© 2008 Universitair Ziekenhuis Gent1 ARIA-guidelines, an update Van Cauwenberge P, MD, PhD Van...

© 2008 Universitair Ziekenhuis Gent 1

ARIA-guidelines, an update

Van Cauwenberge P, MD, PhDVan Hoecke H, MD

Philippe Gevaert, MD, PhD

Department of OtorinolaryngologyGhent University, Belgium

22© 2008 Universitair Ziekenhuis Gent

Allergic rhinitis: treatment modalities

From Diamant Z


allergenavoidanceindicated

when possible

allergenavoidanceindicated

when possible

pharmacotherapysafety

effectivenesseasy to be

administered

pharmacotherapysafety

effectivenesseasy to be

administered

immunotherapyeffectiveness

specialist prescription may alter the

natural course of the

disease

immunotherapyeffectiveness

specialist prescription may alter the

natural course of the

disease patient'seducation

always indicated

patient'seducation

always indicated

COSTS

Cornerstones of AR treatment


Clinical guidelines

‘Clinical guidelines are systematically

developed statements to assist practioners

and patients in making decisions about

appropriate and effective health care in

specific circumstances.’

Jackson R, et al. BMJ

1998


1994 20011996, 1998 2000

Opinion-based guidelines

Evidence-based guidelines

Guidelines for allergic rhinitis

QuickTime™ en een-decompressor

zijn vereist om deze afbeelding weer te geven.

2008


Allergy 1994;49:1-34

V.J. LundD. AaronsonJ. Bousquet

R. DahlR.J. DaviesS. Durham

R. Gerth van WijkK. HolmbergE. Juniper

Ian S. MackayL. Malm

N. MygindM. OkudaC. Ortolani

H.M. SchankerS.L. Spector

P. van CauwenbergeM.R. Wayoff

International Consensus Report

1994


Scan pag 28

International Consensus Report: Flow Chart


D. Skoner

M. Dykewicz

S. Fineman

R. Nicklas

R. Lee

J. Blessing-Moore

Ann All Asthma Immunol 1998; 81:478-518

J. Li

I. Bernstein

W. Berger

S. Spector

D. Schuller

American Guidelines on

Rhinitis1998


P. van Cauwenberge

C. Bachert

J. Bousquet

G. Canonica

S. Durham

W. Fokkens

P. Howarth

Allergy 2000;55:116-134

V Lund

N. Mygind

G. Passalacqua

D. Passali

G. Scadding

D. Wang

EAACI Position Paper 2000


Nasal Corticosteroids

Inadeq.control

Inadeq.control

Inadeq. control

Need for therapy ?

Mild disease or occasional symptoms

Moderate disease or long duration Severe disease

Oral or NasalAntihistamines

(Cromones)


+Oral or Nasal

Antihistamines

Add further symptomatic treatment

Short-course Oral Steroids

Consider Immunotherapy

For eye symptoms :

topical antihistamines or

cromones

Seasonal allergic rhinitis


Perennial allergic rhinitis in adults

Inadeq. control

Need for therapy ?

Avoidance

Environment control

Moderate disease or long duration Severe symptoms

Oral or NasalAntihistamines



+Antihistamines

Inadeq. control

Further examinations

Inadeq. control

Mild disease or occasional symptoms


Perennial allergic rhinitis in adults

If resistant

RESISTANT CASES

Resistant rhinorrhea

Short Course of Topical Decongestants/ Oral Decongestants/Oral Steroids

Nasal Ipratropium

bromide

Immunotherapy

Nasal blockage

Surgical turbinate reduction


J. BousquetP. van CauwenbergeN. Khaltaev

N. Ait-KhaledI. Annesi-MaesanoC. BachertC. Baena-CagnaniE. BatemanS. BoniniG. CanonicaK. CarlsenP. DemolyS. DurhamD. EnarsonW. FokkensR. Gerth van Wijk

P. HowarthN. IvanovaJ. KempJ. KlossekR. LockeyV. LundI. MacKayH. MallingE. MeltzerN. MygindM. OkudaR. PawankarD. PriceG. ScaddingF. SimonsA. SzczeklikE. ValovirtaA. VignolaD. WangJ. WarnerK. Weiss

ARIA 2001In collaboration with WHO

JACI 2001;108 (Suppl 5):S147-S333


• Patients with (persistent) AR should be

evaluated for asthma

• Patients with (persistent) asthma should be

evaluated for AR

• A combined strategy should be developed to

treat co-existing diseases of the upper and

lower airways

Combined approach for AR and asthma


Changed classification for AR

Moderate-severeone or more items

. abnormal sleep

. impairment of daily activities, sport, leisure

. abnormal work and school

. troublesome symptoms

Persistent . > 4 days per week . and > 4 weeks

Mild normal sleep& no impairment of

daily activities, sport, leisure

& normal work and school

& no troublesome symptoms

Intermittent . 4 days per week. or 4 weeks

in untreated patients


PersistentPersistent33%33%

PersistentPersistent33%33%

IntermittentIntermittent67%67%

IntermittentIntermittent67%67%

N=1,265 subjects with physician-based diagnosis N=1,265 subjects with physician-based diagnosis

SAR: SAR: symptomssymptoms restricted to spring and/or summer restricted to spring and/or summer

N=1,265 subjects with physician-based diagnosis N=1,265 subjects with physician-based diagnosis

SAR: SAR: symptomssymptoms restricted to spring and/or summer restricted to spring and/or summer

PARPAR51%51%PARPAR51%51%

SARSAR49%49%SARSAR49%49%

SAR/PAR SAR/PAR ARIAARIAstudy step 1 (N=1,230)study step 1 (N=1,230)

Prevalences are different

Bauchau et al, Eur Respir J 2004


Classification of AR Patients in General Practice during Pollen Season

2% 9%

55%

34%Mild persistent

Mild intermittent

Mod/sev intermittent

Mod/sev persistent

N=804 subjects with GP-based diagnosis Van Hoecke et al, 2005

persistent

Intermittent

Mod/Sev

2%9%

55%

Mild

33%


0

10

20

30

40

50

60

70

80

Grass Tree Mite Animal Other

persistent

intermittent

Van Hoecke et al, 2005

NSNS

NS

NS

NS

N=351 subjects with GP-based diagnosis, responsible allergens confirmed

by allergy testing

Responsible Allergens in Persistent vs Intermittent AR


Symptom Severity in Persistent vs Intermittent AR

N=804 subjects with GP-based diagnosis

Van Hoecke et al, 2005

Intermittent Persistent p value

Runny nose 59.1 59.3 NS

Blocked nose 58.4 66.2 0.03

Itchy nose 50.2 43.8 0.09

Sneezing 61.9 62.4 NS

Conjunctivitis 37.4 43.8 0.09

Severity of each symptom is measured on a scale 1-4, expressed as % with score 3 or 4 - N=804

Headache 11.7 15.5 0.1

Somnolence 6.8 13.8 0.002


Burden of Persistent Rhinitis

N=804 subjects with GP-based diagnosisVan Hoecke et al, 2005

Intermittent Persistent p value

33.5 43.4 0.006

69.8 73.8 NS

51.4 56.6 NS

73.5 84.8 <0.001

Impaired sleep

Impaired activities/sports/leisure

Impaired school/work

Troublesome symptoms

Moderate/severe AR 86.6 94.1 0.001

%

Allergy testing 44.2 69.3 <0.001

Specialist referral 7.0 12.4 0.01


Persistent AR Has Specific Clinical Characteristics

T5SS (from 0 to 15): 8.97 (2.27)*

RQLQ (from 0 to 6): 3.04 (0.93)*

Loss of 17.9 work days per patient per year **

On co-morbidity = asthma, sinusitis, otitis media, upper respiratory infections: 11.8 events per month per 100 patients **

10% mild vs 90% moderate Severe allergic rhinitis:

Mild –moderate –severe subgroups?

Validation ARIA


Ia Evidence from meta-analysis of randomised controlled trials

Ib Evidence from at least one randomised controlled trial

IIa Evidence from at least one controlled study without randomisation

IIb Evidence from at least one other type of quasi-experimental study

III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies

IV Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both

A

B

C

D

Shekelle et al, BMJ 1999

Evidence-based recommendations


Strength of evidence for rhinitis treatments

Intervention SAR

Adult

SAR

Children

PAR

Adult

PAR

Children

Oral anti-H1 A A A A

Nasal anti-H1 A A A A

Nasal CS A A A A

Nasal cromone A A A A

Antileukotriene A A

Subcut SIT A A A A

Subling/nasal IT A A A

Allergen avoidance D D D D


mildintermittent

mildpersistentmoderate

severeintermittent

moderatesevere

persistent

allergen and irritant avoidance

immunotherapy

intra-nasal decongestant (<10 days) or oral decongestant

local cromone intra-nasal steroid

oral or local non-sedative H1-blocker

Stepwise rhinitis treatment


ARIA 2008In collaboration with WHO,

Ga2len and AllerGen

QuickTime™ en een-decompressor

zijn vereist om deze afbeelding weer te geven.

Allergy 2008; 63(Suppl 86):8-160

J. BousquetN. KhaltaevA. CruzJ. DenburgW. FokkensA. TogiasT. Zuberbier C. Baena-CagnaniG. CanonicaC. van WeelI. AgacheN. KhaledC. BachertM. BlaissS. BoniniL. BouletP. BousquetP. CamargosK. CarlsenY. Chen

A. CustovicB. DahlP. DemolyH. DouaguiS. DurhamR. Gerth van WijkO. KalayciM. Kaliner Y. KimM. KowalskiP. KunaL. LeC. LemiereJ. LiR. LockeyS. Mavale-Manuel E. MeltzerY. MohammadJ. MullolR. NaclerioR. Hehir

K. OhtaS. OuedraogoS. PalkonenN. PapadopoulosG. PassalacquaR. PawankarT. A. PopovK.RabeJ. Rosado-PintoG. ScaddingF. SimonsE. ToskalaE. ValovirtaP. Van CauwenbergeD.-Y. WangM. WickmanB. Yawn A. YorganciogluA. YusufA. Zar


International

Consensus 1994EAACI 2000 ARIA 2001 ARIA 2008

Nr of members (should be between 6 & 15

(Shekelle, 1999)

(18) OK (14) (37)

(61)

+ 35

reviewers

Composition of

group

ENT-All: OK

No GP’s

ENT-All: OK

No GP’s

OK

OK

OK

OK

Countries 11 7 17 34

Continents 3 2 4 5

Gender (M/F) 16/2 12/2 30/7 46/15

University vs

non-university16/2 14/0 34/3 53/8

Conflict of interest

(pharmaceutical

industry)

Not

mentioned

Not

mentioned

Not specified

whoSpecified

Expert panel for guideline development


Need for ARIA update

• Increasing knowledge on epidemiology, diagnosis,

management and comorbidities of AR since 1999

• Need for validation of ARIA classification and

management recommendations

• Availability of new evidence-based systems to guide

recommendations, including safety, costs and efficacy of

treatments

• Need to address previous gaps in knowledge (e.g.

complementary and alternative medicine)

2008 Update


Strength of evidence for rhinitis treatmentsIntervention SAR

Adult

SAR

Children

PAR

Adult

PAR

Children

PER

Oral anti-H1 A A A A A

Nasal anti-H1 A A A A A*

Nasal GCS A A A A A*

Nasal cromone A A A A A*

Antileukotriene A A (>6y) A A A*

Subcut SIT A A A A

Sublingual SIT A A A A

Anti-IgE A A (>12y) A A

Homeopathy D D D D

Accupuncture D D D D

Phytotherapy B D D D

Allergen avoidance D D D D

2008 Update

Indirect evidence*


mildintermittent

mildpersistentmoderate

severeintermittent

moderatesevere

persistent

allergen and irritant avoidance

immunotherapy

intra-nasal decongestant (<10 days) or oral decongestant

local cromone intra-nasal steroid

oral or local non-sedative H1-blocker or anti-leukotriene

Stepwise rhinitis treatment

2008 Update


Measure Evidence of effect on allergen levels Evidence of clinical benefit

HOUSE DUST MITES

Encase bedding in impermeable covers SomeNone (adults): Evidence ASome (children): Evidence B

Wash bedding on a hot cycle (55–60°C) Some None: Evidence A

Replace carpets with hard flooring Some None: evidence A

Acaricides and/or tannic acid Weak None: Evidence A

Minimize objects that accumulate dust None None: Evidence B

Use vacuum cleaners with integral HEPA filter and double-thickness bags

Weak None: Evidence B

Remove, hot wash or freeze soft toys None None: Evidence B

PETS Remove cat/dog from the home Weak None: Evidence B

Keep pet from main living areas/bedrooms Weak None: Evidence B

Use HEPA-filter air cleaners Some None: Evidence B

Wash pet Weak None: Evidence B

Replace carpets with hard flooring None None: Evidence B

Use vacuum cleaners with integral HEPA filter and double-thickness bags

None None: Evidence B

SET OF ALLERGEN CONTROL MEASURES Some Some: Evidence B

Effectiveness of avoidance measures in rhinitis and asthma for certain indoor allergens


Validation of guidelines

Treat patients according Treat patients accordingto guidelines to usual practice

Investigators randomised to:

225 patients with SAR 244 patients with SARscreened and enrolled screened and enrolled

Patients treated for 3 weeksRecorded:– Reflective symptoms twice daily– Medicine utilisation daily – RQLQ and SF-36 at day 7 and day 20– Global evaluation at day 21

AA BB

Bousquet J, van Cauwenberge P, Lund V Allergy 2003


Benefits of a guided strategyBousquet J, van Cauwenberge P, Lund V Allergy 2003


Dissemination of ARIA guidelines

Have you heard about

ARIA?


Implementation of ARIA guidelines

Mild intermittent

(n=69)

Mild persistent

(n=17)

Mod/sev intermittent

(n=445)

Mod/sev persistent

(n=273)

Treated according to ARIA

56,5% 64,7% 45,4% 63,0%

Undertreated 10,1% 0% 2,9% 30,4%

Overtreated 33,3% 35,3% 51,7% 6,6%

Treatment prescribed by 95 Belgian GPs in 804 AR patients

Van Hoecke H, Van Cauwenberge P, Allergy 2006


Rhinitis treatment

improves asthma

EVIDENCE A

++ Anti-IgE mAb

Immunotherapy

Leucotriene modifiers

Nasal GCS

+ Antihistamines

Revised GINA 2006: Rhinitis treatment Revised GINA 2006: Rhinitis treatment


Conclusion

• Aim of guidelines is to improve patient care and to

support physicians by informing them and by improving

their decisions

• Benefits of a guided strategy have been validated

• Several barriers to put guidelines into practice

• More efforts are needed to adapt guidelines to the

needs of the end-users

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