Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids

Formulation considerations of intranasal corticosteroids for the treatment of allergic rhinitis

OBJECTIVE

To examine how various aspects of an intranasal corticosteroid (INS) formulation may influence the efficacy, tolerability, and patient preference and adherence to INS therapy.

DATA SOURCES

A PubMed search of the literature was conducted for studies on allergic rhinitis published between January 1977 and January 2006 using the keywords intranasal corticosteroid, preservatives, benzalkonium chloride, and tonicity.

STUDY SELECTION

Prospective studies, retrospective studies, and case reports were selected for inclusion in this review.

RESULTS

Currently available INSs are effective first-line treatments for allergic rhinitis. Differences in patient preference for a particular INS are largely attributable to sensory attributes of the nasal spray, which arise from characteristics of the formulation. Additives and preservatives can cause tolerability issues by irritating the mucosal membranes and causing nasal drying, or they can confer an unpleasant odor or taste to an INS formulation. The relative osmotic pressure, or tonicity, of an INS can modulate nasal absorption and retention, thereby potentially influencing the clinical efficacy. Characteristics such as delivery device and spray volume can affect a patient's perception and experience with a particular INS. Newer INSs, such as ciclesonide, are in development for the treatment of allergic rhinitis, and consideration of the formulation characteristics of these agents is an important part of the development process.

CONCLUSIONS

INSs are an effective treatment option for patients with allergic rhinitis; however, there is room for formulation improvement. Optimization of formulation may increase the efficacy, tolerability, and patient preference and adherence to INSs.

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.

The importance of rhinitis on sleep, daytime somnolence, productivity and fatigue

PURPOSE OF REVIEW

The goal of treatment of allergic rhinitis should include improvement of daytime and nighttime symptoms, sleep, and quality of life. Congestion from allergic rhinitis is associated with decreased learning and productivity at work and school and a reduced quality of life. The release of inflammatory mediators and activation of inflammatory cells results in nasal congestion, causing disrupted sleep and subsequent daytime somnolence.

RECENT FINDINGS

This review presents evidence that allergic rhinitis causes sleep disruption, and discusses the pathophysiology of this process. The medications used to treat allergic rhinitis and their ability to improve sleep in patients with allergic rhinitis are reviewed.

SUMMARY

Some allergic rhinitis medications can be sedating; therefore, it is important to treat allergic rhinitis with medications that improve symptoms while producing few adverse effects. Medications such as the second-generation antihistamines and anticholinergic drugs are well tolerated, but have little effect on congestion. Intranasal corticosteroids reduce congestion, improve sleep and sleep problems, and reduce daytime sleepiness, fatigue, and inflammation. Recently, montelukast, a leukotriene receptor antagonist, has been added to the therapies approved for allergic rhinitis. Montelukast significantly improves both daytime and nighttime symptoms.

Novel therapeutic interventions for allergic rhinitis

Allergic rhinitis is a high-prevalence disease, affecting 10 - 20% of the general population. Allergic rhinitis is sustained by an IgE-mediated reaction and by a complex inflammatory network of cells, mediators and cytokines that becomes chronic when exposure to allergen persists. A T(H)2-biased immune response is the background of the allergic inflammation. The current therapeutic strategy is mainly based on drugs (antihistamines, nasal corticosteroids, cromones and decongestants) and allergen immunotherapy. Drugs are (overall) effective in controlling symptoms but do not modify the immune background that leads to allergic inflammation and safety concerns may be present, especially for prolonged treatments. Immunotherapy can modify the allergic response but there is still room for improvement. Nowadays, several approaches are under investigation to optimise the management of allergic rhinitis. On one hand, new drugs and antimediators are being developed. On the other hand, attempts are being made to selectively block relevant signal pathways of allergic reaction. Finally, one of the major goals is to modify the T(H)2-biased immune response by improving the characteristics and modes of action of allergen immunotherapy.

Effects of intranasal corticosteroid on nasal adenosine monophosphate challenge in persistent allergic rhinitis

BACKGROUND

Response to a single dose nasal adenosine monophosphate challenge has been used as a surrogate inflammatory marker for allergic rhinitis. Attenuation of response following intranasal corticosteroid would further validate the challenge.

OBJECTIVE

To assess the effect of 4 weeks of 200 mcg once daily mometasone furoate nasal spray on a simplified (single 160 mg dose) nasal adenosine monophosphate challenge.

METHODS

Twenty participants with persistent allergic rhinitis completed a double blind placebo-controlled crossover study. Outcome measures were the peak nasal inspiratory flow and total nasal symptoms score responses to nasal adenosine monophosphate challenge, as well as domiciliary peak nasal inspiratory flow and patient symptom diary cards.

RESULTS

Mometasone significantly (P < 0.05) attenuated response time profiles vs. placebo for peak nasal inspiratory flow but not total nasal symptom scores. For the maximum percentage fall this amounted to a mean difference of 9.6% (95% confidence interval 1.3-17.9%). The coefficient of variation for repeatability was 48.7%. Improvements were seen in prechallenge and domiciliary measurements of peak nasal inspiratory flow (both P < 0.05) and total nasal symptom scores (both P < 0.01).

CONCLUSIONS

Mometasone attenuates the peak nasal inspiratory flow response to a single 160 mg nasal adenosine monophosphate challenge. Such challenges have been shown to be sensitive to the effects of antihistamines, antileukotrienes and now nasal steroids. This further supports their application as surrogate inflammatory markers for therapeutic trials in allergic rhinitis, potentially as 20 min challenges which can be conducted in a non-hospital setting.

Perennial non-infectious rhinitis--an independent risk factor for sleep disturbances in Asthma

AIM OF THE STUDY

To evaluate if perennial non-infectious rhinitis is associated with sleep disturbances in asthma.

MATERIALS AND METHODS

This is a questionnaire based study in a random population sample from Denmark, Estonia, Iceland, Norway and Sweden aged 30-54yr. A total of 1127 individuals reporting asthma from an original random population sample of 16,191 were analysed regarding their quality of sleep in relation to perennial non-infectious rhinitis. Perennial non-infectious rhinitis was defined as having nasal symptoms such as nasal blockage and secretion in the absence of common cold, always. Asthma was defined as both ever having had asthma and having physician diagnosed asthma. Odds ratios (OR) for difficulties inducing sleep, difficulties maintaining sleep, early morning awakenings and daytime sleepiness were calculated in a multiple logistic regression controlling for other risk factors for sleep disturbances such as snoring, wheeze, obesity and smoking.

RESULTS

The response rate was 74%. A total of 189 (17%) of the subjects with asthma reported perennial non-infectious rhinitis. Perennial non-infectious rhinitis was associated with an increased OR for difficulties maintaining sleep (1.6 (95% confidence interval (CI) 1.1-2.3)), early morning awakenings (1.5 (95% CI 1.1-2.2)) and daytime sleepiness (1.8 (95% CI 1.2-2.9)). The result show that perennial non-infectious rhinitis is an independant risk factor for sleep disturbances in asthma.

Comparison of fluticasone propionate aqueous nasal spray and oral montelukast for the treatment of seasonal allergic rhinitis symptoms

BACKGROUND

Few studies have directly compared the efficacy of intranasal corticosteroids with that of leukotriene receptor antagonists for the treatment of daytime and nighttime symptoms of seasonal allergic rhinitis (SAR).

OBJECTIVE

To compare fluticasone propionate aqueous nasal spray, 200 microg daily, with oral montelukast, 10 mg daily, for the relief of SAR symptoms.

METHODS

Patients with SAR 15 years or older were randomized to receive either fluticasone propionate (n = 367) or montelukast (n = 369) in this double-blind, double-dummy, parallel-group study. The primary efficacy measure was the mean change from baseline in daytime total nasal symptom scores (TNSSs) (the sum of 4 daytime individual nasal symptom scores [INSSs] assessing nasal congestion, itching, rhinorrhea, and sneezing), averaged across weeks 1 and 2. Secondary efficacy measures included the 4 daytime INSSs, nighttime TNSSs (the sum of 3 nighttime INSSs assessing congestion on awakening, difficulty going to sleep, and nighttime awakenings), and the 3 nighttime INSSs averaged across weeks 1 and 2.

RESULTS

Mean changes from baseline in daytime TNSSs (P < .001), all daytime INSSs (P < .001), nighttime TNSSs (P < .001), and all nighttime INSSs (P < or = .02) showed significant differences favoring fluticasone propionate over montelukast across 2 weeks of treatment.

CONCLUSION

Compared with montelukast, fluticasone propionate provided significantly greater improvement in daytime and nighttime SAR symptoms.

Pharmacologic management of insomnia in children and adolescents: consensus statement

OBJECTIVE

The purpose of this work was to develop a consensus statement on the current status and future role for pharmacologic management of insomnia in children and adolescents.

METHOD

The National Sleep Foundation, in collaboration with Best Practice Project Management, Inc, convened expert representatives involved in the study and treatment of pediatric insomnia and conducted a 2-day conference to examine the role of pharmacologic management of pediatric insomnia and to make recommendations regarding the development of clinical trials in this area. After a series of presentations providing background on the current knowledge of pediatric insomnia and its treatment alternatives, workgroups provided recommendations for the evaluation of pharmacologic treatment of insomnia in specific populations of children and adolescents and developed guidelines for the core methodologic issues relevant to the design of clinical trials. The group developed consensus recommendations for clinical trials in this area encompassing: (1) high-priority patient populations for research, (2) inclusion/exclusion criteria, (3) outcome measures, (4) ethical considerations unique to clinical trials involving children and adolescents, and (5) priorities for future research that will enhance the understanding of pediatric insomnia.

RESULTS

Conference participants unanimously agreed that there is a need for pharmacologic management of pediatric insomnia. Furthermore, the widespread use of "hypnotic" and psychotropic medications for children in the absence of safety and efficacy data indicates a knowledge gap about the best pharmacologic practices for management of pediatric insomnia. Attendees reached consensus on methodologic issues in the study of pharmacologic treatment of pediatric insomnia including agreeing on a definition of pediatric insomnia as "repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite age-appropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family." It was agreed that priority should be given to insomnia studies in children with attention-deficit/hyperactivity disorder and those with pervasive developmental disorders/autism spectrum disorder. There was also agreement on the need for pharmacokinetic and pharmacodynamic studies to determine appropriate dose levels and to evaluate safety with a wide range of doses.

CONCLUSIONS

The treatment of pediatric insomnia is an unmet medical need. Before appropriate pharmacologic management guidelines can be developed, rigorous, large-scale clinical trials of pediatric insomnia treatment are vitally needed to provide information to the clinician on the safety and efficacy of prescription and over-the-counter agents for the management of pediatric insomnia.

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

BACKGROUND

Allergic rhinitis is the most common allergic disease in the US. The predominant symptom of this condition is nasal congestion, which has a significant impact on quality of life and work productivity. This large survey was conducted to determine the impact of nasal congestion on the above parameters in individuals with allergic rhinitis, and treatment patterns for this symptom.

METHODS

Participants were recruited voluntarily via telephone surveys and internet advertisements. Respondents with nasal congestion as a symptom of their allergic rhinitis (or who were primary caregivers to a child with nasal congestion associated with allergic rhinitis) were eligible for participation and completed a 52-question internet survey. Data were normalized to the US adult population using a weighting algorithm.

RESULTS

Of the 2355 individuals with allergic rhinitis screened for participation in the survey, 2002 (85%) had nasal congestion. This was considered severe by 40% of respondents, compared with fewer than 30% who considered any other individual allergy symptom to be severe. Nasal congestion was the symptom that most adults and children wished to prevent, and it affected most respondents at work or school, had a notable emotional impact, and interfered with their ability to perform daily activities. Only 13% of participants receiving allergic rhinitis medication of any type, including over-the-counter medications, claimed to be very satisfied with treatment, and only 20% adhered completely to prescribing instructions. Although intranasal corticosteroids are recommended as first-line therapy for nasal congestion, only 30% of respondents with severe nasal congestion received treatment with intranasal corticosteroids.

CONCLUSIONS

Nasal congestion affects most individuals with allergic rhinitis, and has a notable impact on quality of life, emotional function, productivity, and the ability to perform daily activities. Patients need to be better educated on the appropriate use of medications, particularly intranasal corticosteroids, to manage their nasal congestion.

Obstructive sleep apnea: what does the cardiovascular physician need to know?

Obstructive sleep apnea (OSA) is a common disorder in adults. It is becoming increasingly recognized as a risk factor for cardiovascular diseases such as hypertension, pulmonary hypertension, myocardial infarction, and stroke. Knowing the pathophysiologic effects that occur during obstructive apnea assists in understanding how chronic complications and sequelae develop. OSA is also being recognized as associated with glucose intolerance and motor vehicle accidents. Polysomnography in a sleep laboratory remains the diagnostic method of choice. Treatment options are somewhat limited in scope, but nasal continuous positive airway pressure is the first line and has been shown to clearly improve many of the symptoms and sequelae of the syndrome. Cardiovascular physicians require a working knowledge of OSA and its complications, as many of the diseases they manage have shown links to this sleep disorder.

Nasal obstruction, the airway, and the athlete

Rhinitis is a common condition that affects a significant proportion of the general population, as well as a high proportion of athletes. Nasal congestion is a predominate symptom of the late-phase reaction in allergic rhinitis and can have far-reaching effects that extend through the airway and beyond the nose. Rhinitis is often found in conjunction with asthma and is a risk factor for asthma. Nasal obstruction, which does not permit conditioning of inspired air by the nasal turbinates, may contribute to asthma symptoms and the development of asthma. These adverse conditions may be especially troublesome for the high-performance athlete who has increased nasal airflow turbulence and who competes under extreme conditions that may worsen rhinitis and asthma. Under the theory of the unified airway, an immune response induced in the nose may extend into the lungs via cytokines and other inflammatory mediators. Nasal congestion can significantly contribute to sleep dysfunction, leading to daytime fatigue and decreased performance. Treatment of allergic rhinitis can improve sleep and foster productivity. Control of rhinitis and nasal congestion, which is obtained by various therapies, may reverse lower airway tendency to bronchoconstriction.

[Asthma, allergic rhinitis, sinusitis. Concept of the "unified respiratory tracts"]

Epidemiological studies indicate that allergic rhinoconjunctivitis (ARC) is an important risk factor for bronchial asthma. Both asthma and ARC have now been recognized as inflammatory diseases with similar manifestations in the mucous membranes of the upper (nose and paranasal sinuses) and lower respiratory tract (bronchi). Recent studies show that the deposition of allergen into the lower respiratory tract leads to increased inflammation of the upper respiratory tract, even if the patients are only suffering from ARC. These and other findings indicate that allergic diseases have a systemic component, which might be insufficiently targeted with local therapy. It is currently believed that the impaired function of the upper airways due to ARC causing nasal obstruction, retention of secretions, and disturbed conditioning of the inspired air plays an important role in the development of lower airway symptoms. Studies indicate that treatment of the upper respiratory tract inflammation not only reduces the manifestation of allergen-associated symptoms in the lower respiratory tract, but might also have preventive properties if applied early. ARC should no longer be viewed as a harmless disorder but as the early manifestation of a potentially progressive systemic disease and be treated as such.

Emerging anti-inflammatory agents for allergic rhinitis

Allergic rhinitis (AR) is a high-prevalence disease, affecting 10-15% of the general population. AR is sustained by an IgE-mediated reaction, and by a complex inflammatory network of cells, mediators and cytokines that becomes chronic when exposure to allergen persists. A T helper 2 (TH2)-biased immune response is the basis for the allergic inflammation. The current therapeutic strategy is mainly based on drugs (antihistamines, nasal corticosteroids, cromones, decongestants) and allergen immunotherapy. Drugs are overall effective in controlling symptoms, but do not modify the immune background that leads to allergic inflammation, and safety concerns may be present especially for prolonged treatments. Immunotherapy can modify the allergic response, but there is still space for improvement. Nowadays, several approaches are under investigation to optimise the management of AR. On one hand, new drugs and antimediators are being developed; on the other hand, attempts are made to selectively block relevant signal pathways of allergic reaction. Finally, one of the major goals is to modify the TH2-biased immune response by improving the characteristics and modes of action of allergen immunotherapy.

Effects of poor sleep in allergic rhinitis

PURPOSE OF REVIEW

Allergic rhinitis affects a large portion of the population. These patients often suffer from daytime fatigue, both as a result of the mechanics of the nasal airway in patients with allergic rhinitis as well as through central effects on sleep by immune mediators. By understanding these mechanisms and by becoming familiar with effective treatments for allergic rhinitis that are beneficial in alleviating rather than worsening daytime somnolence, physicians may improve patient quality of life.

RECENT FINDINGS

Children with rhinitis and snoring have poorer school performance compared with controls. The role of rhinitis in chronic fatigue remains controversial despite an increase in literature on this subject. The role of immune mediators on rhinitis and sleep is evolving as well. Nasal steroids effectively treat rhinitis and improve daytime fatigue. Second-generation antihistamines are preferred to first-generation antihistamines based on efficacy and safety studies.

SUMMARY

Understanding the relationship between rhinitis in sleep abnormalities and subsequent daytime fatigue is still developing. Nasal steroids are the mainstay of treatment, but the role of future agents is promising although undefined.

Psychologische Aspekte der Allergischen Rhinitis

Zusammenfassung. Theoretischer Hintergrund und Fragestellung: Die allergische Rhinitis ist die häufigste atopische Erkrankung, ihre Prävalenz scheint stetig zuzunehmen. Wie bei anderen chronischen Erkrankungen ist ein Einfluss psychischer Faktoren auf das Krankheitsgeschehen wahrscheinlich. Methode: Die vorliegende Übersichtsarbeit stellt Befunde aus 70 Jahren Forschung zur Psychologie der allergischen Rhinitis zusammen. Diese werden in ein Gliederungsraster integriert, das die Einordnung biopsychosozialer Bedingungsfaktoren erlaubt und die Manifestation auf verschiedenen Verhaltens- und Erlebensebenen berücksichtigt. Ergebnisse und Schlussfolgerungen: Krankheitsverhalten, Laienstörungskonzepte, Neurotizismus und psychophysiologische Stressreaktivität stellen psychologische Aspekte dar, die zur Chronizität der Erkrankung und zur subjektiven Beeinträchtigung beitragen. Es besteht in diesem Bereich noch erheblicher Forschungsbedarf.

Cognitive Effects of Allergic Rhinitis and its Treatment

Allergic rhinitis (AR) can, by itself, introduce significant sedation and impairment of cognition and performance. AR can also impede restorative sleep, resulting in increased fatigue and decreased daytime performance. It is not clear whether improved alertness resulting from blocking histamine production offsets the sedating effects of antihistamines or whether the effects of disease and treatment combine to create even greater sedation. This article reviews and integrates this literature, offers conclusions based on the collective evidence, and suggests guidelines for future research.

Open-label evaluation of azelastine nasal spray in patients with seasonal allergic rhinitis and nonallergic vasomotor rhinitis

OBJECTIVE

The objective of the study was to evaluate the effectiveness of azelastine (Astelin) nasal spray, a topical second-generation antihistamine, in the treatment of symptoms of seasonal allergic rhinitis, seasonal allergic rhinitis with nonallergic triggers (mixed rhinitis), and nonallergic vasomotor rhinitis.

RESEARCH DESIGN AND METHODS

A total of 2343 primary care physicians, allergists, ENT specialists, and other health professionals participated in this 2-week, open-label evaluation of azelastine nasal spray. Data were collected through a physician questionnaire that included patient demographics, rhinitis diagnosis, medication history, and inclusion/exclusion criteria; and two patient questionnaires that included symptom history, response to previous rhinitis medications, symptom control, and level of satisfaction with azelastine nasal spray. A completed physician questionnaire and two completed patient questionnaires were required for each patient to be included in the analysis. Patients who qualified for enrollment were given open-label azelastine nasal spray and instructed to administer 2 sprays per nostril twice daily for 2 weeks.

RESULTS

A total of 1225 health professionals enrolled 7864 patients into the study. Completed physician and patient questionnaires were returned by 1081 health professionals and 5073 patients, 4364 of whom used azelastine nasal spray as their only rhinitis medication during the 2-week study period. The patients were predominantly caucasian (82.6%) and female (61.1%), with a mean age of 50 years. The majority had a diagnosis of mixed rhinitis (51.5%), followed by seasonal allergic rhinitis (32.3%), and nonallergic (vasomotor) rhinitis (16.2%). After 2 weeks of treatment, the percentage of patients reporting some control or complete control of individual symptoms ranged from 78% for postnasal drip in patients with nonallergic vasomotor rhinitis to 90% for sneezing in patients with seasonal allergic rhinitis. More than 85% of patients who reported difficulty sleeping or impairment of daytime activities due to rhinitis symptoms had improvement in these parameters. Azelastine nasal spray was well tolerated, the discontinuation rate due to adverse events was 2.3%.

CONCLUSIONS

Azelastine nasal spray was reported to control all rhinitis symptoms, including nasal congestion, regardless of rhinitis diagnosis during the 2-week study period. Patients with seasonal allergic rhinitis and patients with seasonal allergic rhinitis plus nonallergic triggers were identified as patient types most likely to respond to azelastine nasal spray.

Allergic rhinitis in children with attention-deficit/hyperactivity disorder

BACKGROUND

Both allergic rhinitis and attention-deficit/hyperactivity disorder (ADHD) are common pediatric conditions associated with learning difficulties and sleep disturbances. There are conflicting research data regarding the association between ADHD and atopic disorders.

OBJECTIVE

To determine the prevalence of allergic rhinitis in patients with physician-diagnosed ADHD.

METHODS

Patients 5 to 18 years of age who presented with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of ADHD to an outpatient pediatric psychiatry clinic were screened for allergic rhinitis with focused history, physical examination, and skin prick testing to common aeroallergens.

RESULTS

Thirty patients were interviewed, with 23 of these undergoing physical examination and skin prick testing. Eighty percent reported allergic rhinitis symptoms, whereas 61% had at least 1 positive prick skin test result. Forty-three percent showed typical physical signs of allergic rhinitis, 100% had a positive atopic family history, and 53% had other associated atopic disorders.

CONCLUSIONS

Most children with ADHD displayed symptoms and skin prick test results consistent with allergic rhinitis. Nasal obstruction and other symptoms of allergic rhinitis could explain some of the cognitive patterns observed in ADHD, which might result from sleep disturbance known to occur with allergic rhinitis. Therefore, evaluation and treatment of allergic rhinitis could benefit patients with ADHD.

Rhinitis and sleep apnea

The nose and pharynx begin the upper airway system and represent a continuum. This is the biologic basis for the mutual influences of rhinitis and obstructive sleep apnea (OSA). Sleep-disordered breathing has a large differential diagnosis that includes snoring, upper airway resistance syndrome, and severe OSA. Nasal obstruction is an independent risk factor for OSA, but there is no correlation of daytime nasal resistance with the severity of OSA. However, nasal resistance was an independent predictor of apnea-hypopnea index in a recent study of nonobese OSA patients. Rhinitis alone is associated with mild OSA, but commonly causes microarousals and sleep fragmentation. Reduction of nasal inflammation with topical treatment improves sleep quality and subsequent daytime sleepiness and fatigue. Patient compliance with the nasal continuous positive airway pressure (nCPAP) device is relatively low, in part due to adverse nasal effects.

Influences of allergic rhinitis on sleep

BACKGROUND

Allergic rhinitis is classically characterized by sneezing, pruritus, rhinorrhea, and nasal congestion. These symptoms can lead to impaired nocturnal sleep, and this impairment results in daytime fatigue and somnolence, reducing both learning and work efficiency and decreasing quality of life.

STUDY DESIGN

In addition, the mediators of AR, including histamine, leukotrienes, cytokines, and prostaglandins, may play a role in sleep regulation and, thus, may be directly involved in this impairment independent of nasal obstruction. Recumbency and/or diurnal variation augments turbinate swelling, causing nasal blockage during nocturnal sleep. Medications directed toward reversal of nasal congestion often concomitantly work through suppression of inflammatory mediators and constitute the primary therapy for sleep disturbance associated with allergic rhinitis. Some pharmaceutical interventions that reduce nasal congestion have adverse effects on sleep. Decongestants effectively reduce nasal congestion but frequently produce stimulatory effects and even insomnia. Antihistamines reduce sneezing and pruritus, but are less effective in relieving congestion. Earlier, "first-generation" antihistamines are associated with significant sedation. They also have anticholinergic properties, which can cause dry mouth and make mouth breathing even more uncomfortable in the allergic individual with nasal obstruction. The absence of anticholinergic properties in second-generation, largely nonsedating antihistamines limits their efficacy in rhinorrhea. Azelastine, a topical antihistamine, significantly reduces rhinorrhea and congestion and improves subjective sleep quality, but is also associated with increased sedation. Intranasal corticosteroids and oral leukotriene receptor antagonists effectively reduce rhinorrhea, congestion, and inflammatory mediators.

CONCLUSIONS

The efficacy of these medications at improving subjective sleep quality has been established through multiple randomized, double-blind, placebo-controlled clinical trials.

Perennial rhinitis in the under 4s: a difficult problem to treat safely and effectively? A comparison of intranasal fluticasone propionate and ketotifen in the treatment of 2-4-year-old children with perennial rhinitis

To compare the safety and efficacy of fluticasone propionate aqueous nasal spray (FPANS) and oral ketotifen in children aged 2-4 years with perennial rhinitis. A randomized, multicentre, double-blind, double dummy, placebo-controlled study. Paediatric patients between the ages of 2-4 years with perennial rhinitis. Rhinitis symptoms score (parent-rated), clinical evaluation of symptoms (investigator-rated) and adverse event profiles during the treatment period. Patients treated with FPANS had a significant reduction in both the total night-time rhinitis symptom assessment for weeks 4-6 (p-value 0.036), and the total daytime rhinitis symptom score over the same period (p-value 0.049). Generally, except for nasal itching/rubbing over weeks 1-3, the patients taking FPANS had lower recorded symptom scores for all individual symptoms measured. Nasal blockage, in particular, was significantly reduced over the 4-6 week period (p-value 0.027). The overall investigator-rated clinical evaluation showed substantial improvement or improvement in nine of 12 of the children taking FPANS compared with four of 14 taking ketotifen. Finally, there were no reports of serious adverse events, the incidence of drug-related adverse events was low and there was no statistical difference between the groups. FPANS may be an appropriate treatment to control the symptoms of rhinitis in children between 2 and 4 years old.

Changes in daytime sleepiness, quality of life, and objective sleep patterns in seasonal allergic rhinitis: a controlled clinical trial

BACKGROUND

It has long been assumed that allergic rhinitis leads to daytime sleepiness and a deterioration of nocturnal sleep, yet systematic studies have only been rarely conducted in this field.

OBJECTIVE

The aim of the present study was to investigate the effects of seasonal allergic rhinitis on subjective and objective sleep patterns, quality of life, and daytime sleepiness in otherwise healthy subjects in comparison with nonallergic volunteers.

METHODS

Twenty-five patients with seasonal allergic rhinitis and 25 healthy volunteers were enrolled in this prospective, controlled clinical trial. Daytime sleepiness and quality of life were assessed with the help of questionnaires (Epworth Sleepiness Scale, SF-36); 2 consecutive nights of fully attended polysomnography were performed before and during the pollen season of 2002.

RESULTS

Statistically significant differences between groups were found in respect to changes in daytime sleepiness and selected parameters of quality of life. Impairment of daytime sleepiness and quality of life were related to the severity of the disease. Statistically significant differences were also found for selected parameters of the sleep studies, although the changes were only minimal, and all values were within normal ranges.

CONCLUSION

Seasonal allergic rhinitis leads to increased daytime sleepiness, as well as to an impairment of quality of life, depending on the severity of the disease. Objective measurements revealed a statistically significant influence of seasonal allergic rhinitis on selected sleep parameters, but changes were not of clinical relevance. Daytime sleepiness seems to be related to the condition itself rather than to an impairment of nocturnal sleep.

Sleep disordered breathing and daytime quality of life in children with allergic rhinitis during treatment with intranasal budesonide

BACKGROUND

Nasal obstruction is recognized as an important cause of sleep disordered breathing. Congestion of the nasal mucosa and obstruction are common symptoms of allergic rhinitis. Daytime sleepiness is a common finding in symptomatic allergic rhinitis. Effective therapy of the nasal congestion of allergic rhinitis should alter sleep patterns in patients with symptomatic allergic rhinitis.

OBJECTIVE

To measure objective changes in polysomnograms (sleep studies) of children with allergic rhinitis before and after therapy with intranasal budesonide and to measure changes in the quality of life of these patients during treatment.

METHODS

Open clinical trial with objective measurements (polysomnography) and subjective data (Rhinitis Quality of Life Questionnaire [RQLQ]). Evaluations were performed before, during, and at completion of therapeutic intervention.

RESULTS

The 14 studied children tolerated the procedures and treatment without problems. The mean number of sleep arousals per hour (all apneas and hypopneas) decreased from a baseline of 8.4 to 1.2 (P = .005) after treatment. The change was mainly in hypopneic episodes (7.5-0.9, P = .003). Objective responses on the RQLQ showed improvements consistent with improved sleep and lessened rhinitis symptoms.

CONCLUSIONS

Decreasing the nasal congestion associated with allergic rhinitis can improve sleep measured by objective sleep studies and lead to improvement in daytime quality of life.

Triamcinolone acetonide aqueous nasal spray improves nocturnal rhinitis-related quality of life in patients treated in a primary care setting: the Quality of Sleep in Allergic Rhinitis study

BACKGROUND

Sleep disturbances due to allergic rhinitis can contribute to daytime fatigue, impair mood, and decrease daytime functioning.

OBJECTIVE

To measure allergic rhinitis patients' nocturnal rhinitis-related quality of life using a new, validated disease-specific instrument, the Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire (NRQLQ).

METHODS

This open-label study was conducted in a primary care setting. Adult patients with seasonal or perennial allergic rhinitis rated nocturnal rhinitis-related quality of life using the NRQLQ and sleep disturbances using the Pittsburgh Sleep Quality Index (PSQI) at baseline and after 3 weeks of treatment with triamcinolone acetonide aqueous nasal spray (TAA AQ), 220 microg/d. Changes from baseline in overall and individual domain scores for both the NRQLQ and PSQI were evaluated using t tests for paired differences.

RESULTS

The majority of the patients (N = 651) were female (58%), were white (85%), and shared a bed with a partner (63%). Mean +/- SD patient age was 45.7 +/- 15.5 years. TAA AQ treatment was associated with significant improvements in overall NRQLQ score (mean +/- SD change, -1.5 +/- 1.3; P < .001) and in individual domain scores (P < .001 for sleep problems, symptoms during sleep, symptoms upon waking in morning, and practical problems). Similarly, overall and individual PSQI domain scores were statistically significantly improved (P < .001). There were strong correlations between NRQLQ and PSQI scores (all comparisons P < .001).

CONCLUSIONS

Treatment with TAA AQ for 3 weeks resulted in statistically significant improvements in nocturnal rhinitis-related quality of life and sleep quality in allergic rhinitis patients treated in a primary care setting.

Poor sleep and daytime somnolence in allergic rhinitis: significance of nasal congestion

Patients with allergic rhinitis frequently present with symptoms of nasal congestion, runny nose, sneezing, daytime somnolence and fatigue associated with decreased cognitive performance and impaired quality of life. Recent research has suggested that daytime somnolence in allergic rhinitis can be attributed to chronic inflammation of the nasal mucosa leading to nasal congestion and obstructed nasal passageways resulting in disturbed sleep. Treating daytime somnolence due to allergic rhinitis requires a reduction in obstruction caused by nasal congestion. Currently available therapy for allergic rhinitis includes topical corticosteroids, sedating and nonsedating antihistamines, topical cromolyn sodium (sodium cromoglycate), decongestants, immunotherapy and topical ipratropium bromide. The effectiveness of antihistamines in patients with allergic rhinitis has long been established. However, results of placebo-controlled trials investigating the effects of azelastine on sleep and daytime somnolence have produced conflicting results. Sleep improved with azelastine therapy, but there was a lack of evidence that azelastine significantly affected daytime sleepiness, sleep severity and nasal congestion. Sedating antihistamines exacerbate daytime somnolence and should be avoided in patients with allergic rhinitis. In a separate study, desloratadine failed to benefit sleep, but did not worsen daytime somnolence. Topical nasal cromolyn sodium is inconvenient to use and is unlikely to have a major effect on nasal congestion. Decongestants do decrease nasal congestion but the effect this has on sleep has not been adequately studied. Recent research has shown that topical corticosteroids are an effective treatment for alleviating nasal congestion secondary to allergic rhinitis. However, few studies have assessed the effect of topical corticosteroids on daytime fatigue and sleep. In 20 patients with allergic rhinitis and symptoms of daytime sleepiness, flunisolide significantly improved sleep quality and congestion but daytime sleepiness was not significantly improved. A similar study with fluticasone propionate showed improvement in nasal congestion and sleep but there was no significant change in objective sleep measurements recorded on polysomnography. Further research involving objective measures of sleep quality is necessary to determine the efficacy of medications in the treatment of allergic rhinitis associated with fatigue and daytime somnolence.

Obstructive sleep apnea in children: do intranasal corticosteroids help?

Obstructive sleep apnea (OSA) is a common condition of childhood, and is associated with significant morbidity. Prevalence of the condition peaks during early childhood, due in part to adenoidal and tonsillar enlargement within a small pharyngeal space. The lymphoid tissues regress after 10 years of age, in the context of ongoing bony growth, and there is an associated fall in the prevalence of OSA. Obstruction of the nasopharynx by adenoidal enlargement promotes pharyngeal airway collapse during sleep, and the presence of large tonsils contributes to airway obstruction. Administration of systemic corticosteroids leads to a reduction in the size of lymphoid tissues due to anti-inflammatory and lympholytic effects. However, a short course of systemic prednisone has been demonstrated not to have a significant effect on adenoidal size or the severity of OSA, and adverse effects preclude the long-term use of this therapy. Intranasal corticosteroids are effective in relieving nasal obstruction in allergic rhinitis, and allergic sensitization is more prevalent among children who snore than among those who do not snore. Intranasal corticosteroids have also been demonstrated to reduce adenoidal size, independent of the individual's atopic status. There is preliminary evidence of an improvement in the severity of OSA in children treated with intranasal corticosteroids, but further studies are needed before such therapy can be routinely recommended. Prescribing clinicians should take into account the potential benefits to the patient, the age of the child, the presence of comorbidities such as allergic rhinitis, the agent used, and the dose and duration of treatment when considering such therapy.

The nose and sleep-disordered breathing: what we know and what we do not know

The relationship between sleep-disordered breathing (SDB) and nasal obstruction is unclear. In order to better understand, we performed an extensive computer-assisted review and analysis of the medical literature on this topic. Data were grouped into reports of normal control subjects, patients with isolated nasal obstruction, and those with SDB. We conclude that SDB can both result from and be worsened by nasal obstruction. Nasal breathing increases ventilatory drive and nasal occlusion decreases pharyngeal patency in normal subjects. Nasal congestion from any cause predisposes to SDB. Although increased nasal resistance does not always correlate with symptoms of congestion, nasal congestion typically results in a switch to oronasal breathing that compromises the airway. Moreover, oral breathing in children may lead to the development of facial structural abnormalities associated with SDB. We postulate that the switch to oronasal breathing that occurs with chronic nasal conditions is a final common pathway for SDB.

Rhinosinusitis

History, physical examination, and allergy testing may distinguish the syndromes of rhinitis, classified as allergic, infectious, perennial, nonallergic, and miscellaneous. All may be associated with sinusitis, probably on the basis of obstruction of the osteomeatal complex. Although topical nasal steroids are useful in the treatment of all forms of rhinitis, diagnosis of the offending type in a given patient is necessary for optimal management.

Assessing satisfaction with desloratadine and fexofenadine in allergy patients who report dissatisfaction with loratadine

BACKGROUND

The FDA recently moved loratadine (Claritin) from prescription only status to over-the-counter (OTC). In response to the availability of an OTC non-sedating antihistamine, many managed care organizations are reevaluating which if any prescription antihistamines should remain on formulary. From a managed care perspective, determining which of the remaining prescription antihistamines results in the greatest patient satisfaction with allergy treatment would be informative.

METHODS

We report on a weighted cross sectional survey (n = 10,023) delivered online to a sample of allergy sufferers in the U.S. during the month of December 2002. Two segments were identified for analysis: patient who were dissatisfied with loratadine and converted to desloratadine (Clarinex; n = 61), and patients who were dissatisfied with loratadine and converted to fexofenadine (Allegra; n = 211). The two segments were compared along a series of measures that the literature suggests are related to treatment satisfaction.

RESULTS

The survey found that two of the satisfaction measures differentiated desloratadine converters from fexofenadine converters (p <.05): mean sum of self-reported adverse events and nighttime awakening due to allergy symptoms. For the remainder of satisfaction measures though, patients who were dissatisfied with loratadine reported equal duration of coverage and satisfaction with desloratadine as fexofenadine. When severity of disease was controlled for in the analysis, a pattern emerged suggesting greater levels of satisfaction amongst loratadine dissatisfied patients who converted to desloratadine. Point estimates suggest a consistent pattern favoring desloratadine patient satisfaction, with statistically significant results reported for sum of adverse effects, nighttime awakening due to symptoms, symptom severity just prior to the next dose, and overall satisfaction (p < 0.05).

CONCLUSIONS

On average, patients who were dissatisfied with loratadine reported equal or better satisfaction with desloratadine as fexofenadine. Patients with severe allergic rhinitis reported greater satisfaction when converted from loratadine to desloratadine than fexofenadine for select satisfaction measures. These results suggest that if managed care intends to position prescription antihistamines as second line for OTC loratadine treatment dissatisfaction, desloratadine is a useful treatment alternative. These findings, while informative to formulary decision-makers, must be interpreted with caution. Only through head-to-head controlled clinical trials can differences in efficacy and safety be established.

The effects of fexofenadine on reaction time, decision-making, and driver behavior

OBJECTIVE

To evaluate the effect of fexofenadine on driver behavior, decision-making, and reaction time in a blinded, randomized, parallel, placebo-controlled study.

METHODS

A total of 259 male and female adult volunteers participated in a standardized BMW advanced driving test (the skid-pan test; Pretoria, South Africa) and a decision and reaction test of the Vienna Psychomotor Test System. The psychomotor test focused on mean decision times, mean reaction time, decision errors and reaction errors. After a baseline pretest run, the test was repeated 2.6 hours after ingesting either fexofenadine hydrochloride (180 mg) or placebo (the posttest; 1:1).

RESULTS

Two hundred fifty-five volunteers were included in the final efficacy analysis (195 males and 60 females). There was a reduction in the road test time going from the pretest to the posttest, signifying a learning effect, and an increase in the decision time. Although there was a consistent increase in the number of errors committed in the road test, decision time, and reaction time, there were no significant differences between the placebo and the fexofenadine groups. Although significant differences were observed between men and women for the road test time (P < 0.001), decision time (P < 0.001), and reaction time (P = 0.003), there were no differences between the fexofenadine and placebo groups in these subgroups.

CONCLUSIONS

No differences were found between the fexofenadine and placebo groups on reaction times, decision-making, driver behavior, or adverse effects.

Impact of impaired nasal breathing on sleep-disordered breathing

OBJECTIVE

The role of the nose and its importance in the development and severity of sleep-disordered breathing (SDB) is still a matter of discussion. In the first part of this study, often-controversial data and theories about the nose are reviewed concerning its influence on the pathophysiology of SDB and to interpret certain clinical findings connected with impaired nasal breathing. In the second part, the effectiveness of some nonsurgical and surgical therapies is evaluated.

METHOD

A worldwide literature research (Medline) was the basis for this review.

RESULTS

The study of the literature on nasal resistance and clinical findings about the effects of incomplete or complete nasal blockage, particularly in comparison of healthy persons and persons with SDB, allows the assumption of the existence of two different groups of responders: a larger group where the importance of the nose for SDB is negligible and a smaller group where the influence of the nose on SDB is crucial. The same seems to hold true for the responses to nonsurgical and surgical treatments with only a few surgical results available in the literature. While the success rate of nasal surgery for patients with obstructive sleep apnea, for instance, seems to be less than 20%, the normalization of nasal resistance often leads to a positive impact on the well-being and the sleep quality of these patients. However, because criteria to identify responders are lacking, the prediction of success of any treatment for the individual with SDB is not possible.

Efficacy of the topical nasal steroid budesonide on improving sleep and daytime somnolence in patients with perennial allergic rhinitis

BACKGROUND

Improving quality of life is considered to be a major endpoint and motivation for clinical intervention in patients with perennial allergic rhinitis (PAR). In addition to classical symptoms of congestion, pruritus, and rhinorrhea, patients will often complain of not being able to sleep well at night and of feeling fatigued during the day. Like sleep apnea, PAR has also been shown to cause sleep disturbance and consequently worsen daytime fatigue and somnolence.

HYPOTHESIS

It is proposed that by decreasing nasal obstruction due to allergic rhinitis by treating with the topical steroid budesonide, symptoms of daytime fatigue and somnolence can be improved.

METHODS

Twenty-two subjects were enrolled in a double-blind, placebo-controlled, crossover study using Baalam's design. Patients were treated with either budesonide 128 g/day or placebo. Subjective data include the Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, Rhino-conjunctivitis Quality of Life Questionnaire, and a daily diary recording nasal symptoms, sleep problems, and daytime fatigue.

RESULTS

The results illustrated that the topical nasal corticosteroid significantly improved daytime fatigue (P = 0.03), somnolence (P = 0.02), and quality of sleep (P = 0.05) compared to placebo in patients suffering from PAR.

SUMMARY

Budesonide is able to improve congestion, sleep, and daytime somnolence.

Fexofenadine is efficacious and safe in children (aged 6-11 years) with seasonal allergic rhinitis

BACKGROUND

This is the first prospective, randomized, double-blind, placebo-controlled study showing statistical improvement of an H(1)-antihistamine in children with seasonal allergic rhinitis in all symptoms throughout the entire treatment period.

OBJECTIVE

This randomized, placebo-controlled, parallel-group, double-blind study was performed to assess the efficacy and safety of fexofenadine in children with seasonal allergic rhinitis.

METHODS

This study was conducted at 148 centers in 15 countries. Nine hundred thirty-five children (aged 6-11 years) were randomized and treated with either fexofenadine HCl 30 mg (n = 464) or placebo (n = 471) tablets twice a day for 14 days. Individual symptoms (sneezing; rhinorrhea; itchy nose, mouth, throat, and/or ears; itchy, watery, and/or red eyes; and nasal congestion) were assessed at baseline and then daily at 7:00 AM and 7:00 PM (+/-1 hour) during the double-blind treatment period. Each total symptom score was the sum of all symptoms, excluding nasal congestion. The primary efficacy variable was the change from baseline in the average of the daily 12-hour evening reflective total symptom scores throughout the double-blind treatment. Safety was evaluated from adverse-event reporting, vital signs, physical examinations, and clinical laboratory data at screening and study end point.

RESULTS

Fexofenadine was significantly superior to placebo in the primary efficacy analysis (P </=.0001). Individual symptom scores showed statistically significant superiority compared with placebo (P <.05), including nasal congestion in the evening reflective assessment (P <.05). There was no significant difference in adverse events between fexofenadine and placebo, either overall or by causality.

CONCLUSION

The efficacy and safety of the H(1)-antihistamine fexofenadine has been confirmed in this multicenter, multinational study of children aged 6 to 11 years with seasonal allergic rhinitis.

7. Rhinitis and sinusitis

Rhinitis and sinusitis are prevalent medical conditions that are often associated with each other and may result in significant morbidity and medical costs. They can cause systemic symptoms, decrease quality of life, and result in reduced workplace productivity and missed school days. Appropriate management of rhinitis or sinusitis may be an important component in effective management of coexisting or complicating conditions, such as asthma, allergic conjunctivitis, or chronic otitis media. Rhinitis may be caused by allergic, non-allergic, infectious, hormonal, occupational, and other factors. Defining the basis for rhinitis in an individual is important in selection of therapeutic options. Rhinitis and sinusitis may be difficult to distinguish from each other on the basis of history alone. Although most acute upper respiratory infections are viral and do not require antibiotic treatment, persistence of symptoms for > or =7 days makes acute bacterial sinusitis more likely and antibiotics an appropriate consideration. Radiographic imaging is not required for diagnosis of acute, uncomplicated sinusitis, although CT scans are indicated in evaluation of suspected chronic sinusitis or treatment failures. Chronic sinusitis may have an infectious or non-infectious basis. Underlying disorders that predispose to chronic sinusitis should be identified and treated as part of the treatment of chronic sinusitis.

Occupational upper airway disease

The upper airway plays a critical role in filtering and conditioning air for the lungs. It provides the first line of warning and defense against microbials, allergens, and toxic inhalants. Current evidence suggests that the upper airway is susceptible to many of the pathogenic processes that the agents cause in the lower respiratory tract. Work-related rhinosinusitis or vocal cord dysfunction should prompt physicians and employers to identify the injurious agent(s) and formulate strategies to eliminate or reduce such exposures. Improving the work environment will prevent the development of new cases and the worsening of symptoms in existing cases.

Budesonide aqueous nasal spray is an effective treatment in children with perennial allergic rhinitis, with an onset of action within 12 hours

BACKGROUND

Budesonide aqueous nasal spray is a topical corticosteroid which at doses of 64 to 256 microg once daily has been found to be effective in the treatment of seasonal allergic rhinitis in adults and children.

OBJECTIVE

This study was conducted to determine the efficacy of budesonide aqueous nasal spray, 128 microg once daily, in children with perennial allergic rhinitis.

METHODS

This double-blind, randomized, placebo-controlled, parallel-group, multicenter study compared the efficacy and safety of budesonide aqueous nasal spray, 128 microg once daily intranasally, with placebo in 202 patients (aged 6 to 16 years) with perennial allergic rhinitis. Efficacy was evaluated daily by measurement of peak nasal inspiratory flow (PNIF), nasal symptom scores over 12 hours, and an overall evaluation of treatment efficacy. In a subset of patients (n = 76), quality of life was measured by validated questionnaires.

RESULTS

Budesonide, 128 microg once daily, was significantly more effective than placebo in improving the PNIF, combined and individual nasal symptom scores, and the overall evaluation of treatment efficacy. The onset of action was found to occur within the first 12-hour time interval evaluated for combined nasal symptoms and within 48 hours for PNIF. Budesonide was associated with reduced percentage of eosinophils in brush samples and reduced intake of rescue medication in comparison with placebo. Quality of life scores were reduced, but the differences did not reach significance.

CONCLUSIONS

Budesonide aqueous nasal spray, 128 microg once daily, is effective in children with perennial allergic rhinitis. Efficacy was demonstrated within 12 hours.

Immune mediators in allergic rhinitis and sleep

OBJECTIVE

Our study goal was to examine polysomnography, indices of sleep and allergy, and serum and nasal cytokines in allergic and nonallergic subjects.

STUDY DESIGN AND SETTING

In this descriptive, exploratory study, 4 allergic and 4 nonallergic subjects underwent 2 nights of polysomnographic recording with serial measurements of cytokines and completed measures of sleep quality and allergic symptoms.

RESULTS

Three serum cytokines (interleukin [IL]-1beta, IL-4, and IL-10) were higher in allergic subjects and were termed proallergic. Three serum cytokines (IL-1ra, IL-2, and IL-12) were higher in nonallergic subjects and were termed allergy inhibitory. Proallergic serum cytokines correlated with increased latency to rapid eye movement sleep, decreased time in rapid eye movement sleep, and decreased latency to sleep onset. Low levels of allergy-inhibitory serum cytokines were associated with increased allergic symptoms.

CONCLUSIONS

Differences in serum cytokines between allergic and nonallergic individuals are associated with variations in polysomnography and allergic symptoms.

SIGNIFICANCE

Understanding these mechanisms may suggest novel approaches to alleviating drowsiness and other symptoms in allergic patients.

Acoustic rhinometry findings in patients with mild sleep apnea

BACKGROUND

Nasal obstruction may contribute to the development of obstructive sleep apnea (OSA). Acoustic rhinometry (AR) measures nasal patency and congestion, which are useful parameters in objectively evaluating nasal obstruction. The nasal obstruction produced by allergic rhinitis may contribute to the development of OSA and can be easily assessed with AR.

OBJECTIVE

This study was undertaken to assess the degree of nasal obstruction seen in allergic patients with and without OSA.

STUDY DESIGN AND SETTING

This study was a retrospective data analysis from a tertiary referral center. The AR data from 10 patients with and 40 patients without mild OSA were compared.

RESULTS

The mean congestion factors at the first cross-sectional area (CSA1) on the AR graph were found to be significantly higher in the OSA group than in the non-OSA group (P = 0.03). The classification of change in congestion factors demonstrated significant differences at CSA1, CSA2, and CSA3 and in volume (t distributions <0.001, 0.0312, <0.001, and <0.001, respectively). The non-OSA patients noted a significant subjective improvement in nasal congestion after topical nasal decongestion, whereas the OSA patients did not (P <or= 0.0001 and 0.064, respectively).

CONCLUSION

Although the role of nasal obstruction in OSA is controversial, our study lends evidence to the thought that the nasal obstruction associated with allergic rhinitis is associated with the presence of mild OSA.

SIGNIFICANCE

Whether allergic rhinitis is a direct cause of OSA is debatable, but we have shown that greater nasal congestion is related to the presence of OSA in a population of patients with allergic rhinitis.

Mizolastine in the treatment of seasonal allergic rhinoconjunctivitis: a European clinical experience with 5408 patients managed in daily practice (PANEOS SAR Study)

BACKGROUND

Mizolastine, a potent H1 antihistamine with additional antiallergic properties, is marketed for the treatment of allergic rhinoconjunctivitis and urticaria. The objective was to investigate the safety and effectiveness of mizolastine under conditions of daily practice in patients with seasonal allergic rhinoconjunctivitis (SAR).

METHODS

In an open multicenter study, mizolastine 10 mg daily was administered for 14 days during the pollen season. Nasal and ocular symptoms, time to onset of symptom relief, and effect of the drug on diurnal alertness were evaluated. Safety was evaluated on the basis of self-reported adverse events (AE).

RESULTS

A total of 5408 patients (36+/-14 years of age, females=57%) with a history of SAR for 8+/-9 years were treated for a mean of 17.1+/-5.0 days. SAR symptoms improved in 93% and decreased by at least 50% in 86% of patients; 78% reported improvement after the first drug intake and 51% from the first hour. Sixty-nine percent considered mizolastine more effective than other antihistamines taken previously. The incidence of AE was low (3.8%).

CONCLUSION

The high responder rate, the rapid onset of action, and the low incidence of AE observed in this large multicenter study confirm the previously reported beneficial efficacy and safety of mizolastine in the management of SAR.