Posted by Cairo on January 29, 2005, at 10:18:38
The latest issue of Fibromyalgia Network newsletter had an interesting article about the role of allergic rhinitis (AR; chronic congestion) and it's effect on sleep and Fibromyalgia (FMS). I've been following many threads on sleep, histamine, urticaria and thought this might be of interest to others.
In the article, several studies were named: nasal congestion leads to daytime drowsiness (Craig TJ, et al. J Allergy Clin Immunol 114:S 139-45, 2004); allergic rhinitis (AR) is a risk factor for developing sleep apnea and Upper Airway Resistance Syndrome (UARS) (Young T, et al. J Allergy Clin Immunol 99(2):S 757-62, 1997).
A study by Harvey Moldofsky, MD, University of Toronto, showed that the AR symptom cycle and FMS pain and fatigue cycle are very similar. The peak FMS pain and fatigue are at 6am, dipping towards noon and rising again after lunch and into the night. This is inverse to the cycle of cytokines IL-6 and TNF-alpha.
The article said that several factors cause stuffy nose in the early morning hours: prone position causes nasal cavity to swell; cortisol levels are lowest at night (cortisol suppresses immune system so at low levels immune substances are more likely to be released, causing nasal inflammation and congestion); the nervous system promotes an expansion of blood vessels at night which lead to swelling of sinus tissues.
A study showed that microarousals in sleep were ten times higher in patients with AR (Lavie, et al. Acta Otolaryngol 92(5-6): 529-33, 1981). Chronic nasal congestion is known to impede airflow and increase snoring which may cause or worsen existing UARS and Obstructive SleepApnea Syndrome.
Although a link between AR and FMS has not been established, University of Minnesota neuroscientist Alice Larson, Ph.D., is investigating the role of mast cells in FMS. Due to a lack of a blood-brain barrier (BBB) surrounding the sinuses, substances released from the mast cells into the nasal tissues have easy access to the pain/fatigue regulating centers in the brain, such as the thalamus. The relationship between leukotrienes and FMS has not been studied, but leukotrienes cause the most congestion.
A list of sinus irritants was given: histamine (balances sleep/wake cycle and increases congestion slightly); leukotrienes (increase deep sleep level and increases congestion); inflammatory cytokines (IL-1, TNF-alpha - associated with sleep disruption); prostaglandins (sleep promoting and increases congestion); substance P (interferes with sleep and increases congestion); nerve growth factor (interferes with sleep and increases congestion).
As to treatments, the article says nasal sprays (eg. Afrin) work quickly by shrinking blood vessels, but make congestion worse if used for more than 4 days ("rebound congestion"). Oral decongestants (eg. Sudafed) are stimulating agents that disturb sleep and cause drying of mucous membranes which may aggravate chronic AR.
Older antihistamines (eg. Benadryl) dry out nasal passages and only work for 4-5 hours so they won't help with their minimal decongestant property in the early morning hours. Second generation antihistamines provide 24 hour relief and do not cause as much drying but do not relieve congestion well. Zyrtec and Clarinex (NOT Claritin) have been shown to be better than others for relieving congestion (Craig TJ, et al. J Allergy Clin Immunol 114:S 139-45, 2004; Nayak AS, Schenkel E. Allergy 56(11); 1077-80, 2001). As 30% of Zyrtec crosses the BBB, it may cause some sedation and should be taken at night.
Nasal sprays are usually supplemental for AR. A dilute steroid spray (flunisolide) was shown to be superior to an antihistamine spray (azelastine) (Berlin, JM, et al. J Amer Orthopedic Assoc 100(7); S8-S13, 2000). Steroid sprays may take up to two weeks to reach full effectiveness and it is optimal to use upon awakening and before bedtime.
Cromolyn nasal spray (NasalCrom) may minimize symptoms of AR (Alice Larson's mat cell research can be found at www.afsafund.org).
The newest class of AR medications work by blocking effects of leukotrienes (Singulair and Accolate). Both have been shown to be superior to other AR meds for reducing nasal congestion and ENHANCING SLEEP (Ferguson BJ. Otolaryngol Head Neck Surg 130(5); 617-29, 2004). "Reduced nasal resistance and increased airflow rates found in pateints taking these medications may be responsible for the improvements in sleep, especially since upper airway resistance appears to be the primary cause of insomnia."
SUMMARY OF TREATMENTS IN ARTICLE: Singulair is the best oral medication; if side effects, then try Accolate. A steroid nasal spray can augment. In addition, saline nasal solutions can flush and moisten sinus membranes. Mast cell stabilizers such as Cromolyn can be used by people who cannot tolerate steroid sprays. A second generation antihistamine such as Zyrtec or Clarinex helps with watery/itchy eyes and runny nose.
Another article in the same issue of FMS Network lists CPAP (continuous positive airway pressure) as being first choice therapy for UARS. Oral applicances may be used by those who cannot use CPAP, but they may aggravate TMJ. Functional endoscopic sinus surgery (outpatient - trims back turbinates, corrects deviated septum and removes polyps) is the only form advocated for UARS. Sleep studies for any patient with fatigue and sleepiness are advocated by Avram Gold, MD (Stony Brook University, NY) who says that it is rare to have a patient with fatigue and sleepiness who does NOT have UARS during sleep.
..........................I don't know about others, but I have always noticed mild congestion upon awakening. While this might not be the CAUSE of my sleep problems, it certainly may contribute to them. Because I been on so many other prescription medications for pain, sleep, etc., I've been reluctant to add more medications for what I've perceived only as a nuisance. The only problem is that I've been on a CPAP for over a year, and have noticed only minimal benefit on my pain levels from FMS. But there might be some out there that the above approaches might benefit.
Cairo
poster:Cairo
thread:449715
URL: http://www.dr-bob.org/babble/20050128/msgs/449715.html