COVID-19 severity in asthma patients: a multi-center matched cohort study.

OBJECTIVE: The evidence pertaining to the effects of asthma on Coronavirus disease 2019 outcomes has been unclear. To improve our understanding of the clinically important association of asthma and Coronavirus disease 2019. METHODS: A matched cohort study was performed using data from the Mass General Brigham Health Care System (Boston, MA). Adult (age ≥18 years) patients with confirmed Coronavirus disease 2019 and without chronic obstructive pulmonary disease, cystic fibrosis, or interstitial lung disease between March 4, 2020 and July 2, 2020 were analyzed. Up to five non-asthma comparators were matched to each asthma patient based on age (within 5 years), sex, and date of positive test (within 7 days). The primary outcomes were hospitalization, mechanical ventilation, and death, using multivariable Cox-proportional hazards models accounting for competing risk of death, when appropriate. Patients were followed for these outcomes from diagnosis of Coronavirus disease 2019 until July 2, 2020. RESULTS: Among 562 asthma patients, 199 (21%) were hospitalized, 15 (3%) received mechanical ventilation, and 7 (1%) died. Among the 2686 matched comparators, 487 (18%) were hospitalized, 107 (4%) received mechanical ventilation, and 69 (3%) died. The adjusted Hazard Ratios among asthma patients were 0.99 (95% Confidence Internal 0.80, 1.22) for hospitalization, 0.69 (95% Confidence Internal 0.36, 1.29) for mechanical ventilation, and 0.30 (95% Confidence Internal 0.11, 0.80) for death. CONCLUSIONS: In this matched cohort study from a large Boston-based healthcare system, asthma was associated with comparable risk of hospitalization and mechanical ventilation but a lower risk of mortality.

Mining social media data to assess the risk of skin and soft tissue infections from allergen immunotherapy.

BACKGROUND: Allergen immunotherapy (AIT) treatment for allergic rhinitis and asthma is used by 2.6 million Americans annually. Clinical and sterility testing studies identify no risk of contamination or infection from extracts prepared using recommended aseptic techniques, but regulatory concerns persist. Social media can be used to investigate rare adverse effects not captured by traditional studies. OBJECTIVE: We sought to investigate large social media databases for suggestion of AIT skin and soft tissue infection (SSTI) risk and compare this risk to a comparator procedure with a sterile pharmaceutical. METHODS: We analyzed US-restricted data from more than 10 common text-based social media platforms including Facebook, Twitter, and Reddit between 2012 and 2016. We used natural language processing (NLP) to identify posts related to AIT and, separately, influenza vaccination (comparator procedure). NLP was followed by manual review to identify posts suggesting a possible SSTI associated with either AIT or influenza vaccination. SSTI frequencies with 95% CIs were compared. RESULTS: We identified 25,126 AIT posts, which were matched by social media platform to 25,126 influenza vaccination-related posts. NLP identified 4088 (16.3%) AIT posts that required manual review, with 6 posts (0.02%; 95% CI, 0.005%-0.043%) indicative of possible AIT-related SSTI. NLP identified 2689 (10.7%) influenza posts that required manual review, with 7 posts (0.03%; 95% CI, 0.007%-0.048%) indicative of possible influenza vaccination-related SSTI. CONCLUSIONS: Social media data suggest that SSTI from AIT and influenza vaccination are equally rare events. Given that AIT's SSTI risk appears comparable to the risk using a sterile pharmaceutical based on social media data, current aseptic technique procedures seem safe.

Sex differences in academic rank in allergy/immunology.

BACKGROUND: Female physicians are significantly less likely than male physicians to be full professors, even after accounting for age, experience, specialty, and measures of research and clinical productivity. OBJECTIVE: We sought to evaluate sex differences in academic rank in the allergy and immunology workforce. METHODS: We used a cross-sectional physician data set containing the allergist's sex, age, years since residency, faculty appointment, authored publications, National Institutes of Health (NIH) funding, clinical trial investigation, and Medicare reimbursement to investigate sex differences in the academic allergy and immunology workforce using multilevel logistic regression models. RESULTS: Among 507 academic allergists (9.3% of practicing US allergists in 2014), 323 (63.7%) were men, and 184 (36.3%) were women. Female allergists were younger (47.9 vs 56.9 years, P < .001), had fewer total (12.5 vs 28.7, P < .001) and first/last author (8.0 vs 21.5, P < .001) average publications, were less likely to have NIH funding (13.0% vs 23.5%, P = .004), were less frequently a clinical trial investigator (10.3% vs 16.1%, P = .07), and generated less average annual Medicare revenue ($44,000 vs $23,000, P = .10). Of 152 (30.0%) full professors, 126 (82.9%) were male, and 26 (17.0%) were female. After multivariable adjustment, rates of full professorship among female and male allergists were not significantly different (absolute adjusted difference for female vs male allergists, 6.0%; 95% CI, -8.3% to 20.2%). CONCLUSIONS: Among allergists with US medical school faculty appointments, men and women were similarly likely to be full professors after accounting for factors influencing promotion. Underlying differences in research productivity and NIH funding not explained by age differences alone warrant additional investigation.

Cardiovascular and cerebrovascular events among patients receiving omalizumab: Results from EXCELS, a prospective cohort study in moderate to severe asthma.

BACKGROUND: EXCELS, a postmarketing observational cohort study, was a commitment to the US Food and Drug Administration to assess the long-term safety of omalizumab in an observational setting, focusing predominantly on malignancies. OBJECTIVE: The aim of this study was to examine a potential association between omalizumab and cardiovascular (CV)/cerebrovascular (CBV) events in EXCELS. METHODS: Patients (≥12 years of age) with moderate to severe allergic asthma and who were being treated with omalizumab (n = 5007) or not (n = 2829) at baseline were followed up for ≤5 years. Analyses included overall CV/CBV events, but focused on the subset of arterial thromboembolic events (ATEs), comprising CV death, myocardial infarction, ischemic stroke, transient ischemic attack, and unstable angina. A prespecified analysis of the end point of ATE was conducted to control for available potential confounders. A blinded independent expert panel adjudicated all events. RESULTS: At baseline, the 2 cohorts had similar demographic characteristics, but severe asthma was more common in the omalizumab versus the non-omalizumab group (50% vs 23%). Omalizumab-treated patients had a higher rate of CV/CBV serious adverse events (13.4 per 1,000 person years [PYs]) than did non-omalizumab-treated patients (8.1 per 1,000 PYs). The ATE rates per 1,000 PYs were 6.66 (101 patients/15,160 PYs) in the omalizumab cohort and 4.64 (46 patients/9,904 PYs) in the non-omalizumab cohort. After control for available confounding factors, the hazard ratio was 1.32 (95% CI, 0.91-1.91). CONCLUSION: This observational study demonstrated a higher incidence rate of CV/CBV events in the omalizumab versus the non-omalizumab cohort. Differences in asthma severity between cohorts likely contributed to this imbalance, but some increase in risk cannot be excluded.

Immune-mediated reactions to vancomycin: A systematic case review and analysis.

BACKGROUND: Vancomycin is a broad-spectrum antibiotic whose use may be limited by adverse drug reactions (ADRs). Although vancomycin toxic effects are known, there are limited data on vancomycin hypersensitivity reactions (HSRs). OBJECTIVE: To understand the most commonly reported vancomycin HSRs through systematic case review. METHODS: We performed a literature search for English-language case reports and series from 1982 through 2015 (last search July 31, 2015) on Ovid MEDLINE and PubMed. The search included the subject heading vancomycin with the subheading adverse effects and separate text searches for vancomycin with a list of specified HSRs. References of identified articles were reviewed to find additional articles. Clinical data were collected and summarized. RESULTS: Of 201 identified articles, 84 were screened and 57 fully assessed; these 57 articles contained 71 vancomycin HSR cases that were included in analysis. Vancomycin HSRs were immediate (anaphylaxis, n = 7) and nonimmediate (n = 64). Nonimmediate HSRs included linear IgA bullous dermatosis (LABD, n = 34), drug rash eosinophilia and systemic symptoms (DRESS) syndrome (n = 16), acute interstitial nephritis (AIN, n = 8), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN, n = 6). Median times of vancomycin therapy before HSR onset was 7 days (interquartile range [IQR], 4-10 days) for LABD, 9 days (IQR, 9-22 days) for SJS/TEN, 21 days (IQR, 17-28 days) for DRESS syndrome, and 26 days (IQR, 7-29 days) for AIN. Overall, 11 patients (16%) died, and 4 (6%) had deaths attributed to the HSR. CONCLUSION: Vancomycin causes a variety of HSRs; the most commonly identified were nonimmediate HSRs, with LABD being most frequent. We observed a high frequency of HSR mortality. Further data are needed to understand the frequency and severity of vancomycin HSRs.

Risk-stratification protocol for carboplatin and oxaliplatin hypersensitivity: repeat skin testing to identify drug allergy.

BACKGROUND: Hypersensitivity reactions (HSRs) to platinum-based chemotherapies are increasingly being recognized. The authors developed a novel risk-stratification protocol that was used successfully in a small number of patients with carboplatin-induced HSRs. OBJECTIVE: To describe the utility of this protocol in a large number of patients with carboplatin- or oxaliplatin-induced HSRs. METHODS: A 5-year retrospective review of patients referred to Massachusetts General Hospital with carboplatin- or oxaliplatin-induced HSR was performed. Patients were managed using a risk-stratification protocol using 3 repeat skin tests (STs) with intervening desensitizations. If the repeat ST result remained negative 3 times, patients received subsequent infusions without desensitization. RESULTS: From 2008 to 2012, 142 patients (92 treated with carboplatin, 50 treated with oxaliplatin) completed 574 desensitizations. Most patients were women (84.5%, mean ± SD 58.1 ± 9.3 years). Patients with carboplatin-induced HSRs were classified as having positive (n = 32, 34.8%), negative (n = 38, 41.3%), or converted (n = 22, 23.9%) ST reactions when the initial negative ST reaction converted to positive at repeat ST. Of those with oxaliplatin-induced HSRs, 22 (44%) had positive, 25 (50%) had negative, and 3 (6%) had converted ST reactions. Of the patients with negative ST reactions, 17 with carboplatin-induced HSRs and 16 with oxaliplatin-induced HSRs safely completed 59 and 95 outpatient infusions, respectively, without desensitizations. For carboplatin and oxaliplatin, ST conversion was associated with an interval of at least 6 months from the HSR to the initial ST (carboplatin, P = .002; oxaliplatin, P = .045). CONCLUSION: This risk-stratification protocol for presumed carboplatin- and oxaliplatin-induced HSRs safely identifies false-negative ST reactions and nonallergic patients who can receive infusions without desensitizations. This leads to fewer unnecessary desensitizations and improved patient care.

A protocol for risk stratification of patients with carboplatin-induced hypersensitivity reactions.

BACKGROUND: Management of patients with carboplatin-induced hypersensitivity reactions (HSR) has been complicated by high false-negative rates of carboplatin skin test (ST) results. These patients might be at risk for future carboplatin-induced HSRs. In this article we identify a strategy to improve risk stratification of patients with a history of carboplatin-induced HSRs by using a protocol that includes repeat skin testing and drug desensitization. OBJECTIVE: We sought to identify a management strategy for patients with a history of carboplatin-induced HSRs with negative carboplatin ST results. METHODS: From 2008-2010, patients with carboplatin-induced HSR underwent risk stratification per a protocol using 3 repeat STs with intervening drug desensitizations. RESULTS: Of the 44 patients with carboplatin-induced HSRs, 39 completed the protocol. Patients were classified as having positive ST results (n = 16), having negative ST results (n = 11), or ST converters when the ST result converted to positive after an initial negative result (n = 12). ST converters are more likely to have HSRs during subsequent desensitizations than patients with negative ST results (56.1% vs 4.5%, P < .001). ST converters had a significantly longer time interval between their initial HSR and initial ST evaluation compared with either patients with true-negative ST results (22.1 vs 6.0 months, P = .03) or patients with positive ST results (22.1 vs 1.8 months, P = .001). CONCLUSION: Our experience suggests that repeat STs are necessary for risk stratification in patients with a remote clinical history of HSR and an initial negative ST result because there is a significant rate of conversion to a positive ST result. ST converters have an increased risk of HSRs during subsequent carboplatin treatment.

The importance of vancomycin in drug rash with eosinophilia and systemic symptoms (DRESS) syndrome.

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome characterized by fever, rash, eosinophilia, atypical lymphocytes, and multiorgan involvement has a significant mortality. Inpatient vancomycin use is increasing and appears to be emerging as an important etiology of DRESS syndrome. This study highlights the importance of vancomycin as a cause of DRESS syndrome. We reviewed all cases of DRESS syndrome among inpatients consulted by the Allergy & Immunology service at Massachusetts General Hospital (MGH) from July 2009 through December 2010. We also reviewed the use of inpatient parenteral vancomycin over the past 4 years at MGH. Six patients fulfilled clinical criteria for DRESS syndrome, including rash, fever, eosinophilia, and hepatitis, with five (83%) having vancomycin as the attributable cause. Onset of symptoms varied from 12 days to 4 weeks after start of vancomycin treatment. Systemic findings included atypical lymphocytes, lymphadenopathy, nephritis, hypotension, tachycardia, and pharyngitis. Treatment with corticosteroids was required in three cases. Recurrence of peripheral eosinophilia was a marker of disease relapse. In three of the five patients (60%), elevated human herpesvirus 6 (HHV6) IgG titers correlated with greater systemic involvement and prolonged time to resolution. MGH pharmacy records indicate a progressive increase in the number of patients treated with parenteral vancomycin over the last 4 years. Causative agents for DRESS syndrome in an inpatient setting is likely different from that seen in the general population. With increasing use of vancomycin, we are likely to see more cases of DRESS syndrome caused by vancomycin. Recognition of vancomycin as a common cause of inpatient DRESS syndrome is important.

Difficult asthma: assessment and management, Part 1.

A minority of asthma patients have disease that proves difficult to control with usual medications and experience ongoing symptoms, poor quality of life, and limitations in activity and/or frequent asthma exacerbations. This group of patients accounts for much of the expense associated with asthma care and is the focus of national and international collaborative study groups. Distinguishing between "difficult-to-manage asthma" and truly "therapy-resistant asthma" is helpful and promotes a systematic consideration of contributory factors. Critical evaluation of factors contributing to difficult-to-manage asthma including adverse environment, comorbidities, nonadherence, and incorrect diagnosis is recommended in a systematic fashion in Part 1 of this contribution.

Difficult asthma: assessment and management, Part 2.

Patients with severe asthma have considerable morbidity related to their asthma and are at risk for serious, life-threatening exacerbations. Their management requires an intensive and comprehensive approach, including attention to reducing exposure to environmental inciters of airway inflammation and triggers of symptoms, patient education (including an asthma action plan), and opportunity for close patient-provider communication. Approved medical options include the lipoxygenase inhibitor, zileuton; the anti-immunoglobulin E monoclonal antibody, omalizumab; and bronchial thermoplasty. Nonapproved interventions of potential benefit are ultrahigh-dose inhaled corticosteroids, anticholinergic bronchodilators (tiotropium), macrolide antibiotics, and vitamin D supplementation for the vitamin D-deficient patient. Potentially toxic, "steroid-sparing" therapies such as methotrexate, cyclosporine, and etanercept are best reserved for patients participating in clinical trials. Recognition of specific subtypes of patients with therapy-resistant asthma permits more targeted treatment approaches, such as for aspirin-sensitive asthma, persistent eosinophilic asthma, asthma complicated by allergic bronchopulmonary aspergillosis, asthma with persistent airflow obstruction, and asthma with life-threatening (near fatal) asthmatic attacks. Novel therapies based on an improved understanding of the pathobiology of therapy-resistant asthma are greatly needed.

mRNA Vaccines to Prevent COVID-19 Disease and Reported Allergic Reactions: Current Evidence and Suggested Approach.

The U.S. Food and Drug Administration (FDA) has recently issued an Emergency Use Authorization (EUA) for 2 highly effective coronavirus disease 2019 (COVID-19) vaccines from Pfizer-BioNTech and Moderna. This has brought hope to millions of Americans in the midst of an ongoing global pandemic. The FDA EUA guidance for both vaccines is to not administer the vaccine to individuals with a known history of a severe allergic reaction (eg, anaphylaxis) to any component of the COVID-19 vaccine. The Centers for Disease Control and Prevention (CDC) additionally advises individuals with a history of an immediate allergic reaction to a vaccine or injectable or any history of anaphylaxis be observed for 30 minutes after COVID-19 vaccination. All other individuals should be observed for 15 minutes after COVID-19 vaccination. Staff at vaccine clinics must be able to identify and manage anaphylaxis. Post-FDA EUA, despite very strong safety signals in both phase 3 trials, reports of possible allergic reactions have raised public concern. To provide reassurance and support during widespread global vaccination, allergists must offer clear guidance to individuals based on the best information available, but also in accordance with the broader recommendations of regulatory agencies. This review summarizes vaccine allergy epidemiology and proposes drug and vaccine allergy expert opinion informed risk stratification for Allergy specialist use in conjunction with guidance of public health and regulatory authorities. The risk stratification schema guide care for (1) individuals with different allergy histories to safely receive their first mRNA COVID-19 vaccine and (2) individuals who develop a reaction to their first dose of mRNA COVID-19 vaccine.

Pet dander and difficult-to-control asthma: Therapeutic options.

The prevalence of sensitization to cat and dog allergens is high in the general population and poses a challenge to the physician managing allergic asthma. Adequate allergen avoidance is difficult to achieve because of the physical characteristics of airborne animal allergens and patient noncompliance. Allergen-specific high-dose subcutaneous immunotherapy has shown benefit in cat-allergic patients with asthma and rhinoconjunctivitis, whereas the data for dog-allergic patients are not as convincing. Alternative immunotherapy approaches including the sublingual route or allergen-derived peptide-based immunotherapy remain experimental. Pharmacotherapy of pet-allergic asthmatic patients requires a stepwise approach following established asthma management guidelines. In addition to short-acting beta-agonists and inhaled corticosteroids, prophylactic antihistamines before anticipated pet exposure, the use of intranasal steroids, and the use of leukotriene antagonists may also be considered as adjunctive therapy in pet-allergic patients with asthma and/or allergic rhinitis. Omalizumab appears to have particular efficacy in pet allergen-induced asthma. Novel therapies such as Fcgamma-Fel d 1 chimeric proteins still have to be evaluated in the human setting.

The usefulness of biomarkers of airway inflammation in managing asthma.

The goal of managing asthma is to maintain disease control. Current approaches to assessment of control do not include measurement of airway inflammation. This study was designed to assess the usefulness of biomarkers of airway inflammation in guiding asthma management decisions. A literature review was performed. Bronchial biopsy is a direct measure of airway inflammation but not practical for routine use. Enumeration of sputum eosinophils is very useful in guiding changes in controller medication to decrease asthma exacerbations, whereas measurement of exhaled nitric oxide has not proven to be useful in this regard. Serial measurement of airway hyperreactivity as a guide to asthma management yields inconclusive results. Use of indirect stimuli for bronchial challenge offers both practical and theoretical advantages in the assessment of airway hyperreactivity. Data on the analysis of exhaled breath condensate have not yet been studied adequately in guiding management decisions. Enumeration of sputum cell counts appears to be the most useful biomarker of airway inflammation in guiding asthma management decisions. Combined approaches using simple methods of measuring airway hyperreactivity and obtaining sputum samples hold promise for the future, particularly if rapid analysis of cellular products in sputum can be developed.

Utility of Risk Stratification for Paclitaxel Hypersensitivity Reactions.

BACKGROUND: Hypersensitivity reactions (HSRs) are a common impediment to paclitaxel therapy. Management strategies to guide care after a paclitaxel-induced HSR are needed. OBJECTIVE: The objective was to evaluate the utility and safety of risk stratification on the basis of severity of the initial HSR. METHODS: A risk stratification pathway was developed on the basis of a retrospective review of the management and outcome of 130 patients with paclitaxel-induced HSRs at Massachusetts General Hospital. This pathway was then studied prospectively in patients referred to Allergy/Immunology with paclitaxel-induced HSRs. RESULTS: The study population (n = 35) had a mean age of 56.1 ± 12 years and most were women (n = 33 [94%]). All 5 patients (15%) with grade 1 initial HSRs were successfully reexposed to paclitaxel, 1 patient at the standard infusion rate and 4 patients at 50% of the standard infusion rate. Thirty patients (85%) with grade 2 to 4 initial HSRs underwent initial paclitaxel desensitization based on the risk stratification pathway. No patients developed severe HSRs using the pathway. Eleven (31%) patients had HSRs that were mild to moderate in nature (grade 1, n = 4 [11%]; grade 2, n = 6 [17%]; grade 3, n = 1 [3%]) during their first desensitization. Sixteen (46%) of the 35 patients safely returned to the outpatient infusion setting for paclitaxel treatment at 50% of the standard infusion rate. Seven (20%) discontinued paclitaxel before the completion of the risk stratification pathway because of disease progression, completion of therapy, or death. CONCLUSIONS: A management strategy using the initial HSR severity for risk stratification allowed patients to receive paclitaxel safely.

The Cost of Penicillin Allergy Evaluation.

BACKGROUND: Unverified penicillin allergy leads to adverse downstream clinical and economic sequelae. Penicillin allergy evaluation can be used to identify true, IgE-mediated allergy. OBJECTIVE: To estimate the cost of penicillin allergy evaluation using time-driven activity-based costing (TDABC). METHODS: We implemented TDABC throughout the care pathway for 30 outpatients presenting for penicillin allergy evaluation. The base-case evaluation included penicillin skin testing and a 1-step amoxicillin drug challenge, performed by an allergist. We varied assumptions about the provider type, clinical setting, procedure type, and personnel timing. RESULTS: The base-case penicillin allergy evaluation costs $220 in 2016 US dollars: $98 for personnel, $119 for consumables, and $3 for space. In sensitivity analyses, lower cost estimates were achieved when only a drug challenge was performed (ie, no skin test, $84) and a nurse practitioner provider was used ($170). Adjusting for the probability of anaphylaxis did not result in a changed estimate ($220); although other analyses led to modest changes in the TDABC estimate ($214-$246), higher estimates were identified with changing to a low-demand practice setting ($268), a 50% increase in personnel times ($269), and including clinician documentation time ($288). In a least/most costly scenario analyses, the lowest TDABC estimate was $40 and the highest was $537. CONCLUSIONS: Using TDABC, penicillin allergy evaluation costs $220; even with varied assumptions adjusting for operational challenges, clinical setting, and expanded testing, penicillin allergy evaluation still costs only about $540. This modest investment may be offset for patients treated with costly alternative antibiotics that also may result in adverse consequences.

Findings from a 1000-patient internet-based survey assessing the impact of morning symptoms on individuals with allergic rhinitis.

BACKGROUND: Although the severity of allergic rhinitis symptoms might depend on the degree of exposure to the triggering allergen, it has also been noted that symptom severity varies over the course of the day. OBJECTIVES: The aims of this study were to investigate the reported impact (influence on behavior and/or feelings) of morning symptoms on individuals with allergic rhinitis and determine their perception of the effectiveness of allergy treatment. METHODS: In January 2005, online interviews based on a 16-item questionnaire were presented to adults (aged >or=18 years) with physician-diagnosed allergic rhinitis in the United States. Participants were recruited from the Roper Public Affairs and Media US national online panel. The survey sample was balanced to reflect the US population by Census Division, ethnicity, sex, and presence of children living at home. Data were weighted by sex (65% female, 35% male) based on previous research of the adult population suffering from allergies. RESULTS: The first 1000 respondents (sex, female,550 [55%]; age, >or=55 years, 378 [38%], race, white, 883 [88%]) that met all inclusion/exclusion criteria were included in the study results. There was no significant difference in the regional distribution of participants: South (34%), Midwest (25%), West (22%), and Northeast (19%). The majority of the sample (83%) reported experiencing morning symptoms of allergic rhinitis; 49% reported that their symptoms were most severe during the morning hours. The most common symptom on awakening was nasal congestion, reported by 85% of those with symptoms when they first woke tip. Of those with symptoms on awakening, the majority reported that these affected their feelings (96;/0) or behavior (87%). Among respondents who experienced symptoms on awakening, the majority reported that their symptoms affected the rest of their day "somewhat" or "a great deal" (51% and 24%, respectively). Of those respondents using allergy medication, 33% reported that its effectiveness wore off before the next dose most or all of the time. A majority of respondents reported feeling that it was very important for an allergy medication to maintain effectiveness until the next dose (68%), provide relief all day and into the next morning (62%), and enable them to wake tip with their symptoms render control (63%). CONCLUSIONS: Based on the results from this large Internet-based survey, the morning symptoms of allergic rhinitis have a negative impact on individuals, both emotionally and in terms of disruption of daily activities. Medication used for treating allergic rhinitis was reported as not always effective for the whole time interval between doses. This suggests that it might be important, when considering management options in allergic rhinitis, to select medications that offer sustained effectiveness throughout the 24-hour period.