Introduction

Allergic rhinitis (AR) is a highly prevalent disease in Latin America (LA).¹ The International Study of Asthma and Allergies in Childhood (ISAAC), carried out in 44 centers in 14 countries in LA, revealed that the average prevalence of AR was 12.7% (5.5% to 21.2%) among 6- to 7-year-old schoolchildren and 18.5%, among adolescents aged 13 to 14 (7.1% to 45.1%).¹ More recently, the global asthma network (GAN), a successor study to ISAAC, documented a small reduction in these rates, in the two age groups evaluated, in the participating LA centers.²

Studies on the prevalence of AR in adults are scarce and many use the diagnosis of hay fever as a synonym for AR, which creates confusion.³ Among parents of adolescents evaluated in Uruguaiana, located in the southern region of Brazil, the average prevalence of AR was 31.7% against 28.0% observed among their children.⁴

Although it is a disease that does not expose the individual to the risk of death, its impact on patients’ quality of life is significant and often debilitating.⁵ More than a decade ago, the Allergies in Latin America (AILA) study evaluated more than 22,000 individuals, above of 4 years of age, diagnosed with nasal allergy for at least 1 year, residing in Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Peru, and Venezuela in terms of symptoms, impact of nasal allergies on the quality of life of these patients, and about the treatments received.⁶ Nasal obstruction was the most mentioned symptom and the one that bothered patients the most. Furthermore, there was compromised productivity at work and school, impaired sleep, and compromised quality of life.⁶ Regarding the treatments received, there were also disappointments and expectations of greater effectiveness.⁶ These results had already been reported in a similar study in other parts of the world.⁷

In spite of growing evidence of the impact of AR on patients’ lives and the various guidelines that attempt to standardize its treatment,^5,8 AR is still an underestimated and undervalued disease. Could it be because of a lack of therapeutic resources, or because of a lack of knowledge of the doctor who treats these patients? The objectives of CAPRA-SLAAI study (Spanish acronym for “Conductas, Actitudes y Prácticas de la Sociedad Latinoamericana de Alergia e Inmunología”) were to evaluate the level of knowledge, attitudes, and prescriptions by allergists and immunologists from different regions of LA when managing patients with AR.

Materials and Methods

Study population

Allergists and clinical immunologists from LA and affiliated with the Sociedad Latinamericana de Alergia, Asma e Inmunologia participated in the study. The questionnaire used was developed based on the self-administered questionnaire, in the English version, of the ARIA One Airways Questionnaire, translated into Portuguese (BR culture) and Spanish, and validated for use,¹ and made available via email (Google forms) to SLAAI members, via local societies. The translations of the written questionnaire (WQ) followed all the steps defined by the Delphi Method with the participation of 10 specialists in allergy and clinical immunology from different LA countries.

This method is used to capture a wide variety of opinions transmitted anonymously with a high degree of reliability, involving experts in equal participation, regardless of hierarchy, and their contributions allow finding criteria and consensus with a high level of objectivity. The questions selected to constitute the final WQ were those that received more than 70% approval from experts.⁹

After all suggestions were made, and the final version of the WQ was incorporated into the Google Forms online platform: https://forms.gle/pP7JmvRJc6bjSoja7 for the Spanish version and https://forms.gle/E253NUHN8LPjKZPk8 in Portuguese. Participants were categorized by their email address to avoid duplication of responses. The WQ consists of three parts: general data, knowledge, and attitudes and practices; demographic data; age; country; place of work; length of service as a specialist; type of institution where you work; the number of patients treated with AR; and the number of patients treated with AR and asthma. Next, knowledge of AR and the ARIA guide was assessed as well as attitudes and practices in AR (Supplementary file 1).

The inclusion criteria were: being a physician specializing in allergy and clinical immunology, being a member of one of the different specialist societies associated with SLAAI, agreeing to participate in the study by signing the digital informed consent form (ICF), providing an email address, and responding appropriately to the first and at least one other part of the questionnaire.

For statistical analysis, responses submitted through the WQ were automatically transferred to the database linked to Google Forms. Participants who did not meet all inclusion criteria were eliminated from the study. For analysis purposes, the experts were divided between those from Brazil and other participating countries, taking the former as a reference (“risk” odds). Descriptive statistics were reported by frequency, mean, and standard deviation (SD). To compare the means between the two groups, the t-Student test and analysis of variance (ANOVA) were used, and to compare the distribution of dichotomous variables, the Chi-square test, crude odds ratio (COR_c), and their respective 95% confidence intervals (95%CI) were used. Next, multivariate models were constructed using the variables that showed significant associations in the univariate analysis in order to assess their independence using ordinal logistic regression, adjusted OR, and their 95% CI. Associations with a p-value of <0.05 were considered significant. All analyses were performed using STATA 23.0 software (StataCorp, CollegeStation, TX, USA).

Results

A total of 799 specialists in allergy and clinical immunology completed the WQ between November 2022 and March 2023. Fifteen were excluded because they were incomplete or did not meet the eligibility criteria, resulting in 784 valid questionnaires for analysis. These valid questionnaires analyzed were provided by participants from 24 different countries, all affiliated with SLAAI. Among them, 390 (49.7%) were from Brazil and 202 (25.8%) from Mexico (Supplementary file 2). The total mean age was 50.1 years (SD:12.3; Min:28;Max:86). There was no significant age difference between BR participants (49.9 years old) and NBR participants (50.2 years old) (p=0.13).

The main characteristics of the study population and the weekly number of patient consultations are summarized in Table 1.

In general, we observed a predominance of doctors working in private services over those from other institutions, and a greater participation of specialists from university services among BR. The majority of participants treat between 11 and 30 patients with asthma and rhinitis weekly; however, a statistically significant difference is observed in the number of patients treated with the association of asthma and rhinitis among NBRs.

Supplementary file 3 compares knowledge about the main guidelines and assessment tools for AR, attitudes and practices regarding diagnosis, and therapy, including immunotherapy among all participants according to the study group.

Tables 2–6 demonstrate the results of multivariate analysis between the associations that were statistically significant in relation to knowledge about the ARIA guidelines, main symptoms, diagnosis, and therapy, respectively, according to the study group. Regarding the ARIA guidelines, almost all participants responded affirmatively that they knew the main concepts contained in this guide (Supplementary file 3). On the other hand, only 41% of the sample knew the Mobile Airways Sentinel NetworK (MASK-AIR) application and less than 12% used it in their daily lives (Table 2). This tool is more widespread in other countries than in Brazil, but its use was very low in the general sample. The frequency of questions about the probable diagnosis of AR made by another doctor during the anamnesis was lower among BR (Table 2).

BR=Brazilians; NBR=Non-Brazilians; ORC=crude odds ratio; 95% CI = 95% confidence interval; ORaj = odds ratio adjusted by MASK-AIR knowledge; Use of MASK-AIR; Medical diagnosis of rhinitis; *p = Chi-square test; italic ^¶ = significant.

There were no significant differences in the frequency of classic symptoms of AR, such as runny nose, sneezing, itching, and nasal obstruction, between BR specialists and those from other countries (Supplementary file 3). On the other hand, the former indicated a significantly higher frequency of extranasal symptoms (eye itching, headache, wheezing, shortness of breath, and cough) and impact on daily activities (sleep/exercise) than the latter (Table 3). “Wheezing” and “shortness of breath” were not statistically significant in the multivariate analysis, probably because they represent the same symptom, that is, because they are competing variables. Interference with exercise also were not significant in this analysis.

In Table 4, we observe the most used practices for diagnosing AR in the two groups of specialists studied. The significantly greater use of serological tests among BR is noteworthy, to the detriment of skin tests with aeroallergens, which are more used by other participants. Conversely, there was greater use of imaging exams by NBR specialists in contrast to the greater frequency of nasal cavity examination by BR specialists.

The frequency of prescription of different medicines, specific immunotherapy, and allergens used in the treatment of AR are listed in Table 5. We observed that second-generation antihistamines and intranasal corticosteroids, considered first-line medications in the treatment of AR, were used consistently by the entire sample (Supplementary file 3). Leukotriene antagonists were used by around 70% of participants and homeopathy by a very small number of specialists (Supplementary file 3). Compared to BR, the other group used significantly more first-generation oral antihistamines, combination of oral antihistamines with decongestants, intranasal antihistamines, intranasal decongestants, combination of antihistamines with intranasal corticosteroids, systemic corticosteroids, and disodium cromoglycate (Table 5).

In general, both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) were more used by NBR, in spite of standardized extracts being more frequently used in Brazil. Except for animal epithelia (Supplementary file 3), there were significant differences in relation to the type of extract used, especially in relation to pollens and fungi. After adjusting the variables, “dust mites” lost statistical significance (Table 5). The two groups studied differed in terms of the number of extracts used in immunotherapy: BR used significantly fewer extracts (>3 extracts used: 9.3% × 31.7%, BR and NBR, respectively; p<0.001). There was no difference in terms of the time of immunotherapy use between the two groups (p=0.063).

Table 6 lists the main second-generation antihistamine compounds and intranasal corticosteroids used by participants to treat AR. There were significant differences in prescribing for virtually all antihistamines except loratadine. BR prescribe more desloratadine, fexofenadine, and bilastine, while in other countries cetirizine, levocetirizine, and rupatadine prevail. Among intranasal corticosteroids, the scenario is practically the same. Except for fluticasone compounds, BR prescribe more mometasone, budesonide, and ciclesonide, while in other countries the prescription of beclomethasone prevails.

Discussion

This multicenter study, organized by the SLAAI and conducted in 24 countries, predominantly in LA, with additional participation from Spain, Portugal, and Italy (<5% of the sample), provided a comprehensive analysis of the knowledge, attitudes, and practices of specialists in allergy and clinical immunology in the management of AR. The findings highlight the wide dissemination of international guidelines while also revealing important differences in diagnostic and therapeutic approaches between BR specialists and those from Spanish-speaking countries.

The almost universal awareness of the ARIA guidelines confirms their consolidation as an international standard.^1,10 However, the limited familiarity with and restricted use of digital monitoring tools, particularly in Brazil, reveal an important gap in the incorporation of these technologies into clinical follow-up.¹¹ The dissemination of digital resources for symptom monitoring could enhance treatment adherence and optimize disease control, an aspect that remains underexplored in our region.¹²

With regard to clinical presentation, no differences were observed in the frequency of classical AR symptoms between groups, suggesting relative uniformity of the disease phenotype. However, BR specialists reported a higher frequency of extra-nasal symptoms and greater impact on daily activities, such as sleep and exercise. This finding may indicate greater disease severity among patients treated in Brazil, higher coexistence with asthma, or differences in how symptoms are recorded and valued by professionals. Diagnostic strategies revealed relevant contrasts. In Brazil, serum tests (total and specific IgE) were more frequently used, whereas in Spanish-speaking countries skin tests and imaging examinations were more common. The greater use of anterior rhinoscopy in Brazil suggests a stronger emphasis on direct physical examination, while the lower use of skin tests may be related to logistical and access barriers.

These findings should be interpreted with caution, as the cross-sectional design does not allow causal inferences, and also in light of the structural heterogeneity of LA health systems, which combine universal public models, mixed systems, and arrangements with strong participation of the private sector. This diversity influences not only the availability of diagnostic and therapeutic resources but also the prioritization of values such as equity, efficiency, and sustainability, shaped by the political, economic, and ideological contexts of each country.¹³

In addition, training in allergy and clinical immunology shows great heterogeneity across the region, with some countries where the specialty is well established and others where it is still scarcely incorporated into undergraduate curricula and residency programs. Studies indicate that this disparity compromises the standardization of care and access to specialized allergy services in LA.^14,15

From a therapeutic perspective, there was uniformity in the use of second-generation antihistamines and intranasal corticosteroids, considered first-line drugs for the treatment of AR.¹⁰ On the other hand, the high prescription rate of leukotriene antagonists—used by approximately 70% of participants—was noteworthy, possibly because of the frequent coexistence with asthma.^5,10 Regional differences in the prescription of antihistamines and intranasal corticosteroids appear to be strongly linked to pharmaceutical market availability and local health policies.¹³ In Brazil, the higher use of drugs such as desloratadine, fexofenadine, bilastine mometasone, budesonide, and ciclesonide can be attributed both to their wide availability in the market and to facilitate access through governmental programs. Within the unified health system, specifically through the Ministry of Health’s Programa Farmácia Popular (“Popular Pharmacy Program”), budesonide, beclomethasone, and loratadine are offered, which contributes to their use as baseline therapies in the country.¹⁶ In other countries, the preference for cetirizine, levocetirizine, rupatadine, and beclomethasone possibly reflects different regulatory contexts.¹³

With regard to allergen-specific immunotherapy (AIT), SCIT and SLIT were more frequently used in Spanish-speaking countries, whereas in Brazil the use of standardized extracts predominated. This difference may be attributed both to epidemiological factors, such as the higher prevalence of pollens in certain regions and to regulatory and cost-related aspects.¹⁷ In addition, BR specialists reported using a smaller number of extracts, which may be related both to the adoption of standardized protocols and to financial constraints. These findings should be interpreted in the context of the LA literature on AIT, which highlights the scarcity of prospective comparative studies and the marked heterogeneity across countries and even within the same country.¹⁷ In Brazil, although specific guidelines for AIT in AR exist, the country’s continental dimensions and environmental diversity result in distinct sensitization patterns and variability in extract availability, which impose additional challenges to the standardization of clinical practice.¹⁸

Another point that deserves emphasis is that, although participants demonstrated a high level of knowledge regarding the ARIA recommendations, there remains a need to advance in the conceptual and terminological harmonization concerning AR. Recent initiatives have emphasized not only the adoption of personalized medicine strategies and digital integration but also the development of a unified vocabulary regarding the definition of control, remission, exacerbation, and disease progression. Such standardization, in addition to facilitating communication between specialists and general practitioners, has the potential to improve the practical implementation of recommendations and to strengthen the physician–patient relationship.^19,20

Its use enables the real-time collection of patient-reported data and allows for a more accurate phenotypic stratification of the disease, including its association with asthma and the impact on ocular and nasal symptoms.²¹ In addition, the most recent ARIA 2024 proposals reinforce the potential of artificial intelligence (artificial intelligence) in building personalized, patient-centered care pathways.²² These AI-enabled digital models not only facilitate adherence to international recommendations but also support clinical decision-making, promote the standardization of practices, and foster the implementation of more equitable care across different health care contexts.^21–23

Overall, the findings of this study highlight the need to reduce regional disparities and promote greater standardization in the diagnosis and treatment of AR in LA. Priority strategies include expanding knowledge and use of digital tools, improving access to validated diagnostic methods, promoting the rational use of medications, and reassessing health policies that directly affect the availability of AIT and first-line drugs.

Among the limitations of this study, the cross-sectional design should be noted, as it does not allow causal inferences. Furthermore, although participants were drawn from more than 20 countries, the sample was predominantly composed of specialists from countries with stronger training structures,¹⁴ with nearly three-quarters concentrated in Brazil (49%) and Mexico (29.5%). This distribution may not fully reflect the regional diversity and should be considered when interpreting and generalizing the findings

Conclusions

This multicenter study highlights important regional differences in the management of AR in LA and underscores the need for future, more representative investigations that take into account professional training, the particularities of health systems, and the growing role of digital technologies and AI in the care of AR and its comorbidities. These recommendations are relevant not only for specialists but also for general practitioners, given the very high prevalence of rhinitis in our continent.