The Burden of Self-Reported Rhinitis and Associated Risk for Exacerbations with Moderate-Severe Asthma in Primary Care Patients

Vicky Kritikos,1,2 David Price,3– 5 Alberto Papi,6 Antonio Infantino,7 Björn Ställberg,8 Dermot Ryan,3,9 Federico Lavorini,10 Henry Chrystyn,11 John Haughney,12 Karin Lisspers,8 Kevin Gruffydd-Jones,13 Miguel Román Rodríguez,14 Svein Høegh Henrichsen,15 Thys van der Molen,16 Victoria Carter,3,4 Sinthia Bosnic-Anticevich1,17,18 1Quality Use of Respiratory Medicines Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; 2Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia; 3Optimum Patient Care, Cambridge, UK; 4Observational and Pragmatic Research Institute, Singapore, Singapore; 5Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; 6Respiratory Medicine, University of Ferrara, Ferrara, Italy; 7Special Interest Respiratory Area, Italian Interdisciplinary Society for Primary Care, Bari, Italy; 8Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden; 9Usher Institute, University of Edinburgh, Edinburgh, UK; 10Department Experimental and Clinical Medicine, University of Florence, Florence, Italy; 11Inhalation Consultancy Ltd, Leeds, UK; 12NHS Greater Glasgow & Clyde R&D, Glasgow, UK; 13Box Surgery, Box, UK; 14Primary Care Respiratory Research Unit Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma, Spain; 15Department of Primary Health Care Services, Norwegian Directorate of Health, Oslo, Norway; 16Department of Primary Care, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands; 17Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; 18Central Sydney Local Area Health District, Sydney, NSW, AustraliaCorrespondence: Vicky KritikosWoolcock Institute of Medical Research, Glebe, Sydney, NSW, AustraliaTel +61 4 0299 5125Fax +61 2 9114 0014Email vicky.kritikos@sydney.edu.auPurpose: There is a dearth of research regarding the prevalence and nature of patient-reported rhinitis and its relationship with risk of asthma exacerbations. The aim of this study was to (i) determine the prevalence, severity and treatment of self-reported rhinitis symptoms among adults aged ≥ 18 years with asthma treated at Global Initiative for Asthma (GINA) Step 3 and above and (ii) compare the demographics, clinical characteristics, medication use, side-effects and healthcare practitioner review between patients who report rhinitis symptoms and those who do not and (iii) determine whether patient-reported rhinitis is associated with risk of asthma exacerbations in the total patient sample.Patients and Methods: This analysis used data from the iHARP (Initiative Helping Asthma in Real-life Patients) asthma review service – a cross-sectional observational study (2011 and 2014) in seven countries that captured data on patient demographics, rhinitis symptoms, asthma symptoms, indicators of exacerbations, medication use, oropharyngeal effects and side-effects, using practitioner- and patient-reported questionnaires. Comparisons between patients with and without rhinitis were tested. Univariate logistic regression was used to identify variables associated with risk of exacerbations for entry into multivariable logistic regression.Results: This report contains data from 4274 patients: 67.4% (2881/4274) reported rhinitis symptoms and of which 65.7% (1894/2881) had not received a doctor diagnosis; 36.5% (1052/2881) had moderate-severe rhinitis, 12.4% (358/2881) had used intranasal corticosteroids and 19.8% (569/2881) oral antihistamines. Patients with coexisting moderate-severe rhinitis were more likely to have GINA-defined uncontrolled asthma than those with mild rhinitis or no rhinitis. Moderate-severe rhinitis was associated with 40% increased risk of asthma exacerbations (OR=1.40, 95% CI: 1.02– 1.90).Conclusion: This study identified a major gap in the diagnosis and management of rhinitis in a cohort of people with asthma treated at GINA Step 3 and above who are managed in general practice. It highlights the need for practitioners to identify, evaluate and optimally treat rhinitis in adults with asthma, which is a significant factor associated with exacerbation risk.Keywords: asthma symptom control, comorbidities, oral steroids, preventer, reliever, side-effects