Date: {{$ActivityAssignDate}}

Dear Dr. {{ $doctorName }},

Subject: An observational, cross-sectional survey on management pattern of patients with Allergic Rhinitis and those with concomitant asthma

Asthma is a complex multifactorial disease and has a significant impact on quality of life. The patient presents with respiratory symptoms such as wheezing, shortness of breath, chest tightness, and cough, which vary over time and in severity.^1,2 Globally, the estimated burden of asthma in India is 34.3 million patients, accounting for 13.09% of the global population. In India, 13.2 per thousand deaths occur due to asthma compared to the global asthma burden, India has a three times higher death rate.^3,4

Rhinitis is a global problem and is defined as the presence of at least one of the following: congestion, rhinorrhoea, sneezing, nasal itching, and nasal obstruction. The two major classifications are allergic and nonallergic rhinitis (NAR).⁵

AR has been associated with both increased risk of asthma development and asthma severity. The exact mechanisms underlying these relationships have yet to be fully elucidated, but evidence supports a role for allergen sensitization. Compared to those with asthma alone, patients with comorbid AR and asthma have greater use of health care resources, including visits to the general practitioner, emergency department and hospitalizations. Pharmacological treatment of AR reduces this health care burden. Immunotherapy for AR improves both asthma and rhinitis symptoms in addition to preventing future allergen sensitizations and asthma development. Appropriate recognition, diagnosis and treatment of AR can significantly reduce asthma morbidity and improve quality of life.⁶

Allergic rhinitis (AR) occurs when an allergen is the trigger for the nasal symptoms. NAR is when obstruction and rhinorrhoea occur in relation to nonallergic, non-infectious triggers such as change in the weather, exposure to caustic doors or cigarette smoke, barometric pressure differences, etc.⁶

Both are highly prevalent diseases that have a significant economic burden on society and negative impact on patient quality of life.⁷

The prevalence of AR has been reported from 10% to 40 % worldwide. AR is primarily driven by an immunoglobulin E (IgE)-mediated type 1 hypersensitivity response, due to an allergen exposure.

Classic AR symptoms include sneezing, rhinorrhoea, and nasal congestion/obstruction. These symptoms are non-specific, and the differential diagnosis of AR is broad⁶

Cysteinyl Leukotrienes (CysLTs) have been correlated with the pathophysiology of asthma and allergic rhinitis. In allergic rhinitis, CysLTs are released from the nasal mucosa after allergen exposure during both early-and late-phase reactions and are associated with symptoms of allergic rhinitis.⁹

H1 antagonists (H1 anti-histamines) competes with endogenous histamine for binding at peripheral H1-receptor sites on the effector cell surface and treat a variety of allergic symptoms including allergic rhinitis⁴.

Montelukast is an orally active compound that binds with high affinity and selectivity to the CysLT1 receptor. Montelukast inhibits the physiologic actions of LTD4 at the CysLT1 receptor.⁹ Levocetirizine is a non-sedating, selective histamine H1 receptor antagonist, with antihistamine and anti-inflammatory properties. Levocetirizine competes with endogenous histamine for binding at peripheral H1-receptor sites on the effector cell surface and treat a variety of allergic symptoms including allergic rhinitis.⁴