Children And Allergic Rhinitis: Quality Of Life Issues Introduction Allergic rhinitis is a major chronic respiratory disease which impacts on quality of life and work/school performance, leading to a significant economic burden1. Allergic rhinitis, often known as hay fever, is a condition, which can seriously impair quality of life for all who suffer from it, as well as close family who have to care for them. In children particularly, the condition can be damaging, not only to a child’s health, but also to their social development. This condition is characterised by numerous symptoms, which include: headaches, throat and nasal itching, persistent runny nose, post-nasal drip and, in most cases, by nasal congestion. Nasal congestion profoundly affects quality of life, largely by undermining the restorative power of sleep. Poor-quality sleep leads to daytime drowsiness, fatigue, indecision and significant impairment in learning and cognition2. This can lead children to be shy, anxious, fearful or even depressed. Inevitably, if left untreated, symptoms may also lead to absenteeism from school. For example, in the United States alone, an estimated total of two million schooldays are lost annually3 owing to allergic rhinitis. The bothersome qualities of allergic rhinitis symptoms and the potential disruption to the daily routine for those affected are supported by a recently conducted landmark survey known as the Allergies in Latin America (AILA) survey. The AILA survey is a comprehensive, first-of-its-kind survey carried out across eight countries into the impact of allergic rhinitis amongst adults and children. It investigated the 1 range of symptoms associated with the condition, the needs patients believe are unmet by their current medication and the overall effects on quality of life. In many cases, parents will frequently self-adjust treatments for their children (both over-the-counter and prescription medications) because of lack of efficacy, deterioration of efficacy, lack of 24-hour relief and bothersome side-effects3. This is supported out by AILA survey, which stated that only 35% of children thought their current medication actually provided 24-hour relief and over half (51%) stated that their nasal allergy medication was not effective enough. As many as 68% of children were simply dissatisfied with their current nasal allergy medication, demonstrating a major unmet need in Latin American children. Furthermore, according to AILA, more than half of Latin American children affected (53%) had to miss school or had school interrupted owing to their symptoms 4. In addition to this, 33% reported significant loss of productivity4, which translates into reduced academic performance. Epidemiology Rhinitis is defined as inflammation of the nasal membranes 5. Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx. The nose invariably is involved and the other organs are affected in certain individuals. Inflammation of the mucous membranes is characterized by a complex interaction of inflammatory mediators but ultimately is triggered by an immunoglobulin E (IgE)–mediated response to an extrinsic protein6. The condition is characterized by four major symptom types, namely: nasal itching, sneezing, rhinorrhoea (persistent runny nose) and nasal obstruction7. 2 Approximately one-third of patients will present before six years of age8. Allergic rhinitis in itself is not a life-threatening condition but it is concerning as it predisposes those affected to other co-morbidities, such as conjunctivitis, sinusitis, otitis media, and, most notably, it is a strong independent risk factor in the development of asthma9. The prevalence of allergic rhinitis is showing an alarming rate of increase: a recent study in Italy predicted that by that year 2020, as many as one out of two people up to 14 years of age may be affected10. With this projected prevalence, allergic rhinitis is fast becoming the most common chronic disease in the pediatric population11. Categorization of allergic rhinitis Allergic rhinitis is often divided into two sub-categories: seasonal and perennial rhinitis depending on the occurrence of their symptoms throughout the year. Seasonal rhinitis tends to bring about symptoms at specific given periods during the year, e.g. hay fever, which is rife during the pollen and fungal sporeproducing months. With perennial rhinitis, patients are fully symptomatic throughout the year. AILA revealed that 62% of Latin American allergic rhinitis patients are seasonally affected, with the remaining 38% suffering year-long symptoms. Nasal congestion was reported as the most troublesome symptom, affecting 54% of the respondents who were surveyed. However, the Allergic Rhinitis and its Impact on Asthma initiative12, in collaboration with the World Health Organization, has also proposed the following two categories: intermittent (IAR) and persistent 3 (PER) in addition to ‘mild’ or ‘moderate/severe’ to classify severity of symptoms and quality of life outcomes. Figure 1, below, illustrates the relationship between these categories 13. Figure 1: Classify allergic rhinitis Treatment goals for allergic rhinitis The symptoms of allergic rhinitis are often intolerable without treatment. The AILA survey revealed that over half (53%) of patients stated they could not cope without medication. According to the ARIA guidelines, the goals for treatment of allergic rhinitis are both effective control of symptoms and improvements in quality of life. The stated priorities within these goals include: unimpaired sleep; no troublesome symptoms; no or minimal side-effects of rhinitis treatment and finally, the ability to undertake normal daily activities, including work and school attendance, without limitation or impairment and the ability to participate fully in sport and leisure activities1. 4 As mentioned previously, certain activities are impaired in those who responded to the AILA survey. Over half of the children surveyed felt that their allergies lead to some or a lot of limitation in playing sports and there was also a major decline in productivity at school. Almost a quarter of children also suffered from disturbed sleep on account of the nasal symptoms of their allergic rhinitis. Allergens and environmental triggers Naturally, as allergic rhinitis is often exacerbated by physiological responses to an allergen, it is important to consider the role that such mediators play in allergic response control. Of great benefit to patients would be knowledge of exactly what environmental triggers tend to lead to allergic symptoms and subsequent proliferation of symptoms. For example, food allergies can cause rhinitis symptoms in 70% of infants and young children8. A comprehensive list of all such triggers could be determined by allergy skin prick or multi-allergen testing, which would give the patient a better idea of precisely what factors to avoid. Also, other causes should also be considered, such as socioeconomic, environmental and ethnic factors12, e.g. smoking parents of affected children. Current management of symptoms Once a child has been confirmed with allergic rhinitis, it is important that a treatment regimen is immediately commenced. The first step for intermittent or mild persistent allergic rhinitis is usually a course of antihistamines (such as cetirizine or loratadine) in combination with a decongestant (such as pseudoephedrine). For more persistent symptoms, physicians may initiate a course of corticosteroid nasal sprays such as budesonide, mometasone or beclometasone. The dilemma with prescribing steroids, despite their potent and proven anti-inflammatory properties as the most effective pharmacologic treatment of allergic rhinitis 14 is concern over side-effects that may be encountered. 5 These include: bone density loss, osteoporosis, growth retardation in children, adrenal suppression, cataracts and glaucoma. However, of the most recently developed steroid treatments for allergic rhinitis, ciclesonide has been shown to have a particular mode of action with a lower tendency for systemic side effects. This is owing to its properties as a steroidal pro-drug that is converted into an active metabolite by esterases in the nasal mucosa. Therefore any pro-drug that is absorbed systemically does not induce side effects as it can only become the active drug where the drug is required in a targeted fashion. Ciclesonide has also shown similar efficacy to other INSs and is also effective over 24-hours 15. Additionally, ciclesonide nasal spray is formulated in a hypotonic solution, which may speed absorption and improve patient experience by eliminating “throat drip” and enhancing drug efficiency so less solution is wasted. Allergen immunotherapy may also be a long-term multi-seasonal treatment for allergic rhinitis in more severe patients. This involves gradual exposure to allergens by injection over a period of months and is considered safe and effective8; however, sublingual therapy is the preferred therapy in young children16, rather than injections, owing to their inability to communicate potential problems effectively. Conclusions The AILA survey results have shown that there is an unmet need in current allergic rhinitis management for children and that their quality of life is significantly affected. The needs of treatment in children are the same as those for adults with allergic rhinitis, i.e. the need for efficacious and well tolerated medication that provides children with 24-hour relief from their debilitating symptoms. However, safety is even more paramount in children and we have to look to the use of novel treatments 6 that have fewer systemic effects. It is vital that management of allergic rhinitis is improved, in order to meet the needs of Latin American children, in line with the ARIA guidelines. The development of local guidelines that consider the regional factors that can influence the behaviour of physicians and patients is also vital in order to improve the lives of children with allergic rhinitis 17. References 1 Bousquet J et al (2008). Allergic rhinitis management pocket reference 2008. Allergy 63:990 – 996. Nathan R (2006). Allergic rhinitis associated with decline in work and school performance. 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Pediatrics; 117:34 – 42. 11 Baena-Cagnani E et al (2007). New perspectives in the treatment of allergic rhinitis and asthma in children. Curr Opin Allergy Immunol. 7:201 – 206. 12 Allergic Rhinitis and its Impact on Asthma: http://www.whiar.org/ 13 Bousquet J et al (2008). Allergic rhinitis and its impact on asthma 2008 update. Allergy 63(suppl. 86):8 – 160. 14 International Primary care Airways Group (IPAG) Handbook available at: http://www.globalfamilydoctor.com 15 Colice G L (2006). The newly developed inhaled corticosteroid ciclesonide for the treatment of asthma. Expert Opin Pharmacother; 7:2107 – 2117. 16 Baena-Cagnani et al (2005). Sublingual immunotherapy in pediatric patients: beyond clinical efficacy. Curr Opin Allergy Clin Immunol;5:173 – 177. 17 Price D and Thomas M (2006). Breaking new ground: challenging existing asthma guidelines. BMC Pulm Med. 6 (Suppl 1):S6. 2 7