EUFOREA Pocket Guide on the Diagnosis and Management of Asthma: an Educational and Practical Tool for General Practitioners, Non-Respiratory Physicians, Paramedics and Patients.

•EUFOREA asthma pocket guide is an educational and practical tool for non-respiratory physicians, paramedics and patients.•EUFOREA asthma pocket guide provides a simplified algorithm on asthma diagnosis, treatment and specialist referral.•EUFOREA asthma pocket guide is a living document which can be accessed at www.euforea.eu/news/asthma-pocket-guide. International and national initiatives on asthma management provide extensive information on asthma pathophysiology, offering expert guidance on diagnosis and recommendations on treatment, highlighting contemporary therapeutic options [1www.ginasthma.comGoogle Scholar, 2www.nice.org.uk/guidance/indevelopment/gid-ng10186Google Scholar, 3Muraro A. Roberts G. Halken S. Agache I. Angier E. Fernandez-Rivas M. Gerth van Wijk R. Jutel M. Lau S. Pajno G. Pfaar O. Ryan D. Sturm G.J. van Ree R. Varga E.M. Bachert C. Calderon M. Canonica G.W. Durham S.R. Malling H.J. Wahn U. Sheikh A. EAACI guidelines on allergen immunotherapy: executive statement.Allergy. 2018 Apr; 73: 739-743https://doi.org/10.1111/all.13420Crossref PubMed Scopus (120) Google Scholar]. Likewise, there are several high-impact task force articles and expert reviews on related topics, including asthma exacerbations, treatable traits, comorbid conditions, biomarkers, biologics and corticosteroids [4Bourdin A. Bjermer L. Brightling C. Brusselle G.G. Chanez P. Chung K.F. Custovic A. Diamant Z. Diver S. Djukanovic R. Hamerlijnck D. Horváth I. Johnston S.L. Kanniess F. Papadopoulos N. Papi A. Russell R.J. Ryan D. Samitas K. Tonia T. Zervas E. Gaga M. ERS/EAACI statement on severe exacerbations in asthma in adults: facts, priorities and key research questions.Eur. Respir. J. 2019 Sep 28; 541900900https://doi.org/10.1183/13993003.00900-2019Crossref Scopus (48) Google Scholar, 5Diamant Z. Vijverberg S. Alving K. Bakirtas A. Bjermer L. Custovic A. Dahlen S.E. Gaga M. Gerth van Wijk R. Giacco S.D. Hamelmann E. Heaney L.G. Heffler E. Ö Kalayci Kostikas K. Lutter R. Olin A.C. Sergejeva S. Simpson A. Sterk P.J. Tufvesson E. Agache I. Seys S.F. Towards clinically applicable biomarkers for asthma: an EAACI position paper.Allergy. 2019 Oct; 74: 1835-1851https://doi.org/10.1111/all.13806Crossref PubMed Scopus (125) Google Scholar, 6Heaney L.G. Busby J. Hanratty C.E. Djukanovic R. Woodcock A. Walker S.M. Hardman T.C. Arron J.R. Choy D.F. Bradding P. Brightling C.E. Chaudhuri R. Cowan D.C. Mansur A.H. Fowler S.J. Niven R.M. Howarth P.H. Lordan J.L. Menzies-Gow A. Harrison T.W. Robinson D.S. Holweg C.T.J. Matthews J.G. Pavord I.D. Investigators for the MRC Refractory Asthma Stratification Programme. Composite type-2 biomarker strategy versus a symptom-risk-based algorithm to adjust corticosteroid dose in patients with severe asthma: a multicentre, single-blind, parallel group, randomised controlled trial.Lancet Respir. Med. 2021 Jan; 9: 57-68https://doi.org/10.1016/S2213-2600(20)30397-0Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 7Khatri S.B. Iaccarino J.M. Barochia A. Soghier I. Akuthota P. Brady A. Covar R.A. Debley J.S. Diamant Z. Fitzpatrick A.M. Kaminsky D.A. Kenyon N.J. Khurana S. Lipworth B.J. McCarthy K. Peters M. Que L.G. Ross K.R. Schneider-Futschik E.K. Sorkness C.A. Hallstrand T.S. American thoracic society assembly on Allergy, immunology, and inflammation. Use of fractional exhaled nitric oxide to guide the treatment of asthma: an official American thoracic society clinical practice guideline.Am. J. Respir. Crit. Care Med. 2021 Nov 15; 204 (PMID: 34779751): e97-e109https://doi.org/10.1164/rccm.202109-2093STCrossref PubMed Scopus (47) Google Scholar, 8Porsbjerg C. Melén E. Lehtimäki L. Shaw D. Asthma. Lancet. 2023 Mar 11; 401: 858-873https://doi.org/10.1016/S0140-6736(22)02125-0Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 9Brusselle G.G. Koppelman G.H. Biologic therapies for severe asthma.N. Engl. J. Med. 2022 Jan 13; 386: 157-171https://doi.org/10.1056/NEJMra2032506Crossref PubMed Scopus (214) Google Scholar, 10García-Marcos L. Chiang C.Y. Asher M.I. Marks G.B. El Sony A. Masekela R. Bissell K. Ellwood E. Ellwood P. Pearce N. Strachan D.P. Mortimer K. Morales E. Global Asthma Network Phase I Study GroupAsthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study.Lancet Global Health. 2023 Feb; 11 (PMID: 36669806): e218-e228https://doi.org/10.1016/S2214-109X(22)00506-XAbstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 11Papaioannou A.I. Diamant Z. Bakakos P. Loukides S. Towards precision medicine in severe asthma: treatment algorithms based on treatable traits.Respir. Med. 2018 Sep; 142 (Epub 2018 Jul 17): 15-22https://doi.org/10.1016/j.rmed.2018.07.006Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 12Ulrik C.S. Vijverberg S. Hanania N.A. Diamant Z. Precision medicine and treatable traits in chronic airway diseases - where do we stand?.Curr. Opin. Pulm. Med. 2020 Jan; 26: 33-39https://doi.org/10.1097/MCP.0000000000000639Crossref PubMed Scopus (12) Google Scholar]. However, the majority of these articles are very comprehensive and require profound background knowledge, and hence, are mainly suitable for experts in the field of respiratory medicine. In contrast, there is a lack of concise and practical information on asthma for non-specialists, including general practitioners (GPs), nurse-practitioners, paramedics and pharmacists, who see these patients in the first instance. In line with the previously well-received concept of pocket guides on allergic rhinitis (AR) [[13]Hellings P.W. Scadding G. Bachert C. et al.EUFOREA treatment algorithm for allergic rhinitis.Rhinology. 2020; 58 (10): 618-622Crossref PubMed Google Scholar,[14]Scadding G.K. Smith P.K. Blaiss M. et al.Allergic rhinitis in childhood and the new EUFOREA algorithm.Frontiers in Allergy. 2021 Jul 14; 2706589Crossref Scopus (24) Google Scholar] and chronic rhinosinusitis (CRS) [[15]Hellings P.W. Fokkens W.J. Orlandi R. Adriaensen G.F. Alobid I. Baroody F.M. Bjermer L. Senior B.A. Cervin A. Cohen N.A. Constantinidis J. De Corso E. Desrosiers M. Diamant Z. Douglas R.G. Gane S. Gevaert P. Han J.K. Harvey R.J. Hopkins C. Kern R.C. Landis B.N. Lee J.T. Lee S.E. Leunig A. Lund V.J. Bernal-Sprekelsen M. Mullol J. Philpott C. Prokopakis E. Reitsma S. Ryan D. Salmi S. Scadding G. Schlosser R.J. Steinsvik A. Tomazic P.V. Van Staeyen E. Van Zele T. Vanderveken O. Viskens A.S. Conti D. Wagenmann M. The EUFOREA pocket guide for chronic rhinosinusitis.Rhinology. 2023 Feb 1; 61: 85-89https://doi.org/10.4193/Rhin22.344Crossref PubMed Scopus (12) Google Scholar], the asthma expert panel of the European Forum for Research & Education in Allergy & Airway Diseases (EUFOREA), in collaboration with several global key opinion leaders in the field of chronic inflammatory airways disease, developed a pocket guide on asthma [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar] largely based on international recommendations [1www.ginasthma.comGoogle Scholar, 2www.nice.org.uk/guidance/indevelopment/gid-ng10186Google Scholar, 3Muraro A. Roberts G. Halken S. Agache I. Angier E. Fernandez-Rivas M. Gerth van Wijk R. Jutel M. Lau S. Pajno G. Pfaar O. Ryan D. Sturm G.J. van Ree R. Varga E.M. Bachert C. Calderon M. Canonica G.W. Durham S.R. Malling H.J. Wahn U. Sheikh A. EAACI guidelines on allergen immunotherapy: executive statement.Allergy. 2018 Apr; 73: 739-743https://doi.org/10.1111/all.13420Crossref PubMed Scopus (120) Google Scholar] complemented by professional experience. The overall aim of this guide is to provide a concise summary of the cornerstones of asthma diagnosis and management and, thus, to promote awareness, educate and support non-specialist stakeholders and patients. To this end, the guide provides listings and tables of common manifestations and triggers of asthma, a summary of the key differential diagnoses, commonly encountered treatable traits and comorbid conditions, which should be proactively explored and addressed [Table 1]. Furthermore, we included a shortlist of essential diagnostic tools: i.e. guidance on lung function tests and assessment of airway inflammation which facilitate subtyping (phenotyping, endotyping) of individual patients leading to more personalized approach to management [Table 2; Table 3]. All these features are implemented in simple and clinically applicable algorithms: one specifically linking asthma diagnosis to management [Fig. 1], while the second one focuses on asthma management in the first (GP) and second (respiratory specialist) line of care [Fig. 2].Table 1Key lung function tests in GP and specialist care [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar].Table 2Asthma pheno-/endotyping and point-of-care inflammometric tests [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar].Table 2Asthma pheno-/endotyping and point-of-care inflammometric tests [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar].Table 3Linking treatable traits to diagnostic tests/markers and treatment options [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar].Table 3Linking treatable traits to diagnostic tests/markers and treatment options [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar].Fig. 1Algorithm linking cornerstones of asthma diagnosis and treatment [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar].View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 2Treatment algorithm for asthma (≥12 years) for the first and second line care [[16]www.euforea.eu/news/asthma-pocket-guideGoogle Scholar].Show full captionACO: asthma COPD overlap.AIT: allergen immunotherapy.AR: allergic rhinitis.COPD: chronic obstructive pulmonary disease.BT: bronchial thermoplasty.ICS: inhaled corticosteroids.LABA: long-acting beta2 agonists.LAMA: long-acting muscarinic antagonists.OSA: obstructive sleep apnea.SABA: short-acting beta2 agonists.TLA: temperature-controlled laminar airflow.TT: treatable traits.View Large Image Figure ViewerDownload Hi-res image Download (PPT) ACO: asthma COPD overlap. AIT: allergen immunotherapy. AR: allergic rhinitis. COPD: chronic obstructive pulmonary disease. BT: bronchial thermoplasty. ICS: inhaled corticosteroids. LABA: long-acting beta2 agonists. LAMA: long-acting muscarinic antagonists. OSA: obstructive sleep apnea. SABA: short-acting beta2 agonists. TLA: temperature-controlled laminar airflow. TT: treatable traits. Apart from chronic use at high doses, even infrequent short bursts of systemic corticosteroids (SCS) are associated with an increased risk of potentially serious side effects [[17]Foster J.M. Aucott L. van der Werf R.H. van der Meijden M.J. Schraa G. Postma D.S. van der Molen T. Higher patient perceived side effects related to higher daily doses of inhaled corticosteroids in the community: a cross-sectional analysis.Respir. Med. 2006 Aug; 100: 1318-1336https://doi.org/10.1016/j.rmed.2005.11.029Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar,[18]Wallace B.I. Waljee A.K. Burst case scenario: why shorter may not be any better when it comes to corticosteroids.Ann. Intern. Med. 2020 Sep 1; 173: 390https://doi.org/10.7326/M20-4234Crossref PubMed Scopus (8) Google Scholar]. These include osteoporosis, fractures, ocular disorders (glaucoma, cataracts), skin bruising, gastro-intestinal bleeding, infections, metabolic syndrome, including diabetes, obesity and cardiovascular disease. In a recent publication, these steroid-induced health issues have been collectively referred to as ‘‘people remodeling’’ [[19]St-Germain O. Lachapelle P. 1 Pavord I.D. Couillard S. Tackling ‘people remodelling’ in corticosteroid-dependent asthma with type-2 targeting biologics and a formal corticosteroid weaning protocol.touchREVIEWS in Respiratory & Pulmonary Diseases. 2022; 7: 44-47https://doi.org/10.17925/USRPD.2022.7.2.44Crossref Google Scholar]. Therefore, patient awareness and education on the chronicity of the disease, preventive (lifestyle) measures, in combination with adequate inhaler technique and intake of controller treatment (or, cf updated GINA2023: maintenance or inhaled corticosteroids (ICS)-containing treatment [[1]www.ginasthma.comGoogle Scholar]) are crucial for an optimized asthma control and to avoid sequelae of ‘‘people remodeling’’ associated with the intake of SCS as well as with frequent asthma exacerbations. Inhaled corticosteroids remain the cornerstone of asthma treatment even in patients with very mild disease with infrequent symptoms [[1]www.ginasthma.comGoogle Scholar]. In this respect, the updated GINA2023 has issued two new terminologies, i.e. ‘‘AIR’’ and ‘‘MART’‘, to reflect the dual purpose of the so-termed ‘anti-inflammatory reliever’ (AIR) consisting of as-needed ICS-formoterol and the recently added as-needed ICS-SABA, and the so-termed ‘maintenance and reliever therapy’ (MART). The AIR-only approach is recommended for treatment Steps 1–2, while the MART strategy is recommended for Steps 3–5 for adolescents (≥12 years) and adults. While in these steps the combination ICS-formoterol may serve as AIR on top of the MART, ICS-SABA combinations are not recommended as part of a MART regimen. Although most asthma patients can reach a satisfactory level of disease control, a distinct group with more severe disease, after assuring adherence and inhalation technique, will require re-evaluation to confirm the diagnosis of asthma, explore treatable traits and comorbidities, assess environmental factors and triggers and to perform additional tests, including inflammometry, i.e. simple tests if available in routine clinical practice [Table 2]. At this level, specialist referral or initiation of the next treatment step by a specialist or a multidisciplinary team may be required [Fig. 1; Fig. 2]. In our pocket guide, we provide a shortlist of indications for referral to an asthma expert which may differ (slightly) across countries. Depending on the clinical and immunological profile (type (T)2 or non-T2) as well as on local availability, eligible patients may be prescribed biologics. Presently, most biologics target type2-inflammatory components (omalizumab, mepolizumab, benralizumab, reslizumab and dupilumab) while the recently registered tezepelumab seems to demonstrate efficacy in both T2- and non-T2 asthma [[9]Brusselle G.G. Koppelman G.H. Biologic therapies for severe asthma.N. Engl. J. Med. 2022 Jan 13; 386: 157-171https://doi.org/10.1056/NEJMra2032506Crossref PubMed Scopus (214) Google Scholar,[20]Striz I. Golebski K. Strizova Z. Loukides S. Bakakos P. Hanania N.A. Jesenak M. Diamant Z. New insights into the pathophysiology and therapeutic targets of asthma and comorbid chronic rhinosinusitis with or without nasal polyposis.Clin. Sci. (Lond.). 2023 May 18; 137: 727-753https://doi.org/10.1042/CS20190281Crossref PubMed Scopus (8) Google Scholar]. Patients with allergen-driven disease should be considered for allergen immunotherapy (AIT, specifically sublingual immunotherapy (SLIT) tablets) in early stages [[1]www.ginasthma.comGoogle Scholar,[3]Muraro A. Roberts G. Halken S. Agache I. Angier E. Fernandez-Rivas M. Gerth van Wijk R. Jutel M. Lau S. Pajno G. Pfaar O. Ryan D. Sturm G.J. van Ree R. Varga E.M. Bachert C. Calderon M. Canonica G.W. Durham S.R. Malling H.J. Wahn U. Sheikh A. EAACI guidelines on allergen immunotherapy: executive statement.Allergy. 2018 Apr; 73: 739-743https://doi.org/10.1111/all.13420Crossref PubMed Scopus (120) Google Scholar,[21]Diamant Z. van Maaren M. Muraro A. Jesenak M. Striz I. Allergen immunotherapy for allergic asthma: the future seems bright.Respir. Med. 2023 Apr-May; 210107125https://doi.org/10.1016/j.rmed.2023.107125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. Switching between biologics, and/or concomitant application of several biologic therapies may be needed in some patients [[22]Pavord I.D. Hanania N.A. Corren J. Controversies in Allergy: choosing a biologic for patients with severe asthma.J. Allergy Clin. Immunol. Pract. 2022 Feb; 10: 410-419https://doi.org/10.1016/j.jaip.2021.12.014Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar]. Close monitoring of several disease manifestations, including evaluation of asthma control, risk of exacerbations and/or side effects, comorbidities and treatable traits, as well as lung function, combined with re-evaluation of patient's expectations and satisfaction remain pivotal aspects of asthma management [Fig. 1; Fig. 2]. As a consequence of the concise lay-out, and despite input from international experts, we are aware that this initiative also comes with several limitations and hence does not (fully) replace ongoing and new concepts or (inter)national recommendations and guidelines - which are subject to quick turnover upon emerging evidence or new insights and/or local preferences as well as the availability of health care resources. Soon after the launch of the EUFOREA pocket guide, GINA2023 was issued online and consequently, some of the latest concepts have not (yet) been fully implemented. EUFOREA aims to present updated versions of the pocket guides online on a regular basis. Conceptualization: ZD and LB have conceived and developed the EUFOREA asthma pocket guide with extensive input by the asthma expert panel: MJ, SQ, LH, RD, NH, DR, IP, VB, MG. GKS, DR and RD performed linguistic corrections. EvS skilfully crafted the format of the tables and figures. Resources: Funding acquisition by PH, ZD, LB., Writing: ZD wrote the manuscript with input from LB and approval from all co-authors., All authors have contributed in several aspects to the development and/or review of the EUFOREA asthma pocket guide and all approved this manuscript. ZD: received consultancy fees/lecture fees/fees for attending advisory boards from ALK, Antabio, Foresee Pharmaceuticals, GlaxoSmithKline, Hippo-Dx, QPS-Netherlands, Sanofi-Genzyme; she served as Director Respiratory & Allergy at QPS-NL and this CRO received research grants for clinical trials from HAL Allergy, Janssen Research & Development LLC, Patara pharma, Cerbios, Merck Sharp & Dohme, Novartis, Foresee Pharmaceuticals and ERA4TB (IMI-project). MJ: ALK, Stallergenes-Greer, Chiesi, GSK, Pfizer, Novartis, AstraZeneca and SANOFI. NH: Received honoraria for serving as advisor or consultant for GSK, AstraZeneca, Sanofi, Regeneron, Amgen, Genentech, Novartis and Teva. His institution received research grant support of his behalf from GSK, Genentech, Sanofi, Teva, Novartis, and AstraZeneca. LH: Has received grant funding, participated in advisory boards and given lectures at meetings supported by Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, Circassia, Hoffmann la Roche, GlaxoSmithKline, Novartis, Theravance, Evelo Biosciences, Sanofi, and Teva; he has received grants from MedImmune, Novartis UK, Roche/ Genentech Inc, and Glaxo Smith Kline, Amgen, Genentech/Hoffman la Roche, Astra Zeneca, MedImmune, Glaxo Smith Kline, Aerocrine and Vitalograph; he has received sponsorship for attending international scientific meetings from AstraZeneca, Boehringer Ingelheim, Chiesi, GSK and Napp Pharmaceuticals; he has also taken part in asthma clinical trials sponsored by AstraZeneca, Boehringer Ingelheim, Hoffmann la Roche, and GlaxoSmithKline for which his institution received remuneration; he is the Academic Lead for the Medical Research Council Stratified Medicine UK Consortium in Severe Asthma which involves industrial partnerships with a number of pharmaceutical companies including Amgen, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Hoffmann la Roche, and Janssen. RD: Declares consulting fees from Synairgen, Sanofi and Galapagos, lecture fees from GSK, AZ and Airways Vista and he holds shares from Synairgen. DR: No COIs related to this work. SQ: ALK, Allergy Therapeutics, AstraZeneca, Chiesi, GSK, Leti, Mundipharma, Novartis, Sanofi-Genzyme, Teva. VB: Has worked as advisor, supervisor, investigator of pharmaceutical studies, unrestricted grants, and others with: AstraZeneca, GSK, MSD & Shering Plough, ALK-Abello; Chiesi,Novartis, Pharmaxis, Pfizer, Boehringer Ingelheim, Aerocrine, Teva, Sanofi, Birk NPC as. MG: No COIs related to this work. IP: In the last 5 years IDP has received speaker’s honoraria for speaking at sponsored meetings from Astra Zeneca, Boehringer Ingelheim, Aerocrine, Almirall, Novartis, Teva, Chiesi, Sanofi/Regeneron, Menarini and GSK and payments for organising educational events from AZ, GSK, Sanofi/Regeneron and Teva. He has received honoraria for attending advisory panels with Genentech, Sanofi/ Regeneron, Astra Zeneca, Boehringer Ingelheim, GSK, Novartis, Teva, Merck, Circassia, Chiesi and Knopp and payments to support FDA approval meetings from GSK. He has received sponsorship to attend international scientific meetings from Boehringer Ingelheim, GSK, AstraZeneca, Teva and Chiesi. He has received a grant from Chiesi to support a phase 2 clinical trial in Oxford. DAA: Has received honoraria as grants/contracts from Sociedad Española de Alergología e Inmunología Clínica (SEAIC), as consulting fees from ALK-Abelló, AstraZeneca, Chiesi and Gebro, as speaker from AstraZeneca, Chiesi, Gebro, GSK, Leti Pharma, Mundipharma, Novartis, Roxall, Sanofi. AS: GSK support for an asthma biologic clinical trial 2021-ongoing. PB: Has received honoraria for presentations and consultancy fees from AstraZeneca, Boehringer Ingelheim, Chiesi, ELPEN, GSK, Menarini, Novartis, Sanofi, and Gilead. AB: Takeda, Novartis, Viatris, ALK, Zentiva, MERCK, Stallergenes Greer, Ewopharma, Astra Zeneca, Chiesi, S&D Pharma, Mundipharma, Berlin Chemie. WB: GlaxoSmithKline, Sanofi, Regeneron. JK: Grants and/or personal fees from ALK, Chiesi, GSK, Novartis, AstraZeneca, Sanofi, Boerhinger, Teva, Viatris, Stallergen, Abbot, all outside the submitted work. SL: Honorarium AstraZeneka, GSK, Chiesi Hellas, Sanofi, Elpen, Menarini, Guidoti. MVM: No COIs related to this work. PP: ALK, AstraZeneca, Stallergenes. HP: No COIs related to this work. AS: Reports lecture fees and/or consultancies from AstraZeneca, Chiesi, B.I., GSK, Merck, Novartis, Zambon, Sanofi. HS: No COIs related to this work. IS: No COIs related to this work. BT: No COIs related to this work. MKV: GlaxoSmithKline, AstraZeneca. Diego Conti: No COIs related to this work. WF: The department of Otorhinolaryngology of the Amsterdam University Medical centre, location AMC received grants for research in Rhinology from: ALK, AllergyTherapeutics, Novartis, EU, GSK, MYLAN, Sanofi-Aventis, and Zon-MW; personal COIs: for consultation and/or speaker fees from Dianosic, GSK, Novartis and Sanofi-Aventis/Regeneron. SL: Advisory Board Sanof-Aventis, GSK and Leo-Pharma. Honoraria by DBV Technologies, Allergopharma, Leti, Nutricia, Sanofi-Aventis. GKS: Honoraria for articles, speaker and advisory boards: ALK, AstraZeneca, Capnia, Church & Dwight, Circassia, Noucor, GSK, Meda/Mylan/Viatris, Merck, Sanofi- Regeneron, Stallergenes. Scientific Chief Editor, Rhinology Section, Frontiers in Allergy. Board Member, Lead for Allergic Rhinitis, EUFOREA. Chair of Data Monitoring Board for Paediatric AR trials of HDM SLIT. EVS: No COIs related to this work. PH: Recipient of research grants, honoraria and/or lecture fees of Sanofi, Regeneron, Viatris, GSK, and Novartis. LB: No COIs related to this work. Funding was provided via an unrestricted grant to EUFOREA by GlaxoSmithKline, Belgium.