Qualitative Development of the Rhinitis Control Assessment Test (RCAT), an Instrument for Evaluating Rhinitis Symptom Control

Concepts for the Development of Person-Centered, Digitally Enabled, Artificial Intelligence-Assisted ARIA Care Pathways (ARIA 2024)

The traditional healthcare model is focused on diseases (medicine and natural science) and does not acknowledge patients' resources and abilities to be experts in their own lives based on their lived experiences. Improving healthcare safety, quality, and coordination, as well as quality of life, is an important aim in the care of patients with chronic conditions. Person-centered care needs to ensure that people's values and preferences guide clinical decisions. This paper reviews current knowledge to develop (1) digital care pathways for rhinitis and asthma multimorbidity and (2) digitally enabled, person-centered care.1 It combines all relevant research evidence, including the so-called real-world evidence, with the ultimate goal to develop digitally enabled, patient-centered care. The paper includes (1) Allergic Rhinitis and its Impact on Asthma (ARIA), a 2-decade journey, (2) Grading of Recommendations, Assessment, Development and Evaluation (GRADE), the evidence-based model of guidelines in airway diseases, (3) mHealth impact on airway diseases, (4) From guidelines to digital care pathways, (5) Embedding Planetary Health, (6) Novel classification of rhinitis and asthma, (7) Embedding real-life data with population-based studies, (8) The ARIA-EAACI (European Academy of Allergy and Clinical Immunology) strategy for the management of airway diseases using digital biomarkers, (9) Artificial intelligence, (10) The development of digitally enabled, ARIA person-centered care, and (11) The political agenda. The ultimate goal is to propose ARIA 2024 guidelines centered around the patient to make them more applicable and sustainable.

Quail egg homogenate with zinc as adjunctive therapy in seasonal allergic rhinitis: a randomised, controlled trial

OBJECTIVE

Because most available treatments for managing seasonal allergic rhinitis show some side effects without reducing recurrence, natural anti-allergic products could represent an interesting treatment addition. This study aimed to analyse the efficacy and tolerance of quail egg as adjunctive therapy in seasonal allergic rhinitis.

METHOD

In a Consolidated Standards of Reporting Trials compliant framework, patients with seasonal allergic rhinitis were prospectively randomised to receive mometasone nasal spray for four weeks or the same topical corticosteroid therapy plus commercially available oral quail egg and zinc tablets.

RESULTS

Forty patients were enrolled. The mometasone + quail egg and zinc tablets group showed a greater reduction in nasal itching, sneezing and total nasal symptom scores than the mometasone nasal spray only group. A higher proportion of participants in the mometasone + quail egg and zinc tablets group had good rhinitis control than in the mometasone nasal spray only group, with no need for rescue medications.

CONCLUSION

Despite the need for a further larger study, quail egg preliminarily appears to be an effective adjunct to topical steroid therapy in seasonal allergic rhinitis.

Knowledge and Attitude Among Patients and Physicians on Allergic Rhinitis (KAPPA): An International Survey

PURPOSE

Our study compared knowledge of, and attitudes towards, allergic rhinitis (AR) among patients and physicians in: Brazil, Japan, Korea, Mexico, Saudi Arabia, Spain, United Arab Emirates, and the United Kingdom.

PATIENTS AND METHODS

Patients with AR were recruited via probability-based sampling. Data were captured via telephone interview, personal interview, or self-administered online survey. Physicians were recruited from an online physician panel and interviewed by self-administered online survey.

RESULTS

In total, 1436 patients and 1637 physicians were surveyed. Most patients (76.9%) reported moderate-to-severe AR, whereas physicians reported more mild (mean cases ranging from 57.0-68.2) than moderate-to-severe AR (mean cases ranging from 31.8-43.0). Overall, most physicians (85.4%) and patients (77.5%) agreed AR could be controlled with treatment. Physicians preferred prescribing oral antihistamines (OAHs) for mild AR (from 45.3% of physicians in Brazil to 73.6% of physicians in Mexico). For moderate and severe AR, more physicians preferred prescribing intranasal corticosteroids (INCSs) and OAHs for moderate and severe AR than other available treatments (from 48.5% of physicians in the UK to 69.5% of physicians in Spain). Patients preferred OAHs to INCSs for treating AR (62.0%). Patients also reported a range of comorbidities: overall, sinus infections were the most common (24.7%), and comorbid asthma was present in 12.9% of patients. Per country, Saudi Arabia had the highest proportion (53.5%) and Mexico had the lowest proportion (8.0%) of patients with comorbid asthma.

CONCLUSION

Patient and physician perceptions of AR mostly differed between and within countries, although there was generally agreement that AR could be controlled with treatment. Differing attitudes towards AR among patients and physicians suggests a need for improved education in and communication between these groups, with subsequent implications for optimizing disease management.

Turkish language validity and reliability of the Control of Allergic Rhinitis and Asthma Test and its comparison with other scales

OBJECTIVES

Patients with asthma often suffer from concomitant allergic rhinitis (AR). The Control of Allergic Rhinitis and Asthma Test (CARAT) is a validated tool to assess asthma and rhinitis multimorbidity. Turkish language validity and reliability of CARAT and its compatibility with other scales were evaluated in the study.

METHODS

Patients with asthma and concomitant AR were tested with CARAT. Pulmonary function tests, Asthma Control Test (ACT), Assessment Tool for Asthma (ATA) questionnaire and visual analogue scale (VAS) were also used at the same day. With the VAS, patients determined their rhinitis symptom levels, and asthma specialist determined the rhinitis and asthma control levels separately. These questionnaires were repeated in 14 ± 2 days.

RESULTS

Three quarters (77%) of the 100 patients were female (mean age 46.5 years). The mean CARAT score was 19.6 ± 7.2. The Cronbach's alpha coefficient of the Turkish version of the CARAT scale was 0.83, showing a high level of internal consistency. Test-retest reliability coefficient was determined as r = 0.98 (p < 0.001). The Kaiser-Meyer-Olkin coefficient of the CARAT scale was 0.79. The p value of the Bartlett test was <0.001. ACT, ATA and VAS expert scales were correlated with CARAT total score (0.577 ≤ r ≤ 0.871). The CARAT scale did not show statistically significant difference according to gender, education, working status, smoking status, presence of polyps and multiple allergen sensitivity (p > 0.05).

CONCLUSION

The Turkish version of the CARAT is a reliable alternative tool for physicians in determining disease control in adult patients with asthma and AR.

COVID-19 lockdown and seasonal allergic rhinitis: our experience in 40 patients

INTRODUCTION

The aim of this article was to study the course of seasonal allergic rhinitis during COVID-19 lockdown in order to understand if being quarantined at home for a long time can constitute a protective factor for allergic patients.

MATERIALS AND METHODS

Telehealth consultations were performed by the departments of Otolaryngology of Foggia and Bari University Hospitals. Participants took part in a phone interview and were asked about their sinonasal symptoms during the COVID-19 lockdown, by answering the sinonasal outcome test (I-SNOT-22) questionnaire. Further data concerning the medications used to treat allergy and the number of days per month in which they were used were collected. The responses about the COVID-19 lockdown were compared to those obtained by the same patients in our clinics the previous year. The statistical analysis was executed by using the paired sample t-test and the Bartlett test considering as significant values with p values <0.05.

RESULTS

Forty patients affected by cypress pollen allergy visited at Foggia and Bari University Hospitals were enrolled in this study. All I-SNOT-22 scores concerning the COVID-19 lockdown were lower than those of the previous year; moreover, 18 (81.8%) clinical parameters were statistically significant (p<0.05). Also, in regard to the treatment, results about COVID-19 lockdown were overall better than those of 2019, with 50% (n=3) of the investigated drugs, reporting statistical significance (p<0.05).

CONCLUSIONS

The present study was able to evidence the fundamental role of primary prevention in Allergology. Paradoxically, the home quarantine ordered by the Italian Government appeared to be an effective measure not only in the fight against COVID-19 but also against pollen exposure.

Validation of the DECA criteria for allergic conjunctivitis severity and control

BACKGROUND

Allergic conjunctivitis (AC) is usually associated to allergic rhinitis (AR), but the severity and control of ocular symptoms should be assessed independently to improve diagnosis and treatment. The criteria from the Spanish consensus document on allergic conjunctivitis (DECA) aimed to be used as a patient-reported instrument for AC management. Here we validate these criteria for classifying AC severity and defining its control following COSMIN guidelines recommendations.

METHODS

Patients with moderate or severe AR [reflective total nasal symptom score (rTNSS) score ≥ 8] and concomitant AC were recruited from hospitals in Spain. Patients were classified according to the severity of ocular symptoms as mild, moderate, or severe, and classified with respect to control as controlled and non-controlled, using the DECA criteria. To validate these criteria, comparisons with the validated modified allergic rhinitis and its impact on asthma (mARIA), reflective total ocular symptom score (rTOSS), rhinitis control assessment test (RCAT), ESPRINT-15 questionnaires, a conjunctival hyperemia scale and a visual analogue scale (VAS) for ocular symptoms were performed.

RESULTS

A total of 128 patients participated in the validation. Mean age was 34.4 ± 12.1 years; 72.7% were women. The DECA criteria showed a good discriminant validity, reflecting a high capacity to differentiate between mild, moderate, and severe patients, and controlled from uncontrolled patients. A strong association between AC and AR was reflected in the comparison between the DECA and the mARIA criteria (p < 0.0001). The DECA criteria for severity and control presented satisfactory properties for longitudinal validity and responsiveness.

CONCLUSIONS

Validation of the DECA criteria for severity and control of AC suggested that it can be useful in the evaluation of eye symptoms and follow-up of therapies.

COVID-19: When dust mites and lockdown create the perfect storm

The aim of the present study was to understand if the course of the disease of patients suffering from dust mite allergy could have been negatively affected by the COVID-19 restrictions, which have been certainly important to fight the pandemic, but forced patients to stay at home for a long time.

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

Use of the Control of Allergic Rhinitis and Asthma Test (CARATkids) in children and adolescents: Validation in Dutch

BACKGROUND

Allergic rhinitis and asthma are common and closely related diseases. Recently, a Portuguese questionnaire has been developed 'The Control of Allergic Rhinitis and Asthma Test' (CARATkids) that measures disease control of both diseases in children. This study aims to validate the CARATkids in Dutch children and for the first time in adolescents and, in addition, to calculate the minimal clinically important difference (MCID).

METHODS

A prospective observational study was conducted in an outpatient clinic. After translation of the CARATkids from Portuguese to Dutch, patients (6-18 years) with asthma or asthma and allergic rhinitis completed the CARATkids, Asthma Control Test, and visual analog scale questionnaire three times. Baseline characteristics, mean scores, internal consistency, test-retest reliability, cross-sectional and longitudinal validity, discriminative properties, responsiveness, and MCID of the CARATkids were assessed.

RESULTS

A total of 111 patients were included. In total, 86% and 79%, respectively, completed the questionnaires at the second and third visits. All children had asthma, and 85% had concomitant allergic rhinitis. The internal consistency was good with all expected a priori correlations met. CARATkids scores were higher in patients with uncontrolled asthma and patients with moderate-severe rhinitis compared to better controlled subjects. Patients with a variable asthma control had significantly higher scores during periods of uncontrolled asthma. Also the Guyatt's responsiveness index was good. The MCID was 2.8.

CONCLUSIONS

The CARATkids questionnaire is a reliable and valid tool to assess allergic rhinitis and asthma control among Dutch children. The tool can be used in adolescents.

An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK: a consensus statement from an expert panel

Allergic rhinitis is a frequent presenting problem in primary care in the UK, and has increased in prevalence over the last 30 years. When symptomatic, patients report significant reduction in their quality of life and impairment in school and work performance. Achieving adequate symptom control is pivotal to successful allergic rhinitis management, and relies mostly on pharmacotherapy. While it is recognised that most mild-moderate allergic rhinitis symptoms can be managed successfully in primary care, important gaps in general practitioner training in relation to allergic rhinitis have been identified. With the availability of new effective combination therapies, such as the novel intranasal formulation of azelastine hydrochloride and fluticasone propionate in a single device (Dymista®; Meda), the majority of allergic rhinitis symptoms can be treated in the primary care setting. The primary objective of this consensus statement is to improve diagnosis and treatment of allergic rhinitis in primary care, and offer guidance on appropriate referral of difficult-to-treat patients into secondary care. The guidance provided herein outlines a sequential treatment pathway for allergic rhinitis in primary care that incorporates a considered approach to improve the management of allergic rhinitis symptoms and improve compliance and patient satisfaction with therapy. Adherence with this care pathway has the potential to limit the cost of providing effective allergic rhinitis management in the UK by avoiding unnecessary treatments and investigations, and avoiding the need for costly referrals to secondary care in the majority of allergic rhinitis cases. The fundamentals presented in this consensus article should apply in most health-care settings.

Severity of Nasal Inflammatory Disease Questionnaire for Canine Idiopathic Rhinitis Control: Instrument Development and Initial Validity Evidence

BACKGROUND

Effective treatments are needed for idiopathic chronic rhinitis in dogs, but assessment of efficacy requires a practical, quantifiable method for assessing severity of disease.

OBJECTIVES

To develop and perform initial validity and reliability testing of an owner-completed questionnaire for assessing clinical signs and dog and owner quality of life (QOL) in canine chronic rhinitis.

ANIMALS

Twenty-two dogs with histopathologically confirmed chronic rhinitis and 72 healthy dogs.

METHODS

In this prospective study, an online questionnaire was created based on literature review and feedback from veterinarians, veterinary internists with respiratory expertise, and owners of dogs with rhinitis. Owners of affected dogs completed the questionnaire twice, 1 week apart, to test reliability. Healthy dogs were assessed once. Data were analyzed using the Rasch Rating Scale Model, and results were interpreted using Messick's framework for evaluating construct validity evidence.

RESULTS

Initial item generation resulted in 5 domains: nasal signs, paranasal signs, global rhinitis severity, and dog's and owner's QOL. A 25-item questionnaire was developed using 5-point Likert-type scales. No respondent found the questionnaire difficult to complete. Strong psychometric evidence was available to support the substantive, generalizability, content, and structural aspects of construct validity. Statistical differences were found between responses for affected and control dogs for all but 2 items. These items were eliminated, resulting in the 23-item Severity of Nasal Inflammatory Disease (SNIFLD) questionnaire.

CONCLUSIONS AND CLINICAL IMPORTANCE

The SNIFLD questionnaire provides a mechanism for repeated assessments of disease severity in dogs with chronic rhinitis.

The Rhinitis Control Scoring System: Development and validation

BACKGROUND

Allergic rhinitis is a common health problem that requires regular monitoring of symptoms to provide adequate treatment. There is a need to develop rhinitis control assessment tools that are meaningful and easy to interpret by both the patient and the practitioner.

OBJECTIVE

To develop a simple, easy-to-interpret instrument, the Rhinitis Control Scoring System (RCSS), for the assessment of rhinitis control, as a companion tool to the Asthma Control Scoring System previously validated.

METHODS

After a literature review and based on the Allergic Rhinitis and its Impact on Asthma guidelines, allergic rhinitis control parameters were identified. The draft items were subjected to cognitive debriefing regarding instructions, wordings, and response options. The second version of the draft was then pretested and modified according to the results. The final draft of the RCSS, based on the intensity and frequency of symptoms, was then pilot tested with 50 subjects who had allergic rhinitis for validation of some psychometric properties. Each subject completed the RCSS in addition to other rhinitis instruments. They also had nasal peak inspiratory flow measurements.

RESULTS

The RCSS showed good internal consistency (Cronbach α = 0.84). There was strong criterion validity between the RCSS scores and the other instruments. The discriminant validity demonstrated as mean RCSS scores differed significantly across groups of patients with different Total Nasal Symptom Score severity (F = 58.8, p < 0.0001).

CONCLUSIONS

This pilot study showed that the RCSS is a simple tool to assess and quantify rhinitis control by using a percentage score. This questionnaire allows the quantification of rhinitis control and, therefore, may help guide therapeutic interventions. Combined with the Asthma Control Scoring System, it can provide a global assessment of rhinitis and asthma control. Clinical Trial number NCT00967967.

Allergic Rhinitis Control Test questionnaire-driven stepwise strategy to improve allergic rhinitis control: a prospective study

BACKGROUND

Allergic Rhinitis Control Test (ARCT) has been validated for assessing allergic rhinitis (AR) control and identifying severe AR. The aim of the study was to assess the ARCT questionnaire as a tool for stepwise pharmacotherapy.

METHODS

A standard pharmacotherapy regimen from Step 1 (oral second-generation H1 antihistamine as needed) to Step 5 (oral corticosteroid) was carried out prospectively in a Chinese AR population. The AR patients were initiated with Allergic Rhinitis and its Impact on Asthma (ARIA) appropriate step treatment and assessed with ARCT every 15 days. If ARCT score was equal or above 20 (controlled AR) and maintained for 15 days, the patient would finish the study; if ARCT score was strictly <20 (uncontrolled AR), the patient would receive higher step treatment according to a predefined open design up to Step 5. The different AR control subgroups were compared.

RESULTS

A total of 255 patients were enrolled in the study; 5 patients dropped out and 2 (0.8%) were controlled at day 0, 85 (34.0%) at day 15, 177 (70.8%) at day 30, 222 (88.8%) at day 45, 241 (96.4%) at day 60 and 242 (96.8%) at day 75. Only 8 (3.2%) patients remained uncontrolled at the endpoint of the study. Patients with ARIA moderate/severe or persistent symptoms, moderate/severe impaired quality of life, asthma history, rhinorrhea and cough symptoms always needed up to Step 4 (nasal corticosteroid plus antihistamine) and prolonged treatments to achieve disease control.

CONCLUSIONS

The majority of AR can be controlled with standard stepwise treatment. ARCT offers an objective criterion for the stepwise pharmacotherapy of AR.

Current controversies and challenges in allergic rhinitis management

There are many obstacles in the path of effective allergy management, in general, and allergic rhinitis (AR) control, in particular. Chief among them are: insufficient symptom relief in some patients provided by some currently considered first-line AR treatments in real life; an over-reliance on randomized controlled trials to direct AR guideline recommendations; the need for a broader interpretation of the AR evidence base (to include randomized controlled trials and real-life studies); poorly designed and interpreted studies; and lack of an AR control concept and common language of control. These controversies are fully reviewed here and challenging solutions have been presented.

Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report

Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.

Mite-Allergic Rhinitis: How to Evaluate Clinical Efficacy in Allergen-Specific Immunotherapy Trials?

House dust mite (HDM) allergen exposure is the most important cause of perennial allergic rhinitis and/or asthma. Although allergen-specific immunotherapy (AIT) with HDM is well established, published studies have been characterized by substantial heterogeneity in clinical endpoints. Standardization in measuring clinical efficacy is required. Moreover, when designing an AIT trial with HDM allergens, several considerations have to be taken into account. The history of HDM allergy is less clear cut than the typical history of pollen allergy. In addition, clinical features of HDM allergy may differ from those of pollen allergy. Moreover, although not easily measurable, fluctuation in allergen exposure may cause variation in symptom severity and determine the timing of assessment of clinical effects of HDM AIT. Key points 1. A combined symptom and medication score (CSMS) is recommended as standard for the primary endpoint in future house dust mite (HDM) allergen-specific immunotherapy trials. 2. The diagnosis of HDM allergy is based on a carefully taken history in combination with sensitization to HDM allergens. 3. Eye symptoms are less prominent in patients with HDM-induced allergic rhinitis. Nasal symptoms, but not eye symptoms, should be included in the CSMS and in symptom scores as well. 4. As methods to determine allergen exposure vary and the efficacy of environmental control is a matter of debate, a practical approach consists of restraining patients from implementing HDM-reducing measures, such as removing carpets and introducing anti-mite covers, after the start of the study. 5. Efficacy evaluation in the period with the highest exposure to mites is recommended.

Recommendations for the standardization of clinical outcomes used in allergen immunotherapy trials for allergic rhinoconjunctivitis: an EAACI Position Paper

BACKGROUND

Allergen immunotherapy (AIT) has been thoroughly documented in randomized controlled trials (RCTs). It is the only immune-modifying and causal treatment available for patients suffering from IgE-mediated diseases such as allergic rhinoconjunctivitis, allergic asthma and insect sting allergy. However, there is a high degree of clinical and methodological heterogeneity among the endpoints in clinical studies on AIT, for both subcutaneous and sublingual immunotherapy (SCIT and SLIT). At present, there are no commonly accepted standards for defining the optimal outcome parameters to be used for both primary and secondary endpoints.

METHODS

As elaborated by a Task Force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) Immunotherapy Interest Group, this Position Paper evaluates the currently used outcome parameters in different RCTs and also aims to provide recommendations for the optimal endpoints in future AIT trials for allergic rhinoconjunctivitis.

RESULTS

Based on a thorough literature review, the TF members have outlined recommendations for nine domains of clinical outcome measures. As the primary outcome, the TF recommends a homogeneous combined symptom and medication score (CSMS) as a simple and standardized method that balances both symptoms and the need for antiallergic medication in an equally weighted manner. All outcomes, grouped into nine domains, are reviewed.

CONCLUSION

A standardized and globally harmonized method for analysing the clinical efficacy of AIT products in RCTs is required. The EAACI TF highlights the CSMS as the primary endpoint for future RCTs in AIT for allergic rhinoconjunctivitis.

Assessment of disease control in allergic rhinitis

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative has had a significant impact, by raising awareness of allergic rhinitis (AR) and improving the diagnosis and treatment of AR sufferers. ARIA classifies the severity of AR as "mild" or "moderate/severe" on the basis of "yes"/"no" answers to four questions. This two-point classification has been criticized as providing little guidance on patient management; patients with "mild" AR are unlikely to consult a physician, whereas the group of patients with "moderate/severe" seen by specialists is heterogeneous. These perceived shortcomings have prompted attempts to improve the ARIA classification or, by analogy with the Global Initiative for Asthma (GINA), adopt approaches based on "disease control" in AR. Even though "disease severity", "disease control" and "responsiveness to treatment" are different (albeit related) metrics, they are not mutually exclusive. Currently, there is no single, accepted definition, but we propose that "disease control" in AR can combine (i) measurements of the severity and/or frequency of daily or nocturnal symptoms, (ii) impairments in social, physical, professional and educational activities, (iii) respiratory function monitoring and (iv) exacerbations (e.g. unscheduled medical consultations and rescue medication use). Although control-based classifications have a number of limitations (e.g. their dependence on treatment compliance and the patient's psychological status), these instruments could be used as an adjunct to the ARIA severity classification and regional practice parameters. Here, we assess the strengths and weaknesses of the current two-level ARIA classification, analyze published proposals for its modification and review the literature on instruments that measure AR control. We conclude that there is a need for research in which severity is compared with control in terms of their effects on patient management.

Reliability, validity, and responsiveness of the Rhinitis Control Assessment Test in patients with rhinitis

BACKGROUND

The Rhinitis Control Assessment Test (RCAT) is a brief, patient-completed tool to evaluate rhinitis symptom control.

OBJECTIVE

We sought to test the reliability, validity, and responsiveness of RCAT and to estimate a cut-point score and minimal important difference (MID).

METHODS

A total of 402 patients 12 years of age and older with allergic or nonallergic rhinitis were enrolled in a noninterventional study. Patients completed the RCAT (6 items; score range, 6-30) and had Total Nasal Symptom Scores (TNSSs) measured at baseline and 2 weeks later. Physicians completed a global assessment of rhinitis symptom control (Physician's Global Assessment) and disease severity. Internal consistency, test-retest reliability, convergent validity, known-groups validity, and responsiveness were evaluated. The MID was determined by using distribution- and anchor-based methods. Content validity of the RCAT was assessed in individual interviews with a separate group of 58 adult patients.

RESULTS

Internal consistency and test-retest reliability of RCAT scores were 0.77 and 0.78, respectively. Convergent validity correlation between RCAT and TNSS scores was 0.57, and that between RCAT and Physician's Global Assessment scores was 0.34. Mean RCAT scores differed significantly (P < .001) across patient groups, differing in TNSS (F = 72.7), Physician's Global Assessment score (F = 28.6), and disease severity (F = 34.1) in the hypothesized direction. Results suggested a cut-point score of 21 or less can be used to identify patients who are experiencing rhinitis symptom control problems. The preliminary estimate of the MID was 3 points. Patients found RCAT items comprehensive, easy to understand, and relevant.

CONCLUSION

The RCAT demonstrated adequate reliability, validity, and responsiveness and was deemed acceptable and appropriate by patients. This tool can facilitate the detection of rhinitis symptom control problems, and its brevity supports its usefulness in clinical care.