A common language to assess allergic rhinitis control: results from a survey conducted during EAACI 2013 Congress

Determinants of uncontrolled allergic rhinitis in Kinshasa hospitals

Objective

To identify the determinants of uncontrolled allergic rhinitis (UCAR) in a hospital setting in Kinshasa, Democratic Republic of Congo.

Methods

Hospital-based cross-sectional study of 153 patients with allergic rhinitis (AR). The diagnosis of AR was based on clinical grounds according to the Allergic Rhinitis and its Impact on Asthma (ARIA) criteria. Categorization into controlled AR (CAR) and UCAR was based on the visual analog scale (VAS with cut off point of 5). Binary logistic regression was used to identify factors associated with UCAR.

Results

Patients with UCAR (60.1%) proportionally outnumbered those with CAR (39.9%). There were significantly more patients younger than 30 years of age among patients with UCAR. Factors significantly associated with UCAR were age below 30 years (OR = 3.31; 95% CI: 1.49-7.36; p = 0.003), low serum vitamin D level (OR = 3.86; 95% CI: 1.72-8.68; p = 0.001), persistent form (OR = 3.11; 95% CI: 1.39-6.98; p = 0.006) and moderate to severe form of AR (OR = 4.31; 95% CI: 1.77-10.49; p = 0.001).

Conclusions

Factors associated with UCAR in this study population were younger age less than 30 years, low vitamin D level, and persistent as well as moderate to severe AR. Further studies are needed to elucidate the underlying mechanisms favoring the occurrence of these factors.

Assessment of Nasal Smear Eosinophil Counts in Allergic Rhinitis: How Useful is it?

Objectives: The aim was to find the relationship between nasal smear eosinophil (NSE) counts and allergic rhinitis (AR) along with the impact of treatment on peak nasal inspiratory flow rates and symptom scores in these patients. Material and methods: An observational, comparative study was carried out with 75 patients of AR. Nasal smears were drawn and eosinophil counts were estimated. Nasal symptoms were assessed and compared by visual analogue scale (VAS) and peak nasal inspiratory flow (PNIF) rates before and after treatment. Equal number of healthy individuals formed the control group. Results: There was a strong association between increase in eosinophil count in nasal smears and AR (p = 0.000). A NSE count of 0.2/HPF had a specificity of 98.7%, sensitivity of 53.3%, and positive predictive value of 97.6% in the diagnosis of AR. The mean VAS scores for nasal obstruction improved from 7.35 to 1.01 and the mean peak nasal inspiratory flow from 69.00 L/min to 103.73 L/min (p < 0.0001) after treatment. The mean NSE counts reduced from 4.20/HPF to 0.090/HPF proving a strong correlation between improvement of symptom scores and NSE counts (p = 0.000) in AR. The study also determined that a PNIF value of ≤ 77.50 L/min can be used as a cut off for diagnosing nasal obstruction in these patients. Conclusion: A NSE count of ≥ 0.2 /HPF is to be considered as diagnostic of AR. Nasal congestion is the commonest symptom associated with AR and addition of systemic decongestant is required for management of these patients.

mHealth and telemedicine utility in the monitoring of allergic diseases

This literature review discusses the use of mHealth technologies and telemedicine for monitoring various allergic diseases both in everyday life and in the context of COVID-19. Telemedicine, whose popularity, and demand has skyrocketed during the pandemic, rely on mHealth technologies, video calls and websites as a resource-saving and safe way of consulting patients. The incorporation of new mHealth technologies into telemedicine practice may not only be relevant in the context of pandemic restrictions but can also be applied in everyday medical practice as an effective method of patient counseling. The mobile healthcare applications include a wide range of mobile apps for patients' education, monitoring, and disease management. However, applications for the people with food allergies lack relevant information about allergies and, like most other applications, are developed without the contribution of healthcare specialists. During the COVID-19 pandemic, low-risk food-allergic patients were able to rely on telemedicine services where they could get the help, they needed without increasing risk of contracting COVID-19 while saving time. Meanwhile, some applications for allergic rhinitis and asthma patients are showing practical benefits in clinical trials by allowing an efficient assessment of treatment regimens and efficacy. The use of digital symptom diaries further facilitates the implementation of real-life studies. However, for respiratory allergic diseases, the often insufficient quality of pollen prediction needs to be taken into account. Even though studies have shown that asthma is better controlled with mHealth technologies, the quality of mobile apps for asthma patients varies widely, as many products provide information that has not been scientifically proven. Inhaler sensors - have been shown to improve the course of asthma and its monitoring, while push notifications prompting people to take their medication double the likelihood of treatment adherence. Teledermatology has a high level of patient satisfaction - as it is perceived as a more time-saving method of consultation. However, the diagnostic accuracy of contact consultations remains higher. mHealth technologies provide a patient's health data from his/her daily life, which enables insights into behavioral patterns. This closer look at the daily routine can have a significant impact on developing individualized treatment and care guidelines.

COVID-19, Anosmia, and Allergies: Is There a Relationship? A Pediatric Perspective

Background: Between June and July 2020, we evaluated children and adolescents concerning post-infection surveillance after a COVID-19 positivity during the lockdown. We aimed to assess whether the anamnestic presence of allergies could correlate with the presence of SARS-CoV-2 symptoms, and in particular with anosmia. Material and methods: For each patient, we collected anamnestic data, the presence of allergies documented by performing skin prick tests, and COVID-19 symptoms. Then, if over six years of age, each patient underwent an active anterior rhinomanometry. Results: A total of 296 patients were enrolled, of whom 105 (35.4%) reported allergies. Considering COVID-19 symptoms, 74 subjects (25%) presented an asymptomatic form, 222 (75%) reported symptoms, and anosmia recurred in 60 subjects (27.03%). A statistically significant relationship was found between allergies and symptomatic COVID-19 (p = 0.042), allergies, and anosmia (p = 0.05), and allergies and anosmia in males (p = 0.007). Moreover, anosmic patients presented a higher body mass index, older age, and a longer COVID-19 duration with statistical significance (p = 0.001, 0.001, 0.006, respectively). Conclusions: Allergic subjects seem to develop symptomatic COVID-19 more frequently and allergies appear to be a protective factor from anosmia’s onset in males.

The MaDo real-life study of dose adjustment of allergen immunotherapy liquid formulations in an indication of respiratory allergic disease: Reasons, practices, and outcomes

Sublingual allergen immunotherapy (SLIT) is a safe, effective, disease-modifying treatment for moderate-to-severe respiratory allergies. The function and responsiveness of the immune system components underlying the effects of allergen immunotherapy may vary from one patient to another. Furthermore, the severity of the symptoms of allergic disease can fluctuate over time, due to changes in environmental allergen exposure, effector cell responsiveness, and cell signaling. Hence, the allergen dose provided through SLIT can be fine-tuned to establish an optimal balance between effectiveness and tolerability. The objective of the MaDo study was to describe and understand dose adjustments of SLIT liquid formulations in France. We performed a retrospective, observational, cross-sectional, real-life study of allergists and other specialist physicians. Physicians described their patients via an anonymous case report form (CRF). The main patient inclusion criteria were age 5 years or over, at least one physician-confirmed IgE-driven respiratory allergy, and treatment for at least 2 years with one or more SLIT liquid preparations. A nationally representative sample of 33 specialist physicians participated in the study. The physicians' main stated reasons for dose adjustment were adverse events (according to 90.9% of the physicians), treatment effectiveness (60.6%), sensitivity to the allergen (42.4%) and other characteristics (30.3%: mainly symptom severity, type of allergen, and asthma). 392 CRFs (mean ± standard deviation patient age: 27.8 ± 17.5; under-18s: 42.1%; polyallergy: 30.9%) were analyzed. Respectively 53.6%, 25.8%, 15.3%, and 8.7% of the patients received house dust mite, grass pollen, birch pollen and cypress pollen SLIT. Dose adjustments were noted in 258 (65.8%) patients (at the start of the maintenance phase for 101 patients (39.2%) and later for 247 (95.7%)). Dose adjustment was not linked to sex, age, or the number of allergens administered. All measures of disease severity (including symptom severity noted on a 0-to-10 visual analogue scale by the physician) decreased significantly during SLIT. Notably, the mean AR symptom severity score decreased to a clinically relevant extent from 7.6 at SLIT initiation to 2.4 at last follow-up, and the mean asthma symptom severity score decreased from 5.0 to 1.3. The few differences in effectiveness between patients with vs. without dose adjustment were not major. For about one patient in five, a specialist physician decided to reduce or increase the SLIT liquid dose at the start of maintenance treatment and/or during maintenance treatment. This decision was influenced by a broad range of patient and treatment factors, mainly to improve tolerability to treatment and/or enhance effectiveness. In France, dose adjustment of SLIT liquid preparations as a function of the patient profile and/or treatment response is anchored in clinical practice. Precision dosing might optimize the overall benefit-risk profile of AIT for individual patients throughout their entire treatment course, enabling them to achieve both short- and long-term treatment goals, whilst maximizing the safety and tolerability.

ARIA digital anamorphosis: Digital transformation of health and care in airway diseases from research to practice

Digital anamorphosis is used to define a distorted image of health and care that may be viewed correctly using digital tools and strategies. MASK digital anamorphosis represents the process used by MASK to develop the digital transformation of health and care in rhinitis. It strengthens the ARIA change management strategy in the prevention and management of airway disease. The MASK strategy is based on validated digital tools. Using the MASK digital tool and the CARAT online enhanced clinical framework, solutions for practical steps of digital enhancement of care are proposed.

Interventions Delivered in the Community Pharmacy to Manage Allergic Rhinitis- A Systematic Review of the Literature

Pharmacists have a valuable role in the management of allergic rhinitis (AR) at the community pharmacy level. This role has been reported extensively in numerous papers. However, a systematic review of the available literature and a comprehensive analysis of the outcomes has not been published. This systematic review aimed to evaluate the impact of interventions developed by pharmacists on clinical AR outcomes. A thorough search was performed in three electronic databases, including studies published between January 2000 and June 2019. After the selection process, only three articles met the inclusion criteria and were further analysed. Despite the scarcity of the available studies, in all of them was clear that the pharmacist plays a pivotal role in the management of AR, significantly improving the patients’ quality of life and symptom control. This systematic review also stresses the utmost importance to investigate and report practices and interventions developed by pharmacists using measurable outcomes.

Mobile Technology in Allergic Rhinitis: Evolution in Management or Revolution in Health and Care?

Smart devices and Internet-based applications (apps) are largely used in allergic rhinitis and may help to address some unmet needs. However, these new tools need to first of all be tested for privacy rules, acceptability, usability, and cost-effectiveness. Second, they should be evaluated in the frame of the digital transformation of health, their impact on health care delivery, and health outcomes. This review (1) summarizes some existing mobile health apps for allergic rhinitis and reviews those in which testing has been published, (2) discusses apps that include risk factors of allergic rhinitis, (3) examines the impact of mobile health apps in phenotype discovery, (4) provides real-world evidence for care pathways, and finally (5) discusses mobile health tools enabling the digital transformation of health and care, empowering citizens, and building a healthier society.

ARIA pharmacy 2018 "Allergic rhinitis care pathways for community pharmacy": AIRWAYS ICPs initiative (European Innovation Partnership on Active and Healthy Ageing, DG CONNECT and DG Santé) POLLAR (Impact of Air POLLution on Asthma and Rhinitis) GARD Demonstration project

Pharmacists are trusted health care professionals. Many patients use over-the-counter (OTC) medications and are seen by pharmacists who are the initial point of contact for allergic rhinitis management in most countries. The role of pharmacists in integrated care pathways (ICPs) for allergic diseases is important. This paper builds on existing studies and provides tools intended to help pharmacists provide optimal advice/interventions/strategies to patients with rhinitis. The Allergic Rhinitis and its Impact on Asthma (ARIA)-pharmacy ICP includes a diagnostic questionnaire specifically focusing attention on key symptoms and markers of the disease, a systematic Diagnosis Guide (including differential diagnoses), and a simple flowchart with proposed treatment for rhinitis and asthma multimorbidity. Key prompts for referral within the ICP are included. The use of technology is critical to enhance the management of allergic rhinitis. However, the ARIA-pharmacy ICP should be adapted to local healthcare environments/situations as regional (national) differences exist in pharmacy care.

MASK 2017: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma multimorbidity using real-world-evidence

mHealth, such as apps running on consumer smart devices is becoming increasingly popular and has the potential to profoundly affect healthcare and health outcomes. However, it may be disruptive and results achieved are not always reaching the goals. Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best evidence-based approach to care pathways suited to real-life using mobile technology in allergic rhinitis (AR) and asthma multimorbidity. Patients largely use over-the-counter medications dispensed in pharmacies. Shared decision making centered around the patient and based on self-management should be the norm. Mobile Airways Sentinel networK (MASK), the Phase 3 ARIA initiative, is based on the freely available MASK app (the Allergy Diary, Android and iOS platforms). MASK is available in 16 languages and deployed in 23 countries. The present paper provides an overview of the methods used in MASK and the key results obtained to date. These include a novel phenotypic characterization of the patients, confirmation of the impact of allergic rhinitis on work productivity and treatment patterns in real life. Most patients appear to self-medicate, are often non-adherent and do not follow guidelines. Moreover, the Allergy Diary is able to distinguish between AR medications. The potential usefulness of MASK will be further explored by POLLAR (Impact of Air Pollution on Asthma and Rhinitis), a new Horizon 2020 project using the Allergy Diary.

Electronic Clinical Decision Support System for allergic rhinitis management: MASK e-CDSS

BACKGROUND

Allergic rhinitis (AR) management has changed in recent years following the switch from the concept of disease severity to the concept of disease control, publication of the AR clinical decision support system (CDSS) and development of mobile health (m-health) tools for patients (eg Allergy Diary). The Allergy Diary Companion app for healthcare providers is currently being developed and will be launched in 2018. It incorporates the AR CDSS to provide evidence-based treatment recommendations, linking all key stakeholders in AR management.

OBJECTIVE

To produce an electronic version of the AR CDSS (e-CDSS) for incorporation into the Allergy Diary Companion, to describe the app interfaces used to collect information necessary to inform the e-CDSS and to summarize some key features of the Allergy Diary Companion.

METHODS

The steps involved in producing the e-CDSS and incorporating it into the Allergy Diary Companion were (a) generation of treatment management scenarios; (b) expert consensus on treatment recommendations; (c) generation of electronic decisional algorithms to describe all AR CDSS scenarios; (d) digitization of these algorithms to form the e-CDSS; and (e) embedding the e-CDSS into the app to permit easy user e-CDSS interfacing.

RESULTS

Key experts in the AR field agreed on the AR CDSS approach to AR management and on specific treatment recommendations provided by Allergy Diary Companion. Based on this consensus, decision processes were developed and programmed into the Allergy Diary Companion using Titanium Appcelerator (JavaScript) for IOS tablets. To our knowledge, this is the first time the development of any m-health tool has been described in this transparent and detailed way, providing confidence, not only in the app, but also in the provided management recommendations.

CONCLUSION

The Allergy Diary Companion for providers provides guideline and expert-endorsed AR management recommendations. [MASK paper No 32].

Rapid onset of action and reduced nasal hyperreactivity: new targets in allergic rhinitis management

Background

This article summarizes a EUFOREA symposium, presented during the European Rhinology Research Forum in Brussels (9–10 November 2017; https://www.rhinologyresearch.eu/) which focused on novel pathways and therapeutic approaches in allergic rhinitis (AR).

Main body

AR remains under-diagnosed, under-estimated and under-treated. A key component in understanding the AR landscape has been the realization of a significant mismatch between how physicians instruct AR patients to manage their disease and what AR patients actually do in real life. Data from the Allergy Diary (developed by MACVIA ARIA) showed that AR patients take their medication prn, rapidly switch treatments, often experience poor control, use multiple therapies and stop treatment when symptoms are controlled. Better control of AR may be achievable by using an AR treatment which has a rapid onset of action and which effectively targets breakthrough symptoms. Indeed, AR patients report complete symptom relief, lack of breakthrough symptoms, rapid onset of action, safety and use on an ‘as needed’ basis as key targets for new nasal sprays. MP-AzeFlu comprises intranasal azelastine and fluticasone propionate (FP) in a novel formulation delivered in a single device. It is the first AR treatment to break the 5 min onset of action threshold and provides clinically relevant symptom relief in 15 min, much faster than that noted for FP + oral loratadine. MP-AzeFlu also significantly reduces nasal hyperresponsiveness (NHR) which may be responsible for the breakthrough symptoms frequently reported by AR patients. Mechanisms underlying MP-AzeFlu’s effect include inhibition of mast cell degranulation, stabilization of the mucosal barrier, synergistic inhibition of inflammatory cell recruitment and a unique desensitization of sensory neurons expressing the transient receptor potential A1 and V1 channels.

Conclusion

With the most rapid onset of action and onset of clinically-relevant effect of any AR medication currently available, and proven efficacy in the treatment of NHR, MP-AzeFlu is an AR treatment which provides what patients want, and fits how patients manage their AR in real life.

The control of allergic rhinitis in real life: a multicenter cross-sectional Italian study

Background

Allergic Rhinitis (AR) is a high-prevalence disease. In Europe about 25% of the general population is affected, and in Italy the prevalence is estimated to be 19.8%. The Allergic Rhinitis and its Impact on Asthma (ARIA) international document underlined that the prevalence of severe or refractory or overlapping rhinitis is increasing and represents a non-negligible socio-economic burden. In general, despite the social healthcare costs, allergic rhinitis remains underestimated, not sufficiently controlled and often undertreated.

Aim of the study

In this multi-center Italian observational and prospective study we assessed the control of AR in patients (> 16 years) without previous asthma diagnosis, referred to Allergy Centers.

Methods

Patients of both sexes and older than 16 with rhinitis symptoms and without asthma were studied. A Visual Analogue Scale (VAS) and the CARAT (Control of Allergic Rhinitis and Asthma Test) were used as patient reported outcome. The possible causes of poor control of AR, as per protocol, were assessed accordingly.

Results

We observed 250 patients in a real-life setting: more than 60% of them had an uncontrolled AR, only about 50% used multiple medications, and only a minority were receiving allergen immunotherapy.

Conclusion

This survey, conducted in a real-life setting, confirmed that AR is overall poorly controlled. The VAS assessment well correlates with the structured CARAT questionnaire and with the relevant symptoms of AR.

CHRODIS criteria applied to the MASK (MACVIA-ARIA Sentinel NetworK) Good Practice in allergic rhinitis: a SUNFRAIL report

A Good Practice is a practice that works well, produces good results, and is recommended as a model. MACVIA-ARIA Sentinel Network (MASK), the new Allergic Rhinitis and its Impact on Asthma (ARIA) initiative, is an example of a Good Practice focusing on the implementation of multi-sectoral care pathways using emerging technologies with real life data in rhinitis and asthma multi-morbidity. The European Union Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) has developed a checklist of 28 items for the evaluation of Good Practices. SUNFRAIL (Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community dwelling persons of EU Countries), a European Union project, assessed whether MASK is in line with the 28 items of JA-CHRODIS. A short summary was proposed for each item and 18 experts, all members of ARIA and SUNFRAIL from 12 countries, assessed the 28 items using a Survey Monkey-based questionnaire. A visual analogue scale (VAS) from 0 (strongly disagree) to 100 (strongly agree) was used. Agreement equal or over 75% was observed for 14 items (50%). MASK is following the JA-CHRODIS recommendations for the evaluation of Good Practices.

Validation of the MASK-rhinitis visual analogue scale on smartphone screens to assess allergic rhinitis control

BACKGROUND

Visual Analogue Scale (VAS) is a validated tool to assess control in allergic rhinitis patients.

OBJECTIVE

The aim of this study was to validate the use of VAS in the MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) app (Allergy Diary) on smartphones screens to evaluate allergic rhinitis symptoms and disease control.

METHODS

Each user filled 4 different VAS measuring overall, nasal, ocular, and asthma symptoms at least once. Following COSMIN guidelines, we evaluated internal consistency, (Cronbach's alpha coefficient and test-retest), reliability (intraclass correlation coefficients), sensitivity, and acceptability of the MASK-Rhinitis VAS.

RESULTS

Between 1 August 2015 and 31 July 2016, the app was used 14 612 times in 15 countries. A total of 1225 users used it more than once, during the evaluated period. The tool resulted to be statistically satisfactory, showing excellent internal consistency (Cronbach's test > 0.84, test-retest > 0.7), reliability (>0.9), and acceptability. In addition, the tool had a good sensitivity when users (n = 521) answered the VAS twice in less than 3 hours.

CONCLUSIONS AND CLINICAL RELEVANCE

The MASK-rhinitis VAS is a reliable and valid tool to assess allergic control on smartphone screens, at the population level.

Allergy immunotherapy across the life cycle to promote active and healthy ageing: from research to policies: An AIRWAYS Integrated Care Pathways (ICPs) programme item (Action Plan B3 of the European Innovation Partnership on active and healthy ageing) and the Global Alliance against Chronic Respiratory Diseases (GARD), a World Health Organization GARD research demonstration project

Allergic diseases often occur early in life and persist throughout life. This life-course perspective should be considered in allergen immunotherapy. In particular it is essential to understand whether this al treatment may be used in old age adults. The current paper was developed by a working group of AIRWAYS integrated care pathways for airways diseases, the model of chronic respiratory diseases of the European Innovation Partnership on active and healthy ageing (DG CONNECT and DG Santé). It considered (1) the political background, (2) the rationale for allergen immunotherapy across the life cycle, (3) the unmet needs for the treatment, in particular in preschool children and old age adults, (4) the strategic framework and the practical approach to synergize current initiatives in allergen immunotherapy, its mechanisms and the concept of active and healthy ageing.

Applications and mechanisms of immunotherapy in allergic rhinitis and asthma

Clinical and immunologic tolerance are hallmarks of successful allergen immunotherapy (AIT). Clinical benefits such as reduced symptoms, pharmacotherapy intake and improvement of quality of life persist following cessation of treatment. Successful AIT is associated with suppression of allergic inflammatory cells such as mast cells, eosinophils and basophils in target organs. Furthermore, AIT down-regulates type 2 innate lymphoid cells and allergen-specific type 2 T-helper (Th2) cells. The immunologic tolerant state following AIT is associated with the induction of distinct phenotypes of regulatory T-cells (T-regs) including interleukin (IL)-10-, IL-35- and transforming growth factor (TGF)-β- producing T-regs and FoxP3⁺ T-regs. B-cell responses, including the induction of IL-10⁺ regulatory B-cells (B-regs) and the production of IgG4-associated blocking antibodies are also induced following successful AIT. These events are associated with the suppression of antigen-specific Th2 responses and delayed immune deviation in favour of Th1 type responses. Insight into the mechanisms of AIT has allowed identification of novel biomarkers with potential to predict the clinical response to AIT and also novel therapeutic strategies for more effective and safer AIT.

Effectiveness of allergic rhinitis treatments in real-life with a focus on MP-AzeFlu

For any allergic rhinitis (AR) treatment, it is crucial to provide evidence not only of efficacy (assessed in randomized controlled trials (RCTs)) but also of effectiveness in real-life. Observational studies provide valuable data on the use and results associated with interventions prescribed in real-life. However, real-life evidence supporting available AR treatment options is sparse with effectiveness only established for oral antihistamines (desloratadine, ebastine), intranasal corticosteroids (mometasone furoate, fluticasone propionate (FP)), allergen immunotherapy and omalizumab. A novel intranasal formulation of azelastine hydrochloride and FP in a single spray (MP-AzeFlu) shows great promise, with the effectiveness observed in real-life exceeding that noted in RCTs. This review summarises real-life data on MP-AzeFlu, which provides rapid and sustained symptom control irrespective of patient age, AR phenotype or disease severity. We call for high quality real-life research in addition to RCTs to inform future AR treatment guidelines.