Association between nasal and bronchial symptoms in subjects with persistent allergic rhinitis

Environmental allergen reduction in asthma management: an overview

Asthma is a prevalent non-communicable disease that affects both children and adults. Many patients with severe, uncontrolled asthma could not achieve total control despite using anti-asthmatic drugs. There is increasing evidence that allergy to environmental allergens, including both indoor and outdoor allergens, is associated with asthma symptoms and severe asthma. Frequently reported sensitized allergens were dust mites, cockroaches, grass pollens, molds, pets, and rodents in allergic asthma patients, although the patterns of widespread allergens differed from each country. Allergen avoidance is the cornerstone of asthma management, especially in sensitized subjects. This review summarizes environmental allergen avoidance and clarifies their effects on asthma control. Despite contrasting results about the impact of allergen exposure reduction on asthma control, several studies supported the beneficial effects of reducing asthma-related symptoms or risk of exacerbations as a nondrug therapy. Identifying environmental allergens is helpful for asthma patients, and further studies on clinically effective avoidance methods are required.

Exhaled and Nasal Nitric Oxide - Impact for Allergic Rhinitis

FeNO measurement is a validated non-invasive technique, which is used for diagnosis and monitoring of asthma. It would be desirable to find a reliable method to monitor allergic rhinitis (AR) via measurement of FeNO, and/or nasal nitric oxide (nNO). The aim of our study was the assessment of the efficacy of FeNO and nNO as markers in AR treatment. FeNO and nNO were measured with the portable NO analyser (NIOX MINO®) in healthy participants and in patients with AR. The patients were examined during the pollen season and out of it. The effect of local corticosteroids and antihistamine therapy was observed in patients with AR during pollen season after three weeks of therapy. There are significant differences between FeNO and nNO in patients with AR compared to healthy controls at all set points of measurements. While FeNO responded well to the treatment with both antihistamines and combined therapy, nNO decreased only after combined therapy with antihistamines and nasal corticosteroids. nNO monitoring alone is not a suitable method to monitor inflammation of the upper airways in AR and its suppression by anti-allergic treatment and should be correlated with other markers as FeNO or symptom scores.

Involvement of T-Helper 9 Activation in a Mouse Model of Allergic Rhinitis

Background

We aimed to investigate the role of T-Helper (TH) 9 cells in the pathogenesis of allergic rhinitis (AR) in mice.

Material/Methods

An AR model was produced in BALB/c mice, and the viral encoding interleukin (IL)-9 silencing sequence was used to reduce IL-9 expression. The experiment was divided into a control group, an AR group, an IL-9 shRNA+AR group, and a vector+AR group. Hematoxylin and eosin (H&E) staining was used to detect pathological changes. The cytokine expression was detected by ELISA method. Cellular typing was detected by flow cytometry.

Results

Cells in the control group were regularly arranged, with clear layers and no congestion, edema, or necrosis observable. By contrast, in the AR model group and the vector treatment group, nasal mucosa showed clear hyperemia and edema in upper tissues and infiltration of inflammatory cells, which were ameliorated by IL-9 silencing. Compared with the control group, interferon-γ (IFN-γ) was significantly down-regulated, while IL-4, IL-17, and IL-9 were significantly elevated in the AR model group. TH1 cells in nasal mucosa, lymph, nasal lavage, spleen, and peripheral blood were significantly reduced, while TH2, TH9, TH17, and Treg cells were significantly elevated in the AR group compared with the control group. Importantly, all these changes in AR model were ameliorated by IL-9 silencing.

Conclusions

AR is related to the changes of cytokines in TH1, TH2, TH9, TH17, and Treg, which are improved by IL-9 silencing. Activation of TH9 cells is involved in the pathogenesis of AR.

Does Nitrogen Dioxide Affect Inflammatory Markers after Nasal Allergen Challenge?

Background

Exposure to high ambient levels of nitrogen dioxide (NO2) enhances the bronchial inflammatory reaction to allergen in humans. We tested whether this NO2 effect occurs also in the upper airways.

Methods

Sixteen allergic subjects with rhinitis and mild asthma were exposed at rest to either purified air or 500 μg/m3 NO2 for 30 minutes, followed 4 hours later by a nasal allergen challenge. Nasal lavage was performed before air/NO2 exposure, before allergen challenge, and 1, 4 and 18 hours after allergen challenge. Symptoms were recorded.

Results

The percentage of eosinophils and neutrophils, eosinophil cationic protein, and myeloperoxidase were similar after exposure to air + allergen and to NO2 + allergen. We noticed a tendency to increased sneezing the day after exposure to NO2 + allergen.

Conclusion

The priming effect of an ambient brief NO2 exposure on subsequent allergic response was not noticeable in activation of inflammatory cells and mediators in the upper airways.

Indoor and Outdoor Allergies

In last 30 to 40 years there has been a significant increase in the incidence of allergy. This increase cannot be explained by genetic factors alone. Increasing air pollution and its interaction with biological allergens along with changing lifestyles are contributing factors. Dust mites, molds, and animal allergens contribute to most of the sensitization in the indoor setting. Tree and grass pollens are the leading allergens in the outdoor setting. Worsening air pollution and increasing particulate matter worsen allergy symptoms and associated morbidity. Cross-sensitization of allergens is common. Treatment involves avoidance of allergens, modifying lifestyle, medical treatment, and immunotherapy.

Allergic Rhinitis: A neglected disease - A community based assessment among adults in Delhi

BACKGROUND AND OBJECTIVES

Allergic Rhinitis is rather erroneously viewed as a trivial disease. It is important in that it can significantly affect quality of life. There is paucity of community based prevalence studies on the disease in India. This study was planned to assess the prevalence of allergic rhinitis in adults, the proportion of asthmatics among them, risk factors associated and treatment seeking behaviour among the patients.

MATERIALS AND METHODS

A community based cross sectional study was conducted in Mehrauli, South Delhi among 1200 adults, aged 30 years and over selected by systematic random sampling from two randomly selected wards. A pre-tested questionnaire was used to collect information regarding symptoms, risk factors and treatment seeking behaviour. Allergic Rhinitis was diagnosed as per ARIA guidelines. Spirometry was done to diagnose asthma among them. Multivariate logistic regression analysis was done to find the association of risk factors with disease.

RESULTS

The prevalence of Allergic Rhinitis was found to be 11% (132 subjects) and 33.3% (44 patients) among them also had asthma. Overcrowding (aOR = 6.4), absence of cross-ventilation (aOR = 2.5), occupational exposure to dust/ smoke (aOR = 2.1), tobacco smoking (aOR = 2.1), family history of allergic diseases (aOR = 2.7) and clinical allergy (aOR = 10.2) were found to be independent risk factors associated with Rhinitis. More patients of Rhinitis with asthma (75%) took treatment, relative to those without asthma (40%) who, mostly relied on home remedies (42%) or, did not seek any treatment (18%) (P = 0.031). Interpretations and Conclusion: The burden of Allergic Rhinitis is high with a considerable overlap with asthma. These allergic diseases and emphasize the importance of early and regular treatment.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lung functions of Japanese patients with chronic rhinosinusitis who underwent endoscopic sinus surgery

BACKGROUND

Chronic rhinosinusitis (CRS), which is clinically classified into CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP), shows considerable geographic differences and heterogeneity. Eosinophilic (E) CRS with nasal polyps (ECRSwNP) has a higher degree of disease severity and higher frequency of comorbid asthma. Epidemiologic studies in different ethnic populations have improved understanding of the pathophysiology of the disease. Here we report the clinical characteristics of Japanese patients with medically refractory CRS undergoing endoscopic sinus surgery (ESS).

METHODS

We recruited a total of 210 CRS patients and assessed them by nasal endoscopy, the Lund-Mackay score using computed tomography (CT), peripheral eosinophilia and smoking status. We also examined the comorbidity of asthma, effects of age and lung functions in the patients.

RESULTS

In this study, 13% of CRSwNP patients and 20% of CRSwNP patients with peripheral blood eosinophilia exhibited obstructive lung dysfunction (FEV1/FVC <70%) despite the absence of an asthma diagnosis. Among elderly nonsmoker patients (≥ 60 years) who had never been diagnosed with asthma, 50% of CRSwNP patients with peripheral blood eosinophilia showed decreased FEV1/FVC <70%.

CONCLUSIONS

Our findings suggest that asthma is under-diagnosed in CRS patients who undergo ESS, especially the elderly. Although the association between CRS and asthma has been recognized, increased attention to the comorbidity of obstructive airway diseases such as asthma is still needed for management of medically refractory CRS.

Poor asthma control?--then look up the nose. The importance of co-morbid rhinitis in patients with asthma

Many factors can impair asthma control. One which is frequently overlooked is rhinitis. Asthma patients with significant rhinitis are over four times more likely to have poorly controlled asthma than those without. Over 80% of patients with asthma have rhinitis, which may be allergic or inflammatory/non-allergic. Both types of rhinitis share pathophysiological similarities with eosinophilic asthma, cause bronchial hyper-reactivity, and are predisposing factors for the subsequent development of asthma. Nasal allergen challenge in allergic rhinitis results in inflammation in the bronchi as well as the nose, and the reverse is also true. This article reviews briefly the evidence for the link between asthma and rhinitis, advocates looking for rhinitis when patients present with poorly controlled asthma, and provides guidance for the diagnosis and treatment of rhinitis.

Spirometric parameters and levels of interferon gamma and IL-5 in induced sputum from patients with allergic rhinitis or asthma

BACKGROUND

This study was designed to analyze spirometric parameters and cytokine (interferon [IFN] gamma and IL-5) levels in induced sputum from patients with asthma or allergic rhinitis (AR) and nonatopic subjects.

METHODS

Thirty-three subjects aged 18-60 years were enrolled in the present study. Eight patients had asthma without AR symptoms, 16 had AR without asthma symptoms or history, and both groups had positive skin-prick test (SPT) to aeroallergens. The nine remaining subjects were healthy nonatopic subjects with negative SPT to aeroallergens. Spirometry was performed by evaluating the forced vital capacity (FVC), forced expiratory volume in the 1st second (FEV(1)), and forced expiratory flow between 25 and 75% (FEF(25-75)) of FVC before and after bronchodilator use. Induced sputum samples were also collected for measuring cytokine (IFN-gamma and IL-5) levels by enzyme-linked immunosorbent assay.

RESULTS

Significant pre- and postbronchodilator change was observed only for FEV(1) with higher variation values in asthmatic subjects compared with patients with AR (p < 0.05) and nonatopic subjects (p < 0.01). There was no significant difference in pre- and postbronchodilator spirometric parameters among the three groups, although asthmatic patients showed lower prebronchodilator FEF(25-75) values (p = 0.065). IL-5 levels were higher in induced sputum from patients with asthma and AR compared with nonatopic subjects (p = 0.020 and p = 0.032, respectively), but IFN-gamma levels showed no significant difference between the groups.

CONCLUSION

Spirometric measurements were not able to show any occurrence of bronchial constriction in patients with AR, but predominant IL-5 levels in induced sputum from these patients reinforce the role of Th2-type immune response in lower respiratory airways that could contribute to the concept of "one airway, one disease."

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.

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.

The CC16 A38G polymorphism is associated with the development of asthma in children with allergic rhinitis

BACKGROUND

Although asthma and allergic rhinitis (AR) are considered to be one syndrome, many questions remain unanswered. Why do some AR patients develop asthma but others do not, and which factors play a role in the development of asthma that have so far not been clearly elucidated.

OBJECTIVE

We hypothesize that children with AR who have the Clara cell secretory protein (CC16, secretoglobin 1A1) 38A/38A genotype (rs3741240) have an increased likelihood of developing asthma.

METHODS

The study sample included 117 children, with AR, but no asthma diagnosed within the following 5 years, as the control group. Cases group (n=202) included age- and gender-matched children with AR first, and asthma developed 3-5 years later, as the study group. The CC16 genotype was determined by PCR and Sau96I restriction digestion of PCR products. The serum CC16 levels were measured by ELISA. Total serum IgE, allergen specific IgE, eosinophil count and pulmonary function were also measured.

RESULTS

In children with rhinitis who develop asthma, the frequencies of the AA genotype were significantly higher than those who did not develop asthma [odds ratio (OR)=2.527; 95% confidence interval (CI)=1.571-4.065; P<0.01]. Serum CC16 levels in the children with rhinitis who develop asthma and carry the AA genotype were significantly lower than those who carry the non-AA genotype and those who did not develop asthma.

CONCLUSIONS AND CLINICAL RELEVANCE

Results of this study suggest that CC16 38A/38A genotype plays a role in the development of early asthma in children with AR. Early identification of rhinitis children at risk may assist in designing preventative approach to asthma development.

Children with allergic and nonallergic rhinitis have a similar risk of asthma

BACKGROUND

Both allergic and nonallergic rhinitis have been associated with increased prevalence of asthma.

OBJECTIVE

To characterize asthma and intermediary asthma endpoints in young children with allergic and nonallergic rhinitis.

METHODS

Thirty-eight 7-year-old children with allergic rhinitis, 67 with nonallergic rhinitis, and 185 without rhinitis from the Copenhagen Prospective Study on Asthma in Childhood birth cohort were compared for prevalence of asthma, eczema, food sensitization, filaggrin null-mutations, total IgE, blood eosinophil count, fractional exhaled nitric oxide (FeNO), lung function, and bronchial responsiveness.

RESULTS

Children with allergic rhinitis compared with asymptomatic controls had increased prevalence of asthma (21% vs 5%; P = .002), food sensitization (47% vs 13%; P < .001), and eczema (66% vs 43%; P = .01) and increased total IgE (155 kU/L vs 41 kU/L; P < .001), blood eosinophil count (0.46 x 10(9)/L vs 0.30 x 10(9)/L; P = .01), FeNO (15.9 ppb vs 6.6 ppb; P < .001), and bronchial hyperresponsiveness (23% vs 9%; P = .008). Filaggrin null-mutations were associated with allergic rhinitis (odds ratio, 3.3; 95% CI, 1.3-8.3) but did not modify these associations. Children with nonallergic rhinitis also had increased asthma prevalence (20% vs 5%; P = .001) but showed no association with filaggrin null-mutations, eczema, food sensitization, total IgE, blood eosinophil count, FeNO, or bronchial responsiveness.

CONCLUSION

Asthma is similarly associated with allergic and nonallergic rhinitis, suggesting a link between upper and lower airways beyond allergy associated inflammation. Only children with allergic rhinitis had increased bronchial responsiveness and elevated FeNO, suggesting different endotypes of asthma symptoms in young children with allergic and nonallergic rhinitis.

The pathophysiology, diagnosis and treatment of allergic rhinitis

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

Upper and lower airway patency are associated in young children

BACKGROUND

Although allergic rhinitis and asthma frequently coexist, the nature of this association is poorly understood. Therefore, we examined whether upper and lower airway patency are associated.

METHODS

We investigated 221 6-year-old children from the Copenhagen Prospective Study on Asthma in Childhood birth cohort, assessing upper airway patency by acoustic rhinometry before and after alpha-agonist, and lower airway patency by spirometry before and after beta2-agonist. Furthermore, we measured blood eosinophil count, nasal eosinophilia, total IgE, and fraction of exhaled nitric oxide. Associations were investigated by generalized linear models.

RESULTS

Decongested nasal airway patency and post-beta2 FEV(1) were significantly associated (P = .007). The association remained significant after adjustments for sex, body size, FVC, and atopic diseases (beta-coefficient 2.85 cm(3); 95% CI, 0.42 to 5.29; P = .02). Baseline values of upper and lower airway patency were also significantly associated (beta-coefficient 0.89 cm(3); 95% CI, 0.26-1.51; P = .01). In addition, blood eosinophil count and nasal eosinophilia were inversely associated with decongested nasal airway patency, beta-coefficient -0.42 cm(3) (95% CI, -0.77 to -0.07; P = .02) and beta-coefficient -0.47 cm(3) (95% CI, -0.89 to -0.05; P = .03), respectively.

CONCLUSIONS

We found a strong and consistent association between upper and lower airway patency. This may be due to a common pathology, as suggested by the inverse association between decongested nasal airway patency, blood eosinophil count, and nasal eosinophilia. Alternatively, the association between upper and lower airway patency might reflect a physiologic background for the common comorbidity.

The atopic march: what's the evidence?

OBJECTIVE

To review and compile data from published studies that provide support for the existence of the atopic march.

DATA SOURCES

Relevant articles and references found via a PubMed search using the following keywords: atopic march, allergic march, atopic dermatitis, eczema, atopic eczema, atopy, rhinitis, wheeze, bronchiolitis, and asthma.

STUDY SELECTION

All articles were reviewed and the most relevant were selected for inclusion in this review and for the compilation and graphical presentation of disease trends.

RESULTS

Data on the prevalence of each phenotype of the atopic march confirm the temporal pattern of progression from eczema to allergic rhinitis and asthma. However, the atopic march as it is currently defined, is lacking precision, which affects its usefulness. Early events in the atopic march, such as eczema, may be more useful with more careful refinement of the phenotype into atopic and nonatopic eczema.

CONCLUSION

Evidence supports that the atopic march is a useful paradigm to describe the clinically observed progression of atopy in certain children. There may be more precise phenotypes of the early stages of the atopic march that may improve its utility in predicting the development of later atopic, comorbid chronic disease.

Allergy and the nose

Allergic rhinitis (AR) is the most common immunological disorder and is characterized by an immunoglobulin E (IgE)-mediated inflammation induced by the allergen exposure. This review will consider some issues concerning pathophysiological aspects of AR: impact on asthma, response to decongestion, link with infections, response to specific immunotherapy, relationship with adiposity, effects on quality of life (QoL) and allergic inflammation. AR, even though not a serious illness, may be a clinically relevant disorder as it may present numerous complications and affect QoL, as reported in this review. Therefore, the management of AR patients should be rigorously careful and multi-disciplinary.

Allergic rhinitis and asthma comorbidity: ARIA classification of rhinitis does not correlate with the prevalence of asthma

BACKGROUND

Allergic rhinitis and asthma comorbidity is supported by both the similar underlying pathogenesis and immunologic mechanisms. The aim of this study was to verify whether the characteristics of rhinitis classified according to the new Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines correlate with the prevalence of asthma.

METHODS

From 1 March to 30 June 2002, a multi-centre cross-sectional study was conducted by 154 allergists chosen from throughout Italy. Duration, severity of rhinitis (according to the ARIA classification) and the type of allergic sensitizations were compared with the prevalence of asthma.

RESULTS

One thousand three hundred and twenty-one consecutive rhinitis-allergic patients aged 18 years or older were enrolled for the study. The majority of patients, 1060 (80.24%), were on medication at the time of their specialist visit. Mild intermittent rhinitis was diagnosed in 7.7% of patients, moderate/severe intermittent in 17.1%, mild persistent in 11.6%, and moderate/severe persistent in 63.6%. The prevalence of asthma was 48% in patients with mild intermittent rhinitis, 49.6% in moderate-severe intermittent rhinitis, 36.6% in mild persistent rhinitis and 47.5% in moderate severe persistent patients. No correlation between the ARIA categories of rhinitis and the prevalence of asthma was found. A multivariate analysis, after adjustment for age, sex, type of sensitization, level of severity and duration of rhinitis classified according to the ARIA guidelines, demonstrated that age, over 41 years [risk ratio (RR) 1.260, 95% confidence interval (CI) 1.072-1.482] and especially over 51 years (RR 1.460, 95% CI 1.237-1.723), sensitization to indoor allergens (mite and cat), (RR 1.203, 95% CI 1.060-1.366), and polysensitization (RR 1.178, 95% CI 1.004-1.383) are significant risk factors for asthma.

CONCLUSION

In allergic rhinitis (AR) patients referred to a specialist, the features of AR as defined by the ARIA classification are not able to predict the presence of asthma, therefore all such patients should be assessed for asthma.

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.

Potential roles in rhinitis for protease and other enzymatic activities of allergens

Exposure to airborne pollen, fungal allergens, and dust mite allergens is associated with the development of allergic rhinitis. Biologic function of allergens is considered to be a key determinant for allergenicity, and many clinically important allergens have been shown to possess enzymatic activity. It is proposed that by enabling allergens to breach the integrity of the airway epithelial barrier, proteolytic activity plays an adjuvant pro-allergic role influencing immunogenicity. In this review, current evidence regarding enzymatic activity of aeroallergens is described, and the potential role of aeroallergens in allergic rhinitis is discussed.

Nasal and bronchial response to exercise in patients with asthma and rhinitis: the role of nitric oxide

BACKGROUND

Physical exercise is associated with a decrease in nasal resistance in rhinitis and an increase in bronchial resistance in asthma. The objective was to evaluate the relationship between the levels of nasal nitric oxide (nNO) and exhaled bronchial nitric oxide (eNO) with bronchial responses to exercise in patients with rhinitis and asthma.

METHODS

We submitted 24 subjects with asthma and rhinitis to an exercise test. A decrease in FEV(1)> or =15% was considered positive. The volume of the nasal cavity and the minimal cross-sectional area (MCA) was evaluated by means of acoustic rhinometry (AR), and nNO and eNO were evaluated by chemoluminiscence. The measurements were recorded at baseline, 15 and 50 min after the end of the exercise test.

RESULTS

The exercise test was positive in 17 cases. Fifteen minutes after exercise test, the nasal volume increased by 57% (P < 0.0001) and was still increased by 30% after 50 min (P < 0.0001). There was no correlation between decrease in FEV(1) and increase in nasal volume. The baseline value of nNO was 1185 +/- 439 ppb, and the value at 15 and 50 min was 1165 +/- 413 and 1020 +/- 368 ppb, the latter value being significantly lower (P < 0.01) than the baseline. The baseline value of eNO was 21 +/- 19 ppb, with no significant differences at 15 and 50 min. There was no significant correlation between either the decrease in FEV(1) and the nasal response, or the baseline eNO and nNO values.

CONCLUSIONS

The nasal and bronchial response to exercise is completely different in rhinitis and asthma; in the former, an increase in nasal volume occurs, while in the latter there is a drop in FEV(1). There is no relationship between the values of nasal or exhaled NO and the nasal and bronchial response after exercise.

Nasal allergies and beyond: a clinical review of the pharmacology, efficacy, and safety of mometasone furoate

Mometasone furoate nasal spray (MFNS; Nasonex, Schering-Plough Corporation, Kenilworth, NJ, USA) is an effective and well-tolerated intranasal corticosteroid approved for the prophylactic treatment of seasonal allergic rhinitis, and the treatment of perennial allergic rhinitis. MFNS is a potent molecule with a rapid onset of action and excellent safety and efficacy profiles. Having recently received approval for the treatment of nasal polyposis, data indicate that MFNS may also be effective in rhinosinusitis.

Repeatability of standardised nasal nitric oxide measurements in healthy and asthmatic adults and children

Several nasal nitric oxide (NO) measurement techniques have been described, but there is not a widespread measurement technique for measurement of nasal NO. In this study we evaluated the repeatability of one technique of nasal NO measurements using the nasal application of the NIOX system.

METHODS

Three nasal NO measurements (NIOX Nitric Oxide Monitoring System, Aerocrine, Sweden) were made on a single occasion in 22 healthy subjects and 27 patients with asthma, aged 5-69 years. Nasal NO was sampled during breath hold from one nostril at a flow rate of 5 ml/s.

RESULTS

The repeatability of nasal NO assessed by the coefficient of variation (CV) was 12.5% (95% Confidence interval (CI) 11.0-14.7%) for the total population. Healthy adults had a significantly better repeatability than healthy children (P<0.008). The mean NO level for the total population was 837 ppb. The mean NO levels in children were lower than in the adults (751 and 897 ppb, respectively). The mean breath hold length needed to obtain a steady NO plateau for all subject categories combined was 20.4+/-6.01 s. The average number of attempts needed to obtain three approved NO measurements was 5.4 (range 3-13) for the total population. There were no significant differences between the different subject categories. When using two measurements per session instead of three, the overall CV was 10.5% (95% CI 8.8-13.1%). Most subjects found the measurements easy to perform and all of them would accept to do the examination as a routine.

CONCLUSIONS

Nasal NO measurements in NIOX may provide a useful reliable clinical tool to assess and monitor upper airways in different diseases, for example PCD and rhinitis, and are acceptable by both healthy and asthmatic adults and children, as a part of their routine visit to a physician.