In an overweight or obese adult with chronic allergic rhinitis, how does elevated body‑mass index influence disease severity and what are the recommended treatment and weight‑loss strategies?

Higher BMI and Chronic Allergic Rhinitis: Impact and Management

In overweight and obese adults with chronic allergic rhinitis, elevated BMI does correlate with more severe symptoms, but standard nasal corticosteroid therapy remains equally effective clinically, though the anti-inflammatory response may be impaired at the cellular level.

Disease Severity and BMI Relationship

The relationship between obesity and allergic rhinitis severity is complex and differs between adults and children:

In Adults

• Obesity is primarily associated with nonallergic rhinitis rather than allergic rhinitis 1
• Overweight or obese adults show 43% increased odds of nonallergic rhinitis, with central obesity conferring 61% increased odds 1
• This association is particularly strong in male adults, while becoming non-significant in females after sex stratification 1
• The chronic systemic inflammatory state induced by obesity creates a Th2-polarized immune environment that may worsen pre-existing allergic disease 2

In Children (for context)

• Obese children with allergic rhinitis demonstrate significantly higher symptom scores (9.5 vs 8.2) and medication scores (3.6 vs 2.9) compared to non-obese children 3
• Serum leptin concentration correlates with elevated Th2 and Th17 cytokines and reduced regulatory T-cell cytokines in obese children with allergic rhinitis 3

Treatment Approach with Nasal Corticosteroids

Standard nasal corticosteroid therapy (beclomethasone 400 mcg/day) produces equivalent clinical improvement in obese and normal-weight patients with allergic rhinitis 4

Clinical Response

• Both obese and normal-weight patients show similar improvements in:
  • Visual analog scale (VAS) scores 4
  • SNOT-22 questionnaire results 4
  • NOSE-5 questionnaire results 4
  • Peak nasal inspiratory flow volumes 4
• No differences exist in baseline nasal endoscopy findings or peak nasal inspiratory flow between weight groups 4

Important Caveat: Impaired Anti-inflammatory Response

• Obese patients demonstrate impaired anti-inflammatory cytokine response during nasal corticosteroid treatment 4
• Specifically, IL-10 (an anti-inflammatory cytokine) shows altered behavior dependent on weight status 4
• Normal-weight patients show increases in INF-γ and IL-5 after treatment, while obese patients do not 4
• This suggests that while symptoms improve equally, the underlying inflammatory resolution may be compromised in obesity 4

Recommended Management Strategy

Primary Treatment

• Initiate standard-dose nasal corticosteroids (e.g., beclomethasone 400 mcg/day) regardless of BMI, as clinical efficacy is preserved 4
• Monitor response using validated symptom scores (VAS, SNOT-22, NOSE-5) rather than relying solely on patient-reported improvement 4

Weight Loss Integration

• Strongly recommend concurrent weight loss interventions given the bidirectional relationship between obesity and allergic disease 5, 2
• The chronic inflammatory state of obesity perpetuates Th2 polarization, potentially worsening allergic symptoms over time 2
• Proper BMI control within normal range is important for long-term disease management 5

Monitoring Considerations

• Be aware that obese patients may require longer treatment duration or higher vigilance for symptom recurrence due to impaired anti-inflammatory response 4
• Consider that male obese adults may have higher risk of developing nonallergic rhinitis components overlapping with allergic disease 1

Clinical Pitfalls to Avoid

• Do not withhold or reduce nasal corticosteroid dosing in obese patients based on weight alone, as clinical response remains intact 4
• Do not assume obesity causes allergic rhinitis—the association is stronger with nonallergic rhinitis in adults 1
• Recognize that the relationship between obesity and rhinitis differs by age group and sex, requiring individualized assessment 1
• Address weight management as part of comprehensive allergic disease control, not as a replacement for standard pharmacotherapy 5, 2