Allergic rhinitis: pharmacotherapy in pregnancy and old age

Chinese expert recommendation on transnasal corticosteroid nebulization for the treatment of chronic rhinosinusitis 2021

Corticosteroids are efficacious in treating chronic rhinosinusitis (CRS), but concerns on the potential side effects remain, especially for long-term usage of systemic corticosteroids. Accumulated evidence shows that transnasal nebulization may be a reasonable solution in balancing both efficacy and safety. However, no consensus or guideline has been formulated on the use of steroid transnasal nebulization in treating CRS. The consensus is achieved through literature review and exchange of Chinese experts in Group of Otorhinolaryngology and Ophthalmology, Chinese Society of Allergy (CSA). This document covers the development, equipment, pharmacological mechanism, and evidence-based efficacy and safety, as well as the special concern of the application of steroid transnasal nebulization during the coronavirus disease (COVID-19) pandemic. The expert consensus clarifies the application of steroid transnasal nebulization in treating CRS and common comorbidities during the perioperative and postoperative periods.

[The role of secretory immunoglobulin E in the differential diagnosis of rhinitis during pregnancy]

OBJECTIVE

To evaluate the role of secretory immunoglobulin E in the differential diagnosis of rhinitis in pregnant women.

MATERIAL AND METHODS

The study involved 97 pregnant women with rhinitis symptoms and 23 healthy pregnant women without rhinitis symptoms. The first group of the study included 37 pregnant women with previously confirmed (anamnestically and immunologically) allergic rhinitis (AR), the 2nd group of the study included 30 pregnant women with suspected beginning of the AR, the 3rd group of the study was 30 women with pregnant women's rhinitis, diagnosed on the base of follow-up study. The study included: anamnesis taking, routine examination of ENT organs, general clinical examination, study of the level of total IgE in blood, nasal secretion cytology study, secretory IgE level in nasal secretion analysis, follow-up telephone gathered catamnestic data analysis.

RESULTS AND DISCUSSION

When analyzing laboratory data, an increase in the average number of eosinophils in the blood was not detected in any group. When examining secretory immunoglobulin E of the nasal secretion in the group of patients with previously confirmed AR, this indicator averaged 2.9±0.7 kE/L, in the group with AR beginning - 5.5±2.6 kE/L, which exceeded the value in the control group (1.2±0.6 kE/l, p<0.05). In the group of patients with pregnant women's rhinitis, the indices of nasal IgE did not differ significantly from the control group (1.9±0.3 and 1.2±0.6 kE/L, respectively, p<0.05).

CONCLUSION

The level of secretory nasal immunoglobulin E can be used in the differential diagnosis of rhinitis in pregnancy.

Phosphodiesterase 4 Inhibitors in Allergic Rhinitis/Rhinosinusitis

Allergic rhinitis/rhinosinusitis (AR) is the most common allergic disease. It affects patients’ quality of life and may influence the severity of lower airway disease such as asthma. Therefore, its treatment is of great importance. AR is treated by a combination of effective approaches; however, in some patients, the disease is uncontrolled. In the last several years, the concept of AR has shifted from increased T helper 2 (Th2) cell signaling and downstream inflammation to disease phenotypes with non-Th2-mediated inflammation. AR is a largely heterogenous group of airway diseases, and as such, research should not only focus on immunosuppressive agents (e.g., corticosteroids) but should also include targeted immunomodulatory pathways. Here, we provide an overview of novel therapies, focusing on the role of phosphodiesterase-4 (PDE4) inhibitors in AR. PDE4 inhibitors are potent anti-inflammatory agents that are used for the treatment of inflammatory airway diseases including AR. The PDE4 inhibitor roflumilast was shown to effectively control symptoms of AR in a randomized, placebo-controlled, double-blinded, crossover study in patients with a history of AR. However, only a few PDE4 inhibitors have proceeded to phase II and III clinical trials, due to insufficient clinical efficacy and adverse effects. Research is ongoing to develop more effective compounds with fewer side effects that target specific inflammatory pathways in disease pathogenesis and can provide more consistent benefit to patients with upper airway allergic diseases. Novel specific PDE4 inhibitors seem to fulfill these criteria.

HIF1α Deficiency in Dendritic Cells Attenuates Symptoms and Inflammatory Indicators of Allergic Rhinitis in a SIRT1-Dependent Manner

BACKGROUND

Allergic rhinitis is the most prevalent atopic disorder worldwide. Inflammation is believed to participate in allergic rhinitis. Previous studies indicate that hypoxia-inducible factor (HIF) promotes the development of allergic rhinitis, and dendritic cells are also involved in allergic rhinitis.

METHODS

We explored the consequences of HIF1α deficiency in dendritic cells on allergic rhinitis. Allergic rhinitis in mice was induced by ovalbumin (OVA). The levels of IgE, leukotriene C4 (LTC4), eosinophil cationic protein (ECP), prostaglandin D2 (PGD2), IFN-γ, IL-2, IL-4, IL-5, IL-10, and IL-13 in serum or nasal lavage fluid (NLF) were detected by ELISA. Inflammatory cells in NLF were counted by hemocytometer. The protein levels of p-ERK1/2, p-p38, p-JNK2, SIRT1, p-IκBα, and p65 were determined by Western blot.

RESULTS

HIF1α deficiency in dendritic cells (HIF1αCD11c-/-) decreased sneezing and nasal rubbing, the production of OVA-specific IgE, LTC4, and ECP in serum and NLF, and the numbers of leukocytes, eosinophils, lymphocytes, and neutrophils in NLF. Th1 cytokines increased, while Th2 cytokines decreased in HIF1aCD11c-/- mice. SIRT1/NF-κB signaling was inhibited in HIF1αCD11c-/- mice, while SIRT1 inhibitor administration in HIF1αCD11c-/- mice attenuated the symptoms and inflammatory indicators of allergic rhinitis.

CONCLUSION

HIF1α deficiency in dendritic cells attenuates symptoms and inflammatory indicators of allergic rhinitis in a SIRT1-dependent manner.

[Allergic rhinitis in the pregnant women]

The objective of the present work was to elucidate the specific features of the clinical picture of allergic rhinitis in the pregnant women. The study included 156 pregnant women presenting with the persisting form of the disease and 63 patients having its intermitting form. The character of the endoscopic manifestations of rhinitis, chronic tonsillitis, and gastroesophageal reflux was evaluated with the use of a scoring system. The progressive development of the clinical symptoms of allergic rhinitis during pregnancy related neither to the contacts with allergens nor to the discontinuation of pharmacotherapy was documented in 33 and 23% of the patients presenting with the persistent and intermitting forms of the disease, respectively. The symptoms of rhinitis in the pregnant women may be influenced by the presence of gastroesophageal reflux (the endoscopic evidence of this condition was documented in 84.6% of the examined patients with persisting form of the disease and in 40.3% of those having intermitting form) and chronic tonsillitis (purulent contents in the palatine tonsil lacunes were found in 46.8 and 40.3% of the women presenting with the persisting and intermitting forms of allergic rhinitis respectively). In 42% of the cases, the cause behind the negative dynamics or the absence of any dynamics during the treatment of allergic rhinitis was the withdrawal of the prescribed pharmacotherapy by the patients themselves. This observation gives evidence of the importance of explaining to the pregnant women suffering from allergic rhinitis the necessity of compliance with the prescribed treatment modalities in order to reduce the probability of development of complications of this condition.

Rhinitis and Sinusitis

Rhinitis is defined as inflammation of the nose, which can extend into and affect the sinuses. The term rhinosinusitis is used to describe inflammation of both the nose and the sinuses. An example of rhinitis is allergic rhinitis, caused by sensitization and exposure to aeroallergens, which, along with other allergic diseases, such as asthma, affect up to one-third of women in the childbearing age. The most common type of rhinosinusitis is infectious, either acute or chronic, which commonly occurs secondarily to a viral respiratory tract infection. Both rhinitis and rhinosinusitis significantly affect the quality of life. The purpose of this chapter is to introduce and describe the differential diagnosis and treatment of these two common clinical entities during pregnancy.

How to fit allergen immunotherapy in the elderly

Asthma, allergic rhinitis (AR) and atopic dermatitis are very common in young people, but in the latest decades it was increasingly recognized that also individuals of higher ages, including the population over 65 years, are concerned. Actually, it is now acknowledged the aging does not considerably alter the immune response to allergens. Allergen immunotherapy (AIT) is the only treatment that works on the causes of allergy, but elderly people are commonly excluded from AIT, except the cases of insect sting allergy. A number of recent studies showed that aged individuals also successfully respond to AIT for respiratory allergy. Therefore, there is no reason to exclude elder patients from AIT. Anyhow, clinical conditions that are considered absolute or relative contraindications are quite frequent in this aged population, thus the risk/benefit ratio must be carefully evaluated for each patient, taking into account that the more frequent occurrence of co-morbidities and the consequent need of daily-based multidrug regimen can favor adverse effects. An important issue concern the ability of AIT, and particularly of sublingual immunotherapy, to significantly improve the quality of life, that often is particularly impaired in the elderly, reducing symptoms and drugs consumption.