Topical steroid treatment for allergic rhinitis and allied conditions

The prescription design and key properties of nasal gel for CNS drug delivery: A review

Central nervous system (CNS) diseases are among the major health problems. However, blood-brain barrier (BBB) makes traditional oral and intravenous delivery of CNS drugs inefficient. The unique direct connection between the nose and the brain makes nasal administration a great potential advantage in CNS drugs delivery. However, nasal mucociliary clearance (NMCC) limits the development of drug delivery systems. Appropriate nasal gel viscosity alleviates NMCC to a certain extent, gels based on gellan gum, chitosan, carbomer, cellulose and poloxamer have been widely reported. However, nasal gel formulation design and key properties for alleviating NMCC have not been clearly discussed. This article summarizes gel formulations of different polymers in existing nasal gel systems, and attempts to provide a basis for researchers to conduct in-depth research on the key characteristics of gel matrix against NMCC.

Nasal Cytology in Clinical Practice

Analysis of the nasal cytology provides information regarding the pathophysiology and response to therapy of the airway. This paper reviews the techniques for obtaining and interpreting specimens. The discussion focuses on the epithelial and inflammatory cells and the patterns seen in allergic, infectious and structural nasal disorders.

Immunopharmacology of Nasal Allergic Reactions

The technique of nasal provocation followed by lavage was used to study the pharmacology and pathophysiology of upper airway allergic reactions. The levels of histamine, TAME-esterase activity, kinins, and arachidonic acid metabolites were measured in the recovered nasal lavage fluid obtained during the early and, in certain cases, the late phase and rechallenge reactions to antigen. Leukocytes contained in the lavage were counted and differentiated. Topical application of azatadine and systemic administration of theophylline reduced both mediators and symptoms during the early reaction, probably by inhibiting antigen-induced mast cell activation. Pretreatment with aspirin decreased the concentration of cyclooxygenase products during the early reaction without ameliorating symptoms. Administration of systemic steroids ablated the increase of mediators and symptoms and the mucosal accumulation of eosinophils and mononuclear cells, but not of neutrophils during the late phase reaction, without affecting the mediators or symptoms of the early reaction, with the exception of kinins. Topical steroids reduced both the amount of mediators and the severity of symptoms during the early, late, and rechallenge reactions. The accumulation of eosinophils, basophils, neutrophils, and mononuclear cells during the late phase reaction was also significantly reduced. Thus, this nasal challenge model has helped us to gain insights into the pathophysiology of allergic reactions and the pharmacology of their treatment and can be used to examine the efficacy of pharmacologic agents designed for the treatment of such reactions.

Exploring of the molecular mechanism of rhinitis via bioinformatics methods

The aim of this study was to analyze gene expression profiles for exploring the function and regulatory network of differentially expressed genes (DEGs) in pathogenesis of rhinitis by a bioinformatics method. The gene expression profile of GSE43523 was downloaded from the Gene Expression Omnibus database. The dataset contained 7 seasonal allergic rhinitis samples and 5 non-allergic normal samples. DEGs between rhinitis samples and normal samples were identified via the limma package of R. The webGestal database was used to identify enriched Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways of the DEGs. The differentially co-expressed pairs of the DEGs were identified via the DCGL package in R, and the differential co-expression network was constructed based on these pairs. A protein-protein interaction (PPI) network of the DEGs was constructed based on the Search Tool for the Retrieval of Interacting Genes database. A total of 263 DEGs were identified in rhinitis samples compared with normal samples, including 125 downregulated ones and 138 upregulated ones. The DEGs were enriched in 7 KEGG pathways. 308 differential co-expression gene pairs were obtained. A differential co-expression network was constructed, containing 212 nodes. In total, 148 PPI pairs of the DEGs were identified, and a PPI network was constructed based on these pairs. Bioinformatics methods could help us identify significant genes and pathways related to the pathogenesis of rhinitis. Steroid biosynthesis pathway and metabolic pathways might play important roles in the development of allergic rhinitis (AR). Genes such as CDC42 effector protein 5, solute carrier family 39 member A11 and PR/SET domain 10 might be also associated with the pathogenesis of AR, which provided references for the molecular mechanisms of AR.

The effect of cilia and the mucociliary clearance on successful drug delivery

Nasal mucociliary clearance is one of the most important factors affecting nasal delivery of drugs and vaccines. This is also the most important physiological defense mechanism inside the nasal cavity. It removes inhaled (and delivered) particles, microbes and substances trapped in the mucus. Almost all inhaled particles are trapped in the mucus carpet and transported with a rate of 8-10 mm/h toward the pharynx. This transport is conducted by the ciliated cells, which contain about 100-250 motile cellular appendages called cilia, 0.3 µm wide and 5 µm in length that beat about 1000 times every minute or 12-15 Hz. For efficient mucociliary clearance, the interaction between the cilia and the nasal mucus needs to be well structured, where the mucus layer is a tri-layer: an upper gel layer that floats on the lower, more aqueous solution, called the periciliary liquid layer and a third layer of surfactants between these two main layers. Pharmacokinetic calculations of the mucociliary clearance show that this mechanism may account for a substantial difference in bioavailability following nasal delivery. If the formulation irritates the nasal mucosa, this mechanism will cause the irritant to be rapidly diluted, followed by increased clearance, and swallowed. The result is a much shorter duration inside the nasal cavity and therefore less nasal bioavailability.

Antifungal treatment and chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is an inflammatory disease with a multifactorial etiology. Antifungal therapy is not routinely used to treat it. However, evidence implicating fungi in some forms of CRS recently has been published. Controversy exists as to whether fungi identified in sinonasal cultures are always pathogenic. Immunologic evidence supporting the role of fungi in the pathogenesis of CRS is also debated. Topical antifungal therapy is more widely used than oral therapy, with amphotericin B irrigation being the most common. Although some studies show benefit from this irrigation, others refute the efficacy. Although oral antifungal agents are used uncommonly, itraconazole is the most commonly used drug. The efficacy of oral itraconazole in CRS has never been assessed in a clinical trial. Given the current evidence, the use of antifungals to treat CRS is controversial and has limited indications.

Comparison of delivery of topical medications to the paranasal sinuses via "vertex-to-floor" position and atomizer spray after FESS

INTRODUCTION

Topical nasal medications are frequently employed for persistent sinonasal symptoms after functional endoscopic sinus surgery (FESS) in chronic rhinosinusitis patients. The optimal means for the delivery of these medications is unclear. In this study, the efficacy of the vertex to floor (VF) position compared to atomizer spray was evaluated in post-FESS patients.

METHODS

Three trials were performed: two trials in which patients maintained the VF position for 1 and 5 minutes, respectively, after nasal drop administration were compared to a third trial utilizing an atomizer spray in the upright position. Two independent observers rated the distribution of fluorescein-dyed dexamethasone drops at 5 sinonasal sites: maxillary sinus (MS), ethmoid cavity (EC), frontal recess (FR), sphenoid sinus (SS), and olfactory cleft (OC).

RESULTS

VF position consistently delivered nasal drops to the MS, EC, SS, and OC. The atomizer distributed drops to the MS, EC, SS, and FR. The greatest difference was noted with the nasal drops in the olfactory cleft in the VF position; statistical significance was achieved with ANOVA testing (P = 0.012). Student's paired t test comparing trial 1 to 2, 1 to 3, and 2 to 3 demonstrated greater distribution in the OC at 5 minutes compared with 1 minute and spray (P = 0.042 and 0.003).

CONCLUSIONS

The VF position and atomizer spray were both effective in delivery of the dexamethasone drops to the paranasal sinuses. This has significant implications for management of patients suffering from recalcitrant chronic rhinosinusitis and/or sinonasal polyposis through the delivery of topical medications to the paranasal sinuses and olfactory cleft.

EBM RATING

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Anosmia and nasal sinus disease

Smell loss associated with nasal sinus disease can be a frustrating condition for patients and their physicians. A better understanding of the causes and pathophysiology of olfactory dysfunction can provide a framework from which the physician can plan appropriate treatment and counsel patients as to probable outcomes. This article reviews the pathophysiology of smell loss and the diagnostic paradigms and treatment approaches for the more common causes of anosmia.

Growth-related oncogene-alpha expression in human nasal polyps

The cytokine growth-related oncogene-alpha (GRO-alpha) is a potent mediator of leukocyte recruitment and proliferation in inflammatory diseases. We hypothesized that GRO-alpha is produced in the inflammatory nasal polyp microenvironment. Evaluation of nasal polyps from 27 patients for distribution and content of GRO-alpha antigen, by use of immunohistochemical techniques and ELISA, revealed its presence in all 27 tissue samples. It was found predominantly within the eosinophils and neutrophils, with tissue levels ranging from 34 pg/mg total protein (TP) to 1746 pg/mg TP, with a mean value of 631 +/-98 pg/mg TP. Control tissues contained between 82 pg/mg TP and 316 pg/mg TP (mean 176+/-38 pg/mg TP). These results were statistically significant (P<0.03). Clinical correlations and statistical comparisons were calculated. These data suggest that GRO-alpha may be an important factor in the recruitment and activation of leukocytes in nasal polyposis, making it a potential target for therapeutic intervention.

Linking upper and lower airways

BACKGROUND

Upper and lower airways are similar in many ways, including common triggers, pathogenic mechanisms, and response to treatment. Explanations for the posed linkage between upper and lower airways include nasal-bronchial reflux, postnasal drainage of inflammatory material into the lower airways, and dry air impinging on the nasal mucosa.

CONCLUSION

Treatment modalities such as antihistamines and corticosteroid aerosols by the nasal route improve both the upper and lower airways.

Effects of systemic steroid treatment in chronic polypoid rhinosinusitis evaluated with magnetic resonance imaging

BACKGROUND

The aim of this prospective study was to evaluate the efficacy of a combined (local and systemic) steroid therapy on the extent of chronic polypoid rhinosinusitis and patient symptoms.

METHODS AND PATIENTS

Subjects of this study were 20 patients with severe chronic polypoid rhinosinusitis with total or subtotal narrowing of the all sinuses. A nasal budesonide spray (2 x 0.1 mg/day) and an oral fluocortolone medication with a daily reduction during a 12-day period (total dose: 560 mg = group 1) and a 20-day period (total dose: 715 mg = group 2), respectively, were administered. Before and after the steroid treatment we evaluated the extent of the sinusitis with MRI and patient symptoms with symptom-related questionnaires.

RESULTS

A significant reduction (> 30%) of the chronic polypoid rhinosinusitis was observed in 50% of MRI findings. The steroid effect on polypoid masses was heterogeneous in different anatomic areas (maxillary sinus 40%, anterior ethmoid 19%, posterior ethmoid 33%, sphenoidal sinus 61%, frontal sinus 46%). Most sinusitis-related symptoms were distinctly diminished in most patients (80%). No major side effects were observed.

CONCLUSIONS

A combined short-term steroid therapy is highly effective in chronic polypoid rhinosinusitis, reducing the mucosal inflammation mainly in the large sinuses and reducing the incidence of symptoms significantly. However, this therapy was insufficient in the anterior ethmoid and cannot replace the current surgical treatment concept of the osteomeatal complex in CPR. The indication for such a short-term steroid therapy is the preoperative treatment. It facilitates functional endoscopic sinus surgery by reducing the extent of surgical procedures, the time, and thereby the risks of sinus surgery.

Characterization of the eosinophil chemokine RANTES in nasal polyps

Previous studies have demonstrated that the cytokine RANTES (Regulated And Normal T cell Expressed and Secreted) has been shown to be a potent mediator of eosinophil chemotaxis in vitro and of leukocyte recruitment. Because eosinophils are the hallmark cells in nasal polyposis, we hypothesize that RANTES is locally produced within the nasal polyp microenvironment and is responsible for the eosinophil recruitment seen in nasal polyposis. To begin to test this hypothesis, we evaluated nasal polyps from 17 patients and 3 control specimens for distribution and content of RANTES using immunohistochemical techniques and enzyme-linked immunosorbent assay technology. Our immunohistochemical studies demonstrated that in nasal polyposis, RANTES antigen staining occurred predominantly within eosinophils and epithelial cells. To quantify the relative levels of RANTES in normal and nasal polyp specimens, tissue homogenates were prepared, quantified, and normalized to protein levels. We detected RANTES in all 17 nasal polyp tissue homogenates (566 +/- 16 pg/mg total protein). The RANTES levels in nasal polyp homogenates were nearly 40-fold higher than the RANTES levels in normal tissue (15.7 +/- 28.2 pg/mg total protein). Thus, it appears that increased expression of RANTES by eosinophils and epithelial cells within the nasal polyp microenvironment promotes eosinophil recruitment and activation within nasal polyps. We hypothesize that RANTES induces increased recruitment and activation of eosinophils, presumably contributing to the increased tissue changes associated with nasal polyposis.

Interleukin-8 Expression in Human Nasal Polyps

The cytokine Interleukin 8 (IL-8) has been shown to be a potent mediator of leukocyte recruitment and neovascularization in inflammatory and neoplastic diseases. In this study we hypothesize that IL-8 produced in the nasal polyp microenvironment is responsible for the leukocyte recruitment seen in nasal polyposis. To test this hypothesis we evaluated nasal polyps for distribution and content of IL-8 antigen with immunohistochemical techniques and radioimmunoassay to determine tissue levels of IL-8. The immunohistochemical results demonstrated that IL-8 antigen staining occurred predominantly within inflammatory cells and epithelium. IL-8 was detected in all nasal polyp tissue homogenates (a mean value of 1767 ± 1633 pg/mg total protein (TP) with a range of 134 to 3668 pg/mg TP vs control specimens with a mean value of 77 pg/mg TP with a range of 0.09 to 255 pg/mg TP). These data demonstrate the presence and distribution and levels of IL-8 antigen in nasal polyps in vivo, supporting our hypothesis that local production of IL-8 could be an important factor in the sustained recruitment of leukocytes in nasal polyposis. Thus IL-8 likely plays a significant role in the pathogenesis of this disease process and therefore is a potential target for therapeutic intervention.

Interferon gamma expression in human nasal polyps

One feature among nasal polyps (NPs) is the predominance of lymphocytes and eosinophils. We hypothesize that elevated levels of interferon gamma (IFN-gamma) activate lymphocytes and eosinophils within the NP microenvironment. Nasal polyps were evaluated for distribution and levels of IFN-gamma in specimens from 27 patients with nasal polyposis and 4 controls. Immunohistochemical study revealed IFN-gamma staining of eosinophils, glandular cells, and epithelium (27 of 27 patients). ELISA analysis indicated elevated IFN-gamma levels in total NP tissues (25.6 +/- 7.23 pg/mg total protein [TP]) compared with controls (16.27 +/- 6.54 pg/mg TP). Three subpopulations were identified based on IFN-gamma levels: low IFN-gamma group (10.7 +/- 5.51 pg/mg TP); medium IFN-gamma group (25.70 +/- 5.90 pg/mg TP); and high IFN-gamma group (52.58 +/- 10.29 pg/mg TP). The latter levels were approximately 3.5 times the control levels (P<0.0025). Patients with previous polypectomy surgery showed higher levels of IFN-gamma compared with controls (P<0.0423). A trend was found with increased IFN-gamma levels and allergy, asthma, and topical steroid use.

Nasal polyps: medical or surgical management?

Nasal polyposis is considered to be a non-IgE-mediated inflammatory condition of the nose and sinuses, often associated with chronic non-allergic rhinitis, aspirin intolerance and non-allergic asthma. The aetiology of nasal polyposis is unknown. The main symptoms are nasal obstruction and disturbance of the sense of smell. Occlusion of the nasal passage by a few large polyps could be treated by simple polypectomy to help the patient breathe through the nose. Polypectomy per se does not worsen asthma. Other surgical procedures can be performed, depending on the degree of the disease. The aim of surgery is to restore the physiological properties of the nose by making the nose as free from polyps as possible, and to allow drainage of infected sinuses. Complementary medical treatment of polyposis is always necessary, as surgery cannot treat the inflammatory component of the mucosal disease. In this respect, topical corticosteroids have long been the drugs of choice to reduce the size of polyps, to prevent recurrence after surgery, and are often the main treatment for the disease in many patients. Fluticasone propionate has now been shown to be at least as effective as beclomethasone dipropionate as a medical tool in the management of polyposis. Short-term treatment with systemic corticosteroids is an alternative method of inducing remission and controlling nasal polyps. However, in most patients with nasal polyps, treatment consists of both medical and surgical management.

Nasal cytology in patients with allergic rhinitis: effects of intranasal fluticasone propionate

BACKGROUND

Nasal cytograms of patients with allergic rhinitis contain increased numbers of eosinophils and basophilic cells. Neutrophils are also more numerous in cytograms of allergic persons. Topical intranasal corticosteroid therapy for allergic rhinitis has been shown to decrease the numbers of some inflammatory cell types. Fluticasone propionate aqueous nasal spray, a potent synthetic corticosteroid preparation, is effective therapy for seasonal and perennial allergic rhinitis.

METHODS

Nasal mucosal scrapings were obtained with a Rhinoprobe (Apotex Scientific, Inc. Arlington, Texas) before and after therapy with fluticasone propionate aqueous nasal spray at several doses in patients with either seasonal allergic rhinitis (2 to 4 weeks' therapy) or perennial allergic rhinitis (24 weeks' therapy). More than 1000 paired nasal cytograms obtained from patients participating in five multicenter studies were evaluated.

RESULTS

The percentage of patients with nasal eosinophils (p < 0.01, most studies) and basophilic cells (p < 0.05, most studies) decreased significantly after treatment with fluticasone propionate compared with placebo-treated patients. Similar findings were observed with beclomethasone dipropionate in one study. The number of neutrophils remained relatively unchanged after treatment with the intranasal corticosteroids or placebo.

CONCLUSIONS

These findings suggest that the therapeutic benefits of topical intranasal fluticasone propionate and beclomethasone dipropionate for the therapy of seasonal and perennial allergic rhinitis are reflected by the decrease in inflammatory cells in the nasal mucosa.

Disorders in taste and smell

Although many conditions and medications have been associated with chemosensory disturbances, data from major chemosensory clinical research centers support three major disorders as being causative: nasal and paranasal sinus disease (21%), post-upper respiratory tract viral infection (19%), and head trauma (14%). Despite extensive evaluation, 22% of patients do not demonstrate identifiable causation.

Information leaflets in the rhinitis clinic?

Failure to get relief from topical steroid nasal spray is often blamed on poor administration knowledge. In a population of patients referred to the rhinitis clinic who have failed to get relief from topical steroid nasal spray when prescribed by the general practitioner, lack of patient education only accounts for 28 per cent of patient treatment failures and other factors e.g. poor compliance, erroneous diagnosis or severity of rhinitis will be responsible for the rest. Information leaflets are considered to be a good idea by nearly all patients but this study demonstrates that they would only be of therapeutic benefit to a minority of patients.

Nasal inhalation of the glucocorticoid budesonide from a spacer for the treatment of patients with pollen rhinitis and asthma

Glucocorticoid sprays are increasingly used for the treatment of allergic rhinitis and asthma. This therapy is highly effective, and side effects are few and mild. It was the aim of the present study to evaluate a physiological nasal inhalation technique, which results in airway deposition of the steroid molecule similar to that of inhaled allergen particles. Thirty adults with grass pollen-induced rhinitis and asthma inhaled the steroid molecule budesonide through the nose from a pressurized aerosol attached to a spacer device. Compared with inhalation of placebo, the treatment resulted in a significant reduction of nasal symptoms (P = 0.005), of bronchial symptoms (P = 0.005), but not of eye symptoms. In addition, nasal peak inspiratory flow (P = 0.0003) and oral peak expiratory flow (P = 0.02) increased. There was no difference between budesonide and placebo with regard to local side effects, such as nose bleeding, hoarseness, and irritation in mouth and throat. It is concluded that nasal inhalation of a steroid from a spacer offers effective therapy of pollen rhinitis and asthma without significant local side effects. This therapeutic modality may have advantages over the ordinarily used nasal and bronchial spray treatment in patients with both rhinitis and asthma, especially when conventional spray therapy is associated with local side effects.

Beclomethasone dipropionate versus flunisolide as topical steroid treatment in patients with perennial rhinitis

After a 2-week run-in period 23 atopics and non-atopics with perennial rhinitis were treated with intranasally nebulized aqueous flunisolide or aqueous beclomethasone dipropionate in a randomized, double-blind cross-over study, each treatment period being 4 weeks. Before and after each treatment period daily rhinitis symptoms were recorded, and additional determination of nasal airway resistance was performed by posterior rhinomanometry. No statistically significant difference between drugs was observed for any effect parameter recorded, and furthermore no difference in patient preference for either drug was found. It is concluded that both steroids are effective for the improvement of nasal airway in patients with perennial, atopic and non-atopic rhinitis.

Double-blind cross-over trial comparing beclomethasone dipropionate and terfenadine in perennial rhinitis

Eighteen patients with perennial rhinitis were evaluated in this double-blind cross-over trial comparing beclomethasone dipropionate (BDP) aqueous nasal spray with terfenadine tablets. Both treatments were effective in reducing symptom scores but BDP was significantly better than terfenadine in relieving running nose and sneezing (P less than 0.05). BDP also had a greater effect on reducing nasal inflammation than terfenadine. Although the clinicians and patients assessed both therapies to be equi-effective, significantly more patients preferred the BDP treatment (P less than 0.003). Overall, BDP therapy proved more beneficial than terfenadine therapy in this small group of perennial rhinitis sufferers.

Early/late response model: implications for control of asthma and chronic cough in children

The observed airways inflammation in asthma and chronic cough supports the conclusions of clinical trials, namely, that our treatment regimens should emphasize inhaled cromolyn. The need for bronchodilators as backup therapy is real but represents testimony to the fact that in some cases it has not been possible to entirely eliminate the inflammation and the consequent airways hyperresponsiveness.

In vitro effect of beclomethasone dipropionate and flunisolide on the mobility of human nasal cilia

Human nasal cilia were perfused with aqueous solutions of two corticosteroid aerosols, beclomethasone dipropionate (BPD) and flunisolide, with the main preservative of flunisolide, propylene glycol, and with placebo. The concentration used were BPD 0.1 mg/ml, 0.05 mg/ml, 0.005 mg/ml and 0.0005 mg/ml, flunisolide 0.25 mg/ml, 0.05 mg/ml, 0.025 mg/ml and 0.00025 mg/ml, and propylene glycol 20 mg/ml and 200 mg/ml. A dose-related decrease in ciliary beating frequency (CBF) was seen after perfusion with both BDP and flunisolide as well as propylene glycol. The decrease in CBF following perfusion with propylene glycol was partially reversible upon re-perfusion with medium alone, whereas the decrease seen after BDP and flunisolide was irreversible. Although previous studies have shown no adverse effect on the mucous membrane except for the areas hit by the impact of the sprays, our results suggest that caution should be taken when the dose and/or the length of treatment is considered, and that the effect of administration of these drugs on CBF in vivo needs to be investigated.

Inhibition of mediator release in allergic rhinitis by pretreatment with topical glucocorticosteroids

Patients with allergic rhinitis often have immediate symptoms after antigen challenge (the early-phase response), followed several hours later by a recurrence of symptoms (the late-phase response). Systemic glucocorticosteroids are known to inhibit the late-phase but not the early-phase response. We studied the effect of one week of pretreatment with topical (rather than systemic) glucocorticosteroids on the response to nasal challenge with antigen in a double-blind, randomized, placebo-controlled crossover study of 13 allergic patients who had previously had a dual response to nasal challenge. The patients were challenged with three 10-fold increments of allergen, producing an early response, and were then followed for 11 hours, encompassing the late response, before they were rechallenged with the lowest dose of allergen. We monitored their responses by means of symptom scores and measurements of the levels of histamine, tosyl-L-arginine methyl ester (TAME)-esterase activity, and kinins in nasal lavages. Topical glucocorticosteroids significantly reduced both the symptoms and the levels of histamine, TAME-esterase activity, and kinins in the early, late, and rechallenge allergic reactions. The fact that, in contrast to treatment with systemic glucocorticosteroids, prolonged pretreatment with topical glucocorticosteroids inhibited the early-phase response to antigen suggests that the route and duration of administration affect the mechanisms of action of the steroids. We conclude that inhibition of the early-phase as well as the late-phase response by topical glucocorticosteroids may provide an advantage over treatment with systemic glucocorticosteroids in patients with allergic rhinitis.

Allergic rhinitis. A useful guide to diagnosis and treatment

Patients presenting with typical signs and symptoms of allergic rhinitis may respond to avoidance of allergens and to medications for symptomatic relief. Treatment may include antihistamines, decongestants, cromolyn sodium, and/or topical nasal steroids. Patients whose symptoms are refractory to these therapeutic measures should be referred to an allergist for further evaluation and consideration for possible allergen immunotherapy.

Effect of beclomethasone dipropionate on nasal metachromatic cell sub-populations

The effect has been investigated of local administration of beclomethasone dipropionate (BDP) on cell numbers of nasal epithelial metachromatic cell (NMC) sub-populations. Twenty-one patients with perennial allergic rhinitis were studied in four groups according to the duration of treatment or after treatment with BDP. Nasal scrapings were taken after 1 week (Group 1) or 2 weeks (Group 2) of BDP treatment, or after discontinuing BDP for 1 week (Group 3) or 2 weeks (Group 4). Cells were fixed with Mota's lead acetate or 10% buffered formalin followed by toluidine blue staining to count the number of NMC and to classify these according to morphological sub-types (basophils or mast cells). Formalin-sensitive mast cells and basophils in nasal scrapings were reduced more than formalin-resistant mast cells with BDP treatment. Formalin-sensitive mast cells were also more prompt to recover from BDP than formalin-resistant mast cells. The results suggest that the formalin-sensitive NMC is a sub-population of cells which responds to BDP treatment in allergic rhinitis.

Relative importance of antibiotic and improved clearance in topical treatment of chronic mucopurulent rhinosinusitis. A controlled study

50 patients with chronic mucopurulent rhinosinusitis were randomly allocated to treatment with nasal sprays of dexamethasone, tramazoline, and neomycin, dexamethasone and tramazoline with no antibiotic, or matched placebo (propellant alone) four times daily to both nostrils for 2 weeks. The patients were assessed in a double-blind manner for symptomatic response and improvement in nasal mucociliary clearance, nasal airway resistance, sinus radiographs, and intranasal bacteriology and appearance. Both active preparations (with antibiotic 14 of 20 patients responded; without antibiotic 12 of 20 patients responded) were more effective than the placebo (2 of 10 patients responded). There was no significant difference in response between the active preparations with and without antibiotic. Thus, in treatment of chronic mucopurulent rhinosinusitis, reduction of the inflammatory response and decongestion make topical antibiotic unnecessary, probably by allowing host clearance mechanisms to recover.

An open cross-over trial comparing two doses of astemizole and beclomethasone dipropionate in the treatment of perennial rhinitis

An open cross-over trial comparing astemizole with intra-nasal aqueous beclomethasone dipropionate was carried out in forty-five perennial rhinitis patients attending a S.W. London general practice. Each drug was given for 12 weeks, separated by 4-8 weeks without medication. The principal outcome measure was a 7-day symptom diary completed by patients during weeks 4, 8 and 12. Patients were skin tested to seven common inhalant allergens. Half the patients beginning either regime failed to respond adequately within 2 weeks. Doubling the dose in these patients achieved satisfactory symptom control in an additional 67% on beclomethasone dipropionate and 45% on astemizole. Symptom diary scores showed beclomethasone dipropionate to be significantly more effective than astemizole in the treatment of skin test negative patients; but the two drugs were of equal benefit in the treatment of skin test positive patients. Sneezing and rhinorrhoea were the same on both drugs, but nasal blockage tended to be less severe on beclomethasone dipropionate. There was no significant difference between drugs in the frequency or duration of side effects. Beclomethasone dipropionate and astemizole are equally effective in the symptomatic treatment of atopic perennial rhinitis, but beclomethasone dipropionate may offer superior symptom relief in non-atopic perennial rhinitis.

Long-term safety and efficacy of budesonide nasal aerosol in perennial rhinitis. A 12-month multicentre study

A long-term safety study of intranasally administered budesonide, a topical glucocorticoid, has been performed. 104 patients with perennial rhinitis, allergic or non-allergic, participated in a multicentre study in seven ENT-clinics utilising an identical protocol. A budesonide dosage of 400 micrograms/day was used as starting dose, but the patients were at liberty to reduce the daily dose to 200 micrograms. The patients were observed at intervals up to 12 months. At the entry and follow-up visits the following parameters were recorded: rhinoscopic findings, nasal symptom scores, blood chemistry, hematology, urinalysis and determination of plasma cortisol levels before and after stimulation with ACTH (Synacthen). Nasal biopsies taken from 50 of the patients at the beginning and completion of the study were examined in a blinded way by an independent pathologist. The analysis revealed no histopathological changes of the nasal mucosa. At rhinoscopy no signs of atrophy or candida were reported. Lividity of the nasal mucosa was significantly reduced during the trial, which was also the case for nasal congestion and secretion. All nasal symptom parameters assessed by the patients were significantly reduced from baseline during the follow-up period. No clinically significant changes in the hematological and blood chemistry parameters were observed. Plasma cortisol analysis before and after challenge with ACTH revealed no influence on the hypothalamic pituitary adrenal axis. No tachyphylaxis was observed; on the contrary, there was a clear tendency for reduction of the daily dose of budesonide necessary to keep the patients symptom-free.(ABSTRACT TRUNCATED AT 250 WORDS)

Psoas muscle hypertrophy: mechanical cause for "jogger's trots?"

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Double blind, placebo controlled trial of betamethasone nasal drops for nasal polyposis

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Nasal bioavailability and systemic effects of the glucocorticoid budesonide in man

Budesonide, a topically potent glucocorticoid, was administered to 4 healthy volunteers by i.v. infusion and by nasal instillation of 100 micrograms tritium-labelled drug. Plasma was analyzed by liquid chromatography plus scintillation counting of collected fractions. After i.v. administration the plasma clearance was 0.921/min and the apparent volume of distribution was 2.81/kg. After nasal administration, the time to reach the peak plasma level was approximately 30 min, and the systemic availability was 102%. Budesonide had marginal effects on plasma cortisol and white blood cell counts either after i.v. or nasal administration. Thus, nasally instilled budesonide in solution is rapidly and completely absorbed from the nasal mucosa. The systemic effects after this clinically recommended nasal dose were negligible.

A single blind clinical comparison between 2 preparations of budesonide in the treatment of seasonal allergic rhinitis

A comparative study was carried out in 118 patients suffering from seasonal allergic rhinitis in order to evaluate possible differences between two different preparations of budesonide with regard to effect and adverse reactions. The glucocorticoid was supplied either as a freon propellant device (Rhinocort) or as a water solution in a mechanical pump spray. The freon aerosol was administered in a daily dosage of 400 micrograms. The water solution was administered in daily dosages of 400 micrograms or 200 micrograms. The patients scored their nasal and ocular symptoms daily for 1 month, and pollen counts were registered over the same period. The drugs employed in the study provided good control of the nasal symptoms. The daily dosage of 400 micrograms in both preparations proved more efficacious than the daily 200 micrograms dose in the nasal pump spray. No difference was found between the delivery systems when the same daily dosage was used. The number of adverse reactions was low and insignificant in all 3 treatment groups.

Comparison of flunisolide and beclomethasone dipropionate in seasonal allergic rhinitis

Sixty-nine patients were entered into a randomized, single-blind, parallel group study. Patients had a history of moderate to severe seasonal allergic rhinitis and all patients commenced treatment before the start of the pollen season. Treatment was with either flunisolide or beclomethasone dipropionate, both being administered as 2 sprays to each nostril twice daily for 7 weeks. Assessments of signs and symptoms of hay fever were made at admission and after 3 and 7-weeks' treatment. Patients were asked to keep a daily record of the severity of their symptoms. The overall effect of treatment was evaluated by both the patient and physician. Side-effects were elicited by indirect questioning. Sixty patients completed the study. Four patients from the flunisolide group and 2 from the beclomethasone group were lost to follow-up. Two further patients withdrew from the flunisolide group and 1 from the beclomethasone group. Analysis of results did not reveal any statistically significant differences between the treatments. Minor side-effects were reported by 1 patient from each treatment group. Both treatments proved to be effective in the treatment of hay fever and were equally well tolerated.