Cromolyn sodium nasal solution in the prophylactic treatment of pollen-induced seasonal allergic rhinitis

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Cromolyn-crosslinked chitosan nanoparticles for the treatment of allergic rhinitis

The aim of this work was to prepare new mucoadhesive nasal decongestant nanoparticles obtained by direct crosslinking between the cationic polymer chitosan and the anionic drug cromolyn. Different chitosan/cromolyn molar ratios were used in order to obtain nanoparticles of suitable size, encapsulation efficiency/drug loading and mucoadhesion. Moreover, the ability of the nanoparticles to deliver cromolyn into and through the nasal mucosa was evaluated. The obtained positively charged nanoparticles, sized 180-400 nm, showed interesting properties in terms of yield, mucoadhesion, encapsulation efficiency and drug loading. Release and permeation/penetration data indicated the ability of the nanoparticles to retain a high amount of cromolyn inside the mucosa, which is rich in mast cells. These findings suggest developing decongestant nanoparticles for potential treatment of allergic rhinitis.

Cromolyn Sodium and Its Effect on Nasal Disease

Current understanding of the mechanism of action of cromolyn sodium in allergic reactions is reviewed with special attention to its role in rhinitis. Currently, the 4% cromolyn sodium solution available for nasal use is efficacious in seasonal and perennial allergic rhinitis. There are few complications associated with its use, and it is a rational choice for first-line or primary therapy in the prevention and treatment of allergic nasal disease.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Allergic conjunctivitis and the impact of allergic rhinitis

Although nasal allergy has been prominent in allergy research, ocular allergy is increasingly recognized as a distinct symptom complex that imposes its own disease burden and reduction in patients' quality of life. In the past year, knowledge of the relationships between allergic conjunctivitis and allergic rhinitis has increased. Allergic conjunctivitis is highly prevalent and has a close epidemiologic relationship with allergic rhinitis. Both conditions also exhibit similar pathophysiologic mechanisms. Pathways of communication are thought to increase the likelihood of an inflammatory reaction at both sites following allergen exposure of nasal or ocular tissue. Clinical trials of intranasal therapies have demonstrated efficacy in allergic conjunctivitis and rhinitis. Newer intranasal steroids decrease ocular symptoms, potentially achieving efficacy by suppressing the naso-ocular reflex, downregulation of inflammatory cell expression, or restoration of nasolacrimal duct patency. Proposed pathophysiologic interactions between allergic rhinitis and ocular allergy underscore the need for therapies with efficacy in both symptom sets.

Omalizumab is more effective than suplatast tosilate in the treatment of Japanese cedar pollen-induced seasonal allergic rhinitis

BACKGROUND

Seasonal allergic rhinitis (SAR) induced by Japanese cedar pollens is a major problem in Japan. Omalizumab, a humanized monoclonal anti-IgE antibody, improves symptoms associated with SAR, but a comparative study with an anti-allergy drug has not yet been conducted.

OBJECTIVE

To compare the efficacy and safety of omalizumab with suplatast tosilate, a selective T-helper type 2 (Th2) cytokine inhibitor, in patients with Japanese cedar pollen-induced SAR.

METHODS

A randomized, double-blind, double-dummy study was conducted in 308 Japanese patients with a history of moderate-to-severe SAR who showed a CAP-RAST value (> or =2+) specifically to Japanese cedar pollens. Patients were treated for 12 weeks with omalizumab plus placebo of suplatast tosilate or suplatast tosilate plus placebo of omalizumab.

RESULTS

The mean daily nasal symptom medication scores (sum of the daily nasal symptom severity score and daily nasal rescue medication score) were significantly lower in the omalizumab group than in the suplatast tosilate group during three evaluation periods (P<0.001). The omalizumab group also had significantly lower mean daily nasal severity scores, each of the mean daily nasal and ocular symptom severity scores (sneezing, runny nose, stuffy nose, itchy nose, itchy eyes, watery eyes, and red eyes). Omalizumab reduced rescue medication requirements, and the proportion of days with any rescue medication use in the omalizumab group was significantly lower. Serum-free IgE levels markedly decreased in the omalizumab group and it was associated with clinical efficacy. The adverse reaction profiles were similar between the two groups. The overall incidence of injection site reactions was higher in the omalizumab group than in the suplatast tosilate group, but all these events were of mild degree. No anti-omalizumab antibodies were detected.

CONCLUSION

Omalizumab showed significantly greater improvements than suplatast tosilate in the treatment of SAR induced by Japanese cedar pollens.

Economic impact and quality-of-life burden of allergic rhinitis

Allergic rhinitis can be a debilitating condition which, if untreated, can result in considerable health-related and economic consequences. A review of the published literature was conducted, with quantitative/qualitative analysis as appropriate, to explore the direct, indirect, and hidden costs of allergic rhinitis, as well as the quality-of-life burdens that the disease presents to patients and to the healthcare system. Lack of treatment, undertreatment, or nonadherence to treatment in allergic rhinitis were seen to increase direct and indirect costs, reinforcing the need for patient education and for physicians to implement existing evidence-based guidelines for prevention and treatment. It was concluded that greater awareness of the total economic burden of allergic rhinitis should encourage appropriate intervention and ultimately ensure clinically favorable and cost-effective outcomes.

Efficacy and patient satisfaction with cromolyn sodium nasal solution in the treatment of seasonal allergic rhinitis: a placebo-controlled study

BACKGROUND

Because the symptoms of seasonal allergic rhinitis are readily recognizable, many individuals self-medicate with nonprescription agents. The mast-cell stabilizer cromolyn sodium is available for over-the-counter (OTC) use in the prevention and treatment of allergic rhinitis.

OBJECTIVE

The goal of the study was to evaluate the efficacy of cromolyn sodium 4% nasal solution for the treatment of allergic rhinitis in self-selected patients in a nonprescription setting. A secondary objective was to determine whether the instructions and warnings in the OTC labeling provide adequate information for safe and proper OTC use.

METHODS

This 2-week, multicenter study had a randomized, double-blind, placebo-controlled, parallel-group design. Advertisements were used to identify allergy sufferers who used OTC products but had not used OTC allergy medications within 48 hours of study entry and did not require prescription medications to control allergy symptoms. Enrolled patients were randomized to receive either cromolyn sodium 4% nasal solution in a metered-spray bottle containing 200 doses or an identical-appearing placebo. They were instructed to follow the directions for use on the label: that is, to administer 1 spray in each nostril every 4 to 6 hours, no more than 6 times per day, for the prevention or relief of symptoms. Daily use of study drug and concomitant medications was recorded in patient diaries. Patients also rated symptom severity, symptom relief, medication efficacy, and helpfulness of the label instructions. Relief of overall and individual rhinitis symptoms was assessed at the end of weeks 1 and 2.

RESULTS

The intent-to-treat population consisted of 1150 patients (580 cromolyn sodium, 570 placebo). Cromolyn sodium provided greater relief than placebo on all efficacy measures and was statistically significantly more effective than placebo in controlling allergy symptoms (P = 0.02), providing overall symptom relief (P = 0.02), and relieving sneezing (P = 0.01) and nasal congestion (P = 0.03). The instructions for use were rated helpful to extremely helpful by >92% of patients, although only approximately 48% of patients used the drug according to the label instructions. The most common adverse events in both groups were headache and rhinitis, and there was no significant difference in the rates of such events between groups.

CONCLUSION

In this study, cromolyn sodium 4% nasal solution was well tolerated and effective, suggesting that it is suitable for OTC use in the treatment of seasonal allergic rhinitis.

Use of intranasal cromolyn sodium for allergic rhinitis

Allergic rhinitis affects 10% to 20% of Americans. It frequently coexists with other conditions, such as allergic conjunctivitis, sinusitis, and asthma, and is associated with impaired occupational function and performance in school, decreased quality of life, and increased health care costs. An efficacious agent with minimal adverse effects and a lack of drug interactions is needed to help simplify treatment of allergic rhinitis, especially in patients with comorbidities. Controlled studies of intranasal cromolyn sodium therapy for patients with seasonal and perennial allergic rhinitis are reviewed, and appropriate candidates for treatment with this agent are discussed. Cromolyn inhibits the degranulation of sensitized mast cells, thereby blocking the release of inflammatory and allergic mediators. It reduces symptoms of allergic rhinitis, and, when used prophylactically, cromolyn can prevent symptoms from occurring. Controlled studies comparing cromolyn with placebo, intranasal corticosteroids, and antihistamines have shown the efficacy of cromolyn in relieving rhinitis symptoms. In addition, because cromolyn is poorly absorbed systemically, it is well tolerated and not associated with drug interactions. Intranasal cromolyn has an excellent safety record, is available as an over-the-counter medication, and has been proved to be efficacious in patients with allergic rhinitis.

Diagnosis and management of rhinitis

This article reviews the differential diagnoses for rhinitis, medications available for the treatment of rhinitis, and special circumstances (such as pregnancy or medication side-effects) that may influence a clinician's decision. Considering the economic impact of rhinitis, the cost of prescription medications, and quality-of-life issues that are affected by rhinitis, physicians dealing with managed care organizations should make their diagnosis and treatment decisions carefully.

Prevention of pollen rhinitis symptoms: comparison of fluticasone propionate aqueous nasal spray and disodium cromoglycate aqueous nasal spray. A multicenter, double-blind, double-dummy, parallel-group study

Fluticasone propionate aqueous spray, a new intranasal corticosteroid preparation, and disodium cromoglycate 2% aqueous nasal spray, an established preventive treatment for seasonal allergic rhinitis, were compared in a double-blind, double-dummy, parallel-group, multicentric study in France. A total of 218 patients with seasonal allergic rhinitis caused by grass pollen (verified by positive skin prick test) were preventively treated before the onset of the grass pollen season with either fluticasone propionate 200 micrograms once daily or disodium cromoglycate 5.2 mg four times daily. Half of these doses was given in each nostril. Treatment started before the onset of the pollen season in most patients (178/218). Diary cards, including symptoms of rhinitis and usage of nasal sprays, were filled in twice daily for 6 weeks. Terfenadine in 60-mg tablets and eye-drops could be used as rescue medications. We treated 110 patients with fluticasone propionate and 108 patients with disodium cromoglycate. Patients treated with fluticasone propionate had significantly more days free of primary efficacy symptoms of sneezing (P < 0.001) and nasal discharge during the day (P = 0.002), as well as free of all the other nasal symptoms (P < 0.01), and significantly lower median scores (P < 0.05) for all nasal symptoms except nasal discharge than patients treated with disodium cromoglycate. There was no difference in eye symptoms or in rescue medication use between the two groups. Compliance with the treatment was assessed.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of sodium cromoglycate on upper and lower respiratory symptoms in children born prematurely

The aims of this study were to assess whether sodium cromoglycate (SCG) was an effective prophylaxis against both upper and lower respiratory tract signs and to determine factors which affected the site and magnitude of the response to SCG. Sixteen children born prematurely were entered into a randomised placebo-controlled trial at 15 months of age (range 4-31 months). The patients received, in random order, either 3 weeks' treatment with SCG (5 mg) or placebo, both given four times a day by inhalation via a spacer device. Parents were asked to record the occurrence and severity of their child's upper respiratory tract signs; sneezing and runny nose and lower respiratory tract signs; day and night time cough and wheeze. During the active compared to the placebo period there was an overall reduction of 47% and 53% in upper and lower respiratory tract signs, respectively. The magnitude of response to SCG as assessed by either the change in upper or lower respiratory tract signs was not significantly related to the patient's gestational or postnatal age, the occurrence of neonatal chronic lung disease, family history of atopy or the order in which the therapy was administered. We conclude that inhaled SCG may be a useful prophylaxis for both upper and lower respiratory tract signs for children born prematurely and less than 3 years of age.

Release of high-molecular-weight neutrophil chemotactic activity from resected human nasal turbinate after antigen challenge

Eleven patients with allergic rhinitis were studied. All subjects were sensitive to house dust mite documented by skin test, RAST score, and nasal provocation test. The patients needed lower turbinectomy because of chronic hypertrophic rhinitis. Tissues of the lower turbinate were obtained at the time of surgery, fragmented, and subsequently challenged with house dust mite in vitro. Diffusates were collected for measurement of neutrophil chemotactic activity (NCA) and histamine. NCA and histamine were released in a dose-dependent manner, and the time course of release of these mediators was identical. Release of NCA and histamine correlated significantly (p less than 0.001). The prior administration of the antiallergic drugs, disodium cromoglycate or tranilast, significantly blocked the release of NCA and histamine from antigen-challenged tissues. NCA released from nasal tissues eluted as a single peak with estimated molecular size of between 669 kd and 440 kd in three subjects and as two or three peaks in two patients. These results provide evidence that NCA might be involved in the pathogenesis of allergic rhinitis.

Cromolyn sodium: a review of mechanisms and clinical use in asthma

The cellular and clinical pharmacology of cromolyn sodium are reviewed. Cromolyn sodium inhibits the release of mediators of inflammation, induced by specific antigens as well as nonspecific mechanisms, such as exercise, from mast cells. Cromolyn may also inhibit the activity of other cell types that produce inflammation. It is the only antiasthmatic that blocks both early and late asthmatic responses induced by allergen inhalation and exercise. Consequently, cromolyn therapy can block the increase in bronchial hyperreactivity induced by chronic allergen exposure. Cromolyn is effective for controlling the symptoms of mild to moderate chronic asthma in 60 to 70 percent of patients. In comparative studies, cromolyn has been as effective as theophylline for controlling symptoms of chronic asthma with fewer side effects, and may be particularly suited for asthmatic patients with learning or behavioral problems. The combination of theophylline and cromolyn is often more effective than either agent alone. Because of the convenience of administration, cromolyn is preferred over theophylline for exercise-induced asthma. Cromolyn may allow the corticosteroid dosage to be reduced in severe steroid-dependent asthmatics, but it is primarily indicated for the prophylaxis of mild to moderate disease. Adverse reactions to cromolyn are uncommon to rare. Cromolyn is now available in a Spinhaler, a metered-dose aerosol, and a nebulizer solution. If taken properly all preparations appear to be equally effective. Attention to proper inhalation technique and appropriate education of the patient is essential to ensure a good outcome with cromolyn.

Allergic rhinitis. A useful guide to diagnosis and treatment

Patients presenting with typical signs and symptoms of allergic rhinitis may respond to avoidance of allergens and to medications for symptomatic relief. Treatment may include antihistamines, decongestants, cromolyn sodium, and/or topical nasal steroids. Patients whose symptoms are refractory to these therapeutic measures should be referred to an allergist for further evaluation and consideration for possible allergen immunotherapy.

Cromolyn sodium: a review

Cromolyn is a white crystalline powder which is poorly absorbed from the gastrointestinal tract. Its therapeutic value lies in its functions as an inhaled or topically applied agent. Cromolyn has been approved in the United States for asthma therapy since 1973. It was marketed at that time as a drug to reduce the corticosteroid requirements of severe asthmatics. It clearly did not live up to that claim. Initial enthusiasm for cromolyn was replaced by disillusionment. In the last few years, investigators have taken another look at cromolyn and have a renewed interest in it. Cromolyn's mechanisms of action remain only partially understood. It appears to block allergic mediator release from certain mast cells. It may also decrease bronchial hyperreactivity. The frequency of drug toxicity at customary dosages is extremely low. Adverse effects tend to be mild, short-lived and without sequelae. Currently, cromolyn is a first line therapy for mild to moderate asthma requiring chronic treatment. It is also of proven efficacy in the treatment of allergic rhinitis, allergic conjunctivitis and vernal keratoconjunctivitis.

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.

Allergic rhinitis and conjunctivitis. Help for the weeping nose and eyes

Both the eyes and the nose are in constant contact with the external environment and thus are common targets for immune-mediated disease. Progress in understanding the pathophysiology of allergic nasal and ocular disease has greatly enhanced the approach to therapy. Chronic rhinitis may be caused by a variety of immunologic and nonimmunologic mechanisms. Allergic and nonallergic factors often coexist, which complicates diagnosis and therapy. In external ocular disorders, both IgE- and IgG-mediated mechanisms may be involved. Elucidation of these mechanisms will be important in improving diagnosis and in facilitating development of new therapeutic modalities.

Treatment of ragweed allergic conjunctivitis with cromolyn sodium 4% ophthalmic solution

We treated 31 patients with ragweed conjunctivitis in an eight-week, double-masked parallel-group study with cromolyn sodium 4% ophthalmic solution. Analysis of data showed preseason serum IgE antibody to ragweed level was a significant predictor of drug response. Of 16 patients with ragweed IgE values of less than 100 ng/ml, the nine treated with cromolyn had significantly fewer symptoms during the course of treatment than the seven in the placebo group. Of the 15 remaining patients, who had IgE levels of more than 100 ng/ml, the eight treated with cromolyn improved but the difference between their symptom scores and those of the seven patients treated with placebo was not statistically significant.

A comparative trial of flunisolide and sodium cromoglycate nasal sprays in the treatment of seasonal allergic rhinitis

A trial of flunisolide nasal spray and sodium cromoglycate nasal spray in the treatment of hay fever was carried out during the summer of 1978. Sixty-seven patients all suffering from grass-pollen hay fever were given either flunisolide or sodium cromoglycate nasal sprays for 7 weeks. Patients were seen at 0, 3 and 7 weeks and they also kept a daily record of symptoms. Overall assessment of symptom control and the patients daily records of sneezing showed flunisolide to be significantly superior to sodium cromoglycate. Patients records of symptoms correlated well with daily pollen counts. Side-effects were similar in both treatment groups and consisted mainly of mild naso-pharyngeal irritations.

A comparative trial of intra-nasal beclomethasone dipropionate and sodium cromoglycate in patients with chronic perennial rhinitis

A double-blind crossover study has compared intra-nasal sodium cromoglycate (SCG) with beclomethasone dipropionate (BDP), and both drugs with placebo, in fifty-two chronic perennial rhinitis patients. BDP was significantly more effective in relieving symptoms than SCG (76.9% and 50% of the patients improved respectively, P < 0.01). Both drugs were more active than placebos but while BDP was very clearly more effective (P < 0.0005) SCG was only marginally better than its placebo (P < 0.05, Fisher; P = 0.068, chi 2). BDP was selected by 56% of the patients as the best agent for continuing therapy at the end of the trial. By contrast SCG was preferred by the same number of patients as chose the two placebos (11.5%).

Comparison of a low and high dose ACTH gel in the treatment of hay fever

The present data show that in fourteen patients treated with 200 iu Acthar gel, hay fever symptoms were less during the period of peak pollen challenge during June, than those experienced by an equivalent group treated with 80 iu. Analysis of the data showed that in the seven worst sufferers in both groups the difference between treatments was statistically significant (P=0.033, estimated by analysis of covariance of the symptom scores over the period of peak pollen challenge). No serious side effects were noted in patients from either group.