Disclosures : Effects on Quality of Life and Co-morbid Conditions Nycomed Pharmaceutical Sepracor Pharmaceutical Michael S. Blaiss, MD Clinical Professor of Pediatrics and Medicine University of Tennessee Health Science Center Memphis, Tennessee Objectives Be familiar with bothersome symptoms, impaired work productivity and quality of life with allergic rhinitis Understand the role of sleep impairment in allergic rhinitis Learn to recognize the co-morbidities of allergic rhinitis, such as conjunctivitis, sinusitis, increased respiratory infections, and asthma Case Report JD is a 26 year old male who presents to my office with a history each spring of developing sneezing, nasal itching, and rhinorrhea. This spring, his symptoms are getting worse. For the first time he also stated that his eyes were watering and itching and noted the whites of his eyes getting red and puffy. He is experiencing headaches and pain in the sinuses Case Report (cont.) He states that it has been hard to function at work as a computer programmer. Staring at the computer terminal has been difficult. He also reports having trouble falling to sleep and staying asleep all night. He likes to jog in the morning, but now he notices that he is coughing and wheezing which makes it difficult to do his normal 5K run. Case Report (cont.) Review of Symptoms he denies ear problems; he has been told that he snores during the spring Past History He had had nasal symptoms each spring since first grade; mild eczema which he outgrew at the age of 8 Family History Mother with asthma, brother with allergic rhinitis Environmental History-Lives in house with wall to wall carpeting; no pets; no basement Non-smoker; does not live with any smokers
JD s Physical Examination Eyes Conjunctiva injected and swollen with increased eye tearing and lid swelling Nose Turbinates very pale and swollen bilaterally with profuse serous drainage Ears Normal Throat Purulent post nasal drip Chest Rare wheeze on forced expiration Skin Clear Evaluation Allergy skin prick tests: Positive to oak and pecan tree pollen CT scan sinuses: bilateral air fluid levels in the maxillary sinuses Spirometry: FEV 1 85% of predicted with a 15% improvement in FEV 1 after bronchodilator Consequences Symptom bother Mood changes Impaired quality of life Impaired work/school productivity Sleep disturbances Co-morbidities Conjunctivitis Rhinosinusitis Respiratory infections Asthma Consequences Symptom bother Mood changes Impaired quality of life Impaired work/school productivity Sleep disturbances Co-morbidities Conjunctivitis Rhinosinusitis Respiratory infections Asthma Nasal Symptoms Are Bothersome: How Bothersome are Symptoms: All AILA Countries Allergies in America at www.myallergiesinamerica.com Q21. When you have nasal allergy attacks, how bothersome are the following symptoms usually: extremely bothersome, moderately bothersome, slightly bothersome, or not bothersome? Base: Had symptom at least a few days a week
and Daily Life Q 31. During allergy season, would you say the condition impacted your daily life.? N=2,500 Allergies in America at www.myallergiesinamerica.com 14 Patient Feelings During Allergy Season: Symptoms Experienced Frequently Impact on Mood: Patients with complaint (%) 100 80 60 40 20 0 Tiredness Irritability Nervousness/ Sadness/ anxiety depression SAR + PAR PAR SAR Poor hearing Sickness Other None a Germany, France, Italy, Spain and the United Kingdom. Q32. During allergy season, how often did you feel (ITEM) frequently, sometimes, rarely, or never? N=1088 Canonica et al. Allergy. 2007;62(suppl 85):17. Impact on Quality of Life: Impact on Quality of Life: QoL Score Control (n=116) PAR (n=111) * * * * * * * * Global RQLQ Score P < 0.01 P < 0.01 Physical function Energy/ fatigue General health Social function Role limitations (physical) Role limitations (emotional) Mental health Pain Mild intermittent (n=84) Moderate-severe intermittent (n=874) Mild persistent (n=64) Moderate-severe persistent (n=1092) *P 0.0005 vs healthy controls. Bousquet et al. J Allergy Clin Immunol. 1994;94:182. Bousquet et al. J Allergy Clin Immunol. 2006;117:158-162.
Impact on Work/School Productivity: WPAI Impairment Score P < 0.01 P < 0.01 P < 0.01 Loss of work productivity (n=1397) Loss of school productivity (n=379) 19 Bousquet et al. J Allergy Clin Immunol. 2006;117:158-162. Nasal Allergies Interfere With Sleep Recent Allergy Interference: All AILA Countries Difficulty in getting to sleep 12% 32% Allergy No allergy Waking up during the night 8% 26% Lack of a good night s sleep 12% 29% 0 10 20 30 40 50 Q34. How troubled have you been by each of these symptoms during the last week as a result of your nasal symptoms? On a scale of 1 to 7, where 1 means not at all troubled and 7 means extremely troubled, how much trouble have nasal allergies caused in? N = 1088 Impact on Sleep Complaints: Impact on Sleep Disorders: Subjects with complaint (%) AR patients (n=591) Controls (n=502) * * * * * * Subjects with complaint (%) AR patients (n=591) Controls (n=502) * * * * Difficulty falling asleep *P<0.001 vs controls. Nocturnal awakening Leger et al. Arch Intern Med. 2006;166:1744. Early Non-restorative awakening sleep Lack of sleep Snoring *P 0.003 vs controls. Insomnia Leger et al. Arch Intern Med. 2006;166:1744. Severe insomnia Sleep apnea syndrome Hypersomnia
Ocular Allergy Symptoms Consequences Symptom bother Mood changes Impaired quality of life Impaired work/school productivity Sleep disturbances Co-morbidities Conjunctivitis Rhinosinusitis Respiratory infections Asthma Redness Itching Tearing 26 Ocular vs. Nasal Symptoms: Frequency Ocular vs. Nasal Complaints: How Bothersome? Percent of patients Percent of patients N = 2,500 N = 2,500 Allergies in America survey, 2006 Allergies in America survey, 2006 Epidemiologic Association Between Allergic Rhinitis and Conjunctivitis Prevalence of Concomitant Conditions Experienced in the Previous Week by AR Sufferers 30 % of Conjunctivitis Allergic Comorbidity Patients No other allergic manifestations 6 Asthma 1 Allergic rhinitis 66 Atopic eczema 0 Urticaria-angioedema 0.4 More than 1 allergic disease 27 Bonini S. Chibret Int J Ophthalmol. 1987;5:12. Reporting of concomitant conditions were similar between adults and children with AR, with the exception of heartburn/gerd, which was reported nearly 5-fold more frequently in adults than in children *Multiple answers were permitted.
Acute Rhinosinusitis Is More Common in Patients With AR AR Increases the Risk for and Duration of Respiratory Infections in Children Patients with Acute Rhinosinusitis (%) P=0.09 AR (n=54) Controls (n=82) P<0.001 Total RI (number) P=0.0001 RI Duration (days) P=0.009 Total population (N=136) Subjects 25 years of age (n=35) Allergic children (n=46) Non-allergic children (n=71) Allergic children (n=46) Non-allergic children (n=71) Ulanovski et al. Am J Rhinol. 2008;22:122. Ciprandi et al. Pediatr Allergy Immunol. 2006;17:389-391. AR Increases the Risk for and Duration of Respiratory Infections in Adults Prevalence of Asthma in Adults and Children With AR 34 Diagnosed with asthma Asthma symptoms in past 12 months RI Rate (episodes) * 3.5 1.6 RI Duration (median, days) * 23 7 AR Patients (n=202) Controls (n=422) AR Patients (n=202) Controls (n=422) *P<0.001. Cirillo et al. Allergy. 2007;62:1087-1090. More children than adults with AR have been diagnosed with asthma or had asthma symptoms in the past 12 months Prevalence of Asthma in Children With and Without AR 35 Tasmanian Asthma Study 36 Diagnosed with asthma Asthma symptoms in past 12 months Associations between childhood AR and asthma incidence from preadolescence to middle age and asthma persistence to middle age Data from 1968, 1974, and 2004 survey of the Tasmanian Asthma Study Children with AR have a > 3-fold increased incidence of asthma diagnosis and asthma symptoms than children without AR Burgess JA, Walters EH, et al. J Allergy Clin Immunol. 2007;120:863-9.
Asthma in Different Life Stages After the Age of 7 Years, Dependent on Childhood Allergic Rhinitis 37 European Community Respiratory Health Survey 38 Childhood allergic rhinitis vs Never allergic rhinitis Age (y) at asthma onset* >7-12, preadolescence >12-20, adolescence >20-44, adult life (n=156) (n=124) (n=607) Homogeneity test, P value HR (95% CI) HR (95% CI) HR (95% CI) 7.12 (3.97-12.75), P<0.001 4.34 (2.23-8.46), P<0.001 2.19 (1.59-3.01), P<0.001 <0.001 1.00 1.00 1.00 Longitudinal population-based study in 14 primary Western European countries Frequency of asthma development in 6461 participants from 20-44 yrs old over 8.8 years Incident asthma was defined as reporting ever having asthma confirmed by a physician Atopy by positive prick skin test HR = hazard ratio. * There were 27 persons of the 2108 with a history of asthma ever for whom no age at onset of asthma could be determined and 1194 with asthma onset by age 7 years. Additionally adjusted for socioeconomic status, current smoking, and passive smoking at age 44 years. Shaabab R, Zureik M, et al. Lancet. 2008;372:1049-1057. 39 Cumulative Incidence Rate of Asthma Positive Skin Test and AR Increase the Risk for New Asthma at 23-Year Follow-Up Control Atopy, no rhinitis Non-allergic rhinitis Allergic rhinitis Number at risk Control 3163 3158 3153 3064 2967 Atopy, no rhinitis 704 701 698 669 642 Non-allergic rhinitis 1377 1396 1358 1268 1199 Allergic rhinitis 1217 1208 1194 1093 1038 Patients Developing New Asthma (%) P<0.001 Allergy skin test Positive Negative P<0.002 Allergic rhinitis Cumulative incidence of asthma by year of follow-up in 3161 individuals in the control group, 704 who had atopy alone, 1377 who had non-allergic rhinitis, and 1217 who had allergic rhinitis. Settipane et al. Allergy Proc. 1994;15:21. Summary Allergic rhinitis can impose multiple burdens on patients Symptom bother Mood changes Impaired quality of life Impaired work/school productivity Sleep disturbances Co-morbidities Treating the underlying pathophysiologic inflammation is the appropriate approach to relieve the symptoms and reduce the risk of consequences and co-morbidities in patients with upper respiratory disease