Discussion
In the AIT-workshop involving 46 doctors dealing with patients seeking
care for seasonal allergic rhinitis, we found that the measurement of
serum specific IgE to the major allergenic molecules of pollens (CRD)
and the use of an eDiary significantly improved the accuracy of AIT
prescription, not only among AS, but also in the group of GP.
In fact, when AS combined the “traditional approach” (anamnesis and
SPT and/or IgE to pollen extracts) with these diagnostic tools (CRD and
eDiary), they frequently modified and harmonized their AIT decision. The
same trend was observed in the group of GP, who improved their clinical
decision up to reproducing the standards of AS.
We have previously reported6 in another cohort
(n=1271), that the inclusion of CRD in the diagnostic algorithm led to a
change in AIT prescription for 44% of the patients. This might be
explained by the presence of highly cross-reactive molecules from
unrelated allergenic sources (e.g. profilins, polcalcins and LTPs),
which may contribute to a confounding SPT-reactivity to extracts. Once
this interference is ruled out by CRD, the clinical decision taking is
simplified, especially for patients with various positive SPT results.
Still, the clinical significance of individual sensitization profiles
remains to be proven before prescribing the correct treatment. In order
to overcome the inaccuracy of a retrospective symptom monitoring, the
present study successfully assessed the use of digital symptom and
medication recording. The access to this real-time clinical information
increased the diagnostic precision of the GP and AS significantly.
In general, it is estimated that only a restricted minority (2-6%) of
eligible patients currently receives AIT25. One reason
for this condition may be the fact that most patients with seasonal
allergic rhinoconjunctivitis are polysensitized26. The
choice of the correct allergen for immunotherapy appears then often
difficult, which may be the cause for clinicians to refrain from this
therapeutic option. Yet, the differentiation between a pure
polysensitization in mono-allergic patients and real poly-allergic
subjects is fundamental, as an AIT prescription for the former is
clearly recommended2. We found that also allergy
specialists were more inclined to prescribe AIT when CRD and eDiary
information were added to clinical history and SPT data. Therefore, more
patients could benefit of AIT, which is currently the only
disease-modifying treatment for SAR.
Our study may have several implications for the clinical practice. Even
though CRD and eDiary have been available for more than one decade,
guidelines for AIT have not yet adopted these diagnostic approaches. Our
findings suggest that a more precise description of the patient’s
sensitization profile before an AIT prescription should be taken into
account. There is a need of controlled studies comparing the efficacy of
AIT in patients in whom the therapeutic decision was based on SPT
results vs SPT and CRD vs SPT, CRD and eDiary. Cost-benefit studies
should also evaluate whether the immediate additional costs, implied by
molecular analysis, are justified in the long-term period. Further, it
is important to underline that the aim of CDSS should never be to
replace a healthcare professional, but to enhance clinical routine by
facilitating basic decisions and proper patient allocation at a primary
care level.
We have to acknowledge some limitations of our study. First, the sample
size is small, though 10% of whole population (200 patients) as
suggested for pilot studies27. Second, our conclusions
apply to settings with high pollen exposure for prolonged, seasonal
periods, such as those of Mediterranean countries and the study should
be repeated in other geographic areas on larger scale. Third, the forms
filled by doctors were anonymous, so no sub-group analyses could be
performed.
In conclusion, our findings suggest that in countries with high and
prolonged exposure to various allergenic pollen sources, a clinical
decision support system involving CRD and eDiary can improve the
diagnostic precision of doctors in the clinical routine significantly.
On one side, it can be useful in improving the diagnostic accuracy of AS
with a positive impact on the therapeutic management and proper AIT
prescriptions. On the other side, it can reinforce the crucial link
between GP and AS by a more conscious referral to specialists by GP,
which calls for a proper GP’s training and investigations regarding GP’s
perceptions and expectations during the referral process. This
conclusion might be useful to update national and international
guidelines on the prescription of AIT in SAR. The hypotheses, that the
precise identification of the proper allergen for AIT also improves its
clinical efficacy, as well as cost-effectiveness, deserves to be tested.