Allergic rhinitis (AR) is one of the most common diseases in rhinologic and allergic clinics; the prevalence was 18.5%–28% and the mean annual cost for AR patients was about $18,000 in Korea [1-3]. Several clinical guidelines proposed by various organizations have been used on AR, and the prescription patterns vary by characteristics of physicians [4-7]. Furthermore, allergen immunotherapy (AIT) is the only medical intervention that modifies the natural course of AR, but it is not popular in Korea compared to Western countries [8]. Thus, an assessment of common diagnostic and therapeutic prescription patterns for AR is essential for recommending the proper management of AR to primary physicians; however, no data are available for Korean populations. Therefore, the aim of this study was to compare the prescription patterns of AR according to specialties and affiliated practice types of physicians in Korea.

A survey of members of the Korean Academy of Asthma, Allergy and Clinical Immunology (KAAACI) and the Korean Association of Otorhinolaryngologists (KAO) was performed between May and September 2016. The authors used both online and offline survey methods. The survey contained 28 questions and was divided into four categories: demographics, diagnosis, treatment, and AIT. The responses were anonymous, and no personal information was collected (Supplementary Table 1). Prescription patterns were compared according to the physicians’ specialties (internal medicine [IM], pediatrics [PED], and otorhinolaryngology [ENT]) and practice types (university hospital, general hospital, local hospital, and private clinic). The statistical analysis was carried out using a chi-square test. To avoid demographical discordance, the authors adjusted the practice type and physician specialty with a multinomial regression. All statistical analyses were approved by the Biostatistics and Clinical Epidemiology Center of Samsung Medical Center and performed with the R software ver. 3.3.0 (R Foundation for Statistical Computing, Vienna, Austria; http://www.R-project.org). A P-value less than 0.05 was considered statistically significant.

In the present study, we identified a different prescribing pattern between physicians according to their specialty or practice type. All physicians primarily used the ARIA guidelines for their diagnoses, but ENT physicians used different secondary guidelines than the others. Furthermore, the percentage of physicians who used no guidelines gradually increased with a lower hospital grade and amongst ENT physicians. Because the ENT group contained more local clinic physicians than any other specialty, we performed an adjustment for this demographic discrepancy to allow us to recommend a proper guideline for ENT and local clinic physicians. Furthermore, a previous study mentioned that a vast majority of allergic patients in Korea are treated by ENTs and 73% of ENT specialists thought the ARIA guidelines are not suitable for daily care practice, although 60% follow ARIA guidelines [3,9,10]. Therefore, the use of proper guidelines by ENT physicians is very important for public health, and thus the development of a complementary Korean-specific guideline is necessary.

In the present study, ENT physicians used MAST or RAST more than other specialties. Because the accuracy rates of MAST/RAST for detecting sensitization to allergens are worse (MAST: 81.8% sensitivity, 89.5% specificity, and 86.4% efficiency; RAST: 85.8%, 87.5%, and 86.2%, respectively) than those of SPT or ImmunoCAP (93.2% sensitivity, 97.8% specificity, and 93.2% efficiency) [11-13], either SPT or ImmunoCAP is recommended for a definitive diagnosis. If SPT cannot be used due to medication or skin problems, ImmunoCap must be considered first. However, because only 6 allergens are checked by ImmunoCap under the Korean insurance system, MAST/RAST is often used in some situations as a second-best line of testing. For a more accurate diagnosis of AR, further education about the limitations of MAST/RAST will be required.

In our study, PED physicians demonstrated a different pattern of combination therapy. Although a majority of them prescribed antihistamines with intranasal steroids, a larger percentage of them preferred antihistamines along with a leukotriene antagonist. However, this difference in clinical behavior is expected because the 2010 ARIA revision guidelines recommended antihistamines in conjunction with leukotriene antagonists in preschool children with persistent AR [14]. However, the combination effect remains controversial in adults [7]. The 2010 ARIA revision guidelines suggested that antihistamines with a leukotriene antagonist were effective only in adults with seasonal AR [14]. Furthermore, Wheatley and Togias [15] suggested that although some randomized trials have shown a benefit of adding montelukast to an antihistamine, this combination should be reserved for patients whose symptoms are inadequately controlled with an antihistamine alone and who do not wish to use a glucocorticoid nasal spray.

In this survey, half of the physicians did not prescribe AIT for AR. The main reason they were reluctant to do so was because 29.1% of the respondents distrusted the efficacy of AIT for AR management. About 30.2% of the respondents did not prescribe AIT due to a lack of facilities or health professional, and 27.6% stated that they did not recommend AIT due to the long-term treatment duration required. In our study, we did not assess the necessity of AIT for AR treatment. Hur et al. [8] reported that 98.6% of physicians agreed on the necessity of AIT for treating allergic disease in Korea. In addition, a Chinese survey conducted among ENT specialists reported that 96.0% of the respondents considered AR to be the most suitable indication for AIT [16]. Despite these results, many physicians still do not prescribe AIT, even in patients where it is clinically indicated. However, the efficacy and safety of AIT and its prevention of asthma progression have been established by many studies [17-22]. In addition, one randomized clinical trials have shown that in AIT group a 58% reduction in symptom scores and a 20% reduction in the use of rescue medication after 1 year of treatment [23]. Furthermore, the effect of AIT maintained up to 7 years after treatment, when it was performed for 3 years [24]. Thus, PED and ENT specialists should be more concerned about AIT, and proper clinical instruction for local hospital and private clinic physicians will be necessary to encourage AIT.

In the present study, the most preferred antigen was HDM, followed by pollen. In Korea, HDM is also the most common allergen, followed by pollen, so the clinicians’ prescribing patterns reflected their natural environment [25]. Although IM physicians preferred to use poly allergens for AIT and other specialists did not, more supporting data will be required to recommend its proper management since the use of single or multi-allergen AIT is still debatable in poly sensitized patients [10,26]. Amar et al. [27] reported that AIT with multiple allergens was not superior to monotherapy alone, but Nelson [28] concluded that the simultaneous administration of more than one allergen extract is clinically effective.

Our study is the first study to compare the diagnostic and therapeutic behavior of AR according to physicians’ specialties and practice types in Korea. Although a similar survey for prescription patterns of AIT was previously conducted, it was confined to AIT alone [8]. However, the present study had some limitations. First, this survey was performed using both on-line and off-line methods; thus, we could not calculate the response rate. Second, the different practice types were not equally distributed across the physicians’ specialties. For example, ENT physicians largely worked at private clinics, and IM physicians were predominantly employed at university hospitals. However, the authors consulted a biostatistics specialist to adjust this unequal distribution using a multinomial regression analysis and then considered this limitation to be resolved.

In conclusion, the prescription patterns for the diagnosis and treatment of AR were different according to distinct physician characteristics observed in Korea. Thus, the development of complementary Korean-specific guidelines is suggested along with proper clinical instruction about AIT.