Summer allergies: the burden of seasonal allergic rhinitis

For many the changing of the seasons and the arrival of warmer weather is something to look forward to. But for those living with seasonal allergic rhinitis (SAR), summer often brings unwanted allergies. 

In Northern Europe where pollen season is largely restricted to the summer months, patients with SAR experience symptoms such as sneezing, nasal itch, rhinorrhoea and/or nasal congestion approximately 50% of the time (Small et al., 2013). Despite these symptoms frequently being bothersome, they are often trivialised by patients. Less than half of patients with allergic rhinitis sought medical advice or treatment in one study (Canonica et al., 2007), while 19% of French patients never consulted their doctor despite 90% reporting that their nasal symptoms affected their day-to-day lives (Didier et al., 1999). If allergic rhinitis frequently goes under-treated and the symptoms can affect patients’ daily lives, what burden does SAR place on patients’ health-related quality of life (HRQoL)?

The physical burden of SAR

While perennial allergic rhinitis (PAR) has been observed to place a greater burden on patients’ physical HRQoL than SAR (Linneberg et al., 2016), the physical burden of SAR should not be underestimated. In a US study of patients with seasonal allergic rhinoconjunctivitis (SARC), 75–80% reported their symptoms being moderate-to-severe and over 50% reported feeling irritable and fatigued, probably because of sleep disruption, which was experienced by approximately 90% of patients on study (Meltzer et al., 2017). Meanwhile, a survey of the parents of Spanish adolescents with SAR reported that 40.1% of children had their daily activities affected by their condition (Battles-Garrido et al., 2010).

The emotional impact

The impact of SAR is not restricted to physical manifestations – 40% of parents reported their children with SARC as being unhappy with a substantial number also experiencing feelings of upset, anger, embarrassment, and a loss of confidence. Interestingly, these feelings were frequently higher among adolescent than adult patients (Meltzer et al., 2017). It is worth noting that while PAR had a greater impact on the physical components of patients’ HRQoL, a comparable impact on the mental components was seen with SAR and PAR (Linneberg et al., 2016). 

The impact of SAR also goes beyond general feelings of unhappiness and SAR is increasingly being associated with depression and anxiety. Major depressive disorder is 1.7 times higher among patients with SAR than those without allergic disease (Cuffel et al., 1999; Hurwitz & Morgenstern, 1999) and patients with SAR are also at increased risk of experiencing panic attacks (Goodwin, 2002) and anxiety disorders (Cuffel et al., 1999). A recent study by Trikojat et al. found that patients with symptomatic SAR saw a significant increase in depressive symptoms compared to when they were asymptomatic and to non-allergic subjects (Trikojat et al., 2017). 

21.95% of patients with SAR experienced clinically relevant depressive symptoms during the allergy season compared with 7.31% of controls (Trikojat et al., 2017).


In a bid to find the cause of this increase in depressive symptoms, significant associations were identified with levels of the proinflammatory cytokine IL-6 as well as ratios of IL-6/IL-10 and IFNγ/IL-10, suggesting a proinflammatory state during allergic responses may promote depressive symptoms. However, larger studies are required to confirm this finding. In addition to the cytokine profile, an early age at manifestation and poor sleep quality were also found to be associated with depressive symptoms in patients with SAR (Trikojat et al., 2017).

Impairments at work and school

The burden of SAR not only affects patients’ physical and mental wellbeing but can also impact their school and work performance. In a sample of French patients with AR, 8% reported missing work because of their condition (Didier et al., 1999). In addition, numerous studies have also identified substantial indirect costs associated with SAR due to absenteeism, presenteeism and production loss (Linneberg et al., 2016). Seventy-seven per cent of patients with SARC reported that their symptoms interfered with their productivity at work or school and 85% said that it affected their leisure and social activities. The impact of this should not be underestimated – patients lost an average of roughly 10 days (9.3 days for adults; 10.2 days for children) of productivity each typical seasonal month (Meltzer et al., 2017).

The loss of productivity among younger patients with SAR is reflected in academic outcomes. In the U.K., adolescents who dropped grades between their winter mock exams and the summer examinations were significantly more likely to have SAR symptoms, be taking AR medication, have a diagnosis of asthma, and have higher mean symptom scores than those that did not drop grades (Walker et al., 2007). Similar results have been observed elsewhere with increasing pollen counts being associated with reductions in national test scores in Norway (Bensnes, 2016) and severe nasal symptoms associated with lower exam scores among children in Sweden (Sundberg et al., 2007).

Addressing the burden of SAR

What can be done to improve the burden that SAR places on patients? Improving the management of SAR is key and greater patient education is critical to achieving this. However, while most patients in a U.S. survey saw a healthcare professional due to their allergy symptoms, many continue to attempt self-management through over-the-counter (OTC) medications or try to cope without treatment (Canonica et al., 2007; Meltzer et al., 2017). While non-prescription OTC medications may be effective for some patients, prescription medications received greater satisfaction ratings (Figure 1) among surveyed patients. Patients taking prescription medications were also less likely to switch or discontinue treatment suggesting greater satisfaction (Meltzer et al., 2017). Therefore, it may be beneficial to encourage patients with SAR, to see a physician to discuss the most appropriate prescription medication for them.

Treatment satisfaction among adult patients with seasonal allergic rhinoconjunctivitis.

Figure 1: Treatment satisfaction among adult patients with seasonal allergic rhinoconjunctivitis (Meltzer et al., 2017).

Despite reasonable satisfaction across the different allergy treatments, many patients are not taking them as recommended. While 47% of adults started treatment in response to symptoms, 41% took their medication year-round to ward off symptoms (Meltzer et al., 2017) suggesting either the presence of PAR or unnecessary over-medication and expense. Meanwhile, just 12% of adults started their medication before the start of the season to prevent symptom onset (Meltzer et al., 2017). 

It is not just the initiation and duration of treatment that appears to differ between patients – so does adherence. In one survey, approximately two-thirds of patients reported taking their medication as recommended, with patients with severe symptoms more likely to be adherent. However, 20% of patients only took their medication when experiencing symptoms (Meltzer et al., 2017), an approach that may exacerbate their condition as well as lead to higher costs (Bukstein et al., 2011). Other reasons for non-adherence included forgetfulness and medication side-effects (Meltzer et al., 2017).

Patient adherence and treatment satisfaction improve with patient understanding of their condition. Patient education and use of shared-decision making when devising a treatment plan are therefore critical to achieving improved adherence and helping to reduce the burden of SAR (Bukstein et al., 2011; Meltzer et al., 2017). While treatment satisfaction is improving many patients continue to struggle to understand their condition and medication. In the U.S., 20% of adult patients reported using an OTC intranasal antihistamine, despite no products being available on the market at that time (Meltzer et al., 2017). 

It is apparent that while SAR can be effectively managed through a host of oral, intranasal and combination medications, more still needs to be done to ensure patients appreciate the need for treatment, understand the potential for disease control, and receive the most suitable treatment for them.  When reviewing suitable treatment options for patients with a known poor adherence, consideration should be given to available combination treatments which have been shown to provide effective symptom control despite poor adherence.

References

Batlles-Garrido J, Torres-Borrego J, Rubí-Ruiz T, Bonillo-Perales A, González-Jiménez Y, Momblán-De Cabo J, et al. Prevalence and factors linked to allergic rhinitis in 10 and 11-year-old children in Almería. Isaac Phase II, Spain. Allergol Immunopathol (Madr). 2010;38(3):135–41.

Bensnes SS. You sneeze, you lose: The impact of pollen exposure on cognitive performance during high-stakes high school exams. J Health Econ. 2016;49:1–13.

Bukstein D, Luskin AT, Farrar JR. The reality of adherence to rhinitis treatment: identifying and overcoming the barriers. Allergy Asthma Proc. 2011;32(4):265–71.

Canonica GW, Bousquet J, Mullol J, Scadding GK, Virchow JC. A survey of the burden of allergic rhinitis in Europe. Allergy. 2007;62 Suppl 85:17–25.

Cuffel B, Wamboldt M, Borish L, Kennedy S, Crystal-Peters J. Economic consequences of comorbid depression, anxiety, and allergic rhinitis. Psychosomatics.

Didier A, Chanal I, Klossek JM, Mathieu J, Bousquet J. Allergic rhinitis: the patient's point of view. Revue Française d'Allergologie et d'Immunologie Clinique. 1999;39:171–85.

Goodwin RD. Self-reported hay fever and panic attacks in the community. Ann Allergy Asthma Immunol. 2002;88(6):556–9.

Hurwitz EL, Morgenstern H. Cross-sectional associations of asthma, hay fever, and other allergies with major depression and low-back pain among adults aged 20-39 years in the United States. Am J Epidemiol. 1999;150(10):1107–16.

Linneberg A, Dam Petersen K, Hahn-Pedersen J, Hammerby E, Serup-Hansen N, Boxall N. Burden of allergic respiratory disease: a systematic review. Clin Mol Allergy. 2016;14:12.

Meltzer EO, Farrar JR, Sennett C. Findings from an Online Survey Assessing the Burden and Management of Seasonal Allergic Rhinoconjunctivitis in US Patients. J Allergy Clin Immunol Pract. 2017;5(3):779–89.

Sundberg R, Torén K, Höglund D, Aberg N, Brisman J. Nasal symptoms are associated with school performance in adolescents. J Adolesc Health. 2007;40(6):581–3.

Trikojat K, Luksch H, Rösen-Wolff A, Plessow F, Schmitt J, Buske-Kirschbaum A. "Allergic mood" - Depressive and anxiety symptoms in patients with seasonal allergic rhinitis (SAR) and their association to inflammatory, endocrine, and allergic markers. Brain Behav Immun. 2017;65:202–9.

 

Publications (5)
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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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