Key points from the REG Allergy Working Group meeting held in Amsterdam in 2015.

1. DATE: FRIDAY SEPTEMBER 25TH
VENUE: Wyndham Apollo Hotel, Amsterdam
ROOM: Boardroom
TIME: 11:00AM-12.30PM
CHAIR: David Price, Professor of Primary Care Respiratory
Medicine, The University of Aberdeen, Aberdeen, UK
ALLERGY WORKING
GROUP UPDATE MEETING

2. Agenda

3. David Price, Professor of Primary Care Respiratory
Medicine, The University of Aberdeen, Aberdeen, UK
Reminder of Barcelona Meeting
Discussions

4. Research ideas discussed
Nasal Hyper-Responsiveness:
• Actions: Peter Hellings;
• Participating collaborators: Sinthia Bosnic Anticevich; Alvaro Cruz; Pete Smith
+ others
• Explore the role of NHR in uncontrolled allergic rhinitis.
• Studies to be run in specialist care; primary care; pharmacy settings.
Urticaria concept:
• Discussion Lead: Martin Church
• Characterise current prescribing behavior for urticaria
• Evaluate the real-life effectiveness of available (and prescribed) treatments.
Patient-centric outcomes
• Discussion Lead: Fulvio & Walter
• Introduce a patient-centered evaluation of effectiveness in AR management
o Ask the patient what they need/want from their treatment;
o Use a VAS to assess attainment of that outcome
Near-patient testing for IgE
• Evaluate the utility of continuous IgE monitoring & circulating IgE as biomarkers

5. Research actions proposed
Nasal Hyper-Responsiveness:
• UK primary care data collection: add ~5 questions to the Optimum Patient
Care clinical service questionnaire so that data can be collected on:
o Upper airway hyper responsiveness
o Lower airway hyper responsiveness
o Upper airway symptoms
o Lower airway symptoms
o Use of over-the-counter medications
o VAS to evaluate control.
• Australia pharmacy data collection:
o Similar questions to be (potentially) integrated into Australian pharmacy study (with
ethics at the time of the previous meeting)
Urticaria concept:
• Investigate number of patients with diagnosed urticaria in the OPC research
database to inform feasibility.

6. David Price: Professor of Primary Care Respiratory Medicine, The University of Aberdeen, UK
Dermot Ryan: Clinical Advisor to Optimum Patient Care; Honorary Fellow at the University of
Edinburgh, UK
Sinthia Bosnic-Anticevich: Associate Professor and Principal Research Fellow, School of Medical
Sciences, University of Sydney, Australia
Nasal & Bronchial Hyper-Reactivity
New Data Collection Opportunities

7. Current OPC Questionnaire Questions (I)

8. Current OPC Questionnaire Data
Do you have any of these symptoms:
itchy, runny, blocked nose or sneezing
when you don’t have a cold?
Do any of the following upset your
asthma? Tick all that apply.
6,817
24,396
No
Yes
31,213
11,623
15,771
Cigarette Smoking
Allergies
15,913Strenuous Activity
19,964Colds

9. New OPC Questions (I)
Nose Chest Nose Chest
Spring Time Cooking Scent
Summer Cigarette Smoke
Food Paint Scent
Pet Animals Perfume
Dust (house) Emotions
Grass Physical Stress
Trees Strong odors
Cold Air Temperature changes
Fog Humidity changes
Which of the following upsets your nose and/or chest…?
GREEN evidence for allergy.
ORANGE evidence for BHR.
RED evidence of NHR.
Any positive answer regard as evidence in a binary analyses yes/no
Are your nasal symptoms always present? Yes No
Combine
Nose &
Chest/
Separate?

10. New OPC Questionnaire? (II)
How often do you consume
fast food?
<1 a month 1-3 a month 1-2 x a week
3-4 x a week >5 x a week
How much fruit and/or soft
drinks do you consume?
<1 a month 1-3 a month 1-2 x a week
3-4 x a week >5 x a week
Allergy Questionnaire?
Evaluation of VAS scores for TNS and individual scores in AR during the last month (and/or during the
pollen season)

11. New OPC Questionnaire Questions (II)
• Data collection to begin Q1 2016
• Dietary questions:
o Need for an allergy questionnaire?
o Clinical reasoning for sending an allergy
questionnaire?
o Feasibility of implementation
• Possibility to integrate into Australian Pharmacy
Study…?

12. Australia Pharmacy Study
• Aim:
o To determine the current status of AR management in primary care.
o To determine the burden of AR on community pharmacy.
o To identify management practices.
o To identify facilitators and barriers to optimal AR management,
• Goal: To develop and pilot test a AR Clinical Management Pathway for community pharmacy based on the
needs of patients and ARIA 2015 (which will be subsequently tested and integrated into future Integrated
Care Pathways for AR.
• Patients/pharmacy customers:
o N=200
o People who either self-select a nasal-symptom related product or approach the pharmacist
• Data capture: People are asked about:
o About the symptoms they are trying to treat
– Including nasal symptoms in recognition that ≥33% of people receive a formal diagnosis for AR or hay fever.
Interested to evaluate degree of self-medication
o About the medication they have chosen
– Why they have chosen it
– What else they have tried in the past.
• Data collection by researcher rather than pharmacist as data collection is post interaction with the
pharmacist and do not want to influence user/patient behaviour.
• Status:
o Data collected for n=168 patients to date
o Completed 50 in depth interviews with patients.
o Interviews with pharmacists and GPs still to be completed.
o Psuedopatient visits to the pharmacy to validate our findings still to be carried out.

13. Group Discussion
Future Study Ideas

14. OPCRD Queries following Barcelona

15. Urticaria
Martin Church
• GPs describe urticaria as one of the most confusing and challenging
conditions they see.
• Little is known of how GPs currently manage urticarial, i.e. what drugs they
prescribe.
• 90% of anti-histamine sensitive patients can be cured by the use of
omalizumab, indicating the presence of an IgE-mediated component to the
condition
• To improve management of urticaria, there is a need to:
o Find out more about the condition (work is on-going at Martin’s centre in Berlin)
o Evaluate the real-life prescribing patterns and associated comparative effectiveness.
As there are many genes involved, it is a condition best investigated via real-life
studies
• Also of potential interests is exploring blood eosinophil count in patients with
urticaria.

16. Rhinitis Personal Treatment Outcomes
Fulvio Braido & Walter Canonica
• Pragmatic survey
o Age __________
o Sex : M F
o Ongoing treatment
– Oral antihistamine
– Nasal antihistamine
– Oral Antihistamine + Decongestant
– Nasal Decongestant
– Oral decongestant
– Nasal Antihistamine + Nasal Inhaled Steroid
– Nasal Inhaled Steroid
– Allergy specific immunotherapy
– Antileukotrienes

17. Survey Questions
• Which is the main aspect of your rhinitis, that you
need to be improved by the treatment?
• How much, the drugs that you are assuming for
rhinitis, allow you to reach this outcome?
• Rhinitis is characterized by sneezing, rhinorrhea,
nasal itching, nasal obstruction and itchy eyes.

18. Survey Questions
• Please indicate in the scale reported below, how
this symptoms is bothering you,
Sneezing
Rhinorrhea
Nasal Itching
Nasal Obstruction
Itchy Eyes

19. Survey Questions
• Questionnaires that should be filled in by
the patients:
o RCAT
o T5SS
o ………

20. Burden of Allergic Disease
Dermot Ryan
• Community pharmacy study
• Patients attending a community pharmacy for
OTC preparations for allergic rhinitis.
• Data collection via computer / iPad ± patient
incentive…?

21. Near patient testing for IgE
• Potential value of on-going IgE monitoring (via a “finger-
pricker”).
• Barcelona comment / discussion:
o There is a need to establish whether circulating IgE is a
biomarker – in urticaria and asthma there are data to suggest
that IgE level and treatment effectiveness are unconnected.
o The interaction of diet and IgE could be interesting to explore.
High blood sugar levels (binging & spikes in blood sugar) can
result in the predictive antibodies being glycated (the reason
that diabetics are prone to infections). It could be interesting
to look at diet scores in patients that exhibit IgE response
interesting.

22. Publication Ideas from Barcelona

23. Concept discussed
Closing the Era of Complex Assessment – moving towards
simplified AR assessment
• Concepts:
o Sharing information on available, simple assessment tools
o There are a range of very useful tools available, but not all clinicians are
aware of them
o Complex, 30-point questionnaires are of no practical utility in clinical
practice
o The Respiratory Allergy Prediction (RAP) is validated for daily use and is the
only tool validated for use in clinical practice
o There is a need for tool standardisation – some teams use 7-item scores for
allergic rhinitis, some use 5-item symptom scores
o “If you can’t fill in a questionnaire in a breath then it is too much.”
o While there is a need for tools to be validated there should be a move
towards use of validated short tools rather than validated long
questionnaires.