Online material - ARIA Masterclass 2018

1. Why is the control suboptimal in AR?

by Joaquim Mullol, Spain

Allergic rhinitis (AR) is a prevalent disease in children and adults. The ARIA initiative has raised AR awareness while improving patient‘s management. ARIA classifies AR by symptom’s duration (intermittent, persistent) and disease severity (mild, moderate, severe). Mild patients usually do self-managed or consult the pharmacist whereas moderate-severe patients are seen by GPs and specialists. Although following guideline recommendations, a high number (40-50%) of AR treated patients remain uncontrolled, taking a high number of medications and continuously seeking for new drugs with higher efficacy. By analogy with GINA, the concept of "control" in AR brings a better achievement, mainly in treated patients, although severity and control are not mutually exclusive. Control in AR combines the assessment of severity, quality of life, and exacerbations, and may be affected by a number of factors related to patient’s disease, diagnosis, and treatment. Loss of smell has also been associated with severe and uncontrolled AR. Control can be measured by questionnaires (ARCT, CARAT, RCAT) and by a Visual Analogue Scale (VAS), validated by MACVIA-ARIA and already used in a Diary Allergy App. Finally, like in asthma there is an unmet need of studies assessing the impact of severity and control to achieve an optimal multidisciplinary management of AR patients.

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2. Are ARIA and US guidelines agreeing?

by Oliver Pfaar, Germany

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3. Next-generation care pathways

by Jean Bousquet, France

The burden and cost of allergic rhinitis are both increasing. The transformation of the health care system for integrated care needs support via organizational health literacy. ARIA Phase 4 proposes a change management strategy to increase self-medication and shared decision making in rhinitis and asthma multimorbidity. MASK (Mobile Airways Sentinel Network) is a new development of the ARIA (Allergic Rhinitis and its Impact on Asthma) initiative. It has developed and validated IT evidence-based tools. These tools can inform patient decisions on the basis of a self-care plan proposed by health care professionals.  In collaboration with professional and patient organizations, POLLAR (Impact of Air Pollution on Asthma and Rhinitis, EIT Health) is proposing real-life care pathways which are centred around the patient and use mHealth monitoring of environmental exposure. Patient participation, health literacy and self-care are all included through technology-assisted “patient activation”, implementation of care pathways by pharmacists and next-generation guidelines assessing the recommendations of GRADE guidelines using real-world evidence (RWE). The EU political agenda is of major importance in supporting healthcare transformation and MASK has been recognized by DG Santé as a Good Practice in the field of digitally-enabled, integrated, person-centred care.

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4. Accurate diagnosis of allergic airway diseases

by Philippe Gevaert, Belgium

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5. Challenge of AR and multimorbidity

by Guy Scadding, UK

Multi-morbidity has been defined as ‘the presence of one or more additional disorders (or diseases) co-occurring with a primary disease or disorder, or the effect of such additional disorders or diseases’ (Cingi et al 2017). Multi-morbidity may occur in allergic rhinitis on account of an individual’s predisposition to atopic disease or due to local anatomic/inflammatory factors, or a combination of both. Most epidemiological data concern the co-morbid presence of allergic rhinitis, asthma and eczema, with data provided by several birth cohorts. These show a presence of allergic multi-morbidity (2 or more of these three conditions) occurring in over 10% of young adults. They also confirm that the majority of asthmatics have rhinitis. Allergic rhinitis is a risk factor for new onset asthma and, notably, a risk factor for asthma in the next generation. Treating allergic rhinitis may improve asthma control. 
Allergic rhinitis is strongly associated with conjunctivitis. Atopy is a risk factor for both upper and lower respiratory tract infections, but has not been clearly demonstrated to be a risk factor for chronic rhinosinusitis. Allergic rhinitis is associated with otitis media with effusion in children, whilst the relationship with adenoid hypertrophy is less well established. Allergic rhinitis impairs sleep quality. Intranasal corticosteroids may be of benefit in obstructive sleep apnoea in children, but evidence for a benefit in adults is lacking. Pollen-food syndrome is common in European children and adults with allergic rhinitis.
 

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6. The need for better symptom control

by Glenis Scadding, UK

The cardinal symptoms in AR are running, blocking, sneezing and itching. These can be extremely troublesome. However the consequences of such symptoms are important, with lack of a good night’s sleep (experienced by 50.3% of adults and 37.3% of children with AR) perhaps being the most vital. Consequent tiredness and poor concentration impinges on quality of life, on work and school performance and on productivity. Unproductivity for 2.3 h per working day when symptomatic costs $593 per person per year. This is greater than that for heart disease, asthma, diabetes, hypertension and respiratory illnesses combined.
 Uncontrolled AR carries a high social burden in other respects: it is socially embarrassing to be seen sneezing, sniffing, or nose-blowing. AR is associated with psychological disturbance and is a risk factor for depressive mood in pre-adolescents. Practical issues exist: untreated AR can impair driving ability.  This is worsened if inappropriate treatment such as sedating antihistamines are used.
Asthma is a known co- morbidity of AR. Uncontrolled rhinitis negatively impacts asthma control to the same degree as smoking. In a paediatric study where 126 children and adolescents with acute asthma on ICS therapy were studied 74.6% (95%CI 65.9–81.7) had AR. This combined with asthma severity represented the greatest risk factors for use of emergency care.
Currently many AR sufferers report poor symptom control and are willing to pay for a treatment for allergic rhinitis which works quickly and provides complete symptom relief.

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7. Patient participation for better control

by Tari Haahtela, Finland

In the digital era, where all information is readily accessible in the smart phone, we are  moving from the guideline era to patient partnership era. We call it participatory medicine, health consumerism or patient-centered care. This means experience of transparency, individualization, recognition, respect, dignity, and choice in all matters in health care (Donald Berwick 2009). Simply, less dictating and worrying about compliance and adherence and more true collaboration with the patient. Individual management solutions are more effective and safe to employ medication and other treatments. The authority of doctors and health-care professionals will stay but means less dictatorship and more democracy. The healing power of doctor´s personality and presence never disappears but is challenged by the new information environment. mHealth is an important solution to meet the growing demand for care. Mobile applications increase health literacy, bridge patient-physician communication, and increase patient participation. Videoconferencing has proven effective, patient reminders have increased patient participation and health applications have individualized management. Problems are lack of research and testing the application before going live as well as patient willingness to use the apps over time. Personal counselling of the patient by a professional is still critical. One important example is guided self-management, which dramatically reduced asthma exacerbations during the Finnish asthma (1994-2004) and allergy (2008-2018) programmes. Altogether, in the modern health-care patients have more rights but also more responsibility of their own health. 

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8. Shared decision-making in adults

by Walter Canonica, Italy

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9. Shared decision-making in children

by Arunas Valiulis, Lithuania

Patient centred care gained a lot of attention over the last few decades in order to improve the quality and cost-effectiveness of health care. A mutual partnership – shared decision making (SDM) –  where both, the patient and the health care provider, are responsible for health related decisions was shown to improve different aspects of health care. However, such a model in paediatric care is often complicated, because barely defined legal and ethical issues regarding children are commonly present.
First of all, children of different ages have different levels of competence regarding all aspects of self care and health, thus, age must be taken into account when SDM is considered. Furthermore, depending on the age of the child, parents or caregivers should be included in the process of SDM. Lastly, motivation is key for a child to sustain an interest in continued health management. 
In terms of chronic diseases, the requirements of long-term and sustained care are more important than in acute illnesses. Also, since many of the chronic diseases span over different stages of a child’s development, the SDM must be constantly reevaluated and readapted to the changing levels of autonomy and needs of a growing child. Despite all the difficulties, a mutual agreement or verbal “contract” on the management of a chronic respiratory disease (CRD) between the child, parents, and physician is possible. 
Today, the principle of confinement is used too often to manage patients with chronic diseases (WHO Bulletin, 2018, 96). Confinement not necessarily means physical isolation, it can also be psychosocial, emotional or other type of active or passive stigmatisation, or simply lack of understanding. It is based on a misconception that human rights have no connection with medicine. A new, human rights based approach for the management of CRDs in children is necessary as it will grant more autonomy to the child and put more emphasis in the patient–physician “swing” where the balance must be shifted to the weaker (patient) side. It is meant to start a step-wise evolution from SDM to guided self-management (GSM) in adults as well as in certain groups of children.
In the wake of eHealth and its most recent development – the mHealth – children are presented with numerous advantages regarding their involvement in health care decision making. The opportunities and ease of use provided by mobile apps such as the MACVIA-ARIA Allergy Diary are essential to empowering children. Finally, with immediate access and constant connection to the internet the GSM using mHealth is key in improving health related quality of life for children with CRDs.

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11. AIT for allergic asthma - the precision medicine approach

by Ioana Agache, Romania

Despite evidence of clinical efficacy allergen immunotherapy (AIT) remains underused in allergic asthma where, both in adults and children, treatment still relies on the maximal optimal use of corticosteroids and bronchodilators, and other controllers recommended to achieve and maintain asthma control and to prevent exacerbations, loss of lung function and improve quality of life. However, patients with allergic asthma not adequately controlled on available pharmacotherapy present an unmet medical need. There is a subgroup of asthmatic patients and related allergy that might benefit most from AIT.  The important prerequisite for a successful treatment is to select the group of patients responding to this causative therapy.  Several endotypes and biomarkers of allergic asthma can help the selection of responders to AIT in asthma. So far only house-dust mite SLIT-tablet showed robust effect in adults on critical asthma end-points (exacerbations, control and safety). Due to easiness of administration at home it represents a highly convenient treatment option as add-on treatment to regular therapy for adults with controlled or partially controlled asthma. HDM SCIT and SLIT drops is recommended for children and adults with controlled HDM – induced asthma as the add-on treatment to regular asthma therapy to decrease symptoms and medication use.

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12. The Value of Real World Evidence

by Ludger Klimek, Germany

Multi-morbidity has been defined as ‘the presence of one or more additional disorders (or diseases) co-occurring with a primary disease or disorder, or the effect of such additional disorders or diseases’. Multi-morbidity may occur in allergic rhinitis on account of an individual’s predisposition to atopic disease or due to local anatomic/inflammatory factors, or a combination of both. Most epidemiological data concern the co-morbid presence of allergic rhinitis, asthma and eczema, with data provided by several birth cohorts. These show a presence of allergic multi-morbidity (2 or more of these three conditions) occurring in over 10% of young adults. They also confirm that the majority of asthmatics have rhinitis. Allergic rhinitis is a risk factor for new onset asthma and, notably, a risk factor for asthma in the next generation. Treating allergic rhinitis may improve asthma control. 
Allergic rhinitis is strongly associated with conjunctivitis. Atopy is a risk factor for both upper and lower respiratory tract infections, but has not been clearly demonstrated to be a risk factor for chronic rhinosinusitis. Allergic rhinitis is associated with otitis media with effusion in children, whilst the relationship with adenoid hypertrophy is less well established. Allergic rhinitis impairs sleep quality. Intranasal corticosteroids may be of benefit in obstructive sleep apnoea in children, but evidence for a benefit in adults is lacking. Pollen-food syndrome is common in European children and adults with allergic rhinitis.

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13. Digital solutions to help AR patients reaching better control

by Gert Marien, Belgium

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