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8 Special Supplement, May 2023 • Canadian Allergy & Immunology Today despite treatment, who needed to switch from current treatment, and who had various allergy-related comorbidities. The concise and easy-to-complete RCAT and VAS provided objective indicators of symptom control that can easily be implemented into daily practice. Improvement in the RCAT score from baseline after four weeks of rupatadine treatment was statis- tically significant and exceeded the 2.4 point difference for a clinically meaningful improvement. 15 The items on the RCAT that were the worst at baseline (e.g., frequency of nasal congestion and how well symptoms were controlled) were the items that improved the most. The 65% improvement in the fre- quency of nasal congestion was encouraging as oral antihistamines generally have only a small effect on congestion. 16 Vascular permeability induced by PAF contributes to nasal congestion, 17 and the anti-PAF effect of rupatadine may have played a role in mitigating this symptom. Congestion was improved by 90% in patients with urticaria. Chronic urti- caria can be associated with markers of airway mucosal inflammation, 18 thus, the substantial improvement in nasal congestion in this group could also be related to the anti-PAF effect of rupatadine. Clinical benefits were also demonstrated in patients with asthma, eczema/atopic dermatitis and nasal polyps, and the presence of these comorbidities did not diminish the response to treatment. The improvement in patients with nasal polyps was not quite as robust as the other comorbidities; however, AR in patients with nasal polyps is traditionally harder to treat. In addition, according to the RCAT scores, AR symptoms in the patients with nasal polyps were not as severe at baseline as in the other groups and therefore had less room for improvement. The anti-PAF action of rupatadine may also explain the improvement in AR symptoms in pa- tients who were already using other antihistamines (e.g., uncontrolled despite treatment and needing treatment switch patient categories). One other real-world study of second-generation antihistamines for AR has been conducted in Canada. 19 In this open-label study, patients rated seasonal AR symptoms during the spring- summer allergy season on a 0-3 scale at baseline and after 7 days of desloratadine treatment. 19 Half of the patients were being treated with AR medications at baseline, yet individual (including congestion) and overall symptom scores significantly improved after desloratadine treatment. Although the study did not evaluate measurement-based care per se, it did demonstrate the same principal as ICAR, namely, that an objective measure of symptoms could be used to track the effect of AR treatment in real-world practice. One particular strength of the ICAR study is that its timing indicates that patients likely had perennial AR, which is typically more difficult to treat than seasonal AR. The study was limited by its open- label, non-controlled design. In addition, few or no patients were included from some of the Canadian provinces; therefore, the results may not be generalizable across all of Canada. The ICAR study demonstrated that using rupatadine, a dual-acting antihistamine and anti-PAF agent, significantly improves symptom con- trol when used daily and monitored objectively by measurement-based care. Incorporating assessment and management tools (measure- ment-based care) may help better determine the impact of symptoms on patients' quality of life. Figure 4. Patient- and clinician-assessed VAS scores at baseline and after 4 weeks of rupatadine treatment. SD: standard deviation; VAS: visual analog score. Clinician VAS Classification of allergic rhinitis control Controlled Uncontrolled Partially Controlled 0 1 2 3 4 5 6 7 8 9 10 Follow-up, mean (S D) 2.6 (2.2) Clinician VAS Nas al S ymptoms : Patient VAS Bas eline, mean (S D) 6.6 (2.2) Not troublesome at all Very troublesome Baseline, mean (SD) 6.6 (2.2) Follow-up, mean (SD) 2.0 (2.2) Patient VAS 0 1 2 3 4 5 6 7 8 9 10 Follow-up, mean (S D) 2.6 (2.2) Clinician VAS Nas al S ymptoms : Patient VAS Bas eline, mean (S D) 6.6 (2.2) Not troublesome at all Very troublesome Follow-up, mean (SD) 2.6 (2.2) Baseline, mean (SD) 6.5 (2.4) How are you feeling today? Think about how troublesome your symptoms have been for the last 24 hours. Nasal symptoms: congestion, itching, secretion, sneezing Ocular symptoms: redness, watery eyes, itching

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