Transcript Rhinitis Sesssion LatAm

Rene Maximiliano Gomez
Head, Allergy & Asthma Unit
Hospital San Bernardo. Salta, Argentina
Latin America perspective
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Situational sketch
Who are we treating/educating
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How are we treating them
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How successful are we
Solé D, Mallol J, Camelo-Nunes IC, Wandalsen GF. Prevalence of rhinitis-related symptoms in
Latin American children (ISAAC) phase three. Pediatr Allergy Immunol 2010; 21(1Pt2): 127-36.
Many patients are being treated by…
Who are we treating /
educating?
 More than half having seasonal and
intermitent symptoms
 More than half having congestion as
main symptom
 QoL partially affected and
 Many having no interference at all
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Aim was to evaluate prescription trend associated to treatment
of AR in a unselected group of ENT physicians.
Material and Methods: Survey of ENT specialists while
attending to a national meeting. Invited to answer a
questionnaire built for our proposal in an anonymous manner,
asking about severity of AR, preferences of drugs for AR
treatment in general, and selected medication for congestion.
Results: 107 ENT doctors completed the survey correctly, 43.3
y.o. mean age, 67.3% male, majority being specialists >10y.
At least 2/3 of their patients have moderate to severe AR .
Preference of Treatment in AR
Antih1 + decongest
NSAH1
INCS
0
1º
20
2º
40
3º
60
80
100
Treatment preferences by ENT in Nasal Congestion
50
40
30
%
20
10
0
INCS
NSAH1
NSAH1 +
Decong
Other
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Conclusions: even considering specialists,
guidelines for the treatment of AR seems to
be partially followed.
These data reinforce the need to recognize
the severity of the disease, and the
consequent evidence based treatment.
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Methods: data of 121,593 patients collected during 9
prospective observational studies (1998 to 2005) examined
using individual patient data meta-analysis method.
Results: Only 14.8% of patients with allergic rhinitis were
treated according to the recommendations. Of the others,
73.8% received insufficient treatment.
36.1% of the patients treated by ENT received therapy
according to guidelines, opposite to 16% treated by general
practitioners.
It could be observed that the rate of guideline compliance was
highest in the year of publication of ARIA.
Background:
 Survey to ask to patients and physicians the same questions to identify differences
in attitudes and opinions about the treatment of AR at global level with the goal of
identifying barriers to optimal management and revealing limitations of currently
available treatments.
Methods:
 An international, multicenter, non–interventional, cross-sectional study was
conducted in adults and children (≥ 6 years). Physicians were selected at random
from a master list provided by country and combining private and public practices.
ISMAR was designed according to the most accepted epidemiological
recommendations based on the success of the WAO-GAPP survey on asthma.
 A questionnaire addressing patient profiles, diagnostic assessment, therapeutic
decisions, and real-life management was answered. The questionnaire also asked
about national/local features, medications availability/cost, laboratory test
facilities, traditions, geographical constraints, among others.
 The participating physicians recruited consecutive patients with AR. Study data
collection was performed during a single visit with 3 types of documents:
Investigator’s questionnaire, Case Record Form, Patient’s questionnaire.
Results:
 234 physicians were surveyed with a mean age of 49
years (28-69), 180 of them were males (76.9%). The type
of medical practice was public sector 16.7%, private
practice 41.9% and mixed 41.4%. Regarding medical
specialty is a follows: GPs/family practitioners/internists
(22.2%), allergologists/pulmonologists (35.9%),
pediatricians (11.1%) and ENT specialist (30.3%).
 Physicians recruited 2776 patients with AR (Egypt,
n=500; Mexico, n=418; Brazil, n=351; Colombia, n=223;
Guatemala, n=216; Iran, n=207; Venezuela, n=201;
Argentina, n=200; Israel, n=176; Kuwait, n=150; UAE,
n=134).
4023 poster / Wed 07 dec
Results:
 Physicians were aware about ARIA (82.5%), GINA (71.4%). They followed guidelines
recommendations to classify severity (84.2%) and for choosing treatment accordingly
(84.6%). Key symptoms to make AR diagnosis were: congestion (84.8%), sneezing
(79.1%), anterior watery rhino rhea (75.9%).
 The main reasons to prescribe medication were: symptom severity/frequency (97.9%),
drug efficacy (85.9%) and safety (76.5%). Other less relevant reasons were: personal
experience (65%), cost (55.1%) and frequency of dosages (54.7%).
 The preferred medications were oral antihistamines (OH1A) and intranasal
corticosteroids (INC) [5 in a 0-5 scale]. Other treatments (oral decongestants,
leukotriene antagonists, SCIT/SLIT), were considered as second level in preference.
Conclusions:
 Guidelines are well known and useful to physicians. Clinical history was the main way
to evaluate the patient’s sleep quality, classification, severity and election of
treatment. Objective measures for assessment were scarcely used. OH1A and INC
were the most recommended treatment for AR and considered effective and safe.
Oral Abstract Session 22 / Tue 06 dec
Results:
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2776 patients ; mean age 31 yrs, female 54%; urban (86.1%), suburban (6.6%) and rural (4.9%).
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Co-morbidities were: sinusitis (50%), asthma (33%), conjunctivitis (36%), otitis (13%) and nasal
polyps (11%). Nasal symptoms were associated to house-dust mites (84%), moulds (33%) animal
dander (31%) and pollens (41%) exposure.
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At least one current treatment was received in 91%, and recommendation to avoid allergens or
irritants in 93% of patients. 80% the patients had received oral anti-H1 antihistamines (OH1A), 66%
intranasal corticosteroids (INC), 63% oral/intranasal decongestants and 14% sub-cutaneous
specific immunotherapy (SCIT).
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Patients´ preference route was oral 51% and intranasal 28%. Patients´ preference mediations
were: OH1A, 76%; INC, 49%; and SCIT 12%. Main factors affecting treatment compliances were
cost (32%), fear of Adverse Events reported (18%) and frequency of doses (34%).
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85% of them received oral explanation on disease and only 51% written indications.
Conclusions:
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OH1A and INC were the most widely used treatments for rhinitis and were considered safe and
effective. The majority of patients preferred the oral route. Written educational material given to
patients is scarce. These might be taken into account to enhance treatment adherence and
outcomes.
Oral Abstract Session 22 / Tue 06 dec
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…estimating noncompliance between 30 and 50%.
Lack of efficacy was reported as the 1st reason for discontinuing.
Studies on glucocorticosteroids, allergen-specific
immunotherapy and antihistamines highlighted the importance
of patient education, demographic factors, duration of therapy,
side-effects and treatment costs, as well as minor details, such
as taste and odour, in improving compliance.
Summary: The variation in the methodologies used and the
durations of treatments assessed in current compliance research
in the field of allergic rhinoconjunctivitis decreases the
comparability of results. Moreover, a gold standard for
measuring and reporting compliance should be determined to
enable better interstudy comparability of the rates and
determinants of compliance.
Big challenge
Koberlein J, Kothe A, Schaffert C.
Determinants of patient compliance in allergic rhinoconjunctivitis.
Curr Opin Allergy Clin Immunol 2011, 11:192–199
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