Prevalence and rate of diagnosis of allergic rhinitis in Europe

Cost-effectiveness of specific subcutaneous immunotherapy in patients with allergic rhinitis and allergic asthma

BACKGROUND

Specific immunotherapy is the only potentially curative treatment in patients with allergic rhinitis and allergic asthma. Health economic evaluations on this treatment, particularly in a German context, are sparse.

OBJECTIVE

To evaluate the cost-effectiveness of specific subcutaneous immunotherapy (SCIT) in addition to symptomatic treatment (ST) compared with ST alone in a German health care setting.

METHODS

The analysis was performed as a health economic model calculation based on Markov models. In addition, we performed a concomitant expert board composed of allergy experts in pediatrics, dermatology, pneumology, and otolaryngology. The primary perspective of the study was societal. Additional sensitivity analyses were performed to prove our results for robustness.

RESULTS

The SCIT and ST combination was associated with annual cost savings of Euro140 per patient. After 10 years of disease duration, SCIT and ST reach the breakeven point. The overall incremental cost-effectiveness ratio (ICER) was Euro-19,787 per quality-adjusted life-year (QALY), with a range that depended on patient age (adults, Euro-22,196; adolescents, Euro-14,747; children, Euro-12,750). From a third-party payer's perspective, SCIT was associated with slightly additional costs. Thus, the resulting ICER was Euro8,308 per QALY for all patients.

CONCLUSIONS

Additional SCIT was associated with improved medical outcomes and cost savings compared with symptomatic treatment alone according to a societal perspective. Taking a European accepted ICER threshold of up to Euro50,000 per QALY into account, additional SCIT is considered clearly cost-effective compared with routine care in Germany. The degree of cost-effectiveness is strongly affected by costs related to SCIT and the target population receiving such treatment.

Geographical distribution of atopic rhinitis in the European Community Respiratory Health Survey I

BACKGROUND

No large studies in adults has examined geographical variation in the prevalence of nasal allergy/allergic rhinitis in adults or considered the proportion of reported nasal symptoms on exposure to allergen attributable to atopy. The aim of this report was to describe the geographic distribution of subjects with nasal symptoms who are sensitized as determined by skin prick tests, using data from the European Community Respiratory Health Survey I.

METHODS

Information on the presence of nasal allergy, nasal symptoms on exposure to allergen and atopy using skin prick tests was collected from 15,394 adults aged 20-44 years living in 35 centres in 15 countries. Age sex standardized prevalence of symptoms and the attributable fraction of IgE sensitization for nasal symptoms on exposure to allergen were determined.

RESULTS

The age-sex standardized prevalence of nasal allergy ranged from 11.8% in Oviedo (Spain) to 46.0% in Melbourne (Australia). The prevalence of atopic nasal allergy ranged from 4.6% in Oviedo to 31.8% in Melbourne (analysis limited on 12,566 subjects). The median attributable fraction for atopy on nasal symptoms on exposure ranged between 12.8% and 65.9% (median 27.2%).

CONCLUSION

In the general population there is a wide variation in the prevalence of nasal allergy in young adults. Many subjects complaining from nasal symptoms on exposure to allergen are not atopic.

Allergic rhinitis: epidemiological aspects, diagnosis and treatment

This study was a review of the literature on the epidemiological, clinical, diagnostic and therapeutic aspects of allergic rhinitis. Bibliographic searches were based on the information contained within the Medline, Latin American and Caribbean Health Sciences Literature and HighWire databases, covering the last thirty years and using the following search terms: 'allergic rhinitis', 'epidemiology', 'diagnosis' and 'treatment'. Sixty articles were selected. This study describes the increase in the prevalence of allergic rhinitis, its relationship with asthma, the diagnostic criteria and the treatment. The classification of allergic rhinitis and strategies for its treatment are presented. Therapeutic modalities presented and discussed include the administration of antihistamines, corticosteroids, immunotherapy, anti-leukotrienes, sodium cromoglycate and anti-IgE antibodies, as well as minimizing exposure to inhaled allergens. Finally, the importance of the management of allergic rhinitis in public health is emphasized.

Molecular cloning, expression and immunological characterisation of Pas n 1, the major allergen of Bahia grass Paspalum notatum pollen

Bahia grass, Paspalum notatum, is a clinically important subtropical grass with a prolonged pollination season from spring to autumn. We aimed to clone and characterise the major Bahia grass pollen allergen, Pas n 1. Grass pollen-allergic patients presenting to a tertiary hospital allergy clinic were tested for IgE reactivity with Bahia grass pollen extract by skin prick testing, ImmunoCAP, ELISA and immunoblotting. Using primers deduced from the N-terminal peptide sequence of a group 1 allergen of Bahia grass pollen extract separated by two-dimensional gel electrophoresis, the complete Pas n 1 cDNA was obtained by rapid amplification of cDNA ends and cloned. Biological relevance of recombinant Pas n 1 expressed in Escherichia coli was assessed by serum IgE reactivity and basophil activation. Twenty-nine of 34 (85%) consecutive patients presenting with grass pollen allergy were skin prick test positive to Bahia grass pollen. The Pas n 1 cDNA has sequence homology with the beta-expansin 1 glycoprotein family and is more closely related to the maize pollen group 1 allergen (85% identity) than to ryegrass Lol p 1 or Timothy grass Phl p 1 (64 and 66% identity, respectively). rPas n 1 reacted with serum IgE in 47 of 55 (85%) Bahia grass pollen-allergic patients, activated basophils and inhibited serum IgE reactivity with the 29 kDa band of Bahia grass pollen extract. In conclusion the cDNA for the major group 1 allergen of the subtropical Bahia grass pollen, Pas n 1, was identified and cloned. rPas n 1 is immunologically active and is a valuable reagent for diagnosis and specific immunotherapy of grass pollen allergy.

Economic burden of rhinitis in managed care: a retrospective claims data analysis

BACKGROUND

Little is known about the specific cost effect of rhinitis on third-party payers. No recently reported studies have examined the economic burden of rhinitis in managed care. Furthermore, the direct costs of chronic rhinitis have not been evaluated and potential differences in health care use and costs of allergic rhinitis have not been examined.

OBJECTIVE

To evaluate the economic burden of allergic rhinitis and chronic rhinitis to third-party payers in a large US managed care plan.

METHODS

In a retrospective analysis using pharmacy and medical claims data from a US health plan covering approximately 15 million members, health care use and cost data were summarized for patients with allergic or chronic rhinitis (n = 301,001) for the 13-month study period (January 1, 2004, to January 31, 2005).

RESULTS

Average rhinitis-related total costs were $657 per patient each year ($319 in medical costs and $338 in pharmacy costs). Ambulatory visits were the primary contributor to rhinitis-related medical costs. Antihistamines were the most common rhinitis medication, followed by intranasal corticosteroids (INSs) and montelukast. Many patients (37% with at least 1 filled prescription for an antihistamine, an INS, or montelukast) used combination therapy. Of the 3 main pharmacotherapy categories, montelukast was associated with the highest pharmacy cost ($353 vs $198 for antihistamines and $231 for INSs per patient each year for monotherapy) and drove the average annual cost of combination therapy regardless of the concomitant medication(s). The most common comorbidities were sinusitis and asthma, present in 51.1% and 27.9% of patients, respectively. Comorbidities increased rhinitis-related health care costs.

CONCLUSIONS

Allergic rhinitis and chronic rhinitis imposed a significant financial burden on third-party payers in a large US managed care plan. The presence of comorbidities further increased the rhinitis-related treatment costs.

Testing for allergic disease: parameters considered and test value

BACKGROUND

Test results for allergic disease are especially valuable to allergists and family physicians for clinical evaluation, decisions to treat, and to determine needs for referral.

METHODS

This study used a repeated measures design (conjoint analysis) to examine trade offs among clinical parameters that influence the decision of family physicians to use specific IgE blood testing as a diagnostic aid for patients suspected of having allergic rhinitis. Data were extracted from a random sample of 50 family physicians in the Southeastern United States. Physicians evaluated 11 patient profiles containing four clinical parameters: symptom severity (low, medium, high), symptom length (5, 10, 20 years), family history (both parents, mother, neither), and medication use (prescribed antihistamines, nasal spray, over-the-counter medications). Decision to recommend specific IgE testing was elicited as a "yes" or "no" response. Perceived value of specific IgE blood testing was evaluated according to usefulness as a diagnostic tool compared to skin testing, and not testing.

RESULTS

The highest odds ratios (OR) associated with decisions to test for allergic rhinitis were obtained for symptom severity (OR, 12.11; 95%CI, 7.1-20.7) and length of symptoms (OR, 1.46; 95%CI, 0.96-2.2) with family history having significant influence in the decision. A moderately positive association between testing issues and testing value was revealed (beta = 0.624, t = 5.296, p < or = 0.001) with 39% of the variance explained by the regression model.

CONCLUSION

The most important parameters considered when testing for allergic rhinitis relate to symptom severity, length of symptoms, and family history. Family physicians recognize that specific IgE blood testing is valuable to their practice.

Chronic rhinosinusitis and risk of lung cancer in the Singapore Chinese Health Study

Epidemiologic evidence suggests that chronic inflammatory conditions of the lung may increase lung cancer risk. These chronic conditions, such as chronic obstructive pulmonary disease and asthma, commonly coexist with chronic rhinosinusitis. We prospectively examined if chronic rhinitis or sinusitis was associated with lung cancer risk in the Singapore Chinese Health Study, a population-based cohort of 63,257 Singapore Chinese, who were aged 45-74 years when recruited between 1993 and 1998. Each subject completed a comprehensive interview on medical conditions, dietary and lifestyle factors at recruitment, and cancer occurrence and survival status were determined via linkage to population-based registries. As of 31 December, 2005, 954 cohort participants had developed lung cancer. Compared with subjects without such history, subjects who reported a history of physician-diagnosed rhinitis or sinusitis at baseline, whether allergic or nonallergic, had a statistically significant 59% increase in risk of lung cancer (hazard ratio [HR] = 1.59; confidence interval [CI] = 1.06-2.37). This association was significant and stronger in women (HR = 2.32; 95% CI = 1.23-4.39) compared to men, and for the adenocarcinoma cell type (HR = 1.91; 95% CI = 1.07-3.42) compared to other histologies. Overall, a history of asthma, hay fever, allergic dermatitis, food allergy or any other allergic conditions asked in a single question was not related to lung cancer risk (HR = 1.11; 95% CI = 0.90-1.36). Chronic rhinosinusitis may be a marker of pan-airway inflammation and its association with lung cancer risk provides evidence linking inflammation to lung carcinogenesis, especially among women.

Hazelnut allergy: from pollen-associated mild allergy to severe anaphylactic reactions

PURPOSE OF REVIEW

Hazelnut allergy can vary between mild oral symptoms and potentially dangerous anaphylaxis. There is a need to predict which subjects are at risk for severe reactions. In this study, possibilities for 'component-resolved diagnosis', based on sensitization to different allergens in hazelnut, are discussed.

RECENT FINDINGS

One type of hazelnut allergy can be associated with sensitization to homologues of pollen allergens, predominantly birch, in hazelnut: Cor a 1 (Bet v 1) and Cor a 2 (profilin). These allergens account for relatively mild symptoms. However, subjects can also be sensitized to several other allergens in hazelnut that are related to more severe symptoms. These allergens are homologues of allergens in other nuts and peanut: Cor a 8 (lipid transfer protein) and Cor a 9 (11S globulin) and perhaps Cor a 11 (7S globulin). The clinical relevance of these and other potential hazelnut allergens has to be further defined. The diagnosis of hazelnut has to be confirmed by oral double-blind placebo-controlled food challenge.

SUMMARY

Sensitization to hazelnut can either be associated with mild oral symptoms, depending on sensitization to pollen, or with more serious allergic symptoms, related to sensitization to homologues of nut and peanut allergens.

Primary care: the cornerstone of diagnosis of allergic rhinitis

Allergic rhinitis (AR) is a very common disease with over 600 million people (200 million of them with concomitant asthma) worldwide suffering from it. The majority of patients who seek medical advice are seen in primary care. Although there is a selection of guidelines focused on the management of AR, there is a paucity of guidance on how best to identify patients who would most benefit from treatment. The aim of this paper was to review the best practice for primary care with respect to the diagnosis of AR within that clinical environment.

Physician and patient survey of allergic rhinitis in France: perceptions on prevalence, severity of symptoms, care management and specific immunotherapy

BACKGROUND

Specific immunotherapy (SIT) is the only aetiological treatment used in allergic rhinitis (AR). A telephone survey of patients and physicians in France was carried out to understand better the real and perceived advantages and inconveniences of this therapeutic approach.

METHODS

A cohort of 453 individuals with AR was selected using the Score For Allergic Rhinitis questionnaire. The survey evaluated the level of understanding of allergic rhinitis and its management, including both pharmacotherapy and SIT. A parallel survey was conducted with 400 general practitioners, allergists and nonallergist specialists.

RESULTS

Approximately 50% of patients had heard about SIT as a therapeutic option. Of these, 56% had a positive view of SIT and 14% a negative image. A majority of patients and physicians with a positive opinion associated SIT with improved well-being and quality of life, while those with a negative opinion considered it to be a long and inconvenient treatment, with uncertain results. Over 50% of patients who had been offered SIT had accepted it and approximately 60% of these were satisfied with it. The future availability of SIT as sublingual tablets was perceived positively by both patients and physicians.

CONCLUSIONS

Many patients with AR are unaware of their pathology and few seek help from health professionals. When patients take medication, they are generally satisfied with their treatment, even if it is only symptomatic. Patients and physicians see the notion of definitive recovery as the main benefit of SIT, whereas the main disadvantage is the duration of treatment.

Lack of effect on adult and adolescent hypothalamic-pituitary-adrenal axis function with use of fluticasone furoate nasal spray

BACKGROUND

Intranasal corticosteroids are recommended as first-line therapy for allergic rhinitis (AR), and because of their pharmacologic class, hypothalamic-pituitary-adrenal (HPA) axis function is evaluated.

OBJECTIVE

To evaluate whether cortisol production was suppressed (as a measure of HPA axis function) by 6 weeks of treatment with fluticasone furoate nasal spray, 110 microg once daily, in patients with perennial AR.

METHODS

A double-blind, randomized, placebo- and active-controlled (prednisone), parallel-group study. Outpatients aged 12 to 65 years with perennial AR for 2 years or more were from 1 center in the United States and 1 center in Canada. Pharmacodynamic and pharmacokinetic samples were collected during 24-hour domiciled visits (overnight in clinic). Measurements included change from baseline in 24-hour serum cortisol weighted mean and 24-hour urinary free cortisol excretion, total 24-hour urinary free cortisol excretion and 6-beta hydroxycortisol excretion, and plasma concentration of fluticasone furoate.

RESULTS

A total of 112 of 183 patients were randomized. Fluticasone furoate was noninferior to placebo with respect to the ratio from baseline in serum cortisol weighted mean (treatment ratio, 0.98; 95% confidence interval, 0.89 to 1.07). In contrast, use of prednisone, 10 mg once daily, significantly reduced the ratio from baseline compared with placebo. Change from baseline in 24-hour urinary cortisol excretion was similar in the fluticasone furoate and placebo groups. Plasma levels of fluticasone furoate were undetectable after 6 weeks of treatment.

CONCLUSION

Fluticasone furoate nasal spray, 110 microg once daily, was not associated with HPA axis suppression in patients 12 years and older with perennial AR.

Safety of sublingual grass pollen immunotherapy after anaphylaxis

Aim:

To demonstrate that sublingual immunotherapy is a safe treatment option in patients who have previously suffered anaphylaxis when undergoing subcutaneous grass pollen immunotherapy.

Case report:

We report two patients who developed a systemic anaphylactic reaction following subcutaneous grass pollen immunotherapy, resulting in discontinuation of treatment. Following treatment of the acute anaphylactic episode, both patients were subsequently safely commenced on sublingual grass pollen immunotherapy.

Conclusion:

Injection immunotherapy has a relatively low risk of severe adverse events, although anaphylaxis is a potentially fatal complication and usually results in termination of the immunotherapy programme. Sublingual immunotherapy has a safer side effect profile than subcutaneous immunotherapy, with no reported cases of anaphylaxis.

Sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis

Sleep impairment is a significant problem for patients with inflammatory disorders of the upper respiratory tract, such as allergic rhinitis, rhinosinusitis, and nasal polyposis. Nasal congestion, one of the most common and bothersome symptoms of these conditions, is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment. This review examines sleep impairment associated with allergic rhinitis, rhinosinusitis, and nasal polyposis. It explores the adverse effects of disturbed sleep on patients' quality of life and how these inflammatory nasal conditions can be reduced by therapies that address the underlying problems affecting sleep. Treatment with intranasal corticosteroids has been shown to reduce nasal congestion in inflammatory disorders of the upper respiratory tract. Data on sleep-related end points from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Further research using measures of sleep as primary end points is warranted, based on the potential of these agents to improve sleep and quality of life in patients with allergic rhinitis, acute rhinosinusitis, and nasal polyposis. Such trials will help to identify the most effective therapies for sleep impairment in these 3 nasal conditions.

Towards a differential definition of atopy: Anisakis simplex and the relationship between parasites and arthropods in respiratory allergy

Protective as well as enhancing effects of parasite infections on allergic disease have been postulated. Previous studies on this relationship focused frequently on skin test reactivity against aeroallergens, being house dust mites (HDM) the main agents responsible for a positive atopy outcome. We aimed to analyse the possible relationship between human parasite infection induced Anisakis simplex urticaria and respiratory allergy. A total of 86 patients with gastro-allergic Anisakiasis and 203 patients with chronic urticaria sensitized against A. simplex were studied for sensitization against aeroallergens and evaluated for rhinoconjunctivitis or bronchial asthma (RCBA). We compared the results with a control group of 250 consecutive patients referred for evaluation of allergic RCBA and atopy prevalence data of our region. Whereas no effect of A. simplex related disease on the overall allergic respiratory disease could be detected, a highly significant higher prevalence of RCBA associated HDM sensitization, but diminished allergy against other common aeroallergens (pollen, mould or dander) was observed in these groups. The relationship between A. simplex parasitism-associated acute or chronic urticaria on one side and allergic respiratory disease on the other side depends on the definition of atopy. We propose a differential definition of atopy, with a special emphasis on arthropod related sensitization.

A systematic review of the clinical effectiveness of acupuncture for allergic rhinitis

Background

Allergies cause a considerable burden to both sufferers and the National Health Service. There is growing interest in acupuncture as a treatment for a range of conditions. Since acupuncture may modulate the immune system it could be a useful treatment for allergic rhinitis (AR) sufferers. We therefore assessed the evidence for the clinical effectiveness of acupuncture in patients with AR by performing a systematic review of the literature.

Methods

Searches (to 2007) were conducted in all major databases for randomised controlled trials (RCTs) evaluating the clinical effectiveness of acupuncture in the treatment of AR. No limits were placed on language. Studies were included if they compared acupuncture to a sham or inactive acupuncture treatment (placebo) with or without standard care. Meta-analysis was performed where feasible.

Results

Seven relevant RCTs were included after screening and application of inclusion and exclusion criteria. The trials were generally of poor quality as assessed by a modified Jadad scale, with the exception of two studies which scored highly. A wide variety of outcomes was measured but most assessed symptom severity on a visual analogue scale. A meta-analysis failed to show any summary benefits of acupuncture treatment for symptom severity scores or serum IgE measures which could not have been accounted for by chance alone. Acupuncture was not associated with any additional adverse events in the trials.

Conclusion

There is currently insufficient evidence to support or refute the use of acupuncture in patients with AR. A large well conducted RCT, which overcomes identified methodological problems in the existing RCTs, would be required to resolve this question.

Rupatadine in allergic rhinitis and chronic urticaria

Histamine is the primary mediator involved the pathophysiology of allergic rhinitis and chronic urticaria, and this explains the prominent role that histamine H(1)-receptor antagonists have in the treatment of these disorders. However, histamine is clearly not the only mediator involved in the inflammatory cascade. There is an emerging view that drugs which can inhibit a broader range of inflammatory processes may prove to be more effective in providing symptomatic relief in both allergic rhinitis and chronic urticaria. This is an important consideration of the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative which provides a scientific basis for defining what are the desirable properties of an 'ideal' antihistamine. In this review of rupatadine, a newer dual inhibitor of histamine H(1)- and PAF-receptors, we evaluate the evidence for a mechanism of action which includes anti-inflammatory effects in addition to a powerful inhibition of H(1)- and PAF-receptors. We assess this in relation to the clinical efficacy (particularly the speed of onset of action) and safety of rupatadine, and importantly its longer term utility in everyday life. In clinical trials, rupatadine has been shown to be an effective and well-tolerated treatment for allergic rhinitis and chronic idiopathic urticaria (CIU). It has a fast onset of action, producing rapid symptomatic relief, and it also has an extended duration of clinical activity which allows once-daily administration. In comparative clinical trials rupatadine was shown to be at least as effective as drugs such as loratadine, cetirizine, desloratadine and ebastine in reducing allergic symptoms in adult/adolescent patients with seasonal, perennial or persistent allergic rhinitis. Importantly, rupatadine demonstrated no adverse cardiovascular effects in preclinical or extensive clinical testing, nor negative significant effects on cognition or psychomotor performance (including a practical driving study). It improved the overall well-being of patients with allergic rhinitis or CIU based on findings from quality of life questionnaires and patient global rating scores in clinical trials. Thus, rupatadine is a recently introduced dual inhibitor of histamine H(1)- and PAF-receptors, which has been shown to be an effective and generally well-tolerated treatment for allergic rhinitis and chronic urticaria. It possesses a broader profile of anti-inflammatory properties inhibiting both inflammatory cells and a range of mediators involved in the early- and late-phase inflammatory response, but the clinical relevance of these effects remain to be clarified.

Impact of the reduction of the prescription charge in Wales on the prescribing of non-sedating antihistamines in primary care

OBJECTIVE

Determine the impact of the phased reduction of the prescription charge in Wales on prescriptions for non-sedating antihistamines.

METHOD

Prescription items for non-sedating antihistamines dispensed in 22 Local Health Boards (LHBs) in Wales and 15 Primary Care Trusts in the South East of England were analysed between October 2001 and September 2006.

RESULTS

There was an increase in percent change (median (interquartile range [IQR])) in prescription items for non-sedating antihistamines dispensed in Wales in the 24 months after the first reduction of the prescription charge in October 2004 compared to the 24 months prior to this (13.7 [10.9-17.1] vs. 7.3 [5.0-10.7], p<0.001). In the South East of England there was no change over the same periods (4.4 [3.4-7.5] vs. 4.5 [0.8-7.9], p=0.73). In the five least deprived LHBs the percent change in prescriptions for non-sedating antihistamines increased in the 24 months after the reduction of the prescription charge compared to the previous 24 months (14.3 [11.5-19.4] vs. 9.0 [9.1-13.5], p=0.04). In contrast there was no change over the two periods in the five most deprived LHBs (13.1 [10.9-17.5] vs. 9.5 [2.9-10.4], p=0.08].

CONCLUSIONS

The phased reduction of the prescription charge in Wales coincided with an increase in the number of non-sedating antihistamines dispensed in Wales. This was only evident in the least deprived LHBs.

Intranasal corticosteroids: the development of a drug delivery device for fluticasone furoate as a potential step toward improved compliance

Devices for the aqueous delivery of intranasal corticosteroids to patients with allergic rhinitis have been available since 1984, so there is a need for new devices to be developed to provide ease of use, efficacy and safety. A novel drug delivery system has been developed for fluticasone furoate (FF; GlaxoSmithKline): a new enhanced-affinity glucocorticoid with a scent-free formulation. The FF system was developed, giving attention to patients' unmet needs, in order to promote acceptance and compliance. It demonstrates a number of key features including its ergonomic design, side-actuation system and short delivery nozzle. Exploiting issues with present devices highlighted the need for the FF system. This review reports data from key studies and surveys conducted by GlaxoSmithKline during development, to determine ease of use and acceptance of the FF system. Findings suggest that the FF system should aid in improving attitudes to the use of intranasal corticosteroids amongst physicians and patients.

A survey of the burden of allergic rhinitis in Europe

BACKGROUND

The perceptions of patients and physicians regarding the symptoms and impact of allergic rhinitis (AR) were assessed in a prospective, cross-sectional, international survey. This paper presents the combined survey results from five European countries (Germany, France, Italy, Spain and the UK).

METHODS

Data were recorded by 1,482 patients and matched with records from 415 primary care physicians and specialists. Diagnostic tests to confirm AR had been performed on 1,279 (86.3%) patients. Both physicians and patients recorded the presence, severity and impact of symptoms at the time of consultation in addition to those symptoms frequently, but not currently, present. Health-related quality of life (HRQoL) was assessed using the Mini Rhinoconjunctivitis Quality of Life Questionnaire.

RESULTS

A large proportion of patients had moderate-severe disease (67.2%; n = 996), persistent disease (42.5%; n = 630) and comorbidities such as asthma (31.5%; n = 467). Overall, patients rated their disease as more severe than did physicians (P < 0.001). At the time of the consultation, one-third of all patients reported that their current nasal and ocular symptoms were moderate or severe in nature. According to the physicians' assessment, good control of nasal and ocular symptoms was achieved in 45.4% (n = 673) and 51.3% (n = 760) of patients, respectively, and poor symptom control in 18.0% (n = 267) and 12.1% (n = 179). Overall, 43.3% (n = 641) of those surveyed were using two or more medicines for their AR. Health-related quality of life was correlated with disease severity and with the number of days without symptoms in the previous 4 weeks. Allergic rhinitis had a significantly greater impact in patients with more persistent disease than in those with intermittent disease (2.3 +/- 1.3 vs 1.9 +/- 1.2; P < 0.001). Nonetheless, 81.8% (n = 601) of patients with intermittent disease reported some impairment of their daily life as a result of their AR.

CONCLUSIONS

Allergic rhinitis remains a significant health problem because of the high burden of symptoms and its impact on general well being and HRQoL among patients consulting for this condition. Overall, there was a poor correlation between patients and physicians in the reporting of disease severity.

Sublingual grass allergen tablet immunotherapy provides sustained clinical benefit with progressive immunologic changes over 2 years

BACKGROUND

This is an interim analysis of a randomized, double-blind, placebo-controlled phase III trial with 3 years of daily treatment with grass tablet immunotherapy (GRAZAX; ALK-Abelló A/S, Hørsholm, Denmark) or placebo, followed by 2 years of follow-up to assess the persistent efficacy.

OBJECTIVE

We sought to evaluate the efficacy and safety of specific immunotherapy with grass allergen tablets compared with placebo after treatment covering 2 consecutive grass pollen seasons.

METHODS

The interim analyses included 351 adult participants with moderate-to-severe allergic rhinoconjunctivitis caused by grass pollen. Participants were treated with active (n = 189) or placebo (n = 162) tablets for an average of 22 months. All participants were allowed to use symptomatic rescue medication.

RESULTS

The primary efficacy analysis showed highly significant mean reductions of 36% in rhinoconjunctivitis symptom score (P < .0001; median reduction, 44%) and 46% in rhinoconjunctivitis medication score (P < .0001; median reduction, 73%) in the active group relative to the placebo group. Mean rhinoconjunctivitis quality of life was 33% better (P < .0001; median, 40%). Clinical improvements were paralleled by significant changes in allergen-specific immunoglobulins. The treatment was well tolerated, and adverse events led to withdrawal in less than 1% of participants. There were no serious adverse events related to treatment.

CONCLUSION

Grass allergen tablet immunotherapy showed progressive immunologic changes and highly significant efficacy over 2 years of continued treatment.

Quality-assessment of disease-specific quality of life questionnaires for rhinitis and rhinosinusitis: a systematic review

The aim of this systematic review was to give a quality-assessed review of the existing disease-specific health related quality of life (QOL) questionnaires concerning rhinitis and rhinosinusitis for adults. The quality is assessed by defining the characteristics of a QOL questionnaire with assessment criteria. The results of the construction, description, feasibility, and the psychometric performance of the instruments are provided. We finally provide a clinician's guide to choose a questionnaire based on the measurement goals, the discriminant validity, responsiveness and the points obtained in the quality assessment. Of the top scoring instruments regarding the overall quality assessment, only four health related QOL questionnaires for rhinitis and rhinosinusitis met our criteria for the discriminant validity and responsiveness.

Prevalence of allergy and anaphylactic symptoms in 210 adult and pediatric patients with mastocytosis in Spain: a study of the Spanish network on mastocytosis (REMA)

BACKGROUND

Mast cells (MCs) play a key role in allergic diseases through the release of inflammatory mediators, which are responsible of allergic symptoms. Mastocytosis is characterized by an abnormal proliferation and accumulation of mast cells, in which mediators are released intermittingly or continuously. Despite these clinical similarities, few studies have addressed the presence of allergic symptoms in mastocytosis patients, including anaphylaxis.

OBJECTIVE

A prospective evaluation was carried out to study the prevalence of allergic diseases in patients with mastocytosis and their impact on the natural history of mastocytosis.

METHODS

A questionnaire was given to 210 patients with mastocytosis to evaluate the history of asthma, rhinitis, conjunctivitis, atopic dermatitis, urticaria and anaphylaxis. Patients underwent total IgE, Phadiatop infant (aeroallergens and food allergens), specific IgE to latex and to Anisakis simplex determinations. Skin tests were done to 72 patients.

RESULTS

The prevalence of allergy, as defined by clinical symptoms associated to specific IgE, was 23.9%. Total IgE level was significantly higher in patients with allergy as compared with patients without allergy (median 58 vs. 16.5 kU/L, P<0.0001). Anaphylactic symptoms were present in 36 patients (22%), in nine the allergen was identified. Males had more allergy and anaphylactic symptoms than females (61.5% vs. 38.5% and 72% vs. 28%, respectively).

CONCLUSIONS

Allergic diseases coexist in patients with mastocytosis with similar frequency as compared with the general population. Anaphylactic symptoms are more prevalent in males with mastocytosis and in patients with elevated IgE.

CAPSULE SUMMARY

The prevalence of allergy in mastocytosis is similar to the general population. Anaphylactic symptoms are more prevalent in males and in patients with elevated IgE. The coexistence of atopy does not influence mastocytosis-associated symptoms.

Short-term effect of pollen exposure on antiallergic drug consumption

BACKGROUND

Several studies have investigated the association between pollen exposure and asthma emergency admissions, but only 2 have investigated the effect of airborne allergens on consultations for rhinitis or conjunctivitis and none has used drug consumption as the health indicator.

OBJECTIVE

To analyze the short-term association between pollen exposure and antiallergic drug consumption in the urban area of Clermont-Ferrand, France, taking into account the potentially confounding effect of air pollution and meteorological factors.

METHODS

We used the French health insurance database to select all individuals from the Clermont-Ferrand urban area having benefited from reimbursement for antiallergic treatment from January 1, 2000, through December 31, 2001, and from January 1, 2003, through December 31, 2004. An episode of treated allergic rhinitis, rhinosinusitus, or conjunctivitis (ARC) was defined as the association of an oral antihistamine and a local antiallergic drug on the same prescription. The relations between daily changes in pollen concentrations and daily changes in the number of treated ARC cases were analyzed using a Poisson regression model with penalized spline functions.

RESULTS

The risk of treated ARC associated with an interquartile increase in pollen concentration increased significantly for Poaceae (5%, P < .001), Fraxinus (7%, P < .001), Betula (7%, P < .001), and Corylus (2%, P < .02). This increase was significant in all age groups for Poaceae and Fraxinus pollen and in people younger than 65 years for Betula pollen. The effect was mainly concentrated on the present day, except for Poaceae pollens, for which the risk remained significantly (P < .001) increased until 3 days lag time.

CONCLUSIONS

This study showed a significant increase in treated ARC cases related to Poaceae, Fraxinus, and Betula. Specific risks are difficult to evaluate for species that share the same pollination period. Time-series studies based on drug consumption are useful to highlight and to supervise pollen-related diseases requiring ambulatory care.

Development and validation of a new Spanish instrument to measure health-related quality of life in patients with allergic rhinitis: the ESPRINT questionnaire

OBJECTIVES

To develop and validate an instrument to measure health-related quality of life (HRQOL) specific to patients with allergic rhinitis (AR) and primarily for use in Spanish and Spanish-speaking populations.

METHODS

An initial item pool was generated from literature review, focus groups with AR patients, and consultations with clinical experts. Item reduction was performed using clinimetric and psychometric approaches after administration of the item pool to 400 AR patients. The resulting instrument's internal consistency, test-retest (2-4 weeks) reliability, known groups and convergent validity, and sensitivity to change were tested in a longitudinal, observational, multicenter study in 210 AR patients who also completed the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ).

RESULTS

The new questionnaire took a mean (SD) of 7.1 (5.4) minutes to answer. Floor and ceiling effects were less than 15% on all dimensions. Cronbach's alpha values and intraclass correlation coefficient values for six of the sevendimensions and the overall score exceeded 0.70. Statistically significant differences (P < 0.01) were observed on all ESPRINT-28 dimensions and the overall score between patients with mild (mean overall score 1.97, SD 0.99), moderate (mean overall score 2.78, SD 0.88), and severe AR (mean overall score 3.89, SD 0.87). Patients with persistent AR had worse scores (P < 0.05) on all dimensions than patients with intermittent AR. Correlations between the ESPRINT-28 and the RQLQ were generally as expected. Effect sizes for score changes between the two study visits ranged from 0.96 to 1.76 for individual dimensions and the overall score.

CONCLUSIONS

This new, Spanish-developed instrument to measure HRQOL in AR patients has shown good reliability, validity, and sensitivity to change. It has also proved easy to use and administer.

Development and validation of the Congestion Quantifier seven-item test (CQ7): a screening tool for nasal congestion

OBJECTIVE

This study aimed to develop and validate a short, simple, patient-completed instrument for identifying patients with congestion in a 15-day study. Allergic rhinitis (AR) is the most common allergic condition worldwide, with congestion as one of the most salient symptoms. Nevertheless, there is no short screening tool designed specifically to identify congestion that can help patients make decisions about seeking treatment.

METHODS

Patients (N = 354) received a clinical exam to confirm congestion and assess its possible causes including confirmation of AR. They completed the 13-item draft of the Congestion Quantifier (CQ) and five additional patient-reported outcome instruments.

RESULTS

The 13-item draft CQ was reduced to a seven-item version, the CQ7. Internal consistency reliability was 0.93; test-retest reliability = 0.85. Construct validity was demonstrated by significant correlations with the Medical Outcomes Study Sleep Scale, the Work Productivity and Activity Impairment Questionnaire-Allergy Specific, and the Positive Affect and Negative Affect Scale Fatigue subscale (r = 0.23-0.67). The CQ7 can discriminate between controls and patients (AUC > 0.9). Moreover, it can discriminate between different levels of severity of symptoms of AR. A score of 7 provided optimum balance of sensitivity (91%), specificity (86%), and correct classification (90%) for detecting congestion.

CONCLUSION

The CQ7 is reliable, valid, and responsive to differences in severity of nasal congestion. The CQ7 can identify patients with congestion that may need to be evaluated by a clinician.

A double blind, placebo-controlled cross over trial of cellulose powder by nasal provocation with Der p1 and Der f1

OBJECTIVE

The purpose of this study was to assess whether inert cellulose powder would reduce the response to nasal challenge with house dust mite antigens. The study aimed to investigate the efficacy of inert cellulose powder applied to the nose for the control of persistent allergic rhinitis in adults due to house dust mite allergy. The powder has been registered as a medical device since 1994 and is available in many countries as a remedy for hay fever. Anecdotal evidence reported that it reduced symptoms of persistent rhinitis but no scientific evidence exists for this.

RESEARCH DESIGN AND METHODS

A double blind, placebo-controlled cross over trial was conducted on 15 adult persistent rhinitis sufferers (diagnosed positive to Der p1 and/or Der f1 by SPT) and who had symptoms over the previous 2 years. The placebo was lactose powder. Challenge was by measured dose of homogenised allergenic dust. The study took place in the spring of 2006 before the main pollen seasons.

MAIN OUTCOME MEASURES

The primary outcome measures were observed severity scores for 3 symptom categories and the amount of ECP in nasal secretions. The secondary outcome measures were symptom scores by subject report (nasal blockage, itching of nose, throat and eyes), nasal peak inspiratory (PIFn) and expiratory flow (PEFn).

RESULTS

The results show significant differences for sneezing, itchy nose, runny nose and ECPs in nasal secretions. Some results are also significantly different between placebo and active for PIFn and for PEFn (all at p = 0.05). There were no adverse reactions.

CONCLUSIONS

The inert cellulose powder can have significant effects in reducing some symptoms of persistent rhinitis due to house dust mite allergy.

Undertreatment of rhinitis symptoms in Europe: findings from a cross-sectional questionnaire survey

BACKGROUND

Allergic rhinitis is a frequent disease affecting one in five Europeans with a significant impact on patient quality of life, health-care costs, and economic productivity. Although effective treatments exist, the disease often remains undiagnosed and not correctly treated, despite clear diagnostic and therapeutic guidelines from WHO, EAACI (European Academy of Allergology and Clinical Immunology), and GA(2)LEN (Global Allergy and Asthma European Network). This study elucidates the reasons for this discrepancy from the patients' point of view.

METHODS

An internet and telephone survey was conducted with 2,966 randomly selected adults with allergies from the general population in the five major EU countries: UK, France, Germany, Italy, and Spain.

RESULTS

The main reason that the majority of respondents first visited a medical professional for their rhinitis symptoms was because these symptoms became intolerable. The respondents had not seen a medical professional in the past year for their rhinitis symptoms in 52.6% of the cases, and 30.2% of the respondents preferred nonprescription medication because it did not require visiting a doctor. 'Nontreaters' and 'homeopathic treaters' together made up 26.2% of the respondents, and 40.2% of them gave the cost of medication as a reason they do not use allergy medications.

CONCLUSIONS

Allergic rhinitis remains widely undertreated in Europe with avoidable socioeconomic consequences. Effective treatment exists, but patients wait too long to seek medical advice, and health providers neglect to actively screen early for allergies.

Therapeutic options for reducing sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis

BACKGROUND

Patients with inflammatory disorders of the upper airways, such as allergic rhinitis, rhinosinusitis, and nasal polyposis, often have significant sleep disturbances. Poor sleep can lead to fatigue, daytime somnolence, impaired daytime functioning as reflected in lower levels of productivity at work or school, and a reduced quality of life. Although the exact mechanisms by which these inflammatory nasal conditions disturb sleep is not fully understood, congestion appears to be a key factor and is generally the most common and bothersome symptom for patients with these conditions. Successful therapy should improve patients' sleep and well-being without introducing any negative effects on sleep. SCOPE OF LITERATURE SEARCH: Literature searches of Medline, Embase, and abstracts from medical/scientific conferences were conducted for the period of 1995 through mid-2006 for primary and review articles and conference presentations about sleep disturbance related to allergic rhinitis, rhinosinusitis, and nasal polyposis. These searches also sought to identify articles examining how treatments for those diseases improved sleep and, consequently, patients' quality of life. Surveys of the impact of congestion on patients' quality of life and their sleep also were consulted. Clinical studies were selected for discussion if they were randomized, double-blind, and placebo-controlled. Limitations of this review include the absence of any direct comparisons of the effectiveness of different drugs on improving sleep and shortcomings in the statistical methods of the patient surveys.

FINDINGS

Intranasal corticosteroids (INSs) are the most effective medication for reducing congestion in patients with inflammatory nasal conditions. There is a growing amount of evidence that a reduction in congestion with INSs is associated with improved sleep, reduced daytime sleepiness, and enhanced patient quality of life.

CONCLUSION

Relief of sleep impairment associated with inflammatory disorders of the nose and sinuses can be addressed with INS therapy.

Grass allergen tablet immunotherapy relieves individual seasonal eye and nasal symptoms, including nasal blockage

BACKGROUND

Symptoms of allergic rhinitis have a considerable impact on the quality of life of the sufferer. Sneezing, runny nose, blocked nose and headache are some of the most common symptoms of allergic rhinitis, which affects work, home and social life for many patients. Sublingual immunotherapy has shown to induce a protective immune response and provide sustained symptom prevention for allergic patients. AIMS OF THE TRIAL: The overall aims were to investigate the efficacy and safety of a sublingual grass allergen tablet (Grazax) 75 000 SQ-T; ALK-Abelló A/S, Denmark). Reported here are the effects of Grazax on individual eye and nasal symptoms.

METHODS

The trial was a double-blind placebo-controlled trial including 634 participants with significant rhinoconjunctivitis because of grass pollen. Participants were randomized 1 : 1 to Grazax (a fast dissolving, once daily immunotherapy tablet for home administration) or placebo and received treatment for at least 16 weeks prior to and continuing during the grass pollen season of 2005. Four nasal symptoms and two eye symptoms were scored on a scale from 0 (no symptoms) to 3 (severe symptoms) every day during the entire grass pollen season. Nasal symptoms included runny nose, blocked nose, sneezing and itchy nose; eye symptoms included gritty feeling/red/itchy eyes and watery eyes.

RESULTS

Consistent and highly significant reductions in individual eye and nasal symptoms (from 22 to 44%) were observed following treatment with Grazax as compared with placebo (P < 0.0001).

CONCLUSIONS

Grazax has effects on multiple allergic symptoms, including nasal blockage, and is an effective treatment of rhinoconjunctivitis, thereby reducing the need for topical anti-allergic drugs.

[Incidence of allergic rhinitis in a cohort of schoolchildren between 1994 and 2002 in Castellón (Spain), following the ISAAC study]

OBJECTIVE

To estimate the incidence of allergic rhinitis in schoolchildren in Castellón by comparing phases I and III of the International Study of Asthma and Allergies in Childhood (ISAAC), carried out in 1994 and 2002, respectively.

MATERIAL AND METHODS

A cohort study was performed with 3607 schoolchildren aged 6-7 years old who participated in phase I of the ISAAC study. Of these, 1805 participated in phase III (8 years later) at the age of 14-15 years, with 1627 schoolchildren without allergic rhinitis in phase I. The cumulative incidence of allergic rhinitis was estimated. Two definitions of new cases of allergic rhinitis were used: the first was based on medical diagnosis or treatment of the disease, and the second also included symptoms of allergic rhinitis in the previous 12 months. Relative risks were calculated using Poisson regression.

RESULTS

Participation was 50.0 %, and 151 new cases of allergic rhinitis according to the first definition (cumulative incidence of 9.3 % and 1.2 % per year) and 339 new cases according to the second definition (cumulative incidence of 20.8 % and 2.6 % per year) were found. No differences in incidence by gender were observed with the first definition (RR = 1.00 95 % CI 0.73-1.38) but with the second definition, the incidence was greater in girls (RR = 1.46 95 % CI 1.18-1.82).

CONCLUSIONS

The cumulative incidence of allergic rhinitis according to the first definition was in the range of incidence from cohort studies of adolescents.

Cost-effectiveness of GRAZAX for prevention of grass pollen induced rhinoconjunctivitis in Southern Europe

BACKGROUND

Allergic rhinoconjunctivitis is a global health problem. Around 14 million people in Spain, France, Italy, and Austria suffer from grass pollen induced allergic rhinitis. Standard care only provides symptoms relief, while allergen specific immunotherapy (SIT) treats the underlying cause of the disease. Grazax from ALK-Abelló is a new, tablet-based, effective route of SIT for home treatment. The objective was to assess the cost-effectiveness of Grazax in four Southern European countries.

METHODS

A prospective pharmacoeconomic analyses was carried out alongside a multinational, clinical trial measuring the efficacy of Grazax. Pooled data on resource use and health outcomes were collected. A societal perspective was adopted, and the analysis had a nine-year time horizon. The primary outcome measure was quality adjusted life years (QALYs).

RESULTS

Grazax was superior to standard care for all efficacy endpoints, including QALYs gained, and resulted in significantly less use of rescue medication and fewer hours missed from work. Grazax was cost-effective for all countries for an annual price in the range of 1500 euros - 1900 euros. The result was improved by inclusion of future costs of asthma and exclusion of Spanish trial centers which experienced an exceptionally low pollen season.

CONCLUSION

The analysis illustrates that allergen SIT with Grazax for grass pollen induced rhinoconjunctivitis is a cost-effective intervention in Southern Europe.

Rhinitis and asthma symptoms in non-domestic cleaners from the Sao Paulo metropolitan area, Brazil

BACKGROUND

Exposure to cleaning products has frequently been reported as a symptom trigger by workers with work-related asthma diagnosed in workers' health clinics in the city of São Paulo, Brazil.

OBJECTIVES

To estimate rhinitis and asthma symptoms prevalence and to analyse associated risk factors.

METHOD

A respiratory symptoms questionnaire (Medical Research Council 1976) and the International Study of Asthma and Allergies in Childhood questionnaire were applied to 341 cleaners working in the city of São Paulo, along with obtaining full occupational histories, skin prick tests and spirometry. Timing their symptoms onset in relation to occupational history allowed estimation of work-related asthma and/or rhinitis. Risk factors related to selected outcomes were analysed by logistic regression.

RESULTS

11% and 35% of the cleaners had asthma and rhinitis, respectively. The risk of work-related asthma/rhinitis increased with years of employment in non-domestic cleaning (OR 1.09, 95% CI 1.00 to 1.18, >0.92-3 years; OR 1.28, 95% CI 1.01 to 1.63, >3-6.5 years; OR 1.71, 95% CI 1.02 to 2.89, >6.5 years). Atopy was associated with asthma and rhinitis (OR 2.91, 95% CI 1.36 to 6.71; OR 2.06, 95% CI 1.28 to 3.35, respectively). There was a higher risk of rhinitis in women (OR 2.07, 95% CI 1.20 to 3.70).

CONCLUSIONS

Cleaning workers are at risk of contracting work-related asthma and/or rhinitis, and the risk increases with years of employment in non-domestic cleaning. Women present higher risk of rhinitis than men.

Impact of native, recombinant, and cross-reactive allergens on humoral and T-cell-mediated immune responses

Many native allergens have been purified to homogeneity from natural sources, and whole arrays of recombinant and cross-reactive allergens have been produced in large amounts as biologically active molecules. These allergens offer potent research tools to investigate humoral and T cell-mediated immune responses to allergens in healthy and allergic individuals, providing methods for verifying the responses in a reproducible and dose-dependent manner. Dissecting the immune responses to allergens at cellular and molecular levels provides models for studying the different aspects of T-cell activation and the development of immunologic memory and effector functions. A deep understanding of these mechanisms will fundamentally change the current practice of allergy diagnosis, treatment, and prevention.

A new criterion by which to discriminate between patients with moderate allergic rhinitis and patients with severe allergic rhinitis based on the Allergic Rhinitis and its Impact on Asthma severity items

BACKGROUND

Allergic Rhinitis and its Impact on Asthma (ARIA) differentiates mild from moderate/severe patients on the basis of 4 severity items. The high prevalence of moderate/severe patients suggests the need to differentiate between them.

OBJECTIVES

To identify the categorization that maximizes discrimination between moderate and severe allergic rhinitis (AR) by using ARIA guidelines.

METHODS

Observational, cross-sectional study. Clinical characteristics, nasal symptoms (Total Symptom Score 4), and health-related quality of life (HRQL; Rhinoconjunctivitis Quality of Life Questionnaire and Short Form 12) were assessed. The association of severity items (sleep, daily activities/sport, work/school, and troublesome symptoms) with symptoms and HRQL was analyzed using linear regression models. ANOVA and effect sizes were used to assess differences in symptoms and HRQL among groups defined by the number of affected ARIA items.

RESULTS

Nontreated patients (N = 141) with moderate/severe AR were studied. All severity items showed a similar independent association with symptoms and HRQL scores, and there were no interaction effects, indicating that categorization of patients into moderate and severe could be based only on the number of items affected. Effect sizes were highest between patients with 4 affected ARIA items and those with 3, 2, or 1 affected item (effect sizes greater than 0.8 in all comparisons using Rhinoconjunctivitis Quality of Life Questionnaire and Short Form 12 Physical Composite Summary, and greater than 0.5 using the Total Symptom Score 4; P < .001).

CONCLUSION

Using ARIA severity items, the criterion that best discriminates AR severity is considering moderate those with 1 to 3 affected items and severe those with 4.

CLINICAL IMPLICATIONS

Discrimination between patients with moderate and severe AR should help to obtain homogeneous populations for both research and clinical purposes.

Cost-effectiveness of grass allergen tablet (GRAZAX�) for the prevention of seasonal grass pollen induced rhinoconjunctivitis ? a Northern European perspective

BACKGROUND

The prevalence of allergic rhinoconjunctivitis has increased dramatically. Seventeen million people in the United Kingdom, Germany, the Netherlands, Sweden, Denmark, Norway and Finland suffer from grass pollen induced allergic rhinitis. Symptomatic therapy with antihistamines and topical steroids is partially effective but allergen-specific immunotherapy by injection or sublingual routes is superior. The grass allergen tablet (GRAZAX) is a new allergen-specific immunotherapy for home administration.

OBJECTIVE

To assess the cost-effectiveness of the grass allergen tablet compared with symptomatic medication in seven Northern European countries.

METHODS

A prospective pharmacoeconomic analysis was carried out alongside a multinational clinical trial. Pooled data on resource use and health outcomes were collected. A societal perspective was adopted, and the analysis had a 9-year time horizon. The outcome measure was Quality Adjusted Life Years (QALYs).

RESULTS

The grass allergen tablet was clinically superior to symptomatic treatment, producing statistically significant differences for all efficacy end-points, including the number of QALYs gained - 0.976 vs. 0.947 QALYs gained. There was a significantly higher usage of the rescue medications loratadine and budesonide, and more hours missed from work (production loss), in the symptomatic treatment group. The cost per QALY gained in the grass allergen tablet group was similar in the seven countries (euro 12,930 to euro 18,263 for an annual cost of the grass allergen tablet of euro 1500). The analysis showed that the grass allergen tablet was cost-effective for all countries for an annual treatment cost below euro 2200.

CONCLUSION

The pharmacoeconomic analysis illustrated that allergen-specific immunotherapy with the grass allergen tablet is a cost-effective intervention for the prevention of grass pollen induced rhinoconjunctivitis in Northern European countries, for a tablet price below euro 6. In Germany for example the price of the tablet is euro 2.95 corresponding to a yearly treatment cost of euro 358 - based on a 9-year time horizon.

Critical look at the clinical practice guidelines for allergic rhinitis

Allergic rhinitis (AR) is a major health concern and numerous guidelines have been developed to standardize and to improve the management of this disease. As in many other areas of medicine, the methodology of the AR guidelines has evolved from opinion-based to evidence-based medicine. Although evidence-based medicine has many benefits, it also has limitations and cannot cancel the value of the individual clinical expertise. More important than the methodology of guideline development is the efficacy of guidelines to change patient and physician behaviour and to improve clinical outcomes. At present, however, studies on the effectiveness of guidelines are few. The International Consensus on Rhinitis from 1994 is the only guideline for AR that has been assessed for its effects on health outcomes. Furthermore, there is a lack of valid and reliable instruments to assess physician's and patient's attitude towards and compliance with guideline recommendations. There is no single effective way to ensure the use of guidelines into practice, but a carefully developed and multifaceted dissemination and implementation strategy and targeting and adapting guideline recommendations to the local and individual level are key elements. The final and most important step of putting guidelines into practice occurs at the level of the patient. Patients should be considered as effective partners in health care. Education of the patient and efforts to change patient's behaviour can maximize compliance, increase satisfaction and optimize health outcomes.

Visual analog scales can assess the severity of rhinitis graded according to ARIA guidelines

BACKGROUND

The allergic rhinitis and its impact on asthma (ARIA) guidelines provide a new classification of allergic rhinitis, but a quantitative analysis for severity assessment is lacking.

OBJECTIVE

To study whether a visual analog scale (VAS) for global rhinitis symptoms could be used to assess the disease severity according to ARIA.

METHODS

Three thousand fifty-two allergic rhinitis patients seen in primary care were tested. Fifty three per cent had an objective diagnosis of allergy and 58% of the patients were treated. Patients were categorized according to ARIA guidelines. The severity of nasal symptoms was assessed using a VAS. Quality of life was measured using the rhinoconjunctivitis quality of life questionnaire (RQLQ).

RESULTS

Severity had more impact on VAS levels than duration: mild intermittent rhinitis (3.5, 2.4-5.0 cm), mild persistent rhinitis (4.5, 3.2-5.6 cm), moderate/severe intermittent rhinitis (6.7, 5.3-7.7 cm) and moderate/severe persistent rhinitis (7.2, 6.1-8.2 cm). The receiver operating characteristic curve results showed that patients with a VAS of under 5 cm could be classified as 'mild' rhinitis (negative predictive value: 93.5%) and those with a VAS of over 6 cm as 'moderate/severe' rhinitis (positive predictive value: 73.6%). Receiver operating characteristic curves and a logistic regression showed that current treatment and allergy diagnosis have no effect on the assessment of rhinitis severity using VAS. Visual analog scale and the RQLQ global score were significantly correlated (rho = 0.46; P < 0.0001).

CONCLUSION

A simple and quantitative method (VAS) can be used for the quantitative evaluation of severity of allergic rhinitis.

Rhinoconjunctivitis in 5-year-old children: a population-based birth cohort study

BACKGROUND

There is a paucity of data on the prevalence, risk factors and natural history of rhinitis in early childhood.

OBJECTIVE

Within the context of a whole-population birth cohort we investigated the prevalence of and risk factors for current rhinoconjunctivitis (CRC) at age 5 years.

METHODS

Children were followed prospectively to age 5 years [questionnaires (n = 815), skin testing (n = 717), specific immunoglobulin E (n = 478), lung function (n = 711), dry air challenge (n = 556)]. Endotoxin and allergen exposures were measured in dust samples.

RESULTS

The prevalence of rhinitis ever, current rhinitis and rhinoconjunctivitis was 28.2%, 26.1%, and 12.1%, respectively. Asthma, wheeze and eczema coexisted with CRC (P < or = 0.01). In a multivariate model, maternal asthma (OR 2.38, 95% CI: 1.30-4.38, P = 0.005), paternal hay fever (1.96, 1.11-3.46, P = 0.02) and sensitization to grass (3.46, 1.86-6.42, P < 0.001) and cat (2.42, 1.14-5.18, P = 0.02) remained significant and independent associates of CRC. Whilst almost half of children with CRC were nonatopic, there was little difference in risk factors between atopic and nonatopic CRC. Amongst children with current wheeze, the presence of concurrent CRC had no effect on either severity or frequency of wheezy episodes. There was no difference in specific airway resistance, forced expiratory volume in 1 second (FEV(1)) or airway reactivity between children with and without CRC after adjustment for the presence of wheeze.

CONCLUSION

Family history of allergic disease and sensitization to inhalant allergens are risk factors for rhinoconjunctivitis in preschool children. In this age group, there is no association between the presence of rhinoconjunctivitis and severity of wheeze, increased airway reactivity and reduced lung function.

The safety and efficacy of desloratadine for the management of allergic disease

Allergic disease is an increasing problem worldwide. Allergic rhinitis, an inflammatory response to an allergen, affects an estimated 20-40 million people in the US, while chronic idiopathic urticaria is a dermatoallergic condition that affects 0.1-3% of people in the US and Europe. The primary goals of treatment for allergic rhinitis are to reduce symptoms, which include sneezing, rhinorrhoea and nasal congestion, improve quality of life and prevent the sequelae associated with this disease, while the goal for chronic idiopathic urticaria is the rapid and prolonged control of symptoms. Quantitatively, histamine is the most abundant mediator present during an allergic episode - thus, antihistamines (historically called histamine H(1) receptor antagonists, now called H(1) receptor inverse agonists) are a first-line defense against allergic rhinitis and chronic idiopathic urticaria. Although first-generation antihistamines can cause sedation and cognitive impairment, second-generation antihistamines are relatively non-sedating and free of such adverse events owing to their comparative inability to penetrate the blood-brain barrier. Desloratadine is one such second-generation antihistamine and is indicated for the treatment of allergic diseases, including allergic rhinitis and chronic idiopathic urticaria. It has proven efficacy against the symptoms associated with seasonal and perennial allergic rhinitis, including nasal congestion, and chronic idiopathic urticaria. As a result, it has been shown to improve patients' quality of life. The safety and efficacy profiles of desloratadine are well established, and published postmarketing analyses have assessed >54 000 patients. Although earlier second-generation antihistamines have been associated with cardiovascular adverse effects, desloratadine has been shown to be safe and well tolerated at nine times the recommended dose. In addition, it has been shown to not interact with concomitantly administered drugs and food. Overall, current data indicate that desloratadine is a safe and effective treatment for allergic diseases.

Local IgE production and positive nasal provocation test in patients with persistent nonallergic rhinitis

BACKGROUND

Allergic rhinitis is an IgE-mediated inflammatory disease of the nasal mucosa, which is usually diagnosed by typical symptoms, positive skin tests, and/or serum specific IgE antibodies to allergens. Despite suggestive symptoms of allergic rhinitis, some patients have a negative diagnostic test for atopy.

OBJECTIVE

To evaluate in the nose the inflammatory response, specific IgE to Dermatophagoides pteronyssinus (DP), and the response to a nasal allergen provocation test with DP (NAPT-DP), in patients with persistent nonallergic rhinitis (PNAR) compared with patients with persistent allergic rhinitis (PAR) and healthy controls.

METHODS

Fifty patients with PNAR, 30 with PAR to DP, and 30 healthy controls were studied by determining the nasal leukocyte-lymphocyte phenotype by flow cytometry (CD16, CD8, CD4, CD33, CD3, and CD45), nasal eosinophil cationic protein (ECP), albumin, total and specific IgE to DP, and NAPT-DP.

RESULTS

The PNAR patients showed a similar leukocyte-lymphocyte phenotype in nasal lavage to the PAR patients and was different to the healthy controls. Within the PNAR group, 54% showed a positive NAPT-DP, with 22% of these having nasal specific IgE to DP.

CONCLUSION

These data support the hypothesis that in persistent nonallergic rhinitis some patients may have local inflammation, nasal IgE production, and a positive response to a nasal allergen provocation test despite no evidence of systemic atopy. Further research is needed to evaluate the influence of other perennial allergens and/or immunologic mechanisms.

CLINICAL IMPLICATIONS

The local production of IgE antibodies without systemic detection is a condition that should be considered in patients with PNAR.