Relationship between ARIA classification and drug treatment in allergic rhinitis and asthma

Efficacy and safety of montelukast-levocetirizine combination therapy in combined allergic rhinitis and asthma syndrome: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aims to evaluate the efficacy and safety of montelukast combined with levocetirizine in the treatment of allergic rhinitis with asthma, and to provide objective and effective evidence-based medical evidence for clinical use.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, WANFANG DATA, CNKI, and Chinese BioMedical Literature Database were retrieved to identify records related to montelukast combined with levocetirizine in the treatment of allergic rhinitis with asthma.

STUDY SELECTIONS

First, the eligibility criteria were employed to screen search results. Then, two investigators independently assessed titles, abstracts, and the full text of all retrieved references to identify potentially eligible studies.

RESULTS

As of 2024-02-03, a total of six articles were included in this meta-analysis, covering 2,950 patients with allergic rhinitis with asthma. The meta-analysis results exhibited a pooled NSS of -1.28 (95%CI: -1.64 to -0.92), suggesting that the combination of montelukast and levocetirizine was effective in the treatment of nasal symptoms of allergic rhinitis complicated with asthma. The meta-analysis of controlled trials showed that the SMD of NSS in the group of montelukast combined with levocetirizine was -2.56 (95%CI: -2.77 to -2.35). The result indicated that compared with the control group, the combination of montelukast with levocetirizine significantly improved the symptoms of allergic rhinitis.

CONCLUSION

In summary, this meta-analysis demonstrated the efficacy of montelukast combined with levocetirizine in the treatment of nasal symptoms in AR with asthma, indicating that the combination of montelukast with levocetirizine is more effective in improving symptoms of allergic rhinitis than monotherapy and has good safety.

Allergic Rhinitis, Rhinosinusitis, and Asthma: Connections Across the Unified Airway

The upper and lower airways are referred to as a single, integrated entity in the unified airway paradigm. When an allergen exposure occurs, the body responds locally and systemically, causing inflammation in other respiratory sites. As a result, asthmatic lower airway inflammation frequently coexists with upper airway inflammation, such as allergic rhinitis. Otolaryngologists are in a unique position to detect undiagnosed lower airway illness, start the proper therapy, and improve patient outcomes since they regularly encounter patients with upper airway problems.

Allergic rhinitis and other comorbidities associated with asthma control in Thailand

Background

Asthma and allergic rhinitis (AR) can coexist and cause disabilities. This study aimed to assess the association between AR, asthma control, asthma-related quality of life, and other comorbidities.

Methods

A cross-sectional study was conducted in adults with asthma in six hospitals in Thailand. The outcomes were association of asthma control assessed by the asthma control test (ACT), AR, and asthma comorbidities. Not-well-controlled asthma was defined as ACT scores ≤22. The severity of AR was determined by visual analog scale (VAS). Severe AR was defined as VAS ≥5. Asthma-related quality of life (AQLQ), comorbidities, and total IgE were recorded.

Results

A total of 682 asthmatic patients were included. Median (IQR) age was 58.0 (47.0-64.0) years. 69.9% were female. Not-well-controlled asthma was present in 44.7%. The prevalence of AR was 86.1%. Moderate/severe persistent AR was diagnosed in 21.7% and severe AR was diagnosed in 30.2% of the patients. Inhaled corticosteroid-containing regimens were prescribed in 97.7% of patients. Intranasal corticosteroid and antihistamine were prescribed in 65.7 and 31.7%, respectively. Patients with not-well-controlled asthma had higher body mass index, VAS scores, proportions of pollution exposure, aeroallergen sensitization, severe AR, nasal polyp, urticaria, food allergy, gastroesophageal reflux disease, depression and anxiety, peptic ulcer, and asthma exacerbations, but younger age, lower AQLQ scores, and lower FEV1. Correlation was found between AR severity and ACT (r = -0.461, p < 0.001), AQLQ (r = -0.512, p < 0.001), and total IgE (r = 0.246, p < 0.023). Multiple regression analysis revealed that ACT, AQLQ, and percentage of FEV1/FVC were significantly associated with severe AR.

Conclusion

Allergic rhinitis is prevalent in Thai asthmatic patients. AR severity is associated with asthma control, quality of life, and pulmonary function. Comprehensive care is essential for patients with uncontrolled asthma, particularly when coexisting with conditions.

The pharmacotherapeutic management of allergic rhinitis in people with asthma

INTRODUCTION

Up to 90% of asthmatic patients have comorbid allergic rhinitis (AR). Although appropriate therapy of AR can improve asthma symptoms and management, AR is often underdiagnosed and under-treated in asthmatics.A non-systematic literature research was conducted on AR as a comorbidity and risk factor of asthma. Latest international publications in medical databases, international guidelines, and the Internet were reviewed.

AREAS COVERED

Based on the conducted literature research there is proved evidence of the necessity of diagnosis and treatment of AR in patients with asthma because it affects health care utilization. Therefore, it is recommended in national and global guidelines.

EXPERT OPINION

AR increases the risk of asthma development and contributes to the severity of an existing asthma. Early treatment of AR with drugs as intranasal steroids, antihistamines, leukotriene receptor antagonists, and especially allergen-specific immunotherapy can reduce the risk of asthma development and the concomitant medication use in addition to severity of symptoms in AR and asthma.

Phenotypes of Allergic Asthma: Does In-Vitro Allergy Testing Help Predict Asthma Disease Severity?

BACKGROUND

Allergy and asthma are often diagnosed concomitantly. Patients with both diagnoses might need to have a more targeted approach to reduce the symptomatic burden and severity of disease.

OBJECTIVE

This study was designed to explore the relationship between specific allergen sensitization, and asthma diagnosis and severity with the hypothesis that patients who tested positive to a higher allergy class of response and to more allergens would be more likely to have severe asthma.

METHODS

A retrospective review was performed on 1419 charts that had a positive IgE allergy class blood test between 2014 and 2018. A total of 701 patients had one or more positive tests and a diagnosis of asthma. Patient demographics and pertinent variables including all clinic and ED visits, specific allergy and class of response, and information related to their asthma treatment and severity were recorded. Logistic regression was used to analyze the likelihood of asthma diagnosis, concomitant diagnosis of asthma and allergic rhinitis, and measures of asthma severity.

RESULTS

Higher class of response to cat dander 1.24 (1.09, 1.41), dog dander 1.29 (1.13, 1.47), lamb's quarter 1.35 (1.06, 1.70), house dust 1.41 (1.11, 1.82), Cladosporium herbarum 1.35 (1.07, 1.67) or cockroach 1.56 (1.00, 2.44) showed increased odds of hospitalizations. There was a statistically significant difference between the average number of classes for patients with and without asthma (P < .001), and those with and without steroids (P < .001).

CONCLUSIONS

This study found that positivity to cat dander, dog dander, some fungus, and house dust was associated with more severe asthma.

Evaluation of Nasal Decongestants by Literature Review

Over-the-counter drugs are medicines that are available to consumers without a prescription. The most common оver - the-counter preparations in self - medication are nasal decongestants that can be used systemically or locally in the form of drops or nasal sprays. The most common indications for nasal decongest-ants are viral infections and allergic conditions in order to alleviate the symptoms so it is necessary to inform the users about the type of drug, the active substance it contains and the correct dosage regimen. Given their availability and the prevailing safety precaution, these preparations can lead to numerous prolonged conditions and complications. The mechanism of action of nasal decongestants is based on the reduction of blood vessels’ swelling in the nose, which helps the opening of the airway. As a result, most nasal decongestants cause vasoconstriction (narrowing of blood vessels). There are nasal decongestants that block histamine and have a good effect on people who suffer from seasonal allergies.

Availability (free sale) and prolonged use of the decongestant lead to a decrease in the sensitivity of the alpha receptor, which leads to the need to increase the dose at shorter time intervals to achieve the same effect. As a consequence, patients use excessive, uncontrolled doses of nasal decongestants, which is a public problem and warns of the necessity of identification and the taking of measures to prevent their uncontrolled procurement and use.

Guidance to 2018 good practice: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma

AIMS

Mobile Airways Sentinel NetworK (MASK) belongs to the Fondation Partenariale MACVIA-LR of Montpellier, France and aims to provide an active and healthy life to rhinitis sufferers and to those with asthma multimorbidity across the life cycle, whatever their gender or socio-economic status, in order to reduce health and social inequities incurred by the disease and to improve the digital transformation of health and care. The ultimate goal is to change the management strategy in chronic diseases.

METHODS

MASK implements ICT technologies for individualized and predictive medicine to develop novel care pathways by a multi-disciplinary group centred around the patients.

STAKEHOLDERS

Include patients, health care professionals (pharmacists and physicians), authorities, patient's associations, private and public sectors.

RESULTS

MASK is deployed in 23 countries and 17 languages. 26,000 users have registered.

EU GRANTS 2018

MASK is participating in EU projects (POLLAR: impact of air POLLution in Asthma and Rhinitis, EIT Health, DigitalHealthEurope, Euriphi and Vigour).

LESSONS LEARNT

(i) Adherence to treatment is the major problem of allergic disease, (ii) Self-management strategies should be considerably expanded (behavioural), (iii) Change management is essential in allergic diseases, (iv) Education strategies should be reconsidered using a patient-centred approach and (v) Lessons learnt for allergic diseases can be expanded to chronic diseases.

Current opinions for the management of asthma associated with ear, nose and throat comorbidities

Ear, nose and throat (ENT) comorbidities are common in patients with asthma and are frequently associated with poorer asthma outcomes. All these comorbidities are "treatable traits" in asthma. Identification and management of these disorders may spare medication usage and contribute to improved asthma control and quality of life, and a decrease in exacerbation rates.This review summarises recent data about the prevalence, clinical impact and treatment effects of ENT comorbidities in asthma including allergic rhinitis, chronic rhinosinusitis with and without nasal polyposis, aspirin-exacerbated respiratory disease, obstructive sleep apnoea and vocal cord dysfunction.Many of these comorbidities are possible to be managed by the pulmonologist, but the collaboration with the ENT specialist is essential for patients with chronic rhinosinusitis or vocal cord dysfunction. Further rigorous research is needed to study the efficacy of comorbidity treatment to improve asthma outcomes, in particular with the development of biotherapies in severe asthma that can also be beneficial in some ENT diseases.

Manifestations of Inhalant Allergies Beyond the Nose

The upper and lower airways are linked epidemiologically and pathophysiologically. The upper and lower airways are considered a single, functional unit characterized by shared immunologic mechanisms, often referred to as the unified airway. Upper and lower airway inflammatory disease frequently coexist in the same patient. Allergic rhinitis and rhinosinusitis are associated with asthma. Treatment of both diseases impacts asthma outcomes. The otolaryngologist may be the first physician to suspect and diagnose asthma in patients with upper airway complaints. A thorough understanding of the relationship between allergic rhinitis, rhinosinusitis, and asthma will facilitate early identification of asthma and improve patient outcomes.

Self-assessment of Allergic Rhinitis and Asthma (SACRA) Questionnaire-based Allergic Rhinitis Treatment Improves Asthma Control in Asthmatic Patients with Allergic Rhinitis

Objective This study was conducted to investigate whether the add-on treatment of allergic rhinitis (AR) based on the Self-assessment of Allergic Rhinitis and Asthma (SACRA) questionnaire for assessing AR control improves both AR and asthma control in asthmatic patients with AR. Methods This multi-center prospective study was performed in Nagano prefecture, Japan. Two hundred five asthmatic patients and 23 respiratory physicians participated in the study. We administered add-on AR treatments based on the results of the SACRA questionnaire. After the first SACRA questionnaire, 67 asthmatic patients agreed to receive an add-on AR treatment. Three months after the AR treatment, a secondary SACRA questionnaire, asthma control test (ACT), and pulmonary function tests were performed. Results After the add-on AR treatment, the visual analogue scales (VASs) for AR and asthma, as assessed by the SACRA questionnaire and ACT score, were significantly improved in the patients of the AR+ group. With regard to the pulmonary function tests, the percent predicted vital capacity, and percent predicted forced expiratory volume in one second were also significantly improved. Regardless of whether the patients had previously undergone leukotriene receptor antagonists (LTRA) treatment, the VASs for AR and asthma and the ACT score were significantly improved in the AR+ group. However, the vital capacity (VC), forced vital capacity (FVC) and forced expiratory volume (FEV₁) were only significantly improved in the AR+ group that had previously undergone LTRA treatment. Conclusion SACRA questionnaire-based add-on AR treatment would be convenient for the detection of AR by respiratory physicians and would offer improved asthma control. This questionnaire can also be used to assess the therapeutic effects.

United airway disease: current perspectives

Upper and lower airways are considered a unified morphological and functional unit, and the connection existing between them has been observed for many years, both in health and in disease. There is strong epidemiologic, pathophysiologic, and clinical evidence supporting an integrated view of rhinitis and asthma: united airway disease in the present review. The term “united airway disease” is opportune, because rhinitis and asthma are chronic inflammatory diseases of the upper and lower airways, which can be induced by allergic or nonallergic reproducible mechanisms, and present several phenotypes. Management of rhinitis and asthma must be jointly carried out, leading to better control of both diseases, and the lessons of the Allergic Rhinitis and Its Impact on Asthma initiative cannot be forgotten.

Attention-Deficit/Hyperactivity Disorder–related Symptoms Improved with Allergic Rhinitis Treatment in Children

Background

Increased prevalence of attention-deficit/hyperactivity disorder (ADHD) in children with allergic rhinitis (AR) has been reported. Our previous study showed that children with untreated AR had higher ADHD scores than did the controls.

Objective

This prospective follow-up study aimed to investigate whether elevated ADHD scores in children with AR could be decreased by AR treatment.

Methods

Sixty-eight children with AR (age range, 6-14 years) and who were drug naive were enrolled and evaluated by AR symptom score, ADHD symptom scores, and computerized continuous performance test, before and after AR therapy, which included nonpharmacologic intervention, oral antihistamines, and topical steroids. Thirty-one age-matched controls and 13 children with pure ADHD were also enrolled for comparison. The relationship between the AR and ADHD score change was analyzed by a partial correlation test, and univariate and multivariate linear regression models were applied to investigate possible predictors for the improvement of ADHD scores by AR treatment.

Results

AR symptom scores in children with AR decreased significantly after treatment (p < 0.001), and their ADHD scores also decreased significantly (p < 0.001). An improved AR symptom score was positively correlated with improved detectability (rp = 0.617, p = 0.001) and commission error (rp = 0.511, p = 0.011). Significant predictors for the improvement of ADHD scores included age, AR drugs, AR subtypes, and multiple atopic diseases (ps < 0.05).

Conclusion

Higher ADHD scores in children with AR compared with healthy controls decreased significantly with AR treatment. For children with AR and borderline ADHD symptoms, who do not meet full ADHD diagnostic criteria, we recommend initially treating their AR and monitoring improvement of ADHD symptoms.

The Heterogeneity Hidden in Allergic Rhinitis and Its Impact on Co-Existing Asthma in Adults: A Population-Based Survey

BACKGROUND

It has been suggested that there is some overlap between allergic rhinitis (AR), sinusitis and polyposis, but this has not been fully documented. The present study aimed to evaluate the prevalence of these co-existing diseases and their impact on bronchial asthma in the general population of Italy.

METHODS

Within the frame of the multicentre Gene Environment Interactions in Respiratory Diseases (GEIRD) study, a postal screening questionnaire including questions about self-reported symptoms of asthma, AR, AR with sinusitis without nasal polyps (AR + SsNP) and AR with sinusitis with nasal polyps (AR + SwNP) was administered. Random samples of subjects aged between 20 and 44 years (n = 5,162) answered the postal questionnaire in 4 Italian centres (Pavia, Sassari, Turin, Verona). In AR subjects, the association among AR only, AR + SsNP, AR + SwNP and bronchial asthma was estimated by the relative risk ratio (RRR) using multinomial regression models.

RESULTS

The prevalence of AR in the sample was 25.4% (95% CI 24.2-26.6). A self-reported diagnosis of AR + SsNP and AR + SwNP was reported by 5.7% (95% CI 5.0-6.3) and by 1.2% (95% CI 0.9-1.5) of the subjects, respectively. Current asthma was reported by 17.5% of the AR subjects. In the adjusted multivariate analysis, the risk of having current asthma (RRR = 2.31, 95% CI 1.29-4.15), of having at least 1 asthma attack per year (RRR = 2.30, 95% CI 1.19-4.46) and of having had an emergency department admission for respiratory diseases (RRR = 5.61, 95% CI 1.81-23.92) was higher for subjects with AR + SwNP than subjects with AR only.

CONCLUSIONS

The diagnosis of AR in the epidemiological setting includes heterogeneous upper airway diseases that affect the clinical features of AR and its interactions with asthma.

Allergic rhinitis: the "Ghost Diagnosis" in patients with asthma

Allergic rhinitis (AR) is a common comorbidity of asthma that contributes to asthma severity. Although over 80 % of asthmatics have AR, the condition is frequently underdiagnosed in subjects with asthma. AR itself is also a highly prevalent condition, affecting 10-30 % of adults and up to 40 % of children. AR has been associated with both increased risk of asthma development and asthma severity. The exact mechanisms underlying these relationships have yet to be fully elucidated, but evidence supports a role for allergen sensitization. Compared to those with asthma alone, patients with comorbid AR and asthma have greater use of health care resources, including visits to the general practitioner, emergency department and hospitalizations. Pharmacological treatment of AR reduces this health care burden. Immunotherapy for AR improves both asthma and rhinitis symptoms in addition to preventing future allergen sensitizations and asthma development. Appropriate recognition, diagnosis and treatment of AR can significantly reduce asthma morbidity and improve quality of life.

Allergic rhinitis: the "Ghost Diagnosis" in patients with asthma

Allergic rhinitis (AR) is a common comorbidity of asthma that contributes to asthma severity. Although over 80 % of asthmatics have AR, the condition is frequently underdiagnosed in subjects with asthma. AR itself is also a highly prevalent condition, affecting 10-30 % of adults and up to 40 % of children. AR has been associated with both increased risk of asthma development and asthma severity. The exact mechanisms underlying these relationships have yet to be fully elucidated, but evidence supports a role for allergen sensitization. Compared to those with asthma alone, patients with comorbid AR and asthma have greater use of health care resources, including visits to the general practitioner, emergency department and hospitalizations. Pharmacological treatment of AR reduces this health care burden. Immunotherapy for AR improves both asthma and rhinitis symptoms in addition to preventing future allergen sensitizations and asthma development. Appropriate recognition, diagnosis and treatment of AR can significantly reduce asthma morbidity and improve quality of life.

The ARGA study with Italian general practitioners: prescriptions for allergic rhinitis and adherence to ARIA guidelines

BACKGROUND

General practitioners (GPs) are the healthcare professionals to whom patients with rhinitis firstly refer for their symptoms.

OBJECTIVE

In the present study, we assessed drug prescriptions for allergic rhinitis (AR) and evaluated prescriptive adherence to ARIA treatment guidelines.

METHODS

Data on 1379 AR patients were collected by 107 Italian GPs. Adherence to ARIA guidelines was evaluated according to AR severity classification.

RESULTS

AR was diagnosed by GPs as mild intermittent for 46.2% of patients, mild persistent for 26.6%, moderate-severe intermittent for 20.2%, and moderate-severe persistent for 7%; 43.7% of AR patients had concomitant asthma. The most frequently prescribed therapeutic groups were antihistamines (anti-H, 76%) and nasal corticosteroids (NCS, 46%). Anti-H were significantly used more often to treat AR alone than AR + asthma (85 vs. 68%, p < 0.001), whereas NCS were used more often to treat AR + asthma than AR alone (50 vs. 42%, p = 0.01). Among patients with only mild intermittent AR, 39% were prescribed combined therapy. Among patients with moderate-severe persistent AR, 30% of those with AR alone and 18% of those with AR + asthma were prescribed monotherapy based on anti-H. GPs were more compliant with ARIA guidelines while treating AR alone (57%) than AR + asthma (46%) patients. The adherence increased according to the severity grade and was satisfactory for moderate-severe persistent AR (89% for AR alone and 95% for AR + asthma).

CONCLUSIONS

Adherence to ARIA guidelines is satisfactory only for treatment of more severe patients, thus GPs often tend to treat patients independently from ARIA guidelines. Since prescription data only provide limited information to judge prescribing quality, some deviation from the gold standard are to be expected.

Allergic Rhinitis and Its Impact on Asthma in Asia Pacific and the ARIA Update 2008

The prevalence of allergic diseases such as allergic rhinitis (AR) and asthma are markedly increasing to epidemic proportions worldwide as societies adopt Western lifestyles. An estimated 300 million persons worldwide have asthma, about 50% of whom live in developing countries, and about 400 million people suffer from AR. AR has a marked impact on quality of life, socially, at school, and in the workplace and is a huge socioeconomic burden. Thus, there was clearly a need for a global evidence-based guideline not only for managing AR but also highlighting the interactions between the upper and lower airways including diagnosis, epidemiology, common risk factors, management, and prevention. The Allergic Rhinitis and its Impact on Asthma (ARIA) document was first published in 2001 as a state-of-the-art document for the specialist, the general practitioner, and other health care professionals. Subsequent research and increasing knowledge have resulted in the ARIA 2008 update. The present review summarizes the ARIA update with particular emphasis on the current status of AR and asthma in Asia Pacific.

Satisfaction with allergy treatments depends on symptom severity but not on allergen specificity in patients with allergic rhinitis

Allergic rhinitis is characterized by troublesome symptoms that may be particularly severe. Most of rhinitics are dissatisfied with drug treatments. The dissatisfaction level depends on symptoms severity, but not on the type of causal allergen.

Fluticasone furoate nasal spray in the treatment of allergic rhinitis

Allergic rhinitis (AR) is a prevalent disease with great morbidity and significant societal and economic burden. Intranasal corticosteroids are recommended as first-line therapy for patients with moderate-to-severe disease, especially when nasal congestion is a major component of symptoms. To compare the efficacy and safety profile of different available intranasal corticosteroids for the treatment of AR, it is important to understand their different structures and pharmacokinetic and pharmacodynamic properties. Knowledge of these drugs has increased tremendously over the last decade. Studies have elucidated mechanisms of action, pharmacologic properties, and the clinical impact of these drugs in allergic respiratory diseases. Although the existing intranasal corticosteroids are already highly efficient, the introduction of further improved formulations with a better efficacy/safety profile is always desired. Fluticasone furoate nasal spray is a new topical corticosteroid, with enhanced-affinity and a unique side-actuated delivery device. As it has high topical potency and low potential for systemic effects, it is a good candidate for rhinitis treatment.

Congruence between international guidelines and mite specific immunotherapy prescribing practices

Both rhinitis (ARIA) and asthma (GINA) guidelines recommend allergen-specific immunotherapy (SIT) tailored to the specific levels of severity of each disease. Real world studies evaluating congruence between these recommendations and prescribing practice in the single patient with comorbidity are lacking. An observational polycentric study was carried out in 518 patients recruited from 34 allergy centers throughout Italy. A questionnaire was administered to each consecutive patient over a span of four months. Taking into account guideline recommendations for both diseases, concomitant in the same patient, three subsets resulted: patients not eligible for SIT (11%); patients eligible for SIT for one disease only (60%); patients eligible for SIT for both diseases (29%). SIT was prescribed in 257 (49.6%) subjects. The level of SIT prescription was about 50% in all three groups. Consistent with the ARIA guidelines, a correlation between the prescription of SIT and the severity of rhinitis was documented (r=0.87; p=0.001). An association with asthma severity was found (p=0.02), but the trend was inconsistent with the GINA recommendations. Young age was the most important factor for SIT prescription both in the eligible for one disease and in the eligible for both diseases subset. The tendency towards worsening of symptoms was a factor for SIT in the eligible for one disease subset. In mite allergic patients with rhinitis and asthma comorbidity, the severity of rhinitis and the young age are the most important factors driving the SIT prescription. The congruence of SIT prescription was better for the ARIA than GINA guidelines.

Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Difficult-to-control asthma management through the use of a specific protocol

The present study is a critical review of difficult-to-control asthma, highlighting the characteristics and severity of the disease. It also presents a protocol for the management of patients with this asthma phenotype. The protocol, which was based on relevant studies in the literature, is described and analyzed.

[Allergic rhinitis and its impact on asthma (ARIA update 2008). The Austrian perspective]

In 1999, during the ARIA (Allergic Rhinitis and its Impact on Asthma) WHO workshop, an evidence-based document was produced using an extensive review of the literature available up to December of the same year. An update of the ARIA guidelines was soon needed and started in 2004. Thereafter, there was the need for an even more global document, which would highlight the interactions between the upper and the lower airways including diagnosis, epidemiology, common risk factors, management and prevention, and comprise the allergy perspective also for developing countries. This goal was achieved with the most recently published ARIA update 2008. The present article is the result of consecutive efforts of the authors of the ARIA update 2008 to accomplish the nationwide comprehensive distribution of information by publication in important national journals, like the WMW.

Clinical assessment of a nasal decongestion test by visual analog scale in allergic rhinitis

BACKGROUND

Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow. That allergy is characterized by inflammation and that the response to the decongestion test correlates with the grade of inflammatory reaction has previously been shown. The aim of this study was to verify the suitability of the use of the visual analog scales (VASs) as a surrogate for rhinomanometry in the decongestion test assessment in patients with persistent allergic rhinitis.

METHODS

One hundred three patients (mean age, 23 years [2.24 SD]) were studied. Nasal symptoms, VAS, rhinomanometry, and nasal decongestion test were assessed in all patients.

RESULTS

A significant association was observed between VAS and nasal airflow after the decongestion test (Spearman R = -33.3%; p < 0.001). Moreover, a significant inverse association between changes in decongestion measures was detected, with a Spearman R = -64.7% (p < 0.001). The associated sensitivity was of 92.5%, and the specificity for this test was 60.0%. The corresponding area under the receiver operating characteristic curve was 0.81.

CONCLUSION

The use of VAS for assessing the decongestion test appears clinically relevant in that it allows, with a fair degree of reliability, such a test to be performed in the absence of rhinomanometry.