Determinants of patient compliance in allergic rhinoconjunctivitis

Effects of a Cloth Panel Containing a Specific Ore Powder on Patients with Chamaecyparis obtusa (Cypress) Pollen Allergy

Pollen allergy to Japanese cedar and cypress is a serious illness that impairs daily life and sleep, especially during pollen season. We have reported that placing a cloth panel containing a specific natural ore powder (CCSNOP) in a room may alleviate the symptoms of hay fever and may also benefit the immune system. This ore is from the Aso mountain range, a volcano on Kyushu Island in the southwestern part of Japan. The purpose of this study was to verify the effect of CCSNOP on cypress pollen. Thirty-one double-blind tests, which investigated cedar pollen allergies, were conducted from February to March 2018 and have already been reported. After this, in early April, 10 of these cases were recruited and all had CCSNOP installed in their bedrooms. Before that, various symptoms and changes in medication were recorded in a “Symptom Diary” and included a mood survey by a questionnaire, stress test using saliva amylase, changes in cypress-specific immunoglobulins IgE and IgG4 by blood sampling, and eosinophil changes. In addition, changes in 29 types of cytokines were investigated. Exposure to CCSNOP relieved symptoms and subjects decreased their intake of medication. There was no change in mood or stress, but eosinophil levels tended to decrease. Although there were no statistical changes in cypress-specific IgE or IgG4, an increase in the former and a decrease in the latter were observed in some individuals during the period of pollen dispersal. Furthermore, levels of GM-CSF and IL8 decreased significantly after use of CCSNOP. The CCSNOP was shown to be effective against cypress pollen allergy, and future investigations will be necessary to observe the long-term effects of CCSNOP.

Which determinants are considered to be important for adherence to Negative Pressure Wound Therapy: A multimethods study

AIM

To explore the extent of patients that choose to cease Negative Pressure Wound Therapy (NPWT) prematurely in a clinical setting, and to explore the determinants of nonadherence.

METHOD

This study exists out of: (1) a retrospective study to assess the number of patients who ceased NPWT prematurely; (2) a narrative review (NR) to identify determinants of nonadherence; and (3) a survey among wound care specialists to explore specific determinants of nonadherence to NPWT.

RESULTS

(1) Based on the retrospective study, 20% ceased NPWT prematurely because of experienced limitations in daily activities. (2) Based on 22 studies, 23 determinants that might influence nonadherence were identified and added as questions in the survey. (3) Twenty-two percent (n = 136) wound care specialists completed the survey. Confidence with the healthcare team, consistency in therapy advices, coping with pain, former negative experiences with NPWT, a normal activity pattern, social support from family or friends, and support from the healthcare team were identified as highly relevant determinants of nonadherence to NPWT. Only religion scored distinctively lower.

CONCLUSION

This study is a first step in exploring the determinants of nonadherence to NPWT. In 20% NPWT was prematurely ceased at the request of the patient, this means that this therapy may have not been the best choice of therapy for this particular patient. The identification of potential determinants of nonadherence may help healthcare professionals in their dialogue with patients. The next step should be a prognostic study to assess which determinants best predict adherence to NPWT.

A survey of primary care practitioners' referral habits and recommendations of allergen-specific immunotherapy for canine and feline patients with atopic dermatitis

BACKGROUND

A recent pilot study of primary care veterinarians' attitudes regarding canine atopic dermatitis and initiation of allergen-specific immunotherapy (ASIT) revealed several barriers to specialist referral (in the USA) and use of ASIT as a treatment modality.

HYPOTHESIS/OBJECTIVES

The primary objective was to collect data on referral habits and ASIT practices among a much larger cohort of primary care veterinarians located around the world, and to explore barriers to referral and management of atopic diseases of dogs and cats with ASIT.

METHODS AND MATERIALS

An online survey, administered through the Veterinary Information Network (VIN, Davis, CA, USA), asked participants to self-report their referral habits and immunotherapy recommendations, and rate barriers and motivating factors using Likert-scale responses.

RESULTS

Of 827 survey responses, 97.6% identified as primary care practitioners. A larger number of practitioners (84.5%) reported seeing atopic dogs often, compared with atopic cats (9.7%). Fewer of these veterinarians (56.6%) referred atopic cats for specialist care, compared to atopic dogs (73.5%). Timely communication, sharing long-term management of the case, and provision of local continuing education were identified as factors associated with increased willingness to refer. A higher proportion of practitioners reported recommending ASIT for dogs (44.3%) than for cats (16.0%). Only 56.0% of respondents considered success rates of ASIT to be acceptable, while 27.9% were neutral on the topic.

CONCLUSIONS AND CLINICAL RELEVANCE

Dermatology specialists might build stronger relationships with referring veterinarians through timely case follow-up and provision of continuing education regarding the long-term benefits of ASIT and symptomatic management practices.

Physicians' prescribing behaviour and clinical practice patterns for allergic rhinitis management in Italy

BACKGROUND

Despite availability of clinical guidelines, underdiagnosis, undertreatment, and poor adherence are still significant concerns in allergic rhinitis (AR) therapeutic management. We investigated clinical practice patterns and prescribing behavior of Italian healthcare professionals (HCPs) specialized in AR.

METHODS

One-hundred allergologists, 100 ear, nose and throat (ENT) specialists, and 150 general practitioners (GPs) were recruited. The survey assessed: socio-demographic, work experience, monthly caseload, prescription drivers. Next, HCPs were invited to retrospectively recover patients' clinical data to investigate: AR clinical characteristics, therapy management, prescription patterns, patient adherence. Descriptive statistics, Chi square, One-Way analysis of variance, and Two-Way Analysis of Variance were performed.

RESULTS

Allergologists visited more AR patients (31% of monthly caseload) than ENTs (21%, p < 0.001), while GPs' caseload was the lowest (6%). Clinical information of 2823 patients were retrieved of whom 1906 (67.5%) suffered from moderate/severe AR (discomfort score: 7.7 ± 1.3) and 917 (32.4%) from mild AR (5.7 ± 1.9). About one-third of mild patients had a discomfort score ≥ 7. Main prescription drivers were "effective on all symptoms" (54.3% patients) and "quick symptom relief" (47.8%), whereas minor drivers were "affordable price" (13.4%) and "refundable" (8.7%). The most prescribed drugs were antihistamines and intranasal corticosteroids (79% and 55% prescriptions), followed by fixed-dose-combination of intranasal azelastine/fluticasone (19%). Polytherapy was the most common treatment strategy (59.6%). HCPs' believe that the majority of the patients was adherent to treatment (88% with score > 7).

CONCLUSIONS

This survey describes the therapeutic approach adopted by Italian physicians to cope with AR and shows that HCPs underestimated AR severity and had a non-realistic perception of patients' adherence. These findings suggest that further efforts are required to improve AR clinical management in Italy.

Why do patients follow physicians' advice? The influence of patients' regulatory focus on adherence: an empirical study in China

Background

In general, medical regimens and treatments are more likely to be effective if patients follow their physicians’ advice. However, limited studies have focused on the relationship between regulatory focus and patient adherence. This study explores the antecedents of patient adherence employing regulatory focus theory.

Methods

This study established a research model consisting of two independent variables, two mediators, one dependent variable, two moderators, three control variables, and six hypotheses. An online survey involving 336 valid responses was conducted to collect data in China. We used structural equation modelling and confirmatory factor analysis to test the hypotheses and to develop the research model.

Results

The reliability and validity of the measures were accepted. In terms of control variables, age had a positive effect on conservative treatment-related health information seeking behaviour, and patients with different resident statuses held different attitudes towards seeking conservative treatment-related health information. However, educational level did not have any effect on the variables of the research model. The hypothesis testing results corroborate that promotion focus had a positive impact on patients’ emerging treatment-related health information seeking behaviour; prevention focus had a positive impact on patients’ conservative treatment-related health information seeking behaviour, which had a positive impact on patient adherence. In addition, media campaigns had a positive impact on the relationship between promotion focus and emerging treatment-related health information seeking behaviour, and website reputation had a positive impact on the relationship between prevention focus and conservative treatment-related health information seeking behaviour.

Conclusions

Individuals can be encouraged to seek health information and share health-related knowledge through mass media, such as the Internet, when the quality of information, especially information from online sources, is guaranteed. In addition, physicians need to improve their professionalism and expand their knowledge of conservative healthcare. As a further application of our work, an Internet information recommendation system can be designed to recommend different types of health information for users according to their regulatory focus.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4127-9) contains supplementary material, which is available to authorized users.

Management of allergic rhinitis in the era of effective over-the-counter treatments

Allergic rhinitis (AR) may be regarded as a trivial issue unworthy of the doctor's time, and with the availability of many different over-the-counter (OTC) treatments, up to two thirds of patients self-manage AR before seeking medical care. Yet, AR can have a significant impact on health-related quality of life and is associated with a greater detriment to work productivity than other chronic diseases such as diabetes and hypertension. For many patients, the impact on quality of life is greater than suggested by reported symptoms and should also be a focus of treatment. Although many patients can effectively manage AR symptoms independently, a significant percentage will need direction from a physician to obtain optimal results. The availability of several different classes of treatment - including decongestants, sedating and non-sedating antihistamines, and more recently intranasal corticosteroids (INS) - has increased the complexity of self-management, leaving patients confused about the best approach to treatment. Treatment guidelines universally classify INS as the most effective medical agents available for use in the OTC and primary care settings. Many patients are unaware that INS are available OTC and that they are more effective than other therapies. Patients may have negative perceptions about the safety of INS and may have experienced unpleasant taste, scent, and feel with nasal sprays. Unless a patient volunteers the information, healthcare professionals (HCPs) may be unaware that the patient has significant AR and is using one or more OTC AR therapies. To address this gap in communication, HCPs must be proactive in identifying, assessing, and advising patients with AR, including best strategies to assess allergen trigger symptoms, which treatments are appropriate, and when and how to use them. Proper use of delivery devices is especially important. This article reviews the primary care management of AR in the context of the availability of effective OTC medicines.

[Adherence in specific immunotherapy]

Allergies are steadily gaining in importance in the Western world. For over one hundred years, immunology has been the only causal treatment. Specific immunotherapy (SIT) aims at the cure of allergy or at least freedom from allergy symptoms. In association with this, adherence poses a complex problem. Both treatment applications commonly used in Germany-sublingual and subcutaneous immunotherapy-show poor persistence on the part of the patients. In most cases, SIT is not carried out to the end of the recommended duration and instead is discontinued prematurely. Corresponding figures from 3‑year studies in the literature range from 41- 93% for uncompleted SLIT and from 40-77% for uncompleted SCIT. Patient adherence is subject to influencing factors of various dimensions that are interdependent in complex relationships. The physician-patient relationship is just as decisive a factor for treatment success as the patient's understanding of allergy, treatment, and the importance of adherence.

Allergen-specific immunotherapy prescription patterns in veterinary practice: a US population-based cohort study

BACKGROUND

Poor adherence to continuing allergen-specific immunotherapy treatment (ASIT) may be an issue in veterinary medicine. No studies describe how allergen tests are used in general veterinary practice, including the percentage of patients that receive ASIT after allergen testing.

HYPOTHESIS/OBJECTIVES

Assess veterinary ASIT patterns in United States general practices.

ANIMALS

Dogs (n = 2,557) and 121 cats allergen-tested at 177 hospitals (173 general practice and four specialty practices) in 44 states.

METHODS

Invoiced service descriptions of allergen tests and ASIT orders were retrieved from an aggregated database of veterinary practices.

RESULTS

In general practice, 42% (992 of 2,360) of patients did not begin ASIT after allergen testing. ASIT was not refilled for 29% (398 of 1,368) of patients after the initial order. ASIT was initiated and refilled more often in dogs (56.6%, 71.4%, respectively) than cats (38%, 67.4%). Specialty practice patients had the highest ASIT initiation (94.4%) and refill (92.7%) percentages in comparison to general practices (P < 0.001). Size, age, geographical region and type of practice were associated with whether dogs were started on ASIT. Geographical region was also associated with refilling a prescription for ASIT, which was considered to be evidence of adherence to continuing treatment.

CONCLUSIONS AND CLINICAL IMPORTANCE

Almost one third of clients failed to continue ASIT beyond the initial order, which is a much shorter duration of therapy than the 12 months recommended for determining ASIT efficacy. A large number of general practice patients did not begin ASIT after allergen testing, likely due to differences in how clinicians in general and dermatology practices use allergen tests.

Comprehensive Study of Patients' Compliance with Sublingual Immunotherapy in House Dust Mite Perennial Allergic Rhinitis

INTRODUCTION

Allergen immunotherapy is a long-term treatment that has been associated with patient adherence issues. The aim of the study was to increase the knowledge on compliance of patients allergic to house dust mites, receiving sublingual immunotherapy (SLIT).

METHODS

A retrospective observational study was performed in 53 Spanish allergy units. We enrolled patients undergoing the SLIT treatment for house dust mites including a scheduled control visit 12 months after initiating the therapy. We conducted a comprehensive assessment of compliance using three methods. In the first step, an allergist evaluated the patients according to the results of an interview and the existing medical records. The subjects taking more than 80% of the overall prescription were defined as compliant. The remaining noncompliant patients were divided into groups taking less than 25%, 25-50%, and 50-80% of the prescribed SLIT. In the second stage, we conducted the Morisky-Green test. Finally, the noncompliant patients were asked to fill a self-report assessment form. Data were stratified into age groups. The potential factors affecting compliance were also investigated.

RESULTS

Overall, 380 subjects participated in the study. The compliance rate was 79.7%, and the treatment discontinuation rate was 22.5%, while 66.8% of patients were adherent (both compliant and continuing with the treatment). The results showed that children were the most compliant and adolescents the least compliant (86.6% and 60.9%, respectively). The main reason for noncompliance was "forgetting some doses" in 31.0% of the children, 48.0% of the adolescents, and 53.2% of the adults. Compliance was associated with the following factors: age, number of annual control visits, and reduction in symptomatic medication.

CONCLUSION

Our results showed that two out of three patients with house dust mite-induced allergic rhinitis adhered to the SLIT treatment. Multidisciplinary and integral solutions are needed to improve the compliance, with special attention paid to adolescents.

FUNDING

Stallergenes Greer Spain.

Adherence to Sublingual Immunotherapy

Adherence is a major issue in any medical treatment. Allergen immunotherapy (AIT) is particularly affected by a poor adherence because a flawed application prevents the immunological effects that underlie the clinical outcome of the treatment. Sublingual immunotherapy (SLIT) was introduced in the 1990s, and the early studies suggested that adherence and compliance to such a route of administration was better than the traditional subcutaneous route. However, the recent data from manufacturers revealed that only 13% of patients treated with SLIT reach the recommended 3-year duration. Therefore, improved adherence to SLIT is an unmet need that may be achieved by various approaches. The utility of patient education and accurate monitoring during the treatment was demonstrated by specific studies, while the success of technology-based tools, including online platforms, social media, e-mail, and a short message service by phone, is currently considered to improve the adherence. This goal is of pivotal importance to fulfill the object of SLIT that is to modify the natural history of allergy, ensuring a long-lasting clinical benefit, and a consequent pharmaco-economic advantage, when patients complete at least a 3-year course of treatment.

Characteristics and predictors of allergic rhinitis undertreatment in primary care

Although allergic rhinitis is considered a raising medical problem in many countries it is often undertreated. The reasons for this phenomenon are not completely clear.The aim of this study is to evaluate factors associated with allergic rhinitis under-/no treatment.A sample of 518 allergic rhinitis patients recruited by their primary care physicians, as a part of the ARGA study, were invited to fill in a specific questionnaire regarding rhinitis symptoms, treatment, and rhinitis-related work/social disability. Chi-square test and logistic regression were performed to assess risk factors for allergic rhinitis under-/no treatment.Over one out of four patients had no treatment despite the symptoms and 13.5% were inadequately treated. Participants with asthma (OR 0.47, 95% CI 0.30-0.75) and conjunctivitis (0.44, 95% CI 0.27-0.71) were at lower risk of allergic rhinitis under-/no treatment: in asthmatics this reduction was related mainly to the concomitant asthma treatment (OR 0.19, 95% CI 0.10-0.37).Asthmatics with under-/not treated rhinitis had the highest prevalence of rhinitis-related quality of life impairment.Under-/no treatment for allergic rhinitis is still rather frequent despite the relevance of this disease. The simultaneous presence of asthma and an anti-asthmatic therapy are able to influence positively the treatment. Targeted interventions toward a better characterization and a tight follow-up of rhinitis patient without asthma are needed.

Persistence of treatment with 5-grass pollen tablets in patients with allergic rhinitis: a real-life study

BACKGROUND

In patients with allergic rhinitis, treatment adherence to allergen immunotherapy varies greatly in randomized and real-life studies.

OBJECTIVE

To evaluate the use of a 5-grass pollen tablet as sublingual immunotherapy, its treatment persistence, and the reasons for discontinuation in a real-life clinical setting.

METHODS

This multicenter, prospective, open-label, noncontrolled observational study evaluated the use of sublingual immunotherapy with a 5-grass pollen tablet in a cross-sectional population of patients (≥5 years old) with grass pollen-induced allergic rhinitis with or without asthma. The primary objective was to determine the percentage of patients persisting with treatment across 1 season in a pre-co-seasonal scheme. Secondary objectives included evaluation of reasons for treatment discontinuation, safety and adverse events; effectiveness (based on physician and patient assessments), and treatment compliance.

RESULTS

The study included 196 patients (49.2% male, mean age 27.5 years, range 5.3-65.7 years), with treatment provided by 47 participating physicians. Sixty-seven percent of patients had polysensitivity and 32% had coexistent asthma. On average, patients were treated for 7 months with the 5-grass pollen tablet. After 1 month, 85% of all patients persisted with treatment, and 70% persisted after 7 months. Treatment discontinuation was due chiefly to known side effects (mild to moderate local allergic reactions). Most patients reported symptom improvement; 80% of all patients intended to continue treatment next season.

CONCLUSION

Most patients with allergic rhinitis treated pre-co-seasonally with a 5-grass pollen tablet persisted with treatment after the first pollen season. Patients were willing to continue their treatment in the following season owing to improvement of symptoms.

Prevalence of uncontrolled allergic rhinitis in Wuhan, China: a prospective cohort study

BACKGROUND

Allergic rhinitis (AR) is a highly prevalent disease that affects the quality of life, especially in the "severe chronic upper airway disease" (SCUAD) group of patients who still have severe symptoms after adequate treatment. This study investigated the prevalence of uncontrolled AR and SCUAD consulting in the Allergy Department of Tongji Hospital, Wuhan, China.

METHODS

In this prospective cohort study, all patients consulting for AR were prospectively assessed using visual analog scale (VAS) and Allergic Rhinitis Control Test (ARCT) and put on standardized treatment based on the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines. After 15 days, they were reevaluated by a telephone interview using a numerical scale (NS) and ARCT. A score of ARCT of <20 defined uncontrolled AR and a score of NS of ≥5 at day 15 defined SCUAD patients.

RESULTS

A total of 252 patients were included. Moderate/severe AR (VAS ≥ 5) was diagnosed in 82.9% of the patients which had an impact on sleep (86.9%), work life (84.9%), social activities (81%), and physical activities (90.1%). Patients with uncontrolled AR (27.7%) at day 15 more frequently presented a higher weight (p = 0.042), history of ear, nose, and throat (ENT) infection or antibiotics intake for respiratory infection in the last 12 months (62.3% versus 45.6%; p = 0.018), smoking (15.9% versus 6.7%; p = 0.024), and smell disturbance (26.1% versus 11.7%; p = 0.005). Patients with SCUAD (24.5%) more frequently presented a history of ENT infection or antibiotics intake for respiratory infection in the last 12 months (63.9% versus 45.7%; p = 0.014) and smell disturbance (27.9% versus 11.7%; p = 0.003), and less commonly had atopic dermatitis (13.1% versus 28.2%; p = 0.017).

CONCLUSION

Uncontrolled AR and SCUAD patients are numerous. VAS and ARCT are simple and quantitative methods and self-completion questionnaires that can be used for a global evaluation of the severity and control of AR.

Reasons for prescribing second generation antihistamines to treat allergic rhinitis in real-life conditions and patient response

Background

Second generation H1 antihistamines (H1A) are currently recommended as first choice medications for allergic rhinitis and rhinoconjunctivitis. However, little is known about what influences the choice of prescription of one second generation (H1A) as opposed to another in real-life conditions.

Objective

The aim of the study was to identify the main criteria determining the choice of a second generation H1A by allergy specialists in mainland France.

Methods

Consecutive patients suffering from allergic rhinitis or rhinoconjunctivitis were included and followed prospectively for 30 days from the prescription of a second generation H1A in monotherapy. Patients were asked to fill in auto-questionnaires at baseline, daily during the first 10 days of the new treatment, and at the end of follow-up. Data on efficacy, tolerance, safety, rate and type of response to treatment, as well as patient satisfaction were recorded and analyzed.

Results

1,080 patients were included between March 2011 and October 2012, mostly suffering from moderate to severe rhinitis (82.0%). The most frequently cited reason for choosing a specific H1A was the expected efficacy (85.3%). The mean time to nasal and ocular recovery was 6 days and 78.2% of patients responded to treatment within this interval. The presence of conjunctivitis was significantly associated with a more rapid response. At the end of follow-up, the satisfaction rate was higher for patients who were switched from a previous treatment (87.5%), compared to those receiving their first treatment (78.8%).

Conclusion and clinical relevance

The main reason for choosing a specific second generation H1A was its expected efficacy. Concomitant conjunctivitis is associated with a more rapid response to treatment. Symptom recovery necessitates a mean of 6 days.

Patient initiation and persistence with allergen immunotherapy

BACKGROUND

Allergen immunotherapy (AIT) is advised for patients with allergic rhinitis who remain symptomatic despite the use of pharmacotherapy and allergen avoidance. Several factors influence the decision to initiate and complete the AIT regimen.

OBJECTIVE

To evaluate patient initiation and persistence with subcutaneous and sublingual immunotherapies (SCIT and SLIT) according to physician recommendation.

METHODS

A retrospective review of electronic health records of patients with allergic rhinitis for whom AIT was recommended was conducted in a large private allergy practice in Pennsylvania.

RESULTS

Of 8,790 patients advised to consider AIT, 36.2% initiated AIT (57% adults, 43% children); 78% chose SCIT and 22% chose SLIT drops. Election of AIT was significantly associated with select comorbidities, specifically chronic sinusitis (8.1% for AIT vs 10% for no AIT), allergic conjunctivitis (12.5% for AIT vs 18.5% for no AIT), and asthma (33.8% for AIT vs 37.4% for no AIT; P < .05). Choice of SCIT vs SLIT drops was significantly associated with older age, female sex, select comorbidities, and more allergy medications at initiation (P < .05). Of adults, 30.2% completed at least 3 years of recommended treatment. Median time on treatment was longer for adults on SCIT vs SLIT drops (3 vs 1.6 years). Similarly, 35.4% of children completed treatment, with a longer median time on treatment for SCIT (4.7 years) vs SLIT drops (3.5 years).

CONCLUSION

A minority of patients initiated AIT according to allergist recommendation and a subset of these patients completed therapy. AIT might be an underused option that could benefit patients unable to manage allergic rhinitis symptoms by other means.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01549340.

Allergic conjunctivitis: an update on diagnosis and management

PURPOSE OF REVIEW

The focus of this review is to provide a logical paradigm for the diagnosis and treatment of ocular allergies, with a focus on seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC).

RECENT FINDINGS

Several classes of topical medications are currently available for the management of ocular allergies, including: lubricating agents, vasoconstrictors, antihistamines, mast cell stabilizers, and topical corticosteroids.

SUMMARY

SAC and PAC make up the vast majority of ocular allergy cases. A proactive approach to these diseases, anticipating the regional spring and fall allergen spikes, is needed for optimally managing these disorders. A multifaceted treatment regimen comprising patient education, lifestyle modification, and topical medications (such as antihistamines and/or mast cell stabilizers and corticosteroids) may be required in order to manage ocular allergies effectively. The appropriate treatment paradigm is based on the severity of the patients' signs and symptoms. For moderate-to-severe cases, especially chronic vernal keratoconjunctivitis, atopic keratoconjunctivitis, and giant papillary conjunctivitis, comanagement with an ophthalmologist is recommended.

Emerging drugs for allergic conjunctivitis

INTRODUCTION

Allergic conjunctivitis (AC) is a very common disease, especially in association with allergic rhinitis but may also occur in isolated presentation. The treatment of AC has long been based on antihistamines, cromones and topical corticosteroids, but none of these drugs completely abolishes the clinical expression of AC.

AREAS COVERED

The development of new drugs for AC is analyzed highlighting the recent insights into the pathophysiological mechanisms of the disease. The major aim of development of drugs for AC is to have agents able to prevent the inflammatory effects of the interaction between the allergen and the specific IgE antibodies on mast cell surface. This may be obtained by blocking the effects of histamine (the main mediator of early allergic response) by H1-receptor antagonists, inhibiting the release of soluble factors able to recruit inflammatory cells (that sustain prolonged inflammation) by mast-cell stabilizers, inhibiting the effects of single mediators, inducing tolerance to the allergen by specific immunotherapy or even acting on factors related to activation and differentiation of T lymphocytes such as the toll-like receptors.

EXPERT OPINION

AC is an underestimated disease for which there is a search of more effective treatments. The availability of the drugs under current evaluation will allow more refined therapeutic strategies to apply according to the characteristics and the clinical severity of AC.

Laboratory tests and compliance of dermatologic outpatients

Laboratory tests, including blood tests and urine analysis, are frequently performed in the dermatology outpatient clinic, but doctors often do not consider the cognitive or psychological effect of the examinations. Based on terror management theory, we hypothesized that performing laboratory tests increases the patient’s fear of mortality, and therefore has a positive effect on the patient’s attitude toward the doctor’s recommendations and willingness to accept them. The study employed a single factor between-subjects design, using a questionnaire completed by the patients. One group consisted of patients who had undergone laboratory tests 1 week before the survey, and the other group consisted of patients who had not undergone a laboratory test. Although the differences between two groups were not statistically significant, the patients who had laboratory tests had tendency to show even lower positive attitude toward the doctor’s recommendations and less intention to follow the recommendations. In contrast to our hypothesis, performing laboratory tests does not subliminally increase patients’ fears or anxieties about their disease or their compliance with doctors’ recommendations.

Patients' compliance with different administration routes for allergen immunotherapy in Germany

BACKGROUND

Allergen immunotherapy (AIT) is the practice of administering gradually increasing quantities of an allergen extract to an allergic subject to ameliorate the symptoms associated with the subsequent exposure to the causative allergen. It is the only treatment that may alter the natural course of allergic diseases. According to AIT guidelines and summary of product characteristics (SmPCs), the treatment should be carried out for at least 3 years. It is controversially discussed whether subcutaneous or sublingual administration routes cause higher patients' compliance.

METHODS

German sales data for different preparations of the allergen manufacturer Allergopharma GmbH & Co. KG were retrospectively evaluated for 5 consecutive years, based on prescriptions per patient: pollen sublingual immunotherapy (SLIT) and high-dose hypoallergenic (allergoid) or unmodified depot pollen and mite preparations for subcutaneous immunotherapy (SCIT). To identify patients' compliance, "completed treatment years" were determined. A completed treatment year was defined by the required number of prescribed allergen preparations according to the recommended dosage scheme given in the respective SmPCs.

RESULTS

Prescription data of 85,241 patients receiving pollen or mite SCIT and 706 patients receiving pollen SLIT were included in this analysis. Patients' compliance for at least 3 treatment years with high-dose hypoallergenic pollen SCIT was higher when administered perennially (60%) compared to preseasonally (27%). Prescriptions for at least 3 years were received from 42% of patients with pollen SCIT and from 45% of patients with mite SCIT. Compliance with SLIT was lowest with only 16% of patients receiving prescriptions for at least 3 treatment years. Children and adolescents were more compliant than adults, independent of whether they received SLIT or SCIT.

CONCLUSION

In general, patients' compliance with SCIT using high-dose hypoallergenic or unmodified depot preparations was higher than with pollen SLIT. Perennial application of SCIT seems to increase compliance in comparison to the preseasonal application. Children and adolescents were most compliant, independent of the preparation applied.

Patient adherence to allergy immunotherapy

PURPOSE OF REVIEW

This article reviews the literature on patient adherence to two different approaches to allergen-specific immunotherapy for allergic disease. Factors related to adherence in general, as well as the various methods used to measure adherence, will be discussed.

RECENT FINDINGS

Although a complex interaction of factors related to both the physician and the patient influence the adherence to a particular therapeutic regimen, effective communication between these two parties and the simplicity of the regimen are frequently noted to be of primary importance. Variability with respect to the definition of adherence, the method of measuring adherence, and the length of the measuring period has resulted in a wide range of adherence rates to allergy immunotherapy reported in the literature. Patients most often site inconvenience, side-effects, and poor efficacy as reasons for discontinuing allergy immunotherapy.

SUMMARY

Adherence to therapy not only improves individual patient outcomes, but also helps determine the best treatment modalities and reduces the burden of disease on society. As new methods of delivering immunotherapy are being developed, such as allergy immunotherapy tablets and oral mucosal immunotherapy, the factors associated with patient adherence should be carefully considered.

Adherence to pharmacological treatment and specific immunotherapy in allergic rhinitis

The term compliance simply indicates how much doses of the prescribed medication are taken, whereas the term adherence implies also an agreement between patient and physician about the therapeutic plan, and it is therefore preferred. Adherence is a main problem in all long-term treatments. Thus, it represents a problem also in the case of rhinitis, expecially concerning specific immunotherapy that must be assumed continuously for several years. Many factors can affect the adherence, depending on patient, on treatment itself and on the healthcare context, and all those factors usually interact. The adherence measured in controlled trials is usually good, but this does not reflect what happens in real life, where adherence should be preferably measured. There are few data on the adherence in real life for pharmacological treatments of allergic rhinitis (e.g. nasal steroids or antihistamines), whereas more data are available for specific immunotherapy. In this latter case, in real life, adherence seems to be far from optimal, for both sublingual and subcutaneous immunotherapy, although the recent studies agree on the fact that some interventions (i.e. patients' education, strict follow-up, regular contacts) could effectively improve the adherence. In this article, the literature concerning the adherence to pharmacological treatments and immunotherapy in allergic rhinitis was searched and reviewed.

Diagnostics and new developments in the treatment of ocular allergies

About 30% of people suffer from allergic symptoms, and 40% to 80% of them have eye symptoms. Atopic conjunctivitis is divided into seasonal allergic conjunctivitis and perennial allergic conjunctivitis. The treatment of seasonal allergic conjunctivitis is simple: antihistamines, anti-inflammatory agents, or cromoglycate. Perennial allergic conjunctivitis needs longer therapy with mast cell stabilizers and sometimes local steroids. Atopic keratoconjunctivitis requires long-term treatment of the lid eczema and keratoconjunctivitis. Vernal keratoconjunctivitis mainly affects children and young people. It commonly calms down after puberty. It demands intensive therapy, often for many years, to avoid serious complicating corneal ulcers. Giant papillary conjunctivitis is a foreign body reaction in contact lens users or patients with sutures following ocular surgery. Nonallergic eosinophilic conjunctivitis affects mostly middle-aged and older women with eosinophilic conjunctivitis and dry eye. Contact allergic blepharoconjunctivitis is often caused by cosmetics and eye medication. Work-related ocular allergies should be considered as a cause of resistant ocular symptoms in workplaces.

Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today?

State-of-the-art documents like ARIA and EPOS provide clinicians with evidence-based treatment algorithms for allergic rhinitis (AR) and chronic rhinosinusitis (CRS), respectively. The currently available medications can alleviate symptoms associated with AR and RS. In real life, a significant percentage of patients with AR and CRS continue to experience bothersome symptoms despite adequate treatment. This group with so-called severe chronic upper airway disease (SCUAD) represents a therapeutic challenge. The concept of control of disease has only recently been introduced in the field of AR and CRS. In case of poor control of symptoms despite guideline-directed pharmacotherapy, one needs to consider the presence of SCUAD but also treatment-related, diagnosis-related and/or patient-related factors. Treatment-related issues of uncontrolled upper airway disease are linked with the correct choice of treatment and route of administration, symptom-oriented treatment and the evaluation of the need for immunotherapy in allergic patients. The diagnosis of AR and CRS should be reconsidered in case of uncontrolled disease, excluding concomitant anatomic nasal deformities, global airway dysfunction and systemic diseases. Patient-related issues responsible for the lack of control in chronic upper airway inflammation are often but not always linked with adherence to the prescribed medication and education. This review is an initiative taken by the ENT section of the EAACI in conjunction with ARIA and EPOS experts who felt the need to provide a comprehensive overview of the current state of the art of control in upper airway inflammation and stressing the unmet needs in this domain.

A survey of the burden of allergic rhinitis in Hungary from a specialist's perspective

BACKGROUND

The casual and severity distribution of allergic rhinitis (AR) in Hungary is unknown.The aim of this survey was to evaluate symptom perception, disease severity, concomitant asthma frequency and the impact of AR on everyday life activities in a cross-sectional, multicenter study in Hungary under the supervision of Hungarian Respiratory Society.

METHODS

Data were recorded by 933 AR patients (65.93% women) and their treating specialists. The perceptions of patients regarding the symptoms (nasal, ocular and others) of AR and its severity, together with its impact on everyday life were assessed. Physicians recorded data regarding the diagnosis and severity of AR, and comorbidities.

RESULTS

52.5% of patients suffered from seasonal AR, 35.1% from perennial AR. A large proportion of patients had moderate to severe disease (MS-AR) (57.34%), persistent disease (98.0%) and concomitant asthma (53.32% in the mild, 57.52% in the MS-AR group). MS-AR was more frequent among women. Despite the treatment used, in MS-AR the proportions of patients reporting moderate to severe rhinorrhoea, nasal obstruction, ocular itching/redness, watering, itchy throat and sneezing were as high as 52.0%, 54.0%, 33.8%, 26.5%, 44.0% and 31.2%, respectively. Overall, there was a poor agreement between disease severity reported by patients and specialists. The adherence to oral antihistamines and intranasal corticosteroids was found to be between 50 and 65%; mostly depending on the dosage form.

CONCLUSIONS

AR remains a significant health problem in Hungary because of the burden of symptoms, high rate of concomitant asthma and the significant proportion of MS-AR affecting general well being.

A comparison of attrition rates in patients undergoing sublingual immunotherapy vs subcutaneous immunotherapy

BACKGROUND

Effective allergy immunotherapy (IT) requires patient compliance. Numerous studies have shown high noncompliance rates in patients undergoing IT. For patients enrolled in subcutaneous IT (SCIT), noncompliance rates were noted to range from 11% to 50%, whereas sublingual IT (SLIT) patients had noncompliance rates ranging from 3% to 25%. Comparing noncompliance rates is difficult because noncompliance in SCIT is defined as withdrawal from therapy, whereas in SLIT it is considered poor adherence to daily administration. The aim of this study was to compare attrition rates in patients enrolled in SCIT vs SLIT, as well as major factors leading to termination of IT.

METHODS

We retrospectively compared attrition rates, IT duration, and reasons for termination between patients enrolled in SCIT (n = 139) and SLIT (n = 78), over a 4-year period.

RESULTS

Attrition rates for SCIT and SLIT were 45% and 41%, respectively (p = 0.669). No significant difference in duration of IT was observed between the groups (≤1 month, p = 0.079; 1-2 months, p = 0.486; 2-3 months, p = 0.165; 3-6 months, p = 0.575; 6-12 months, p = 0.361; 12-24 months, p = 1.000; and ≥24 months, p = 0.258). Among reasons cited for discontinuing IT, SCIT patients reported inconvenience (p = 0.001), whereas SLIT patients indicated efficacy concerns (p = 0.022) as the major basis for withdrawal.

CONCLUSION

No significant difference was observed in attrition rates between SCIT and SLIT. While there was no significant difference in duration of IT prior to withdrawal, there was a trend toward earlier withdrawal in SCIT patients. The reasons for withdrawal, however, were considerably different between the 2 groups.

[Pharmacoprophylaxis and co-medications in allergen-specific immunotherapy]

Drugs that are used in relation to allergen-specific immunotherapy (SIT) can be separated into pharmacoprophylaxis to avoid or decrease local and systemic adverse effects of SIT and in co-medications to treat other diseases. Regarding pharmacoprophylaxis, H1-antihistamines are able to reduce local and mild systemic, but not severe systemic side effects of SIT. H1-antihistamines do not attenuate the efficacy of SIT. Severe systemic side effects have been blocked in some cases with omalizumab; currently this agent can be used off-label during venom SIT. With regard to co-medication, the concomitant use of immunomodulating drugs during SIT must be individualized, if the effective profile and side effects of the immunomodulating drug are well-known and a negative effect on SIT is not likely. Recently approved immunosuppressive drugs and biologics are perceived critically due to their unpredictable immunologic effects. For forensic reasons cardioselective beta blockers should be discontinued although no data are available demonstrating adverse effects. If discontinuation is not justified and venom SIT is indicated, SIT can be performed while taking beta blockers. In contrast, ACE-inhibitors should always be stopped in patients with insect venom allergy.