Alvaro Augusto Cruz

Allergic Rhinitis and its Impact on Asthma (ARIA) was, up until 2017, a guideline using the best evidence (Grading of Recommendations, Assessment, Development and Evaluation, GRADE) and developed as a change management strategy. A second change management strategy—in collaboration with the European Academy of Allergy and Clinical Immunology (ARIA‐EAACI)—was developed as a person‐centred, digitally enabled, artificial intelligence‐assisted care (person‐centred care) with strong political involvement. The digital tools of ARIA are mainly based on MASK‐air, an Organisation for Economic Co‐operation and Development (OECD) Best Practice for integrated care for chronic diseases. Artificial intelligence was used, in particular, to approach the patients' views and expectations. The current paper describes the steps to build and achieve a new change management strategy. The future of the Change Management strategy is (i) a collaboration between ARIA and EAACI, (ii) the development of ARIA 2024‐2025 guidelines, (iii) the new ARIA‐MeDALL classification of multimorbid airway diseases and (iv) embedding MASK‐air in a registry for severe allergic diseases. The ultimate goals of the ARIA‐EAACI change management strategy will be (i) the transformation of health and care in rhinitis and asthma multimorbidity and (ii) the development of novel guidelines and policies in a cost‐effective manner, improving shared‐decision‐making.

BACKGROUND: Periodontal disease is part of complex and multifactorial diseases. The presence of dysbiotic microbial communities, with the potential for destructive inflammation by itself, may not trigger periodontitis. If they are associated with predisposing and host genetic factors, the probability increases. The objective of this study was to search for factors associated with periodontitis through an adequate logistic model. METHODOLOGY: A cross-sectional study (n=506) observed that the independent variables older age, sex, lower education, obesity, being a mouth breather, not using dental floss daily, being a smoker or ex-smoker, and the presence of asthma; are indicators of risk of periodontitis. Associations were measured by the Chi-square test and binary logistic regression, adjusted. The suitability of the model was tested by the Hosmer-Lemeshow test. Comparison of results was performed by StepAIC analysis. RESULTS AND CONCLUSIONS: Older age, lower education level, obesity, mouth breathing, no use of dental floss and presence of asthma make up the most appropriate model (p<0.001). In the population studied, a composite of variables, including older age, lower education, obesity, mouth breathing, flossing and asthma were the most fit to adjust for the logistic regression analysis. In addition, obesity, not using dental floss and the presence of asthma are associated with the development of periodontitis.

Introduction: Medication availability and costs can be highly variable across countries and in different time periods. We aimed to conduct a survey among local experts to obtain information on the availability and costs of allergic rhinitis medications in different countries. Methods: We sent a survey to members of the Allergic Rhinitis and its Impact on Asthma (ARIA) group, asking for the availability and the lowest cost of specific allergic rhinitis medications in their respective countries. Data in local currencies were converted to 2024 US Dollars adjusted for Purchasing Power Parity (PPP). We compared the costs of different medication classes, assuming, for each class, the least expensive drug in each country, as well as full treatment adherence. Results: We received responses from ARIA experts in 51 different countries. Intranasal corticosteroids (INCS) and oral antihistamines (OAH) were available in all countries, but this was not observed for intranasal antihistamines (INAH) or for INAH+INCS. In most countries, OAH was the least costly drug class, while INAH+INCS was the most expensive. Among INCS, beclomethasone was the medication most frequently identified as the cheapest, while cetirizine and loratadine were the OAH most frequently reported as the least expensive. Among INAH+INCS, azelastine‐fluticasone was more frequently identified as less costly than olopatadine‐mometasone. Conclusion: There is an important across‐country and across‐class variability in terms of costs of allergic rhinitis medications. The results of this study will inform the ARIA‐EAACI 2024–2025 guidelines.

Background: Oral and ocular medications are frequently used in the treatment of allergic rhinitis (AR). As part of the update of the Allergic Rhinitis and its Impact on Asthma (ARIA)‐EAACI guidelines, this manuscript presents the ARIA‐EAACI 2024–2025 recommendations for oral and ocular treatments. Methods: The ARIA‐EAACI 2024–2025 guideline panel issued recommendations following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence‐to‐decision framework. Several sources of evidence were used to inform panel judgements and recommendations, including systematic reviews, mHealth and pharmacovigilance data as well as a survey on costs. Results: Eight guideline questions concerning oral treatments for AR and three questions concerning ocular treatments were addressed. These questions led to the recommendations. Overall, these questions concern the choice between different classes of medication. They also discuss the role of oral antihistamines (OAH), leukotriene receptor antagonists (LTRA), ocular antihistamines (OcAH) and ocular mast cell stabilisers. Four questions had not been previously evaluated in ARIA guidelines, while, for the other four, there was a change in the strength or directionality of the recommendations. Overall, these guidelines recommend using intranasal corticosteroids over OAH and using OAH over LTRA. Moreover, they suggest using OAH over OcAH and suggest being against adding LTRA to OAH. Finally, considerations for choosing between different individual OAHs are presented. Conclusion: This ARIA‐EAACI 2024–2025 article supports patients, their caregivers and healthcare professionals in choosing oral and ocular treatments for AR. Decisions on treatment should consider the clinical variability of the disease, patients' values and the affordability of medications.

Summary: Genetic polymorphisms on ILC2 receptors (CD127, IL‐17RB and CRTH2) increase the asthma and atopy susceptibilities. Cohort analysis suggests that alleles' combination from ILC2 variants contributes to asthma and atopy risk.

Background: Existing asthma polygenic risk scores (PRSs) have minimal validation in African‐ancestry populations, leaving gaps in our understanding of the wide applicability of PRSs. To widen our understanding of the applicability of asthma PRSs, we apply published PRSs in African‐ancestry individuals and quantify the extent to which the PRS‐asthma relationship is mediated by clinical biomarkers and gene‐expression signatures of asthma. Methods: We applied 22 PRSs from the PGS Catalog in 673 individuals from the Consortium on Asthma among African‐Ancestry Populations in the Americas (CAAPA) and calculated the percent of the PRS‐asthma relationship that is statistically mediated by clinical and nasal epithelium transcriptomic biomarkers of asthma. Asthma case/control status was defined as ever/never having a doctor's diagnosis of disease. For gene expression mediation analysis, we limited the cases to those with current disease. Results: The PRS (PGS001782) created by the Global Biobank Meta‐analysis Initiative ( N = 32,658 individuals of African ancestry) performed the best (ΔAUC = 0.104, AUC = 0.657) adjusted for age, sex, study site, and the first two genetic principal components (PC1‐2). The PRS's effect on asthma was mediated by total IgE (tIgE) (38.8%, p .adj < 0.0002), multi‐allergen ImmunoCAP phadiatop specific IgE (sIgE) (38.7%, p .adj < 0.0002), and eosinophils (7.3%, p .adj = 0.004). Mediation was observed for gene expression modules related to T2 inflammation (21.9%, p .adj < 0.0024), wound healing (11.9%, p .adj = 0.008), and medication response (6.8%, p .adj = 0.049). Conclusion: We found the best PRS to be the one derived using the largest sample size and including African‐ancestry individuals. Mediation supports the well‐documented biology of T2 inflammation in asthma as well as pathophysiological components of asthma like wound healing and medication response.

Background: Allergic rhinitis (AR) impacts quality of life, work and school productivity. Over the last years, an important body of evidence resulting from mHealth data has led to a better understanding of AR. Such advances have motivated an EAACI‐endorsed update of the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines (ARIA 2024–2025). This manuscript presents the ARIA 2024–2025 recommendations for intranasal treatments, one of the mainstays for AR management. Methods: The ARIA 2024–2025 guideline panel issued recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence‐to‐decision framework. Several sources of evidence were used to inform panel judgments and recommendations, including systematic reviews, evaluation of mHealth and pharmacovigilance data, as well as a survey of experts on costs. Results: Eleven guideline questions concerning intranasal treatments for AR were prioritized, leading to recommendations. Overall, these questions concern the choice between different classes of intranasal medications—most notably, intranasal corticosteroids (INCS), antihistamines (INAH), fixed combinations of INAH+INCS and decongestants—or between different individual medications within each class. Four questions had not been evaluated in previous ARIA guidelines, while for the other three there was a change in the strength or directionality of recommendations. Overall, recommendations point to the suggested use of INAH+INCS over INAH or INCS and INCS over INAH. Conclusion: This ARIA 2024–2025 article supports patients, their caregivers, and healthcare professionals in choosing an intranasal treatment. However, decisions on AR treatment should consider the clinical variability of the disease, patients' values, and the affordability of medications.

The 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.