1.Introduction
Allergic rhinitis, or allergic rhinitis, is a non-infectious inflammatory disease of the nasal mucosa mediated mainly by IgE after exposure to allergens, which is an allergic inflammatory disease caused by an imbalance between Thl and Th2 immune responses due to the action of environmental allergens on the atopic organism in vitro.
Allergic rhinitis has become a global disease of international concern with its high prevalence and increasing trend year by year in recent years. A preliminary study in a central urban population in China showed that the average self-reported prevalence of allergic rhinitis was about 11.1%, with significant variation between regions. According to the data published in the 2008 edition of ARIA, it is conservatively estimated that there are more than 500 million patients with AR worldwide. A telephone questionnaire survey in 11 central cities in mainland China showed that the average prevalence of AR was 11%, and in a study of children aged 3-6 years with a questionnaire combined with skin prick tests to confirm the diagnosis, the prevalence of AR also reached 11%.
Although the diagnostic criteria and treatment methods for allergic rhinitis have been continuously improved and gradually perfected, there are still various problems in the diagnosis and treatment process, making the diagnosis and treatment of allergic rhinitis still relatively arbitrary and failing to meet the standardized requirements.
2. Different diagnostic criteria and diagnostic accuracy of allergic rhinitis
The data given in some studies show that the proportion of diagnoses based on patient symptoms and signs only, without tests such as skin prick tests and serum-specific IgE tests, in the process of diagnosing AR is 61%, while the proportion of diagnoses based on comprehensive medical history and skin prick tests or serological tests is 35%, with large differences in data from various provinces and cities.
However, more than 60% of clinicians do not perform skin prick tests or in vitro serological tests when diagnosing AR, relying only on the patient’s subjective symptoms. These serious deficiencies in clinical care are also present in Western developed countries.
Therefore, in the process of AR diagnosis, it is necessary to adhere to the standard definition and examination methods to reduce the misdiagnosis rate.
3. Physicians’ knowledge of allergens in the region
The prevalence of AR varies in different regions, and the distribution of major allergens also differs. Some studies conducted allergen distribution surveys in different regions found that the differences between the positive rates of house dust mite, dust mite, pasture, dog epithelium, cat epithelium, and birch 6 allergens in different regions of the population were statistically significant. Other studies showed that due to the wide geographical area of China, the distribution of allergens also differed, with the highest positive rate for dust mite in the southwest and the lowest in northern China; the highest for cockroach in the southern coastal region and the lowest in northern China; the Pollen and fungi are the highest in northern China.
In the diagnostic process, if the physician does not know the allergens in the region, it is possible to make a detour in the diagnosis and increase the diagnostic cost. Therefore, it is important to conduct epidemiological surveys in different regions, and the distribution of allergens collected in each region can help improve the diagnosis of AR.
4. Diagnosis is not made according to the recommended classification and grading
Only seasonal and perennial classification methods are used in clinical practice, or only allergic rhinitis is diagnosed without classification, and rarely is the diagnosis graded according to medical history. In contrast, the WHO ARIA working group (2001) recommended a new classification based on the patient’s onset, duration and impact on the patient’s quality of life. Further, in ARIA 2008, AR is also no longer classified by perennial or seasonal, but more emphasis is placed on classification by degree and duration: it is classified according to its impact on quality of life as ” mild” and “moderate to severe”, and “intermittent” and “persistent” according to the duration of the disease within one year.
New classification and grading methods should be used for AR diagnosis and research, so that individualized treatment can be given to different patients for different conditions, thus making treatment more effective and reducing the side effects of drugs.
5. Judgment of allergen intradermal test and specific IgE antibody test results
At present, the diagnosis of allergic rhinitis is more often made by allergen intradermal test and specific IgE test. The diagnosis of allergy must be confirmed by the presence of clinical symptoms and a positive allergen test. A positive allergen test (skin test or serum test) only indicates that the patient may be allergic and may experience high concentrations of allergens and may develop allergic disease, but not necessarily disease now.
Allergen SPT (in vivo test) has a high positive predictive value (up to about 90%), is easy to perform, time-saving and rapid, and is the main method commonly used in clinical practice, but is susceptible to H1 antihistamines, antidepressants and skin characteristics as well as age. Serum-specific IgE test (in vitro test) commonly used ImmunoCAP system, the results are generally not affected by drugs, for those who can not interrupt drug therapy, patients with skin diseases or children who do not cooperate with the skin test is particularly suitable.
6.Health education for patients
The optimal treatment plan for allergic diseases recommended by WHO includes patient education, allergen avoidance, drug therapy and immunotherapy (desensitization), and emphasizes the “four-in-one” approach. The implementation of health education is “people-oriented”, with patients as the main service targets, so that patients can initially understand the pathogenesis of AR, the possible complications, the risks of AR to the general health and the resulting losses, as well as the instructions for medical treatment and self-care. Through health education, a harmonious doctor-patient relationship can be created, which can improve the patient’s compliance and subjective motivation and strengthen the close cooperation between doctors and patients.
In the current treatment of AR, health education for patients is often neglected, which will reduce the treatment effect and increase the treatment cost, and should be avoided as much as possible.
7. Pay attention to psychological status and quality of life
In addition to causing lesions in the nasal sinuses and adjacent organs, AR can also cause neuropsychiatric symptoms such as fatigue, decreased energy and poor perception. 10% of AR patients have poor mental health status and 13% are in a psychological subhealth state; AR patients differ from the norm in terms of somatization symptoms, obsessive-compulsive symptoms, anxiety, hostility and psychotic performance.
Allergic diseases also put a tremendous strain on mental health. Due to the lack of specific eradication of allergic diseases, allergic diseases affect the quality of life of patients and plague their mental life, sleep quality and daily communication. A vicious circle is formed between allergic diseases and psychological problems.
Psychological interventions are an effective means of treating allergic diseases with psychological disorders. Effective psychological interventions to help patients establish a positive attitude toward treatment will improve the outcome of treatment.
8. Relationship with asthma
ARIA 2008 guidelines put forward the concept of “one airway, one disease”, pointing out that because the upper and lower airways are closely connected anatomically, the inflammatory response is rarely confined to one site, and various studies have confirmed the consistency of the inflammatory response in the upper and lower airways.
Epidemiological surveys have found that approximately 20-50% of patients with allergic rhinitis have concurrent asthma, and more than 80% of asthma patients have chronic nasal symptoms. Allergic rhinitis is an independent risk factor for asthma, and children with a history of allergic rhinitis are 2-7 times more likely to develop persistent wheezing than normal children. The risk of asthma in adult patients with perennial allergic rhinitis and non-allergic rhinitis is 8 and 12 times higher than normal, respectively.
In view of the holistic approach to the respiratory tract, there is a need to further optimize treatment protocols based on established treatment strategies for AR and asthma in order to improve clinical efficacy and safety. The current treatment plan often separates AR and asthma, which should be taken seriously and needs to be improved urgently.
9. Misunderstanding of surgical treatment
What needs to be clarified in AR treatment is that surgery itself cannot treat allergies. However, many patients are suffering from the impact of allergic rhinitis on their lives and hope to cure it through surgery, and many hospitals have expanded the indications for surgery out of profit considerations, thus making patients suffer unnecessary injuries.
In the course of AR treatment, the indications for surgery should be strictly adhered to: inferior turbinate hypertrophy, nasal anatomical abnormalities affecting the function of the nasal cavity, secondary sinusitis and allergic fungal sinusitis that have not been treated with medication. In the absence of indications, surgical treatment should not be performed.
10.Rationalization of drug use
Antihistamines and local glucocorticoids are the first-line clinical medications for allergic rhinitis, and both types of medications are effective for the symptoms of allergic rhinitis. How they are used, however, varies greatly. It is not reasonable to use medications when there are symptoms and stop them when they are reduced.
In general, the following factors need to be considered in drug therapy: degree of disease, presence of comorbidities, purpose of treatment (symptom control and anti-inflammation), efficacy, safety, cost effectiveness of the drug, and patient compliance. It should be noted that the efficacy of the same drug may vary from patient to patient, and the efficacy of a drug may diminish after long-term use and not continue after discontinuation of the drug. Therefore, it is necessary to adjust the medication and maintenance treatment at the right time.
11.Patients’ resistance to corticosteroids
The use of hormones plays an important role in the treatment of allergic rhinitis, but the lack of understanding of hormones makes many people very resistant to hormones in the treatment process, especially the parents of children with allergic rhinitis because of the fear of hormones affecting growth, and young women worried about hormones causing obesity, so that the treatment can not be carried out smoothly. This requires a detailed explanation from the clinician.
For the current nasal corticosteroids, there is no significant difference in clinical efficacy of different products, and the safety of all of them at regular doses is fully guaranteed. In contrast, for special cases such as younger children, pregnant women, and patients on combination drugs, more reference to relevant pharmacological indices may be needed to select the theoretically optimal drug.
12.Immunotherapy
Specific immunotherapy (SIT) is the only treatment modality that can change the natural course of allergic diseases through immunomodulatory mechanisms. Compared with drug therapy, immunotherapy can significantly reduce the severity of allergic rhinitis, reduce the use of anti-allergic drugs, and improve the quality of life of patients. further aggravation of the disease and prevent the creation of new allergens. Immunotherapy in children can prevent the development of new allergic reactions and reduce the likelihood of allergic rhinitis developing into asthma.
The WHO opinion states that SIT is indicated when drug therapy is ineffective or intolerable, while the ARIA guidelines suggest that SIT can be used as a complementary measure to avoid allergens, preferably in the early stages of the disease, to reduce the risk of side effects and prevent further progression to severe disease. In other words, SIT should not be used as a definitive treatment for AR.
Overall, immunotherapy is indicated for seasonal allergic rhinitis caused by pollen (grasses, trees, weeds), perennial allergic rhinitis caused by mites, etc., and for patients who have failed to respond to conventional drug therapy (antihistamines and glucocorticoids).
13.Randomness of treatment
One study showed that 36% of patients had purchased over-the-counter medications for treatment, while 49% of patients who had previously self-diagnosed upper respiratory tract infections took medications and 38% of patients who had taken antibiotics.
The above results indicate that patients currently have a high degree of discretion in the treatment of AR, which poses a great obstacle to the treatment process of AR. The publicity and education for AR patients should be strengthened to reduce the arbitrariness of treatment.
14.Traditional medicine
Some herbal ingredients and formulas may have therapeutic effects on AR, asthma or food allergies. Traditional Chinese medicine from the motherland may play an important supporting role for complex diseases like AR, and in the process of internationalization of Chinese medicine, otorhinolaryngology-head and neck surgery and Chinese medicine need to have a closer integration in order to fully integrate our valuable medical cultural heritage in the diagnosis and treatment of rhinological diseases represented by AR. We will continue to study the role of traditional medicine in the treatment of AR.
Continued in-depth research on the application of traditional medicine in the treatment of AR is a direction worth investing in.
15.Consideration on the treatment of allergic rhinitis in children
The increase in the number of patients with allergic rhinitis in children and the increase in the prevalence of bronchial asthma in children with allergic rhinitis require us to improve the accuracy of diagnosis and the effectiveness of treatment for pediatric patients. Especially today, when topical hormones are the preferred treatment for allergic rhinitis, the safety of medication for children is a subject that deserves careful consideration by every doctor.
16. Conclusion and outlook
During the diagnosis and treatment of AR, there are many problems that bring obstacles to the diagnosis and treatment. Some of these problems are the patients’ own and some need to be improved during the treatment process, and the causes of these problems should be analyzed and solutions should be found.
There may be some new factors such as global warming, air pollution, indoor environment and lifestyle changes, exposure to new allergens and psychological stress, etc. AR exacerbation may be related to the above factors. In the face of such challenges, treatment strategies must be adjusted. First, sensitivity testing should be performed on a wider range of allergens, including traditional and new allergens, especially for patients with late onset and new diagnoses, in order to optimize individualized treatment. Secondly, newer antihistamines or nasal corticosteroids with high efficiency and better safety profile are preferred for pharmacological treatment. In order to achieve maximum effect, medication should be started once diagnosed and, if necessary, continuously, with emphasis on the treatment of allergic co-morbidities.