Poor control common among patients with rhinitis

Key takeaways:

• 59.6% of patients reported suboptimal rhinitis control.
• 72.4% experienced daily symptoms, and 65.5% experienced perennial symptoms.
• 90.6% reported moderate to severe symptoms.

Most patients with rhinitis have suboptimal control of the disease, with errors in nasal spray use and poor adherence to intranasal glucocorticoid treatment, according to a study published in The Journal of Allergy and Clinical Immunology.

Improving the use of these medications may improve disease control, Sophie Scheire, MPharm, scientific employee, pharmaceutical care unit, Faculty of Pharmaceutical Sciences, Ghent University, and colleagues wrote.

The cross-sectional, observational study comprised 1,514 adults (mean age, 48.7 years; 62% women) with persistent rhinitis who bought rhinitis medication for themselves at 215 community pharmacies in Belgium between November 2016 and April 2017.

With a median symptom duration of 10 years (interquartile range [IQR], 16), 72.4% of the cohort had daily symptoms and 65.5% had perennial symptoms. Physicians diagnosed predominantly allergic rhinitis and/or rhinosinusitis in 78.3%.

Also, 90.6% had moderate to severe symptoms, 32.7% completely managed their symptoms themselves and 55% used just one drug to control their symptoms, with the rest of the cohort using up to six drugs.

The most common rhinitis symptoms were nasal congestion (59.6%), rhinorrhea (36.7%) and postnasal drip (32.4%). The mean Rhinitis Control Assessment Test (RCAT) score among the 1,506 patients who completed it was 20.2 (standard deviation, 4.25).

Defined as an RCAT score of 21 or less out of 30, suboptimal rhinitis control was exhibited by 59.6%. Similarly, 56.9% of patients who were not diagnosed with rhinosinusitis had suboptimal control.

Percentages of patients who were satisfied with their current level of symptom control included 60.2% of the overall cohort — 45.6% with suboptimal rhinitis control and 82.8% of those with optimal rhinitis control.

Nasal symptom severity in the previous week had a median VAS score of 56 mm (IQR, 46 mm). The VAS’s predictive performance in identifying suboptimal rhinitis control had an area under the receiver operating characteristic curve of 0.776 (95% CI, 0.752-0.8).

The researchers also said that 51.5 mm was the optimal threshold for the VAS, with 73.8% sensitivity and 69.3% specificity. With a 50 mm threshold, which the researchers called more practical, they found 78.1% sensitivity and 64% specificity.

The most frequently used rhinitis medications included intranasal glucocorticoids (55.6%), nasal decongestants (47.4%) and oral H1 antihistamines (21.7%), with 65.1% of nasal decongestant users reporting long-term use.

Also, 33.6% used saline solution, 2.6% reported current use of systemic steroids, 31.4% reported ever use of systemic corticosteroids and 11.7% reported ever use of allergen-specific immunotherapy.

Findings additionally included 10.9% of patients reporting at least one adverse event. By treatment, proportions of patients experiencing at least one adverse event included 15% of those using oral decongestants, 11.9% of those on oral H1 antihistamines, 10.3% of those on nasal decongestants and 5.7% of those on intranasal glucocorticoids.

Nasal decongestants and other nasal treatments mostly were associated with dry nose and other local adverse events, the researchers said, whereas oral H1 antihistamines and other oral treatments led to fatigue and other systemic adverse events.

Assessments of nasal spray technique among 1,274 patients who used it revealed 10.3% with perfect technique, including 9.4% of those with suboptimal control and 11.5% of those with adequate rhinitis control.

Among the patients who used inhaled glucocorticoids, 11.6% of those with suboptimal rhinitis control and 14.9% of those with adequate control had perfect technique.

The most common errors included pointing the spray toward the nasal septum (63.7%), not clearing the nostrils (49.4%), sniffing strongly while or immediately after administering (44%) and holding the head backward while administering (16.9%).

With a median VAS score of 4 mm (IQR, 12 mm), patients considered the nasal spray/drop technique to be easy, the researchers said. Also, 40.8% of the 1,404 patients who had ever used nasal spray or drops were never taught how to use them.

Among patients who were taught how to use nasal spray or drops, 56% had verbal instruction, and 44% had verbal instruction combined with a demonstration. Instructors included pharmacists (32%) and general practitioners (26.7%).

The median medication possession ratio (MPR) indicating adherence to inhaled glucocorticoid treatment for 281 patients, representing 33.4% of all those patients in the cohort who used these drugs, was 71.5% (IQR, 43.1%-107.4%).

The researchers classified 54.8% of patients who used inhaled glucocorticoids as under-adherent, with MPRs of 80% or less, and 18.5% as over-adherent or stockpiling, with MPRs higher than 120%.

Further, 44.9% of inhaled glucocorticoid users said that they did not adhere to treatment all the time because they did not have any symptoms (34.9%), they only use these drugs when they have severe symptoms (20.1%) or they were forgetful (27.5%).

Significant indicators of poorer rhinitis control based on lower RCAT scores included female sex, attainment of secondary education, self-reported nasal hyperactivity, active asthma, use of decongestants and use of nasal saline.

The researchers also noted an association between diagnosed but inactive or controlled asthma and increased RCAT scores.

Odds for suboptimal rhinitis control decreased with a history of nasal surgery (OR = 0.733; 95% CI, 0.569-0.944) and increased with use of oral H1 antihistamines (OR = 1.37; 95% CI, 1.031-1.821).

The approximately six out of 10 patients with suboptimal control of their rhinitis were high compared with earlier estimates, the researchers said, but aligned with previous estimates of uncontrolled asthma.

Noting the satisfaction with current level of symptom control reported by nearly half of the cohort, the researchers continued, along with reports of symptom severity and decision not to see a physician for a third of the cohort, patients appeared to tolerate symptoms that indicate poor control and may live with them instead of seeking treatment.

Based on these findings, the researchers said that it is important for providers to easily and accurately assess rhinitis control, optimize treatment selection, recognize and adequately treat comorbidities, and account for nasal spray technique and non-adherence.