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CURRENT MEDICAL RESEARCH AND OPINION� 0300-7995

VOL. 25, NO. 5, 2009, 1073–1080 doi:10.1185/03007990902820733

� 2009 Informa UK Ltd. All rights reserved: reproduction in whole or part not permitted

ORIGINAL ARTICLE

Allergic rhinitis in patients withasthma: the Swiss LARA (LinkAllergic Rhinitis in Asthma) surveyAnne B. Taegtmeyera, Claudia Steurer-Steyb,Francois Spertinic, Andreas Bircherd, Arthur Helblinge,David Miedingerf, Salome Schafrothf, Kathrin Schererd

and Joerg D. Leuppia,f

aDepartment of Internal Medicine, University Hospital Basel, SwitzerlandbDepartment of General Practice and Health Services Research, University of

Zurich, SwitzerlandcDivision of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois,

Lausanne, SwitzerlanddAllergology, University Hospital Basel, SwitzerlandeAllergology and Clinical Immunology, University Hospital Bern, SwitzerlandfDepartment of Respiratory Medicine, University Hospital Basel, Switzerland

Address for correspondence: Joerg D. Leuppi, MD, PhD, Department of Internal Medicine,University Hospital Basel, Petersgraben 4, CH4031 Basel, Switzerland. Tel.:þ41-61-265-42-94; Faxþ41-61-265-53-53; jleuppi@uhbs.ch

Key words: Allergic rhinitis – Asthma – Asthma control – Drug therapy

ABSTRACT

Objective: To determine the characteristics of asthma (A)

and allergic rhinitis (AR) among asthma patients in primary

care practice.

Research design and methods: Primary care physicians,

pulmonologists, and allergologists were asked to recruit

consecutive asthma patients with or without allergic

rhinitis from their daily practice. Cross-sectional data on

symptoms, severity, treatment and impact on quality of

life of A and AR were recorded and examined using

descriptive statistics. Patients with and without AR

were then compared.

Results: 1244 asthma patients were included by 211

physicians. Asthma was controlled in 19%, partially

controlled in 27% and not controlled in 54%. Asthma

treatment was generally based on inhaled corticosteroids

(ICS) with or without long acting beta 2 agonists (78%).

A leukotriene receptor antagonist (LTRA) was used by 46%

of the patients. Overall, 950 (76%) asthma patients had

AR (Aþ AR) and 294 (24%) did not (A� AR). Compared to

patients with A� AR, Aþ AR patients were generally

younger (mean age� standard deviation: 42� 16

vs. 50� 19 years, p50.001) and fewer used ICS

(75% vs. 88%, p50.001). LTRA usage was similar in

both groups (46% vs. 48%). Asthma was uncontrolled

in 53% of Aþ AR and 57% of A� AR patients. Allergic

rhinitis was treated with a mean of 1.9 specific AR

medications: antihistamines (77%), nasal steroids

(66%) and/or vasoconstrictors (38%), and/or LTRA (42%).

Rhinorrhoea, nasal obstruction, or nasal itching were

the most frequently reported AR symptoms and the

greatest reported degree of impairment was in daily

activities/sports (55%).

Conclusions: Allergic rhinitis was more common among

younger asthma patients, increased the burden of symp-

toms and the need for additional medication but was

associated with improved asthma control. However, most

asthma patients remained suboptimally controlled regardl-

ess of concomitant AR.

Article 4815/382243 1073

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Introduction

Asthma is characterized by chronic inflammation of the

airways associated with airway hyper-responsiveness,

recurrent symptoms and exacerbations, and airflow

obstruction1. Allergic rhinitis (AR) and asthma (A)

are linked by a common pathogenic process involving

the same inflammatory cells, mediators, and cyto-

kines2–4. In addition, the upper and lower airways are

connected anatomically, physiologically, and immuno-

logically5. Epidemiology studies have provided strong

evidence for associated dysfunction in showing that

upper airway impairment with allergic rhinitis affects

the lower airways5. Therapeutic modalities (including

antihistamines, inhaled or nasal steroids, cromoglycate,

and leukotriene receptor antagonists) indicated for the

treatment of one portion of the airway are frequently

used for the other5. Finally, rhinitis is a risk factor for

the development of asthma that generally precedes its

onset6,7. Together, these facts support the concept of

one airway disease8,9.

The asthma management guidelines issued by the

Global Initiative for Asthma (GINA), known as

the ‘GINA Guidelines’, were revised in 2006 and the

primary goal of asthma treatment was redefined as

achieving optimum control (minimization of day and

night time symptoms, activity limitation, broncho-

constriction and short-acting bronchodilator use)1.

Recognizing the link between upper and lower airways

in allergic disease, the ARIA ‘Allergic Rhinitis and Its

Impact on Asthma’ working group (in collaboration

with the WHO in Geneva) have published a compre-

hensive review, have derived recommendations for the

diagnosis and assessment of disease severity and have

drawn up guidelines for the management of rhinitis and

asthma10,11. The new paradigm for treating allergic

rhinitis relies on the classification of allergic rhinitis as

either intermittent or persistent with gradations of

either ‘mild’ or ‘moderate–severe’11. GINA and ARIA

recommend that patients with asthma should be appro-

priately evaluated for rhinitis and that a combined strat-

egy should ideally be used to treat coexistent upper and

lower airway diseases in order to maximize control11.

However, physicians’ awareness of the association

between asthma and allergic rhinitis was shown to be

extremely low and undertreatment of AR to be fre-

quent12. The degree of asthma symptom control and

prescription patterns in Swiss patients with both

asthma and allergic rhinitis is currently not known.

The aim of the present survey was therefore to deter-

mine the characteristics of the association of asthma

(A) and allergic rhinitis (AR) in asthma patients, to

compare the levels of control in asthma patients with

(AþAR) and without allergic rhinitis (A�AR), and

to document the current prescription patterns for the

treatment of this ‘one airway disease’ in everyday out-

of-hospital patient care in Switzerland.

Patients and methods

Primary care physicians, pulmonologists and allergolo-

gists were asked to participate in the LARA (Link

Allergic Rhinitis in Asthma patients) cross-sectional

survey and to collect data on five consecutive asthma

patients over the age of 18 years attending for consulta-

tion between March and August 2007. The diagnoses of

asthma and allergic rhinitis relied on the physicians’

diagnostic records. Data were collected anonymously

within a single visit to the physician’s office. Only

data collected as part of physicians’ daily clinical prac-

tice for asthmatic patients with or without allergic rhi-

nitis were required. There was no follow-up visit.

Patients were informed of the anonymous data collec-

tion and all gave verbal consent for the use of their

records in the study.

Data were collected on single datasheets which

included the following items: patient demographics

(age, gender, smoking status); level of asthma control

defined as ‘controlled’, ‘partially controlled’, or ‘not

controlled’ based on the presence or absence of six

characteristics: daytime symptoms, limitation of activ-

ities, nocturnal symptoms/awakening, need for reliever

medication, lung function (peak expiratory flow or

FEV1 expressed as percentage of predicted) and the

presence of at least one exacerbation during the last

month, as recommended by the GINA Guidelines

20061 (Table 1).

Therapeutic classes of medication used for current

treatment of asthma were also recorded. These

included short-acting beta-agonists (SABA), inhaled

corticosteroids (ICS) not in a fixed combination,

long-acting beta-agonists (LABA) not in a fixed combi-

nation, fixed combination of ICS and LABA (FC),

leukotriene receptor antagonists (LTRA), and other.

The physicians were then asked to assess whether

their asthma patients had AR, either currently or at

some point in the past. In patients with AþAR, the

following additional data were collected: type of AR

(‘intermittent’ defined as �4 days/week or54 weeks/

year, or ‘persistent’ defined as 44 days/week and �4

weeks/year); therapeutic classes used for the treatment

of AR (antihistamines, nasal corticosteroids, nasal

anticongestives, nasal cromoglycate, LTRA, and

other); the current symptoms of AR (rhinorrhoea,

nasal obstruction, nasal itching and sneezing, conjunc-

tivitis, or none) and the level of severity of AR based on

the level of impairment (impairing or not impairing) of

1074 Allergic rhinitis in patients with asthma: Swiss LARA survey � 2009 Informa UK Ltd - Curr Med Res Opin 2009; 25(5)

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four characteristics (sleep, daily activities/sport/leisure,

work or school, and symptoms) as recommended by

the ARIA guidelines11 (Table 1).

The primary statistical analysis was descriptive.

Differences between groups were assessed using confi-

dence intervals and formally tested by the Student’s

t test for normally distributed data and Mann

Whitney U test for non-normally distributed data. An

exploratory multiple regression analysis was performed

to identify potential predictors of the level of asthma

control, correlations between AR symptoms and degree

of impairment and between AR symptoms and AR

treatments. The significance level was 5%. Statistical

analysis was performed using StatsDirect version

2.6.5 on a Windows Vista Professional operating

system. Missing values occurred at a frequency of less

than 10% and all data were handled on an intention to

treat basis, unless otherwise stated.

Results

Between March and August 2007, 211 general practi-

tioners, pulmonologists, and allergologists in private

practice included 1244 asthma patients in the survey

(range 1–15 patients over 3–4 weeks, mean 6.2 patients

per physician). Overall, the patients were 44� 17 years

old (mean � standard deviation), 46% were male and

27% were smokers. Asthma was controlled in 19%,

partially controlled in 27%, and not controlled in 54%

of patients. There were no differences between the

levels of control achieved by setting type (primary

care versus specialists). Whether specialists had more

severe asthma patients treated more intensively or simi-

lar patient populations to those in the primary care

setting could not be determined in this survey.

Therefore, data analysis was not stratified according

to this variable. Asthma treatment was based on ICS

with or without LABA in 78% of the patients. Fifty-

seven percent of patients were prescribed SABA and

46% were taking a LTRA. Of all included patients,

950 (76%) had AþAR and 294 (24%) had A�AR

(Table 2).

Patients with AþAR were significantly younger than

patients without AR (mean�SD, 42� 16 vs. 50� 19

years, p50.001), with no apparent difference in gender

and smoking status (46% male and 26% smokers vs.

47% male and 29% smokers for AþAR and A�AR

respectively). Asthma was overall better controlled

among AþAR patients: 47% (95% confidence interval

44 to 50%) of patients with AR had controlled or par-

tially controlled asthma compared to 43% (95%CI 37

to 49%) of patients with A�AR. Conversely, 53%

(95%CI 50 to 56%) of AþAR patients had poorly con-

trolled asthma compared with 57% (95%CI 51 to 63%)

of A�AR patients. The mean number of GINA char-

acteristics by patient did not differ significantly

(2.9�2.1 in AþAR patients compared to 3.0�2.2

among patients without AR). Better asthma control

was not linked to greater use of steroids or LTRAs. In

contrast, fewer patients with AþAR were using ster-

oids, either as ICS or FC: 75% (95%CI 72 to 78%)

Table 1. Level of asthma control (adapted from the GINA guidelines 20061) and degree of severity of allergic rhinitis

(adapted from ARIA guidelines 200711)

Asthma

Characteristics Controlled* Partially controlled** Not controlled

Daytime symptoms None (�2�/week) 42�/week 3 or more characteristics

Limitation of activities None Any of partially controlled asthma

Nocturnal symptoms/awakening None Any in any week

Need for reliever medication None (�2�/week) 42�/week

Lung function (PEF or FEV1) Normal 580% of predicted..... .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. .

Exacerbations None �1/year 1 in any week

Allergic rhinitis

Characteristic Mild* Moderate to severe**

Sleep Not impaired Impaired

Daily activities/sport/leisure Not impaired Impaired

Work or school Not impaired Impaired

Symptoms None or not troublesome Troublesome/impairing

*All of the following**One or more of these characteristics in any week

� 2009 Informa UK - Curr Med Res Opin 2009; 25(5) Allergic rhinitis in patients with asthma: Swiss LARA survey Taegtmeyer et al. 1075

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vs. 89% (95%CI 85 to 92%) of patients without AR

(p50.001). Of the 279 AþAR patients not receiving

any form of inhaled steroids, 162 (58%) were on nasal

steroids. LABA use, either alone or in combination

with steroid, was also less among patients with AR

than among patients without AR (73% (95%CI 70 to

76%) vs. 84% (95%CI 80 to 88%), respectively,

p50.001). The use of FC and LTRA were similar

among AþAR and A�AR patients. A further analysis

of steroid use did not show LTRA use to be different

among patients with and without steroids (Table 2).

As shown in Table 3, 62% of all asthma patients with

AR had intermittent and 35% persistent AR (no data

for 3%). They were treated with additional mean 1.9

medications (not including LTRA) to help control AR

symptoms, generally an oral or nasal antihistamine

(77%) and/or a nasal steroid (66%) and/or a nasal

vasoconstrictor (38%). Forty-two percent received a

LTRA of which 92% as a treatment prescribed to con-

trol AR. Rhinorrhoea, nasal obstruction, or nasal itch-

ing was reported by more than 50% of the patients,

while only 13% had no AR symptoms at the time of

consultation. On average, the patients had 1.8�1.5

prevalent characteristics of moderate to severe AR,

mainly limitation in daily activities/sports (55%) and

bothering symptoms (52%) (Table 3).

Comparing AþAR patients without topical steroids

(neither inhaled nor nasal, n¼ 127) with AþAR

patients receiving nasal steroids only (n¼ 152), patients

receiving nasal steroids had better controlled asthma:

mean number of asthma characteristics per patient

1.9� 1.8, median 1 vs. 2.5� 2.0, median 2.0

(p50.05). AþAR patients receiving both nasal and

inhaled steroids showed the poorest asthma control

Table 2. Comparison of asthma characteristics in patients with (AþAR) and without (A�AR) concomitant allergic rhinitis

AþAR 95%CIs A – AR 95%CIs

Number of subjects (% of total) 950 (76) 294 (24)

Age in years (mean� SD) 42� 16 41–43 50� 19 48–52*

Male gender (% of total) 434 (46) 138 (47)

Smoking (% of total) 249 (26) 85 (29)

Characteristics of asthma control (% of total)

Daytime symptoms 524 (55) 165 (56)

Limitation of activities 421 (44) 140 (48)

Nighttime symptoms/awakening 413 (44) 123 (42)

Use of reliever medication 445 (47) 132 (45)

Lung function (PEF or FEV580%) 343 (36) 33–39 136 (46) 40–52*

Exacerbations41�/yr 575 (61) 184 (63)

Level of asthma control

Controlled (0 characteristics) 177 (19) 61 (21)

Partially controlled (1–2 char.) 270 (28) 65 (22)

Not controlled (3–4 char.) 240 (25) 77 (26)

Not controlled (5–6 char.) 263 (28) 91 (31)

Controlled or partially controlled 447 (47) 126 (43)

Not controlled 503 (53) 168 (57)

Current treatment for asthma

SABA 543 (57) 165 (56)

ICS 155 (16) 14–19 77 (26) 21–32*

LABA 133 (14) 12–16 64 (22) 17–27*

FC 559 (59) 184 (62)

LTRA 436 (46) 140 (48)

Other 118 (12) 42 (14)

ICS alone or in combination 714 (75) 72–78 261 (89) 85–92*

No steroids 236 (25) 22–28 33 (11) 8–15*

LABA alone or in combination 692 (73) 70–76 248 (84) 80–88*

No LABA 258 (27) 24–30 46 (16) 12–20*

*Significant difference in confidence intervals (95%CIs)PEF: peak expiratory flow, FEV: forced expiratory volume, SABA: short acting beta agonist, ICS: inhaled corticosteroid, LABA: long actingbeta agonist, FC: fixed combination, LTRA: leukotriene receptor antagonist

1076 Allergic rhinitis in patients with asthma: Swiss LARA survey � 2009 Informa UK Ltd - Curr Med Res Opin 2009; 25(5)

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(mean characteristics 3.3� 2.1, median 3.5), even

when compared to A�AR patients receiving inhaled

steroids (mean characteristics 3.1� 2.1, median 3.0).

AþAR patients receiving inhaled steroids alone

(n¼ 195) had a mean of 2.9� 2.1 and a median of

three asthma characteristics but reduced AR severity

symptoms, with a mean number of severity character-

istics of 1.4� 1.5 median 1.0, compared to 1.8� 1.5,

median 2.0 among the 152 patients receiving intranasal

steroids alone. Of patients receiving inhaled corticos-

teroids only, 16% were free of AR symptoms at the

time of questioning, compared to 7% of patients receiv-

ing intranasal steroids alone, implying that while

inhaled steroids reduce AR severity, intranasal steroids

may reduce the frequency of AR flare ups.

The significant correlations between the AR symp-

toms and degree of severity and AR symptoms and AR

treatments are shown in Table 4. Of particular note are

the correlations between conjunctivitis and a negative

impact on quality of life measures (all p� 0.05) and

between the presence of conjunctivitis and the use of

oral antihistamines (R¼ 0.12, p¼0.001).

Discussion

The present survey reports the clinical characteristics of

the ‘one airway disease’ (the comorbid association of

asthma and allergic rhinitis) in asthmatic patients in

primary care practice in Switzerland. The data were

obtained from a large group of patients treated accord-

ing to the most up-to-date guidelines for the manage-

ment of these two conditions1,11.

According to GINA guidelines, ‘the goal of asthma

care is to achieve and maintain control’ of the clinical

manifestations of asthma for prolonged periods1. In this

survey, only one fifth of all asthma patients were ade-

quately controlled and more than half were uncon-

trolled. This observation is consistent with the earlier

Table 3. Characteristics of allergic rhinitis

Number Percentage

Type of AR

Intermittent 590 62

Persistent 332 35

Data unavailable 28 3

Current treatment of AR

Antihistamines (oral or nasal) 730 77

Nasal steroids 629 66

Nasal decongestants 358 38

Nasal cromones 38 4

LTRA 400 42

Other 55 6

Actual AR symptoms

Rhinorrhoea 611 64%

Nasal obstruction 566 60%

Nasal itching 555 58%

Conjunctivitis 416 44%

No symptoms 125 13%

1–2 symptoms 382 40%

3–4 symptoms 443 47%

Severity of AR

Sleep disorder 341 36%

Limitation in daily activities, sports 525 55%

Limitations at work/school 311 33%

Bothering symptoms 481 52%

No characteristics of severity 296 31%

1–2 characteristics of severity 312 33%

3–4 characteristics of severity 342 36%

Table 4. Exploratory correlation tables between AR symptoms and degree of severity and between AR symptoms and

treatments for AR

Rhinorrhoea Nasal obstruction Nasal itching Conjunctivitis

Degree of severity

Sleep disorder R¼ 0.07 (p¼ 0.041) R¼ 0.16 (p50.001) R¼ 0.06 (p¼ 0.05) R¼ 0.07 (p¼ 0.05)

Limitation in daily activities,

sport

n.s. n.s. R¼ 0.12 (p50.001) R¼ 0.11 (p50.001)

Limitations at work/school R¼ 0.07 (p¼ 0.041) R¼ 0.07 (p¼ 0.023) R¼ 0.06 (p¼ 0.05) R¼ 0.1 (p¼ 0.003)

Bothering symptoms R¼ 0.11 (p50.001) R¼ 0.07 (p¼ 0.041) n.s R¼ 0.07 (p¼ 0.05)

Treatment

Antihistamines R¼ 0.08 (p¼ 0.022) n.s. R¼ 0.08 (p¼ 0.023) R¼ 0.12 (p¼ 0.001)

Nasal steroids R¼ 0.1 (p¼ 0.006) n.s. R¼ 0.13 (p50.001) n.s.

Nasal decongestants n.s. R¼ 0.12 (p50.001) R¼ 0.08 (p¼ 0.031) n.s.

Nasal cromones n.s. n.s. n.s. n.s.

LTRA n.s. n.s. n.s. n.s.

Other n.s. n.s. n.s. n.s.

� 2009 Informa UK - Curr Med Res Opin 2009; 25(5) Allergic rhinitis in patients with asthma: Swiss LARA survey Taegtmeyer et al. 1077

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reported levels of asthma control achieved in private

practices in Switzerland13,14 and emphasizes the

urgent need for a broad scale implementation of routine

use of validated questionnaires such as the Asthma

Control Test (ACT) and others as recommended in

the GINA guidelines1. In addition to this standardized

approach aimed at determining the level of asthma con-

trol, the presence of potentially aggravating cofactors

such as allergic rhinitis11 or gastro-intestinal reflux dis-

ease should be systematically evaluated. The treatment

of concomitant allergic rhinitis in asthma patients was

previously shown to significantly reduce the risk of

emergency room treatment and hospitalization for

asthma15.

In our survey, 76% of the asthmatic patients pre-

sented with either current or previous AR, a finding

consistent with the previously reported prevalence of

AR in asthma patients of up to 90%16,17. Patients with

AþAR were generally younger than patients with

A�AR, also consistent with previously reported

data18. Using the most recent classification of asthma

by GINA1, more than half of the included patients had

uncontrolled asthma as found in a previously published

Swiss survey which used the Juniper Asthma Control

Questionnaire (ACQ)19,20. In this latter survey, asthma

control was insufficient in 58% of asthma patients13.

In the survey presented here, a greater proportion of

A�AR patients had uncontrolled asthma (57%) com-

pared with AþAR patients (53%) despite greater use

of inhaled steroids. Patients with AþAR receiving

intranasal steroids alone had the best asthma control.

The largest mean number of asthma characteristics per

patient was seen among AþAR patients receiving both

inhaled and intranasal steroids, a figure which exceeded

that seen among A�AR patients receiving inhaled

steroids.

The finding that asthma patients with comorbid

allergic rhinitis have superior asthma control (which

is not related to increased steroid or LTRA use) is not

consistent with previously reported findings according

to which asthma is more severe in patients with AR

than in those without17,18,21–23 (although our AþAR

patients receiving both inhaled and intranasal steroids

did have poorer asthma control than similar patients

without AR). There may be several reasons for this

discrepancy in findings. First, the use of intranasal ster-

oids among AþAR patients appears to treat asthma as

well as the allergic rhinitis resulting in superior control

(and provides further support of the ‘one airway dis-

ease’ theory). Second, the cross-sectional nature of this

survey may have a patient selection bias. Physicians

may have preferentially selected uncontrolled patients,

reasonably expected to visit their physician more often

than well controlled patients. Third, the present survey

used the classification of levels of asthma control as

proposed by the GINA guidelines 2006 and not one

of the recommended validated questionnaires, such as

the Asthma Control Questionnaire (ACQ), which may

make the comparison of results across studies diffi-

cult19,20. Fourth, this survey was limited to a single

visit, which prohibited the assessment of disease

dynamics, i.e. it was not possible to analyse whether

or not the worsening of A or AR leads to the worsening

of the other comorbidity. Fifth, patients with A�AR

were significantly older (on average 7.6 years) than

AþAR patients. This age difference could account

for a more pronounced effect of airway remodelling,

which may account for a decreased reversibility of

symptoms and therefore for an overall lower level of

asthma control24,25. Sixth, almost 50% of the patients

in both groups were treated with a LTRA compared to

only 7% in a previous survey assessing asthma control

among asthmatics treated by general practitioners in

Switzerland performed in 200513.

Cysteinyl leukotrienes are inflammatory mediators

found in bronchoalveolar and nasal lavage fluids as

well in natural disease as after allergen challenge26,27.

They promote smooth muscle contraction, increased

blood flow, mucus secretion, and oedema in the

airway mucosa28,29. Furthermore, cysteinyl leukotriene

receptor antagonists have been shown to improve

symptoms of asthma and allergic rhinitis in randomized

controlled trials30–32. However, earlier studies have

shown that asthma patients’ response to drug therapy

with the LTRA montelukast may be subject to inter-

individual variations33, highlighting the need for iden-

tification of the ‘right’ patient to optimize the

responder rate. Therefore, another hypothesis that

may explain the present findings could be that the

treating physicians identified the patients who

responded best to treatment with a LTRA and that

high treatment rate with a LTRA has blunted the dif-

ference between groups by improving the overall level

of asthma control.

Asthmatic patients with AR were taking on average

two drugs for AR in addition to those for asthma treat-

ment. Ninety-two percent of all patients treated for

asthma with a LTRA used it also for the treatment of

AR, which may represent a considerable lowering of

the overall drug burden for patients with AþAR.

The vast majority of patients (87%) had symptoms of

rhinitis and 69% had moderate to severe AR according

to the ARIA classification11, which represents a high

symptom burden, especially when taking into account

the asthma symptoms as well. These observations are

consistent with earlier findings showing that AR had a

considerable impact on general well-being and health-

related quality of life34.

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It has been suggested that AR patients may be cate-

gorized as ‘sneezers and runners’ or ‘blockers’, whereby

‘runners’ were shown to correlate with seasonal/inter-

mittent AR and ‘blockers’ with perennial/persistent

AR35. Interestingly, in the present survey, patients

with intermittent AR were significantly more often

treated with antihistamines and/or nasal steroids and

patients with persistent AR significantly more often

with nasal decongestants (data not shown). This obser-

vation is consistent with reports in earlier publications,

which suggest that antihistamines may not be effective

in relieving persistent AR symptoms35. Furthermore,

the use of oral antihistamines correlated positively

with the presence of conjunctivitis, whereby the use

of topical steroids or decongestants did not. This sug-

gests that treating physicians may preferentially use oral

drugs in the presence of additional systemic symptoms

and that their perception of ‘one disease’ extends to

ocular symptoms. As shown by the exploratory multi-

ple regression analyses, all AR symptoms (rhinorrhoea,

nasal obstruction, nasal itching, and conjunctivitis)

correlated well with the quality of life restrictions

qualifying the degree of severity of AR (sleep disorder,

limitation in daily or occupational activities, and both-

ersomeness of the symptoms) recommended by the

ARIA guidelines11. While keeping in mind that the

multiple regression analyses were of exploratory

nature and should be confirmed by a prospectively

designed primary endpoint study, these observations

may indicate that the ARIA classification may be

more appropriate for correct patient identification,

diagnostic accuracy and possibly subsequent treatment

optimization than the earlier classification of AR into

seasonal and perennial rhinitis.

Overall, 27% of the asthma patients included in the

survey were smokers compared to 30% in our earlier

survey on asthma control13. Smokers were more likely

to be males, to exhibit nighttime asthma symptoms,

and to be treated with ICS (data not shown) but not

more likely to have AR. Cigarette smoking was pre-

viously reported to increase the likelihood of nighttime

asthma symptoms36 and chronic rhinitis to be more

frequent among smokers than non smokers37.

By design, the present survey aimed to collect data

directly related to the level of control of asthma and

allergic rhinitis, if present. A detailed characterization

of seasonal and perennial allergen sensitivities, levels of

specific and total IgE antibodies, and results of skin

prick tests as well as their degree of correlation with

lung and nasal symptoms would be a subject of interest

for future research. Similarly, asthma control also

depends on non-drug measures, such as the availability

and quality of a written personal asthma action

plan, the identification and reduction of exposure to

risk factors, and asthma self-assessment and monitor-

ing. The relative contribution of these measures to drug

therapy for improved asthma control exceeded the

scope of this survey and remains an attractive research

area for future prospective studies. Furthermore, the

results from the exploratory multiple regression ana-

lyses suggest that although AR symptoms generally cor-

related with the degree of severity, only sleep disorder

and limitations at work/school correlated with all

symptoms. This raises the question whether AR sever-

ity could be adequately estimated by using these two

characteristics alone. In addition, nasal decongestants

were preferentially used in patients with nasal obstruc-

tion and nasal steroids in patients with rhinorrhoea.

Whether this approach is the most effective in improv-

ing AR control remains to be established prospectively.

Conclusion

Allergic rhinitis was seen more commonly among

younger asthma patients and increased the burden of

symptoms of the ‘one airway disease’. Asthma itself

was better controlled probably due to the effect of

appropriate responder identification and the use of

intranasal steroids. Most patients with asthma, with

or without allergic rhinitis, however, remain subopti-

mally controlled.

Acknowledgements

Declaration of interest: The survey was funded by

Merck Sharp and Dohme-Chibret AG, Switzerland,

manufacturers of the LTRA montelukast. We are

grateful to Dr Philippe Kress, Kressmed Glattbrugg

Switzerland, for his contribution to data analysis and

the writing of the manuscript. All authors listed have

contributed to its editing and approved the final version

for publication; none of the authors report other

potential conflicts of interest in relation to this study.

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CrossRef links are available in the online published version of this paper:

http://www.cmrojournal.com

Paper CMRO-4815_3, Accepted for publication: 12 February 2009

Published Online: 17 March 2009

doi:10.1185/03007990902820733

1080 Allergic rhinitis in patients with asthma: Swiss LARA survey � 2009 Informa UK Ltd - Curr Med Res Opin 2009; 25(5)

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