Allergy and asthma proceedings: the offi(IM)
`v. 22, no. 4 (Jul-Aug 2001)
`, General Collection
`W1 AL5632L
`2001-09-05 ~
`
`t ' I
`
`!
`f
`
`I
`r
`
`)
`
`Vol. 22, No. 4
`July-August 2001
`Advances in the Treatment of Allergic and Nonallergic Rhinitis
`(Symposium)
`185 Demographics and epidemiology of allergic and nonallergic rhinitis
`Russell A. Settipane, M.D.
`Treatment update: Allergic rhinitis
`William E. Berger, M.D., M.B.A.
`Treatment update: Nonallergic rhinitis
`Phil Lieberman, M.D.
`
`199
`
`191
`
`203
`
`209
`
`Future advances of immunotherapy
`Harold S. Nelson, M.D.
`Herbal therapies: What allergist-immunologists should know regarding patient use of
`complementary and alternative medicine
`Marianne Frieri, M.D., Ph.D.
`Combination therapy of bronchial asthma
`Harold S. Nelson, M.D.
`How to avoid fraud and abuse by following compliance guidelines
`Richard W. Honsinger, M.D.
`Occupational asthma: A practical approach
`Mark S. Dykewicz, M.D.
`Diagnostic approach and management of occupational asthma by persulfate salts in a
`hairdresser
`Gaspar Gala Ortiz, M.D., Santiago Q . Gancedo, M.D., Ph.D., Rosario F. Ordonez, M.D.,
`Ignacio P. Garno, M.D., Eloina G. Mancebo, M.D., Manuela C. Agustin, M.D., Ph.D., and
`Eloy L. Cosmes, M.D., Ph.D. (Spain)
`239 Variations of pollen and mold concentrations in 1998 during the strong El Nino event of 1997-
`1998 and their impact on clinical exacerbations of allergic rhinitis, asthma and sinusitis
`Henry 8 . Freye, M.D., John King, Ph.D., and Catherine M. Litwin, R.N.
`Research Abstracts Presented at the 39th Annual Scientific Session of the Western Society
`of Allergy, Asthma, and Immunology
`249 Successful one-day outpatient rush immunotherapy for fire ant allergy
`P.C. Sharkey, M.D. and M.M. Barret, M.D.
`Efficacy of azelastine nasal spray in allergic and nonallergic rhinitis
`David Cook, M.D.
`Inhibitory effects of azelastine on cytokines
`William Berger, M.D.
`
`217
`
`221
`
`225
`
`235
`
`255 Minutes of state, regional, and local allergy societies
`Minutes of the WSAAI 39th Annual Scientific Session-January 24, 2001
`Minutes of the RSL Governors Monthly Conference Call-February 13, 2001 and March 27, 2001
`Announcement of the NitM-1s ~Qi~l~1· ,nSoi::iety
`RSL Societies Annual M~M.ifJMW~ .ai:cn 19, 2001 (AAAAI)
`Announcement of the WStffiJWR ~$\¥i t WJJY, Asthma and Immunology
`
`Continued on Table of Contents
`
`

`

`ALLERGY and ASTHMA PROCEEDINGS
`
`CO-EDITOR-IN-CHIEF: Guy A. Settipane, M.D. and Paul A. Greenberger, M.D.
`
`CONTRIBUTING EDITORS
`Lawrence M. DuBuske, M.D.
`Stanford E. Avner, M.D.
`Jack E. Farnham, M.D.
`Joseph A. Bellanti, M.D.
`William Franklin, M.D.
`Warren C. Bierman, M.D.
`Michael H. Grieco, M.D.
`Lawrence A. Caliguiri, M.D.
`Saul Malkiel, M.D.
`John T. Connell, M.D.
`Gailen D. Marshall, M.D.
`Pio Conti, Ph.D.
`(Original manuscripts): Paul A. Greenberger, M.D.
`
`EXECUTIVE EDITORIAL BOARD
`Jordan N. Fink, M.D.
`John A. Anderson, M.D.
`Raif S. Geha, M.D.
`Zuhair Balllas, M.D.
`Leslie C. Grammer, M.D.
`David Bernstein, M.D.
`Paul A. Greenberger, M.D.
`Sandra Christiansen, M.D.
`Kathleen E. Harris
`William Dolen, M.D.
`Dan Hamilos, M.D.
`Mark S. Dykewicz, M.D.
`Michael Kaliner, M.D.
`Elliot F. Ellis, M.D.
`David Kamp, M.D.
`Richard Evans Ill, M.D.
`PARTICIPATING ALLERGY SOCIETIES
`Hawaii Allergy Society
`Alabama Society of Allergy and
`President: Allan Wang, M.D., Ph.D.
`Immunology
`President: Carolyn Conner, M.D.
`
`Allergy Association of Northern
`California
`President: Myngoc Nguyen, M.D.
`
`Illinois Society of Allergy and
`Clinical Immunology
`President: Mark Miller, M.D.
`
`Arizona Allergy and Asthma Society
`President: Michael Manning, M.D.
`
`Iowa Society of Allergy and
`Immunology
`President: Edward G. Nassif, M.D.
`
`Allen Cazort Society of Arkansas
`President: Eddie Shields, M.D.
`
`Buffalo Allergy Society
`President: Jeffrey B. Rockoff, M.D.
`
`Colorado Allergy & Asthma Society
`President: David L. Goodman, M.D.
`
`Connecticut Society of Allergy and
`Clinical Immunology
`President: Joseph F. Sproviero, M.D., Ph.D.
`
`Eastern Allergy Conference
`Co-ordinator: Guy A. Settipane, M.D.
`
`Florida Allergy and Immunology
`Society
`President: Roger N. Danziger, M.D.
`
`Allergy/Asthma/Immunology
`Society of Georgia
`President: William Dolen, M.D.
`
`Kentucky Society of Allergy,
`Asthma and Clinical Immunology
`President: Kenneth L. Gerson, M.D.
`
`Long Island Allergy and
`Immunology Society
`President: Gene Gerardi, M.D.
`
`Louisiana Allergy Society
`President: Benjamin B. Close, M.D.
`
`Maine Society of Allergy and
`Clinical Immunology
`President: Jonathan Musmand, M.D.
`
`Maryland Asthma and Allergy
`Society
`President: Jonathan Matz, M.D.
`
`Massachusetts Allergy Society
`President: Stuart Rhein, M.D.
`
`Greater Kansas City Allergy Society
`President: Mark R. Neustrom, D.O.
`
`Michigan Allergy & Asthma Society
`President: Michael Simon, M.D.
`
`Greater Washington Asthma
`Allergy and Immunology Society
`President: Paul M. Goldberg, D.0.
`
`Mid-South Allergy Forum
`President: D. Betty Lew, M.D.
`
`Louis M. Mendelson, M.D.
`Robert A. Nathan, M.D.
`Harold S. Novey, M.D.
`Agile H. Redmon, Jr., M.D.
`John Seiner, M.D.
`Russell A. Settipane, M.D.
`
`Gail G. Shapiro, M.D.
`Ronald A. Simon, M.D.
`Clifford M. Tepper, M.D.
`Frank J. Twarog, M.D.
`Joel K. Weitman, M.D., Ph.D.
`
`Michael Kaplan, M.D.
`Ira D. Lawrence, M.D.
`Lawrence Lichtenstein, M.D.
`Phillip L. Lieberman, M.D.
`Eric Macy, M.D.
`Roy Patterson, M.D.
`Mark Schubert, M.D.
`Albert L. Sheffer, M.D.
`
`Sheldon C. Siegel, M.D.
`Ronald A. Simon, M.D.
`Raymond G. Slavin, M.D.
`Lewis Smith, M.D.
`William R. Solomon, M.D.
`T. C. Theoharides, Ph.D., M.D.
`Peter Weller, M.D.
`C. Raymond Zeiss, M.D.
`
`Mid-West Forum on Allergy
`Host: Michigan Allergy Society
`
`Missouri State Allergy Association
`President: Susan S. Berdy, M.D.
`
`Pennsylvania Allergy & Asthma
`Association
`President: Ed H. Hein, M.D.
`
`Pittsburgh Allergy Society
`President: Philip Fireman, M.D.
`
`Nebraska Allergy Society
`President: Thomas Nilsson, M.D.
`
`New England Society of Allergy
`President: Kevin P. McGrath, M.D.
`
`New Hampshire Allergy Society
`President: William Monafo, M.D.
`
`New Jersey Allergy Society
`President: Arthur J. Torre, M.D.
`
`New Mexico Allergy Society
`President: Michael Clayton, M.D.
`
`Allergy, Asthma and Immunology
`Society of Greater New York
`President: Eugenia Hawrylko, M.D.
`
`New York State Society of Allergy,
`Asthma & Immunology
`President: Daniel Mayer, M.D.
`
`Ohio Society of Allergy, Asthma
`and Immunology
`President: Douglas P. Bolden, M.D.
`
`Oklahoma Allergy and Asthma
`Society
`President: Terence Carey, M.D.
`
`Rhode Island Society of Allergy
`President: Amir H. Missaghian, M.D.
`
`South Carolina Society for Allergy,
`Asthma, and Immunology
`President: Albert F. Finn, Jr., M.D.
`
`Southwest Allergy Forum
`Director: Agile Redmon, M.D.
`
`Tennessee Society of Allergy and
`Immunology
`President: Hyman M. Kaplan, M.D.
`
`Texas Allergy and Immunology
`Society
`President: Joseph Diaz, M.D.
`
`Asthma & Allergy Society of Virginia
`President: George W. Ward, Jr., M.D.
`
`Washington State Society of
`Allergy, Asthma and Immunology
`President: Michael Weiss, M.D.
`
`Westchester Allergy Society (N.Y.)
`President: James Pollowitz, M.D.
`
`Western Society of Allergy and
`Immunology
`President: Bradley E. Chipps, M.D.
`
`Orange County Society of Allergy
`and Clinical Immunology (California)
`President: Mark Sugar, M.D.
`
`Wisconsin Allergy Society
`President: John Basich, M.D.
`
`Assistant to Editor and Circulation: Michele Doherty; Distribution and Production Manager: Virginia Loiselle; Executive Secretary:
`Carole Fico.
`Allergy and Asthma Proceedings is owned and published bimonthly by OceanSide Publications, Inc.
`95 Pitman Street, Providence, R./. 02906. Single copies: $15.00 (add $5.00 for outside USA address): 2001 Subscriptions: $120.00 per year, Institution price
`$200.00 (outside USA add $30.00). ISSN 1088-5412
`Copyright©, 2001, OceanSide Publications, Inc. (401-331-2510) FAX (401-331-5138). Printed in the U.S.A.
`Advertising Representative-Jim Brady, James T. Brady, Inc., 259 Mineola Blvd., Suite 206, Mineola, N.Y. 11501 (516-742-7960)
`
`This material 1vascopied
`at the NLM a nd m aybe
`Saubjec~ USCop,yright La1Vs
`
`

`

`TABLE OF CONTENTS
`
`Vol. 22, No. 4
`July-August 2001
`
`Advances in the Treatment of Allergic and
`Nonallergic Rhinitis (Symposium)
`185 Demographics and epidemiology of allergic and nonallergic rhinitis
`Russell A. Settipane, M.D.
`191 Treatment update: Allergic rhinitis
`William E. Berger, M.D., M.B.A.
`199 Treatment update: Nonallergic rhinitis
`Phil Lieberman, M.D.
`
`203 Future advances of immunotherapy
`Harold S. Nelson, M.D.
`209 Herbal therapies: What allergist-immunologists should know regarding patient
`use of complementary and alternative medicine
`Marianne Frieri, M.D., Ph.D.
`217 Combination therapy of bronchial asthma
`Harold S. Nelson, M.D.
`221 How to avoid fraud and abuse by following compliance guidelines
`Richard W. Honsinger, M.D., FAA.A.A.I., F.A.C.A.A.I., M.A.C.P.
`225 Occupational asthma: A practical approach
`Mark S. Dykewicz, M.D.
`235 Diagnostic approach and management of occupational asthma by persulfate
`salts in a hairdresser
`Gaspar Gala Ortiz, M.D., Santiago Q. Gancedo, M.D., Ph.D., Rosario F. Ordonez, M.D.,
`Ignacio P. Garno, M.D., Elofna G. Mancebo, M.D., Manuela C. Agustin, M.D., Ph.D., and
`Eloy L. Cosmes, M.D., Ph.D. (Spain)
`239 Variations of pollen and mold concentrations in 1998 during the strong El Nino
`event of 1997-1998 and their impact on clinical exacerbations of allergic rhinitis,
`asthma and sinusitis
`Henry B. Freye, M.D., John King, Ph.D., and Catherine M. Litwin, R.N.
`
`Research Abstracts Presented at the 39th Annual Scientific Session of the
`Western Society of Allergy, Asthma, and Immunology
`249 Successful one-day outpatient rush immunotherapy for fire ant allergy
`P.C. Sharkey, M.D. and M.M. Barret, M.D.
`Efficacy of azelastine nasal spray in allergic and nonallergic rhinitis
`David Cook, M.D.
`Inhibitory effects of azelastine on cytokines
`William Berger, M.D.
`Efficacy of flunisolide aqueous nasal spray compared with azelastine
`hydrochloride nasal spray in the treatment of perennial allergic rhinitis
`Joshua M. Berlin, M.D., Stanley J. Golden, M.D., Stephanie Teets, M.D.,
`Erik B. Lehman, M.A., and Timothy J. Craig, D.O.
`Activation of CD4 T-cells with mitogens, Candida, and grass allergen
`J.F. Halsey, Ph.D. and Terrance R. Kordash, M.D.
`Relationship between asthma-related emergency department visits and outdoor
`air pollutants in the Bronx
`G. Hudes, A. Thanjan, L. Bastone, M. Khananashvili, M.D., and D.L. Rosenstreich, M.D.
`continued on next page
`Allergy and Asthma Proceedings has been selected for listing in
`INDEX MEDICUS, MEDLINE, CURRENT CONTENTS, and EXCERPTA MEDICA
`
`Th is materia I ,vas cop,i ed
`attheNLMandma y ~
`!>ubject US Copy.right Laws,
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`

`

`TABLE OF CONTENTS .
`
`Vol. 22, No. 4
`July-August 2001
`
`Evaluation of administration of intravenous gammaglobulin in immunodeficient
`patients in a private practice setting
`B.V. Kettelhut, T.A. Burns, J.M. Tracy, and R.H. Kobayashi
`Reactions to Hylan G-F20 {Synvisc) in patients receiving intraarticular injections
`for osteoarthritis
`R.H. Kobayashi, M.D., T. Burns, R.N., and C.M. Kelly, M.D.
`Fluticasone propionate/salmeterol combination versus adding montelukast to
`low-dose fluticasone
`K.A. Rickard, M.D., N.L. Church, M.S., A.H. Emmett, M.S., and K. Knobil, M.D.
`Low-dose fluticasone propionate vs. montelukast in asthma patients
`K.A. Rickard, M.D., S.P. Goode-Sellers, B.S., LE. Edwards, Ph.D., S.H. Srebro, M.D., and
`C.J. Kalberg, Ph.D.
`Montelukast alone or in combination with loratadine: an analysis of three
`seasonal allergic rhinitis studies
`W.W. Stroms, M.D., S. Lu, M.P. Malice, K. Malmstrom, C. LaForce, J. Wolfe, E. Meltzer,
`T.F. Reiss, and The Montelukast Spring Allergic Rhinitis Study Group
`Basketball urticaria/angioedema
`S.J. Tkachyk, M.D., F.R.C.P.C.
`Levalbuterol improves outcomes and patient care costs compared to albuterol in
`hospitalized patients
`T. Truitt, J. Witko, and M. Halpern
`Doses of extrafine HFA-BDP aerosol supported by clinical efficacy review
`G. Gross and J. Vanden Burgt
`A high-potency steroid and a high-deposition steroid in the treatment of asthma:
`is there a difference in asthma control?
`A.J. Fairfax, M. Aubier, and J. Vanden Burgt
`
`255 Minutes of state, regional, and local allergy societies
`Minutes of the WSMI 39th Annual Scientific Session-January 24, 2001
`Minutes of the RSL Governors Monthly Conference Call-February 13, 2001 and
`March 27, 2001
`Announcement of the New Mexico Allergy Society
`RSL Societies Annual Meeting Minutes, March 19, 2001 (MAAI)
`Announcement of the Western Society of Allergy, Asthma and Immunology
`
`Th is ma t:eria I w as. copied
`at the NL.:M a nd ma y be
`Siubject USCop,yright Laws
`
`

`

`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`Treatment Update:
`Nonallergic Rhinitis
`
`Phil Lieberman, M.D.
`
`ABSTRACT
`/Chronic nonallergic rhinitis is a diagnosi.1· 1!f' exclusion. 11,e
`/Hltho11hysio!ogy underlying this disorder is unknown. 111ere prob(cid:173)
`ably are several 111eclwni.1·111.1· involved and several different \'ari(cid:173)
`a1io11.1· of' this condition. T/1ero11ies which have heen approvedfi1r
`use in the treatment <if'clmmic 11mwl/ergic rhinitis i,1c/11de ropical
`corticosteroids and az.elastil1e. Topical cortico.1·/eroid prepara(cid:173)
`tirms that have received approval are.fluticasone, budesonide, and
`beclomethasone. Topical nasal .wline also !ws been established as
`a beneficial adjunct to therapy in some instances. Other therapies
`have included ca11.wicin, .vilver nitrate, botulin toxin, and various
`.rnrgical procedures. '/11ese 11rocedures include turbinate reduc(cid:173)
`tion, which has heen per/im11ed by a number 1!( techniques inclll(l(cid:173)
`ing ,rnbmucosal diather111y, c1yo.rnrge1:v, laser caute,y, and classic
`resection. Ethmoidal and vidian neurectomies have been per(cid:173)
`.fimned hy excision, diathermy, and cryotherapy. These procedures
`have met with varying degrees 1!f' succe~(Allergy and Asthma
`Proc 22: 199-202, 200 I)
`
`R hinitis is defined as an inflammation of the lining of the_
`
`nose and is characterized clinically by one or more of(cid:173)
`the following symptoms: rhinorrhea, sneezing and nasal
`itching, congestion, and postnasal drainage.
`The diagnosis of chronic nonallergic rhinitis is made by
`exclusion. There is no generally accepted definition and
`therefore there is a lack of consensus regarding terminology.
`
`From th{]j_epar/ments 1!f' Medicine and Pediatrics, Division rl
`Allergy and lmnumology, University 1Jj' Te1111essee, Memphis, Ten-
`nes.1·<:_!) \)S ~
`.
`.
`.
`.
`Presented at the Post-Symposium 11/ the Co111lm1ed Meeting r1f
`Southwest Allergy Fornm and Eastem Allergy Conference, Aca(cid:173)
`pulco, Mexico , January 14, 2001. Supported by a11 educational
`gralll Ji-0111 Wallace Laboratories
`Address correspondence and reprint requests to Phil Lieberman,
`M.D., Allergy and Asthma Care, 300 Waillut Bend Road South,
`Cordova, TN 38018
`
`There are no characteristic physical findings and therefore a
`diagnosis is based mainly on the patient's complaints. The
`term should refer to any form of chronic rhinitis that is not
`caused by allergic disease. A classification of the forms of
`nonallergic rhinitis suggested by Settipane I is noted in Ta(cid:173)
`ble I.
`
`EPIDEMIOLOGY
`
`Statistics on the incidence and demographics of nonaller(cid:173)
`
`gic rhinitis are difficult to evaluate. There are at least
`five studies in the literature that have investigated this
`issue2- 6 (Table II).
`Mullarkey et al., 2 Enberg, 3 Togias,4 and a joint task force
`each evaluated the incidence of nonallergic rhinitis as pa(cid:173)
`tients with this condition presented to the allergist's office .
`Mullarkey et al.2 found that 52% of 142 rhinitis patients had
`nonallergic rhinitis. Enberg3 evaluated 152 adults and found
`a 30% incidence of perennial nonallergic rhinitis. Togias4
`found that 17% of 362 rhinitis patients had the nonallergic
`variety of this condition. A joint task force (National Rhi(cid:173)
`nitis Classification Task Force) of several allergists sur(cid:173)
`veyed 975 patients and found that 23 % had nonallergic
`rhinitis. 1 n addition, they found that 34% of the subjects
`had a combination of allergic and nonallergic disease
`(mixed rhinitis). 5 The European Community Respiratory
`Health Survey (ECRHS)6 took a different approach. They
`performed a general population survey and selected 1412
`subjects based on the fact that they had a history sug(cid:173)
`gesting rhinitis. They found that 25% of 1400 subjects
`complaining of rhinitis suffered from the nonallergic
`variety .
`Of course, it is "risky" to extrapolate a general incidence
`from these data. However, the incidence ranged from 17 to
`52% . Thus, using a rough incidence of 33% and considering
`that there are probably 50 million individuals suffering from
`rhinitis in the United States, one could conclude that per(cid:173)
`haps 17 million of these suffer from the chronic nonallergic
`variety of this condition. Probably an additional one-third
`has a mixture of both allergic and nonallergic disease. Thus,
`
`Allergy and Asthma Proc.
`
`Th is. m:atefra I w.as copded
`at the NLM :andm:ayGe
`Subject USCopy,right Law s
`
`199
`
`

`

`TABLE I
`Classification of Chronic Nonallergic Rhinitis Based on Etiology or Systemic Disease Association
`
`Syndromes of unknown etiology
`Vasomotor rhinitis
`Nonallergic rhinitis with eosinophils (NARES and BENARS)
`Basophilic/metachromatic nasal disease
`Syndromes of suggested etiology
`Chronic sinusitis
`Immunodeficiencies
`Osteomeatal obstruction
`Metabolic conditions
`Estrogen related (oral contraceptive/hormone replacement therapy, pregnancy)
`Hypothyroidism
`Acromegaly
`Vasculitides/autoimmune and granulomatous diseases
`Sjogren's syndrome
`Systemic lupus erythematosus
`Relapsing polychondritis
`Churg-Strauss syndrome
`Sarcoidosis
`Wegener's granulomatosis
`Drug-induced
`Topical decongestants
`Eye drops
`Systemic medications
`Rhinitis with nasal polyps
`Aspirin intolerance
`Chronic sinusitis
`Churg-Strauss syndrome
`Young's syndrome (sinopulmonary disease, azoospermia, and nasal polyps)
`Cystic fibrosis
`Kartagener's syndrome (bronchiectasis, chronic sinusitis, and nasal polyps)
`Structurally related rhinitis
`Septa! deviation
`Turbinate deformation
`Nasal valve dysfunction
`Obstructive adenoid hyperplasia
`Trauma (e.g., cerebrospinal fluid rhinorrhea)
`Congenital
`Neoplastic
`Atrophic rhinitis
`Resulting from surgery
`Ozena
`Physical/chemical/irritant-induced
`Dry air
`Gustatory
`Bright light
`Air pollution
`Occupational
`Occupational rhinitis
`Annoyance
`Irritant
`Immunologic
`Corrosive
`CSF rhinorrhea
`
`I
`
`NARES, nonallergic rhinitis with eosinophilia syndrome; BENARS, blood eosinophilia nonallergic rhinitis syndrome; CSF,
`cerebrospinal fluid.
`
`200
`
`This material was copied
`at the NLM and may t,e
`Subje<t US Copyright Laws
`
`July-August 2001, Vol. 22, No. 4
`
`

`

`I nvcstigator/Y car
`
`TABLE II
`Frequency of Occurrence: Allergic vs Nonallergic Rhinitis
`Rhinitis Type
`Number
`Mixed(%)
`
`Allergic(%)
`
`Mullarkey2
`l
`Enberg·
`
`142
`152 ( 128)*
`
`48
`54
`
`Togias4
`362
`ECRHS6
`1,412
`NRCTF5
`975
`*Diagnosis determined in only I 28.
`#"Mixed" co1111ted by allergic for total analysis except E11berg 's "undeter111ined" iroup.
`NRCTf,~ National Rhinilis Clas.1·{/irn1io11 Task Force.
`
`83
`75
`43
`
`Not studied
`16%#
`Undetermined
`Not studied
`Not studied
`34
`
`Nonallergic(%)
`
`52
`30
`
`17
`25
`23
`
`perhaps as many as 34 million people have a nonallergic
`component to their illness.
`There are some distinctions that can be used to separate
`allergic from nonallergic rhinitis. Lindberg and Malm
`clearly showed that nonallergic rhinitis occurs in an older
`population than allergic disease.7 They found a peak inci(cid:173)
`dence of allergy before the age 30 years with a declining
`incidence thereafter. This contrasted with the incidence of
`nonallergic rhinitis, which remained steady between the
`20th and 50th year. They also noted that a few simple
`questions could distinguish patients with allergy from those
`with nonallergic rhinitis. The question offering the most
`discrimination was whether symptoms were made worse by
`exposure to grass pollen.
`Females may have nonallergic rhinitis more frequently
`than males. Settipane and Kline found that 58% of patients
`with nonallergic rhinitis were l'emale8 ; Enberg3 found that
`74% of patients with nonallergic rhinitis were women; and
`the National Rhinitis Classification Task Force5 survey
`found an incidence of 71 %. This contrasted with an 111c1-
`dence of 55% female gender in allergic rhinitis.5
`
`THERAPY
`
`A gen~s. that. h~•:e been stu_died in the therapy of nonal(cid:173)
`
`le1 g1c rhm1t1s are seen 111 Table III . Only two classes
`of medication have received Federal Drug Administration
`approval for use in chronic rhinitis. Included arc first(cid:173)
`generation oral antihistamines, topical corticosteroids and
`the topical second-generation antihistamine azelastine. The
`topical corticosteroid preparations that have been approved
`for use are beclomethasone, tluticasone, and budesonide.
`It is assumed that the anti-inflammatory activities of
`topical corticosteroids account for their beneficial effect in
`this condition. Fluticasone nasal spray, applied unilaterally,
`has been shown to decrease the number of CD3 + cells, the
`amount of major basic protein, and the number of tryptase(cid:173)
`positive cells in subjects with nonallergic rhinitis.9 ln addi(cid:173)
`tion, the use of this agent effectively lowered messenger
`RNA (mRNA) expression for interleukin (IL)-4 and IL-5.9
`
`TABLE III
`Agents and Surgical Procedures Found Helpful in the
`Treatment of Chronic Nonallergic Rhinitis
`
`Intranasal corticosteroids
`Beclomethasone
`Buclesonide
`Fluticasone
`Intranasal antihistamines
`Azelastine
`Intranasal antichol inergics
`lpratropium bromide
`Intranasal saline
`Intranasal capsaicin
`Intranasal silver nitrate
`Intranasal injection of botulin toxin
`Surgical procedures
`Turbinate reduction
`Submucosal diathermy
`Cryosurgery
`Laser
`Classical resection
`Ethmoidal/vidian neurectomy
`Diathermy
`Cryotherapy
`Excision
`
`Recently, azelastine was granted approval by the Food
`and Drug and Administration (FDA) for the treatment of
`this disorder. In clinical trials it has been shown to reduce
`components of the symptom complex including postnasal
`drainage, sneezing, rhinorrhea, and congestion. 10 There are
`two multicentered placebo-controlled trials of azelastine for
`the treatment of nonallergic vasomotor rhinitis, Both trials
`used identical protocols. Over 200 patients were evaluated.
`The response rate was between 82 and 85% with the pla(cid:173)
`cebo response being 73%. The rather high placebo response
`is expected because saline nasal spray also has been shown
`to have a beneficial effect in this disorder.
`
`Allergy and Asthma Proc.
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`This m ate.ri.al w asco-p,ied
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`The exact mode of action of azelastine in nonallergic
`vasomotor rhinitis has not been determined, because the
`pathophysiology of this condition itself is unclear. How(cid:173)
`ever, there are several putative mechanisms including a
`diminution in the production of neurokinin, 11 the prevention
`of mast cell degranulation, 12 a reduction in eosinophil ac(cid:173)
`cumulation associated with a decrease in expression of
`adhesion molecules, 13 and a decrease in the synthesis of
`inflammatory cytokines and nitric oxide via an effect on
`transcription mediated through NF-1<8. 14 The latter obser(cid:173)
`vation signifies that azelastine has significant effects on
`transcription. This has been shown both in vitro 14 and in
`vivo. 15
`[n addition to the broad-based approach of using topical
`corticosteroids and/or azelastine, the treatment can be di(cid:173)
`rected to speci fie symptoms. For example, patients with
`predominantly secretory/rhinorrhea symptoms may respond
`to ipratropium bromide. 16 Topical saline also may be help(cid:173)
`ful.1 Several experimental treatments have been devised.
`These include the topical use of capsaicin 17 and the appli(cid:173)
`cation of silver nitrate. 18
`A number of different surgical approaches have been
`used including vidian nerve resection, sphenopalatine gan(cid:173)
`glion block, and turbinectomy. 1 These therapies have met
`with varying successes but have been limited by associated
`side effects.
`[n summary, the mainstay of the treatment of chronic
`nonallergic rhinitis is the application of topical nasal ste(cid:173)
`roids and/or azelastine. Adjunctive measures might include
`ipratropium bromide, and
`antihistamines-decongestants,
`saline nose sprays. For severe cases, surgical therapy can be
`considered. If profuse rhinorrhea cannot be controlled, e.g.,
`vidian neurectomy has been used. For intractable conges(cid:173)
`tion, turbinate resection has been used.
`
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`Ito H, Nakamura Y, Takagi S, and Sakai K. Effects of Azclastine on
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`the nasal mucosa reduces symptoms in patients with non-alleroic
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`Th is m aterial -was co,p,ied
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`Scubje<t US Cop,yright Laws
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`July-August 2001, Vol. 22, No. 4
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