Allergic rhinitis in children : diagnosis and management strategies

IL-6 mediates olfactory dysfunction in a mouse model of allergic rhinitis

BACKGROUND

Immune-inflammatory response is a key element in the occurrence and development of olfactory dysfunction (OD) in patients with allergic rhinitis (AR). As one of the core factors in immune-inflammatory responses, interleukin (IL)-6 is closely related to the pathogenesis of allergic diseases. It may also play an important role in OD induced by diseases, such as Sjögren's syndrome and coronavirus disease 2019. However, there is no study has reported its role in OD in AR. Thus, this study aimed to investigate the role of IL-6 in AR-related OD, in an attempt to discover a new target for the prevention and treatment of OD in patients with AR.

METHODS

Differential expression analysis was performed using the public datasets GSE52804 and GSE140454 for AR, and differentially expressed genes (DEGs) were obtained by obtaining the intersection points between these two datasets. IL-6, a common differential factor, was obtained by intersecting the DEGs with the General Olfactory Sensitivity Database (GOSdb) again. A model of AR mice with OD was developed by sensitizing with ovalbumin (OVA) to verify the reliability of IL-6 as a key factor of OD in AR and explore the potential mechanisms. Furthermore, a supernatant and microglia co-culture model of nasal mucosa epithelial cells stimulated by the allergen house dust mite extract Derp1 was established to identify the cellular and molecular mechanisms of IL-6-mediated OD in AR.

RESULTS

The level of IL-6 in the nasal mucosa and olfactory bulb of AR mice with OD significantly increased and showed a positive correlation with the expression of olfactory bulb microglia marker Iba-1 and the severity of OD. In-vitro experiments showed that the level of IL-6 significantly increased in the supernatant after the nasal mucosa epithelial cells were stimulated by Derp1, along with significantly decreased barrier function of the nasal mucosa. The expression levels of neuroinflammatory markers IL-1β and INOS increased after a conditioned culture of microglia with the supernatant including IL-6. Then knockdown (KD) of IL-6R by small interfering RNA (siRNA), the expression of IL-1β and INOS significantly diminished.

CONCLUSION

IL-6 plays a key role in the occurrence and development of OD in AR, which may be related to its effect on olfactory bulb microglia-mediated neuroinflammation.

Inflammatory cytokines and risk of allergic rhinitis: A Mendelian randomization study

BACKGROUND

Epidemiological and experimental evidences have implicated chronic inflammation in the association with allergic rhinitis (AR). However, it remains unclear whether specific circulating cytokines are the cause of AR or the consequence of bias. To examine whether genetic-predicted changes in circulating cytokine concentrations are related to the occurrence of AR, we conducted a two-sample Mendelian randomization (MR) analysis.

METHODS

We investigated the causal effects of 26 circulating inflammatory cytokines on AR through MR analysis. The primary method employed in this study was the inverse variance-weighted (IVW) method. Sensitivity analyses were conducted using simple median, weighted median, penalized weighted median, and MR-Egger regression.

RESULTS

Our study revealed suggestive evidence that higher levels of circulating IL-18 (OR per one standard deviation [SD] increase: 1.006; 95 % CI, 1.002 to 1.011; P = 0.006, PFDR = 0.067, random-effects IVW method) and Macrophage inflammatory protein-1α (MIP-1α) (OR per one SD increase: 1.015; 95 % CI, 1.004 to 1.026; P = 0.009, PFDR = 0.048, random-effects IVW method) were associated with an increased risk of AR. Conversely, higher levels of circulating TRAIL were associated with a decreased risk of AR (OR per one SD increase: 0.993; 95 % CI, 0.989 to 0.997; P = 4.58E-4, PFDR = 0.004, random-effects IVW method). Only the results of TRAIL exist after Bonferroni-correction (the p-value < 0.0019). Sensitivity analysis yielded directionally consistent results. No significant associations were observed between other circulating inflammatory cytokines and AR.

CONCLUSION

Genetically predicted levels of IL-18, and MIP-1α are likely to associated with an increased risk of AR occurrence. Genetically predicted levels of TRAIL are statistically significant in reducing the risk of AR occurrence. However, the current research evidence does not support an impact of other inflammatory cytokines on the risk of AR. Future studies are needed to provide additional evidence to support the current conclusions.

Allergic Rhinitis

Allergic rhinitis (AR) affects more than 400 million people worldwide, making it 1 of the most prevalent chronic diseases. Childhood AR is increasing, and almost half of patients with AR develop symptoms before age 6 years. Although a diagnosis of AR is associated with higher socioeconomic status, underserved and urban populations have more indoor aeroallergen sensitizations and are likely underdiagnosed with AR, further exacerbating health-care disparities. AR negatively impacts quality of life, school performance, and overall health outcomes. Untreated AR in children increases the risk for poor asthma control, increased asthma severity, and exacerbations. Many patients believe that they have seasonal allergies only but in reality have both perennial and seasonal AR, which may change the approach to allergen avoidance measures and treatment recommendations. Pharmacotherapy of AR has expanded, with many intranasal corticosteroids, intranasal antihistamines, and second-generation oral antihistamines approved for pediatric use. Allergen immunotherapy, including both subcutaneous and sublingual forms, are approved for children and are disease modifying, potentially reducing further allergen sensitization and progression to asthma. Many of the currently available biological therapies indicated for pediatric asthma and/or atopic diseases reduce AR symptoms as well. Children with moderate to severe or refractory AR or those with comorbidities should be referred to allergists for diagnostic testing and expanded management options, including immunotherapy and potential biological treatment.

Unique inverse association between allergic rhinitis and periodontitis: a nationwide population-based study

The increase in fine dust levels in the atmosphere has been associated with a growth in the incidence of environmental diseases, including allergic rhinitis (AR). Nasal obstruction caused by AR can impact the conditions in the oral cavity. The aim of this study was to determine the association between AR and periodontitis in the Republic of Korea. This study was based on data from the Seventh Korea National Health and Nutrition Examination Survey (KNHANES VII-1, 2016), which was conducted by the Korea Centers for Disease Control and Prevention. The study included 6129 adults older than 19 years. Sociodemographic information and medical variables including history of treatment of periodontitis (HTP) reflecting diagnosis of periodontitis and diagnosis of diseases such as AR were extracted from the data. HTP and AR were reported for 22.81 ± 0.84% (weighted percentage ± standard error) and 15.32 ± 0.63% of the studied population, respectively. A diagnosis of AR was reported for 11.07 ± 1.28% of those with HTP and for 17.55 ± 1.84% of those without HTP. From these, it was inferred that the prevalence of HTP was 1.536-fold higher in the non-AR group than in their counterparts with AR. Significant association was found between AR and HTP among those aged ≤ 64 years and the odds ratio (OR) of AR group for HTP was 0.62 (95% confidence interval:0.44-0.87; P = 0.0057). From this result, it can be inferred that patients diagnosed AR have lower risk of periodontitis.

Prevalence and risk factors of allergic rhinitis among Chinese adults: A nationwide representative cross-sectional study

Background

The prevalence of allergic rhinitis (AR) has been increasing steadily worldwide, especially in countries with increasing industrialization such as China. However, available evidence regarding AR prevalence among Chinese adults is scarce and limited to regional data collected in earlier years. We therefore aimed to provide a more recent and robust estimate of AR prevalence using a nationwide representative cross-sectional study in China.

Methods

Data of 184 326 participants aged 18 years or older were obtained from the China Chronic Disease and Risk Factor Surveillance conducted in 2018-2019. AR was determined by self-reported sneezing, nasal itching, obstruction, or rhinorrhea symptoms for at least 1 h in the absence of a cold or flu within the last 12 months. Multivariable logistic model was used to examine the risk factors of AR, and a possible non-linear relationship was further tested by restricted cubic spline. Potential additive interactions of risk factors with sex, residence, and geographic region were assessed by relative excess risk due to interaction (RERI).

Results

The weighted prevalence of AR was 8.1% (95% confidence interval [CI], 7.4%-8.7%), of whom 23.7% (95% CI, 21.3%-26.0%) were aware of their diagnosis. Increased odds of AR were associated with younger age, men, living in urban area or north region, more education, smoking, underweight, and higher income. Despite the nonsignificant linear trend, the spline regression demonstrated a non-linear association between AR and sleep duration, with higher odds at both ends. Additionally, the observed associations were generally stronger among men and people living in urban area and north region, with significant RERI ranging from 0.07 (95% CI, 0.00-0.14) to 0.40 (95% CI, 0.12-0.67).

Conclusions

AR is prevalent in China and the associated factors and interactions are helpful to design targeted preventive strategies towards certain subpopulations. The low awareness of AR calls for a national effort on AR screening.

Parental Education Moderates the Relation between Physical Activity, Dietary Patterns and Atopic Diseases in Adolescents

Background: Atopic diseases, particularly asthma, eczema, and rhinitis, are among the most common chronic diseases in childhood, with several factors implicated in their pathogenesis. Our study examined the role of parental education in the association between diet, physical activity, and atopy in adolescents. Methods: 1934 adolescents (47.5% boys) aged 13−14 years old reported information about their diet and physical activity and their parents reported their highest educational level. The moderating role of parental education level (primary/secondary vs. tertiary) in the relation between lifestyle patterns and atopic diseases was examined with logistic regression analyses. Results: High consumption of dairy products was inversely associated to adolescents’ asthma and rhinitis symptoms overall, but this relation was almost 50% stronger for the adolescents with high parental education level background. The same pattern of reduction of the odds was noticed also regarding the association among the high intake of fruits, vegetables, pulses, with all three atopic diseases and the adherence to a physically active lifestyle only with current asthma and eczema (all p < 0.05). Conclusion: Adolescents who are physically active and consume a higher intake of fruits, vegetables, and pulses and a lower intake of fast-food and sweets, and their parents/guardians having higher education, are less likely to have any current symptoms of asthma, eczema, and rhinitis than the ones who have low educated parents.

Visual analysis of allergic rhinitis in children based on web of science and CiteSpace software

BACKGROUND

In recent years, Allergic Rhinitis (AR) in children has caused widespread public concern. However, there are few studies concerning the overall trends in AR research in children based on bibliometric analysis.

OBJECTIVE

This study aims to explore hotspots and emerging trends in AR in children.

METHODS

The relevant publications were searched for in the Web of Science (WOS) Core Collection on December 31, 2021. The searched studies were exported to CiteSpace and Microsoft Excel for further visualized analysis.

RESULTS

In total, 649 articles were included. The number of publications related to AR in children has increased steadily in the last 20 years. Giorgio Ciprandi from Italy has the most articles and the leading countries were China and the USA. Guangzhou Medical University in China and Hallym University in Korea were the institutions with the most articles. The high-frequency keywords included AR, asthma, children, prevalence, and symptoms. Pathogenesis, comorbidity, epidemiology, symptoms, and therapy of AR in children are research hotspots.

CONCLUSION

Over the past 20 years, research on AR in children has gradually improved. Visualization analysis indicates that pathogenesis, comorbidity, epidemiology, symptoms, and therapy are research hotspots, and immunotherapy and severity are probably the main research directions.

Fexofenadine: review of safety, efficacy and unmet needs in children with allergic rhinitis

Allergic rhinitis (AR) is the most common undiagnosed chronic condition in children. Moderate/severe AR symptoms significantly impair quality of life, and cause sleep disruption, absenteeism and decreased productivity. Additionally, untreated AR predisposes children to asthma and other chronic conditions. Although intranasal corticosteroids are the most effective pharmacologic treatment for AR, oral antihistamines are often preferred. First-generation antihistamines may be chosen to relieve AR symptoms as they are inexpensive and widely available; however, they cause sedative and cardiovascular negative effects due to poor receptor selectivity. Therefore, second-generation antihistamines were developed to reduce adverse effects while retaining efficacy. There are fewer clinical trials in children than adults, therefore, efficacy and safety data is limited, particularly in children under 6 years, highlighting the need to generate these data in young children with AR. Fexofenadine, a highly selective second-generation antihistamine, effectively alleviates symptoms of AR, is non-sedating due to decreased blood-brain barrier permeability, and is devoid of cardiovascular side effects. Importantly, fexofenadine relieves the ocular symptoms of allergic conjunctivitis, which occur concomitantly with AR, improving quality of life. Overall, fexofenadine displays a favorable safety profile and results in greater treatment satisfaction in children compared with other second-generation antihistamines. This review aimed to evaluate and compare the safety and efficacy of fexofenadine with other available first- and second-generation antihistamines in children with AR.

Differential induction of allergen-specific IgA responses following timothy grass subcutaneous and sublingual immunotherapy

INTRODUCTION

There is no detailed comparison of allergen-specific immunoglobulin responses following sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT).

OBJECTIVE

We sought to compare nasal and systemic timothy grass pollen (TGP)-specific antibody responses during 2 years of SCIT and SLIT and 1 year after treatment discontinuation in a double-blind, double-dummy, placebo-controlled trial.

METHODS

Nasal fluid and serum were obtained yearly (per-protocol population, n = 84). TGP-specific IgA₁, IgA₂, IgG₄, IgG, and IgE were measured in nasal fluids by ELISA. TGP-specific IgA₁, IgA₂, and Phleum pratense (Phl p)1, 2, 4, 5b, 6, 7, 11, and 12 IgE and IgG₄ were measured in sera by ELISA and ImmunoCAP, respectively.

RESULTS

At years 2 and 3, TGP-IgA_1/2 levels in nasal fluid were elevated in SLIT compared with SCIT (4.2- and 3.0-fold for IgA₁, 2.0- and 1.8-fold for IgA₂, respectively; all P < .01). TGP-IgA₁ level in serum was elevated in SLIT compared with SCIT at years 1, 2, and 3 (4.6-, 5.1-, and 4.7-fold, respectively; all P < .001). Serum TGP-IgG level was higher in SCIT compared with SLIT (2.8-fold) at year 2. Serum TGP-IgG₄ level was higher in SCIT compared with SLIT at years 1, 2, and 3 (10.4-, 27.4-, and 5.1-fold, respectively; all P < .01). Serum IgG₄ levels to Phl p1, 2, 5b, and 6 were increased at years 1, 2, and 3 in SCIT and SLIT compared with placebo (Phl p1: 11.8- and 3.9-fold; Phl p2: 31.6- and 4.4-fold; Phl p5b: 135.5- and 5.3-fold; Phl p6: 145.4- and 14.7-fold, respectively, all at year 2 when levels peaked; P < .05). IgE to TGP in nasal fluid increased in the SLIT group at year 2 but not at year 3 compared with SCIT (2.8-fold; P = .04) and placebo (3.1-fold; P = .02). IgA to TGP and IgE and IgG₄ to TGP components stratified participants according to treatment group and clinical response.

CONCLUSIONS

The observed induction of IgA_1/2 in SLIT and IgG₄ in SCIT suggest key differences in the mechanisms of action.

Immunosuppressive Regulation of Dendritic Cells and T Cells in Allergic Rhinitis by Semaphorin 3A

BACKGROUND

Semaphrin3A (Sema3A) was found to play a major role in immune regulation in autoimmune diseases and to be of importance in allergic disease. However, the effect of Sema3A on allergic rhinitis (AR) is not fully clear.

OBJECTIVE

We sought to elucidate the effects of Sema3A on the regulation of dendritic cells (DCs) and naive CD4⁺ T cells in AR.

METHODS

The expression of Sema3A in nasal mucosa was measured by immunohistochemical staining and western blotting. Human peripheral blood mononuclear cells were separated by the Ficoll-Hypaque method. DCs and naive CD4⁺ T cells were purified by magnetic selection. A human Sema3A Fc chimera was added to DCs and naive CD4⁺ T cells in vitro to evaluate the effect of Sema3A on the function of DCs and T cells. Labeling T cells with CFSE was used to determine cell proliferation. Flow cytometry was used to detect the DC maturation markers (CD40 and CD83) and T helper 17 (Th17) and regulatory T cell (Treg) percentages. ELISA was used to detect the IL10, IL17, IL4, and IFNγ cytokine levels.

RESULTS

The expression of Sema3A in AR inferior turbinate tissue was lower than that in healthy control tissue. Compared with healthy control DCs, AR DCs showed decreased levels of the DC maturation markers CD40 and CD83 after Sema3A treatment. Furthermore, Sema3A decreased naive CD4⁺ T cell proliferation in AR. In addition, Sema3A increased the percentage of Tregs but had no obvious effect on Th17 cells. Moreover, Sema3A significantly increased levels of IL10 and IFNγ, and decreased level of IL4, but had no obvious effect on level of IL17.

CONCLUSION

AR presented with low expression of Sema3A in nasal mucosa, and Sema3A could decrease DC maturation, T cell proliferation, and Treg polarization.

[Allergic rhinitis in children: from diagnosis to therapy]

Allergic rhinitis, according to modern data, affects up to a quarter of the population of developed countries. The disease affects not only the nasal mucosa, but also affects the receptors and mediators of inflammation in the bone marrow. A significant decrease in the quality of life of patients against the background of exacerbation of allergic rhinitis makes us look for new approaches to both the treatment of attacks and their prevention. Correction, including surgical, of concomitant pathology of the nasal cavity and paranasal sinuses significantly improves the quality of life of patients with allergic rhinitis. For a long time, surgical treatment of concomitant pathology of the nasal cavity in children was extremely limited due to the risk of damage to the growth zones and, as a consequence, a high probability of recurrence of deformation of the structures of the nose and paranasal sinuses. With the development of endoscopic methods of surgical treatment of the nasal cavity and paranasal sinuses, operations with minimal invasiveness and, as a consequence, safe at any age were introduced into practice. Surgical intervention on the structures of the lymphoid pharyngeal ring in children with allergic rhinitis is causing heated debate in the pediatric community to date. The article considers modern approaches to the diagnosis and treatment of allergic rhinitis in children. Topical problems of conservative and surgical treatment are discussed. Special attention is paid to the safety of various treatment regimens. The discussed practical issues of tactics of treatment of allergic rhinitis are relevant for both pediatric allergists and ENT pediatricians.

Role of Allergy in Eustachian Tube Dysfunction

PURPOSE OF REVIEW

Eustachian tube dysfunction (ETD) presents with symptoms of aural fullness and pressure, muffled hearing, tinnitus, and otalgia. When severe, it can lead to many common ear disorders such as otitis media with effusion, tympanic membrane retraction/perforation, and cholesteatoma. These diseases are prevalent in both the pediatric and adult population and significantly impact quality of life. The pathophysiology of ETD in the absence of an obstructive lesion has long been debated but is thought to be related to functional obstruction (i.e., inefficient tensor veli palatini muscle) and/or nasal cavity and nasopharyngeal inflammation. In the acute setting, the most common cause of nasal inflammation is an upper respiratory infection. When symptoms become chronic, however, the inflammation is thought to be associated with nasal irritants such as nasal allergens, i.e., allergic rhinitis (AR). The purpose of this review is to summarize our current understanding of the relationship between allergy and ETD.

RECENT FINDINGS

Past studies are either lacking or have reported equivocal findings regarding the relationship between allergy and ETD, and the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis has deemed the current level of evidence linking AR and ETD as low quality. A more recent study using a large adult population dataset did support an association between AR and ETD, but did not find that all cases of ETD are related to allergies. Furthermore, current evidence suggests that the use of medications that can decrease intranasal inflammation, such as intranasal corticosteroids or oral antihistamines, does not result in significant symptomatic improvement in patients with ETD. However, these studies included all patients with ETD, and evidence is lacking regarding the treatment effect of these medications on the subset of patients with concurrent AR and ETD. Current best evidence does support an association between AR and ETD; however, not all patients with ETD suffer from AR, and vice versa. Further research is necessary to understand the mechanism behind this positive association and to elucidate the cause of chronic ETD in patients without associated allergies.

Distraction of olfactory bulb-medial prefrontal cortex circuit may induce anxiety-like behavior in allergic rhinitis

Allergic rhinitis is a chronic inflammatory disease of the upper respiratory tract, which is associated with high incidence of anxiety symptom. There is evidence that medial prefrontal cortex modulates anxiety-related behaviors and receives projections from olfactory bulb. Since olfactory dysfunction has been reported in allergic rhinitis, we aimed to evaluate anxiety-like behavior and oscillations of olfactory bulb-medial prefrontal cortex circuit in an animal model of allergic rhinitis. The number of open arm entries in elevated zero maze was significantly reduced in sensitized rats exposed to intranasal ovalbumin compared to the control group, which was indicating the enhancement of anxiety-like behavior in allergic rhinitis animals. Analysis of local field potentials in olfactory bulb and medial prefrontal cortex during immobility and exploration state showed that anxiety-like behavior induced by allergic rhinitis was in association with increased activity of medial prefrontal cortex and enhancement of olfactory bulb-medial prefrontal cortex coupling in delta and theta bands. Moreover, in allergic rhinitis animals, theta strongly coordinates local gamma activity in olfactory bulb and medial prefrontal cortex, which means to have a strong local theta/gamma coupling. We suggested that disruption of olfactory bulb-medial prefrontal cortex circuit due to allergic reactions might have a governing role for inducing anxiety-like behavior in the allergic rhinitis experimental model.

Demographics and clinical features predictive of allergic versus non-allergic rhinitis in children aged 6-18 years: A single-center experience of 1535 patients

BACKGROUND

Chronic rhinitis (CR) is one of the most common causes accounting for lost-school days, absenteeism and resource utilization in pediatric patients. Distinction between common causes of CR, allergic (AR)and non-allergic rhinitis (NAR), based upon clinical features is critical, especially in primary care settings or facilities with lack of allergen sensitivity testing, as management strategies differ considerably. The current study elucidates clinical factors, particularly facial features associated with AR and NAR using a large cohort.

METHODS

In a retrospective cohort analysis of pediatric patients aged 6-18 years, we assessed patient demographics, clinical symptoms, and signs associated with allergic rhinitis using multivariable regression techniques.

RESULTS

Overall, 1490 patients (mean age: 10.11 ± 3.31 years; 48% female; 69% AR and 31% NAR) were included in the study. In multivariable regression analysis, major clinical features associated with AR were: sneezing (OR: 3.53; 95% CI: 2.35-5.32; p < 0.001), rhinorrhea (OR: 1.77; 95% CI: 1.18-2.66; p = 0.006), nasal itching (OR: 17.88; 95% CI: 11.92-26.83; p < 0.001), horizontal nasal crease (OR: 5.09; 95% CI: 1.29-20.01; p = 0.020) and conjunctivitis (OR: 4.66; 95% CI: 3.28-6.62; p < 0.001). On the contrary, we noted presence of Dennie-Morgan fold (OR: 1.67; 95% CI: 1.11-2.56; p = 0.014), moderate to severe persistent or intermittent symptoms to be likely associated with NAR than AR.

CONCLUSION

In pediatric patients presenting with symptoms of rhinitis, facial hallmarks serve as an adjunct to sensitivity testing in establishing a diagnosis as well as differentiating between NAR from AR, albeit individualized upon patient history and clinical features.

Adenoidectomy: Long-term Follow-Up

OBJECTIVE: To assess the long-term (3-5 years) success of adenoidectomy and reasons for unsatisfactory results.

STUDY DESIGN AND SETTING: The parents of all children who underwent adenoidectomy alone at a major tertiary center from 1998 to 2000 were asked to complete a questionnaire assessing their child's well-being and symptomatology 3-5 years after surgery; some were invited for follow-up. Symptom improvement, persistent symptoms, and adenoid regrowth were evaluated.

RESULTS: Among the 206 parents who complied, 74%-87% reported improvement in all main symptoms: nasal obstruction, snoring, chronic rhinorrhea, hyponasal speech, and obstructive sleep disorder. At follow-up (n = 36), the symptomatic patients had significantly more anatomic nasal abnormalities ( P = 0.01) and a higher rate of significant adenoid enlargement ( P = 0.08), 3 patients (19%) vs none (0%).

CONCLUSIONS AND SIGNIFICANCE: Adenoidectomy alone is satisfactory treatment for nasal obstruction and obstructive sleep apnea in selected children. Though some adenoid regrowth is not rare, clinically significant adenoid regrowth is infrequent. Persistent or recurrent symptoms are attributable mainly to nasal pathology.

Montelukast in the treatment of perennial allergic rhinitis in paediatric Japanese patients; an open-label clinical trial

Background: This study was conducted to evaluate the safety and tolerability, and population pharmacokinetics (PPK) of montelukast as well as efficacy in the treatment of perennial allergic rhinitis (PAR) in paediatric Japanese patients aged between 1 and 15 years. Methods: In this multi-centre, open-label trial, 87 paediatric Japanese patients with PAR received montelukast 4 mg oral granules (OG) for 4 weeks (1-5-year-olds, N = 15), 4 mg OG for 12 weeks (1-5-year-olds, N = 36), 5 mg chewable tablets (CT) for 12 weeks (6-9-year-olds, N = 18), or 5 mg CT for12 weeks (10-15-year-olds, N = 18). Clinical exams and laboratory assessments were conducted at study visits, and adverse events (AE) were monitored throughout the study up to 14 days after the last visit. Population pharmacokinetic approach was used to estimate AUC0-∞, Cmax, Tmax and apparent elimination half-life in each age group. Efficacy was assessed based on global evaluations by the subject's caregiver. Results: There were no serious AEs and one discontinuation due to an AE. The most common AEs in any of the treatment groups were nasopharyngitis, pharyngitis, and acute sinusitis. Montelukast exposure (AUC0-∞) was similar in the 1-5-year-old group and the 6-9-year-old group, but 19% lower in the 10-15-year-old group. Among all patients, the total proportion of patients whose global evaluation was "very much better" was 5.7% (week 2), 11.5% (week 4), and 16.9% (week 12) reflecting improvement in symptoms over time. Conclusion: Montelukast was generally well tolerated in Japanese children with PAR. AUC0-∞was similar in 1-5 and 6-9-year-olds, while a lower exposure was observed in the 10-15-year-old group likely due to differences in bodyweight. The exposure in Japanese paediatric patients was generally consistent with that in non-Japanese paediatric and adult patients. As assessed by the patients' caregivers, montelukast also demonstrated symptomatic improvement based on global evaluations of PAR.

Association of serum eosinophilia and total immunoglobulin E concentration with the risk of allergic symptoms and allergic sensitization, respectively: A 2-year follow-up study

OBJECTIVES

Serum eosinophil percentage (SEP), eosinophil cationic protein (ECP) concentration, and total IgE (TIgE) concentration are known to increase in patients with allergic disease; however, the relevance of these elevated markers in children with negative allergic test results remains unclear. Therefore, this 2-year follow-up study aimed to investigate whether SEP, ECP concentration, and TIgE concentration are associated with an increased risk for allergic sensitization and allergic symptoms.

METHODS

In 2012, SEP, ECP concentration, and TIgE concentration of third- and fourth-grade students from 6 elementary schools were measured. Skin prick test was performed, and the presence of allergic nasal symptoms was investigated using a questionnaire. In 2014, the same examinations were performed in the same set of students, who were then in the fifth and sixth grades, respectively, of the same schools. The cut-off value and usefulness of serologic markers (eosinophil count, ECP concentration, and TIgE concentration) were calculated using the receiver operating characteristic curve.

RESULTS

Serum eosinophil percentage (cut-off value, 3.8%) was associated with the newly developed allergic nasal symptoms (sensitivity, 77.9; specificity, 41.8). A high serum TIgE concentration (cut-off value, 17.7 IU/mL) was also associated with the risk for allergic sensitization (sensitivity, 46.3; specificity, 85.3).

CONCLUSION

SEP and TIgE concentration were associated with the development of allergic symptoms and allergic sensitization, respectively, 2 years after the first examination.

Nonallergic Rhinitis: Diagnosis

Nonallergic rhinitis (NAR) is one of the most common conditions in medicine, affecting the quality of life of millions of patients throughout the United States. Despite its ubiquitous nature, NAR remains a poorly managed and often difficult to treat condition. NAR is often suboptimally managed by clinicians with poor clinical outcomes. Establishing the correct diagnosis requires a keen understanding of the unique underlying mechanisms involved in NAR, which is still evolving. Ultimately epidemiologic studies that better define NAR prevalence and its economic burden on society are needed to convince funding agencies of the need for research to elucidate mechanisms and specific treatment approaches for this condition.

Treatment of allergic rhinitis is associated with improved attention performance in children: the Allergic Rhinitis Cohort Study for Kids (ARCO-Kids)

Background

It has been well known that pediatric allergic rhinitis was associated with poor performance at school due to attention deficit. However, there were no cohort studies for the effect of treatment of allergic rhinitis on attention performance in pediatric population. Thus, the aim of this study was to investigate whether attention performance was improved after treatment in children with allergic rhinitis.

Methods

In this ARCO-Kids (Allergic Rhinitis Cohort Study for Kids), consecutive pediatric patients with rhinitis symptoms underwent a skin prick test and computerized comprehensive attention test. According to the skin prick test results, the children were diagnosed as allergic rhinitis or non- allergic rhinitis. All of the patients were regularly followed up and treated with oral medication or intranasal corticosteroid sprays. The comprehensive attention tests consisted of sustained and divided attention tasks. Each of the tasks was assessed by the attention score which was calculated by the number of omission and commission errors. The comprehension attention test was repeated after 1 year.

Results

A total of 797 children with allergic rhinitis and 239 children with non-allergic rhinitis were included. Initially, the attention scores of omission and commission errors on divided attention task were significantly lower in children with allergic rhinitis than in children with non-allergic rhinitis. After 1 year of treatment, children with allergic rhinitis showed improvement in attention: commission error of sustained (95.6±17.0 vs 97.0±16.6) and divided attention task (99.1±15.8 vs 91.8±23.5). Meanwhile, there was no significant difference of attention scores in children with non-allergic rhinitis.

Conclusions

Our study showed that management of allergic rhinitis might be associated with improvement of attention.

Effects of Hyeonggaeyeongyo-tang in ovalbumin-induced allergic rhinitis model

Allergic rhinitis (AR) is an allergic inflammation of the nasal airways. The prevalence of AR is increasing worldwide. We investigated whether Hyeonggaeyeongyo-tang (HYT) is effective to suppress the progression of AR induced by ovalbumin (OVA). Male BALB/c mice were used for this study. Allergic rhinitis was induced by OVA. Treatment with HYT was assessed to study the effect of HYT on allergic rhinitis in mice. Histological analysis, immunohistochemistry, multiplex cytokine assay, blood analysis, and cell viability assay were performed to verify inhibitory effect of HYT on allergic rhinitis. HYT did not show any toxicity maintaining body weight. Food intake was steady without variation in mice. HYT reduced infiltration of inflammatory cells and mast cells into nasal cavity. HYT reduced the levels of cytokines and leukocytes in the blood. HYT decreased the splenocyte cell viability. Antihistamines and steroids are the most common medications used to treat allergic rhinitis. However, long-term use of drug generates resistance or side effects requiring the development of new drug. Our present study clearly demonstrates that HYT suppresses the progression of allergic rhinitis induced by OVA. This suggests that HYT might be a useful drug for the treatment of allergic rhinitis.

Active or passive exposure to tobacco smoking and allergic rhinitis, allergic dermatitis, and food allergy in adults and children: a systematic review and meta-analysis

BACKGROUND

Allergic rhinitis, allergic dermatitis, and food allergy are extremely common diseases, especially among children, and are frequently associated to each other and to asthma. Smoking is a potential risk factor for these conditions, but so far, results from individual studies have been conflicting. The objective of this study was to examine the evidence for an association between active smoking (AS) or passive exposure to secondhand smoke and allergic conditions.

METHODS AND FINDINGS

We retrieved studies published in any language up to June 30th, 2013 by systematically searching Medline, Embase, the five regional bibliographic databases of the World Health Organization, and ISI-Proceedings databases, by manually examining the references of the original articles and reviews retrieved, and by establishing personal contact with clinical researchers. We included cohort, case-control, and cross-sectional studies reporting odds ratio (OR) or relative risk (RR) estimates and confidence intervals of smoking and allergic conditions, first among the general population and then among children. We retrieved 97 studies on allergic rhinitis, 91 on allergic dermatitis, and eight on food allergy published in 139 different articles. When all studies were analyzed together (showing random effects model results and pooled ORs expressed as RR), allergic rhinitis was not associated with active smoking (pooled RR, 1.02 [95% CI 0.92-1.15]), but was associated with passive smoking (pooled RR 1.10 [95% CI 1.06-1.15]). Allergic dermatitis was associated with both active (pooled RR, 1.21 [95% CI 1.14-1.29]) and passive smoking (pooled RR, 1.07 [95% CI 1.03-1.12]). In children and adolescent, allergic rhinitis was associated with active (pooled RR, 1.40 (95% CI 1.24-1.59) and passive smoking (pooled RR, 1.09 [95% CI 1.04-1.14]). Allergic dermatitis was associated with active (pooled RR, 1.36 [95% CI 1.17-1.46]) and passive smoking (pooled RR, 1.06 [95% CI 1.01-1.11]). Food allergy was associated with SHS (1.43 [1.12-1.83]) when cohort studies only were examined, but not when all studies were combined. The findings are limited by the potential for confounding and bias given that most of the individual studies used a cross-sectional design. Furthermore, the studies showed a high degree of heterogeneity and the exposure and outcome measures were assessed by self-report, which may increase the potential for misclassification.

CONCLUSIONS

We observed very modest associations between smoking and some allergic diseases among adults. Among children and adolescents, both active and passive exposure to SHS were associated with a modest increased risk for allergic diseases, and passive smoking was associated with an increased risk for food allergy. Additional studies with detailed measurement of exposure and better case definition are needed to further explore the role of smoking in allergic diseases.

Variability of histamine pharmacodynamic response in children with allergic rhinitis

Histamine iontophoresis with laser Doppler monitoring (HILD) is a robust and dynamic surrogate for histamine microvasculature response. We characterized histamine pharmacodynamics in children using HILD. HILD was performed in 54 children with allergic rhinitis. A non-compartmental analysis and non-linear mixed-effects model with a linked effect PK/PD model was used to provide estimates for area under the effect curve (AUEC), maximal response over baseline (EffmaxNT), and time of EffmaxNT (Tmax). Data were placed in sub-groups by visualization of time vs. response relationships. ANOVA and regression analyses were used for sub-group comparisons. Three histamine response phenotypes were identified. One group demonstrated a hyper-responsive phenotype (higher Tmax, EffmaxNt and AUEC, P < .01). AUEC and EffmaxNT were more strongly associated in this group (r(2)  = 0.86) than the entire cohort (r(2)  = 0.64). These data demonstrate a hyper-responsive histamine phenotype via HILD. This finding is important to future pharmacologic studies of antihistamines.

Comparative analysis of allergic rhinitis in children and adults

Allergic rhinitis (AR) is a worldwide health problem that generates a significant healthcare burden in adults, adolescents, and children. Epidemiological studies have indicated that the prevalence of AR has progressively increased over the last three decades in developed and industrialized countries. AR currently affects up to 40 % of the worldwide population, with differences between adults and children and different countries of the World. Although not life-threatening, AR symptoms are frequently bothersome, adversely affecting work and quality of life of the affected patients, and causing a significant burden on both the individual and society. The symptoms have the potential to lead to both physical and mental complications, with sleep-disordered breathing in childhood and adolescence being associated with disorders in learning performance, behavior, and attention. Clinical features and comorbidities are very important for the "allergic march", and in both adults and children there is some evidence of association between AR and asthma. ARIA classifications of both symptom duration (intermittent, persistent) and severity (mild, moderate, severe) have been validated in both adult and pediatric populations. Based on the duration and severity of patient's disease, an appropriate treatment strategy has been issued for both adults and children, which consists of patient's education, allergen avoidance, and pharmacological as well as allergen-specific immunotherapy treatment. The present review will attempt to compare the characteristics of AR between children and adults, either in the epidemiology, clinical features, impact on QOL, and management of the disease.

Evaluation of oral functions of the stomatognathic system according to the levels of asthma severity

PURPOSE

To compare the orofacial functions (chewing, swallowing and speech) in children with asthma and healthy children.

METHODS

A cross sectional study including 54 children of both genders with ages between 7 and 10 years was conducted. Twenty-seven of these subjects composed the experimental group, and were subdivided into two severity levels of asthma: Group I - mild intermittent and persistent asthma; Group II - persistent moderate to severe asthma. Twenty-seven healthy children were included in the control group (Group III). Speech-language pathology evaluation used the adapted Orofacial Myofunctional Assessment Protocol. Adaptation consisted in the exclusion of the structural part of the test, since this was not the aim of the study. The structural part was excluded because it was not the aim of this study.

RESULTS

It was found alterations in oral functions, with significant differences between the three groups. These alterations showed no correlation with asthma severity, since the highest rate of alterations was found in Group I (mild asthma).

CONCLUSION

Regardless of the severity level, children with asthma have altered patterns of chewing, swallowing and speech.

Diagnosis and treatment of allergic rhinitis in children: results of the PETRA study

BACKGROUND

Good control of allergic rhinitis (AR) in children is desirable because it is associated with diseases such as asthma. The aim of this analysis of the PETRA study was to characterise its diagnosis and treatment in Spanish children.

METHODS

Data were analysed for paediatric patients (age 5-17 years, inclusive) included in the PETRA study, which included consecutive patients with allergic rhinitis attending respiratory specialists throughout Spain. Demographic information, disease characteristics (duration, severity according to the Allergic Rhinitis and its Impact on Asthma [ARIA] classification), diagnostic procedures, treatments and physicians' attitudes to treatment were recorded.

RESULTS

Of the original sample of 1043 patients, 260 children were included (mean age, 11.7 years; 56.2% boys; 61.9% allergic to house dust mites (HDM) and 38.1% allergic to grass pollen). By ARIA classification, 180/260 (69.4%) had persistent AR and 176/280 (63%) had moderate disease. Asthma was reported in 89/161 (55%) with HDM allergy and 44/99 (45%) with grass pollen allergy. Symptomatic treatment was prescribed in 98.5%, although disease control had been no better than poor in 57.3%. Allergen specific immunotherapy was administered to 56.9%, and was used more often for HDM AR. When asked why specific immunotherapy was not prescribed, two-thirds of the investigators preferred a wait-and-see approach, prescribing immunotherapy if symptoms worsened or asthma developed.

CONCLUSIONS

Paediatric patients treated by specialists for allergic rhinitis have moderate or severe disease. Symptomatic treatment was extensively prescribed but often did not achieve good disease control. Many specialists preferred a wait-and-see approach before prescribing immunotherapy.

Allergic rhinitis and quality of life in children

Allergic rhinitis is a respiratory disease caused by an inflammatory process related to IgE mediated reaction versus allergens to which the subject is sensitized. Allergic rhinitis is not an isolated disease because the nasal mucosa inflammation involves paranasal sinuses and lower airways, thus worsening the asthmatic symptoms. Recently, a new classification of allergic rhinitis based on the duration and severity of clinical symptoms has been proposed. This classification takes into consideration both the quality of life and the possible impact of the symptoms on school, work and free-time activities. Children&#x0027;s quality of life is severely compromised by frequent night awakenings, easy fatigue, defects of language and irritability, which can have a negative influence on learning abilities. Allergic rhinitis has a negative impact on the quality of life of the whole family because it can cause interference on social life, and financial costs.

Atypical "allergic crease"

BACKGROUND

The allergic crease (nasal crease) is a transverse line, common among patients who suffer from allergic rhinitis. Although it is a very prevalent condition, the skin manifestations which accompany this condition have been only sparsely reported.

MAIN OBSERVATION

We describe an 18-year-old man with allergic rhinitis, who developed cornified papules along an allergic crease. Dermoscopic examination revealed oval, slightly raised, gray, sharply demarcated papules. Histopathology revealed seborrheic keratosis like hyperplasia, accompanied by horn cysts.

CONCLUSIONS

To our knowledge, cornified papules have not been reported previously along the allergic crease. Considering the fact that allergic rhinitis is a common chronic condition of childhood, increased awareness of the skin manifestations which accompany this condition is essential.

Differences in leisure activities between children with allergic rhinitis and healthy peers

OBJECTIVE

The symptoms of allergic rhinitis (AR) are frequently evoked when individuals with AR perform daily activities. Thus, AR may interfere the optimal participation in daily life, negatively impact the patient's productivity and quality of life (QOL). While most studies refer to adult with AR, this pilot study examined participation of children with AR as expressed in their daily activity preferences.

METHODS

Participants were 31 children with AR and 31 healthy children, aged 5-11 years. All children completed the Preference for Activities of Children (PAC).

RESULTS

Children with AR showed significantly lower preference to participate in skill-based, social and informal activities, as compared to their healthy peers (F(7,53)=2.61, p=0.02, ES-η(2)=0.27). Children with AR showed 5-20% lower preference to participate in activity than their typical peers.

CONCLUSIONS

AR may negatively impact children's preference to participate in daily activities. Treatment of children with AR should consider a multi-disciplinary intervention for encouraging their optimal development, improve their well-being and QOL.

Functional alterations of the stomatognathic system in patients with allergic rhinitis: case-control study

Mouth breathing can cause structural and functional alterations to the stomatognathic system.

AIM

The aim of this investigation was to study breathing, chewing, swallowing and speaking alterations present in patients with allergic rhinitis and associate it to rhinitis symptom intensity.

MATERIALS AND METHODS

170 patients between the ages of 6 and 55 years were prospectively evaluated in this study, all of them underwent both otorhinolaryngological and speech evaluation. Data on breathing, chewing, swallowing and speaking was gathered, as well as data from the medical evaluation. The data was compared and statistically analyzed.

RESULTS

The difference in signs and symptoms' score between GR and GC was significant. We noticed a significant difference between GR and GC in breathing, chewing and swallowing. We observed a significant association between the score of nasal obstruction and the intensity of breathing and chewing alterations.

CONCLUSION

Patients with allergic rhinitis have functional alterations in their stomatognathic system and an increase in nasal obstruction scores can be considered as a indication of such alterations.

The pathophysiology, diagnosis and treatment of allergic rhinitis

Treatment of AR requires a stepwise approach depending on the severity and duration of symptoms. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy and surgery. For the mechanisms of AR, anti-IgE antibody and specific antibody to cytokines such as IL-4 or IL-5 that correlate with allergic inflammation have recently emerged. SLIT is currently widely used due to its efficacy, safety and convenience, which replaces subcutaneous immunotherapy. Although allergen avoidance and immunotherapy are theoretically ideal, antihistamines and intranasal corticosteroids will play the main role in the management of AR until an innovative treatment develops. However, patients' main symptom, the duration and severity of AR, patients' compliance, safety of medication and cost-effectiveness should be considered when treatment options are chosen. In conclusion, physicians should be aware of etiology, pathophysiology, symptoms, signs and diseases related to AR in order to make a correct diagnosis and choose a proper treatment option for each patient.

Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica

OBJETIVO: avaliar e comparar a deglutição de sujeitos respiradores orais e nasais, por meio da avaliação clínica e eletromiográfica dos músculos orbiculares orais, superior e inferior. MÉTODOS: participaram deste estudo 16 sujeitos na faixa etária de 6:8 a 10:10 distribuídos em dois grupos, um de respiradores orais e outro de respiradores nasais. Foram submetidos à avaliação clínica fonoaudiológica e eletromiográfica de superfície. O exame fonoaudiológico contemplou as estruturas e funções do sistema estomatognático, e a avaliação eletromiográfica consistiu na captação da atividade elétrica dos músculos orbiculares orais, superior e inferior, durante as situações de isometria e de deglutição. Da avaliação clínica consideraram-se somente os resultados referentes à deglutição, observando-se a presença de ação labial e mentual, e de projeção lingual, as quais foram analisados de forma descritiva. Para análise estatística dos dados eletromiográficos, utilizou-se o Teste t para comparação entre os grupos. A significância adotada foi de 5% (p < 0,05). RESULTADOS: na avaliação clínica foram observadas alterações na deglutição, sendo que 87,5% dos sujeitos respiradores orais apresentaram ação labial, 75% ação mentual e 75% projeção lingual como características da deglutição adaptada,enquanto que nenhum dos sujeitos respiradores nasais apresentou tais alterações. Na avaliação eletromiográfica, verificou-se atividade muscular superior nos respiradores orais, em comparação aos respiradores nasais, em ambos os músculos estudados com diferença estatisticamente significante. CONCLUSÃO: concluiu-se que os respiradores orais apresentam alterações evidentes na função de deglutição, verificadas por meio da avaliação clínica fonoaudiológica e da avaliação eletromiográfica, quando comparados aos respiradores nasais.

Allergic rhinitis induces anxiety-like behavior and altered social interaction in rodents

Epidemiological and clinical studies report higher incidences of anxiety and increased emotional reactivity in individuals suffering from respiratory allergies. To evaluate if respiratory allergies are capable of promoting anxiety-like behavior in rodents, we used models of allergic rhinitis and behavioral evaluations followed by assessment of mRNA for cytokines in relevant brain regions. Mice and rats were sensitized to ovoalbumin or pollen, respectively, following standard sensitization and challenge protocols. After challenge, the animals were evaluated in the open field, elevated plus-maze and resident-intruder tests. Cytokines and corticotropin-releasing factor expression were assessed in several brain regions by real-time RT-PCR and plasma corticosterone concentrations by radioimmunoassay. Mice and rats sensitized and exposed to allergen showed increased anxiety-like behavior and reduced social interaction without any overt behavioral signs of sickness. T-helper type 2 (T(H)2) cytokines were induced in both rats and mice in the olfactory bulbs and prefrontal cortex and remained unchanged in the temporal cortex and hypothalamus. The same results were found for CRF mRNA expression. No differences were observed in corticosterone concentrations 1h after the last behavioral test. These results show that sensitization and challenge with allergens induce anxiety across rodent species and that these effects were paralleled by an increased expression of T(H)2 cytokines and CRF in the prefrontal cortex. These studies provide experimental evidence that sensitized rodents experience neuroimmune-mediated anxiety and reduced social interaction associated with allergic rhinitis.

Undertreatment of allergy: exploring the utility of sublingual immunotherapy

Allergic syndromes are highly prevalent and are comprised of a wide variety of clinical problems, including rhinitis, conjunctivitis, atopic dermatitis and urticaria, asthma, and food allergies. Numerous studies have shown that allergic syndromes are both underdiagnosed and undertreated. This is related to many factors, including trivialization of allergic conditions by physicians and patients, failure to adhere to diagnostic and treatment guidelines, and dissatisfaction with conventional pharmacologic treatments. Immunotherapy involves the administration of allergen extracts in an attempt to induce immunologic tolerance and has been used for the treatment of allergic syndromes and the prevention of long-term complications. Conventional subcutaneous immunotherapy is effective but is also associated with a risk of serious adverse events, requires administration by a trained health care professional, and is contraindicated in certain populations. By contrast, sublingual immunotherapy has been used extensively in Europe and possesses most of the benefits of subcutaneous immunotherapy along with increased safety, tolerability, and convenience. This narrative review explores data from selected clinical studies and concludes that sublingual immunotherapy may be well suited to fill the gap posed by the undertreatment of allergic syndromes in the United States.

Efficacy and safety of once-daily fluticasone furoate nasal spray in children with seasonal allergic rhinitis treated for 2 wk

The objective of this study was to evaluate the efficacy and safety of fluticasone furoate (FF) nasal spray 55 and 110 microg once daily in children with seasonal allergic rhinitis (SAR). Patients (n = 554) received placebo nasal spray or FF, administered using a unique side-actuated device, in a 2-wk, randomized, double-blind study. Symptoms were evaluated by patients using a 4-point categorical scale. Efficacy assessments included reflective and instantaneous total nasal symptom scores (r/iTNSS). Primary analyses were conducted in patients aged 6-11 yr in the intent-to-treat population (ITT); the 2-11 yr group provided supportive analyses. In patients aged 6-11 yr, FF 110 microg once daily significantly improved the daily rTNSS compared with placebo. FF 55 microg once daily was only numerically better for rTNSS and iTNSS. Secondary pre-dose iTNSS and overall response to therapy were significant with FF 110 microg. The significant findings for FF 110 microg were supported by analyses in the entire ITT population of 2-11 yr olds. Both doses of FF were well tolerated. These study results suggest that FF nasal spray administered once daily for 2 wk is well tolerated and effective for the treatment of SAR symptoms in children aged 2-11 yr.

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.

Quantitative assessment of allergic shiners in children with allergic rhinitis

BACKGROUND

The knowledge on allergic shiners is extremely limited. A conceivable tool able to quantify allergic shiners has not been established.

OBJECTIVES

We sought to determine the significance and changeability of allergic shiners through our newly developed computerized method.

METHODS

We developed a novel computerized method to measure allergic shiners and enrolled a cohort of children with or without allergic rhinitis. Children with allergic rhinitis were prospectively assessed. A standardized digital photograph was taken during each visit, and a modified Pediatric Rhinoconjunctivitis Quality of Life Questionnaire was completed. Subject global assessment for nose symptoms and subject global assessment for eye symptoms (SGAE) were self-recorded daily.

RESULTS

We included 126 children with allergic rhinitis and 123 healthy control subjects. One hundred three (82%) participants with allergic rhinitis completed at least 4 prospective assessments. Shiners were darker (P < .001) and larger (P < .001) in children with allergic rhinitis. Darkness and sizes of allergic shiners were paradoxically inversely correlated (P = .02). Darkness of allergic shiners positively correlated with the duration of allergic rhinitis, practical problem scores, and SGAE values (P = .02, P = .004, and P = .002, respectively), but sizes of allergic shiners did not. Shiners were found to be darker in children with scores of eye symptoms of greater than 6, scores of practical problems of greater than 5, and SGAE values of greater than 0 (P = .02, P < .001, and P = .003, respectively), whereas shiners were larger in children with scores of other symptoms of greater than 9 and activity limitations of greater than 4 (P = .02 and P = .002, respectively).

CONCLUSION

Computer-analyzed allergic shiners correlate with the chronicity and severity of allergic rhinitis.

Clinical efficacy and safety of a combined loratadine-betamethasone oral solution in the treatment of severe pediatric perennial allergic rhinitis

BACKGROUND

: Allergic rhinitis is a highly prevalent condition, particularly among children, whose schoolwork and quality of life may be impaired by its symptoms.

METHODS

: In this prospective, multicenter study, children between 6 and 12 years old with a diagnosis of severe perennial allergic rhinitis received a combination of the nonsedating antihistamine loratadine and the corticosteroid betamethasone in an oral solution for 5 days.

RESULTS

: The total nasal and ocular symptom score was significantly reduced from 11.4 (±2.1) before treatment to 2.9 (±2.4) after treatment (P < 0.01). Significant reductions (P < 0.01) were also observed for sneezing, nasal pruritus, nasal congestion, rhinorrhea, postnasal drip, and ocular erythema and pruritus. No adverse events were reported, and no subject discontinued treatment.

CONCLUSIONS

: The combination of loratadine and betamethasone in an oral solution was safe and effective as initial short-term treatment for symptoms of severe perennial allergic rhinitis in school-aged children.

Safety and tolerability of fluticasone furoate nasal spray once daily in paediatric patients aged 6-11 years with allergic rhinitis: subanalysis of three randomized, double-blind, placebo-controlled, multicentre studies

BACKGROUND

Fluticasone furoate is a novel enhanced-affinity corticosteroid that has demonstrated favourable safety and tolerability in paediatric patients. Three pivotal phase III studies were conducted in children as young as 2 years of age; however, because the European Medicines Agency has recently approved fluticasone furoate for use in children aged>or=6 years, a subanalysis has been conducted to support safety and tolerability in the 6- to 11-year age group.

METHODS

All three trials included in the subanalysis were randomized, double-blind, placebo-controlled, parallel-group studies: a 2-week US study in patients with seasonal allergic rhinitis (SAR), a 12-week global study in patients with perennial allergic rhinitis (PAR) and a 6-week US hypothalamic-pituitary-adrenal (HPA) axis safety study in patients with PAR. Randomized patients received once-daily treatment with either fluticasone furoate nasal spray (FFNS) 55 microg (n=297; 2-week SAR and 12-week PAR studies only), FFNS 110 microg (n=321) or vehicle placebo nasal spray (n=330). Safety assessments included clinical adverse event (AE) monitoring, clinical laboratory tests, detailed nasal examinations, monitoring of vital signs, and 12-lead ECGs. Ophthalmic examinations (12-week PAR study only) were conducted by an ophthalmologist or optometrist before randomization and at final treatment visit. Twenty-four-hour urinary cortisol (UC) excretions (6- and 12-week PAR studies) and serum cortisol (SC) concentrations (6-week PAR study only) were assessed at specified timepoints over 24 hours as a measure of HPA axis function. In the 6-week HPA axis safety study in patients with PAR, 24-hour UC and SC samples were collected in a domiciled (clinical) setting.

RESULTS

No unexpected safety results were observed in patients aged 6-11 years enrolled in the three studies. Across all three trials, AEs considered by the investigator to be drug related were observed in 10%, 7% and 8% of patients in the FFNS 55 microg, FFNS 110 microg and placebo groups, respectively. The most common AEs were headache (8%, 9% and 8% in the FFNS 55 microg, FFNS 110 microg and placebo groups, respectively), nasopharyngitis (5%, 6% and 5%, respectively), pharyngolaryngeal pain (5%, 3% and 4%, respectively), epistaxis (4% in both active treatment groups and 4% in the placebo group) and pyrexia (3% in both active treatment groups and 2% in the placebo group). Findings from nasal examinations were similar across the treatment and placebo groups. Ophthalmic examinations found no differences between the treatment groups for mean change from baseline in intraocular pressure (assessed in the 12-week PAR study only), and no posterior subcapsular cataracts were reported in patients in either FFNS-treatment group. In the 6-week HPA axis study, 24-hour SC geometric mean concentrations were similar for FFNS and placebo groups. The lower limit of two-sided 95% confidence interval (CI) for the treatment ratio was greater than the prespecified noninferiority margin of 0.8 (treatment ratio=0.92, 95% CI 0.80, 1.05).

CONCLUSIONS

FFNS has a favourable safety and tolerability profile in patients aged 6-11 years with PAR or SAR.

Mometasone furoate: a review of its intranasal use in allergic rhinitis

Mometasone furoate (Nasonex) is a high-potency intranasal corticosteroid available for the treatment and/or prophylaxis of the nasal symptoms of seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR). In the EU, it is approved for use in patients aged > or =6 years and, in the US, it is approved as a treatment in patients aged > or =2 years and as prophylaxis in those > or =12 years of age.Extensive experience in both clinical trials and the clinical practice setting has firmly established the efficacy and good tolerability profile of intranasal mometasone furoate in children and adults with PAR or SAR. Thus, intranasal mometasone furoate is a useful first-line option for the treatment and prophylactic management of these conditions, including in children as young as 2 years of age in some countries and 6 years of age in others.

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.

Identification and management of undiagnosed and undertreated allergic rhinitis in adults and children

Allergic rhinitis (AR) is a common health problem that affects adults, adolescents and children and is often undiagnosed or inadequately treated. Because AR is not a life-threatening disease, many patients do not seek medical treatment for their symptoms, and others self-medicate with over-the-counter medications, often sedating antihistamines. However, untreated or inadequately treated AR can substantially impair overall quality of life (QOL) by causing fatigue, headache, cognitive impairment and other problems. The risk for comorbid conditions, such as asthma, otitis media, and lymphoid hypertrophy with obstructive sleep apnea, can increase, and the symptoms of AR can worsen if AR is not adequately treated. Among the symptoms of AR, nasal congestion has been described by patients as the most bothersome because it disrupts sleep, resulting in diminished daytime performance. A new congestion screening tool, the Congestion Quantifier, has been developed to aid in the diagnosis and treatment of AR and to help guide treatment decisions. Intranasal corticosteroids (INSs) are recommended as effective pharmaceutical treatments for controlling the symptoms of AR. Randomized, controlled trials in children and adults have demonstrated that INSs relieve rhinitis symptoms, thereby improving QOL in individuals with seasonal or perennial AR. Most INSs are approved for use in children >or=6 years of age, but mometasone furoate and fluticasone furoate are approved for use in children as young as 2 years of age and fluticasone propionate for children >or=4 years old. Long-term benefits have also been seen with the use of immunotherapy, although some patients, especially children, resist the injections used in subcutaneous immunotherapy. Recent studies with sublingual immunotherapy have indicated that it might be an effective and well-tolerated alternative to immunotherapy injections.

Safety and tolerability of fexofenadine hydrochloride, 15 and 30 mg, twice daily in children aged 6 months to 2 years with allergic rhinitis

BACKGROUND

Antihistamines are an established first-line treatment for allergic rhinitis and are widely prescribed in infants for allergic symptoms.

OBJECTIVE

To establish the safety and tolerability of fexofenadine hydrochloride in children aged 6 months to 2 years in 2 studies (T/3001 and T/3002).

METHODS

Both studies had a multicenter, randomized, placebo-controlled design. Mean treatment duration was 8 days. Subjects were randomized (T/3001, n = 174; and T/3002, n = 219) to twice-daily fexofenadine hydrochloride, 15 or 30 mg, or placebo mixed with a standard vehicle.

RESULTS

In the combined population, the incidence of treatment-emergent adverse events (TEAEs) was comparable between groups (placebo, 48.2% [96/199]; fexofenadine hydrochloride, 15 mg, 40.0% [34/85]; and fexofenadine hydrochloride, 30 mg, 35.2% [38/108]). Vomiting was the most common TEAE (placebo, 13.6%; fexofenadine hydrochloride, 15 mg, 14.1%; and fexofenadine hydrochloride, 30 mg, 5.6%). Most TEAEs were unrelated to study medication, as evaluated by investigators; those possibly related to study medication were mild or moderate in intensity. No clinical differences were seen between fexofenadine and placebo for vital signs, electrocardiographic results, or physical examination results.

CONCLUSION

Fexofenadine hydrochloride, 15 or 30 mg, given for a mean duration of 8 days is well tolerated, with a good safety profile, in children aged 6 months to 2 years.

Safety and efficacy of fluticasone furoate in pediatric patients with perennial allergic rhinitis

Objective

To evaluate the safety and efficacy of once-daily (QD) fluticasone furoate (FF) nasal spray in children with perennial allergic rhinitis (PAR).

Study Design

A global, randomized, double-blind, placebo-controlled study.

Subjects and Methods

Pediatric patients (aged 2–11 years; n = 558) with PAR received once-daily placebo, FF 110 μg, or FF 55 μg for 12 weeks. Efficacy was evaluated by nasal symptom scores. General safety and corticosteroid-specific safety (nasal and ophthalmic examinations, and hypothalamic—pituitary—adrenal assessments) were assessed.

Results

No findings of clinical concern were identified from the safety assessments. For primary efficacy analysis of mean change from baseline over the first 4 weeks of treatment in daily reflective total nasal symptom score, FF 55 μg demonstrated significant improvement ( P = 0.003) compared with placebo; however, the improvement for FF 110 μg versus placebo did not reach statistical significance ( P = 0.073).

Conclusion

FF QD was well tolerated and demonstrated efficacy in children aged 2 to 11 years with PAR.