Rhinitis and Asthma

Comorbidities or United Airway Disease ?

Nastiti Kaswandani
Dept. Child Health, Faculty of Medicine
University of Indonesia
 Burden of asthma
• Asthma is one of the most common chronic diseases
worldwide with an estimated 300 million affected
individuals
• Prevalence is increasing in many countries, especially
in children
• Asthma is a major cause of school and work absence
• Health care expenditure on asthma is very high
• Poorly controlled asthma is expensive
• However, investment in prevention medication is likely to
yield cost savings in emergency care

GINA 2017
 Asthma drugs

Reliever Controller
• Relieve attack or asthma • Overcome asthma basic
symptoms problems i.e. chronic respiratory
• Use as needed, if inflammation
symptoms relieved, drug • Prevent asthma attack
is stopped • Long term
• Short acting β2-agonist, • Inhaled steroid, antileukotrienes,
anticholinergics, systemic combination of inhaled steroid
steroids long-acting ß2-agonist, slow
release teophylline, anti-
immunoglobuline E

Mark FitzFerald, M. H. R., MD (2012). "Global Strategy for Asthma Management and Prevention Update 2012." GINA.
When to initiate controllers
administration
 Steps in asthma long term management

6-8
weeks

8-12 weeks

Images description: SI (steroid inhalasi) ICS (inhaled corticosteroids);

LTRA (Leukotriene Receptor Antagonist); SABA (short acting beta
agonist); LABA (long acting beta agonist)
 Stepwise approach – key issues UPDATED
2017

KEY ALL CHILDREN

ISSUES
• Assess symptom control, future risk, comorbidities
• Self-management: education, inhaler skills, written asthma action plan, adherence
• Regular review: assess response, adverse events, establish minimal effective treatment
• (Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution

 Assess asthma control

• Symptom control, future risk, comorbidities
 Self-management
• Education, inhaler skills, written asthma action plan, adherence
 Regular review
• Assess response, adverse events, establish minimal effective treatment
• Record height each year, as poorly-controlled asthma may influence growth, and
ICS may be associated with growth delay in first 1-2 years
 Other
• (Where relevant): environmental control for smoke, allergens, indoor or outdoor
air pollution

GINA 2017, Box 6-5 (4/8)

Factors to be assessed before stepping-up
 Some common asthma-related comorbidities.
Louis-Philippe Boulet & Marie-Ève Boulay (2011) . Expert Review of Respiratory Medicine, 5:3, 377-393
8
AR-Sinusitis-Asthma
• Allergic rhinitis (AR), rhino-sinusitis, & asthma
are frequently co-morbid conditions
• Up to 40% AR patients suffer from asthma (5-
10% asthma in general population)
• Up to 80% asthma patients suffer from AR
(20% AR in general population)
• Radiographic studies: 40-60% asthma patients
(adults & children) abnormal sinus
radiograph
 AR, Sinusitis, Asthma: The link
Common Triggers and Pathophysiology

Anatomy/ Physiology Same mediators

• Upper and lower airways are contiguous • IgE
• Functional linkage – nose vs mouth breathing • Histamine
• Similar histology(epithelial, neural, vascular) • Cytokines
• Leukotrienes

Same triggers
• HDM, pollen, pet dander, moulds, fungi
Same drugs
Allergic • Anti IgE ?
Same cells Rhinitis • Steroids(ICS/ INS)
• Mast cells • Antihistamines ?
• Eosinophils • Antileukotrienes ?
Asthma Sinusitis

J Allergy Clin Immunol 2001;108:S147-336.

 Pathophysiology UAD

• Rhinitis promote breathing through the mouth

adverse effect on the lower airway
• Secretions (liquid/gaseous) may drip or diffuse from
upper to lower airway – postnasal drip
• A neurogenic (nasobronchial) reflex – eg transient
broncho-constriction resulting from irritant stimulation
of nasal mucosa
• Communication between upper & lower via bone
marrow derived systemic inflammatory response
Thorax 2000;55 (Suppl 2):S26-7
J Manag Care Pharm 2004; 10:310-7
Med J Aust 2006; 185:565-71
 Naso-bronchial interaction

Shift from nasal to

Postnasal drainage of
mouth breathing
inflammatory material
into lower airway

Activation of Systemic absorption

nasopharyngeal of mediators or
bronchial reflexes chemotactic factors
from inflammatory
process in nose or
sinuses, induce lower
airway effects

Pediatr Pulmonol 2001; 31:165-72

Source: South Med J © 2009 Lippincott Williams & Wilkins
 Management of
Asthma and Allergic Rhinits
Therapeutic implication UAD
• Optimal control of rhinitis has a beneficial
effect on asthma
• Fix the sneeze to control the wheeze
• Control of asthma can not be achieved if there
are concomitant disease at the upper airway,
i.e allergic rhinitis or sinusitis
• Continuous use of 2nd gen antihistamine is
better for controlling symptoms, allergic
inflammation & occurrence of AURI in children

Thorax 2000;55 (Suppl 2):S26-7

J Manag Care Pharm 2004; 10:310-7
Integrated treatment of CRIS

Nose Bronchi

Anti-
INS & ICS
leukotrienes
Antihistamines

Long-acting
Specific immunotherapy 2 agonists

Allergen avoidance education

ALGORITHM OF ALLERGIC RHINITIS THERAPY
ALLERGIC RHINITIS APPROACH
SUMMARY
• Allergic rhinitis (AR), rhino-sinusitis, & asthma
are frequently co-morbid conditions
• Evidence shows that allergic rhinitis and
asthma are united airway disease in
pathophysiology and therapy implication
• Physicians should manage asthma and allergic
rhinitis with comprehensive approach as
united airway disease