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Wise et al.

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analysis found that AR is associated with worsened PSG parameters 712,714,716-719 ; however, 2 level 3b studies found either no difference or a modest change. 720,721 Two studies looked at variations in sleep symptoms with changes in nasal inflammation over time. It seems that changes in nasal cytokine levels are associated with changes in PSG 719 and that AR patients have worse PSG parameters and sleep disturbance when their symptoms are present or during their peak allergen season. 718 In children, level 2 and 3 studies suggest that AR is associated with sleep disturbance in the form of increased risk of snoring, sleep disordered breathing, and OSA. Furthermore, AR has been suggested to be a risk factor for deterioration of OSA QOL after adenotonsillectomy. 722 (See section X.K. Associated conditions – Sleep disturbance and obstructive sleep apnea for additional information on this topic.) • Aggregate Grade of Evidence: B (Level 1b: 5 studies; Level 2b: 10 studies; Level 2c: 3 studies; Level 3a: 1 study; Level 3b: 21 studies; Level 4: 6 studies; Tables VII.A.2-1 and VII.A.2-2). • Benefit: Successful management of AR leads to decreased sleep disturbance. • Harm: Management strategies for AR are associated with variable levels of harm and are further specified in Section IX. Management. • Cost: Management strategies for AR are associated with variable levels of cost and are further specified in Section IX. Management. • Benefits-Harm Assessment: The benefits of treating patients with AR for symptoms of sleep disturbance may outweigh risks of treatment. • Value Judgments: Successful control of AR symptoms leads to improvements in sleep. • Policy Level: Recommend treatment of AR to decrease sleep disturbance. • Intervention: AR patients may be offered various management strategies to improve sleep. As described in Section VII.A.1, AR may have significant negative effects on QOL with considerable consequences if left untreated. For many years, AR has been trivialized despite its prevalence, chronicity, and the burden it imposes on individuals and society. 101,681,753 The total burden for AR lies not only in the impairment of physical and social functioning, but also in the financial burden, which is greater when its role in comorbid conditions such as asthma and rhinosinusitis are taken into account. 754-756 In Europe, the total societal cost of AR and its comorbidities in 2002 was estimated at 355.06 Euros per patient per month. 755 The burden of AR is now being recognized by the European Academy of Allergy & Clinical Immunology (EAACI) and also at the European Union (EU) parliament level in order to feature the dramatic impact this condition has on the QOL of patients with AR. 757,758

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VII.B. Societal burden

In terms of the overall economic burden of illness, AR ranks fifth among chronic conditions in the United States. 759 Estimates of the annual direct cost of AR range from $2 billion to $5

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.

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