Mechanisms of Glucocorticoid Action in Chronic Rhinosinusitis

Research progress of glucocorticoid resistance in chronic rhinosinusitis with nasal polyps: A review

Chronic rhinosinusitis with nasal polyps (CRSwNP) is one of the common chronic inflammatory diseases in otolaryngology. Glucocorticoid (GC) acts as the first-line drug for the treatment of CRSwNP in clinical practice, and they play an irreplaceable role in reducing nasal mucosal inflammation and restoring the normal physiological function of the nasal mucosa. However, many patients are still insensitive to GC treatment, known as GC resistance, which leads to poor control of the disease, and the underlying mechanisms are still not fully elucidated. This article provides a comprehensive overview of the research progress of GC resistance of patients with CRSwNP in recent years.

Effects of Age on Recovery of Olfactory Function After Endoscopic Sinus Surgery and Related Risk Factors

OBJECTIVES

To study the effects of age on the olfactory function recovery of chronic rhinosinusitis patients after endoscopic sinus surgery and related risk factors.

METHODS

A total of 176 chronic rhinosinusitis (CRS) patients enrolled from February 2017 to October 2019 were divided into child, youth, middle-aged, and elderly groups. Their baseline data, T&T olfactory test score, visual analogue scale (VAS) olfactory score, sinus computed tomography (CT) Lund-Mackay score, and Lund-Kennedy score were compared. Based on postoperative olfactory function, they were divided into good and poor improvement groups.

RESULTS

Complication with nasal polyps, allergic rhinitis history, and sinus surgery history had significant differences among patients of different ages (P < .05). Three months after surgery, T&T olfactory, VAS olfactory, Lund-Mackay, and Lund-Kennedy scores all rose with increasing age, with significant differences between any 2 groups (P < .05). The improvement of postoperative olfactory function became poorer with aging (P < .05). T&T and VAS olfactory scores had significant positive correlations with Lund-Mackay and Lund-Kennedy scores (P < .001). Age, preoperative Lund-Mackay and Lund-Kennedy scores, complication with nasal polyps, allergic rhinitis history, sinus surgery history, and postoperative complications were risk factors for the poor improvement of postoperative olfactory function. Doctor-directed treatment was a protective factor for good improvement.

CONCLUSIONS

The improvement of olfactory function of CRS patients after endoscopic sinus surgery declines with aging. Age, preoperative Lund-Mackay and Lund-Kennedy scores, complication with nasal polyps, allergic rhinitis history, sinus surgery history, and postoperative complications are risk factors for the poor improvement of postoperative olfactory function. Doctor-directed treatment is a protective factor for good improvement.

IL-10 family cytokines in chronic rhinosinusitis with nasal polyps: From experiments to the clinic

Chronic rhinosinusitis with nasal polyps (CRSwNP) is considered a nasal sinus inflammatory disease that can be dominated by immune cells and cytokines. IL-10 family cytokines exert essential functions in immune responses during infection and inflammation. Recently, the understanding of the roles of the IL-10 family in CRSwNP is being reconsidered. IL-10 family members are now considered complex cytokines that are capable of affecting epithelial function and involved in allergies and infections. Furthermore, the IL-10 family responds to glucocorticoid treatment, and there have been clinical trials of therapies manipulating these cytokines to remedy airway inflammatory diseases. Here, we summarize the recent progress in the understanding of IL-10 family cytokines in CRSwNP and suggest more specific strategies to exploit these cytokines for the effective treatment of CRSwNP.

Alleviation of Surgery-Induced Osteitis in Sinonasal Cavity by Dexamethasone-Loaded Poly(lactic-co-glycolic acid) (PLGA) Microparticles with Strong Calcium-Binding Affinity

For the treatment of sinus surgery-induced osteitis in chronic rhinosinusitis (CRS), oral or intranasal administration of corticoids is generally used, although it has critical limitations and unavoidable side effects. To overcome these limitations, we designed dexamethasone (Dex)-loaded poly(lactic-co-glycolic acid) (PLGA) microparticles with bone-specific binding affinity, which could release the encapsulated Dex in a sustained manner on the exposed bone after the surgical wound in the nasal cavity. In a previous report, we prepared poly(butyl methacrylate-co-methacryloyloxyethyl phosphate) (PBMP) with both calcium-binding phosphomonoester groups and PLGA-binding butyl groups to introduce strong calcium-binding property to PLGA particles. In this study, after successful encapsulation of Dex in the PBMP-coated PLGA particles, we applied the Dex-PLGA/PBMP to the treatment of post-operative osteitis in the sinonasal cavity. The Dex-PLGA/PBMP showed more than 5-times higher binding affinity to the hydroxyapatite (HA) surface compared to the non-coated PLGA particles, without altering the morphology and encapsulation efficiency. After establishing the neo-osteogenesis mouse model by mechanical injury of the nasal mucosa, the activity of intranasally administered Dex-PLGA/PBMP was examined to inhibit the formation of undesirable new woven bone during the wound healing process. In addition, significantly lower osteocalcin activity was observed in the group treated with Dex-PLGA/PBMP, indicating decreased activation of osteoblasts. Overall, these results demonstrate that the PLGA/PBMP microparticle strategy has great potential for the treatment of CRS-related osteitis by localized corticoid delivery on the exposed bones with minimal side effects.

Transcriptomic and Lipidomic Profiles in Nasal Polyps of Glucocorticoid Responders and Non-Responders: Before and After Treatment

Background: The pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) and mechanisms underlying different responses to systemic glucocorticoids (GC) remain unclear. The major aim of this study was to explore the transcriptomic and oxidative lipidomic signatures and the effects of GC in patients with different clinical responses.

Methods: Nasal polyp biopsies were obtained before and after 14-day oral GC treatment from 16 patients with CRSwNP, and normal nasal mucosa specimens were collected from 12 control subjects. RNA sequencing and oxidative lipidomics were performed, and differential gene expression analysis was conducted in the Responder and Non-responder groups at baseline and after treatment.

Results: In the Responder group, GC significantly improved clinical symptoms and reduced tissue eosinophil infiltration. Meanwhile, GC led to a pronounced transcriptomic reversion with robust suppression of inflammatory responses and abnormal metabolism of extracellular matrix, as well as restoration of cilia function. However, non-responders were mainly characterized by epithelial hyperplasia and keratinization, with much less transcriptomic improvement after GC treatment. Higher expression of type 2 inflammatory molecules (CCL13, IGHE, CCL18, CCL23, CCR3, and CLC) with lower levels of LACRT, PPDPFL, DES, C6, MUC5B, and SCGB3A1 were related to a stronger clinical response to GC. Besides decreased prostaglandins and increased leukotrienes, increased dysregulation in other oxylipid mediators derived from polyunsaturated fatty acids was determined in nasal polyps, which was ameliorated by GC treatment.

Conclusion: Systemic GC exert anti-inflammatory effects, improve tissue remodeling, restore cilia function, and ameliorate dysregulation of oxylipid mediator pathway in CRSwNP. GC-responders exhibited different transcriptomic signatures from non-responders.

Effects of implants with steroids after endoscopic sinus surgery: A systematic review with meta-analysis of randomized controlled trials

BACKGROUND

Chronic rhinosinusitis affects approximately 5%-2% of the general population worldwide. Steroid implants after endoscopic sinus surgery (ESS) have drawn considerable interest for their cost savings, but relevant guidelines indicate that evidence on this topic is of low quality with high heterogeneity. The purpose of this study was to examine the efficacy of steroid implants after ESS by synthesizing relevant randomized controlled trials (RCTs).

METHODS

Two authors independently assessed the eligibility of potential references from five biomedical databases. They further extracted relevant data from the included studies, including (a) mean, standard deviation, or standard error for Lund-Kennedy endoscopic (LKE) score and Perioperative Sinus Endoscopy (POSE) score and (b) events and sample sizes of each group for further intervention. Data were pooled in a random-effects model, and results were presented as the weighted mean difference (WMD) or risk ratio (RR) with 95% confidence interval (CI) and I² .

RESULTS

Eleven RCTs (n = 853) were included and showed that the steroid implant group had lower LKE scores (WMD, -1.19; 95% CI, -1.75 to -0.62; I²  = 0%) and POSE scores (WMD, -1.62; 95% CI, -2.47 to -0.76; I²  = 48%) than the placebo implant group at postoperative week 2. Moreover, the reoperation rate in the steroid implant group was also lower than in the placebo implant group (RR, 0.49; 95% CI, 0.30 to 0.80; I²  = 0%). However, no significant difference was observed in the postoperative oral steroid requirement between both groups.

CONCLUSIONS

Collectively, steroid implant decreases LKE and POSE among patients receiving ESS in the short term, but long-term effects remain unclear. Patient-based outcomes are worth further discussion in the future.

Dexamethasone Conjugates: Synthetic Approaches and Medical Prospects

Dexamethasone (DEX) is the most commonly prescribed glucocorticoid (GC) and has a wide spectrum of pharmacological activity. However, steroid drugs like DEX can have severe side effects on non-target organs. One strategy to reduce these side effects is to develop targeted systems with the controlled release by conjugation to polymeric carriers. This review describes the methods available for the synthesis of DEX conjugates (carbodiimide chemistry, solid-phase synthesis, reversible addition fragmentation-chain transfer [RAFT] polymerization, click reactions, and 2-iminothiolane chemistry) and perspectives for their medical application as GC drug or gene delivery systems for anti-tumor therapy. Additionally, the review focuses on the development of DEX conjugates with different physical-chemical properties as successful delivery systems in the target organs such as eye, joint, kidney, and others. Finally, polymer conjugates with improved transfection activity in which DEX is used as a vector for gene delivery in the cell nucleus have been described.

Transcriptomic Signatures and Functional Network Analysis of Chronic Rhinosinusitis With Nasal Polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic sinonasal inflammatory disease with limited treatment options of corticosteroids, sinus surgery, or both. CRSwNP is frequently associated with allergic rhinitis and asthma, but the molecular mechanisms underlying CRSwNP inflammation are not completely understood. We obtained four gene expression profiles (GSE136825, GSE36830, GSE23552, and GSE72713) from four Gene Expression Omnibus (GEO), which collectively included 65 nasal polyp samples from CRSwNP patients and 54 nasal mucosal samples from healthy controls. Using an integrated analysis approach, we identified 76 co-differentially expressed genes (co-DEGs, including 45 upregulated and 31 downregulated) in CRSwNP patients compared with the healthy controls. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses identified the terms including immune effector process, leukocyte migration, regulation of the inflammatory response, Staphylococcus aureus infection, and cytokine-cytokine receptor interaction. protein-protein interaction (PPI) network analysis and real-time quantitative PCR (RT-qPCR) showed that 7 genes might be crucial in CRSwNP pathogenesis. Repurposing drug candidates (Alfadolone, Hydralazine, SC-560, Iopamidol, Iloprost, etc) for CRSwNP treatment were identified from the Connectivity Map (CMap) database. Our results suggest multiple molecular mechanisms, diagnostic biomarkers, potential therapeutic targets, and new repurposing drug candidates for CRSwNP treatment.

Differences in Mechanisms of Steroid Therapy and Olfactory Training for Olfactory Loss in Mice

Objective

Steroid therapy and olfactory training are common treatments for olfactory loss. Systemic steroid treatment is the most effective approach for treating sinonasal olfactory loss. Olfactory training is typically effective for treating sensorineural olfactory loss. However, the differences in mechanisms of steroid therapy and olfactory training for olfactory dysfunction are unclear. The aim of this study was thus to evaluate the differences in mechanisms of olfactory training and steroid therapy.

Subjects and Methods

Mice in each group were administered 3-methylindole at a dose of 300 mg/kg. Olfactory function was evaluated with a food-finding test once a week. The olfactory neuroepithelium was harvested for histologic examination and protein analysis. Subsequently, data analysis, gene ontology and pathway analysis, quantitative real-time polymerase chain reaction of mRNA, and western blot analysis were conducted.

Results

Mice were divided into four groups according to treatment. Control, anosmia, training, and steroid groups resumed food-finding. MMP27, CCL22 and IL18rap mRNA expression were significantly increased in the training group compared to that in the steroid group. IL1R2 mRNA expression was significantly higher in the olfactory neuroepithelium of steroid-treated mice than in that of the training group mice.

Conclusions

Steroid therapy improved olfactory function via anti-inflammatory effects, unlike olfactory training which involved cell regeneration and tissue remodeling. Protein and gene analyses revealed that steroid therapy and olfactory training are underpinned by distinct mechanisms. Selection of the most appropriate treatment will be dependent on the cause of olfactory loss.

Exhalation delivery system with fluticasone improves quality of life and health status: pooled analysis of phase 3 trials NAVIGATE I and II

Background

Chronic rhinosinusitis with or without nasal polyps (CRSwNP/CRSsNP) seriously impairs health‐related quality of life (HRQoL). This analysis describes the impact of the exhalation delivery system with fluticasone (EDS‐FLU) on HRQoL, assessed by the 36‐item Short‐Form Health Survey version 2 (SF‐36v2), and on utilities, assessed via the Short‐Form 6‐Dimension (SF‐6D), in patients with CRSwNP.

Methods

Post hoc analysis of pooled randomized clinical trial data (NAVIGATE I and II; N = 643) to examine change from baseline in SF‐36v2 and SF‐6D at end‐of‐double‐blind (EODB: 16 weeks) and end‐of‐open‐label (EOOL: 24 weeks; following 8 weeks of open‐label treatment) for EDS‐FLU vs placebo (EDS‐PBO). Baseline characteristics predictive of change in SF‐36 and SF‐6D scores were assessed.

Results

Mean baseline SF‐36v2 scores were below population norms. At EODB, mean improvement was greater for all SF‐36v2 domain and component scores with EDS‐FLU (range: 2.9 [physical functioning] to 5.11 [bodily pain {BP}]) vs EDS‐PBO (range: 0.81 [mental health] to 2.87 [BP]) (each comparison p < 0.01); physical and mental component score improvements within the EDS‐FLU group exceeded the minimal clinically important difference (MCID). Clinically meaningful and statistically significant improvements in SF‐6D utility scores were seen in EDS‐FLU–treated patients compared to EDS‐PBO–treated patients (0.058 vs 0.023, respectively, p < 0.001). At EOOL, SF‐36v2 and SF‐6D mean scores were at or above population norms, with clinically meaningful and statistically significant improvements from baseline.

Conclusion

In this pooled analysis of 2 large pivotal EDS‐FLU trials, health domain and health utilities improvements were significantly greater with EDS‐FLU than EDS‐PBO and were comparable to population norms.

Dexamethasone along with ciprofloxacin modulates S. aureus induced microglial inflammation via glucocorticoid (GC)-GC receptor-mediated pathway

Microglial inflammation is the hallmark of S. aureus induced brain abscesses. Conventional antibiotic therapy could not regulate inflammation and the use of steroids in CNS infection remained controversial. To address this issue the effect of dexamethasone along with ciprofloxacin on microglial inflammation has been attempted both in glucocorticoid receptor (GR) opened and blocked condition. We have investigated the effects of ciprofloxacin (0.24 μg/ml, pre-treatment) and dexamethasone (150 nM, pre-treatment) in combination with murine microglia infected with S. aureus for 30, 60 and 90 min by either keeping GR opened or blocked with GR antagonist RU486. Alterations in cellular motility, intracellular killing assay, free radical production, antioxidant enzyme activities, corticosterone, and cytokine levels were determined. The expressions of TLR-2, GR, and other inflammatory markers were determined in terms of this combinatorial treatment. Combination treatment significantly (p < 0.05) reduced the bacterial burden of microglia only when GR remained open and effectively suppressed S. aureus induced oxidative stress by augmenting SOD and catalase enzyme activity and suppressing other pro-inflammatory markers at 90 min. Arginase activity, a critical determinant of microglial polarization was found to be higher after treatment at 60 and 90 min. This situation was reversed when this combination treatment was applied by keeping GR blocked using GR antagonist RU486. Therefore, it can be concluded that combination treatment of ciprofloxacin and dexamethasone could regulate S. aureus induced microglial activation, in the presence of functional GR via utilizing glucocorticoid (GC)-GR pathway and ultimately confers protection to the host from brain inflammation.

The olfactory mucosa, first actor of olfactory detection, is sensitive to glucocorticoid hormone

The olfactory mucosa (OM) is the primary site of odorant detection, and its axonal projections relay information to brain structures for signal processing. We have previously observed that olfactory function can be affected during a prolonged stress challenge in Wistar rats. The stress response is a neuroendocrine retro-controlled loop allowing pleiotropic adaptive tissue alterations, which are partly mediated through the release of glucocorticoid hormones. We hypothesised that, as part of their wide-ranging pleiotropic effects, glucocorticoids might affect the first step of olfactory detection. To study this, we used a number of approaches ranging from the molecular detection and functional characterisation of glucocorticoid receptors (GRs) in OM cells, to the study of GR acute activation in vivo at the molecular, electrophysiological and behavioural levels. In contrast to previous reports, where GR was reported to be exclusive in olfactory sensory neurones, we located functional GR expression mostly in olfactory ensheathing cells. Dexamethasone (2 mg/kg) was injected intraperitoneally to activate GR in vivo, and this led to functional odorant electrophysiological response (electro-olfactogram) and OM gene expression changes. In a habituation/cross-habituation test of olfactory sensitivity, we observed that DEX-treated rats exhibited higher responsiveness to a complex odorant mixture. These findings support the idea that olfactory perception is altered in stressed animals, as glucocorticoids might enhance odour detection, starting at the first step of detection.

Contribution of Epithelial Cell Dysfunction to the Pathogenesis of Chronic Rhinosinusitis with Nasal Polyps

Background

In the past, the airway epithelium was thought to be primarily an inert physical barrier. We now know that the upper airway epithelium plays a critical role in both innate and adaptive immunity, and that epithelial dysfunction is strongly associated with inflammatory airway disease. The pathogenesis of chronic rhinosinusitis is poorly understood, but growing evidence supports a key role for the airway epithelium in the pathophysiology of the disease.

Objective

The purpose of this study is to explore our current understanding of how dysfunction in human sinonasal epithelial cells (HSNECs) contributes to the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) and to examine how current and developing therapies affect epithelial cell functions.

Methods

A literature review of papers published in English pertaining to epithelial cell dysfunction in patients with CRSwNP was performed using the PubMed database. The search utilized combinations of the following key words: sinusitis, polyps, epithelium, pathophysiology, barrier function, dendritic cells, eosinophils, T cells, complement, mucociliary clearance, vitamin D, cytokines, chemokines, taste receptors, steroids, saline, and therapy.

Results

HSNEC mucociliary clearance, barrier function, secretion of cytokines, influence on dendritic cells, influence on T-cells, regulation of eosinophils, vitamin D metabolism, complement production, and taste receptor function are altered in patients with CRSwNP and contribute to the pathogenesis of the disease. Current therapies utilized to manage CRSwNP counteract the effects of HSNEC dysfunction and relieve key symptoms of the disease.

Conclusion

HSNECs are key players in both innate and adaptive immunity, and altered epithelial functions are closely intertwined with the pathogenesis of CRSwNP. Our review supports further investigation of altered HSNEC function in patients with CRSwNP and supports development of novel epithelial-targeted therapies for its management.

Optimization of the Surgical Field in Endoscopic Sinus Surgery: an Evidence-Based Approach

PURPOSE OF REVIEW

The advent of endoscopic sinus surgery (ESS) has enabled the development of minimally invasive surgical procedures in Rhinology. However, proficiency with ESS techniques can still be hampered by poorly controlled bleeding limiting visibility of the surgical field (VSF). This can lead to increased operating time and, more importantly, increased risk of major and minor complications. To optimize the VSF and mitigate the risk of complications, many strategies have been explored.

RECENT FINDINGS

This is a narrative review of the relative risks and benefits of pre- and intra-operative interventions aimed at optimizing intraoperative conditions during ESS. The value of these interventions is determined based on their impact on intraoperative blood loss, time of surgery, and the VSF, and weighed against their adverse event profile. This review provides a comprehensive overview of the evidence relating to the safety and efficacy of interventions used to improve intraoperative conditions during ESS.

Real-World Database Examining the Association between Sjögren's Syndrome and Chronic Rhinosinusitis

Objective: To investigate the risk of chronic rhinosinusitis (CRS) among patients with Sjögren’s syndrome (SS). Method: A total of 18,723 patients diagnosed with SS between 1997 and 2011 were retrospectively analyzed. Moreover, 59,568 patients without SS were matched to patients with SS at a 1:4 ratio on the basis of sex, age, urbanization level, income level, and the comorbidities of rhinitis and nasal sepal deviation. Patients were followed up until death or the end of the study period (31 December, 2013). The primary outcome was the occurrence of CRS. Results: The cumulative incidence of CRS was significantly higher in patients with SS than in those without SS (p < 0.001). The adjusted Cox proportional hazard model showed that patients with SS had a significantly higher incidence of CRS (hazard ratio, 2.51; 95% confidence interval, 2.22–2.84; p < 0.001). Sensitivity and subgroup analyses demonstrated SS was an independent risk factor for CRS. The dosage of intranasal corticosteroid spray used was not different between the SS and non-SS groups. Fewer patients with CRS in the SS group underwent sinus surgery (82/407 (20.2%)) than those in the non-SS group (179/667 (26.8%)) and this finding was statistically significant (p = 0.013). The number of operations did not differ significantly between patients with CRS in the SS and non-SS groups. Conclusions: SS is an independent risk factor for CRS. Our study extends the disease spectrum and prompts physicians to be aware of potential CRS occurrence after SS.

The ratio of 11β-hydroxysteroid dehydrogenase 1/11β-hydroxysteroid dehydrogenase 2 predicts glucocorticoid response in nasal polyps

BACKGROUND

Glucocorticoids are the first-line medical treatment for chronic rhinosinusitis with nasal polyps (CRSwNP), whose local metabolism is catalyzed by 11β-HSD1 and 11β-HSD2. This study investigates the role of 11β-HSD1 and 11β-HSD2 on the glucocorticoid response of CRSwNP patients and the pathogenic mechanism of these polyps.

METHODS

Forty-three adult CRSwNP patients were enrolled in this study. We evaluated the endoscopic scores by a nasal polyp grading system before and after treatment. We estimated the response to glucocorticoids by the total endoscopic scores. The logistic regression models and inflammatory characteristic curves were conducted to explore the prediction of the response to glucocorticoid in CRSwNP. The expression of 11β-HSD1 and 11β-HSD2 on human sinonasal epithelial cells (HSECS) was measured under the stimulation of toll-like receptor agonists and dexamethasone.

RESULTS

The endoscopic scores in the CRSwNP group declined, the expression of 11β-HSD1/11β-HSD2 increased (r = 0.5276, P = 0.0011), and the cutoff value of the ratio of 11β-HSD1/11β-HSD2 was 0.4654 (sensitivity 79.17%, specificity 88.89%). Dexamethasone induced a decrease in the ratio of 11β-HSD1/11β-HSD2 (P = 0.049) by the stimulation of PGN-BS.

CONCLUSION

We found a strong correlation between the response to glucocorticoids and the ratio of 11β-HSD1/11β-HSD2, which could be used as a marker in predicting the level of tissue response to glucocorticoid therapy in CRSwNP. In addition, PGN-BS could also be a therapeutic target, as it is the negative factor that will decrease the sensitivity of glucocorticoids by reducing the ratio of 11β-HSD1/11β-HSD2.

Effects of double-dose intranasal corticosteroid for allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

When a standard dose of intranasal corticosteroid (INCS) fails to control symptoms of allergic rhinitis (AR), a double dose of INCS is optional. This systematic review aimed to assess the effects of double-dose INCS.

METHODS

Literature searches were performed using MEDLINE and EMBASE. Randomized controlled trials that studied the effects of double-dose INCS vs standard-dose INCS for treating patients with AR were included. Data from the included studies were extracted and collected for meta-analyses. The outcomes were nasal symptoms, ocular symptoms, and adverse events.

RESULTS

Twelve studies (4166 patients) met the inclusion criteria. There were 5 pediatric studies (1868 patients), 5 adult studies (1414 patients), and 2 studies with mixed populations (884 patients). The meta-analysis results in adult patients favored the effects of double-dose INCS on: total nasal symptom score (standardized mean difference [SMD] -0.25; 95% confidence interval [CI], -0.41 to -0.08; 4 studies; 568 patients) and total ocular symptom score (SMD -0.27; 95% CI, -0.52 to -0.03; 1 study; 259 patients). The meta-analysis results in pediatric patients did not show the difference between groups on total nasal symptom score (SMD -0.16; 95% CI, -0.40 to 0.07; 3 studies; 801 patients). The meta-analysis of ocular symptom score in pediatric patients had insufficient data. There were no differences between groups on adverse events.

CONCLUSION

Double-dose INCS showed better improvement in nasal and ocular symptoms in adult patients with AR when compared to the standard dose. These beneficial effects were not seen in the pediatric population. Adverse events between groups were not different.

Effects of decongestant addition to intranasal corticosteroid for chronic rhinitis: a systematic review and meta-analysis

BACKGROUND

Intranasal corticosteroid (INCS) is the most efficacious medicine for treating chronic rhinitis. A decongestant and INCS combination (INCS-D) is considered for nasal congestion that is not improved by INCS. This study aimed to investigate the effects of INCS-D on chronic rhinitis.

METHODS

Literature searches were performed using MEDLINE and EMBASE. Randomized controlled trials studying the effects of INCS-D vs INCS alone for treating chronic rhinitis were included. Data were pooled for meta-analysis. Outcomes were nasal symptoms, disease-specific quality of life, objective tests for nasal patency, and adverse events.

RESULTS

Six studies (1071 patients) met the inclusion criteria. There were no differences between INCS-D and INCS on total nasal symptom scores (standardized mean difference [SMD] -0.85; 95% confidence interval [CI], -2.09 to 0.40; p = 0.18), nasal congestion scores (SMD -0.13; 95% CI, -0.46 to 0.20; p = 0.43), and the Rhinoconjunctivitis Quality of Life Questionnaire score (SMD -0.12; 95% CI, -0.66 to 0.42; p = 0.66). After 1 week, there were no differences on objective tests for nasal patency (acoustic rhinometry: SMD 0.04; 95% CI, -0.68 to 0.76, p = 0.91; and peak nasal inspiratory flow: SMD 0.08; 95% CI, -0.16 to 0.32; p = 0.52). Adverse events were not different between INCS-D and INCS (risk ratio 1.09; 95% CI, 0.73 to 1.62).

CONCLUSION

Meta-analyses did not show benefits of topical decongestants addition to INCS. Adverse events of INCS-D were comparable with INCS.

Effects of H1 antihistamine addition to intranasal corticosteroid for allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

A combination of H1 antihistamine (AH) with intranasal corticosteroid (INCS) is commonly prescribed to patients with allergic rhinitis (AR) who have an inadequate response to monotherapy. In this systematic review we aimed to determine the effects of AH combined with INCS (AH-INCS) for treating AR.

METHODS

Literature searches were performed using Medline and Embase. Randomized, controlled trials that studied the effects of AH-INCS vs INCS monotherapy for treating patients with AR were included. The primary outcomes were total nasal symptom scores, total ocular symptom scores, and disease-specific quality of life. The secondary outcomes were objective tests for nasal patency and adverse events.

RESULTS

Sixteen studies (4026 patients) met the inclusion criteria. Compared with INCS, AH-INCS decreased total nasal symptom scores (standardized mean difference [SMD], -0.13; 95% confidence interval [CI], -0.19 to -0.06; p < 0.001; 10 trials, 3348 patients) and total ocular symptom scores (SMD, -0.12, 95% CI, -0.20 to -0.04; p = 0.003; 6 trials, 2378 patients). Subgroup analysis indicated no benefit with the oral AH-INCS combination but did show benefit with intranasal AH-INCS (SMD, -0.18; 95% CI, -0.27 to -0.09; p < 0.001). There were no significant differences with regard to disease-specific quality of life (SMD, -0.07; 95% CI, -0.16 to 0.02; p = 0.12; 6 trials, 1981 patients), nasal inspiratory flow (MD, -0.03 L/min; 95% CI, -0.57 to 0.50; p = 0.91; 1 trial, 54 patients), or adverse events.

CONCLUSION

Intranasal AH-INCS has benefit over INCS on nasal and ocular symptom improvement for treating AR. Oral AH-INCS is not recommended.

The Role and Regulation of the 11 Beta-Hydroxysteroid Dehydrogenase Enzyme System in Patients with Inflammatory Bowel Disease

INTRODUCTION

Glucocorticoids are known to modulate a number of immunological responses including counteracting inflammation. Within tissues expressing the glucocorticoid and mineralocorticoid receptors including the colon, glucocorticoid metabolism is regulated by the isoenzymes of 11ß-hydroxysteroid dehydrogenase (11β-HSD). 11β-HSD1 acts as an oxidoreductase converting inactive cortisone into active cortisol, while 11β-HSD2 acts as a dehydrogenase converting active cortisol to inactive cortisone. Hexose-6 phosphate dehydrogenase (H6PDH) is a key regulator of 11β-HSD1 activity via its generation of NADPH. Variations in the 11β-HSD enzyme system in relation to levels of expression and regulation may have a role in IBD. The aim of this study was to investigate possible abnormalities of 11β-HSD enzyme system in the colon of patients with IBD.

METHODS

By using quantitative real-time PCR, we investigated the transcription levels of 11β-HSD1 and 2 in colonic tissue from IBD patients and healthy controls undergoing a colonoscopy for disease assessment. Disease activity was recorded using clinical (Mayo Score/Harvey-Bradshaw Index), Biochemical (C-reactive protein), histological, and endoscopic parameters. In addition, transcription levels of H6PDH and the glucocorticoid receptor alpha (GR-α) as well as key pro-inflammatory cytokines (TNF-α, IL-1β, IL-6, Rela (subunit for NF Kappa B)) were later examined among this group, and results were correlated with 11β-HSD2 gene expression. Results and patient demographics were expressed as a mean (and SD), and differences between IBD patients and control groups were analyzed using a Student's t test or Mann-Whitney U test as appropriate, with a p value of ≤0.05 considered significant. Results were controlled for disease activity as outlined above.

RESULTS

Results have demonstrated a significant downregulation in 11β-HSD2 expression in IBD patients compared with controls (13.8 ± 17.1 au vs. 318.4 ± 521.1 au, p = 0.01), whereas levels of 11β-HSD1 did not appear to vary across the two groups. Among IBD patients, there was a trend toward higher 11β-HSD1 expression in inflamed tissue compared with matched non-inflamed tissue (422.1 ± 944 au vs. 102.2 ± 103.9, P = 0.09). Levels of H6PDH and the GR-α expression did not appear to vary among active inflamed IBD tissue and controls. As a result, we examined the association between pro-inflammatory cytokines and levels of 11β-HSD2 expression. Results showed an upregulation of key pro-inflammatory cytokine mRNA expression (TNF-α, IL-1β, IL-6) during inflammation with an associated downregulation of 11β-HSD2 mRNA expression when compared to controls. Dysregulation in this pathway could have a potential role in IBD pathogenesis and may account for exogenous glucocorticoid resistance in IBD. Further work assessing the role of the 11β-HSD enzyme system in steroid-resistant subjects is warranted.

Update on Intranasal Medications in Rhinosinusitis

This review describes beneficial effects and adverse events of various intranasal medications in treating rhinosinusitis. Application of intranasal steroids has been described in treating all subtypes of adult rhinosinusitis, but reports are limited in pediatrics and mostly in acute pediatric subgroups resulted in benefits While saline irrigation is effective for patients with chronic rhinosinusitis without polyps and in pediatric acute rhinosinusitis, there is no evidence yet for saline drips and sprays. Application of intranasal antifungals and nasal irrigation with surfactant brings more harm than benefits. There is no evidence supporting the use of intranasal antibiotics. We also review influence of devices, methods, and patient head position on nasal and paranasal sinus drug delivery.

Identification of phenotypic clusters of nonsteroidal anti-inflammatory drugs exacerbated respiratory disease

BACKGROUND

Clinical presentation of nonsteroidal anti-inflammatory drugs exacerbated respiratory disease (NERD) is found to be heterogeneous. This study classified phenotypic clusters to determine NERD subtypes.

METHODS

We performed two-step cluster analysis using urticaria, chronic rhinosinusitis (CRS), and atopy, in a NERD cohort comprising 302 patients. Asthma exacerbation was defined as receiving at least one burst of intravenous steroid treatment and/or at least two bursts of oral steroid use (≥ 45 mg/3 days) per year. The possession rate of anti-asthmatic medications was estimated during the follow-up period.

RESULTS

There were four subtypes: subtype 1 (NERD with CRS/atopy and no urticaria), subtype 2 (NERD with CRS and no urticaria/atopy), subtype 3 (NERD without CRS/urticaria), and subtype 4 (NERD with urticaria). Significant differences were found between the four subtypes in the female proportion, baseline FEV1%, serum total IgE level, and sputum/peripheral eosinophil count. A higher frequency of asthma exacerbations was noted in subtype 1 compared to subtype 3. The possession rates of medium- to high-dose inhaled corticosteroids/long-acting beta₂ -agonists showed significant differences among the four subtypes. Metabolomic analysis showed that the four subtypes of NERD had a higher serum leukotriene E4 (LTE4) level than those with aspirin-tolerant asthma. The patients with subtypes 1 and 3 had a higher urine LTE4 level than those with subtype 2.

CONCLUSION

We found four distinct subtypes with different clinical/biochemical findings and asthma exacerbations in a NERD cohort. These findings suggest that stratified strategies by applying subtype classification may help achieve better outcomes in the management of NERD.

[The use of intranasal glucocorticosteroids in the treatment of rhinosinusitis: Focus on mometasone furoate]

The authors discuss the mechanism of action, effectiveness, and safety of intranasal glucocorticosteroids (inGCS) used to treat acute, recurrent and chronic rhinosinusitis (RS). The last version of the European guidelines concerning the application of inGCS assigns the highest level of evidence-Ia and the highest strength of recommendations-A to these medications when applied for the treatment of acute and polypoid rhinosinusitis. Moreover, they acquire the status of the agents of choice for the therapy of chronic RS without polyps. Mometasone furoate is one of the best explored preparations of this group of medicines. It is possessed of favourable pharmacodynamic and pharmacokinetic properties when prescribed for local application. The new mometasone furoate preparation in the form of an intranasal spray Dezrinit produced by "Teva" Ltd. was registered in the Russian Federation. In a comparative randomized clinical trial (RCT), the preparation was shown to be an equivalent to the Nasonex spray.