Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.

In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.

This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.

The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.

Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.

The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

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Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Authors Jan L. Brozek, MD, PhD – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada Jean Bousquet, MD, PhD – Service des Maladies Respiratoires, Hopital Arnaud de Villeneuve, Montpellier, France, INSERM, CESP U1018, Respiratory and Environmental Epidemiology Team, France, and WHO Collaborating Center for Rhinitis and Asthma Carlos E. Baena-Cagnani, MD – Faculty of Medicine, Catholic University of Cordoba, Cordoba, Argentina Sergio Bonini, MD – Institute of Neurobiology and Molecular Medicine – CNR, Rome, Italy and Department of Medicine, Second University of Naples, Naples, Italy G. Walter Canonica, MD – Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy Thomas B. Casale, MD – Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, Nebraska, USA Roy Gerth van Wijk, MD, PhD – Section of Allergology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands Ken Ohta, MD, PhD – Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan Torsten Zuberbier, MD – Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany Holger J. Schunemann, MD, PhD, MSc – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada

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Allergic Rhinitis and Its Impact on Asthma

Background: Allergic rhinitis represents a global health problem affecting 10% to 20% of the population. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines have been widely used to treat the approximately 500 million affected patients globally. Objective: To develop explicit, unambiguous, and transparent clinical recommendations systematically for treatment of allergic rhinitis on the basis of current best evidence. Methods: The authors updated ARIA clinical recommendations in collaboration with Global Allergy and Asthma European Network following the approach suggested by the Grading of Recommendations Assessment, Development and Evaluation working group. Results: This article presents recommendations about the prevention of allergic diseases, the use of oral and topical medications, allergen specific immunotherapy, and complementary treatments in patients with allergic rhinitis as well as patients with both allergic rhinitis and asthma. The guideline panel developed evidence profiles for each recommendation and considered health benefits and harms, burden, patient preferences, and resource use, when appropriate, to formulate recommendations for patients, clinicians, and other health care professionals. Conclusion: These are the most recent and currently the most systematically and transparently developed recommendations about the treatment of allergic rhinitis in adults and children. Patients, clinicians, and policy makers are encouraged to use these recommendations in their daily practice and to support their decisions.

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Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision

The allergenic content of the atmosphere varies according to climate, geography and vegetation. Data on the presence and prevalence of allergenic airborne pollens, obtained from both aerobiological studies and allergological investigations, make it possible to design pollen calendars with the approximate flowering period of the plants in the sampling area. In this way, even though pollen production and dispersal from year to year depend on the patterns of preseason weather and on the conditions prevailing at the time of anthesis, it is usually possible to forecast the chances of encountering high atmospheric allergenic pollen concentrations in different areas. Aerobiological and allergological studies show that the pollen map of Europe is changing also as a result of cultural factors (for example, importation of plants such as birch and cypress for urban parklands), greater international travel (e.g. colonization by ragweed in France, northern Italy, Austria, Hungary etc.) and climate change. In this regard, the higher frequency of weather extremes, like thunderstorms, and increasing episodes of long range transport of allergenic pollen represent new challenges for researchers. Furthermore, in the last few years, experimental data on pollen and subpollen-particles structure, the pathogenetic role of pollen and the interaction between pollen and air pollutants, gave new insights into the mechanisms of respiratory allergic diseases.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1398-9995.2007.01393.x

Allergenic pollen and pollen allergy in Europe

The increasing mobility of Europeans for business and leisure has led to a need for reliable information about exposure to seasonal airborne allergens during travel abroad. Over the last 10 years or so, aeropalynologic and allergologic studies have progressed to meet this need, and extensive international networks now provide regular pollen and hay-fever forecasts. Europe is a geographically complex continent with a widely diverse climate and a wide spectrum of vegetation. Consequently, pollen calendars differ from one area to another; however, on the whole, pollination starts in spring and ends in autumn. Grass pollen is by far the most frequent cause of pollinosis in Europe. In northern Europe, pollen from species of the family Betulaceae is a major cause of the disorder. In contrast, the mild winters and dry summers of Mediterranean areas favor the production of pollen types that are rarely found in central and northern areas of the continent (e.g., the genera Parietaria, Olea, and Cupressus). Clinical and aerobiologic studies show that the pollen map of Europe is changing also as a result of cultural factors (e.g., importation of plants for urban parklands) and greater international travel (e.g., the expansion of the ragweed genus Ambrosia in France, northern Italy, Austria, and Hungary). Studies on allergen-carrying paucimicronic or submicronic airborne particles, which penetrate deep into the lung, are having a relevant impact on our understanding of pollinosis and its distribution throughout Europe.

Pollen‐related allergy in Europe*

Pollen of Parietaria officinalis causes season-associated respiratory symptoms. In Southern Croatia (Yugoslavia) we found 65% patients with rhinitis and/or asthma to be allergic to this pollen. They showed positive cutaneous reactions and had specific IgE antibodies to the respective isolated allergen. The finding represents the first report on Parietaria officinalis-induced allergy on the east Adriatic coast.

Allergy Induced by Parietaria officinalis Pollen in Southern Croatia

Hypersensitivity to Parietaria officinalis (wall pellitory) pollen and other environmental allergens was studied in pollinosis patients allergic to P. officinalis pollen who were born in areas without P. officinalis and later moved to the city of Split, where P. officinalis is responsible for some 65% of pollinosis cases. Highly significant positive correlations were found for both the intensity of skin test reaction and concentration of specific serum IgE with the length of residence in the area. In contrast, the respective data on subjects hypersensitive to P. officinalis pollen allergen, but born and living in the area of Split, revealed a tendency to negative correlation between age and intensity of hypersensitivity to P. officinalis. A number of patients from both groups were tested for presence of serum IgE antibodies specific for 14 common environmental allergens. Hypersensitivity to P. officinalis pollen was associated with hypersensitivity to olive, mugwort, and birch pollen in newcomers; hypersensitivity to birch and, to some extent, olive pollen was significantly more frequent in newcomers than in autochthonous patients who were allergic to P. officinalis pollen. Regardless of whether the patients were autochthons or newcomers to the area with P. officinalis, hypersensitivity to P. officinalis mostly excluded hypersensitivity to Dermatophagoides farinae and D. pteronyssinus, and vice versa.

Hypersensitivity to Parietaria officinalis pollen in newcomers to the area with the plant.

In central south Croatia, i.e., the Adriatic coast with the city of Split at the center, year-long pollen concentrations in the air were determined for typical local plants, and the area's plant pollination calendar was established. High concentrations of Parietaria officinalis pollen dominated during the year (up to 20% from April to June). Pollens of Pistacia lentiscus, Olea europaea, Pinus halepensis, Juniperus oxycedrus, Mimosa and Cistus monspeliensis were found in lower concentrations and for shorter time periods. Using both commercially available standard inhalation allergens and specifically prepared pollen allergens, skin testing was performed and the cause of hypersensitivity was determined in a population of 4116 atopic patients with respiratory symptoms. Some 38.8% of patients were allergic to standard pollen allergens (mixed grass pollen, mixed tree pollen, P. officinalis and Pittosporum tobira). Hypersensitivity to more than one allergen was found in 53% of patients, whereas 19% of patients did not react to any of the standard allergens. Additional testing with newly prepared individual allergens (P. lentiscus, O. europaea, P. halepensis, J. oxycedrus, Mimosa and C. monspeliensis) revealed the causes of hypersensitivity in a number of patients, but the testing of patients nonreactive to standard allergens still left 44% of these individuals without reaction to any of the allergens used. Hypersensitivity to the pollens of P. tobira, C. monspeliensis and J. oxycedrus is described for the first time.

Hypersensitivity to pollen allergens on the Adriatic coast.

The levels of IgE antibodies specific for toluene-diisocyanate (TDI), diphenylmethane-diisocyanate (MDI) and hexamethylene-diisocyanate (HDI) were determined in eight workers with an unequivocal history of professional asthma, all having been exposed to isocyanates in the working atmosphere. Five workers were examined at the clinical onset of asthma. They had serum IgE antibodies specific for TDI, MDI and HDI, and depressed pulmonary ventilation parameters. In contrast, three workers, who had only a mild bronchial obstruction at the time of testing, had no anti-isocyanate IgE antibodies. The results indicated that asthma was induced by type I allergic reaction, but other pathogenetic mechanisms of bronchoobstruction could not be completely ruled out.

Occurrence and specificity of IgE antibodies to isocyanates in occupationally exposed workers

The effects of specific hyposensitization in 40 patients with Parietaria officinalis-sensitive seasonal rhinoconjunctivitis were studied during three years of treatment. The patients were treated with subcutaneous injections of a new, partially purified, characterized and standardized pollen extract of P. officinalis allergen (alum-absorbed depot preparation). Treatment was applied from November to mid March and it was clinically assessed during the plant flowering season (mid March to end of June). Laboratory tests were performed yearly when beginning and ending treatment. Serum concentrations of P. officinalis pollen allergen-specific IgE antibodies decreased (first year: from 18.7 +/- 7.7 to 17.9 +/- 7.6 PRU/ml; second year: from 16.3 +/- 7.1 to 14.1 +/- 6.6 PRU/ml; third year: from 12.3 +/- 5.6 to 10.9 +/- 5.6 PRU/ml) and those of specific IgG increased (first year: from 15.3 +/- 13.2 to 21.7 +/- 14.0%; second year: from 28.5 +/- 13.0 to 36.3 +/- 15.9%; third year: from 29.9 +/- 14.1 to 38.9 +/- 16.8%) during the treatment. Histamine release from peripheral blood leukocytes challenged in vitro with the allergen decreased during the three years of the treatment (first year: from 42.3 +/- 13.0 to 33.1 +/- 10.8%; second year: from 31.9 +/- 11.9 to 19.1 +/- 8.5%; third year: from 19.4 +/- 4.6 to 14.3 +/- 4.6%), whereas the size of skin test reaction and the percentage of eosinophils among white blood cells remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Cvitanović S

Papers

Allergy Induced by Parietaria officinalis Pollen in Southern Croatia

Hypersensitivity to Parietaria officinalis pollen in newcomers to the area with the plant.

Hypersensitivity to pollen allergens on the Adriatic coast.

Occurrence and specificity of IgE antibodies to isocyanates in occupationally exposed workers

Specific hyposensitization in patients allergic to Parietaria officinalis pollen allergen.