Once daily fluticasone propionate aqueous nasal spray controls symptoms of most patients with seasonal allergic rhinitis

Intranasal Fluticasone Once Daily Compared with Once-Daily Cetirizine in the Treatment of Seasonal Allergic Rhinitis : Results of a Multicentre, Double-Blind Study

The efficacy and tolerability of fluticasone aqueous nasal spray, 200µg once daily for 21 days, was compared with cetirizine, 10mg once daily for 21 days, in a multicentre, randomised, double-blind, double-dummy, parallel group study. 237 evaluable patients aged 12 years and above, with seasonal allergic rhinitis (defined as having a positive skin test and a total symptom score of ≥ 6/15), received either fluticasone aqueous nasal spray (n = 119) or cetirizine (n = 118). Improvement in total symptom score was observed in patients from both treatment groups, with the improvement in the fluticasone treatment group being significantly greater (decrease in total symptom score from 9.23 to 2.13) than in the cetirizine treatment group (decrease in total symptom score from 9.36 to 4.31; p < 0.001). There was also a significantly greater improvement in the number of symptom-free days for all symptoms in favour of fluticasone aqueous nasal spray compared with cetirizine (p < 0.001). Furthermore, the percentage of days when patients did not require terfenadine as rescue therapy was significantly greater in the fluticasone group (87%) than in the cetirizine group (80%; p < 0.05). Five adverse events were reported during intranasal fluticasone treatment and 10 adverse events were reported during cetirizine therapy. There were no treatment-related withdrawals from therapy in the fluticasone group, but 5 treatment-related withdrawals were reported in the cetirizine group.This study demonstrated that fluticasone aqueous nasal spray, 200µg once daily, was significantly more effective than cetirizine, 10mg once daily, and had comparable (if not better) tolerability, in the treatment of seasonal allergic rhinitis.

Lower respiratory tract complications during nasal provocation: nonspecific stimulant or specific allergen?

BACKGROUND

Allergic rhinitis (AR) is an allergic inflammatory disease in which allergen exposure leads to the appearance of symptoms in sensitized individuals because of histamine liberation from nasal mucosal mast cells. Comorbidity of this disease with allergic asthma is common. Therefore, the one airway one disease theory has been put forward. Lower respiratory tract provocation tests with both nonspecific (methacholine) and specific stimulants (allergen) have yielded positive results in nonasthmatic patients with AR. However, not enough research is available to demonstrate whether there is a response in the lower respiratory tract during nasal provocation tests (NPTs) performed to evaluate only nasal airway in these patients.

OBJECTIVES

To determine if the lower respiratory tract was affected as a result of NPTs with nonspecific and specific stimulants in nonasthmatic patients with AR and to determine the frequency of lower respiratory tract obstruction due to NPT with nonspecific and specific stimulants.

METHODS

Thirty-six participants were enrolled in the study between November 2005 and January 2006 (18 AR patients and 18 healthy control subjects). Patients underwent 2 sessions of NPT. The first session was performed with nasal methacholine as a nonspecific stimulant, and the second session was performed with nasal Olea europaea extract as a specific stimulant. The control group underwent only nonspecific nasal provocation with methacholine. Basal nasal opening and nasal pressures were evaluated spirometrically by rhinomanometric measurements and basal respiratory function tests in both groups before methacholine nasal provocation. Whether or not nasal provocation was achieved, spirometric measurements were performed in all patients and controls after NPTs.

RESULTS

NPTs with methacholine resulted in a similar frequency of nasal provocation in the patient and control groups (P = .63). However, the mean methacholine dose was lower in patients with AR (P = .049). There was a decrease in parameters of asthma, including the ratio of forced expiratory volume in 1 second to forced vital capacity (P = .04), peak expiratory flow (P = .01), and forced expiratory flow between 25% and 75% (P = .004), as a result of NPTs with methacholine in the patient group. However, NPTs with allergen did not cause a change in lower respiratory tract obstruction criteria.

CONCLUSIONS

Lower respiratory tract obstruction can occur after NPTs with nonspecific stimulants; therefore, tests performed with specific allergens can be regarded as safer.

Topical nasal steroids for intermittent and persistent allergic rhinitis in children

BACKGROUND

Allergic rhinitis is a very common chronic illness affecting 10% to 40% of children worldwide. There has been a significant increase in prevalence among children over the last two decades and this increase has been accompanied by a parallel increase in comorbid illnesses such as asthma.

OBJECTIVES

To evaluate the therapeutic effectiveness and adverse event profiles of topical nasal steroids for intermittent and persistent allergic rhinitis in children.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1950 onwards) and EMBASE (1974 onwards) on 5(th) September 2005. CINAHL, mRCT(a meta-database of controlled trials), NRR (the National Research Register), LILACS, MedCarib, KOREAMED, IndMed, Samed, Panteleimon, Zetoc, ISI Proceedings, the GlaxoSmithKline Clinical Trials Database and the websites of AstraZeneca, Schering Plough and Aventis were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing topical nasal steroid preparations against each other or placebo, prescribed for allergic rhinitis in children.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data from the included trials. The limited and variable quality of reported data precluded any pooling of results and only a descriptive summary is presented.

MAIN RESULTS

Three trials involving a total of 79 participants were included. All three trials, which compared topical nasal steroids against placebo for perennial rhinitis, provided some, albeit limited data, relevant to our primary outcomes; but in two of the trials the data analysis was flawed and in the third trial it was incomprehensible. None of the trials provided data relevant to our secondary outcomes. There were no adverse events reported from any of the interventions.

AUTHORS' CONCLUSIONS

The three included trials provided some weak and unreliable evidence for the effectiveness of Beconase(R) and flunisolide used topically intranasally for the treatment of intermittent and persistent allergic rhinitis in children. The reduction of severity in symptoms as assessed by the trialists could not be confirmed with the data provided and decisions on the use of these medications should, until such time as more robust evidence is available, be guided by the physician's clinical experience and patients' individual circumstances and preferences.

Topical glucocorticosteroids in rhinitis: clinical aspects

The introduction of nasal glucocorticosteroids, 30 years ago, has been the most important therapeutic progress in rhinitis management since the introduction of the first generation of antihistamines. Our knowledge of the mode of action of glucocorticosteroids in the nose has improved as the airway mucous membrane of the nose is easily accessible for investigation. However, the exact mechanism behind the marked clinical effect remains unclear. Topical glucocorticosteroids are highly effective in diseases characterized by eosinophil-dominated inflammation (allergic rhinitis, nasal polyposis), but not in diseases characterized by neutrophil-dominated inflammation (common cold, infectious rhinosinusitis). Experience for 30 years and a long series of controlled studies have shown that the treatment is highly effective and that the side effects are few and benign. Intranasal glucocorticosteroids can therefore be considered as first-line treatment for allergic and non-allergic, non-infectious rhinitis and nasal polyps.

A randomized comparison of the effects of budesonide and mometasone furoate aqueous nasal sprays on nasal peak flow rate and symptoms in perennial allergic rhinitis

BACKGROUND

Using conventional methods, it has been difficult to show differences in efficacy between intranasal corticosteroids in perennial rhinitis.

OBJECTIVE

To compare the effects of budesonide and mometasone on nasal symptoms and nasal airflow in perennial allergic rhinitis.

METHODS

Four hundred thirty-eight patients (age > 18 years old) were randomized to budesonide, 256 microg or 128 microg, mometasone furoate 200 microg, or placebo, once daily for 4 weeks. Efficacy was evaluated by nasal index score (NIS; the sum of scores for blocked nose, runny nose, and itchy nose/sneezing) and peak nasal inspiratory flow (PNIF).

RESULTS

All three active treatments significantly reduced the NIS compared with placebo. There was no significant difference between the treatments, although the effect of budesonide, 256 microg, tended to be greater than that of the other regimens. PNIF was significantly improved with all three active treatments: the effect of budesonide 256 microg on morning and evening PNIF was significantly greater than that of mometasone furoate and 128 microg budesonide. Budesonide had a rapid onset of action, showing a significantly greater effect on evening PNIF than mometasone furoate during the first 10 days. For all active treatments, significant improvements in NIS were seen within 4 hours of the first dose. All three treatments were well tolerated.

CONCLUSION

The objective parameter PNIF was capable of demonstrating greater efficacy of budesonide 256 microg compared with budesonide 128 microg and mometasone furoate 200 microg, whereas the combined nasal symptom score could only distinguish active treatment from placebo.

Intranasal heparin reduces eosinophil recruitment after nasal allergen challenge in patients with allergic rhinitis

BACKGROUND

Recently, several studies have shown that heparin possesses various anti-inflammatory and antiallergic properties. It has been proposed that heparin might play an important role in limiting the inflammatory events associated with asthma and allergic rhinitis by neutralizing inflammatory mediators, such as eosinophil cationic protein and major basic protein, and by limiting eosinophil recruitment.

OBJECTIVE

To test the hypothesis that heparin can limit the extent and magnitude of eosinophilic inflammation, we examined the effect of inhaled intranasal heparin on nasal response to allergen challenge in 10 patients with allergic rhinitis.

METHODS

The capacity of heparin to reduce nasal response was studied by evaluating symptom score, eosinophil cationic protein concentration, and eosinophil counts in nasal lavage fluids 10, 60, and 360 minutes after allergen challenge.

RESULTS

Pretreatment with intranasal heparin produced a significant reduction in symptom score 10 minutes after allergen challenge and reduced the eosinophil influx at each time point after antigen challenge, statistical significance being reached 60 and 360 minutes after allergen challenge. Similarly, the amount of eosinophil cationic protein in the nasal wash was reduced at each time point; this reached statistical significance 360 minutes after allergic challenge.

CONCLUSION

Heparin was shown to provide protection with respect to nasal allergen challenge. The mechanism by which heparin produces its protective activity seems to be related to the neutralization of eosinophil cationic protein as well as to the reduction of eosinophil recruitment.

Comparison of once daily fluticasone propionate aqueous nasal spray with once daily budesonide reservoir powder device in patients with perennial rhinitis

BACKGROUND

Previous studies comparing the corticosteroids fluticasone propionate (FP) and budesonide (BUD) in both perennial and seasonal rhinitis have shown no consistent difference between treatments. However, the therapeutic outcomes may have been influenced by study design.

OBJECTIVE

To compare the effect of FP aqueous nasal spray (ANS; 200 microg/day) with BUD reservoir powder device (RPD; 200 microg/day) on rhinitis symptoms, productivity loss and device preference in patients with perennial rhinitis.

METHODS

After a 2-week run-in period, 440 patients were randomized to receive either FPANS, BUD RPD or matched placebo (ANS or RPD) for 8 weeks, followed by an open-label 4-week follow-up treatment with FPANS. Patients completed diary card visual analogue scores for nasal symptoms, and questionnaires on satisfaction with the treatment and preferred choice of device.

RESULTS

During weeks 1-4, the visual analogue total nasal symptom scores (VATNS) in the FPANS group were significantly lower than scores in the BUD RPD group (mean difference = -17.8; 95% CI = -34.4, -1.3; P = 0.036). FPANS also significantly reduced the VATNS compared with the ANS placebo at all time-points assessed (P < or = 0.005). BUD RPD did not significantly differ from the RPD placebo at weeks 5-8 (P = 0.167), or the ANS placebo at any time-point (P < or = 0.151). Over the 8-week treatment period FPANS was significantly more effective than BUD RPD at reducing sneezing (mean difference = -4.4; 95% CI = -8.6, -0.3; P = 0.036) and nasal itching (mean difference = -5.3; 95% CI = -9.9, -0.8; P = 0.022), and was significantly superior to the ANS placebo for all symptoms assessed at weeks 1-4 and 1-8 (P < 0.016). At the same time-points BUD RPD was no better at alleviating nasal itching than the RPD placebo (P < or = 0.306), and compared with the ANS placebo, significantly reduced only one symptom; nasal blockage (P < or = 0.016). After 8 weeks of treatment, patients preferred the ANS device to the RPD (P < 0.001), and at 12 weeks a significantly greater number of patients were satisfied with FPANS treatment compared with BUD RPD (P = 0.0019) or the respective placebos (P = 0.0001).

CONCLUSION

FPANS and BUD RPD are effective therapies with a good safety profile for the treatment of perennial rhinitis but, in this direct placebo-controlled comparison, FPANS was more efficacious than BUD RPD, and the patients preferred the ANS device to the RPD.

Grading the severity of allergic rhinitis for treatment strategy and drug study purposes

Grading the severity of rhinitis symptoms is essential for the evaluation of drug efficacy. However, a uniform grading system has not been standardized. A review of 44 journal articles and symposia from Japan, Copenhagen, and the World Health Organization indicates major differences among systems. All except the World Health Organization used a sum of rhinitis scores. The lack of standardization limits comparisons of subjective symptom changes after comparable treatments. Corrective measures include the use of evidence-based definitions of independent nasal symptoms, avoidance of biases in evaluation, and establishment of international consensus for a standardized scale in this era of globalization.

Patient and physician perspectives on the impact and management of perennial and seasonal allergic rhinitis

Patient and physician perspectives on the impact and management of perennial (PAR) and seasonal allergic rhinitis (SAR) were studied. In all, 2139 subjects were questioned about their medical conditions, severity and frequency of symptoms and satisfaction with treatment. A group of general practitioners (GPs) were also invited to discuss their experiences in the management of rhinitis. In this UK survey, allergic rhinitis was more common than asthma, hypertension, skin rashes, eczema and diabetes. The prevalence of SAR and PAR was 15% and 2%, respectively. Sneezing and runny nose were the most common symptoms and GPs were the main contact for advice and treatment (54% of patients). Symptoms were well-controlled in 32% of patients. Allergic rhinitis affected work, home and social life in 29%, 34% and 30% of patients, respectively. The GPs considered PAR to be more difficult to treat than SAR, and GP and patient level of satisfaction in the treatment of PAR was low. This suggests that education of patients and physicians on the benefits of allergen avoidance, and the selective use of the highly effective therapies available on prescription could improve the level of satisfaction with therapy. Adherence to current guidelines on the management of rhinitis could lead to an effective, structured treatment plan for patients.

Fluticasone propionate aqueous nasal spray: a well-tolerated and effective treatment for children with perennial rhinitis

A total of 535 children aged 4-11 years with perennial rhinitis were recruited to two double-blind studies performed at 56 centres in eight European countries, Israel, and South Africa. One study compared the efficacy and tolerability of fluticasone propionate aqueous nasal spray (FPANS), at either 100 micrograms once daily (od) or 100 micrograms twice daily (bd), with beclomethasone dipropionate (BDPANS) 200 micrograms bd for 12 weeks in 120 children aged 6-11 years. The second study compared FPANS 100 micrograms od with FPANS 200 micrograms od and placebo for 4 weeks in 415 children aged 4-11 years. Efficacy was determined by means of patient assessments of nasal symptoms of perennial rhinitis and by investigator assessments of symptoms and nasal condition. The symptoms of nasal blockage, on waking and during the day, sneezing, rhinorrhoea, and nasal itching were assessed by the investigator at clinic visits and by the completion of a patient daily diary card. Safety was assessed by collection of adverse event information, routine haematology and biochemistry testing, and monitoring plasma cortisol levels. FPANS demonstrated good control of symptoms at each dose regimen, which was equivalent or superior to BDPANS and superior to placebo. There was no difference between the dose regimens of FPANS. FPANS was as well tolerated as placebo and BDPANS. It is concluded that FPANS 100 micrograms od is an effective and well-tolerated treatment for perennial rhinitis in children aged 4-11 years.