BACKGROUND: Co-medication is common among patients with allergic rhinitis (AR), but its dimension and patterns are unknown. This is particularly relevant since AR is understood differently across European countries, as reflected by rhinitis-related search patterns in Google Trends. This study aims to assess AR co-medication and its regional patterns in Europe, using real-world data. METHODS: We analysed 2015-2020 MASK-air® European data. We compared days under no medication, monotherapy and co-medication using the visual analogue scale (VAS) levels for overall allergic symptoms ('VAS Global Symptoms') and impact of AR on work. We assessed the monthly use of different medication schemes, performing separate analyses by region (defined geographically or by Google Trends patterns). We estimated the average number of different drugs reported per patient within 1 year. RESULTS: We analysed 222,024 days (13,122 users), including 63,887 days (28.8%) under monotherapy and 38,315 (17.3%) under co-medication. The median 'VAS Global Symptoms' was 7 for no medication days, 14 for monotherapy and 21 for co-medication (p < .001). Medication use peaked during the spring, with similar patterns across different European regions (defined geographically or by Google Trends). Oral H1 -antihistamines were the most common medication in single and co-medication. Each patient reported using an annual average of 2.7 drugs, with 80% reporting two or more. CONCLUSIONS: Allergic rhinitis medication patterns are similar across European regions. One third of treatment days involved co-medication. These findings suggest that patients treat themselves according to their symptoms (irrespective of how they understand AR) and that co-medication use is driven by symptom severity.

Allergy and Clinical Immunology Unit Centro Hospitalar e Universitário de Coimbra and Institute of Immunology Faculty of Medicine University of Coimbra and Coimbra Institute for Clinical and Biomedical Research Faculty of Medicine University of Coimbra Coimbra Portugal

Allergy Center CUF Descobertas Hospital Lisbon Portugal

Allergy Department 2nd Pediatric Clinic University of Athens Athens Greece

Allergy Section Department of Internal Medicine Hospital Vall d'Hebron and ARADyAL Research Network Barcelona Spain

Allergy Unit D Kalogeromitros 2nd Department of Dermatology and Venereology National and Kapodistrian University of Athens Attikon University Hospital Athens Greece

Center for Rhinology and Allergology Wiesbaden Germany

Center of Excellence in Asthma and Allergy Médica Sur Clinical Foundation and Hospital México City Mexico

CIBER Epidemiología y Salud Pública Barcelona Spain

CINTESIS Center for Health Technology and Services Research University of Porto Porto Portugal

Department of Allergology and Clinical Immunology of the Kazakh National Medical University Almaty Kazakhstan

Department of Allergy and Immunology Hospital Quironsalud Bizkaia Bilbao Spain

Department of Biomedical Sciences Humanitas University Pieve Emanuele Italy

Department of Chest Medicine Centre Hospitalier Universitaire UCL Namur Université Catholique de Louvain Yvoir Belgium

Department of Clinical Immunology ALL MED Medical Research Institute Wrocław Poland

Department of Clinical Immunology Wrocław Medical University Wroclaw Poland

Department of General ORL H and NS Medical University of Graz ENT University Hospital Graz Graz Austria

Department of Immunoallergology Cova da Beira University Hospital Centre Covilhã Portugal

Department of Medical Sciences Allergy and Clinical Immunology Unit University of Torino and Mauriziano Hospital Torino Italy

Department of Medicine and Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada

Department of Medicine Clinical Immunology and Allergy McMaster University Hamilton Ontario Canada

Department of Medicine Surgery and Dentistry Scuola Medica Salernitana University of Salerno Salerno Italy

Department of Otolaryngology Head and Neck Surgery Eye and Ear University Hospital Beirut Lebanon and ENT Department Dar Al Shifa Hospital Salmiya Kuwait

Department of Otolaryngology Head and Neck Surgery Universitätsmedizin Mainz Mainz Germany

Department of Otorhinolaryngology Amsterdam University Medical Centres Location AMC Amsterdam The Netherlands

Department of Otorhinolaryngology Chiba University Hospital Chiba Japan

Department of Otorhinolaryngology Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps Universität Marburg Marburg Germany

Department of Otorhinolaryngology Head and Neck Surgery Semmelweis University Budapest Hungary

Department of Prevention of Environmental Hazards Allergology and Immunology Medical University of Warsaw Warsaw Poland

Department of Pulmonary Diseases Istanbul University Cerrahpasa Cerrahpasa Faculty of Medicine Istanbul Turkey

Department of Pulmonary medicine and tuberculosis University Hospital Brno Brno Czech Republic

Department of Pulmonary Medicine CHU Sart Tilman and GIGA I3 Research Group Liege Belgium

Department of Pulmonology Celal Bayar University Manisa Turkey

Division of Allergy and Clinical Immunology Department of Medicine Agency of Health ASL Salerno Santa Maria della Speranza Hospital Battipaglia Salerno Italy

Division of Allergy Immunology University of South Florida Tampa Florida USA

Division of Internal Medicine Asthma and Allergy Barlicki University Hospital Medical University of Lodz Lodz Poland

Ecole Polytechnique Palaiseau IRBA Bretigny France

EFA European Federation of Allergy and Airways Diseases Patients' Associations Brussels Belgium

ERS President 2017 2018 7th Resp Med Department and Asthma Center Athens Chest Hospital Athens Greece

Eskisehir Osmangazi University Medical Faculty ENT Department Eskisehir Turkey

Faculty of Health Sciences University of Beira Interior Covilha Portugal

Fraunhofer Institute for Translational Medicine and Pharmacology ITMP Allergology and Immunology Berlin Germany

Fundaçao ProAR Federal University of Bahia and GARD WHO Planning Group Salvador Brazil

Fundacion Jimenez Diaz CIBERES Faculty of Medicine Autonoma University of Madrid Madrid Spain

Health Planning Unit Department of Social Medicine Faculty of Medicine University of Crete Crete Greece and International Primary Care Respiratory Group IPCRG Aberdeen Scotland

IMIM Barcelona Spain

IMSB Medical Faculty University of Cologne and ClinCompetence Cologne GmbH Cologne Germany

Institute of Allergology Charité Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin Berlin Germany

Institute of Biomedical Sciences Department of Pathology Faculty of Medicine Vilnius University and Institute of Clinical Medicine Clinic of Chest Diseases and Allergology Faculty of Medicine Vilnius University Vilnius Lithuania

Institute of Clinical Medicine and Institute of Health Sciences Medical Faculty of Vilnius University Vilnius Lithuania

ISGlobal Barcelona Institute for Global Health Barcelona Spain

KYomed INNOV Montpellier France

MASK air Montpellier France

MEDCIDS Department of Community Medicine Information and Health Decision Sciences Faculty of Medicine University of Porto Porto Portugal

Medical Consulting Czarlewski Levallois France

NOVA Medical School Comprehensive Health Research Center Lisbon Portugal

Nova Southeastern University Fort Lauderdale Florida USA

Personalized Medicine Asthma and Allergy Humanitas Clinical and Research Center IRCCS Rozzano Italy

Poltava State Medical University Poltava Ukraine

Rhinology Unit and Smell Clinic ENT Department Hospital Clínic Clinical and Experimental Respiratory Immunoallergy IDIBAPS CIBERES University of Barcelona Barcelona Spain

RISE Health Research Network; University of Porto Porto Portugal

School of Medicine University CEU San Pablo Madrid Spain

Scottish Centre for Respiratory Research Cardiovascular and Diabetes Medicine Medical Research Institute Ninewells Hospital University of Dundee Dundee UK

Servicio de Alergia e Immunologia Clinica Santa Isabel Buenos Aires Argentina

Serviço de Imunoalergologia Hospital de Dona Estefânia Centro Hospitalar Universitário de Lisboa Central Lisbon Portugal

Skin and Allergy Hospital Helsinki University Hospital and University of Helsinki Helsinki Finland

Skin and Allergy Hospital Helsinki University Hospital University of Helsinki Helsinki Finland

SOS Allergology and Clinical Immunology USL Toscana Centro Prato Italy

UBIAir Clinical and Experimental Lung Centre University of Beira Interior Covilha Portugal

UCIBIO REQUINTE Faculty of Pharmacy and Competence Center on Active and Healthy Ageing of University of Porto Porto Portugal

Universitat Pompeu Fabra Barcelona Spain

University Clinic of Respiratory and Allergic Diseases Golnick and University of Ljubljana Faculty of Medicine Ljubljana Slovenia

University Hospital Montpellier Montpellier France

University of Bari Medical School Unit of Geriatric Immunoallergology Bari Italy

VIM Suresnes UMR_0892 Pôle des Maladies des Voies Respiratoires Hôpital Foch Université Paris Saclay Suresnes France

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