Effects of levocetirizine as add-on therapy to fluticasone in seasonal allergic rhinitis

KAAACI Allergic Rhinitis Guidelines: Part 1. Update in Pharmacotherapy

The prevalence of allergic rhinitis (AR) and the socioeconomic burden associated with the medical cost and quality of life (QOL) of AR have progressively increased. Therefore, practical guidelines for the appropriate management of AR need to be developed based on scientific evidence while considering the real-world environment, values, and preferences of patients and physicians. The Korean Academy of Asthma, Allergy and Clinical Immunology revised clinical guidelines of AR to address key clinical questions of the management of AR. Part 1 of the revised guideline covers the pharmacological management of patients with AR in Korea. Through a meta-analysis and systematic review, we made 4 recommendations for AR pharmacotherapy, including intranasal corticosteroid (INCS)/intranasal antihistamine (INAH) combination therapy, oral antihistamine/INCS combination therapy, leukotriene receptor antagonist treatment in AR patients with asthma, and prophylactic treatment for patients with pollen-induced AR. However, all recommendations are conditional because of the low or very low evidence of certainty. Well-designed and strictly executed randomized controlled trials are needed to measure and report appropriate outcomes.

Combined medical therapy in the treatment of allergic rhinitis: Systematic review and meta-analyses

BACKGROUND

Antihistamines (ATH) and intranasal corticosteroids (INCS) are primary treatments for patients with allergic rhinitis (AR). When monotherapy of either primary treatment fails to control symptoms, combined medical therapy is an option. In this meta-analysis we assessed the additional effects of different medical combinations compared with primary treatments.

METHODS

Systematic searches on PubMed and EMBASE were updated on November 4, 2021. Randomized, controlled trials comparing the effects of combinations with monotherapy were included. There were 7 comparisons: (1) ATH-decongestant vs ATH; (2) ATH-leukotriene receptor antagonist (LTRA) vs ATH; (3) INCS-ATH vs INCS; (4) INCS-LTRA vs INCS; (5) INCS-decongestion vs INCS; (6) INCS-saline irrigation vs INCS; and (7) ATH-saline irrigation vs ATH. Data were pooled for meta-analysis. Outcomes were composite nasal symptom score, composite ocular symptom score, quality of life (QoL), and adverse events.

RESULTS

Fifty-three studies were included. Compared with ATH alone, the ATH-decongestant combination improved composite nasal symptoms; ATH-LTRA improved nasal symptoms in patients with perennial AR; and ATH-nasal saline improved both symptoms and QoL. Compared with INCS alone, the INCS-intranasal ATH combination improved nasal symptoms, ocular symptoms, and QoL; INCS-LTRA improved ocular symptoms but not nasal symptoms; and INCS-nasal saline improved QoL but not symptoms. There were no additional effects observed from adding oral ATH or topical decongestant to INCS.

CONCLUSION

After ATH monotherapy fails to control symptoms, addition of decongestant, saline, or LTRA can improve the outcomes. When INCS monotherapy is ineffective, addition of intranasal ATH can improve nasal symptoms; LTRA can improve ocular symptoms, and saline irrigation can improve QoL.

The correlation between FeNO and nNO in allergic rhinitis and bronchial asthma

This study aimed to evaluate the correlation between fractional exhaled nitric oxide (FeNO) and nasal nitric oxide (nNO) in allergic rhinitis (AR) and patients with or without bronchial asthma (BA).A total of 90 patients who were diagnosed with persistent AR (AR group, n = 30), BA (BA group, n = 30), or allergic rhinitis with bronchial asthma (AR-BA) (AR-BA group, n = 30), were enrolled in this study, along with 30 healthy adult volunteers (control group, n = 30). The participants were further divided into 2 groups based on the results of a skin-prick test (SPT): a highly atopic group (SPT = 3+ and above) and a moderately atopic group (SPT = 2+ and below). All participants underwent FeNO and nNO measurement, an absolute blood eosinophil count, total serum immunoglobulin measurement, and horizontal baseline lung capacity determination.The results showed that the FeNO levels in the 3 observation groups were significantly higher than those in the control group (P < .01), and in the BA group they were significantly higher than in the AR-BA group (P < .01). The levels of nNO in both the AR group and the AR-BA group were higher than those in the control group and the BA group (P < .01), but there was no significant difference between the AR group and the AR-BA group (P > .05). The levels of nNO in the BA group were also significantly different from those in the control group (P < .01).FeNO and nNO are positively correlated with the degree of AR in patients with BA; therefore, nNO levels can be used as an inflammatory marker of AR in patients with BA. FeNO can also be used as an inflammatory marker of AR in patients complicated with BA as a warning indicator of asthma.

Intranasal antihistamine is superior to oral H1 antihistamine as an add-on therapy to intranasal corticosteroid for treating allergic rhinitis

BACKGROUND

Currently, a combination of intranasal corticosteroid (INCS) plus oral H₁ antihistamine (OAH) or intranasal H₁ antihistamine (INAH) therapy is frequently used in the treatment of allergic rhinitis (AR). The superiority of the 2 combined treatments needs to be further examined.

OBJECTIVE

To identify the better of the 2 therapeutic strategies for treating AR.

METHODS

A literature review was performed on MEDLINE, Cochrane Library, and EMBASE databases. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses, meta-analyses of the total nasal symptom scores and individual nasal symptom scores were pooled based on studies that compared concomitant H₁ antihistamines plus INCS with INCS alone in the treatment of AR. The pooled results were expressed as weighted mean differences between the treatments. For each selected study, we calculated the relative clinical impact based on the total nasal symptom scores as follows: 100 × (Score_Monotherapy - Score_{Combined therapy}) / Score_Monotherapy.

RESULTS

A total of 13 publications met our selection criteria, with 5066 patients. The pooled results revealed no significant weighted mean difference on the total nasal symptom scores between concomitant OAH plus INCS and INCS alone. As for the individual symptoms, the most common symptom that revealed remission was rhinorrhea, which was after OAH in combination with INCS. The combination therapy of INAH and INCS was superior to INCS alone. In an indirect comparison, the weighted mean relative clinical impact of INAH plus INCS was significantly higher than that of OAH plus INCS.

CONCLUSION

Intranasal H₁ antihistamines have an add-on effect on intranasal corticosteroids, and the combination of intranasal H₁ antihistamines plus intranasal corticosteroid is superior to that of oral H₁ antihistamines plus intranasal corticosteroid in improving nasal symptoms for patients with AR.

Add-On Omalizumab for Inadequately Controlled Severe Pollinosis Despite Standard-of-Care: A Randomized Study

BACKGROUND

Cedar pollinosis (CP), a common form of seasonal allergic rhinitis (AR), is a substantial medical problem in Japan due to its high prevalence and severe symptoms. Omalizumab (anti-IgE therapy) has previously proven to be effective in CP/AR, but no studies for inadequately controlled severe CP/AR despite standard-of-care (SoC) have been conducted.

OBJECTIVE

To determine the efficacy of omalizumab added to SoC in patients with inadequately controlled severe CP in a randomized, double-blinded, placebo-controlled, phase III study.

METHODS

Adult/adolescent patients with severe CP whose symptoms were inadequately controlled despite nasal corticosteroids plus 1 or more oral medications in the previous 2 seasons were randomized to receive omalizumab (n = 162) or placebo (n = 175). All patients received concomitant antihistamines and nasal corticosteroids as SoC. The primary endpoint was the mean nasal symptom score during the severe symptom period. Secondary endpoints included mean ocular symptom score, quality of life (QoL), and safety.

RESULTS

The SoC + omalizumab treatment had statistically significantly and clinically important lower nasal (least squares mean difference, -1.03, P < .001) and ocular (-0.87, P < .001) symptom scores compared with SoC + placebo, respectively. Differences in scores for individual components of nasal and ocular symptoms were also statistically and clinically significant. SoC + omalizumab also improved QoL scores as overall and in all domains. No unexpected safety signals were observed.

CONCLUSIONS

In patients with severe CP, omalizumab added to SoC demonstrated consistent efficacy in improving symptoms and QoL, and was well tolerated. These results indicate that omalizumab could be a promising therapeutic option for severe CP/AR.

Effects of double-dose intranasal corticosteroid for allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

When a standard dose of intranasal corticosteroid (INCS) fails to control symptoms of allergic rhinitis (AR), a double dose of INCS is optional. This systematic review aimed to assess the effects of double-dose INCS.

METHODS

Literature searches were performed using MEDLINE and EMBASE. Randomized controlled trials that studied the effects of double-dose INCS vs standard-dose INCS for treating patients with AR were included. Data from the included studies were extracted and collected for meta-analyses. The outcomes were nasal symptoms, ocular symptoms, and adverse events.

RESULTS

Twelve studies (4166 patients) met the inclusion criteria. There were 5 pediatric studies (1868 patients), 5 adult studies (1414 patients), and 2 studies with mixed populations (884 patients). The meta-analysis results in adult patients favored the effects of double-dose INCS on: total nasal symptom score (standardized mean difference [SMD] -0.25; 95% confidence interval [CI], -0.41 to -0.08; 4 studies; 568 patients) and total ocular symptom score (SMD -0.27; 95% CI, -0.52 to -0.03; 1 study; 259 patients). The meta-analysis results in pediatric patients did not show the difference between groups on total nasal symptom score (SMD -0.16; 95% CI, -0.40 to 0.07; 3 studies; 801 patients). The meta-analysis of ocular symptom score in pediatric patients had insufficient data. There were no differences between groups on adverse events.

CONCLUSION

Double-dose INCS showed better improvement in nasal and ocular symptoms in adult patients with AR when compared to the standard dose. These beneficial effects were not seen in the pediatric population. Adverse events between groups were not different.

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.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Combination therapy in allergic rhinitis: What works and what does not work

Allergic rhinitis and other rhinitis subtypes are increasingly becoming some of the most prevalent and expensive medical conditions that affect the U.S.

POPULATION

Both direct health care costs and indirect costs significantly impact the health care system due to delays in diagnosis, lack of treatment, ineffective treatment, poor medication adherence, and associated comorbidities. Many patients who have AR turn to over-the-counter medications for relief but often find themselves dissatisfied with the results. Determining the correct diagnosis, followed by initiation of the most-effective treatment(s), is essential to provide patients with better symptomatic management and quality of life. Although there are many options, currently available combination therapies, e.g., azelastine with fluticasone and intranasal corticosteroids with nasal decongestants, offer distinct advantages for the management of complex rhinitis phenotypes. Further research is required to investigate the pathomechanisms and biomarkers for mixed rhinitis and nonallergic vasomotor rhinitis subtypes that will lead to novel targeted therapies for these conditions.

Update on local allergic rhinitis

We here provide an update on the literature regarding local allergic rhinitis (LAR). In reviewing LAR, we have included an updated definition, classifications, mechanisms, comorbidities, and recommendations for diagnosis and treatment for LAR, as well as the defined research areas for future evidence-based studies. LAR is a localised nasal allergic response in the absence of systemic atopy characterised by local production of specific IgE (sIgE) antibodies, a TH2 pattern of mucosal cell infiltration during natural exposure to aeroallergens, and a positive nasal allergen provocation test response, with the release of inflammatory mediators. The localised allergic response of LAR is an important topic for the study of allergies. This review provides an update on the current knowledge of LAR.

Minimal Clinically Important Difference (MCID) in Allergic Rhinitis: Agency for Healthcare Research and Quality or Anchor-Based Thresholds?

BACKGROUND

In 2013, the Agency for Healthcare Research and Quality (AHRQ) recommended that allergic rhinitis (AR) studies calculate a minimal clinically important difference (MCID) based on an estimated threshold equal to 30% of the maximum total nasal symptom score. Applying this threshold, their data showed no differences between well-established treatments, and a subsequent analysis using prescribing information found no differences between active treatments and placebo controls.

OBJECTIVE

The objective of this study was to demonstrate the application of an evidence-based model to determine MCIDs for AR studies, with an absolute value for an anchor-based threshold and validated methods for calculating distribution-based thresholds.

METHODS

Using the same studies as the AHRQ report, anchor- and distribution-based MCID thresholds were determined for 3 clinical comparisons identified by the AHRQ: (1) oral antihistamine+intranasal corticosteroid (INCS) versus INCS, (2) montelukast versus INCS, and (3) intranasal antihistamine+INCS in a single device versus the monotherapies. The outcomes were compared with those reported using the AHRQ threshold.

RESULTS

No treatment comparison met the AHRQ-defined MCID threshold; all treatments were determined to be equivalent for all 3 queries. In contrast, the evidence-based model revealed some differences between treatments: INCS > montelukast; intranasal antihistamine+INCS > either monotherapy. No clinically relevant benefit was observed for adding an oral antihistamine to INCS, but some studies were not optimal choices for quantitative determination of MCIDs. Updating the literature search revealed no additional studies that met the AHRQ inclusion criteria.

CONCLUSIONS

The evidence-based threshold for MCID determination for AR studies should supersede the threshold recommended in the AHRQ report.

Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report

Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.

Clinical application of nasal nitric oxide measurement in pediatric airway diseases

Nitric oxide plays an important role in several physiological and pathophysiological processes in the respiratory tract. Different ways to measure nasal nitric oxide levels in children are currently available. The possibility of obtaining nasal nitric oxide measurement from relatively young children, combined with the availability of portable devices that can be used even in the office setting, opens new perspectives for nasal nitric oxide analysis in the pediatric daily practice. This review presents a synopsis about the current clinical applications of nasal nitric oxide measurement in the pediatric clinical practice. A total of 3,775 articles on the topic were identified, of which 883 duplicates were removed, and 2,803 were excluded based on review of titles and abstracts. Eighty-nine full text articles were assessed for eligibility and 32 additional articles were obtained from the reference lists of the retrieved studies. Since very low nasal nitric oxide levels are found in the majority of patients with primary ciliary dyskinesia, most publications support a central role for nasal nitric oxide to screen the disease, and indicate that it is a very helpful first-line tool in the real-life work-up in all age groups. Decreased nasal nitric oxide concentration is also typical of cystic fibrosis, even though nasal nitric oxide is not as low as in primary ciliary dyskinesia. In other upper airway disorders such as allergic rhinitis, rhinosinusitis, nasal polyposis, and adenoidal hypertrophy, clinical utility of nasal nitric oxide is still critically questioned and remains to be established. Since nNO determination is flow dependent, a general consensus from the major investigators in this area is highly desirable so that future studies will be performed with the same flow rate. A shared nNO methodology will enable to overcome the challenges that lie ahead in incorporating nNO measurement into the mainstream clinical setting of pediatric airway diseases.

Comparison of intranasal ciclesonide, oral levocetirizine, and combination treatment for allergic rhinitis

Purpose

To evaluate the efficacy and safety of once-daily ciclesonide in comparison to both levocetirizine alone, and a ciclesonide/levocetirizine combination in patients with seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR).

Methods

Subjects exhibiting moderate to severe allergic rhinitis for longer than 1 year were randomized in an open-label, 3-arm, parallel group, multicenter study. Subjects received 200 µg ciclesonide, 5 mg levocetirizine, or a combination of both. Changes from baseline until the end-of-study visit (2 weeks following) were evaluated by reflective total nasal symptom scores (rTNSSs), reflective total ocular symptom scores (rTOSSs), physician-assessed overall nasal signs and symptoms severity (PANS), and rhinoconjunctivitis quality-of-life questionnaires (RQLQ).

Results

Significant improvements in rTNSS, PANS, and RQLQ in the ciclesonide monotherapy group were observed in comparison to the levocetirizine alone group. Three individual symptoms of rTNSS, including runny nose, nasal itching, and congestion, were improved in the ciclesonide-treated group. rTOSS scores for ciclesonide monotherapy improved from baseline, but no superiority over levocetirizine was shown. The absolute score and changes in rTNSS and PANS were positively correlated. Ciclesonide spray was more effective than levocetirizine in reducing nasal symptoms in both SAR and PAR patients. Ciclesonide and levocetrizine were well tolerated alone and in combination.

Conclusions

Our results provide support for an AR and its Impact on Asthma (ARIA) recommendation stipulating that ciclesonide is superior to levocetirizine for the treatment of AR, with tolerable safety. Addition of levocetirizine to ciclesonide did not give further clinical benefit over monotherapy.

The use of large volume low pressure nasal saline with fluticasone propionate for the treatment of pediatric acute rhinosinusitis

OBJECTIVES

Fluticasone propionate and nasal saline irrigation have been used in the treatment of sinonasal diseases for a long time. Our study investigates the effect of the combination of large volume low pressure nasal saline irrigation and fluticasone propionate for the treatment of pediatric acute rhinosinusitis.

METHODS

Ninety-one pediatric patients with acute rhinosinusitis were included in our study. The patients were randomized into two groups. The first group (n=45) was treated with standard therapy (antibiotherapy+nasal decongestant) for 2 weeks, the second group was treated with the large volume low pressure nasal saline+fluticasone propionate combination for 3 weeks. The clinical scores, radiologic evaluations (X-ray Waters view), peak nasal inspiratory flow (PNIF) measurements, total symptom scores and hematologic parameters (WBC, CRP, ESR) of the patients were evaluated and compared.

RESULTS

There were no significant differences in between the two groups regarding age, gender, height and weight. Even though the clinical scores of Group 2 improved more rapidly, there were no significant differences in between groups regarding clinical scores by the 21st day. There were no significant differences in post treatment radiologic evaluations (Waters graphy). Both groups had significant improvement of their post treatment PNIF values, yet the improvement was more marked in Group 2 than in Group 1. The rhinorrhea, nasal congestion, throat itching and cough symptoms improved more rapidly in Group 2 than in Group 1. Post-treatment nose itching and sneezing symptoms were significantly less in Group 2. The values of hematologic parameters were significantly reduced at the end of the 3rd week in both groups.

CONCLUSIONS

Our study is a first in investigating the combined use of large volume low pressure nasal saline and fluticasone propionate in acute pediatric rhinosinusitis, and the results reveal that the combination therapy was effective. Low pressure large volume nasal saline+fluticasone propionate combination can be employed as a new line of therapy for the treatment of pediatric acute rhinosinusitis, either by itself or combined with standard therapy.

Azelastine enhances the clinical efficacy of glucocorticoid by modulating MKP-1 expression in allergic rhinitis

Azelastine was suggested as a supplementary choice of glucocorticoid for the control of moderate to severe allergic rhinitis (AR). However, the underlying mechanism has not been completely understood. In this study, primary cultured nasal epithelial cells and bronchial epithelial cells were stimulated with proinflammatory cytokines (IL-1β and IL-17A) and anti-inflammatory agents (azelastine and budesonide) in vitro. The expression of intercellular adhesion molecule 1 (ICAM-1) and mitogen-activated protein kinase phosphatase-1 (MKP-1) was examined using qPCR and ELISA, respectively. Moreover, the additive effects of azelastine and budesonide nasal spray on nasal ICAM-1 level and total nasal symptom scores were evaluated in six uncontrolled severe AR patients by budesonide nasal spray alone. We found azelastine significantly inhibited cytokine-induced ICAM-1 upregulation, which is reversed by MKP-1 silencing. Azelastine and budesonide additively increased MKP-1 expression and inhibited ICAM-1 expression in vitro. After treatment for two consecutive weeks, combined azelastine and budesonide nasal spray significantly decreased nasal ICAM-1 level and TNSS in six uncontrolled AR patients. Our findings suggested that azelastine is able to additively enhance the anti-inflammatory effect of budesonide by modulating MKP-1 expression, which may implicate in the treatment of uncontrolled severe AR.

Food allergy and quality of life: what have we learned?

Health-related quality of life (HRQL) has become an emerging focus of interest in food allergy. Food allergy is a disease characterized by low mortality and symptoms which only occur during an allergic reaction. However, food-allergic patients continuously need to be alert when eating in order to prevent potentially severe allergic reactions, which may be fatal. Fear of such reactions and the need to be continuously vigilant may seriously compromise their HRQL. During the last decade, numerous studies have been published on food allergy and HRQL. The development of reliable, valid and responsive instruments for measuring HRQL in food allergic patients has facilitated this research even further. Such instruments have given insight into the specific problems a patient may face and the impact of food allergy-related interventions from the patient's perspective. This paper focuses on the most significant findings regarding this topic since its first appearance in the literature in 2000.

Current and future directions in pediatric allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common pediatric problem that significantly affects sleep, learning, performance, and quality of life. In addition, it is associated with significant comorbidities and complications.

OBJECTIVE

The aim was to provide an update on the epidemiology, comorbidities, pathophysiology, current treatment, and future direction of pediatric AR.

METHODS

Literature reviews in each of these areas were conducted, and the results were incorporated.

RESULTS

The prevalence of AR is increasing in the pediatric population and is associated with significant morbidity, comorbidities, and complications. The mainstay of current treatment strategies includes allergen avoidance, pharmacotherapy, and allergen specific immunotherapy.

CONCLUSIONS

In the future, diagnosis will be improved by microarrayed recombinant allergen testing and therapy will be expanded to include emerging treatments such as sublingual immunotherapy and combination products.

Nasal nitric oxide and nasal eosinophils decrease with levocetirizine in subjects with perennial allergic rhinitis

BACKGROUND

Allergic rhinitis is commonly treated with antihistamines. Monitoring improvement of airway inflammation noninvasively using nasal nitric oxide (nNO) would be clinically useful. To determine the anti-inflammatory effect of oral levocetirizine dihydrochloride (LC), we measured nNO and nasal eosinophils (nEos) in perennial allergic rhinitis (PAR) subjects.

METHODS

A randomized double-blind placebo-controlled crossover design was used. Inclusion criteria consisted of subjects having a PAR history, exam and diary scores consistent with active symptoms, and positive skin testing. Subjects taking allergy medications 1 month before the study were not enrolled. After consenting, 31 subjects (24 female subjects; mean age, 29 years) were randomized to either oral LC (5 mg) or matching placebo for 2 weeks. After 2 week washout, subjects started the other 2-week treatment. At each visit, nNO was measured by aspiration at each nare using a nasal kit from NIOX (Aerocrine, Sweden) in parts per billion; nEos was collected from nasal smears and measured by microscopy using the scoring system (0-4+) and symptoms were self-reported using the allergic Rhinitis Quality of Life Questionnaire (RQLQ). Daily allergy symptom scores (total symptom score [TSS] 4) were collected at each visit.

RESULTS

During LC, mean baseline nNO was 807 ± 317 parts per billion (ppb; left) and 831 ± 332 ppb (right) and decreased significantly to 688 ± 266 ppb and 702 ± 286 ppb, respectively (p < 0.05). No significance was found during placebo treatment (778 ± 270 ppb, 808 ± 299 ppb to 802 ± 271 ppb, 813 ± 273 ppb). The mean nNO change was also significant compared with placebo (-125 ppb versus +14 ppb; p < 0.05). There was a significant decrease in nEos with LC compared with placebo (3.1-2.5 versus 2.9-2.6; p < 0.05). RQLQ scores were significantly improved with LC only. In TSS-4 scoring, a trend toward improvement during LC and significant worsening during placebo was found. Baseline nNO predicted changes in nasal eosinophils (nEos) and RQLQ.

CONCLUSION

We showed that oral LC therapy decreased objective markers of rhinitis inflammation, nNO and nEos, in patients with PAR. Improvement in symptom scoring was also found with LC treatment.

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.

A Comparison of the Psychometric Properties of the Mini–Rhinitis Quality of Life Questionnaire and the Rhinitis Control Assessment Test

Background

The relationships between validated quality of life tools and control tools have not been explored for rhinitis. This study was designed to determine relationships of the Mini–Rhinitis Quality of Life Questionnaire (MiniRQLQ) and the Rhinitis Control Assessment Test (RCAT) to each other regarding content and predictive abilities.

Methods

Participants were adult members of a large integrated care organization with an encounter diagnosis of rhinitis in the prior 2 years. Patients completed mailed questionnaires at baseline that contained the MiniRQLQ and the RCAT and three follow-up questionnaires that contained those tools as well as questions regarding missed work or school because of rhinitis and frequency and effectiveness of medications used for rhinitis. Medications dispensed during the follow-up year were obtained from computerized pharmacy records. Results of allergy tests were retrieved for patients seen in the Allergy Department.

Results

The final cohort included 1051 patients. Baseline RCAT scores were strongly correlated with baseline MiniRQLQ scores in both allergic (r = -0.80) and nonallergic (r = -0.84) patients. Baseline MiniRQLQ and RCAT scores we significantly related to patient reports of missed school/work, medication use, and effectiveness over the next 3 months and to dispensing during the following year of total and some individual rhinitis medications. Test–retest reliability, responsiveness, and a preliminary minimal important difference (>2.5) were shown for the RCAT, using the MiniRQLQ as an anchor.

Conclusion

The MiniRQLQ and RCAT are strongly related to each other and both predict subsequent rhinitis outcomes. Determining the comparative usefulness of these tools will require further study.

Management of rhinitis: guidelines, evidence basis, and systematic clinical approach for what we do

Whereas very mild rhinitis may be simply and successfully self-managed by patients using medications available over the counter, most patients with rhinitis who present to medical offices have more severe rhinitis that may need a more comprehensive diagnostic and therapeutic approach. Optimal care may require special diagnostic studies and combination therapies that are arrived at only after trying multiple different medication and therapeutic options. This article presents a systematic approach to office care of rhinitis from the perspective of an allergist-immunologist. More emphasis is given to discussion of dilemmas that face the specialist or more involved considerations that have been highlighted in recently published guidelines.

The role of nasal corticosteroids in the treatment of rhinitis

Intranasal corticosteroids (INSs) are the first choice for rhinitis pharmacotherapy. This preference is because of their broad range of actions that result in reductions of proinflammatory mediators, cytokines, and cells. Over the past 30 years, INSs have been modified to improve their pharmacodynamic, pharmacokinetic, and delivery system properties, with attention to improving characteristics such as receptor binding affinity, lipophilicity, low systemic bioavailability, and patient preference. Clinically, they have been shown to be the most effective class of nasal medications for treating allergic rhinitis and nonallergic rhinopathy, with no clear evidence that any specific INS is superior to others.

Effects of intranasal salmeterol and fluticasone given alone and in combination in persistent allergic rhinitis

BACKGROUND

β(2)-Agonists have previously been shown to be effective inhibitors of mediator release from airway mucosal mast cells.

OBJECTIVE

To evaluate the effects of intranasal salmeterol and fluticasone propionate alone and in combination on the response to nasal adenosine monophosphate (AMP) challenge to assess mast cell activation.

METHODS

Twenty-three patients with persistent allergic rhinitis completed a randomized, double-blind, placebo-controlled, 4-way crossover trial. They received once daily treatment with placebo, salmeterol, 50 μg, fluticasone propionate, 500 μg, or fluticasone propionate and salmeterol combination, 500/50 μg, delivered via an antistatic spacer with nasal adapter for 1 week each, with trough measurements being made 12 hours after the first and last dose. The primary outcome was the maximum percentage decrease in peak nasal inspiratory flow after nasal AMP challenge.

RESULTS

For the primary outcome there was significant protection after single and long-term dosing with fluticasone alone and fluticasone-salmeterol combination, whereas salmeterol alone only afforded protection after the first dose. Fluticasone-salmeterol combination and fluticasone but not salmeterol conferred significant chronic dosing effects on secondary outcomes of nasal symptoms and disease-specific quality of life. There was no potentiation of the response to fluticasone by salmeterol on any outcomes when given in combination.

CONCLUSION

Chronic dosing with fluticasone but not salmeterol confers anti-inflammatory activity against nasal AMP challenge, but there was no potentiation of fluticasone when given in combination with salmeterol. Thus, salmeterol may not be an effective treatment for use in allergic rhinitis.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01388595.

Antihistamine therapy in allergic rhinitis

Antihistamines have long been a mainstay in the therapy for allergic rhinitis. Many different oral antihistamines are available for use, and they are classified as first generation or second generation based on their pharmacologic properties and side-effect profiles. The recent introduction of intranasal antihistamines has further expanded the role of antihistamines in the treatment of allergic rhinitis. Certain patient populations, such as children and pregnant or lactating women, require special consideration regarding antihistamine choice and dosing as part of rhinitis therapy.

Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children

BACKGROUND

Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide and its prevalence among children has significantly increased over the last two decades. Prevalence and severity are related to age, with children of school age most commonly affected.

OBJECTIVES

To assess the effectiveness and adverse event profile of antihistamines (oral or topical) used as an adjunct to topical nasal steroids for intermittent and persistent allergic rhinitis in children.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 21 September 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in children under the age of 18 with a history of allergic rhinitis, with or without allergic conjunctivitis or asthma, comparing topical nasal steroids with antihistamines to topical nasal steroids only.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data and assessed risk of bias.

MAIN RESULTS

One study including 24 participants met the inclusion criteria for this review. This study compared the administration of topical nasal steroids with oral antihistamines to topical nasal steroids only in children, but it did not provide sufficient data to address the clinical question of this review.

AUTHORS' CONCLUSIONS

In view of the lack of evidence for the benefit or lack of benefit of antihistamine add-on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred.

Relationship between fractional exhaled nitric oxide and nasal nitric oxide in airways disease

BACKGROUND

Invasive techniques show evidence of a unified allergic airway. Nitric oxide is measured noninvasively from the lungs (fractional exhaled nitric oxide [FeNO]) and nose (nasal nitric oxide [nNO]).

OBJECTIVE

To investigate the relationship between FeNO and nNO in different airway conditions.

METHODS

A total of 227 participants were assessed: 41 healthy volunteers (HVs), 33 patients with asthma, 52 patients with allergic rhinitis (AR), 63 with unified airway disease (UAD), and 38 with nasal polyposis (NP). Correlation and multiple linear regression analyses were performed.

RESULTS

Geometric means (95% confidence intervals) for FeNO were as follows: 14.7 (12.4-17.5) ppb for HVs, 29.0 (22.5-37.4) ppb for asthma patients, 23.1 (19.0-28.1) for AR patients, 27.2 (23.0-32.4) for UAD patients, and 28.5 (21.5-37.8) for NP patients. For nNO, the values were as follows: 878.1 (807.0-955.6) ppb for HVs, 674.1 (557.4-815.1) for asthma patients, 853.3 (778.8-934.8) ppb for AR patients, 763.4 (694.1-839.5) for UAD patients, and 388.6 (317.9-474.9) for NP patients. The nNO was lower in the NP group than the other groups (P < .001). The nNO and FeNO were correlated in the AR patients (r = 0.56; P < .0001) and HVs (r = 0.44; P = .004) but not significantly in the other groups. Multiple linear regression of the whole cohort demonstrated that after diagnosis, age, sex, and inhaled corticosteroids were taken into account nNO had a significant association with FeNO (P = .02).

CONCLUSION

Reduced nNO in NP patients is due to ostiomeatal complex obstruction. FeNO is sensitive to suppression by inhaled corticosteroids. The AR and HV groups have no such confounders; hence, correlation is most evident. Exclusion of confounders reveals a correlation between upper and lower airway inflammation with noninvasive techniques.

Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion

RATIONALE

Chronic use of intranasal decongestants, such as oxymetazoline, leads to tachyphylaxis of response and rebound congestion, caused by alpha-adrenoceptor mediated down-regulation and desensitization of response.

OBJECTIVES

We evaluated if tachyphylaxis can be reversed by intranasal fluticasone propionate, and the relative alpha(1)- and alpha(2)-adrenoceptor components of tachyphylaxis using the alpha(1)-antagonist prazosin.

METHODS

In a randomized, double-blind, placebo-controlled, crossover design, 19 healthy subjects received intranasal oxymetazoline, 200 microg three times a day for 14 days, followed by the addition of fluticasone, 200 microg twice a day for a further 3 days. At Days 1, 14, and 17, participants received a single dose of oral prazosin, 1 mg, or placebo with measurements made before and 2 hours later.

MEASUREMENTS AND MAIN RESULTS

Outcomes evaluated were peak nasal inspiratory flow, nasal resistance, blood flow, and oxymetazoline dose-response curve (DRC). On Day 14 versus Day 1, inspiratory flow decreased (mean difference, 95% confidence interval) (-47.9 L x min(-1); -63.9 to -31.9; P < 0.001) and the DRC shifted downward (24.8 L x min(-1); 20.3-29.3; P < 0.001). On Day 17 versus Day 14, after fluticasone, inspiratory flow increased (45 L x min(-1); 30-61; P < 0.001) and the DRC shifted upward (26.2 L x min(-1); 21.7-30.7; P < 0.001). On Day 1, prazosin reduced inspiratory flow (-52.6 L x min(-1); -19.2 to -86) compared with baseline. This effect was abolished on Day 14 (7.9 L x in(-1); -41.3 to 25.5).

CONCLUSIONS

Oxymetazoline-induced tachyphylaxis and rebound congestion are reversed by intranasal fluticasone. Further studies are indicated to evaluate if combination nasal sprays of decongestant and corticosteroid are an effective strategy to obviate tachyphylaxis and rebound in rhinitis. Clinical trial registered with www.clinicaltrials.gov (NCT 00487032).

Levocetirizine for the treatment of allergic rhinitis and chronic idiopathic urticaria in adults and children

BACKGROUND

Levocetirizine (LCZ) is a second-generation antihistamine that was approved in January 2008 for the relief of symptoms of seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR), and chronic idiopathic urticaria (CIU) in adults and children aged > or = 6 years.

OBJECTIVES

This article reviews the available literature on the pharmacokinetics and pharmacodynamics, clinical efficacy and tolerability, and effect on quality of life (QoL) of LCZ.

METHODS

A search of the English-language literature was performed using the following databases: MEDLINE (1966-February 2009), International Pharmaceutical Abstracts (19 70-February 2009), Database of Abstracts of Reviews of Effectiveness, Cochrane Database of Systematic Reviews, EMBASE Drugs & Pharmacology (1991-February 2009), Blackwell Synergy, CINAHL Plus with Full Text, EBSCOhost, ScienceDirect, and Wiley Interscience. The search terms were levocetirizine, allergic rhinitis, chronic idiopathic urticaria, antihistamine, pharmacokinetics, quality of life, drug interactions, case reports, and cost. Publications describing studies of > or = 2 weeks' duration that concerned the efficacy, tolerability, pharmacoeconomics, and/or QoL effects of LCZ were included in the review.

RESULTS

In 4 studies in adult patients with moderate to severe PAR, LCZ 5 mg/d was associated with significant improvements in symptom scores for sneezing, rhinorrhea, and ocular/nasal pruritus at 4 to 6 weeks compared with placebo (P < or = 0.05). In 3 studies, nasal congestion scores were significantly improved within 4 to 6 weeks compared with placebo (P < 0.001). LCZ 5 mg/d was associated with improvements compared with placebo in scores for the ability to do housework, complete work activities, and engage in outdoor activities at 6 months (P < or = 0.011). In a 6-week study in children with moderate to severe SAR, LCZ 5 mg/d was associated with significant improvements compared with placebo in sneezing, rhin-orrhea, and itchy nose (P < 0.004); significant improvements in symptoms from baseline were also seen in a 4-week study in adults with SAR (P < 0.001). One study in patients with SAR reported no significant difference between LCZ and fluticasone compared with fluticasone monotherapy in terms of improvement in QoL, nasal airflow obstruction, sneezing, or pruritus. In a 6-week study in patients with moderate to severe CIU, LCZ 5 mg/d was significantly more effective than placebo in reducing overall CIU symptoms (P < 0.05). In two 4-week studies, one comparing LCZ 5 mg/d with placebo and the other comparing it with desloratadine (DSL), LCZ was significantly more effective than either comparator in terms of improvement in scores for pruritus severity (P < or = 0.001 vs placebo; P < 0.004 vs DSL) and duration (P < or = 0.001 vs placebo; P = 0.009 vs DSL). LCZ was significantly more effective than placebo (but not DSL) in reducing the number and size of wheals (both, P = 0.001). In a 12-week, open-label, crossover study, patients reported significantly longer symptom relief with cetirizine than LCZ (P < 0.005). The most commonly reported adverse events in two 6-month studies in adults with PAR treated with LCZ 5 mg/d included headache (23.8%), pharyngitis (19.4%), influenza (14.6%), fatigue (8.3%), and somnolence (8.3%). There is serious concern about the possibility of febrile seizures in infants treated with LCZ. Three pharmacoeconomic studies of LCZ 5 mg/d were identified, one comparing it with placebo in patients with PAR, one comparing it with placebo in patients with CIU, and another comparing it with second-generation antihistamines and montelukast in patients with PAR. Because of design limitations and differences in comparators in these studies, it was not possible to determine the cost-effectiveness of LCZ in the treatment of PAR or CIU.

CONCLUSIONS

In the studies reviewed, LCZ 5 mg/d was effective in reducing symptoms of PAR, SAR, and CIU and improving QoL, with an acceptable tolerabili-ty profile. There is a need for studies of longer durations, head-to-head comparisons against other anti-histamines, drug-interaction studies, safety studies in infants, and cost-effectiveness analyses.

Azelastine and olopatadine in the treatment of allergic rhinitis

OBJECTIVE

To review the literature supporting current recommendations for nasal antihistamines as first-line therapy for allergic rhinitis.

DATA SOURCES

Published articles in the peer-reviewed medical literature.

STUDY SELECTION

Clinical trials focusing on the efficacy, safety, and recommended uses of the currently approved nasal antihistamines in the United States: azelastine nasal spray, 0.1%, and olopatadine nasal spray, 0.6%.

RESULTS

Azelastine nasal spray, 0.1%, and olopatadine nasal spray, 0.6%, have rapid onsets of action, are well tolerated, and have clinical efficacy for treating allergic rhinitis that is equal or superior to oral second-generation antihistamines. Both also have a clinically significant effect on nasal congestion. Azelastine is also approved for nonallergic rhinitis. Although older data suggest that intranasal steroids have greater clinical efficacy than nasal antihistamines, more recent comparisons in patients with mild to moderate disease have shown equal or noninferior efficacy. In addition, in contrast to oral antihistamines or leukotriene antagonists, the combination of a nasal antihistamine and intranasal steroid may provide additive benefits for treating patients with more severe disease.

CONCLUSION

The data support current recommendations for nasal antihistamines as first-line therapy for allergic rhinitis. Future studies should address possible as needed use, the use of premixed antihistamine-steroid combinations, and the treatment of mixed rhinitis.

The minimal clinically important difference in allergic rhinitis

BACKGROUND

When presented with results from clinical measurements or research findings, clinicians must first make an interpretation of their importance, not only in statistical terms, but also the 'clinical importance' given the size of the change observed. To do this, they require an understanding of the relationship between their outcome measures, and the patient's perception of change. The minimal clinically important difference (MCID) illustrates this relationship by calculating the smallest change in a given outcome that is meaningful to a patient. There are few reports of calculated MCIDs in the Rhinology literature.

OBJECTIVE

To calculate MCIDs for common subjective and objective outcome measures in allergic rhinitis (AR).

METHODS

Nine randomized, blinded, placebo-controlled clinical trials in intermittent and persistent AR (pooled subjects, n=204) were analysed using anchor- and distribution-based approaches, applying regression and meta-analysis techniques.

RESULTS

MCIDs were obtained for the Mini Rhinoconjunctivitis Quality of Life Questionnaire: 0.4 units, peak nasal inspiratory flow: 5 L/min and total nasal symptoms score: 0.55 units. Nasal NO measurement changes had no correlation with patient perceptions of benefit.

CONCLUSION

Estimates of MCIDs were obtained for common subjective and objective rhinological outcomes. MCIDs can and should be applied by physicians interpreting research findings, as well as researchers reporting their findings. We can then be confident that our changes in practice will be of perceptible benefit to the patient.

Effect of levocetirizine on nasal provocation testing with adenosine monophosphate compared with allergen challenge in allergic rhinitis

BACKGROUND

End-organ hyperreactivity is an important feature of the allergic airway. There are no data directly comparing the responsiveness to treatment of different nasal provocation tests (NPT).

OBJECTIVE

We compared the effect of levocetirizine on nasal adenosine 5'-monophosphate (AMP) with specific allergen challenge in patients with intermittent and persistent allergic rhinitis (AR).

METHODS

Patients with AR were randomized in double-blind cross-over fashion to receive single doses of levocetirizine 5 mg or identical placebo, with nasal challenge performed 12 h after dosing. Sixteen participants completed per protocol. Nasal AMP or allergen challenge was conducted on separate days with 1- and 2-week washout periods in between, respectively. Measurements of peak nasal inspiratory flow (PNIF) were made over 60 min after each challenge. The primary end-point was the provocative concentration of AMP or allergen causing a 20% drop in the PNIF (PC(20)).

RESULTS

The time-profile for PNIF recovery [area under the 60 min time-response curve as % PNIF change (min)] were significantly attenuated for AMP challenge, as mean difference [95% confidence interval (CI)]: 11.57 (3.87, 19.25), P=0.005 and for allergen challenge: 17.82 (0.11, 35.53), P=0.04. A highly significant correlation was shown between methods for the area under the curve: (R=0.86, P<0.001). A statistically significant correlation was also seen for the PC(20): (R=0.94, P<0.001). PC(20) improvement amounted to a 1.26 (95% CI 0.16, 2.35) and 0.16 (95% CI -0.41, 0.73) doubling-dilution shifts for allergen and AMP challenges, respectively. Bland-Altman plots confirmed good agreement between methods.

CONCLUSION

A high correlation and statistical agreement has been demonstrated between AMP and allergen challenge for all outcome measures. In particular, the recovery profile after NPT is a sensitive and discriminatory measure of anti-allergic treatment.

Comparative safety and efficacy of 2 formulations of fluticasone aqueous nasal spray in persistent allergic rhinitis

BACKGROUND

There are few data on the clinical equivalence of different nasal corticosteroids in persistent allergic rhinitis (AR). Studies measuring plasma concentrations after a single dose may not predict relative systemic bioactivity at steady state.

OBJECTIVE

To compare a test formulation of fluticasone propionate with the innovator using a noninferiority design.

METHODS

Twenty-three patients with persistent AR were randomized to completion in a double-blind, placebo-controlled, crossover manner to receive the formulations at 200 microg/d for 4 weeks, with baselines measured after 2-week run-in and washout periods. The primary outcome measure was the Mini Rhinoconjunctivitis Quality of Life Questionnaire (MiniRQLQ) score.

RESULTS

Both formulations produced significant improvements in MiniRQLQ scores as change from baseline (P < .001), with a nonsignificant mean difference (test vs innovator) of -0.06 U (95% confidence interval [CI], -0.41 to 0.52 U) and the lower bound of the 95% CI being above the predefined noninferiority limit of -0.7 U. Both formulations produced significant improvements in peak nasal inspiratory flow rates as change from baseline (P < .01), with a nonsignificant mean difference of 0.5 L x min(-1) (95% CI, 9.8 to 10.8 L x min(-1)). There were also significant reductions in total nasal symptom scores (P < .01), with a nonsignificant mean difference of 0.4 U (95% CI, 0.3 to 1.1 U). No significant suppression of the 10-hour overnight urinary cortisol to creatinine ratio was seen with either formulation.

CONCLUSIONS

The test formulation was noninferior to the innovator for the primary outcome of MiniRQLQ score. The secondary efficacy and safety end points also support the interchangeability of the 2 formulations.

ARIA-suggested drugs for allergic rhinitis: what impact on quality of life? A GA2LEN review

Allergic diseases constitute a global health problem, as they have an increasing economic and social impact and, especially, they can deeply interfere with the patients' daily life, being a cause of physical and emotional discomfort. This is why the health-related quality-of-life (HRQoL) has become increasingly important in health care research; in fact, the assessment of the impact the disease and its treatment have on patients, provides a more comprehensive approach in outcome evaluation. Numerous validated questionnaires are available and many studies have been performed evaluating HRQoL in people affected by allergic rhinitis (AR), thus testifying a great interest in this topic. The aims of the present review are: to examine the scientific literature of the last 3 years dealing with the impact of AR treatments suggested by allergic rhinitis and its impact on asthma guidelines on patients' QoL, and to identify the unexplored or not-fully-investigated areas concerning this issue.

Clinical benefits of combination treatment with mometasone furoate nasal spray and loratadine vs monotherapy with mometasone furoate in the treatment of seasonal allergic rhinitis

BACKGROUND

Intranasal corticosteroids and nonsedating antihistamines are the drug classes most often prescribed to treat allergic rhinitis (AR). Treatment guidelines recommend a combination of these agents for moderate-to-severe AR. However, clinical studies have found that combining an antihistamine with an intranasal corticosteroid provides few or no advantages over monotherapy with an intranasal corticosteroid.

OBJECTIVE

To compare the efficacy of mometasone furoate nasal spray (NS) plus loratadine with that of monotherapy with the individual agents in patients 12 years and older with at least a 2-year history of seasonal AR.

METHODS

In a multicenter, randomized, double-blind, parallel-group, placebo-controlled clinical study, 702 patients were randomized to receive mometasone furoate NS, 200 microg, plus loratadine, 10 mg (n = 169); mometasone furoate NS, 200 microg (n = 176); loratadine, 10 mg (n = 181); or placebo (n = 176) once daily for 15 days. Primary efficacy variables were total nasal symptom score (TNSS) and total symptom score (TSS) as recorded on diary cards.

RESULTS

No statistically significant differences were observed between mometasone furoate NS plus loratadine and mometasone furoate NS monotherapy for the primary efficacy variables. For TNSS and TSS, all 3 active drug therapies were more effective than placebo (P < or = .02). Both mometasone furoate NS treatment regimens were more effective than loratadine or placebo for TNSS (P < .01 for both) and TSS (P < or = .03 for both), whereas loratadine was more effective than placebo for TNSS only (P = .02).

CONCLUSIONS

Combination therapy with mometasone furoate NS and loratadine provided benefits similar to monotherapy with mometasone furoate NS for the symptoms of seasonal AR. Therefore, mometasone furoate NS monotherapy was shown to be an effective treatment for seasonal AR.

[Antihistamines in allergic rhinitis]

Antihistamines are the first line of pharmacotherapy in allergic diseases, especially in allergic rhinitis. The article also presents the interesting 2005-2007 publications on the use of antihistamine in practical point of view, especially the newly introduced ones (desloratadine, fexofenadine, levocetirizine) and those which are to be introduced soon (rupatadine). The efficacy in skin histamine provocation model and various clinical model were discussed.

Allergic rhinitis: the impact of discordant perspectives of patient and physician on treatment decisions

BACKGROUND

A wealth of literature is available that documents the effects of inadequately controlled allergic rhinitis (AR) on patients' daily activities, including impaired sleep, reduced cognitive functioning, and interference with sport and leisure activities. However, despite its high prevalence and significant impact on health-related quality of life (HRQOL) and productivity, AR may be undertreated. This might arise, in part, from the low priority given to the disease by physicians.

OBJECTIVE

This article aims to assess the existence of disparities between the attitudes of patients and physicians to AR, and to comment on the impact these disparities may have on treatment choices.

METHODS

A search was conducted of MEDLINE (1990-2006) and data presented at recent congresses (The 25th Congress of the European Academy of Allergology and Clinical Immunology, June 10-14, 2006, Vienna, Austria, and the 62nd Annual American Academy of Allergy, Asthma and Immunology Meeting, March 3-7, 2006, Miami Beach, Florida) for articles that contained combinations of the terms allergic rhinitis, patient, physician, perspective, attitude, opinion, experience, or burden. Appropriate articles were selected for review in combination with data from a recent Adelphi Group Products (New York, New York) survey.

RESULTS

A study of the impact of seasonal AR on HRQOL found that adolescent patients (n = 83) scored practical problems higher in terms of importance. AR was found to affect the home and social life of > or =33% of patients in a study from the United Kingdom. A European survey of 1494 patients with AR found that nasal congestion was the most common moderate or severe nasal symptom (55%) and that 44% of patients suffered moderate or severe ocular symptoms. A Danish study of adults and adolescents found that AR was undiagnosed in 32% of patients. In a study of 100 physicians in the United States, approximately 30% of physicians under-estimated the severity of AR and its impact on patients' work or school activities. Furthermore, 1 study indicated that approximately 99% of physicians did not issue adequate treatment, although no study was found that directly linked physicians' perspectives of AR and their treatment decisions to date.

CONCLUSIONS

In a review of the existing literature, evidence of disparities between patients' and physicians' perspectives of AR were found, although no studies linked perspectives to prescribing behavior; therefore, research into the impact on treatment decisions might be warranted. In the future, the patient-physician dialogue might be improved by a standardized questionnaire designed to identify the most bothersome symptoms of a patient's disease, so that the most appropriate treatments can be selected to maximize quality of life.

Relationship between ARIA classification and drug treatment in allergic rhinitis and asthma

INTRODUCTION

The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines provide a stepwise treatment to rhinitis, which classifies the disease according to its duration and severity.

OBJECTIVES

The aim of the study was to verify whether these variables influence drug prescriptions for rhinitis and asthma.

METHODS

A multi-centre cross-sectional pharmaco-epidemiological survey was carried out on 1,610 allergic rhinitis patients and the relationship between the clinical features of rhinitis and drug therapy for rhinitis and asthma was evaluated.

RESULTS

A total of 1,321 adult patients were enrolled. Mild intermittent rhinitis was diagnosed in 7.7%of the patients, moderate/severe intermittent in 17.1%, mild persistent in 11.6%, and moderate/severe persistent in 63.6%. A high level of rhinitis-asthma comorbidity (616/1,321 = 46.6%) was found. The majority of patients [1,060 (80.24%)] were treated. Significant associations between the severity of rhinitis and the presence of therapy (P = 0.008), the use of oral antihistamines (P < 0.001), topical nasal steroids (P = 0.020) and systemic steroids (P = 0.005) were found. A weak association was found between the features of rhinitis and the therapy for asthma, and vice versa the comorbidity with asthma increases the prescription of inhalant (P < 0.001) and oral steroids (P = 0.015) to treat rhinitis.

CONCLUSION

The severity of rhinitis influences patient request for rhinitis therapy and the type of medication more than the duration. These features of rhinitis seem to poorly influence asthma therapy. As the ARIA classification is able to reveal a relevant impairment notwithstanding therapy, its role in treated patients merits further study.