595779

research-article2015
IJI0010.1177/0394632015595779International Journal of Immunopathology and PharmacologySpinozzi et al.

Letter to the editor

International Journal of

Characteristics and predictors of allergic Immunopathology and Pharmacology

2016, Vol. 29(1) 129­–136
© The Author(s) 2015
rhinitis undertreatment in primary care Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0394632015595779
iji.sagepub.com

F Spinozzi,1 N Murgia,2 S Baldacci,3 S Maio,3 AP Pala,4

C Casciari,1 M dell’Omo,2 and G Viegi,3,5 on behalf of ARGA study group

Abstract
Although allergic rhinitis is considered a raising medical problem in many countries it is often undertreated. The reasons
for this phenomenon are not completely clear.
The aim of this study is to evaluate factors associated with allergic rhinitis under-/no treatment.
A sample of 518 allergic rhinitis patients recruited by their primary care physicians, as a part of the ARGA study, were
invited to fill in a specific questionnaire regarding rhinitis symptoms, treatment, and rhinitis-related work/social disability.
Chi-square test and logistic regression were performed to assess risk factors for allergic rhinitis under-/no treatment.
Over one out of four patients had no treatment despite the symptoms and 13.5% were inadequately treated.
Participants with asthma (OR 0.47, 95% CI 0.30–0.75) and conjunctivitis (0.44, 95% CI 0.27–0.71) were at lower risk
of allergic rhinitis under-/no treatment: in asthmatics this reduction was related mainly to the concomitant asthma
treatment (OR 0.19, 95% CI 0.10–0.37).
Asthmatics with under-/not treated rhinitis had the highest prevalence of rhinitis-related quality of life impairment.
Under-/no treatment for allergic rhinitis is still rather frequent despite the relevance of this disease. The simultaneous
presence of asthma and an anti-asthmatic therapy are able to influence positively the treatment. Targeted interventions
toward a better characterization and a tight follow-up of rhinitis patient without asthma are needed.

Keywords
allergic rhinitis, asthma, conjunctivitis, general practitioners, medicines, perennial, quality of life, seasonal, treatment,
undertreatment

Date received: 6 October 2014; accepted: 17 June 2015

Introduction
Allergic rhinitis is characterized by a considerable
medical and social burden, mainly because of its
high prevalence in industrialized countries, the
relationship with asthma and the impact on quality
of life.1,2 In Italy, a rise in allergic rhinitis preva-
lence, from 16.8% to 25.8% over the last 20 years,
1Laboratory of Experimental Immunology and Allergy, Department
of Medicine, University of Perugia, Piazzale Gambuli, 06100 Perugia,
Italy
2Section of Occupational Medicine, Respiratory Diseases and
Toxicology, University of Perugia, Piazzale Gambuli, 06100 Perugia,
Italy
3Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical

Physiology, Via Trieste 41, 56126 Pisa, Italy

in a particular setting has recently been reported.3 4Technosciences Unit, CNR Institute of Clinical Physiology, Via Trieste
Furthermore, there is increasing evidence that 41, 56126 Pisa, Italy
allergic rhinitis is also a rising medical issue in 5CNR Institute of Biomedicine and Molecular Immunology “A.

regions of the world other than Europe and North Monroy”, Via Ugo La Malfa 153, 90146 Palermo, Italy

America.4 Besides, the economic impact of allergic Corresponding author:

rhinitis remains substantial: in the USA, the total Nicola Murgia, Section of Occupational Medicine, Respiratory Diseases
and Toxicology, University of Perugia, Piazzale Gambuli, 06100 Perugia,
direct medical cost of allergic rhinitis is approxi- Italy.
mately $3.4 billion per year;5 in Sweden the cost of Email: nicola.murgia@unipg.it
130 International Journal of Immunopathology and Pharmacology 29(1)
rhinitis in terms of lost productivity is €2.7 billion
per year.6 Such data reinforce the need to imple-
ment the guidelines for early diagnosis and effec-
tive treatment of allergic rhinitis prepared by
scientific societies and expert panels.7 However,
allergic rhinitis is still considered a trivial disease
by some physicians, resulting often in underdiag-
nosis and inadequate treatment.8 Recently, some
authors also pointed out that patients’ compliance
to the treatment, properly prescribed by their phy-
sicians, is very poor.9 Under-/no treatment of aller-
gic rhinitis is associated with delayed medical
examinations, patient preference for non-prescrib-
ing drugs, and the fear of drug-related costs, but
the specific characteristics of patients undertreated
or not treated for allergic rhinitis are still not com-
pletely clear.7 Having information on which group
of patients needs more attention in terms of educa-
tion, follow-up, and adherence to the therapy could
help tailoring practical interventions by general
practitioners and specialists toward a better control
of allergic rhinitis symptoms. The aim of this study
is to elucidate predictors of allergic rhinitis under-/
no treatment in participants recruited by their gen-
eral practitioners, as a part of the ARGA study,10–12
focusing mainly on patients characteristics, type of
symptoms, and on the relationship between aller-
gic rhinitis and asthma.
Methods
Study population
This survey is a part of the ARGA study
(‘Allergopatie Respiratorie: studio di monitoraggio
delle linee guida GINA e ARIA’),10 funded by the
Italian Drug Agency (AIFA) and performed
between March 2007 and February 2010. The
study was carried out in collaboration with a ran-
dom sample of 27 general practitioners (GPs) and
family pediatricians (FPs) of Perugia Province
(Umbria, Italy), an area of 671,820 inhabitants.
GPs and FPs were invited to administer a question-
naire to their patients when they came to their
offices with symptoms suggesting an allergic rhini-
tis, enrolled consecutively, during the period
January 2008 to December 2009. All 750 patients
recruited by GPs and FPs were accepted to partici-
pate in the study; in Figure 1 the patient recruit-
ment and selection flow chart are described.
Briefly, 662 patients had symptoms suggesting
allergic rhinitis by ARIA guidelines;13 among
them, 144 were excluded due to missing informa-
tion (e.g. sex, age, answers to the key questions).
Each of the 518 participants provided written
informed consent for the participation in the study,
anonymous management of individual and collec-
tive data, as well as anonymous publication of the
research results. The study protocol, patient infor-
mation sheet, and consent form were approved by
the Ethic Committee of the Region Umbria (CEAS
Umbria).
Questionnaire
“Allergic rhinitis” was defined as having watery
runny nose with one or more of the following: (1)
nasal itching; (2) sneezing; and/or (3) nasal obstruc-
tion.13 Symptoms were classified as perennial if
they were present almost all year round or seasonal
if they were present in just some seasons. Patients
reporting a skin prick test (SPT) positive reaction
only to grass pollen and/or tree pollen and/or other
seasonal allergens were included in the category
“seasonal allergens sensitization”, while a SPT
positive reaction only to dust mites and/or cat and/
or dog and/or other perennial allergens was defined
as “perennial allergens sensitization”. If the patient
reported a SPT positive reaction to seasonal and
perennial allergens he/she was classified having
“both sensitization”. A SPT positive response to
food was defined as “food allergens sensitization”.
Rhinitis-related quality of life (QoL) impairment,
indicating a “disabling rhinitis”, was identified by
an affirmative answer to one or more questions on
sleep, work, and school or everyday life impair-
ment (Figure 2). Participants were classified as
having “asthma” if they reported in the question-
naire asthma-like symptoms (wheezing, shortness
of breath, chest tightness) or use of medication for
asthma. To avoid a possible overlap with chronic
bronchitis and to increase the likelihood of asthma
diagnosis, a score system for some key questions
(e.g. having cough and phlegm as cough character-
istic) was set up. Participants with allergic rhinitis
who reported no treatment for this disease were
classified as “not treated”, whereas participants
with a rhinitis-related QoL impairment, character-
ized by a poor control, who were treated just with
antihistamine and/or vasocostrictor as needed,
but needing by ARIA guidelines a more continu-
ous treatment, were classified as “undertreated”.
Spinozzi et al. 131
Participants
n = 750
Subjects with allergic rhinitis
(AR)
n = 662
Subjects with AR forming the study population
n = 518
Subjects treated for Subjects not adequately treated for AR
AR
n = 70
n = 312
Figure 1.  Flow chart of the study population enrolment and selection.
Patients not treated or undertreated formed the
category “under-/not treated” and in the logistic
regression analysis (see below) were those having
“under-/no treatment”.
Statistical analyses
To assess the distribution of subject characteristics
among patients treated, not adequately treated and
not treated, the chi-square test was used; a two-tailed
test with a 5% level of significance was considered
appropriate for the analysis. A similar subgroup
analysis was conducted dividing each treatment
class in subject with or without asthma, calculating
chi-square test for trend. Risk factors for under-/no
treatment were evaluated by logistic regression
models, adjusting for sex and age. Independent vari-
ables were those factors not equally distributed in
the different treatment categories by the chi-square
83 excluded because information on allergic rhinitis
were missing
5 subjects had no allergic
rhinitis
52 excluded because basic information (sex, age,
etc.) were missing
92 excluded because of incomplete answers to the
key questions
Subjects not treated
for AR
n = 136
test. In one regression model the overall under-/no
treatment risk was considered. Since the presence of
asthma appears an important factor also able to
influence rhinitis treatment, another regression anal-
ysis was performed in asthmatics only, adding a
treatment for asthma as a possible influencing fac-
tor. The goodness of fit of the logistic regression
models was confirmed by the Hosmer-Lemeshow
test.14 Statistical analyses were performed with the
statistical software package SPSS Statistics 20.0
(IBM SPSS, Chicago, IL, USA).
Results
A total of 136 (26.3%) participants with self-
reported symptoms of allergic rhinitis received no
pharmacological treatment, 70 (13.5%) patients
were undertreated; for reasons of sampling size
comparability they were placed together in the
132 International Journal of Immunopathology and Pharmacology 29(1)
80
p<0.001
70
60 p<0.001
50
40
%
30
20
10
0
Rhinitis related quality Rhinitis related sleep
of life impairment impairment
Figure 2.  Quality of life impairment of the allergic rhinitis patients treated and under-/not treated, divided by the occurrence of
asthma.
category “Under-/no treatment” and compared to
those treated (Table 1).
Almost all the patients (99.6%) had undergone
skin prick test for common aero-allergens which had
resulted positive (Table 1). The percentage of
patients with perennial symptoms and perennial
allergens sensitization was higher in those under-/
not treated, while the proportion of participants with
seasonal allergens sensitization was lower in this
latter group (Table 1). Out of 518 patients, more
than an half (51.4%) reported a disabling rhinitis
causing a sleep/work/life impairment. After stratify-
ing the two categories of rhinitis patients by pres-
ence/absence of asthma (Table 2), those with asthma
showed higher frequency of perennial symptoms, as
well as lower frequency of conjunctivitis.
Prevalence of quality of life impairment signifi-
cantly increased from the group of patients treated
without asthma to the group of patients under-
treated/not treated with asthma (Figure 1). This
trend was also evident for each of the three specific
domains.
Treated without asthma
Treated with asthma
Undertreated/not treated without asthma
Undertreated/not treated with asthma
p<0.001
p<0.001
Rhinitis related Rhinitis related daily
work/school impairment activities impairment
In the logistic regression model performed in the
whole population, adjusting for sex and age, par-
ticipants with conjunctivitis or asthma had a lower
risk of under-/no treatment (Table 3). In another
model, limited to asthmatics, the role of conjuncti-
vitis was confirmed and participants in treatment
for asthma were at lower risk of rhinitis under-/no
treatment, whereas patients with perennial sensiti-
zation alone were at higher risk of rhinitis under-/
no treatment (Table 4).
Discussion
Main findings
In this study risk factors for allergic rhinitis under-/
no treatment have been evaluated. The presence of
asthma and conjunctivitis was associated with a
more adequate treatment.
Allergic rhinitis undertreatment has previously
been explored but did not focus on individual/
disease characteristics. For example, in a large
European survey over half of patients with rhinitis
Spinozzi et al. 133

Table 1.  Characteristics of the allergic rhinitis patients treated and under-/not treated.

Partipants with AR treated Participants with AR under-/ P

(n = 312) not treated (n = 206)
Women (%) 52.2 55.8 NS
Age >15 years (%) 87.8 83.5 NS
Nasal obstruction (%) 96.8 96.1 NS
Nasal itching (%) 89.1 88.8 NS
Sneezing (%) 98.1 94.7 NS
Seasonal allergic rhinitis (%) 71.2 62.1 <0.05
Perennial allergic rhinitis (%) 28.8 37.9  
Nasal symptoms lasting 12 months (%) 97.4 94.2 NS
SPT performed (%) 99.4 100 NS
Atopy by SPT (%) 100 100 NS
Seasonal allergens sensitization (%) 40.2 29.6 <0.005
Perennial allergens sensitization (%) 10.9 22.3  
Both sensitization (%) 48.9 48.1  
Food sensitization (%) 7.1 3.9 NS
Rhinitis-related QoL impairment (%) 39.1 69.9 <0.01
Rhinitis-related sleep impairment (%) 28.5 52.4 <0.01
Rhinitis-related work/school impairment (%) 19.6 33.5 <0.01
Rhinitis-related daily activities impairment (%) 29.8 45.6 <0.01
Conjunctivitis (%) 65.7 53.4 <0.01
Asthma (%) 63.1 36.9 <0.01
Childhood onset asthma (%) 29.5 25.2 NS

AR, allergic rhinitis; SPT, skin prick tests.

Table 2.  Characteristics of the allergic rhinitis patients treated and under-/not treated divided by the occurrence of asthma.

Participants treated for allergic Participants with allergic rhinitis P

rhinitis under-/not treated

  Without asthma With asthma Without asthma With asthma

(n = 148) (n = 164) (n = 110) (n = 96)
Women (%) 51.4 53 57.3 54.2 NS
Age >15 years (%) 85.8 89.6 80.9 86.5 NS
Nasal obstruction (%) 98 95.7 99.1 92.7 NS
Nasal itching (%) 93.2 85.4 90.9 86.5 NS
Sneezing (%) 97.3 98.8 96.4 92.7 NS
Seasonal allergic rhinitis (%) 77.7 65.2 73.6 49 <0.001
Perennial allergic rhinitis (%) 22.3 34.8 26.4 51.0
Nasal symptoms lasting 12 months (%) 97.3 97.6 97.3 90.6 <0.05
Atopy by SPT (%) 99.3 100 100 100 NS
Seasonal allergens sensitization (%) 51 30.5 38.2 19.8  
Perennial allergens sensitization (%) 11.6 10.4 20.9 24 <0.001
Both sensitization (%) 37.4 59.1 40.9 56.2  
Food sensitization (%) 5.4 8.5 2.7 5.2 NS
Conjunctivitis (%) 95.5 59.8 84.9 38.5 <0.001

SPT, skin prick tests.

had not seen a physician in the last year, preferring
either non-prescription medication or nothing,
mainly due to the high cost of drugs.7 Hence, even
if allergic rhinitis is widely accepted as clinically
relevant and disabling,15 a not negligible proportion
of patients are still considering it as a trivial dis-
ease.8 In our survey, over half of the patients had an
impairment of their daily/social life, in particular
sleep impairment, confirming previous findings.5
As regards sleep disturbances, it is to point out that
134 International Journal of Immunopathology and Pharmacology 29(1)

Table 3.  Predictors of allergic rhinitis under-/no treatment, serious symptoms throughout the year, not driving
adjusted for sex and age. them to seek for medical attention, or their doctors
ORa 95% CI P tend to concentrate their effort in treating the con-
Type of rhinitis
comitant asthma symptoms. Furthermore, partici-
Seasonal allergic rhinitis 1   pants with a perennial allergen sensitization, since
Perennial allergic rhinitis 1.35 0.85–2.15 NS symptoms usually are continuous, could underes-
Type of sensitization timate the importance of following a correct treat-
Seasonal allergens 1   ment. It is known that lack of efficacy, side effects,
Perennial allergens 1.96 1–3.86 NS treatment duration, and costs are associated with a
Both 1.23 0.77–1.95 NS lower compliance to allergic rhinitis treatment.18
Conjunctivitis
In a recent Spanish survey, just 15% of allergic
No  
Yes 0.44 0.27–0.71 <0.005
rhinitis patients sensitized to dust mites reported
Asthma an improvement after pharmacological treat-
No   ment.19 Another possibility would be that patients
Yes 0.47 0.30–0.75 <0.005 with perennial allergic rhinitis do not take ade-
quate treatment due to an effective allergen avoid-
ance. A recent update of the Cochrane Review on
Table 4.  Predictors of allergic rhinitis under-/no treatment in house dust mites avoidance and allergic rhinitis
asthmatics, adjusted for sex and age.
stated that dust mites impermeable bedding and
ORa 95% CI P other preventive measures are not proven to give a
Type of rhinitis substantial benefit to control rhinitis symptoms.20
Seasonal allergic rhinitis 1   The role of asthma in the difference between
Perennial allergic rhinitis 1.47 0.80–2.70 NS perennial and seasonal allergic rhinitis needs to be
Type of sensitization further evaluated. We have shown in another study,
Seasonal allergens sensitization 1   with general practitioners from other Italian
Perennial allergens sensitization 3.59 1.33–9.72 <0.05 regions, that GPs tend to be more compliant with
Both 1.69 0.82–3.51 NS
ARIA guidelines while treating allergic rhinitis
Conjunctivitis
No 1  
alone than allergic rhinitis  + asthma patients21.
Yes 0.44 0.25–0.79 <0.01 Conversely, in the present study in the Umbria
In treatment for asthma region, the logistic regression analysis, adjusting
No 1   for sex, age, and rhinitis symptoms/sensitization
Yes 0.19 0.10–0.37 <0.0001 seasonality, demonstrated that asthma and con-
junctivitis are the only two independent factors
able to influence the treatment for allergic rhinitis.
they might have an important effect on mental The results on asthma and conjunctivitis suggest
health, including increased depression, anxiety, and that those with associated co-morbidity might have
alcohol abuse.2 a more severe disease or be more aware of it; alter-
In the univariate analysis the prevalence of rhi- natively, they might just be more under control by
nitis under-/no treated was lower in patients with a their physician because of the associated diseases.
sensitization to seasonal allergens, the reason of When limiting the analysis to asthmatics patients,
this finding is to be elucidated. It is possible that this hypothesis is insofar as asthmatics under ther-
patients with seasonal sensitization and symptoms apy are at lower risk of rhinitis under-/no treat-
experience intense symptoms related to the peaks ment. It is known that in asthmatics a coexistent
of pollen exposure16 which drive them to seek for allergic rhinitis increases the severity of asthma11
medical attention. Indeed, global climate changes as well as the annual number of GPs visits,22 thus
have been related to increase in pollen concentra- increasing the likelihood to be properly treated also
tion over the last 20 years.17 On the other hand, in for allergic rhinitis. Moreover, the presence of ocu-
the univariate analysis participants with perennial lar symptoms worsens the quality of life of rhinitic
sensitization and symptoms tend to be under/not patients23 and this could push the patient to be more
treated, especially when asthma coexists. We compliant with the allergic rhinitis treatment since
hypothesize that either patients experienced less the pharmacological treatments are often the
Spinozzi et al. 135
same.13 As a matter of fact, the presence of con-
junctivitis has been associated with an increased
number of allergic rhinitis drug prescriptions.24
A possible limitation of our study might be the
sample size. However, the peculiarity of the study
population (a homogeneous group of participants
coming from the same small Region, sharing the
same healthcare system, recruited by a small team
of primary care physicians) and the presence of
analogous numbers in similar surveys25 may over-
come such limitations.
Conclusions
In this study of patients with allergic rhinitis
recruited by their primary care physicians, more
than 25% had no treatment despite the symptoms
and 13.5% were treated inadequately. Patients with
asthma, especially if treated with anti-asthmatics
medications, and conjunctivitis were at lower risk
of being under-/not treated. These findings
strengthen the need of targeted educational inter-
ventions on selected groups of patients and primary
care physicians towards a better characterization
and a tight follow-up of the disease
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publication
of this article.
Funding
This study was a part of the ARGA study (‘Allergopatie
Respiratorie: studio di monitoraggio delle linee guida GINA
e ARIA’) supported by the Italian Drug Agency (AIFA).
References
1. Canonica GW, Bousquet J, Mullol J, et al. (2007) A
survey of the burden of allergic rhinitis in Europe.
Allergy 62 Suppl 85: 17–25.
2. Nathan RA (2007) The burden of allergic rhinitis.
Allergy & Asthma Proceedings 28: 3–9.
3. de Marco R, Cappa V, Accordini S, et al. (2012)
Trends in the prevalence of asthma and allergic rhi-
nitis in Italy between 1991 and 2010. European
Respiratory Journal 39: 883–892.
4. Katelaris CH, Lee BW, Potter PC, et al. (2012)
Prevalence and diversity of allergic rhinitis in regions
of the world beyond Europe and North America.
Clinical & Experimental Allergy 42: 186–207.
5. Meltzer EO and Bukstein DA (2011) The economic
impact of allergic rhinitis and current guidelines for
treatment. Annals of Allergy Asthma & Immunology
106 Suppl 2: S12–16.
6. Hellgren J, Cervin A, Nordling S, et al. (2010)
Allergic rhinitis and the common cold–high cost to
society. Allergy 65: 776–783.
7. Maurer M and Zuberbier T (2007) Undertreatment of
rhinitis symptoms in Europe: Findings from a cross-
sectional questionnaire survey. Allergy 62: 1057–
1063.
8. Bauchau V and Durham SR (2004) Prevalence
and rate of diagnosis of allergic rhinitis in Europe.
European Respiratory Journal 24: 758–764.
9. Loh CY, Chao SS, Chan YH, et al. (2004) A clini-
cal survey on compliance in the treatment of rhinitis
using nasal steroids. Allergy 59: 1168–1172.
10. Baldacci S, Maio S, Simoni M, et al. (2012) The
ARGA study with general practitioners: Impact of
medical education on asthma/rhinitis management.
Respiratory Medicine 106: 777–785.
11. Maio S, Baldacci S, Simoni M, et al. (2012) Impact
of asthma and comorbid allergic rhinitis on quality of
life and control in patients of Italian general practi-
tioners. Journal of Asthma 49: 854–861.
12. Braido F, Comaschi M, Valle I, et al. (2012) Knowledge
and health care resource allocation: CME/CPD course
guidelines-based efficacy. European Annals of Allergy
and Clinical Immunology 44: 193–199.
13. Bousquet J, Khaltaev N, Cruz AA, et al. (2008)
Allergic rhinitis and its impact on asthma (ARIA)
2008 update (in collaboration with the World Health
Organization, GA(2)LEN and AllerGen). Allergy 63
Suppl 86: 8–160.
14. Hosmer DW and Lemeshow S (1989) Applied Logistic
Regression. New York, NY: John Wiley & Sons.
15. Greiner AN, Hellings PW, Rotiroti G, et al. (2011)
Allergic rhinitis. Lancet 378: 2112–2122.
16. Annesi-Maesano I, Rouve S, Desqueyroux H, et al.
(2012) Grass pollen counts, air pollution levels and
allergic rhinitis severity. International Archives of
Allergy and Immunology 158: 397–404.
17. Ariano R, Canonica GW and Passalacqua G (2010)
Possible role of climate changes in variations in pol-
len seasons and allergic sensitizations during 27
years. Annals of Allergy Asthma & Immunology 104:
215–222.
18. Köberlein J, Kothe AC and Schaffert C (2011)
Determinants of patient compliance in allergic rhi-
noconjunctivitis. Current Opinion in Allergy and
Clinical Immunology 11: 192–199.
19. Valero A, Justicia JL, Vidal C, et al. (2012) Diagnosis
and treatment of allergic rhinitis due to house-dust
mites in Spain. American Journal of Rhinology &
Allergy 26: 23–26.
20. Nurmatov U, van Schayck CP, Hurwitz B, et al. (2012)
House dust mite avoidance measures for perennial
136 International Journal of Immunopathology and Pharmacology 29(1)
allergic rhinitis: An updated Cochrane systematic
review. Allergy 67: 158–165.
21. Maio S, Simoni M, Baldacci S, et al. (2012) The ARGA
study with Italian general practitioners: Prescriptions
for allergic rhinitis and adherence to ARIA guidelines.
Current Medical Research and Opinion 28: 1743–1751.
22. Price D, Zhang Q, Kocevar VS, et al. (2005) Effect
of a concomitant diagnosis of allergic rhinitis on
asthma-related health care use by adults. Clinical &
Experimental Allergy 35: 282–287.
23. Bousquet PJ, Demoly P, Devillier P, et al. (2013)
Impact of allergic rhinitis symptoms on quality of life
in primary care. International Archives of Allergy and
Immunology 160: 393–400.
24. Virchow JC, Kay S, Demoly P, et al. (2011) Impact
of ocular symptoms on quality of life (QoL), work
productivity and resource utilisation in allergic rhi-
nitis patients–an observational, cross sectional study
in four countries in Europe. Journal of Medical
Economics 14: 305–314.
25. Van Hoecke H, Vastesaeger N, Dewulf L, et al.
(2006) Classification and management of allergic rhi-
nitis patients in general practice during pollen season.
Allergy 61: 705–711.