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Sousa-Pinto B, Vieira RJ, Brozek J, Cardoso-Fernandes A, Lourenço-Silva N, Ferreira-da-Silva R, Ferreira A, Gil-Mata S, Bedbrook A, Klimek L, Fonseca JA, Zuberbier T, Schünemann HJ, Bousquet J. Intranasal antihistamines and corticosteroids in allergic rhinitis: A systematic review and meta-analysis. J Allergy Clin Immunol 2024:S0091-6749(24)00419-6. [PMID: 38685482 DOI: 10.1016/j.jaci.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/08/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND There is insufficient systematized evidence on the effectiveness of individual intranasal medications in allergic rhinitis (AR). OBJECTIVES We sought to perform a systematic review to compare the efficacy of individual intranasal corticosteroids and antihistamines against placebo in improving the nasal and ocular symptoms and the rhinoconjunctivitis-related quality of life of patients with perennial or seasonal AR. METHODS The investigators searched 4 electronic bibliographic databases and 3 clinical trials databases for randomized controlled trials (1) assessing adult patients with seasonal or perennial AR and (2) comparing the use of intranasal corticosteroids or antihistamines versus placebo. Assessed outcomes included the Total Nasal Symptom Score, the Total Ocular Symptom Score, and the Rhinoconjunctivitis Quality-of-Life Questionnaire. The investigators performed random-effects meta-analyses of mean differences for each medication and outcome. The investigators assessed evidence certainty using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. RESULTS This review included 151 primary studies, most of which assessed patients with seasonal AR and displayed unclear or high risk of bias. Both in perennial and seasonal AR, most assessed treatments were more effective than placebo. In seasonal AR, azelastine-fluticasone, fluticasone furoate, and fluticasone propionate were the medications with the highest probability of resulting in moderate or large improvements in the Total Nasal Symptom Score and Rhinoconjunctivitis Quality-of-Life Questionnaire. Azelastine-fluticasone displayed the highest probability of resulting in moderate or large improvements of Total Ocular Symptom Score. Overall, evidence certainty was considered "high" in 6 of 46 analyses, "moderate" in 23 of 46 analyses, and "low"/"very low" in 17 of 46 analyses. CONCLUSIONS Most intranasal medications are effective in improving rhinitis symptoms and quality of life. However, there are relevant differences in the associated evidence certainty.
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Affiliation(s)
- Bernardo Sousa-Pinto
- CINTESIS@RISE, Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rafael José Vieira
- CINTESIS@RISE, Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jan Brozek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - António Cardoso-Fernandes
- CINTESIS@RISE, Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nuno Lourenço-Silva
- CINTESIS@RISE, Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Renato Ferreira-da-Silva
- CINTESIS@RISE, Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - André Ferreira
- MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Ophthalmology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Sara Gil-Mata
- CINTESIS@RISE, Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Ludger Klimek
- Department of Otolaryngology, Head and Neck Surgery, Universitätsmedizin Mainz, Mainz, Germany; Center for Rhinology and Allergology, Wiesbaden, Germany
| | - João A Fonseca
- CINTESIS@RISE, Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Torsten Zuberbier
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology, Immunology, and Allergology, Berlin, Germany
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jean Bousquet
- ARIA, Montpellier, France; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology, Immunology, and Allergology, Berlin, Germany.
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Marko M, Pawliczak R. Pharmacotherapy and immunotherapy of allergic rhinitis induced by house dust mite, grass, and birch pollen allergens: a meta-analysis of randomized clinical trials. Expert Rev Respir Med 2023; 17:607-621. [PMID: 37489655 DOI: 10.1080/17476348.2023.2241364] [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: 04/06/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND The aim of this study was to assess the efficacy and safety of oral antihistamines (AHs), intranasal antihistamines (INAH) intranasal glucocorticosteroids (INCS), subcutaneous immunotherapy (SCIT), and sublingual immunotherapy (SLIT) in the management of allergic rhinitis (AR). The authors focused on the division into selected AR's triggers: house dust mites (HDMs), grass pollen, and birch pollen. METHODS For each drug and allergen class, a meta-analysis of the efficacy and adverse events (AEs) was performed. The obtained results were presented as a therapeutic index (TIX-Score). RESULTS Twenty-seven randomized clinical trials (RCTs) were included. The best total efficacy was observed for: HDMs for INCS and grass pollen for combination of INCS with INAH in a single device and for INAH. Considering the data that was obtained for birch pollen, SLIT showed statistically significant total efficacy. Summation scores for efficacy and AEs showed highest TIX-Score for combination of INCS and INAH in a single device in grass pollen. CONCLUSIONS Treatment methods selected for this review may serve as an effective and safe treatment in reducing perennial and seasonal AR's symptoms. However, due to high heterogeneity probably associated with potential confounders existence in control in some cases, results should be interpreted with caution.
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Affiliation(s)
- Monika Marko
- Department of Immunopathology, Faculty of Medicine, Division of Biomedical Science, Medical University of Lodz, Lodz, Poland
| | - Rafał Pawliczak
- Department of Immunopathology, Faculty of Medicine, Division of Biomedical Science, Medical University of Lodz, Lodz, Poland
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Soe KK, Krikeerati T, Pheerapanyawaranun C, Niyomnaitham S, Phinyo P, Thongngarm T. Comparative efficacy and acceptability of licensed dose intranasal corticosteroids for moderate-to-severe allergic rhinitis: a systematic review and network meta-analysis. Front Pharmacol 2023; 14:1184552. [PMID: 37288109 PMCID: PMC10242043 DOI: 10.3389/fphar.2023.1184552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/09/2023] [Indexed: 06/09/2023] Open
Abstract
No evidence shows that one intranasal corticosteroid (INCS) is better than another for treating moderate-to-severe allergic rhinitis (AR). This network meta-analysis assessed the comparative efficacy and acceptability of licensed dose aqueous INCSs. PubMed/MEDLINE, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials were searched until 31 March 2022. Eligible studies included randomized controlled trials comparing INCSs with placebo or other types of INCSs in patients with moderate-to-severe allergic rhinitis. Two reviewers independently screened and extracted data following the Preferred Reporting Items in Systematic Reviews and Meta-analysis guideline. A random-effects model was used for data pooling. Continuous outcomes were expressed as standardized mean difference (SMD). The primary outcomes were the efficacy in improving total nasal symptom score (TNSS) and treatment acceptability (the study dropout). We included 26 studies, 13 with 5,134 seasonal AR patients and 13 with 4,393 perennial AR patients. Most placebo-controlled studies had a moderate quality of evidence. In seasonal AR, mometasone furoate (MF) was ranked the highest efficacy, followed by fluticasone furoate (FF), ciclesonide (CIC), fluticasone propionate and triamcinolone acetonide (TAA) (SMD -0.47, 95% CI: -0.63 to -0.31; -0.46, 95% CI: -0.59 to -0.33; -0.44, 95% CI: -0.75 to -0.13; -0.42, 95% CI: -0.67 to -0.17 and -0.41, 95% CI: -0.81 to -0.00), In perennial AR, budesonide was ranked the highest efficacy, followed by FF, TAA, CIC, and MF (SMD -0.43, 95% CI: -0.75 to -0.11; -0.36, 95% CI: -0.53 to -0.19; -0.32, 95% CI: -0.54 to -0.10; -0.29, 95% CI: -0.48 to -0.11; and -0.28, 95% CI: -0.55 to -0.01). The acceptability of all included INCSs was not inferior to the placebo. According to our indirect comparison, some INCSs have superior efficacy to others with moderate quality of evidence in most placebo-controlled studies for treating moderate-to-severe AR.
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Affiliation(s)
- Kay Khine Soe
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanachit Krikeerati
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chatkamol Pheerapanyawaranun
- Siriraj Institute of Clinical Research, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suvimol Niyomnaitham
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Torpong Thongngarm
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Humphrey TJL, Dosanjh D, Hiemstra TF, Richter A, Chen-Xu M, Qian W, Jha V, Gatley K, Adhikari R, Dowling F, Smith RM. PROphylaxis for paTiEnts at risk of COVID-19 infecTion (PROTECT-V). Trials 2023; 24:185. [PMID: 36915199 PMCID: PMC10009350 DOI: 10.1186/s13063-023-07128-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Despite the introduction of vaccination, there remains a need for pre-exposure prophylactic agents against SARS-CoV-2. Several patient groups are more vulnerable to SARS-CoV-2 infection by virtue of underlying health conditions, treatments received or suboptimal responses to vaccination. METHODS PROTECT-V is a platform trial testing pre-exposure prophylactic interventions against SARS-CoV-2 infection in vulnerable patient populations (organ transplant recipients; individuals with oncological/haematological diagnoses, immune deficiency or autoimmune diseases requiring immunosuppression or on dialysis). Multiple agents can be evaluated across multiple vulnerable populations sharing placebo groups, with the option of adding additional treatments at later time points as these become available. The primary endpoint is symptomatic SARS-CoV-2 infection, and each agent will be independently evaluated in real time when the required number of events occurs. Presently, three agents are approved in the platform: intranasal niclosamide, nasal and inhaled ciclesonide and intravenous sotrovimab. DISCUSSION Despite the introduction of vaccination, there remains a need for pre-exposure prophylactic agents against SARS-CoV-2. Several patient groups are more vulnerable to COVID-19 disease by virtue of underlying health conditions, treatments received or suboptimal responses to vaccination. TRIAL REGISTRATION ClinicalTrials.gov NCT04870333. EudraCT 2020-004144-28.
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Affiliation(s)
- Toby J L Humphrey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Davinder Dosanjh
- Birmingham and West Midlands Lung Research Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Alex Richter
- Birmingham and West Midlands Lung Research Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Michael Chen-Xu
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Wendi Qian
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Katrina Gatley
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rakshya Adhikari
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Francis Dowling
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rona M Smith
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- University of Cambridge, Cambridge, UK.
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Vinokurtseva A, Fung M, Ai Li E, Zhang R, Armstrong JJ, Hutnik CML. Impact of Inhaled and Intranasal Corticosteroids Exposure on the Risk of Ocular Hypertension and Glaucoma: A Systematic Review and Meta-Analysis. Clin Ophthalmol 2022; 16:1675-1695. [PMID: 35669010 PMCID: PMC9165658 DOI: 10.2147/opth.s358066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Anastasiya Vinokurtseva
- Department of Ophthalmology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Correspondence: Anastasiya Vinokurtseva, Department of Ophthalmology, Schulich School of Medicine and Dentistry, 268 Grosvenor St., London, ON, N6A 4V2, Canada, Tel +1 519.646.6100 x.66272, Fax +1 519.646.6410, Email
| | - Matthew Fung
- Department of Ophthalmology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Erica Ai Li
- Department of Pathology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Richard Zhang
- Department of Ophthalmology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - James J Armstrong
- Department of Ophthalmology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Department of Pathology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Cindy M L Hutnik
- Department of Ophthalmology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Department of Pathology, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Ivey Eye Institute, St Joseph’s Healthcare, London, Ontario, Canada
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The Effects of Intranasal, Inhaled and Systemic Glucocorticoids on Intraocular Pressure: A Literature Review. J Clin Med 2022; 11:jcm11072007. [PMID: 35407615 PMCID: PMC8999749 DOI: 10.3390/jcm11072007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 02/07/2023] Open
Abstract
Topical glucocorticoids are a well-known risk factor of intraocular pressure (IOP) elevation in one third of the general population and in up to 90% of glaucomatous patients. Whether this steroid response is caused by intranasal, inhaled or systemic glucocorticoids, is less known. This study presents an overview of the current literature on the topic, thereby providing guidance on when ophthalmological follow-up is indicated. A literature study was performed in Medline, and 31 studies were included for analysis. Twelve out of fourteen studies discussing intranasal glucocorticoids show no significant association with an elevated IOP. Regarding inhaled glucocorticoids, only three out of twelve studies show a significant association. The observed increase was either small or was only observed in patients treated with high inhaled doses or in patients with a family history of glaucoma. An elevated IOP caused by systemic glucocorticoids is reported by four out of the five included studies, with one study reporting a clear dose–response relationship. This review concludes that a steroid response can be triggered in patients treated with systemic glucocorticoids. Inhaled glucocorticoids may cause a significant IOP elevation when administered in high doses or in patients with a family history of glaucoma. At present, there is no evidence for a clinically significant steroid response caused by intranasally administered glucocorticoids.
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Zhang M, Ni JZ, Cheng L. Safety of intranasal corticosteroids for allergic rhinitis in children. Expert Opin Drug Saf 2022; 21:931-938. [PMID: 35199623 DOI: 10.1080/14740338.2022.2046731] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Allergic rhinitis (AR) is a common chronic inflammatory disease of the nasal mucosa, affecting about 10-40% of children worldwide. Intranasal corticosteroids (INCSs) are the first line anti-inflammatory drug in the treatment of pediatric AR. The systemic and local adverse effects of INCSs in children with AR should be assessed. AREAS COVERED Randomized controlled trials (RCTs) reporting local and systemic adverse effects of INCSs in pediatric populations with AR were searched out of PubMed and Embase. EXPERT OPINION Overall, INCSs displayed a favorable safety profile and high local-systemic balance of bioavailability with a low incidence of adverse events in the treatment of AR children. Nevertheless, the use of INCSs should be designed depending on one patient's response and adverse effects. The benefits and risks of INCSs should be assessed to ensure the clinical efficacy and avoid the insidious events.
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Affiliation(s)
- Min Zhang
- Department of Otorhinolaryngology & Clinical Allergy Center, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Jing-Zi Ni
- Department of Otorhinolaryngology & Clinical Allergy Center, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Lei Cheng
- Department of Otorhinolaryngology & Clinical Allergy Center, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China.,International Centre for Allergy Research, Nanjing Medical University, Nanjing, China
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Abstract
Paediatric rhinosinusitis (PDRS) is commonly used as a synonym for rhinitis within healthcare. Although they may share common symptoms, the pathophysiology does differ; PDRS is the inflammation of the nasal mucosa in addition to the sinuses whereas rhinitis is the inflammation of just nasal mucosa. This review provides a comprehensive overview of the epidemiology, pathophysiology, symptoms, diagnosis and management of PDRS. There is a greater emphasis on the diagnosis and management of PDRS within this review due to a lack of clear guidelines, which can lead to the common misconception that PDRS can be treated indifferently to rhinitis and other upper respiratory conditions. PDRS has detrimental effects on children's current health, long-term health into adulthood and education. Therefore, having a comprehensive guide of PDRS would provide a greater understanding of the condition as well as improved diagnosis and management. This article primarily focuses on the position of Europe and the United Kingdom; however, the recommendations can be applied to other countries as the causes and treatments would not differ significantly.
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Donaldson AM, Choby G, Kim DH, Marks LA, Lal D. Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Adults. Otolaryngol Head Neck Surg 2020; 163:1097-1108. [DOI: 10.1177/0194599820931455] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To address concerns related to the safety profile of both Food and Drug Administration (FDA)–approved and non–FDA-approved intranasal corticosteroid (INCS) use in the adult population. Data Source Systematic review of MEDLINE, PubMed, and EMBASE databases using a comprehensive search strategy including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles. Review Methods A structured literature search was conducted. Each study was graded for level of evidence using the Oxford Centre for Evidence-Based Medicine. Extracted data included population size, study design, drug (dosage, route, and frequency), presence of hypothalamus pituitary axis suppression, ocular symptoms, and treatment-related adverse events. Results A total of 60 studies met inclusion criteria. The studies included use of INCS as metered nasal sprays, drops, injections, aerosols, and irrigations. There were no persistent abnormalities in cortisol level or intraocular pressure change. Meta-analysis of epistaxis showed a significantly increased risk in the FDA-approved treatment group in comparison with control (risk ratio 1.56; 95% confidence interval, 1.13-2.14; P = .007). Conclusions Overall, it appears that the use of both FDA and published non-FDA application of INCS are safe in the adult population. Meta-analysis demonstrated an increased risk of epistaxis in patients using INCS compared with placebo. Otherwise, there was no significant difference between in adults in the treatment group and placebo group. As an important caveat, the interpretation of safety of nonstandard INCS is restricted to delivery methods and dosages published in the literature.
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Affiliation(s)
- Angela M. Donaldson
- Department of Otolaryngology Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Garret Choby
- Department of Otolaryngology Head and Neck Surgery, Mayo Clinic in Rochester, Rochester, New York, USA
| | - Daniel H. Kim
- Department of Pediatrics, University of California Irvine, Irvine, California, USA
| | - Lisa A. Marks
- Department of Neurological Surgery, Mayo Clinic in Arizona, Phoenix, Arizona, USA
| | - Devyani Lal
- Department of Otolaryngology Head & Neck Surgery, Mayo Clinic in Arizona, Phoenix, Arizona, USA
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Yang Q, Wang F, Li B, Wu W, Xie D, He L, Xiang N, Dong Y. The efficacy and safety of ciclesonide for the treatment of perennial allergic rhinitis: a systematic review and meta-analysis. Braz J Otorhinolaryngol 2019; 85:371-378. [PMID: 30522830 PMCID: PMC9442893 DOI: 10.1016/j.bjorl.2018.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/24/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction Allergic rhinitis is a chronic inflammatory disease which affects 1 out of 6 individuals. Perennial allergic rhinitis accounts for 40% of AR cases. Ciclesonide is one of the relatively new intranasal steroid for allergic rhinitis. Objective The purpose of this study was to evaluate the efficacy and safety of ciclesonide in the treatment of perennial allergic rhinitis. Methods We searched Pubmed, Scientific Citation Index, Embase, Clinical Trial Registries for randomized controlled trials and Cochrane Central Register of Controlled Trials to find out the randomized controlled Trial comparing ciclesonide with placebo for PAR. Results Eight studies were included. In comparison with placebo groups, ciclesonide groups significantly decreased Reflective Total Nasal Symptom Score (MD = −0.56; 95% CI −0.72 to 0.39, p < 0.00001) with heterogeneity (p = 0.19, I2 = 24%), Instantaneous Total Nasal Symptom Score (MD = −0.57; 95% CI −0.75 to −0.39, p < 0.00001) with heterogeneity (p = 0.34, I2 = 11%). A significant effect for Reflective Nasal Symptom Score Subtotal (MD = −0.15; 95% CI −0.18 to −0.13, p < 0.00001) with heterogeneity (p = 0.12, I2 = 24%) was also demonstrated. Rhinoconjunctivitis quality of life questionnaire score (RQLQs) (MD = −0.27; 95% CI −0.39 to −0.15, p < 0.00001) with heterogeneity (p = 0.58, I2 = 0%) in the treatment of ciclesonide was also significantly reduced. In addition, the difference in Treatment-Emergent Adverse Events between the two groups was not significant. Conclusion Ciclesonide can improve perennial allergic rhinitis without increasing adverse events. Ciclesonide may be another valuable choice for perennial allergic rhinitis in the future.
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Wu EL, Harris WC, Babcock CM, Alexander BH, Riley CA, McCoul ED. Epistaxis Risk Associated with Intranasal Corticosteroid Sprays: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2019; 161:18-27. [DOI: 10.1177/0194599819832277] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective Intranasal corticosteroids (INCSs) are widely utilized for the treatment of allergic rhinitis. Epistaxis is a known adverse effect of INCSs, but it is not known if the risk of epistaxis differs among INCSs. Data Sources Systematic review of primary studies identified through Medline, Embase, Web of Science, PubMed Central, and Cochrane databases. Review Methods Systematic review was conducted according to the PRISMA standard. English-language studies were queried through February 1, 2018. The search identified randomized controlled trials of INCSs for treatment of allergic rhinitis that reported incidence of epistaxis. An itemized assessment of the risk of bias was conducted for each included study, and meta-analysis was performed of the relative risk of epistaxis for each INCS. Results Of 949 identified studies, 72 met the criteria for analysis. Meta-analysis demonstrated an overall relative risk of epistaxis of 1.48 (95% CI, 1.32-1.67) for all INCSs. The INCSs associated with the highest risk of epistaxis were beclomethasone hydrofluoroalkane, fluticasone furoate, mometasone furoate, and fluticasone propionate. Beclomethasone aqueous, ciclesonide hydrofluoroalkane, and ciclesonide aqueous were associated with the lowest risk of epistaxis. Conclusions about epistaxis with use of budesonide, triamcinolone, and flunisolide are limited due to the low number of studies and high heterogeneity. Conclusions While a differential effect on epistaxis among INCS agents is not clearly demonstrated, this meta-analysis does confirm an increased risk of epistaxis for patients using INCSs as compared with placebo for treatment of allergic rhinitis.
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Affiliation(s)
- Eric L. Wu
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - William C. Harris
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Casey M. Babcock
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Bailin H. Alexander
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Charles A. Riley
- Department of Otolaryngology–Head and Neck Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Edward D. McCoul
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
- Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, School of Medicine, University of Queensland, New Orleans, Louisiana, USA
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Zimmerman KO, Smith PB, McMahon AW, Temeck J, Avant D, Murphy D, McCune S. Duration of Pediatric Clinical Trials Submitted to the US Food and Drug Administration. JAMA Pediatr 2019; 173:60-67. [PMID: 30452504 PMCID: PMC6526087 DOI: 10.1001/jamapediatrics.2018.3227] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The increasing prevalence of pediatric chronic disease has resulted in increased exposure to long-term drug therapy in children. The duration of recently completed drug trials that support approval for drug therapy in children with chronic diseases has not been systematically evaluated. Such information is a vital first step in forming safety pharmacovigilance strategies for drugs used for long-term therapy in children. Objective To characterize the duration of clinical trials submitted to the US Food and Drug Administration (FDA) for pediatric drug approvals, with a focus on drugs used for long-term therapy. Design and Setting A review was performed of all safety and efficacy clinical trials conducted under the Best Pharmaceuticals for Children Act or the Pediatric Research Equity Act and submitted to the FDA from September 1, 2007, to December 31, 2014, to support the approval of drugs frequently used for long-term therapy in children. Statistical analysis was performed from July 1, 2015, to December 31, 2017. Main Outcomes and Measures Maximum duration of trials submitted to support FDA approval of drugs for children. Results A total of 306 trials supporting 86 drugs intended for long-term use in children were eligible for the primary analysis. The drugs most commonly evaluated were for treatment of neurologic (25 [29%]), pulmonary (16 [19%]), and anti-infective (14 [16%]) indications. The median maximum trial duration by drug was 44 weeks (minimum, 1.1 week; maximum, 364 weeks). For nearly two-thirds of the drugs (52 [61%]), the maximum trial duration was less than 52 weeks. For 10 of the drugs (12%), the maximum trial duration was 3 years or more. Maximum duration of trials did not vary by therapeutic category, minimum age of enrollment, calendar year, or legislative mandate. Conclusions and Relevance Pediatric clinical trials designed to sufficiently investigate drug safety and efficacy to support FDA approval are of relatively limited duration. Given the potential long-term exposure of patients to these drugs, the clinical community should consider whether new approaches are needed to better understand the safety associated with long-term use of these drugs.
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Affiliation(s)
- Kanecia O Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Ann W McMahon
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, Maryland
| | - Jean Temeck
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, Maryland
| | - Debbie Avant
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, Maryland
| | - Dianne Murphy
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, Maryland
| | - Susan McCune
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, Maryland
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13
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Valenzuela CV, Liu JC, Vila PM, Simon L, Doering M, Lieu JEC. Intranasal Corticosteroids Do Not Lead to Ocular Changes: A Systematic Review and Meta-analysis. Laryngoscope 2018; 129:6-12. [PMID: 30229924 DOI: 10.1002/lary.27209] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The safety and efficacy of intranasal corticosteroids (INCS) are well established, but there remains apprehension that INCS could lead to systemic side effects, as with oral steroids. The objective of this systematic review was to assess whether the use of INCS lead to increased intraocular pressure (IOP) above 20 mm Hg, glaucoma, or formation of posterior subcapsular cataracts in adult patients with rhinitis. METHODS Two medical librarians searched the published literature for records discussing the use of "nasal steroids" in "rhinitis" and their effect on "intraocular pressure," "cataracts," or "glaucoma." RESULTS A total of 484 studies were identified, and 10 randomized controlled trials met our inclusion criteria. Meta-analysis of 2,226 patients revealed that the relative risk of elevated IOP in those who received INCS was 2.24 (95% confidence interval [CI]: 0.68 to 7.34) compared to placebo. The absolute increased incidence of elevated IOP in patients using INCS compared to placebo was 0.8% (95% CI: 0% to 1.6%). There were zero cases of glaucoma in both placebo and INCS groups at 12 months. The absolute increased incidence of developing a posterior subcapsular cataract was 0.02% (95% CI: -0.3% to 0.4%). CONCLUSIONS Use of INCS is not associated with a significant risk of elevating IOP or developing a posterior subcapsular cataract in patients with allergic rhinitis. Presence of glaucoma, however, is the real clinical adverse event of concern. There were zero reported cases of glaucoma at 12 months. Future studies should formally evaluate for glaucoma rather than use IOP measures as a surrogate. Laryngoscope, 129:6-12, 2019.
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Affiliation(s)
- Carla V Valenzuela
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - James C Liu
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Peter M Vila
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Laura Simon
- Bernard Becker Medical Library , Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Michelle Doering
- Bernard Becker Medical Library , Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
| | - Judith E C Lieu
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, U.S.A
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14
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Wise SK, Lin SY, Toskala E, Orlandi RR, Akdis CA, Alt JA, Azar A, Baroody FM, Bachert C, Canonica GW, Chacko T, Cingi C, Ciprandi G, Corey J, Cox LS, Creticos PS, Custovic A, Damask C, DeConde A, DelGaudio JM, Ebert CS, Eloy JA, Flanagan CE, Fokkens WJ, Franzese C, Gosepath J, Halderman A, Hamilton RG, Hoffman HJ, Hohlfeld JM, Houser SM, Hwang PH, Incorvaia C, Jarvis D, Khalid AN, Kilpeläinen M, Kingdom TT, Krouse H, Larenas-Linnemann D, Laury AM, Lee SE, Levy JM, Luong AU, Marple BF, McCoul ED, McMains KC, Melén E, Mims JW, Moscato G, Mullol J, Nelson HS, Patadia M, Pawankar R, Pfaar O, Platt MP, Reisacher W, Rondón C, Rudmik L, Ryan M, Sastre J, Schlosser RJ, Settipane RA, Sharma HP, Sheikh A, Smith TL, Tantilipikorn P, Tversky JR, Veling MC, Wang DY, Westman M, Wickman M, Zacharek M. International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis. Int Forum Allergy Rhinol 2018; 8:108-352. [PMID: 29438602 PMCID: PMC7286723 DOI: 10.1002/alr.22073] [Citation(s) in RCA: 217] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.
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Affiliation(s)
| | | | | | | | - Cezmi A. Akdis
- Allergy/Asthma, Swiss Institute of Allergy and Asthma Research, Switzerland
| | | | - Antoine Azar
- Allergy/Immunology, Johns Hopkins University, USA
| | | | | | | | | | - Cemal Cingi
- Otolaryngology, Eskisehir Osmangazi University, Turkey
| | | | | | | | | | | | | | - Adam DeConde
- Otolaryngology, University of California San Diego, USA
| | | | | | | | | | | | | | - Jan Gosepath
- Otorhinolaryngology, Helios Kliniken Wiesbaden, Germany
| | | | | | | | - Jens M. Hohlfeld
- Respiratory Medicine, Hannover Medical School, Airway Research Fraunhofer Institute for Toxicology and Experimental Medicine, German Center for Lung Research, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | - Amber U. Luong
- Otolaryngology, McGovern Medical School at the University of Texas Health Science Center Houston, USA
| | | | | | | | - Erik Melén
- Pediatric Allergy, Karolinska Institutet, Sweden
| | | | | | - Joaquim Mullol
- Otolaryngology, Universitat de Barcelona, Hospital Clinic, IDIBAPS, Spain
| | | | | | | | - Oliver Pfaar
- Rhinology/Allergy, Medical Faculty Mannheim, Heidelberg University, Center for Rhinology and Allergology, Wiesbaden, Germany
| | | | | | - Carmen Rondón
- Allergy, Regional University Hospital of Málaga, Spain
| | - Luke Rudmik
- Otolaryngology, University of Calgary, Canada
| | - Matthew Ryan
- Otolaryngology, University of Texas Southwestern, USA
| | - Joaquin Sastre
- Allergology, Hospital Universitario Fundacion Jiminez Diaz, Spain
| | | | | | - Hemant P. Sharma
- Allergy/Immunology, Children's National Health System, George Washington University School of Medicine, USA
| | | | | | | | | | | | - De Yun Wang
- Otolaryngology, National University of Singapore, Singapore
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15
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Seidman MD, Gurgel RK, Lin SY, Schwartz SR, Baroody FM, Bonner JR, Dawson DE, Dykewicz MS, Hackell JM, Han JK, Ishman SL, Krouse HJ, Malekzadeh S, Mims JWW, Omole FS, Reddy WD, Wallace DV, Walsh SA, Warren BE, Wilson MN, Nnacheta LC. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015; 152:S1-43. [PMID: 25644617 DOI: 10.1177/0194599814561600] [Citation(s) in RCA: 372] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options. PURPOSE The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients. ACTION STATEMENTS The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.
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Affiliation(s)
- Michael D Seidman
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford West Bloomfield Hospital West Bloomfield, Michigan, USA
| | - Richard K Gurgel
- Department of Surgery Otolaryngology-Head and Neck Surgery University of Utah, Salt Lake City, Utah, USA
| | - Sandra Y Lin
- Johns Hopkins School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, USA
| | | | - Fuad M Baroody
- University of Chicago Medical Center, Department of Otolaryngology, Chicago, Illinois, USA
| | | | | | - Mark S Dykewicz
- Department of Internal Medicine, St Louis University School of Medicine, St Louis, Missouri, USA
| | | | - Joseph K Han
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | - William D Reddy
- Acupuncture and Oriental Medicine (AAAOM), Annandale, Virginia, USA
| | - Dana V Wallace
- Florida Atlantic University, Boca Raton, Florida and Nova Southeastern University, Davie, Florida, USA
| | - Sandra A Walsh
- Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Barbara E Warren
- Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Meghan N Wilson
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Lorraine C Nnacheta
- Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Verkerk MM, Bhatia D, Rimmer J, Earls P, Sacks R, Harvey RJ. Intranasal Steroids and the Myth of Mucosal Atrophy: A Systematic Review of Original Histological Assessments. Am J Rhinol Allergy 2015; 29:3-18. [DOI: 10.2500/ajra.2015.29.4111] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Intranasal corticosteroids (INCSs) are well established in the treatment of allergic rhinitis, chronic rhinosinusitis, and nasal polyposis. Although reversible atrophy of keratinized skin is seen with corticosteroids, the respiratory mucosa is histologically very different and but concerns remain among patients and some health-care professionals over local side effects on nasal respiratory mucosa. A systematic review and meta-analysis were performed of the available evidence for nasal mucosal atrophy as an adverse effect of INCSs in patients with sinonasal disease. Methods A systematic search of Embase (1974-) and Medline (1946-) databases to September 27, 2013 was performed. Inclusion criteria selected any study where the histopathology of nasal mucosa was assessed in patients with sinonasal disease using intranasally administered corticosteroids with or without a control group. Results Twenty-three hundred sixty-four publications were retrieved with a subsequent full text review of 149 publications for 34 articles that met the selection criteria. These articles included 11 randomized controlled trials, 5 cohorts, and 20 case series. Duration of treatment varied from 5 days to 5.5 years. “Mucosal atrophy” as an outcome was reported in 17 studies. The definition of “mucosal atrophy” was highly variable with a definition given in only 10 studies. One hundred thirty-six patients were represented in controlled studies of atrophy with only one study reporting the event in both groups with an odds ratio of “mucosal atrophy” at 0.51 (95% CI, 0.09-3.11; p = 0.47). Conclusion The concept of nasal mucosal atrophy is poorly defined and there is no histological evidence for deleterious effects from INCS use on human nasal mucosa.
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Affiliation(s)
- Misha M. Verkerk
- Department of Otolaryngology, Head and Neck Surgery, and Freeman Hospital, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Daman Bhatia
- Department of Otolaryngology, Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia
| | - Janet Rimmer
- Department of Thoracic Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Peter Earls
- Department of Pathology, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Raymond Sacks
- Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney, and Macquarie University, Sydney, New South Wales, Australia
| | - Richard J. Harvey
- Department of Otolaryngology, Head and Neck Surgery, St. Vincent's Hospital, University of New South Wales, and Macquarie University, Sydney, New South Wales, Australia
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Abstract
Because of its burden on patient's lives and its impact on asthma, allergic rhinitis must be treated properly with more effective and safer treatments. According to guidelines by Allergic Rhinitis and Its Impact on Asthma (ARIA), the classification, pathogenesis, and treatment of allergic rhinitis are well defined. Currently, second-generation antihistamines and inhaled steroids are considered the cornerstone of first-line therapy. However, new formulations of available drugs (e.g., loratadine and rupatadine oral solution, ebastine fast-dissolving tablets, and the combination of intranasal fluticasone propionate and azelastine hydrochloride), recently discovered molecules (e.g., ciclesonide, bilastine, and phosphodiesterase-4 inhibitors), immunologic targets (e.g., omalizumab), and unconventional treatments (e.g., homeopathic treatments) are currently under investigation and represent a new frontier in modern medicine and in allergic rhinitis management. The aim of this review is to provide an update on allergic rhinitis treatment, paying particular attention to clinical trials published within the past 20 months that assessed the efficacy and safety of new formulations of available drugs or new molecules.
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Roberts G, Xatzipsalti M, Borrego LM, Custovic A, Halken S, Hellings PW, Papadopoulos NG, Rotiroti G, Scadding G, Timmermans F, Valovirta E. Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology. Allergy 2013; 68:1102-16. [PMID: 23952296 DOI: 10.1111/all.12235] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2013] [Indexed: 12/13/2022]
Abstract
Rhinitis is a common problem in childhood and adolescence and impacts negatively on physical, social and psychological well-being. This position paper, prepared by the European Academy of Allergy and Clinical Immunology Taskforce on Rhinitis in Children, aims to provide evidence-based recommendations for the diagnosis and therapy of paediatric rhinitis. Rhinitis is characterized by at least two nasal symptoms: rhinorrhoea, blockage, sneezing or itching. It is classified as allergic rhinitis, infectious rhinitis and nonallergic, noninfectious rhinitis. Similar symptoms may occur with other conditions such as adenoidal hypertrophy, septal deviation and nasal polyps. Examination by anterior rhinoscopy and allergy tests may help to substantiate a diagnosis of allergic rhinitis. Avoidance of relevant allergens may be helpful for allergic rhinitis (AR). Oral and intranasal antihistamines and nasal corticosteroids are both appropriate for first-line AR treatment although the latter are more effective. Once-daily forms of corticosteroids are preferred given their improved safety profile. Potentially useful add-on therapies for AR include oral leukotriene receptor antagonists, short bursts of a nasal decongestant, saline douches and nasal anticholinergics. Allergen-specific immunotherapy is helpful in IgE-mediated AR and may prevent the progression of allergic disease. There are still a number of areas that need to be clarified in the management of rhinitis in children and adolescents.
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Affiliation(s)
| | - M. Xatzipsalti
- First Department of Pediatrics; P. & A. Kyriakou Children's Hospital; Athens; Greece
| | | | - A. Custovic
- Manchester Academic Health Science Centre; NIHR Respiratory and Allergy Clinical Research Facility; The University of Manchester; University Hospital of South Manchester NHS Foundation Trust; Manchester; UK
| | - S. Halken
- Hans Christian Andersen Children's Hospital; Odense University Hospital; Odense; Denmark
| | - P. W. Hellings
- Department of Otorhinolaryngology, Head and Neck Surgery; University Hospitals of Leuven; Catholic University of Leuven; Leuven; Belgium
| | - N. G. Papadopoulos
- Allergy Department; 2nd Pediatric Clinic; University of Athens; Athens; Greece
| | | | - G. Scadding
- Royal National Throat Nose and Ear; Hospital - Part of UCL Hospitals NHS Foundation Trust; London; UK
| | - F. Timmermans
- Nederlands Anafylaxis Netwerk; Dordrecht; the Netherlands
| | - E. Valovirta
- Terveystalo Turku; Allergy Clinic; University of Turku; Turku; Finland
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Berger WE, Mohar DE, LaForce C, Raphael G, Desai SY, Huang H, Hinkle J. A 26-week tolerability study of ciclesonide nasal aerosol in patients with perennial allergic rhinitis. Am J Rhinol Allergy 2012; 26:302-7. [PMID: 22801019 DOI: 10.2500/ajra.2012.26.3773] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A new, hydrofluoroalkane nasal aerosol solution formulation of ciclesonide (CIC-HFA) delivered via a metered dose inhaler is currently in clinical development for treatment of allergic rhinitis. OBJECTIVE To study tolerability and quality of life following administration of CIC-HFA 74- or 148-μg doses once-daily compared with placebo in patients with perennial allergic rhinitis (PAR) over 26 weeks. METHODS Patients ≥12 years of age with a ≥2 year history of PAR were randomized in a placebo-controlled, double-blind, parallel group, multicenter study to CIC-HFA 74 μg, 148 μg, or placebo QD AM for 26 weeks. Safety was assessed by monitoring treatment-emergent adverse events (TEAEs). Quality of life was assessed by using a rhinoconjunctivitis quality of life questionnaire with standardized activities (RQLQ[S]) in patients with baseline RQLQ ≥3.00. Reflective total nasal symptom scores (rTNSS) and instantaneous total nasal symptom scores (iTNSS) over 26 weeks were also evaluated. RESULTS In this study, 1111 patients were randomized. The overall incidence of TEAEs was comparable between the treatment groups. Treatment with CIC-HFA 74- or 148-μg doses showed improvements in RQLQ[S] [least squares (LS) mean change 0.40 and 0.37, respectively from baseline, p < 0.01 versus placebo for both], rTNSS (LS mean change 0.65 and 0.52, respectively from baseline; p ≤ 0.01 versus placebo for both), and iTNSS (LS mean change 0.51 and 0.42, respectively from baseline; p < 0.05 versus placebo for both) from baseline. CONCLUSION In this study, once-daily treatment with CIC-HFA 74- or 148-μg doses over 26 weeks was well tolerated with comparable incidence of TEAEs between the treatment groups.
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20
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Nathan RA. Intranasal steroids in the treatment of allergy-induced rhinorrhea. Clin Rev Allergy Immunol 2011; 41:89-101. [PMID: 20514529 DOI: 10.1007/s12016-010-8206-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
While nasal congestion has been identified as one of the most bothersome and prevalent symptoms of allergic rhinitis, it is underappreciated that many patients find rhinorrhea also to be bothersome. Rhinorrhea as a symptom of allergic rhinitis virtually never occurs alone; about 97% of patients with allergic rhinitis suffer from at least two symptoms, a finding that underscores the advantage of treating a broad range of symptoms with a single medication. Along with sneezing and nasal obstruction, rhinorrhea is a classic acute symptom of allergic rhinitis; it appears as a late-phase symptom as well. In this review, the characterization and epidemiology of rhinorrhea, the pathophysiology of rhinorrhea in allergic rhinitis, the roles played by mediators in early- and late-phase rhinorrhea, the prevalence and impact of this symptom, and the efficacy and safety of available treatment options are all discussed in context of relevant literature. A review of the clinical studies assessing the efficacy of intranasal corticosteroids (INS) for rhinorrhea is presented. Many clinical studies and several meta-analyses conclusively demonstrate that, in addition to being safe and well-tolerated, INS are more effective than other agents (including oral and intranasal antihistamines) across the spectrum of AR symptoms, including rhinorrhea and nasal congestion.
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Affiliation(s)
- Robert A Nathan
- Asthma and Allergy Associates, Colorado Springs, CO 80907, USA.
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21
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An investigation of the pharmacokinetics, pharmacodynamics, safety, and tolerability of ciclesonide hydrofluoroalkane nasal aerosol in healthy subjects and subjects with perennial allergic rhinitis. Pulm Pharmacol Ther 2011; 24:426-33. [DOI: 10.1016/j.pupt.2011.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 03/25/2011] [Accepted: 04/03/2011] [Indexed: 11/20/2022]
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Treatment of seasonal allergic conjunctivitis with ophthalmic corticosteroids: in search of the perfect ocular corticosteroids in the treatment of allergic conjunctivitis. Curr Opin Allergy Clin Immunol 2010; 10:469-77. [DOI: 10.1097/aci.0b013e32833dfa28] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Meltzer EO, Caballero F, Fromer LM, Krouse JH, Scadding G. Treatment of congestion in upper respiratory diseases. Int J Gen Med 2010; 3:69-91. [PMID: 20463825 PMCID: PMC2866555 DOI: 10.2147/ijgm.s8184] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Indexed: 12/19/2022] Open
Abstract
Congestion, as a symptom of upper respiratory tract diseases including seasonal and perennial allergic rhinitis, acute and chronic rhinosinusitis, and nasal polyposis, is principally caused by mucosal inflammation. Though effective pharmacotherapy options exist, no agent is universally efficacious; therapeutic decisions must account for individual patient preferences. Oral H1-antihistamines, though effective for the common symptoms of allergic rhinitis, have modest decongestant action, as do leukotriene receptor antagonists. Intranasal antihistamines appear to improve congestion better than oral forms. Topical decongestants reduce congestion associated with allergic rhinitis, but local adverse effects make them unsuitable for long-term use. Oral decongestants show some efficacy against congestion in allergic rhinitis and the common cold, and can be combined with oral antihistamines. Intranasal corticosteroids have broad anti-inflammatory activities, are the most potent long-term pharmacologic treatment of congestion associated with allergic rhinitis, and show some congestion relief in rhinosinusitis and nasal polyposis. Immunotherapy and surgery may be used in some cases refractory to pharmacotherapy. Steps in congestion management include (1) diagnosis of the cause(s), (2) patient education and monitoring, (3) avoidance of environmental triggers where possible, (4) pharmacotherapy, and (5) immunotherapy (for patients with allergic rhinitis) or surgery for patients whose condition is otherwise uncontrolled.
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Affiliation(s)
- Eli O Meltzer
- Allergy and Asthma Medical Group and Research Center, San Diego, CA and Department of Pediatrics, University of California, San Diego, USA
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LaForce C, van Bavel J, Meltzer EO, Wingertzahn MA. Efficacy and safety of ciclesonide hydrofluoroalkane nasal aerosol once daily for the treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2009; 103:166-73. [PMID: 19739431 DOI: 10.1016/s1081-1206(10)60171-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aerosol-based corticosteroid nasal formulations may be preferred over current aqueous nasal sprays by some patients because they traditionally cause less pharyngeal and anterior nose runoff. OBJECTIVE To determine the optimal dose, safety, and tolerability of ciclesonide hydrofluoroalkane nasal aerosol in patients with seasonal allergic rhinitis (SAR). METHODS Patients 12 years or older with a history of SAR received ciclesonide hydrofluoroalkane nasal aerosol to a total dose of 75, 150, or 300 microg or placebo once daily (half dose per nostril) for 2 weeks. The primary efficacy assessment was patient-reported average morning and evening reflective (24-hour) total nasal symptom scores (rTNSS). Secondary efficacy assessments included patient-reported average morning and evening instantaneous TNSS (iTNSS), patient-reported morning iTNSS, physician-assessed nasal signs and symptom severity, and Rhinoconjunctivitis Quality of Life Questionnaire responses. Safety and tolerability were also assessed. RESULTS Ciclesonide hydrofluoroalkane nasal aerosol demonstrated a statistically significantly greater reduction from baseline in average morning and evening rTNSS (24-hour) vs placebo, with treatment differences as follows: 0.81 (P = .001; 300 microg), 0.90 (P < .001; 150 microg), and 0.66 (P = .01; 75 microg). Improvements in average morning and evening iTNSS and patient-reported morning iTNSS were also significantly improved regardless of dose (P < or = .003 for all ciclesonide groups vs placebo). The incidence of treatment-related adverse events was low (< 1.6% for all) and similar among groups. CONCLUSIONS Ciclesonide hydrofluoroalkane nasal aerosol demonstrated statistically significant improvements in SAR symptoms vs placebo. On the basis of comparable efficacy and safety profiles observed for all doses, these results suggest that the 75-microg and 150-microg doses of ciclesonide hydrofluoroalkane appear appropriate for further evaluation of efficacy.
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Affiliation(s)
- Craig LaForce
- North Carolina Clinical Research, Raleigh, North Carolina 27607, USA.
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Abstract
BACKGROUND Allergy affects about 50% of the pediatric population globally. Allergic rhinitis (AR), one form of allergy, causes considerable impairment in quality of life, including disruption of sleep and, in children, interference with school attendance and performance. SCOPE Traditional formulations and delivery systems - tablets, capsules, or intranasal sprays - successfully used by adults for treatment of AR may not be as easily administered in children. Liquid oral medications are more readily taken by children but contain sugars and excipients; they can also be inconvenient with less accurate dosing and are associated with dental caries and gastrointestinal upset. METHODOLOGY This review evaluated medications for treatment of AR currently available for pediatric patients and identified the attitudes of parents and health care professionals toward these medications. Guidelines from international organizations and governmental websites were reviewed for recommendations and product labeling requirements. A Medline search was conducted using the terms dyes, excipients, palatability, prescribing habits, sugar, among others. FINDINGS In recent years, governmental regulatory agencies and professional organizations in Europe and the United States have recommended avoidance of sugar in pediatric medicines and required stricter labeling of their ingredients. Public awareness about the adverse effects of sugar and some excipients has also increased, and parents more frequently express the desire for safer and more convenient medicines for their children. In response, more sugar-free, dye-free liquid medicines and other formulations, such as granules, filmstrips, chewable tablets, fast-dissolving tablets, and drops, are becoming available for pediatric use. LIMITATIONS Data from well-designed trials conducted in children for the treatment of AR are lacking. In addition, the possibility of a social response bias may exist for parents and physicians about sugar and other ingredients in children's medications. CONCLUSION Treatment for AR is often long-term, particularly in persistent AR; therefore, safety, tolerability, convenience, and patient/parental acceptance are important considerations when deciding which medication to prescribe.
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Affiliation(s)
- Glenis Scadding
- Royal National Throat Nose & Ear Hospital, London WC1X 8DA, UK.
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27
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Benninger M. Diagnosis and management of nasal congestion: the role of intranasal corticosteroids. Postgrad Med 2009; 121:122-31. [PMID: 19179820 DOI: 10.3810/pgm.2009.01.1961] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Nasal congestion is considered the most bothersome of allergic rhinitis (AR) symptoms and can significantly impair ability to function at work, home, and school. Effective management of AR-related nasal congestion depends on accurate diagnosis and appropriate treatment. Many individuals with AR and AR-related congestion remain undiagnosed and do not receive prescription medication. However, new tools intended to improve the diagnosis of nasal congestion have been developed and validated. Intranasal corticosteroids (INSs) are recommended as first-line therapy for patients with moderate-to-severe AR and also when nasal congestion is a prominent symptom. Double blind, randomized clinical trials have demonstrated greater efficacy of INSs versus placebo, antihistamines, or montelukast for relief of all nasal symptoms, especially congestion. Patient adherence to treatment also affects outcomes, and this may be influenced by patient preferences for the sensory attributes of an individual drug. Increased awareness of the effects of AR-related nasal congestion, the efficacy and safety of available pharmacotherapies, and barriers to adherence may improve clinical outcomes.
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Affiliation(s)
- Michael Benninger
- The Cleveland Clinic, Head and Neck Institute, Cleveland, OH 44195, USA.
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Couroux P, Kunjibettu S, Hall N, Wingertzahn MA. Onset of action of ciclesonide once daily in the treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2009; 102:62-8. [DOI: 10.1016/s1081-1206(10)60110-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Williams B, Smith WB, Kette FE. Intranasal ciclesonide for allergic rhinitis. J Asthma Allergy 2008; 1:49-54. [PMID: 21436985 PMCID: PMC3121337 DOI: 10.2147/jaa.s3082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ciclesonide is a novel corticosteroid which is optimized for topical use. It is a pro-drug which is activated locally in the airway mucosa, lipid-conjugated for local retention, and has very high protein binding in circulation leading to low systemic bioavailability. These characteristics should lead to highly selective activity with reduced local and systemic side effects. It has been established as an inhaled medication for asthma and has also been shown in double-blind trials to be efficacious for the treatment of seasonal and perennial allergic rhinitis. However no data have yet demonstrated superiority over existing nasal topical corticosteroids, either in terms of efficacy or adverse effects, and trials have not yet clearly shown efficacy in rhinitis in children. Therefore the place of ciclesonide in the treatment of allergic rhinitis relative to other existing products remains unclear.
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Affiliation(s)
- Ben Williams
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide South Australia
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30
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Abstract
Ciclesonide nasal spray delivers the corticosteroid ciclesonide as a hypotonic spray via a metered-dose manual pump. Systemic exposure to ciclesonide and its active metabolite desisobutyryl-ciclesonide is low after intranasal administration. High protein binding (approximately 99%) and rapid first-pass clearance further reduce systemic exposure to the drug. In well designed trials, intranasal ciclesonide 200 microg once daily for 2-4 weeks was more effective than placebo in terms of improving nasal symptoms in adolescents and adults with moderate to severe seasonal allergic rhinitis. Quality of life measures were statistically significantly improved in ciclesonide relative to placebo recipients during the first 2 weeks of therapy. Similarly, in adolescents and adults with moderately severe perennial allergic rhinitis, ciclesonide 200 microg once daily was more effective than placebo in terms of reducing nasal symptoms in well designed trials of 6 weeks' and 1 year's duration. Improvements relative to placebo in quality of life measures were not considered clinically relevant. Ciclesonide nasal spray was generally well tolerated in these clinical trials; most adverse events were mild to moderate in intensity.
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Affiliation(s)
- Sohita Dhillon
- Wolters Kluwer Health/Adis, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore 0754, Auckland, New Zealand.
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Berger WE, Nayak A, Lanier BQ, Kaiser HB, LaForce C, Darken P, Hall N, Wingertzahn M. Efficacy and Safety of Once-Daily Ciclesonide Nasal Spray in Children With Allergic Rhinitis. ACTA ACUST UNITED AC 2008. [DOI: 10.1089/pai.2007.0022.73] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Patel P, Patel D, Kunjibettu S, Hall N, Wingertzahn MA. Onset of Action of Ciclesonide Once Daily in the Treatment of Seasonal Allergic Rhinitis. EAR, NOSE & THROAT JOURNAL 2008. [DOI: 10.1177/014556130808700612] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ciclesonide is an intranasal corticosteroid approved for the treatment of allergic rhinitis. We conducted a randomized, double-blind, parallel-group, placebo-controlled study to evaluate the time to onset of action of ciclesonide 200 μg once daily in 502 adults with seasonal allergic rhinitis of at least 2 years’ duration. To trigger immunologic priming, patients underwent between one and five priming sessions with exposure to 3,500 grains/m3 (±500) of ragweed pollen in an environmental exposure chamber. The criteria for a successful priming session was a patient-assessed instantaneous total nasal symptom score of at least 6 (of a possible 12) and a nasal congestion or rhinorrhea score of at least 2 (of a possible 3) 90 minutes after allergen exposure during at least two consecutive priming sessions. Patients were then randomly assigned to receive either a single dose of ciclesonide 200 μg (n = 251) or placebo (n = 251) administered intranasally. The difference in the change from baseline total nasal symptom scores in the two groups was assessed hourly for 12 hours after administration. Onset of action was determined to have taken place the first time that the effects of ciclesonide, as reflected in the total nasal symptom score, were significantly greater than those of placebo at a particular hourly assessment, provided that the subsequent hourly assessment also showed a statistically significant difference. The onset of action of ciclesonide occurred within 1 hour of administration (p = 0.01 vs. placebo), and the significant difference in total nasal symptom scores between ciclesonide and placebo was maintained through post-treatment hour 12 (p ≤ 0.018).
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Affiliation(s)
- Piyush Patel
- From Allied Research International, Mississauga, Ont
| | - Deepen Patel
- From Allied Research International, Mississauga, Ont
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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