Allergic rhinitis: current options and future perspectives

Treatment of Allergic Rhinitis with Acupuncture Based on Pathophysiological

Allergic rhinitis is a prevalent allergic diseases and has a profound impact on physical well-being. In recent years, more and more people have changed to allergic diseases, such as allergic rhinitis, allergic asthma, allergic dermatitis and so on. In the incidence of allergic rhinitis, covering all ages. The common clinical treatment of allergic rhinitis are drugs and immunotherapy, but these therapies have certain limitations. Therefore, an effective and economical treatment for AR is urgently needed. Acupuncture are widely used in the clinical treatment of various diseases, but the effect of acupuncture in the treatment of allergic rhinitis (AR) is significant, and the mechanism of acupuncture in the treatment of AR is also a hot spot. Acupuncture is one of the traditional treatment methods of traditional Chinese medicine, which achieves therapeutic effect by pressing a needle or other means at a specific location on the skin to produce a special sensation. Among them, acupuncture, as a popular treatment method, has attracted more and more attention. In this review, we provide an overview of the current understanding of acupuncture and AR, as well as current studies investigating the efficacy and safety of acupuncture for AR.

Gene Therapy for Immunoglobulin E, Complement-Mediated, and Eosinophilic Disorders

Immunoglobulin E, complement, and eosinophils play an important role in host defense, but dysfunction of each of these components can lead to a variety of human disorders. In this review, we summarize how investigators have adapted gene therapy and antisense technology to modulate immunoglobulin E, complement, and/or eosinophil levels to treat these disorders.

Effects of 101BHG-D01, a novel M receptor antagonism, on allergic rhinitis in animal models and its mechanism

Allergic rhinitis (AR) is a nasal mucosal disease with sneezing and nasal itching as the main symptoms. Although AR treatment continues to improve, there remains a lack of effective drugs. There are still controversies regarding whether anticholinergic drugs can effectively and safely relieve the symptoms of AR and reduce inflammation in the nasal mucosa. Here, we synthesized 101BHG-D01, which is a novel anticholinergic drug that mainly targets the M3 receptor and may reduce the adverse effects of other anticholinergic drugs on the heart. We evaluated the effects of 101BHG-D01 on AR and investigated the potential molecular mechanism of anticholinergic therapy for AR. We found that 101BHG-D01 effectively alleviated AR symptoms, reduced the infiltration of inflammatory cells and attenuated the expression of inflammatory factors (IL-4, IL-5, IL-13, etc.) in various AR animal models. In addition, 101BHG-D01 reduced the activation of mast cells and the release of histamine from rat peritoneal mesothelial cells (RPMCs) challenged by IgE. Moreover, 101BHG-D01 reduced the expression of MUC5AC in IL-13-challenged rat nasal epithelial cells (RNECs) and human nasal epithelial cells (HNEpCs). Furthermore, IL-13 stimulation significantly increased JAK1 and STAT6 phosphorylation, which was suppressed by 101BHG-D01. We demonstrated that 101BHG-D01 reduced mucus secretion and inflammatory cell infiltration in the nasal mucosa, which may occur through a reduction in activation of the JAK1-STAT6 signaling pathway, indicating that 101BHG-D01 is a potent and safe anticholinergic therapy for AR.

Pharmacokinetics and Tissue Distribution of Nasal Spray of a Novel Muscarinic Receptor Blocker, 101BHG-D01, in Dogs and Rats

BACKGROUND

101BHG-D01 is a novel selective anti-muscarinic (M) 3 receptor-blocking drug. 101BHG-D01 nasal spray is intended to be used to relieve sneezing and runny nose symptoms caused by allergic rhinitis.

METHODS

In this study, we examined the plasma pharmacokinetics, tissue distribution, and major excretion mode of 101BHG-D01 in Beagle dogs and rats following nasal spray and intranasal administration, respectively, using HPLC-MS/MS.

RESULTS/DISCUSSION

We found that the pharmacokinetics of 101BHG-D01 was linear in dogs. 101BHG-D01 entered the bloodstream rapidly following nasal spray. Its plasma half-life was approximately 6 h and resided at least 24 h in the body. Moreover, 101BHG-D01 retained a significant amount in the nasal cavity. Finally, we found that 101BHG-D01 was eliminated mainly in the form of stools in rats.

CONCLUSION

In conclusion, we provided pertinent reference information regarding the design and optimization of drug delivery regimens for clinical trials.

Physicians' prescribing behaviour and clinical practice patterns for allergic rhinitis management in Italy

BACKGROUND

Despite availability of clinical guidelines, underdiagnosis, undertreatment, and poor adherence are still significant concerns in allergic rhinitis (AR) therapeutic management. We investigated clinical practice patterns and prescribing behavior of Italian healthcare professionals (HCPs) specialized in AR.

METHODS

One-hundred allergologists, 100 ear, nose and throat (ENT) specialists, and 150 general practitioners (GPs) were recruited. The survey assessed: socio-demographic, work experience, monthly caseload, prescription drivers. Next, HCPs were invited to retrospectively recover patients' clinical data to investigate: AR clinical characteristics, therapy management, prescription patterns, patient adherence. Descriptive statistics, Chi square, One-Way analysis of variance, and Two-Way Analysis of Variance were performed.

RESULTS

Allergologists visited more AR patients (31% of monthly caseload) than ENTs (21%, p < 0.001), while GPs' caseload was the lowest (6%). Clinical information of 2823 patients were retrieved of whom 1906 (67.5%) suffered from moderate/severe AR (discomfort score: 7.7 ± 1.3) and 917 (32.4%) from mild AR (5.7 ± 1.9). About one-third of mild patients had a discomfort score ≥ 7. Main prescription drivers were "effective on all symptoms" (54.3% patients) and "quick symptom relief" (47.8%), whereas minor drivers were "affordable price" (13.4%) and "refundable" (8.7%). The most prescribed drugs were antihistamines and intranasal corticosteroids (79% and 55% prescriptions), followed by fixed-dose-combination of intranasal azelastine/fluticasone (19%). Polytherapy was the most common treatment strategy (59.6%). HCPs' believe that the majority of the patients was adherent to treatment (88% with score > 7).

CONCLUSIONS

This survey describes the therapeutic approach adopted by Italian physicians to cope with AR and shows that HCPs underestimated AR severity and had a non-realistic perception of patients' adherence. These findings suggest that further efforts are required to improve AR clinical management in Italy.

The effect of the standard length of the first prescription on the adherence to sublingual immunotherapy for patients with allergic rhinitis

BACKGROUND

Poor adherence to sublingual immunotherapy (SLIT) has become a major cause of unsatisfactory clinical efficacy for patients with allergic rhinitis (AR). This study was designed to identify the effect of different first prescription lengths on the adherence to SLIT.

METHODS

The clinical data of 306 patients with AR who started SLIT between January 2017 and June 2018 were retrospectively reviewed. Patients were divided into 3 groups according to the length of their first prescription (group A: less than 3 months, group B: 3 to 6 months, group C: more than 6 months). The numbers of adherent or nonadherent patients in each group and the main reasons of nonadherence were analyzed.

RESULTS

Groups A, B, and C included 102, 161, and 43 patients, respectively. The average lengths of the first prescription for group A, B, and C were 62.52 ± 17.63, 102.21 ± 9.22, and 189.07 ± 17.97 days. There were significance differences among the 3 groups (p < 0.05). There were 42 (41.18%), 112 (69.57%), and 37 (86.05%) adherent patients in group A, B, and C. There were 60 (58.82%), 49 (30.43%), and 6 (13.95%) nonadherent patients in group A, B, and C. There were significant differences in the proportions of adherent and nonadherent patients among the 3 groups (p < 0.05). The following reasons were cited for nonadherence to SLIT: the long course of SLIT; inconvenience of getting the prescription; ineffectiveness; side effects; and other reasons.

CONCLUSION

Under certain conditions, 6 months is recommended as the standard length for the first prescription, which can significantly improve adherence to SLIT in patients with AR.

Acquisition and generalization of cough trigger beliefs in allergic rhinitis

In allergic conditions, trigger identification is often inaccurate, and may be influenced by pre-existing beliefs. In this study, we investigated the acquisition and generalization of symptom trigger beliefs in individuals with allergic rhinitis (n = 24) and control participants (n = 24). In a lab-based trigger acquisition task, unique exemplars of two trigger categories were either paired with saline inhalation (CS- category) or citric acid inhalation (CS+ category). The next day, we tested recognition and symptom expectancy for CS category exemplars and exemplars of novel trigger categories. Participants acquired differential symptom expectancies for CS+ compared to CS- exemplars, with faster acquisition in participants with rhinitis. Differential symptom expectancies persisted the next day, and generalized to novel trigger categories, with stronger generalization in rhinitis vs. control participants. These patterns of acquisition and generalization suggest that overgeneralization of trigger beliefs may complicate trigger identification in participants with allergic conditions.

Strong dose response after immunotherapy with PQ grass using conjunctival provocation testing

Background

Pollinex Quattro Grass (PQ Grass) is an effective, well-tolerated, short pre-seasonal subcutaneous immunotherapy to treat seasonal allergic rhinoconjunctivitis (SAR) due to grass pollen. In this Phase II study, 4 cumulative doses of PQ Grass and placebo were evaluated to determine its optimal cumulative dose.

Methods

Patients with grass pollen-induced SAR were randomised to either a cumulative dose of PQ Grass (5100, 14400, 27600 and 35600 SU) or placebo, administered as 6 weekly subcutaneous injections over 31-41 days (EudraCT number 2017-000333-31). Standardized conjunctival provocation tests (CPT) using grass pollen allergen extract were performed at screening, baseline and post-treatment to determine the total symptom score (TSS) assessed approximately 4 weeks after dosing. Three models were pre-defined (Emax, logistic, and linear in log-dose model) to evaluate a dose response relationship.

Results

In total, 95.5% of the 447 randomized patients received all 6 injections. A highly statistically significant (p < 0.0001), monotonic dose response was observed for all three pre-specified models. All treatment groups showed a statistically significant decrease from baseline in TSS compared to placebo, with the largest decrease observed after 27600 SU (p < 0.0001). The full course of 6 injections was completed by 95.5% of patients. Treatment-emergent adverse events were similar across PQ Grass groups, and mostly mild and transient in nature.

Conclusions

PQ Grass demonstrated a strong curvilinear dose response in TSS following CPT without compromising its safety profile.

Acupuncture for the treatment of allergic rhinitis: A systematic review protocol

BACKGROUND

Allergic rhinitis is a major chronic inflammatory disease of the respiratory tract. A large number of epidemiological investigations have shown that the prevalence of allergic rhinitis (AR) is increasing, resulting in a large burden of disease. Desensitizing drugs such as nasal glucocorticoids and antihistamines are commonly used to treat allergic rhinitis, but this method has a long treatment period and is prone to repeated attacks, and there are certain adverse reactions. Acupuncture can be used to treat a wide variety of diseases including allergic rhinitis without the occurrence of drug damage. We aim to evaluate the efficacy and safety of acupuncture in the treatment of allergic rhinitis.

METHODS

Relevant databases include the English databases incorporating Web of science, PubMed, Springer, Medline, Cochrane Library, EBASE, WHO International Clinical Trials Registry Platform (ICTRP), as well as the Chinese databases like the China National Knowledge Infrastructure Database (CNKI), Chinese Scientific Journal Database (VIP), Wanfang Database, and Chinese Biomedical Literature Database will be searched normatively according to the rule of each database from the inception to September 1, 2018. Reference list of identified studies, potential gray literatures, relevant conference abstracts, and clinical trial registrations will also be searched. The literature screening, data extraction, and quality assessment will be conducted by 2 researchers independently. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. Symptom score will be assessed as the primary outcome. Rhinoconjunctivitis quality of life questionnaire (RQLQ), participants with asthma can use asthma control test (ACT), medicine usage and scoring, laboratory examination, and side effects or adverse events will be evaluated as the secondary outcome. Meta-analysis will be performed using RevMan5.3.5 software provided by the Cochrane Collaboration.

RESULTS

This study will provide high-quality synthesis based on current evidence of acupuncture treatment for allergic rhinitis in several aspects, including symptom score, drug score, quality of life score, asthma control score, side effects and laboratory examination such as nasal function test, serum total immunoglobulin (IgE), nasal secretion smear, etc. CONCLUSION:: The results of this study will provide updated evidence for weather acupuncture is an effective and safe intervention for allergic rhinitis.

ETHICS AND DISSEMINATION

It is not necessary for this systematic review to acquire an ethical approval. This review will be disseminated in a peer-reviewed journal or conference presentation.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018109105.

Evaluating the Impacts of Methylsulfonylmethane on Allergic Rhinitis After a Standard Allergen Challenge: Randomized Double-Blind Exploratory Study

Background

The sulfur-containing compound methylsulfonylmethane (MSM) has been used as a dietary supplement for a variety of reported health benefits. Clinical observations and case studies have indicated that MSM may help alleviate allergic rhinitis; however, this effect has not been evaluated under controlled conditions.

Objective

This study aimed to determine the effects of MSM consumption on allergic rhinitis symptoms after provocation with a standardized allergen.

Methods

We recruited healthy participants with a history of allergic nasal congestion to participate in a randomized, double-blind, adaptive-design study. Participants were administered a standardized allergen in clinic to determine the presence or absence of an allergic response. Participant responses were recorded using a recognized measure of nasal patency, peak nasal inspiratory flow (PNIF), and by a visual analog scale to score the severity of their allergy-related nasal symptoms. After we collected baseline nasal responses to allergen, followed by a 1-week washout period, participants returned to the clinic and were exposed to allergen after taking an acute high dose of 12 g of MSM. We then randomly assigned participants to a lower dose of MSM (1 g, 3 g, or 6 g), which they consumed once a day for 14 days. Participants returned to the clinic for repeat assessments while again taking their assigned daily dose of MSM.

Results

All MSM treatment courses significantly reduced visual analog scale average nasal symptoms in a longitudinal comparison across all participants, with low-dose treatments decreasing symptoms by 53.72% (P=.001), and an acute 12-g dose decreasing symptoms by 22.49% (P=.03). Although the acute dose of MSM did not yield significant changes in nasal patency, low “everyday” doses significantly relieved nasal obstruction as indicated by a 17.32% (P=.02) increase in PNIF across all participants. The most effective dose across all measurements was daily consumption of 3 g of MSM, which significantly decreased all nasal symptoms (nasal obstruction, rhinorrhea, watery or itchy eyes and nose, and sneezing) and further was found to significantly (P=.01) increase PNIF.

Conclusions

The MSM study product provided significant relief of allergic rhinitis symptoms and objective nasal obstruction measurements without the occurrence of adverse events. Oral consumption of the study product may reduce the symptoms and onset of allergic rhinitis without the side effects associated with standard-care medication.

Trial Registration

ClinicalTrials.gov NCT02342483; https://clinicaltrials.gov/ct2/show/NCT02342483 (Archived by WebCite at http://www.webcitation.org/73vLKNvAp)

Genetic Modification of the Lung Directed Toward Treatment of Human Disease

Genetic modification therapy is a promising therapeutic strategy for many diseases of the lung intractable to other treatments. Lung gene therapy has been the subject of numerous preclinical animal experiments and human clinical trials, for targets including genetic diseases such as cystic fibrosis and α1-antitrypsin deficiency, complex disorders such as asthma, allergy, and lung cancer, infections such as respiratory syncytial virus (RSV) and Pseudomonas, as well as pulmonary arterial hypertension, transplant rejection, and lung injury. A variety of viral and non-viral vectors have been employed to overcome the many physical barriers to gene transfer imposed by lung anatomy and natural defenses. Beyond the treatment of lung diseases, the lung has the potential to be used as a metabolic factory for generating proteins for delivery to the circulation for treatment of systemic diseases. Although much has been learned through a myriad of experiments about the development of genetic modification of the lung, more work is still needed to improve the delivery vehicles and to overcome challenges such as entry barriers, persistent expression, specific cell targeting, and circumventing host anti-vector responses.

Nanomaterials in the Context of Type 2 Immune Responses-Fears and Potentials

The type 2 immune response is an adaptive immune program involved in defense against parasites, detoxification, and wound healing, but is predominantly known for its pathophysiological effects, manifesting as allergic disease. Engineered nanoparticles (NPs) are non-self entities that, to our knowledge, do not stimulate detrimental type 2 responses directly, but have the potential to modulate ongoing reactions in various ways, including the delivery of substances aiming at providing a therapeutic benefit. We review, here, the state of knowledge concerning the interaction of NPs with type 2 immune responses and highlight their potential as a multifunctional platform for therapeutic intervention.

Recent pharmacological developments in the treatment of perennial and persistent allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) has a major negative impact on patients' quality of life (QoL) and carries a high socio economic burden. This is particularly the case for patients who experience symptoms for extended periods of time (i.e. those with perennial (PAR) or persistent AR (PER), depending on the classification system used). This review covers available pharmacological advances and recent developments in the treatment of PAR or PER.

AREAS COVERED

Pharmacological AR treatment is used to reduce symptom burden and help restore patients' normal daily routine. Traditionally, non-sedating antihistamines and intranasal corticosteroids (INS) were the two drug classes recommended for use first line. These, along with antileukotrienes, decongestants, mast cell stabilizers and anticholinergics, constituted the bulk of the AR treatment arsenal. MP-AzeFlu (Dymista®, Meda, Solna, Sweden) is the most recent addition to that arsenal. It is a novel intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP) delivered in a single spray and has surpassed available therapies in terms of symptom control and treatment response. Other relatively new treatments for PAR or PER include H3 antihistamines, toll-like receptor (TLR) agonists, cellulose powders and micro-emulsions, novel biomolecular formulations and omalizumab. Each of these new additions is reviewed here.

EXPERT OPINION

A new AR drug class has recently been introduced (i.e. RO1AD58). Currently MP-AzeFlu is the only treatment option within this drug class. It can be estimated that combination treatments like MP-AzeFlu will become the mainstay of PAR and PER therapy since use will result in better compliance, improved efficacy over INS and a faster response together with good levels of tolerability. The challenge is to find other equally, or more effective, combination treatments, as has been the therapeutic standard in bronchial asthma for decades. The potential of biologics, as well as TLR-agonists and other new treatment options needs to be further evaluated.

Knowledge and Attitude of Medical Resident Doctors Toward Antihistamines

Background:

Allergic rhinitis and urticaria are chronic persistent allergic conditions that need proper management as they significantly reduce quality of life measures. Of the many pharmacological options of allergic rhinitis and urticaria, second-generation antihistamines are the mainstay of therapy.

Aims:

This review focuses on the knowledge of medical residents toward prescribing antihistamines, according to the new ARIA and GA2LEN guidelines for allergic rhinitis and urticaria, attempting to find the cause of less prescription of newer second-generation antihistamines by finding out the knowledge and attitude of the doctors prescribing them to the patients.

Materials and Methods:

The study was carried out among resident doctors at a tertiary care teaching hospital. Primary data from 100 resident doctors, who gave their informed consent, was collected. A prevalidated questionnaire regarding knowledge, attitude and prescribing practice of antihistamines was filled up. The data was then analyzed with suitable statistical tests. Every question was first validated using the Chi-square test, and significance was below 10% hence proving validity of the questions.

Results:

Out of the doctors surveyed, 82% of doctors said they prescribed second-generation antihistamines, while 18% still prescribed first-generation antihistamines. Out of the 82% that prescribed second-generation antihistamines, 8.9% also prescribed first-generation antihistamines as well. 23% of doctors surveyed had heard about the ARIA and GAL2EN guidelines and their recommendations for prescribing second-generation antihistamines over the older first-generation antihistamines, while 77% of them had not heard of these position papers.

Conclusion:

First-generation or classic antihistamines are still overused due to the lack of knowledge of various guidelines that have been published. The main reason for not prescribing the second-generation antihistamines was due to the increased cost per tablet compared to the more economical first-generation antihistamines.

Increased Expression of miR-146a in Children With Allergic Rhinitis After Allergen-Specific Immunotherapy

Purpose

MicroRNAs (miRs) were recently recognized to be important for immune cell differentiation and immune regulation. However, whether miRs were involved in allergen-specific immunotherapy (SIT) remains largely unknown. This study sought to examine changes in miR-146a and T regulatory cells in children with persistent allergic rhinitis (AR) after 3 months of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT).

Methods

Twenty-four HDM-sensitized children with persistent AR were enrolled and treated with SCIT (n=13) or SLIT (n=11) for 3 months. Relative miR-146a and Foxp3 mRNA expression, the TRAF6 protein level, and the ratio of post-treatment to baseline IL-10⁺CD4⁺ T cells between the SCIT and SLIT groups were examined in the peripheral blood mononuclear cells (PBMCs) of AR patients using quantitative reverse transcription polymerase chain reaction (qRT-PCR), flow cytometry, and Western blot analysis, respectively. Serum levels of IL-5 and IL-10 were determined using ELISA.

Results

After 3 months of SIT, both the TNSS and INSS scores were significantly decreased compared to the baseline value (P<0.01). The relative expression of miR-146a and Foxp3 mRNA was significantly increased after both SCIT and SLIT (P<0.01). The ratio of post-treatment to baseline IL-10⁺CD4⁺ T cells and the serum IL-10 level were significantly increased in both the SCIT and SLIT groups (P<0.01), whereas the TRAF6 protein level and serum IL-5 level were significantly decreased (P<0.01). No significant differences in these biomarkers were observed between the SCIT and SLIT groups.

Conclusions

Our findings suggest that miR-146a and its related biomarkers may be comparably modulated after both SCIT and SLIT, highlighting miR-146a as a potential therapeutic target for the improved management of AR.

A, Canales M, Morales S. RGE, Mardones P. P, Leiva G. MA. Trends and threshold exceedances analysis of airborne pollen concentrations in Metropolitan Santiago Chile

Pollen is one of the primary causes of allergic rhinoconjunctivitis in urban centers. In the present study, the concentrations of 39 different pollens in the Santiago de Chile metropolitan area over the period 2009–2013 are characterized. The pollen was monitored daily using Burkard volumetric equipment. The contribution of each type of pollen and the corresponding time trends are evaluated. The concentrations of the pollens are compared with the established threshold levels for the protection of human health. The results show that the total amount of pollen grains originating from trees, grasses, weeds and indeterminate sources throughout the period of the study was 258,496 grains m-3, with an annual average of 51,699 ± 3,906 grains m-3 year-1. The primary source of pollen is Platanus orientalis, which produces 61.8% of the analyzed pollen. Grass pollen is the third primary component of the analyzed pollen, with a contribution of 5.82%. Among the weeds, the presence of Urticacea (3.74%) is remarkable. The pollination pattern of the trees is monophasic, and the grasses have a biphasic pattern. The trends indicate that the total pollen and tree pollen do not present a time trend that is statistically significant throughout the period of the study, whereas the grass pollen and weed pollen concentrations in the environment present a statistically significant decreasing trend. The cause of this decrease is unclear. The pollen load has doubled over the past decade. When the observed concentrations of the pollens were compared with the corresponding threshold levels, the results indicated that over the period of the study, the pollen concentrations were at moderate, high and very high levels for an average of 293 days per year. Systematic counts of the pollen grains are an essential method for diagnosing and treating patients with pollinosis and for developing forestation and urban planning strategies.