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- Adherence to treatment in allergic rhinitis during the pollen season in Europe: A MASK‐air StudyPublication . Bousquet, Jean; Amaral, RitaAdherence to rhinitis treatment has been insufficiently assessed. We aimed to use data from the MASK-airmHealth app to assess adherence to oral antihistamines (OAH), intra-nasal corticosteroids (INCS) or azelastine-fluticasone inpatients with allergic rhinitis. We included regular European MASK-air users with self-reported allergic rhinitis and reporting at least 1 day of OAH,INCS or azelastine-fluticasone. We assessed weeks during which patients answered the MASK-air questionnaire on all days. Werestricted our analyses to data provided between January and June, to encompass the pollen seasons across the different assessedcountries. We analysed symptoms using visual analogue scales (VASs) and the combined symptom-medication score (CSMS),performing stratified analyses by weekly adherence levels. Medication adherence was computed as the proportion of days inwhich patients reported rhinitis medication use. Sensitivity analyses were performed considering all weeks with at most 1 day ofmissing data and all months with at most 4 days of missing data. We assessed 8212 complete weeks (1361 users). Adherence (use of medication > 80% days) to specific drug classesranged from 31.7% weeks for azelastine-fluticasone to 38.5% weeks for OAH. Similar adherence to rhinitis medication was foundin users with or without self-reported asthma, except for INCS (better adherence in asthma patients). VAS and CSMS levelsincreased from no adherence to full adherence, except for INCS. A higher proportion of days with uncontrolled symptoms was observed in weeks with higher adherence. In full adherence weeks, 41.2% days reported rhinitis co-medication. The sensitivityanalyses displayed similar results. A high adherence was found in patients reporting regular use of MASK-air. Different adherence patterns werefound for INCS compared to OAH or azelastine-fluticasone that are likely to impact guidelines.
- Allergic Rhinitis and its Impact on Asthma (ARIA) Classes in MASK-air usersPublication . Bousquet, Jean; Amaral, Rita; Amaral, RitaThe Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines classify rhinitis as "intermittent" or "persistent" and "mild" or "moderate-severe". To assess ARIA classes in a real-world study in terms of phenotypic differences and their association with asthma. We performed a cross-sectional real-world study based on users of the MASK-air® app who reported data for at least 3 different months. We assessed the frequency of users according to the ARIA classes and compared these classes in terms of rhinitis symptoms, use of comedication, frequency of comorbid asthma, and the association between comorbid asthma and rhinitis control. A total of 2273 users (180 796 days) were assessed. Most users had moderate-severe rhinitis (n=2003; 88.1%) and persistent rhinitis (n=1144; 50.3%). The frequency of patients with probable asthma was 35.7% (95%CI, 34.5%-37.0%) for intermittent rhinitis and 48.5% (95%CI, 47.1%-49.9%) for persistent rhinitis. The maximum values on the visual analog scale (VAS) for rhinitis symptoms and the combined symptom-medication score were lower in patients with mild rhinitis than in those with moderate-severe rhinitis (irrespective of whether they had persistent or intermittent rhinitis). In most ARIA classes, VAS nose and VAS eye and rhinitis comedication were more frequent in patients with rhinitis+asthma than in those with rhinitis alone. This study suggests that the presence of asthma is more closely related to persistence of rhinitis than to severity and that the presence of comorbid asthma may be associated with poorer control of rhinitis across the different ARIA classes.
- Control of allergic rhinitis and asthma test for children (CARATkids): A systematic review and meta-analysis of its measurement propertiesPublication . Didi, Hadla Sami El; Pereira, Ana Margarida; Jácome, Cristina; Amaral, Rita; Wandalsen, Gustavo F.; Emons, Joyce; Grutta, Stefania La; Cilluffo, Giovanna; Batmaz, Sehra Birgül; Linhares, Daniela; Sole, Dirceu; Pinto, Bernardo Sousa; Fonseca, João Almeida; Vieira, Rafael José; Amaral, RitaControl of Allergic Rhinitis and Asthma Test for Children (CARATkids) is the first patient-reported outcome measure (PROM) designed to assess both allergic rhinitis and asthma simultaneously in children aged 6 to 12 years. CARATkids has been validated in several languages and countries, highlighting the need for a review of its psychometric properties. This study aims to evaluate the measurement properties of CARATkids. This systematic review follows PRISMA and COSMIN guidelines. A systematic search was performed across three databases (Ovid/MEDLINE, Web of Science, and Scopus in October 2023, updated in June 2025). We included studies focused on the development, cultural adaptation, or validation of CARATkids, as well as studies comparing CARATkids with other PROMs. We evaluated the quality of CARATkids development, the methodological quality of primary studies, the overall rating, and the certainty of evidence for each CARATkids measurement property and performed a meta-analysis of its measurement properties. Our search retrieved 193 results. We included nine studies. CARATkids displayed sufficient content validity. Regarding internal consistency, we found a meta-analytical Cronbach alpha of 0.81 (95% CI = 0.79; 0.83). CARATkids displayed sufficient reliability (meta-analytical intraclass correlation coefficient 0.86 [95% CI = 0.61; 0.96]). The minimal clinically important difference was 2.76. Construct validity had sufficient evidence for most correlations, with absolute meta-analytical Spearman coefficients from 0.37 to 0.71. Responsiveness showed strong correlations between CARATkids and most outcome measurement instruments. These findings support CARATkids as a suitable tool for assessing asthma and allergic rhinitis in children aged 6 to 12 years who present both conditions simultaneously.
- Methodology for the development of the Allergic Rhinitis and its Impact on Asthma (ARIA)-EAACI 2024–2025 Guidelines: From evidence-to-decision frameworks to digitalised shared decision-making algorithmsPublication . Bousquet, Jean; Amaral, Rita; Amaral, RitaThe Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines produced their first edition in 1999, with subsequent revisions in 2008, 2010, 2016 and 2019. A new iteration of ARIA—ARIA 2024–2025—in collaboration with EAACI is currently being developed, focusing on the management of allergic rhinitis. ARIA 2024–2025 follows the GRADE framework and is endorsed by the European Academy of Allergy and Clinical Immunology (EAACI). A set of approaches has been used to develop guideline questions, including surveying key opinion leaders and using artificial intelligence (AI)-based tools to analyse web searches on allergic rhinitis and to generate questions. Each prioritised guideline question is assessed through an Evidence-to-Decision (EtD) framework. EtDs support the systematic and transparent formulation of recommendations, comprising 12 criteria for which the best available evidence should be sought. In the context of ARIA-EAACI 2024–2025, such evidence is derived not only from randomised controlled trials but also—among others—from patient-generated data sources that better reflect the affected individuals' perspectives. Moreover, ARIA-EAACI 2024–2025 incorporates evidence on planetary health. Developed guideline recommendations will support the creation of digitalised decision algorithms and care pathways. This paper describes the methodology used to develop the person-centred, digitally enabled and AI-assisted ARIA-EAACI 2024–2025. Among others, it describes (i) the development and prioritisation of guideline questions, (ii) sources of evidence for EtDs and (iii) the development of digitalised decision algorithms and care pathways.