Obtaining concomitant control of allergic rhinitis and asthma with a nasally inhaled corticosteroid

A Synopsis of Guidance for Allergic Rhinitis Diagnosis and Management From ICAR 2023

An updated edition of the International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR) has recently been published. This consensus document, which included the participation of 87 primary authors and 40 additional consultant authors, who critically appraised evidence on 144 individual topics concerning allergic rhinitis, provides guidance for health care providers using the evidence-based review with recommendations (EBRR) methodology. This synopsis highlights topical areas including pathophysiology, epidemiology, disease burden, risk and protective factors, evaluation and diagnosis, aeroallergen avoidance and environmental controls, single and combination pharmacotherapy options, allergen immunotherapy (subcutaneous, sublingual, rush, cluster), pediatric considerations, alternative and emerging therapies, and unmet needs. Based on the EBRR methodology, ICAR:AR includes strong recommendations for the treatment of allergic rhinitis: (1) for the use of newer generation antihistamines compared with first-generation alternatives, intranasal corticosteroid, intranasal saline, combination therapy with intranasal corticosteroid plus intranasal antihistamine for patients not responding to monotherapy, and subcutaneous immunotherapy and sublingual tablet immunotherapy in properly selected patients; (2) against the use of oral decongestant monotherapy and routine use of oral corticosteroids.

Evaluation of olfactory dysfunction to estimate the presence of eosinophilic chronic rhinosinusitis in patients with asthma

BACKGROUND

Eosinophilic chronic rhinosinusitis (ECRS) is often complicated by asthma and can be difficult to diagnose. This study aimed to clarify the usefulness of the self-administered odor questionnaire (SAOQ) and visual analog scale (VAS) to identify olfactory disorders in patients with asthma.

METHODS

This retrospective study was conducted on patients with asthma who were referred to the Otolaryngology clinic between May and September 2018. The treatment step of asthma, asthma control test (ACT), pulmonary function test, peripheral blood eosinophils, and fractional exhaled nitric oxide (FeNO) were analyzed. ECRS was diagnosed based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis Study score. Olfactory dysfunction was evaluated using the SAOQ and VAS for olfactory disorders.

RESULTS

The study included 56 patients (18 males and 38 females), who were divided into two groups; those with ECRS (n = 18) and those without ECRS (n = 38). Age, sex, treatment step, ACT score, and pulmonary function were not significantly different between the groups. The ECRS group had a significantly higher FeNO value (89.1 ppb vs. 39.1 ppb) and a significantly lower SAOQ score (40.1% vs. 96.1%). The area under the receiver operating characteristic curve for the efficacy of ECRS diagnosis was 0.88, 0.889, 0.799, and 0.757 for SAOQ, VAS, blood eosinophil count, and FeNO, respectively.

CONCLUSION

The SAOQ and VAS scores were useful tools that presented similar results to the blood eosinophil count and FeNO, and may help to improve the diagnosis of ECRS in patients with asthma.

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

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

Fractional Exhaled Nitric Oxide: A Potential Biomarker in Allergic Rhinitis?

BACKGROUND

The fractional concentration of exhaled nitric oxide (FeNO) is a surrogate biomarker for Th2-dependent bronchial inflammation. The present study investigated whether FeNO may characterize allergic rhinitis (AR) patients.

METHODS

A total of 553 AR patients (497 males, mean age 28.8 years) were evaluated. Those patients with a high FeNO underwent a 2-year follow-up.

RESULTS

Increased FeNO was associated with a significantly longer AR duration, impaired lung function, more severe symptoms, and more frequent bronchial hyperresponsiveness (BHR). At follow-up, 22 out of 82 patients (26.8%) with high FeNO levels (>50 ppb) developed asthma.

CONCLUSIONS

AR patients may frequently have high FeNO values, exceeding 50 ppb. This might be associated with an initial impaired lung function, BHR, a perceived worsening of respiratory symptoms, and potential progression to asthma.

Optimal management of allergic rhinitis

Allergic rhinitis (AR), the most common chronic disease in childhood is often ignored, misdiagnosed and/or mistreated. Undertreated AR impairs quality of life, exacerbates asthma and is a major factor in asthma development. It can involve the nose itself, as well as the organs connected with the nose manifesting a variety of symptoms. Evidence-based guidelines for AR therapy improve disease control. Recently, paediatric AR guidelines have been published by the European Academy of Allergy and Clinical Immunology and are available online, as are a patient care pathway for children with AR and asthma from the Royal College of Paediatrics and Child Health. Management involves diagnosis, followed by avoidance of relevant allergens, with additional pharmacotherapy needed for most sufferers. This ranges, according to severity, from saline sprays, through non-sedating antihistamines, oral or topical, with minimally bioavailable intranasal corticosteroids for moderate/severe disease, possibly plus additional antihistamine or antileukotriene. The concept of rhinitis control is emerging, but there is no universally accepted definition. Where pharmacotherapy fails, allergen-specific immunotherapy, which is uniquely able to alter long-term disease outcomes, should be considered. The subcutaneous form (subcutaneous immunotherapy) in children has been underused because of concerns regarding safety and acceptability of injections. Sublingual immunotherapy is both efficacious and safe for grass pollen allergy. Further studies on other allergens in children are needed. Patient, carer and practitioner education into AR and its treatment are a vital part of management.

Phenotypes of severe asthma among children and adolescents in Brazil: a prospective study

BACKGROUND

The morbidity associated with severe uncontrolled asthma is disproportionately higher in low- and middle-income countries than in high-income countries. The aim of this study was to describe the phenotypic characteristics of difficult-to-treat severe asthma and treatment-resistant severe asthma in a sample of children and adolescents in Brazil.

METHODS

This was a prospective study, conducted between 2010 and 2014, following 61 patients (6-18 years of age) who had been diagnosed with severe uncontrolled asthma. The patients were classified and managed in accordance with the World Health Organization asthma follow-up protocol, which calls for re-evaluations of the diagnosis, level of control (functional and clinical), comorbidities, inhaler technique, and environmental factors, together with adjustment of the treatment to achieve a target level of control. We assessed pulmonary function, measured fractional exhaled nitric oxide, and performed sputum cytology. After the target rate of ≥ 80% adherence to inhaled corticosteroid treatment had been reached and all of the re-evaluations had been performed, the patients incorrectly diagnosed with severe uncontrolled asthma were excluded and the remaining patients were classified as having treatment-resistant or difficult-to-treat severe asthma.

RESULTS

We found that, of the 61 patients evaluated, 10 had been misdiagnosed (i.e., they did not have asthma), 15 had moderate asthma, and 36 had severe uncontrolled asthma. Among those 36 patients, the asthma was classified as treatment-resistant in 20 (55.6%) and as difficult-to-treat in 16 (44.4%). In comparison with the patients with difficult-to-treat severe asthma, those with treatment-resistant severe asthma showed a higher median level of fractional exhaled nitric oxide (40 ppb vs. 12 ppb; P < 0.037) and a lower median forced expiratory volume in one second (61% vs. 87%; P < 0.001).

CONCLUSIONS

Although patients with treatment-resistant severe asthma cannot always be distinguished from those with difficult-to-treat severe asthma on the basis of baseline clinical characteristics, reduced airflow and elevated fractional exhaled nitric oxide are factors that could distinguish the two groups. Patients diagnosed with severe uncontrolled asthma should be re-evaluated on a regular basis, in order to exclude other diagnoses, to reduce exacerbations, and to identify patients with persistent airflow limitation.

Pediatric allergic rhinitis and asthma: can the march be halted?

The strong epidemiologic and pathophysiologic link between allergic rhinitis (AR) and asthma has led to the concept of 'united airways disease' or 'respiratory allergy', implying that allergy, in its widest sense, underlies this clinical syndrome. Progression from AR to asthma is frequent and part of the 'atopic march'. Since pediatric immune responses are more adaptable and therefore may be more amenable to treatment, interventions at early childhood are characterized by a higher chance to affect the natural history of respiratory allergy. Although current treatments are quite effective in alleviating respiratory allergy symptoms, it has proven much more difficult to confirm any influence on the progression of the disease. Much more promising is the field of specific allergen immunotherapy, where current evidence, although not yet of ideal robustness, points towards a disease-modifying effect. In addition, newer or emerging, possibly more effective or more targeted interventions are promising in the preventive sense.

Impact of intranasal corticosteroids on asthma outcomes in allergic rhinitis: a meta-analysis

Given the relationship between allergic rhinitis (AR) and asthma, it can be hypothesized that reducing inflammation in the upper airway with intranasal corticosteroid (INCS) medications may improve asthma outcomes. The goal of this study was to perform a systematic review with meta-analysis of the efficacy of INCS medications on asthma outcomes in patients with AR and asthma. Asthma-specific outcomes from randomized, controlled studies evaluating INCS medications in patients with AR were evaluated, including studies that compared INCS sprays to placebo, INCS sprays plus orally inhaled corticosteroids to orally inhaled corticosteroids alone, and nasally inhaled corticosteroids to placebo. Sufficient data for meta-analysis were retrieved for 18 trials with a total of 2162 patients. Asthma outcomes included pulmonary function, bronchial reactivity, asthma symptom scores, asthma-specific quality of life, and rescue medication use. The subgroup of studies comparing INCS spray to placebo had significant improvements in FEV1 (SMD = 0.31; 95% CI, 0.04-0.58), bronchial challenge (SMD = 0.46; 95% CI, 0.12-0.79), asthma symptom scores (SMD = -0.42; 95% CI, -0.53 to -0.30), and rescue medication use (SMD = -0.29; 95% CI, -0.58 to -0.01). Nasal inhalation of corticosteroids significantly improved morning and evening peak expiratory flow. There were no significant changes in asthma outcomes with the addition of INCS spray to orally inhaled corticosteroids. Thus, the results of this meta-analysis demonstrated that intranasal corticosteroid medications significantly improve some asthma-specific outcome measures in patients suffering from both AR and asthma. This effect was most pronounced with INCS sprays when patients were not on orally inhaled corticosteroids, or when corticosteroid medications were inhaled through the nose into the lungs. Overall, intranasal corticosteroid medications improve some asthma-specific outcome measures in patients with both AR and asthma. Further research is needed to clarify the role of INCS sprays as asthma-specific therapy, as well as the role of the nasal inhalation technique as a monotherapy in patients suffering from both asthma and AR.

Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology

Rhinitis is a common problem in childhood and adolescence and impacts negatively on physical, social and psychological well-being. This position paper, prepared by the European Academy of Allergy and Clinical Immunology Taskforce on Rhinitis in Children, aims to provide evidence-based recommendations for the diagnosis and therapy of paediatric rhinitis. Rhinitis is characterized by at least two nasal symptoms: rhinorrhoea, blockage, sneezing or itching. It is classified as allergic rhinitis, infectious rhinitis and nonallergic, noninfectious rhinitis. Similar symptoms may occur with other conditions such as adenoidal hypertrophy, septal deviation and nasal polyps. Examination by anterior rhinoscopy and allergy tests may help to substantiate a diagnosis of allergic rhinitis. Avoidance of relevant allergens may be helpful for allergic rhinitis (AR). Oral and intranasal antihistamines and nasal corticosteroids are both appropriate for first-line AR treatment although the latter are more effective. Once-daily forms of corticosteroids are preferred given their improved safety profile. Potentially useful add-on therapies for AR include oral leukotriene receptor antagonists, short bursts of a nasal decongestant, saline douches and nasal anticholinergics. Allergen-specific immunotherapy is helpful in IgE-mediated AR and may prevent the progression of allergic disease. There are still a number of areas that need to be clarified in the management of rhinitis in children and adolescents.

Asthma medication delivery: mists and myths

Asthma is usually treated with inhaled corticosteroids (ICS) and bronchodilators generated from pressurized metered dose inhalers (pMDI), dry powder inhalers (DPI), or nebulizers. The target areas for ICS and beta 2-agonists in the treatment of asthma are explained. Drug deposition not only depends on particle size, but also on inhalation manoeuvre. Myths regarding inhalation treatments lead to less than optimal use of these delivery systems. We discuss the origin of many of these myths and provide the background and evidence for rejecting them.

Capability of hypertonic saline cough provocation test to predict the response to inhaled corticosteroids in chronic cough: a prospective, open-label study

BACKGROUND

Many patients with chronic cough respond to treatment with inhaled corticosteroids but it is difficult to predict which patients are likely to respond. The primary aim of the present study was to define the capability of hypertonic saline cough provocation test to predict the responsiveness to inhaled corticosteroids in chronic cough. The secondary aim was to assess the ability of the saline test to monitor the healing of cough during corticosteroid treatment.

METHODS

Forty-three patients with chronic cough were recruited. Before therapy, spirometry, ambulatory peak flow monitoring, nitric oxide measurement, histamine airway challenge, and saline test were performed. Those responding to the first saline test repeated it and the nitric oxide measurement during the subsequent visits. The patients used inhaled budesonide, 400 ug twice daily, for twelve weeks. The treatment response was assessed by Leicester Cough Questionnaire at baseline, and at one, four, and twelve weeks.

RESULTS

Seventy-seven % of the patients demonstrated the minimal important difference in the Leicester Cough Questionnaire indicating a symptomatic response. Neither the response magnitude nor the speed was predicted by the saline test. Histamine challenge showed the strongest predictive ability: The maximal improvement in Leicester Cough Questionnaire total score was 5.08 (3.76 - 6.40) points in the histamine positive and 2.78 (1.55 - 4.01) points in the histamine negative subjects (p = 0.006). Baseline nitric oxide level also associated with the improvement in Leicester Cough Questionnaire total score (p = 0.02). During the treatment, the cough sensitivity to saline gradually decreased among the budesonide responders but not in the non-responders. Nitric oxide levels decreased very rapidly among the responders.

CONCLUSIONS

Saline test cannot predict the responsiveness to inhaled corticosteroids in chronic cough but it may be utilized to monitor the effect of this treatment.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov database (KUH5801112). ClinicalTrials.gov Identifier: NCT00859274.

Comparative study in the management of allergic rhinitis in children using LED phototherapy and laser acupuncture

OBJECTIVE

The objective of this study was to compare the outcomes of LED phototherapy and laser acupuncture treatment on allergic rhinitis in children.

METHODS

40 patients with perennial allergic rhinitis were divided randomly into two groups. Patient's ages ranged from 7 to 18 years. One group was subjected to LED phototherapy and the other group was managed by laser acupuncture .The patients were followed-up for 1 year.

RESULTS

There was a significant improvement in the severity score symptoms in both groups through and by the end of the follow up period.

CONCLUSION

This led to the conclusion that both techniques are equally safe, reliable, non invasive and successful.

Current and future directions in pediatric allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common pediatric problem that significantly affects sleep, learning, performance, and quality of life. In addition, it is associated with significant comorbidities and complications.

OBJECTIVE

The aim was to provide an update on the epidemiology, comorbidities, pathophysiology, current treatment, and future direction of pediatric AR.

METHODS

Literature reviews in each of these areas were conducted, and the results were incorporated.

RESULTS

The prevalence of AR is increasing in the pediatric population and is associated with significant morbidity, comorbidities, and complications. The mainstay of current treatment strategies includes allergen avoidance, pharmacotherapy, and allergen specific immunotherapy.

CONCLUSIONS

In the future, diagnosis will be improved by microarrayed recombinant allergen testing and therapy will be expanded to include emerging treatments such as sublingual immunotherapy and combination products.

Wheezy child program: the experience of the belo horizonte pediatric asthma management program

Background

Until 1994, assistance provided by the Municipal Public Health System to children with asthma in Belo Horizonte, Brazil, was ineffective because it focused only on treating exacerbations. This scenario motivated the implementation of the Wheezy Child Program.

Objectives

The main objectives were to reduce emergency room visits and hospitalizations.

Methods

The strategies adopted were as follows: continued medical education for pediatricians, reorganization of public assistance into different levels of complexity regarding asthma care, and free dispensation of inhaled beclomethasone, albuterol, and valved spacers. A partnership between the Pediatric Pulmonology staff of the Federal University of Minas Gerais and the Belo Horizonte Municipal Health Authority made these strategies come to fruition, especially through the training of health workers and the devising of protocol after GINA guidelines.

Results

Of 2149 patients with a history of hospitalization after program admission, only 453 were re-admitted in the 6 to 12 months after, a reduction of 79%. There was a 300% increase in the use of aerosol and a reduction to 50% in the use of oxygen-driven nebulizers (P < 0.001) in the management of exacerbations. For patients enrolled in the program with moderate and severe persistent asthma, the median adherence rate was 50%.

Conclusions

The Wheezy Child Program has significantly reduced hospitalizations and emergency room visits, has improved quality of life, and has shown that programs of this kind are feasible in low- to middle-income countries. More than 30,000 children have been assisted by the program, and now it seeks to optimize asthma control and increase adherence rates.

Empirical evaluation of age groups and age-subgroup analyses in pediatric randomized trials and pediatric meta-analyses

BACKGROUND

An important step toward improvement of the conduct of pediatric clinical research is the standardization of the ages of children to be included in pediatric trials and the optimal age-subgroups to be analyzed.

METHODS

We set out to evaluate empirically the age ranges of children, and age-subgroup analyses thereof, reported in recent pediatric randomized clinical trials (RCTs) and meta-analyses. First, we screened 24 RCTs published in Pediatrics during the first 6 months of 2011; second, we screened 188 pediatric RCTs published in 2007 in the Cochrane Central Register of Controlled Trials; third, we screened 48 pediatric meta-analyses published in the Cochrane Database of Systematic Reviews in 2011. We extracted information on age ranges and age-subgroups considered and age-subgroup differences reported.

RESULTS

The age range of children in RCTs published in Pediatrics varied from 0.1 to 17.5 years (median age: 5; interquartile range: 1.8-10.2) and only 25% of those presented age-subgroup analyses. Large variability was also detected for age ranges in 188 RCTs from the Cochrane Central Register of Controlled Trials, and only 28 of those analyzed age-subgroups. Moreover, only 11 of 48 meta-analyses had age-subgroup analyses, and in 6 of those, only different studies were included. Furthermore, most of these observed differences were not beyond chance.

CONCLUSIONS

We observed large variability in the age ranges and age-subgroups of children included in recent pediatric trials and meta-analyses. Despite the limited available data, some age-subgroup differences were noted. The rationale for the selection of particular age-subgroups deserves further study.

Allergic Rhinitis and Its Impact on Asthma in Asia Pacific and the ARIA Update 2008

The prevalence of allergic diseases such as allergic rhinitis (AR) and asthma are markedly increasing to epidemic proportions worldwide as societies adopt Western lifestyles. An estimated 300 million persons worldwide have asthma, about 50% of whom live in developing countries, and about 400 million people suffer from AR. AR has a marked impact on quality of life, socially, at school, and in the workplace and is a huge socioeconomic burden. Thus, there was clearly a need for a global evidence-based guideline not only for managing AR but also highlighting the interactions between the upper and lower airways including diagnosis, epidemiology, common risk factors, management, and prevention. The Allergic Rhinitis and its Impact on Asthma (ARIA) document was first published in 2001 as a state-of-the-art document for the specialist, the general practitioner, and other health care professionals. Subsequent research and increasing knowledge have resulted in the ARIA 2008 update. The present review summarizes the ARIA update with particular emphasis on the current status of AR and asthma in Asia Pacific.

Unified disease, unified management: treating allergic rhinitis and asthma with nasally inhaled corticosteroid

Persistent allergic rhinitis (AR) and asthma constitute a common comorbidity. Combined treatment is recommended by prescribing intranasal plus oral inhaled corticosteroids. This study was carried out to assess the efficacy of an alternative regimen to treat this condition. All recruited patients suffered from persistent AR and asthma. Diagnosis and classification of AR and asthma were based on international guidelines. The experimental group received fluticasone propionate (FP), 500microg/day during six weeks, inhaled exclusively through the nose using a valved large volume spacer attached to a face mask. The comparison group also received the same dose of orally inhaled FP, during the same time period, plus intranasal aqueous fluticasone, 200microg/day. There were no statistical differences between both groups regarding AR and asthma severity, clinical scores, acoustic rhinometry, lung function, and FeNO upon admission and during the follow up period. Intragroup analysis demonstrated a significant improvement for allergic rhinitis and asthma scores as well as for FeNO from admission to the sixth week (p<0.01) in both groups. Results suggest that exclusive nasally inhaled fluticasone propionate should be considered as an alternative step in the management of patients suffering from AR and asthma comorbidity.

[Nose and lungs--two of a kind]

BACKGROUND

Diseases in the upper and lower airways often occur concomitantly, and evidence indicates a close relationship between them. Optimal treatment of airway disease requires knowledge about this relationship; the article presents an updated overview of the field.

MATERIAL AND METHODS

This paper is based on extensive clinical experience with airway disease, own research and literature studies.

RESULTS

It is well documented that patients suffering from asthma have rhinitis more often than those without. Likewise, those suffering from nose and sinus disease, e.g. allergic rhinitis, sinusitis and nasal polyposis, have an increased incidence of asthma. Treatment of disorders in one airway compartment often has a positive impact on the airways in general.

INTERPRETATION

Disorders in the upper and lower airways should be considered as the same disease to a larger extent than they are today. Patients with disease in one airway compartment should be considered for pathology elsewhere in the airways. Therapeutically, the airways should be regarded as one entity.

[Allergic rhinitis and its impact on asthma (ARIA update 2008). The Austrian perspective]

In 1999, during the ARIA (Allergic Rhinitis and its Impact on Asthma) WHO workshop, an evidence-based document was produced using an extensive review of the literature available up to December of the same year. An update of the ARIA guidelines was soon needed and started in 2004. Thereafter, there was the need for an even more global document, which would highlight the interactions between the upper and the lower airways including diagnosis, epidemiology, common risk factors, management and prevention, and comprise the allergy perspective also for developing countries. This goal was achieved with the most recently published ARIA update 2008. The present article is the result of consecutive efforts of the authors of the ARIA update 2008 to accomplish the nationwide comprehensive distribution of information by publication in important national journals, like the WMW.

Adherence rate to inhaled corticosteroids and their impact on asthma control

BACKGROUND

Poor asthma control is associated to high morbidity. The objective of this study was to assess the association between adherence rates to beclomethasone dipropionate (BDP) and the degree of asthma control.

METHODS

A cohort concurrent study was carried out for 12 months with 122 asthmatic patients, aged 3-12 years, randomly selected in a pediatric pulmonology outpatient clinic, who received BDP free of charge. Adherence rates were verified by pharmacy records. Clinical control was assessed through a scoring system comprised four variables (nocturnal and morning symptoms, limitation of physical activities and exacerbations). Total score was 16 points. Patients whose score was below or equal to two were considered controlled (group 1), and patients whose score was above or equal to three were considered uncontrolled (group 2). For patients able to perform spirometry, we considered as controlled the patients with forced expiratory volume in 1 s (FEV(1)) equal to or above 80% of the predicted value, and as uncontrolled the patients with FEV(1) below 80%.

RESULTS

Fewer than half (40.3% maximum) of the 122 patients maintained asthma control. Median adherence rate of groups 1 and 2 were 85.5% and 33.8%, (P < 0.001) in the 4th month, 90.0% and 48.0% (P < 0.001) in the 8th month and 84.4% and 47.0% in the 12th month (P < 0.001), respectively.

CONCLUSION

In all periods, there were statistically significant differences in adherence rates for maintaining or not maintaining the asthma control. Optimal asthma control entailed adherence rate higher than 80%. Strategies for reducing asthma morbidity should include a regular monitoring of adherence to inhaled steroids.

Allergic rhinitis: epidemiological aspects, diagnosis and treatment

This study was a review of the literature on the epidemiological, clinical, diagnostic and therapeutic aspects of allergic rhinitis. Bibliographic searches were based on the information contained within the Medline, Latin American and Caribbean Health Sciences Literature and HighWire databases, covering the last thirty years and using the following search terms: 'allergic rhinitis', 'epidemiology', 'diagnosis' and 'treatment'. Sixty articles were selected. This study describes the increase in the prevalence of allergic rhinitis, its relationship with asthma, the diagnostic criteria and the treatment. The classification of allergic rhinitis and strategies for its treatment are presented. Therapeutic modalities presented and discussed include the administration of antihistamines, corticosteroids, immunotherapy, anti-leukotrienes, sodium cromoglycate and anti-IgE antibodies, as well as minimizing exposure to inhaled allergens. Finally, the importance of the management of allergic rhinitis in public health is emphasized.

Correlations of health-related quality of life questionnaire results in asthma and allergic rhinitis: effects of a leukotriene receptor antagonist

Bronchial asthma and allergic rhinitis frequently coexist. This study investigated correlations of health-related quality of life (QOL) questionnaires for these diseases, assessing whether the selective leukotriene receptor antagonist (LTRA), pranlukast, had additional benefits to overall asthma control when there was concomitant allergic rhinitis. Patients with asthma-associated allergic rhinitis were randomly allocated to either LTRA(+) (n = 21, treated for 3 months with pranlukast), or LTRA(-) (n = 8, no pranlukast). At study start and at 3 months, pulmonary function was evaluated and QOL assessments were made using the Asthma Health Questionnaire-Japan (AHQ-Japan) and the Japan Rhino-conjunctivitis Quality of Life Questionnaire (JRQLQ). Total scores were significantly correlated both before and after therapy. After 3 months' therapy, pulmonary function and total AHQ-Japan and JRQLQ scores significantly improved in the LTRA(+) group, but not in the LTRA(-) group. A significant correlation between change at 3 months in the AHQ-Japan and JRQLQ scores from baseline values was seen in the LTRA(+) group. LTRA therapy improved allergic rhinitis symptoms, asthma symptoms and pulmonary function.