Lack of effect of fluticasone propionate aqueous nasal spray on the hypothalamic-pituitary-adrenal axis in 2- and 3-year-old patients

Allergic Rhinitis

Allergic rhinitis is a common ailment in primary and acute care settings. Diagnosis is clinical, by means of history and physical examination. Referral to an allergist is considered when symptoms are difficult to manage and/or confirmation by means of further testing is desired. Management of allergic rhinitis should not be considered trivial, as multiple secondary effects can present as the course progresses. Several treatment modalities exist but should begin with glucocorticoid nasal sprays and systemic second- or third-generation antihistamines.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Allergic Rhinitis

Allergic rhinitis is a common ailment in primary and acute care settings. Diagnosis is clinical, by means of history and physical examination. Referral to an allergist is considered when symptoms are difficult to manage and/or confirmation by means of further testing is desired. Management of allergic rhinitis should not be considered trivial, as multiple secondary effects can present as the course progresses. Several treatment modalities exist but should begin with glucocorticoid nasal sprays and systemic second- or third-generation antihistamines.

Safety of intranasal corticosteroids for allergic rhinitis in children

INTRODUCTION

Allergic rhinitis (AR) is a common chronic inflammatory disease of the nasal mucosa, affecting about 10-40% of children worldwide. Intranasal corticosteroids (INCSs) are the first line anti-inflammatory drug in the treatment of pediatric AR. The systemic and local adverse effects of INCSs in children with AR should be assessed.

AREAS COVERED

Randomized controlled trials (RCTs) reporting local and systemic adverse effects of INCSs in pediatric populations with AR were searched out of PubMed and Embase.

EXPERT OPINION

Overall, INCSs displayed a favorable safety profile and high local-systemic balance of bioavailability with a low incidence of adverse events in the treatment of AR children. Nevertheless, the use of INCSs should be designed depending on one patient's response and adverse effects. The benefits and risks of INCSs should be assessed to ensure the clinical efficacy and avoid the insidious events.

[Pharmacotherapy of allergic rhinitis: position of a clinical pharmacologist]

Pharmacotherapy for allergic rhinitis is based on different categories of drugs used either in monotherapy or in combination regimens. The current clinical guidelines suggest a stepwise approach to pharmacotherapy for allergic rhinitis. The use of intranasal corticosteroids is considered as the preferred second-stage pharmacotherapy. Inadequate control of AR symptoms in first-line therapy is a common problem. Integrated care pathways (ICP), developed taking into account the data obtained about patients using a mobile application, suggest the use of intranasal corticosteroids as the first line of therapy, including in patients with intermittent rhinitis who have not previously received treatment when assessing the condition according to the VAS for more than 5 points, in patients who received earlier treatment when assessing the condition according to the VAS less than 5 points. According to the data in the medical decision support system and continuing medical education UpToDate, inhaled corticosteroids are considered as the first-line drugs for the pharmacotherapy of allergic rhinitis. In terms of pharmacodynamic efficacy, intranasal corticosteroids are comparable to each other. The selection criteria can be considered: the value of systemic absorption; lipophilicity; the start time of the action; frequency of introduction, organoleptic properties; the possibility of influencing non-nasal symptoms. The use of sprays containing both a glucocorticoid and an antihistamine (mometasone furoate/azelastine hydrochloride) opens up additional pharmacotherapeutic possibilities in the treatment of allergic rhinitis.

Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Children

OBJECTIVES

To address concerns related to the safety profile of both Food and Drug Administration (FDA)-approved and non-FDA-approved intranasal corticosteroid (INCS) use in the pediatric population.

DATA SOURCE

Systematic review of MEDLINE, PubMed, and EMBASE databases using comprehensive search strategy, including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles.

REVIEW METHODS

A structured literature search was conducted. Extracted data included age, population size, study design, drug (dosage, route, and frequency), presence of hypothalamic-pituitary-adrenal (HPA) axis suppression, ocular symptoms, and growth velocity adverse events.

RESULTS

A total of 33 studies met inclusion criteria. The studies included use of INCS as nasal sprays and drops. There were no persistent abnormalities noted in cortisol level or intraocular pressure change. Growth velocity reduction was reported in 3 of 10 randomized trials. Meta-analysis of epistaxis and headache showed no significant difference in the incidence of headache or epistaxis when FDA-approved INCSs were compared to placebo, with a relative risk of 1.12 (95% CI, 0.77-1.63; P = .56) and 0.84 (95% CI, 0.60-1.18; P = .32), respectively. Meta-analysis was not performed for growth velocity, HPA axis suppression, and ocular change.

CONCLUSIONS

INCSs in FDA-approved routes of administration are generally safe to use in the pediatric population. Use of non-FDA-approved INCS drops may increase risk of iatrogenic Cushing's syndrome. Growth velocity reduction, HPA axis suppression, and visual changes due to INCS are uncommon.

Epistaxis Risk Associated with Intranasal Corticosteroid Sprays: A Systematic Review and Meta-analysis

Objective

Intranasal corticosteroids (INCSs) are widely utilized for the treatment of allergic rhinitis. Epistaxis is a known adverse effect of INCSs, but it is not known if the risk of epistaxis differs among INCSs.

Data Sources

Systematic review of primary studies identified through Medline, Embase, Web of Science, PubMed Central, and Cochrane databases.

Review Methods

Systematic review was conducted according to the PRISMA standard. English-language studies were queried through February 1, 2018. The search identified randomized controlled trials of INCSs for treatment of allergic rhinitis that reported incidence of epistaxis. An itemized assessment of the risk of bias was conducted for each included study, and meta-analysis was performed of the relative risk of epistaxis for each INCS.

Results

Of 949 identified studies, 72 met the criteria for analysis. Meta-analysis demonstrated an overall relative risk of epistaxis of 1.48 (95% CI, 1.32-1.67) for all INCSs. The INCSs associated with the highest risk of epistaxis were beclomethasone hydrofluoroalkane, fluticasone furoate, mometasone furoate, and fluticasone propionate. Beclomethasone aqueous, ciclesonide hydrofluoroalkane, and ciclesonide aqueous were associated with the lowest risk of epistaxis. Conclusions about epistaxis with use of budesonide, triamcinolone, and flunisolide are limited due to the low number of studies and high heterogeneity.

Conclusions

While a differential effect on epistaxis among INCS agents is not clearly demonstrated, this meta-analysis does confirm an increased risk of epistaxis for patients using INCSs as compared with placebo for treatment of allergic rhinitis.

The Comparison of Nasaleze and Mometasone Nasal Spray to Control the Symptoms of Allergic Rhinitis

BACKGROUND

Nasal corticosteroids are the main drug class for the treatment of allergic rhinitis, and their long-term continuous use can be problematic. The current study aimed to compare the use of Nasaleze and mometasone nasal spray in patients with allergic rhinitis.

MATERIALS AND METHODS

In this study, 64 patients were studied in two groups of 32 patients. Nasaleze was used for the first group and mometasone for the second group for 4 weeks. The severity of sneezing, runny nose, tearing, nasal congestion, itchy eyes, and scratchy throat were evaluated at the onset of the study, and also 14 and 28 days after treatment in the form of a single-blind study. Statistical analysis was performed using SPSS Software (SPSS Inc., Chicago, IL, USA, Version 20).

RESULTS

The severity of allergic rhinitis symptoms had a significant difference in both groups of Nasaleze and mometasone at three times. Furthermore, in the Nasaleze group, the intensity of tearing significantly reduced 14 and 28 days after treatment compared to the mometasone group. In addition, the mean pretreatment score of allergic had no significant difference in the two groups neither14 days nor 28 days after the treatment.

CONCLUSION

The efficacy of Nasaleze nasal spray is very similar to that of mometasone nasal spray to control the symptoms of allergic rhinitis. Therefore, Nasaleze nasal spray can be a suitable alternative for nasal corticosteroids in children older than 18 months, pregnant and lactating women.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety of intranasal corticosteroids

BACKGROUND

Concurrent use of intranasal corticosteroids (INCSs) and inhaled corticosteroids (ICSs) is indicated for patients who are comorbid for asthma and allergic rhinitis. Clinicians need to know the data regarding INCS safety for their patients with asthma.

OBJECTIVE

To discuss INCS safety data for the use of INCSs in patients with asthma and allergic rhinitis.

METHODS

INCS safety studies were selected for their relevance to the discussion.

RESULTS

To date, most studies regarding INCS safety are performed in patients with allergic rhinitis. These studies reveal no evidence of increased risk of nasal atrophy, and only isolated cases of septal perforation have been reported. Evidence of hypothalamic-pituitary-adrenal axis suppression is inconsistent and not clinically significant. Early growth studies indicated that beclomethasone dipropionate but not other INCSs have systemic effects on growth; however, newer, larger, and better designed studies are detecting small but significant growth effects in other INCSs. INCSs do not increase the risk of cataracts or glaucoma, although there are anecdotal data on transient elevated intraocular pressure. Data on concurrent use of INCSs and ICSs are limited, but these limited data reveal no evidence of systemic effects on the hypothalamic-pituitary-adrenal axis.

CONCLUSION

More studies of concurrent therapy are needed because concurrent use of ICSs and INCSs is common in practice. Clinicians might want to consider monitoring whether there are risk factors, such as a family history of glaucoma.

Intranasal Fluticasone Propionate Observational Cohort Safety Studies: Reviewing Evidence from Databases on Two Continents

Purpose

Our objective was to highlight the importance of database selection in observational research and to determine the incidence of corticosteroid-related events in patients exposed to fluticasone propionate intranasal spray (FPNS) compared with other intranasal steroids (INS).

Methods

After a feasibility study using an electronic medical record database in the UK (1990–2002), a retrospective cohort study was conducted using a large administrative claims database in the USA from 1994 to 2002 comparing the incidence and rate ratios of steroid-related events among intermittent, sub-chronic, and chronic FPNS use and other INS use episodes.

Results

Most patients used INS intermittently; power was low to evaluate risk associated with chronic use. Significantly elevated adjusted rate ratios were observed in the US study comparing FPNS with other INS for hypercorticism, sinusitis, abscess, and empyema, as well as a significantly decreased rate ratio for cataracts. The US claims database provided greater granularity on covariates and markers of severity to improve control of confounding for this study and time period, but neither database was able to assess the indication for prescription and the UK study could not address the use of INS without a prescription.

Conclusions

The FPNS results were consistent with the risk profile for INS and did not raise any new safety signals at the time of study conduct, which is consistent with the current safety profile. We were not able to discern the extent of potential off-label use of FPNS or other INS. Differences in the available data and healthcare systems highlight important considerations for database selection in the feasibility phase to assess the precision and limitations prior to formal risk evaluation.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0057-y) contains supplementary material, which is available to authorized users.

Optimal Duration of Allergic Rhinitis Clinical Trials

OBJECTIVE: Guidelines have been published by the Food and Drug Administration (FDA) and the European Agency for the Evaluation of Medicinal Products (EMEA) for the conduct of seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR) studies. These guidelines have differences regarding the duration of such trials: the FDA suggests 2 weeks for SAR and 4 weeks for PAR but the EMEA suggests 2 to 4 weeks for SAR and 6 to 12 weeks for PAR trials. In the interest of global harmonization, it would be desirable to have a uniform duration of such trials so that investigators, internationally, would be able to readily compare results for various types of treatments based on a single standard. Therefore, we performed an evidence-based review to answer the clinical question, What is the optimal duration for SAR and PAR clinical trials?

METHODS: We performed a MEDLINE search of the published literature from 1995 to the present. We used appropriate search terms, such as allergic rhinitis, seasonal allergic rhinitis, perennial allergic rhinitis, SAR, and PAR, to identify pertinent articles. These articles were reviewed and graded according to the evidence quality.

RESULTS: After an initial screening of more than 300 articles, 138 articles were analyzed thoroughly. No study specifically addressed the question of the optimal duration of SAR or PAR clinical trials.

CONCLUSIONS: We conclude that the current FDA (draft) guidelines calling for a study length of 2 weeks for the assessment of drug efficacy for SAR and 4 weeks for the study of drug efficacy in PAR are appropriate and that longer study periods are not likely to add meaningfully to the assessment of drug efficacy.

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Pediatric allergic rhinitis

Allergic rhinitis is a common pediatric problem with significant comorbidities and potential complications. This article is an overview of the epidemiology, pathophysiology, and current therapeutic strategies. Allergic rhinitis management in a specific child is age dependent and influenced by the severity and frequency of the symptoms and the presence of any concurrent conditions. Current strategies permit symptomatic control and improved quality of life for most patients.

Impact of study design on the evaluation of inhaled and intranasal corticosteroids' effect on hypothalamic-pituitary-adrenal axis function

In part I of this review, an overview of the designs of hypothalamic-pituitary-adrenal (HPA) axis studies in the setting of inhaled corticosteroids (ICS) or intranasal corticosteroids (INS) use was discussed. Part II provides detailed discussion on the HPA axis evaluation results for each common ICS and INS, and how these results are possibly affected by the factors of study design. Significant adrenal suppression at conventional ICS/INS doses appears to be rare in clinical settings. The magnitude of cortisol suppression varies widely among different study designs. Factors potentially impacting this variability include: the choice of dose, dosing duration, assay sensitivity, statistical methodology, study population, and compliance. All of these factors have the potential to affect the extent of HPA axis effects detected and should be considered when designing or interpreting the results of a HPA axis study.

The safety and efficacy of short-term budesonide delivered via mucosal atomization device for chronic rhinosinusitis without nasal polyposis

BACKGROUND

Budesonide is a potent corticosteroid commonly prescribed for management of inflammation in chronic rhinosinusitis (CRS). The standard for prescribing budesonide is via impregnated nasal saline irrigation (INSI), although recently the mucosal atomization device (MAD) has emerged as a theoretically superior method of distributing medication into the sinuses. The MAD atomizes medication into small droplets and this is thought to enhance absorption and improve bioavailability. However, no studies have shown whether enhanced absorption and improved bioavailability of budesonide via MAD causes adrenal suppression. The objective of this study is to determine whether budesonide via MAD affects the hypothalamic-pituitary-adrenal (HPA) axis.

METHODS

Twenty CRS patients were recruited from a tertiary rhinology clinic and randomized to take budesonide (1 mg) via MAD or via INSI twice a day for 60 days. The adrenocorticotropic hormone (ACTH) stimulation test and 22-item Sinonasal Outcomes Test (SNOT-22) questionnaire were administered on days 1, 30, and 60 of the study. Plasma budesonide and cortisol levels were simultaneously quantified using a high-performance liquid chromatography-tandem mass spectrometry technique.

RESULTS

There was no indication of adrenal suppression in either group (n = 20) based on ACTH stimulation test results nor was there significant plasma budesonide levels detected in either group. Quality of life, as indicated by SNOT-22, did not differ between groups at 60 days (p = 0.404; 95% confidence interval [CI], -37.2 to 15.9), but SNOT-22 scores for patients using MAD did show statistically significant improvement at 60 days compared to baseline (p = 0.02).

CONCLUSION

The MAD is likely a safe and effective method of delivering budesonide to the sinuses in the short term.

Impact of mometasone furoate nasal spray on individual ocular symptoms of allergic rhinitis: a meta-analysis

BACKGROUND

Intranasal corticosteroids (INSs) are a mainstay of treatment of allergic rhinitis (AR) nasal symptoms. The INS mometasone furoate nasal spray (MFNS) has well-documented efficacy and safety for the treatment and prophylaxis of nasal symptoms of seasonal AR (SAR) and for the treatment of nasal symptoms of perennial AR (PAR). Increasing interest has focused on whether INSs, including MFNS, may have beneficial effects on the ocular symptoms frequently associated with AR.

METHODS

We performed a meta-analysis of 10 randomized, placebo-controlled trials of the efficacy of MFNS 200 mcg daily in relieving ocular allergy symptoms, including itching/burning, redness, and tearing/watering in both SAR and PAR. Four PAR studies and six SAR studies are included in the analysis. A fixed-effect inverse variance model was used to calculate weighted mean differences, 95% confidence intervals (CIs) for each comparison, and a combined overall treatment effect (Z) with P-value.

RESULTS

In both analyses of SAR and PAR studies, including 3132 patients, all individual ocular symptoms were reduced in patients treated with MFNS. Overall treatment effect was significant for all three individual ocular symptoms in the SAR studies (Z = 9.18 for tearing, Z = 10.15 for itching, and Z = 8.88 for redness; P < 0.00001 for all) and in the PAR studies (Z = 5.94, P < 0.00001 for tearing; Z = 2.43, P = 0.02 for itching; and Z = 2.42, P = 0.02 for redness).

CONCLUSIONS

Our findings add to the growing body of literature supporting the positive class effect of INSs, including MFNS, on ocular symptoms associated with SAR and PAR.

Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation

Adenoidal hypertrophy (AH) and adenotonsillar hypertrophy are common disorders in the pediatric population and can cause symptoms such as mouth breathing, nasal congestion, hyponasal speech, snoring, and obstructive sleep apnea (OSA), as well as chronic sinusitis and recurrent otitis media. More serious long-term sequelae, typically secondary to OSA, include neurocognitive abnormalities (e.g. behavioral and learning difficulties, poor attention span, hyperactivity, below average intelligence quotient); cardiovascular morbidity (e.g. decreased right ventricular ejection fraction, left ventricular hypertrophy, elevated diastolic blood pressure); and growth failure. Adenoidectomy (with tonsillectomy in cases of adenotonsillar hypertrophy) is the typical management strategy for patients with AH. Potential complications have prompted the investigation of non-surgical alternatives. Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) in the management of patients with AH. This article reviews the epidemiology and pathophysiology of AH with a particular focus on evidence of its association with allergy and allergic rhinitis. Current treatment options are briefly considered with discussion on the rationale and evidence for the use of INS.

Efficacy and long-term safety of mometasone furoate nasal spray in children with perennial allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) affects up to 40% of children by age 6 years. Perennial AR (PAR) causes sleep disturbance, diminishes concentration in school, impairs psychosocial functioning, and reduces quality of life. This study evaluated efficacy and long-term safety of the intranasal corticosteroid mometasone furoate nasal spray (MFNS) in children with PAR.

METHODS

This study comprised a double-blind, 4-week efficacy and safety period followed by a 6-month, open-label safety period. Primary efficacy variable during the double-blind period was mean change in physician-evaluated total nasal symptom score (TNSS) from baseline to day 15. Other efficacy variables during this phase included subject-evaluated TNSS, individual nasal symptoms, and total symptom score (TSS, nasal and non-nasal symptoms, summed). Physician-evaluated improvement in overall condition of PAR was assessed during the open-label period. Adverse events (AEs) were monitored throughout.

RESULTS

Subjects aged 3-11 years with PAR (n = 381) were randomized to MFNS 100 microg (n = 190) or placebo (n = 191) daily for 4 weeks; 357 subjects continued into the open-label period, receiving MFNS only. Between baseline and day 15, significantly greater mean changes were seen with MFNS-treated patients than placebo in physician-evaluated TNSS (-2.8, -39%, vs. -2.2, -32%; p = 0.02). Statistically significant improvements in MFNS versus placebo were reported for subject-evaluated TNSS, TSS, and individual nasal symptom scores (p < or = 0.03 for all). Improvement continued through the open-label period. Subjects treated with MFNS in both periods experienced a 45% further reduction in TSS in this study phase, while those who switched from placebo to MFNS saw a further 49% decrease. MFNS was well-tolerated in both periods. The most frequently reported treatment-related AEs during the double-blind period for MFNS and placebo, respectively, were epistaxis, seven (4%) and nine (5%); sneezing, five (3%) and seven (4%); headache, six (3%) and five (3%). During the open-label period, the AEs reported most often were epistaxis 37 (10%), headache nine (3%), and rhinitis 12 (3%).

LIMITATIONS

Studies in children present unique challenges because subjects are too young to grasp subjective concepts such as symptom severity, especially as rated on a numbered scale. In addition, the 6-month extension of the placebo-controlled phase used a single agent. It is also possible that subjects' symptoms could have abated independent of mometasone furoate treatment.

CONCLUSION

MFNS 100 microg/day effectively reduces TNSS, TSS (including ocular symptoms), and individual symptoms associated with PAR and is well-tolerated for up to 6 months in children aged 3-11 years with a safety profile similar to placebo.

HPA axis safety of fluticasone furoate nasal spray once daily in children with perennial allergic rhinitis

The effects of intranasal corticosteroids (INSs) on the hypothalamic-pituitary-adrenal (HPA) axis should be assessed for any to be marketed INS. The objective of this study was to assess the effects of fluticasone furoate nasal spray (FFNS) on cortisol production (as a measure of HPA axis function) following 6 wk of treatment with FFNS 110 microg once daily (QD) compared with placebo in pediatric patients with perennial allergic rhinitis (PAR). In this double-blind, parallel-group study, patients (n = 112) aged 2-11 yr with a 1-yr history of PAR (6 months for patients aged 2-3 yr) were randomized in a 1:1 ratio to either placebo or FFNS. Serum cortisol (SC) concentrations and urinary cortisol (UC) excretion were measured over a 24-h period at the randomization (baseline) and final treatment (week 6) visits for HPA axis evaluation in a domiciled environment (overnight in the clinic). Plasma samples were collected for FFNS at several time points over the 24 h after the final dose for pharmacokinetic analyses. FFNS was non-inferior to placebo with respect to change from baseline (expressed as a ratio) in 24-h SC weighted mean. The lower limit of the two-sided 95% confidence interval (CI) for the treatment ratio was greater than the pre-specified non-inferiority margin of 0.8 (treatment ratio = 0.97, 95% CI 0.88-1.07). UC excretion over 24 h at baseline and end of treatment was similar between treatment groups; no patients had 24-h excretion levels below normal range after 6 wk of treatment. Plasma concentrations of FFNS were generally non-quantifiable (<10 pg/ml). Results of the current study indicate that FFNS 110 microg QD has no significant effect on HPA axis function in 2- to 11-yr-old pediatric patients with PAR.

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.

Effect on growth of long-term treatment with intranasal triamcinolone acetonide aqueous in children with allergic rhinitis

BACKGROUND

Guidelines recommend treatment with intranasal corticosteroids for patients with allergic rhinitis (AR), but concerns remain about possible adverse effects.

OBJECTIVE

To present the 1- and 2-year growth results for children with AR treated with triamcinolone acetonide aqueous nasal spray.

METHODS

Thirty-nine children (aged 6.1-14.3 years at study entry) were treated with triamcinolone acetonide aqueous for 1 year, and a subset of 30 children completed a second year of treatment. The dose was physician titered to achieve control over AR symptoms. For each child, statural heights at baseline and at the 1- and 2-year (where available) visits, together with growth rates, were measured and were compared with predicted values.

RESULTS

There were no significant differences between measured and predicted heights at the 1- and 2-year visits. The mean (SD) measured--predicted difference was 0.3 (2.2) cm (95% confidence interval, -0.4 to 1.0 cm) at the 1-year visit and 0.5 (3.0) cm (95% confidence interval, -0.6 to 1.6 cm) at the 2-year visit. Mean differences in measured and predicted growth rates were nonsignificant at the 1- and 2-year visits.

CONCLUSIONS

Triamcinolone acetonide aqueous titered to control AR symptoms and given for 1 or 2 years had no significant effect on statural growth in children with AR.

Evaluating the safety of intranasal steroids in the treatment of allergic rhinitis

: Given that intranasal corticosteroids (INCs) are widely considered first-line therapies for treatment of rhinitis, it is important for the clinician to be comfortable with the side-effect profile and be able to discuss potential safety concerns regarding these therapies. Among the safety concerns with the use of INCs are the potential for growth suppression both short and long term, the potential for hypothalamic-pituitary-adrenal axis suppression, ocular safety, and the use of INCs concomitantly with inhaled corticosteroids in asthma patients. As all clinicians are aware, each patient can have individual responses to both efficacy and safety; however, the data reviewed suggest that the benefits outweigh the potential risks. Understanding the potential concerns and the data behind these concerns should give clinicians the information to be able to discuss this with patients and parents to incorporate appropriate therapy for those with allergic rhinitis.

Optimal management of nasal congestion caused by allergic rhinitis in children: safety and efficacy of medical treatments

Nasal congestion is such a frequent and multifactorial occurrence in young children that parents and medical caregivers often overlook the need for medical intervention. However, children with congestion can suffer quality-of-life detriments resulting from sleep disturbance, learning impairment, and fatigue. Congestion also impairs the normal nasal breathing that is physiologically important for the efficient cleaning and conditioning of inspired air. Further, the most common cause of congestion, allergic rhinitis, is considered a potential risk factor for asthma. Published guidelines on the treatment of allergic rhinitis agree that management strategies in children should follow the same principles as in adults, while recognizing the need for dosage adjustments and being aware of unique safety issues. Intranasal corticosteroids, with robust effects in reducing congestion and good tolerability, remain a treatment of choice. Despite lingering concerns about the potential for growth suppression with these drugs, clinical evidence suggests a very low risk at prescribed dosages, especially with compounds that have a low systemic bioavailability. Oral antihistamines are commonly cited as first-line options for allergic rhinitis, although their effect on nasal congestion is relatively modest. First-generation antihistamines should not be administered to children because of their sedative properties, which can worsen learning problems associated with allergic rhinitis. Second-generation oral antihistamines are preferred, although this class is not completely devoid of adverse effects. Other treatments, such as a nasal antihistamine, decongestants, and immunotherapy, present varying levels of safety and tolerability issues in children.

Use of intranasal corticosteroids in the management of congestion and sleep disturbance in pediatric patients with allergic rhinitis

Allergic rhinitis affects a large number of children and exerts a considerable socioeconomic impact. It is underdiagnosed and inadequately treated, which predisposes children to potentially serious comorbidities. Allergic rhinitis symptoms may create nighttime breathing problems and sleep disturbances and have a negative effect on a child's ability to learn in the classroom. Although antihistamines have shown efficacy in relieving many symptoms, they have little effect on nasal congestion. This article summarizes the advantages of intranasal corticosteroids, including their effectiveness against congestion and excellent safety profile. Intranasal corticosteroids with minimal systemic bioavailability provide topical drug delivery that minimizes the potential for systemic side-effects.

Intranasal corticosteroids: the development of a drug delivery device for fluticasone furoate as a potential step toward improved compliance

Devices for the aqueous delivery of intranasal corticosteroids to patients with allergic rhinitis have been available since 1984, so there is a need for new devices to be developed to provide ease of use, efficacy and safety. A novel drug delivery system has been developed for fluticasone furoate (FF; GlaxoSmithKline): a new enhanced-affinity glucocorticoid with a scent-free formulation. The FF system was developed, giving attention to patients' unmet needs, in order to promote acceptance and compliance. It demonstrates a number of key features including its ergonomic design, side-actuation system and short delivery nozzle. Exploiting issues with present devices highlighted the need for the FF system. This review reports data from key studies and surveys conducted by GlaxoSmithKline during development, to determine ease of use and acceptance of the FF system. Findings suggest that the FF system should aid in improving attitudes to the use of intranasal corticosteroids amongst physicians and patients.

Corticosteroids (inhaled and/or intranasal) in the treatment of respiratory allergy in children: safety vs. efficacy

BACKGROUND

Topical administration of Corticosteroids (CS) can reduce the total dose of CS required to treat the patient and minimize side effects. Topical CS is extremely effective and has an excellent safety profile. Nonetheless, care must be taken when multiple sites such as lungs, nose and skin are being treated. CS mechanisms of action on the inflammatory process are complex. The aim of this study is to review such mechanisms and the adverse events secondary to it.

METHODS

Review English database (Embase, PubMed, Scielo) searching words: CS, adverse events, inhaled CS, intranasal CS, and children.

RESULTS

There is a classic mechanism involving a genomic effect of CS and a non-genomic effect, independently of gene transcription process. This mechanism acts by reducing mucosal blood flow in the asthmatic airways. Second-generation topical CS is the treatment of choice in allergic diseases control because of their good anti-inflammatory activity, poor absorption and first-pass hepatic metabolism. When comparing different CS, it is important to compare therapeutically equivalent doses. Although topical CS reduces systemic side effects, local and even systemic side effects can occur. Many factors affect the amount of drug that reaches the lung, including inhaler technique and inhaler type, fine particle dose and particle distribution.

CONCLUSION

Most patients with allergic diseases respond to CS treatment, but there is a small subset of them whose response is unsatisfactory even with high doses of CS. They are classified as corticosteroid-resistant asthmatics. Pro-inflammatory cytokines appear to up regulate the expression of GRb that has been associated with CS resistance.

Caring for patients with allergic rhinitis

PURPOSE

Allergic rhinitis (AR) affects up to 40 million Americans, with an estimated cost of $2.7 billion per annum. This review discusses several therapeutic options that reduce the symptoms of AR, including allergen avoidance, antihistamines, intranasal corticosteroids (INS), leukotriene receptor antagonists, and immunotherapy.

DATA SOURCES

The articles included in this review were retrieved by a search of Medline literature on the subjects of AR, antihistamines, INS, leukotriene antagonists, and immunotherapy, as well as current published guidelines for the treatment of AR.

CONCLUSIONS

Allergen avoidance is recommended for all patients prior to pharmacologic therapy. Oral and nasal H(1)-antihistamines are recommended to alleviate the mild and intermittent symptoms of AR, and INS are recommended as the first-line treatment choice for mild persistent and more moderate-to-severe persistent AR.

IMPLICATIONS FOR PRACTICE

There are a number of different types of therapy for the management of AR; with so many options available, successful tailoring of treatment to suit individual requirements is realistically achievable.

Mometasone Furoate Nasal Spray

The development of corticosteroids that are delivered directly to the nasal mucosa has alleviated much of the concern about the systemic adverse effects associated with oral corticosteroid therapy. However, given the high potency of these drugs and their widespread use in the treatment of allergic rhinitis, it is important to ensure that intranasal corticosteroids have a favourable benefit-risk ratio. One agent that typifies the systemic safety found in the majority of intranasal corticosteroids is mometasone furoate nasal spray, a potent and effective treatment for seasonal and perennial allergic rhinitis and nasal polyposis. Mometasone furoate does not reach high systemic concentrations or cause clinically significant adverse effects. Results from pharmacokinetic studies in adults and children suggest that systemic exposure to mometasone furoate after intranasal administration is negligible. This is probably because of the inherently low aqueous solubility of mometasone furoate, which allows only a small fraction of the drug to cross the nasal mucosa and enter the bloodstream, and because a large amount of the administered drug is swallowed and undergoes extensive first-pass metabolism. There is no clinical evidence that mometasone furoate nasal spray suppresses the function of the hypothalamus-pituitary-adrenal axis when the drug is administered at clinically relevant doses (100-200 microg/day); consequently, mometasone furoate nasal spray has not been associated with growth inhibition in children. The safety and tolerability of mometasone furoate nasal spray have been rigorously assessed in clinical trials involving approximately 4,500 patients, with epistaxis, headache and pharyngitis being the most common adverse effects associated with treatment in adolescents and adults. The clinical effectiveness of mometasone furoate nasal spray, coupled with its agreeable safety and tolerability profile, confirms its favourable benefit-risk ratio.

Concerns about intranasal corticosteroids for over-the-counter use: position statement of the Joint Task Force for the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology

The Joint Task Force for the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology was charged with formulating a position paper regarding the potential release of intranasal corticosteroids for over-the-counter use. We took the position that safety issues regarding this proposal would be our sole concern. We reviewed the literature to evaluate the frequency and severity of potential adverse events related to the administration of intranasal corticosteroids. We limited this review to 5 areas: (1) effects on growth, (2) ocular effects, (3) effects on bone, (4) effects on the hypothalamic-pituitary-adrenal axis, and (5) local adverse effects. After review of the available data, we concluded that intranasal corticosteroids should remain prescription-only drugs. Patients receiving an intranasal corticosteroid should be instructed in its use and that use should be monitored by a physician or an appropriately trained medical provider (eg, nurse practitioner or physician assistant) under the direct supervision of a physician. This conclusion was reached based on the evidence that corticosteroids administered by any route, including the intranasal route, have the potential to cause adverse effects in all the areas noted herein. Our conclusion was strengthened by the fact that these adverse effects can be insidious and therefore not evident for many years; there is the potential for overuse; patients could also have access to other forms of topically administered corticosteroids, thus increasing their total dose; and individuals vary in their susceptibility to corticosteroid-induced adverse effects. We were also influenced to take this position knowing that generally reassuring data regarding the use of respiratory tract-administered corticosteroids are based on mean data and that all such studies have shown outliers in whom adverse effects were evident. Thus, as stated, we recommend that intranasal corticosteroids remain prescription-only drugs.

Pediatric Allergic Rhinitis: Treatment

Allergic rhinitis, an IgE-mediated disease, is the most common chronic childhood condition and is characterized by nasal sneezing, rhinorrhea, palate and eye itchiness, and congestion. Allergic rhinitis should be diagnosed as early as possible to avoid detrimental effects on the quality of life and comorbid disorders. Treatment initially involves avoidance measures and, when necessary, pharmacotherapy or immunotherapy. Pharmacotherapy generally involves antihistamines or nasal corticosteroids, but other medications such as leukotriene antagonists have demonstrated effectiveness in treating allergic rhinitis symptoms. Immunotherapy generally is reserved for patients unresponsive to therapy or unable to take medications.

Nasal corticosteroids for children with snoring

Nasal corticosteroids improve polysomnography indices but not symptoms in children with mild to moderate sleep-disordered breathing. We hypothesized that administration of nasal corticosteroids for 4 weeks to snoring children with only mild elevation in their apnea-hypopnea index would improve both polysomnography findings and symptoms of sleep-disordered breathing. Budesonide 50 mcg per nostril twice daily was administered for 4 weeks to children (2-14 years old) with habitual snoring and an apnea-hypopnea index of 1-10 episodes/hr. Subjects were evaluated before treatment and at 2 weeks and 9 months after its completion. Primary outcome variables were changes in apnea-hypopnea index and symptom score. Twenty-seven children were studied. At 2 weeks, the mean apnea-hypopnea index decreased from 5.2 (+/-2.2) episodes/hr to 3.2 (+/-1.5) episodes/hr, and median oxygen desaturation of hemoglobin index fell from 3.1 (0.4-8.2) to 1.9 (0.2-5.4) (P < 0.0001). Mean symptom score was 1.33 (+/-2.11) at baseline, and decreased to -0.008 (+/-2.24) at 2 weeks after treatment and to -1.08 (+/-1.75) at 9 months after treatment (P < 0.05). Four weeks of nasal budesonide improved both polysomnography findings and symptoms in children with mild sleep-disordered breathing. The clinical effect is maintained for several months after treatment.

Atopic diseases of childhood

PURPOSE OF REVIEW

The incidence of atopic diseases, including atopic dermatitis, allergic rhinitis, and asthma, has increased in developed countries over the past several decades. These diseases comprise a large component of general pediatric practice. This review will highlight some of the recent advances in understanding the pathogenesis and natural history of these diseases, as well as the current approaches to the treatment of children with atopic diseases.

RECENT FINDINGS

Recent studies have identified multiple risk factors for the development and progression of atopic diseases. As a result, much research is focused on identifying therapies that can be initiated at a young age to prevent disease progression. New treatment options have become available in recent years, such as topical immunomodulators for atopic dermatitis, leukotriene antagonists for seasonal allergic rhinitis, and alpha-immunoglobulin E therapy for asthma. The importance of viewing allergic rhinitis and asthma as disorders of a single airway has been emphasized. Finally, an update on the national asthma guidelines was recently released in an effort to promote optimal asthma care.

SUMMARY

This review summarizes many of the recent advances in the diagnosis and treatment of atopic diseases in children. Although not intended to be a comprehensive review of this broad field, it provides a framework for appreciating the complexity of these diseases and for effectively managing them.