A substantial number of allergic rhinitis (AR) cases in Singapore, particularly those with more severe symptoms, remain undiagnosed or receive inadequate treatment. This contributes to a hidden but significant burden of AR in the population, as shown in a study.
In a cohort of 9,323 young adults (mean age22.6 years, 57.9 percent female) in Singapore, AR prevalence was estimated at 35.4 percent. Of the 3,304 individuals with AR, a staggering 85.2 percent were undiagnosed and 72.5 percent were untreated. Even more concerning is that 65.4 percent of the cases were neither diagnosed nor treated. Meanwhile, 19.8 percent of the cases were self-medicated. [World Allergy Organ J 2024;17:100954]
Across all classifications of AR, a large proportion of cases went undiagnosed. This was true even among individuals with severe AR, the investigators pointed out.
When AR was classified by persistency, diagnosis was made only in 12.5 percent of intermittent AR cases and in 23.1 percent of persistent AR cases. By AR severity classifications, only 8.5 percent of mild AR cases and 17.7 percent of moderate-severe AR cases were diagnosed.
Among those experiencing moderate-severe AR, the proportion of undiagnosed cases decreased steadily as the number of disturbances increased but remained substantial nevertheless. Diagnosis rates ranged from 12.9 percent among individuals experiencing only one disturbance to 33.1 percent among those experiencing four disturbances. A similar trend was observed for diagnoses by AR duration, with the rates ranging from 4.1 percent among individuals with AR duration of less than a year to 19.0 percent among those with AR duration of at least 10 years.
“Overlaying the proportions of AR medication and diagnosis showed that out of those attempting to manage their AR via diagnosis or medication, more individuals engaged in self-medication without an AR diagnosis,” the investigators noted.
“Our findings pointed to an undermanagement of AR in young adults, especially among those suffering from AR of increased severity. Not only do the proportions of self-medicating undiagnosed AR cases point to an unaddressed burden of AR, there also exists a high likelihood of uninformed therapeutic choices being made in the treatment of AR symptoms, possibly resulting in an undertreatment of bothersome AR symptoms,” they added.
Our findings, along with previous research, highlight a significant undermanagement of allergic rhinitis (AR) in young adults. Many individuals self-medicate without a proper diagnosis, leading to potential misdiagnosis and ineffective treatment. This undermanagement can negatively impact quality of life and incur substantial costs.
The investigators noted that the undermanagement of AR is a widespread issue and not limited to the present population. Likewise, many individuals without a doctor’s diagnosis of AR rely on over-the-counter medications. Undiagnosed, untreated, or undertreated AR can have a significant negative impact on affected people’s quality of life, leading to both direct and indirect costs, they added. [Asthma Res Pract 2017;3:8; Clin Res J 2013;7:354-358; Clin Exp Allergy 2008;38:751-760]
Driving factors of hidden AR burden
Generally, this seemingly hidden burden of AR appears to be driven by two key factors—low public awareness of AR and a tendency for affected individuals to tolerate symptoms due to the nonlife-threatening nature of AR, according to the investigators. [Clin Exp Allergy 2008;38:751-760; Eur Respir J 2004;24:758-764]
“With regards to AR in Singapore, we posit that … there are additional dimensions of management deficit contributing to its under-recognition. Firstly, research studies establishing an updated prevalence and epidemiology of AR in the general Singaporean population are few and far between, with the latest population-based study having been published in 2004. Furthermore, surveys of primary care management for AR are lacking for the Singapore healthcare scene, [and] there is yet to be a local consensus on the use of ARIA guidelines in the diagnosis and treatment of AR,” the investigators said, adding that analyses of patient databases from primary healthcare providers and hospitals could provide insight into these areas. [Ann Acad Med Singapore 2020;49:885-896]
“Finally, since there is a proportion of self-medicating AR patients in the current study population, policymakers might consider the education of pharmacists in the classification and management of AR to better address patients who forego visiting the doctor,” they stated.
In the present study, rhinorrhoea was perceived as the most severe (mean Nasal Symptom Score [mNSS] 1.42), while nasal pruritus was the least severe (mNSS 1.24). Among individuals with moderate-severe AR (68.1 percent), most had either troublesome symptoms (27.7 percent) or sleep disturbances (18.4 percent). In terms of Allergic Rhinitis and its Impact on Asthma (ARIA) classes, 26.6 percent were mild intermittent, 5.4 percent were mild persistent, 50.3 percent were moderate-severe intermittent, and 17.6 percent were moderate-severe persistent. The mean TNSS (mTNSS) of AR cases was 4.43, with significantly different mTNSS across AR classifications.
