Asthma and Allergic Rhinitis

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Two sides of the same coin
Asthma and Allergic Rhinitis

• Dr. S. K. Jindal
• Department of Pulmonary Medicine
• www.jindalchest.com

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Asthma and Allergic Rhinitis

• One Membrane One Disease (Grossman 1997)
• Allergic Rhinobronchitis (Simons 1999)
• Allergic Rhinitis and its Impact on Asthma,
  Workshop (Bousquet et al 2001)
• Disease continuum or A.R. as a risk factor of
  asthma (Koh and Kim 2003)

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Where is the Evidence?

• Morphological
• Epidemiological
• Immunological
• Pathological
• Clinical
• Therapeutic

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Morphological

• Structural continuity
• Common passage
• Similar/same exposures, insults Inflammatory
  responses

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NOSE Sentry to the Lungs

• Protective functions
• Filtration
• Humidification
• Temp. regulation
• Airflow control

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Anatomical Relationship with Lung
Nose Lower Airways
Mucosal lining Continuous/common Continuous/common
Lumen Continuous/common Continuous/common
Airflow Continuous/common Continuous/common
Differences Differences Differences
- Smooth muscle Nil Present
- Venous sinusoids Prominent Nil
- Submucosal glands Prominent Few
- Cavity/Lumen Rigid Elastic
- Epithelium in disease state Maintained (e.g. A.R.) Fragile (Asthma)
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RHINITIS

• Infectious
• Allergic
• Occupational
• Drug induced
• Hormonal
• Others
• Idiopathic

• Viral/bacterial
• Intermittent/Persistent
• Allergic/Non allergic
• Aspirin/Others
• Pitutary Snuff
• Atrophic, emotional,
• Food, GER, irritants

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Rhinitis Differential Diagnosis

• Polyps
• Mechanical DNS,F.B., adenoids
• Tumours Benign/Malignant
• Granulomatous WG, Sarcoid, infection
• Ciliary defects
• CSF rhinorrhoea

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Allergic Rhinitis

• Symptom disorder of the nose induced after
  allergen exposure or IgE mediated inflammation
• Increasing prevalence/incidence
• Affects performance and productivity

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Rhinitis Clinical Classification
Sneezers and Runners Blockers
Sneezing Paroxysmal Little or none
Rhinorrhoea Watery Anterior posterior Thick More posterior
Itching Yes No
Nasal block Variable Often severe
Diurnal rhythm Worse during day Improves at night Constant may be worse at night
Conjunctivitis Often present -
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Classification of A.R. (ARIA Workshop 2002)

• Intermittent
  Persistent
• lt 4 days/week
  4 days/week
• or lt 4 weeks and
  gt 4 weeks
• Mild Moderate Severe
• Normal sleep and
  One or more items
• No impairment of daily
  - abnormal sleep
• activities, sports, leisure
  - impairment of daily
• Normal work school
  activities
• No troublesome - abnormal
  work/school
• symptoms - troublesome
  symptoms

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Epidemiological Evidence

• Coexistence
• Increasing prevalence of both
• Rhinitis in asthma
• In over 3/4th of pts (50-80)
• - Concurrent
• - Sometimes
• Asthma in Rhinitis
• Significant occurrence (20-30)

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Immunological Link

• Common initiating step IgE
• - Antigen trigger
• - Inflammatory cell activation
• - Mediator release
• - Widespread effects
• Similar inflammmatory cell infiltrate and
  proinflammmatory mediators (hist, cys LT, Th2
  cytokines, chemokines, etc.)

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Pathological Changes

• Common respiratory mucosa
• Simultaneous inflammation of upper and lower
  respiratory tract
• - Eosinophilic oedema
• - Mucosal oedema
• - Increased permeability
• - Increased mucous secretions

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Clinical Association

• Common triggers
• Seasonal similarity
• Severity association
• Severe/poorly controlled AR
• with severe persistent asthma
• Provocation studies

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Provocation Studies

• Allergic Rhinitis
• - Endobronchial provocation mast cell
  degranulation and basophil influx in nose
• Br. Asthma
• - Nasal provocation (methacholine)
• - Increased Raw

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Therapeutic Issues

• Trigger control
• Common pharmacotherapy
• Surgical treatment for polyps, sinus disease
• Specific immunotherapy
• Prevention of asthma by timely tmt of AR?

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Common drug therapy

1. Use of anti-inflammatory (steroids, anti
   leukotrienes), anti histaminics and
   anticholinergics
2. Topical nasal steroids improve AR and BHR
3. Inhaled CS improve AR
4. Anti-IgE antibodies for both AR and asthma

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Different Treatments

1. Minimal role of several decongestants and
   antihistaminics in asthma
2. No role of theophyllines and beta agonists in
   A.R.
3. Specific Immunotherapy ??

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Possible Mechanisms

1. Common tract or systemic progression of
   inflammation
2. Nasal obstruction mouth breathing of cold and
   dry air
3. Loss of nasal protection
4. Post nasal drip
5. Nasobronchial reflex

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Unexplained Issues

1. Not all asthmatics have concurrent or preceding
   AR
2. Not all AR develop asthma
3. Common genetics and not a common Systemic
   Inflammatory Response
4. Anatomical differences
5. Treatment differences

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Clinical Implications of the Comorbidities

1. Increased health care costs
2. Impaired quality of life
3. Investigate for the co-occurrence
4. Secondary interventions in AR to interrupt the
   allergic march to asthma

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Stepwise Treatment Approach

• Allergic Rhinitis
• Allergen avoidance
• Intermittent
  Persistent
• Mild Moderate
  Mild Moderate
• 
  Severe
  Severe
• I/N CS
• Oral H1B
  Oral H1 I/N
  H1B and/or I/N H1B and/or DCs
  Review 2-4 wk
• DCs I/N
  CS
• Improvement Failure
• If persistent review at 2-4 wks Step down
  Review

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Failure of tmt at 2-4 weeks

• Review diagnosis/complications
• Query infections or other causes
• - Increase I/N corticosteroids
• - Add H1 blockers if itch/sneeze
• - Add ipratropium, if rhinorrhoea
• - Oral decongestants or steroids
• - Surgical review
• - Consider specific immunotherapy

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Role of Patient Training

• Training on the use of nasal spray
  (corticosteroids)
• Patients given training and a lesson on rhinitis
  and asthma
• - Improved compliance
• - Reduced concomitant asthma symptoms
• - Reduced use of rescue drugs
• 
  (Gani et al, 2001)

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SUMMARY

• ARIA Recommendations on Allergic Rhinitis
• Classify as a major chronic respir disease
• Risk factor for asthma
• New classification
• Stepwise treatment approach
• Combined strategy to evaluate, treat and control

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THANK YOU