Dr. Stoloff: People need to understand that the cost of not spending money to be healthy has a consequence that is sometimes the greater cost of being unhealthy—cost in terms of morbidity, cost in terms of missed days from work, absenteeism, presenteeism, poor ability to function in the usual domains of physical, social, emotional, and mental.
Dr. Hadley: That’s what the public just does not understand. We have not achieved the goal of informing the lay public and practitioners about how effective management can get these patients better, reduce their costs, and enable patients to go back to work and their activities.
What should be done to better act on the challenges highlighted by these important surveys? Is there a need to increase the awareness of allergic rhinitis among health care providers?
Dr. Meltzer: If we’re not making progress then we have to make some changes. It seems to me that education could drive change. The public needs to better understand that it is not insignificant to have an inflammatory process called allergic rhinitis. Allergic rhinitis is clearly underestimated in terms of its burden. It is too often unrecognized or ignored as an inconsequential problem. It is important that the person who has allergic rhinitis does not disregard the burden of disease. The NASAL survey reports that allergic rhinitis affects the ability to sleep well in 40 of patients. We know that allergic rhinitis also compromises people’s activities and we know that they are not as productive when they’re at work. We also know there are many comorbidities—asthma in particular, and sinusitis, otitis, conjunctivitis are other common associated conditions. Patients and clinicians need to be educated to appreciate the significant morbidity associated with allergic rhinitis, and that nasal allergies need attention and effective control.
Dr. Hadley: One of the things that we all see is patients not always getting important information about the medications that they take; there is a walk-in to the grocery store and the pharmacy shelves are filled with medications that are over-the-counter. The problem is there is not enough education about what the benefits are and what the side effects are of all those medications. There is also a lot of direct to consumer advertising—radio, television, etc., that also leads to misconceptions about the benefits of some of these medications. Patients are somewhat aware that they have a problem, but they just don’t know where to go. From the health care provider perspective, the emphasis is on treating the major problems—diabetes, hypertension—and rhinitis is considered a minor problem. So I don’t think we are educating our patients well enough. And I think that is a misconception and misunderstanding, which should be corrected.
Dr. Stoloff: Most physicians will see on their schedule a brief description of what problems their upcoming patients have. In primary care, the person filling the schedule will often say that the patient with nasal symptoms has sinusitis, which overwhelmingly it is not. That is an “easy” quick visit and the typical conversation is “Here, take this pill—if you’ve tried that pill, then take this nasal inhaler—and if you didn’t like this one I’ve got another sample for you. And then we’ll figure out which one is going to be on your list, what is covered by your insurance, and what’s the generic.” There is very little discussion about the type of impairment suffered and the overall burden on the individual. Importantly, that burden is often substantial, especially if nasal allergy symptoms were the primary reason for the office visit.
In primary care, people can have a multitude of other conditions, and allergic rhinitis is down at the bottom of the list. For example, the patient may be a hypertensive diabetic who also has seasonal allergic rhinitis. So by the time a family doctor gets to discuss allergic rhinitis, the office visit time is over and it is easier for the physician to just give a medication. But when the presence of allergic rhinitis has an enormous influence on the other diseases as far as activity, sleep, fatigue, depression, all the other emotional components, as well as physical components, that the survey highlighted—that really needs to be brought to the attention of both the patient and the health care provider to spend the appropriate time discussing it. Because it will influence care in everything else the person does.
How would you work up a patient who you might consider as potentially having allergic rhinitis?
Dr. Meltzer: When physicians view their schedule, a word or phrase supposedly informs them in advance of the patient’s condition. In reality, every patient is different and, moreover, patients with allergic rhinitis vary over the course of days, months and years in their symptomatology. So when I evaluate a patient for rhinitis and their chief complaint is “I’m having problems with my nose,” I first find out the full range of symptoms, and which symptom is for them the most bothersome (most often it will turn out to be congestion). Secondly, I would find out whether the symptoms are intermittent, or persistent. If they are fairly persistent, this informs me about somewhat of their severity, which is another very important consideration. Thirdly, I would try to find out what are the triggers for the symptoms such as non-allergic precipitants (eg, climate changes, tobacco smoke, and other environmental pollutants), or specific allergen triggers (eg, pets, springtime pollens). I would also ask about any comorbid conditions because if they are having more than just nasal symptoms that expands what I am going to need to address. I need to know all of those things before I make a treatment plan. If the disease is intermittent and mild or not very bothersome, then I am going to initiate a modest management plan. If their allergic rhinitis is more problematic, then I will need to educate the patient about what they have, why they have it and what to do about it. The patient and I will need to agree about our expectations of treatment. We are going to have an action plan for the short-term as well as a plan for follow-up visits to see if in fact our initial plan is successful. Again, the specifics will depend upon the individual patient.