Risk-benefit assessment of fluticasone propionate in the treatment of asthma and allergic rhinitis

BENEFITS

Fluticasone propionate (FP) is a new topical corticosteroid spray for the treatment of allergic rhinitis and asthma. FP has been shown to be effective for the treatment of adult and pediatric asthma, even at rather low doses (25 microg twice daily [b.i.d.]); many studies in asthma have shown clinical efficacy of fluticasone at half the dose of the comparison steroid (such as beclomethasone dipropionate [BDP] or budesonide [BUD]). However, exact dose comparisons cannot be made because dose-ranging comparison studies have not been done. Studies in allergic rhinitis in children and adults have shown good efficacy in FP-treated patients at a dose of 200 microg once daily (o.d.), intranasally. In summary, FP is effective in both asthma and allergic rhinitis.

RISKS

FP has minimal systemic activity because the portion of drug that is swallowed is not absorbed from the gut. Thus, the amount available for systemic activity is only that which is absorbed through the nasal mucosa (in the treatment of rhinitis) or through the alveoli of the lungs (in the treatment of asthma). When laboratory assays of adrenal function or bone formation are measured, FP and other inhaled corticosteroids can be shown to cause suppression of these markers, especially at high doses. There have been no consistent reports of clinical adrenal suppression or osteoporosis caused by FP. In summary, the risk-benefit ratio of FP at the usual doses (therapeutic ratio) is very favorable. High doses may show evidence of suppression of the hypothalamic pituitary axis as measured by in vitro tests, but evidence of corresponding clinical adverse effects is lacking.

Oral glucocorticosteroid-sparing effect of budesonide administered by Turbuhaler: a double-blind, placebo-controlled study in adults with moderate-to-severe chronic asthma. Pulmicort Turbuhaler Study Group

OBJECTIVE

To determine the ability of budesonide via an inhaler (Pulmicort Turbuhaler; Astra Draco AB) to replace oral glucocorticosteroids (GCSs) in adult subjects with moderate-to-severe asthma.

DESIGN

Double-blind, randomized, and placebo-controlled study, with parallel groups.

SETTING

Multicenter study in outpatient setting.

PARTICIPANTS

Eighty men and 79 women, aged 20 to 69 years, with moderate-to-severe asthma and a mean FEV1 of 58.3% predicted normal. All subjects were receiving oral GCS treatment and 79% of subjects were also receiving inhaled beclomethasone dipropionate (BDP). The mean daily doses of prednisone at baseline, including converted dose of BDP, for the placebo, budesonide 400 microg, and budesonide 800 microg, respectively, were 19.7 mg, 19.5 mg, and 18.7 mg.

MEASUREMENTS AND INTERVENTIONS

After a 2-week baseline period, subjects entered a 20-week treatment period, during which the oral dose of prednisone was reduced by forced down-titration at 2-weekly intervals.

RESULTS

Subjects receiving 400 microg or 800 microg bid of budesonide achieved a significantly greater reduction (82.9% and 79.0% respectively) in oral GCS dose compared with placebo-treated subjects (27%; p<0.001). Two thirds of the subjects receiving budesonide were able to achieve sustained oral corticosteroid cessation, compared with 8% in the placebo group. Additionally, both doses of budesonide resulted in significant improvement in results of pulmonary function tests and asthma symptoms scores, and a significant decrease in the use of bronchodilator therapy. The mean plasma cortisol levels before and after adrenocorticotropic hormone stimulation increased most toward the normal range in the budesonide-treated groups compared with placebo-treated subjects.

CONCLUSION

Budesonide administered via Turbuhaler has a significant oral GCS-sparing capacity with maintained or improved asthma control in adult subjects with moderate-to-severe asthma.

Clinical adverse effects of inhaled corticosteroids: results of a questionnaire survey of asthma specialists

BACKGROUND

Inhaled corticosteroids are recognized as the mainstay of prophylactic anti-inflammatory therapy in patients with persistent asthma. In large multiclinic trials, the clinical adverse event profiles have been not significantly different than patients treated with placebo or other medications; however, in small studies evaluating very sensitive in vitro measurements of the hypothalamic pituitary adrenal axis there have been adverse laboratory events noted with moderate and high doses of inhaled steroids.

OBJECTIVE

To survey asthma specialists in North America with regard to their personal clinical experience of adverse events with the use of inhaled corticosteroids.

METHODS

Two hundred thirteen physicians specializing in the treatment of asthma responded to questionnaires asking their experiences with specific adverse clinical events that have the potential to occur after the use of inhaled corticosteroids (see appendix A for questionnaire).

RESULTS

There was a 67% response rate for the questionnaire. Eighty percent of the respondents were allergists/immunologists and 20% were pulmonologists. The average length of time they had been in practice was 16 years. In general, side effects from inhaled steroids were seen very infrequently in the hands of these physicians in spite of the fact that they were primarily secondary or tertiary referral physicians for the treatment of asthma. The local oropharyngeal adverse events were seen 48% of the time on an occasional basis but only 3% of the time on a frequent basis. When spacers were used the oropharyngeal symptoms were reduced significantly. Skin changes such as bruising or thin skin were seen frequently 6% of the time and occasionally 24% of the time only. In general, these skin changes were found in elderly or middle-aged individuals. Weight gain was very unusually seen, as were adverse effects on bone (osteoporosis, fractures, growth problems, etc.). Hypothalamic pituitary axis abnormalities were seen quite infrequently and primarily in patients who had also received oral corticosteroids.

CONCLUSIONS

This study shows that inhaled corticosteroids are generally safe in the treatment of asthma and are rarely associated with systemic side effects, as detected in routine clinical practice.

The effects of salmeterol on power output in nonasthmatic athletes

BACKGROUND

Salmeterol xinafoate is a new aerosol inhalant that is used in the treatment of asthma. It is currently banned by the International Olympic Committee because of the concern that it may lend an unfair competitive advantage to the user.

OBJECTIVE

The purpose of this study was to determine whether salmeterol improves short-term anaerobic performance in elite nonasthmatic track cyclists.

METHODS

Eleven elite track cyclists volunteered to perform a 30-second all-out cycle ergometer test 3 hours after receiving either 42 micrograms of salmeterol xinafoate or placebo applied in a double-blind crossover procedure. During the ergometer test, peak power output, total work, time to peak power, and percent fatigue (decline in power output) were measured. Pulmonary measurements were also taken before and at various time points after inhalation and the ergometer test. A methacholine challenge was administered to each subject before participation in the study to ensure that none of the subjects had any reactive airway diseases.

RESULTS

There were no significant differences (p > 0.05) between the placebo and salmeterol trials for peak power output, total work performed during the 30-second test, percent fatigue, and time to peak power. No differences between trials were observed for the pulmonary function test variables at any of the time points. Blood lactate concentrations before and after administration of drug or placebo were also not significantly different between trials. Additionally, salmeterol did not affect the maximal heart rate achieved during the test as compared with the placebo.

CONCLUSIONS

Short-term salmeterol use within the prescribed dosage was not shown to increase short-term power output in nonasthmatic cyclists.

Update on exercise-induced asthma: a report of the olympic exercise asthma summit conference

Exercise-induced asthma (EIA) can be easily overlooked and underdiagnosed, especially in school children or recreational athletes. It affects individuals of all levels of activity, from recreational sports to competition. This article summarizes the results of the Olympic Exercise Asthma Summit Conference, organized by the Sports Medicine Division of the US Olympic Committee. Making the correct diagnosis of EIA is very important and usually requires some form of pulmonary function testing. Because effective pharmacologic and nonpharmacologic treatment is available for this condition, patients should be followed until the condition is controlled.

Treatment of allergic rhinitis: effects of allergic rhinitis and antihistamines on performance

Antihistamines are the most commonly used drugs for allergic rhinitis, and many antihistamines may cause subclinical side effects which are not noticeable by the patient. These include impaired driving performance, impaired work performance, reduced coordination, reduced motor skills, sleepiness and impaired information processing (arithmetic, verbal, and office skills). The newer nonsedating antihistamines should be used for the treatment of allergic rhinitis because they do not produce these effects. Recent studies have shown that children's learning in school may also be negatively affected by traditional antihistamines, and therefore, school children should definitely be given the nonsedating antihistamines. Not only does the treatment cause some impaired performance, but allergic rhinitis itself may result in changes in the patient's mood affect, and other aspects of personality. Physicians who treat allergic rhinitis should be aware of the potential performance effects of medications that they prescribe and the potential effects of the disease itself on the patient's personality.

Clinical studies of the efficacy and tolerability of ebastine 10 or 20 mg once daily in the treatment of seasonal allergic rhinitis in the US

396 adult and adolescent patients with seasonal allergic rhinitis participated in this randomised double-blind parallel-group study in which the efficacy and tolerability of ebastine 10 or 20mg administered once daily in the morning or evening for 3 weeks were compared with those of placebo. Clinical efficacy was assessed by measuring improvement in rhinitis symptoms (nasal discharge, nasal stuffiness, sneezing, itchy nose and itchy/watery eyes) recorded by patients twice daily on diary cards. The improvement in individual and total symptom scores at the end of the 3-week treatment period in patients treated with ebastine 10mg in the morning or ebastine 20mg in the morning or evening was significantly greater than the improvement in placebo recipients. The 20mg dose of ebastine administered in the morning was associated with the greatest improvement in symptom scores. There was no significant effect with the 10mg evening dose compared with placebo. Ebastine was well tolerated by the majority of patients - the incidence of adverse events, including headache, dry mouth, somnolence and asthenia being similar to that reported in placebo recipients. Electrocardiograms showed no evidence of any clinically relevant changes in QTc intervals. In a subsequent nonblinded 4-month study that included 230 patients from the initial study, global evaluations at monthly intervals showed overall symptom improvement in > or = 72% of patients who received ebastine 10mg or 20mg once daily. The drug was well tolerated during prolonged therapy, with adverse events being similar in nature and incidence to those reported in the 3-week double-blind study. In conclusion, ebastine 10mg once daily in the morning is an appropriate starting dose for the treatment of rhinitis, and this can be increased to 20mg as required.

Improving the treatment of nocturnal asthma: use of an office questionnaire to identify nocturnal asthma symptoms

Nocturnal asthma is a major problem in many asthma patients and it is important to recognize and treat it. We previously reported the incidence of nocturnal asthma in our practice (1); the current study was done to try to improve upon the incidence of nocturnal asthma in our patients. After our previous survey, which indicated a 67% incidence of nocturnal asthma in our practice, we instituted a previsit questionnaire regarding nocturnal asthma to be filled out by all follow-up asthma patients in our office. After a period of time, we mailed a nocturnal asthma questionnaire to all asthma patients to see if the intervention had improved our incidence of nocturnal asthma. This questionnaire was identical to the one used in our prior study and was mailed to 2019 patients. We had 602 responders, 560 of whom had asthma. A total of 328 of these patients (59%) had nocturnal asthma. This was similar to the results of our previous survey, and our initial conclusion was that the new in-office questionnaire that we instituted had not improved the situation. Then we discovered that the in-office questionnaire had inadvertently been distributed only to the patients of one or our physicians (Dr. A). His patients were then compared with those of the other two doctors (Drs. B and C), and it was found that Dr. A's patients had fewer nocturnal symptoms than did the patients of the other doctors. The percent of asthmatics with nocturnal asthma 4-7 nights per week (more than half the nights in a week) for Dr. A was 16%, for Dr. B 47%, and for Dr. C 39%. The use of a short office questinnaire for asthma patients before they see the doctor for follow-up visits leads to greater recognition and better treatment of nocturnal asthma.

The effects of albuterol on power output in non-asthmatic athletes

The purpose of this study was to evaluate the effect of the beta 2-agonist albuterol (salbutamol) at twice the normal dosage (360 micrograms) on power output during a 30-second Wingate test and pulmonary function in highly trained cyclists (4 category 1 and 10 category II U.S.C.F. track cyclists). The cyclists did not have a history of exercise induced bronchial spasms, and a 5 step methacholine challenge confirmed all subjects to be non-asthmatic. The project was performed in a random block, double blind design. Twenty minutes before the 30-second Wingate cycle ergometer exercise, albuterol (90 micrograms per dose) or a saline placebo was administered by inhaler in 4 metered doses. Pulmonary function tests were performed at rest, 20 minutes post-inhalation, and 5, 10, 15 minutes post-exercise. After a standard warm-up, a 30-second Wingate anaerobic power test was performed on a cycle ergometer at a resistance of 0.10 kg (kg body mass)-1. Multi-variate ANOVA revealed no significant difference between the albuterol and placebo treatment for the anaerobic power measures: peak power (1,136.7 +/- 40.9 vs 1,124.8 +/- 39.8 W, mean +/- s.e.), total work (27,213.6 +/- 653.1 vs 27,093.3 +/- 677.4j), time to peak power (4.5 +/- 0.2 vs 4.8 +/- 0.5 s), and fatigue index (16.5 +/- 1.8 vs 16.6 +/- 1.8 W.s-1). Peak heart rate (181.6 +/- 3.7 vs 181.4 +/- 3.8 bpm), or blood lactate (14.0 +/- 0.9 vs 13.8 +/- 0.8 mmol.l-1) 3 min after the exercise bout were not significantly different between treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of seasonal allergic rhinitis with fluticasone propionate aqueous nasal spray: review of comparator studies

Studies have been conducted in the USA comparing fluticasone propionate aqueous nasal spray 200 micrograms once daily with beclomethasone dipropionate aqueous nasal spray 168 micrograms twice daily, oral terfenadine 60 mg twice daily, or oral astemizole 10 mg once daily given for 2 or 4 weeks during tree, grass or ragweed pollen seasons. All six were multicentre, randomised, placebo-controlled, double-blind, parallel-group studies. Efficacy was evaluated by patient and clinician assessments of individual nasal symptoms and overall response to therapy. Fluticasone propionate was superior to beclomethasone dipropionate in one trial according to patient evaluations of symptoms, but response to fluticasone propionate and beclomethasone dipropionate was similar in the second study. Comparisons with antihistamines showed fluticasone propionate to have greater efficacy. It was more effective than terfenadine in both trials according to evaluations by clinicians and patients. Similar findings were observed in the first astemizole trial. The second astemizole study showed superiority of fluticasone propionate over astemizole in terms of patient and clinician evaluations of overall response to therapy and occasionally in terms of symptom evaluations. There were no significant adverse effects, including effects on plasma cortisol concentrations, noted in any of these comparator studies.

Effectiveness of azelastine nasal solution in seasonal allergic rhinitis

Azelastine is a novel antiallergy medication currently under investigation for the treatment of allergic rhinitis and asthma. Pharmacologic studies in laboratory animals and in vitro model systems indicate that azelastine exerts multiple actions including modulation of airways smooth muscle response, interference with inflammatory processes, and inhibition of allergic reactions. In a previous controlled clinical trial, azelastine nasal solution (ASTELIN N.S.) demonstrated effectiveness in controlling symptoms of seasonal allergic rhinitis (SAR). The objective of this 2-week double-blind, parallel-group study was to further assess the effectiveness of azelastine nasal solution in improving allergic rhinitis symptoms. Two hundred forty-seven patients (> or = 12 years) with symptomatic SAR who satisfied a minimum symptoms score during a 1-week, single-blind, baseline evaluation period were randomized to receive azelastine 2 sprays per nostril bid, azelastine 2 sprays per nostril qd, chlorpheniramine 12 mg bid, or placebo using a double-dummy technique to insure blinding. The primary efficacy variables were changes in Major Symptom Complex (nose blows, sneezes, runny nose/sniffles, itch nose, and watery eyes) and Total Symptom Complex (Major plus itchy eyes/ears/throat/palate, cough, and postnasal drip) severity scores. Patients treated with azelastine nasal solution qd and bid had mean percent improvements in the Total and Major Symptom Complex severity scores that were clinically significant (> or = 50% improvement over placebo) after both weeks, at endpoint, and overall. The improvements for the azelastine bid group were statistically significant (P < or = .05) at all evaluation points. Adverse experiences occurred infrequently, and none was considered serious or potentially limiting to the clinical utility of the nasal solution.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term safety of triamcinolone acetonide nasal aerosol for the treatment of perennial allergic rhinitis

A 1-year, open-label extension of a 12-week, double-blind clinical trial was conducted to evaluate the long-term safety and efficacy of once-daily therapy with triamcinolone acetonide nasal aerosol (110, 220, or 440 micrograms) in 93 patients with perennial allergic rhinitis. All three doses of triamcinolone acetonide were associated with sustained improvement in allergic rhinitis symptoms over the course of 1 year, as evidenced by physicians' and patients' global evaluations, ratings of the nasal environment (appearance and color of the nasal mucosa, as well as the quality of nasal secretions), nasal eosinophil counts, and requirement for escape medication. Among patients who reported adverse clinical experiences, most were considered unrelated or remotely related to therapy. Few patients experienced nasal irritation or throat discomfort, and no serious adverse experiences were attributed to treatment. Among 6 patients who withdrew from the study because of adverse experiences, a possible drug relationship was cited in 2 individuals (1 with headache and 1 with nasal blood) and a remote relationship in 1 (with acne). No clinically meaningful changes in vital signs, physical examinations, or laboratory values were noted, and mean serum cortisol levels were not suppressed during long-term treatment. These findings demonstrate that both safety and efficacy are maintained during long-term once-daily therapy with triamcinolone acetonide nasal aerosol in patients with perennial allergic rhinitis.

Nocturnal asthma symptoms may be more prevalent than we think

We evaluated the prevalence of nocturnal asthma in our subspecialty allergy clinic to see whether it was significantly different than the prevalence in a previous study (3). A questionnaire was sent to 1258 patients, and there were 325 responses. Of the 325, 304 patients had asthma. A total of 204 (67%) of these had nocturnal symptoms of asthma. Eleven percent of the total population awakened every night, 16% awakened three to six nights per week, 20% one or two nights per week, 20% one night per month, and 33% not at all. We discovered that patients had a rather nonchalant view of their asthma and frequently did not report nocturnal symptoms to their doctors. We conclude that even in a specialty allergy and asthma practice, nocturnal asthma symptoms may be more prevalent than suspected. The reason for this is unclear but may be related to a problem with patient perception and possibly to a lack of diligence in physician history taking.

Effects of acute inhalation of albuterol on submaximal and maximal VO2 and blood lactate

The acute effects of inhaled albuterol, a selective beta-2 adrenergic agonist, on measures of endurance cycling performance and pulmonary function were assessed in 21 competitive road cyclists. A 5 step methacholine challenge revealed all cyclists to be non-asthmatic. Albuterol (A) total dose 360 micrograms or a saline placebo (P) was administered by inhaler, in 4 metered doses of 90 micrograms each, 15 minutes before cycle ergometry exercise. Heart rate, whole blood lactate, perceived exertion and VO2 were determined at the submaximal workloads of 150, 200, 225, 250, 275, 300 watts and at max. Pulmonary function tests determining forced vital capacity, forced expiratory volume during the first second of expiration, forced mid-expiratory flow and maximal voluntary ventilation were performed prior to and 10 minutes after inhalation; and 5, 10 and 15 minutes after termination of the exercise protocol. Heart rate was significantly greater during the A compared to the P treatment at 200 (150.8 +/- 2.5 vs 146.7 +/- 2.8 beats per minute), 225 (159.7 +/- 2.4 vs 154.6 +/- 2.7 beats per minute) and 250 watts (166.9 +/- 2.4 vs 164.4 +/- 2.6 beats per minute). Whole blood lactate was significantly greater during the A compared to the P treatment at 275 watts (4.7 +/- 0.3 vs 4.2 +/- 0.4 mmol.l-1). No other significant differences were found between the 2 treatments at any time point. These data indicate that the acute effect of albuterol inhalation at twice the recommended dosage has no positive effect on endurance performance measures or pulmonary function in athletes who are not asthmatic.

The effect of repeat action albuterol sulfate (Proventil Repetabs) in nocturnal symptoms of asthma

At four medical centers, 98 patients with stable asthma, histories of nighttime awakening at least three times weekly and nighttime declines of pulmonary function of at least 15%, who were not taking oral adrenergic agonists, were randomly treated with either oral repeat-action albuterol sulfate (Proventil Repetabs), 4 mg in the morning and 4-16 mg at bedtime, or a placebo for 2 weeks. All patients were required to have nocturnal symptoms of asthma, with prior use of bronchodilators other than oral adrenergic agonists to be eligible for the study. The patients maintained a diary of asthma symptom scores and recorded peak flow rates at home at bedtime and in the morning. They had spirometry (FEV1, FVC, and PEFR) after a 1-week baseline stabilization period, and after 1 and 2 weeks of double-blind oral therapy as noted above. Efficacy was evaluated by changes in the bedtime and morning peak flow rates, changes in the number of nighttime awakenings, results of office spirometry testing, and by physician and patient global evaluations of response to therapy. Of the 98 patients in the study, 47 received oral albuterol, and 51 received placebo. The patients on albuterol had a statistically significant reduction in the number of nighttime awakenings (p less than or equal to 0.01), as compared with the patients on placebo; this included both the average number of awakenings per week (p = 0.04), and the mean number of nights with awakenings per week (p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Metaproterenol (Alupent) metered dose inhaler in children 5-12 years of age

This multiclinic study was performed to evaluate the safety and efficacy of metaproterenol sulfate (Alupent) metered dose inhaler in children with asthma ages 5 to 12 years. A total of 268 children completed this study according to the protocol, having received either metaproterenol or placebo for 30 consecutive days. Full spirometric testing was done pre- and postdose on Days 1 and 30 for a total duration of 6 hours on each day. The results showed that metaproterenol was consistently superior to placebo in all pulmonary function parameters measured on Days 1 and 30. This difference was statistically significant for peak values and areas under the curves for both FEV1 and FEF25-75%. There were no significant side effects noted. We conclude that metaproterenol metered dose inhaler is safe and effective in the treatment of asthma in children ages 5 to 12 years.

Evaluation of the safety and efficacy of multiple doses of azelastine to adult patients with bronchial asthma over time

Azelastine is a new oral antiasthma agent with bronchodilating and antiallergic properties. This 12-wk study compared azelastine (2, 4, 6, and 8 mg) and placebo given twice a day in asthmatics 12 to 60 yr of age requiring daily bronchodilator therapy. Patients were allowed albuterol aerosol, short-acting theophylline, and pseudoephedrine only as needed. The study was completed by 221 asthmatic subjects. No significant differences in symptoms, medication, or pulmonary function existed between groups at baseline. Analysis of the zero hour FEV1 before azelastine administration on eight occasions during the 12 wk of therapy indicated an increasing slope for azelastine 6 mg that was statistically different from that of placebo; similarly, the slope for azelastine 4 mg showed the same trend, but it did not reach statistical significance. All azelastine groups had significant reductions of as-needed medication after 1 wk; only in the 4-mg and 6-mg groups was this reduction sustained for 12 wk. Asthma symptom scores and peak expiratory flow measurements remained stable in the azelastine groups despite significant reductions in concomitant medication administration. Side effects were minor and included: altered taste (30.1 to 51.9%), drowsiness (6.0 to 16.9%), and dry mouth (3.8 to 6.1%). The occurrence of these adverse events decreased with time throughout the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Procaterol metered-dose inhaler: a multiclinic study evaluating the efficacy and safety in patients with asthma

Procaterol hydrochloride aerosol, a potent beta 2-adrenergic bronchodilator, was evaluated in a double-blind, placebo-controlled study for efficacy and safety in 210 patients with documented mild to moderate reversible airway obstruction. Patients were randomized to receive procaterol in two inhalations (high dose) or one inhalation (low dose), 0.01 mg/inhalation, three times daily, or placebo. Pulmonary function tests were recorded at five and 30 minutes and hourly for eight hours after the first dose and following 1 and 2 weeks of treatment. Both doses of procaterol produced significantly greater improvement in PFTs at one hour and for up to seven hours after dosing compared with placebo (p less than 0.05). Mean percent increases in FEV1 were 35% in the high-dose group and 29% in the low-dose group at week 2. The high-dose group showed no loss of duration of bronchodilation with continued dosing. Improvement in PFTs and peak flow rates was significantly greater in the high-dose than in the low-dose group (p less than 0.05). Tremor was the most frequent side effect. Procaterol had no effect on electrocardiograms, heart rate, blood pressure, or clinical laboratory tests. The high dose of procaterol aerosol was shown to be an effective and well-tolerated bronchodilator with a rapid onset and long duration of action.