Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: findings from a large online survey

Comparison of sensory attributes and immediate efficacy of intranasal ciclesonide and fluticasone propionate in allergic rhinitis: a randomized controlled trial

Objectives:

Intranasal corticosteroids (INCs) are the most effective modality for treating allergic rhinitis and their sensory attributes are important in patient compliance. This study aimed to compare the sensory attributes (scent, immediate taste, aftertaste, run down to throat, nose run off, soothing feel, nasal irritation, and urge to sneeze) and immediate response to the new intranasal steroid, ciclesonide (CIC), with fluticasone propionate (FLP) in allergic rhinitis.

Materials and Methods:

A randomized, double blind, single dose, crossover study was done with 74 patients presenting with acute allergic rhinitis. Eligible subjects were randomized in 1:1 ratio to one of the two treatment sequences – CIC followed by FLP or vice versa. Sensory attributes were assessed using a questionnaire to score each item on a seven-point Likert scale, immediately and 2 min after dosing. Total nasal symptom score (TNSS) was calculated to evaluate immediate efficacy 10 min after first drug administration. Overall preference was recorded 10 min after the second drug administration. Patients were queried about treatment emergent adverse events following study drug administration and also 24 h later over the phone.

Results:

Patients (58% males; pooled median age 32 years [Interquartile range, IQR, 25–41]; pooled median symptom duration 24 months [IQR 12–72]) preferred FLP over CIC nasal spray overall (55.41% vs. 25.68%, P = 0.007) and also with respect to attributes of scent, soothing feel, and nasal irritation. There was no statistically significant difference in immediate efficacy. Two patients reported mild headache following CIC first, while three felt mild headache, one dizziness, and one nasal congestion following FLP first administration. There were no delayed adverse events.

Conclusions:

There was no difference in immediate outcome following use of either of the two INCs. FLP was preferred over CIC with respect to scent, soothing feel and nasal irritation, and also overall. There were no significant adverse events.

Does the duration and time of sleep increase the risk of allergic rhinitis? Results of the 6-year nationwide Korea youth risk behavior web-based survey

Allergic rhinitis (AR) is the most common chronic disorder in the pediatric population. Although several studies have investigated the correlation between AR and sleep-related issues, the association between the duration and time of sleep and AR has not been analyzed in long-term national data. This study investigated the relationship between sleep time and duration and AR risk in middle- and high-school students (adolescents aged 12–18). We analyzed national data from the Korea Youth Risk Behavior Web-based Survey by the Korea Centers for Disease Control and Prevention from 2007–2012. The sample size was 274,480, with an average response rate of 96.2%. Multivariate logistic regression analyses were conducted to determine the relationship between sleep and AR risk. Furthermore, to determine the best-fitted model among independent variables such as sleep duration, sleep time, and the combination of sleep duration and sleep time, we used Akaike Information Criteria (AIC) to compare models. A total of 43,337 boys and 41,665 girls reported a diagnosis of AR at baseline. The odds ratio increased with age and with higher education and economic status of the parents. Further, students in mid-sized and large cities had stronger relationships to AR than those in small cities. In both genders, AR was associated with depression and suicidal ideation. In the analysis of sleep duration and sleep time, the odds ratio increased in both genders when sleep duration was <7 hours, and when the time of sleep was later than 24∶00 hours. Our results indicate an association between sleep time and duration and AR. This study is the first to focus on the relationship between sleep duration and time and AR in national survey data collected over 6 years.

Impact of sleep as a specific marker of quality of life in allergic rhinitis

Allergic rhinitis (AR) is a common disorder, which represents a considerable burden both on individual patients and society. It is associated with bothersome symptoms, which may impair usual daily activities, sleep quality, and productivity. Associated with impaired sleep, quality of life is significantly impaired in AR patients. AR significantly contributes to sleep-disordered breathing through multiple mechanisms, with the greatest impact mediated through nasal obstruction. Sleep impairment is very common in AR patients and has a significant impact on disease-specific measures of general health and quality of life. The degree of sleep disturbance is directly related to the severity of the disease. Nasal congestion also demonstrates circadian rhythm and positional variability, worsening during nighttime hours and in supine position. Increased sleep disordered events lead to poor sleep with fatigue and daytime somnolence, impaired performance, productivity and social functioning, and an increased risk of associated diseases.

Relieving nasal congestion in children with seasonal and perennial allergic rhinitis: efficacy and safety studies of mometasone furoate nasal spray

Background

In surveys of children with allergic rhinitis (AR), nasal congestion has been identified as the most frequently experienced and bothersome symptom. This analysis was conducted to investigate the effect of mometasone furoate nasal spray (MFNS) on congestion in children with AR.

Methods

Two multicenter, double-blind, placebo-controlled studies randomly assigned children to MFNS 100 μg or placebo, 1 spray/nostril QD for 4 weeks (Study 1: ages 6–11 years with seasonal AR [SAR] ≥1 year; Study 2: ages 3–11 years with perennial AR [PAR] ≥1 year). Least square (LS) means were obtained from an ANCOVA model with treatment and study center effects, with baseline score as a covariate. We conducted post hoc evaluation of changes from baseline in AM/PM PRIOR (average of reflective AM and PM scores) nasal congestion (0=none to 3=severe).

Results

Study 1: MFNS (n=134) reduced congestion significantly more than placebo (n=135) on day 2 (P=.004) and on 23/29 days (P≤.037). Change from baseline was −0.53 and −0.28 for MFNS and placebo (P<.001) over days 1–15 and −0.64 and −0.38 for MFNS and placebo (P<.001) over days 1–29. Study 2: MFNS (n=185) reduced congestion significantly more than placebo (n=189) on day 3 (P=.015) and on 22/29 days (P≤.047). Change from baseline was −0.56 and −0.36 for MFNS and placebo (P<.001) over days 1–15 and −0.64 and −0.45 for MFNS and placebo (P<.001) over days 1–29. MFNS was well tolerated, with no unusual or unexpected adverse events.

Conclusion

MFNS effectively relieved nasal congestion and was well tolerated in children with SAR or PAR.

Patient perceptions of allergic rhinitis and quality of life: findings from a survey conducted in europe and the United States

BACKGROUND

: Allergic rhinitis (AR) is a common, costly, and troublesome condition, impairing patients' quality of life (QoL), cognitive function, and productivity. Patients with AR report disturbed sleep, fatigue, irritability, and a range of practical problems. However, there is a relative lack of data on how patients with AR perceive their QoL.

OBJECTIVE

: To better understand how patients perceive AR and their attitudes toward this condition (including QoL) and its treatment options.

METHODS

: An online and telephone survey of 3635 people identified as having outdoor and indoor allergies, urticaria, and/or pet allergies was performed in 6 countries.

RESULTS

: The survey confirmed that patients with allergies perceive their symptoms as causing significant disruptions to their daily lives. Respondents were affected for a considerable part of each day, with the most severe symptoms occurring in the morning. The most important desired effect of medication was the restoration of normal breathing, and the most highly rated attributes of the "ideal" AR drug were efficacy, safety, and freedom from undesirable side effects.

CONCLUSIONS

: The information gathered from allergy sufferers who participated in this survey sheds light on the degree to which people with allergies are affected by their disease and the limitations imposed by associated symptoms.

Treatment of allergic rhinitis with desloratadine: results of a multinational observational study in the middle East gulf region

Background

Allergic rhinitis (AR) affects up to 36% of the population in the Middle East Gulf States. The second-generation nonsedating antihistamine desloratadine has demonstrated safety and efficacy in the treatment of AR; however, few studies have evaluated this agent in Arab and Asian populations in the Middle East.

Methods

This open-label study enrolled subjects ≥ 12 years with moderate-to-severe AR; they received desloratadine 5 mg QD for 2 weeks. Endpoints included change in mean individual nasal and ocular symptom scores, total symptom score (TSS), and peak nasal inspiratory flow (PNIF) and percentage improvement in global response to therapy.

Results

There were 602 subjects from 5 Middle East countries enrolled. After 2 weeks, desloratadine significantly (P < 0.0001) reduced mean scores for individual nasal and total ocular symptom scores and TSS. PNIF measures of nasal congestion were significantly (P < 0.0001) improved after treatment. Most subjects obtained complete (38.1%) or marked (47.2%) relief of AR symptoms. Treatment failure was reported in 2.2% of subjects. No adverse events were reported, and no subjects discontinued treatment.

Conclusion

Most subjects reported significant symptom relief with desloratadine 5 mg/d for 2 weeks. Desloratadine is effective in the treatment of AR in Arab and Asian subjects in the Middle East Gulf region.

Allergic rhinitis and its associated co-morbidities at Bugando Medical Centre in Northwestern Tanzania; A prospective review of 190 cases

BACKGROUND

Allergic rhinitis is one of the commonest atopic diseases which contribute to significant morbidity world wide while its epidemiology in Tanzania remains sparse. There was paucity of information regarding allergic rhinitis in our setting; therefore it was important to conduct this study to describe our experience on allergic rhinitis, associated co-morbidities and treatment outcome in patients attending Bugando Medical Centre.

METHODS

This was descriptive cross-sectional study involving all patients with a clinical diagnosis of allergic rhinitis at Bugando Medical Centre over a three-month period between June 2011 and August 2011. Data was collected using a pre-tested coded questionnaire and analyzed using SPSS statistical computer software version 17.0.

RESULTS

A total of 190 patients were studied giving the prevalence of allergic rhinitis 14.7%. The median age of the patients was 8.5 years. The male to female ratio was 1:1. Adenoid hypertrophy, tonsillitis, hypertrophy of inferior turbinate, nasal polyps, otitis media and sinusitis were the most common co-morbidities affecting 92.6% of cases and were the major reason for attending hospital services. Sleep disturbance was common in children with adenoids hypertrophy (χ2 = 28.691, P = 0.000). Allergic conjunctivitis was found in 51.9%. The most common identified triggers were dust, strong perfume odors and cold weather (P < 0.05). Strong perfume odors affect female than males (χ2 = 4.583, P = 0.032). In this study family history of allergic rhinitis was not a significant risk factor (P =0.423). The majority of patients (68.8%) were treated surgically for allergic rhinitis co morbidities. Post operative complication and mortality rates were 2.9% and 1.6% respectively. The overall median duration of hospital stay of in-patients was 3 days (2 - 28 days). Most patients (98.4%) had satisfactory results at discharge.

CONCLUSION

The study shows that allergic rhinitis is common in our settings representing 14.7% of all otorhinolaryngology and commonly affecting children and adolescent. Sufferers seek medical services due to co-morbidities of which combination of surgical and medical treatment was needed. High index of suspicions in diagnosing allergic rhinitis and early treatment is recommended.

Rhinoplasty from a rhinologist's perspective: need for recognition of associated sinonasal conditions

BACKGROUND

Facial plastic surgeons may primarily focus on esthetic improvement of the nasal shape in patients seeking rhinoplasty (RP). However, medical conditions inside the nasal cavity should not be neglected because they may lead to unresolved sinonasal problems and, hence, dissatisfaction after esthetic RP. This observational study investigated the prevalence of sinonasal symptoms and endonasal pathology in patients requesting esthetic RP.

METHODS

Patients seeking RP (n = 269) were given a questionnaire evaluating nasal obstruction and sinonasal symptoms using visual analog scales and the 22-item Sino-Nasal Outcome Test. In addition, patients underwent nasal endoscopy to evaluate anatomic and/or mucosal disease and skin-prick testing in case of clinical suspicion of allergy. Two control groups consisted of patients with an otological or general ear/nose/throat problem (n = 65) and patients who planned for endoscopic sinus surgery (ESS; n = 90).

RESULTS

The general appraisal of nasal breathing on a scale from 0-10 in patients seeking RP was as low as 4.3 ± 3.1. Structural pathology was found in 62% of RP patients, with septal deviation being the most frequent problem encountered (54%), followed by internal nasal valve dysfunction (14%). Mucosal disease was present in 28% of RP patients. The mean SNOT-22 score of RP patients (31.8 ± 23.3) was significantly higher than the control group (11.6 ± 7.9; p < 0.001), but lower than the ESS patients (48.5 ± 22.0; p < 0.001).

CONCLUSION

The prevalence of endonasal structural or mucosal pathology in patients seeking RP is high and should not be overlooked at the time of planning surgery.

Upper airway symptoms among workers with work-related respiratory complaints

BACKGROUND

Work-related rhinitis and asthma symptoms frequently co-exist.

AIMS

To determine the prevalence and nature of nasal, pharyngeal, laryngeal and sinus symptoms among individuals with work-related respiratory symptoms.

METHODS

Individuals referred to a tertiary occupational asthma clinic for investigations with specific inhalation challenges were evaluated using the RHINASTHMA quality of life questionnaire and a questionnaire that assessed the nature and frequency of upper airway symptoms, their relationship to the workplace and their temporal relationship with the onset of asthma symptoms.

RESULTS

There were 83 study participants. At least one upper airway symptom was reported by all of these individuals: nasal in 92%; pharyngeal in 82%; laryngeal in 65% and sinus in 53% of participants. Overall, there were no significant differences in the frequencies of nasal, pharyngeal, laryngeal and sinus symptoms when comparing these with occupational asthma (OA), work-exacerbated asthma (WEA) and work-related respiratory symptoms (WRS), except that nasal bleeding was most frequent among those with WRS. The presence of laryngeal symptoms was significantly associated with rhinitis-specific quality of life impairment. Individuals with workplace exposures to high molecular weight agents had greater impaired quality of life than those who were exposed to low molecular weight agents (RHINASTMA Upper Airway sub-scores: 24.0±10.4 versus 19.8±6.8; P < 0.05).

CONCLUSIONS

Individuals who were referred for work-related respiratory symptoms experienced high rates of work-related nasal, pharyngeal, laryngeal and sinus symptoms, regardless of having OA, WEA or WRS.

Twenty-Four–hour Duration of Effect of Intranasal Corticosteroids for Seasonal Allergic Rhinitis Symptoms: Clinical Evidence and Relevance

Background

Seasonal allergic rhinitis (SAR) symptoms are often most severe and/or disruptive during overnight and morning hours, resulting in cognitive/performance impairments and reduced quality of life throughout the following day. Surveys of allergy patients and health care practitioners reveal a common perception that intranasal steroids (INSs), many of which are dosed q.d., fail to adequately relieve symptoms for a full 24 hours. This review assessed whether perceptions of the 24-hour duration of action of INSs correspond with duration of action documented in clinical literature.

Methods

SAR clinical trial literature of the last 5 years was reviewed to identify studies of INSs incorporating morning instantaneous (A.M. NOW) or instantaneous assessments of 24-hour duration of action.

Results

In numerous placebo-controlled trials of INSs in patients with SAR, treatment was associated with significantly greater improvements in A.M. NOW symptoms from baseline versus placebo. For congestion, this is noteworthy, because patients often cite this symptom, especially in the morning, as the most bothersome symptom. Comparison of A.M. NOW and daily scores suggests minimal drop in efficacy at 24 hours postdose. In several studies, INS treatment was found superior to intranasal or oral antihistamines in A.M. NOW symptom improvement.

Conclusion

Once-daily INSs have potential for effective 24-hour symptom relief; however, there is an apparent disconnect between these findings and patient/physician perceptions. This discrepancy may be explained, in part, by less-than-ideal treatment adherence among “real-world” patients versus subjects treated in clinical trials. Proactive counseling can encourage proper INS use and help maximize treatment benefits.

Spa therapy of upper respiratory tract inflammations

The upper airway respiratory diseases (i.e. common cold, allergic rhinitis, nonallergic/vasomotor rhinitis, acute and chronic rhinosinusitis and nasal polyposis) in which nasal congestion is a common symptom are often undertreated due to the frequent inadequate efficacy and safety concern with current therapies. In scientific literature, few studies seem to support the hypothesis that nasal inhalatory treatment with thermal water promotes the improvement of nasal symptoms, even if the mechanisms by which the improvement from SPA therapy can be expected remain debated. A prospective comparative study with a pre-post design has been performed consecutively enrolling 33 (males 70 %) patients of both genders older than 12 years of age, affected by chronic sinonasal inflammation. All patients underwent a 14-days course of radioactive water warm vapour inhalations followed by nasal aerosol of the same thermal water 10 min each once/day at Merano Therme. At the beginning and end of the study, in all the subjects, nasal function evaluation by active anterior rhinomanometry, mucociliary transport time (MCTt) determination and nasal cytology were performed. After the inhalatory treatment, the mucociliary function was improved and the pathologic mucociliary transport times recorded at the beginning of the study being significantly reduced to physiologic ones. Besides, before treatment, the cytologic picture showed an inflammatory cell infiltration (eosinophils, neutrophils with/without bacteria, mast cells) in 37 % of patients; after therapy in 66 % of these patients, the rhinocytogram was normal. Our results suggest, according to the literature data, that SPA therapy with radioactive water could represent an alternative choice in chronic inflammatory diseases of the upper airways, nonresponsive to pharmacological therapy.

Impact of allergic rhinitis in school going children

Allergic rhinitis (AR) is the most common chronic pediatric disorder. The International Study for Asthma and Allergies in Childhood phase III found that the global average of current rhinoconjunctivitis symptoms in the 13-14 year age-group was 14.6% and the average prevalence of rhinoconjunctivitis symptoms in the 6-7 year age-group was 8.5%. In addition to classical symptoms, AR is associated with a multidimensional impact on the health related quality of life in children. AR affects the quality of sleep in children and frequently leads to day-time fatigue as well as sleepiness. It is also thought to be a risk factor for sleep disordered breathing. AR results in increased school absenteeism and distraction during class hours. These children are often embarrassed in school and have decreased social interaction which significantly hampers the process of learning and school performance. All these aspects upset the family too. Multiple co-morbidities like sinusitis, asthma, conjunctivitis, eczema, eustachian tube dysfunction and otitis media are generally associated with AR. These mostly remain undiagnosed and untreated adding to the morbidity. To compound the problems, medications have bothersome side effects which cause the children to resist therapy. Children customarily do not complain while parents and health care professionals, more often than not, fail to accord the attention that this not so trivial disease deserves. AR, especially in developing countries, continues to remain a neglected disorder.

Quality of life in allergic rhinitis

Allergic rhinitis is a global health problem that causes major illness and disability worldwide. Although nasal and nonnasal symptoms are directly attributable to inflammation in the upper respiratory tract, individuals also experience generalized symptoms that include fatigue, mood changes, depression, anxiety and impairments of work and school performance, and cognitive function. Health-related quality of life focuses on patients’ perceptions of their disease and measures impairments that have a significant impact on the patient. The burden of disease, as the patient perceives it, forms the basic motivation to seek medical aid or to undergo therapy. Adherence to therapy requires changes in health, perceived by patients as relevant and outweighing eventual disadvantages of intervention. Because so many factors are involved in health-related quality of life, there are multiple ways in which it can be measured. A variety of validated and standardized questionnaires have been developed including assessments of school performance, work performance, productivity, and other parameters that quantify the impact of allergic rhinitis and its treatment on quality of life. The aim of this review is to highlight the impact of allergic rhinitis on the quality of life and to analyze the most commonly used health-related quality of life instruments.

Sneezing and runny nose: should allergy testing be routinely performed?

The need for routine determination of rhinitis subtypes by allergy testing and the relevance between symptoms and allergy were evaluated. A retrospective study at a tertiary hospital, ENT clinic. One hundred and twenty-seven adult patients with sneezing and runny nose for at least 6 months for the last two consecutive years were included. The age range was 16-60. Allergy testing was only positive in 43.4% of the patients. Excluding mixed rhinitis, persistent sneezing and runny nose were mostly related to anatomical deformities, mainly septal deviation followed by vasomotor rhinitis. Persistent sneezing and runny nose may be caused by different etiologies other than allergy. Determination of rhinitis subtypes is important for accurate treatment of patients with these symptoms. Taking appropriate medical history and performing a good physical exam with objective allergy testing are highly recommended.

Intranasal steroids in the treatment of allergy-induced rhinorrhea

While nasal congestion has been identified as one of the most bothersome and prevalent symptoms of allergic rhinitis, it is underappreciated that many patients find rhinorrhea also to be bothersome. Rhinorrhea as a symptom of allergic rhinitis virtually never occurs alone; about 97% of patients with allergic rhinitis suffer from at least two symptoms, a finding that underscores the advantage of treating a broad range of symptoms with a single medication. Along with sneezing and nasal obstruction, rhinorrhea is a classic acute symptom of allergic rhinitis; it appears as a late-phase symptom as well. In this review, the characterization and epidemiology of rhinorrhea, the pathophysiology of rhinorrhea in allergic rhinitis, the roles played by mediators in early- and late-phase rhinorrhea, the prevalence and impact of this symptom, and the efficacy and safety of available treatment options are all discussed in context of relevant literature. A review of the clinical studies assessing the efficacy of intranasal corticosteroids (INS) for rhinorrhea is presented. Many clinical studies and several meta-analyses conclusively demonstrate that, in addition to being safe and well-tolerated, INS are more effective than other agents (including oral and intranasal antihistamines) across the spectrum of AR symptoms, including rhinorrhea and nasal congestion.

Differences in leisure activities between children with allergic rhinitis and healthy peers

OBJECTIVE

The symptoms of allergic rhinitis (AR) are frequently evoked when individuals with AR perform daily activities. Thus, AR may interfere the optimal participation in daily life, negatively impact the patient's productivity and quality of life (QOL). While most studies refer to adult with AR, this pilot study examined participation of children with AR as expressed in their daily activity preferences.

METHODS

Participants were 31 children with AR and 31 healthy children, aged 5-11 years. All children completed the Preference for Activities of Children (PAC).

RESULTS

Children with AR showed significantly lower preference to participate in skill-based, social and informal activities, as compared to their healthy peers (F(7,53)=2.61, p=0.02, ES-η(2)=0.27). Children with AR showed 5-20% lower preference to participate in activity than their typical peers.

CONCLUSIONS

AR may negatively impact children's preference to participate in daily activities. Treatment of children with AR should consider a multi-disciplinary intervention for encouraging their optimal development, improve their well-being and QOL.

Intranasal mometasone furoate therapy for allergic rhinitis symptoms and rhinitis-disturbed sleep

BACKGROUND

Allergic rhinitis (AR) and related nasal congestion cause rhinitis-disturbed sleep (RDS). Intranasal corticosteroids reduce nasal congestion and improve sleep quality in AR but have not been extensively studied in RDS.

OBJECTIVE

To evaluate the efficacy of mometasone furoate nasal spray (NS) on nasal symptoms, nasal patency, sleep variables, quality of life, and daytime functioning in perennial AR (PAR) and concomitant RDS.

METHODS

In this double-blind 4-week study, 30 adults with PAR and moderate RDS were randomized 2:1 to receive mometasone furoate NS, 200 microg, or placebo each morning. The primary end point was the apnea-hypopnea index. Secondary outcome measures included changes in total nasal symptom score (TNSS), nighttime symptom score, daytime peak nasal inspiratory flow, nighttime flow limitation index, Rhinoconjunctivitis Quality of Life Questionnaire-Standardized (RQLQ-S) score, Epworth Sleepiness Scale score, and Work Productivity and Activities Impairment-Allergy Specific (WPAI-AS) questionnaire score. Analysis of covariance was used for all efficacy end points.

RESULTS

The apnea-hypopnea index at study end was not statistically significantly different between groups. However, mometasone furoate NS therapy significantly improved morning (P = .04) and evening (P = .01) TNSSs, morning (P = .049) and evening (P = .03) nasal obstruction/blockage/congestion, daily peak nasal inspiratory flow (P = .03), flow limitation index (P = .02), Epworth Sleepiness Scale score (P = .048), RQLQ-S score (P = .03), and 2 of 5 WPAI-AS domains. Among patients receiving mometasone furoate NS, TNSS improvements were significantly correlated with improved work- and non-work-related productivity.

CONCLUSIONS

In patients with PAR and RDS, mometasone furoate NS use improved nasal symptoms, sleepiness, and impairment in daily activities. Correlated reduced nasal symptoms and improved performance suggest that improving AR symptoms with mometasone furoate NS administration can benefit sleep and daytime functioning.

The psychosocial impact of self-reported morning allergy symptoms: findings from an Australian internet-based survey

Background. Allergies can substantially impact health-related quality of life (HRQL). We investigated the psychosocial impact of morning symptoms amongst Australian adults with self-reported allergic rhinitis (AR). Method. An online survey comprising 24 questions was conducted in August 2008. Inclusion criteria were age (20-49 years) and self-reported moderate to severe symptoms of AR. Results. One thousand sixty respondents met the inclusion criteria. Amongst consumers with self-reported AR, symptoms were more severe in the morning in 597 (56%) and affected mood in 1025 (97%). Nine hundred seventy (91%) indicated that their symptoms had some impact on their day ahead and 868 (82%) reported a negative impact on relationships. Morning symptoms in particular had a substantial affect on mood for the day. HRQL impact was more pronounced in those who reported severe symptoms and in females. Discussion. Encouraging consumers with self-diagnosed AR to seek formal diagnosis and offering appropriate treatment strategies, such as those offering sustained effectiveness over 24-hours, may aid in negating the negative impact of morning symptoms.

Eczema and sleep and its relationship to daytime functioning in children

Chronic childhood eczema has significant morbidity characterised by physical discomfort, emotional distress, reduced child and family quality-of-life and, of particular note, disturbed sleep characterised by frequent and prolonged arousals. Sleep disturbance affects up to 60% of children with eczema, increasing to 83% during exacerbation. Even when in clinical remission, children with eczema demonstrate more sleep disturbance than healthy children. Notably, disturbed sleep in otherwise healthy children is associated with behavioural and neurocognitive deficits. Preliminary evidence suggests that disturbed sleep in children with eczema is also associated with behavioural deficits while the impact on neuropsychological functioning remains unexplored. In conclusion, a disease which affects up to 20% of children in some countries and may produce long-term behavioural and neurocognitive deficits merits further evaluation using standardised tests of sleep, behaviour and neurocognition.

Epidemiology and burden of nasal congestion

Nasal congestion, which may be described as fullness, obstruction, reduced airflow, or being "stuffed up," is a commonly encountered symptom in clinical practice. Systematic study of congestion has largely considered it as a component of a disease state. Conditions associated with congestion include nasal polyposis, obstructive sleep apnea, and anatomic variation; however, most information on the burden of congestion comes from studies of allergic rhinitis and rhinosinusitis, diseases of which congestion is the major symptom. Congestion can be caused by other rhinologic conditions, such as non-allergic rhinitis, viral or bacterial rhinitis, and vasomotor rhinitis. Allergic rhinitis affects as much as one quarter of the population worldwide and imposes a significant economic burden. Additionally, allergic rhinitis significantly impairs quality of life; congestion causes allergic rhinitis sufferers decreased daytime productivity at work or school and reduces night-time sleep time and quality. Annually, rhinosinusitis affects tens of millions of Americans and leads to approximately $6 billion in overall health care expenditures; it has been found to be one of the most costly physical conditions for US employers. Given the high prevalence and significant social and economic burden of nasal congestion, this symptom should be a key consideration in treating patients with rhinologic disease, and there continues to be a significant unmet medical need for effective treatment options for this condition.

Treatment of congestion in upper respiratory diseases

Congestion, as a symptom of upper respiratory tract diseases including seasonal and perennial allergic rhinitis, acute and chronic rhinosinusitis, and nasal polyposis, is principally caused by mucosal inflammation. Though effective pharmacotherapy options exist, no agent is universally efficacious; therapeutic decisions must account for individual patient preferences. Oral H₁-antihistamines, though effective for the common symptoms of allergic rhinitis, have modest decongestant action, as do leukotriene receptor antagonists. Intranasal antihistamines appear to improve congestion better than oral forms. Topical decongestants reduce congestion associated with allergic rhinitis, but local adverse effects make them unsuitable for long-term use. Oral decongestants show some efficacy against congestion in allergic rhinitis and the common cold, and can be combined with oral antihistamines. Intranasal corticosteroids have broad anti-inflammatory activities, are the most potent long-term pharmacologic treatment of congestion associated with allergic rhinitis, and show some congestion relief in rhinosinusitis and nasal polyposis. Immunotherapy and surgery may be used in some cases refractory to pharmacotherapy. Steps in congestion management include (1) diagnosis of the cause(s), (2) patient education and monitoring, (3) avoidance of environmental triggers where possible, (4) pharmacotherapy, and (5) immunotherapy (for patients with allergic rhinitis) or surgery for patients whose condition is otherwise uncontrolled.

Safety and efficacy of desloratadine in subjects with seasonal allergic rhinitis or chronic urticaria: results of four postmarketing surveillance studies

BACKGROUND AND OBJECTIVE

Allergic rhinitis (AR) and chronic urticaria (CU) are common diseases with symptoms that impair quality of life. Second-generation antihistamines (e.g. cetirizine, desloratadine, fexofenadine, loratadine and mizolastine) are recommended first-line treatment for both conditions; however, studies of clinically relevant differences among these agents are lacking. The aim of this investigation was to evaluate the safety, tolerability and efficacy of desloratadine 5 mg once daily in four postmarketing surveillance studies in subjects with seasonal AR (SAR) or chronic idiopathic urticaria (CIU) in real-world clinical practice settings.

METHODS

This programme of prospective surveillance studies was conducted in Germany between February 2001 and March 2002 in allergy; dermatology; ear, nose and throat; or general practice settings. Subjects (total number 77 880) were aged > or =12 years and met the requirements for treatment of SAR or CIU with desloratadine as outlined in the package insert. All subjects received oral desloratadine 5 mg once daily for a mean duration of up to 40.4 days. Adverse events (AEs) were reported throughout the studies; serious AEs were recorded for up to 30 days after treatment. Investigators and subjects both rated tolerability at the end of treatment. Symptom severity and sleep and daily activity impairment were evaluated at baseline and after treatment using 4-point scales (0 = none; 1 = mild; 2 = moderate; 3 = severe). A post hoc subanalysis assessed desloratadine efficacy and onset of symptom relief in subjects who had received monotherapy with another second-generation antihistamine.

RESULTS

A total of 386 AEs were reported by 287 subjects (0.37%) in the four studies. The most commonly reported treatment-related AEs were fatigue (0.07%), headache (0.07%), dry mouth (0.04%) and nausea (0.03%). Tolerability was rated as excellent/good by 99.1% of investigators and 98.5% of subjects. Desloratadine therapy significantly reduced nasal and ocular symptom severity, itching and wheals, and sleep and activity disruption (p < 0.0001), as indicated by a reduction in mean total and individual symptom scores, and reported impairment of sleep and daily activities. The efficacy of desloratadine was rated as significantly greater by 59.4-88.0% of subjects who had previously received monotherapy with cetirizine, fexofenadine, loratadine or mizolastine (p < 0.01 for all). The percentage of subjects who rated onset of symptom relief with desloratadine as faster than previous treatment ranged from 51.6% to 82.4%.

CONCLUSION

Desloratadine was safe, well tolerated and efficacious in this series of surveillance studies. A post hoc analysis of subjects who had received previous monotherapy with a second-generation antihistamine found that most subjects rated efficacy as higher than their previous treatment, with a faster onset of symptom relief.

Impact of pretreatment nasal symptoms on treatment outcome in allergic rhinitis

OBJECTIVE

The Allergic Rhinitis and its Impact on Asthma (ARIA) classification of allergic rhinitis (AR) is based on the severity and duration of nasal symptoms. Whether nasal symptoms have an impact on treatment outcome is unclear. The aim of this study was to evaluate the correlation between pretreatment nasal symptoms and therapeutic response in AR.

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Sixty-nine AR patients were classified according to ARIA class: mild or moderate-severe intermittent AR (MIAR or MSIAR) and mild or moderate-severe persistent AR (MPAR or MSPAR). All patients were treated over 28 days with 220 microg of intranasal triamcinolone acetonide once daily. Nasal symptoms, peak expiratory flow index, and global symptom control were used to evaluate treatment outcome.

RESULTS

At 28 days after treatment, MSPAR patients showed the worst global symptom control, followed by MSIAR, MPAR, and MIAR (mean global symptom controls were 76.5%, 83.8%, 87.7%, and 89.0%, respectively). Pretreatment total nasal symptom score was inversely correlated with global symptom control (rho = -0.405, P < 0.001), but positively correlated with percent total nasal symptom score and peak expiratory flow index improvements (rho = 0.271, P = 0.024; and rho = 0.371, P = 0.002, respectively). Blocked nose had the best inverse correlation with global symptom control (rho = -0.389, P = 0.001).

CONCLUSION

A worse treatment outcome despite more clinical improvements during the treatment period in a higher severity score suggests the therapeutic predictive value of pretreatment nasal symptom scoring and the need for more dosing and continuing medication in higher scores, especially in blocked nose.

Desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis

BACKGROUND

Symptoms of allergic rhinitis (AR), particularly nasal congestion, can impair quality-of-life (QoL). However, only a modest correlation exists between these symptoms and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores, suggesting that both be evaluated for a complete assessment of health.

METHODS

Subjects with a > or =2-year history of moderate-to-severe AR to dust mite or cat dander were randomized to desloratadine 5 mg/day (n = 293) or placebo/day (n = 291) for 28 days. Primary endpoint was change from baseline in a.m./p.m. nasal congestion score. Secondary outcomes included change from baseline in total nasal symptom score, individual symptom scores and RQLQ scores (completed on days 1, 7, and 28).

RESULTS

The Allergic Rhinitis and its Impact on Asthma criteria for persistent allergic rhinitis (PER) were fulfilled by 99% of subjects in the placebo arm. Between-treatment difference in a.m./p.m. nasal congestion score, observed from day 8 onward, significantly favored desloratadine (P = 0.0003). Desloratadine significantly improved a.m./p.m. nasal congestion and RQLQ scores after 1 week and at treatment end (P < 0.05). Improvements in 5 of 7 RQLQ domain scores exceeded the minimal important difference. On days 7 and 28, desloratadine was also significantly superior to placebo in mean change from baseline in a.m./p.m. total nasal symptom score and rhinorrhea score (both P < or = 0.01). Symptomatic benefit was primarily driven by improvement in nasal congestion and rhinorrhea.

CONCLUSIONS

Desloratadine 5 mg/day significantly improved symptoms associated with PER, including nasal congestion, and provided significant improvement in QoL after 1 week of treatment.

A review of the efficacy of desloratadine, fexofenadine, and levocetirizine in the treatment of nasal congestion in patients with allergic rhinitis

BACKGROUND

Nasal congestion is the most troublesome symptom of allergic rhinitis (AR). First-generation and older second-generation antihistamines, while effective against nasal itching, sneezing, and rhinorrhea, have limited efficacy in relieving nasal congestion.

OBJECTIVE

This review included nasal challenge studies and clinical trials that reported the effects on nasal congestion of the newer second-generation antihistamines desloratadine, fexofenadine, and levocetirizine.

METHODS

MEDLINE and EMBASE were searched for nasal challenge studies and clinical trials published in English between January 1, 1991, and January 31, 2009, using the following terms, alone or in combination: antihistamines, second-generation antihistamines, allergic rhinitis, intermittent allergic rhinitis, perennial allergic rhinitis, persistent allergic rhinitis, seasonal allergic rhinitis, nasal challenge, nasal blockage, and nasal congestion. Studies that were not active or placebo controlled, that did not evaluate change in nasal congestion scores, or that focused on treatments other than desloratadine, fexofenadine, and levocetirizine for nasal congestion associated with AR were excluded.

RESULTS

Twenty-six clinical trials met the criteria for inclusion in the review. In 11 placebo-controlled trials that included objective assessment of nasal congestion, desloratadine, fexofenadine, and levocetirizine were associated with reductions in the severity of nasal congestion through maintenance of nasal airflow. The mean AUC for nasal airflow over 6 hours was significantly greater with desloratadine compared with placebo in 3 studies (P < 0.05); placebo-controlled trials of fexofenadine and levocetirizine had similar results. In 25 placebo- and active-controlled trials that reported subject-rated symptom scores, the 3 newer antihistamines were efficacious in the treatment of nasal congestion associated with AR. In 10 trials that reported objective and/or subjective measures, desloratadine was associated with significant improvements in nasal congestion compared with placebo (P < or = 0.05), beginning as early as the first 2 hours after allergen challenge. Fexofenadine was associated with significantly lower nasal congestion scores compared with placebo in 4 studies (P <- 0.05); nasal congestion scores were significantly reduced with levocetirizine in 3 placebo-controlled trials (P < or = 0.005).

CONCLUSIONS

In the studies reviewed, desloratadine, fexofenadine, and levocetirizine were effective in relieving the nasal congestion associated with AR compared with placebo. This effect began as early as day 2 and was consistent and progressive throughout treatment. Desloratadine, fexofenadine, and levocetirizine are appropriate options for the treatment of nasal congestion in patients with AR.

The correlation between nasal symptom and mucociliary clearance in allergic rhinitis

OBJECTIVE/HYPOTHESIS

The Allergic Rhinitis and Its Impact on Asthma (ARIA) classification of allergic rhinitis (AR) is based on the severity and duration of nasal symptoms. Whether the nasal symptoms actually represent underlying nasal inflammation is unclear. The aim of this study was to evaluate the correlation between nasal symptoms and nasal inflammation using mucociliary clearance time (MCCT) in AR.

STUDY DESIGN

A prospective cross-sectional study.

METHODS

73 AR patients were classified according to ARIA class: mild or moderate-severe intermittent AR (MIAR or MSIAR) and mild or moderate-severe persistent AR (MPAR or MSPAR). Each nasal symptom was scored as 1 to 3 on a severity scale (mild-moderate-severe). The sum of the individual nasal symptom scores gave the total symptoms score (TSS). MCCT was determined with the charcoal-saccharin method. MCCTs between ARIA classes were compared and correlations between TSS or days with symptoms per week (DSW) and MCCT were analyzed.

RESULTS

Of the patients, 67.1% were moderate-severe degree. MSPAR had the worst MCCT, followed by MSIAR, MPAR, and MIAR (mean MCCTs of 14.32, 13.87, 11.94, and 10.28 minutes, respectively). TSS was well correlated with MCCT (P = .538, P < .001). DSW was also correlated with MCCT, but did not reach statistical significance (r = 0.217, P = .065). The mean MCCT of overall nasal symptoms increased along with each score step and a significant difference was noted between scores 2 and 3 (P < .001).

CONCLUSIONS

A high percentage of moderate-severe disease and a significant correlation of the severity and MCCTs suggest an important heterogeneity in this disease severity group. Discriminating between moderate and severe rhinitis should help to obtain homogeneous populations and develop improved disease management strategies.

Immunogenic yeast-based fermentation product reduces allergic rhinitis-induced nasal congestion: a randomized, double-blind, placebo-controlled trial

INTRODUCTION

Allergic rhinitis (AR) impacts around 25% of the worldwide population. However, cost, safety, and a high dissatisfaction rate with numerous conventional medications continues to be an issue in the largest patient surveys, due primarily to a lack of efficacy on nasal congestion. Our previously published randomized trial demonstrated a significant reduction in cold and flu-like symptoms, and a secondary potential observation of a decrease in nasal congestion with an oral yeast-derived compound; therefore, the objective of this study was to test the effects of this same product on nasal congestion and other notable AR symptoms.

METHODS

A 12-week, randomized, double-blind, placebo-controlled clinical trial of 96 healthy subjects with a recent clinically documented history of seasonal allergies and AR was conducted. Participants received once-daily supplementation with 500 mg of a dried, modified Saccharomyces cerevisiae oral fermentation product (EpiCor, Embria Health Sciences, Ankeny, Iowa, USA) or placebo during the 12-week period of the highest recorded concentrations of total pollen counts for this Midwest geographic area. Clinical outcome measurements included in-clinic examinations, validated questionnaire and standard diary, and serologic analysis at baseline, 6 and 12 weeks.

RESULTS

During the highest pollen count period (weeks 1-6), EpiCor significantly reduced the mean severity of specific AR symptoms, including a significant reduction in nasal congestion (P=0.04), rhinorrhea (P=0.005), and a nonsignificant reduction in ocular discharge symptoms. A significantly (P=0.04) reduced total number of days with nasal congestion (12.5 fewer days) favored EpiCor compared with placebo, as did the nasal congestion section of the quality of life questionnaire (P=0.04). Subjects receiving the intervention also experienced significantly (P=0.03) higher salivary IgA levels. Adverse events were similar to placebo.

CONCLUSION

This yeast-derived product appeared to be safe and efficacious, and should receive more clinical research with and without standard medications to reduce the impact of seasonal allergies, especially AR-induced nasal congestion.

Efficacy of loratadine-montelukast on nasal congestion in patients with seasonal allergic rhinitis in an environmental exposure unit

BACKGROUND

Nasal congestion is considered to be one of the most bothersome symptoms of allergic rhinitis (AR) and often the most difficult to treat. Oral therapies providing safe, effective, and reliable relief of AR symptoms, including nasal congestion, are limited.

OBJECTIVE

To evaluate the efficacy of a single dose of loratadine-montelukast (10 mg/10 mg) vs placebo and phenylephrine (10 mg) in relieving nasal congestion over 6 hours after ragweed pollen exposure in the environmental exposure unit at the Kingston General Hospital.

METHODS

After a screening visit and up to 6 priming visits, patients who met minimum symptom requirements during ragweed pollen exposure were randomized to receive loratadine-montelukast, phenylephrine, or placebo. Patients evaluated nasal congestion and other symptoms of AR and measured peak nasal inspiratory flow before dosing and at 20-minute intervals during the subsequent 8 hours of pollen exposure.

RESULTS

During the first 6 hours after treatment (primary end point), loratadine-montelukast treatment resulted in greater improvement in the mean nasal congestion score vs placebo (P = .007) and phenylephrine (P < .001). Loratadine-montelukast was more effective than placebo (P < or = .02) and phenylephrine (P < or = .002) in relieving total symptoms, nasal symptoms, and nonnasal symptoms and in improving peak nasal inspiratory flow. There were no statistically significant differences between phenylephrine and placebo for any measures. Fewer patients in the loratadine-montelukast group (3.9%) reported adverse events than in the phenylephrine (7.9%) and placebo (7.1%) groups; most adverse events were mild or moderate.

CONCLUSIONS

Loratadine-montelukast was more effective than placebo and phenylephrine in relieving nasal congestion and other nasal and nonnasal symptoms resulting from ragweed pollen exposure. There was no statistically significant difference between phenylephrine and placebo.

Does asthma control correlate with quality of life related to upper and lower airways? A real life study

BACKGROUND

The goal of asthma therapy is to achieve an optimal level of disease control, but the relationship between asthma control, impact of comorbid rhinitis and health related quality of life (HRQoL) in real life remains unexplored.

OBJECTIVE

The aims of this real life study were to evaluate asthma control, the impact of asthma (with and without rhinitis) on HRQoL, the relationship between asthma control and HRQoL, and the role of rhinitis on asthma control and HRQoL.

METHODS

122 asthma patients completed the Asthma Control Test, Rhinitis Symptoms score (T5SS) and RHINASTHMA.

RESULTS

Asthma control was unsatisfactory (44.27% of uncontrolled patients), as well as HRQoL. Controlled patients controlled showed significantly lower scores in all the RHINASTHMA domains compared to uncontrolled. Irrespective of their level of control, patients with rhinitis symptoms showed worse HRQoL in Upper Airways (UA) (P < 0.0001), Lower Airways (LA) (P < 0.001), and Global Summary (GS) (P < 0.0001). In patients with symptomatic rhinitis, RHINASTHMA were lower in controlled asthma patients (UA P = 0.002; LA P < 0.0001; RAI P < 0.01; GS P < 0.0001). Asthma control was associated with lower T5SS score (P = 0.034).

CONCLUSION

Asthma control in real life is unsatisfactory. Rhinitis and asthma influence each other in terms of control and HRQoL. The control of rhinitis in asthma patients can lead to an optimization of HRQoL related to the upper airways, while this phenomenon is not so evident in asthma. These results suggest to strengthen the ARIA recommendation that asthma patients must be evaluated for rhinitis and vice versa.

Change in visual analog scale score in a pragmatic randomized cluster trial of allergic rhinitis

BACKGROUND

Most patients with allergic rhinitis consult in primary care. A simple test is needed to evaluate globally the severity of allergic rhinitis to assess the efficacy of treatment.

OBJECTIVE

This study compared the responsiveness of visual analog scale (VAS) scores between baseline and treatment with the 2 gold-standard outcomes (symptom score and quality of life). Five hundred eighty-six subjects were included, all with allergic rhinitis caused by grass pollens and all seen in primary care.

METHODS

A randomized, multicenter, open-label parallel study was designed to compare 2 therapeutic strategies in patients with allergic rhinitis. The disease-specific Rhinoconjunctivitis Quality of Life Questionnaire total score, the symptom score, and the VAS score (0-10 cm) were all self-assessed by the patient before and after 2 weeks of treatment. Receiver operating characteristic curves and cost function were used to assess VAS cutoff scores and to distinguish between patients with no clinical improvement and patients with improvement in symptoms, quality of life, or both.

RESULTS

The optimal cutoff in VAS score change separating the patients without improvement from those with improvement is 0.30 cm. By using the cost of false-positive and false-negative results, a difference of more than 1 cm is significant. However, when patients show an improvement in both symptoms and Rhinoconjunctivitis Quality of Life Questionnaire scores, the median improvement on the VAS is 7 cm.

CONCLUSIONS

A VAS, when used for a global evaluation of rhinitis, is highly responsive to change during the treatment of a large number of patients in a cluster randomized pragmatic trial.

A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber

BACKGROUND

Studies on the efficacy of phenylephrine in the treatment of nasal congestion have yielded inconsistent results, notwithstanding its approval for this indication.

OBJECTIVE

To evaluate and compare the decongestant effect of a single dose of phenylephrine to placebo and pseudoephedrine in patients with seasonal allergic rhinitis.

METHODS

This randomized, placebo-controlled, 3-way crossover study evaluated patient-scored nasal congestion, peak nasal inspiratory flow, and rhinomanometry at more than 6 hours in 39 grass-sensitive patients exposed to grass pollen in the Vienna Challenge Chamber. Patients were dosed with immediate-release formulations of phenylephrine, 12 mg, pseudoephedrine, 60 mg, as a control, or placebo.

RESULTS

Phenylephrine was not significantly different from placebo in the primary end point, mean change in nasal congestion score at more than 6 hours (P = .56), whereas pseudoephedrine was significantly more effective than both placebo (P < .01) and phenylephrine (P = .01). Phase 1 results showed a difference between phenylephrine and placebo that was 64% of the difference between pseudoephedrine and placebo, substantially greater than the 17% difference observed for all phases. Carryover bias due to patient recall of the pseudoephedrine effect may have influenced these results. Rhinomanometry and peak nasal inspiratory flow results were consistent with these data. Neither phenylephrine nor pseudoephedrine had an effect on the nonnasal symptoms. No adverse events were reported in this study.

CONCLUSIONS

During a 6-hour observation period, a single dose of pseudoephedrine but not phenylephrine resulted in significant improvement in measures of nasal congestion. Neither phenylephrine nor pseudoephedrine had an effect on nonnasal symptoms.

Diagnosis and management of nasal congestion: the role of intranasal corticosteroids

Nasal congestion is considered the most bothersome of allergic rhinitis (AR) symptoms and can significantly impair ability to function at work, home, and school. Effective management of AR-related nasal congestion depends on accurate diagnosis and appropriate treatment. Many individuals with AR and AR-related congestion remain undiagnosed and do not receive prescription medication. However, new tools intended to improve the diagnosis of nasal congestion have been developed and validated. Intranasal corticosteroids (INSs) are recommended as first-line therapy for patients with moderate-to-severe AR and also when nasal congestion is a prominent symptom. Double blind, randomized clinical trials have demonstrated greater efficacy of INSs versus placebo, antihistamines, or montelukast for relief of all nasal symptoms, especially congestion. Patient adherence to treatment also affects outcomes, and this may be influenced by patient preferences for the sensory attributes of an individual drug. Increased awareness of the effects of AR-related nasal congestion, the efficacy and safety of available pharmacotherapies, and barriers to adherence may improve clinical outcomes.

Effects of loratadine/montelukast on vigilance and alertness task performance in a simulated cabin environment

INTRODUCTION

Sedating effects of some medications used to treat allergic rhinitis (AR) symptoms can impair an individual's ability to function optimally. The objective of this study was to characterize the effects of a single dose of loratadine/montelukast (L/M) versus placebo and diphenhydramine on daytime somnolence and psychomotor performance in healthy volunteers.

METHODS

In this single-center, randomized, double-blind, placebo- and active-controlled,three-way crossover study, healthy volunteers received single doses of placebo, L/M 10 mg/10 mg, and diphenhydramine 50 mg. Subjects (n=23) were evaluated under simulated cabin pressure using the following tools: Vigilance and Tracking Task (VigTrack), measuring vigilance and tracking performance; the Multi-Attribute Task Battery (MAT), measuring ability to perform multiple tasks simultaneously; and the Stanford Sleepiness Scale (SSS), measuring sedative effects of medication, at baseline and each hour from 1 to 6 hours postdose. Safety was monitored via adverse events and vital signs.

RESULTS

Performances on VigTrack and MAT from 1 to 6 hours after dosing were not significantly different between L/M and placebo groups; in contrast, diphenhydramine resulted in significant impairment of tracking for up to 5 hours (P< or =0.01) and vigilance performance for up to 3 hours (P< or =0.05) on VigTrack versus placebo. Scores of subjective sleepiness as measured by SSS were similar for patients treated with L/M versus placebo, whereas significant increases in sleepiness occurred between 1-5 hours posttreatment in diphenhydramine-treated patients versus placebo-treated patients (P< or =0.05).

CONCLUSIONS

L/M is similar to placebo in effects on daytime somnolence and psychomotor performance. L/M treatment resulted in significantly less sleepiness and impairment of vigilance and tracking than diphenhydramine.

The pathophysiology, clinical impact, and management of nasal congestion in allergic rhinitis

BACKGROUND

Nasal congestion is a cardinal symptom of allergic rhinitis (AR). It is difficult to treat and is associated with decreased quality of life.

OBJECTIVE

This article reviews the clinical features of nasal congestion, its complex pathophysiology in the context of AR, its clinical impact, and the strengths and weaknesses of available treatments.

METHODS

Primary studies and reviews in the peer-reviewed, English-language literature were identified through searches of MEDLINE (1966-2008) and the Cochrane Library (1996-2008) using the terms nasal congestion, allergic rhinitis, pathophysiology, quality of life, and burden. Additional references were obtained by searching the reference lists of the identified articles. Abstracts from the 2006 and 2007 meetings of the American Academy of Allergy, Asthma, and Immunology were also searched. Pertinent articles were included in the review if they were recently published and patient-focused, and if their authors were recognized leaders in the field.

RESULTS

A survey of 2355 patients with AR or their guardians found that almost half of respondents rated nasal congestion the most bothersome symptom; in a survey of 2500 adults with AR, 78% rated nasal congestion either extremely or moderately bothersome. Histamine and leukotrienes are major mediators of the allergic inflammation associated with nasal congestion, as indicated by reductions in nasal cross-sectional area in response to histamine challenge (P<0.001) and increases in nasal airway resistance in response to leukotriene challenge (P<0.05).Therapy for nasal congestion in AR is often hampered by limitations associated with the individual agents; for example, decongestants are effective in the control of nasal congestion, but their use is restricted by their adverse-event profiles. A meta-analysis of 16 controlled studies involving 2267 patients with AR found that intranasal corticosteroids provided significantly greater relief of nasal congestion than oral antihistamines (95% CI for combined standardized mean difference, -0.73 to -0.53). The results of several clinical trials have suggested that leukotriene-receptor antagonists may be associated with reduced nasal congestion; however, no agents in this class are currently approved for the treatment of nasal congestion in AR.

CONCLUSION

There is a need for therapies that are well tolerated and effective in relieving nasal congestion in AR.

Allergic rhinitis in family practice: the role of levocetirizine in clinical care

Allergic rhinitis is one of the most common presentations of allergic disorders in the United States, affecting more than 20% of the population. Chronic rhinitis affects patients' quality of life and exacerbates comorbid conditions. Its widespread burden affects society by substantially decreasing worker and scholastic productivity. Allergic rhinitis is typically managed with pharmacotherapy to alleviate symptoms and control comorbid conditions, yet many of these agents carry their own burden due to bothersome and sometimes severe side effects that can compromise patient safety. A new generation of non- or less-sedating antihistamines has recently emerged. These agents offer the promise of enhanced efficacy and tolerability. Of these agents, levocetirizine is the latest antihistamine introduced in the United States. It appears to be safe and effective for the treatment of allergic rhinitis. In addition to covering the above topics, this article reviews the value of levocetirizine for the treatment of allergic rhinitis based on its pharmacologic and pharmacokinetic profile, its efficacy compared with placebo and other new-generation antihistamines, and its safety and tolerability.

Identification and management of undiagnosed and undertreated allergic rhinitis in adults and children

Allergic rhinitis (AR) is a common health problem that affects adults, adolescents and children and is often undiagnosed or inadequately treated. Because AR is not a life-threatening disease, many patients do not seek medical treatment for their symptoms, and others self-medicate with over-the-counter medications, often sedating antihistamines. However, untreated or inadequately treated AR can substantially impair overall quality of life (QOL) by causing fatigue, headache, cognitive impairment and other problems. The risk for comorbid conditions, such as asthma, otitis media, and lymphoid hypertrophy with obstructive sleep apnea, can increase, and the symptoms of AR can worsen if AR is not adequately treated. Among the symptoms of AR, nasal congestion has been described by patients as the most bothersome because it disrupts sleep, resulting in diminished daytime performance. A new congestion screening tool, the Congestion Quantifier, has been developed to aid in the diagnosis and treatment of AR and to help guide treatment decisions. Intranasal corticosteroids (INSs) are recommended as effective pharmaceutical treatments for controlling the symptoms of AR. Randomized, controlled trials in children and adults have demonstrated that INSs relieve rhinitis symptoms, thereby improving QOL in individuals with seasonal or perennial AR. Most INSs are approved for use in children >or=6 years of age, but mometasone furoate and fluticasone furoate are approved for use in children as young as 2 years of age and fluticasone propionate for children >or=4 years old. Long-term benefits have also been seen with the use of immunotherapy, although some patients, especially children, resist the injections used in subcutaneous immunotherapy. Recent studies with sublingual immunotherapy have indicated that it might be an effective and well-tolerated alternative to immunotherapy injections.

Use of intranasal corticosteroids in the management of congestion and sleep disturbance in pediatric patients with allergic rhinitis

Allergic rhinitis affects a large number of children and exerts a considerable socioeconomic impact. It is underdiagnosed and inadequately treated, which predisposes children to potentially serious comorbidities. Allergic rhinitis symptoms may create nighttime breathing problems and sleep disturbances and have a negative effect on a child's ability to learn in the classroom. Although antihistamines have shown efficacy in relieving many symptoms, they have little effect on nasal congestion. This article summarizes the advantages of intranasal corticosteroids, including their effectiveness against congestion and excellent safety profile. Intranasal corticosteroids with minimal systemic bioavailability provide topical drug delivery that minimizes the potential for systemic side-effects.

Assessing outcomes from the sleep disturbance associated with rhinitis

PURPOSE OF REVIEW

The purpose of this review is to identify which aspects of allergic rhinitis limit the quality of life in patients, to present information on how rhinitis affects sleep, and to review instruments available to assess the impact that rhinitis has on sleep.

RECENT FINDINGS

Subjective and objective instruments reveal patients with allergic rhinitis frequently suffer from sleep-disordered breathing, poor sleep quality, daytime somnolence, and fatigue. Sleep disturbances associated with allergic rhinitis can lead to decreased cognitive and psychomotor abilities, impaired work performance, decreased productivity, impaired learning, difficulty concentrating, and memory deficits.

SUMMARY

Objective and subjective instruments are available to measure the extent of compromise in quality of life in affected patients. Subjective measurements available to evaluate allergic rhinitis include general and disease specific quality of life questionnaires, including rhinitis specific and sleep specific questionnaires. Objective measurements available include evaluation of nasal patency and physiology in rhinitis, nasal inspiratory peak flow, acoustic rhinometry, rhinomanometry, polysomnography, the Multiple Sleep Latency Test, the Maintenance of Wakefulness Test, and learning and performance testing. The continued utilization of these and other available instruments is vital for further assessment on the effect of allergic rhinitis on sleep.

Allergic rhinitis and its effect on sleep, fatigue, and daytime somnolence

OBJECTIVE

To examine the adverse effects of sleep impairment on the quality of life of patients with the disorder and how these effects can be treated with therapies targeted at the underlying problems that influence sleep.

DATA SOURCES

Medline and Ovid search for sleep and rhinitis.

STUDY SELECTION

All literature on this topic were reviewed, and, if significant, were incorporated into this review.

RESULTS

Intranasal corticosteroids used as treatment for allergic rhinitis have been shown to reduce the nasal congestion characteristic of the disorder. Data on sleep-related end points from clinical trials on intranasal corticosteroids also reveal that the treatment's effectiveness in alleviating nasal congestion leads to better sleep, reduced daytime somnolence, and improved quality of life.

CONCLUSION

Further research, specifically using sleep measurements as primary end points, is needed to definitively show that intranasal corticosteroids reduce nasal congestion, thereby improving sleep and, consequently, quality of life in patients with allergic rhinitis. These future trials will serve to identify the most effective therapies that target the adverse effects of sleep impairment in this disorder.

Allergic diseases and their impact on quality of life

OBJECTIVE

To review the results of studies that have evaluated the impact of allergic diseases on patients' health-related quality of life (HRQL).

DATA SOURCES

We performed a MEDLINE search of the literature published between January 1990 and May 2006 (English language only) on HRQL and allergic diseases.

STUDY SELECTION

Representative studies that used validated questionnaires that assessed the effect of allergic diseases on HRQL were selected for inclusion in this review.

RESULTS

Allergic diseases can deeply interfere with patients' HRQL, with detrimental effects on the physical, psychological, and social dimensions of life. Numerous validated questionnaires that are now available can easily be adopted; most of them are specifically developed for rhinitis and asthma.

CONCLUSIONS

HRQL has become an increasingly important aspect in outcome evaluation in health care research, providing a more comprehensive approach to the patient and proving that nowadays we cannot renounce this tool. Most of the studies evaluate patients with respiratory allergy. Further studies are needed to explore HRQL in other allergic conditions (urticaria, food allergy, sting allergy, drug allergy) by means of specific, validated questionnaires.

Sleep disturbances in allergic diseases

Sleep is fundamental for physical and mental health as well as daytime performance and represents a crucial aspect in the personal representations of well-being. Sleep disturbances in patients with chronic disorders constitute a factor that contributes to exacerbate symptoms, complicate management, and affect mood and quality of life (QoL). Allergic diseases are a global health problem of increasing prevalence that affects up to 15% of the population in Western countries. Sleep problems associated with allergic diseases may play a role in worsening the burden of illness, contributing to impairment of the QoL. The aim of this review was to describe the most common causes leading to sleep disturbance in allergic patients and their consequences on the QoL. The possible negative effects of treatment on sleep parameters has been also considered.