Impact of Immunotherapy on Refractory Allergic Rhinitis in Armed Force Hospital Southern Region, Saudi Arabia
Authors: Al Hamoud Mohammed Al , Kadasah Sultan Khalid , Najmi Albaraa , Al-Qahtani Abdulazeiz , Magboul Nasir A. , Alahmari Ahmed Khallufah , Mubaraki Musleh 
Published: September 2022

Background:
One of the most common types of allergies is allergic rhinitis (AR). According to recent studies, its prevalence has fluctuated from 1.4% to 45% in the last few decades. AR has both direct and indirect consequences on one's quality of life, and it's often accompanied by asthma, middle ear irritation, nasal polyps, sinusitis, and lower respiratory tract infections. There is evidence that AR is frequently undertreated, mainly in its moderate and severe/intense persistent forms. The management of patients with AR involves proper pharmacological therapies, including allergen immunotherapy. Immunotherapy with allergens has been shown to be effective in the treatment of AR, asthma, and insect sting allergies.

Objectives:
The objective of this study was to measure the impact of immunotherapy on refractory AR patients in armed force hospital southern region, Saudi Arabia. In addition to detect the minimal duration required for immunotherapy. Materials and Methods: The study was conducted as an quasi-experimental intuitional – based study, total number of 52 patients used in this study which is all patients who fulfilled the inclusion criteria and initiated immunotherapy for refractory AR during period from Jan 2019 to Oct 2021, Data was collected using standardized online self-administered questionnaires using google forms.

Results:
A total of 52 patients responded to the questionnaire. About two-thirds of patients were males (67.3%), and aged 21–40 years (76.9%). The majority of them had a history of chronic rhinosinusitis (90.4%), whereas less than half of the patients had bronchial asthma (46.2%), nasal polyps (36.5%) and skin allergy (36.5%). Regarding the characteristics of immunotherapy, about one-quarter of the patients were receiving the immunotherapy for less than 6 months (26.9%), whereas 32.7%, 36.5% and 3.8% of them were receiving the therapy for 7 months to 1 year, more than 1 year to 2 years and more than 2 years, respectively. The reliability of the SNOT-22 scale was excellent as indicated by a Cronbach's alpha (α = 0.907). The most common problematic aspects before the immunotherapy (responses ranging from moderate to bad problems) were related to sneezing (96.1%), blockage/congestion of nose (94.2%) and runny nose (92.3%). These problematic aspects were indicated by 17.3%, 15.3% and 11.5% of patients after the intervention, respectively. The overall SNOT-22 score decreased significantly after the immunotherapy compared to before the intervention (median = 79.5, interquartile range [IQR] = 67.5–87.0 before the intervention and median = 18.0, IQR = 13.5–23.0 after the intervention, P < 0.0001). Similarly, the median values of all items of the SNOT-22 questionnaire reduced significantly (P < 0.0001 for all). The percentage improvement of the SNOT-22 score was 71.3% ±19.5 for the whole sample. Results of the correlation testing revealed a significant association between the pre-immunotherapy score and the percentage improvement (Spearman correlation coefficient = 0.32, P = 0.019), which indicates that patients with higher pre-therapeutic scores had a greater improvement with immunotherapy. Considering the factors associated with percentage improvement, results showed that the improvement in the overall SNOT-22 score differed significantly based on the duration of immunotherapy.

Conclusion:
As overall, this study can conclude that sublingual immunotherapy as treatment of AR led to a reduction in all symptoms studied, improving the quality of life of patients, proving itself as an important therapeutic tool for these pathological conditions. In addition to that, it has a known and relatively low risk of severe adverse events. Furthermore, a significant association was noted between the preimmunotherapy score and the percentage improvement which indicates that patients with higher pretherapeutic scores had a greater improvement with immunotherapy.