Executive Summary of Joint Task Force Practice Parameters on Diagnosis and Management of Rhinitis

Effect of GHX02 on an Asthma-Rhinitis Mouse Model Induced by Ovalbumin and Diesel Particulate Matter

Fine dust concentrations come in direct contact with the human respiratory system, thereby reducing lung function and causing respiratory diseases such as asthma and rhinitis. The aim of this study was to evaluate the efficacy of GHX02 (combination of four herbs [Trichosanthes kirilowii, Prunus armeniaca, Coptis japonica, and Scutellaria baicalensis]), a herbal extract with established efficacy against bronchitis and pulmonary disease, in the treatment of asthma accompanied by rhinitis aggravated by fine dust. Therefore, we constructed an asthma-rhinitis mouse model of Balb/c mice challenged with ovalbumin (OVA) and fine diesel particulate matter, which were administered with three concentrations of GHX02. GHX02 significantly inhibited the increase of total cells and immune cells in bronchoalveolar lavage fluid, lung tissue, and nasal ductal lymphoid tissue (NALT). GHX02 also reduced the severity of histological lung injury and the expression of interleukin (IL)-1α and nuclear factor kappa B (NF-κB), which regulate inflammatory responses. The results indicate that GHX02 inhibited the inflammatory immune response in mice. Therefore, this study highlights the potential of GHX02 as a treatment for patients with asthma accompanied by rhinitis. Balb/c mice were challenged with OVA and PM10D, and then treated with three concentration of GHX02. GHX02 significantly inhibited the increase of total cells, immune cells lymphocytes, neutrophils, and macrophages, as well as their expression in lung tissue. GHX02 significantly inhibited the increase of total cells and immune cells in NALT. GHX02 decreased the severity of histological lung injury, expression of IL-1α and NF-κB. This study suggests the probability that GHX02 is effective for asthma patients with rhinitis by inhibiting inflammatory immune response.

Pharmacoeconomic Assessment of Antiallergic Drugs by Comparing Serum Immunoglobulin E Level as a Diagnostic and Monitoring Indicator of Allergic Rhinitis in Rural Population of India

Allergic rhinitis (AR) is a chronic inflammatory disease induced by IgE mediated reaction and identified clinically by presence of nasal discharge, sneezing, itching and nasal congestion. Aim of this study was to determine Serum IgE level which is an important indicator of AR. To analyse the diagnostic significance of serum IgE level and their pharmacoeconomic status in the management of AR with commonly used antihistaminic. Estimation of serum IgE can serve as a simple and reliable investigative tool in the diagnostic and management of AR. Fifty two adult patient with history of allergic rhinitis were randomly divided into four study groups and administered either Cetirizine, Levocetirizine, Loratidine or Fexofenadine respectively for one week. Blood samples were analysed to determine serum IgE level and the results were subjected to statistical analysis. The mean value and standard deviation were obtained and tabulated using paired t test. A total 52 patient were divided into four group, 13 in each group of age between 18 and 65 years (mean age 33.73 ± 10.23 years); 48.08% females and 51.92% male were randomized. Mean compliance with treatment was 100% for all study groups. The mean serum IgE level was significantly reduced in Levocetirizine as compared to Cetirizine, Loratidine and Fexofenadine groups. Levocetirizine controls the symptoms of AR better as compared to Cetirizine, Loratidine and Fexofenadine and is a better choice due to its cost effectiveness, tolerability and safety profile.

Skin Prick Test Reactivity to Common Allergens among Allergic Rhinitis Patients in Kocaeli Province, Turkey

Objective: The identification of the most common aeroallergens causing allergic rhinitis (AR) in a specific geographic area is important in the diagnosis and treatment of AR. This study evaluates the prevalence of sensitivity to aeroallergens among patients with AR who live in Kocaeli province, Turkey. Methods: This cross-sectional, descriptive study included a retrospective review of skin prick test (SPT) results from patients with suspected AR who were examined at a tertiary hospital rhinology clinic. Results: The SPT results of 85 patients with an AR diagnosis were included in this study. House dust mites (HDM) had the highest frequency of positive test responses (57.6%), followed by tree pollen (40.0%), grass pollen (36.5%), weed pollen (32.9%), cockroach (18.8%), animal dander (14.1%), and mold (11.8%). The majority of the AR patients were polysensitized (57.6%), and the most common allergens in polysensitized patients were tree pollen (61.2%), grass pollen (57.1%), and HDM (55.1%), respectively. The strongest single allergen in monosensitized subjects was HDM, with a rate of 61.1%. Conclusion: The most prevalent allergen was HDM among AR patients in the Kocaeli region, followed by tree pollen and grass pollen. Polisensitization occurs more frequently than monosensitization. These allergens should be prioritized in the diagnosis and treatment of allergic rhinitis in Kocaeli region patients.

Biomarkers and their Clinical Applications in Pediatrics

Biomarker studies are becoming increasingly interesting for many fields of medicine. The use of biomarkers in medicine is involved in detecting diseases and supporting diagnosis and treatment decisions. New research and new discoveries on the molecular basis of the disease show that there may be a number of promising new biomarkers for use in daily clinical practice. Clinical trials in children lag behind adult research both in quality and quantity. The number of biomarkers validated to optimize pediatric patient management is limited. In the pathogenesis of many diseases, it should not be extrapolated to the pediatric clinical setting, taking into account that biomarkers that are effective in adults are clearly different in children and that ontogeny directly affects disease development and therapeutic response in children. The search for ideal biomarkers or markers that can make an early and definitive diagnosis in neonatal sepsis is still ongoing. The ideal biomarker for pediatric diseases should be costeffective, noninvasive, applicable to pediatric specific diseases, and its results should correspond to age-related physiological changes. Lactate, troponin and B-type natriuretic peptide are valuable biomarkers in the evaluation and management of critically ill children with cardiac disease. Tumor markers in children are biochemical substances used in the clinical treatment of pediatric tumors and to detect the presence of cancer (regression or progression). In this chapter, current and brief information about biomarkers and their clinical applications used in the diagnosis and monitoring of pediatric diseases is presented.;

Efficacy and Safety of Fluticasone Furoate and Oxymetazoline Nasal Spray: A Novel First Fixed Dose Combination for the Management of Allergic Rhinitis with Nasal Congestion

Objective

To compare the efficacy and safety of a fixed dose combination of Fluticasone Furoate and Oxymetazoline Hydrochloride Nasal Spray 27.5/50 mcg (FDC) with Fluticasone Furoate Nasal Spray 27.5 mcg (Fluticasone) in the management of allergic rhinitis.

Patients and Methods

A prospective, randomized, double-blind, two-arm, active-controlled, parallel, multicenter, comparative clinical study was conducted in patients with allergic rhinitis aged 18 years and above having moderate-to-severe nasal congestion.

Results

A total of 250 patients were randomized (1:1) to receive either the FDC or Fluticasone alone in a dose of two sprays in each nostril once daily at night. There was a significantly (P<0.001) greater reduction in night-time Total Nasal Symptom Score with the FDC as compared to Fluticasone at all the time points starting from as early as day 3 and sustained till the end of treatment (Day 28) (Day 3: −3.1 vs −2.2; Day 7: −4.0 vs −3.4; Day 14: −5.7 vs −5.0; Day 28: −7.0 vs −6.4). A significantly greater number of patients (P<0.05) had complete relief in Nasal Congestion with the FDC (44.7%) as compared to Fluticasone (26.8%). Both the study medications were well tolerated by all the patients. The proportion of patients showing worsening of symptoms (rebound congestion/rhinitis medicamentosa) after stoppage of medication was similar in both groups (P>0.05).

Conclusion

The FDC was superior to Fluticasone alone in relieving the nasal congestion and reduction of Total Nasal Symptom Score in allergic rhinitis patients with moderate-to-severe nasal congestion when administered once daily in the evening. Oxymetazoline when used along with the nasal steroid in a once daily dose does not cause rebound congestion and rhinitis medicamentosa even after long-term continuous use of 28 days.

The correlation between middle schoolchildren allergic symptoms and airborne particle season: A cross-sectional study

Limited studies correlate allergic symptoms and associated outdoor biological particle exposure among schoolchildren globally.This study aimed to investigate the relationship between the seasonality of symptoms of allergic diseases among middle schoolchildren and the annual variation of airborne pollen and fungal spore in a hot and humid geographical region (Qatar).During November 2017 to January 2018, a self-reported study of middle schoolchildren living in the Doha capital city of Qatar was conducted, and data gathered were evaluated in relation to the collected monthly pollen and fungal spores. Participants' data were collected by conducting a survey based on a modified questionnaire adopted from the International Study of Asthma and Allergy in Childhood (ISAAC). The airborne pollen and fungal spore in Doha's atmosphere were extracted from the Doha aerobiology project (2017-2020).Among the 1000 distributed questionnaires, 100 were excluded due to significant missing data and 644 middle schoolchildren living in Doha city responded and were included in the final analysis. The symptoms of allergic rhinitis (AR) pattern among the responders with positive symptoms were strongly linked with the higher airborne fungal spore incidence during the month of November. Out of 331 students with positive symptoms, the prevalence of AR, lifetime wheeze, and eczema was 62.8%, 28.1%, and 26.6%, respectively. Asthma was significantly higher in Qatari (39.8%) compared to non-Qatari (26.7%) middle schoolchildren (P = .02).Outdoor aeroallergen may be a contributing factor in addition to other environmental and genetic predisposing factors for childhood atopic diseases in the prevalence rate of allergic symptoms among middle schoolchildren in the peninsula of Qatar.

Allergic rhinitis, asthma and laryngopharyngeal reflux disease: a cross-sectional study on their reciprocal relations

Allergic rhinitis (AR) is a common medical condition worldwide. It is an inflammation in the nasal mucosa due to allergen exposure throughout the year. Laryngopharyngeal reflux (LPR) is another medical condition that can overlap with AR. LPR can be considered an extra oesophageal manifestation of gastro-oesophageal reflux disease (GORD) or a different entity. Its diagnosis imposes a real challenge as it has a wide range of unspecific symptoms. Although AR and LPR are not life-threatening, they can severely affect the quality of life for years and cause substantial distress. Moreover, having AR is associated with having asthma which is also in turn associated with GORD. This is a cross-sectional study which used surveys distributed online on Social Media and targeted people across Syria. All participants who responded to the key questions were included. Reflux symptom index (RSI) was used for LPR, and score for allergic rhinitis (SFAR) was used for AR. Demographic questions and whether the participant had asthma were also included in the survey. We found that there was an association between the symptoms of LPR and AR p < 0.0001 (OR, 2.592; 95% CI 1.846-3.639), and their scores were significantly correlated (r = 0.334). Having asthma was associated with LPR symptoms p = 0.0002 (OR 3.096; 95% CI 1.665-5.759) and AR p < 0.0001 (OR 6.772; 95% CI 2.823-16.248). We concluded that there was a significant association between having LPR, AR, and asthma. We need more studies to distinguish between their common symptoms and aetiologies.

A Randomized Trial of Comparing a Combination of Montelukast and Budesonide With Budesonide in Allergic Rhinitis

OBJECTIVES/HYPOTHESIS

It is not unequivocally proven whether a combination of an intranasal corticosteroids (INSs) and a cysteinyl leukotriene receptor antagonist has greater efficacy than INSs in the treatment of seasonal allergic rhinitis (SAR).

STUDY DESIGN

Single-center, randomized, open-label study.

METHODS

Study subjects included 46 participants with SAR. Participants were randomized to receive budesonide (BD; 256 μg) plus montelukast (MNT; 10 mg) (BD + MNT) or BD alone (256 μg) for 2 weeks. Visual analog scale scores for five major symptoms of SAR, nasal cavity volume (NCV), nasal airway resistance (NAR), and fractional exhaled nitric oxide (FeNO) were assessed before and at the end of treatments.

RESULTS

Both treatments significantly improved the five main SAR symptoms from baseline; however, BD + MNT produced significantly greater improvements in nasal blockage and nasal itching compared to BD alone. At baseline, the nasal blockage score was significantly correlated with NCV and NAR (r = -0.473, P = .002 and r = -0.383, P = .013, respectively). After 2 weeks of treatment, BD + MNT significantly improved NCV, but not NAR, to a greater level than BD. The number of patients with FeNO concentration ≥ 30 ppb at baseline was significantly decreased after BD + MNT treatment, but not after BD treatment. Similarly, BD + MNT treatment led to a significantly greater decrease in FeNO concentration than BD treatment.

CONCLUSIONS

BD + MNT treatment may have an overall superior efficacy than BD monotherapy for patients with SAR, especially in improvement of nasal blockage, itching, and subclinical lower airway inflammation. Also, NCV and NAR could be used to assess nasal blockage more accurately.

LEVEL OF EVIDENCE

1b Laryngoscope, 131:E1054-E1061, 2021.

Comparative study of aeropollen and pollinosis cases

Research linking pollen grains in the air with allergy cases (pollinosis) is still incipient in Africa. To close this gap, aerosamplers were placed in Gbagada, Lagos State and harvested monthly from January 2013 to December 2014. Data obtained was correlated with allergy cases (wheezing cough, rhinitis, and allergic conjunctivitis) from Gbagada General Hospital Lagos. Dominant pollen grains recovered were those of Alchornea cordifolia, Amaranthaceae, Casuarina equisetifolia, Cyperaceae, and Poaceae. Pollinosis data revealed that wheezing cough had the highest records in 2013 (1153) and 2014 (1409) while individuals of the age group 15-49 years had the highest number of pollinosis cases for both years. Peak pollen season in 2013 was from October-December; similarly, October, November, and December recorded the highest incidence of wheezing cough (225), rhinitis (21), and allergic conjunctivitis (56) respectively. In 2014, peak pollen season was from October-March while October recorded the highest number of cases of allergic conjunctivitis and rhinitis (81 and 32 respectively) and wheezing cough cases were highest in November (299). Total pollen count had positive significant correlation (p ≤ 0.05) with wheezing cough cases for both years. Individually, each dominant pollen had positive significant correlation (p ≤ 0.05) with wheezing cough cases in 2013 while only Cyperaceae and Poaceae pollen had positive significant correlation (p ≤ 0.05) with wheezing cough in 2014. Continuous collection of aeropollen and pollinosis data from more locations within Nigeria is recommended to provide an appropriate epidemiology of pollinosis cases in the country and ascertain possible responsible pollen grains.

Correlation between Allergic Rhinitis and Laryngopharyngeal Reflux

Background and Objectives

Laryngopharyngeal reflux (LPR) exhibits nonspecific clinical presentations, and these symptoms may be associated with other conditions such as allergies, including allergic rhinitis and laryngitis. However, there is a gap in the literature regarding the correlation of laryngopharyngeal reflux with allergic rhinitis/laryngitis. Hence, the aim of this study is to explore the correlation between these two conditions.

Patients and Methods

A total of 126 patients with suggestive manifestations of laryngopharyngeal reflux were included in this study. Patients were classified into LPR positive and negative groups based on the results of a 24-hour oropharyngeal pH monitoring system while allergic rhinitis status was assessed with the score for allergic rhinitis (SFAR).

The results of the two groups were compared regarding the SFAR score. Correlation between the pH results and SFAR score was explored. Results

The LPR positive group demonstrated significantly higher SFAR scores compared to the negative LPR group (p < 0.0001). In addition, the Ryan score was significantly correlated with the SFAR total score and its symptomatology-related items (r ranged between 0.35 and 0.5). Conclusion. It seems that laryngopharyngeal reflux increases patients' self-rating of allergic manifestations. It appears that there is an association between laryngopharyngeal reflux and allergic rhinitis/laryngitis.

The role of allergy immunotherapy in the treatment of asthma

PURPOSE OF REVIEW

Asthma and allergic rhinitis are two of the most widespread chronic medical conditions. Asthma, a condition which encompasses chronic inflammation of the lower airway resulting in expiratory obstruction, may represent an end phase along the allergic disease spectrum ultimately stemming initially from nasal allergic rhinitis and bronchial hyper-reactivity. The purpose of this review was to evaluate the available published literature over the past 12 months regarding the role of allergy immunotherapy in the treatment of asthma.

RECENT FINDINGS

Recent clinical trials, systematic reviews, and meta-analyses have demonstrated that allergen-specific immunotherapy (ASI), especially sublingual immunotherapy for as short as 12 months, may help improve asthma symptoms and reduce medication usage. However, studies have not demonstrated overall improvement in pulmonary function tests despite improvement in symptoms. Barriers to asthmatic patients initiating and maintaining ASI include lack of payment by health insurer, inconvenience, and potentially worsening asthma exacerbations/symptoms for patients with severe disease.

SUMMARY

ASI may change the natural course of allergic asthma by reducing the risk of acute respiratory exacerbations and symptoms. Additional studies are necessary to examine whether early treatment of allergy sensitivities with ASI may ultimately prevent the progression to asthma.

Could seasonal allergy be a risk factor for acute rhinosinusitis in children?

OBJECTIVE

To evaluate the incidence of acute rhinosinusitis in children with grass pollen induced rhinitis during the period of grass pollinosis.

METHODS

Children with nasal symptoms from grass pollen induced rhinitis but without rhinosinusitis symptoms were selected. Their parents were asked to complete a diary during pollen exposure to report nasal symptoms and drugs used daily. When rhinosinusitis was suspected, the confirmatory diagnosis of acute rhinosinusitis was made by fibro-endoscopy. Children without inhalant allergy served as controls.

RESULTS

Seventeen out of 242 children (7.0 per cent) had a diagnosis of acute rhinosinusitis, confirmed by fibro-endoscopy, during grass pollination, compared to 3 out of 65 (4.6 per cent) in the control group (p = 0.49). Among allergic children, those with acute rhinosinusitis had symptoms for a greater number of days and/or a higher symptoms score than children without acute rhinosinusitis.

CONCLUSION

Children with grass pollen induced rhinitis during exposure to pollen have an incidence of endoscopically confirmed acute rhinosinusitis comparable to non-allergic children. This suggests that grass pollen induced rhinitis is a negligible risk factor for acute rhinosinusitis.

Topical Olopatadine Hydrochloride versus Ketotifen Fumarate for Allergic Conjunctivitis

Purpose:

Allergic conjunctivitis (AC) is associated with itching, redness, tearing, pain, and burning sensation in the eyes. The inflammatory process is caused by the mechanism of immediate hypersensitivity due to direct contact with the allergen. This process triggers mast cells in the conjunctiva to activate and release mediators. The purpose of this study was to compare topical olopatadine and ketotifen in terms of effectiveness and safety for the management of AC.

Methods:

Patients clinically diagnosed with AC were randomized into two groups of 60 patients each and received either topical olopatadine HCl 0.1% or ketotifen fumarate 0.025%. They were followed up on the 4^th, 15^th, and 30^th days to evaluate symptoms, signs, and quality of life (QOL) scoring.

Results:

There were a total of 120 patients (67 men and 53 women) with a mean age of 36.35 ± 11 years. Compared to baseline, scores of itching, tearing, redness, eyelid swelling, chemosis and papillae addition of all the individual scores mentioned above and QOL scores reduced significantly (P = 0.001) by the 4^th and 15^th days of olopatadine and ketotifen application. Compared with ketotifen, olopatadine significantly reduced itching, tearing, hyperemia, and total AC scores by the 4^th day (P = 0.001) and conjunctival papillae by the 15^th day (P = 0.001). Adverse reactions were reported in 10% and 18% of patients treated with olopatadine and ketotifen, respectively.

Conclusion:

Compared to ketotifen, olopatadine provided quicker relief of symptoms, and improved symptoms of AC and QOL, with fewer side effects.

Allergen-specific immunoglobulin E and allergic rhinitis severity

Background:

Allergic rhinitis (AR) is a common disorder. The diagnosis is based on the concordance between allergy sensitization and history. Serum allergen specific immunoglobulin E (sIgE) assessment allows characterization of the relevant sensitizing allergens. Presently, Allergic Rhinitis and its Impact on Asthma (ARIA) classification subdivides AR based on symptoms severity and duration. However, the relationship between sIgE levels and symptom severity is still a matter of debate.

Objective:

Therefore, this study aimed at relating sIgE levels with symptom severity assessed by ARIA classification in a group of patients with AR.

Methods:

We enrolled 217 patients with AR (123 women; median age, 39.5 years). The sIgE levels (expressed in kUA/L) to house-dust mite were detected by the fluorescence enzyme immunoassay in peripheral blood samples. The IgE calibrators were traceable to the second international reference preparation 75/502 of human serum IgE from the World Health Organization. Symptom severity was assessed by ARIA classification.

Results:

We found a significant difference in sIgE levels in patients with mild intermittent versus mild persistent symptoms (p < 0.05), mild intermittent versus moderate-to-severe persistent symptoms (p < 0.001), moderate-to-severe intermittent versus moderate-to-severe persistent symptoms (p < 0.01), and mild persistent versus moderate-to-severe persistent symptoms (p < 0.05).

Conclusion:

Analysis of these findings indicated that the sIgE level to house-dust mite might be a reliable biomarker for symptom severity in patients with AR. This outcome might be clinically relevant, particularly in candidates for immunotherapy.

Prevention of food and airway allergy: consensus of the Italian Society of Preventive and Social Paediatrics, the Italian Society of Paediatric Allergy and Immunology, and Italian Society of Pediatrics

BACKGROUND

Allergic sensitization in children and allergic diseases arising therefrom are increasing for decades. Several interventions, functional foods, pro- and prebiotics, vitamins are proposed for the prevention of allergies and they can't be uncritically adopted.

OBJECTIVE

This Consensus document was developed by the Italian Society of Preventive and Social Paediatrics and the Italian Society of Paediatric Allergy and Immunology. The aim is to provide updated recommendations regarding allergy prevention in children.

METHODS

The document has been issued by a multidisciplinary expert panel and it is intended to be mainly directed to primary care paediatricians. It includes 19 questions which have been preliminarily considered relevant by the panel. Relatively to each question, a literature search has been performed, according to the Italian National Guideline Program. Methodology, and a brief summary of the available literature data, has been provided. Many topics have been analyzed including the role of mother's diet restriction, use of breast/formula/hydrolyzed milk; timing of introduction of complementary foods, role (if any) of probiotics, prebiotics, vitamins, exposure to dust mites, animals and to tobacco smoke.

RESULTS

Some preventive interventions have a strong level of recommendation. (e.g., the dehumidifier to reduce exposure to mite allergens). With regard to other types of intervention, such as the use of partially and extensively hydrolyzed formulas, the document underlines the lack of evidence of effectiveness. No preventive effect of dietary supplementation with polyunsaturated fatty acids, vitamins or minerals has been demonstrated. There is no preventive effect of probiotics on asthma, rhinitis and allergic diseases. It has demonstrated a modest effect, but steady, in the prevention of atopic dermatitis.

CONCLUSIONS

The recommendations of the Consensus are based on a careful analysis of the evidence available. The lack of evidence of efficacy does not necessarily imply that some interventions may not be effective, but currently they can't be recommended.

Optimal Duration of Allergic Rhinitis Clinical Trials

OBJECTIVE: Guidelines have been published by the Food and Drug Administration (FDA) and the European Agency for the Evaluation of Medicinal Products (EMEA) for the conduct of seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR) studies. These guidelines have differences regarding the duration of such trials: the FDA suggests 2 weeks for SAR and 4 weeks for PAR but the EMEA suggests 2 to 4 weeks for SAR and 6 to 12 weeks for PAR trials. In the interest of global harmonization, it would be desirable to have a uniform duration of such trials so that investigators, internationally, would be able to readily compare results for various types of treatments based on a single standard. Therefore, we performed an evidence-based review to answer the clinical question, What is the optimal duration for SAR and PAR clinical trials?

METHODS: We performed a MEDLINE search of the published literature from 1995 to the present. We used appropriate search terms, such as allergic rhinitis, seasonal allergic rhinitis, perennial allergic rhinitis, SAR, and PAR, to identify pertinent articles. These articles were reviewed and graded according to the evidence quality.

RESULTS: After an initial screening of more than 300 articles, 138 articles were analyzed thoroughly. No study specifically addressed the question of the optimal duration of SAR or PAR clinical trials.

CONCLUSIONS: We conclude that the current FDA (draft) guidelines calling for a study length of 2 weeks for the assessment of drug efficacy for SAR and 4 weeks for the study of drug efficacy in PAR are appropriate and that longer study periods are not likely to add meaningfully to the assessment of drug efficacy.

Response to Nonallergenic Irritants in Children With Allergic and Nonallergic Rhinitis

Purpose

Nonallergenic irritants can aggravate the symptoms of rhinitis. We investigated the clinical responses of children with allergic rhinitis (AR) and nonallergic rhinitis (NAR) to nonallergenic irritants, and identified factors associated with these responses.

Methods

Children with chronic rhinitis (n=208) were classified as having AR or NAR based on the presence of aeroallergen-specific IgE. Healthy controls (n=24) were recruited for comparison. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines were used to classify patients, and their irritant score (0-21 points) and current symptom score (5-35 points) were measured. Subjects with irritant scores ≥3 and <3 were classified as having irritant and nonirritant rhinitis, respectively.

Results

The mean age of enrolled subjects was 6.8 years (range: 1.8-16.0 years). The AR and NAR groups had similar irritant scores (P=0.394) and proportions of subjects with irritant scores ≥3 (P=0.105). Irritant score correlated positively with symptom score (P=0.005), and the proportion of subjects with irritant scores ≥3 was greater in children with moderate-severe rhinitis than in those with mild rhinitis (P=0.046). Multiple logistic regression analysis indicated that the presence of atopic eczema increased the risk for sensitivity to a nonallergenic irritant (aOR=2.928, 95% CI 1.567-5.473, P=0.001).

Conclusions

Response to a nonallergenic irritant was useful for gauging the severity of rhinitis, but not for differentiating AR from NAR. AR and NAR patients with atopic eczema may increase nasal sensitivity to nonallergenic irritants.

Mometasone furoate in the treatment of mild, moderate, or severe persistent allergic rhinitis: a non-inferiority study (PUMA)

Introduction

Allergic rhinitis is considered the most prevalent respiratory disease in Brazil and worldwide, with great impact on quality of life, affecting social life, sleep, and also performance at school and at work.

Objective

To compare the efficacy and safety of two formulations containing mometasone furoate in the treatment of mild, moderate, or severe persistent allergic rhinitis after four weeks of treatment.

Methods

Phase III, randomized, non-inferiority, national, open study comparing mometasone furoate in two presentations (control drug and investigational drug). The primary endpoint was the percentage of patients with reduction of at least 0.55 in nasal index score (NIS) after four weeks of treatment. Secondary outcomes included total nasal index score score after four and 12 weeks of treatment; individual scores for symptoms of nasal obstruction, rhinorrhea, sneezing, and nasal pruritus; as well as score for pruritus, lacrimation, and ocular redness after four and 12 weeks of treatment. The study was registered at clinicaltrials.gov with the reference number NCT01372865.

Results

The efficacy primary analysis demonstrated non-inferiority of the investigational drug in relation to the control drug, since the upper limit of the confidence interval (CI) of 95% for the difference between the success rates after four weeks of treatment (12.6%) was below the non-inferiority margin provided during the determination of the sample size (13.7%). Adverse events were infrequent and with mild intensity in most cases.

Conclusion

The efficacy and safety of investigational drug in the treatment of persistent allergic rhinitis were similar to the reference product, demonstrating its non-inferiority.

Recent pharmacological developments in the treatment of perennial and persistent allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) has a major negative impact on patients' quality of life (QoL) and carries a high socio economic burden. This is particularly the case for patients who experience symptoms for extended periods of time (i.e. those with perennial (PAR) or persistent AR (PER), depending on the classification system used). This review covers available pharmacological advances and recent developments in the treatment of PAR or PER.

AREAS COVERED

Pharmacological AR treatment is used to reduce symptom burden and help restore patients' normal daily routine. Traditionally, non-sedating antihistamines and intranasal corticosteroids (INS) were the two drug classes recommended for use first line. These, along with antileukotrienes, decongestants, mast cell stabilizers and anticholinergics, constituted the bulk of the AR treatment arsenal. MP-AzeFlu (Dymista®, Meda, Solna, Sweden) is the most recent addition to that arsenal. It is a novel intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP) delivered in a single spray and has surpassed available therapies in terms of symptom control and treatment response. Other relatively new treatments for PAR or PER include H3 antihistamines, toll-like receptor (TLR) agonists, cellulose powders and micro-emulsions, novel biomolecular formulations and omalizumab. Each of these new additions is reviewed here.

EXPERT OPINION

A new AR drug class has recently been introduced (i.e. RO1AD58). Currently MP-AzeFlu is the only treatment option within this drug class. It can be estimated that combination treatments like MP-AzeFlu will become the mainstay of PAR and PER therapy since use will result in better compliance, improved efficacy over INS and a faster response together with good levels of tolerability. The challenge is to find other equally, or more effective, combination treatments, as has been the therapeutic standard in bronchial asthma for decades. The potential of biologics, as well as TLR-agonists and other new treatment options needs to be further evaluated.

Improvement and prevention of asthma with concomitant treatment of allergic rhinitis and allergen-specific therapy

BACKGROUND

Asthma and allergic rhinitis are 2 of the most prevalent chronic medical diseases. Asthma is estimated to affect 8% of adults and 9% of children, with nearly 300 million people affected worldwide. Poorly controlled allergic rhinitis may be associated with worsening asthma symptoms over time. Various treatments have been proposed in the improvement and prevention of asthma in children and adults with allergic symptoms, which have included pharmacotherapy with antihistamines and topical intranasal corticosteroids, as well as allergen-specific immunotherapy.

METHODS

Articles were selected through PubMed and personal knowledge of the authors based on a comprehensive literature review examining whether treatment of allergic rhinitis improves and/or prevents concomitant symptoms of asthma. The largest and highest-quality studies were included in the literature review. The search selection was not standardized. Articles written in a language other than English were excluded.

RESULTS

Clinical trials have showed improvement in asthma symptoms with concomitant treatment of allergic rhinitis with antihistamines and topical intranasal corticosteroids, though improvement in objective pulmonary function parameters has not been uniformly demonstrated with antihistamine use alone. There is very strong evidence to suggest that subcutaneous and sublingual immunotherapy may in addition prevent the progression of asthma in high-risk atopic patients by inducing immunological tolerance.

CONCLUSION

Traditional pharmacotherapy with antihistamines and topical intranasal steroids has been shown to improve allergic rhinitis symptoms with concomitant allergic asthma; however, only allergen-specific immunotherapy offers long-term control in improving asthma symptoms, exacerbations, and likely ultimate prevention in developing asthma.

A role for the intranasal formulation of azelastine hydrochloride/fluticasone propionate in the treatment of allergic rhinitis

Rhinitis is a very common disease and represents a health problem for both children and adults globally. Rhinitis can be allergic or occur without any IgE-mediated sensitization to aeroallergens. Common symptoms include nasal congestion, postnasal drainage, nasal itching, rhinorrhea and sneezing. The most effective drugs for the treatment of rhinitis are antihistamines and topical glucocorticoids. MP29-02 (Dymista(®)) is a novel intranasal formulation combining the second-generation antihistamine, azelastine hydrochloride, with fluticasone propionate in a single device that has recently been developed. Here, we review the efficacy and safety profile of this intranasal formulation in the treatment of allergic and nonallergic rhinitis.

Bilastine: new insight into antihistamine treatment

Bilastine is a new second generation H1-antihistamine recently approved for the symptomatic treatment of allergic rhinitis (AR) and chronic urticaria (CU). Bilastine epitomizes the evolution of research on antihistamines concerning both efficacy and safety. In AR treatment, a number of large controlled clinical trials documented its efficacy, as assessed by improvement of all nasal and ocular symptoms and quality of life. These outcomes show that bilastine meets current EAACI/ARIA criteria for medications used in the treatment of AR. Also in CU, the review of the literature indicates that once-daily treatment with bilastine 20 mg was effective in managing symptoms and improving patient's quality of life. Concerning safety and tolerability, the profile of bilastine is very similar to placebo and in particular the adverse effects on central nervous system are insignificant. The balance of efficacy and safety of bilastine is particularly helpful when dosages higher than standard are needed to control the symptoms, as frequently occurs in patients with urticaria, in whom antihistamines doses up to four times the standard dose may be administered.

Comparing the effects of ketotifen fumarate eye drops and ketotifen oral pills on symptom severity and quality of life in patients with allergic rhinitis: a double-blind randomized clinical trial

BACKGROUND

Allergic rhinitis is a chronic inflammatory disease of nasal mucosa. Previous studies have shown the therapeutic effects of ketotifen eye drops on allergic conjunctivitis and rhinitis patients. This study was designed to compare the effects of ketotifen drops and oral ketotifen pills on symptoms and quality of life in allergic rhinitis patients.

METHODS

In this double-blind randomized clinical trial, patients with mild allergic rhinitis who were referred to the allergy clinic of Baqiyatallah Hospital from March to April 2014 were randomly allocated to 2 groups; the first group received ketotifen drops (1 drop every 12 hours) with placebo pills (2 pills daily), and the second group received placebo eye drops with ketotifen pills for 4 weeks. Symptoms (sneezing, runny nose, itching, and nasal obstruction) severity were examined and Rhinitis Quality of Life Questionnaire (RQLQ) scores were evaluated in the second and fourth weeks.

RESULTS

A total of 140 patients were evaluated in 2 groups. The mean age was 30.33 years. There were no significant differences in demographic data between the groups (p > 0.05). Both groups showed a significant improvement in rhinorrhea, nasal congestion, nasal itching, coughing, sneezing, RQLQ, and nasal smear eosinophil percent compared to baseline amounts (p < 0.05). Improvements were significantly more in the drops group (p < 0.05).

CONCLUSION

Because of the absence of systemic complications in ketotifen eye drops in patients with allergic rhinitis and their easy availability in Iran, using this medication instead of systemic therapies is suggested. Nevertheless, more studies are required to evaluate the long-term effects of using this drug and the recurrence rate of symptoms.

Does allergic rhinitis affect communication skills in young adults?

Allergic rhinitis (AR) is a chronic disorder with a high prevalence in the general population. The symptoms of AR can impair the cognitive capabilities of the affected people. The study of communication skills and AR interaction has not been adequately discussed. We aimed to analyze Social Communication Skills of university students with AR. Fifty patients suffering from AR and 50 healthy subjects were studied. All participants completed two questionnaires [Social Communication Skills Rating Scale (SCSRS) and Communication Questionnaire] for the assessment of social communication skills. Total scores of both SCSRS and Communication Questionnaire were higher in participants with AR than controls. When the questions of SCSRS were compared between the groups one by one, significant difference was observed between the groups for questions numbered 1-9 and 11, 12 (p < 0.05). Also, significant differences were observed between the groups for questions numbered 4, 5, 6, 7 and 8 of Communication Questionnaire (p < 0.05). Results of our study indicate that AR could negatively affect the social communication skills of the patients with AR. More research is however needed to validate this hypothesis.

Advances in asthma drug discovery: evaluating the potential of nasal cell sampling and beyond

INTRODUCTION

Inhaled corticosteroid anti-inflammatory therapy is effective at controlling disease symptoms of asthma, but a subset of patients remains symptomatic despite optimal treatment, creating a clear unmet medical need. Moreover, none of the currently available drugs for asthma are really disease-modifying or curative. Although murine models of asthma, based on transgenic and knockout animals, may offer an integrated pathophysiological system for studying the characteristics of airway inflammation and hyperresponsiveness, these alterations are noteworthily different compared with those observed in asthmatic patients. Since a clear functional and inflammatory relationship between the nasal mucosa and bronchial tissue in patients suffering from asthma and allergic rhinitis has been recognized, using preclinical models based on human nasal cells sampling might support a prompt and effective anti-inflammatory drug discovery in asthma.

AREAS COVERED

The authors provide a review, which discusses the potential role of nasal cell sampling and its application in advanced drug discovery for asthma. The contents range from the similarities and differences between asthma and allergic rhinitis up to artificial airway models based on sophisticated human lung-on-a-chip devices.

EXPERT OPINION

Nasal cell sampling and processing have reached a great potential in asthma drug discovery. The authors believe that models of asthma, which are based on human nasal cells, can provide valuable indications of proof of pharmacological and potential therapeutic efficacy in both preclinical and early clinical settings.

Symptom score for allergic rhinitis

OBJECTIVES

To determine the prevalence of allergic rhinitis in our study population and the correlation between the Score for Allergic Rhinitis (SFAR) and nasal smear eosinophil count.

STUDY DESIGN

Cross-sectional study.

SETTING

Ear, nose, and throat clinic, University of Ilorin Teaching Hospital, Nigeria; a 450-bed tertiary health facility.

SUBJECTS

Two hundred seventy-five consecutive, consenting patients who presented with nasal symptoms.

METHODS

Information on the 8-parameter symptom score was collected using a semistructured questionnaire by interview. Nasal smear slides were air dried, fixed with 95% alcohol, stained using May-Grünwald-Giemsa stain, and examined under a light microscope.

RESULTS

Of the 275 participants seen during the 1-year study, 116 (42.2%) were males. The mean ± SD age was 38.5 ± 16.3 (range, 14-75) years. Eighty-one (29.5%) were diagnosed with allergic rhinitis using a nasal smear eosinophil count. The most common symptom was excessive sneezing, involving 93% of patients with allergic rhinitis (P < .001). The prevalence of allergic rhinitis using SFAR was 31.6%. The SFAR cutoff was set at >8 (P < .001). The sensitivity and specificity for SFAR were 94.8% (confidence interval [CI], 90.5%-97.4%) and 95.1% (CI, 87.2%-98.4%), respectively. A high Spearman's correlation (0.88) was obtained for SFAR when correlated with nasal smear eosinophil count.

CONCLUSION

The prevalence of allergic rhinitis using SFAR was 31.6%. The study shows that SFAR can be used as a simple, valid diagnostic tool in allergic rhinitis. This is important in rural settings where access to laboratory investigations might not be readily available.

Assessment of Patient Attitudes About Mometasone Furoate Nasal Spray: The Ease-of-Use Patient Survey

Background

Intranasal corticosteroids (INS) are recommended as first-line therapy for allergic rhinitis. To date, no studies have evaluated the impact of an INS delivery system on patient satisfaction. Unless patients use a medication appropriately and consistently, they will not fully benefit from its therapeutic effects.

Objective

To determine whether the characteristics of the mometasone furoate nasal spray (MFNS) delivery device are an impediment to its use.

Methods/Database

A random sample of preidentified MFNS users was recruited through e-mail (N = 1544). In online interviews, participants were asked about MFNS ease of use and attributes.

Results

Ninety-eight percent of respondents reported that MFNS is easy to use, and 96% said that the applicator is easy to administer. Nearly all elderly users and users with arthritis said that the applicator fits comfortably in the nostril (96% and 97%, respectively) and is appropriately sized (97% and 96%, respectively); 96% of pediatric users agreed that the applicator fits comfortably. All users said the applicator's ease of use and comfortable fit were its most important attributes.

Conclusions

The perceived ease of use of MFNS may help providers appropriately treat patients with allergic rhinitis and may improve patient adherence to INS use.

Seasonal Specificity of Seasonal Allergens and Validation of the ARIA Classification in Korea

Purpose

In Korea, tree pollens are known to be prevalent in spring, grass pollens in summer and weed pollens in autumn. However, few studies have revealed their seasonal specificity for allergic rhinitis symptoms. An ARIA (Allergic Rhinitis and its Impact on Asthma) classification of allergic rhinitis was recently introduced and its clinical validation has not been well proved. The aim of this study was to evaluate the seasonal specificity of seasonal allergens and to validate the ARIA classification with the conventional seasonal and perennial allergic rhinitis (SAR/PAR) classification.

Methods

Two hundred twenty six patients with allergic rhinitis were included in this study. The patients were classified according to the sensitized allergens and the ARIA classifications. A questionnaire survey was performed and the data on the seasonal symptom score, the severity of symptoms and the SNOT (sinonasal outcome test)-20 score was obtained and the data was analyzed and compared between the conventional SAR/PAR classification and the ARIA classification.

Results

Seasonal pollens (tree, grass, weed) were not specific to the pollen peak season and the patients' symptoms were severe during spring and autumn regardless of the offending pollens. More than 60% of the patients with SAR showed persistent symptoms and 33% of the patients with perennial allergic rhinitis (PAR) had intermittent symptoms, showing the lack of association between the SAR/PAR/PAR+SAR classification and the ARIA classification. The ARIA classification showed better association not only with the symptomatic score, but also with the SNOT-20 score, which showed better validity than the conventional SAR/PAR classifications.

Conclusions

Seasonal pollens were not specific to their season of prevalence in terms of the severity of symptoms, and the ARIA classification showed better representation of allergic symptoms and quality of life (SNOT-20 score) than did the SAR/PAR classification.

Qualitative Development of the Rhinitis Control Assessment Test (RCAT), an Instrument for Evaluating Rhinitis Symptom Control

BACKGROUND

: Effective management of allergic rhinitis requires ongoing monitoring of its control. This article describes the qualitative phase of development of a patient-completed instrument, the Rhinitis Control Assessment Test (RCAT), designed to assist patients and providers in the detection of problems with rhinitis symptom control.

OBJECTIVE

: To identify concepts to be measured and to develop initial questionnaire items to be tested further in the next phase of development.

METHODS

: A literature review and input from patient focus groups were utilized to generate concepts to be measured in the draft questionnaire. The draft items were subjected to cognitive testing to ensure that the items were understood by patients and to eliminate ambiguity as well as to select an optimal recall period and meaningful response scales. Patients aged ≥18 years self-reporting a rhinitis diagnosis who had experienced rhinitis symptoms in the past 12 months were eligible for participation in the focus groups (n = 39) and the cognitive interviews (n = 23).

RESULTS

: This qualitative process yielded a draft instrument with 26 items assessing five constructs of rhinitis symptom control: frequency and bothersomeness of nasal and non-nasal symptoms, symptom impact, activity interference, symptom control, and medication use. A five-point Likert response scale and a 1-week recall period for each item were adopted based on patient input.

CONCLUSION

: The qualitative phase of development of the RCAT produced constructs and items for an instrument that is anticipated to facilitate accurate assessment of rhinitis control and improve the quality of care for patients with allergic rhinitis.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Diagnosis and treatment of allergic rhinitis due to house-dust mites in Spain

BACKGROUND

The prevalence of allergic rhinitis due to house-dust mites (HDMs) is high and increasing. Treatment guidelines and consensus statements are available, but few data exist on how these are followed in clinical practice in Spain. This study was designed to collect data on diagnosis and treatment of allergic rhinitis due to HDMs and adherence to guidelines in Spanish specialized clinical practice.

METHODS

In this observational study, patients referred to specialists for a first consultation were collected. Diagnosis of allergic rhinitis due to HDMs was confirmed by skin-prick tests and measurement of specific immunoglobulin E levels. Variables included patient demographics, diagnosis, and treatment. Moreover, investigators answered a questionnaire on their attitudes to allergic rhinitis treatment.

RESULTS

Two hundred forty-seven clinicians collected evaluable data from 519 patients (mean age, 24.8 years; SD, 11.9 years; 54% women) with confirmed allergic rhinitis (86.2% with moderate or severe disease and 70.5% with persistent disease; 40% with concomitant asthma) caused by Dermatophagoides. In 85.6% of patients, symptoms had not improved since diagnosis and good disease control was only being achieved in 43.4%. At the study visit, pharmacologic treatment was prescribed in 98.3% and allergen immunotherapy was prescribed in 52.2% of patients.

CONCLUSION

When patients with HDM-induced allergic rhinitis are referred to an allergy specialist in Spain, they have moderate-to-severe persistent disease and are generally not achieving good control with symptomatic treatment. Allergen immunotherapy is prescribed in approximately one-half of patients. In this representative sample of Spanish allergy specialists, the level of adherence to clinical guidelines in these patients is encouraging.

No mucosal atrophy and reduced inflammatory cells: active-controlled trial with yearlong fluticasone furoate nasal spray

BACKGROUND

Fluticasone furoate nasal spray (FFNS) and mometasone furoate nasal spray (MFNS) are well tolerated and more effective than placebo at relieving the symptoms of seasonal and perennial allergic rhinitis. Effects of FFNS on the nasal histology have not been previously reported. This study examines the effects of FFNS and MFNS, administered daily for 1 year, on the nasal mucosa in subjects with perennial allergic rhinitis.

METHODS

Subjects with perennial allergic rhinitis were randomized 1:1 to q.d., open-label treatment with FFNS, 110 μg, or MFNS, 200 μg, for 1 year. These groups and a healthy control group that did not receive study medication underwent nasal biopsies at baseline and 12 months.

RESULTS

The nasal biopsy population comprised 96 participants (37 using FFNS, 42 using MFNS, and 17 healthy controls). Epithelial thickness did not change appreciably from baseline to week 52 in any of the groups and mean change from baseline did not differ between FFNS and MFNS (least square mean difference, -0.001 mm, 95% confidence interval, -0.007, 0.006). Although not tested for significance, improvements over baseline were observed in epithelial histology in the FFNS group with more epithelium including intact columnar and ciliated epithelial cells. No appreciable change in the percentage of goblet cells was established. FFNS and MFNS were associated with decreases in epithelial and subepithelial nasal mucosal eosinophils and basophils from baseline to week 52. The percentage of subjects with no inflammatory cells at week 52 was 49 and 33% for eosinophils and 46 and 24% for basophils, for FFNS and MFNS, respectively.

CONCLUSION

Yearlong therapy with either FFNS or MFNS showed no changes in epithelial thickness or the percentage of goblet cells as well as a reduction in inflammatory cell infiltrate. FFNS was associated with improvements in epithelial histology. These data support the long-term safety of FFNS in subjects with perennial allergic rhinitis.

Pathophysiology, favoring factors, and associated disorders in otorhinosinusology

The pathogenesis of rhinosinusitis (RS) is related to inflammation, caused by infections in the acute form of the disease but also by other agents in the chronic forms. Cytology allows to evaluate the defensive components, such as hair cells and muciparous cells, while the presence in the nasal mucosa of eosinophils, mast cells, bacteria and/or fungal hyphae, or spores indicates the nasal pathology. The anatomic and physiologic characteristics of the otorhinosinusal system account for the frequent concomitant involvement of the different components. The pivotal pathophysiologic sites are the ostiomeatal complex, the spheno-ethmoidal recess, and the Eustachian tube. The latter is the link with acute otitis media (AOM), which is the most common disease in infants and children and has major medical, social, and economic effects. Moreover, because of the strict relationship between upper and lower airways, nasal sinus disease may contribute to asthma and sinusitis may be considered as an independent factor associated with frequent severe asthma exacerbations. Concerning the role of allergy, the available data do not permit to attribute a central role to atopy in sinusitis and thus allergy testing should not be a routine procedure, while an allergologic evaluation may be indicated in children with OM, especially when they have concomitant rhinitis.

The burden of allergic rhinitis (AR) in Canada: perspectives of physicians and patients

Background

Allergic rhinitis (AR) is a common problem and we sought to examine the burden of disease and its management in Canada from the perspectives of patients and physicians.

Methods

Two parallel, Canadawide structured telephone interviews surveyed 1,001 AR patients and 160 physicians in July 2006.

Results

44% of patients had experienced nasal symptoms unrelated to a cold and 20% had a physician diagnosis of AR. At screening 27% reported asthma, 15% chronic or recurrent sinusitis and 5% nasal polyps. With attacks nasal congestion and runny nose were the most bothersome symptoms. Other problems experienced were fatigue (46%), poor concentration (32%), and reduced productivity (23%). Most (77%) had not seen a physician in the past year. Physicians estimated they prescribed intranasal cortico steroids (INCS) to most AR patients (77%) consistent with guidelines but only 19% of patients had used one in the last month. Only 48% of patients were very satisfied with their current INCS. 41% of AR patients reported discontinuing their INCS with the most common reason being a perceived lack of long-lasting symptom relief (44%). 52% of patients felt that their current INCS lost effectiveness over 24 h. The most common INCS side effects included dripping down the throat, bad taste, and dryness. Most AR patients reported lifestyle limitations despite treatment (66%). 61% of patients felt that their symptoms were only somewhat controlled or poorly/not controlled during their worst month in the past year.

Conclusions

AR symptoms are common and many patients experience inadequate control. Physicians report they commonly prescribe intranasal corticosteroids, but patient’s perceived loss of efficacy and side effects lead to their discontinuation. Persistent relief of allergic rhinitis symptoms remains a major unmet need. Better treatments and education are required.

Predictive capabilities of serum eosinophil cationic protein, percentage of eosinophils and total immunoglobulin E in allergic rhinitis without bronchial asthma

This study identified cut-off values for allergy markers for use in the diagnosis of allergic rhinitis in the absence of other allergic diseases. Total immunoglobulin E (IgE), eosinophil cationic protein (ECP) and the numbers of eosinophils were measured in serum samples from 442 patients with typical symptoms of allergic rhinitis. A definite diagnosis was made on the basis of the presence of specific IgE levels. Cut-off values with a maximal discrimination to diagnose allergic rhinitis were found to be 98.7 IU/ml, 24.7 μg/ml and 4.0% for total IgE, ECP and eosinophils, respectively. Sensitivity, specificity and odds ratio for these values were 75.2%, 69.7% and 6.93, respectively, for total IgE, 55.7%, 74.4% and 3.70 for ECP, and 57.5%, 72.0% and 3.47 for eosinophils. A composite score representing positive results for all three markers had a positive predictive value of 85.3%, with an odds ratio of 8.55. It was concluded that total serum IgE, ECP and eosinophil percentage are strong predictors of allergic rhinitis and the determination of cut-off values for these markers can aid in the diagnosis of allergic rhinitis in the clinical setting.

Two-year results: transantral balloon dilation of the ethmoid infundibulum

BACKGROUND

Multiple prospective and retrospective studies have reported results from balloon-only procedures and hybrid balloon sinus surgeries through intermediate follow-up periods of up to 1 year. Long-term durability results beyond 2 years are limited.

METHODS

One-year results from the original study of standalone transantral balloon dilation in patients with computed tomography (CT) evidence of chronic inflammation in the maxillary sinuses alone or maxillary and anterior ethmoid sinuses combined were previously reported. Revision rate, symptom improvement, and productivity improvement were prospectively evaluated after a minimum follow-up of 2 years.

RESULTS

Fifty-nine patients (107 maxillary ostia) underwent balloon dilation of the maxillary sinus outflow tract and completed postprocedure follow-up assessment at 27.0 ± 3.6 months. Patient 20-item Sino-Nasal Outcome Test (SNOT-20) score improved from 2.65 ± 0.97 at baseline to 0.79 ± 0.71 at long-term follow-up (p < 0.0001). Improvement in work productivity and activity due to sinus-related health issues for all patients was statistically significant across all survey instrument characteristics (p range, <0.0001 to 0.02). An analysis of the outcomes in a subgroup of patients with maxillary and anterior ethmoid disease (20; 34%) showed similar significant improvement in symptoms (SNOT-20 decrease = -2.1; p < 0.0001). Approximately 92% of all patients reported satisfaction with the balloon procedure. Four (6.8%) patients underwent revision sinus surgery at 11.1 ± 7.3 months after treatment.

CONCLUSION

Patients with chronic rhinosinusitis and radiographic evidence of isolated maxillary disease with or without anterior ethmoid disease have reported clinically meaningful and statistically significant improvement in symptoms, productivity, and activity through a minimum of 2 years following standalone balloon dilation.

The burden of allergic rhinitis and asthma

Asthma and allergic rhinitis are common health problems that cause major illness and disability worldwide. The prevalence of allergic rhinitis is estimated to range from 10% to 20% in the USA and Europe. Multiple factors contribute to the wide range of reported prevalence rates. These include type of prevalence rate reported (current or cumulative), study selection criteria, age of participants, differences in survey methods, varied geographic locations and socioeconomic status, any of which are significant enough to confound direct comparison between studies. There is no standard set of diagnostic criteria for allergic rhinitis. In most studies, the criteria for diagnosis are based on the subject's reporting, solely by questionnaire and rarely confirmed by skin testing. In addition, most studies focus on hay fever, leaving perennial allergic rhinitis underestimated. Sinus imaging is generally not performed and, therefore, rhinosinusitis not differentiated. Some investigators report 'current' prevalence while others report 'cumulative' or 'lifetime' prevalence. Epidemiologic studies have consistently shown that asthma and rhinitis often coexist in the same patients. The prevalence of asthma is <2% in subjects without rhinitis while it varies from 10% to 40% in patients with rhinitis. Furthermore, the majority of patients with asthma experience rhinitis, which is a factor in the risk for asthma. Despite recognition that allergic rhinitis and asthma are global health problems, there are insufficient epidemiologic data and more data are needed with regard to their etiologic risk factors and natural history. This aim of this review is to enable the reader to discuss prevalence, risk factors and prognosis of allergic rhinitis and asthma.

Association between maternal allergic rhinitis and asthma on the prevalence of atopic disease in offspring

BACKGROUND

Asthma is a common co-morbidity of allergic rhinitis (AR). The prevalence of these two allergic diseases has increased in China and has been shown to cluster in families independently. This study evaluated the association between maternal AR (presenting with or without asthma) and the allergic conditions in offspring.

METHODS

Women (n = 592) diagnosed with AR were recruited for this study; 379 patients presented with AR and 213 presented with both AR and asthma. Total serum IgE levels and nasal eosinophil counts were analyzed and correlated with disease presentation.

RESULTS

The prevalence of allergic conditions in offspring of mothers diagnosed with AR and asthma was significantly higher than the prevalence observed in children born to mothers presenting with AR only. Maternal total serum IgE and eosinophil counts were predictive of atopy in offspring. Children born to mothers presenting with persistent moderate-to-severe AR had the highest risk of developing atopic conditions (OR 6.26, 95% CI 3.26-12.02). Maternal age of 25-30 years at delivery was also associated with a higher risk for the allergic disease in offspring compared to maternal age of 36-40 (OR 2.13, 95% CI 1.31-3.47).

CONCLUSIONS

The severity of maternal AR, asthma co-morbidity, elevated serum IgE levels and nasal eosinophilia were all associated with an increased risk of offspring developing allergic conditions. Children born to older mothers were protected against developing atopic disease.

A review of the use of fluticasone furoate since its launch

INTRODUCTION

Fluticasone furoate (FF) is the latest glucocorticoid officially approved for the treatment of allergic rhinitis. FF has shown the highest affinity and selectivity for the glucocorticoid receptors as well the longest tissue retention compared with other available intranasal steroids; these new pharmacologic characteristics provide the basis for its potent and prolonged anti-inflammatory activity at the target site.

AREAS COVERED

A literature review achieved through PubMed and Medline research methods supports the clinical efficacy of FF versus placebo in reducing ocular and nasal symptoms related to allergic rhinitis (at the recommended starting doses of 110 μg once daily for adults and adolescents and 55 μg once daily for children), with a good safety profile. Moreover, the present review also compares FF with other intranasal steroids: FF represents a molecular evolution of fluticasone propionate (FP), and there is scientific evidence of therapeutic advantages over FP.

EXPERT OPINION

Fluticasone furoate is a promising molecule in the treatment of allergic rhinitis as it fits fully all the official guidelines' criteria. It is now being considered as a topical steroid that is quite close to the ideal pharmacological model for glucocorticoids due to its satisfying safety/tolerability profile, both in adults and children, leads FF to be considered as a topical steroid that is quite close to the ideal pharmacologic model for glucocorticoids. More studies should be directed to assess the improvement of quality of life in subjects with allergic rhinitis treated with FF, in comparison with other intranasal steroids and even H1-antihistamines; in addition, it could be also interesting to analyze eventual, additional effects of FF in patients with bronchial asthma, which is frequently associated with allergic rhinitis.

Skin prick test reactivity to common aeroallergens and ARIA classification of allergic rhinitis in patients of Central Greece

Allergic rhinitis (AR) is prevalent in Mediterranean countries, but there are no epidemiological studies in the Hellenic milieu in accordance with the recent ARIA guidelines. We investigated aetiological aeroallergens in AR patients of Central Greece using the ARIA classification. Between 2002 and 2006, 911 patients with rhinitis symptomatology were interviewed and underwent Skin prick testing and 623 completed the study. Seasonal rhinitis (SAR) represented 37.6%, Perennial rhinitis (PAR) 46.4% and SAR + PAR 16%. Intermittent mild and moderate/severe AR was evident in 9.3 and 24.5%, persistent mild and moderate/severe in 23.2 and 43.0%. Persistent AR appeared in overall 66.2% of patients and was prevalent in PAR and SAR + PAR (p < 0.0001). Severity of AR symptoms did not correlate more with ARIA than with the traditional subgroups. Marked statistical (p < 0.05) differences were evident for seven aeroallergens between the four geographic areas of the study. Pollen allergy was found in 77.8% but all pollens were significantly lower in coastal areas (p < 0.001), besides Parietaria (p < 0.003). Mite sensitivity manifested in 43.2%. Alternaria affected mostly the paediatric population (p < 0.0001). 12.4% (N = 77) was monosensitive, 58.7% (N = 366) oligosensitive, and 28.9% (N = 180) polysensitive. Rhinitis and asthma comorbidity was high (45.3%) and occurrence of asthma was related with PAR (p < 0.007) and SAR + PAR (p < 0.023) but not with the ARIA classification subgroups. This study provides compelling evidence of a typical Mediterranean allergic profile of patients of Central Greece with significant regional variability. Both classifications had approximately equal diagnostic value in our study besides the fact that ARIA subdivision is considered superior in determining treatment.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses

In this review, anatomy and physiology of the respiratory mucosa of nose and paranasal sinuses are summarized under the aspect of its clinical significance. Basics of endonasal cleaning including mucociliary clearance and nasal reflexes, as well as defence mechanisms are explained. Physiological wound healing, aspects of endonasal topical medical therapy and typical diagnostic procedures to evaluate the respiratory functions are presented. Finally, the pathophysiologies of different subtypes of non-allergic rhinitis are outlined together with treatment recommendations.

Impact of chronic rhinosinusitis on work productivity through one-year follow-up after balloon dilation of the ethmoid infundibulum

BACKGROUND

Although multiple clinical trials have demonstrated that balloon dilation of sinus ostia in patients diagnosed with chronic rhinosinusitis (CRS) results in sustained symptomatic improvement, less data are available to measure the effects of sinusitis on worker productivity. The objective of our research was to analyze work and activity impairment before and after transantral, endoscopically-guided balloon dilation of the maxillary sinus ostia and ethmoid infundibulum.

METHODS

Subjects diagnosed with CRS and computed tomography (CT) evidence of disease in the maxillary sinuses alone, or maxillary and anterior ethmoid sinuses, completed the Work Productivity and Activity Impairment (WPAI) questionnaire and the Work Limitation Questionnaire (WLQ) before treatment and at 3, 6, and 12 months postprocedure.

RESULTS

A total of 56 subjects were enrolled and 53 completed the 1-year follow-up. The lost productivity composite score computed from the WLQ improved by 73% (9.0 to 2.4; p < 0.0001) at 1-year follow-up whereas lost productivity at work as measured by the WPAI improved by approximately 76% (38.3 to 9.2; p < 0.0001) 12 months after treatment.

CONCLUSION

These results indicate that sinus-related health problems impose a substantial burden on work productivity and physical/mental activity levels. Treatment of CRS by dilating the maxillary sinus ostium and ethmoid infundibulum can significantly improve quality of life (QOL) and work productivity.

Acoustic rhinometry, spirometry and nitric oxide in relation to airway allergy and smoking habits in an adolescent cohort

OBJECTIVE

This study aimed to analyze upper and lower airway function and the impact of smoking habits in a cohort of allergic and healthy adolescents. The influence of smoking habits on the outcomes of rhinitis and asthma is well documented, but only few reports are available showing smoke related upper airway impairment by rhinometric measurements, and none with focus on early changes in adolescents.

METHODS

A cohort followed from infancy was re-examined at the age of 18 years concerning allergy development. Acoustic rhinometry (VOL2), spirometry (FEV(1)) and measurements of nitric oxide levels from the upper (nNO) and lower airways (eNO) were performed before and after physical exercise, and smoking habits were registered.

RESULTS

Active smoking habits were reported by 4/21 subjects suffering from allergic rhinitis, by 1/4 from probable allergic rhinitis, by 0/3 subjects with atopic dermatitis and by 2/10 healthy controls. Smoking habits were reported as daily by 2 and occasional by 5 of the 7 active smokers. VOL2 did not increase in smokers after exercise as in non-smokers, resulting in a post-exercise group difference (7.3±1.1cm(3) vs. 8.8±1.5cm(3); p=0.02), and FEV(1) values were lower in smokers compared to non-smokers (89±7% vs. 98±8%; p=0.02). The nNO and eNO levels were, however, only slightly reduced in smokers. Airway allergy was discerned only in subjects with current allergen exposure by increased eNO levels compared to healthy controls (41±44ppb vs. 13±5ppb). The levels of VOL2, nNO and FEV(1) did not differentiate allergic subjects from healthy controls.

CONCLUSIONS

Low levels of tobacco smoke exposure resulted in reduced airway functions in this adolescent cohort. Acoustic rhinometry and spirometry were found to be more sensitive methods compared to nitric oxide measurements in early detection of airway impairment related to smoke exposure. A possible difference in airway vulnerability between allergic and healthy subjects due to smoke exposure remains to be evaluated in larger study groups.

Antioxidant status and immune activity of glycyrrhizin in allergic rhinitis mice

Oxidative stress is considered as a major risk factor that contributes to increased lipid peroxidation and declined antioxidants in some degenerative diseases. Glycyrrhizin is widely used to cure allergic diseases due to its medicinal properties. In the present study, we evaluated the role of glycyrrhizin on lipid peroxidation and antioxidant status in the blood and nasal mucosa of allergic rhinitis (AR) mice. Mice were divided into six groups: normal control mice, model control (MC) mice, three glycyrrhizin-treated mice groups and lycopene-treated mice. Sensitization-associated increase in lipid peroxidation was observed in the blood and nasal mucosa of MC mice. Activities of antioxidant enzymes like superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px), total antioxidant capacity (TAOC) and levels of glutathione (GSH) were found to be significantly decreased in the blood and nasal mucosa in MC mice when compared to normal control mice. However, normalized lipid peroxidation and antioxidant defenses were reported in the glycyrrhizin-treated and lycopene-treated mice. Moreover, glycyrrhizin treatment still enhanced IFN-γ and reduced IL-4 levels in glycyrrhizin-treated mice. These findings demonstrated that glycyrrhizin treatment enhanced the antioxidant status and decreased the incidence of free radical-induced lipid peroxidation and improved immunity activities in the blood and nasal mucosa of AR mice.