Estimate of the total costs of allergic rhinitis in specialized care based on real-world data: the FERIN Study

Multi-omic integration reveals alterations in nasal mucosal biology that mediate air pollutant effects on allergic rhinitis

BACKGROUND

Allergic rhinitis is a common inflammatory condition of the nasal mucosa that imposes a considerable health burden. Air pollution has been observed to increase the risk of developing allergic rhinitis. We addressed the hypotheses that early life exposure to air toxics is associated with developing allergic rhinitis, and that these effects are mediated by DNA methylation and gene expression in the nasal mucosa.

METHODS

In a case-control cohort of 505 participants, we geocoded participants' early life exposure to air toxics using data from the US Environmental Protection Agency, assessed physician diagnosis of allergic rhinitis by questionnaire, and collected nasal brushings for whole-genome DNA methylation and transcriptome profiling. We then performed a series of analyses including differential expression, Mendelian randomization, and causal mediation analyses to characterize relationships between early life air toxics, nasal DNA methylation, nasal gene expression, and allergic rhinitis.

RESULTS

Among the 505 participants, 275 had allergic rhinitis. The mean age of the participants was 16.4 years (standard deviation = 9.5 years). Early life exposure to air toxics such as acrylic acid, phosphine, antimony compounds, and benzyl chloride was associated with developing allergic rhinitis. These air toxics exerted their effects by altering the nasal DNA methylation and nasal gene expression levels of genes involved in respiratory ciliary function, mast cell activation, pro-inflammatory TGF-β1 signaling, and the regulation of myeloid immune cell function.

CONCLUSIONS

Our results expand the range of air pollutants implicated in allergic rhinitis and shed light on their underlying biological mechanisms in nasal mucosa.

Comparison of clinical traits for seasonal and perennial allergic rhinitis during allergen exposure

Background: Allergic rhinitis (AR) is traditionally subdivided into seasonal AR (SAR) and perennial AR (PAR) according to the type of allergen and the occurrence of symptoms during the year. There are currently no reports on the comparison of trait profiles for SAR and PAR during the allergen exposure. Purpose: The purpose of this study was to analyze the clinical characteristics of SAR and PAR during respective allergen exposure periods to provide valuable information for the development of treatment strategies. Methods: This study was performed between August 1, 2021, and January 31, 2022, in the Department of Allergy, Beijing Tongren Hospital. We continuously included diagnosed SAR and PAR outpatients who volunteered to participate in the survey. A questionnaire with regard to medical history, severity of symptoms, and diagnosis and treatment status was collected. Results: A total of 296 patients with SAR and 448 with PAR were finally recruited. Patients with SAR had more severe rhinorrhea compared with patients with PAR (p < 0.001), whereas there was no statistically significant difference in the severity of itching, sneezing, and congestion between the two entities (p ≥ 0.05). Both the gritty and watery eyes of patients with SAR were noticeably more severe than those of patients with PAR (PTotal Ocular Symptom Score [PTOSS] < 0.001). AR symptom severity is mainly associated with the comorbid allergic conjunctivitis (odds ratio 1.94 [95% confidence interval, 1.21-3.09]). SAR patients and PAR patients show no statistically significant differences in terms of their frequency of visits, annual expenditure, and choice of medication treatment for AR (p > 0.05). The overall control under standard medication of both patients with PAR and those with SAR is not ideal, especially in SAR. Conclusion: The current cross-sectional study demonstrated that the patients with SAR exhibited more severe overall clinical symptoms than those with PAR, especially nasal rhinorrhea and gritty and watery eyes. Both of the two disease entities have poor control under standardized medication treatment, especially in SAR. Further multicenter longitudinal studies that involve larger and more diverse populations should be conducted to provide a more accurate and comprehensive understanding of the condition.

Environmental DNA analysis of airborne poaceae (grass) pollen reveals taxonomic diversity across seasons and climate zones

BACKGROUND

Grasses populate most biogeographical zones, and their diversity influences allergic sensitisation to pollen. Previously, the contribution of different Poaceae subfamilies to airborne pollen has mostly been inferred from historical herbarium records. We recently applied environmental (e)DNA metabarcoding at one subtropical site revealing that successive airborne grass pollen peaks were derived from repeated flowering of Chloridoid and Panicoid grasses over a season. This study aimed to compare spatiotemporal patterns in grass pollen exposure across seasons and climate zones.

METHODS

Airborne pollen concentrations across two austral pollen seasons spanning 2017-2019 at subtropical (Mutdapilly and Rocklea, Queensland) and temperate (Macquarie Park and Richmond, New South Wales) sites, were determined with a routine volumetric impaction sampler and counting by light microscopy. Poaceae rbcL metabarcode sequences amplified from daily pollen samples collected once per week were assigned to subfamily and genus using a ribosomal classifier and compared with Atlas of Living Australia sighting records.

RESULTS

eDNA analysis revealed distinct dominance patterns of grass pollen at various sites: Panicoid grasses prevailed in both subtropical Mutdapilly and temperate Macquarie Park, whilst Chloridoid grasses dominated the subtropical Rocklea site. Overall, subtropical sites showed significantly higher proportion of pollen from Chloridoid grasses than temperate sites, whereas the temperate sites showed a significantly higher proportion of pollen from Pooideae grasses than subtropical sites. Timing of airborne Pooid (spring), Panicoid and Chloridoid (late spring to autumn), and Arundinoid (autumn) pollen were significantly related to number of days from mid-winter. Proportions of eDNA for subfamilies correlated with distributions grass sighting records between climate zones.

CONCLUSIONS

eDNA analysis enabled finer taxonomic discernment of Poaceae pollen records across seasons and climate zones with implications for understanding adaptation of grasslands to climate change, and the complexity of pollen exposure for patients with allergic respiratory diseases.

The Burden of Asthma and Allergic Rhinitis: Epidemiology and Health Care Costs

Allergic rhinitis affects up to 78% of people with asthma, and asthma occurs in 38% of people with allergic rhinitis. Asthma has a prevalence of 8.7% among adults and 6.2% among children and accounts for $50 billion in medical costs and $32 billion in indirect and mortality costs in the United States, respectively. Allergic rhinitis occurs in 5% to 15% of people in the United States. Allergic rhinitis also accounts for a significant health care cost burden, predominantly in terms of indirect costs related to reduced quality of life and presenteeism.

Efficacy and safety of stapokibart (CM310) in uncontrolled seasonal allergic rhinitis (MERAK): an investigator-initiated, placebo-controlled, randomised, double-blind, phase 2 trial

Background

There is no trial to assess the benefits of periodically using biologics during the pollen season in patients with uncontrolled seasonal allergic rhinitis (SAR), who have moderate-to-severe symptoms even after standard-of-care. This trial aimed to evaluate the efficacy and safety of the add-on administration of stapokibart, a humanised monoclonal antibody that targets interleukin-4 receptor alpha, in patients with uncontrolled SAR.

Methods

In this investigator-initiated, randomised, double-blind, placebo-controlled trial, eligible patients received either stapokibart 600-300 mg weekly (QW), every 2 weeks (Q2W), or placebo QW for 4 weeks. All patients were given mometasone furoate nasal spray and loratadine throughout the trial. The primary endpoint was the mean change from baseline in daily reflective total nasal symptom score (rTNSS) during 2-week treatment. Secondary efficacy outcomes included: the mean change from baseline in daily rTNSS during 4-week treatment; the mean changes and the mean percentage changes from baseline during 2-week and 4-week treatment in 1) daily rTNSS and reflective total ocular symptom score (rTOSS), 2) morning (AM)/evening (PM) rTNSS and rTOSS, 3) AM instantaneous total nasal symptom score (iTNSS) and instantaneous total ocular symptom score (iTOSS), 4) individual nasal and ocular symptoms; the change from baseline in Rhinoconjunctivitis Quality of-Life Questionnaire score during 4-week treatment. Exploratory endpoints included the change of prespecified markers related to type 2 inflammation pre- and post-treatment. Safety, immunogenicity, and pharmacokinetics were also evaluated. This study is registered with www.clinicaltrials.gov (NCT05470647).

Findings

Between August 17, 2022, and December 28, 2022, 92 patients with uncontrolled SAR were enrolled from 4 centres in China and randomly assigned to receive stapokibart 600-300 mg QW (n = 31), stapokibart 600-300 mg Q2W (n = 30), or placebo QW (n = 31), of whom 86 (93%) completed the study. Both stapokibart Q2W and QW did not significantly improve mean change from baseline in daily rTNSS compared with placebo in 2 weeks. The least-squares (LS) mean differences (97.5% confidence interval [CI]) compared with placebo were -1.0 (-2.3, 0.2) in stapokibart Q2W group (p = 0.065) and -0.2 (-1.5, 1.0) in stapokibart QW group (p = 0.67). For the secondary outcomes, compared with placebo, stapokibart Q2W presented significant improvements in the mean percentage change from baseline in daily rTNSS in 2 weeks (LS mean difference -12.9%, 95% CI -25.3%, -0.4%, p = 0.043), as well as AM iTNSS over 2 weeks (LS mean difference -17.4%, 95% CI -31.0%, -3.8%, p = 0.013) and 4 weeks (LS mean difference -15.4%, 95% CI -29.0%, -1.9%, p = 0.026). Additionally, the nasal congestion score was significantly lower in stapokibart Q2W than placebo during 2-week (LS mean difference -0.4, 95% CI -0.7, -0.1, p = 0.014) and 4-week (LS mean difference -0.4, 95% CI -0.7, -0.04, p = 0.028) treatment. Treatment-emergent adverse events (TEAEs) occurred in 48% (15/31), 33% (10/30), and 61% (19/31) of patients receiving stapokibart QW, Q2W, and placebo, respectively. Most reported TEAEs were sinus bradycardia, hyperlipidaemia, and blood uric acid increased.

Interpretation

In this phase 2 trial, both stapokibart regimens had an acceptable safety and tolerability profile but did not significantly improve daily rTNSS in patients with uncontrolled SAR. The efficacy of stapokibart in patients with uncontrolled SAR is being further investigated in ongoing phase 3 trials (clinicaltrials.gov, NCT05908032).

Funding

Ministry of Science and Technology of the People's Republic of China; Ministry of Education of the People's Republic of China; National Natural Science Foundation of China; Chinese Academy of Medical Sciences.

Pulmonology for the rhinologist

PURPOSE OF REVIEW

The upper and lower airways are inter-related despite serving different functions and can no longer be considered separately. Rhinologists are becoming increasingly aware of the role the lower airway plays in optimizing outcomes for their patients. This review highlights recent developments in pulmonology that impact rhinologic conditions.

RECENT FINDINGS

The unified airway concept now supports the multidisciplinary management of respiratory and rhinologic pathologies. Biomarkers, biologics and the concept of treatable traits have permitted the development of personalized and precise treatment of the entire respiratory tract. The concept of corticosteroid stewardship, the introduction of steroid sparing agents for the treatment of respiratory diseases and the development of biomarkers, now forces us to be more considerate and precise with oral corticosteroid (OCS) prescribing and to consider reduction regimens. Finally, current research on climate change and vaping will allow us to better educate and prepare our patients to improve adherence and avoid exacerbations to maintain optimal global respiratory health.

SUMMARY

The inter-relatedness of the upper and lower airway has encouraged a multidisciplinary focus in respiratory medicine. More research is required to improve the precision respiratory medicine model, particularly in the realm of biomarkers and endotyping. These developments must also consider the impact of climate change, pollution and toxins for us to provide optimum care for our patients.

Impact of Climate Change on Indoor Air Quality

Climate change may affect the quality of the indoor environment through heat and mass transfer between indoors and outdoors: first by a direct response to global warming itself and related extreme weather phenomena and second by indirect actions taken to reduce greenhouse gas emissions that can lead to increased concentrations of indoor air contaminants. Therefore, both indoor and outdoor air pollution contribute to poor indoor air quality in this context. Exposures to high concentrations of these pollutants contribute to inflammatory respiratory diseases. Climate change adaptation and mitigation measures could minimize these risks and bring associated health benefits.

Long-term health care resource and cost savings with allergy immunotherapy: REACT study results

Background

Allergy immunotherapy (AIT) can be administered as subcutaneous immunotherapy (SCIT) injections in the clinic or as sublingual immunotherapy (SLIT) tablets at home after initiation under medical supervision. To achieve long-term, sustained effects, a 3-year treatment duration is recommended.

Objective

Our aim was to assess the association of AIT (SCIT and SLIT tablets) with long-term health care resource use (HRU) and costs in subjects with allergic rhinitis.

Methods

REACT was a retrospective propensity score-matched cohort study using claims data from a German health insurance database (2007-2017), with up to 9 years of follow-up after AIT initiation. HRU and costs were evaluated for hospitalizations, ambulatory care visits, and prescriptions, in subjects who received AIT versus in matched controls with allergic rhinitis who had not received AIT, as well as for SCIT and SLIT tablets.

Results

Across all 9 years, the subjects who received AIT had a significantly lower incidence of hospitalization than the controls did. Generally, proportions of subjects with ambulatory care visits and hospitalizations were lower, and length of hospitalization was shorter, for those receiving SLIT tablets than those who received SCIT. Total costs were significantly higher with AIT versus for the controls during the treatment period (years 1 to 3), driven by prescriptions and ambulatory care visits, but they were lower in years 4 to 9. During years 1 to 3, prescription costs were generally higher for SLIT tablets than for SCIT, whereas ambulatory care costs were numerically lower. In most years, hospitalization costs were numerically lower for SLIT tablets than for SCIT.

Conclusion

Initial higher HRU and costs of AIT during the expected treatment period are offset in the long term. At-home administration of SLIT tablets may further reduce ambulatory care costs.

Exploring the role of information and communication technologies in allergic rhinitis in specialist centers: Patient perspectives on usefulness, value, and impact on healthcare

INTRODUCTION

Information and communication technologies (ICTs) improve patient-centered care and are routinely used in Allergic Rhinitis (AR), but patients' preferences and attitudes are unexplored. This study examines AR-related information preferences and ICT use by AR patients.

METHODS

A survey-based cross-sectional study was carried out in Ecuador from July to September 2019 in seven centers of reference for allergic disease. Participants were 18 years or older, diagnosed with AR and had access to ICT and the Internet. Descriptive and binomial logistic regressions were performed. A value of less than 0.05 was considered statistically significant.

RESULTS

217 patients were included. 47% (n = 102) used ICTs to learn about AR, of which 38.2% (n = 83) found it useful. Most of participants (75%, n = 164) did not think that ICTs reduce their need to see a doctor. Individuals with poorer quality of life were more likely to utilize ICTs to contact their doctor (OR 1.27, 95% CI 1.04-1.55), and more likely to be interested in AR-related content (OR 1.23, 95% CI 1.00-1.52). Patients with long-term AR or other allergies were less likely to use ICTs (OR 0.92 and OR 0.40 respectively). Higher education and lower quality of life may increase AR apps adoption (OR 4.82, 95% CI 1.11-21.00). Academic preparation five-fold increased ICT use for health provider communication (OR 5.29, 95% CI 1.18-23.72). Mild-persistent AR enhanced the probabilities of using ICTs to share experiences and communicate with other patients (OR 12.59, 95% CI 1.32-120.35).

CONCLUSIONS

Our study emphasizes the importance of tailoring digital resources to patient needs by considering factors such as quality of life, education, and specific subgroups within the AR patient population. Additionally, the findings suggest that while ICTs can play a valuable role in patient education and support, they should complement, rather than replace, traditional medical care for many AR patients.

Self-Management in Allergic Rhinitis: Strategies, Outcomes and Integration into Clinical Care

Allergic rhinitis (AR) is a common disease, characterized by typical symptoms and type 2 inflammation. Standard treatment is usually effective and safe, and most medications are available as over-the-counter (OTC). Therefore, AR patients, mostly at the AR onset or if symptoms are mild, prefer to manage symptoms themselves. However, self-management could be associated with problems, including inadequate control or medication abuse. Therefore, this paper aimed at presenting and discussing this issue. Ideally, self-management should be conducted under medical supervision. In this regard, telemedicine could represent a valuable tool for implementing self-management. Visual analog scale (VAS) is a perfect parameter to measure symptom severity, medications use, and AR control. In addition, VAS is easily monitored over time. Presently, a mobile application allows to AR patients of self-managing themselves. Therefore, mobile healthcare may supply fundamental support in communication and decision-making. In this regard, VAS represents the best tool to monitor symptoms' severity and control over time. Finally, pharmacological and non-pharmacological remedies are numerous and effective but should be used wisely.

House dust mite subcutaneous immunotherapy has sustained long-term effectiveness on allergic rhinitis and asthma: A 10-year follow-up

BACKGROUND

Maintenance doses for allergen immunotherapy (AIT) have been recommended for at least 3 years but little data on long-term efficacy is available depending on AIT duration. To show sustained efficacy 10 years after completion of treatment with depigmented-polymerized house dust mite (dpg-pol HDM) allergen extract in adults with asthma and/or rhinoconjunctivitis.

METHODS

Patients included in a double-blind placebo-controlled AIT study with dpg-pol HDM allergen extract were reviewed at completion of the perennial treatment and 10-year follow-up (10y-FU). Change in symptom and rescue medication score was the primary objective. Visual analog scale (VAS), asthma control test (ACT), and degree of disease control were the secondary objectives. A comparative analysis between patients who underwent AIT treatment for <3 years and ≥3 years was performed.

RESULTS

Data from 31 patients (mean age 38 years) were available at 10y-FU. All had asthma and 29 had rhinoconjunctivitis at baseline. Twenty-three patients were treated ≥3 years and 8 for <3 years. Seventeen (55%) patients were asymptomatic at completion of AIT, with significant differences for nasal, conjunctival, and bronchial symptoms (p < .0001) compared with baseline only in those patients treated ≥3 years. Nine (52.9%) patients remained completely asymptomatic at 10y-FU, all were treated for ≥3 years. Moreover, significant reduction in the number of patients with rhinitis (p = .0117), conjunctivitis (p < .0001), and bronchial (p = .0005) symptoms was observed at 10y-FU compared with baseline only in the ≥3 years treated. Ten (32.3%) patients did not require any rescue medication at 10y-FU, all had been treated for ≥3 years. ACT at 10y-FU showed a good control of asthma (median 23.5; 95% IC[22.0, 25.0]). No significant differences were observed between VAS at end of treatment compared with VAS at 10y-FU.

CONCLUSIONS

Sustained clinical efficacy is achieved 10 years after completion of depigmented-polymerized HDM, however, these findings were observed only if patients are treated for at least 3 years.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Current situation of allergological health care at German hospitals

BACKGROUND

Allergic medical care in Germany is organized on an interdisciplinary basis. An overview of the current care situation is necessary to manage and improve interdisciplinary cooperation.

METHODS

Between January and February 2022, questionnaires were sent online and by mail to chief physicians of inpatient clinical departments to which most allergological diseases are assigned (dermatology, otorhinolaryngology [ENT], pulmonology, pediatrics, environmental/occupational medicine, gastroenterology; n = 899).

RESULTS

The response rate was 52.1%. Allergology departments of dermatology, ENT and pulmonology were predominantly located in metropolitan areas (> 100,000 inhabitants), whereas responses of pediatric departments were mostly from smaller towns. 76.8% of the respondents reported existing interdisciplinary treatment plans with other specialties. Pediatric and pulmonology clinics stated disproportionately few interdisciplinary treatment concepts with dermatology and ENT clinics, especially in smaller cities with < 100,000 inhabitants. Diagnosis and therapy of allergic rhinitis were performed in particular by the departments of ENT, asthma mainly by the pulmonology departments. Care of other allergological diseases was most frequently reported by chief physicians of dermatology and pediatrics.

CONCLUSIONS

In metropolitan areas, participating departments provide allergology care in a cooperative manner. A large spectrum of care is covered in cooperation with dermatological clinics. In more rural areas, cooperation is rarer; here, mainly pediatric departments provide allergological care, which may explain the more limited range of services compared to metropolitan areas.

Aktuelle Situation der allergologischen Versorgung an deutschen Kliniken

Hintergrund

Die Allergologie ist in Deutschland interdisziplinär organisiert. Zur Steuerung und Verbesserung fachbereichsübergreifender Kooperationen ist ein Überblick über die aktuelle Versorgungssituation notwendig.

Methode

Zwischen Januar und Februar 2022 wurden online und postalisch Fragebögen an Leitungen stationärer klinischer Fachbereiche versendet, denen die meisten allergologischen Krankheitsbilder zugeordnet werden (Dermatologie, HNO, Pneumologie, Pädiatrie, Umwelt/Arbeitsmedizin, Gastroenterologie; n = 899).

Ergebnisse

Die Rücklaufquote betrug 52,1%. Allergologische Abteilungen von Dermatologie, HNO und Pneumologie waren überwiegend in Ballungsgebieten verfügbar (> 100 000 Einwohner), während Antworten pädiatrischer Abteilungen größtenteils aus kleinen Städten kamen. 76,8% der befragten Kliniken gaben bestehende interdisziplinäre Behandlungskonzepte mit anderen Fachrichtungen an. Kliniken der Pädiatrie und der Pneumologie vermeldeten, insbesondere in kleineren Städten mit < 100 000 Einwohnern, unterproportional wenig interdisziplinäre Behandlungskonzepte mit Dermatologie und HNO‐Kliniken. Diagnostik und Therapie der allergischen Rhinitis wurden insbesondere durch die Abteilungen für HNO und Asthma vor allem durch die Abteilungen für Pneumologie durchgeführt. Die Betreuung der weiteren allergologischen Erkrankungen wurde am häufigsten aus der Dermatologie und Pädiatrie zurückgemeldet.

Schlussfolgerungen

In Ballungsgebieten übernehmen beteiligte Fachbereiche die allergologische Versorgung kooperativ. Ein großes Spektrum der Versorgung wird in Kooperationen mit dermatologischen Kliniken abgedeckt. In ländlicheren Gebieten sind Kooperationen seltener, wobei hier die Versorgung vor allem durch pädiatrische Abteilungen erfolgt, was im Vergleich zu Ballungsgebieten das eingeschränktere Leistungsangebot erklären könnte.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Hospital admissions due to vasomotor and allergic rhinitis in England and Wales between 1999 and 2019: an ecological study

BACKGROUND

Allergic rhinitis is among the most prevalent chronic disorders in high-income countries. Its estimated cost is €30-€50 billion annually in the European Union and in the UK, it is approximately €1.8 billion per year.

AIM

To study hospital admissions for vasomotor and allergic rhinitis in England and Wales during the past 20 years.

METHOD

This was an ecological study using publicly available data extracted from the Hospital Episode Statistics (HES) database in England and the Patient Episode Database for Wales (PEDW). The trend in hospital admissions was assessed using a Poisson model.

RESULTS

Admission rate increased by 2.14-fold [from 2.59 (95% CI 2.46-2.73) in 1999 to 8.16 (95% CI 7.93-8.39) in 2020 per 100,000 persons, trend test, p < 001]. The most prevalent hospital admission reasons were allergic rhinitis due to pollen, other allergic rhinitis, and unspecified allergic rhinitis, which accounted for 56.4%, 22.3%, and 15.7%, respectively. The age group 15-59 years accounted for 69.5% of the total number of admissions. Admission rate between males increased by 2.25-fold. Admission rate between females increased by 2.02-fold.

CONCLUSION

Vasomotor and allergic rhinitis are common cause of hospital admissions in England and Wales that showed a clear increase in the rate of their admissions in the past 20 years. Allergic rhinitis due to pollen was the most dominant cause of admission, which warrants further investigation to identify its preventable risk factors and decrease the probability of the exacerbation of patients' cases and the need for hospitalization.

Intradermal delivery of Cryj1 loaded in CpG DNA hydrogel for inhibiting allergic reactions in mice

Immunotherapy for allergic rhinitis alleviates symptoms associated with antigen exposure by administering pathogenic antigens. However, many current immunotherapies fail to induce sufficient immune responses, resulting in frequent and prolonged hospital visits. Consequently, the development of more effective immunotherapies is necessary. In this study, we focused on the skin, which is rich in immune cells, as an administration site for inducing antigen-specific immune responses. To efficiently and sustainably deliver the cedar pollen antigen Cryj1 to immune cells, we attempted to load Cryj1 in an immunostimulatory CpG DNA hydrogel, prepared using self-gelatinizable nucleic acid technology. In this technology, the hydrogel became gelatinized by self-assembly of multiple predesigned DNA units containing potent CpG motifs. Cryj1 loaded in the CpG DNA hydrogel showed sustained release, was taken up by mouse macrophage-like RAW264.7 and mouse dendritic DC2.4 cells, and induced efficient production of interleukin-12 after intradermal injection into mice. Intradermal injection of Cryj1 loaded CpG DNA hydrogel into mice increased the production of Cryj1-specific IgG while suppressing the production of immunoglobulin E (IgE) antibodies. Furthermore, when Cryj1 was resensitized to mice, a stronger induction of IgG production and suppression of IgE production was observed. These results suggest that intradermal administration of Cryj1 loaded CpG DNA hydrogel is a novel immunotherapy for allergic symptoms caused by cedar pollen and can be used as a replacement for current immunotherapies.

Development and Evaluation of a Nomogram for INCS Insensitivity in Chinese Adults with Allergic Rhinitis

Objective

The objective of this study was to design and validate a nomogram of intranasal corticosteroid (INCS) insensitivity for adult patients with allergic rhinitis (AR).

Methods

Training and validation datasets comprised randomly divided groups of AR patients diagnosed between 2019 and 2022, with a 7 : 3 ratio. These patients were categorized according to their INCS insensitivity status, and LASSO and multivariate logistic regression analyses were conducted to identify associated risk factors. These factors were incorporated into a nomogram for predicting INCS insensitivity. The performance of the nomogram was assessed using receiver operating characteristic (ROC) curves, calibration curves, and discrimination techniques.

Results

In this study, 313 patients were included, of which 120 (38.3%) showed INCS insensitivity. The type of AR, comorbidities, family history of AR, and duration of AR were identified as predictors and incorporated into the nomogram using least absolute shrinkage and selection operator and multivariate logistic regression. The calibration curves showed excellent agreement between predicted and actual probabilities of INCS insensitivity in both the training and validation sets. The area under the curve values observed in the validation set were 0.918 (95% confidence interval, 0.859-0.943), and 0.932 (95% confidence interval, 0.849-0.953) in the training set, indicating strong performance on both sets. Decision curve analysis showed that the constructed nomogram yielded a net clinical benefit for AR patients.

Conclusion

The nomogram constructed from risk predictors of INCS insensitivity in patients with AR demonstrated strong predictive power and enabled clinicians to identify high-risk patients, aiding them in developing an optimal treatment plan for AR.

The Allergic Rhinitis and Its Impact on Asthma (ARIA) Approach of Value-Added Medicines: As-Needed Treatment in Allergic Rhinitis

Drug repurposing is a major field of value-added medicine. It involves investigating and evaluating existing drugs for new therapeutic purposes that address unmet healthcare needs. Several unmet needs in allergic rhinitis could be improved by drug repurposing. This could be game-changing for disease management. Current medications for allergic rhinitis are centered on continuous long-term treatment, and medication registration is based on randomized controlled trials carried out for a minimum of 14 days with adherence of 70% or greater. A new way of treating allergic rhinitis is to propose as-needed treatment depending on symptoms, rather than classical continuous treatment. This rostrum will discuss existing clinical trials on as-needed treatment for allergic rhinitis and real-world data obtained by the mobile health app MASK-air, which focuses on digitally-enabled, patient-centered care pathways.

Research Advances in the Treatment of Allergic Rhinitis by Probiotics

Allergic rhinitis (AR) impairs the quality of life of patients and reduces the efficiency of social work, it is an increasingly serious public medical and economic problem in the world. Conventional anti-allergic drugs for the treatment of allergic rhinitis (AR) can cause certain side effects, which limit the quality of life of patients. Therefore, it makes sense to look for other forms of treatment. Several studies in recent years have shown that probiotics have shown anti-allergic effects in various mouse and human studies. For example, the application of certain probiotic strains can effectively relieve the typical nasal and ocular symptoms of allergic rhinitis in children and adults, thereby improving the quality of life and work efficiency. At the same time, previous studies in humans and mice have found that probiotics can produce multiple effects, such as reduction of Th2 cell inflammatory factors and/or increase of Th1 cell inflammatory factors, changes in allergy-related immunoglobulins and cell migration, regulate Th1/Th2 balance or restore intestinal microbiota disturbance. For patients with limited activity or allergic rhinitis with more attacks and longer attack duration, oral probiotics have positive effects. The efficacy of probiotics in the prevention and treatment of allergic rhinitis is remarkable, but its specific mechanism needs further study. This review summarizes the research progress of probiotics in the treatment of allergic rhinitis in recent years.

Health and economic impact of subcutaneous allergen immunotherapy in patients with pollen-induced allergic rhinoconjunctivitis: real-word evidence from the Czech Republic

Background: The prevalence of allergic rhinoconjunctivitis (AR) has been increasing over the years, and allergen immunotherapy (AIT) remains the only disease-modifying treatment. However, cost-effectiveness data remain scarce. Methods: In this single-arm, noninterventional, prospective, multicenter study, we describe the effectiveness, safety and costs of subcutaneous AIT for pollen-induced allergic rhinoconjunctivitis. Results: Of 471 new AIT users, 317 completed three courses of treatment, and symptoms improved in 96%; no serious adverse reactions were reported. The cost of symptomatic medication decreased by 49% and the cost of unscheduled specialist visits decreased by 73%. Except for AIT administration, total healthcare costs decreased by 54% compared with the baseline pollen season without AIT. Conclusion: In clinical practice, subcutaneous AIT is an effective treatment generating savings on symptomatic medication and unscheduled consultations.

The NLRP3 inflammasome as a new target in respiratory disorders treatment

In recent years a continuous increase in new cases of respiratory disorders, such as rhinitis, asthma, and chronic obstructive pulmonary disease (COPD), has been observed. The exact pathomechanism of these diseases is still blurry, resulting in the lack of targeted and effective therapy. The conventional use of treatment strategies, such as antihistamine drugs and/or glucocorticosteroids act mainly symptomatically and have significant side effects. Specific allergen immunotherapy is only useful in the management of specific allergies and selected patients. Therefore, new therapeutic solutions are constantly being sought. The novelty of recent years has been the association between NLRP3 inflammasome activation and the development of airway inflammatory diseases. This seems to be an interesting therapeutic target that may support or even replace traditional therapies in the future. The review presented, discusses the contribution of NLRP3 inflammasome to the development of allergic rhinitis, allergic asthma, and COPD. Moreover, the modulatory properties of probiotics as potential inhibitors of NLRP3 inflammasome are emphasised.

A Questionnaire Survey on the Prevalence and Parents' Perceptions of Respiratory Allergies in a 3- to 16-Year-Old Population in Wuhan, China

(1) Background: The prevalence of allergic rhinitis (AR) and asthma has increased rapidly in China. However, perceptions of respiratory allergies and barriers to their management have not attracted enough attention. (2) Objective: To investigate the prevalence of, parents’ perceptions of and their unmet needs for information concerning respiratory allergies in a 3- to 16-year-old children population. (3) Methods: A cross-sectional survey was conducted from June to July 2021 in three schools in Wuhan, China. A total of 1963 participants were recruited through cluster sampling for their parents to complete an online questionnaire regarding respiratory allergic symptoms. The diagnosis of respiratory allergies was based on self-reported symptoms and face-to-face physician evaluation. All the participants with respiratory allergies were asked to complete the Brief Illness Perception Questionnaire (B-IPQ), the Asthma Knowledge Questionnaire (AKQ) and a questionnaire regarding their unmet needs for disease management. (4) Results: The prevalence of respiratory allergies was 29.3% (576/1963) in the 3- to 16-year-old population, among whom AR accounted for 25.7%; asthma, 1.8% and AR-complicated asthma (AR&Asthma), 1.9%. The total B-IPQ score was 40.2 ± 10.9 in the participants with respiratory allergies, and there were no differences among the AR, asthma and AR&Asthma groups (all p > 0.05). The B-IPQ score correlated significantly with symptom onset time and a history of atopic dermatitis (p < 0.01). Nearly one fifth, 18.9%, of the participants with respiratory allergies never went to hospital for treatment, but those with higher B-IPQ scores were more likely to seek professional treatment (p < 0.001). The accuracy rates of AKQ were 72.5% in the participants with asthma and 76.7% in those without asthma (p = 0.147). Among the 576 participants with respiratory allergies, 568 (98.6%) had tried to obtain disease-management information from online platforms, and 55.5% (315/568) were dissatisfied with current platforms; the reasons included incomprehensive contents of illness (45.7%), lack of voice from leading experts (40.3%), too many advertisements (37.5%) and similar contents on different platforms (36.8%). (5) Conclusions: The prevalence of respiratory allergies is high in the 3- to 16-years old population in Wuhan, China. Yet the parents’ perceptions of respiratory allergies and knowledge of asthma are insufficient. It is crucial to increase parents’ awareness of the illness and facilitate their access to truly informative and professional platforms.

Association of fine particulate matter to allergic rhinitis: A systematic review and meta-analysis

Objective:

Fine particulate matter (PM2.5) has become a major concern for global environmental health, as it can lead to inflammatory diseases, such as allergic rhinitis (AR) and cause a high burden of disease. The aim of this study is to carry out a systematic review and meta-analysis based on available research to present the link between ambient PM2.5 and the risk of AR in global populations. Methods: We systematically searched six databases from their inception to 30 November 2020. An expanded literature search was carried out using the references of the included studies. Data extraction was performed using Excel 2016 software, and meta-analysis and heterogeneity analysis were performed using Review Manager 5.3 software. Results: A total of 14 out of 1361 studies were included in the meta-analysis. The quality assessment showed these studies to be of high quality. Seven out of 14 studies reported a relationship between ambient PM2.5 and AR through Odds ratios (OR, ORoverall = 1.14, 95% CI [1.00, 1.29]), but with a non-significant statistical overall test result (the test result for overall effect was Z = 1.98, p =.05). For subgroups by ages and regions, ORChildren = 1.08 (95% CI [1.04, 1.13]), and OROther ages = 1.50 (95% CI [1.24, 1.81]. The differences between age-related subgroups were significant (p <.01). Meanwhile, the relationship between PM2.5 and the risk of AR in Asia was significant (ORAsia = 1.20, 95% CI [1.01, 1.44], p =.001); whereas the association studies from outside of Asia have reported the relationship as non-significant (OROut-Asia = 1.04, 95% CI [0.82, 1.31], p =.76). Conclusion: There are reports that recognize that the exposure to PM2.5 may contribute to the development of AR. An international framework with a whole-of-society approach, including air quality control efforts and well-being health promotion among AR patients and at-risk populations, should be implemented.

Direct and indirect costs of allergic and non‐allergic rhinitis to adults in Beijing, China

Background

Chronic rhinitis is generally classified as either allergic rhinitis (AR) or non‐allergic rhinitis (NAR). There is currently no report on the economic burden of AR and NAR in Beijing, China.

Methodology

A total of 1013 valid questionnaires from 448 AR patients and 565 NAR patients living in Beijing were continuously collected for investigation of the direct (e.g., drugs, medical visits) and indirect costs (absenteeism and presenteeism) from August 2020 to April 2021.

Results and Conclusion

The total cost of AR and NAR was € 195.6 patient/year and € 185.3 patient/year respectively. The total societal cost for adult AR and NAR patients in Beijing is around € 440.9 and € 671.9 million per year in terms of the standardized prevalence of the diseases. The patient's level of education, disease duration, predilection time of disease, severity of symptoms and comorbidity with other allergic disease were factors that affected the economic burden on patients with rhinitis.

The impact of omalizumab on paid and unpaid work productivity among severe Japanese cedar pollinosis (JCP) patients

AIMS

Japanese cedar pollinosis (JCP) is a form of seasonal allergic rhinitis that affects 38.8% of the Japanese population. Particularly severe and most severe symptoms among JCP patients can lead to impairments of paid work productivity and unpaid work activities. Indeed, the current standard of care (SoC) is not always able to relieve these symptoms. Omalizumab, a novel JCP treatment recently approved in Japan, provides an effective add-on therapy to the SoC. This study estimates the effect of omalizumab on paid and unpaid work activities (i.e. its social impact) in patients with severe and most severe JCP symptoms in Japan.

METHODS

The impact of omalizumab was estimated through a one-year static cohort model using the Work Productivity and Activity Impairment Allergy Specific (WPAI-AS) questionnaire derived from a clinical trial on omalizumab enrolling patients with severe and most severe JCP symptoms, which had been conducted in Japan. This effect was quantified using Japanese official statistics on employment and time use. The human capital approach and the proxy good approach were employed to monetize paid and unpaid work activities, respectively. A sensitivity analysis was implemented to account for modeling structural uncertainties.

RESULTS

Our results show that the use of omalizumab might reduce the paid and unpaid work productivity losses due to severe and most severe JCP by nearly one-third. In the severe symptom period of three weeks, 36.6 million hours of lost paid and unpaid work hours could be avoided, which sums up to a monetized productivity loss of 728.3 million USD.

CONCLUSIONS

Omalizumab could provide substantial benefits in terms of paid and unpaid work activities in patients with severe and most severe JCP. Our results also highlight the importance of considering unpaid work in estimating productivity costs due to poor health.

Humanistic and socioeconomic burden of COPD patients and their caregivers in Malaysia

Chronic obstructive pulmonary disease (COPD) is associated with substantial humanistic and socioeconomic burden on patients and their caregivers. COPD is expected to be 7th leading cause of disease burden till 2030. The objective of the current study was to assess the humanistic and socioeconomic burden of COPD patients and their caregivers in Malaysia. The burden includes the cost of management of COPD, QOL of COPD patients and their caregivers, work productivity and activity impairment of COPD patients and their caregivers due to COPD. One hundred and fifty COPD patients and their caregivers from the chest clinic of Penang Hospital were included in the study from August 2018 to August 2019. Caregiving cost was estimated using the replacement cost approach, while humanistic and social burden was assessed with the help of health status questionnaires. Overall, 64.66% and 7.1% of COPD patients reported to depend on informal caregivers and professional caregivers respectively. COPD patients reported dyspnoea score as 2.31 (1.31), EQ-5D-5L utility index 0.57 (0.23), CCI 2.3 (1.4), SGRQ-C 49.23 (18.61), productivity loss 31.87% and activity impairment 17.42%. Caregivers reported dyspnoea score as 0.72 (0.14), EQ-5D-5L utility index 0.57 (0.23), productivity loss 7.19% and social activity limitation as 21.63% due to taking care of COPD patients. In addition to the huge direct cost of management, COPD is also associated with substantial burden on society in terms of compromised quality of life, reduced efficiency at the workplace, activity impairment and caregiver burden.

Sleep, Fatigue, and Depressive Symptoms among Female Nurses with Allergic Rhinitis

Allergic rhinitis (AR) is a common chronic disease that negatively affects physical and mental health. The purpose of this study was to determine the effects of allergic rhinitis on sleep, fatigue, and depressive symptoms among Korean female nurses. This was a cross-sectional study conducted using data from the Korea Nurses' Health Study (KNHS), and a total of 8645 female nurses was selected for the final analysis. The demographic characteristics, Body Mass Index, alcohol consumption, shift work, comorbidities (atopic dermatitis and asthma), self-rated health, sleep disturbance (Jenkins Sleep Questionnaire), fatigue (Chalder Fatigue Scale), and depressive symptoms (Perceived Health Questionnaire-9) were collected. The data were analyzed using chi-square tests, t-tests, and hierarchical multiple regression analyses. Participants with allergic rhinitis had significantly greater sleep disturbance, fatigue, and depressive symptoms than those without allergic rhinitis, and allergic rhinitis was a significant factor influencing sleep disturbance and fatigue among the participants after controlling for confounding variables. Therefore, it is imperative to develop effective interventions to manage allergic rhinitis symptoms and improve sleep and fatigue in affected nurses.

The Role of Environmental Risk Factors on the Development of Childhood Allergic Rhinitis

Environmental factors play an important role in the development and exacerbation of allergic rhinitis (AR) in childhood. Indoor air pollution, such as house dust mites and secondhand smoke, can significantly increase the onset of AR, while pet dander may affect the exacerbation of AR symptoms in children. Furthermore, traffic related air pollution and pollen are outdoor air pollutants that can affect immune competency and airway responsiveness, increasing the risk of AR in children. Climate change has increased AR in children, as growth patterns of allergenic species have changed, resulting in longer pollen seasons. More extreme and frequent weather events also contribute to the deterioration of indoor air quality due to climate change. Additionally, viruses provoke respiratory tract infections, worsening the symptoms of AR, while viral infections alter the immune system. Although viruses and pollution influence development and exacerbation of AR, a variety of treatment and prevention options are available for AR patients. The protective influence of vegetation (greenness) is heavily associated with air pollution mitigation, relieving AR exacerbations, while the use of air filters can reduce allergic triggers. Oral antihistamines and intranasal corticosteroids are common pharmacotherapy for AR symptoms. In this review, we discuss the environmental risk factors for AR and summarize treatment strategies for preventing and managing AR in children.

What are the health and socioeconomic impacts of allergic respiratory disease in Tasmania?

Objective The aim of this study was to quantify the direct and indirect costs of asthma and allergic rhinitis (AR) for 2018 in Tasmania. Methods We used publicly available data, and Tasmanian-specific values where available, to estimate direct and indirect costs of both diseases. Direct costs included outcomes such as emergency department (ED) presentations, hospitalisations, general practice visits and medication use. Indirect costs included premature mortality and lost productivity. Results Direct health impacts for both conditions combined included 1454 ED presentations, 682 hospitalisations, 72446 general practice visits and 7122 specialist visits. Indirect health impacts included 13 deaths and between 483000 and 2.8 million days of lost productivity. Total costs ranged between A$126.5 million and A$436.7 million for asthma and between A$65.3 million and A$259.7 million for AR. Per-person annual costs ranged between A$1918 and A$6617 for asthma and between A$597 and A$2374 for AR. Conclusions The main financial burden due to asthma and AR was related to productivity losses from presenteeism and absenteeism. The magnitude of the economic impacts of AR and asthma warrants further analysis to produce a national-level assessment. Such analyses could identify cost-effective interventions that produce highest benefits for the management of these conditions in our community. What is known about the topic? Allergic respiratory diseases, and particularly asthma and AR, pose a significant health burden, with effects including asthma-related hospital admissions, significant pharmaceutical expenditure and lost workforce and school education productivity. Australia, and particularly Tasmania, has a high prevalence of these conditions, but no recent studies have appraised or estimated their health impacts and costs. What does this paper add? This paper proposes a unique and transparent costing model that allows the costs of these conditions to be estimated while accounting for restrictions in data availability. The model is used to provide the first comprehensive costings of asthma and AR in Tasmania, Australia. We identified that the estimated health costs are dominated by productivity losses from presenteeism and absenteeism, and that total per person costs are higher for a person with asthma compared to one with AR. What are the implications for practitioners? This analysis has the potential to guide cost-effective interventions by identifying where the highest benefits may be obtained when managing these conditions in our community.

Rhinitis Phenotypes

Rhinitis is an umbrella term of a group of upper airway diseases with nasal symptoms and signs with different etiologies and various clinical features or traits. It can be classified into different "phenotypes," based on these observable traits. A proper differential diagnosis is necessary to adequately manage the disease. The objective of this review is to clarify the concept of rhinitis phenotypes while analyzing the clinical features and/or traits of each in order to determine a proper differential diagnosis and appropriate treatment.

Heterogeneity of the pharmacologic treatment of allergic rhinitis in Europe based on MIDAS and OTCims platforms

BACKGROUND

The practice of allergology varies widely between countries, and the costs and sales for the treatment of rhinitis differ depending on practices and health systems. To understand these differences and their implications, the rhinitis market was studied in some of the EU countries.

METHODS

We conducted a pharmaco-epidemiological database analysis to assess the medications that were being prescribed for allergic rhinitis in the years 2016, 2017 and 2018. We used the IQVIA platforms for prescribed medicines (MIDAS^®- Meaningful Integration of Data, Analytics and Services) and for OTC medicines (OTC International Market Tracking-OTCims). We selected the five most important markets in the EU (France, Germany, Italy, Poland and Spain).

RESULTS

Intranasal decongestants were excluded from the analyses because they are rarely prescribed for allergic rhinitis. For both Standard Units (SU) and costs, France is leading the other countries. In terms of SU, the four other countries are similar. For costs, Poland is lower than the three others. However, medication use differs largely. For 2018, in SU, intranasal corticosteroid is the first treatment in Poland (70.0%), France (51.3%), Spain (51.1%) and Germany (50.3%), whereas the Italian market is dominated by systemic antihistamines (41.4%) followed by intranasal corticosteroids (30.1%). Results of other years were similar.

DISCUSSION

There are major differences between countries in terms of rhinoconjunctivitis medication usage.

Grass Gazers: Using citizen science as a tool to facilitate practical and online science learning for secondary school students during the COVID-19 lockdown

The coronavirus disease of 2019 (COVID-19) pandemic has impacted educational systems worldwide during 2020, including primary and secondary schooling. To enable students of a local secondary school in Brisbane, Queensland, to continue with their practical agricultural science learning and facilitate online learning, a "Grass Gazers" citizen science scoping project was designed and rapidly implemented as a collaboration between the school and a multidisciplinary university research group focused on pollen allergy. Here, we reflect on the process of developing and implementing this project from the perspective of the school and the university. A learning package including modules on pollen identification, tracking grass species, measuring field greenness, using a citizen science data entry platform, forensic palynology, as well as video guides, risk assessment and feedback forms were generated. Junior agriculture science students participated in the learning via online lessons and independent data collection in their own local neighborhood and/or school grounds situated within urban environments. The university research group and school coordinator, operating in their own distributed work environments, had to develop, source, adopt, and/or adapt material rapidly to meet the unique requirements of the project. The experience allowed two-way knowledge exchange between the secondary and tertiary education sectors. Participating students were introduced to real-world research and were able to engage in outdoor learning during a time when online, indoor, desk-based learning dominated their studies. The unique context of restrictions imposed by the social isolation policies, as well as government Public Health and Department of Education directives, allowed the team to respond by adapting teaching and research activity to develop and trial learning modules and citizen science tools. The project provided a focus to motivate and connect teachers, academic staff, and school students during a difficult circumstance. Extension of this citizen project for the purposes of research and secondary school learning has the potential to offer ongoing benefits for grassland ecology data acquisition and student exposure to real-world science.

Multidisciplinary Care for Severe or Uncontrolled Chronic Upper Airway Diseases

PURPOSE OF REVIEW

A multidisciplinary approach is regarded as the best practice for many chronic diseases, such as cancer and asthma, with well-documented value. There is also evidence that it may be beneficial to patients with chronic rhinosinusitis (CRS) and/or allergic airway disease presenting to tertiary referral centres. We discuss here whether and how organizing this kind of healthcare transition into a more integrated care pathway would benefit severe chronic upper airways disease (SCUAD) management.

RECENT FINDINGS

Based on a recent related EUFOREA panel discussion, literature search, and review of the best overseas practices, an appropriate implementation strategy of multidisciplinary care and its potential results are presented. Organizational principles, hurdles, and challenges of the process, as well as envisaged solutions and results, are being reported. The efficiency of care and the quality control assessment are concepts that are currently gaining importance. At the same time, novel treatment options based on molecular and precision medicine advancements, such as biologics, are being increasingly prescribed. Appropriately organized multidisciplinary care teams can adapt to new demands, data, and discoveries to assure maximum benefit for both patients and healthcare professionals.

A TRiP Through the Roles of Transient Receptor Potential Cation Channels in Type 2 Upper Airway Inflammation

PURPOSE OF REVIEW

Despite their high prevalence, the pathophysiology of allergic rhinitis (AR) and chronic rhinosinusitis (CRS) remains unclear. Recently, transient receptor potential (TRP) cation channels emerged as important players in type 2 upper airway inflammatory disorders. In this review, we aim to discuss known and yet to be explored roles of TRP channels in the pathophysiology of AR and CRS with nasal polyps.

RECENT FINDINGS

TRP channels participate in a plethora of cellular functions and are expressed on T cells, mast cells, respiratory epithelial cells, and sensory neurons of the upper airways. In chronic upper airway inflammation, TRP vanilloid 1 is mostly studied in relation to nasal hyperreactivity. Several other TRP channels such as TRP vanilloid 4, TRP ankyrin 1, TRP melastatin channels, and TRP canonical channels also have important functions, rendering them potential targets for therapy. The role of TRP channels in type 2 inflammatory upper airway diseases is steadily being uncovered and increasingly recognized. Modulation of TRP channels may offer therapeutic perspectives.

Economic Burden of Chronic Obstructive Pulmonary Disease Patients in Malaysia: A Longitudinal Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) requires long-term pharmacological and non-pharmacological management that encompasses continuous economic burden on patients and society, and also results in productivity losses due to compromised quality of life. Among working-age patients, COPD is the 11th leading cause of work productivity loss.

OBJECTIVE

The aim of this study was to assess the economic burden of COPD in Malaysia, including direct costs for the management of COPD and indirect costs due to productivity losses for COPD patients.

METHODOLOGY

Overall, 150 patients with an established diagnosis of COPD were followed-up for a period of 1 year from August 2018 to August 2019. An activity-based costing, 'bottom-up' approach was used to calculate direct costs, while indirect costs of patients were assessed using the Work Productivity and Activity Impairment Questionnaire.

RESULTS

The mean annual per-patient direct cost for the management of COPD was calculated as US$506.92. The mean annual costs per patient in the management phase, emergency department visits, and hospital admissions were reported as US$395.65, US$86.4, and US$297.79, respectively; 31.66% of COPD patients visited the emergency department and 42.47% of COPD patients were admitted to the hospital due to exacerbation. The annual mean indirect cost per patient was calculated as US$1699.76. Productivity losses at the workplace were reported as 31.87% and activity limitations were reported as 17.42%.

CONCLUSION

Drugs and consumables costs were the main cost-driving factors in the management of COPD. The higher ratio of indirect cost to direct medical costs shows that therapeutic interventions aimed to prevent work productivity losses may reduce the economic burden of COPD.

Effectiveness and Response Predictors of Omalizumab in Treating Patients with Seasonal Allergic Rhinitis: A Real-World Study

Background

Omalizumab has been proven effective and safety in treating seasonal allergic rhinitis (SAR) by several randomized clinical trials in many countries. However, there is lack of clinical reports of Chinese patients with SAR treated by omalizumab.

Objective

In the present real-world-designed study, we aimed to investigate the effectiveness of omalizumab in treating patients with SAR.

Methods

SAR patients administered omalizumab in various dosages were recruited, and follow-up was done. Their quality of life (QOL) and symptoms were assessed by the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), Total Nasal Symptoms Score (TNSS), Asthma Control Test (ACT), and clinical outcomes were compared between post- and pre-treatment conditions.

Results

Sixty SAR patients received omalizumab therapy in the study (mean age 35.47±17.02 years, 35 females). Omalizumab treatment significantly improved the quality of life (change in RQLQ overall score: -2.08±1.01, paired t-test p<0.001) and nasal symptoms (change in TNSS: -7.33±2.50, paired t-test p<0.001) of SAR patients. In 21 patients with co-existing asthma, the ACT score significantly increased from 16.10 to 22.57 on average (paired t-test p<0.001), indicating better-controlled asthma. Using a threshold of ≥1 point improvement in RQLQ overall score, 83.3% of patients responded to omalizumab. The responder group had a higher baseline RQLQ score and TNSS (p<0.05), but both responders and non-responders had comparable scores after treatment. Multiple linear regression analysis identified the baseline RQLQ overall score as a predictor of change in the RQLQ score in omalizumab-treated SAR.

Conclusion

Omalizumab is effective and safe in SAR treatment in a real-world setting.

Allergic rhinitis

Allergic rhinitis (AR) is caused by immunoglobulin E (IgE)-mediated reactions to inhaled allergens and is one of the most common chronic conditions globally. AR often co-occurs with asthma and conjunctivitis and is a global health problem causing major burden and disability worldwide. Risk factors include inhalant and occupational allergens, as well as genetic factors. AR impairs quality of life, affects social life, school and work, and is associated with substantial economic costs. The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative classified AR into intermittent or persistent and mild or moderate/severe. The diagnosis is based on the clinical history and, if needed in patients with uncontrolled rhinitis despite medications or with long-lasting symptoms, on skin tests or the presence of serum-specific IgE antibodies to allergens. The most frequently used pharmacological treatments include oral, intranasal or ocular H₁-antihistamines, intranasal corticosteroids or a fixed combination of intranasal H₁-antihistamines and corticosteroids. Allergen immunotherapy prescribed by a specialist using high-quality extracts in stratified patients is effective in patients with persistent symptoms. Real-world data obtained by mobile technology offer new insights into AR phenotypes and management. The outlook for AR includes a better understanding of novel multimorbid phenotypes, health technology assessment and patient-centred shared decision-making.

Leukotriene A4 Hydrolase Is a Candidate Predictive Biomarker for Successful Allergen Immunotherapy

Background

Allergic rhinitis is a common disorder that affects 10% to 40% of the population worldwide. Allergen immunotherapy (AIT) represents the only therapy that has the potential to resolve clinical symptoms of allergic rhinitis. However, up to 30% of patients do not respond to AIT. Biomarkers predicting the clinical efficacy of AIT as early as possible would significantly improve the patient selection and reduce unnecessary societal costs.

Methods

Artemisia pollen allergic patients who received at least 1-year AIT were enrolled. Clinical responses before and after 1-year AIT were evaluated to determine AIT responders. Artemisia specific IgE and IgG4 levels were measured by using ImmunoCAP and enzyme-linked immunosorbent assay (ELISA) separately. Stepwise regression analysis was performed to identify which rhinitis-relevant parameters explained the most variability in AIT results. Liquid chromatography-tandem mass spectrometry (LC-MS/MS)-based proteomics was applied to identify the potential candidate biomarkers in the sera of responders and non-responders collected before and after 1-year therapy. The diagnostic performance of the potential biomarkers was then assessed using enzyme-linked immunosorbent assay (ELISA) in 30 responders and 15 non-responders.

Results

Artemisia specific IgE and IgG4 levels were elevated only in the responders. Regression analysis of allergic rhinitis-relevant parameters provided a robust model that included two most significant variables (sneeze and nasal congestion). Thirteen candidate biomarkers were identified for predicting AIT outcomes. Based on their association with allergy and protein fold change (more than 1.1 or less than 0.9), four proteins were identified to be potential biomarkers for predicting effective AIT. However, further ELISA revealed that only leukotriene A₄ hydrolase (LTA₄H) was consistent with the proteomics data. The LTA₄H level in responders increased significantly (P < 0.001) after 1-year therapy, while that of non-responders remained unchanged. Assessment of LTA₄H generated area under curve (AUC) value of 0.844 (95% confidence interval: 0.727 to 0.962; P < 0.05) in distinguishing responders from the non-responders, suggesting that serum LTA₄H might be a potential biomarker for predicting the efficiency of AIT.

Conclusion

Serum LTA₄H may be a potential biomarker for early prediction of an effective AIT.

A new portable sampler to monitor pollen at street level in the environment of patients

Allergic rhinitis caused by pollen exposure is one of the most common allergic diseases. Therefore monitoring pollen levels in ambient air is an important tool in research and health care. Most European monitoring stations collect airborne pollen at rooftop levels for measurements in the larger surrounding of the sampling station, and not in the direct environment of sensitized subjects. Here we present the development and evaluation of a portable pollen sampler, called "Pollensniffer", that was designed to collect pollen in the immediate environment of allergic subjects. Validation of the Pollensniffer against the standard volumetric pollen sampler showed for most pollen types high correlations between the number of pollen collected by those two devices (Spearman's Correlation Coefficient > 0.8); the Pollensniffer appeared to collect on average 5.8 times more pollen per hour than the static sampler. Pollen monitoring was performed using this Pollensniffer at street level at 3 different locations in the city of Leiden during 22 weeks in 2017 and 21 weeks in 2018, during three 15-min periods a day and at one day in the week. The results showed that the pollen levels for birch and grass pollen can significantly differ from location to location and per time of day. Furthermore, the Pollensniffer measurements at street level showed that birch and grass pollen grains were detected 1 1/2 and 2-3 weeks, respectively, before detection at rooftop level. The street measurements show that allergic subjects can encounter varying pollen levels throughout the city and that they can be exposed to grass and birch pollen and may experience hay fever symptoms, even before the sampler at rooftop level registers these pollen.

Burden and socioeconomics of asthma, allergic rhinitis, atopic dermatitis and food allergy

INTRODUCTION

Asthma, allergic rhinitis, atopic dermatitis, and food allergy affect approximately 20% of the global population. Few studies describe the burden of the totality of these diseases and only a handful studies provide a comprehensive overview of the socioeconomic impact of these diseases.

AREAS COVERED

For this narrative review, we searched Pubmed using selected keywords and inspected relevant references using a snowballing process. We provide an overview of the socioeconomic burden of allergic diseases (in particular, asthma, allergic rhinitis, atopic dermatitis, and food allergy). The focus of this review is on their epidemiology (incidence, prevalence), burden (disability-adjusted life years, quality of life), and direct and indirect costs (absenteeism and presenteeism). We have put special emphasis on differences between countries.

EXPERT COMMENTARY

Both the prevalence and the burden of allergic diseases are considerable with prevalence varying between 1% and 20%. We identified a plethora of studies on asthma, but studies were generally difficult to compare due to the heterogeneity in measures used. There were only few studies on the burden of food allergy; therefore, more studies on this allergy are required. For future studies, we recommend standardizing epidemiologic, socioeconomic impact, and quality of life measures of allergic diseases.

The need for clean air: The way air pollution and climate change affect allergic rhinitis and asthma

Air pollution and climate change have a significant impact on human health and well-being and contribute to the onset and aggravation of allergic rhinitis and asthma among other chronic respiratory diseases. In Westernized countries, households have experienced a process of increasing insulation and individuals tend to spend most of their time indoors. These sequelae implicate a high exposure to indoor allergens (house dust mites, pets, molds, etc), tobacco smoke, and other pollutants, which have an impact on respiratory health. Outdoor air pollution derived from traffic and other human activities not only has a direct negative effect on human health but also enhances the allergenicity of some plants and contributes to global warming. Climate change modifies the availability and distribution of plant- and fungal-derived allergens and increases the frequency of extreme climate events. This review summarizes the effects of indoor air pollution, outdoor air pollution, and subsequent climate change on asthma and allergic rhinitis in children and adults and addresses the policy adjustments and lifestyle changes required to mitigate their deleterious effects.

Allergic rhinitis and asthma symptoms in a real-life study of MP-AzeFlu to treat multimorbid allergic rhinitis and asthma

Background

Asthma affects up to nearly 40% of patients with allergic rhinitis (AR). Poor control of AR symptoms is associated with poor asthma control. The goal of this study was to evaluate the effect of AR treatment with MP-AzeFlu on symptoms of AR as well as symptoms of asthma.

Methods

This prospective study used a visual analog scale (VAS) to assess symptoms of AR and asthma before and after treatment with MP-AzeFlu (Dymista^®; azelastine hydrochloride plus fluticasone propionate; 1 spray in each nostril twice daily for 2 weeks). Participants suffered from moderate-to-severe AR according to Allergic Rhinitis and its Impact on Asthma criteria, with acute AR symptoms (AR-VAS scores ≥ 50 mm) on inclusion day. In addition to symptom assessment, patients recorded the impact of AR symptoms on quality-of-life measures before, during, and at the conclusion of the treatment period (approximately 14 days). Patients self-reported change in frequency of their usage of asthma reliever medication on the last day of treatment.

Results

Of 1103 study participants, 267 (24.2%) had comorbid asthma. These participants reported using a mean of 5.1 puffs of asthma reliever medication in the week before treatment with MP-AzeFlu. A total of 81.8% of patients with comorbid asthma responded to AR therapy (AR-VAS < 50 mm on at least 1 study day). Among patients with AR and comorbid asthma, MP-AzeFlu was associated with improved VAS scores across all study parameters, including AR symptom severity, asthma symptom severity, sleep quality, daily work or school activities, daily social activities, and daily outdoor activities. Asthma symptom severity decreased from a mean of 48.9 mm to 24.1 mm on the VAS. Self-reported frequency of asthma reliever medication use was reduced for 57.6% of participants (n = 139/241).

Conclusion

MP-AzeFlu used to relieve AR symptoms was associated with reduced asthma symptom VAS scores and frequency of asthma reliever medication usage. Changes in overall symptoms of AR and asthma were correlated.

Higher efficacy of rupatadine 20 mg and 10 mg versus placebo in patients with perennial allergic rhinitis: a pooled responder analysis

Background

The clinical efficacy of rupatadine in terms of responders has not been previously explored in perennial allergic rhinitis (PAR).

Methods

This pooled analysis included data from 6 randomised, double-blind, placebo-controlled trials conducted in PAR patients treated with rupatadine 10 mg or 20 mg, or placebo. Participants were aged ≥ 18 years, with diagnosis of PAR and a Total 4 Nasal Symptom Score (T4NSS) ≥ 5. We evaluated the T4NSS and Total 5 Symptom Score (T5SS) for 28 days of treatment, the responder proportion (50% and 75% response), and the time to response.

Results

Efficacy data from 1486 patients were analysed: 585 received placebo, 682 rupatadine 10 mg, and 219 rupatadine 20 mg. Compared with placebo, rupatadine promoted greater symptom improvements and higher responder proportions (50% and 75% response) for T4NSS and T5SS over 28 days. Symptom improvements and responder proportions were higher in the rupatadine 20 mg group vs the 10 mg group. The time to response was shorter in the rupatadine 20 mg group vs the 10 mg group for T4NSS (16 and 9 days for the 50% and 75% responses, respectively) and for T5SS (13 and 8 days for the 50% and 75% responses, respectively).

Conclusions

Rupatadine was efficacious in reducing allergic rhinitis symptoms, showing high responder proportions. The faster and stronger effect of rupatadine 20 mg may suggest its use in patients with severe PAR or not responding to the standard dose.

Future research trends in understanding the mechanisms underlying allergic diseases for improved patient care

The specialties of allergy and clinical immunology have entered the era of precision medicine with the stratification of diseases into distinct disease subsets, specific diagnoses, and targeted treatment options, including biologicals and small molecules. This article reviews recent developments in research and patient care and future trends in the discipline. The section on basic mechanisms of allergic diseases summarizes the current status and defines research needs in structural biology, type 2 inflammation, immune tolerance, neuroimmune mechanisms, role of the microbiome and diet, environmental factors, and respiratory viral infections. In the section on diagnostic challenges, clinical trials, precision medicine and immune monitoring of allergic diseases, asthma, allergic and nonallergic rhinitis, and new approaches to the diagnosis and treatment of drug hypersensitivity reactions are discussed in further detail. In the third section, unmet needs and future research areas for the treatment of allergic diseases are highlighted with topics on food allergy, biologics, small molecules, and novel therapeutic concepts in allergen‐specific immunotherapy for airway disease. Unknowns and future research needs are discussed at the end of each subsection.

Cost-Effectiveness Of The SQ® Grass SLIT-Tablet In Children With Allergic Rhinitis: A German Payer Perspective

Background

The Grazax Asthma Prevention (GAP) trial has recently demonstrated significant reductions in the odds of asthma symptoms or medication use in patients treated with SQ^® grass SLIT-tablet relative to placebo, both in combination with allergy and asthma pharmacotherapy. The objective of the present analysis was to evaluate the cost-effectiveness of SQ grass SLIT-tablet relative to placebo in children with AR from the perspective of a German healthcare payer.

Methods

A cost-utility model was developed in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) to evaluate the cost-utility of SQ grass SLIT-tablet in combination with pharmacotherapy versus pharmacotherapy alone in patients with AR. Transition probabilities were derived from the GAP trial, and costs were taken from a real-world insurance database analysis. Future costs and effects were discounted at 3% per annum, and extensive deterministic and probabilistic sensitivity analyses were performed.

Results

Over a 10-year time horizon, the base case analysis showed an increase in overall treatment costs of €897 per child being treated with SQ grass SLIT-tablet relative to pharmacotherapy alone. The increased treatment costs were accompanied by an improvement in patient quality of life of 0.10 quality-adjusted life years (QALYs) yielding an ICER of €8978 per QALY gained, falling well below a willingness-to-pay threshold of €17,800 per QALY gained. The base case results were insensitive to changes in all individual model parameters.

Discussion

Improvements in quality of life with the SQ grass SLIT-tablet would be accompanied by only a modest increase in costs over a 10-year time horizon, with the SQ grass SLIT-tablet therefore representing excellent value for money from the German healthcare payer perspective.

Clinically relevant effect of rupatadine 20 mg and 10 mg in seasonal allergic rhinitis: a pooled responder analysis

Background

Different clinical trials showed the superior efficacy of rupatadine compared to placebo at improving seasonal allergic rhinitis (SAR) symptoms, but no study has assessed if the response promoted is clinically meaningful.

Methods

This study is a pooled analysis of data of seven randomized, double-blind, placebo-controlled SAR studies comparing responder proportions upon treatment with rupatadine (10 or 20 mg) or placebo. We evaluated the following symptom scores at baseline (Visit 1) and over 14 days of treatment: Total 4 Nasal Symptom Score (T4NSS), Total 2 Ocular Symptom Score (T2OSS) and Total 6 Symptom Score (T6SS). The proportion of responders (50% and 75% response) and the time to response were compared between groups on days 7 (Visit 2) and 14 (Visit 3). Responder rates were compared between groups on days 7 and 14 for the complete/near-to-complete response for T4NSS (TN4SS score ≤ 2 and each symptom score ≤ 1) and T6SS (T6SS score ≤ 3 and each symptom score ≤ 1).

Results

Data from 1470 patients were analyzed: 332 treated with placebo, 662 with rupatadine 10 mg and 476 with rupatadine 20 mg. The reduction in T4NSS, T2OSS and T6SS over 14 days of treatment relative to baseline was statistically higher in rupatadine groups vs the placebo group, with greater improvements in the 20 mg group. A statistically higher proportion of patients reached the 50% and 75% response for T4NSS, T2OSS and T6SS in rupatadine groups compared to the placebo group across the visits. Among rupatadine-treated patients, those receiving 20 mg compared favourably for both cut-off responses. The time to achieve a proportion of responders was shorter in the rupatadine 20 mg group than in the rupatadine 10 mg and placebo groups for all the symptom scores. The number of patients who achieved a complete/near-to-complete response for both symptom scores was higher in rupatadine groups than in the placebo group, with higher proportions in the 20 mg group.

Conclusions

This responder analysis confirms the superior efficacy of rupatadine vs placebo to treat SAR. Rupatadine promoted higher proportions of responders according to stringent response criteria and in a dose-dependent manner, with faster and higher response rates in the 20 mg group.

Mobile health tools for the management of chronic respiratory diseases

BACKGROUND

The market of mobile health (mHealth) technology is rapidly evolving, making new mobile technologies potentially available for healthcare systems. Patient empowerment through self-monitoring of symptoms, shared decision making with the physician, and easily accessible education are important features extending the reach of mHealth technology beyond traditional care.

METHODS

Two digital distribution platforms (Apple App Store and Google Play Store) were searched for currently available mobile applications (apps) for patients with chronic respiratory diseases (CRDs). A new index (score ranging from 0 to 10) was developed to assess the potential of apps as a tool to empower patients through mobile technology (based on self-monitoring, personalized feedback, and patient education app features).

RESULTS

One hundred and twelve apps were retained for analysis and could be classified in 5 categories: Asthma (n = 71), COPD (n = 15), Asthma and COPD (n = 15), Rhinitis and Asthma (n = 5), and Rhinosinusitis (n = 6). Eighty percent were developed by medical technology companies compared to 18% by medical doctors and 2% by pharmaceutical companies. Two-thirds of apps allow disease self-monitoring, whereas over half of apps provide patient feedback through graphs. Sixty percent of apps contain easily accessible patient education material. Only three percent of apps reach a score of ≥7 on the newly designed patient empowerment index.

CONCLUSIONS

A variety of apps are available for patients with CRDs of which only few were developed by or jointly with medical doctors. The majority of these apps include self-monitoring tools, but only few also provide personalized feedback, which is needed to adopt these apps into daily care.