Allergic rhinitis and asthma often co-exist, with allergic rhinitis preceding and potentially contributing to asthma. They share similar inflammatory pathways and epidemiological data finds allergic rhinitis in 65.24% of asthma patients in India. Second-generation antihistamines and inhaled nasal steroids are first-line treatments for mild-moderate allergic rhinitis, while immunotherapy may be used for moderate-severe or persistent cases. Proper treatment of allergic rhinitis can help control asthma symptoms and reduce costs.

1. Allergic Rhinitis and Co-
morbid Asthma

2. Allergic rhinitis classification
https://iapindia.org/pdf/Ch-014-Allergic-Rhinitis.pdf

3. Allergic rhinitis & Asthma

4. Allergic Rhinitis:
Occurs in up-to 20-30 % general population.
Occurs in greater than 80 % of Asthmatics.
Asthma:
Occurs in 5-15 % of the general population.
Occurs in up-to 40 % of AR patients
Allergic rhinitis (AR) & Asthma

5. Prevalence of co-existing AR in Asthma Patients (India)
The prevalence of co-existing AR in asthma patients was found to be 65.24%
Jaggi et al. The CARAS survey 2019

6. Prevalence allergic rhinitis & asthma across India.
AR: allergic rhinitis;
South zone: Chennai, Hyderabad, Thiruvananthapuram, Bengaluru; West zone: Jaipur, Mumbai;
East zone: Kolkata; North zone: Delhi, Lucknow, Meerut
Jaggi et al. The CARAS survey 2019

7. Treating Allergic Rhinitis cuts Asthma Costs

8. Interaction between Nasal Airway & Lower
Airway
Physiologic function of the nose is to condition inhaled air so that it reaches the
lower airways in a state that does not threaten their homeostasis.
NO has strong antiviral and
bacteriostatic activity, improves
oxygenation, exerts
bronchodilatory effects

9. Relationships between Allergic Rhinitis and
Asthma.
• The horizontal axis represents the severity of the syndrome, whereas the vertical axis represents the severity of each of the syndrome’s components (ie, allergic
• rhinitis and asthma).
• The tracings represent the relationship between syndrome severity and the severity of each component.
• Individuals with only allergic rhinitis are at the low end of the wide severity spectrum of the syndrome. These individuals have no clinically evident lower airways disease, but
their large airways show pathologic changes that are not very different from those seen in patients with mild asthma.
• In individuals with a more severe expression of the syndrome, the rhinitis is worse, and the abnormalities in the lower airways manifest themselves clinically with asthma.
From there on, the severity of asthma and rhinitis follows a parallel track in correlation with the overall severity of the chronic allergic respiratory syndrome. The bidirectional
arrows represent the interactions between rhinitis and asthma that result from (a) the beneficial functions that the nose provides for the lower airways and (b) the concept that
rhinitis and asthma are manifestations of a systemic syndrome that allows for cross-talk between the nasal and the lower airways. Because of its functions, the nose signals to
the lower airways more intensely and through a variety of mechanisms compared with the signals that the lower airways send to the nose

10. Similar Inflammatory Cascade

11. Physiopathological hypotheses explaining the concept of
‘one airway disease

12. Allergic Rhinitis & Asthma

13. Airway Remodeling: Asthma

14. Allergic Rhinitis & Asthma

15. Pharmacological treatment
• Second-generation antihistamines are drugs of choice in mild intermittent AR for better safety
efficacy ratio.
• The choice of drugs predominantly depends on the dominant symptoms the patient suffers
from.
• Inhaled nasal steroids (INS) are the controller medications of choice. Choose an INS with low
systemic bioavailability like mometasone or fluticasone furoate at a minimum dose required to
achieve symptom control.
• Allergen-specific immunotherapy (AIT or desensitization) is recommended in difficult to treat
moderate-to-severe and/or persistent AR by a trained allergist.
• Sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT) are the two most
common modes of immunotherapy.
https://iapindia.org/pdf/Ch-014-Allergic-Rhinitis.pdf

16. Second-generation antihistamines:
Recommended age and dosage
https://iapindia.org/pdf/Ch-014-Allergic-Rhinitis.pdf

17. Characteristics of drugs used in allergic rhinitis
https://iapindia.org/pdf/Ch-014-Allergic-Rhinitis.pdf

18. Commonly used intranasal corticosteroids (INS) in
allergic rhinitis and dosage
NB: Duration of INS therapy is symptom oriented and highly individualised. May require for 3 months and beyond (does not
need weaning).
https://iapindia.org/pdf/Ch-014-Allergic-Rhinitis.pdf

19. Practical stepwise approach of management of allergic
rhinitis (ARIA, 2019)
(ARIA: Allergic Rhinitis and its Impact on Asthma; HPF: high power field; IgE: immunoglobulin E; INAH: intranasal antihistamine; INS: inhaled nasal steroids;
LTRA: leukotriene receptor antagonist) https://iapindia.org/pdf/Ch-014-Allergic-Rhinitis.pdf

20. The next-generation ARIA* care pathway
* ARIA: Allergic Rhinitis & its Impact on Asthma
Allergologie select, Volume 3/2019 (22-50)

21. Step-up algorithm in untreated patients (adolescents over
12 years and adults) based on visual analogue scales
Allergologie select, Volume 3/2019 (22-50)

22. Step-up algorithm in treated patients (adolescents over
12 years and adults) based on visual analogue scales
Allergologie select, Volume 3/2019 (22-50)

23. Summary
• Rhinitis and asthma are often associated and the two disorders interact at various levels.
• Rhinitis typically precedes the development of asthma and can contribute to
unsatisfactory asthma control.
• There is increasing evidence that suggests a major involvement of airway epithelial cells
in the pathogenesis of both asthma and allergic rhinitis.
• Second-generation antihistamines are drugs of choice in mild intermittent AR for better
safety efficacy ratio.
• Inhaled nasal steroids (INS) are the controller medications of choice.
• Allergen-specific immunotherapy (AIT or desensitization) is recommended in difficult to
treat moderate-to-severe and/or persistent AR by a trained allergist.
https://iapindia.org/pdf/Ch-014-Allergic-Rhinitis.pdf

24. Thank You