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

Comparative efficacy of intranasal mometasone furoate monotherapy or combination therapy with montelukast in pediatric adenoid hypertrophy: A systematic review and meta-analysis of randomized clinical trials

PURPOSE

Adenoid hypertrophy (AH) is a prevalent pediatric condition associated with nasal obstruction, sleep-disordered breathing, and related comorbidities. This study evaluated comparative efficacies of Mometasone Furoate (MF) monotherapy and MF-Montelukast combination therapy in pediatric AH.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Web of Science, Google Scholar, and Ovid MEDLINE were searched from their inception to August 22, 2024, and five randomized clinical trials (RCTs) with pediatric patients (age <15 years, n = 416) with clinically diagnosed AH, managed with MF monotherapy or MF-montelukast combination therapy, were identified. Outcomes included changes in x-ray adenoids/nasopharynx ratio, endoscopic adenoid obstruction, total symptom score, and individualized symptoms scores of nasal obstruction, rhinorrhea, mouth breathing, and snoring. Although safety data, including neuropsychiatric adverse effects of montelukast, were of interest, they were not reported in the included studies.

RESULTS

Compared to MF-monotherapy, MF-montelukast combination therapy significantly improved (mean difference [95 % confidence interval], p-value) adenoids/nasopharynx ratio (-7.01 [-8.96 to -5.07], <0.001), total symptom score (-1.05 [-1.51 to -0.59], <0.001), rhinorrhea (-0.92 [-1.50 to -0.34], 0.002), mouth breathing (-0.67 [-1.27 to -0.08], 0.02), and endoscopic Grade 4 adenoid obstruction (relative risk 0.25 [0.07-0.84], 0.03); no intergroup differences were noted in nasal obstruction (-0.06 [-0.26 to 0.14], 0.56), snoring (-0.56 [-1.19 to 0.08], 0.08), and endoscopic Grade 3 adenoid obstruction (relative risk 0.70 [0.45-1.09], 0.11).

CONCLUSION

MF-montelukast combination therapy is superior to MF monotherapy in reducing AH symptoms. However, Montelukast has an FDA black box warning due to potential neuropsychiatric side effects, including suicidal thoughts, depression and behavioral changes. None of the included studies systematically assessed these adverse effects highlighting a critical gap in safety evaluation. High-quality RCT-based research is required to evaluate long-term efficacy, safety, dosage, and cost-effectiveness.

A Randomized Comparison of Bencycloquidium Bromide, Mometasone Furoate, and a Combination for Persistent Allergic Rhinitis

BACKGROUND

Moderate to severe persistent allergic rhinitis (AR) poses a substantial socioeconomic burden.

OBJECTIVES

We aimed to establish the superiority of bencycloquidium bromide (BCQB) nasal spray and BCQB combined with mometasone furoate nasal spray (MFNS) over MFNS alone in adults with moderate to severe persistent AR.

METHODS

In this multicenter, randomized, controlled clinical trial (NCT05038202), adults with moderate to severe persistent AR were randomly assigned to receive BCQB, MFNS, or a combination treatment for 4-week periods. Mean changes from baseline in the daily reflective runny nose, nasal congestion, sneezing, nasal itching scores, total nasal symptom score (TNSS) and Rhinoconjunctivitis Quality of Life Questionnaire scores were recorded. We also assessed the exploratory end points and adverse events.

RESULTS

Bencycloquidium bromide led to a significant improvement in the mean change from baseline in daily reflective runny nose during the 4-week treatment, compared with MFNS (least-squares mean difference, -0.27; 95% CI, -0.44 to -0.09; P = .004). The BCQB combined with MFNS significantly improved runny nose, nasal congestion, sneezing, TNSS, and Rhinoconjunctivitis Quality of Life Questionnaire scores compared with MFNS alone, except for nasal itching. Bencycloquidium bromide significantly decreased the percent change in eosinophilic cationic protein, eotaxin, vasoactive intestinal peptide, and IL-6 levels. Treatment-emergent adverse events were similar among the three groups.

CONCLUSIONS

Bencycloquidium bromide was superior to MFNS in reducing daily runny nose symptoms. The combination of BCQB and MFNS was superior to MFNS alone in alleviating TNSS in patients with moderate to severe persistent AR with a predominant symptom of runny nose.

Efficacy of combination therapy with mometasone and montelukast versus mometasone alone in treatment of adenoid hypertrophy in children: A systematic review and meta-analysis

INTRODUCTION

Intranasal mometasone and oral montelukast have been found to be effective for adenoid hypertrophy in children. We aimed to compare the efficacy of combination therapy of mometasone and montelukast versus mometasone alone for adenoid hypertrophy in children.

METHODS

Following PRISMA guidelines, we systematically searched PubMed, Embase, Cochrane CENTRAL, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing combination therapy of mometasone and montelukast with mometasone alone for adenoid hypertrophy in children. The outcomes of interest were rhinorrhea, snoring, mouth breathing, and adenoid/nasopharynx ratio. Data were pooled using a random effects model to generate mean differences (MD).

RESULTS

3 RCTs comprising a total of 207 patients were included; (combination therapy n = 104 (50.2 %). Rhinorrhea (MD -1.47; 95 % CI -1.85 to -1.09; p < 0.01; I2 = 0 %), snoring (MD -1.33; 95 % CI -1.65 to -1.00; p < 0.01; I2 = 0 %), and mouth breathing (MD -1.06; 95 % CI -1.40 to -0.71; p < 0.01; I2 = 0 %) were significantly lower in patients treated with combination therapy. No difference was observed in the adenoid/nasopharynx ratio between the groups. However, analysis excluding the study with a high risk of bias showed a significant reduction in the adenoid/nasopharynx ratio (MD -10.73; 95 % CI -13.56 to -7.90; p < 0.01; I2 = 0 %) in the combination therapy group. During the 3-month follow-up period after cessation of treatment, adenoid/nasopharynx ratio, rhinorrhea, snoring, and mouth breathing were significantly lower in the combination therapy group.

CONCLUSION

In children with adenoid hypertrophy, combination therapy reduced rhinorrhea, snoring, mouth breathing, and adenoid/nasopharynx ratio at the end of the treatment period and 3 months after treatment cessation.

Appropriate Allergic Rhinitis Medications Can Reduce Systemic Steroid Requirement and Prevent Rhinosinusitis

Background: Allergic rhinitis (AR) is quite common and sometimes it requires systemic steroids and can be accompanied by coronavirus disease-2019 (COVID-19), rhinosinusitis, or asthma. We aimed to determine the comparative effect of different types of AR medications on clinical prognosis in real-world settings. Methods: We used national claims data provided by the National Health Insurance Service in the Republic of Korea. We enrolled 275,895 adult patients who were first diagnosed with AR and started AR medications between 1 January 2018 and 31 December 2018. We classified them into five groups according to the type of AR medication prescribed and analyzed their 3-year follow-up data. Results: The prescription rate of systemic steroids was low in the INCS group (19%), whereas it was 35-40% in other groups. INCS users needed less systemic steroids than other AR medication users (hazard ratio [HR], 0.503; 95% confidence interval [CI], 0.452-0.560; p-value < 0.001). The incidence of rhinosinusitis was approximately 11% in the other AR medication group and 6-8% in the other groups. AH (HR, 0.745; 95% CI, 0.616-0.903; p = 0.003), AH-LTRA (HR, 0.667; 95% CI, 0.551-0.808; p < 0.001), and INCS (HR, 0.746, 95% CI, 0.615-0.904; p = 0.003) significantly prevent rhinosinusitis, compared with other AR medication. However, other prognosis factors were not significantly correlated with the type of AR medications. Conclusions: INCS can reduce systemic steroid requirements and AH, AH-LTRA, and INCS prevent rhinosinusitis compared with other AR medications. As choosing an appropriate AR medication can determine the clinical outcomes, clinicians should be careful in prescribing proper AR medications.

[Short-term quality of life assessment after sinus surgery for chronic rhinosinusitis]

BACKGROUND

Chronic rhinosinusitis (CRS) has a negative impact on health-related quality of life (HRQoL). Functional endoscopic sinus surgery (FESS) is the treatment of choice for those not responding to medical treatments. To date, the short-term effects of FESS on HRQoL are still unclear.

OBJECTIVE

Evaluation of the short-term effects of FESS on HRQoL in CRS patients using the SNOT-22 questionnaire.

METHODS

The results of the validated German version of the Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire were analysed from 89 patients with CRS before surgery and 10-14 days (n = 77), four (n = 77), six weeks (n = 76) and 6 months (n = 71) after FESS, and compared with those of 1,000 healthy controls selected using a non-probability quota sample in accordance to the distribution of the German Microcensus.

RESULTS

Compared to the preoperative mean SNOT-22 score (47.35), CRS patients significantly improved in HRQoL 10-14 days (31.75, p < 0.01), 4 weeks (25.84, p < 0.01), 6 weeks (24.16, p < 0.01) and 6 months after FESS (27.16, p < 0.01). Pre- and 6 months postoperatively, the five most important SNOT-22 items were nasal obstruction, smell and taste reduction, thick, mucous nasal secretions, need to blow the nose and postnasal drip. At the 2, 4 and 6-week follow-up, the reduction in smell and taste was most frequently perceived as limiting the HRQoL.

CONCLUSIONS

This follow-up study shows for the first time that the reduction in smell and taste should be treated and controlled concervatively in the short term after FESS.

Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

Efficacy and safety of various corticosteroids in the treatment of children with allergic rhinitis: A systematic review and network meta-analysis

BACKGROUND

Intranasal corticosteroids were recommended as first-line drugs for the treatment of allergic rhinitis (AR) children. A variety of corticosteroids were available for clinical choice; however, which could relieve the clinical symptoms of patients to the greatest extent was currently unknown. Thus, we performed a network meta-analysis (NMA) to systematically evaluate the effectiveness and safety of different corticosteroids in treating children with AR, which might provide a basis for more rational clinical treatment decisions.

METHODS

Seven electronic databases were searched, and the retrieval time range was the time from their inception to November 2023. The literature screening, data extraction, and assessment of the risk of bias of included studies were completed independently by two reviewers. A frequentist NMA was performed with Stata17.0 software.

RESULTS

A total of 43 RCTs covering 10,897 participants were included. In the improvement of reflective total nasal symptom score (rTNSS) and instantaneous total nasal symptom score (iTNSS), fluticasone furoate nasal spray (FFNS) and beclomethasone dipropionate (BDP) nasal aerosol presented the best efficacy. Regarding the incidence of adverse reactions, mometasone furoate aqueous nasal spray (MFANS) and BDP showed a good safety profile. In terms of the influence of cortisol (urinary free cortisol, plasma cortisol) and growth, no significant difference was observed between the different groups.

CONCLUSION

The results showed that BDP nasal aerosol and FFNS had best efficacy; MFANS and BDP had the best safety profile. However, this conclusion was less convincing because of the limited numbers of patients/controls and study quality.

Comparison of Budesonide/formoterol versus Fluticasone furoate/vilanterol as maintenance and reliever therapy for asthma control: a real-world observational study

BACKGROUND

Previous studies have reported reduced acute exacerbation rates and improved symptom control in asthma patients treated using inhaled corticosteroids plus formoterol maintenance and reliever therapy (MART). Fluticasone furoate (FF) and vilanterol (VIL) also provide rapid bronchodilation and sustained anti-inflammatory effects, however no studies have investigated FF/VIL as MART for asthma control.

METHODS

From October 1, 2021 to September 30, 2023, this retrospective study included asthma patients classified as step 3 or 4 according to the Global Initiative for Asthma guidelines, who were then divided into two groups. One group received BUD/FOR as MART, while the other received FF/VIL as MART. Pulmonary function tests, exacerbation rates, Asthma Control Test (ACT), fractional exhaled nitric oxide (FeNO) levels, and blood eosinophil counts were measured before and after 12 months of treatment.

RESULTS

A total of 161 patients were included, of whom 36 received BUD/FOR twice daily as MART, and 125 received FF/VIL once daily as MART. After 12 months of treatment, the FF/VIL group showed a significant increase in ACT scores by 1.57 (p < 0.001), while the BUD/FOR group had an increase of 0.88 (p = 0.11). In terms of FeNO levels, the BUD/FOR group experienced a decline of -0.2 ppb (p = 0.98), whereas the FF/VIL group had a mild increase of + 0.8 ppb (p = 0.7). Notably, there was a significant difference in the change of FeNO between the two groups (∆ FeNO: -0.2 ppb in BUD/FOR; + 0.8 ppb in FF/VIL, p < 0.001). There were no significant alterations observed in FEV1, blood eosinophil count, or acute exacerbation decline in either group.

CONCLUSIONS

In the current study, patients treated with FF/VIL as MART showed improvements in ACT scores, while those treated with BUD/FOR as MART exhibited a reduction in FeNO levels. However, the difference between the two treatment groups did not reach clinical significance. Thus, FF/VIL as MART showed similar effectiveness to BUD/FOR as MART.

Efficacy of montelukast for adenoid hypertrophy in paediatrics: A systematic review and meta-analysis

INTRODUCTION

Leukotrienes play a significant role in the pathogenesis of adenoid hypertrophy (A.H.). Therefore, we aimed to analyse the role of montelukast, a leukotriene receptor antagonist, alone or in combination with mometasone, a potent local intranasal steroid, for the treatment of A.H.

METHODS

Participants were children with A.H. were treated with montelukast alone or montelukast and mometasone furoate. The main outcome measures were effect of montelukast on clinical symptoms of A.H. A literature review was conducted using online search engines, Cochrane Library, PubMed, Web of Science and Scopus, for randomized clinical trials assessing children with A.H. treated with montelukast alone or montelukast and mometasone furoate. Seven randomized clinical trials (RCTs) were included with 742 children.

RESULTS

Our study reveals that montelukast alone or in combination with intranasal mometasone furoate significantly improves clinical symptoms of adenoid hypertrophy such as snoring, sleeping disturbance, mouth breathing and A/N ratio. Montelukast was superior to placebo in decreasing snoring (SMD = -1.00, 95% CI [-1.52, -0.49]), sleep discomfort (SMD = -1.26, 95% CI [-1.60, -0.93]), A/N ratio (MD = -0.11, 95% CI [-0.14, -0.09]) and mouth breathing (SMD = -1.36, 95% CI [-1.70, -1.02]). No difference was detected between montelukast and mometasone versus mometasone alone in snoring (SMD = -0.21, 95%CI [-0.69, 0.27]); however, the combination group was superior to the mometasone alone in mouth breathing (SMD = -0.46, 95% CI [-0.73, -0.19]).

CONCLUSIONS

The limitation of studies included a small sample size, with an overall low to medium quality. Thus, further larger, higher-quality RCTs are recommended to provide more substantial evidence.

Pharmacological interventions for pediatric obstructive sleep apnea (OSA): Network meta-analysis

IMPORTANCE

Pediatric obstructive sleep apnea (OSA) is a common disease that can have significant negative impacts on a child's health and development. A comprehensive evaluation of different pharmacologic interventions for the treatment of OSA in children is still lacking.

OBJECTIVE

This study aims to conduct a comprehensive systematic review and network meta-analysis of pharmacological interventions for the management of obstructive sleep apnea in pediatric population.

DATA SOURCES

PubMed, Web of Science, Embase, The Cochrane Library, and CNKI were searched from 1950 to November 2022 for pediatric OSA.

STUDY SELECTION

Multiple reviewers included Randomized controlled trials (RCTs) concerning drugs on OSA in children.

DATA EXTRACTION AND SYNTHESIS

Multiple observers followed the guidance of the PRISMA NMA statement for data extraction and evaluation. Bayesian network meta-analyses(fixed-effect model) were performed to compare the weighted mean difference (WMD), logarithmic odds ratios (log OR), and the surface under the cumulative ranking curves (SUCRA) of the included pharmacological interventions. Our protocol was registered in PROSPERO website (CRD42022377839).

MAIN OUTCOME(S) AND MEASURE(S)

The primary outcomes were improvements in the apnea/hypopnea index (AHI), while secondary outcomes included adverse events and the lowest arterial oxygen saturation (SaO2).

RESULTS

17 RCTs with a total of 1367 children with OSA aged 2-14 years that met the inclusion criteria were eventually included in our systematic review and network meta-analysis. Ten drugs were finally included in the study. The results revealed that Mometasone + Montelukast (WMD-4.74[95%CrIs -7.50 to -2.11], Budesonide (-3.45[-6.86 to -0.15], and Montelukast(-3.41[-5.45 to -1.39] exhibited significantly superior therapeutic effects compared to the placebo concerning apnea hypopnea index (AHI) value with 95%CrIs excluding no effect. Moreover, Mometasone + Montelukast achieved exceptionally high SUCRA values for both AHI (85.0 %) and SaO2 (91.0 %).

CONCLUSIONS AND RELEVANCE

The combination of mometasone furoate nasal spray and oral montelukast sodium exhibits the highest probability of being the most effective intervention. Further research is needed to investigate the long-term efficacy and safety profiles of these interventions in pediatric patients with OSA.

Intranasal combo: fixed-dose combination of mometasone furoate and olopatadine hydrochloride in therapeutic strategies for rhinosinusitis

A novel strategy for the treatment of allergic rhinitis results from the innovative combination of antihistamine and intranasal corticosteroid drugs. By combining two preparations with different mechanism of action, this novel approach facilitates quick and effective controls of all upper respiratory tract allergy symptoms. The article presents the results of a study of olopatadine hydrochloride and mometasone furoate fixed-dose combination (GSP301) administered intranasally from a spray formulation, with an attempt at positioning the treatment within the ARIA and EPOS guidelines.

Oral liposomal delivery of an activatable budesonide prodrug reduces colitis in experimental mice

Inflammatory bowel disease (IBD) is one of the most common intestinal disorders, with increasing global incidence and prevalence. Numerous therapeutic drugs are available but require intravenous administration and are associated with high toxicity and insufficient patient compliance. Here, an oral liposome that entraps the activatable corticosteroid anti-inflammatory budesonide was developed for efficacious and safe IBD therapy. The prodrug was produced via the ligation of budesonide with linoleic acid linked by a hydrolytic ester bond, which was further constrained into lipid constituents to form colloidal stable nanoliposomes (termed budsomes). Chemical modification with linoleic acid augmented the compatibility and miscibility of the resulting prodrug in lipid bilayers to provide protection from the harsh environment of the gastrointestinal tract, while liposomal nanoformulation enables preferential accumulation to inflamed vasculature. Hence, when delivered orally, budsomes exhibited high stability with low drug release in the stomach in the presence of ultra-acidic pH but released active budesonide after accumulation in inflamed intestinal tissues. Notably, oral administration of budsomes demonstrated favorable anti-colitis effect with only ∼7% mouse body weight loss, whereas at least ∼16% weight loss was observed in other treatment groups. Overall, budsomes exhibited higher therapeutic efficiency than free budesonide treatment and potently induced remission of acute colitis without any adverse side effects. These data suggest a new and reliable approach for improving the efficacy of budesonide. Our in vivo preclinical data demonstrate the safety and increased efficacy of the budsome platform for IBD treatment, further supporting clinical evaluation of this orally efficacious budesonide therapeutic.

Bilosomes and Biloparticles for the Delivery of Lipophilic Drugs: A Preliminary Study

In this study, bile acid-based vesicles and nanoparticles (i.e., bilosomes and biloparticles) are studied to improve the water solubility of lipophilic drugs. Ursodeoxycholic acid, sodium cholate, sodium taurocholate and budesonide were used as bile acids and model drugs, respectively. Bilosomes and biloparticles were prepared following standard protocols with minor changes, after a preformulation study. The obtained systems showed good encapsulation efficiency and dimensional stability. Particularly, for biloparticles, the increase in encapsulation efficiency followed the order ursodeoxycholic acid < sodium cholate < sodium taurocholate. The in vitro release of budesonide from both bilosytems was performed by means of dialysis using either a nylon membrane or a portion of Wistar rat small intestine and two receiving solutions (i.e., simulated gastric and intestinal fluids). Both in gastric and intestinal fluid, budesonide was released from bilosystems more slowly than the reference solution, while biloparticles showed a significant improvement in the passage of budesonide into aqueous solution. Immunofluorescence experiments indicated that ursodeoxycholic acid bilosomes containing budesonide are effective in reducing the inflammatory response induced by glucose oxidase stimuli and counteract ox-inflammatory damage within intestinal cells.

Allergic rhinitis: Review of the diagnosis and management: South African Allergic Rhinitis Working Group

BACKGROUND

Allergic rhinitis (AR) has a significant impact on the community as a whole with regard to quality of life and its relationship to allergic multi-morbidities. Appropriate diagnosis, treatment and review of the efficacy of interventions can ameliorate these effects. Yet, the importance of AR is often overlooked, and appropriate therapy is neglected. The availability of effective medications and knowledge as to management are often lacking in both public and private health systems.

METHODS

This review is based on a comprehensive literature search and detailed discussions by the South African Allergic Rhinitis Working Group (SAARWG).

RESULTS

The working group provided up-to-date recommendations on the epidemiology, pathology, diagnosis and management of AR, appropriate to the South African setting.

CONCLUSION

Allergic rhinitis causes significant, often unappreciated, morbidity. It is a complex disease related to an inflammatory response to environmental allergens. Therapy involves education, evaluation of allergen sensitisation, pharmacological treatment, allergen immunotherapy (AIT) and evaluation of the success of interventions. Regular use of saline; the important role of intranasal corticosteroids, including those combined with topical antihistamines and reduction in the use of systemic steroids are key. Practitioners should have a thorough knowledge of associated morbidities and the need for specialist referral.Contribution: This review summarises the latest developments in the diagnosis and management of AR such that it is a resource that allows easy access for family practitioners and specialists alike.

Chronic intranasal corticosteroid treatment induces degeneration of olfactory sensory neurons in normal and allergic rhinitis mice

BACKGROUND

Nasal eosinophilic inflammation is the therapeutic target for olfactory dysfunction in allergic rhinitis (AR). Intranasal corticosteroids are commonly considered to offer targetable benefit given their immunosuppressive property. However, experimental evidence suggests that continuous corticosteroid exposure may directly cause olfactory damage by disrupting the turnover of olfactory sensory neurons (OSNs). This potentially deleterious effect of corticosteroids calls into question their long-term topical use for treating olfactory loss related to AR. The aim of this study was to assess the impacts of chronic intranasal corticosteroid treatment on olfactory function and OSN population in mice under normal and pathological conditions.

METHODS

BALB/c mice were intranasally treated with fluticasone propionate (FP, 0.3 mg/kg) for up to 8 weeks. Additional mice were used to establish an ovalbumin-induced mouse model of AR, followed by nasal challenge with ovalbumin for 8 weeks in the presence or absence of intranasal FP treatment. The authors examined olfactory function, OSN existence, neuronal turnover, and nasal inflammation using behavioral test, histological analyses, Western blotting, and enzyme-linked immunosorbent assay.

RESULTS

Intranasal treatment with FP for 8 weeks (FP-wk8) reduced odor sensitivity in normal mice. This reduction was concomitant with loss of OSNs and the axons projecting to the olfactory bulb, primarily resulting from increased neuronal apoptosis. In FP-wk8 AR mice, intranasal FP treatment attenuated olfactory impairment and eosinophilic inflammation but failed to reconstitute OSN population and axonal projections.

CONCLUSION

These results suggest that chronic intranasal corticosteroid treatment contributes to OSN degeneration that may reduce the therapeutic effectiveness for AR-related olfactory loss.

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.

A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults

STUDY OBJECTIVES

The treatment of obstructive sleep apnea is often impeded by intolerance of positive airway pressure therapy, which is frequently attributed to the inability to breathe through the nose. Providers caring for patients with sleep apnea need a working knowledge of nasal passage disease and available treatments to better manage this common comorbidity.

METHODS

This review examines the literature connecting rhinosinusitis to adverse sleep and sleep apnea outcomes. It explores the different types of nasal and sinus diseases a sleep apnea provider might encounter, focusing on the medications used to treat them and indications for referral to otolaryngology.

RESULTS

Chronic rhinosinusitis can be either allergic or nonallergic. Both types can interfere with sleep and sleep apnea therapy. The successful management of chronic rhinosinusitis can improve positive airway pressure tolerance and adherence. A wide range of over-the-counter and prescription pharmacotherapy is available, with data supporting intranasal over oral treatment. Surgical treatment for chronic rhinosinusitis in obstructive sleep apnea addresses nasal obstruction, often with inferior turbinate reduction and septoplasty.

CONCLUSIONS

Sleep specialists should have a working knowledge of the available options to treat chronic rhinosinusitis. These options are often safe, effective, and readily accessible. Otolaryngologists and allergists/immunologists provide additional treatment options for more complicated patients. Providing treatment for chronic rhinosinusitis should be included as part of comprehensive sleep apnea care.

CITATION

Ali MM, Ellison M, Iweala OI, Spector AR. A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults. J Clin Sleep Med. 2023;19(8):1545-1552.

Comparative efficacy and acceptability of licensed dose intranasal corticosteroids for moderate-to-severe allergic rhinitis: a systematic review and network meta-analysis

No evidence shows that one intranasal corticosteroid (INCS) is better than another for treating moderate-to-severe allergic rhinitis (AR). This network meta-analysis assessed the comparative efficacy and acceptability of licensed dose aqueous INCSs. PubMed/MEDLINE, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials were searched until 31 March 2022. Eligible studies included randomized controlled trials comparing INCSs with placebo or other types of INCSs in patients with moderate-to-severe allergic rhinitis. Two reviewers independently screened and extracted data following the Preferred Reporting Items in Systematic Reviews and Meta-analysis guideline. A random-effects model was used for data pooling. Continuous outcomes were expressed as standardized mean difference (SMD). The primary outcomes were the efficacy in improving total nasal symptom score (TNSS) and treatment acceptability (the study dropout). We included 26 studies, 13 with 5,134 seasonal AR patients and 13 with 4,393 perennial AR patients. Most placebo-controlled studies had a moderate quality of evidence. In seasonal AR, mometasone furoate (MF) was ranked the highest efficacy, followed by fluticasone furoate (FF), ciclesonide (CIC), fluticasone propionate and triamcinolone acetonide (TAA) (SMD -0.47, 95% CI: -0.63 to -0.31; -0.46, 95% CI: -0.59 to -0.33; -0.44, 95% CI: -0.75 to -0.13; -0.42, 95% CI: -0.67 to -0.17 and -0.41, 95% CI: -0.81 to -0.00), In perennial AR, budesonide was ranked the highest efficacy, followed by FF, TAA, CIC, and MF (SMD -0.43, 95% CI: -0.75 to -0.11; -0.36, 95% CI: -0.53 to -0.19; -0.32, 95% CI: -0.54 to -0.10; -0.29, 95% CI: -0.48 to -0.11; and -0.28, 95% CI: -0.55 to -0.01). The acceptability of all included INCSs was not inferior to the placebo. According to our indirect comparison, some INCSs have superior efficacy to others with moderate quality of evidence in most placebo-controlled studies for treating moderate-to-severe AR.

Quercetin-Induced Enhancement of Nasal Epithelial Cells' Ability to Produce Clara Cell 10-kD Protein In Vitro and In Vivo

Background: Quercetin, a polyphenolic flavonoid found in various plants and foods, is known to have antioxidant, antiviral and anticancer effects. Although quercetin is well known to exert anti-inflammatory and anti-allergic effects, the precise mechanisms by which quercetin favorably modifies the clinical status of allergic diseases, such as allergic rhinitis (AR), remain unclear. The present study examined whether quercetin could modulate the production of the endogenous anti-inflammatory molecule, Clara cell 10-kD protein (CC10), in vitro and in vivo. Methods: Human nasal epithelial cells (1 × 10⁵ cells/mL) were stimulated with 20 ng/mL of tumor necrosis factor-alpha (TNF) in the presence of quercetin for 24 h. CC10 levels in culture supernatants were examined by ELISA. Sprague Dawley rats were sensitised with toluene 2,4-diisocyanate (TDI) by intranasal instillation of 10% TDI in ethyl acetate at a volume of 5.0 μL once daily for five days. This sensitisation procedure was repeated after an interval of two days. The rats were treated with different dosages of quercetin once daily for five days starting on the 5th day following the second sensitization. Nasal allergy-like symptoms induced by the bilateral application of 5.0 μL of 10% TDI were assessed by counting sneezing and nasal-rubbing behaviours for 10 min immediately after the TDI nasal challenge. The levels of CC10 in nasal lavage fluids obtained 6 h after TDI nasal challenge were examined using ELISA. Results: The treatment of cells with low doses of quercetin (<2.5 μM) scarcely affected TNF-induced CC10 production from nasal epithelial cells. However, the ability of nasal epithelial cells to produce CC10 after TNF stimulation significantly increased on treatment with quercetin doses (>5.0 μM). The oral administration of quercetin (>25 mg/kg) for five days significantly increased the CC10 content in nasal lavage fluids and attenuated the nasal symptoms induced by the TDI nasal challenge. Conclusions: Quercetin inhibits AR development by increasing the ability of nasal epithelial cells to produce CC10.

Comparison of Conventional Nasal Douching with Corticosteroid Nasal Douching in Chronic Rhinosinusitis Patients Post Surgery

Objectives

Chronic rhinosinusitis has a preponderance for recurrence even after functional endoscopic sinus surgery. Nasal Douching with saline has been used for decades as a treatment and as an adjunct following surgery. Steroid nasal wash has been introduced recently for the postoperative management of patients with chronic rhinosinusitis. The objective of this study was to evaluate the efficacy of postoperative steroid irrigation in patients with chronic rhinosinusitis with and without polyps.

Methods

This prospective study was done over a period of 2 years involving 70 chronic rhinosinusitis patients with and without nasal polyps who underwent functional endoscopic sinus surgery. The patients were divided into two groups, in group A, patients were given saline nasal douching and in group B, the budesonide nasal douching. The 22-item Sinonasal Outcomes Test (SNOT-22) and Lund-Kennedy endoscopy scores were checked before and 1, 2, 4, and 6 months after the nasal irrigation.

Results

In group A, the mean SNOT-22 score improved from 52.5 ± 9.1 before irrigation to 22.1 ± 11.3 after 6 months of irrigation. The LK endoscopy score also improved from 7.2 ± 2.1 before irrigation to 2.1 ± 1.2 after 6 months. In group B, the mean SNOT-22 score improved from 48.9 ± 10.6 before irrigation to 19.8 ± 11.7 after 6 months of irrigation. The endoscopy score also improved from 6.9 ± 2.3 before irrigation to 1.5 ± 1.1 after 6 months. The mean SNOT-22 and Lund-Kennedy scores improved in both groups. Group B with budesonide irrigation was found to have improved significantly than the saline nasal irrigation group, however, the difference between the 2 groups was not significant.

Conclusion

Nasal douching with budesonide is an effective postoperative treatment for chronic rhinosinusitis with polyps. The addition of budesonide in douching improves the quality of life and reduces the chance of recurrence.

Fluticasone furoate plus vilanterol in patients with moderate persistent asthma: a cost-utility analysis

BACKGROUND

In recent years, the combination of fluticasone furoate and vilanterol (FF/VI) has emerged as an alternative therapy, since it is administered every 24 h, in contrast to other ICS/LABAs such as fluticasone propionate plus salmeterol (FP/Salm), which requires administration every 12 h. Concerns have arisen over whether the benefit generated by FF/VI justifies the additional costs it involves over FP/Salm. This study aimed at assessing the health and economic consequences of FF/VI in patients with moderate-severe persistent asthma.

METHODS

A probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with persistent asthma. Total costs and QALYs for FF/VI and FP/Salm were calculated over a lifetime horizon. Multiple sensitivity analyses were conducted. Cost-effectiveness was evaluated at a willingness-to-pay value of $19,000.

RESULTS

We estimated a gain of 16.8 and 10.7 QALYs per patient per year on FF/VI and FP/Salm, respectively. At the same time, we observed a difference of US$216 in total discounted cost per person-year on FF/VI with respect to FP/Salm. The incremental cost-effectiveness ratio (ICER) of FF/VI was USD $70 per QALY with respect to FP/Salm. In the deterministic and probabilistic sensitivity analyses, our base-case results were robust to variations in all assumptions and parameters.

CONCLUSION

FF/VI is more cost-effective than FP/Salm. The evidence supports using FF/VI therapy in Colombia, and the study should be replicated in other middle-income countries.

Laryngeal Plasmacytosis Responsive to Inhaled Budesonide

Mucous membrane plasmacytosis (MMP) is rare condition characterized by diffuse plasma cell infiltration of upper aero-digestive tract mucosa. It results in epithelial hyperplasia that has a classic papillary appearance. We describe a case of MMP primarily affect laryngeal and oropharyngeal mucosa resulting in progressive airway obstruction. We highlight airway management and histopathology. The patient had near complete clinical response with inhaled budesonide, which has not yet been described as a treatment option in the literature. Laryngoscope, 133:70-72, 2023.

Off-Label Use of Ciprofloxacin/Dexamethasone Drops in the Pediatric Upper Airway: Case Presentation and Review of Adverse Effects

OBJECTIVE

This report describes a new observation of hyperglycemia in a child with Type 1 diabetes after off-label use of otic ciprofloxacin/dexamethasone drops in the nasal passage and reviews previous reports of adverse endocrine effects from intranasal corticosteroids in pediatric patients.

METHODS

We describe the clinical case and conducted a literature review of MEDLINE (PubMed) and EMBASE.

RESULTS

A 9-month-old female with a history of Type 1 diabetes who underwent unilateral choanal atresia repair was started on 1 week of ciprofloxacin 0.3%/dexamethasone 0.1% otic drops twice a day for choanal obstruction with granulation tissue. While the patient's airway patency improved, average daily blood glucose increases by 40 to 50 points were noted on the patient's continuous glucose monitor. The hyperglycemia resolved within 2 days after switching to mometasone furoate 0.05% spray. We also review 21 pediatric otolaryngology cases of iatrogenic Cushing's syndrome associated with on- and off-label use of topical steroid suspensions in the airway. Patients ranged from 3 months to 16 years in age and used doses of 50 μg/day to 2 mg/day.

CONCLUSION

This is the first reported pediatric case of increased blood glucose levels associated with intranasal steroid suspensions, to the best of our knowledge. Counseling families on precise dose administration and potential endocrine disturbances is critical when prescribing these medications for off-label use in infants and small children, particularly among patients with underlying endocrine disorders such as diabetes.

As-needed intranasal corticosteroid spray for allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

As-needed intranasal corticosteroid spray (INCS) is commonly used by patients with allergic rhinitis (AR) who have suboptimal symptom control. This systematic review aimed to assess the effectiveness of as-needed INCS for treating AR.

METHODOLOGY

Systematic searches for randomized controlled trials studying the effects of as-needed INCS compared to regular INCS, as-needed antihistamine, or placebo were performed. Primary outcomes were total nasal symptom score (TNSS) and disease-specific quality of life (DSQoL).

RESULTS

Eight studies (882 participants) met the criteria. Regular use of INCS showed greater improvements than as-needed INCS in TNSS, DSQoL, nasal peak inspiratory flow, sneezing, and nasal congestion scores with small effect sizes. There were no differences between regular and as-needed INCS usage for ocular symptoms, symptom-free days, nasal itching, and rhinorrhea scores. As-needed INCS was superior to as-needed antihistamine and placebo with medium effect sizes. There were no differences in risk of adverse events between the groups in all three comparisons.

CONCLUSIONS

Regular use of INCS improved total nasal symptoms score and DSQoL better than as-needed INCS. However, as-needed INCS improved TNSS better than as-needed antihistamine and placebo. The effects of as-needed INCS were closer to regular INCS usage than to placebo or as-needed AH usage.

[Effective intranasal GCS application strategy of mono and combines forms in treating patients, suffering from allergic rhinitis. Evidence-based medicine to help a practitioner]

OBJECTIVE

To summarize effective intranasal glucocorticosteroids (GCS) application strategies in treatment of patients, suffering from allergic rhinitis (depending on disease type), based on actual research results. Current study determines the place of fixed intranasal GCS and topic antihistamine medication combination, specifically azelastine and mometasone furoate, as a first line of choice therapy in treatment of patients, suffering from allergic rhinitis. Effective application of stage therapy allows us establish control over allergic inflammation and significantly decrease pharmaceutical load in cases of patients, suffering from allergic rhinitis.

[Features of adherence to treatment of patients with chronic rhinosinusitis with nasal polyps]

Chronic polypous rhinosinusitis (CPR) is characterized by refractory to drug therapy and a high potential for recurrence after surgical treatment. One of the important factors limiting the effectiveness of drug therapy of CPR, in particular intranasal glucocorticosteroids (inGCSs), is the insufficient level of adherence to treatment of patients with CPR.

OBJECTIVE

Generalization of data on the significance and ways to increase adherence to treatment of patients with CPR.

MATERIAL AND METHODS

Materials of scientific publications included in the Cochrane Library, Russian Science Citation Index, MEDLINE, PubMed information bases were used as a data source. The material was selected based on the following keywords: "chronic rhinosinusitis", "nasal polyps", "intranasal glucocorticosteroids", "adherence to treatment".

RESULTS

Despite the fact that inGCSs are one of the main pathogenetically justified methods of treating CPR, their use is limited by many factors, one of which is the level of patient compliance with the treatment regimen.

CONCLUSION

Improving adherence to treatment is one of the important reserves for increasing the effectiveness of drug therapy for chronic polypous rhinosinusitis.

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.

Tanshinone IIA improves degranulation of mast cells and allergic rhinitis induced by ovalbumin by inhibiting the PLCγ1/PKC/IP3R pathway

Allergic rhinitis (AR) is a common allergic inflammatory and chronic reactive disease caused by allergen-induced immunoglobulin E (IgE). Tanshinone IIA (Tan IIA) is one of the active ingredients in Salvia miltiorrhiza Bunge (Danshen) and plays a vital role in inhibiting inflammation. Thus, we hypothesized that Tan IIA has anti-allergic effects and studied the function of Tan IIA in mast cells and an AR animal model. We induced RBL-2H3 cell sensitization with monoclonal anti-2,4,6-dinitrophenyl-immunoglobulin (Ig) E/human serum albumin (DNP-IgE/HSA) and constructed an ovalbumin (OVA)-induced AR model in mice. The role of Tan IIA in AR progression was studied using the MTT assay, ELISA, western blot, toluidine blue staining, HE staining, and Alcian blue and safranin O (A&S) staining. Tan IIA treatment significantly increased IgE/HSA-induced cell viability. However, Tan IIA treatment markedly downregulated the expression levels of β-hexosaminidase, histamine, tumor necrosis factor (TNF-α), interleukin 1β (IL-1β), IL-4, and IL-5 in IgE/HSA-induced cells. Furthermore, Tan IIA improved typical symptoms in the OVA-induced AR model mice by inhibiting the phospholipase Cγ1 (PLCγ1)/protein kinase C (PKC)/IP3R pathway. Additionally, Tan IIA effectively improved the degranulation of RBL-2H3 cells and OVA-induced AR in mice. Together, these results suggest that Tan IIA may be a potential drug for the treatment of AR in the future.

The possibility of short-term hypothalamic-pituitary-adrenal axis suppression with high-volume, high-dose nasal mometasone irrigation in postsurgical patients with chronic rhinosinusitis

BACKGROUND

Medically refractory chronic rhinosinusitis (CRS) is often treated with functional endoscopic sinus surgery (FESS) and high-volume steroid nasal irrigation. While budesonide is the most common steroid irrigation for this indication, mometasone has a superior pharmacokinetic profile, which may allow dose escalation. The safety and efficacy of mometasone at higher concentrations than previously used in treating CRS have not been explored.

METHODS

Patients were recruited from a tertiary level clinic between June 2018 and December 2019. Inclusion criteria included adults (>18 years); CRS diagnosis; previous FESS; pre-treatment morning cortisol within normal range; minimum of twice daily high-volume sinonasal mometasone irrigations (total dose of 4 mg) for 12 weeks; and post-treatment morning cortisol measured within 2 weeks following the study period. Patients with potential for endogenous or exogenous disruption of the HPA axis were excluded.

RESULTS

14 patients were enrolled in this prospective cohort study. In all but one patient, pre- and post-treatment morning cortisol levels were not significantly different and were within normal limits (6.7-25.4 μg/dL). Following an uninterrupted 12-week treatment course, no evidence of HPA axis suppression was found (P = 0.915). The single patient who was found to have a low (1.3 μg/dL) post-treatment morning serum cortisol level reportedly received an intraarticular steroid shot several days prior to the blood draw. She remained asymptomatic and her rechecked serum cortisol was within normal limits at 12.3 μg/dL.

CONCLUSIONS

High-volume 2 mg twice daily sinonasal mometasone irrigations did not cause HPA axis suppression in a representative sample of patients with refractory CRS post-FESS with normal baseline cortisol levels.

Intranasal Corticosteroids: Topical Potency, Systemic Activity and Therapeutic Index

Intranasal corticosteroid (INCS) therapy is the preferred treatment option for allergic rhinitis (AR). Although all INCSs for the treatment of AR are considered safe and effective, differences in potency, molecular structure features and physicochemical and pharmacokinetic properties could result in differences in clinical efficacy and safety. Higher glucocorticoid receptor (GR) binding affinity of INCS is associated with higher lipophilicity, nasal tissue retention and topical potency. Higher topical potency is also accompanied by low oral bioavailability and high systemic clearance conferring low systemic exposure, reduced potential for systemic adverse effects and an improved therapeutic index. It has been shown that adverse events related to systemic exposure of INCSs in children are low. Although INCSs mostly produce low systemic effects, use of an INCS with low systemic exposure in patients on multiple corticosteroid (CS) therapies could help reduce the total systemic burden of CS therapy. Despite differences in topical potency, physicochemical and pharmacokinetic properties between INCSs, clinical studies of INCSs in the treatment of AR generally show no clinically important differences between these compounds, and poor correlation between INCS topical potency and clinical response. However, the lack of head-to-head comparisons of INCSs in clinical studies conducted in more severe AR patients should be noted. This narrative review provides an assessment of the therapeutic relevance of topical potency and the physicochemical and pharmacokinetic properties of INCSs and describes for the first time the relationship between topical potency and therapeutic index using pharmacological features of INCSs. It concludes that higher GR binding affinity and topical potency can potentially improve the therapeutic index of an INCS. Therefore, both efficacy and systemic exposure profiles should be considered when comparing INCS regimens in terms of therapeutic equivalence, to aid clinical decision-making and avoid the assumption that all INCS formulations are the same when considering treatment options.

Drug Release and Pharmacokinetic Evaluation of Novel Implantable Mometasone Furoate Matrices in Rabbit Maxillary Sinuses

BACKGROUND

Intranasal corticosteroid sprays (INCSs) used to treat chronic rhinosinusitis are suboptimal due to limited penetration into the middle meatus, rapid clearance, and poor patient compliance. A bioresorbable drug matrix, developed with the XTreo^TM drug delivery platform, may overcome the limitations of INCS by providing continuous dosing over several months.

OBJECTIVE

To evaluate the in vitro drug release and in vivo pharmacokinetics of novel mometasone furoate (MF) matrices in a rabbit dorsal maxillary osteotomy model.

METHODS

XTreo^TM matrices were formulated to consistently elute MF for up to 6 months. Matrices were surgically placed bilaterally into the maxillary sinuses of New Zealand White (NZW) rabbits. Tissue and plasma MF concentrations were measured to assess the in vivo drug delivery. The in vivo and in vitro drug release kinetics of the matrices were quantified and compared to those of rabbits receiving daily Nasonex^® MF nasal sprays.

RESULTS

XTreo^TM matrices self-expanded upon deployment to conform to the irregular geometry of the maxillary sinus cavities in the NZW rabbits. Sustained release of MF was demonstrated in vitro and in vivo for 2 MF matrices of distinct release durations and an in vitro-in vivo correlation was established. Therapeutic levels of MF in local tissues were measured throughout the intended dosing durations. In contrast to the variable peaks and troughs of daily nasal sprays, sustained dosing via a single administration of MF matrices was confirmed by quantifiable plasma MF concentrations over the intended dosing duration.

CONCLUSION

The XTreo^TM MF matrices provided targeted and efficient dosing to local sinus tissues that was superior to INCS. Sustained drug release was confirmed both in vitro and in vivo. The novel XTreo^TM technology may provide precisely tuned, long-lasting drug delivery to sinus tissues with a single treatment.

Hypothalamic-pituitary-adrenal axis suppression and intranasal corticosteroid use: A systematic review and meta-analysis

BACKGROUND

Intranasal corticosteroids (INCS) are used in the management of sinonasal conditions. Use of exogenous steroids can be associated with hypothalamic-pituitary-adrenal axis dysfunction and adrenal insufficiency (AI). We aimed to estimate the rate of AI after INCS use in a meta-analysis, stratified by steroid type and treatment duration.

METHODS

Ovid Medline, Embase Classic, PubMed, Web of Science, and CINAHL databases were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies investigating INCS use and AI. AI was defined as morning serum cortisol <550 nmol/L and <80 nmol/L with and without adrenocorticotropic hormone stimulation. INCS were classified as first (beclomethasone dipropionate, triamcinolone acetonide, beclomethasone, budesonide, dexamethasone) and second (ciclesonide, mometasone furoate, and fluticasone propionate) generation. Duration of treatment was classified as short (<1 month), medium (1-12 months), and long-term (>12 months) time periods.

RESULTS

This search identified 3668 articles. A total of 39 studies (1678 patients) were included in the final analysis. The pooled percentage of AI for routinely utilized first- and second-generation INCS was 0.70% (95% confidence interval [CI], 0.29-1.12%). Stratified by type, AI was observed in 0.78% (95% CI, 0.25-1.30%) of first-generation and 0.58% (95% CI, -0.1% to 1.26%) of second-generation steroids. AI was seen in 0.48% (95% CI, -0.01% to 0.96%) of short-term, 1.13% (95% CI, 0.2-2.1%) of medium-term, and 1.67% (95% CI, 0.37-2.9%) of long-term use of INCS.

CONCLUSION

Overall, the use of INCS carries a low risk for AI. Although modest, this risk may differ depending on the length of duration and type of INCS used. Informing patients of these risks is of importance for the treatment of chronic sinonasal conditions.

Safety and Efficacy of Maxitrol in Pediatric Age Group Below Two Years With Adenoid Hypertrophy: A Retrospective Cohort Study

Introduction Adenoid hypertrophy, a common condition in children, represents one of the common indications for surgery in pediatrics. Medical treatment alone is not effective, and most of the time patients are managed by surgical removal of the adenoid. The aim of this study is to assess the safety and efficacy of intranasal Maxitrol® drops (Novartis Pharmaceuticals, Basel, Switzerland) in pediatric patients with adenoid hypertrophy aged less than two years and to document any side effects during its use. Methods This retrospective cohort study was conducted at King Abdullah Specialist Children's Hospital (KASCH). We reviewed the charts of 86 pediatric patients aged less than two years who were diagnosed with adenoid hypertrophy between 2015 and 2018. Patients were grouped according to the type of intervention (use of Maxitrol®, and no use). The follow-up time was up to one year. Results Out of 86 patients, 55 (63.9%) patients had adenoid hypertrophy alone and 31 (36.1%) had adenoid hypertrophy plus another disease. Patients with obstructive sleep apnea symptoms (p=0.026) and grade of adenoid (p=0.040) showed a significant relationship with surgery booking after one year. The probability of booking for surgery for those who used Maxitrol® was 1.394 times higher than for those who were not using it (odds ratio [OR]=1.394; 95% confidence interval [CI]=0.549-3.537). Suppression of growth and eye complications were not reported in any of our patients. Conclusion In this small sample, the use of Maxitrol® in the pediatric age group below two years with adenoid hypertrophy was safe and effective in relieving nasal symptoms; however, eventually, surgery was needed in most of our patients. Suppression of growth and eye complications were not reported in any of our patients during the follow-up time.

Budesonide transnasal pulsating nebulization after surgery in chronic rhinosinusitis with nasal polyps

Intranasal corticosteroid drugs are widely used in chronic rhinosinusitis with nasal polyps (CRSwNP). In contrast to classical delivery with nasal pump sprays, pulsating aerosols can deliver significant doses into superior and posterior sinonasal spaces. A case-control study was designed to assess the efficacy of corticosteroid transnasal nebulization on short-term mucosal recovery and quality of life (QoL) following endoscopic sinus surgery in CRSwNP. Thirty patients were prospectively enrolled to receive either 1-month budesonide nasal pump spray or 1-month budesonide 100-Hz acoustic pulsating nebulization at the first postoperative visit (day 8). Patients were evaluated with Lund-Kennedy endoscopic score at day 8 (D8) and 1 month later (M1). CRS-related QoL questionnaires (SNOT22 and RhinoQOL) were fulfilled at M1. The Lund-Kennedy endoscopic scores compared between D8 and M1 were suggestively improved in the group treated with budesonide nebulization (mean difference between groups, - 18.28 units; 95%CI, - 31.29 to - 5.28 units, p = 0.014). QoL measurements were comparable at M1 between the groups of patients. No unexpected adverse event was described with both budesonide delivery protocols. In the early postoperative period, patients with CRswNP may benefit from pulsating nebulization. Large studies should be conducted to confirm the results. Safety profile related to systemic steroid absorption and bioavailability in chronic respiratory diseases also need to be addressed for further use.

Prediction of pharmacokinetic studies outcome for locally acting nasal sprays by using different in vitro methods

Demonstration of bioequivalence of locally acting nasal spray formulations is a challenging task and the regulatory agencies have different approach towards this goal. The pharmacokinetic bioequivalence studies are recognized as necessary for assessment of equivalent systemic exposure. We utilized three different in vitro methods for nasal spray evaluation and compared those results with the results of pharmacokinetic studies of different formulations of four intranasal corticosteroids, in order to evaluate their in vivo relevance. Two cell lines, RPMI 2650 and Calu-3, Transwell® polycarbonate membranes with different pore size and lipid-oil-lipid tri-layer membrane in the parallel artificial membrane permeability assay (PAMPA) system were used for this purpose. The in vitro results correlated with the results of pharmacokinetic studies and correctly predicted (non)equivalence of the nasal sprays, showing that in vitro methods are good indicator of the in vivo outcome. The Transwell® and PAMPA in vitro methods were additionally implemented for testing batch-to-batch variability of reference nasal spray formulations. The results from the Transwell® assay for the two poorly soluble corticosteroids are possibly over-discriminatory in showing differences between batches of reference nasal sprays. Overall, the three in vitro methods have potential to predict the results of bioequivalence testing of nasal spray products.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Effect of oral steroids on olfactory function in chronic rhinosinusitis with nasal polyps

AIMS

The present study aimed to investigate the effects of oral steroids on olfactory disturbances in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

MATERIAL AND METHODS

This is a prospective randomized non-blinded study. Selected CRSwNP patients (n=140), with hyposmia, were devided into two groups; group A received a 7-day course of oral steroids with a 12-weeks course of nasal steroids and douching; group B received a 12-weeks course of nasal steroids and douching. Assessment included Sniffin' Sticks scores, visual analogue scale score for olfaction and discomfort (VASsmell, VASdis), the Sinonasal Outcome Test-22, Greek-version (SNOT22-Gr) and the endoscopic appearance (EAS).

OBJECTIVES

The main objective was to compare the olfactory effect of the different therapy in group A and group B, at 2, 12 and 24 weeks. Accessory objectives included the comparison of EAS, VASdis and SNOT22-Gr between groups, the evaluation of the therapeutic outcome duration, and, the investigation of potential correlation between the evaluated parameters.

RESULTS

The 2-weeks evaluation showed a significant statistical difference (P<0.001) for all parameters except VASdis. Olfactory outcomes (Sniffin' Sticks and VASsmell scale scores) were found significantly better in group A at the 24-weeks evaluation (P<0.001). Within groups, the therapeutic result remained stable between the 12-weeks and 24-weeks evaluation (P>0.05). Sniffin' Sticks score was strongly correlated at 12-weeks evaluation with EAS (rho=0.58, P<0.001).

CONCLUSION

Our results suggest that a combination treatment of oral and nasal steroids in well-selected patients with CRSwNP may result in early olfaction restoration with a possible long-term effect.

Use of Off-Label Nasal Steroid Irrigations in Long-Term Management of Chronic Rhinosinusitis

OBJECTIVE

Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses and mucosa. Topical nasal corticosteroids are a mainstay treatment for CRS by reducing sinonasal inflammation and improving mucociliary clearance. However, topical corticosteroids have limited paranasal distribution, and patient response to treatment has been variable in randomized controlled trials (RCT). Thus, there is significant interest in evaluating the efficacy of nasal steroids delivered by nasal irrigation in order to improve penetration and absorption of topical steroids into the sinonasal mucosa. In this review, we discuss the use of off-label nasal steroid irrigations in the management of CRS.

METHODS

A review of clinical trials evaluating the use of nasal steroid irrigations for CRS in the PubMed electronic database was performed.

RESULTS

Of the 12 clinical studies identified, 10 evaluated budesonide irrigations while the remaining 2 focused on mometasone. The overwhelming majority of studies for both budesonide and mometasone supported the use of nasal irrigations with corticosteroids over nasal corticosteroid sprays alone. However, the heterogeneity in study design, patient cohort, and volume of steroid irrigation limit the interpretations of these studies.

CONCLUSIONS

Nasal irrigation with corticosteroids is beneficial and safe for the treatment of CRS. Future RCTs controlling for type of surgical intervention, CRS pheno- and endo-type, as well as dosing and duration of nasal corticosteroid irrigations are warranted.

The Nose as a Route for Therapy: Part 1. Pharmacotherapy

This article reviews nasal structure and function in the light of intranasal pharmacotherapy. The nose provides an accessible, fast route for local treatment of nose and sinus diseases, with lower doses than are necessary systemically and few adverse effects. It can also be used for other medications as it has sufficient surface area protected from local damage by mucociliary clearance, absence of digestive enzymes, responsive blood flow, and provides a rapid route to the central nervous system.

A sensitive and high-throughput LC-ESI-MS/MS method to detect budesonide in human plasma: application to an evaluation of pharmacokinetics of budesonide intranasal formulations with and without charcoal-block in healthy volunteers

Budesonide is one of the intranasal corticosteroids, referred as first-line therapy for allergic rhinitis. Its determination is a challenging task due to its extremely low plasma levels, which limits the progress in the investigation of pharmacokinetics and quality control of preparations. In this study, a sensitive and high-throughput method to determine budesonide in human plasma using budesonide-d8 as the internal standard was developed and validated. A small volume of plasma sample (0.2 mL) was diluted with 0.2 mL water, followed by a solid-phase extraction using Cleanert PEP-2 products. Extracted samples were analyzed by liquid chromatography coupled to electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS). Chromatographic separation of analytes was performed on an InertSustain AQ-C18 HP column (3 µm, 2.1 × 50 mm) under the reversed-phase condition with gradient elution. With the assay, linear calibration curves were obtained over the concentration range of 10-1200 pg/mL for budesonide, with considerable extraction recoveries (84.7-89.4%), and negligible matrix effects (<4.1). Moreover, the newly developed method was successfully applied to the evaluation of pharmacokinetics of two budesonide intranasal formulations with and without charcoal block in healthy volunteers.

Effects of corticosteroid on mRNA levels of histamine H1 receptor in nasal mucosa of healthy participants and HeLa cells

The purpose of this study is to examine the effect of intranasal corticosteroid (INCS) administration on histamine H1 receptor (H1R) gene expression in the nasal mucosa of healthy participants and the effects of dexamethasone on basal and histamine-induced H1R mRNA expression, and histamine-induced phosphorylation of extracellular signal-regulated kinase (ERK) in HeLa cells. Sixteen healthy participants were given INCS once daily for a week. After pretreatment of dexamethasone, HeLa cells were treated with histamine. Levels of H1R mRNA and phosphorylation of ERK were measured using real time PCR and immunoblot analysis, respectively. Levels of H1R mRNA in the nasal mucosa of healthy participants receiving INCS was significantly decreased. Dexamethasone suppressed basal levels of H1R mRNA, and histamine-induced up-regulation of H1R mRNA and ERK phosphorylation in HeLa cells. These data suggested that corticosteroid inhibited both basal transcription and histamine-induced transcriptional activation of H1R through its suppression of ERK phosphorylation in the signaling pathway involved in H1R gene transcription. It is further suggested that pre-seasonal prophylactic administration of INCS suppresses both basal and pollen-induced upregulation of H1R gene expression in the nasal mucosa of patients with pollinosis, leading to prevention of the exacerbation of nasal symptoms during peak pollen season. J. Med. Invest. 67 : 311-314, August, 2020.

Montelukast combined with intranasal mometasone furoate versus intranasal mometasone furoate; a comparative study in treatment of adenoid hypertrophy

OBJECTIVES

To evaluate the role of combined therapy using montelukast and intranasal mometasone furoate compared to intranasal mometasone furoate alone in treatment of adenoid hypertrophy regarding efficacy and recurrence rate.

METHODS

The study included 100 children with adenoid hypertrophy, they were randomly assigned to two groups. Group I (50 patients) received combined therapy using montelukast and mometasone furoate nasal spray. Group II (50 patients) received only mometasone furoate nasal spray. Patients were treated for 3 months and observed for 3 months after stoppage of treatment. Patients were evaluated using symptoms scores, Adenoid/Nasopharyngeal ratio and endoscopic grading of adenoid hypertrophy.

RESULTS

After 3 months of treatment, group I showed significant better scores of main symptoms than group II; (P = 0.001), (P = 0.019) and (P = 0.008) for rhinorrhea, mouth breathing and snoring respectively. The mean A/N ratio was 52.8 ± 11.3 in group I better than 62.88 ± 12.10 in group II (P < 0.001). Regarding the adenoid hypertrophy grading, significant reduction in size was found in group I in 34 (68%) patients better than in group II in 18 (36%) patients (P = 0.001). After further 3 months of follow up, the mean A/N ratio was 58.46 ± 10.05 in group I better than 66.36 ± 10.46 in group II (P < 0.001). Recurrence occurred in 8 (23.5%) cases out of 34 improved cases in group I better than 10 (55.5%) cases out of 18 cases in group II (P = 0.02).

CONCLUSION

Combining oral montelukast with intranasal mometasone in treatment of adenoid hypertrophy provided better improvements and less recurrence in comparison with single therapy using intranasal mometasone alone.

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.

4-Carvomenthenol ameliorates the murine combined allergic rhinitis and asthma syndrome by inhibiting IL-13 and mucus production via p38MAPK/NF-κB signaling pathway axis

The aim of this study was to analyze the 4-carvomenthenol (carvo) oral treatment on the experimental model of the combined allergic rhinitis and asthma syndrome (CARAS). BALB/c mice were OVA-sensitized on day zero and 7th (50 μg/mL OVA in 10 mg/mL Al (OH)3) and OVA-challenged (5 mg/mL, 20 μL/animal) for three weeks. In the last week, the animals were dally challenged with aerosol of OVA and the carvo treatment (12.5, 25 or 50 mg/kg) occurred one hour before each OVA-challenge. Data were analyzed and p < 0.05 was considered significant. Carvo (12.5-50 mg/kg) decreased significantly the eosinophil migration into the nasal (NALF) and bronchoalveolar (BALF) cavities as well as on the nasal and lung tissues of sick animals. The treatment also decreased mucus production on both tissue sections stained with PAS (periodic acid-Schiff satin). In addition, the histological analyzes demonstrated that sick mice presented hyperplasia and hypertrophy of the lung smooth muscle layer followed by increasing of extracellular matrix and carvo (50 mg/kg) inhibited these asthmatic parameters. We analyzed the allergic rhinitis signals as nasal frictions and sneezing and observed that carvo decreased these two signals as well as serum OVA-specific IgE titer, type 2 cytokine synthesis, mainly IL-13, with increasing of IL-10 production. Decreasing of IL-13 production corroborated with decreasing of mucus production and these effects were dependent on p38MAPK/NF-κB(p65) signaling pathway inhibition. Therefore, these data demonstrated that a monoterpene of essential oils presents anti-allergic property on an experimental model of CARAS suggesting a new drug prototype to treat this allergic syndrome.

Rhinitis 2020: A practice parameter update

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

Fast effectiveness of a solubilized low-dose budesonide nasal spray in allergic rhinitis

Background

Budesonide, a poorly water‐soluble corticosteroid, is currently marketed as a suspension. Budesolv is a novel aqueous formulation containing dissolved budesonide showing increased local availability in preclinical models. Budesolv contains ~85% less corticosteroid than the marketed comparator.

Objective

The study (EudraCT:2018‐001324‐19) was designed to assess non‐inferiority of Budesolv compared to Rhinocort® Aqua 64 (RA) and early onset of action.

Methods

In a three‐way cross‐over double‐blinded randomized trial, Budesolv 10 was compared to RA and placebo in grass pollen allergic rhinoconjunctivitis volunteers (n = 83 (ITT); n = 75 (PP)). On day 1, participants entered the Vienna Challenge Chamber (VCC) for 6 hours; first treatment took place at 1:45 hours after entry. Participants treated themselves for further 6 days; on day 8, the last treatment was applied before entering the VCC. Subjective symptom scores, nasal airflow and nasal secretion were measured regularly during allergen challenge.

Results

Budesolv 10 was equally effective compared to RA with respect to TNSS and nasal airflow after eight days of treatment with a strongly reduced dose (more than 80% reduction). After first dose, only Budesolv 10 showed a significant reduction of nasal and respiratory symptoms starting 90 minutes (P < .05) and 15 minutes (P < .05) after application onwards, respectively, demonstrating an early onset of efficacy. A clinically significant 1 point reduction in nasal symptom score was reached at 195 minutes (P < .05) after application.

Conclusions and clinical relevance

The novel preservative‐free, aqueous low‐dose budesonide formulation is highly efficacious even after an initial single treatment. Thus, Budesolv 10 appears to be an effective acute treatment for allergic rhinitis as well as for AR comorbidities like mild asthma and conjunctivitis.

Understood? Evaluating the readability and understandability of intranasal corticosteroid delivery instructions

BACKGROUND

Allergic rhinitis is a widespread disease that has significant quality-of-life ramifications. Symptoms include rhinorrhea, nasal obstruction, cough, and postnasal drip. Intranasal corticosteroids are a hallmark of treatment of allergic rhinitis. However, the benefits of treatment are dependent on correct nasal spray technique, of which many patients are not aware. Patient instructions are included with the purchase of these medications. The readability and understandability for these educational materials has been minimally assessed in the medical literature. The aim of this study was to evaluate the readability and understandability of commonly used intranasal steroids.

METHODS

Three readability measures (Gunning Fog, Simple Measure of Gobbledygook [SMOG], and FORCAST) and an understandability assessment (Patient Education Materials Assessment Tool for Printable Materials [PEMAT-P]) were used to evaluate the instructions for use of commonly prescribed intranasal steroids. Instructions with 6th grade readability level or lower were considered to meet health literacy experts' recommendations. Higher understandability values correlate to easier understandability.

RESULTS

Instructions for 10 intranasal corticosteroid brands were reviewed. Gunning Fog consistently estimated easiest readability, whereas FORCAST estimated most difficult readability. Twenty percent (20%) of analyzed instructions met National Institutes of Health and health literacy experts' recommended reading levels. Understandability of instructions ranged from 33% to 90%, with an average of 66%.

CONCLUSION

The benefit of intranasal corticosteroids is contingent on correct use by patients. However, the prepackaged instructions provided are most often above recommended reading levels and are difficult to understand. Future development of intranasal steroid instructions should meet recommended readability levels and be understandable to maximize their utility.