Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

The CONSORT statement checklist in allergen-specific immunotherapy: a GA2LEN paper

The methodology of randomized clinical trials is essential for the critical assessment and registration of therapeutic interventions. The CONSORT (Consolidated Standards of Reporting Trials) statement was developed to alleviate the problems arising from the inadequate reporting of randomized controlled trials. The present article reflects on the items that we believe should be included in the CONSORT checklist in the context of conducting and reporting trials in allergen-specific immunotherapy. Only randomized, blinded (in particular blinding of patients, health care providers, and outcome assessors), placebo-controlled Phase III studies in this article. Our analysis focuses on the definition of patients' inclusion and exclusion criteria, allergen standardization, primary, secondary and exploratory outcomes, reporting of adverse events and analysis.

Mometasone furoate nasal spray reduces symptoms and improves quality of life in Chinese patients with moderate to severe allergic rhinitis: a multicenter open-label study

CONCLUSION

Mometasone furoate nasal spray (MFNS) can reduce the symptoms and improve quality of life in Chinese patients with moderate to severe allergic rhinitis (AR).

OBJECTIVE

To evaluate the effects of MF on symptoms and quality of life in Chinese patients with moderate to severe AR.

PATIENTS AND METHODS

In a multicenter and open-label study, 500 patients with moderate to severe AR were enrolled and received MFNS 200 microg once daily. We visited the patients four times (at baseline, and week 1, 2, and 4) to record symptom scores and the influence of AR on daytime activities and quality of sleep. The Mini Rhinoconjunctivitis Quality of Life Questionnaire (Mini-RQLQ) and the Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire (NRQLQ) were used in this study.

RESULTS

Compared with the baseline, MFNS significantly reduced the total and individual symptom scores and nocturnal sleep and daytime activities scores at week 1, 2, and 4 according to the Mini-RQLQ and NRQLQ.

The ImmunoCAP Rapid Wheeze/Rhinitis Child test is useful in the initial allergy diagnosis of children with respiratory symptoms

Recurrent upper or lower respiratory symptoms, possibly allergy-related, are very frequent in childhood. It is therefore important that physicians involved in the primary care of these children have an accurate initial diagnostic tool available. In this study, we investigated the value of an in vitro diagnostic device testing 10 common allergens, the ImmunoCAP Rapid Wheeze/Rhinitis Child, for the primary evaluation of allergy. Children with non-infectious upper or lower respiratory symptoms possibly related to allergy were recruited in the primary health care setting of private practices of physician trained in immunology/allergology. The investigators carried out their usual diagnostic work-up including IgE tests, and the ImmunoCAP Rapid test was performed with capillary whole blood in a blinded way to the investigator. The investigators' conclusions on major triggering allergens were compared to the ImmunoCAP Rapid test results. In the whole patient population (n = 185), the sensitivity of the ImmunoCAP Rapid test for unveiling allergic disease was 92% (95% CI: 86-96%) and the specificity 97% (95% CI: 86-100%). Current guidelines for allergy diagnosis suggest screening children with recurrent, moderate/severe diseases for allergies. For children with asthma falling into these categories, sensitivity was 100% (95% CI: 88-100%) and specificity 100% (95% CI: 69-100%); for children with moderate and severe rhinitis sensitivity was 93% (95% CI: 86-97%) and the specificity 100% (95% CI: 79-100%). The ImmunoCAP Rapid test is an accurate test, in particular with regard to high specificity, for diagnosing allergy in children with recurrent respiratory diseases in primary care settings.

Levocetirizine in the treatment of allergic diseases

BACKGROUND

Levocetirizine, the R-enantiomer of cetirizine dihydrochloride, is a new molecule with a potent and selective antihistamine activity.

OBJECTIVE

To investigate the evidence that levocetirizine is an effective therapy for allergic disease.

METHODS

Evaluation of published articles in English, or having an English abstract.

RESULTS

Clinical trials indicate that levocetirizine is safe and effective for the treatment of allergic rhinitis and chronic idiopathic urticaria. The compound shows a rapid onset of action, high bioavailability and affinity for the H1 receptor. Moreover, this molecule demonstrates many anti-inflammatory effects that enhance the clinical therapeutic benefit not only in short-term but also in long-term treatments, as reported in recent trials utilizing levocetirizine for several months.

CONCLUSION

Levocetirizine confirms its safe effective activity for treatment of allergic disease in both adults and children.

A contemporary review of sublingual immunotherapy

The sublingual route has become an interesting and novel therapeutic option for the immunotherapeutic management of patients with allergies. Immunotherapy modifies the immune response by decreasing the specific IgE levels and Th2-type inflammation in the mucosa when allergen exposure occurs, shifting this toward a Th1-type response. Credible evidence exists of both effectiveness and safety of sublingual immunotherapy (SLIT) from several placebo-controlled double-blind studies. SLIT has been shown to be an effective treatment of allergic rhinitis and asthma in both children and adults. The therapy is well tolerated with mainly minor gastrointestinal side effects that subside in few weeks. The ideal treatment length and dosage still require further verification. Additional studies evaluating long-term efficacy and the immune response of SLIT still need to be performed, and additional standardized antigens still need to be developed.

Additional disease burden from hay fever and sinusitis accompanying asthma

OBJECTIVES

We sought to determine the additional disease burden imparted by sinusitis and hay fever (allergic rhinitis) to patients with asthma.

METHODS

Patients with a diagnosis of asthma, hay fever, or sinusitis were extracted from the National Health Interview Survey for the 1997 to 2006 adult sample. Disease groups consisting of patients with asthma alone, asthma + hay fever, asthma + sinusitis, and asthma + hay fever + sinusitis were assembled. Disease groups were then compared according to total health-care visits per year, emergency room visits per year, health-care spending per year, and number of workdays lost per year to determine the disease burden.

RESULTS

We identified 11,813 patients (mean age, 45.5 years) who reported active asthma with or without hay fever or sinusitis comorbidity. Of these, 5,931 patients (50%) were identified with asthma alone, 1,134 (10%) with combined asthma + hay fever, 2,461 (21%) with asthma + sinusitis, and 2,287 (19%) with combined asthma + hay fever + sinusitis. Patients with asthma + sinusitis and those with asthma + sinusitis + hay fever had more total health-care visits and emergency room visits than did those with asthma alone (p <0.001). All three groups with comorbidities had higher healthcare expenditures than did the group with asthma alone (p < or = 0.002). Patients with asthma + sinusitis and those with asthma + hay fever + sinusitis missed more workdays than did patients in the group with asthma alone (10.0 and 13.1 versus 7.2, respectively; p <0.001). Comorbid hay fever alone did not increase workdays lost (6.6 days; p = 0.983).

CONCLUSIONS

The additional disease burden of sinusitis on asthma is greater than that of hay fever. These data highlight the importance of identifying comorbid diagnoses with asthma.

Desloratadine for the treatment of cypress pollen-induced allergic rhinitis

BACKGROUND

Few studies have been conducted to assess treatment options for patients with sensitivities to cypress pollens, important triggers of allergic rhinitis (AR) in the Mediterranean region.

OBJECTIVE

To evaluate the effect of desloratadine, a second-generation antihistamine, on AR symptoms caused by cypress pollens native to France.

METHODS

Adults (N=233) with symptomatic cypress pollen allergies were randomized to receive desloratadine, 5 mg, or placebo daily for 15 days during 2 consecutive cypress pollen seasons. The primary end point was the percentage change from baseline in morning total nasal symptom scores on day 14; secondary assessments included total symptom score, peak nasal inspiratory flow, the Rhinoconjunctivitis Quality of Life Questionnaire, and global response to therapy.

RESULTS

On day 14, the desloratadine group had a significantly greater percentage decrease in total nasal symptom score vs the placebo group (-40% vs. -30%; P < .04). Similarly, on day 14, there was a 47% and 37% respective decrease in total symptom score (P = .01). Mean peak nasal inspiratory flow scores showed numeric, albeit not statistically significant, improvements from baseline through day 14 with desloratadine. A significantly greater improvement in Rhinoconjunctivitis Quality of Life Questionnaire scores occurred with desloratadine vs placebo on day 14 (-1.4 vs. -0.9; P = .004). The mean global response to therapy was better with desloratadine vs placebo (3.4 vs. 3.9; P = .004). The adverse event rate was similar in both groups.

CONCLUSION

Desloratadine is efficacious and safe for the treatment of AR induced by cypress pollens; it also improved disease-related quality of life.

[Allergic rhinitis and related diseases]

Allergic disease prevalence including allergic rhinitis has increased. It's relationship with other allergic diseases including asthma makes imperative it's diagnosis as well as co- -morbidity identification and associated complications. The most recent classification of the disease highlights the duration of symptoms and it's interference in the quality of life. The therapeutic strategy presented is based on eviction measures, pharmacological treatment, immunotherapy and, in selected cases, surgery. Pharmacological treatment should be done by "steps" according to the severity of the disease.

Exercise-Induced Asthma Symptoms and Nighttime Asthma: Are They Similar to AHR?

Background. Asthma experienced during exercise and during the night is based on the presence of airway hyperresponsiveness (AHR). The aim of the present study was to examine whether AHR is a predictor of exercise-induced asthma (EIA) and nighttime symptoms. Material. We included 793 asthmatics subjects with symptoms and a positive asthma test. Results. Mean (SD) FEV1 was 93% (15), 71% had rhinitis, and 62% had atopy. Both EIA and nighttime symptoms were associated with AHR; however, when including other factors of importance in a multivariate analysis, logRDR was eliminated, whereas FEV1% pred (P < .001), smoking (P < .05), atopy (P < .001), sex (P < .001), and treatment (P < .01) were associated with having EIA while dyspnoea (P < .001), cough (P < .001), and eosinophils (P < .01) were associated with frequent night symptoms. The risk of having nighttime awakenings due to asthma was more than twofold higher among those with EIA symptoms than among those without symptoms (OR (CI95%) 2.77 (2.0–3.8) (P < .001)). In Conclusion. EIA and night symptoms are associated with AHR, but other factors of importance eliminated this close association. Night asthma is more closely associated with airway inflammation than AHR.

Efficacy of sublingual specific immunotherapy in intermittent and persistent allergic rhinitis in children: an observational case-control study on 171 patients. The EFESO-children multicenter trial

Sublingual-specific immunotherapy (SLIT) is considered as a valid treatment of respiratory allergies. However, there are few data on large sample size regarding its clinical role in 'real life' in term of reduction of symptoms, rescue medications and prevention of asthma in patients suffering from allergic rhinitis (AR) especially in children. We performed a multicenter, case-control study to evaluate the effect of SLIT in children (age 6-18 yr) with intermittent or persistent AR. 171 children (27% girls and 73% boys) with AR due to seasonal or perennial allergens were enrolled in a multicenter case-control study. Cases (n = 90) were defined as patients with intermittent (64%) or persistent (36%) AR who were treated for at least two consecutive years with specific SLIT with the related allergen extracts (SLITone ALK-Abellò). Controls (n = 81) were defined as sex-age- and type of allergen matched AR children who were never treated with specific immunotherapy and had no asthmatic symptoms at the beginning of observation period. Main outcomes of the study were the rhinoconjunctivitis symptom score (SS) (sneezing, rhinorrea, nasal itch, congestion, ocular itch and watery eyes) with a ranging scale from 0 (=no symptoms) to 3 (=severe symptoms) and the medication score (MS) evaluating symptomatic drug intake (antihystamine and inhaled corticosteroids). SS and MS were evaluated at the end of the observational period in relation with the period, considering the last 12 months, in which patients suffered the highest symptoms levels (i.e., peak of relevant pollen season (seasonal AR) or during the period of maximum allergen exposure in case of perennial AR). Secondary outcome of the study was the development of asthma symptoms during the observation period. SS (mean +/- SD) was 4.5 +/- 2.5 in cases and 9.0 +/- 3.0 in controls (-50%) (p = 0.0001). MS (mean +/- SD) was 2.5 +/- 1.9 and 3.6 +/- 2.1 in the case and control groups, respectively (-31%) (p = 0.0001). At the end of the observation period asthma symptoms were present in 14 subjects in the case group (15%) and in 20 children (24%) in the control group (p = 0.13). New skin sensitizations appeared in 6% of cases (n = 2) and in 36% (n = 12) of the controls (p = 0.001). The EFESO trial shows that a 2-yr once daily SLIT treatment in children with intermittent or persistent AR is associated with lower symptom and medication scores in comparison with subjects treated with symptomatic drugs only.

The efficacy of sublingual immunotherapy for house dust mites respiratory allergy: results of a GA2LEN meta-analysis

Recent meta-analyses documented the efficacy and safety of sublingual immunotherapy (SLIT) in patients with allergic rhinitis (AR) and asthma (AA). Although SLIT appeared globally effective, the sub-analyses for single allergens provided uncertain results. This study is aimed to investigate the efficacy of SLIT with house dust mite (HDM) extracts in AR and AA through an updated reassessment of randomized controlled trials. Electronic databases were searched up to March 31, 2008, for randomized DBPC trials, assessing the efficacy of SLIT in AR and AA due to HDM sensitization. Outcomes were symptom scores and rescue medications use. For AR, eight studies fulfilled the selection criteria. A significant reduction in symptoms of AR (SMD -0.95; CI 95%-1.77 to -0.14 P = 0.02) was found in 194 patients (adults and children) receiving SLIT compared to 188 receiving placebo. For AA, with nine studies, similar results were found for symptoms (SMD -0.95; CI 95%-1.74 to -0.15 P = 0.02) in 243 patients (adults and children) receiving SLIT compared to 209 receiving placebo. A reduction in rescue medication use was found for AR (SMD -1.88; CI 95%-3.65 to -0.12 P = 0.04) in 89 patients, and AA (SMD -1.48; CI 95%-2.70 to -0.26 P = 0.02) in 202 patients. A relevant inter-study heterogeneity was detected. Promising evidence of efficacy for SLIT, using mite extract in allergic patients suffering from AR and AA, are herein shown. These findings suggest that more data are needed, derived from large-population-based high quality studies, and corroborated by objective outcomes, mainly for AA.

Desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis

BACKGROUND

Symptoms of allergic rhinitis (AR), particularly nasal congestion, can impair quality-of-life (QoL). However, only a modest correlation exists between these symptoms and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores, suggesting that both be evaluated for a complete assessment of health.

METHODS

Subjects with a > or =2-year history of moderate-to-severe AR to dust mite or cat dander were randomized to desloratadine 5 mg/day (n = 293) or placebo/day (n = 291) for 28 days. Primary endpoint was change from baseline in a.m./p.m. nasal congestion score. Secondary outcomes included change from baseline in total nasal symptom score, individual symptom scores and RQLQ scores (completed on days 1, 7, and 28).

RESULTS

The Allergic Rhinitis and its Impact on Asthma criteria for persistent allergic rhinitis (PER) were fulfilled by 99% of subjects in the placebo arm. Between-treatment difference in a.m./p.m. nasal congestion score, observed from day 8 onward, significantly favored desloratadine (P = 0.0003). Desloratadine significantly improved a.m./p.m. nasal congestion and RQLQ scores after 1 week and at treatment end (P < 0.05). Improvements in 5 of 7 RQLQ domain scores exceeded the minimal important difference. On days 7 and 28, desloratadine was also significantly superior to placebo in mean change from baseline in a.m./p.m. total nasal symptom score and rhinorrhea score (both P < or = 0.01). Symptomatic benefit was primarily driven by improvement in nasal congestion and rhinorrhea.

CONCLUSIONS

Desloratadine 5 mg/day significantly improved symptoms associated with PER, including nasal congestion, and provided significant improvement in QoL after 1 week of treatment.

Serum adipsin levels in patients with seasonal allergic rhinitis: preliminary data

BACKGROUND

Several studies have outlined a possible relationship between adipokines and respiratory allergic diseases. However, there are no data about a role for adipsin in allergic rhinitis.

OBJECTIVE

The aim of the study was to evaluate the serum adipsin levels in patients with seasonal allergic rhinitis (SAR), subdivided into two sub-groups: treated or not treated with sublingual immunotherapy (SLIT), and in a group of healthy controls.

METHODS

The study included 110 subjects; i) 24 SLIT-treated SAR patients, ii) 62 untreated SAR patients, and iii) 24 normal subjects. All subjects were consecutively evaluated. A skin prick test and blood sampling for assessing serum adipsin levels were performed in all subjects.

RESULTS

Serum adipsin was increased in SAR patients, even though significant only in males. There was also a significant positive association between adipsin and adiponectin.

CONCLUSION

This preliminary study reports that adipsin serum levels may be increased in some SAR patients, but further functional studies should be performed.

Increased oral nitric oxide in obstructive sleep apnoea

BACKGROUND

Hypoxia and snoring-related mechanical trauma contribute to airway inflammation in obstructive sleep apnoea (OSA). Increased exhaled nitric oxide (FENO), an airway inflammation marker, has been reported in OSA patients. We propose the measure of NO in the oral cavity (oNO) as marker of oropharyngeal inflammation in OSA.

METHODS

We compared oNO and FENO of 39 OSA patients with those of 26 mild asthmatics (ASTHMA), 15 patients with chronic rhinitis or rhinosinusitis (CRS) and 24 healthy subjects. A special device was used for oNO measurement. Apnoea/hypopnoea index (AHI), oxygen desaturation index, mean and nadir SaO2 were calculated from the polysomnography.

RESULTS

oNO was significantly increased in OSA (104.2 95%CI 80.2-135.5ppb) as compared to ASTHMA (71.9 95%CI 56.3-91.9ppb; p=0.015), CRS (54.4 95%CI 40.2-73.7ppb; p=0.009) and healthy subjects (63.6 95%CI 59-73ppb; p<0.001). oNO was directly related to AHI (r=0.466, p=0.003) and to minutes slept with SaO2 <90% (r=0.471, p=0.011) and it was inversely related to nadirSaO2 (r=-0.393, p=0.018). FENO was highest in asthmatics (40.3 95%CI 32.5-50.1ppb) and only slightly elevated in OSA (23.1 95%CI 19,8-28.3ppb) and CRS (22.8 95%CI 16.8-32.5ppb).

CONCLUSIONS

The finding that oral NO is increased in OSA and is related to upper airway obstructive episodes and to hypoxemia severity, strengthens the clinical and pathogenic role of oral inflammation in OSA.

Local cytokines and clinical symptoms in children with allergic rhinitis after different treatments

Background

Therapy for allergic rhinitis aims to control symptoms and improve the quality of life. The treatment of allergic rhinitis includes allergen avoidance, environmental controls, pharmacologic treatment, and specific immunotherapy.

Objectives

The aim of this study is to evaluate the clinical changes and the levels of interferon-γ (IFN-γ) and interleukin-5 (IL-5) in nasal lavage fluid from children with allergic rhinitis after different types of pharmacologic treatment (mometasone, montelukast, or desloratadine).

Methods

Twenty-four children aged from six to 12 years with moderate persistent allergic rhinitis were randomized into three groups receiving monotherapy treatment over four weeks: nasal corticosteroid (mometasone), leukotriene modifier (montelukast), or antihistamine (desloratadine). The perception of symptom improvement during the medication use was evaluated at the end of the treatment. Samples of nasal lavage fluid were collected before and after treatment for measuring IFN-γ and IL-5 cytokines by ELISA.

Results

All parents perceived an improvement in symptoms. Significant enhancement was seen in the mometasone group compared to those with montelukast (P = 0.01) and desloratadine (P = 0.02). No significant differences were found among the three groups in the levels of IL-5 and IFN-γ in nasal fluid at baseline or after treatment. Only the group treated with mometasone showed a slight but significant reduction in IL-5 levels after the treatment period as compared with levels before the treatment (P = 0.0469).

Conclusion

The group treated with mometasone showed better improvement of clinical symptoms and a slight reduction in IL-5 levels in the nasal fluid. This may indirectly reflect the relative immunomodulatory effects of the drugs tested.

Time interval and the factors associated with the development of asthma in patients with allergic rhinitis

Rhinitis and asthma commonly coexist and studies have shown a positive association between rhinitis and asthma in both atopic and nonatopic adults. Longitudinal studies have shown that in many cases rhinitis precedes the onset of asthma. The aims of this study were to study the time interval for the development of asthma after the onset of rhinitis, to determine the proportion of patients in whom rhinitis precedes asthma, and to study the factors associated with the development of asthma in patients with allergic rhinitis compared to patients who continue to have allergic rhinitis alone. This was a cross-sectional study done at a tertiary care allergy center in Mysore, South India. It included consecutive patients between 2004 and 2006 with allergic rhinitis and/or asthma. We used a structured questionnaire, clinical evaluation, spirometry, and skin-prick testing. A total of 1,141 subjects were included in the study. Among them, 700 had allergic rhinitis for varying intervals before developing asthma and 355 had rhinitis without asthma. In subjects aged 20 years or younger, logistic regression analysis confirmed an independent association with a family history of allergic rhinitis and sensitization to house dust mites as risk factors and ever-used nasal steroids as protective against developing asthma in subjects with allergic rhinitis. In subjects older than 20 years, a family history of allergic rhinitis, atopy, and sensitization to house dust mites and trees were risk factors and ever-user of nasal steroids was protective. Rhinitis often preceded asthma and a high proportion of patients, both children and adults, developed asthma within 2 years after the onset of rhinitis. A family history of allergic rhinitis, atopy, and sensitization to house dust mites and trees are associated with the development of asthma in patients with allergic rhinitis.

Sublingual Immunotherapy Affects Specific Antibody and TGF-β Serum Levels in Patients with Allergic Rhinitis

Allergic rhinitis (AR) is characterized by Th2 polarized immune response, such as increased IL-4 and reduced IFN-γ production. Sublingual allergen-specific immunotherapy (SLIT) induces several immunological changes, most of which are still little known. The aim of this study is firstly to investigate the changes of allergen-specific IgE, IgG, IgG4, and IgA serum levels after SLIT. Secondly, this study aims at relating immunoglobulin (Ig) values with some Th1-, Th2-, and Treg-dependent cytokines. Twenty-three patients with pollen-induced AR were enrolled, and they assumed two pre-seasonal SLIT courses for 2 years. Serum allergen-specific IgE, IgG, IgG4 and IgA levels were determined by ELISA method at baseline and after each SLIT course. Serum IL-4, IFN-γ, IL-10, and TGF-β levels were also assessed. Allergen-specific IgE, IgG, IgG4, and IgA serum levels significantly increased after SLIT. Serum TGF-β significantly increased after SLIT. There was a significant correlation between IgA and TGF-β, both after the first and the second SLIT course. In conclusion, the present study provides the first evidence that pollen SLIT significantly affects Ig production, mainly concerning IgA; and IgA increase is related with TGF-β production. Moreover, this is the first study that measured Ig classes by using a quantitative method.

Visual analog scale (VAS) and nasal obstruction in persistent allergic rhinitis

OBJECTIVE

Nasal airflow resistance, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). However, rhinomanometry is scarcely available. The aim of this study was to verify the suitability of the use of visual analog scales (VAS) as a surrogate for rhinomanometry in quantifying nasal obstruction in patients with persistent allergic rhinitis.

STUDY DESIGN

Prospective study on patients with allergic rhinitis.

SETTING

ENT clinic.

SUBJECTS AND METHODS

Fifty patients (27 males, mean age 23 years, SD 2.24) were studied. VAS for nasal obstruction and other AR symptoms and rhinomanometry were performed in all patients.

RESULTS

A significant, very strong correlation has been observed between VAS for nasal obstruction and nasal airflow resistance (Spearman r = 0.879, P < 0.001). Moreover, a significant correlation exists between VAS for rhinorrhea and resistance (Spearman r = 0.313, P = 0.027).

CONCLUSION

The use of VAS for assessing the nasal obstruction appears clinically relevant in that it allows, with good reliability, the quantification of this symptom in the absence of rhinomanometry.

Efficacy of desloratadine in intermittent allergic rhinitis: a GA(2)LEN study

BACKGROUND

The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines proposed a classification for allergic rhinitis based on the duration of symptoms (intermittent, persistent) rather than on the time of allergen exposure (seasonal, perennial). There is no placebo-controlled, randomized clinical trial on intermittent allergic rhinitis (IAR) to date. Desloratadine (DL) is recommended for the first-line treatment of seasonal and perennial allergic rhinitis.

OBJECTIVES

To assess the efficacy and safety of DL in subjects with IAR based on the ARIA classification.

METHODS

Patients over 12 years of age with IAR were assessed over 15 days of treatment with DL 5 mg once daily (n = 276) or placebo (n = 271). The primary endpoint was the AM/PM reflective total 5 symptom score (T5SS). Secondary endpoints included AM/PM instantaneous T5SS and individual symptoms, therapeutic response, symptom severity by visual analogue scale, and quality-of-life.

RESULTS

The mean reduction of AM/PM reflective T5SS was significantly greater with DL than with placebo over 15 days (-3.01 vs-2.13, P < 0.001) and on each individual day (P < 0.05). Mean AM instantaneous T5SS was reduced significantly with DL compared to placebo as early as day 2 (-1.84 vs-0.89; P < 0.001). The therapeutic response and improvement in quality-of-life were significantly greater with DL than with placebo (P < 0.001 for each). The frequency of treatment-related adverse events was low and similar between DL (7.2%) and placebo (7.0%).

CONCLUSIONS

This is the first large trial to show that treatment can be effective in IAR. Desloratadine was effective and safe.

Continuous assessment of nasal airflow resistance by adaptive modeling

A method to assess nasal airflow resistance is presented that provides a continuous resistance value and applies a novel minimally obtrusive measurement technique. Instead of calculating the resistance once for each breathing cycle conventionally, it is calculated for each signal sample at any sampling frequency. The continuous pressure recording is produced with a nasopharyngeal catheter inserted 8 cm deep along the floor of the other nasal cavity and the flow recording is produced with respiratory effort bands. A least-mean-square (LMS) extension for the resistance model of Broms is developed that dynamically adapts to the time-varying characteristics of the nasal functioning and produces the continuous resistance values. Experimental results are shown that demonstrate the uniqueness and applicability of the new technique in assessing quickly changing resistance in a histamine/xylometatsolin challenges, the differences between normal and symptomatic patients, and the effect of nasal treatment of patients.

Clinical Importance of Eosinophil Count in Nasal Fluid in Patients with Allergic and Non-Allergic Rhinitis

Eosinophil count in nasal fluid (ECNF) was used to differentiate nasal pathologies. Receiver Operating Characteristic (ROC) curve analysis and the area under the curve (AUC) were performed to evaluate the ECNF's accuracy in distinguishing allergic rhinitis (AR) from non-allergic rhinitis (NAR). We also evaluated the accuracy of ECNF in recognizing patients with mild and severe symptoms of rhinitis and patients with ineffective and effective clinical responses to antihistamines. 1,170 consecutive adult patients with a clinical history of rhinitis were studied. ECNF's median in AR was 6.0 and 2.0 in NAR and the best cut-off value was > 3.0, AUC = 0.75. ECNF's median in AR with mild nasal symptoms was 3.0 and 7.0 with severe symptoms, and the best cut-off value was 4.0, AUC = 0.90. ECNF's median in NAR with mild nasal symptoms was 2.0 and 8.5 with severe symptoms, and the best cut-off value was > 4.0, AUC = 0.86. ECNF's median in AR with effective clinical response to antihistamines was 4.0 and 8.0 with ineffective response, the best cut-off value was ≤ 5.0, AUC = 0.94. ECNF's median in NAR with an effective clinical response to antihistamines was 1.0 and 2.0 with ineffective response, and the best cut-off value was ≤ 3.0, AUC = 0.64. Our results suggest an interesting practical use of ECNF data as evaluator of the clinical severity both AR and NAR. As predictor of the clinical response to antihistamines, ECNF is accurate only in patients with AR. The ECNF's performance was moderately accurate in distinguish patients with AR and NAR.

[GA2LEN (Global Allergy and Asthma European Network)]

Allergic diseases represent a major health problem in Europe. They are increasing in prevalence, severity and costs. GA2LEN (Global Allergy and Asthma European Network), an FP6 Network of Excellence, was created in 2005 as a vehicle to ensure excellence in research bringing together research and clinical institutions to combat fragmentation in the European research area and to tackle Allergy in its globality. GA2LEN benefited greatly from the voluntary efforts of researchers who are strongly committed to this model of pan-European collaboration. The network was organized in order to increase networking for scientific projects in allergy and asthma around Europe and to make GA2LEN the world leader in the field. Besides these activities, research has been jointly made and the first papers are being published. GA2LEN achievements in general can be grouped as those for a durable infrastructure built up during the project phase those which are project-related work based on these novel infrastructures, and the development and implementations of guidelines. The major achievements of GA2LEN are reported in this paper.

Management of patients with allergic rhinitis and asthma: literature review

Allergic rhinitis (AR) and asthma are disorders of the airway characterized by inflammation of the respiratory mucosa. The presence of one disorder increases the likelihood that the other will also occur. As they are mechanistically intertwined, one can exacerbate the other when both conditions are present. In addition, comorbid AR and asthma have an additive impact on patients' health-related quality of life. The Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations suggest that asthma patients should be evaluated for AR, and all AR patients should undergo tests for asthma. They also suggest that ideally, a combined strategy should be used to treat the upper and lower airway diseases. While treatment for AR includes antihistamines, intranasal glucocorticosteroids, antileukotrienes, and specific immunotherapy, data suggest that these treatment approaches may also improve asthma outcomes. This article reviews current clinical approaches to the diagnosis and management of patients with comorbid AR and asthma.

Early compliance and efficacy of sublingual immunotherapy in patients with allergic rhinitis for house dust mites

OBJECTIVES

Sublingual immunotherapy (SLIT) has recently received much attention around the world as a treatment for allergic rhinitis. This study aimed to investigate the efficacy and adverse effects of SLIT in Korean patients with allergic rhinitis caused by house dust mites. The treatment compliance and the patient satisfaction with SLIT were also assessed.

METHODS

The patients who were sensitized to Dermatophagoides pteronyssinus and Dermatophagoides farinae and who started SLIT between November 2007 and July 2008 were included in this study. The symptom questionnaires, which included items on rhinorrhea, sneezing, nasal obstruction, itchy nose, olfactory disturbance, eye discomfort and sleep disturbance, were obtained before and 6 months after SLIT. The patient satisfaction and the adverse effects were also investigated.

RESULTS

One hundred forty-two patients started SLIT and 98 of them continued SLIT for 6 months or more. Ninety-two of the 98 patients completed the questionnaires. The duration of receiving SLIT was 9.8 months on average (range, 6 to 13 months). All the symptoms of allergic rhinitis were improved with SLIT. Forty-five percent of the patients were satisfied for SLIT, while 12% were unsatisfied. The incidence of adverse effects was 12% during maintenance therapy, although it was 48% during the up-dosing phase. The drop-out rate of SLIT was 31.0%.

CONCLUSION

The subjective symptoms were improved with SLIT in Korean patients with allergic rhinitis for house dust mites. Yet the drop out rate was high despite of the symptomatic improvement.

Recommendations for appropriate sublingual immunotherapy clinical trials

Sublingual immunotherapy is gaining widespread attention as a viable alternative to subcutaneous immunotherapy for the treatment of allergic rhinoconjunctivitis. In addition, sublingual immunotherapy has been studied in other allergic disorders including asthma. However, a review of published studies indicates that there are deficiencies and considerable heterogeneity in both design and data interpretation of sublingual immunotherapy studies. These deficiencies have made it somewhat difficult to assess the appropriate place of sublingual immunotherapy in guidelines for the therapy of allergic diseases. Moreover, several unpublished oral and sublingual immunotherapy studies in the United States failed to meet primary endpoints. This article reviews data from sublingual immunotherapy trials and makes recommendations about appropriate designs of future sublingual immunotherapy studies. It is hoped that these recommendations will result in more adequately designed sublingual immunotherapy trials to facilitate the appropriate placement of this therapy to treat patients with allergic rhinoconjunctivitis and other allergic diseases.

Montelukast: Pharmacology, Safety, Tolerability and Efficacy

Allergic rhinitis and asthma are common disorders effecting large percentages of the population of Western countries. There are multiple treatment options available for allergic rhinitis and asthma and stepwise approaches to therapy have been recommended. Montelukast is a cysteinyl leukotriene receptor antagonist that has been found to be effective both in the treatment of allergic rhinitis and asthma. This paper will describe the pharmacology, safety, efficacy and tolerability of montelukast. It will examine the comparative efficacy of montelukast to other medications for the treatment of allergic rhinitis and asthma, as well as discuss the recent studies of combination therapy.

Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea

BACKGROUND

Although allergic rhinitis (AR) is accepted as a risk factor for obstructive sleep apnea syndrome (OSAS), the role of nonallergic rhinitis (NAR) is unknown.

OBJECTIVE

To compare OSAS in patients with AR vs NAR.

METHODS

We performed an observational study in 48 adults with AR and NAR that included a review of rhinitis and sleep symptoms, skin prick test results, self-administered questionnaire (Epworth Sleepiness Scale and 36-Item Short Form Health Survey) findings, and all-night polysomnography records.

RESULTS

The most frequent sleep symptom was snoring. Patients with AR had a significantly longer sleep duration and better sleep efficiency than did those with NAR. Both groups had frequent arousals. OSAS was diagnosed in 36% of patients with AR and in 83% of those with NAR (P = .001). Severe OSAS existed only in the NAR group. NAR showed a high correlation with OSAS (odds ratio, 6.4) and with apneas (odds ratio, 0.2). Body mass index, sex, and coexisting asthma did not have any predictable effect on OSAS, but age was correlated with OSAS. The impairment in quality of life was similar in both groups.

CONCLUSIONS

Both AR and NAR are risk factors for a high apnea-hypopnea index, and both can predispose to sleep apnea. However, NAR seems to have a greater risk according to impaired polysomnography results and higher Epworth Sleepiness Scale scores. Therefore, patients with rhinitis should be treated not only for nasal symptoms but also for a better quality of sleep.

[Skin sensitisation profiles of outpatients with symptoms of respiratory allergies]

AIM

The main objective of the survey was to determine the frequency of the mono and polysensitizations in patients consulting for respiratory allergy, rhinitis or/and asthma. The secondary objectives were to evaluate the severity, the number and the type of the sensitizations, the frequency of the asthma or rhinitis as a function of the sensitizations, the evolution of the sensitizations with age, and identify the principal responsible pneumallergens.

PATIENTS AND METHODS

The multicentric survey included a patient questionnaire allowing the collection and anonymous treatment of data on socio-demographic characteristics, clinical symptoms, cutaneous tests and sensitizations.

RESULTS

A sample of 505 patients, mean age 24 years, consulting for rhinitis or asthma, monosensitized (36%) or polysensitized (64%), was evaluated. The percentage of polysensitized patients was similar in asthmatics, patients with rhinitis, and patients with both asthma and rhinitis (60%, 65%, and 63%, respectively). The mean number of the sensitizations was 2.4 for patients with asthma, 2.6 for those with rhinitis, and 2.6 for patients with both asthma and rhinitis. The greater the severity of the rhinitis or asthma, the higher the number of the sensitizations. Sensitizations to acarids, gramineae and cat were the most frequent. When practioners were asked about their intention to undertake desensitization in polysensitized patients, 52% of them replied positively.

CONCLUSION

Data collected during this survey showed that a large proportion of the patients who consulted for rhinitis or asthma were monosensitized (36%). Sensitization to acarids was the most frequent. Even in polysensitized patients, more than half the practioners said they would use desensitization.

TGF-beta and IL-17 serum levels and specific immunotherapy

Two new T cell subsets may be involved in allergic rhinitis (AR) pathogenesis: Th17 and T regulatory cells, mainly producing IL-17 and TGF-beta respectively. Successful Sublingual Immunotherapy (SLIT) induces relevant immunological changes, thus the aim of this study was to evaluate serum IL-17 and TGF-beta levels in AR patients treated with SLIT for 2 years. Patients' blood samples were collected before initiating SLIT (baseline), three months after the end of the first pre-seasonal SLIT course, and at the end of the second pre-seasonal course. IL-17 was detectable only in the most severe allergic patients. SLIT significantly induced an increase in serum TGF-beta levels. There was moreover a significant relationship between TGF-beta and symptom severity and drug use at the end of the study. Therefore, this study provides clinically relevant evidence that two pre-seasonal SLIT courses may significantly affect serum TGF-beta levels.

Two year sublingual immunotherapy affects serum leptin

BACKGROUND

It has been demonstrated that serum leptin is elevated in females with allergic rhinitis. Recently, it has been reported that one course of sublingual immunotherapy (SLIT) does not affect serum leptin levels.

OBJECTIVE

The aim of this study was to evaluate the serum leptin levels in a cohort of patients with pollen-induced allergic rhinitis, before and after two pre-seasonal SLIT courses.

METHODS

Forty-one patients (22 males and 19 females, median age 39 years) with AR, due to pollen allergy, and 34 healthy subjects (16 males and 18 females, median age 43 years) were included in the study. Blood sampling for assessing serum leptin was performed in all subjects before and after the second SLIT course.

RESULTS

All patients were responders to SLIT. Serum leptin was significantly increased only in males (p=0.0056) after the second SLIT course.

CONCLUSION

This preliminary study shows that at least two pre-seasonal SLIT courses were required to induce significant modifications in serum leptin levels, but it occurred only in males. Some hypotheses might be outlined, including a leptin protective effect, however further studies must clarify this issue.

Serum interleukin-17 levels are related to clinical severity in allergic rhinitis

BACKGROUND

T helper (Th)-17 cells are a subset of T helper lymphocytes that exert regulatory activities. Recently, it has been reported that serum interleukin (IL)-17 levels are high in the most severe cases of birch allergy studied outside the pollen season.

OBJECTIVE

The aim of this study was to investigate a possible relationship between serum IL-17 levels and clinical parameters in patients with allergic rhinitis studied during the pollen season.

METHODS

In all, 56 patients with persistent pollen-induced allergic rhinitis were evaluated during the pollen season. Serum IL-17 levels were evaluated by enzyme-linked immunosorbent assay. Symptoms were assessed by visual analogue scale, drug use was monitored and peripheral eosinophils were counted.

RESULTS

Serum IL-17 levels were significantly related to clinical symptoms, drug use and peripheral eosinophil counts (P = 0.0001 for all).

CONCLUSION

This study provides evidence that serum IL-17 level assessment might be considered to classify allergy severity.

Unmet needs in severe chronic upper airway disease (SCUAD)

Although the majority of patients with chronic upper airway diseases have controlled symptoms during treatment, many patients have severe chronic upper airway diseases (SCUADs). SCUAD defines those patients whose symptoms are inadequately controlled despite adequate (ie, effective, safe, and acceptable) pharmacologic treatment based on guidelines. These patients have impaired quality of life, social functioning, sleep, and school/work performance. Severe uncontrolled allergic rhinitis, nonallergic rhinitis, chronic rhinosinusitis, aspirin-exacerbated respiratory diseases, or occupational airway diseases are defined as SCUADs. Pediatric SCUADs are still unclear. In developing countries SCUADs exist, but risk factors can differ from those seen in developed countries. Comorbidities are common in patients with SCUADs and might increase their severity. The present document is the position of a group of experts considering that SCUADs should be considered differently from mild chronic upper airway diseases. It reviews the state of the art, highlighting gaps in our knowledge, and proposes several areas for a better understanding, prevention, and management of SCUADs. This document can also serve to optimize the pharmacoeconomic evaluation of SCUADs by means of comparison with mild chronic upper airway diseases.

A review of the efficacy of desloratadine, fexofenadine, and levocetirizine in the treatment of nasal congestion in patients with allergic rhinitis

BACKGROUND

Nasal congestion is the most troublesome symptom of allergic rhinitis (AR). First-generation and older second-generation antihistamines, while effective against nasal itching, sneezing, and rhinorrhea, have limited efficacy in relieving nasal congestion.

OBJECTIVE

This review included nasal challenge studies and clinical trials that reported the effects on nasal congestion of the newer second-generation antihistamines desloratadine, fexofenadine, and levocetirizine.

METHODS

MEDLINE and EMBASE were searched for nasal challenge studies and clinical trials published in English between January 1, 1991, and January 31, 2009, using the following terms, alone or in combination: antihistamines, second-generation antihistamines, allergic rhinitis, intermittent allergic rhinitis, perennial allergic rhinitis, persistent allergic rhinitis, seasonal allergic rhinitis, nasal challenge, nasal blockage, and nasal congestion. Studies that were not active or placebo controlled, that did not evaluate change in nasal congestion scores, or that focused on treatments other than desloratadine, fexofenadine, and levocetirizine for nasal congestion associated with AR were excluded.

RESULTS

Twenty-six clinical trials met the criteria for inclusion in the review. In 11 placebo-controlled trials that included objective assessment of nasal congestion, desloratadine, fexofenadine, and levocetirizine were associated with reductions in the severity of nasal congestion through maintenance of nasal airflow. The mean AUC for nasal airflow over 6 hours was significantly greater with desloratadine compared with placebo in 3 studies (P < 0.05); placebo-controlled trials of fexofenadine and levocetirizine had similar results. In 25 placebo- and active-controlled trials that reported subject-rated symptom scores, the 3 newer antihistamines were efficacious in the treatment of nasal congestion associated with AR. In 10 trials that reported objective and/or subjective measures, desloratadine was associated with significant improvements in nasal congestion compared with placebo (P < or = 0.05), beginning as early as the first 2 hours after allergen challenge. Fexofenadine was associated with significantly lower nasal congestion scores compared with placebo in 4 studies (P <- 0.05); nasal congestion scores were significantly reduced with levocetirizine in 3 placebo-controlled trials (P < or = 0.005).

CONCLUSIONS

In the studies reviewed, desloratadine, fexofenadine, and levocetirizine were effective in relieving the nasal congestion associated with AR compared with placebo. This effect began as early as day 2 and was consistent and progressive throughout treatment. Desloratadine, fexofenadine, and levocetirizine are appropriate options for the treatment of nasal congestion in patients with AR.

The correlation between nasal symptom and mucociliary clearance in allergic rhinitis

OBJECTIVE/HYPOTHESIS

The Allergic Rhinitis and Its Impact on Asthma (ARIA) classification of allergic rhinitis (AR) is based on the severity and duration of nasal symptoms. Whether the nasal symptoms actually represent underlying nasal inflammation is unclear. The aim of this study was to evaluate the correlation between nasal symptoms and nasal inflammation using mucociliary clearance time (MCCT) in AR.

STUDY DESIGN

A prospective cross-sectional study.

METHODS

73 AR patients were classified according to ARIA class: mild or moderate-severe intermittent AR (MIAR or MSIAR) and mild or moderate-severe persistent AR (MPAR or MSPAR). Each nasal symptom was scored as 1 to 3 on a severity scale (mild-moderate-severe). The sum of the individual nasal symptom scores gave the total symptoms score (TSS). MCCT was determined with the charcoal-saccharin method. MCCTs between ARIA classes were compared and correlations between TSS or days with symptoms per week (DSW) and MCCT were analyzed.

RESULTS

Of the patients, 67.1% were moderate-severe degree. MSPAR had the worst MCCT, followed by MSIAR, MPAR, and MIAR (mean MCCTs of 14.32, 13.87, 11.94, and 10.28 minutes, respectively). TSS was well correlated with MCCT (P = .538, P < .001). DSW was also correlated with MCCT, but did not reach statistical significance (r = 0.217, P = .065). The mean MCCT of overall nasal symptoms increased along with each score step and a significant difference was noted between scores 2 and 3 (P < .001).

CONCLUSIONS

A high percentage of moderate-severe disease and a significant correlation of the severity and MCCTs suggest an important heterogeneity in this disease severity group. Discriminating between moderate and severe rhinitis should help to obtain homogeneous populations and develop improved disease management strategies.

Alleviation and prevention of severe allergic rhinitis and conjunctivitis following long-term lemon juice use: a case report

Allergic rhinitis (often coexisting with allergic conjunctivitis) is a highly prevalent, chronic, inflammatory disease. Most cases are not extraordinary; however, they may result in significant impairment in quality of life of patients, as well as in economical damage for both health-care system and patients. This case report describes the experiences of a middle-aged woman with the illness, who managed to completely alleviate and prevent her symptoms, in terms of intensity and chronicity, by drinking natural lemon juice diluted with water. Lemon changed her life radically.

Why do doctors and patients not follow guidelines?

PURPOSE OF REVIEW

The aim of this review is to evaluate the factors related to the doctor and the patient that could make following the guidelines difficult. It also underlines the importance of the adherence to guidelines themselves in order to ameliorate both the control of healthcare and the patients' quality of life.

RECENT FINDINGS

Following guidelines not only depend on factors related to guidelines themselves, to social-cultural context or to the strategies used to spread them: different studies have underlined that the characteristics linked to the doctor's and patient's subjectivity are crucial.

SUMMARY

Guidelines are recommendations regarding clinical behaviour, and their implementation is a complex process that is influenced by different factors, related both to the characteristics of guidelines themselves and to the social, organizational, economic and political context or to implementation strategies. During the last few years, different studies and theories have tried to explain the reason why doctors and patients do not follow the guidelines. Following the guidelines most of all depends on the characteristics linked to the doctor's and patient's subjectivity, which can be a real obstacle. Knowledge, attitude, skills, experiences, believes and values play a fundamental role both in physician and patient. By addressing these issues to physician's and patient's adherence, more exhaustive approaches to guidelines development and spread can be applied in order to improve care and outcomes.