Therapy efficacy of hyperreative rhinitis by the combination of intranasal steroid and oral H 1-antihistamine

Background Hyperreative rhinitis (HRR) is identified as rhinitis which has at least two symptoms such as sneeze, itches, watery secretion and nasal blockage. Little is known about the pathology of HRR, as well as its clinical features and treatment. Objective To investigate efficacy HRR by combined therapy with intranasal steroids and antihistamines Methods The age, gender, predisposing factors and clinical symptoms of 200 HRR patients were analyzed. Both intranasal steroids and antihistamines were applied for 8 weeks. Symptoms were assessed with VAS score before and after the treatment. Result: Before the therapy, 87% of HRR patients showed persistent symptoms; 69% complained about severe and persistent effects on the quality on the life; sneezing (96%) and rhinorrhea (78%) were the top 2 symptoms reported; All patients completed the 8-wk combined therapy with intranasal steroids and antihistamines; 96% patients were satisfied with the therapy, with all symptoms except wheezing have been clear relief (p <0.05); the remaining 4% reported the unsatisfied result of the therapy. Conclusion The combined therapy with intranasal steroids and antihistamines controlled most of clinical symptoms of HRR. 1 Instruction Rhin itis is an ext remely common rh inopathy. Rhinit is has been divided into four main categories: infectious rhinitis, a llergic rhin itis (A R), structural rhinit is, and non-allerg ic rh initis (NA R). Differential diagnosis of AR from NAR is often difficu lt because of their similar clin ical presentation. NAR is now a diagnosis of exclusion characterized by similar symptoms to A R, but with no allergic sensitization-related symptoms and signs of infection [1]. Hyperreactive rhin itis (HRR) is identified as the combination of AR and NAR because of similar symptoms. HRR affects a significant number o f patients in clinical practice. Studies have shown an increase in the prevalence of asthma in patients with HRR[2] it has been hypothesized that there was a link between upper and lower airways beyond allergy associated inflammation. Our current study focused on the efficacy of one combined therapy with intranasal steroid and oral antihistamine on HRR. 2 Materials and methods a Corresponding author: lilin01@jlu.edu.cn DOI: 10.1051/ , 010 (2017) 708010 BIO Web of Conferences 8 bioconf/201


Instruction
Rhin itis is an ext remely co mmon rh inopathy.Rhinit is has been divided into four main categories: infectious rhinitis, a llergic rhin itis (A R), structural rhinit is, and non -allerg ic rh initis (NA R).Differential diagnosis of AR fro m NAR is often difficu lt because of their similar clin ical presentation.NAR is now a diagnosis of exclusion characterized by similar sympto ms to A R, but with no allergic sensitization-related symptoms and signs of infection [1].Hyperreactive rhin itis (HRR) is identified as the combination of AR and NAR because of similar sympto ms.
HRR affects a significant number o f patients in clinical practice.Studies have shown an increase in the prevalence of asthma in patients with HRR [2] it has been hypothesized that there was a link between upper and lower airways beyond allergy associated inflammation.Our current study focused on the efficacy of one co mbined therapy with intranasal steroid and oral antihistamine on HRR.

Clinical data
200 consecutive untreated patients (110 females and 90 males), who were d iagnosed of HRR, participated the study.The cases were co llected fro m th e files recorede between January, 2015 and December, 2015, fro m the Depart ment of Otolaryngology, Head and Neck Surgery of the University of China-Japan Union Hospital attached to Jilin University, China.The study was approved by the institutional review board of China-Japan Union Hospital.A ll the participants provided written informed consent before the study.

Clinical questionnaire and medical interview
Data of the initial evaluation of NAR patients were extracted fro m the med ical history obtained d uring their first visit to our center.A clin ical questionnaire, a co mplete file of physical examinat ion and symptoms were included.Visual Analogue Scale (VA S) was used to evaluate the severity of nasal symptoms before and after the therapy.The range of the score was 0-3: higher scores indicated more severe symptoms, and score 0 indicated no sympto ms.One year follow-up evaluation was also conducted after the treatment.NAR was defined by the presence of two or more nasal symptoms (sneezing, itching, rhinorrhea, or nasal obstruction) plus a negative SPT response and serum Ig E level specific to aeroallergens.

Therapy procedure s
Patients were treated with once-daily intranasal budesonide for 8 weeks.200 mg Budesonide were given to patients aged <11 years at study entry and 400 mg to patients aged >11 years at study entry.Simu ltaneously, Lo ratadine was ad ministered orally to patients (>12 years old) with 10 mg per day before sleeping for 8 weeks

Stati stical analysi s
Descriptive statistics (frequency, mean, med ian, SD, and range) were used to analyzed the clin ical features of HRR.Paired t -test was used to analyze the therapy results.The data were analyzed with SPSS for Windows 17.0 (SPSS, Inc, Chicago, Ill).P -values < 0.05 were considered statistical significant.

Age and sex distribution
A total of 200 patients were survey in our study.They aged fro m 4 to 76, with an average of 38 r 14) years old.87% of patients showed persistent symptoms and 69% co mplained about severe and persistent effects on the quality on the life; there was no significant difference in the age between male and female patients (p=0.983)

The efficacy of an 8-wk combined therapy of intrana sal steroid and oral antihistamine
All 200 patients were contacted by telephone for fo llo w-up evaluation after 8-wk therapy.All the symptoms were significantly decreased after the 8 -wk therapy (p<0.05)96% patients were satisfied with the therapy, with all symptoms have been clear relief (p <0.05); the remaining 4% reported the unsatisfied result of the therapy but still has decreased VAS after the co mbined treat ment.(Tab le 1).

Discussion
Both NA R and AR are associated with the nasal mucosa hyper-responsiveness and resulted in similar symptoms and physical signs , so we identified the hyperreactive rhinitis (HRR) according to symptoms.Cu rrently, the diagnosis of HRR relies on the clinical sympto ms.Standard treatment reference of HRR has not been established yet.Similar treat ment designed for AR has been used to treat to HRR due to the shared symptoms and morbidity between this two types of rhinit is.Studies showed that intranasal steroids such as Budesonide, Fluticasone and Mometasone, could relieve the edema condition of nasal cavity and decrease the symptoms of NA R. Rinne [3] reported that intranasal steroids could successfully control the recurrence of the NA R. Patients with sneezing as a predominant symptom responded well to oral antih istamines.The co mbination of Flunisolide and Loratadine showed better clinical efficacy than intranasal steroid alone [ 4].In our study, 96% patients showed allev iated symptoms of nose, eye and lower airway after a co mbined therapy of intranasal steroids and oral anti-histamines for 8 weeks, indicating the therapy was effective in HRR treat ment.The histamine receptor 3 was the decisive factors in nasal neural system, whereas the target of Loratadine is histamine receptor 1 that main ly responsib le to the allergic reaction.Studies have showed that Azelastine decreased all the sympto ms of NA R [5] and AR.Azelastine is the intranasal antihistamine co mmercially available.Studies showed that Azelstine interfered with vasoactive neuroperptide substance P and inhib ited the production of leukotrienes B4 and C, wh ich might possibly decrease the expression of nuclear factor-kB, which was a transcription factor for mu ltip le proin flammatory substances [6].The efficacy of intranasal Azelastine might be fu rther explored to replace Loratadine in the co mbination therapy to treat NAR and AR.
In conclusion, HRR had it own clinical feature, such as high risk population is adults (30-39), slightly more in female, The comb ined therapy of intranasal steroid and oral h istamines was effective in controlling HRR sympto ms.In addit ion, the individualized therapy procedure needs further consideration for the inter-individual variability of the therapy efficacy observed in our study.

Table 1 .
All the HRR symptoms were significantly decreased after the 8-wk combined therapy