Survey on Treatment-Seeking Patterns in Patients With Allergic Rhinitis

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J Rhinol. 2024;31(3):138-144

Publication date (electronic) : 2024 November 30

doi : https://doi.org/10.18787/jr.2024.00023

Gwanghui Ryu, MD, PhD^1,*, Do Hyun Kim, MD, PhD^2,*, Chang Yeong Jeong, MD², Sang Min Lee, MD, PhD³, Il Hwan Lee, MD, PhD⁴, Soo Whan Kim, MD, PhD², Hyeon-Jong Yang, MD, PhD⁵, Mi-Ae Kim, MD, PhD^,6, Dong-Kyu Kim, MD, PhD^,4, Work Group for Rhinitis, the Korean Academy of Asthma, Allergy and Clinical Immunology

¹Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

²Department of Otolaryngology-Head and Neck Surgery, Seoul Saint Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

³Division of Respiratory Disease and Allergy, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea

⁴Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea

⁵Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University College of Medicine, Seoul, Republic of Korea

⁶Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea

Address for correspondence: Dong-Kyu Kim, MD, PhD, Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon 24253, Republic of Korea Tel: +82-33-240-5181, Fax: +82-33-241-2909, E-mail: doctordk@naver.com

Address for correspondence: Mi-Ae Kim, MD, PhD, Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Republic of Korea Tel: +82-31-780-5148, Fax: +82-31-780-6143, E-mail: ccutte@hanmail.net

^*

These authors contributed equally to this work.

Received 2024 June 23; Revised 2024 September 15; Accepted 2024 September 23.

Abstract

INTRODUCTION

Allergic rhinitis is the most common allergic disease worldwide and affects a large portion of the population. Estimates of prevalence vary, depending on the region and population studied. A European multinational study (Global Allergy and Asthma Network of Excellence study) reported that the prevalence of allergic rhinitis was 22% to 41% [1]. According to the National Health and Nutrition Examination Survey (NHANES) conducted in the USA from 2005–2006, the lifetime prevalence of allergic rhinitis diagnosed by doctors was 11.3% [2]. The Korean NHANES study was conducted in 2013–2015, 2016–2018, and 2019. The pooled data indicated that the prevalence of allergic rhinitis was 15.4% [3]. The disease burden of allergic rhinitis includes the direct impact on individuals’ health and quality of life and the indirect costs such as lost productivity due to symptoms like sneezing, congestion, itching, and nasal discharge. These symptoms can lead to impaired sleep, decreased cognitive function, and decreased productivity at work or school. To reduce the burden of allergic rhinitis on individuals and society, it is essential to prevent and manage it using allergen avoidance, medication treatment, and immunotherapy.

The recommended primary treatments for allergic rhinitis are oral medications or intranasal sprays [4,5]. If symptoms are mild and intermittent, oral H1-antihistamines, intranasal corticosteroids, or a combination of the two are prescribed, whereas intranasal sprays are recommended as first-line treatment for severe and persistent symptoms. However, in actual clinical practice, patients with prescription or over-the-counter (OTC) medicines often develop their own patterns of medication usage [6]. Furthermore, some patients discontinue treatment due to ineffectiveness or side effects of the medication [7]. Although numerous studies have investigated the degree of symptom control in patients with allergic rhinitis, their actual patterns of medication use and preferences remain unclear. Patient preference is vital in the effective management of allergic rhinitis because it is a chronic condition that requires long-term management. Patient preferences can significantly impact treatment compliance, satisfaction, and outcomes. Most patients prefer treatment that quickly and effectively relieves their allergic rhinitis symptoms. Convenience and ease of administration are also essential considerations. Depending on their preferences and lifestyle, some people prefer oral medications over nasal sprays or vice versa. Physicians must also consider the tolerability, potential side effects, cost, affordability, long-term safety, and rebound effects upon discontinuation.

In addition to primary medical treatment, it is essential to determine patients’ attitudes toward allergen-specific immunotherapy, environmental controls, and surgical treatment. For patients with inadequate symptom control or concerns about long-term medication use, shared decision-making based on individual patient needs, preferences, and treatment goals can help ensure optimal management of allergic rhinitis symptoms and increase patient satisfaction with treatment. A previous survey found that 86.4% of patients with allergic rhinitis were satisfied with allergen-specific immunotherapy [8]. The effectiveness of pet avoidance and environmental control remains controversial [5]. Although pet avoidance and high-efficiency particulate air filters can reduce the concentration of allergens, the results were equivocal on whether this results in symptom relief [9,10]. Septoplasty or inferior turbinate reduction may be considered to resolve nasal congestion [11,12]. Most allergic rhinitis patients reported that nasal congestion and runny nose were resolved after surgery [13]. Although there are additional treatments for allergic rhinitis, patients often do not receive enough information from healthcare providers. Furthermore, before healthcare professionals can ensure that people receive accurate, evidence-based guidance to manage allergic rhinitis effectively, they need to know the patients’ attitudes and preferences regarding allergic rhinitis treatment.

This study surveyed the treatment-seeking behaviors of patients with allergic rhinitis, especially their preferences regarding medical treatments, environmental controls, and surgical treatment.

METHODS

Questionnaire

A 37-item anonymous questionnaire was developed by the Allergic Rhinitis Work Group of the Korean Academy of Asthma, Allergy, and Clinical Immunology to assess medical treatment, environmental control, and surgical treatment for allergic rhinitis (Table 1). Internal medicine, pediatric, and otorhinolaryngology specialists participated in creating the questionnaire. The items regarding medical treatment assessed prescription and OTC medication use patterns, such as whether the medication was used regularly or as needed, and medication preferences. In addition, patients with asthma were asked about treatment preferences and their awareness of allergen-specific immunotherapy. Items regarding environmental controls assessed the use of air purifiers and pet avoidance. Finally, items regarding surgical treatment evaluated the patients’ attitudes toward and experiences with surgery.

Table 1.

List of survey items to assess medical treatment, environmental control, and surgical treatment in patients with allergic rhinitis

The questionnaire responses consisted of strongly agree, agree, neutral, disagree, and strongly disagree. If the answer was “strongly agree” or “agree,” the question was rated positively.

RESULTS

In this study, we observed 51 patients with an average age of 31.6 (±16.0) years, ranging from 7 to 66 years, of whom 33 (64.7%) were male. Among the 51 patients, six patients (11.8%) had bronchial asthma, and 12 (23.5%) had undergone surgical interventions for rhinitis. Thirteen children (25.5%) and 38 adults (74.5%, average age 38.1 years) responded to the survey. The response rate to our inquiry varied across departments, with the pediatric department contributing 17 patients (33.3%), the internal medicine department 15 patients (29.4%), and the otorhinolaryngology department 19 patients (37.3%). This distribution underscores the interdisciplinary interest and diverse patient demographic engaged in the study, highlighting the relevance of our findings across different age groups and medical specializations.

Medical treatment

Regarding medical treatment of allergic rhinitis, 41 (80.4%) and 13 (25.5%) patients used prescribed medications and OTC medicines, respectively (Fig. 1A). Most pediatric patients responded that they were prescribed medication at the clinic rather than OTC medicines (76.9% vs. 30.8%, p=0.047). Eight patients (15.7%) reported taking medications or using an intranasal spray in advance of exposure, even in the absence of symptoms. In contrast, 39 patients (76.5%; children and adults equally) only took medications when they were symptomatic (Fig. 1B). Forty-seven patients (92.2%) were diagnosed with a pollen allergy, of whom 27 (57.4%) took medication for any symptoms, and 14 (29.8%) only took medication for severe symptoms. Others reported taking medication when the pollen season began (n=3, 6.4%), after checking the pollen forecast (n=1, 2.1%), or year-round (n=2, 4.3%).

Fig. 1.

The preferences of patients with allergic rhinitis for medication type and pattern of usage. A: Whether the patient uses a prescribed or over-the-counter (OTC) medication. B: Whether the patient takes their medication continuously or as needed.

Thirty patients (58.8%) used intranasal sprays and oral medications concurrently, while 21 (41.2%) patients did not (Fig. 2). There was no significant difference in the preferred medication (oral drugs 56.9% vs. sprays 43.1%), whether the intranasal spray or oral medications were used simultaneously or not (p=0.973). The reasons given for preferring the intranasal spray included good effect (n=12, 54.6%), simple use (n=7, 31.8%), and few adverse effects (n=2, 9.1%). Alternatively, the reasons given for preferring oral medications included good effect (n=16, 59.3%), simple use (n=8, 29.6%), cost (n=1, 3.7%), and recommendation by a physician (n=1, 3.7%). Children strongly preferred oral medications (84.6%), while 47.4% of adults preferred oral medications (p=0.025). Twenty-one patients used nasal irrigation (41.2%); however, it had a lower preference (n=1, 1.9%) than oral medications (n=29, 56.9%) and nasal sprays (n=21, 41.2%).

Fig. 2.

Usage of oral medications and intranasal sprays for allergic rhinitis: both or either. Patient preferences for oral medication or intranasal spray.

Thirty-three patients (64.7%) were aware of allergen-specific immunotherapy for allergic rhinitis. Among them, 32 (97%) and 23 (69.7%) patients reported being aware of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), respectively. Moreover, 26 (52%) and 24 (48%) patients preferred SCIT and SLIT, respectively, for allergen-specific immunotherapy, if available.

Environmental controls

Regarding environmental control, 36 patients (70.6%) used air purifiers; 16 people (44.5%) used it for >12 hours/day, four people (11.1%) for 8–12 hours/day, seven people (19.4%) for 5–7 hours/day, and nine people (25%) for <4 hours/day. Moreover, 14 (38.9%) patients considered air purifiers helpful in preventing symptoms of allergic rhinitis, while 13 (37.1%) patients considered them helpful in the treatment of allergic rhinitis (Fig. 3).

Fig. 3.

Whether air purifiers helped prevent and treat allergic rhinitis (AR) in a study of 51 patients in South Korea.

Regarding pets, 14 (27.5%) patients reported currently or previously living with a companion animal. Seven (50%) patients reported that their symptoms were worsened by contact with the pet and improved after reduced contact. However, all respondents answered that they did not intend to rehome their companion animals to improve their symptoms of allergic rhinitis.

DISCUSSION

The behavior of many patients with chronic illnesses is inconsistent with their doctor’s prescription [14]. Specifically, unlike patients with diabetes or cardiovascular disease, patients with allergic rhinitis have relatively lower compliance since their symptoms range from absent to severe [15]. Physicians should engage patients in shared decision-making when choosing treatment options for allergic rhinitis. They should also consider patient preferences, clinical effectiveness, and safety to improve treatment adherence and patient satisfaction, thus leading to better management of allergic rhinitis symptoms and improved quality of life. An international multicenter study reported that patients with allergic rhinitis preferred oral antihistamines (75.9%) and topical steroids (49.2%) [16]. In the present study, patients showed a slight preference for oral medications (56.9%) over nasal sprays (43.1%). Attempts have been made to increase patient adherence and compliance by introducing the concept of shared decision-making in the management of allergic rhinitis [4,14,17,18]. This is especially important for the treatments currently available (including SCIT or SLIT) for allergic rhinitis, which require high adherence and a shared decision-making process, rather than simply taking OTC medications [18]. Since some patients seek alternative treatments such as herbal medicine or acupuncture, there is a need to provide accurate information and treatment options to these patients.

Our study found that many patients only took medications when they experienced symptoms, likely because most participants had a pollen allergy. Notably, half of the patients used intranasal sprays and oral drugs simultaneously and considered oral drugs as effective as intranasal sprays. In contrast, patients reported a low preference for nasal irrigation. Patients prefer a simple treatment plan, and whether an oral medication or spray is more comfortable varies from patient to patient. It is necessary to simplify drug regimens whenever possible to minimize complexity and increase compliance. Combining drugs or using once-daily agents to reduce treatment burden should be considered. More than two-thirds of the patients (a higher rate than expected) were aware of allergen-specific immunotherapy, and reported similar preferences for SCIT and SLIT. Although it was difficult to know whether actual immunotherapy was being carried out from this survey, this information suggests that immunotherapy can be actively recommended to patients. Regarding environmental control, more than two-thirds of the participants used air purifiers. This could be attributed to the frequent exposure in Korea to fine dust, yellow dust, and harmful air-borne substances due to its geographic location. Approximately 40% of the participants considered air purifiers helpful in preventing allergic rhinitis symptoms. Air purifiers may help reduce allergens in indoor environments, such as dust mites, pet dander, mold spores, and pollen that can circulate in the air. Filtering out these particles potentially improves indoor air quality and reduces exposure to allergens. However, it is important to note that while air purifiers can be beneficial, they may not eliminate allergic rhinitis symptoms, especially if the allergen exposure occurs from sources outside the home or in unfiltered areas. For pet owners, avoiding pets can improve allergic rhinitis symptoms, and half of responders experienced an alleviation of symptoms by doing so. However, complete avoidance may not always be feasible or desirable for companion animal owners. A comprehensive treatment plan tailored to their specific needs and circumstances should be applied in such cases.

Most of our participants considered surgical treatment a favorable option. This can be attributed to the high rate of nasal congestion and rhinorrhea improvement in patients who had previously undergone surgery. The overall satisfaction with surgery was >80%; however, a longer-term investigation of the effectiveness of surgical treatment is warranted. Surgical treatment for allergic rhinitis is generally indicated when medical management is ineffective or for anatomical abnormalities such as nasal septal deviation or inferior turbinate hypertrophy. Septoplasty and turbinoplasty can reduce nasal congestion, and interestingly, more than half of the patients (58.3%) also reported improvement in their rhinorrhea.

Notably, our patients showed similar preferences for oral medications and intranasal corticosteroids, which are both recommended as first-line treatments in the latest guidelines, including Allergic Rhinitis and Its Impact on Asthma. This indicates a need to reevaluate the various options for combining oral medications and intranasal corticosteroids. Furthermore, when considering combination therapies, it is crucial to investigate the differences between intermittent administration (or other usage patterns) versus taking them uniformly and continuously since many patients showed a preference for intermittent medication intake. Long-term management of allergic rhinitis can lead to treatment fatigue or burnout, with patients becoming disillusioned or disengaged with their treatment plan over time. Long-term compliance is essential for allergen-specific immunotherapy. Therefore, sufficient explanation and consent from the patients are required before treatment, and continuous encouragement is needed to maintain the treatment.

Another notable finding was the favorability and satisfaction with surgery. Analyzing surgical treatments for allergic rhinitis has major drawbacks, given the difficulty in designing randomized control trials and long-term follow-ups. Therefore, given the relatively weak evidence for surgery, it is currently recommended as a second-line treatment “option” by most guidelines. Thus, further comprehensive long-term follow-up studies are warranted.

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