Tara Haelle

June 30, 2017

HELSINKI — A mobile app is being developed to make treatment recommendations to prescribers, using information provided by patients in a tandem system.

"We're moving away from guidelines to more simplified treatment algorithms, and to get there, we need care pathways that are different from guidelines, in that they incorporate a multifactorial team," said Ruth Murray, PhD, director of MedScript Ltd, in Dundalk, Ireland.

"To connect all the stakeholders in a care pathway, you need very simple language" that is common to healthcare providers, pharmacists, and patients, and is easy to use, she explained here at the European Academy of Allergy and Clinical Immunology Congress 2017.

In Allergic Rhinitis and Asthma
Currently, patients can keep a daily record of medication use and allergic rhinitis and asthma symptoms with a free Allergy Diary app.

The new app will use the allergic rhinitis clinical decision support system (J Allergy Clin Immunol. 2016;138:367-374.e2) to provide treatment recommendations on the basis of specific data reported by the patient: the type of allergic rhinitis, current treatments, allergen exposure, and visual analogue score.

"The idea is to input basic information into the companion app, and the healthcare professional will receive a simple treatment recommendation based on that information," Dr Murray said. "The aim is to simplify care management and use the same visual analogue score throughout the application to improve patient and healthcare communication."

To validate treatment recommendations, investigators consulted a group of allergic rhinitis experts on step-up and step-down treatment strategies.

"The idea is that no matter what a patient or healthcare provider inputs into the Allergy Diary Companion, that scenario has been thought of by us," explained Dr Murray.

Her team sent a Survey Monkey questionnaire to 70 experts in allergic rhinitis from Australia, Europe, and North America; the response rate was 50%.

Specialists Have Their Say
The survey asked about the overall approach and indications for starting, stepping up, and stepping down treatment. It also asked about specific treatment recommendations at each of those steps, scored on visual analogue scale of 0 (strongly disagree) to 100 (strongly agree).

"Rather than just advising a step up in treatment or a step down in treatment, we wanted to be able to say, this is the treatment we advise you to step up to based on the information that you've provided about your patient," said Dr Murray.

The experts generally agreed on when to step up and when to step down treatment.

Table 1. Consensus of Experts on Changes in Treatment Strategy

Visual Analogue Score Action Consensus, %
≥5 Step up 91
2 to <5 If intermittent, continue 76
  If persistent, continue or step up 88
<2 If intermittent, step down 85
  If persistent, step down 75

 

There was also general agreement on step-up and step-down strategies.

But there were conflicting opinions. "Some people thought oral corticosteroids were being recommended too early and allergen immunotherapy was being offered too late," Dr Murray reported. "Some believed that if your patient has congestion, you should step down to oral corticosteroids because oral histamines have not shown great benefit with congestion."

Table 2. Consensus on Treatment Changes

Initial Treatment Treatment Consensus, %
Step-up Therapy
Antihistamines Intranasal corticosteroids with or without azelastine 91
Intranasal corticosteroids Add azelastine 83
Polypharmacy Intranasal corticosteroids plus azelastine 80
Intranasal corticosteroids plus azelastine Add short course of oral corticosteroids; if VAS ≥5, refer 64
Step-down Therapy
Intranasal corticosteroids plus azelastine Intranasal corticosteroids (preferred if congestion is dominant symptoms) or antihistamines 78
Intranasal corticosteroids plus antihistamines Intranasal corticosteroids (preferred if congestion is dominant symptoms) or antihistamines 87
Intranasal corticosteroids Antihistamines 75
Antihistamines Continuation dependent on allergen exposure 84–86

 

Anne Ellis, MD, chair of the division of allergy and immunology at Queen's University in Kingston, Ontario, Canada, said she thinks a specialist referral should precede an oral steroids prescription.

"Prednisone or other systemic corticosteroids should be a last resort," Dr Ellis told Medscape Medical News. "If patients aren't responding to step 3, the referral should be made to allergy/immunology in tandem with the step-up to combination intranasal steroid with azelastine."

Providers should certainly check treatment compliance, technique, and patient preference at each step, Dr Murray advised.

"That's clearly stated in the recommendations — that you should listen to your patient," she added. Although "these are recommendations open to interpretation and flexibility, we are confident this will improve the way we manage our patients."

Dr Ellis said she liked the idea of an app taking clinicians through each step, though use will depend on doctors' comfort level with technology and interest in managing allergic rhinitis.

"I think it's a step in the right direction to get physicians more interested and engaged in the management of allergic rhinitis," she said. "The quality of life burden of this disease is huge, and many patients suffer in silence. Hopefully a strategy like this will encourage patients to see an allergist and find relief."

It is expected that the free app will be available next year, Dr Murray reported.

This study received no external funding. Dr Murray is a medical communications consultant at Medscript Ltd. Dr Ellis has reported no relevant financial relationships.

European Academy of Allergy and Clinical Immunology (EAACI) Congress 2017: Abstract 0183. Presented June 18, 2017.

Follow Medscape Allergy & Clinical Immunology on Twitter @MedscapeAllergy and Tara Haelle @TaraHaelle

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