[Long-term treatment of nasal polyps with beclomethasone dipropionate aerosol. III. Morphological studies and conclusions]

Intranasal Steroids and the Myth of Mucosal Atrophy: A Systematic Review of Original Histological Assessments

Background

Intranasal corticosteroids (INCSs) are well established in the treatment of allergic rhinitis, chronic rhinosinusitis, and nasal polyposis. Although reversible atrophy of keratinized skin is seen with corticosteroids, the respiratory mucosa is histologically very different and but concerns remain among patients and some health-care professionals over local side effects on nasal respiratory mucosa. A systematic review and meta-analysis were performed of the available evidence for nasal mucosal atrophy as an adverse effect of INCSs in patients with sinonasal disease.

Methods

A systematic search of Embase (1974-) and Medline (1946-) databases to September 27, 2013 was performed. Inclusion criteria selected any study where the histopathology of nasal mucosa was assessed in patients with sinonasal disease using intranasally administered corticosteroids with or without a control group.

Results

Twenty-three hundred sixty-four publications were retrieved with a subsequent full text review of 149 publications for 34 articles that met the selection criteria. These articles included 11 randomized controlled trials, 5 cohorts, and 20 case series. Duration of treatment varied from 5 days to 5.5 years. “Mucosal atrophy” as an outcome was reported in 17 studies. The definition of “mucosal atrophy” was highly variable with a definition given in only 10 studies. One hundred thirty-six patients were represented in controlled studies of atrophy with only one study reporting the event in both groups with an odds ratio of “mucosal atrophy” at 0.51 (95% CI, 0.09-3.11; p = 0.47).

Conclusion

The concept of nasal mucosal atrophy is poorly defined and there is no histological evidence for deleterious effects from INCS use on human nasal mucosa.

No mucosal atrophy and reduced inflammatory cells: active-controlled trial with yearlong fluticasone furoate nasal spray

BACKGROUND

Fluticasone furoate nasal spray (FFNS) and mometasone furoate nasal spray (MFNS) are well tolerated and more effective than placebo at relieving the symptoms of seasonal and perennial allergic rhinitis. Effects of FFNS on the nasal histology have not been previously reported. This study examines the effects of FFNS and MFNS, administered daily for 1 year, on the nasal mucosa in subjects with perennial allergic rhinitis.

METHODS

Subjects with perennial allergic rhinitis were randomized 1:1 to q.d., open-label treatment with FFNS, 110 μg, or MFNS, 200 μg, for 1 year. These groups and a healthy control group that did not receive study medication underwent nasal biopsies at baseline and 12 months.

RESULTS

The nasal biopsy population comprised 96 participants (37 using FFNS, 42 using MFNS, and 17 healthy controls). Epithelial thickness did not change appreciably from baseline to week 52 in any of the groups and mean change from baseline did not differ between FFNS and MFNS (least square mean difference, -0.001 mm, 95% confidence interval, -0.007, 0.006). Although not tested for significance, improvements over baseline were observed in epithelial histology in the FFNS group with more epithelium including intact columnar and ciliated epithelial cells. No appreciable change in the percentage of goblet cells was established. FFNS and MFNS were associated with decreases in epithelial and subepithelial nasal mucosal eosinophils and basophils from baseline to week 52. The percentage of subjects with no inflammatory cells at week 52 was 49 and 33% for eosinophils and 46 and 24% for basophils, for FFNS and MFNS, respectively.

CONCLUSION

Yearlong therapy with either FFNS or MFNS showed no changes in epithelial thickness or the percentage of goblet cells as well as a reduction in inflammatory cell infiltrate. FFNS was associated with improvements in epithelial histology. These data support the long-term safety of FFNS in subjects with perennial allergic rhinitis.

Effect of topical nasal steroid sprays on nasal mucosa and ciliary function

PURPOSE OF REVIEW

This review was conducted to examine current evidence focusing on the effect of nasal steroid sprays on nasal ciliary function.

RECENT FINDINGS

Review of current literature suggests that long term effects of topical corticosteroid nasal sprays are safe and fail to cause damage to local nasal structure and function.

SUMMARY

The use of corticosteroid nasal sprays for the treatment of allergic rhinitis is widely accepted. Popularity of this class of medications is based on a well-established combination of efficacy, tolerability, and safety. Although current literature suggests that the use of intranasal steroids is indeed safe, increasing indications for prolonged administration continue to fuel debate regarding the long-term effect on local nasal structure and function. The purpose of this article is to review current literature addressing the effects of the components of local intranasal steroid sprays on the structure and function of the nasal mucosa.

Expression of glucocorticoid receptors and cyclooxygenase-2 in nasal polyps from nonallergic patients

Glucocorticoid treatment has been widely used to suppress inflammatory and immune responses. However, from a clinical point of view, its efficacy in the treatment of nasal polyposis seems to vary individually from patient to patient. In the present study, we examined the presence of glucocorticoid receptors (GRs) and cyclooxygenase-2 (COX-2) in the nasal polyps of nonallergic patients as compared with normal controls. Reverse transcription-polymerase chain reaction analyses revealed the presence of both GR messenger RNA and COX-2 messenger RNA expression in nasal polyps from nonallergic patients, as well as in normal nasal mucosa from controls. Consistent with this finding, immunohistochemical analysis demonstrated that GRs and COX-2 were labeled in both tissues. In nasal polyps, GR labeling was associated with the cytoplasm and nucleus of surface mucosa, submucosal glands, endothelial cells, and inflammatory cells. Importantly, COX-2 labeling was seen in the cytoplasm of surface mucosa, submucosal glands, and the vascular wall in nasal polyps. In contrast, in normal nasal tissues, COX-2 labeling was only found in the vascular wall, and the expression was weaker--a finding demonstrating that COX-2 is upregulated in nasal polyps. Therefore, 1) the presence of GRs and COX-2 in nasal polyps from nonallergic patients, as well as upregulation of COX-2 expression, suggests that inflammation may play an important role in the pathophysiology of nasal polyps; and 2) glucocorticoid could be a potential treatment method for suppressing inflammatory processes.

Prophylactic budesonide nasal spray after polypectomy

This double blind study compared the effect of budesonide nasal spray with placebo, in the prophylaxis of nasal polyp recurrence after avulsion. 38 cases were given budesonide nasal spray and 25 placebo for 3 months after polypectomy. Follow up of 9 months revealed budesonide treated patients to have significantly lower recurrence rate as compared to the placebo. Interestingly patients with recurrent nasal polyposis benefitted much more from topical budesonide treatment as compared to ones with no previous history of polypectomy.

Mode of action of intranasal corticosteroids

The mode of action of intranasal corticosteroids (INCS) is complex. It is not known whether INCS penetrate the nasal mucosa or act on target cells; however, their low systemic activity supports the concept of local action on nasal mucosa. This local effect can nonetheless influence a variety of inflammatory cells and their mediators such as epithelial cells, lymphocytes, basophils, mast cells, and Langerhans cells. Corticosteroid-induced inhibition of immunoglobulin E-dependent release of histamine is a possible but unproven mode of action. Epithelial cells are an important target for corticosteroids, and INCS concentration is high at the epithelial surface. INCS may combine with the corticosteroid receptors in epithelial cells, which are then expelled into the airway lumen together with the dead epithelial cells or migrating inflammatory cells. A reduced influx of mediator cells may explain some of the effects of INCS on rhinitis symptoms, but it cannot explain all of the effects because INCS also reduce the early-phase sneezing and rhinorrhea after an allergen challenge outside the pollen season. In this situation, the number of surface mast cells/basophils is very low, as it is in the absence of allergic rhinitis. The mechanism by which INCS treatment of allergic rhinitis reduces itching, sneezing, and rhinorrhea, the characteristic symptoms of an early-phase response involving mast cell release of histamine, remains to be determined. Studies should be conducted to characterize the broad range of mechanisms by which INCS produce their therapeutic effects in allergic rhinitis.

Cell and cytokine profiles in nasal secretions from patients with nasal polyposis: effects of topical steroids and surgical treatment

BACKGROUND

Nasal polyposis (NP), a chronic inflammatory disease of the paranasal sinus mucosa, is frequently associated with asthma. Previous reports showed that surgical treatment for nasal polyps may influence asthma evolution. We hypothesized that sinus surgery may alter the cytokine network in nasal secretions.

METHODS

We evaluated the characteristics (cells and mediators) of nasal lavages in nine patients with untreated NP (group A), 17 patients treated with topical steroids (group B), 21 patients treated by nasal surgery endonasal ethmoidectomy associated with topical steroids (group C), and 12 healthy subjects (controls).

RESULTS

Percentages of both eosinophils and neutrophils were higher in NP patients than in controls. Percentages of eosinophils and interleukin-5 (IL-5) level were higher in group A than in group C and controls. There was a positive correlation between IL-5 and eosinophils. In marked contrast, IL-8, IL-10, and IL-1beta levels were significantly higher in group C than in groups A and B and controls; TNF-alpha concentration was significantly lower in group C than in groups A and B and controls; and there was a negative correlation between IL-10 and TNF-alpha. The percentage of eosinophils was higher in asthmatic patients with NP than in nonasthmatic patients. In addition, in group C, asthmatic patients also had a significantly higher level of IL-10 than nonasthmatic patients.

CONCLUSIONS

Our study demonstrates that percentages of eosinophils and neutrophils, and IL-5 level were increased in nasal secretions from untreated patients with NP. Topical steroid treatment is associated with a decrease of inflammatory cells and mediators. In marked contrast, nasal surgery is associated with marked changes, in cytokine profile in nasal secretions, that are clearly different from those of controls and topical steroid-treated NP patients.

Impact of allergic rhinitis treatment on quality of life

Allergic rhinitis is a chronic inflammatory disorder of the nasal passages. It affects approximately 20% of the population, is a significant health and economic burden, and severely impairs quality of life. Two main instruments, Medical Outcomes Study 36-Item Short Form health survey (SF-36) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) have been used to assess quality of life in patients with allergic rhinitis. Antihistamines, corticosteroids, anticholinergic agents, decongestants, cromoglycates, and immunotherapy are used to treat patients with allergic rhinitis. Of these, antihistamines and intranasal corticosteroids are the most efficacious and frequently utilised medications. Studies have demonstrated improvements in quality of life with both of these medications in patients with allergic rhinitis.

Localization of cystic fibrosis transmembrane conductance regulator in epithelial cells of nasal polyps and postoperative polypoid mucosae

Cystic fibrosis transmembrane conductance regulator (CFTR) is a chloride channel protein that plays an important role in electrolyte and water transport through the respiratory epithelial cells. In order to understand the possible role of CFTR in the pathogenesis of nasal polyps and postoperative polypoid mucosae, we aimed to characterize the localization of CFTR in the epithelia of nasal polyps and postoperative polypoid mucosae of subjects who did not manifest the phenotypic expression of cystic fibrosis. Immunohistochemical staining for CFTR, using monoclonal mouse anti-human CFTR, was performed on tissue sections of 4 normal turbinates and nasal polyps and postoperative polypoid mucosae from 10 patients who underwent endoscopic intranasal operations. CFTR showed a typical apical distribution in the normal turbinate mucosae whereas, in the nasal polyps, CFTR demonstrated a heterogenous pattern of localization comprising diffuse or scattered cytoplasmic labelling, very low to undetectable labelling, intense perinuclear staining and intermingled typical apical location. In postoperative polypoid mucosae, the pattern of CFTR localization was less heterogeneous than in the nasal polyp epithelial cells and showed a more prominent feature of diffuse cytoplasmic staining. These results suggest that an altered localization of the CFTR may have a role in the pathogenesis of nasal polyps and postoperative polypoid mucosa.

Immunoglobulins in nasal secretions of healthy humans: structural integrity of secretory immunoglobulin A1 (IgA1) and occurrence of neutralizing antibodies to IgA1 proteases of nasal bacteria

Certain bacteria, including overt pathogens as well as commensals, produce immunoglobulin A1 (IgA1) proteases. By cleaving IgA1, including secretory IgA1, in the hinge region, these enzymes may interfere with the barrier functions of mucosal IgA antibodies, as indicated by experiments in vitro. Previous studies have suggested that cleavage of IgA1 in nasal secretions may be associated with the development and perpetuation of atopic disease. To clarify the potential effect of IgA1 protease-producing bacteria in the nasal cavity, we have analyzed immunoglobulin isotypes in nasal secretions of 11 healthy humans, with a focus on IgA, and at the same time have characterized and quantified IgA1 protease-producing bacteria in the nasal flora of the subjects. Samples in the form of nasal wash were collected by using a washing liquid that contained lithium as an internal reference. Dilution factors and, subsequently, concentrations in undiluted secretions could thereby be calculated. IgA, mainly in the secretory form, was found by enzyme-linked immunosorbent assay to be the dominant isotype in all subjects, and the vast majority of IgA (median, 91%) was of the A1 subclass, corroborating results of previous analyses at the level of immunoglobulin-producing cells. Levels of serum-type immunoglobulins were low, except for four subjects in whom levels of IgG corresponded to 20 to 66% of total IgA. Cumulative levels of IgA, IgG, and IgM in undiluted secretions ranged from 260 to 2,494 (median, 777) microg ml(-1). IgA1 protease-producing bacteria (Haemophilus influenzae, Streptococcus pneumoniae, or Streptococcus mitis biovar 1) were isolated from the nasal cavities of seven subjects at 2.1 x 10(3) to 7.2 x 10(6) CFU per ml of undiluted secretion, corresponding to 0.2 to 99.6% of the flora. Nevertheless, alpha-chain fragments characteristic of IgA1 protease activity were not detected in secretions from any subject by immunoblotting. Neutralizing antibodies to IgA1 proteases of autologous isolates were detected in secretions from five of the seven subjects but not in those from two subjects harboring IgA1 protease-producing S. mitis biovar 1. alpha-chain fragments different from Fc(alpha) and Fd(alpha) were detected in some samples, possibly reflecting nonspecific proteolytic activity of microbial or host origin. These results add to previous evidence for a role of secretory immunity in the defense of the nasal mucosa but do not help identify conditions under which bacterial IgA1 proteases may interfere with this defense.

Comparison of the effects of fluticasone propionate, aqueous nasal spray and levocabastine on inflammatory cells in nasal lavage and clinical activity during the pollen season in seasonal rhinitics

BACKGROUND

Treatment options for allergic rhinitis include antihistamines, decongestants, anticholinergics, cromolyn sodium and corticosteroids. As the nose is a small organ, comprising less than 1% of total body mass and surface area, it seems logical to confine treatment of rhinitis to the diseased organ.

OBJECTIVE

To evaluate the effects of therapy with intranasal fluticasone propionate (FP), both on subjective symptoms and pathophysiological mechanisms, in rhinitis patients during pollen season when the patients were symptomatic.

METHODS

We used a double-blind, placebo (PLA)-controlled, randomized, double dummy, parallel group study of the effect of 6 weeks treatment. The double-blind comparison was made between the following three treatments: FP aqueous nasal spray, 200 microg taken once daily, levocabastine (LEV) nasal spray, 200 microg taken twice daily and PLA nasal spray. Clinical evaluation and the levels of cells and mediators in nasal washing were performed before and after treatments. Twenty-four patients (11 men and 13 women, aged 17-50 years, mean age 30.1 +/- 8.5) with strictly seasonal allergic rhinitis to Parietaria entered the study. Clinical evaluation and the levels of inflammatory cells (eosinophils and activated eosinophils, i.e. EG2+) and their mediators (tryptase, eosinophil cationic protein, eosinophil protein X and neutrophil myeloperoxidase) in nasal-lavage were performed before and after treatments.

RESULTS

Treatment with FP significantly increased, with respect to placebo, the percentage of days without sneezing (P < 0. 001), nasal blockage (P < 0.001), rhinorrhea (P < 0.001), nasal itching (P < 0.001). Furthermore, treatment with FP showed additional benefits with respect to LEV. The percentage of days without nasal blockage was significantly higher in the FP group that in the placebo group (P = 0.018). The same applied to rhinorrhea (P = 0.009). The percentages of days without sneezing and itching were instead not significantly different between the two groups. As expected, no significant differences were observed in baseline medians of the rhinitis symptom scores as well as in mean values of all mediators and eosinophils in nasal lavages of the various groups under study. After treatment the mean of subjective symptoms as well as all values in nasal lavage level fell significantly only in the FP group, whereas no significant changes were observed either in LEV or PLA groups. Accordingly, significant differences were observed at the end of the treatments between the values of fluticasone group vs LEV and PLA group values. Significant correlations between these values and symptom scores were found, according with literature data suggesting a pathogenetic role for these mediators and eosinophils in rhinitis.

CONCLUSION

FP (200 microg once daily) affords a significant degree of improvement in rhinitis control during pollen season, as measured by subjective and objective parameters, compared with LEV (200 microg twice daily) and PLA. The therapeutic benefits of intranasal FP are reflected in, and may be caused by, the decrease in nasal inflammatory cells.

Use of nasal steroids in managing allergic rhinitis

Intranasal steroids are highly effective drugs for treating patients with allergic rhinitis. First-line use of intranasal steroids is becoming increasingly common, and intranasal steroids can be used alone or in combination with other therapies to achieve optimal improvement in rhinitis symptoms. The major adverse effect of intranasal steroids is local irritation. This article reviews the mechanism of action of corticosteroids, the effects of intranasal steroids on chemical mediators of inflammation, and the risks and benefits associated with their use.

Efficacy of an aqueous and a powder formulation of nasal budesonide compared in patients with nasal polyps

Nasal polyps are commonly treated surgically. Intranasal administration of topical corticosteroids has gained increased acceptance as a treatment alternative. The aim of our study was to compare the efficacy of treatment of two formulations of budesonide with placebo on nasal polyps. At four Danish clinics 138 patients suffering from moderate or severe nasal polyps were randomized to a twice daily treatment with Rhinocort Aqua 128 micrograms, Rhinocort Turbuhaler 140 micrograms or placebo (Astra Draco, Sweden) for 6 weeks. Polyp size (primary efficacy variable), nasal symptoms, sense of smell, and patients' overall evaluation of treatment of efficacy were assessed by scores. Polyp size was reduced significantly in both budesonide treated groups compared with placebo, but there was no statistical difference between the two actively treated groups. Patients' nasal symptom scores was significantly more reduced in the Aqua compared to the Turbuhaler treated group, and both reduced symptom scores were significantly better compared to placebo. Sense of smell was significantly improved in the actively treated groups compared to placebo. The proportion of patients rating substantial or total control over symptoms after 6 weeks treatment was 60.9% and 48.2% in the Aqua and Turbuhaler-treated groups, respectively, which was significantly better compared with 29.8% in the placebo-treated group. Rhinocort Aqua and Rhinocort Turbuhaler were equally well tolerated.

Fluticasone propionate aqueous nasal spray in the treatment of nasal polyposis

BACKGROUND

Topical glucocorticoids are the medical treatment of choice in a majority of patients suffering from nasal polyposis. Fluticasone propionate is a fluorinated steroid reported to be highly effective when used topically in the nose for seasonal and perennial allergic and nonallergic rhinitis.

OBJECTIVES

To evaluate the efficacy and tolerability of intranasal fluticasone propionate in the treatment of long-standing polyposis.

METHODS

Fifty-five patients with long-standing nasal polyposis were treated over a 26-week period with fluticasone propionate aqueous nasal spray 200 micrograms bid, beclomethasone dipropionate aqueous nasal spray 200 micrograms bid or placebo, administered intranasally in an aqueous spray in a double-blind, placebo-controlled parallel-group design at a single center. The primary efficacy endpoint was the physicians' assessment of symptoms and polyp score. Peak nasal inspiratory flow was performed twice daily and on every visit to evaluate the effect of the corticosteroids on nasal air flow.

RESULTS

A significant difference in the primary efficacy endpoint between fluticasone propionate aqueous nasal spray and beclomethasone dipropionate aqueous nasal spray compared with placebo was seen after 14 weeks of treatment. This was further verified by the peak nasal inspiratory flow results. There was some evidence of earlier onset in the fluticasone propionate aqueous nasal spray group compared with the beclomethasone dipropionate aqueous nasal spray group after 4 weeks in terms of the primary efficacy endpoint. From the daily record cards patients receiving fluticasone propionate aqueous nasal spray had a significantly higher percentage of days on which they required no rescue medication (P < .009) and a higher percentage of days with an overall nasal blockage score on waking of < 2 (P < .013) when compared with placebo-treated patients. No other statistically significant results were found between the two active compounds.

CONCLUSION

Fluticasone propionate aqueous nasal spray 200 micrograms bid and beclomethasone dipropionate aqueous nasal spray 200 micrograms bid are effective in treating the symptoms of nasal polyps, with some evidence that fluticasone propionate aqueous nasal spray has a faster onset of action and is tolerated at least as well as beclomethasone dipropionate aqueous nasal spray at the same dose.

Nasal polyps: medical or surgical management?

Nasal polyposis is considered to be a non-IgE-mediated inflammatory condition of the nose and sinuses, often associated with chronic non-allergic rhinitis, aspirin intolerance and non-allergic asthma. The aetiology of nasal polyposis is unknown. The main symptoms are nasal obstruction and disturbance of the sense of smell. Occlusion of the nasal passage by a few large polyps could be treated by simple polypectomy to help the patient breathe through the nose. Polypectomy per se does not worsen asthma. Other surgical procedures can be performed, depending on the degree of the disease. The aim of surgery is to restore the physiological properties of the nose by making the nose as free from polyps as possible, and to allow drainage of infected sinuses. Complementary medical treatment of polyposis is always necessary, as surgery cannot treat the inflammatory component of the mucosal disease. In this respect, topical corticosteroids have long been the drugs of choice to reduce the size of polyps, to prevent recurrence after surgery, and are often the main treatment for the disease in many patients. Fluticasone propionate has now been shown to be at least as effective as beclomethasone dipropionate as a medical tool in the management of polyposis. Short-term treatment with systemic corticosteroids is an alternative method of inducing remission and controlling nasal polyps. However, in most patients with nasal polyps, treatment consists of both medical and surgical management.

Effects of corticosteroid therapy in non-allergic rhinosinusitis

Corticosteroids have a multifactorial effect initiated by their binding to a specific cytoplasmic glucocorticoid receptor. At the cellular level there is a reduction in the number of antigen-presenting cells, in the number and activation and T cells, in the number of epithelial mast cells, and in the number and activation of eosinophils. Steroids have a proven effect on symptoms and signs in non-allergic rhinosinusitis with eosinophilia and in nasal polyposis. Topically applied drugs, studied in many controlled trials, reduce rhinitis symptoms, improved nasal breathing, reduce the size of polyps and their recurrence, but have a poor effect on the sense of smell and no direct effect on sinus pathology. Systemic steroids, less well studied, appear to have an effect on all types of symptoms and pathology, the sense of smell included. A short course of systemic steroids is as effective as polypectomy with a snare. Individualized management of nasal polyposis and non-allergic rhinosinusitis with eosinophilia may consist of long-term topical steroids, short-term systemic steroids, or surgery, in various combinations.

Nasal cytological changes following pharmacological intervention

Symptoms of allergic rhinitis are associated with increased numbers of inflammatory cells in the nasal mucosa. The effects of fluticasone propionate on the nasal mucosal cells of patients with symptomatic allergic rhinitis were evaluated in seven multicentre, double-blind, parallel-group, placebo-controlled, randomised studies. In three seasonal allergic rhinitis studies, significantly more patients receiving fluticasone propionate had a decrease in nasal eosinophils following treatment compared with patients receiving placebo. Similarly, more patients receiving fluticasone propionate had a decrease in nasal basophilic cells, but differences from placebo were not significant in all studies. Nearly identical results were observed in two 24-week perennial allergic rhinitis studies: significantly more patients receiving fluticasone propionate or beclomethasone dipropionate had a decrease in nasal eosinophils compared with patients receiving placebo. Furthermore, a higher percentage of patients receiving corticosteroids also had a decrease in the number of basophilic cells. In two separate seasonal allergic rhinitis studies, significantly more patients receiving fluticasone propionate had a decrease in nasal eosinophils compared with patients receiving terfenadine or astemizole, respectively. The decrease in nasal basophilic cells was also significantly greater with fluticasone propionate compared with astemizole. Inhibition of mediator release from eosinophilic and basophilic cells has also been demonstrated in patients receiving fluticasone propionate compared with patients receiving antihistamines. The results of these studies suggest that the therapeutic benefits of fluticasone propionate aqueous nasal spray in the treatment of seasonal and perennial allergic rhinitis may be related to its ability to reduce nasal mucosal inflammatory cells and to inhibit local mediator activity.

Glucocorticoid-induced attenuation of mucosal exudation of fibrinogen and bradykinins in seasonal allergic rhinitis

The mucosal plasma exudate with its proteins, enzymes, derived peptides, and matrix molecules is an important factor in inflammatory airway diseases. This study investigated whether topical glucocorticosteroid treatment influences mucosal exudation of bulk plasma (fibrinogen) and the generation of plasma-derived mediators (bradykinins) in seasonal allergic rhinitis. Twenty-two patients with birch-pollen-induced allergic rhinitis participated in a double-blind, randomized, placebo-controlled study during the birch pollen season in 1989. After a 2-week run-in period, the participants received treatment with budesonide (200 micrograms per nasal cavity and day) or placebo. The patients kept a diary to record their daily nasal symptoms (itching, sneezing, nasal blockage, and secretion). The amount of birch pollen in the air was determined with the aid of a Burkhard pollen trap. A nasal lavage was performed once a week, and the levels of bradykinins and fibrinogen were determined in the lavage fluid samples. The birch pollen season was very mild, resulting in only minor nasal symptoms. In spite of the low pollen exposure, treatment with budesonide reduced the lavage fluid levels of both bradykinins and fibrinogen. The present results show that topical glucocorticosteroid treatment attenuates plasma exudation and the generation of plasma-derived mediators in seasonal allergic rhinitis. This action may not result from simple vascular antipermeability effects of the drug but may rather reflect the anti-inflammatory efficacy of topical glucocorticoids in the airway mucosa.

Developments in anti-asthma glucocorticoids

Studies carried out by Swedish and English workers in the mid 1950s appear to be the first successful uses of topical glucocorticoids in asthma. As shown with beclomethasone dipropionate during the 1970s, and expanded with budesonide during the 1980s, inhaled glucocorticoids have a very broad clinical efficacy and are safe to use. With increasing lung selectivity glucocorticoid drugs may well become a primary treatment for asthma. Even prolonged treatment with large doses of budesonide may not affect the contractile and relaxant characteristics of airway smooth muscle suggesting that this tissue is not a direct target for glucocorticoid actions. In IgE-sensitized guinea-pigs, as in atopic asthmatics, inhalational budesonide and other glucocorticoids inhibit both immediate and late phase pulmonary reactions occurring after allergen provocation. The anti-anaphylactic lung effects of glucocorticoids are not necessarily associated with inhibition of histamine and leukotriene release and, although PAF release was reduced by budesonide, the importance of this effect is as yet unknown. Airway eosinophilia is seen at the late phase reaction but may not consistently be reduced by glucocorticoids. These drugs reduce plasma leakage that is associated with both atopic and non-atopic asthma. Hence, a stabilising effect on airway endothelial-epithelial barriers may be one of the significant actions of glucocorticoids in the inflamed airways of patients with asthma or chronic obstructive pulmonary disease.

Influx of kininogens into nasal secretions after antigen challenge of allergic individuals

We have recently demonstrated that kinins are generated in vivo after nasal challenge with antigen of allergic, but not nonallergic, individuals. The present study was undertaken as a first step in determining the mechanism(s) of kinin formation during the allergic reaction and was directed towards establishing the availability and origin of kininogens in nasal secretions. Allergic individuals (n = 6) and nonallergic controls (n = 5) were challenged with antigen; and by using specific radioimmunoassays, nasal washes, obtained before and after challenge, were assayed for high molecular weight kininogen (HMWK), total kininogen (TK), albumin, and kinins. Dramatic increases in HMWK (1,730 +/- 510 ng/ml), TK (3,810 +/- 1035 ng/ml), kinin (9.46 +/- 1.75 ng/ml), and albumin (0.85 +/- 0.2 mg/ml) were observed after challenge of allergic individuals which correlated (P less than 0.001) with increases in histamine and N-alpha-tosyl-L-arginine methyl esterase activity and with the onset of clinical symptoms. For nonallergic individuals, levels of kininogens, albumin, and all mediators after antigen challenge were not different from base line. Linear regression analysis revealed excellent correlations (P less than 0.001 in each case) between increases in HMWK, TK, kinin, and albumin during antigen titration experiments and between the time courses of appearance and disappearance of HMWK, TK, kinin, and albumin after antigen challenge. Gel filtration revealed no evidence of degradation products of kininogens in nasal washes. For each allergic individual the ratio of HMWK/TK in postchallenge nasal washes was similar to the ratio of these two proteins in the same individual's plasma. These data suggest that, during the allergic reaction, there is an increase in vascular permeability and a transudation of kininogens from plasma into nasal secretions, where they can provide substrate for kinin-forming enzymes.

Histamine H1 receptors and affinity analyses in human nasal mucosa in cases of nasal allergy

An increased number (density) or sensitivity (affinity) of histamine H1 receptors could cause an increase of allergic symptoms. Using the specific H1 receptor blocker 3H-mepyramine, we have demonstrated for the first time an H1 receptor number (Bmax) and a binding affinity (Kd) in guinea pig and human nasal mucosa. H1 antihistamines inhibited that 3H-mepyramine binding sites represent H1 receptors in nasal mucosa. Bmax and Kd values were not significantly different among the nonallergic sinusitis, vasomotor rhinitis, or the nasal allergy group, suggesting that H1 receptors do not change quantitatively and qualitatively in allergic nasal mucosa. There was no significant correlation between H1 receptor number and clinical data (IgE, peripheral eosinophils, RAST). These data suggest that H1 receptor number and affinity are not main etiological and pathophysiological factors in nasal allergy.

Chronic rhinitis

The author provides a well-detailed update on chronic rhinitis, the most common disease of the respiratory tract. Discussed are the anatomy and physiology of the nose, investigation of the patient, etiology, and treatment, including avoidance of provoking factors, pharmacologic therapy, and immunotherapy.

Pharmacologic treatment of rhinitis

Major improvements in the quality of recent pharmacologic studies of rhinitis are evident. In many of the studies, the criteria for patient selection are being more carefully described and patients with allergic rhinitis, nonallergic rhinitis with eosinophilia, and vasomotor rhinitis are no longer grouped together. In most studies, efficacy is still being ascertained by subjective symptom scores, although in some of the challenge studies, investigators are making noble attempts to quantitate symptoms objectively, eg, amount of secretions, sneezing, and even itching of the nares. Although nasal congestion is only one symptom of chronic rhinitis, the various methods of measuring nasal resistance by rhinometry are increasingly well described and standardized. General concepts that are emerging from the vast literature on pharmacologic treatment of rhinitis are as follows: 1) The much-maligned H1 receptor antagonists may actually be more useful than previously thought, once further information about how to use them optimally is available. Interesting new antihistamines are being developed. Further investigations of allied drugs such as the tricyclic antidepressants (doxepin) are definitely in order. 2) alpha-adrenergic agonists definitely have short-term usefulness but side effects from this class of drugs have, if anything, been underestimated. Exploration of the use of beta-adrenergic agonists and anti-cholinergics in the treatment of chronic rhinitis has begun. 3) Disodium cromoglycate is not universally effective in chronic rhinitis, perhaps in part because compliance with a prophylactic drug requiring insufflation four or six times daily may not be high. The degree of response and the percentage of patients having an excellent response to the drug is lower than for the new corticosteroids. 4) Topical corticosteroids administered intranasally are clearly the most effective medications for treatment of chronic rhinitis. Further study of the benefit versus the long-term risk of these drugs is mandatory, but their remarkable efficacy and safety in the treatment of chronic rhinitis is undisputed. Some comparisons between the four major groups of drugs are now being made, and further attempts to define the relative roles and the interactions of drugs used in the pharmacologic treatment of rhinitis are definitely needed.

Effects of beclomethasone dipropionate aerosol on nasal mucosa

Rhinoscopic examination and histological studies of the nasal mucosa in patients with perennial allergic rhinitis and nasal polyposis treated with beclomethasone dipropionate aerosol provided no evidence that this form of treatment, given for one year, produced any harmful effects, such as atrophic rhinitis.

Beclomethasone dipropionate aerosol and nasal mucosa

1. Biopsies taken from the inferior turbinates of patients undergoing treatment with beclomethasone dipropionate aerosol for allergic rhinitis showed no changes attributable to this treatment. 2. A reduction in oedema and eosinophilia was noted but there was no effect on the thickening of the basement membrane.

Long-term treatment of nasal polyps with beclomethasone dipropionate aerosol. II. Clinical results

The effect of a one-year treatment with intranasal beclomethasone dipropionate in 33 patients with long-standing nasal polyps was determined. About 80% of the patients obtained good or excellent relief of symptoms. No adverse reactions of any importance occurred. It is suggested that intranasal beclomethasone dipropionate is close to the ideal basic treatment for patients with nasal polyps.

Long-term treatment of nasal polyps with beclomethasone dipropionate aerosol. I. Treatment and rationale

Beclomethasone dipropionate is a potent corticosteroid, which when applied by a pressurized metered dose aerosol in the airways has pronounced anti-allergic effects with no risk of systemic steroid side effects at the recommended dosage. An impressive effect in hay fever and perennial rhinitis has been demonstrated. A double-blind short-term trial showed that the drug was effective in about 80% of patients suffering from moderate to severe nasal polyposis. A study of the long-term effects on the nasal mucosa is indicated.