Perennial rhinitis in the under 4s: a difficult problem to treat safely and effectively? A comparison of intranasal fluticasone propionate and ketotifen in the treatment of 2-4-year-old children with perennial rhinitis

Intranasal corticosteroids compared with oral antihistamines in allergic rhinitis: A systematic review and meta-analysis

BACKGROUND

Intranasal corticosteroids (INS) (corticosteroid nasal sprays) and oral antihistamines (OA) are two of the most common treatments for patients with allergic rhinitis (AR). To our knowledge, there are no systematic reviews on this topic including trials published after 2007.

OBJECTIVE

To compare INS with nonsedating OAs as treatments for AR.

METHODS

The systematic review and meta-analysis were based on the Grades of Recommendation, Assessment, Development, and Evaluation principles and the Patient, Intervention, Comparison, and Outcome approach. Primary literature was searched up to January 22, 2015. Criteria for eligibility were randomized controlled trials that compared the efficacy and/or adverse effects of INS and OA in patients with AR. Continuous outcome data were analyzed by using standardized mean differences (SMD) for multiple outcome measures, and mean differences in the case of a single study or outcome. Pooled estimates of effects, 95% confidence interval (CI), were calculated by using random-effects models.

RESULTS

The meta-analysis included five randomized controlled trials with a total of 990 patients. INS were superior to OAs in improving total nasal symptoms score (SMD -0.70 [95% CI, -0.93 to -0.47]) and in relieving the following: nasal obstruction (SMD -0.56 [95% CI, -0.82 to -0.29]), rhinorrhea (SMD -0.47 [95% CI, -1.00 to 0.05]), nasal itching (SMD -0.42 [95% CI, -0.65 to -0.18]), sneezing (SMD -0.52 [95% CI, -0.73 to -0.32]), and quality of life mean difference -0.90 [95% CI, -1.18 to -0.62]). There was no difference in relief of ocular symptoms (SMD -0.08 [95% CI, -0.23 to 0.08]). In addition, four randomized controlled trials were included in a narrative analysis. The results in the narrative analysis were comparable with those found in the meta-analysis.

CONCLUSION

INS were superior to OAs in improving nasal symptoms and quality of life in patients with AR.

Recent pharmacological developments in the treatment of perennial and persistent allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) has a major negative impact on patients' quality of life (QoL) and carries a high socio economic burden. This is particularly the case for patients who experience symptoms for extended periods of time (i.e. those with perennial (PAR) or persistent AR (PER), depending on the classification system used). This review covers available pharmacological advances and recent developments in the treatment of PAR or PER.

AREAS COVERED

Pharmacological AR treatment is used to reduce symptom burden and help restore patients' normal daily routine. Traditionally, non-sedating antihistamines and intranasal corticosteroids (INS) were the two drug classes recommended for use first line. These, along with antileukotrienes, decongestants, mast cell stabilizers and anticholinergics, constituted the bulk of the AR treatment arsenal. MP-AzeFlu (Dymista®, Meda, Solna, Sweden) is the most recent addition to that arsenal. It is a novel intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP) delivered in a single spray and has surpassed available therapies in terms of symptom control and treatment response. Other relatively new treatments for PAR or PER include H3 antihistamines, toll-like receptor (TLR) agonists, cellulose powders and micro-emulsions, novel biomolecular formulations and omalizumab. Each of these new additions is reviewed here.

EXPERT OPINION

A new AR drug class has recently been introduced (i.e. RO1AD58). Currently MP-AzeFlu is the only treatment option within this drug class. It can be estimated that combination treatments like MP-AzeFlu will become the mainstay of PAR and PER therapy since use will result in better compliance, improved efficacy over INS and a faster response together with good levels of tolerability. The challenge is to find other equally, or more effective, combination treatments, as has been the therapeutic standard in bronchial asthma for decades. The potential of biologics, as well as TLR-agonists and other new treatment options needs to be further evaluated.

Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children

Allergic rhinitis (AR) is a very common childhood disease that is associated with a significant reduction in the patients' quality of life. Its treatment combines educating the patients and their parents, immunotherapy and drug administration. However, even the best approach does not relieve the symptoms of a number of patients. Alternative therapies are particularly needed for children because the fear of adverse events frequently reduces parental compliance to the prescribed drugs, and immunotherapy is less easy to administer than in adults. In this prospective investigator-blinded study we evaluated whether children, with a documented history of seasonal grass pollen-related AR, benefit from nasal irrigation by assessing the effects on nasal signs and symptoms, on middle ear effusion and on adenoidal hypertrophy. We randomized children aged 5 to 9 years (median age 82 months) to normal saline or hypertonic saline (a 2.7% sodium chloride solution), administered twice-daily using a disposable 20 ml syringe, or no treatment. Nasal symptoms (rhinorrhea, itching, sneezing, nasal obstruction), swelling of turbinates, adenoid hypertrophy or middle ear effusion were assessed at baseline and after 4 weeks of treatment. Two hundred and twenty children (normal saline: 80; hypertonic saline: 80; no treatment: 60) completed the study. After four weeks, all the considered items were significantly reduced in the group receiving hypertonic saline (P < 0.0001), whereas in the group receiving normal saline only rhinorrhea (P = 0.0002) and sneezing (P = 0.002) were significantly reduced. There was no significant change in any of the items in the control group. The duration of oral antihistamines was significantly lower in the children receiving hypertonic saline than in those treated with normal saline or in controls. No adverse events were reported and parental satisfaction and compliance with the procedure were globally very good, regardless of the solution used. Using our procedure, hypertonic saline is effective, inexpensive, safe, well tolerated and easily accepted by children with seasonal grass pollen-related AR and their parents. Our data suggest that nasal irrigation with hypertonic saline might be included in the wide spectrum of therapies recommended for grass-pollen AR.

Cost-utility analysis of topical intranasal steroids for otitis media with effusion based on evidence from the GNOME trial

OBJECTIVES

To estimate the cost-effectiveness of topical intranasal steroids for the treatment of otitis media with effusion (OME) in primary care from the perspective of the UK National Health Service.

METHODS

An economic evaluation was conducted based on evidence from the double-blind, randomized, placebo-controlled GPRF [General Practice Research Framework] Nasal Steroids for Otitis Media with Effusion (GNOME) trial. Participants comprised 217 children aged 4-11 years who had at least one episode of otitis media or related ear problem in the previous 12 months and had tympanometrically confirmed bilateral OME. Children were randomly allocated to receive either mometasone furoate 50 microg or placebo spray once daily into each nostril for 3 months. The main outcome measure was the incremental cost per quality-adjusted life-year (QALY) gained for topical steroids compared with placebo. The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves at alternative willingness to pay thresholds.

RESULTS

Children receiving topical steroids accrued nonsignificantly higher costs (incremental cost/child: pound11, 95% confidence interval [CI]: - pound199 to pound222) and nonsignificantly fewer QALYs (incremental QALY gain/child: -0.0166, 95% CI: -0.0652 to 0.0320) than those receiving placebo. Topical steroids had a 24.19% probability of being cost-effective at a pound20,000 per QALY gained threshold, a 23.82% probability of being more effective and a 46.25% probability of being less costly. Sensitivity and subgroup analyses showed incremental costs and benefits to be highly sensitive to the methods used and the patient group considered, although differences between groups did not reach statistical significance in any analysis.

CONCLUSIONS

Topical steroids are unlikely to be a cost-effective treatment for OME in general practice.

Corticosteroid treatment in chronic rhinosinusitis: the possibilities and the limits

Chronic rhinosinusitis, including nasal polyps, is an inflammatory disease of the nose and sinuses. The medical treatment, mainly topical intranasal and oral corticosteroids, constitutes its first line of therapy. Long-term treatment with corticosteroid nasal spray reduces inflammation and nasal polyp size, and improves nasal symptoms such as nasal blockage, rhinorrea, and the loss of smell. Corticosteroid intranasal drops may be used when intranasal spray fails to demonstrate efficacy. Short courses of oral steroids are recommended in severe chronic rhinosinusitis with nasal polyps or when a rapid symptomatic improvement is needed. Endoscopic sinus surgery is only recommended when the medical treatment fails. Intranasal corticosteroids should be continued postoperatively. When using intranasal corticosteroids, care should be taken in selected populations such as children, pregnant women, and elderly patients; especially in those patients with comorbid conditions such as asthma, in which the overall steroid intake can be high due to the administration of both intranasal and inhaled corticosteroids.

Topical intranasal corticosteroids in 4-11 year old children with persistent bilateral otitis media with effusion in primary care: double blind randomised placebo controlled trial

OBJECTIVE

To determine the clinical effectiveness of topical intranasal corticosteroids in children with bilateral otitis media with effusion.

DESIGN

Double blind randomised placebo controlled trial.

SETTING

76 Medical Research Council General Practice Research Framework practices throughout the United Kingdom, between 2004 and 2007.

PARTICIPANTS

217 children aged 4-11 years who had at least one practice recorded episode of otitis media or a related ear problem in the previous 12 months, and with bilateral otitis media with effusion confirmed by a research nurse using otoscopy plus micro-tympanometry (B/B or B/C2, modified Jerger types).

INTERVENTION

Mometasone furoate 50 microg or placebo spray given once daily into each nostril for three months.

MAIN OUTCOME MEASURES

Proportions of children cured of bilateral otitis media with effusion assessed with tympanometry (C1 or A type) at one month (primary end point), three months, and nine months; adverse events; three month diary symptoms. Results 41% (39/96) of the topical steroid group and 45% (44/98) of the placebo group were cured in one or both ears at one month (difference favouring placebo 4.3% (95% confidence interval -9.3% to 18.1%). Poisson regression was done with adjustment for four pre-specified covariates (clinical severity, P=0.003; atopy, P=0.67; age, P=0.92; season, P=0.71). The adjusted relative risk at one month was 0.97 (95% confidence interval 0.74 to 1.26). At three months, 58% of the topical steroid group and 52% of the placebo group were cured (relative risk 1.23, 0.84 to 1.80). Diary symptoms did not differ between the two groups, and no significant harms were reported.

CONCLUSIONS

Topical steroids are unlikely to be an effective treatment for otitis media with effusion in general practice. High rates of natural resolution occurred by 1-3 months.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38988331; National Research Register NO575123823; MREC 03/11/073.

Efficacy and safety of triamcinolone acetonide aqueous nasal spray in children aged 2 to 5 years with perennial allergic rhinitis: a randomized, double-blind, placebo-controlled study with an open-label extension

BACKGROUND

Intranasal corticosteroids (INSs) are the most effective treatment for allergic rhinitis (AR). However, available INS safety and efficacy data in children younger than 6 years are limited.

OBJECTIVE

To report the first well-controlled study assessing the safety and efficacy of an INS in children aged 2 to 5 years with perennial AR.

METHODS

In a 4-week, multicenter, double-blind, parallel-group study, patients were randomized to receive triamcinolone acetonide aqueous nasal spray (TAA AQ), 110 microg once daily, or placebo. A subset of children continued into a 6-month, open-label phase. Efficacy end points included total nasal symptom scores. Safety measures included reports of adverse events, morning serum cortisol levels before and after cosyntropin infusion, and growth as measured using office stadiometry.

RESULTS

A total of 474 patients were randomized to receive TAA AQ (n = 236) or placebo (n = 238); 436 entered the open-label extension phase. Adjusted mean (SE) changes from baseline during the double-blind period in instantaneous and reflective total nasal symptom scores were -2.28 (0.16) and -2.31 (0.15), respectively, in the TAA AQ group (P = .09) vs -1.92 (0.16) and -1.87 (0.15) in the placebo group (P = .03). Adverse event rates were comparable between treatment groups. There was no significant change from baseline in serum cortisol levels after cosyntropin infusion at study end. The distribution of children by stature-for-age percentile remained stable during the study.

CONCLUSIONS

Use of TAA AQ, 110 microg once daily, for up to 6 months offers a favorable efficacy to safety ratio in children aged 2 to 5 years with perennial AR.

Allergic rhinitis

Childhood rhinitis may be classified into non-allergic and allergic. Allergic rhinitis is further divided into seasonal and perennial. Seasonal rhinitis is a disease particularly of teenagers and young adults and appears to be less common in primary and pre school age children. In seasonal rhinitis, with relevant grass pollen sensitization, the link between the allergen exposure and rhinitis is clear cut. However, in other situations such as perennial rhinitis and house dust mite allergen sensitization, the link between symptoms and allergen exposure is less certain. Avoidance of allergens often proves to be difficult in practice. Intranasal steroids are the treatment of choice for persistent moderate-severe allergic rhinitis and are more effective than antihistamines for relief of nasal obstruction. Antihistamines are effective for control of histamine related symptoms such as itching, rhinorrhoea and sneezing. The use and benefits of sublingual or injectable immunotherapy in children are controversial.

Mometasone furoate nasal spray is safe and effective for 1-year treatment of children with perennial allergic rhinitis

OBJECTIVE

Perennial allergic rhinitis (PAR) affects children at a young age. Current guidelines recommend intranasal corticosteroids as the first-line treatment in patients with moderate-to-severe or persistent disease or in those who have congestion. In this study, the long-term safety and efficacy of mometasone furoate nasal spray (MFNS) were assessed in children with PAR.

METHODS

In this multicenter, active-controlled, evaluator-blind, 12-month study, 255 children aged 6-11 years with a >or=1-year history of PAR were randomized to receive once-daily MFNS 100 microg (n=166) or the active comparator beclomethasone dipropionate (BDP) 168 microg (n=85). Changes from baseline in overall PAR symptoms and response to treatment were rated at each visit. Cosyntropin stimulation testing, as well as tonometry and slit lamp procedures, were performed. Safety variables were assessed.

RESULTS

A total of 137 subjects in the MFNS group and 68 in the BDP group completed treatment. The mean reductions in physician- and subject-rated overall condition of PAR at week 52 were -42.1% and -39.7%, respectively, for MFNS, compared with -44.0% and -39.0%, respectively, for BDP. A total of 94% and 100% of MFNS and BDP subjects, respectively, reported adverse events (AEs), which were mostly mild or moderate. The most frequently reported treatment-related AEs in both groups were epistaxis, headache, and pharyngitis. Response to cosyntropin was normal and no posterior subcapsular cataracts were observed in either group. Although no significant changes in intraocular pressure were observed with MFNS, one subject receiving BDP demonstrated this effect.

CONCLUSIONS

Treatment with MFNS 100 microg once daily for 1 year was well tolerated in children 6-11 years old, with negligible systemic exposure and no evidence of suppression of the hypothalamic-pituitary-adrenal axis or ocular changes.

Pharmacologic and anti-IgE treatment of allergic rhinitis ARIA update (in collaboration with GA2LEN)

The pharmacologic treatment of allergic rhinitis proposed by ARIA is an evidence-based and step-wise approach based on the classification of the symptoms. The ARIA workshop, held in December 1999, published a report in 2001 and new information has subsequently been published. The initial ARIA document lacked some important information on several issues. This document updates the ARIA sections on the pharmacologic and anti-IgE treatments of allergic rhinitis. Literature published between January 2000 and December 2004 has been included. Only a few studies assessing nasal and non-nasal symptoms are presented as these will be discussed in a separate document.

Environmental risk factors of rhinitis in early infancy

Previous studies of allergic rhinitis in children have not documented the environmental risk factors for infants at age one. We examined the relationship of environmental tobacco smoke (ETS) and visible mold exposures on the development of allergic rhinitis, rhinitis and upper respiratory infection (URI) in a birth cohort where at least one parent was skin prick test (SPT) positive. ETS exposure and upper respiratory symptoms were obtained by questionnaires. Visible mold was classified as none, low or high during home visit. Infants had a SPT at age one. After adjustment for potential confounders, exposure to >20 cigarettes per day was associated with an increased risk of developing allergic rhinitis at age one [odds ratio (OR)=2.7; 95% CI 1.04-6.8] and rhinitis symptoms during the first year (OR=1.9; 95% CI 1.1-3.2). Infants with low (OR=1.5; 95% CI 1.1-2.3) or high (OR=5.1; 95% CI 2.2-12.1) levels of visible mold in their homes were more likely to have more frequent URI during the first year. Older siblings were protective for development of both rhinitis symptoms and allergic rhinitis. This study suggests that ETS exposure, rather than visible mold, is associated with rhinitis and allergic rhinitis in infants. The analysis also suggests that mold may be a stronger risk factor for URI that ETS.