”I tell my allergic rhinitis patients they’ve got ‘asthma of the nose’ and will be on medication for the rest of their lives.” So said a consultant in ENT/rhinology from a major UK teaching hospital during an ENT masterclass I attended.
Current ARIA (allergic rhinitis and its impact on asthma) guideline options for allergic rhinitis (AR) are: a) Long-term antihistamines only; then b) long-term antihistamines plus steroid nasal sprays; and then c) variations of montelukast plus antihistamine plus steroid nasal spray.
The UK consultant did touch briefly on allergen immunotherapy as a way of reducing symptom and medication load. However, NHS doctors have at best a lukewarm attitude to allergy immunotherapy, preferring a ‘keep taking the tablets’ approach.
The consultant then advised on studies of patient satisfaction with GP-led rhinitis treatments: ‘Poor’ and ‘worse than poor’ after ENT surgical intervention. No surprises there, I thought. Surgical intervention in an allergic nose defies logic. AR is a medical, not a surgical, condition.
‘Reps’ for various pharma companies with rhinitis sprays have found that GPs consider AR ‘a pain’, with doctors admitting to a poor understanding of the condition. They usually want to see the backs of these presentations so they can move on to the next, hopefully easier-to-manage, condition.
However, AR is here to stay and growing at an alarming rate. Some 24 per cent of the population have AR and it is reckoned that, in the next decade, this figure will rise to 50 per cent. Ignore AR at your peril and your patients’ misfortune.
AR involves the sinuses as well as the nose, may cause nose and sinus symptoms only, and may provoke lower airways hyper-reactivity. Untreated or poorly-treated AR may eventually trigger asthma. AR may coexist with asthma, and untreated it can allow nasal polyps to develop.
Coexistent allergic rhinitis in asthmatic children causes more asthma-related hospital admissions and greater total days spent in hospital.
For further reading, see an excellent paper: <em>The relationship between the upper and lower airway — an ENT perspective</em> in <em>J ENT Masterclass</em> 2014; 7 (1): 65-69.
<h3 class=”subheadMIstyles”>‘Poor understanding’</h3>
Why is AR such a nuisance to treat? Simple: Few doctors actually inspect the nose to see the pathology from allergic challenge and so have a poor understanding of what should be the appropriate treatment. Antihistamines ease symptoms but mask the developing turbinate swelling/oedema. By the time steroid sprays are added, the nose is so blocked it cannot ‘accept’ the medication. The end result is expensive drugs wasted and patient dissatisfaction, as well as probable slow-but-steady evolution of chronic sinusitis (which is now considered at epidemic levels in developed countries).
This is so reminiscent of asthma management in the late 1970s and early 1980s. Inhalers were prescribed without explaining inhaler technique. The doctors didn’t even know how the products should be used and therefore couldn’t demonstrate to the patients. There were reports of asthma deaths where the unfortunate victim was found with a Ventolin inhaler clutched in a blue and lifeless hand.
Asthma was considered an illness of bronchoconstriction rather than airway inflammation. It took years before inhaled steroids moved to the front of treatment choices and inhaler technique was refined. There were a lot of poorly-controlled asthmatics and fatal asthma attacks in that time. We are currently at that stage with allergic rhinitis. It is poorly understood and badly managed. Prescriptions are handed out in hope rather than expectation of benefit.
Let me remind you of the UK consultant’s comment that AR patients “will be on medication for the rest of their lives”. No matter how true those words may be, if that advice is offered to the parents of a five-year-old with AR, it’ll more than likely be rejected and the nearest homeopath will be sought.
However, there is a new treatment for AR making its way to Ireland and the UK from Europe, which could end that heart-sink ‘asthma of the nose with lifelong medication’ forewarning.
Rhinolight is a medical device that uses UV phototherapy to reverse the allergically-damaged nasal mucosa and turbinates.
<h3 class=”subheadMIstyles”>Background</h3>
For decades, UV phototherapy has been used successfully in atopic dermatitis. The inflammatory effect that occurs in the skin in eczema is very similar to the changes seen in allergic challenge to the nose. In 2001, the developers of Rhinolight worked on the concept of using UV phototherapy (UV-B 5 per cent, UV-A 25 per cent and visible light 70 per cent) to treat that allergic damage.
During the initial research, both standard anti-allergy medications and phototherapy were combined. As patient symptoms significantly improved, it was decided to use Rhinolight only. There was as much patient satisfaction with Rhinolight alone as with the combination of Rhinolight and anti-allergy medications.
Phototherapy blocks histamine release from mast cells; induces apoptosis of eosinophils and lymphocytes; reduces the number of eosinophil cells; and reduces the quantity of ECP and IL-5 in nasal secretions.
Rhinolight does not damage healthy nasal tissue and thus can be safely used as a long-term treatment in allergic conditions affecting the nose and sinuses. It is a safe treatment for AR in pregnant/breastfeeding women and elite athletes worried about what they can or cannot take during an allergy attack.
<h3 class=”subheadMIstyles”>Dosing regimens</h3>
<strong><em>Seasonal allergic rhinitis </em></strong>
Best started just before the pollen season. Two-to-three minutes for each nostril three times a week for two weeks.
<strong><em>Perennial allergic rhinitis </em></strong>
Start any time of the year. Two-to-three minutes for each nostril three times in week one, then once a week for five weeks. Each treatment session should take just 10-to-15 minutes in total.
It can be administered by a practice nurse, with or without the presence of the overseeing doctor.
<h3 class=”subheadMIstyles”>Safety</h3>
Rhinolight has CE approval (the product and treatment meet European Medical Device Directive requirements) and is classified as a Medical Device Class IIa. There have been no serious adverse incident reports in 15 years of continuous treatments in many centres around the world. Compare that with the fears of long-term effects of antihistamines and intranasal steroids, or even worse, nasosinus surgery.
With regard to the question of risk of the UV light creating malignant change in the nasal mucosa, this has been checked repeatedly:
Lajos Kemény, Andrea Koreck: Ultraviolet light phototherapy for allergic rhinitis. Review in the <em>Journal of Photochemistry and Photobiology B: Biology</em> 2007, 87: 58–65
L Kemény, A Koreck, A Szechenyi, M Morocz, A Cimpean, Zs Bella, E Garaczi, M Raica, TR Olariu, I Rasko: Effects of intranasal phototherapy on nasal mucosa in patients with allergic rhinitis. <em>Journal of Photochemistry and Photobiology B: Biology</em> 2007, 89: 163–169
Detlef Brehmer, Michael P Schön: Endonasal phototherapy significantly alleviates symptoms of allergic rhinitis, but has a limited impact on the nasal mucosal immune cells.
<em>Eur Arch Otorhinolaryngol</em>. Issue 3/2011.
Dryness and crusting of the nasal lining can occur, but can be treated with Nozoil (vitamin E oil from Sweden) or Coldastop (vitamin A/E oil from Germany). Both products are available online to patients in the UK and Ireland.
Rhinolight compares very favourably to standard anti-rhinitis medication.
Please see the following paper: Garaczi E, Boros-Gyevi M, Bella Zs, Tóth E, Csoma Zs, Dósa-Rácz É, Kemény L, Koreck A: Intranasal phototherapy is more effective than fexofenadine hydrochloride in the treatment of seasonal allergic rhinitis. <em>Photochemistry and Photobiology</em> 2011, 87(2): 474-7.
Consultant Allergy Specialist Dr Javier Subiza (Madrid Medical University) reported that Rhinolight treatment was as effective as immunotherapy and the efficacy was especially pronounced among poly-sensitised patients (www.clinicasubiza.com/en-/enfermedades/generales/fototerapiaintranasalconrhinolight.aspx).
For most patients, symptoms improve after the first few sessions. With six-to-eight sessions twice a year for three years, there is a good chance of long-term remission. This is the same as for allergen immunotherapy.
My personal experience in treating close to 80 patients is that Rhinolight is more effective than any prescribed therapy, with no other oral or intranasal treatments needed. Indeed, I hope to have a poster presentation on Rhinolight at this year’s British Society for Allergy and Clinical Immunology (BSACI) conference.
A Sydney-based ENT/allergist started with one Rhinolight treatment unit and then bought another three, one for each of his practices. He now has sole distribution rights for Australia and New Zealand (www.australianallergycentre.com.au/rhinolight-phototherapy-for-the-treatment-of-allergic-rhinitis-symptoms/).
Rhinolight is in use in approximately 300 centres worldwide. In the UK, this treatment is currently going through an NHS-NICE Medical Technologies Evaluation Programme (www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-medical-technologies-evaluation-programme).
Unfortunately, this is delaying its availability for Britain’s millions of allergy sufferers. But I believe that within the next five years there will be a Rhinolight centre in many UK hospitals, and certainly in most private allergy practices.
I, unfortunately, have no distribution rights — anywhere.
Another business opportunity missed.
