Reducing Hospitalizations for Patients With Chronic Conditions

Hospital readmission for COPD is a major healthcare burden, and comorbid conditions such as diabetes and obesity and known to increase the likelihood that patients return to the hospital soon after discharge. What providers might not be aware of is that chronic rhinitis is also a significant comorbidity for early readmission in patients with COPD, according to Jonathan Bernstein, MD, a professor of medicine at the University of Cincinnati. He has always been very interested in exploring how chronic rhinitis subtypes and pathomechanisms impact obstructive lung disease and his recent research linked chronic rhinitis to increased risk of 30-day readmissions among asthma and COPD patients.

Dr. Bernstein took a few minutes to discuss the underappreciated condition that can impact the overall care of obstructive lung disease.

Why is it important to assess the connection between chronic rhinitis and COPD?

Rhinitis is not a trivial disease, even though it doesn’t get a lot of attention. No one dies from rhinitis, but the nasal passages serve a lot of important processes and the chronic condition contributes to serious health risks. It’s also a significant comorbidity of more complex diseases like asthma and COPD. We’re passionate about getting the word out about the relationship between rhinitis and COPD because we think rhinitis is a marginalized condition. 

What do providers need to know about rhinitis’s impact on COPD?

First, providers must pay attention to the upper respiratory tract when treating patients with COPD. The opposite is true, too. When treating upper respiratory symptoms, providers must ensure patients don’t have lower respiratory disease, which could be impacted by how well rhinitis is managed. Second, there’s a difference between allergic and non-allergic rhinitis, and both must be treated appropriately. There’s no one-size-fits-all method because there are different pathomechanisms at work.

How specifically does allergic and non-allergic rhinitis differ?

Allergic rhinitis occurs in patients who are predisposed to developing allergen-specific immunoglobulin E (IgE), the antibodies the immune system produces in response to environmental allergens. The antibodies attach to IgE receptors on mast cells and when the receptors are reexposed to environmental triggers, they release various mediators that elicit physiologic responses that lead to clinical symptoms. Non-allergic rhinitis, on the other hand, doesn’t involve IgE-mediated pathways and is triggered by environmental factors such as weather, changes in barometric pressure, and exposure to smoke. It’s believed to be mediated through transient receptor potential (TRP) channels, which are ubiquitous in the body, including the nose and lungs. The receptors send signals to the central nervous system and into the peripheral nervous system to cause an imbalance between the parasympathetic and sympathetic nervous pathways. That typically results in an over active parasympathetic nervous system response, which increases blood vessel dilation and mucus secretion — symptoms that are similar to the allergic rhinitis experience.

Why is it difficult find treatment options for both types of rhinitis?

The triggers and pathways are different. It's very difficult to get industry to develop therapies for this disorder because it's not well characterized. So, providers often use anticholinergic drugs, such as nasal steroids and non-sedating antihistamines that induce drainage and decongest to treat non-allergic rhinitis. But those therapies are not as effective in non-allergic rhinitis because they don’t block histamine receptors as much as they attempt to treat the condition’s symptoms.

What does your study add to current management guidelines of chronic rhinitis?

Treatments largely depend on clinicians’ knowledge and experience — there’s still an art to managing the clinical pathway — so different providers manage the condition in various ways. It’s important to recognize that individual patient outcomes will be different, and appreciate that rhinitis has a big impact on the burden of COPD and its economic ramifications. Ear, nose and throat physicians treat ailments above the neck and pulmonologists treat the lungs, but the two groups don’t often integrate their processes to treat the entire airway. It’s important to focus more on that integration moving forward.

—Dan Cook

For articles by IH Executive, click here

For articles by First Report Managed Care, click here