Vol. 11 •Issue 9 • Page 12
Allergy & Asthma
Allergic Rhinitis and Asthma: One Airway, One Disease?
Allergists, pulmonologists and asthma specialists are emphasizing the nose and its relationship to the lungs — a link many clinicians may have long been aware of in theory, but few have put into practice.
“Surprisingly, until fairly recently, many physicians considered these two organs as entirely separate and treated disorders of each as unrelated conditions,” said James P. Kemp, MD, clinical professor of pediatrics at the University of California School of Medicine, San Diego, division of immunology and allergy.
“It’s clear that these parts of the respiratory system — the nose and the lungs — are connected in many ways. Structurally, to a large degree, the only major difference in these two organs within the same system is that the nose doesn’t have smooth muscle and the lung does.”
The two are so connected that they often share common disorders. In fact, at least 60 percent of people with asthma also suffer from rhinitis, according to a report by the Allergic Rhinitis and its Impact on Asthma initiative. Yet many patients are treated for one condition alone.
Information collected through various databases showed that between 85 percent and 95 percent of patients with asthma also had at least two symptoms of rhinitis, either seasonal or year-round, according to Alkis G. Togias, MD, associate professor and senior laboratory investigator at Johns Hopkins University School of Medicine, Baltimore.
In another study, investigators performed biopsies of the nasal airways of asthmatic patients who didn’t complain of rhinitis symptoms — about 10 percent to 15 percent. “Those who complain of symptoms of rhinitis compared to those who do not, have absolutely no difference in terms of the inflammatory status of the upper airways, even if these individuals are asymptomatic,” Dr. Togias reported in his lecture on the link between rhinitis and asthma during the 2001 American College of Allergy, Asthma and Immunology annual meeting in Orlando. This illustrates that even patients who don’t complain of rhinitis may, in fact, have inflamed airways.
He cited a study where clinicians performed nasal provocation with allergens on allergic rhinitis patients after obtaining a nasal and bronchial biopsy. Twenty-four hours after the nasal challenge, they repeated the biopsies.
“What is the most impressive finding is not only nasal eosinophilia was increased 24 hours after the challenge, but most importantly that bronchial eosinophilia was increased as well,” he said. “This study puts these observations together; a nasal inflammatory allergic reaction does induce systemic changes, and those changes end up giving you some inflammatory response that is targeted in the lower airways.”
In the same lecture series, William W. Storms, MD, Asthma & Allergy Associates, P.C. in Colorado Springs, Colo., mentioned a study of 34 centers where 20- to 44-year-old subjects completed a survey, were skin-tested and had methacholine challenges.
“If they had atopic rhinitis, their risk for any asthma was 8.1 versus the control group who did not have rhinitis. If they had non-atopic rhinitis, their risk factor was greater, 11.6,” he stated. The data indicates rhinitis is an independent risk factor for asthma, whether it’s allergic or non-allergic rhinitis.
Dr. Kemp, a past president of the American Academy of Allergy, Asthma and Immunology who has been in practice for 30 years, said his facility has seen patients as children who, as adults, bring their own children back to their practice, providing an interesting perspective in terms of the inheritance and genetics of asthma and rhinitis.
Allergy often affects the entire body and may show its primary manifestation in one target organ over others. For example, children may start with their allergic disorder manifested as eczema or atopic dermatitis, and then as they get older, they might develop allergic rhinitis and its complications, such as otitis media and chronic tonsillar adenoid problems. Children could develop chronic sinusitis and later develop asthma, Dr. Kemp said.
It’s his belief that asthma is more of a syndrome than a disease, and not all asthma is the same. Further, childhood asthma may be more allergic than adult asthma, and adult onset asthma may be due to other factors.
The problem of asthma and allergy is seen often as a progression from one to the other, which isn’t to say that the conditions don’t overlap. In children, asthma is likely to be an allergic disorder. If clinicians go more deeply into the patient’s history, they will often find the patient has allergic rhinitis also, but it is asthma that is affecting them more and brings them to the clinic, Dr. Kemp said.
In addition, rhinitis can predispose a person to chronic sinusitis and acute sinusitis, which can cause asthma to flare-up, said Richard F. Lockey, MD, professor of medicine, pediatric and public health, and director of the division of allergy and immunology, University of South Florida College of Medicine and James A. Haley Veterans Administration Hospital, Tampa, Fla.
“When you get acute or chronic sinusitis, you certainly can’t bring the asthma under control until you control those problems appropriately,” he said.
With a thorough physical examination and a careful history, clinicians treating patients with asthma often may find they have symptoms of allergic rhinitis, including congestion, excessive mucus and nasal symptoms, along with the wheezing and chest tightness of their asthma.
Clinicians should do a complete workup of the upper and lower airway, as well as find out if patients have problems, such as gastroesophageal reflux disease or obesity, which could affect their asthma, Dr. Lockey said.
“They also should find out if the patient has osteoporosis, as people with asthma have a higher incidence of osteoporosis than non-asthmatics because of some of the systemic steroids used,” he said.
The allergist’s focus is usually on the upper airway when a patient is complaining of nasal symptoms. The opposite may occur when patients present to pulmonologists and the focus is asthma. When clinicians perform a lung function test on allergic patients who don’t have asthma, they may find the patient’s FEV1 is somewhat below normal. Also, if when breathing cold, dry air, or after exercise, the patient coughs and possibly wheezes, it should raise a strong suspicion that the airways are hyperactive and mild asthma exists, Dr. Kemp said.
“I think the message, particularly for all respiratory caregivers, is if there is some suggestion of allergy producing the patient’s asthma, then a good examination of the upper airway and a good allergic history be taken,” he said.
TREATING DUAL PROBLEMS
Another connection between the upper and lower airway is treatment. Asthmatics can benefit from treatment of their allergic rhinitis, and likewise, allergic rhinitis patients’ symptoms can improve with some asthma medications. Allergic rhinitis patients with mild asthma who get treatment for nasal allergy with a topical corticosteroid can show signs of asthma improvement, Dr. Kemp said.
“We don’t know why that is, but it probably is due in part to the fact that the nose is there to filter, warm and humidify the air,” he said. “If the nose is not functioning properly, the person must mouth-breathe more and particles of dust and allergens reach the lung in greater concentrations.”
While treatment therapy for rhinitis and asthma sufferers should be tailored to patients’ needs, eliminating exposure to air pollution and controlling allergens, such as dust mites, should be the first line of defense. Following elimination therapy, clinicians should treat rhinitis with intranasal steroids for moderate to severe problems in combination with antihistamines to help with symptoms and decongestants to relieve nasal decongestion, Dr. Lockey said.
Another possible approach for sinus sufferers is nasal irrigation, which uses a saline solution to help clear out the nasal passages. Nasal irrigation can temporarily reduce the symptoms of post-nasal drip, help reduce congestion, clear the nostrils of pollen and other irritants, and can relieve dryness in the nasal passages, which can improve breathing.
In a recent study, including the use of daily nasal irrigation resulted in an improvement of chronic sinusitis symptoms in the majority of study participants.1 Medication usage was decreased in about one-third of participants.
In addition, the process of vaccination and immunization may help control asthma onset in allergy patients.
A European study concluded that im.munotherapy could reduce the development of asthma in children with seasonal rhinoconjunctivitis.2 Researchers studied 205 children ages 6 to 14 years with grass and/or birch pollen allergy who received either placebo or immunotherapy for three years. For those children in the control group, 44.4 percent developed asthma, while only 24.1 percent developed asthma in the immunotherapy group.
“One of the questions that needs to be addressed is: Should we be targeting people who are younger with immunotherapy rather than people who are older and already have the allergic rhinitis and/or allergic asthma?” Dr. Lockey asked.
More clinical studies are needed to help clinicians understand the link between rhinitis and asthma and treat both problems appropriately.
“The lung is not an isolated organ system,” he said. “If someone has allergies affecting the upper airway and asthma in the lower airway, you have to take care of the problem in the upper and lower airway, not just one or the other.”
1. Heatley DG, McConnell KE, Kille TL, Leverson GE. Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg. 2001 Jul;125(1):44-8.
2. Mšller C, Dreborg S, Ferdousi HA, Halken S, H¿st A, Jacobsen L. Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol. 2002;109(2):251-6.
Diehl is a free-lance writer in Gettysburg, Pa.
Examining the ARIA Initiative
As the incidence of allergy and asthma seems to grow hand in hand, clinicians are getting new information to help them treat their allergy and asthma patients.
The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative is a concept formalized by the World Health Organization by convening a panel of more than 30 physicians chaired by Jean Bousquet, MD, department of allergy and respiratory diseases, University Hospital and INSERM, Montpellier, France.
Ultimately, ARIA aims to:
• translate evolving science on rhinitis into recommendations for the management and prevention of the disease
• better assess the interactions between rhinitis and asthma
• increase awareness of rhinitis and its public health consequences
• and make effective treatment of rhinitis available and affordable for every patient in the world.
The panel met in December 1999 and began work on an extensive document, which was published in the November 2001 issue of the Journal of Allergy and Clinical Immunology, the scientific journal of the American Academy of Allergy, Asthma and Immunology.
The ARIA summary states that asthma and rhinitis are common comorbidities, suggesting the concept of “one airway, one disease.” To support this idea, it cites several clinical findings:
• at least 60 percent of asthmatics suffer from rhinitis
• about 20 percent to 30 percent of patients with allergic rhinitis also have asthma
• patients with nonallergic asthma also commonly present with rhinitis
• nonspecific bronchial hyperreactivity is more common in patients with rhinitis than in the general population.
The summary suggests a combined strategy be used to treat the upper and lower airway diseases in terms of efficacy and safety.
Allergic rhinitis is big business, accounting for more than $2 billion in yearly expenditures, said Richard Weber, MD, National Jewish Medical and Research Center, Denver, at the 2001 American College of Allergy, Asthma and Immunology meeting. This, in addition to the effect it has on patients’ lives, makes proper treatment important.
“One of the things that this panel has suggested is we need to look at rhinitis in a slightly different fashion,” Dr. Weber said. “They have recommended a new classification of allergic rhinitis, and they have attempted to stress the importance of nasal inflammation (and) stressed the importance of having treatment that is based on evidence that has appeared in the literature.”
The ARIA panel recommends that clinicians discontinue using the modifiers “seasonal” and “perennial” to classify allergy, and instead term allergies as “intermittent” and “persistent” to bring the diagnoses into line with the asthma nomenclature. They hope this will reinforce the fact that clinicians should look at the lungs and the nose as two ends of the same organ system.
Intermittent allergy is defined by allergy present fewer than four days per week or less than four weeks a year, as is the case with someone who has an allergy to a flower that has a season of two weeks. Persistent allergy is one that lasts more than four days a week or four months a year, as is the case with an oak allergy that lasts three months.
“Another recommendation from ARIA is patients with persistent allergic rhinitis should be evaluated for asthma, by physical examination at the minimum and then hopefully by some formal evaluation of airflow obstruction, before and after bronchodilator,” Dr. Weber said. The same should be true in evaluating asthmatics for the presence of allergic rhinitis.
Treatment should be monitored carefully as well. The ARIA panel suggests the use of oral or intranasal antihistamines and intra-nasal decongestants for mild intermittent rhinitis, with the addition of intranasal corticosteroids for severe intermittent or moderate persistent rhinitis.
“People really need to be re-evaluated and not written a script and told to come back in three months,” Dr. Weber said. Instead, there should be a step-wise approach to treating the disease — similar to that for asthma — and patients should be evaluated closely after the initial meeting to make sure the prescription is helping.
—Tracy Schmierer Diehl