Local corticosteroid treatment: the effect on cells and cytokines in nasal allergic inflammation

Intranasal Corticosteroids Do Not Lead to Ocular Changes: A Systematic Review and Meta-analysis

OBJECTIVES

The safety and efficacy of intranasal corticosteroids (INCS) are well established, but there remains apprehension that INCS could lead to systemic side effects, as with oral steroids. The objective of this systematic review was to assess whether the use of INCS lead to increased intraocular pressure (IOP) above 20 mm Hg, glaucoma, or formation of posterior subcapsular cataracts in adult patients with rhinitis.

METHODS

Two medical librarians searched the published literature for records discussing the use of "nasal steroids" in "rhinitis" and their effect on "intraocular pressure," "cataracts," or "glaucoma."

RESULTS

A total of 484 studies were identified, and 10 randomized controlled trials met our inclusion criteria. Meta-analysis of 2,226 patients revealed that the relative risk of elevated IOP in those who received INCS was 2.24 (95% confidence interval [CI]: 0.68 to 7.34) compared to placebo. The absolute increased incidence of elevated IOP in patients using INCS compared to placebo was 0.8% (95% CI: 0% to 1.6%). There were zero cases of glaucoma in both placebo and INCS groups at 12 months. The absolute increased incidence of developing a posterior subcapsular cataract was 0.02% (95% CI: -0.3% to 0.4%).

CONCLUSIONS

Use of INCS is not associated with a significant risk of elevating IOP or developing a posterior subcapsular cataract in patients with allergic rhinitis. Presence of glaucoma, however, is the real clinical adverse event of concern. There were zero reported cases of glaucoma at 12 months. Future studies should formally evaluate for glaucoma rather than use IOP measures as a surrogate. Laryngoscope, 129:6-12, 2019.

Allergy is associated with suicide completion with a possible mediating role of mood disorder - a population-based study

BACKGROUND

With increasing research suggesting a role of allergy on suicidality, this study, on a population level, delved into how allergy affects risk for suicide completion in the context of mood disorder and other factors.

METHODS

Based on the entire population of Denmark, we included 27,096 completed suicides and 467,571 live controls matched on sex and age with a nested case-control design. We retrieved personal information on hospital contacts for allergy and other variables from various Danish longitudinal registries and analyzed the data with conditional logistic regression.

RESULTS

We noted that 1.17% suicide victims, compared with 0.79% matched controls, had a history of hospital contact for allergy and that a history of allergy predicted an increased risk for suicide completion; however, the effect was confined to allergy that led to inpatient treatment (IRR: 1.59, 95% CI: 1.41-1.80). The increased risk was attenuated somewhat but remained significant when adjusted for personal psychiatric history and socioeconomic status. Meanwhile, we observed a nonsignificantly stronger effect in women than in men, and a significant age difference with a stronger effect for individuals at high ages. Moreover, we detected a significant interaction between allergy and mood disorder - even an antagonism effect of the two exposures. Allergy increased suicide risk only in persons with no history of mood disorder, whereas it eliminated suicide risk in those with a history of mood disorder.

CONCLUSIONS

The findings support a link between allergy and suicidality, with a possible mediating role of mood disorder.

Therapeutic management of allergic diseases

Allergic diseases are characterized by the activation of inflammatory cells and by a massive release of mediators. The aim of this chapter was to describe succinctly the modes of action, indications, and side effects of the major antiallergic and antiasthmatic drugs. When considering the ideal pharmacokinetic characteristics of a drug, a poorly metabolized drug may confer a lower variability in plasma concentrations and metabolism-based drug interactions, although poorly metabolized drugs may be prone to transporter-based disposition and interactions. The ideal pharmacological properties of a drug include high binding affinity, high selectivity, and appropriate association and dissociation rates. Finally, from a patient perspective, the frequency and route of administration are important considerations for ease of use.

Minimal persistent inflammation in allergic rhinitis: implications for current treatment strategies

Patients with allergic rhinitis have traditionally been placed into 'seasonal' and 'perennial' categories, which do not account for the subclinical inflammatory state that exists in many patients. In subjects with seasonal and perennial allergic rhinitis, even subthreshold doses of allergen have been found to cause inflammatory cell infiltration in the nasal mucosa, including increases in expression of cellular adhesion molecules, nasal and conjunctival eosinophilia, and other markers of inflammation, which do not result in overt allergy symptoms. This state - which has been termed 'minimal persistent inflammation'- may contribute to hyperreactivity and increased susceptibility to development of clinical symptoms as well as common co-morbidities of allergic rhinitis, such as asthma. Treating overt allergy symptoms as well as this underlying inflammatory state requires agents that have well-established clinical efficacy, convenient administration, potent anti-inflammatory effects and proven long-term safety, so that long-term continuous administration is feasible. Of the three major classes of commonly used allergic rhinitis medications - intranasal corticosteroids, anti-histamines, and anti-leukotrienes - intranasal corticosteroids appear to represent the most reasonable therapeutic option in patients who would benefit from continuous inhibition of persistent inflammation.

BSACI guidelines for the management of allergic and non-allergic rhinitis

This guidance for the management of patients with allergic and non‐allergic rhinitis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practicing in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web‐based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are clinical classification of rhinitis, aetiology, diagnosis, investigations and management including subcutaneous and sublingual immunotherapy. There are also special sections for children, co‐morbid associations and pregnancy. Finally, we have made recommendations for potential areas of future research.

Glucocorticosteroids in allergic inflammation: clinical benefits in allergic rhinitis, rhinosinusitis, and otitis media

Allergic rhinitis, rhinosinusitis, and otitis media are among the most common health problems encountered in general practice. Although frequently trivialized, they affect the quality of life, represent a significant socioeconomic burden, and are associated with some serious complications. In addition, allergic rhinitis, rhinosinusitis, and otitis media are often considered as comorbidities. These disorders involve an inflammatory process of the respiratory mucosa of the nose, paranasal sinuses, or middle ear. Because of their well-known anti-inflammatory effects, the role of glucocorticosteroids in the management of these three disorders has been questioned, evaluated, and, in some cases, established.

Evaluation of an intranasal house dust mite provocation model as a tool in clinical research

BACKGROUND

As a result of the all-year-round exposure to house dust mite (HDM), perennial rhinitis patients never have a clear symptom-free period. In this study, we investigated whether, despite these symptoms, we can still use nasal HDM provocations to study perennial allergic rhinitis and the effects of treatment.

METHODS

In a parallel-group study, after 1 week treatment with either fluticasone propionate aqueous nasal spray (FPANS) or placebo, 20 patients, allergic to HDM, registered symptoms (nasal obstruction, rhinorrhoea, sneezing, pruritus and eye symptoms) using three different scoring methods [Lebel, categorical and visual analogue scale (VAS)] and peak nasal inspiratory flow (PNIF) after HDM provocations. Provocations were performed with 1000 biological units/ml and 24 h later with 10,000 biological units/ml of HDM. Before and after the provocations, nasal mucosa biopsies were taken for immunohistochemical staining to determine the number of eosinophils.

RESULTS

House dust mite provocations resulted in an increase in symptoms and a decrease in PNIF. Even at high-dose provocation, the FPANS group registered significantly lower symptoms than the placebo group for nasal blockage, sneezing, eye symptoms, and PNIF in both early and late phases. FPANS also suppressed rhinorrhoea during the late phase and the influx of eosinophils in the lamina propria.

CONCLUSION

Despite the high background of symptoms, allergic responses can be induced in this perennial rhinitis model. The VAS score seems most suited to detect these changes and the suppression of symptoms by 7 days of FPANS treatment. Epithelial eosinophilia at baseline was correlated positively with the severity of the reaction after the first provocation.

Comparisons of two Intranasal Corticosteroid Preparations in Treating Allergic Rhinitis

OBJECTIVES: Intranasal corticosteroid preparations can relieve symptoms of allergic rhinitis. Different aqueous corticosteroid forms have been developed for intranasal use. The objectives of this study were to compare efficacy and safety between fluticasone propionate and budesonide in the treatment for patients with allergic rhinitis.

METHODS: The study was conducted in a prospective and randomized manner; a total of 24 adult patients were enrolled. All patients received MAST allergen test at entry and again at 2 months after treatments. Fourteen patients received fluticasone propionate 200 μg once daily, and 10 patients received budesonide 200 μg twice daily. To investigate the efficacy of fluticasone propionate and budesonide, a subjective scoring system was designed to evaluate the symptom improvement of patients. Adverse events were recorded on a diary card then were analyzed. Mann-Whitney U test and Kruskal-Wallis 1-way analysis of variance were used for statistical analysis.

RESULTS: Analysis on patient-based symptom scores revealed that both fluticasone propionate and budesonide were equally efficacious in improving the symptoms of nasal blockage, sneezing, nasal itching, and watery rhinorrhea. There were no significant side effects reported for both groups during this follow-up period. However, analysis showed that the fluticasone propionate group demonstrated significantly greater improvement in some MAST allergen tests ( Candida, mite, house dust; P < 0.05).

CONCLUSION: Clinically, fluticasone propionate 200 μg once daily was efficacious as budesonide 200 μg twice daily in the relief of allergic rhinitis symptoms. However, fluticasone propionate can achieve greater immunologic improvement. Both preparations showed no evidence of short-term side effects.

Prolonged nasal eosinophilia in allergic patients after common cold

BACKGROUND

Viral respiratory tract infections may cause both harmless common colds and severe asthma exacerbations; the differences in disease expression probably depend on the allergic status of the patient. To determine whether altered immunologic mechanisms underlie these differences, we investigated nasal inflammation during naturally acquired common cold.

METHODS

In a group of 16 patients (eight allergic), nasal brush samples were taken, and nasal symptoms were recorded during common cold, 2 weeks later (convalescence), and at baseline (>4 weeks without nasal symptoms). Nasal brush cells were stained immunohistochemically for Langerhans cells, T cells, monocytes, neutrophils, B cells, macrophages, natural killer (NK) cells, mast cells, eosinophils, eotaxin, and RANTES.

RESULTS

Four rhinovirus, four coronavirus, three RSV, one Mycoplasma pneumoniae, and one influenza A/enterovirus double infection were confirmed. Increased numbers of T cells, monocytes, macrophages, NK cells, eosinophils, and RANTES- and eotaxin-positive cells, but not neutrophils, were observed during common cold in allergic and nonallergic patients, and increased numbers of mast cells in allergic patients. Compared to nonallergic patients, in allergic patients eosinophil influx persisted into convalescence.

CONCLUSION

Prolonged nasal eosinophil influx was observed in allergic patients after common cold. What immunologic factors can induce prolonged eosinophil influx and whether this may increase the risk of subsequent allergen-induced hypersensitivity reactions must be studied further.

Evidence-based treatment of allergic rhinitis

Allergic rhinitis is an extremely common disease worldwide, affecting 10% to 50% of the population. An increasing prevalence of allergic rhinitis over the past decades and its frequent association with asthma have raised concerns about treating the disease appropriately. New knowledge of the pathophysiologic mechanisms underlying allergic inflammation of the airways has resulted in the development of newer and better therapeutic strategies. This review focuses on evidence-based treatment of allergic rhinitis, highlighting the most recent international consensus and evidence-based guidelines on allergic rhinitis.

Preventive treatment of intranasal fluticasone propionate reduces cytokine mRNA expressing cells before and during a single nasal allergen provocation

BACKGROUND

The local production and release of a number of cytokines regulate allergic upper airway inflammation. Medication is usually used at the presentation of the first symptoms. There are, however, clues that it is advisable to start taking the corticosteroid before the grass pollen season begins.

METHODS

This single allergen provocation study was conducted in autumn, out of the hay fever season. Nasal mucosa biopsies were taken twice before provocation (before and after 4 weeks of preventive treatment) and three times after allergen provocation (1 h, 24 h and 1 week). The preventive treatment used was fluticasone propionate aqueous nasal spray (FPANS) (n = 10) or a placebo (n = 9). Eosinophils and mRNA positive cells (in situ hybridization for IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, IFNgamma, RANTES and TNFalpha) were counted in the biopsies.

RESULTS

Preventive treatment with FPANS out of season resulted in a decrease in eosinophils and mRNA positive cells for IL-5 and IL-6. After allergen provocation, levels of most of the measured cytokines (IL-3, IL-5, IL-6, IL-13, IFNgamma, RANTES and TNFalpha) and eosinophils were reduced using corticosteroids. The numbers of cells (eosinophils, IL-3, IL-6 and IL-8) correlated with nasal symptoms. Significant correlations in the early and late allergic phase were found between eosinophils and cytokines (IL-3, IL-10 and IL-13).

CONCLUSION

These results indicate that preventive treatment with FPANS prior to contact with grass pollen is effective in reducing the increase of cytokine mRNA positive cells in reaction to grass pollen contact.

Glucocorticosteroids rapidly inhibit allergen-induced expression of E-selectin in vitro in a mucosal model of allergic rhinitis

BACKGROUND

Transendothelial migration of cells to sites of inflammation is a hallmark of the allergic reaction. The adhesion cascade involves the initial expression of the adhesion molecule E-selectin on endothelial cells. The aim of the study was to determine the efficacy of a 30-min preincubation of the glucocorticosteroids (GCS) fluticasone, prednisolone, and fluocortin butyl on allergen- and interleukin (IL)-1beta-induced E-selectin expression in allergic rhinitis.

METHODS

Freshly taken nasal inferior turbinate mucosa of 19 subjects with allergic rhinitis was cut into small cubes and preincubated for 30 min with prednisolone (n = 6), fluticasone (n = 5), and fluocortin butyl (n = 3) in different concentrations, followed by allergen exposure at a concentration of 1000 BU/ml for 1 and 2 h. Additionally, fluticasone-preincubated tissues were exposed to recombinant human rhIL-1beta (n = 5) at a concentration of 2 pg/ml. The expression of E-selectin was assessed by immunohistochemistry (APAAP technique) and computerized image evaluation.

RESULTS

In this model, E-selectin expression was significantly upregulated by allergen and rhIL- 1beta within 1 and 2 h. After 30-min preincubation with prednisolone and fluocortin butyl at drug concentrations of 10-8 mol/1, we found a significant (> or = 50%) reduction of the E-selectin expression after 1 and 2 h. Allergen-induced E-selectin expression was nearly abolished at concentrations of 10-5 (prednisolone) and 10-4 mol/l (fluocortin butyl). Fluticasone significantly inhibited E-selectin expression by > or = 50% at concentrations of 10-14 and 10-12 mol/l after 1 and 2 h, and abolished E-selectin induction at concentrations of 10-12 and 10-10 mol/l, respectively. Exposure of mucosal cubes to rhIL-lbeta (n = 5) also induced rapid upregulation of E-selectin expression, an effect which could be only partially suppressed by fluticasone preincubation at concentrations of 10-l0 mol/l.

CONCLUSIONS

Allergen-induced E-selectin expression is significantly and rapidly inhibited by GCS preincubation, fluticasone being more potent than prednisolone and fluocortin butyl. We suggest that this rapid effect is mainly indirect, possibly by inhibition of allergen-induced cytokine release.

A review of the preclinical and clinical data of newer intranasal steroids used in the treatment of allergic rhinitis

The anti-inflammatory activity of corticosteroids has prompted the exploration of their use in the treatment of allergic rhinitis. The development of intranasal steroids has resulted in several agents with quick actions, localized effects, and great efficacy in the treatment of seasonal allergic rhinitis and the prophylactic management of perennial rhinitis. This article presents a concise review of the preclinical and clinical evidence with these new agents and provides data-based guidance for the selection of optimal agents. The survey reveals that mometasone furoate, a new inhaled steroid with topical activity, has the greatest binding affinity for the glucocorticoid receptor, followed by fluticasone propionate, budesonide, triamcinolone acetonide, and dexamethasone. Mometasone furoate also has strong anti-inflammatory activity, with IL-4 and IL-5 inhibition activities equivalent to those of fluticasone propionate. Clinically, both mometasone furoate and fluticasone propionate appear to be well tolerated, to have quick onsets of action, and to be equivalent in efficacy in the treatment of seasonal allergic and perennial rhinitis. Of the intranasal steroids currently available, mometasone furoate has been shown to have the least systemic availability and, consequently, is expected to have the fewest systemic side effects. Some suppression of overnight cortisol levels has been reported with fluticasone propionate (indicative of hypothalamic-pituitary-adrenal axis suppression).