The systemic safety of inhaled corticosteroid therapy: a focus on ciclesonide

Ciclesonide: A Pro-Soft Drug Approach for Mitigation of Side Effects of Inhaled Corticosteroids

Inhaled corticosteroids are used as one of the first-line drug therapy in patients with asthma. However, their long-term use is associated with various oropharyngeal and systemic side and adverse effects. Design of pro-soft drug is one of the strategies, which was adopted in the design of ciclesonide for mitigation of side effects usually observed with the use of inhaled corticosteroids. Ciclesonide, a pro-soft drug, is converted to an active metabolite desisobutyryl-ciclesonide in the lungs. The anti-inflammatory effect of desisobutyryl-ciclesonide is much higher than ciclesonide, and therefore, the local effect of the metabolite is higher with lower systemic side effects. Ciclesonide has favorable pharmacokinetic and pharmacodynamic properties as inhaled corticosteroid including low oral bioavailability, high plasma protein binding and rapid systemic clearance, high pulmonary deposition and distribution and long pulmonary residence duration. These advantageous properties make ciclesonide a very effective treatment option with low side effects. Various clinical studies support safety and efficacy of ciclesonide use in mild, moderate, and severe asthma patients.

Ciclesonide for the treatment of seasonal allergic rhinitis

Allergic rhinitis is considered one of the most common afflictions of humans, affecting up to 30% of the world's population, and is increasing in incidence. Primary symptoms, comorbid conditions and complications of this disorder exact a significant toll, resulting in an enormous physical, social and economic impact on society. Single-season allergic rhinitis accounts for approximately 20% of cases of allergic rhinitis with another 40% having mixed seasonal-perennial presentations. Management of this disorder encompasses several treatment options, with intranasal corticosteroids recommended as first-line treatment in moderate-to-severe seasonal allergic rhinitis in current practice parameters. Ciclesonide is the most recently approved product in this category for the management of seasonal allergic rhinitis and is the subject of this article.

Clinical pharmacokinetic and pharmacodynamic profile of inhaled ciclesonide

Asthma is a chronic inflammatory disease of the airways, and inhaled corticosteroids (ICSs) are recommended as first-line therapy for persistent asthma of all severities. Ciclesonide is a novel ICS, which is administered as an aerosol solution in a metered-dose inhaler, using hydrofluoroalkane-134a as a propellant. Because of the high respirable particle fraction, high pulmonary deposition is obtained in patients, which constitutes the basis of effective therapeutic action. The parent compound, ciclesonide, is pharmacologically inactive and is activated in the target organ, the lung, to form its only pharmacologically active metabolite, desisobutyryl-ciclesonide (des-CIC). Low oral deposition combined with minimal formation of des-CIC in the oropharynx may minimize the typical oropharyngeal adverse events associated with ICSs. Low oral bioavailability, rapid clearance and high protein binding reduce pharmacologically relevant systemic exposure. The unique pharmacokinetic and pharmacodynamic profile of ciclesonide offers a rationale that supports the favourable risk-benefit profile observed in clinical trials in patients with persistent asthma.

New treatment options in allergic rhinitis: patient considerations and the role of ciclesonide

Allergic rhinitis (AR) is a chronic inflammatory respiratory disease affecting 5%-50% of the worldwide population and its prevalence is increasing (Herman 2007). In addition, AR is associated with asthma and other co-morbidities such as conjunctivitis and sinusitis. The main symptoms are nasal congestion, rhinorrea, sneezing, itching, and post-nasal drainage induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. AR is not a life-threatening disease, but it has been shown to have a significant impact on quality of life. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines propose a classification of AR in intermittent and persistent, each graded as mild or moderate-severe, and provide a stepwise approach to the treatment. Inhaled steroids and antihistamine are the main tools in AR therapy but more safe and effective drugs are, however, needed. Inhaled steroid ciclesonide appears to be safe and effective.

New perspectives in the treatment of allergic rhinitis and asthma in children

PURPOSE OF REVIEW

Allergic rhinitis and asthma are some of the most prevalent chronic diseases in children. Meticulous evaluations of the therapeutic options and interventions are needed to control this burden. The central pathogenic mechanism is an immediate hypersensitivity reaction, followed by interventions in the allergic cascade. Once inflammation is established, potent anti-inflammatory agents or mediator antagonists could help control the phenomenon and reduce the characteristic symptoms related to severity.

RECENT FINDINGS

Monoclonal antibody against IgE has demonstrated its efficacy in reducing the symptoms of asthma and rhinitis. In difficult-to-treat asthma patients it allows a reduction in the dose of inhaled steroids, the number of exacerbations, emergency visits and hospitalizations. Its broad implementation is limited by its high cost because adverse events are not a concern. Specific sublingual immunotherapy gave promising results in clinical trials, while modifying immunoglobulins and cytokine profiles, also inducing T-cell tolerance. Safety issues of subcutaneous immunotherapy have been surpassed by the sublingual route, with equivalent efficacy. The new inhaled steroid ciclesonide is effective in established inflammation, is activated only in the respiratory system, and has negligible systemic effects.

SUMMARY

Robust evidence on the efficacy and safety of several novel therapies in rhinitis and asthma is available.