Links between bronchial asthma and allergic rhinitis in the Oita Prefecture, Japan

Coexistence of allergic rhinitis and asthma in Indian patients: The CARAS survey

Context

Asthma patients often suffer from concomitant allergic rhinitis (AR). However, there is paucity of such data from India.

Aims

This questionnaire-based survey evaluated the coexistence of AR in Indian asthmatics, and examined the inter-relationship between the two disease conditions.

Subjects and Methods

This survey conducted in ten cities across India, aimed to generate information on exposure to risk factors, history of atopy, the severity of asthma, and treatment regimen in patients with physician-diagnosed asthma.

Results

Data were obtained from 1161 asthma patients (mean age [±standard deviation]: 40.41 [±17.05] years). Prevalence of coexisting AR was found to be 65.24%, with the highest prevalence (80%) in the southern regions of India. Sneezing (71.78%) followed by watery, runny nose (63.59%) were the most common AR symptoms. Majority (72.32%) of the patients had seasonal AR. Coexistence of AR and asthma was significantly associated with the presence of personal and family history of atopy (odds ratio 2.53 and 1.51 respectively; both P < 0.005). Passive smoking, exposure to biomass fuel, and the presence of pets and animals at home were also significantly (P < 0.005) associated with AR-asthma coexistence. Prevalence of AR was found to increase with increasing asthma severity. The usage of oral steroids was significantly higher in patients with coexistent AR-asthma. Sixty-six percent of the patients with coexistent AR-asthma were prescribed intranasal corticosteroids.

Conclusions

The results of the Coexistence of Allergic Rhinitis and ASthma (CARAS) survey highlight the high prevalence of concomitant AR in Indian patients with asthma, and reinforce the need for early diagnosis and guideline-based management of AR in patients with asthma.

The impact of co-existing seasonal allergic rhinitis caused by Japanese Cedar Pollinosis (SAR-JCP) upon asthma control status

BACKGROUND

Seasonal Allergic Rhinitis Caused by Japanese Cedar Pollinosis (SAR-JCP) is a most common allergic rhinitis, affecting about 40% in Japan, but the influence from SAR-JCP upon asthma is controversial. The purpose of this study is to investigate the effect of coexistence of SAR-JCP upon control status of asthma using SACRA (Self-Assessment of Allergic Rhinitis and Asthma Questionnaire).

METHODS

The design was prospective, single-center, observational study. Asthmatic patients were classified into 3 groups, patients without rhinitis, those with perennial rhinitis or those with SAR-JCP from the results of SACRA. The control status of asthma were evaluated by Visual Analog Scale (VAS) in SACRA and Asthma Control Test (ACT) score. They were evaluated twice, from September to January (nonpollen-season) and February to April (pollen-season) and compared.

RESULTS

451 patients were enrolled and 325 cases (72%) were diagnosed as having comorbidity of rhinitis, among which 173 with only perennial rhinitis, while 152 with SAR-JCP. There was no significant difference in asthma control level measured by VAS and ACT score among 3 groups during nonpollen-season. The asthma control level measured by VAS (1.91-2.95) and ACT score (22.7-21.6) got worse during pollen-season among patients with SAR-JCP, even though 84% received treatment for rhinitis. Although it differed according to criteria, asthma control during pollen-season was impaired in 18-38% asthmatic patients with SAR-JCP.

CONCLUSION

It is possible to minimize the influence of AR on asthma control by obtaining an accurate diagnosis and providing sufficient treatment for rhinitis.

Does allergic rhinitis make a difference to the respiratory resistance and reactance of asthma?

BACKGROUND

Concomitant allergic rhinitis (AR) in asthmatic patients can contribute to increased asthma exacerbations and poorer symptom control. A recent study indicated that impulse oscillometry is a more sensitive measure of change in airway function than spirometry, but this has not been used to compare asthmatic patients with or without AR.

OBJECTIVE

We used impulse oscillometry (Mostgraph-01) to examine the impact of AR on asthma.

METHODS

Impulse oscillometry and spirometry were assessed in 50 patients with asthma only and 95 patients with asthma and AR.

RESULTS

Mean age in the asthma only group was significantly higher than in the asthma with AR group. Therefore, analysis of covariance adjusted for age was used to compare between these two groups. Percentage of mean forced expiratory volume in 1 s (FEV1), respiratory resistance at 5 Hz (R5) minus respiratory resistance at 20 Hz (R20), and resonant frequency (Fres) in the asthma with AR group were significantly less severe than in the asthma only group. Parameters of resistance and reactance were correlated with age and body mass index only in the asthma with AR group but not in the asthma only group. Correlations were observed between rate of change of maximum mid-expiratory flow and impulse oscillometry values of R5 and Fres in the asthma only group, but not between the rate of change of FEV1 and impulse oscillometry values.

CONCLUSION

Asthma with AR was associated with higher lung function and better values of resistance and reactance than asthma only.

Comparison of leukotriene receptor antagonists and anti-histamines as an add-on therapy in patients with asthma complicated by allergic rhinitis

Patients with asthma are often complicated by allergic rhinitis, and the intimate pathophysiological association between allergic rhinitis and asthma often imposes a significant morbidity on affected individuals. The present study was conducted to assess the clinical efficacies of leukotriene receptor antagonists (LTRAs) and anti-histamines on asthma as an add-on therapy in patients with asthma complicated by allergic rhinitis. Consecutive patients with asthma were recruited to fill in systematic self-administered questionnaires concerning symptoms and conditions related to asthma and allergic rhinitis. The questionnaire was conducted twice, one month apart, and the attending physicians gave detailed information on disease control and medications on both occasions. In the study 3,140 patients with asthma participated, and 634 had concomitant allergic rhinitis (mean age: 53.1, 389 female). The second survey disclosed that treatment with LTRAs or anti-histamines had been added in 26 patients and 19 patients, respectively, without any changes in other medications. There were no significant differences in age, gender, severity of disease, or baseline treatments. The initial survey indicated that the patients who were treated with LTRAs had significantly more severe asthma-related symptoms (i.e. wheeze, cough and sleep disturbance) and experienced greater dissatisfaction with the treatment than did those who were treated with anti-histamines. The second survey disclosed significant reductions in sneezing (p=0.03), rhinorrhea (p=0.01), dyspnea (p=0.046), sleep disturbance (p=0.02), over-all asthma symptoms (p=0.013), and an improvement in satisfaction with treatment (p=0.019) in patients to whom LTRAs were added-on, whereas the patients receiving anti-histamines reported no significant changes in these symptoms. These results suggest that LTRAs are more effective than anti-histamines as an add-on therapy in symptomatic patients with asthma complicated by allergic rhinitis.

Allergic rhinitis in northern vietnam: increased risk of urban living according to a large population survey

BACKGROUND

Little is known about prevalence and risk factors of allergic rhinitis and chronic nasal symptoms among adults in Vietnam. We aimed to estimate the prevalence, risk factor patterns and co-morbidities of allergic rhinitis and chronic nasal symptoms in one urban and one rural area in northern Vietnam.

METHODS

A cross-sectional questionnaire survey was conducted from August 2007 to January 2008 in urban Hoankiem and rural Bavi in Hanoi among adults aged 21-70 years. Of 7008 randomly selected subjects, 91.7% participated in Bavi and 70.3% in Hoankiem.

RESULTS

Allergic rhinitis ever or chronic nasal symptoms were reported by 50.2%. The prevalence of allergic rhinitis ever was considerably higher in Hoankiem compared to Bavi, 29.6% vs 10.0% (p < 0.001). Allergic rhinitis ever and chronic nasal symptoms were both significantly associated with asthma and respiratory symptoms, respectively (p < 0.001). Exposure to gas, dust or fumes at work was significantly associated with allergic rhinitis ever, OR 1.57 (95% CI 1.34 - 1.84), nasal blocking, OR 1.90 (95% CI 1.68 - 2.15) and runny nose, OR 1.32 (95% CI 1.17 - 1.49), while somewhat surprisingly no association with smoking was found. Female sex was a significant risk factor for both nasal blocking and runny nose.

CONCLUSIONS

Allergic rhinitis ever was considerably more common in the urban area. Nasal blocking and runny nose was each reported by about one third of the studied sample with no major urban-rural difference. Further, exposure to air pollution at work was significantly associated with allergic rhinitis ever, nasal blocking and runny nose.

Allergic rhinitis: an update on disease, present treatments and future prospects

Allergic rhinitis (AR) is an inflammation of nasal mucosa mediated by IgE-associated processes occurring independently, or concurrently with asthma. AR is characterized by sensitization-formation and expression of antigen specific IgE, followed by inflammation in two phases. The early phase response involves cross linking of IgE molecules leading to degranulation of mast cells and release of preformed mediators such as histamine and tryptase, or newly synthesized mediators such as prostaglandins and leukotrienes. The late phase response is predominated by the presence of eosinophils, lymphocytes, cytokines, and adhesion molecules. Newer insights reveal that the whole phenomenon of immunological inflammation is intricately knit with neural pathways, which strongly influence the process. Furthermore, AR can impact psychological health and vice versa. Classical pharmacotherapy of AR includes use of oral or topical antihistamines, oral antileukotrienes, topical corticosteroids, mast cell stabilizers, decongestants, and an anticholinergic agent. Among immunomodulatory treatments, immunotherapy is gaining widespread use, while antibody treatment is restricted mainly to resistant cases. Several small molecules with improved safety profile, or targeting novel mechanisms are in the clinical research. Newer antihistamines and corticosteroids with improved safety profile and antagonists of the prostaglandin D(2) (CRTH2) receptors are likely to be available for clinical use in the near future. Lack of properly validated animal models and complexities associated with clinical evaluation are some of the challenges facing the researchers in AR. Comprehensive understanding of immunological and neurological processes in AR would facilitate the future quest for more effective and safer management of this disease.

A survey of allergic rhinitis in Taiwanese asthma patients

BACKGROUND

Allergic rhinitis (AR) often coexists with and can significantly worsen bronchial asthma (BA). We evaluated the proportion of patients with BA and concomitant AR (BA+AR) diagnosed and treated in an average clinical practice.

METHODS

A cross-sectional study methodology was used to determine the prevalence of AR in patients more than 15 years of age with a documented history of asthma who experienced wheezing during the prior 12 months. The International Study of Asthma and Allergies in Childhood standardized written questionnaire was used and therapeutic class choices were recorded.

RESULTS

Among 750 surveyed asthma patients, 524 patients (69.9%) experienced AR. Of those with BA and AR, there were 44 patients (8.4%) who were not diagnosed with AR, and the treatment rate for AR was 62.1%. The most frequent severity level of BA and AR were moderate persistent (38.9%) and intermittent mild (52.5%), respectively. There were no significant differences between patients with AR and without AR.

CONCLUSIONS

The prevalence of AR in patients with asthma was 69.9% in this study. Despite Allergic Rhinitis and its Impact on Asthma guideline recommendations encouraging evaluation and treatment of AR among asthmatics, nearly 8.4% of asthmatics with AR were undiagnosed, and 37.9% of asthmatics with AR were untreated for AR.

[Prevalence and characteristics of rhinitis in adult asthmatic patients attending allergist, primary care and pulmonologist settings in Spain (AIR study)]

BACKGROUND AND OBJECTIVES

Rhinitis and asthma are linked by common epidemiological, clinical and inflammatory features. The objective of the AIR study was to understand the prevalence and characteristics of rhinitis in adult asthmatic patients who were seen in either primary or secondary care (Allergy or Pulmonology) in Spain.

PATIENTS AND METHODS

This was a prospective epidemiological study with the participation of 1,369 randomly selected physicians. Five thousand six hundred sixteen asthmatic patients older than 18 years of age were selected and the study was carried out between February-September 2006. Demographic data, rhinitis prevalence, pulmonary function, allergy tests and treatments were analyzed.

RESULTS

Some 75% (N=4,212) of the asthmatic patients presented with additional rhinitis and these were characterised as being both younger (41.3 vs 50.4 years; p<0.0001) and with less severe asthma (FEV(1)=86.6 vs 79.3%, p<0.0001) than asthmatic patients without rhinitis. A positive correlation was found between asthma and rhinitis severity (p<0.0001) whilst atopy was significantly associated with the presence of rhinitis (81 vs 48%; OR: 4.80; CI 95%: 4.2-5.5). The presence of co-morbid rhinitis was associated with a higher number of asthma exacerbations (p<0.001).

CONCLUSIONS

Some 75% of our asthmatic patients had associated rhinitis and this association was more frequent in atopic subjects. There is a positive correlation between the severity of rhinitis and asthma and between the number of asthma exacerbations and the presence of rhinitis. These results support the main message of ARIA and GEMA recommendations regarding the integral management of airways to improve the control of asthma.

The relationship between asthma and allergic rhinitis in the Iraqi population

BACKGROUND

Recently, extensive research has established that epidemiologic and therapeutic links exist between allergic rhinitis and asthma. The objective of this study was to clarify this association in Iraq.

METHODS

The data included in this study were collected from five surveys for asthma and allergic rhinitis that were performed during the period from September 2000 to July 2008. These surveys were parts of Tikrit University College of Medicine PHC program.

RESULTS

The frequency of allergic rhinitis (AR) was 61.6% among individuals with asthma versus 6% among non-asthmatic (control) subjects (Odd Ratio [OR] = 25.5; P < 0.0001). All studies indicated a significant frequency of AR among asthmatic patients in comparison with non-asthmatic subjects, whether the patients were adults or children (OR for adults = 14.9 and 22.5, for children 34.7 and 48.4; P < 0.001 for all). Furthermore, the high frequency of AR in asthmatic patients was seen whether the study was a community based study (CBS)(OR = 14.9 and 48.4; P < 0.0001) or a hospital based study (HBS)(OR = 22.5 & 34.7; P < 0.0001). The frequency of current asthma was 51.8% among individuals with AR versus 5.4% among control subjects (OR = 23.1; P < 0.0001).

CONCLUSIONS

This study provided evidence that AR and asthma are strongly associated with each other and the treatment approach should consider the entire airway rather than only a part.

Impact of nasal condition on self-assessed disease control and treatment satisfaction in patients with asthma complicated by allergic rhinitis

BACKGROUND

Bodies of evidences have suggested that upper and lower airways are intricately interconnected with each other in patients with allergic airways diseases, however, few data are available concerning the impact of allergic rhinitis on self-assessed asthma condition and treatment satisfaction. The present study was conducted to clarify the association between nasal condition and self-assessment of asthma control and treatment satisfaction.

METHODS

Adult patients with asthma were consecutively recruited for a systematic self-administered questionnaire to obtain information on nasal condition, self-perceived condition of asthma, and asthma treatment satisfaction.

RESULTS

3,140 adult patients with asthma completed the questionnaire, and of these 634 patients (mean age:53.1, 389 female) had physician-diagnosed allergic rhinitis. There were significant correlations between nasal symptoms (sneeze, rhinorrhea, nasal obstruction) and self-perceived asthma condition (limited daily activity, wheeze, dyspnea/chest tightness, cough, sputum, sleep disturbance, overall asthma condition). Patients who considered their overall nasal condition as unfavorable or bad were more likely than those who considered their condition as good or favorable to be dissatisfied with asthma treatment (p<0.01).

CONCLUSIONS

Nasal condition is closely associated with self-assessed asthma condition and asthma treatment satisfaction. Controlling allergic rhinitis is critical to attain optimal management of asthma in patients complicated by allergic rhinitis.

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.