Unawareness and undertreatment of asthma and allergic rhinitis in a general population

The aim of this study was to determine the extent of unawareness and undertreatment of asthma and allergic rhinitis in an adolescent and adult population in Copenhagen, Denmark. METHODS: Patients with asthma and rhinitis were recruited by a standardised asthma and rhinitis screening questionnaire. Out of a random sample of 10,877 subjects aged 14-44 years, 1149 subjects were treated or reported symptoms of asthma or rhinitis and agreed to participate. Those subjects were assessed on history, lung function tests, and skin prick tests. Disease severity and optimal treatment were decided according to the GINA and ARIA guidelines. RESULTS: A total of 726 participants suffered from asthma and/or allergic rhinitis. Concomitant upper and lower airways disease was found in 47%. Seventy-five per cent were allergic and 44% with a known allergy had been tested previously. Asthma was undiagnosed and untreated in 50% of all the asthmatics. According to the guideline recommendation, 76% of asthmatics were undertreated. Rhinitis was undiagnosed in 32% of patients and 83% with moderate to severe rhinitis were undertreated. Patient knowledge about self-care and education was low. CONCLUSIONS: In this population a large proportion of patients were unaware of having asthma or rhinitis. The pharmaceutical treatment and management practice were inadequate. Our study emphasises the need for additional intervention.     

Lower Airway Disease in Asthmatics with and without Rhinitis

STUDY OBJECTIVES: The purpose of this study was to determine if asthma with rhinitis and asthma without rhinitis represent distinct forms of disease. DESIGN: We performed a prospective cross-sectional study. PARTICIPANTS: The study included healthy controls, participants with asthma without rhinitis, and participants with both asthma and rhinitis. Interventions We compared lung function and airway inflammation between the three groups of participants. RESULTS: We recruited 32 participants: 12 normals, 8 asthmatics without rhinitis, and 12 with rhinitis. Compared to asthmatics with rhinitis, asthmatics without rhinitis had more severe airflow limitation (FEV(1)/FVC = 60.6% [IQR = 22.8] vs. 74.8% [IQR = 7.8] and fewer induced sputum eosinophils (2.8 [IQR = 5.8] and 9.6 [IQR = 23.8], respectively). Sputum interleukin-6 correlated inversely with lung function measured by postbronchodilator FEV(1) in the study cohort (Spearman correlation coefficient = -0.55, p < 0.01). CONCLUSIONS: Asthmatics without rhinitis tend to have lower lung function and less eosinophilic inflammation in the lung. This small study suggests that asthmatics without rhinitis represent a distinct phenotype of asthma in which low lung function is dissociated from eosinophilic cellular inflammation, and it suggests that larger studies addressing this phenotype are warrented.     

Prevalence and comorbidity of allergic eczema, rhinitis, and asthma in a city in western Turkey.

BACKGROUND: Allergic diseases co-occur in many patients. There is no published population-based epidemiologic study about allergic diseases in Turkey. OBJECTIVE: The aim of this population-based study was to investigate the prevalence of allergic eczema, allergic rhinitis, and asthma and their co-occurence in Manisa. METHODS: The sample size was calculated using an estimated prevalence of ever wheezing for the analyzed age group. Interviews were conducted with 725 children. The survey instrument consisted of a set of sociodemographic questions plus the questionnaire of the International Study of Asthma and Allergies in Childhood. RESULTS: The mean (SD) age of the children studied was 8.94 (5.16) years. The prevalence of ever having allergic eczema was 4.7% whereas that of current allergic eczema was 3.2%. Current allergic rhinitis and allergic conjunctivitis were present in 14.5% and 13%, respectively. Asthma was reported in 14.7% of the children older than 3 years of age while the prevalence of physician-diagnosed asthma was 7.9%. The burden of allergy was 27.1%. The prevalence of concomitant eczema and rhinitis was 1.9%. Among children aged between 3 and 17 years, 1.5% and 4.7% had asthma along with eczema and rhinitis respectively. Asthma was significantly more common in children with rhinitis (31.5% vs 11.8%; P < .01; odds ratio [OR], 3.45). Asthma was diagnosed in 28.1% of children with eczema and 14% of children without eczema (P = .03; OR, 2.41). CONCLUSIONS: Atopic diseases seem to significantly increase the risk of developing another atopic disease with ORs that range from 2.4 to 3.4.     

Allergic bronchopulmonary aspergillosis: an Indian perspective

PURPOSE OF REVIEW: Allergic bronchopulmonary aspergillosis is an immunologically mediated lung disease that is caused by hypersensitivity to antigens of the genus Aspergillus. This review summarizes the clinical presentation, radiologic profile, lung functions and immunologic studies on allergic bronchopulmonary aspergillosis from India. Data regarding Aspergillus sensitization in asthmatics are presented. The association of allergic bronchopulmonary aspergillosis with allergic Aspergillus sinusitis and aspergilloma is also highlighted. RECENT FINDINGS: Allergic bronchopulmonary aspergillosis is now an emerging disease in India. Sensitization to Aspergillus antigens is not uncommon in our patients with asthma. Although asthma commenced in these subjects in their early 20s, allergic bronchopulmonary aspergillosis was recognized more than a decade later. Allergic bronchopulmonary aspergillosis can also occur in patients without clinical asthma. Radiology is crucial to the diagnosis of allergic bronchopulmonary aspergillosis. The remarkable radiological similarity to pulmonary tuberculosis has important clinical implications in our country as patients with allergic bronchopulmonary aspergillosis often receive antituberculous therapy for a long time. Although oral corticosteroids still remain the cornerstone for management, itraconazole has emerged as an adjunct therapy in appropriate situations. Concomitant occurrence of allergic bronchopulmonary aspergillosis and allergic Aspergillus sinusitis is now being increasingly recognized. SUMMARY: All asthmatic subjects with a positive skin prick test to Aspergillus antigens must be evaluated for allergic bronchopulmonary aspergillosis and allergic Aspergillus sinusitis should be excluded.     

变应性鼻炎与支气管哮喘相关性研究进展

变应性鼻炎能够增加支气管哮喘（简称哮喘）患者的就诊率和用药剂量，不利于哮喘患者的临床控制并使其肺功能下降，但研究结果尚存在争论。变应性鼻炎在哮喘的发生和进展过程中扮演了重要角色，推测肺通气功能异常和气道高反应可能是部分变应性鼻炎患者的特征，该类人群可能更容易发展为哮喘。然而目前尚不明确变应性鼻炎患者的肺功能特点，针对此问题的研究较少。此外，关于治疗变应性鼻炎能否改善存在气道高反应的变应性鼻炎患者的肺功能并预防哮喘发生尚不清楚。这些问题对哮喘的预防具有重要意义，本文将讨论这方面问题的国内外研究进展，并提出可能的研究方向。     

Allergic rhinitis and asthma: more similarities than differences

Clinical epidemiological and pathophysiological studies suggest a strong functional and immunological relationship between the nose and the bronchi. Nasal stimulation, can induce bronchoconstriction by a proposed rhinobronchial reflex and inflammatory mediators originating from the nose could be inhaled and trigger bronchial inflammation. Bronchial provocation in sensitised subjects results in nasal inflammation through systemic circulation. There is an increased prevalence of asthma in patients with rhinitis relatively to patients without nasal complaints and allergic rhinitis patients have an increased risk to develop asthma. Nasal and bronchial co-morbidity is high, 75% of asthmatics have rhinitis and 20% to 40% of rhinitic patient suffer from asthma. In the World Health Initiative on Allergic Rhinitis and its effect on Asthma (ARIA) it is quoted that asthma and rhinitis are common co-morbidities suggesting the concept of one airway one disease. The term allergy rhinobronchitis has been proposed to link the association between asthma and rhinitis. The treatment of rhinitis and sinusitis is important for management of asthma. Treatment of chronic rhinitis not only reduces nasal inflammation obstruction and discharge but also can reduce lower airway hyperesponsiveness and symptoms of asthma. Treating nasal inflammation is a key point in asthma control. These data strength the functional and allergologial link between nose and bronchi. Nasal inflammation induced by nasal challenge in patients with rhinitis has the ability to also induce bronchial changes in some asthmatic patients.     

Asthma exacerbations in patients with asthma and rhinitis: Factors associated with asthma exacerbation and its effect on QOL in patients with asthma and rhinitis

BackgroundThe comorbidity of asthma and allergic rhinitis is remarkably high, but not much is known about the effects of this combined condition on the quality of life. We aimed to evaluate the factors associated with asthma exacerbations and the effect of the exacerbations on the quality of life (QOL) through a one-year, large-scale, observational study in Japanese patients with asthma and rhinitis.MethodsA case survey by attending physicians and a patient survey was conducted at each assessment timepoint over a period of one year. Patients were divided into two groups according to the presence or absence of asthmatic attacks after enrollment and were matched using propensity scores to evaluate the factors associated with asthma exacerbations and the effect of the exacerbation on QOL.ResultsPotential factors associated with asthma exacerbations included high body mass index value, low forced expiratory flow 75% of forced vital capacity (FEF75%), severe rhinitis as determined based on ARIA (Allergic Rhinitis and its Impact on Asthma). Although patients with asthma exacerbations had significantly impaired quality of life at baseline as evidenced by the economic aspects, in addition to physical, mental, and social activities, no further reduction with the attacks was observed.ConclusionsThis study suggested that higher body mass index (BMI) and severe asthma as well as severe rhinitis were factors associated with asthma exacerbations. Although patients with asthma exacerbations had impaired QOL, attacks caused no further reduction.     

The effect of mold sensitization and humidity upon allergic asthma

Introduction: Humidity is commonly associated with increased airway hyperresponsiveness in asthma. Objective: To examine mold sensitization in patients with allergic asthma or allergic rhinitis and self‐reports of humidity as exacerbating factors of clinical symptoms. Methods: A retrospective, cross‐sectional study at a University hospital outpatient allergy and asthma clinic was performed. A total of 106 patients with either allergic asthma or allergic rhinitis completed standard prick‐puncture skin testing with 17 allergens and controls and completed standardized forms addressing trigger factors for clinical symptoms. Results: Allergic asthmatics sensitized to Cladosporium were more likely to have a more severe asthma severity class (odds ratio = 4.26, confidence interval = 1.30–16.93). Sensitization to Alternaria, Cladosporium, Helminthosporium, Aspergillus and Dermatophagoides pteronyssinus in asthma was associated with higher likelihood for previous hospitalization, while sensitization to Cladosporium, Helminthosporium, Aspergillus, Dermatophagoides pteronyssinus and cockroach in asthma was associated with higher likelihood of having reduced pulmonary function based on forced expiratory volume in 1 s. Furthermore, allergic asthmatics more commonly reported humidity as an exacerbating factor of symptoms than did patients only with allergic rhinitis (68.42% vs 42.86%, respectively; P < 0.05). Conclusion: Mold sensitization is highly associated with more severe asthma, while humidity is more of an exacerbating factor in patients with allergic asthma as compared with allergic rhinitis alone. Further delineation between mold sensitization and humidity is needed to determine whether these are independent factors in asthma. Please cite this paper as: Hayes D Jr, Jhaveri MA, Mannino DM, Strawbridge H and Temprano J. The effect of mold sensitization and humidity upon allergic asthma. Clin Respir J 2013; 7: 135–144.     

ARIA (Allergic Rhinitis and its Impact on Asthma) achievements in 10 years and future needs

Allergic rhinitis and asthma represent global health problems for all age groups. Asthma and rhinitis frequently co-exist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization (WHO) workshop in 1999 and was published in 2001. ARIA has reclassified allergic rhinitis as mild/moderate-severe and intermittent/persistent. This classification schema closely reflects the impact of allergic rhinitis on patients. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of allergic rhinitis and asthma co-morbidities based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation). ARIA has been disseminated and implemented in over 50 countries of the world. In Turkey, it is important to make a record of ARIA achievements and to identify the still unmet clinical, research and implementation needs in order to strengthen the 2011 EU Priority on allergy and asthma in children.     

Occurrence and impact of sinusitis in patients with asthma and/or allergic rhinitis

Objective: The occurrence of radiological sinusitis in patients with asthma without any obvious nasal symptoms could possibly increase the severity of asthma. We investigated the occurrence and impact of sinusitis on computed tomography of the paranasal sinuses (CT-PNS) in patients with asthma and/or allergic rhinitis. Effect of sinusitis on the quality of life (QoL) was also assessed. Methods: All subjects underwent spirometry with reversibility, CT-PNS, intradermal test against common aeroallergens and responded to Symptom Severity Score and Rhinosinusitis Disability Index (RSDI). Of the 216 consecutive patients, 27 had asthma without nasal symptoms (Group 1), 58 had asthma with allergic rhinitis (Group 2) and 131 had allergic rhinitis (Group 3). Thirty normal healthy controls without atopy were also included (Group 4). Results: 20/27 (74%) patients in Group 1 had sinusitis on CT-PNS. 48/58 (82%) patients in Group 2 and 88/131 (67%) patients in Group 3 had chronic rhinosinusitis (CRS) as confirmed on CT-PNS. 6/30 (20%) healthy controls in Group 4 had mucosal thickening. Asthmatics with radiological sinusitis in Group 1 and with CRS in Group 2 had significantly lower FEV1, FEV1/FVC ratio, were more symptomatic and had a greater impairment of QoL. The mean sinus severity score was significantly higher in Group 2. In Group 3, sinusitis occurred significantly higher in “blockers” than “sneezers-runners” (41/79 versus 47/52, p = 0.045). Conclusions: Occurrence of radiological sinusitis on CT-PNS in asthmatics without nasal symptoms and CRS in allergic rhinitis with or without asthma increases the severity of the disease and affects the QoL.     

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变应性鼻炎(AR)与支气管哮喘均是上、下气道的一种慢性炎症性疾病,在流行病学、病理生理学和治疗方法上存在相似性和相关性,在临床上被称为"同一气道,同一疾病"。AR增加支气管哮喘患者的症状和就诊的需求,不利于支气管哮喘控制,AR对支气管哮喘的影响(ARIA)推荐对AR和支气管哮喘要进行联合诊断并同时治疗。     

Demographic, laboratory and clinical characterisation of adult portuguese asthmatic patients

BackgroundAsthma is a heterogeneous chronic inflammatory condition characterised by reversible airway obstruction and hyperresponsiveness associated with underlying bronchial inflammation and structural changes. It represents an increasing health problem and is a huge burden on the patients, their families and society. The aim of the study was to characterise the adult asthmatic population attending a Hospital Allergy Clinic between the years of 2003 and 2006.MethodsClinical files from the Allergy Outpatient Clinic of Cova da Beira Hospital were sequentially studied. The total population analysed included 335 female and 130 male asthmatic patients. Bronchial asthma was characterised by clinical history, skin prick testing to aeroallergens, determination of total and specific IgE and lung function testing, and classified according to international guidelines.ResultsOf the patients studied, 70 % had allergic asthma, and 30 % had non-allergic asthma. When compared to allergic asthma, non-allergic asthma was more frequently associated with older age, perennial symptoms and female gender. More allergic than non-allergic asthma patients also had rhinitis and the reverse was true regarding drug allergy and oesophageal reflux. Grass pollen and mites were the major sensitisers for allergic asthmatics. The sensitization profile was significantly different between urban- and rural-based asthmatic patients regarding tree pollen, fungi and moulds.ConclusionsIn this population, rhinitis was more frequently associated with allergic than with non-allergic asthma. The two types of asthma did not differ in clinical severity or changes in lung function. Sensitisation profiles were different between the urban and rural patients.     

Asthma exacerbations: pharmacological prevention

Asthma exacerbations are responsible for many emergency medical interventions and account for a significant proportion of the health costs of the disease. Increased airway inflammation is a key feature of exacerbations in asthma and therefore inhaled corticosteroids (ICS) are considered as first-line therapy for long-term asthma control. ICS have been demonstrated to reduce the risk of asthma exacerbations, as well as improving lung function. Oral leukotriene receptor antagonists also reduce the incidence of asthma exacerbations but are less effective than ICS. In patients with inadequately controlled persistent asthma despite low-dose ICS, the addition of a long-acting inhaled beta-agonist (LABA) should be considered. LABA should not be given alone and should always be associated with ICS in asthma. The anti-immunoglobulin E antibody, omalizumab, reduces severe exacerbations and emergency visits in patients with severe allergic asthma. In clinical trials measurement of the inflammatory response in induced sputum could provide information concerning appropriate drug therapy. Asthma-associated comorbidities should be investigated and treated, particularly in severe asthma. Despite a high prevalence of both gastro-oesophageal reflux and allergic rhinitis among patients with asthma, treatment with proton-pump inhibitors or nasal corticosteroids does not reduce the rate of asthma exacerbations.     

Pharmacotherapy to prevent the complications of allergic rhinitis.

Allergic rhinitis is an immunologic disease with effects that extend beyond the symptoms that occur subsequent to allergen exposure. A reduced quality of life and medical conditions such as asthma, sinusitis and otitis media are well recognized complications of allergic rhinitis. Craniofacial abnormalities, nasal ployps, and respiratory infections have been linked to allergic rhinitis, but the evidence is conflicting. This article reviews the complications of allergic rhinitis, their prevalences, possible mechanisms for their relationship to allergic rhinitis, and the prevention of these complications via pharmacologic treatment of allergic rhinitis.     

Serum interleukins 12 and 18 and immunoglobulin E concentrations and allergic symptoms in Japanese schoolchildren.

BACKGROUND: There is considerable concern about the rising trend in the prevalence of asthma and allergic diseases. The ability to monitor this trend would be enhanced by the use of a biological marker for these diseases. OBJECTIVE: This study investigated whether serum interleukin (IL) 12 and IL-18 levels were associated with allergic symptoms such as those of asthma, allergic rhinitis, and atopic eczema in Japanese schoolchildren. METHODS: Allergic symptoms and serum IL-12, IL-18, and immunoglobulin (Ig) E levels were examined in 370 schoolchildren aged 9-10 years living in urban Japanese areas. Allergic symptoms were assessed with a questionnaire designed in accordance with the protocol of the International Study of Asthma and Allergies in Childhood (ISAAC). RESULTS: Serum IL-12 levels in children were not associated with any allergic symptoms. However, serum IL-18 levels were significantly higher in children who had asthma, allergic rhinitis, or atopic eczema than in those who did not have such symptoms. Serum IL-18 levels were also significantly higher in children with IgE levels of 250 IU/mL or above than in those with levels below 250 IU/mL. Gender-adjusted serum IL-18 levels were still significantly higher in children with allergic rhinitis, atopic eczema, or at least one allergic symptom than in those without symptoms. CONCLUSION: These results suggest that serum IL-18 levels are associated with allergic symptoms in children, independent of serum IgE levels. Thus, serum IL-18 may be a useful biological marker of these diseases.     

Clinical characterization of children with resistant airflow obstruction,a multicenter study

Objective: To characterize a cohort of children with airflow limitation resistant to bronchodilator (BD) therapy. Methods: Pulmonary function tests performed in children 6–17 years of age at 15 centers in a clinical research consortium were screened for resistant airflow limitation, defined as a post-BD FEV₁ and/or an FEV₁/FVC less than the lower limits of normal. Demographic and clinical data were analyzed for associations with pulmonary function. Results: 582 children were identified. Median age was 13 years (IQR: 11, 16), 60% were males; 62% were Caucasian, 28% were African-American; 19% were obese; 32% were born prematurely and 21% exposed to second hand smoke. Pulmonary diagnoses included asthma (93%), prior significant pneumonia (28%), and bronchiectasis (5%). 65% reported allergic rhinitis, and 11% chronic sinusitis. Subjects without a history of asthma had significantly lower post-BD FEV₁% predicted (p = 0.008). Subjects without allergic rhinitis had lower post-BD FEV₁% predicted (p = 0.003). Children with allergic rhinitis, male sex, obesity and Black race had better pulmonary function post-BD. There was lower pulmonary function in children after age 11 years without a history of allergic rhinitis, as compared to those with a history of allergic rhinitis. Conclusions: The most prevalent diagnosis in children with BD-resistant airflow limitation is asthma. Allergic rhinitis and premature birth are common co-morbidities. Children without a history of asthma, as well as those with asthma but no allergic rhinitis, had lower pulmonary function. Children with BD-resistant airflow limitation may represent a sub-group of children with persistent obstruction and high risk for life-long airway disease.