The correlation between allergic rhinitis and sleep disturbance

doi:10.1016/j.jaci.2004.08.044

Journal of Allergy and Clinical Immunology

Volume 114, Issue 5, Supplement, November 2004, Pages S139-S145

https://doi.org/10.1016/j.jaci.2004.08.044 Get rights and content

Nasal congestion, a common symptom related to allergic rhinitis (AR), often is associated with poor sleep quality, leading to decreased learning ability, decreased productivity at work or school, and a reduced quality of life. The release of inflammatory mediators and activation of inflammatory cells results in nasal congestion, causing disrupted sleep and subsequent daytime somnolence. Therefore it is important to treat AR with medications that improve congestive symptoms without exacerbating sedation. Second-generation antihistamines and anticholinergic drugs are well tolerated but have little effect on congestion and therefore are limited in their ability to reduce AR-associated daytime somnolence. However, intranasal corticosteroids reduce congestion, improve sleep and sleep problems, and reduce daytime sleepiness, fatigue, and inflammation. Recently, montelukast, a leukotriene receptor antagonist, has joined the approved therapies for AR. Montelukast significantly improves both daytime and nighttime symptoms. AR treatment should endeavor to improve daytime and nighttime symptoms, sleep, and productivity, thereby improving quality of life.

Section snippets

Allergic rhinitis produces sleep disturbance

AR can impair learning,⁶ affect performance,⁷ and often decrease productivity at work, during sports, and at school.⁸ The daytime fatigue experienced by patients with AR is often attributed to medication side effects, although it might in fact be the result of nasal congestion and associated sleep fragmentation.9, 10, 11 Some AR medications can be sedating, but AR itself might also contribute to sleepiness.6, 12 Compared with asymptomatic individuals, patients with chronic nighttime symptoms of

Mechanism of allergic rhinitis and sleep disturbances

In addition to the obvious effect of the symptoms of AR on sleep, the pathophysiologic elements, such as inflammatory cells and mediators, can also contribute to poor sleep. The early-phase response of AR, which is initiated within minutes of allergen exposure, follows mast cell release of chemical mediators. These mediators include histamine, cysteinyl leukotrienes (CysLTs), cytokines, chemotactic factors, and enzymes, all of which contribute to the early symptoms of AR (primarily sneezing,

Temporal variation in inflammation and sleep disturbance

Many biologic processes exhibit a circadian rhythm. For example, lung functions in healthy persons have a circadian rhythm that peaks at 4 pm and is lowest at 4 am.³⁴ Circadian variations are exaggerated by more than 15% in patients with nocturnal asthma compared with in patients with nonnocturnal asthma, including nighttime increases of inflammatory eosinophils and basophils.³⁴ Likewise, the levels of these inflammatory cells in patients with AR are highest in the early morning (P < .05 for 6

Therapy of allergic rhinitis improves associated sleep disturbances

Therapy aimed at reducing AR symptoms, particularly congestion, should significantly improve sleep quality and directly improve an individual's QOL. Medications available to aid in managing AR include intranasal corticosteroids (INSs), intranasal or oral decongestants, intranasal or oral antihistamines, anticholinergic medications, and leukotriene antagonists.

The mainstay of therapy for AR should focus on the use of INSs. INSs have been shown to reduce congestion (P = .001) and improve sleep (P =

Conclusion

Patients with AR symptoms, most importantly nasal congestion, frequently have disturbed sleep, daytime somnolence, and fatigue. Complaints of excessive fatigue and poor sleep should immediately trigger consideration of AR as a culprit. Close monitoring of an individual's sleep pattern and daytime alertness should be used to establish the diagnosis of AR and potential treatment strategy. In asthma and AR, inflammation increases at night, often leading to disturbed sleep and early-morning

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Disclosure of potential conflict of interest: T. J. Craig has received grants–research support from GlaxoSmithKline, Schering, BI. Genentech, AstraZeneca, Glaxo, Merck, Schering, Novartis, and Pfizer support the PAAA, of which Dr Craig is the president. J. L. McCann—none disclosed. F. Gurevich—none disclosed. M. J. Davies—none disclosed.

Reprint requests: Lauri Sweetman, American Academy of Allergy, Asthma and Immunology, 611 East Wells St, Milwaukee, WI 53202. E-mail: [email protected].

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