Influences of allergic rhinitis on sleep

Risk and Protective Factors for Obstructive Sleep Apnea Syndrome Throughout Lifespan: From Pregnancy to Adolescence

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) in children is indeed a significant and often underdiagnosed condition. The risk factors for OSAS vary across different stages of life.

OBJECTIVES

Identifying risk factors early can help in taking preventive measures to reduce the likelihood of developing OSAS, and different life stages may require different interventions.

RESULTS

During pregnancy, maternal factors such as obesity, smoking, and genetic predispositions can increase the risk of OSAS, while breastfeeding serves as a protective factor. For children aged 2 to 12, adenotonsillar hypertrophy is the primary cause of airway narrowing, with other contributing factors including obesity, craniofacial abnormalities, and increased nasal resistance. In adolescence, obesity and craniofacial abnormalities remain the main risk factors.

CONCLUSIONS

By reviewing and understanding these risk factors, healthcare providers can offer more personalized and effective care, ultimately leading to better health outcomes for individuals at all stages of life.

Mutual Influence Between Allergic Rhinitis and Sleep: Factors, Mechanisms, and interventions-A Narrative Review

Patients with allergic rhinitis (AR) have a high incidence of sleep disorders, such as insomnia, which can easily exacerbate nasal symptoms. The aggravation of nasal symptoms further promotes the deterioration of sleep disorders, forming a vicious cycle. Severe cases may even trigger psychological and neurological issues, such as anxiety, depression, and cognitive impairment, causing significant distress to patients, making clinical diagnosis and treatment difficult, and increasing costs. Furthermore, satisfactory therapeutics remain lacking. As the pathogenesis of AR-associated sleep disorders is not clear and research is still insufficient, paying attention to and understanding AR-related sleep disorders is crucial in clinical practice. Multiple studies have shown that the most crucial issues in current research on AR and sleep are analyzing the relationship between AR and sleep disorders, searching for the influencing factors, and investigating potential targets for diagnosis and treatment. This review aimed to identify and summarize the results of relevant studies using "AR" and "sleep disorders" as search terms. In addition, we evaluated the correlation between AR and sleep disorders and examined their interaction and potential mechanisms, offering a foundation for additional screening of potential diagnostic biomarkers and therapeutic targets.

Allergic Diseases and Mental Health

Neuropsychiatric symptoms have long been acknowledged as a common comorbidity for individuals with allergic diseases. The proposed mechanisms for this relationship vary by disease and patient population and may include neuroinflammation and/or the consequent social implications of disease symptoms and management. We review connections between mental health and allergic rhinitis, atopic dermatitis, asthma, vocal cord dysfunction, urticaria, and food allergy. Many uncertainties remain and warrant further research, particularly with regard to how medications interact with pathophysiologic mechanisms of allergic disease in the neuroimmune axis. Proactive screening for mental health challenges, using tools such as the Patient Health Questionnaire and Generalized Anxiety Disorder screening instruments among others, can aid clinicians in identifying patients who may need further psychiatric evaluation and support. Although convenient, symptom screening tools are limited by variable sensitivity and specificity and therefore require healthcare professionals to remain vigilant for other mental health "red flags." Ultimately, understanding the connection between allergic disease and mental health empowers clinicians to both anticipate and serve the diverse physical and mental health needs of their patient populations.

An Observational Study to Determine the Real-Life Effectiveness of MP-AzeFlu® in Austrian Patients with Persistent Allergic Rhinitis

BACKGROUND

Many patients with allergic rhinitis (AR) have moderate-to-severe persistent AR. Meda Pharma's AzeFlu (MP-AzeFlu®) is an intranasal AR treatment comprising a novel formulation of azelastine hydrochloride and fluticasone propionate in a single device.

METHODS

This prospective observational study of 214 adults and adolescents in Austria with moderate-to-severe persistent AR assessed the effectiveness of MP-AzeFlu (one spray/nostril twice daily; daily doses: azelastine hydrochloride 548 μg; and fluticasone propionate 200 μg) for AR control in clinical practice using the visual analog scale. Symptom severity was reported on days 0, 1, 3, 7, 14, 21, 28, 35, and 42. Patient demographics, AR phenotype, allergen sensitization, symptomatology, AR treatments in the previous year, and the reason for the MP-AzeFlu prescription were recorded.

RESULTS

MP-AzeFlu treatment was associated with a rapid and statistically significant reduction in the visual analog scale score from baseline to each timepoint measured, including day 1 (all p < 0.0001). Mean (standard deviation) visual analog scale score was 53.5 mm (26.3) at baseline, 25.3 mm (21.0) on day 28, and 19.6 mm (17.4) on day 42, a mean overall reduction from baseline of 41.4 (23.9) mm for completers. Results were consistent irrespective of patient age, gender, severity, or traditional AR phenotype. Prior to MP-AzeFlu prescription, congestion was considered the most bothersome symptom. The majority of patients reported using at least two AR therapies in the past year, including oral antihistamines, intranasal corticosteroids, and intranasal antihistamines.

CONCLUSIONS

Many patients in Austria live with uncontrolled persistent AR despite treatment. MP-AzeFlu provides effective and rapid control of persistent AR in a real-world Austrian setting.

Treatment of the Nose for Patients with Sleep Apnea

Nasal obstruction is common in patients with obstructive sleep apnea (OSA) and may variably impact symptoms and severity of OSA. It is associated with decreased continuous positive airway pressure (CPAP) compliance, and both medical and surgical management of nasal obstruction have resulted in increased CPAP adherence. Treatment of OSA with comorbid rhinitis via topical nasal steroids demonstrates a beneficial impact on daytime sleepiness. Isolated nasal surgery has been shown to result in decreased daytime sleepiness and snoring, with minimal effect on OSA severity.

Allergic Rhinitis and Its Effect on Sleep

Allergic rhinitis (AR) is associated with increased sleep disturbances in adults and children. Pathogenesis is multifactorial, with nasal obstruction playing a large role. Intranasal corticosteroids, antihistamines, leukotriene inhibitors, and allergen immunotherapy have been demonstrated to relieve self-reported symptoms of sleep impairment. Given the high prevalence of sleep impairment in AR, providers should consider evaluating any patient with AR for sleep disturbances and sleep-disordered breathing.

Impact of antiallergy agents on CPAP therapy and sleep quality with spring pollinosis in Japanese

PURPOSE

Allergic rhinitis (AR) is associated with obstructive sleep apnea (OSA) and nasal obstruction causes decreased adherence to continuous positive airway pressure (CPAP). The purpose is to evaluate the effects of antiallergic agents on CPAP adherence and sleep quality.

METHODS

A longitudinal study was made of patients who use CPAP for OSA and treated with antiallergy agents for spring pollinosis. We compared the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), nasal symptoms scores (NSS), and data from CPAP before and after treatment. Then, we classified the subjects into two groups based on the baseline PSQI score: one group without a decreased sleep quality (PSQI < 6) and the other group with decreased sleep quality (PSQI ≥ 6).

RESULTS

Of 28 subjects enrolled, 13 had good sleep quality and 15 had poor sleep quality. PSQI showed significant improvements after medication (p = 0.046). ESS showed no significant differences after AR medication (p = 0.565). Significant improvement was observed after the prescription of antiallergy agents in all items of NSS (sneezing, p < 0.05; rhinorrhea, p < 0.01; nasal obstruction, p < 0.01; QOL, p < 0.01). The percentage of days with CPAP use more than 4 h increased significantly after the administration of rhinitis medication (p = 0.022). In the intragroup comparisons of PSQI ≥ 6 group, PSQI decreased significantly (p < 0.05). For the NSS in intragroup comparisons of PSQI ≥ 6 group, all parameters showed significant improvement (sneezing, p = 0.016; rhinorrhea, p = 0.005; nasal obstruction, p < 0.005; QOL, p < 0.005).

CONCLUSION

The use of antiallergy agents can improve CPAP adherence and sleep quality in patients with OSA on CPAP.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Real-Life Effectiveness of MP-AzeFlu (Dymista®) in Swedish Patients with Persistent Allergic Rhinitis, Assessed by the Visual Analogue Scale

Background

Many allergic rhinitis (AR) patients have moderate/severe persistent disease. MP-AzeFlu (Dymista^®) comprises intranasal azelastine hydrochloride and fluticasone propionate in a novel formulation delivered in a single device.

Objective

This prospective, noninterventional study assessed the effectiveness of MP-AzeFlu (one spray/nostril twice daily; azelastine hydrochloride = 548 μg; fluticasone propionate = 200 μg) on relieving AR symptom severity.

Methods

A visual analogue scale (VAS; 0 mm [not at all bothersome] to 100 mm [very bothersome]) was used during a 42-day MP-AzeFlu treatment period by 161 persistent AR (PER) patients in routine clinical practice in Sweden. Patients also assessed their sleep quality.

Results

VAS scores decreased from baseline during the treatment period and patients achieved a clinically relevant VAS score cutoff before Day 7, with 89.3% reporting well or partly controlled symptoms on Day 1. VAS score decreased from 61.4 ± 22.4 mm (baseline) to 32.1 ± 24.6 mm on Day 28 and 26.1 ± 24.3 mm on Day 42 (both p < 0.0001), an overall reduction from baseline on Day 42 of 38.1 ± 28.2 mm. The percentage of patients with very good/good sleep quality increased from 3.7%/28.6% on Day 0 to 16.5%/51.5% on Day 42.

Conclusion

MP-AzeFlu provides effective, rapid control of PER assessed by VAS in a real-world clinical setting in Sweden. Symptom improvement was observed at Day 1, sustained for 42 days, and associated with improved sleep quality. MP-AzeFlu significantly improved the QoL of the patients and was well tolerated.

Allergic rhinitis and sleep disorders in children - coexistence and reciprocal interactions

OBJECTIVE

To review, critically analyze and synthesize knowledge from the international literature regarding the association between allergic rhinitis (AR) and sleep disorders, the impact of AR treatment on children's sleep, and lay the foundation for future research on this topic.

SOURCE OF DATA

A literature search using PubMed database including original and review articles, systematic reviews and meta-analyses using keywords related to AR, sleep disorders and sleep-disordered breathing.

SYNTHESIS OF DATA

Sleep is fundamental to health, and its assessment and control of conditions that trigger or aggravate disturbances are of the uttermost importance. Allergic rhinitis (AR) is common in children and may interfere with both their quality of life and quality of sleep. It has emerged as one of the most important risk factors for habitual snoring in children and appeared to increase the risk of Obstructive Sleep Apnea (OSA), with AR severity exhibiting a significant and independent association with pediatric OSA severity. However, in some studies, those associations between AR and OSA in children are not very consistent.

CONCLUSIONS

A substantial level of controversy exists regarding the interactions between AR and OSA in children. Notwithstanding, identifying and treating AR in clinical settings is probably an important step toward improving symptoms and preventing deterioration of sleep quality in children and may improve the severity of underlying OSA. Considering the high prevalence, morbidity, economic and social implications of both AR and sleep problems, it is crucial that healthcare providers improve their understanding of the relationships between those conditions among children.

Association between allergic rhinitis-related factors and sleep duration in adolescents: Korea National Health and Nutrition Examination Survey V (2010-2012)

OBJECTIVES

Previous studies have shown that sleep and allergic rhinitis (AR) is closely associated, bidirectionally affecting each other. Adolescence is a period that adequate sleep is essential, and the burden of AR increases, both of which greatly affect the quality of life. The aim of the present study was to investigate the correlation between inappropriate sleep duration and each AR-related subjective/objective factor in Korean adolescents.

METHODS

We analyzed the data of 1936 adolescents aged between 12 and 18 years who participated in the Korea National Health and Nutrition Examination Survey from 2010 to 2012. Data on sleep duration, physician-diagnosed AR, and presence of rhinitis symptoms were collected using a self-administered questionnaire. Nasal endoscopic findings, including watery rhinorrhea and pale inferior turbinate mucosa, and aeroallergen sensitization based on serum specific immunoglobulin E levels were examined.

RESULTS

There was a higher prevalence of AR (23.68%) in the inappropriate sleep duration group than in the control group (16.56%; odds ratio = 1.56, p = 0.0024). The presence of endoscopic findings of AR showed a positive association with inappropriate sleep duration in males (odds ratio = 1.52, p = 0.008). In addition, in all three indoor allergens investigated, aeroallergen sensitization was not associated with inappropriate sleep duration.

CONCLUSION

Inappropriate sleep duration was associated with increased prevalence of AR in Korean adolescents. Especially, this association was relevant in nasal endoscopic findings in male.

Crowdsourcing without Data Bias: Building a Quality Assurance System for Air Pollution Symptom Mapping

Crowdsourcing is one of the spatial data sources, but due to its unstructured form, the quality of noisy crowd judgments is a challenge. In this study, we address the problem of detecting and removing crowdsourced data bias as a prerequisite for better-quality open-data output. This study aims to find the most robust data quality assurance system (QAs). To achieve this goal, we design logic-based QAs variants and test them on the air quality crowdsourcing database. By extending the paradigm of urban air pollution monitoring from particulate matter concentration levels to air-quality-related health symptom load, the study also builds a new perspective for citizen science (CS) air quality monitoring. The method includes the geospatial web (GeoWeb) platform as well as a QAs based on conditional statements. A four-month crowdsourcing campaign resulted in 1823 outdoor reports, with a rejection rate of up to 28%, depending on the applied. The focus of this study was not on digital sensors’ validation but on eliminating logically inconsistent surveys and technologically incorrect objects. As the QAs effectiveness may depend on the location and society structure, that opens up new cross-border opportunities for replication of the research in other geographical conditions.

House Dust Mite Related Allergic Rhinitis and REM Sleep Disturbances

PURPOSE

Sleep disturbances are common in patients with allergic rhinitis (AR). Perennial allergens like house dust mites (HDM) are difficult to avoid and have nocturnal impacts on the respiratory system and Quality of Life (QOL). The Rapid Eye Movement (REM) sleep stage is associated with memory, cognition, dreams, and overall restfulness, which can be impaired in AR patients with Sleep Disordered Breathing (SDB) even when normal all-night apnea-hypopnea (AHI) or respiratory disturbance (RDI) indices are noted on polysomnography (PSG). We hypothesized that AR HDM allergen positive patients would show REM-specific SDB reflected in their objectively elevated REM-RDI values.

MATERIALS AND METHODS

This retrospective analysis of 100 patients included 47 with HDM positive allergy testing. All patients underwent PSG testing calculating the RDI during REM. Multivariate logistic regression models evaluated relationships between allergic statuses and sleep parameters while controlling for potential confounders.

RESULTS

Compared with allergy negative patients, HDM allergen positive patients were significantly more likely (OR 4.29, 95%CI 1.26-14.62) to have a REM-RDI in the moderate/severe range (≥15 events/h).

CONCLUSIONS

Our study highlighted the significance of respiratory allergies to HDM in patients with SDB. We revealed a significant relationship between HDM allergen positivity and SDB characterized by elevated REM-RDI regardless of all-night AHI, RDI, or REM-AHI values. Clinical implications of knowing about disturbed REM and/or HDM allergenicity include better preparation, treatment, outcomes, and QOL for allergic, SDB, and upper airway surgery patients.

The complex pathophysiology of allergic rhinitis: scientific rationale for the development of an alternative treatment option

Allergic rhinitis (AR) poses a global health problem and can be challenging to treat. Many of the current symptomatic treatments for AR have been available for decades, yet there has been little improvement in patient quality of life or symptom burden over the years. In this review, we ask why this might be and explore the pathophysiological gaps that exist within the various AR treatment classes. We focus on the benefits and drawbacks of different treatment options and delivery routes for AR treatments and consider how, given what is known about AR pathophysiology and symptomatology, patients may be offered more effective treatment options for rapid, effective, and sustained AR control. In particular, we consider how a new AR preparation, MP-AzeFlu (Dymista^®, Meda, Sweden), comprising a formulation of an intranasal antihistamine (azelastine hydrochloride), an intranasal corticosteroid (fluticasone propionate), and excipients delivered in a single spray, may offer benefits over and above single and multiple AR therapy options. We review the evidence in support of this treatment across the spectrum of AR disease. The concept of AR control is also reviewed within the context of new European Union and Contre les Maladies Chroniques pour un VIeillissement Actif-Allergic Rhinitis and its Impact on Asthma initiatives.

Real-life effectiveness of MP-AzeFlu in Irish patients with persistent allergic rhinitis, assessed by visual analogue scale and endoscopy

INTRODUCTION

Most allergic rhinitis (AR) patients have moderate-to-severe, persistent disease. Meda Pharma's AzeFlu (MP-AzeFlu) combines intranasal azelastine hydrochloride (AZE) and fluticasone propionate (FP) in a novel formulation in a single device to treat AR. This prospective, noninterventional study sought to assess the effectiveness of MP-AzeFlu (one spray/nostril twice daily; 548 µg AZE/200 µg FP daily dose) in relieving AR symptom severity.

METHODS

A visual analogue scale (VAS) was used prior to MP-AzeFlu treatment on days 0, 1, 3, 7, 14, 21, 28, 35, and 42 by 53 persistent AR (PER) patients seen in routine clinical practice in Ireland. An endoscopy was performed on days 0 and 28, and symptoms of edema, discharge, and redness were scored on a three-point scale (for both nostrils).

RESULTS

Patients using MP-AzeFlu experienced rapid VAS score reduction from 73.4 mm (standard deviation [SD], 20.3) at Day 0 to 31.5 mm (SD, 25.0) at day 28 (P < 0.0001) to 28.1 mm (SD, 24.1) at day 42 (P < 0.0001), a 45.3-mm reduction. On average, patients achieved a clinically relevant VAS score cutoff of 50 mm before Day 7. Total endoscopy score decreased from 7.5 mm (SD, 3.1) at baseline to 3.5 mm (SD, 2.5) at Day 28. The incidence of severe edema on endoscopy decreased from 53.1% at baseline to 3.8% at Day 28. A similar reduction in the incidence of thick/mucousy discharge (from 28.3% to 4.8%) and severe redness (from 34.9% to 0%) was also observed.

CONCLUSIONS

MP-AzeFlu provided effective, rapid control of PER as assessed by VAS in a real-world clinical setting in Ireland. Symptom improvement was observed at Day 1, sustained for 42 days, and associated with improved mucosal appearance after 28 days. These results confirm the safety of MP-AzeFlu and exceed the efficacy demonstrated in phase 3 clinical studies for controlling AR in PER patients.

Association between allergic and nonallergic rhinitis and obstructive sleep apnea

PURPOSE OF REVIEW

Allergic rhinitis and nonallergic rhinitis (NAR) are common disorders, which have been considered as potential risk factors for obstructive sleep apnea (OSA). This review summarizes the proposed underlying pathophysiological mechanisms to provide a better understanding of the relationship between these conditions.

RECENT FINDINGS

In adults, allergic rhinitis and NAR may be considered as symptoms potentiating, rather than risk potentiating factors in the pathophysiology of OSA, whereas in children, these are considered to be independent predictors for sleep-disordered breathing (SDB) and failure of adeno-tonsillectomy, the recommended first-line therapy for children with OSA. Current advances suggest IL-6 may be important in regulating the sleep-wake cycle, and serum soluble IL-6 receptor (sIL-6R) levels may reflect the severity of OSA. Elevated Th17/Treg ratio correlates positively with apnea-hypopnea index of OSA patients, and Th17 and Treg imbalances caused by allergic rhinitis and OSA, respectively, may possibly promote each other, leading to further imbalance. Moreover, obesity is a strong risk factor for OSA, and leptin plays an important role in ventilatory function and upper airway obstruction. The variant trigeminocardiac reflex and nasotrigeminal reflex may also be involved in the association between rhinitis and OSA.

SUMMARY

Allergic rhinitis/NAR and OSA are closely associated, and each condition can be detrimental to the other. Thus, clinicians should pay attention to the potential presence of allergic rhinitis/NAR in OSA patients and vice versa.

Severity of allergic rhinitis impacts sleep and anxiety: results from a large Spanish cohort

Background

Allergic rhinitis (AR) is a highly prevalent disease that generates high social and health care costs and also has a significant effect on quality of life and quality of sleep. It has also been related to some psychological disorders like anxiety or depression.

Objective

To evaluate anxiety, depression, and quality of sleep and life alteration in a group of patients with perennial AR compared to a group of seasonal AR patients.

Methods

Six-hundred seventy adults (> 18 years) with perennial and seasonal AR were recruited consecutively in 47 centers in Spain. Individuals were grouped in “Perennial” and “Seasonal” according to the seasonality of their symptoms. Anxiety, depression, sleep quality and health related quality of life were evaluated using the Hospital Anxiety and Depression Scale, Medical Outcomes Study Sleep Scale (MOS Sleep Scale) and the Health-related quality of life questionnaire ESPRINT-15, respectively. Both groups of patients were evaluated in and out of the pollen season.

Results

AR symptoms are related to worse quality of life and more anxiety and depression symptoms. Indeed, symptom severity also correlates with worse outcomes (quality of life, sleep and depression/anxiety) regardless allergen seasonality. Symptoms severity, compared with seasonality and persistence, is the most important factor related with more anxiety and depression and poor sleep. However, symptoms severity, persistence and seasonality are independently affecting the quality of life in patients with AR.

Conclusions

Although AR symptoms have a great impact on depression and anxiety symptoms, quality of life and quality of sleep in all AR patients, as expected, individuals with more severe AR seem to suffer more intensely their effects.

Electronic supplementary material

The online version of this article (10.1186/s13601-018-0212-0) contains supplementary material, which is available to authorized users.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Impact of self-reported symptoms of allergic rhinitis and asthma on sleep disordered breathing and sleep disturbances in the elderly with polysomnography study

BACKGROUND

Sleep disordered breathing (SDB) and sleep disturbances have been reported to be associated with allergic rhinitis and asthma. However, population-based studies of this issue in the elderly are rare.

OBJECTIVE

To investigate the impact of self-reported rhinitis and asthma on sleep apnea and sleep quality using polysomnography in an elderly Korean population.

METHODS

A total of 348 elderly subjects who underwent one-night polysomnography study among a randomly selected sample were enrolled. Study subjects underwent anthropometric and clinical evaluations. Simultaneously, the prevalence and co-morbid status of asthma and allergic rhinitis, and subjective sleep quality were evaluated using a self-reported questionnaire.

RESULTS

Ever-diagnosis of allergic rhinitis was significantly more prevalent in subjects with SDB compared with those without SDB. Subjects with an ever-diagnosis of allergic rhinitis showed a higher O2 desaturation index and mean apnea duration. Indices regarding sleep efficiency were affected in subjects with a recent treatment of allergic rhinitis or asthma. Waking after sleep onset was longer and sleep efficiency was lower in subjects who had received allergic rhinitis treatment within the past 12 months. Subjects who had received asthma treatment within the past 12 months showed significantly lower sleep efficiency than others.

CONCLUSION

Our study indicates that a history of allergic rhinitis is associated with increased risk of SDB in the elderly. Sleep disturbance and impaired sleep efficiency were found in the subjects who had received recent treatment of allergic rhinitis or asthma. Physicians should be aware of the high risk of sleep disorders in older patients with respiratory allergic diseases.

The Rhinitis Control Scoring System: Development and validation

BACKGROUND

Allergic rhinitis is a common health problem that requires regular monitoring of symptoms to provide adequate treatment. There is a need to develop rhinitis control assessment tools that are meaningful and easy to interpret by both the patient and the practitioner.

OBJECTIVE

To develop a simple, easy-to-interpret instrument, the Rhinitis Control Scoring System (RCSS), for the assessment of rhinitis control, as a companion tool to the Asthma Control Scoring System previously validated.

METHODS

After a literature review and based on the Allergic Rhinitis and its Impact on Asthma guidelines, allergic rhinitis control parameters were identified. The draft items were subjected to cognitive debriefing regarding instructions, wordings, and response options. The second version of the draft was then pretested and modified according to the results. The final draft of the RCSS, based on the intensity and frequency of symptoms, was then pilot tested with 50 subjects who had allergic rhinitis for validation of some psychometric properties. Each subject completed the RCSS in addition to other rhinitis instruments. They also had nasal peak inspiratory flow measurements.

RESULTS

The RCSS showed good internal consistency (Cronbach α = 0.84). There was strong criterion validity between the RCSS scores and the other instruments. The discriminant validity demonstrated as mean RCSS scores differed significantly across groups of patients with different Total Nasal Symptom Score severity (F = 58.8, p < 0.0001).

CONCLUSIONS

This pilot study showed that the RCSS is a simple tool to assess and quantify rhinitis control by using a percentage score. This questionnaire allows the quantification of rhinitis control and, therefore, may help guide therapeutic interventions. Combined with the Asthma Control Scoring System, it can provide a global assessment of rhinitis and asthma control. Clinical Trial number NCT00967967.

Complications of Rhinitis

Chronic rhinitis involves inflammation of the upper airways. An association with comorbid conditions, such as rhinosinusitis, asthma, and chronic obstructive pulmonary disease, has been commonly observed in epidemiologic studies. The underlying pathogenesis of these disorders may be similar. Complications of rhinitis include sleep disturbances, learning impairment, and decreased quality of life. It is vital to recognize the complications of rhinitis so that treatment strategies can address rhinitis as well as its comorbidities and complications in a coordinated manner.

Risk factors for sleep impairment in adult patients with chronic rhinosinusitis

OBJECTIVE

Although sleep impairment is reported by patients with chronic rhinosinusitis, the associated factors have not been well studied. Therefore, we determined the associated risk factors for sleep impairment in patients with chronic rhinosinusitis (CRS).

METHODS

This study was a prospective cohort study. A total of 572 adult patients (171 women, 401 men; mean age, 49.0 years; range, 18-64 years) who completed a questionnaire, had a clinical examination, and underwent endoscopic sinus surgery were analyzed using stepwise multiple linear regression.

RESULTS

With regard to subjective symptoms, nasal obstruction (beta coef., 0.27; p<0.001), anterior nasal drainage (beta coef., 0.13; p=0.004), facial pain/pressure (beta coef., 0.09; p=0.048), headache (beta coef., 0.10; p=0.010), and cough (beta coef., 0.14; p<0.001) were predictors of an increased risk of sleep impairment of CRS (adjusted R(2), 0.240; p=0.048). In the matter of background parameters, total polyp score (polyp grading system) (beta coef., 0.16; p<0.001) and allergic rhinitis (beta coef., 0.09; p=0.034) were predictors of an increased risk of sleep impairment of CRS (adjusted R(2), 0.029; p=0.034).

CONCLUSION

These results suggest that sleep impairment in these patients is caused by the various mechanisms associated with nasal symptoms themselves, CRS and allergic rhinitis. However, the specific pathophysiology has not been clarified yet; further studies are expected to elucidate that of sleep impairment in patients with CRS.

Personalized symptoms forecasting for pollen-induced allergic rhinitis sufferers

Hay fever is a pollen-induced allergic reaction that strongly affects the overall quality of life of many individuals. The disorder may vary in severity and symptoms depending on patient-specific factors such as genetic disposition, individual threshold of pollen concentration levels, medication, former immunotherapy, and others. Thus, information services that improve the quality of life of hay fever sufferers must address the needs of each individual separately. In this paper, we demonstrate the development of information services that offer personalized pollen-induced symptoms forecasts. The backbone of these services consists of data of allergic symptoms reported by the users of the Personal Hay Fever Diary system and pollen concentration levels (European Aeroallergen Network) in several sampling sites. Data were analyzed using computational intelligence methods, resulting in highly customizable forecasting models that offer personalized warnings to users of the Patient Hay Fever Diary system. The overall system performance for the pilot area (Vienna and Lower Austria) reached a correlation coefficient of r = 0.71 ± 0.17 (average ± standard deviation) in a sample of 219 users with major contribution to the Pollen Hay Fever Diary system and an overall performance of r = 0.66 ± 0.18 in a second sample of 393 users, with minor contribution to the system. These findings provide an example of combining data from different sources using advanced data engineering in order to develop innovative e-health services with the capacity to provide more direct and personalized information to allergic rhinitis sufferers.

Allergy and asthma: Effects of the exposure to particulate matter and biological allergens

The prevalence of asthma and allergies including atopy has increased during the past decades, particularly in westernized countries. The rapid rise in the prevalence of such diseases cannot be explained by genetic factors alone. Rapid urbanization and industrialization throughout the world have increased air pollution and population exposures, so that most epidemiologic studies are focusing on possible links between air pollution and respiratory diseases. Furthermore, a growing body of evidence shows that chemical air pollution may interact with airborne allergens enhancing the risk of atopic sensitization and exacerbation of symptoms in sensitized subjects. These phenomena are supported by current in vitro and animal studies showing that the combined exposure to air pollutants and allergens may have a synergistic or additive effect on asthma and allergies, although there is an insufficient evidence about this link at the population level. Further research is needed in order to elucidate the mechanisms by which pollutants and biological allergens induce damage in exposed subjects. The abatement of the main risk factors for asthma and allergic diseases may achieve huge health benefits. Thus, it is important to raise awareness of respiratory allergies as serious chronic diseases which place a heavy burden on patients and on society as a whole.

SQ house dust mite sublingually administered immunotherapy tablet (ALK) improves allergic rhinitis in patients with house dust mite allergic asthma and rhinitis symptoms

BACKGROUND

House dust mite (HDM) allergy is associated with persistent allergic rhinitis (AR) and allergic asthma.

OBJECTIVE

To investigate the efficacy and safety of a SQ HDM sublingually administered immunotherapy tablet (ALK, Hørsholm, Denmark) in adults and adolescents with HDM respiratory allergic disease and report the AR results.

METHODS

Six hundred four subjects at least 14 years old with HDM AR and mild to moderate HDM allergic asthma were randomized 1:1:1:1 to double-blinded daily treatment with 1, 3, 6 SQ-HDM or placebo. End-of-treatment rhinoconjunctivitis symptoms and medication score were predefined extrapulmonary end points. A subgroup analysis was conducted post hoc in subjects with a total combined rhinitis score (TCRS) > 0 (ie, with AR symptoms and/or AR medication use during the 4-week baseline period). The subgroup was comprised of 498 subjects (82%).

RESULTS

In the subgroup, the absolute difference in end-of-treatment TCRS between 6 SQ-HDM and placebo was -0.78 (95% confidence interval -1.47 to -0.07, relative difference 28.8%, P = .0357). Furthermore, a significant difference was found for the total score of the Rhinitis Quality of Life Questionnaire with Standardized Activities RQLQ(S) and for the individual domains: activities, sleep, non-nose and non-eye symptoms, and nasal symptoms. For the TCRS and Rhinitis Quality of Life Questionnaire score, a dose response was seen, with numerically lower, nonsignificant differences for 1 and 3 SQ-HDM. The predefined analysis for the entire trial population showed no statistically significant difference between the placebo and actively treated groups. No safety concerns were observed.

CONCLUSION

Efficacy in mild to severe AR of 6 SQ-HDM compared with placebo was demonstrated by statistically significant improvements in TCRS and Rhinitis Quality of Life Questionnaire score in subjects with AR present at baseline. The treatment was well tolerated.

TRIAL REGISTRATION

EudraCT, no 2006-001795-20; ClinicalTrials.gov, identifier NCT00389363.

Nasal involvement in obstructive sleep apnea syndrome

Numerous studies have reported an association between nasal obstruction and obstructive sleep apnea syndrome (OSAS), but the precise nature of this relationship remains to be clarified. This paper aimed to summarize data and theories on the role of the nose in the pathophysiology of sleep apnea as well as to discuss the benefits of surgical and medical nasal treatments. A number of pathophysiological mechanisms can potentially explain the role of nasal pathology in OSAS. These include the Starling resistor model, the unstable oral airway, the nasal ventilatory reflex, and the role of nitric oxide (NO). Pharmacological treatment presents some beneficial effects on the frequency of respiratory events and sleep architecture. Nonetheless, objective data assessing snoring and daytime sleepiness are still necessary. Nasal surgery can improve the quality of life and snoring in a select group of patients with mild OSAS and septal deviation but is not an effective treatment for OSA as such. Despite the conflicting results in the literature, it is important that patients who are not perfectly adapted to CPAP are evaluated in detail, in order to identify whether there are obstructive factors that could be surgically corrected.

Effectiveness of the leukotriene receptor antagonist pranlukast hydrate for the treatment of sleep disorder in patients with perennial allergic rhinitis

CONCLUSION

We found that addition of pranlukast to the conventional treatment for perennial allergic rhinitis may contribute to improvements in sleep disorder symptoms through a decrease in nasal congestion.

OBJECTIVE

We aimed to determine whether the leukotriene receptor antagonist pranlukast hydrate is effective in treating sleep disorder in patients with perennial allergic rhinitis.

METHODS

We conducted a questionnaire survey to determine the symptoms of rhinitis and sleep disturbances in 48 adult patients with perennial allergic rhinitis who visited the outpatient otolaryngology departments in hospitals in Yamaguchi Prefecture, Japan. The subjects presented with nasal symptoms and symptoms of sleep disorder during the last 2 weeks of treatment for allergic rhinitis that lasted for at least 1 month. A questionnaire based on the Pittsburgh Sleep Quality Index and Athens Insomnia Scale with some modifications was administered before and 4 weeks after the addition of pranlukast to the conventional treatment.

RESULTS

Addition of pranlukast improved the symptoms of perennial allergic rhinitis, with responses to all items of the questionnaire administered 4 weeks after pranlukast addition indicating significant improvements. Furthermore, the improvement in sleep disorder symptoms significantly correlated with improvement in nasal congestion, but not with improvements in sneezing and nasal discharge.

Does the duration and time of sleep increase the risk of allergic rhinitis? Results of the 6-year nationwide Korea youth risk behavior web-based survey

Allergic rhinitis (AR) is the most common chronic disorder in the pediatric population. Although several studies have investigated the correlation between AR and sleep-related issues, the association between the duration and time of sleep and AR has not been analyzed in long-term national data. This study investigated the relationship between sleep time and duration and AR risk in middle- and high-school students (adolescents aged 12–18). We analyzed national data from the Korea Youth Risk Behavior Web-based Survey by the Korea Centers for Disease Control and Prevention from 2007–2012. The sample size was 274,480, with an average response rate of 96.2%. Multivariate logistic regression analyses were conducted to determine the relationship between sleep and AR risk. Furthermore, to determine the best-fitted model among independent variables such as sleep duration, sleep time, and the combination of sleep duration and sleep time, we used Akaike Information Criteria (AIC) to compare models. A total of 43,337 boys and 41,665 girls reported a diagnosis of AR at baseline. The odds ratio increased with age and with higher education and economic status of the parents. Further, students in mid-sized and large cities had stronger relationships to AR than those in small cities. In both genders, AR was associated with depression and suicidal ideation. In the analysis of sleep duration and sleep time, the odds ratio increased in both genders when sleep duration was <7 hours, and when the time of sleep was later than 24∶00 hours. Our results indicate an association between sleep time and duration and AR. This study is the first to focus on the relationship between sleep duration and time and AR in national survey data collected over 6 years.

Nasal allergies in the Middle Eastern population: results from the "Allergies in Middle East Survey"

BACKGROUND

Chronic respiratory diseases such as asthma and allergic rhinitis (AR) are a major public health problem in developing countries including those in the Middle East. However, to date, there is a paucity of information related to physician-diagnosed AR in this region. The Allergies in Middle East Survey was undertaken to help clarify and broaden the understanding of physician-diagnosed AR across Egypt, Iran, Lebanon, Saudi Arabia, and the United Arab Emirates. The survey explores the frequency of physician-diagnosed AR, prevalence and types of associated symptoms, the impact on quality of life (QOL), current treatment practices, and therapy expectations.

METHODS

In total, 7411 households in five countries (Egypt, Lebanon, Saudi Arabia, Iran and the United Arab Emirates) were screened to identify individuals that were ≥4 years old with a physician diagnosis of AR and either symptoms and/or treatment in the past 12 months. A total of 501 respondents from the five countries completed the survey. Standardized questionnaires were used to make comparisons across the regions; however, the data collection procedures were tailored for each country. The sample was probability based to ensure valid statistical inference to the population.

RESULTS

Ten percent of the Middle East population surveyed had a physician diagnosis of AR, with 65% of respondents stating that their allergies were intermittent in nature. An otolaryngologist or allergist diagnosed the majority of the individuals surveyed. Runny nose, nasal and throat itching, postnasal drip, and nasal congestion or stuffed up nose were the most common and bothersome symptoms of AR. The majority of survey participants (58% of the overall survey population) with AR reported that the condition had an impact on their daily private and professional life. Seventy-two percent of adults reported that their AR symptoms limited their work/school activities and 35% reported that their AR interfered with and caused them to miss work or school within the past 12 months. One factor, in addition to the outward AR symptoms, that could have contributed to these function impairments may have been sleep disturbances. Although a secondary symptom to AR, sleep disturbances (difficulty getting to sleep, waking up during the night or lack of a good night's sleep) were shown in this survey to be extremely troubling in ∼15% of AR sufferers. In the past year >90% of patients reported taking a medication of any type for their AR, with nearly a 4:1 ratio of patients taking a prescription medication versus an over-the-counter (OTC) medication in the past 4 weeks. Over 75% of survey respondents reported taking an intranasal corticosteroid (INCS) in the last 4 weeks and the satisfaction rate of INCS medications was similar to that reported for OTC medications. The most common reasons cited for dissatisfaction with INCS medications were inadequate effectiveness, bothersome side effects (e.g., unpleasant taste and retrograde drainage into the pharynx), decreased effectiveness with chronic use, and failure to provide 24-hour relief.

CONCLUSION

These data show that AR is common in the Middle East region as elsewhere in the world. Many patients with AR in Middle East region suffer from their symptoms (e.g., runny nose, nasal itching, nasal congestion, postnasal drip, and other symptoms) on all or most days during the times of the year that their allergies are worst. These symptoms have been shown to reduce QOL and performance at work/school to a significant degree. Additionally, the survey data underscore a considerable treatment gap with current therapies for AR and that many AR patients still have not found adequate effectiveness with currently available medications. Thus, through identification of disease impact on the Middle East population and highlighting treatment gaps, clinicians in the Middle East may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.

Impact of sleep as a specific marker of quality of life in allergic rhinitis

Allergic rhinitis (AR) is a common disorder, which represents a considerable burden both on individual patients and society. It is associated with bothersome symptoms, which may impair usual daily activities, sleep quality, and productivity. Associated with impaired sleep, quality of life is significantly impaired in AR patients. AR significantly contributes to sleep-disordered breathing through multiple mechanisms, with the greatest impact mediated through nasal obstruction. Sleep impairment is very common in AR patients and has a significant impact on disease-specific measures of general health and quality of life. The degree of sleep disturbance is directly related to the severity of the disease. Nasal congestion also demonstrates circadian rhythm and positional variability, worsening during nighttime hours and in supine position. Increased sleep disordered events lead to poor sleep with fatigue and daytime somnolence, impaired performance, productivity and social functioning, and an increased risk of associated diseases.

DSM-IV psychiatric comorbidity according to symptoms of insomnia: a nationwide sample of Korean adults

PURPOSE

The diagnosis of insomnia is based on the presence of four different symptoms: difficulty in initiating sleep (DIS), difficulty in maintaining sleep (DMS), early morning awakening (EMA), and non-restorative sleep (NRS). This study investigated the differences in sociodemographic correlates and psychiatric comorbidity between the four symptoms of insomnia in the general population of South Korea.

METHODS

A sample of the population aged 18-64 (N = 6,510) was questioned using a face-to-face interview. Insomnia was defined as having at least one of the four following symptoms three or more times per week: DIS, DMS, EMA, and NRS. Psychiatric disorders were evaluated using the Korean version of Composite International Diagnostic Interview. Logistic regression analysis was used to test each of the sleep outcomes (DIS, DMS, EMA, or NRS) for an association with sociodemographic and clinical variables.

RESULTS

The prevalence of DIS, DMS, EMA, and NRS were 7.9 % (95 % CI 6.6-9.5 %), 7.9 % (95 % CI 6.5-9.6 %), 4.9 % (95 % CI 3.9-6.0 %), and 14.8 % (95 % CI 12.6-17.4 %), respectively. The overall prevalence of insomnia was 19.0 % (95 % CI 16.1-22.2 %). Being separated, divorced, or widowed, being single, having a part-time job, having a psychiatric illness, and having a physical illness were all significantly related to insomnia. Older age also increased the risk of DMS and EMA, and younger age was a risk factor for NRS. The presence of most psychiatric disorders was significantly related to insomnia. However, the relationship between the psychiatric illness and each insomnia symptom varied and was dependent on the insomnia symptom.

CONCLUSIONS

Most psychiatric disorders were significantly associated with each insomnia symptom in different ways. Differences in sociodemographic and clinical correlates between the four insomnia symptoms implied the heterogeneous characteristics of insomnia as defined by the current diagnostic criteria.

Sleep and allergic disease: a summary of the literature and future directions for research

Atopic diseases, such as asthma and allergic rhinitis, are common conditions that can influence sleep and subsequent daytime functioning. Children and patients with allergic conditions from ethnic minority groups might be particularly vulnerable to poor sleep and compromised daytime functioning because of the prevalence of these illnesses in these groups and the high level of morbidity. Research over the past 10 years has shed light on the pathophysiologic mechanisms (eg, inflammatory mediators) involved in many atopic diseases that can underlie sleep disruptions as a consequence of the presence of nocturnal symptoms. Associations between nocturnal symptoms and sleep and poorer quality of life as a result of missed sleep have been demonstrated across studies. Patients with severe illness and poor control appear to bear the most burden in terms of sleep impairment. Sleep-disordered breathing is also more common in patients with allergic diseases. Upper and lower airway resistance can increase the risk for sleep-disordered breathing events. In patients with allergic rhinitis, nasal congestion is a risk factor for apnea and snoring. Finally, consistent and appropriate use of medications can minimize nocturnal asthma or allergic symptoms that might disrupt sleep. Despite these advances, there is much room for improvement in this area. A summary of the sleep and allergic disease literature is reviewed, with methodological, conceptual, and clinical suggestions presented for future research.

Nasal allergies in the Asian-Pacific population: results from the Allergies in Asia-Pacific Survey

BACKGROUND

The Allergies in Asia-Pacific Survey describes the symptoms, impact, and treatment of allergic rhinitis (AR) across Australia, China, Hong Kong, Malaysia, Singapore, Taiwan, Vietnam, and the Philippines. The Allergies in Asia-Pacific Survey was undertaken to further clarify the prevalence of physician-diagnosed nasal allergies (NAs), impact on quality-of-life (QOL), existing treatment paradigms and gaps, and NA medications currently used in treatment.

METHODS

Thirty-three thousand three hundred seventy-eight households were screened for individuals, ≥ 4 years old, with a physician diagnosis of AR or NA and either symptoms or treatment in the past 12 months. Standardized questionnaires were used to make comparisons across regions. A total of 1043 adults and 192 children were included in the survey.

RESULTS

Nine percent of participants were diagnosed with AR with two of three responding that their NAs were seasonal in nature. Nasal congestion was the most common and bothersome symptom of AR. Most participants reported that AR impacted their QOL with nearly one-half citing impairments in school/work performance/productivity. Sleep disturbances, secondary to AR, were also shown to be appreciable. Two-thirds of patients took medication for their AR. Less than one-quarter of survey respondents reported taking an intranasal corticosteroid and the satisfaction rate was similar to that of over-the-counter medications. The most common reasons cited for dissatisfaction were related to inadequate efficacy and bothersome side effects.

CONCLUSION

AR appears to be extremely common across Asia-Pacific nations. Many individuals with AR suffer from symptoms that reduce QOL and treatment gaps exist with current therapies. Through identification of disease impact and highlighting treatment gaps, clinicians may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.

Disease severity impairs sleep quality in allergic rhinitis (The SOMNIAAR study)

BACKGROUND

Sleep is impaired in allergic rhinitis (AR) patients, with subsequent effects on daytime performance and health-related quality of life (QOL). Sleep quality in AR has rarely been considered through validated tools and consensus classifications.

OBJECTIVE

To evaluate sleep quality and daytime somnolence in AR patients, and to estimate its relationship to disease severity according to Allergic Rhinitis and Its Impact on Asthma (ARIA) conventional and modified classifications, as well as in terms of QOL and comorbidities.

METHODS

Allergic rhinitis adult patients were evaluated through a prospective, observational, multicentre survey in Spain. Symptoms were assessed using the Total Symptoms Score (TSS), specific QOL by the Rhinitis Quality of Life Questionnaire (RQLQ), sleep quality by Pittsburgh scale, and diurnal somnolence by a scale based on Epworth's, all recorded in a unique visit.

RESULTS

A total of 2275 patients were included. According to ARIA criteria, 50.2% had persistent and 49.8% intermittent rhinitis, whereas 87.6% were classified as moderate-severe and 12.4% as mild; 52.8% had poor sleep quality, with a global median score for Pittsburgh scale of 6 (normal < 5) and 21.1% suffered from excessive diurnal somnolence. Correlation between Pittsburgh scale and RQLQ was moderate (r = 0.54). Among symptoms, nasal obstruction and concomitant asthma mainly, contributed to bad sleep quality. In a logistic regression model, moderate-severe rhinitis and nasal obstruction were all associated with a worse sleep quality.

CONCLUSIONS AND CLINICAL RELEVANCE

Sleep quality is altered in AR patients. Sleep quality was worse in moderate-severe, and particularly in severe AR. Nasal obstruction and RQLQ deterioration are associated with a poorer sleep quality. Sleep impairment is common in allergic rhinitis, particularly in more severe forms. Nasal obstruction and concomitant asthma should be considered as contributing factors.

CAPSULE SUMMARY

This is a large epidemiological survey of patients with allergic rhinitis showing a strong relationship between disease severity, as assessed by a consensus classification, and sleep impairment, as measured by a validated sleep quality tool.

The role of the nose in snoring and obstructive sleep apnoea: an update

Multilevel anatomic obstruction is often present in snoring and obstructive sleep apnoea (OSA). As the nose is the first anatomical boundary of the upper airway, nasal obstruction may contribute to sleep-disordered breathing (SDB). A number of pathophysiological mechanisms can potentially explain the role of nasal pathology in SDB. These include the Starling resistor model, the unstable oral airway, the nasal ventilatory reflex and the role of nitric oxide (NO). Clinically, a number of case–control studies have shown that nasal obstruction is associated with snoring and mild SDB. However, there is not a linear correlation between the degree of nasal obstruction and the severity of SDB, while nasal obstruction is not the main contributing factor in the majority of patients with moderate to severe OSA. Randomised controlled studies have shown that in patients with allergic rhinitis or non-allergic rhinitis and sleep disturbance, nasal steroids could improve the subjective quality of sleep, and may be useful for patients with mild OSA, however, they are not by themselves an adequate treatment for most OSA patients. Similarly, nasal surgery may improve quality of life and snoring in a subgroup of patients with mild SDB and septal deviation, but it is not an effective treatment for OSA as such. On the other hand, in patients who do not tolerate continuous positive airway pressure (CPAP) well, if upper airway evaluation demonstrates an obstructive nasal passage, nasal airway surgery can improve CPAP compliance and adherence.

Intranasal Mometasone Furoate for Treatment of Allergic Rhinitis

Allergic rhinitis (AR) is a chronic nasal disease that affects the upper respiratory tract. This disorder is characterized by inflammation of the mucous membranes and it manifests with several nasal symptoms accompanied sometimes by non-nasal symptoms. Best therapy aims to prevent and improve the AR-clinical picture. Steroids have an important role in the treatment of AR. The development of steroids administrated directly on nasal mucosa has much reduced the systemic adverse affects associated with oral steroids therapy. Mometasone furoate aqueous nasal spray is a synthetic steroid assessed for intranasal use in the therapy of adults and children affected by AR. Such topical nasal steroid is an effective molecule improving clinical picture of AR and it is also approved as prophylactic therapy. In this article, apart from a careful description of its successful clinical use the authors review pharmacokinetic/pharmacodynamic profile, mechanism of action, safety, and efficacy of such steroid molecule.

Fluticasone furoate nasal spray: Profile of an enhanced-affinity corticosteroid in treatment of seasonal allergic rhinitis

Of the classes of pharmacotherapy for seasonal allergic rhinitis, intranasal corticosteroids are the preferred treatment and are recommended in practice guidelines as first-line pharmacotherapy for rhinitis with prominent nasal congestion. The enhanced-affinity intranasal corticosteroid fluticasone furoate nasal spray (GW685698X), is one of the newest additions to the armamentarium for allergic rhinitis. This review summarizes the preclinical and clinical data on fluticasone furoate nasal spray and discusses its place in pharmacotherapy for seasonal allergic rhinitis. Important attributes of fluticasone furoate in seasonal allergic rhinitis include low systemic bioavailability (<0.5%), onset of symptom relief as early as eight hours after initiation of treatment, 24-hour symptom relief with once-daily dosing, comprehensive coverage of both nasal and ocular symptoms, safety and tolerability with daily use, and availability in a side-actuated device that makes medication delivery simple and consistent. With these attributes, fluticasone furoate nasal spray has the potential to enhance patient satisfaction and compliance and reduce the need for polypharmacy in the management of seasonal allergic rhinitis.

Psychometric validation of the rhinitis control assessment test: a brief patient-completed instrument for evaluating rhinitis symptom control

BACKGROUND

Allergic rhinitis is common, but a validated tool for comprehensive assessment of disease control is not available.

OBJECTIVE

To develop a simple patient-completed instrument (the Rhinitis Control Assessment Test [RCAT]) to help detect problems with control of rhinitis symptoms.

METHODS

During a visit to an allergy specialist, 410 patients with allergic rhinitis completed a Total Nasal Symptom Score (TNSS) assessment and the 26-item developmental RCAT. Physicians also completed a global assessment of rhinitis symptom control for each patient.

RESULTS

Stepwise regression methods identified 6 items from the developmental RCAT (frequency of nasal congestion, sneezing, and watery eyes; sleep interference; activity avoidance; and self-assessed control) that were most predictive of the allergist's global rating of rhinitis symptom control. A summated rating scale from these 6 items showed good convergent validity (r > 0.70) with scale scores from the TNSS. The discriminant validity of the 6-item scale was demonstrated as mean RCAT scale scores differed significantly across groups of patients differing in physician-rated disease severity (F = 54.4), TNSS severity (F = 193.8), and physician-recommended change in therapy (F = 50.6) (P < .001 for all).

CONCLUSIONS

The RCAT, a 6-item patient-completed instrument, has satisfactory psychometric properties and seems to be a valid tool for assessing control of allergic rhinitis. Further validation studies will provide confirmation.

Loratadine and montelukast administered in combination produce decongestion in an experimental feline model of nasal congestion

BACKGROUND

Histamine and leukotrienes act to exert numerous local and systemic effects that contribute to the pathophysiology of allergic rhinitis. The aim of these experiments was to evaluate the nasal decongestant effects of loratadine and montelukast alone and in combination in a feline model of nasal congestion. We also studied the decongestant actions of the alpha-agonist adrenergic agonist D-pseudoephedrine with and without desloratadine.

METHODS

Acoustic rhinometry was used to determine nasal cavity dimensions after intranasal compound 48/80. Cats were given D-pseudoephedrine (0.3 mg/kg) alone or in combination with desloratadine (5 mg/kg) 1 hour before nasal provocation with compound 48/80 (1%, 75 microliters) to either the left or right nasal passageway. Using a similar design, the nasal decongestant effects of montelukast (1 mg/kg) and loratadine (10 mg/kg) were studied alone and in combination.

RESULTS

The addition of desloratadine to D-pseudoephedrine did not improve decongestant efficacy compared with each drug given individually. In contrast, when montelukast (1 mg/kg) was given in combination with loratadine (10 mg/kg), the decongestant activity was greater than when these drugs were administered separately. Sixty minutes after compound 48/80 provocation the nasal cavity volume ratio (volume ratio of the compound 48/80 treated/untreated nasal passageway) for the control, montelukast alone, loratadine alone, and the montelukast plus loratadine-treated groups were 0.20 +/- 0.03, 0.24 +/- 0.01, 0.28 +/- 0.03, and 0.50 +/- 0.03.

CONCLUSION

Concomitant montelukast plus loratadine produces a greater degree of nasal decongestion compared with montelukast or loratadine alone in an experimental model of nasal congestion.

Relative strength of relationships of nasal congestion and ocular symptoms with sleep, mood and productivity

BACKGROUND

Nasal congestion associated with allergic rhinitis has been shown to be the most bothersome symptom. Ocular symptoms may be troublesome to patients as well.

OBJECTIVE

To estimate the relative strength of relationships of nasal congestion and ocular symptoms associated with allergic rhinitis with patient-reported outcomes of sleep quality; practical problems; somnolence; impairment at work, class, activities; and mood.

METHODS

Patients (n = 404) presenting with symptoms of allergic rhinitis completed five patient-reported outcomes that assessed the effect of morning allergic rhinitis symptoms on patients' reports of sleep, work and activity impairment, and mood. Multiple regression analyses were used to compare the relative strength of relationships of congestion and ocular symptoms with the patient-reported outcomes.

RESULTS

The majority of patients had both nasal congestion and ocular symptoms at baseline. A single nasal congestion item and a 3-item ocular symptom score were significantly related to the patient-reported outcomes: those with more severe congestion or ocular symptoms reported more negative scores on the patient-reported outcomes. Nasal congestion had the stronger relationship with patient-reported outcomes total scores or subscales in 14 of 20 regressions.

CONCLUSION

Although nasal congestion is generally more strongly related to the patient-reported outcomes, ocular symptoms have a significant negative effect on patients' lives. Study limitations include: (1) only baseline data were used because of greater severity and variability of symptoms scores; we are unable to establish causal relationships or discuss change, only correlation/covariation; (2) recruitment took place from September through November, thus different patients might have been recruited if sampling took place during the spring; (3) patients were screened for nasal congestion not for ocular symptoms, though there was high co-occurrence of each. These limitations aside, congestion and ocular symptoms are troublesome to patients and typically co-occur. Evaluating and treating these symptoms are key to managing allergic rhinitis and improving patient-reported outcomes.

Diagnosis and management of acute rhinosinusitis

Acute rhinosinusitis (ARS) is a highly prevalent condition with substantial public health implications. The disease is associated with a high degree of disability, impairment of quality of life, and school and workplace absenteeism. Acute rhinosinusitis is most often precipitated by a viral upper respiratory infection or an episode of allergic rhinitis. Typical signs and symptoms include nasal congestion, purulent nasal discharge, headache, cough, and facial pain or tenderness. Diagnosis is usually based on patient history and physical examination. Specialist consultation is indicated for intractable or complicated disease, signified by signs or symptoms suggestive of orbital, intraosseous, or intracranial extension of sinus disease. Most cases of ARS in the ambulatory setting are viral. In the absence of severe or rapidly worsening symptoms, antibiotic prescription should be delayed until an appropriate surveillance period has elapsed. Symptomatic therapy is the most efficient approach for uncomplicated ARS. There is a paucity of data supporting use of commonly used symptomatic therapies, with the exception of intranasal corticosteroids, which have demonstrated rapid improvement of the symptoms of ARS and return to normal functioning when used as monotherapy or as an adjunct to antibiotics.

Are the birch trees in Southern England a source of Betula pollen for North London?

Birch pollen is highly allergenic. Knowledge of daily variations, atmospheric transport and source areas of birch pollen is important for exposure studies and for warnings to the public, especially for large cities such as London. Our results show that broad-leaved forests with high birch tree densities are located to the south and west of London. Bi-hourly Betula pollen concentrations for all the days included in the study, and for all available days with high birch pollen counts (daily average birch pollen counts>80 grains/m3), show that, on average, there is a peak between 1400 hours and 1600 hours. Back-trajectory analysis showed that, on days with high birch pollen counts (n=60), 80% of air masses arriving at the time of peak diurnal birch pollen count approached North London from the south in a 180 degree arc from due east to due west. Detailed investigations of three Betula pollen episodes, with distinctly different diurnal patterns compared to the mean daily cycle, were used to illustrate how night-time maxima (2200-0400 hours) in Betula pollen counts could be the result of transport from distant sources or long transport times caused by slow moving air masses. We conclude that the Betula pollen recorded in North London could originate from sources found to the west and south of the city and not just trees within London itself. Possible sources outside the city include Continental Europe and the Betula trees within the broad-leaved forests of Southern England.