Gabriel Ortiz, PA

Introduction

Allergic rhinitis (AR) is a growing challenge for primary care because most AR patients consult primary health care providers (HCPs) who generally make the diagnosis, initiate treatment, give the relevant information, and monitor the condition.1 It is already a very common disease, affecting up to 40% of the population in young adults, and its prevalence is ever increasing.2,3 The effective management of AR involves allergen avoidance, pharmacotherapy, immunotherapy, or a combination of these methods.4 Options for pharmacotherapy include intranasal corticosteroids, oral and intranasal antihistamines, intranasal chromones, oral and intranasal decongestants, oral and intranasal anticholinergic agents, and antileukotrienes. Of these choices, the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines state, "intranasal glucocorticosteroids are recommended for the treatment of allergic rhinitis in adults and children. They are the most effective drugs for the treatment of allergic rhinitis."4 Although effective treatments have been available for many years, numerous studies show that the care offered to patients is often suboptimal, with significant problems of patient nonadherence to medication.5 Considering that AR is usually a long-term condition and that patient adherence to prophylactic therapy directly impacts long-term symptom control, it is vital that all efforts are made to improve medication adherence.

Medication nonadherence is a complex issue with many contributing factors.6 Reasons for nonadherence in patients with chronic illnesses include patient self-efficacy, social support, disease knowledge, costs, and side effects. In addition, it has been shown that physicians contribute to patients' poor adherence by prescribing complex regimens, failing to explain the benefits and side effects of a medication adequately, not giving consideration to the patient's lifestyle or the cost of the medications, and having poor therapeutic relationships with their patients.6 In many areas of medicine, there is often a significant mismatch between the way a patient and physician view the illness in question.7-10 It is therefore important that physicians treating AR understand the patient perspective and take this into account when planning long-term management of the patient's symptoms. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine patients' perspectives (N = 400) on their experiences with AR and its management, focusing in particular on the attributes of nasal allergy medications that contribute to patient satisfaction with therapy. To promote a better understanding of how the patient perspective matches the HCP perspective, data from the HCP survey (N = 250) are also included. The sample of HCPs included a national sample of 200 physicians in direct patient care in outpatient settings in the United States, including 100 in adult primary care specialties (family medicine and internal medicine), 100 specialists (allergy and otolaryngology), and 50 nurse practitioners (NPs) and physician assistants (PAs). Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy Survey Assessing Limitations

Allergy Triggers

Nasal allergy symptoms may be triggered by allergens, and different allergens may affect individuals in different ways. Hence, the first question asked of this national sample of adult nasal allergy sufferers was what things usually trigger or make their nasal allergy symptoms worse. Adults with nasal allergies most commonly volunteered pollen (63%) as the usual trigger or thing that worsens their symptoms; other common triggers were dust (34%); grass (32%); changes in weather (20%); animals (18%); mold (10%); perfume (7%); fumes or odors (6%); chemicals (6%); and tobacco smoke (4%) (FIGURE 1A). The survey further showed that these triggers often have a large effect on the severity of nasal allergy symptoms. More than half of adults with nasal allergies (54%) reported that these triggers made their allergy symptoms a lot worse, 32% reported that these triggers made their allergy symptoms moderately worse, and just 13% reported that the triggers made their symptoms only a little worse or not worse at all (FIGURE 1B).

FIGURE 1

(A) Nasal allergy triggers and (B) effect on nasal allergy symptoms

Respondents were asked: (A) What things usually trigger or make your nasal allergy symptoms worse? (B) Do these triggers usually make your allergy symptoms a lot worse, moderately worse, or only a little worse than normal?

Base: All respondents, unweighted, N = 400.

Preferred Classes of Medications for Nasal Allergy Symptoms

Results of the HCP survey clearly showed that prescription intranasal steroid sprays or inhaled corticosteroids are the preferred choice of most HCPs (all HCPs, 67%: allergists, 94%; otolaryngologists, 68%; primary care physicians [PCPs], 67%; NP/PAs, 40%) for adults with moderate to severe persistent allergy symptoms. This preference was supported by the fact that virtually all HCPs said that they believe the benefits probably or definitely outweigh the drawbacks of intranasal steroid sprays for the management of nasal allergies. Only a very small proportion of PCPs (4%) and NP/PAs (6%) said that the drawbacks probably or definitely outweigh the benefits in the management of nasal allergies.

By contrast, although the vast majority of patients (83%) reported taking some type of medication for their nasal allergies in the past 4 weeks, only 30% reported using an intranasal steroid spray. Instead, 62% of patients reported using over-the-counter (OTC), nonprescription medicine, 25% reported using some other type of prescription medication, and 17% reported that they took none of these types of medication (FIGURE 2).

FIGURE 2

Medications used by the patient in the preceding 4 weeks

Patients were asked: (A) In the past 4 weeks have you used any over-the-counter, nonprescription medicine to relieve your nasal allergy symptoms? (B) In the past 4 weeks have you used any intranasal steroid spray for your nasal allergy symptoms? (C) Have you taken any (other) prescription medications for your nasal allergies in the past 4 weeks?

Base: All respondents, unweighted, N = 400.

Perceived Control of Nasal Allergies

Although the majority of allergy sufferers reported being at least somewhat bothered by nasal congestion and sneezing in the past week, most patients (53%) described their allergies as completely controlled or well controlled in the past week. On the other hand, 36% of respondents said that their allergies were somewhat controlled in the last week, and 11% described their allergies in the last week as poorly controlled or not controlled at all (FIGURE 3A).

In contrast to the patients' report, HCPs were generally less positive about how well controlled their patients' nasal allergies were. Almost one-third of HCPs (all HCPs, 28%: allergists, 34%; otolaryngologists, 26%; PCPs, 25%; NP/PAs, 30%) felt that all or most of their patients with nasal allergies would be classified as completely controlled or well controlled in May or June. Most HCPs (all HCPs, 53%: allergists, 44%; otolaryngologists, 62%; PCPs, 53%; NP/PAs, 56%) felt that some of their patients with nasal allergies would be classified as completely controlled or well controlled in May or June. Surprisingly, a small number of HCPs (all HCPs, 17%: allergists, 22%; otolaryngologists, 12%; PCPs, 19%; NP/ PAs, 12%) felt that few or none of their patients have completely controlled or well-controlled allergies in May or June (FIGURE 3B).

FIGURE 3

Perceived control of nasal allergies symptoms: (A) patient perspective and (B) health care provider perspective

(A) Patients were asked: Overall, how well would you say that your nasal allergies have been controlled in the last week? Would you say they were completely controlled, well controlled, somewhat controlled, poorly controlled, or not controlled at all?

Base: All respondents, unweighted, N = 400.

(B) Health care providers were asked: What proportion of your patients with nasal allergies would you classify as having completely controlled or well-controlled allergies in May or June? All (91%-100%), most (51%-90%), some (11%-50%), few (1%-10%), or none (0%)?

Base: All respondents, N = 250.

Patient Perceptions of Intranasal Steroid Sprays

There appeared to be many reasons why the physicians' preferred choice of AR medication was not always used in practice. First, 37% of AR patients reported that they were not too familiar, not at all familiar, or did not know how familiar they were with intranasal steroid sprays for nasal allergies. Of the 63% of AR patients who reported at least some familiarity with intranasal steroid sprays, nearly half (49%) said that they had heard intranasal steroid sprays relieved symptoms and 10% thought that intranasal steroid sprays reduced nasal swelling (FIGURE 4A). Patients who had some familiarity with intranasal steroid sprays were also asked what, if anything, bad they had heard for these drugs. The most commonly volunteered concerns were: they lead to nasal damage (15%), they were addictive (13%), there were side effects (12%), they contain steroids (8%), they are not effective (5%), and they cause headaches (4%) (FIGURE 4B). Further questioning revealed that the majority (64%) of these patients with nasal allergies said that, based on what they knew or had heard, the benefits of steroid nasal sprays definitely or probably outweighed the drawbacks, whereas 18% said that drawbacks of intranasal steroid sprays probably or definitely outweighed the benefits, and 18% were not sure.

FIGURE 4

Patient perceptions of nasal steroid medications: (A) good things they have heard or (B) bad things they have heard

Patients who were familiar with intranasal steroid sprays were asked:
(A) What good things, if any, have you heard about these drugs?
(B) What bad things, if any, have you heard about these drugs?

Base: Familiar with intranasal steroid sprays, unweighted, n = 288.

Patients who had used a prescription intranasal steroid spray for their nasal allergies in the past, but not in the past 4 weeks, were asked why they had not recently used their intranasal steroid spray. Most commonly, past users of prescription nasal sprays said that they had no symptoms (20%) or the symptoms were not bad enough (17%). Other reasons for not using within the past 4 weeks included lack of effectiveness (12%), side effects (9%), poor tolerability (2%), and concerns about dependence (2%). A similar proportion of past users said they had not used prescription nasal sprays in the past 4 weeks because they did not like sprays (8%) or the delivery mechanism (5%). Finally 8% of AR patients reported that they had not used prescription nasal sprays in the past 4 weeks because of barriers to care (no insurance coverage, 3%; cost or co-pay too expensive, 3%; no access to a provider, 2%) (FIGURE 5).

FIGURE 5

Patient reasons for not using nasal steroids in the past 4 weeks

Patients who no longer use an intranasal steroid spray were asked:
Why haven't you used a prescription intranasal steroid spray for your nasal allergies in the past 4 weeks?

Base: No longer use an intranasal steroid spray, unweighted, n = 158.

The survey showed that patient satisfaction with prescription intranasal steroid sprays varies with their experience with side effects. The majority of patients (72%) who have ever used prescription intranasal steroid sprays for their allergies said that, in general, they had been somewhat satisfied or very satisfied with their prescription steroid nasal spray, whereas 19% reported they were somewhat dissatisfied or very dissatisfied. There was a statistically significant difference in satisfaction between those who feel the medication drip down the throat sometimes or more often (81%) and those who rarely or never did (96%) (P < 0.05, FIGURE 6A) and an even more dramatic and statistically significant difference in the satisfaction with their intranasal steroid sprays between those who felt any discomfort from these sprays at least sometimes (66%) and those who rarely or never felt discomfort from the sprays (92%) (P < 0.05, FIGURE 6B).

FIGURE 6

Patient satisfaction with intranasal steroid sprays, based on frequency of side-effect experiences: (A) feeling the medication drip down the throat and (B) feeling discomfort from the spray

Patients who had used intranasal steroid spray within the past year were asked: When you use your intranasal steroid spray, how often do you (A) feel the medication drip down the throat or (B) feel any discomfort from the spray: always, most of the time, sometimes, rarely, or never? Patients were also asked: In general, how satisfied were you with the prescription intranasal steroid spray you used for your nasal allergies in the past?

Base: Used intranasal steroid spray in the past year, unweighted, n = 171;
*Pearson chi-square, P = 0.05.

Reasons for Using a Particular Intranasal Steroid Spray

Nearly 1 in 10 patients who have used intranasal steroid sprays (8%) said that they had asked their HCP to prescribe a particular intranasal steroid spray (FIGURE 7A). Of these, 40% said they wanted it because they believed it was more effective, 25% said that they did so because of previous experience with that product, 11% said that the product requested was easier to administer, and 11% said that the product they requested had less smell. Only 4% of those who requested a specific intranasal steroid spray said that they did so because it was covered by their insurance or because of an advertisement.

On the other side of the table, HCPs were asked how often their patients asked them to prescribe a particular intranasal steroid spray. A number of allergists and otolaryngologists reported that they were asked to prescribe a particular intranasal spray at least daily (14% and 18%, respectively), a few days a week (20% and 14%), or at least once a week (16% and 18%). Substantially fewer PCPs (6%) and NP/PAs (6%) reported requests for specific intranasal steroid sprays on a daily basis. But nearly 2 in 5 PCPs (39%) and NP/PAs (38%) said that patients asked them to prescribe a particular intranasal spray at least once a week (FIGURE 7B).

FIGURE 7

Introduction

Allergic rhinitis (AR) is a growing challenge for primary care because most AR patients consult primary health care providers (HCPs) who generally make the diagnosis, initiate treatment, give the relevant information, and monitor the condition.1 It is already a very common disease, affecting up to 40% of the population in young adults, and its prevalence is ever increasing.2,3 The effective management of AR involves allergen avoidance, pharmacotherapy, immunotherapy, or a combination of these methods.4 Options for pharmacotherapy include intranasal corticosteroids, oral and intranasal antihistamines, intranasal chromones, oral and intranasal decongestants, oral and intranasal anticholinergic agents, and antileukotrienes. Of these choices, the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines state, "intranasal glucocorticosteroids are recommended for the treatment of allergic rhinitis in adults and children. They are the most effective drugs for the treatment of allergic rhinitis."4 Although effective treatments have been available for many years, numerous studies show that the care offered to patients is often suboptimal, with significant problems of patient nonadherence to medication.5 Considering that AR is usually a long-term condition and that patient adherence to prophylactic therapy directly impacts long-term symptom control, it is vital that all efforts are made to improve medication adherence.

Medication nonadherence is a complex issue with many contributing factors.6 Reasons for nonadherence in patients with chronic illnesses include patient self-efficacy, social support, disease knowledge, costs, and side effects. In addition, it has been shown that physicians contribute to patients' poor adherence by prescribing complex regimens, failing to explain the benefits and side effects of a medication adequately, not giving consideration to the patient's lifestyle or the cost of the medications, and having poor therapeutic relationships with their patients.6 In many areas of medicine, there is often a significant mismatch between the way a patient and physician view the illness in question.7-10 It is therefore important that physicians treating AR understand the patient perspective and take this into account when planning long-term management of the patient's symptoms. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine patients' perspectives (N = 400) on their experiences with AR and its management, focusing in particular on the attributes of nasal allergy medications that contribute to patient satisfaction with therapy. To promote a better understanding of how the patient perspective matches the HCP perspective, data from the HCP survey (N = 250) are also included. The sample of HCPs included a national sample of 200 physicians in direct patient care in outpatient settings in the United States, including 100 in adult primary care specialties (family medicine and internal medicine), 100 specialists (allergy and otolaryngology), and 50 nurse practitioners (NPs) and physician assistants (PAs). Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy Survey Assessing Limitations

Allergy Triggers

Nasal allergy symptoms may be triggered by allergens, and different allergens may affect individuals in different ways. Hence, the first question asked of this national sample of adult nasal allergy sufferers was what things usually trigger or make their nasal allergy symptoms worse. Adults with nasal allergies most commonly volunteered pollen (63%) as the usual trigger or thing that worsens their symptoms; other common triggers were dust (34%); grass (32%); changes in weather (20%); animals (18%); mold (10%); perfume (7%); fumes or odors (6%); chemicals (6%); and tobacco smoke (4%) (FIGURE 1A). The survey further showed that these triggers often have a large effect on the severity of nasal allergy symptoms. More than half of adults with nasal allergies (54%) reported that these triggers made their allergy symptoms a lot worse, 32% reported that these triggers made their allergy symptoms moderately worse, and just 13% reported that the triggers made their symptoms only a little worse or not worse at all (FIGURE 1B).

FIGURE 1

(A) Nasal allergy triggers and (B) effect on nasal allergy symptoms

Respondents were asked: (A) What things usually trigger or make your nasal allergy symptoms worse? (B) Do these triggers usually make your allergy symptoms a lot worse, moderately worse, or only a little worse than normal?

Base: All respondents, unweighted, N = 400.

Preferred Classes of Medications for Nasal Allergy Symptoms

Results of the HCP survey clearly showed that prescription intranasal steroid sprays or inhaled corticosteroids are the preferred choice of most HCPs (all HCPs, 67%: allergists, 94%; otolaryngologists, 68%; primary care physicians [PCPs], 67%; NP/PAs, 40%) for adults with moderate to severe persistent allergy symptoms. This preference was supported by the fact that virtually all HCPs said that they believe the benefits probably or definitely outweigh the drawbacks of intranasal steroid sprays for the management of nasal allergies. Only a very small proportion of PCPs (4%) and NP/PAs (6%) said that the drawbacks probably or definitely outweigh the benefits in the management of nasal allergies.

By contrast, although the vast majority of patients (83%) reported taking some type of medication for their nasal allergies in the past 4 weeks, only 30% reported using an intranasal steroid spray. Instead, 62% of patients reported using over-the-counter (OTC), nonprescription medicine, 25% reported using some other type of prescription medication, and 17% reported that they took none of these types of medication (FIGURE 2).

FIGURE 2

Medications used by the patient in the preceding 4 weeks

Patients were asked: (A) In the past 4 weeks have you used any over-the-counter, nonprescription medicine to relieve your nasal allergy symptoms? (B) In the past 4 weeks have you used any intranasal steroid spray for your nasal allergy symptoms? (C) Have you taken any (other) prescription medications for your nasal allergies in the past 4 weeks?

Base: All respondents, unweighted, N = 400.

Perceived Control of Nasal Allergies

Although the majority of allergy sufferers reported being at least somewhat bothered by nasal congestion and sneezing in the past week, most patients (53%) described their allergies as completely controlled or well controlled in the past week. On the other hand, 36% of respondents said that their allergies were somewhat controlled in the last week, and 11% described their allergies in the last week as poorly controlled or not controlled at all (FIGURE 3A).

In contrast to the patients' report, HCPs were generally less positive about how well controlled their patients' nasal allergies were. Almost one-third of HCPs (all HCPs, 28%: allergists, 34%; otolaryngologists, 26%; PCPs, 25%; NP/PAs, 30%) felt that all or most of their patients with nasal allergies would be classified as completely controlled or well controlled in May or June. Most HCPs (all HCPs, 53%: allergists, 44%; otolaryngologists, 62%; PCPs, 53%; NP/PAs, 56%) felt that some of their patients with nasal allergies would be classified as completely controlled or well controlled in May or June. Surprisingly, a small number of HCPs (all HCPs, 17%: allergists, 22%; otolaryngologists, 12%; PCPs, 19%; NP/ PAs, 12%) felt that few or none of their patients have completely controlled or well-controlled allergies in May or June (FIGURE 3B).

FIGURE 3

Perceived control of nasal allergies symptoms: (A) patient perspective and (B) health care provider perspective

(A) Patients were asked: Overall, how well would you say that your nasal allergies have been controlled in the last week? Would you say they were completely controlled, well controlled, somewhat controlled, poorly controlled, or not controlled at all?

Base: All respondents, unweighted, N = 400.

(B) Health care providers were asked: What proportion of your patients with nasal allergies would you classify as having completely controlled or well-controlled allergies in May or June? All (91%-100%), most (51%-90%), some (11%-50%), few (1%-10%), or none (0%)?

Base: All respondents, N = 250.

Patient Perceptions of Intranasal Steroid Sprays

There appeared to be many reasons why the physicians' preferred choice of AR medication was not always used in practice. First, 37% of AR patients reported that they were not too familiar, not at all familiar, or did not know how familiar they were with intranasal steroid sprays for nasal allergies. Of the 63% of AR patients who reported at least some familiarity with intranasal steroid sprays, nearly half (49%) said that they had heard intranasal steroid sprays relieved symptoms and 10% thought that intranasal steroid sprays reduced nasal swelling (FIGURE 4A). Patients who had some familiarity with intranasal steroid sprays were also asked what, if anything, bad they had heard for these drugs. The most commonly volunteered concerns were: they lead to nasal damage (15%), they were addictive (13%), there were side effects (12%), they contain steroids (8%), they are not effective (5%), and they cause headaches (4%) (FIGURE 4B). Further questioning revealed that the majority (64%) of these patients with nasal allergies said that, based on what they knew or had heard, the benefits of steroid nasal sprays definitely or probably outweighed the drawbacks, whereas 18% said that drawbacks of intranasal steroid sprays probably or definitely outweighed the benefits, and 18% were not sure.

FIGURE 4

Patient perceptions of nasal steroid medications: (A) good things they have heard or (B) bad things they have heard

Patients who were familiar with intranasal steroid sprays were asked:
(A) What good things, if any, have you heard about these drugs?
(B) What bad things, if any, have you heard about these drugs?

Base: Familiar with intranasal steroid sprays, unweighted, n = 288.

Patients who had used a prescription intranasal steroid spray for their nasal allergies in the past, but not in the past 4 weeks, were asked why they had not recently used their intranasal steroid spray. Most commonly, past users of prescription nasal sprays said that they had no symptoms (20%) or the symptoms were not bad enough (17%). Other reasons for not using within the past 4 weeks included lack of effectiveness (12%), side effects (9%), poor tolerability (2%), and concerns about dependence (2%). A similar proportion of past users said they had not used prescription nasal sprays in the past 4 weeks because they did not like sprays (8%) or the delivery mechanism (5%). Finally 8% of AR patients reported that they had not used prescription nasal sprays in the past 4 weeks because of barriers to care (no insurance coverage, 3%; cost or co-pay too expensive, 3%; no access to a provider, 2%) (FIGURE 5).

FIGURE 5

Patient reasons for not using nasal steroids in the past 4 weeks

Patients who no longer use an intranasal steroid spray were asked:
Why haven't you used a prescription intranasal steroid spray for your nasal allergies in the past 4 weeks?

Base: No longer use an intranasal steroid spray, unweighted, n = 158.

The survey showed that patient satisfaction with prescription intranasal steroid sprays varies with their experience with side effects. The majority of patients (72%) who have ever used prescription intranasal steroid sprays for their allergies said that, in general, they had been somewhat satisfied or very satisfied with their prescription steroid nasal spray, whereas 19% reported they were somewhat dissatisfied or very dissatisfied. There was a statistically significant difference in satisfaction between those who feel the medication drip down the throat sometimes or more often (81%) and those who rarely or never did (96%) (P < 0.05, FIGURE 6A) and an even more dramatic and statistically significant difference in the satisfaction with their intranasal steroid sprays between those who felt any discomfort from these sprays at least sometimes (66%) and those who rarely or never felt discomfort from the sprays (92%) (P < 0.05, FIGURE 6B).

FIGURE 6

Patient satisfaction with intranasal steroid sprays, based on frequency of side-effect experiences: (A) feeling the medication drip down the throat and (B) feeling discomfort from the spray

Patients who had used intranasal steroid spray within the past year were asked: When you use your intranasal steroid spray, how often do you (A) feel the medication drip down the throat or (B) feel any discomfort from the spray: always, most of the time, sometimes, rarely, or never? Patients were also asked: In general, how satisfied were you with the prescription intranasal steroid spray you used for your nasal allergies in the past?

Base: Used intranasal steroid spray in the past year, unweighted, n = 171;
*Pearson chi-square, P = 0.05.

Reasons for Using a Particular Intranasal Steroid Spray

Nearly 1 in 10 patients who have used intranasal steroid sprays (8%) said that they had asked their HCP to prescribe a particular intranasal steroid spray (FIGURE 7A). Of these, 40% said they wanted it because they believed it was more effective, 25% said that they did so because of previous experience with that product, 11% said that the product requested was easier to administer, and 11% said that the product they requested had less smell. Only 4% of those who requested a specific intranasal steroid spray said that they did so because it was covered by their insurance or because of an advertisement.

On the other side of the table, HCPs were asked how often their patients asked them to prescribe a particular intranasal steroid spray. A number of allergists and otolaryngologists reported that they were asked to prescribe a particular intranasal spray at least daily (14% and 18%, respectively), a few days a week (20% and 14%), or at least once a week (16% and 18%). Substantially fewer PCPs (6%) and NP/PAs (6%) reported requests for specific intranasal steroid sprays on a daily basis. But nearly 2 in 5 PCPs (39%) and NP/PAs (38%) said that patients asked them to prescribe a particular intranasal spray at least once a week (FIGURE 7B).

FIGURE 7

Introduction

Allergic rhinitis (AR) is a growing challenge for primary care because most AR patients consult primary health care providers (HCPs) who generally make the diagnosis, initiate treatment, give the relevant information, and monitor the condition.1 It is already a very common disease, affecting up to 40% of the population in young adults, and its prevalence is ever increasing.2,3 The effective management of AR involves allergen avoidance, pharmacotherapy, immunotherapy, or a combination of these methods.4 Options for pharmacotherapy include intranasal corticosteroids, oral and intranasal antihistamines, intranasal chromones, oral and intranasal decongestants, oral and intranasal anticholinergic agents, and antileukotrienes. Of these choices, the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines state, "intranasal glucocorticosteroids are recommended for the treatment of allergic rhinitis in adults and children. They are the most effective drugs for the treatment of allergic rhinitis."4 Although effective treatments have been available for many years, numerous studies show that the care offered to patients is often suboptimal, with significant problems of patient nonadherence to medication.5 Considering that AR is usually a long-term condition and that patient adherence to prophylactic therapy directly impacts long-term symptom control, it is vital that all efforts are made to improve medication adherence.

Medication nonadherence is a complex issue with many contributing factors.6 Reasons for nonadherence in patients with chronic illnesses include patient self-efficacy, social support, disease knowledge, costs, and side effects. In addition, it has been shown that physicians contribute to patients' poor adherence by prescribing complex regimens, failing to explain the benefits and side effects of a medication adequately, not giving consideration to the patient's lifestyle or the cost of the medications, and having poor therapeutic relationships with their patients.6 In many areas of medicine, there is often a significant mismatch between the way a patient and physician view the illness in question.7-10 It is therefore important that physicians treating AR understand the patient perspective and take this into account when planning long-term management of the patient's symptoms. The objective of this part of the National Allergy Survey Assessing Limitations (NASAL; www.nasalsurvey.com), a study sponsored by Teva Respiratory, LLC, was to examine patients' perspectives (N = 400) on their experiences with AR and its management, focusing in particular on the attributes of nasal allergy medications that contribute to patient satisfaction with therapy. To promote a better understanding of how the patient perspective matches the HCP perspective, data from the HCP survey (N = 250) are also included. The sample of HCPs included a national sample of 200 physicians in direct patient care in outpatient settings in the United States, including 100 in adult primary care specialties (family medicine and internal medicine), 100 specialists (allergy and otolaryngology), and 50 nurse practitioners (NPs) and physician assistants (PAs). Full details of the survey methodology have been provided elsewhere in this supplement.

Results of the National Allergy Survey Assessing Limitations

Allergy Triggers

Nasal allergy symptoms may be triggered by allergens, and different allergens may affect individuals in different ways. Hence, the first question asked of this national sample of adult nasal allergy sufferers was what things usually trigger or make their nasal allergy symptoms worse. Adults with nasal allergies most commonly volunteered pollen (63%) as the usual trigger or thing that worsens their symptoms; other common triggers were dust (34%); grass (32%); changes in weather (20%); animals (18%); mold (10%); perfume (7%); fumes or odors (6%); chemicals (6%); and tobacco smoke (4%) (FIGURE 1A). The survey further showed that these triggers often have a large effect on the severity of nasal allergy symptoms. More than half of adults with nasal allergies (54%) reported that these triggers made their allergy symptoms a lot worse, 32% reported that these triggers made their allergy symptoms moderately worse, and just 13% reported that the triggers made their symptoms only a little worse or not worse at all (FIGURE 1B).

FIGURE 1

(A) Nasal allergy triggers and (B) effect on nasal allergy symptoms

Respondents were asked: (A) What things usually trigger or make your nasal allergy symptoms worse? (B) Do these triggers usually make your allergy symptoms a lot worse, moderately worse, or only a little worse than normal?

Base: All respondents, unweighted, N = 400.

Preferred Classes of Medications for Nasal Allergy Symptoms

Results of the HCP survey clearly showed that prescription intranasal steroid sprays or inhaled corticosteroids are the preferred choice of most HCPs (all HCPs, 67%: allergists, 94%; otolaryngologists, 68%; primary care physicians [PCPs], 67%; NP/PAs, 40%) for adults with moderate to severe persistent allergy symptoms. This preference was supported by the fact that virtually all HCPs said that they believe the benefits probably or definitely outweigh the drawbacks of intranasal steroid sprays for the management of nasal allergies. Only a very small proportion of PCPs (4%) and NP/PAs (6%) said that the drawbacks probably or definitely outweigh the benefits in the management of nasal allergies.

By contrast, although the vast majority of patients (83%) reported taking some type of medication for their nasal allergies in the past 4 weeks, only 30% reported using an intranasal steroid spray. Instead, 62% of patients reported using over-the-counter (OTC), nonprescription medicine, 25% reported using some other type of prescription medication, and 17% reported that they took none of these types of medication (FIGURE 2).

FIGURE 2

Medications used by the patient in the preceding 4 weeks

Patients were asked: (A) In the past 4 weeks have you used any over-the-counter, nonprescription medicine to relieve your nasal allergy symptoms? (B) In the past 4 weeks have you used any intranasal steroid spray for your nasal allergy symptoms? (C) Have you taken any (other) prescription medications for your nasal allergies in the past 4 weeks?

Base: All respondents, unweighted, N = 400.

Perceived Control of Nasal Allergies

Although the majority of allergy sufferers reported being at least somewhat bothered by nasal congestion and sneezing in the past week, most patients (53%) described their allergies as completely controlled or well controlled in the past week. On the other hand, 36% of respondents said that their allergies were somewhat controlled in the last week, and 11% described their allergies in the last week as poorly controlled or not controlled at all (FIGURE 3A).

In contrast to the patients' report, HCPs were generally less positive about how well controlled their patients' nasal allergies were. Almost one-third of HCPs (all HCPs, 28%: allergists, 34%; otolaryngologists, 26%; PCPs, 25%; NP/PAs, 30%) felt that all or most of their patients with nasal allergies would be classified as completely controlled or well controlled in May or June. Most HCPs (all HCPs, 53%: allergists, 44%; otolaryngologists, 62%; PCPs, 53%; NP/PAs, 56%) felt that some of their patients with nasal allergies would be classified as completely controlled or well controlled in May or June. Surprisingly, a small number of HCPs (all HCPs, 17%: allergists, 22%; otolaryngologists, 12%; PCPs, 19%; NP/ PAs, 12%) felt that few or none of their patients have completely controlled or well-controlled allergies in May or June (FIGURE 3B).

FIGURE 3

Perceived control of nasal allergies symptoms: (A) patient perspective and (B) health care provider perspective

(A) Patients were asked: Overall, how well would you say that your nasal allergies have been controlled in the last week? Would you say they were completely controlled, well controlled, somewhat controlled, poorly controlled, or not controlled at all?

Base: All respondents, unweighted, N = 400.

(B) Health care providers were asked: What proportion of your patients with nasal allergies would you classify as having completely controlled or well-controlled allergies in May or June? All (91%-100%), most (51%-90%), some (11%-50%), few (1%-10%), or none (0%)?

Base: All respondents, N = 250.

Patient Perceptions of Intranasal Steroid Sprays

There appeared to be many reasons why the physicians' preferred choice of AR medication was not always used in practice. First, 37% of AR patients reported that they were not too familiar, not at all familiar, or did not know how familiar they were with intranasal steroid sprays for nasal allergies. Of the 63% of AR patients who reported at least some familiarity with intranasal steroid sprays, nearly half (49%) said that they had heard intranasal steroid sprays relieved symptoms and 10% thought that intranasal steroid sprays reduced nasal swelling (FIGURE 4A). Patients who had some familiarity with intranasal steroid sprays were also asked what, if anything, bad they had heard for these drugs. The most commonly volunteered concerns were: they lead to nasal damage (15%), they were addictive (13%), there were side effects (12%), they contain steroids (8%), they are not effective (5%), and they cause headaches (4%) (FIGURE 4B). Further questioning revealed that the majority (64%) of these patients with nasal allergies said that, based on what they knew or had heard, the benefits of steroid nasal sprays definitely or probably outweighed the drawbacks, whereas 18% said that drawbacks of intranasal steroid sprays probably or definitely outweighed the benefits, and 18% were not sure.

FIGURE 4

Patient perceptions of nasal steroid medications: (A) good things they have heard or (B) bad things they have heard

Patients who were familiar with intranasal steroid sprays were asked:
(A) What good things, if any, have you heard about these drugs?
(B) What bad things, if any, have you heard about these drugs?

Base: Familiar with intranasal steroid sprays, unweighted, n = 288.

Patients who had used a prescription intranasal steroid spray for their nasal allergies in the past, but not in the past 4 weeks, were asked why they had not recently used their intranasal steroid spray. Most commonly, past users of prescription nasal sprays said that they had no symptoms (20%) or the symptoms were not bad enough (17%). Other reasons for not using within the past 4 weeks included lack of effectiveness (12%), side effects (9%), poor tolerability (2%), and concerns about dependence (2%). A similar proportion of past users said they had not used prescription nasal sprays in the past 4 weeks because they did not like sprays (8%) or the delivery mechanism (5%). Finally 8% of AR patients reported that they had not used prescription nasal sprays in the past 4 weeks because of barriers to care (no insurance coverage, 3%; cost or co-pay too expensive, 3%; no access to a provider, 2%) (FIGURE 5).

FIGURE 5

Patient reasons for not using nasal steroids in the past 4 weeks

Patients who no longer use an intranasal steroid spray were asked:
Why haven't you used a prescription intranasal steroid spray for your nasal allergies in the past 4 weeks?

Base: No longer use an intranasal steroid spray, unweighted, n = 158.

The survey showed that patient satisfaction with prescription intranasal steroid sprays varies with their experience with side effects. The majority of patients (72%) who have ever used prescription intranasal steroid sprays for their allergies said that, in general, they had been somewhat satisfied or very satisfied with their prescription steroid nasal spray, whereas 19% reported they were somewhat dissatisfied or very dissatisfied. There was a statistically significant difference in satisfaction between those who feel the medication drip down the throat sometimes or more often (81%) and those who rarely or never did (96%) (P < 0.05, FIGURE 6A) and an even more dramatic and statistically significant difference in the satisfaction with their intranasal steroid sprays between those who felt any discomfort from these sprays at least sometimes (66%) and those who rarely or never felt discomfort from the sprays (92%) (P < 0.05, FIGURE 6B).

FIGURE 6

Patient satisfaction with intranasal steroid sprays, based on frequency of side-effect experiences: (A) feeling the medication drip down the throat and (B) feeling discomfort from the spray

Patients who had used intranasal steroid spray within the past year were asked: When you use your intranasal steroid spray, how often do you (A) feel the medication drip down the throat or (B) feel any discomfort from the spray: always, most of the time, sometimes, rarely, or never? Patients were also asked: In general, how satisfied were you with the prescription intranasal steroid spray you used for your nasal allergies in the past?

Base: Used intranasal steroid spray in the past year, unweighted, n = 171;
*Pearson chi-square, P = 0.05.

Reasons for Using a Particular Intranasal Steroid Spray

Nearly 1 in 10 patients who have used intranasal steroid sprays (8%) said that they had asked their HCP to prescribe a particular intranasal steroid spray (FIGURE 7A). Of these, 40% said they wanted it because they believed it was more effective, 25% said that they did so because of previous experience with that product, 11% said that the product requested was easier to administer, and 11% said that the product they requested had less smell. Only 4% of those who requested a specific intranasal steroid spray said that they did so because it was covered by their insurance or because of an advertisement.

On the other side of the table, HCPs were asked how often their patients asked them to prescribe a particular intranasal steroid spray. A number of allergists and otolaryngologists reported that they were asked to prescribe a particular intranasal spray at least daily (14% and 18%, respectively), a few days a week (20% and 14%), or at least once a week (16% and 18%). Substantially fewer PCPs (6%) and NP/PAs (6%) reported requests for specific intranasal steroid sprays on a daily basis. But nearly 2 in 5 PCPs (39%) and NP/PAs (38%) said that patients asked them to prescribe a particular intranasal spray at least once a week (FIGURE 7B).

FIGURE 7