Effects of orally inhaled budesonide in seasonal allergic rhinitis

Higher Prevalence and Severity of Eosinophilic Otitis Media in Patients with Asthma-COPD Overlap Compared with Asthma Alone

INTRODUCTION

Eosinophilic otitis media (EOM) is well-known to frequently co-exist with adult-onset asthma. Both diseases are similar type 2 inflammation and are considered to have a "one airway, one disease" relationship. Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO), characterized by airway obstruction caused by airway wall thickening (AWT), is a severe condition with a higher incidence of mortality compared to asthma alone or COPD alone. Based on the "one airway, one disease" concept, we hypothesized that the inflammatory pathophysiology of EOM differs depending on its comorbidity with ACO or with asthma alone.

METHODS

A total of 77 chronic rhinosinusitis (CRS) patients with asthma were enrolled in this study. The subjects were divided into 2 groups: a group with comorbid asthma alone (asthma group; 46 patients), and a group with comorbid ACO (ACO group; 31 patients). The 2 groups were compared and assessed with regard to various factors, including the patients' clinical characteristics, prevalence rate of EOM, EOM severity, EOMs relationships with smoking and AWT, and the eosinophil and neutrophil cell counts in the middle ear effusion (MEE).

RESULTS

The ACO group included significantly more males (p < 0.05), was significantly older (p < 0.05), and showed significantly lower lung function values (FEV1 [L], FEV1 [%pred]) (p < 0.01) compared with the asthma group. The ACO group also had a significant history of smoking as shown by the Brinkman index (p < 0.01) and greater AWT as assessed by high-resolution computed tomography (p < 0.05). The EOM prevalence rate was significantly higher in the ACO group (p < 0.05), especially with increased ACO severity (p < 0.05). The EOM severity was also significantly higher in the ACO group (p < 0.05) and also correlated with the ACO severity (p < 0.05). The pretreatment ear clinical characteristics score and the average air conduction hearing level were significantly higher in the ACO group (p < 0.05). The eosinophil percentage in the MEE/otorrhea was significantly lower in the ACO group (25.3%) than in the asthma group (54.7%) (p < 0.05). Conversely, the neutrophil percentage was significantly higher in the ACO group (75.7% vs. 41.9%) (p < 0.05).

CONCLUSIONS

Our findings suggest that, in CRS patients with asthma, comorbidity with ACO may be a clinical factor leading to increased EOM prevalence and severity, as well as a higher neutrophil infiltration percentage in the middle ear. Cessation of smoking and early therapeutic intervention for ACO may mitigate progression of bronchial remodeling (i.e., reduce AWT) and help reduce the prevalence and severity of EOM.

May a different kinetic mode explain the high efficacy/safety profile of inhaled budesonide?

The claimed functional basis for ICSs in asthma and COPD is airway selectivity, attained by inhaling a potent, lipophilic compound with long local dissolution/absorption time. The development has been empirically based, resulting in five widely used ICSs. Among them, budesonide (BUD) deviates by being less lipophilic, leading to a more rapid systemic uptake with plasma peaks with some systemic anti-inflammatory activity. By this, BUD fits less well into the current pharmacological dogma of optimal ICS profile. In this review we compared the physicochemical, pharmacological and clinical properties of BUD, fluticasone propionate (FP) and fluticasone furoate (FF), representing different levels of lipophilicity, airway and systemic kinetics, focusing on their long-acting β2-agonist (LABA) combinations, in line with current GINA and GOLD recommendations. We are aware of the differences between formoterol (FORM) and the not rapid acting LABAs such as e.g. salmeterol and vilanterol but our comparisons are based on currently available combination products. A beclomethasone dipropionate (BDP)/FORM combination is also commented upon. Based on clinical comparisons in asthma and COPD, we conclude that the BUD/formoterol (BUD/FORM) combination is as effective and safe as the FP and FF combinations, and is in some cases even better as it can be used as "maintenance plus reliever therapy" (MART) in asthma and as maintenance in COPD. This is difficult to explain by current views of required ICS's/LABAs pharmacokinetic profiles. We propose that BUD achieves its efficacy by a combination of airway and systemic activity. The airway activity is dominating. The systemic activity contributes by plasma peaks, which are high enough for supportive anti-inflammatory actions at the blood and bone marrow levels but not sufficiently long to trigger a similar level of systemic adverse effects. This may be due to BUD's capacity to exploit a systemic differentiation mechanism as programmed for cortisol's various actions. This differentiation prospect can be reached only for an ICS with short plasma half-life. Here we present an alternative mode for an ICS to reach combined efficacy and safety, based on a poorly investigated and exploited physiological mechanism. A preference of this mode is broader versatility, due to that its straighter dose-response should allow a better adaptation to disease fluctuations, and that its rapid activity enables use as "anti-inflammatory reliever".

Eosinophilic otitis media and comorbid asthma

PURPOSE OF REVIEW

Eosinophilic otitis media (EOM) is an intractable otitis media characterized by numerous eosinophils infiltrating the middle ear cavity, which is part of the upper airway. EOM shows a high rate of comorbidity with asthma. They are considered to have a 'one airway, one disease' relationship. Here, we summarize our current knowledge regarding the characteristics of EOM, EOM's relationship with asthma and the efficacy of optimal treatments for EOM.

RECENT FINDINGS

The greater the severity of asthma, the more pronounced the development of EOM. Asthma control is usually inadequate in asthmatics who develop EOM, and appropriate strengthening of asthma inhalation therapy leads to improvement in the EOM. EOM severity can be divided into mild, moderate, and severe. Intratympanic infusion therapy using a topical steroid such as triamcinolone acetone is effective for mild EOM, whereas moderate EOM requires a systemic steroid in addition to triamcinolone acetone, and severe EOM forms granulation tissue that requires surgical removal. Recently, the effectiveness of molecularly targeted drugs is being reported, but more data need to be accumulated.

SUMMARY

EOM and asthma are closely related. Optimal asthma treatment is important for treating EOM. Treatments commensurate with the severity of EOM are being developed.

Rapid and remarkable effectiveness of benralizumab for treating severe bronchial asthma with intractable eosinophilic rhinosinusitis and eosinophilic otitis media: A case report

Severe bronchial asthma is a challenging disorder to treat and can impair quality of life (QOL) under conventional therapeutic modalities. We report the case of a 52-year-old woman with severe asthma associated with eosinophilic chronic rhinosinusitis (ECRS) and eosinophilic otitis media (EOM). Although the patient was treated with a full dose of inhaled corticosteroid, leukotriene receptor antagonist (LTRA), theophylline, burst use of oral corticosteroids (OCS), her asthmatic condition aggravated, disrupting her daily life. ECRS and EOM symptoms were also getting worse despite treatment with topical application of corticosteroids to the nose and ears, LTRA, and occasional use of OCS. In addition to asthmatic symptom, the patient always suffered from intractable nasal obstruction and hearing disturbance, which contributed to the heavily impaired QOL. However, the administration of benralizumab showed rapid and remarkable improvement not only in her asthmatic conditions but also in the symptoms of ECRS and EOM within a month. These results suggest that the use of benralizumab for the treatment of severe asthma with intractable ECRS and EOM should be considered when the patient's QOL is severely deteriorated.

Evaluation of olfactory dysfunction to estimate the presence of eosinophilic chronic rhinosinusitis in patients with asthma

BACKGROUND

Eosinophilic chronic rhinosinusitis (ECRS) is often complicated by asthma and can be difficult to diagnose. This study aimed to clarify the usefulness of the self-administered odor questionnaire (SAOQ) and visual analog scale (VAS) to identify olfactory disorders in patients with asthma.

METHODS

This retrospective study was conducted on patients with asthma who were referred to the Otolaryngology clinic between May and September 2018. The treatment step of asthma, asthma control test (ACT), pulmonary function test, peripheral blood eosinophils, and fractional exhaled nitric oxide (FeNO) were analyzed. ECRS was diagnosed based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis Study score. Olfactory dysfunction was evaluated using the SAOQ and VAS for olfactory disorders.

RESULTS

The study included 56 patients (18 males and 38 females), who were divided into two groups; those with ECRS (n = 18) and those without ECRS (n = 38). Age, sex, treatment step, ACT score, and pulmonary function were not significantly different between the groups. The ECRS group had a significantly higher FeNO value (89.1 ppb vs. 39.1 ppb) and a significantly lower SAOQ score (40.1% vs. 96.1%). The area under the receiver operating characteristic curve for the efficacy of ECRS diagnosis was 0.88, 0.889, 0.799, and 0.757 for SAOQ, VAS, blood eosinophil count, and FeNO, respectively.

CONCLUSION

The SAOQ and VAS scores were useful tools that presented similar results to the blood eosinophil count and FeNO, and may help to improve the diagnosis of ECRS in patients with asthma.

Janus looks both ways: How do the upper and lower airways interact?

Our understanding of the relationship between the upper and lower airways has greatly increased as a consequence of epidemiologic and pharmacologic studies. A consistent body of scientific evidence supports the concept that rhinitis, rhinosinusitis and asthma may be the expression of a common inflammatory process, which manifests at different sites of the respiratory tract, at different times. This paradigm states that allergic reactions may begin at the local mucosa, but tend to propagate along the airway. Central to the allergic diathesis is the eosinophil and its interaction with the airway epithelium. The implications of the interplay between upper and lower airway are not only academic, but also important for diagnostic and therapeutic reasons. Furthermore, there is significant overlap in symptomatology and pathophysiology for childhood sleep disordered breathing (SDB) and asthma. Recent evidence supports an association between these two conditions, but causality has not been demonstrated. Regardless, it is important to recognize the overlap and evaluate for the other condition when one is present. In children with poorly controlled asthma, the presence of SDB may significantly contribute to asthma morbidity and, as such, should be actively excluded. On the other hand, clinical evaluation for asthma should be considered in children with SDB. Future robust longitudinal research is needed to explore the association between upper and lower airway diseases using objective measures in children.

Optimal control of asthma improved eosinophilic otitis media

Background

Eosinophilic otitis media (EOM) is often associated with comorbid asthma. The middle ear cavity is part of the upper airway. Therefore, EOM and asthma can be considered to be a crucial part of the “one airway, one disease” phenomenon. Based on the concept of one airway, one disease in the context of allergic rhinitis and asthma, optimal level of inhalation therapy for better asthma control leads to improvement in allergic rhinitis.

Objective

We conducted a pilot study to determine whether appropriate strengthening of inhalation therapy for asthma is effective for EOM.

Methods

Fifteen patients with EOM and comorbid asthma were enrolled in this study. Eight patients were randomly selected and administered appropriately strengthened inhalation therapy for asthma (strengthened group). The effect of the therapy on EOM was assessed by comparing a questionnaire for ear symptoms, clinical characteristic score, pure tone audiometry, blood tests and temporal bone computed tomography (CT) examination before and after the therapy. Seven other EOM + asthma patients without the above mentioned therapy were included as controls.

Results

In the strengthened group, the score of ear symptoms, clinical characteristics score, peripheral blood eosinophil count, CT score, and air conduction hearing level improved significantly after strengthening the inhalation therapy, but not in the control group. The lung function tests (forced vital capacity [%predicted], forced expiratory volume in 1 second [FEV₁] [L], and FEV₁ [%predicted]) significantly increased in the strengthened group after the therapy, but not in the control group.

Conclusion

In this study we demonstrated that EOM improved along with improved lung function when appropriately optimal inhalation therapy was implemented in patients with EOM and asthma. Administration of optimizing therapy for asthma might be effective for concomitant EOM.

IL-33/ST2 axis controls Th2/IL-31 and Th17 immune response in allergic airway diseases

IL-33 targeting ST2 receptor (T1/ST2), expressed on Th2 cell surface, regulates the production of cytokines like IL-17A and IL-31. We studied the role of IL-33/ST2 axis in IL-31 and IL-17A production in patients with allergic rhinitis (AR) and with concomitant allergic asthma and rhinitis (AAR). 20 healthy control subjects (HC), 14 AR and 17 AAR subjects were recruited and blood samples collected. IL-33, soluble ST2 (sST2), IL-17A and IL-31 plasma concentrations were measured by ELISA method. T1/ST2, IL-31 and IL-17A cellular expression were studied in peripheral blood mononuclear cells (PBMC) from HC, AR and AAR (n=6 for each group) by flow-cytometry. In vitro, we also evaluated the effect of beclomethasone dipropionate (BDP) on T1/ST2, IL-31 and IL-17A expression in CD3(+)T-cells from PBMC of AAR (n=6). Plasma levels of IL-33, IL-31 and IL-17A were significantly higher and sST2 was lower in patients with AR and AAR than in HC. IL-31 and IL-17A intracellular levels significantly increased, whereas T1/ST2 expression was significantly lower, in CD3(+)T-cells from AR and AAR compared to HC. Positive correlations were observed between plasmatic components of IL-33/ST2 axis and IL-31 in both AR and AAR and IL-17A in AAR. In vitro IL-31 and IL-17A intracellular levels decreased after BDP treatment, whereas T1/ST2 expression increased in cultured CD3(+)T-cells obtained from AAR. IL-33/ST2 axis is involved in Th2/IL-31 and Th17 immune response during the progression of allergic airway disease. In vitro BDP is able to control Th2/IL-31 and Th17 immune response in PBMC from allergic patients.

Eosinophilic otitis media is associated with asthma severity and smoking history

PURPOSE

Eosinophilic otitis media (EOM) is an intractable otitis media characterized by an accumulation of eosinophils in the middle ear and a strong association with asthma. We investigated the relationship between EOM and asthma severity, asthma risk factors, lung function, and airway structural changes assessed by high-resolution computed tomographic (HRCT) scanning.

MATERIALS AND METHODS

Forty-one asthma patients with chronic rhinosinusitis (18 men and 23 women; mean age 56 years; age range 25-82 years) were included in this study. EOM was diagnosed according to the published diagnostic criteria. Asthma severity and risk factors for asthma, such as smoking history (Brinkman index, BI), were examined. Airway wall thickness and emphysema were assessed with HRCT scanning by a blinded respiratory specialist using a validated method. Lung function was measured using standard procedures.

RESULTS

EOM was diagnosed in 34% of the patients. Asthma severity, BI and airway wall thickness were each statistically greater in patients with EOM than in patients without EOM.

CONCLUSION

There was a close relationship between EOM and asthma severity in asthma patients with chronic rhinosinusitis. Cessation of smoking might help prevent EOM by reducing airway wall thickness.

Pediatric allergic rhinitis and asthma: can the march be halted?

The strong epidemiologic and pathophysiologic link between allergic rhinitis (AR) and asthma has led to the concept of 'united airways disease' or 'respiratory allergy', implying that allergy, in its widest sense, underlies this clinical syndrome. Progression from AR to asthma is frequent and part of the 'atopic march'. Since pediatric immune responses are more adaptable and therefore may be more amenable to treatment, interventions at early childhood are characterized by a higher chance to affect the natural history of respiratory allergy. Although current treatments are quite effective in alleviating respiratory allergy symptoms, it has proven much more difficult to confirm any influence on the progression of the disease. Much more promising is the field of specific allergen immunotherapy, where current evidence, although not yet of ideal robustness, points towards a disease-modifying effect. In addition, newer or emerging, possibly more effective or more targeted interventions are promising in the preventive sense.

Improvement of eosinophilic otitis media by optimized asthma treatment

Eosinophilic otitis media (EOM) shows a very high rate of association with asthma, and intractable otitis media involves marked eosinophil infiltration into the middle ear. The middle ear space is connected to the nasopharynx by the Eustachian tube, and it is considered a part of the upper respiratory tract. Allergic rhinitis and asthma often coexist as chronic inflammatory diseases of the upper and lower airways, respectively, and have an impact on each other. In fact, inhaled corticosteroids reduce seasonal eosinophilia systemically in the circulation and locally in the nasal mucosa, as well as attenuate seasonal nasal symptoms. We report a case of EOM associated with adult-onset asthma that improved following optimal asthma therapy after changing the treatment from inhaled fluticasone propionate (FP) (200 µg b.i.d.) to a combination of FP/salmeterol (250/50 µg b.i.d.). This result supports the hypothesis that EOM and asthma are closely linked, presenting as different manifestations of a similar disease syndrome.

Histopathologic and morphometric evaluation of the nasal and pulmonary airways of cats with experimentally induced asthma

BACKGROUND

Allergic rhinitis frequently occurs as a comorbid condition in asthmatic people, suggesting that the upper and lower airways may be immunologically linked. Our research group has developed an experimental aeroallergen model of asthma in cats. We hypothesized that aeroallergen sensitization and challenge would induce morphologic changes in the nasal airways of cats that mimic those observed in the bronchial airways.

METHODS

Five mixed breed cats were sensitized to Bermuda grass allergen and then serially challenged with aerosolized Bermuda grass allergen to induce an asthmatic phenotype. Four control cats were similarly treated with saline vehicle. Nasal tissues and lungs were processed for histopathological and morphometric analyses.

RESULTS

Eosinophilic inflammation, epithelial hypertrophy and mucous cell metaplasia were observed along the pulmonary axial airway mucosa of allergen-sensitized (asthmatic) cats. Mild eosinophilic inflammation was observed in the nasal airways of asthmatic cats. This alteration was confined primarily to the anterior nasal cavity, resulting in an increase in tissue eosinophils at this site compared to controls (p < 0.05). A marked increase in tissue mast cells was observed throughout all regions of the nasal airways of asthmatic cats compared to control cats (p < 0.05). There was no difference in intraepithelial mucosubstances between the nasal airways of controls and asthmatic cats. There was no correlation between upper and lower airway eosinophils or mast cells.

CONCLUSION

Cats with experimentally induced asthma exhibit morphologic changes in the nasal airways that are distinct from the alterations observed in the lungs. These results are similar to those observed in people with comorbid asthma and allergic rhinitis.

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.

Asthma and rhinitis: comorbidities

The connection between asthma and rhinitis is not a new discovery. Significant progress has been made in understanding the relationship of these two conditions, however, and the implications of the asthma-rhinitis link make it increasingly important. Patients who have asthma and rhinitis tend to have more severe disease with higher treatment costs. Treatment of rhinitis may improve asthma control, and early treatment of allergies may prevent the development of asthma. This article more fully explores the epidemiologic, pathophysiologic, and clinical relationships between asthma and rhinitis.

Treating allergic rhinitis and asthma: different sides of the same fence

Allergic asthma and rhinitis are highly prevalent diseases. Although they are diagnosed and treated separately, many patients suffer from both. There is data suggesting that they can be considered as manifestations of the same disease or syndrome, but in different locations. This article discusses the evidence favouring a joint clinical approach, and the main therapeutic tactics to achieve disease control; tries to establish the importance of isolated and adjuvant treatment of rhinitis and asthma, highlighting a small number of clinical studies regarding the subject; and indicates points for future research.

6: Rhinitis and asthma: united airway disease

United airway disease is characterised by inflammation of the respiratory tract, in which asthma and rhinitis are the upper and lower respiratory tract manifestations, respectively, of the same disease process. Irrespective of cause, the upper and lower respiratory tract manifestations are characterised by a systemic inflammatory response. Patients with rhinitis or asthma should always be assessed for coexistent disease in the reciprocal area. Treatment of upper airway disease can modify the severity of lower airway disease and vice versa. The potential for early treatment of allergic rhinitis to prevent progression to asthma merits further study.

Topical glucocorticosteroids in rhinitis: clinical aspects

The introduction of nasal glucocorticosteroids, 30 years ago, has been the most important therapeutic progress in rhinitis management since the introduction of the first generation of antihistamines. Our knowledge of the mode of action of glucocorticosteroids in the nose has improved as the airway mucous membrane of the nose is easily accessible for investigation. However, the exact mechanism behind the marked clinical effect remains unclear. Topical glucocorticosteroids are highly effective in diseases characterized by eosinophil-dominated inflammation (allergic rhinitis, nasal polyposis), but not in diseases characterized by neutrophil-dominated inflammation (common cold, infectious rhinosinusitis). Experience for 30 years and a long series of controlled studies have shown that the treatment is highly effective and that the side effects are few and benign. Intranasal glucocorticosteroids can therefore be considered as first-line treatment for allergic and non-allergic, non-infectious rhinitis and nasal polyps.

Effect of treating allergic rhinitis with corticosteroids in patients with mild-to-moderate persistent asthma

STUDY OBJECTIVES

Rhinitis and asthma are considered to be synchronic or sequential forms of the same allergic syndrome. Treating the inflammation associated with allergic rhinitis influences the control of asthma. However, few studies have investigated the effect of treating perennial rhinitis on persistent asthma and vice versa. We determined the effects of inhaled or topical nasal beclomethasone dipropionate (BDP) administered separately or in combination on the control of asthma and bronchial hyperresponsiveness (BHR) in patients with the rhinitis/asthma association.

DESIGN

A double-blind, parallel, three-group study.

SETTING

Outpatient clinic of Pulmonary Division/Heart Institute (InCor) and the Division of General Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil.

PATIENTS

Seventy-four patients with mild-to-moderate asthma and allergic rhinitis (median age, 25 years).

INTERVENTIONS

Patients received nasal or inhaled BDP separately or in combination for 16 weeks after a 2-week placebo run-in period.

MEASUREMENTS AND RESULTS

Nasal and pulmonary symptoms, as well as pulmonary function and BHR, were compared among the three groups after 4 weeks and 16 weeks of treatment. Patients in all three groups demonstrated a progressive and significant decrease in nasal and pulmonary symptoms, which started after 4 weeks (p < 0.05) and continued through the end of treatment (p < 0.001). Clinical improvement was similar and parallel in the three groups. Asthma-related morbidity, evaluated by quantifying absence from work, emergency department visits, and nighttime awakenings, also decreased in the three groups (p < 0.05).

CONCLUSIONS

Failure to consider treatment of rhinitis as essential to asthma management might impair clinical control of asthma. Furthermore, these data suggest that asthma and rhinitis in some patients can be controlled by the exclusive use of nasal medication.

Asthma rescue and allergy medication use among asthmatic children with prior allergy prescriptions who initiated asthma controller therapy

BACKGROUND

Asthma and allergic rhinitis are frequently comorbid conditions. Montelukast is effective in treating both diseases and may reduce total medication use among children with asthma and allergic rhinitis.

OBJECTIVE

To determine the differences in respiratory and allergy medication use and costs, as proxies for control, in pediatric patients with asthma and allergy who initiated asthma controller therapy.

METHODS

A 24-month, retrospective, pre-post cohort study using a pharmacy claims database of children (age < 16 years) with 2 or more consecutive asthma controller prescriptions and 1 or more allergy prescription (within 12 months before initial controller prescription). Children taking inhaled corticosteroids (ICSs) and montelukast were matched one to one based on age, days of prior allergic rhinitis therapy supply, duration of controller therapy, and propensity score. Differences in costs of rescue or acute asthma medications, prescription allergy medications, other respiratory medications, and the number of days of rescue or acute asthma medication use and allergy medication use were calculated.

RESULTS

A total of 1,236 children were matched into ICS and montelukast groups (n = 618 each). Montelukast patients had a smaller cost increase overall compared with ICS patients (combined cost for rescue or acute asthma medications, allergy medications, and other respiratory medications: $5.55 vs $12.08, P < .001). Cost increase for rescue or acute asthma medications was significantly lower in the montelukast group ($0.94 vs $3.82, P = .003). The cost increase for allergy medications ($5.29 vs $10.06, P < .001) was also significantly lower in the montelukast group. Patients taking montelukast also had fewer days of therapy with asthma rescue medication and allergy medication compared with patients taking ICSs.

CONCLUSIONS

Initiating therapy with montelukast was associated with better asthma and allergy control demonstrated via lower increase in use and costs of asthma rescue and allergy medications compared with initiating ICS therapy.

Nasal lavage fluid concentrations of eotaxin-1 (CCL11) in naturally occurring allergic rhinitis: relationship to disease activity, nasal luminal eosinophil influx, and plasma protein exudation

BACKGROUND

Eotaxin-1 (CCL11) is a CC chemokine whose nasal eosinophilic chemotactic activity in vivo and in vitro has been demonstrated primarily using nasal allergen challenge models. The extension of these challenge findings to the in vivo setting has been limited.

OBJECTIVE

To obtain nasal lavage fluid from volunteers with perennial and seasonal (in- and out-of-season) allergic rhinitis (AR) and non-atopic non-rhinitic controls for the measurement of eotaxin-1 concentrations and to relate these findings to the symptomatic disease severity, the percentage of lavage eosinophils, and to alpha(2)-macroglobulin (alpha(2)-MG) lavage concentrations, as a marker of vascular permeability and an index of airway inflammation.

METHODS

Thirty-seven volunteers with AR (16 seasonal and 21 perennial) and 20 non-atopic non-rhinitic volunteers were recruited and phenotyped. Nasal lavage fluid was obtained by standardized protocol. The nasal lavage fluid concentrations of eotaxin and alpha(2)-MG were measured by ELISA, and differential cell counts performed on cytospins.

RESULTS

Eotaxin-1 nasal lavage fluid concentrations were significantly higher in both the perennial and seasonal (in-season) AR groups compared with the controls, and significantly related to the severity of symptom expression and to the percentage of lavage eosinophils. The lavage eosinophil counts were significantly higher in both the symptomatic rhinitis groups compared with the control groups and correlated with the lavage concentrations of alpha(2)-MG. alpha(2)-MG levels were significantly increased in seasonal (in-season) rhinitics compared with both non-atopic controls and seasonal (out-of-season) rhinitics. A significant correlation was observed between the levels of alpha(2)-MG and levels of eotaxin in the symptomatic allergic rhinitic groups.

CONCLUSIONS

This study clearly demonstrates the relevance of eotaxin-1 to the pathogenesis of naturally occurring AR.

Relationship between Asthma and Rhinitis: Epidemiologic, Pathophysiologic, and Therapeutic Aspects

Over the last few years, the evidence of links between rhinitis and asthma has been strengthened. This has led to the introduction of the concept of united airway disease. Rhinitis and asthma appear to be interrelated at the epidemiologic level and at the pathophysiologic level. This article reviews current epidemiologic and pathophysiologic evidence of the relationship between rhinitis and asthma and discusses the effect of treatment of one site on the other site.

Clinical implications of the allergic rhinitis-asthma link

A possible link between allergic rhinitis (AR) and allergic asthma has long been a subject of debate. Surveys report that up to 78% of asthma patients have AR and 38% of patients with AR have asthma. Evidence points to a causal or coincidental relation between these upper and lower airway diseases. Various agents used to manage one entity have shown benefit in treating the other. The 2001 Allergic Rhinitis and Its Impact on Asthma guidelines call for patients with either condition to be assessed for the other. Medical therapy for AR or asthma should be chosen with awareness of the probable coexistence of these diseases. We present the case for and against the united airway theory proposed to explain the association between these diseases. The roles of various therapies for dually afflicted patients are evaluated, including topical corticosteroids, antihistamines, leukotriene modifiers, anti-immunoglobulin E monoclonal antibody, theophylline, and immunotherapy.

The impact of rhinosinusitis on asthma

The nasal cavity, paranasal sinuses, and lungs are considered separate organs of the respiratory tract. However, a growing body of evidence links the upper and lower airways. For example, the coexistence and impact of allergic and nonallergic rhinitis on asthma is now documented. In addition, inflammation of the nose (rhinitis) commonly is associated with inflammation of sinuses (sinusitis), as reflected in the term rhinosinusitis. In this paper, we review the impact of rhinosinusitis on asthma as it relates to the links between allergic and nonallergic rhinitis and asthma; viral upper respiratory tract infections and asthma; allergic and nonallergic infectious/inflammatory rhinosinusitis and allergic and nonallergic hyperplastic rhinosinusitis and asthma; and the aspirin-exacerbated respiratory disease syndrome and asthma.

Interleukin-1beta and interleukin-1ra levels in nasal lavages during experimental rhinovirus infection in asthmatic and non-asthmatic subjects

BACKGROUND

Exacerbations of asthma are often associated with rhinovirus (RV)-induced common colds. During experimental RV-infection in healthy subjects, increased levels of the pro-inflammatory mediator IL-1beta and the anti-inflammatory IL-1 receptor antagonist (IL-1ra) have been found in nasal lavage.

OBJECTIVE

We postulated that the balance between nasal pro- and anti-inflammatory mediator expression is disturbed in asthma, resulting in more extensive inflammation following RV-exposure in asthma.

METHODS

We determined IL-1ra, IL-1beta, and IL-8 in nasal lavages (days -2, 3, and 6) of non-asthmatics and asthmatics (with and without pre-treatment with the inhaled steroid budesonide) before and after experimental RV16-infection (days 0 and 1).

RESULTS

Following RV16-infection, a significant increase in IL-8 was observed in the placebo- and budesonide-treated asthmatics (P=0.033 and 0.037, respectively), whereas IL-1beta only increased in the two asthma groups combined (P=0.035). A small, but significant, increase in IL-1ra was only observed in the budesonide-treated asthmatics (P=0.047). At baseline, IL-1ra levels were significantly higher in the non-asthmatics than in the placebo-treated asthmatics (P=0.017).

CONCLUSION

These results demonstrate differences between non-asthmatic and asthmatic subjects in the basal levels of nasal cytokines and their inhibitors, and in the effect of experimental RV-infection on these levels. The results indicate that RV may enhance inflammation more markedly in asthmatics, and suggest that this may in part be explained by lower IL-1ra levels. In addition, the observation that budesonide-treatment may result in higher nasal IL-1ra levels supports the hypothesis that steroids act in part by increasing the endogenous anti-inflammatory screen.

Links between rhinitis and asthma

There is compelling evidence of a close relationship between the upper and lower airways in asthma and rhinitis. Rhinitis is present in the majority of patients with asthma, and a significant minority of patients with rhinitis have concomitant asthma. Similarities between the two conditions occur in the nature of the inflammation present in the target tissues. A common initiating step in the inflammatory process of allergic airways disease is the presence of immunoglobulin E providing an adaptor molecule between the offending allergen and inflammatory cell activation and mediator release. Differences in the two conditions arise largely from the structural differences between the nose and the lungs. In an asthmatic, concomitant allergic rhinitis increases healthcare costs and further impairs quality of life. The presence of rhinitis should always be investigated in children and young adults with asthma. Subjects with allergic rhinitis have an increased risk of developing asthma and may form a suitable population for secondary intervention to interrupt the 'allergic march'.

Episodic viral wheeze in preschool children: effect of topical nasal corticosteroid prophylaxis

BACKGROUND

The effect of prophylactic nasal corticosteroids on wheezing episodes associated with colds was investigated in a 12 week parallel group, double blind, randomised controlled trial in preschool children.

METHODS

Data were collected from 50 children aged 12-54 months with a history of at least three episodes of wheeze associated with colds over the previous winter, but few or no interval symptoms; 24 were given one dose of fluticasone aqueous nasal spray (50 micro g) into each nostril twice daily and 26 received an indistinguishable placebo spray. Episodes of lower respiratory illness occurring within 2 days of the onset of a cold were identified from daily symptom diaries. The main outcome was nocturnal symptom score during the first 7 days of an episode.

RESULTS

The groups were well balanced on entry except that the treatment group had a history of more prolonged episodes. During the trial there was no significant difference in the number of episodes in the treatment and control groups (27 and 37, respectively), in the severity of nocturnal symptoms (mean score 1.33 and 1.22, respectively, confidence interval of difference -0.24 to +0.47) or in daytime symptoms, activity or total scores during episodes. Compliance was estimated to be over 50% in 43 of the children.

CONCLUSIONS

Nasal corticosteroid treatment does not prevent acute wheezy episodes associated with upper respiratory infections (common colds) in preschool children.

Allergic rhinitis and asthma: the link further unraveled

Allergic asthma and rhinitis are manifestations of the atopic syndrome. Although the diseases commonly occur together, it is still unclear why some allergic patients develop only asthma and others only rhinitis. The reason for the variety in clinical expression of allergic airway disease is not known. Besides a genetic predisposition, environmental factors contribute to the development of the allergic phenotype. Local and systemic inflammatory processes also seem to be involved, however, their exact contribution to the clinical picture of airway allergy still remains to be elucidated. Although it is clear that the condition of the upper airways has an impact on lower airway physiology, the mechanisms underlying this relation are far from being resolved. To date, most data point towards a systemic link between upper and lower airways, involving bloodstream and bone marrow. In this article, the latest developments with regard to nasobronchial interaction in allergic airway disease will be reviewed. Epidemiologic, experimental and clinical data underline the importance of a global approach in allergic rhinitis and asthma.

Relationship between nasal and bronchial responsiveness in perennial allergic rhinitic patients with asthma

BACKGROUND

The nasal and bronchial mucosa present similarities and most patients with asthma also have rhinitis, suggesting the concept of 'one airway one disease'. Although many studies may suggest the relationship between nasal and bronchial responsiveness in patients with allergic rhinitis and asthma, few studies have been published which address this question directly. The aim of this study is to investigate whether the relationship between nonspecific nasal and bronchial responsiveness exists in perennial allergic rhinitic patients with asthma.

METHODS

Fifty-one perennial allergic rhinitic patients with the definitive or suspected asthma underwent methacholine bronchial provocation tests and nasal histamine challenge tests. A slope of the absolute changes in nasal symptoms score/log concentrations of histamine was calculated by linear regression analysis. A ratio of the final absolute change in nasal symptoms score to the sum of all the doses of histamine given to the subject was also calculated. The degree of bronchial responsiveness to methacholine was categorized as positive bronchial hyperresponsiveness (BHR) if PC(20) (provocative concentration of methacholine resulting in 20% fall in FEV(1)) was <4 mg/ml, borderline BHR if PC(20) was >or=4 but <or=16 mg/ml, and negative BHR if PC(20) was >16 mg/ml. Another index of bronchial responsiveness (BRindex) was calculated as the log [(% decline in FEV(1)/log final methacholine concentration as mg/dl) + 10].

RESULTS

The geometric means of the slope (4.47 vs. 2.95, p < 0.05) and the ratio (1.68 vs. 0.54, p < 0.01) were higher in patients with positive BHR (n = 23) than in patients with negative BHR (n = 19), respectively. The geometric means of the slope (3.50) and the ratio (1.13) in patients with borderline BHR (n = 9) were between the two groups, respectively. In all patients, the log-slope (r = 0.48, p < 0.001) and the log-ratio (r = 0.51, p < 0.001) were correlated well with the BRindex, respectively. Even in allergic rhinitic patients with definitive asthma, the log-slope was correlated with the BRindex (r = 0.39, p < 0.05) or log-PC(20) (r = -0.36, p < 0.05).

CONCLUSIONS

The nonspecific nasal responsiveness may be related to the nonspecific bronchial responsiveness in patients with allergic rhinitis and asthma, which may support the viewpoint that allergic rhinitis and asthma represent a continuum of inflammation involving one common airway.

Rhinitis, sinusitis and asthma: one linked airway disease

Understanding the relationship between upper and lower airways has greatly increased through epidemiological and pharmacological studies. Scientific evidence supports the concept that rhinosinusitis and asthma may be the expression of an inflammatory process which appears in different sites of the respiratory tract at different times. The implications are not only academic but are important for diagnostic and therapeutic purposes.

The nasal passage of subjects with asthma has a decreased ability to warm and humidify inspired air

We previously showed that individuals with seasonal allergic rhinitis (SAR) had a reduced ability to condition air, which was improved by inflammation. We hypothesized that individuals with perennial allergic rhinitis (PAR) would condition air like SAR with inflammation. Because individuals with asthma usually have inflammation in the nose, we hypothesized that they would condition air like individuals with PAR. We performed a prospective, parallel study on 15 normal subjects, 15 subjects with SAR outside their allergy season, 15 subjects with PAR, and 15 subjects with asthma. Cold, dry air (CDA) was delivered to the nose and the temperature and humidity of the air were measured before entering and after exiting the nasal cavity. The total water gradient (TWG) was calculated and represents the nasal conditioning capacity. The TWG in the SAR group was significantly lower than that in normal subjects. There were no significant differences in TWG between the PAR and normal groups. Subjects with asthma had a significantly lower TWG than did normal subjects. There was a significant negative correlation between TWG and Aas score in the group with asthma (r(s) = -0.8, p = 0.0007). Our data show that subjects with asthma have a reduced ability of the nose to condition CDA compared with normal subjects, but which is similar to SAR out of season.

Prevalence of nasal symptoms and their relation to self-reported asthma and chronic bronchitis/emphysema

Little information is available on associations between rhinitis and chronic bronchitis/emphysema (CBE). Self-reported upper airway symptoms, asthma, and CBE were examined in 12,079 adults living in southern Sweden. The response rate was 70% (n=8,469), of whom 33% reported significant nasal symptoms: a blocked nose was reported by 21%; sneezing by 18%; nasal discharge by 17%; and thick yellow nasal discharge by 5.7%. Nasal symptoms and combined nasal and self-reported bronchial disease were generally more common among smokers than nonsmokers. There was little overlap between asthma and CBE, but 46% of those with asthma and 40% of those with CBE had significant nasal symptoms. Best predicting factors (odds ratios >3) for asthma and CBE were nasal symptoms due to exposure to animals and damp/cold air, respectively. One-third of an adult, southern Swedish population, had significant allergic and/or nonallergic nasal symptoms. Nasal symptoms were frequently found to coexist with both asthma and chronic bronchitis/emphysema, suggesting that pan-airway engagement is common in both diseases. Differing associations between types of nasal symptoms and allergic and irritant triggers of nasal symptoms, with regard to asthma and chronic bronchitis/emphysema, emphasize the different natures of these bronchial diseases.

Allergic rhinobronchitis: the asthma-allergic rhinitis link

Allergic rhinitis and asthma are linked by epidemiologic, histologic, physiologic, and immunopathologic characteristics and by a common therapeutic approach. Epidemiologically, the disorders often coexist. Histologically, the upper and lower airways are lined, and linked, by the respiratory epithelium. Physiologically, they may be linked by the nasobronchial reflex. Pathologically, they are linked by similar early- and late-phase allergic responses throughout the airways and by the systemic immunologic response to airborne allergens. Uncontrolled allergic rhinitis may be associated with worsening of coexisting asthma, and optimal treatment of allergic rhinitis may improve coexisting asthma. The key to managing both disorders is prevention and relief of chronic allergic inflammation in both the upper and lower airways. The similarities between allergic rhinitis and asthma outweigh the differences. To facilitate appropriate recognition and treatment of the common inflammatory process throughout the airways, consideration should be given to introducing the new term "allergic rhinobronchitis."