|ORIGINAL CONTRIBUTION: BREAKING FRONTIERS IN OTORHINOLARYNGOLOGY
|Year : 2015 | Volume
| Issue : 1 | Page : 8-11
Therapeutic significance of Vitamin D in allergic rhinitis
Vijay Kumar, Ashok Kumar, Isha P Tuli, Anil K Rai
Department of ENT, Post Graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India
|Date of Web Publication||26-Oct-2015|
Dr. Vijay Kumar
Room No. 228, Doctors Hostel, RML Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Allergic Rhinitis (AR), a common health problem, imposes a substantial burden on public health. New evidence suggests a possible link between AR and Vitamin D deficiency. This study was done with the purpose of determining whether serum Vitamin D levels are altered in AR as opposed to healthy controls and whether such alterations modify the severity of the disease. Materials and Methods: A cross-sectional study was done on 100 adults aged 18–50 (50 clinically diagnosed with AR and 50 age and sex matched controls). They were evaluated clinically and by determining serum levels of 25-hydroxyvitamin D [25(OH) D]. Results: The most common symptom was paroxysmal sneezing (96%). The mean concentration of serum 25(OH) D was 16.52 ng/ml in test patients and 22.47 ng/ml in controls. This study demonstrated a statistically significant Vitamin D deficiency (defined as serum 25(OH) D, <20 ng/mL) among patients with AR as compared to healthy controls (P = 0.001). The deficiency was significantly more (P = 0.01) in patients with moderate–severe AR (n = 28, mean serum 25(OH) D = 12.36 ng/ml) than that in mildly symptomatic patients (n = 22, mean serum 25(OH) D = 21.82 ng/ml). Conclusions: A strong association exists between low serum Vitamin D levels and AR in this population sample of AR patients, suggesting that suboptimal levels of Vitamin D may modify the disease behavior. Supplementation can be a useful therapeutic adjunct.
Keywords: Allergic rhinitis, deficiency, prospective study, Vitamin D
|How to cite this article:|
Kumar V, Kumar A, Tuli IP, Rai AK. Therapeutic significance of Vitamin D in allergic rhinitis. Astrocyte 2015;2:8-11
| Introduction|| |
Allergic rhinitis (AR) is the inflammation of the membranes lining the nose, consequent to an allergen exposure, characterized by sneezing, nasal congestion, itching of the nose, and/or postnasal discharge. The prevalence varies worldwide, perhaps due to the geographic and aeroallergen difference, with 10% and 30% of the world's population suffering from AR. Vitamin D (25-hydroxyvitamin D [25(OH) D]) can influence not only skeletal and bone health, but is also an immune regulator, participating in the development and maintenance of lung structure and function. Genetic factors of Vitamin D metabolism are involved in the development of allergic conditions, showing a direct association between Vitamin D receptor polymorphism and atopic asthma. The hormonal form of Vitamin D affects both adaptive and innate immune functions involved in the development of allergies. These associations suggest that Vitamin D and consequently its deficiency may be directly linked with asthma and other allergic diseases, prompting our study to see whether Vitamin D deficiency is a disease-modifying factor for AR.
| Materials and Methods|| |
This cross-sectional prospective study was conducted in a Tertiary Care Centre. One hundred subjects were selected, out of which 50 were AR patients (seasonal and perennial) diagnosed clinically and remainder were 50 age- and sex-matched controls. Diagnosis of AR and its classification into mild and moderate–severe group was made according to AR and its impact on asthma (ARIA) classification. The cardinal symptoms according to ARIA guidelines are paroxysmal sneezing, itching in the nose, itching of eyes, palate or pharynx, watery nasal discharge, nasal obstruction, and history of urticaria, while the clinical signs include pale boggy nasal mucosa, hypertrophied turbinates, thin watery or mucoid discharge, allergic shiner, and transverse nasal crease (allergic salute). Levels of Vitamin D were measured by enzyme-linked immunosorbent assay. The levels of Vitamin D required may vary for different biological needs but >75 nmol/L (30 ng/mL) is currently considered optimal, while 50–75 nmol/L may be insufficient and <50 nmol/L (<20 ng/ml) deficient. The aim of the study was to calculate and compare the serum Vitamin D (25(OH) D) levels in patients of AR with matched control group and correlate its level with severity of symptoms.
Patients aged between 15 and 50 years, either sex, clinically diagnosed as AR, seasonal or perennial.
Patients with bronchial asthma and nasal polyposis or comorbid conditions affecting serum Vitamin D level, e.g., rickets, osteomalacia, sarcoidosis, and thyroid dysfunctions or those with a history of intake of medications affecting serum Vitamin D level, e.g., corticosteroids, bisphosphonates, and Vitamin D supplements. Data were analyzed using SPSS version 17 (Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc.) and P < 0.05 was considered significant.
| Results|| |
Subjects were divided into two groups of 50 each, with Group 1 being the study group, that is, patients of AR, and Group 2 being the age- and sex-matched healthy controls. The mean age among the study group was 29.36 years and among the control group was 28.24 years. There was no statistically significant difference in age or gender distribution among the two groups. Group 1 patients had a mean serum 25(OH) D level of 16.52 ng/ml (41.23 nmol/L), the range being 5.6–41.9 ng/ml, while Group 2 had an average of 22.47 ng/ml (56.09 nmol/L), the range being 4.8–56 ng/ml. A statistically significant difference (P = 0.001) was found between serum 25(OH) D levels of Group 1 and Group 2 [Figure 1]. Thirty-six patients in Group 1 had deficient 25(OH) D levels, while 19 in Group 2 were deficient. Among the patients included in our study, paroxysmal sneezing was the most common symptom found in 96% of patients followed by rhinorrhea (92%), and urticaria was the least common found in 24% patients [Figure 2]. Most common symptom among males was rhinorrhea (95.65%), while among females paroxysmal sneezing was the most common symptom (100%). Most frequent signs were turbinate hypertrophy and watery discharge (94%) both being equally frequent, and the least frequent was allergic salute (6%) [Figure 3]. The ARIA workshop report proposed that based on these symptoms and signs, the disease be categorized as "intermittent" and "persistent," while severity be classified as "mild" and "moderate-severe," based on the number of days per week and the number of weeks per year during which the patient is symptomatic  [Figure 4]. There were statistically significant differences (P = 0.001) in serum 25(OH) D levels among the AR patients having ≤1 episodes of paroxysmal sneezing per day (mean level: 19.87 ng/ml, 31 cases) and patients having >1 episodes of paroxysmal sneezing per day (mean level: 11.47 ng/ml, 17 cases) [Table 1]. However, the difference in serum 25(OH) D levels between the AR patients having paroxysmal sneezing, duration <4 weeks, and patients having paroxysmal sneezing, duration ≥4 weeks, was not statistically significant. There was also no significant difference found in serum Vitamin D levels among the AR patients having rhinorrhea and nasal obstruction for a duration of <4 weeks and patients having these symptoms for a duration of ≥4 weeks. No significance was also noted in different serum 25(OH) D levels in those with or without a history of itching or urticaria. We found a statistically significant correlation between the severity of AR and serum 25(OH) D levels (P = 0.01). Twenty-two patients had mild disease and a mean 25(OH) D level of 21.82 ng/ml (54.46 nmol/L) but this was much lower in the 28 patients of moderate–severe disease with a mean 25(OH) D level of 12.36 ng/ml (30.85 nmol/L) [Table 2].
|Figure 1: Bar representation showing comparison of mean serum Vitamin D (25-hydroxyvitamin D) levels among the two groups|
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|Figure 2: Column representation of frequency of symptoms among patients.|
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|Figure 4: Allergic rhinitis and its impact on asthma classification of allergic rhinitis.|
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|Table 1: Correlation of Severity of Paroxysmal Sneezing and Serum Vitamin D (25(OH) D) Levels|
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|Table 2: Correlation between Severity of Allergic Rhinitis and Serum Vitamin D (25(OH) D) Levels|
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| Discussion|| |
The Asthma Epidemiology Study Group of the Indian Council of Medical Research reports that recurrent coryza occurs in 3.45%, recurrent skin rashes in 2.1%, and recurrent eye itching in 2.78% of Indian adults. Considering a population of 1.2 billion, these numbers suggest that the burden of rhinitis in India is immense. Nevertheless, in India, AR does not receive the attention it deserves by either patients or clinicians, often treated as an "orphan" disease. This is because it falls in the grey area between an otorhinolaryngologist and a pulmonologist, resulting in the lack of focus on research in AR by either speciality. Despite significant and widespread morbidity, AR is often viewed, rather erroneously, as a trivial disease. It significantly affects the quality of life (QOL) of the patient by causing fatigue, headache, cognitive impairment, and other associated symptoms. These influence the physical, psychological, and social aspects of the patients' life and impact their functions at work. In a study done at VP Chest Institute Delhi, India, the QOL of AR patients was assessed with the help of the rhinitis QOL Questionnaire. The disease caused significant practical problems, emotional distress, and limitation in activities. The presence of AR adversely affected behavior, work performance, and life style of these patients. AR, being a multi-factorial disease, has been investigated around the world to find both genetic and environmental risk factors., Recent studies indicate that the worldwide increase in allergic diseases such as asthma, AR, and food allergy is associated with low-serum Vitamin D levels. Vitamin D is a fat-soluble vitamin, with its active form being 1,25, dihydroxyvitamin D. It is primarily responsible for musculoskeletal health. It is also accountable for immune modulation and innate immunity, maintenance of normal proliferation and apoptosis of cells of breast, colon and prostate, blood sugar, and blood pressure homeostasis. Vitamin D deficiency causes rickets in children, predisposes to osteopenia, osteoporosis, and fractures in adults, and increases risk of common cancers, autoimmune diseases, hypertension, and infectious diseases. Vitamin D deficiency is now recognized as a pandemic. The major cause of Vitamin D deficiency is the lack of sun exposure, the major source of Vitamin D. The availability of few food sources, dietary changes away from fatty fish consumption, and the use of sunscreen, covering clothes and host factors (age, skin color, and body weight) have made Vitamin D deficiency a ubiquitous problem. In adults, reduced Vitamin D levels correlate with impaired lung function, increased airway hyper-responsiveness, and reduced responsiveness of asthmatics to glucocorticoids. An association has recently been reported in asthmatic children between serum Vitamin D levels and increased glucocorticoid use. Treatment of glucocorticoid resistance in asthmatic patients by Vitamin D replacement therapy supports its role of maintaining airway health., As a corollary, Vitamin D may affect the pathophysiology of AR. Arshi et al. assessed Vitamin D level of 50 patients with AR. They reported a significantly higher prevalence of severe Vitamin D deficiency in patients with AR than the normal population, 30% and 5.1%, respectively (P = 0.03). Further, female patients had lower Vitamin D levels. Another cross-sectional study done by Bener et al. over 1833 children below 5 years observed that the proportion of severe Vitamin D deficiency was significantly higher in children with wheezing (23.4%), AR (18.5%), and asthma (17%) than in healthy children (10.5%). Exposure to the sun was significantly lesser in Vitamin D-deficient children with asthma (60.3%), AR (62.5%), and wheezing (64.4%) than in controls (47.1%) (P = 0.008). Vitamin D deficiency emerged as a significant correlate for asthma, AR, and wheezing. Conflicting reports, however, that render these observations uncertain exist. Yao et al. in a large population-based study of suboptimal Vitamin D status and atopy in 2014 suggested that after adjusting for potential confounders, serum 25(OH) D status had no association with asthma, rhinitis, eczema, or atopy. However, Yao et al. also reported the prevalence of markedly low-serum Vitamin D levels in their study subjects, making it a public health problem. We found a significant association between low-serum Vitamin D (25(OH) D) levels and severity of AR (P = 0.01). The mean Vitamin D level in patients of AR was deficient and lower opposed to higher levels in healthy controls. The severity of disease was significantly more with lower serum Vitamin D levels. The most affected symptom was paroxysmal sneezing, severity being significantly higher with lower serum Vitamin D levels. Thirty-six patients (72%) in the study group had deficient serum Vitamin D levels (<20 ng/ml), but 19 patients (38%) in the control group also had deficiency.
| Conclusions|| |
Our findings suggest that there is an overall deficiency of Vitamin D in the population. Additionally, the strong association of low-serum Vitamin D levels with AR suggests a possible therapeutic role of Vitamin D supplementation in AR. We recommend that estimation of serum Vitamin D levels in patients of AR is an invaluable tool in the armamentorium of the clinicial. Nevertheless, a randomized control trial should be the next logical research undertaken to establish the advantage of Vitamin D in treating AR and other allergic diseases.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]