Symptoms of Allergic Rhinitis* Physical (%) Mental (%) Stuffed-up nose 78 Feels tired 80 Runny nose 62 Feels miserable 65 Postnasal drip 61 Feels irritable 64 Red itching eyes 53 Depression 36 Watering eyes 51 Embarrassment 23 Repeated sneezing 51 Headache 51 Nasal itching 46 Facial pain 43 Ear pain 30 * Allergies in America Survey, see reference 1 WAO White Book on Allergy 2 9 Copyright 2011 World Allergy Organization Psychological effects: Fatigue, irritability, anxiety, depression, frustration, self-consciousness and lower energy, motivation, alertness, and ability to concentrate, are commonly present in patients with AR (Table 2). Decreased quality of life: Investigators have used health status questionnaires to assess the quality of life of patients with asthma or rhinitis. While physical functioning was slightly higher in patients with AR compared with patients with asthma, social functioning was lower in the AR group. Sleep disturbances: Nasal congestion is often associated with sleep-disordered breathing. Up to 57% of adult patients and up to 88% of children with AR have sleep problems, including micro-arousals, leading to daytime fatigue and somnolence, and decreased cognitive functioning. These are accompanied by disorders of learning performance, behaviour and attention in children. Interference with social interaction: Social isolation, activity limitations, limited visits to friends and family, and an inability to visit open spaces such as parks and closed spaces (restaurants, cinemas), are frequent consequences of AR. Patients are forced to carry handkerchiefs or tissues, and need to rub and blow the nose repeatedly. Use of medications: On average, patients with AR usually use two or more medicines to treat their AR. Self-medication with over the counter sedating antihistamines results in drowsiness and further impairment of cognitive and motor functions. Financial burden: It has been demonstrated that patients with AR support two-fold increases in medication costs and 1.8 times the number of visits to health practitioners when compared with matched controls. Expenses for AR include direct and indirect costs (Table 3). Table 3 — Components of the Financial Burden of Allergic Rhinitis Direct costs Indirect costs Physician office visits Laboratory tests Medication Immunotherapy Treatment of co-morbidities Absenteeism Presenteeism (decreased productivity while at work) Impaired productivity (52% of patients) In the United States of America, direct costs for AR increased from $ 2.7 billion in 1995 to $7.3 billion in 2002. Indirect costs in 2002 were estimated at $4.28 billion, with a total amount of $11.58 billion for that year. Additionally 3.5 million lost workdays and 2 million lost school-days occur annually. On any given day, about ten thousand children are absent from school in the USA because of AR. Therapeutic considerations Treatment modalities recommended for patients with AR are discussed in Chapter 3. According to the ARIA guidelines, the management strategies include four components: 1) Patient education; 2) Prevention of exposure to environmental allergens and irritants; 3) Pharmacological therapies; and 4) Immunotherapy. The effective first line drugs for AR are non-sedating antihistamines and intranasal corticosteroids. Other drugs with favorable efficacy and safety profiles include leukotriene receptor antagonists, chromones, and topical and oral decongestants. Subcutaneous immunotherapy and sublingual immunotherapy are effective and have preventative as well as long lasting effects on the disease. In developing countries, there are limitations for the adequate treatment of AR, such as little access to specialized diagnosis and treatment, the small number of allergists, lack of confirmatory in vivo and in vitro diagnostic tests, and the cost of medications or immunotherapy. Co-morbidities, and especially asthma, must be treated concomitantly with AR. The ARIA guidelines strongly recommend that patients with AR be evaluated for asthma, and that patients with asthma be assessed for AR. Unmet Needs • To define control of AR. • To define severe AR. • To define phenotypes and disease heterogeneity. • Additional therapies for unresponsive patients. • Pharmaco-economic studies.