The Prevalence and Impact of Allergic Rhinitis on Asthma Exacerbations in Asthmatic Adult Patients in the Qassim Region of Saudi Arabia: A Cross-Sectional Study

Objective We aim to evaluate the prevalence and impact of allergic rhinitis comorbidity in asthmatic patients in the Qassim region and identify whether rhinitis affects asthma control. Methods This is an observational cross-sectional study on asthmatic adults who live in the Qassim region of Saudi Arabia. An online questionnaire was distributed through social media. The questionnaire is composed of the validated Arabic versions of the Score for Allergic Rhinitis (SFAR) questionnaire, the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines, and the Asthma Control Test (ACT) questionnaire. Results The total number of participants was 380; however, after 98 were excluded, 282 asthmatic patients were included in this study. Of them, 33% had allergic rhinitis. Females constitute 67% of the study participants, while males comprise 33%. The findings of the study indicate that there is a significant association between allergic rhinitis and asthma control in the Qassim region. Symptoms such as runny nose, sneezing, and nasal obstruction are significantly associated with poor asthma control (p = 0.006). Having a known family history of asthma, eczema, or allergic rhinitis is significantly associated with worse asthma control (0.004). Conclusion In summary, this study found a high prevalence of rhinitis symptoms comorbidity in asthmatic patients in the Qassim region. Overall, the study established the existence of a relationship between allergic rhinitis and asthmatic control. Symptoms such as a runny nose, sneezing, and nasal obstruction are significantly associated with allergic rhinitis and asthmatic symptoms. However, there is no significant association between nose problems that occur in specific seasons or months and allergic rhinitis and asthmatic symptoms, suggesting that seasonality may not have a strong impact on asthma control. House dust mite allergies have a borderline significant association with allergic rhinitis and asthmatic symptoms. Having a family history of asthma, eczema, or allergic rhinitis is associated with allergic rhinitis and asthmatic symptoms, thereby indicating a significant impact on asthma control.


Introduction
Asthma is known as a chronic respiratory disease, and it is a widespread disease in the world.The World Health Organization defines it as having frequent attacks of wheezing, shortness of breath, and coughing.However, the seriousness of asthma varies from person to person [1].Allergic rhinitis (AR), defined as an inflammation of the nasal mucosa caused by exposure to allergens like pollen, trees, weeds, and house dust mites, is also known as a chronic respiratory disease [2].Rhinorrhea, nasal itching, nasal congestion, and sneezing are known characteristics of AR [3].Moreover, it has been known that asthma and AR are related.The pathophysiology of both diseases is largely influenced by the immune system.Recent research found that asthma severity could increase the likelihood of AR by triggering an inflammatory response in the upper respiratory tract [4].
According to some studies, the severity of AR and asthma may be related, with the frequency and severity of AR increasing with the severity of asthma [5,6].In the Riyadh region, a cross-sectional study was conducted

Data collection methods
After gaining ethical approval, an online questionnaire was distributed among the chosen population to be filled out voluntarily through social media.Patients were asked whether they agreed to participate before filling out the questionnaire.After obtaining permission, we used a questionnaire from a previous study which was taken completely in both languages (Arabic and English) [7].It starts first with questions that include and exclude the participants' asthma diagnosis and comorbidity and is composed of the validated Arabic versions of the Score for Allergic Rhinitis (SFAR) questionnaire [12], Allergic Rhinitis and Its Impact on Asthma (ARIA) Guidelines [7], and the Asthma Control Test (ACT) questionnaire [13].

Data management and analysis plan
The pre-analysis data obtained from the questionnaires were organized in a Microsoft Excel file.The Excel file containing the participants' data was then exported into SPSS Statistics for statistical analysis.Any missing entries in the record were marked as "not replied."If double entries were found, the initial answer was selected to represent the correct value.The chi-square test was used to determine the significant association between categorical variables.The p-value < 0.05 was taken as the fixed point for statistical significance.

Ethical considerations
Qassim University Research Ethics Committee approval was obtained (approval number: 23-41-07) for this study before proceeding with it.All of the information was treated confidentially.The participants signed an electronic informed consent form at the beginning of the questionnaire that explained the purpose of this study.All participant data were kept in coded forms and destroyed once the data collection was complete.

Results
Figure 1 shows the flow of participants throughout the study.A total of 380 respondents were viable to carry The respondents' characteristics are summarized in Table 1.

Category and features
Frequency and proportion of the respondents, n (%)

Association between SFAR and asthmatic control
Table 2 shows the association between SFAR and asthmatic symptom control.All those diagnosed with asthma (n = 282) are subjected to SFAR assessment in order to determine some common symptoms for AR and asthmatic patients and to get the respondents who tested positive for allergy (Skin Prick Test/SPT, IgE) so that they can be used to test the association between AR severity and asthmatic control.The results from the chi-square test show that there is a statistically significant association between nasal symptoms, runny nose, sneezing, and nasal obstruction (p = 0.006) among AR and asthmatic patients.On the other hand, there is no statistically significant association between nose problems related to certain seasons or months among AR and asthmatic patients (p = 0.264).This suggests that the seasonality of AR may not have a strong impact on asthma control.There is no statistically significant association between the triggering factors (p = 0.085).A statistically significant association is found between having a family member with asthma, eczema, or AR and having a similar scenario among AR and asthmatic patients (p=0.004).

Association between allergic rhinitis severity and asthmatic control
The results of the statistical analysis show a significant association between AR severity and asthmatic control.The p-value for the ARIA results is 0.001, indicating the presence of a relationship between these two variables, which implies that symptoms do disturb the majority of the respondents' activities, sleep, work in school, and daily activities (sports, leisure, etc.) and was troublesome.When looking at the specific categories of AR severity, there are also significant associations with asthmatic control.

Skin Prick Test (SPT)
However, there were no patients with partially controlled asthmatic control in this group.This relationship was also statistically significant with a p-value of 0.001.The results at each level are shown in Table 3.

ACT analysis
To assess the relationship, we used a chi-square test of independence.The results indicated that there is no significant association between the effect of the work done at work, school, or at home in the past four weeks; frequency of shortness of breath in the past four weeks; and asthma control based on the data (p > 0.05).However, there was a statistically significant association between the frequency at which asthma symptoms (wheezing, coughing, and shortness of breath) wake you up at night or earlier than usual in the morning (in the past four weeks), frequency of using rescue inhaler or nebulizer medication in the past four weeks, and asthma control (p < 0.05).The results are shown in Table 4.

Respondents' characteristics
The findings of the study indicate that a significant proportion of asthmatic patients in the Qassim region also suffer from rhinitis.Approximately one-quarter of the participants had been diagnosed with AR by a physician.This suggests a high prevalence of rhinitis comorbidity in asthmatics in the region.The study also found that the majority of participants were female, which may have implications for the relationship between gender and asthma-rhinitis comorbidity.The majority of the respondents (51.06%) were shown to have normal weight, which implies that asthma does not have much effect on both health.Similarly, the majority of them were between 14 and 29 years old, which means the incidences of asthmatic condition is gradually increasing among the Qassim region population based on the fact that the young generation is more affected.Additionally, the majority of participants (65.6%) did not have any chronic pulmonary disease.The study also found that the majority of participants had never smoked at all; however, we did not take into account the effect of those who smoked for a year and above as it was not the major concern of the study.In terms of education, the majority of participants had a college education or above.This may indicate a higher level of awareness and healthcare-seeking behavior among individuals with higher education levels, which could contribute to the higher prevalence of diagnosed rhinitis in this group.In terms of treatment, intranasal corticosteroids were the most commonly used medication for AR, followed by antihistamines and nasal decongestants.The majority of participants reported not taking any medication for their AR, suggesting a potential treatment gap in this population which might have been contributed by financial constraints, ignorance, or the use of traditional methods of treatment.Based on the study by Mahfouz et al., it is noted that patients with AR had a significantly higher risk of experiencing asthma exacerbations compared to those without AR.Over 80% of patients with AR reported experiencing at least one asthma exacerbation in the past year, compared to 72% of patients without AR [7].The study conducted by Lababidi et al. indicated that the Arabic ACT showed a good correlation with the clinical assessment of asthma control based on Global Initiative for Asthma (GINA) guidelines.The sensitivity of the Arabic ACT was 88.84%, and the specificity was 82.5% for detecting poorly controlled asthma [13].

SFAR and asthmatic control
The findings of the study indicate that there is a significant association between the common AR symptoms and asthma control in the Qassim region.Symptoms such as a runny nose, sneezing, and nasal obstruction are significantly associated with AR and asthmatic symptoms.However, there is no significant association between nose problems occurring in specific seasons or months and AR and asthmatic symptoms, suggesting that seasonality may not have a strong impact on asthma control.House dust mite allergies have a borderline significant association with AR and asthmatic symptoms.Having a family history of asthma, eczema, or AR is associated with AR and asthmatic symptoms, thus indicating a significant impact on asthma control.Overall, these findings suggest that AR plays a role in asthma control, with certain symptoms and allergies having a stronger association.Understanding and addressing these comorbidities may be essential to effectively manage asthma in individuals in the Qassim region.This concurs with the findings obtained by de Andrade et al. in their study, which noted that there is a high prevalence of comorbidity between asthma and AR among adolescents.The findings of the study reveal that approximately 70% of the participants with asthma also had AR, and 57% of participants with AR also had asthma.This suggests that there is a strong association and potential shared underlying mechanisms between these two conditions in this age group [14].Ohta et al. in their study also found that the prevalence of rhinitis in asthmatic patients in Japan is high, with 84.5% of asthmatics also reporting rhinitis symptoms.
The study further reported that rhinitis symptoms have a significant impact on the quality of life of asthmatic patients, with higher rates of sleep disturbance, fatigue, and impairment in daily activities [15].

ARIA and asthmatic control
The results of the statistical analysis show a significant association between AR severity and asthmatic control.The study noted that symptoms do disturb the majority of the respondents' activities, including sleep, work in school, and daily activities (sports, leisure, etc.) and were troublesome.In summary, the results indicate that as the severity of AR increases, the level of asthmatic control tends to decrease.This suggests a possible link between the two conditions and emphasizes the importance of managing both conditions in order to achieve optimal control.This corresponds with Stern et al.'s study, which noted that there is a significant association between AR and asthma outcomes in city schoolchildren.The study found that children with both AR and asthma had poorer asthma control, increased asthma symptoms, and higher healthcare utilization compared to children with asthma alone.This suggests that managing AR could potentially improve asthma outcomes in this population [16].
Further, the findings of the study suggest that there is no significant association between the amount of work done at work, school, or home in the past four weeks, the frequency of shortness of breath in the past four weeks, and asthma control based on the data.On the other hand, the study revealed that there is a statistically significant association between the frequency at which asthma symptoms (wheezing, coughing, and shortness of breath) wake you up at night or earlier than usual in the morning in the past four weeks, the frequency of using your rescue inhaler or nebulizer medication in the past four weeks, and asthma control, indicating that the observed associations between these two factors and asthma control were statistically significant and not due to chance.Ciprandi et al.'s main finding of their study is that patient-related factors, such as duration of disease and the presence of comorbidities, can significantly impact the satisfaction of patients with allergy treatment for rhinitis and asthma.The study found that younger patients, female patients, patients with shorter disease durations, and patients without comorbidities were more satisfied with their allergy treatment.These findings highlight the importance of considering patient characteristics and preferences when developing and delivering allergy treatment strategies [17].

Limitations of the study
The study was limited to evaluating the prevalence and severity of rhinitis comorbidity in asthmatics patients utilizing asthma medication in the Qassim region and identifying whether rhinitis affects control; hence, it did not take into account the effect of smoking for more than one year and ex-smokers who have stopped in the past one year.Additionally, the study concentrated on the general effect of allergy rhinitis on asthma control without considering the effect across the participants of different ages.Further, the presence of a high percentage of the participants with rhinitis fully controlled could give biased results.More so, statistical tests used can only provide significance without commenting on the strength of the association.

Conclusions
In summary, this study found a high prevalence of rhinitis symptoms comorbidity in asthmatic patients in the Qassim region.Overall, the study established the existence of a relationship between AR and asthmatic control.Symptoms such as a runny nose, sneezing, and nasal obstruction are significantly associated with AR and asthmatic symptoms.However, there is no significant association between nose problems occurring in specific seasons or months and AR and asthmatic symptoms, suggesting that seasonality may not have a strong impact on asthma control.House dust mite allergies have a borderline significant association with AR and asthmatic symptoms.Having a family history of asthma, eczema, or AR is associated with AR and asthmatic symptoms, thus indicating a significant impact on asthma control.
much work done at work, school, or home in the past four weeks 0.

TABLE 2 : Short-form allergic rhinitis (SFAR) and ACT analysis
SPT: Skin prick test; ACT: Asthma control test.

TABLE 3 : Allergic rhinitis severity and asthmatic control
ARIA: Allergic Rhinitis and Its Impact on Asthma.