The cost of treating allergic rhinitis

The effect of face mask usage on the allergic rhinitis symptoms in patients with pollen allergy during the covid-19 pandemic

PURPOSE

The study aims to evaluate the use of face masks on allergic rhinitis symptoms in pollen allergy patients who were compulsorily using face masks due to the covid-19 pandemic.

MATERIALS AND METHODS

A 15-item questionnaire was developed following the study goals by a team experienced in allergic rhinitis. Then the records of patients who underwent allergy tests in our hospital between 2013 and 2019 were retrospectively analyzed. Fifty participants with isolated pollen allergy were included in the study. Patients who agreed to participate in the research answered the questions over the phone.

RESULTS

Of the 50 participants, 30 (60%) were female and 20 (40%) were male, with a mean age of 34.34 ± 9.41 years. While the rate of participants who defined their nasal symptoms as severe-moderate in the pre-pandemic period was 92% (46 patients), this rate decreased to 56% (28 patients) during the pandemic when they used face masks. In ocular symptoms, the same rate decreased from 60% (30 patients) to 32% (16 patients). A statistically significant decrease was found in both nasal and ocular symptoms of patients after mask use (p < 0.001). The most regression in allergy symptoms was observed in sneezing (p = 0.029) and nasal discharge (p = 0.039).

CONCLUSIONS

This study observed that the use of face masks reduced both nasal and ocular allergic rhinitis symptoms in individuals with pollen allergy. These results support the hypothesis that the use of face masks would reduce the severity of allergic rhinitis symptoms.

Association of body mass index and season with histamine skin reactivity in Chinese children with allergic rhinitis

BACKGROUND

To investigate the association between histamine skin reactivity and body mass index (BMI) and other clinical factors, 526 children (3-6 years old) who underwent a skin-prick test (SPT) to diagnose allergic rhinitis were enrolled.

METHODS

The SPT was carried out using 43 common allergens (commercial kit). The wheal size was analyzed. The associations between histamine reactivity and age, gender, BMI, atopy, parental smoking history, and testing season were examined.

RESULTS

Mean age was 4.6 ± 1.1 years. Among all 526 children, 202 (38.4%) had intermittent allergic rhinitis (IAR), 164 (32.1%) had IAR + persistent allergic rhinitis (PER), and 160 (30.4%) had PER. The size of the histamine skin wheal and maximum diameter for positive allergens showed significant seasonal differences (P = 0.001 and P = 0.02, respectively). Children with biparental allergy history had a higher BMI (P = 0.006). BMI (P < 0.001), summer testing (P = 0.001), and autumn testing (P < 0.001) were independently associated with the size of the histamine skin wheal. Only winter testing was independently associated with the maximal diameter for positive allergens (P = 0.002).

CONCLUSIONS

Higher histamine skin reactivity was associated with higher BMI and summer or autumn testing. Subject BMI and season should be considered for better interpretation of the SPT. The mechanisms underlying these associations require further study.

Clinical associations between allergies and rapid eye movement sleep disturbances

Background

Allergic rhinitis, an immunoglobulin E inflammatory condition including nasal congestion, obstruction, sneezing, pruritus, and fatigue symptoms, has significant impact on quality of life and impairs sleep. Sleep‐disordered breathing (SDB) patients often have normal all‐night apnea‐hypopnea (AHI) or respiratory‐disturbance (RDI) indices on polysomnography (PSG). We hypothesized that the rapid eye motion–respiratory disturbance index (REM‐RDI) may be a novel predictor of allergic status.

Methods

A retrospective analysis of 100 patients compared REM‐RDI results in 67 allergen‐positive patients with 33 nonallergic patients who presented with nasal blockage. Subjects completed STOP‐Bang©, 22‐item Sino‐Nasal Outcome Test (SNOT‐22)©, and Epworth Sleepiness Scale© questionnaires and underwent skin‐prick testing (SPT) and PSGs including REM‐RDI values. Using multivariate logistic regression models, we evaluated relationships between allergic status and sleep parameters while controlling for possible confounders including body mass index (BMI).

Results

Using REM‐RDI as the outcome of interest, allergen‐positive patients were 3.92 times more likely to have REM‐RDI values in a moderate/severe range (≥15 events/hour); and patients with moderate/severe REM‐RDI values were more likely to be allergen positive (p < 0.05). Allergic status was not significantly related to all‐night AHI, RDI, or REM‐AHI. BMI was not significantly related to REM‐RDI. STOP‐Bang© was related to allergy status (p = 0.02) and REM‐RDI (p < 0.01). Allergic patients had increased REM latency and less total amount of REM.

Conclusion

We revealed significant bidirectional associations between allergen positivity and increased REM‐RDI values independent of BMI, AHI, RDI, and REM‐AHI. Allergic inflammation and REM‐RDI data may play important roles in diagnosing and treating fatigued SDB patients and as objective perioperative safety and outcomes measures.

Management of allergic rhinitis in the era of effective over-the-counter treatments

Allergic rhinitis (AR) may be regarded as a trivial issue unworthy of the doctor's time, and with the availability of many different over-the-counter (OTC) treatments, up to two thirds of patients self-manage AR before seeking medical care. Yet, AR can have a significant impact on health-related quality of life and is associated with a greater detriment to work productivity than other chronic diseases such as diabetes and hypertension. For many patients, the impact on quality of life is greater than suggested by reported symptoms and should also be a focus of treatment. Although many patients can effectively manage AR symptoms independently, a significant percentage will need direction from a physician to obtain optimal results. The availability of several different classes of treatment - including decongestants, sedating and non-sedating antihistamines, and more recently intranasal corticosteroids (INS) - has increased the complexity of self-management, leaving patients confused about the best approach to treatment. Treatment guidelines universally classify INS as the most effective medical agents available for use in the OTC and primary care settings. Many patients are unaware that INS are available OTC and that they are more effective than other therapies. Patients may have negative perceptions about the safety of INS and may have experienced unpleasant taste, scent, and feel with nasal sprays. Unless a patient volunteers the information, healthcare professionals (HCPs) may be unaware that the patient has significant AR and is using one or more OTC AR therapies. To address this gap in communication, HCPs must be proactive in identifying, assessing, and advising patients with AR, including best strategies to assess allergen trigger symptoms, which treatments are appropriate, and when and how to use them. Proper use of delivery devices is especially important. This article reviews the primary care management of AR in the context of the availability of effective OTC medicines.

Association of body mass index and other factors with histamine skin reactivity in adults with allergic nasal symptoms

BACKGROUND

The skin-prick test is the most commonly used method to diagnose allergy. In addition, histamine skin reactivity is used as a positive control for the skin-prick test. However, there is individual variation in histamine skin reactivity. The factors that influence individual variation in histamine skin reactivity remain unknown.

OBJECTIVES

We aimed to investigate the factors associated with histamine skin reaction.

METHODS

Ninety-seven subjects who underwent a skin-prick test to diagnose allergic rhinitis were enrolled in this study. The skin-prick test was performed with six common allergens. The wheal size of the histamine skin reaction was analyzed; other variables included age, sex, body mass index (BMI), atopy, smoking history, and the testing season.

RESULTS

The wheal size in the histamine skin test was significantly associated with age and BMI. The association between histamine skin reactivity and BMI was also present in multivariate analysis, adjusted for age, sex, atopy, smoking history, and season.

CONCLUSION

Histamine skin reactivity increased with BMI (degree of obesity). This association should be considered for better interpretation of the skin-prick test. Further studies regarding the mechanism for this association are needed.

Underdiagnosed and Undertreated Allergic Rhinitis in Urban School-Aged Children with Asthma

Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.

Sublingual or subcutaneous immunotherapy for seasonal allergic rhinitis: an indirect analysis of efficacy, safety and cost

RATIONALE, AIMS AND OBJECTIVES

The standard of preventive care for poorly controlled seasonal allergic rhinitis (AR) is subcutaneous immunotherapy (SCIT) with allergen extracts, administered in a physician's office. As an alternative to SCIT, sublingual immunotherapy (SLIT) is now an option for patients with seasonal AR. Oralair, a SLIT tablet containing freeze-dried allergen extracts of five grasses [cocksfoot (Dactylis glomerata), meadow grass (Poa pratensis), rye grass (Lolium perenne), sweet vernal grass (Anthoxanthum odoratum) and timothy grass (Phleum pratense)], and Grazax, a SLIT tablet containing a standardized extract of grass pollen allergen from timothy grass (P pratenase), are two such agents currently available in many countries. However, head-to-head comparative data are not available. In this study, an indirect comparison on efficacy, safety and cost was undertaken between Oralair, Grazax and SCIT.

METHODS

A systematic review was conducted for double-blind placebo-controlled randomized trials evaluating Oralair, Grazax or SCIT in patients with grass-induced seasonal AR. Using placebo as the common control, an indirect statistical comparison between treatments was performed using meta regression analysis with active drug as the primary independent variable. An economic analysis, which included both direct and indirect costs for the Canadian setting, was also undertaken.

RESULTS

Overall, 20 placebo-controlled trials met the study inclusion criteria. The indirect analysis suggested improved efficacy with Oralair over SCIT [standardized mean difference (SMD) in AR symptom control = -0.21; P = 0.007] and Grazax (SMD = -0.18; P = 0.018). In addition, there were no significant differences in the risk of discontinuation due to adverse events between therapies. Oralair was associated with cost savings against year-round SCIT ($2471), seasonal SCIT ($948) and Grazax ($1168) during the first year of therapy.

CONCLUSIONS

Oralair has at least non-inferior efficacy and comparable safety against SCIT and Grazax at a lower annual cost.

Sleep impairment and daytime sleepiness in patients with allergic rhinitis: the role of congestion and inflammation

OBJECTIVE

To investigate the association of rhinitis with stress, fatigue, decrease productivity, inflammation, and sleep disordered breathing.

DATA SOURCES

Medical literature obtained from OVID and PubMed searches in February 2013 using the search terms "sleep," "rhinitis," "allergic rhinitis," "somnolence," and "fatigue".

STUDY SELECTIONS

Studies were selected based on the US Preventive Services Task Force levels 1, 2, and 3.

RESULTS

Allergic rhinitis is a disease that severely affects patients' quality of life and is increasing in prevalence worldwide. Nasal congestion is reported as the most common and bothersome symptom; it is often associated with sleep-disordered breathing, a likely cause of sleep impairment in rhinitis-affected individuals. The end result is a reduced quality of life and productivity and an increase in daytime sleepiness, fatigue, and stress. Current treatment modalities include intranasal corticosteroids, which have been found to reduce nasal congestion. Clinical trials on intranasal corticosteroids have provided data on sleep-related end points, and these studies report that the improved nasal congestion is associated with improved quality of life with better sleep and reduced daytime fatigue. Alternate therapies, including montelukast, also decrease nasal congestion and positively influence sleep, but to a lesser extent.

CONCLUSION

This review examines nasal congestion and cytokine changes and the associated sleep impairment in allergic rhinitis patients and the effect on daytime performance. It elaborates the adverse effects of disturbed sleep on quality of life and how therapies directed at reducing nasal congestion can relieve such effects.

The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review

BACKGROUND

The objective of this work was to systematically review existing literature on the association between allergic rhinitis (AR) and sleep-disordered breathing (SDB) in children.

METHODS

We performed a literature search encompassing the last 25 years in PubMed, EMBASE, and Cochrane CENTRAL. Inclusion criteria included English-language papers containing original human data, number of subjects ≥7, and age <18 years old. Data was systematically collected on study design, patient demographics, clinical characteristics/outcomes, and level-of-evidence. Two investigators independently reviewed all articles.

RESULTS

The initial search yielded 433 abstracts, of which 18 articles were included. Twelve (67%) of the 18 articles showed a statistically significant association between AR and SDB. All articles were either case-series or case-control studies. Based on the Newcastle-Ottawa scale, the quality of the articles was determined to be fair to good. For characterizing AR, 7 (39%) studies included skin-prick testing and/or in vitro testing. For determining presence of SDB, 7 (39%) of the studies used polysomnographic data, of which 1 study incorporated data from a home polysomnogram. Habitual snoring was the most common form of SDB studied, in 10 (56%) of the articles. Obstructive sleep apnea was studied in 6 (33%) articles.

CONCLUSION

Although the majority of the studies included in this review showed a significant association between AR and SDB, all of the studies were evidence level 3b and 4, for an overall grade of B- evidence (Oxford Evidence-Based Medicine Center). Further higher-quality studies should be performed in the future to better evaluate the relationship between AR and SDB in children.

Short-term use of inhaled and intranasal corticosteroids is not associated with glaucoma progression on optical coherence tomography

PURPOSE

To compare the changes in retinal nerve fiber layer (RNFL) thickness and optic nerve cup/disc ratio on optical coherence tomography (OCT) between users and nonusers of inhaled and intranasal corticosteroids (ICS).

METHODS

Retrospective study of participants with glaucoma or glaucoma suspect having 2 or more OCTs during a 6-year period. The rates of change in Stratus OCT fast RNFL thickness scan and fast optic disc scan data were compared between ICS users and nonuser controls using random coefficient models.

RESULTS

A total of 170 participants met the inclusion criteria, of whom 42 (25%) were ICS users and 128 (75%) were controls. The mean duration of follow-up was 3.2 years. There were no significant differences in the mean rates of change in superior RNFL (-0.8874 µm/y ICS users; -0.8592 µm/y controls; p=0.943), nasal RNFL (-0.0529 µm/y ICS users; -0.3577 µm/y controls; p=0.419), inferior RNFL (0.2703 µm/y ICS users; -0.1910 µm/y controls; p=0.165), and temporal RNFL (-0.3618 µm/y ICS users; -0.3612 µm/y controls; p=0.998) between ICS users and controls. There were no significant differences in the mean rates of change in horizontal cup/disc ratio (-0.0047 µm/y ICS users; 0.0002 µm/y controls; p=0.212) and vertical cup/disc ratio (0.0013 µm/y ICS users; 0.0029 µm/y; p=0.717) between ICS users and controls.

CONCLUSIONS

We found no significant difference in the rates of RNFL or optic nerve cup/disc ratio progression among individuals with glaucoma or glaucoma suspect following short-term ICS use.

Allergic rhinitis

Allergic rhinitis is a costly disease associated with significant morbidity. It impacts the quality of life of millions of individuals, particularly in industrialized nations, and it is on the rise. Lost productivity and total healthcare expenditure exceeds several billion dollars annually in the United States, with an estimate of >$6 billion spent on prescription medications alone. It is also associated with asthma and other atopic conditions, sinusitis, otitis media, and sleep apnea. Primary care physicians should be well adept at recognizing and initiating empiric first-line therapy for chronic rhinitis. Allergen avoidance, topical nasal steroids, and antihistamines may be sufficient for some patients. In most cases, referral to a board-certified allergy specialist for skin testing and targeted management is indicated. It is essential to make sure that patients abstain from using antihistamines at least 1 week prior to reporting to the allergist for skin testing in order to avoid false-negative results. Traditional subcutaneous allergen immunotherapy, when performed by an experienced allergist, affords relief in >75% of cases. The growing armament of treatment options for refractory allergic rhinitis includes oral and sublingual immunotherapy, recombinant allergens, conjugated DNA vaccines, and anti-immunoglobulin E monoclonal antibody.

Nasal carbon dioxide for the symptomatic treatment of perennial allergic rhinitis

BACKGROUND

Brief nasal carbon dioxide insufflation has previously been shown to provide rapid relief of the symptoms of allergic rhinitis.

OBJECTIVE

To examine the safety and efficacy of nasal carbon dioxide on the symptoms of perennial allergic rhinitis.

METHODS

This was a randomized, double-blind, placebo-controlled, multicenter, in-clinic study that evaluated 2 flow rates (5 or 10 mL/s) and 2 administration durations (10 or 30 seconds per nostril) for nasal carbon dioxide vs placebo. Study participants rated their symptoms in clinic for 4 hours after administration and then through 24 hours outside the clinic. A total of 348 symptomatic patients with a minimum 2-year history of perennial allergic rhinitis requiring pharmacotherapy were randomized and treated.

RESULTS

The mean change in total nasal symptom score from baseline at 30 minutes (the primary end point) showed greater improvement in the nasal carbon dioxide-treated groups compared with placebo. This change was statistically significant in the group treated with 10 mL/s for 10 seconds per nostril: -4.69 carbon dioxide vs -2.00 placebo (P = .03). The effect of a single dose lasted approximately 4 to 6 hours. The mean change from baseline at 30 minutes in total nonnasal symptom score was also statistically significant (-4.06 carbon dioxide vs -2.25 placebo, P = .029) for this group. The most common adverse events were nasal discomfort, lacrimation, and headache.

CONCLUSION

The study provides further evidence that nasal carbon dioxide is a potentially efficacious treatment for the symptoms of allergic rhinitis.

The economic impact of allergic rhinitis and current guidelines for treatment

OBJECTIVE

To describe the economic burden of allergic rhinitis treatment and current guidelines for treatment.

DATA SOURCES

Review articles and original research were retrieved from MEDLINE, OVID, PubMed (1950-November 2009), personal files of articles, and bibliographies of located articles that addressed the topic of interest.

STUDY SELECTION

Articles were selected for their relevance to the burden of allergic rhinitis and current guidelines for treatment. Publications included reviews, treatment guidelines, and clinical studies.

RESULTS

Despite the common symptoms of allergic rhinitis, its impact on patient quality of life, and the huge cost to society and individuals of treatment, including pharmacotherapy, many patients do not adhere to their medication regimens because the medications do not adequately address their symptoms or are otherwise problematic for them to use.

CONCLUSIONS

The economic impact of allergic rhinitis is substantial; the total direct medical cost of allergic rhinitis is approximately $3.4 billion, with almost half of this cost attributable to prescription medications. Multiple treatment options are available, and these were reviewed to provide an update on effectiveness and adverse effects that may affect patient adherence.

The patient with allergies

Allergic disease affects a sizeable percentage of the general population, has a significant impact on patient quality of life, and exerts a significant financial burden on society. Atopic symptoms from inhalant allergens are among the most frequent complaints in outpatient medical visits. Key history and physical examination findings help to distinguish allergic rhinitis from other forms of chronic rhinosinusitis. Diagnostic testing may not be necessary unless immunotherapy is contemplated.

Congestion and sleep impairment in allergic rhinitis

Allergic rhinitis is a prevalent disease in developed nations, and its prevalence has been increasing throughout the world. Nasal congestion is the most common and bothersome symptoms of rhinitis. Congestion is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment in individuals with rhinitis. The end result is a decrease in quality of life and productivity and an increase in daytime sleepiness. Treatment with intranasal corticosteroids has been shown to reduce nasal congestion. Data on sleep-related end points from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Other therapies, such as montelukast, also have a positive influence on congestion and sleep. This review examines nasal congestion and the associated sleep impairment of allergic rhinitis patients. It explores the adverse effects of disturbed sleep on quality of life and how these conditions can be reduced by therapies that decrease congestion.

Local production of IgE in the respiratory mucosa and the concept of entopy: does allergy exist in nonallergic rhinitis?

OBJECTIVE

To review research regarding locally produced IgE and its impact on patients with chronic rhinitis.

DATA SOURCES

PubMed search with the following keywords: entopy, local IgE, nonallergic rhinitis, idiopathic rhinitis, vasomotor rhinitis, and allergic rhinitis.

STUDY SELECTION

Articles were selected based on their relevance to entopy and locally produced IgE and its clinical effect and relationship to idiopathic rhinitis (IR).

RESULTS

Local IgE has been found in a variety of tissues, including nasal and bronchial mucosa. IgE is produced in these local tissues and not simply the product of migration to the tissue from regional lymphoid tissue or blood. Local IgE has been identified in most of both atopic and nonatopic asthmatic patients and allergic rhinitis patients. Up to 40% of patients with IR and a positive nasal provocation test result have evidence of locally produced IgE, which has been coined entopy. Although patients with allergic rhinitis and IR show similar inflammatory patterns with increased activated mast cells, eosinophils, and T-cell subsets in some studies, other studies on IR patients are conflicting with regard to both inflammation and allergen-specific nasal provocation test results.

CONCLUSION

The concept of local allergy in IR patients is both intriguing and controversial. Studies have reported conflicting results, and currently there is no single best test to evaluate for entopy. It is known that there are a large number of IR patients for whom current treatment regimens are suboptimal. Therefore, further research elucidating the mechanisms of IR and the concept of localized IgE are needed to optimally diagnose this condition and treat this group of patients.

Sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis

Sleep impairment is a significant problem for patients with inflammatory disorders of the upper respiratory tract, such as allergic rhinitis, rhinosinusitis, and nasal polyposis. Nasal congestion, one of the most common and bothersome symptoms of these conditions, is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment. This review examines sleep impairment associated with allergic rhinitis, rhinosinusitis, and nasal polyposis. It explores the adverse effects of disturbed sleep on patients' quality of life and how these inflammatory nasal conditions can be reduced by therapies that address the underlying problems affecting sleep. Treatment with intranasal corticosteroids has been shown to reduce nasal congestion in inflammatory disorders of the upper respiratory tract. Data on sleep-related end points from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Further research using measures of sleep as primary end points is warranted, based on the potential of these agents to improve sleep and quality of life in patients with allergic rhinitis, acute rhinosinusitis, and nasal polyposis. Such trials will help to identify the most effective therapies for sleep impairment in these 3 nasal conditions.

Evolving paradigm in the management of allergic rhinitis-associated ocular symptoms: role of intranasal corticosteroids

BACKGROUND

Along with nasal symptoms, ocular symptoms such as itching, tearing, and redness are common, bothersome components of the allergic rhinitis (AR) profile. Treatment of the patient with ocular allergy symptoms should take into account a variety of factors, including severity of symptoms, convenience/compliance issues, and patient preferences.

OBJECTIVES

To review from the primary care perspective the epidemiology, pathophysiology, and management of ocular symptoms associated with AR, and to evaluate the emerging role of intranasal corticosteroids (INSs).

FINDINGS

A search of the PubMed database identified clinical trials that assessed efficacy of agents in reducing ocular allergy symptoms. Internet searches identified further information including data on over-the-counter agents for treatment of ocular symptoms. Searches were conducted using search terms such as pathophysiology, epidemiology, ocular allergy, quality of life, drug class, and drug names. Primary care physicians are often the first point of contact for patients with seasonal AR (SAR) or perennial AR (PAR) symptoms. Ocular allergy associated with SAR and PAR (seasonal and perennial allergic conjunctivitis, respectively) is characterized by both early- and late-phase reactions, with symptoms often persisting long after allergen exposure. Non-pharmacologic measures such as allergen avoidance, use of artificial tears, and cool compresses are pertinent for all ocular allergy sufferers, but may not afford adequate symptom control. Pharmacotherapy options have traditionally included topical ophthalmic products for cases of isolated ocular symptoms, and oral antihistamines for patients with both nasal and ocular symptoms. However, this paradigm is changing with new evidence regarding the efficacy of INSs in reducing ocular symptoms. A number of meta-analyses and individual studies, most of which studied ocular symptoms as secondary variables, have demonstrated the ocular effects of INSs versus topical and oral antihistamines. Additional prospective studies on this topic are encouraged to provide further evidence for these findings.

CONCLUSIONS

In light of their well-established efficacy in reducing nasal allergy symptoms, INSs offer a comprehensive treatment option in patients with nasal and ocular symptoms. Oral antihistamines and/or topical eye drops may also be necessary depending on symptom control.

A survey of the burden of allergic rhinitis in the USA

BACKGROUND

A prospective, cross-sectional, international survey was conducted among patients and physicians to identify symptom perception and the impact of allergic rhinitis (AR) on health-related quality of life (HRQoL). This paper presents the results from the USA.

METHODS

Data were recorded by 447 patients and matched with data collected on these patients by primary care physicians or specialists. Tests to confirm a diagnosis of AR had been performed on 345 (77.2%) patients. Because of the intermittent nature of the disease, both physicians and patients recorded the presence, severity and impact of symptoms at the time of consultation, in addition to symptoms frequently, but not currently, present. Health-related quality of life was assessed using the Mini Rhinoconjunctivitis Quality of Life Questionnaire.

RESULTS

According to the physicians' assessment, a large proportion of patients had moderate or severe disease (62.6%; n = 280), persistent disease (47.0%; n = 213) and comorbidities such as asthma (28.4%; n = 127). Comparison of the physicians' and patients' assessment of disease severity found that patients rated their disease as more severe than physicians across all three types of AR (P < 0.001). At the time of the consultation, 44.0% (n = 197) of patients were suffering from nasal and ocular symptoms, and 23.7% (n = 106) of all patients reported that their current nasal and ocular symptoms were moderate or severe in nature. More than 50% of the patients surveyed (56.4%; n = 252) were using two or more medications for their AR. Health-related quality of life correlated negatively with the number of symptom-free days in the previous 4 weeks. Allergic rhinitis had a significantly greater impact on patients with more persistent disease compared with those with intermittent disease (2.3 +/- 1.3 vs 1.4 +/- 1.1; P < 0.001); nevertheless, approximately two-thirds of patients with intermittent disease reported some impairment of their professional or daily life as a result of AR.

CONCLUSIONS

The results of this survey highlight the unmet needs of the many patients in the USA who present during routine care with moderate or severe and/or persistent disease and an associated high symptom burden and impaired HRQoL.

Intranasal noninhaled carbon dioxide for the symptomatic treatment of seasonal allergic rhinitis

BACKGROUND

Noninhaled intranasal carbon dioxide (CO2) has been shown to be effective in the abortive treatment of migraine headache. Migraine headache is associated with trigeminal neuronal activation and release of calcitonin gene-related peptide, events also implicated in allergic rhinitis. Intranasal CO2 might inhibit trigeminal neuronal activation and suppress the release of calcitonin gene-related peptide.

OBJECTIVE

We studied whether noninhaled intranasal CO2 would be effective in the treatment of seasonal allergic rhinitis.

METHODS

We conducted a single-center, randomized, double-blind, placebo-controlled, parallel-group study. Treatment consisted of either CO2 (verum) or air (placebo) at a 2:1 ratio administered in each nostril for 60 seconds per nostril at a flow rate of 10 mL/s. The primary efficacy end point was the change from baseline in total nasal symptom score (TNSS), the sum of congestion, rhinorrhea, itching, and sneezing scored on a 0- to 5-point scale, at 30 minutes.

RESULTS

Eighty-nine subjects received treatment, 60 with CO2 and 29 with placebo, and all subjects completed the study. CO2 resulted in a statistically significant improvement in TNSS at 30 minutes over placebo (absolute changes of 5.0 for CO2 and 2.2 for placebo, P = .00019). Improvement from baseline in TNSS (CO2 vs placebo) was statistically significant at 10 minutes and remained so for 24 hours.

CONCLUSION

Two 60-second intranasal CO2 treatments resulted in rapid (10 minutes) and sustained (24 hours) relief of seasonal allergic rhinitis symptoms.

Long-term safety and efficacy of intranasal ciclesonide in adult and adolescent patients with perennial allergic rhinitis

BACKGROUND

Ciclesonide is a corticosteroid in development for allergic rhinitis that has been shown to be safe and effective in seasonal allergic rhinitis and perennial allergic rhinitis (PAR) trials of up to 6 weeks in duration. However, the long-term safety and efficacy of ciclesonide are unknown.

OBJECTIVE

To demonstrate the long-term safety of intranasal ciclesonide, 200 microg once daily, in patients with PAR.

METHODS

Patients (> or = 12 years old) with a 2-year or longer history of PAR were randomized in a double-blind fashion to receive ciclesonide, 200 microg, or placebo once daily in the morning for up to 52 weeks. Spontaneous and elicited adverse events were monitored throughout the study. Ear, nose, and throat examinations were performed to evaluate local tolerability. Additionally, 24-hour urinary free cortisol level, morning plasma cortisol level, intraocular pressure, and lens opacification were monitored to evaluate the systemic safety of intranasal ciclesonide. Ciclesonide efficacy was determined by measuring 24-hour reflective total nasal symptom scores.

RESULTS

No clinically relevant differences were observed between the ciclesonide and placebo groups in adverse events, ear, nose, and throat examinations, or 24-hour urinary free or morning plasma cortisol levels. Similarly, no clinically relevant differences were found between treatment groups in intraocular pressure, visual acuity, or lens opacification. With regard to efficacy, ciclesonide achieved a significantly greater reduction in 24-hour reflective total nasal symptom score compared with placebo over more than 52 weeks (P < .001).

CONCLUSION

In this study, intranasal ciclesonide, 200 microg once daily, was safe and effective for the long-term treatment of PAR, with no evidence of tachyphylaxis.

Efficacy, cost-effectiveness, and tolerability of mometasone furoate, levocabastine, and disodium cromoglycate nasal sprays in the treatment of seasonal allergic rhinitis

BACKGROUND

Current guidelines recommend intranasal glucocorticosteroids as first-line therapy for seasonal allergic rhinitis.

OBJECTIVE

To compare the efficacy, cost-effectiveness, and tolerability of the topical glucocorticosteroid mometasone furoate, the topical antihistamine levocabastine hydrochloride, and the cromone disodium cromoglycate in seasonal allergic rhinitis.

METHODS

This study was performed during the 2003 grass pollen season as an open, randomized, parallel-group, single-center study of 123 patients assigned to receive mometasone furoate (200 microg once daily), levocabastine hydrochloride (200 microg twice daily), or disodium cromoglycate (5.6 mg 4 times daily). Symptom scores and nasal inspiratory peak flow measurements were recorded in a patient diary. The global efficacy of the study medication was evaluated by patients after treatment. Eosinophil cationic protein concentrations were measured in nasal secretions before and after treatment. Cost-effectiveness was evaluated as medication cost per treatment success.

RESULTS

Mometasone furoate therapy was significantly superior to the use of levocabastine or disodium cromoglycate with respect to all nasal symptoms, the global evaluation of efficacy, and eosinophil cationic protein concentration. Furthermore, mometasone furoate therapy was significantly superior to disodium cromoglycate therapy with respect to nasal inspiratory peak flow. Medication cost per treatment success was lowest with mometasone furoate use and highest with levocabastine use.

CONCLUSION

This is the first study to compare mometasone furoate nasal spray with nonsteroidal topical treatments for seasonal allergic rhinitis. Mometasone furoate nasal spray was confirmed as a first-choice topical treatment option for seasonal allergic rhinitis.

Cost and utilization impacts of oral antihistamines in the California Medi-Cal program

OBJECTIVES

Newer oral allergic rhinitis (AR) medications, the second-generation antihistamines (SGAs) have gained widespread acceptance because of their efficacy and reduced side effects relative to first-generation antihistamines (FGAs). There are no empirical studies comparing the costs of treatment of SGAs relative to FGAs.

METHODS

We analyzed data from a 20% beneficiary sample (approximately 120,000 continuously enrolled beneficiaries per year) for the Medi-Cal Fee-for-Service program during 1999 to 2000. AR medications available under Medi-Cal included three SGA medications (loratadine, fexofenadine, and cetirizine) and over 200 FGA products containing either diphenhydramine or chlorpheniramine or both. Because multiple medications were evaluated, a sample selection model was estimated using a two-stage multinomial logistic--variance components regression framework.

RESULTS

SGA medications have significantly lower total direct health-care treatment costs per patient than FGA medications with costs ranging from US 347 dollars to US 448 dollars less (P < 0.001), despite higher AR medication costs. Total drug expenditures were also not significantly different for patients using SGA or FGA medications despite SGA prescriptions averaging US 47 dollars higher than FGAs. Emergency department visits, inpatient admissions and physician office visits were also significantly lower for patients using SGA medications.

CONCLUSIONS

Significant cost and utilization reductions were associated with all of the SGA medications relative to FGA drugs, despite their higher acquisition costs. If facing higher copayments for prescription AR drugs, many patients, particularly lower income patients, may choose cheaper over-the-counter (OTC) FGAs rather than SGAs. Our analysis finds this might lead to increased overall health-care treatment costs, unless Medicaid and health insurance plans subsidize OTC AR medications.

The relationship between vaccine refusal and self-report of atopic disease in children

BACKGROUND

In the last 3 decades, there has been an unexplained increase in the prevalence of asthma and hay fever.

OBJECTIVE

We sought to determine whether there is an association between childhood vaccination and atopic diseases, and we assessed the self-reported prevalence of atopic diseases in a population that included a large number of families not vaccinating their children.

METHODS

Surveys were mailed to 2964 member households of the National Vaccine Information Center, which represents people concerned about vaccine safety, to ascertain vaccination and atopic disease status.

RESULTS

The data included 515 never vaccinated, 423 partially vaccinated, and 239 completely vaccinated children. In multiple regression analyses there were significant ( P < .0005) and dose-dependent negative relationships between vaccination refusal and self-reported asthma or hay fever only in children with no family history of the condition and, for asthma, in children with no exposure to antibiotics during infancy. Vaccination refusal was also significantly ( P < .005) and negatively associated with self-reported eczema and current wheeze. A sensitivity analysis indicated that substantial biases would be required to overturn the observed associations.

CONCLUSION

Parents who refuse vaccinations reported less asthma and allergies in their unvaccinated children. Although this relationship was independent of measured confounders, it could be due to differences in other unmeasured lifestyle factors or systematic bias. Further research is needed to verify these results and investigate which exposures are driving the associations between vaccination refusal and allergic disease. The known benefits of vaccination currently outweigh the unproved risk of allergic disease.

Treatment of Seasonal Allergic Rhinitis Using Homeopathic Preparation of Common Allergens in the Southwest Region of the US: A Randomized, Controlled Clinical Trial

BACKGROUND:

Studies using homeopathy have reported beneficial effects from treating allergy-related conditions.

OBJECTIVE:

To investigate the effects of a homeopathic drug prepared from common allergens (tree, grass, weed species) specific to the Southwest region of the US.

METHODS:

A 4-week, double-blind clinical trial comparing homeopathic preparations with placebo was conducted in the Phoenix metropolitan area during the regional allergy season from February to May. Participants included 40 men and women, 26–63 years of age, diagnosed with moderate to severe seasonal allergic rhinitis symptoms. Study outcomes included allergy-specific symptoms using the rhinoconjunctivitis quality-of-life questionnaire (RQLQ), functional quality of life using the Medical Outcomes Study Short Form-36 (MOS SF-36), and the work productivity and activity impairment (WPAI) questionnaire.

RESULTS:

Scales from the RQLQ, MOS SF-36, and WPAI questionnaire showed significant positive changes from baseline to 4 weeks in the homeopathic group compared with the placebo group (p < 0.05). Subjects reported no adverse effects during the intervention period.

CONCLUSIONS:

These preliminary findings indicate potential benefits of the homeopathic intervention in reducing symptoms and improving quality of life in patients with seasonal allergic rhinitis in the Southwestern US.

Intranasal irradiation with the xenon chloride ultraviolet B laser improves allergic rhinitis

We earlier reported that the 308 nm xenon chloride (XeCl) ultraviolet B (UVB) laser is highly effective for the treatment of inflammatory skin diseases. Since UVB irradiation has been shown to exert both local and systemic immunosuppression, we investigated the clinical efficacy of UVB irradiation in allergic rhinitis. In an open study, groups of patients with severe allergic rhinitis received intranasal irradiation with a 308 nm XeCl UVB excimer laser for two weeks. In the low-dose group (n=10), treatment was given twice weekly, starting with 0.25x the individual minimal erythema dose (MED), whereas patients in the medium-dose group (n=8) were treated four times weekly, starting with 0.4x MED. In each group, the dosage was gradually increased. Evaluation was based on the symptom scores. The effect of the XeCl laser on the skin prick test reaction was also studied. In the low-dose group, seven patients completed the study, and there was no improvement in the nasal symptoms. In the medium-dose group, the XeCl UVB irradiation significantly inhibited the rhinorrhoea, the sneezing, the nasal obstruction and the total nasal score (p<0.05). The XeCl UVB excimer laser also inhibited the allergen-induced skin prick test in a dose-dependent manner. These results suggest that the XeCl UVB excimer laser might serve as a new therapeutic tool in the treatment of allergic rhinitis.

Evaluation of patients' preferences for triamcinolone acetonide aqueous, fluticasone propionate, and mometasone furoate nasal sprays in patients with allergic rhinitis

OBJECTIVE

To compare product attributes, preferences, and expected compliance associated with triamcinolone acetonide aqueous (TAA-AQ), fluticasone propionate (FP), and mometasone furoate (MF) nasal sprays in patients with allergic rhinitis.

STUDY DESIGN AND SETTING

Data from 2 randomized, double-blind crossover studies with identical design were pooled (N = 215). Patients completed a 14-item sensory attributes questionnaire immediately after each product, and stated their preference and expected compliance with a prescription after receiving all products.

RESULTS

Compared with FP and MF, TAA-AQ was associated with significantly less odor and greater liking of odor ( P < 0.001); and less taste, less dryness of nose/throat, less aftertaste, and greater overall liking ( P < 0.05). Significantly more patients preferred most a prescription of TAA-AQ (50.0%) versus FP (25.0%; P < 0.001) and MF (25.0%; P < 0.001), and would "definitely comply" with TAA-AQ (62.5%) versus FP (49.0%; P < 0.01) and MF (51.0%; P < 0.01).

CONCLUSION

TAA-AQ was associated with significantly more positive sensory attributes, higher preference, and better expected compliance than FP and MF.

SIGNIFICANCE

Patients' preferences for the sensory attributes of an intranasal corticosteroid may affect adherence to treatment.

Economic impact and quality-of-life burden of allergic rhinitis

Allergic rhinitis can be a debilitating condition which, if untreated, can result in considerable health-related and economic consequences. A review of the published literature was conducted, with quantitative/qualitative analysis as appropriate, to explore the direct, indirect, and hidden costs of allergic rhinitis, as well as the quality-of-life burdens that the disease presents to patients and to the healthcare system. Lack of treatment, undertreatment, or nonadherence to treatment in allergic rhinitis were seen to increase direct and indirect costs, reinforcing the need for patient education and for physicians to implement existing evidence-based guidelines for prevention and treatment. It was concluded that greater awareness of the total economic burden of allergic rhinitis should encourage appropriate intervention and ultimately ensure clinically favorable and cost-effective outcomes.

Relationships between atopy and bacterial infections

Atopy in its most common forms (asthma, allergic rhinitis, and atopic dermatitis) has a significant impact on society in terms of health care costs and quality of life. Aside from having significant morbidity from these diseases, patients with atopy have also been noted to have a high incidence of comorbidities, including bacterial infections such as otitis media and sinusitis. In this paper, current evidence is reviewed that supports the close associations among allergic rhinitis and the two commonly diagnosed bacterial diseases, otitis media and sinusitis.

Treatment of allergic rhinitis

Allergic rhinitis, a common and often debilitating disease marked by rhinorrhea, nasal congestion, nasal itching, and sneezing, is on the increase worldwide. Treatment involves allergen avoidance, pharmacotherapy, and, in selected cases, immunotherapy. This overview describes the characteristics, pathogenesis, and diagnosis of allergic rhinitis. The major contributing allergens of seasonal and perennial allergic rhinitis are identified. Pharmacotherapy is described within the context of treatment guidelines developed by the major asthma and allergy professional organizations. Oral H1 antihistamines are first-line therapy for mild-to-moderate allergic rhinitis. The newer, nonsedating agents are recommended over first-generation antihistamines. Some of the newer oral antihistamines, such as cetirizine, desloratadine, and fexofenadine, have been shown to relieve the symptom of nasal congestion. Intranasal steroids are first-line therapy for patients with more severe symptoms.

Atopic diseases of childhood

The atopic diseases of childhood consist of the triad of asthma, allergic rhinitis, and atopic dermatitis. All share a common pathogenesis, being mediated by IgE, and are frequently present together in the same individual and family. These disorders and their comorbidities comprise a large component of general pediatric practice and their incidence in developed countries has been increasing over the past few decades. They are a leading reason for clinic and emergency room visits, as well as hospital admissions. They have the potential to interfere with education, physical activity, socialization, and self-esteem. Fortunately, we now have a reasonable armamentarium of maintenance medications available to help control these disorders and improve the quality of life for children suffering from them. In addition, early diagnosis and aggressive management of these disorders seem to offer the possibility of altering their natural history. As such, developing a sensible approach to the diagnosis and treatment of these disorders in an outpatient setting is essential. In this review, I summarize the most current literature and provide a framework for effectively diagnosing and managing these disorders.