April 2021

The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD). Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient’s health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient’s quality of life.

The Manifesto concludes that patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.

Health disparities negatively impact groups with greater social or economic obstacles in health based on race, ethnicity, religion, socioeconomic status, gender, age, disability, sexual orientation, and/or geographic location. The American Academy of Allergy, Asthma, and Immunology participated in a Commission to End Health Disparities 10 years ago. This study describes health disparities in allergy/immunology in racial and ethnic underserved populations and how they address people with allergic rhinitis and other allergic conditions.

Certain racial and ethnic populations are frequently not included in guidelines of care for patients with allergic rhinitis. Racial minorities show less allergic rhinitis prevalence, probable due to variability in self-reporting the disease: a 2017 report revealed that 5% of black children and 5% of Hispanic children had allergic rhinitis, compared to 9% of white children.

It is known that allergic rhinitis significantly impacts the quality of life and morbidity in underserved populations, and allergic rhinitis control was associated with fewer school absences.

Studies have shown that low-income and minority groups are less likely to receive allergen immunotherapy and have highlighted that additional burdens faced by these minorities can contribute to fewer resources needed to adhere to AIT schedules.

In conclusion, adherence could be improved when medical resources are provided to increase specialty care access in underserved communities. Observational and interventional studies are important for allergic rhinitis diagnosis, management, and outcomes for these underserved populations. A multi-level approach should also be addressed, involving patients, health providers, local agencies, professional societies, and national governmental agencies.

Allergic rhinitis treatment options include allergen immunotherapy (AIT). There are different guidelines and national practice parameters or care pathways for AIT. However, the decision to prescribe AIT should be personalized and based on the importance of the allergens and the persistence of the symptoms, even when using appropriate medications.

The practice of medicine has been revolutionized by digital transformation, including mHealth and artificial intelligence, where the patient is placed at the health system’s center. There are different biomarkers associated with mHealth and clinical decision support systems. However, there are two conditions that should be considered before any mHealth tool is used: comply with privacy regulations and validation. Of the few tools available for allergic rhinitis, evidence-based development was found for four Apps: MASK-air, AllergyMonitor, Polle, and Air Rater.

This review focuses on patient stratification for AIT, symptom medication scores for follow-up, clinical trials, and the European Academy of Allergy and Clinical Immunology (EAACI).

Patient stratification is required to:

–           Identify the best candidates for intervention through complex care management

–           Reduce the time and resources needed to match a patient to a care management programme

–           Optimize costs.

Symptom medication scores are needed to assess the efficacy of AIT, especially in clinical trials and observational studies.

The EAACI task force was created to evaluate the state of the art and the future potential of technology in the field of allergic rhinitis. This task force evaluated the design, user engagement, content, potential of inducing behavioural change, credibility, and privacy policies of mHealth products.

In conclusion, mHealth technology is a potential tool to aid AIT’s decision-making, increase adherence, monitor efficacy and safety, and identify responders to the treatment. However, these tools may also have their inconveniences, namely if they are improperly used or are not validated.