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Rhinitis in children and adolescents with asthma: almost always present, difficult to manage and closely related with asthma severity

Published online: September 10, 2018

The medical community is largely aware of the links between asthma and rhinitis, but detailed explorations of these links, especially in children and adolescents, are missing. The National Institute of Allergy and Infectious Diseases – supported Asthma Phenotypes in the Inner City (APIC) study has reported its findings in 619 children and adolescents with asthma shedding light into the nature or rhinitis and its strong relationships with asthma. This report was published in The Journal of Allergy and Clinical Immunology by Togias and colleagues.

The APIC study, conducted by the Inner-City Asthma Consortium, recruited children and adolescents with asthma broadly covering all levels of severity. Study physicians treated all participants for 12 months with asthma guidelines-based medications, while several tests and examinations were conducted. At the same time, the study examined all participants for rhinitis.  Specifically, at the beginning of the study, participants were asked about the presence and seasonality of rhinitis symptoms and had blood and skin tests for allergies. This information was used to categorize them into distinct groups such as Seasonal Allergic Rhinitis (SAR), Perennial Allergic Rhinitis (PAR), Perennial Allergic Rhinitis with Seasonal Exacerbations (PARSE) or Nonallergic Rhinitis (NAR). Based on the level of symptoms, participants were given free medications for rhinitis and, every 2 months during the next year, symptoms were re-evaluated and medications adjusted based on pre-determined study rules.

The objectives of the published work were to determine the prevalence of rhinitis and its phenotypes in children and adolescents with asthma, assess symptom severity and medication requirements for rhinitis control, and investigate associations between rhinitis and asthma.

The study found that 93.5% of children and adolescents with asthma have rhinitis.  The most common phenotype (34.2%) was PARSE and the least common (11.3%) NAR. During the 12-month prospective evaluation, the phenotypes determined at baseline manifested the expected seasonal oscillations in symptom intensity and frequency with peaks in the spring and fall and with summertime troughs, but no phenotype had complete symptom resolution at any time during the year. The vast majority of participants required continuous rhinitis treatment.  In PARSE, 84.2% required treatment with a nasal corticosteroid and an antihistamine and, out of those, 67% remained symptomatic throughout the year. A strong relationship between the severity of rhinitis symptoms and asthma outcomes was observed. The magnitude of rhinitis symptoms and the rhinitis medication requirements were higher in participants with difficult-to-control asthma compared to those with easy-to-control asthma. In participants with seasonal rhinitis peaks, asthma outcomes peaked either at the same time (spring) or with 2 month delay (fall).  

In this unique prospective study of asthma and rhinitis in children and adolescents, the authors conclude that rhinitis is almost ubiquitous in asthma that its clinical activity tracks that of lower airway disease and that rhinitis phenotypes appear stable. They further claim that the data offer strong support to the concept that rhinitis and asthma represent the manifestations of a disease that affects the entire respiratory tract.              

The Journal of Allergy and Clinical Immunology (JACI) is the official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.  

Rhinitis in Children and Adolescents with Asthma: Ubiquitous, Difficult to Control, and Associated with Asthma Outcomes