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Consider what you know about asthma. Now think about allergies. If these two conditions seem especially estranged or disconnected, reconstruction of your respiratory knowledge is mandatory.

A good starting place is to integrate the guidelines for diagnosis and treatment developed in the summary of “Allergic Rhinitis and its Impact On Asthma” or ARIA, an ongoing project of the World Health Organization. ARIA implementation is the standard of care in more than 50 countries around the world but has been slow to catch on here in the United States. (notice only one or two of the hundred-or-so authors is American)

The cornerstone of the ARIA paradigm is an appreciation for the comorbidity of allergic rhinitis (AR) and asthma. In fact, AR and asthma often affect the same patient in the context of, what is referred to as, the “unified airway.” The ARIA definitions of AR and asthma with regard to “persistence” and “severity” are also key for the proper management of AR. Without consideration of how these conditions are related and their interactions, its likely that the physician will overlook some symptom or treatment option, and the patient will suffer for it.

Most patients with asthma also have rhinitis and about 10% to 40% of patients with AR also have asthma, asthma being more common when patients have moderate to severe, persistent AR. In children, asthma is associated with allergies but in adults, rhinitis is a risk factor for asthma. This means that different patients deserve different considerations when treating their asthma and allergies. Adults may need AR management as it puts them at higher risk for asthma exacerbations while children experience a more integrated influence of their allergies as giving rise to their asthma.

The classification of AR as intermittent or persistent by ARIA is patient-based insofar as the patient’s complaints of duration and hospitalizations determine how their disease is categorized. Intermittent and persistent definitions are meant to emphasize the comorbidity of asthma and AR since AR does not always occur as seasonal, perennial, or occupational, as allergens may.

Mild/moderate-severe AR classifications are also patient-centered. Patients with moderate-severe AR will complain similarly about quality-of-life and productivity whether reporting persistent or intermittent symptoms. These are the majority of patients that seek medical care for their AR.

Based on these definitions of persistence and severity, ARIA has developed a useful flowchart for treatment, copied here for easy reference. (image of flowchart here)

With thorough review of numerous resources, these guidelines for diagnosis and treatment of AR have been developed and gaps in the literature dealing with elderly and very young patients have, unfortunately, also been identified. Even with the availability of these standardized guidelines and the availability of many of the recommended treatments, ARIA recommends further tailoring treatment to each patient’s environment, genetic makeup etc.


The importance of the unified airway: asthma and allergIc rhinitis are one problem is stressed by the recognition of the links between the two diseases.