Cost-effective pharmacotherapy for allergic rhinitis

Bacterial Colonization of Nasal Steroid Inhalers in Chronic Rhinosinusitis

Background

The aim of this study was to determine if nasal steroid inhalers harbor bacteria.

Methods

Nasal steroid inhalers were randomly selected from an adult patient population with chronic rhinosinusitis. Swab cultures of the tip of the nasal inhaler were obtained and submitted for microbiological analysis. Contemporaneous control cultures were obtained from freshly opened nasal steroid inhalers. Comparisons were conducted between bacterial recovery rates and types of organisms recovered from the patient and control groups.

Results

Among 31 nasal inhalers in use, 14 inhalers (45%) were found to harbor bacteria. The most common organisms were coagulase negative Staphylococci (11 inhalers) followed by oral flora (2 inhalers) and bacillus species (1 inhaler). None of the 10 control cultures were found to harbor bacteria. Nasal steroid inhalers in use were more likely to have bacterial colonization than new inhalers (p = 0.008, chi-square).

Conclusions

Nasal steroid inhalers may harbor pathogenic bacteria. Therefore, they may serve as a vehicle for subsequent reinfection.

Pharmacoeconomics of levocetirizine in allergic rhinitis and chronic idiopathic urticaria: considerations for the USA

BACKGROUND

Levocetirizine, a recent, second-generation oral antihistamine, was approved by the US FDA in May 2007 to treat symptoms of allergic rhinitis and chronic idiopathic urticaria.

OBJECTIVE

To review the economic literature for levocetirizine.

METHODS

Two reviewers conducted a systematic review of the literature to identify abstracts that met the inclusion criteria. Abstracts that were considered acceptable were retrieved with full text for further assessment.

RESULTS

A total of 82 potential studies were identified. After reviewing abstracts, 11 articles were preselected for potential inclusion. Of the 11 full-text articles, three articles met the inclusion criteria.

CONCLUSION

The pharmacoeconomic literature for levocetirizine was limited. The findings were consistent across the literature, suggesting levocetirizine improved outcomes, leading to incremental cost savings and cost-effectiveness. Since many of the available levocetirizine data come from European studies, differences in practice patterns and medical resources should be considered when extrapolating data to a US clinical setting.

Rhinologic pharmacotherapy in rhinoplasty

Rhinoplasty surgeons inevitably encounter therapeutic considerations in managing their patients, and a thorough understanding of nasal function, as well as of disorders of the nose and sinuses, is requisite for positive clinical outcomes. Patients suffering from allergic rhinitis are not precluded from undergoing rhinoplasty, whereas other disease processes may warrant an otolaryngologic evaluation before proceeding with surgery. A thorough medical history and examination elucidate sinonasal disease conditions that may not improve after septorhinoplasty but potentially could respond to pharmacologic therapy.

Radiofrequency for the treatment of allergic rhinitis refractory to medical therapy

OBJECTIVES/HYPOTHESIS

The ideal treatment for allergic rhinitis refractory to medical therapy is still lacking. The aim of the study is to evaluate the efficacy of turbinate surgery with radiofrequency for the treatment of allergic rhinitis that is unresponsive to medical therapy.

STUDY DESIGN

A prospective, nonrandomized clinical study.

METHODS

From February 2000 to April 2002, 108 consecutive patients (45 men and 63 women [mean age, 29.5 y]) with allergic rhinitis refractory to medical therapy who underwent radiofrequency turbinate surgery were enrolled in the study. Postoperative follow-up ranged from 12 to 26 months. A standard 0-to-10 visual analogue scale with an anchor was used to assess the pain and the allergic symptoms, including nasal obstruction, rhinorrhea, sneezing, itchy nose, and itchy eyes, preoperatively and postoperatively at the end of weeks 1 and 2 and months 1, 3, 6, and 12 after surgery. Statistical analysis was determined by repeated measures of ANOVA.

RESULTS

None of the 108 patients had obvious discomfort other than mild numbness over the premaxillary area (24 of 108 [22.2%]) during operation. Also, no adverse reactions including bleeding, infection, adhesion, or a worsening of allergic symptoms were encountered. One hundred one patients were included in the final statistical analysis. Only nine patients reported no improvement at all after treatment. The response rate of radiofrequency turbinate surgery for allergic rhinitis refractory to medical therapy was 91.1% (92 of 101). At 1 year after the treatment, the degree of nasal obstruction had changed on the visual analogue scale (mean +/- SD) from 6.84 +/- 2.09 to 2.47 +/- 1.60, an improvement of 63.9%. The degree of rhinorrhea had changed from 5.74 +/- 2.75 to 2.57 +/- 2.31, an improvement of 55.2%. The degree of sneezing had changed from 5.30 +/- 2.80 to 2.59 +/- 2.13, an improvement of 51.1%. The degree of itchy nose had changed from 3.74 +/- 3.16 to 1.82 +/- 2.27, an improvement of 51.3%. The degree of itchy eyes had changed from 3.17 +/- 3.09 to 1.68 +/- 2.38, an improvement of 47.0%. The visual analogue scale scores for nasal obstruction, rhinorrhea, sneezing, itchy nose, and itchy eyes decreased significantly with time, from preoperative scores to scores at 1 year after surgery. Other additional effects and improvements, including headache, lumpy throat, night cough, and tinnitus, were also reported by the patients. Most of the patients stated that they would consider repeating this procedure if necessary and would recommend the new method to their friends with the same problems.

CONCLUSIONS

The study demonstrates that radiofrequency appears to be an effective and safe tool for treating allergic rhinitis with poor response to medical therapy. In the future, radiofrequency has the potential to be one of the most popular surgical modalities for the treatment of allergic rhinitis refractory to medical therapy.

Effects of budesonide and fluticasone propionate in a placebo-controlled study on symptoms and quality of life in seasonal allergic rhinitis

BACKGROUND

Intranasal glucocorticosteroids are effective in seasonal allergic rhinitis. This study compared the efficacy of budesonide (Rhinocort Turbuhaler) and fluticasone propionate (Flixonase) in this respect.

METHODS

Patients (n = 280) were randomized to receive budesonide, 140 microg (delivered dose) once daily, fluticasone, 200 microg once daily, or matching placebos for 5 weeks. The primary efficacy variable was the change in combined nasal symptom (nasal blockage, runny nose, sneezing) scores. Quality of life was measured in 121 patients by means of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and the Short-form Health Survey (SF-36).

RESULTS

Both steroids significantly reduced combined nasal symptoms, compared with placebo. There was no significant difference between the two treatments. Substantial or total symptom control was achieved in 89.9% of the budesonide-treated patients, compared with 88.7% with fluticasone and 42.7% with placebo. Four of the five domains of the RQLQ were significantly improved with budesonide, whereas with fluticasone only two domains were improved. Budesonide significantly improved scores in five out of eight domains of the SF-36, whereas no domains were improved with fluticasone.

CONCLUSION

There was no significant difference in efficacy between budesonide and fluticasone in this study. However, greater improvements in quality of life were seen with budesonide than with fluticasone.

The cost of treating allergic rhinitis

Allergic rhinitis is a high-cost, high-prevalence disease. In the year 2000, over $6 billion was spent on prescription medications to treat this illness. Although it is not associated with severe morbidity and mortality, allergic rhinitis has a major effect on the quality of life of the more than 50 million Americans with this illness. Intranasal corticosteroids (INCS) and nonsedating antihistamines (NSAH) are the most common prescription medications for this disease. INCS are recognized as the most effective treatment regimen for chronic symptoms. NSAH are perceived as important in the treatment of patients with mild disease, or as add-on therapy to INCS. When the literature is reviewed, the INCS produce the greatest decrease in total nasal symptom scores, the largest effect size, when compared with NSAH. Both classes of medications produce similar effects on concurrent allergic conjunctivitis. Further recent studies indicate that the INCS are also superior when used on an as-needed basis, and that there is little clinical benefit from the addition of loratadine to intranasal fluticasone. INCS have lower average wholesale prices as a class than the NSAH. Since the INCS are the dominant medication in efficacy studies and cost less, cost-effectiveness studies always favor intranasal corticosteroids.

Anti-allergic activity of the Sophorae radix water extract in experimental animals

The water extract of Sophorae radix was tested for its preventive effects against cardiovascular anaphylaxis elicited in experimental animals. In actively sensitized pithed rats, the extract partially protected the animals from death resulting from antigen challenge. Of the cardiovascular changes observed during the anaphylaxis in the pithed animals, the initial pressor response was significantly attenuated by the extract. The extract also improved anaphylactic cardiac dysfunction in passively sensitized isolated guinea hearts: improvement was noted in the contractility, arrhythmic duration and lactate dehydrogenase elevation. The perfusion pressure change to antigen challenge was not altered by the extract in passively sensitized isolated mesenteric artery preparations. The extract however significantly inhibited homologous passive cutaneous anaphylaxis responses in rats. When examined in isolated guinea pig tracheal muscle, the extract did not influence at reasonable concentrations on the contraction elicited by three major anaphylactic mediators, histamine, leukotriene D4 and serotonin. These results suggest that the water extract of Sophorae radix possesses anti-anaphylactic effect in cardiovascular system, primarily acting on the heart not the peripheral resistance vessels.

Pharmaceuticals--cost or investment? An employer's perspective

Employers are becoming increasingly concerned about rising pharmaceutical costs. Are improved health and cost outcomes achieved as a result of increasing pharmaceutical costs? One should approach this issue with a holistic view that considers the overall impact that disease conditions have on health and productivity. To illustrate, we first identified the "top ten" most expensive physical and mental health concerns facing American businesses, using data from over 60 firms from the 1996 MarketScan Private Pay Fee-For-Service Research Database. For some of these top ten conditions, the literature already addresses the drug cost versus investment issue, with mixed results. For conditions in which uncertainty prevails and for other high-cost conditions, empirical analyses should address the drug cost versus investment issue to minimize the risk of a penny-wise and pound-foolish payment/coverage policy. A similar strategy should be applied to individual corporate diagnostic assessments.