Rhinitis medicamentosa: aspects of pathophysiology and treatment

Use, Abuse, and Misuse of Nasal Medications: Real-Life Survey on Community Pharmacist’s Perceptions

Background: Medication overuse is an increasing global problem, especially for those rhinology diseases whose management requires over-the-counter drugs. This observational community pharmacy-based study aimed to investigate the actual use of the best-selling topical nasal medications and to characterize the clinical issues underlying their query through the pharmacist’s perception. Methods: In the pilot phase, a preliminary survey was developed by a team of researchers and tested on a small sample of practitioners to assess usability and intelligibility. Eventual amendments were made according to the feedback obtained, and the final version was submitted to practitioners working in 376 pharmacies evenly distributed over the Italian territory. Results: Two groups of customers (18–30 years old and 60–75 years old) were the ones who most frequently purchased topical decongestants. The dosage applied for sympathomimetic amines was higher than recommended in up to 44.4% and the duration of use longer than 5 days in up to 31.9% of the cases. Patients’ queries of alpha agonists and topical corticosteroids resulted in significantly higher numbers than practitioners’ prescriptions. Allergic rhinitis was the most common disease affecting patients seeking sympathomimetic amines. Conclusions: The prolonged use of sympathomimetic amines in patients suffering from rhinology diseases is a significant problem that requires greater attention in terms of social education and surveillance.

The selectivity of α-adrenoceptor agonists for the human α1A, α1B, and α1D-adrenoceptors

Highly selective drugs offer a way to minimize side-effects. For agonist ligands, this could be through highly selective affinity or highly selective efficacy, but this requires careful measurements of intrinsic efficacy. The α1-adrenoceptors are important clinical targets, and α1-agonists are used to manage hypotension, sedation, attention deficit hypersensitivity disorder (ADHD), and nasal decongestion. With 100 years of drug development, there are many structurally different compounds with which to study agonist selectivity. This study examined 62 α-agonists at the three human α1-adrenoceptor (α1A, α1B, and α1D) stably expressed in CHO cells. Affinity was measured using whole-cell 3 H-prazosin binding, while functional responses were measured for calcium mobilization, ERK1/2-phosphorylation, and cAMP accumulation. Efficacy ratios were used to rank compounds in order of intrinsic efficacy. Adrenaline, noradrenaline, and phenylephrine were highly efficacious α1-agonists at all three receptor subtypes. A61603 was the most selective agonist and its very high α1A-selectivity was due to selective α1A-affinity (>660-fold). There was no evidence of Gq-calcium versus ERK-phosphorylation biased signaling at the α1A, α1B, or α1D-adrenoceptors. There was little evidence for α1A calcium versus cAMP biased signaling, although there were suggestions of calcium versus cAMP bias the α1B-adrenoceptor. Comparisons of the rank order of ligand intrinsic efficacy suggest little evidence for selective intrinsic efficacy between the compounds, with perhaps the exception of dobutamine which may have some α1D-selective efficacy. There seems plenty of scope to develop affinity selective and intrinsic efficacy selective drugs for the α1-adrenoceptors in future.

Drug-related problems and pharmacy interventions in non-prescription medication, with a focus on high-risk over-the-counter medications

Background The risks associated with over-the-counter medication are often underestimated by consumers. The incorrect use of certain medications can lead to significant patient harm. Inappropriate use can be prevented by pharmaceutical counselling. Objective To determine the number and nature of drug-related problems in over-the-counter medication with a special emphasis on high-risk over-the-counter medications. Setting Fifty-two community pharmacies in Finland. Method This observational study was conducted as a questionnaire survey. The pharmacists working in participating pharmacies documented the observed drug-related problems and pharmacy interventions in over-the-counter medication during 1 week using an electronic study form based on the Westerlund drug-related problem classification system. Main outcome measure The prevalence of drug-related problems and problem types in different medication categories. Results The 52 community pharmacies documented 339 drug-related problems in 0.6% of over-the-counter customers, the most common problem being “Uncertainty about the indication for the drug” (39.2%). A significant proportion of the documented problems (26.3%) concerned high-risk over-the-counter medications, and the majority of these cases were associated with non-steroidal anti-inflammatory drugs (21.8%). In total, pharmacies made 641 interventions to resolve the drug-related problems. For majority of drug-related problems (87%), pharmacist’s intervention involved counselling. In more than half of the problem cases, the pharmacy intervention was precautionary. Conclusion Pharmacists intervene in and prevent problems related to over-the-counter medications, including high-risk medications like analgesics, in which inappropriate use due to consumers’ lack of knowledge can lead to severe consequences. As the selection and use of over-the-counter medications is continuously increasing, pharmaceutical counselling should be readily available and actively provided for consumers to achieve safer self-medication.

Effect of withdrawal of fusafungine from the market on prescribing of antibiotics and other alternative treatments in Germany: a pharmacovigilance impact study

PURPOSE

Knowledge on unintended consequences of product withdrawals is limited. Fusafungine, indicated for treatment of upper respiratory airways disease (URAD), was withdrawn in the EU on May 28, 2016. Given concerns about possible substitution with antibiotics, this study aimed to assess the impact of the withdrawal of fusafungine on prescribing of antibiotics and other treatments.

METHODS

The study was conducted using data from general practitioner (GP) and ear, nose and throat (ENT) practices in IMS® Disease Analyzer Germany. The quarterly prevalence of fusafungine prescribing was analysed for consultations involving the most common URAD between May 29, 2013 and May 28, 2017 in regular fusafungine-prescribing practices. Trends in the quarterly prevalence of antibiotics (AB), other nasal or throat preparations (N&T) and tyrothricin were analyzed. Practices with no fusafungine prescribing during the study served as controls. Changes in prescribing trend were evaluated using interrupted time series regression analysis.

RESULTS

In fusafungine-prescribing practices, withdrawal of fusafungine was associated with an immediate increase in prescribing of other N&Ts among patients consulting for URAD (+ 6.4%, 95% CI 2.3-10.5% in GP practices and + 9.0%, 95% CI 5.5-12.5% in ENT practices). There was no increase in antibiotic prescribing. In ENT practices; a small transient increase in tyrothricin prescribing occurred. No changes were seen in non-fusafungine-prescribing practices.

CONCLUSIONS

Withdrawal of fusafungine was not associated with increased prescribing of antibiotics but was associated with increased prescribing of other N&Ts. The unintended impact of substitution to other treatments should be considered routinely when products are withdrawn or restricted in other ways.

Management of Rhinitis Medicamentosa: A Systematic Review

OBJECTIVE

Rhinitis medicamentosa (RM) is a common condition resulting from overuse of topical nasal decongestants. Despite the prevalence in otolaryngologic practice, a clear treatment protocol has not been established. Our objective was to review the current published literature pertaining to the treatment of RM with the possibility of finding data that support one treatment over another.

DATA SOURCES

PubMed, Embase, Cochrane, and Web of Science databases were examined for patients diagnosed with RM resulting from chronic use of topical nasal decongestants.

REVIEW METHODS

The PRISMA standard (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was utilized to identify English-language studies reporting treatment of patients with the primary diagnosis of RM after chronic use of a topical decongestant. Outcome measures of interest included patient-reported symptom relief and objective parameters. MINORS criteria (methodological index for nonrandomized studies) were used to assess the quality of articles.

RESULTS

A total of 350 articles were identified, 9 of which met final inclusion criteria for qualitative analysis. Outcomes defined in each publication were highly varied and relied on several unstandardized measures. The most commonly reported treatment option was topical nasal steroids, although overall there was limited evidence on which to base treatment recommendation.

CONCLUSIONS

There is not adequate evidence to develop a standardized treatment protocol for RM. The development of a uniform questionnaire, standard outcomes to be measured, and a method of assessing such outcomes is necessary. Prospective randomized controlled studies are warranted to determine the optimal treatment regimen following diagnosis of RM.

Pharmacological Characterization of Postjunctional α-Adrenoceptors in Human Nasal Mucosa

Background

Functional α1- and α2-adrenoreceptor subtype pharmacology was characterized in an in vitro human nasal mucosa contractile bioassay.

Methods

Nasal mucosa was obtained from 49 donor patients and mucosal strips were placed in chambers filled with Krebs–Ringer solution and attached to isometric force transducers.

Results

Nonselective α-adrenoreceptor agonists epinephrine, norepinephrine, and oxymetazoline produced concentration-dependent contractions of isolated human nasal mucosa (pD2= 5.2, 4.9, and 6.5, respectively). The α2-adrenoreceptor agonist BHT-920 (10 μM)–induced contractions were blocked by yohimbine (0.01–1 μM) and prazosin (0.01–1 μM) inhibited the contractile response to the α1-adrenoreceptor agonist phenylephrine (10 μM). Histological analysis showed that phenylephrine and BHT-920 differentially contracted the arteries and veins of human nasal mucosa, respectively.

Conclusion

Our results indicate that functional α1- and α2-adrenoceptors are present and functional in human nasal mucosa. The a 2-adrenoceptors display a predominant role in contracting the veins and the α1-adrenoceptors appear to preferentially constrict the human nasal arteries.

Intranasal Application of the α2-Adrenoceptor Agonist BHT-920 Produces Decongestion in the Cat

The effect of α2-selective adrenoreceptor activation on nasal cavity dimension in an experimental model of congestion has not been defined. Presently, we used acoustic rhinometry to evaluate the decongestant activity of BHT-920, a selective α2-adrenergic agonist against nasal congestion produced by intranasal compound 48/80. Administration of the mast cell liberator compound 48/80 (1%) into a nasal passageway decreased ipsilateral volume and minimum cross-sectional area by 73 ± 4% and 42 ± 6%, respectively. The congestant effect of compound 48/80 was blocked by topical BHT-920 (0.3 and 1%) in a dose related manner. In addition, the decrease in minimum cross-sectional area produced by compound 48/80 was attenuated after topical BHT-920 treatment. As a comparison we also evaluated the topical decongestant activity effects of the α1-adrenergic agonist phenylephrine, and the nonselective α-agonist oxymetazoline. Both phenylephrine (0.1–1.0%) and oxymetazoline (0.01–0.3%) produced decongestion. The blood pressure effects of these three drugs also were evaluated. At doses of 0.3 and 1.0%, BHT-920 did not produce hypertension. In contrast, oxymetazoline (0.01–0.1%) produced a transient hypertension that peaked at 15 minutes and fully recovered 45 minutes after administration. The hypertensive effect of phenylephrine at 0.3 and 1.0% lasted over 60 minutes. The present findings indicate that selective α2-agonists may produce decongestant activity with an improved cardiovascular profile compared with current sympathomimetic drugs such as phenylephrine.

Effects of the inverse alpha-agonist doxazosin in allergic rhinitis

BACKGROUND

We examined the paradoxical hypothesis that the alpha-receptor inverse agonist doxazosin might produce beneficial effects in allergic rhinitis.

OBJECTIVES

To evaluate single and chronic dosing effects of doxazosin on nasal airflow and symptoms in allergic rhinitis.

METHODS

Fifteen patients randomized to receive 3-5 weeks of oral doxazosin 4 mg daily or placebo in crossover fashion. Measurements were taken at baseline and after first and last doses.

RESULTS

There was a fall in peak nasal inspiratory flow (PNIF) between baseline vs. first dose of doxazosin: mean difference -19 L/min (95% CI -35 to -2) P = 0.03, with recovery between first and last doses: 21 L/min (95% CI 7-34) P = 0.006. Nasal visual analogue scale (VAS) and blockage scores were worse between baseline vs. first dose of doxazosin: mean difference VAS -10 mm (95% CI -18 to -2) P = 0.02, blockage -0.7 (95% CI -1.3 to -0.1) P = 0.02, with recovery between first and last doses: VAS 15 mm (95% CI 4-25) P = 0.009, blockage 1.1 (95% CI 0.5-1.6) P = 0.001. The oxymetazoline dose-response for PNIF was blunted after single vs chronic dosing with doxazosin: mean difference -17 L/min (95% CI -30 to -4) P = 0.01. Heart rate and diastolic blood pressure showed the same pattern. There was a significant difference between doxazosin and placebo for nasal blockage score and heart rate after single but not chronic dosing.

CONCLUSIONS

There was a disconnect between single and chronic dosing effects of doxazosin for nasal symptoms, oxymetazoline response and cardiovascular outcomes, in turn suggesting alpha-1 receptor up-regulation.

[Possibilities of azelastine in the treatment of chronic rhinitis]

There is considered modern classification of rhinitis and the accents in diagnostic and therapeutic approaches to patients with this disease are indicated, as well as the possibilities of using topical intranasal antihistamines in the treatment of allergic, vasomotor and medicamentous rhinitis.

[Medically-induced rhinitis]

This paper summarizes the currently accepted concepts of the pathogenetic mechanisms underlying the morphological and functional changes in intranasal mucosa of the patients having a long history of the application of the long-acting topical vasoconstrictor agents. The author presents the data illustrating the effectiveness of various methods for the pharmacotherapeutic treatment of medically-induced rhinitis.

[The use of modern topical medications for the stepwise treatment of allergic rhinitis: the effectiveness and prospects for the further extension of their application]

The objective of the present work was to summarize the results of clinical studies designed to evaluate the effectiveness of 'Momate Rhino Advance' in the form of the nasal spray (based on the fixed combination of mometasone furoate and azelastine) that finds an increasingly wide application for the treatment of allergic rhinitis. The available data give evidence that this medication can be prescribed to the patients presenting with the severe and moderate form of allergic rhinitis. The treatment should be started with the use of the combined preparation and continued, after the adequate control of the clinical symptoms of allergic rhinitis is achieved, using 'Momate Rhino' during the next 2-4 weeks for the reliable management of the disease. It is concluded that the proposed strategy makes it possible to avoid the simultaneous application of multiple medications (polypragmasy) and thereby reduce the intake of medicines by the patients suffering from allergic rhinitis.

Use of Mometasone Furoate Aqueous Nasal Spray in the Treatment of Rhinitis Medicamentosa: An Experimental Study

OBJECTIVE: We aimed to investigate, histopathologic changes in the nasal mucosa of guinea pig's after prolonged administration of oxymetazoline and the development of rhinitis medicamentosa, and the efficacy of mometasone furoate aqueous nasal spray and saline in reversing the ultrastructural changes attributable to rhinitis medicamentosa.

METHODS: In the study, 24 male guinea pigs (500 to 600 gr) were used. Oxymetazolin (0.05%) was sprayed into the nasal cavities of the guinea pigs 3 times daily for 8 weeks. At the end of this period, 6 guinea pigs were killed and examined to make sure that the animals had developed rhinitis medicamentosa. The remaining guinea pigs were randomly divided into 3 groups. In the first group, one spray-puff of 0.05% mometasone furoate aqueous nasal spray (50 μg) was applied twice daily for 14 days. In the second group, saline solution (0.9% NaCl) was applied twice daily for 14 days. No treatment was performed in the third group. At the end of the treatment period, nasal mucosal changes were evaluated by light microscopy and electron microscopy.

RESULTS: After oxymetazolin application for 8 weeks, the main histologic changes were edema, congestion, proliferation of subepithelial glands, and squamous cell metaplasia. After topical mometasone furoate aqueous spray application for 2 weeks, the edema fluid was found to diminish markedly. In the saline and no treatment groups, edema and congestion continued. In these groups of guinea pigs, fibrosis has been seen in the nasal mucosa.

CONCLUSION: We found that mometasone furoate nasal spray was effective against experimentally induced rhinitis medicamentosa in guinea pigs. Mometasone furoate nasal spray may have value in the treatment of patients with rhinitis medicamentosa.

Self-medication in persistent rhinitis: overuse of decongestants in half of the patients

BACKGROUND

Patients with rhinitis often self-medicate with over-the-counter drugs, however this self-treating population has remained largely unstudied.

OBJECTIVE

To characterize individuals self-medicating persistent rhinitis and to determine the prevalence of and risk factors for intranasal decongestant overuse within this population.

METHODS

A cross-sectional observational study of individuals self-medicating persistent rhinitis (defined according to the Allergic Rhinitis and its Impact on Asthma guidelines). Participants (n = 895) completed a self-administered questionnaire to assess current symptoms, rhinitis medication, and previous physician diagnosis. Intranasal decongestant overuse was defined as daily use for at least 1 year.

RESULTS

The vast majority of subjects (95%) had moderate-to-severe rhinitis. Nasal congestion was the predominant symptom (median visual analog scale, 6.6 cm; interquartile range, 3.4 cm). Sixty-five percent had had their current nasal problems for more than 5 years. Approximately 80% had a physician diagnosis (mainly allergic rhinitis or rhinosinusitis). The prevalence of intranasal decongestant overuse was high (49%), despite the fact that most of the patients (80%) were educated about the limit on duration of use. Use of intranasal glucocorticosteroids was inversely related to being an overuser (odds ratio 0.24 [95% CI, 0.17-0.35]). The risk of intranasal decongestant overuse also was reduced by use of other medications (oral H1 antihistamines and decongestants), use of nasal saline solution, and more symptoms of itchy and/or runny eyes or colored mucus. Risk was increased by a more severely blocked nose, longer duration of symptoms, the presence of sleep disturbance, higher body mass index, and previous advice to limit the duration of intranasal decongestant use.

CONCLUSION

Half of the individuals self-medicating persistent rhinitis overused intranasal decongestants, despite the fact that they were educated about the limit on duration of use.

Mometasone furoate nasal spray plus oxymetazoline nasal spray: short-term efficacy and safety in seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) and associated congestion adversely affect patients' lives. The intranasal corticosteroid mometasone furoate nasal spray (MFNS) is effective for AR symptoms including nasal congestion, and the intranasal decongestant oxymetazoline (OXY) is effective against nasal congestion, but the combination has not been fully studied. This study was designed to assess the efficacy of the combination of MFNS and OXY for the relief of seasonal allergic rhinitis (SAR) symptoms.

METHODS

This phase 2 controlled clinical trial randomized adolescent and adult subjects (≥12 years; 2-year SAR) to MFNS q.d. (200 μg) + 3 sprays/nostril of OXY 0.05% (MFNS + OXY3); MFNS q.d. + 1 spray/nostril of OXY (MFNS + OXY1); MFNS q.d.; OXY b.i.d.; or placebo for 15 days, with 1-week follow-up. Coprimary end points were change from baseline in morning/evening (A.M./P.M.) instantaneous (NOW) total nasal symptom score (TNSS) over days 1-15 and AUC (AUC[0-4 hr]) change from baseline in day 1 congestion.

RESULTS

In 705 subjects, both combinations reduced A.M./P.M. NOW TNSS over days 1-15 significantly more than OXY b.i.d. or placebo (p ≤ 0.002). Mean standardized AUC(0-4 hr) day 1 congestion change from baseline was significantly greater in combination and OXY b.i.d. groups (MFNS + OXY3, -0.92; MFNS + OXY1, -0.80; OXY b.i.d., -1.06) versus placebo (-0.57) and MFNS q.d. (-0.63). Combinations and MFNS q.d. were significantly effective for A.M./P.M. NOW TNSS over each weekly period; OXY b.i.d. was superior to placebo in week 1. Adverse events (AEs) were few and similar across treatments; one MFNS q.d. and one placebo subject experienced a serious AE, with neither considered treatment related.

CONCLUSION

Combining MFNS with OXY relieves SAR symptoms, including congestion, with faster onset of action than MFNS q.d. and better sustained efficacy than OXY b.i.d.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses

In this review, anatomy and physiology of the respiratory mucosa of nose and paranasal sinuses are summarized under the aspect of its clinical significance. Basics of endonasal cleaning including mucociliary clearance and nasal reflexes, as well as defence mechanisms are explained. Physiological wound healing, aspects of endonasal topical medical therapy and typical diagnostic procedures to evaluate the respiratory functions are presented. Finally, the pathophysiologies of different subtypes of non-allergic rhinitis are outlined together with treatment recommendations.

Pathophysiology of nasal congestion

Nasal congestion is a common symptom in rhinitis (both allergic and nonallergic), rhinosinusitis and nasal polyposis. Congestion can also be caused by physical obstruction of nasal passages and/or modulation of sensory perception. Mucosal inflammation underlies many of the specific and interrelated factors that contribute to nasal congestion, as well as other symptoms of both allergic rhinitis and rhinosinusitis. A wide range of biologically active agents (eg, histamine, tumor necrosis factor-α, interleukins, cell adhesion molecules) and cell types contribute to inflammation, which can manifest as venous engorgement, increased nasal secretions and tissue swelling/edema, ultimately leading to impaired airflow and the sensation of nasal congestion. Inflammation-induced changes in the properties of sensory afferents (eg, expression of peptides and receptors) that innervate the nose can also contribute to altered sensory perception, which may result in a subjective feeling of congestion. Increased understanding of the mechanisms underlying inflammation can facilitate improved treatment selection and the development of new therapies for congestion.

WITHDRAWN: Nasal decongestants for the common cold

BACKGROUND

The common cold is a major and recurrent cause of morbidity, on average affecting children and adults two or more times each year. Nasal congestion is its commonest symptom and many therapies are marketed for its relief. There is no meta-analysis of controlled clinical trials on the effects of nasal decongestants in the common cold.

OBJECTIVES

To assess the efficacy of nasal decongestants at reducing the symptom of nasal congestion in adults and children with the common cold and to identify possible adverse effects associated with their use.

SEARCH STRATEGY

In this updated review in 2006, the following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2006, issue 3); MEDLINE (January 1996 to September 2006); OLDMEDLINE (1951 to 1965); EMBASE (1980 to Week 36, 2006). We contacted known principal investigators and pharmaceutical companies.

SELECTION CRITERIA

Randomised, placebo controlled trials of single-active oral and topical nasal decongestants in adults and children suffering from common cold.

DATA COLLECTION AND ANALYSIS

Two review authors (DT, GJL) independently extracted data. All outcomes variables were continuous. Subjective outcomes were normalised to a common scale and a weighted mean difference (WMD) was calculated. A standardised mean difference (SMD) was calculated for the objective outcomes.

MAIN RESULTS

Seven studies in adults, but none in children, fitted all inclusion criteria. There was a small but statistically significant 6% decrease in subjective symptoms after a single dose of decongestant compared with placebo. This was supported by a significant decrease in nasal airways resistance. With repeated doses, nasal decongestants produce a very small statistical benefit of 4% over three to five days, again supported by a decrease in nasal airways resistance. Two studies provided safety data for this meta-analysis, showing a relatively small number of adverse events and only a small increased risk of insomnia with pseudoephedrine compared to placebo.

AUTHORS' CONCLUSIONS

A single oral dose of nasal decongestant in the common cold is modestly effective for the short term relief of congestion in adults, and these drugs also provide benefit in some individuals after regular use over three to five days. Adverse events in adults are rare and mild. There is insufficient data on the use of these medications in children and therefore they are not recommended for use in children younger than 12 years of age with the common cold.

Nasal decongestants for the common cold

BACKGROUND

The common cold is a major and recurrent cause of morbidity, on average affecting children and adults two or more times each year. Nasal congestion is its commonest symptom and many therapies are marketed for its relief. There is no meta-analysis of controlled clinical trials on the effects of nasal decongestants in the common cold.

OBJECTIVES

To assess the efficacy of nasal decongestants at reducing the symptom of nasal congestion in adults and children with the common cold and to identify possible adverse effects associated with their use.

SEARCH STRATEGY

In this updated review in 2006, the following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2006); MEDLINE (January 1996 to September 2006); OLDMEDLINE (1951 to 1965); EMBASE (1980 to Week 36, 2006). We contacted known principal investigators and pharmaceutical companies.

SELECTION CRITERIA

Randomised, placebo controlled trials of single-active oral and topical nasal decongestants in adults and children suffering from common cold.

DATA COLLECTION AND ANALYSIS

Two review authors (DT and GJL) independently extracted data. All outcomes variables were continuous. Subjective outcomes were normalised to a common scale and a weighted mean difference (WMD) was calculated. A standardised mean difference (SMD) was calculated for the objective outcomes.

MAIN RESULTS

Seven studies in adults, but none in children, fitted all inclusion criteria. There was a small but statistically significant 6% decrease in subjective symptoms after a single dose of decongestant compared with placebo. This was supported by a significant decrease in nasal airways resistance. With repeated doses, nasal decongestants produce a very small statistical benefit of 4% over three to five days, again supported by a decrease in nasal airways resistance. Two studies provided safety data for this meta-analysis, showing a relatively small number of adverse events and only a small increased risk of insomnia with pseudoephedrine compared to placebo.

AUTHORS' CONCLUSIONS

A single oral dose of nasal decongestant in the common cold is modestly effective for the short term relief of congestion in adults, and these drugs also provide benefit in some individuals after regular use over three to five days. Adverse events in adults are rare and mild. There is insufficient data on the use of these medications in children and therefore they are not recommended for use in children younger than 12 years of age with the common cold.

Nasal Septal Perforation Secondary to Rhinitis Medicamentosa

Nasal septal perforation is a rarely reported complication of rhinitis medicamentosa. We describe such a complication in a 54-year-old man, and we discuss the clinical, pathologic, and imaging aspects of this case.

Idiopathic rhinitis, the ongoing quest

The term rhinitis in daily practice is used for nasal dysfunction causing symptoms-like nasal itching, sneezing, rhinorrhea and or nasal blockage. Chronic rhinitis can roughly be classified into allergic, infectious or nonallergic/noninfectious. When allergy, mechanical obstruction and infections have been excluded as the cause of rhinitis, a number of poorly defined nasal conditions of partly unknown aetiology and pathophysiology remain. The differential diagnosis of nonallergic noninfectious rhinitis is extensive. Although the percentage of patients with nonallergic noninfectious rhinitis with a known cause has increased the last decades, still about 50% of the patients with nonallergic noninfectious rhinitis has to be classified as suffering from idiopathic rhinitis (IR), or rather e causa ignota. Specific immunological, clinical and sometimes radiological and functional tests are required to distinguish known causes. Research to the underlying pathophysiology of IR has moved from autonomic neural dysbalans to inflammatory disorders (local allergy), the nonadrenergic noncholinergic (NANC) sensory peptidergic neural system and central neural hyperaesthesia, still without solid ground or proof. This review summarizes the currently known causes for nonallergic noninfectious rhinitis and possible treatments. Also possible pathophysiological mechanisms of IR are discussed.

Mucosal changes in rhinitis medicamentosa

To evaluate the nasal mucosal changes in rhinitis medicamentosa (RM), especially those related to goblet cells and subepithelial glands, we studied specimens of the inferior turbinate mucosa from 8 patients with RM, 8 patients with chronic hypertrophic rhinitis (CHR), and 5 patients with normal nasal mucosa. All specimens were assessed by electron microscopy and immunohistochemical study. Under a scanning electron microscope, hyperplasia of goblet cells was most prominent in the RM group, and an increased number of gland openings was evident in the RM and CHR groups. In addition, the immunoreactivity of epidermal growth factor receptor staining was strongest in the hyperplastic epithelium of the RM group. According to our results, it is feasible that the mucosa of patients with RM is in a chronic inflammatory, hypersecretory state. Degenerative changes in the secretory elements may cause impairment of mucociliary transport and may be responsible for the nasal obstruction and posterior nasal drip in RM.

[Tolerance and effectiveness of oxymetazoline and xylometazoline in treatment of acute rhinitis]

BACKGROUND

Local alpha-sympathomimetics in hydrous solution are well known in the therapy of acute rhinitis and sinusitis. However, added preservatives like benzalkonium chloride have a negative effect on compatibility.

PATIENTS AND METHOD

A total of 307 patients with acute rhinitis entered the study. The treatment with oxymetazoline with preservative, oxymetazoline without preservative and xylometazoline with preservative was evaluated.

RESULTS

This randomised, double-blind, multi-centered, verum-controlled tolerance study confirmed that the local sympathomimetics oxymetazoline and xylometazoline are well tolerated in the treatment of acute rhinitis. When evaluated according to the parameters "feeling of dryness in nasal mucosa" and "burning sensation", the Nasivin sanft 0.05% spray, which contains the active agent oxymetazoline without preservatives, proved to be considerably superior to preparations containing the preservative benzalkonium chloride.

CONCLUSION

Preparations without preservatives should be the preferred choice of treatment for acute rhinitis.

Management of allergic rhinitis: a common part of practice in primary care clinics

BACKGROUND

Allergic rhinitis (AR) is an extremely common disease worldwide and one of the top-ten reasons for a visit to primary care clinics. This study aimed to investigate the understanding of current guidelines and concepts of management for AR among general practitioners (GPs) in Singapore.

METHODS

A postal questionnaire was designed to survey the dispensing practice and understanding of current guidelines in the management of AR among Singapore GPs.

RESULTS

Two hundred GPs completed the questionnaire. AR was estimated to be 10-40% of total patient visits in 50% of the primary care clinics surveyed. There was no significant difference in diagnosis and management of AR among GPs practicing solo, as a group or in polyclinics. The use of allergy tests (skin or in vitro tests) was <50%. Most physicians understood correctly the efficacy, side-effects, and cost effectiveness of first and newer generation H1-antihistamines and nasal glucocorticosteroids. However, first generation H1-antihistamines and oral/nasal decongestants are commonly used to reduce the cost of medication and to achieve quick relief from nasal obstruction.

CONCLUSION

Management of allergic rhinitis is common in primary care clinics. Quick symptomatic relief with low-cost medications is a major concern for GPs in the management of AR, as it will affect a patient's compliance and perception of efficacy. However, inappropriate use of decongestants and other nonevidence-based therapies should not be recommended. Implementing the current evidence-based international guidelines for AR needs to be improved.

Safety review of benzalkonium chloride used as a preservative in intranasal solutions: an overview of conflicting data and opinions

BACKGROUND

For most multiuse aqueous nasal, ophthalmic, and otic products, benzalkonium chloride (BKC) is the preservative of choice. The American College of Toxicology has concluded that BKC can be safely used as an antimicrobial agent at concentrations up to 0.1%. BKC has been in clinical use since 1935 and is contained in a wide variety of prescription and over-the-counter products. However, over the past several years there have been conflicting reports of damage to human nasal epithelia and/or exacerbation of rhinitis medicamentosa associated with intranasal products containing BKC.

OBJECTIVE

We sought to review the published literature and determine whether there is sufficient, clinically significant data that would confirm that intranasal products containing BKC are likely to damage human nasal epithelia or exacerbate rhinitis medicamentosa.

METHODS

A literature search was conducted for in vivo and in vitro studies that evaluated the effects of BKC on human nasal epithelia.

RESULTS

A total of 18 studies (14 in vivo, 4 in vitro) were identified that evaluated short- and long-term exposure of concentrations of BKC in concentrations ranging from 0.00045% to 0.1%. Eight studies, including a 6-month and 1-year long-term treatment study, demonstrated no toxic effects associated with BKC, indicating that BKC was neither harmful to nasal tissue nor prone to exacerbate rhinitis medicamentosa. Furthermore, of the 10 studies that concluded that BKC resulted in degenerative changes in human nasal epithelia (eg, ciliary beat frequency, ciliary morphology, mucociliary clearance, epithelial thinning and/or destruction) or that BKC exacerbates rhinitis medicamentosa, only 2 (it was 2 according to the Results section) of these studies were supported by statistically significant differences between BKC and placebo or active control groups were compared. It is important to note that in both of these studies, the protocol incorporated the use or oxymetazoline in some or all of the subjects. Oxymetazoline is associated with rhinitis medicamentosa.

CONCLUSION

Intranasal products containing the preservative BKC appear to be safe and well tolerated for both long- and short-term clinical use.

Comparison of the clinical efficacy of standard and mucoadhesive-based nasal decongestants

AIMS

To compare two xylometazoline 0.1% preparations: reference commercial solution (RS) and test mucoadhesive solution (TS).

METHODS

Twenty subjects with perennial allergic rhinitis (age range 18-69 years, 5 atopic, 7 men) applied randomly in turn TS and RS for 5 days in a double-blind crossover clinical trial. Nasal airflow resistance (NAR), nasal symptoms (6 grade scoring), frequency of application (times/day), and side-effects were recorded.

RESULTS

Mean ratio TS/RS of areas under the resistance/time curves for NAR +/- 90% CI: 3.56 +/- 0.92; mean TS-RS differences +/- 95% CI: for congestion: -1.12 +/- 0.59, for frequency of application: -1.10 +/- 0.20. Subjects experienced fewer side-effects with TS.

CONCLUSIONS

A mucoadhesive solution with a decongestant had a greater and longer lasting effect on nasal congestion in subjects with perennial allergic rhinitis than the commercially available decongestant solution. It also caused fewer side effects.

Benzalkonium chloride as a preservative in nasal solutions: re-examining the data

Recent studies have suggested that benzalkonium chloride (BKC), an antimicrobial agent used as a preservative in nasal sprays, lacks deleterious effects on the nasal ciliated epithelium. Other data, including recent in vivo findings, suggest that BKC may, in fact, produce adverse clinical effects on human nasal tissue, including the aggravation of rhinitis medicamentosa. Toxic effects have also been reported. In light of the discrepancy between negative results and studies suggesting no safety concerns, we consider the possibility of problems in the design and methodology of some of the studies and in the interpretation of results. Clearly, further research is warranted to clarify the significance of conflicting findings. In the meantime, without conclusive data regarding BKC and the possibility of harmful effects, the use of nasal formulations without BKC might be a reasonable alternative.

Therapeutic options in allergic disease: antihistamines as systemic antiallergic agents

As has been reported throughout this supplement, the pathophysiologic factors of allergic diseases involve many elements of systemic disease-effector-cell recruitment from circulation, stimulation of bone marrow progenitors, systemic effector-cell priming, anaphylactic reactions, and others. With this understanding, allergic inflammation can be thought of as a reflection of systemic immunologic responses with compartmentalized manifestations in various organ systems, including the upper respiratory tract, lungs, gastrointestinal tract, and skin. Thus, any therapeutic approach to the treatment of allergic disease should address, in addition to the localized disease manifestations, the systemic immunologic dysregulation. Second-generation antihistamines (cetirizine, fexofenadine, loratadine) have been used since the 1980s to treat localized allergy symptoms in upper airways, skin, and, in some cases, the lungs; however, the efficacy of these agents in controlling systemic immune dysregulation and chronic allergic inflammation (eg, nasal congestion) has not been proved. The potential role of newer antihistamines in the amelioration of both localized and systemic aspects of allergic disease represents an active area of interest. Desloratadine, a new selective histamine H(1)-receptor antagonist with potent antihistaminic and anti-inflammatory activity, is introduced and its potential for treating the systemic aspects of allergic disease is discussed.

Allergic rhinitis: treating the adult

Allergic rhinitis is now recognized as a chronic medical condition that markedly affects patient quality of life and is a cause of substantial medical care expenditures. Effective treatment of adults with allergic rhinitis usually requires an integrated regimen that combines allergen avoidance measures, pharmacotherapy, and possible specific-allergen immunotherapy. This approach can control bothersome symptoms with minimal adverse effects in most patients. New medications, such as anti-immunoglobulin E therapy and cytokine antagonists, may provide relief to patients who are refractory to or do not tolerate currently available treatments.

Adverse effects of benzalkonium chloride on the nasal mucosa: allergic rhinitis and rhinitis medicamentosa

Prolonged, repeated use of nasal decongestants for symptomatic relief of allergic rhinitis often results in rhinitis medicamentosa (RM), a condition involving "rebound swelling" and additional congestion. Most decongestant sprays contain the preservative benzalkonium chloride (BKC), which causes toxic reactions in the nose, eyes, ears, and lungs, and may exacerbate the symptoms of allergic rhinitis. Recent studies demonstrate the effects of nasal sprays containing BKC or the decongestant oxymetazoline (OXY) in the development of RM. Using rhinostereometry, a technique that measures nasal mucosal swelling and nasal reactivity (with histamine challenge tests), prolonged use of OXY has been shown to induce nasal mucosal swelling and hyperreactivity. Sustained use of BKC alone induces nasal mucosal swelling and, in combination with OXY, BKC appears to have a long-term adverse effect on nasal mucosa. Its presence may also contribute to the RM resulting from overuse of decongestant sprays. Additional research is needed to confirm the deleterious effects of BKC in nasal products. However, these potential effects may be points of clinical differentiation in the treatment of allergic rhinitis and prevention of RM.