The role of nasal corticosteroids in the treatment of rhinitis

Effectiveness of mobile health interventions to improve nasal corticosteroid adherence in allergic rhinitis: A systematic review

BACKGROUND

Mobile health interventions (MHI) offer the potential to help improve nasal corticosteroid (NCS) adherence in allergic rhinitis (AR). The aim of this systematic review was to summarise the current evidence on the effectiveness of MHI for improving NCS adherence in AR.

METHODS

We systematically searched MEDLINE, Embase and the Cochrane Central register of Controlled Trials (CENTRAL) for randomised controlled trials filtered for publication dates between 2010 and 2021. We evaluated the effects of MHI aiming to improve NCS adherence on self-management outcomes in AR and comorbid conditions. Two reviewers independently screened potential studies, extracted study characteristics and outcomes from eligible papers and assessed risk of bias using the Cochrane Risk of Bias tool 2.0. High heterogeneity precluded meta-analysis. Data were descriptively and narratively synthesised.

RESULTS

Our searches identified 776 individual studies of which 4 met the inclusion criteria. These studies were heterogeneous with respect to participant, intervention and outcome characteristics. We considered all outcome-specific overall risk of bias assessments to be of high risk of bias except for two studies examining NCS adherence which received 'some concern' grades. The three studies which reported on NCS adherence found that MHI were associated with improvement in NCS adherence. Significant MHI-associated improvement in symptoms or disease-specific quality of life was found in one study each, whilst no study reported significant differences in nasal patency.

CONCLUSIONS

Whilst MHI showed potential to improve NCS adherence, their effect on clinical outcomes varied. Furthermore, robust studies with longer intervention durations are needed to adequately assess effects of MHI and their individual features on NCS adherence and clinical outcomes.

miR-124-3p relieves allergic rhinitis by inhibiting dipeptidyl peptidase-4

MicroRNA-124-3p (miR-124-3p) and dipeptidyl peptidase-4 (DPP4) are closely related to the development of inflammation. Allergic rhinitis (AR) models in mice and HNEpC cells were established. AR progression was assessed assessing by the frequency of nasal rubbing and sneezing, hematoxylin and eosin (HE), and TUNEL staining. Tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), granulocyte-macrophage colony-stimulating factor (GM-CSF), eotaxin, and MUC5AC were assessed by enzyme-linked immunosorbent assay and quantitative reverse-transcription polymerase chain reaction (qRT-PCR). Apoptosis in HNEpC cells was assessed using flow cytometry. DPP4, activated-caspase-3, and pro-caspase-3 protein expression were evaluated by western blotting. In addition, we clarified the influence of miR-124-3p-targeted DPP4 on AR inflammation and cell injury. MiR-124-3p was downregulated in AR nasal mucosa tissue. Upregulation of miR-124-3p reduced the frequency of nasal rubbing and sneezing, pathological changes, eosinophil number, and apoptosis of nasal mucosa, TNF-α and IL-6 protein and mRNA levels in serum and HNEpC cells, and MUC5AC, eotaxin, and GM-CSF levels in HNEpC cells. Downregulation of miR-124-3p has the opposite effect. Therefore, the miR-124-3p /DPP4 axis may be an attractive target for AR therapy.

Efficacy of sodium hyaluronate in relieving nasal symptoms of children with intermittent allergic rhinitis: a randomized controlled trial

PURPOSE

Nasal irrigation is recommended as add-on therapy in patients with intermittent allergic rhinitis (AR). We aimed to evaluate the clinical efficacy of adding hyaluronic acid (HA) or normal saline solution (NSS) to nasal corticosteroid (NC) therapy as add-on therapy in improving quality of life and reducing nasal symptom scores of children with intermittent AR compared to NC therapy.

METHOD

In this 28-day long, open-label, randomized controlled trial, one puff of NC was administered once a day through both nostrils of 76 children with SAR (6-12 years old), whose Total Nasal Symptom Score (TNSS) was ≥ 4. Twenty-six patients received NC only (Group 1); 24 patients received NSS (Group 2), and 26 patients received HA (Group 3) twice a day by means of nasal douche device. Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ) and TNSS were measured as subjective parameters, and nasal eosinophil count (NEC) in nasal cytology, nasal airflow (NAF), and resistance were measured as objective parameters.

RESULTS

No significant difference was found in post-treatment between groups in terms of TNSS, PRQLQ, and NEC values. Mean values of post-treatment left NAF of the groups were significantly different (p = 0.030), and the mean value of Group 3 was the highest (mean ± SD = 247.62 ± 155.8 ccm/sn). In comparing pre- and post-treatment intragroup mean total NAR (TNAR) values, a statistically significant decrease was recorded only in group three (p = 0.025).

CONCLUSION

The addition of HA to NC as an adjunct therapy in children with intermittent AR has limited beneficial effects in our study and deserves further investigation.

TRIAL REGISTRY

The clinical trial registration number ID:NCT04752956.

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Benefits and harm of systemic steroids for short- and long-term use in rhinitis and rhinosinusitis: an EAACI position paper

Because of the inflammatory mechanisms of most chronic upper airway diseases such as rhinitis and chronic rhinosinusitis, systemic steroids have been used for their treatment for decades. However, it has been very well documented that—potentially severe—side-effects can occur with the accumulation of systemic steroid courses over the years. A consensus document summarizing the benefits of systemic steroids for each upper airway disease type, as well as highlighting the potential harms of this treatment is currently lacking. Therefore, a panel of international experts in the field of Rhinology reviewed the available literature with the aim of providing recommendations for the use of systemic steroids in treating upper airway disease.

Anti-inflammatory effects of intranasal cyclosporine for allergic rhinitis in a mouse model

BACKGROUND

Although topical corticosteroids are considered a safe and effective drug for allergic rhinitis (AR), some AR patients do not show sufficient symptomatic improvement by use of topical corticosteroids. Topical cyclosporine is a safe and effective drug for patients with allergic conjunctivitis, particularly for those with steroid-resistant allergic conjunctivitis. We investigated the anti-inflammatory effects of intranasal cyclosporine for AR using a mouse model.

METHODS

After establishment of allergic inflammation in 5-week-old BALB/c mice, cyclosporine was administered intranasally 3 times per week for 2 weeks. To confirm its anti-inflammatory effects, triamcinolone acetonide (TAC) was utilized as a control drug. Histopathologic changes were evaluated using Sirius red and Giemsa staining for eosinophilic and mast cell infiltration, respectively. The levels of cytokines in sinonasal tissues, including tumor necrosis factor (TNF), interleukin (IL)-4, IL-5, and IL-13, were assessed based on a cytometric bead array.

RESULTS

The degree of eosinophilic infiltration was significantly decreased by instillation of cyclosporine, the potency being similar to TAC. However, the number of mast cells was not decreased by cyclosporine or TAC. The levels of TNF, IL-4, IL-5, and IL-13 were significantly decreased after treatment with cyclosporine.

CONCLUSION

The anti-inflammatory effects of topical cyclosporine for AR were equivalent to those of topical corticosteroids. Topical cyclosporine may be useful for the treatment of AR, although human studies are required.

Clinical Efficacy of Nasal Steroids on Nonallergic Rhinitis and the Associated Inflammatory Cell Phenotypes

Background

Although good response to nasal steroid therapy has been documented in allergic rhinitis (AR), the efficacy of this treatment in non-AR, and the associated inflammatory cell phenotypes has not been fully investigated.

Objective

To compare the response to steroids in non-AR versus AR and to assess the impact of inflammatory cell phenotypes on non-AR treatment outcomes.

Methods

A total of 149 patients with rhinitis were divided into non-AR and AR groups by using the allergy skin-prick test. Based on nasal cytology, the non-AR group was further divided into inflammatory non-AR (INAR) and noninflammatory non-AR (NINAR) groups, and the INAR groups were further subdivided into four phenotypes according to inflammatory cell type: non-AR with eosinophils (NARES), non-AR with mast cells (NARMA), non-AR with neutrophils (NARNE), and NARES and mast cells (NARESMA). All the patients were treated over 28 days with 220 μg of nasal triamcinolone acetonide once daily. Nasal symptom score, peak inspiratory flow index, and nasal mucociliary clearance time (NMCCT) were used to evaluate treatment outcomes.

Results

The initial screening found 67 patients with non-AR and 82 patients with AR. At 28 days after nasal steroid treatment, all nasal symptom score, peak inspiratory flow indexes, and NMCCTs were significantly improved within each group; however, the non-AR group recorded significantly lower levels of improvement in blocked nose, rhinorrhea, sneezing, nasal itching, peak flows, and NMCCTs than the AR group. The NINAR group overall indicated lower levels of improvement than the INAR group. Among the INAR subgroups, the NARESMA, NARES, and NARMA phenotypes had similar outcome improvements, all better than the NARNE phenotype.

Conclusion

Although both patients with non-AR and those with AR had good steroid response, the patients with non-AR had less improvement than the patients with AR. Patients with NINAR had the worst treatment outcome among the non-AR phenotypes.

Allergic rhinoconjunctivitis in the Australian population: burden of disease and attitudes to intranasal corticosteroid treatment

BACKGROUND

Allergic rhinoconjunctivitis (AR/C) is a global health problem causing significant morbidity and has a major impact on quality of life (QOL) and health expenditure. Despite the widespread prevalence, the overall health impact of AR/C may be underappreciated. The results of a survey designed to capture the burden of allergic rhinitis within the Asia-Pacific region have been published recently. Of particular note when evaluating treatment in this region was the fact that despite the value of intranasal corticosteroid (INCS) use, only a small percentage of patients used them. Whether this same trend is present within the population of Australian sufferers is unknown. This study examines the burden of AR/C and explores use of, and attitudes, to INCS sprays in the Australian population.

METHODS

Three hundred three completed interviews from adults and children who had physician-diagnosed AR/C and who were symptomatic or had received treatment in the previous 12 months were analyzed for QOL measures and attitudes to INCS use.

RESULTS

Most patients surveyed had received their diagnosis from a general practitioner (GP), and in most cases, a GP provided the majority of ongoing medical care. Only 8% of respondents had consulted a relevant specialist. Diagnostic tests had not been performed in 55% of respondents. The major symptoms causing most distress were nasal congestion and ocular symptoms. The burden of AR/C was considerable; 42% described significant work or school interference because of symptoms, one-third reporting moderate-to-extreme interference with sleep. Despite the significant impact on QOL reported by this sample, 17% had never used INCS and 27% had not used them in the previous 12 months. Respondents' knowledge about INCSs was poor.

CONCLUSION

AR/C is a common disease associated with significant morbidity and impairment of QOL. Improvement in diagnosis, management, and patient education is needed.

Inhalational Steroids and Iatrogenic Cushing's Syndrome

Bronchial asthma (BA) and Allergic rhinitis (AR) are common clinical problems encountered in day to day practice, where inhalational corticosteroids (ICS) or intranasal steroids (INS) are the mainstay of treatment. Iatrogenic Cushing syndrome (CS) is a well known complication of systemic steroid administration. ICS /INS were earlier thought to be safe, but now more and more number of case reports of Iatrogenic Cushing syndrome have been reported, especially in those who are taking cytochrome P450 (CYP 450) inhibitors. Comparing to the classical clinical features of spontaneous Cushing syndrome, iatrogenic Cushing syndrome is more commonly associated with osteoporosis, increase in intra-ocular pressure, benign intracranial hypertension, aseptic necrosis of femoral head and pancreatitis, where as hypertension, hirsuitisum and menstrual irregularities are less common. Endocrine work up shows low serum cortisol level with evidence of HPA (hypothalamo-pituitary-adrenal) axis suppression. In all patients with features of Cushing syndrome with evidence of adrenal suppression always suspect iatrogenic CS. Since concomitant administration of cytochrome P450 inhibitors in patients on ICS/INS can precipitate iatrogenic CS, avoidance of CYP450 inhibitors, its dose reduction or substitution of ICS are the available options. Along with those, measures to prevent the precipitation of adrenal crisis has to be taken. An update on ICS-/INS- associated iatrogenic CS and its management is presented here.

Characterisation of interleukin-10 expression on different vascular structures in allergic nasal mucosa

BACKGROUND

Interleukin-10 (IL-10) is a negative regulator of immune responses and was previously shown to be expressed by human nasal endothelial cells, while the adhesion molecule MECA-79 plays a role in trans-endothelial migration of immune competent cells. In this study we investigate the relationship between endothelial IL-10 and MECA-79 expression to address the question whether immune competent cells could be affected at the mucosal entry site.

METHODS

Nasal turbinate biopsies were taken from house dust mite allergic patients, before and after nasal allergen provocation. Subsequent slides of biopsies were stained for IL10, MECA-79, CD34, and IL10-Receptor. Capillaries, arteries/veins, and sinusoids were evaluated separately.

RESULTS

90% of sinusoids are IL-10 positive and all sinusoids are negative for MECA-79, while 4.8% of capillaries are positive for IL-10, and 2.2% are positive for MECA-79. Although about 47% of arteries/veins are positive for IL-10 and 57.1% are positive for MECA-79, only about 20% are positive for both markers. Furthermore, we showed that the myo-fibroblasts surrounding all sinusoids stain positive for IL10R.

CONCLUSIONS

IL10 expression on vascular structures is not related to MECA expression for sinusoids and capillaries and only partly related on arteries/veins, however sinusoidal endothelial IL10 expression is always seen in combination with IL-10R expression of sinusoidal myo-fibroblasts.

Fumigation in Ayurveda: potential strategy for drug discovery and drug delivery

ETHNOPHARMACOLOGICAL RELEVANCE

Ayurveda has its unique perceptions and resultant methodologies for defining and treating human diseases. Fumigation therapy is one of the several treatment methods described in Ayurveda whereby fumes produced from defined drug formulations are inhaled by patients. This therapeutic procedure offers promising research opportunities from phytochemical and ethnopharmacological viewpoints, however, it remains under-noticed. Considering these facts, this review is primarily aimed at introducing said Ayurvedic fumigation therapy and discussing its scientific gaps and future challenges.

METHODOLOGY

A search of multiple bibliographical databases and traditional Ayurvedic text books was conducted and the articles analyzed under various key themes, e.g., Ayurvedic fumigation, fumigation therapy, medicinal fumigation, inhalation of drugs and aerosol therapy.

RESULT

Ayurveda recommends fumigation as a method of sterilization and therapeutic procedure for various human diseases including microbial infections and psychological disorders. However, it has not gained much attention as a prospective field with multiple research opportunities.

CONCLUSION

It is necessary to have a more detailed and systematic investigation of the phytochemical and pharmacodynamic properties of Ayurvedic fumigation therapy in order to facilitate the identification of novel bioactive compounds and more effective drug administration methods.

Inhaled Cissampelos sympodialis down-regulates airway allergic reaction by reducing lung CD3+ T cells

Cissampelos sympodialis Eichl. (Menispermaceae) root infusion is used in Northeast Brazil to treat allergic asthma. We have previously shown that oral use of the plant extract reduces eosinophil infiltration into the lung of ovalbumin (OVA)- sensitized mice. However, drugs taken by inhalation route to treat asthma achieve better outcomes. Thereby, in this study, we evaluated the inhaled C. sympodialis alcoholic extract as a therapeutic treatment in OVA-sensitized BALB/c mice. The parameters which were analyzed consisted of leukocyte recruitment to the airway cavity, tissue remodeling and cell profile. The inhaled extract inhibited mainly eosinophil recruitment to the pleural cavity, bronchoalveolar lavage and peripheral blood. This treatment reduced the OVA-specific IgE serum titer and leukocyte infiltration in the peribronchiolar and pulmonary perivascular areas as well as mucus production. In addition, we also tested isolated alkaloids from the plant extract. The flow cytometric analysis showed that methylwarifteine (MW) and, mainly, the inhaled extract reduced the number of CD3+T cells and eosinophil-like cells. Therefore, inhaled C. sympodialis extract and MW lead to down-regulation of inflammatory cell infiltration with remarkable decrease in the number of T cells in an experimental model of respiratory allergy, suggesting that the plant can be delivered via inhalation route to treat allergic asthma.