Ipratropium nasal spray in children with perennial rhinitis

Ipratropium Bromide Nasal Spray in Non-Allergic Rhinitis: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aims to compare the effectiveness of intranasal ipratropium bromide (INIB) to a placebo in reducing nasal symptoms, particularly rhinorrhea, and enhancing quality of life in non-allergic rhinitis (NAR) patients.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive review of the literature was conducted on Medline, Embase, and Cochrane libraries. Randomized controlled trials (RCTs) and non-randomized comparative parallel group trials comparing IB nasal spray to placebo were included.

RESULTS

Five RCTs assessed a total of 472 participants with a diagnosis of NAR. IB nasal spray 0.03% were used across all studies. IB has a better impact on decreasing rhinorrhea than the placebo, with a standardized mean difference (SMD) of 0.93 (95% CI 0.06-1.8). The mean change in rhinorrhea severity was 85% (95% CI 77-92%) and I^2 26% (p = 0.24). IB outperformed the placebo in terms of shortening the symptom's duration/day, as shown by an SMD of 0.35 (95% CI 0.15-0.55). The difference between treatments was noticeable within the first week and remained consistent throughout the treatment. Patients who were administered IB experienced a substantially greater improvement in physical and mental outcomes. Nasal adverse events with IB were generally intermittent and brief.

CONCLUSION

Compared with a placebo, IB nasal spray is both safe and effective in treating the rhinorrhea associated with NAR. IB significantly reduces the severity and duration of rhinorrhea. The treatment was determined to be beneficial by both patients and physicians and resulted in a better quality of life.

LEVEL OF EVIDENCE

1 Laryngoscope, 133:3247-3255, 2023.

Effects of 101BHG-D01, a novel M receptor antagonism, on allergic rhinitis in animal models and its mechanism

Allergic rhinitis (AR) is a nasal mucosal disease with sneezing and nasal itching as the main symptoms. Although AR treatment continues to improve, there remains a lack of effective drugs. There are still controversies regarding whether anticholinergic drugs can effectively and safely relieve the symptoms of AR and reduce inflammation in the nasal mucosa. Here, we synthesized 101BHG-D01, which is a novel anticholinergic drug that mainly targets the M3 receptor and may reduce the adverse effects of other anticholinergic drugs on the heart. We evaluated the effects of 101BHG-D01 on AR and investigated the potential molecular mechanism of anticholinergic therapy for AR. We found that 101BHG-D01 effectively alleviated AR symptoms, reduced the infiltration of inflammatory cells and attenuated the expression of inflammatory factors (IL-4, IL-5, IL-13, etc.) in various AR animal models. In addition, 101BHG-D01 reduced the activation of mast cells and the release of histamine from rat peritoneal mesothelial cells (RPMCs) challenged by IgE. Moreover, 101BHG-D01 reduced the expression of MUC5AC in IL-13-challenged rat nasal epithelial cells (RNECs) and human nasal epithelial cells (HNEpCs). Furthermore, IL-13 stimulation significantly increased JAK1 and STAT6 phosphorylation, which was suppressed by 101BHG-D01. We demonstrated that 101BHG-D01 reduced mucus secretion and inflammatory cell infiltration in the nasal mucosa, which may occur through a reduction in activation of the JAK1-STAT6 signaling pathway, indicating that 101BHG-D01 is a potent and safe anticholinergic therapy for AR.

Intranasal Anticholinergics for Treatment of Chronic Rhinitis: Systematic Review and Meta-Analysis

OBJECTIVE

Topical intranasal anticholinergics are commonly prescribed for the relief of chronic rhinitis and associated symptoms, warranting thorough assessment of the supporting evidence. The present study aimed to evaluate the safety and efficacy of anticholinergic nasal sprays in the management of allergic and non-allergic rhinitis symptom severity and duration.

METHODS

A search encompassing the Cochrane Library, PubMed/MEDLINE, and Scopus databases was conducted. Primary studies describing rhinorrhea, nasal congestion, and/or postnasal drip outcomes in rhinitis patients treated with an anticholinergic spray were included for review.

RESULTS

The search yielded 1,029 unique abstracts, of which 12 studies (n = 2,024) met inclusion criteria for qualitative synthesis and 9 (n = 1,920) for meta-analysis. Median follow-up was 4 weeks and ipratropium bromide was the most extensively trialed anticholinergic. Compared to placebo, anticholinergic treatment was demonstrated to significantly reduce rhinorrhea severity scores (standardized mean difference [95% CI] = -0.77 [-1.20, -0.35]; -0.43 [-0.72, -0.13]) and duration (-0.62 [-0.95, -0.30]; -0.29 [-0.47, -0.10]) in allergic and non-allergic rhinitis patients respectively. Benefit was less consistent for nasal congestion, postnasal drip, and sneezing symptoms. Reported adverse effects included nasal mucosa dryness or irritation, epistaxis, headaches, and pharyngitis, though comparison to placebo found significantly greater risk for epistaxis only (risk ratio [95% CI] = 2.19 [1.22, 3.93]).

CONCLUSION

Albeit treating other symptoms with less benefit, anticholinergic nasal sprays appear to be safe and efficacious in reducing rhinorrhea severity and duration in both rhinitis etiologies. This evidence supports their continued use in the treatment of rhinitis-associated rhinorrhea.

LEVEL OF EVIDENCE

1 Laryngoscope, 133:722-731, 2023.

Bencycloquidium bromide nasal spray is effective and safe for persistent allergic rhinitis: a phase III, multicenter, randomized, double-blinded, placebo-controlled clinical trial

PURPOSE

To investigate the efficacy and safety of bencycloquidium bromide nasal spray (BCQB) in patients with persistent allergic rhinitis (PAR).

METHODS

We enrolled 720 patients from 15 hospitals across China and randomly assigned them into BCQB group or placebo group (90 μg per nostril qid) to receive a 4-week treatment. Visual analog scale (VAS) for rhinorrhea, sneezing, nasal congestion, itching and overall symptoms were recorded by patients every day. Anterior rhinoscopy scoring was completed by doctors on every visit. Adverse events were recorded in detail.

RESULTS

A total of 354 and 351 patients were included in BCQB group and in placebo group. Baseline information was comparable. At the end of the trial, the decrease of VAS for rhinorrhea from baseline was 4.83 ± 2.35 and 2.46 ± 2.34 in BCQB group and placebo group, respectively (P < 0.001). The change ratio from baseline of VAS for rhinorrhea in BCQB group was 72.32%, higher than 31.03% in placebo group (P < 0.001). VAS for other symptoms and overall symptoms also improved significantly in the BCQB group, while no inter-group difference was found in anterior rhinoscopy scoring. The incidence of adverse reaction was similar between the two groups. Most reactions were mild and no severe reactions happened.

CONCLUSION

90 μg BCQB per nostril four times daily is effective and safe in the treatment of rhinorrhea as well as sneezing, nasal congestion and itching for patients with PAR.

RETROSPECTIVELY REGISTERED

ChiCTR2000030924, 2020/3/17.

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.

Optimal Duration of Allergic Rhinitis Clinical Trials

OBJECTIVE: Guidelines have been published by the Food and Drug Administration (FDA) and the European Agency for the Evaluation of Medicinal Products (EMEA) for the conduct of seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR) studies. These guidelines have differences regarding the duration of such trials: the FDA suggests 2 weeks for SAR and 4 weeks for PAR but the EMEA suggests 2 to 4 weeks for SAR and 6 to 12 weeks for PAR trials. In the interest of global harmonization, it would be desirable to have a uniform duration of such trials so that investigators, internationally, would be able to readily compare results for various types of treatments based on a single standard. Therefore, we performed an evidence-based review to answer the clinical question, What is the optimal duration for SAR and PAR clinical trials?

METHODS: We performed a MEDLINE search of the published literature from 1995 to the present. We used appropriate search terms, such as allergic rhinitis, seasonal allergic rhinitis, perennial allergic rhinitis, SAR, and PAR, to identify pertinent articles. These articles were reviewed and graded according to the evidence quality.

RESULTS: After an initial screening of more than 300 articles, 138 articles were analyzed thoroughly. No study specifically addressed the question of the optimal duration of SAR or PAR clinical trials.

CONCLUSIONS: We conclude that the current FDA (draft) guidelines calling for a study length of 2 weeks for the assessment of drug efficacy for SAR and 4 weeks for the study of drug efficacy in PAR are appropriate and that longer study periods are not likely to add meaningfully to the assessment of drug efficacy.

Pediatric allergy medications: review of currently available formulations

BACKGROUND

Allergy affects about 50% of the pediatric population globally. Allergic rhinitis (AR), one form of allergy, causes considerable impairment in quality of life, including disruption of sleep and, in children, interference with school attendance and performance.

SCOPE

Traditional formulations and delivery systems - tablets, capsules, or intranasal sprays - successfully used by adults for treatment of AR may not be as easily administered in children. Liquid oral medications are more readily taken by children but contain sugars and excipients; they can also be inconvenient with less accurate dosing and are associated with dental caries and gastrointestinal upset.

METHODOLOGY

This review evaluated medications for treatment of AR currently available for pediatric patients and identified the attitudes of parents and health care professionals toward these medications. Guidelines from international organizations and governmental websites were reviewed for recommendations and product labeling requirements. A Medline search was conducted using the terms dyes, excipients, palatability, prescribing habits, sugar, among others.

FINDINGS

In recent years, governmental regulatory agencies and professional organizations in Europe and the United States have recommended avoidance of sugar in pediatric medicines and required stricter labeling of their ingredients. Public awareness about the adverse effects of sugar and some excipients has also increased, and parents more frequently express the desire for safer and more convenient medicines for their children. In response, more sugar-free, dye-free liquid medicines and other formulations, such as granules, filmstrips, chewable tablets, fast-dissolving tablets, and drops, are becoming available for pediatric use.

LIMITATIONS

Data from well-designed trials conducted in children for the treatment of AR are lacking. In addition, the possibility of a social response bias may exist for parents and physicians about sugar and other ingredients in children's medications.

CONCLUSION

Treatment for AR is often long-term, particularly in persistent AR; therefore, safety, tolerability, convenience, and patient/parental acceptance are important considerations when deciding which medication to prescribe.

Pediatric asthma and related allergic and nonallergic diseases: patient-oriented evidence-based essentials that matter

Asthma is the most common medical diagnosis among hospitalized children. In the USA, asthma has accounted for approximately 15% of nonsurgical admissions to hospital in the pediatric age group. Asthma is also one of the leading causes for emergency care requirements, one of the leading causes for missed school, and a cause for considerable morbidity, disability and occasional mortality at all ages. Despite these discouraging statistics, convincing data indicate that this failure of asthma management is not the result of inadequate therapeutic potential, but instead represents ineffective delivery of medical care. Management of asthma and its major co-morbidities, allergic and nonallergic rhinitis, and atopic dermatitis requires a knowledge of the alternative therapies, natural history, and educational techniques for providing patients and families with the ability to manage these troublesome chronic disorders.

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

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

Pediatric Allergic Rhinitis: Treatment

Allergic rhinitis, an IgE-mediated disease, is the most common chronic childhood condition and is characterized by nasal sneezing, rhinorrhea, palate and eye itchiness, and congestion. Allergic rhinitis should be diagnosed as early as possible to avoid detrimental effects on the quality of life and comorbid disorders. Treatment initially involves avoidance measures and, when necessary, pharmacotherapy or immunotherapy. Pharmacotherapy generally involves antihistamines or nasal corticosteroids, but other medications such as leukotriene antagonists have demonstrated effectiveness in treating allergic rhinitis symptoms. Immunotherapy generally is reserved for patients unresponsive to therapy or unable to take medications.

Use of 0.06% ipratropium bromide nasal spray in children aged 2 to 5 years with rhinorrhea due to a common cold or allergies

BACKGROUND

Rhinorrhea from common colds or allergies in children is similar to that in adults, yet there are few data on the use of ipratropium bromide nasal spray in children younger than 5 years.

OBJECTIVE

To evaluate the safety and efficacy of 0.06% ipratropium bromide nasal spray in 2- to 5-year-old children with rhinorrhea from a common cold or allergies.

METHODS

A total of 230 children (43 with common colds and 187 with allergies) participated in an open-label, multicenter study. Patients with a common cold received ipratropium bromide nasal spray (84 microg per nostril) 3 times daily for 4 days; those with allergies received ipratropium bromide nasal spray (42 microg per nostril) 3 times daily for 14 days.

RESULTS

In the common cold and allergy groups, 91% and 90% of the parents, respectively, found that ipratropium bromide was either "very useful" or "somewhat useful." Furthermore, 67% and 91% of parents in the common cold and allergy groups, respectively, found that administration of a nasal spray was either "extremely easy" or "very easy." Symptom scores were improved from baseline in both groups. The nasal spray was well tolerated and was not associated with serious or systemic anticholinergic adverse effects. Most adverse events were infrequent and mild to moderate, and study discontinuation due to an adverse event occurred in less than 3% of patients.

CONCLUSIONS

The 0.06% ipratropium bromide nasal spray, 42 or 84 microg per nostril 3 times daily, is easy to administer, safe, and effective for the control of rhinorrhea in children aged 2 to 5 years with a common cold or allergies.

The measurement of health-related quality of life (QOL) in paediatric clinical trials: a systematic review

Background

The goal of much care in chronic childhood illness is to improve quality of life (QOL). However, surveys suggest QOL measures are not routinely included. In addition, there is little consensus about the quality of many QOL measures.

Objectives

To determine the extent to which quality of life (QOL) measures are used in paediatric clinical trials and evaluate the quality of measures used.

Design

Systematic literature review.

Review Methods

Included paediatric trials published in English between 1994 and 2003 involving children and adolescents up to the age of 20 years, and use of a standardised QOL measure. Data Sources included MEDLINE, CINAHL, EMB Reviews, AMED, BNI, PSYCHINFO, the Cochrane library, Internet, and reference lists from review articles.

Results

We identified 18 trials including assessment of QOL (4 Asthma, 4 Rhinitis, 2 Dermatitis, and single studies of Eczema, Cystic fibrosis, Otis media, Amblyopia, Diabetes, Obesity associated with a brain tumour, Idiopathic short stature, and Congenital agranulocytosis). In three trials, parents rated their own QOL but not their child's. Fourteen different QOL measures were used but only two fulfilled our minimal defined criteria for quality.

Conclusions

This review confirms previous reports of limited use of QOL measures in paediatric clinical trials. Our review provides information about availability and quality of measures which will be of especial value to trial developers.

The health-related quality of life effects of once-daily cetirizine HCl syrup in children with seasonal allergic rhinitis

Seasonal allergic rhinitis (SAR) can adversely impact children's physical, psychological, and social functioning and well-being, that is, their health-related quality of life (HRQL). This study assessed HRQL in children 6 to 11 years treated with cetirizine HCl syrup, while concurrently assessing symptomatic relief and safety. In an open-label, non-comparative study, 544 children from 124 centers in the United States were instructed to take cetirizine HCl syrup (10 cc of 1 mg/mL) each evening for 4 weeks. Children experienced statistically significant improvements in HRQL with significant reductions in mean symptom score (p < 0.001) during the treatment period. Results were consistent across age groups (6-7, 8-9, 10-11 years). These results suggest that the symptomatic relief and tolerability profile of cetirizine HC1 syrup daily translates into improvements in the HRQL of children with SAR. This 4-week open label study is among the first to evaluate the effect of antihistamine treatment on HRQL outcomes in children.

Clinical prescribing of allergic rhinitis medication in the preschool and young school-age child: what are the options?

Allergic rhinitis (AR) is the most common chronic condition in children and is estimated to affect up to 40% of all children. It is usually diagnosed by the age of 6 years. The major impact in children is due to co-morbidity of sinusitis, otitis media with effusion, and bronchial asthma. AR also has profound effects on school absenteeism, performance and quality of life. Pharmacotherapy for AR should be based on the severity and duration of signs and symptoms. For mild, intermittent symptoms lasting a few hours to a few days, an oral second-generation antihistamine should be used on an as-needed basis. This is preferable to a less expensive first-generation antihistamine because of the effect of the latter on sedation and cognition. Four second-generation antihistamines are currently available for children under 12 years of age: cetirizine, loratadine, fexofenadine and azelastine nasal spray; each has been found to be well tolerated and effective. There are no clearcut advantages to distinguish these antihistamines, although for children under 5 years of age, only cetirizine and loratadine are approved. Other agents include pseudoephedrine, an oral vasoconstrictor, for nasal congestion, and the anticholinergic nasal spray ipratropium bromide for rhinorrhoea. Sodium cromoglycate, a mast cell stabiliser nasal spray, may also be useful in this population. For patients with more persistent, severe symptoms, intranasal corticosteroids are indicated, although one might consider azelastine nasal spray, which has anti- inflammatory activity in addition to its antihistamine effect. With the exception of fluticasone propionate for children aged 4 years and older, and mometasone furoate for those aged 3 years and older, the other intranasal corticosteroids including beclomethasone dipropionate, triamcinolone, flunisolide and budesonide are approved for children aged 6 years and older. All are effective, so a major consideration would be cost and safety. For short term therapy of 1 to 2 months, the first-generation intranasal corticosteroids (beclomethasone dipropionate, triamcinolone, budesonide and flunisolide) could be used, and mometasone furoate and fluticasone propionate could be considered for longer-term treatment. Although somewhat more costly, these second-generation drugs have lower bioavailability and thus would have a better safety profile. In patients not responding to the above programme or who require continuous medication, identification of specific triggers by an allergist can allow for specific avoidance measures and/or immunotherapy to decrease the allergic component and increase the effectiveness of the pharmacological regimen.

Quality of life in allergic rhinitis

OBJECTIVE

This review will furnish the reader current information on the importance of quality of life evaluation in patients suffering from allergic rhinitis, the different types of quality of life instruments used, and how they can be used in judging different pharmaceutical therapies.

DATA SOURCES

Computer-assisted MEDLINE searches for articles assessing "quality of life" and "outcomes" in rhinitis. Also MEDLINE searches evaluating health-related quality of life in relationship to different pharmacologic treatments in allergic rhinitis.

STUDY SELECTIONS

Pertinent abstracts and articles in two broad areas were selected. The first groups were articles in the fields of outcomes, quality of life, allergic rhinitis, and its relationship to health-related quality of life. The second group of articles evaluated different pharmacologic agents' effect on the health-related quality of life of rhinitis patients. Both sets of articles were critically analyzed with important representative studies selected for this review.

RESULTS

Health-related quality of life of patients with allergic rhinitis is impaired as measured by both generic and specific health-related quality of life instruments. Use of second generation antihistamines, intranasal corticosteroids, and intranasal ipratropium bromide have been shown to improve the health-related quality of life of sufferers of allergic rhinitis.

CONCLUSIONS

The measuring of health-related quality of life is assuming a primary position in outcomes analysis in the patient with allergic rhinitis. Studies have documented the validity of using generic and specific health-related quality of life instruments in allergic rhinitis. Each type has its own weaknesses and strengths that the user needs to appreciate. Appraising the role of different pharmacologic agents in allergic rhinitis in improving the patient's quality of life is an important part of proving the medication's worth to the health care community.

Comparison of ipratropium bromide 0.03% with beclomethasone dipropionate in the treatment of perennial rhinitis in children

OBJECTIVE

To compare the safety and efficacy of ipratropium bromide 0.03% (IB) with beclomethasone dipropionate 0.042% (BDP) in the treatment of perennial rhinitis in children.

METHODS

Thirty-three children with nonallergic perennial rhinitis (NAPR) and 113 with allergic perennial rhinitis (APR) were randomly assigned to either IB or BDP for 6 months in a single-blind, multicenter protocol in which the physician was blinded to treatment. At each visit, patients and physicians rated symptom control of rhinorrhea, nasal congestion, and sneezing. Patients also completed quality of life questionnaires at baseline and after 6 months of therapy.

RESULTS

Both treatments showed a significant improvement in control of rhinorrhea, congestion, and sneezing compared with baseline over the 6 months of treatment (P < .05). Only for the control of sneezing was BDP consistently better than IB (P < .05). Among the patients given IB, 61% to 73% assessed the control of rhinorrhea as good or excellent on different study visit days, 43% to 60% similarly rated the control of nasal congestion, and 39% to 43% the control of sneezing. The results for BDP were 68% to 78% for the control of rhinorrhea, 55% to 72% for the control of nasal congestion, and 54% to 68% for the control of sneezing. Quality of life assessment documented that both drugs significantly reduced interference with daily activities and disturbance of mood due to rhinorrhea compared with baseline (P < .05). Both treatments were well tolerated with IB causing less nasal bleeding and irritation than BDP.

CONCLUSIONS

Ipratropium bromide was safe and effective in controlling rhinorrhea and diminishing the interference by rhinorrhea in school attendance, concentration on school work, and sleep. Ipratropium bromide was as effective as BDP in the control of rhinorrhea and showed a relatively good effect on congestion. Patient and physician assessment favored BDP in the control of sneezing.

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.