[Antileukotrienes and Churg-Strauss syndrome]

Advances in the pharmacotherapeutic management of eosinophilic granulomatosis with polyangiitis

INTRODUCTION

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare but potentially lethal systemic vasculitis. Only a few prospective therapeutic trials had been conducted in EGPA, and its treatment was mostly adapted from other vasculitides. Monoclonal antibodies inhibiting various pathways (e.g. interleukin-5 [IL5] or B cells) have been investigated.

AREAS COVERED

Published studies on treatments for EGPA using glucocorticoids, conventional immunosuppressants (such as cyclophosphamide or azathioprine), antiIL5 pathway agents (mepolizumab, approved by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) for EGPA; benralizumab and reslizumab), other and future possible treatments [PubMed search, 01/1990-02/2023] are reviewed.

EXPERT OPINION

With advances made in the pharmacotherapeutic management of EGPA, the prognosis has gradually shifted from a potentially fatal to a more chronic course, for which more targeted and safer treatments can be used. However, glucocorticoids remain central. Rituximab is now a possible alternative to cyclophosphamide for induction, although data are still limited. AntiIL5 pathway therapies have been shown to be safe and effective in relapsing patients with EGPA, who often experience asthma and/or ears, nose, and throat (ENT) manifestations, but long-term data are needed. Treatment strategies need to be optimized based on individual patient characteristics, likely with sequential, combination-based approaches, while topical airway treatments should not be forgotten.

Ethnic differences in adverse drug reactions to asthma medications: a systematic review

BACKGROUND

Information on ethnic diversity of adverse drug reactions (ADRs) to asthma medications is rare despite evidence suggesting higher risk for African Americans when using β2-adrenergic receptor agonists. The objectives are to investigate how ethnic background was involved in ADR assessment and to examine the relationship between ethnic background and ADRs to asthma medications.

METHODS

MEDLINE was searched until March 2014. All types of studies reporting ADRs to asthma medications involving more than one ethnic group were included. Extracted information includes study designs, ethnic backgrounds, intervention, and types and severities of ADRs.

RESULTS

Among the selected 15 randomised clinical trials, six pooled analyses of randomized clinical trials, and five prospective observational studies, only six studies compared ADRs across different ethnic groups. The majority of the comparisons were either statistically insignificant or inconclusive.

CONCLUSIONS

Ethnicity was largely overlooked. Most studies neglected to report ADRs by ethnicity. Lack of consistency in defining ethnicities complicated further pooled analyses. Despite the higher prevalence of asthma among specific ethnic minority groups, few studies disaggregated information by ethnic background, and reports of ADRs to asthma medications in different ethnic groups were rare. We suggest that the inclusion of ADR analysis by different ethnic backgrounds is desirable.

Exercise-induced bronchoconstriction: The effects of montelukast, a leukotriene receptor antagonist

Exercise-induced bronchoconstriction (EIB) is very common in both patients with asthma and those who are otherwise thought to be normal. The intensity of exercise as well as the type of exercise is important in producing symptoms. This may make some types of exercise such as swimming more suitable and extended running more difficult for patients with this condition. A better understanding of EIB will allow the physician to direct the patient towards a type of exercise and medications that can result in a more active lifestyle without the same concern for resulting symptoms. This is especially important for schoolchildren who are usually enrolled in physical education classes and elite athletes who may desire to participate in competitive sports. Fortunately several medications (short- and long-acting beta(2)-agonists, cromolyn, nedocromil, inhaled corticosteroids, and more recently leukotriene modifiers) have been shown to be effective in preventing or attenuating the effects of exercise in many patients. In addition, inhaled beta(2)-agonists have been shown to quickly reverse the airway obstruction that develops in patients and continue to be the reliever medications of choice. Inhaled corticosteroids are increasingly being recommended as regular therapy now that the role of inflammation and airway injury has been identified in EIB. With the discovery that there is a release of mediators such as histamine and leukotrienes from cells in the airway following exercise with resulting airway obstruction in susceptible individuals, interest has turned to attenuating their effects with mediator antagonists especially those that block the effects of leukotrienes. Studies with an oral leukotriene antagonist, montelukast, have shown beneficial effects in adults and children aged as young as 6 years with EIB. These effects can be demonstrated as soon as two hours and as long as 24 hours after administration without a demonstrated loss of a protective effect after months of treatment. The studies leading up to and resulting in an approval of montelukast for EIB for patients aged 15 years and older are reviewed in this paper.