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Allergic rhinitis increases the risk of driving accidents

Published:March 08, 2017DOI:https://doi.org/10.1016/j.jaci.2017.01.037
      To the Editor:
      Allergic rhinitis (AR) disturbs patients' quality of life with consequences on their occupational and daily activities; it also reduces quality of sleep and induces daytime drowsiness,
      • Suzuki H.
      • Kitamura T.
      • Shiomori T.
      • Hiraki N.
      • Fujimura T.
      • Ueda N.
      Relationships among nasal obstruction, daytime sleepiness, and quality of life.
      which can increase the risk of driving accidents. Connor et al
      • Connor J.
      • Norton R.
      • Ameratunga S.
      • Robinson E.
      • Civil I.
      • Dunn R.
      • et al.
      Driver sleepiness and risk of serious injury to car occupants: population based case control study.
      showed that when people complained of feeling very drowsy while driving, the risk of having a traffic accident compared with a nondrowsy person was multiplied by 8.2. Some authors have hypothesized that drowsiness due to poor sleep may be a more common cause of accidents than alcohol and reported that studies are urgently needed.
      • Smolensky M.H.
      • Di Milia L.
      • Ohayon M.M.
      • Philip P.
      Sleep disorders, medical conditions, and road accident risk.
      Therefore, we conducted the “EVEIL” national survey. The main aim was to assess the consequences of AR on daytime awareness and driving and to identify through cluster analysis methodology the existence of a patient group at increased risk of car accidents on the basis of the features of their AR.
      We conducted a cross-sectional observational national survey in primary care allergy medicine and general practice on a randomized sample stratified geographically (quotas method). We involved 976 practitioners who were required to include the next 4 consecutive patients older than 18 years driving a vehicle and consulting for untreated AR or AR poorly controlled with a previous treatment.
      The consequences of AR on daytime awareness were assessed by the EPWORTH drowsiness score
      • Kaminska M.
      • Jobin V.
      • Mayer P.
      • Amyot R.
      • Perraton-Brillon M.
      • Bellemare F.
      The Epworth Sleepiness Scale: self-administration versus administration by the physician, and validation of a French version.
      and awareness at the wheel by the Karolinska Sleepiness Scale (KSS) score.
      • Horne J.A.
      • Stuart D.
      Awareness of sleepiness when driving.
      The EPWORTH scale is made up of 8 questions scored from 0 to 3, giving a sum of 0 to 24, which reflects the severity of daytime drowsiness. The KSS scale is made up of 9 awareness/asleep graduation scales varying from 1 (“extremely aware”) to 9 (“very sleepy, considerable effort needed to remain awake and stop going to sleep”). An ascending hierarchical cluster analysis (Ward method)
      • Ball G.H.
      • Hall D.J.
      A clustering technique for summarizing multivariate data.
      was used to identify the existence of groups at high risk of drowsiness and driving accidents incorporating the EPWORTH and KSS scores.
      In our study, 3850 patients, average age 39 ± 14 years, with a sex ratio close to 1, were included.
      In 25.4%, the AR was intermittent and mild; in 8.8%, persistent and mild; in 17.9%, intermittent and moderate to severe; and in 48.0%, persistent and moderate to severe. Half of the patients (53.3%) had a family history of allergy and 84.8% had a personal history of not only AR but also asthma (23.6%) and/or atopic dermatitis (18.2%). Allergy had been confirmed by tests in 46.9% of the patients. The allergens, which were found in 61.0% of these patients, were predominantly pollens (79.3%), moulds and dust mites (44.1%), and animals (14.5%).
      The EPWORTH score was 7.6 ± 5.4 (out of 24). On the basis of this score, 30.3% of the patients had moderate (25.9%; 95% CI, 24.5-27.3) or severe (4.4%; 95% CI, 3.7-5.0) drowsiness. The KSS score was 3.9 ± 1.8, which showed that not only were 39.4% (95% CI, 37.8-40.9) of the patients at risk of reduced awareness when driving, 24.4% were also at high risk of having an accident: 18.8% had signs of sleepiness, 3.6% felt sleepy but remained awake without efforts, and 2.0% felt sleepy and needed to make efforts to remain awake.
      In addition, 63.8% of the patients described on questioning that their AR had an effect on driving, some of which had been dangerous including not having the right reflex in some situations (18.9%), having made an unusual driving error (13.6%), or falling asleep for a fraction of a second (9.5%). Almost one-fifth of the patients (17.5%) also reported that they had needed to stop on the edge of the road or even that they did not feel capable of driving (16.4%) and 0.7% reported they had a car accident.
      The cluster analysis of the whole population using Ward's ascending hierarchy method identified 2 almost equivalent sized patient groups: cluster 1 (n = 1739 [47.7%]) and cluster 2 (n = 1910 [52.3%]). This methodology overcomes one of the limitations of the study of not having a control group. The comparisons of their features show that cluster 1 contained patients experiencing drowsiness and lack of awareness when driving, which was far more severe than in cluster 2: EPWORTH score 12.2 ± 3.4 versus 3.2 ± 2.6 (P < .0001) and KSS score: 4.8 ± 1.6 versus 3.1 ± 1.5 (P < .0001). The effect of AR on driving statistically differs between clusters 1 and 2. In particular, 85.2% versus 45.3% of the patients described that their AR had an effect on driving, 26.2% versus 12.4% that they had not the right reflex in some situations, 18.6% versus 9.7% that they made an unusual driving error, 15.2% versus 4.3% that they fell asleep for a fraction of a second, 23.7% versus 11.9% that they had needed to stop on the edge of the road, 23.5% versus 9.9% that they did not feel capable of driving, and 0.9% versus 0.6% reported that they had a car accident.
      Cluster 1 could also be distinguished on the ARIA classification by more persistent (60.9% vs 51.9%; P < .0001) and moderate to severe AR (76.7% vs 54.8%; P < .0001). The group at risk of drowsiness and accident (cluster 1) not only had more severe nasal symptoms than the other patients but also had eye, pharyngeal, and respiratory signs, fatigue, and headaches, which were 1.5 to 2 times as common. As a consequence of their more severe nasal symptoms and more frequent ocular symptoms, they were also more often treated with oral and ocular H1 antihistamine. One limitation of the study is that the type of antihistamines, and especially the proportion of first-generation sedating antihistamines, was not reported.
      These results show the impact of AR on the risk of sleeping while driving. Drowsiness is responsible for 1 out of 5 cases of road accidents. It affects all drivers, although some conditions increase the risk. The case of sleep apnea syndrome is well known
      • Ward K.L.
      • Hillman D.R.
      • James A.
      • Bremner A.P.
      • Simpson L.
      • Cooper M.N.
      • et al.
      Excessive daytime sleepiness increases the risk of motor vehicle crash in obstructive sleep apnea.
      : when untreated, it triples the accident rate compared with the general population. This risk is not known today for AR but the fact that almost 50% of the patients with AR were at increased risk of a driving accident confers a level of seriousness that is usually not acknowledged. A case control study should be conducted to evaluate the ratio of incidence rate of motor vehicle crashes in patients with AR by comparison to a nonrhinitis population of drivers. This study should also more precisely document the allergic origin of the rhinitis, which is also a limitation of our study. However, the present results, describing an increase in the driving problems described by the patients themselves, justify active management and increased patient information about the risks they run if they are not appropriately treated and adhere correctly to their treatment. They confirm the experimental work of Vuurman et al
      • Vuurman E.F.
      • Vuurman L.L.
      • Lutgens I.
      • Kremer B.
      Allergic rhinitis is a risk factor for traffic safety.
      on a small number of patients who conclude that untreated AR can impair driving ability and put patients at risk and that drug therapy could reduce this impairment. In particular, it is recommended
      • Papadopoulos N.G.
      • Bernstein J.A.
      • Demoly P.
      • Dykewicz M.
      • Fokkens W.
      • Hellings P.W.
      • et al.
      Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report.
      to adapt treatment according to the severity and level of management of the AR and not using sedatives, particularly first-generation H1 antihistamines, which affect driving. Information strategies should also be developed for dispensing pharmacists who are increasingly being consulted directly by patients because of the apparently mild nature of the disorder.
      Our study points out the extent of the consequences of AR on daytime drowsiness and awareness when driving and identifies the existence of a homogeneous group of patients at high risk of reduced awareness and driving accidents, characterized by a profile involving severe nasal, ocular, pharyngeal, and respiratory symptoms. These patients should be informed of this risk and managed specifically.

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