Patient characteristics and prescription fill patterns for allergic rhinitis medications, with a focus on montelukast, in a commercially insured population

Intranasal Azelastine and Fluticasone as Combination Therapy for Allergic Rhinitis: Systematic Review and Meta-analysis

Objective

Combination therapy with intranasal azelastine and fluticasone propionate is an option for treatment of allergic rhinitis. This systematic review and meta-analysis examines existing literature to determine efficacy in treating allergic rhinitis compared to monotherapy.

Data Sources

The PubMed, EMBASE, Cochrane, and MEDLINE databases were systematically searched for randomized controlled trials using AzeFlu nasal spray.

Review Methods

Randomized, controlled trials that reported symptom relief of allergic rhinitis in males and females of all ages were included. Results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard.

Results

Systematic review identified 8 articles suitable for review. The risk of bias was generally low. All studies exhibited a greater decrease in patient-reported symptom scores in patients treated with combination therapy compared to monotherapy or placebo. Meta-analysis revealed superiority of combination therapy in reducing Total Nasal Symptom Score compared to placebo (mean change from baseline: −2.41; 95% confidence interval [CI], −2.82 to −1.99; P < .001; I 2 = 60%), azelastine (mean change from baseline: −1.40; 95% CI, −1.82 to −0.98; P < .001; I 2 = 0%), and fluticasone (mean change from baseline: −0.74; 95% CI, −1.17 to −0.31; P < .001; I 2 = 12%).

Conclusion

Current evidence supports both efficacy and superiority of combination intranasal azelastine and fluticasone in reducing patient-reported symptom scores in patients with allergic rhinitis. Combination nasal spray should be considered as second-line therapy in patients with allergic rhinitis that is not controlled with monotherapy.

Montelukast use-a 19-year nationwide drug utilisation study

PURPOSE

Montelukast is a leukotriene receptor antagonist used in asthma and rhinitis treatment. Despite being marketed nearly two decades ago, little is known about its utilisation pattern.

METHODS

Using the Danish National Prescription Registry, we identified subjects filling a montelukast prescription between 1998 and 2017. Using descriptive statistics, we reported the development in incidence, and prevalence, as well as a measure of treatment duration, and concomitant use of asthma- or anti-allergic therapy.

RESULTS

We identified 147,247 individuals filling 1,327,489 montelukast prescriptions. A total of 54,349 users (37%) filled only one montelukast prescription. The prevalence increased from 0.9/1000 persons in 1998 to 3.3/1000 persons in 2016. The rate of new users reached its maximum of 2.1/1000 person-years in 2009. Among new montelukast users, 28% were still users after 1 year. Among all montelukast initiators, 60% filled at least one prescription of short-acting beta-2-agonists (SABA) up to a year prior to montelukast initiation, and 49% filled a prescription of inhaled corticosteroids (ICS). Only 0.8% (n = 1148) of all individuals initiated montelukast without a redeemed prescription of short- or long-term inhalation therapy, systemic antihistamines, or nasal topical anti-allergic treatment.

CONCLUSIONS

The usage of montelukast has increased over threefold since its market entry in 1998, mainly driven by an increased number of prevalent users. The majority of individuals who initiated montelukast filled a prescription of SABA up to a year prior to montelukast initiation, whereas almost half filled a prescription of ICS.

Medication Identification Among Caregivers of Urban Children With Asthma

OBJECTIVE

To determine caregiver ability to name their child's inhaled asthma medications, and examine whether perceived ease of remembering names is associated with accurate naming and asthma outcomes.

METHODS

As part of the School-Based Telemedicine-Enhanced Asthma Management trial in Rochester, New York, we asked caregivers of children with persistent asthma to: 1) name their child's inhaled medications, and 2) indicate agreement with the statement, "it is easy to remember the names of my child's asthma medications." We limited analyses to subjects with 1 inhaled medication. Reported names were compared with canisters available during a home visit; complete matches were considered concordant. We compared ease of remembering names with concordance, asthma symptoms, and adherence using bivariate and multivariate analyses.

RESULTS

Overall, 141 caregivers (87%) had children with 1 inhaled medication (62% black race, 68% Medicaid). Most (74%) perceived it easy to remember medication names, yet only 46% reported names concordant with medications at home. Caregivers who did not easily remember medication names were less likely to concordantly name available medications (23% vs 54%; P = .002), and more likely to report that their child experienced >2 symptom days per week (33% vs 16%; P = .03), >2 symptom nights per month (31% vs 12%; P = .02), and missed >1 dose(s) of preventive medication in the previous 2 weeks (52% vs 28%; P = .03). Findings were consistent in multivariate regression analyses.

CONCLUSIONS

Caregivers of urban children with persistent asthma who considered medication names difficult to remember were less able to accurately name available medications, and reported worse control and medication adherence. Greater attention to medication identification might improve outcomes in this population.

Montelukast Use and Patterns of Ambulatory Care among Asian versus Non-Asian Adult Patients with Asthma and/or Allergic Rhinitis in the United States

Background: Asthma and allergic rhinitis (AR) are inflammatory conditions that are similar in pathophysiology. Mild-to-moderate persistent asthma has been widely treated with inhaled corticosteroids, while allergic rhinitis is commonly treated with antihistamines, nasal corticosteroids, anticholinergics, and other allergy specific medications. The introduction of montelukast, a leukotriene receptor antagonist, has opened a treatment pathway that is common to both conditions. Previous real world studies of montelukast (Singulair®) relative to other medications have not investigated the role of race in the management of asthma and AR, specifically as relates to differences among Asian versus non-Asian patients. Objective: To contrast montelukast use and patterns of ambulatory care for adult Asian versus non-Asian patients in the United States with asthma and/or AR. Methods: Data for adult asthma and AR patients were extracted from a national electronic medical records database for the years 2006-2014. Patients were classified into condition cohort (Asthma-Only, AR-Only, Asthma & AR), and treatment condition (monotherapy or combination therapy, with or without montelukast for Asthma and Asthma & AR cohorts, usual care with or without montelukast for AR-Only) and stratified by race (Asian vs. non-Asian). Results: Overall patterns of use of montelukast were similar for Asian and non-Asian patients, but Asians were more likely to receive it as part of a combination therapy regimen. Changes in treatment regimen followed similar patterns for both groups. Asian patients with both asthma and AR were found to have lower service utilization rates if their therapy included montelukast, whereas for non-Asians there was no significant difference between regimens with or without montelukast. Conclusion: Differences in montelukast use and outcomes of care exist between Asian and non-Asian patients in the United States. Future research should explore the reasons for these differences and whether they can be replicated in non-US settings.

The ARGA study with Italian general practitioners: prescriptions for allergic rhinitis and adherence to ARIA guidelines

BACKGROUND

General practitioners (GPs) are the healthcare professionals to whom patients with rhinitis firstly refer for their symptoms.

OBJECTIVE

In the present study, we assessed drug prescriptions for allergic rhinitis (AR) and evaluated prescriptive adherence to ARIA treatment guidelines.

METHODS

Data on 1379 AR patients were collected by 107 Italian GPs. Adherence to ARIA guidelines was evaluated according to AR severity classification.

RESULTS

AR was diagnosed by GPs as mild intermittent for 46.2% of patients, mild persistent for 26.6%, moderate-severe intermittent for 20.2%, and moderate-severe persistent for 7%; 43.7% of AR patients had concomitant asthma. The most frequently prescribed therapeutic groups were antihistamines (anti-H, 76%) and nasal corticosteroids (NCS, 46%). Anti-H were significantly used more often to treat AR alone than AR + asthma (85 vs. 68%, p < 0.001), whereas NCS were used more often to treat AR + asthma than AR alone (50 vs. 42%, p = 0.01). Among patients with only mild intermittent AR, 39% were prescribed combined therapy. Among patients with moderate-severe persistent AR, 30% of those with AR alone and 18% of those with AR + asthma were prescribed monotherapy based on anti-H. GPs were more compliant with ARIA guidelines while treating AR alone (57%) than AR + asthma (46%) patients. The adherence increased according to the severity grade and was satisfactory for moderate-severe persistent AR (89% for AR alone and 95% for AR + asthma).

CONCLUSIONS

Adherence to ARIA guidelines is satisfactory only for treatment of more severe patients, thus GPs often tend to treat patients independently from ARIA guidelines. Since prescription data only provide limited information to judge prescribing quality, some deviation from the gold standard are to be expected.

Management of rhinitis: guidelines, evidence basis, and systematic clinical approach for what we do

Whereas very mild rhinitis may be simply and successfully self-managed by patients using medications available over the counter, most patients with rhinitis who present to medical offices have more severe rhinitis that may need a more comprehensive diagnostic and therapeutic approach. Optimal care may require special diagnostic studies and combination therapies that are arrived at only after trying multiple different medication and therapeutic options. This article presents a systematic approach to office care of rhinitis from the perspective of an allergist-immunologist. More emphasis is given to discussion of dilemmas that face the specialist or more involved considerations that have been highlighted in recently published guidelines.