Treating rhinitis may benefit patients with asthma

April 2005

BAL HARBOUR, Fla. — Treating rhinitis may benefit patients with asthma, because they may not be two conditions, but be components of one inflammatory disease, said Michael S. Blaiss, MD, at the Masters of Pediatrics Meeting held here.

Allergic rhinitis occurs in nearly all patients with asthma, but your patients may not recognize the severity of their rhinitis due to the impact of the asthma.

“Treatments which target rhinitis definitely exert short- and probably long-term benefits as far as the treatment of that child with asthma,” explained Blaiss, who is clinical professor of pediatrics and medicine at the division of clinical immunology and asthma at the University of Tennessee Health Science Center in Memphis.

At least 90% of people with asthma have allergic rhinitis, and young patients with allergic rhinitis, but not asthma, have a three-fold higher risk of developing asthma.

Similar triggers

Allergic rhinitis and asthma are inflammatory conditions with similar triggers. The same cells are involved in both inflammatory conditions: the mast cell releases chemical mediators, such as histamines, leukotrienes, eosinophils and cytokines. And the same drugs are effective in treating upper and lower airway diseases: steroids, antihistamines, anti-leukotrienes and monoclonals against immunoglobulin E, he said.

“There are data that show that lower airway symptoms may trigger upper airway disease,” said Blaiss. After all, there really is no demarcation between the upper and lower airways, he said.

Italian researchers looked at patients with chronic sinusitis and severe steroid-dependent asthma and compared them with a group of mild or moderate asthma patients. They enrolled 35 patients with severe asthma that were on daily doses of oral corticosteroids and 34 patients with mild to moderate asthma. The patients with mild to moderate asthma had significantly less rhinitis than the patients with severe steroid-dependent asthma ( P =0.05).

Another study published in the Journal of Allergy and Clinical Immunology in 2001 tried to show the relationship immunologically between upper and lower airway disease. Patients with rhinitis but not asthma were compared with patients without either condition. The researchers did a baseline biopsy, and then challenged them with grass pollen. Every two hours they recorded nasal and lung symptoms. At the end of 24 hours, they repeated the biopsy. The group with allergic rhinitis developed significant symptomatology, while the placebo group did not. Within two hours, the rhinitis patients also reported some lung symptomatology. In addition, the rhinitis patients saw a drop in their peak flows at four, six, 10 and 12 hours after challenge.

Another study looked at whether nasal steroids affected lower airways in patients with seasonal allergic rhinitis and seasonal asthma. This was a single-blind study of 120 patients with ragweed hay fever and about half of these patients said ragweed triggered their asthma. The researchers looked at two intranasal corticosteroids, beclomethasone and flunisolide, they looked at cromolyn and the placebo over a six-week period and they monitored the patients’ nasal and asthma symptoms. The patients all remained on their normal asthma medications during the study.

Patients who were on the intranasal corticosteroids during ragweed season saw significant improvement in their upper airway disease, more so than those on cromolyn or placebo. “In both the groups that received intranasal corticosteroids, there was no worsening effect of their asthma during the ragweed season,” Blaiss said.

A retrospective analysis study in the Journal of Allergy and Clinical Immunology concluded that an asthma patient who also took intranasal corticosteroids had fewer emergency room visits than one who did not use intranasal steroids.

Amy Grant, MD, of Galveston and colleagues looked at whether antihistamines affect asthma symptoms in patients with seasonal allergic rhinitis and asthma in a randomized, double-blind, placebo-controlled trial. Her team compared cetirizine HCl (Zyrtec, Pfizer) with placebo. They measured peak flow and measured nasal asthma symptomatology. As you would expect, the nasal symptomatology significantly improved in this study. But so did the asthma – even peak flow improved.

“Now, does that mean we want you to use antihistamine or intranasal steroids in the treatment of asthma? No. But this does tell us that these medications in the treatment of the upper airway do have a beneficial effect on lower airway disease,” Blaiss said.

Leukotriene receptor antagonists are now indicated for rhinitis and asthma. A study comparing montelukast (Singular, Merck) alone and with an H1 antihistamine loratadine in seasonal allergic rhinitis in 800 patients between 15 and 82 years of age found montelukast, loratadine or a combination of the two medications were significantly better than placebo, but there was no significant difference among the combination and the two individual agents.

Other studies have confirmed the effectiveness of leukotriene receptor antagonists for rhinitis and asthma.

“Now, one of the most interesting agents in the treatment approved in the United States for patients 12 and older with moderate to severe persistent asthma that are not responding to inhaled corticosteroids and have positive allergy skin tests is the use of omalizumab (Xolair, Genentech, Novartis) or anti-IgE therapy. This agent binds all types of IgE. So, it doesn’t matter whether it’s IgE for dust mites or IgE to cats or IgE to peanuts. It binds all types of IgE and basically acts as a sponging system binding it so it cannot attach to mast cells,” Blaiss said.

Omalizumab is given subcutaneously every two to four weeks depending upon the patient’s serum IgE level. Omalizumab binds the IgE in the serum therefore preventing it from attaching to the mast cell. Therefore when the patient is exposed to an allergen it cannot trigger the mast cell and blocks the allergic reaction.

Similar treatments

Since IgE is very important in asthma and allergic rhinitis, this treatment works for both upper and lower airway problems, he said.

“Now, of all these treatments for both upper and lower airway disease, immunotherapy is the only treatment that is disease modifying, that affects the immune system and turns off the allergic march. The question is, is there data out there that shows that immunotherapy is effective in both upper and lower airway disease?” Blaiss said the answer was yes, many studies show that immunotherapy affects both upper and lower airway disease.

One double-blind, placebo-controlled study tested 43 patients who were allergic to grass pollens, who received immunotherapy for two years. They saw a decrease in rhinitis symptoms.

“They were able to show a significant drop in methacholine challenge, therefore, showing the decreased bronchial hyperreactivity with the treatment of immunotherapy. When they looked at allergic rhinitis symptoms, they significantly dropped. And when they looked at skin test positivity, it significantly dropped,” Blaiss said.

For more information:

• Blaiss M. The allergy-asthma connection. Presented at the Masters of Pediatrics Meeting. Jan. 26-31, 2005. Bal Harbor, Fla.

• Dr. Blaiss is on the speaker’s bureau and a consultant for GlaxoSmithKline, Aventis, Merck, Genentech and AstraZeneca.