Screening QUestionnaire for AllergicRhinitis - Electronic = SQUAR-E

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Allergic rhinitis: is it a publichealth problem?The increasing incidence of allergicdiseases over the last 30 years is of concern[1]. In particular, allergic rhinitis has nowreached epidemic proportions. A recentlypublished survey [2] shows that an averageof 23% of the adult population in Europehas allergic rhinitis. The prevalence of thisdisease, in each country, is presented inFigure 1.

Allergic rhinitis : only onepatient out of 4 treated !Management varies from one country toanother.The same survey [2] demonstrated that onlyhalf of the symptomatic allergic rhinitissubjects were diagnosed. It can beassumed that some of the other half ofpatients self-diagnosed themselves, thuscarrying the risk of administering aninactive, inadequate or inappropriatemedicinal product compared to currentavailable therapies. For example, firstgeneration H1-antihistamines, available inpharmacies without a doctor's prescription,are known to decrease work efficiency [3]and learning performance in school (Fig. 2)[4], and increase the risk of traffic accidentsand work-related accidents [5].

Allergic Rhinitis

Fig. 1 – Prevalence of AR in general population [2]

Fig. 2Decrease of learning ability attributed to allergic

rhinitis (placebo vs healthy) and its treatmentwith first-generation anti-H1

(diphenhydramine vs placebo) [4]

BelgiumFra

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Germany

Italy

Spain UK All0

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30% 29

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2623

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Placebo Diphenhydramine 25 mg

Learning and seasonal allergic rhinitisChildren 10 to 12 years

Factual knowledge score

FER. Simons, Allergy and Asthma Proc 17: 185-188, 1996

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Among diagnosed patients, only halfreceive pharmacological therapy (Fig. 3) [2].In other words, currently only one out offour patients suffering from allergic rhinitisis pharmacologically treated, even thoughthis percentage varies from one country toanother.

Allergic rhinitis and complicationsMore and more evidence supports theassumption that poorly controlled allergicrhinitis exposes the patient to the risk ofworsening of the disease over time [6]which manifests itself by the followingclinical presentations:

1. Multiple sensitization (i.e., sensitizationto several allergens in the same category,for example, different airborne allergens)

2. The occurrence of cross-reactions (orsensitization to several allergens indifferent categories, but with a similarstructure, such as apple and birch treeallergens)

3. Rising hyperresponsiveness (i.e., anincrease in the incidence and severity ofsymptoms by non-allergic factors such ascold weather or air pollution)

4. An increase in the incidence, durationand severity of symptoms

5. Extension of nasal inflammation toadjacent organs: conjunctivitis andsinusitis

6. The progression of the allergic disorderfrom rhinitis to asthma.

Fig. 3 – Percentage of the general populationwith allergic rhinitis [2]

Population 10 000 persons

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In terms of pathophysiology, the risk ofworsening of allergic rhinitis seems todepend mainly on the duration of thedisease and of its severity. This observationhas led a group of ARIA experts (AllergicRhinitis and its Impact on Asthma) topropose a new classification of allergicrhinitis [1]. This classification breaks downallergic rhinitis into intermittent rhinitis and

persistent rhinitis, depending on thefrequency and duration of symptoms (Table 1).Persistent rhinitis is defined by thepresence of symptoms for more than 4 daysa week and more than 4 consecutive weeksper year, while intermittent rhinitis involvessymptoms which occur less than 4 days aweek or less than 4 weeks per year.

Allergic Rhinitis

Classification of allergic rhinitis

IntermittentSymptoms

< 4 days / weekor

< 4 weeks

PersistentSymptoms

≥≥ 4 days / weekand

≥≥ 4 weeks

SeverityMild

• Normal sleep• Normal daily activities,

sport, leisure• Normal work and school• No troublesome symptom

SeverityModerate - Severeone or more items

• Abnormal sleep • Impairment of daily

activities, sport, leisure• Problems caused at work

or school• Troublesome symptoms

Table 1 – ARIA classification of allergic rhinitis [1]

The ARIA classification of Allergic Rhinitis: why, how?

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The above-mentioned survey [7] clearlydemonstrates that this new classificationdiffers from the current one, based more onetiological factors (Fig. 4). In other words,the concepts of seasonal rhinitis andintermittent rhinitis are not identical, as well as perennial and persistent rhinitis.Furthermore, intermittent rhinitis should notonly be associated with pollens and mouldsnor should persistent rhinitis be associatedonly with house dust mites [7] (Fig. 5).

Fig. 4 – Breakdown of types of rhinitis accordingto the current and the new ARIA classifications [7]

Fig.5 – Sensitization (IgE) to specific allergensaccording to sub-types of allergic rhinitis [7]

Persistent33%

Intermittent67%

SAR49%

PAR51%

SAR: symptoms restricted to spring and/or summerN=1,265 subjects with physician - based diagnosis

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Pollen Gra

ss

Pollen Tr

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Pollen W

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Animal D

anders

Dust M

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Mould

Perennial Allergic Rhinitis (PAR)

Intermittent Rhinitis

Persistent Rhinitis

Seasonal Allergic Rhinitis (SAR)

0

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Allergic rhinitis classificationsPrevalences are different

SAR = Seasonal Allergic Rhinitis - PAR = Perennial Allergic Rhinitis

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The new ARIA concept [1] also recognizesthat assessing the impairment of thepatient's quality of life is the most accuratemeans of evaluating the severity of allergicrhinitis (Table 1). This evaluation method isbroader than a simple evaluation ofsymptoms: it better reflects the actualimpact of the disease, it is morereproducible and has proven to beresponsive to pharmacological therapy [8].Thus, the degree of severity of rhinitisshould be considered as moderate tosevere when sleep disorders, impaired dailyactivity and problems at work or at schoolare present, and when symptoms are poorlytolerated by the patient. In all other cases,it should be considered as mild.

This new ARIA classification is useful andimportant in so far as the presence ofmoderate to severe persistent rhinitis is arisk factor predictive of progression toasthma (Fig. 7) [11]. In fact, allergic rhinitisand asthma are closely related. Currently,more careful screening would reveal that 20-50% of patients with allergic rhinitis presentwith bronchial hyperresponsiveness, and upto 80% of asthma patients with allergicrhinitis [12].

Allergic Rhinitis

Fig. 6 – Comparison of quality-of-life impairmentinduced by asthma and rhinitis [9, 10]

PhysicalFunctioning

100SF-36 scores

0

20

40

60

80

SocialFunctioning

PhysicalProblems

EmotionalProblems

MentalHealth

Energy Fatigue

Pain GeneralPerceptionof Health

Changein Health

● severe rhinitis● mild asthma● moderate asthma● severe asthma

Comparison of quality of life in asthma and severerhinitis as measured by the generic health profile SF-36

Consequently, this is whya decrease in quality of lifeinduced by severe rhinitisis comparable to that observedin moderate to severe asthma(Fig. 6). [9, 10]

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Finally, epidemiological and clinical findingsemphasize the importance of properlydiagnosing allergic rhinitis. Special attentionshould be paid in the case of moderate tosevere persistent rhinitis, which requirescontinuing therapy (rather than "on demand"treatment) and long-term therapy (evenchronic therapy) with the most potentmedicinal products available [1].

Fig. 7 – Risk of progression to asthma according to thetype of rhinitis and its severity [11]. (NB: this study wasconducted before the criteria for the classification andevaluation of severity of rhinitis, according to the ARIAclassification, were published).

Test for trend, p ‹ .001

No RH Persistent RH

No RHInconsistent RH

Mild RH ModerateRH

SevereRH

Test for trend, p ‹ .001

OR

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In the context of underdiagnosis of allergicrhinitis and considering the importance ofearly diagnosis, the UCB Institute of Allergyis proud to provide physicians with asimple, fast and reliable diagnostic tool forthe screening of allergic rhinitis. This test is based on the results of data collected in the European epidemiological surveymentioned above [2,7,13]. The mostrevealing questions for the diagnosis ofallergic rhinitis have been sought amongdifferent questionnaires used in this survey.From these data 11 questions were selected,each of which were weighted differently. Fora "0" score, this simple questionnaire has asensitivity of 93.8% and a specificity of80.3%, a positive predictive value of 58.4%and a negative predictive value of 97.8%.Thus, the probability that this score willyield a false-positive diagnosis of allergicrhinitis is extremely low [13]

The available electronic version of thisquestionnaire makes it easy to calculate aspecific score for each adult patient. Thisscore is automatically converted into a riskprobability (%) that patients will haveallergic rhinitis. Furthermore, the type ofrhinitis, intermittent or persistent, is alsodetermined and displayed.

The Allergic Rhinitis diagnosis :SQUAR-E

The UCB Institute of Allergy and the need for assistance diagnosing allergic rhinitis:the Screening Questionnaire for Allergic Rhinitis (SQUAR-E)

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Installation of the CD ROM

It is important that all open applications areclosed before launching the CD.Click on the UCB logo (on the desk) to launchthe SQUAR-E to the first use. Many languagesare available, please choose your own (it ispossible to change it thereafter).

To save your patients’ results click on "save" atthe end of each simulation. The customisedresults are saved on your hard disk.

To consult these results: go in C: /, open the fileprogram files, then the file "SQUAR-E" andfinally the file data.txt. which must be open withmsn excel application.

Certain pages can be printed by clicking on theprint button.

This version is also available on the UCBInstitute of Allergy web site:

www.theucbinstituteofallergy.comunder Members section

How to use the electronic version of the questionnaire?

Minimum system requirements

PC: Windows 98/2000 or XP with rightsof writing

• Pentium III 256Mo of Traditional RAM

• For the first use, insert CD in the reader,the application launches out automati-cally and settles on the station, a shortcut is created on the desk.

Macintosh

• MacOS 9.2 minimum

• Power Macintosh G3 with 64Mo of RAM

Macintosh OS X:

• MacOS 10.2 minimum

• Power Macintosh G3 with 128Mo of RAM

• Open the CD reader (D: or E: ) and carryout the programUCB_Calculateur_inst_Classic.exe orUCB_Calculateur_inst_X.exe present onCD according to your system. The appli-cation is now settled on your station anda short cut is created on the desk.

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1. Bousquet J, van Cauwenberge P and Khaltaev N, J Allergy Clin Immunol2001, 108 : S147-S334.

2. Bauchau V, Durham SR, Eur Respir J 2004, 24 : 758-764.

3. Cockburn IM et al, J Occup Environ Med 1999, 41: 948-953.

4. Simons FER, Allergy Asthma Proc 1996, 17 : 185-189.

5. Hanrahan LP et al, Am J Ind Med 2003, 44 : 438-446.

6. Togias A, J Allergy Clin Immunol 2004, 113 : S8-S14.

7. Bauchau V, Durham SR, Allergy 2005, 60 : 350-353.

8. Bachert C et al, J Allergy Clin Immunol 2004, 114 : 838-844.

9. Bousquet J et al, Am J Respir Crit Care Med 1994, 140 : 371-375.

10. Bousquet J et al, J Allergy Clin Immunol 1994 : 182-188.

11. Guerra S et al, J Allergy Clin Immunol 2002, 109 : 419-425.

12. Bousquet J et al, Allergy 2003, 58 : 691-706.

13. Bauchau V et al, to be published

References

The IOA thanks for their active collaboration:V. Bauchau, D. Philippart - UCB, Outcomes Research, Braine l'Alleud, Belgium

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coming years. Moreover the IOA favourscooperation between various allergyrelated organisations. The Institute ispresent all around Europe with 20 nationalsections and in South Africa.

The Institute’s web site(http://www.theucbinstituteofallergy.com)and central membership library providemembers with current relevant informationand publications about allergy. For thegeneral public, schools and children, theIOA has produced videos (e.g. "Who’ssleeping in your pillow?", "Allergic: to beor not to be?...Rhinitis), educational gamesand other information material. The IOAalso organises and holds meetings,symposia, conferences, panel discussions.

As a result of these activities, The UCBInstitute of Allergy hopes to forestallthe sobering prediction of certainepidemiologists: In 30 years’ time,everyone may be allergic... Unless we actnow!

The UCB Institute of AllergyDivision of UCB S.A., The UCB Institute ofAllergy (IOA) is an independent, Europeanand not-for-profit organisation, created in1987 to combat allergy.

In response to the international epidemic ofthis disease, the Institute’s objective is toimplement all the resources necessary toraise awareness of allergy as a major healthissue amongst the general public, patients,health care professionals and publicauthorities.

Under the supervision of a ScientificAdvisory Board made up of eminentEuropean specialists in the field of allergy,the IOA has initiated many actions. Theseaim to inform and educate about allergy, toimprove prevention, to promote research,to analyse the current situation and todefine key actions to be taken over the

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The UCB Institute of Allergy Allée de la recherche, 60B-1070 Brussels (Belgium) U

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