Glucocorticosteroids in allergic inflammation: clinical benefits in allergic rhinitis, rhinosinusitis, and otitis media

Intranasal Corticosteroids: Topical Potency, Systemic Activity and Therapeutic Index

Intranasal corticosteroid (INCS) therapy is the preferred treatment option for allergic rhinitis (AR). Although all INCSs for the treatment of AR are considered safe and effective, differences in potency, molecular structure features and physicochemical and pharmacokinetic properties could result in differences in clinical efficacy and safety. Higher glucocorticoid receptor (GR) binding affinity of INCS is associated with higher lipophilicity, nasal tissue retention and topical potency. Higher topical potency is also accompanied by low oral bioavailability and high systemic clearance conferring low systemic exposure, reduced potential for systemic adverse effects and an improved therapeutic index. It has been shown that adverse events related to systemic exposure of INCSs in children are low. Although INCSs mostly produce low systemic effects, use of an INCS with low systemic exposure in patients on multiple corticosteroid (CS) therapies could help reduce the total systemic burden of CS therapy. Despite differences in topical potency, physicochemical and pharmacokinetic properties between INCSs, clinical studies of INCSs in the treatment of AR generally show no clinically important differences between these compounds, and poor correlation between INCS topical potency and clinical response. However, the lack of head-to-head comparisons of INCSs in clinical studies conducted in more severe AR patients should be noted. This narrative review provides an assessment of the therapeutic relevance of topical potency and the physicochemical and pharmacokinetic properties of INCSs and describes for the first time the relationship between topical potency and therapeutic index using pharmacological features of INCSs. It concludes that higher GR binding affinity and topical potency can potentially improve the therapeutic index of an INCS. Therefore, both efficacy and systemic exposure profiles should be considered when comparing INCS regimens in terms of therapeutic equivalence, to aid clinical decision-making and avoid the assumption that all INCS formulations are the same when considering treatment options.

The Efficacy of Corticosteroids in the Treatment of Peritonsillar Abscess: A Meta-Analysis

Despite widespread use of antibiotics and surgical procedures for treating peritonsillar abscess (PTA), symptoms of severe inflammation such as pain and trismus during treatment result in patient dissatisfaction. The goal of this study was to perform a systematic review and meta-analysis of the efficacy of systemic steroids on the clinical course of PTA. Two reviewers independently searched the databases (MEDLINE, Scopus, and the Cochrane Database) from inception to December 2014. Studies comparing systemic administration of steroids (steroid group) with placebo (placebo group), where the outcomes of interest were pain, body temperature, hospitalization, and oral intake during the posttreatment period, were included. Baseline study characteristics, study quality data, numbers of patients in the steroid and control groups, and outcomes were extracted. Sufficient data for meta-analysis were retrieved for 3 trials with a total of 153 patients. Pain-related parameters (patient-reported scores and trismus), body temperature, and dysphagia during the first 24 hours after treatment were significantly improved in the steroid group compared with placebo group. The discharge rate during the first 5 days of the posttreatment period was significantly higher in the steroid group than the control group. However, although more patients in the steroid group returned to normal activities and dietary intake at 24 hours after treatment, the differences between the groups were not significant and disappeared after 48 hours. In the treatment of PTA, systemic administration of steroids with antibiotics could reduce pain-related symptoms, as well as provide a benefit with respect to the clinical course. However, further trials with well-designed research methodologies should be conducted to confirm our results.

Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report

Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.

Topical triamcinolone acetonide/carboxymethylcellulose foam for acute exacerbations of chronic rhinosinusitis/nasal polyposis

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRS/NP) is a medical disease that is managed more effectively after endoscopic sinus surgery (ESS). Despite topical treatment with intranasal steroids, acute inflammatory exacerbations (AEs) are common and are typically treated with oral prednisone, which has significant and well-documented side effects. The objective of the current study was to critically evaluate the topical application of triamcinolone acetonide (80) in carboxymethylcellulose (TA/CMC) foam for AEs in CRS/NP patients after ESS.

METHODS

CRS/NP patients managed with ESS by a single rhinologist over a 5-year period were included in the study. Data were reviewed regarding demographics, number of AEs, revision surgery, 22-item Sino-Nasal Outcomes Test (SNOT-22) scores, frequency of oral prednisone and/or TA/CMC, and notable side effects.

RESULTS

A total of 371 CRS/NP patients were treated with ESS over a 5-year period. Mean follow-up was 49.3 weeks (range, 2-249 weeks). During this time period, 130 patients (46 years; range, 28-48 years) developed a cumulative 267 AEs. Before initiating use of TA/CMC in 2010, 66 AEs were treated with prednisone. Subsequently, 116 of 201 AEs were managed with TA/CMC with a sequential decrease in prednisone use over the last 3 years (77, 39, and 32%). SNOT-22 scores (n = 33) decreased significantly after TA/CMC instillation (preinstillation, 1.69 ± 0.86, versus postinstillation, 1.23 ± 0.8; p < 0.01).

CONCLUSION

Management of AEs with TA/CMC decreased overall prednisone use in a large population of CRS/NP patients in this retrospective evaluation. TA/CMC appears well tolerated and is a useful treatment option for AEs in postoperative CRS/NP patients.

Fluticasone furoate nasal spray in the treatment of allergic rhinitis

Allergic rhinitis (AR) is a prevalent disease with great morbidity and significant societal and economic burden. Intranasal corticosteroids are recommended as first-line therapy for patients with moderate-to-severe disease, especially when nasal congestion is a major component of symptoms. To compare the efficacy and safety profile of different available intranasal corticosteroids for the treatment of AR, it is important to understand their different structures and pharmacokinetic and pharmacodynamic properties. Knowledge of these drugs has increased tremendously over the last decade. Studies have elucidated mechanisms of action, pharmacologic properties, and the clinical impact of these drugs in allergic respiratory diseases. Although the existing intranasal corticosteroids are already highly efficient, the introduction of further improved formulations with a better efficacy/safety profile is always desired. Fluticasone furoate nasal spray is a new topical corticosteroid, with enhanced-affinity and a unique side-actuated delivery device. As it has high topical potency and low potential for systemic effects, it is a good candidate for rhinitis treatment.

Safety of intranasal corticosteroids in acute rhinosinusitis

Treatment guidelines for acute rhinosinusitis (RS) recommend the use of intranasal corticosteroids (INSs) as monotherapy or adjunctive therapy. However, the adverse event (AE) profiles of oral glucocorticoids, which result largely from the systemic absorption of those agents, have engendered concerns about the safety of INSs. These concerns persist for INSs despite significant or marked clinical differences between them and systemic corticosteroids in systemic absorption and among the INSs in bioavailability, mechanism of action, and lipophilicity, which may contribute to differences in AEs. For example, the systemic bioavailability of the INSs as a percentage of the administered drug is less than 0.1% for mometasone furoate, less than 1% for fluticasone propionate, 46% for triamcinolone acetonide, and 44% for beclomethasone dipropionate. A review of the safety profiles of INSs, as reported in clinical trials in acute and chronic RS and allergic rhinitis, shows primarily local AEs (eg, epistaxis and headache) that are generally classified as mild to moderate, with occurrence rates that are similar to those with placebo. Studies of the safety of mometasone furoate, fluticasone propionate, budesonide, and triamcinolone acetonide did not identify any evidence of systemic AEs, such as growth retardation in children due to suppression of the hypothalamic-pituitary-adrenal axis, bone mineral density loss, or cataracts, which suggests that INSs can be safely administered in patients with acute RS without concern for systemic AEs.

Increased risk of otitis media with effusion in allergic children presenting with adenoiditis

Objective

Otitis media with effusion (OME) is a common disorder in childhood. The aim of the study was to assess the association of atopy and endoscopic features with the presence of OME.

Subjects and Methods

This cross-sectional study evaluated 287 children presenting with acute upper-airway infections persistent for at least ten days and tested through nasal endoscopy and skin-prick test.

Results

Fifty-three patients had a diagnosis of OME; out of them, 23 showed acute rhinosinusitis, ten adenoiditis, and 20 both features. OME was diagnosed in 26 atopic children and in 27 nonatopic ones. On a multivariable analysis, allergic rhinitis, endoscopic pattern of adenoiditis, and younger age were all shown to be independently associated with a diagnosis of OME.

Conclusions

This study suggests that allergic rhinitis and adenoiditis are significant risk factors to OME development and that the risk becomes higher when these two conditions are con-comitantly present.

The links between allergy and otitis media with effusion

PURPOSE OF REVIEW

In this review we will examine evidence indicating that allergic inflammation is present in middle ear effusion. We will also discuss several of the problems relating to the diagnosis of allergy and allergic sensitization, and why anti-allergy treatments have been unsuccessful. This will provide a rationale for future studies in the field linking allergic inflammation with otitis media with effusion.

RECENT FINDINGS

Recent findings in atopic children demonstrated higher levels of eosinophils, T lymphocytes, and interleukin-4+ and interleukin-5+ cells compared with nonatopic patients. T-helper 2 cells and cytokines were found not only in middle ear effusions in atopic children but also in specimens from adenoid tissue. This demonstrates a strong correlation between allergic reaction in the middle ear and the upper airway.

SUMMARY

In summary, as our knowledge of the allergic and nonallergic influences on inflammation broadens, the paradigms of treatment may be altered. The accumulating experimental and clinical data suggest that it may be wiser to screen every child with otitis media with effusion for allergic rhinitis and ultimately to manage those with allergic inflammation differently to nonatopic individuals with otitis media with effusion.

Glucocorticosteroids in allergic inflammation: clinical benefits in otitis media with effusion

Allergy and otitis media with effusion are often considered as comorbidities. Evidence points to a role for allergy in the pathogenesis of otitis media with effusion in reports of increased prevalence of allergy in patients with otitis media with effusion and presence of late-phase allergic-response inflammatory mediators and cytokines in the middle-ear effusion of allergic subjects. However, the exact mechanism remains unknown. Many speculations have been made, but well-controlled studies to prove the efficacy of anti-allergic medication in the treatment of otitis media with effusion are lacking. Therefore, we do not recommend the use of glucocorticosteroids in allergic patients with otitis media with effusion.

Los glucocorticoides y el rendimiento deportivo

There are endogenous and exogenous glucocorticoids whose hormonal properties are derived from hydrocortisone. The physiological and pharmacological effects of the glucocorticoids are antiinflammatory and immunosuppressor, basically. As other drugs, they have secondary effects, which are minimum when the prescription is correct and controlled by a medical doctor. Although antiinflammatory, antialgic, anxiolytic, and antiasthenic effects have been described in corticosteroids, all these effects have been seen at patients at rest and there is no study to confirm these effects in subjects that do exercise. These studies that tend to analyze the effects of corticosteroids on sport's performance have concluded that there is not any improvement of performance.