The symptoms of allergic rhinitis may occur seasonally or persist over a long period of time. The disease is a growing global problem. In addition, the cost of therapy is enormous and often underestimated.
Allergic rhinitis (AR) is a disease of the nasal mucosa. It is based on an IgE-mediated inflammatory reaction triggered by certain, usually harmless substances. In addition to the characteristic signs, an allergy test can confirm the suspicion. A prospective study in Germany, France, Italy, Spain, and the United Kingdom examined the burden of an AR. Seasonal, perennial AR, and co-occurrence of both types were distinguished. The data of 1482 patients were collected and matched with the records of 415 physicians. A large proportion of sufferers had moderate to severe symptoms (67.2%; n=996), 42.5% (n=630) had a persistent form, and 31.5% (n=467) had comorbidities such as asthma [1].
Growing problem
Compared to physicians, patients were significantly more likely to rate their disease as more severe in all three types queried (p<0.001). Especially for patients, the high burden of AR is a very serious issue: uncontrolled symptoms can negatively affect sleep, general well-being and quality of life [1]. Further, this can be manifested by a drop in performance at school or work, anxiety and depression, as well as fatigue and mood swings [2].
The ARIA (Allergic Rhinitis and its Impact on Asthma) expert panel of the WHO sees an increasing prevalence of AR: more than 40-50% of allergy tests in Europe, the USA and Australia-New Zealand by skin or serum tests are positive. Of these, the majority of patients were diagnosed with AR and/or asthma. Conservative estimates suggest that approximately 500 million people worldwide suffer from AR. The trend is increasing, especially in regions where only low or moderate incidence of AR has been observed [2].
The 3-pillar therapy
Allergen avoidance is paramount in the treatment of AR. The allergen-specific immunotherapy is the second basic measure, with which a causal elimination of the problem is possible. In addition to subcutaneous administration, sublingual forms of the preparation are now also available, which are unlikely to cause anaphylactic shock.
Furthermore, symptomatic therapy with drugs plays a major role. H1 receptor antagonists of the 1st generation are now only used with restraint. Their biggest drawback: they can cause fatigue and anticholinergic effects. Therefore, H1 receptor antagonists of the 2nd generation preferred. Maximum plasma levels are reached after about an hour when taken orally, and nasal sprays or eye drops relieve symptoms in as little as half that time. In contrast, the full onset of action of the mast cell-stabilizing cromoglicic acid occurs after two weeks at the earliest, and often only moderate success is achieved.
Intranasal preparations
The situation is different with intranasal glucocorticoids: They are said to be the most effective. Also worth mentioning are intranasal anticholinergics, which are particularly suitable for the treatment of rhinorrhea in perennial allergic and non-allergic rhinitis [2]. In addition, there is a growing number of studies advocating intranasal antihistamines, and guidelines continue to recommend mainly intranasal preparations [3].
High costs, low compliance
The economic impact of AR is enormous. In 2005, it was estimated that the U.S. incurred approximately USD 3.4 billion in total direct medical costs. Of this, nearly half was spent on prescription drugs. In addition, there are hidden costs due to antibiotics, asthma, chronic sinusitis or emergency hospital admissions, as well as indirect costs such as missed work days. In addition, the total cost to treat AR is rising: while about 6 billion was spent in 2000, by 2005 it was 11.2 billion in the United States.
Nevertheless, many patients do not remain loyal to their therapy. Possible reasons: The medication does not relieve the symptoms as expected, undesirable side effects occur, or handling is impractical. Therefore, good patient compliance should be aimed for with tailored therapy, e.g., with intranasal anticholinergics [3].
Monika Lenzer
Literature:
- Canonica GW, et al: A survey of the burden of allergic rhinitis in Europe. Allergy 2007; 62 (85): 17-25.
- Bousquet J, et al: Allergic rhinitis and its impact on asthma (ARIA) 2008 Update. Allergy 2008; 63(86): 8-160.
- Meltzer EO, et al: The economic impact of allergic rhinitis and current guidelines for treatment. Ann Allergy Asthma Immunol 2011; 106: S12-S16.
