How do current guidelines influence your current treatment practice? Which guidelines are useful?
Dr. Meltzer: The ARIA guidelines originate from a WHO program, initiated in 1999, to create an international appreciation of the morbidity associated with allergic rhinitis. They borrowed from the NIH guidelines for asthma, the classification concept of intermittent and persistent and rating of the disease into mild, moderate, and severe categories. I think that this is clinically more relevant than the FDA classifications of seasonal and perennial allergic rhinitis. If a person suffers symptoms when they visit a family member with cats for 2 weeks over Christmas—then that’s an intermittent problem. It is not really a “perennial” problem in terms of the allergen. The FDA view may be appropriate for approval of medications, but from the management standpoint of patients, classifications of persistent, intermittent and mild, moderate or severe are much more useful. Indeed US guidelines now also use these classifications.
The name ARIA actually stands for Allergic Rhinitis Impact on Asthma, and the impact on asthma was a key driver for the WHO program. ARIA recognized the concept of the unified airway and the consequence that having inflammation in one area of the airway created for other parts of the airway. The guidelines highlighted the recommendation to evaluate patients with allergic rhinitis for lower airway disease (be it with a pulmonary function or at least a good history), and conversely for patients with lower airway disease to check for an upper airway history of problems as well. This is important because there is crosstalk, and we should be managing the whole airway—reducing inflammation in all of it.
Dr. Stoloff: From my viewpoint, very few of my peers are aware of ARIA and what it recommends. Similarly, many of them are not aware of the differences between the FDA classification and clinical guidelines. They simply do not know that the field is moving away from using seasonal and perennial terminology and towards a redefinition in terms of severity, frequency, and intensity.
Dr. Hadley: I agree that the awareness of the ARIA guidelines in general medical communities is low. We should point outthat the American Academy of Asthma, Allergy & Immunology (AAAAI) did publish practice parameters for rhinitis in 2008 and those have made a lot of sense as they give a practitioner a stepwise process to look at whether the symptoms are intermittent versus persistent, the degree of severity, and then makes recommendations on the types of medication that can be of clinical benefit to the patient. These guidelines are much more useful to the primary care physician.
Dr. Stoloff: Speaking as an author of both the ARIA and the AAAAI practice parameters, one of the major problems is that my colleagues in primary care do not routinely read the journals where the guidelines are published. Thus, the information is not disseminated and consequently not incorporated into their clinical practice. If presented and disseminated properly, guidelines should influence the way clinicians look at these health care issues, for the patient’s benefit, for cost benefit, and for improving their practice, gaining better out come for everyone.
Dr. Meltzer: I think there are some common concepts that have been incorporated into each of the guidelines discussed. Firstly, we need to classify people by severity. Secondly, we need to appreciate that people with upper airway disease (including allergic rhinitis), often have involvement of other areas of the respiratory tract. In other words we need to consider the comorbidities of the associated diseases. Thirdly, once we appreciate the magnitude of the problems, the patient together with the clinician needs to establish goals. Fourthly, there are step recommendations; if the symptoms are mild or intermittent, less management is needed. If the symptoms are moderate to severe, and/or persistent, more intensive management is required. There are also defined therapeutic steps as to when one might include immunotherapy as part of the regimen. Finally, patients should be monitored as part of the long-term management of this chronic condition.
The ultimate goal is control—control based on what the patient’s goals were when defined during their discussions with their clinician. If we incorporate those basic five concepts into our clinical practice—it will be good for the upper airway, good for the lower airway, and good for long-term health.
Given the range of products available at present for allergic rhinitis, what criteria influence your choice of product?
Dr. Hadley: The problem is that our patients have problems that they do not consider allergic rhinitis as serious, compared to conditions such as hypertension or diabetes. However, they still have a problem that significantly influences their life. As far as the range of products, many of them have already been on an oral antihistamine and many have used and abused decongestant therapy, which is over-the-counter or now behind-the-counter that they have to ask for. Patients often try to first alleviate their symptoms with some of these products, and by the time the come to see me as a specialist they have already usually started on something already, and I have to look and determine whether or not they would be acceptable to use a more advanced product.