Munich may have seen its busiest May with record breaking numbers of allergy, dermatology, asthma, and immunology specialists travelling from all over the world for this year’s European Academy of Allergy and Clinical Immunology (EAACI) Congress. With the latest data and guidelines from a range of therapy areas and the opportunity to exchange ideas with peers through networking events, EAACI has become one of the most popular Congresses in Europe. This year’s Congress focussed on innovation in allergy, with numerous advances in allergic rhinitis (AR) discussed; including the burden of AR, the benefits of the Allergic Rhinitis and its impact on Asthma (ARIA) guidelines, and the diagnosis of local allergic rhinitis (LAR).
AR impacts patients’ quality of life causing problems such as fatigue during the day due to poor sleep quality. However, one of the lesser explored areas is the impact of the disease on productivity. Henrik Brandi from ALK Pharma Denmark stated that “allergic rhinitis is considered an expensive disease to treat because of its high prevalence and productivity losses” during the presentation of his poster, ‘Productivity losses for moderate and severe allergic rhinitis patients in the Netherlands’. An online survey combining the ARIA questionnaire and questions about absenteeism (work days lost due to AR symptoms) and presenteeism (productivity loss on attended work days caused by AR symptoms) was completed by 162 patients; the majority of which suffered from persistent AR with moderate symptoms.
Unsurprisingly, those with severe AR symptoms took more sick days than those with moderate AR symptoms, averaging 5.4 sick days per year due to AR symptoms, versus 2.2 sick days per year. This difference was also reflected in productivity losses (figure 1).
The economic impact of this productivity loss was also substantial, with a significant difference seen between severe and moderate AR (€3,887 vs. €1,396, respectively). In addition, 85% of productivity loss can be attributed to presenteeism. The researchers concluded that productivity loss increases with disease severity and it is beneficial to patients, employers, and society to effectively treat and control AR symptoms (Brandi et al., 2018).
To help patients with AR receive optimal treatment and management ARIA has established guidelines and clinical questions to aid health care professionals’ treatment decisions. The use of these guidelines was a talking point at this year’s EAACI Congress, with data exploring the benefits of guideline use in Ireland and a study analysing pharmacists’ knowledge of the ARIA guidelines in Brazil and Paraguay.
Dr Anne Marie McGinley from the Weir Clinic, Ireland, presented an ‘Assessment of impact of ARIA guideline implementation vs routine care on rhinitis related quality of life in a primary care setting in Ireland’ which analysed the effect of ARIA guideline implementation on quality of life (QoL). The study compared two groups of patients with AR, using the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) in 2015 and then again in 2016 to compare QoL after guidelines had been implemented in the intervention group and continuing existing practice in the control group. The researchers discovered a significant improvement in scores across all 7 QoL question categories between the intervention and treatment group, demonstrating that ARIA guideline implementation improved patient QoL. Dr Anne Marie McGinley stated that as this study was conducted in a primary care setting, it is essential that educational resources are invested in primary care to ensure these patients receive optimal care (McGinley et al., 2018).
Pharmacists’ knowledge of the ARIA guidelines is also of interest given their regular interaction with patients. Pharmacists play a key role in the diagnostic and treatment journey of many patients with AR who do not seek medical attention. Because of this key role, it is vital that pharmacists understand and use the ARIA guidelines to offer the most appropriate treatments and suggest GP consultations when necessary.
An online questionnaire revealed large gaps in pharmacist knowledge in both Brazil and Paraguay, with 80% of Brazilian pharmacists and 100% of Paraguayan pharmacists being unaware of the ARIA guidelines.
Despite not knowing about the guidelines, pharmacists were able to correctly identify the symptoms of AR – although key questions weren’t being asked (such as previous AR diagnosis, allergies, asthma diagnosis, worsening asthma symptoms etc.) in large proportions of the participants. It is clear that more education is needed to properly implement the ARIA guidelines, to aid appropriate advice, treatments and disease management (Urrutia-Pereira et al., 2018).
A real hot topic at this years EAACI Congress was local allergic rhinitis (LAR). Patients presenting with LAR often have typical AR symptoms but test negatively for skin prick tests and serum specific IgE. LAR can be diagnosed by testing for the presence of specific IgE in the nasal mucosa, but is this testing ready to be used in a routine clinical setting?
A thought-provoking debate between Dr Carmen Rondon from Hospital Regional Universitario de Málaga, Spain and Professor Ludger Klimek from the Center for Rhinology and Allergology, Wiesbaden, Germany discussed their opinions in a pro and con session. At the start of the session, the chair, Professor Philippe Gevaert asked the audience to vote on whether they believed LAR is ready for routine diagnosis; the majority were against with 32% in favour of routine diagnosis and 68% opposed. But how influential would the speakers be, and could audience opinion be swayed?
On the pro side, Dr Carmen Rondon, known for her academic research in LAR, described the condition as a persistent phenotype that worsens over time. She explored the idea of routine diagnosis being made possible with nasal allergen provocation tests (NAPT). She showed that several patients diagnosed with nonallergic rhinitis (NAR) had been misdiagnosed and actually had LAR as they had a positive response to NAPT. If this wasn’t enough, Dr Rondon highlighted that testing for LAR is cheap, quick, and non-invasive making it ideal for clinical practice.
However, this was countered by a convincing argument by Professor Ludger Klimek who described the diagnosis of LAR as “finding a needle in a haystack”. Professor Klimek uncovered issues surrounding diagnosis with the main theme being a lack of universal understanding – “before we can diagnose LAR in a routine setting we need a commonly accepted definition of the disease and a commonly accepted diagnostic test”. In addition to the unknowns surrounding the disease and how best we diagnose it, Professor Klimek raised the issue of prevalence stating that it was too low for this test to be useful in a routine setting with inconsistent numbers seen across Europe.
At the end of the debate, the audience voted once more with 71% against the routine assessment of LAR. A lot of discussion was being had about LAR and its diagnosis at this year’s EAACI Congress at oral abstract sessions and poster presentations, but the same questions were being raised – how useful is this test in real-life practice? It’s clear that the relatively new concept of LAR is a growing one but the majority of delegates attending the Congress still need convincing.
Brandi H, Elliott L, Hjørnholm A. Productivity losses for moderate and severe allergic rhinitis patients in the Netherlands. Poster presented at EAACI 27 May 2018.
McGinley A, Falvey E, Hourihane O’B. Assessment of impact of ARIA guideline implementation vs routine care on rhinitis related quality of life in a primary care setting in Ireland. Poster presented at EAACI 27 May 2018.
Urrutia-Pereira M, Bittencourt R, Fernandez C, Cruz A, Simon L, Rianelli P et al. Knowledge of pharmacists about Allergic Rhinitis and its Impact on Asthma guidelines (ARIA guidelines): a comparative Brazilian/Paraguayan pilot survey. Poster presented at EAACI 27 May 2018.
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The EAACI 2018 Congress focussed on innovation in allergy, with numerous advances in allergic rhinitis discussed; including the burden of AR, the benefits of the Allergic Rhinitis and its impact on Asthma guidelines, and the diagnosis of local allergic rhinitis.
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