David Price - Progetto LIBRA

David Price
GPIAG Professor of Primary Care Respiratory Medicine, University of Aberdeen
Honorary Professor University of Adelaide
IPCRG Research sub-committee chair
Member of ARIA executive
Sessional General Practitioner Norfolk

Selling haggis
Catching fish
Making kilts
Making whisky

Aberdeen because of the “Silver Darling”

UK BTS 1997 –word rhinitis
not mentioned
BTS 2003:
assisting in making a diagnosis
of asthma
immunotherapy for rhinitis
sufferers might reduce rate of
onset of asthma
many patients with asthma
may have rhinitis
but no evidence that its
treatment improves asthma
outcomes
GINA 2002
treatment of rhinitis may
improve asthma outcomes

Rhinitis
Allergic
• Intermittent
• Persistent
Infectious
• Acute
• Chronic
Other
eg:
• Idiopathic
• Hormonal
• Drug-induced
• Differential diagnosis
– Polyps – Malignancy
– Septum – Bacterial/viral infections

Allergic 1,2* Non-Allergic 1
Pollen
House dust mite
Animal dander
Moulds
Grasses
Occupational
allergens
Infection eg: virus
Chemical irritants
Hormonal
Drug-induced
Emotional
Idiopathic
*
Allergic rhinitis symptoms may be further exacerbated by airborne pollutants 3,4
1. International Rhinitis Management Working Group. Allergy 1994; 49 (Suppl 19): 1-34.
2. Dykewicz et al. Ann Allergy Asthma Immunol 1998; 81: 478-518.
3. DoH Advisory Group on the Aspects of Air Pollution Episodes. London: HMSO 1995.
4. Ormstad et al. Clin Exp Allergy 1998; 28: 702-708.

Gendo, K. et. al. Ann Intern Med 2004;140:278-289

Gendo, K. et. al. Ann Intern Med 2004;140:278-289

If disease persistent or not responding as should
allergy testing is essential before considering
immunotherapy
SPTs and IgE testing little differential in terms of
likelihood of success

Asthma
(range 1.6–36.8%)
8.0%
Allergic
rhinitis
(range 1.4–39.7%)
3.4%
1.2%
1.3%
7.5%
1.3% 3.6%
Atopic dermatitis
(range 0.3–20.5%)
n=463,801 aged 13–14 years
ISAAC. Lancet 1998

ARIA Classification
Intermittent
. ≤ 4 days per week
. or ≤ 4 weeks
Persistent
. > 4 days per week
. and > 4 weeks
Mild
normal sleep
& no impairment of daily
activities, sport, leisure
& normal work and school
& no troublesome symptoms
Moderate‐severe
one or more items
. abnormal sleep
. impairment of daily activities,
sport, leisure
. abnormal work and school
. troublesome symptoms
in untreated patients

IPCRG rhinitis guidelines based on ARIA:
Unimpaired sleep
Ability to undertake normal daily activities, including
work and school attendance, without limitation or
impairment, and the ability to participate fully in
sport and leisure activities
No troublesome symptoms
No or minimal side‐effects of rhinitis treatment
Price D, Bond C, Bouchard J, Costa R, Keenan J, Levy M, Orru M, Ryan D, Walker S, Watson M. International Primary Care
Respiratory Group (IPCRG) Guidelines: Management of allergic rhinitis. Primary Care Respiratory Journal. 2006;15:58-70

Assessment: Royal College of
Physicians of London three questions
IN THE LAST WEEK / MONTH
“Have you had difficulty sleeping because of your asthma
symptoms (including cough)?”
“Have you had your usual asthma symptoms during the day
(cough, wheeze, chest tightness or breathlessness)?”
“Has your asthma interfered with your usual activities
(e.g. housework, work, school, etc)?”
Date / / /
YES
NO
Page 20
© Imperial College London
Outcomes and audit. Thorax 2003; 58 (Suppl I): i1-i92

Asthma Control Test (ACT)
1. In the past 4 weeks, how much of the time did your asthma keep you from
getting as much done at work, school or at home?
Score
2. During the past 4 weeks, how often have you had shortness
of breath?
3. During the past 4 weeks, how often did your asthma symptoms
(wheezing, coughing, shortness of breath, chest tightness or pain)
wake you up at night, or earlier than usual in the morning?
4. During the past 4 weeks, how often have you used your rescue
inhaler or nebulizer medication (such as salbutamol)?
5. How would you rate your asthma control during the past
4 weeks?
Copyright 2002, QualityMetric Incorporated.
Asthma Control Test Is a Trademark of QualityMetric Incorporated.
Patient Total Score

Sneezing
72%
Runny nose
66%
Intermittent allergic
rhinitis only
71%
Blocked nose
59%
Itchy nose
58%
Persistent allergic
rhinitis only
25%
Itchy/ red eyes
Watery eyes
39%
45%
Post nasal drip
33%
Both IAR and PAR
5%
Itchy palate
29%
Cough
26%
Headache
23%
Snoring as a result of symptoms
22%
Sinus pressure
21%
Waking up in the night as a result of
symptoms
19%
Sore throat
17%
Wheezing
15%
0% 40% 80%

Impact of symptoms
Q11. For each of the symptoms you’ve mentioned, please rank them in order of the
degree of impact they have on your ability to perform your daily tasks
Symptom
Frequency
% PCPs ranking this
symptom in the TOP third*
% PCPs ranking this
symptom in the BOTTOM
third*
Runny nose 66% 32% 19%
Increasing impact of symptoms
Blocked nose 59% 33% 14%
Itchy / red eyes 45% 22% 14%
Sneezing 72% 27% 26%
Watery eyes 39% 16% 13%
Cough 26% 13% 8%
Headache 23% 10% 7%
Sinus pressure 21% 9% 7%
Waking up in the night 19% 5% 10%
Sore throat 17% 6% 9%
Wheezing 15% 6% 5%
Itchy nose 58% 15% 28%
Post nasal drip 33% 9% 16%
Itchy palate 29% 6% 17%
Snoring 22% 4% 16%
Base: AR sufferers (n = 600)
* symptoms ranked in order of the degree of impact they have on PCP’s ability to perform daily tasks

Q14. During a week when you experience symptoms typical of your allergic rhinitis, how
many hours of work did you miss because of these symptoms?
100%
73%
Mean Scores
50%
Overall Mean : 1.6
hours lost
0%
18%
6%
2% 1% 1%
0 1 - 5 6 - 10 11 - 15 16 - 20 Over 20
Hours of work lost
27 % of PCPs reported that their AR symptoms caused them to miss time from work,
amounting to an average of six hours a week
Base: AR sufferers (n = 600)

Impact of seasonal allergic
rhinitis
Comparing adolescents’ exam
performance during ‘mock’
examinations (conducted in
winter) with formal exam in
summer :
current symptomatic hay fever
associated with 50% increase in
risk of dropping exam grade
between winter and summer.
For those taking hay fever
medications risk increased by
40%
And those taking sedating
medications risk increased by
70%
Walker S, et al. Hayfever has a significant detrimental impact on
national exam performance in UK teenagers: case control study.
Unpublished data presented at BSACI Annual meeting, 2006.

81% of asthma patients report rhinitis and even mild
disease associated with worse outcomes
Price D et. Al. GPIAG conference 2005

Thomas M, von Ziegenweidt J, Lee AJ, Price D. High-dose inhaled corticosteroids versus add-on long-acting beta -agonists in
asthma: An observational study. J Allergy Clin Immunol 2009;123:116-21
General Practice Research Database of “real‐life”
increasing ICS or adding a LABA
Inclusion criteria:
‐ Min 12 months data in both baseline and outcome periods
‐ GP diagnosis of asthma and no COPD receiving ICS
Success definition based on proxy of GINA control including SABA
and oral steroid use
Index event:
first change is +LABA or increase ICS
0
-12m +12m
Prescribed ICS
Baseline period
• confounding factor definition
Outcome period
• outcome comparison
• adjusted for baseline confounders
Dec 1990 – Jan 2004

Thomas M, von Ziegenweidt J, Lee AJ, Price D. High-dose inhaled corticosteroids versus add-on long-acting
beta -agonists in asthma: An observational study. J Allergy Clin Immunol 2009;123:116-21
Symptom based control better with adding a LABA
Increasing ICS worse than adding a LABA when composite of SABA use & oral steroids

Thomas M, von Ziegenweidt J, Lee AJ, Price D. High-dose inhaled corticosteroids versus add-on long-acting
beta -agonists in asthma: An observational study. J Allergy Clin Immunol 2009;123:116-21
Exacerbations reduced by increased antiinflammatory
therapy
Increasing ICS associated with lower rates of exacerbations

Overall Asthma Control
achieving
Current Control
reducing
Future Risk
defined by
defined by
Symptoms
Reliever use
Instability/
worsening
Exacerbations
Activity
Lung function
Lung function
loss
Medication
adverse effects
GINA 2006; NIH/NAEPP Expert Report No.3 2007; ATS/ERS Task Force on Asthma Severity & Control, ERJ 2008

‣Denudation of epithelial layer
‣Swelling of epithelium
‣Plasma exudation
‣Eosinophilia
Schlecht H, Schwenker G. Uber die Beziehungen der Eosinophilie zur Anaphylaxie. Ditsch Arch Klin Med 1912; 108:405-28

p

Presence of concomitant AR in
children with asthma studied
in regular clinical practice:
Increases annual number of
physician visit [4.4 vs 3.4,
p

Variable OR 95% CI p
Rhinitis
Compared to no rhinitis:
Significant rhinitis
4.21
3.35 –5.28

Asthma control assessed
Uncontrolled either current
symptoms or exacerbations
Well controlled
Continue / consider
step‐down
Incorrect
diagnosis
Poor
compliance
Poor
inhaler
technique
Rhinitis
Smoking
Inadequate
therapy /
incorrect
therapy
Other
phenotypes
Low necessity
High concerns
Mixed devices
Increased
inflammation
Produces
steroid
resistance
Higher risk
patient
Viral associated
wheeze
Side‐effects
Poor training
Not right for
that patient
Exercised induced
Concerns
Erosion
Need for
more therapy
Intrusiveness
Haughney J, Price D et al. Resp Med 2009

Symptom severity
Impact
On health status
Work / school
Co‐morbid conditions particularly asthma

Standard 1:
Identification of symptoms
Standard 2:
Collection of information to support
a clinical diagnosis
Standard 3:
Examining and testing to support
the clinical diagnosis
Standard 4:
Treating and managing the disease
n=188
No. GPs
26
43
0
1
% of total GPs
13.8
22.9
0
0.6
Ryan D, Grant-Casey J, Scadding G, Pereira S, Pinnock H, Sheikh A. Management of allergic rhinitis in UK
primary care: baseline audit. Prim Care Respir J. 2005 Aug;14(4):204-9

No. GPs (n=188)
0 50 100 150 200
Nasal itching
Sneezing
Runny nose
Blocked nose
History of allergies
General medical history
Recent symptoms
Post treatment
Eliminates LRTI
Eliminates skin symptoms
Eliminates pollen allergies
Examines nose
Skin prick testing
Allergy specific IgE
Symptom control
Allergen identified
Environment control
Treatment: antihistamines
Treatment: nasal steroids
Treatment: combination
Treatment: additional
Ryan D, Grant-Casey J, Scadding G, Pereira S, Pinnock H, Sheikh A. Management of allergic rhinitis in UK
primary care: baseline audit. Prim Care Respir J. 2005 Aug;14(4):204-9

So why is Norwich so wealthy?

www.asthmatrak.org
www.theipcrg.org

04-09 SGA/13042-08

Rhinitis frequently under‐diagnosed and
misdiagnosed in practice
Simple tools to support diagnosis
Rhinitis frequently poorly assessed
Tools to assess impact in clinical practice as opposed
to clinical trials not fully developed but rapid
development in this area
Need to ensure link to assessment of asthma as
rhinitis severity important predictor of future risk in
patients with asthma