Unique mechanistic features of allergic rhinitis

Levels of IgE sensitization drive symptom thresholds in allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common respiratory disease encompassing a variety of phenotypes. Patients can be sensitized to 1 or more allergens. There are indications that polysensitization is associated with more severe disease. However, the extent to which the level of sensitization is associated with clinical disease variability, underlying the distinct nature of AR from AR+ conjunctivitis or AR+ asthma, is not known.

OBJECTIVE

To evaluate phenotypical differences between monosensitized and polysensitized patients with AR and to quantify their symptomatic variability.

METHODS

A total of 565 patients with a confirmed diagnosis of AR were included in this cross-sectional study. Of those, 155 were monosensitized and 410 were polysensitized. Interactions between sensitization levels and the reporting of different symptoms of AR and co-morbidities, disease duration, and impact were assessed. Furthermore, patients were stratified into monosensitized, oligosensitized, and polysensitized to assess whether the effect of sensitization on the phenotype was ranked.

RESULTS

Polysensitized patients reported itchy eyes significantly more often (P = .001) and had a higher number of ocular (P = .005), itch-related (P = .036), and total symptoms (P = .007) than monosensitized patients. In addition, polysensitized adults and children more often reported wheeze (P = .015) and throat-clearing (P = .04), respectively. Polysensitization was associated with more burdensome AR based on a visual analog scale (P = .005). Increased sensitization level was reflected in more itchy eyes, a higher number of ocular, itch-related, and total number of symptoms, and disease burden.

CONCLUSION

With an increasing number of sensitizations, patients with AR experience an increased diversity of symptoms. Multimorbidity-related symptoms increase with sensitization rank, suggesting organ-specific thresholds.

TGF-β, IL-1β, IL-6 levels and TGF-β/Smad pathway reactivity regulate the link between allergic diseases, cancer risk, and metabolic dysregulations

The risk of cancer is higher in patients with asthma compared to those with allergic rhinitis for many types of cancer, except for certain cancers where a contrasting pattern is observed. This study offers a potential explanation for these observations, proposing that the premalignant levels of circulating transforming growth factor-β (TGF-β), IL-1β, and IL-6 as well as the reactivity of the TGF-β/Smad signaling pathway at the specific cancer site, are crucial factors contributing to the observed disparities. Circulating TGF-β, IL- β and IL-6 levels also help clarify why asthma is positively associated with obesity, Type 2 diabetes, hypertension, and insulin resistance, whereas allergic rhinitis is negatively linked to these conditions. Furthermore, TGF-β/Smad pathway reactivity explains the dual impact of obesity, increasing the risk of certain types of cancer while offering protection against other types of cancer. It is suggested that the association of asthma with cancer and metabolic dysregulations is primarily linked to the subtype of neutrophilic asthma. A binary classification of TGF-β activity as either high (in the presence of IL-1β and IL-6) or low (in the presence or absence of IL-1β and IL-6) is proposed to differentiate between allergy patients prone to cancer and metabolic dysregulations and those less prone. Glycolysis and oxidative phosphorylation, the two major metabolic pathways utilized by cells for energy exploitation, potentially underlie this dichotomous classification by reprogramming metabolic pathways in immune cells.

Allergic rhinitis and other comorbidities associated with asthma control in Thailand

Background

Asthma and allergic rhinitis (AR) can coexist and cause disabilities. This study aimed to assess the association between AR, asthma control, asthma-related quality of life, and other comorbidities.

Methods

A cross-sectional study was conducted in adults with asthma in six hospitals in Thailand. The outcomes were association of asthma control assessed by the asthma control test (ACT), AR, and asthma comorbidities. Not-well-controlled asthma was defined as ACT scores ≤22. The severity of AR was determined by visual analog scale (VAS). Severe AR was defined as VAS ≥5. Asthma-related quality of life (AQLQ), comorbidities, and total IgE were recorded.

Results

A total of 682 asthmatic patients were included. Median (IQR) age was 58.0 (47.0-64.0) years. 69.9% were female. Not-well-controlled asthma was present in 44.7%. The prevalence of AR was 86.1%. Moderate/severe persistent AR was diagnosed in 21.7% and severe AR was diagnosed in 30.2% of the patients. Inhaled corticosteroid-containing regimens were prescribed in 97.7% of patients. Intranasal corticosteroid and antihistamine were prescribed in 65.7 and 31.7%, respectively. Patients with not-well-controlled asthma had higher body mass index, VAS scores, proportions of pollution exposure, aeroallergen sensitization, severe AR, nasal polyp, urticaria, food allergy, gastroesophageal reflux disease, depression and anxiety, peptic ulcer, and asthma exacerbations, but younger age, lower AQLQ scores, and lower FEV1. Correlation was found between AR severity and ACT (r = -0.461, p < 0.001), AQLQ (r = -0.512, p < 0.001), and total IgE (r = 0.246, p < 0.023). Multiple regression analysis revealed that ACT, AQLQ, and percentage of FEV1/FVC were significantly associated with severe AR.

Conclusion

Allergic rhinitis is prevalent in Thai asthmatic patients. AR severity is associated with asthma control, quality of life, and pulmonary function. Comprehensive care is essential for patients with uncontrolled asthma, particularly when coexisting with conditions.

The Effect of Pollen on Coral Health

Corals are facing a range of threats, including rises in sea surface temperature and ocean acidification. Some now argue that keeping corals ex situ (in aquaria), may be not only important but necessary to prevent local extinction, for example in the Florida Reef Tract. Such collections or are already becoming common place, especially in the Caribbean, and may act as an ark, preserving and growing rare or endangered species in years to come. However, corals housed in aquaria face their own unique set of threats. For example, hobbyists (who have housed corals for decades) have noticed seasonal mortality is commonplace, incidentally following months of peak pollen production. So, could corals suffer from hay fever? If so, what does the future hold? In short, the answer to the first question is simple, and it is no, corals cannot suffer from hay fever, primarily because corals lack an adaptive immune system, which is necessary for the diagnosis of such an allergy. However, the threat from pollen could still be real. In this review, we explore how such seasonal mortality could play out. We explore increases in reactive oxygen species, the role of additional nutrients and how the microbiome of the pollen may introduce disease or cause dysbiosis in the holobiont.

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.

Nasal Spray Formulations Based on Combined Hyalurosomes and Glycerosomes Loading Zingiber officinalis Extract as Green and Natural Strategy for the Treatment of Rhinitis and Rhinosinusitis

A total green nanotechnological nasal spray has been manufactured and proposed as an alternative treatment of rhinitis and rhinosinusitis. It was obtained by combining the strengthening effect of liposomes on barrier function, the hydrating and lubricating properties of sodium hyaluronan and the anti-inflammatory and antioxidant activities of the extract of Zingiber officinalis. To this purpose, the extract was loaded in special phospholipid vesicles immobilized with hyaluronic acid (hyalurosomes), which were further enriched with glycerol in the water phase. Liposomes and glycerosomes were prepared as well and used as reference. Vesicles were oligolamellar and multicompartment, as confirmed by cryogenic transmission electron microscopy (cryo-TEM) observation, small in size (~140 nm) and negatively charged (~−23 mV). Spray characteristics were evaluated by using the Spraytec^® and instant images, from which the plume angle was measured. The range of the droplet size distribution and the narrow spray angle obtained suggest a good nebulization and a possible local deposition in the nasal cavity. In vitro studies performed by using human keratinocytes confirmed the high biocompatibility of vesicles and their ability to effectively counteract oxidative damage on cells induced by hydrogen peroxide. The overall collected data suggest that our vesicles are suitable as nasal spray.

Occupational Rhinitis

There is convincing evidence that tight relationships between the upper and lower airways also apply to the workplace context. Most patients with occupational asthma (OA) also suffer from occupational rhinitis (OR), although OR is 2 to 3 times more common than OA. OR most often precedes the development of OA, especially when high-molecular-weight protein agents are involved, and longitudinal cohort studies have confirmed that OR is associated with an increased risk for the development of OA. The level of exposure to sensitizing agents at the workplace is the most important determinant for the development of IgE-mediated sensitization and OR. Atopy is a risk factor for the development of IgE-mediated sensitization only to high-molecular-weight agents. In workers with work-related rhinitis symptoms, documentation of IgE-mediated sensitization to a workplace agent via skin prick testing or serum specific IgE confirms a diagnosis of probable OR, whereas specific nasal provocation testing in the laboratory remains the reference method to establish a definite diagnosis of OR. Complete avoidance of exposure to the causal agent is the most effective therapeutic option for controlling work-related nasal symptoms and preventing the development of OA. If complete elimination of exposure is expected to induce meaningful adverse socioeconomic consequences, reduction of exposure can be considered as an alternative approach, but it is important to consider the individual risk factors for the development of OA to implement a more personalized management of OR.

Biological Effects of Thermal Water-Associated Hydrogen Sulfide on Human Airways and Associated Immune Cells: Implications for Respiratory Diseases

Natural mineral (thermal) waters have been used for centuries as treatment for various diseases. However, the scientific background of such therapeutic action is mostly empiric and based on knowledge acquired over time. Among the various types of natural mineral waters, sulfurous thermal waters (STWs) are the most common type in the center of Portugal. STWs are characterized by high pH, poor mineralization, and the presence of several ions and salts, such as bicarbonate, sodium, fluoride, silica, and carbonate. Furthermore, these waters are indicated as a good option for the treatment of various illnesses, namely respiratory diseases (e.g., allergic rhinitis, asthma, and chronic obstructive pulmonary disease). From the sulfide species present in these waters, hydrogen sulfide (H₂S) stands out due to its abundance. In healthy conditions, H₂S-related enzymes (e.g., cystathionine β-synthase and cystathionine γ-lyase) are expressed in human lungs, where they have mucolytic, antioxidant, anti-inflammatory, and antibacterial roles, thus contributing to airway epithelium homeostasis. These roles occur mainly through S-sulfhydration, a post-translational modification through which H₂S is able to change the activity of several targets, such as ion channels, second messengers, proteins, among others. However, in respiratory diseases the metabolism of H₂S is altered, which seems to contribute somehow to the respiratory deterioration. Moreover, H₂S has been regarded as a good biomarker of airway dysfunction and severity, and can be measured in serum, sputum, and exhaled air. Hence, in this review we will recapitulate the effects of STWs on lung epithelial-immune crosstalk through the action of its main component, H₂S.

Rhinitis in children and adolescents with asthma: Ubiquitous, difficult to control, and associated with asthma outcomes

BACKGROUND

Rhinitis and asthma are linked, but substantial knowledge gaps in this relationship exist.

OBJECTIVE

We sought to determine the prevalence of rhinitis and its phenotypes in children and adolescents with asthma, assess symptom severity and medication requirements for rhinitis control, and investigate associations between rhinitis and asthma.

METHODS

Seven hundred forty-nine children with asthma participating in the Asthma Phenotypes in the Inner-City study received baseline evaluations and were managed for 1 year with algorithm-based treatments for rhinitis and asthma. Rhinitis was diagnosed by using a questionnaire focusing on individual symptoms, and predefined phenotypes were determined by combining symptom patterns with skin tests and measurement of serum specific IgE levels.

RESULTS

Analyses were done on 619 children with asthma who completed at least 4 of 6 visits. Rhinitis was present in 93.5%, and phenotypes identified at baseline were confirmed during the observation/management year. Perennial allergic rhinitis with seasonal exacerbations was most common (34.2%) and severe. Nonallergic rhinitis was least common (11.3%) and least severe. The majority of children remained symptomatic despite use of nasal corticosteroids with or without oral antihistamines. Rhinitis was worse in patients with difficult-to-control versus easy-to-control asthma, and its seasonal patterns partially corresponded to those of difficult-to-control asthma.

CONCLUSION

Rhinitis is almost ubiquitous in urban children with asthma, and its activity tracks that of lower airway disease. Perennial allergic rhinitis with seasonal exacerbations is the most severe phenotype and most likely to be associated with difficult-to-control asthma. This study offers strong support to the concept that rhinitis and asthma represent the manifestations of 1 disease in 2 parts of the airways.

Role of Superantigens in Allergic Inflammation: Their Relationship to Allergic Rhinitis, Chronic Rhinosinusitis, Asthma, and Atopic Dermatitis

OBJECTIVES

Our intention was to review all material published to date regarding superantigens (SAgs) and allergy from an otorhinolaryngological viewpoint to understand this association more clearly.

METHODS

We identified all materials published mentioning both SAg and allergic rhinitis (AR), chronic sinusitis, asthma, and atopic dermatitis (AD) that are indexed on PubMed, Google, or the ProQuest Central databases.

RESULTS

Staphylococcus aureus is a significant bacterial pathogen in humans and has the ability to produce enterotoxins with superantigenic features. The inflammatory response in allergy seen in both B cell and T cell may be attributed to SAgs. Sufferers of both allergic asthma with rhinitis and AR alone produce serological evidence of immunoglobulin E formation to SAgs produced by S. aureus. Perennial AR sufferers carry S. aureus more frequently and the presence of the organism within the nasal cavity may exacerbate perennial AR. SAg produced by S. aureus potentially worsens the asthmatic inflammatory response within the airway and may lead to the airways becoming hyperresponsive, as well as possibly activating T cells if asthmatic control is poor. Staphylococcal SAgs potentially increase the risk of developing chronic rhinosinusitis with nasal polyposis, additionally being a marker for more severe disease. If SAgs bring about chronic inflammatory responses in the nose and sinuses, then T cells excreting interferon-gamma may be a crucial mediator. In allergic dermatitis, S. aureus could be a key player in exacerbation of the condition. Even in younger pediatric patients with allergic dermatitis, allergic hypersensitivity to SAgs is frequent and may be a factor explaining how severe the condition becomes.

CONCLUSION

Just as SAgs are known to feature in many allergic conditions, they play their part in AR, chronic rhinosinusitis, asthma, and AD. Further research is required before the relationship between SAgs and allergy can be adequately explained.

Is Allergen Immunotherapy in Children Disease Modifying? A Review of the Evidence

PURPOSE OF REVIEW

Although evidence supports a beneficial effect of allergen immunotherapy on the symptoms of allergic respiratory disease and food allergy, it is not clear whether immunotherapy modifies the natural history of these conditions.

RECENT FINDINGS

In aeroallergen immunotherapy, studies suggest that prevention of asthma can be attained. Less evident is the ability of immunotherapy to prevent new allergen sensitizations and more studies are needed to test whether immunotherapy can continue suppressing airway symptoms after treatment discontinuation. In food allergen immunotherapy, there is evidence that unresponsiveness to a food challenge can be sustained in some treatment recipients, but little knowledge exists as to the dose and duration of treatment that can optimize this effect. Suggestive evidence exists that allergen immunotherapy can modify allergic disease in children, but definitive studies are lacking. More research in the field is required.

Strontium chloride hexahydrate as a candidate molecule for long-term treatment of allergic rhinitis

Background & objectives:

Neurogenic inflammation plays a role in the pathophysiology of allergic rhinitis (AR). Strontium salts are highly effective in reducing the sensory irritation. This study was aimed to investigate the efficacy of strontium chloride (SC) on AR symptoms based on the duration of SC use before the symptoms begin.

Methods:

Wistar albino rats (n=18) were randomly divided into three groups: Group 1, received 1μg mometasone furoate (MF); Group 2, three per cent SC; and Group 3 received five per cent SC (2 μl/site). Drugs were administered to the each nasal cavity for three weeks every morning. On the days 7, 14 and 21, histamine dihydrochloride (HD) 5 μmol (2 μl/site) was administered and the frequencies of nasal rubbing and sneezing were counted for 15 min.

Results:

After 7, 14 and 21 day medication period, the groups were compared in terms of the frequency of sneezing and nasal rubbing following HD. There was a significant difference among the groups in terms of the frequency of sneezing on the day 7 (P< 0.05). Intragroup comparisons for the nasal rubbing showed significance (P< 0.05). In Group 3, there was a decrease in the number of nasal rubbings on the day 14 and 21; however, the difference was not significant.

Interpretation & conclusions:

Our results showed that three and five per cent SC were less effective than MF for sneezing during the first week, but the efficiency was equal to that of MF after the first 14 days. Long-term use of SC was as effective as MF on nasal rubbing. SC can be as effective as MF on both sneezing and nasal rubbing on regular use over three weeks.

How Could We Influence Systemic Inflammation in Allergic Rhinitis? The Role of H1 Antihistamines

The aim of the study was the analysis of adhesion molecules' profile (ICAM-1, VCAM-1, and E-selectin) in patients with allergic rhinitis and the influence of H1 antihistamines on those markers. Seventy-nine patients with persistent allergic rhinitis (PAR) and 30 healthy volunteers were included in the study. The patients with PAR were treated with desloratadine 5 mg/day or levocetirizine 5 mg/day for 4 weeks. The clinical (rhinitis symptoms and total symptoms score (TSS), type of sensitization) and biological evaluation (total IgE, eosinophils, ICAM-1, VCAM-1, and E-selectin) as well as fractionate nitric oxide in exhaled air (FeNO) measurement was performed before and after treatment. The plasmatic levels of ICAM-1, VCAM-1, total IgE, and eosinophils and FeNO were significantly increased in patients with PAR compared to healthy volunteers. H1 antihistamines significantly improved TSS, with no differences between the investigated drugs. There was a significant decrease of eosinophils, total IgE, and FeNO after treatment. H1 antihistamines significantly decreased the plasmatic levels of ICAM-1 and E-selectin but not VCAM-1 compared to basal values. There is no difference between levocetirizine and desloratadine in the reduction of CAMs. A systemic inflammation characterized by increased levels of CAMs is present in patients with PAR. H1 antihistamines improve symptoms and reduce CAMs and FeNO levels after 1 month of treatment. H1 antihistamines might reduce the systemic inflammation which could be responsible to asthma occurrence in patients with PAR.

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.

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.

Tympanometric Patterns of Children with Allergic Rhinitis Treated at a Tertiary Health Institution

Objectives

To determine the prevalence of otitis media with effusion (OME) and compare patterns of tympanogram between children with and without allergic rhinitis in Ibadan, Nigeria.

Study Design

A case-control study of children (2-7 years) with AR from May 2015 to March 2016.

Setting

Tertiary hospital.

Subjects and Methods

Consecutive 86 children with AR and 86 healthy controls (nonallergic) participated in the study. A structured questionnaire was administered to parents or caregivers of the participants to obtain relevant sociodemographic and clinical information. Diagnosis of AR was by symptomatology and nasal cytology. Both groups had ear, nose, and throat examination and tympanometric evaluation. OME was diagnosed according to Jerger’s tympanometric patterns.

Results

The mean ± SD ages of cases and controls were 3.80 ± 1.72 and 3.78 ± 1.71 years, respectively. All cases presented with watery nasal discharge, bouts of sneezing, and nasal itching. The duration of AR symptoms was 18 ± 13 months. Among cases and controls, Jerger’s type A tympanogram was the most common pattern, while type C was the least common. Thirty-nine (45.3%) children with AR had OME, as compared with 8 (9.3%) controls, and the difference was statistically significant (P < .001; odds ratio = 8.090; 95% CI = 3.48-18.79).

Conclusion

Prevalence of OME was significantly high among children with AR. Jerger’s type B and C tympanograms were more common among children with AR than the healthy pediatric population. This background information supports the need for routine tympanometric evaluation of children with AR.

The prevalence and associated lifestyle risk factors of self-reported allergic rhinitis in Kazakh population of Fukang City

This study is to analyze the prevalence and the associated lifestyle risk factors of self-reported allergic rhinitis (AR) in Kazakh population of Fukang City.A cross-sectional study was conducted using stratified random sampling method and 1689 Kazak people were surveyed. A standard questionnaire was used for face-to-face interview.The prevalence of self-reported AR of Kazakh population in Fukang City was 13.7%, and sneezing was the most common symptoms (54.6%) with no significant differences among age, sex, and weight. The incidence of asthma in Kazakh people was correlated with age, and the incidence of allergies in Kazakh people was correlated with weight. Skin pruritus was the most common symptom for allergy (42.7%). The AR incidence was correlated with sinusitis and asthma, and was mostly associated with carpet use. For diet, the AR incidence was positively correlated with meat and fruit, and negatively correlated with beans and milk.The prevalence of AR is high among Kazakh people in Fukang City, and its incidence is closely related with lifestyle risk factors such as carpet use and meat and fruit consumption.

Autonomic nervous system evaluation in allergic rhinitis

OBJECTIVES: To evaluate the relationship between allergic rhinitis (AR) and autonomic nervous system (ANS) dysfunction.

METHODS: Quantitative ANS testing was completed in 10 patients with AR confirmed by clinical findings and allergy testing. This data was compared to 16 age-matched controls.

RESULTS: ANS scores were significantly abnormal in AR patients when compared to normal controls. The composite autonomic scale score for the AR group was significantly impaired when compared to controls (1.6 vs 0.63, P < 0.0001). Additionally, subscore values quantifying the level of dysfunction within the sympathetic nervous system (1.0 for sudomotor and 0.5 adrenergic) were found to be significantly different ( P < 0.0001 and 0.018). The mean subscore value quantifying the level of dysfunction within the parasympathetic system (cardiovagal) was not found to be significantly different from controls ( P = 0.38).

CONCLUSIONS: ANS dysfunction, specifically sympathetic hypofunction, was identified in all of the allergic rhinitis patients studied. Further characterization of the type of ANS abnormality may allow the development of novel pharmacologic therapies for these disorders.

© 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Can an airway challenge test predict respiratory diseases? A population-based international study

BACKGROUND

Evidence on the longitudinal association of airway responsiveness with respiratory diseases is scarce. The best indicator of responsiveness is still undetermined.

OBJECTIVE

We investigated the association of airway responsiveness with the incidence of asthma, chronic obstructive pulmonary disease (COPD), and allergic rhinitis.

METHODS

We studied 3851 subjects who underwent spirometry and methacholine challenge tests both at baseline (1991-1993), when they were 20 to 44 years old, and at follow-up (1999-2002) in the European Community Respiratory Health Survey. Airway responsiveness was defined based on the methacholine dose-response slope on both occasions. Incidence rate ratios for the association of airway responsiveness with disease occurrence were computed by using Poisson regression.

RESULTS

With respect to reference (slope of the fourth quintile or greater), subjects with the greatest degree of airway responsiveness (slope less than the first quintile) showed the greatest risk of developing asthma, COPD, and allergic rhinitis (incidence rate ratios of 10.82, 5.53, and 4.84, respectively; all P < .01). A low slope predicted disease occurrence, even in subjects who did not reach a 20% decrease in FEV1 at the cumulative dose of 1 mg of methacholine (PD20 >1 mg). A decrease in slope over time was an independent predictor of disease risk.

CONCLUSION

Airway responsiveness predicted new-onset asthma, COPD, and allergic rhinitis. Our study supports the use of a continuous noncensored indicator of airway responsiveness, such as the slope of the methacholine dose-response curve, in clinical practice and research because it showed clear advantages over PD20.

Autonomic dysfunction and clinical severity of disease in children with allergic rhinitis

OBJECTIVES

The involvement of autonomic imbalance has been reported in the pathogenesis of allergic diseases.

PURPOSE

To investigate the association between the clinical severity of childhood allergic rhinitis and autonomic nervous system (ANS) dysfunction, to define whether the severity of disease correlates with ANS activity.

METHODS

In this cross-sectional, case-control study, we evaluated the ANS testing by measuring sympathetic skin response (SRR) and heart rate (R-R) interval variation (RRIV) in 55 children with perennial allergic rhinitis (PAR), aged 7-12 yrs without any chronic co-morbidity, and the results were compared with 40 sex- and age-matched control subjects. The patients were divided into two groups according to the severity of allergic rhinitis.

RESULTS

There were significant increase in calculated RRIV variables during at rest and deep breathing in children with PAR compared to controls, which reflect parasympathetic nervous system (PNS) activity (p<0.005). The mean amplitude of SSR in patients, which reflect sympathetic nervous system (SNS) activity was smaller compared with the controls, but this difference was not significant (0.61±0.35 μV vs controls 0.94±0.46, p>0.05). Lower RRIV and the prolonged SSR latencies in children with AR were closely correlated with disease severity (r=-0.65, p<0.05, and r=-0.59, p<0.05 respectively).

CONCLUSION

Combined use of these two tests, allows separate testing of PNS and SNS function, and are very sensitive methods in assessing of severity of disease in children with PAR.

The link between allergic rhinitis and asthma: the united airways disease

Rhinitis and asthma are often associated and the two disorders interact at various levels. Rhinitis typically precedes the development of asthma and can contribute to unsatisfactory asthma control. The presence and type of asthma is influenced by sensitization, and the duration and severity of allergic rhinitis. Nasal symptoms, airflow and markers of inflammation directly correlate with lower airway involvement. Local tissue factors, such as microbial stimuli and systemic inflammatory mechanisms, play a role in the clinical expression of the allergic airway syndrome. There is increasing evidence that suggests a major involvement of airway epithelial cells in the pathogenesis of both asthma and allergic rhinitis. Even in patients with rhinitis who do not have asthma, subclinical changes in the lower airways and inflammatory mediators can be detected. The pathogenic role of paranasal sinus infections in respiratory allergy has been better elucidated but there remains a need for further research. Treatment of established rhinitis may affect asthma control and could have some impact on airway obstruction, but a direct effect of rhinitis therapy on lower airway inflammation remains to be clearly established.

Objective improvement in nasal congestion and nasal hyperreactivity with use of nasal steroids in persistent allergic rhinitis

OBJECTIVE

Our objective was to evaluate the action of topical nasal steroid in nasal congestion and nasal hyper-reactivity in children and adolescents with persistent allergic rhinitis.

METHODS

Twenty atopic children and adolescents (6 to 18 years) with moderate-to-severe persistent allergic rhinitis (PAR) were treated with mometasone furoate (100 microg once a day) for 21 days. At the beginning and end of treatment, the following were recorded: a) nasal symptoms score; b) several parameters of nasal congestion measured by acoustic rhinometry (SRE 2000 Rhinometrics); c) degree of nasal hyper-reactivity to histamine (concentration of histamine necessary to induce at least 100% increase in total nasal resistance during nasal provocation test). Data were compared with those from 20 controls.

RESULTS

Compared to controls, PAR patients had significantly higher score of symptoms, as well as higher degree of nasal hyper-reactivity and lower nasal volumes. After treatment, there was a significant decrease in the mean nasal symptoms score (8.0 versus 3.8; p < 0.001) and in the nasal hyper-reactivity (histamine concentration: 0.72 mg/ml versus 2.60 mg/ml; p < 0.001). Congestion improvement was observed by the increase in all acoustic rhinometry parameters. Among all studied volumes, the volume in the segment between 2 and 5 cm showed the highest mean increase (19.8%).

CONCLUSION

Treatment with topical nasal steroid objectively reduced nasal congestion and nasal histamine hyper-reactivity in children and adolescents with PAR.

Rhinitis in the geriatric population

The current geriatric population in the United States accounts for approximately 12% of the total population and is projected to reach nearly 20% (71.5 million people) by 20301. With this expansion of the number of older adults, physicians will face the common complaint of rhinitis with increasing frequency. Nasal symptoms pose a significant burden on the health of older people and require attention to improve quality of life. Several mechanisms likely underlie the pathogenesis of rhinitis in these patients, including inflammatory conditions and the influence of aging on nasal physiology, with the potential for interaction between the two. Various treatments have been proposed to manage this condition; however, more work is needed to enhance our understanding of the pathophysiology of the various forms of geriatric rhinitis and to develop more effective therapies for this important patient population.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

RESULTS

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

CONCLUSION

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

Pathophysiology of nasal congestion

Nasal congestion is a common symptom in rhinitis (both allergic and nonallergic), rhinosinusitis and nasal polyposis. Congestion can also be caused by physical obstruction of nasal passages and/or modulation of sensory perception. Mucosal inflammation underlies many of the specific and interrelated factors that contribute to nasal congestion, as well as other symptoms of both allergic rhinitis and rhinosinusitis. A wide range of biologically active agents (eg, histamine, tumor necrosis factor-α, interleukins, cell adhesion molecules) and cell types contribute to inflammation, which can manifest as venous engorgement, increased nasal secretions and tissue swelling/edema, ultimately leading to impaired airflow and the sensation of nasal congestion. Inflammation-induced changes in the properties of sensory afferents (eg, expression of peptides and receptors) that innervate the nose can also contribute to altered sensory perception, which may result in a subjective feeling of congestion. Increased understanding of the mechanisms underlying inflammation can facilitate improved treatment selection and the development of new therapies for congestion.

The pathophysiology, diagnosis and treatment of allergic rhinitis

Treatment of AR requires a stepwise approach depending on the severity and duration of symptoms. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy and surgery. For the mechanisms of AR, anti-IgE antibody and specific antibody to cytokines such as IL-4 or IL-5 that correlate with allergic inflammation have recently emerged. SLIT is currently widely used due to its efficacy, safety and convenience, which replaces subcutaneous immunotherapy. Although allergen avoidance and immunotherapy are theoretically ideal, antihistamines and intranasal corticosteroids will play the main role in the management of AR until an innovative treatment develops. However, patients' main symptom, the duration and severity of AR, patients' compliance, safety of medication and cost-effectiveness should be considered when treatment options are chosen. In conclusion, physicians should be aware of etiology, pathophysiology, symptoms, signs and diseases related to AR in order to make a correct diagnosis and choose a proper treatment option for each patient.

Fexofenadine: biochemical, pharmacokinetic and pharmacodynamic properties and its unique role in allergic disorders

BACKGROUND

Fexofenadine is one of several second-generation H(1)-antihistamines approved for the treatment of various allergic disorders; however, it shows numerous unique properties that make it an optimal choice for many patients.

OBJECTIVE

To review the pharmacology, efficacy and safety of fexofenadine and the attributes differentiating it from other H(1)-antihistamines.

METHODS

We performed a literature search in PubMed/MEDLINE (1966 - March 2009) using the keywords fexofenadine, antihistamine, allergic rhinitis and chronic urticaria. We also reviewed data provided by the manufacturer in addition to reports from various governmental agencies.

RESULTS/CONCLUSIONS

Fexofenadine is devoid of sedative and anticholinergic effects and may offer equivalent or greater efficacy in treating allergic disorders compared with other currently available second-generation H(1)-antihistamines. In addition, fexofenadine may offer cost savings over other selected H(1)-antihistamines owing to its recent availability in generic form in the US.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy of add-on montelukast in patients with non-controlled asthma: a Belgian open-label study

OBJECTIVE

To evaluate the efficacy of add-on montelukast on asthma control and allergic rhinitis symptoms in asthmatic patients still symptomatic with chronic treatment with inhaled corticosteroid and long-acting beta(2) agonist (ICS/LABA), irrespective of the dose.

RESEARCH DESIGN AND METHODS

This 2-month, open-label, real-life, multicentre, observational study was undertaken by 499 general practitioners in Belgium. Patients (>or= 4 years old) with uncontrolled asthma despite fluticasone/salmeterol or budesonide/formoterol therapy had oral montelukast 4, 5, or 10 mg daily added to their therapy, depending on the registered dose for their age. Asthma control, assessed by the 6-item Juniper Asthma Control Questionnaire (ACQ) was recorded at baseline and after 2 months of treatment with montelukast and the patients' global evaluation of asthma was also recorded at the end of the study. Concomitant allergic rhinitis symptoms were evaluated according to the patients' perception.

RESULTS

A total of 5769 patients were eligible for analysis. Addition of montelukast was associated with significant decrease in mean (SD) ACQ score (from 1.97 [0.77] at baseline to 1.05 [0.69] after add-on treatment, p < 0.001). There was also a significant improvement in all individual symptoms of the ACQ score (p < 0.001). After 2 months, 89% of the patients reported global improvement of their asthma, with a good correlation between patients' global evaluation and change in ACQ scores. Of the 2442 patients who reported allergic rhinitis symptoms at baseline, 91% showed a global improvement of their asthma symptoms and 82% in their rhinitis symptoms after adding montelukast.

CONCLUSION

This open-label observational study showed an improvement, after 2 months of add-on therapy with montelukast, in both asthma and allergic rhinitis symptoms in patients not adequately controlled on a fixed association of ICS/LABA.

The effects of the nasal antihistamines olopatadine and azelastine in nasal allergen provocation

BACKGROUND

Olopatadine, an antihistamine used in allergic conjunctivitis, is under development as a nasal preparation for the treatment of allergic rhinitis.

OBJECTIVES

To evaluate the efficacy of olopatadine in suppressing symptoms and biomarkers of the immediate reaction induced by nasal allergen provocation and to compare olopatadine with azelastine in the same model.

METHODS

The study was approved by the Johns Hopkins University institutional review board, and all subjects gave written consent. We studied 20 asymptomatic subjects with seasonal allergic rhinitis. The study had 2 randomized, double-blind, placebo-controlled, crossover phases that evaluated 2 concentrations of olopatadine, 0.1% and 0.2%. In a third exploratory phase, olopatadine, 0.1%, was compared with topical azelastine, 0.1%, in a patient-masked design. Efficacy variables were the allergen-induced sneezes, other clinical symptoms, and the levels of histamine, tryptase, albumin, lysozyme, and cysteinyl-leukotrienes (third study only) in nasal lavage fluids.

RESULTS

Both concentrations of olopatadine produced significant inhibition of all nasal symptoms, compared with placebo. Olopatadine, 0.1%, inhibited lysozyme levels, but olopatadine, 0.2%, inhibited histamine, albumin, and lysozyme. The effects of olopatadine, 0.1%, were comparable to those of azelastine, 0.1%.

CONCLUSIONS

Olopatadine, at 0.1% and 0.2% concentrations, was effective in suppressing allergen-induced nasal symptoms. At 0.2%, olopatadine provided evidence suggestive of inhibition of mast cell degranulation.

The link between allergic rhinitis and asthma: a role for antileukotrienes?

Allergic rhinitis and asthma are both chronic heterogeneous disorders, with an overlapping epidemiology of prevalence, health care costs and social costs in quality of life. Both are inflammatory disorders with a similar pathophysiology, and both share some treatment approaches. However, each disorder has an array of treatments used separately in controlling these atopic disorders, from inhaled corticosteroids, beta(2)-agonists and antihistamines to newer monoclonal antibody-based treatments. The present article reviews the shared components of allergic rhinitis and asthma, and examines recent evidence supporting antileukotrienes as effective agents in reducing the symptoms of both diseases.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

Topical levamisole hydrochloride therapy attenuates experimental murine allergic rhinitis

Allergic rhinitis is one of the most common chronic diseases. There are a number of effective therapeutic options for allergic rhinitis patients, such as intranasal corticosteroids. How to avoid the adverse effects of these traditional medicines has come to public attention and started the search for effective and safe medicine. We used BALB/c mice with experimental allergic rhinitis, and determined that levamisole delivered locally (intranasal, i.n.) could attenuate early-phase inflammatory response, decrease histamine, suppress edema and eosinophil infiltration, and diminish the ovalbumin-specific serum IgE level. Detailed analysis of cytokine gene expression showed that levamisole can decrease IL-4, IL-5 and IL-13 mRNA and increase IL-12, IL-18 and IFN-gamma mRNA. Levamisole showed analogous effects of down-regulating Th2 cytokines with budesonide and distinct up-regulating effects on Th1 cytokines gene expression. Our findings offer potential options for allergic rhinitis therapy.

Nasal hyperreactivity in allergic and non-allergic rhinitis: a potential risk factor for non-specific building-related illness

Self-reported non-allergic nasal symptom triggers in non-allergic ('vasomotor') rhinitis overlap with commonly identified environmental exposures in non-specific building-related illness. These include extremes of temperature and humidity, cleaning products, fragrances, and tobacco smoke. Some individuals with allergic rhinitis also report non-allergic triggers. We wished to explore the phenotypic overlap between allergic and non-allergic rhinitis by ascertaining self-reported non-allergic nasal symptom triggers among allergic rhinitics. Sixty subjects without work-related respiratory exposures or symptoms, aged 19-68 years, stratified by age, gender and (skin test-proven) allergic rhinitis status, were queried with regard to self-reported non-allergic nasal symptom triggers (aggregate score 0-8). In this sample, the number of self-reported non-allergic triggers was bimodal, with peaks at 1 and 5. Forty-two percent of seasonal allergic rhinitic subjects reported more than three non-allergic triggers, compared with only 3% of non-allergic non-rhinitics (P < 0.01). Subjects over 35 years were more likely to report one or more non-allergic triggers, particularly tobacco smoke (P < 0.05). Allergic rhinitics reported more non-allergic symptom triggers than did non-allergic, non-rhinitics. As indexed by self-reported reactivity to non-specific physical and chemical triggers, both non-allergic rhinitics and a subset of allergic rhinitics may constitute susceptible populations for non-specific building-related illness.

PRACTICAL IMPLICATIONS

Judging by self-report, a substantial subset of individuals with allergic rhinitis--along with all individuals with nonallergic rhinitis (by definition)--are hyperreactive to non-allergic triggers. There is overlap between these triggers (elicited in the process of obtaining a clinical diagnosis) and environmental characteristics associated with ''problem buildings.'' Since individuals with self-identified rhinitis report an excess of symptoms in most epidemiologic studies of problem buildings (even in the absence of unusual aeroallergen levels), rhintics may be acting as a ''sentinel'' subgroup when indoor air quality is suboptimal. Together, non-allergic rhinitics plus allergic rhinitics with prominent non-allergic triggers, are thought to constitute approximately one-sixth of the US population.

Montelukast in the treatment of allergic rhinitis: an evidence-based review

Cysteinyl-leukotrienes (CysLTs) are endogenous mediators of inflammation and play an important role in allergic airway disease by stimulating bronchoconstriction, mucus production, mucosal oedema and inflammation, airway infiltration by eosinophils, and dendritic cell maturation that prepares for future allergic response. Montelukast inhibits these actions by blocking type 1 CysLT receptors found on immunocytes, smooth muscle and endothelium in the respiratory mucosa. Initially developed as a treatment for asthma, montelukast has more recently found use in the treatment of allergic rhinitis (AR). We conducted a systematic review of studies that have evaluated montelukast in the treatment of seasonal AR (SAR) and perennial AR (PAR), with and without concomitant asthma. Primary consideration was given to large, randomised, placebo-controlled, double-blind clinical trials in which AR endpoints were assessed and the use of concurrent treatments for AR was excluded. Eight such studies were found in the literature. The primary endpoint in these was daytime nasal symptom severity represented by a composite score derived from individual self-ratings of nasal congestion, rhinorrhoea, nasal pruritus and sneezing. Secondary endpoints have included these individual nasal symptom scores, additional scores for eye, ear and throat symptoms, the impact of rhinitis on quality of sleep, global evaluations of outcome by patients and physicians, and measures of the severity of concomitant asthma. A general outcome was that patients treated with montelukast had significantly greater improvements in their symptoms of SAR and PAR than did patients who were given a placebo. As monotherapy, montelukast exhibited efficacy similar to that of loratadine, but less than that of the intranasally administered corticosteroid fluticasone propionate. The use of montelukast in combination with antihistamines such as loratadine or cetirizine has generally resulted in greater efficacy than when these agents were used alone, and in some studies has produced results comparable with intranasally applied corticosteroids. In patients with AR comorbid with asthma, montelukast treatment has resulted in significant improvements in both, compared with placebo. Montelukast is well tolerated and has a favourable safety profile; adverse events have occurred at similar frequencies in patients taking either montelukast or placebo. Montelukast provides an effective and well tolerated oral treatment for allergic airway inflammation in patients with SAR or PAR without asthma, and in patients in whom AR is comorbid with asthma.

Montelukast in the management of allergic rhinitis

Allergic rhinitis is the most common atopic disorder seen in the outpatient clinic setting diagnosed by history, physical exam and objective testing. According to the Allergic Rhinitis and its Impact on Asthma (ARIA) document, it is classified by chronicity (intermittent or persistent), and severity which is based on symptoms and quality of life (mild, or moderate/severe). It has enormous socioeconomic costs and significant reduction in quality of life. Allergen avoidance should be implemented, particularly in children, to reduce level of exposure; unfortunately efforts are often inadequate. Montelukast, a novel medication, is an antagonist to the leukotriene receptor. It is nonsedating, dosed once daily, and has a safety profile similar in adults and children with approval down to 6 months of age. A review of the literature undoubtedly establishes montelukast as a viable alternative for the treatment of seasonal allergic rhinitis. Its benefits are equivalent to antihistamines, when used as monotherapy, but less than intranasal corticosteroids. The addition of an antihistamine to montelukast does appear to have added benefits and at times is reported to be equivalent to intranasal corticosteroids.

Burden of concomitant allergic rhinitis in adults with asthma

Asthma (A) and allergic rhinitis (AR) are common conditions with evidence of shared epidemiological and patho-physiological backgrounds. A systematic review of the literature in the last three decades was performed to summarize both the prevalence and the economic burden of concomitant AR in adult patients with asthma. The reported prevalence estimates of concomitant AR in patients with asthma in the United States and in Europe studies is in excess of 50%, with up to 100% prevalence reported in patients with allergic asthma. In these populations, asthma-related medical resource use, including asthma attacks, emergency room visits, physician visits, and prescription medication use, is higher among asthmatic patients with concomitant AR compared to those without AR. These patients also experience more frequent absence from work and decreased productivity. A low prevalence (6.2%) of comorbid AR in people with asthma has been reported in a single study from Asia. A combined treatment strategy as recommended by international guidelines may improve asthma outcomes in asthmatic patients with concomitant AR.

Asthma control in patients with asthma and allergic rhinitis receiving add-on montelukast therapy for 12 months: a retrospective observational study

BACKGROUND

Montelukast, a potent leukotriene receptor antagonist, is approved for treatment of both asthma and allergic rhinitis (AR). No studies to date have examined whether montelukast can improve asthma control over a long period of time in patients with seasonal AR and asthma.

OBJECTIVE

To evaluate asthma control and use of asthma-related medical resources by patients with inadequately controlled mild to moderate persistent asthma and seasonal AR who required addition of montelukast as part of routine care.

METHODS

This multicenter, 24-month, pre-post retrospective observational study included patients receiving current inhaled corticosteroid (ICS) therapy (alone or in combination with long-acting beta-agonist [LABA]), who received add-on treatment with montelukast for 12 consecutive months. The incidence of asthma attacks, defined as emergency department visit, hospitalization, or oral corticosteroid use for asthma, was compared for the year before and the year after addition of montelukast to therapy.

RESULTS

For the 696 patients from Italy, Poland, and Spain who were included in the analyses, the proportion of patients experiencing an asthma attack declined from 31.5% in the year before to 10.1% (p < 0.001) the year after addition of montelukast to therapy. Proportions of patients with an asthma-related emergency room visit, hospitalization, and oral corticosteroid use declined from 18.7% to 3.9%, from 5.2% to 1.4%, and from 17.5% to 5.9% (all p < 0.01), respectively. The incidence of these outcomes declined in all three countries, regardless of baseline asthma severity or asthma therapy (ICS alone or ICS + LABA). Important study limitations include the possibility of selection bias or missing medical chart data in this retrospective study design. Also noteworthy is the inclusion of only those patients who remained persistent with montelukast therapy. Therefore, the results of the study are relevant for patients who remain persistent with montelukast therapy.

CONCLUSIONS

Addition of montelukast to current ICS therapy improved long-term asthma control and resulted in substantial reductions in asthma-related resource use by patients with mild or moderate persistent asthma and concomitant seasonal AR who were persistent with montelukast therapy in this retrospective observational study.

Pathophysiology of nasal obstruction and meta-analysis of early and late effects of levocetirizine

Nasal obstruction, also referred to as congestion, blockage or stuffiness, is a crucial symptom in allergic rhinitis (AR) and may affect sleep as well as quality of life. Early- and late-phase-allergic reactions both contribute to nasal obstruction, although it primarily represents a major symptom in the chronic allergic reaction. A complex network of inflammatory and neurogenic phenomena relates to chronic nasal obstruction, including the subepithelial accumulation of inflammatory cells, particularly mast cells and eosinophils, and the release of neuropeptides. Nasal obstruction is a difficult-to-treat symptom. Vasoconstrictors (decongestants) and intranasal corticosteroids, due to their anti-inflammatory properties, have mainly been used for relieving the nasal passages from the congested mucosa. However, there is accumulating evidence recently that the latest-generation potent antihistamines have decongestant properties in AR. This paper aims to review the pathophysiologic background of nasal obstruction and the evidence for an antihistamine, levocetirizine, in relieving nasal congestion. A meta-analysis on the early and late effects of levocetirizine on nasal obstruction under artificial and natural allergen exposure conditions is presented, demonstrating convincingly that levocetirizine shows a consistent effect on nasal obstruction as early as over the first 2 h and sustained over 6 weeks.

Enhancement of the release of inflammatory mediators by substance P in rat basophilic leukemia RBL-2H3 cells

Substance P (SP), a neurotransmitter, may play an important role in neurogenic inflammation. Ginseng has been used extensively in traditional medicine; however, few studies were focused on their anti-allergic effect. Therefore, the effect and mechanism of ginsenoside Rb1 on the SP enhancement of allergic mediators were explored. In this study, SP and dinitrophenyl-bovine serum albumin (DNP-BSA) were used to activate rat basophilic leukemia (RBL)-2H3 cells. The cultured supernatants were assayed for histamine, leukotriene C(4)(LTC(4)) and interleulin-4 (IL-4) production. The mitogen-activated protein kinases (MAPKs) signaling pathway was determined by Western blotting analysis. We found that IgE/DNP-BSA, SP, ginsenoside Rb1, or MAPK specific inhibitors had no effect on cell viability and cytotoxicity. SP (30 microM) alone, did not induce histamine and LTC(4) release, but it enhanced allergen-induced histamine and LTC(4) release. In addition, SP significantly induced and enhanced allergen-activated IL-4. Ginsenoside Rb1 dose-dependently inhibited these effects. SP enhanced the allergen-activated ERK pathway in RBL-2H3 cells, and Rb1 effectively inhibited the ERK pathway activation. Although MAPK specific inhibitors suppressed LTC(4) and IL-4, only U0126 inhibited the SP enhanced histamine release. These results demonstrate that Rb1 dose-dependently inhibited SP enhanced allergen-induced mediator release and its mechanism was through the inhibition of the ERK pathway.

Factors contributing to nasal allergic late phase eosinophilia

OBJECTIVE

This study focused on factors contributing to eosinophilia after intranasal allergen challenge.

METHODS

Nasal secretions of 13 allergic individuals were gained over a period of 8 hours after nasal allergen challenge. Early and late phase reactions were determined by acoustic rhinometry and changes of volume and total protein in nasal secretions. Eosinophilia was demonstrated by nasal eosinophilic cationic protein. Interleukin (IL)-5; the chemokines IL-8, monocyte chemotactic protein (MCP)-1 and MCP-3, and eotaxin; soluble vascular cell adhesion molecule 1 (sVCAM-1); and the leukotriene C4 (LTC4) were analyzed by enzyme-linked immunosorbent assay for their suggested impacts on tissue eosinophilia.

RESULTS

By means of rhinometry, we observed in 69% an alternating type of late phase response, followed by a bilateral (15%) or unilateral (8%) type. A biphasic kinetic could be demonstrated by changes in nasal volume and total protein of nasal secretions, reflecting the early and late phase responses. A typical late phase kinetic was observed for IL-5, MCP-1, eotaxin, sVCAM-1, and LTC4. Interleukin 8 was characteristic for early phase reaction but increased in late phase as well. We could not detect any MCP-3 in our samples.

CONCLUSIONS

Our data point to a relevant role of the T(H)2 cytokine IL-5; of the chemokines IL-8, MCP-1, and eotaxin; of the adhesion molecule sVCAM-1; and of the leukotriene LTC4 for the allergic late phase eosinophilia.

Capsaicin for allergic rhinitis in adults

BACKGROUND

Allergic rhinitis represents a global health problem. Non-specific nasal hyperresponsiveness is an important feature of allergic and non-allergic rhinitis. This phenomenon is believed to result from the effect of allergic inflammation on the sensory nerves that supply the upper airway mucosa. A pharmacologic agent that has proved useful in the investigation of effects of neuronal stimulation is capsaicin, the pungent component of hot pepper. Intranasal capsaicin specifically stimulates afferent nerves consisting mostly of unmyelinated C fibers and some myelinated A-delta fibers. As a result it can trigger central and axonal reflexes, the latter being putatively mediated by the release of neuropeptides. Capsaicin as a blocking agent of neuropeptides, blocks the axon reflex and may exert a curative effect on allergic rhinitis.

OBJECTIVES

To assess the effectiveness of capsaicin for allergic rhinitis in adults.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to 2006) and EMBASE (1974 to 2006). We assessed bibliographies from included studies, and contacted authors of known studies for additional information about published and unpublished trials. The date of the most recent search was January 2006.

SELECTION CRITERIA

Randomised controlled trials of capsaicin for allergic rhinitis in adults were included.

DATA COLLECTION AND ANALYSIS

Three reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently.

MAIN RESULTS

One small trial did not find evidence that intranasal capsaicin had a therapeutic effect in allergic rhinitis. A small pharmacological effect on clinical histamine dose response was found. After treatment, leukotriene levels in nasal lavage did not increase in the capsaicin group.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the use of capsaicin in clinical practice.

The effects of nasal histamine challenge on cough reflex in healthy volunteers

The aim of the study was to investigate the effects of nasal histamine on the intensity of cough reflex and the effects of intensified nasal breathing following the nasal histamine challenge on cough sensitivity (CS) in humans. 20 volunteers (mean age 23, nonsmokers, no history of nasal or respiratory system diseases and atopy) were recruited to the study. Baseline CS was determined in all subjects. 2 days later the subjects (n = 20) were challenged with nasal histamine (8 mg/ml, 0.1 ml) and the number of coughs was determined after four consecutive single-breath inhalations of capsaicin C2 concentration during the period of the most intensive nasal symptoms (sneezing, itching of the nose). The same capsaicin C2 challenge was performed after nasal saline challenge two days later. One week later CS was determined after nasal histamine challenge with subsequent 10 min of intensified breathing (5-6 sniff-like aspirations to total lung capacity per minute) through the nose and mouth in randomized order in ten volunteers, and with a two-day interval between the challenges. The same manoeuvres after intranasal saline challenge were performed in volunteers of the control group (n = 10). The number of coughs after nasal histamine was significantly higher than that after intranasal saline challenge (8(6-10) vs 5(3-7); p = 0.038(. CS was not significantly different between the baseline challenge and challenges after nasal histamine followed by the intensified nasal and mouth breathing ((2.21 (1.8-2.62) vs 2.04 (1.57-2.51) vs 2.05 (1.6-2.5) log(10) of capsaicin concentration in mumol.l(-1); p = 0.09).

CONCLUSIONS

During the period of maximum nasal symptoms after nasal histamine challenge the cough response to inhaled capsaicin was enhanced. Capsaicin cough sensitivity measured after a 10-min. intensified nasal breathing after nasal histamine challenge, compared to a previous measurement of CS, remain unchanged.

Interpretation of cough provoked by airway challenges

STUDY OBJECTIVE

To analyze the cough response to three airway challenges in order to clarify whether the recording of the provoked coughs would be beneficial in the management of asthma.

DESIGN

A prospective study.

SETTING

University hospital.

PARTICIPANTS

Fifteen healthy subjects, 16 steroid-naïve subjects with asthma, and 16 subjects with steroid-treated asthma.

INTERVENTIONS

Inhalation challenges with isotonic histamine, hypertonic saline solution, and hypertonic histamine, using an ultrasonic nebulizer and 2-min tidal breathing method.

MEASUREMENTS

Airflow parameters were measured with a spirometer, and the coughs were recorded manually.

RESULTS

Coughing during the isotonic histamine challenge was associated with the degree of the bronchoconstriction induced. When this was taken into account, the healthy subjects coughed as frequently as the asthmatic subjects. During the two hypertonic challenges, the asthmatic subjects coughed more frequently than did the healthy subjects when the induced bronchoconstriction had not yet developed. At that stage of the hypertonic saline solution challenge, the mean coughing frequency was 0.7 coughs per minute (95% confidence interval [CI], 0.03 to 1.3 coughs per minute) for the healthy subjects, 2.7 coughs per minute (95% CI, 0.8 to 4.5 coughs per minute) for the steroid-naïve asthmatic subjects, and 1.3 coughs per minute (95% CI, 0.6 to 1.9 coughs per minute) for the steroid-treated asthmatic subjects (p = 0.018). For the hypertonic histamine challenge, the respective values were 0.8 coughs per minute (95% CI, 0.4 to 1.2 coughs per minute), 3.6 coughs per minute (95% CI, 2.4 to 4.9 coughs per minute), and 2.1 coughs per minute (95% CI, 1.0 to 3.1 coughs per minute; p = 0.001). This cough did not correlate with airway hyperresponsiveness.

CONCLUSIONS

Coughing during isotonic histamine challenge seems to be a manifestation of bronchoconstriction, and recording of the coughs may not provide additional information to airflow measurements. Frequent coughing during hypertonic saline solution and hypertonic histamine challenges in the absence of bronchoconstriction is a pathologic phenomenon. Sensitivity to the cough-provoking effect of hypertonic challenges seems to be enhanced in patients with asthma but unrelated to airway hyperresponsiveness. Therefore, the recording of the provoked coughs during these challenges may add to the information obtained from airflow measurements.

Mometasone furoate improves congestion in patients with moderate-to-severe seasonal allergic rhinitis

BACKGROUND

A recent survey estimated that 85% of patients with allergic rhinitis experience nasal congestion. This symptom considerably impacts quality of life.

OBJECTIVE

To evaluate the effectiveness of mometasone furoate nasal spray (MFNS) in subjects with seasonal allergic rhinitis (SAR) experiencing moderate-to-severe nasal congestion.

METHODS

Data were obtained from 4 randomized, double-blind, placebo-controlled studies of MFNS 200 microg once daily in patients with SAR. Subject-evaluated nasal congestion score data (score range 0-3) from subjects receiving MFNS or placebo were analyzed as a pool and grouped according to baseline score (all pts. with scores >2.5, >2.75, or 3.0). The 2-week average change in score from baseline was analyzed.

RESULTS

Significant improvements in mean nasal congestion score were seen with MFNS (n = 490) versus placebo (n = 492; p < 0.001). Overall, there was a 27% improvement in this score in patients receiving MFNS versus 13% with placebo. MFNS produced significant reductions in the nasal congestion score compared with placebo, even in patients with the most severe baseline congestion (0.98 vs 0.52; p < 0.001). Improvements in scores from baseline of 32%, 33%, and 34% were seen with MFNS versus 22%, 21%, and 18% with placebo (for baseline scores of >2.5, >2.75, or 3.0, respectively), confirming the effectiveness of MFNS regardless of congestion severity. This represents an improvement approximating a decrease from severe to moderate congestion or from moderate-to-severe to mild-to-moderate congestion. MFNS was well tolerated.

CONCLUSIONS

MFNS 200 microg once daily produces statistically significant improvements in nasal congestion score compared with placebo, alleviating severe congestion in patients with moderate-to-severe SAR.

Nasal allergies and beyond: a clinical review of the pharmacology, efficacy, and safety of mometasone furoate

Mometasone furoate nasal spray (MFNS; Nasonex, Schering-Plough Corporation, Kenilworth, NJ, USA) is an effective and well-tolerated intranasal corticosteroid approved for the prophylactic treatment of seasonal allergic rhinitis, and the treatment of perennial allergic rhinitis. MFNS is a potent molecule with a rapid onset of action and excellent safety and efficacy profiles. Having recently received approval for the treatment of nasal polyposis, data indicate that MFNS may also be effective in rhinosinusitis.