The largest survey to date of patients with allergic rhinitis (AR) and physicians who treat them revealed that patients’ and physicians’ perceptions of this disorder are not always in sync. Physicians thought that patients were more satisfied with their medications and their quality of life (QOL) than they were; a sizable proportion of patients reported that their medications either did not work well or worked at first but lost effectiveness over time. Two-thirds of respondents said that AR compromised quality of life. Further, more patients reported more year-round symptoms than seasonal symptoms, although AR has been assumed to be seasonal.
These findings imply that physicians who treat patients with AR should be more mindful about the dissatisfactions and suffering associated with these allergies. We are not doing a good enough job in communicating with patients about the results of treatment. Many physicians consider allergies a minor problem and downplay them. However, allergies have a huge impact on quality of life. The survey revealed that physicians need to pay more attention to AR symptoms and their impact on quality of life. We need to use appropriate methods to evaluate patients and prescribe medications that effectively control symptoms that interfere with quality of life, said James Hadley, MD, Associate Professor of Otolaryngology at the University of Rochester Medical Center in Rochester, NY.
The survey, conducted in January 2006, included 2500 patients who received a diagnosis of AR from a physician and who were symptomatic within the past year. The patient survey was carried out by structured 35-minute telephone interviews with respondents with AR who were questioned about allergies, severity and frequency of symptoms, and satisfaction with treatment. The survey also included a separate physicians’ section that included 300 US physicians who provide direct patient care in an outpatient setting (100 primary care physicians, 100 allergists, and 100 otolaryngologists). During structured 20-minute interviews, physicians were asked about the burden of AR on patients diagnosed by a physician as having AR and symptomatic during the past year, their treatment algorithm for AR management, and their perceptions of patient satisfaction with treatment.
According to M. Jennifer Derebery, MD, who is an associate at the House Clinic and Institute and Clinical Professor of Otolaryngology at USC Keck School of Medicine in Los Angeles, the survey revealed two major surprises. One was that a higher percentage of patients reported perennial symptoms of AR than has been found in the past; 56% of patients had symptoms all year long, while 44% reported seasonal AR.
It wouldn’t surprise me if a high percentage of people in Southern California reported perennial symptoms, but it does surprise me about people in other areas of the country. Although many people believed that allergic rhinitis is a seasonal problem, that is not what patients are reporting, Dr. Derebery said. She pointed out that although this survey was not a randomized controlled trial, the findings carry weight because of the large number of patients who responded.
A second important finding was that AR takes a big toll on productivity and quality of life. The survey showed that on asymptomatic days, patients self-estimated their work productivity at 95%, whereas they said their productivity was 72% on days when allergy symptoms flared.
These findings imply that allergic rhinitis is a year-round disorder, and this is not well recognized by the medical profession and the lay public. We need to raise awareness about the persistence of symptoms and not rely on television commercials for our information. Also, although allergic rhinitis is not life-threatening, it does have a major impact on quality of life and productivity. Doctors should not discount AR, because these patients report a lot of misery, Dr. Derebery said.
The major symptoms that patients found bothersome (in descending order) were nasal congestion, headache, and postnasal drip. In addition, fatigue was common, along with depression and irritability. About 40% of patients said they were unable to tolerate the discomfort of their allergies.
In general, patients reported that AR had a big impact on QOL, said Robert Naclerio, MD, who is Professor and Chief of Otolaryngology and Head and Neck Surgery at the University of Chicago. Twenty-six percent reported that symptoms had some impact on quality of life, 25% said a moderate impact, and 15% said a lot of impact, for a total of 66% of patients reporting an impact on QOL.
Patients used a variety of medications to control AR. Slightly more than half of respondents said they used over-the-counter medications; 36% used nasal sprays; 45% used whatever medications were on hand; and 31% used no medications.
Nasal Spray Users
Responses of nasal spray users (n = 919) suggest that there is an unmet need for a better nasal spray, Dr. Naclerio said. When asked whether their currently prescribed nasal spray provided relief, 46% said for most symptoms, 16% said for all symptoms, and 37% said not very much relief.
In registered trials for intranasal steroid sprays, about 66% of patients have excellent relief but 33% do not. This survey showed the same results, but this was not a clinical trial, Dr. Naclerio said.
Fifty-eight percent of 919 patients said that their nasal spray worked within an hour, but Dr. Naclerio said this is strange, because the known mechanism of action does not suggest that a nasal spray would work this rapidly.
The perception is that relief is fast, but this defies the known mechanism of action. Patients’ opinions differ from reality, he commented.
Even when prescription nasal sprays provide relief, 48% of patients said effectiveness waned. Among those who said this, 70% said the nasal sprays lost effectiveness within 12 hours. This is different than one would expect. Most sprays show effectiveness 24 hours after the last dose. Patients’ perceptions differ from what studies have shown, Dr. Naclerio commented.
One third of all respondents said that they had asked their doctor at some point in time to change their allergy medication. About two-thirds of patients change their prescription medications every few years; reasons included suboptimal efficacy (37%), doctor wanted to try other medication (23%), patient wanted to try another medication (11%), and patient had bothersome side effects (8%).
For all respondents, side effects of medications included dryness (50%), drowsiness (40%), post-nasal drip (40%); bad taste (30+%); burning (19%), and headache (15%). When asked why patients did not follow their physicians’ instructions regarding prescribed medications, 41% said lack of symptom relief, 37% said the medications lacked effectiveness over time, 35% noted that their symptoms disappeared, and 27% said troublesome side effects.
These findings imply that although we prescribe medications, we really don’t follow through to find out whether patients are satisfied or are taking their medications. A lot of patients don’t tell you they are unhappy; they just stop taking their medications. Prescribing medications is not enough. We need to follow our patients and find out if they are adherent. We need to determine if the medications are helping, or whether it is time to switch to a different medication. Also, the diagnosis may not be correct if the medications aren’t effective, Dr. Naclerio commented.
Patients were asked to list attributes that were important to them in an allergy medication. Thirty-nine percent said fast relief, 62% said long-lasting relief, and 52% said complete relief of symptoms. The following answers were unexpected: only 6% said easy to take, 19% said few side effects, and 18% said low cost.
The physicians’ part of the survey revealed some interesting findings about their perceptions of AR patients’ responses and assumptions about medications, said Dr. Hadley. The main implication of the findings was that physicians believe that patients are doing better than they actually are, according to their self-reports. As mentioned earlier, physicians who treat patients with AR need to raise their level of awareness as to the compromising effects of symptoms on quality of life and productivity and the suboptimal efficacy of many allergy medications.
Dr. Hadley said the national survey of patients and physicians was supported by Altana, a drug company. that had developed a nasal spray that has been approved by FDA. Recently, Altana was acquired by a larger European pharmaceutical company. The nasal spray they developed is a good product that can help patients with AR, Dr. Hadley said, but it is not clear whether it will be marketed in the US. Other companies are studying an inhaled corticosteroid in the same drug class called ciclesonide that appears to provide relief of asthma and of symptoms of nasal allergies as well.
©2007 The Triological Society