Rhinitis phenotypes correlate with different symptom presentation and risk factor patterns of asthma

Exploration of Allergic Rhinitis: Epidemiology, Predisposing Factors, Clinical Manifestations, Laboratory Characteristics, and Emerging Pathogenic Mechanisms

Allergic rhinitis (AR) is a widespread allergic condition, with its prevalence continuing to rise globally. This disease has a significant impact on patients' quality of life. Understanding the underlying pathophysiology is important to develop better-targeted therapies. For decades, the primary assumption has been that an allergy is caused by unbalanced and overactive immunological responses against allergens, driven mainly by activated T helper 2 (Th2) cells and due to aberrant T-regulatory cells. The more recent hypothesis that is gaining attention relies on the dysregulation of the epithelial barrier, which might result in allergen uptake as a primary defect in the pathogenesis of allergic reactions. The nasal epithelial barrier is considered a crucial first line of defense in the upper airway, as it protects the host's immune system from exposure to allergens. Thus, this review will discuss AR's epidemiology, predisposing factors, clinical manifestations, laboratory characteristics, and pathogenic mechanisms.

Causal Effects of Asthma on Upper Airway Diseases and Allergic Diseases: A Two-Sample Mendelian Randomization

INTRODUCTION

Asthma is associated with upper airway diseases and allergic diseases; however, the causal effects need to be investigated further. Thus, we performed this two-sample Mendelian randomization (MR) analysis to explore and measure the causal effects of asthma on allergic rhinitis (AR), vasomotor rhinitis (VMR), allergic conjunctivitis (AC), atopic dermatitis (AD), and allergic urticaria (AU).

METHODS

The data for asthma, AR, VMR, AC, AD, and AU were obtained from large-scale genome-wide association studies summarized recently. We defined single-nucleotide polymorphisms satisfying the MR assumptions as instrumental variables. Inverse-variance weighted (IVW) approach under random-effects was applied as the dominant method for causal estimation. The weighted median approach, MR-Egger regression analysis, MR pleiotropy residual sum and outlier test, and leave-one-out sensitivity analysis were performed as sensitivity analysis. Horizontal pleiotropy was measured using MR-Egger regression analysis. Significant causal effects were attempted for replication and meta-analysis.

RESULTS

We revealed that asthma had causal effects on AR (IVW, odds ratio [OR] = 1.93; 95% confidence interval [CI], 1.74-2.14; p < 0.001), VMR (IVW, OR = 1.40; 95% CI, 1.15-1.71; p < 0.001), AC (IVW, OR = 1.65; 95% CI, 1.49-1.82; p < 0.001), and AD (IVW, OR = 2.13; 95% CI, 1.82-2.49; p < 0.001). No causal effect of asthma on AU was observed. Sensitivity analysis further assured the robustness of these results. The evaluation of the replication stage and meta-analysis further confirmed the causal effect of asthma on AR (IVW OR = 1.81, 95% CI 1.62-2.02, p < 0.001), AC (IVW OR = 1.44, 95% CI 1.11-1.87, p < 0.001), and AD (IVW OR = 1.85, 95% CI 1.42-2.41, p < 0.001).

CONCLUSIONS

We revealed and quantified the causal effects of asthma on AR, VMR, AC, and AD. These findings can provide powerful causal evidence of asthma on upper airway diseases and allergic diseases, suggesting that the treatment of asthma should be a preventive and therapeutic strategy for AR, VMR, AC, and AD.

Circulating mast cell progenitors increase during natural birch pollen exposure in allergic asthma patients

BACKGROUND

Mast cells (MCs) develop from a rare population of peripheral blood circulating MC progenitors (MCps). Here, we investigated whether the frequency of circulating MCps is altered in asthma patients sensitized to birch pollen during pollen season, compared to out of season.

METHODS

Asthma patients were examined during birch pollen season in late April to early June (May), and out of season in November-January. Spirometry measurements, asthma and allergy-related symptoms, asthma control questionnaire (ACQ), and asthma control test (ACT) scores were assessed at both time points. The MCp frequency was determined by flow cytometry in ficoll-separated blood samples from patients with positive birch pollen-specific IgE, and analyzed in relation to basic and disease parameters.

RESULTS

The frequency of MCps per liter of blood was higher in May than in November (p = .004), particularly in women (p = .009). Patients that reported moderate to severe asthma symptoms (<.0001), nose or eye symptoms (p = .02; p = .01), or reduced asthma control (higher ACQ, p = .01) had higher MCp frequency in May than those that did not report this. These associations remained significant after adjusting for sex and BMI. The change in asthma control to a lower ACT score in May correlated with an increase in MCp frequency in May (p = .006, rho = 0.46).

CONCLUSIONS

The data suggest that the frequency of MCps increases in symptomatic patients with allergic asthma. Our results unravel a link between asthma symptoms and circulating MCps, and bring new insight into the impact of natural allergen exposure on the expansion of MCs.

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.

Transcriptomic analysis of asthma and allergic rhinitis reveals CST1 as a biomarker of unified airways

Background

Allergic rhinitis (AR) is an important risk factor for the development of asthma. The "unified airway" theory considers the upper and lower airways as a morphological and functional whole. However, studies exploring biomarkers linking the upper and lower airways in allergic disease are lacking, which may provide insight into the mechanisms underlying AR comorbid asthma.

Purpose

To integrate bioinformatics techniques to explore biomarkers in airway allergic diseases, and to provide a molecular etiology profile for preventing the development of asthma in AR patients.

Methods

Biomarkers were screened by identifying key genes common between AR and asthma through WGCNA and differential gene analysis. GO and KEGG analyses were performed using DAVID. Immuno-infiltration analysis was performed by CIBERSORTx. The predictive value of CST1 to distinguish Th2-high asthma was determined by ROC curves. GSEA was used to analyze the signaling pathways involved in CST1. TargetScan and miRNet were combined with GSE142237 to construct ceRNA network. CMap was used to explore potential therapeutic drugs.

Results

Validation of datasets showed that CST1 was the only gene that was up-regulated in both upper and lower airways in patients with AR and asthma, and correlation heatmaps showed that CST1 was the gene with the highest sum of correlation coefficients. GO and KEGG analysis demonstrated that the lower airways of AR patients were mainly involved in inflammatory and immune responses, similar to asthma. Immune infiltration showed that CST1 was mainly positively correlated with activated CD4 memory T cells. According to the ROC curve, CST1 showed excellent diagnostic efficiency for Th2-high asthma. GSEA indicated that CST1 was involved in the FcϵRI signaling pathway and O-glycan biosynthesis. A ceRNA network including the lncRNAs KCNQ1OT1 and NEAT1 was constructed. Four drugs, including verrucarin-A, had the potential to prevent the development of asthma in AR patients. In addition, corticosteroids were found to downregulate CST1 expression.

Conclusion

CST1 plays a key role in the development of AR comorbid asthma and may be a biomarker for airway allergic diseases. Targeted treatment of CST1 has the potential to prevent the development of asthma in AR patients and deserves further study.

The majority of children sensitized before school-age develop allergic disease before adulthood: a longitudinal population-based study

BACKGROUND

Allergic sensitization increases the risk of and asthma and allergic rhinitis, but the impact of age at onset of sensitization is less studied.

OBJECTIVE

To examine the cumulative incidence of asthma and rhinitis up to age 19 years in relation to age at onset of sensitization to airborne allergens.

METHOD

All children in grade one and two (median age 8 years) in two municipalities in Northern Sweden were invited to skin prick tests and a questionnaire about allergic diseases, and 88% participated. At ages 12 and 19 years the protocol was repeated, and n=1510 individuals participated in all three examinations. Specific IgE was collected in a random sample at age 19, n=770. Onset of sensitization was defined; ≤8 years, 8-12 years, 12-19 years, and never sensitized. Adjusted Poisson regression was utilized to calculate risk ratios.

RESULTS

At age 19, those sensitized ≤8 year had the highest risk of asthma (RR 4.68 (95%CI 3.14-6.97)) and rhinitis (RR 22.3 (95%CI 13.3-37.6)), and 84% had developed either asthma or rhinitis. The combination of sensitization ≤8 year and family history of allergic diseases rendered high risks for asthma (RR 10.6 (6.71-16.7)) and rhinitis (RR 36.3 (18.9-69.7). Individuals sensitized ≤8 year showed significantly highest level of sensitization, as judged by number of positive skin tests and titers of specific IgE.

CONCLUSION

The majority of individuals with sensitization ≤8 years developed asthma or rhinitis before young adulthood. The high level of sensitization in early sensitized contribute to the high incidence of allergic airway conditions.

Prevalence and risk factors of allergic rhinitis and asthma in the southern edge of the plateau grassland region of northern China: A cross-sectional study

Background

The prevalence rates of allergic rhinitis (AR) and asthma in the border region of China may be different from those in the central region of plateau grasslands. A survey was performed to investigate the prevalence and risk factors for AR, asthma, and AR combined with asthma among adults (age ≥ 20 years) residing in the southern border of plateau grasslands in northern China.

Methods

From May to August 2018, a cross-sectional survey was completed by subjects that were selected using a cluster random sampling method. The subjects completed a questionnaire and were administered skin prick tests (SPTs). Risk factors for AR, asthma, and AR combined with asthma were examined by multivariate logistic regression analyses.

Results

A total of 1815 adult subjects in the selected region completed study. The prevalence rates of physician-diagnosed AR, asthma, and AR combined with asthma were 13.9% (253), 9.8% (177), and 2.9% (52), respectively. Among the patients with AR, 20.6% were found to have concurrent asthma; among the patients with asthma, 29.4% were found to have concurrent AR. Artemisia and Humulus pollen were the most common sensitizing pollen types. Approximately 70% of subjects with AR and <30% of asthma patients were sensitized to Artemisia and Humulus pollen. Symptoms of AR and asthma mainly appeared during August. A multivariable logistic regression analysis identified sensitization pollen as an independent risk factor for both AR and AR combined with asthma (AR: OR = 16.23, 95% CI: 10.15–25.96; AR combined with asthma: OR = 6.16, 95% CI: 1.28–29.66). An age >40 years old, family history of asthma, moderate-to-severe AR, adverse food reactions, and mold allergies were independent risk factors for AR combined with asthma.

Conclusions

This study identified the prevalence rates of AR and asthma in the southern borders of the plateau grassland in northern China (>1500 m above sea level). Sensitization pollen is an independent risk factor for AR and AR combined with asthma.

Patterns of allergen sensitization in patients with asthma in Yaqui Valley, Mexico

Introduction. People who live in highly allergenic regions have a greater risk of being sensitized; therefore, these areas have a higher prevalence of mono and polysensitized patients. The aim of the present study was to investigate the allergen sensitization profiles in patients with asthma in an agricultural zone in Mexico.Methods. An analytical cross-sectional study was conducted in a secondary care hospital in Obregon City, Mexico. The allergen sensitization pattern profiles were analyzed through a skin prick test (SPT) in 294 patients. Data was collected before SPT: asthma control was classified according to the Global Initiative for Asthma Criteria, nutritional status was assessed with the Body Mass Index (BMI) using Quetelet's index (BMI = weight/height²), and comorbidities, asthma, and smoking habits were collected from the patients' medical records.Results. In this study, in a group of adults with asthma, the prevalence of sensitization was 77%. The most frequent categories of aeroallergens were in indoors, in zones with weeds and abundant trees. A low proportion of monosensitized patients (2%) was observed. House dust mites were the most common allergens.Conclusions. Our study describes the sensitization pattern among asthma patients. This study will help identify the panel of most common allergens in this region of Mexico, and aid in selection of specific treatment through immunotherapy.

Cognitive dysfunction and quality of life during pollen season in children with seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis often gives rise to impaired quality of life and is believed to also affect cognitive function. We aimed to examine whether cognitive functions were impaired during grass pollen season in symptomatic allergic children and to relate the degree of impairment to quality of life and biomarkers related to stress and inflammation.

METHODS

Forty-three grass pollen-allergic children (age 8-17 years) with non-satisfactory effect of medication (antihistamines and nasal steroids daily) during previous seasons were included. In addition, 26 matched non-allergic children were included as controls. Both groups performed cognitive tests (CANTAB) and completed Quality of Life questionnaires outside and during the pollen season. Blood samples were collected and analyzed for stress and inflammatory biomarkers. Pollen level was measured daily.

RESULTS

Impaired cognitive function was found in spatial working memory, where the allergic group made more errors compared to the non-allergic group during pollen season, but not off-season. No significant differences could be seen between the allergic group and the controls in the other tests investigating visual memory or attention. Quality of health questionnaires revealed more symptoms and impaired quality of life in allergic compared to non-allergic children, and increased symptoms in allergic children were associated with longer reaction time for simple movement during pollen season. No differences in stress or inflammatory biomarkers could be found between the groups.

CONCLUSION

Cognitive function was affected during pollen season in pollen-allergic children, and the more symptoms the allergic children had, the longer the reaction time in the cognitive tests.

Novel therapeutic targets for allergic airway disease in children

The aim of precision medicine is setting up targeted therapies for selected patients that would ideally have high effectiveness and few side effects. This is made possible by targeted therapy drugs that selectively act on a specific pathway. Precision medicine is spreading to many medical specialties, and there is increasing interest in the context of allergic airway diseases, such as allergic rhinitis, chronic rhinosinusitis, and asthma. This review is an update of new targets in the treatment of childhood allergic upper airway diseases and asthma, including the most recent biologic drugs that have already been licensed or are in the pipeline to be tested with children.

Dampness, mould, onset and remission of adult respiratory symptoms, asthma and rhinitis

STUDY QUESTION

Is dampness and indoor mould associated with onset and remission of respiratory symptoms, asthma and rhinitis among adults?

MATERIALS AND METHODS

Associations between dampness, mould and mould odour at home and at work and respiratory health were investigated in a cohort of 11 506 adults from Iceland, Norway, Sweden, Denmark and Estonia. They answered a questionnaire at baseline and 10 years later, with questions on respiratory health, home and work environment.

RESULTS

Baseline water damage, floor dampness, mould and mould odour at home were associated with onset of respiratory symptoms and asthma (OR 1.23-2.24). Dampness at home during follow-up was associated with onset of respiratory symptoms, asthma and rhinitis (OR 1.21-1.52). Dampness at work during follow-up was associated with onset of respiratory symptoms, asthma and rhinitis (OR 1.31-1.50). Combined dampness at home and at work increased the risk of onset of respiratory symptoms and rhinitis. Dampness and mould at home and at work decreased remission of respiratory symptoms and rhinitis.

THE ANSWER TO THE QUESTION

Dampness and mould at home and at work can increase onset of respiratory symptoms, asthma and rhinitis, and decrease remission.

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

A Systematic Review of the Association between Cigarette Smoke Exposure and Chronic Rhinosinusitis

Objectives Cigarette smoking and passive smoke exposure have been associated with chronic rhinosinusitis (CRS). Our goal in this systematic review was to (1) determine if there was a strong correlative effect in large population studies between cigarette smoke exposure and the prevalence of CRS, (2) investigate pathogenic mechanisms of cigarette smoke in the upper airway, and (3) determine if a history of cigarette smoking affects the medical and surgical outcomes of CRS. Data Sources MEDLINE, Embase, Cochrane CENTRAL, Web of Science SCI and CPCI-S, and websites. Methods A comprehensive literature review and quantitative meta-analysis of studies based on the PRISMA protocol and examining the relationship between cigarette smoke exposure and CRS was performed. A search strategy was developed using various terms such as sinusitis, rhinitis, rhinosinusitis, and smoking. The articles were categorized by (1) epidemiology, (2) pathophysiology, and (3) outcomes. Data regarding study design, population/setting, methods, and bias were collected. Results The initial search generated 2621 titles/abstracts with 309 articles undergoing secondary review and 112 articles for final review. We determined that there is a strong correlation between active and passive cigarette smoke with the prevalence of CRS. Cigarette smoke challenge to sinonasal epithelia results in the release of inflammatory mediators and altered ciliary beat frequency. Pediatric patients exposed to secondhand smoke appear to have particularly poor outcomes. Conclusion There is clear evidence that cigarette smoke is related to CRS, but longitudinal and mechanistic studies are required to determine a causative effect. This information is critical for greater understanding of CRS health outcomes.

Relationship between upper airway diseases, exhaled nitric oxide, and bronchial hyperresponsiveness to methacholine

OBJECTIVE

The "united airway disease" concept is based on the bidirectional interaction between asthma and rhinitis. The aim of this study was to determine the relationship between upper airway diseases and bronchial hyperresponsiveness (BHR), as well as their association with the fractional concentration of exhaled nitric oxide (FeNO) and atopy in patients with persistent symptoms suggestive of asthma requiring methacholine challenge testing (MCT) to confirm asthma diagnosis.

METHODS

A cross-sectional prospective study was carried out in adult patients with persistent asthma-like symptoms and negative bronchodilator testing. FeNO and MCT were performed in all patients. Asthma was confirmed based on the presence of suggestive symptoms and MCT results. Associated upper airway diseases included allergic rhinitis, nonallergic rhinitis, chronic rhinosinusitis with nasal polyps (CRSwNP), and aspirin-exacerbated respiratory disease (AERD).

RESULTS

The study included 575 patients; asthma was confirmed in 32.3%, and FeNO values ≥ 50 ppb were found in 27% of the patients. Elevated FeNO was significantly associated to AERD. The prevalence of atopy in asthma patients was 86.6%. Atopy was present in 90.4% of patients with asthma and FeNO levels ≥ 50 ppb. A significant association was found between AERD, asthma, and FeNO ≥ 50 ppb.

CONCLUSIONS

Patients with symptoms suggestive of asthma but negative bronchodilator testing are commonly seen in usual practice. In this population, the association of high FeNO levels and BHR to atopy, as well as to AERD, suggests the presence eosinophilic inflammation in both the upper and lower airways and supports the "one airway" hypothesis.

Comorbidity, disease burden and mortality across age groups in a Swedish primary care asthma population: An epidemiological register study (PACEHR)

BACKGROUND

Asthma is often associated with other diseases. To identify and manage comorbidities is important, as these conditions may increase the disease burden.

OBJECTIVE

To describe the prevalence of comorbidities, disease burden and mortality across age groups in a large Swedish primary care real-life asthma population.

METHODS

Observational cohort study of asthma patients, all ages, identified from electronic medical records by ICD-10-CM code, data from 36 primary care centers. Data were linked to national mandatory Swedish health registers. Comorbidities were identified by ICD-10-CM codes and collected from electronic medical records and the National Patient Registers, mortality data from the Cause of Death Register. Exacerbations were defined as hospitalizations due to asthma, and/or emergency visits at hospital and/or prescription claims of oral steroids.

RESULTS

In total 33,468 patients (58% women) were included. The most prevalent comorbidities were acute upper respiratory tract infection (53%), rhinitis (25%), acute lower respiratory tract infection (25%), hypertension (21%), anxiety and depression (20%). The comorbidities associated with highest risk for an exacerbation were COPD OR 1.98 (95%CI: 1.80-2.19), nasal polyps OR 1.75 (95%CI: 1.49-2.05) and rhinitis OR 1.52 (95%CI: 1.41-1.63). All-cause mortality was similar to the Swedish population, 1011 deaths per 100,000 person/year compared with 1058 deaths (standardized risk = 0.99 [95%CI:0.95-1.04]). The pulmonary related death rate was greater in the study population versus the Swedish population (122 versus 72 per 100,000person/year).

CONCLUSION

Comorbid disease was frequent in this large real-life asthma population with an impact on exacerbations. To identify and treat comorbidities with impact on asthma outcomes are essential to improve asthma care.

Patient-reported signs of dampness at home may be a risk factor for chronic rhinosinusitis: A cross-sectional study

BACKGROUND

An association between dampness at home and respiratory conditions has been convincingly demonstrated in children. Fewer studies have been performed in adults, and data are lacking for chronic rhinosinusitis (CRS). With a prevalence of 10.9% in Europe, CRS imposes a significant burden on quality of life, as well as economy.

OBJECTIVE

Our aim was to study CRS and other respiratory conditions in relation to dampness at home in a representative sample of adults.

METHODS

The Swedish GA² LEN questionnaire was answered by 26 577 adults (16-75 years) and included questions on respiratory symptoms, smoking, education and environmental exposure. CRS was defined according to the EP³ OS criteria. Dampness was defined as reporting water damage, floor dampness or visible moulds in the home during the last 12 months. The dampness score was ranked from 0 to 3, counting the number of signs of dampness reported.

RESULTS

Dampness at home was reported by 11.3% and was independently related to respiratory conditions after adjustment for demographic and socio-economic factors and smoking: CRS odds ratio (OR) 1.71; allergic rhinitis OR 1.24; current asthma OR 1.21; wheeze OR 1.37; nocturnal dyspnoea OR 1.80; nocturnal coughing OR 1.34; and chronic bronchitis OR 1.64. The risk of CRS and most of the other respiratory conditions was further elevated in subjects reporting multiple signs of dampness.

CONCLUSIONS AND CLINICAL RELEVANCE

This study demonstrated an independent association between dampness at home and CRS in adults. The high burden of this and the other respiratory conditions studied is a strong argument in favour of countering indoor dampness by improving building standards.

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

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

Commonality of the IL-4/IL-13 pathway in atopic diseases

INTRODUCTION

Allergy results from an aberrant Type 2 inflammatory response, triggered by a wide range of environmental antigens (allergens) that lead to various immune responses, culminating in the production of immunoglobulin E (IgE). Two key cytokines, interleukin (IL)-4 and IL-13, are critical to the induction and perpetuation of the Type 2 response, and have been implicated in multiple atopic diseases. Area covered: This review summarizes recent milestone developments that have elucidated components of the pathogenesis of atopic diseases such as atopic dermatitis (AD), asthma, and chronic sinusitis with nasal polyposis (CSwNP). Expert commentary: Several therapeutic agents that selectively target potentiators of the Type 2 pathway have shown efficacy in one or more of these atopic diseases, but few agents have proven to be broadly applicable across all three atopic diseases. Dupilumab, a human monoclonal antibody that simultaneously inhibits signaling of IL-4 and IL-13, has demonstrated significant clinical efficacy in AD, asthma, and CSwNP. The fact that these diseases often occur as comorbidities and respond to the same therapy suggests that there is a common underlying pathogenic pathway, and that IL-4 and IL-13 cytokines are central to regulating the pathogenesis of these atopic diseases.

Impact of rhinitis on lung function in children and adolescents without asthma

BACKGROUND

Subclinical spirometric abnormalities may be detected in patients with rhinitis without asthma, proportional to the severity established by ARIA (Allergic Rhinitis and Its Impact on Asthma) guidelines. New criteria of rhinitis classification were recently validated according to the ARIA modified (m-ARIA), which allow the discrimination between moderate to severe grades. The impact of rhinitis on lung function according to frequency and severity is unknown.

OBJECTIVES

To investigate subclinical spirometric impairment in children and adolescents with allergic and non-allergic rhinitis without overt symptoms of asthma, according to the frequency and severity criteria of rhinitis classified by m-ARIA.

METHODS

An observational cross-sectional study, including children and adolescents aged 5-18 years with allergic and non-allergic rhinitis without asthma. We analysed the functional abnormalities and bronchodilator response with spirometry in relation to the grade of rhinitis established by m-ARIA using an adjusted logistic model. A value of p<0.05 was considered statistically significant.

RESULTS

We studied 189 patients; 22.2% showed spirometric abnormalities. Patients with persistent rhinitis had greater impairment of lung function compared to intermittent grade (p=0.026). Lung functional impairment was more frequent in severe and moderate rhinitis than mild grade (p=0.005) and was independent of the atopic status to both frequency (p=0.157) and severity (p=0.538). There was no difference in bronchodilator reversibility between groups (p>0.05).

CONCLUSIONS

Impaired lung function was associated with persistence and severity of rhinitis and there was no significant difference between patients with moderate and severe rhinitis. The spirometric abnormality was demonstrated in patients with allergic and non-allergic rhinitis.

Prevalence of asthma and rhinitis in a Tunisian population

BACKGROUND

Asthma and rhinitis are a major public health problem because of their frequency, their impact on quality of life and economic burden. In Tunisia, epidemiological data are scarce. The aim of the present study was to estimate the prevalence of asthma and rhinitis in a representative Tunisian population and to analyze the association between them.

METHODS

It was a cross-sectional population-based study, involving individuals aged between 2 and 52 years, living in Tunis. A sample of the general population was generated using a random stratified sampling method. A detailed face-to-face questionnaire based on ISAAC and the ECRHS survey was used. Classification of rhinitis was evaluated according to ARIA.

RESULTS

Data were obtained from 4470 responders (40.2% male and 59.8% female). The response rate was 96.5%. The prevalence of current asthma was 6.5% (CI 5.9%-7.8%). A slight female predominance was observed in children and adolescents but in adulthood gender-specific prevalence estimates were similar. The prevalence of rhinitis in the general population was 11.7% (CI 10.1%-13.5%) in children and 13.4% (CI 11.1%-14.6%) in 15 years and older. No statistically significant differences were found according to gender and age. Almost half of asthmatics' had current rhinitis or rhinoconjunctivitis versus 13.4% in the population sample (P < 0.001). Current asthma was reported in 22.5% subjects with current rhinitis or with rhinoconjunctivitis.

CONCLUSIONS

Asthma and rhinitis represent a considerable public health problem in children and adults up to age 52 in Tunisian population. Our results confirm also the strong association between them. These findings highlight the need for a clinical global assessment of asthma together with rhinitis.

Subjects with well-controlled asthma have similar health-related quality of life as subjects without asthma

BACKGROUND

The burden of asthma and rhinitis on health-related quality of life (HRQL) among adults has been assessed mainly in studies of patients seeking health-care, while population-based studies are relatively scarce. The objective of this study was to investigate HRQL among subjects with asthma and rhinitis derived from a random population sample and to identify factors related to impairment of HRQL.

METHODS

A randomly selected cohort was invited to participate in a postal questionnaire survey. Of those who responded, a stratified sample of 1016 subjects was invited to clinical examinations and interviews, and 737 subjects in ages 21-86 years participated. Of these, 646 completed HRQL questions. HRQL was assessed with the generic SF-36 Health Survey.

RESULTS

The physical score was lower among subjects with asthma vs. subjects without asthma (p < 0.001). No significant difference was found in the mental score. Subjects with well-controlled asthma had higher physical score compared to subjects with partly and un-controlled asthma (p = 0.002). Actually, subjects with well-controlled asthma had similar physical HRQL as subjects without asthma. Asthmatics who were current smokers had lower physical score compared to those who were non-smokers (p = 0.021). No significant differences in physical or mental scores were found between subjects with and without rhinitis. Subjects with both asthma and rhinitis had lower physical score compared to subjects without these conditions (p < 0.001), but subjects with asthma alone had even worse physical score.

CONCLUSIONS

The physical score was significantly lower in asthmatics compared to subjects without asthma. Importantly, non-smoking and well-controlled asthmatics have similar HRQL compared to subjects without asthma. Thus, subjects with asthma should be supported to achieve and maintain good asthma control and if they smoke, be offered smoking cessation as means to improve their HRQL.

Direct measurement of upper airway inflammation in children with chronic rhinosinusitis: implications for asthma

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a common heterogenous multifactorial disorder affecting children and adults. The exact mechanism is not completely understood. In this review, we aim to summarize our recent findings regarding etiologies and pathogenesis of CRS in children and review recent studies investigating inflammatory patterns in the upper airways in children and adults with CRS.

RECENT FINDINGS

There are only a few small studies measuring upper airway inflammation in children with CRS. These studies demonstrated more toward eosinophilic and T-cell driven inflammatory pattern. Cytokine patterns in upper airways seem to correlate with asthma symptoms in children with CRS. Adult studies demonstrate eosinophilic and Th-2 (T helper-1) driven inflammation in CRS with nasal polyps and Th-1 (T helper-2) driven inflammation in CRS without nasal polyps.

SUMMARY

Current knowledge about the characteristics of tissue inflammation in upper airways in children with CRS is limited. More studies are needed to better understand the pathogenesis and better define the subgroups of CRS. The findings of such studies will lead to identifying the biological targets to treat this condition.

Asthma and rhinitis have different genetic profiles for IL13, IL17A and GSTP1 polymorphisms

BACKGROUND

Asthma and rhinitis have a complex etiology, depending on multiple genetic and environmental risk factors. An increasing number of susceptibility genes are currently being identified, but the majority of reported associations have not been consistently replicated across populations of different genetic backgrounds.

PURPOSE

To evaluate whether polymorphisms of IL4R (rs1805015), IL13 (rs20541), IL17A (rs2275913) and GSTP1 (rs1695) genes are associated with rhinitis and/or asthma in adults of Portuguese ancestry.

METHODS

192 unrelated healthy individuals and 232 patients, 83 with rhinitis and 149 with asthma, were studied. All polymorphisms were detected by real time polymerase chain reaction (PCR) using TaqMan assays.

RESULTS

Comparing to controls, significant association with asthma was observed for GSTP1 rs1695 AA genotype (odds ratio (OR) - 1.96; 95% CI - 1.18 to 3.25; p=0.010). The association sustains for allergic asthma (OR - 2.17; 95% CI - 1.23 to 3.80; p=0.007). IL13 rs20541 GG genotype was associated with less susceptibility to asthma (OR - 0.55, 95% CI - 0.33 to 0.94, p=0.028). Among patients, IL17A rs2275913 AA genotype was less associated with asthma than with rhinitis (OR - 0.20; 95% CI of 0.07 to 0.56; p=0.002). A similar association was found for IL13 rs20541 GG genotype (OR - 0.48; 95% CI of 0.25 to 0.93; p=0.031). There were no significant differences in the distribution of allelic and genotypic frequencies between patients and controls for the IL4R polymorphism' analyzed.

CONCLUSION

These results support the existence of a significant association between GSTP1 rs1695 and IL13 rs20541 SNPs, with susceptibility to asthma, in the population studied. Different genotype profiles of IL17A and IL13 genes seem to influence the clinical pattern of disease expression mainly confined to the upper airways, as rhinitis, or including the lower airways, as asthma.

Occupational exposure to chemicals drives the increased risk of asthma and rhinitis observed for exposure to vapours, gas, dust and fumes: a cross-sectional population-based study

OBJECTIVES

Occupational exposure to the composite measure vapours, gases, dusts and fumes (VGDF), contribute to the burden of asthma and rhinitis. The objective was to evaluate occupational exposure to VGDF, which is further divided into the components chemicals, organic and inorganic dust in relation to asthma and rhinitis.

METHODS

Previously examined participants from three population-based cohorts in the Obstructive Lung disease In Northern Sweden (OLIN) studies were re-examined during 2002-2004. In total, 4036 participated in a structured interview and answered a questionnaire on occupational exposures.

RESULTS

Occupational exposure to VGDF increased the risk of asthma, and concomitant asthma and rhinitis. Exposure to chemicals, but not dust, showed a similar pattern. Exposure to chemicals increased the risks (OR, 95% CI) of rhinitis without asthma (1.29, 1.10 to 1.52), asthma without rhinitis (1.42, 1.15 to 1.77) and concomitant asthma and rhinitis (1.60, 1.31 to 1.96) when adjusted for confounders such as age, smoking habits, body mass index and sex. The association between exposure to chemicals and asthma and rhinitis remained independent of exposure to dust and was also so when excluding exposure to isocyanates and welding fumes. The results were similar for women and men, as well as for never-smokers and participants without a history of allergy.

CONCLUSIONS

In this cross-sectional population-based study, occupational exposure to chemicals contributed substantially to the increased risk of asthma and rhinitis observed for occupational exposure to VGDF.

A rhinitis phenotype associated with increased development of bronchial hyperresponsiveness and asthma in children

BACKGROUND

Allergic rhinitis (AR) has a wide range of clinical features and may be accompanied by comorbid allergic diseases.

OBJECTIVE

To identify rhinitis phenotypes in school aged children and to predict the prognosis for developing bronchial hyperresponsiveness (BHR) and asthma.

METHODS

This prospective follow-up study involved schoolchildren from the Children's Health and Environment Research cohort with current rhinitis, which was defined based on parental-reported, physician-diagnosed rhinitis and symptoms of rhinitis in the previous 12 months. All participants were followed up at 2 and 4 years later. Rhinitis clusters were identified by latent class analysis that used demographic, clinical, and environmental variables.

RESULTS

In 512 eligible children (age range, 6-8 years), 4 rhinitis phenotypes were identified: cluster 1 (25% of children) was associated with nonatopy and a low socioeconomic status; cluster 2 (36%) was associated with a high-atopic burden but normal lung function; cluster 3 (22%) was associated with a high-atopic burden and impaired lung function; and cluster 4 (17%) was associated with low atopy and a high socioeconomic status. Cluster 3 was associated with the highest total serum IgE levels and blood eosinophil percentages at enrollment and the highest incidence of new cases of BHR (P = .04) and asthma symptoms (P = .005) during follow-up.

CONCLUSION

The rhinitis cluster of schoolchildren with atopy and impaired lung function is associated with allergic march. This identification of distinct rhinitis phenotypes in affected children may help to prevent allergic march in children with rhinitis.

Occurrence and impact of sinusitis in patients with asthma and/or allergic rhinitis

OBJECTIVE

The occurrence of radiological sinusitis in patients with asthma without any obvious nasal symptoms could possibly increase the severity of asthma. We investigated the occurrence and impact of sinusitis on computed tomography of the paranasal sinuses (CT-PNS) in patients with asthma and/or allergic rhinitis. Effect of sinusitis on the quality of life (QoL) was also assessed.

METHODS

All subjects underwent spirometry with reversibility, CT-PNS, intradermal test against common aeroallergens and responded to Symptom Severity Score and Rhinosinusitis Disability Index (RSDI). Of the 216 consecutive patients, 27 had asthma without nasal symptoms (Group 1), 58 had asthma with allergic rhinitis (Group 2) and 131 had allergic rhinitis (Group 3). Thirty normal healthy controls without atopy were also included (Group 4).

RESULTS

20/27 (74%) patients in Group 1 had sinusitis on CT-PNS. 48/58 (82%) patients in Group 2 and 88/131 (67%) patients in Group 3 had chronic rhinosinusitis (CRS) as confirmed on CT-PNS. 6/30 (20%) healthy controls in Group 4 had mucosal thickening. Asthmatics with radiological sinusitis in Group 1 and with CRS in Group 2 had significantly lower FEV1, FEV1/FVC ratio, were more symptomatic and had a greater impairment of QoL. The mean sinus severity score was significantly higher in Group 2. In Group 3, sinusitis occurred significantly higher in "blockers" than "sneezers-runners" (41/79 versus 47/52, p = 0.045).

CONCLUSIONS

Occurrence of radiological sinusitis on CT-PNS in asthmatics without nasal symptoms and CRS in allergic rhinitis with or without asthma increases the severity of the disease and affects the QoL.

Diagnosing Allergic Rhinitis

Allergic rhinitis (AR) is the most common immunologic disease in industrialized societies and has a significant impact on quality of life. Most asthmatics also have rhinitis. AR may present with comorbidities, including chronic otitis media with effusion, cough, and pollen-food cross-reactivity. AR may occur in isolation or be part of a mixed rhinitis.

Phenotyping asthma in the elderly: allergic sensitization profile and upper airways comorbidity in patients older than 65 years

BACKGROUND

Data about allergic rhinitis in elderly patients with asthma are lacking.

OBJECTIVE

To investigate the presence of rhinitis and the role of sensitization of airborne allergens in elderly patients with asthma.

METHODS

This was a multicenter cross-sectional study involving subjects at least 65 years old with asthma. Demographic features, comorbidities, and the presence of allergic respiratory disease were retrieved through interview. Skin prick tests for common allergens were performed. Associations of demographic and clinical features were evaluated in relation to asthma control and forced expiratory volume in the first second less than 80% in the total population and in the subgroup with features resembling chronic obstructive pulmonary disease.

RESULTS

Of 368 elderly subjects with asthma, 101 had features resembling chronic obstructive pulmonary disease. Rhinitis was present in 59.0% of subjects (allergic rhinitis in 47.6%), with an age of onset significantly different from that of asthma (49 ± 18 vs 57 ± 18 years). At least 1 sensitization was observed in 52.4% of subjects, more frequently for house dust mite (HDM; 31.8%). The prevalence of poorly and partially controlled asthma was higher in patients sensitized to airborne allergens (odds ratio 1.64, 95% confidence interval 1.03-2.61), in particular to HDM (odds ratio 1.73, 95% confidence interval 1.05-2.85).

CONCLUSION

Approximately 60% of elderly subjects with asthma had rhinitis, mainly allergic and often untreated, whose onset preceded asthma symptoms by a mean of approximately 10 years. Nonallergic asthma was better controlled than allergic asthma. However, HDM sensitization was greater in subjects with asthma with features resembling chronic obstructive pulmonary disease (39% vs 28%). When restricting analysis to this group, the negative role of HDM in overall asthma control (forced expiratory volume in first second and Asthma Control Test) was significant.

Evaluation of Association of Allergic Rhinitis with Bronchial Asthma

Allergic rhinitis represents a global health problem. It is a common disease worldwide affecting about 10-50 % of the population and its prevalence is increasing. Although allergic rhinitis is not a fatal disease, it alters the social life of patients, affecting learning performance and work productivity. Moreover, the costs incurred by allergic rhinitis are substantial. In recent years allergic rhinitis has been recognized to be an important risk factor for asthma. The concept of "One Airway, One Disease" was highlighted in the 'Allergic rhinitis and its Impact on Asthma 'guidelines and has arisen as a result of the now well-established link between the upper and lower airways. The aim of this study was to evaluate the association between allergic rhinitis and bronchial asthma by determining the incidence of bronchial asthma in patients of allergic rhinitis and the incidence of allergic rhinitis in patients of bronchial asthma. 83 diagnosed cases each of allergic rhinitis and bronchial asthma were recruited from patients attending Otorhinolaryngology and pulmonary department of the institute. All patients were subjected to detail ENT and pulmonary examination and investigated for nasal and bronchial allergy. In the allergic group, which consisted of 83 diagnosed patients of allergic rhinitis, 49 (59.03 %) were diagnosed to have bronchial asthma, whereas in the bronchial asthma group, which consisted of 83 diagnosed patients of bronchial asthma 61 (78.20 %) were diagnosed to have comorbid allergic rhinitis. It was observed that patients with allergic rhinitis were likely to develop bronchial asthma, and patients of allergic rhinitis should be evaluated for bronchial asthma, for early detection and treatment of the co morbid condition.

Neural Abnormalities in Nonallergic Rhinitis

Sensory nerve endings within the airway epithelial cells and the solitary chemoreceptor cells, synapsing with sensory nerves, respond to airborne irritants. Transient receptor potential (TRP) channels (A1 and V1 subtypes, specifically) on these nerve endings initiate local antidromic reflexes resulting in the release of neuropeptides such as substance P and calcitonin G-related peptides. These neuropeptides dilate epithelial submucosal blood vessels and may therefore increase transudation across these vessels resulting in submucosal edema, congestion, and rhinitis. Altered expression or activity of these TRP channels can therefore influence responsiveness to irritants. Besides these pathogenic mechanisms, additional mechanisms such as dysautonomia resulting in diminished sympathetic activity and comparative parasympathetic overactivity have also been suggested as a probable mechanism. Therapeutic effectiveness for this condition has been demonstrated through desensitization of TRPV1 channels with typical agonists such as capsaicin. Other agents effective in treating nonallergic rhinitis (NAR) such as azelastine have been demonstrated to exhibit TRPV1 channel activity through the modulation of Ca(2+) signaling on sensory neurons and in nasal epithelial cells. Roles of antimuscarinic agents such as tiotropium in NAR have been suggested by associations of muscarinic cholinergic receptors with TRPV1. The associations between these channels have also been suggested as mechanisms of airway hyperreactivity in asthma. The concept of the united airway disease hypothesis suggests a significant association between rhinitis and asthma. This concept is supported by the development of late-onset asthma in about 10-40 % of NAR patients who also exhibit a greater severity in their asthma. The factors and mechanisms associating NAR with nonallergic asthma are currently unknown. Nonetheless, free immunoglobulin light chains and microRNA alteration as mediators of these inflammatory conditions may play key roles in this association.

Effect of the potent and selective DP1 receptor antagonist, asapiprant (S-555739), in animal models of allergic rhinitis and allergic asthma

Prostaglandin (PG) D2 elicits responses through either the DP1 and/or DP2 receptor. Experimental evidence suggests that stimulation of the DP1 receptor contributes to allergic responses, such that antagonists are considered to be directed therapies for allergic diseases. In this study, we demonstrate the activity of a novel synthetic DP1 receptor antagonist termed asapiprant (S-555739) for the DP1 receptor and other receptors in vitro, and assess the efficacy of asapiprant in several animal models of allergic diseases. We determined the affinity and selectivity of asapiprant for the DP1 receptor in binding assays. In the animal models of allergic rhinitis, changes in nasal resistance, nasal secretion, and cell infiltration in nasal mucosa were assessed after antigen challenge with and without asapiprant. Similarly, in the animal models of asthma, the effect of antigen challenge with and without asapiprant on antigen-induced bronchoconstriction, airway hyper-responsiveness, mucin production, and cell infiltration in lung were assessed. In binding studies, asapiprant exhibited high affinity and selectivity for the DP1 receptor. Significant suppression of antigen-induced nasal resistance, nasal secretion, and cell infiltration in nasal mucosa was observed with asapiprant treatment. In addition, treatment with asapiprant suppressed antigen-induced asthmatic responses, airway hyper-responsiveness, and cell infiltration and mucin production in lung. These results show that asapiprant is a potent and selective DP1 receptor antagonist, and exerts suppressive effects in the animal models of allergic diseases. Thus, asapiprant has potential as a novel therapy for allergic airway diseases.

Sinus and adenoid inflammation in children with chronic rhinosinusitis and asthma

BACKGROUND

Chronic rhinosinusitis (CRS) and asthma frequently coexist in children and adults. However, the precise pathophysiologic mechanism of this interaction is still poorly understood, especially in children, owing to the lack of direct measurements of mucosal inflammation in the upper airways.

OBJECTIVE

To determine the pathophysiologic mechanism by analyzing the expression of a large array of inflammatory cytokines and chemokines in the sinus and adenoid tissues surgically removed from pediatric patients with CRS refractory to medical management.

METHODS

Twenty-eight children 2 to 12 years old diagnosed with CRS with or without asthma and 10 controls were included in this prospective, nonrandomized study. Mucosal expression of 40 inflammatory cytokines was measured with a multiplex assay and was normalized to total tissue protein.

RESULTS

Compared with children with CRS and without asthma, children with CRS and asthma had significantly higher sinus levels of tumor necrosis factor-α and adenoid levels of epidermal growth factor, eotaxin, fibroblast growth factor-2, growth-related oncogene, and platelet-derived growth factor-AA.

CONCLUSION

The inflammatory response in the upper airway mucosa of children with asthma and CRS was similar, but more severe, compared with children with CRS without asthma. This observation is consistent with the hypothesis that asthma in these patients is caused or exacerbated by severe upper airway disease and supports the concept that treating sinus disease is paramount in the management of chronic asthma in children using, for the first time, direct measurements of airway inflammation in children.

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Rhinosinusitis and asthma: a very long engagement

Upper and lower airways may be considered as a unique entity, interested by coexisting inflammatory processes that share common etiopathogenic mechanisms. Previous studies have strongly demonstrated a relationship between rhinosinusitis and asthma. This has led to the introduction of the concept of “United Airways”, which has also been included in the WHO document Allergic Rhinitis and its Impact on Asthma (ARIA); this concept has important consequences also on the treatment of these disorders. To better summarize the evident connection between upper and lower airway disease we decided to describe it as a multilayered construction, each level pointing out more deeply the relationship between these entities.

The association between asthma and rhinitis is stable over time despite diverging trends in prevalence

BACKGROUND

Despite the well-known association between asthma and rhinitis, in Swedish adults the prevalence of rhinitis rose from 22% to 31% between 1990 and 2008 while asthma prevalence was unchanged. We tested whether the association of rhinitis with asthma was stable over time using the same population-based databases.

METHODS

Two surveys of adults (20-44 years) living in three regions of Sweden, carried out in 1990 (n = 8982) and 2008 (n = 9156) were compared. Identical questions regarding respiratory symptoms, asthma and rhinitis were used. Asthmatic wheeze: Wheeze with breathlessness apart from colds. Current asthma: Asthma attacks and/or asthma medication use.

RESULTS

Subjects with rhinitis had level time trends in asthmatic wheeze, current asthma and most nocturnal respiratory symptoms between 1990 and 2008, adjusted for age, sex, area and smoking. Any wheeze however decreased slightly. In never-smokers asthma symptoms were similarly associated with rhinitis in 1990 and 2008: any wheeze OR 4.0 vs. 4.4 (p = 0.339); asthmatic wheeze OR 6.0 vs. 5.9 (p = 0.937); and current asthma OR 9.6 vs. 7.7 (p = 0.213). In the whole population there were decreases in the asthma symptoms most closely associated to smoking, which decreased by half 1990-2008. Conversely current asthma, which was strongly associated with rhinitis and not with smoking, increased (p < 0.001).

CONCLUSIONS

The association of rhinitis with asthma was stable between 1990 and 2008. The pattern in the time trends of asthma outcomes strongly suggests that decreased smoking counterbalanced the driving effect of increased rhinitis on asthma prevalence. The findings illustrate the public health benefits of decreased smoking.

Bronchial inflammation in seasonal allergic rhinitis with or without asthma in relation to natural exposure to pollen allergens

BACKGROUND

Nasal inflammation in allergic rhinitis enhances bronchial Th2 driven inflammation and development of asthma. We assessed bronchial inflammation induced by natural allergen exposure during pollen season in patients with pollinosis with or without asthma to show the intensity of inflammation in asthma and rhinitis and possible persistence of inflammation in periods without allergen exposure.

METHODS

Sputum was induced in 52 patients with seasonal allergic rhinitis without asthma, 38 patients with seasonal allergic rhinitis and seasonal asthma and 23 healthy volunteers. Sampling was performed 6-8 weeks before the expected beginning of symptoms, during symptomatic period and 6-8 weeks after the end of symptoms. Sputum ECP was measured by means of chemi-luminiscent immunometric assay and sputum cell counts were assessed by classical staining and immunocytochemistry.

RESULTS

Sputum eosinophils were on the whole higher in both asthma and rhinitis compared to controls (p<0.001, p=0.003). The rise of eosinophils during pollen season compared with values out of pollen season was significant in asthma (classical staining) (p=0.014) and slightly apparent in rhinitis (immunocytochemistry) (p=0.073). The seasonal rise of sputum ECP was observed only in rhinitis (p=0.006).

CONCLUSIONS

Inflammation of the lower airway in patients with allergic rhinitis with and without asthma has been confirmed by means of both sputum eosinophil count and sputum ECP level. Persistent inflammation of lower airway in periods without allergen exposure was proven in seasonal asthma. This may have implications for the therapy of seasonal allergic rhinitis with and without asthma in terms of promoting long-term anti-inflammatory treatment.

Frequent cough in unsatisfactory controlled asthma--results from the population-based West Sweden Asthma study

BACKGROUND

Asthma is a complex disease presenting with variable symptoms which are sometimes hard to control. The purpose of the study was to describe the prevalence of asthma symptoms, use of asthma medications and allergic sensitization in subjects with asthma. We also related those indices to the level of asthma control, lung function and in particular, cough.

METHODS

An extensive questionnaire was sent to randomly selected adults from the West Sweden region. Clinical examinations and interview were performed in a subset. Of the participants, 744 were defined as having an ongoing asthma - reported ever having asthma or physician diagnosed asthma and one of the following - use of asthma medications, recurrent wheeze or attacks of shortness of breath with or without wheeze in the last 12 months. A respiratory disease-free control group of 847 subjects was also described.

RESULTS

According to GINA guidelines, 40.6% of the asthmatics had partly controlled and 17.8% had uncontrolled asthma. Asthmatic subjects reported significantly more symptoms in the last 12 months than the control group - wheezing (79.4 vs 9.2%), shortness of breath (36.1 vs 2.5%), wheezing with shortness of breath (58.7 vs 1.3%). Important complaints were morning cough (42.5 vs 15.5%), cough with sputum production (36.1 vs 6.8%) and longstanding cough (32.5 vs 11.1%), which bothered two thirds of the uncontrolled and one third of partly controlled subjects. Asthma medications were used by 87.5% of the asthmatics, although around 30% of them who had insufficiently controlled disease used only short-acting beta-agonists. Asthmatics also had lower lung function, reacted to lower doses of methacholine that the controls and 13.6% of them had a FEV1/FVC ratio below 0.7. Allergic rhinitis was reported by 73.8% of the asthmatics and they were more frequently sensitized to several common allergens.

CONCLUSIONS

Approximately 60% of asthmatics from this population-based study had insufficiently controlled asthma and persistent complaints, despite a high use of asthma medications. These self-reported symptoms were supported by clinical examination data. Increased cough frequency is an indicator of a more severe and difficult to control disease and should be considered when asthma is characterized.

Identifying the heterogeneity of young adult rhinitis through cluster analysis in the Isle of Wight birth cohort

BACKGROUND

Rhinitis affects many young adults and often shows comorbidity with asthma.

OBJECTIVE

We hypothesized that young adult rhinitis, like asthma, exhibits clinical heterogeneity identifiable by means of cluster analysis.

METHODS

Participants in the Isle of Wight birth cohort (n = 1456) were assessed at 1, 2, 4, 10, and 18 years of age. Cluster analysis was performed on those with rhinitis at age 18 years (n = 468) by using 13 variables defining clinical characteristics.

RESULTS

Four clusters were identified. Patients in cluster 1 (n = 128 [27.4%]; ie, moderate childhood-onset rhinitis) had high atopy and eczema prevalence and high total IgE levels but low asthma prevalence. They showed the best lung function at 18 years of age, with normal fraction of exhaled nitric oxide (Feno), low bronchial hyperresponsiveness (BHR), and low bronchodilator reversibility (BDR) but high rhinitis symptoms and treatment. Patients in cluster 2 (n = 199 [42.5%]; ie, mild-adolescence-onset female rhinitis) had the lowest prevalence of comorbid atopy, asthma, and eczema. They had normal lung function and low BHR, BDR, Feno values, and total IgE levels plus low rhinitis symptoms, severity, and treatment. Patients in cluster 3 (n = 59 [12.6%]; ie, severe earliest-onset rhinitis with asthma) had the youngest rhinitis onset plus the highest comorbid asthma (of simultaneous onset) and atopy. They showed the most obstructed lung function with high BHR, BDR, and Feno values plus high rhinitis symptoms, severity, and treatment. Patient 4 in cluster 4 (n = 82 [17.5%]; ie, moderate childhood-onset male rhinitis with asthma) had high atopy, intermediate asthma, and low eczema. They had impaired lung function with high Feno values and total IgE levels but intermediate BHR and BDR. They had moderate rhinitis symptoms.

CONCLUSION

Clinically distinctive adolescent rhinitis clusters are apparent with varying sex and asthma associations plus differing rhinitis severity and treatment needs.

Prevalence of asthma and its association with rhinitis in the elderly

BACKGROUND

Asthma and rhinitis are frequent respiratory diseases in children and adults. Despite the increase in the aging population, there are few epidemiologic data on both diseases in the elderly. So far, no population-based study has analyzed the association between asthma and rhinitis symptoms and severity in this age group. This study aimed to estimate the prevalence of physician-diagnosed asthma in the population aged ≥65 years in mainland Portugal and to evaluate its association with the presence and classification of rhinitis according to ARIA recommendations, in this age group.

METHODS

A cross-sectional, nationwide, population-based survey of individuals aged ≥65 years, living in mainland Portugal was performed.

RESULTS

Data were obtained from 3678 respondents. The prevalence of physician-diagnosed asthma was 10.9% (95% confidence interval (95%CI) 9.9-11.9). The frequency of asthma diagnosis increased with the number of nasal symptoms (p < 0.001). A strong association between asthma and rhinitis was found (odds ratio (OR) 13.86 (95%CI 10.66-18.02)). The strength of this association increased with the persistence and severity of rhinitis, being particularly high in elderly subjects with moderate-severe persistent rhinitis (OR 39.9 (95%CI 27.5-58.0)).

CONCLUSIONS

Asthma is common in the elderly and strongly associated with rhinitis. The OR for asthma is especially high in persistent and severe ARIA classification rhinitis types. This study strengthens the need for an integrated assessment of asthma together with rhinitis in the elderly.

Rhinitis symptoms and asthma among parents of preschool children in relation to the home environment in Chongqing, China

Risk factors for rhinitis and asthma in the home environment were studied by a questionnaire survey. Parents of 4530 1-8 year old children (one parent per child) from randomly selected kindergartens in Chongqing, China participated. 70.4% were females; 47.1% had rhinitis symptoms in the last three months (current rhinitis, CR); 1.6% reported a history of allergic asthma (AA); 2.7% reported a history of allergic rhinitis (AR); 16.4% were current smokers; 50.8% males and 2.4% females were current smokers. Stuffy odor, unpleasant odor, tobacco smoke odor and dry air were associated with CR (adjustment for gender, current smoking and other perceptions of odor or humidity). Associations between home environment and CR, AR, and AA were studied by multiple logistic regression analyses, adjusting for gender, current smoking and other significant home factors. Living near a main road or highway was a risk factor for both CR (OR(95%CI): 1.31(1.13,1.52)) and AR (OR(95%CI): 2.44(1.48,4.03)). Other risk factors for CR included living in rural areas (OR(95%CI): 1.43(1.10,1.85)), new furniture (OR(95%CI): 1.28(1.11,1.49)), water damage (OR(95%CI): 1.68(1.29,2.18)), cockroaches (OR(95%CI): 1.46(1.23,1.73)), and keeping pets (OR(95%CI): 1.24(1.04,1.49)). Other risk factors for AR included redecoration (OR(95%CI): 2.14(1.34,3.41)), mold spots (OR(95%CI): 2.23(1.06,4.68)), window pane condensation (OR(95%CI): 2.04(1.28,3.26)). Water damage was the only home factor associated with AA (2.56(1.34,4.86)). Frequently put bedding to sunshine was protective for CR (OR(95%CI): 0.79(0.68,0.92); cleaning every day was protective for AR (OR(95%CI): 0.40(0.22,0.71)). In conclusion, parents' CR and AR were related to a number of factors of the home environment.

Effects of wheezing in early childhood in the development of allergic rhinitis in later years

BACKGROUND

Studies on the long-term effects of wheezing in infancy have particularly focused on asthma. There isn't adequate information about the effects of wheezing in the development of allergic rhinitis in later years.

OBJECTIVE

In this study, children with wheezing in the first year of life were investigated in terms of allergic rhinitis after five years of age.

METHODS

The study consisted of children with early-transient wheezing or persistent wheezing. The study groups were evaluated in terms of allergic rhinitis with physical examination and a questionnaire translated from International Study of Asthma and Allergies in Children (ISAAC) questionnaire after five years of age.

RESULTS

The study included 50 children; 23 (46%) had early-transient wheezing and 27 (54%) had persistent wheezing. The symptoms of allergic rhinitis were reported in 13 (48%) of children with persistent wheezing but in none of children with early-transient wheezing (p < 0.05). Skin prick tests showed positive results in 4.3% of children with early-transient wheezing and in 48.1% of children with persistent wheezing (p < 0.05).

CONCLUSION

Persistent wheezing, but not early transient wheezing seems to be a risk factor in the development of allergic rhinitis in children after five years of age.

Association between allergic rhinitis and asthma in a Northern Alberta cohort

Background

Many published epidemiologic studies confirm a marked increase in the prevalence of asthma and allergic rhinitis. The link between allergic rhinitis and asthma has been extensively studied and approximately 75% of patients with asthma have allergic rhinitis. The proportion of patients with asthma in populations of allergic rhinitis patients has not been well studied.

Objective

The purpose of this study is to estimate the prevalence of undiagnosed asthma in a specific population of patients presenting to an Otolaryngologist with symptoms of allergic rhinitis.

Study design

Prospective cohort study. Methods: Patients presenting with symptoms of allergic rhinitis to two tertiary care Rhinology practices in Northern Alberta were asked to undergo allergy skin testing, serum IgE quantification, and pulmonary functional testing. Patients with previous asthma screening or known history of reactive airway disease or asthma were excluded.

Results

107 patients with allergic rhinitis symptoms were recruited between September 2010 to January 2013. Patients predominantly had perennial or persistent rhinitis (64.5%) with moderate-severe symptoms (50.5%). While only 14.9% of patients had abnormal IgE levels, 68.8% had positive skin testing. Abnormal pulmonary function tests were obtained in 39.1% of patients and 26.1% of patients were diagnosed with asthma.

Conclusions

There is a high prevalence of undiagnosed asthma in patients presenting to tertiary Rhinology care with moderate to severe allergic rhinitis symptoms. Screening lung function testing should be considered in this patient population.

Prevalence and classification of rhinitis in the elderly: a nationwide survey in Portugal

BACKGROUND

Nationwide epidemiologic data on rhinitis in the elderly do not exist. This study aimed to estimate the prevalence of rhinitis in the population aged 65 years or above in mainland Portugal and to characterize and classify rhinitis in this age group.

METHODS

Cross-sectional, nationwide, population-based survey of citizens aged 65 years or above, living in mainland Portugal. Current rhinitis (CR) was defined as the presence of at least two symptoms: 'repeated sneezing and itchy nose', 'blocked nose for more than one whole hour', or 'runny nose when not having a cold or flu', either usually or in the last 12 months. Rhinitis severity was assessed using a visual analogue scale; rhinitis was classified according to ARIA.

RESULTS

Data were obtained from 3678 responders (92.5% response rate). The prevalence of CR was 29.8% (95% confidence interval (CI): 28.4%-31.3%): 49.1% had mild intermittent, 7.0% mild persistent, 27.5% moderate-severe intermittent, and 16.4% moderate-severe persistent rhinitis. Only 38.6% of patients with CR had been physician diagnosed and 38.7% were under treatment for this disease in the previous year. Allergic conjunctivitis symptoms were referred by 68.6% of subjects with CR (rhinoconjunctivitis population prevalence, 20.5% (95% CI: 19.2%-21.8%)).

CONCLUSIONS

Rhinitis and rhinoconjunctivitis are common but underdiagnosed and undertreated diseases in the geriatric population. This was the first nationwide epidemiological survey classifying rhinitis according to ARIA guidelines in this age group. More than 40% of old-age patients presented moderate-severe disease.

Non-IgE-mediated and irritant-induced work-related rhinitis

PURPOSE OF REVIEW

Recently there has been growing interest in non-IgE-mediated and irritant-induced occupational rhinitis due to old and new low-molecular-weight and irritant agents. The purpose of this review is to summarize the scientific evidence on agents and work activities responsible for non-IgE-mediated and irritant-induced occupational rhinitis and work-exacerbated rhinitis published in 2011 and 2012.

RECENT FINDINGS

Several epidemiological, surveillance and experimental studies, case reports and reviews showed that workers exposed to drugs, wood dust, chemicals, metals and biocides are at high risk of non-IgE-mediated and irritant-induced occupational rhinitis; among activities at risk are healthcare, antibiotic manufacturing and cleaning workers. Work-exacerbated rhinitis has not been specifically studied, but it is reasonable to expect that it is frequently associated with work-exacerbated asthma. Recently, work-related anosmia/microsmia, nasal polyps and sinusitis have also been described. Reducing or eliminating workplace exposure to the specific agent has been confirmed to be effective in preventing symptoms of nonallergic occupational rhinitis.

SUMMARY

In consideration of the relevance of non-IgE-mediated and irritant-induced work-related rhinitis, physicians should recognize work-related rhinitis symptoms due to old and new low-molecular-weight and irritant agents. The mechanisms of non-IgE-mediated and irritant-induced occupational rhinitis remain largely unclear and need to be studied further. Substitution of responsible agents, reduction or elimination of exposure at the workplace should be enforced as effective measures.

Allergic rhinitis, chronic rhinosinusitis and asthma: unravelling a complex relationship

PURPOSE OF REVIEW

Allergic rhinitis, chronic rhinosinusitis (CRS) and asthma have a high worldwide prevalence and confer a significant socioeconomic burden. This article reviews the recent advances in allergic rhinitis, CRS and asthma with view to understanding the upper and lower airway as one system.

RECENT FINDINGS

Allergic rhinitis, CRS and asthma demonstrate strong epidemiological coassociation, and early life risk factors for upper airway disease are now apparent. The absence of demonstrable peripheral IgE does not strictly classify airway disease as nonallergic. Excess mucosal inflammation with immune dysregulation is a common feature to all. An important role for innate immunity is now apparent and offers prospects of novel therapeutic approaches in the future. A role for bacterial superantigens is also emerging in all three diseases. Genetic studies highlight common associations between allergic rhinitis, CRS and asthma.

SUMMARY

Whether such overlapping pathological findings reflect a manifestation of the same disease but in relation to the different airway locations in individuals with genetic predisposition remains unknown, although likely. This continues under investigation and debate. The current research priorities are to understand what key events predispose to both upper and lower airway disease together and the critical immunological factors that establish and sustain airway inflammation.