Comorbid allergic rhinitis and asthma: important clinical considerations

ABSTRACT

Introduction

The numerous links between allergic rhinitis and asthma have been extensively explored in the last two decades, gaining great concern within the scientific community. These two conditions frequently coexist in the same patient and share numerous pathogenetic and pathophysiological mechanisms.

Areas covered

We reviewed major pathophysiological, epidemiological, and clinical links between allergic rhinitis and asthma. We also provided a comprehensive discussion of allergic rhinitis treatment according to current guidelines, with a particular focus on the relevance of allergic rhinitis therapies in patients with comorbid asthma.

Expert opinion

We believe that there are several unmet needs for our patients, however, there are promising advances forecasted for the future. Although allergic rhinitis is a recognized risk factor for asthma, a proper asthma detection and prevention plan in allergic rhinitis patients is not available. Allergen immunotherapy (AIT) represents a promising preventive strategy and may deserve an earlier positioning in allergic rhinitis management. A multidisciplinary approach should characterize the journey of patients with respiratory allergies, with an adequate referral to specialized Allergy/Asthma centers. Molecular Allergy Diagnosis may provide support for optimal AIT use. Finally, a possible evolution of biological treatment can be envisaged, mainly if biosimilars decrease such therapies’ costs.

KEYWORDS:

• United airway disease
• asthma
• allergic rhinitis
• respiratory allergies
• asthma comorbidities
• allergic rhinitis treatment
• allergen immunotherapy

LIST OF ABBREVIATIONS

UAD: united airway disease

MPI: minimal persistent inflammation

ARIA: allergic rhinitis and its impact on asthma

HRQoL: health-related quality of life

CI: confidence interval

GINA: global initiative for asthma

GRADE: grading of recommendations assessment, development and evaluation

HDM: house dust mites

GWAS: genome wide association study

TLR: toll-like receptor

TSLP: thymic stromal lymphoprotein

ILC2: type 2 innate lymphoid cells

Th2: type 2 T helper

VAS: visual analog scale

INCS: intranasal corticosteroids

AH: anti-histamines

INAH: inhaled anti-histamines

OAH: oral anti-histamines

LRA: leukotriene receptor antagonists

OCS: oral corticosteroids

AIT: allergen immunotherapy

mAb: monoclonal antibody

Article highlights

• Allergic rhinitis is the most frequent asthma comorbidity, affecting approximately 80% of patients with asthma.

• Allergic rhinitis and asthma share pathogenetic and pathophysiological mechanisms as both conditions have an overlapping genetic predisposition and are characterized by a type 2 inflammatory responses in most cases.

• Allergic rhinitis has a negative impact on several asthma facets representing a risk factor for asthma development and increased severity while contributing to a higher use of health care resources and a poorer quality of life.

• The link between the upper and the lower airways (United Airway Disease) calls for a comprehensive management of patients with respiratory allergies, spanning from patient education to the choice of an appropriate treatment plan for both asthma and allergic rhinitis.

• Allergen immunotherapy (AIT) is the only disease modifying treatment of allergic rhinitis and asthma, possibly deserving an earlier positioning in respiratory allergy management.

Declaration of interest

G Paoletti reports personal fees from GSK, Novartis and Lusofarma, outside the submitted work. E Heffler reports receiving grants and personal fees from: AstraZeneca; Sanofi; Novartis; GSK; Circassia; Nestlè, Purina, Regeneron, Stallergenes-Greer, outside the submitted work. F Puggioni reports personal fees from Astrazeneca, Sanofi, Regeneron, GSK, Menarini, Chiesi, Mundipharma, Guidotti, Malesci, Almirall, Valeas, Alk Abello, Allergy Therapeutics, Stallergenes greer, Boehringer outside the submitted work. L Malvezzi received grants and personal fees from Sanofi; Novartis; Astrazeneca; GSK outside the submitted work. G Canonica reports grants and personal fees from Menarini, Alk Abello’, Anallergo Boehringer Ingelheim, Chiesi,

Circassia, Genentech, Guidotti Malesci, GSK, Hal Allergy, Meda, Merck, Merck Sharp and Dome, Novartis, RecordatiInnuvaPharma, Roche, Sanofi, Stallergenes, UCB Pharma, Uriach Pharma, Teva Astrazeneca, Thermo Fisher, Valeas, Vibor Pharma, outside the submitted work. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.