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ARIA-guidelines, an update
Van Cauwenberge P, MD, PhD
Van Hoecke H, MD
Philippe Gevaert, MD, PhD
Department of Otorinolaryngology
Ghent University, Belgium
© 2008 Universitair Ziekenhuis Gent
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Allergic rhinitis: treatment modalities
© 2008 Universitair Ziekenhuis Gent
From Diamant Z
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Cornerstones of AR treatment
allergen
avoidance
indicated
when possible
pharmacotherapy
safety
effectiveness
easy to be
administered
© 2008 Universitair Ziekenhuis Gent
COSTS
patient's
education
always
indicated
immunotherapy
effectiveness
specialist
prescription
may alter the
natural
course of the
disease
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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
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Guidelines for allergic rhinitis
1994
1996, 1998
2000
2001
2008
Qu ickT ime™ en een
-de com press or
zij n ver eist o m d eze a fbee lding we er te geve n.
Opinion-based
guidelines
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Evidence-based
guidelines
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V.J. Lund
D. Aaronson
J. Bousquet
R. Dahl
R.J. Davies
S. Durham
R. Gerth van Wijk
K. Holmberg
E. Juniper
International
Consensus Report
1994
© 2008 Universitair Ziekenhuis Gent
Ian S. Mackay
L. Malm
N. Mygind
M. Okuda
C. Ortolani
H.M. Schanker
S.L. Spector
P. van Cauwenberge
M.R. Wayoff
Allergy 1994;49:1-34
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International Consensus Report: Flow Chart
Scan pag 28
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D. Skoner
M. Dykewicz
S. Fineman
R. Nicklas
R. Lee
J. Blessing-Moore
J. Li
I. Bernstein
W. Berger
S. Spector
D. Schuller
American
Guidelines on
Rhinitis
1998
Ann All Asthma Immunol 1998; 81:478-518
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P. van Cauwenberge
C. Bachert
J. Bousquet
G. Canonica
S. Durham
W. Fokkens
P. Howarth
EAACI Position
Paper
2000
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V Lund
N. Mygind
G. Passalacqua
D. Passali
G. Scadding
D. Wang
Allergy 2000;55:116-134
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Seasonal allergic rhinitis
Need for therapy ?
Mild disease or
occasional symptoms
Oral or Nasal
Antihistamines
(Cromones)
Moderate disease or
long duration
Inadeq.
control
For eye symptoms :
topical antihistamines
or
cromones
© 2008 Universitair Ziekenhuis Gent
Severe disease
Nasal
Corticosteroids
Inadeq.
Nasal
+
Corticosteroids control Oral or Nasal
Antihistamines
Inadeq.
control
Add further symptomatic treatment
Short-course Oral Steroids
Consider Immunotherapy
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Perennial allergic rhinitis in adults
Avoidance
Need for therapy ?
Environment control
Mild disease or
occasional symptoms
Oral or Nasal
Antihistamines
Moderate disease or
long duration
Inadeq.
Nasal
control Corticosteroids
Severe symptoms
Nasal
Inadeq. Corticosteroids
control
+
Antihistamines
Inadeq.
control
© 2008 Universitair Ziekenhuis Gent
Further examinations
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Perennial allergic rhinitis in adults
RESISTANT CASES
Nasal
blockage
Short Course of
Topical Decongestants/
Oral Decongestants/
Oral Steroids
Resistant
rhinorrhea
Nasal
Ipratropium
bromide
Immunotherapy
If resistant
Surgical turbinate
reduction
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J. Bousquet
P. van Cauwenberge
N. Khaltaev
ARIA 2001
N. Ait-Khaled
I. Annesi-Maesano
C. Bachert
C. Baena-Cagnani
E. Bateman
S. Bonini
G. Canonica
K. Carlsen
P. Demoly
S. Durham
D. Enarson
W. Fokkens
R. Gerth van Wijk
In collaboration with WHO
JACI 2001;108 (Suppl 5):S147-S333
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P. Howarth
N. Ivanova
J. Kemp
J. Klossek
R. Lockey
V. Lund
I. MacKay
H. Malling
E. Meltzer
N. Mygind
M. Okuda
R. Pawankar
D. Price
G. Scadding
F. Simons
A. Szczeklik
E. Valovirta
A. Vignola
D. Wang
J. Warner
K. Weiss
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Combined approach for AR and asthma
•
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
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Changed classification for AR
Intermittent
.  4 days per week
. or  4 weeks
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
Moderate-severe
one or more items
. abnormal sleep
. impairment of daily
activities, sport, leisure
. abnormal work and
school
. troublesome symptoms
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in untreated patients
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Prevalences are different
SAR/PAR
ARIA
study step 1 (N=1,230)
PAR
51%
Persistent
33%
SAR
49%
Intermittent
67%
N=1,265 subjects with physician-based diagnosis
SAR: symptoms restricted to spring and/or summer
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Bauchau et al, Eur Respir J 2004
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Classification of AR Patients in General Practice
during Pollen Season
2% 2%
9%9%
Mild
34%
Mild persistent
33%
Mild intermittent
persistent
Mod/sev intermittent
Intermittent
55%
Mod/sev persistent
Mod/Sev
55%
N=804 subjects with GP-based diagnosis
Van Hoecke et al, 2005
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Responsible Allergens in
Persistent vs Intermittent AR
80
70
NS
NS
NS
60
50
persistent
intermittent
NS
40
30
NS
20
10
0
Grass
Tree
Mite
Animal
Other
N=351 subjects with GP-based diagnosis, responsible allergens confirmed
© 2008 Universitair Ziekenhuis Gent
by allergy testing
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Van Hoecke et al, 2005
Symptom Severity in Persistent vs Intermittent AR
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
Headache
11.7
15.5
0.1
Somnolence
6.8
13.8
0.002
N=804 subjects with GP-based diagnosis
Severity of each symptom is measured on a scale 1-4, expressed as % with score 3
or 4 - N=804
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Van Hoecke et al, 2005
Burden of Persistent Rhinitis
Intermittent
Persistent
p value
Impaired sleep
33.5
43.4
0.006
Impaired
activities/sports/leisure
69.8
73.8
NS
Impaired school/work
51.4
56.6
NS
Troublesome
symptoms
73.5
84.8
<0.001
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
%
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N=804 subjects with GP-based diagnosis
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Van Hoecke et al, 2005
Validation ARIA
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?
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Evidence-based recommendations
Ia Evidence from meta-analysis of randomised controlled trials
A
Ib Evidence from at least one randomised controlled trial
IIa Evidence from at least one controlled study without
randomisation
B
IIb Evidence from at least one other type of quasi-experimental
study
C
III Evidence from non-experimental descriptive studies, such as
comparative studies, correlation studies and case-control
studies
D
IV Evidence from expert committee reports or opinions or clinical
experience of respected authorities, or both
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Shekelle et al, BMJ 1999
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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
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D
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Stepwise rhinitis treatment
mild
intermittent
moderate
severe
intermittent
mild
persistent
moderate
severe
persistent
intra-nasal steroid
local cromone
oral or local non-sedative H1-blocker
intra-nasal decongestant (<10 days) or oral decongestant
allergen and irritant avoidance
immunotherapy
© 2008 Universitair Ziekenhuis Gent
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Qu ickT ime™ en een
-de com press or
zij n ver eist o m d eze a fbee lding we er te geve n.
ARIA 2008
In collaboration with WHO,
Ga2len and AllerGen
© 2008 Universitair Ziekenhuis Gent
J. Bousquet
N. Khaltaev
A. Cruz
J. Denburg
W. Fokkens
A. Togias
T. Zuberbier
C. Baena-Cagnani
G. Canonica
C. van Weel
I. Agache
N. Khaled
C. Bachert
M. Blaiss
S. Bonini
L. Boulet
P. Bousquet
P. Camargos
K. Carlsen
Y. Chen
A. Custovic
B. Dahl
P. Demoly
H. Douagui
S. Durham
R. Gerth van Wijk
O. Kalayci
M. Kaliner
Y. Kim
M. Kowalski
P. Kuna
L. Le
C. Lemiere
J. Li
R. Lockey
S. Mavale-Manuel
E. Meltzer
Y. Mohammad
J. Mullol
R. Naclerio
R. Hehir
K. Ohta
S. Ouedraogo
S. Palkonen
N. Papadopoulos
G. Passalacqua
R. Pawankar
T. A. Popov
K.Rabe
J. Rosado-Pinto
G. Scadding
F. Simons
E. Toskala
E. Valovirta
P. Van Cauwenberge
D.-Y. Wang
M. Wickman
B. Yawn
A. Yorgancioglu
A. Yusuf
A. Zar
Allergy 2008; 63(Suppl 86):8-160
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Expert panel for guideline development
International
Consensus 1994
Nr of members
EAACI 2000
ARIA 2001
ARIA 2008
(61)
 (18)
OK (14)
 (37)
+ 35
reviewers
Composition of
group
ENT-All: OK
ENT-All: OK
OK
OK
No GP’s
No GP’s
OK
OK
Countries
11
7
17
34
Continents
3
2
4
5
Gender (M/F)
16/2
12/2
30/7
46/15
16/2
14/0
34/3
53/8
Not
mentioned
Not specified
who
Specified
(should be between 6 & 15
(Shekelle, 1999)
University vs
non-university
Conflict of interest
(pharmaceutical
industry)
© 2008 Universitair Ziekenhuis Gent
Not
mentioned
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Need for ARIA update
•
Increasing knowledge on epidemiology, diagnosis,
management and comorbidities of AR since 1999
2008 Update
•
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 Universitair Ziekenhuis Gent
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2008 Update
Strength of evidence for rhinitis treatments
Intervention
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 Universitair Ziekenhuis Gent
Indirect evidence*
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Stepwise rhinitis treatment
2008 Update
mild
intermittent
moderate
severe
intermittent
mild
persistent
moderate
severe
persistent
intra-nasal steroid
local cromone
oral or local non-sedative H1-blocker or anti-leukotriene
intra-nasal decongestant (<10 days) or oral decongestant
allergen and irritant avoidance
immunotherapy
© 2008 Universitair Ziekenhuis Gent
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Effectiveness of avoidance measures
in rhinitis and asthma for certain indoor allergens
Measure
Evidence of effect on allergen levels Evidence of clinical benefit
HOUSE DUST MITES
Encase bedding in impermeable covers
Some
None (adults): Evidence A
Some (children): Evidence B
Wash bedding on a hot cycle (55–60°C)
Replace carpets with hard flooring
Acaricides and/or tannic acid
Minimize objects that accumulate dust
Some
Some
Weak
None
None: Evidence A
None: evidence A
None: Evidence A
None: Evidence B
Use vacuum cleaners with integral HEPA filter and doublethickness bags
Weak
None: Evidence B
Remove, hot wash or freeze soft toys
None
None: Evidence B
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
Wash pet
Replace carpets with hard flooring
Some
Weak
None
None: Evidence B
None: Evidence B
None: Evidence B
Use vacuum cleaners with integral HEPA filter and doublethickness bags
None
None: Evidence B
Some
Some: Evidence B
PETS
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SET OF ALLERGEN CONTROL MEASURES
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Validation of guidelines
Bousquet J, van Cauwenberge P, Lund V Allergy 2003
A
Investigators randomised to:
B
Treat patients according
to guidelines
Treat patients according
to usual practice
225 patients with SAR
screened and enrolled
244 patients with SAR
screened and enrolled
Patients treated for 3 weeks
Recorded:
– Reflective symptoms twice daily
– Medicine utilisation daily
– RQLQ and SF-36 at day 7 and day 20
– Global evaluation at day 21
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Benefits of a guided strategy
Bousquet J, van Cauwenberge P, Lund V Allergy 2003
© 2008 Universitair Ziekenhuis Gent
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Dissemination of ARIA guidelines
Have you
heard about
ARIA?
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Implementation of ARIA guidelines
Treatment prescribed by 95 Belgian GPs in 804 AR patients
Mild
Mild
intermittent persistent
(n=69)
(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%
Van Hoecke H, Van Cauwenberge P, Allergy 2006 3434
© 2008 Universitair Ziekenhuis Gent
Revised GINA 2006: Rhinitis treatment
Rhinitis treatment
improves asthma
EVIDENCE A
++ Anti-IgE mAb
Immunotherapy
Leucotriene modifiers
Nasal GCS
+
Antihistamines
© 2008 Universitair Ziekenhuis Gent
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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
© 2008 Universitair Ziekenhuis Gent
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