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Hossenbaccus L, Linton S, Ramchandani R, Burrows AG, Ellis AK. Study of Cat Allergy Using Controlled Methodology-A Review of the Literature and a Call to Action. FRONTIERS IN ALLERGY 2022; 3:828091. [PMID: 35386639 PMCID: PMC8974834 DOI: 10.3389/falgy.2022.828091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
The prevalence of cat allergen-induced AR is increasing worldwide, prompting its study using controlled methodology. Three general categories of allergen exposure models currently exist for the study of cat allergen-induced AR: natural exposure cat rooms, allergen exposure chambers (AEC), and nasal allergen challenges (NAC). We evaluated existing literature surrounding the use of these models to study cat allergen induced AR using online research databases, including OVID Medline, Embase, and Web of Science. We report that natural exposure cat rooms have been important in establishing the foundation for our understanding of cat allergen-induced AR. Major limitations, including variable allergen ranges and differing study designs highlight the need for a more standardized protocol. In comparison, AECs are an exceptional model to mimic real-world allergen exposure and study long-term implications of AR with large sample sizes. Existing AECs are limited by heterogeneous facility designs, differing methods of cat allergen distribution, and issues surrounding cost and accessibility. Conversely, NACs allow for smaller participant cohorts for easier biological sampling and are ideal for phase I, phase 2 or proof-of-concept studies. NACs generally have a standardized protocol and are less expensive compared to AECs. Nevertheless, NACs solely capture acute allergen exposure and have the further limitation of using allergen extracts rather than natural allergen. As the use of combined controlled methodologies is sparse, we recommend concurrent use of AECs and NACs to study short- and long-term effects of AR, thereby providing a more holistic representation of cat allergen-induced AR.
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Affiliation(s)
- Lubnaa Hossenbaccus
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Allergy Research Unit, Kingston Health Sciences Centre – KGH Site, Kingston, ON, Canada
| | - Sophia Linton
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Allergy Research Unit, Kingston Health Sciences Centre – KGH Site, Kingston, ON, Canada
| | - Rashi Ramchandani
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Allergy Research Unit, Kingston Health Sciences Centre – KGH Site, Kingston, ON, Canada
| | - Alyssa G. Burrows
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Allergy Research Unit, Kingston Health Sciences Centre – KGH Site, Kingston, ON, Canada
| | - Anne K. Ellis
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Allergy Research Unit, Kingston Health Sciences Centre – KGH Site, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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Ellis AK, DeVeaux M, Steacy L, Ramesh D, Suprun M, Langdon S, Wang CQ, Adams D, Thiele J, Walker T, Perlee LT, O'Brien MP. Environmental exposure unit simulates natural seasonal birch pollen exposures while maximizing change in allergic symptoms. Ann Allergy Asthma Immunol 2021; 127:488-495.e5. [PMID: 34186172 DOI: 10.1016/j.anai.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/07/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Birch pollen is a prevalent aeroallergen during the springtime allergy season. In field studies, variable allergen exposure and environmental factors can affect data quality while environmental exposure units (EEUs) deliver controlled, standardized, and reproducible allergen exposures. OBJECTIVE To inform study design for EEU trials evaluating antiallergic therapies. METHODS In this prospective study, 76 participants with birch allergy experienced 3 exposures to birch pollen: (1) an out-of-season EEU challenge (two 3-hour sessions on consecutive days); (2) a natural seasonal exposure; and (3) an in-season EEU challenge (3-hour exposure for 2 weeks after birch pollen season initiation). RESULTS The total nasal symptom score, total ocular symptom score, and total symptom score (TSS = total nasal symptom score plus total ocular symptom score) were assessed every 30 minutes and daily during EEU and natural exposures. A high association between TSSs and day 2 of the out-of-season and in-season EEU challenges was noted, with a good association between the maximum TSS during the natural and in-season EEU challenges, and natural season and day 2 of the out-of-season EEU challenge (P < .001 for all). Participants had higher maximum change from the baseline TSS during day 2 of the out-of-season EEU challenge (12.4) vs the following: (1) first day (9.8); (2) in-season EEU challenge (8.4); and (3) natural seasonal exposure (7.6) (P < .001 for all). CONCLUSION A strong association was seen between the presence of allergy symptoms and exposure to birch pollen in the EEU (maximum change in symptom scores during day 2) and in the field. A hybrid trial design may be useful to demonstrate the clinical efficacy of novel antiallergic therapies requiring fewer participants and shorter timelines and expediting treatment availability.
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Affiliation(s)
- Anne K Ellis
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada; Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
| | | | - Lisa Steacy
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Divya Ramesh
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Maria Suprun
- Department of Pediatrics, Allergy, and Immunology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shaun Langdon
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Claire Q Wang
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Daniel Adams
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Jenny Thiele
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Terry Walker
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
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Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Dinakar C, Ellis AK, Finegold I, Golden DBK, Greenhawt MJ, Hagan JB, Horner CC, Khan DA, Lang DM, Larenas-Linnemann DES, Lieberman JA, Meltzer EO, Oppenheimer JJ, Rank MA, Shaker MS, Shaw JL, Steven GC, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Dinakar C, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Khan DA, Lang DM, Lieberman JA, Oppenheimer JJ, Rank MA, Shaker MS, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Finegold I, Hagan JB, Larenas-Linnemann DES, Meltzer EO, Shaw JL, Steven GC. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020; 146:721-767. [PMID: 32707227 DOI: 10.1016/j.jaci.2020.07.007] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.
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Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, School of Medicine, Saint Louis University, St Louis, Mo.
| | - Dana V Wallace
- Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David J Amrol
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Fuad M Baroody
- Department of Otolaryngology-Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Timothy J Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, Pa
| | - Chitra Dinakar
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, Calif
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ira Finegold
- Division of Allergy and Immunology, Department of Medicine, Mount Sinai West, New York, NY
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Md
| | - Matthew J Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colo
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Caroline C Horner
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, School of Medicine, Washington University, St Louis, Mo
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | - Jay A Lieberman
- Division of Pulmonology Allergy and Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Eli O Meltzer
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, University of California, San Diego, Calif; Allergy and Asthma Medical Group and Research Center, San Diego, Calif
| | - John J Oppenheimer
- Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, New Brunswick, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Hossenbaccus L, Steacy LM, Walker T, Ellis AK. Utility of Environmental Exposure Unit Challenge Protocols for the Study of Allergic Rhinitis Therapies. Curr Allergy Asthma Rep 2020; 20:34. [PMID: 32506346 DOI: 10.1007/s11882-020-00922-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW This paper explores how the Environmental Exposure Unit (EEU) experimental model can be used to further our understanding of pharmacotherapies and immunotherapies for the treatment of allergic rhinitis (AR). RECENT FINDINGS EEUs are used increasingly for the study of combination therapies, immunotherapies, and novel AR treatments. A combined antihistamine/corticosteroid nasal spray formulation was seen to have a faster onset of action relative to the therapies individually in the Environmental Exposure Chamber. House dust mite sublingual immunotherapy tablets are both safe and efficacious as evaluated by the Vienna Challenge Chamber. The Kingston EEU found that a novel peptide-based immunotherapy approach to be effective in reducing grass pollen-induced AR. Lastly, nasal filters were determined to reduce seasonal AR symptoms, given out-of-season in the Denmark Environmental Exposure Unit. EEUs are controlled, replicable models that provide valuable insight into the efficacy, onset and duration of action, and dose-related impacts of AR therapeutics, with direct clinical relevance.
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Affiliation(s)
- Lubnaa Hossenbaccus
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.,Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, ON, Canada
| | - Lisa M Steacy
- Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, ON, Canada
| | - Terry Walker
- Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, ON, Canada
| | - Anne K Ellis
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada. .,Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, ON, Canada. .,Department of Medicine, Queen's University, Kingston, ON, Canada.
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Geller-Bernstein C, Portnoy JM. The Clinical Utility of Pollen Counts. Clin Rev Allergy Immunol 2020; 57:340-349. [PMID: 30043255 DOI: 10.1007/s12016-018-8698-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In this review, we describe how pollen counts are performed, the health effects caused by exposure to varying amounts of pollen, the clinical utility of reporting pollen counts to the public, and how that information can be used by patients who have allergies to improve their health. The public is very interested in pollen counts, particularly if the counts provide a forecast of expected pollen exposure for the next few days. Traditional pollen counts are labor-intensive; poorly distributed; and, since the counts are usually 1-day-old, do not provide forecasts that can be acted on. New methods that provide short- and long-term pollen forecasts can provide this information to allergic individuals so that they can respond to changing outdoor conditions. Studies of the relationship between artificial and natural exposure to pollen and development of symptoms have provided improved understanding into how much pollen it takes to cause symptoms. Thresholds for pollen counts that trigger symptoms vary by pollen type, sensitivity of the population, and interactions with other atmospheric exposures. Strategies to inform the public when the pollen count poses a health risk have been proposed along with computerized systems that provide personalized pollen alerts. The best performing public notification system was a "traffic light system" that reported pollen exposure as low, 0-30; intermediate, 31-50; or high, 51-150. This system outperformed other threshold systems used in Sweden and in Britain/Denmark. Continued improvements in pollen forecasting models combined with data provided by automated pollen counters and better public reporting should permit allergic individuals and urban planners to adapt effectively to changes in outdoor aeroallergen exposures.
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Affiliation(s)
- Carmi Geller-Bernstein
- Zabludovicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Jay M Portnoy
- Division of Allergy, Asthma & Immunology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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Tenn MW, Steacy LM, Adams DE, Walker TJ, Ellis AK. Comparison of allergic rhinitis outcomes of the environmental exposure unit and nasal allergen challenge model. Ann Allergy Asthma Immunol 2019; 123:105-106.e1. [PMID: 30959101 DOI: 10.1016/j.anai.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/21/2019] [Accepted: 04/01/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Mark W Tenn
- Department of Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada; Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Lisa M Steacy
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Daniel E Adams
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Terry J Walker
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Anne K Ellis
- Department of Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada; Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada; Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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Ellis AK, Jacobs RL, Tenn MW, Steacy LM, Adams DE, Walker TJ, Togias A, Ramirez DA, Andrews CP, Visness CM, James RL, Rather CG. Clinical standardization of two controlled allergen challenge facilities: The Environmental Exposure Unit and the Biogenics Research Chamber. Ann Allergy Asthma Immunol 2019; 122:639-646.e2. [PMID: 30878629 DOI: 10.1016/j.anai.2019.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/09/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Controlled allergen challenge facilities (CACF), in disparate geographic regions with dissimilar engineering and base populations, have historically functioned as single, independent sites in clinical allergy trials. We aimed to demonstrate "between-unit reproducibility" to allow controlled challenge trials of participants using 2 CACFs. OBJECTIVE To compare and standardize 2 CACFs located in Kingston, Ontario, Canada, and San Antonio, Texas, by examining participant-reported symptom severity during qualifying and treatment visits and evaluating response to treatment, while using the same allergen. METHODS At 2 different CACFs, participants were enrolled in a double-blind, placebo-controlled, crossover intervention trial with cetirizine 10 mg. Different distribution devices delivered common short ragweed pollen via laminar air flow and maintained an airborne concentration of 3500 ± 700 grains/m3 in both facilities. A 1-hour "sham" run with no pollen release preceded a priming exposure of 3 hours and was followed 3 days later by a qualifying/treatment 5-hour exposure. At least 14 days later, another priming exposure was followed by the crossover exposure and treatment. RESULTS Forty-eight and 43 subjects completed the study at Kingston and San Antonio, respectively. Demographics were similar. Fewer than 10% exhibited symptoms with sham exposure. No significant differences were found between the 2 facilities in maximal total rhinoconjunctivitis symptom score, total nasal symptom score, and total ocular symptom score, nor in areas under the curve. In both facilities, no significant effects of cetirizine 10 mg over placebo were detected. CONCLUSION The results were equivalent, demonstrating that the 2 CACFs can be used together in dual-center clinical trials and show the possibility of multicenter trials involving multiple CACFs.
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Affiliation(s)
- Anne K Ellis
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada.
| | | | - Mark W Tenn
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Lisa M Steacy
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Daniel E Adams
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Terry J Walker
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
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Ellis AK. Novel application of the controlled allergen challenge facility model. Ann Allergy Asthma Immunol 2019; 116:481-2. [PMID: 27264561 DOI: 10.1016/j.anai.2016.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/22/2016] [Accepted: 04/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Anne K Ellis
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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9
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Kim YW, Singh A, Shannon CP, Thiele J, Steacy LM, Ellis AK, Neighbour H, Gliddon DR, Hickey PLC, Larché M, Tebbutt SJ. Investigating Immune Gene Signatures in Peripheral Blood from Subjects with Allergic Rhinitis Undergoing Nasal Allergen Challenge. THE JOURNAL OF IMMUNOLOGY 2017; 199:3395-3405. [DOI: 10.4049/jimmunol.1700378] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/14/2017] [Indexed: 12/31/2022]
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Gomes PJ, Lane KJ, Angjeli E, Stein L, Abelson MB. Technical and clinical validation of an environmental exposure unit for ragweed. J Asthma Allergy 2016; 9:215-221. [PMID: 28008277 PMCID: PMC5167464 DOI: 10.2147/jaa.s123547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Allergic rhinitis is a common condition, with ragweed pollen one of the more prevalent aeroallergens. Environmental exposure units such as the Allergen BioCube® are valuable models for clinical allergy studies. A study was conducted to validate the Allergen BioCube for uniform ragweed pollen concentrations and clinically relevant sign and symptom responses to ragweed exposure. Methods Ragweed pollen concentrations were measured on 3 consecutive days in the Allergen BioCube and verified by Rotorod collection and continuous laser particle count measurements. Subjects (N=10) were exposed to ragweed pollen in the BioCube for 3 hours per day for 3 consecutive days. Subjects assessed their nasal itching, sneezing, rhinorrhea, and nasal congestion during each BioCube exposure; total nasal symptom score was computed. Peak nasal inspiratory flow was also assessed during BioCube exposure. Results Uniform ragweed pollen concentrations were obtained throughout each of the 3-hour testing periods in the Allergen BioCube, both spatially and temporally, at all subject positions, with a low mean standard deviation of 10%. Pronounced increases in mean total nasal symptom scores (6.7±0.94 to 7.6±0.86, last 90 minutes of exposure) occurred for all three BioCube ragweed pollen exposure visits. Mean peak nasal inspiratory flow decreased 24% at 3 hours of BioCube exposure on Day 3. No safety issues of concern occurred in this study. Conclusion The Allergen BioCube achieved technical and clinical validation for ragweed allergen. Ragweed pollen concentration was uniform both temporally and spatially. Allergic rhinitis signs and symptoms were induced in subjects during exposure to ragweed in the BioCube at clinically meaningful levels for allergy studies.
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Affiliation(s)
| | | | | | | | - Mark B Abelson
- Ora, Inc., Andover, MA, USA; Department of Ophthalmology, Harvard Medical School, Cambridge, MA, USA
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Kenney P, Bønløkke J, Hilberg O, Ravn P, Schlünssen V, Sigsgaard T. Method for a homogeneous distribution of pollens in an environmental exposure chamber. Clin Exp Allergy 2016; 46:1176-84. [PMID: 27144495 DOI: 10.1111/cea.12747] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/16/2016] [Accepted: 04/15/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND A variety of different environmental exposure chambers (EECs) have been used to evaluate treatments for allergic rhinitis. OBJECTIVE To describe and test a system for a homogenous distribution of grass pollen, Phleum Pratense, in an EEC to be used for controlled pollen exposure studies in allergic participants. METHODS A chamber made of stainless steel with completely rounded corners, seating four individuals at a time, was used. Room pressure, temperature, humidity and the air change rate were kept constant throughout the study period. A rotating pipette dispensed a uniform supply of pollen into a turntable's v-shaped grooves. A stainless steel capillary tube sucked the pollens into a venturi throat at which time the pollens were mixed with a high-pressure airstream of compressed high-efficiency particulate arrestance filtered air and then transported to a spreading plate inside the EEC. To achieve uniform concentrations in the EEC, the turntable's rotating speed was continuously adjusted using information from video-coupled feedback and feed forward mechanisms. Pollen levels were detected using standard volumetric air samplers and laser particle counters. The target pollen exposure level was 1000 pollens/m(3) . Twenty-one participants were exposed to pollens in the EEC twice for 210 min. Participants evaluated their symptoms every 30 min using a total nasal symptom score (TNSS) consisting of blocked nose, runny nose, nasal itching and sneezing. RESULTS Across fifteen study days, the average pollen level was 982 pollens/m(3) (SD, 102 pollens/m(3) ). On average, participants experienced a 10% difference in overall pollen levels between their two visits to the EEC. The mean TNSSs rose throughout the exposure period, with a low at baseline of 0.43 (SD, 0.68) to a high of 4.71 (SD, 2.43) just before exiting the EEC. CONCLUSION AND CLINICAL RELEVANCE This EEC provides a reproducible, precise and homogenous distribution of pollens making it suitable for single-centre allergy clinical trials.
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Affiliation(s)
- P Kenney
- Department of Public Health, Section for Environment, Occupation and Health, Aarhus University, Aarhus, Denmark.,Rhinix ApS, Aarhus, Denmark
| | - J Bønløkke
- Department of Public Health, Section for Environment, Occupation and Health, Aarhus University, Aarhus, Denmark
| | - O Hilberg
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Aarhus, Denmark
| | - P Ravn
- Department of Public Health, Section for Environment, Occupation and Health, Aarhus University, Aarhus, Denmark
| | - V Schlünssen
- Department of Public Health, Section for Environment, Occupation and Health, Aarhus University, Aarhus, Denmark.,National Research Center for the Working Environment, Copenhagen, Denmark
| | - T Sigsgaard
- Department of Public Health, Section for Environment, Occupation and Health, Aarhus University, Aarhus, Denmark
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Abstract
Allergic rhinitis and migraine remain on the list of the most common diseases affecting adults. Migraines and headaches due to allergic rhinitis are easily confused because the symptoms of both conditions often overlap. Both may occur with sinus headache, nasal congestion, and lacrimation and may worsen with weather changes and exposure to allergens. No precise clinical definition exists for what constitutes a sinus headache, which has always been a diagnostic dilemma. Contrary to popular belief, headache is not a typical symptom of rhinitis. Some studies have shown that up to 90 % of sinus headaches are actually migraines. Nevertheless, patients with self-diagnosed sinus headache self-treat or are treated by primary care physicians and/or otolaryngologists with medications for rhinosinusitis, ignoring the neurogenic causes of the symptoms when most of these patients fulfill diagnostic criteria for chronic migraine. Chronic migraine affects 2 % of the general population and has a significant socioeconomic impact on society, incurring health care costs and diminishing quality of life; therefore, the proper diagnosis and treatment of these headache patients should be a priority.
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Affiliation(s)
- Anna Gryglas
- Department of Neurology, Gromkovski Voivodship Hospital, Department of Social Pediatrics, Wroclaw Medical University, Wroclaw, Poland.
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Meltzer EO, Ratner PH, McGraw T. Phenylephrine hydrochloride modified-release tablets for nasal congestion: a randomized, placebo-controlled trial in allergic rhinitis patients. Ann Allergy Asthma Immunol 2015; 116:66-71. [PMID: 26560899 DOI: 10.1016/j.anai.2015.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/06/2015] [Accepted: 10/19/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Over-the-counter phenylephrine hydrochloride (PEH) is used for relief of nasal congestion caused by allergic rhinitis; however, data to support its efficacy are lacking. The US Food and Drug Administration recommended clinical trials to evaluate the efficacy and safety of PEH in patients with this condition. OBJECTIVE To evaluate the efficacy and safety of PEH 30-mg modified-release (MR) tablets in patients with nasal congestion caused by allergic rhinitis in a multicenter, randomized, double-blinded, placebo-controlled, 2-arm, parallel-group study. METHODS Eligible adults at least 18 years old with documented hypersensitivity to fall pollen allergens were randomized to PEH-MR or placebo every 12 hours for 7 days from August 30 to October 12, 2011. The primary end point was mean change from baseline during the entire treatment period in daily reflective nasal congestion score. Secondary end points included changes in other symptom score assessments, time to maximal effect, duration of effect, and quality of life. Safety assessments included adverse events, serious adverse events, vital signs, physical examination, and electrocardiograms. RESULTS Of 575 patients, 288 received PEH-MR and 287 received placebo. No significant beneficial difference was detected between PEH-MR and placebo for the primary end point (PEH-MR, mean -0.394, SD 0.4880; placebo, mean -0.412, SD 0.5383; P = .2655). Likewise, no significant differences were observed for most secondary end points or quality of life. Overall, 89 of 575 patients (15.5%), equally distributed between the PEH-MR and placebo groups, experienced at least 1 treatment-emergency adverse event. CONCLUSION PEH-MR 30-mg tablets taken orally every 12 hours for 7 days is not more efficacious than placebo in relieving nasal congestion caused by allergic rhinitis. TRIAL REGISTRATION clinicaltrials.gov, identifier NCT01413958, protocol CL2011-06.
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Affiliation(s)
- Eli O Meltzer
- Allergy and Asthma Medical Group and Research Center, San Diego, California
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Controlled Allergen Challenge Facilities and Their Unique Contributions to Allergic Rhinitis Research. Curr Allergy Asthma Rep 2015; 15:11. [PMID: 26130471 DOI: 10.1007/s11882-015-0514-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this study is to review advances in basic and clinical allergic rhinitis (AR) research over the past decade that have been conducted using controlled allergen challenge facility (CACF) models of allergen challenge. Databases, including PubMed, Medline, and Web of Science were searched for articles employing an ambient pollen exposure in a controlled facility to study AR, published between 2004 and the present date, using the terms as follows: CACF, Environmental Exposure Unit (EEU), Vienna Challenge Chamber (VCC), Fraunhofer Institute Environmental Challenge Chamber, Atlanta Allergen Exposure Unit, Biogenics Research Chamber, Allergen BioCube, Chiba and Osaka Environmental Challenge Chamber, exposure unit, challenge chamber, or environmental exposure chamber. Articles were then selected for relevance to the goals of the present review, including important contributions toward clinical and/or basic science allergy research. CACFs offer sensitive, specific, and reproducible methodology for allergen challenge. They have been employed since the 1980s and offer distinct advantages over traditional in-season multicentre trials when evaluating new treatments for AR. They have provided clinically applicable efficacy and pharmacologic information about important allergy medications, including antihistamines, decongestants, antileukotrienes, immunotherapies, and nasal steroids. CACF models have also contributed to basic science and novel/experimental therapy research. To date, no direct studies have been conducted comparing outcomes from one CACF to another. Over the past decade, CACF models have played an essential role in investigating the pathophysiology of AR and evaluating new therapies. The future opportunities for this model continue to expand.
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Ellis AK, Soliman M, Steacy L, Boulay MÈ, Boulet LP, Keith PK, Vliagoftis H, Waserman S, Neighbour H. The Allergic Rhinitis - Clinical Investigator Collaborative (AR-CIC): nasal allergen challenge protocol optimization for studying AR pathophysiology and evaluating novel therapies. Allergy Asthma Clin Immunol 2015; 11:16. [PMID: 25945101 PMCID: PMC4419495 DOI: 10.1186/s13223-015-0082-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 04/08/2015] [Indexed: 01/17/2023] Open
Abstract
Background The Nasal Allergen Challenge (NAC) model allows the study of Allergic Rhinitis (AR) pathophysiology and the proof of concept of novel therapies. The Allergic Rhinitis – Clinical Investigator Collaborative (AR-CIC) aims to optimize the protocol, ensuring reliability and repeatability of symptoms to better evaluate the therapies under investigation. Methods 20 AR participants were challenged, with 4-fold increments of their respective allergens every 15 minutes, to determine the qualifying allergen concentration (QAC) at which the Total Nasal Symptom Score (TNSS) of ≥10/12 OR a Peak Nasal Inspiratory Flow (PNIF) reduction of ≥50% from baseline was achieved. At the NAC visit, the QAC was used in a single challenge and TNSS and PNIF were recorded at baseline, 15 minutes, 30 minutes, 1 hour, and hourly up to 12 hours. 10 additional ragweed allergic participants were qualified at TNSS of ≥8/12 AND ≥50% PNIF reduction; the Cumulative Allergen Challenge (CAC) of all incremental doses was used during the NAC visit. 4 non-allergic participants were challenged with the highest allergen concentration. Results In the QAC study, a group qualified by only meeting PNIF criteria achieved lower TNSS than those achieving either TNSS criteria or PNIIF+TNSS (p<0.01). During the NAC visit, participants in both studies reached their peak symptoms at 15minutes followed by a gradual decline, significantly different from non-allergic participants. The “PNIF only” group experienced significantly lower TNSS than the other groups during NAC visit. QAC and CAC participants did not reach the same peak TNSS during NAC that was achieved at screening. QAC participants qualifying based on TNSS or TNSS+PNIF managed to maintain PNIF scores. Conclusions Participants experienced reliable symptoms of AR in both studies, using both TNSS and PNIF reduction as part of the qualifying criteria proved better for qualifying participants at screening. Phenotyping based on pattern of symptoms experienced is possible and allows the study of AR pathophysiology and can be applied in evaluation of efficacy of a novel medication. The AR-CIC aims to continue to improve the model and employ it in phase 2 and 3 clinical trials.
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Affiliation(s)
- Anne K Ellis
- Departments of Medicine and Biomedical & Molecular Science, Queen's University, Kingston, ON Canada ; Allergy Research Unit, Kingston General Hospital, Kingston, ON Canada
| | - Mena Soliman
- Departments of Medicine and Biomedical & Molecular Science, Queen's University, Kingston, ON Canada
| | - Lisa Steacy
- Allergy Research Unit, Kingston General Hospital, Kingston, ON Canada
| | - Marie-Ève Boulay
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, QC Canada
| | - Louis-Philippe Boulet
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, QC Canada
| | - Paul K Keith
- Department of Medicine, McMaster University, Hamilton, ON Canada
| | | | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Helen Neighbour
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON Canada
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Ellis AK, Steacy LM, Hobsbawn B, Conway CE, Walker TJB. Clinical validation of controlled grass pollen challenge in the Environmental Exposure Unit (EEU). ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2015; 11:5. [PMID: 25653682 PMCID: PMC4316395 DOI: 10.1186/s13223-015-0071-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/14/2015] [Indexed: 11/17/2022]
Abstract
RATIONALE The Environmental Exposure Unit (EEU), a controlled allergen exposure model of allergic rhinitis (AR), has traditionally utilized ragweed pollen. We sought to clinically validate the use of grass pollen in the EEU. METHODS Healthy volunteers with a history of AR symptoms during grass pollen season and supportive skin test responses attended the EEU for 3 hrs of rye grass pollen exposure (Lolium Perenne). Non-atopic controls were also recruited. Participants assessed individual rhinoconjunctivitis symptoms to generate Total Nasal Symptom Score (TNSS; max 12) and Total Symptom Score (TSS; max 24) and recorded Peak Nasal Inspiratory Flow (PNIF) q30min while in the EEU. Participants returned the following day for an additional 3 hrs of pollen exposure. Two separate groups allowed for the exploration of lower vs. higher pollen concentrations and subsequent effects on symptoms. RESULTS 78 participants were screened, of whom 39 were eligible and attended the 2x3h EEU visits, plus 8 non-atopic controls. Mean TSS, TNSS and PNIF values amongst participants in the higher pollen concentration group (target 3500 grains/m3) after the first 3 hr exposure were 18.9, 9.7 and 68 L/min, respectively. In comparison, mean TSS, TNSS and PNIF values in the lower pollen concentration (2500 grains/m3) group were only 13.3, 7.6, and 82 L/min, respectively. The subsequent day of pollen exposure did not appreciably alter the maximal TSS/TNSSs, but rather resulted in a more rapid onset of symptomatology, with higher mean scores at the 30 min, 60 min and 90 min timepoints. The non-atopic controls remained asymptomatic. CONCLUSIONS This study provides clinical validation of the ability to generate allergic rhinoconjunctivitis symptoms amongst grass-allergic individuals in the EEU.
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Affiliation(s)
- Anne K Ellis
- />Division of Allergy & Immunology, Department of Medicine, Queen’s University, Kingston, ON Canada
- />Allergy Research Unit, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7 Canada
| | - Lisa M Steacy
- />Allergy Research Unit, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7 Canada
| | - Barnaby Hobsbawn
- />Allergy Research Unit, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7 Canada
| | - Caroline E Conway
- />Allergy Research Unit, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7 Canada
| | - Terry JB Walker
- />Allergy Research Unit, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7 Canada
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Rösner-Friese K, Kaul S, Vieths S, Pfaar O. Environmental exposure chambers in allergen immunotherapy trials: Current status and clinical validation needs. J Allergy Clin Immunol 2014; 135:636-43. [PMID: 25528360 DOI: 10.1016/j.jaci.2014.10.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 09/24/2014] [Accepted: 10/31/2014] [Indexed: 11/17/2022]
Abstract
As required by the European Medicines Agency and the US Food and Drug Administration for pivotal trials involving allergen immunotherapy (AIT) products, clinical efficacy assessment is currently based on double-blind, placebo-controlled field studies with natural allergen exposure during the allergen season. However, this study design is associated with several drawbacks, such as the high variability of allergen exposure in different trial sites or seasons and the presence of confounding environmental factors. On the contrary, environmental exposure chambers (EECs) aim to operate with a stable and reproducible allergen exposure under highly standardized environmental conditions. Technical validation parameters for different EECs worldwide have been published by several groups. However, full clinical validation of EEC study outcomes is required for their classification as an appropriate alternative to natural allergen exposure for AIT product efficacy assessment. Some clinical validation parameters have already been addressed for EEC units. The reliability of provoked symptoms in repeated EEC sessions is high, but the predictive power of EEC settings for the clinical response on natural exposure and the impact of seasonal priming on test results still have to be validated systematically, as does the inter-EEC variability. Thus the authors recommend a continued in-depth validation of EECs to exploit the potential of this technology for future AIT product development.
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Affiliation(s)
- Karen Rösner-Friese
- Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Susanne Kaul
- Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany.
| | - Stefan Vieths
- Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden and the Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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Soliman M, North ML, Steacy LM, Thiele J, Adams DE, Ellis AK. Nasal allergen challenge studies of allergic rhinitis: a guide for the practicing clinician. Ann Allergy Asthma Immunol 2014; 113:250-6. [PMID: 25168223 DOI: 10.1016/j.anai.2014.06.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/18/2014] [Accepted: 06/24/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Mena Soliman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
| | - Michelle L North
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
| | - Lisa M Steacy
- Allergy Research Unit, Kingston General Hospital, Kingston, Ontario
| | - Jenny Thiele
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
| | - Daniel E Adams
- Allergy Research Unit, Kingston General Hospital, Kingston, Ontario
| | - Anne K Ellis
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario; Allergy Research Unit, Kingston General Hospital, Kingston, Ontario; Department of Medicine, Queen's University, Kingston, Ontario.
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North ML, Walker TJ, Steacy LM, Hobsbawn BG, Allan RJ, Hackman F, Sun X, Day AG, Ellis AK. Add-on histamine receptor-3 antagonist for allergic rhinitis: a double blind randomized crossover trial using the environmental exposure unit. Allergy Asthma Clin Immunol 2014; 10:33. [PMID: 25024716 PMCID: PMC4094756 DOI: 10.1186/1710-1492-10-33] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/15/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral antihistamines that target the histamine receptor-1, such as fexofenadine, offer suboptimal relief of allergic rhinitis-associated nasal congestion. Combinations with oral sympathomimetics, such as pseudoephedrine, relieve congestion but produce side effects. Previous animal and human studies with histamine receptor-3 antagonists, such as PF-03654764, demonstrate promise. METHODS Herein we employ the Environmental Exposure Unit (EEU) to conduct the first randomized controlled trial of PF-03654764 in allergic rhinitis. 64 participants were randomized in a double-blind, placebo-controlled 4-period crossover study. Participants were exposed to ragweed pollen for 6 hours post-dose in the EEU. The primary objective was to compare the effect of PF-03654764 + fexofenadine to pseudoephedrine + fexofenadine on the subjective measures of congestion and Total Nasal Symptom Score (TNSS). The objectives of our post-hoc analyses were to compare all treatments to placebo and determine the onset of action (OA). This trial was registered at ClinicalTrials.gov (NCT01033396). RESULTS PF-03654764 + fexofenadine was not superior to pseudoephedrine + fexofenadine. In post-hoc analyses, PF-03654764 + fexofenadine significantly reduced TNSS, relative to placebo, and OA was 60 minutes. Pseudoephedrine + fexofenadine significantly reduced congestion and TNSS, relative to placebo, with OA of 60 and 30 minutes, respectively. Although this study was not powered for a statistical analysis of safety, it was noted that all PF-03654764-treated groups experienced an elevated incidence of adverse events. CONCLUSIONS PF-03654764 + fexofenadine failed to provide superior relief of allergic rhinitis-associated nasal symptoms upon exposure to ragweed pollen compared to fexofenadine + pseudoephedrine. However, in post-hoc analyses, PF-03654764 + fexofenadine improved TNSS compared to placebo. Side effects in the PF-03654764-treated groups were clinically significant compared to the controls.
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Affiliation(s)
- Michelle L North
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada ; Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Terry J Walker
- Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Lisa M Steacy
- Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Barnaby G Hobsbawn
- Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | | | | | - Xiaoqun Sun
- Clinical Research Centre, Kingston General Hospital, Kingston, Ontario, Canada
| | - Andrew G Day
- Clinical Research Centre, Kingston General Hospital, Kingston, Ontario, Canada
| | - Anne K Ellis
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada ; Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada ; Division of Allergy and Immunology, Department of Medicine, Queen's University, Doran 1, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7, Canada
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Ellis AK, North ML, Walker T, Steacy LM. Environmental exposure unit: a sensitive, specific, and reproducible methodology for allergen challenge. Ann Allergy Asthma Immunol 2013; 111:323-8. [DOI: 10.1016/j.anai.2013.07.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/28/2013] [Accepted: 07/17/2013] [Indexed: 11/16/2022]
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Ellis AK, Zhu Y, Steacy LM, Walker T, Day JH. A four-way, double-blind, randomized, placebo controlled study to determine the efficacy and speed of azelastine nasal spray, versus loratadine, and cetirizine in adult subjects with allergen-induced seasonal allergic rhinitis. Allergy Asthma Clin Immunol 2013; 9:16. [PMID: 23635091 PMCID: PMC3655060 DOI: 10.1186/1710-1492-9-16] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 03/18/2013] [Indexed: 12/02/2022] Open
Abstract
Background Azelastine has been shown to be effective against seasonal allergic rhinitis (SAR). The Environmental Exposure Unit (EEU) is a validated model of experimental SAR. The objective of this double-blind, four-way crossover study was to evaluate the onset of action of azelastine nasal spray, versus the oral antihistamines loratadine 10 mg and cetirizine 10 mg in the relief of the symptoms of SAR. Methods 70 participants, aged 18-65, were randomized to receive azelastine nasal spray, cetirizine, loratadine, or placebo after controlled ragweed pollen exposure in the EEU. Symptoms were evaluated using the total nasal symptom score (TNSS). The primary efficacy parameter was the onset of action as measured by the change from baseline in TNSS. Results Azelastine displayed a statistically significant improvement in TNSS compared with placebo at all time points from 15 minutes through 6 hours post dose. Azelastine, cetirizine, and loratadine reduced TNSS compared to placebo with an onset of action of 15 (p < 0.001), 60 (p = 0.015), and 75 (p = 0.034) minutes, respectively. The overall assessment of efficacy was rated as good or very good by 46% of the participants for azelastine, 51% of the participants for cetirizine, and 30% of the participants for loratadine compared to 18% of the participants for placebo. Conclusions Azelastine’s onset of action for symptom relief was faster than that of cetirizine and loratadine. The overall participant satisfaction in treatment with azelastine is comparable to cetirizine and statistically superior to loratadine. These results suggest that azelastine may be preferential to oral antihistamines for the rapid relief of SAR symptoms.
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Affiliation(s)
- Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada ; Allergy Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Yifei Zhu
- Life Sciences, Queen's University, Kingston, ON, Canada
| | - Lisa M Steacy
- Allergy Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Terry Walker
- Allergy Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - James H Day
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada ; Allergy Research Unit, Kingston General Hospital, Kingston, ON, Canada
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Correlation between a pollen challenge chamber and a natural allergen exposure study design for eliciting ocular and nasal symptoms: Early evidence supporting a paradigm shift in drug investigation? J Allergy Clin Immunol 2012; 130:128-9. [DOI: 10.1016/j.jaci.2012.05.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 05/29/2012] [Indexed: 11/20/2022]
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Hashiguchi K, Okubo K, Wakabayashi KI, Tanaka N, Watada Y, Suematsu K, Gotoh M. The assessment of the optimal duration of early intervention with montelukast in the treatment of Japanese cedar pollinosis symptoms induced in an artificial exposure chamber. J Drug Assess 2012; 1:40-7. [PMID: 27536427 PMCID: PMC4980728 DOI: 10.3109/21556660.2012.728547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2012] [Indexed: 11/25/2022] Open
Abstract
Objective The study objective was to investigate the prophylactic efficacy of montelukast (MLK) 10 mg in suppressing seasonal allergic rhinitis (SAR) symptoms induced by Japanese cedar (JC) pollen and to determine how many days before exposure to JC in the artificial exposure chamber (OHIO chamber) would be optimal to start administration. Methods This was a single-institution, double-blind, randomized placebo-controlled four-group parallel inter-group comparison study. Adult volunteers with JC pollinosis were divided into four groups: an MLK 7-day administration group (n = 27), an MLK 3-day administration group (n = 27), an MLK 1-day administration group (n = 26), and a placebo group (n = 26). The mean change in total nasal symptom scores (nasal obstruction, nasal discharge and sneezing) (TNSS) and each of the nasal symptom scores during exposure of JC pollen in the OHIO chamber were investigated. Results The mean change in TNSS was significantly lower in the MLK treatment group, regardless of the number of days of administration, than in the placebo group (p = 0.0192). The results for the individual nasal symptoms showed that nasal obstruction was significantly suppressed in the 1-day administration group as compared with placebo (p = 0.0076), but no differences were found in sneezing score between any of the groups. For nasal discharge, we found a trend towards the effect clearing up after 3 days of administration. No serious adverse events were observed during the study. Conclusion Although this study was acute and this artificial exposure model was conducted out of the pollen season, nasal symptoms that developed in the pollen exposure chamber, especially nasal obstruction, were significantly suppressed by starting oral administration of MLK 10 mg at least 1 day before exposure. These results suggest that prophylactic administration of MLK is effective and safe in the treatment of SAR.
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Affiliation(s)
| | - Kimihiro Okubo
- Department of Otolaryngology, Nippon Medical School, TokyoJapan
| | | | - Nobuaki Tanaka
- Tanaka ENT Clinic, Tokyo, Japan; Department of Otorhinolaryngology, Tokyo Women's Medical University Medical Center East, TokyoJapan
| | - Yukiko Watada
- Department of Otorhinolaryngology, Keio University School of Medicine, TokyoJapan
| | - Kiyochika Suematsu
- Pharmaceutical Department, Medical Corporation Shinanokai, Samoncho Clinic, TokyoJapan
| | - Minoru Gotoh
- Department of Otolaryngology, Nippon Medical School, TokyoJapan
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Rousseau MC, Boulay ME, Goronfolah L, Denburg J, Keith P, Boulet LP. Comparative responses to nasal allergen challenge in allergic rhinitic subjects with or without asthma. Allergy Asthma Clin Immunol 2011; 7:8. [PMID: 21507261 PMCID: PMC3104480 DOI: 10.1186/1710-1492-7-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 04/20/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nasal allergen challenge (NAC) is useful to study the pathophysiology of rhinitis, and multiple challenges may more adequately approximate natural exposure. OBJECTIVE To determine the effect of 4 consecutive daily NAC, on clinical and inflammatory parameters in rhinitics with or without asthma. METHODS Rhinitic subjects were recruited: 19 with mild asthma and 13 without asthma. Subjects underwent a control challenge (normal saline) followed by 4 consecutive daily NAC. Allergen challenge consisted of spraying the chosen allergen extract into each nostril until a positive nasal response occurred. Symptoms were recorded on a Likert scale, and oral peak expiratory and nasal peak inspiratory flows allowed assessment of a nasal blockage index (NBI), for a period of 7 hours. Induced sputum and nasal lavage were performed on control day and after 1 and 4 days of NAC. RESULTS Compared with the control day, there was a significant increase in symptom scores and NBI 10 minutes after each last daily NAC in both groups (p < 0.05). Symptom scores and NBI were similar for the 2 groups, except for nasal obstruction and rhinorrhea, which were more marked in subjects with asthma and rhinitis, respectively. Nasal lavage eosinophils were increased after 4 days of challenges in both groups, but there was no change in sputum eosinophils. No cumulative effect or any late response were observed in any of the groups over the challenge period. CONCLUSION Multiple NAC may be a useful tool to study the pathophysiology of allergic rhinitis or its relationships with asthma. TRIAL REGISTRATION ClinicalTrials.gov NCT01286129.
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Affiliation(s)
- Marie-Claire Rousseau
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada.
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Ito K, Terada T, Yuki A, Ichihara T, Hyo S, Kawata R, Takenaka H, Amano K, Ishiguro T, Ro T. Preliminary study of a challenge test to the patients with Japanese cedar pollinosis using an environmental exposure unit. Auris Nasus Larynx 2010; 37:694-9. [DOI: 10.1016/j.anl.2010.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Revised: 03/30/2010] [Accepted: 04/01/2010] [Indexed: 10/19/2022]
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Salapatek AM, Patel P, Gopalan G, Varghese ST. Mometasone Furoate Nasal Spray Provides Early, Continuing Relief of Nasal Congestion and Improves Nasal Patency in Allergic Patients. Am J Rhinol Allergy 2010; 24:433-8. [DOI: 10.2500/ajra.2010.24.3548] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Patients report nasal congestion as the most bothersome seasonal allergic rhinitis (SAR) symptom. Measurement of this symptom in previous research has largely been based on subjective patient ratings. This study was designed to measure efficacy, onset, and duration of action of the corticosteroid mometasone furoate nasal spray (MFNS) on nasal congestion using an environmental exposure chamber (EEC) and the objective assessment acoustic rhinometry (AcR). Methods In a randomized, double-blind, placebo-controlled study, ragweed-sensitive subjects were exposed to ragweed pollen (3500 ± 500 pollen grains/m3) in an EEC (day 1). Subjects rated instantaneous total nasal symptom score (TNSS), including NSS for congestion (NSS-C). Qualifying subjects received MFNS, 200 micrograms, or placebo and rated postdosing symptoms; a subset received MFNS, 200 micrograms, or placebo q.d. for 6 subsequent days, returning to EEC on day 8. Days 1 and 8 assessments included AcR, TNSS, and the Rhinoconjunctivitis Quality of Life Questionnaire developed for use in the EEC (RQOLQ-EEC). Results At day 1, hour 6, patients receiving MFNS (n = 155) reported significantly reduced congestion versus placebo (n = 155) per AcR and NSS-C after one dose, showing numerically superior TNSS change from baseline (p = NS). Among the subset who received 6 additional days of treatment, MFNS (n = 78) yielded significantly lower TNSS versus placebo (n = 77) before day 8 EEC entry and throughout 4-hour exposure (p < 0.05), except at 3.5 hours. AcR showed lower congestion with MFNS versus placebo before day 8 EEC exposure and at 24 and 26 hours after final dose (p < 0.05 for all). AcR and NSS-C correlated at multiple time points. Day 8 RQOLQ-EEC between-group scores were significantly different (p = 0.02) for practical problems. Conclusion MFNS, 200 micrograms, showed onset of nasal congestion relief at 6 hours and duration of action beyond 24 hours postdosing. Objective and subjective assessments were correlated in subjects with maximal (placebo) or minimal (MFNS treatment) congestion symptoms; both assessments were correlated with improved QOL.
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Affiliation(s)
| | | | - Gokul Gopalan
- Schering-Plough Corporation, now Merck & Co., Inc., Kenilworth, New Jersey
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Hohlfeld JM, Holland-Letz T, Larbig M, Lavae-Mokhtari M, Wierenga E, Kapsenberg M, van Ree R, Krug N, Bufe A. Diagnostic value of outcome measures following allergen exposure in an environmental challenge chamber compared with natural conditions. Clin Exp Allergy 2010; 40:998-1006. [PMID: 20412138 DOI: 10.1111/j.1365-2222.2010.03498.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Efficacy testing of drugs in seasonal allergic rhinitis (SAR) is often disturbed by seasonal variations of environmental allergens, and assessment of onset and duration of action is hardly possible under natural conditions. Allergen provocation in an environmental challenge chamber (ECC) can be of added value in this respect. However, the specificity, sensitivity, and reproducibility of outcome measures under both settings are unclear. OBJECTIVE The aim of this study was to investigate and compare the diagnostic value (specificity, sensitivity, and reproducibility) of clinical end-points and biomarkers both following allergen provocation in an ECC and under natural conditions. METHODS Sixty adult patients with SAR to grass and 60 healthy subjects were exposed twice to grass pollen in an ECC and observed twice during the pollen season. Symptoms, nasal flow, as well as exhaled and nasal nitric oxide (NO) were investigated. RESULTS The total nasal symptom score (TNSS) in the ECC had the best reproducibility (intraclass correlation coefficient ICC=0.86) and sensitivity/specificity [area under receiver operating characteristic curve (AUC)=0.99] of all measures. Symptoms in season also had good sensitivity/specificity but were far less reproducible. Nasal flow in the ECC had good sensitivity/specificity but reproducibility was limited. NO measurements showed good reproducibility but sensitivity/specificity were limited, except for exhaled NO in season (AUC=0.75). CONCLUSION The high reproducibility and sensitivity/specificity in the ECC suggests that TNSS is a valuable outcome measure. While exhaled NO can be considered to monitor airway inflammation, nasal NO appears to be unspecific.
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Affiliation(s)
- J M Hohlfeld
- Department of Clinical Airway Research, Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany.
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Ellis AK, Ratz JD, Day AG, Day JH. Factors that affect the allergic rhinitis response to ragweed allergen exposure. Ann Allergy Asthma Immunol 2010; 104:293-8. [DOI: 10.1016/j.anai.2010.01.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Proud D, Riker DK, Togias A. Reproducibility of nasal allergen challenge in evaluating the efficacy of intranasal corticosteroid treatment. Clin Exp Allergy 2010; 40:738-44. [PMID: 20337650 DOI: 10.1111/j.1365-2222.2010.03466.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although nasal challenge with allergen has often been used to evaluate the efficacy of therapeutic modalities used for the treatment of allergic rhinitis, the reproducibility of this model in quantitatively evaluating efficacy has not been rigorously examined. OBJECTIVE To examine the reproducibility of the suppressive effects of an intranasal corticosteroid on the clinical and biochemical outcomes of a nasal allergen challenge during two identical treatment periods using the same subjects. METHODS In a single-blind study, 25 seasonal allergic subjects with positive skin tests to grass or ragweed were studied outside of their pollen season. Subjects underwent a baseline, three-dose allergen challenge. Beginning 1 week later, subjects received two 7-day courses of intranasal beclomethasone (168 microg b.i.d.) separated by a 1-month washout period. Nasal challenges with allergen were performed after each treatment period. The nasal allergic response was evaluated by counting sneezes, recording symptom scores and measuring levels of albumin (an index of vascular permeability), lysozyme (an index of serous glandular secretion) and kinins (proinflammatory peptides) in recovered nasal lavages. RESULTS Compared with the baseline challenge, each course of beclomethasone significantly reduced sneezing, symptom scores, albumin and kinins, but not lysozyme. Reproducibility analysis of the net changes from diluent challenge in the two beclomethasone treatment periods, showed the following intraclass correlation coefficients: sneezing (0.92), lysozyme (0.82), symptom scores (0.72), albumin (0.64) and kinins (0.28). CONCLUSION We conclude that the nasal challenge model is a reproducible method to evaluate the efficacy of anti-allergic medications. For nasal corticosteroid trials, sneezing, symptom scores and albumin levels are recommended as the most reproducibly suppressive outcome measures.
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Affiliation(s)
- D Proud
- Johns Hopkins Asthma & Allergy Center, Baltimore, MD, USA.
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Church MK, Gillard M, Sargentini-Maier ML, Poggesi I, Campbell A, Benedetti MS. From pharmacokinetics to therapeutics. Drug Metab Rev 2009; 41:455-74. [PMID: 19601722 DOI: 10.1080/10837450902891535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Whilst pharmacokinetics describe the relationship between dose levels and concentration-time profiles of a drug in the body and pharmacodynamics describe the concentration-response relationships, pharmacokinectics-pharmacodynamics(PK-PD) models link these two items providing a framework for modelling the time course of drug response. In this chapter, PK-PD models, describing the therapeutic effects of drugs used for the therapy of allergic diseases have been reviewed. Emphasis was given also to the description of the receptor occupancy, which is tightly related to the downstream clinical response. PK - PD models describing unwanted effects were also commented. An integrated use of these models allows choosing appropriate dosing regimens and providing an objective evaluation of the benefit/risk balance.
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Affiliation(s)
- Martin K Church
- Charité - Universitätsmedizini Berlin, Germany. mkc@ southampton.ac.uk
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Day JH, Briscoe MP, Ratz JD, Danzig M, Yao R. Efficacy of loratadine-montelukast on nasal congestion in patients with seasonal allergic rhinitis in an environmental exposure unit. Ann Allergy Asthma Immunol 2009; 102:328-38. [PMID: 19441605 DOI: 10.1016/s1081-1206(10)60339-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Nasal congestion is considered to be one of the most bothersome symptoms of allergic rhinitis (AR) and often the most difficult to treat. Oral therapies providing safe, effective, and reliable relief of AR symptoms, including nasal congestion, are limited. OBJECTIVE To evaluate the efficacy of a single dose of loratadine-montelukast (10 mg/10 mg) vs placebo and phenylephrine (10 mg) in relieving nasal congestion over 6 hours after ragweed pollen exposure in the environmental exposure unit at the Kingston General Hospital. METHODS After a screening visit and up to 6 priming visits, patients who met minimum symptom requirements during ragweed pollen exposure were randomized to receive loratadine-montelukast, phenylephrine, or placebo. Patients evaluated nasal congestion and other symptoms of AR and measured peak nasal inspiratory flow before dosing and at 20-minute intervals during the subsequent 8 hours of pollen exposure. RESULTS During the first 6 hours after treatment (primary end point), loratadine-montelukast treatment resulted in greater improvement in the mean nasal congestion score vs placebo (P = .007) and phenylephrine (P < .001). Loratadine-montelukast was more effective than placebo (P < or = .02) and phenylephrine (P < or = .002) in relieving total symptoms, nasal symptoms, and nonnasal symptoms and in improving peak nasal inspiratory flow. There were no statistically significant differences between phenylephrine and placebo for any measures. Fewer patients in the loratadine-montelukast group (3.9%) reported adverse events than in the phenylephrine (7.9%) and placebo (7.1%) groups; most adverse events were mild or moderate. CONCLUSIONS Loratadine-montelukast was more effective than placebo and phenylephrine in relieving nasal congestion and other nasal and nonnasal symptoms resulting from ragweed pollen exposure. There was no statistically significant difference between phenylephrine and placebo.
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Affiliation(s)
- James H Day
- Department of Medicine, Queen's University, and Division of Allergy and Immunology, Kingston General Hospital, Kingston, Ontario, Canada.
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Vaidyanathan S, Nair A, Barnes ML, Meldrum K, Lipworth BJ. Effect of levocetirizine on nasal provocation testing with adenosine monophosphate compared with allergen challenge in allergic rhinitis. Clin Exp Allergy 2009; 39:409-16. [PMID: 19187327 DOI: 10.1111/j.1365-2222.2008.03166.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND End-organ hyperreactivity is an important feature of the allergic airway. There are no data directly comparing the responsiveness to treatment of different nasal provocation tests (NPT). OBJECTIVE We compared the effect of levocetirizine on nasal adenosine 5'-monophosphate (AMP) with specific allergen challenge in patients with intermittent and persistent allergic rhinitis (AR). METHODS Patients with AR were randomized in double-blind cross-over fashion to receive single doses of levocetirizine 5 mg or identical placebo, with nasal challenge performed 12 h after dosing. Sixteen participants completed per protocol. Nasal AMP or allergen challenge was conducted on separate days with 1- and 2-week washout periods in between, respectively. Measurements of peak nasal inspiratory flow (PNIF) were made over 60 min after each challenge. The primary end-point was the provocative concentration of AMP or allergen causing a 20% drop in the PNIF (PC(20)). RESULTS The time-profile for PNIF recovery [area under the 60 min time-response curve as % PNIF change (min)] were significantly attenuated for AMP challenge, as mean difference [95% confidence interval (CI)]: 11.57 (3.87, 19.25), P=0.005 and for allergen challenge: 17.82 (0.11, 35.53), P=0.04. A highly significant correlation was shown between methods for the area under the curve: (R=0.86, P<0.001). A statistically significant correlation was also seen for the PC(20): (R=0.94, P<0.001). PC(20) improvement amounted to a 1.26 (95% CI 0.16, 2.35) and 0.16 (95% CI -0.41, 0.73) doubling-dilution shifts for allergen and AMP challenges, respectively. Bland-Altman plots confirmed good agreement between methods. CONCLUSION A high correlation and statistical agreement has been demonstrated between AMP and allergen challenge for all outcome measures. In particular, the recovery profile after NPT is a sensitive and discriminatory measure of anti-allergic treatment.
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Affiliation(s)
- S Vaidyanathan
- Asthma & Allergy Research Group, Department of Medicine and Therapeutics, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland, UK.
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Sharma HP, Wood RA, Bravo AR, Matsui EC. A comparison of skin prick tests, intradermal skin tests, and specific IgE in the diagnosis of mouse allergy. J Allergy Clin Immunol 2008; 121:933-9. [DOI: 10.1016/j.jaci.2008.01.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 01/16/2008] [Accepted: 01/21/2008] [Indexed: 11/25/2022]
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Korenblat P. Methods for evaluating allergic rhinitis medications. Ann Allergy Asthma Immunol 2006; 96:255. [PMID: 16498843 DOI: 10.1016/s1081-1206(10)61231-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Day JH, Horak F, Briscoe MP, Canonica GW, Fineman SM, Krug N, Leynadier F, Lieberman P, Quirce S, Takenaka H, Cauwenberge P. The role of allergen challenge chambers in the evaluation of anti-allergic medication: an international consensus paper. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1365-2222.2005.00099.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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