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Alexander G, Moore SA, Lenert PS. Eosinophilic granulomatosis with polyangiitis and its association with montelukast: a case-based review. Clin Rheumatol 2024; 43:2153-2165. [PMID: 38720163 DOI: 10.1007/s10067-024-07000-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/17/2024] [Accepted: 05/05/2024] [Indexed: 05/24/2024]
Abstract
The association between the use of certain medications (including sulfonamides, hydralazine, and procainamide) and the occurrence of drug-induced lupus or hepatitis is well established. More recently, cases of immune-related adverse events ranging from inflammatory polyarthritis to necrotizing myositis in patients taking checkpoint inhibitors have been reported. However, data linking drugs to systemic vasculitis are scarce and at times debatable. Propylthiouracil, hydralazine, and minocycline have been associated with rare cases of ANCA-associated syndromes, including life-threatening pulmonary-renal syndromes and systemic polyarteritis nodosa-like diseases. Eosinophilic granulomatosis with polyangiitis (EGPA) has been reported in patients taking leukotriene inhibitors. Since the link between the use of leukotriene inhibitors and occurrence of EGPA remains highly controversial, we performed a literature review for cases of EGPA in patients taking montelukast without prior history of oral corticosteroid use. We found 24 cases, along with our own two cases described, making 26 cases in total. The mean age was 43 and a majority (18/26) were female. In majority of cases EGPA-like disease never relapsed after they were taken off leukotriene inhibitors suggesting a clear causal relationship between the use of these drugs and occurrence of eosinophil-rich systemic EGPA.
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Affiliation(s)
- Grace Alexander
- Department of Internal Medicine, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Steven A Moore
- Department of Pathology, University of Hospitals & Clinics, Iowa City, IA, USA
| | - Petar S Lenert
- Department of Internal Medicine, Division of Immunology, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.
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Di Salvo E, Patella V, Casciaro M, Gangemi S. The leukotriene receptor antagonist Montelukast can induce adverse skin reactions in asthmatic patients. Pulm Pharmacol Ther 2019; 60:101875. [PMID: 31837440 DOI: 10.1016/j.pupt.2019.101875] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 11/30/2022]
Abstract
Montelukast the leukotriene receptor antagonist is an anti-inflammatory drug that causes bronchodilation and for this reason it is used to improve inflammatory states in asthma and allergic rhinitis. Montelukast is generally considered a safe drug with the occurrence of a few adverse drug reactions (ADRs) and anti-leucotrienes are usually well-tolerated by adults and young patients. Starting from these premises the purpose of this review is so give un up-to-date scenario about skin adverse reactions due to Montelukast administration. Only few cases were reported during last years, however interestingly some recent reports let us enlarging our ADR data about Montelukast. We decided to divide the paragraph into sections evaluating the following skin lesions: vasculitic lesions, rash, urticaria and angioedema. As described in the results, CSS were the most frequent cases reported, belonging to the Vasculitis category. We speculated several mechanisms leading to the spread of the skin reactions. Montelukast still remains a safe drug used for the treatment of severe and moderate asthma. However, for some reasons still in course of analysis, in rare cases patients could develop ADR. Among these, about half of the patients show skin signs as rash, vescicles, bullous skin, purpura, maculopapular cutis, erythematous exanthema, urticaria and angioedema. Most of these symptoms are a consequence of the onset of a vasculitis as CSS and allergic granulomatous angiitis. In many cases the onset of the reactions happen within the first months of intake. For this reason, the prescribing physicians should be alert for signs, symptoms and genetic predisposition of these skin diseases.
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Affiliation(s)
- Eleonora Di Salvo
- National Research Council of Italy (CNR), Institute of Applied Science and Intelligent System (ISASI), Messina Unit, Messina, Italy.
| | - Vincenzo Patella
- Division Allergy and Clinical Immunology, Department of Medicine ASL Salerno, "Santa Maria della Speranza" Hospital, Salerno, Italy.
| | - Marco Casciaro
- School and Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Sebastiano Gangemi
- School and Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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Martín-Suñé N, Ríos-Blanco JJ. Pulmonary affectation of vasculitis. Arch Bronconeumol 2012; 48:410-8. [PMID: 22682604 DOI: 10.1016/j.arbres.2012.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
Abstract
Respiratory tract affectation is frequent in some types of vasculitis, fundamentally in those associated with anti-neutrophil cytoplasmic antibodies (ANCA). The clinical, radiological and histopathological presentation is also heterogeneous and conditions the evolution. It is therefore necessary to establish an early diagnosis based on the symptoms because, thanks to new treatments, and despite them being potentially serious diseases, their prognosis has improved considerably in recent years. The present paper updates the diagnosis and the new therapeutic options for pulmonary vasculitis.
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Gatenby PA. Anti-neutrophil cytoplasmic antibody-associated systemic vasculitis: nature or nurture? Intern Med J 2012; 42:351-9. [DOI: 10.1111/j.1445-5994.2011.02705.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Granel B, Rossi P, Koeppel MC, Hermine O, Charpin D. Churg and Strauss vasculitis in the course of masitinib treatment: a first report. Allergy 2010; 65:1059-60. [PMID: 19958320 DOI: 10.1111/j.1398-9995.2009.02273.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- B Granel
- Service de Médecine Interne, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille (AP-HM), Université de la Méditerranée, 13915 Marseille, France.
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GAO YING, ZHAO MINGHUI. Review article: Drug-induced anti-neutrophil cytoplasmic antibody-associated vasculitis. Nephrology (Carlton) 2009; 14:33-41. [DOI: 10.1111/j.1440-1797.2009.01100.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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8
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Keogh KA. Leukotriene receptor antagonists and Churg-Strauss syndrome: cause, trigger or merely an association? Drug Saf 2007; 30:837-43. [PMID: 17867722 DOI: 10.2165/00002018-200730100-00003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Concern has been raised in the medical literature that the use of leukotriene receptor antagonists for the treatment of asthma may be associated with an increased incidence of Churg-Strauss syndrome, a rare small-vessel vasculitic syndrome. This review provides a critical appraisal of the literature to address this question. The incidence of Churg-Strauss syndrome in the general population is one to four cases per million. In patients with asthma it is 20-60 cases per million patient-years, which is similar to that seen in a population receiving leukotriene receptor antagonists. There is no evidence for a direct causative role of leukotriene receptor antagonists in the development of Churg-Strauss syndrome. There may be multiple other non-causative reasons for an association, including the fact that these agents may be initiated in patients who are already in the process of developing Churg-Strauss syndrome, or that the use of leukotriene receptor antagonists leads to a reduction in corticosteroid use, which in turn allows the Churg-Strauss syndrome to be 'unmasked'.
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Affiliation(s)
- Karina A Keogh
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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Watanabe T, Iinuma Y, Naito SI, Nitta K. Eosinophilic tumor in a patient with bronchial asthma receiving pranlukast. Eur J Pediatr 2007; 166:183-4. [PMID: 16915372 DOI: 10.1007/s00431-006-0226-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Accepted: 06/21/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Toru Watanabe
- Department of Pediatrics, Niigata City General Hospital, 2-6-1 Shichikuyama, 950-8739 Niigata, Japan.
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10
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Olowu WA. Nephropathy, polyneuropathy, and gastroenteritis in a child with Churg-Strauss syndrome. Clin Rheumatol 2006; 26:831-5. [PMID: 16897116 DOI: 10.1007/s10067-006-0362-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 09/05/2005] [Accepted: 09/09/2005] [Indexed: 11/24/2022]
Abstract
Churg-Strauss syndrome (CSS) is a serious but rare pauci-immune vasculitis of small- and medium-sized blood vessels. It is commonly seen in association with bronchial asthma and/or allergic disorders. The syndrome is characterized by the presence of asthma, hypereosinophilia, and vasculitis in any part of the body. Vasculitis is often associated with significant distortion of normal functions. A rather severe case of CSS in an 8-year-old Nigerian girl with asthma and allergic rhinoconjunctivitis is reported. She presented with multiple morbidities, namely, vasculitic polyneuropathy and also nephritic-nephrotic syndrome that eventuated in acute renal failure after an onset of vasculitic gastroenteritis. Routine screening of all asthmatic patients for CSS is advocated.
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Affiliation(s)
- Wasiu A Olowu
- Paediatric Nephrology and Hypertension Unit, Obafemi Awolowo University Teaching Hospitals Complex, PMB 5538, Ile-Ife, Osun State, Nigeria.
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Prenner BM, Schenkel E. Allergic rhinitis: treatment based on patient profiles. Am J Med 2006; 119:230-7. [PMID: 16490466 DOI: 10.1016/j.amjmed.2005.06.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2005] [Accepted: 06/07/2005] [Indexed: 12/11/2022]
Abstract
Allergic rhinitis is a common medical condition characterized by nasal, throat, and ocular itching; rhinorrhea; sneezing; nasal congestion; and, less frequently, cough. The treatment of allergic rhinitis should control these symptoms without adversely affecting daily activities or cognitive performance and should prevent sequelae such as asthma exacerbation or sinusitis. This review describes a stepwise approach to treatment of allergic rhinitis derived from a synthesis of clinical trial results, patient preferences, and real-world tolerability data. Key clinical considerations include frequency and intensity of symptoms, patient age, comorbidities, compliance with treatment regimens (influenced by formulation, route and frequency of administration), and effects on quality of life. Oral second-generation antihistamines, versus first-generation agents and inhaled corticosteroids, should be considered first-line treatment because they provide rapid relief of most allergic rhinitis symptoms without safety and tolerability issues. Additional therapeutic agents can then be added or substituted based on individual symptom response.
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Affiliation(s)
- Bruce M Prenner
- Allergy Associates Medical Group, San Diego, Calif 92120, USA.
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12
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Frankel SK, Cosgrove GP, Fischer A, Meehan RT, Brown KK. Update in the Diagnosis and Management of Pulmonary Vasculitis. Chest 2006; 129:452-465. [PMID: 16478866 DOI: 10.1378/chest.129.2.452] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The term vasculitis encompasses a number of distinct clinicopathologic disease entities, each of which is characterized pathologically by cellular inflammation and destruction of the blood vessel wall, and clinically by the types and locations of the affected vessels. While multiple classification schemes have been proposed to categorize and simplify the approach to these diseases, ultimately their diagnosis rests on the identification of particular patterns of clinical, radiologic, laboratory, and pathologic features. While lung involvement is most commonly seen with the primary idiopathic, small-vessel or antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides of Wegener granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome, one should remember that medium-vessel vasculitis (ie, classic polyarteritis nodosa), large-vessel vasculitis (ie, Takayasu arteritis), primary immune complex-mediated vasculitis (ie, Goodpasture syndrome), and secondary vasculitis (ie, systemic lupus erythematosus) can all affect the lung. However, for the purpose of this review, we will focus on the ANCA-associated vasculitides.
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Affiliation(s)
- Stephen K Frankel
- Interstitial Lung Disease Program, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Gregory P Cosgrove
- Interstitial Lung Disease Program, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Aryeh Fischer
- Division of Rheumatology, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Richard T Meehan
- Division of Rheumatology, Department of Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Kevin K Brown
- Interstitial Lung Disease Program, Department of Medicine, National Jewish Medical and Research Center, Denver, CO.
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Brown KK. Pulmonary vasculitis. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2006; 3:48-57. [PMID: 16493151 PMCID: PMC2658676 DOI: 10.1513/pats.200511-120jh] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2005] [Accepted: 12/02/2005] [Indexed: 12/31/2022]
Abstract
Pulmonary vasculitis describes a number of distinct disorders that are pathologically characterized by the destruction of blood vessels. The clinical manifestations of each disorder are defined by the size, type, and location of the affected vasculature. The clinical approach to these disorders rests upon an astute clinician considering the diagnosis and identifying the specific patterns of clinical, radiologic, laboratory, and pathologic abnormalities. Lung involvement is most commonly seen with the primary, idiopathic, small-vessel, or antineutrophil cytoplasmic antibody-associated vasculitides; Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome. However, primary, idiopathic medium and large-vessel vasculitis, primary immune complex-mediated vasculitis, and secondary vasculitis are all capable of presenting with lung involvement. In this article, we focus on the more common, antineutrophil cytoplasmic antibody-associated disorder, vasculitides.
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Affiliation(s)
- Kevin K Brown
- Pulmonary Division, Department of Medicine, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO 80206, USA.
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McDanel DL, Muller BA. The linkage between Churg-Strauss syndrome and leukotriene receptor antagonists: fact or fiction? Ther Clin Risk Manag 2005; 1:125-40. [PMID: 18360552 PMCID: PMC1661620 DOI: 10.2147/tcrm.1.2.125.62913] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Epidemiologic evidence has shown that the worldwide prevalence of asthma is increasing. The leukotriene receptor antagonists (LTRAs) represent a new class of therapy for asthma. They have been developed in the last decade and play a pivotal steroid-sparing role in treating the inflammatory component of asthma. Consequently, reports of Churg-Strauss syndrome (CSS), a rare form of systemic vasculitis, have been recognized as a potential side effect in individuals with moderate to severe asthma on LTRA therapy. The serious nature of this disorder is worthy of prompt recognition by clinicians and aggressive therapy to avoid the subsequent longstanding effects of vasculitis. To validate the postulated linkage between the LTRAs and CSS, this review comprehensively evaluates reported cases in the literature and supports a pathophysiological relationship between the LTRAs and the development of CSS.
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Affiliation(s)
- Deanna L McDanel
- Departments of Pharmaceutical Care University of Iowa Hospitals and ClinicsIowa City, IA, USA
| | - Barbara A Muller
- Internal Medicine, University of Iowa Hospitals and ClinicsIowa City, IA, USA
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15
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Spahr JE, Krawiec ME. Leukotriene receptor antagonists – risks and benefits for use in paediatric asthma. Expert Opin Drug Saf 2005. [DOI: 10.1517/14740338.3.3.173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hamad AM, Sutcliffe AM, Knox AJ. Aspirin-induced asthma: clinical aspects, pathogenesis and management. Drugs 2005; 64:2417-32. [PMID: 15482000 DOI: 10.2165/00003495-200464210-00004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Aspirin (acetylsalicylic acid)-induced asthma (AIA) consists of the clinical triad of asthma, chronic rhinosinusitis with nasal polyps, and precipitation of asthma and rhinitis attacks in response to aspirin and other NSAIDs. The prevalence of the syndrome in the adult asthmatic populations is approximately 4-10%. Respiratory disease in these patients may be aggressive and refractory to treatment. The aetiology of AIA is complex and not fully understood, but most evidence points towards an abnormality of arachidonic acid (AA) metabolism. Cyclo-oxygenase (COX), the rate-limiting enzyme in AA metabolism, exists as two main isoforms. COX-1 is the constitutive enzyme responsible for synthesis of protective prostanoids, whereas COX-2 is induced under inflammatory conditions. A number of theories regarding its pathogenesis have been proposed. The shunting hypothesis proposes that inhibition of COX-1 shunts AA metabolism away from production of protective prostanoids and towards cysteinyl leukotriene (cys-LT) biosynthesis, resulting in bronchoconstriction and increased mucus production. The COX-2 hypothesis proposes that aspirin causes a structural change in COX-2 that results in the generation of products of the lipoxygenase pathway. It is speculated that this may result in the formation of mediators that cause respiratory reactions in AIA. Related studies provide evidence for abnormal regulation of the lipoxygenase pathway, demonstrating elevated levels of cys-LTs in urine, sputum and peripheral blood, before and following aspirin challenge in AIA patients. These studies suggest that cys-LTs are continually and aggressively synthesised before exposure to aspirin and, during aspirin-induced reactions, acceleration of synthesis occurs. A genetic polymorphism of the LTC4S gene has been identified consisting of an A to C transversion 444 nucleotides upstream of the first codon, conferring a relative risk of AIA of 3.89. Furthermore, carriers of the C444 allele demonstrate a dramatic rise in urinary LTE(4) following aspirin provocation, and respond better to the cys-LT antagonist pranlukast than A444 homozygotes.AIA patients have an aggressive form of disease, and treatment should include combination therapy with inhaled corticosteroids, beta(2)-adrenoceptor agonists and LT modifiers. Furthermore, recently developed inhibitors of COX-2 may be safer in patients with AIA.
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Affiliation(s)
- Ahmed M Hamad
- Department of Respiratory Medicine, Al-Mansourah University, Al-Dakahlia, Egypt
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De Nardo D, De Sanctis G, Biancone L, Khalil J, Kroegler B, De Risi E, Franconi G, Capria A, Fontana L. Churg-Strauss Syndrome Development during Asthma Therapy with Leukotriene Receptor Antagonists: Just a Coincidental Association? EUR J INFLAMM 2004. [DOI: 10.1177/1721727x0400200307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A report on our clinical experience based on 3 male patients who developed Churg-Strauss syndrome (CSS) after standard oral montelukast use. All patients affected by moderate asthma and chronic hyperplastic rhinosinusitis were treated with inhaled corticosteroids and ß2 agonists. Systemic corticosteroid treatment consisted in oral daily prednisone in case 1, in short courses of oral betamethasone in case 2, and in remote and isolated administrations of oral betamethasone and intramuscular methylprednisolone in case 3. Because of the improvement of the asthma symptoms after montelukast use, patient 1 decided to take half the dose of prednisone for 10 days and patient 2 decided to discontinue systemic and inhaled corticosteroids for 45 days. Overt CSS was heralded by vasculitic skin lesions and developed in each patient with severe organ damage, consisting in renal, myocardial and gastrointestinal involvement. Remission was obtained by standard CSS therapy after montelukast withdrawal. According to the unmasking hypothesis, antileukotriene treatment, by enabling the reduction in systemic corticosteroid therapy in case 1 and its discontinuation in case 2, might have only permitted the precipitation of the vasculitis. However antileukotriene-associated CSS reportedly occurred in systemic corticosteroid-naïve patients and relapsed in one patient after antileukotriene treatment. These observations lend support to the concept that the precipitation of the vasculitic phase may be associated with leukotriene modifier deleterious effects. In conclusion there is not enough evidence to prove that antileukotriene treatment plays a direct causative role in the pathogenesis of CSS. Further clinical and experimental research is required to clarify the antileukotriene associated CSS controversy.
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Affiliation(s)
| | | | - L. Biancone
- Cattedra di Gastroenterologia, Department of Internal Medicine, Tor Vergata University of Rome, Italy
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Moraes TJ, Selvadurai H. Management of exercise-induced bronchospasm in children: the role of leukotriene antagonists. ACTA ACUST UNITED AC 2004; 3:9-15. [PMID: 15174889 DOI: 10.2165/00151829-200403010-00002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This review assesses the evidence on the efficacy of leukotriene antagonists in the management of exercise-induced bronchospasm (EIB) in children. Only two randomized, double-blind, placebo-controlled, crossover studies have examined the effect of leukotriene antagonists in EIB in a pediatric setting. All other studies, including those comparing leukotriene antagonists with other agents such as beta(2)-adrenoceptor agonists (beta(2)-agonists) and inhaled corticosteroids, primarily involve adult patients. In children, not receiving other asthma medication, leukotriene antagonists can offer statistically significant protection from EIB compared with placebo. However, protection is not complete, as a significant proportion of children will continue to experience a >15% reduction in FEV(1). None of the studies involved children treated concurrently with other asthma medications; therefore, comments on additive therapy cannot be made. Despite evidence from only a few studies, leukotriene antagonists are seen to be well tolerated, efficacious, and of benefit to some children. In addition, current management for EIB with short-acting beta(2)-agonists is less than ideal. It is therefore concluded that in children with EIB, leukotriene antagonists are indicated on a trial basis with individualized therapy and follow-up to evaluate treatment response.
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Affiliation(s)
- Theo J Moraes
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Minciullo PL, Saija A, Bonanno D, Ferlazzo E, Gangemi S. Montelukast-induced generalized urticaria. Ann Pharmacother 2004; 38:999-1001. [PMID: 15113985 DOI: 10.1345/aph.1d547] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of generalized urticaria induced by montelukast treatment. CASE SUMMARY A 28-year-old man with allergic rhinitis and moderate persistent asthma developed generalized urticaria 5 days after the initiation of montelukast and inhaled fluticasone. Symptoms disappeared within one day after suspension of both drugs. Two months later, after the resumption of montelukast and fluticasone, the patient developed generalized urticaria and eyelid angioedema, which were successfully treated with intravenous betamethasone, achieving complete remission within hours. After 2 days, the patient resumed inhaled fluticasone only and continued this therapy for several months without any adverse reaction. DISCUSSION We attributed the adverse reaction to montelukast because of the temporal relationship between use of montelukast and urticaria, the absence of other identified causative factors and other explanations for allergic reactions, and the positive dechallenge and rechallenge. The Naranjo probability scale showed a probable relationship between skin manifestations and montelukast treatment. CONCLUSIONS The use of antileukotrienes is increasing in asthma therapy. In cases of generalized urticaria in asthmatic patients undergoing montelukast therapy, physicians should be aware of a potential adverse reaction to this drug.
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Affiliation(s)
- Paola L Minciullo
- Department of Human Pathology, Division and School of Allergy and Clinical Immunology, University of Messina, 98123 Messina, Italy
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Hellmich B, Gross WL. Recent progress in the pharmacotherapy of Churg-Strauss syndrome. Expert Opin Pharmacother 2004; 5:25-35. [PMID: 14680433 DOI: 10.1517/14656566.5.1.25] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Churg-Strauss syndrome (CSS) is a primary systemic vasculitis occurring primarily in patients with asthma. Unlike other small vessel vasculitides, CSS is characterised by blood and tissue eosinophilia. Corticosteroids are the therapy of first choice for all stages of the disease when active vasculitis needs to be treated rapidly. In patients with severe disease and organ- or life-threatening manifestation, the addition of cyclophosphamide appears to improve the outcome and reduces the incidence of relapses. In cases with an apparently better prognosis and less severe disease, methotrexate can be given as a corticosteroid-sparing agent in order to reduce the cumulative dose of corticosteroids, which is generally high in most cases as long-term administration of corticosteroids is often inevitable in order to control asthma, even if the vasculitis is inactive. In very severe cases of CSS, cyclophosphamide and corticosteroids may be insufficient to induce remission. In these cases, anti-TNF blocking agents such as infliximab or etanercept, may be added for a limited period of time. As this intense immunosuppression increases the risk for infections, a prophylaxis with sulfamethoxazole/trimethoprim is advised. Alternatively, the administration of recombinant IFN-alpha can be a effective when given on a short-term basis in otherwise refractory cases. Whether a continuous administration of immunosuppressive agents in addition to corticosteroids can reduce the frequency of relapses in CSS who are in remission is still unknown. As relapses occur in > 25% of all patients, studies addressing the prevention of relapses in CSS are highly desirable in the future.
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Affiliation(s)
- Bernhard Hellmich
- Poliklinik für Rheumatologie, Universitätsklinikum Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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García-Marcos L, Schuster A, Pérez-Yarza EG. Benefit-risk assessment of antileukotrienes in the management of asthma. Drug Saf 2003; 26:483-518. [PMID: 12735786 DOI: 10.2165/00002018-200326070-00004] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Antileukotrienes are a relatively new class of anti-asthma drugs that either block leukotriene synthesis (5-lipoxygenase inhibitors) like zileuton, or antagonise the most relevant of their receptors (the cysteinyl leukotriene 1 receptor [CysLT1]) like montelukast, zafirlukast or pranlukast. Hence, their major effect is an anti-inflammatory one. With the exception of pranlukast, the other antileukotrienes have been studied and marketed in the US and Europe for long enough to establish that they are useful drugs in the management of asthma. Their effects, significantly better than placebo, seem more pronounced in subjective measurements (i.e. symptoms scores or quality-of-life tests) than in objective parameters (i.e. forced expiratory volume in 1 second or peak expiratory flow rate). Also, there is some evidence that these drugs work better in some subsets of patients with certain genetic polymorphisms - probably related to their leukotriene metabolism - or patients with certain asthma characteristics. There are a small number of comparative studies only, and with regard to long-term asthma control differences between the agents have not been evaluated. Nevertheless, their overall effect appears comparable with sodium cromoglycate (cromolyn sodium) or theophylline, but significantly less than low-dose inhaled corticosteroids. Antileukotrienes have been shown to have a degree of corticosteroid-sparing effect, but salmeterol appears to perform better as an add-on drug. Montelukast is probably the most useful antileukotriene for continuous treatment of exercise-induced asthma, performing as well as salmeterol without inducing any tolerance. All antileukotrienes are taken orally; their frequency of administration is quite different ranging from four times daily (zileuton) to once daily (montelukast). Antileukotrienes are well tolerated drugs, even though zileuton intake has been related to transitional liver enzyme elevations in some cases. Also Churg-Strauss syndrome (a systemic vasculitis), has been described in small numbers of patients taking CysLT1 antagonists. It is quite probable that this disease appears as a consequence of an 'unmasking' effect when corticosteroid dosages are reduced in patients with severe asthma once CysLT1 antagonists are introduced, but more data are needed to definitely establish the mechanism behind this effect. Overall, however, the benefits of antileukotrienes in the treatment of asthma greatly outweigh their risks.
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Affiliation(s)
- Luis García-Marcos
- Department of Pediatrics, University of Murcia and Pediatric Research Unit, Cartagena, Spain.
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Keogh KA, Specks U. Churg-Strauss syndrome: clinical presentation, antineutrophil cytoplasmic antibodies, and leukotriene receptor antagonists. Am J Med 2003; 115:284-90. [PMID: 12967693 DOI: 10.1016/s0002-9343(03)00359-0] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the association of antineutrophil cytoplasmic antibodies (ANCA) and leukotriene receptor antagonists with disease activity in a large series of patients with Churg-Strauss syndrome. METHODS Potential subjects were identified by a computerized search of the Mayo Clinic Rochester database for the years 1990 to 2000. Patients meeting one of three classification schemes for Churg-Strauss syndrome were included. RESULTS Ninety-one patients met the inclusion criteria. Clinical manifestations were similar to those in previous reports. Mortality was similar to that in the general population. ANCA testing was performed in 74 patients. Seventy-three percent (n = 22) of the 30 patients tested before therapy were ANCA positive, as were 75% (n = 12) of the 16 patients tested during a disease flare. In comparison, 16% (n = 8) of the 49 tested during remission were ANCA positive. Serial measurements indicated a correlation of ANCA levels with disease activity. Central nervous system involvement was the only clinical manifestation that correlated with ANCA status (P = 0.05). Twenty-three patients received leukotriene receptor antagonists, of whom 16 (70%) began treatment before diagnosis and 6 (27%) began during remission. Two of those treated after diagnosis relapsed. In 1 patient the relation between disease and leukotriene receptor antagonist use could not be determined. Use of leukotriene receptor antagonists did not affect the time between onset of asthma and manifestations of vasculitis, and was not correlated with organ manifestations, except sinus disease. CONCLUSION No one classification scheme identified all patients. Churg-Strauss syndrome has a better prognosis than other ANCA-associated vasculitides. ANCA status correlates with disease activity, whereas a pathogenic role for leukotriene receptor antagonists in the development of Churg-Strauss syndrome was not noted.
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Affiliation(s)
- Karina A Keogh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
Hepatotoxicity is the most common cause of fulminant hepatic failure in the United States and the main indication for market withdrawal of drugs. This condition has been increasingly recognized as a problem of enormous medical, financial legal, and regulatory importance. It is in context of this heightened awareness of hepatotoxicity, particularly associated with new high profile drugs, that the authors reviews the published data regarding liver injury related to a novel group of asthma drugs.
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Affiliation(s)
- Timothy J Davern
- University of California, Division of Gastroenterology, 513 Parnassus Avenue, Room S-357, San Francisco 94143, CA, USA.
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Abstract
Churg-Strauss syndrome is a rare disorder characterized by necrotizing vasculitis, granulomas with eosinophilic necrosis, and tissue infiltration by eosinophils. Sudden cardiac death is rarely described in Churg-Strauss syndrome. In this article, we describe a case of Churg-Strauss syndrome with multiorgan involvement manifested as sudden cardiac death. To the best of our knowledge, this form of presentation has not been reported. A 49-year-old woman was found dead in her room. No premonitory complaints had been noted during the days preceding her death. Past medical history did not reveal any relevant illness. At autopsy, multiorganic Churg-Strauss syndrome with prominent cardiac involvement was found. Therefore, this syndrome in the active vasculitic phase may be asymptomatic and may involve predominantly the heart. This variant of the syndrome may be fulminant and present as sudden cardiac death. This form can only be elucidated by autopsy study.
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Affiliation(s)
- J Fernando Val-Bernal
- Department of Anatomical Pathology, Marqués de Valdecilla University Hospital, Medical Faculty, University of Cantabria, Santander, Spain.
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Abstract
This review summarizes the recent advances regarding pathogenesis, diagnosis, and treatment of immunological diseases of the lung. Rather than attempt a comprehensive analysis, we have focused on selected diseases that are of particular relevance to the practicing physician, and the material has been organized according to the dominant immunologic mechanisms underlying the disease. Because of the redundancy that characterizes the mammalian immune repertoire, this system of classification inevitably produces overlap but facilitates acquisition of what is otherwise a disparate collection of facts. The principal lung immunologic mechanisms are most broadly classified as innate or adaptive immune processes. Innate immunity includes neutrophils and complement that are important in diseases, such as pneumonia and the acute respiratory distress syndrome. Adaptive immunity involves T and B cells capable of recognizing discrete antigens. T(H)1- and T(H)2-dependent adaptive immune responses underlie some of the most common and important of lung diseases, including tuberculosis and asthma, respectively. Other important immunopathologic processes include granulomatous inflammation that characterizes sarcoidosis and Churg-Strauss vasculitis, and autoimmunity, which is characteristic of antiglomerular basement membrane disease and others.
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Affiliation(s)
- Joseph E Prince
- Biology of Inflammation Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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Abstract
Understanding the role of inflammation in childhood asthma has led to major changes in the approach to management of this disease. Based on the guidelines from the NIH, inhaled long-term control medications that target the underlying inflammatory processes in asthma are now recommended as the mainstay of drug treatment. Long-term control medications are recommended for all children who have asthma symptoms that occur more frequently than twice weekly or nocturnal symptoms more than twice monthly. Environmental control measures to decrease allergen exposure are important, as is attention to sinusitis and GER. The main impediment to improved asthma care is poor patient compliance. Many patients do not understand the role and importance of prophylactic medications in asthma treatment. Further, inconvenient dosing regimens, difficulties with metered-dose inhalers, and fear of potential side effects have all contributed to poor patient compliance. Increased efforts at patient education are needed to improve adherence to asthma plans. These efforts at improving patient compliance, along with improved physician adherence to the guidelines from the NIH, are needed to decrease the morbidity and mortality of childhood asthma.
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Affiliation(s)
- Mary Beth Hogan
- Section of Pediatric Allergy and Immunology, Department of Pediatrics, Robert C. Byrd Health Science Center, West Virginia University, Morgantown, WV 26506-9214, USA
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Masi AT, Hamilos DL. Leukotriene antagonists: bystanders or causes of Churg-Strauss syndrome? Semin Arthritis Rheum 2002; 31:211-7. [PMID: 11836654 DOI: 10.1053/sarh.2002.30439] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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