapeutic strategies in the future.
Perennial allergic rhinitis may impair social life. General scales of quality of life (QOL) are used to detect the importance of social life impairment, but the reliability and validity of QOL measures should be tested in patients with perennial allergic rhinitis. The extent to which QOL scores differ in patients with rhinitis and healthy subjects is unknown.
A cross-sectional study was carried out in 111 patients with moderate to severe perennial allergic rhinitis and 116 healthy subjects to assess the validity of a general QOL scale, the SF-36 Health Status Questionnaire. This scale is based on 36 items selected to represent nine health concepts (dimensions). The internal reliability of each dimension of the questionnaire was examined. The differences in QOL scores between patients with rhinitis and healthy subjects were studied.
Most QOL scores were highly reliable. There was a significant impairment in eight of nine QOL dimensions in patients with perennial allergic rhinitis in comparison with healthy subjects.
The SF-36 Health Status Questionnaire allows discrimination between patients with perennial allergic rhinitis and healthy subjects.
The objectives of the study were to evaluate impairment in quality of life in 12- to 17-year-old patients with seasonal allergic rhinoconjunctivitis and to develop and test a questionnaire suitable for evaluating change in quality of life during clinical trials.
Patients were asked to identify physical and emotional impairments associated with allergic rhinoconjunctivitis. The resultant questionnaire was tested for responsiveness and validity in a clinical trial in which fluticasone nasal spray and loratadine were compared for treatment of ragweed pollen-induced rhinoconjunctivitis. Eighty-three patients, 12 to 17 years of age, with grass- or ragweed-induced hayfever participated in the instrument development phase. They were recruited for the study from an allergy clinic and local schools and recreational organizations. Two hundred forty patients with ragweed hayfever participated in the clinical trial and provided quality of life data.
The survey showed that in addition to local symptoms, patients experienced impairment of quality of life because of systemic symptoms, activity limitations, and emotional and practical problems. The resultant questionnaire has 25 items in six domains. In the clinical trial responsiveness was demonstrated by the questionnaire's ability to detect change over time and differences between treatments. Construct validity was demonstrated by moderate to strong relationships between changes in diary symptom scores and quality of life.
The items identified by 12- to 17-year-old patients were not identical to those previously identified by adults. This suggests that impairment of quality of life may not be the same in the two groups and that it is appropriate to have a questionnaire specifically designed for adolescent rhinoconjunctivitis clinical trials.
This multicentre, randomized, double-blind, parallel-group study was designed to compare the efficacy and tolerability of fluticasone propionate aqueous nasal spray 200 micrograms once daily (FPANS 200 micrograms od) with FPANS 200 micrograms twice daily (bd) in patients whose seasonal rhinitis symptoms were not completely controlled with FPANS 200 micrograms od. A total of 549 patients initially received FPANS 200 micrograms od during the open-treatment phase of the study. After 2 weeks, 65% of patients had their symptoms well controlled by FPANS 200 micrograms od and continued with this treatment for a further 2 weeks. The remainder received either FPANS 200 micrograms od or FPANS 200 micrograms bd for a further 2 weeks. Efficacy was evaluated by the analysis of symptom-free days. In the uncontrolled group, there was a significant increase in the percentage of symptom-free days in the FPANS 200 micrograms bd group over the FPANS 200 micrograms od group for nasal blockage on waking (P < 0.05) and nasal blockage during the day (P < 0.05). Similar trends were observed for sneezing, rhinorrhoea, nasal itching, and eye symptoms. There was a significant increase in the percentage of days with a symptom score of less than 2 in FPANS 200 micrograms bd group for nasal blockage during the day (P < 0.05). Adverse events were similar in nature and frequency in each treatment group. It is concluded that in the majority of patients symptoms of seasonal rhinitis are well controlled by FPANS 200 micrograms od. In the minority of patients whose symptoms are not adequately controlled by a once daily dose, FPANS 200 micrograms bd provides additional relief, particularly from nasal blockage.
Fluticasone propionate (FP) is a topical corticosteroid with minimal systemic activity. We examined safety and compared the efficacy of FP aqueous nasal spray, 200 micrograms every day with loratadine tablets, 10 mg by mouth every day in 240 adolescents with ragweed pollen-induced seasonal allergic rhinitis for 4 weeks in a randomized, double-blind, parallel-group study. Nasal and eye symptoms were recorded daily on a 4-point (0 to 3) scale. A higher percentage of symptom-free days was observed for nasal blockage on waking during treatment with FP (p < 0.0001). Significant results were also obtained for all other nasal symptoms when analyzed for both symptom-free days and symptom scores. No differences were found for eye irritation symptoms (p = 0.14). Morning and evening nasal peak inspiratory flow (PIF) was recorded daily by 57 subjects. FP treatment was associated wit significantly higher PIF values than loratadine both morning (p = 0.0051) and evening (p = 0.0036). A greater improvement over 4 weeks was observed for PIF morning values in the FP group (p = 0.008) but not for evening values (p = 0.358). Statistically significant correlations were found for nasal blockage and PIF in the morning (r = -0.54, p = 0.0001) and in the evening (r = -0.46, p = 0.008).
Patients with rhinitis are bothered both by the nasal symptoms themselves and by associated symptoms such as headache and fatigue. The combination can produce quite severe impairment of day-to-day physical, emotional, occupational, and social functioning and can cause emotional distress. This breadth of impairment of health-related quality of life in patients with rhinitis is often not recognized and is sometimes trivialized by some health care professionals. One of the aims of treating patients with rhinitis must be to ensure that all individual patient problems are recognized and treated appropriately. Several studies now show that correlations between conventional nasal symptom-severity diaries and health-related quality of life are only weak to moderate. Therefore, to get an overall picture of a patient's health status, it is essential to measure quality of life. Genetic health-status questionnaires are able to compare burden of illness across different medical conditions, but they are often not responsive enough to small but clinically important changes in patients' quality of life. As a result, we have seen the emergence of disease-specific instruments for rhinitis that have strong measurement properties and that are much more sensitive to these changes. Most clinical trials in rhinitis now include a measure of health-related quality of life as a primary outcome, and many clinicians are incorporating quality of life into routine clinical assessments.
The intranasal corticosteroid fluticasone propionate is an effective agent for the treatment of rhinitis, demonstrating potent local anti-inflammatory activity and little, if any, systemic activity. Intranasal fluticasone propionate has shown clinical efficacy similar to that of other intranasal corticosteroids, including beclomethasone (administered at up to a 2-fold higher dosage than fluticasone), budesonide, flunisolide and triamcinolone acetonide, and provides greater relief from nasal symptoms (including nasal blockage) than antihistamine agents and intranasal sodium cromoglycate. Its efficacy in the treatment of seasonal allergic rhinitis and perennial allergic and nonallergic rhinitis has been demonstrated in large well-controlled studies in which the drug maintained adequate control of symptoms when administered in a once daily dose of 200 micrograms. In addition, fluticasone propionate has shown similar efficacy to that of beclomethasone in the treatment of nasal polyps; however, its use in the postoperative setting requires further investigation. Intranasal fluticasone propionate is well tolerated in the majority of patients, the incidence of adverse events being similar to that seen with placebo. Pharmacoeconomic analyses indicate that intranasal fluticasone propionate is significantly more cost-effective than the antihistamines terfenadine and loratadine. Overall quality of life was improved to a similar extent by fluticasone propionate and beclomethasone. In conclusion, recent clinical experience has confirmed that intranasal fluticasone propionate is a convenient, effective and well tolerated alternative to other intranasal corticosteroids and antihistamines for the treatment of rhinitis when administered once daily.
Allergic rhinitis involves an early phase, largely mediated through mast cells, and a late phase which involves cellular infiltration and mediator release. In the early phase, mast cells release mediators as a result of antigen cross-linking adjacent immunoglobulin E molecules bound to mast cell surfaces. This results in an accumulation of histamine which gives rise to the characteristic symptoms of rhinitis--sneezing, itching, rhinorrhoea and congestion. The late phase of the allergic response (hours after challenge) involves infiltration of the nasal epithelium by eosinophils, basophils, monocytes and T-lymphocytes, which release leukotrienes, kinins, histamine and a host of other mediators. The most important part of the late-phase response is probably mediated via the production of cytokines (IL-4, IL-5, IL-6, IL-8, GM-CSF and RANTES) by mast cells, TH2 lymphocytes or epithelial cells. The infiltration of tissues by cells normally present only in the blood is brought about by the production of adhesion molecules, such as VCAM-1 and E-selectin, which cause circulating eosinophils, basophils and T-lymphocytes to adhere to endothelial cells before moving through the endothelium into the tissue (diapedesis). Neuronal reflexes also play a role in the allergic response, both by mediating local responses to mediators and possibly playing a part in the activation of T-lymphocytes. The allergic response has also been shown to be less intense in a hot, humid environment, and more marked in a cold, dry environment, possibly due to changes in osmolality of the nasal surface fluid. Similar factors may play a role in the aetiology of non-allergic rhinitis.
Many clinicians now recognize the importance of incorporating an assessment of health-related quality of life (HRQL) into their clinical studies and practice. Conventional clinical measures provide valuable information about the status of the affected organ system, but they rarely capture the functional impairments (physical, emotional, and social) that are important to the patients in their everyday lives. In order to obtain a complete picture of a patient's health status, both the conventional clinical indices and the patient's HRQL must be measured. Both adults and children with asthma and rhinitis are distressed by the symptoms, and they are limited in their day-to-day activities such as sports, work or school work, and participation in other activities with friends. In addition, both adults and children experience emotional strain as a result of both conditions. Disease-specific HRQL questionnaires have been developed and validated for both adults and children with asthma and rhinitis. These questionnaires have good measurement properties and validity and can be used in both clinical trials and clinical practice to assess the impact of the condition on a patient's life. Since one of the aims of treatment is to ensure that patients benefit from it, an essential component of clinical assessment should be an evaluation of HRQL.
Allergic rhinitis is a common condition in managed care populations. The direct medical cost of rhinitis exceeded 4 billion resulted from the exacerbation of other concomitant conditions, such as asthma or otitis media. Costs continued to increase in 1999; sales of prescription antihistamines and nasal steroids exceeded 1 billion, respectively. The indirect costs of allergic rhinitis include lost work productivity, reduced performance and learning, and increased workplace and traffic accidents. Rhinitis treatments include allergen avoidance, over-the-counter (OTC) sedating antihistamines, nonsedating antihistamines, nasal steroids, and immunotherapy. Allergen avoidance strategies for patients with asthma and rhinitis are ineffective or are of very limited benefit. Allergists criticize the use of OTC sedating antihistamines, which are associated with reduced learning and performance even when sedation does not occur. Evidence-based literature reviews of clinical trials have shown that nasal steroids are more effective than nonsedating antihistamines in the treatment of rhinitis. The most commonly prescribed nasal steroid, fluticasone, has been shown to be effective in treating rhinitis and in improving patients' quality of life. It is also more cost effective than the most commonly prescribed antihistamine, loratadine. Clinical trials have indicated that immunotherapy is expensive and of limited benefit. As these evidence-based findings are used to develop managed care treatment guidelines, nasal steroids are likely to be recommended as the first-line treatment for rhinitis, which should result in lower treatment costs and improved outcomes for patients with rhinitis.