Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Mechanisms and clinical implications of glucocorticosteroids in the treatment of allergic rhinitis

Allergic rhinitis is a common airway disease characterized by hypersensitivity, exudation, hypersecretion, inflammatory cell infiltration and remodelling. Intranasal glucocorticosteroids are the most effective drugs for controlling the inflammation caused by allergic rhinitis. Glucocorticosteroids exert anti-inflammatory effects through at least two pathways: the transactivation pathway and the transrepression pathway. Glucocorticosteroids also exert regulatory functions by inducing regulatory cytokines and forkhead box P3 (FoxP3(+)) regulatory T cells. Evidence suggests that intranasal glucocorticosteroids control not only nasal symptoms but also ocular symptoms. In contrast to sedating H1 receptor antagonists, intranasal glucocorticosteroids can improve impaired performance symptoms, such as daytime sleepiness, associated with allergic rhinitis. Recent studies suggest that intranasal glucocorticosteroids might also be useful for the prophylactic treatment of pollinosis; this possibility is supported by the molecular mechanism of the anti-inflammatory action of glucocorticosteroids. These findings suggest that intranasal glucocorticosteroids might be positioned as first-line drugs for the treatment of both perennial and seasonal allergic rhinitis.

[Asthma and pregnancy. Review of the current literature and management according to the GINA 2006-2007 guidelines]

INTRODUCTION

Many pregnant women are asthmatics and maternal asthma is a source of questions and complications concerning both the progress of the pregnancy itself and the impact on the foetus. In this situation good asthma control is essential as the disease can deteriorate with acute exacerbations, possibly precipitated by reduction or even withdrawal of treatment on account of fear of teratogenicity.

BACKGROUND

Even though asthma treatments are not totally harmless during pregnancy, their use has been validated by several studies and guidelines. To help clinicians, we undertake here a review of the complications induced by maternal asthma and its medications, and then suggest management guidelines according to the most recent publications.

CONCLUSIONS

The risks and benefits of asthma treatments should be explained in a real partnership between the patient and her general practitioner and specialists (obstetrician, chest physician or allergist). In order to reduce complications to both mother and child, perfect control of asthma is required and inhaled steroids remain the treatment of choice for partially or uncontrolled asthma in the pregnant woman.

Are intranasal corticosteroids all equally consistent in managing ocular symptoms of seasonal allergic rhinitis?

BACKGROUND

Nasal and ocular symptoms of allergic rhinitis (AR) are reported by >70% of patients and have a profound impact on quality of life while also incurring substantial healthcare costs. It has been suggested that intranasal corticosteroids (INS), in addition to effectively treating the nasal components of AR, are effective in treating the ocular symptoms.

OBJECTIVE

This review provides a comprehensive, updated assessment of available data in the public domain to determine the consistency of INS efficacy in treating ocular AR symptoms.

METHODS

MEDLINE and EMBASE searches, and research of governmental and regulatory institution sources identified 35 randomised, placebo-controlled trials of INS and seasonal AR (SAR) published between 1990 and May 2009 that specifically contained ocular efficacy as part of the study analyses.

RESULTS

Examination of these studies reveals substantial inconsistency of effect of some INS across, and even within, trials, casting doubt on the suggestion that ocular efficacy is a class effect of INS. Conflicting, inconsistent or even negative effects were observed for most INS examined including mometasone furoate and fluticasone propionate. Only fluticasone furoate nasal spray, in addition to established efficacy in treating nasal symptoms, demonstrated a consistent positive effect on ocular symptoms of SAR compared with placebo in a large number of patients across all of its prospective studies. Moreover, these results were consistent across different allergy seasons, including grass, ragweed, and mountain cedar seasons, and different geographical locations throughout Europe and the USA.

CONCLUSION

While additional prospective head-to-head clinical trials comparing the efficacy of INS in treating ocular symptoms of AR are needed to fully elucidate the benefits of one INS compared with another, data available to date suggest that not all INS are equally consistent in managing ocular symptoms of SAR. Fluticasone furoate is currently the most consistent.

Soluble serum HLA-G and HLA-A, -B, -C molecules in patients with seasonal allergic rhinitis exposed to pollens

BACKGROUND

Allergic rhinitis (AR) is characterized by a Th2 polarized immune response and soluble HLA (sHLA) molecules play an immunomodulatory role in this response. Previously, it has been reported that these molecules are increased in sera of patients with pollen-induced allergic rhinitis studied outside the pollen season. To date, however, no study has investigated there in AR patients during the pollen season.

OBJECTIVE

The aim of this study was to evaluate serum sHLA-G and sHLA-A, -B, -C levels in both AR patients and healthy controls.

METHODS

60 symptomatic allergic patients were enrolled. A group of 50 healthy subjects was included as a control. Serum sHLA-G and sHLA-A, -B, -C levels were determined by an immunoenzymatic method. Allergy severity was assessed by VAS for symptoms and drug use.

RESULTS

Allergic patients had significantly higher levels of both sHLA-G (p<0.001) and sHLA-A, -B, -C (p=0.001) than normal controls. In addition, there was a very strong correlation between sHLA-G levels and clinical severity.

CONCLUSION

The present study confirms evidence that serum sHLA-G and sHLA-A, -B, -C molecules are significantly increased in patients with pollen-induced AR also during the pollen season. Moreover, sHLA-G might be considered as a biomarker for assessing clinical severity.

Parental attitudes toward new dosage forms of desloratadine in an online survey: results from four European countries

BACKGROUND

Allergic disease affects an estimated 50% of children worldwide and causes considerable impairment in academic performance and daily activities. Pediatric formulations for allergy treatment are often highly sugared or contain ingredients to improve palatability, appearance, and patient acceptance/adherence. These excipients, however, are associated with dental caries, gastrointestinal intolerance, and dermatologic reactions.

OBJECTIVE

To assess the appeal of new sugar-free/dye-free syrup and orodispersible formulations of the second-generation antihistamine desloratadine to parents of children with allergy in four European countries.

DESIGN

In an online survey of households with children aged < or =12 years with allergies in France, Italy, the Netherlands, and Spain, respondents were asked to consider one of two desloratadine product concepts: a sugar-free, dye-free oral solution or an orodispersible tablet.

PARTICIPANTS

Eligible households had to have at least one child aged < or =12 years with symptomatic seasonal, pet, or indoor allergies or hives for > or =1 week/year. Respondents had to be the decision makers regarding their child's allergy medication and to be likely to treat symptoms with prescription medication some of the time.

RESULTS

There were 627 eligible households. Most (88%) parents in Spain were likely to ask their physician about and to consider trying sugar-free, dye-free desloratadine syrup, followed by 76% of those in France, 68% in Italy, and 56% in the Netherlands. About three-quarters of parents in France, Spain, and Italy and more than half of those in the Netherlands were likely to ask their physician about and to consider trying the orodispersible formulation.

LIMITATIONS

There is no control group for comparisons between the study's online responses and those that would have resulted from another survey methodology. Further, response biases do exist across countries based on cultural norms.

CONCLUSION

Survey respondents were generally receptive to the new sugar-free, dye-free syrup and orodispersible tablet formulations of the second-generation antihistamine desloratadine. At least half of parents surveyed indicated their willingness to try the new products.

[INSTANT: national survey of allergic rhinitis in a French adult population based-sample]

OBJECTIVE

To assess the prevalence of allergic rhinitis (AR) (according to the SFAR, Score For Allergic Rhinitis and the ARIA Allergic Rhinitis and its Impact on Asthma classification) in the French adult general population and to describe its impact on quality of life, quality of sleep and prevalence of associated ocular symptoms.

METHODS

This cross-sectional survey was carried out in 2006 in a French population-based sample. The data were collected by a polling organization in 3 waves using face-to-face interviews at home. Subjects answered to questionnaires of AR management, quality of life (SF-12), quality of sleep (MOS-Sleep) and daytime sleepiness (Epworth). Statistical analysis was performed using SAS software.

RESULTS

Among the 10, 038 interviewed subjects, (mean age: 43 years), the overall prevalence of AR was 31%, with regional variations (from 26% in South West to 37% in the Mediterranean area). The prevalence was higher in younger subjects (39% in 18-25 years, 35% in 26-35 years, vs. 22% in >65 years, p<0.001) and in women (36% vs. 25% in men, p<0.001). Among the 2005 subjects of the 1st wave, the first 601 subjects with a SFAR> or =7 constituted the AR group and 706 subjects with SFAR<7 the Control group. According to the ARIA classification, 44 % of individuals had a moderate to severe persistent AR, 6% a mild persistent AR, 43.5% a moderate to severe intermittent AR and 6.5% a mild intermittent AR. Asthma (26%) and eczema (14%) were the most frequent allergic conditions associated with AR. Ocular symptoms were present in 52% of AR subjects. Quality of life and of sleep did not differ significantly between the intermittent and the persistent forms of AR (or according to the length...) but were more significantly deteriorated in the AR group compared to the Control group (summary psychic score of SF-12: 45.5 vs. 49, p<0.001 and index 1 of MOS-Sleep: 34 vs. 25; p<0.01). The Epworth sleepiness score was also higher in the AR group than in the Control group (6.9 vs. 5.5, p<0.01). Furthermore, sleepiness was more frequent in the AR persistent form than in the AR intermittent form (MOS-sleep scores: 28.5 vs. 33, p<0.05).

CONCLUSION

This national survey confirmed the elevated prevalence of AR as assessed using the SFAR and associated ocular symptoms at the general population level and highlighted the important negative impact of AR on quality of life and sleep.

When allergic rhinitis is not only allergic

BACKGROUND

In clinical practice it can be observed that some patients with seasonal allergic rhinitis (AR) continue to have symptoms even when the exposure to allergens is expected to be low or absent. We studied the clinical and cytological characteristics of these atypical forms of (AR) in a large population of patients.

METHODS

Consecutive patients with symptoms of rhinitis and with positive skin test to pollens only were interviewed for the duration of symptoms, correlation with sensitization pattern, and presence of reactivity to nonspecific stimuli. All underwent rhinoscopy and nasal scraping for cytology.

RESULTS

Five hundred nineteen patients with AR were studied. Of these 519 patients 60 (11.5%) had an atypical or mixed form of rhinitis, with symptoms independent of the exposure and also elicited by nonspecific stimuli. These patients clearly differed from typical forms, especially for the nasal inflammation. They had a greater number of eosinophils and mast cells out of season (p < 0.05). Moreover, these atypical forms had, more frequently, asthma and eosinophilic polyps.

CONCLUSION

In approximately 12% of patients with AR, other mechanisms of inflammation seem to intervene. Nasal cytology can be helpful in discriminating these atypical forms.

Allergic and nonallergic rhinitis: can we find the differences/similarities between the two pictures?

The diagnostic challenge of rhinitis is to determine the etiology, specifically whether it is allergic or nonallergic. We therefore evaluated the general features of patients with allergic (AR) and nonallergic rhinitis (NAR), as well as health-related quality of life (HRQoL). The study group consisted of 323 patients (201 F/122 M) with a mean age of 31.79 +/- 12.64 years. Almost two thirds of the population had AR (63.5%). Neither the demographic characteristics nor the duration of rhinitis was different between the two groups. Total immunoglobulin E was significantly higher in AR. Although both groups displayed a mild-intermittent rhinitis profile, patients with AR had more seasonal and NAR had more perennial symptoms (p = 0.01). Frequency of nasal obstruction was comparable in both groups, whereas patients with AR significantly complained of rhinorrhea (86.8%), followed by nasal obstruction, sneezing, and nasal itching compared with the NAR group. Conjunctivitis and sinusitis were more prominent in the AR than NAR group (p = 0.01). However, the prevalences of asthma and bronchial hyperreactivity were not different, as well as the other allergic or systemic comorbidities. Furthermore, the impairment in HRQoL was similar in both groups, using a generic questionnaire- Short form-36 (SF-36). In conclusion, although the allergy test results still remain the only relevant difference, the diagnosis of NAR is important as it has many differences/similarities with AR and is seen almost half as often as AR in patients with chronic rhinitis.

Acupuncture for persistent allergic rhinitis: a multi-centre, randomised, controlled trial protocol

Background

Allergic rhinitis is one of the most common health complaints worldwide. Complementary and alternative medical approaches have been employed to relieve allergic rhinitis symptoms and to avoid the side effects of conventional medication. Acupuncture has been widely used to treat patients with allergic rhinitis, but the available evidence of its effectiveness is insufficient. Our objective is to evaluate the effectiveness of acupuncture in patients in Korea and China with persistent allergic rhinitis compared to sham acupuncture treatment or waitlist control.

Methods

This study consists of a multi-centre (two centres in Korea and two centres in China), randomised, controlled trial with three parallel arms (active acupuncture, sham acupuncture, and waitlist group). The active acupuncture and sham acupuncture groups will receive real or sham acupuncture treatment, respectively, three times per week for a total of 12 sessions over four weeks. Post-treatment follow-up will be performed a month later to complement these 12 acupuncture sessions. Participants in the waitlist group will not receive real or sham acupuncture treatments during this period but will only be required to keep recording their symptoms in a daily diary. After four weeks, the same treatment given to the active acupuncture group will be provided to the waitlist group.

Discussion

This trial will provide evidence for the effectiveness of acupuncture as a treatment for persistent allergic rhinitis. The primary outcome between groups is a change in the self-reported total nasal symptom score (i.e., nasal obstruction, rhinorrhea, sneezing, and itching) from baseline at the fourth week. Secondary outcome measures include the Rhinitis Quality of Life Questionnaire score and total non-nasal symptom score (i.e., headache, itching, pain, eye-dropping). The quantity of conventional relief medication used during the follow-up period is another secondary outcome measure.

Trial registration

Current Controlled Trials ISRCTN90807007

GA2LEN (Global Allergy and Asthma European Network) addresses the allergy and asthma 'epidemic'

Allergic diseases represent a major health problem in Europe. They are increasing in prevalence, severity and costs. The Global Allergy and Asthma European Network (GA(2)LEN), a Sixth EU Framework Program for Research and Technological Development (FP6) Network of Excellence, was created in 2005 as a vehicle to ensure excellence in research bringing together research and clinical institutions to combat fragmentation in the European research area and to tackle allergy in its globality. The Global Allergy and Asthma European Network has benefited greatly from the voluntary efforts of researchers who are strongly committed to this model of pan-European collaboration. The network was organized in order to increase networking for scientific projects in allergy and asthma around Europe and to make GA(2)LEN the world leader in the field. Besides these activities, research has also been carried out and the first papers are being published. Achievements of the Global Allergy and Asthma European Network can be grouped as follows: (i) those for a durable infrastructure built up during the project phase, (ii) those which are project-related and based on these novel infrastructures, and (iii) the development and implementation of guidelines. The major achievements of GA(2)LEN are reported in this paper.

Economic studies of immunotherapy: a review

PURPOSE OF REVIEW

To analyse and discuss the growing body of evidence on the economic advantages offered by immunotherapy for allergic rhinitis and asthma, in the various perspectives (society, national healthcare system, patients, etc) and according to the various types of standardized economic evaluations.

RECENT FINDINGS

This review shows that the economic studies of allergic rhinitis and asthma focus on three main research areas: studies aimed at determining the cost of illness and studies focused either on a simple cost comparison amongst available therapeutic alternatives, or directly comparing alternatives using full economic evaluations (cost-effectiveness, cost-utility measures, etc).

SUMMARY

Studies exploring the full cost of allergic rhinitis and asthma are still lacking; on the contrary, studies on immunotherapy (in its many administration forms, subcutaneous, sublingual, tablet, etc) in comparison with standard pharmaceutical treatment, have shown that immunotherapy may be very beneficial to the healthcare systems, in that either it could bring more clinical outcome at a reduced cost, versus standard therapy alone, or it could bring extra benefit at a very acceptable extra cost. This is even more correct under the societal perspective, that is, when indirect costs of lost productivity are considered and included in the economic analysis.

Immunoglobulin production pattern is allergen-specific in polysensitized patients

Allergic rhinitis (AR) is characterized by Th2 polarized immune response, such as increased IL-4 and reduced IFN-gamma production, and by a functional defect of T regulatory cells. This impaired immune response profile influences the pattern of immunoglobulin production in allergic patients. Therefore, the aim of this study is firstly to investigate the allergen-specific IgE, IgG, IgG4, and IgA serum level pattern in polysensitized AR patients with the same skin prick test positivity to some pollen allergens. Secondly, this study aims at relating immunoglobulin (Ig) values with some clinical and immunological parameters. Eighty polysensitized patients with AR were enrolled. Serum allergen-specific IgE, IgG, IgG4, and IgA for mites, Parietaria, grasses, and birch, TGF-beta and sHLA-G were determined by the ELISA method. Allergic symptoms and drugs use were also assessed. Allergen-specific IgE, IgG, IgG4, and IgA serum levels were significantly different for each tested allergen (p=0.0001). There was a significant correlation between IgE levels and allergy severity, whereas IgA had an antagonistic behaviour, considering mite-specific immunoglobulins. In conclusion, the present study provides the first evidence that immunoglobulin production pattern depends on the specificity of the allergenic response.

Control of allergic rhinitis and asthma test--a formal approach to the development of a measuring tool

Background

The concurrent management of allergic rhinitis and asthma (ARA) has been recommended by Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. However, a tool capable of assessing simultaneously the control of upper and lower airways diseases is lacking.

Aim

To describe the studies conducted to design the control of ARA test (CARAT) questionnaire.

Methods

We performed a literature review to generate a list of potentially important items for the assessment of control of ARA. A formal consensus development process, that used an innovative web-based application, was designed – 111 experts in ARA and 60 patients participated. At the final consensus meeting, 25 primary and secondary care physicians formulated the questions and response options. A qualitative feasibility study (n = 31 patients) was conducted to evaluate the comprehensibility of the questionnaire while testing two different designs.

Results

Thirty-four potentially important items were identified. All the steps of the consensus process were completed in 2.5 months. The opinions of experts and patients lead to the formulation of 17 questions. At the feasibility study the instructions and wording problems were corrected and a semi-tabular format was chosen.

Conclusion

A tool to measure the control of allergic rhinitis and asthma was developed using a comprehensive set of methodological steps ensuring the design quality and the face and content validity. Additional validation studies to assess the psychometric properties of the questionnaire have started.

Efficacy and safety of triamcinolone acetonide aqueous nasal spray in children aged 2 to 5 years with perennial allergic rhinitis: a randomized, double-blind, placebo-controlled study with an open-label extension

BACKGROUND

Intranasal corticosteroids (INSs) are the most effective treatment for allergic rhinitis (AR). However, available INS safety and efficacy data in children younger than 6 years are limited.

OBJECTIVE

To report the first well-controlled study assessing the safety and efficacy of an INS in children aged 2 to 5 years with perennial AR.

METHODS

In a 4-week, multicenter, double-blind, parallel-group study, patients were randomized to receive triamcinolone acetonide aqueous nasal spray (TAA AQ), 110 microg once daily, or placebo. A subset of children continued into a 6-month, open-label phase. Efficacy end points included total nasal symptom scores. Safety measures included reports of adverse events, morning serum cortisol levels before and after cosyntropin infusion, and growth as measured using office stadiometry.

RESULTS

A total of 474 patients were randomized to receive TAA AQ (n = 236) or placebo (n = 238); 436 entered the open-label extension phase. Adjusted mean (SE) changes from baseline during the double-blind period in instantaneous and reflective total nasal symptom scores were -2.28 (0.16) and -2.31 (0.15), respectively, in the TAA AQ group (P = .09) vs -1.92 (0.16) and -1.87 (0.15) in the placebo group (P = .03). Adverse event rates were comparable between treatment groups. There was no significant change from baseline in serum cortisol levels after cosyntropin infusion at study end. The distribution of children by stature-for-age percentile remained stable during the study.

CONCLUSIONS

Use of TAA AQ, 110 microg once daily, for up to 6 months offers a favorable efficacy to safety ratio in children aged 2 to 5 years with perennial AR.

[Influence of breastfeeding and diet in the development of allergies in children]

OBJECTIVE

To evaluate the relationship between breastfeeding and the development of allergic diseases (AD).

DESIGN

A cases-controls study.

SETTING

Santander University Hospital, Bucaramanga, Colombia, South America. Level II health care.

PARTICIPANTS

A total of 1460 boys and girls between 3 and 7 years old attending an outpatient clinic.

MAIN MEASUREMENTS

Partial (BF) and exclusive breastfeeding (EBF); relationship between the presence of allergic diseases and BF and EBF, adjusting for the confounding factors due to other exposures using logistic regression.

RESULTS

Out of a total of 1460 patients, 41.6% (95%CI 39.0-44.2) received EBF, while 44.4% (95%CI 41.9-47.0) were partially breastfed. Among those who had an allergy, 34.8% (95%CI 32.4-37.3) had rhinitis, 27.8% (95%CI 25.6-30.2) asthma and 11.6% (95%CI 10.0-13.4) atopic dermatitis; 7.0% (95%CI 5.1-9.3) had the three conditions. To breastfeed exclusively for >or= 3 months is a protective factor for AD (OR 0.70, 95%CI 0.48-1.03). Breastfeeding for 3 months, regardless of whether or not it is exclusive, is a risk factor for AD (OR 2.05, 95%CI 1.47-2.86).

CONCLUSIONS

The recommendation to exclusively breastfeed for as long as possible continues to be valid, as there was a significant preventive impact on the development of AD with the length of time breastfed. Prospective studies including lung function tests and immunological analyses need to be performed to confirm these findings.

[Allergic rhinitis and its impact on asthma (ARIA update 2008). The Austrian perspective]

In 1999, during the ARIA (Allergic Rhinitis and its Impact on Asthma) WHO workshop, an evidence-based document was produced using an extensive review of the literature available up to December of the same year. An update of the ARIA guidelines was soon needed and started in 2004. Thereafter, there was the need for an even more global document, which would highlight the interactions between the upper and the lower airways including diagnosis, epidemiology, common risk factors, management and prevention, and comprise the allergy perspective also for developing countries. This goal was achieved with the most recently published ARIA update 2008. The present article is the result of consecutive efforts of the authors of the ARIA update 2008 to accomplish the nationwide comprehensive distribution of information by publication in important national journals, like the WMW.

The respiratory health of swimmers

Regular physical activity is recognized as an effective health promotion measure. Among various activities, swimming is preferred by a large portion of the population. Although swimming is generally beneficial to a person's overall health, recent data suggest that it may also sometimes have detrimental effects on the respiratory system. Chemicals resulting from the interaction between chlorine and organic matter may be irritating to the respiratory tract and induce upper and lower respiratory symptoms, particularly in children, lifeguards and high-level swimmers. The prevalence of atopy, rhinitis, asthma and airway hyper-responsiveness is increased in elite swimmers compared with the general population. This may be related to the airway epithelial damage and increased nasal and lung permeability caused by the exposure to chlorine subproducts in indoor swimming pools, in association with airway inflammatory and remodelling processes. Currently, the recommended management of swimmers' respiratory disorders is similar to that of the general population, apart from the specific rules for the use of medications in elite athletes. Further studies are needed to better understand the mechanisms related to the development or worsening of respiratory disorders in recreational or competitive swimmers, to determine how we can optimize treatment and possibly help prevent the development of asthma.

Montelukast in guidelines and beyond

In all asthma guidelines, preventive anti-inflammatory treatment is essential in all patients with persistent asthma. Inhaled corticosteroids are the mainstay of treatment in the control of asthma, but other treatments may be used as a monotherapy in patients with mild asthma or as an add-on treatment in those with moderate-to-severe asthma. Leukotriene modifiers are the only validated preventive treatment for all age groups. This review discusses the place of montelukast, a leukotriene receptor antagonist, using guidelines and consensus reports on asthma and rhinitis: the US National Asthma Education and Prevention Program (NAEPP); the British Guideline on the Management of Asthma; the Global Initiative on Asthma (GINA); and Allergic Rhinitis and its Impact on Asthma (ARIA). This review includes new studies that have not yet been considered in guidelines.

Desloratadine for the Relief of Nasal and Non-nasal Allergy Symptoms: An Observational Study

Introduction

The rates of allergic rhinitis, allergic asthma, and atopic eczema range from 6% to 16% globally. Second-generation antihistamines have been shown to be safe and effective for the treatment of symptoms of allergic disease. This study investigated the efficacy and safety of desloratadine, a nonsedating second-generation antihistamine, in the treatment of common allergy symptoms.

Methods

In this open-label, uncontrolled, non-randomized, observational study, subjects (N = 973) with allergy symptoms were given desloratadine 5 mg daily for 3 weeks. Nasal, ocular, and dermal symptom severity was rated as asymptomatic, mild, moderate, or severe; changes in the percentage of subjects in each severity category were assessed. Overall efficacy and tolerability of desloratadine treatment were evaluated separately by physicians and subjects.

Results

Allergic rhinitis was the most frequent diagnosis, occurring in 59.0% of subjects. Approximately 40% of subjects had received previous treatment with other antihistamines, systemic/topical glucocorticosteroids, or beta-sympathicomimetics. Slightly more than half of subjects received concomitant medication during the study; 263 (53.0%) of those used intranasal steroids. A significant reduction in severity scores was observed in all symptom subgroups (P < 0.001). Desloratadine efficacy was judged to be excellent or good by 90.2% of physicians and 88.6% of subjects; 82.5% of investigators and 80.9% of subjects considered it more effective than previous therapy. The tolerability of desloratadine was rated excellent or good by 97.0% of both groups. Thirty-one subjects (3.2%) experienced adverse events.

Conclusions

In an open-label, uncontrolled, non-randomized, observational study allergy symptoms improved significantly in subjects treated with desloratadine.

Clinical efficacy of halophilic lactic acid bacterium Tetragenococcus halophilus Th221 from soy sauce moromi for perennial allergic rhinitis

BACKGROUND

Recently, some common foods in daily life, especially lactic acid bacteria, have been found to have anti-allergic effects. We previously isolated a halophilic lactic acid bacterium, Tetragenococcus halophilus Th221, from soy sauce moromi, a mixture of koji and salt solution, and showed that it possesses an immunomodulatory activity that promotes T helper type 1 immunity.

METHODS

To evaluate the anti-allergic effects of Th221, we performed a randomized, double-blind, placebo-controlled study in 45 subjects with perennial allergic rhinitis (PAR) treated by oral administration of Th221 (high dose, 60 mg/day, 15 subjects; low dose, 20.4 mg/day, 15 subjects) or a placebo (15 subjects) for 8 weeks.

RESULTS

There were no significant differences among the groups that ingested Th221 and the placebo group regarding the disease severities, total nasal symptom scores and total nasal sign scores examined by physicians. However, the disease severity examined by physicians significantly improved in the high-dose group at the end of the trial compared with the beginning (p < 0.05). The total score for nasal symptoms of subjects who received a high dose of Th221 also showed a significant improvement at the end of the trial compared with the beginning (p < 0.01). According to the subjects' diaries, significant improvements in sneezing and rhinorrhea were observed during some periods in the high-dose group. The change in serum total immunoglobulin E improved significantly at the end of the trial compared with the beginning in this group (p < 0.05). The safety of Th221 treatment was confirmed by laboratory tests and inspection of the general condition of each subject.

CONCLUSIONS

Th221 can be expected to safely improve the symptoms of PAR.

Effectiveness of fluticasone furoate 110 microg once daily in the treatment of nasal and ocular symptoms of seasonal allergic rhinitis in adults and adolescents sensitized to mountain cedar pollen

BACKGROUND

Fluticasone furoate (FF) is a novel enhanced-affinity corticosteroid for the treatment of allergic rhinitis, delivered by a unique side-actuated device. This study was designed to investigate the efficacy and safety of FF nasal spray (FFNS) 110 microg once daily compared with placebo in adults and adolescents (aged > or =12 years) with seasonal allergic rhinitis (SAR) symptoms caused by mountain cedar (Juniperus ashei) pollen.

METHODS

This was a randomized, double-blind, placebo-controlled, parallel-group, phase III study conducted over a 2-week period (between 10 December 2004 and 19 January 2005) at seven study sites, in Austin, Texas, USA, and San Antonio, Texas, two metropolitan cities in the central Texas Hill Country located approximately 80 miles apart. Adult and adolescent patients (aged > or =12 years) with SAR, who were sensitized to mountain cedar (Juniperus ashei) pollen, were randomized to receive either FFNS 110 microg (n = 152) or placebo (n = 150) once daily. Patients rated the severity of each nasal symptom (rhinorrhea, nasal congestion, nasal itching, and sneezing) and ocular symptom (redness, watery eyes, itching and burning) on a 4-point categorical scale (0 = none, 3 = severe) in a reflective and instantaneous manner. Patients also rated their overall evaluation of response to therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT00115622.

RESULTS

FFNS significantly improved the nasal symptoms of SAR compared with placebo. The least square (LS) mean difference in the reflective total nasal symptom score (TNSS) was -0.777 (p = 0.003). A significant reduction in morning pre-dose instantaneous TNSS was also observed compared with placebo (LS mean difference -0.902; p < 0.001). Patients receiving FFNS had significantly greater improvements from baseline in reflective total ocular symptom scores (TOSS) than those receiving placebo (LS mean difference -0.546; p = 0.008). Significant improvements in ocular symptoms with FFNS versus placebo were also observed for morning pre-dose instantaneous TOSS (LS mean difference -0.519; p = 0.009). FFNS had a favorable safety and tolerability profile: fewer adverse events occurred with FFNS (22%) than with placebo (29%), and no serious adverse events were observed.

CONCLUSIONS

FFNS 110 microg once daily demonstrated efficacy in relieving both the nasal and ocular symptoms of SAR in adult and adolescent patients.

Costs of second-generation antihistamines in the treatment of allergic rhinitis: US perspective

OBJECTIVE

To review the pharmacoeconomic literature evaluating use of antihistamines in treating allergic rhinitis (AR) in the US.

METHODS

Three independent reviewers conducted a comprehensive search of the current literature with PubMed. They identified articles describing original research comprising US cost analyses or pharmacoeconomic evaluations that reported both costs and consequences of using second-generation anthistamines (SGAs), first-generation antihistamines (FGAs), or both for the treatment of patients with AR. The search was limited to studies performed in humans and published in English between 1998 and 2008.

RESULTS

Five of 200 articles met the inclusion criteria and examined costs associated primarily with chlorpheniramine, diphenhydramine, cetirizine, and fexofenadine. The first two studies retrospectively analyzed a claims database and concluded that fexofenadine was associated with slightly lower overall costs than loratadine and cetirizine. A third study compared total healthcare costs associated with FGAs and SGAs, concluding that despite their higher prescription cost, SGAs result in lower medical resource use and lower cost for treatment of AR versus FGAs, although no individual SGA could be distinguished as providing substantial healthcare cost savings or increased cost-effectiveness over the other SGAs. Two studies investigated the impact of transitioning a prescription SGA to over-the-counter status and concluded that such a transition would provide cost savings to healthcare plans, but did not address the cost or health effect of such a switch on specific populations whose plans might no longer cover prescription SGAs.

CONCLUSIONS

Preliminary evidence suggests that newer SGAs offer clinical, pharmacodynamic, and pharmacokinetic advantages that may translate into superior cost-effectiveness in the treatment of AR. Further study is warranted to clarify the pharmacoeconomic impact of the newer SGAs and to establish their relative cost-effectiveness.

Humoral and cellular immune responses to Blomia tropicalis and concanavalin A-binding fractions in atopic patients

Blomia tropicalis, Dermatophagoides pteronyssinus and D. farinae are prevalent house dust mites. Concanavalin A-binding components derived from B. tropicalis (Bt-ConA extract) are highly immunogenic in allergic diseases. The aim of the present study was to evaluate the humoral and cellular immune responses to B. tropicalis in mite-sensitized patients. A total of 137 patients with allergic rhinitis with/without asthma and 109 non-atopic subjects were selected and analyzed by the skin prick test, and for total serum IgE and specific IgE levels to both Bt-total and Bt-ConA extracts, their proliferative response and cytokine (IFN-gamma and IL-5) production by peripheral blood mononuclear cells (PBMC) stimulated with both extracts. Skin prick test showed that 70% of the patients were sensitized to Bt (Bt+) and similar levels of specific IgE to Bt-total and Bt-ConA extracts were demonstrable in Bt+ patients. Significant PBMC proliferation was observed in response to Bt-total extract in Bt+, but not in Bt- patients and non-atopic subjects (P < 0.001). Bt-ConA extract induced increased proliferative responses in all patient groups compared to medium alone (P < 0.05), but these responses were significantly decreased in the presence of the mannopyranoside ConA inhibitor (P < 0.05). Significant IFN-gamma production was observed after Bt-ConA stimulation of Bt+ patients (P < 0.05), while Bt-total extract had no effect. IL-5 production was consistently detected in Bt+ patients after allergen-specific stimulation or with no stimulus, indicating that PBMC from allergic patients are prone to produce Th2 profile cytokines, spontaneously or inductively by allergen restimulation. These data showed that ConA-binding components isolated from B. tropicalis may contain relevant antigens that are involved in both humoral and cellular immune responses. However, without an additional purification procedure to eliminate the residual contamination with ConA, its use in immunotherapeutic procedures cannot be recommended.

Bepotastine besilate OD tablets suppress nasal symptoms caused by Japanese cedar pollen exposure in an artificial exposure chamber (OHIO Chamber)

OBJECTIVE

To investigate the efficacy and safety of bepotastine, we conducted a randomized, investigator-blind, placebo-controlled and parallel study to evaluate the allergic symptoms and the cognitive function of the subjects with Japanese cedar (JC) pollinosis in response to JC pollen exposure in an artificial exposure chamber.

METHODS

Twenty-four volunteers with JC pollinosis were enrolled in this study. The subjects were randomly divided into two groups: a bepotastine group and a placebo group (12 subjects each). Subjects received either a 10-mg bepotastine OD (orally disintegrating) tablet or a placebo 10 min before entering the chamber for a 3-h exposure. The nasal and ocular symptoms were evaluated by each patient at regular intervals. The amount of nasal discharge was measured and the number of sneezes recorded. To evaluate the cognitive function, a digit cancellation test (D-CAT), in which the subjects have to eliminate certain numbers within a fixed time, was conducted.

RESULTS

Twelve subjects in the placebo group developed nasal and/or ocular symptoms, whereas six subjects in the bepotastine group showed none of the symptoms during exposure. Mean secretion weights and number of sneezes were significantly lower in the bepotastine group than in the placebo group. In D-CAT, no deterioration of work performance was observed in the bepotastine group. No adverse effects were observed in either group.

CONCLUSION

Bepotastine treatment is effective and well tolerated in patients with allergen-induced symptoms exposed to JC pollen in an exposure chamber.

Sublingual immunotherapy in children: complete and updated review supporting evidence of effect

PURPOSE OF REVIEW

The interest in sublingual immunotherapy (SLIT) is still growing worldwide and especially for the pediatric age group, this modality is appealing. Lately, some negative systematic review articles have been published on SLIT in children. However, high quality articles published from 2007 onward had not been included.

RECENT FINDINGS

Explanations are sought for the negative outcomes in these reviews and shortcomings are discussed. New pediatric studies - not included in the previous reviews -designed taking into account the golden rules for SLIT (high daily dose, starting at least 4 months before pollen season) do show statistically significant improvement in symptom and medication scores for rhinitis and asthma in pollen allergy. New house dust mite studies still show inconsistent data.

SUMMARY

Evidence of effect is confirmed for SLIT in children with allergic rhinitis or asthma caused by pollen exposure. For house dust mite asthma, evidence is still nonconcordant. New techniques to improve SLIT efficacy are under investigation.

Mometasone furoate nasal spray is safe and effective for 1-year treatment of children with perennial allergic rhinitis

OBJECTIVE

Perennial allergic rhinitis (PAR) affects children at a young age. Current guidelines recommend intranasal corticosteroids as the first-line treatment in patients with moderate-to-severe or persistent disease or in those who have congestion. In this study, the long-term safety and efficacy of mometasone furoate nasal spray (MFNS) were assessed in children with PAR.

METHODS

In this multicenter, active-controlled, evaluator-blind, 12-month study, 255 children aged 6-11 years with a >or=1-year history of PAR were randomized to receive once-daily MFNS 100 microg (n=166) or the active comparator beclomethasone dipropionate (BDP) 168 microg (n=85). Changes from baseline in overall PAR symptoms and response to treatment were rated at each visit. Cosyntropin stimulation testing, as well as tonometry and slit lamp procedures, were performed. Safety variables were assessed.

RESULTS

A total of 137 subjects in the MFNS group and 68 in the BDP group completed treatment. The mean reductions in physician- and subject-rated overall condition of PAR at week 52 were -42.1% and -39.7%, respectively, for MFNS, compared with -44.0% and -39.0%, respectively, for BDP. A total of 94% and 100% of MFNS and BDP subjects, respectively, reported adverse events (AEs), which were mostly mild or moderate. The most frequently reported treatment-related AEs in both groups were epistaxis, headache, and pharyngitis. Response to cosyntropin was normal and no posterior subcapsular cataracts were observed in either group. Although no significant changes in intraocular pressure were observed with MFNS, one subject receiving BDP demonstrated this effect.

CONCLUSIONS

Treatment with MFNS 100 microg once daily for 1 year was well tolerated in children 6-11 years old, with negligible systemic exposure and no evidence of suppression of the hypothalamic-pituitary-adrenal axis or ocular changes.

Guaifenesin in rhinitis

Mucus in the airways is a complex mixture of water, lipids, glycoproteins, sugars, and electrolytes that serves as a lubricant for the epithelium. The efficient flow of respiratory mucus is a first level of immune defense that requires an appropriate viscosity and elasticity for optimal barrier and ciliary functions. Thickening and drying of airway mucus by respiratory tract infections, allergies, and drugs can impair evacuation. Tenacious, bothersome mucus is an annoying and frequent symptom of rhinitis that is difficult to manage. Common remedies include adequate hydration through fluid intake and nasal washes. The use of mucoactive agents is controversial due to limited data and equivocal efficacy in available studies. Nonetheless, some patients benefit. This review examines the use of guaifenesin (glyceryl guaiacolate) on bothersome nasal mucus associated with rhinitis, including the available published data and clinical experience.

Change in visual analog scale score in a pragmatic randomized cluster trial of allergic rhinitis

BACKGROUND

Most patients with allergic rhinitis consult in primary care. A simple test is needed to evaluate globally the severity of allergic rhinitis to assess the efficacy of treatment.

OBJECTIVE

This study compared the responsiveness of visual analog scale (VAS) scores between baseline and treatment with the 2 gold-standard outcomes (symptom score and quality of life). Five hundred eighty-six subjects were included, all with allergic rhinitis caused by grass pollens and all seen in primary care.

METHODS

A randomized, multicenter, open-label parallel study was designed to compare 2 therapeutic strategies in patients with allergic rhinitis. The disease-specific Rhinoconjunctivitis Quality of Life Questionnaire total score, the symptom score, and the VAS score (0-10 cm) were all self-assessed by the patient before and after 2 weeks of treatment. Receiver operating characteristic curves and cost function were used to assess VAS cutoff scores and to distinguish between patients with no clinical improvement and patients with improvement in symptoms, quality of life, or both.

RESULTS

The optimal cutoff in VAS score change separating the patients without improvement from those with improvement is 0.30 cm. By using the cost of false-positive and false-negative results, a difference of more than 1 cm is significant. However, when patients show an improvement in both symptoms and Rhinoconjunctivitis Quality of Life Questionnaire scores, the median improvement on the VAS is 7 cm.

CONCLUSIONS

A VAS, when used for a global evaluation of rhinitis, is highly responsive to change during the treatment of a large number of patients in a cluster randomized pragmatic trial.

Evolution of patients with nonallergic rhinitis supports conversion to allergic rhinitis

BACKGROUND

Nonallergic rhinitis (NAR) affects a significant number of patients in clinical practice. However, the different entities involved within NAR require further study. Once allergy has been ruled out, most of these patients are not usually followed up in allergy clinics, despite the persistence of rhinitis symptoms. Thus few data are available concerning the natural evolution of these patients.

OBJECTIVE

We sought to re-evaluate over time the severity, accompanying disorders, and possible allergen sensitizations in subjects with NAR.

METHODS

A representative sample of 180 patients given diagnoses of NAR during 2000-2004 was re-evaluated in 2007 by using sociodemographic and clinical questionnaires, spirometry, skin prick testing, and measurement of specific IgE to common aeroallergens.

RESULTS

Patients with NAR generally experienced worsening disease (52%), with an increase in the persistence (12%) and severity of nasal symptoms (9%) and new comorbidities (24%) over time. The most frequent comorbidities at the re-evaluation were asthma (increasing from 32% to 55%) and conjunctivitis (from 28% to 43%), followed by chronic rhinosinusitis. Sensitization to aeroallergens not present at the initial evolution was detected by means of skin prick testing, serum specific IgE measurement, or both in 24% of the patients.

CONCLUSIONS

Persistent moderate-to-severe rhinitis associated with asthma, conjunctivitis, or both and sensitization to aeroallergens are likely to appear at a later date in adults initially given diagnoses of NAR. A periodic re-evaluation of these patients might therefore be necessary.

Control of asthma in children: still unacceptable? A French cross-sectional study

BACKGROUND

The goal of asthma management focuses on adequate control of asthma, although little is known about the optimal level of asthma control to be reached. The ELIOS study was conducted in France to address this lack of information.

METHODS

Cross-sectional study of asthmatic children (4-15 years) visiting their medical practitioner. The primary objective was to assess the level of asthma control with a 3-level composite score based on French (ANAES) guidelines criteria (optimal, acceptable, and unacceptable).

RESULTS

Asthma control was assessed in 3431 children and classified as optimal (26%), acceptable (41.3%), and unacceptable (32.7%). When PEFR was studied, asthma control was optimal in 23.0%, acceptable in 35.8% and unacceptable in 41.2% (p<0.001) of children. Unacceptable asthma control was significantly associated with higher BMI (p=0.002), more recent diagnosis of asthma (p=0.008), passive exposure to parental tobacco smoke (p<0.001), number of associated allergic diseases (p<0.001), frequent respiratory tract infections (p<0.001) and low socioeconomic status (p<0.001). Multivariate analysis identified presence of respiratory tract infections (p<0.0001), passive exposure to parental tobacco smoke (p=0.009) and low socioeconomic status (p=0.042) as variables associated with unacceptable asthma control.

CONCLUSIONS

There is room for improvement in France as only 25% of asthmatic children are optimally controlled. Public health strategies should increase awareness among physicians and parents about the importance of using asthma control tools, eliminating exposure to tobacco smoke and treating associated allergic diseases.

Clinical Immunology Review Series: An approach to the patient with allergy in childhood

Allergic conditions are common, with asthma being the most common chronic illness in childhood in most developed countries. Some 80% of asthmatic children are sensitized to aeroallergens, usually indoor animal dander and house dust mite. Some 80% of asthmatics also have rhinitis. Rhinitis and eczema receive less medical attention than asthma, but they can cause longterm morbidity and have substantial direct and indirect economic costs. Food allergy and anaphylaxis are increasingly recognised and are usually easily diagnosed and managed.Clinicians can use in vivo and in vitro measurements of allergen-specific immunoglobulin E to better time reintroduction of implicated foods. Specific parenteral and sublingual immunotherapy is widely practiced internationally but is uncommon in the UK. It may alter the natural history of aeroallergen reactive diseases in the upper and lower airways. Specific oral tolerance induction represents the current cutting edge in clinical allergy research. It remands resource intensive at present and cannot be adopted into routine clinical practice at this time.

Clinical efficacy and safety of a combined loratadine-betamethasone oral solution in the treatment of severe pediatric perennial allergic rhinitis

BACKGROUND

: Allergic rhinitis is a highly prevalent condition, particularly among children, whose schoolwork and quality of life may be impaired by its symptoms.

METHODS

: In this prospective, multicenter study, children between 6 and 12 years old with a diagnosis of severe perennial allergic rhinitis received a combination of the nonsedating antihistamine loratadine and the corticosteroid betamethasone in an oral solution for 5 days.

RESULTS

: The total nasal and ocular symptom score was significantly reduced from 11.4 (±2.1) before treatment to 2.9 (±2.4) after treatment (P < 0.01). Significant reductions (P < 0.01) were also observed for sneezing, nasal pruritus, nasal congestion, rhinorrhea, postnasal drip, and ocular erythema and pruritus. No adverse events were reported, and no subject discontinued treatment.

CONCLUSIONS

: The combination of loratadine and betamethasone in an oral solution was safe and effective as initial short-term treatment for symptoms of severe perennial allergic rhinitis in school-aged children.

Clinical and Immunological Correlates of Pre-Co-Seasonal Sublingual Immunotherapy with Birch Monomeric Allergoid in Patients with Allergic Rhinoconjunctivitis

Sublingual immunotherapy is safe and efficacious in the treatment of patients with allergic rhinitis. The clinical and biological efficacy of modified allergens (allergoids) has not been fully clarified. We investigated in birch allergic patients the effect of a pre-co-seasonal sublingual immunotherapy regimen with a modified allergen extract on clinical parameters and on T cell proliferation and regulatory cytokine production (IL-10, TGF-beta). We found that during the birch pollen season symptoms and drug usage scores were 30 and 40% improved, respectively, in treated versus control subjects (p<0.0001 for both comparisons) whereas well days were 23.5 (33%) versus 16.9 (23%) (p=0.0024), respectively. Bet v 1 allergen specific proliferation decreased (p = 0.0010), whereas IL-10 transcription increased (p = 0.0010) in treated, but not in control patients. Moreover, TGF-beta transcription was increased, although not significantly (p=0.066), following immunotherapy. Thus, sublingual immunotherapy with modified allergen in birch-allergic subjects was safe, clinically efficacious and associated with the reduction of allergen-specific proliferation and with the increased production of the IL-10 regulatory cytokine.

Persistent allergic rhinitis has a moderate impact on the sense of smell, depending on both nasal congestion and inflammation

OBJECTIVES/HYPOTHESIS

A degree of smell disturbance has been found in seasonal and perennial allergic rhinitis, but alterations in olfaction in patients with persistent allergic rhinitis (PER) have not yet been evaluated. The aims of the study were to evaluate the impact of PER on the sense of smell, and to characterize this impact based on self-reported hyposmia (SRH) and PER severity.

STUDY DESIGN/METHODS

A prospective controlled study was performed on 49 consecutive patients with PER. PER patients were subclassified depending on severity and the presence of SRH. Olfactory function was evaluated by the Barcelona Smell Test-24 (BAST-24) olfactometry for smell detection, identification, and forced choice for first and fifth cranial nerve (CN) dependent odors in comparison to a group of 60 healthy volunteers. In patients with SRH, obstruction was evaluated by peak nasal inspiratory flow (PNIF) and acoustic rhinometry; and nasal inflammation was evaluated by nasal nitric oxide (nNO).

RESULTS

Most patients with PER (67%) presented SRH. Moderate/severe PER (84.8%) predominated among patients with SRH, while mild PER (75%) predominated among patients without SRH. Smell detection, identification, and forced choice tests were significantly worse in PER patients (P < .05) than in healthy controls for the odors related to the first and fifth CN. Among subgroups, patients with moderate/severe PER and/or with SRH presented a significant reduction in smell detection (P < .05) compared to healthy controls. Nasal NO correlated (R: 0.4; P < .05) with loss of smell.

CONCLUSIONS

Patients with PER have a moderate loss of smell (BAST-24) with a higher impairment in those with self-reported hyposmia and moderate-to-severe PER. These results suggest that the sense of smell should be further investigated in all patients with allergic rhinitis, both in a clinical setting and in clinical trials.

Complexities of diagnosis and treatment of allergic respiratory disease in the elderly

Atopic diseases such as rhinitis and asthma are relatively common in children and young adults. However, many patients aged >65 years are also affected by these disorders. Indeed, the literature suggests that between 3-12% and 4-13% of individuals in this age range have allergic rhinitis and asthma, respectively. However, these numbers are most likely underestimates because atopic diseases are frequently not considered in older patients. The diagnosis of both allergic rhinitis and asthma in older patients is more difficult than in younger patients because of a wide differential diagnosis of other diseases that can produce similar symptoms and must be excluded. Furthermore, treatment of these disorders is complicated by the potential for drug interactions, concern about the adverse effects of medications, in particular corticosteroids, and the lack of drug trials specifically targeting treatment of older patients with allergic rhinitis and asthma.

Safety and tolerability of fluticasone furoate nasal spray once daily in paediatric patients aged 6-11 years with allergic rhinitis: subanalysis of three randomized, double-blind, placebo-controlled, multicentre studies

BACKGROUND

Fluticasone furoate is a novel enhanced-affinity corticosteroid that has demonstrated favourable safety and tolerability in paediatric patients. Three pivotal phase III studies were conducted in children as young as 2 years of age; however, because the European Medicines Agency has recently approved fluticasone furoate for use in children aged>or=6 years, a subanalysis has been conducted to support safety and tolerability in the 6- to 11-year age group.

METHODS

All three trials included in the subanalysis were randomized, double-blind, placebo-controlled, parallel-group studies: a 2-week US study in patients with seasonal allergic rhinitis (SAR), a 12-week global study in patients with perennial allergic rhinitis (PAR) and a 6-week US hypothalamic-pituitary-adrenal (HPA) axis safety study in patients with PAR. Randomized patients received once-daily treatment with either fluticasone furoate nasal spray (FFNS) 55 microg (n=297; 2-week SAR and 12-week PAR studies only), FFNS 110 microg (n=321) or vehicle placebo nasal spray (n=330). Safety assessments included clinical adverse event (AE) monitoring, clinical laboratory tests, detailed nasal examinations, monitoring of vital signs, and 12-lead ECGs. Ophthalmic examinations (12-week PAR study only) were conducted by an ophthalmologist or optometrist before randomization and at final treatment visit. Twenty-four-hour urinary cortisol (UC) excretions (6- and 12-week PAR studies) and serum cortisol (SC) concentrations (6-week PAR study only) were assessed at specified timepoints over 24 hours as a measure of HPA axis function. In the 6-week HPA axis safety study in patients with PAR, 24-hour UC and SC samples were collected in a domiciled (clinical) setting.

RESULTS

No unexpected safety results were observed in patients aged 6-11 years enrolled in the three studies. Across all three trials, AEs considered by the investigator to be drug related were observed in 10%, 7% and 8% of patients in the FFNS 55 microg, FFNS 110 microg and placebo groups, respectively. The most common AEs were headache (8%, 9% and 8% in the FFNS 55 microg, FFNS 110 microg and placebo groups, respectively), nasopharyngitis (5%, 6% and 5%, respectively), pharyngolaryngeal pain (5%, 3% and 4%, respectively), epistaxis (4% in both active treatment groups and 4% in the placebo group) and pyrexia (3% in both active treatment groups and 2% in the placebo group). Findings from nasal examinations were similar across the treatment and placebo groups. Ophthalmic examinations found no differences between the treatment groups for mean change from baseline in intraocular pressure (assessed in the 12-week PAR study only), and no posterior subcapsular cataracts were reported in patients in either FFNS-treatment group. In the 6-week HPA axis study, 24-hour SC geometric mean concentrations were similar for FFNS and placebo groups. The lower limit of two-sided 95% confidence interval (CI) for the treatment ratio was greater than the prespecified noninferiority margin of 0.8 (treatment ratio=0.92, 95% CI 0.80, 1.05).

CONCLUSIONS

FFNS has a favourable safety and tolerability profile in patients aged 6-11 years with PAR or SAR.

A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber

BACKGROUND

Studies on the efficacy of phenylephrine in the treatment of nasal congestion have yielded inconsistent results, notwithstanding its approval for this indication.

OBJECTIVE

To evaluate and compare the decongestant effect of a single dose of phenylephrine to placebo and pseudoephedrine in patients with seasonal allergic rhinitis.

METHODS

This randomized, placebo-controlled, 3-way crossover study evaluated patient-scored nasal congestion, peak nasal inspiratory flow, and rhinomanometry at more than 6 hours in 39 grass-sensitive patients exposed to grass pollen in the Vienna Challenge Chamber. Patients were dosed with immediate-release formulations of phenylephrine, 12 mg, pseudoephedrine, 60 mg, as a control, or placebo.

RESULTS

Phenylephrine was not significantly different from placebo in the primary end point, mean change in nasal congestion score at more than 6 hours (P = .56), whereas pseudoephedrine was significantly more effective than both placebo (P < .01) and phenylephrine (P = .01). Phase 1 results showed a difference between phenylephrine and placebo that was 64% of the difference between pseudoephedrine and placebo, substantially greater than the 17% difference observed for all phases. Carryover bias due to patient recall of the pseudoephedrine effect may have influenced these results. Rhinomanometry and peak nasal inspiratory flow results were consistent with these data. Neither phenylephrine nor pseudoephedrine had an effect on the nonnasal symptoms. No adverse events were reported in this study.

CONCLUSIONS

During a 6-hour observation period, a single dose of pseudoephedrine but not phenylephrine resulted in significant improvement in measures of nasal congestion. Neither phenylephrine nor pseudoephedrine had an effect on nonnasal symptoms.

Comparative safety and efficacy of 2 formulations of fluticasone aqueous nasal spray in persistent allergic rhinitis

BACKGROUND

There are few data on the clinical equivalence of different nasal corticosteroids in persistent allergic rhinitis (AR). Studies measuring plasma concentrations after a single dose may not predict relative systemic bioactivity at steady state.

OBJECTIVE

To compare a test formulation of fluticasone propionate with the innovator using a noninferiority design.

METHODS

Twenty-three patients with persistent AR were randomized to completion in a double-blind, placebo-controlled, crossover manner to receive the formulations at 200 microg/d for 4 weeks, with baselines measured after 2-week run-in and washout periods. The primary outcome measure was the Mini Rhinoconjunctivitis Quality of Life Questionnaire (MiniRQLQ) score.

RESULTS

Both formulations produced significant improvements in MiniRQLQ scores as change from baseline (P < .001), with a nonsignificant mean difference (test vs innovator) of -0.06 U (95% confidence interval [CI], -0.41 to 0.52 U) and the lower bound of the 95% CI being above the predefined noninferiority limit of -0.7 U. Both formulations produced significant improvements in peak nasal inspiratory flow rates as change from baseline (P < .01), with a nonsignificant mean difference of 0.5 L x min(-1) (95% CI, 9.8 to 10.8 L x min(-1)). There were also significant reductions in total nasal symptom scores (P < .01), with a nonsignificant mean difference of 0.4 U (95% CI, 0.3 to 1.1 U). No significant suppression of the 10-hour overnight urinary cortisol to creatinine ratio was seen with either formulation.

CONCLUSIONS

The test formulation was noninferior to the innovator for the primary outcome of MiniRQLQ score. The secondary efficacy and safety end points also support the interchangeability of the 2 formulations.

Determination of parameters related to nasal inspiratory pressures in children utilizing valved-holding chambers (valved spacers)

OBJECTIVE

The administration of medication by the nasal route using valved spacers, may be an alternative for the concomitant treatment of allergic rhinitis and asthma. The aim of this study was to determine if children are capable, in using a spacer and face mask, of opening the inspiratory valve using only nasal inhalation.

METHODS

Prospective cross-sectional. The study included 85 children aged 4-9 years. Four types of valved spacers connected to a digital vacuum manometer were evaluated. The patients were prompted to inhale through their nose and the pressure reached in the first curve, maximal peak and time between the start of the inspiratory action and the first effective inspiration (opening of the valve) were determined. The results were compared with factors such as age, weight, BMI, gender, and presence of rhinitis or asthma.

RESULTS

In two of the spacers, the valve opened in 98.8% of the tests with nasal inspiration only. The spacer ACE holding chamber showed initial and maximal inspiratory pressures that were significantly greater than with the others (p<0.001). No correlation was observed between the parameters examined for each spacer and the patient variables considered.

CONCLUSION

The results suggest that children 4-9 years old are able to open the spacer valve with only nasal inspiration. The spacer ACE holding chamber was shown to be significantly more effective than the others tested. Studies that demonstrate that air inspired nasally reaches the lungs effectively are necessary so that this airway can be utilized for the administration of therapeutic agents.

Impact of allergic rhinitis on asthma: effects on bronchial hyperreactivity

BACKGROUND

Remarkable relationship exists between upper and lower airways. Bronchial hyperreactivity (BHR) is a paramount feature of asthma and may be considered a strong risk factor for the onset of asthma in patients with allergic rhinitis.

OBJECTIVE

This study is aimed at evaluating the presence of BHR in a large group of patients with moderate-severe persistent allergic rhinitis alone, and at investigating possible risk factors related to severe BHR.

METHODS

Three hundred and forty-two patients with moderate-severe persistent allergic rhinitis were prospectively and consecutively evaluated. Clinical examination, skin prick test, spirometry and bronchial methacholine (MCH) test were performed in all patients.

RESULTS

Twenty-two (6.4%) patients had severe BHR, 74 (21.6%) patients had mild BHR and 192 (56.2%) had borderline BHR; 54 (15.8%) patients had a negative MCH test. The logistic regression analysis evidenced that trees and house dust mites sensitization (ORAdj: 8.1), rhinitis duration > 5 years (ORAdj: 5.4) and FEV1 < or = 86% of predicted (ORAdj: 4.0) were significantly associated with severe BHR. The discriminative ability of this model is appreciably satisfactory, being the AUC = 0.90.

CONCLUSION

This study highlights the close link between upper and lower airways and the role of some risk factors, such as tree and mite sensitization, > 5-year duration, and < or = 86% FEV1 values, as risk factors for severe BHR in patients with moderate-severe persistent allergic rhinitis alone. Therefore, BHR is frequently present in patients with chronic rhinitis and should be suspected in the presence of defined risk factors.