Prevalence and rate of diagnosis of allergic rhinitis in Europe

Allergic rhinitis and its effect on sleep, fatigue, and daytime somnolence

OBJECTIVE

To examine the adverse effects of sleep impairment on the quality of life of patients with the disorder and how these effects can be treated with therapies targeted at the underlying problems that influence sleep.

DATA SOURCES

Medline and Ovid search for sleep and rhinitis.

STUDY SELECTION

All literature on this topic were reviewed, and, if significant, were incorporated into this review.

RESULTS

Intranasal corticosteroids used as treatment for allergic rhinitis have been shown to reduce the nasal congestion characteristic of the disorder. Data on sleep-related end points from clinical trials on intranasal corticosteroids also reveal that the treatment's effectiveness in alleviating nasal congestion leads to better sleep, reduced daytime somnolence, and improved quality of life.

CONCLUSION

Further research, specifically using sleep measurements as primary end points, is needed to definitively show that intranasal corticosteroids reduce nasal congestion, thereby improving sleep and, consequently, quality of life in patients with allergic rhinitis. These future trials will serve to identify the most effective therapies that target the adverse effects of sleep impairment in this disorder.

Treatment and outcomes in patients with asthma and allergic rhinitis in the United kingdom

BACKGROUND

Since allergic rhinitis in asthma patients is associated with worse asthma control, the treatment of the comorbid condition may improve outcomes.

METHODS

A 1-year retrospective study using the UK Mediplus database (2001-2004) included asthmatic patients aged 15-55 with allergic rhinitis. Patients starting therapy based on the Global Initiative for Asthma guidelines, defined as an increase in inhaled corticosteroids (high-dose inhaled corticosteroids, hdICS), or the addition of montelukast (ICS+MON) or long-acting beta-agonists (ICS+LABA) to ICS, were studied. Univariable and multiple logistic regressions evaluated asthma-related outcomes.

RESULTS

Among 2,596 asthma and allergic rhinitis patients, 83.2% initiated ICS+LABA, 12.1% hdICS and 4.7% ICS+MON. The mean age was 34 years and 60% were female. ICS+MON patients had more moderate-severe asthma (p = 0.04). Approximately 84% of the ICS+LABA patients experienced an asthma control failure compared to 50% in the other groups (p < 0.0001). The proportions of patients requiring treatment change were 73.8, 22 and 27.3% in the ICS+LABA, hdICS and ICS+MON groups, respectively (p = 0.001). Asthma-related resource use was similar among all groups. The ICS+MON group received fewer mean prescriptions for oral corticosteroids (p = 0.024) than the other groups (p = 0.026).

CONCLUSIONS

In asthma and allergic rhinitis, treatment with ICS+MON or hdICS was associated with lower rates of asthma control failure and fewer treatment changes than the ICS+LABA group. MON users also required fewer oral corticosteroids.

Incidence and remission of self-reported allergic rhinitis symptoms in adults

BACKGROUND

A few studies have examined the incidence and remission of allergic rhinitis (AR) in the same general population.

METHODS

A questionnaire focused on respiratory symptoms and airway diseases was mailed out in 1992 and in 2000 to the same subjects. Of 4933 subjects, in 1992 aged 20-59 years, 4280 (86.8%) answered at both occasions. AR was defined on self-reported AR and a simultaneous report of nasal symptoms provoked by exposure either to tree-, grass-pollen, furred animals or house dust. Multiple logistic regression adjusted for age and gender was used to analyze potential predictors, reported in 1992, for incidence and remission of AR.

RESULTS

The prevalence of AR increased from 12.4% in 1992 to 15.0% in 2000. The incidence of AR from 1992 to 2000 was 4.8%, while 23.1% of the cases with AR in 1992 stated no AR symptoms in 2000 indicating remission. The highest incidence was seen in the youngest age group (20-29 years), whereas remission was highest in the oldest age group (50-59 years). Asthma symptoms during the last year (as reported in 1992) predicted increased incidence of AR and less chance for remission, 1.89 (95%CI 1.08-3.31) and 0.52 (0.31-0.87), respectively. Family histories of AR or asthma predicted increased incidence of AR 1.99 (1.42-2.80) and 1.62 (1.10-2.37), respectively, but were not associated with chance for remission, OR = 1.23 (0.81-1.87) and 0.94 (0.60-1.48).

CONCLUSION

This study showed that AR became more common between 1992 and 2000, but also indicated remission in about 20% of the cases within the 8-year period, particularly in older ages. Asthma seems to be associated with higher risk for AR as well as less chance for remission, while heredity of asthma (or AR) may only be associated with the risk for the development and not remission of AR.

Once-daily sublingual allergen-specific immunotherapy improves quality of life in patients with grass pollen-induced allergic rhinoconjunctivitis: a double-blind, randomised study

The effect of sublingual immunotherapy on quality of life (QoL) was examined in patients with grass pollen-induced rhinoconjunctivitis. Patients (n = 855) were randomised to once-daily grass allergen tablets (2,500; 25,000; or 75,000 SQ-T Phleum pratense extract; GRAZAX or placebo. Treatment was initiated 8 weeks before the start of the grass pollen season and continued throughout. If symptoms were present, patients received loratadine or placebo rescue medication. There were three major findings: in patients using loratadine, grass allergen tablets provided QOL benefits over placebo; Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score was 17% (p = 0.006) and 20% (p = 0.020) greater with 75,000 SQ-T tablet than with placebo at first and second seasonal visit, respectively; in patients not using loratadine, grass allergen tablets improved QoL more than placebo; RQLQ score was 21% greater (p = 0.021) with 75,000 SQ-T tablet at second seasonal visit; grass tablets (without loratadine) had a greater effect on QoL than loratadine alone. RQLQ score was 26% (p = 0.014) greater with 75,000 SQ-T tablets than loratadine at second seasonal visit. These data show that sublingual immunotherapy with grass allergen tablets improves QOL in allergic rhinoconjunctivitis, reduces symptoms, and that this effect is greater than rescue antihistamine alone.

Do patients with skin allergies have higher levels of anxiety than patients with allergic respiratory diseases? Results of a large-scale cross-sectional study in a French population

BACKGROUND

Psychological comorbidity is a known aspect of allergic disease. However, there is recent evidence that a large proportion of allergic patients remains undiagnosed and untreated for psychological disease. In addition, the complexities of the anxiety-allergy relationship, i.e. differences for current and past disease, or differences among allergic disease types, are not well understood.

OBJECTIVES

To measure the level of anxiety in a large allergic population in France using a standardized measure, the State/Trait Anxiety Inventory (STAI).

METHODS

Allergy patients in France (n = 3939) who visited their allergy specialists participated in the study. The patients completed a questionnaire which was then linked to the questionnaire completed by their physician. Only patients with both subject and physician questionnaire were kept in the analyses. Mean STAI scores for the State (S) and Trait (T) scales were obtained for each allergic disease. ANCOVA models testing group differences on the mean scores, using the categories "current disease", "past disease" and "allergic disease ever", were assessed along with relevant confounders.

RESULTS

Allergic rhinitis (AR), asthma and atopic dermatitis (AD) were the most prevalent conditions of the 12 allergic diseases assessed in the study. Women had higher mean STAI S/T scores than men and age was also found to be associated with higher S scores; therefore, both age and gender were included as covariates where relevant. A single ANCOVA model for each STAI scale showed a statistical difference among the various allergic diseases. Using the category "current disease" each allergic disease was assessed separately regarding the presence or absence of that disease. Higher, statistically significant mean STAI scores were found for AD and allergic urticaria on the S scale and for AD on the T scale. Similarly, for the category "allergic disease ever", AD and allergic urticaria reached statistical significance on the S scale, while on the T scale only AD was statistically significant. When patients were assessed for anxiety based on their past disease, asthma, AR and sinusitis were significant on the S scale while asthma and nasal polyps were statistically significant on the T scale. When asthma and AD were tested simultaneously, only the latter was significant.

CONCLUSIONS

High mean scores for State and Trait anxiety were mostly associated with AD.

Strategies for recombinant allergen vaccines and fruitful results from first clinical studies

Recombinant DNA technology has delivered the prospect of a new generation of preparations for allergen-specific immunotherapy. The first clinical studies with recombinant allergens have yielded encouraging results, suggesting that there is a good chance that such preparations will become available for use in the routine management of allergic disease.

Prevalence, classification and perception of allergic and nonallergic rhinitis in Belgium

BACKGROUND

Allergic rhinitis (AR) and noninfectious, nonallergic rhinitis (NINA) are common disorders, which may prompt patients to seek medical help.

METHODS

We performed a survey in a representative sample of the Belgian population (n=4959) with an overall prevalence of self-declared recent rhinitis symptoms of 39.3%. Detailed information on patients having experienced nasal symptoms over the past year was then obtained from a random sample of respondents (n=743).

RESULTS

The adjusted prevalence was 29.8% for AR and 9.6% for NINA, respectively. According to the ARIA classification, there was significantly more 'persistent' symptomatology in the AR group (40.8%) than in NINA (23.5%) (P<0.001), and more 'moderate/severe' symptom intensity in AR (75.4%) than in NINA (53.1%) (P<0.001). Allergic rhinitis patients suffered from a greater number of symptoms than NINA patients (P<0.001). Asthma, skin and food allergy as co-morbidities were all found to be significantly more prevalent in the AR vs the NINA group (P<0.05 for all). The percentage of consulting patients (total: 66.8%), who subjectively perceived their rhinitis as moderate/severe, was 94.0%, whereas 75.6% of these patients were classified accordingly based on ARIA criteria.

CONCLUSIONS

We found a high prevalence of self-declared rhinitis symptoms in the Belgian population, AR being about three times more prevalent than NINA. In addition, AR patients suffered from a greater number of symptoms and displayed a more 'persistent' and 'moderate-severe' ARIA profile than NINA. About 75% of patients seeking medical help suffer from 'moderate to severe' forms of rhinitis.

Is outdoor air pollution associated with physician visits for allergic rhinitis among the elderly in Toronto, Canada?

BACKGROUND

While a number of studies suggest that air pollution is associated with allergic rhinitis in children, findings among adults have been equivocal. The aim of this study was to examine the relationship between outdoor air pollution and physician visits for allergic rhinitis among individuals>or=65 years of age in Toronto, Canada.

METHODS

Physician visits were identified by using data from the Ontario provincial health insurance plan that is made available to all residents. Our analyses are based on 52,691 physician visits for allergic rhinitis among individuals>or=65 years of age in the Toronto metropolitan area between 1995 and 2000. Generalized linear models were used to regress daily counts of physician visits against daily measures of gaseous and particulate components of air pollution after controlling for seasonality, potential confounders (temperature, relative humidity, aeroallergens), overdispersion and serial correlation.

RESULTS

A large number of comparisons were undertaken, with most showing no statistically significant associations between daily levels of air pollution and the number of physician visits for rhinitis. In contrast, an interquartile increase in the 10-day average of ragweed particles increased the mean number of daily rhinitis consultations by 6.4% (95% CI=0.7-12.4%).

CONCLUSIONS

Our findings suggest that outdoor air pollution is a poor predictor of physician visits for allergic rhinitis among the elderly.

Classification and management of allergic rhinitis patients in general practice during pollen season

BACKGROUND

Allergic rhinitis (AR) represents a major challenge in primary care. The Allergic Rhinitis and its Impact on Asthma (ARIA) group proposed a new classification for AR and developed evidence-based guidelines for the management of this disease. We conducted this study to further characterize the classes of AR described by ARIA, and to evaluate whether the management of AR in general practice is in accordance with the ARIA guidelines.

METHODS

During the pollen season of 2003, 95 Belgian general practitioners (GPs) enrolled 804 patients who presented with symptoms of AR. For each patient, a questionnaire comprising the clinical presentation and management was completed.

RESULTS

In 64% of the patients, AR was classified as intermittent and in 36% as persistent. Persistent rhinitis caused more discomfort than intermittent rhinitis. Only 50% of the patients had ever undergone allergy testing. Among them, 51% were allergic to both seasonal and perennial allergens. Eighty-two per cent of the persistent rhinitics were allergic to at least one seasonal allergen and 72% of the intermittent rhinitics to at least one perennial allergen. When compared strictly with the ARIA recommendations, 49% of the patients with mild and/or intermittent AR were overtreated, whereas about 30% of those with moderate/severe persistent rhinitis were undertreated.

CONCLUSION

This study confirms that the previous classification of AR into 'seasonal' and 'perennial' is not satisfactory and that intermittent and persistent AR are not equivalent to seasonal and perennial AR respectively. Furthermore, persistent rhinitis has been shown to be a distinct disease entity. Further efforts are required to disseminate and implement evidence-based diagnostic and treatment guidelines for AR in primary care practice.

Phl p 3: Structural and immunological characterization of a major allergen of timothy grass pollen

BACKGROUND

The relevant importance of individual allergens for allergic sensitization is only partially understood. More detailed information on allergen structure and how it influences immunological responses can lead to better diagnosis of disease and improved preparations for allergen-specific immunotherapy. Grass pollen contains several different allergens, and although the group 3 allergens have been classified long ago, their structure and allergenicity have been poorly investigated.

OBJECTIVE

To characterize Phl p 3 from timothy grass pollen and compare it with Phl p 2 with respect to biochemical structure and allergenicity.

METHODS

Natural Phl p 2 and Phl p 3 were separated from a pollen extract by chromatography and characterized by 2D electrophoresis and protein sequencing. The complete sequences were determined by DNA cloning and detected in natural pollen extracts by mass spectrometry. Further comparisons of the allergens were made for IgE-binding and cross-reactivity, allergenicity was determined by basophil CD203c activation and skin prick test and 3D structures were compared by molecular modelling.

RESULTS

Phl p 3 reveals molecular masses of 10.958 and 10.973 kDa and pIs of 8.9 and 9.3, respectively, Phl p 2 a molecular mass of 10.816 kDa and a pI of 4.6. The sequence identity is 58%. In spite of these differences in the primary structures, both allergens reveal similar conformational structures, resulting in similar immunological and allergological moieties.

CONCLUSIONS

The group 3 and group 2 allergens are major allergens with similar 3D structures. Although they differ considerably in their protein sequences and their pIs, they show only a slightly higher immunological reactivity for Phl p 3 on the B-cell level (conformational epitopes). But distinct differences between the sequences may influence reactivity at the T cell level.

Efficacy and safety of allergen-specific immunotherapy in rhinitis, rhinoconjunctivitis, and bee/wasp venom allergies

The prevalence of allergic diseases, such as rhinoconjunctivitis, is increasing worldwide, particularly in Westernized countries, where more than 30% of the population is affected. Insect venom allergy is also very common, affecting up to 5% of the population. Allergen-specific immunotherapy is the only immunomodulatory treatment that may alter the natural course of allergic disease, for example by preventing the development of asthma in rhinitic patients. Nonetheless, the risk-benefit ratio for subcutaneous immunotherapy has changed little from when it was first developed a century ago. However, the rapid evolution of new developments, including new methods of administration and new forms of antigen to stimulate the immune system, now offers improvements in both the safety and the efficacy of specific immunotherapy. These developments include the sublingual administration of the relevant antigens, which has a superior safety profile than the original subcutaneous route. This may enable higher dosages to be used over shorter treatment periods, with a lower risk of anaphylactic reactions. Improvements in the purity, specificity, and immunogenicity of the antigens, often as a result of advances in biotechnology, coupled with the development of new adjuvants, may further increase the efficacy of this form of treatment. This review describes and discusses these new developments in the context of the many recent advances in our understanding of the mechanisms by which immunotherapy appears to act.

Specific immunotherapy with SQ standardized grass allergen tablets in asthmatics with rhinoconjunctivitis

BACKGROUND

The best way to prevent allergy symptoms is to treat the allergic condition. Specific immunotherapy with grass allergen tablets 75,000 SQ-T (Grazax, Phleum pratense, ALK-Abelló) is safe and efficacious in rhinoconjunctivitis patients. As rhinoconjunctivitis often co-exists with asthma, we aimed to confirm safety and efficacy in grass allergic subjects with asthma and rhinoconjunctivitis.

METHODS

A randomized, double-blind, placebo-controlled, multicentre trial was performed 10-14 weeks prior to and during the grass pollen season 2004. About 114 subjects were randomized 2 : 1 to grass allergen tablets or placebo. The primary end points were average asthma medication and symptom scores during the grass pollen season, and secondary variables were average rhinoconjunctivitis symptom and medication scores during the grass pollen season. Additionally, number of well days was defined post hoc.

RESULTS

Differences in asthma medication and symptom scores between the treatment groups were negligible. The mean difference in asthma medication score was below 0.1 and 0.3 for asthma symptom score [a single inhalation of salbutamol (200 microg) was scored 2]. No serious adverse events were reported. A reduction in rhinoconjunctivitis symptom score of 37% (P = 0.004) and a 41% (P = 0.036) reduction in medication score was found in the grass pollen season for subjects treated with the grass allergen tablet compared with placebo. Well days increased by 54% (P = 0.002).

CONCLUSIONS

Self-administration of the grass allergen tablet was safe. The treatment did not impair asthma control and confirmed considerable symptom prevention and reduced medication use. It addresses the allergic condition and represents a baseline treatment for grass pollen allergy.

[Immunotherapy with allergen extracts for allergic rhinitis]

Immunotherapy with allergens is an established therapy for allergic rhinitis. It reverses the T(H2)-skewed immune response and induces immune tolerance to the allergen applied. Weekly and later monthly allergen injections with sustained-release preparations over 3 years are the current reference method. Also chemically modified allergens and immune adjuvants may be used. Immunotherapy reduces allergy symptoms, the consumption of antiallergic drugs, and the mucosal inflammatory reaction. A particular characteristic is the reduction of asthma morbidity and additional sensitizations to new allergens. In Germany, serious side effects arise on the average per every 10,000 injections, and an anaphylactic shock approximately per every 250,000 injections. Serious adverse events are substantially rarer with sublingual immunotherapy, but they also occur. At present, efficacy of sublingual immunotherapy has been demonstrated in adults with pollen allergy. The effects of immunotherapy last for several years after its termination. As a consequence, immunotherapy is also economically reasonable.

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.

Costs associated with persistent allergic rhinitis are reduced by levocetirizine

BACKGROUND

Allergic rhinitis was recently classified by the ARIA guidelines as persistent or intermittent. Levocetirizine was shown to improve symptoms and health-related quality of life of patients with persistent allergic rhinitis in the XPERT study, a 6-month randomized double blind placebo-controlled trial.

OBJECTIVE

To assess the total costs of persistent allergic rhinitis, and the effect of long-term treatment with levocetirizine on these costs from several perspectives (societal, social security system, and employers).

METHODS

Direct medical cost parameters (medications, physician visits and hospitalizations) and time lost parameters (workdays and Usual Daily Activities (UDA) lost) related to persistent allergic rhinitis and its comorbidities (asthma, sinusitis, otitis and upper respiratory infection) were measured. A cost analysis was performed using 2002 French costing data.

RESULTS

From a societal perspective, the total cost of persistent allergic rhinitis without long-term treatment was estimated at 355.06/patient/month. From a social security perspective, levocetirizine treatment yielded an additional cost of 2.78/patient/month, compared to no-treatment. However, levocetirizine reduced the total cost of persistent allergic rhinitis and its comorbidities by 152.93/patient/month from a societal perspective and by 64.70/patient/month from an employer perspective. Most gains resulted from a decrease in the lost workdays and UDA in the levocetirizine group.

CONCLUSION

The cost of persistent allergic rhinitis is substantial. Treatment with levocetirizine reduces the cost of persistent allergic rhinitis and its comorbidities to the society by 152.93/patient/month while improving symptoms and health-related quality of life.

Epidemiological characterization of the intermittent and persistent types of allergic rhinitis

BACKGROUND

A new classification of allergic rhinitis (AR) has been proposed by the allergic rhinitis and its impact on asthma (ARIA) workgroup. The validity of this new classification is still largely unknown, especially the extent to which it differs from the classical seasonal/perennial (SAR/PAR) classification, and how and whether intermittent and persistent types of AR, as defined by ARIA, differ from each other.

METHODS

Two-step cross-sectional, population-based, in six Western Europe countries; telephone interview followed by clinical diagnosis [including specific immunoglobulin E (IgE) measurements] in a selected subset.

RESULTS

Within the population with AR, 29% of the subjects had persistent AR. There was no association between the intermittent/persistent and the SAR/PAR classifications. Subjects with persistent AR had more severe symptoms, and higher rate of self-awareness and previous diagnosis of AR; they were also clearly distinct in their sensitization pattern and medication use.

CONCLUSIONS

The classic types of SAR/PAR cannot be used interchangeably with the new classification of intermittent/persistent, as they do not represent the same stratum of disease. There is also evidence that the persistent type describes a distinct group with characteristics that differentiates them from intermittent AR. These results support the validity of the new ARIA classification.