Mode of action of intranasal corticosteroids

Efficacy of montelukast for adenoid hypertrophy in paediatrics: A systematic review and meta-analysis

INTRODUCTION

Leukotrienes play a significant role in the pathogenesis of adenoid hypertrophy (A.H.). Therefore, we aimed to analyse the role of montelukast, a leukotriene receptor antagonist, alone or in combination with mometasone, a potent local intranasal steroid, for the treatment of A.H.

METHODS

Participants were children with A.H. were treated with montelukast alone or montelukast and mometasone furoate. The main outcome measures were effect of montelukast on clinical symptoms of A.H. A literature review was conducted using online search engines, Cochrane Library, PubMed, Web of Science and Scopus, for randomized clinical trials assessing children with A.H. treated with montelukast alone or montelukast and mometasone furoate. Seven randomized clinical trials (RCTs) were included with 742 children.

RESULTS

Our study reveals that montelukast alone or in combination with intranasal mometasone furoate significantly improves clinical symptoms of adenoid hypertrophy such as snoring, sleeping disturbance, mouth breathing and A/N ratio. Montelukast was superior to placebo in decreasing snoring (SMD = -1.00, 95% CI [-1.52, -0.49]), sleep discomfort (SMD = -1.26, 95% CI [-1.60, -0.93]), A/N ratio (MD = -0.11, 95% CI [-0.14, -0.09]) and mouth breathing (SMD = -1.36, 95% CI [-1.70, -1.02]). No difference was detected between montelukast and mometasone versus mometasone alone in snoring (SMD = -0.21, 95%CI [-0.69, 0.27]); however, the combination group was superior to the mometasone alone in mouth breathing (SMD = -0.46, 95% CI [-0.73, -0.19]).

CONCLUSIONS

The limitation of studies included a small sample size, with an overall low to medium quality. Thus, further larger, higher-quality RCTs are recommended to provide more substantial evidence.

The nasal and systemic inflammatory responses in early phase of acute radiation rhinosinusitis: A pilot study

KEY POINTS

Disease severity in acute radiation rhinosinusitis (ARRS) peaks after radiation therapy. ARRS is mainly local inflammation, manifested by increased pro-inflammatory cytokines. Intranasal corticosteroids are effective anti-inflammatory drugs in the treatment of ARRS.

The nasal microbiome in patients suffering from non-steroidal anti-inflammatory drugs-exacerbated respiratory disease in absence of corticosteroids

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease phenotypically classified by the absence (CRSsNP) or presence of nasal polyps (CRSwNP). The latter may also be associated with asthma and hypersensitivity towards non-steroidal anti-inflammatory drugs (NSAID) as a triad termed NSAID-exacerbated respiratory disease (N-ERD). The role of the microbiome in these different disease entities with regard to the underlying inflammatory process and disease burden is yet not fully understood. To address this question, we measured clinical parameters and collected nasal samples (nasal mucosal fluids, microbiome swabs from middle meatus and anterior naris) of patients suffering from CRSsNP (n=20), CRSwNP (n=20) or N-ERD (n=20) as well as from patients without CRS (=disease controls, n=20). Importantly, all subjects refrained from taking local or systemic corticosteroids or immunosuppressants for at least two weeks prior to sampling. The nasal microbiome was analyzed using 16S rRNA gene amplicon sequencing, and levels of 33 inflammatory cytokines were determined in nasal mucosal fluids using the MSD platform. Patients suffering from N-ERD and CRSwNP showed significantly worse smell perception and significantly higher levels of type 2 associated cytokines IL-5, IL-9, Eotaxin and CCL17. Across all 4 patient groups, Corynebacteria and Staphylococci showed the highest relative abundances. Although no significant difference in alpha and beta diversity was observed between the control and the CRS groups, pairwise testing revealed a higher relative abundance of Staphylococci in the middle meatus in N-ERD patients as compared to CRSwNP (p<0.001), CRSsNP (p<0.01) and disease controls (p<0.05) and of Lawsonella in patients suffering from CRSwNP in middle meatus and anterior naris in comparison to CRSsNP (p<0.0001 for both locations) and disease controls (p<0.01 and p<0.0001). Furthermore, we observed a positive correlation of Staphylococci with IL-5 (Pearson r=0.548) and a negative correlation for Corynebacteria and Eotaxin-3 (r=-0.540). Thus, in patients refraining from oral and nasal corticosteroid therapy for at least two weeks known to alter microbiome composition, we did not observe differences in microbiome alpha or beta diversity between various CRS entities and disease controls. However, our data suggest a close association between increased bacterial colonization with Staphylococci and decreased colonization by Corynebacteria as well as increased type 2 inflammation.

Pharmacological Management of Allergic Rhinitis: A Consensus Statement from the Malaysian Society of Allergy and Immunology

The goal of allergic rhinitis (AR) management is to achieve satisfactory symptom control to ensure good quality of life. Most patients with AR are currently treated with pharmacotherapy. However, knowledge gaps on the use of pharmacotherapy still exist among physicians, particularly in the primary care setting, despite the availability of guideline recommendations. Furthermore, it is common for physicians in the secondary care setting to express uncertainty regarding the use of new combination therapies like intranasal corticosteroid plus antihistamine combinations. Inadequate treatment leads to significant reduction of quality of life that affects daily activities at home, work, and school. With these concerns in mind, a practical consensus statement was developed to complement existing guidelines on the rational use of pharmacotherapy in both the primary and secondary care settings.

[Features of adherence to treatment of patients with chronic rhinosinusitis with nasal polyps]

Chronic polypous rhinosinusitis (CPR) is characterized by refractory to drug therapy and a high potential for recurrence after surgical treatment. One of the important factors limiting the effectiveness of drug therapy of CPR, in particular intranasal glucocorticosteroids (inGCSs), is the insufficient level of adherence to treatment of patients with CPR.

OBJECTIVE

Generalization of data on the significance and ways to increase adherence to treatment of patients with CPR.

MATERIAL AND METHODS

Materials of scientific publications included in the Cochrane Library, Russian Science Citation Index, MEDLINE, PubMed information bases were used as a data source. The material was selected based on the following keywords: "chronic rhinosinusitis", "nasal polyps", "intranasal glucocorticosteroids", "adherence to treatment".

RESULTS

Despite the fact that inGCSs are one of the main pathogenetically justified methods of treating CPR, their use is limited by many factors, one of which is the level of patient compliance with the treatment regimen.

CONCLUSION

Improving adherence to treatment is one of the important reserves for increasing the effectiveness of drug therapy for chronic polypous rhinosinusitis.

Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses

BACKGROUND AND OBJECTIVES

Treatment of retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs) includes antibiotics, with possible surgical drainage. Although corticosteroids may decrease inflammation, their role in the management of RPAs and PPAs is unclear. We evaluated the association of corticosteroid administration as part of initial medical management on drainage rates and length of stay for children admitted with RPAs and PPAs.

METHODS

We conducted a retrospective study using administrative data of children aged 2 months to 8 years discharged with RPAs and PPAs from 2016 to 2019. Exposure was defined as systemic corticosteroids administered as part of initial management. Primary outcome was surgical drainage. Bivariate comparisons were made between patients in the corticosteroid and noncorticosteroid groups by using Wilcoxon rank or χ² tests. Outcomes were modeled by using generalized linear mixed-effects models.

RESULTS

Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22-0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92-1.02).

CONCLUSIONS

Corticosteroids were associated with lower odds of surgical drainage among children with RPAs and PPAs.

Complications of combination intranasal corticosteroids and anti-retroviral therapy

BACKGROUND

Intranasal corticosteroids are widely used for management of many upper airway diseases because of their ability to effectively deliver local relief of inflammation.

CASE REPORT

This paper presents the case of a 51-year-old man with human immunodeficiency virus treated with ritonavir who was started on fluticasone intranasal spray for presumed chronic rhinosinusitis. Months after starting this therapy, he developed symptoms of Cushing's syndrome and avascular necrosis of the shoulder due to the pharmacological interactions between fluticasone and ritonavir.

CONCLUSION

Although intranasal corticosteroids are deemed a low-risk route of drug administration, clinicians need to be vigilant in appropriately prescribing corticosteroids in the setting of drug potentiators, particularly in these high-risk patients. Alternative corticosteroids such as beclomethasone dipropionate should be considered in such cases.

Effect of Medical Therapy in Allergic Rhinitis: A Systematic Review and Meta-Analysis

BACKGROUND

Intranasal corticosteroids (INCS), oral antihistamines (POAH), and allergen-specific immunotherapy (ASIT) are widely used in the treatment of allergic rhinitis (AR); however, appraisal of treatment effect has been heterogenous, and few studies have interpreted these outcomes in context with measures of nasal airflow.

OBJECTIVE

To provide a systematic review and meta-analysis of randomized placebo-controlled trials for common therapy classes for AR to assess standardized treatment effect on validated patient-reported outcomes and physiologic measures of airflow.

METHODS

A systematic search was performed in PubMed, Scopus, OVID, and Cochrane library databases to identify randomized controlled trials meeting inclusion criteria. Treatment effects of INCS, POAH, and ASIT on total nasal symptom score (TNSS), visual analog scale (VAS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and peak nasal inspiratory flow (PNIF) were analyzed by meta-analysis.

RESULTS

Twenty-two studies with 4673 AR patients were identified, with 5 INCS, 8 POAH, and 9 ASIT trials. INCS improved TNSS (mean difference [MD] 0.90; P = .002) and PNIF (MD 13.31 L/min [P = .0007]. POAH improved quality of life assessed by RQLQ [MD 0.36; P < .001], but no improvement was found in PNIF. ASIT improved RQLQ [MD 0.65; P < .001], with a trend toward improvement in TNSS.

CONCLUSION

Overall, INCS resulted in a clinically and statistically meaningful improvement in symptom scores and physiologic measures in AR. POAH and ASIT both improved symptom scores and quality of life, but their impacts upon nasal airflow are uncertain. There is a lack of studies assessing the effect of INCS on quality of life and the effect of POAH on symptom severity, particularly for mild AR. Future studies should assess the effect of treatment for each of these patient-reported measures.

Effect of intranasal corticosteroid treatment on allergen-induced changes in group 2 innate lymphoid cells in allergic rhinitis with mild asthma

BACKGROUND

Allergic rhinitis is characterized by rhinorrhea, nasal congestion, sneezing and nasal pruritus. Group 2 innate lymphoid cells (ILC2s), CD4⁺ T cells and eosinophils in nasal mucosa are increased significantly after nasal allergen challenge (NAC). Effects of intranasal corticosteroids (INCS) on ILC2s remain to be investigated.

METHODS

Subjects (n = 10) with allergic rhinitis and mild asthma were enrolled in a single-blind, placebo-controlled, sequential treatment study and treated twice daily with intranasal triamcinolone acetonide (220 µg) or placebo for 14 days, separated by a 7-day washout period. Following treatment, subjects underwent NAC and upper airway function was assessed. Cells from the nasal mucosa and blood, sampled 24 h post-NAC, underwent flow cytometric enumeration for ILC2s, CD4⁺ T and eosinophil progenitor (EoPs) levels. Cell differentials and cytokine levels were assessed in nasal lavage.

RESULTS

Treatment with INCS significantly attenuated ILC2s, IL-5⁺ /IL-13⁺ ILC2s, HLA-DR⁺ ILC2s and CD4⁺ T cells in the nasal mucosa, 24 h post-NAC. EoP in nasal mucosa was significantly increased, while mature eosinophils were significantly decreased, 24 h post-NAC in INCS versus placebo treatment arm. Following INCS treatment, IL-2, IL-4, IL-5 and IL-13 were significantly attenuated 24 h post-NAC accompanied by significant improvement in upper airway function.

CONCLUSION

Pre-treatment with INCS attenuates allergen-induced increases in ILC2s, CD4⁺ T cells and terminal differentiation of EoPs in the nasal mucosa of allergic rhinitis patients with mild asthma, with little systemic effect. Attenuation of HLA-DR expression by ILC2s may be an additional mechanism by which steroids modulate adaptive immune responses in the upper airways.

Montelukast combined with intranasal mometasone furoate versus intranasal mometasone furoate; a comparative study in treatment of adenoid hypertrophy

OBJECTIVES

To evaluate the role of combined therapy using montelukast and intranasal mometasone furoate compared to intranasal mometasone furoate alone in treatment of adenoid hypertrophy regarding efficacy and recurrence rate.

METHODS

The study included 100 children with adenoid hypertrophy, they were randomly assigned to two groups. Group I (50 patients) received combined therapy using montelukast and mometasone furoate nasal spray. Group II (50 patients) received only mometasone furoate nasal spray. Patients were treated for 3 months and observed for 3 months after stoppage of treatment. Patients were evaluated using symptoms scores, Adenoid/Nasopharyngeal ratio and endoscopic grading of adenoid hypertrophy.

RESULTS

After 3 months of treatment, group I showed significant better scores of main symptoms than group II; (P = 0.001), (P = 0.019) and (P = 0.008) for rhinorrhea, mouth breathing and snoring respectively. The mean A/N ratio was 52.8 ± 11.3 in group I better than 62.88 ± 12.10 in group II (P < 0.001). Regarding the adenoid hypertrophy grading, significant reduction in size was found in group I in 34 (68%) patients better than in group II in 18 (36%) patients (P = 0.001). After further 3 months of follow up, the mean A/N ratio was 58.46 ± 10.05 in group I better than 66.36 ± 10.46 in group II (P < 0.001). Recurrence occurred in 8 (23.5%) cases out of 34 improved cases in group I better than 10 (55.5%) cases out of 18 cases in group II (P = 0.02).

CONCLUSION

Combining oral montelukast with intranasal mometasone in treatment of adenoid hypertrophy provided better improvements and less recurrence in comparison with single therapy using intranasal mometasone alone.

A Scholarly Review of the Safety and Efficacy of Intranasal Corticosteroids Preparations in the Treatment of Chronic Rhinosinusitis

OBJECTIVE

The purpose of this scholarly review is to present an update of the efficacy, safety, and distribution of intranasal corticosteroids (INCS) in the context of treatment for chronic rhinosinusitis (CRS).

MATERIALS AND METHODS

A literature review from 1999 to 2020 of MEDLINE, PubMed, and EMBASE databases was performed, using a comprehensive search strategy. Studies reporting on efficacy, safety, and distribution of all INCS formulations, both Food and Drug Administration (FDA) and non-FDA approved, were reviewed.

RESULTS AND CONCLUSIONS

High-level evidence publications and position papers support the role of INCS in medical treatment for CRS. Significant improvement in disease-specific and general quality of life measures is observed with all formulations of INCS. Overall, the use of both FDA and published non-FDA INCS appears to be safe. Several novel distribution devices might improve penetration to specific areas within the sinuses.

Corticosteroids as standalone or add-on treatment for sore throat

BACKGROUND

Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract. This review is an update to our review published in 2012.

OBJECTIVES

To assess the clinical benefit and safety of corticosteroids in reducing the symptoms of sore throat in adults and children.

SEARCH METHODS

We searched CENTRAL (Issue 4, 2019), MEDLINE (1966 to 14 May 2019), Embase (1974 to 14 May 2019), the Database of Abstracts of Reviews of Effects (DARE, 2002 to 2015), and the NHS Economic Evaluation Database (inception to 2015). We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared steroids to either placebo or standard care in adults and children (aged over three years) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis (glandular fever), sore throat following tonsillectomy or intubation, or peritonsillar abscess.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included one new RCT in this update, for a total of nine trials involving 1319 participants (369 children and 950 adults). In eight trials, participants in both corticosteroid and placebo groups received antibiotics; one trial offered delayed prescription of antibiotics based on clinical assessment. Only two trials reported funding sources (government and a university foundation). In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by 2.40 times (risk ratio (RR) 2.4, 95% confidence interval (CI) 1.29 to 4.47; P = 0.006; I² = 67%; high-certainty evidence) and at 48 hours by 1.5 times (RR 1.50, 95% CI 1.27 to 1.76; P < 0.001; I² = 0%; high-certainty evidence). Five people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 11.6 hours, respectively, although significant heterogeneity was present (moderate-certainty evidence). At 24 hours, pain (assessed by visual analogue scales) was reduced by an additional 10.6% by corticosteroids (moderate-certainty evidence). No differences were reported in recurrence/relapse rates, days missed from work or school, or adverse events for participants taking corticosteroids compared to placebo. However, the reporting of adverse events was poor, and only two trials included children or reported days missed from work or school. The included studies were assessed as moderate quality evidence, but the small number of included studies has the potential to increase the uncertainty, particularly in terms of applying these results to children.

AUTHORS' CONCLUSIONS

Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat. Given the limited benefit, further research into the harms and benefits of short courses of steroids is needed to permit informed decision-making.

The microbiome of the upper respiratory tract in health and disease

The human upper respiratory tract (URT) offers a variety of niches for microbial colonization. Local microbial communities are shaped by the different characteristics of the specific location within the URT, but also by the interaction with both external and intrinsic factors, such as ageing, diseases, immune responses, olfactory function, and lifestyle habits such as smoking. We summarize here the current knowledge about the URT microbiome in health and disease, discuss methodological issues, and consider the potential of the nasal microbiome to be used for medical diagnostics and as a target for therapy.

Intranasal corticosteroids for non-allergic rhinitis

BACKGROUND

Non-allergic rhinitis is defined as dysfunction and non-infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post-nasal drip and sneezing. Several subgroups of non-allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non-allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non-allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients.

OBJECTIVES

To assess the effects of intranasal corticosteroids in the management of non-allergic rhinitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient-reported disease severity and a significant adverse effect - epistaxis. Secondary outcomes were (disease-specific) health-related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno- and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow-up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient-reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient-reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD -0.74, 95% confidence interval (CI) -1.15 to -0.33; 4 studies; 131 participants; I2 = 22%) (low-certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD -0.24, 95% CI -0.67 to 0.20; 3 studies; 85 participants; I2 = 0%) (very low-certainty evidence). Intranasal corticosteroid treatment may slightly improve patient-reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD -0.15, 95% CI -0.25 to -0.05; 4 studies; 1465 participants; I2 = 35%) (low-certainty evidence). All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I2 = 0%) (moderate-certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF-12v2 range 0 to 800); however, this disappeared at longer-term follow-up (148.4 versus 145.6) (low-certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD -0.46, 95% CI -1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI -0.47 to 2.03; 11 participants) (very low-certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I2 = 0%) (moderate-certainty evidence). Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported.

AUTHORS' CONCLUSIONS

Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient-reported disease severity in non-allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions.

Strategies to facilitate or block nose-to-brain drug delivery

Nose-to-brain delivery has gained significant interest over the past several decades. This has resulted in numerous strategies described to improve the delivery of drugs to the brain directly through the olfactory epithelium of the nasal cavity. In some cases, intranasal administration may be more effective than other routes of administration in treating central nervous system and related disorders. Here, we briefly review the strategies that have been used to facilitate nose-to-brain delivery as well as approaches to block the delivery of drugs from the nose to the brain. Even though numerous strategies have already been used to increase nose-to-brain delivery, the research for strategies inhibitory of nose-to-brain delivery seems to be scarce.

Evaluation of Intranasal Corticosteroid Sensory Attributes and Patient Preference for Fluticasone Furoate for the Treatment of Allergic Rhinitis

PURPOSE

Allergic rhinitis (AR) is a highly prevalent disease, affecting the quality of life of millions of Americans. Intranasal corticosteroids (INCs) are widely recommended as first-line therapy for moderate to severe AR. Although these drugs exhibit similar safety and efficacy, a potentially differentiating factor within this class is the varying sensory attributes associated with each INC. The objective of this literature review was to evaluate product characteristics, sensory attributes, and patient preferences of fluticasone furoate intranasal spray (FFNS) compared with other INCs.

METHODS

A narrative literature search for studies evaluating FFNS was performed in MEDLINE and Google Scholar. Key terms included "allergic rhinitis," "anti-allergic agents," "intranasal administration," "fluticasone furoate," and "patient preference." Studies published from 2007 to present were included. Nine trials met the search criteria, each evaluating FFNS versus placebo or other INCs for efficacy, safety, and/or preference, and were included. Approximately 2400 patients with AR were enrolled across varying study protocols.

FINDINGS

In 4 placebo-controlled trials, FFNS showed significant efficacy in relieving symptoms of AR and a tolerable safety profile. Three trials evaluating FFNS and fluticasone propionate nasal spray (FPNS) found that FFNS was significantly preferred over FPNS regarding scent, aftertaste, and leakage down the throat/nose. The results of 2 trials found that FFNS was preferred overall over mometasone furoate nasal spray (MFNS).

IMPLICATIONS

INCs are effective first-line treatments for AR and show significant reduction in nasal and ocular symptoms. Patients preferred the scent, aftertaste, and mist gentleness of FFNS ∼2:1 over the same sensory attributes of FPNS. Patients experienced less negative sensory characteristics with FFNS compared with MFNS, preferring FFNS to MFNS overall. Selecting an INC with favorable attributes in accordance with patient preferences could potentially improve adherence, therapeutic outcomes, and health care costs.

The complex pathophysiology of allergic rhinitis: scientific rationale for the development of an alternative treatment option

Allergic rhinitis (AR) poses a global health problem and can be challenging to treat. Many of the current symptomatic treatments for AR have been available for decades, yet there has been little improvement in patient quality of life or symptom burden over the years. In this review, we ask why this might be and explore the pathophysiological gaps that exist within the various AR treatment classes. We focus on the benefits and drawbacks of different treatment options and delivery routes for AR treatments and consider how, given what is known about AR pathophysiology and symptomatology, patients may be offered more effective treatment options for rapid, effective, and sustained AR control. In particular, we consider how a new AR preparation, MP-AzeFlu (Dymista^®, Meda, Sweden), comprising a formulation of an intranasal antihistamine (azelastine hydrochloride), an intranasal corticosteroid (fluticasone propionate), and excipients delivered in a single spray, may offer benefits over and above single and multiple AR therapy options. We review the evidence in support of this treatment across the spectrum of AR disease. The concept of AR control is also reviewed within the context of new European Union and Contre les Maladies Chroniques pour un VIeillissement Actif-Allergic Rhinitis and its Impact on Asthma initiatives.

The inferior turbinate: An autonomic organ

The inferior turbinate has well-recognized respiratory and immune functions to provide the airway with appropriate warmth, humidification, and filtration of the inspired air while sampling the environment for pathogens. Normal functioning of the inferior turbinate relies on an intact autonomic system to maintain homeostasis within the nasal cavity. The autonomic nervous system innervates the submucosal glands and the vasculature within the inferior turbinate, resulting in control of major turbinate functions: nasal secretions, nasal patency, warmth, and humidification. This review will summarize the autonomic innervations of the turbinates, both the normal and abnormal autonomic processes that contribute to the turbinate functions, and the clinical considerations regarding optimal functioning of the turbinate autonomic system.

Determinants of the Nasal Microbiome: Pilot Study of Effects of Intranasal Medication Use

Introduction

A role for bacteria and other microbes has long been suspected in the chronic inflammatory sinonasal diseases. Recent studies utilizing culture-independent, sequence-based identification have demonstrated aberrant shifts in the sinus microbiota of chronic rhinosinusitis subjects, compared with ostensibly healthy controls. Examining how such microbiota shifts occur and the potential for physician-prescribed interventions to influence microbiota dynamics are the topics of the current article.

Methods

The nasal cavity microbiota of 5 subjects was serially examined over an 8-week period using pan-bacterial 16S rRNA gene sequencing. Four of the subjects were administered topical mometasone furoate spray, while 1 subject underwent a mupirocin decolonization procedure in anticipation of orthopedic surgery.

Results

Measures of microbial diversity were unaffected by intranasal treatment in 2 patients and were markedly increased in the remaining 3. The increase in microbial diversity was related to clearance of Moraxella spp. and a simultaneous increase in members of the phylum Actinobacteria. Both effects persisted at least 2 weeks beyond cessation of treatment. Transient changes in the relative abundance of several bacterial genera, including Staphylococcus and Priopionibacteria, were also observed during treatment.

Conclusions

The effects of intranasal steroids on the sinonasal microbiome are poorly understood, despite their widespread use in treating chronic sinonasal inflammatory disorders. In this longitudinal study, administration of intranasal mometasone furoate or mupirocin resulted in shifts in microbial diversity that persisted to some degree following treatment cessation. Further characterization of these effects as well as elucidation of the mechanism(s) underlying these changes is needed.

Effects of H1 antihistamine addition to intranasal corticosteroid for allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

A combination of H1 antihistamine (AH) with intranasal corticosteroid (INCS) is commonly prescribed to patients with allergic rhinitis (AR) who have an inadequate response to monotherapy. In this systematic review we aimed to determine the effects of AH combined with INCS (AH-INCS) for treating AR.

METHODS

Literature searches were performed using Medline and Embase. Randomized, controlled trials that studied the effects of AH-INCS vs INCS monotherapy for treating patients with AR were included. The primary outcomes were total nasal symptom scores, total ocular symptom scores, and disease-specific quality of life. The secondary outcomes were objective tests for nasal patency and adverse events.

RESULTS

Sixteen studies (4026 patients) met the inclusion criteria. Compared with INCS, AH-INCS decreased total nasal symptom scores (standardized mean difference [SMD], -0.13; 95% confidence interval [CI], -0.19 to -0.06; p < 0.001; 10 trials, 3348 patients) and total ocular symptom scores (SMD, -0.12, 95% CI, -0.20 to -0.04; p = 0.003; 6 trials, 2378 patients). Subgroup analysis indicated no benefit with the oral AH-INCS combination but did show benefit with intranasal AH-INCS (SMD, -0.18; 95% CI, -0.27 to -0.09; p < 0.001). There were no significant differences with regard to disease-specific quality of life (SMD, -0.07; 95% CI, -0.16 to 0.02; p = 0.12; 6 trials, 1981 patients), nasal inspiratory flow (MD, -0.03 L/min; 95% CI, -0.57 to 0.50; p = 0.91; 1 trial, 54 patients), or adverse events.

CONCLUSION

Intranasal AH-INCS has benefit over INCS on nasal and ocular symptom improvement for treating AR. Oral AH-INCS is not recommended.

Local and Systemic Administration of Corticosteroids in the Treatment of Olfactory Loss

Background

The aim of this study was to evaluate the benefit of patients with olfactory dysfunction from local (group A) or systemic (group B) administration of corticosteroids.

Methods

This unblinded study was conducted at a smell and taste outpatient clinic of an institutional referral center. Patients with olfactory loss after infections of the upper respiratory tract, patients with apparent sinonasal disease, and patients suffering from “idiopathic” smell loss were included. Effects of mometasone nasal spray, administered for 1–3 months, were studied in 37 patients. In addition, effects of oral prednisolone were analyzed in 55 patients who received decreasing doses over 21 days, starting with a dose of 40 mg. Olfactory function before and after treatment was measured.

Results

Although odor identification scores tended to increase (p = 0.05), mometasone nasal spray did not significantly improve olfactory function, when looking at the entire group of patients or when analyzing the three diagnostic categories separately. In contrast, after systemic administration of corticosteroids, improvement of olfactory function was seen over all diagnostic categories (p < 0.001). Interestingly, olfactory function also improved in patients diagnosed with olfactory loss after upper respiratory tract infection (p = 0.05) and in patients initially diagnosed with “idiopathic” olfactory dysfunction (p = 0.008).

Conclusion

In many patients, local application of corticosteroids appears to have little or no positive effect on olfactory dysfunction, especially when considering long-term changes. Duration of disease, the patient's age/sex, or the presence of parosmia does not appear to predict the response to therapy with corticosteroids.

Causality Assessment of Olfactory and Gustatory Dysfunction Associated with Intranasal Fluticasone Propionate: Application of the Bradford Hill Criteria

Causality assessment is crucial to post-marketing pharmacovigilance and helps optimize safe and appropriate use of medicines by patients in the real world. Self-reported olfactory and gustatory dysfunction are common in the general population as well as in patients with allergic rhinitis and nasal polyposis. Intranasal corticosteroids, including intranasal fluticasone propionate (INFP), are amongst the most effective drugs indicated in the treatment of allergic rhinitis and nasal polyposis. While intranasal corticosteroids are associated with olfactory and gustatory dysfunction and are currently labeled for these adverse events, causality assessment has not been performed to date. Although there is no single widely accepted method to assess causality in pharmacovigilance, the Bradford Hill criteria offer a robust and comprehensive approach because nine distinct aspects of an observed potential drug–event association are assessed. In this literature-based narrative review, Hill’s criteria were applied to determine causal inference between INFP and olfactory and gustatory dysfunction.

Vitamin A maintains the airway epithelium in a murine model of asthma by suppressing glucocorticoid-induced leucine zipper

BACKGROUND

The effects of glucocorticoids (GCs) on the repair of the airway epithelium in asthma are controversial, and we previously reported that the GC dexamethasone (Dex) inhibits the repair of human airway epithelial cells and that this process is mediated by glucocorticoid-induced leucine zipper (GILZ) through MAPK-ERK signaling in vitro. Vitamin A (VA) is involved in the regulation of the MAPK-ERK pathway but has not been widely supplied during asthma treatment. It is unclear whether VA attenuates the negative regulation of GILZ on the MAPK-ERK pathway and maintains airway epithelium integrity during asthma treatment.

METHODS

Female BALB/c mice were sensitized and challenged with ovalbumin (OVA) and subsequently treated with Dex, VA or intranasal inhalation of adenovirus sh-GILZ vectors. Indexes of airway epithelium integrity, including pathological alterations, pulmonary EGFR expression and airway hyperresponsiveness (AHR), were then measured. The expression of GILZ and key components of activated MAPK-ERK signals (p-Raf-1, p-MEK, and p-Erk1/2) were also detected.

RESULTS

Dex failed to relieve OVA-induced asthma airway epithelium injury, as assessed through H&E staining, EGFR expression and AHR. Moreover, in the OVA-challenged mice treated with Dex, GLIZ expression was increased, whereas the ratios of p-Raf-1/Raf-1, p-MEK/MEK and p-Erk1/2/Erk1/2 were significantly decreased. Further study indicated that GILZ expression was decreased and that the ratios of p-Raf-1/Raf-1, p-MEK/MEK and p-Erk1/2/Erk1/2 were up-regulated in the GILZ-silenced OVA-challenged mice and VA-fed OVA-challenged mice, independent of Dex treatment. The airway epithelium integrity of the OVA-challenged mice was maintained by treatment with both VA and Dex.

CONCLUSIONS

Vitamin A maintained the Dex-treated asthma airway epithelium via the down-regulation of GILZ expression and the activation MAPK-ERK signaling, and these effects might contribute to improving the effects of GC therapeutics on asthma.

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial

IMPORTANCE

Acute sore throat poses a significant burden on primary care and is a source of inappropriate antibiotic prescribing. Corticosteroids could be an alternative symptomatic treatment.

OBJECTIVE

To assess the clinical effectiveness of oral corticosteroids for acute sore throat in the absence of antibiotics.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, placebo-controlled randomized trial (April 2013-February 2015; 28-day follow-up completed April 2015) conducted in 42 family practices in South and West England, enrolled 576 adults recruited on the day of presentation to primary care with acute sore throat not requiring immediate antibiotic therapy.

INTERVENTIONS

Single oral dose of 10 mg of dexamethasone (n = 293) or identical placebo (n = 283).

MAIN OUTCOMES AND MEASURES

Primary: proportion of participants experiencing complete resolution of symptoms at 24 hours. Secondary: complete resolution at 48 hours, duration of moderately bad symptoms (based on a Likert scale, 0, normal; 6, as bad as it could be), visual analog symptom scales (0-100 mm; 0, no symptom to 100, worst imaginable), health care attendance, days missed from work or education, consumption of delayed antibiotics or other medications, adverse events.

RESULTS

Among 565 eligible participants who were randomized (median age, 34 years [interquartile range, 26.0-45.5 year]; 75.2% women; 100% completed the intervention), 288 received dexamethasone; 277, placebo. At 24 hours, 65 participants (22.6%) in the dexamethasone group and 49 (17.7%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 4.7% (95% CI, -1.8% to 11.2%) and a relative risk of 1.28 (95% CI; 0.92 to 1.78; P = .14). At 24 hours, participants receiving dexamethasone were not more likely than those receiving placebo to have complete symptom resolution. At 48 hours, 102 participants (35.4%) in the dexamethasone group vs 75 (27.1%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 8.7% (95% CI, 1.2% to 16.2%) and a relative risk of 1.31 (95% CI, 1.02 to 1.68; P = .03). This difference also was observed in participants not offered delayed antibiotic prescription, for a risk difference of 10.3% (95% CI, 0.6% to 20.1%) and a relative risk of 1.37 (95% CI, 1.01 to 1.87; P = .046). There were no significant differences in any other secondary outcomes.

CONCLUSIONS AND RELEVANCE

Among adults presenting to primary care with acute sore throat, a single dose of oral dexamethasone compared with placebo did not increase the proportion of patients with resolution of symptoms at 24 hours. However, there was a significant difference at 48 hours.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN17435450.

Use of intranasal corticosteroids in adenotonsillar hypertrophy

Objectives:

This review examined the efficacy of intranasal corticosteroids for improving adenotonsillar hypertrophy.

Method:

The related literature was searched using PubMed and Proquest Central databases.

Results:

Adenotonsillar hypertrophy causes mouth breathing, nasal congestion, hyponasal speech, snoring, obstructive sleep apnoea, chronic sinusitis and recurrent otitis media. Adenoidal hypertrophy results in the obstruction of nasal passages and Eustachian tubes, and blocks the clearance of nasal mucus. Adenotonsillar hypertrophy and obstructive sleep apnoea are associated with increased expression of various mediators of inflammatory responses in the tonsils, and respond to anti-inflammatory agents such as corticosteroids. Topical nasal steroids most likely affect the anatomical component by decreasing inspiratory upper airway resistance at the nasal, adenoidal or tonsillar levels. Corticosteroids, by their lympholytic or anti-inflammatory effects, might reduce adenotonsillar hypertrophy. Intranasal corticosteroids reduce cellular proliferation and the production of pro-inflammatory cytokines in a tonsil and adenoid mixed-cell culture system.

Conclusion:

Intranasal corticosteroids have been used in adenoidal hypertrophy and adenotonsillar hypertrophy patients, decreasing rates of surgery for adenotonsillar hypertrophy.

Nasal inflammation and its response to local glucocorticoid regular treatment in patients with persistent non-allergic rhinitis: a pilot study

BACKGROUND

The pathogenesis of non-allergic rhinitis (NAR) is still largely unknown. Furthermore, it is unclear whether there is a correlation between the effect of nasal glucocorticoids on nasal inflammation and on nasal symptoms and quality of life.

METHODS

In this pilot study we recruited 12 healthy subjects and 24 patients with recently diagnosed persistent NAR [12 untreated and 12 under regular treatment with nasal fluticasone furoate (two sprays of 27.5 μg each in each nostril once daily, total daily dose = 110 μg) for at least 20 days]. Each subject filled a mini rhinoconjunctivitis quality of life questionnaire (mini RQLQ). Nasal scrapings were obtained from each subject and used to prepare slides for Diff-Quik and immunocytochemical staining for inflammatory and epithelial cells count, MUC5AC expression and the general pro-inflammatory transcription factor nuclear factor kB (NF-kB) activation.

RESULTS

The nasal score of the mini RQLQ, the number of nasal inflammatory cells (neutrophils, eosinophils) and the number of goblet cells are significantly higher in untreated patients with persistent NAR compared with control subjects and treated NAR patients. The percentage of MUC5AC+ nasal epithelial cells is significantly increased in untreated patients with persistent NAR compared with the control subjects (41.8 ± 6.4 vs 22.3 ± 4.8, respectively; p = 0.0403) without significant differences between control subjects and patients with persistent NAR on regular fluticasone furoate treatment (33.9 ± 5.0 %; p = 0.0604) nor between the 2 groups of persistent NAR subjects (p = 0.3260). The number of cytosolic and/or nuclear p65+ nasal epithelial and inflammatory cells was not significantly different between the three groups.

CONCLUSIONS

Patients with persistent untreated NAR, compared with normal control subjects and patients with persistent NAR under regular treatment with nasal fluticasone furoate by at least 20 days, have more nasal symptoms, worst quality of life and an increased number of nasal inflammatory cells (neutrophils, eosinophils), goblet cells and MUC5AC+ nasal epithelial cells. This nasal inflammation seems unrelated to NF-kB activation.

Anti-inflammatory effects of intranasal cyclosporine for allergic rhinitis in a mouse model

BACKGROUND

Although topical corticosteroids are considered a safe and effective drug for allergic rhinitis (AR), some AR patients do not show sufficient symptomatic improvement by use of topical corticosteroids. Topical cyclosporine is a safe and effective drug for patients with allergic conjunctivitis, particularly for those with steroid-resistant allergic conjunctivitis. We investigated the anti-inflammatory effects of intranasal cyclosporine for AR using a mouse model.

METHODS

After establishment of allergic inflammation in 5-week-old BALB/c mice, cyclosporine was administered intranasally 3 times per week for 2 weeks. To confirm its anti-inflammatory effects, triamcinolone acetonide (TAC) was utilized as a control drug. Histopathologic changes were evaluated using Sirius red and Giemsa staining for eosinophilic and mast cell infiltration, respectively. The levels of cytokines in sinonasal tissues, including tumor necrosis factor (TNF), interleukin (IL)-4, IL-5, and IL-13, were assessed based on a cytometric bead array.

RESULTS

The degree of eosinophilic infiltration was significantly decreased by instillation of cyclosporine, the potency being similar to TAC. However, the number of mast cells was not decreased by cyclosporine or TAC. The levels of TNF, IL-4, IL-5, and IL-13 were significantly decreased after treatment with cyclosporine.

CONCLUSION

The anti-inflammatory effects of topical cyclosporine for AR were equivalent to those of topical corticosteroids. Topical cyclosporine may be useful for the treatment of AR, although human studies are required.

Intranasal corticosteroids for nasal polyposis : biological rationale, efficacy, and safety

Nasal polyposis, occurring in about 2% of the general population, is the ultimate form of inflammation of the upper airways. For unknown reasons, polyps develop preferentially in subtypes of inflammatory diseases and are associated with perennial non-allergic rhinitis, asthma, intolerance of aspirin (acetylsalicylic acid)/NSAIDs, allergic fungal rhinosinusitis, cystic fibrosis, and primary ciliary dyskinesia. In contrast to common beliefs, IgE-mediated allergy does not seem to play an etiological role in nasal polyposis.The polyps originate from the mucosa around the clefts of the lateral nasal wall, especially in the region of the ostiomeatal complex. The factors that determine the localization of the disease to a few square centimeters of the airways are not known.Polyps are edematous bags covered by respiratory epithelium and contain very few nerves, blood vessels, and glands that have undergone cystic degeneration. They contain degranulated mast cells, have a very high concentration of histamine, and are characteristically infiltrated by eosinophils. These cells accumulate due to the release of proinflammatory cytokines (in particular, interleukin-5).Nasal polyposis is preceded by a prolonged history of rhinitis accompanied by severe and persistent nasal blockage; typically, the sense of smell is seriously impaired when polyps develop. The diagnosis is based on anterior rhinoscopy or, preferably, endoscopy.Nasal polyposis is medically treatable. Surgical treatment is carried out when medication fails. Intranasal corticosteroids reduce rhinitis symptoms, improve nasal breathing, reduce the size of polyps, and prevent, in part, their recurrence, but this treatment has little effect on the sense of smell. Intranasal corticosteroids can, as basic long-term therapy, be used alone in mild cases or together with systemic corticosteroids and/or surgery in severe cases. Systemic corticosteroids administered for 2-3 weeks have a beneficial effect on all observed symptoms and pathology, including the sense of smell. When nasal blockage is a problem in spite of medical treatment, surgery is recommended. Simple polypectomy can be performed, but endoscopic surgery is recommended in more severe and persistent cases.

Corticosteroids for the common cold

BACKGROUND

The common cold is a frequent illness, which, although benign and self limiting, results in many consultations to primary care and considerable loss of school or work days. Current symptomatic treatments have limited benefit. Corticosteroids are an effective treatment in other upper respiratory tract infections and their anti-inflammatory effects may also be beneficial in the common cold. This updated review has included one additional study.

OBJECTIVES

To compare corticosteroids versus usual care for the common cold on measures of symptom resolution and improvement in children and adults.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 4), which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) (2015, Issue 2), NHS Health Economics Database (2015, Issue 2), MEDLINE (1948 to May week 3, 2015) and EMBASE (January 2010 to May 2015).

SELECTION CRITERIA

Randomised, double-blind, controlled trials comparing corticosteroids to placebo or to standard clinical management.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We were unable to perform meta-analysis and instead present a narrative description of the available evidence.

MAIN RESULTS

We included three trials (353 participants). Two trials compared intranasal corticosteroids to placebo and one trial compared intranasal corticosteroids to usual care; no trials studied oral corticosteroids. In the two placebo-controlled trials, no benefit of intranasal corticosteroids was demonstrated for duration or severity of symptoms. The risk of bias overall was low or unclear in these two trials. In a trial of 54 participants, the mean number of symptomatic days was 10.3 in the placebo group, compared to 10.7 in those using intranasal corticosteroids (P value = 0.72). A second trial of 199 participants reported no significant differences in the duration of symptoms. The single-blind trial in children aged two to 14 years, who were also receiving oral antibiotics, had inadequate reporting of outcome measures regarding symptom resolution. The overall risk of bias was high for this trial. Mean symptom severity scores were significantly lower in the group receiving intranasal steroids in addition to oral amoxicillin. One placebo-controlled trial reported the presence of rhinovirus in nasal aspirates and found no differences. Only one of the three trials reported on adverse events; no differences were found. Two trials reported secondary bacterial infections (one case of sinusitis, one case of acute otitis media; both in the corticosteroid groups). A lack of comparable outcome measures meant that we were unable to combine the data.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only three trials, one of which was very poor quality, and there was limited statistical power overall. Further large, randomised, double-blind, placebo-controlled trials in adults and children are required to answer this question.

Oral corticosteroid use for clinical and cost-effective symptom relief of sore throat: study protocol for a randomized controlled trial

BACKGROUND

Management of acute sore throat poses a significant burden on UK general practices, with almost 10% of registered patients attending their GP with sore throat every year. Nearly half of all patients presenting with acute sore throat are treated with antibiotics, despite their limited effect. In a recent systematic review we demonstrated that a single dose of steroids reduced the severity and time to resolution of sore throat. However, all of the trials included looked at the use of steroids alongside antibiotics and only one was in a primary care setting. This trial aims to assess the efficacy and cost-effectiveness of a single oral dose of corticosteroids on symptoms of sore throat in patients receiving either a delayed antibiotic prescription or no antibiotics at all in UK primary care.

METHODS/DESIGN

A double-blind, two arm, randomized, placebo controlled trial in adults (≥ 18 years of age) presenting to primary care with acute sore throat (

DISCUSSION

This will be the first randomized controlled trial of oral corticosteroids in adults presenting to primary care with sore throat in the UK, and the first to examine the clinical and cost-effectiveness of oral corticosteroids for the treatment of sore throat in the absence of antibiotics.

TRIAL REGISTRATION

This trial is registered with Current Controlled Trials on 26 March 2013, registration number: ISRCTN17435450.

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Key Words

• sore throat
• steroid
• antibiotics
• delayed antibiotic prescription
• dexamethasone
• same day recruitment
• adults
• randomized
• placebo-controlled

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MESH Headings

• Administration, Oral
• Adrenal Cortex Hormones/administration & dosage
• Adrenal Cortex Hormones/economics
• Anti-Bacterial Agents/administration & dosage
• Clinical Protocols
• Cost-Benefit Analysis
• Dexamethasone/administration & dosage
• Dexamethasone/economics
• Double-Blind Method
• Drug Costs
• Drug Therapy, Combination
• England
• Female
• Humans
• Male
• Pharyngitis/diagnosis
• Pharyngitis/drug therapy
• Pharyngitis/economics
• Pharyngitis/microbiology
• Primary Health Care/economics
• Research Design
• Time Factors
• Treatment Outcome
• Unnecessary Procedures/economics

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Grants

• NIHR-RP-02-12-012 Department of Health

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Affiliation(s)

Johanna Cook />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Gail Hayward />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Matthew Thompson />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK />Department of Family Medicine, University of Washington, 1959 Ne Pacific St, Seattle, WA 98195 USA
Alastair D Hay />Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
Michael Moore />Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST UK
Paul Little />Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST UK
Kim Harman />Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
Jane Wolstenholme />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Rafael Perera />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Merryn Voysey />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Julie Allen />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Maria Breen />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Carl Heneghan />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK

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Current recommendations and emerging options for the treatment of allergic rhinitis

Allergic rhinitis (AR) is one of the most common diseases and represents a global health problem, currently affecting up to 30% of the general population, with a continuously increasing prevalence and significant comorbidities and complications. The aim of this review is to provide an update on AR treatment, with a focus on current therapies defined by AR and its impact on asthma guidelines and with a particular emphasis on new and future therapeutic perspectives.

The normative value of inflammatory cells in the nasal perfusate of Chinese adults: a pilot study

OBJECTIVE

To establish stable, well-accepted nasal perfusion and a normative value of classifying cells in the nasal perfusate of Chinese adults.

METHODS

A total of 500 healthy adults were divided into two groups of 250 people per group (group A, 16-30 years old and group B, 31-60 years old; male-to-female ratio, 1:1). All volunteers were non-smokers; they were irrigated with saline, and multiple inflammatory cells in the perfusate were analyzed.

RESULTS

Irrigation was successfully performed in 479 cases, a success rate of 95.80%. The types of inflammatory cells showed a skewed distribution. The median number and interquartile range (IQR) of eosinophils were 0 and 0.2, respectively. These values were 0.4 and 2.2, respectively, for neutrophils and 0 and 0, respectively, for both lymphocytes and macrophages. There was no significant difference between males and females (P>0.05). There was a significant difference in the numbers of neutrophils and lymphocytes in the different age groups (P=0.000), but there was no significant difference in the numbers of eosinophils and macrophages (P>0.05). The 95% unilateral upper limited values (UULVs) of eosinophils and neutrophils in the nasal perfusates were 2.99 and 14.94, respectively, for group A and 1.41 and 17.08 for group B. As a result, the total 95% UULVs of eosinophils and neutrophils in the nasal perfusate were 2.00 and 16.80.

CONCLUSIONS

We established stable, well-accepted nasal perfusions and normal values for classifying the cells in the nasal perfusate of Chinese adults; the normative values of the inflammatory cells in nasal perfusate are 2.00 for the 95% UULV of eosinophils and 16.80 for neutrophils. Age might be one of the factors affecting the cells in rhinitis.

Azelastine and budesonide (nasal sprays): Effect of combination therapy monitored by acoustic rhinometry and clinical symptom score in the treatment of allergic rhinitis

The aim of this study was to objectively evaluate the effects of intranasal therapy with azelastine (AZE), budesonide (BUD), and combined AZE plus BUD (AZE/BUD) using a nasal provocation test (NPT) and acoustic rhinometry in patients with allergic rhinitis. A randomized, single-blind, crossover study with three treatment sequences was used. Thirty patients with persistent AR received the three treatments using a nasal spray twice daily for 30 days and were evaluated by an NPT with histamine before and after each period of treatment. The treatment comparison, assessed by the nasal responsiveness to histamine, was monitored based on subjective (symptom score) and objective parameters (acoustic rhinometry). The minimal cross-area 2 (MCA2) was measured by acoustic rhinometry at 1, 4, 8, and 12 minutes after NPT for each histamine concentration administered (0.5, 1, 2, 4, and 6 mg/mL) up to at least a 20% reduction in the MCA2 from baseline (NPT₂₀). The subjects were scored regarding nasal response encompassing histamine dose and time after histamine administration that caused nasal obstruction (NPT₂₀ score) to assess the treatments' effects. Combination therapy produced a significant increase in baseline MCA2, viz., the improvement of nasal patency (p = 0.005). The symptoms score was significantly decreased after treatment with AZE (p = 0.03), BUD (p < 0.0001), and AZE/BUD (p < 0.0001), compared with pretreatment. The NPT₂₀ score was significantly higher (p = 0.0009) after AZE/BUD, compared with AZE and BUD on their own. Thus, AZE therapy combined with BUD might provide more therapeutic benefits than the isolated drugs for improving nasal patency.

Systemic corticosteroids for acute sinusitis

BACKGROUND

Acute sinusitis is the inflammation and swelling of the nasal and paranasal mucous membranes and is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.

OBJECTIVES

To assess the effects of systemic corticosteroids on clinical response rates and to determine adverse effects and relapse rates of systemic corticosteroids compared to placebo or standard clinical care in children and adults with acute sinusitis.

SEARCH METHODS

We searched CENTRAL (2014, Issue 1), MEDLINE (1966 to February week 1, 2014) and EMBASE (January 2009 to February 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of the trials and extracted data.

MAIN RESULTS

Five RCTs with a total of 1193 adult participants met our inclusion criteria. We judged methodological quality to be moderate in four trials and high in one trial. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in four trials and non-steroidal anti-inflammatory drugs (NSAIDs) in one trial). In four trials antibiotics were prescribed in addition to oral corticosteroids or control treatment, while one trial investigated the effects of oral corticosteroids as a monotherapy.When combining data from the five trials, participants treated with oral corticosteroids were more likely to have short-term resolution or improvement of symptoms than those receiving the control treatment: at days three to seven (risk ratio (RR) 1.3, 95% confidence interval (CI) 1.1 to 1.6; risk difference (RD) 17%, 95% CI 6% to 29%) and at days four to 14 (RR 1.2, 95% CI 1.0 to 1.5; RD 14%, 95% CI 1% to 27%). A sensitivity analysis including the four trials with placebo as a control treatment showed similar results but with a lesser effect size: at days three to seven (RR 1.2, 95% CI 1.1 to 1.3; RD 11%, 95% CI 4% to 17%) and days four to 14 (RR 1.1, 95% CI 1.0 to 1.2; RD 8%, 95% CI 2% to 13%). Statistical heterogeneity was high for many analyses. Subgroup analyses revealed that corticosteroid monotherapy had no beneficial effects. Furthermore, scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst-case scenario showed no statistically significant beneficial effect of oral corticosteroids). No trial reported effects on relapse or recurrence rates. Reported side effects in patients treated with oral corticosteroids were mild (nausea, vomiting, gastric complaints) and did not significantly differ from those receiving placebo.

AUTHORS' CONCLUSIONS

Oral corticosteroids as a monotherapy appear to be ineffective for adult patients with clinically diagnosed acute sinusitis. Current data on the use of oral corticosteroids as an adjunctive therapy to oral antibiotics are limited: almost all trials are performed in secondary care settings and there is a significant risk of bias. This limited evidence suggests that oral corticosteroids in combination with antibiotics may be modestly beneficial for short-term relief of symptoms in acute sinusitis, with a number needed to treat to benefit of seven for resolution or symptom improvement. A large primary care factorial trial is needed to establish whether oral corticosteroids offer additional benefits over antibiotics in acute sinusitis.

Intranasal steroids for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school.

OBJECTIVES

We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop-outs before the end of the study, rates of relapse, complications and return to school or work.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus.

MAIN RESULTS

No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well-designed and double-blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow-up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta-analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS.

AUTHORS' CONCLUSIONS

Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy.

The management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a clinicopathologic, chronic esophageal inflammatory disease resistant to acid suppressive therapy and is associated with variable symptoms indicative of upper gastrointestinal dysfunction. Per current guidelines established by The International Group of Eosinophil Researchers (TIGERS), the diagnosis is made in symptomatic patients after a biopsy that confirms a peak eosinophil level of ≥15 eosinophils/high-powered field (HPF). The esophagus is distinguished by pronounced tissue eosinophilia in which dietary antigens are key inciting factors for disease pathogenesis; EoE being reversed by elimination of triggering food allergens suggests that the disease is mediated in part by allergic sensitization to foods. Moreover, experimental EoE in mice can be induced not only via food exposure but also via aeroallergen exposure. Consistent with an allergic etiology rather than an acid-induced esophagitis, swallowed glucocorticoids are effective for the treatment of EoE. Evaluation by an allergist is a recommended part of the diagnostic workup, especially for management of allergic comorbidities. Clinical practice for the evaluation of patients with EoE mainly relies on prick skin tests due to the ease and validation of these tests in the context of immediate hypersensitivity. However, both atopy patch testing and serum IgE testing have been used in EoE. Herein, we reviewed the basic clinical features of EoE with a focus on the approach to diagnosing causative food allergens and to dietary therapy.

Safety, Tolerability, and Exposure of Ciclesonide Nasal Spray in Healthy and Asymptomatic Subjects With Seasonal Allergic Rhinitis

Ciclesonide is an intranasal corticosteroid in development for the treatment of allergic rhinitis. To assess the safety, tolerability, and pharmacokinetics of ciclesonide, adult healthy volunteers and asymptomatic subjects with seasonal allergic rhinitis were randomized to receive intranasal ciclesonide or placebo for 14 days. Serum concentrations of ciclesonide and its active metabolite, desisobutyryl-ciclesonide, were measured using high-performance liquid chromatography assay with tandem mass spectrometric detection, with lower limits of quantification of 25 and 10 pg/mL, respectively. Adrenal function was monitored by diurnal serum free and 24-hour urine cortisol concentrations. Despite the use of a sensitive assay and a high ciclesonide dose (800 microg/d), serum levels of ciclesonide and desisobutyryl-ciclesonide were below the lower limits of quantification for the majority of samples assayed. Ciclesonide was well tolerated and did not appear to affect serum or urine free cortisol levels. The low systemic exposure and favorable safety profile support the continued clinical development of ciclesonide nasal spray.

Corticosteroids as standalone or add-on treatment for sore throat

BACKGROUND

Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract.

OBJECTIVES

To assess the clinical benefit and safety of corticosteroids for symptoms of sore throat in adults and children.

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 5) which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects and the NHS Health Economics Database, MEDLINE (1966 to November Week 4, 2012) and EMBASE (1974 to June 2012).

SELECTION CRITERIA

We included randomised controlled trials that compared steroids to either placebo or standard care in adults and children (older than three years of age) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis, sore throat following tonsillectomy or intubation, or peritonsillar abscess.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed and selected trials from searches, assessed and rated study quality, and extracted relevant data.

MAIN RESULTS

We included eight trials involving 743 participants (369 children and 374 adults). All trials gave antibiotics to both placebo and corticosteroid groups; no trials assessed corticosteroids as standalone treatment for sore throat. In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by more than three times (risk ratio (RR) 3.2, 95% confidence interval (CI) 2.0 to 5.1, P < 0.001, I(2) statistic 44%) and at 48 hours by 1.7 times. Fewer than four people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 14 hours, respectively, although significant heterogeneity was present. At 24 hours, pain (assessed by visual analogue scores) was reduced by an additional 14% by corticosteroids. No difference in rates of recurrence, relapse or adverse events were reported for participants taking corticosteroids compared to placebo, although reporting of adverse events was poor.

AUTHORS' CONCLUSIONS

Oral or intramuscular corticosteroids, in addition to antibiotics, increase the likelihood of both resolution and improvement of pain in participants with sore throat. Further trials assessing corticosteroids in the absence of antibiotics and in children are warranted.

No evidence for the effectiveness of systemic corticosteroids in acute pharyngitis, community-acquired pneumonia and acute otitis media

Corticosteroids have been used to treat infectious diseases for more than 50 years but, although it has been shown that they are highly effective in improving the clinical course of some diseases, their effects have not been clearly defined in others. Nevertheless, they are still used by a considerable number of physicians. This review analyses the role of systemic corticosteroids in the treatment of acute pharyngitis (AP), community-acquired pneumonia (CAP) and acute otitis media (AOM). A number of trials involving patients with AP have been carried out, but most are marred by methodological flaws that do not allow any firm conclusions to be drawn. The number of trials involving CAP patients is even higher, and the data suggest that corticosteroids may reduce the risk of death only in patients with severe disease. There are very few data concerning AOM, and there is currently no reason for prescribing corticosteroids to treat it. Overall, the data showed that there is, currently, no indication for the universal use of systemic corticosteroids in any of the reviewed diseases and, further, high-quality studies of all of these respiratory tract infections are needed in order to identify the patients for whom the prescription of corticosteroids is rationally acceptable.

Corticosteroids for the common cold

BACKGROUND

The common cold is a frequent illness, which, although benign and self-limiting, results in many consultations to primary care and considerable loss of school or work days. Current symptomatic treatments have limited benefit. Corticosteroids are an effective treatment in other upper respiratory tract infections and their anti-inflammatory effects may also be beneficial in the common cold.

OBJECTIVES

To compare corticosteroids versus usual care for the common cold on clinical response rates in children and adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 5 which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) 2012, Issue 4 and the NHS Health Economics Database 2012, Issue 5; MEDLINE (1948 to May week 2, 2012) and EMBASE (January 2010 to May 2012).

SELECTION CRITERIA

Randomised, double-blind, controlled trials comparing corticosteroids to placebo or to standard clinical management.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We were unable to perform meta-analysis and instead analysed results using narrative description of the available evidence.

MAIN RESULTS

We included two trials (253 participants). Both compared intranasal corticosteroids to placebo; no trials studied oral corticosteroids. No benefit of intranasal corticosteroids was demonstrated for duration or severity of symptoms. In one trial of 54 participants, the number of symptomatic days was 10.3 in the placebo group, compared to 10.7 in those using intranasal corticosteroids (P = 0.72). A second trial of 199 participants reported no significant differences in duration of symptoms. There were no differences reported in terms of: adverse events; complications (one case of sinusitis, one case of acute otitis media, both in corticosteroid groups); presence of rhinovirus in nasal aspirates; or treatment for secondary infections. Neither trial reported our primary outcome measure of percentage of participants with resolution at different time points. A lack of comparable outcome measures meant we were unable to combine the data.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only two trials and limited statistical power. Further large randomised placebo-controlled trials in adults and children are required to answer this question.

Effects of intranasal mometasone furoate on itchy ear and palate in patients with seasonal allergic rhinitis

BACKGROUND

Intranasal steroids relieve nasal symptoms and ocular itch in allergic rhinitis. Itchy ear and palate are also common and bothersome symptoms but have received little attention in clinical trials of allergic rhinitis.

OBJECTIVE

To ascertain the efficacy of mometasone furoate nasal spray in alleviating itchy ear and palate in seasonal allergic rhinitis.

METHODS

Data were pooled from 4 randomized, double-blind, placebo-controlled trials of mometasone furoate nasal spray, 200 μg/d. Participants rated ear and palate itching from baseline through treatment day 15 as follows: 0, none; 1, mild; 2, moderate; and 3, severe.

RESULTS

A total of 962 study participants received mometasone furoate nasal spray or placebo. Baseline least squares mean itchy ear and palate score was 1.81 for participants receiving mometasone furoate nasal spray (n = 480) and 1.85 for participants receiving placebo (n = 482). Mometasone furoate nasal spray was associated with a greater decrease in itchy and ear palate score vs placebo during the 15-day study period (least squares mean change, -0.73 vs -0.45; P < .001). The difference reached significance on day 2 and persisted through day 15 (P ≤ .01 for each day). Results were similar in a subgroup of patients (n = 305) with moderate-to-severe symptoms at baseline. Adverse events with mometasone furoate nasal spray were similar to those observed in other studies of intranasal steroid therapy.

CONCLUSION

These preliminary findings suggest that mometasone furoate nasal spray effectively treats itchy ear and palate in individuals with seasonal allergic rhinitis. Itchy ear and palate is a relevant end point for future clinical trials of allergic rhinitis.

Systemic corticosteroids for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.

OBJECTIVES

To assess the effectiveness of systemic corticosteroids in relieving symptoms of acute sinusitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2011, which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) and the NHS Health Economics Database, MEDLINE (1966 to June week 2, 2011) and EMBASE (January 2009 to June 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality of the trials and extracted data.

MAIN RESULTS

Four RCTs with a total of 1008 adult participants met our inclusion criteria. We judged studies to be of moderate methodological quality. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants received oral antibiotics and were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in three trials and non-steroidal anti-inflammatory drugs (NSAIDs) in one trial). In all trials, participants treated with oral corticosteroids were more likely to have short-term resolution or improvement of symptoms than those receiving the control treatment: at Days 3 to 7, risk ratio (RR) 1.4, 95% CI 1.1 to 1.8; risk difference (RD) 20% (6% to 34%) and at Days 4 to 10 or 12, RR 1.3, 95% CI (1.0 to 1.7), RD 18% (3% to 33%). An analysis of the three trials with placebo as a control treatment showed similar results but with a lesser effect size: Days 3 to 6: RR 1.2, 95% CI (1.1 to 1.4), RD 12% (5% to 19%) and Days 4 to 10 or 12: RR 1.1, 95% CI (1.0 to 1.2), RD 10% (3% to 16%). Scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst-case scenario showed no statistically significant beneficial effect of oral corticosteroids). We did not identify any data on the long-term effects of oral corticosteroids on this condition, such as effects on relapse or recurrence rates. Reported side effects of oral corticosteroids were limited and mild.

AUTHORS' CONCLUSIONS

Current evidence suggests that oral corticosteroids as an adjunctive therapy to oral antibiotics are effective for short-term relief of symptoms in acute sinusitis. However, data are limited and there is a significant risk of bias. High quality trials assessing the efficacy of systemic corticosteroids both as an adjuvant and a monotherapy in primary care patients with acute sinusitis should be initiated.

Intranasal steroids in the treatment of allergy-induced rhinorrhea

While nasal congestion has been identified as one of the most bothersome and prevalent symptoms of allergic rhinitis, it is underappreciated that many patients find rhinorrhea also to be bothersome. Rhinorrhea as a symptom of allergic rhinitis virtually never occurs alone; about 97% of patients with allergic rhinitis suffer from at least two symptoms, a finding that underscores the advantage of treating a broad range of symptoms with a single medication. Along with sneezing and nasal obstruction, rhinorrhea is a classic acute symptom of allergic rhinitis; it appears as a late-phase symptom as well. In this review, the characterization and epidemiology of rhinorrhea, the pathophysiology of rhinorrhea in allergic rhinitis, the roles played by mediators in early- and late-phase rhinorrhea, the prevalence and impact of this symptom, and the efficacy and safety of available treatment options are all discussed in context of relevant literature. A review of the clinical studies assessing the efficacy of intranasal corticosteroids (INS) for rhinorrhea is presented. Many clinical studies and several meta-analyses conclusively demonstrate that, in addition to being safe and well-tolerated, INS are more effective than other agents (including oral and intranasal antihistamines) across the spectrum of AR symptoms, including rhinorrhea and nasal congestion.

A pathway-based approach to find novel markers of local glucocorticoid treatment in intermittent allergic rhinitis

BACKGROUND

Glucocorticoids (GCs) may affect the expression of hundreds of genes in different cells and tissues from patients with intermittent allergic rhinitis (IAR). It is a formidable challenge to understand these complex changes by studying individual genes. In this study, we aimed to identify (i) pathways affected by local GC treatment and (ii) examine if those pathways could be used to find novel markers of local GC treatment in nasal fluids from patients with IAR.

METHODS

Gene expression microarray- and iTRAQ-based proteomic analyses of nasal fluids, nasal fluid cells and nasal mucosa from patients with IAR were performed to find pathways enriched for differentially expressed genes and proteins. Proteins representing those pathways were analyzed with ELISA in an independent material of nasal fluids from 23 patients with IAR before and after treatment with a local GC.

RESULTS

Transcriptomal and proteomic high-throughput analyses of nasal fluids, nasal fluid cells and nasal mucosal showed that local GC treatment affected a wide variety of pathways in IAR such as the glucocorticoid receptor pathway and the acute phase response pathway. Extracellular proteins encoded by genes in those pathways were analyzed in an independent material of nasal fluids from patients. Proteins that changed significantly in expression included known biomarkers such as eosinophil cationic protein but also proteins that had not been previously described in IAR, namely CCL2, M-CSF, CXCL6 and apoH.

CONCLUSION

Pathway-based analyses of genomic and proteomic high-throughput data can be used as a complementary approach to identify novel potential markers of GC treatment in IAR.

To treat snoring with nasal steroids - effects on more than one level?

CONCLUSION

An inflammatory swelling in the uvula and nose due to vibration might be a contributing factor in snoring. The presence of corticosteroid receptors in the uvula indicates the possibility for treatment with local steroids. Use of mometasone furoate (MF) for 3 months reduced snoring and related symptoms in some patients.

OBJECTIVE

To investigate the effect of a nasal steroid, MF, on snoring and related discomfort.

SUBJECTS AND METHODS

In the first part of the study, uvular and nasal biopsies from six patients with social snoring were examined using immunohistochemistry to evaluate whether corticosteroid receptors were present. Then 100 snoring patients were invited to participate in the second part of the study. In all, 72 men and 22 women with a mean age of 47 years and BMI 27 answered a questionnaire about symptoms, had ENT status assessed and reported sleep and related variables for a 7 day period. After randomization to placebo or MF, they used a nasal spray for 3 months at a dosage of 200 microg. Thereafter the procedure was repeated.

RESULTS

Corticosteroid receptors were present in the mucous membranes and around the blood vessels in all uvulas examined. A total of 84 patients were evaluated. No decrease in 'mean snoring score' was seen. Daytime sleepiness showed a slight improvement in the MF group and partners were less disturbed. Minor side effects were equal for both groups.

Bepotastine besilate ophthalmic solution for the relief of nonocular symptoms provoked by conjunctival allergen challenge

BACKGROUND

Bepotastine besilate is a selective histamine1-receptor antagonist and mast cell stabilizer with inhibitory effects on eosinophilic activity.

OBJECTIVE

To evaluate the safety and efficacy of 1.5% bepotastine besilate ophthalmic solution in alleviating nonocular symptoms induced by a conjunctival allergen challenge (CAC), a clinical model of allergic conjunctivitis.

METHODS

This was a single-center, double-masked, randomized, placebo-controlled clinical trial performed from March 1 to April 4, 2007. Patients 10 years or older with a history of allergic conjunctivitis and a reproducible, positive, clinical response to a CAC were eligible. Patients received either placebo or 1.5% bepotastine besilate, 1 drop in each eye. After 15 minutes, 8 hours, or 16 hours after dosing, a CAC was performed and patients evaluated nonocular symptoms using standardized grading scales.

RESULTS

Seventy-one patients were enrolled in the study, and 66 comprised the per protocol population. A clinically meaningful reduction (> or = 1.0 unit) compared to placebo was achieved for rhinorrhea and nasal congestion at most time points after 1.5% bepotastine besilate instillation at 8 hours before a CAC test. Significant reductions (P < or = .05) in mean values were seen with 1.5% bepotastine besilate at 15 minutes and 8 hours after dosing for CAC-induced nasal congestion, rhinorrhea, ear or palate pruritus, nasal pruritus, and summed nonocular composite symptom (NOCS) scores and also at 16 hours after dosing for nasal congestion and rhinorrhea.

CONCLUSIONS

The 1.5% bepotastine besilate formulation produced statistically significant reductions after a CAC in individual nonocular symptoms and NOCS scores at onset of allergic response and for at least 8 hours after instillation, with the greatest reduction seen for nasal congestion and rhinorrhea.

Impact of baseline nasal polyp size and previous surgery on efficacy of fluticasone delivered with a novel device: a subgroup analysis

BACKGROUND

Little information exists on the impact of baseline polyp size and previous nasal surgery on the efficacy of intranasal steroids. This study was designed to investigate whether baseline polyp size and previous nasal surgery influence the efficacy of an intranasal steroid delivered with a novel device.

METHODS

A post hoc analysis of recently published results with intranasal administration using a novel bidirectional delivery device containing fluticasone propionate (Opt-FP) was performed in 109 patients with mild-to-moderate bilateral polyposis. Patients were allocated to subgroups based on summed polyp score at baseline (2, 3, or 4) and on their history of previous sinus surgery.

RESULTS

A highly significant and progressive reduction in summed polyp size was observed for Opt-FP versus placebo in all three polyp size subgroups (p < 0.001). A greater relative reduction in polyp size (p < 0.05) and an increase in peak nasal inspiratory flow (p < 0.001) were observed for Opt-FP at 12 weeks in the 28 patients with a baseline summed score of 3 and 4 compared with the 27 with a summed score of 2. Nevertheless, in patients with small polyps at baseline, the polyps were completely resolved on both sides in 7 of 27 patients. Previous sinus surgery had no impact on efficacy.

CONCLUSION

The highly significant progressive treatment effect of Opt-FP was observed regardless of baseline polyps score. Coupled with the complete removal of polyps in many patients with small polyps, this suggests that improved deposition to target sites achieved with the bidirectional delivery device may translate into true clinical benefits and reduced need for surgery.