Reviews and feature article
Allergic Rhinitis and its Impact on Asthma (ARIA): Achievements in 10 years and future needs

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Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

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Scientific publications using the ARIA classification

A Medline search carried out August 1, 2011, retrieved 251 original articles conducted in 43 countries that used the ARIA classification of intermittent and persistent AR. These studies have involved more than 170,000 subjects (see Table E1 in this article's Online Repository at www.jacionline.org), including preschool children, but no study has specifically targeted the elderly. The articles included epidemiologic studies in the general population (cross-sectional16, 17, 18, 19, 20, 21, 22, 23

The ARIA classification of AR is close to patients' needs

The classification of AR was revised by ARIA in 2001. A major change was the introduction of the terms “intermittent” and “persistent.”4 Previously, AR was classified based on the time and type of exposure and symptoms as seasonal, perennial, and occupational.2, 33 However, this classification is not entirely satisfactory because of the following:

  • In certain areas, pollens and molds are perennial allergens,34 whereas house dust mites show seasonal trends.35

  • Most patients are polysensitized to

Comorbidity between asthma and rhinitis

The links between rhinitis and asthma were identified 2 centuries ago. However, before the ARIA workshop, asthma and rhinitis comorbidity was disregarded, and even in 2012, some guidelines do not report these links properly. However, the ARIA update literature review clearly supported the links between the upper and the lower airways.11 Most patients with asthma (both allergic and nonallergic) also have rhinitis, whereas 10% to 40% of patients with AR have asthma comorbidity.11 Some,36 but not

Clinical effect of the ARIA classification

Large observational cross-sectional studies have found that severity (mild-moderate to severe) and persistence (intermittent/persistent) are 2 separate and possibly independent components of rhinitis.

In studies often carried out in primary care settings, adults or children with moderate-to-severe rhinitis have a similar impairment of quality of life or productivity irrespective of whether they have intermittent or persistent rhinitis. Mean Rhinoconjunctivitis Quality of Life Questionnaires or

Subphenotyping of patients with AR

Severity is one of the phenotypic characteristics of allergic disease that has received particular attention. Severity fluctuates from year to year in relation to allergen exposure. Most patients seeking medical care present with moderate-to-severe AR,56, 57, 58, 59, 60 whereas in the general population they have mild AR.18 Severe chronic upper airway disease, as proposed by a joint ARIA–Global Allergy and Asthma European Network (GA2LEN)–World Allergy Organization expert group,61 is defined by

ARIA statements, position papers, and recommendations

The ARIA expert panel has produced several recommendations, statements, and position papers, often in collaboration with other organizations and/or the WHO Collaborating Center for Asthma and Rhinitis (Montpellier) (Table I).61, 66, 67, 68, 69

ARIA has proposed stepwise guidelines (Fig 1).8

ARIA 2010 Revision

The ARIA 2010 Revision was developed following the GRADE approach70 by the ARIA-GA2LEN guideline panel71 in total independence from the private sector.15 It summarized the potential benefits and harms underlying the recommendations, as well as assumptions around the values and preferences that influenced the strength and direction of the recommendations.

Two independent methodologists developed evidence summaries with the help of an information scientist with experience in GRADE and 2

Dissemination and implementation

Guidelines need simplicity and educational outputs (ie, Web-based activities [www.whiar.org, www.ariaenespanol.org],76 pocket guides, and questionnaires77), which are essential to facilitate implementation.78 The pocket guide, developed after the ARIA Workshop report, has been translated into more than 50 languages. A version for the pharmacist has also been produced.79

The 2008 update executive summary has been translated into more than 30 languages.80, 81, 82, 83, 84, 85, 86, 87, 88 In the

Global applicability of ARIA and unmet needs

Many unmet needs for AR have been published. In this document, unmet needs specific to ARIA are proposed from existing ARIA documents.

Interactions with the private sector

The private sector has been involved in ARIA with the status of observer, as described according to the WHO Global Alliance Against Chronic Respiratory Diseases (GARD) (http://www.who.int/gard):

  • industry associations/umbrella organizations representing manufacturers of diagnostic reagents, devices, drugs, or other products or services relevant to the surveillance, prevention, and control of allergic and respiratory diseases and

  • commercial enterprises and private sector entities.

The role of

ARIA in the political agenda

ARIA was initiated during a WHO workshop (1999) and published in collaboration with WHO. It was then involved in the activities of the WHO Collaborating Center for Asthma and Rhinitis (Montpellier). The 2008 Update was carried out in collaboration with WHO, GA2LEN (Framework Programme 6), and AllerGen (the Canadian network on allergy).

The European Medical Agency has accepted the ARIA classification of intermittent and persistent rhinitis.

ARIA has been used in several guidelines recommended by

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  • Cited by (0)

    Disclosure of potential conflict of interest: J. Bousquet has received honoraria from Stallergenes, Actelion, Almirall, AstraZeneca, Chiesi, GlaxoSmithKline, Merck, Novartis, OM Pharma, Sanofi, Teva, and Uriach. P. Demoly is a speaker for and on the advisory board of Stallergenes and ALK-Abelló; is a consultant for Therabel and Crucell; is a speaker for Merck/Schering-Plough, AstraZeneca, and GlaxoSmithKline; has received research support from Stallergenes and ALK-Abelló; and is the Vice President of the European Academy of Allergy and Clinical Immunology (EAACI). S. Bonini has a scientific board member and speaker at Symposia sponsored by A. Menarini, MS&D, Novartis, Nycomed/Takeda, PHADIA/Thermo Fischer, and Stallergenes and is a member of the LIBRA (Italian Guidelines for Asthma, Rhinitis, and COPD) executive board. L. P. Boulet is on the advisory boards for AstraZeneca, GlaxoSmithKline, Merck Frosst, and Novartis; has received lecture fees from 3M, AstraZeneca, GlaxoSmithKline, Merck Frosst, and Novartis; has received research support from Altair, Amgen, Asmacure, AstraZeneca, Boehringer-Ingelheim, Genentech, GlaxoSmithKline, Pharmaxis, Schering, Wyeth, and Merck Frosst; is chair for the Canadian Thoracic Society Respiratory Guidelines Committee and the Global Initiative for Asthma (GINA) Guidelines and Implementation Committee; is an organizational holder for the Laval University Chair on Knowledge Transfer, Prevention and Education in Respiratory and Cardiovascular Health; and is a member of the Knowledge Translation Canada. T. B. Casale is on the Stallergenes advisory board, is a consultant for Roche has received research support from Stallergenes and Roche, and is Executive Vice President for the American Academy of Allergy, Asthma & Immunology (AAAAI). A. A. Cruz is an advisor and lecturer for Merck and Mantecorp; is a lecturer for GlaxoSmithKline, Novartis, Chiesi, and Aventis; has received an educational grant from Ache; and has received research support from the Brazilian Research Council, Fundação de Amparo à Pesquisa da Bahia, and GlaxoSmithKline. W. J. Fokkens has received research support from GlaxoSmithKline and provided legal consultation/expert witness testimony for Stallergenes. J. A. Fonseca has received lecture and consulting fees from Merck has received research support from the Fundação Ciencia e Tecnologia and is Vice President of the Sociedade Portuguesa de Alergologia e Immunologia Clinica. L. Grouse has received funds from Novartis for personal services. T. Haahtela has received lecture fees from Abdi Ibrahim, GlaxoSmithKline, MSD, and OrionPharma and has received research support from Stallergenes. K. C. Lødrup Carlsen has received research support from MeDALL EU. R. Naclerio is on the speaker's bureau for Merck and Sunovion; is a consultant for Teva, Kalypsys, and Regeneron; and has received research support from Nasonebs, GlaxoSmithKline, Merck, and McNeal. K. Ohta has received lecture honoraria from MSD, Novartis, and GlaxoSmithKline. S. Palkonen's employer received grants from Novartis, GlaxoSmithKline, Boehringer-Ingelheim, Pfizer, Chiesi, ALK-Abelló, Stallergenes, Nycomed, AstraZeneca, and Air Liquid Healthcare. N. G. Papadopoulos has received honoraria from Merck, AllergoPharma, Abbott, and Uriach. D. Price has received consultancy fees from Merck, Mundipharma, Novartis, GlaxoSmithKline, Almirall, Chiesi, Kyorin, and Teva; has received consultancy fees and grants from Pfizer, AstraZeneca, and Boehringer-Ingelheim; has received research support from the UK National Health Service, Aerocrine, and Nycomed; holds shares in AKL Ltd; and is director of Research in Real Life Ltd. D. Ryan is a consultant for Uriach and is Allergy Lead for the International Primary Care Respiratory Group. F. E. R. Simons is on the Rupatadine Medical Advisory Board. D. Williams's spouse is employed by GlaxoSmithKline. A. Yorgancioglu has received honoraria from MSD, GlaxoSmithKline, and Novartis and has received research support from Chiesi. O. M. Yosuf has received honoraria from and is director and chair of research for the International Primary Care Respiratory Group. C. A. Akdis has received research support from Novartis, PREDICTA, Swiss National Science Foundation, MeDALL, the Global Allergy and Asthma European Network (GA2LEN), and the Christine Kuthe Center for Allergy Research and Education; has provided legal consultation/expert witness testimony on the topics of Actellion Th2-specific receptors, Aventis T-cell and B-cell regulation, Stallergenes allergen-specific immunotherapy, and Allergopharma allergen-specific immunotherapy; is a Fellow and interest group member of the AAAAI; is president of the EAACI; and is a GA2LEN ex-com member WP leader. I. J. Ansotegui has received consulting fees and honoraria from Faes Farma and Bial, has received consulting fees from Johnson & Johnson and Sanofi, and has received honoraria from AstraZeneca. E. D. Bateman is a consultant for and on the advisory board of Almirall; is on the advisory board of Forest, Novartis, Napp Pharma, and Actelion; has received lecture and consultancy fees and grants and is on the advisory board for Boehringer Ingelheim; has received lecture fees and is on the advisory board for GlaxoSmithKline, Nycomed, and AstraZeneca; is a consultant for ALK-Abelló; and is the GINA chair of board. E. H. Bel has received research support from GlaxoSmithKline, Novartis, and Innovative Medicine Initiative (EU). M. S. Blaiss is a speaker for GlaxoSmithKline, Merck, AstraZeneca, Nycomed, Sunovion, and Genentech; is a consultant for Alcon, ISTA, Allergan, Proctor & Gamble, and Pfizer; has received research support from GlaxoSmithKline; and is HAD treasurer. M. A. Calderon is a speaker for ALK-Abelló, Merck, and STG. K. H. Carlsen has received research support from Helse Sør-Øst RHF (Southern and Eastern Norway Regional Health Authority). W. Carr is a consultant for and has received research support from MEDA, Alcon, and ISTA. A. M. Cepeda is a speaker for MSD, AstraZeneca, and Novartis and has received research support from Novartis and Universidad Metropolitana. L. Cox is a speaker for Thermo-Fisher and ISTA and has received research support from Stallergenes and Teva. A. Custovic has received lecture fees from GlaxoSmithKline, Thermo-Fisher, MSD, and Airsonett; is on the advisory board for Novartis; and has received research support from the Medical Research Council and Moulton Charitable Trust. R. Dahl has received lecture fees from ALK-Abelló and MSD, has received research support from ALK-Abelló and Stallergenes, and is chair of the Danish Respiratory Society. U. Darsow is a consultant for Benoard. F. De Blay has received research support from Stallergenes, ALK-Abelló, Novartis, GlaxoSmithKline, AB Science, and Amgen. J. A. Denburg has received research support from the Canadian Institutes for Health Research and AllerGen NCE. P. Devillier has received consultancy fees and honoraria from Stallergenes and has received consultancy fees from Merck/Schering-Plough, GlaxoSmithKline, and AstraZeneca. S. R. Durham is a consultant and speaker for ALK- Abelló and Merck, is a speaker for GlaxoSmithKline, has received consultancy fees from Boehringer Ingelheim and Circassia, has received research support from ALK-Abelló and Novartis, has provided legal consultation/expert witness testimony on the topic of topical corticosteroids and antihistamines in allergic rhinitis is on the Immune Tolerance Network/National Institute of Allergy and Infectious Diseases (NIAID) steering committee, and is on the British Society for Allergy and Clinical Immunology standards of care committee. M. S. Dykewicz is a consultant for Merck; is on the AAAAI Board of Directors, Needs Assessment Committee, Rhinitis/Sinusitis/Ocular Diseases Committee, and Web Site Oversight Committee; and is on the American College of Allergy, Asthma & Immunology (ACAAI) Program Directors Advisory Committee (chair), Annual Program Planning Committee, Publications Committee, Rhinitis-Sinusitis Committee, Occupational Health Committee, Ocular Allergy Committee. A. Fiocchi has received research support from Stallergenes. S. Gonzalez Diaz is a speaker for GlaxoSmithKline, MSD, and Takeda and has received research support from the University Hospital and Medical School of Universidad Autonoma de Nuevo Leon, Mexico. M. Gotua has received honoraria from GlaxoSmithKline and AstraZeneca. J. O'B. Hourihane has received research support from the Children's Research Foundation (Ireland), Danone, the Food Standards Agency (United Kingdom), and Stallergenes; in addition, his employer, University College Cork, holds a patent on challenge outcome predictor software. M. Humbert has received consultancy and lecture fees from AstraZeneca, GlaxoSmithKline, Novartis, Pfizer, Stallergenes, and Teva. J. C. Ivancevich is on the Faes Farma advisory board, is speaker for Laboratorios Casasco Argentina, and is Web editor for the World Allergy Organization and Interasma. O. Kalayci was the Uriach Pharma chairperson at the company sponsor symposium. M. A. Kaliner is a consultant for Ista and Alcon, has received research support from multiple allergy and asthma companies, and has provided legal consultation/expert witness testimony for Alcon. T. Keil has received research support from the European Union (EU) and DTG. P. K. Keith is a speaker for and has received research support from GlaxoSmithKline and Merck. B. Koffi N'Goran is a speaker for AstraZeneca and GlaxoSmithKline. G. H. Koppelman has received research support from the Netherlands Asthma Foundation and MeDALL. D. E. Larenas-Linnemann has received a speaker's fee and travel grant from Merck-Sharp-Dohme, Mexico; has received a speaker's fee from AstraZeneca; has received travel grants from Allerquim Mexico, ALK-Abelló, and Stallergenes; has received research support from Allerquim Mexico, ALK-Abelló, Stallergenes, and Greer Laboratories; and is chair of the IT committee for the AAAAI and Mexican College of Clinical Immunology and Allergy. L. T. Le has received honoraria from GlaxoSmithKline and AstraZeneca, has received research support and honoraria from MSD, and is chair of the Respiratory Society of Ho Chi Minh City, Vietnam. C. Lemière is on the AstraZeneca advisory board. P. Lieberman is an advisor for the Allergy Foundation of America. B. Lipworth has provided legal consultation/expert witness testimony for Nycomed on the topic of nasal ciclesonide. B. Mahboub is employed by the Dubai Health Authority and the University of Sharjah. F. D. Martinez is a consultant for MedImmune and has received lecture honorarium and travel fees from Abbott. E. O. Meltzer is a consultant and on the advisory board for Alcon, AstraZeneca, Bausch + Lomb, Dey, Forest, Ista, Johnson & Johnson, Meda, Merck, ONO Pharma, OptiNose, Proctor & Gamble, Rady Children's Hospital, Rigel, Sanofi Aventis, Sepracor, Stallergenes, Teva, Alexza, Boehringer Ingelheim, Kalypsys, and Sunovion; is a speaker for the AAAAI, Alcon, Allergists for Israel, Dey, Florida Allergy Asthma Immunol Society, Ista, Sepracor, Teva, Merck, and Sunovion; has received research support from Amgen, Apotex, HRA, MedImmune, Schering-Plough, Alcon, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, Proctor & Gamble, Sunovion (Sepracor), and Teva; has provided legal consultation/expert witness testimony for Aventis Pharmaceuticals and Sanofi Aventis in the USLLC v. Barr Laboratories Fexofenadine Litigation; and is a Fellow of the AAAAI, ACAAI, and World Allergy Organization (WAO). H. Merk has received research support from Phadia and has provided legal consultation/expert witness testimony for Novartis and ALK-Abelló. F. Mihaltan has received consulting fees and honoraria from AstraZeneca, GlaxoSmithKline, MSD, Novartis, Nycomed, Boehringer Ingelheim, Servier, Sanofi, Pfizer, CSC Johnson & Johnson, Oxygen Plus, and New Medics. S. Nafti has received research support from the European Respiratory Society and the Société de Pneumologie de Langue Française Asthma and has provided legal consultation/expert witness testimony for GlaxoSmithKline on the topics of asthma and chronic obstructive pulmonary disease. Y. Okamoto is a medical advisory for Taibo Pharmaceutical Co, Ono Pharmaceutical Co, and Meiji Nyugyo Co and has received research support from the Ministry of Health, Welfare, and Labor. D. S. Postma has received consultancy fees from Nycomed, GlaxoSmithKline, AstraZeneca, and Chiesi. K. F. Rabe has received research support from Altana, Novartis, AstraZeneca, and MSD and has provided legal consultation/expert witness testimony for AstraZeneca, Chiesi, Novartis, MSD, and GlaxoSmithKline. J. Ring has received research support from ALK-Abelló, Allergopharma, Almirall-Hermal, Astellas, Bencard, Biogen-Idec, Gladerma, GlaxoSmithKline, Leo, MSD, Novartis, Phadia, PLS Design, and Stallergenes. R. Roberts is president of the World Organization of Family Doctors and the American Academy of Family Physicians Foundation and is Vice Chair of the Interstate Postgraduate Medical Association. B. Rogala has received lecture fees from Takeda, Nycomed, Teva, UCB, and Chiesi and is on the advisory board for MSD and AstraZeneca. G. K. Scadding has received research support from and is a speaker for ALK-Abelló and GlaxoSmithKline, is on the Uriach advisory board, and is a speaker for Merck. A. Sheikh has received consultancy fees from Phadia and NAPP and is a Royal College of GPs Clinical Champion in Allergy. S. W. Stoloff is a consultant and on the advisory board for Teva and is a consultant for Aerocrine, Merck, and Sunovion. B. P. Yawn has received research support from the Agency for Healthcare Research and Quality (AHRQ) and the National Heart, Lung, and Blood Institute (NHLBI). T. Zuberbier has received consultancy fees, honoraria, and/or research support from AnseII, Bayer Schering, OST, Fujisawa, IHAL, Henkel, Kryolan, Leti, MSO, Novartis, Procter and Gamble, Sanofi-Aventis, Schering-Plough, Stallergenes, and UCB; is on the Scientific Advisory Board for the German Society for Allergy and Clinical Immunology; is on the Expert Commission “Novel Food” of the German Federal Ministry of Consumer Protection; is Head of the European Centre for Allergy Research Foundation (ECARF); is a Committee member of the World Health Organization (WHO) Initiative Allergic Rhinitis and its Impact on Asthma (ARIA); is a Member or the WAO Communications Council; and is Secretary General of GA2LEN. The rest of the authors declare that they have no relevant conflicts of interest.

    For a list of the authors' institutional affiliations and the disclosures of potential conflicts of interest, see Appendix 1.

    Deceased.

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