allergic rhinitis

Allergic rhinitis is a chronic disease with a high prevalence with an impact on quality of life. The original Allergic Rhinitis and Its Impact on Asthma Guideline (ARIA) severity classification uses 4 items (sleep, daily activities/sport, work/school performance and troublesome symptoms) and defines allergic rhinitis as mild (no items affected) or moderate/severe (1 to 4 items affected). A validated modified three-level ARIA (mARIA) classification was proposed to discriminate allergic rhinitis severity between moderate (1 to 3 items affected) and severe (4 items affected).

The aim of this prospective, observational, cross-sectional study was to use the 4 original ARIA items to validate a three-level evaluation of allergic rhinitis control (ARIA-C): controlled, partially controlled and not controlled, by estimating control of symptoms, impairment in activities and respiratory function.

A total of 252 adult participants with moderate-to-severe allergic rhinitis were included using both mARIA severity criteria and a reflective total nasal symptom score (rTNSS) ≥ 8. They followed their routine treatments and were interviewed twice a month. Demographic, concomitant diseases, allergic sensitization, AR severity and impact on quality of life data were collected. Additionally, participants’ control was assessed with the validated Spanish version of the Rhinitis Control Assessment Test (RCAT).

At baseline, 20 % of the participants had their allergic rhinitis controlled with the ARIA-C. At follow-up, 30 % of them were controlled and 40 % partially controlled.

Disease control was evaluated and showed that the three categories of ARIA-C can effectively discriminate between controlled, partially controlled and not controlled allergic rhinitis. Its validation shows favorable and statistically significant results for test-retest reliability, convergent validity, discrimination among groups, and responsiveness to change.

These results suggest that the ARIA-C can be used to obtain a fast screening of patients with inadequate allergic rhinitis control, or to help their communication with specialists.

A mobile application (MASK-air®) has demonstrated usefulness in assessing patient behaviour in allergic rhinitis. This app measures general, nasal, ocular and asthma symptoms with a visual scale and daily medication intake.

The objective of this study was to validate the app for allergic rhinitis, comparing it to a written questionnaire for a month.

A total of 252 participants were randomly assigned to one of two groups: participants with allergic rhinitis who used the Spanish version of the app on a daily basis and participants with allergic rhinitis who were asked to use the questionnaire at days 1, 3, 7, 14, 21 and 28 and at a final visit one week later.

The usefulness of the allergic rhinitis app was evaluated at baseline and at the end using the Rhinitis Control Assessment Tool questionnaire. Other allergic rhinitis outcomes included treatment adherence, reflective total nasal symptom score, ocular symptom score, the modified ARIA severity classification, a quality-of-life questionnaire and daily visual analogue scales for nasal, conjunctival, asthma, and global for overall allergy symptoms, and the asthma control test for asthmatic patients at baseline and at end of study. Participants and specialists’ satisfaction with the app were evaluated using a Likert scale.

Most participants in the app group (90 %) had downloaded it to their smartphone and 92 % of them used it. Most users (88 %) reported being satisfied or very satisfied with the app, with 72% of the specialists reporting that their patients were satisfied.

At the end of the study, a relevant improvement on the Rhinitis Control Assessment Tool score was observed, but with no significant or clinically relevant difference between groups. Other outcomes were not different between study groups either.

This study demonstrated that the app contributed to the improvement of allergic rhinitis as effectively as the written questionnaire. It has shown that the MASK-air® app is practical ad useful.

Chronic rhinitis can be classified in allergic rhinitis and non-allergic rhinitis (NAR). Allergic rhinitis is an inflammatory disease of the nasal mucosa with symptoms such as nasal discharge, sneezing, nasal itching and congestion. It is characterized by eosinophilic inflammation as a result of IgE-sensitization to seasonal or perennial aeroallergens. NAR is a highly heterogeneous group that includes disorders characterized by either immunological or neurogenic inflammation (hormonal rhinitis, rhinitis of the elderly, gustatory rhinitis, drug-induced rhinitis and occupational rhinitis).

Local allergic rhinitis (LAR) is neither classical allergic rhinitis neither NAR. Its symptoms, duration, severity and complications are similar to those of allergic rhinitis and can affect adults and children. It is characterized by a localized nasal allergic response and the absence of systemic atopy since specific IgE antibodies are produced locally. A Th2 pattern of mucosal cell infiltration during natural exposure to aeroallergens and a positive nasal allergen provocation test (NAPT) response, with the release of inflammatory mediators such as mast cells, eosinophils, IgE, B cells, and T cells, are detected.

LAR is an underdiagnosed entity that affects a significant number of people with chronic rhinitis, mainly in Mediterranean countries. It is a chronic condition that tends to worsen and is associated with conjunctivitis and bronchial symptoms. Its diagnosis is a challenge and should be based on a detailed clinical history, the demonstration of a nasal allergic response to aeroallergens by NAPT in patients with negative skin prick test and non-detectable serum sIgE, and the exclusion of chronic rhinosinusitis with/without nasal polyps.

Oral antihistamines and intranasal corticosteroids, alone or in an intranasal formulation of fluticasone + azelastine in severe cases, are the two traditional bases of allergic rhinitis treatment. Clinical experience indicates that these drugs are similarly effective in LAR patients. Also, subcutaneous immunotherapy has shown to be effective and well tolerated in LAR. A correct early diagnosis through nasal allergen challenge enables the establishment of an etiologic treatment, improving quality of life and preventing the development of lower airway disease.

Acute COVID-19 infection and onset of seasonal allergic rhinitis share some features, which may be confusing, especially in those new to such symptoms. Cough and fever are the most prominent symptoms of COVID-19, while conjunctivitis and itching are allergic rhinitis symptoms. Sudden and complete anosmia may be an early sign of COVID-19 infection, differentiating it from allergic rhinitis. The EUFOREA expert teams makes an overview of recommendations for people with seasonal allergic rhinitis.

Given that 44 % of all COVID-19 transmission occurs from asymptomatic people, it is important to keep seasonal allergic rhinitis under the best possible control in order to diminish symptoms, such as sneezing, rhinorrhoea and coughing, which may be responsible for viral spread to others via aerosol formation in those who do not realise that they also have COVID-19.

They recommend that seasonal allergic rhinitis treatment to be started early and used regularly in the pollen season. Systemic corticosteroids should be avoided as they may suppress the immune system. There is no contraindication to the use of intranasal corticosteroids, as they do not reduce immunity and normalize the structure and function of the nasal mucosa. Asthma inhalers should be continued as before and taken regularly to maintain control in the pollen season. Inhaled corticosteroids and inhaled corticosteroids combinations with bronchodilators, long acting beta agonists protect against virally induced asthma exacerbations and may be beneficial in COVID-19. Also, treatment with biologicals for people with more severe asthma and severe chronic rhinosinusitis with nasal polyps should be continued to avoid aggravation of these diseases. Ongoing allergen-specific immunotherapy (AIT) should be continued, if feasible within the health care system, as long as no COVID-19 infection has been diagnosed. New AIT treatments are not advised, except for sublingual immunotherapy, which requires only one does under supervision.

In case of COVID-19 infection, oral corticosteroids may be needed in asthma patients for severe virus-evoked exacerbations. NSAIDs, which were suggested to be avoided for all possible patients, are vital in NSAID-sensitive asthma.

Exposition to pollution and climate change worsen symptoms in people with allergic rhinitis. The aim of this study was to summarize the conclusions of an International Expert Consensus on the management of allergic rhinitis aggravated by air pollution.

Epidemiological and clinical studies have shown that co-exposure to aeroallergens and pollutants have an immunological effect that induces inflammatory responses with recruitment of inflammatory cells, cytokines and interleukins. In addition, allergic rhinitis symptoms can be mediated by a neurogenic component upon contact with environmental irritants. Other studies that included specific pollutants exposure and allergen challenge propose that pollution can exacerbate allergic airway disease and increase responsiveness.

Although there have been advances in the understanding of the mechanistic ways of airway inflammation, there is lack of evidence about the benefits of management of allergic rhinitis aggravated by pollution. Fexofenadine, a non-sedating oral antihistamine as shown to improve allergic rhinitis symptoms aggravated by pollution, however, more studies with other related antihistamines in mitigating symptoms resulting from co-exposure to pollution and allergens are needed.

Nevertheless, an individual and careful approach with avoidance measures and conventional pharmacotherapy can improve symptoms caused by allergic rhinitis and air pollution.

The exposition to airborne pollen is the main cause of seasonal allergic rhinitis. This exposition induces local and systemic allergic immune responses in sensitized and non-sensitized individuals. The mechanisms of action of the expression of symptoms under natural pollen exposure is not fully understood. The aim of this study was to monitor the humoral immune response under natural pollen exposure to categorise and understand nasal biomarkers for in-season symptom severity and to identify protective factors.

50 participants with seasonal allergic rhinitis and non-allergic rhinitis were included from November 2015 to October 2016. Immune monitoring to compare humoral immune response kinetics and cross-sectional and interseasonal differences in levels of serum and nasal, total and Bet v 1-specific immunoglobulin isotypes, immunoglobulin free light chains, cytokines and chemokines was performed every 4 weeks out of season and bi-weekly within the main pollen season. Nasal immune variables were registered with non-supervised principal component analysis and single immune variables were correlated with in-season severity by Spearman test.

Participants with seasonal allergic rhinitis had symptoms in 0 to 13 days after airborne pollen exposure, depending on the pollen type. 4 out of 7 non-allergic participants also exhibited in-season symptoms. Non-allergic participants had lower cumulative symptoms than participants with seasonal allergic rhinitis but followed the pollen exposure with similar kinetics. Seasonal allergic rhinitis participants had higher levels of nasal eotaxin-2, MDC and MCP-1, non-allergic participants had higher levels of IL-7. Non-supervises principal component analysis and Spearman correlations identified nasal IL-8, IL-33, Bet v 1-specific IgG4 and sIgE antibodies a prognostic for seasonal symptom severity.

Nasal IL-8, IL-33, sIgG3 and sIgE could be predictive biomarkers for pollen-specific symptom expression, irrespective of atopy, while nasal pollen-specific IgA and IgG isotypes seem to be potentially protective within the humoral compartment.

Seasonal allergic rhinitis affects patients exposed to pollens to which they are sensitized. The etiological diagnosis and therapy of allergic rhinitis require an evidence that exposure to the sensitizing pollen triggers allergic symptoms. Electronic clinical diaries can demonstrate this association as patients can record disease severity scores and pollen exposure. However, there is a lack of adherence in patients who have spontaneously downloaded an e-diary application.

The aim of the study @IT-2020 project was to evaluate adherence of patients with seasonal allergic rhinitis to symptom recording via e-diary clearly prescribed by a specialist within a blended care approach. Italian children and adults with seasonal allergic rhinitis were included and instructed to record their symptoms, medication intake and general conditions daily through a mobile app (Allergy.Monitor) during pollen season.

A total of 101 children and 93 adults with seasonal allergic rhinitis were included and showed a slow decline in the adherence to device use during monitoring: from 90% at the end of the first week to 70 to 80% from the seventh week onward. At the individual level, the adherence evaluated in the second and third weeks predicted with enough confidence the overall participant adherence to recording.

If prescribed and motivated by an allergist in a blended care setting, the adherence to daily recording in an e-diary is very high, which supports their use in addition to face-to-face visits for diagnosis and treatment of seasonal allergic rhinitis. The proper use of mobile health technology in monitoring seasonal allergic rhinitis strengthens the blended care approach.

Allergic rhinitis is an immunoglobulin E (IgE) mediated inflammatory disorder of the nose. Its prevalence ranges from 10 to 30% in North America. Grass pollens are common allergens that can provoke allergic rhinitis symptoms, such as sneezing, nasal itching, congestion and postnasal drip. Uncontrolled allergic rhinitis symptoms can have a negative impact on sleep quality, work productivity, driving ability and academic performance. Antihistamines and nasal corticoids are the usual treatments to reduce symptoms severity. This study objective was to evaluate whether Bermuda grass allergens can provoke allergic rhinitis symptoms in sensitized participants and to determine if nasal allergen challenge model is adequate to study this type of allergic rhinitis.

The study included 22 participants sensitized to Bermuda grass and 12 nonallergic participants, who completed a titrated nasal allergen challenge with increasing allergen concentrations at a screening visit. Total nasal symptom score (TNSS) and peak nasal inspiratory flow were registered before allergen exposure and 10 minutes after each concentration.

At titrated nasal allergen challenge, 19 of 22 sensitized participants met the criteria for positive allergic response when challenged. During single-dose nasal allergen challenge, sensitized participants had significantly greater TNSS between 15 min and 3 hours after nasal allergen challenge than nonallergic participants. Likewise, allergic participants had a significantly increased number of nasal lavage eosinophils at both 1 and 6 hours after nasal allergen challenge. Also, Bermuda grass specific IgE was significantly increased in Bermuda grass allergic participants at nasal allergen challenge than at screening visit.

In conclusion, Bermuda grass induces allergic rhinitis symptoms in sensitized participants and the model of nasal allergen challenge is adequate to study this type of allergic rhinitis.

Allergen immunotherapy (AIT) is the only disease-modifying treatment available for allergic rhinitis. It works by inducing allergen-specific immune tolerance and by preventing the development of new allergen sensitization. Studies have shown that AIT has proven long-term efficacy in people with allergic rhinitis, however there is a lack of studies of real-world evidence.

In this review, retrospective studies from France and Germany have confirmed the sustained benefits of grass and pollen AIT. When compared to standard of care, AIT improved allergic rhinitis symptom control after treatment cessation (reduced allergic rhinitis symptomatic medication use), as well as asthma control and decreased the risk of developing asthma.

Real-world evidence studies have advantages over randomizes clinical trials, such as evaluation of a broader patient population that mirrors clinical practice, greater generalizability and enabling the assessment of long-term safety and effectiveness. In particular real-world evidence of AIT in people with allergic rhinitis and asthma confirm and build on the efficacy findings of regular studies, and their results can be used to guide clinical management and assist counselling of patients, so much so that recent guidance supports the inclusion of real-world evidence data in updated guidelines.