Emerging role of antileukotriene therapy in allergic rhinitis

Montelukast Effectively Treats the Nighttime Impact of Seasonal Allergic Rhinitis

Background

Nighttime problems constitute a significant burden on the quality of life of patients with seasonal allergic rhinitis (SAR). The aim of this study was to evaluate the effectiveness of montelukast on nighttime AR symptoms.

Methods

In seven multicenter, double-blind, parallel-group trials, nighttime problems were assessed as the nighttime symptoms score (NSS), an average of three individual symptom scores: difficulty going to sleep, nighttime awakening, and nasal congestion on awakening (each rated 0 = none to 3 = severe). Patients (aged 15–82 years) were randomized to receive montelukast, 10 mg (n = 1751), placebo (n = 1557), or the positive control loratadine, 10 mg (n = 1616).

Results

In a combined analysis, changes from baseline (mean ± SE) in NSS were -0.28 ± 0.01, -0.16 ± 0.01, and —0.24 ± 0.01 for the montelukast, placebo, and loratadine groups, respectively. Difference versus placebo in least-squares mean change from baseline were —0.11 (95% confidence interval, -0.14, -0.08; p ≤ 0.001) for montelukast and -0.09 (-0.12, -0.06; p ≤ 0.001) for loratadine. Strong baseline correlations (R > 0.70; p < 0.001) of NSS and two of its individual symptoms with the sleep domain of the validated Rhinoconjunctivitis Quality of Life Questionnaire support the validity and importance of measuring nighttime morbidity in SAR. Furthermore, a clinically important benefit of montelukast on the nighttime impact of SAR was shown using an analysis anchored on the Patient's Global Evaluation.

Conclusion

These data underscore the importance of nighttime problems in patients with SAR and the need to treat nighttime symptoms. In these studies, montelukast significantly improved the NSS, a clinically relevant and valid measure in patients with SAR.

The leukotriene receptor antagonist montelukast and its possible role in the cardiovascular field

BACKGROUND

Cysteinyl leukotrienes (LTC4, LTD4, and LTE4) are pro-inflammatory mediators of the 5-lipooxygenase (5-LO) pathway, that play an important role in bronchoconstriction, but can also enhance endothelial cell permeability and myocardial contractility, and are involved in many other inflammatory conditions. In the late 1990s, leukotriene receptor antagonists (LTRAs) were introduced in therapy for asthma and later on, approved for the relief of the symptoms of allergic rhinitis, chronic obstructive pulmonary disease, and urticaria. In addition, it has been shown that LTRAs may have a potential role in preventing atherosclerosis progression.

PURPOSE

The aims of this short review are to delineate the potential cardiovascular protective role of a LTRA, montelukast, beyond its traditional use, and to foster the design of appropriate clinical trials to test this hypothesis.

RESULTS AND CONCLUSIONS

What it is known about leukotriene receptor antagonists? •Leukotriene receptor antagonist, such as montelukast and zafirlukast, is used in asthma, COPD, and allergic rhinitis. • Montelukast is the most prescribed CysLT₁ antagonist used in asthmatic patients. • Different in vivo animal studies have shown that leukotriene receptor antagonists can prevent the atherosclerosis progression, and have a protective role after cerebral ischemia. What we still need to know? • Today, there is a need for conducting clinical trials to assess the role of montelukast in reducing cardiovascular risk and to further understand the mechanism of action behind this effect.

Placebo-controlled study with OHIO chamber of prophylactic pranlukast for children with Japanese cedar pollinosis: TOPIC-J III study

Objective

This double-blind, placebo-controlled comparative study was designed to investigate whether pranlukast dry syrup, a leukotriene receptor antagonist, has a protective effect against priming, controlled pollen exposure, and natural pollen exposure in children with Japanese cedar pollinosis.

Research design and methods

Thirty children aged 12–15 years with Japanese cedar pollinosis (positive skin test for Japanese cedar pollen), who had suffered from pollinosis for at least 2 years and developed severe nasal obstruction when exposed to Japanese cedar pollen, were enrolled in this study. They were randomly allocated to treatment with pranlukast or placebo orally after breakfast and dinner for 8 weeks during the Japanese cedar pollen season. Soon after the start of the pollen season, all subjects underwent a challenge by exposure for 3 h to Japanese cedar pollen (8000 grains/m³) in an artificial exposure chamber (OHIO chamber).

Clinical trial registration

The University Hospital Medical Information Network in Japan (UMIN000009840).

Main outcome measures

The effect of pranlukast was evaluated using self-rating of nasal symptoms by the subjects and measurement of eosinophil cationic protein in nasal discharge specimens.

Results

Scores for the symptoms of pollinosis were lower in the pranlukast group than in the placebo group during treatment in the priming state, as well as after controlled pollen exposure and natural pollen exposure. Pranlukast significantly improved the score for nasal obstruction, compared with placebo. A correlation was found between changes of the scores for symptoms of pollinosis and changes of the eosinophil cationic protein level.

Conclusions

These results confirm a protective effect of pranlukast against both priming and challenge (controlled and natural) with Japanese cedar pollen. The present findings suggested that pranlukast dry syrup may be useful for prophylaxis against pollinosis in children.

Delay of onset of symptoms of Japanese cedar pollinosis by treatment with a leukotriene receptor antagonist

BACKGROUND

Leukotriene receptor antagonists (LTRAs) are effective for prophylactic treatment of pollinosis based on studies showing that administration of LTRAs prior to or at the start of the pollen season reduces symptoms and QOL disturbance at the peak of pollen dispersal. Two goals of prophylactic treatment of pollinosis are use of fewer types of drugs and delay of onset of symptoms and impairement of QOL. Therefore, this study was performed to determine if pranlukast, a LTRA, met these goals in treatment of pollinosis.

METHODS

Pranlukast or placebo was administered to patients who visited our hospital immediately before the start of Japanese cedar pollen dispersal. The study was performed for 4 weeks as a double blind randomized trial. Subsequently, all patients were given pranlukast for a further 4 weeks from the peak until the end of pollen dispersal. The incidence of symptoms and use of concomitant drugs were investigated from daily nasal allergy records kept by patients. QOL was evaluated using the JRQLQ questionnaire.

RESULTS

In the double blind period of the study, the percentage of patients who used concomitant drugs for nasal symptoms was significantly lower in the pranlukast group compared to the placebo group. Development of nasal symptoms (sneezing, runny nose and nasal congestion) and disturbance of daily activities were significantly delayed in the pranlukast group. No serious adverse reactions occurred in the pranlukast group and no patient withdrew from treatment with pranlukast.

CONCLUSIONS

Pranlukast is effective for prophylactic treatment of pollinosis.

Leukotriene receptor antagonist in the treatment of childhood allergic rhinitis--a randomized placebo-controlled study

OBJECTIVE

This study was designed to assess the hypothesis that leukotriene receptor antagonists (LTRAs) would provide additional symptom relief in asthmatic children with persistent AR already taking regular antihistamine. The effects of 16-week treatment of LTRA in addition to fexofenadine (FEX) on persistent AR in asthmatic children were examined.

STUDY DESIGN

Consecutive children with stable asthma and persistent AR were invited in this randomized, double-blind, placebo-controlled study. After a 2-week run-in period in which subjects were given FEX alone, they were randomly assigned to take LTRA or placebo in addition to FEX for 16 weeks, followed by 8 weeks of follow-up phase with FEX taken alone. Symptom scoring, rhinoscopy, acoustic rhinometry, spirometry, nasal secretion extraction and blood taking for IL-4 and IL-13 analysis were performed after a 2-week run-in and at the end of treatment.

RESULTS

Forty-four subjects with a median (IQR) age of 12.2 (10.1-14.1) years were recruited. At week 4 of treatment, the between-group differences in the mean changes of daytime sneezing score (mean difference (95% CI) = -0.35 (-0.59, -0.12), P = 0.004), nighttime sneezing score (mean difference (95% CI) = -0.37 (-0.62, -0.11), P = 0.007) and daytime composite score (mean difference (95% CI) = -1.08 (-1.92, -0.25), P = 0.013) were significant. Acoustic rhinometry also demonstrated a nearly significant difference in nasal volume change between groups at 16 weeks of treatment (mean difference (95% CI) = 0.572 (0.090-1.054), P = 0.021). IL-4 and IL-13 were not detected in the majority of nasal secretion or serum samples.

CONCLUSIONS

Additional LTRA provided a more rapid relief on sneezing at the 4-week time point. This combination therapy also maintained a greater nasal volume and this might translate to lesser nasal congestion.

Montelukast as an adjunct to oral and inhaled steroid therapy in chronic nasal polyposis

OBJECTIVE

To examine the potential of montelukast, a leukotriene receptor antagonist, as an adjunct to oral and inhaled steroid in subjects with chronic nasal polyps.

STUDY DESIGN

Prospective, randomized controlled trial.

SUBJECTS AND METHODS

Thirty-eight consecutive adult patients with bilateral nasal polyps were randomized into two groups. Eighteen subjects were treated with oral prednisolone for 14 days and budenoside nasal spray for 8 weeks. Twenty subjects received similar treatment with additional oral montelukast for 8 weeks. Subjects completed a modified nasal ICSD symptom score at 8 and 12 weeks after beginning treatment and the SF-36 quality of life questionnaire at 12 weeks.

RESULTS

Symptom scores improved in both groups after treatment. Subjects treated with montelukast reported significantly less headache (P = 0.013), facial pain (P = 0.048) and sneezing (P = 0.03) than controls. Four weeks after completing treatment, no significant differences were recorded.

CONCLUSION

Montelukast therapy may have clinical benefit as an adjunct to oral and inhaled steroid in chronic nasal polyposis, but effects are not maintained after cessation of treatment.

Omalizumab is more effective than suplatast tosilate in the treatment of Japanese cedar pollen-induced seasonal allergic rhinitis

BACKGROUND

Seasonal allergic rhinitis (SAR) induced by Japanese cedar pollens is a major problem in Japan. Omalizumab, a humanized monoclonal anti-IgE antibody, improves symptoms associated with SAR, but a comparative study with an anti-allergy drug has not yet been conducted.

OBJECTIVE

To compare the efficacy and safety of omalizumab with suplatast tosilate, a selective T-helper type 2 (Th2) cytokine inhibitor, in patients with Japanese cedar pollen-induced SAR.

METHODS

A randomized, double-blind, double-dummy study was conducted in 308 Japanese patients with a history of moderate-to-severe SAR who showed a CAP-RAST value (> or =2+) specifically to Japanese cedar pollens. Patients were treated for 12 weeks with omalizumab plus placebo of suplatast tosilate or suplatast tosilate plus placebo of omalizumab.

RESULTS

The mean daily nasal symptom medication scores (sum of the daily nasal symptom severity score and daily nasal rescue medication score) were significantly lower in the omalizumab group than in the suplatast tosilate group during three evaluation periods (P<0.001). The omalizumab group also had significantly lower mean daily nasal severity scores, each of the mean daily nasal and ocular symptom severity scores (sneezing, runny nose, stuffy nose, itchy nose, itchy eyes, watery eyes, and red eyes). Omalizumab reduced rescue medication requirements, and the proportion of days with any rescue medication use in the omalizumab group was significantly lower. Serum-free IgE levels markedly decreased in the omalizumab group and it was associated with clinical efficacy. The adverse reaction profiles were similar between the two groups. The overall incidence of injection site reactions was higher in the omalizumab group than in the suplatast tosilate group, but all these events were of mild degree. No anti-omalizumab antibodies were detected.

CONCLUSION

Omalizumab showed significantly greater improvements than suplatast tosilate in the treatment of SAR induced by Japanese cedar pollens.

Pharmacotherapy of diseases mediated by 5-lipoxygenase pathway eicosanoids

Inflammatory eicosanoids generated by the 5-lipoxygenase (5-LO) pathway of arachidonic acid metabolism are now known to have at least 6 receptors: OXE, which recognizes 5-HETE and 5-oxo-ETE; a putative receptor recognizing a potent 5-oxo-ETE metabolite, FOG(7); the LTB(4) receptors, BLT1 and BLT2; the cysteinyl leukotriene receptors, CysLT(1) and CysLT(2), which recognize leukotrienes LTC(4), LTD(4), LTE(4) and LTF(4). The 5-LO pathway is activated in many diseases and invokes inflammatory responses not affected by glucocorticoids, but therapy with selective BLT1 or CysLT(1) antagonists in asthma has met with variable success. Studies show that 5-LO pathway eicosanoids are not primary mediators in all cases of asthma, but may be especially important in severe persistent asthma, aspirin- and exercise-induced asthma, allergic rhinitis, COPD, idiopathic pulmonary fibrosis, atherosclerosis, atopic dermatitis, acne and ischemia-related organ injury. These disorders appear to involve multiple 5-LO pathway eicosanoids and receptor subtypes, suggesting that inhibition of the pathway at the level of 5-LO may be necessary for maximal efficacy.

The role of antileukotriene therapy in seasonal allergic rhinitis: a systematic review of randomized trials

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.

Therapeutic modulation of allergic airways disease with leukotriene receptor antagonists

Although asthma is one of the most common chronic respiratory conditions, it often remains unrecognized and undertreated, while patients are often reluctant to comply with regular inhaled anti-inflammatory and bronchodilator therapy. Allergic rhinitis co-exists with asthma in as many as 40% of patients, and can be regarded as a continuum of the same inflammatory disease process. Corticosteroids are the 'gold standard' first-line treatment for both conditions, and have a significant impact upon underlying inflammation, symptoms and long-term outcome. Cysteinyl leukotrienes are potent airway inflammatory mediators, suggesting that treatment antagonizing their effects could play a role in disease management. In recent years, leukotriene receptor antagonists have provided a further therapeutic option in the management of allergic airways disease. These drugs are orally active, can be administered once daily, and provide a systemic approach to the management of patients with asthma and allergic rhinitis. We review the pharmacology of leukotriene receptor antagonists, their potential role in clinical practice in patients with allergic airways disease, and likely areas for further research.

Zafirlukast for severe recurrent vulvovaginal candidiasis: an open label pilot study

BACKGROUND

Recurrent vulvovaginal candidiasis (VVC) has been linked to allergic disease, particularly allergic rhinitis.

OBJECTIVE

A pilot study to assess the possible use of the leukotriene receptor antagonist zafirlukast as a treatment for recurrent VVC.

METHODS

20 women with six or more symptomatic attacks of VVC in the past year (at least four proved microbiologically). Clinical atopy determined by the International Study for Asthma and Allergies in Childhood (ISAAC) questionnaire assessed blindly. Monitoring by daily symptom diary and self taken vaginal swabs. Treatment with zafirlukast 20 mg twice daily for 24 weeks or until three microbiologically confirmed episodes of VVC. Response assessed by daily symptom diary and self taken vaginal swabs. Subjective response scales for improvement, side effects, and change in other allergic disease completed when stopping treatment. Semistructured telephone interview 1 year after stopping medication.

RESULTS

14 patients (70%) reported a subjective response on the improvement response scale. Six (30%) showed a complete response with no further symptomatic attacks of VVC or negative swabs when symptomatic. Seven (37%) remained symptom free 18 months after entering the study-that is, 12 months after stopping therapy. 11 (58%) remained symptom free for at least 3 months after stopping therapy. This does not include one patient who remained symptom free but continued on zafirlukast because of an improvement in her asthma. There was no clear relation between response and atopic status. Six of nine atopic subjective responders reported improvements in other allergic symptoms. Side effects were minimal; one seemed clearly attributable to the drug.

CONCLUSION

Zafirlukast offers a potential new treatment for recurrent VVC that requires confirmation in controlled studies.

The effects of histamine and leukotriene receptor antagonism on nasal mannitol challenge in allergic rhinitis

AIMS

It is unclear as to which mediators are involved in mediating the response to nasal mannitol challenge, a novel osmotic stimulus.

METHODS

A double-blind, randomized, placebo-controlled, crossover design was employed. Nine patients with allergic rhinitis were randomized to receive a single-dose of desloratadine 5 mg, montelukast 10 mg or placebo, and underwent nasal mannitol challenges with nasal peak inspiratory flow recordings over 60 min. The change in peak nasal inspiratory flow was calculated as percentage change from baseline as the peak response and area under the time-response curve (AUC).

RESULTS

Desloratadine and montelukast conferred a significant degree of protection compared to placebo for peak and AUC response, but there were no significant differences between the two drugs. For the peak response as percentage fall, the mean difference (95% CI) vs placebo was 27.7 (8.0, 47.4)% for desloratadine and 17.6 (1.9, 33.3)% for montelukast.

CONCLUSIONS

Our results suggest that histamine and cysteinyl-leukotrienes are involved in mediating the response to nasal mannitol in allergic rhinitis.

Second-line controller therapy for persistent asthma uncontrolled on inhaled corticosteroids: the step 3 dilemma

The asthma syndrome is characterised by airway inflammation with associated bronchial hyperresponsiveness (BHR) and reversible airflow obstruction. Therapy has benefited from an enhanced understanding of the pathophysiology of asthma and the resulting guidelines that emphasise the pivotal role of anti-inflammatory inhaled corticosteroids (ICS) as first-line therapy. Most patients with mild-to-moderate asthma can be adequately controlled on low-to-medium dosages of ICS alone. For patients with moderate-to-severe asthma who are not adequately controlled by ICS, it is unclear which medication should be added on. The two principal drugs under consideration are long-acting beta(2)-agonists (LABAs) and leukotriene antagonists (LTAs). Although both LABAs and LTAs are both effective at improving lung function, reducing symptoms and decreasing exacerbations, important differences exist that may determine the selection of one over the other in particular circumstances. LABAs and LTAs are equally effective at reducing exacerbations and improving symptoms and quality of life when used as add-on therapy. LABAs tend to be more effective bronchodilators than LTAs. Although LABAs stabilise the airway smooth muscle, they do not affect the underlying inflammatory process. Their long-term use also leads to subsensitivity of response to both LABAs and short-acting beta(2)-agonists (SABAs). The subsensitivity of response to SABAs is more pronounced in the presence of acute bronchoconstriction, which could be relevant during an acute attack. When combined with an ICS, LTAs provide additive non-steroidal anti-inflammatory properties and alleviate associated BHR, but do not induce subsensitivity of response. Not only is the efficacy of LTAs maintained over time, but also they do not affect the response to SABAs as reliever therapy. LTAs also have beneficial effects in patients who have concomitant allergic rhinitis, thus treating the unified airway. The choice between LABA and LTA as add-on therapy will therefore be determined by the needs of the individual patient in terms of providing anti-inflammatory versus bronchodilatory control. For patients with poor lung function where bronchodilatation is required, then an LABA would seem to be a logical choice. For the patient whose lung function is less impaired, with evidence of ongoing BHR where bronchoprotection is needed (e.g. exercise, allergen, cold air), or when there is concomitant allergic rhinitis, then an LTA would be more suitable.

Atopic diseases of childhood

The atopic diseases of childhood consist of the triad of asthma, allergic rhinitis, and atopic dermatitis. All share a common pathogenesis, being mediated by IgE, and are frequently present together in the same individual and family. These disorders and their comorbidities comprise a large component of general pediatric practice and their incidence in developed countries has been increasing over the past few decades. They are a leading reason for clinic and emergency room visits, as well as hospital admissions. They have the potential to interfere with education, physical activity, socialization, and self-esteem. Fortunately, we now have a reasonable armamentarium of maintenance medications available to help control these disorders and improve the quality of life for children suffering from them. In addition, early diagnosis and aggressive management of these disorders seem to offer the possibility of altering their natural history. As such, developing a sensible approach to the diagnosis and treatment of these disorders in an outpatient setting is essential. In this review, I summarize the most current literature and provide a framework for effectively diagnosing and managing these disorders.