Rhinitis in children and adolescents with asthma: Ubiquitous, difficult to control, and associated with asthma outcomes

Abstract

Background: Rhinitis and asthma are linked, but substantial knowledge gaps in this relationship exist.

Objective: We sought to determine the prevalence of rhinitis and its phenotypes in children and adolescents with asthma, assess symptom severity and medication requirements for rhinitis control, and investigate associations between rhinitis and asthma.

Methods: Seven hundred forty-nine children with asthma participating in the Asthma Phenotypes in the Inner-City study received baseline evaluations and were managed for 1 year with algorithm-based treatments for rhinitis and asthma. Rhinitis was diagnosed by using a questionnaire focusing on individual symptoms, and predefined phenotypes were determined by combining symptom patterns with skin tests and measurement of serum specific IgE levels.

Results: Analyses were done on 619 children with asthma who completed at least 4 of 6 visits. Rhinitis was present in 93.5%, and phenotypes identified at baseline were confirmed during the observation/management year. Perennial allergic rhinitis with seasonal exacerbations was most common (34.2%) and severe. Nonallergic rhinitis was least common (11.3%) and least severe. The majority of children remained symptomatic despite use of nasal corticosteroids with or without oral antihistamines. Rhinitis was worse in patients with difficult-to-control versus easy-to-control asthma, and its seasonal patterns partially corresponded to those of difficult-to-control asthma.

Conclusion: Rhinitis is almost ubiquitous in urban children with asthma, and its activity tracks that of lower airway disease. Perennial allergic rhinitis with seasonal exacerbations is the most severe phenotype and most likely to be associated with difficult-to-control asthma. This study offers strong support to the concept that rhinitis and asthma represent the manifestations of 1 disease in 2 parts of the airways.

Keywords: Rhinitis prevalence; asthma; rhinitis management; rhinitis phenotypes; rhinoconjunctivitis.

FIGURE 1.

Numbers and percentages of participants in each rhinitis phenotype. Rhinitis phenotypes are denoted as Seasonal Allergic Rhinitis (SAR; red), Perennial Allergic Rhinitis (PAR; blue), Perennial Allergic Rhinitis with Seasonal Exacerbations (PARSE; green), Indeterminate Atopic Rhinitis (IAR, purple), Non-Allergic Rhinitis (NAR; orange). The percentage with No Rhinitis is included (gray).

FIGURE 2.

Seasonal variation in rhinoconjunctivitis total symptom scores, stratified by rhinitis phenotype. Each line (shaded region) represents the mean (95% CI) of rhinoconjunctivitis total symptom scores over 12 months for participants with Seasonal Allergic Rhinitis (SAR; red line), Perennial Allergic Rhinitis (PAR; blue line), Perennial Allergic Rhinitis with Seasonal Exacerbation (PARSE; green line), Indeterminate Atopic Rhinitis (IAR; purple line), Non-Allergic Rhinitis (NAR; orange line). No Rhinitis (black) is also included. P-values correspond to statistical test of seasonal trend in each rhinitis phenotype.

FIGURE 3.

Left Panel: percentage of participants at each treatment level and at each visit stratified by rhinitis phenotype. Treatment levels: no treatment (yellow), antihistamine alone (orange), and nasal steroid ± antihistamine (purple). Right Panel: percentage of participants receiving the highest treatment level (nasal steroid ± antihistamine) at each visit who remained symptomatic (whose therapy would have been stepped-up if another level was available) or who did not (not symptomatic), stratified by rhinitis phenotype. Symptomatic is denoted by lined purples and not symptomatic by light purple.

FIGURE 4.

Seasonal variation in rhinoconjunctivitis total symptom scores (left panel) and in the percentage of participants that were prescribed the highest treatment level (nasal steroid ± antihistamine) (right panel), stratified by asthma severity. Each line (shaded region) represents the mean (95% CI) of rhinoconjunctivitis total symptom scores or percentage of participants (95% CI) that were prescribed nasal steroid ± antihistamine over 12 months for participants with Difficult-to-Control Asthma (blue line) and with Easy-to-Control Asthma (green line). P-values correspond to a statistical test of the difference in the seasonal trend between Difficult-to-Control Asthma and Easy-to-Control Asthma.

FIGURE 5.

Seasonal variation of asthma clinical severity measures superimposed on the rhinoconjunctivitis total symptom scores in the combined group of participants with Seasonal Allergic Rhinitis (SAR) and Perennial Allergic Rhinitis with Season Exacerbations (PARSE), who had Difficult-to- Control Asthma. Each line (shaded region) represents the mean (95% CI) of the respective outcome.Note that the same rhinoconjunctivitis total symptom score data (purple) are depicted in each panel for comparison with the respective asthma measure. Asthma measures: Asthma Day Symptom Score measuring day symptoms and albuterol use in the last two weeks prior to a study visit (blue), Asthma Night Symptom Score measuring night symptoms and albuterol use in the last two weeks prior to a study visit (green), Asthma Exacerbation measuring exacerbation rates in the 2 months prior to a study visit (red) and FEV1 % predicted at each study visit (orange).