This explorative cross-sectional study focuses on relevant patient reported outcomes in view of medical treatment for AR. More specifically, patients' perceived knowledge, expectations, preferences, and fear for side effects of AR treatment were studied. Patient’s beliefs and attitudes are important drivers in health behaviour including medication nonadherence and poor persistence in chronically ill patient populations ([6, 7]). Also fear of side effects hinders patient’s engaging in prescribed treatment. So far, these factors have been underinvestigated in AR although we can infer from empirical evidence of other chronically ill patient groups that they influence patients’ motivation to start medical treatment and the impact of these factors on patients’ adherence and persistence to treatment. The latter factors are however considered to be of utmost importance in disease control ().
Our findings show that 22% of patients presenting with rhinitis at ourn outpatient visit report some knowledge on anti-allergic treatment. These data strengthen therefore clinicians’ perceptions that a substantial proportion of patients already have some knowledge on the treatment of the disease. The perceived level of knowledge was highest in those who were treated previously, in patients with the highest educational level and in females. However, the correctness of this knowledge always needs to be checked in patients, irrespective of educational level or gender, as their knowledge about anti-allergic treatment may not be perfect. Indeed, the knowledge on anti-allergic treatment is often incorrect in Europe, as demonstrated by a large-scale survey. Maurer et al. studied the problem of underdiagnosis and undertreatment of patients with AR in Europe (), demonstrating the presence of several false beliefs of patients on anti-allergic therapy like lack of availability of effective medical treatment and habit-forming effect of anti-allergic therapy.
It had been demonstrated before that patients with AR have a low level of satisfaction with their treatment for AR (). This is not a surprise in the light of the current data showing high expectations of anti-allergic treatment. A large portion of patients expected to be cured from their allergy, or to have suppression of their complaints. Interestingly, there seem to be subtle differences in gender when it comes to expectations of anti-allergic treatment. More men expected an actual cure for their disease, whereas women tended to more frequently expect a suppression of their symptoms. The lesson to be drawn from these observations is to clearly discuss with the patient the goal of treatment of AR, albeit symptom reduction by medical treatment or alteration of the immune system and hence cure by immunotherapy. Therefore, it seems important to address unrealistic expectations in patients by explaining the underlying etiology, mechanisms and aims of anti-allergic treatment.
Concerning the way of treatment for AR, a nasal spray was preferred above oral treatment, combination treatment and injection therapy (Figure 3A). Therefore, treating the affected organ in AR seemed for most patients the preferred medical approach in AR. The anti-allergic treatment as combined treatment, with step down to monotherapy at the time of symptom control, was preferred over monotherapy with eventual combination treatment at the time of insufficient symptom control with monotherapy. This patient preference might be influenced by the severity of the symptoms, previous treatment experience, and type of medical center. Being a tertiary referral center, the majority of patients included in this trial were at the most severe spectrum of allergic disease, i.e. moderate to severe persistent allergic rhinitis, explaining in part why most patients would chose a combination treatment rather than monotherapy.
In spite of the availability of novel corticosteroids with low bioavailability, high receptor specificity and selectivity, there still exists a strong prejudice against the use of corticosteroids amongst patients (). We illustrate here that 48% of our study population is concerned about adverse effects when using a nasal spray containing corticosteroids. The adverse events associated with nasal corticosteroid treatment ranged from habituation, to local damage to systemic adverse events. A similar fear for side effects was reported for oral treatment with antihistamines, but there appears to be more confidence since only 33% expressed their concern about the presence of fatigue as major side effect. Indeed, fatigue was a common adverse events in the first generation anti-histamines, but is no longer an issue in the newer second generation antihistamines. Taken together the large portion of patients fearing adverse events, medical doctors treating patients with AR should have a clear view on the potential adverse events of any of the prescribed drugs for AR and discuss with these with patients the unrealistic fear for adverse events. Concerning leukotriene receptor antagonists and immunotherapy, the patient does not seem to fear these options as much as the latter, without specification of adverse events. We estimate that the latter two treatment options are less well known amongst the general popultion, explaining the lack of fear of adverse events in most rhinitis patients.
As in every observational study, some methodological shortcomings are present. First, we only enrolled a highly selected group of patients consulting a tertiary care center for diagnosis and treatment. It remains unclear if knowledge and patient preferences would be similar in other healthcare settings, e.g. primary care. Moreover, about 42% of the study population had positive SPT results, revealing a higher percentage of allergic disease in the patients consulting the department of Otorhinolaryngology and Allergology than in the general population (), relfecting a referal bias. Given the fact that the SPT results were not disclosed to patients at the time of completion of the questionnaire and knowledge levels were not different between those patients with and without positive SPT results, we decided not to omit the information obtained in the patients with non-allergic rhinitis. For the sake of clarity, we have chosen to limit the questionnaire to the most relevant questions on anti-allergic treatment involving the most commonly prescribed medical approaches.
In spite of the shortcomings, the results of the present study have some important clinical implications. The ultimate goal of any medical treatment is to fully control symptoms and improve quality of life in affected patients. Involving patients in the decision process regarding their treatment may enhance their self-care commitment and hence increase therapeutic adherence and efficiency. In AR, up to 96% of physicians state that taking the patients’ opinion into account increases therapeutic adherence () and patients' satisfaction with treatment. However, clinical reality often learns that patients are ill-informed, and may have false expectations and prejudices about anti-allergic therapy. It remains to be determined if investment in better support for patient self management and incorporating the patients’ view on disease and treatment will indeed result in better adherence, persistence of treatment and improved patient satisfaction.