Physicians’ Perception on Allergic Rhinitis and Its Management: A Questionnaire Based Survey

Abstract

Despite high prevalence and impact on quality of life, Allergic Rhinitis (AR) is undertreated. Furthermore, existence of a relationship between AR and upper respiratory tract infection (URTI) is less explored. This Pan-India survey intended to assess physicians’ perception about AR and URTI, and management practices in Indian setting. This questionnaire-based survey was conducted by telephonically interviewing 300 physicians [Consultant Physicians (CP): 33%; General Physicians (GP): 32%; ENT surgeons: 16%; pediatricians: 11%; allergy specialists: 8%] across India. CPs (33%) and GPs (32%) treated more AR patients in a month, versus other specialties. According to physicians, about 29.6% of patients with AR develop URTI in a month. Majority of the physicians (98%) believed that recurrent URTI can be considered as an indicator of undiagnosed AR. Majority of the physicians (98%) also considered AR to be a predisposing factor for increased risk of URTI. About 62% agreed that prompt diagnosis and treatment of AR can reduce the risk of complications such as URTI. Most preferred first- and second-line of treatment (alone or in combination) in AR management were oral antihistamines (41%) and intranasal corticosteroids (40%), respectively. Similar treatment preferences were observed irrespective of physicians’ specialization and years of experience. This survey sheds light on the need to implement clear guidelines for the diagnosis and management of AR.

Introduction

Allergic rhinitis is a chronic inflammatory respiratory disease, affecting 10–40% of the population worldwide [1]. It is defined as an inflammation of the membranes lining the nose, and is characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or post-nasal discharge. The prevalence in India ranges between 20 and 30% [2].

Allergic rhinitis is caused by an IgE-mediated inflammatory response of the nasal mucosa to the allergen [3, 4]. This results in the typical symptom presentation of rhinorrhea, sneezing, itching and nasal blockage. Systemic circulation of inflammatory cells allows their infiltration into other tissues where chemoattractant and adhesion molecules already exist. Thus, besides local inflammation, allergic rhinitis also triggers a systemic inflammation, which can augment inflammation in both the upper and lower airways [4]. Consequently, allergic rhinitis is frequently associated with comorbidities such as asthma, sinusitis, otitis media or bridge warp and sleep disorders.

The allergic rhinitis thus significantly impairs the quality of life (QoL) of the patient due to its impact on sleep quality and cognitive function, thereby limiting daily functioning, and reducing productivity. Recently, a link between allergic rhinitis and allied conditions in the upper airways like rhinosinusitis, nasal polyps, recurrent viral infections, adenoid hypertrophy, tubal dysfunction, otitis media with effusion and laryngitis has been postulated [5]. It is hence imperative to consider the etiological role of IgE-mediated inflammation of the nasal mucosa in upper respiratory tract, considering the surge in the patient population. This Pan-India survey was conducted to understand the physicians’ perception about association between allergic rhinitis and upper respiratory tract infections (URTI), in Indian setting. An attempt was also done to gain accurate understanding of the current real-world management of allergic rhinitis in India.

Methods

This prospective, cross-sectional, Pan-India survey was conducted over a period of ~ 1 month, from April to May 2018. Considering the regional differences within India, the centers were selected from five geographically different regions of the country: West (Mumbai, Pune, Ahmedabad, Jaipur), North (Delhi, Chandigarh, Lucknow, Allahabad), South (Chennai, Bengaluru, Kochi, Vizag), East (Kolkata, Guwahati, Patna, Ranchi), and Central (Bhopal, Indore, Hyderabad, Nagpur). Physicians with a clinical experience of ≥ 5 years, treating allergic rhinitis patients and willing to participate were enrolled. As this was an interview-based survey with physicians treating allergic rhinitis patients and did not involve direct participation of any patient, this survey was not submitted to any ethics committee for approval.

Study coordinators at each participating centre explained the study purpose and details to the physicians prior to enrolling them to the survey program. The survey was carried out by personal telephonic interviewing, and the information was collected on a real-time basis via online survey link data capture. Each survey link had a unique respondent identification ensuring that each physician who were interviewed could be tracked, if required. Interviews were in English and conducted by qualified and trained physicians across India who were a part of physician panel of the contracted Healthcare/Medical fieldwork Organization. The interviews were conducted in accordance with the questionnaire to maintain uniformity in the collected data.

Questionnaire

Given the paucity of the relevant research, a questionnaire was developed based on the literature review and a discussion of the expert group. The expert group comprised of an independent senior key opinion leader, experts from physician panel of the contracted Healthcare/Medical fieldwork Organization, and experts from the sponsor company, who were all skillful in patient education, and had several meetings to develop and finalize the questionnaire. Questionnaire included enquiries regarding physicians’ opinion on the association between allergic rhinitis and URTI, and the prevailing management practices for allergic rhinitis. The survey also recoded the percentage of allergic rhinitis patients presenting to the physician in a month, age and gender of the patients, and the percentage of physicians encouraging lifestyle changes and other preventive measures for the management of allergic rhinitis and URTI (Appendix).

Statistical Analysis

Descriptive statistics were used to assess the responses to the questions. All statistical analyses were performed using Quantum Software, universal version, and a p value of < 0.05 was considered statistically significant.

Results

A total of 300 physicians were interviewed across India. Participants comprised of 98 (33%) Consultant Physicians (CP), 97 (32%) General practitioners (GP), 47 (16%) Ear–Nose–Throat (ENT) surgeons, 33 (11%) Pediatricians, and 25 (8%) Allergy Specialists.

Characteristics of Participants

Table 1 shows the characteristics of the participating physicians. Majority of the physicians were men [250 (83%) physicians] and had an experience of > 10 years [279 (93%)].

Table 1.

Summary of physician’s characteristics

Characteristics of physicians	Total number of physicians (N = 300) N (%)
Age (mean in years)	49.9
Gender
Men	250 (83%)
Women	50 (17%)
Area of medical specialty
General physician (MBBS)	97 (32%)
Consulting physicians (MD Internal Medicine)	98 (33%)
Allergy specialists	25 (8%)
ENT surgeons	47 (16%)
Pediatricians	33 (11%)
Number of patients treated per month
< 150 patients	0 (0%)
151–200 patients	37 (12%)
201–300 patients	66 (22%)
301–500 patients	74 (25%)
> 500 patients	123 (41%)
Years of experience
5–10 years	21 (7%)
More than 10 years	279 (93%)

About 41% physicians (n = 123) treated more than 500 patients per month; only 12% physicians (n = 37) treated less than 200 patients per month. The CPs and GPs treated more number of allergic rhinitis patients in a month, compared to physicians of other medical specialties (Table 2).

Table 2.

Medical specialty versus frequency of patients treated in a month

Area of medical specialty	Number (%) of physicians (N = 300)	Number (%) of patients treated in a month
		< 150 patients	151–200 patients	201–300 patients	301–500 patients	> 500 patients
		N = 0	N = 37	N = 66	N = 74	N = 123
General physician (MBBS)	97 (32%)	0	24 (65%)	19 (29%)	20 (27%)	34 (28%)
Consulting physicians (MD Internal Medicine)	98 (33%)	0	6 (16%)	24 (36%)	27 (36%)	41 (33%)
ENT surgeons	47 (16%)	0	3 (8%)	14 (21%)	10 (14%)	20 (16%)
Pediatricians	33 (11%)	0	3 (8%)	4 (6%)	11 (15%)	15 (12%)
Allergy specialists	25 (8%)	0	1 (3%)	5 (8%)	6 (8%)	13 (11%)

Allergic Rhinitis and Upper Respiratory Tract Infection

According to physicians, around 29.6% of patients with allergic rhinitis develop URTI in a month. About 176 (59%) physicians ‘agreed’ and 118 (39%) physicians ‘strongly agreed’ that recurrent URTI can be considered as an indicator of undiagnosed allergic rhinitis. Only 3 (1%) physicians each were ‘neutral’ or ‘disagreed’ to consider recurrent URTI as an indicator of undiagnosed allergic rhinitis. Further, 176 (59%) physicians ‘agreed’ and 118 (39%) physicians ‘strongly agreed’ that allergic rhinitis may predispose a patient to an increased risk of URTI. Only 1% of the physicians ‘disagreed’. This was in corroboration with earlier responses on the association between allergic rhinitis and URTI. Moreover, more than half of the physicians (62%) agreed that prompt diagnosis and treatment of allergic rhinitis reduces the risk of complications like repeated rhino-sinusitis and URTI (Table 3).

Table 3.

Association between allergic rhinitis and upper respiratory tract infection: physicians’ responses

Percentage of patients with allergic rhinitis who develop URTI in a month	Number (%) of physicians Total number of physicians (N = 300)
Less than 10	23 (8%)
10–25	114 (38%)
26–50	110 (37%)
More than 50	53 (18%)
Recurrent URTI to be an indicator of undiagnosed AR
Strongly agree	118 (39%)
Agree	176 (59%)
Neutral	3 (1%)
Disagree	3 (1%)
Strongly disagree	0
AR to be a predisposing factor for increased risk of URTI
Strongly agree	118 (39%)
Agree	176 (59%)
Neutral	4 (1%)
Disagree	2 (1%)
Strongly disagree	0
Prompt diagnosis and treatment of AR reduce the risk of complications
Strongly agree	107 (36%)
Agree	186 (62%)
Neutral	3 (1%)
Disagree	3 (1%)
Strongly disagree	1 (0.33%)

URTI upper respiratory tract infection, AR allergic rhinitis

Management Practices of Allergic Rhinitis

Majority of the physicians [219 (73%)] followed a case-to-case approach (based on treatment response) for treating allergic rhinitis cases, while 81 (27%) physicians referred to ARIA guideline-based approach for treating allergic rhinitis.

Of the preventive measures, about 221 (74%) physicians suggested avoiding allergens as the most common preventive measure for allergic rhinitis management, followed by patient education [172 (57%)], and early presentation to the physicians [60 (20%)]. About 188 (63%) physicians suggested in-clinic patient education/counselling as the most effective way of creating awareness about allergic rhinitis, followed by public awareness campaigns [133 (44%)], digital medium [113 (38%)], and information leaflets [107 (36%)].

About 145 (48%) physicians responded that an antibiotic along with antihistamine may be beneficial in cases of recurrent sinusitis. Other conditions in which a combination of antibiotics and antihistamine were preferred was allergic rhinitis [114 (38%)], unexplained recurrent URTI [46 (15%)], and all cases of URTI [45 (15%)].

About 124 (41%) physicians preferred oral antihistamines [alone (70%) or in combination with other drugs (30%) for the first-line management of initial stages of allergic rhinitis, followed by intranasal antihistamines (39%)]. Intranasal corticosteroids (16%), nasal decongestant (13%), leukotriene receptor antagonist (5%), and oral corticosteroids (4%) were also preferred as the first-line drugs (Table 4). Intranasal corticosteroids (alone or in combination with other drugs) was the most preferred second-line drug for allergic rhinitis (40%) physicians, followed by oral antihistamines (31%) (Table 4). Physicians across all specialties had similar preferences for first- and second-line treatment for the management of allergic rhinitis (Tables 5 and 6).

Table 4.

First-line and second-line of management of allergic rhinitis

Allergic rhinitis treatment options/line of management	Number (%) of physicians Total number of physicians (N = 300)
First-line of management
Intranasal antihistamines	117 (39%)
Oral antihistamines	124 (41%)
Intranasal corticosteroids	47 (16%)
Nasal decongestants	38 (13%)
Leukotriene receptor antagonists	15 (5%)
Oral corticosteroids	13 (4%)
Second-line of management
Intranasal corticosteroids	121 (40%)
Oral antihistamines	94 (31%)
Oral corticosteroids	65 (22%)
Intranasal antihistamines	50 (17%)
Nasal decongestants	39 (13%)
Leukotriene receptor antagonists	34 (11%)

Table 5.

Comparison of medical specialty versus first-line and second-line of treatment in management of allergic rhinitis

Area of medical specialty	First line management Number of physicians						Second line management Number of physicians
	Intranasal antihistamines	Intranasal corticosteroids	Oral antihistamines	Oral corticosteroids	Leukotriene receptor antagonists	Nasal decongestants	Intranasal antihistamines	Intranasal corticosteroids	Oral antihistamines	Oral corticosteroids	Leukotriene receptor antagonists	Nasal decongestants
	N = 117	N = 47	N = 124	N = 13	N = 15	N = 38	N = 50	N = 121	N = 94	N = 65	N = 34	N = 39
General physicians (MBBS) (n = 97)	34	18	37	4	6	12	21	40	32	17	8	12
Consulting physicians (MD Internal Medicine) (n = 98)	43	5	44	5	7	17	14	45	23	24	16	14
Allergy specialists (n = 25)	9	9	9	0	0	5	7	8	9	5	1	6
ENT surgeons (n = 47)	18	10	20	2	2	1	4	17	20	12	4	4
Pediatricians (n = 33)	13	5	14	2	0	3	4	11	10	7	5	3

Table 6.

Comparison of years of experience with first-line and second-line of treatment in management of allergic rhinitis

Years of experience	First-line management Number of physicians						Second-line management Number of physicians
	Intranasal antihistamines	Intranasal corticosteroids	Oral antihistamines	Oral corticosteroids	Leukotriene receptor antagonist	Nasal decongestant	Intranasal antihistamines	Intranasal corticosteroids	Oral antihistamines	Oral corticosteroids	Leukotriene receptor antagonist	Nasal decongestant
	N = 117	N = 47	N = 124	N = 13	N = 15	N = 38	N = 50	N = 121	N = 94	N = 65	N = 34	N = 39
5–10 years	8	2	10	0	1	0	2	7	7	3	0	2
More than 10 years	109	45	114	13	14	38	48	114	87	62	34	37

Patient Data

Regarding patients’ characteristics, participants responded that about 49.4% of patients who consulted them were men and 50.6% were women. The mean (SD) age of these patients were about 20.6 (17.3) years.

About number of patients in a month, 153 (51%) physicians responded that 10–25% of allergic rhinitis patients visited them in a month, while 96 (32%) physicians responded that 26–40% of allergic rhinitis patients visited them in a month.

Knowledge and Awareness

Nearly half of the physicians [140 (47%)] believed that there was enough knowledge and awareness about allergic rhinitis among healthcare practitioners, while 40% remaining physicians responded as ‘no’ or ‘can’t say’ (13%). About 49% of physicians referred to recent journals/articles and about 35% attended CMEs/workshops to keep themselves abreast on the nuances of allergic rhinitis. The digital mode (10%) and reading guidelines (5%) were the other modes to keep well-informed of the latest updates on allergic rhinitis.

Discussion

Allergic rhinitis is a common manifestation of allergic diseases, resulting in substantial morbidity and health care expenditures, in turn impairing patients’ QoL. Though many guidelines and consensus statements for the management of allergic rhinitis has been recently established to augment the efficiency in managing allergic rhinitis patients, the impact of these guidelines in the diagnosis and management of rhinitis from a physician’s perspective is implicit [1, 6, 7]. This is likely due to the variances in the phase of guidelines implementation, social and economic setting, implementation strategies, and more importantly, physicians’ and patients’ subjectivity [8]. Furthermore, in many cases, upper and lower respiratory tract infections frequently complicate allergic rhinitis. Hence the objective of this study was to obtain insights on physicians’ perspective on the association between allergic rhinitis and URTI and to understand the management practices related to allergic rhinitis, in Indian setting.

Data shows that allergic rhinitis is one of the ten reasons for a visit to the primary care clinics, constituting 10–40% of the total patient visits in about 50% of the primary care clinics [9, 10]. For patients suffering from allergic rhinitis, GPs are often their first source of medical advice [11]. Only a small proportion of patients visit a specialist [12]. Wang et al. in a population-based survey reported that only 53% of rhinitis patients seek for medical help. Of these, 71% patients visited a primary care physician and only 20% visited a specialist (otolaryngologist) [13]. Our survey indicated that about 10–40% of the allergic rhinitis patients visited their physicians in a month. Further, results of this survey also showed that patients visited CPs and GPs for allergic rhinitis, compared to other specialists.

Although allergic rhinitis may be caused by a variety of conditions, often requiring a multidisciplinary approach, they rarely prompt referral to a specialist or for specific investigation. This could be one of the reasons for allergic rhinitis being underdiagnosed and undertreated, often leading to many upper airway consequences, especially secondary bacterial infection. Hence, there is an unmet need to increase awareness amongst GPs and CPs to recognize the importance of precise assessment and prompt referral of cases, if required. To the best of our knowledge, this is the first of its kind study in Indian context to understand the prevalence of allergic rhinitis patients reaching out to physicians for management.

In this survey, the mean age of allergic rhinitis patients was reported to be 20.6 years with no significant difference in the proportion of men and women. In a similar survey of 234 physicians, it was reported that about 20 patients with rhinitis visited them in a week. The mean age of the patients was reported to be 29 years, with no gender difference [14].

During allergic rhinitis, there is an increase in the number of mucosal lymphocytes, T cells, eosinophils, and mast cells along with an overexpression of intracellular adhesion molecule (ICAM)-1 and IL-13, impairing the ciliary beat frequency and increasing the susceptibility of rhinovirus invasion of nasal mucosa [15]. Also, an increase in surface expression of Fcε RIα+ on plasmacytoid and myeloid dendritic cells is noted, in turn resulting in significant reduction in IFN-α and IFN-λ1, and higher susceptibility to viral infections [16]. In line with this, in this survey, there has been an agreement that 10–50% of allergic rhinitis patients may develop URTI in a month (75% physicians) and more than half of the physicians (59%) agreed that recurrent URTI could be considered as an indicator of undiagnosed allergic rhinitis or allergic rhinitis predisposes a patient to increased risk of URTI. Moreover, about 62% physicians agreed that a prompt diagnosis and treatment of allergic rhinitis can reduce the risk of complications like repeated rhino-sinusitis and URTI.

The mast cells are found to abundantly accumulate in the epithelial compartment of the nasal mucosa [4]. Under allergic inflammatory conditions, primed mast cells express increased levels of high affinity receptor for IgE and the ligand for the surface antigen CD40, involved in T/B cell interactions, leading to IgE production [4]. Thus, there is a local production of IgE in the nasal mucosal cells of allergic rhinitis patients, which further actuates mast cells, resulting in augmentation of the production of immunomodulatory cytokines and chemical mediators like histamine. This release of histamines is primarily responsible for early phase symptoms like rhinorrhea, itching, sneezing, and vasodilation. With the increasing incidence of allergic rhinitis over time, the need for prophylactic measures is pertinent.

According to the Allergic Rhinitis and its Impact on Asthma guidelines published in cooperation with the WHO, treatment of allergic rhinitis should include a combination of patient education, allergen avoidance, pharmacotherapy, and immunotherapy [6]. In this survey, among preventive measures, about 74% of the physicians suggested evading allergens as the most effective approach to avoid AR and its complications. Moreover, despite scientific advancement in allergy, patient’s knowledge and perception of their own condition is scarce. However, only half of the physicians in this survey believed on the need for patient education as a pre-emptive to avoid allergic rhinitis. This study thus sheds light on the lack of relevance given by healthcare professionals as well as the lack of awareness amongst patients in Indian context. This necessitates an approach targeting awareness among physicians and patients through social media and digital platforms. However, only 10% physicians opted for digital mode and 5% for reading guidelines to keep themselves abreast on the latest updates on allergic rhinitis.

Current pharmacology treatment for allergic rhinitis includes antihistamines, decongestants, anticholinergic agents, intranasal cromolyn, leukotriene modifiers and inhaled steroids. The therapy of choice depends on the symptoms, their severity, past response to medications, and other medical conditions, to ultimately attain the objective of restoring the normal upper airway functioning. Antihistamines has been proven to be effective against histamine-mediated early phase symptoms of allergic rhinitis and are usually prescribed alone or in combination [17]. Antihistamines, alone or in combination, are effective in controlling symptoms of sneezing, nasal itching, rhinorrhea, and conjunctival itching and redness by competitive inhibition at the receptor level [18].

In this survey, it was indicated that 26% of the physicians suggested antihistamine alone and 65% of the physicians recommended antihistamines in combination with other drugs, viz: antihistamines with leukotriene receptor antagonist (28%), antihistamines with intranasal steroids (24%), and antihistamines with decongestant and analgesic/antipyretic (13%). About 41% physicians preferred oral antihistamines as the first-line of treatment for allergic rhinitis management, followed by intranasal antihistamines (39%), regardless of physicians’ medical specialty or years of experience. The preference towards oral antihistamines could be attributed towards its additional advantage of reducing nonnasal symptoms such as conjunctivitis etc. Topical antihistamines have a rapid onset of action (< 15 min) at low drug dosage, but their action is limited to the treated organ [19].

Further, intranasal corticosteroids (40% physicians) (alone or in combination with other drugs) was the most preferred second-line management for allergic rhinitis, irrespective of physicians’ medical specialties and years of experience. Intranasal corticosteroids are considered to be effective in controlling the symptoms of allergic rhinitis and have become the mainstay in allergic rhinitis treatment [17, 20, 21]. This class of drugs relieves symptoms by controlling the rate of protein synthesis and inhibiting the release of mediators by inflammatory cells, leading to vasoconstriction and decreased influx of inflammatory cells into the nasal mucosa. Intranasal corticosteroids ensue high drug concentration at the receptor sites in the nasal mucosa, with a minimal risk of systemic adverse effects. Among intranasal corticosteroids, physicians preferred Fluticasone (55% physicians), Budesonide (23% physicians) and Mometasone (18% physicians).

In conclusion, majority of physicians believed that recurrent URTI can be considered as an indicator of undiagnosed AR. About 10–50% of allergic rhinitis patients seen by physicians develop URTI in a month. The most preferred first- and second-line of treatment (alone or in combination) in allergic rhinitis management were oral antihistamines and intranasal corticosteroids, respectively. Similar treatment preferences were observed irrespective of physicians’ specialization and years of experience. This survey sheds light on the need to implement clear guidelines for the diagnosis and management of allergic rhinitis. This would aid in amelioration of manifestations, attenuating the predisposition of allergic rhinitis to URTI and ultimately decrease the medical burden of the disease. Further, there is a need to raise public awareness, to promote a greater understanding, and to educate about the health care needs of individuals with allergy. This will in turn aid in attaining patient adherence to prophylactic therapy, impacting the long-term symptom control. However, further studies are warranted with larger sample size to substantiate our findings.

Appendix: Questionnaires

1. What is your age (years)?

2. $\text{Gender:}\text{M}\text{F}$

3. What is your specialty?

   • i.
     General physician (MBBS)
   • ii.
     Consulting physician (MD Internal Medicine)
   • iii.
     Allergy specialist
   • iv.
     ENT surgeon
   • v.
     Pediatrician
   • vi.
     Other (specify)
4. How many patients do you treat in a typical month?

   • i.
     Less than 150
   • ii.
     Up to 200 patients
   • iii.
     200–300 patients
   • iv.
     Up to 500 patients
   • v.
     More than 500 patients
   • vi.
     Other (specify)
5. City of practice

   West	North	South	East	Central
   Mumbai	Delhi	Chennai	Kolkata	Bhopal
   Pune	Chandigarh	Bengaluru	Guwahati	Indore
   Ahmedabad	Lucknow	Kochi	Patna	Hyderabad
   Jaipur	Allahabad	Vizag	Ranchi	Nagpur

6. Years of experience

   • i.
     5–10 years
   • ii.
     More than 10 years
7. What is the income level of patients treated in a typical month (in %): instruction: (sum of all the income level should be 100)

   Income level	Description	%
   Upper class (creamy layer)	(SEC A1, A2, B1)
   Upper middle classz	(SEC B2)
   Middle class	(SEC C)
   Lower middle class	(SEC D)
   Low salary class	(SEC E)
   Others

8. [From 2] Out of …… patients treated in a typical month, what is the gender & age (in %) among patients,

   Gender
   Male	%
   Female	%

9. Age of patients treated:

   Gender	Less than 12 years	13–18 years	18–30 years	31–45 years	More than 45 years
   Male	%	%	%	%	%
   Female	%	%	%	%	%

10. In your practice, what is the % of patients with allergic rhinitis in a typical month?

    • i.
      Less than 10
    • ii.
      10–25
    • iii.
      25–40
    • iv.
      More than 40
11. Average age of patients with allergic rhinitis:

    Gender	Less than 12 years	13–18 years	18–30 years	31–45 years	More than 45 years
    Male	%	%	%	%	%
    Female	%	%	%	%	%

12. Do you think recurrent upper respiratory tract infection could be an indicator of undiagnosed allergic rhinitis?

    • i.
      Strongly agree
    • ii.
      Agree
    • iii.
      Neutral
    • iv.
      Disagree
    • v.
      Strongly disagree
13. Does allergic rhinitis predispose the patient to increased risk of upper respiratory tract infection and/or sinusitis?

    • i.
      Strongly agree
    • ii.
      Agree
    • iii.
      Neutral
    • iv.
      Disagree
    • v.
      Strongly disagree
14. What is the % of patients with AR typically in a month who develop upper respiratory tract infection?

    • i.
      Less than 10
    • ii.
      10–25
    • iii.
      25–50
    • iv.
      More than 50
15. Would prompt diagnosis and treatment of allergic rhinitis reduce the risk of complications, such as repeated rhino-sinusitis and URTI?

    • i.
      Strongly agree
    • ii.
      Agree
    • iii.
      Neutral
    • iv.
      Disagree
    • v.
      Strongly disagree
16. How do you treat allergic rhinitis in your patients?

    • i.
      Antihistamine
    • ii.
      Antihistamine + leukotriene receptor antagonist
    • iii.
      Intranasal steroid + antihistamine
    • iv.
      Antihistamine + decongestant and analgesic/antipyretic
    • v.
      Intranasal steroid
17. In what conditions, according to you, an antibiotic along with antihistamine may be beneficial in? (may choose more than one answer)

    • i.
      All cases of URTI
    • ii.
      Unexplained recurrent URTI
    • iii.
      Hay fever/allergic rhinitis
    • iv.
      Recurrent sinusitis
    • v.
      Any other (if yes, mention the condition)
18. What according to you is the first-line management for initial stages of allergic rhinitis? (may choose more than one answer)

    • i.
      Intranasal antihistamines
    • ii.
      Intranasal corticosteroids
    • iii.
      Oral antihistamines
    • iv.
      Oral corticosteroids
    • v.
      Leukotriene receptor antagonist
    • vi.
      Nasal decongestant
19. What do you prefer in second-line of management? (may choose more than one answer)

    • i.
      Intranasal antihistamines
    • ii.
      Intranasal corticosteroids
    • iii.
      Oral antihistamines
    • iv.
      Oral corticosteroids
    • v.
      Leukotriene receptor antagonist
    • vi.
      Nasal decongestant
20. What is your approach towards treating allergic rhinitis?

    • i.
      Case to case basis—based on treatment response
    • ii.
      Guideline based (ARIA guidelines)
21. Which is the preferred intranasal corticosteroid in allergic rhinitis?

    • i.
      Fluticasone
    • ii.
      Budesonide
    • iii.
      Beclomethasone
    • iv.
      Mometasone
    • v.
      Ciclesonide
22. What preventive measures would you suggest for allergic rhinitis?

    • i.
      Early presentation to the physician
    • ii.
      Avoidance of allergen
    • iii.
      Patient education
    • iv.
      Others (specify)
23. According to you, is there enough knowledge and awareness about allergic rhinitis among healthcare practitioners?

    • i.
      Yes
    • ii.
      No
    • iii.
      Can’t say
24. When do you refer a case of allergic rhinitis to a specialist? (only for GPs)

    • i.
      Persisting symptoms despite guideline based treatment for more than 2–4 weeks
    • ii.
      Recurrent cases
    • iii.
      Allergic rhinitis associated with sinusitis/upper respiratory tract infection
    • iv.
      Others
25. How do you keep yourself updated on the newer aspects of allergic rhinitis?

    • i.
      CME/workshop
    • ii.
      Recent journals/articles
    • iii.
      Digital
    • iv.
      Guidelines
26. According to you, what are the ways of patient education in creating awareness about allergic rhinitis?

    • i.
      In clinic patient education/counselling
    • ii.
      Information leaflets
    • iii.
      Public awareness campaigns
    • iv.
      Digital medium
    • v.
      Patient support groups

Funding

This survey was supported by Abbott Healthcare Pvt. Ltd.

Compliance with Ethical Standards

Conflict of interest

Dr. Sholapuri and Dr. Uchit authored this publication in the capacity as an employee of Abbott Healthcare Pvt Ltd. The authors have declared and confirmed that there is no other conflict of interest with respect to this authored publication.