Recent data indicate that more than 10 million Americans have chronic rhinosinusitis (CRS), an inflammatory disease that is associated with $50 to $60 billion in annual healthcare costs. With no optimal treatment, quality of life in patients with CRS is generally poor. Prior research has also shown that 11% to 15% of patients with CRS also have GERD or reflux, making this disease much more common in CRS patients than in the general population. “Reflux affects sinusitis in these patients, making it nearly refractory to therapy,” says Mahboobeh Mahdavinia, MD, PhD, “therefore making GERD an important topic to study in the setting of CRS.”
For a study published in Annals of Allergy, Asthma & Immunology, Dr. Mahdavinia and colleagues sought to determine risk factors for the development of reflux in patients with CRS. “Unfortunately, the symptoms of both diseases overlap, and reflux often remains undiagnosed in CRS patients for a long time,” Dr. Mahdavinia says. “Understanding the characteristics of CRS patients who develop GERD can enable clinicians to screen these patients early and treat their reflux appropriately before the disease becomes advanced.” The study group analyzed more than 1,000 patients with CRS to determine who among them had reflux. Among those with reflux, they aimed to find out what makes these individuals prone to developing it.
The study consisted of a retrospective arm that included a large cohort of CRS cases and a prospective arm that evaluated a series of CRS cases and controls in the clinic. In the retrospective arm, 10.5% of patients had GERD. The research team found that allergic rhinitis and asthma were the most important risk factors for reflux (Table). Odds ratios for asthma and allergic rhinitis in those with CRS and GERD were 2.89 and 2.02, respectively, when compared with patients with CRS but without GERD.
“About 15% of patients with CRS had the combination of allergies, asthma, and reflux,” says Dr. Mahdavinia. “In this subgroup, reflux could be the underlying cause of the development of CRS. Higher BMI, female gender, and advanced age were also identified as risk factors for GERD in patients with CRS, but these factors are known predispositions for reflux in the general population. Allergies and asthma appear to be specific to CRS patients.” Interestingly, no association was observed between GERD and asthma or allergic rhinitis in study participants without CRS.
Dr. Mahdavinia recommends early screening for reflux in all CRS patients with allergies, noting that treatment becomes particularly difficult in patients with advanced CRS, asthma, or both. “If patients with allergies and reflux are identified and treated early, we might be able to prevent the development of refractory CRS,” she adds.
While the current study assessed patients at a point in time when they already had CRS, Dr. Mahdavinia notes that CRS likely developed as a result of their other conditions. “People are born with atopic genes and, in the right environment, develop allergies, asthma, or both,” she explains. “If they develop reflux early in life—which was significantly associated with the development of these atopic diseases in our study—it can progress into inflammation in their upper airway, making them prone to developing other chronic diseases like sinusitis.”
GERD was also associated with a greater duration of CRS. Patients who had CRS and GERD also had a younger age at onset of CRS. “Patients with GERD had a longer duration of CRS because they developed CRS when they were in their 20s or early 30s, whereas the normal age for developing the condition is during the late 30s or 40s,” says Dr. Mahdavinia. “These are atopic patients, so they developed CRS earlier.”
Dr. Mahdavinia and colleagues have conducted yet-to-be-published studies looking into the mechanisms behind the associations between atopic disease, GERD, and CRS. “It appears that these associations are likely due to the effect of asthma on the nasal microbiome,” she says. Additional research is needed to apply this understanding to better care for this patient population.
In the meantime, Dr. Mahdavinia recommends that clinicians who care for patients with allergic rhinitis, asthma, or both carefully ask questions about reflux after diagnosing CRS. “Clinicians should ask patients if they have regurgitation or feelings of reflux or heartburn,” she says. “If they do, it’s important to treat these patients appropriately. We may be able to prevent CRS from becoming severe by paying extra attention to those who are atopic, inquiring about the symptoms patients experience, and treating reflux early.”
Mahdavinia M, Bishehsari F, Waqas H, et al. Prevalence of allergic rhinitis and asthma in patients with chronic rhinosinusitis and gastroesophageal reflux disease. Ann Allergy Asthma Immunol. 2016;117:158-162. www.annallergy.org/article/S1081-1206(16)30268-X/fulltext .
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