WAC 2011: Patient Education and Treatment Compliance in Allergic Rhinitis Latin America

1. Rene Maximiliano Gomez Head, Allergy & Asthma Unit Hospital San Bernardo. Salta, Argentina WAC 2011:Patient Education and Treatment Compliance in Allergic Rhinitis Latin America

2. Latin America perspective Situational sketch Who are we treating/educating How are we treating them How successful are we

3. Nasal allergies in the Latin American population: Results from the Allergies in Latin America surveyNeffen H, Mello Jr. J, Sole D, Naspitz Ch et al. Allergy Asthma Proc 31:S9–S27, 2010

4. Nasal allergies in the Latin American population: Results from the Allergies in Latin America surveyNeffen H, Mello Jr. J, Sole D,Naspitz Ch et al. Allergy Asthma Proc 31:S9–S27, 2010 Solé D, Mallol J, Camelo-Nunes IC, Wandalsen GF. Prevalence of rhinitis-related symptoms in Latin American children (ISAAC) phase three. Pediatr Allergy Immunol 2010; 21(1Pt2): 127-36.

5. Many patients are being treated by… Who are we treating / educating?

6. Nasal allergies in the Latin American population: Results from the Allergies in Latin America surveyNeffen H, Mello Jr. J, Sole D, Naspitz Ch et al. Allergy Asthma Proc 31:S9–S27, 2010

7. Nasal allergies in the Latin American population: Results from the Allergies in Latin America surveyNeffen H, Mello Jr. J, Sole D, Naspitz Ch et al. Allergy Asthma Proc 31:S9–S27, 2010

9. How are wetreatingthem? • More than half having seasonal and intermitent symptoms • More than half having congestion as main symptom • QoL partially affected and • Many having no interference at all

10. Medication used (AII AILA)

11. Nasal sprays

12. EAACI 2010 LondonTreatment of allergic rhinitis in Argentina: the ENT perspectiveZernotti, M; Gomez, RM; Ivancevich, JC; Roques M; Baena-Cagnani, CE • Aim was to evaluate prescription trend associated to treatment of AR in a unselected group of ENT physicians. • Material and Methods: Survey of ENT specialists while attending to a national meeting. Invited to answer a questionnaire built for our proposal in an anonymous manner, asking about severity of AR, preferences of drugs for AR treatment in general, and selected medication for congestion. • Results: 107 ENT doctors completed the survey correctly, 43.3 y.o. mean age, 67.3% male, majority being specialists >10y. At least 2/3 of their patients have moderate to severe AR .

13. Preference of Treatment in AR Antih1 + decongest NSAH1 INCS 0 20 40 60 80 100 1º 2º 3º Treatment of allergic rhinitis in Argentina: the ENT perspectiveZernotti, M; Gomez, RM; Ivancevich, JC; RoquesRevol, M; Baena-Cagnani, CE

14. Treatment preferences by ENT in Nasal Congestion 50 40 30 % 20 10 0 INCS NSAH1 NSAH1 + Other Decong Treatment of allergic rhinitis in Argentina: the ENT perspectiveZernotti, M; Gomez, RM; Ivancevich, JC; RoquesRevol, M; Baena-Cagnani, CE

15. Treatment of allergic rhinitis in Argentina: the ENT perspectiveZernotti, M; Gomez, RM; Ivancevich, JC; RoquesRevol, M; Baena-Cagnani, CE • Conclusions: even considering specialists, guidelines for the treatment of AR seems to be partially followed. These data reinforce the need to recognize the severity of the disease, and the consequent evidence based treatment.

16. Koberlein J, Vent J, Mosgues R. On the sustainability of Guideline Implementation. WAO Journal 2010 (3-11): 258-261 • Methods: data of 121,593 patients collected during 9 prospective observational studies (1998 to 2005) examined using individual patient data meta-analysis method. • Results: Only 14.8% of patients with allergic rhinitis were treated according to the recommendations. Of the others, 73.8% received insufficient treatment. • 36.1% of the patients treated by ENT received therapy according to guidelines, opposite to 16% treated by general practitioners. • It could be observed that the rate of guideline compliance was highest in the year of publication of ARIA.

17. International Survey On the Management of Allergic Rhinitis by Physicians and Patients (ISMAR) RM Gomez, Teijeiro A, Badellino H, Zernotti M, Murrieta-Agutes M, Baena-Cagnani CE Background: • Survey to ask to patients and physicians the same questions to identify differences in attitudes and opinions about the treatment of AR at global level with the goal of identifying barriers to optimal management and revealing limitations of currently available treatments. Methods: • An international, multicenter, non–interventional, cross-sectional study was conducted in adults and children (≥ 6 years). Physicians were selected at random from a master list provided by country and combining private and public practices. ISMAR was designed according to the most accepted epidemiological recommendations based on the success of the WAO-GAPP survey on asthma. • A questionnaire addressing patient profiles, diagnostic assessment, therapeutic decisions, and real-life management was answered. The questionnaire also asked about national/local features, medications availability/cost, laboratory test facilities, traditions, geographical constraints, among others. • The participating physicians recruited consecutive patients with AR. Study data collection was performed during a single visit with 3 types of documents: Investigator’s questionnaire, Case Record Form, Patient’s questionnaire.

18. Results: • 234 physicians were surveyed with a mean age of 49 years (28-69), 180 of them were males (76.9%). The type of medical practice was public sector 16.7%, private practice 41.9% and mixed 41.4%. Regarding medical specialty is a follows: GPs/family practitioners/internists (22.2%), allergologists/pulmonologists (35.9%), pediatricians (11.1%) and ENT specialist (30.3%). • Physicians recruited 2776 patients with AR (Egypt, n=500; Mexico, n=418; Brazil, n=351; Colombia, n=223; Guatemala, n=216; Iran, n=207; Venezuela, n=201; Argentina, n=200; Israel, n=176; Kuwait, n=150; UAE, n=134). 4023 poster / Wed 07 dec

19. ISMAR: Physicians' ViewBadellino HA, Teijeiro A, Gomez RM, Zernotti M, Croce JS, Murrieta-Aguttes M, Baena-Cagnani CE Results: • Physicians were aware about ARIA (82.5%), GINA (71.4%). They followed guidelines recommendations to classify severity (84.2%) and for choosing treatment accordingly (84.6%). Key symptoms to make AR diagnosis were: congestion (84.8%), sneezing (79.1%), anterior watery rhino rhea (75.9%). • The main reasons to prescribe medication were: symptom severity/frequency (97.9%), drug efficacy (85.9%) and safety (76.5%). Other less relevant reasons were: personal experience (65%), cost (55.1%) and frequency of dosages (54.7%). • The preferred medications were oral antihistamines (OH1A) and intranasal corticosteroids (INC) [5 in a 0-5 scale]. Other treatments (oral decongestants, leukotriene antagonists, SCIT/SLIT), were considered as second level in preference. Conclusions: • Guidelines are well known and useful to physicians. Clinical history was the main way to evaluate the patient’s sleep quality, classification, severity and election of treatment. Objective measures for assessment were scarcely used. OH1A and INC were the most recommended treatment for AR and considered effective and safe. Oral Abstract Session 22 / Tue 06 dec

20. ISMAR: The Patients' ViewTeijeiro A, Badellino HA, Gomez RM, Zernotti M, Croce JS, Murrieta-Aguttes M, Baena-Cagnani CE. Results: • 2776 patients ; mean age 31 yrs, female 54%; urban (86.1%), suburban (6.6%) and rural (4.9%). • Co-morbidities were: sinusitis (50%), asthma (33%), conjunctivitis (36%), otitis (13%) and nasal polyps (11%). Nasal symptoms were associated to house-dust mites (84%), moulds (33%) animal dander (31%) and pollens (41%) exposure. • At least one current treatment was received in 91%, and recommendation to avoid allergens or irritants in 93% of patients. 80% the patients had received oral anti-H1 antihistamines (OH1A), 66% intranasal corticosteroids (INC), 63% oral/intranasal decongestants and 14% sub-cutaneous specific immunotherapy (SCIT). • Patients´ preference route was oral 51% and intranasal 28%. Patients´ preference mediations were: OH1A, 76%; INC, 49%; and SCIT 12%. Main factors affecting treatment compliances were cost (32%), fear of Adverse Events reported (18%) and frequency of doses (34%). • 85% of them received oral explanation on disease and only 51% written indications. Conclusions: • OH1A and INC were the most widely used treatments for rhinitis and were considered safe and effective. The majority of patients preferred the oral route. Written educational material given to patients is scarce. These might be taken into account to enhance treatment adherence and outcomes. Oral Abstract Session 22 / Tue 06 dec

21. Koberlein J, Kothe A, Schaffert C. Determinants of patient compliance in allergic rhinoconjunctivitis. CurrOpinAllergy ClinImmunol 2011, 11:192–199 • …estimating noncompliance between 30 and 50%. • Lack of efficacy was reported as the 1st reason for discontinuing. Studies on glucocorticosteroids, allergen-specific immunotherapy and antihistamines highlighted the importance of patient education, demographic factors, duration of therapy, side-effects and treatment costs, as well as minor details, such as taste and odour, in improving compliance. • Summary: The variation in the methodologies used and the durations of treatments assessed in current compliance research in the field of allergic rhinoconjunctivitis decreases the comparability of results. Moreover, a gold standard for measuring and reporting compliance should be determined to enable better interstudy comparability of the rates and determinants of compliance.

22. How successful are we? Big challenge

23. Koberlein J, Kothe A, Schaffert C. Determinants of patient compliance in allergic rhinoconjunctivitis. Curr Opin Allergy Clin Immunol 2011, 11:192–199

24. Steroid?What are you giving to me!Are you going to poison my child?

25. Do you have enough time to explain? • Why you need it • Is it affordable for you? • How safe • How effective • How to use it • Most common adverse events • Any concern? • Any barrier?