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Management of asthma and allergic rhinitis in primary care

Dave Burns
National Training Manager
Respiratory Education UK
Aintree Hospital Liverpool

This article looks at the diagnosis and management of allergy and asthma, with a focus on symptoms and treatment recommended in the current guidelines

Asthma and allergic rhinitis are two of the most common manifestations of atopy. In this condition genetically predisposed individuals produce excessive quantities of the antibody Immunoglobulin E (IgE) in response to molecules such as animal dander, pollens and other molecules which are in essence harmless.

The IgE binds to inflammatory cells in the respiratory tract, and in those individuals who develop allergic responses, the mast cells then secrete numerous inflammatory mediators which drive the symptoms of allergy in the relevant site. In allergic rhinitis, sufferers have well recognised symptoms of sneezing, runny nose, itchy nose and nasal congestion. In the lower airways, asthma sufferers may experience bronchospasm, oedema of the airway wall, and mucus hypersecretion. These all contribute to the symptoms experienced by the sufferer, such as chest tightness, shortness of breath, cough and wheeze. In both conditions the range of symptoms and their severity can vary both between and within individuals.

The disease burden imposed by asthma is well recognised. While the disease has been shown to be controllable in most patients (perhaps as many as 80% should be able to achieve very good or even complete control), it is estimated that only half of this is achieved. In addition, approximately 1,200 patients per year die, with many of these deaths being seen as preventable.

In terms of allergic rhinitis, the Allergic Rhinitis and its Impact on Asthma (ARIA) group have published evidence-based guidelines pertaining to all aspects of the disease.1 One of a number of bodies in the UK influencing care of AR patients is the British Society for Allergy and Clinical Immunology (BSACI).

BSACI's most recent guidelines acknowledge the impact of AR on sufferers in terms of social and work life, school children's exam performance and healthcare costs associated with the condition.2 The relationship between the two conditions is widely recognised. Both have similar aetiologies and pathophysiologies, the 'gold standard' treatment for both conditions is the same (ie. topical corticosteroids), and
treatment failures can frequently occur for similar reasons.

Diagnosis of asthma
Current guidelines offer advice on this aspect, with some emphasis on the importance of the clinical history. Interestingly, while diurnal peak expiratory flow (PEF) monitoring has been seen as a useful tool, more recent guidelines from the British Thoracic Society and the Scottish Intercollegiate Guideline Network (BTS/SIGN) have been more circumspect about the role of PEF monitoring as a diagnostic tool, and state that spirometry is the preferred measurement.3

Spirometry is seen as the gold standard of measurement in terms of airflow; however, a problem with the stance advocated by the guidelines is that many patients present without airflow obstruction, raising the question of what to do next. One option offered by the guidelines is to offer a trial of therapy where asthma is a high probability, and reviewing the patient.

Management of asthma
BTS/SIGN maintain the approach they have advocated since the early 1990s. This is a five-step approach with step 1 representing the mildest form of asthma and step 5 the most severe. As severity increases, treatment is also increased (on the assumption that the patient is adherent with current treatment, and is using their inhaler device correctly).
Checking inhaler technique is essential; a review of evidence in this area by Crompton et al found large numbers of asthma patients have problems using their inhaler.4

A previous study by Giraud et al found a correlation between the degree of incorrect device technique and level of poor control.5 It is also important to check for other factors impinging on asthma control such as current smoking, which has been shown to reduce the efficacy of ICS and concomitant AR, which is discussed below.6,7 The treatment of asthma is outlined in Box 1.

[[Box 1 all]]

Diagnosis of allergic rhinitis
It is important to take a careful history. The key elements of rhinitis are outlined by all guidelines, and include sneezing, rhinorrhoea, itching and congestion of the nose. Physical examination may reveal mucosal congestion and crustation within the nostrils, and mouth breathing may be present; in addition, there may be creasing across the bridge of the nose.

Guidelines describe a variety of investigations which are possible, but also acknowledge that many of these are either not accessible, or may not be suitable. One investigation which is commonly discussed is allergy testing, via a skin prick test, or measuring serum IgE. However, the results of these tests need to be interpreted in the context of the clinical history, and even where a specific allergen is identified, avoidance measures have been shown to be of little benefit.

Pharmacological management of allergic rhinitis
This also involves a stepped approach. The first step is the use of an oral antihistamine (OAH). These are very useful in milder forms of AR; however, one note of caution is that they have very little impact on nasal congestion, which can be quite problematic for sufferers. Generally, it is better to use a second generation antihistamine such as ceterizine or loratidine as these tend to be less sedating than first generation ones. Other advice regarding the use of antihistamines includes taking them in advance of the hayfever season (where the AR is seasonal) and even shopping around, as generic products can be significantly than branded ones.

In addition, some patients have a poor initial response, or seem to develop a degree of tolerance over time. This can be overcome by prescribing a different molecule; for example, switching from ceterizine to loratadine. Antihistamines can also be used topically. However, unsurprisingly, their effects are limited to the site of application. One example of where they may be of value is where patients generally well controlled with intranasal corticosteroids (INCs) may experience 'breakthrough' ocular symptoms on high pollen count days; these may require treatment with antihistamine eyedrops.

The next step is the use of INCs. As in asthma, these are seen as gold standard treatment. The reason for this is that in terms of pathophysiology of both conditions, a key player in the inflammatory process is the eosinophil - a cell which is particularly sensitive to corticosteroids in most individuals.

Effects of corticosteroids on eosinophils include reduced recruitment to target sites such as the airways and the nose; decreased inflammatory activity; and shorter survival times. INCs have been shown to have marked effects upon the nasal symptoms, and importantly, upon the nasal congestion.
However, one advantage of OAHs is their impact upon eye symptoms, which can also be troublesome for many patients.

While INCs are reported to have some impact upon eye symptoms, this is not a class effect, and patients who require INCS for severe nasal symptoms, may still require OAH as well or, as discussed above, topical antihistamine for breakthrough symptoms. A more recent INCs formulation, fluticasone furoate has been reported as having consistent benefits in terms of relieving both nasal and eye symptoms, and this may be worth considering in some patients.

Other topical nasal preparations, such as cromones and antihistamines, are available, but are less effective compared to INCs in more severe cases, and require multiple doses during the day, compared to the daily dosing regimen of the newer INCs molecules such as fluticasone and mometasone. These newer molecules have negligible systemic bioavailability, making them an attractive option where clinicians may worry about patients taking both ICS and INCs where asthma and
AR coexist.

For administration of INCs, a very common problem leading to poor treatment response is incorrect use of nasal sprays. It is essential patients are advised on the correct technique for use of these; failure to do so will lead to poor adherence, poor control and all the problems associated with this. The major steps in using an INCS spray are described in Box 2.

[[Box 2 all]]

Allergic rhinitis and asthma
These conditions frequently coexist. A summary of studies within the Allergic Rhinitis and its Impact on Asthma (ARIA) reveals overall approximately 50% of asthma sufferers will have some degree of rhinitis.2 Angier et al report a figure of 75%.1 Allergic rhinitis has been found to be a risk factor for asthma, with the risk of asthma in AR sufferers being increased by approximately four-fold.

In addition to the increased risk of asthma developing in AR sufferers, there is the issue of the impact of poorly controlled AR on asthma. Simple patient surveys indicate a deterioration in asthma control where AR is present; more robust studies such as case control studies have demonstrated that patients with both conditions who fail to treat their AR effectively have higher asthma exacerbation rates.8

Valovirta and Panakwar surveyed over 1,600 asthma patients, and found that 73% reported AR symptoms before their asthma diagnosis, supporting the idea of AR as a risk factor for asthma.9 Patients with both conditions reported sleep disruption (79%), problems with leisure/sport (75%), poor asthma control when AR was present (79%) and avoiding being outdoors in pollen season as their asthma becomes poorly controlled (56%). Both ARIA and BSACI, and the International Primary Care Respiratory Group (IPCRG) have stated that the failure to treat AR adequately may make asthma more difficult to control.10 Given these recommendations and the evidence they are based upon, it would seem logical to suppose that if AR is active, and asthma control deteriorates, then treating the AR would help stabilise the asthma. However, this has been hard to demonstrate effectively in a way which would satisfy BTS/SIGN, who, in reference to the presence of AR and asthma together, state that while many asthma patients have rhinitis, there is no evidence of any improvement in asthma control as a result of treating AR.3

A recent study has demonstrated this point. Dahl randomised
patients with AR and asthma into one of four treatment groups.11 Two groups received either placebo or active treatment for the two conditions; two other groups received active treatment at one site and placebo at another. The authors found no additional benefit from treating the other inflammatory condition. The message from this study overall was that where patients have both conditions, each must be treated adequately. This message is emphasised by guidelines such as ARIA and BSACI, who advise that, where the patient has an allergic inflammatory condition at one end of the airway, clinicians should assess the other end of the airway for co-existing disease - so check asthma patients for AR, and check AR patients for asthma.

Baser et al demonstrated the validity of this advice in a study of 89 AR patients.12 Following screening with an asthma questionnaire, lung function testing and a trial of treatment with ICS for three months, 29 previously undiagnosed asthma patients were uncovered.

Other treatment options
Leukotrienes have been found to be important mediators of inflammation in some individuals, and leukotriene receptor antagonists (LTRAs) are recommended as add on therapy in asthma at step three in the BTS/SIGN asthma guidelines.3 They are recommended in guidelines on managing AR. One school of thought argues that where patients at step 2 of the British guidelines have poorly controlled asthma (and assuming this is not due to poor compliance, poor inhaler technique, or smoking), and their lung function is satisfactory, the addition of a LTRA may be a more effective option that the addition of a LABA.

Some of the evidence for this approach is discussed by Currie et al,13 and anecdotally this is a common approach used in primary care. A study by Virchow and Bachert surveyed almost 6,000 patients with asthma and AR, and after baseline assessment of a number of variables such as general perception of control of both conditions, and more specific areas such as sleep and work, prescribed a LTRA for all patients.14 After three months of treatment over 80% of patients reported very good or good improvements in both conditions, suggesting that LTRAs confer significant benefit to patients with both asthma and AR. 

Asthma and AR are common manifestations of atopy. Both conditions commonly co-exist; AR has been shown to be a risk factor for future development of asthma, and where AR exists with asthma but is poorly controlled it can make asthma more difficult to control. Evidence of the benefits of treating AR in terms of better asthma control appear to be contradictory; but, certainly, treating both ends of the airway is logical and essential.

For both conditions, a common cause of poor outcome is a failure to use the medication device correctly, be it an inhaler for asthma or nasal spray for AR; correct education of patients is essential. Guidelines specific to management of AR advise checking AR patients for asthma and vice versa. Regardless of one's view of the potential benefits of AR treatment on asthma control, AR can be very debilitating and can severely impact upon numerous areas of an individual's life, making robust management essential.


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