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Chitsuthipakorn W, Hoang MP, Kanjanawasee D, Seresirikachorn K, Snidvongs K. Combined medical therapy in the treatment of allergic rhinitis: Systematic review and meta-analyses. Int Forum Allergy Rhinol 2022; 12:1480-1502. [PMID: 35446512 DOI: 10.1002/alr.23015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/05/2022] [Accepted: 04/17/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antihistamines (ATH) and intranasal corticosteroids (INCS) are primary treatments for patients with allergic rhinitis (AR). When monotherapy of either primary treatment fails to control symptoms, combined medical therapy is an option. In this meta-analysis we assessed the additional effects of different medical combinations compared with primary treatments. METHODS Systematic searches on PubMed and EMBASE were updated on November 4, 2021. Randomized, controlled trials comparing the effects of combinations with monotherapy were included. There were 7 comparisons: (1) ATH-decongestant vs ATH; (2) ATH-leukotriene receptor antagonist (LTRA) vs ATH; (3) INCS-ATH vs INCS; (4) INCS-LTRA vs INCS; (5) INCS-decongestion vs INCS; (6) INCS-saline irrigation vs INCS; and (7) ATH-saline irrigation vs ATH. Data were pooled for meta-analysis. Outcomes were composite nasal symptom score, composite ocular symptom score, quality of life (QoL), and adverse events. RESULTS Fifty-three studies were included. Compared with ATH alone, the ATH-decongestant combination improved composite nasal symptoms; ATH-LTRA improved nasal symptoms in patients with perennial AR; and ATH-nasal saline improved both symptoms and QoL. Compared with INCS alone, the INCS-intranasal ATH combination improved nasal symptoms, ocular symptoms, and QoL; INCS-LTRA improved ocular symptoms but not nasal symptoms; and INCS-nasal saline improved QoL but not symptoms. There were no additional effects observed from adding oral ATH or topical decongestant to INCS. CONCLUSION After ATH monotherapy fails to control symptoms, addition of decongestant, saline, or LTRA can improve the outcomes. When INCS monotherapy is ineffective, addition of intranasal ATH can improve nasal symptoms; LTRA can improve ocular symptoms, and saline irrigation can improve QoL.
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Affiliation(s)
- Wirach Chitsuthipakorn
- Center of Excellence in Otolaryngology, Head and Neck Surgery, Rajavithi Hospital, Bangkok, Thailand.,College of Medicine, Rangsit University, Bangkok, Thailand
| | - Minh P Hoang
- Department of Otolaryngology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam.,Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Dichapong Kanjanawasee
- Center of Research Excellence in Allergy and Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Biodesign Innovation Center, Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kachorn Seresirikachorn
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Seresirikachorn K, Chitsuthipakorn W, Kanjanawasee D, Khattiyawittayakun L, Snidvongs K. Leukotriene Receptor Antagonist Addition to H1-Antihistamine Is Effective for Treating Allergic Rhinitis: A Systematic Review and Meta-analysis. Am J Rhinol Allergy 2019; 33:591-600. [PMID: 31007040 DOI: 10.1177/1945892419844459] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kachorn Seresirikachorn
- 1 Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,2 Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Dichapong Kanjanawasee
- 1 Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,2 Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Likhit Khattiyawittayakun
- 1 Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,4 Department of Otolaryngology, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Kornkiat Snidvongs
- 1 Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,2 Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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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: 218] [Impact Index Per Article: 36.3] [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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Liu G, Zhou X, Chen J, Liu F. Oral Antihistamines Alone vs in Combination with Leukotriene Receptor Antagonists for Allergic Rhinitis: A Meta-analysis. Otolaryngol Head Neck Surg 2018; 158:450-458. [PMID: 29337654 DOI: 10.1177/0194599817752624] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To evaluate whether an adjuvant therapy of leukotriene receptor antagonists (LTRAs) based on oral H1-antihistamines (H1) can increase efficacy of allergic rhinitis (AR) treatment. Data Sources The search involved databases of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials, from inception up to September 23, 2017. Randomized controlled trials (RCTs) that compared efficacy of LTRAs + H1 vs H1 alone were eligible. Review Methods Pooled comparative effects were measured using weighted mean difference (WMD) and 95% confidence interval (CI). Subgroup analysis comparing seasonal vs perennial AR was prespecified to explore the source of heterogeneity. The evidence quality of each outcome was assessed by the GRADE approach. Results A total of 8 RCTs were included (n = 1886), and all measured outcomes used scaled scores. Compared with H1 alone, H1 + LTRAs were superior to improve overall daytime (WMD, -0.11; 95% CI, -0.19 to -0.03, high quality) and composite (WMD, -0.12; 95% CI, -0.23 to -0.01; low quality) nasal symptoms. Specifically, H1 + LTRAs had better efficacy against composite nasal rhinorrhea, sneezing, and daytime itching but not congestion. The effects were more pronounced in patients with perennial AR compared to those with seasonal AR. There were no significant differences in nighttime nasal symptoms and eye symptoms between the 2 groups. Conclusion The current evidence suggests that LTRAs + H1 can increase the therapeutic efficacy against daytime and composite nasal symptoms, including rhinorrhea, sneezing, and itching; however, it does not affect nighttime nasal symptoms and eye symptoms. The patients with perennial AR may benefit more from the combination therapy.
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Affiliation(s)
- Guo Liu
- 1 Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xu Zhou
- 2 Evidence-based Medicine Research Center, School of Basic Medical Sciences, Jiangxi University of Traditional Chinese Medicine, Jiangxi, China
| | - Jianrong Chen
- 3 Department of Endocrinology, the Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Feng Liu
- 1 Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
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Krouse JH, Roland PS, Marple BF, Wall GM, Hannley M, Golla S, Hunsaker D. Optimal Duration of Allergic Rhinitis Clinical Trials. Otolaryngol Head Neck Surg 2016; 133:467-87; discussion 488. [PMID: 16213915 DOI: 10.1016/j.otohns.2005.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Accepted: 07/19/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE: Guidelines have been published by the Food and Drug Administration (FDA) and the European Agency for the Evaluation of Medicinal Products (EMEA) for the conduct of seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR) studies. These guidelines have differences regarding the duration of such trials: the FDA suggests 2 weeks for SAR and 4 weeks for PAR but the EMEA suggests 2 to 4 weeks for SAR and 6 to 12 weeks for PAR trials. In the interest of global harmonization, it would be desirable to have a uniform duration of such trials so that investigators, internationally, would be able to readily compare results for various types of treatments based on a single standard. Therefore, we performed an evidence-based review to answer the clinical question, What is the optimal duration for SAR and PAR clinical trials? METHODS: We performed a MEDLINE search of the published literature from 1995 to the present. We used appropriate search terms, such as allergic rhinitis, seasonal allergic rhinitis, perennial allergic rhinitis, SAR, and PAR, to identify pertinent articles. These articles were reviewed and graded according to the evidence quality. RESULTS: After an initial screening of more than 300 articles, 138 articles were analyzed thoroughly. No study specifically addressed the question of the optimal duration of SAR or PAR clinical trials. CONCLUSIONS: We conclude that the current FDA (draft) guidelines calling for a study length of 2 weeks for the assessment of drug efficacy for SAR and 4 weeks for the study of drug efficacy in PAR are appropriate and that longer study periods are not likely to add meaningfully to the assessment of drug efficacy.
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Affiliation(s)
- John H Krouse
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, MI 48201, USA.
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Ottaviano G, Fokkens WJ. Measurements of nasal airflow and patency: a critical review with emphasis on the use of peak nasal inspiratory flow in daily practice. Allergy 2016; 71:162-74. [PMID: 26447365 DOI: 10.1111/all.12778] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 12/26/2022]
Abstract
Objective measures can be used to assist the clinician to diagnose and treat nasal obstruction and also to quantify nasal obstruction in research. Objective measurements of nasal obstruction are as important as objective measurements of lung function. peak nasal inspiratory flow (PNIF), acoustic rhinometry (AR) and rhinomanometry (RM), with their specific peculiarity, assess different aspects of nasal obstruction. From the studies available in the literature, it seems that these methods roughly correlate with each other and that all of them can be alternatively utilized very well in research as well as in clinical practice. This review describes the various methods that can be used to measure nasal patency, airflow and resistance, mainly peak nasal inspiratory flow, rhinomanometry and acoustic rhinometry. PNIF has been demonstrated to be reproducible and as good an indication of objective nasal patency as formal rhinomanometry and has the advantage to be cheap, simple and suitable for serial measurements and for home use even in the paediatric population. PNIF normative data are available for children, adults and elderly subjects, and the availability of unilateral PNIF normal values allows evaluation of nasal sides separately. Just as in the lower airways, objective and subjective evaluation gives different information that together optimizes the diagnosis and the treatment of our patients. We argue that PNIF should be used regularly in every outpatient clinic that treats patients with nasal obstruction.
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Affiliation(s)
- G. Ottaviano
- Otolaryngology Section; Department of Neurosciences; University of Padova; Padova Italy
| | - W. J. Fokkens
- Department of Otorhinolaryngology; Academic Medical Centre; Amsterdam The Netherlands
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Concomitant corticosteroid nasal spray plus antihistamine (oral or local spray) for the symptomatic management of allergic rhinitis. Eur Arch Otorhinolaryngol 2015; 273:3477-3486. [DOI: 10.1007/s00405-015-3832-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/02/2015] [Indexed: 11/25/2022]
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Kirtsreesakul V, Leelapong J, Ruttanaphol S. Nasal peak inspiratory and expiratory flow measurements for assessing nasal obstruction in allergic rhinitis. Am J Rhinol Allergy 2015; 28:126-30. [PMID: 24717950 DOI: 10.2500/ajra.2014.28.4008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although nasal peak flow measurements have been proposed as a simple alternative method to assess nasal patency, which of nasal peak expiratory flow or nasal peak inspiratory flow (NPEF/NPIF) or the peak expiratory flow index or peak inspiratory flow index (PEFI/PIFI; the ratios between nasal and oral PEF or nasal and oral PIF, respectively) is the more accurate method is unclear. The aim of this study was to evaluate the correlation between NPEF, NPIF, PEFI, and PIFI, and blocked nose score (BNS) and mucociliary clearance time (MCCT) in diagnostic and follow-up assessments. METHODS Ninety-nine allergic rhinitis (AR) patients were treated with 220 micrograms once daily of intranasal triamcinolone acetonide for 28 days. BNS, NPEF, NPIF, PEFI, and PIFI and MCCT were used to evaluate treatment outcome. Correlations of initial visit scores and score changes after treatment between peak flow rates and BNSs and MCCTs were analyzed. RESULTS All nasal symptoms, peak flows, and MCCTs showed statistically significant improvements after the nasal steroid treatment. PEFI showed the best negative correlation with BNS and MCCTs, followed by PIFI, NPEF, and NPIF. Nasal peak flows showed better correlations with MCCTs than BNSs. Mean changes of peak flow rates between visits showed better correlation with BNSs and MCCTs than absolute values of peak flow rates at the initial visit. CONCLUSION Among nasal peak flow measurements, PEFI is the most appropriate objective tool for assessing nasal patency in AR. Peak flows can indicate underlying mucosal inflammation and are more sensitive to assess score changes after treatment than cross-sectional assessment at the initial visit.
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Affiliation(s)
- Virat Kirtsreesakul
- Department of Otolaryngology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Koinis-Mitchell D, Esteban C, Kopel SJ, Jandasek B, Dansereau K, Fritz GK, Klein RB. Perceptual accuracy of upper airway compromise in children: Clinical relevance and future directions for research. ALLERGY & RHINOLOGY 2013; 4:e54-62. [PMID: 24124637 PMCID: PMC3793113 DOI: 10.2500/ar.2013.4.0060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12-18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251-256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms "guesses" by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.
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Affiliation(s)
- Daphne Koinis-Mitchell
- Bradley/Hasbro Children's Research Center, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Gane J, Buckley R. Leukotriene receptor antagonists in allergic eye disease: a systematic review and meta-analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2012; 1:65-74. [PMID: 24229824 DOI: 10.1016/j.jaip.2012.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 07/06/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND Allergic eye diseases are common and cause significant morbidity. Leukotrienes are implicated in the pathogenesis of seasonal and perennial allergic conjunctivitis (AC), commonly seen in conjunction with allergic rhinitis, and in vernal keratoconjunctivitis and atopic keratoconjunctivitis. OBJECTIVES To assess the available evidence for an effect of leukotriene receptor antagonists (LTRAs) on the ocular symptoms of allergic eye diseases. METHODS Selected studies, identified with systematic review search methods, were single/double-blind, randomized, controlled trials that compared LTRAs with other common treatments. RESULTS Eighteen trials, using the LTRA montelukast (in AC only), were identified. Six studies were suitable for meta-analysis, in patients with seasonal AC [treated over a 2-week period, symptoms scored 0 (mild) to 3 (severe)]. These trials were at low risk of bias without significant heterogeneity. Six trials were analyzed and showed that montelukast improved patients' ocular symptoms to a greater extent than placebo, with a difference in mean change-from-baseline score of -0.10 (95% CI, -0.14 to -0.07; P < .00001). Three trials compared montelukast with oral antihistamine. The difference in mean change-from-baseline score was 0.08 (95% CI, 0.02 to 0.14; P = .007), in favor of antihistamines. Two trials compared montelukast and oral antihistamine with placebo. The difference in mean change-from-baseline score was -0.30 (95% CI, -0.38 to -0.21; P < .00001), in favor of combination treatment. CONCLUSIONS In seasonal AC LTRAs are more efficacious than placebo but less efficacious than oral antihistamines in adult patients. Clinical trials should be conducted to determine whether combination treatment with LTRA and oral antihistamine has a synergistic effect. Further research is required to clarify the role of LTRAs in other allergic eye diseases.
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Affiliation(s)
- Jennie Gane
- Clinical Research Fellow, University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom.
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Raudenbush B. Stenting the nasal airway for maximizing inspiratory airflow: internal Max-Air Nose Cones versus external Breathe Right strip. Am J Rhinol Allergy 2011; 25:249-51. [PMID: 21819762 DOI: 10.2500/ajra.2011.25.3621] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Several nasal dilator devices designed to stent the anterior nasal airway to increase peak nasal inspiratory flow (PNIF) currently exist; however, comparisons of such devices are limited. This study was designed to compare the efficacy of two different nasal dilator devices, an internal device (Max-Air Nose Cones; Sanostec Corp., Beverly Farms, MA) and an external device (Breathe Right nasal strip; GlaxoSmithKline, Brentford, Middlesex, U.K.) on stenting of the anterior nasal airway to maximize PNIF. METHODS Repeated measurements of PNIF were obtained in 30 individuals noting complaints of sleep-disordered breathing due to nasal breathing discomfort and nasal airway obstruction, both with and without the two different nasal dilator devices. RESULTS A one-within analysis of variance (ANOVA) was performed among the three conditions (control, Max-Air Nose Cones, and Breathe Right nasal strip), and a statistically significant effect was found (F[2,58] = 298.13; p< 0.00001). Tukey post hoc contrasts revealed that the control condition PNIF (66.07 L/min) was significantly lower than both the Max-Air Nose Cones (138.73 L/min) and the Breathe Right nasal strip (102.17 L/min) conditions. The Max-Air Nose Cone increased inspiratory airflow by 73 L/min, or a 110% improvement over baseline. In addition, the Max-Air Nose Cone condition PNIF was significantly higher than both the control condition and the nasal strip condition. CONCLUSION Although both the Max-Air Nose Cones and the Breathe Right nasal strips increased PNIF from baseline, the Max-Air Nose Cones showed significantly greater efficacy at stenting the anterior nasal airway, providing twice the improvement in PNIF over baseline than did the Breathe Right nasal strips.
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Affiliation(s)
- Bryan Raudenbush
- Department of Psychology, Human Psychophysiology Laboratory, Wheeling Jesuit University, Wheeling, WV 26003, USA.
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Given JT, Cheema AS, Dreykluft T, Stillerman A, Silvey M, Wu W, Snowise NG, Philpot E. Fluticasone Furoate Nasal Spray is Effective and Well Tolerated for Perennial Allergic Rhinitis in Adolescents and Adults. Am J Rhinol Allergy 2010; 24:444-50. [DOI: 10.2500/ajra.2010.24.3534] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Fluticasone furoate nasal spray (FFNS), an intranasal corticosteroid, has been shown to be effective in perennial allergic rhinitis in randomized, double-blind, placebo-controlled studies but has been less extensively studied in perennial allergic rhinitis than seasonal allergic rhinitis. This study was designed to evaluate the efficacy and safety of FFNS in perennial allergic rhinitis in adolescents and adults ≥12 years of age. Methods In this randomized, double-blind, placebo-controlled, parallel-group study (FFU111439), patients ≥12 years old with perennial allergic rhinitis received FFNS, 110 micrograms (n = 160), or placebo (n = 155) q.d. for 4 weeks. Results Over the entire treatment period, FFNS was significantly (p < 0.05) more effective than placebo with respect to mean changes from baseline in daily reflective total nasal symptoms (primary end point), morning and evening reflective total nasal symptoms, daily reflective individual nasal symptoms, morning predose instantaneous total and individual nasal symptoms, and morning and evening peak nasal inspiratory flow. FFNS did not show a statistically significant difference from placebo in comparisons of ocular symptom measures. Clinically meaningful improvement versus placebo was observed on the Rhinoconjunctivitis Quality of Life Questionnaire with Standardised Activities overall score. Adverse events reported in >3% of patients in a treatment group and reported more frequently with FFNS than placebo were epistaxis (15% FFNS, 8% placebo) and nasopharyngitis (5% FFNS, 1% placebo). Conclusion Once-daily FFNS was well tolerated and more effective than placebo at improving nasal symptoms of perennial allergic rhinitis in adolescents and adults ≥12 years of age.
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Affiliation(s)
| | | | | | | | | | - Wei Wu
- GlaxoSmithKline, Research Triangle Park, North Carolina
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Meltzer EO, Munafo DA, Chung W, Gopalan G, Varghese ST. Intranasal mometasone furoate therapy for allergic rhinitis symptoms and rhinitis-disturbed sleep. Ann Allergy Asthma Immunol 2010; 105:65-74. [PMID: 20642206 DOI: 10.1016/j.anai.2010.04.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Allergic rhinitis (AR) and related nasal congestion cause rhinitis-disturbed sleep (RDS). Intranasal corticosteroids reduce nasal congestion and improve sleep quality in AR but have not been extensively studied in RDS. OBJECTIVE To evaluate the efficacy of mometasone furoate nasal spray (NS) on nasal symptoms, nasal patency, sleep variables, quality of life, and daytime functioning in perennial AR (PAR) and concomitant RDS. METHODS In this double-blind 4-week study, 30 adults with PAR and moderate RDS were randomized 2:1 to receive mometasone furoate NS, 200 microg, or placebo each morning. The primary end point was the apnea-hypopnea index. Secondary outcome measures included changes in total nasal symptom score (TNSS), nighttime symptom score, daytime peak nasal inspiratory flow, nighttime flow limitation index, Rhinoconjunctivitis Quality of Life Questionnaire-Standardized (RQLQ-S) score, Epworth Sleepiness Scale score, and Work Productivity and Activities Impairment-Allergy Specific (WPAI-AS) questionnaire score. Analysis of covariance was used for all efficacy end points. RESULTS The apnea-hypopnea index at study end was not statistically significantly different between groups. However, mometasone furoate NS therapy significantly improved morning (P = .04) and evening (P = .01) TNSSs, morning (P = .049) and evening (P = .03) nasal obstruction/blockage/congestion, daily peak nasal inspiratory flow (P = .03), flow limitation index (P = .02), Epworth Sleepiness Scale score (P = .048), RQLQ-S score (P = .03), and 2 of 5 WPAI-AS domains. Among patients receiving mometasone furoate NS, TNSS improvements were significantly correlated with improved work- and non-work-related productivity. CONCLUSIONS In patients with PAR and RDS, mometasone furoate NS use improved nasal symptoms, sleepiness, and impairment in daily activities. Correlated reduced nasal symptoms and improved performance suggest that improving AR symptoms with mometasone furoate NS administration can benefit sleep and daytime functioning.
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Affiliation(s)
- Eli O Meltzer
- Allergy and Asthma Medical Group and Research Center, San Diego, California 92123, USA.
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Barnes ML, Vaidyanathan S, Williamson PA, Lipworth BJ. The minimal clinically important difference in allergic rhinitis. Clin Exp Allergy 2009; 40:242-50. [PMID: 19895590 DOI: 10.1111/j.1365-2222.2009.03381.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND When presented with results from clinical measurements or research findings, clinicians must first make an interpretation of their importance, not only in statistical terms, but also the 'clinical importance' given the size of the change observed. To do this, they require an understanding of the relationship between their outcome measures, and the patient's perception of change. The minimal clinically important difference (MCID) illustrates this relationship by calculating the smallest change in a given outcome that is meaningful to a patient. There are few reports of calculated MCIDs in the Rhinology literature. OBJECTIVE To calculate MCIDs for common subjective and objective outcome measures in allergic rhinitis (AR). METHODS Nine randomized, blinded, placebo-controlled clinical trials in intermittent and persistent AR (pooled subjects, n=204) were analysed using anchor- and distribution-based approaches, applying regression and meta-analysis techniques. RESULTS MCIDs were obtained for the Mini Rhinoconjunctivitis Quality of Life Questionnaire: 0.4 units, peak nasal inspiratory flow: 5 L/min and total nasal symptoms score: 0.55 units. Nasal NO measurement changes had no correlation with patient perceptions of benefit. CONCLUSION Estimates of MCIDs were obtained for common subjective and objective rhinological outcomes. MCIDs can and should be applied by physicians interpreting research findings, as well as researchers reporting their findings. We can then be confident that our changes in practice will be of perceptible benefit to the patient.
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Affiliation(s)
- M L Barnes
- Asthma & Allergy Research Group, Department of Medicine and Therapeutics, Ninewells Hospital & Medical School, University of Dundee, Scotland, UK.
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Ibiapina CDC, Sarinho ESC, Camargos PAM, Andrade CRD, Cruz Filho AASD. Allergic rhinitis: epidemiological aspects, diagnosis and treatment. J Bras Pneumol 2008; 34:230-40. [PMID: 18425260 DOI: 10.1590/s1806-37132008000400008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Accepted: 10/04/2007] [Indexed: 11/22/2022] Open
Abstract
This study was a review of the literature on the epidemiological, clinical, diagnostic and therapeutic aspects of allergic rhinitis. Bibliographic searches were based on the information contained within the Medline, Latin American and Caribbean Health Sciences Literature and HighWire databases, covering the last thirty years and using the following search terms: 'allergic rhinitis', 'epidemiology', 'diagnosis' and 'treatment'. Sixty articles were selected. This study describes the increase in the prevalence of allergic rhinitis, its relationship with asthma, the diagnostic criteria and the treatment. The classification of allergic rhinitis and strategies for its treatment are presented. Therapeutic modalities presented and discussed include the administration of antihistamines, corticosteroids, immunotherapy, anti-leukotrienes, sodium cromoglycate and anti-IgE antibodies, as well as minimizing exposure to inhaled allergens. Finally, the importance of the management of allergic rhinitis in public health is emphasized.
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Affiliation(s)
- Cássio da Cunha Ibiapina
- Pediatrics Department, Universidade Federal de Minas Gerais - UFMG, Federal University of Minas Gerais - School of Medicine, Belo Horizonte, Brazil.
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Wilson AM, Orr LC, Sims EJ, Lipworth BJ. Effects of monotherapy with intra-nasal corticosteroid or combined oral histamine and leukotriene receptor antagonists in seasonal allergic rhinitis. Clin Exp Allergy 2008. [DOI: 10.1111/j.1365-2222.2001.00964.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shirasaki H. Cysteinyl leukotriene receptor CysLT1 as a novel therapeutic target for allergic rhinitis treatment. Expert Opin Ther Targets 2008; 12:415-23. [PMID: 18348678 DOI: 10.1517/14728222.12.4.415] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cysteinyl leukotrienes (cys-LTs) play an important role in allergic rhinitis because CysLT(1) receptor antagonists relieve the symptoms of allergic rhinitis. OBJECTIVE I overview the clinical pharmacology of CysLT(1) receptor antagonists and their potential role in patients with allergic rhinitis. METHODS I review the evidence regarding the release of cys-LTs and localization of CysLT(1) receptor on nasal mucosa, and evaluate the clinical efficacy of CysLT(1) receptor antagonist in allergic rhinitis. RESULTS/CONCLUSION Immunohistochemical studies show that in allergic rhinitis, the major target of CysLT(1) receptor antagonists are the vascular bed and infiltrated leukocytes such as mast cells, eosinophils and macrophages. CysLT(1) receptor antagonists provide a new opportunity for simultaneous management of allergic diseases of the upper and lower respiratory tract.
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Affiliation(s)
- Hideaki Shirasaki
- Sapporo Medical University, Department of Otolaryngology, S-1 W-16, Chuo-ku, Sapporo, 060-8543, Japan.
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Pinar E, Eryigit O, Oncel S, Calli C, Yilmaz O, Yuksel H. Efficacy of nasal corticosteroids alone or combined with antihistamines or montelukast in treatment of allergic rhinitis. Auris Nasus Larynx 2008; 35:61-6. [PMID: 17826020 DOI: 10.1016/j.anl.2007.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2007] [Revised: 06/05/2007] [Accepted: 06/14/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Topical corticosteroids are recommended as initial therapy in allergic rhinitis (AR) patients. We investigated clinical efficacy of monotherapy with topical steroid and combined therapy in AR patients. METHODS Ninety-five AR patients sensitive to grass pollens according to skin prick test results were enrolled in this placebo-controlled and open study. Patients were divided to four groups. Group-1 received only intranasal mometasone furoate (MF) 200microg (n=25), group-2 received intranasal MF and oral desloratadine (DLR) 5mg (n=25), group-3 received intranasal MF and oral montelukast (MSK) 10mg (n=25), group-4 received only placebo (n=20). Efficacy was assessed on the basis of total nasal symptom scores, rhinoconjunctivitis quality of life questionnaire scores and nasal inspiratory peak flow rates. RESULTS All groups that received treatment had better results when compared to the placebo group. Significant improvement in total nasal symptom scores was first evident at the end of the 2nd week in group-2. Group-3 had better results than those of the other groups at the end of the 1st month (p<0.05). Quality of life scores were significantly better in group-2 and -3 when compared to those in group-1 (p<0.05). CONCLUSION Although corticosteroids are the mainstay of treatment in allergic rhinitis, montelukast may be considered as an additional agent especially in treatment of patients with impaired quality of life and it may be used to reduce nasal symptom scores.
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Affiliation(s)
- Ercan Pinar
- ENT Department, Izmir Ataturk Training and Research Hospital, Izmir, Turkey.
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Zeyrek D, Tanac R, Altinoz S, Berdeli A, Gulen F, Koksoy H, Demir E. FcgammaRIIIa-V/F 158 polymorphism in Turkish children with asthma bronchiale and allergic rhinitis. Pediatr Allergy Immunol 2008; 19:20-4. [PMID: 18199088 DOI: 10.1111/j.1399-3038.2007.00553.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fc receptors (FcR) play an important role in immune regulation. This might be linked to the variability in immune response, therefore relating to the pathogenesis of atopic diseases. The aim of the present study was to evaluate the FcgammaRIIIa gene polymorphism in Turkish children with asthma and allergic rhinitis. The study included 364 atopic children (184 bronchial asthma, 180 allergic rhinitis) and 234 healthy subjects as the control group, aged between 5 to 16 years. Patients were recruited from outpatient clinics of allergy and general pediatric care. Plasma IgE concentrations were measured by immunoassays and skin prick test was done in children with atopic diseases. The FcgammaRIIIa gene polymorphism was determined using the polymerase chain reaction method. Distribution of V158V genotype was significantly different among patient groups compared to controls (for asthmatic children OR: 5.33, 95% CI: 2.80-10.23, p < 0.001; for allergic rhinitis OR: 3.25, 95% CI: 1.75-6.07, p = 0.001). Distribution of 158 V allele was significantly different among asthmatic children (OR: 2.20, 95% CI: 1.65-2.92, p < 0.001) and allergic rhinitis patients (OR: 1.77, 95% CI: 1.32-2.35, p < 0.001) compared to healthy controls. Our study shows that the V158V genotype in FcgammaRIIIa gene polymorphism may be a genetic risk factor for the development of atopic diseases.
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Affiliation(s)
- Dost Zeyrek
- Department of Pediatric Allergy and Pulmonology, Aegean University, Izmir, Turkey.
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Dufour X, Gohler C, Delagranda A, Fontanel JP, Klossek JM. [Peak Nasal Inspiratory Flow: learning curve for the measurement method and reproducibility]. ACTA ACUST UNITED AC 2007; 124:115-9. [PMID: 17509517 DOI: 10.1016/j.aorl.2007.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 03/05/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVES A prospective study on the learning curve and reproducibility of PNIF measurement with 18 different operators. MATERIAL AND METHODS Five hundred twenty-eight patients in two groups were prospectively enrolled in this study from September 2003 to April 2004. The learning curve of the technique was monitored after five patients had been measured. Reproducibility was evaluated with all patients after two consecutive measurements. RESULTS The technique was acquired by all operators after the fifth patient. The mean PNIF measurements in controls and patients were 86.02+/-36.96 l/min and 89.59+/-41.97 l/min, respectively. Reproducibility (PNIF2-PNIF1=5.51+/-24.93 l/min) was obtained for all operators, whatever the number of measurements taken. CONCLUSIONS The study confirms the good reproducibility and the easy training in PNIF measurement.
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Affiliation(s)
- X Dufour
- Département d'ORL, de chirurgie cervicomaxillofaciale, et d'audiophonologie, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France.
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Grayson MH, Korenblat PE. The role of antileukotriene drugs in management of rhinitis and rhinosinusitis. Curr Allergy Asthma Rep 2007; 7:209-15. [PMID: 17448333 DOI: 10.1007/s11882-007-0074-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Antileukotriene drugs have been studied for more than 15 years. In this review we examine the role of leukotrienes in rhinitis and rhinosinusitis, and explore the clinical literature supporting the use of anti-leukotriene agents in these diseases. Although these medications clearly are efficacious in rhinitis, it is unclear where in the armamentarium they should be used. The evidence for use in sinusitis has not been well studied except in sinusitis-associated aspirin-exacerbated respiratory disease. In this circumstance there is information that allows use of antileukotriene agents to be considered efficacious. We provide our rationale for use and await future clinical studies to answer this important question.
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Affiliation(s)
- Mitchell H Grayson
- Division of Allergy and Immunology, Department of Internal Medicine, Washington University School of Medicine, Campus Box 8122, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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Abstract
BACKGROUND The efficacy of subcutaneous pollen immunotherapy has been documented in published double-blind, placebo-controlled studies related to treatment of seasonal allergic rhinitis. In the present study, subjective (symptom scores) and objective (nasal peak inspiratory flow, nasal smear, nasal biopsy) parameters were used to study the efficacy of pollen immunotherapy. METHODS Forty-eight patients (32 male), mean +/- SE age 13.6 +/- 2.8 years allergic to grass-pollen participated in the present study. Patients were divided into three groups: group I, 24 patients who did not receive pollen immunotherapy; group II, 12 patients who received the build-up phase of pollen immunotherapy; and group III, 12 patients who had just finished pollen immunotherapy. With regard to objective and subjective parameters these three groups were compared. RESULTS When group I was compared to groups II and III, the patients who had not received any immunotherapy were found to have a high daytime nasal symptoms score (P < 0.01), high daytime eye symptoms score(P < 0.01) and high night-time symptoms score (P < 0.01). In objective parameters, it was found that group I had low nasal peak inspiratory flow (P < 0.05), and a high eosinophil count in nasal smears (P < 0.05) and peripheral blood (P < 0.05). It was also demonstrated that there was an increased eosinophil infiltration (P < 0.01) and mast cell infiltration (P < 0.05) in nasal biopsy in group I. There was no significant difference between group II and group III according to these results (P > 0.05). CONCLUSIONS Immunotherapy leads to a better clinical and histopathological prognosis in children with seasonal allergic rhinitis.
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Affiliation(s)
- Demet Can
- Division of Pediatric Allergy and Pulmonology, Behcet Uz Children Hospital, Izmir, Turkey.
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Gulen F, Tanac R, Altinoz S, Berdeli A, Zeyrek D, Koksoy H, Demir E. The Fc gammaRIIa polymorphism in Turkish children with asthma bronchial and allergic rhinitis. Clin Biochem 2007; 40:392-6. [PMID: 17291475 DOI: 10.1016/j.clinbiochem.2006.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Revised: 10/27/2006] [Accepted: 11/08/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the Fc gammaRIIa polymorphism in Turkish children with atopic asthma and allergic rhinitis. DESIGN AND METHODS In this study, 372 atopic children (192 asthma bronchial, 180 allergic rhinitis) between ages of 5 and 16 years old (11.3+/-2.9) who were followed at Aegean University Paediatric Allergy and Pulmonology Outpatient Clinics and 234 healthy subjects as the control group were included. The evaluation of subjects included routine biochemical blood analysis and allergic workup based on the following laboratory determinants. The Fc gammaRIIa polymorphism was determined using the polymerase chain reaction method. RESULTS Distribution of R131R genotype was significantly different among patient groups compared to controls (for asthmatic children OR: 2.64 95%CI: 1.22-5.79, p=0.006; for allergic rhinitis OR: 2.58 95%CI: 1.18-5.71, p=0.009). Frequency of 131R allele was significantly different among patient groups compared to controls (for asthmatic children OR: 1.66 95%CI: 1.22-2.26, p=0.0007; for allergic rhinitis OR: 1.93 95%CI: 1.42-2.63, p=0.00001). CONCLUSION This study shows that Fc gammaRIIa gene 131R allele represents an important genetic risk factor for bronchial asthma and allergic rhinitis susceptibility.
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Affiliation(s)
- Figen Gulen
- Aegean University School of Medicine, Department of Paediatrics, Division of Allergy and Pulmonology, TR-35100, Bornova/Izmir, Turkey.
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Barnes ML, Ward JH, Fardon TC, Lipworth BJ. Effects of levocetirizine as add-on therapy to fluticasone in seasonal allergic rhinitis. Clin Exp Allergy 2006; 36:676-84. [PMID: 16650054 DOI: 10.1111/j.1365-2222.2006.02478.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Addition of H(1) antagonists to intranasal corticosteroid treatment of allergic rhinitis (AR) is common in clinical practice and recommended by guidelines, despite some evidence that the additive benefits are negligible. OBJECTIVE To assess additional benefits of 5 mg levocetirizine dihydrochloride in seasonal AR patients using 200 mcg fluticasone propionate nasal spray once daily. METHODS In a double-blind placebo-controlled crossover study of 27 patients, following 2 weeks without treatment, subjects used fluticasone with levocetirizine or identical placebo for 2 weeks each. Assessments were the Juniper mini Rhinoconjunctivitis Quality-of-Life Questionnaire (mini-RQLQ), domiciliary peak nasal inspiratory flow (PNIF), total nasal symptoms (TNS) scores and nasal nitric oxide concentrations. Effects were interpreted and tested against minimal clinically important differences. RESULTS Add-on effects for levocetirizine vs. placebo excluded any clinically significant benefits: mean effects (one sided 95% confidence intervals) were mini-RQLQ -0.11 (-0.34), PNIF +0.57 (+5.23), and TNS -0.11 (-0.60). Numbers needed to treat (95% confidence intervals) by outcome were mini-RQLQ 14 (5 to 49), PNIF 4 (3-7), and TNS 3 (2-6). No significant within or between treatment effects were seen for nasal nitric oxide. CONCLUSION Contrary to current practice, the present results demonstrate that for the majority of patients, antihistamine add-on to effective nasal steroid treatment is inappropriate. Further work is required to confirm that this is also true in the most severe cases, and the available evidence needs to be put into guidelines and implemented.
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Affiliation(s)
- M L Barnes
- Asthma & Allergy Research Group, Department of Medicine and Therapeutics, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland, UK
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Abstract
Allergic rhinitis is common. This systematic review outlines the evidence regarding montelukast in allergic rhinitis and provides a meta-analysis of its efficacy. The evidence suggests that montelukast does reduce nasal symptom score by 3.4% (95% CI: 2.5% to 4.2%) when compared with placebo. Montelukast is not as effective as topical nasal steroids or antihistamines and should therefore be regarded as second line therapy. When used, montelukast should be used in combination with an antihistamine.
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Affiliation(s)
- J Grainger
- Department of Otorhinolaryngology, University Hospital Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
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Bousquet J, van Cauwenberge P, Aït Khaled N, Bachert C, Baena-Cagnani CE, Bouchard J, Bunnag C, Canonica GW, Carlsen KH, Chen YZ, Cruz AA, Custovic A, Demoly P, Dubakiene R, Durham S, Fokkens W, Howarth P, Kemp J, Kowalski ML, Kvedariene V, Lipworth B, Lockey R, Lund V, Mavale-Manuel S, Meltzer EO, Mullol J, Naclerio R, Nekam K, Ohta K, Papadopoulos N, Passalacqua G, Pawankar R, Popov T, Potter P, Price D, Scadding G, Simons FER, Spicak V, Valovirta E, Wang DY, Yawn B, Yusuf O. Pharmacologic and anti-IgE treatment of allergic rhinitis ARIA update (in collaboration with GA2LEN). Allergy 2006; 61:1086-96. [PMID: 16918512 DOI: 10.1111/j.1398-9995.2006.01144.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The pharmacologic treatment of allergic rhinitis proposed by ARIA is an evidence-based and step-wise approach based on the classification of the symptoms. The ARIA workshop, held in December 1999, published a report in 2001 and new information has subsequently been published. The initial ARIA document lacked some important information on several issues. This document updates the ARIA sections on the pharmacologic and anti-IgE treatments of allergic rhinitis. Literature published between January 2000 and December 2004 has been included. Only a few studies assessing nasal and non-nasal symptoms are presented as these will be discussed in a separate document.
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MESH Headings
- Animals
- Anti-Allergic Agents/administration & dosage
- Anti-Allergic Agents/adverse effects
- Anti-Allergic Agents/therapeutic use
- Antibodies, Anti-Idiotypic/administration & dosage
- Antibodies, Anti-Idiotypic/adverse effects
- Antibodies, Anti-Idiotypic/therapeutic use
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Humans
- Immunoglobulin E/immunology
- Rhinitis, Allergic, Perennial/drug therapy
- Rhinitis, Allergic, Perennial/immunology
- Rhinitis, Allergic, Perennial/therapy
- Rhinitis, Allergic, Seasonal/drug therapy
- Rhinitis, Allergic, Seasonal/immunology
- Rhinitis, Allergic, Seasonal/therapy
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Affiliation(s)
- J Bousquet
- University Hospital and INSERM U454, Montpellier, France
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Rodrigo GJ, Yañez A. The role of antileukotriene therapy in seasonal allergic rhinitis: a systematic review of randomized trials. Ann Allergy Asthma Immunol 2006; 96:779-86. [PMID: 16802764 DOI: 10.1016/s1081-1206(10)61339-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the effect of oral leukotriene receptor antagonists as monotherapy or combined with other drugs in the treatment of seasonal allergic rhinitis. DATA SOURCES The MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health), and Cochrane databases; review articles; and references of included trials. STUDY SELECTION Published (1966-2005) randomized controlled trials with nasal and eye symptoms and quality-of-life scores as primary outcomes. RESULTS Seventeen studies including 6,231 adults with seasonal allergic rhinitis were selected. Oral leukotriene antagonists significantly reduced daytime nasal symptoms (standardized mean difference [SMD], -0.24; 95% confidence interval [CI], -0.33 to -0.16), nighttime nasal symptoms (SMD, -0.23; 95% CI, -0.30 to -0.16), and eye symptoms and significantly improved quality of life compared with placebo. There were no significant differences between oral leukotriene antagonists and oral histamine H1 antagonists on nasal and eye symptoms and quality-of-life overall score. We also found that leukotriene receptor antagonists were inferior to intranasal corticosteroids for decreasing daytime (SMD, 0.41; 95% CI, 0.27 to 0.56) and nighttime nasal symptoms. The combination of leukotriene receptor antagonists plus histamine H1 antagonists produced greater relief of eye symptoms compared with histamine H1 antagonists alone. Finally, intranasal corticosteroids significantly reduced nasal congestion compared with leukotriene receptor antagonists plus histamine H1 antagonists. CONCLUSIONS Leukotriene receptor antagonists were better than placebo, equivalent to oral histamine H1 antagonists, and inferior to intranasal corticosteroids for treating seasonal allergic rhinitis. Alternatively, leukotriene receptor antagonists plus histamine H1 antagonists were more effective than histamine H1 antagonists alone but inferior to intranasal corticosteroids.
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Affiliation(s)
- Gustavo J Rodrigo
- Departamento de Emergencia, Hospital Central de las Fuerzas Armadas, and Clinica Respirar, Benito Nardone, Montevideo, Uruguay.
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Kim K, Sussman G, Hébert J, Lumry W, Lutsky B, Gates D. Desloratadine therapy for symptoms associated with perennial allergic rhinitis. Ann Allergy Asthma Immunol 2006; 96:460-5. [PMID: 16597081 DOI: 10.1016/s1081-1206(10)60914-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Perennial allergic rhinitis (PAR) has a substantial negative social and economic impact. Recent studies emphasize the potential seriousness of PAR and the need for improved treatment of this condition. OBJECTIVE To confirm the efficacy and safety of the H1-antihistamine desloratadine in reducing the symptoms of PAR in a randomized, double-blind, placebo-controlled trial. METHODS Patients with PAR (N = 1,179) from 67 US/international centers received desloratadine, 5 mg once daily, or identical placebo tablets. The primary efficacy measure was the change from baseline to week 4 in average morning and evening reflective total symptom scores (TSSs). Secondary end points included changes from baseline in total nasal and nonnasal symptom scores and peak nasal inspiratory flow (PNIF) rates. RESULTS Desloratadine was significantly more effective than placebo in reducing morning and evening reflective TSSs for each week and during weeks 1 through 4 (P = .001). Mean changes in TSSs during the 4-week study were -3.9 (26.6% reduction) and -3.2 (22.3% reduction) for the desloratadine and placebo groups, respectively (P = .001, desloratadine vs placebo). With desloratadine therapy, significant improvements were also seen in secondary efficacy end points compared with placebo use (total nasal and nonnasal symptom scores: P < or = .04). Improvements in mean morning PNIF were significantly greater in the desloratadine-treated group than in the placebo group (P = .03). CONCLUSIONS These results confirm and extend previous findings that desloratadine is safe and is associated with a statistically significant reduction in nasal and nonnasal symptoms in patients with PAR. Objective nasal airflow, evaluated by PNIF, was statistically significantly improved after desloratadine treatment.
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Affiliation(s)
- Kenneth Kim
- West Coast Clinical Trials, LLC, Long Beach, California 92626, USA.
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Peynegre R, Dessanges JF, Bruhwyler J, Concas V. Efficacité de Dérinox® chez des patients souffrant d’une rhinite virale évaluée par un PNIF (Peak Nasal Inspiratory Flow). ACTA ACUST UNITED AC 2005; 122:246-55. [PMID: 16439935 DOI: 10.1016/s0003-438x(05)82356-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The aim of this study was to compare the efficacy and tolerance of Dérinox (D) to Rhinofluimucil (R) and placebo (P) in the treatment of common cold, using an objective measure of nasal obstruction, the Peak Nasal Inspiratory Flow (PNIF--Clement Clarke International, Harlow, Angleterre). PATIENTS AND METHODS This randomized, double-blind, double-dummy, parallel group study enrolled 354 patients (34 P, 165 D et 155 R) included by 85 general practitioners. The treatment duration was 5 days at usual recommended dosage regimens. PNIF measures were done before drug administration (T0) as well as 15 min and 3 h after each intake. Moreover, nasal obstruction, rhinorrhea and global discomfort were subjectively assessed. RESULTS The efficacy of D was superior to that of P and R when comparing PNIF from T0 to T3 h after the first intake. At T15 min, rhinorrhea was significantly improved with both active treatments and global discomfort was significantly improved with D only. Treatment tolerance was satisfactory and comparable between the 3 groups. CONCLUSION Efficacy of Dérinox(R) was superior to that of P and R for the improvement of the nasal obstruction (PNIF) between T0 and T3h (main criteria) after the first intake in patients suffering from common cold.
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Affiliation(s)
- R Peynegre
- Hôpital Intercommunal, 40 rue de Verdun--94000 Créteil, France
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Lange B, Lukat KF, Rettig K, Holtappels G, Bachert C. Efficacy, cost-effectiveness, and tolerability of mometasone furoate, levocabastine, and disodium cromoglycate nasal sprays in the treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2005; 95:272-82. [PMID: 16200819 DOI: 10.1016/s1081-1206(10)61225-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Current guidelines recommend intranasal glucocorticosteroids as first-line therapy for seasonal allergic rhinitis. OBJECTIVE To compare the efficacy, cost-effectiveness, and tolerability of the topical glucocorticosteroid mometasone furoate, the topical antihistamine levocabastine hydrochloride, and the cromone disodium cromoglycate in seasonal allergic rhinitis. METHODS This study was performed during the 2003 grass pollen season as an open, randomized, parallel-group, single-center study of 123 patients assigned to receive mometasone furoate (200 microg once daily), levocabastine hydrochloride (200 microg twice daily), or disodium cromoglycate (5.6 mg 4 times daily). Symptom scores and nasal inspiratory peak flow measurements were recorded in a patient diary. The global efficacy of the study medication was evaluated by patients after treatment. Eosinophil cationic protein concentrations were measured in nasal secretions before and after treatment. Cost-effectiveness was evaluated as medication cost per treatment success. RESULTS Mometasone furoate therapy was significantly superior to the use of levocabastine or disodium cromoglycate with respect to all nasal symptoms, the global evaluation of efficacy, and eosinophil cationic protein concentration. Furthermore, mometasone furoate therapy was significantly superior to disodium cromoglycate therapy with respect to nasal inspiratory peak flow. Medication cost per treatment success was lowest with mometasone furoate use and highest with levocabastine use. CONCLUSION This is the first study to compare mometasone furoate nasal spray with nonsteroidal topical treatments for seasonal allergic rhinitis. Mometasone furoate nasal spray was confirmed as a first-choice topical treatment option for seasonal allergic rhinitis.
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Affiliation(s)
- Bernd Lange
- Institut für Atemwegsforschung GmbH, Düsseldorf, Germany.
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Abstract
Antihistamines are useful medications for the treatment of a variety of allergic disorders. Second-generation antihistamines avidly and selectively bind to peripheral histamine H1 receptors and, consequently, provide gratifying relief of histamine-mediated symptoms in a majority of atopic patients. This tight receptor specificity additionally leads to few effects on other neuronal or hormonal systems, with the result that adverse effects associated with these medications, with the exception of noticeable sedation in about 10% of cetirizine-treated patients, resemble those of placebo overall. Similarly, serious adverse drug reactions and interactions are uncommon with these medicines. Therapeutic interchange to one of the available second-generation antihistamines is a reasonable approach to limiting an institutional formulary, and adoption of such a policy has proven capable of creating substantial cost savings. Differences in overall efficacy and safety between available second-generation antihistamines, when administered in equivalent dosages, are not large. However, among the antihistamines presently available, fexofenadine may offer the best overall balance of effectiveness and safety, and this agent is an appropriate selection for initial or switch therapy for most patients with mild or moderate allergic symptoms. Cetirizine is the most potent antihistamine available and has been subjected to more clinical study than any other. This agent is appropriate for patients proven unresponsive to other antihistamines and for those with the most severe symptoms who might benefit from antihistamine treatment of the highest potency that can be dose-titrated up to maximal intensity.
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Affiliation(s)
- Larry K Golightly
- Pharmacy Care Team, University of Colorado Hospital, Denver, Colorado 80262, USA.
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Lee DKC, Haggart K, Lipworth BJ. Reproducibility of response to nasal lysine-aspirin challenge in patients with aspirin-induced asthma. Ann Allergy Asthma Immunol 2004; 93:185-8. [PMID: 15328680 DOI: 10.1016/s1081-1206(10)61473-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Peak nasal inspiratory flow (PNIF) and acoustic rhinometry objectively measure the effects of nasal provocation testing. Although the latter is conventionally used in nasal lysine-aspirin challenge, use of the former in aspirin-induced asthma (AIA) has never been evaluated. OBJECTIVE To evaluate the reproducibility of PNIF and acoustic rhinometry following nasal lysine-aspirin challenge in AIA. METHODS Fourteen patients with a clear-cut history of AIA underwent nasal lysine-aspirin challenge at 2 separate visits 1 week apart. Both PNIF and minimum cross-sectional area (MCA) were measured using acoustic rhinometry for 120 minutes following standard nasal lysine-aspirin challenge (25 mg). RESULTS Prechallenge values were not significantly different at visit 1 vs visit 2 for mean [SEM] PNIF (128 [13] vs 127 [9] L/min) and MCA (6.89 [0.51] vs 6.94 [0.57] cm2). The mean (SEM) maximum percent PNIF change from baseline for visit 1 and visit 2 was -42 (5) and -42 (6), respectively, and the mean (SEM) average percent PNIF change from baseline was -25 (4) and -25 (6), respectively. The mean (SEM) maximum percent MCA change from baseline for visit 1 and visit 2 was -49 (4) and -48 (3), respectively, and the mean (SEM) average percent MCA change from baseline was -25 (8) and -24 (4), respectively. Coefficients of variation for maximum and average responses were 2.3% and 6.5%, respectively, for PNIF and 7.4% and 16.1% for MCA. CONCLUSIONS Measurement of PNIF following nasal lysine-aspirin challenge is a simple and reproducible alternative to acoustic rhinometry, with maximum response being a more reproducible outcome measure than average response.
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Affiliation(s)
- Daniel K C Lee
- Asthma & Allergy Research Group, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland
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Abstract
Asthma and allergic rhinitis (AR) form a well-recognized comorbidity. This study aims at assessing the efficacy of nasally inhaled beclomethasone dipropionate (BDP) in their simultaneous treatment. A randomized controlled trial was conducted with 78 allergic rhinitis and asthma patients aged 5-17 years. Seventy-five individuals completed the study. During 8 weeks, 38 subjects received BDP-CFC aerosol (>or= 500 mcg/day) exclusively via nasal inhalation through a facemask attached to a plastic valved spacer. The control group (37 patients) received 200 mcg/day of aqueous intranasal beclomethasone plus oral inhalation of BDP-CFC (>or= 500 mcg/day) through a mouthpiece connected to the same spacer. Primary outcomes analyzed in order to assess the response to treatment were clinical scoring for allergic rhinitis and measurements of nasal inspiratory peak flow (NIPF). AR clinical scoring and NIPF did not differ in the two groups at admission or at nearly all follow-up visits. Nasal inhalation of beclomethasone dipropionate provides AR symptom relief while maintaining control of asthma by delivering it to the lungs. Therefore, this therapeutic strategy might be considered for patients suffering from this comorbidity, especially in low-resource countries, since it is less expensive than the conventional treatment.
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Affiliation(s)
- Paulo A M Camargos
- Department of Pediatrics, Medical School and University Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil.
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Gray RD, Haggart K, Lee DKC, Cull S, Lipworth BJ. Effects of butterbur treatment in intermittent allergic rhinitis: a placebo-controlled evaluation. Ann Allergy Asthma Immunol 2004; 93:56-60. [PMID: 15281472 DOI: 10.1016/s1081-1206(10)61447-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Butterbur (Petasites hybridus) contains the active ingredient petasin, which exhibits antileukotriene and antihistamine activity. Previous studies of intermittent allergic rhinitis (IAR) have demonstrated a comparable response to butterbur compared with a histamine H1-receptor antagonist on the 36-Item Short-Form Health Survey quality-of-life score. However, there has been no placebo-controlled study of the effects of butterbur use on objective and subjective outcomes in IAR. OBJECTIVE To evaluate the effects of treatment with butterbur vs placebo on objective and subjective outcomes in IAR. METHODS A double-blind, placebo-controlled, crossover study was carried out during the grass pollen season in Tayside, Scotland. Thirty-five patients (14 men and 21 women) with IAR received butterbur, 50 mg twice daily, or placebo for 2 weeks. Domiciliary measurements were taken in the morning and evening for peak nasal inspiratory flow (PNIF) (the primary outcome variable), nasal and eye symptoms, and rhinoconjunctivitis-specific quality-of-life score. RESULTS Butterbur treatment had no significant effect on PNIF, total nasal symptom score, eye symptom score, or quality of life compared with placebo use. Mean (SEM) morning and evening PNIF values were 107 (6) and 114 (6) L/min, respectively, for butterbur vs 105 (6) and 117 (6) L/min for placebo. Mean (SEM) morning and evening total nasal symptom scores (maximum total score, 12) were 3.4 (0.4) and 3.5 (0.4), respectively, for butterbur vs 3.7 (0.3) and 3.8 (0.4) for placebo. CONCLUSIONS There was no significant clinical efficacy of butterbur use vs placebo use on objective and subjective outcomes in IAR. Further studies are now indicated to investigate the use of butterbur in persistent allergic rhinitis.
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Affiliation(s)
- Robert D Gray
- Asthma & Allergy Research Group, Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland
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Grayson MH, Korenblat PE. The emerging role of leukotriene modifiers in allergic rhinitis. ACTA ACUST UNITED AC 2004; 2:441-50. [PMID: 14719983 DOI: 10.1007/bf03256671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Leukotriene modifiers have been shown to be efficacious in the treatment of asthma. Because of this success, and the fact that leukotrienes can be recovered not only from bronchoalveolar lavage fluid but also nasal lavage fluid, some researchers have suggested that these medications may also be useful for treating allergic rhinitis. Because the upper and lower airways are linked physically, there has been an assumption that therapy for upper and lower airway disease should be similar. This critical appraisal examines available data both supporting and refuting the emerging role of leukotriene modifiers in the treatment of allergic rhinitis. Although many studies have shown an improvement in nasal symptoms when comparing a leukotriene modifier with placebo, few studies have conclusively shown that a leukotriene modifier is any more effective in treating allergic rhinitis than an antihistamine. Results from several reported studies suggest that the addition of a leukotriene antagonist to an antihistamine is no more efficacious than antihistamine alone. However, many of these studies were small and/or primarily designed to examine the asthmatic response, with nasal symptoms being a lesser endpoint. To better understand how, where, and when leukotriene modifiers should be used in the armamentarium of therapies for allergic rhinitis, larger clinical investigations designed specifically to study allergic rhinitis need to be undertaken. We conclude that currently, the data do not support widespread use of a leukotriene modifier with or without an antihistamine in place of an intranasal corticosteroid with or without an antihistamine in the treatment of allergic rhinitis.
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Affiliation(s)
- Mitchell H Grayson
- Division of Allergy and Immunology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Wilson AM, O'Byrne PM, Parameswaran K. Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis. Am J Med 2004; 116:338-44. [PMID: 14984820 DOI: 10.1016/j.amjmed.2003.10.030] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2003] [Accepted: 09/19/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare the clinical efficacy of leukotriene receptor antagonists with that of placebo, antihistamines, and nasal corticosteroids in patients with allergic rhinitis or nasal polyposis. METHODS We performed a systematic review and meta-analysis of randomized controlled trials of the effectiveness of leukotriene receptor antagonists in patients with rhinitis. Composite daily rhinitis symptom scores (as a percentage of the maximum score) and rhinitis-specific quality of life (unit scores ranging from 0 to 6) were pooled after assessing heterogeneity among studies. The pooled estimates were expressed as weighted mean differences between treatments in a random-effects model. We considered a difference of 10% in nasal score and 0.6 units in quality-of-life score to be clinically relevant. RESULTS Of the 196 citations, 11 studies on seasonal allergic rhinitis were used in the analysis: eight evaluating leukotriene receptor antagonists alone or in combination with other treatments versus placebo or other treatments (n = 3924) and three evaluating leukotriene receptor antagonists plus an antihistamine (n = 80). Leukotriene receptor antagonists reduced mean daily rhinitis symptom scores (in absolute terms) 5% (95% confidence interval [CI]: 3% to 7%) more than did placebo. However, antihistamines improved the nasal symptoms score 2% (95% CI: 0% to 4%) more than did leukotriene receptor antagonists, and nasal corticosteroids improved the score 12% (95% CI: 5% to 18%) more than did leukotriene antagonists. Leukotriene receptor antagonists significantly improved rhinoconjunctivitis quality of life by 0.3 units (95% CI: 0.24 to 0.36 units) when compared with placebo. There were no randomized controlled trials evaluating the effect of leukotriene receptor antagonists on perennial allergic rhinitis or polyposis. CONCLUSION Leukotriene receptor antagonists are modestly better than placebo, as effective as antihistamines, but less effective than nasal corticosteroids in improving symptoms and quality of life in patients with seasonal allergic rhinitis.
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Affiliation(s)
- Andrew M Wilson
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Pacor ML, Di Lorenzo G, Martinelli N, Mansueto P, Rini GB, Corrocher R. Monosodium benzoate hypersensitivity in subjects with persistent rhinitis. Allergy 2004; 59:192-7. [PMID: 14763933 DOI: 10.1046/j.1398-9995.2003.00380.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Very few data are available from the literature on whether nonatopic subjects affected by persistent rhinitis may show the appearance of objective symptoms of rhinitis after the ingestion of food additives such as tartrazine (E102), erythrosine (E127), monosodium benzoate (E211), p-hydroxybenzoate (E218), sodium metabisulphite (E223), and monosodium glutamate (E620). It is still unclear whether the ingestion of food additive may cause, as well, a consensual reduction of nasal peak inspiratory flow (NPIFR). Therefore, we used a double-blind placebo-controlled (DBPC) study to evaluate this hypothesis. PATIENTS AND METHODS Two hundred and twenty-six consecutive patients (76 males and 150 females) aged 12-60 years (mean age 40.2 +/- 16.3 years). After 1 month of an additive-free diet regimen, an open challenge was carried out (food additive-rich diet for 2 weeks). After this period, challenges were administered in a DBPC manner using the above-mentioned substances under investigation. RESULTS Twenty of 226 subjects (8.8%) reported an improvement of the symptoms of rhinitis after additive-free diet. More precisely, six of 226 (2.6%) were symptom-free and 14 of 226 (6.2%) showed an improvement in their symptoms after an additive-free diet. As far as the results for DBPC are concerned, 20 challenges with monosodium benzoate induced both objective (i.e. sneezing and rhinorrhoea) and subjective symptoms (nasal blockage and nasal itching) of rhinitis with reduction of NPIFR >/=20%, 45 challenges induced subjective symptoms of rhinitis (i.e. nasal blockage and nasal itching), without reduction of NPIFR >/=20% of the basal value, two with tartrazine, seven with erythrosine, 19 with monosodium benzoate, three with p-hydroxybenzoate, six with sodium metabisulphite, and eight with monosodium glutamate, respectively. CONCLUSIONS The observation that nonatopic persistent rhinitis may be caused by the frequent, probably daily, ingestion of small doses of a nontolerated substance is intriguing and suggests that at least some patients with 'chronic vasomotor rhinitis' may be intolerant to a particular food additive. Therefore, food additives can be considered triggers or aggravating factors, rather than aetiological factors.
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Affiliation(s)
- M L Pacor
- Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Verona, Verona, Italy
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Rappai M, Collop N, Kemp S, deShazo R. The nose and sleep-disordered breathing: what we know and what we do not know. Chest 2004; 124:2309-23. [PMID: 14665515 DOI: 10.1378/chest.124.6.2309] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The relationship between sleep-disordered breathing (SDB) and nasal obstruction is unclear. In order to better understand, we performed an extensive computer-assisted review and analysis of the medical literature on this topic. Data were grouped into reports of normal control subjects, patients with isolated nasal obstruction, and those with SDB. We conclude that SDB can both result from and be worsened by nasal obstruction. Nasal breathing increases ventilatory drive and nasal occlusion decreases pharyngeal patency in normal subjects. Nasal congestion from any cause predisposes to SDB. Although increased nasal resistance does not always correlate with symptoms of congestion, nasal congestion typically results in a switch to oronasal breathing that compromises the airway. Moreover, oral breathing in children may lead to the development of facial structural abnormalities associated with SDB. We postulate that the switch to oronasal breathing that occurs with chronic nasal conditions is a final common pathway for SDB.
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Affiliation(s)
- Maria Rappai
- Division of Pulmonary/Critical Care Medicine, University of Mississippi Medical Center, Jackson, MS., USA
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Bukstein DA. Role of leukotriene receptor antagonists (LTRAs) in seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2003; 91:417-8; author reply 418-9. [PMID: 14582824 DOI: 10.1016/s1081-1206(10)61692-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Simons FER, Prenner BM, Finn A. Efficacy and safety of desloratadine in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol 2003; 111:617-22. [PMID: 12642846 DOI: 10.1067/mai.2003.168] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The evidence base for the use of H1-antihistamines in the treatment of perennial allergic rhinitis is considerably smaller than it is in the treatment of seasonal allergic rhinitis. OBJECTIVE We hypothesized that desloratadine, a new, nonsedating selective H1-antihistamine, would be efficacious and safe in the treatment of perennial allergic rhinitis. METHODS In a multicenter, randomized, placebo-controlled, double-blind, parallel-group study, 676 patients with symptomatic perennial allergic rhinitis were randomly assigned to 4 weeks of treatment with either 5 mg of desloratadine once daily or placebo. Efficacy was assessed by using a morning-evening instantaneous total symptom score (TSS), which was composed of scores for 4 individual nasal symptoms (rhinorrhea, itching, sneezing, and postnasal drip) and 3 individual nonnasal symptoms (itching eyes, watering eyes, and itching of the ears or palate). Secondary outcome measures included a morning-evening reflective TSS, total nasal and nonnasal symptoms scores, and individual symptom scores. Safety evaluations, including 12-lead electrocardiograms, were performed. RESULTS Six hundred thirty-four patients completed the study. Desloratadine consistently diminished perennial allergic rhinitis symptoms, reducing the morning-evening instantaneous TSS (P =.005), the morning-evening reflective TSS (P =.007), the morning-evening reflective total nonnasal score (P =.023), and the individual nasal symptom scores for rhinorrhea, nasal itching, sneezing, and postnasal drip/drainage (P =.05 to P =.013) during weeks 1 through 4. Improvement in symptoms was observed after the first dose. Dropouts, and the type and frequency of adverse events (headache, viral infection, pharyngitis, and upper respiratory tract infection), were similar in both treatment groups. No clinically significant changes in QTc intervals were observed. CONCLUSIONS Desloratadine rapidly and safely reduced the symptoms of perennial allergic rhinitis, and its efficacy did not diminish during 4 weeks of treatment.
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Affiliation(s)
- F Estelle R Simons
- Section of Allergy and Clinical Immunology, Department of Pedia-trics and Child Health, University of Manitoba, Winnipeg, Canada
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Nathan RA. Pharmacotherapy for allergic rhinitis: a critical review of leukotriene receptor antagonists compared with other treatments. Ann Allergy Asthma Immunol 2003; 90:182-90; quiz 190-1, 232. [PMID: 12602664 DOI: 10.1016/s1081-1206(10)62138-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review the mechanisms and clinical efficacy of leukotriene receptor antagonists, which are investigational therapies for allergic rhinitis, compared with intranasal corticosteroids and nonsedating antihistamines, which are the most commonly prescribed pharmacotherapies for allergic rhinitis. DATA SOURCES Computer-assisted MEDLINE searches for articles and manual searches of conference proceedings on intranasal corticosteroid, antihistamine, leukotriene receptor antagonist, leukotriene modifier, zafirlukast, montelukast, allergic rhinitis, rhinitis, and asthma. SELECTION Published articles and pertinent abstracts on the topics identified above were selected. Head-to-head comparator trials as well as data from placebo-controlled trials were selected. RESULTS AND CONCLUSIONS The studies published to date demonstrate that leukotriene receptor antagonists are sometimes more effective than placebo, are no more effective than nonsedating antihistamines, and are less effective than intranasal corticosteroids in the treatment of allergic rhinitis. The combination of a leukotriene receptor antagonist and an antihistamine has not been proven to be more effective than either agent alone. This review reveals several inconsistencies that require resolution. First, whereas leukotriene receptor antagonists are predicted on the basis of their mechanism of action to improve nasal congestion significantly, clinical studies reveal leukotriene receptor antagonists to be no better than antihistamines at improving congestion. Second, leukotriene receptor antagonists would not be expected on the basis of their putative mechanism of action or nasal challenge data to improve significantly sneezing, nasal itching, or drainage. However, some studies show improvement in these symptoms during treatment with leukotriene receptor antagonists. Considered in aggregate, the data available to date do not clearly support a unique role of leukotriene receptor antagonists in the treatment of allergic rhinitis whether or not it is accompanied by asthma.
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Affiliation(s)
- Robert A Nathan
- University of Colorado Health Sciences Center, Denver, Colorado, USA.
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Wilson AM, Haggart K, Sims EJ, Lipworth BJ. Effects of fexofenadine and desloratadine on subjective and objective measures of nasal congestion in seasonal allergic rhinitis. Clin Exp Allergy 2002; 32:1504-9. [PMID: 12372132 DOI: 10.1046/j.1365-2745.2002.01509.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In vitro studies have shown much higher H1-receptor antagonist potency with desloratadine (DL) compared to fexofenadine (FEX), although it is unclear whether this has any clinical relevance on disease control parameters in seasonal allergic rhinitis (SAR), especially for nasal congestion. OBJECTIVE To compare the relative efficacy between presently recommended doses of DL and FEX on daily measurements of peak nasal inspiratory flow (PNIF) and nasal symptoms in SAR. METHODS Forty-nine patients with SAR were randomized into a double-blind, placebo-controlled cross-over study during the grass pollen season, comparing 2 weeks of once daily treatment with (a) 180 mg FEX or (b) 5 mg DL, taken in the morning. There was a 7-10 day placebo run-in and washout prior to each randomized treatment. Measurements were made in the morning (AM) and in the evening (PM) for PNIF (the primary outcome variable), nasal and eye symptoms. The average of AM/PM values were used for analysis. RESULTS There were significant (P < 0.05) improvements, compared to placebo, with FEX and DL, for PNIF, nasal blockage, nasal irritation, and total nasal symptoms, but not nasal discharge or eye symptoms. There were no significant differences between active treatments. Values for PNIF (L/min) for mean placebo baseline, mean difference from baseline (95% CI for difference) were 126, 10 (4-16) for FEX; and 122, 11 (4-17) for DL. The mean difference (95% CI) between FEX vs. DL was 1 L/min (-7-8). Values for total nasal symptoms (out of 12) were: 3.2, 0.7 (0.2-1.2) for FEX; and 3.4, 0.9 (0.3-1.5) for DL, and for nasal blockage (out of 3) were: 1.1, 0.2 (0.1-0.4) for FEX; and 1.2, 0.3 (0.1-0.5) for DL. The mean difference (95% CI) in total nasal symptoms and nasal blockage between FEX vs. DL was 0.1 (-0.6-0.8) and 0.1 (-0.2-0.3), respectively. CONCLUSIONS Recommended once daily doses of fexofenadine and desloratadine were equally effective in improving nasal peak flow and nasal symptoms in SAR.
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Affiliation(s)
- A M Wilson
- Asthma & Allergy Research Group, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
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Bende M, Carrillo T, Vóna I, da Castel-Branco MG, Arheden L. A randomized comparison of the effects of budesonide and mometasone furoate aqueous nasal sprays on nasal peak flow rate and symptoms in perennial allergic rhinitis. Ann Allergy Asthma Immunol 2002; 88:617-23. [PMID: 12086370 DOI: 10.1016/s1081-1206(10)61894-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Using conventional methods, it has been difficult to show differences in efficacy between intranasal corticosteroids in perennial rhinitis. OBJECTIVE To compare the effects of budesonide and mometasone on nasal symptoms and nasal airflow in perennial allergic rhinitis. METHODS Four hundred thirty-eight patients (age > 18 years old) were randomized to budesonide, 256 microg or 128 microg, mometasone furoate 200 microg, or placebo, once daily for 4 weeks. Efficacy was evaluated by nasal index score (NIS; the sum of scores for blocked nose, runny nose, and itchy nose/sneezing) and peak nasal inspiratory flow (PNIF). RESULTS All three active treatments significantly reduced the NIS compared with placebo. There was no significant difference between the treatments, although the effect of budesonide, 256 microg, tended to be greater than that of the other regimens. PNIF was significantly improved with all three active treatments: the effect of budesonide 256 microg on morning and evening PNIF was significantly greater than that of mometasone furoate and 128 microg budesonide. Budesonide had a rapid onset of action, showing a significantly greater effect on evening PNIF than mometasone furoate during the first 10 days. For all active treatments, significant improvements in NIS were seen within 4 hours of the first dose. All three treatments were well tolerated. CONCLUSION The objective parameter PNIF was capable of demonstrating greater efficacy of budesonide 256 microg compared with budesonide 128 microg and mometasone furoate 200 microg, whereas the combined nasal symptom score could only distinguish active treatment from placebo.
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Affiliation(s)
- Mats Bende
- Department of Otorhinolaryngology, Central Hospital, Skövde, Sweden.
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Wilson A. Antihistamines alone and in combination with leukotriene antagonists in nasal congestion. ACTA ACUST UNITED AC 2002. [DOI: 10.1046/j.1472-9725.2002.00045.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Creticos PS. Clinical considerations of leukotriene modifiers in the treatment of rhinitis. ACTA ACUST UNITED AC 2002. [DOI: 10.1046/j.1472-9725.2001.00003.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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