Effects of semprex-D and diphenhydramine on learning in young adults with seasonal allergic rhinitis

Diphenhydramine: Time to Move on?

Diphenhydramine is one of the most widely available, longest-used antihistamine medications but has many side effects including sedation and risk of toxicity in overdose including cardiac toxicity. It is frequently inappropriately used when newer, more favorable antihistamine medications are available. Second-generation antihistamines are also widely available and affordable, with many of the same desired effects as diphenhydramine and fewer, if any, of the undesirable side effects. Because of the negative side effects and wide availability of alternative antihistamine medications, it is definitively time to move on from diphenhydramine.

Central Histamine Boosts Perirhinal Cortex Activity and Restores Forgotten Object Memories

BACKGROUND

A method that promotes the retrieval of lost long-term memories has not been well established. Histamine in the central nervous system is implicated in learning and memory, and treatment with antihistamines impairs learning and memory. Because histamine H₃ receptor inverse agonists upregulate histamine release, the inverse agonists may enhance learning and memory. However, whether the inverse agonists promote the retrieval of forgotten long-term memory has not yet been determined.

METHODS

Here, we employed multidisciplinary methods, including mouse behavior, calcium imaging, and chemogenetic manipulation, to examine whether and how the histamine H₃ receptor inverse agonists, thioperamide and betahistine, promote the retrieval of a forgotten long-term object memory in mice. In addition, we conducted a randomized double-blind, placebo-controlled crossover trial in healthy adult participants to investigate whether betahistine treatment promotes memory retrieval in humans.

RESULTS

The treatment of H₃ receptor inverse agonists induced the recall of forgotten memories even 1 week and 1 month after training in mice. The memory recovery was mediated by the disinhibition of histamine release in the perirhinal cortex, which activated the histamine H₂ receptor. Histamine depolarized perirhinal cortex neurons, enhanced their spontaneous activity, and facilitated the reactivation of behaviorally activated neuronal ensembles. A human clinical trial revealed that treatment of H₃ receptor inverse agonists is specifically more effective for items that are more difficult to remember and subjects with poorer performance.

CONCLUSIONS

These results highlight a novel interaction between the central histamine signaling and memory engrams.

Recent Developments in Atopic Dermatitis

Atopic dermatitis (AD) is a bothersome and common skin disease affecting ∼10.7% of children in the United States. This skin condition significantly decreases quality of life in not only patients, but in their families as well. Pediatricians are often the first physicians to diagnose and manage these patients and thus are relied on by families to answer questions about this disease. AD is complex, multifactorial, and has historically had limited therapeutic options, but the landscape of this disease is now rapidly changing. Pathways contributing to the pathogenesis of this disease are continually being discovered, and new therapies for AD are being developed at an unprecedented rate. With this article, we will review the current guidelines regarding the management of AD, outline updates in the current understanding of its pathophysiology, and highlight novel developments available for the treatment of this burdensome disease.

An assessment of the use of antihistamines in the management of atopic dermatitis

BACKGROUND

Antihistamines are often used to treat pruritus associated with atopic dermatitis (AD) despite lack of evidence for their efficacy. The American Academy of Dermatology does not recommend the general use of antihistamines in the management of AD, although the value of short-term sedating antihistamine use for insomnia secondary to itch is recognized.

OBJECTIVE

To assess the use of sedating and nonsedating antihistamines for AD in 2003-2012.

METHODS

The National Ambulatory Medical Care Survey provided data on physician visits in 2003-2012. Sedating and nonsedating antihistamine use was identified at visits for AD.

RESULTS

There were 990,000 annual visits for AD. Antihistamines were prescribed for AD in a significant proportion of visits across physician specialties (16%-44%). Dermatologists and pediatricians primarily used sedating antihistamines (58%-70%), whereas the majority of family/general practitioners, internists, and other specialists prescribed nonsedating antihistamines for AD (55%-100%) LIMITATIONS: We were limited by the accuracy of AD diagnosis and medication recording.

CONCLUSIONS

Antihistamines are widely used for the treatment of AD. There is no high-level evidence to suggest that nonsedating antihistamines reduce itch in patients with AD or that sedating antihistamines provide benefit in controlling AD symptoms (except perhaps sleep and AD comorbidities, such as allergic rhinitis).

Estimate of the total costs of allergic rhinitis in specialized care based on real-world data: the FERIN Study

BACKGROUND

Despite the socioeconomic importance of allergic rhinitis (AR), very few prospective studies have been performed under conditions of clinical practice and with a sufficiently long observation period outside the clinical trial scenario. We prospectively estimated the direct and indirect costs of AR in patients attending specialized clinics in Spain.

METHODS

Patients were recruited at random from allergy outpatient clinics in 101 health centers throughout Spain over 12 months. We performed a multicenter, observational, prospective study under conditions of clinical practice. We analyzed direct costs from a funder perspective (healthcare costs) and from a societal perspective (healthcare and non-healthcare costs). Indirect costs (absenteeism and presenteeism [productivity lost in the workplace]) were also calculated. The cost of treating conjunctivitis was evaluated alongside that of AR.

RESULTS

The total mean cost of AR per patient-year (n = 498) was €2326.70 (direct, €553.80; indirect, €1772.90). Direct costs were significantly higher in women (€600.34 vs €484.46, P = 0.02). Total costs for intermittent AR were significantly lower than for persistent AR (€1484.98 vs €2655.86, P < 0.001). Total indirect costs reached €1772.90 (presenteeism, €1682.71; absenteeism, €90.19). The direct costs of AR in patients with intermittent asthma (€507.35) were lower than in patients with mild-persistent asthma (€719.07) and moderate-persistent asthma (€798.71) (P = 0.006).

CONCLUSIONS

The total cost of AR for society is considerable. Greater frequency of symptoms and more severe AR are associated with higher costs. Indirect costs are almost threefold direct costs, especially in presenteeism. A reduction in presenteeism would generate considerable savings for society.

Attention Deficit Disorder and Allergic Rhinitis: Are They Related?

The association between ADHD and allergy remains controversial. Our previous findings suggest that nerve growth factor may link the nervous and immune systems. The primary objective of this study was to determine if a combination of cetirizine + methylphenidate is effective in children with comorbid ADHD and allergic rhinitis. We also examined the role of nerve growth factor in these comorbidities. Our randomized, double-blind, placebo-controlled, crossover study enrolled 38 children diagnosed with comorbid ADHD and allergy using cetirizine (n = 12), sustained-release methylphenidate (n = 12), or cetirizine + methylphenidate (n = 14). Endpoints compared baseline to posttreatment evaluations for allergic rhinitis and ADHD scores. Serum nerve growth factor levels were measured using ELISA. For allergy endpoints, combination therapy produced results superior to individual therapy. For ADHD, similar scores were achieved for individual therapy; however, combination therapy resulted in improved scores. Nerve growth factor levels were downregulated following this trend. We conclude that ADHD and allergic rhinitis may have common mechanism and represent a comorbid condition that links the nervous system to the immune system. Further studies are needed.

A simulated car-driving study on the effects of acute administration of levocetirizine, fexofenadine, and diphenhydramine in healthy Japanese volunteers

OBJECTIVE

Antihistamines are often used for treating allergic rhinitis. However, many older antihistamines cause sedative side effects. The sedative effects of antihistamines on car-driving have been investigated. This has not been investigated for levocetirizine, a new-generation antihistamine, in Asian populations, and so we evaluated its sedative effects in healthy Japanese subjects.

METHODS

In this double-blind, placebo-controlled, four-way crossover study, healthy volunteers received single doses of levocetirizine 5 mg, fexofenadine 60 mg, diphenhydramine 50 mg, and placebo at intervals of at least 6 days. Simple brake reaction time and choice brake reaction time task (CBRT), a lateral tracking (LT) task, and a multiple task, a mixture of CBRT and LT task, were used to compare driving performance between the four drugs. Subjective sedation was also assessed.

RESULTS

The simple brake reaction time and CBRT, and the CBRT component of the multiple task, did not show any significant differences between the drugs. In contrast, the LT, both as a single parameter and as a component of the multiple task, showed significant differences between diphenhydramine and the newer-generation antihistamines in a manner that corresponds with subjective sedation.

CONCLUSIONS

Levocetirizine and fexofenadine did not impair psychomotor performance in subjects performing simulated car-driving tasks, while diphenhydramine did impair psychomotor performance in the subjects. Copyright © 2016 John Wiley & Sons, Ltd.

Prevalence of allergic rhinitis among elementary and middle school students in Changsha city and its impact on quality of life

OBJECTIVES

To investigate the prevalence of allergic rhinitis among elementary and middle school students and examine its impact on their quality of life.

METHODS

Stratified sampling and cluster sampling surveys were performed among 10-17-year-old students in Changsha city from June 2011 to April 2012.

RESULTS

In the stratified sampling survey, the self-reported allergic rhinitis rate was 42.5 per cent. Further examination demonstrated that the average prevalence of allergic rhinitis was 19.4 per cent. The cluster sampling survey demonstrated that 214 of 814 students appeared to be atopic (26.3 per cent). The prevalence of allergic rhinitis and asthma was 17.2 and 2.1 per cent, respectively. In total, 71 atopic individuals (8.7 per cent) were without any symptoms of allergic disease. Further analysis showed that allergic rhinitis influenced the students' sleep, emotions and memory (p < 0.001).

CONCLUSION

The prevalence of allergic rhinitis was 15.8 -19.4 per cent, showing an increase with age. Allergic rhinitis affected students' sleep, emotions and memory.

Does allergic rhinitis affect communication skills in young adults?

Allergic rhinitis (AR) is a chronic disorder with a high prevalence in the general population. The symptoms of AR can impair the cognitive capabilities of the affected people. The study of communication skills and AR interaction has not been adequately discussed. We aimed to analyze Social Communication Skills of university students with AR. Fifty patients suffering from AR and 50 healthy subjects were studied. All participants completed two questionnaires [Social Communication Skills Rating Scale (SCSRS) and Communication Questionnaire] for the assessment of social communication skills. Total scores of both SCSRS and Communication Questionnaire were higher in participants with AR than controls. When the questions of SCSRS were compared between the groups one by one, significant difference was observed between the groups for questions numbered 1-9 and 11, 12 (p < 0.05). Also, significant differences were observed between the groups for questions numbered 4, 5, 6, 7 and 8 of Communication Questionnaire (p < 0.05). Results of our study indicate that AR could negatively affect the social communication skills of the patients with AR. More research is however needed to validate this hypothesis.

Burden of illness and quality of life in patients being treated for seasonal allergic rhinitis: a cohort survey

Background

Allergic Rhinitis is an inflammatory disease which is characterised by burdensome nasal and/or ocular symptoms. This study aimed to assess the impact of symptoms (number of symptom-free days (SFD) and Quality of Life (QoL)) in patients with Seasonal Allergic Rhinitis (SAR) being treated with fluticasone furoate (FF), mometasone furoate (MF) or fluticasone propionate (FP).

Methods

In a cross-sectional, non-interventional, cohort analysis, primary care physicians and allergy specialists in France, Germany, and Spain were recruited via telephone interviews. Each physician prospectively recruited 4 SAR patients - 2 receiving FF, 1 receiving MF and 1 receiving FP - during June 2009. Patients answered questions on symptoms and completed questionnaires on QoL (mini-rhinoconjunctivitis Quality of Life Questionnaire, RQLQ) and burden of illness (Pittsburgh Sleep Quality Index).

Results

A total of 540 patients were recruited during June 2009. 88 patients were subsequently found to be ineligible and excluded from the analyses. In the 4 weeks prior to assessment, patients reported a mean of 14.58 (±8.42) SFD. Patients receiving FF had more SFD (mean 15.45 ±8.29) than patients receiving MF (adjusted mean difference -1.22, 95% Confidence Interval (CI) [-3.16 to 0.72], p=0.434) or FP (adjusted mean difference -1.95, 95% CI [-3.87 to -0.03], p=0.092), although statistical significance was not achieved. The mean RQLQ score was 1.54 (±1.06). Patients receiving FF had a better quality of life in the previous week (mini-RQLQ score: mean 1.42, ±1.04) than patients receiving MF (adjusted mean difference 0.28, 95% CI [0.03 to 0.52], p=0.052) or FP (adjusted mean difference 0.18, 95% CI [-0.05 to 0.41], p=0.244). Again, none of these results achieved statistical significance.

Conclusions

At the height of the allergy season, patients with SAR suffer symptoms approximately 50% of the time, and report an impact on their QoL. No significant differences were observed between FF, FP and MF related to SFD or QoL.

Trial registration

ClinicalTrials.gov identifier: NCT01199757

Antihistamine therapy in allergic rhinitis

Antihistamines have long been a mainstay in the therapy for allergic rhinitis. Many different oral antihistamines are available for use, and they are classified as first generation or second generation based on their pharmacologic properties and side-effect profiles. The recent introduction of intranasal antihistamines has further expanded the role of antihistamines in the treatment of allergic rhinitis. Certain patient populations, such as children and pregnant or lactating women, require special consideration regarding antihistamine choice and dosing as part of rhinitis therapy.

Impact of ocular symptoms on quality of life (QoL), work productivity and resource utilisation in allergic rhinitis patients--an observational, cross sectional study in four countries in Europe

OBJECTIVE

It is hypothesised that the presence of ocular, in addition to nasal, symptoms among patients with allergic rhinitis (AR) results in poorer quality of life, reduced work productivity and increased resource utilisation. This study investigated the impact on quality of life, burden of illness and healthcare resources among 1640 AR patients.

METHODS

Data were drawn from an observational cross-sectional study of consulting patients undertaken in May/June 2008 in four European countries. Doctors provided records for the next four to five patients presenting with AR who filled out a self-completion survey which included the Work Productivity and Activity Impairment Allergic Specific Questionnaire (WPAI:AS), the Mini Rhinoconjunctivitis Quality of Life Questionnaire (RQOLQ) and the Pittsburgh Sleep Quality Index (PSQI). Propensity scoring allied to regression-type analysis was used to assess the extra burden associated with ocular symptoms utilising two comparison groups (patients with nasal-only symptoms versus those with nasal and ocular symptoms). The analysis controlled for differences between the groups on confounding variables age, gender, smoking status and co-morbidities. The analysis was conducted twice, once controlling for differences between the groups in nasal severity and once without, recognising that it is not clear whether or not increased nasal severity symptoms are naturally associated with ocular symptoms. The severity of ocular symptoms as opposed to their presence alone was also assessed on outcome measures using regression type methods.

RESULTS

A total of 1009 patient records met the inclusion criteria, of whom 69% presented with both ocular and nasal symptoms. The results show that the presence of ocular symptoms reduces quality of life, reduces work productivity and increases resource utilisation irrespective of whether differences in severity of nasal symptoms are accounted for between the comparison groups. Patients with nasal and ocular symptoms require more healthcare consultations. All work-related domains were statistically different, with the presence of ocular symptoms associated with greater impact on work hours missed and impairment while working. For each of the above this was the case regardless of whether or not adjustment was made for nasal severity (both p < 0.05). Patients with nasal and ocular symptoms also record an additional half a day more time off work in the last 3 months as a result of AR (nasal severity unadjusted or adjusted, both p < 0.05). Clinically meaningful differences were found in overall quality of life score as represented by RQLQ, with a mean score increase of 0.6 (nasal severity unadjusted) and 0.5 (nasal severity adjusted) associated with the presence of ocular symptoms (both p < 0.05). With regard to sleep quality, the presence of ocular symptoms was associated with a mean increase in PSQI of 1 when no adjustment was made for nasal severity (p < 0.05). When nasal severity was adjusted for, no significant difference was observed. Similarly, for the number of prescribed medications, when no adjustment was made for nasal severity, patients with ocular symptoms were observed to receive a significantly higher number of AR drugs (+0.19, p < 0.05) whereas with nasal severity adjusted for the difference was +0.17 which was not significant. In addition, with the exception of the number of AR drugs prescribed, for all outcome variables, the severity of ocular symptoms, and not just their presence, had a detrimental impact on the outcome.

LIMITATIONS

Since patients were recruited via the physician, the study aim was to represent the consulting population. In addition, it cannot be fully excluded that the likelihood for an individual patient to complete a questionnaire is influenced by differences in patient typology compared with those patients who chose not to complete. Given the geographical dispersion of the sample patients, it may be reasonable to assume possible differences in the intensity of the AR season based on latitude.

CONCLUSION

The added presence of ocular symptoms in AR patients suffering with nasal symptoms deteriorates patients' quality of life, leads to greater lost productivity and places higher burden on resource utilisation. Studies are therefore needed to test whether treatment options that address ocular in addition to nasal symptoms will improve quality of life and reduce both direct and indirect resource use associated with AR.

Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper

BACKGROUND

First-generation H(1)-antihistamines obtained without prescription are the most frequent form of self-medication for allergic diseases, coughs and colds and insomnia even though they have potentially dangerous unwanted effects which are not recognized by the general public.

AIMS

To increase consumer protection by bringing to the attention of regulatory authorities, physicians and the general public the potential dangers of the indiscriminate use first-generation H(1)-antihistamines purchased over-the counter in the absence of appropriate medical supervision.

METHODS

A GA(2)LEN (Global Allergy and Asthma European Network) task force assessed the unwanted side-effects and potential dangers of first-generation H1-antihistamines by reviewing the literature (Medline and Embase) and performing a media audit of US coverage from 1996 to 2008 of accidents and fatal adverse events in which these drugs were implicated.

RESULTS

First-generation H(1)-antihistamines, all of which are sedating, are generally regarded as safe by laypersons and healthcare professionals because of their long-standing use. However, they reduce rapid eye movement (REM)-sleep, impair learning and reduce work efficiency. They are implicated in civil aviation, motor vehicle and boating accidents, deaths as a result of accidental or intentional overdosing in infants and young children and suicide in teenagers and adults. Some exhibit cardiotoxicity in overdose.

CONCLUSIONS

This review raises the issue of better consumer protection by recommending that older first-generation H(1)-antihistamines should no longer be available over-the-counter as prescription- free drugs for self-medication of allergic and other diseases now that newer second- generation nonsedating H(1)-antihistamines with superior risk/benefit ratios are widely available at competitive prices.

Therapeutic management of allergic diseases

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

Undertreatment of allergy: exploring the utility of sublingual immunotherapy

Allergic syndromes are highly prevalent and are comprised of a wide variety of clinical problems, including rhinitis, conjunctivitis, atopic dermatitis and urticaria, asthma, and food allergies. Numerous studies have shown that allergic syndromes are both underdiagnosed and undertreated. This is related to many factors, including trivialization of allergic conditions by physicians and patients, failure to adhere to diagnostic and treatment guidelines, and dissatisfaction with conventional pharmacologic treatments. Immunotherapy involves the administration of allergen extracts in an attempt to induce immunologic tolerance and has been used for the treatment of allergic syndromes and the prevention of long-term complications. Conventional subcutaneous immunotherapy is effective but is also associated with a risk of serious adverse events, requires administration by a trained health care professional, and is contraindicated in certain populations. By contrast, sublingual immunotherapy has been used extensively in Europe and possesses most of the benefits of subcutaneous immunotherapy along with increased safety, tolerability, and convenience. This narrative review explores data from selected clinical studies and concludes that sublingual immunotherapy may be well suited to fill the gap posed by the undertreatment of allergic syndromes in the United States.

Investigation of attention deficit and hyperactivity disorder in adult patients with atopic dermatitis

Background. Atopic dermatitis (AD) is a common chronic inflammatory disease that is associated with significant psychosocial morbidity and a decrease in health-related quality of life. Attention deficit hyperactivity disorder may be present in atopic dermatitis patients. Objective. The present study aims to investigate the co-presence of ADHD in adult patients with AD. Material and method. The study registered 60 adult patients with AD (48 females and 12 males) and 50 non-atopic control subjects (38 females and 12 males). The AD patient group and the control group were assessed using the Turgay adult Attention-Deficit/Hyperactivity Disorder (ADD/ADHD) DSM-IV-Based Diagnostic Screening and Rating Scale (Turkish Version), which was studied by a team of psychologists and psychiatrists in Turkey for validity, reliability and norms. The scale covers three dimensions of the disease, namely inattention, hyperactivity and impulsivity, and associated features of ADHD. The groups were compared and contrasted in terms of their similarities and differences in ADD/ADHD symptoms. Results. Three sub-dimensions of ADD/ADHD scale (Attention Deficit, Hyperactivity/ Impulsivity and Problem subdivisions) in AD patients were found statistically significantly elevated relative to controls (P<0.001, P<0.001, P<0.001, respectively). Conclusions. In conclusion we established the co-presence of ADHD in AD patients in the adult age group.

Allergic rhinitis: the impact of discordant perspectives of patient and physician on treatment decisions

BACKGROUND

A wealth of literature is available that documents the effects of inadequately controlled allergic rhinitis (AR) on patients' daily activities, including impaired sleep, reduced cognitive functioning, and interference with sport and leisure activities. However, despite its high prevalence and significant impact on health-related quality of life (HRQOL) and productivity, AR may be undertreated. This might arise, in part, from the low priority given to the disease by physicians.

OBJECTIVE

This article aims to assess the existence of disparities between the attitudes of patients and physicians to AR, and to comment on the impact these disparities may have on treatment choices.

METHODS

A search was conducted of MEDLINE (1990-2006) and data presented at recent congresses (The 25th Congress of the European Academy of Allergology and Clinical Immunology, June 10-14, 2006, Vienna, Austria, and the 62nd Annual American Academy of Allergy, Asthma and Immunology Meeting, March 3-7, 2006, Miami Beach, Florida) for articles that contained combinations of the terms allergic rhinitis, patient, physician, perspective, attitude, opinion, experience, or burden. Appropriate articles were selected for review in combination with data from a recent Adelphi Group Products (New York, New York) survey.

RESULTS

A study of the impact of seasonal AR on HRQOL found that adolescent patients (n = 83) scored practical problems higher in terms of importance. AR was found to affect the home and social life of > or =33% of patients in a study from the United Kingdom. A European survey of 1494 patients with AR found that nasal congestion was the most common moderate or severe nasal symptom (55%) and that 44% of patients suffered moderate or severe ocular symptoms. A Danish study of adults and adolescents found that AR was undiagnosed in 32% of patients. In a study of 100 physicians in the United States, approximately 30% of physicians under-estimated the severity of AR and its impact on patients' work or school activities. Furthermore, 1 study indicated that approximately 99% of physicians did not issue adequate treatment, although no study was found that directly linked physicians' perspectives of AR and their treatment decisions to date.

CONCLUSIONS

In a review of the existing literature, evidence of disparities between patients' and physicians' perspectives of AR were found, although no studies linked perspectives to prescribing behavior; therefore, research into the impact on treatment decisions might be warranted. In the future, the patient-physician dialogue might be improved by a standardized questionnaire designed to identify the most bothersome symptoms of a patient's disease, so that the most appropriate treatments can be selected to maximize quality of life.

Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study

BACKGROUND

Seasonal allergic rhinitis is common globally, and symptoms have been shown to impair learning ability in children in laboratory conditions. Critical examinations in children are often held in the summer during the peak grass pollen season.

OBJECTIVE

To investigate whether seasonal allergic rhinitis adversely impacts examination performance in United Kingdom teenagers.

METHODS

Case-control analysis of 1,834 students (age 15-17 years; 50% girls) sitting for national examinations. Cases were those who dropped 1 or more grades in any of 3 core subjects (mathematics, English, and science) between practice (winter) and final (summer) examinations; controls were those whose grades were either unchanged or improved. Associations between allergic rhinitis symptoms, clinician-diagnosed allergic rhinitis, and allergic rhinitis-related medication use, recorded on examination days immediately before the examination, were assessed using multilevel regression models.

RESULTS

Between 38% and 43% of students reported symptoms of seasonal allergic rhinitis on any 1 of the examination days. There were 662 cases (36% of students) and 1,172 controls. After adjustment, cases were significantly more likely than controls to have had allergic rhinitis symptoms during the examination period (odds ratio [OR], 1.4; 95% CI, 1.1-1.8; P = .002), to have taken any allergic rhinitis medication (OR, 1.4; 95% CI, 1.1-1.7; P = .01), or to have taken sedating antihistamines (OR, 1.7; 95% CI, 1.1-2.8; P = .03).

CONCLUSION

Current symptomatic allergic rhinitis and rhinitis medication use are associated with a significantly increased risk of unexpectedly dropping a grade in summer examinations.

CLINICAL IMPLICATIONS

This is the first time the relationship between symptomatic allergic rhinitis and poor examination performance has been demonstrated, which has significant implications for clinical practice.

Cognitive Effects of Allergic Rhinitis and its Treatment

Allergic rhinitis (AR) can, by itself, introduce significant sedation and impairment of cognition and performance. AR can also impede restorative sleep, resulting in increased fatigue and decreased daytime performance. It is not clear whether improved alertness resulting from blocking histamine production offsets the sedating effects of antihistamines or whether the effects of disease and treatment combine to create even greater sedation. This article reviews and integrates this literature, offers conclusions based on the collective evidence, and suggests guidelines for future research.

Current concepts and therapeutic strategies for allergic rhinitis in school-age children

BACKGROUND

Allergic rhinitis (AR) is a common debilitating disorder that can adversely affect the quality of life and the academic performance of school-age children. Symptoms during the day can hamper concentration and lead to learning problems. Nocturnal symptoms can cause sleep loss and secondary daytime fatigue, further undermining a child's ability to function well during the school day Oral antihistamines are the foundation of pharmacologic therapy, but there are important differences between the agents.

OBJECTIVE

The purpose of this review is to provide an overview of the diagnostic and treatment challenges posed by AR in school-age children. The paper discusses and compares the available treatment modalities for this age group, with a focus on their beneficial and adverse effects.

METHODS

Pertinent articles were identified in the literature through a MEDLINE search (1990-2003). Keywords used were antihistamines cetirizine fexofenadine loratadine desloratadine intranasal corticosteroids and CNS effects. Results of numerous clinical trials of first-generation early second-generation and the newer antihistamines were identified.

RESULTS

This review established that the socioeconomic costs of AR are considerable. In children aged > or =12 years, direct US expenditures (eg, physician visits, medications) in 1996 amounted to $2.3 billion. Indirect costs measured by variables such as missed school days and poor performance also have an impact Major concerns include underdiagnosis and inadequate treatment, increasing the risk of serious comorbid conditions such as asthma. Advantages and drawbacks of antihistamines show that first-generation agents (eg, hydroxyzine) are effective and readily available over the counter, but are associated with sedation and the potential for suboptimal dosing. Newer agents, such as cetirizine, loratadine, desloratadine, and fexofenadine are effective and safer than the older drugs tie, no cardiotoxicity and less sedation). Of these, fexofenadine has been shown to be beneficial and nonsedating, even at higher-than-recommended doses. Other therapies reviewed include intranasal corticosteroids and leukotriene modifiers.

CONCLUSIONS

AR has a considerable negative impact on children in terms of their physical, social, and psychological well-being and academic performance. An appropriate treatment must be effective and tolerable. Of particular importance for enhancing treatment adherence in the school-age population are pleasant taste and ease of use of medication. A drug that has minimal or no sedative or anticholinergic effects is optimal.

Pediatric Allergic Rhinitis: Factors Affecting Treatment Choice

Allergic rhinitis is the most prevalent chronic allergic disease in children. Although it is not life-threatening, it can have a significantly detrimental effect on a child's quality of life, and it may exacerbate a number of common comorbidities, including asthma and sinusitis. The Allergic Rhinitis and its Impact on Asthma guidelines, an evidence-based algorithm for the treatment of allergic rhinitis, advocate the use of antihistamines for the treatment of the broad spectrum of the disease. However, first-generation antihistamines are associated with a number of adverse events, including central nervous system impairment and anticholinergic and cardiovascular effects. Moreover, these agents have not been rigorously tested in the pediatric population. Nevertheless, first-generation antihistamines remain the most frequently prescribed agents in this class of drugs. This is despite the fact that the second-generation antihistamines are largely free of the undesirable side effects associated with their predecessors and the fact that they have been shown to be effective in relieving allergic rhinitis symptoms in children in a number of large-scale clinical trials. Therefore, when selecting an antihistamine for a child, it would be prudent to consider the full range of antihistamines and to base the selection of a particular drug on its efficacy, onset and duration of action, and safety profile.

Allergic rhinitis in children with attention-deficit/hyperactivity disorder

BACKGROUND

Both allergic rhinitis and attention-deficit/hyperactivity disorder (ADHD) are common pediatric conditions associated with learning difficulties and sleep disturbances. There are conflicting research data regarding the association between ADHD and atopic disorders.

OBJECTIVE

To determine the prevalence of allergic rhinitis in patients with physician-diagnosed ADHD.

METHODS

Patients 5 to 18 years of age who presented with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of ADHD to an outpatient pediatric psychiatry clinic were screened for allergic rhinitis with focused history, physical examination, and skin prick testing to common aeroallergens.

RESULTS

Thirty patients were interviewed, with 23 of these undergoing physical examination and skin prick testing. Eighty percent reported allergic rhinitis symptoms, whereas 61% had at least 1 positive prick skin test result. Forty-three percent showed typical physical signs of allergic rhinitis, 100% had a positive atopic family history, and 53% had other associated atopic disorders.

CONCLUSIONS

Most children with ADHD displayed symptoms and skin prick test results consistent with allergic rhinitis. Nasal obstruction and other symptoms of allergic rhinitis could explain some of the cognitive patterns observed in ADHD, which might result from sleep disturbance known to occur with allergic rhinitis. Therefore, evaluation and treatment of allergic rhinitis could benefit patients with ADHD.

Haloperidol Impairs Learning and Error-related Negativity in Humans

Humans are able to monitor their actions for behavioral conflicts and performance errors. Growing evidence suggests that the error-related negativity (ERN) of the event-related cortical brain potential (ERP) may index the functioning of this response monitoring system and that the ERN may depend on dopaminergic mechanisms. We examined the role of dopamine in ERN and behavioral indices of learning by administering either 3 mg of the dopamine antagonist (DA) haloperidol (n = 17); 25 mg of diphenhydramine (n = 16), which has a similar CNS profile but without DA properties; or placebo (n = 18) in a randomized, double-blind manner to healthy volunteers. Three hours after drug administration, participants performed a go/no-go Continuous Performance Task, the Eriksen Flanker Task, and a learning-dependent Time Estimation Task. Haloperidol significantly attenuated ERN amplitudes recorded during the flanker task, impaired learning of time intervals, and tended to cause more errors of commission, compared to placebo, which did not significantly differ from diphenhydramine. Drugs had no significant effects on the stimulus-locked P1 and N2 ERPs or on behavioral response latencies, but tended to affect post-error reaction time (RT) latencies in opposite ways (haloperidol decreased and diphenhydramine increased RTs). These findings support the hypothesis that the DA system is involved in learning and the generation of the ERN.

Improvements in simulated real-world relevant performance for patients with seasonal allergic rhinitis: impact of desloratadine

BACKGROUND

Seasonal allergic rhinitis (SAR) diminishes task performance and decreases quality of life. Antihistamines are frequently used to treat the symptoms of SAR. First generation antihistamines often have their own detrimental effects upon human functioning while second generation antihistamines appear to have fewer or no undesirable side-effects.

OBJECTIVE

This study evaluated the impact of desloratadine on simulated real-world performance demands in individuals suffering from SAR.

METHODS

This was a randomized, double-blind, cross-over study where asymptomatic participants were treated with placebo and symptomatic participants were treated with desloratadine or placebo. They then participated in a real-world equivalent task performance simulation that assessed information processing capacity at multiple levels of task difficulty ranging from easy to difficult decision-making tasks.

RESULTS

Desloratadine either completely restored performance to the level of the asymptomatic placebo control or improved performance in six of the nine performance categories, where it had been diminished by the presence of SAR.

CONCLUSIONS

These findings suggest that treatment with desloratadine has considerable beneficial effects on work place performance when individuals suffer from SAR.

Diphenhydramine-induced amnesia is mediated by Gi-protein activation

The effect of the i.c.v. administration of antisense oligodeoxynucleotides directed against the alpha subunit of different Gi-proteins (anti-Gialpha(1), anti-Gialpha(2), anti-Gialpha(3), anti-Goalpha(1), anti-Goalpha(2)) on the amnesia induced by the H(1)-antihistamine diphenhydramine (20 mg kg(-1) s.c.) was evaluated in the mouse passive avoidance test. Pretreatment with anti-Gialpha(1) (12.5-25 microg per mouse i.c.v.) and anti-Gialpha(2) (25 microg per mouse i.c.v.), administered 24 and 18 h before test, prevented antihistamine-induced amnesia. By contrast, pretreatment with an anti-Gialpha(3) (25 microg per mouse i.c.v.), anti-Goalpha(1) (25 microg per mouse i.c.v.) and anti-Goalpha(2) (25 microg per mouse i.c.v.) did not modify the detrimental effect induced by diphenhydramine. At the highest effective doses, none of the compounds used impaired motor coordination, as revealed by the rota rod test, nor modified spontaneous motility and inspection activity, as revealed by the hole board test. These results suggest the important role played by the Gi(1)- and Gi(2)-protein pathway in the transduction mechanism involved in the impairment of memory processes produced by the H(1)-antihistamine diphenhydramine.

Sedation and performance impairment of diphenhydramine and second-generation antihistamines: a meta-analysis

BACKGROUND

Antihistamines are among the most frequently used medications in the United States. Despite dramatically higher cost, second-generation antihistamines are replacing diphenhydramine because of the perception that they are not constrained by its sedating effects.

OBJECTIVE

We sought to examine, through meta-analytic procedures, the collective evidence regarding the sedating and performance-impairing effects of diphenhydramine relative to placebo and second-generation antihistamines.

METHODS

A search that began with the MEDLINE database was limited to those studies that included patients with atopic disease and control subjects, were blinded and randomized clinical trials, objectively examined alertness and psychomotor performance, reported means and variances, and were written in English. Information was systematically abstracted from the resulting 18 articles, and effect size was calculated.

RESULTS

Diphenhydramine impaired performance relative to placebo control and second-generation antihistamines, including acrivastine, astemizole, cetirizine, fexofenadine, loratadine, and terfenadine. However, results were quite varied, the average sedating effect of diphenhydramine was modest, and in some instances results of tests of performance in the diphenhydramine group showed less sedation than in the control or second-generation antihistamine groups. A significant (P <.05) average effect size indicated a mild sedating effect caused by second-generation antihistamines in comparison with placebo.

CONCLUSION

The absence of a consistent finding of diphenhydramine-induced sedation is surprising given that most studies have been designed to increase the probability of this outcome, including administering a 50-mg dose. On the basis of this meta-analysis of performance-impairment trials, a clear and consistent distinction between sedating and nonsedating antihistamines does not exist.

Long-term evaluation of the impact of the h1-receptor antagonist cetirizine on the behavioral, cognitive, and psychomotor development of very young children with atopic dermatitis

The impact of the prolonged use of cetirizine at high dose (0.25 mg/kg twice a day over 18 mo) on behavior and cognitive ability was examined in a double-blind, randomized, placebo-controlled trial (ETAC-Early Treatment of the Atopic Child) designed to establish whether it was possible to prevent young children (1-2 y old at study entry) with atopic dermatitis from developing asthma. Well-validated and standardized measures of behavior (Behavior Screening Questionnaire) and cognition (McCarthy Scales of Children's Abilities) were used. In addition, the ages of attainment of psychomotor milestones were established. These measures were taken between an average of 32 and 53 mo of age, both during the study treatment with cetirizine or placebo and after the study treatment had been discontinued. The Behavior Screening Questionnaire was completed at least once on approximately 300 children in each group and on approximately 200 children on five occasions. The McCarthy Scales of Children's Abilities were administered to approximately 100 in each group at three different times. There were no significant differences between the cetirizine and placebo groups on either of the behavior and cognition measures or in psychomotor milestones during or after the study treatment. These findings suggest that there are no adverse effects on behavior or learning processes associated with the prolonged use of cetirizine in young children with atopic dermatitis.

The burden of allergic rhinitis: beyond dollars and cents

OBJECTIVE

This article presents information about the economic burden of allergic rhinitis and its effect on quality of life. After reading this article, readers should have a greater awareness of the economic impact of this disease and how important it is for both patient and society to diagnose and treat it properly.

DATA SOURCES

Relevant and appropriately controlled clinical studies, data compiled from surveys and patient questionnaires, and studies of direct and indirect costs associated with allergic rhinitis were used. Only literature in the English language was reviewed.

STUDY SELECTION

Material was taken from academic/scholarly journals and appropriate reviews.

RESULTS

Allergic rhinitis occurs in approximately 20% of the general population in the United States. In recent years, its economic impact has increased, with spending for direct and indirect medical costs estimated between 1.5 and $2 billion a year. In addition to its financial burden, however, allergic rhinitis exacts a considerable toll on patients' quality of life, cognitive and learning functions, decision-making, and self-perception. Low energy levels associated with allergic rhinitis can lead to impairments of both memory and decision-making abilities.

CONCLUSIONS

Effective treatment and greater understanding on the part of both physicians and patients can help to reduce direct and indirect costs as well as to lessen the impact of allergic rhinitis on quality of life for both patient and society.

Safety of antihistamines in children

The histamine H1 receptor antagonists (antihistamines) are an important class of medications used for the relief of common symptoms associated with hyperhistaminic conditions occurring in children and adults. This group of drugs may be subdivided into 3 classes, or generations, based upon their propensity to induce sedation and cardiotoxicity. The first generation (classical) antihistamines are highly effective in treating hyperhistaminic conditions. However, they frequently induce sedation and may adversely affect a child's learning ability. First generation antihistamine-induced sedation has been described to occur in more than 50% of patients receiving therapeutic dosages. Serious adverse events are unusual following overdoses of first generation antihistamines although life-threatening adverse events have been described. When the so-called 'second generation' antihistamines terfenadine and astemizole were introduced they were widely embraced and quickly used by clinicians of all specialities, including paediatricians, as nonsedating alternatives to the first generation compounds. These new agents were found to be equally or more effective than first generation antihistamines in relieving symptoms associated with hyperhistaminic conditions without the soporific effects of the first generation agents. Unfortunately, after approximately 10 years of widespread clinical use, disturbing reports of potentially life-threatening dysrhythmias, specifically torsades de pointes, were described. Both terfenadine and astemizole have been shown in vitro to inhibit several ion channels, and in particular the delayed outward rectifier potassium channel in the myocardium, predisposing the heart to dysrhythmias. The potential life-threatening cardiotoxicities of the second generation antihistamines led to the search for noncardiotoxic and nonsedating agents. Loratadine, fexofenadine, mizolastine, ebastine, azelastine and cetirizine are the first of the new third generation antihistamines. These drugs have been shown to be efficacious with few adverse events including no clinically relevant cytochrome P450 mediated metabolic-based drug-drug interactions or QT interval prolongation/cardiac dysrhythmias. Appropriate treatment of an antihistamine overdose depends upon which class of compound has been ingested. There is no specific antidote for antihistamine overdose and treatment is supportive particularly for ingestions of first generation compounds. Ingestion of excessive doses of terfenadine or astemizole requires immediate medical attention. Children who accidentally ingest excessive doses of a third generation compound may usually be adequately managed at home. However, patients ingesting large amounts (approximately >3 to 4 times the normal therapeutic daily dose) should receive medical attention. These patients should be monitored for 2 to 3 hours after the ingestion and patients ingesting cetirizine should be advised about the potential for sedation. The availability of newer generation antihistamine compounds has clearly added to the clinical effectiveness and patient tolerance of a widely prescribed class of drugs. These advances have also been accompanied by improved safety profiles, particularly in the case of third generation antihistamine overdose.

Paediatric issues relating to the pharmacotherapy of allergic rhinitis

The prevalence of allergic rhinitis in children has risen significantly over the last two decades. Important comorbidities like asthma have grown in parallel due to a complex mix of environmental and genetic factors. These conditions have similar allergic inflammatory mechanisms, which raises the possibility of treating both conditions by targeting shared inflammatory mediators pharmacologically. The first line treatment for paediatric allergic rhinitis is a topical nasal corticosteroid or a non-sedating antihistamine. Available intranasal corticosteroids show superior symptom control to second-generation antihistamines. However, most topical steroids and non-sedating antihistamines have equivalent clinical efficacy within their respective classes, so the choice of agent depends on safety and tolerability. Ideally, topical nasal steroids should exhibit high local receptor binding affinity and low systemic bioavailability, allied with a lack of long-term growth suppression in children and adolescents. Regular use of topical steroids is advisable, but intermittent and prophylactic use is also effective. Second-generation antihistamines are effective and some have no adverse cardiac or sedative effects. Non-sedating antihistamine treatment can ameliorate rhinitis-induced decrements in learning. alpha-Adrenergic nasal decongestants provide short-term benefit, but topical agents can cause rebound symptoms. Prophylactic treatment with chromones is safe and effective, but multiple daily dosing is needed. Ipratroprium bromide nasal spray is useful as an intermittent therapy for mild disease or as add-on treatment, but its effect is limited to the control of rhinorrhoea. Children with allergic rhinitis should receive pharmacotherapy if allergen avoidance measures are ineffective, ideally with a topical intranasal steroid or a second-generation antihistamine.

Effects of seasonal allergic rhinitis on selected cognitive abilities

BACKGROUND

Many allergy patients complain of slowed thinking, memory problems, and difficulty sustaining attention during their allergy seasons.

OBJECTIVE

This study evaluated the effect of symptomatic allergic rhinitis on speed of cognitive processing, ability to divide and sustain attention, working memory, and recent verbal memory.

METHODS

Symptomatic ragweed-allergic rhinitis patients and nonatopic control subjects did cognitive testing in, out of, and in ragweed seasons.

RESULTS

Test results indicate that, during ragweed seasons, allergic patients experience subtle slowed speed of cognitive processing but not deficits in attention and recent memory. Some patients also have difficulties in working memory.

CONCLUSIONS

These findings suggest that having allergic reactions to ragweed pollen causes significant cognitive difficulties in a subgroup of patients.

Onset-of-action for antihistamine and decongestant combinations during an outdoor challenge

BACKGROUND

Medications containing a combination antihistamine-decongestant are commonly used for allergic rhinitis yet onset-of-action comparisons for symptom relief after a single dose have not been performed.

OBJECTIVE

To determine the onset of symptom relief and efficacy of antihistamine-decongestant medications (acrivastine-pseudoephedrine and loratadine-pseudoephedrine) compared with placebo in an outdoor park.

METHODS

This study was conducted during the spring of 1997 using a double-blind, placebo-controlled design. Patients completed baseline rhinitis symptom diaries from 7:30 to 9:30 AM. Subjects with qualifying symptom scores received one dose of either acrivastine-pseudoephedrine, loratadine-pseudoephedrine, or placebo at 10:00 AM. Symptom diaries were recorded for the next 4 hours.

RESULTS

Of 593 patients randomized to treatment, 592 were included in efficacy analysis. Acrivastine-pseudoephedrine and loratadine-pseudoephedrine demonstrated a mean onset-of-action by 45 and 30 minutes respectively for total symptom and rhinitis symptom scores for the five sites. Onset-of-action for nasal congestion scores was 45 minutes for both medications. Sites having higher pollen exposure (>100 pollen grains over 6 hours) demonstrated a difference between the antihistamine combinations: acrivastine-pseudoephedrine had an onset of action at 45 minutes for total symptom and rhinitis symptom scores, and 15 minutes for nasal congestion scores whereas loratadine-pseudoephedrine had onset-of-action for nasal congestion score of 105 minutes but failed to reach significance at any timepoint for total symptom and rhinitis symptom scores.

CONCLUSIONS

Both antihistamine-decongestant combinations demonstrate an onset-of-action within 60 minutes of administration but under conditions of higher pollen exposure, the acrivastine combination was more effective for total symptoms, rhinitis symptoms, and nasal congestion with an onset-of-action within 45 minutes for rhinitis symptoms and 15 minutes for congestion.

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.