Become a Patient

Executive Summary of "Allergic Rhinitis - 2008 Update"

Learning Objectives
1. Describe the patient's perspective of the burden of rhinitis and the current unmet needs of rhinitis treatment.
2. List 3 ways in which current rhinitis treatment is less than fully effective.
3. Summarize the connection between upper airway and lower airway disease in patients with rhinitis and asthma and describe the impact of treating rhinitis on asthma.

 

Allergic rhinitis is the fifth most common chronic illness in the United States, affecting more than 40 million Americans. It affects both physical and mental health status. The loss of productivity is immense, with more than 3.6 million lost work and school days annually and a total cost of $8 billion per year.

Patients with allergic rhinitis find the condition very disruptive of their daily life. A nationwide survey in 2006 (“Allergies in America”) identified 8,735 adults with current nasal allergies among 61,655 adults in the households screened (14%). Of these, slightly more than half had allergy symptoms year-round. During allergy season, 44% complained of frequent tiredness; an additional 36% complained of being tired “sometimes.” More than 50% complained of sometimes/frequently feeling irritable and/or miserable, and 80% found having a “stuffed up nose” to be extremely or moderately bothersome. Forty percent
complained of moderate to “a lot” of impact of allergies on their daily life, and an additional 26% replied “some” impact. 

What should also be of concern to physicians is that no more than half of these patients were satisfied with any of the types of medication they had taken recently, whether they were taking OTC medications or prescription nasal sprays. Studies on nasal therapy support the patient’s perspective that much of the treatment is less than fully effective. The results from many studies demonstrate the need for more complete relief of allergic rhinitis symptoms.

  • A meta-analysis of 11 studies of leukotriene receptor antagonists (LTRA) for allergic rhinitis found that LTRAs reduced mean daily rhinitis symptoms scores only 5% (95% confidence interval, 3-7%) more than placebo, and, in comparative studies, antihistamines improved symptoms an additional 2% and nasal steroids an additional 12% more. [1]
  • Combining an LTRA with an antihistamine was somewhat more helpful than using either drug alone in a study of 460 adults with spring seasonal allergic rhinitis. The combination also significantly improved eye symptoms, nighttime symptoms, individual daytime nasal symptoms, global evaluations, and quality of life compared with placebo in one study.[2] However, these results were not duplicated in subsequent studies.
  • Based on an expert panel recommendation, when nasal congestion is a major component of rhinitis, a nasal corticosteroid is (NCS) is the first line of therapy.[3]
  • Intranasal corticosteroids produce significantly greater relief than oral antihistamines for nasal blockage, nasal discharge, sneezing, post nasal drip and total nasal symptoms scores, but there is no significant difference for eye symptoms.[4]
  • Regular use of nasal corticosteroids (NCS) is superior to as needed.[5] In a study comparing regular and "as required" (PRN) use of aqueous beclomethasone dipropionate nasal in the treatment of ragweed pollen-induced rhinitis, 27% of patients in the PRN group reported unsatisfactory control of symptoms.
  • Starting before season is better than starting once symptomatic.[6] Sixty ragweed-sensitive adults were randomly assigned to aqueous beclomethasone dipropionate nasal spray taken from 1 week before until 1 week after the ragweed-pollen season (“regular” group) or as required (“as required” group). Sneezing, stuffy nose, and rhinorrhea were significantly better controlled in the regular-treated group (P< 0.025). Impairment of quality of life, including sleep disturbance, was greater in the “as required” treatment group (P< 0.001).
  • PRN use of NCS is superior to PRN use of antihistamines.[7] A randomized, open-label, parallel-group study compared the as-needed use of an H-1 receptor antagonist (loratadine) with that of an intranasal corticosteroid (fluticasone propionate) in the management of fall seasonal allergic rhinitis. Each medication was used on about half of the days. Patients treated with fluticasone had significantly better scores in the Rhinoconjunctivitis Quality of Life Questionnaire, a lower mean total symptom score, and fewer eosinophils compared with the loratadine-treated group.
  • Addition of an antihistamine to a NCS adds little or nothing to relief of asthma symptoms.[8] In a double-blind placebo-controlled crossover study of 27 patients, subjects used fluticasone with levocetirizine or identical placebo for 2 weeks each (following 2 weeks without treatment). No clinically significant benefits in total nasal symptom score, domiciliary peak nasal inspiratory flow, nasal nitric oxide concentrations, or quality of life measure were noted with the addition of levocetirizine.

Physicians should also be aware of the link between upper and lower airway disease, and the need to consider both for optimal results. Rhinitis and asthma commonly coexist. Patients who clinically have only rhinitis frequently demonstrate bronchial hyperresponsiveness and sometimes asymptomatic impairment of pulmonary function. Patients with rhinitis are also at increased risk to develop asthma. The upper airway can influence the lower airway through a number of mechanisms, including mouth breathing, drainage of inflammatory cells and mediators into the lungs, nasal-bronchial reflex, and systemic release of mediators and cytokines. However, treatment of the upper airway in patients with allergic rhinitis and asthma produces little or no clinical improvement the lower airway. In contrast, there does appear to be a strong relationship between nasopharyngeal receptors and laryngeal function, which leads to vocal cord dysfunction. Treatment of the upper airway in these patients has clear clinical benefit on the lower airway symptoms.

 

References
1. Wilson AM, O'Byrne PM, Parameswaran K. Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis. Am J Med. 2004;116(5):338-344.

2. Meltzer EO, Malmstrom K, Lu S, et al. Concomitant montelukast and loratadine as treatment for seasonal allergic rhinitis: a randomized, placebo-controlled clinical trial. J Allergy Clin Immunol. 2000;105(5):917-922.

3. Task Force on Allergic Disorders — American Academy of Allergy, Asthma and Immunology. The Allergy Report. Available at http://www.theallergyreport.com/main.html. Downloaded 4-10-2008.

4. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ. 1998;317(7173):1624-1629.

5. Juniper EF, Guyatt GH, Archer B, Ferrie PJ. Aqueous beclomethasone dipropionate in the treatment of ragweed pollen-induced rhinitis: further exploration of "as needed" use. J Allergy Clin Immunol. 1993;92(1 Pt 1):66-72.

6. Juniper EF, Guyatt GH, O'Byrne PM, Viveiros M. Aqueous beclomethasone dipropionate nasal spray: regular versus "as required" use in the treatment of seasonal allergic rhinitis. J Allergy Clin Immunol. 1990;86(3 Pt 1):380-386.

7. Kaszuba SM, Baroody FM, deTineo M, Haney L, Blair C, Naclerio RM. Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis. Arch Intern Med. 2001;161(21):2581-2587.

8. Barnes ML, Ward JH, Fardon TC, Lipworth BJ. Effects of levocetirizine as add-on therapy to fluticasone in seasonal allergic rhinitis. Clin Exp Allergy. 2006;36(5):676-684.


This information has been approved by Harold Nelson, MD (April 2008).

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