Effects of intranasal corticosteroids on the hypothalamic-pituitary-adrenal axis in children

Mometasone Furoate Use for Recurrent Adenoid Hypertrophy: Randomized Controlled Clinical Trial

Background& Objective: Adenoid hypertrophy (AH) in children is one of the most causes of nasal obstruction and is associated with many nasal and respiratory symptoms. Till now, surgery is the main option for managing the associated symptom of AH. The intranasal steroid has an effective role in the control of allergic rhinitis and associated AH. This work aimed to assess the effects of local mometasone on recurrent AH in children. Patients& Methods: A randomized controlled trial enrolled 39 patients aged between 2 and 15 years with recurrent AH. Those patients were randomly subdivided into three groups; group (A) received topical mometasone furoate (MF), group (B) did not receive any medication, and group (C) received topical normal saline. All groups were followed up for 8 weeks. Results: Patients who received Mometasone furoate had temporary relief of adenoid hypertrophy-related symptoms (84.6%) in comparison to the control group and placebo group during the duration of treatment. After cessation of treatment with local steroids, all cases experienced symptoms caused by adenoid hypertrophy, and by the end of the third month of follow up all cases underwent adenoidectomy. Conclusion: Mometasone furoate can temporarily reduce the adenoid size, reducing symptoms related to adenoid hypertrophy.

Pharmacology, particle deposition and drug administration techniques of intranasal corticosteroids for treating allergic rhinitis

This review presents an overview of the available literature regarding intranasal corticosteroids (INCs) for the treatment of allergic rhinitis (AR). Various treatment options exist for AR including INCs, antihistamines and leucotriene antagonists. INCs are considered to be the most effective therapy for moderate-to-severe AR, as they are effective against nasal and ocular symptoms and improve quality of life. Their safety has been widely observed. INCs are effective and safe for short-term use. Local adverse events are observed but generally well-tolerated. The occurrence of (serious) systemic adverse events is unlikely but cannot be ruled out. There is a lack of long-term safety data. INC may cause serious eye complications. The risk of INCs on the hypothalamic-pituitary-adrenal axis, on bone mineral density reduction or osteoporosis and on growth in children, should be considered during treatment. Pharmacological characteristics of INCs (e.g. the mode of action and pharmacokinetics) are well known and described. We sought to gain insight into whether specific properties affect the efficacy and safety of INCs, including nasal particle deposition, which the administration technique affects. However, advances are lacking regarding the improved understanding of the effect of particle deposition on efficacy and safety and the effect of the administration technique. This review emphasizes the gaps in knowledge regarding this subject. Advances in research and health care are necessary to improve care for patients with AR.

Pulmonary drug delivery applications of natural polysaccharide polymer derived nano/micro-carrier systems: A review

Respiratory distress syndrome and pneumothorax are the foremost causes of death as a result of the changing lifestyle and increasing air pollution. Numerous approaches have been studied for the pulmonary delivery of drugs, proteins as well as peptides using meso/nanoparticles, nanocrystals, and liposomes. These nano/microcarrier systems (NMCs) loaded with drug provide better systemic as well as local action. Furthermore, natural polysaccharide-based polymers such as chitosan (CS), alginate (AG), hyaluronic acid, dextran, and cellulose are highly used for the preparation of nanoparticles and delivery of the drug into the pulmonary tract due to their advantageous properties such as low toxicity, high hydrophobicity, supplementary mucociliary clearance, mucoadhesivity, and biological efficacy. These properties ease the delivery of drugs onto the targeted site. Herein, recent advances in the natural polymer-derived NMCs have been reviewed for their transport and mechanism of action into the bronchiolar region as well as the respiratory region. Various physicochemical properties such as surface charge, size of nanocarrier system, surface modifications, and toxicological effects of these nanocarriers in vitro and in vivo are elucidated as well. Furthermore, challenges faced for the preparation of a model NMCs for pulmonary drug delivery are also discoursed.

Adverse Drug Reactions of Intranasal Corticosteroids in the Netherlands: An Analysis from the Netherlands Pharmacovigilance Center

BACKGROUND

Intranasal corticosteroids are one of the cornerstone treatment options for allergic rhinitis and chronic sinusitis complaints. Safety information in the summary of product characteristics may not be representative for observations in daily clinical practice. The Netherlands Pharmacovigilance Center (Lareb) collects post-marketing safety information, using spontaneous reporting systems.

OBJECTIVE

Our objective was to analyse reports of adverse drug reactions associated with intranasal corticosteroids reported in the Dutch spontaneous reporting database of the Netherlands Pharmacovigilance Center Lareb to obtain insight into real-world safety data.

METHODS

We retrospectively examined all adverse drug reactions of intranasal corticosteroids reported to the Netherlands Pharmacovigilance Center Lareb, entered into the database from 1991 until 1 July, 2020.

RESULTS

In total, 2263 adverse drug reactions after intranasal corticosteroid use were reported in 1258 individuals. Headache (n = 143), epistaxis (n = 124) and anosmia (n = 57) were reported most frequently. Nasal septum perforation (reporting odds ratio 463.2; 95% confidence interval: 186.7-1149.7) had the highest reporting odds ratio, followed by nasal mucosal disorder (reporting odds ratio 104.5; 95% confidence interval 36.3-301.3) and hyposmia (reporting odds ratio 90.8; 95% confidence interval 45.1-182.7). Moreover, 101 (4.5%) reports were classified as serious by Lareb, including reports of Cushing's syndrome, adrenal cortical hypofunction and growth retardation.

CONCLUSIONS

Many side effects are consistent with the safety information in the summary of product characteristics of intranasal corticosteroids. Several serious (systemic) side effects are reported and it is important to realise that intranasal corticosteroids may contribute to the development. Healthcare providers and patients should be aware of the potential (individual) adverse drug reactions of intranasal corticosteroids. This information could help in discussing treatment options.

Safety of intranasal corticosteroids for allergic rhinitis in children

INTRODUCTION

Allergic rhinitis (AR) is a common chronic inflammatory disease of the nasal mucosa, affecting about 10-40% of children worldwide. Intranasal corticosteroids (INCSs) are the first line anti-inflammatory drug in the treatment of pediatric AR. The systemic and local adverse effects of INCSs in children with AR should be assessed.

AREAS COVERED

Randomized controlled trials (RCTs) reporting local and systemic adverse effects of INCSs in pediatric populations with AR were searched out of PubMed and Embase.

EXPERT OPINION

Overall, INCSs displayed a favorable safety profile and high local-systemic balance of bioavailability with a low incidence of adverse events in the treatment of AR children. Nevertheless, the use of INCSs should be designed depending on one patient's response and adverse effects. The benefits and risks of INCSs should be assessed to ensure the clinical efficacy and avoid the insidious events.

Chinese expert recommendation on transnasal corticosteroid nebulization for the treatment of chronic rhinosinusitis 2021

Corticosteroids are efficacious in treating chronic rhinosinusitis (CRS), but concerns on the potential side effects remain, especially for long-term usage of systemic corticosteroids. Accumulated evidence shows that transnasal nebulization may be a reasonable solution in balancing both efficacy and safety. However, no consensus or guideline has been formulated on the use of steroid transnasal nebulization in treating CRS. The consensus is achieved through literature review and exchange of Chinese experts in Group of Otorhinolaryngology and Ophthalmology, Chinese Society of Allergy (CSA). This document covers the development, equipment, pharmacological mechanism, and evidence-based efficacy and safety, as well as the special concern of the application of steroid transnasal nebulization during the coronavirus disease (COVID-19) pandemic. The expert consensus clarifies the application of steroid transnasal nebulization in treating CRS and common comorbidities during the perioperative and postoperative periods.

Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature

OBJECTIVE

To review the literature on corticosteroid use and provide recommendations on patient counseling and/or consent to promote judicious prescribing and reduce the incidence of corticosteroid-related lawsuits.

METHOD

A conventional literature search of PubMed on corticosteroid-related medicolegal cases was undertaken. Search terms included "medicolegal," "otolaryngology," and "adrenocorticosteroids." A medical subjects headings search with the keywords "adrenal cortex hormones" and "jurisprudence" was also performed.

RESULTS

Corticosteroids have been reported as the third most frequent medication involved in malpractice claims, oftentimes leading to disproportionately costly payments. The most common specialties found to be involved in corticosteroid related medicolegal cases included dermatology (12%), primary care (10%), and neurologists or neurosurgeons (6%). The most common complications encountered were avascular necrosis (39%), changes in mood (16%), infection (14%), and vision changes (14%). Only a few cases corticosteroid-related litigation regarding otolaryngologists were identified. More frequent causes for otolaryngology claims were intraoperative complications, deficits in diagnoses, and failures or delays in treatment. Three medicolegal pitfalls regarding corticosteroid use were identified from this review included: (1) insufficient advising, (2) lack of or incomplete informed consent, and (3) the significance of the patient-physician relationship.

CONCLUSION

Despite the scarcity of corticosteroid-related medicolegal literature pertaining to otolaryngologists, corticosteroids are one of the most widely prescribed medications in the field of otolaryngology and have been shown to have a high rate of medical malpractice claims in medicine. Counseling and consenting the patient, as well as developing a strong physician-patient relationship, are integral processes in addressing any adverse effects occurring during therapy, and may also help to decrease the incidence and success of litigation against otolaryngologists.

The NIMH Intramural Longitudinal Study of the Endocrine and Neurobiological Events Accompanying Puberty: Protocol and rationale for methods and measures

Delineating the relationship between human neurodevelopment and the maturation of the hypothalamic-pituitary-gonadal (HPG) axis during puberty is critical for investigating the increase in vulnerability to neuropsychiatric disorders that is well documented during this period. Preclinical research demonstrates a clear association between gonadal production of sex steroids and neurodevelopment; however, identifying similar associations in humans has been complicated by confounding variables (such as age) and the coactivation of two additional endocrine systems (the adrenal androgenic system and the somatotropic growth axis) and requires further elucidation. In this paper, we present the design of, and preliminary observations from, the ongoing NIMH Intramural Longitudinal Study of the Endocrine and Neurobiological Events Accompanying Puberty. The aim of this study is to directly examine how the increase in sex steroid hormone production following activation of the HPG-axis (i.e., gonadarche) impacts neurodevelopment, and, additionally, to determine how gonadal development and maturation is associated with longitudinal changes in brain structure and function in boys and girls. To disentangle the effects of sex steroids from those of age and other endocrine events on brain development, our study design includes 1) selection criteria that establish a well-characterized baseline cohort of healthy 8-year-old children prior to the onset of puberty (e.g., prior to puberty-related sex steroid hormone production); 2) temporally dense longitudinal, repeated-measures sampling of typically developing children at 8-10 month intervals over a 10-year period between the ages of eight and 18; 3) contemporaneous collection of endocrine and other measures of gonadal, adrenal, and growth axis function at each timepoint; and 4) collection of multimodal neuroimaging measures at these same timepoints, including brain structure (gray and white matter volume, cortical thickness and area, white matter integrity, myelination) and function (reward processing, emotional processing, inhibition/impulsivity, working memory, resting-state network connectivity, regional cerebral blood flow). This report of our ongoing longitudinal study 1) provides a comprehensive review of the endocrine events of puberty; 2) details our overall study design; 3) presents our selection criteria for study entry (e.g., well-characterized prepubertal baseline) along with the endocrinological considerations and guiding principles that underlie these criteria; 4) describes our longitudinal outcome measures and how they specifically relate to investigating the effects of gonadal development on brain development; and 5) documents patterns of fMRI activation and resting-state networks from an early, representative subsample of our cohort of prepubertal 8-year-old children.

Hypothalamic-Pituitary-Adrenal Axis Pediatric Safety Studies Submitted to the FDA

BACKGROUND

Corticosteroid use has been associated with hypothalamic-pituitary-adrenal (HPA) axis suppression which can predispose the pediatric patient to multiple immune- and growth-related adverse effects. The objectives of this review were to identify the pediatric drug development programs involving corticosteroids and the associated pediatric HPA axis suppression studies submitted to the US Food and Drug Administration (FDA), capture FDA guidance topic related recommendations, and determine the consistency of HPA axis data in prescription corticosteroid labeling.

METHODS

A review of FDA submissions from January 2002 to July 2018 involving corticosteroid products and HPA axis testing in pediatric patients was conducted. The adrenal function testing methods, number of pediatric HPA axis dedicated studies, duration of these studies, and the labeling outcomes were assessed.

RESULTS

Of the 437 total drug products that were submitted to FDA, only 36 products were corticosteroids or a corticosteroid combination product yielding a total of 83 pediatric clinical studies. Twenty-four of the 36 products included 37 HPA axis suppression dedicated studies which employed different measurement methods. The pediatric HPA axis suppression trial data collected did not necessitate any new actionable recommendations in the FDA labeling.

CONCLUSION

Future pediatric drug development program goals would be to determine whether HPA axis suppression studies should be conducted, establish optimal testing methods if HPA axis testing is performed, continue to update guidances for industry, and actionable labeling recommendations. However, regulatory policy related to conducting pediatric HPA axis studies requires additional scientific research and discussion by the pediatric drug development community.

A Scholarly Review of the Safety and Efficacy of Intranasal Corticosteroids Preparations in the Treatment of Chronic Rhinosinusitis

OBJECTIVE

The purpose of this scholarly review is to present an update of the efficacy, safety, and distribution of intranasal corticosteroids (INCS) in the context of treatment for chronic rhinosinusitis (CRS).

MATERIALS AND METHODS

A literature review from 1999 to 2020 of MEDLINE, PubMed, and EMBASE databases was performed, using a comprehensive search strategy. Studies reporting on efficacy, safety, and distribution of all INCS formulations, both Food and Drug Administration (FDA) and non-FDA approved, were reviewed.

RESULTS AND CONCLUSIONS

High-level evidence publications and position papers support the role of INCS in medical treatment for CRS. Significant improvement in disease-specific and general quality of life measures is observed with all formulations of INCS. Overall, the use of both FDA and published non-FDA INCS appears to be safe. Several novel distribution devices might improve penetration to specific areas within the sinuses.

Evaluation of a steroid releasing sinus implant for the treatment of patients undergoing frontal sinus surgery for chronic rhinosinusitis

INTRODUCTION

Management of the frontal sinus places great demands on the otolaryngologist. Given that the fronto-ethmoidal region is susceptible to recurrent inflammation, scarring, and stenosis, maintaining long-term patency of the frontal sinus is a difficult challenge. Oral and topical anti-inflammatory therapy, post-operative stenting, and 'home-brew' drug elution have been used for the treatment of the frontal sinus with mixed success. Recently an implant has been approved for post-operative placement into the frontal recess. This implant provides reliable and consistent steroid drug elution to address inflammation of the frontal recess secondary to chronic sinusitis. Areas covered: This review discusses the development and application of steroid eluting implants in the postoperative care of patients with chronic frontal sinusitis. All randomized controlled trials evaluating steroid eluting implants are discussed. Relevant supporting material discussing background, economics, safety are included. Expert commentary: Steroid eluting implants fulfill a unique niche in the treatment following frontal sinus surgery. They are shown to decrease the need for post-operative interventions and improve outcomes in patients with chronic sinusitis. There is significant potential for growth in the use of steroid eluting implants.

Combination of mometasone furoate and oxymetazoline for the treatment of adenoid hypertrophy concomitant with allergic rhinitis: A randomized controlled trial

In the clinic, approximately 30% of children with adenoid hypertrophy (AH) concomitant with allergic rhinitis (AR) report poor responses to intranasal steroids. To determine whether the combination of mometasone furoate (MF) and oxymetazoline (OXY) is more effective than either agent alone, we performed a two-stage, parallel, randomized, double-blind, double-dummy, clinical trial with 240 AH children with concomitant perennial AR. During the first stage, all children were randomly assigned to the MF or control group for six weeks of treatment. During the second stage, the non-responders from stage one were randomly assigned to 4 groups for 8 weeks of treatment that involved receiving the following treatments: MF/OXY, MF/placebo, placebo/OXY, or placebo/placebo. During the first stage of treatment, 39% of the responders treated with MF achieved greater reductions in total and individual symptom scores than did those on placebo. During the second stage of treatment, the nasal congestion scores of the MF/OXY group significantly decreased. The adenoid/choana ratio of the MF/OXY-treated group decreased and the nasal volume increased significantly. Our results suggest that the combination of OXY and MF is effective and safe for the treatment of AH children with concomitant AR and has a rapid onset of action.

Does Atopy Influence the Effectiveness of Treatment of Adenoid Hypertrophy with Mometasone Furoate?

Background

The effect of topical mometasone for adenoid hypertrophy treatment is well established. Nevertheless, the influence of atopy on this treatment remains ill defined.

Objective

This study aims to compare the effects of topical mometasone furoate treatment on the adenoid tissue between atopic and nonatopic children.

Methods

Fifty-one children with obstructive respiratory complaints underwent a semistructured clinical questionnaire on nasal symptoms, prick test, and nasoendoscopy. Nasoendoscopic images were digitalized, and both adenoid and nasopharyngeal areas were measured in pixels; the relative adenoid/ nasopharyngeal area was calculated. Patients were initially treated for 40 days with nasal saline solution. In a subsequent 40-day period, topical mometasone furoate (total dose, 100 μg/day) was used.

Results

Topical mometasone significantly improved nasal obstruction, snoring, and apnea and also significantly reduced the adenoid tissue area related to the nasopharynx (p < 0.0001). Treatment with this glucocorticoid was not influenced by atopy, neither for symptoms nor for adenoid area.

Conclusion

Topical mometasone furoate significantly reduced the adenoid tissue area and led to a supplementary improvement ofnasal symptoms. This improvement was similar for atopic and nonatopic patients.

Current recommendations and emerging options for the treatment of allergic rhinitis

Allergic rhinitis (AR) is one of the most common diseases and represents a global health problem, currently affecting up to 30% of the general population, with a continuously increasing prevalence and significant comorbidities and complications. The aim of this review is to provide an update on AR treatment, with a focus on current therapies defined by AR and its impact on asthma guidelines and with a particular emphasis on new and future therapeutic perspectives.

Long-term, randomized safety study of MP29-02 (a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate in an advanced delivery system) in subjects with chronic rhinitis

BACKGROUND

MP29-02 is a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate (FP) in an advanced delivery system for the treatment of seasonal allergic rhinitis.

OBJECTIVE

The objective of this study was to evaluate the long-term safety of MP29-02 in subjects with chronic allergic (perennial) or nonallergic (vasomotor) rhinitis.

METHODS

This was a 1-year, randomized, open-label, active-controlled, parallel-group study in subjects with chronic allergic or nonallergic rhinitis. A total of 612 subjects were randomized in a 2:1 ratio to (1) MP29-02, one spray per nostril twice daily (total daily doses of azelastine hydrochloride and FP were 548 mcg and 200 mcg, respectively); or (2) FP, 2 sprays per nostril once daily (total daily dose 200 mcg). Safety and tolerability assessments were made at months 1, 3, 6, 9, and 12.

RESULTS

The incidence of treatment-related adverse events was low with both MP29-02 (9.4%) and FP (11.1%), with no evidence of late-occurring adverse events. Nasal examinations showed no evidence of nasal mucosal ulcerations or septal perforations with MP29-02, and the overall incidence of adverse findings was reduced as the study progressed. There were no unusual or unexpected ocular examination findings and no clinically important laboratory findings or clinically important differences between groups in fasting AM serum cortisol levels after 12 months of treatment.

CONCLUSIONS

MP29-02 was well tolerated. There were no safety findings that would preclude the long-term use of MP29-02 in the treatment of allergic rhinitis.

Safety, Tolerability, and Exposure of Ciclesonide Nasal Spray in Healthy and Asymptomatic Subjects With Seasonal Allergic Rhinitis

Ciclesonide is an intranasal corticosteroid in development for the treatment of allergic rhinitis. To assess the safety, tolerability, and pharmacokinetics of ciclesonide, adult healthy volunteers and asymptomatic subjects with seasonal allergic rhinitis were randomized to receive intranasal ciclesonide or placebo for 14 days. Serum concentrations of ciclesonide and its active metabolite, desisobutyryl-ciclesonide, were measured using high-performance liquid chromatography assay with tandem mass spectrometric detection, with lower limits of quantification of 25 and 10 pg/mL, respectively. Adrenal function was monitored by diurnal serum free and 24-hour urine cortisol concentrations. Despite the use of a sensitive assay and a high ciclesonide dose (800 microg/d), serum levels of ciclesonide and desisobutyryl-ciclesonide were below the lower limits of quantification for the majority of samples assayed. Ciclesonide was well tolerated and did not appear to affect serum or urine free cortisol levels. The low systemic exposure and favorable safety profile support the continued clinical development of ciclesonide nasal spray.

Hypothalamic-pituitary-adrenal axis suppression in asthmatic school children

BACKGROUND AND OBJECTIVE

Hypothalamic-pituitary-adrenal axis suppression (HPAS) when treating children with corticosteroids is thought to be rare. Our objective was to determine the prevalence of and predictive factors for various degrees of HPAS.

METHODS

Clinical features of HPAS, doses, adherence, asthma score, and lung functions were recorded in 143 asthmatic children. The overnight metyrapone test was performed if morning cortisol was >83 nmol/L. Spearman correlations coefficients (r) were calculated between 3 postmetyrapone outcomes and each continuous variable. A multiple linear regression model of √postmetyrapone adrenocorticotropic hormone (ACTH) and a logistic regression model for HPAS were developed.

RESULTS

Hypocortisolemia was seen in 6.1% (1.8-10.5), hypothalamic-pituitary suppression (HPS) in 22.2% (14.5-29.9), adrenal suppression in 32.3% (23.7-40.9), HPAS in 16.3% (9.3-23.3), and any hypothalamic-pituitary-adrenal axis dysfunction in 65.1% (56.5-72.9). Log daily nasal steroid (NS) dose/m(2) was associated with HPAS in the logistic regression model (odds ratio = 3.7 [95% confidence interval: 1.1-13.6]). Daily inhaled corticosteroids (ICSs) + NS dose/m(2) predicted HPAS in the univariate logistic regression model (P = .038). Forced expiratory volume in 1 second/forced vital capacity <80% was associated with HPAS (odds ratio = 4.1 [95% confidence interval: 1.0-14.8]). Daily ICS + NS/m(2) dose was correlated with the postmetyrapone ACTH (r = -0.29, P < .001). BMI (P = .048) and percent adherence to ICS (P < .001) and NS (P = .002) were predictive of √postmetyrapone ACTH (R(2) = .176).

CONCLUSIONS

Two-thirds of children on corticosteroids may have hypothalamic-pituitary-adrenal axis dysfunction. In one-third, central function had recovered but adrenal suppression persisted. Predictive factors for HPAS are NS use, BMI, and adherence to ICS and NS.

Objective reduction in adenoid tissue after mometasone furoate treatment

OBJECTIVE

Chronic rhinitis and adenoid hypertrophy are the main causes of nasal obstruction in children and proper treatment of these factors seem essential for controlling nasal obstructive symptoms. This study aims to evaluate the effects of topical mometasone treatment on symptoms and size of adenoid tissue in children with complaints of nasal obstruction and to compare this approach to continuous nasal saline douching plus environmental control alone.

METHODS

Fifty-one children with nasal obstructive complaints were submitted to a semi-structured clinical questionnaire on nasal symptoms, prick test and nasoendoscopy. Nasoendoscopic images were digitalized, and both adenoid and nasopharyngeal areas were measured in pixels. The relation adenoid/nasopharyngeal area was calculated. Patients were subsequently re-evaluated in two different periods: following 40 days of treatment with nasal douching and environmental prophylaxis alone; and after an subsequent 40 day-period, when topical mometasone furoate (total dose: 100μg/day) was superposed.

RESULTS

Nasal symptoms and snoring significantly improved after nasal douching, and an additional gain was observed when mometasone furoate was included to treatment. Saline douching did not influence the adenoid area, whereas a significant reduction on adenoid tonsil was observed after 40 days of mometasone treatment (P<0.0001).

CONCLUSION

Nasal saline douching significantly improved nasal symptoms without interfering in adenoid dimension. In contrast, mometasone furoate significantly reduced adenoid tissue, and led to a supplementary improvement of nasal symptoms.

Examining the safety of prednisolone acetate 1% nasal spray for treatment of nasal polyposis

BACKGROUND

Topical intranasal corticosteroid sprays are a mainstay of treatment for nasal polyposis. Newer treatment strategies for refractory polypoid disease include "off label" topical steroids such as prednisolone acetate. This study investigates the safety of intranasal prednisolone acetate; evaluating its effect on serum cortisol and adrenocorticotropin hormone (ACTH) levels.

METHODS

This retrospective study included adult patients with refractory nasal polyposis, who had not taken oral steroids for 3 months prior to entry into the study. Patients applied 2 sprays of 1% prednisolone acetate delivered via a 15-mL standardized spray bottle twice daily. Morning serum cortisol and ACTH levels were collected prior to treatment and 6 to 8 weeks posttreatment. Pretreatment and posttreatment values were compared.

RESULTS

Nine patients were included in this study. The average serum cortisol and ACTH levels prior to treatment was 12.09 μg/dL (95% confidence interval [CI], 6.94-17.24) and 12.33 ng/L (95% CI, 8.97-15.70), respectively. After 6 to 8 weeks of treatment, the average serum cortisol and ACTH levels were 11.76 μg/dL (95% CI, 9.51-14.00) and 13.22 ng/L (95% CI, 10.68-15.77), respectively. There was no statistically significant difference between pretreatment and posttreatment values for cortisol (p = 0.89) or ACTH (p = 0.63).

CONCLUSION

Intranasal delivery of prednisolone acetate, at the specified dose, does not result in suppression of the adrenal axis. It can be considered as a safe alternative for management of aggressive nasal polyposis refractory to traditional treatment strategies.

The role of nasal corticosteroids in the treatment of rhinitis

Intranasal corticosteroids (INSs) are the first choice for rhinitis pharmacotherapy. This preference is because of their broad range of actions that result in reductions of proinflammatory mediators, cytokines, and cells. Over the past 30 years, INSs have been modified to improve their pharmacodynamic, pharmacokinetic, and delivery system properties, with attention to improving characteristics such as receptor binding affinity, lipophilicity, low systemic bioavailability, and patient preference. Clinically, they have been shown to be the most effective class of nasal medications for treating allergic rhinitis and nonallergic rhinopathy, with no clear evidence that any specific INS is superior to others.

Role of intranasal topical steroid in pediatric sleep disordered breathing and influence of allergy, sinusitis, and obesity on treatment outcome

Objectives

To evaluate efficacy of short term intranasal corticosteroid (mometasone furoate) treatment in pediatric sleep-disordered breathing (SDB) patients.

Methods

A prospective, observational study was done. A total of 41 children (2-11 years old) were enrolled into this study. All patients received 4-weeks course of mometasone furoate 100 µg/day treatment. They were evaluated at pretreatment and immediately after treatment with obstructive sleep apnea (OSA)-18 quality of life survey and lateral neck X-ray. Also, the assessment of each patients included history, skin prick test or CAP test, and sinus radiography. We compared the OSA-18 survey score and adenoidal-nasopharyngeal (AN) ratio between before and after treatment.

Results

Total OSA-18 score and AN ratio decreased significantly after treatment regardless of allergy, sinusitis, and obesity (P=0.003, P=0.006). There was no complication after treatment of mometasone furoate.

Conclusion

Pediatric SDB patients with adenoid hypertrophy could be effectively treated with 4-weeks course of mometasone furoate. Allergy, obesity, and sinusitis did not affect on the result of treatment.

Hypothalamic-pituitary-adrenal axis suppression in asthmatic children on inhaled and nasal corticosteroids--more common than expected?

BACKGROUND

Hypothalamic pituitary adrenal axis suppression (HPAS) when treating asthmatic children with inhaled corticosteroids (ICS) is thought to be rare.

OBJECTIVE

To determine the prevalence of HPAS in asthmatic children treated with ICS and nasal steroids (NS).

METHODS

Twenty-six asthmatic children were recruited. Clinical features of HPAS, height, weight, height and weight velocity, steroid dose, adherence, symptom control and lung functions were documented. Metyrapone test was performed if the serum cortisol was > 83 nmol/L (> 3 microg/dL).

RESULTS

No child had a serum cortisol < 83 nmol/L (< 3 microg/dL). Prevalence of HPAS was 35 (CI = 17%-56%). Daily NS dose/ m2 and cumulative NS dose/m2 were significantly (p = 0.03) inversely correlated with the post-metyrapone ACTH (r = -0.42 for both). Current ICS dose was not associated with the post-metyrapone ACTH (r = 0). There was a weak correlation with the daily ICS dose/m2 (r = -0.12) and cumulative ICS dose/m2 (r = -0.26).

CONCLUSIONS

A third of asthmatic children on ICS and NS develop HPAS. Contributing factors are the use of NS, body size and cumulative dose of ICS.

Efficacy and long-term safety of mometasone furoate nasal spray in children with perennial allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) affects up to 40% of children by age 6 years. Perennial AR (PAR) causes sleep disturbance, diminishes concentration in school, impairs psychosocial functioning, and reduces quality of life. This study evaluated efficacy and long-term safety of the intranasal corticosteroid mometasone furoate nasal spray (MFNS) in children with PAR.

METHODS

This study comprised a double-blind, 4-week efficacy and safety period followed by a 6-month, open-label safety period. Primary efficacy variable during the double-blind period was mean change in physician-evaluated total nasal symptom score (TNSS) from baseline to day 15. Other efficacy variables during this phase included subject-evaluated TNSS, individual nasal symptoms, and total symptom score (TSS, nasal and non-nasal symptoms, summed). Physician-evaluated improvement in overall condition of PAR was assessed during the open-label period. Adverse events (AEs) were monitored throughout.

RESULTS

Subjects aged 3-11 years with PAR (n = 381) were randomized to MFNS 100 microg (n = 190) or placebo (n = 191) daily for 4 weeks; 357 subjects continued into the open-label period, receiving MFNS only. Between baseline and day 15, significantly greater mean changes were seen with MFNS-treated patients than placebo in physician-evaluated TNSS (-2.8, -39%, vs. -2.2, -32%; p = 0.02). Statistically significant improvements in MFNS versus placebo were reported for subject-evaluated TNSS, TSS, and individual nasal symptom scores (p < or = 0.03 for all). Improvement continued through the open-label period. Subjects treated with MFNS in both periods experienced a 45% further reduction in TSS in this study phase, while those who switched from placebo to MFNS saw a further 49% decrease. MFNS was well-tolerated in both periods. The most frequently reported treatment-related AEs during the double-blind period for MFNS and placebo, respectively, were epistaxis, seven (4%) and nine (5%); sneezing, five (3%) and seven (4%); headache, six (3%) and five (3%). During the open-label period, the AEs reported most often were epistaxis 37 (10%), headache nine (3%), and rhinitis 12 (3%).

LIMITATIONS

Studies in children present unique challenges because subjects are too young to grasp subjective concepts such as symptom severity, especially as rated on a numbered scale. In addition, the 6-month extension of the placebo-controlled phase used a single agent. It is also possible that subjects' symptoms could have abated independent of mometasone furoate treatment.

CONCLUSION

MFNS 100 microg/day effectively reduces TNSS, TSS (including ocular symptoms), and individual symptoms associated with PAR and is well-tolerated for up to 6 months in children aged 3-11 years with a safety profile similar to placebo.

Dissociation of local anti-inflammatory effect and systemic effects of mometasone furoate in mice

Mometasone furoate (MF) is a topical glucocorticoid used for atopic dermatitis, allergic rhinitis, and bronchial asthma. To elucidate the usefulness of MF, the dissociation between local anti-inflammatory effects and systemic effects of MF was compared with that of beclomethasone 17,21-dipropionate (BDP). MF was more potent than BDP in croton oil-induced ear edema tests in mice. Oral systemic effects of MF were inversely lower than that of BDP on thymolysis, plasma corticosterone lowering, and suppression of body weight gain in mice. These results indicate that MF has a higher therapeutic index and superior clinical usefulness as a topical glucocorticoid compared to BDP.

The Effects of Serum and Urinary Cortisol Levels of Topical Intranasal Irrigations with Budesonide Added to Saline in Patients with Recurrent Polyposis after Endoscopic Sinus Surgery

Background

The delivery of topical intranasal corticosteroid sprays has traditionally been the primary method of treating recurrent nasal polyposis. An emerging treatment for polyposis is budesonide nasal irrigations. Delivered at concentrations nearly 100 times greater than found in prescription nasal sprays, there have been little studies on the effects of budesonide irrigation on the adrenal axis. Therefore, we investigated whether irrigation with budesonide solution was associated with any increase in serum cortisol and 24-hour urinary cortisol levels.

Methods

Patients who previously had undergone endoscopic sinus surgery and were not taking prednisone for 3 months were prospectively enrolled in this study. Patients irrigated twice daily with 0.5 mg/2 mL of budesonide mixed with 240 mL of saline solution. Serum cortisol and 24-hour urinary cortisol were collected before drug administration and 6 weeks after continuous use.

Results

Ten patients completed this study. The average serum cortisol and 24-hour urinary cortisol before drug administration were 9.8 ± 5.4 μg/dL and 28.1 ± 15.1 μg/24 hours, respectively. After 6-week follow-up, the average serum cortisol and 24-hour urinary cortisol were 12.8 ± 3.5 μg/dL and 16.5 ± 5.6 μg/24 hours, respectively. Normal ranges for serum cortisol and 24-hour urinary cortisol are 5–25 μg/dL and 4–50 μg/24 hours, respectively. Conclusions: Irrigation with budesonide, 0.5 mg/2 mL, in 250 mL of saline solution does not result in decreases of serum cortisol and 24-hour urinary cortisol levels. Based on this, we feel irrigation with budesonide solution is safe to perform in patients as an alternative to traditional aerosolized steroid sprays or systemic corticosteroids.

Nasal steroid perspective: knowledge and attitudes

Intranasal corticosteroids (INCSs) seem to be the best medication available to control and eliminate symptoms of allergic rhinitis. However, the amounts of nasal steroids prescribed and used were not directly proportional to the number of allergic rhinitis cases in Turkey. Herein, we aimed to clarify the unexpectedly low prescription and use of INCSs in Turkey by checking the outlook of patients' and physicians' perspectives. The patients' perspective on oral and nasal steroids was evaluated with a custom-designed questionnaire drawn up specifically for this preliminary study. The physicians' perspective on prescribing nasal steroids was evaluated with the data obtained from the IMS Health Turkey reports. The findings we obtained in this survey by analyzing data from the self-administered questionnaires showed that among these young people, oral and nasal steroids were on the whole well-known drugs. Hence, even though steroids in general are well-known drugs, the young people we surveyed mainly remained uninformed about their safety. The incidence of using nasal steroids if prescribed is higher than the one with oral steroids; that may be due to the lack of knowledge about nasal steroids. The analysis of the IMS Health Turkey data for nasal steroid prescriptions between 2005 and 2008 shows that the market share has increased steadily. The role of INCSs in the treatment of allergic rhinitis is increasingly being recognized as an appropriate and effective treatment option. However, patients' and parents' concerns over the safety of INCS therapy have frequently resulted in their being positioned as a second-line treatment choice. Physicians need to be aware that patients may have a significant information gap. Instructing the family and caregivers about the correct use of INCS therapy is an important part of treatment.

Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications

Intranasal corticosteroids (INSs) are effective treatments for allergic rhinitis, rhinosinusitis, and nasal polyposis. In recent years, increased understanding of corticosteroid and glucocorticoid receptor pharmacology has enabled the development of molecules designed specifically to achieve potent, localized activity with minimal risk of systemic exposure. Pharmacologic potency studies using affinity and other assessments have produced similar rank orders of potency, with the most potent being mometasone furoate, fluticasone propionate, and its modification, fluticasone furoate. The furoate and propionate ester side chains render these agents highly lipophilic, which may facilitate their absorption through nasal mucosa and uptake across phospholipid cell membranes. These compounds demonstrate negligible systemic absorption. Systemic absorption rates are higher among the older corticosteroids (flunisolide, beclomethasone dipropionate, triamcinolone acetonide, and budesonide), which have bioavailabilities in the range of 34-49%. Studies, including 1-year studies with mometasone furoate, fluticasone propionate, and budesonide that evaluated potential systemic effects of INSs in children have generally found no adverse effects on hypothalamic-pituitary-adrenal axis function or growth. Clinical data suggest no significant differences in efficacy between the INSs. Theoretically, newer agents with lower systemic availability may be preferable, and may come closer to the pharmacokinetic/pharmacologic criteria for the ideal therapeutic choice.

Lack of effect on adult and adolescent hypothalamic-pituitary-adrenal axis function with use of fluticasone furoate nasal spray

BACKGROUND

Intranasal corticosteroids are recommended as first-line therapy for allergic rhinitis (AR), and because of their pharmacologic class, hypothalamic-pituitary-adrenal (HPA) axis function is evaluated.

OBJECTIVE

To evaluate whether cortisol production was suppressed (as a measure of HPA axis function) by 6 weeks of treatment with fluticasone furoate nasal spray, 110 microg once daily, in patients with perennial AR.

METHODS

A double-blind, randomized, placebo- and active-controlled (prednisone), parallel-group study. Outpatients aged 12 to 65 years with perennial AR for 2 years or more were from 1 center in the United States and 1 center in Canada. Pharmacodynamic and pharmacokinetic samples were collected during 24-hour domiciled visits (overnight in clinic). Measurements included change from baseline in 24-hour serum cortisol weighted mean and 24-hour urinary free cortisol excretion, total 24-hour urinary free cortisol excretion and 6-beta hydroxycortisol excretion, and plasma concentration of fluticasone furoate.

RESULTS

A total of 112 of 183 patients were randomized. Fluticasone furoate was noninferior to placebo with respect to the ratio from baseline in serum cortisol weighted mean (treatment ratio, 0.98; 95% confidence interval, 0.89 to 1.07). In contrast, use of prednisone, 10 mg once daily, significantly reduced the ratio from baseline compared with placebo. Change from baseline in 24-hour urinary cortisol excretion was similar in the fluticasone furoate and placebo groups. Plasma levels of fluticasone furoate were undetectable after 6 weeks of treatment.

CONCLUSION

Fluticasone furoate nasal spray, 110 microg once daily, was not associated with HPA axis suppression in patients 12 years and older with perennial AR.

Randomised, crossover clinical trial, in healthy volunteers, to compare the systemic availability of two topical intranasal budesonide formulations

BACKGROUND

Budesonide has a long history as intranasal drug, with many marketed products. Efforts should be made to demonstrate the therapeutic equivalence and safety comparability between them. Given that systemic availability significantly varies from formulations, the clinical comparability of diverse products comes to be of clinical interest and a regulatory requirement. The aim of the present study was to compare the systemic availability, pharmacodynamic effect, and safety of two intranasal budesonide formulations for the treatment of rhinitis.

METHODS

Eighteen healthy volunteers participated in this randomised, controlled, crossover, clinical trial. On two separated days, subjects received a single dose of 512 mug budesonide (4 puffs per nostril) from each of the assayed devices (Budesonida nasal 64(R), Aldo-Union, Spain and Rhinocort 64(R), AstraZeneca, Spain). Budesonide availability was determined by the measurement of budesonide plasma concentration. The pharmacodynamic effect on the hypothalamic-adrenal axis was evaluated as both plasma and urine cortisol levels. Adverse events were tabulated and described. Budesonide availability between formulations was compared by the calculation of 90%CI intervals of the ratios of the main pharmacokinetic parameters describing budesonide bioavailability. Plasma cortisol concentration-time curves were compared by means of a GLM for Repeated Measures. Urine cortisol excretion between formulations was compared through the Wilcoxon's test.

RESULTS

All the enrolled volunteers successfully completed the study. Pharmacokinetic parameters were comparable in terms of AUC(t) (2.6 +/- 1.5 vs 2.2 +/- 0.7), AUC(i) (2.9 +/- 1.5 vs 2.4 +/- 0.7), t(max) (0.4 +/- 0.1 vs 0.4 +/- 0.2), C(max)/AUC(i) (0.3 +/- 0.1 vs 0.3 +/- 0.0), and MRT (5.0 +/- 1.4 vs 4.5 +/- 0.6), but not in the case of C(max) (0.9 +/- 0.3 vs 0.7 +/- 0.2) and t(1/2) (3.7 +/- 1.8 vs 2.9 +/- 0.4). The pharmacodynamic effects, measured as the effect over plasma and urine cortisol, were also comparables between both formulations. No severe adverse events were reported and tolerance was comparable between formulations.

CONCLUSION

The systemic availability of intranasal budesonide was comparable for both formulations in terms of most pharmacokinetic parameters. The pharmacodynamic effect on hypothalamic-pituitary-adrenal axis was also similar. Side effects were scarce and equivalent between the two products. This methodology to compare different budesonide-containing devices is reliable and easy to perform, and should be recommended for similar products intented to be marketed or already on the market.

TRIAL REGISTRATION

No Eudra CT: 2005-003727-39.

Impact of inhaled corticosteroids on cortisol suppression in adults with asthma: a quantitative review

BACKGROUND

Studies examining the effects of inhaled corticosteroids (ICSs) on cortisol suppression show inconsistent results, and there is uncertainty regarding the dose-response relationship between ICSs and cortisol suppression.

OBJECTIVE

To determine, using meta-analysis, the extent of cortisol suppression after administration of clinically relevant ICS doses in adults with asthma.

METHODS

Database searches (MEDLINE, EMBASE, and The Cochrane Library) using appropriate indexed terms were performed to identify eligible articles for review. Articles reporting the effects of ICSs on cortisol levels in asthmatic adults, measured using the cumulative serum or plasma cortisol, morning serum or plasma cortisol, or cumulative overnight urinary free cortisol method, were identified. All available cortisol measurements were extracted. Cortisol suppression was estimated, and treatment arms were grouped into low-, medium-, and high-dose ranges according to the Global Initiative for Asthma guidelines. A multivariate model was used to determine relationships between ICS dose and cortisol suppression and to explore sources of heterogeneity among trials.

RESULTS

Thirty-one studies providing information on 216 measures of cortisol suppression were included in this meta-analysis. Cortisol suppression in the low-, medium-, and high-dose groups were estimated to be 17.92% (95% confidence interval [CI], 11.08%-24.77%), 26.55% (95% CI, 17.29%-35.80%), and 36.31% (95% CI, 26.48%-46.13%), respectively.

CONCLUSIONS

Statistically significant cortisol suppression was evident at low doses of ICSs and increased with dose. These results support an impact of all ICSs on endogenous cortisol levels and underscore the importance of titrating ICS doses to the minimum required to maintain symptom control.

Therapeutic options for reducing sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis

BACKGROUND

Patients with inflammatory disorders of the upper airways, such as allergic rhinitis, rhinosinusitis, and nasal polyposis, often have significant sleep disturbances. Poor sleep can lead to fatigue, daytime somnolence, impaired daytime functioning as reflected in lower levels of productivity at work or school, and a reduced quality of life. Although the exact mechanisms by which these inflammatory nasal conditions disturb sleep is not fully understood, congestion appears to be a key factor and is generally the most common and bothersome symptom for patients with these conditions. Successful therapy should improve patients' sleep and well-being without introducing any negative effects on sleep. SCOPE OF LITERATURE SEARCH: Literature searches of Medline, Embase, and abstracts from medical/scientific conferences were conducted for the period of 1995 through mid-2006 for primary and review articles and conference presentations about sleep disturbance related to allergic rhinitis, rhinosinusitis, and nasal polyposis. These searches also sought to identify articles examining how treatments for those diseases improved sleep and, consequently, patients' quality of life. Surveys of the impact of congestion on patients' quality of life and their sleep also were consulted. Clinical studies were selected for discussion if they were randomized, double-blind, and placebo-controlled. Limitations of this review include the absence of any direct comparisons of the effectiveness of different drugs on improving sleep and shortcomings in the statistical methods of the patient surveys.

FINDINGS

Intranasal corticosteroids (INSs) are the most effective medication for reducing congestion in patients with inflammatory nasal conditions. There is a growing amount of evidence that a reduction in congestion with INSs is associated with improved sleep, reduced daytime sleepiness, and enhanced patient quality of life.

CONCLUSION

Relief of sleep impairment associated with inflammatory disorders of the nose and sinuses can be addressed with INS therapy.

Caring for patients with allergic rhinitis

PURPOSE

Allergic rhinitis (AR) affects up to 40 million Americans, with an estimated cost of $2.7 billion per annum. This review discusses several therapeutic options that reduce the symptoms of AR, including allergen avoidance, antihistamines, intranasal corticosteroids (INS), leukotriene receptor antagonists, and immunotherapy.

DATA SOURCES

The articles included in this review were retrieved by a search of Medline literature on the subjects of AR, antihistamines, INS, leukotriene antagonists, and immunotherapy, as well as current published guidelines for the treatment of AR.

CONCLUSIONS

Allergen avoidance is recommended for all patients prior to pharmacologic therapy. Oral and nasal H(1)-antihistamines are recommended to alleviate the mild and intermittent symptoms of AR, and INS are recommended as the first-line treatment choice for mild persistent and more moderate-to-severe persistent AR.

IMPLICATIONS FOR PRACTICE

There are a number of different types of therapy for the management of AR; with so many options available, successful tailoring of treatment to suit individual requirements is realistically achievable.

The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: preliminary results of a prospective, randomized study

OBJECTIVE

We evaluated the efficacy of mometasone furoate aqueous nasal spray in decreasing adenoid size and reducing the severity of chronic nasal obstruction symptoms in children affected by adenoidal hypertrophy.

METHODS

Sixty children were recruited in a 2-stage, randomized, placebo-controlled trial. All patients complained of chronic nasal obstruction symptoms, and nasal endoscopy showed >75% choanal obstruction attributable to adenoid pads. In the first stage, 30 patients (group A) underwent mometasone treatment (50 microg per nostril per day) for 40 days, and 30 children (group B) received placebo. In the second stage, at the end of the first 40-day treatment period, patients in group A who showed subjective and objective clinical improvement were divided into 2 subgroups; group A1 (11 children) received topical intranasal steroid treatment on alternate days for the first 2 weeks per month, whereas group A2 (10 children) continued daily mometasone treatment for the first 2 weeks per month. After 3 months, all children were reassessed.

RESULTS

Fifty-seven children completed the study according to the protocol. After the first treatment period, the severity of symptoms and adenoid size decreased for 21 patients (77.7%) in group A. No improvement was observed in the placebo group. After 3 months of additional therapy, group A2 patients demonstrated a more-pronounced reduction in adenoid size compared with group A1 patients. No statistically significant change in symptoms was identified. Mometasone treatment was well tolerated by all patients.

CONCLUSIONS

Mometasone furoate aqueous nasal spray may be considered useful in decreasing adenoid pad size and the severity of symptoms related to adenoidal hypertrophy. Children with adenoidal hypertrophy that is not associated with tonsillar hypertrophy should be considered for intranasal mometasone treatment before surgery is planned.

Basal and cosyntropin-stimulated plasma cortisol concentrations, as measured by high-performance liquid chromatography, in children aged 5 months to younger than 6 years

CONTEXT

Topical corticosteroids are the recommended first-line treatment for all severities of persistent asthma and moderate to severe allergic rhinitis. Potential adrenal suppression resulting from corticosteroid administration necessitates monitoring of children participating in clinical studies. Measurement of pretreatment cortisol concentrations is necessary to assess effects on adrenal function.

OBJECTIVE

Plasma cortisol concentrations are assay dependent; normal reference range values must be obtained for each assay. Our objective is to provide these values for children as determined by HPLC.

DESIGN AND PATIENTS

Two multicenter, randomized, double-blind, placebo-controlled studies evaluating basal and cosyntropin-stimulated morning plasma cortisol concentrations for patients aged 5 to younger than 12 months with asthma and patients aged 2 to younger than 6 yr with allergic rhinitis using HPLC were conducted.

MAIN OUTCOME MEASURES

Main planned outcomes of these studies are reported elsewhere. This manuscript reports plasma cortisol concentration reference range values.

RESULTS

In general, mean basal plasma cortisol concentrations (n = 177) (mean +/- sd, nmol/liter) were similar among the 5 to younger than 9 months, 9 to younger than 12 months, 2 to younger than 3 yr, 3 to younger than 4 yr, 4 to younger than 5 yr, and 5 to younger than 6 yr age groups (218 +/- 149, 281 +/- 144, 257 +/- 105, 231 +/- 83, 298 +/- 118, and 237 +/- 65, respectively) and increased to comparable levels 60 min after cosyntropin stimulation (n = 178; 622 +/- 176, 638 +/- 176, 697 +/- 99, 655 +/- 103, 662 +/- 113, and 610 +/- 68, respectively). However, patients younger than 12 months had wider ranges of basal and stimulated values.

CONCLUSIONS

Basal and cosyntropin-stimulated morning plasma cortisol concentrations of children aged 5 to younger than 12 months and 2 to younger than 6 yr were consistently measurable, with the large majority similar among the age groups examined, and comparable with those reported elsewhere for adults.

The Role of Mometasone Furoate Aqueous Nasal Spray in the Treatment of Adenoidal Hypertrophy in the Pediatric Age Group: Preliminary Results of a Prospective, Randomized Study

OBJECTIVE. We evaluated the efficacy of mometasone furoate aqueous nasal spray in decreasing adenoid size and reducing the severity of chronic nasal obstruction symptoms in children affected by adenoidal hypertrophy.

METHODS. Sixty children were recruited in a 2-stage, randomized, placebo-controlled trial. All patients complained of chronic nasal obstruction symptoms, and nasal endoscopy showed &gt;75% choanal obstruction attributable to adenoid pads. In the first stage, 30 patients (group A) underwent mometasone treatment (50 μg per nostril per day) for 40 days, and 30 children (group B) received placebo. In the second stage, at the end of the first 40-day treatment period, patients in group A who showed subjective and objective clinical improvement were divided into 2 subgroups; group A1 (11 children) received topical intranasal steroid treatment on alternate days for the first 2 weeks per month, whereas group A2 (10 children) continued daily mometasone treatment for the first 2 weeks per month. After 3 months, all children were reassessed.

RESULTS. Fifty-seven children completed the study according to the protocol. After the first treatment period, the severity of symptoms and adenoid size decreased for 21 patients (77.7%) in group A. No improvement was observed in the placebo group. After 3 months of additional therapy, group A2 patients demonstrated a more-pronounced reduction in adenoid size compared with group A1 patients. No statistically significant change in symptoms was identified. Mometasone treatment was well tolerated by all patients.

CONCLUSIONS. Mometasone furoate aqueous nasal spray may be considered useful in decreasing adenoid pad size and the severity of symptoms related to adenoidal hypertrophy. Children with adenoidal hypertrophy that is not associated with tonsillar hypertrophy should be considered for intranasal mometasone treatment before surgery is planned.

The role of intranasal corticosteroids in the management of pediatric allergic rhinitis

Allergic rhinitis (AR) is currently the most common chronic disease in children in the United States, affecting as many as 40% of the children in the population. AR can substantially decrease a child's quality of life and can contribute to school absenteeism. Intranasal corticosteroids (INS) are thought to be the most effective treatment choice for controlling the symptoms of AR. However, parent and physician concerns over INS safety in children have often led to INS being used as a second-line treatment option. More recently, safety studies have shown that the newer INS agents have improved safety profiles compared with older INS agents. The newer INS drugs have been found to have minimal adverse effects on growth and hypothalamic-pituitary-adrenal-axis function in children, which is a concern when prescribing corticosteroids. This review will discuss the pathophysiology, diagnosis, and classification of AR. The mechanism of action, efficacy, and safety of INS will also be discussed by focusing on clinical evidence. Furthermore, other considerations, such as parent or caregiver education and patient compliance, will be reviewed.

Quantitative, Highly Sensitive Liquid Chromatography–Tandem Mass Spectrometry Method for Detection of Synthetic Corticosteroids

Background: Measurements of serum or urine concentrations of synthetic glucocorticoids are useful for assessing suspected iatrogenic hypothalamic-pituitary-adrenal axis suppression and Cushing syndrome. We have developed a liquid chromatography–tandem mass spectrometry (LC-MS/MS) assay for the simultaneous quantitative analysis of beclomethasone dipropionate, betamethasone, budesonide, dexamethasone, fludrocortisone, flunisolide, fluorometholone, fluticasone propionate, megestrol acetate, methylprednisolone, prednisolone, prednisone, triamcinolone, and triamcinolone acetonide.

Methods: Stable isotopes of cortisol-9,11,12,12-d4 and triamcinolone-d1 acetonide-d6 were added as internal standards to calibrators, controls, and unknown samples. After acetonitrile precipitation, these samples were extracted with methylene chloride, and the extracts were washed and dried. Reconstituted extract (15 μL) was injected on a reversed-phase column and analyzed by LC-MS/MS in positive-ion mode. Assay precision, accuracy, linearity, and sample stability were determined by use of enriched samples. Clinical validation included analysis of 8 serum and 20 urine samples from patients with undetectable cortisol concentrations and analysis of different types of tablets.

Results: Functional assay sensitivity was as low as 0.6–1.6 nmol/L for all compounds except for triamcinolone (7.6 nmol/L). Interassay CVs were 3.0–20% for concentrations of 0.6–364 nmol/L for all analytes. Recoveries of all analytes (except triamcinolone in serum) were 82–138% at 19.2–693 nmol/L. All but one of the serum and urine samples from patients who were tested because of suppressed cortisol concentrations contained at least one synthetic steroid. Tablet analysis recovered 75% of the synthetic steroids in suspected drugs.

Conclusions: LC-MS/MS allows simultaneous quantitative detection of various synthetic steroids in serum, plasma, urine, and tablets. This provides a valuable tool for evaluating the clinical effects of topical and systemic synthetic corticosteroids.

Effect of budesonide aqueous nasal spray on hypothalamic-pituitary-adrenal axis function in children with allergic rhinitis

BACKGROUND

Intranasal corticosteroids are safe and effective for treating allergic rhinitis in adults. Since children may receive more systemic corticosteroid on a dose-per-weight basis than adults, the safety of corticosteroid therapy in pediatric patients is an important issue.

OBJECTIVE

To determine the effects of treatment with budesonide aqueous nasal spray using the recommended once-daily dose for adults and children 6 years and older on hypothalamic-pituitary-adrenal (HPA) axis function in pediatric patients with allergic rhinitis.

METHODS

In a 6-week, multicenter, double-blind, placebo-controlled study, 78 patients aged 2 to 5 years with allergic rhinitis were treated with budesonide aqueous nasal spray (64 microg/d) or placebo. Mean change in morning plasma cortisol levels from baseline to study end 0, 30, and 60 minutes after low-dose (10-microg) cosyntropin stimulation and mean change in the difference from 0 to 30 minutes and from 0 to 60 minutes after cosyntropin stimulation were used to evaluate HPA axis function.

RESULTS

Mean change from baseline to study end in plasma cortisol levels 0, 30, and 60 minutes after cosyntropin stimulation and the difference from 0 to 30 minutes and from 0 to 60 minutes were not significantly different between the treatment and placebo groups (P > .05 for all). At the end of the study, 3 budesonide aqueous nasal spray and 6 placebo patients were classified as having subnormal HPA axis function. The safety and tolerability profile of budesonide aqueous nasal spray was comparable to that of placebo.

CONCLUSIONS

Administration of budesonide aqueous nasal spray for 6 weeks was well tolerated and safe and had no measurable suppressive effects on HPA axis function in patients aged 2 to 5 years with allergic rhinitis.

Development of a real-time PCR and a sandwich ELISA for detection of potentially allergenic trace amounts of peanut (Arachis hypogaea) in processed foods

Hidden allergens in food products are, especially for peanut-allergic consumers, a serious problem because even low amounts (approximately 200 microg) of peanut can elicit allergic reactions. Undeclared peanut traces can be found in processed food products, because contaminations with peanut during production processes are frequent. To minimize the risk of such cross-contaminations, it is necessary to develop sensitive analytical methods for the detection of hidden allergens in foods. For this approach we developed two peanut-specific assays based on the detection of peanut protein by specific antibodies (sandwich ELISA) and by the detection of peanut-specific DNA (part of the coding region of Ara h 2) by a real-time PCR. Both tests did not show any cross-reactivity with 22 common food ingredients (cereals, nuts, legumes), and the limit of detection is <10 ppm peanut in processed foods. Thirty-three random samples of food products were tested for the presence of peanut to compare both assay types with each other and to evaluate the percentage of foods on the German market that are contaminated with peanut traces. We found that four products (13.3%) without peanut in the list of ingredients contained peanut protein in a range from 1 to 74 ppm peanut protein and that the results of both tests correlated well. The real-time PCR was able to detect one more positive sample than the sandwich ELISA. In conclusion, both assays are sensitive and specific tools for the detection of hidden allergens in processed foods.

Obstructive sleep apnea in children: do intranasal corticosteroids help?

Obstructive sleep apnea (OSA) is a common condition of childhood, and is associated with significant morbidity. Prevalence of the condition peaks during early childhood, due in part to adenoidal and tonsillar enlargement within a small pharyngeal space. The lymphoid tissues regress after 10 years of age, in the context of ongoing bony growth, and there is an associated fall in the prevalence of OSA. Obstruction of the nasopharynx by adenoidal enlargement promotes pharyngeal airway collapse during sleep, and the presence of large tonsils contributes to airway obstruction. Administration of systemic corticosteroids leads to a reduction in the size of lymphoid tissues due to anti-inflammatory and lympholytic effects. However, a short course of systemic prednisone has been demonstrated not to have a significant effect on adenoidal size or the severity of OSA, and adverse effects preclude the long-term use of this therapy. Intranasal corticosteroids are effective in relieving nasal obstruction in allergic rhinitis, and allergic sensitization is more prevalent among children who snore than among those who do not snore. Intranasal corticosteroids have also been demonstrated to reduce adenoidal size, independent of the individual's atopic status. There is preliminary evidence of an improvement in the severity of OSA in children treated with intranasal corticosteroids, but further studies are needed before such therapy can be routinely recommended. Prescribing clinicians should take into account the potential benefits to the patient, the age of the child, the presence of comorbidities such as allergic rhinitis, the agent used, and the dose and duration of treatment when considering such therapy.

The safety of intranasal steroids

The increasing use of intranasal steroids in the management of allergic rhinitis reflects their efficacy, tolerability, and safety. However, issues related to the safety of intranasal steroids continue to generate debate and confusion among clinicians. Consequently, there is often reluctance and uncertainty in prescribing these effective agents for the treatment of perennial and seasonal allergic rhinitis. Issues of particular concern are whether intranasal steroids adversely affect various homeostatic systems, influence growth and bone metabolism, and compromise ocular function. Furthermore, the expanding role of intranasal steroids in the pediatric, geriatric, and postmenopausal populations has raised concerns that these agents may result in a steroid burden that more readily causes adverse effects. An extensive review of the literature overwhelmingly supports the assertion that intranasal steroids are safe in prescribed doses and should allay the misconceptions regarding their appropriate use in the management of allergic rhinitis.

Systemic activity of inhaled corticosteroid treatment in asthmatic children: corticotrophin releasing hormone test

BACKGROUND

A study was undertaken to assess the function of the hypothalamic-pituitary-adrenal axis (HPA) in a group of asthmatic children before and after treatment with inhaled corticosteroids.

METHODS

Thirty prepubertal patients of mean (SD) age 6.7 (1.8) years were treated with inhaled corticosteroids. All children underwent a corticotrophin releasing hormone (CRH) test with evaluation of serum cortisol and adrenocorticotrophin hormone (ACTH) levels before and after 3 months of treatment. Twenty four hour urine samples were also collected to measure free cortisol (UFC) excretion.

RESULTS

Subjects showed no difference between basal serum cortisol levels (mean change -18; 95% CI -41 to 5; p=0.118) and delta (peak minus basal) levels (mean change -13; 95% CI -38 to 12; p=0.308) before and after treatment, whereas the peak cortisol level (mean change -31; 95% CI -55 to -7; p=0.013) and area under the curve (AUC) (mean change -175; 95% CI -288 to -63; p=0.003) after CRH were significantly lower following treatment. Basal, peak and AUC ACTH were significantly lower after treatment (p<0.05, p=0.004 and p=0.003, respectively), while delta ACTH was similar before and after treatment ((mean change -12; 95% CI - 31 to -7; p=0.199). No significant reduction in 24 hour UFC was observed after the treatment period (before 14.9 (7.1), after 15.0 (11.6); mean change 0.1, 95% CI -5.2 to 5.4; p=0.967). No correlation was found between UFC and any of the parameters of cortisol excretion following the CRH test, either before or after treatment.

CONCLUSIONS

These data suggest that, at the dosage and for the treatment period used, inhaled steroids do not seem to suppress the HPA axis in the majority of patients. The CRH test may be more sensitive than 24 hour UFC and morning plasma cortisol levels in evaluating systemic activity of inhaled corticosteroid treatment.