Advances in upper airway diseases and allergen immunotherapy

Epidemiologic studies continue to find an increased prevalence of rhinitis, asthma, and atopy in more westernized countries. Both allergic and nonallergic rhinitis are risk factors for development of asthma, particularly in adulthood. In patients who have both asthma and rhinitis, treatment of the latter decreases the likelihood of emergency department visits or hospitalization for asthma. The protective effect of intranasal cortico-steroids is much greater than that of antihistamines. This mirrors the effect on rhinitis symptoms, in which nasal corticosteroids are much more effective than antihistamines, leukotriene receptor antagonists, or the combination of both. In patients with severe asthma, sinus mucosal thickening on computed tomography (CT) correlates with the severity of lower airway disease indicated by sputum eosinophilia, exhaled nitrous oxide (NO), functional residual capacity, and diffusing capacity. Preseasonal specific immunotherapy (SIT) is less effective, but additive to treatment with omalizumab. It is also somewhat less effective in reducing nasal symptoms than nasal corticosteroids; however, it is superior to them for reducing lower airway inflammation. SIT in children with only allergic rhinitis reduces both the incidence of asthma and bronchial hyperresponsiveness to methacholine. High-dose sublingual immunotherapy appears to be safe and effective, but less effective than injection immunotherapy. It is not clear that there are cost savings with sublingual immunotherapy, as home administration savings may be offset by the much larger amount of allergen extracts required. New approaches to allergen immunotherapy, designed to increase efficacy and safety, include conjugation of allergens to immunostimulatory sequences and encapsulation in liposomes. Cross-reactivity between inhalants and foods demonstrated by skin prick tests is more predictive of clinically important sensitivity than is that demonstrated by RAST testing. The latter, because of cross-reacting profilins, is often clinically irrelevant.