Allergic Rhinitis and Its Impact on Asthma

Abstract

1.Allergic rhinitis is a major chronic respiratory disease due to its: •prevalence,•impact on quality of life,•impact on work/school performance and productivity,•economic burden,•links with asthma.•In addition, allergic rhinitis is associated with sinusitis and other co-morbidities such as conjunctivitis.•Allergic rhinitis should be considered as a risk factor for asthma along with other known risk factors.•A new subdivision of allergic rhinitis has been proposed: •intermittent•persistent•The severity of allergic rhinitis has been classified as “mild' and “moderate/severe” depending on the severity of symptoms and quality of life outcomes.•Depending on the subdivision and severity of allergic rhinitis, a stepwise therapeutic approach has been proposed.•The treatment of allergic rhinitis combines: •allergen avoidance (when possible),•pharmacotherapy,•immunotherapy.•The environmental and social factors should be optimised to allow the patient to lead a normal life.•Patients with persistent allergic rhinitis should be evaluated for asthma by history, chest examination and, if possible and when necessary, the assessment of airflow obstruction before and after bronchodilator.•Patients with asthma should be appropriately evaluated (history and physical examination) for rhinitis.•A combined strategy should ideally be used to treat the upper and lower airway diseases in terms of efficacy and safety. Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose. Symptoms of rhinitis include rhinorrhea, nasal obstruction, nasal itching and sneezing which are reversible spontaneously or under treatment. It is subdivided into “intermittent” or “persistent” disease (Table 1). The severity of allergic rhinitis can be classified as “mild” or “moderate-severe.”Table 1Classification of allergic rhinitis1- “Intermittent” means that the symptoms are present: • Less than 4 days a week, • Or for less than 4 weeks.2- “Persistent” means that the symptoms are present: • More than 4 days a week, • And for more than 4 weeks.3- “Mild” means that none of the following items are present: • Sleep disturbance, • Impairment of daily activities, leisure and/or sport, • Impairment of school or work, • Troublesome symptoms.4- “Moderate-severe” means that one or more of the following items are present: • Sleep disturbance, • Impairment of daily activities, leisure and/or sport, • Impairment of school or work, • Troublesome symptoms. Open table in a new tab Previously, allergic rhinitis was subdivided, based on the time of exposure, into seasonal, perennial and occupational diseases (1Allergy. 1994; 49 (International Rhinitis Management Working Group): 1-34Google Scholar, 2Dykewicz MS Fineman S Executive Summary of Joint Task Force Practice Parameters on Diagnosis and Management of Rhinitis.Ann Allergy Asthma Immunol. 1998; 81: 463-468Abstract Full Text PDF PubMed Google Scholar, 3Van-Cauwenberge P Bachert C Passalacqua G Bousquet J Canonica G Durham S et al.Consensus statement on the treatment of allergic rhinitis.EAACI Position paper. Allergy. 2000; 55: 116-134Google Scholar). Perennial allergic rhinitis is most frequently caused by indoor allergens such as dust mites, moulds, insects (cockroaches) and animal danders. Seasonal allergic rhinitis is related to a wide variety of outdoor allergens such as pollens or moulds. However, this is not entirely satisfactory as: •There are some places where pollens and moulds are perennial allergens (e.g. grass pollen allergy in Southern California and Florida (4Bucholtz GA Lockey RF Wunderlin RP Binford LR Stablein JJ Serbousek D et al.A three-year aerobiologic pollen survey of the Tampa Bay area, Florida.Ann Allergy. 1991; 67: 534-540PubMed Google Scholar) or Parietaria pollen allergy in the Mediterranean area (5D'Amato G Ruffilli A Sacerdoti G Bonini S Parietaria pollinosis: a review.Allergy. 1992; 47: 443-449Crossref PubMed Google Scholar)).•Symptoms of perennial allergy may not always be present all year round.•The majority of patients are sensitised to many different allergens and therefore present symptoms throughout the year (6Sibbald B Rink E Epidemiology of seasonal and perennial rhinitis: clinical presentation and medical history.Thorax. 1991; 46: 895-901Crossref PubMed Google Scholar). In many patients, perennial symptoms are often present and patients present seasonal exacerbations when exposed to pollens or moulds.•Many patients allergic to pollen are also allergic to moulds and it is difficult to define the pollen season (7Bruce CA Norman PS Rosenthal RR Lichtenstein LM The role of ragweed pollen in autumnal asthma.J Allergy Clin Immunol. 1977; 59: 449-459Abstract Full Text PDF PubMed Google Scholar).•Due to the priming effect on the nasal mucosa induced by low levels of pollen allergens (8Connell J Quantitative intranasal pollen challenges.II. Effect of daily pollen challenge, environmental pollen exposure and placebo challenge on the nasal membrane. J Allergy. 1968; 41: 123-129Google Scholar) and minimal persistent inflammation of the nose in patients with symptom free rhinitis (9Ciprandi G Buscaglia S Pesce G Pronzato C Ricca V Parmiani S et al.Minimal persistent inflammation is present at mucosal level in patients with asymptomatic rhinitis and mite allergy.J Allergy Clin Immunol. 1995; 96: 971-979Abstract Full Text Full Text PDF PubMed Google Scholar), symptoms do not necessarily occur strictly in conjunction with the allergen season. Thus, a major change in the subdivision of allergic rhinitis has been proposed in this document with the terms “intermittent” and “persistent”. However, in the present document, the terms “seasonal” and “perennial” are still retained to enable the interpretation of published studies. Allergic rhinitis is characterised by nasal obstruction, rhinorrhea, sneezing, itching of the nose and/or post-nasal drainage. It is often associated with ocular symptoms. Several other conditions can cause similar symptoms: infections, hormonal imbalance, physical agents, anatomical anomalies and the use of some drugs. Therefore, a detailed and correct aetiological diagnosis forms the basis for selecting optimal treatment. Allergic rhinitis represents a global health problem. It is an extremely common disease worldwide affecting 10 to 25 % of the population (1Allergy. 1994; 49 (International Rhinitis Management Working Group): 1-34Google Scholar, 10Sibbald B Epidemiologyof allergic rhinitis.ML B, editor. Epidemiology of clinical allergy. Monographs in Allergy. Basel: karger. 1993; : 61-69Google Scholar, 11Wuthrich B Schindler C Leuenberger P Ackermann-Liebrich U Prevalence of atopy and pollinosis in the adult population of Switzerland (SAPALDIA study). Swiss Study on Air Pollution and Lung Diseases in Adults.Int Arch Allergy Immunol. 1995; 106: 149-156Crossref PubMed Google Scholar, 12Strachan D Sibbald B Weiland S Ait-Khaled N Anabwani G Anderson HR et al.Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: the International Study of Asthma and Allergies in Childhood (ISAAC).Pediatr Allergy Immunol. 1997; 8: 161-176Crossref PubMed Google Scholar). However, this figure probably underestimates the prevalence of the disease, as many patients do not recognise rhinitis as a disease and therefore do not consult a physician (10Sibbald B Epidemiologyof allergic rhinitis.ML B, editor. Epidemiology of clinical allergy. Monographs in Allergy. Basel: karger. 1993; : 61-69Google Scholar). An increasing prevalence of allergic rhinitis over the last decades has been recognised (13Aberg N Sundell J Eriksson B Hesselmar B Aberg B Prevalence of allergic diseases in schoolchildren in relation to family history, upper respiratory infections, and residential characteristics.Allergy. 1996; 51: 232-237PubMed Google Scholar, 14Ciprandi G Vizzaccaro A Cirillo I Crimi P Canonica GW Increase of asthma and allergic rhinitis prevalence in young Italian men.Int Arch Allergy Immunol. 1996; 111: 278-283Crossref PubMed Google Scholar). Allergic rhinitis has been identified as one of the top ten reasons for visits to primary care clinics (15Gregory C Cifaldi M Tanner LA Targeted intervention programs: creating a customized practice model to improve the treatment of allergic rhinitis in a managed care population.Am J Manag Care. 1999; 5: 485-496PubMed Google Scholar). Although allergic rhinitis is not usually a severe disease, it significantly alters the social life of patients (16Bousquet J Bullinger M Fayol C Marquis P Valentin B Burtin B Assessment of quality of life in patients with perennial allergic rhinitis with the French version of the SF-36 Health Status Questionnaire.J Allergy Clin Immunol. 1994; 94: 182-188Abstract Full Text PDF PubMed Google Scholar, 17Spaeth J Klimek L Mosges R Sedation in allergic rhinitis is caused by the condition and not by antihistamine treatment.Allergy. 1996; 51: 893-906PubMed Google Scholar) and affects school learning performance (18Vuurman EF van-Veggel LM Uiterwijk MM Leutner D O'Hanlon JF Seasonal allergic rhinitis and antihistamine effects on children's learning.Ann Allergy. 1993; 71: 121-126PubMed Google Scholar, 19Simons FE Learning impairment and allergic rhinitis.Allergy Asthma Proc. 1996; 17: 185-189Crossref PubMed Google Scholar) as well as work productivity (20Cockburn IM Bailit HL Berndt ER Finkelstein SN Loss of work productivity due to illness and medical treatment.J Occup Environ Med. 1999; 41: 948-953Crossref PubMed Scopus (86) Google Scholar). 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Although not universally accepted (28Immunobiology of Asthma and Rhinitis Pathogenic factors and therapeutic options.Am J Respir Crit Care Med. 1999; 160: 1778-1787Crossref PubMed Google Scholar), the term “allergic rhinobronchitis” has been proposed to link the association between allergic asthma and rhinitis (29Simons FE Allergic rhinobronchitis: the asthma-allergic rhinitis link.J Allergy Clin Immunol. 1999; 104: 534-540Abstract Full Text Full Text PDF PubMed Google Scholar). Non-allergic asthma and rhinitis are also associated (30Leynaert B Bousquet J Neukirch C Liard R Neukirch F Perennial rhinitis: An independent risk factor for asthma in nonatopic subjects: Results from the European Community Respiratory Health Survey.J Allergy Clin Immunol. 1999; 301: 4Google Scholar) but the mechanisms underlying the two diseases are not fully understood except, possibly, for aspirin-induced asthma (31Szczeklik A Sanak M Leukotrienes and aspirin-sensitive asthma.in: Novel inhibitors of leukotrienes. Birkhauser Vlg, Basel1999: 165-176Google Scholar). Moreover, costs for asthma are significantly increased in patients with allergic rhinitis (32Yawn BP Yunginger JW Wollan PC Reed CE Silverstein MD Harris AG Allergic rhinitis in Rochester, Minnesota residents with asthma: frequency and impact on health care charges.J Allergy Clin Immunol. 1999; 103: 54-59Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar). Patients with persistent allergic rhinitis should therefore be evaluated for asthma, and patients with asthma should be evaluated for rhinitis. A strategy combining the treatment of both upper and lower airway disease in terms of efficacy and safety appears to be optimal. Clinical guidelines are systematically developed statements designed to help practitioners and patients make decisions about appropriate and effective health care (33Jackson R Feder G Guidelines for clinical guidelines.BMJ. 1998; 317: 427-428Crossref PubMed Google Scholar). Guidelines have existed in various countries for decades and hundreds of them have been published for many diseases (34Woolf SH Grol R Hutchinson A Eccles M Grimshaw J Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.BMJ. 1999; 318: 527-530Crossref PubMed Google Scholar) including asthma (35Allergy. 1992; 47: 1-61Google Scholar, 36Global strategy for asthma management and prevention. January 1995Google Scholar) and allergic rhinitis (1Allergy. 1994; 49 (International Rhinitis Management Working Group): 1-34Google Scholar, 2Dykewicz MS Fineman S Executive Summary of Joint Task Force Practice Parameters on Diagnosis and Management of Rhinitis.Ann Allergy Asthma Immunol. 1998; 81: 463-468Abstract Full Text PDF PubMed Google Scholar, 3Van-Cauwenberge P Bachert C Passalacqua G Bousquet J Canonica G Durham S et al.Consensus statement on the treatment of allergic rhinitis.EAACI Position paper. 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There is considerable interest in guidelines as a tool for implementing health care based on proof of effectiveness. Guidelines should be informative, simple, easy to use and in a form that can be widely disseminated within the medical community in order to improve patient care. Unfortunately, many guidelines are not tested and may be difficult to use by nonspecialists. Evidence-based medicine is an important method of preparing guidelines (41Sackett DL Rosenberg WM Gray JA Haynes RB Richardson WS Evidence based medicine: what it is and what it isn't.BMJ. 1996; 312: 71-72Crossref PubMed Google Scholar). Moreover, the implementation of guidelines is equally important. New knowledge on the pathophysiological mechanisms underlying allergic inflammation of the airways has resulted in better therapeutic strategies. New routes of administration, dosages and schedules have been studied and validated. In addition, asthma co-morbidity should be well understood in order to achieve optimal treatment for patients. The present document is intended to be a state-of-the-art for the specialist as well as for the general practitioner: •to update their knowledge of allergic rhinitis,•to highlight the impact of allergic rhinitis on asthma,•to provide an evidence-based documented revision on the diagnosis methods,•to provide an evidence-based revision on the treatments available,•to propose a stepwise approach to the management of the disease. The ARIA Paper is not intended to be a standard of care document for individual countries. It is provided as a basis for physicians and organisations involved in the treatment of allergic rhinitis and asthma in various countries to develop relevant local standard of care documents for their patients. Rhinitis (rhinosinusitis) is classified as follows (Table 2). Table 2Classification of rhinitis• Infectious Viral Bacterial Other infectious agents• Allergic Intermittent Persistent• Occupational (allergic and non-allergic) Intermittent Persistent• Drug-induced Aspirin Other medications• Hormonal• Other causes NARES Irritants Food Emotional Atrophic Gastroesophageal reflux• Idiopathic Open table in a new tab The differential diagnosis of rhinitis is presented in Table 3. Table 3Differential diagnosis of rhinitis• Polyps• Mechanical Factors Deviated septum Adenoidal hypertrophy Foreign bodies Choanal atresia• Tumours Benign Malignant• Granulomas Wegener's Granulomatosis Sarcoid Infectious Malignant - midline destructive granuloma• Ciliary defects• Cerebrospinal Rhinorrhea Open table in a new tab Acute viral rhinosinusitis is one of the most common health complaints, affecting millions of people annually (42Gwaltney Jr, J Acute community-acquired sinusitis.Clin Infect Dis. 1996; 23 (quiz 24-5.): 1209-1223Crossref PubMed Google Scholar). 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In conditions such as cystic fibrosis, Staphylococcus aureus and Pseudomonas aeruginosa are regarded as important pathogens. In addition, many other bacteria may be encountered whose role is as yet undetermined (52Van Cauwenberge PB Ingels KJ Bachert C Wang DY Microbiology of chronic sinusitis.Acta Otorhinolaryngol Belg. 1997; 51: 239-246PubMed Google Scholar). Fungi such as Aspergillus or the Dermataceous fungi, Alternaria, Bipolaris or Curvularia , appear to be assuming greater importance (53Lawson W Blitzer A Fungal infections of the nose and paranasal sinuses. 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Other organisms such as Mycobacterium tuberculosis, Klebsiella rhinoscleromatis, Mycobacterium leprae and Treponema pallidum can also occur and both protozoan infection (leishmaniasis) and parasitic infection have been described. Ciliary abnormalities, both congenital and acquired, immunodeficiency and direct trauma may all predispose individuals to the development of both acute and chronic infection (58Afzelius BA A human syndrome caused by immotile cilia.Science. 1976; 193: 317-319Crossref PubMed Google Scholar, 59Pedersen H Mygind N Absence of axonemal arms in nasal mucosa cilia in Kartagener's syndrome.Nature. 1976; 262: 494-495Crossref PubMed Google Scholar, 60Lund VJ Scadding GK Immunologic aspects of chronic sinusitis.J Otolaryngol. 1991; 20: 379-381PubMed Google Scholar). Allergic rhinitis is subdivided into “intermittent”, “persistent”, “mild” and “moderate-severe” (Table 1). Occupational rhinitis arises in response to an airborne agent present in the workplace and may be due to an allergic reaction or non-allergic hyperresponsiveness. Many occupational agents are irritant. Causes of occupational rhinitis include laboratory animals (rats, mice, guinea pigs, etc.), grains (bakers and agricultural workers), wood dust, particularly hard woods (mahogany, Western Red Cedar, etc.), latex and chemicals such as acid anhydrides, platinum salts, glues and solvents (61Schiffman SS Nagle HT Effect of environmental pollutants on taste and smell.Otolaryngol Head Neck Surg. 1992; 106: 693-700Crossref PubMed Google Scholar). A range of medications is known to cause nasal symptoms. These include: •aspirin and other non-steroidal anti-inflammatory agents (NSAID). 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Symptoms disappear at delivery. In women with perennial rhinitis, symptoms may improve or deteriorate during pregnancy (74Schatz M Special considerations for the pregnant woman and senior citizen with airway disease.J Allergy Clin Immunol. 1998; 101: S373-S378Abstract Full Text Full Text PDF PubMed Google Scholar). Physical and chemical factors can induce nasal symptoms which may mimic rhinitis in subjects with sensitive mucous membranes, and even in normal subjects if the concentration of chemical triggers is high enough (75Leroyer C Malo JL Girard D Dufour JG Gautrin D Chronic rhinitis in workers at risk of reactive airways dysfunction syndrome due to exposure to chlorine.Occup Environ Med. 1999; 56: 334-338Crossref PubMed Google Scholar, 76Shusterman DJ Murphy MA Balmes JR Subjects with seasonal allergic rhinitis and nonrhinitic subjects react differentially to nasal provocation with chlorine gas.J Allergy Clin Immunol. 1998; 101: 732-740Abstract Full Text Full Text PDF PubMed Google Scholar). 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Food allergy is a very rare cause of isolated rhinitis (80Bousquet J Metcalfe D Warner J Food allergy. Report of the Codex Alimentarius.ACI International. 1997; 9: 10-21Google Scholar). However, nasal symptoms are common among the many symptoms of food-induced anaphylaxis (80Bousquet J Metcalfe D Warner J Food allergy. Report of the Codex Alimentarius.ACI International. 1997; 9: 10-21Google Scholar). On the other hand, foods and alcoholic beverages in particular may induce symptoms by unknown non-allergic mechanisms. Some spicy food such as red pepper can induce rhinorrhea, probably because it contains capsaicin. This is able to stimulate sensory nerve fibres inducing them to release tachykinins and other neuropeptides (81Lacroix JS Buvelot JM Polla BS Lundberg JM Improvement of symptoms of non-allergic chronic rhinitis by local