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Asthma Rhinitis link
By 
Dr . Ashraf El-Adawy 
Consultant Chest Physcian 
TB TEAM Expert - WHO
Asthma and allergic Rhinitis are common health 
problems that cause major illness and disability 
world wide. 
Both are common chronic diseases that affect 
the quality of life of patients and have a significant 
economic impact 
European Respiratory Disease 2006
The prevalence of asthma and rhinitis varies 
all over the world with allergic Rhinitis being 
two times more prevalent than asthma. 
The worldwide incidence of allergic 
Rhinitis and asthma has been on 
the rise . 
European Respiratory Disease 2006
Australia 
asthma 18% 
rhinitis 25% 
Canada 
asthma 13% 
rhinitis 25% 
Sweden 
asthma 8% 
rhinitis 15% 
China 
asthma 5% 
rhinitis 10% 
Worldwide prevalence 
Brasil 
asthma 10% 
rhinitis 22% 
Kenya 
asthma 8% 
rhinitis 13% 
ISAAC study, Lancet 1998
Using a conservative estimate, it is proposed 
that allergic rhinitis occurs in around 500 
million people 
Studies suggest that there are more than 300 
million persons worldwide who are affected 
by asthma
Co-Existence of Asthma and 
Allergic Rhinitis: A 23-Year follow- 
Up Study of College Students 
William A. Greinsner, Robert J. Settipane and Guy A. Settipane 
Allergy and Asthma Proc 1998
Allergic Rhinitis and Asthma 
frequently occur together 
40% of allergic rhinitis patients have asthma 
80% of asthma patients have concomitant 
Rhinitis symptoms 
European Respiratory Disease 2006
Most Patients with Asthma Have Allergic Rhinitis 
• Approximately 80% of asthmatics have allergic rhinitis 
Asthma 
alone 
Allergic rhinitis 
alone 
Allergic 
rhinitis 
+ 
asthma 
Adapted from The Workshop Expert Panel. Management of Allergic Rhinitis and its Impact on Asthma (ARIA) Pocket Guide. A 
Pocket Guide for Physicians and Nurses. 2001; Bousquet J and the ARIA Workshop Group J Allergy Clin Immunol 2001;108(5):S147- 
S334; Sibbald B, Rink E Thorax 1991;46:895-901; Leynaert B et al Am J Respir Crit 
Care Med 2000;162:1391-1396.
IMPACT OF ASTHMA AND 
ALLERGIC RHINITIS ON EACH 
• Epidemiologic 
• Anatomic 
• Physiologic 
• Immunopathologic 
• Therapeutic
Allergic Rhinitis is a risk factor for asthma 
Allergic Rhinitis increased the risk of asthma ~3-fold 
12 
10 
8 
6 
4 
2 
0 
Subjects with 
asthma at 23- 
year follow-up 
(%) 
10.5 
Allergic rhinitis 
at baseline 
(n=162) 
3.6 
No allergic rhinitis 
at baseline 
(n=528) 
p<0.002 
23-year follow-up of college freshmen undergoing allergy testing; data based on 738 individuals (69% male) with average age of 40 
years. 
Adapted from Settipane RJ et al Allergy Proc 1994;15:21-25.
Rhinitis as an independent risk factor for adult-onset 
asthma (atopic and non-atopic) 
(European Community Respiratory Health Survey) 
Asthma (%) 
Atopic Non atopic 
25 
20 
15 
10 
5 
Adapted from Leynaert B et al. J Allergy Clin Immunol 1999; 
no rhinitis, N=5198 
rhinitis, N=1412 
OR=11 
OR=17 
0
Prevalence of asthma (physician diagnosed) in Rhinitis 
- 591 patients 
- 502 controls 
- allergic to pollens, mite, 
-epithelia 
Bousquet, CEA 2005 
35 
30 
25 
20 
% subjects 
15 
10 
5 
0 
contr mild severe mild severe 
intermittent persistent 
% pazienti
The prevalence of asthma in subjects without 
Rhinitis is usually less than 2%. 
The prevalence of asthma in patients with Rhinitis 
varies from 10 to 40% depending on studies 
Patients with moderate/severe persistent Rhinitis 
may be more likely to suffer from asthma than 
those with an intermittent and/or a milder form of 
the disease
BHR was found in 24% to 40% 
of patients with active Rhinitis 
(In the general population the BHR prevalence is 10-20%) 
Di Lorenzo G. et al. 
“ Non-specific airway responsiveness in mono-sensitive Sicilian patients 
with allergic rhinitis: its relationship to total serum IgE levels 
and blood eosinophils during and out of the pollen season” 
Clin Exp Allergy 1997; 27: 1052-59 
Ramsdale EH et al. 
“ Asymptomatic bronchial hyperresponsiveness in rhinitis” 
J Allergy Clin Immunol 1985; 75: 573-577 
Annesi I. et al. 
“ Relationship of upper airways disorders to FEV1 and bronchial 
hyperresponsiveness in an epidemiological study” 
Eur Respir J 1992; 5: 1104-1110
Several studies suggested that patients 
with allergic Rhinitis and BHR are at 
higher risk of developing asthma 
Braman SS et al. 
“ Airway hyperresponsiveness in allergic rhinitis: 
a risk factor for asthma” 
Chest 1987; 91: 671-674 
Laprise C. et al. 
“ Asymptomatic airway hyperresponsiveness: 
A three-year follow-up” 
Am J Respir Crit Care Med 1997; 156: 403-9
The current concept is that AR precedes 
Rhinitis 
asthma 
Disease severity 
time 
Togias, Allergy 1999 
asthma in most patients
The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs 
CHDs 
Atopic 
Dermatitis 
GI 
Distress 
Recurrent 
Otitis 
Media 
Allergic 
Asthma 
Allergic 
Rhinitis 
Food 
Sensitivity 
Inhalant 
Sensitivity 
Time (~years) 
Genetic 
Predispositi 
on
Links between Rhinitis and asthma 
Epidemiologic evidence 
Rhinitis is a significant risk factor for adult-onset 
asthma in both atopic and non-atopic 
subjects increased the risk by about 3 times. 
76% asthmatic patients reported presence 
of Rhinitis before onset asthma.
Links between Rhinitis and asthma 
Epidemiologic evidence 
Patients with moderate/severe persistent Rhinitis 
may be more likely to suffer from asthma than 
those with an intermittent and/or mild Rhinitis 
Asthma prevalence is increased in allergic and 
non-allergic Rhinitis 
Non-specific bronchial hyperreactivity is 
increased in persistent Rhinitis
Allergic Rhinitis and Asthma Share 
Common Triggers
• . 
Allergic Rhinitis and asthma share 
similar inflammatory processes 
Common triggers 
Similar inflammatory cascade on exposure to 
allergen 
Similar pattern of early- and late-phase responses 
Infiltration by the same inflammatory cells 
(e.g.eosinophils) 
Several potential connecting pathways including 
systemic transmission of inflammatory mediators
Allergic asthma and allergic Rhinitis are 
characterized by a similar inflammatory process 
Eosinophils in airway mucosa are regarded as the 
hallmark of allergic Rhinitis and asthma 
Eosinophilic inflammation has been found in the 
lower airways of allergic Rhinitis patients without 
asthma and in the upper airways of asthmatic 
patients without nasal complaints
Bronchial biopsioes after 
Specific provocation in 
patients with rhinitis or 
asthma 
ASTHMA 
Crimi E et al, JAP 2001 
RHINITIS ALONE 
Same inflammation
Nasal allergen challenge 
Increases bronchial reactivity 
Induces bronchial inflammation 
Littell NT, Changes in airways resistance following nasal provocation. Am Rev Respir Dis 1990 
Corren J Changes in bronchial responsiveness following nasal provocation with allergens. JACI 1992 
Small P ET AL The effects of allergen-induced nasal provocation on pulmonary function in patients 
with perennial allergic rhinitis. Am J Rhinol 1989
Induces nasal inflammation 
Bronchial endoscopic challenge 
With allergen
Mechanisms of pathologic relationships 
between upper and lower airways. 
Togias A Allergy 1999;54(suppl 57):94.. 
Aspiration of 
Inflammatory 
Material 
Oral breathing 
Nasopharyngo-bronchial 
reflex 
Systemic 
Propagation of 
Nasal 
Inflammation
Naso-bronchial reflex 
Allergen 
INFLAMMATION 
nose 
Cytokines bone marrow 
bronchi 
Bronchial hyperreactivity 
physical filter function 
adhesion molecules 
viral infection
The relationships between Rhinitis and asthma can be 
viewed under the concept that the 2 conditions are 
manifestations of one syndrome, in 2 parts of the 
respiratory tract , the upper and lower airways, 
respectively 
At the low end of the severity spectrum, Rhinitis may 
occur alone , in the middle range of the spectrum, 
Rhinitis and AHR may be present and, at the high end, 
Rhinitis and asthma may both be present, with the 
severity of each condition tracking in parallel. 
. 
Togias A, J Allergy Clin Immunol Jun2003
Chronic Allergic Inflammatory Airway 
Syndrome 
Allergic Rhinitis 
Allergic rhinitis + Bronchial Hyperreactivity 
Allergic Rhinitis + Asthma
Allergic Rhinitis and Asthma: 
Two Related Conditions Linked 
by One Common Airway 
The United Airways Disease
The allergic Rhinitis and asthma frequently co-exist 
leading to the concept that these seemingly separate 
disorders are manifestations of the same disease 
expressed to a greater or lesser extent in either 
the upper or the lower airways. 
In some patients Rhinitis predominates and asthma is 
undiagnosed or sub-clinical, in others it is reversed, 
while in many both are clinically expressed. 
Togias A, J Allergy Clin Immunol Jun2003
The nose-lung interaction in 
allergic rhinitis and asthma: 
united airways disease 
G.Passalacqua, 
G.Ciprandi & G.W.Canonica 
2004 
Asthma and Rhinitis as different 
Aspects of a sinlge disorder
Clinical links
Influence of comorbid conditions on asthma 
Boulet LP, ERJ 2009
Risk factors of frequent exacerbation 
in difficult-to-treat asthma 
Ten Brinke A et al Eur Resp J 2005 
51
Clinical aspects of the link between 
chronic sinonasal diseases and asthma. 
Dursun et al. Allergy Asthma Proc 2006
The coexistence of sinusitis and asthma, especially in 
children, is known, and infection of the paranasal 
sinuses is frequently implicated in the development 
of disease of the lower respiratory tract in allergic 
patients. 
Sinusitis and/or adenoiditis have been shown by 
endoscopic assessment to occur in more than 50% 
of children with asthma. 
ARIA 2008
Infected sinuses are a reservoir of proliferating 
bacteria and are frequently associated with 
worsening of asthma. 
Endotoxins from the cell walls of gram-negative 
bacteria have potent pro-inflammatory properties, 
and inhalation of endotoxin has been shown to 
induce airway narrowing and hyperresponsiveness 
in patients with asthma.
Good correlation among abnormal sinus x-rays, 
blood eosinophilia and asthma symptoms 
Steroid-dependent asthmatics usually have 
abnormal sinus computed tomography 
The sinonasal inflammation is a risk for asthma 
exacerbation 
Treatment of sinusitis improves asthma
Cruz, Allergy 2008
Untreated rhinitis increases the risk of asthma 
attacks. 
Asthma 
Asthma + rhinitis 
Bousquet, Clin Exp Allergy 2005
Treatment of Rhinitis reduces 
emergency visits for asthma 
Baena-Cagnani et al, Int Arch Allergy Immunol 2003 
Nelson HS, JACI 2003 
Crystal-Peters, JACI 2002 
Fuhlbrigge, Curr Opin Allergy Immunol 2003 
Adams et al. J.A.C.I. 2002
Treating allergic rhinitis cuts asthma costs 
• 61% fewer hospitalisations in treated patients 
0.9 
2.3 
p<0.01 
Patients 
hospitalised 
over 1-year 
period (%) 
Patients untreated 
for AR 
(n=1357) 
Patients treated 
for AR 
(n=3587) 
2.5 
2.0 
1.5 
1.0 
0.5 
0.0
• therapeutic 
Therapeutic aspects
The severity of allergic rhinitis was shown to be directly 
correlated with asthma severity. 
Those patients whose allergic rhinitis was severe or poorly 
controlled had worse asthma control and tended to have 
more persistent asthma than those with mild or well 
controlled rhinitis. 
In addition, bronchial hyperresponsiveness can be present 
in patients with allergic rhinitis without clinical evidence of 
asthma 
ARIA 2008
Prompt and effective treatment of nasal disease can have 
a marked effect on preventing the development of 
asthma, and on existing asthma symptoms. 
The World Allergy Organization IAACI, 2003 
Treatment of rhinitis has the potential to reduce asthma 
symptoms to such an extent that treatment with 
prophylactic anti-asthma drugs may be unnecessary in 
some patients with a diagnosis of mild asthma. 
Curr Opin Allergy Clin Immunol 2003
Among a population with co-existing asthma and 
allergic rhinitis, treatment for allergic rhinitis was 
associated with a decrease in the risk of subsequent 
asthma-related events by one-third to one-half 
compared with persons who did not receive 
treatment for this disorder. 
Fuhlbrigge A, Curr Opin Allergy Clin Immunol 2003
The recommended clinical approach is to manage 
the two disorders discretely but simultaneously. 
You should treat each disease separately; that even 
though it's 1 disease, you can't just treat the nose and 
take care of the asthma,or treat the asthma and 
take care of the nose. Each one has to be treated 
appropriately. 
Asthma Management: An Expert Interview With Harold Nelson, MD 4/1/2005 
Harold Nelson, MD, Professor of Medicine at National Jewish Medical and 
Research Center, discusses data presented at AAAAI 2005 in asthma 
management.
Asthma Pathophysiology 
Symptoms 
The tip of the iceberg 
Airflow 
obstruction 
Bronchial 
hyperresponsiveness 
Airway 
inflammation
Minimal persistent inflammation is also 
Present in patients with seasonal allergic 
rhinitis 
V. Ricca, M.Landi, P.Ferrero, A.Bairo, C.Tazzer,G.W.Canonica 
and G.Ciprandi 
gw111199 
J.A.C.I. 2001
Concept of "minimal persistent inflammation" 
Threshold level 
for symptoms 
100 
10 
1 
0,1 
0 2 4 6 8 10 12 Months 
mite allergen (μg/g of dust) 
Minimal persistent 
inflammation 
Symptoms 
inflammation 
Ciprandi et al, J Allergy Clin Immunol 1996
Instead of considering allergic rhinitis as a disease of 
acute symptoms, it needs to be understood as a 
chronic inflammatory disease. 
Even in the absence of symptoms, continuous 
exposure to low levels of allergen results in an 
inflammatory infiltration and ICAM-1 expression, 
which is known as "minimal persistent inflammation" 
(MPI).
The concept of minimal persistent inflammation 
suggests a different approach to therapy in which 
symptoms can be considered the “tip of the iceberg” 
of the allergic reaction with inflammation and hyper-responsiveness 
representing the submerged iceberg 
Therefore, any optimal therapeutic strategy for AR 
should focus on minimizing inflammatory 
phenomena rather than only on alleviating acute 
symptoms.
Therapeutic implications of minimal persistent 
inflammation 
The intranasal corticosteroids (INCSs) are the current 
first-line therapy for moderate to severe cases of 
seasonal and perennial AR 
Regular persistent use of INCSs has been effective in 
reducing all symptoms nasal congestion, rhinorrhoea, 
sneezing, and nasal itching in both adults and 
children. They also suppress multiple mediators and 
several stages of the inflammatory process.
INCS are 
the most effective drug 
In A.R. 
ICS are 
the milestone 
asthma treatment 
• ICS+INCS in the same UAD patients???????
Taramarcaz, Cochrane 2008
Conclusions: Treatment of nasal conditions, particularly 
with intranasal steroids, confers significant protection 
against exac-erbations of asthma leading to ED visits for 
asthma. 
These results support the use of intranasal steroids by 
individuals with asthma and upper airways conditions. 
J Allergy Clin Immunol. 2002 
Apr;109(4):636-42
mild 
intermittent 
TREATMENT OF ALLERGIC RHINITIS 
ARIA -Allergic Rhinitis and its Impact on Asthma 
Mild 
persistent 
Moderate-severe 
intermittent 
Moderate-severe 
persistent 
Antileukotrienes (if asthma) 
Nasal steroid 
Cromones 
2nd Generation antihistamine 
Decongestant (<10 days) 
Allergen avoidance 
Im immunotherapy
Treatment of comorbid Rhinitis & asthma
"integrated" therapeutic approach in patients with rhinitis and asthma.
Treatment of rhinitis and asthma using 
a single approach 
● Oral H1-antihistamines are not recommended, but 
not contraindicated in the treatment of asthma. 
● Intranasal glucocorticosteroids are at best 
moderately effective in asthma. 
● Intranasal glucocorticosteroids may be effective in 
reducing asthma exacerbations and 
hospitalizations. 
● The role of intrabronchial glucocorticosteroids in 
rhinitis is unknown. 
ARIA 2008
● Montelukast is effective in the treatment of allergic 
rhinitis and asthma in patients over 6 years of age. 
● Subcutaneous immunotherapy is recommended in 
both rhinitis and asthma in adults, but it is burdened 
by side effects, in particular in asthmatics. 
● Anti-IgE monoclonal antibody is effective for both 
rhinitis and asthma. 
ARIA 2008
combined simultaneous treatment of 
co-existing asthma & rhinitis 
Pulmonary 
steroid 
Twice daily 
& 
Pulmonary 
bronchodilator 
Rescue 
medication 
Oral 
Anti-histamine 
Once daily 
Or 
Oral 
Anti-leukotriene 
Once daily 
+ + & 
Nasal 
steroid 
Once daily 
Or 
Pulmonary 
combination 
: 
ICS+LABA 
Twice daily 
+ +
When to Consider Immunotherapy 
Mild 
Moderate ± 
conjunctivitis 
Allergen avoidance when possible 
RHINITIS 
Pharmacotherapy 
Severe ± 
conjunctivitis 
Consider immunotherapy 
Intermittent Mild persistent 
Pharmacotherapy 
Moderate 
persistent 
Consider immunotherapy 
Severe 
persistent
Final Remarks 
“Allergic rhinitis and asthma are chronic 
inflammatory disorders that have been linked 
epidemiologically, pathophysiologically, and 
therapeutically as “one airway disease.”
Final Remarks 
1-Patients with persistent Rhinitis should be 
evaluated for asthma 
2-Patients with persistent asthma should be 
evaluated for Rhinitis 
3-A combined strategy should be used in the 
treatment of upper and lower airways
Thank you for staying awake!

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Asthma Rhinitis

  • 1.
  • 3. By Dr . Ashraf El-Adawy Consultant Chest Physcian TB TEAM Expert - WHO
  • 4. Asthma and allergic Rhinitis are common health problems that cause major illness and disability world wide. Both are common chronic diseases that affect the quality of life of patients and have a significant economic impact European Respiratory Disease 2006
  • 5. The prevalence of asthma and rhinitis varies all over the world with allergic Rhinitis being two times more prevalent than asthma. The worldwide incidence of allergic Rhinitis and asthma has been on the rise . European Respiratory Disease 2006
  • 6. Australia asthma 18% rhinitis 25% Canada asthma 13% rhinitis 25% Sweden asthma 8% rhinitis 15% China asthma 5% rhinitis 10% Worldwide prevalence Brasil asthma 10% rhinitis 22% Kenya asthma 8% rhinitis 13% ISAAC study, Lancet 1998
  • 7. Using a conservative estimate, it is proposed that allergic rhinitis occurs in around 500 million people Studies suggest that there are more than 300 million persons worldwide who are affected by asthma
  • 8. Co-Existence of Asthma and Allergic Rhinitis: A 23-Year follow- Up Study of College Students William A. Greinsner, Robert J. Settipane and Guy A. Settipane Allergy and Asthma Proc 1998
  • 9. Allergic Rhinitis and Asthma frequently occur together 40% of allergic rhinitis patients have asthma 80% of asthma patients have concomitant Rhinitis symptoms European Respiratory Disease 2006
  • 10. Most Patients with Asthma Have Allergic Rhinitis • Approximately 80% of asthmatics have allergic rhinitis Asthma alone Allergic rhinitis alone Allergic rhinitis + asthma Adapted from The Workshop Expert Panel. Management of Allergic Rhinitis and its Impact on Asthma (ARIA) Pocket Guide. A Pocket Guide for Physicians and Nurses. 2001; Bousquet J and the ARIA Workshop Group J Allergy Clin Immunol 2001;108(5):S147- S334; Sibbald B, Rink E Thorax 1991;46:895-901; Leynaert B et al Am J Respir Crit Care Med 2000;162:1391-1396.
  • 11. IMPACT OF ASTHMA AND ALLERGIC RHINITIS ON EACH • Epidemiologic • Anatomic • Physiologic • Immunopathologic • Therapeutic
  • 12. Allergic Rhinitis is a risk factor for asthma Allergic Rhinitis increased the risk of asthma ~3-fold 12 10 8 6 4 2 0 Subjects with asthma at 23- year follow-up (%) 10.5 Allergic rhinitis at baseline (n=162) 3.6 No allergic rhinitis at baseline (n=528) p<0.002 23-year follow-up of college freshmen undergoing allergy testing; data based on 738 individuals (69% male) with average age of 40 years. Adapted from Settipane RJ et al Allergy Proc 1994;15:21-25.
  • 13. Rhinitis as an independent risk factor for adult-onset asthma (atopic and non-atopic) (European Community Respiratory Health Survey) Asthma (%) Atopic Non atopic 25 20 15 10 5 Adapted from Leynaert B et al. J Allergy Clin Immunol 1999; no rhinitis, N=5198 rhinitis, N=1412 OR=11 OR=17 0
  • 14. Prevalence of asthma (physician diagnosed) in Rhinitis - 591 patients - 502 controls - allergic to pollens, mite, -epithelia Bousquet, CEA 2005 35 30 25 20 % subjects 15 10 5 0 contr mild severe mild severe intermittent persistent % pazienti
  • 15. The prevalence of asthma in subjects without Rhinitis is usually less than 2%. The prevalence of asthma in patients with Rhinitis varies from 10 to 40% depending on studies Patients with moderate/severe persistent Rhinitis may be more likely to suffer from asthma than those with an intermittent and/or a milder form of the disease
  • 16. BHR was found in 24% to 40% of patients with active Rhinitis (In the general population the BHR prevalence is 10-20%) Di Lorenzo G. et al. “ Non-specific airway responsiveness in mono-sensitive Sicilian patients with allergic rhinitis: its relationship to total serum IgE levels and blood eosinophils during and out of the pollen season” Clin Exp Allergy 1997; 27: 1052-59 Ramsdale EH et al. “ Asymptomatic bronchial hyperresponsiveness in rhinitis” J Allergy Clin Immunol 1985; 75: 573-577 Annesi I. et al. “ Relationship of upper airways disorders to FEV1 and bronchial hyperresponsiveness in an epidemiological study” Eur Respir J 1992; 5: 1104-1110
  • 17. Several studies suggested that patients with allergic Rhinitis and BHR are at higher risk of developing asthma Braman SS et al. “ Airway hyperresponsiveness in allergic rhinitis: a risk factor for asthma” Chest 1987; 91: 671-674 Laprise C. et al. “ Asymptomatic airway hyperresponsiveness: A three-year follow-up” Am J Respir Crit Care Med 1997; 156: 403-9
  • 18. The current concept is that AR precedes Rhinitis asthma Disease severity time Togias, Allergy 1999 asthma in most patients
  • 19. The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Atopic Dermatitis GI Distress Recurrent Otitis Media Allergic Asthma Allergic Rhinitis Food Sensitivity Inhalant Sensitivity Time (~years) Genetic Predispositi on
  • 20. Links between Rhinitis and asthma Epidemiologic evidence Rhinitis is a significant risk factor for adult-onset asthma in both atopic and non-atopic subjects increased the risk by about 3 times. 76% asthmatic patients reported presence of Rhinitis before onset asthma.
  • 21. Links between Rhinitis and asthma Epidemiologic evidence Patients with moderate/severe persistent Rhinitis may be more likely to suffer from asthma than those with an intermittent and/or mild Rhinitis Asthma prevalence is increased in allergic and non-allergic Rhinitis Non-specific bronchial hyperreactivity is increased in persistent Rhinitis
  • 22. Allergic Rhinitis and Asthma Share Common Triggers
  • 23. • . Allergic Rhinitis and asthma share similar inflammatory processes Common triggers Similar inflammatory cascade on exposure to allergen Similar pattern of early- and late-phase responses Infiltration by the same inflammatory cells (e.g.eosinophils) Several potential connecting pathways including systemic transmission of inflammatory mediators
  • 24.
  • 25. Allergic asthma and allergic Rhinitis are characterized by a similar inflammatory process Eosinophils in airway mucosa are regarded as the hallmark of allergic Rhinitis and asthma Eosinophilic inflammation has been found in the lower airways of allergic Rhinitis patients without asthma and in the upper airways of asthmatic patients without nasal complaints
  • 26. Bronchial biopsioes after Specific provocation in patients with rhinitis or asthma ASTHMA Crimi E et al, JAP 2001 RHINITIS ALONE Same inflammation
  • 27. Nasal allergen challenge Increases bronchial reactivity Induces bronchial inflammation Littell NT, Changes in airways resistance following nasal provocation. Am Rev Respir Dis 1990 Corren J Changes in bronchial responsiveness following nasal provocation with allergens. JACI 1992 Small P ET AL The effects of allergen-induced nasal provocation on pulmonary function in patients with perennial allergic rhinitis. Am J Rhinol 1989
  • 28. Induces nasal inflammation Bronchial endoscopic challenge With allergen
  • 29. Mechanisms of pathologic relationships between upper and lower airways. Togias A Allergy 1999;54(suppl 57):94.. Aspiration of Inflammatory Material Oral breathing Nasopharyngo-bronchial reflex Systemic Propagation of Nasal Inflammation
  • 30. Naso-bronchial reflex Allergen INFLAMMATION nose Cytokines bone marrow bronchi Bronchial hyperreactivity physical filter function adhesion molecules viral infection
  • 31. The relationships between Rhinitis and asthma can be viewed under the concept that the 2 conditions are manifestations of one syndrome, in 2 parts of the respiratory tract , the upper and lower airways, respectively At the low end of the severity spectrum, Rhinitis may occur alone , in the middle range of the spectrum, Rhinitis and AHR may be present and, at the high end, Rhinitis and asthma may both be present, with the severity of each condition tracking in parallel. . Togias A, J Allergy Clin Immunol Jun2003
  • 32. Chronic Allergic Inflammatory Airway Syndrome Allergic Rhinitis Allergic rhinitis + Bronchial Hyperreactivity Allergic Rhinitis + Asthma
  • 33. Allergic Rhinitis and Asthma: Two Related Conditions Linked by One Common Airway The United Airways Disease
  • 34.
  • 35. The allergic Rhinitis and asthma frequently co-exist leading to the concept that these seemingly separate disorders are manifestations of the same disease expressed to a greater or lesser extent in either the upper or the lower airways. In some patients Rhinitis predominates and asthma is undiagnosed or sub-clinical, in others it is reversed, while in many both are clinically expressed. Togias A, J Allergy Clin Immunol Jun2003
  • 36. The nose-lung interaction in allergic rhinitis and asthma: united airways disease G.Passalacqua, G.Ciprandi & G.W.Canonica 2004 Asthma and Rhinitis as different Aspects of a sinlge disorder
  • 38. Influence of comorbid conditions on asthma Boulet LP, ERJ 2009
  • 39. Risk factors of frequent exacerbation in difficult-to-treat asthma Ten Brinke A et al Eur Resp J 2005 51
  • 40. Clinical aspects of the link between chronic sinonasal diseases and asthma. Dursun et al. Allergy Asthma Proc 2006
  • 41. The coexistence of sinusitis and asthma, especially in children, is known, and infection of the paranasal sinuses is frequently implicated in the development of disease of the lower respiratory tract in allergic patients. Sinusitis and/or adenoiditis have been shown by endoscopic assessment to occur in more than 50% of children with asthma. ARIA 2008
  • 42. Infected sinuses are a reservoir of proliferating bacteria and are frequently associated with worsening of asthma. Endotoxins from the cell walls of gram-negative bacteria have potent pro-inflammatory properties, and inhalation of endotoxin has been shown to induce airway narrowing and hyperresponsiveness in patients with asthma.
  • 43. Good correlation among abnormal sinus x-rays, blood eosinophilia and asthma symptoms Steroid-dependent asthmatics usually have abnormal sinus computed tomography The sinonasal inflammation is a risk for asthma exacerbation Treatment of sinusitis improves asthma
  • 45. Untreated rhinitis increases the risk of asthma attacks. Asthma Asthma + rhinitis Bousquet, Clin Exp Allergy 2005
  • 46. Treatment of Rhinitis reduces emergency visits for asthma Baena-Cagnani et al, Int Arch Allergy Immunol 2003 Nelson HS, JACI 2003 Crystal-Peters, JACI 2002 Fuhlbrigge, Curr Opin Allergy Immunol 2003 Adams et al. J.A.C.I. 2002
  • 47. Treating allergic rhinitis cuts asthma costs • 61% fewer hospitalisations in treated patients 0.9 2.3 p<0.01 Patients hospitalised over 1-year period (%) Patients untreated for AR (n=1357) Patients treated for AR (n=3587) 2.5 2.0 1.5 1.0 0.5 0.0
  • 49. The severity of allergic rhinitis was shown to be directly correlated with asthma severity. Those patients whose allergic rhinitis was severe or poorly controlled had worse asthma control and tended to have more persistent asthma than those with mild or well controlled rhinitis. In addition, bronchial hyperresponsiveness can be present in patients with allergic rhinitis without clinical evidence of asthma ARIA 2008
  • 50. Prompt and effective treatment of nasal disease can have a marked effect on preventing the development of asthma, and on existing asthma symptoms. The World Allergy Organization IAACI, 2003 Treatment of rhinitis has the potential to reduce asthma symptoms to such an extent that treatment with prophylactic anti-asthma drugs may be unnecessary in some patients with a diagnosis of mild asthma. Curr Opin Allergy Clin Immunol 2003
  • 51. Among a population with co-existing asthma and allergic rhinitis, treatment for allergic rhinitis was associated with a decrease in the risk of subsequent asthma-related events by one-third to one-half compared with persons who did not receive treatment for this disorder. Fuhlbrigge A, Curr Opin Allergy Clin Immunol 2003
  • 52. The recommended clinical approach is to manage the two disorders discretely but simultaneously. You should treat each disease separately; that even though it's 1 disease, you can't just treat the nose and take care of the asthma,or treat the asthma and take care of the nose. Each one has to be treated appropriately. Asthma Management: An Expert Interview With Harold Nelson, MD 4/1/2005 Harold Nelson, MD, Professor of Medicine at National Jewish Medical and Research Center, discusses data presented at AAAAI 2005 in asthma management.
  • 53. Asthma Pathophysiology Symptoms The tip of the iceberg Airflow obstruction Bronchial hyperresponsiveness Airway inflammation
  • 54.
  • 55. Minimal persistent inflammation is also Present in patients with seasonal allergic rhinitis V. Ricca, M.Landi, P.Ferrero, A.Bairo, C.Tazzer,G.W.Canonica and G.Ciprandi gw111199 J.A.C.I. 2001
  • 56. Concept of "minimal persistent inflammation" Threshold level for symptoms 100 10 1 0,1 0 2 4 6 8 10 12 Months mite allergen (μg/g of dust) Minimal persistent inflammation Symptoms inflammation Ciprandi et al, J Allergy Clin Immunol 1996
  • 57. Instead of considering allergic rhinitis as a disease of acute symptoms, it needs to be understood as a chronic inflammatory disease. Even in the absence of symptoms, continuous exposure to low levels of allergen results in an inflammatory infiltration and ICAM-1 expression, which is known as "minimal persistent inflammation" (MPI).
  • 58. The concept of minimal persistent inflammation suggests a different approach to therapy in which symptoms can be considered the “tip of the iceberg” of the allergic reaction with inflammation and hyper-responsiveness representing the submerged iceberg Therefore, any optimal therapeutic strategy for AR should focus on minimizing inflammatory phenomena rather than only on alleviating acute symptoms.
  • 59. Therapeutic implications of minimal persistent inflammation The intranasal corticosteroids (INCSs) are the current first-line therapy for moderate to severe cases of seasonal and perennial AR Regular persistent use of INCSs has been effective in reducing all symptoms nasal congestion, rhinorrhoea, sneezing, and nasal itching in both adults and children. They also suppress multiple mediators and several stages of the inflammatory process.
  • 60. INCS are the most effective drug In A.R. ICS are the milestone asthma treatment • ICS+INCS in the same UAD patients???????
  • 62.
  • 63. Conclusions: Treatment of nasal conditions, particularly with intranasal steroids, confers significant protection against exac-erbations of asthma leading to ED visits for asthma. These results support the use of intranasal steroids by individuals with asthma and upper airways conditions. J Allergy Clin Immunol. 2002 Apr;109(4):636-42
  • 64. mild intermittent TREATMENT OF ALLERGIC RHINITIS ARIA -Allergic Rhinitis and its Impact on Asthma Mild persistent Moderate-severe intermittent Moderate-severe persistent Antileukotrienes (if asthma) Nasal steroid Cromones 2nd Generation antihistamine Decongestant (<10 days) Allergen avoidance Im immunotherapy
  • 65. Treatment of comorbid Rhinitis & asthma
  • 66. "integrated" therapeutic approach in patients with rhinitis and asthma.
  • 67. Treatment of rhinitis and asthma using a single approach ● Oral H1-antihistamines are not recommended, but not contraindicated in the treatment of asthma. ● Intranasal glucocorticosteroids are at best moderately effective in asthma. ● Intranasal glucocorticosteroids may be effective in reducing asthma exacerbations and hospitalizations. ● The role of intrabronchial glucocorticosteroids in rhinitis is unknown. ARIA 2008
  • 68. ● Montelukast is effective in the treatment of allergic rhinitis and asthma in patients over 6 years of age. ● Subcutaneous immunotherapy is recommended in both rhinitis and asthma in adults, but it is burdened by side effects, in particular in asthmatics. ● Anti-IgE monoclonal antibody is effective for both rhinitis and asthma. ARIA 2008
  • 69. combined simultaneous treatment of co-existing asthma & rhinitis Pulmonary steroid Twice daily & Pulmonary bronchodilator Rescue medication Oral Anti-histamine Once daily Or Oral Anti-leukotriene Once daily + + & Nasal steroid Once daily Or Pulmonary combination : ICS+LABA Twice daily + +
  • 70. When to Consider Immunotherapy Mild Moderate ± conjunctivitis Allergen avoidance when possible RHINITIS Pharmacotherapy Severe ± conjunctivitis Consider immunotherapy Intermittent Mild persistent Pharmacotherapy Moderate persistent Consider immunotherapy Severe persistent
  • 71.
  • 72. Final Remarks “Allergic rhinitis and asthma are chronic inflammatory disorders that have been linked epidemiologically, pathophysiologically, and therapeutically as “one airway disease.”
  • 73. Final Remarks 1-Patients with persistent Rhinitis should be evaluated for asthma 2-Patients with persistent asthma should be evaluated for Rhinitis 3-A combined strategy should be used in the treatment of upper and lower airways
  • 74. Thank you for staying awake!