MACVIA clinical decision algorithm in adolescents and adults with allergic rhinitis
Authors: Jean Bousquet, Holger J. Schünemann, Peter W. Hellings, Sylvie Arnavielhe, Claus Bachert, Anna Bedbrook, Karl-Christian Bergmann, Sinthia Bosnic-Anticevich, Jan Brozek, Moises Calderon, G. Walter Canonica, Thomas B. Casale, Niels H. Chavannes, Linda Cox, Henry Chrystyn, Alvaro A. Cruz, Ronald Dahl, Giuseppe De Carlo, Pascal Demoly, Phillipe Devillier, Gérard Dray, Monica Fletcher, Wytske J. Fokkens, Joao Fonseca, Sandra N. Gonzalez-Diaz, Lawrence Grouse, Thomas Keil, Piotr Kuna, Désirée Larenas-Linnemann, Karin C. Lodrup Carlsen, Eli O. Meltzer, Jaoquim Mullol, Antonella Muraro, Robert N. Naclerio, Susanna Palkonen, Nikolaos G. Papadopoulos, Giovanni Passalacqua, David Price, Dermot Ryan, Boleslaw Samolinski, Glenis K. Scadding, Aziz Sheikh, François Spertini, Arunas Valiulis, Erkka Valovirta, Samantha Walker, Magnus Wickman, Arzu Yorgancioglu, Tari Haahtela, Torsten Zuberbier, Werner Aberer, Mitsuru Adachi, Ioana Agache, Cezmi Akdis, Mubeccel Akdis, Isabella Annesi-Maesano, Ignacio J. Ansotegui, Josep M. Anto, S. Hasan Arshad, Ilaria Baiardini, Abay K. Baigenzhin, Cristina Barbara, Eric D. Bateman, Bianca Beghé, Elisabeth H. Bel, Ali Ben Kheder, Kazi S. Bennoor, Michael Benson, David Bernstein, Bewick Michael, Bieber Thomas, Carsten Bindslev-Jensen, Leif Bjermer, Hubert Blain, Attilio Boner, Matteo Bonini, Sergio Bonini, Isabelle Bosse, Jacques Bouchard, Louis-Philippe Boulet, Rodolphe A. Bourret, Philippe J. Bousquet, Fulvio Braido, Andrew H. Briggs, Christopher E. Brightling, Roland Buhl, Peter Burney, Andrew Bush, Fernando Caballero-Fonseca, Davide P. Caimmi, Paulo Camargos, Thierry Camuzat, Kai-Hakon Carlsen, Warner Carr, Thomas B. Casale, Alfonso Cepeda Sarabia, Leda Chatzi, Yuzhi Chen, Raphaël Chiron, Ekaterine Chkhartishvili, Alexander Chuchalin, Georgio Ciprandi, Ieva Cirule, Jaime Correia de Sousa, David Costa, George Crooks, Adnan Custovic, Sven-Erik Dahlen, Ulf Darsow, Frédéric De Blay, Esteban De Manuel Keenoy, Tony Dedeu, Diana Deleanu, Judah Denburg, Alain Didier, Anh-Tuan Dinh-Xuan, Dejan Dokic, Habib B. Douagui, Ruta Dubakiene, Stephen Durham, Mark Dykewicz, Yehia El-Gamal, Regina Emuzyte, Antje Fink-Wagner, Alessandro Fiocchi, Francesco Forastiere, Amiran Gamkrelidze, Bilun Gemicioğlu, Jose E. Gereda, Roy Gerth van Wijk, Maia Gotua, Ineta Grisle, M. Antonieta Guzmán, Tari Haahtela, Joachim Heinrich, Birthe Hellquist-Dahl, Friedrich Horak, Peter H. Howarth, Marc Humbert, Michael Hyland, Juan-Carlos Ivancevich, Edgardo J. Jares, Sebastian L. Johnston, Olivier Jonquet, Guy Joos, Ki-Suck Jung, Jocelyne Just, Marek Jutel, Igor P. Kaidashev, Musa Khaitov, Omer Kalayci, Fuat Kalyoncu, Paul Keith, Nikolai Khaltaev, Jorg Kleine-Tebbe, Ludger Klimek, Bernard Koffi N'Goran, Vitezlav Kolek, Gerard H. Koppelman, Marek Kowalski, Inger Kull, Violeta Kvedariene, Bart Lambrecht, Susanne Lau, Daniel Laune, Lan Le Thi Tuyet, Jing Li, Phillipe Lieberman, Brian J. Lipworth, Louis Renaud, Yves Magard, Antoine Magnan, Bassam Mahboub, Ivan Majer, Mika Makela, Peter J. Manning, Mohamad R. Masjedi, Marcus Maurer, Sandra Mavale-Manuel, Erik Melén, Elisabete Melo-Gomes, Jacques Mercier, Hans Merk, Neven Miculinic, Florin Mihaltan, Branislava Milenkovic, Yousser Mohammad, Mathieu Molimard, Isabelle Momas, Anna Montilla-Santana, Mario Morais-Almeida, Ralph Mösges, Rachel Nadif, Leyla Namazova-Baranova, Hugo Neffen, Kristof Nekam, Angelos Neou, Bodo Niggemann, Dieudonné Nyembue, Robyn O'Hehir, Ken Ohta, Yoshitaka Okamoto, Kim Okubo, Solange Ouedraogo, Pier-Luigi Paggiaro, Isabella Pali-Schöll, Stephen Palmer, Petr Panzner, Alberto Papi, Hae-Sim Park, Ian Pavord, Ruby Pawankar, Oliver Pfaar, Robert Picard, Bernard Pigearias, Isabelle Pin, Davor Plavec, Wolfgang Pohl, Todor Popov, Dirkje S. Postma, Paul Potter, Lars K. Poulsen, Klaus F. Rabe, Filip Raciborski, Françoise Radier Pontal, Sakari Reitamo, Maria-Susana Repka-Ramirez, Carlos Robalo-Cordeiro, Graham Roberts, Francisco Rodenas, Christine Rolland, Miguel Roman Rodriguez, Antonino Romano, José Rosado-Pinto, Nelson A. Rosario, Larry Rosenwasser, Menachem Rottem, Mario Sanchez-Borges, Joaquim Sastre-Dominguez, Peter Schmid-Grendelmeier, Eli Serrano, F. Estelle R. Simons, Juan-Carlos Sisul, Ingebjorg Skrindo, Henriette A. Smit, Dirceu Solé, Talant Sooronbaev, Otto Spranger, Rafael Stelmach, Timo Strandberg, Jordi Sunyer, Carel Thijs, Ana-Maria Todo-Bom, Massimo Triggiani, Rudolf Valenta, Antonio L. Valero, Marianne van Hage, Olivier Vandenplas, Giorgio Vezzani, Pakit Vichyanond, Giovanni Viegi, Martin Wagenmann, Ulrich Wahn, Wang De Yun, Denis Williams, John Wright, Barbara P. Yawn, Panayiotis Yiallouros, Osman M. Yusuf, Heather J. Zar, Mario Zernotti, Luo Zhang, Nanshan Zhong, Mihaela Zidarn
Journal: Journal of Allergy and Clinical Immunology (2016)

The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, prominent symptoms, symptom severity, control of AR, patient preferences, and cost. Allergen exposure and the resulting symptoms vary, and treatment adjustment is required. Clinical decision support systems (CDSSs) might be beneficial for the assessment of disease control. CDSSs should be based on the best evidence and algorithms to aid patients and health care professionals to jointly determine treatment and its step-up or step-down strategy depending on AR control. Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon (MACVIA-LR [fighting chronic diseases for active and healthy ageing]), one of the reference sites of the European Innovation Partnership on Active and Healthy Ageing, has initiated an allergy sentinel network (the MACVIA-ARIA Sentinel Network). A CDSS is currently being developed to optimize AR control. An algorithm developed by consensus is presented in this article. This algorithm should be confirmed by appropriate trials. The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, prominent symptoms, symptom severity, control of AR, patient preferences, and cost. Allergen exposure and the resulting symptoms vary, and treatment adjustment is required. Clinical decision support systems (CDSSs) might be beneficial for the assessment of disease control. CDSSs should be based on the best evidence and algorithms to aid patients and health care professionals to jointly determine treatment and its step-up or step-down strategy depending on AR control. Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon (MACVIA-LR [fighting chronic diseases for active and healthy ageing]), one of the reference sites of the European Innovation Partnership on Active and Healthy Ageing, has initiated an allergy sentinel network (the MACVIA-ARIA Sentinel Network). A CDSS is currently being developed to optimize AR control. An algorithm developed by consensus is presented in this article. This algorithm should be confirmed by appropriate trials. The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, such as age, prominent symptoms, symptom severity, control of AR, patient preferences, availability of treatment, and cost.1Meltzer E.O. Pharmacotherapeutic strategies for allergic rhinitis: matching treatment to symptoms, disease progression, and associated conditions.Allergy Asthma Proc. 2013; 34: 301-311Crossref PubMed Scopus (37) Google Scholar With allergen exposure and the resulting symptoms varying daily, patients with AR would benefit from regular monitoring of their symptoms to facilitate treatment adjustment. Clinical decision support systems (CDSSs) might be beneficial for the accomplishment of this task by assessing disease control, such as in response to treatment.2Bousquet J. Schunemann H.J. Fonseca J. Samolinski B. Bachert C. Canonica G.W. et al.MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation.Allergy. 2015; 70: 1372-1392Crossref PubMed Scopus (163) Google Scholar A CDSS is a health information technology system designed to assist health care professionals and patients with clinical decision-making tasks. Knowledge-based CDSSs consist of 3 parts: the knowledge base, an inference engine, and a mechanism to communicate.3Berlin A. Sorani M. Sim I. A taxonomic description of computer-based clinical decision support systems.J Biomed Inform. 2006; 39: 656-667Crossref PubMed Scopus (89) Google Scholar, 4Berner E. Clinical decision support systems: State of the Art. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville (MD)2009Google Scholar The knowledge base contains the rules and associations of compiled data. The inference engine combines the rules from the knowledge base with the patient's data. The communication mechanism allows the system to show the results to the user, as well as have input into the system. CDSSs should be based on the best evidence and algorithms to aid patients and health care professionals to jointly determine the treatment and its step-up or step-down strategy depending on AR control.1Meltzer E.O. Pharmacotherapeutic strategies for allergic rhinitis: matching treatment to symptoms, disease progression, and associated conditions.Allergy Asthma Proc. 2013; 34: 301-311Crossref PubMed Scopus (37) Google Scholar Thus CDSSs should help optimize treatment. Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon (MACVIA-LR [fighting chronic diseases for active and healthy ageing], http://macvia.cr-languedocroussillon.fr) is one of the reference sites of the European Innovation Partnership on Active and Healthy Ageing.5Bourret R. Bousquet J. An integrated approach to telemonitoring noncommunicable diseases: best practice from the European innovation partnership on active and healthy ageing.World Hosp Health Serv. 2013; 49: 25-28PubMed Google Scholar It initiated the project Integrated Care Pathways for Airway diseases (AIRWAYS ICPs)6Bousquet J. Barbara C. Bateman E. Bel E. Bewick M. Chavannes N. et al.AIRWAYS ICPs (European Innovation Partnership on Active and Healthy Ageing) from concept to implementation.Eur Respir J. 2016; 47: 1028-1033Crossref PubMed Scopus (42) Google Scholar and the allergy sentinel network MACVIA-ARIA Sentinel NetworK (MASK).2Bousquet J. Schunemann H.J. Fonseca J. Samolinski B. Bachert C. Canonica G.W. et al.MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation.Allergy. 2015; 70: 1372-1392Crossref PubMed Scopus (163) Google Scholar A knowledge-based CDSS is currently being developed to optimize AR control. The communication mechanism of MASK uses interconnected tablets and cell phones.7Bousquet J. Hajjam J. Piette F. Jean-Bart B. Wlosik C. Robine J.M. et al.[The French reference sites of the European Innovation Partnership on active and healthy ageing].Presse Med. 2013; 42: 1558-1561Crossref PubMed Scopus (23) Google Scholar, 8Bousquet J. Addis A. Adcock I. Agache I. Agusti A. Alonso A. et al.Integrated care pathways for airway diseases (AIRWAYS-ICPs).Eur Respir J. 2014; 44: 304-323Crossref PubMed Scopus (147) Google Scholar The proposed algorithm of the MACVIA-CDSS is presented in this article. In asthmatic patients, the treatment strategy is based on disease control and current treatment.9Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma—summary report 2007.J Allergy Clin Immunol. 2007; 120: S94-S138PubMed Google Scholar, 10O'Byrne P.M. Reddel H.K. Eriksson G. Ostlund O. Peterson S. Sears M.R. et al.Measuring asthma control: a comparison of three classification systems.Eur Respir J. 2010; 36: 269-276Crossref PubMed Scopus (71) Google Scholar, 11Reddel H.K. Bateman E.D. Becker A. Boulet L.P. Cruz A.A. Drazen J.M. et al.A summary of the new GINA strategy: a roadmap to asthma control.Eur Respir J. 2015; 46: 622-639Crossref PubMed Scopus (578) Google Scholar The variability in symptom control is challenging and necessitates careful monitoring, as well as the step up/step down of individualized therapeutic regimens over time. Both long- and short-term maintenance and reliever approaches have been proposed,12Thomas A. Lemanske Jr., R.F. Jackson D.J. Approaches to stepping up and stepping down care in asthmatic patients.J Allergy Clin Immunol. 2011; 128: 915-926Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar including the combination of an inhaled corticosteroid and fast-onset long-acting β-agonist inhaler as maintenance and reliever therapy.13Patel M. Pilcher J. Beasley R. Combination ICS/fast-onset LABA inhaler as maintenance and reliever therapy: the future for uncontrolled adult asthma?.Expert Rev Respir Med. 2013; 7: 451-454Crossref PubMed Scopus (7) Google Scholar The symptoms of AR can cause considerable morbidity in physical and emotional comfort, as well as in functional capacity and quality of life (QOL). The control and severity of AR have been defined in a similar manner to asthma.2Bousquet J. Schunemann H.J. Fonseca J. Samolinski B. Bachert C. Canonica G.W. et al.MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation.Allergy. 2015; 70: 1372-1392Crossref PubMed Scopus (163) Google Scholar, 14Bousquet J. Mantzouranis E. Cruz A.A. Ait-Khaled N. Baena-Cagnani C.E. Bleecker E.R. et al.Uniform definition of asthma severity, control, and exacerbations: document presented for the World Health Organization Consultation on Severe Asthma.J Allergy Clin Immunol. 2010; 126: 926-938Abstract Full Text Full Text PDF PubMed Scopus (535) Google Scholar, 15Bousquet J. Anto J.M. Demoly P. Schunemann H.J. Togias A. Akdis M. et al.WHO Collaborating Center for Asthma and RhinitisSevere chronic allergic (and related) diseases: a uniform approach—a MeDALL—GA2LEN—ARIA position paper.Int Arch Allergy Immunol. 2012; 158: 216-231Crossref PubMed Scopus (77) Google Scholar Measures of AR control include symptom scores, patients' self-administered visual analog scales (VASs), objective measures of nasal obstruction, a recent modification of the Allergic Rhinitis and its Impact on Asthma severity classification, and patients' reported outcomes, such as QOL or scores with several items.16Schatz M. Meltzer E.O. Nathan R. Derebery M.J. Mintz M. Stanford R.H. et al.Psychometric validation of the rhinitis control assessment test: a brief patient-completed instrument for evaluating rhinitis symptom control.Ann Allergy Asthma Immunol. 2010; 104: 118-124Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 17Demoly P. Jankowski R. Chassany O. Bessah Y. Allaert F.A. Validation of a self-questionnaire for assessing the control of allergic rhinitis.Clin Exp Allergy. 2011; 41: 860-868Crossref PubMed Scopus (66) Google Scholar However, the challenges of managing AR are increased by the fact that patients do not often recognize their AR symptoms or confuse them with those of asthma.18Nolte H. Nepper-Christensen S. Backer V. Unawareness and undertreatment of asthma and allergic rhinitis in a general population.Respir Med. 2006; 100: 354-362Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Therefore it is important for patients to be able to use an AR symptom scoring system that is simple to use and rapidly responsive to change. As is the case for asthma, the best control of AR should be achieved as early as possible to (1) improve patient satisfaction and concordance to treatment and (2) reduce the consequences of AR, including symptoms, reduced QOL, and school and work absenteeism. Untreated AR can impair driving ability and put patients at risk.19Vuurman E.F. Vuurman L.L. Lutgens I. Kremer B. Allergic rhinitis is a risk factor for traffic safety.Allergy. 2014; 69: 906-912Crossref PubMed Scopus (45) Google Scholar The ultimate goal of AR control is to reduce the costs incurred by AR.20Hellgren J. Cervin A. Nordling S. Bergman A. Cardell L.O. Allergic rhinitis and the common cold—high cost to society.Allergy. 2010; 65: 776-783Crossref PubMed Scopus (129) Google Scholar, 21Zuberbier T. Lotvall J. Simoens S. Subramanian S.V. Church M.K. Economic burden of inadequate management of allergic diseases in the European Union: a GA(2) LEN review.Allergy. 2014; 69: 1275-1279Crossref PubMed Scopus (252) Google Scholar, 22Lamb C.E. Ratner P.H. Johnson C.E. Ambegaonkar A.J. Joshi A.V. Day D. et al.Economic impact of workplace productivity losses due to allergic rhinitis compared with select medical conditions in the United States from an employer perspective.Curr Med Res Opin. 2006; 22: 1203-1210Crossref PubMed Scopus (223) Google Scholar, 23Walker S. Khan-Wasti S. Fletcher M. Cullinan P. Harris J. Sheikh A. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study.J Allergy Clin Immunol. 2007; 120: 381-387Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar A step-up/step-down approach to AR pharmacotherapy based on patient response might hold potential for optimal AR control and cost of treatment.1Meltzer E.O. Pharmacotherapeutic strategies for allergic rhinitis: matching treatment to symptoms, disease progression, and associated conditions.Allergy Asthma Proc. 2013; 34: 301-311Crossref PubMed Scopus (37) Google Scholar MASK has proposed that electronic daily monitoring with VASs might help patients achieve optimal control of AR symptoms.2Bousquet J. Schunemann H.J. Fonseca J. Samolinski B. Bachert C. Canonica G.W. et al.MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation.Allergy. 2015; 70: 1372-1392Crossref PubMed Scopus (163) Google Scholar Well-controlled AR is defined as a VAS score of 2 or less of 10. VAS cutoff values to step up or down treatment were proposed by comparison with pain VAS scores and step-up schemes or from the literature in the field of allergy (see the additional material in this article's Online Repository at www.jacionline.org).24Bousquet P.J. Bachert C. Canonica G.W. Casale T.B. Mullol J. Klossek J.M. et al.Uncontrolled allergic rhinitis during treatment and its impact on quality of life: a cluster randomized trial.J Allergy Clin Immunol. 2010; 126 (e1-5): 666-668Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 25Demoly P. Bousquet P.J. Mesbah K. Bousquet J. Devillier P. 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Wang X. Wang Y. Fan E. Li Y. et al.Effect of budesonide transnasal nebulization in patients with eosinophilic chronic rhinosinusitis with nasal polyps.J Allergy Clin Immunol. 2015; 135: 922-929.e6Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 46Mullol J. Bousquet J. Bachert C. Canonica G.W. Gimenez-Arnau A. Kowalski M.L. et al.Update on rupatadine in the management of allergic disorders.Allergy. 2015; 70: 1-24Crossref PubMed Scopus (47) Google ScholarBox 1Summary of recommendations for the treatment of AR and conjunctivitis used in the algorithm•Oral or intranasal H1-antihistamines are less effective than intranasal corticosteroids for the control of all rhinitis symptoms.28Scadding G.K. Durham S.R. Mirakian R. Jones N.S. Leech S.C. Farooque S. et al.BSACI guidelines for the management of allergic and non-allergic rhinitis.Clin Exp Allergy. 2008; 38: 19-42Crossref PubMed Scopus (261) Google Scholar, 29Wallace D.V. Dykewicz M.S. Bernstein D.I. Blessing-Moore J. Cox L. Khan D.A. et al.The diagnosis and management of rhinitis: an updated practice parameter.J Allergy Clin Immunol. 2008; 122: S1-S84Abstract Full Text Full Text PDF PubMed Scopus (865) Google Scholar, 30Brozek J.L. Bousquet J. Baena-Cagnani C.E. Bonini S. Canonica G.W. Casale T.B. et al.Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision.J Allergy Clin Immunol. 2010; 126: 466-476Abstract Full Text Full Text PDF PubMed Scopus (1187) Google Scholar, 31Roberts G. Xatzipsalti M. Borrego L.M. Custovic A. Halken S. Hellings P.W. et al.Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology.Allergy. 2013; 68: 1102-1116Crossref PubMed Scopus (213) Google Scholar, 32Scadding G.K. Optimal management of allergic rhinitis.Arch Dis Child. 2015; 100: 576-582Crossref PubMed Scopus (68) Google Scholar, 33Larenas-Linnemann D. Mayorga-Butron J.L. Sanchez-Gonzalez A. Ramirez-Garcia A. Medina-Avalos M. Figueroa-Morales M.A. et al.[ARIA Mexico 2014. Adaptation of the Clinical Practice Guide ARIA 2010 for Mexico. Methodology ADAPTE].Rev Alerg Mex. 2014; 61: S3-S116PubMed Google Scholar•Leukotriene receptor antagonists are usually considered less effective than oral H1-antihistamines.30Brozek J.L. Bousquet J. Baena-Cagnani C.E. Bonini S. Canonica G.W. Casale T.B. et al.Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision.J Allergy Clin Immunol. 2010; 126: 466-476Abstract Full Text Full Text PDF PubMed Scopus (1187) Google Scholar, 34Seidman M.D. Gurgel R.K. Lin S.Y. Schwartz S.R. Baroody F.M. Bonner J.R. et al.Clinical practice guideline: allergic rhinitis executive summary.Otolaryngol Head Neck Surg. 2015; 152: 197-206Crossref PubMed Scopus (117) Google Scholar, 35Seidman M.D. Gurgel R.K. Lin S.Y. Schwartz S.R. Baroody F.M. 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