All of ARIA in One Puff?

tems, given the hundreds of millions of patients affected worldwide. Many SCUAD patients feel abandoned by their allergists, and, as a consequence, the majority of European rhinitis patients do not consult their physician any more [4] . The flourishing market for alternative therapies in allergy speaks for itself. Some years ago, Michael Kaliner [5] , then president of the American Academy of Allergy, Asthma, and Immunology, claimed to have discovered the ultimate treatment for all types of rhinitis, be it allergic, nonallergic (Americans still use the term ‘vasomotor’ for this entity), or a mixed type of allergic rhinitis with nonallergic triggers like smoke or cold air. He proposed to use a combination of a nasal antihistamine and a nasal steroid. Since the scientific evidence for this approach was still missing at the time, they only smiled at his suggestion and insisted on their ARIA algorithm. It took only 5 years to produce the evidence for Kaliner’s concept and the drug stepping now into the worldwide arena claims to combine the entire ARIA guideline in one single nasal application. Antihistamine, mast cellstabilizing, and anti-leukotriene effects as well as steroidal properties have been described in clinical trials with the two compounds, fluticasone proprionate and azelastine hydrochloride. These two active ingredients therefore It is a paradox of our specialty that more than a century after the definition of the term ‘allergy’, 100 years after the first clinical application of specific immunotherapy as causal treatment, 80 years after the discovery of antihistamines as acute remedies, and 50 years after the introduction of the first nasal steroid, more patients than ever are affected by the disease. Furthermore, the severity and the persistence of the disorder have increased in most individuals who are concerned, so that an expert group recognized the necessity to define a new clinical entity, namely the ‘severe chronic upper airway disease’ (SCUAD) [1] . In spite of all therapeutic innovations, there remains a hard core of allergic rhinitis patients who do not benefit from the current rhinitis management approaches defined in the latest ARIA (Allergic Rhinitis and Its Impact on Asthma) documents [2] . In a representative sample in the US population, the majority (60%) of hay fever patients are still complaining about insufficient symptom control during the pollen season [3] . In fact, there are salvage therapies, for instance the administration of systemic steroids, for most severely affected patients, but they are not applicable on a permanent basis due to pronounced side effects. Similarly, although there are remarkable reports about the effects of the monoclonal antibody omalizumab, a widespread introduction of this upscale pharmacon would ruin our health care sysPublished online: December 18, 2013