Allergic rhinitis symptoms increase with multiple sensitizations
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Key takeaways:
- Nasal symptoms were most common regardless of the number of sensitizations.
- Polysensitized patients had more ocular and itch-related symptoms.
- Most cases were moderate to severe.
Patients with allergic rhinitis experience a greater number and diversity of symptoms when they have increasing numbers of sensitizations, according to a study published in Annals of Allergy, Asthma & Immunology.
Increases in symptoms related to multi-morbidities with sensitization rank also suggest organ-specific thresholds, Nikolaos G. Papadopoulos, MD, PhD, head of the allergy department, second pediatric clinic, P&A Kyriakou Children’s Hospital, and colleagues wrote.
“This was part of a study trying to understand different phenotypes and end-types of rhinitis,” Papadopoulos told Healio.
Traditionally, rhinitis has been characterized as allergic, nonallergic or infectious, he continued. But it has become apparent that both the mechanisms (endotypes) and clinical presentations (phenotypes) are much more complex than that, he added.
“Understanding the subtle differences can help with optimizing management,” Papadopoulos said.
The multicenter, cross-sectional study involved allergy, respiratory, pediatric, otolaryngologic and primary care outpatient clinics across Greece, with data collected between 2018 and 2020.
The cohort included 565 adults and children with allergic rhinitis, with 155 (27.43%; 56.13% male; median age, 31 years) who were monosensitized and 410 (72.56%; 60.5% male; median age, 32 years) who were polysensitized.
Sensitizations in the monosensitized group included house dust mites (33.55%), grasses (18.06%), olive tree pollen (14.19%), weeds (21.94%), molds (4.52%), and cats or dogs (3.87%).
In the polysensitization group, sensitizations also included house dust mites (50.24%), grasses (62.68%), olive tree pollen (63.41%), weeds (48.29%), molds (22.43%) and cats or dogs (33.9%).
The most common symptom triggers included tree pollen (52.9%), dust (49.03%), humidity (35.48%) and grasses (29.03%) in the monosensitized group and tree pollen (75.85%), grasses (64.15%), dust (64.88%) and humidity (44.88%) in the polysensitized group.
“We find that the more allergic sensitizations a person has, the more extensive and complex are their symptoms,” Papadopoulos said. “This is particularly true for symptoms from the eyes and the lower airway.”
Both groups reported nasal symptoms including stuffy, runny and itchy nose as their most common symptoms, with no differences in the total number of nasal symptoms between the groups.
The only significant differences in individual symptoms between the groups included 45.85% of the polysensitized group and 36.3% of the monosensitized group who reported itch of the palate or ears (P = .047) and 56.34% of the polysensitized group and 40% of the monosensitized group who reported itchy eyes (P = .001).
The patients in the polysensitized group had significantly more ocular symptoms (P = .007) and itch-related symptoms (P = .036) than the monosensitized group, as well as total number of symptoms (median, 5 vs. 4; P = .007).
Most rhinitis was moderate-severe, the researchers said, and this degree of disease was marginally but not significantly more prominent among the polysensitized group. The polysensitized group also had marginally higher severity based on Allergic Rhinitis and Its Impact on Asthma (ARIA) criteria.
But using the VAS, median scores included 7 for the polysensitized group and 6 for the monosensitized group, which the researchers called a clear difference. The polysensitized group also nasal symptoms in April, May and June more often than the monosensitized group as well.
Additionally, the polysensitized group demonstrated significantly more frequent reactivity to putative allergen riggers including cat dander, molds, tree pollen and grasses as well as to nonspecific physical triggers such as light, warm temperature, dust, strong smells or fragrances and exercise.
Mean total numbers of trigger factors included five for the polysensitized patients and three for the monosensitized patients (P < .001). There also were differential associations between sensitization rates and itchy eyes (P < .001), itching of the palate or ears (P = .017), wheezing (P = .025) and the sum of symptoms (P = .001).
In the age group analysis, 251 of 348 adults (72.12%) and 78 of 103 children (75.72%) were polysensitized.
Allergies among monosensitized vs. polysensitized adults included house dust mites (21.65% vs. 43.42%), grasses (23.71% vs. 64.9%), olive tree pollen (14.43% vs. 62.9%), weeds (26.8% vs. 52.19%), molds (4.12% vs. 18.72%) and cats or dogs (5.15% vs. 31.07%).
Differences in allergies among monosensitized vs. polysensitized children included house dust mites (36% vs. 50%), grasses (12% vs. 65.38%), olive tree pollen (24% vs. 70.51%), weeds (8% vs. 35.89%), molds (12% vs. 29.48%) and cats or dogs (4% vs. 41%).
Other differences between polysensitized and monosensitized adults included frequency of itchy eyes (63.75% vs. 44.33%; P = .002), total number of ocular symptoms (P = .0386) and total number of symptoms (median, 7 vs. 5; P = .024).
Differences between polysensitized and monosensitized children included 44.87% vs. 20% (P = .047) for higher frequency of itchy eyes and medians of five vs. three total symptoms (P = .02). Also, polysensitized children had more ocular symptoms (P = .038).
There were no significant differences between frequency of ear or palate itching or in the total number of itching symptoms within each age group, the researchers said.
Polysensitization only had a significant effect on disease burden among adults, the researchers said, with a median of 7 compared with a median of 6 among monosensitized adults (P = .043).
Also, among adults, wheezing frequencies included 27.49% of the polysensitized group and 14.43% of the monosensitized group (P = .015). Polysensitized adults had an increased number of asthma symptoms as well (P = .012).
Among children, the polysensitized group experienced more repeated throat clearing than the monosensitized group (25.64% vs. 4%; P = .04).
Durations of nasal symptoms from onset were longer among the polysensitized adults compared with the monosensitized adults too. For example, 66.93% of the polysensitized group and 50.52% of the monosensitized group reported that their symptoms began “many years ago.”
When patients were stratified into groups with one sensitization, two or three sensitizations or more than three sensitizations, stepwise associations included itchy eyes for the full cohort (P = .003) and for adults (P = .0002); repeated throat clearing for children (P = .0001); and wheezing for adults (P = .0001).
These stepwise associations also included total number of ocular symptoms for the full cohort (P = .0012) and for adults (P = .0003); total number of asthma symptoms for adults (P = .0003); total number of itch-related symptoms for the full cohort (P = .021); total number of symptoms for the whole group (P = .0001) and adults (P = .0004); and disease burden VAS score for the whole group (P = .0001) and adults (P = .0004).
There also was a significant association between sensitization rank and moderate-to-severe persistent allergic rhinitis based on ARIA class for the full cohort (P = .0044) and for adults (P = .0027).
Finally, the researchers said there was a highly significant but weak correlation between the number of allergic sensitizations and the number of symptoms, according to a Spearman correlation analysis (rS = 0.164; P < .0001).
Based on these findings, the researchers concluded that there were associations between polysensitization and a larger variety of symptoms, differences in specific individual symptoms, a higher number of symptoms, and more burdensome disease.
Since levels of sensitization constitute phenotypic characteristics, with combinations of symptoms revealing comorbidities, the researchers said that there may be organ-specific thresholds, indicating that rhinitis alone may be distinct from rhinitis with asthma or rhinoconjunctivitis.
“The development of allergic sensitization is a progressive process,” Papadopoulos said. “Our findings suggest that if we can stop sensitization, we may be able to stop symptom development, particularly those of asthma.”
For example, he added, allergen immunotherapy may stop new sensitizations from developing.
“Therefore, there is a tool available for this,” he said.
As a result, Papadopoulos said, it is important to identify all the allergic sensitizations that a patient may have.
“In patients with sensitizations amenable to specific treatments, these should be considered as early as possible,” he said.
The researchers are now further analyzing the data of their survey to evaluate the effect of age in both allergic and non-allergic rhinitis.
“It will also be of interest to see how different medical specialists understand phenotypes and endotypes to help design education,” Papadopoulos said.
For more information:
Nikolaos G. Papadopoulos, MD, PhD, can be reached at ngp@allergy.gr.