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Richards GA, McDonald M, Gray CL, De Waal P, Friedman R, Hockman M, Karabus SJ, Lodder CM, Mabelane T, Mosito SM, Nanan A, Peter JG, Quitter THC, Seedat R, Van den Berg S, Van Niekerk A, Vardas E, Feldman C. Allergic rhinitis: Review of the diagnosis and management: South African Allergic Rhinitis Working Group. S Afr Fam Pract (2004) 2023; 65:e1-e11. [PMID: 37916698 PMCID: PMC10623625 DOI: 10.4102/safp.v65i1.5806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Allergic rhinitis (AR) has a significant impact on the community as a whole with regard to quality of life and its relationship to allergic multi-morbidities. Appropriate diagnosis, treatment and review of the efficacy of interventions can ameliorate these effects. Yet, the importance of AR is often overlooked, and appropriate therapy is neglected. The availability of effective medications and knowledge as to management are often lacking in both public and private health systems. METHODS This review is based on a comprehensive literature search and detailed discussions by the South African Allergic Rhinitis Working Group (SAARWG). RESULTS The working group provided up-to-date recommendations on the epidemiology, pathology, diagnosis and management of AR, appropriate to the South African setting. CONCLUSION Allergic rhinitis causes significant, often unappreciated, morbidity. It is a complex disease related to an inflammatory response to environmental allergens. Therapy involves education, evaluation of allergen sensitisation, pharmacological treatment, allergen immunotherapy (AIT) and evaluation of the success of interventions. Regular use of saline; the important role of intranasal corticosteroids, including those combined with topical antihistamines and reduction in the use of systemic steroids are key. Practitioners should have a thorough knowledge of associated morbidities and the need for specialist referral.Contribution: This review summarises the latest developments in the diagnosis and management of AR such that it is a resource that allows easy access for family practitioners and specialists alike.
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Affiliation(s)
- Guy A Richards
- Department of Pulmonology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg.
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Mehmood Y, Shahid H, Abbas M, Farooq U, Alshehri S, Alam P, Shakeel F, Ghoneim MM. Developing Nanosuspension Loaded with Azelastine for Potential Nasal Drug Delivery: Determination of Proinflammatory Interleukin IL-4 mRNA Expression and Industrial Scale-Up Strategy. ACS OMEGA 2023; 8:23812-23824. [PMID: 37426214 PMCID: PMC10324090 DOI: 10.1021/acsomega.3c02186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/06/2023] [Indexed: 07/11/2023]
Abstract
In order to increase bioavailability and intranasal absorbance, the current work set out to create azelastine nasal spray based on nanosuspension. Chondroitin was utilized as a polymer to prepare azelastine nanosuspension through the precipitation procedure. A size of 500 nm and a polydispersity index of 0.276 with a negative potential (-20 mV) were achieved. X-ray diffraction, scanning electron microscopy, Fourier transform infrared spectroscopy, thermal analysis including differential scanning calorimetry and thermogravimetric analysis, in vitro release, and diffusion studies were used to characterize the optimized nanosuspension. MTT assay was used to assess the viability of the cells, and hemolysis assay was used to assess the blood compatibility. Using RNA extraction and reverse transcription polymerase chain reaction, the levels of the anti-inflammatory cytokine IL-4, which is most closely related to cytokines in allergic rhinitis, were measured in mouse lungs. The drug dissolution and diffusion study indicated 2.0-fold increase compared to pure reference sample. Therefore, the azelastine nanosuspension could be suggested as a practical and simple nanosystem for intranasal delivery with improved permeability and bioavailability. The outcome obtained in this study indicated that azelastine nanosuspension has great potential to treat allergic rhinitis as intranasal treatment.
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Affiliation(s)
- Yasir Mehmood
- Department
of Pharmaceutics, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, P. O. Box 38000, Faisalabad 38040, Pakistan
- Riphah
Institute of Pharmaceutical Sciences (RIPS), Riphah International University, Faisalabad, P. O. Box 38000, Punjab 44000, Pakistan
| | - Hira Shahid
- Department
of Pharmacology, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, P. O. Box 38000, Faisalabad 38040, Pakistan
| | - Muhammad Abbas
- Imran
Adress College of Pharmacy, P. O. Box 51310, Sialkot 51310, Pakistan
| | - Umar Farooq
- Faculty
of Pharmacy, Grand Asian University, P. O. Box 51310, Sialkot, 51040 Punjab, Pakistan
| | - Sultan Alshehri
- Department
of Pharmaceutics, College of Pharmacy, King
Saud University, Riyadh 11451, Saudi Arabia
| | - Prawez Alam
- Department
of Pharmacognosy, College of Pharmacy, Prince
Sattam Bin Abdul Aziz University, Al-Kharj 11942, Saudi Arabia
| | - Faiyaz Shakeel
- Department
of Pharmaceutics, College of Pharmacy, King
Saud University, Riyadh 11451, Saudi Arabia
| | - Mohammed M. Ghoneim
- Department
of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Ad Diriyah 13713, Saudi Arabia
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Wu FM, Ulloa R, Badash I, Hur K. Geographic Variation in Otolaryngologist Intranasal Steroid Prescribing Patterns Among Medicare Beneficiaries. Ann Otol Rhinol Laryngol 2023; 132:126-132. [PMID: 35176893 DOI: 10.1177/00034894221079094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Intranasal corticosteroids (INCS) are a commonly prescribed medication to treat various rhinological conditions. However, no prior studies have looked at factors and patterns that influence the rates of INCS prescriptions among Medicare beneficiaries in the United States. OBJECTIVE This study aims to describe the patterns of INCS prescriptions by otolaryngologists for Medicare beneficiaries in the United States between 2013 and 2017. METHODS Data on the most common INCS prescriptions by otolaryngologists for Medicare beneficiaries were obtained from the 2013 to 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (PUF) and the Part D Public Use Files from the Centers for Medicare and Medicaid Services (CMS). INCS prescriptions were analyzed by cost, state, provider, and regional temperature. State temperature data was collected through the National Centers for Environmental Information. RESULTS From 2013 to 2017, the total claims per beneficiary for fluticasone, mometasone, and triamcinolone combined increased from 2.31 to 2.39. Combined cost/beneficiary was similar for mometasone and triamcinolone at 102.47 and 103.60 respectively, while it was much lower for fluticasone at 39.12. There was a strong correlation between otolaryngology providers per beneficiary in each state and total claims per state with a correlation coefficient of .79. Additionally, comparing the average state temperature to the claims/beneficiary yielded a moderately strong correlation coefficient of .44, suggesting that temperature was a possible factor for INCS prescription patterns. CONCLUSIONS INCS prescriptions by otolaryngologists and the number of INCS beneficiaries have increased between 2013 and 2017. Over the same time period, the costs of fluticasone and triamcinolone have decreased while the cost of mometasone increased. Total providers by state correlated with claims per state. Additionally, average annual temperature was positively correlated with INCS claims per beneficiary in each state.
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Affiliation(s)
- Franklin M Wu
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ruben Ulloa
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ido Badash
- Caruso Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Kevin Hur
- Caruso Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Xu J, Zhang P, Huang Y, Zhou Y, Hou Y, Bekris LM, Lathia J, Chiang CW, Li L, Pieper AA, Leverenz JB, Cummings J, Cheng F. Multimodal single-cell/nucleus RNA sequencing data analysis uncovers molecular networks between disease-associated microglia and astrocytes with implications for drug repurposing in Alzheimer's disease. Genome Res 2021; 31:1900-1912. [PMID: 33627474 PMCID: PMC8494225 DOI: 10.1101/gr.272484.120] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/18/2021] [Indexed: 11/25/2022]
Abstract
Because disease-associated microglia (DAM) and disease-associated astrocytes (DAA) are involved in the pathophysiology of Alzheimer's disease (AD), we systematically identified molecular networks between DAM and DAA to uncover novel therapeutic targets for AD. Specifically, we develop a network-based methodology that leverages single-cell/nucleus RNA sequencing data from both transgenic mouse models and AD patient brains, as well as drug-target network, metabolite-enzyme associations, the human protein-protein interactome, and large-scale longitudinal patient data. Through this approach, we find both common and unique gene network regulators between DAM (i.e., PAK1, MAPK14, and CSF1R) and DAA (i.e., NFKB1, FOS, and JUN) that are significantly enriched by neuro-inflammatory pathways and well-known genetic variants (i.e., BIN1). We identify shared immune pathways between DAM and DAA, including Th17 cell differentiation and chemokine signaling. Last, integrative metabolite-enzyme network analyses suggest that fatty acids and amino acids may trigger molecular alterations in DAM and DAA. Combining network-based prediction and retrospective case-control observations with 7.2 million individuals, we identify that usage of fluticasone (an approved glucocorticoid receptor agonist) is significantly associated with a reduced incidence of AD (hazard ratio [HR] = 0.86, 95% confidence interval [CI] 0.83-0.89, P < 1.0 × 10-8). Propensity score-stratified cohort studies reveal that usage of mometasone (a stronger glucocorticoid receptor agonist) is significantly associated with a decreased risk of AD (HR = 0.74, 95% CI 0.68-0.81, P < 1.0 × 10-8) compared to fluticasone after adjusting age, gender, and disease comorbidities. In summary, we present a network-based, multimodal methodology for single-cell/nucleus genomics-informed drug discovery and have identified fluticasone and mometasone as potential treatments in AD.
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Affiliation(s)
- Jielin Xu
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Pengyue Zhang
- Department of Biostatistics, School of Medicine, Indiana University, Indianapolis, Indiana 46202, USA
| | - Yin Huang
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Yadi Zhou
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Yuan Hou
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Lynn M Bekris
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio 44195, USA
| | - Justin Lathia
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio 44195, USA
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Chien-Wei Chiang
- Department of Biomedical Informatics, College of Medicine, Ohio State University, Columbus, Ohio 43210, USA
| | - Lang Li
- Department of Biomedical Informatics, College of Medicine, Ohio State University, Columbus, Ohio 43210, USA
| | - Andrew A Pieper
- Harrington Discovery Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio 44106, USA
- Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio 44106, USA
- Geriatric Psychiatry, GRECC, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio 44106, USA
- Institute for Transformative Molecular Medicine, School of Medicine, Case Western Reserve University, Cleveland 44106, Ohio, USA
- Weill Cornell Autism Research Program, Weill Cornell Medicine of Cornell University, New York, New York 10065, USA
- Department of Neuroscience, Case Western Reserve University, School of Medicine, Cleveland, Ohio 44106, USA
| | - James B Leverenz
- Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Jeffrey Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas, Las Vegas, Nevada 89154, USA
| | - Feixiong Cheng
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio 44195, USA
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
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Daley-Yates PT, Larenas-Linnemann D, Bhargave C, Verma M. Intranasal Corticosteroids: Topical Potency, Systemic Activity and Therapeutic Index. J Asthma Allergy 2021; 14:1093-1104. [PMID: 34526783 PMCID: PMC8436259 DOI: 10.2147/jaa.s321332] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Peter T Daley-Yates
- Clinical Pharmacology and Experimental Medicine, GlaxoSmithKline plc., Research and Development, Uxbridge, UK
| | - Désirée Larenas-Linnemann
- Center of Excellence in Asthma and Allergy, Médica Sur Clinical Foundation and Hospital, México City, Mexico
| | | | - Manish Verma
- Respiratory and Allergy, GlaxoSmithKline plc., Mumbai, India
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Zolkowska D, Wu CY, Rogawski MA. Intranasal Allopregnanolone Confers Rapid Seizure Protection: Evidence for Direct Nose-to-Brain Delivery. Neurotherapeutics 2021; 18:544-555. [PMID: 33405197 PMCID: PMC8116426 DOI: 10.1007/s13311-020-00985-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/22/2023] Open
Abstract
Allopregnanolone, a positive modulator of GABAA receptors with antiseizure activity, has potential in the treatment of seizure emergencies. Instillation of allopregnanolone in 40% sulfobutylether-β-cyclodextrin into the nose in mice rapidly elevated the seizure threshold in the timed intravenous pentylenetetrazol (ED50, 5.6 mg/kg), picrotoxin (ED50, 5.9 mg/kg), and bicuculline seizure tests. The effect peaked at 15 min, decayed over 1 h, and was still evident in some experiments at 6 h. Intranasal allopregnanolone also delayed the onset of seizures in the maximal PTZ test. At an allopregnanolone dose (16 mg/kg) that conferred comparable effects on seizure threshold as the benzodiazepines midazolam and diazepam (both at doses of 1 mg/kg), allopregnanolone caused minimal sedation or motor toxicity in the horizontal screen test whereas both benzodiazepines produced marked behavioral impairment. In addition, intranasal allopregnanolone failed to cause loss-of-righting reflex in most animals, but when the same dose was administered intramuscularly, all animals became impaired. Intranasal allopregnanolone (10 mg/kg) caused a rapid increase in brain allopregnanolone with a Tmax of ~5 min after initiation of the intranasal delivery. High levels of allopregnanolone were recovered in the olfactory bulb (Cmax, 16,000 ng/mg) whereas much lower levels (Cmax, 670 ng/mg) were present in the remainder of the brain. We conclude that the unique ability of intranasal allopregnanolone to protect against seizures without inducing behavioral adverse effects is due in part to direct nose-to-brain delivery, with preferential transport to brain regions relevant to seizures. Benzodiazepines are commonly administered intranasally for acute seizure therapy, including for the treatment of acute repetitive seizures, but are not transported from nose-to-brain. Intranasal allopregnanolone acts with greater speed, has less propensity for adverse effects, and has the ability to overcome benzodiazepine refractoriness. This is the first study demonstrating rapid functional central nervous system activity of a nose-to-brain-delivered steroid. Intranasal delivery circumvents the poor oral bioavailability of allopregnanolone providing a route of administration permitting its evaluation as a treatment for diverse neuropsychiatric indications.
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Affiliation(s)
- Dorota Zolkowska
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA
| | - Chun-Yi Wu
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA
- Bioanalysis and Pharmacokinetics Core Facility, UC Davis Medical Center, Sacramento, CA, 95817, USA
| | - Michael A Rogawski
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA.
- Department of Pharmacology, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA.
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Mucoadhesive dexamethasone-glycol chitosan nanoparticles for ophthalmic drug delivery. Int J Pharm 2020; 575:118943. [DOI: 10.1016/j.ijpharm.2019.118943] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/22/2019] [Accepted: 12/06/2019] [Indexed: 02/06/2023]
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Hwang PH, Lin B, Weiss R, Atkins J, Johnson J. Cryosurgical posterior nasal tissue ablation for the treatment of rhinitis. Int Forum Allergy Rhinol 2017; 7:952-956. [PMID: 28799727 PMCID: PMC5656830 DOI: 10.1002/alr.21991] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/05/2017] [Accepted: 06/18/2017] [Indexed: 11/28/2022]
Abstract
Background Endoscopic posterior nasal nerve (PNN) resection has been described as an efficacious surgical treatment of allergic and nonallergic rhinitis, but the requirement for surgery under general anesthesia has limited its acceptance. We report the first series of patients treated for chronic rhinitis using a novel device designed for office‐based cryosurgical ablation of the PNN. Methods Twenty‐seven patients with chronic rhinorrhea and/or nasal congestion for >3 months were recruited (allergic or nonallergic rhinitis), with minimum rhinorrhea and/or congestion subscores of 2 as part of the Total Nasal Symptom Score [TNSS]). Under local anesthesia, the cryotherapy device was applied endoscopically to the posterior middle meatus and was used to freeze the PNN region bilaterally. Patients were followed up after 7, 30, 90, 180, and 365 days to assess TNSS. Results The procedure was successfully completed in 100% of patients, with no complications; 74% reported no or mild discomfort by the first postprocedure day. TNSS was reduced significantly at 30 days (mean ± standard deviation: 6.2 ± 0.5 at baseline, 2.6 ± 0.3 at 30 days, n = 27, p < 0.001), with continued reduction at 90 (2.7 ± 0.4, n = 24, p < 0.001), 180 (2.3 ± 0.5, n = 21, p < 0.001), and 365 days (1.9 ± 0.3, n = 15, p < 0.001). Both rhinorrhea and congestion subscores decreased significantly at 30, 90, 180, and 365 days compared to baseline (p < 0.001). Allergic and nonallergic subcohorts both appeared to benefit from treatment. Conclusion Office‐based cryotherapy of the PNN region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days.
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Affiliation(s)
- Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Bryant Lin
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
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9
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Ellis AK, Steacy LM, Joshi A, Bhowmik S, Raut A. Efficacy of the novel nasal steroid S0597 tested in an environmental exposure unit. Ann Allergy Asthma Immunol 2017; 117:310-7. [PMID: 27613466 DOI: 10.1016/j.anai.2016.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/28/2016] [Accepted: 07/13/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND S0597 is a novel glucocorticosteroid that was formulated as an intranasal spray to treat seasonal allergic rhinitis (SAR). In a previous phase 2 study, doses of 100 to 400 μg twice daily were well tolerated and more effective than placebo for improving nasal symptoms induced by grass pollen. OBJECTIVE To assess the clinical efficacy and safety of a once-daily S0597 nasal spray for treatment of SAR induced by ragweed pollen in an environmental exposure unit (EEU). METHODS A single-center, phase 2, randomized, double-blind study in 222 adults with SAR and a positive skin prick test result to short ragweed. Participants underwent ragweed pollen challenge in the EEU at the screening or priming visit and on days 1, 7, and 14 and received 50, 200, or 400 μg of S0597 or placebo in the evening for 13 days. The primary efficacy end point was change in total nasal symptom score (TNSS) from baseline to day 14. RESULTS Improvement in TNSS from baseline to day 14 was statistically significant in all S0597 groups compared with placebo. Least-squares mean differences in change from baseline between active treatment and placebo were 1.18, 1.84, and 1.17 for the 50-, 200-, and 400-μg/d S0597 groups, respectively (P < .05). The 200-μg group demonstrated statistically significant improvements in all TNSS subscales (rhinorrhea, nasal congestion, sneezing, nasal itching) compared with placebo at days 7 and 14. CONCLUSION Treatment with 50 to 400 μg of S0597 once daily was well tolerated and significantly more effective than placebo in relieving nasal symptoms of SAR associated with ragweed pollen. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01940146.
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Affiliation(s)
- Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada; Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
| | - Lisa M Steacy
- Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | | | | | - Atul Raut
- Sun Pharma Advanced Research Company Ltd, Mumbai, India
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10
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Abstract
Allergic rhinitis and sinusitis are chronic conditions of the airway and cause significant morbidity. Both can require pharmacotherapy with nonprescription products to relieve symptoms or with prescription products to treat the underlying pathophysiology. Because these diseases are prevalent conditions, the pharmacist is in the unique position of being the first health professional contact for many patients. The pharmacist can assist the patient in selection of nonprescription antihistamines, decongestants, and nasal saline sprays as well as provide instruction on the use of steam therapy, aromatic vapors, and warm compresses for the relief of symptoms. Equally important, the pharmacist can encourage patients to seek care from a physician when treatment with intranasal corticosteroids, antibiotics, and nonsedating antihistamines are needed.
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Affiliation(s)
- Kathryn Blake
- Research Department 5 North, Nemours Children’s Clinic, 807 Nira Street, Jacksonville, FL 32207,
| | - Julie Larsen
- Clinical Research Institute, College of Pharmacy, University of Minnesota, Minneapolis, MN 55402
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11
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Badorrek P, Hohlfeld JM, Krug N, Joshi A, Raut A. Efficacy and safety of a novel nasal steroid, S0597, in patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2015; 115:325-329.e1. [PMID: 26272281 DOI: 10.1016/j.anai.2015.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 07/17/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Allergic rhinitis (AR) poses a significant global burden with increasing prevalence. Although intranasal glucocorticosteroids are effective, older agents can have limiting side effects. S0597, a novel intranasal glucocorticosteroid, has demonstrated good safety and tolerability during preclinical and phase 1 studies. OBJECTIVE To assess the clinical efficacy, safety, and tolerability of different doses of S0597 nasal spray vs placebo in patients with seasonal AR. METHODS This phase 2, randomized, double-blinded, placebo-controlled, parallel-group, single-center study randomized 159 patients 18 to 65 years old (mean age 37.8 years) with a positive skin prick test reaction for Dactylis glomerata to receive S0597 at 200, 400, or 800 μg/d or placebo for 15 days. On days 1 (baseline), 15, and 16, patients underwent a 4-hour pollen challenge to evaluate treatment efficacy measured by the change in total nasal symptom score (TNSS) from baseline to days 15 and 16 and changes in TNSS subscales and nasal secretion. RESULTS Statistically significant improvements in TNSS from baseline to days 15 and 16 were observed with all S0597 doses vs placebo (P = .0005 overall), with the greatest improvements observed in the highest-dose group (P < .0001). Significant decreases were observed in each S0597 dose group vs placebo for TNSS subscales and nasal secretion. Improvements in nasal secretion were related to dose, with the greatest decreases from baseline in the 800-μg/d group on days 15 and 16 (P < .0001). CONCLUSION Treatment with S0597 at 200, 400, and 800 μg/d by 2 divided doses for 2 weeks was safe and significantly more effective than placebo for improving nasal symptoms associated with grass pollen-induced seasonal AR in adults. TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT01614691.
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Affiliation(s)
- Philipp Badorrek
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany.
| | - Jens M Hohlfeld
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Norbert Krug
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Abhijeet Joshi
- Clinical Research Department, Sun Pharma Advanced Research Company Ltd, Mumbai, India
| | - Atul Raut
- Clinical Research Department, Sun Pharma Advanced Research Company Ltd, Mumbai, India
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12
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Allen DB. Inhaled corticosteroids and growth: still an issue after all these years. J Pediatr 2015; 166:463-9. [PMID: 25631291 DOI: 10.1016/j.jpeds.2014.09.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 08/27/2014] [Accepted: 09/29/2014] [Indexed: 11/25/2022]
Affiliation(s)
- David B Allen
- Division of Endocrinology and Diabetes, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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Abstract
Topical steroid therapy has been used to treat eosinophilic esophagitis (EoE) for more than 15 years. We review the treatment trials of topical steroid therapy in adult patients with EoE. Currently, there is no commercially available preparation designed to deliver the steroid to the esophagus. Current regimens consist of swallowing steroid preparations designed for inhalation treatment for asthma. In the short term, steroids are associated with an approximately 15% to 25% incidence of asymptomatic esophageal candidiasis, but otherwise appear to be well tolerated.
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Nave R, Wingertzahn MA, Brookman S, Kaida S, Matsunaga T. Safety, Tolerability, and Exposure of Ciclesonide Nasal Spray in Healthy and Asymptomatic Subjects With Seasonal Allergic Rhinitis. J Clin Pharmacol 2013; 46:461-7. [PMID: 16554455 DOI: 10.1177/0091270006286437] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ciclesonide is an intranasal corticosteroid in development for the treatment of allergic rhinitis. To assess the safety, tolerability, and pharmacokinetics of ciclesonide, adult healthy volunteers and asymptomatic subjects with seasonal allergic rhinitis were randomized to receive intranasal ciclesonide or placebo for 14 days. Serum concentrations of ciclesonide and its active metabolite, desisobutyryl-ciclesonide, were measured using high-performance liquid chromatography assay with tandem mass spectrometric detection, with lower limits of quantification of 25 and 10 pg/mL, respectively. Adrenal function was monitored by diurnal serum free and 24-hour urine cortisol concentrations. Despite the use of a sensitive assay and a high ciclesonide dose (800 microg/d), serum levels of ciclesonide and desisobutyryl-ciclesonide were below the lower limits of quantification for the majority of samples assayed. Ciclesonide was well tolerated and did not appear to affect serum or urine free cortisol levels. The low systemic exposure and favorable safety profile support the continued clinical development of ciclesonide nasal spray.
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Affiliation(s)
- Ruediger Nave
- ALTANA Pharma AG, Byk-Gulden-Str. 2, 78467 Konstanz, Germany
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15
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Corry DB, Kheradmand F, Luong A, Pandit L. Immunological mechanisms of airway diseases and pathways to therapy. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00054-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Chaaban M, Corey JP. Pharmacotherapy of Rhinitis and Rhinosinusitis. Facial Plast Surg Clin North Am 2012; 20:61-71. [DOI: 10.1016/j.fsc.2011.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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17
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Park DM, Carvalho TLL, Franci JAA, Anselmo-Lima WT. Influence of treatment with intranasal corticosteroids on the nasal mucosa, weight, and corticosteroid concentration in rats. Am J Rhinol Allergy 2011; 26:e46-9. [PMID: 22182666 DOI: 10.2500/ajra.2012.26.3702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The effect of intranasal corticosteroids on the nasal epithelium mucosa is an important parameter of treatment safety. This study was designed to examine whether treatment with topical corticosteroids in patients with allergic rhinitis causes atrophic nasal mucosal changes, when compared with systemic corticosteroids, in rats. METHODS Male Wistar rats were treated daily during 7 weeks with topical administration with 10 microliters of normal saline (control group), 10 microliters of mometasone furoate group, 10 microliters of triamcinolone acetonide (T group), and 8 mg/kg of daily subcutaneous injections of methylprednisolone sodium succinate (MP group). Body weight was evaluated weekly. At the end of the treatment, rats were killed by decapitation to collect blood for determination of corticosterone levels and nasal cavities were prepared for histological descriptive analyses. RESULTS Treatment with T and MP decreased body weight. Plasma corticosterone concentration was significantly reduced by MP treatment and presented a clear tendency to decrease after T treatment. Histological changes observed in group T included ripples, cell vacuolization, increase in the number of nuclei, and decrease in the number of cilia in the epithelial cells. CONCLUSION Growth and corticosterone concentration were impaired by T and MP at the same proportion, suggesting a role of this hormone in body gain. With the exception of T, intranasal or systemic treatment with the corticosteroids evaluated in this study did not affect nasal mucosa.
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Affiliation(s)
- Danielle Morello Park
- Department of Ophthalmology, Otolaryngology, and Head and Neck Surgery, School of Medicine, University of São Paulo, Ribeirão Preto, SP, Brazil
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Crawford B, Stanford RH, Wong AY, Dalal AA, Bayliss MS. Development of a questionnaire to assess experience and preference of intranasal corticosteroids in patients with allergic rhinitis. Patient Relat Outcome Meas 2011; 2:119-26. [PMID: 22915972 PMCID: PMC3417927 DOI: 10.2147/prom.s19195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Allergic rhinitis affects 10%-20% of the US population. Its chronic nature, combined with patients' perceptions of safety/efficacy, administration, and sensory attributes of nasal sprays (corticosteroids), impact patient adherence to therapy. The purpose of this study was to develop a measure of experience with and preference for corticosteroid therapy for treatment of allergic rhinitis. METHODS Questionnaire development was conducted through qualitative research including concept elicitation and content testing in 153 patients with allergic rhinitis. Patient focus groups (n = 66), in conjunction with content confirmation and saturation in additional groups (n = 87), provided research data. A literature-based conceptual framework was incorporated into the interview guide. An iterative process of data collection, analysis, and theory development yielded the conceptual framework. RESULTS Consistent comments from the focus groups combined with those from cognitive debriefing interviews led to the incorporation of 14 finalized attributes into the Experience with Allergic Rhinitis Nasal Spray Questionnaire (EARNS-Q) items. Between the first and second cognitive debriefing interviews, researchers revised the EARNS-Q for retesting. Face and content validity tests indicated that the items, responses, and instructions were understood by study participants. The EARNS-Q is comprised of two modules that measure patient experience with nasal sprays (experience module), and patient preference for a nasal spray relative to another (preference module). CONCLUSION The EARNS-Q accurately measured patient experience with and preference for nasal sprays used in treating allergic rhinitis. A potential application of this questionnaire may be as a patient-reported outcomes endpoint in clinical trials of intranasal corticosteroids in patients with allergic rhinitis.
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Bachert C. Evidence-based management of nasal polyposis by intranasal corticosteroids: from the cause to the clinic. Int Arch Allergy Immunol 2011; 155:309-21. [PMID: 21346361 DOI: 10.1159/000321406] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nasal polyposis is an inflammatory disorder involving the mucosa of the nose and paranasal sinuses and affecting approximately 2-4% of the general population. METHODS A literature search of Medline and Embase was conducted to obtain an overview of the epidemiology, pathophysiology, and current treatment of nasal polyposis, focusing on evidence-based efficacy of intranasal corticosteroids (INSs) as primary and postoperative therapy. Recent research on INSs in nasal polyp treatment, along with notable historic findings, was reviewed. RESULTS Nasal polyps are mostly characterized by eosinophil infiltration, a complex inflammation of nasal mucosa, and possibly production of polyclonal IgE. Current treatment modalities include INSs, oral corticosteroids, and surgery; surgery is generally limited to those with an insufficient response to medical treatment. Because of their effects on eosinophil-dominated inflammation, INSs and oral corticosteroids are the primary medical treatment strategies. The very low (≤1%) systemic bioavailability of newer INSs minimizes the systemic adverse effects seen with oral corticosteroids. CONCLUSION Based on randomized, controlled trials, guidelines recommend INSs as first-line therapy for nasal polyps and for care after polypectomy. Clinical data suggest INSs are effective in reducing polyp size and relieving nasal symptoms. INS treatment has also reduced nasal polyp recurrence in patients undergoing functional endoscopic sinus surgery. Treatment with these mainstay options has been found to improve quality of life, which, along with symptom improvement, is a key factor in disease treatment.
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Affiliation(s)
- Claus Bachert
- Department of Otorhinolaryngology, University Hospital Ghent, Ghent, Belgium. claus.bachert @ ugent.be
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20
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Scadding G. Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation. Pediatr Allergy Immunol 2010; 21:1095-106. [PMID: 20609137 DOI: 10.1111/j.1399-3038.2010.01012.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Adenoidal hypertrophy (AH) and adenotonsillar hypertrophy are common disorders in the pediatric population and can cause symptoms such as mouth breathing, nasal congestion, hyponasal speech, snoring, and obstructive sleep apnea (OSA), as well as chronic sinusitis and recurrent otitis media. More serious long-term sequelae, typically secondary to OSA, include neurocognitive abnormalities (e.g. behavioral and learning difficulties, poor attention span, hyperactivity, below average intelligence quotient); cardiovascular morbidity (e.g. decreased right ventricular ejection fraction, left ventricular hypertrophy, elevated diastolic blood pressure); and growth failure. Adenoidectomy (with tonsillectomy in cases of adenotonsillar hypertrophy) is the typical management strategy for patients with AH. Potential complications have prompted the investigation of non-surgical alternatives. Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) in the management of patients with AH. This article reviews the epidemiology and pathophysiology of AH with a particular focus on evidence of its association with allergy and allergic rhinitis. Current treatment options are briefly considered with discussion on the rationale and evidence for the use of INS.
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Abstract
Although nasal allergy has been prominent in allergy research, ocular allergy is increasingly recognized as a distinct symptom complex that imposes its own disease burden and reduction in patients' quality of life. In the past year, knowledge of the relationships between allergic conjunctivitis and allergic rhinitis has increased. Allergic conjunctivitis is highly prevalent and has a close epidemiologic relationship with allergic rhinitis. Both conditions also exhibit similar pathophysiologic mechanisms. Pathways of communication are thought to increase the likelihood of an inflammatory reaction at both sites following allergen exposure of nasal or ocular tissue. Clinical trials of intranasal therapies have demonstrated efficacy in allergic conjunctivitis and rhinitis. Newer intranasal steroids decrease ocular symptoms, potentially achieving efficacy by suppressing the naso-ocular reflex, downregulation of inflammatory cell expression, or restoration of nasolacrimal duct patency. Proposed pathophysiologic interactions between allergic rhinitis and ocular allergy underscore the need for therapies with efficacy in both symptom sets.
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22
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Wong YC, Zuo Z. Intranasal delivery--modification of drug metabolism and brain disposition. Pharm Res 2010; 27:1208-23. [PMID: 20372990 DOI: 10.1007/s11095-010-0127-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/22/2010] [Indexed: 01/01/2023]
Abstract
Intranasal route continues to be one of the main focuses of drug delivery research. Although it is generally perceived that the nasal route could avoid the first-pass metabolism in liver and gastrointestinal tract, the role of metabolic conversions in systemic and brain-targeted deliveries of the parent compounds and their metabolites should not be underestimated. In this commentary, metabolite formations after intranasal and other routes of administration are compared. Also, the disposition of metabolites in plasma and brain after nasal administrations of parent drugs, prodrugs and preformed metabolites will be discussed. The importance and implications of metabolism for future nasal drug development are highlighted.
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Affiliation(s)
- Yin Cheong Wong
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Room 610, Basic Medical Sciences Building, Shatin, New Territories, Hong Kong
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23
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Welch KC, Thaler ER, Doghramji LL, Palmer JN, Chiu AG. The Effects of Serum and Urinary Cortisol Levels of Topical Intranasal Irrigations with Budesonide Added to Saline in Patients with Recurrent Polyposis after Endoscopic Sinus Surgery. Am J Rhinol Allergy 2010; 24:26-8. [DOI: 10.2500/ajra.2010.24.3418] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The delivery of topical intranasal corticosteroid sprays has traditionally been the primary method of treating recurrent nasal polyposis. An emerging treatment for polyposis is budesonide nasal irrigations. Delivered at concentrations nearly 100 times greater than found in prescription nasal sprays, there have been little studies on the effects of budesonide irrigation on the adrenal axis. Therefore, we investigated whether irrigation with budesonide solution was associated with any increase in serum cortisol and 24-hour urinary cortisol levels. Methods Patients who previously had undergone endoscopic sinus surgery and were not taking prednisone for 3 months were prospectively enrolled in this study. Patients irrigated twice daily with 0.5 mg/2 mL of budesonide mixed with 240 mL of saline solution. Serum cortisol and 24-hour urinary cortisol were collected before drug administration and 6 weeks after continuous use. Results Ten patients completed this study. The average serum cortisol and 24-hour urinary cortisol before drug administration were 9.8 ± 5.4 μg/dL and 28.1 ± 15.1 μg/24 hours, respectively. After 6-week follow-up, the average serum cortisol and 24-hour urinary cortisol were 12.8 ± 3.5 μg/dL and 16.5 ± 5.6 μg/24 hours, respectively. Normal ranges for serum cortisol and 24-hour urinary cortisol are 5–25 μg/dL and 4–50 μg/24 hours, respectively. Conclusions: Irrigation with budesonide, 0.5 mg/2 mL, in 250 mL of saline solution does not result in decreases of serum cortisol and 24-hour urinary cortisol levels. Based on this, we feel irrigation with budesonide solution is safe to perform in patients as an alternative to traditional aerosolized steroid sprays or systemic corticosteroids.
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Affiliation(s)
- Kevin C. Welch
- Department of Otolaryngology–Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Erica R. Thaler
- Department of Otorhinolaryngology–Head and Neck Surgery, Division of Rhinology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Laurie L. Doghramji
- Department of Otorhinolaryngology–Head and Neck Surgery, Division of Rhinology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - James N. Palmer
- Department of Otorhinolaryngology–Head and Neck Surgery, Division of Rhinology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Alexander G. Chiu
- Department of Otorhinolaryngology–Head and Neck Surgery, Division of Rhinology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Benedetti MS, Whomsley R, Poggesi I, Cawello W, Mathy FX, Delporte ML, Papeleu P, Watelet JB. Drug metabolism and pharmacokinetics. Drug Metab Rev 2009; 41:344-90. [PMID: 19601718 DOI: 10.1080/10837450902891295] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
In this article, aspects of absorption, distribution, metabolism, and excretion have been described bearing in mind the pathogenesis of allergic diseases and their possible therapeutic opportunities. The importance of the routes of administration of the different therapeutic groups has been emphasized. The classical aspects of drug metabolism and disposition related to oral administration have been reviewed, but special emphasis has been given to intranasal, cutaneous, transdermal, and ocular administration as well as to the absorption and the subsequent bioavailability of drugs. Drug-metabolizing enzymes and transporters present in extrahepatic tissues, such as nasal mucosa and the respiratory tract, have been particularly discussed. As marketed antiallergic drugs include both racemates and enantiomers, aspects of stereoselective absorption, distribution, metabolism, and excretion have been discussed. Finally, a new and promising methodology, microdosing, has been presented, although it has not yet been applied to drugs used in the treatment of allergic diseases.
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Abstract
Mometasone furoate (Nasonex) is a high-potency intranasal corticosteroid available for the treatment and/or prophylaxis of the nasal symptoms of seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR). In the EU, it is approved for use in patients aged > or =6 years and, in the US, it is approved as a treatment in patients aged > or =2 years and as prophylaxis in those > or =12 years of age.Extensive experience in both clinical trials and the clinical practice setting has firmly established the efficacy and good tolerability profile of intranasal mometasone furoate in children and adults with PAR or SAR. Thus, intranasal mometasone furoate is a useful first-line option for the treatment and prophylactic management of these conditions, including in children as young as 2 years of age in some countries and 6 years of age in others.
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Demoly P. Safety of intranasal corticosteroids in acute rhinosinusitis. Am J Otolaryngol 2008; 29:403-13. [PMID: 19144302 PMCID: PMC7115254 DOI: 10.1016/j.amjoto.2007.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 11/19/2007] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Pascal Demoly
- Clinical Department of Allergology, Maladies Respiratoires, INSERM U657, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier Cedex 5, France.
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Algorta J, Pena MA, Francisco S, Abajo Z, Sanz E. Randomised, crossover clinical trial, in healthy volunteers, to compare the systemic availability of two topical intranasal budesonide formulations. Trials 2008; 9:34. [PMID: 18541030 PMCID: PMC2453102 DOI: 10.1186/1745-6215-9-34] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 06/09/2008] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Budesonide has a long history as intranasal drug, with many marketed products. Efforts should be made to demonstrate the therapeutic equivalence and safety comparability between them. Given that systemic availability significantly varies from formulations, the clinical comparability of diverse products comes to be of clinical interest and a regulatory requirement. The aim of the present study was to compare the systemic availability, pharmacodynamic effect, and safety of two intranasal budesonide formulations for the treatment of rhinitis. METHODS Eighteen healthy volunteers participated in this randomised, controlled, crossover, clinical trial. On two separated days, subjects received a single dose of 512 mug budesonide (4 puffs per nostril) from each of the assayed devices (Budesonida nasal 64(R), Aldo-Union, Spain and Rhinocort 64(R), AstraZeneca, Spain). Budesonide availability was determined by the measurement of budesonide plasma concentration. The pharmacodynamic effect on the hypothalamic-adrenal axis was evaluated as both plasma and urine cortisol levels. Adverse events were tabulated and described. Budesonide availability between formulations was compared by the calculation of 90%CI intervals of the ratios of the main pharmacokinetic parameters describing budesonide bioavailability. Plasma cortisol concentration-time curves were compared by means of a GLM for Repeated Measures. Urine cortisol excretion between formulations was compared through the Wilcoxon's test. RESULTS All the enrolled volunteers successfully completed the study. Pharmacokinetic parameters were comparable in terms of AUC(t) (2.6 +/- 1.5 vs 2.2 +/- 0.7), AUC(i) (2.9 +/- 1.5 vs 2.4 +/- 0.7), t(max) (0.4 +/- 0.1 vs 0.4 +/- 0.2), C(max)/AUC(i) (0.3 +/- 0.1 vs 0.3 +/- 0.0), and MRT (5.0 +/- 1.4 vs 4.5 +/- 0.6), but not in the case of C(max) (0.9 +/- 0.3 vs 0.7 +/- 0.2) and t(1/2) (3.7 +/- 1.8 vs 2.9 +/- 0.4). The pharmacodynamic effects, measured as the effect over plasma and urine cortisol, were also comparables between both formulations. No severe adverse events were reported and tolerance was comparable between formulations. CONCLUSION The systemic availability of intranasal budesonide was comparable for both formulations in terms of most pharmacokinetic parameters. The pharmacodynamic effect on hypothalamic-pituitary-adrenal axis was also similar. Side effects were scarce and equivalent between the two products. This methodology to compare different budesonide-containing devices is reliable and easy to perform, and should be recommended for similar products intented to be marketed or already on the market. TRIAL REGISTRATION No Eudra CT: 2005-003727-39.
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Affiliation(s)
- Jaime Algorta
- Clinical Trials Unit, Fundacion LEIA-Txagorritxu Hospital, Vitoria-Gasteiz, Spain
- University of Basque Country, Spain
- European Academy of Allergy and Clinical Immunology, EAACI 2007 Goteborg, Sweden
| | - Maria Angeles Pena
- Clinical Trials Unit, Fundacion LEIA-Txagorritxu Hospital, Vitoria-Gasteiz, Spain
- European Academy of Allergy and Clinical Immunology, EAACI 2007 Goteborg, Sweden
| | - Silvia Francisco
- Clinical Trials Unit, Fundacion LEIA-Txagorritxu Hospital, Vitoria-Gasteiz, Spain
- European Academy of Allergy and Clinical Immunology, EAACI 2007 Goteborg, Sweden
| | - Zurine Abajo
- Clinical Trials Unit, Fundacion LEIA-Txagorritxu Hospital, Vitoria-Gasteiz, Spain
- European Academy of Allergy and Clinical Immunology, EAACI 2007 Goteborg, Sweden
| | - Emilio Sanz
- Clinical Trials Unit, Fundacion LEIA-Txagorritxu Hospital, Vitoria-Gasteiz, Spain
- European Academy of Allergy and Clinical Immunology, EAACI 2007 Goteborg, Sweden
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Pharmacokinetic/pharmacodynamic profile of mometasone furoate nasal spray: Potential effects on clinical safety and efficacy. Clin Ther 2008; 30:1-13. [DOI: 10.1016/j.clinthera.2008.01.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2007] [Indexed: 11/22/2022]
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Schenkel E. Oral antihistamines have proven efficacy in treating ocular symptoms of allergic rhinitis. J Allergy Clin Immunol 2007; 120:1473-4; author reply 1474. [PMID: 17889929 DOI: 10.1016/j.jaci.2007.07.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 07/23/2007] [Indexed: 11/25/2022]
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Brunton SA, Fromer LM. Treatment Options for the Management of Perennial Allergic Rhinitis, with a Focus on Intranasal Corticosteroids. South Med J 2007; 100:701-8. [PMID: 17639750 DOI: 10.1097/smj.0b013e3180485560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Perennial allergic rhinitis (PAR) can have a significant impact on a patient's quality of life. While allergen avoidance is the first line of management for PAR, complete avoidance is difficult. Therapeutic options available for PAR include intranasal corticosteroids (INS), H1-antihistamines, decongestants and local chromones, as well as immunotherapy. For mild symptoms, INS and antihistamines are the standard of care, whereas for moderate-to-severe PAR, INS are the preferred therapy due to their proven efficacy. Patient quality of life and therapy preference play a role in maintaining adherence to treatment.
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Affiliation(s)
- Stephen A Brunton
- Cabarrus Family Medicine Residency Program, Charlotte, NC 28226, USA.
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31
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Abstract
Allergic rhinitis (AR) is currently the most common chronic disease in children in the United States, affecting as many as 40% of the children in the population. AR can substantially decrease a child's quality of life and can contribute to school absenteeism. Intranasal corticosteroids (INS) are thought to be the most effective treatment choice for controlling the symptoms of AR. However, parent and physician concerns over INS safety in children have often led to INS being used as a second-line treatment option. More recently, safety studies have shown that the newer INS agents have improved safety profiles compared with older INS agents. The newer INS drugs have been found to have minimal adverse effects on growth and hypothalamic-pituitary-adrenal-axis function in children, which is a concern when prescribing corticosteroids. This review will discuss the pathophysiology, diagnosis, and classification of AR. The mechanism of action, efficacy, and safety of INS will also be discussed by focusing on clinical evidence. Furthermore, other considerations, such as parent or caregiver education and patient compliance, will be reviewed.
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Affiliation(s)
- Jacqueline Kaari
- Department of Pediatrics, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, Turnersville, NJ 08012, USA
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Claflin JR. Good clinical practice or a tool for marketing? Ann Allergy Asthma Immunol 2006; 96:638-9. [PMID: 16729774 DOI: 10.1016/s1081-1206(10)61059-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Pitsios C, Papadopoulos D, Kompoti E, Manoussakis E, Garris V, Petalas K, Tassios I, Baibas N, Kontou-Fili K, Saxoni-Papageorgiou P, Papadopoulos NG. Efficacy and safety of mometasone furoate vs nedocromil sodium as prophylactic treatment for moderate/severe seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2006; 96:673-8. [PMID: 16729779 DOI: 10.1016/s1081-1206(10)61064-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The preventive use of medications has been proposed to be effective in the treatment of seasonal rhinitis. OBJECTIVE To evaluate the efficacy and safety of mometasone furoate and nedocromil sodium nasal sprays as prophylactic treatment for moderate to severe seasonal allergic rhinitis (SAR). PATIENTS Sixty-one patients were recruited from 3 referral allergy centers. Inclusion criteria were history of SAR for 2 years or longer, sensitization to relevant local pollen (grasses, Parietaria, and olive), and age older than 12 years. METHODS An open-label, randomized, parallel-group, "real-life" study design was used. Patients received mometasone furoate nasal spray once daily or nedocromil sodium nasal spray 3 times daily starting 2 to 4 weeks before the pollen season and continuing for up to 4 months. Instructions regarding the use of additional medications were given. Diary cards recording symptoms, use of medication, and adverse events were kept by the patients. RESULTS All 61 patients completed the study. The prophylactic use of mometasone furoate vs nedocromil sodium led to significantly more days without symptoms (75.1% vs 54.5%; P < .001). The mometasone furoate group also had lower nasal symptom scores (mean, 1.4 vs 2.9; median, 0 vs 2; P < .001) and was more satisfied (93.1% vs 43.5%; P < .001). No serious adverse event was recorded, and there was no difference between the treatments in any adverse event. CONCLUSIONS Prophylactic administration of mometasone furoate before the pollen season is safe and may lead to improved control of SAR compared with the use of nedocromil sodium.
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Affiliation(s)
- Constantinos Pitsios
- Department of Allergology and Clinical Immunology, Laikon General Hospital, Athens, Greece
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Krug N, Hohlfeld JM, Geldmacher H, Larbig M, Heermann R, Lavallee N, Nguyen DT, Petzold U, Hermann R. Effect of loteprednol etabonate nasal spray suspension on seasonal allergic rhinitis assessed by allergen challenge in an environmental exposure unit. Allergy 2005; 60:354-9. [PMID: 15679722 DOI: 10.1111/j.1398-9995.2005.00703.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Loteprednol etabonate (LE) is a novel soft steroid that was designed to improve the benefit/risk ratio of topical corticosteroid therapy. This study assesses the clinical efficacy and safety of three different doses of LE nasal spray in seasonal allergic rhinitis (SAR). METHODS In this single-center, double-blind, placebo-controlled, parallel-group trial 165 subjects with SAR to grass pollen received daily single doses of either 100, 200, 400 microg LE nasal spray, or placebo for 14 days. The patients underwent three 4-h allergen challenges with grass pollen in an environmental exposure unit at a screening visit (baseline) and on days 7 and 14 of treatment. Standardized nasal symptom scores were obtained every 20 min. Nasal flow, nasal secretions, and FEV(1) were measured every hour during allergen challenges. RESULTS After 14 days of treatment, patients who received 400 microg LE had significantly lower total nasal symptom scores compared with those receiving placebo (P = 0.007). LE400 reduced rhinorrhea, nasal congestion, nasal itching, the amount of nasal secretions, and improved nasal flow as compared with placebo (P < 0.05). LE100 and LE200 were not significantly different from placebo. All treatments were well tolerated. CONCLUSIONS Loteprednol 400 microg once daily is superior to placebo and the only effective dose tested in improving nasal symptoms and objective parameters in patients with SAR.
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Affiliation(s)
- N Krug
- Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
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Portnoy JM, Van Osdol T, Williams PB. Evidence-based strategies for treatment of allergic rhinitis. Curr Allergy Asthma Rep 2005; 4:439-46. [PMID: 15462709 DOI: 10.1007/s11882-004-0009-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this review, an evidence-based medicine approach to diagnosis and treatment for allergic rhinitis is reviewed. We performed a search of the medical literature for randomized, placebo-controlled trials of nonsedating antihistamines, intranasal corticosteroids, montelukast, azelastine, allergen immunotherapy, and anti-IgE. The mean numbers needed to treat were: nonsedating antihistamines--15.2; nasal corticosteroids--4.4; montelukast--14.3; azelastine--5.0; allergen immunotherapy--4.6; and anti-IgE--12.4. Treatment thresholds for use were: antihistamines--23%; nasal corticosteroids--8%; azelastine--16%; montelukast--8%; anti-IgE--50%; and immunotherapy--25%. When used appropriately, this information could become very useful for clinicians, particularly if cost, convenience, and other indirect factors can be included.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Evidence-Based Medicine
- Histamine H1 Antagonists/therapeutic use
- Humans
- Randomized Controlled Trials as Topic
- Rhinitis, Allergic, Perennial/diagnosis
- Rhinitis, Allergic, Perennial/drug therapy
- Rhinitis, Allergic, Perennial/prevention & control
- Rhinitis, Allergic, Seasonal/diagnosis
- Rhinitis, Allergic, Seasonal/drug therapy
- Rhinitis, Allergic, Seasonal/prevention & control
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Affiliation(s)
- Jay M Portnoy
- Section of Allergy, Asthma, and Immunology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Orhan F, Sekerel BE, Adalioglu G, Pinar M, Tuncer A. Effect of nasal triamcinolone acetonide on seasonal variations of bronchial hyperresponsiveness and bronchial inflammation in nonasthmatic children with seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2004; 92:438-45. [PMID: 15104196 DOI: 10.1016/s1081-1206(10)61780-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent evidence suggests that patients with allergic rhinitis have lower airway inflammation and a higher prevalence of bronchial hyperresponsiveness (BHR) regardless of asthma. OBJECTIVE To investigate markers of lower airway inflammation in nonasthmatic children with seasonal allergic rhinitis (SAR) before and during pollen season and the effect of nasal triamcinolone acetonide on seasonal variations in these parameters. METHODS Thirty-two nonasthmatic children with SAR in response to grass and/or weed pollens were recruited and separated into 2 groups. Group 1 was treated with triamcinolone acetonide (220 microg once daily) for 6 weeks, and group 2 received no intranasal corticosteroid treatment. Bronchial responsiveness to methacholine [concentration that caused a decrease in forced expiratory volume in 1 second of 20% (PC20)], eosinophil counts in sputum and peripheral blood, and eosinophil cationic protein (ECP) levels in sputum and serum were measured before and during grass pollen season. RESULTS Twenty-eight patients completed the study. During the pollen season, methacholine PC20 significantly decreased in both groups when compared with the corresponding preseasonal values (P = .01 and P = .003, respectively). The mean percentage of sputum eosinophils increased significantly during the pollen season compared with preseasonal values in group 1 and group 2 (12.7% +/- 2.1% vs 16.5% +/- 2.1%, P = .007, and 11.0% +/- 2.0% vs 20.2% +/- 1.4%, P = .003, respectively). Median [interquartile ranges (IQR)] sputum ECP levels were significantly higher during the pollen season when compared with the preseasonal values in group 1 and group 2 [7.5 microg/L (3.5-36.0 microg/L) vs 35.5 microg/L (13.0-71.7 microg/L), P = .04, and 18.0 microg/L (6.0-36.0 microg/L) vs 69.0 microg/L (39.0-195.0 microg/L), P = .003, respectively], as were the serum ECP levels [6.0 microg/L (2.0-13.0 microg/L) vs 19.0 microg/L (14.0-43.5 microg/L), P = .004, and 6.0 microg/L (3.0-7.0 microg/L) vs 18.0 microg/L (6.0-36.0 microg/L), P = .001, respectively]. Although the mean number of eosinophils in blood increased during the pollen season in both groups, it was only significant in group 2 (70.0 +/- 20.0 vs 161.6 +/- 29.0, P = .02). CONCLUSIONS Although prophylactic nasal corticosteroid treatment provides significant reduction of nasal symptoms and rescue antihistamine use, there is no significant prevention in the seasonal increase of bronchial inflammation and methacholine BHR.
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Affiliation(s)
- Fazil Orhan
- Faculty of Medicine, Department of Pediatric Allergy, Hacettepe University, Ankara, Turkey
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Nielsen LP, Dahl R. Comparison of intranasal corticosteroids and antihistamines in allergic rhinitis: a review of randomized, controlled trials. ACTA ACUST UNITED AC 2004; 2:55-65. [PMID: 14720022 DOI: 10.1007/bf03256639] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
For several years there has been discussion of whether first-line pharmacological treatment of allergic rhinitis should be antihistamines or intranasal corticosteroids. No well documented, clinically relevant differences seem to exist for individual nonsedating antihistamines in the treatment of allergic rhinitis. Likewise, the current body of literature does not seem to favor any specific intranasal corticosteroid. When comparing efficacy of antihistamines and intranasal corticosteroids in allergic rhinitis, present data favor intranasal corticosteroids. Interestingly, data do not support antihistamines as superior in treating conjunctivitis associated with allergic rhinitis. Safety data from comparative studies in allergic rhinitis do not indicate differences between antihistamines and intranasal corticosteroids. Combining antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis does not provide additional beneficial effects to intranasal corticosteroids alone. Considering present data, intranasal corticosteroids seem to offer superior relief in allergic rhinitis, when compared with antihistamines.
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Affiliation(s)
- Lars P Nielsen
- Department of Clinical Pharmacology, University of Aarhus, Aarhus, Denmark.
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Salib RJ, Howarth PH. Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis. Drug Saf 2004; 26:863-93. [PMID: 12959630 DOI: 10.2165/00002018-200326120-00003] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Intranasal corticosteroids and intranasal antihistamines are efficacious topical therapies in the treatment of allergic rhinitis. This review addresses their relative roles in the management of this disease, focusing on their safety and tolerability profiles. The intranasal route of administration delivers drug directly to the target organ, thereby minimising the potential for the systemic adverse effects that may be evident with oral therapy. Furthermore, the topical route of delivery enables the use of lower doses of medication. Such therapies, predominantly available as aqueous formulations following the ban of chlorofluorocarbon propellants, have minimal local adverse effects. Intranasal application of therapy can induce sneezing in the hyper-reactive nose, and transient local irritation has been described with certain formulations. Intranasal administration of corticosteroids is associated with minor nose bleeding in a small proportion of recipients. This effect has been attributed to the vasoconstrictor activity of the corticosteroid molecules, and is considered to account for the very rare occurrence of nasal septal perforation. Nasal biopsy studies do not show any detrimental structural effects within the nasal mucosa with long-term administration of intranasal corticosteroids. Much attention has focused on the systemic safety of intranasal application. When administered at standard recommended therapeutic dosage, the intranasal antihistamines do not cause significant sedation or impairment of psychomotor function, effects that would be evident when these agents are administered orally at a therapeutically relevant dosage. The systemic bioavailability of intranasal corticosteroids varies from <1% to up to 40-50% and influences the risk of systemic adverse effects. Because the dose delivered topically is small, this is not a major consideration, and extensive studies have not identified significant effects on the hypothalamic-pituitary-adrenal axis with continued treatment. A small effect on growth has been reported in one study in children receiving a standard dosage over 1 year, however. This has not been found in prospective studies with the intranasal corticosteroids that have low systemic bioavailability and therefore the judicious choice of intranasal formulation, particularly if there is concurrent corticosteroid inhalation for asthma, is prudent. There is no evidence that such considerations are relevant to shorter-term use, such as in intermittent or seasonal disease. Intranasal therapy, which represents a major mode of drug delivery in allergic rhinitis, thus has a very favourable benefit/risk ratio and is the preferred route of administration for corticosteroids in the treatment of this disease, as well as an important option for antihistaminic therapy, particularly if rapid symptom relief is required.
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Affiliation(s)
- Rami Jean Salib
- Respiratory Cell and Molecular Biology, Faculty of Medicine, Southampton General Hospital, Southampton, United Kingdom.
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Abstract
The increasing use of intranasal steroids in the management of allergic rhinitis reflects their efficacy, tolerability, and safety. However, issues related to the safety of intranasal steroids continue to generate debate and confusion among clinicians. Consequently, there is often reluctance and uncertainty in prescribing these effective agents for the treatment of perennial and seasonal allergic rhinitis. Issues of particular concern are whether intranasal steroids adversely affect various homeostatic systems, influence growth and bone metabolism, and compromise ocular function. Furthermore, the expanding role of intranasal steroids in the pediatric, geriatric, and postmenopausal populations has raised concerns that these agents may result in a steroid burden that more readily causes adverse effects. An extensive review of the literature overwhelmingly supports the assertion that intranasal steroids are safe in prescribed doses and should allay the misconceptions regarding their appropriate use in the management of allergic rhinitis.
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Affiliation(s)
- Michael S Benninger
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, MI 48202, USA.
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Tillmann HC, Stuck BA, Feuring M, Rossol-Haseroth K, Tran BM, Lösel R, Schmidt BM, Hörmann K, Wehling M, Schultz A. Delayed genomic and acute nongenomic action of glucocorticosteroids in seasonal allergic rhinitis. Eur J Clin Invest 2004; 34:67-73. [PMID: 14984440 DOI: 10.1111/j.1365-2362.2004.01293.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Glucocorticosteroids are effective in the treatment of allergic rhinitis, a disease characterized by a variety of symptoms, e.g. rhinorrhea and itching. The time course of symptomatic relief for allergic rhinitis by steroids has not been examined in detail to date, although the onset of steroid action is one of the main discriminations between genomic and nongenomic actions of steroids. We therefore investigated the time course of subjective and objective measures of nasal affection after steroid administration in patients with allergic rhinitis following specific allergen challenge. METHODS Six female and 18 male volunteers (median age 26 years) with a history of allergic rhinitis but currently free of symptoms were included in this randomized, placebo-controlled, double-blind, three-period crossover study. A single dose of either betamethasone (60 mg), methylprednisolone (400 mg) or placebo was given intravenously, 5 min after intranasal allergen provocation. After 10, 20, 60, 150 and 240 min, nasal itching and nasal obstruction were assessed using a standardized visual analogue scale. In addition, nasal airflow was measured by anterior rhinomanometry. RESULTS Nasal itching was markedly reduced following either of the two steroids within 10 min after administration of study drug. Itching was depressed by 38% following betamethasone (P<0.05) and by 18% following methylprednisolone (P=0.07) compared with placebo. Nasal airflow and nasal obstruction were not significantly altered by steroids during the first 2 h of the study. However, after 150 min, nasal airflow was 21% rsp. 19% higher after methylprednisolone and betamethasone (P<0.05) compared with placebo. After 240 min, nasal airflow was increased by 20% following betamethasone (P<0.05) and by 19% following methylprednisolone. Nasal obstruction was also beneficially affected by both steroids 150 and 240 min after administration compared with placebo (P<0.05 for both time points following betamethasone). CONCLUSION This study for the first time shows rapid in vivo effects of external glucocorticosteroids in humans. Itching, a pathophysiologically complex sensation, is favourably influenced by steroids within 10 min, therefore presumably via nongenomic mechanisms. Though no detailed mechanisms can be derived from this study, steroid interaction with receptors in the central nervous system may play an important role in mediating this effect.
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Affiliation(s)
- H-C Tillmann
- Institute of Clinical Pharmacology, University of Heidelberg, Mannheim, Germany
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Schenkel E. Features of mometasone furoate nasal spray and its utility in the management of allergic rhinitis. Expert Opin Pharmacother 2003; 4:1579-91. [PMID: 12943488 DOI: 10.1517/14656566.4.9.1579] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mometasone furoate aqueous nasal spray (NS; Nasonex, Schering Corporation), is a synthetic corticosteroid approved for the prophylaxis and treatment of seasonal allergic rhinitis (SAR) and the treatment of perennial allergic rhinitis (PAR) in patients >or= 12 years of age, and for the treatment of SAR and PAR in children as young as 2 years of age. Studies demonstrate that mometasone furoate NS is a potent, clinically effective and well-tolerated intranasal corticosteroid with negligible systemic activity and which offers the convenience of once-daily dosing.
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Affiliation(s)
- Eric Schenkel
- Valley Allergy and Asthma Treatment Center/Valley Clinical Research Center, Easton, PA, USA.
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Sugimoto Y, Ogawa M, Tai N, Kamei C. Inhibitory effects of glucocorticoids on rat eosinophil superoxide generation and chemotaxis. Int Immunopharmacol 2003; 3:845-52. [PMID: 12781701 DOI: 10.1016/s1567-5769(03)00055-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Eosinophil infiltration into inflammatory tissues and the subsequent release of inflammatory mediators are the hallmarks of several inflammatory allergic diseases. Although there have been a considerable number of publications on anti-inflammatory effects of glucocorticoids, little is known about whether glucocorticoids affect the activation of eosinophils directly. We studied the effects of three glucocorticoids, mometasone furoate, dexamethasone and beclomethasone dipropionate, on superoxide generation and the chemotaxis of rat eosinophils. Highly purified rat eosinophils were treated for 6 h with mometasone furoate, dexamethasone or beclomethasone dipropionate. Eosinophils were stimulated with phorbol myristate acetate (PMA) for superoxide generation, while for induction of chemotaxis, platelet-activating factor (PAF) or leukotriene B(4) (LTB(4)) was used. None of the glucocorticoids used in the present study caused significant suppressive effects on superoxide generation induced by PMA. On the other hand, both PAF- and LTB(4)-induced migration of rat eosinophils were inhibited in a concentration-dependent manner by glucocorticoids. Mometasone furoate showed a significant effect at concentrations higher than 10(-11) M. Dexamethasone and beclomethasone dipropionate also caused a significant inhibition at concentrations higher than 10(-8) and 10(-7) M, respectively. These results indicated that the anti-inflammatory effects of glucocorticoids were mediated by direct inhibition of eosinophil migration. Furthermore, mometasone furoate was suggested to be more useful than the other drugs in the treatment of allergic diseases responsible for eosinophil chemotaxis.
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Affiliation(s)
- Yukio Sugimoto
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, 700-8530, Okayama, Japan
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Hughes K, Glass C, Ripchinski M, Gurevich F, Weaver TE, Lehman E, Fisher LH, Craig TJ. Efficacy of the topical nasal steroid budesonide on improving sleep and daytime somnolence in patients with perennial allergic rhinitis. Allergy 2003; 58:380-5. [PMID: 12797340 DOI: 10.1034/j.1398-9995.2003.00093.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Improving quality of life is considered to be a major endpoint and motivation for clinical intervention in patients with perennial allergic rhinitis (PAR). In addition to classical symptoms of congestion, pruritus, and rhinorrhea, patients will often complain of not being able to sleep well at night and of feeling fatigued during the day. Like sleep apnea, PAR has also been shown to cause sleep disturbance and consequently worsen daytime fatigue and somnolence. HYPOTHESIS It is proposed that by decreasing nasal obstruction due to allergic rhinitis by treating with the topical steroid budesonide, symptoms of daytime fatigue and somnolence can be improved. METHODS Twenty-two subjects were enrolled in a double-blind, placebo-controlled, crossover study using Baalam's design. Patients were treated with either budesonide 128 g/day or placebo. Subjective data include the Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, Rhino-conjunctivitis Quality of Life Questionnaire, and a daily diary recording nasal symptoms, sleep problems, and daytime fatigue. RESULTS The results illustrated that the topical nasal corticosteroid significantly improved daytime fatigue (P = 0.03), somnolence (P = 0.02), and quality of sleep (P = 0.05) compared to placebo in patients suffering from PAR. SUMMARY Budesonide is able to improve congestion, sleep, and daytime somnolence.
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Affiliation(s)
- K Hughes
- College of Medicine, Hershey Medical Center, Hershey, PA, USA
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Haddad JJ, Saadé NE, Safieh-Garabedian B. Cytokines and neuro-immune-endocrine interactions: a role for the hypothalamic-pituitary-adrenal revolving axis. J Neuroimmunol 2002; 133:1-19. [PMID: 12446003 DOI: 10.1016/s0165-5728(02)00357-0] [Citation(s) in RCA: 301] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cytokines, peptide hormones and neurotransmitters, as well as their receptors/ligands, are endogenous to the brain, endocrine and immune systems. These shared ligands and receptors are used as a common chemical language for communication within and between the immune and neuroendocrine systems. Such communication suggests an immunoregulatory role for the brain and a sensory function for the immune system. Interplay between the immune, nervous and endocrine systems is most commonly associated with the pronounced effects of stress on immunity. The hypothalamic-pituitary-adrenal (HPA) axis is the key player in stress responses; it is well established that both external and internal stressors activate the HPA axis. Cytokines are chemical messengers that stimulate the HPA axis when the body is under stress or experiencing an infection. This review discusses current knowledge of cytokine signaling pathways in neuro-immune-endocrine interactions as viewed through the triplet HPA axis. In addition, we elaborate on HPA/cytokine interactions in oxidative stress within the context of nuclear factor-kappaB transcriptional regulation and the role of oxidative markers and related gaseous transmitters.
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Affiliation(s)
- John J Haddad
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco, School of Medicine, Medical Sciences, San Francisco, CA 94143-0542, USA.
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Abstract
Intranasal corticosteroids are accepted as safe and effective first-line therapy for allergic rhinitis. Several intranasal corticosteroids are available: beclomethasone dipropionate, budesonide, flunisolide, fluticasone propionate, mometasone furoate, and triamcinolone acetonide. All are efficacious in treating seasonal allergic rhinitis and as prophylaxis for perennial allergic rhinitis. In general, they relieve nasal congestion and itching, rhinorrhea, and sneezing that occur in the early and late phases of allergic response, with studies showing almost complete prevention of late-phase symptoms. The rationale for topical intranasal corticosteroids in the treatment of allergic rhinitis is that adequate drug concentrations can be achieved at receptor sites in the nasal mucosa. This leads to symptom control and reduces the risk of systemic adverse effects. Adverse reactions usually are limited to the nasal mucosa, such as dryness, burning and stinging, and sneezing, together with headache and epistaxis in 5-10% of patients regardless of formulation or compound. Differences among agents are limited to potency, patient preference, dosing regimens, and delivery, device and vehicle.
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Affiliation(s)
- Amanda J Trangsrud
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, Illinois, USA
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Bachert C, El-Akkad T. Patient preferences and sensory comparisons of three intranasal corticosteroids for the treatment of allergic rhinitis. Ann Allergy Asthma Immunol 2002; 89:292-7. [PMID: 12269650 DOI: 10.1016/s1081-1206(10)61957-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although they have comparable safety and efficacy profiles, different intranasal corticosteroids possess different sensory/chemical properties that can be easily differentiated by patients, and which may influence their preference and compliance. OBJECTIVE We sought to compare patient assessments of sensory attributes of three intranasal corticosteroid sprays: triamcinolone acetonide aqueous (TAA), fluticasone propionate (FP), and mometasone furoate (MF). METHODS In a multicenter, randomized, double-blind, crossover study, 95 patients with allergic rhinitis rated 14 sensory items (100-point scales), product preference, and likelihood of compliance with treatment. RESULTS Immediately after administration, compared with MF, TAA was rated as having significantly better comfort during administration, less irritation, less odor strength, preferred odor, more moistness of nose/throat, milder taste (all P < or = 0.001), and preferred taste (P < or = 0.01). Compared with FP, TAA was rated as having significantly less odor strength, preferred odor (both P < or = 0.001), more moistness of nose/throat (P < or = 0.01), and milder taste (P < or = 0.05). Two minutes after application, TAA was rated as having less aftertaste than FP (P < or = 0.01) or MF (P < or = 0.001), and produced significantly less irritation (FP P < or = 0.05; MF P < or = 0.01). Of patients, 54.7% said they would prefer a prescription of TAA over one for MF (24.2%; P = 0.001) or FP (21.1%; P = 0.001). More patients indicated that they would be more compliant with treatment if given the TAA prescription (67.4%) than if given a prescription with FP (54.7%) or MF (49.5%). CONCLUSION Several of the TAA sensory attributes were preferred over those of MF and FP. Patient preference may play a role in enhancing treatment compliance. Such findings indicate that TAA nasal spray may be a better choice than MF or FP in the treatment of seasonal and perennial allergic rhinitis.
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Affiliation(s)
- Claus Bachert
- Department of Ear, Nose, and Throat, University Hospital, Ghent, Belgium.
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Adams RJ, Fuhlbrigge AL, Finkelstein JA, Weiss ST. Intranasal steroids and the risk of emergency department visits for asthma. J Allergy Clin Immunol 2002; 109:636-42. [PMID: 11941313 DOI: 10.1067/mai.2002.123237] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND In patients with asthma, treatment for associated conditions, such as rhinitis, is recommended. It is unknown whether this treatment can reduce the risk for emergency department (ED) visits for asthma. OBJECTIVES We sought to determine whether treatment with intranasal steroids or prescription antihistamines in persons with asthma is associated with a reduced risk for ED visits caused by asthma. METHODS We performed a retrospective cohort study of members of a managed care organization aged greater than 5 years who were identified during the period of October 1991 to September 1994 as having a diagnosis of asthma by using a computerized medical record system. The main outcome measure was an ED visit for asthma. RESULTS Of the 13,844 eligible persons, 1031 (7.4%) had an ED visit for asthma. The overall relative risk (RR) for an ED visit among those who received intranasal corticosteroids, adjusted for age, sex, frequency of orally inhaled corticosteroid and beta-agonist dispensing, amount and type of ambulatory care for asthma, and diagnosis of an upper airways condition (rhinitis, sinusitis, or otitis media), was 0.7 (95% confidence interval [CI], 0.59-0.94). For those receiving prescription antihistamines, the risk was indeterminate (RR, 0.9; 95% CI, 0.78-1.11). When different rates of dispensing for intranasal steroids were examined, a reduced risk was seen in ED visits in those with greater than 0 to 1 (RR, 0.7; 95% CI, 0.57-0.99) and greater than 3 (RR, 0.5; 95% CI, 0.23-1.05) dispensed prescriptions per year. CONCLUSIONS Treatment of nasal conditions, particularly with intranasal steroids, confers significant protection against exacerbations of asthma leading to ED visits for asthma. These results support the use of intranasal steroids by individuals with asthma and upper airways conditions.
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Affiliation(s)
- Robert J Adams
- Department of Medicine, University of Adelaide, The Queen Elizabeth Hospital Campus, Woodville, Australia
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Ciprandi G, Tosca MA, Passalacqua G, Canonica GW. Intranasal mometasone furoate reduces late-phase inflammation after allergen challenge. Ann Allergy Asthma Immunol 2001; 86:433-8. [PMID: 11345288 DOI: 10.1016/s1081-1206(10)62491-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Allergen specific nasal challenge (ASNC) is an optimal model to study the pathophysiologic mechanisms sustaining allergic inflammation, particularly the adhesion molecules promoting cellular infiltration of nasal mucosa. Topical corticosteroids have been accepted as a highly effective anti-inflammatory therapy for allergic rhinitis. OBJECTIVE The aim of this double-blind, randomized, placebo-controlled study was the evaluation of inflammatory events, during the late-phase, after a 2-week treatment with nasal mometasone furoate (MF), 200 microg daily, or placebo, using the model of ASNC. METHODS A total of 42 patients with allergic rhinitis underwent nasal challenge before and after treatment. The following parameters were evaluated at baseline, and 6 hours (late-phase) after ASNC: 1) nasal symptoms (rhinorrhea, itching, sneezing, obstruction); 2) inflammatory cells (eosinophils and neutrophils); 3) eosinophil cationic protein (ECP) and tumor necrosis factor-alpha (TNF-alpha) in nasal lavage; and 4) intercellular adhesion molecule-1 expression on nasal epithelial cells. RESULTS MF nasal spray was associated with late-phase reductions of: 1) clinical symptoms (P < 0.03); 2) eosinophil (P < 0.004) and neutrophil (P < 0.003) infiltration; 3) ECP (P < 0.001) and TNF-alpha (P < 0.05); and 4) intercellular adhesion molecule-1 expression on nasal epithelial cells (P < 0.001). CONCLUSIONS The present results demonstrate that MF has a significant effect on late-phase events, reducing the cellular influx and activation.
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Affiliation(s)
- G Ciprandi
- Allergy & Respiratory Diseases, Department of Internal Medicine, University of Genoa, Italy.
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