Journal of Allergy and Clinical Immunology
Allergic Rhinitis and Its Impact on Asthma☆,☆☆
Section snippets
Recommendations
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Allergic rhinitis is a major chronic respiratory disease due to its:
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prevalence,
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impact on quality of life,
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impact on work/school performance and productivity,
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economic burden,
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links with asthma.
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In addition, allergic rhinitis is associated with sinusitis and other co-morbidities such as conjunctivitis.
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Allergic rhinitis should be considered as a risk factor for asthma along with other known risk factors.
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A new subdivision of allergic rhinitis has been proposed:
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intermittent
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persistent
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The severity of
1- Classification
Rhinitis (rhinosinusitis) is classified as follows (Table 2).
• 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 • Polyps • Mechanical Factors Deviated
2-1- Epidemiology of allergic rhinitis
Despite the recognition that allergic rhinitis is a global health problem and is increasing in prevalence 94, 95, 96, 97, 98, there are insufficient epidemiological data with regards to its distribution, aetiological risk factors and natural history. However, new national or multinational studies are rapidly improving our knowledge in the prevalence of rhinitis and its possible risk factors. These include:
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the second National Health and Nutrition Examination Survey (NHANES II) 99, 100,
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the
3-1- Allergens
Allergens are antigens which induce and react with specific IgE antibodies. Since drugs or insect venoms, reactive haptens from occupational agents or drugs and the discovery by Charles Blackley in the 1860s that pollens can cause allergic diseases, the number of allergenic substances which have been identified has expanded enormously. Allergens originate from a wide range of animals, insects, plants and fungi or are small molecular weight chemicals. They include proteins or glycoproteins from
4- Mechanisms
Allergy is classically considered to result from an IgE-mediated allergy associated with nasal inflammation of variable intensity.
However, it is now also appreciated that allergens, on account of their enzymatic proteolytic activity, may directly activate cells (636). House dust mite allergens have been shown to activate epithelial cells in vitro (637). They induce cytokine and chemokine release (638) and thus have the potential to induce airway inflammation independent of IgE. Moreover, Der p1
5- Non-infectious, non-allergic rhinitis
Stricto sensu “rhinitis” means inflammation of the nasal mucous membrane. However, markers of inflammation are not examined in daily clinical work. Therefore, the term rhinitis is used for a disease of the nasal mucosa, which results in nasal itching, sneezing, rhinorrhea and nasal blockage.
The disease is “non-allergic” when allergy has not been proven by proper allergy examination (history, skin prick testing, measurement of serum specific IgE antibodies).
Rhinitis is called “non-infectious”
6- Co-morbidity and complications
Allergic inflammation does not necessarily limit itself to the nasal airway. Multiple co-morbidities have been associated with rhinitis. These include asthma, sinusitis and conjunctivitis.
7- Diagnosis and assessment of severity
The tests and procedures listed below represent the spectrum of investigations, which may be used in the diagnosis of allergic rhinitis. However, only a number of these are routinely available or applicable to each individual patient (Table 8).
Routine tests History General ENT examination Allergy tests - skin tests - serum specific IgE Endoscopy - rigid - flexible Nasal secretions - cytology Nasal challenge - allergen - lysine aspirin Radiology - CT-scan Optional tests
8- Management
The management of allergic rhinitis includes allergen avoidance, medication (pharmacological treatment), immunotherapy and education. Surgery may be used as an adjunctive intervention.
It is recommended to propose a strategy combining the treatment of both the upper and lower airway disease in terms of efficacy and safety.
9 - Education
The education of the patient and /or the patient's care giver regarding the management of rhinitis is essential. Such education maximises compliance and the possibility of optimising treatment outcomes (37).
After the initiation of therapy, an appropriate follow-up for patients with rhinitis optimises the chances that a patient will benefit from the broad array of therapeutic approaches available, and that possible complications from rhinitis or its treatment are identified and addressed. At
10- Prevention of rhinitis
There is a general misconception that the same factors involved in the induction of allergy are also likely to incite disease once established. However, this is not necessarily the case. Thus, strategies for primary prevention or prophylaxis may be very different to those required for the management of established disease. Using the analogy of prophylaxis for tuberculosis, prevention can therefore be divided into primary, secondary and tertiary intervention:
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Primary prophylaxis will be employed
11- Quality of life
Quality of life (QOL) is a concept including a large set of physical and psychological characteristics assessing problems in the social context of lifestyle. Nowadays, it has been recognised that allergic rhinitis comprises more than the classical symptoms of sneezing, rhinorrhea and nasal obstruction. In the last decade, an increasing effort has been made to understand the socio-economic burden of rhinitis in terms of effects on health-related quality of life (HRQL) and health care costs. It
12- The social economic impact of asthma and rhinitis
Asthma and rhinitis are chronic conditions with a substantial economic impact on the affected persons, their families, the health care systems and society as a whole. This burden is composed of direct expenditures generated within the health care system as well as indirect costs associated with the loss of economic productivity. Persons with asthma or rhinitis must cope with both the immediate and long-term impact of a condition that often affects daily functioning. They are frequently required
13-1- Epidemiological evidence
There are many studies, which have shown that rhinitis and asthma often co-exist in the same patient. It seems that perennial rhinitis is more often associated with asthma than seasonal rhinitis.
Research needs:
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More epidemiological studies need to be carried out in order to better assess the prevalence of intermittent and persistent rhinitis as well as to better understand the cause of rhinitis.
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More epidemiological evidence is needed to link rhinitis, asthma, conjunctivitis and other allergic
14- Recommendations for developing countries
Nadia Aït-Khaled, Donald Enarson
International Union Against Tuberculosis and Lung Disease (IUATLD)
In developing countries, health care planners are faced with establishing priorities for the allocation of limited health care resources and infectious diseases, both of which remain a public health priority. When deciding on priorities for public health action, it is important to remember that, just as with clinical practice, public health practice needs to be evidence-based. Evidence for public
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Reprint requests: Jean Bousquet, MD, PhD, Allergic Rhinitis and its Impact on Asthma (ARIA), Service des Maladies Respiratoires, Hôpital Arnaud de Villeneuve, 371, avenue Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France.
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J Allergy Clin Immunol 2001;108:S147-336.