Complementary and alternative medicine for allergic rhinitis in Japan

Background

Complementary and alternative medicine (CAM) is extensively used in patients with allergic diseases worldwide. The purpose of this study was to investigate the actual situation of CAM practice in the treatment of allergic rhinitis.

Complementary DNA microarray analysis of chemokines and their receptors in allergic rhinitis.

OBJECTIVE: To analyze the roles of chemokines and their receptors in the pathogenesis of allergic rhinitis by observing the complementary DNA (cDNA) expression of the chemokines and their receptors in the nasal mucosa of patients with and without allergic rhinitis, using gene chips. METHODS: The total RNAs were isolated from the nasal mucosa of 20 allergic rhinitis patients and purified to messenger RNAs, and then reversely transcribed to cDNAs and incorporated with samples of fluorescence-labeled with Cy5-dUPT (rhinitis patient samples) or Cy3-dUTP (control samples of nonallergic nasal mucosa). Thirty-nine cDNAs of chemokines and their receptors were latticed into expression profile chips, which were hybridized with probes and then scanned with the computer to study gene expression according to the different fluorescence intensities. RESULTS: The cDNAs of the following chemokines were upregulated: CCL1, CCL2, CCL5, CCL7, CCL8, CCL11, CCL13, CCL14, CCL17, CCL18, CCL19, CCL24, and CX3CL1 in most of the allergic rhinitis sample chips. CCR2, CCR3, CCR4, CCR5, CCR8 and CX3CR1 were the highly expressed receptor genes. Low expression of CXCL4 was found in these tissues. CONCLUSION: The T helper cell (T(H)) immune system is not well regulated in allergic rhinitis. Most of the upregulated genes we identified are of chemokines and their receptors that play important roles in T(H)2 response, and some are involved in the induction of allergic reaction, accumulation of inflammatory cells, and degranulation of sensitized cells. These findings can point to new strategies for allergic rhinitis immunotherapy.     

Combination therapy in the treatment of allergic rhinitis.

Allergic rhinitis is a common allergic condition. There are a variety of pharmacologic treatments, including antihistamines, oral decongestants, and intranasal corticosteroids. Leukotrienes cause significant nasal obstruction. Leukotriene receptor antagonists decrease symptoms and improve quality of life in patients with seasonal allergic rhinitis. Similar to antihistamines, antileukotrienes appear to be less efficacious than nasal corticosteroids. Combination therapy of histamine and leukotriene antagonists produces symptomatic improvement as well as improved quality of life. Areas of study for combination antimediator therapy include expanding the initial findings with regard to nasal steroids, investigation of patient preference and compliance, use in perennial allergic rhinitis, and treatment of "one airway," i.e., treatment of concurrent allergic rhinitis and asthma.     

Childhood allergic rhinitis

Allergic rhinitis is the most common chronic disease in children. This frequency is in strong progress. According to ISAAC' study, it concerns a child (6/7 years) on four and a teenager on two. The seasonal rhinitises are generally well treated. Perennial allergic rhinitises are chronic and often neglected. They are more often complicated or associated to asthma which represents the major evolutionary risk. In a general way, allergic rhinitis are sub-diagnosed and untreated while we have more and more effective therapeutic means. Although allergic rhinitis is not considered as a severe disease, its echo on children's quality of life, physical and psychological well-being, and capacity to learn. It has also important socio-economic consequences. A better coverage is imperative itself as far as the diagnosis based on the symptoms and the allergy cutaneous tests which are easy. The options for treating allergic rhinitis in the child are not so different as those for adult. Complete avoidance of inhalant allergens is not always possible and medication are quite always possible. Intranasal corticosteroids are sometimes prescribed. In persistent disease, allergen immunotherapy may be considered according to the last OMS consensus statement.     

Treating allergic rhinitis in pregnancy

Numerous pregnant women suffer from allergic rhinitis, and particular attention is required when prescribing drugs to these patients. In addition, physiologic changes associated with pregnancy could affect the upper airways. Evidence-based guidelines on the management of allergic rhinitis have been published. Medication can be prescribed during pregnancy when the apparent benefit of the drug is greater than the apparent risk. Usually, there is at least one "safe" drug from each major class used to control symptoms. All glucocorticosteroids are teratogenic in animals but, when the indication is clear (for diseases possibly associated, such as severe asthma exacerbation), the benefit of the drug is far greater than the risk. Inhaled glucocorticosteroids (eg, beclomethasone or budesonide) have not been incriminated as teratogens in humans and are used by pregnant women who have asthma. A few H1-antihistamines can safely be used as well. Most oral decongestants (except pseudoephedrine) are teratogenic in animals. There are no such data available for intranasal decongestants. Finally, pregnancy is not considered to be a contraindication for the continuation of immunotherapy.     

Mechanisms of allergic rhinitis

The pathogenesis of allergic rhinitis can be better appreciated by understanding the numerous protective mechanisms available for mucosal defense. The system of TH2 lymphocytes, IgE production, mast cell degranulation, eosinophil infiltration, and resident cell responses are central to our understanding and treatment of allergic rhinitis. Histamine remains preeminent in causing the cardinal symptoms of the immediate allergic reaction: itching, watery discharge, and nasal swelling. Recruitment and activation mechanisms responsible for the late-phase allergic response are also reviewed.     

Monosensitization and polysensitization in allergic rhinitis

Background

Polysensitization is common in patients with allergic rhinitis (AR) and may affect clinical feature. However, there are patients who remain monosensitized.

Objective

This cross-sectional study aimed at evaluating a large cohort of AR patients to define the percentage and the features of mono- and poly-sensitized subjects.

Methods

This observational cross-sectional study included a large group of AR patients: 2415 subjects (1958 males, mean age 24.6 ± 5 years) were consecutively evaluated. Symptom severity, type and number of sensitizations, and AR duration were considered.

Results

621 patients (25.7%) were monosensitized: 377 to Parietaria, 194 to house dust mites, 19 to birch, 17 to grasses, 12 to molds, 2 to olive, and 1 to cypress. There was no difference between mono- and polysensitized patients concerning the duration of rhinitis (6 ± 2.14 years vs 6 ± 3.7).Severity of symptoms was higher in polysensitized patients than in monosensitized (p < 0.05); in addition, there was a difference among monosensitized patients: Parietaria-allergy induces the most severe symptoms.

Conclusion

This study conducted in a large AR population might suggest that monosensitized and polysensitized AR patients could constitute two different categories. In addition, the specific type of allergy may condition the clinical feature.     

Biomarkers in asthma and allergic rhinitis

A biological marker (biomarker) is a physical sign or laboratory measurement that can serve as an indicator of biological or pathophysiological processes or as a response to a therapeutic intervention. An applicable biomarker possesses the characteristics of clinical relevance (sensitivity and specificity for the disease) and is responsive to treatment effects, in combination with simplicity, reliability and repeatability of the sampling technique. Presently, there are several biomarkers for asthma and allergic rhinitis that can be obtained by non-invasive or semi-invasive airway sampling methods meeting at least some of these criteria.In clinical practice, such biomarkers can provide complementary information to conventional disease markers, including clinical signs, spirometry and PC₂₀methacholine or histamine. Consequently, biomarkers can aid to establish the diagnosis, in staging and monitoring of the disease activity/progression or in predicting or monitoring of a treatment response. Especially in (young) children, reliable, non-invasive biomarkers would be valuable.Apart from diagnostic purposes, biomarkers can also be used as (surrogate) markers to predict a (novel) drug’s efficacy in target populations. Therefore, biomarkers are increasingly applied in early drug development.When implementing biomarkers in clinical practice or trials of asthma and allergic rhinitis, it is important to consider the heterogeneous nature of the inflammatory response which should direct the selection of adequate biomarkers. Some biomarker sampling techniques await further development and/or validation, and should therefore be applied as a “back up” of established biomarkers or methods. In addition, some biomarkers or sampling techniques are less suitable for (very young) children. Hence, on a case by case basis, a decision needs to be made what biomarker is adequate for the target population or purpose pursued.Future development of more sophisticated sampling methods and quantification techniques, such as – omics and biomedical imaging, will enable detection of adequate biomarkers for both clinical and research applications.     

Alternaria in patients with allergic rhinitis

Inhalation of fungal spores is shown to participate in the development of allergic rhinitis symptoms. In this study, relation between presence of Alternaria in the human nasal cavity and allergic rhinitis is assessed. In a case-control study, 58 allergic rhinitis patients were compared with a well-matched control group of fifty healthy volunteers for sensitization to Alternaria (by skin prick test) and detection of Alternaria in their nasal mucous by conventional methods (microscopy with Methylene Blue stain and culture in Sabourad dextrose agar). Severity of the disease was determined according to the ARIA classification. Pearson chi-square test was applied to compare the proportional difference between the study groups for detection of Alternaria in the nasal cavity, and sensitization to Alternaria. Relation between detection of Alternaria and allergic rhinitis was significant [OR = 18.18 (4.02-82.50)] In addition, sensitization to Alternaria showed a significant relation with the disease [OR = 2.8 (2.1-3.8)]. There was a significant relation between the presence of Alternaria in the nasal cavity and sensitization to Alternaria [OR = 10.4 (3.8-28.3)]. Both sensitization to Alternaria and presence of Alternaria in the nasal cavity did not have a significant relation with the severity of allergic rhinitis. This study suggests Alternaria as a major allergen that its presence in the nasal cavity and subsequent development of sensitization have significant role in the induction of allergic rhinitis.     

Quality of life in allergic rhinitis

Allergic rhinitis is a global health problem that causes major illness and disability worldwide. Although nasal and nonnasal symptoms are directly attributable to inflammation in the upper respiratory tract, individuals also experience generalized symptoms that include fatigue, mood changes, depression, anxiety and impairments of work and school performance, and cognitive function. Health-related quality of life focuses on patients' perceptions of their disease and measures impairments that have a significant impact on the patient. The burden of disease, as the patient perceives it, forms the basic motivation to seek medical aid or to undergo therapy. Adherence to therapy requires changes in health, perceived by patients as relevant and outweighing eventual disadvantages of intervention. Because so many factors are involved in health-related quality of life, there are multiple ways in which it can be measured. A variety of validated and standardized questionnaires have been developed including assessments of school performance, work performance, productivity, and other parameters that quantify the impact of allergic rhinitis and its treatment on quality of life. The aim of this review is to highlight the impact of allergic rhinitis on the quality of life and to analyze the most commonly used health-related quality of life instruments.     

Evidence-based treatment of allergic rhinitis

Allergic rhinitis is an extremely common disease worldwide, affecting 10% to 50% of the population. An increasing prevalence of allergic rhinitis over the past decades and its frequent association with asthma have raised concerns about treating the disease appropriately. New knowledge of the pathophysiologic mechanisms underlying allergic inflammation of the airways has resulted in the development of newer and better therapeutic strategies. This review focuses on evidence-based treatment of allergic rhinitis, highlighting the most recent international consensus and evidence-based guidelines on allergic rhinitis.     

Sublingual immunotherapy and allergic rhinitis

This paper reviews the safety and efficacy of sublingual immunotherapy (SLIT) in the treatment of allergic rhinitis. The literature from 1986 through 2007 shows approximately a 6000-fold range in doses found to be effective with SLIT. However, recent studies in large patient populations have demonstrated a clear dose response with an effective dose range that appears to be equivalent to one to two times the monthly subcutaneous immunotherapy dose administered daily or weekly (ie, 15 to 30 μg of major allergen). Further study is needed to establish the optimal dose and dosing schedule for each formulation. Local reactions (eg, oral itchiness) are common, and serious adverse reactions, although rare, have been reported. Cost-effective analysis cannot be made until the effective dose is established. SLIT appears to be a promising treatment for allergic rhinitis, but it is currently considered investigational in the United States until a formulation approved by the US Food and Drug Administration is available.     

Complications of allergic rhinitis.

With unfortunate high frequency, clinicians consider allergic rhinitis to be more of a nuisance than an illness. When in fact, allergic rhinitis is not only a very common disease process, affecting up to a cumulative frequency of 42% of the U.S. population by age 40, but can lead to significant short-term and long-term medical complications. Poorly controlled symptoms of allergic rhinitis may contribute to sleep loss, secondary daytime fatigue, learning impairment, decreased overall cognitive functioning, decreased long-term productivity and decreased quality of life. Additionally, poorly controlled allergic rhinitis may also contribute to the development of other related disease processes including acute and chronic sinusitis, recurrence of nasal polyps, otitis media/otitis media with effusion, hearing impairment, abnormal craniofacial development, sleep apnea and related complications, aggravation of underlying asthma, and increased propensity to develop asthma. Treatment of allergic rhinitis with sedating antihistamine therapy may result in negative neuropsychiatric effects that contribute to some of these complications. Sedating antihistamines may also be dangerous to use in certain other settings such as driving or operating potentially dangerous machinery. In contrast nonsedating antihistamines have been demonstrated to result in improved performance in allergic rhinitis.