WASHINGTON, DC—Rhinitis—inflammation of the nasal mucosa—has two main types: allergic (IgE-mediated) and nonallergic; together, they affect more than 50 million Americans. Both types diminish quality of life, result in about 20 million physician visits each year, and cost billions of dollars. Robert M. Naclerio, MD, Professor of Surgery and Section Chief of Otolaryngology Head and Neck Surgery at the University of Chicago, and two of his colleagues at that institution, Fuad M. Baroody, MD, and Jayant M. Pinto, MD, discussed new developments in the management of rhinitis.
Seasonal Allergic Rhinitis
Assessing the severity of seasonal allergic rhinitis (SAR), contrary to what one would intuit, is related more to quality-of-life factors than to physiological ones, said Dr. Naclerio. For example, sufferers performed worse on cognitive tests and exhibited sometimes dangerous daytime sleepiness because SAR affects their ability to sleep at night.
One also might think that avoidance of allergens would alleviate most of the symptoms, but that too is wrong, he added. “Although the studies we have are poor, we do know, for instance, that reducing dust mites, by current recommendations, has little effect on the clinical impact of dust mite-induced rhinitis. In fact, not many environmental factors appear to have much of an effect—except stopping smoking and reducing exposure to secondhand smoke.” Both alter dendritic cell function, increase respiratory symptoms, and decrease the effect of inhaled corticosteroids when they are used.
Avoidance issues are especially pertinent for children whose allergic parents are often unduly worried about their children developing allergies. SAR can be delayed with avoidance to allergens, but it will show up eventually. “What you buy in the short run, you lose in the long run,” Dr. Naclerio said. “Smoking is the one thing parents can control and they should stop it. A number of studies support this recommendation.”
Dr. Pinto told the audience that people with SAR and asthma have a reduced ability to condition air. “Because these individuals have inflammation in the nose, we hypothesized that treatment with an intranasal steroid would reduce nasal inflammation and decrease nasal conditioning capacity.”
Therefore, Dr. Pinto and his colleagues performed a randomized, double-blind, placebo-controlled study on 20 people with asthma to compare the effect of treatment with intranasal budesonide (Rhinocort) on nasal conditioning for two weeks. The drug reduced inflammation in the nonsmokers, but had no effect in the smokers. In the subgroup of nonsmokers who had a significant reduction in inflammation, the nasal conditioning was also reduced, as predicted.
“Not many environmental factors appear to have much of an effect—except stopping smoking and reducing exposure to secondhand smoke.”
—Robert M. Naclerio, MD
“We speculate that inflammation in nonsmoking individuals with asthma increases the conditioning capacity, and reducing it with in intranasal steroid worsens the ability of the nose to condition air. In addition, smoking interferes with the effect of the intranasal steroids.”
Antihistamines and Decongestants
Dr. Naclerio had some news for the audience: cetirizine (Zyrtec) will be sold over the counter beginning in 2008, and a new drug called levocetirizine, a modified form of Zyrtec, will be available by prescription in the American market soon.
In the world of decongestants, he stated that in a meta-analysis, oral phenylephrine was shown to have no efficacy whatever, and therefore patients should be discouraged from spending their money on it. On the other hand, “pseudoephedrine [Sudafed], which has efficacy, has been put away behind the drugstore counter so patients will have to show identification to purchase it. This discourage some patients from buying it.”
Intranasal steroids should be first-line treatment for symptoms of SAR because they are very effective. A new intranasal steroid, fluticasone furoate, was recently approved for sale in the United States.
Dr. Baroody described a study he conducted with colleagues in which montelukast (Singulair) was compared with pseudoephedrine for the treatment of SAR. The two-week trial was randomized, double-blind, and enrolled 58 adults with ragweed rhinitis.
After recording their own baseline nasal symptoms, nasal peak inspiratory flow, and diurnal and nocturnal rhinoconjunctivitis quality of life score, the patients were randomized to receive daily morning oral doses of 240 mg of pseudoephedrine hydrochloride or 10 mg of montelukast sodium. They recorded their nasal symptoms twice daily, and at the end of the study, they completed another quality of life questionnaire.
Dr. Baroody said that both treatments resulted in significant improvement in all symptoms of allergic rhinitis, as well as in overall quality of life. There were no significant differences between the two drugs except for nasal congestion, where pseudoephedrine was more effective. Surprisingly, both drugs were equally well tolerated.
Immunotherapy
We speculate that inflammation in nonsmoking individuals with asthma increases the conditioning capacity, and reducing it with in intranasal steroid worsens the ability of the nose to condition air. In addition, “smoking interferes with the effect of the intranasal steroids.”
—Jayant M. Pinto, MD
Dr. Baroody told the audience that subcutaneous immunotherapy (SCIT) is effective for SAR and for prevention of asthma. SCIT involves an initiation period followed by three to five years of maintenance treatment. Dr. Baroody warned, however, SCIT is not without risk of anaphylactic reaction. Sublingual immunotherapy (SLIT)—for example, phleum pratense vaccine (Grazax)—is also effective, as are replicon DNA vaccines.
Dr. Baroody mentioned that SAR is a worldwide phenomenon that has increased considerably in the past two decades. Patients whose symptoms remain uncontrolled with the usual medications should be treated with specific allergen immunotherapy.
He said that a Cochrane Collection review of SCIT for SAR identified 51 studies with a total of 2871 subjects who received treatment lasting from three days to three years. It showed that injection immunotherapy in suitably selected patients with SAR produced significant reductions in symptom severity, with a known and relatively low risk of serious adverse events.
©2007 The Triological Society