Patient Adherence to Allergic Rhinitis Treatment: Results From Patient Surveys

Erkka Valovirta, MD, PhD; Dermot Ryan, MD


October 28, 2008


Allergic rhinitis (AR) is an inflammation of the mucous membranes lining the nose that is caused by a reaction to airborne allergens, such as pollen, mold, dust mites, and animal dander. The early-phase response is prompted by histamine released after allergen exposure and results in the acute symptoms of sneezing; nasal pruritus; rhinorrhea; nasal congestion; and ocular itching/burning, redness, and tearing/watering. Some hours later, the late-phase reaction occurs and is marked by activation of eosinophils and Th2 lymphocytes, leading to chronic nasal congestion, postnasal drip, and nasal hyperreactivity (Figure 1).[1,2,3]

Mechanism of allergic rhinitis.[1]
IgE = immunoglobulin E; IL = interleukin; GM = granulocyte macrophage; CSF = cerebrospinal fluid; VCAM = vascular cell adhesion molecule.

Republished with permission from Scadding et al.[1]

Allergic rhinitis causes significant discomfort and impairs work productivity, school performance, social interactions, and sleep.[4,5,6] Annual direct costs due to AR have been estimated to be €1.29 billion in Europe[7] and $4.5 billion in the United States.[8] Patients say that AR significantly reduces their quality of life (QoL).[9,10] According to the results of one survey, AR is associated with more lost work productivity than are other chronic conditions, including depression, arthritis, migraine, diabetes, coronary heart disease, and asthma.[10,11,12]

The management of AR may involve allergen avoidance, pharmacotherapy, allergen-specific immunotherapy, or a combination of all three. Pharmacologic options include intranasal corticosteroids (INSs), oral and intranasal antihistamines, intranasal chromones, oral and intranasal decongestants, oral and intranasal anticholinergic agents, and antileukotrienes.[13] The Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines[13] and the European Academy of Allergology and Clinical Immunology (EAACI) consensus statement[14] note that INSs are a highly effective first-line treatment for moderate/severe or persistent AR because they relieve symptoms to a greater degree than other classes of drugs and are especially effective in controlling nasal congestion. The anti-inflammatory properties of INSs may explain their strong effect on clinical symptoms.

Intranasal corticosteroids are safe and well tolerated. When administered at indicated doses, most INSs do not lead to the systemic adverse events associated with oral corticosteroids, including suppression of the hypothalamic-pituitary-adrenal axis or impairment of bone growth.[15,16,17,18,19] Local side effects of INSs are generally mild to moderate, similar in incidence to those of placebo, and include headache, irritation of the nose and throat, sneezing, crusting, transient dryness, and epistaxis. Side effects are often limited to the start of treatment; occasionally they persist, and in such cases a change in formulation or delivery system may be required.[15,20]

Intranasal corticosteroids may possess quite different sensory attributes, such as odor, taste, irritation, and drying effect, and patients often prefer the attributes of one preparation over another.[21] Patient surveys reveal attitudes toward treatment of AR that may contribute to a better understanding of how patients develop a preference for a particular therapy or class of therapy.

We identified and compared surveys that investigated patient preference in AR therapy. The topics covered included comparative burden of the symptoms of AR on patients; impact of symptoms on QoL; patterns of AR medication use; and, finally, patients' satisfaction with their AR treatments, focusing on attributes of AR medications in general, and attributes of INSs specifically. These surveys were evaluated to reveal commonalities and patterns in each of the domains listed above.

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