What effect does undiagnosed allergic rhinitis have on asthma control?

Allergic rhinitis and asthma are often comorbid conditions sharing a ‘unified airway’, with over 80% of patients with asthma having comorbid allergic rhinitis (Bousquet et al., 2008) and up to 40% of patients with allergic rhinitis experiencing asthma symptoms (Esteban et al., 2014). But after Dr Glenis Scadding revealed how often allergic rhinitis is undiagnosed in the previous expert opinion video, what effect does undiagnosed allergic rhinitis have on asthma control?

Sharing evidence for this potential link, Professor Erkka Valovirta discusses results from a recent study of adult-onset asthma. This study provides a useful insight into asthma control over time, but could upper airway disease, such as allergic rhinitis, be contributing to uncontrolled asthma?

The link between undiagnosed allergic rhinitis and asthma control has been a talking point for some time. One study from the USA conducted by Esteban et al. investigated how often allergic rhinitis is undiagnosed and undertreated in children with persistent asthma and revealed that 86% of participants had comorbid allergic rhinitis. Of these patients, a staggering 53% were previously undiagnosed. 

Without a diagnosis, undertreatment of allergic rhinitis is a natural concern. In this study, only 33% of patients with allergic rhinitis were receiving appropriate treatment in line with the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines.

The combination of undiagnosed and undertreated allergic rhinitis may have also resulted in the small number of patients (16%) reporting well-controlled asthma, a possibly unsurprising result as 45% of patients received oral burst steroids in the previous 12 months for asthma exacerbations. A positive correlation was also seen between asthma control and allergic rhinitis control scores (p<0.05). In particular, patients with poorly controlled allergic rhinitis had significantly less control over their asthma symptoms (p<0.05) (Esteban et al., 2014).

This problem can be seen across the globe with a Taiwanese study of patients with asthma finding allergic rhinitis to be undiagnosed in 8.4% of participants and a treatment rate of 61.1% (Tsao et al., 2011). As well as a recent study in South East Nigeria which found having an allergy symptom, including allergic rhinitis, was associated with asthma exacerbations (Ayuk et al., 2018).

It is clear there is a need for better education for healthcare professionals treating patients with asthma; approximately 27–30% of physicians underestimate the impact of allergic rhinitis on their patients’ daytime functioning (Meltzer, 2007).

One suggestion made to improve the diagnosis of allergic rhinitis is including the Rhinitis Control Assessment Test (R-ACT) in asthma consultations. The simple self-reporting questionnaire asks patients 6 questions about allergic rhinitis symptoms and may be a helpful tool to guide physicians in allergy referral decisions (Meltzer et al., 2013).

While it is clear the two respiratory diseases are affected by one another, how can we effectively treat the two together? In the coming months, we will be discussing the socioeconomic burden of allergic rhinitis and asthma and if simultaneous treatment could be beneficial for wider society.


Ayuk AC, Eze JN, Edelu BO, Oguonu T. The prevalence of allergic diseases among children with asthma: What is the impact on asthma control in South East Nigeria? Niger J Clin Pract. 2018;21:632–8.

Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy. 2008;86:8–160.

Esteban CA, Klein RB, Kopel SJ, McQuaid EL, Fritz GK, Seifer R, et al. Underdiagnosed and Undertreated Allergic Rhinitis in Urban School-Aged Children with Asthma. Pediatr Allergy Immunol Pulmonol. 2014;27:75–81.

Meltzer EO, Schatz M, Nathan R, Garris C, Stanford RH, Kosinski M. Reliability, validity, and responsiveness of the Rhinitis Control Assessment Test in patients with rhinitis. J Allergy Clin Immunol. 2013;131:379–86.

Meltzer EO. Allergic rhinitis: the impact of discordant perspectives of patient and physician on treatment decisions. Clin Ther. 2007;29:1428–40.

Tsao SM, Ko YK, Chen MZ, Chiu MH, Lin CS, Lin MS, et al. A survey of allergic rhinitis in Taiwanese asthma patients. J Microbiol Immunol Infect. 2011;44:139–43.


Publications (3)
  • Living with undiagnosed allergic rhinitis

    View the latest expert opinions from Dr Glenis Scadding, consultant allergist and rhinologist, discussing the burden undiagnosed allergic rhinitis creates and how this could be improved using positive skin prick and PAP testing.

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