Bradley F. Marple, MD

Introduction

Allergic rhinitis (AR) is a common health problem that affects all ages and is often inadequately treated. Because it is often perceived as just a nuisance, many patients do not seek medical treatment, and others self-medicate with over-the-counter products. However, as discussed by Meltzer et al¹ earlier in this supplement, untreated or inadequately treated AR can substantially impair overall quality of life. Importantly, AR is rarely found in isolation and should be considered in the context of systemic allergic disease. The presence of AR has been associated with numerous comorbid disorders, including asthma,^2-4 chronic otitis media,⁵ rhinosinusitis,^6,7 and oropharyngeal lymphoid hypertrophy, with secondary obstructive sleep apnea and disordered sleep.^8-10 Poorly controlled AR can trigger exacerbations of these comorbidities because they often share pathophysiologic (inflammatory) pathways in common with AR.^11,12 Moreover, if left untreated, AR symptoms themselves can worsen, leading to a spiral of worsening comorbidities.

Although there is significant evidence supporting the link between AR and other comorbidities, most studies have necessarily focused on selected populations and there has been relatively little information on how comorbidities affect the general AR population. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine the full range of symptoms patients with AR experience and how these symptoms relate to other, potentially more serious conditions. To enable comparison between the prevalence of comorbidities in the AR population (N = 400) and that in the general population, selected results of the general population survey (N = 522) are also included. Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy survey Assessing limitations

Worst Month for Nasal Allergies

Most adults with AR experience symptoms that are worse during certain times of year. In line with this, 76% of AR patients questioned reported that their nasal allergy symptoms have been worse or more frequent during a particular season or time of year in the past 12 months. Of these, most reported that the worst months of their allergy symptoms were in the spring, with 26% reporting March, 58% reporting April, and 44% reporting May as the worst month for allergy symptoms (FIGURE 1A). As expected, the most frequently reported symptom was nasal congestion, and 56% of AR patients reported experiencing this congestion every day or most days during the worst month in the past year. Other common symptoms that occurred every day or most days during the worst month were postnasal drip (48%), repeated sneezing (45%), watering or tearing eyes (41%), rhinorrhea (41%), red or itching eyes (38%), and nasal pruritus (31%). Importantly, not all of the symptoms reported were nasal, as 26% of AR patients reported cough, 21% reported headache, 20% reported throat itching, 18% reported facial pain or pressure, and 16% reported ear pain or pressure every day or most days during the worst month in the past year (FIGURE 1B).

FIGURE 1

Patient-rated nasal allergies (A) during months when symptoms are worst and symptoms suffered (B) during the worst allergy months

Patients with nasal allergies were asked: (A) During what particular months of the year are your nasal allergies the worst? (B) Which symptoms did you have during the worst one month period in the past year?
(A) Base: Allergies are worst during certain times of the year, n = 305; (B) Base: All respondents, unweighted, N = 400.

Asthma and Allergy

The survey found a strong relationship between asthma and nasal allergies, with 38% of AR patients reporting that they have been previously diagnosed with asthma. By contrast, only 8% of adults without nasal allergies reported that they have ever been diagnosed with asthma (FIGURE 2A). According to those patients with asthma and nasal allergies, their asthma symptoms are related to their allergy symptoms. The majority of adults with both nasal allergies and asthma (52%) reported that asthma gets better when their nasal allergies are under control; 37% said that their asthma stays about the same when their nasal allergies are under control, and 11% were not sure.

Nasal Allergies and Sinus Conditions

The survey also documents that a strong relationship exists between nasal allergies and sinus conditions, with 66% of AR patients reporting that they also suffer with rhinosinusitis or sinus conditions. By contrast, only 20% of adults without nasal allergies suffer from rhinosinusitis or sinus problems (FIGURE 2B). Moreover, although rhinosinusitis or sinus problems occur in about 3 times as many adults with nasal allergies as without nasal allergies, the proportion of individuals who have ever had nasal or sinus surgery is 7 times higher in adults with nasal allergies as in those without (15% vs 2%).

Other Comorbidities and Impact on Sleep

Compared with the general population, 3 times as many adults with nasal allergies reported that they had been extremely or moderately bothered by difficulty getting to sleep in the past week (24% vs 8%); twice as many reported being at least moderately bothered by waking up during the night as a result of their nasal symptoms in the past week (31% vs 13%) for any health-related reason; and more than twice as many adults with nasal allergies were extremely or moderately troubled by lack of a good night’s sleep as a result of the nasal symptoms (26% vs 11%) (FIGURE 2C).

Finally, when questioned about other problems suffered in the past 4 weeks, the proportion of adults with nasal allergies who have had rhinosinusitis, sleep disturbances, earaches, skin rashes, heartburn, gastroesophageal reflux disease, migraines, sleep apnea, conjunctivitis, and chronic tonsillitis were all noticeably higher in patients with AR than in people without nasal allergies. Indeed, a large number of adults without AR (66%) did not have any comorbidities, while only 29% of adults with AR did not report any (FIGURE 3).

FIGURE 2

Incidence of specific comorbidities associated with allergic rhinitis in the allergy vs general population: (A) asthma,* (B) rhinosinusitis,* and (C) sleep problems*

Respondents were asked: (A) Have you ever been diagnosed with asthma? (B) Do you suffer from sinusitis or sinus problems? (C) How troubled have you been by each of these symptoms (difficulty getting to sleep, waking up during the night, lack of a good night’s sleep) during the last week as a result of your health? Were you not troubled, hardly troubled at all, somewhat troubled, moderately troubled, or extremely troubled?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

Discussion

The results of this survey clearly demonstrate that compared with the general United States (US) population, people who have AR are at greater risk of suffering associated comorbidities such as asthma, rhinosinusitis, and other conditions noted previously. Although this is not novel information, most clinical trials have studied these associations only in selected populations, and the current study involving a more representative sample of US allergy sufferers confirms the high prevalence of comorbidities in the “real world.”

Many physicians and patients often dismiss AR as “just a runny nose,” but the results of the present survey clearly show that, especially during the worst spring months, patients with AR suffer a diverse range of symptoms. Although nasal congestion and postnasal drip are the most common symptoms, it is important to note that up to 20% of AR patients reported nonnasal symptoms, such as headache, facial pain or pressure, and ear pain or pressure, every day or most days during the worst month in the past year. Again, this information is not really new: the Allergies in America survey in 2006 found results on symptom frequency that were very similar to the findings of this survey.¹³ However, it is important information that needs to reach physicians and patients alike because effective management of AR would likely alleviate many nonnasal symptoms.¹⁴

This tendency to ignore or deprioritize AR in the face of other symptoms is very common in people who suffer the various comorbidities associated with AR; a person with asthma and AR is more likely to worry about their symptoms of wheezing than about their rhinorrhea. However, it is increasingly understood that these disorders are deeply connected at the pathologic level. For example, despite differences in the anatomic location of AR and asthma, they share a common inflammatory pattern in which many upper airways cells and mediators are the same as those involved in lower airway disease.^4,12 Supporting the concept of a “unified airway disease,” bronchial hyperresponsiveness and subclinical changes in the lower airways can be detected even in patients with AR who do not have asthma.¹⁵ As demonstrated in this survey, the presence of AR symptoms is associated with a worsening in asthma control and patient quality of life. The presence and type of asthma is influenced by sensitization, and the duration and severity of AR.⁴ However, much evidence suggests that effective AR management can lead to a better asthma control. Indeed, AR often precedes the onset of asthma and studies have shown that treatment with specific immunotherapy can prevent or delay asthma onset.¹⁶

FIGURE 3

Incidence of other comorbidities associated with allergic rhinitis in the allergy vs general population

Respondents were asked: During the past 4 weeks, have you had heartburn, reflux or gastroesophageal reflux disease (GERD), migraines, sleep disturbances, sleep apnea, sinusitis, skin rashes, earaches, chronic tonsillitis, conjunctivitis or red eye, or none of these?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

As demonstrated in this study, rhinosinusitis is another common complication of AR, which can lead to inflammation of the sinus mucosa and obstruction of the sinus drainage pathway or ostium.^6,17 Moreover, rhinosinusitis may be implicated in the genesis of nasal polyps, which are common when rhinosinusitis complicates AR. Although the reasons for nasal surgery were not collected in this survey, it is interesting to note the relatively high proportion of patients with AR who have had nasal surgery (15%), which may have included surgery to remove nasal polyps.

Common pathologic pathways can also explain the higher prevalence of other comorbidities seen in the survey of AR patients compared with the general population. Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, paranasal sinuses, and pharynx. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause eustachian tube obstruction, possibly leading to middle ear effusions.¹⁸ Similarly, chronic allergic inflammation of the upper airway causes oropharyngeal lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This is important, as retrospective analysis of medical claims data has shown that claims for rhinosinusitis, tonsillitis, otitis media, migraines, and asthma all increase during the allergy season with significant increases in the cost of treatment.¹⁹ Finally, the survey also confirmed the significant impact of AR on sleep quality. Several studies have found that AR patients, and particularly those with nasal congestion, often have significant sleep disturbances leading to fatigue, daytime somnolence, and impaired daytime functioning as reflected in lower levels of productivity at work or school.^8,10 As discussed in more detail by Meltzer et al¹ earlier in this supplement, sleep problems and the associated daytime fatigue are common problems reported by many AR patients. There may be a link between AR patients being tired and feelings of depression and anxiety. Therefore, although there is no direct pathologic link between AR and mental health, they certainly should be considered as serious potential consequences of uncontrolled AR.

In summary, the NASAL survey found that patients with AR are at a higher risk of other comorbidities compared with the general US population. Moreover, it showed that these comorbidities were exacerbated during the spring months when the symptoms of AR are worst. It therefore follows that timely diagnosis and treatment should be a priority for patients and physicians, not only to control AR symptoms but also to improve the management of associated diseases.

Introduction

Allergic rhinitis (AR) is a common health problem that affects all ages and is often inadequately treated. Because it is often perceived as just a nuisance, many patients do not seek medical treatment, and others self-medicate with over-the-counter products. However, as discussed by Meltzer et al¹ earlier in this supplement, untreated or inadequately treated AR can substantially impair overall quality of life. Importantly, AR is rarely found in isolation and should be considered in the context of systemic allergic disease. The presence of AR has been associated with numerous comorbid disorders, including asthma,^2-4 chronic otitis media,⁵ rhinosinusitis,^6,7 and oropharyngeal lymphoid hypertrophy, with secondary obstructive sleep apnea and disordered sleep.^8-10 Poorly controlled AR can trigger exacerbations of these comorbidities because they often share pathophysiologic (inflammatory) pathways in common with AR.^11,12 Moreover, if left untreated, AR symptoms themselves can worsen, leading to a spiral of worsening comorbidities.

Although there is significant evidence supporting the link between AR and other comorbidities, most studies have necessarily focused on selected populations and there has been relatively little information on how comorbidities affect the general AR population. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine the full range of symptoms patients with AR experience and how these symptoms relate to other, potentially more serious conditions. To enable comparison between the prevalence of comorbidities in the AR population (N = 400) and that in the general population, selected results of the general population survey (N = 522) are also included. Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy survey Assessing limitations

Worst Month for Nasal Allergies

Most adults with AR experience symptoms that are worse during certain times of year. In line with this, 76% of AR patients questioned reported that their nasal allergy symptoms have been worse or more frequent during a particular season or time of year in the past 12 months. Of these, most reported that the worst months of their allergy symptoms were in the spring, with 26% reporting March, 58% reporting April, and 44% reporting May as the worst month for allergy symptoms (FIGURE 1A). As expected, the most frequently reported symptom was nasal congestion, and 56% of AR patients reported experiencing this congestion every day or most days during the worst month in the past year. Other common symptoms that occurred every day or most days during the worst month were postnasal drip (48%), repeated sneezing (45%), watering or tearing eyes (41%), rhinorrhea (41%), red or itching eyes (38%), and nasal pruritus (31%). Importantly, not all of the symptoms reported were nasal, as 26% of AR patients reported cough, 21% reported headache, 20% reported throat itching, 18% reported facial pain or pressure, and 16% reported ear pain or pressure every day or most days during the worst month in the past year (FIGURE 1B).

FIGURE 1

Patient-rated nasal allergies (A) during months when symptoms are worst and symptoms suffered (B) during the worst allergy months

Patients with nasal allergies were asked: (A) During what particular months of the year are your nasal allergies the worst? (B) Which symptoms did you have during the worst one month period in the past year?
(A) Base: Allergies are worst during certain times of the year, n = 305; (B) Base: All respondents, unweighted, N = 400.

Asthma and Allergy

The survey found a strong relationship between asthma and nasal allergies, with 38% of AR patients reporting that they have been previously diagnosed with asthma. By contrast, only 8% of adults without nasal allergies reported that they have ever been diagnosed with asthma (FIGURE 2A). According to those patients with asthma and nasal allergies, their asthma symptoms are related to their allergy symptoms. The majority of adults with both nasal allergies and asthma (52%) reported that asthma gets better when their nasal allergies are under control; 37% said that their asthma stays about the same when their nasal allergies are under control, and 11% were not sure.

Nasal Allergies and Sinus Conditions

The survey also documents that a strong relationship exists between nasal allergies and sinus conditions, with 66% of AR patients reporting that they also suffer with rhinosinusitis or sinus conditions. By contrast, only 20% of adults without nasal allergies suffer from rhinosinusitis or sinus problems (FIGURE 2B). Moreover, although rhinosinusitis or sinus problems occur in about 3 times as many adults with nasal allergies as without nasal allergies, the proportion of individuals who have ever had nasal or sinus surgery is 7 times higher in adults with nasal allergies as in those without (15% vs 2%).

Other Comorbidities and Impact on Sleep

Compared with the general population, 3 times as many adults with nasal allergies reported that they had been extremely or moderately bothered by difficulty getting to sleep in the past week (24% vs 8%); twice as many reported being at least moderately bothered by waking up during the night as a result of their nasal symptoms in the past week (31% vs 13%) for any health-related reason; and more than twice as many adults with nasal allergies were extremely or moderately troubled by lack of a good night’s sleep as a result of the nasal symptoms (26% vs 11%) (FIGURE 2C).

Finally, when questioned about other problems suffered in the past 4 weeks, the proportion of adults with nasal allergies who have had rhinosinusitis, sleep disturbances, earaches, skin rashes, heartburn, gastroesophageal reflux disease, migraines, sleep apnea, conjunctivitis, and chronic tonsillitis were all noticeably higher in patients with AR than in people without nasal allergies. Indeed, a large number of adults without AR (66%) did not have any comorbidities, while only 29% of adults with AR did not report any (FIGURE 3).

FIGURE 2

Incidence of specific comorbidities associated with allergic rhinitis in the allergy vs general population: (A) asthma,* (B) rhinosinusitis,* and (C) sleep problems*

Respondents were asked: (A) Have you ever been diagnosed with asthma? (B) Do you suffer from sinusitis or sinus problems? (C) How troubled have you been by each of these symptoms (difficulty getting to sleep, waking up during the night, lack of a good night’s sleep) during the last week as a result of your health? Were you not troubled, hardly troubled at all, somewhat troubled, moderately troubled, or extremely troubled?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

Discussion

The results of this survey clearly demonstrate that compared with the general United States (US) population, people who have AR are at greater risk of suffering associated comorbidities such as asthma, rhinosinusitis, and other conditions noted previously. Although this is not novel information, most clinical trials have studied these associations only in selected populations, and the current study involving a more representative sample of US allergy sufferers confirms the high prevalence of comorbidities in the “real world.”

Many physicians and patients often dismiss AR as “just a runny nose,” but the results of the present survey clearly show that, especially during the worst spring months, patients with AR suffer a diverse range of symptoms. Although nasal congestion and postnasal drip are the most common symptoms, it is important to note that up to 20% of AR patients reported nonnasal symptoms, such as headache, facial pain or pressure, and ear pain or pressure, every day or most days during the worst month in the past year. Again, this information is not really new: the Allergies in America survey in 2006 found results on symptom frequency that were very similar to the findings of this survey.¹³ However, it is important information that needs to reach physicians and patients alike because effective management of AR would likely alleviate many nonnasal symptoms.¹⁴

This tendency to ignore or deprioritize AR in the face of other symptoms is very common in people who suffer the various comorbidities associated with AR; a person with asthma and AR is more likely to worry about their symptoms of wheezing than about their rhinorrhea. However, it is increasingly understood that these disorders are deeply connected at the pathologic level. For example, despite differences in the anatomic location of AR and asthma, they share a common inflammatory pattern in which many upper airways cells and mediators are the same as those involved in lower airway disease.^4,12 Supporting the concept of a “unified airway disease,” bronchial hyperresponsiveness and subclinical changes in the lower airways can be detected even in patients with AR who do not have asthma.¹⁵ As demonstrated in this survey, the presence of AR symptoms is associated with a worsening in asthma control and patient quality of life. The presence and type of asthma is influenced by sensitization, and the duration and severity of AR.⁴ However, much evidence suggests that effective AR management can lead to a better asthma control. Indeed, AR often precedes the onset of asthma and studies have shown that treatment with specific immunotherapy can prevent or delay asthma onset.¹⁶

FIGURE 3

Incidence of other comorbidities associated with allergic rhinitis in the allergy vs general population

Respondents were asked: During the past 4 weeks, have you had heartburn, reflux or gastroesophageal reflux disease (GERD), migraines, sleep disturbances, sleep apnea, sinusitis, skin rashes, earaches, chronic tonsillitis, conjunctivitis or red eye, or none of these?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

As demonstrated in this study, rhinosinusitis is another common complication of AR, which can lead to inflammation of the sinus mucosa and obstruction of the sinus drainage pathway or ostium.^6,17 Moreover, rhinosinusitis may be implicated in the genesis of nasal polyps, which are common when rhinosinusitis complicates AR. Although the reasons for nasal surgery were not collected in this survey, it is interesting to note the relatively high proportion of patients with AR who have had nasal surgery (15%), which may have included surgery to remove nasal polyps.

Common pathologic pathways can also explain the higher prevalence of other comorbidities seen in the survey of AR patients compared with the general population. Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, paranasal sinuses, and pharynx. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause eustachian tube obstruction, possibly leading to middle ear effusions.¹⁸ Similarly, chronic allergic inflammation of the upper airway causes oropharyngeal lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This is important, as retrospective analysis of medical claims data has shown that claims for rhinosinusitis, tonsillitis, otitis media, migraines, and asthma all increase during the allergy season with significant increases in the cost of treatment.¹⁹ Finally, the survey also confirmed the significant impact of AR on sleep quality. Several studies have found that AR patients, and particularly those with nasal congestion, often have significant sleep disturbances leading to fatigue, daytime somnolence, and impaired daytime functioning as reflected in lower levels of productivity at work or school.^8,10 As discussed in more detail by Meltzer et al¹ earlier in this supplement, sleep problems and the associated daytime fatigue are common problems reported by many AR patients. There may be a link between AR patients being tired and feelings of depression and anxiety. Therefore, although there is no direct pathologic link between AR and mental health, they certainly should be considered as serious potential consequences of uncontrolled AR.

In summary, the NASAL survey found that patients with AR are at a higher risk of other comorbidities compared with the general US population. Moreover, it showed that these comorbidities were exacerbated during the spring months when the symptoms of AR are worst. It therefore follows that timely diagnosis and treatment should be a priority for patients and physicians, not only to control AR symptoms but also to improve the management of associated diseases.

Introduction

Allergic rhinitis (AR) is a common health problem that affects all ages and is often inadequately treated. Because it is often perceived as just a nuisance, many patients do not seek medical treatment, and others self-medicate with over-the-counter products. However, as discussed by Meltzer et al¹ earlier in this supplement, untreated or inadequately treated AR can substantially impair overall quality of life. Importantly, AR is rarely found in isolation and should be considered in the context of systemic allergic disease. The presence of AR has been associated with numerous comorbid disorders, including asthma,^2-4 chronic otitis media,⁵ rhinosinusitis,^6,7 and oropharyngeal lymphoid hypertrophy, with secondary obstructive sleep apnea and disordered sleep.^8-10 Poorly controlled AR can trigger exacerbations of these comorbidities because they often share pathophysiologic (inflammatory) pathways in common with AR.^11,12 Moreover, if left untreated, AR symptoms themselves can worsen, leading to a spiral of worsening comorbidities.

Although there is significant evidence supporting the link between AR and other comorbidities, most studies have necessarily focused on selected populations and there has been relatively little information on how comorbidities affect the general AR population. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine the full range of symptoms patients with AR experience and how these symptoms relate to other, potentially more serious conditions. To enable comparison between the prevalence of comorbidities in the AR population (N = 400) and that in the general population, selected results of the general population survey (N = 522) are also included. Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy survey Assessing limitations

Worst Month for Nasal Allergies

Most adults with AR experience symptoms that are worse during certain times of year. In line with this, 76% of AR patients questioned reported that their nasal allergy symptoms have been worse or more frequent during a particular season or time of year in the past 12 months. Of these, most reported that the worst months of their allergy symptoms were in the spring, with 26% reporting March, 58% reporting April, and 44% reporting May as the worst month for allergy symptoms (FIGURE 1A). As expected, the most frequently reported symptom was nasal congestion, and 56% of AR patients reported experiencing this congestion every day or most days during the worst month in the past year. Other common symptoms that occurred every day or most days during the worst month were postnasal drip (48%), repeated sneezing (45%), watering or tearing eyes (41%), rhinorrhea (41%), red or itching eyes (38%), and nasal pruritus (31%). Importantly, not all of the symptoms reported were nasal, as 26% of AR patients reported cough, 21% reported headache, 20% reported throat itching, 18% reported facial pain or pressure, and 16% reported ear pain or pressure every day or most days during the worst month in the past year (FIGURE 1B).

FIGURE 1

Patient-rated nasal allergies (A) during months when symptoms are worst and symptoms suffered (B) during the worst allergy months

Patients with nasal allergies were asked: (A) During what particular months of the year are your nasal allergies the worst? (B) Which symptoms did you have during the worst one month period in the past year?
(A) Base: Allergies are worst during certain times of the year, n = 305; (B) Base: All respondents, unweighted, N = 400.

Asthma and Allergy

The survey found a strong relationship between asthma and nasal allergies, with 38% of AR patients reporting that they have been previously diagnosed with asthma. By contrast, only 8% of adults without nasal allergies reported that they have ever been diagnosed with asthma (FIGURE 2A). According to those patients with asthma and nasal allergies, their asthma symptoms are related to their allergy symptoms. The majority of adults with both nasal allergies and asthma (52%) reported that asthma gets better when their nasal allergies are under control; 37% said that their asthma stays about the same when their nasal allergies are under control, and 11% were not sure.

Nasal Allergies and Sinus Conditions

The survey also documents that a strong relationship exists between nasal allergies and sinus conditions, with 66% of AR patients reporting that they also suffer with rhinosinusitis or sinus conditions. By contrast, only 20% of adults without nasal allergies suffer from rhinosinusitis or sinus problems (FIGURE 2B). Moreover, although rhinosinusitis or sinus problems occur in about 3 times as many adults with nasal allergies as without nasal allergies, the proportion of individuals who have ever had nasal or sinus surgery is 7 times higher in adults with nasal allergies as in those without (15% vs 2%).

Other Comorbidities and Impact on Sleep

Compared with the general population, 3 times as many adults with nasal allergies reported that they had been extremely or moderately bothered by difficulty getting to sleep in the past week (24% vs 8%); twice as many reported being at least moderately bothered by waking up during the night as a result of their nasal symptoms in the past week (31% vs 13%) for any health-related reason; and more than twice as many adults with nasal allergies were extremely or moderately troubled by lack of a good night’s sleep as a result of the nasal symptoms (26% vs 11%) (FIGURE 2C).

Finally, when questioned about other problems suffered in the past 4 weeks, the proportion of adults with nasal allergies who have had rhinosinusitis, sleep disturbances, earaches, skin rashes, heartburn, gastroesophageal reflux disease, migraines, sleep apnea, conjunctivitis, and chronic tonsillitis were all noticeably higher in patients with AR than in people without nasal allergies. Indeed, a large number of adults without AR (66%) did not have any comorbidities, while only 29% of adults with AR did not report any (FIGURE 3).

FIGURE 2

Incidence of specific comorbidities associated with allergic rhinitis in the allergy vs general population: (A) asthma,* (B) rhinosinusitis,* and (C) sleep problems*

Respondents were asked: (A) Have you ever been diagnosed with asthma? (B) Do you suffer from sinusitis or sinus problems? (C) How troubled have you been by each of these symptoms (difficulty getting to sleep, waking up during the night, lack of a good night’s sleep) during the last week as a result of your health? Were you not troubled, hardly troubled at all, somewhat troubled, moderately troubled, or extremely troubled?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

Discussion

The results of this survey clearly demonstrate that compared with the general United States (US) population, people who have AR are at greater risk of suffering associated comorbidities such as asthma, rhinosinusitis, and other conditions noted previously. Although this is not novel information, most clinical trials have studied these associations only in selected populations, and the current study involving a more representative sample of US allergy sufferers confirms the high prevalence of comorbidities in the “real world.”

Many physicians and patients often dismiss AR as “just a runny nose,” but the results of the present survey clearly show that, especially during the worst spring months, patients with AR suffer a diverse range of symptoms. Although nasal congestion and postnasal drip are the most common symptoms, it is important to note that up to 20% of AR patients reported nonnasal symptoms, such as headache, facial pain or pressure, and ear pain or pressure, every day or most days during the worst month in the past year. Again, this information is not really new: the Allergies in America survey in 2006 found results on symptom frequency that were very similar to the findings of this survey.¹³ However, it is important information that needs to reach physicians and patients alike because effective management of AR would likely alleviate many nonnasal symptoms.¹⁴

This tendency to ignore or deprioritize AR in the face of other symptoms is very common in people who suffer the various comorbidities associated with AR; a person with asthma and AR is more likely to worry about their symptoms of wheezing than about their rhinorrhea. However, it is increasingly understood that these disorders are deeply connected at the pathologic level. For example, despite differences in the anatomic location of AR and asthma, they share a common inflammatory pattern in which many upper airways cells and mediators are the same as those involved in lower airway disease.^4,12 Supporting the concept of a “unified airway disease,” bronchial hyperresponsiveness and subclinical changes in the lower airways can be detected even in patients with AR who do not have asthma.¹⁵ As demonstrated in this survey, the presence of AR symptoms is associated with a worsening in asthma control and patient quality of life. The presence and type of asthma is influenced by sensitization, and the duration and severity of AR.⁴ However, much evidence suggests that effective AR management can lead to a better asthma control. Indeed, AR often precedes the onset of asthma and studies have shown that treatment with specific immunotherapy can prevent or delay asthma onset.¹⁶

FIGURE 3

Incidence of other comorbidities associated with allergic rhinitis in the allergy vs general population

Respondents were asked: During the past 4 weeks, have you had heartburn, reflux or gastroesophageal reflux disease (GERD), migraines, sleep disturbances, sleep apnea, sinusitis, skin rashes, earaches, chronic tonsillitis, conjunctivitis or red eye, or none of these?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

As demonstrated in this study, rhinosinusitis is another common complication of AR, which can lead to inflammation of the sinus mucosa and obstruction of the sinus drainage pathway or ostium.^6,17 Moreover, rhinosinusitis may be implicated in the genesis of nasal polyps, which are common when rhinosinusitis complicates AR. Although the reasons for nasal surgery were not collected in this survey, it is interesting to note the relatively high proportion of patients with AR who have had nasal surgery (15%), which may have included surgery to remove nasal polyps.

Common pathologic pathways can also explain the higher prevalence of other comorbidities seen in the survey of AR patients compared with the general population. Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, paranasal sinuses, and pharynx. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause eustachian tube obstruction, possibly leading to middle ear effusions.¹⁸ Similarly, chronic allergic inflammation of the upper airway causes oropharyngeal lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This is important, as retrospective analysis of medical claims data has shown that claims for rhinosinusitis, tonsillitis, otitis media, migraines, and asthma all increase during the allergy season with significant increases in the cost of treatment.¹⁹ Finally, the survey also confirmed the significant impact of AR on sleep quality. Several studies have found that AR patients, and particularly those with nasal congestion, often have significant sleep disturbances leading to fatigue, daytime somnolence, and impaired daytime functioning as reflected in lower levels of productivity at work or school.^8,10 As discussed in more detail by Meltzer et al¹ earlier in this supplement, sleep problems and the associated daytime fatigue are common problems reported by many AR patients. There may be a link between AR patients being tired and feelings of depression and anxiety. Therefore, although there is no direct pathologic link between AR and mental health, they certainly should be considered as serious potential consequences of uncontrolled AR.

In summary, the NASAL survey found that patients with AR are at a higher risk of other comorbidities compared with the general US population. Moreover, it showed that these comorbidities were exacerbated during the spring months when the symptoms of AR are worst. It therefore follows that timely diagnosis and treatment should be a priority for patients and physicians, not only to control AR symptoms but also to improve the management of associated diseases.

Introduction

Allergic rhinitis (AR) is a common health problem that affects all ages and is often inadequately treated. Because it is often perceived as just a nuisance, many patients do not seek medical treatment, and others self-medicate with over-the-counter products. However, as discussed by Meltzer et al¹ earlier in this supplement, untreated or inadequately treated AR can substantially impair overall quality of life. Importantly, AR is rarely found in isolation and should be considered in the context of systemic allergic disease. The presence of AR has been associated with numerous comorbid disorders, including asthma,^2-4 chronic otitis media,⁵ rhinosinusitis,^6,7 and oropharyngeal lymphoid hypertrophy, with secondary obstructive sleep apnea and disordered sleep.^8-10 Poorly controlled AR can trigger exacerbations of these comorbidities because they often share pathophysiologic (inflammatory) pathways in common with AR.^11,12 Moreover, if left untreated, AR symptoms themselves can worsen, leading to a spiral of worsening comorbidities.

Although there is significant evidence supporting the link between AR and other comorbidities, most studies have necessarily focused on selected populations and there has been relatively little information on how comorbidities affect the general AR population. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine the full range of symptoms patients with AR experience and how these symptoms relate to other, potentially more serious conditions. To enable comparison between the prevalence of comorbidities in the AR population (N = 400) and that in the general population, selected results of the general population survey (N = 522) are also included. Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy survey Assessing limitations

Worst Month for Nasal Allergies

Most adults with AR experience symptoms that are worse during certain times of year. In line with this, 76% of AR patients questioned reported that their nasal allergy symptoms have been worse or more frequent during a particular season or time of year in the past 12 months. Of these, most reported that the worst months of their allergy symptoms were in the spring, with 26% reporting March, 58% reporting April, and 44% reporting May as the worst month for allergy symptoms (FIGURE 1A). As expected, the most frequently reported symptom was nasal congestion, and 56% of AR patients reported experiencing this congestion every day or most days during the worst month in the past year. Other common symptoms that occurred every day or most days during the worst month were postnasal drip (48%), repeated sneezing (45%), watering or tearing eyes (41%), rhinorrhea (41%), red or itching eyes (38%), and nasal pruritus (31%). Importantly, not all of the symptoms reported were nasal, as 26% of AR patients reported cough, 21% reported headache, 20% reported throat itching, 18% reported facial pain or pressure, and 16% reported ear pain or pressure every day or most days during the worst month in the past year (FIGURE 1B).

FIGURE 1

Patient-rated nasal allergies (A) during months when symptoms are worst and symptoms suffered (B) during the worst allergy months

Patients with nasal allergies were asked: (A) During what particular months of the year are your nasal allergies the worst? (B) Which symptoms did you have during the worst one month period in the past year?
(A) Base: Allergies are worst during certain times of the year, n = 305; (B) Base: All respondents, unweighted, N = 400.

Asthma and Allergy

The survey found a strong relationship between asthma and nasal allergies, with 38% of AR patients reporting that they have been previously diagnosed with asthma. By contrast, only 8% of adults without nasal allergies reported that they have ever been diagnosed with asthma (FIGURE 2A). According to those patients with asthma and nasal allergies, their asthma symptoms are related to their allergy symptoms. The majority of adults with both nasal allergies and asthma (52%) reported that asthma gets better when their nasal allergies are under control; 37% said that their asthma stays about the same when their nasal allergies are under control, and 11% were not sure.

Nasal Allergies and Sinus Conditions

The survey also documents that a strong relationship exists between nasal allergies and sinus conditions, with 66% of AR patients reporting that they also suffer with rhinosinusitis or sinus conditions. By contrast, only 20% of adults without nasal allergies suffer from rhinosinusitis or sinus problems (FIGURE 2B). Moreover, although rhinosinusitis or sinus problems occur in about 3 times as many adults with nasal allergies as without nasal allergies, the proportion of individuals who have ever had nasal or sinus surgery is 7 times higher in adults with nasal allergies as in those without (15% vs 2%).

Other Comorbidities and Impact on Sleep

Compared with the general population, 3 times as many adults with nasal allergies reported that they had been extremely or moderately bothered by difficulty getting to sleep in the past week (24% vs 8%); twice as many reported being at least moderately bothered by waking up during the night as a result of their nasal symptoms in the past week (31% vs 13%) for any health-related reason; and more than twice as many adults with nasal allergies were extremely or moderately troubled by lack of a good night’s sleep as a result of the nasal symptoms (26% vs 11%) (FIGURE 2C).

Finally, when questioned about other problems suffered in the past 4 weeks, the proportion of adults with nasal allergies who have had rhinosinusitis, sleep disturbances, earaches, skin rashes, heartburn, gastroesophageal reflux disease, migraines, sleep apnea, conjunctivitis, and chronic tonsillitis were all noticeably higher in patients with AR than in people without nasal allergies. Indeed, a large number of adults without AR (66%) did not have any comorbidities, while only 29% of adults with AR did not report any (FIGURE 3).

FIGURE 2

Incidence of specific comorbidities associated with allergic rhinitis in the allergy vs general population: (A) asthma,* (B) rhinosinusitis,* and (C) sleep problems*

Respondents were asked: (A) Have you ever been diagnosed with asthma? (B) Do you suffer from sinusitis or sinus problems? (C) How troubled have you been by each of these symptoms (difficulty getting to sleep, waking up during the night, lack of a good night’s sleep) during the last week as a result of your health? Were you not troubled, hardly troubled at all, somewhat troubled, moderately troubled, or extremely troubled?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

Discussion

The results of this survey clearly demonstrate that compared with the general United States (US) population, people who have AR are at greater risk of suffering associated comorbidities such as asthma, rhinosinusitis, and other conditions noted previously. Although this is not novel information, most clinical trials have studied these associations only in selected populations, and the current study involving a more representative sample of US allergy sufferers confirms the high prevalence of comorbidities in the “real world.”

Many physicians and patients often dismiss AR as “just a runny nose,” but the results of the present survey clearly show that, especially during the worst spring months, patients with AR suffer a diverse range of symptoms. Although nasal congestion and postnasal drip are the most common symptoms, it is important to note that up to 20% of AR patients reported nonnasal symptoms, such as headache, facial pain or pressure, and ear pain or pressure, every day or most days during the worst month in the past year. Again, this information is not really new: the Allergies in America survey in 2006 found results on symptom frequency that were very similar to the findings of this survey.¹³ However, it is important information that needs to reach physicians and patients alike because effective management of AR would likely alleviate many nonnasal symptoms.¹⁴

This tendency to ignore or deprioritize AR in the face of other symptoms is very common in people who suffer the various comorbidities associated with AR; a person with asthma and AR is more likely to worry about their symptoms of wheezing than about their rhinorrhea. However, it is increasingly understood that these disorders are deeply connected at the pathologic level. For example, despite differences in the anatomic location of AR and asthma, they share a common inflammatory pattern in which many upper airways cells and mediators are the same as those involved in lower airway disease.^4,12 Supporting the concept of a “unified airway disease,” bronchial hyperresponsiveness and subclinical changes in the lower airways can be detected even in patients with AR who do not have asthma.¹⁵ As demonstrated in this survey, the presence of AR symptoms is associated with a worsening in asthma control and patient quality of life. The presence and type of asthma is influenced by sensitization, and the duration and severity of AR.⁴ However, much evidence suggests that effective AR management can lead to a better asthma control. Indeed, AR often precedes the onset of asthma and studies have shown that treatment with specific immunotherapy can prevent or delay asthma onset.¹⁶

FIGURE 3

Incidence of other comorbidities associated with allergic rhinitis in the allergy vs general population

Respondents were asked: During the past 4 weeks, have you had heartburn, reflux or gastroesophageal reflux disease (GERD), migraines, sleep disturbances, sleep apnea, sinusitis, skin rashes, earaches, chronic tonsillitis, conjunctivitis or red eye, or none of these?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

As demonstrated in this study, rhinosinusitis is another common complication of AR, which can lead to inflammation of the sinus mucosa and obstruction of the sinus drainage pathway or ostium.^6,17 Moreover, rhinosinusitis may be implicated in the genesis of nasal polyps, which are common when rhinosinusitis complicates AR. Although the reasons for nasal surgery were not collected in this survey, it is interesting to note the relatively high proportion of patients with AR who have had nasal surgery (15%), which may have included surgery to remove nasal polyps.

Common pathologic pathways can also explain the higher prevalence of other comorbidities seen in the survey of AR patients compared with the general population. Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, paranasal sinuses, and pharynx. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause eustachian tube obstruction, possibly leading to middle ear effusions.¹⁸ Similarly, chronic allergic inflammation of the upper airway causes oropharyngeal lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This is important, as retrospective analysis of medical claims data has shown that claims for rhinosinusitis, tonsillitis, otitis media, migraines, and asthma all increase during the allergy season with significant increases in the cost of treatment.¹⁹ Finally, the survey also confirmed the significant impact of AR on sleep quality. Several studies have found that AR patients, and particularly those with nasal congestion, often have significant sleep disturbances leading to fatigue, daytime somnolence, and impaired daytime functioning as reflected in lower levels of productivity at work or school.^8,10 As discussed in more detail by Meltzer et al¹ earlier in this supplement, sleep problems and the associated daytime fatigue are common problems reported by many AR patients. There may be a link between AR patients being tired and feelings of depression and anxiety. Therefore, although there is no direct pathologic link between AR and mental health, they certainly should be considered as serious potential consequences of uncontrolled AR.

In summary, the NASAL survey found that patients with AR are at a higher risk of other comorbidities compared with the general US population. Moreover, it showed that these comorbidities were exacerbated during the spring months when the symptoms of AR are worst. It therefore follows that timely diagnosis and treatment should be a priority for patients and physicians, not only to control AR symptoms but also to improve the management of associated diseases.

Introduction

Allergic rhinitis (AR) is a common health problem that affects all ages and is often inadequately treated. Because it is often perceived as just a nuisance, many patients do not seek medical treatment, and others self-medicate with over-the-counter products. However, as discussed by Meltzer et al¹ earlier in this supplement, untreated or inadequately treated AR can substantially impair overall quality of life. Importantly, AR is rarely found in isolation and should be considered in the context of systemic allergic disease. The presence of AR has been associated with numerous comorbid disorders, including asthma,^2-4 chronic otitis media,⁵ rhinosinusitis,^6,7 and oropharyngeal lymphoid hypertrophy, with secondary obstructive sleep apnea and disordered sleep.^8-10 Poorly controlled AR can trigger exacerbations of these comorbidities because they often share pathophysiologic (inflammatory) pathways in common with AR.^11,12 Moreover, if left untreated, AR symptoms themselves can worsen, leading to a spiral of worsening comorbidities.

Although there is significant evidence supporting the link between AR and other comorbidities, most studies have necessarily focused on selected populations and there has been relatively little information on how comorbidities affect the general AR population. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine the full range of symptoms patients with AR experience and how these symptoms relate to other, potentially more serious conditions. To enable comparison between the prevalence of comorbidities in the AR population (N = 400) and that in the general population, selected results of the general population survey (N = 522) are also included. Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy survey Assessing limitations

Worst Month for Nasal Allergies

Most adults with AR experience symptoms that are worse during certain times of year. In line with this, 76% of AR patients questioned reported that their nasal allergy symptoms have been worse or more frequent during a particular season or time of year in the past 12 months. Of these, most reported that the worst months of their allergy symptoms were in the spring, with 26% reporting March, 58% reporting April, and 44% reporting May as the worst month for allergy symptoms (FIGURE 1A). As expected, the most frequently reported symptom was nasal congestion, and 56% of AR patients reported experiencing this congestion every day or most days during the worst month in the past year. Other common symptoms that occurred every day or most days during the worst month were postnasal drip (48%), repeated sneezing (45%), watering or tearing eyes (41%), rhinorrhea (41%), red or itching eyes (38%), and nasal pruritus (31%). Importantly, not all of the symptoms reported were nasal, as 26% of AR patients reported cough, 21% reported headache, 20% reported throat itching, 18% reported facial pain or pressure, and 16% reported ear pain or pressure every day or most days during the worst month in the past year (FIGURE 1B).

FIGURE 1

Patient-rated nasal allergies (A) during months when symptoms are worst and symptoms suffered (B) during the worst allergy months

Patients with nasal allergies were asked: (A) During what particular months of the year are your nasal allergies the worst? (B) Which symptoms did you have during the worst one month period in the past year?
(A) Base: Allergies are worst during certain times of the year, n = 305; (B) Base: All respondents, unweighted, N = 400.

Asthma and Allergy

The survey found a strong relationship between asthma and nasal allergies, with 38% of AR patients reporting that they have been previously diagnosed with asthma. By contrast, only 8% of adults without nasal allergies reported that they have ever been diagnosed with asthma (FIGURE 2A). According to those patients with asthma and nasal allergies, their asthma symptoms are related to their allergy symptoms. The majority of adults with both nasal allergies and asthma (52%) reported that asthma gets better when their nasal allergies are under control; 37% said that their asthma stays about the same when their nasal allergies are under control, and 11% were not sure.

Nasal Allergies and Sinus Conditions

The survey also documents that a strong relationship exists between nasal allergies and sinus conditions, with 66% of AR patients reporting that they also suffer with rhinosinusitis or sinus conditions. By contrast, only 20% of adults without nasal allergies suffer from rhinosinusitis or sinus problems (FIGURE 2B). Moreover, although rhinosinusitis or sinus problems occur in about 3 times as many adults with nasal allergies as without nasal allergies, the proportion of individuals who have ever had nasal or sinus surgery is 7 times higher in adults with nasal allergies as in those without (15% vs 2%).

Other Comorbidities and Impact on Sleep

Compared with the general population, 3 times as many adults with nasal allergies reported that they had been extremely or moderately bothered by difficulty getting to sleep in the past week (24% vs 8%); twice as many reported being at least moderately bothered by waking up during the night as a result of their nasal symptoms in the past week (31% vs 13%) for any health-related reason; and more than twice as many adults with nasal allergies were extremely or moderately troubled by lack of a good night’s sleep as a result of the nasal symptoms (26% vs 11%) (FIGURE 2C).

Finally, when questioned about other problems suffered in the past 4 weeks, the proportion of adults with nasal allergies who have had rhinosinusitis, sleep disturbances, earaches, skin rashes, heartburn, gastroesophageal reflux disease, migraines, sleep apnea, conjunctivitis, and chronic tonsillitis were all noticeably higher in patients with AR than in people without nasal allergies. Indeed, a large number of adults without AR (66%) did not have any comorbidities, while only 29% of adults with AR did not report any (FIGURE 3).

FIGURE 2

Incidence of specific comorbidities associated with allergic rhinitis in the allergy vs general population: (A) asthma,* (B) rhinosinusitis,* and (C) sleep problems*

Respondents were asked: (A) Have you ever been diagnosed with asthma? (B) Do you suffer from sinusitis or sinus problems? (C) How troubled have you been by each of these symptoms (difficulty getting to sleep, waking up during the night, lack of a good night’s sleep) during the last week as a result of your health? Were you not troubled, hardly troubled at all, somewhat troubled, moderately troubled, or extremely troubled?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

Discussion

The results of this survey clearly demonstrate that compared with the general United States (US) population, people who have AR are at greater risk of suffering associated comorbidities such as asthma, rhinosinusitis, and other conditions noted previously. Although this is not novel information, most clinical trials have studied these associations only in selected populations, and the current study involving a more representative sample of US allergy sufferers confirms the high prevalence of comorbidities in the “real world.”

Many physicians and patients often dismiss AR as “just a runny nose,” but the results of the present survey clearly show that, especially during the worst spring months, patients with AR suffer a diverse range of symptoms. Although nasal congestion and postnasal drip are the most common symptoms, it is important to note that up to 20% of AR patients reported nonnasal symptoms, such as headache, facial pain or pressure, and ear pain or pressure, every day or most days during the worst month in the past year. Again, this information is not really new: the Allergies in America survey in 2006 found results on symptom frequency that were very similar to the findings of this survey.¹³ However, it is important information that needs to reach physicians and patients alike because effective management of AR would likely alleviate many nonnasal symptoms.¹⁴

This tendency to ignore or deprioritize AR in the face of other symptoms is very common in people who suffer the various comorbidities associated with AR; a person with asthma and AR is more likely to worry about their symptoms of wheezing than about their rhinorrhea. However, it is increasingly understood that these disorders are deeply connected at the pathologic level. For example, despite differences in the anatomic location of AR and asthma, they share a common inflammatory pattern in which many upper airways cells and mediators are the same as those involved in lower airway disease.^4,12 Supporting the concept of a “unified airway disease,” bronchial hyperresponsiveness and subclinical changes in the lower airways can be detected even in patients with AR who do not have asthma.¹⁵ As demonstrated in this survey, the presence of AR symptoms is associated with a worsening in asthma control and patient quality of life. The presence and type of asthma is influenced by sensitization, and the duration and severity of AR.⁴ However, much evidence suggests that effective AR management can lead to a better asthma control. Indeed, AR often precedes the onset of asthma and studies have shown that treatment with specific immunotherapy can prevent or delay asthma onset.¹⁶

FIGURE 3

Incidence of other comorbidities associated with allergic rhinitis in the allergy vs general population

Respondents were asked: During the past 4 weeks, have you had heartburn, reflux or gastroesophageal reflux disease (GERD), migraines, sleep disturbances, sleep apnea, sinusitis, skin rashes, earaches, chronic tonsillitis, conjunctivitis or red eye, or none of these?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

As demonstrated in this study, rhinosinusitis is another common complication of AR, which can lead to inflammation of the sinus mucosa and obstruction of the sinus drainage pathway or ostium.^6,17 Moreover, rhinosinusitis may be implicated in the genesis of nasal polyps, which are common when rhinosinusitis complicates AR. Although the reasons for nasal surgery were not collected in this survey, it is interesting to note the relatively high proportion of patients with AR who have had nasal surgery (15%), which may have included surgery to remove nasal polyps.

Common pathologic pathways can also explain the higher prevalence of other comorbidities seen in the survey of AR patients compared with the general population. Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, paranasal sinuses, and pharynx. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause eustachian tube obstruction, possibly leading to middle ear effusions.¹⁸ Similarly, chronic allergic inflammation of the upper airway causes oropharyngeal lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This is important, as retrospective analysis of medical claims data has shown that claims for rhinosinusitis, tonsillitis, otitis media, migraines, and asthma all increase during the allergy season with significant increases in the cost of treatment.¹⁹ Finally, the survey also confirmed the significant impact of AR on sleep quality. Several studies have found that AR patients, and particularly those with nasal congestion, often have significant sleep disturbances leading to fatigue, daytime somnolence, and impaired daytime functioning as reflected in lower levels of productivity at work or school.^8,10 As discussed in more detail by Meltzer et al¹ earlier in this supplement, sleep problems and the associated daytime fatigue are common problems reported by many AR patients. There may be a link between AR patients being tired and feelings of depression and anxiety. Therefore, although there is no direct pathologic link between AR and mental health, they certainly should be considered as serious potential consequences of uncontrolled AR.

In summary, the NASAL survey found that patients with AR are at a higher risk of other comorbidities compared with the general US population. Moreover, it showed that these comorbidities were exacerbated during the spring months when the symptoms of AR are worst. It therefore follows that timely diagnosis and treatment should be a priority for patients and physicians, not only to control AR symptoms but also to improve the management of associated diseases.

Introduction

Allergic rhinitis (AR) is a common health problem that affects all ages and is often inadequately treated. Because it is often perceived as just a nuisance, many patients do not seek medical treatment, and others self-medicate with over-the-counter products. However, as discussed by Meltzer et al¹ earlier in this supplement, untreated or inadequately treated AR can substantially impair overall quality of life. Importantly, AR is rarely found in isolation and should be considered in the context of systemic allergic disease. The presence of AR has been associated with numerous comorbid disorders, including asthma,^2-4 chronic otitis media,⁵ rhinosinusitis,^6,7 and oropharyngeal lymphoid hypertrophy, with secondary obstructive sleep apnea and disordered sleep.^8-10 Poorly controlled AR can trigger exacerbations of these comorbidities because they often share pathophysiologic (inflammatory) pathways in common with AR.^11,12 Moreover, if left untreated, AR symptoms themselves can worsen, leading to a spiral of worsening comorbidities.

Although there is significant evidence supporting the link between AR and other comorbidities, most studies have necessarily focused on selected populations and there has been relatively little information on how comorbidities affect the general AR population. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine the full range of symptoms patients with AR experience and how these symptoms relate to other, potentially more serious conditions. To enable comparison between the prevalence of comorbidities in the AR population (N = 400) and that in the general population, selected results of the general population survey (N = 522) are also included. Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy survey Assessing limitations

Worst Month for Nasal Allergies

Most adults with AR experience symptoms that are worse during certain times of year. In line with this, 76% of AR patients questioned reported that their nasal allergy symptoms have been worse or more frequent during a particular season or time of year in the past 12 months. Of these, most reported that the worst months of their allergy symptoms were in the spring, with 26% reporting March, 58% reporting April, and 44% reporting May as the worst month for allergy symptoms (FIGURE 1A). As expected, the most frequently reported symptom was nasal congestion, and 56% of AR patients reported experiencing this congestion every day or most days during the worst month in the past year. Other common symptoms that occurred every day or most days during the worst month were postnasal drip (48%), repeated sneezing (45%), watering or tearing eyes (41%), rhinorrhea (41%), red or itching eyes (38%), and nasal pruritus (31%). Importantly, not all of the symptoms reported were nasal, as 26% of AR patients reported cough, 21% reported headache, 20% reported throat itching, 18% reported facial pain or pressure, and 16% reported ear pain or pressure every day or most days during the worst month in the past year (FIGURE 1B).

FIGURE 1

Patient-rated nasal allergies (A) during months when symptoms are worst and symptoms suffered (B) during the worst allergy months

Patients with nasal allergies were asked: (A) During what particular months of the year are your nasal allergies the worst? (B) Which symptoms did you have during the worst one month period in the past year?
(A) Base: Allergies are worst during certain times of the year, n = 305; (B) Base: All respondents, unweighted, N = 400.

Asthma and Allergy

The survey found a strong relationship between asthma and nasal allergies, with 38% of AR patients reporting that they have been previously diagnosed with asthma. By contrast, only 8% of adults without nasal allergies reported that they have ever been diagnosed with asthma (FIGURE 2A). According to those patients with asthma and nasal allergies, their asthma symptoms are related to their allergy symptoms. The majority of adults with both nasal allergies and asthma (52%) reported that asthma gets better when their nasal allergies are under control; 37% said that their asthma stays about the same when their nasal allergies are under control, and 11% were not sure.

Nasal Allergies and Sinus Conditions

The survey also documents that a strong relationship exists between nasal allergies and sinus conditions, with 66% of AR patients reporting that they also suffer with rhinosinusitis or sinus conditions. By contrast, only 20% of adults without nasal allergies suffer from rhinosinusitis or sinus problems (FIGURE 2B). Moreover, although rhinosinusitis or sinus problems occur in about 3 times as many adults with nasal allergies as without nasal allergies, the proportion of individuals who have ever had nasal or sinus surgery is 7 times higher in adults with nasal allergies as in those without (15% vs 2%).

Other Comorbidities and Impact on Sleep

Compared with the general population, 3 times as many adults with nasal allergies reported that they had been extremely or moderately bothered by difficulty getting to sleep in the past week (24% vs 8%); twice as many reported being at least moderately bothered by waking up during the night as a result of their nasal symptoms in the past week (31% vs 13%) for any health-related reason; and more than twice as many adults with nasal allergies were extremely or moderately troubled by lack of a good night’s sleep as a result of the nasal symptoms (26% vs 11%) (FIGURE 2C).

Finally, when questioned about other problems suffered in the past 4 weeks, the proportion of adults with nasal allergies who have had rhinosinusitis, sleep disturbances, earaches, skin rashes, heartburn, gastroesophageal reflux disease, migraines, sleep apnea, conjunctivitis, and chronic tonsillitis were all noticeably higher in patients with AR than in people without nasal allergies. Indeed, a large number of adults without AR (66%) did not have any comorbidities, while only 29% of adults with AR did not report any (FIGURE 3).

FIGURE 2

Incidence of specific comorbidities associated with allergic rhinitis in the allergy vs general population: (A) asthma,* (B) rhinosinusitis,* and (C) sleep problems*

Respondents were asked: (A) Have you ever been diagnosed with asthma? (B) Do you suffer from sinusitis or sinus problems? (C) How troubled have you been by each of these symptoms (difficulty getting to sleep, waking up during the night, lack of a good night’s sleep) during the last week as a result of your health? Were you not troubled, hardly troubled at all, somewhat troubled, moderately troubled, or extremely troubled?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

Discussion

The results of this survey clearly demonstrate that compared with the general United States (US) population, people who have AR are at greater risk of suffering associated comorbidities such as asthma, rhinosinusitis, and other conditions noted previously. Although this is not novel information, most clinical trials have studied these associations only in selected populations, and the current study involving a more representative sample of US allergy sufferers confirms the high prevalence of comorbidities in the “real world.”

Many physicians and patients often dismiss AR as “just a runny nose,” but the results of the present survey clearly show that, especially during the worst spring months, patients with AR suffer a diverse range of symptoms. Although nasal congestion and postnasal drip are the most common symptoms, it is important to note that up to 20% of AR patients reported nonnasal symptoms, such as headache, facial pain or pressure, and ear pain or pressure, every day or most days during the worst month in the past year. Again, this information is not really new: the Allergies in America survey in 2006 found results on symptom frequency that were very similar to the findings of this survey.¹³ However, it is important information that needs to reach physicians and patients alike because effective management of AR would likely alleviate many nonnasal symptoms.¹⁴

This tendency to ignore or deprioritize AR in the face of other symptoms is very common in people who suffer the various comorbidities associated with AR; a person with asthma and AR is more likely to worry about their symptoms of wheezing than about their rhinorrhea. However, it is increasingly understood that these disorders are deeply connected at the pathologic level. For example, despite differences in the anatomic location of AR and asthma, they share a common inflammatory pattern in which many upper airways cells and mediators are the same as those involved in lower airway disease.^4,12 Supporting the concept of a “unified airway disease,” bronchial hyperresponsiveness and subclinical changes in the lower airways can be detected even in patients with AR who do not have asthma.¹⁵ As demonstrated in this survey, the presence of AR symptoms is associated with a worsening in asthma control and patient quality of life. The presence and type of asthma is influenced by sensitization, and the duration and severity of AR.⁴ However, much evidence suggests that effective AR management can lead to a better asthma control. Indeed, AR often precedes the onset of asthma and studies have shown that treatment with specific immunotherapy can prevent or delay asthma onset.¹⁶

FIGURE 3

Incidence of other comorbidities associated with allergic rhinitis in the allergy vs general population

Respondents were asked: During the past 4 weeks, have you had heartburn, reflux or gastroesophageal reflux disease (GERD), migraines, sleep disturbances, sleep apnea, sinusitis, skin rashes, earaches, chronic tonsillitis, conjunctivitis or red eye, or none of these?

Base: All respondents, N = 522; *Pearson chi-square, P ≤ 0.05.

As demonstrated in this study, rhinosinusitis is another common complication of AR, which can lead to inflammation of the sinus mucosa and obstruction of the sinus drainage pathway or ostium.^6,17 Moreover, rhinosinusitis may be implicated in the genesis of nasal polyps, which are common when rhinosinusitis complicates AR. Although the reasons for nasal surgery were not collected in this survey, it is interesting to note the relatively high proportion of patients with AR who have had nasal surgery (15%), which may have included surgery to remove nasal polyps.

Common pathologic pathways can also explain the higher prevalence of other comorbidities seen in the survey of AR patients compared with the general population. Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, paranasal sinuses, and pharynx. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause eustachian tube obstruction, possibly leading to middle ear effusions.¹⁸ Similarly, chronic allergic inflammation of the upper airway causes oropharyngeal lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This is important, as retrospective analysis of medical claims data has shown that claims for rhinosinusitis, tonsillitis, otitis media, migraines, and asthma all increase during the allergy season with significant increases in the cost of treatment.¹⁹ Finally, the survey also confirmed the significant impact of AR on sleep quality. Several studies have found that AR patients, and particularly those with nasal congestion, often have significant sleep disturbances leading to fatigue, daytime somnolence, and impaired daytime functioning as reflected in lower levels of productivity at work or school.^8,10 As discussed in more detail by Meltzer et al¹ earlier in this supplement, sleep problems and the associated daytime fatigue are common problems reported by many AR patients. There may be a link between AR patients being tired and feelings of depression and anxiety. Therefore, although there is no direct pathologic link between AR and mental health, they certainly should be considered as serious potential consequences of uncontrolled AR.

In summary, the NASAL survey found that patients with AR are at a higher risk of other comorbidities compared with the general US population. Moreover, it showed that these comorbidities were exacerbated during the spring months when the symptoms of AR are worst. It therefore follows that timely diagnosis and treatment should be a priority for patients and physicians, not only to control AR symptoms but also to improve the management of associated diseases.