BACKGROUND: Different treatments exist for allergic rhinitis (AR), including pharmacotherapy and allergen immunotherapy (AIT), but they have not been compared using direct patient data (i.e., "real-world data"). We aimed to compare AR pharmacological treatments on (i) daily symptoms, (ii) frequency of use in co-medication, (iii) visual analogue scales (VASs) on allergy symptom control considering the minimal important difference (MID) and (iv) the effect of AIT. METHODS: We assessed the MASK-air® app data (May 2015-December 2020) by users self-reporting AR (16-90 years). We compared eight AR medication schemes on reported VAS of allergy symptoms, clustering data by the patient and controlling for confounding factors. We compared (i) allergy symptoms between patients with and without AIT and (ii) different drug classes used in co-medication. RESULTS: We analysed 269,837 days from 10,860 users. Most days (52.7%) involved medication use. Median VAS levels were significantly higher in co-medication than in monotherapy (including the fixed combination azelastine-fluticasone) schemes. In adjusted models, azelastine-fluticasone was associated with lower average VAS global allergy symptoms than all other medication schemes, while the contrary was observed for oral corticosteroids. AIT was associated with a decrease in allergy symptoms in some medication schemes. A difference larger than the MID compared to no treatment was observed for oral steroids. Azelastine-fluticasone was the drug class with the lowest chance of being used in co-medication (adjusted OR = 0.75; 95% CI = 0.71-0.80). CONCLUSION: Median VAS levels were higher in co-medication than in monotherapy. Patients with more severe symptoms report a higher treatment, which is currently not reflected in guidelines.

ALL MED Medical Research Institute Wrocław Poland

Allergy and Clinical Immunology Unit Centro Hospitalar e Universitário de Coimbra 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

ARIA Montpellier France

Celal Bayar University Department of Pulmonology Manisa Turkey

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 Medical University of Gdańsk Gdansk Poland

Department of Allergy and Immunology Hospital Quironsalud Bizkaia Bilbao Spain

Department of Biomedical Sciences Humanitas University Pieve Emanuele Italy

Department of Cardiovascular and Thoracic Sciences Fondazione Policlinico Universitario A Gemelli IRCCS Università Cattolica del Sacro Cuore Rome Italy

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

Department of Clinical Immunology Wrocław Medical University Wrocław Poland

Department of Computing Science Umeå University Umeå Sweden

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

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 Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology University Hospital Duilio Casula University of Cagliari Cagliari 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 ON Canada

Department of Otolaryngology Head and Neck Surgery Eye and Ear University Hospital Beirut Lebanon

Department of Otolaryngology Head and Neck Surgery Universitätsmedizin Mainz Mainz and Center for Rhinology and Allergology Wiesbaden Germany

Department of Otorhinolaryngology Amsterdam University Medical Centres AMC Amsterdam The Netherlands

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

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

ENT Department Dar Al Shifa Hospital Salmiya Salmiya Kuwait

ENT Department Medical Faculty Eskisehir Osmangazi University Eskisehir Turkey

Faculty of Health Sciences University of Beira Interior Covilhã Portugal

Faculty of Medicine University of Ljubljana Ljubljana Slovenia

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 Greece and International Primary Care Respiratory Group IPCRG Aberdeen Scotland

IMIM Barcelona Spain

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

Imunoalergologia Centro Hospitalar Universitário de Coimbra and Faculty of Medicine University of Coimbra Coimbra Portugal

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

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

Medical Consulting Czarlewski Levallois France

National Research Center Institute of Immunology Federal Medicobiological Agency Laboratory of Molecular Immunology Moscow Russia and Pirogov Russian National Research Medical University Moscow Russia

NOVA Medical School Comprehensive Health Research Centre 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

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

Quality Use of Respiratory Medicine Group Woolcock Institute of Medical Research The University of Sydney and Sydney Local Health District Sydney NSW Australia

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 University of Helsinki Helsinki Finland

SOS Allergology and Clinical Immunology USL Toscana Centro Prato Italy

Transylvania University Brasov Brasov Romania

UBIAir Clinical and Experimental Lung Centre University of Beira Interior Covilhã 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 Slovenia

University Hospital Montpellier Montpellier France

University of Bari Medical School Unit of Geriatric Immunoallergology Bari Italy

Usher Institute The University of Edinburgh Edinburgh UK

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

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Adherence to Treatment in Allergic Rhinitis During the Pollen Season in Europe: A MASK-air Study

Digitally-enabled, patient-centred care in rhinitis and asthma multimorbidity: The ARIA-MASK-air® approach