Seasonal increase of bronchial reactivity in allergic rhinitis

The Effect of Seasonal Priming on Specific Inhalation Challenges With Birch and Grass Allergen Among Persons With Allergic Rhinitis

Objectives: Allergic diseases are prevalent in the working population, and work-related airborne pollen exposure might be substantial, especially among outdoor workers, resulting in work-exacerbated effects. Seasonal exposure to pollen may induce a priming effect on the allergic bronchial response resulting in exaggerated effects at the end of the natural pollen season. This was previously observed among people with asthma but may also be of importance for persons with allergic rhinitis. In this study, we examined the effect of seasonal priming on bronchial responsiveness among young adults with allergic rhinitis and no or mild asthma. In addition, we explored the association between the baseline characteristics of participants and the severity of bronchoconstriction. Finally, we evaluated the application of a novel non-linear regression model to the log-dose-response curves.

Material and methods: In a crossover design, 36 participants underwent specific inhalation challenges (SICs) with either grass or birch allergen outside and at the end of the pollen season. The differences in bronchial response were evaluated by comparing the dose-response profiles and PD₂₀ estimates derived by applying a non-linear regression model.

Results: The results showed that 12 of the 19 grass pollen-exposed participants had a lower PD₂₀ at the end of the season compared with the outside season. For birch, this was true for nine out of the 17 participants. However, no statistically significant effects of the seasonal pollen exposure were found on neither the shape nor the magnitude of the modeled dose-response curves for either birch allergen, p = 0.77, or grass allergen, p = 0.45. The model depicted a good fit for the data. Among the baseline characteristics, only the size of the skin prick test for grass allergen was associated with PD₂₀.

Conclusion: This study does not support a priming effect of pollen exposure on the bronchial response from the natural seasonal exposure levels of grass or birch allergens among young adults with allergic rhinitis.

Management of adult asthma and chronic rhinitis as one airway disease

Introduction: Chronic rhinitis is defined as nasal inflammation with the presence of minimum two symptoms such as nasal obstruction, rhinorrhea, sneezing and/or itching one hour daily for a minimum of 12 weeks/year. According their etiology, four groups of rhinitis are described: allergic, infectious, non-allergic non-infectious and mixed.Chronic rhinitis is frequently associated with asthma, shares similar mechanisms of the pathogenesis and has a negative impact of its outcomes sustaining the concept of unified airways disease.Areas covered: The present review summarizes the complex relationship between chronic rhinitis and asthma on the basis of recent epidemiological data, clinical characteristics, diagnosis and therapeutic management. All four groups are discussed with the impact of their specific treatment on asthma outcomes. Some medications are common for chronic rhinitis and asthma while others are more specific but able to treat the associated comorbidity.Expert opinion: The systematic assessment of chronic rhinitis in patients with asthma and its specific treatment improves both disease outcomes. Conversely, several therapies of asthma demonstrated beneficial effects on chronic rhinitis. Treating both diseases at the same time by only one medication is an interesting option to explore in the future in order to limit drugs administration, related costs and side effects.

Allergen immunotherapy for house dust mite-induced rhinitis: prescriptive criteria

Allergic rhinitis (AR) is a very common disease. In most cases, therapy is based on symptomatic drugs, while allergen immunotherapy (AIT), which is the only one to act on the cause of the disease, is reserved for patients with a greater burden of disease. In particular, the possible evolution towards asthma substantiates the use of AIT, but requires the availability of diagnostic indices related to the risk of developing asthma. We analyzed the available literature on risk factors for onset of asthma in patients with AR, including bronchial hyperresponsiveness, uncovering by respiratory function tests of airway impairment, measurement of fractioned exhaled nitric oxide, given IgE sensitization pattern, and respiratory infections detected by nasal mucus samples or by particular microbiomes. Most of these risk predictors have been investigated too little or do not have consistent results, while various studies have confirmed that early bronchial impairment in AR patients, particularly concerning small airways, should be considered as prescriptive criteria for AIT. (www.actabiomedica.it)

Current opinions for the management of asthma associated with ear, nose and throat comorbidities

Ear, nose and throat (ENT) comorbidities are common in patients with asthma and are frequently associated with poorer asthma outcomes. All these comorbidities are "treatable traits" in asthma. Identification and management of these disorders may spare medication usage and contribute to improved asthma control and quality of life, and a decrease in exacerbation rates.This review summarises recent data about the prevalence, clinical impact and treatment effects of ENT comorbidities in asthma including allergic rhinitis, chronic rhinosinusitis with and without nasal polyposis, aspirin-exacerbated respiratory disease, obstructive sleep apnoea and vocal cord dysfunction.Many of these comorbidities are possible to be managed by the pulmonologist, but the collaboration with the ENT specialist is essential for patients with chronic rhinosinusitis or vocal cord dysfunction. Further rigorous research is needed to study the efficacy of comorbidity treatment to improve asthma outcomes, in particular with the development of biotherapies in severe asthma that can also be beneficial in some ENT diseases.

Small-airway dysfunction precedes the development of asthma in children with allergic rhinitis

BACKGROUND

Epidemiological evidence suggests the existence of a direct link between allergic rhinitis (AR) and asthma. Several studies also support the presence of small-airway dysfunction (SAD) in non-asthmatic children with AR. However, it remains unknown whether SAD can predict the progression of AR to asthma. Our objective was to explore the existence of SAD in non-asthmatic children with AR and to assessed its ability to predict the development of asthma.

METHODS

Seventy-three 6-year-old children with intermittent moderate-severe AR but without asthma symptoms/medication within the last two years, underwent spirometry and measurement of respiratory resistance (Rrs) and reactance (Xrs) before and after bronchodilation (BD) (300mcg salbutamol). Lung function measurements were performed in the absence of nasal symptoms and repeated at AR exacerbation. SAD was defined as >30% decrease in Rrs or >50% increase in Xrs at 6 or 8Hz post-BD. Participants were followed for five years.

RESULTS

Twenty-three children (31.5%) developed asthma; this group presented significant post-BD changes in Rrs and Xrs, but only at AR exacerbation. The ability of these changes to predict the development of asthma was exceptional and superior to that of the spirometric parameters. SAD (22 children, 30.1%), emerged as the single most efficient predictor of asthma, independently of other risk factors such as parental asthma, personal history of eczema and type of allergic sensitisation.

CONCLUSION

SAD precedes the development of asthma in children with AR. Changes in respiratory impedance at AR exacerbation may assist in identifying those at risk to progress to asthma.

The Effects of Allergen-Induced Nasal Provocation on Pulmonary Function in Patients with Perennial Allergic Rhinitis

Fifteen patients with perennial allergic rhinitis responded intranasally to ragweed antigen challenge. Concomitant measurements of pulmonary function did not reveal a significant decrement on flow rates over a 30-minute period.

Subclinical lower airways correlates of chronic allergic and non-allergic rhinitis

The upper and lower airways behave as a physiological and pathophysiological unit. Subclinical lower airways abnormalities have been described in patients with rhinitis without asthma. These are expressed as bronchial hyperreactivity, abnormalities in lung function and bronchial inflammation, likely as a result of the same phenomenon with systemic inflammatory impact that reaches both the nose and the lungs, which for unknown reasons does not always have a full clinical expression. Patients with rhinitis are at increased risk of developing asthma; therefore, most authors suggest a careful clinical evaluation and monitoring of these patients, especially if symptoms related to inflammation in the lower airways are observed. Although current treatments, such as H1-antihistamines, intranasal steroids and allergen immunotherapy, are quite effective for the management of rhinitis, it is difficult to prove their capacity to prevent asthma among subjects with rhinitis. Evidence showing that the treatment of rhinitis has a favourable impact on indicators of bronchial hyperreactivity and inflammation among subjects that have no symptoms of asthma is more frequently described. In this review, we address the frequency and characteristics of lower airway abnormalities in subjects with rhinitis, both in paediatric and adult populations, their likely predictive value for the development of asthma and the possibilities for therapeutic intervention that could modify the risk of subjects with rhinitis towards presenting asthma.

Comorbidities of asthma and the unified airway

BACKGROUND

Asthma is a comorbid condition that may be seen by otolaryngic allergists when treating their patients with allergic rhinitis (AR). Often asthma is overlooked when aggressive treatment could prevent the development or progression of early disease.

METHODS

This article is a retrospective review of the current literature on asthma as a comorbidity of the unified airway. The unified airway and asthma are clearly defined. The epidemiology, morbidity, mortality, pathophysiologic mechanisms, and the chronicity of asthma are reviewed.

RESULTS

The otolaryngic allergist will become familiar the unified airway concept and the close relationships between AR, chronic rhinosinusitis, and asthma.

CONCLUSION

Otolaryngologists should be aware of the unified airway in order to most effectively treat their patients with AR. Knowledge of the close relationships between asthma and AR will help prevent progression of disease, identify early asthma, and improve the outcomes and quality of life for our patients.

Relation of the Timing of Onset of Rhinitis and Cough to Asthma Attack in Children

If the risk of progression to asthma could be predicted in patients with rhinitis, prevention of asthma might become possible. The purpose of this study was to clarify the relationship between the duration of rhinitis symptoms and acute asthma attacks in children with a history of asthma who were not on treatment for asthma. In 94 children with a history of asthma who were asymptomatic after completing asthma treatment, we investigated the onset and duration of nasal discharge and cough related to allergic rhinitis. Then the children were followed up for 2 weeks and were classified into either an asthma attack group (Group A) or non-asthma group(Group B). A total of 78 subjects were evaluated after 16 were excluded. The duration of nasal discharge was significantly shorter in Group A than in Group B (5.5±1.9 days vs. 10.4±3.1 days, P<0.0001). The interval between the onset of cough and nasal discharge was -1.0±3.1 days in Group A and -5.7±4.1 days in Group B (P<0.0001). The risk of progression to asthma attack may be higher when the onset of cough precedes nasal discharge or when nasal discharge has a short duration and cough shows an early onset. These results may provide assistance when selecting patients for early anti-allergy therapy from among those presenting with upper respiratory tract symptoms.

United airway disease: current perspectives

Upper and lower airways are considered a unified morphological and functional unit, and the connection existing between them has been observed for many years, both in health and in disease. There is strong epidemiologic, pathophysiologic, and clinical evidence supporting an integrated view of rhinitis and asthma: united airway disease in the present review. The term “united airway disease” is opportune, because rhinitis and asthma are chronic inflammatory diseases of the upper and lower airways, which can be induced by allergic or nonallergic reproducible mechanisms, and present several phenotypes. Management of rhinitis and asthma must be jointly carried out, leading to better control of both diseases, and the lessons of the Allergic Rhinitis and Its Impact on Asthma initiative cannot be forgotten.

Complications of Rhinitis

Chronic rhinitis involves inflammation of the upper airways. An association with comorbid conditions, such as rhinosinusitis, asthma, and chronic obstructive pulmonary disease, has been commonly observed in epidemiologic studies. The underlying pathogenesis of these disorders may be similar. Complications of rhinitis include sleep disturbances, learning impairment, and decreased quality of life. It is vital to recognize the complications of rhinitis so that treatment strategies can address rhinitis as well as its comorbidities and complications in a coordinated manner.

Bronchial hyperresponsiveness

BACKGROUND

Bronchial hyperresponsiveness (BHR) is often regarded as a 'hallmark' of asthma and bronchoprovocation testing is frequently performed to support a diagnosis of asthma. However, BHR is also found in a spectrum of other lung diseases and can be provoked by a variety of specific stimuli.

AIMS

To review the pathophysiology of BHR, discuss various methods of testing for BHR and describe the epidemiology of BHR in a variety of previously studied populations.

METHODS

We performed a systematic review of references identified using Medline and hand searches of identified articles. Because of space limitations, we have included those reports that seem most representative of the overall BHR literature.

RESULTS

BHR can be induced by a variety of stimuli that trigger a number of different but overlapping physiological mechanisms. Bronchoprovocation testing can be performed using a variety of stimuli, various protocols and differing test criteria, yielding results that may be discordant. Elevated rates of BHR have been reported in studies of smokers, chronic obstructive pulmonary disease patients, atopics, athletes, exposed workers and the general population.

CONCLUSIONS

Due to the prevalence of BHR in a spectrum of clinical patients and working populations, clinicians should be aware that BHR is not specific for asthma. When performed correctly, the greatest clinical value of BHR testing is to rule out suspected asthma in patients in whom testing is negative. Assessment of BHR also provides insights into the pathological mechanisms of airway disease.

Association of nasal inflammation and lower airway responsiveness in schoolchildren based on an epidemiological survey

BACKGROUND/AIMS

We sought to increase our understanding of the rhinitis-asthma relationship and improve strategies for the treatment of patients with these diseases. The aim of this study was to identify a connection between upper airway inflammation and lower airway responsiveness.

METHODS

We counted eosinophils on nasal smears, and performed spirometry, allergic skin tests, and methacholine challenge tests in 308 schoolchildren plus a questionnaire on respiratory symptoms. The methacholine concentration causing a 20% fall in forced expiratory volume in 1 second (PC20 < 25 mg/mL) was used as the threshold of bronchial hyperresponsiveness (BHR).

RESULTS

In total, 26% of subjects had positive nasal eosinophils on a smear, and 46.2% of subjects had BHR at < 25 mg/mL methacholine PC20. Nasal symptoms were higher in subjects with than without nasal eosinophils (p = 0.012). Asthma symptoms did not differ between subjects with and without nasal eosinophils. Nasal eosinophils were higher in subjects with atopy than those without (p = 0.006), and there was no difference in PC20 methacholine according to atopy (15.5 ± 1.07 vs. 17.5 ± 0.62; p > 0.05). No difference in BHR was detected when comparing subjects with and without nasal eosinophils. There were significant differences in the PC20 between subjects with greater than 50% nasal eosinophils and without nasal eosinophils (11.01 ± 2.92 mg/mL vs. 17.38 ± 0.61 mg/mL; p < 0.001).

CONCLUSIONS

These findings demonstrated that nasal eosinophilic inflammation might contribute to lower airway responsiveness in schoolchildren, based on an epidemiological survey.

Allergic sensitization to perennial allergens in adults and children sensitized to Japanese cedar or Japanese cypress pollen in Japan

In Japan, seasonal allergic rhinitis in the spring due to exposure to Japanese cedar or Japanese cypress pollen is common. However, the allergic profile for perennial allergens in spring pollinosis remains unclear. Therefore, in this study, we investigated the allergic profiles of 652 patients with rhinitis. Total serum IgE, serum-specific IgE, and blood eosinophil counts were measured. Allergic sensitization, determined by the serum allergen-specific IgE level, did not always correspond with the patient's symptoms. Only 27% of patients with allergic symptoms in response to spring pollens were sensitized to these allergens alone; 31% of patients were also sensitized to perennial allergens, even without symptoms due to perennial allergens. Total serum IgE and eosinophil cell counts were significantly elevated in patients sensitized to perennial allergens and spring pollens, as compared to patients sensitized only to spring pollens. Most children sensitized to spring pollen (84%) were sensitized to perennial allergens, at a higher rate than adults (49%). Patients sensitized to spring pollens are likely to be latently sensitized to perennial allergens. This is especially true for children and should be monitored closely. Improvement in seasonal allergic conditions, including latent perennial allergy, is important to prevent symptoms that could advance to asthma.

The role of rhinosinusitis in severe asthma

The prevalence of asthma is approximately 5% to 10% in the general population. Of these, approximately 5% to 10% are severe asthmatics who respond poorly to asthmatic drugs, including high-dose inhaled steroids. Severe asthmatics have persistent symptoms, frequent symptom exacerbation, and severe airway obstruction even when taking high-dose inhaled steroids. The medical costs of treating severe asthmatics represent ~50% of the total healthcare costs for asthma. Risk factors for severe asthma are genetic and environmental, including many kinds of aeroallergens, β-blockers, and anti-inflammatory drugs. Gastroesophageal reflux disease and factors such as denial, anxiety, fear, depression, socioeconomic status, and alcohol consumption can exacerbate asthma. Rhinitis and asthma usually occur together. There is increasing evidence that allergic rhinitis and rhinosinusitis may influence the clinical course of asthma. This review discusses the role of rhinosinusitis in severe asthma.

Relationship between atopy and bronchial hyperresponsiveness

Both atopy and bronchial hyperresponsiveness (BHR) are characteristic features of asthma. They are also found among non-asthmatic subjects, including allergic rhinitis patients and the general population. Atopy and BHR in asthma are closely related. Atopy induces airway inflammation as an IgE response to a specific allergen, which causes or amplifies BHR. Moreover, significant evidence of the close relationship between atopy and BHR has been found in non-asthmatic subjects. In this article, we discuss the relationship between atopy and BHR in the general population, asthmatic subjects, and those with allergic rhinitis. This should widen our understanding of the pathophysiology of atopy and BHR.

Are chronic urticaria, analgesic intolerance and seasonal rhinitis markers of different severities and phenotypes of the asthma they accompany?

BACKGROUND

Asthma is a heterogeneous disease that presents with different clinical phenotypes. We aimed to compare the patients with asthma diagnosis alone with the patients, who, in addition to their asthma had accompanying analgesic intolerance (AI), chronic urticaria (CU) or seasonal rhinitis (SR) if there are any distinctions and specific characteristics of these defined patient groups.

METHODS

Eighty-four asthma patients diagnosed with SR, 46 with CU, 75 with AI and 71 patients with asthma alone were enrolled to the study retrospectively. The reference group for the comparisons was the group with asthma diagnosis alone.

RESULTS

The mean age of all patients was 37.2±13 (15-80) and 70.7% of them were females. Asthma patients with SR had a significantly earlier onset of asthma (age: 27.4±10.8 and 34.5±15.9; respectively, p<0.01), significantly better pulmonary function tests and were significantly more atopic (92.9% and 28.8%; p<0.001). Moderate-to-severe asthma significantly correlated with older age at the time of diagnosis, older age of asthma onset, higher body mass index, less atopy and fewer pollen sensitivity. Asthma severity of patients with SR was significantly milder than the reference group (OR: 0.6, 95% CI 0.5-0.8). Asthma with AI tended to be more severe although the relation was insignificant (OR:1.6 95% CI:0.8-3.5).

CONCLUSIONS

Asthma patients with SR have significantly milder and earlier onset of asthma, better pulmonary function tests and are significantly more atopic while asthma with AI tends to be more severe. Asthma with CU does not show a specific phenotypic characteristic.

Impact of comorbidities on asthma

Asthma is a common and serious illness with suboptimal outcomes of care. Epidemiological studies show certain comorbidities occurring more frequently than expected with asthma, with some being associated with poor control and a differential response to therapy options. This review summarizes the evidence of clinically important comorbidities, focusing on the best-explored conditions, including rhinitis and rhinosinusitis, anxiety and depression, obesity, gastroesophageal reflux, smoking and dysfunctional breathing. The evidence of epidemiological and pathophysiological associations for these comorbidities is explored, and the practical therapeutic implications are considered. Comorbidities are important for clinicians treating asthma as they may be markers of patients at risk of poor outcomes, they may point to specific effective treatment options and they are important to researchers as possible confounding factors in clinical trials.

Asthmatics without rhinitis have more fixed airway obstruction than those with concurrent rhinitis

PURPOSE

Rhinitis and asthma usually occur together. There are increasing evidences that allergic rhinitis (AR) may influence the clinical course of asthma. The aim of this study is to evaluate clinical parameters and therapeutic response in patients with between asthma and asthma with AR.

METHODS

Four-hundred eighty-five patients with asthma and 428 asthmatics with AR, who had lesser than 50 years old and smoked less than 10 pack-years were recruited. We compared FEV1 and FEV1/FVC following bronchodilator, atopy, IgE, emphysema on HRCT, and aspirin intolerance between two groups. Also we compared physiologic fixed airway obstruction defined using FEV1/FVC and FEV1 less than 75% following anti-asthmatic drug for 1 year.

RESULTS

46.8% (428/913) asthmatics suffered from AR. There were no differences of total IgE, body mass index, PC20, sputum eosinophils and emphysema on HRCT between two groups. The age in asthmatics was higher than that in those with AR. FEV1/FVC was lower in asthmatics than in those with AR. The prevalence of atopy was higher in asthmatics with AR than in asthmatics. Aspirin intolerance was higher in asthmatics with AR than in asthmatics (42/218 vs 13/109, P=0.001). Fixed airway obstruction were more observed in asthmatics than in those with AR (39/319 vs 28/355, P=0.001) after anti-asthmatic drug for 1 year.

CONCLUSIONS

Asthmatics with AR had more atopy and aspirin intolerance than asthmatics, and asthmatics had poor response to anti-inflammatory drugs than those with concurrent rhinitis, indicating that asthmatics have more fixed airway obstruction than those with concurrent rhinitis.

The pathophysiology, diagnosis and treatment of allergic rhinitis

Treatment of AR requires a stepwise approach depending on the severity and duration of symptoms. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy and surgery. For the mechanisms of AR, anti-IgE antibody and specific antibody to cytokines such as IL-4 or IL-5 that correlate with allergic inflammation have recently emerged. SLIT is currently widely used due to its efficacy, safety and convenience, which replaces subcutaneous immunotherapy. Although allergen avoidance and immunotherapy are theoretically ideal, antihistamines and intranasal corticosteroids will play the main role in the management of AR until an innovative treatment develops. However, patients' main symptom, the duration and severity of AR, patients' compliance, safety of medication and cost-effectiveness should be considered when treatment options are chosen. In conclusion, physicians should be aware of etiology, pathophysiology, symptoms, signs and diseases related to AR in order to make a correct diagnosis and choose a proper treatment option for each patient.

Effects of pranlukast hydrate on airway hyperresponsiveness in non-asthmatic patients with Japanese cedar pollinosis

BACKGROUND

Recent studies have suggested that allergic rhinitis is closely related to bronchial asthma, reflecting the "one airway-one disease" hypothesis. It is unclear if the effects of pranlukast, a leukotriene-receptor antagonist, are consistent with this hypothesis.

OBJECTIVE

The goal of the study was to determine if pranlukast has effects on the upper and lower airways through a comparison of the effects of fexofenadine and pranlukast on airway hyperresponsiveness in non-asthmatic patients with cedar pollinosis before the Japanese cedar pollen season and during the peak pollen season.

METHODS

Patients received fexofenadine hydrochloride plus oral mequitazine (fexofenadine group) or pranlukast hydrate plus oral mequitazine (pranlukast group) as an initial treatment. Subsequent changes in airway responsiveness to acetylcholine were measured.

RESULTS

Among patients in whom coughing developed during the peak pollen season, airway responsiveness significantly increased in the fexofenadine group. In the pranlukast group, airway responsiveness did not increase significantly, regardless of the presence or absence of coughing.

CONCLUSIONS

The results indicate that pranlukast hydrate inhibits airway hyperresponsiveness in non-asthmatic patients with Japanese cedar pollinosis. In turn, this suggests that cysteinyl leukotrienes have a role in increased airway responsiveness.

Exhaled leukotrienes and bronchial responsiveness to methacholine in patients with seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis and bronchial asthma can coexist and affect each other.

OBJECTIVE

To investigate the relationship between the postseasonal increase in the concentration of leukotriene (LT) B4 and LTE4 in exhaled breath condensate (EBC) and bronchial responsiveness to methacholine (BRM) in patients with seasonal allergic rhinitis (SAR).

METHODS

In 28 patients with SAR and 50 healthy study patients, the leukotrienes were measured in EBC during and after the pollen season by gas chromatography/mass spectrometry. The BRM was determined after the pollen season.

RESULTS

In 7 patients with SAR, significantly increased concentrations of both the leukotrienes were found in EBC during and 5 months after the pollen season. The following seasonal and postseasonal median values were measured in patients with SAR in comparison with control patients: LTB4: 131 and 90 pg/mL vs 80 and 79 pg/mL, P < .001 and P = .03, respectively; LTE4: 122 and 86 pg/mL vs 76 and 74 pg/mL, P < .001 and P = .02, respectively. Five months after the pollen season, the concentrations of LTB4 and LTE4 decreased with respect to their seasonal values (90 and 86 pg/mL, respectively, P < .001, for both leukotrienes). In 7 patients with SAR and leukotriene levels exceeding the reference limits, significantly increased BRM was also found (LTB4: P = .02; LTE4: P = .002).

CONCLUSIONS

The seasonal and postseasonal increases in LTB4 and LTE4 concentrations in EBC of the patients with SAR correlated significantly with the later increase in BMR. This relationship could provide a useful predictive parameter for early inflammatory processes in the lower airways of patients with allergic rhinitis.

Long-acting beta(2) agonists in asthma and allergic rhinitis

BACKGROUND

Long-acting beta(2) agonists (LABAs) are effective second-line bronchodilator controller agents in asthma, although they may also increase the risk of hospitalization and asthma-related death in certain situations. Despite the interesting findings obtained with short-acting beta(2) agonists (SABAs), negative studies are available with LABAs in the treatment of allergic rhinitis. This is quite surprising given that there is now clear documentation of the link between asthma and allergic rhinitis.

OBJECTIVE

The aim of this review is to examine the role of beta(2) agonists in patients with asthma who also suffer from allergic rhinitis and to try to explain the differences observed between SABAs and LABAs in rhinitis.

METHODS

SCOPUS, GOOGLE SCHOLAR and MEDLINE were searched for abstracts and papers; the search was completed in March 2008. No restriction was placed on language.

CONCLUSION

The intriguing united airway concept led to the hypothesis that common therapies may influence both and asthma and allergic rhinitis. Consequently, better designed studies with LABAs in allergic rhinitis are now mandatory. In particular, further studies are necessary to investigate clinically relevant anti-inflammatory synergy between inhaled corticosteroids and LABAs in upper airways. It will also be interesting to assess whether ultra-LABAs (once-daily LABAs) are active in allergic rhinitis, although the information we have seems to exclude a role for these agents.

Asthma and rhinitis: comorbidities

The connection between asthma and rhinitis is not a new discovery. Significant progress has been made in understanding the relationship of these two conditions, however, and the implications of the asthma-rhinitis link make it increasingly important. Patients who have asthma and rhinitis tend to have more severe disease with higher treatment costs. Treatment of rhinitis may improve asthma control, and early treatment of allergies may prevent the development of asthma. This article more fully explores the epidemiologic, pathophysiologic, and clinical relationships between asthma and rhinitis.

How strong is the evidence that immunotherapy in children prevents the progression of allergy and asthma?

PURPOSE OF REVIEW

The purpose of this review is to describe the scientific evidence that specific immunotherapy can prevent the development of asthma in patients suffering from rhinoconjunctivitis as well as reduce the number of new allergies developing.

RECENT FINDINGS

Proposed strategies for the prevention of the development of allergic rhinoconjunctivitis and asthma include allergen avoidance, pharmacological treatment (antihistamines and steroids) and specific immunotherapy. Long-term follow-up on immunotherapy studies demonstrates that specific immunotherapy for 3 years shows persistent long-term effects on clinical symptoms after termination of treatment and long-term, preventive effects on later development of asthma in children with seasonal rhinoconjunctivitis. It is so far the only treatment for allergic diseases that has been shown to be able to prevent worsening of disease and development of asthma. Also, specific immunotherapy seems to reduce the development of new allergic sensitivities as measured by the skin prick test as well as specific IgE measurements.

SUMMARY

Specific immunotherapy is the only treatment that interferes with the basic pathophysiological mechanisms of the allergic disease and thereby carries the potential for changes in the long-term prognosis of respiratory allergy. Specific immunotherapy should be recognized not only as first-line therapeutic treatment for allergic rhinoconjunctivitis, but also as secondary preventive treatment for respiratory allergic diseases.

Asthma and the unified airway

Inflammatory processes of the upper and lower airway commonly co-exist. Patients with upper respiratory illnesses such as allergic rhinitis and acute and chronic rhinosinusitis often present to both otolaryngologists and primary care physicians for treatment of their symptoms of nasal and sinus disease. These patients often have concurrent lower respiratory illnesses such as asthma that may be contributing to their overall symptoms and quality of life. Unfortunately, asthma frequently remains undiagnosed in this population. It was the objective of this paper to examine the relationship between upper respiratory illnesses such as rhinitis and rhinosinusitis and lower respiratory illnesses such as asthma, and to provide a framework for primary care and specialty physicians to approach these illnesses as a spectrum of inflammatory disease. The present manuscript was developed by a multidisciplinary workgroup sponsored by the American Academy of Otolaryngic Allergy. Health care providers in various specialties contributed to the manuscript through preparation of written materials and through participation in a panel discussion held in August 2006. Each author was tasked with reviewing a specific content area and preparing a written summary for inclusion in this final document. Respiratory inflammation commonly affects both the upper and lower respiratory tracts, often concurrently. Physicians who are treating patients with symptoms of allergic rhinitis and rhinosinusitis must be vigilant to the presence of asthma among these patients. Appropriate diagnostic methods should be used to identify individuals with concurrent respiratory illnesses, and comprehensive treatment should be instituted to reduce symptoms and improve quality of life.

Allergic rhinitis: evidence for impact on asthma

Background

This paper reviews the current evidence indicating that comorbid allergic rhinitis may have clinically relevant effects on asthma.

Discussion

Allergic rhinitis is very common in patients with asthma, with a reported prevalence of up to 100% in those with allergic asthma. While the temporal relation of allergic rhinitis and asthma diagnoses can be variable, the diagnosis of allergic rhinitis often precedes that of asthma. Rhinitis is an independent risk factor for the subsequent development of asthma in both atopic and nonatopic individuals. Controlled studies have provided conflicting results regarding the benefits for asthma symptoms of treating comorbid allergic rhinitis with intranasal corticosteroids. Effects of other treatments for comorbid allergic rhinitis, including antihistamines, allergen immunotherapy, systemic anti-IgE therapy, and antileukotriene agents, have been examined in a limited number of studies; anti-IgE therapy and antileukotriene agents such as the leukotriene receptor antagonists have benefits for treating both allergic rhinitis and asthma. Results of observational studies indicate that treating comorbid allergic rhinitis results in a lowered risk of asthma-related hospitalizations and emergency visits. Results of several retrospective database studies in the United States and in Europe indicate that, for patients with asthma, the presence of comorbid allergic rhinitis is associated with higher total annual medical costs, greater prescribing frequency of asthma-related medications, as well as increased likelihood of asthma-related hospital admissions and emergency visits. There is therefore evidence suggesting that comorbid allergic rhinitis is a marker for more difficult to control asthma and worsened asthma outcomes.

Conclusion

These findings highlight the potential for improving asthma outcomes by following a combined therapeutic approach to comorbid allergic rhinitis and asthma rather than targeting each condition separately.

Does specific immunotherapy injection cause an increase in bronchial reactivity?

BACKGROUND

Several well-controlled studies have proven the clinical benefit of specific immunotherapy (SIT) for seasonal allergic rhinitis (AR). However, whether subcutaneous SIT injection could cause a transient increase in bronchial reactivity (BR) remains unknown.

OBJECTIVE

To investigate whether subcutaneous SIT injection, either during or outside the pollen season, could cause an increase in BR in children with pollen allergy.

METHODS

Twenty-two children (mean age 13.6 +/- 0.7 years) with AR who were receiving maintenance SIT for 15 months were included in the study. Pre-injection BR of the patients was evaluated with methacholine provocation test immediately before maintenance dose of SIT during the peak pollen season and outside the season. The post-injection test was administered 24 hours after SIT injection.

RESULTS

There was no difference in FEV1 measures recorded during [98(93-109)%] and outside [102(96-111)%] the pollen season. There was no significant difference between pre- [64(7-64) mg/mL] and post-allergen injection [32(7.5-64) mg/mL] BR outside the pollen season (p = 0.9). A trend towards improvement following allergen injection [64(5.4-64)] as compared to pre-allergen injection [14.6(3.5-64)] was shown during the pollen season (p = 0.053). Although PC20 measures in the pollen season were lower than outside the season, the difference was not significant. The percentage of the patients with bronchial hyperreactivity was 62% during and 43% outside the season.

CONCLUSION

SIT injections both during and outside the pollen season cause no increase in BR in children with AR. This calls into question the necessity of empirical dose reduction during the pollen season.

Atopic march: link to upper airways

PURPOSE OF REVIEW

This review examines the role of the upper airways in the atopic march. Evidence examining the theory that allergic rhinitis precedes asthma will be discussed. In addition, the role of allergic rhinitis as an end point in the atopic march will be reviewed.

RECENT FINDINGS

Ciprandi and colleagues found that nasal symptoms, airflow and markers of inflammation (eosinophils, cytokine levels) directly correlated with lower airway markers. This confirms previous studies finding that many patients with allergic rhinitis have lower airway hyperreactivity or bronchial hyperresponsiveness and the link between upper and lower airways. Leynaert and colleagues questioned over 90 000 individuals and found that patients with rhinitis have increased risk for asthma and lower airway reactivity compared with patients without rhinitis. In the German Multicenter Atopy Study, a longitudinal study of 1300 children, patients with atopic dermatitis were found to have increased risk for asthma at 7 years of age. Patients with atopic dermatitis and no wheezing in the first 3 years, however, did not have an increased risk for developing current wheezing or bronchial hyperresponsiveness at 7 years of age. It was proposed that atopic dermatitis and asthma are linked, but atopic dermatitis does not precede asthma.

SUMMARY

Allergic rhinitis is a risk factor for asthma and can precede asthma in the atopic march.

Exhaled nitric oxide in asthmatic children and adolescents after nasal allergen challenge

Epidemiological data suggest a comorbidity link between nasal and bronchial allergic disease. Exhaled nitric oxide (FENO) is a sensitive marker of bronchial inflammation and increases after bronchial allergen provocation. We studied FENO in 19 children and adolescents with allergic asthma and 10 controls before and 2, 6 and 24 h after a single nasal allergen challenge. The correlation between FENO and other markers of allergic inflammation, such as eosinophils in blood and eosinophil cationic protein (ECP) in serum and nasal lavage was also assessed. FENO remained unchanged 24 h post-challenge in both steroid and steroid-naive patients. At 6 h post-challenge, FENO decreased in both asthmatics and controls. The asthmatic subjects showed a positive correlation between FENO and blood eosinophils before (r=0.71, p=0.001) and after the challenge, and between FENO and ECP in nasal lavage (r=0.62, p=0.02) 2 h after the challenge. Mean ECP in nasal lavage increased post-challenge but not significantly. We conclude that a single nasal allergen challenge does not augment bronchial inflammation although FENO, is related to blood eosinophil count and to the nasal inflammatory response. Our data do not support the theory of a direct transmission of the nasal inflammation to the lower airways.

Allergen immunotherapy in the prevention of asthma

PURPOSE OF REVIEW

Asthma is a disease causing significant morbidity and mortality. In the recent past, there has been an explosion of pharmacotherapeutic options attempting to control the disease. Unfortunately, none of the current options offers the promise of prevention or a permanent cure. However, there appear to be exciting, new data emerging to support the hypothesis that the prevention or early treatment of allergic rhinitis, such as with the use of allergen immunotherapy, may help mitigate the severity of bronchial symptoms and even prevent the development of asthma. In this paper, we review recent research published proposing immunotherapy as a means of preventing the development of, or at least ameliorating, allergic asthma.

RECENT FINDINGS

There is evidence that the upper and lower airways may be considered a single unit, with the nasal and bronchial mucosa having features in common. Epidemiological, pathophysiological and clinical studies have shown that they can be affected by similar inflammatory triggers, with interconnected mechanisms amplifying the inflammatory cascade. Allergic rhinitis is interrelated to, and is a risk factor for, the development of asthma. An evidence-based review validates the successful use of allergen immunotherapy in treating allergic rhinitis and asthma. There is promising evidence advocating its use in the prevention of clinical asthma.

SUMMARY

This article explores current research pertaining to the use of immunomodulation, such as by using allergen immunotherapy, to ameliorate and prevent the development of allergic asthma.

Effect of intranasal triamcinolone acetonide on bronchial hyper-responsiveness in children with seasonal allergic rhinitis and comparison of perceptional nasal obstruction with acoustic rhinometric assessment

OBJECTIVE

Many patients with allergic rhinitis (AR) have bronchial hyper-responsiveness (BHR), and seasonal variation of BHR has been demonstrated in these patients. We aimed to investigate how BHR in children with seasonal AR is modified by triamcinolone acetonide aqueous nasal spray (TANS) therapy during the pollen season. A secondary aim was to assess the efficacy of TANS on nasal congestion by acoustic rhinometry and symptom scores.

METHODS

A total of 34 children aged 7-18 years with grass pollen-induced AR and 18 age and sex-matched healthy controls were included in study. The patients were divided into the following two subgroups: 22 patients who had AR only; and 12 patients who had AR and asthma. All of them had a baseline BHR (PC20FEV1 methacholine < 8mg/ml). All patients received 220 microg TANS once daily for 4 weeks following a 1-week run-in period. Nasal patency was measured by acoustic rhinometry and patients recorded their nasal obstruction scores in a diary.

RESULTS

There was no significant difference at baseline pulmonary function test parameters between the patients and the healthy control children. None of the control subjects had BHR. Asthmatic children with AR had significantly reduced baseline PC20FEV1 when compared with the AR only group [mean +/- S.E.M., (1.60 +/- 0.57 mg/ml versus 2.93 +/- 0.42 mg/ml, P = 0.021)]. The mean PC20FEV1 values increased slightly at the end of treatment in both group (from 1.60 +/- 0.57 mg/ml to 3.25 +/- 1.11 and from 2.93 +/- 0.42 mg/ml to 3.93 +/- 1.41 mg/ml), but the change was not statistically significant. TANS produced substantial symptomatic recovery in nasal obstruction according to patients' daily diary assessments, and significantly improved all objective acoustic rhinometry parameters.

CONCLUSIONS

Once-daily intranasal TANS 220 microg effectively controlled nasal obstruction in children with seasonal AR according to subjective and objective assessments, and blocked the increase in BHR to methacholine after high-load natural pollen exposure. There was no correlation between patients' own subjective assessment of nasal obstruction and objective acoustic rhinometric assessment.

Monitoring of seasonal variability in bronchial hyper-responsiveness and sputum cell counts in non-asthmatic subjects with rhinitis and effect of specific immunotherapy

Bronchial hyper-responsiveness (BHR) is documented in a proportion of non-asthmatic individuals with allergic rhinitis (NAAR) and reflects inflammatory events in the lower airways. Natural exposure to allergens is known to modulate BHR and the level of airway inflammation in asthma, but less consistently in NAAR. Specific immunotherapy (SIT) attenuates symptoms possibly by reducing BHR and airway inflammation. The influence of natural exposure to Parietaria pollen on BHR and sputum cell counts of NAAR was investigated and the effect of Parietaria SIT examined. Thirty NAAR, monosensitized to Parietaria judaica, participated in a randomized, double-blind, placebo-controlled, parallel group study of the effects of a Parietaria pollen vaccine on symptoms/medication score, BHR to inhaled methacholine and adenosine 5'-monophosphate (AMP), and cell counts in the sputum collected out of and during the pollen seasons for 36 months. Seasonal variation in BHR to inhaled methacholine and AMP and changes in sputum cell counts were documented. Changes were consistent for AMP, but not methacholine, and invariably associated with modifications in sputum eosinophils and epithelial cells. The clinical efficacy of Parietaria SIT was associated with a decline in the seasonal deterioration of BHR to AMP, whereas no significant effect was observed on BHR to methacholine or sputum cell differentials. Between-groups comparison of the seasonal changes in PC15 methacholine values and sputum cell differentials calculated as the AUC were not statistically significant, whereas a significant difference in PC15 AMP was demonstrated throughout the study (P=0.029), the median (inter-quartile range) AUC values being 2478.5 (1153.3-3600.0) and 1545.5 (755.3-1797.9) for the SIT- and placebo-treated group, respectively. Bronchial airways of NAAR exhibit features of active inflammation that deteriorate during natural allergen exposure, particularly with regard to BHR to AMP. The clinical efficacy of Parietaria SIT was exclusively associated with attenuation in seasonal worsening of PC15 AMP, suggesting that AMP may be useful in monitoring changes in allergic inflammation of the airways.

Immunotherapy for rhinitis

Allergen-specific immunotherapy in the treatment of allergic rhinitis has a well-documented clinical efficacy that indicates a statistically significant and clinically relevant reduction in symptom scores and the need for pharmacotherapy. The clinical efficacy of recently published studies is equivalent to or superior to the effect of standard anti-allergic drugs. Additional advantages are related to a downregulation of the allergic phenotype with the additional induction of a Th1 cytokine profile. The immunoregulatory capacity and the global downregulation of the allergic inflammation in mucous membranes might be important factors in the capacity to ensure long-term clinical efficacy (after termination of treatment) and the preventive capacity of immunotherapy in reducing the progression of rhinitis to asthma as well as deflowering the development of new sensitizations. Subcutaneous immunotherapy is optimal in severe allergic rhinitis with signs of bronchial hyperreactivity; however, sublingual immunotherapy might be an option for patients with milder disease.

A pre-seasonal birch/hazel sublingual immunotherapy can improve the outcome of grass pollen injective treatment in bisensitized individuals. A case-referent, two-year controlled study

BACKGROUND

The study tests the hypothesis of a reduction of priming due to tree allergy in patients sensitised to both birch/hazel and grass pollen undergoing an associated preseasonal Sublingual/Injective immunotherapy.

METHODS

36 out of 49 bisensitized candidates were pair-matched into 18 case-referent couples. During two years all patients were administered preseasonal grass-SIT and one patient in each couple received also birch/hazel-SLIT. Diary cards were fulfilled for three consecutive grass pollen seasons. Specific Nasal Provocation Test (NPT) for grass and aspecific bronchial challenge were done; sera were analyzed for specific IgE and IgG.

RESULTS

During the peak of the grass pollen season both groups showed a significant improvement in total symptom-score. Conjunctivitis and cough improved significantly more in patients with associated therapies. While antihistamine score decreased significantly in both groups, antiasthmatics did only in the SLIT-SIT group. The follow-up documented a significant increase in grass- and birch-specific IgG and a decrease in grass-specific IgE. Grass-NPT threshold was clearly higher in SLIT-SIT-group (p = 0.01) and only in this group PD20 methacholine improved significantly (p < 0.05).

CONCLUSIONS

Combined birch/hazel-SLIT and grass-SIT are safe and improve clinical outcomes of SIT alone in young bisensitized patients. Priming reduction is supported by specific NPT and bronchial hyperresponsiveness.

Current opinion of immunotherapy for ocular allergy

PURPOSE OF REVIEW

Allergic conjunctivitis is common and may be the most prominent or the only feature of allergies. Immunotherapy has been used as a primary treatment for allergies since the early 1900s. Currently the use of immunotherapy for allergic rhinoconjunctivitis is well established and has been shown to decrease the development of bronchial hyperreactivity and asthma. However, the role of immunotherapy for primary treatment of allergic conjunctivitis is unclear. We reviewed the studies where immunotherapy was used with particular attention to the affects on ocular allergies.

RECENT FINDINGS

There are many schedules and methods of delivering immunotherapy. Recent studies have started to assess ocular symptoms as one of the parameters to monitor efficacy of therapy. They follow the affects of immunotherapy on conjunctival provocation tests, ocular symptoms, or the use of eye drops. The literature suggests that using the various immunotherapy modalities at different schedules, ocular symptoms improved even when immunotherapy was used on a rush schedule.

SUMMARY

The initiation of immunotherapy for allergic rhinoconjunctivitis has been shown to switch the immune response to T helper 1 and thus avoid the progression of other atopic conditions. Current literature shows that using many allergens with different forms of immunotherapy appear to have a significant improvement in ocular allergy symptoms and this can be achieved rapidly and safely in most patients. Whether using immunotherapy early in allergic conjunctivitis will alter the progression of other atopic conditions remains to be investigated.

Comparison of bronchial responsiveness to histamine in asthma, allergic rhinitis and allergic sensitization at the age of 7 years

BACKGROUND

Bronchial responsiveness (BR) to histamine or methacholin is a common finding in adult non-asthmatic patients with allergic rhinitis.

OBJECTIVE

We tested whether BR is also present in children with a comparatively short history of allergic rhinitis in a paediatric cohort.

METHODS

We performed pulmonary function tests and histamine challenges in a total of 654 children (age 7 years, participants of the German Multicenter Allergy Study) and compared PC20 FEV1 values in children with asthma, allergic rhinitis, asymptomatic allergic sensitization and non-atopic controls.

RESULTS

Most pronounced BR to histamine was observed in allergic asthmatics (n = 28), irrespective of the presence or absence of allergic rhinitis. Furthermore, PC(20)FEV(1) values in non-asthmatic children with allergic rhinitis (n = 24) were not significantly different from those seen in asymptomatic atopic (n = 54) or non-atopic controls (n = 92).

CONCLUSIONS

In contrast to adult study populations, 7-year-old non-asthmatic children with allergic rhinitis do not show a higher degree of BR than asymptomatic atopic or non-atopic controls. Therefore, secondary preventive measures in non-asthmatic children with allergic rhinitis (such as regular local anti-inflammatory therapy or specific immunotherapy) should be studied and applied more intensely to prevent bronchial hyper-responsiveness (BHR) and asthma in this high-risk group.

Rethinking our approach to allergic rhinitis management

OBJECTIVE

This article reviews the recommendations by the World Health Organization's new guidelines, "Allergic Rhinitis and Its Impact on Asthma" (ARIA), and the paradigm for treating allergic rhinitis based on disease classification. After reading this article, readers should understand the ARIA guidelines and the salient issues involving the challenges inherent in the management of allergic rhinitis.

DATA SOURCES

Relevant and appropriately controlled clinical studies and results of patient surveys were used. Only literature in the English language was reviewed.

STUDY SELECTION

Material was taken from academic/scholarly journals, published abstracts, and presentations at a major congress.

RESULTS

The ARIA guidelines' new classification categorizes patients' allergic rhinitis as either intermittent or persistent with gradations from mild to moderate-severe. These guidelines propose a stepwise approach to management guided by symptom severity and evaluation of treatment response, with the underlying concept for treatment being to select therapies that address individual patients' symptoms. Although few data were available at the time of their inception, the guidelines recognize that antileukotriene medications may play an important role in the treatment of allergic rhinitis. Results of recent clinical trials support the use of antileukotriene medications in allergic rhinitis, alone or concomitantly with an antihistamine.

CONCLUSIONS

Targeting specific and multiple mechanisms of allergic rhinitis and individualizing all available and effective treatments to each patient, with specific medications for specific symptoms, will be of particular benefit to patients with allergic rhinitis.

Rhinitis as an independent risk factor for adult-onset asthma

BACKGROUND

For many years, the association between asthma and rhinitis has primarily been attributed to a common allergic background. Recently, it has been suggested that asthma and rhinitis are associated in the absence of atopy. The nature of this association is not well known.

OBJECTIVE

The purpose of this study, which was performed in a large, longitudinal community population, was to determine the extent to which rhinitis is an independent risk factor for adult-onset asthma.

METHODS

We carried out a nested case-control study from the longitudinal cohort of the Tucson Epidemiologic Study of Obstructive Lung Diseases. One hundred seventy-three incident patients with physician-confirmed asthma were compared with 2177 subjects who reported no asthma or shortness of breath with wheezing. Potential risk factors, including the presence of rhinitis, were assessed before the onset of asthma (patients) or before the last completed survey (control subjects).

RESULTS

Rhinitis was a significant risk factor for asthma (crude odds ratio, 4.13; 95% confidence interval, 2.88-5.92). After adjustment for years of follow-up, age, sex, atopic status, smoking status, and presence of chronic obstructive pulmonary disease, the magnitude of the association was reduced but still highly significant (adjusted odds ratio, 3.21; 95% confidence interval, 2.19-4.71). After stratification, rhinitis increased the risk of development of asthma by about 3 times both among atopic and nonatopic patients and by more than 5 times among patients in the highest IgE tertile. Patients with rhinitis with persistent and severe nasal symptoms and a personal history of physician-confirmed sinusitis had an additional increased risk of asthma development.

CONCLUSION

We conclude that rhinitis is a significant risk factor for adult-onset asthma in both atopic and nonatopic subjects. The nature of the association between rhinitis and asthma is open to interpretation.

Respiratory allergy

Allergic rhinitis (AR) and asthma are common respiratory allergic disorders which are increasing globally more in developed countries. Although much has been written about childhood asthma and guidelines published by various international and national fora, not much information is available on AR. This is most common in children, is a significant risk factor for developing asthma, is a common comorbidity with asthma and affects quality of life. This paper highlights the risk factors for developing respiratory allergy asthma and AR, linkages between them and the management issues, particularly in relation to the allergic or allergological aspects as they have important bearing on management of children suffering from respiratory allergy. Specific immunotherapy (SIT) is re-emerging as useful therapy which alone has the potential to modify the natural history of disease and prevent the 'allergic march'. Timely diagnosis, correct management including timely referrals can ensure good quality life for those suffering from respiratory allergies.

Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study)

BACKGROUND

Children with allergic rhinitis are likely to develop asthma.

OBJECTIVE

The purpose of this investigation was to determine whether specific immunotherapy can prevent the development of asthma and reduce bronchial hyperresponsiveness in children with seasonal allergic rhinoconjunctivitis.

METHODS

From 6 pediatric allergy centers, 205 children aged 6 to 14 years (mean age, 10.7 years) with grass and/or birch pollen allergy but without any other clinically important allergy were randomized either to receive specific immunotherapy for 3 years or to an open control group. All subjects had moderate to severe hay fever symptoms, but at inclusion none reported asthma with need of daily treatment. Symptomatic treatment was limited to loratadine, levocabastine, sodium cromoglycate, and nasal budesonide. Asthma was evaluated clinically and by peak flow. Methacholine bronchial provocation tests were carried out during the season(s) and during the winter.

RESULTS

Before the start of immunotherapy, 20% of the children had mild asthma symptoms during the pollen season(s). Among those without asthma, the actively treated children had significantly fewer asthma symptoms after 3 years as evaluated by clinical diagnosis (odds ratio, 2.52; P <.05). Methacholine bronchial provocation test results improved significant in the active group (P <.05).

CONCLUSION

Immunotherapy can reduce the development of asthma in children with seasonal rhinoconjunctivitis.

History and future perspectives of treating asthma as a systemic and small airways disease

Asthma is an inflammatory disorder in which the small airways of the lung play an important role. There is also evidence for the systemic nature of asthma. No current method adequately measures small airways function alone. Therefore, a combination of functional and clinical parameters should be used to ensure that patients with asthma are adequately treated with due consideration of the small airways. Previously therapeutic strategies have focused on bronchodilation and attenuation of airway inflammation. While early oral therapies had the advantage of reaching the small airways and treating the systemic aspect of asthma, they were associated with serious side-effects. Inhaled therapies were therefore developed to limit these effects. However, inhaled therapies have the disadvantage of limited penetration into the peripheral airways and an inability to treat the systemic component of asthma. They are also associated with local and systemic side-effects. The future for asthma treatment is likely to be a systemically administered medication with few side-effects targeting disease-specific mediators. The leukotriene receptor antagonists and anti-IgE monoclonal antibodies are examples of such therapies and the emergence of other new strategies is awaited.

Preventive aspects of immunotherapy: prevention for children at risk of developing asthma

OBJECTIVES

This review describes the connection between hay fever and asthma in patients suffering from specific IgE-mediated allergy. The short-term and longterm benefits of allergen specific immunotherapy (SIT), including potential prevention of exacerbation of disease from hay fever into asthma, are discussed.

DATA SOURCES

A review of literature on recent studies of SIT as treatment for allergic disease was conducted. Preliminary data emerging from the ongoing preventive allergy treatment study in Northern Europe are also presented.

STUDY SELECTION

The author's expert opinion was used to select relevant data.

RESULTS

Treatment with allergenic vaccines (immunotherapy) resulted in decreased symptoms of allergic rhinitis, decreased development of new allergies, and less asthma in the treated group, compared with the untreated control group.

CONCLUSIONS

SIT performed with characterized and standardized allergen extracts in an optimal dosage has been shown to interfere with the basic mechanisms of the allergy, resulting in immediate symptomatic relief and offering the patient a long-lasting and preventive effect.

Seasonal variation in bronchial hyperreactivity (BHR) in allergic patients

As summarized in Table 1, the literature consistently supports the hypothesis that allergic asthmatic patients have seasonal BHR changes that parallel allergen exposure. These seasonal changes appear to be preventable by treatment with corticosteroids (systemic, inhaled, or nasal), disodium cromoglycate, and immunotherapy. Studies have almost exclusively focused on pollens, though similar limited data exist for dust mites. Though the dust mite is a perennial allergen, mite levels are well known to fluctuate with seasonal temperature and humidity trends (44-46), and therefore, seasonal BHR variation in mite-sensitive asthmatic patients is not surprising. Allergenic mold species have not been studied in this regard. In allergic rhinitis patients, the data are less consistent (see Table 2). However, the studies that failed to identify a seasonal BHR difference were either small or had other design limitations. The seasonal changes identified by the larger analyses were similar to those identified for asthmatic patients. Thus, although confirmatory studies would be helpful, it seems likely that in the absence of clinical asthma, allergic rhinitis patients with baseline BHR have allergen-related seasonal changes in BHR. The BHR effects of seasonal changes in air pollution and viral URIs are not known, since they have not yet been directly studied. However, interesting recent reports have identified possible synergistic effects of air pollution exposure on BHR and allergic responses. Similarly, the availability of new viral identification techniques has resulted in the discovery that viral infection may be more prevalent during clinical asthma exacerbation than previously realized. Therefore, air pollution and viral infections may well influence BHR seasonally, and (along with allergens) may contribute to seasonal asthma morbidity and mortality peaks. The mechanism(s) underlying seasonal BHR changes is (are) not known. One plausible possibility with regard to allergen-driven BHR changes involves a type I hypersensitivity late-phase reaction. Characterized by recruitment of eosinophils, lymphocytes, and other cells that are central components of allergic inflammation and are not normally found in the lower airways, this reversible inflammatory process could in turn act, presumably via chemical mediators, on the airway smooth muscle. This may cause bronchoconstriction, but may also increase responsiveness to bronchoconstrictive stimuli independent of bronchoconstriction. This explanation for seasonal BHR changes is supported by findings of blood eosinophil (31,47) and BAL eosinophilic cationic protein (31) level changes that parallel BHR. Prevention of seasonal BHR changes using anti-inflammatory medications (32,33,35) also supports this hypothesis (30) however, and the complex potential interactions between infectious agents and air pollutants on seasonal BHR changes have yet to be studied directly. Therefore, although BHR indeed may predictably vary season to season in allergic individuals, additional investigation is needed to better characterize the reasons for this phenomenon. Further insight in this area may help address the reasons why there are often seasonal epidemics in asthma morbidity and mortality.

Effect of cetirizine on bronchial hyperresponsiveness in patients with seasonal allergic rhinitis and asthma

Although H1 antihistamine compounds (H1) are highly effective in the treatment of allergic rhinitis (AR), their role in the treatment of asthma is still controversial. Because a strong association between AR and bronchial hyperresponsiveness (BHR) has been reported, this study was designed to assess the effect of a new H1 anti histamine, cetirizine (C), on nonspecific BHR in patients with AR. Twelve patients were included in a double-blind, crossover, placebo-controlled trial. All patients had positive skin tests for common allergens and showed BHR to inhaled methacholine after specific nasal allergenic challenge. After a washout period of 1 week to ensure the stability of the BHR, the patients received, by crossover randomization, C 10 mg daily or placebo (P) for 2 weeks. After each treatment period, BHR and nasal blocking index (NBI) were measured 1 and 6 h after nasal challenge. Bronchial responsiveness was expressed as methacholine PD20, the provocation dose of methacholine causing a 20% decrease in FEV1. Measurements were then performed after 2 weeks of C and after 2 weeks of P. Baseline values of PD20 (median) measured before challenge showed no difference after cetirizine or after placebo (1.36 mg). Results 1 h after allergen did not show significant differences between C (methacholine PD20=0.522 mg) and placebo (methacholine PD20=0.455 mg). By contrast, 6 h after challenge, methacholine PD20 was 0.918 mg for C and 0.483 mg for P (P=0.042). Similarly, NBI showed no change between C and P 1 h after challenge, whereas the difference was significant 6 h after challenge (P=0.011 ). These data demonstrate a protective nasal effect of C against BHR measured 6 h after nasal allergen challenge in patients with AR. They suggest that C may be useful in patients with asthma associated with AR.

Epidemiologic evidence for asthma and rhinitis comorbidity

Asthma and rhinitis are often comorbid conditions, and the overall characteristics of the diseases and the treatment options for the disorders are similar. Several recent epidemiologic studies in the general population have provided evidence to strongly associate the development of asthma with a previous history of either allergic or perennial rhinitis. Additional links between asthma and rhinitis include a description of increased aspirin intolerance in both disorders and the observation that most subjects with occupational asthma experience rhinitis. Further, the likelihood of the development of asthma is much higher in individuals with both perennial and seasonal rhinitis than for individuals with either condition alone. Asthma and rhinitis were found to be comorbidities regardless of atopic state, and perennial rhinitis has been associated with an increase in nonspecific bronchial hyperresponsiveness. Several studies have identified rhinitis as a risk factor for asthma, with the prevalence of allergic rhinitis in asthmatic patients being 80% to 90%. These studies and others demonstrate that the coexistence of asthma and allergic rhinitis is frequent, that allergic rhinitis usually precedes asthma, and that allergic rhinitis is a risk factor for asthma. Finally, studies that have examined the age of onset of atopy as a confounding factor for the development of asthma and allergic rhinitis have suggested that early age atopy may be an important predictive factor for respiratory symptoms that continue into late childhood. In conclusion, rhinitis and asthma are strongly associated, and rhinitis has been identified as a risk factor for asthma.