Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion

Evolving paradigms of treatment of allergic and nonallergic rhinitis

Allergic rhinitis (AR) is a prevalent disease affecting approximately 15% of the US population, which is approximately 50 million individuals. More broadly, it is estimated that 400 to 500 million people worldwide experience AR. Not surprisingly, AR has a significant impact on quality of life due to increased fatigue, cognitive impairment, sleep disturbances, presenteeism or absenteeism, and impairment of performance, which all contribute to an increased cost burden to the medical system. Recent studies have identified social determinants of health including income level, age of migration from rural to urban areas or to high-income countries, and access to health care as important factors associated with the prevalence of allergic diseases. However, up to 25% of individuals have non-AR triggered by mechanical, osmotic, and chemical irritants, and 50% have mixed rhinitis characterized by allergic and nonallergic triggers. Uncontrolled chronic rhinitis subtypes have all been associated with asthma, eczema, chronic or recurrent sinusitis, cough, and both tension and migraine headaches. This review will address AR and non-AR with a focus on evolving treatments in adults.

Variants of rhinitis medicamentosa treatment: a systematic review

PURPOSE

Nasal breathing dysfunction resulting from uncontrolled decongestant use is an extremely urgent public health problem. This condition is referred to as rhinitis medicamentosa. Despite the high incidence of patients with this diagnosis, there is still no consensus on treatment tactics. The purpose of this study was to review the available literature on rhinitis medicamentosa treatment and summarize the findings reported in different approaches.

METHODS AND MATERIALS

We conducted a systematic review of PubMed (MEDLINE), The Cochrane Library, and Clinicaltrials.gov databases to identify studies that describe conservative and surgical treatments for rhinitis medicamentosa.

RESULTS

Twelve studies, including 373 patients, met the search criteria. Out of these, seven studies used topical intranasal steroids like budesonide or fluticasone propionate sprays as a conservative treatment. One study used dexamethasone nasal drops. Five studies involved surgical treatment for patients; three of these studies used radiofrequency ablation to reduce the inferior turbinates, while the other two studies used diode laser and kinetic stimulation, respectively.

CONCLUSION

All studies included in this systematic review demonstrate the high efficacy of the separately presented treatment methods. However, the different design and evaluation methods do not allow us to systematize the data and develop a unified algorithm for treating rhinitis medicamentosa. We see the potential for conducting comparative evidence-based studies on a larger sample, along with the evaluation of long-term treatment results.

Outcomes after Functional Nasal Surgery in Patients with Versus without Rhinitis Medicamentosa

OBJECTIVE

Topical nasal decongestants (TNDs) are used to reduce nasal soft tissue edema and obstruction. However, after frequent TND use, patients can develop rhinitis medicamentosa (RM) with rebound nasal edema and obstruction. Management of RM has centered largely on TND cessation ± intranasal corticosteroids. The purpose of this study was to compare nasal obstruction outcomes following nasal obstruction surgery in patients with versus without RM.

METHODS

A retrospective case-control study was conducted with adult patients who underwent bilateral inferior turbinate reduction (ITR) with or without septoplasty and nasal valve repair. Patients with versus without RM were assessed. RM was defined as at least daily TND use for ≥4 weeks. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores, and long-term TND cessation rates were collected. NOSE score changes were compared between patients with versus without RM.

RESULTS

Of the 36 RM patients, mean age was 52.0 years, and 63.9% were male. Of 116 non-RM patients, mean age was 41.6 years, and 46.6% were male. Postoperative NOSE scores were collected at a mean 972.1 days postoperatively for RM patients, and 565.0 days for non-RM patients. Mean NOSE score reductions were - 9.8 for RM and - 8.6 for non-RM patients, both of which were significant (p < 0.0001). NOSE score reductions were not significantly between the two groups (p = 0.2438). Long-term TND cessation was maintained in 86.1% of RM patients.

CONCLUSION

Patients with and without RM achieved similar long-term significant NOSE score reductions following nasal obstruction surgery, and 86.1% of RM patients maintained long-term TND cessation.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1015-1020, 2025.

Rhinitis in Primary Care

Rhinitis affects a significant portion of the world population and increases the cost of health care by billions of dollars in treatment costs and missed days of work. Allergic rhinitis is the most common cause. Rhinitis is primarily a clinical diagnosis which can be confirmed with specific testing as indicated to ascertain causative agents. Initial treatment includes using topical agents like intranasal corticosteroids and inhaled antihistamines as the first-line therapies for both allergic rhinitis and chronic rhinitis. Therapy can evolve in a stepwise manner depending on the primary symptom complaint prior to referral for advanced therapies such as allergen immunotherapy.

Nonallergic Rhinopathy: A Comprehensive Review of Classification, Diagnosis, and Treatment

Chronic nonallergic rhinitis syndromes encompass various conditions, of which vasomotor rhinitis is the most common form, representing approximately 80% of patients, also referred to as nonallergic rhinopathy (NAR), nasal hyperreactivity, neurogenic rhinitis, or idiopathic rhinitis. Expert panels have recommended replacing vasomotor rhinitis terminology because it is more descriptive of this condition that is characterized by symptoms triggered by chemical irritants and weather changes through chemosensors, mechanosensors, thermosensors, and/or osmosensors activated through different transient receptor potential calcium ion channels. Elucidating the specific role of transient receptor potential vanilloid 1, triggered by capsaicin, has been an important advancement in better understanding the pathophysiology of NAR because it has now been shown that downregulation of transient receptor potential vanilloid 1 receptors by several therapeutic compounds provides symptomatic relief for this condition. The classification of NAR is further complicated by its association with allergic rhinitis referred to as mixed rhinitis, which involves both immunoglobulin E-mediated and neurogenic mechanistic pathways. Comorbidities associated with NAR, including rhinosinusitis, headaches, asthma, chronic cough, and sleep disturbances, underscore the need for comprehensive management. Treatment options for NAR include environmental interventions, pharmacotherapy, and in refractory cases, surgical options, emphasizing the need for a tailored approach for each patient. Thus, it is extremely important to accurately diagnose NAR because inappropriate therapies lead to poor clinical outcomes and unnecessary health care and economic burdens for these patients. This review provides a comprehensive overview of NAR subtypes, focusing on classification, diagnosis, and treatment approaches for NAR.

Adrenoceptor Desensitization: Current Understanding of Mechanisms

G-protein coupled receptors (GPCRs) transduce a wide range of extracellular signals. They are key players in the majority of biologic functions including vision, olfaction, chemotaxis, and immunity. However, as essential as most of them are to body function and homeostasis, overactivation of GPCRs has been implicated in many pathologic diseases such as cancer, asthma, and heart failure (HF). Therefore, an important feature of G protein signaling systems is the ability to control GPCR responsiveness, and one key process to control overstimulation involves initiating receptor desensitization. A number of steps are appreciated in the desensitization process, including cell surface receptor phosphorylation, internalization, and downregulation. Rapid or short-term desensitization occurs within minutes and involves receptor phosphorylation via the action of intracellular protein kinases, the binding of β-arrestins, and the consequent uncoupling of GPCRs from their cognate heterotrimeric G proteins. On the other hand, long-term desensitization occurs over hours to days and involves receptor downregulation or a decrease in cell surface receptor protein level. Of the proteins involved in this biologic phenomenon, β-arrestins play a particularly significant role in both short- and long-term desensitization mechanisms. In addition, β-arrestins are involved in the phenomenon of biased agonism, where the biased ligand preferentially activates one of several downstream signaling pathways, leading to altered cellular responses. In this context, this review discusses the different patterns of desensitization of the α 1-, α 2- and the β adrenoceptors and highlights the role of β-arrestins in regulating physiologic responsiveness through desensitization and biased agonism. SIGNIFICANCE STATEMENT: A sophisticated network of proteins orchestrates the molecular regulation of GPCR activity. Adrenoceptors are GPCRs that play vast roles in many physiological processes. Without tightly controlled desensitization of these receptors, homeostatic imbalance may ensue, thus precipitating various diseases. Here, we critically appraise the mechanisms implicated in adrenoceptor desensitization. A better understanding of these mechanisms helps identify new druggable targets within the GPCR desensitization machinery and opens exciting therapeutic fronts in the treatment of several pathologies.

Rhinitis medicamentosa - comparing two treatment strategies: a retrospective analysis

OBJECTIVE

Rhinitis medicamentosa poses a therapeutic challenge for both patients and physicians. Treatment strategies vary, starting with avoidance of decongestants, followed by medications or surgical intervention. This study aimed to compare two treatment strategies for this condition.

METHODS

A review was conducted of patients diagnosed with rhinitis medicamentosa from 2013 to 2021, who were managed conservatively with medications or surgically by inferior turbinate reduction.

RESULTS

Forty-seven patients were included: 21 patients were treated conservatively and 26 underwent turbinate reduction. Following surgical therapy, the frequency of using decongestants was significantly reduced (p < 0.001), with a significant improvement in Sino-Nasal Outcome Test-22 scores (p < 0.001). The conservative treatment group was significantly older with more co-morbidities. Following medical therapy, the conservative treatment group had a significant decrease in the frequency of decongestant use, but there was no significant improvement in their Sino-Nasal Outcome Test-22 scores.

CONCLUSION

Compared to conservative treatment, inferior turbinate reduction for rhinitis medicamentosa resulted in reduced decongestant use and improved quality of life.

A Real-World Observational Study to Evaluate the Safety and Effectiveness of Fluticasone Furoate-Oxymetazoline Fixed Dose Combination Nasal Spray in Patients with Allergic Rhinitis

BACKGROUND

Allergic rhinitis (AR) has shown an increasing prevalence leading to a considerable medical and social burden. Nasal congestion is the cardinal symptom of AR, and the upper respiratory tract is most affected by this long-lasting ailment. Intranasal corticosteroids alleviate nasal congestion, along with other symptoms of AR, but their effect is not evident immediately. Oxymetazoline has a rapid onset of action, but its use should be limited to 3-5 days.

OBJECTIVE

The study aimed to evaluate the safety and effectiveness of the fixed-dose combination nasal spray containing fluticasone furoate and oxymetazoline hydrochloride (FF + OXY) 27.5/50 mcg once daily in patients with AR in a real-world clinical setting.

METHODS

The study was a prospective, open-label, single-arm, multicenter, real-world observational study conducted in patients with AR for a period of 28 days. Patients (n = 388) with a diagnosis of AR were treated with a combination of FF + OXY nasal spray. Total nasal symptom score (TNSS), total ocular symptom score (TOSS) and total symptom score (TSS) were documented at baseline and at the end of study period. The overall effectiveness of treatment with FF + OXY was rated by the investigators as very good/good/satisfactory/poor (4-point Likert scale) for each patient.

RESULTS

Treatment with FF + OXY resulted in significant reduction in the TNSS, TOSS and TSS, from 7.18 ± 3.38 at baseline to 0.20 ± 0.84 (p < 0.001), from 2.34 ± 2.29 at baseline to 0.09 ± 0.53 (p < 0.001), from 9.51 ± 4.94 at baseline to 0.29 ± 1.32 (p < 0.001) at 28 days respectively. With respect to effectiveness, the investigators reported very good effectiveness in 52.12% of patients. No serious adverse events were reported.

CONCLUSION

The fixed-dose combination of once-daily fluticasone furoate and oxymetazoline hydrochloride nasal spray 27.5/50 mcg was effective in relieving the nasal congestion and reduction of TNSS, TOSS and TSS in patients suffering from AR. The combination was safe and well tolerated with no rebound congestion throughout the treatment period.

Use, Abuse, and Misuse of Nasal Medications: Real-Life Survey on Community Pharmacist’s Perceptions

Background: Medication overuse is an increasing global problem, especially for those rhinology diseases whose management requires over-the-counter drugs. This observational community pharmacy-based study aimed to investigate the actual use of the best-selling topical nasal medications and to characterize the clinical issues underlying their query through the pharmacist’s perception. Methods: In the pilot phase, a preliminary survey was developed by a team of researchers and tested on a small sample of practitioners to assess usability and intelligibility. Eventual amendments were made according to the feedback obtained, and the final version was submitted to practitioners working in 376 pharmacies evenly distributed over the Italian territory. Results: Two groups of customers (18–30 years old and 60–75 years old) were the ones who most frequently purchased topical decongestants. The dosage applied for sympathomimetic amines was higher than recommended in up to 44.4% and the duration of use longer than 5 days in up to 31.9% of the cases. Patients’ queries of alpha agonists and topical corticosteroids resulted in significantly higher numbers than practitioners’ prescriptions. Allergic rhinitis was the most common disease affecting patients seeking sympathomimetic amines. Conclusions: The prolonged use of sympathomimetic amines in patients suffering from rhinology diseases is a significant problem that requires greater attention in terms of social education and surveillance.

The Effect of Topical Oxymetazoline on Eyelid Position, Eye Redness, and Patient-Reported Eye Appearance: A Randomized Controlled Trial

PURPOSE

This study assesses the effects of topical oxymetazoline 0.1% on eyelid position, eye redness, and patient-perceived eye appearance in patients without severe ptosis.

METHODS

This is a randomized double-blinded controlled trial conducted at a single institute. Patients aged 18-100 years were randomized to receive one drop of oxymetazoline hydrochloride 0.1% or placebo bilaterally. Marginal reflex distance (MRD) 1 and 2, palpebral fissure height, eye redness, and patient-perceived eye appearance were assessed at baseline and two hours after drop instillation. Primary outcome measures included the change in MRD1, MRD2, and palpebral fissure height. Secondary outcome measures included changes in eye redness and patient-perceived eye appearance after drop instillation.

RESULTS

In total, 114 patients were included, 57 treatment patients (mean age 36.4 ± 12.7 years, 31.6% male) and 57 controls (mean age 31.3 ± 10.1 years, 33.3% male). Baseline mean MRD1, MRD2, and palpebral fissure were similar between groups (p = 0.24, 0.45, and 0.23, respectively). Changes in MRD1 and eye redness in the treatment group were significantly greater than those in the control group (0.9 ± 0.9 mm vs. - 0.3 ± 0.4 mm, p < 0.001; - 2.6 ± 4.4 vs. - 0.5 ± 2.3, p = 0.002, respectively). Patient-perceived eye appearance was significantly improved in the treatment group compared to the controls (p = 0.002), with more treatment group patients also reporting increased eye size and decreased eye redness (p = 0.008, p = 0.003, respectively). There were 9 treatment-emergent adverse events (TEAEs) in 7 treatment group patients and 5 TEAEs in 5 control patients (p = 0.25), all of which were mild in severity.

CONCLUSIONS

Topical oxymetazoline 0.1% increases MRD1 and palpebral fissure height, decreases eye redness, and improves patient-perceived eye appearance.

Brimonidine tartrate ophthalmic solution 0.025% for redness relief: an overview of safety and efficacy

INTRODUCTION

Ocular redness, or conjunctival hyperemia, is a common ophthalmic sign associated with reduced quality of life. For redness without apparent underlying pathology, topical ophthalmic decongestants have been widely used.

AREAS COVERED

Brimonidine tartrate was approved in 2017 as a topical vasoconstrictor at a 0.025% concentration for relief of ocular redness. Since then, investigators have reported on efficacy and safety findings from studies evaluating low-dose brimonidine for reducing ocular redness.

EXPERT OPINION

Brimonidine is highly selective for α₂-adrenergic receptors. Clinical trials have so far shown that the drug in low doses significantly reduces ocular redness in comparison to vehicle for up to 8 hours. Brimonidine-treated eyes did not present side effects of other vasoconstrictors, such as hypotension, cardiac arrhythmia or drowsiness. Ocular adverse events such as allergic reactions and redness rebound were also minimal. In this review, we examine in detail published literature on the mechanism of brimonidine tartrate and its efficacy and safety in relieving conjunctival hyperemia.

Efficacy and Safety of Fluticasone Furoate and Oxymetazoline Nasal Spray: A Novel First Fixed Dose Combination for the Management of Allergic Rhinitis with Nasal Congestion

Objective

To compare the efficacy and safety of a fixed dose combination of Fluticasone Furoate and Oxymetazoline Hydrochloride Nasal Spray 27.5/50 mcg (FDC) with Fluticasone Furoate Nasal Spray 27.5 mcg (Fluticasone) in the management of allergic rhinitis.

Patients and Methods

A prospective, randomized, double-blind, two-arm, active-controlled, parallel, multicenter, comparative clinical study was conducted in patients with allergic rhinitis aged 18 years and above having moderate-to-severe nasal congestion.

Results

A total of 250 patients were randomized (1:1) to receive either the FDC or Fluticasone alone in a dose of two sprays in each nostril once daily at night. There was a significantly (P<0.001) greater reduction in night-time Total Nasal Symptom Score with the FDC as compared to Fluticasone at all the time points starting from as early as day 3 and sustained till the end of treatment (Day 28) (Day 3: −3.1 vs −2.2; Day 7: −4.0 vs −3.4; Day 14: −5.7 vs −5.0; Day 28: −7.0 vs −6.4). A significantly greater number of patients (P<0.05) had complete relief in Nasal Congestion with the FDC (44.7%) as compared to Fluticasone (26.8%). Both the study medications were well tolerated by all the patients. The proportion of patients showing worsening of symptoms (rebound congestion/rhinitis medicamentosa) after stoppage of medication was similar in both groups (P>0.05).

Conclusion

The FDC was superior to Fluticasone alone in relieving the nasal congestion and reduction of Total Nasal Symptom Score in allergic rhinitis patients with moderate-to-severe nasal congestion when administered once daily in the evening. Oxymetazoline when used along with the nasal steroid in a once daily dose does not cause rebound congestion and rhinitis medicamentosa even after long-term continuous use of 28 days.

Allergic Rhinitis: A Clinical and Pathophysiological Overview

Allergic rhinitis (AR) represents a global health concern where it affects approximately 400 million people worldwide. The prevalence of AR has increased over the years along with increased urbanization and environmental pollutants thought to be some of the leading causes of the disease. Understanding the pathophysiology of AR is crucial in the development of novel therapies to treat this incurable disease that often comorbids with other airway diseases. Hence in this mini review, we summarize the well-established yet vital aspects of AR. These include the epidemiology, clinical and laboratory diagnostic criteria, AR in pediatrics, pathophysiology of AR, Th2 responses in the disease, as well as pharmacological and immunomodulating therapies for AR patients.

Attenuation of Response to Repeated Drug Administration: A Proposal for Differentiating Tachyphylaxis and Tolerance

Attenuation of drug response with repeated administration is referred to as tachyphylaxis or tolerance, though the distinction between these two is obscured through both their usage in the literature and imprecise definitions in common pharmacology texts. In this perspective, I propose that these terms be distinguished by the mechanisms underlying the attenuation of drug response. Specifically, tachyphylaxis should be reserved for attenuation that occurs in response to cellular depletion, whereas tolerance should be used to describe attenuation that arises from cellular adaptations. A framework for understanding behavioral tolerance, physiologic tolerance, and dispositional tolerance as distinct phenomena is also discussed. Using this framework, a classification of drugs exhibiting attenuation of drug response with repeated administration is presented. SIGNIFICANCE STATEMENT: Distinction between tachyphylaxis and tolerance is unclear in the literature. Nonetheless, a mechanistic basis for distinguishing these important terms has practical implications for managing or preventing attenuation of drug response with repeated administration.

Can bleeding in trabeculectomy be decreased? Effectiveness of brimonidine pre-treatment

PURPOSE

To evaluate the efficacy of preoperative topical brimonidine use to maintain visibility during trabeculectomy and control intraoperative bleeding and postoperative subconjunctival hemorrhage.

METHODS

The first group comprised 35 eyes of 34 patients administered brimonidine tartrate 0.15% (Brimogut, Bilim Ilac, Turkey) eye drops 6 and 3 min before surgery, and 33 eyes of 31 patients who received no medication for vasoconstriction formed the second group. Preoperative and postoperative photographs and operation video images were taken and vision analysis software used. Black-and-white images were obtained to identify the blood vessel and surface hemorrhage areas. The surface area of the hemorrhage was calculated by counting the black pixels with Image J software.

RESULTS

There was no significant difference between two groups in terms of baseline (preoperative) eye redness (p > 0.05). In the first group, the eye redness values were 344.7 ± 19.5 pixels preoperatively and 244.1 ± 23.3 pixels at the beginning of the surgery, respectively (p < 0.001). However, no significant change was observed in the second group in eye redness (348.2 ± 17.5 pixels preoperatively and 360.7 ± 26.8 pixels at the beginning of the surgery, p > 0.05). Cautery was used for an average of 11.91 ± 1.96 s in the first group and 25.57 ± 4.66 s in the second to control intraoperative bleeding (P < 0.001).

CONCLUSION

Preoperative topical brimonidine use in trabeculectomy surgery significantly decreased intraoperative bleeding and postoperative subconjunctival hemorrhage and facilitated bleeding control.

Intranasal corticosteroid and oxymetazoline for chronic rhinitis: a systematic review

OBJECTIVE

This study aimed to summarise the evidence for efficacy of combination treatment of intranasal corticosteroid spray with oxymetazoline hydrochloride nasal spray for chronic rhinitis.

METHOD

Nine databases were systematically searched from study inception in September 2016 to 1 June 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.

RESULTS

A total of 130 studies were screened, and 4 randomised controlled trials comprising 838 patients met inclusion criteria. The study found superior improvement of nasal congestion from onset of treatment to completion in intranasal corticosteroid spray and oxymetazoline hydrochloride groups compared with control groups. Intranasal corticosteroid spray and oxymetazoline hydrochloride use resulted in higher nasal volume (standard error of mean 1, 15.8 + 1.1 ml; p < .03) compared with either placebo (12.1 + 0.9 ml) or oxymetazoline hydrochloride (12.4 + 0.8 ml) alone (p = 0.003).

CONCLUSION

Intranasal corticosteroid spray and oxymetazoline hydrochloride combination treatment may be superior in reducing rhinitis symptoms compared with either intranasal corticosteroid spray or oxymetazoline hydrochloride alone, without inducing rhinitis medicamentosa.

Safety of Once-Daily Oxymetazoline HCl Ophthalmic Solution, 0.1% in Patients with Acquired Blepharoptosis: Results from Four Randomized, Double-Masked Clinical Trials

Purpose

An oxymetazoline 0.1% ophthalmic solution was recently approved for treatment of acquired blepharoptosis in adults. This study's objective was to evaluate the safety profile of oxymetazoline 0.1% when administered once daily for 14-84 days.

Patients and Methods

Pooled analysis examined safety outcomes from four randomized, double-masked, placebo-controlled clinical trials conducted at 6, 16, 27, and 35 sites, respectively, in the United States. In total, 568 participants with acquired blepharoptosis were evaluated. Median age was 66 years and 74.8% of participants were female. Overall, 375 participants self-administered oxymetazoline 0.1% to both eyes once/day and 193 self-administered placebo (vehicle) daily. Treatment-emergent adverse event (TEAE) rates, severity, and causality were evaluated in the overall population and within participant subgroups defined based on age, race, and ethnicity. Vital signs and ophthalmic findings were evaluated at predefined study visits. Patient-reported treatment tolerability was recorded at study end.

Results

TEAE incidence was similar among participants using oxymetazoline 0.1% (31.2%) or vehicle (30.6%). Nearly all TEAEs were mild-to-moderate, and most were not suspected of being treatment related. Serious TEAEs occurred in four participants receiving oxymetazoline 0.1% and one participant receiving vehicle. Nine and two participants in the oxymetazoline 0.1% and vehicle groups, respectively, discontinued due to a TEAE. Ocular TEAEs occurring in ≥2% of participants receiving oxymetazoline 0.1% were punctate keratitis, conjunctival hyperemia, dry eye, blurred vision, instillation site pain, and corneal vital dye staining, with none occurring in >3.5% of participants. TEAE rates were similar across subgroups based on age, race, and ethnicity. No clinically significant mean changes in vital signs or ophthalmologic findings occurred, and >98% of participants rated oxymetazoline 0.1% as causing no/mild discomfort.

Conclusion

Once-daily oxymetazoline 0.1% was safe and well tolerated in participants with acquired blepharoptosis when used for 14-84 days. Safety did not appear to differ based on age, race, or ethnicity.

Prevalence, comorbidities, diagnosis, and treatment of nonallergic rhinitis: real-world comparison with allergic rhinitis

Rhinitis is among the most common respiratory diseases in children. Nonallergic rhinitis, which involves nasal symptoms without evidence of systemic allergic inflammation or infection, is a heterogeneous entity with diverse manifestations and intensities. Nonallergic rhinitis accounts for 16%-89% of the chronic rhinitis cases, affecting 1%-50% (median 10%) of the total pediatric population. The clinical course of nonallergic rhinitis is generally rather mild and less likely to be associated with allergic comorbidities than allergic rhinitis. Here, we aimed to estimate the rate of coexisting comorbidities of nonallergic rhinitis. Nonallergic rhinitis is more prevalent during the first 2 years of life; however, its underestimation for children with atopic tendencies is likely due to low positive rates of specific allergic tests during early childhood. Local allergic rhinitis is a recently noted phenotype with rates similar to those in adults (median, 44%; range, 4%-67%), among patients previously diagnosed with nonallergic rhinitis. Idiopathic rhinitis, a subtype of nonallergic rhinitis, has been poorly studied in children, and its rates are known to be lower than those in adults. The prevalence of nonallergic rhinitis with eosinophilia syndrome is even lower. A correlation between nonallergic rhinitis and pollution has been suggested owing to the recent increase in nonallergic rhinitis rates in highly developing regions such as some Asian countries, but many aspects remain unknown. Conventional treatments include antihistamines, intranasal corticosteroids, and recent treatments include combination of intranasal corticosteroids with azelastin or decongestants. Here we review the prevalence, diagnosis, comorbidities, and treatment recommendations for nonallergic rhinitis versus allergic rhinitis in children.

Association of Oxymetazoline Hydrochloride, 0.1%, Solution Administration With Visual Field in Acquired Ptosis: A Pooled Analysis of 2 Randomized Clinical Trials

Importance

Treatment of acquired blepharoptosis (ptosis) is currently limited to surgical intervention.

Objective

To examine the efficacy and safety of oxymetazoline hydrochloride, 0.1%, ophthalmic solution (oxymetazoline, 0.1%) in participants with acquired ptosis.

Design, Setting, and Participants

This pooled analysis of 2 randomized, double-masked, placebo-controlled, multicenter phase 3 clinical trials included participants 9 years and older with acquired ptosis and superior visual field deficit. The 2 studies were conducted across 16 and 27 sites in the United States. Patients were enrolled from May 2015 to April 2019. Analyses for the individual trials were initiated after database lock and completed on September 6, 2017, and May 16, 2019. Pooled analysis was completed on August 25, 2019.

Interventions

Participants (randomized 2:1) received oxymetazoline, 0.1%, or vehicle, self-administered as a single drop per eye, once daily, for 42 days.

Main Outcomes and Measures

The primary efficacy end point was change from baseline in the number of points seen on the Leicester Peripheral Field Test, a test to detect superior visual field deficits due to ptosis, on days 1 (6 hours after instillation) and 14 (2 hours after instillation). The secondary end point, change from baseline in marginal reflex distance 1, was assessed at the same time points.

Results

In total, 304 participants were enrolled (mean [SD] age, 63.8 [13.8] years; 222 women [73%]). Overall, 97.5% (198 of 203) of participants receiving oxymetazoline, 0.1%, and 97.0% (98 of 101) of participants receiving vehicle completed the studies. Oxymetazoline, 0.1%, was associated with a significant increase in the mean (SD) number of points seen on the Leicester Peripheral Field Test vs vehicle (day 1: 5.9 [6.4] vs 1.8 [4.1]; mean difference, 4.07 [95% CI, 2.74-5.39]; P < .001; day 14: 7.1 [5.9] vs 2.4 [5.5]; mean difference, 4.74 [95% CI, 3.43-6.04]; P < .001). Oxymetazoline, 0.1%, also was associated with a significant increase in marginal reflex distance 1 from baseline (mean [SD]: day 1: 0.96 [0.89] mm vs 0.50 [0.81] mm; mean difference, 0.47 mm [95% CI, 0.27-0.67]; P < .001; day 14: 1.16 [0.87] mm vs 0.50 [0.80] mm; mean difference, 0.67 mm [95% CI, 0.46-0.88]; P < .001). Treatment-emergent adverse events (TEAEs) occurred in 31.0% (63 of 203) of participants receiving oxymetazoline, 0.1%, and 35.6% (36 of 101) of participants receiving vehicle. Among participants receiving oxymetazoline, 0.1%, with a TEAE, 81% (51 of 63) had a maximum TEAE intensity of mild, and 62% (39 of 63) had no TEAE suspected of being treatment related.

Conclusions and Relevance

Oxymetazoline, 0.1%, was associated with positive outcomes and was well tolerated in phase 3 trials after instillation at days 1 and 14, demonstrating its potential promise for the treatment of acquired ptosis, although further study is needed to elucidate the clinical relevance of these findings beyond 6 weeks.

Rapid and Sustained Eyelid Elevation in Acquired Blepharoptosis with Oxymetazoline 0.1%: Randomized Phase 3 Trial Results

Purpose

Oxymetazoline 0.1% is a novel ophthalmic agent for the treatment of acquired blepharoptosis in adults that has been shown to improve upper eyelid elevation and superior visual field deficits. This analysis characterized the rapid onset of upper eyelid elevation with once-daily oxymetazoline 0.1% and durability of this effect over 42 days.

Materials and Methods

Pooling data from two prospective, randomized, placebo-controlled, phase 3 studies, change in marginal reflex distance 1 (MRD-1) was evaluated at a range of post-instillation time points on treatment days 1, 14, and 42. Onset of effect was assessed beginning at 5 minutes post-administration (one study) and through 6 hours at the first two visits (both studies). Overall, 203 subjects received oxymetazoline 0.1% and 101 received vehicle.

Results

Oxymetazoline 0.1% demonstrated a rapid onset of action on all days evaluated. Mean changes from baseline 5 and 15 minutes post-oxymetazoline 0.1% instillation on day 1 were 0.59 ± 0.72 mm and 0.93 ± 0.81 mm, respectively (vs 0.20 ± 0.57 mm and 0.32 ± 0.64 mm with vehicle; both p<0.001). On day 14, mean changes from baseline 5 and 15 minutes post-oxymetazoline 0.1% instillation were 0.77 ± 0.85 mm and 1.11 ± 0.92 mm, respectively (vs 0.42 ± 0.78 mm and 0.41 ± 0.83 mm with vehicle; both p<0.05). This effect was also observed immediately post-instillation on day 42, where mean increases 5 and 15 minutes post-oxymetazoline 0.1% instillation were 0.86 ± 0.85 mm and 1.04 ± 0.91 mm, respectively (vs 0.42 ± 0.80 mm and 0.47 ± 0.93 mm with vehicle; both p<0.005). Significant improvements vs vehicle (p<0.001) were also observed at 2–6 hours on days 1 and 14. At all time points, the proportion of subjects showing a positive response to treatment (>0% MRD-1 increase) was >15% greater in the oxymetazoline 0.1% group (range 16.6–36.1% more responders vs vehicle), with the largest differences observed 2 and 6 hours post-instillation.

Conclusion

Oxymetazoline 0.1% provided rapid and sustained upper eyelid elevation. Together with data demonstrating superior visual field improvement and a favorable safety profile, this analysis supports oxymetazoline 0.1% as an effective non-surgical treatment for acquired ptosis.

Ocular redness - II: Progress in development of therapeutics for the management of conjunctival hyperemia

Conjunctival hyperemia is one of the most common causes for visits to primary care physicians, optometrists, ophthalmologists, and emergency rooms. Despite its high incidence, the treatment options for patients with conjunctival hyperemia are restricted to over-the-counter drugs that provide symptomatic relief due to short duration of action, tachyphylaxis and rebound redness. As our understanding of the immunopathological pathways causing conjunctival hyperemia expands, newer therapeutic targets are being discovered. These insights have also contributed to the development of animal models for mimicking the pathogenic changes in microvasculature causing hyperemia. Furthermore, this progress has catalyzed the development of novel therapeutics that provide efficacious, long-term relief from conjunctival hyperemia with minimal adverse effects.

The Results of Preoperative Use of Topical Brimonidine in Strabismus Surgery

Purpose: In this study, we wanted to retrospectively evaluate the effect of the use of topical brimonidine on intraoperative bleeding and surgical hemostasis before strabismus surgery. Methods: Brimonidine tartrate 0.15% (Brimogut, Bilim Ilac, Turkey) eye drops were applied 6 and 3 min before surgery to 44 eyes of 22 patients in group 1 for vasoconstriction. Drops were not applied to 46 eyes of 23 patients in group 2. Preoperative and postoperative photographs and video images were taken. Black-and-white images were used to define the surface areas of the blood vessels. The surface area was calculated by counting the black pixels with ImageJ software. Results: In group 1, redness of eye was observed, on average, at preoperative 339.25 ± 11.52 pixels and intraoperative 247.93 ± 10.63 pixels (P < 0.001). But there was no change in group 2 (preoperative 338.87 ± 8.45 pixels to intraoperative 339.71 ± 9.52 pixels, P > 0.05). The incidence of intraoperative bleeding evaluated by the number of eyes on which cautery was used shows that it was significantly less in group 1 than in group 2 (P < 0.001). Conclusions: The use of topical brimonidine before strabismus surgery facilitates clear monitoring of anatomical structures during surgery by effectively controlling hemorrhage. In the postoperative period, it significantly reduces subconjunctival hemorrhage.

[Rhinitis medicamentosa]

One type of non-allergic non-infectious rhinitis is represented by a heterogeneous group of rhinitis medicamentosa, which can be divided into several pathogenetic types. The most common rebound nasal congestion associated with the use of topical decongestants. Excessive use of intranasal decongestants leads to a decrease in the number of alpha-adrenoreceptors on the surface of cell membranes and uncoupling their connection with the G-protein and the development of tachyphylaxis. To prevent the development of rebound nasal congestion caused by topical decongestants, it is important to limit the frequency of their use. In most cases, the duration of the use of vasoconstrictor drugs should be limited to 5-7 days, according to Patient information leaflets for the drugs. However, in patients who have had a history of episodes of rebound nasal congestion, which develops including the previously indicated periods, the duration of decongestant therapy should be limited to 3 days. Rhinitis associated with local inflammation is caused by the intake of acetylsalicylic acid (ASA) or other non-steroidal anti-inflammatory drugs. Currently, the so-called "aspirin triad" is well known - a combination of bronchial asthma, rhinosinusitis (often polyposis) and intolerance to ASA. Neurogenic rhinitis develops due to the use of drugs that violate vascular tone, for example, antihypertensive drugs or type 5 phosphodiesterase inhibitors. Drug-induced rhinitis has a significant impact on the patient's quality of life: nasal congestion, rhinorrhea, secondary night apnea, insomnia as a result of nasal breathing disturbances, headaches, irritability, weakness after sleepless nights disturb patients to a large extent. Timely diagnosis and withdrawal of a provocative drug, the use of topical corticosteroids in case of severe rhinitis are the basis of the treatment of rhinitis medicamentosa. In severe cases, there is a need, including surgical treatment, such as, for example, submucosal laser destruction of the lower nasal concha.

Over-the-Counter Ocular Decongestants in the United States - Mechanisms of Action and Clinical Utility for Management of Ocular Redness

To manage ocular redness effectively, health-care practitioners require an understanding of the pathophysiology, clinical features and differential diagnosis of ocular redness, as well as comprehensive knowledge of medical therapies available and their pharmacologic properties. This review aims to provide a clinically relevant summary of the current literature on the mechanism of action, efficacy, and safety of current over-the-counter (OTC) decongestants available for reduction of ocular redness due to minor irritations. Currently marketed OTC products indicated for such use in the United States include topical solutions of tetrahydrozoline 0.05%, naphazoline 0.012% to 0.03%, and brimonidine 0.025%. All 3 agents are adrenergic receptor agonists but vary in their receptor-binding profiles: tetrahydrozoline is a selective α1 receptor agonist; naphazoline is a mixed α1/α2 receptor agonist; and brimonidine is a selective α2 receptor agonist. These OTC decongestants produce vasoconstriction of conjunctival blood vessels, which results in a rapid reduction in ocular redness. In general, ocular adverse events reported in published studies of these OTC decongestants were minimal, mild, and transient, with no significant adverse systemic effects. However, ocular decongestants with α1-adrenergic receptor agonist activity can be associated with loss of effectiveness with continued use (ie, tachyphylaxis) and rebound redness upon treatment discontinuation. In clinical trials of the selective α2-adrenergic receptor agonist brimonidine 0.025%, tachyphylaxis was not observed, and rebound redness was rarely reported.

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.

Rhinitis medicamentosa: a nationwide survey of Canadian otolaryngologists

Background

Rhinitis medicamentosa is a non-allergic form of rhinitis that is typically caused by prolonged use of topical nasal decongestants. This condition commonly affects young adults and treatment is not trivial. We aimed to survey Canadian Otolaryngologists to determine practice patterns and their opinions regarding this under-studied condition.

Methods

An electronic survey was sent to practicing Otolaryngologists within the Canadian Society of Otolaryngology – Head and Neck Surgery. The survey contained 16 questions pertaining to the diagnosis and treatment of rhinitis medicamentosa, as well as opinions on public and primary care awareness of proper use of nasal decongestants.

Results

The survey was distributed to 533 Otolaryngologists and 69 surveys were returned (response rate of 13%). Cessation and weaning of decongestant (96%), and intranasal steroids (94%) were the most common methods for treating RM. Intranasal saline rinses (55%) and oral steroids (25%) were also supported by some respondents. For those who recommended cessation/weaning, 61% also concurrently introduced an intranasal steroid during this process. The majority responded that current warnings on nasal decongestants were inadequate (75%), and were not visible enough (79%).

Conclusions

Rhinitis medicamentosa is a common, and very preventable condition. Although the literature lacks a standardized approach to RM, our survey has shown that many Otolaryngologists diagnose and treat RM in a similar manner. Treatment tends to focus on decongestant cessation, often with concurrent introduction of intranasal steroids. It was felt the warning labels on the topical medications are not currently satisfactory.

Evaluation of Nasal Decongestants by Literature Review

Over-the-counter drugs are medicines that are available to consumers without a prescription. The most common оver - the-counter preparations in self - medication are nasal decongestants that can be used systemically or locally in the form of drops or nasal sprays. The most common indications for nasal decongest-ants are viral infections and allergic conditions in order to alleviate the symptoms so it is necessary to inform the users about the type of drug, the active substance it contains and the correct dosage regimen. Given their availability and the prevailing safety precaution, these preparations can lead to numerous prolonged conditions and complications. The mechanism of action of nasal decongestants is based on the reduction of blood vessels’ swelling in the nose, which helps the opening of the airway. As a result, most nasal decongestants cause vasoconstriction (narrowing of blood vessels). There are nasal decongestants that block histamine and have a good effect on people who suffer from seasonal allergies.

Availability (free sale) and prolonged use of the decongestant lead to a decrease in the sensitivity of the alpha receptor, which leads to the need to increase the dose at shorter time intervals to achieve the same effect. As a consequence, patients use excessive, uncontrolled doses of nasal decongestants, which is a public problem and warns of the necessity of identification and the taking of measures to prevent their uncontrolled procurement and use.

Should Excess Topical Decongestant Use Raise a Red Flag? Rhinitis Medicamentosa and Opioid Use Disorder

OBJECTIVE

The objective of this study was to determine whether patients with rhinitis medicamentosa (RM) have an increased odds of having an opioid use disorder (OUD) and which characteristics may predict this association.

METHODS

The authors conducted a retrospective case control study of patients 18 years and older who presented to the otolaryngology clinic at an academic medical center from January 2013 through December 2017. Cases, defined as patients who presented with excessive decongestant nasal spray usage based on history, were matched to control patients who presented with chronic rhinitis and did not report regular nasal decongestant usage. The charts were reviewed for patients that carried a problem of opioid abuse, identified using ICD-9 codes 304.XX or ICD-10 codes F11.XX. The primary outcome of this study was the odds of having an OUD. Secondary outcomes were assessed by summary statistics.

RESULTS

One hundred and thirty-one cases of RM were matched to 1871 controls of chronic rhinitis. Seven cases (5.3%) and 24 (1.3%) controls had a diagnosis of OUD, consistent with an odds ratio of 3.98 for opioid abuse in patients with RM (95% CI: 1.47-9.71). Oxymetazoline was used by 85.5% (n = 112) of patients with RM. Thirty-six patients (27.1%) with RM underwent nasal surgery following a diagnosis of RM, of which twenty patients (55.6%) were prescribed opioids following the procedure.

CONCLUSIONS

RM is associated with increased odds of having an OUD.

Xylitol treats nasal mucosa in rhinitis medicamentosa: an experimental rat model study

OBJECTIVE

Rhinitis medicamentosa is drug-induced rhinitis which occurs by prolonged and overdose usage of topical nasal decongestants. There is not much of treatment choice rather than nasal steroids. In this pathological study, we have been aimed to represent the healing effects of xylitol on damaged nasal mucosa due to rhinitis medicamentosa.

METHOD

30 Wistar rats were separated into 5 groups. During 2 months, oxymetazoline was given to the first group, and saline was given to second group intranasally. First and second group animals were examined at the end of 2 months and rhinitis medicamentosa was detected. Oxymetazoline was given to the third, fourth, and fifth groups during 2 months. Then xylitol solution, mometasone, and saline were applied, respectively, for 15 days. After the experiment, rats' nasal mucosas were evaluated histopathologically.

RESULTS

Xylitol and mometasone were found to be more effective than the control group in terms of histopathological changes. Effectivity of xylitol and mometasone was compared and not a significant value was determined.

CONCLUSIONS

According to the results, xylitol solution is effective as mometasone, usable and well-priced in the treatment of rhinitis medicamentosa. More comprehensive and ultrastructural studies on animals and human studies with rhinometric evaluation should be performed.

Pupo A. Updates in the function and regulation of α1 -adrenoceptors

α1 -Adrenoceptors are seven transmembrane domain GPCRs involved in numerous physiological functions controlled by the endogenous catecholamines, noradrenaline and adrenaline, and targeted by drugs useful in therapeutics. Three separate genes, whose products are named α1A -, α1B -, and α1D - adrenoceptors, encode these receptors. Although the existence of multiple α1 -adrenoceptors has been acknowledged for almost 25 years, the specific functions regulated by each subtype are still largely unknown. Despite the limited comprehension, the identification of a single class of subtype-selective ligands for the α1A - adrenoceptors, the so-called α-blockers for prostate dysfunction, has led to major improvement in therapeutics, demonstrating the need for continued efforts in the field. This review article surveys the tissue distribution of the three α1 -adrenoceptor subtypes in the cardiovascular system, genitourinary system, and CNS, highlighting the functions already identified as mediated by the predominant activation of specific subtypes. In addition, this review covers the recent advances in the understanding of the molecular mechanisms involved in the regulation of each of the α1 -adrenoceptor subtypes by phosphorylation and interaction with proteins involved in their desensitization and internalization. LINKED ARTICLES: This article is part of a themed section on Adrenoceptors-New Roles for Old Players. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.14/issuetoc.

Consideraciones acerca del reporte y la evaluación del fallo terapéutico en farmacovigilancia

Introducción. Los fallos terapéuticos representan un problema de salud pública. Aunque existe abundante información al respecto, se requiere una revisión crítica de las definiciones existentes.Objetivo. Realizar una revisión crítica del concepto actual de fallo terapéutico, su clasificación y su importancia en farmacovigilancia.Materiales y métodos. Dos revisores independientes realizaron una búsqueda sistemática de las definiciones de fallo terapéutico existentes en la literatura y de los sistemas de clasificación descritos. Con base en esta información, se realizó un análisis crítico y la proposición de una nueva definición consensuada de fallo terapéutico.Resultados. La concepción actual de fallo terapéutico es imperfecta, pues desconoce la disminución del efecto de un medicamento en el uso real en comparación con el periodo de precomercialización, donde la estimación de la eficacia se basa en ensayos clínicos controlados. Aunque la clasificación actual es adecuada, tanto el algoritmo de Vaca-González et al. como las otras herramientas empleadas para evaluar la causalidad en farmacovigilancia dependen de la calidad del reporte.Conclusiones. Es necesario perfeccionar las definiciones actuales de fallo terapéutico y mejorar la calidad del reporte para sacar el máximo provecho de los sistemas de clasificación. Se propone realizar estudios clínicos pragmáticos para los medicamentos comercializados recientemente con el fin de establecer su verdadero perfil de efectividad y seguridad.

Low-dose brimonidine for relief of ocular redness: integrated analysis of four clinical trials

BACKGROUND

The aim of this study was to provide an integrated analysis of safety and efficacy data for brimonidine tartrate ophthalmic solution 0.025 per cent (low-dose; Bausch & Lomb Incorporated), a topical vasoconstrictor for relief of ocular redness.

METHODS

Integrated efficacy data from two randomised, double-masked, vehicle-controlled studies in subjects with ocular redness as well as safety data from the two efficacy studies, a vehicle-controlled safety study, and a pharmacokinetic study were analysed. Efficacy outcomes analysed included investigator-assessed ocular redness (scale, 0-4) before treatment instillation and at five to 240 minutes post-instillation on Day 1, at five minutes post-instillation on Days 15 and 29, and one week after treatment discontinuation (Day 36), and redness self-assessed by subjects recorded daily in diaries. Safety assessments included adverse events, ophthalmic examinations, and rebound redness upon treatment discontinuation. Drop comfort (scale, 0-10) was a tolerability measure.

RESULTS

The efficacy population included 117 subjects (brimonidine, n = 78; vehicle, n = 39). The safety population included 635 subjects (brimonidine, n = 426; vehicle, n = 209). Investigator-assessed ocular redness was significantly lower with brimonidine versus vehicle at all post-instillation time points on Day 1 (mean change from pre-instillation of -1.4 units for brimonidine and -0.2 units for vehicle; p < 0.0001). Subject-assessed ocular redness was also significantly lower with brimonidine versus vehicle (mean treatment difference in average daily ratings of -0.9; p < 0.0001). There was no evidence of tachyphylaxis through Day 29 and rebound redness was rare. Incidence of ocular adverse events was low, the most common being reduced visual acuity (brimonidine, 4.0 per cent; vehicle, 4.3 per cent) and conjunctival hyperaemia (2.6 and 2.9 per cent, respectively). Both brimonidine and vehicle were rated as very comfortable (mean post-instillation scores, 0.4-0.5).

CONCLUSION

In this integrated analysis, low-dose brimonidine significantly reduced ocular redness with no tachyphylaxis, and minimal rebound redness, and was generally safe and well tolerated.

Management of Rhinitis Medicamentosa: A Systematic Review

OBJECTIVE

Rhinitis medicamentosa (RM) is a common condition resulting from overuse of topical nasal decongestants. Despite the prevalence in otolaryngologic practice, a clear treatment protocol has not been established. Our objective was to review the current published literature pertaining to the treatment of RM with the possibility of finding data that support one treatment over another.

DATA SOURCES

PubMed, Embase, Cochrane, and Web of Science databases were examined for patients diagnosed with RM resulting from chronic use of topical nasal decongestants.

REVIEW METHODS

The PRISMA standard (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was utilized to identify English-language studies reporting treatment of patients with the primary diagnosis of RM after chronic use of a topical decongestant. Outcome measures of interest included patient-reported symptom relief and objective parameters. MINORS criteria (methodological index for nonrandomized studies) were used to assess the quality of articles.

RESULTS

A total of 350 articles were identified, 9 of which met final inclusion criteria for qualitative analysis. Outcomes defined in each publication were highly varied and relied on several unstandardized measures. The most commonly reported treatment option was topical nasal steroids, although overall there was limited evidence on which to base treatment recommendation.

CONCLUSIONS

There is not adequate evidence to develop a standardized treatment protocol for RM. The development of a uniform questionnaire, standard outcomes to be measured, and a method of assessing such outcomes is necessary. Prospective randomized controlled studies are warranted to determine the optimal treatment regimen following diagnosis of RM.

Brimonidine Ophthalmic Solution 0.025% for Reduction of Ocular Redness: A Randomized Clinical Trial

SIGNIFICANCE

The α2-adrenergic receptor agonist brimonidine has been reported to induce conjunctival blanching in cataract, strabismus, laser refractive, and filtration procedures. Clinicians are often faced with red eyes with no apparent underlying pathology. Low-dose brimonidine reduced ocular redness in such subjects with efficacy maintained over 1 month and negligible rebound redness.

PURPOSE

The aim of this study was to evaluate the safety and efficacy of brimonidine tartrate ophthalmic solution 0.025% for the treatment of ocular redness.

METHODS

In this single-center, double-masked, phase 3 clinical trial, adult subjects with baseline redness of more than 1 unit in both eyes (0- to 4-unit scale) were randomized 2:1 to brimonidine 0.025% or vehicle. A single dose was administered in-office (day 1); thereafter subjects instilled treatment four times a day for 4 weeks, with clinic visits on days 15, 29, and 36 (7 days post-treatment). Efficacy end points included investigator-evaluated redness 5 to 240 minutes post-instillation on day 1 (primary); investigator-evaluated change from baseline 1, 360, and 480 minutes post-instillation on day 1, and 1 and 5 minutes post-instillation on days 15 and 29; total clearance of redness, and subject-assessed redness. Safety/tolerability measures included adverse events, rebound redness, and drop comfort.

RESULTS

Sixty subjects were randomized (n = 40 brimonidine, n = 20 vehicle). Investigator-assessed redness was lower with brimonidine versus vehicle over the 5- to 240-minute post-instillation period (mean [SE], 0.62 [0.076] vs. 1.49 [0.108]; P < .0001) and at each time point within that period (P < .0001). At 1, 360, and 480 minutes post-instillation, respectively, the mean differences (95% confidence interval) between treatments were -0.73 (-1.05 to -0.41), -0.57 (-0.84 to -0.29), and -0.39 (-0.67 to -0.10), respectively. No tachyphylaxis was evident with brimonidine on days 15 and 29, and minimal rebound redness was observed following discontinuation. Adverse events were infrequent, and brimonidine was rated as very comfortable.

CONCLUSIONS

Brimonidine 0.025% appeared safe and effective for reduction of ocular redness, with an 8-hour duration of action, no evidence of tachyphylaxis, and negligible rebound redness.

[Possibilities of azelastine in the treatment of chronic rhinitis]

There is considered modern classification of rhinitis and the accents in diagnostic and therapeutic approaches to patients with this disease are indicated, as well as the possibilities of using topical intranasal antihistamines in the treatment of allergic, vasomotor and medicamentous rhinitis.

Evaluation of Efficacy and Safety of Brimonidine Tartrate Ophthalmic Solution, 0.025% for Treatment of Ocular Redness

Purpose/Aims: This study assessed the efficacy and safety of brimonidine tartrate ophthalmic solution, 0.025% for treating ocular redness in adult subjects.

MATERIALS AND METHODS

This was a single-center, double-masked, randomized, vehicle-controlled, parallel-group study in subjects ≥40 years, with ocular redness. Subjects were randomized 2:1 to brimonidine or vehicle, instilled QID for four weeks. Subjects completed four visits, the last occurring one week after treatment discontinuation. The investigator assessed ocular redness on a scale of 0-4 pre-instillation and 5-240 minutes post-instillation on Day 0, pre-instillation and 5 minutes post-instillation on Days 14 and 28, and on Day35; subjects assessed redness in diaries throughout the 28-day treatment period and following treatment discontinuation. Safety assessments included adverse events (AEs), rebound redness on treatment discontinuation, comprehensive ophthalmic exams, and vital signs. Drop comfort was assessed upon instillation, and 30 seconds and 1 minute post-instillation at Day 0.

RESULTS

Fifty-seven subjects (brimonidine, n = 38; vehicle, n = 19) were randomized. Investigator-assessed ocular redness was significantly reduced with brimonidine across the entire post-instillation time period (overall treatment difference: -1.37; P < 0.0001) and at all individual time points (P < 0.0001). Subject-assessed ocular redness was also significantly lower with brimonidine (P ≤ 0.0005). No tachyphylaxis was evident. There were few ocular AEs, all mild to moderate in severity, and no redness rebound was observed upon brimonidine discontinuation. There were no effects on any safety measures, and both brimonidine and its vehicle were reported to be very comfortable.

CONCLUSIONS

Brimonidine 0.025% appeared safe, well tolerated, and reduced ocular redness for at least 4 hours. No tachyphylaxis or rebound redness upon treatment discontinuation was observed.

Noradrenaline, oxymetazoline and phorbol myristate acetate induce distinct functional actions and phosphorylation patterns of α1A-adrenergic receptors

In LNCaP cells that stably express α_1A-adrenergic receptors, oxymetazoline increased intracellular calcium and receptor phosphorylation, however, this agonist was a weak partial agonist, as compared to noradrenaline, for calcium signaling. Interestingly, oxymetazoline-induced receptor internalization and desensitization displayed greater effects than those induced by noradrenaline. Phorbol myristate acetate induced modest receptor internalization and minimal desensitization. α_1A-Adrenergic receptor interaction with β-arrestins (colocalization/coimmunoprecipitation) was induced by noradrenaline and oxymetazoline and, to a lesser extent, by phorbol myristate acetate. Oxymetazoline was more potent and effective than noradrenaline in inducing ERK 1/2 phosphorylation. Mass spectrometric analysis of immunopurified α_1A-adrenergic receptors from cells treated with adrenergic agonists and the phorbol ester clearly showed that phosphorylated residues were present both at the third intracellular loop and at the carboxyl tail. Distinct phosphorylation patterns were observed under the different conditions. The phosphorylated residues were: a) Baseline and all treatments: T233; b) noradrenaline: S220, S227, S229, S246, S250, S389; c) oxymetazoline: S227, S246, S381, T384, S389; and d) phorbol myristate acetate: S246, S250, S258, S351, S352, S401, S402, S407, T411, S413, T451. Our novel data, describing the α_1A-AR phosphorylation sites, suggest that the observed different phosphorylation patterns may participate in defining adrenoceptor localization and action, under the different conditions examined.

Combination therapy in allergic rhinitis: What works and what does not work

Allergic rhinitis and other rhinitis subtypes are increasingly becoming some of the most prevalent and expensive medical conditions that affect the U.S.

POPULATION

Both direct health care costs and indirect costs significantly impact the health care system due to delays in diagnosis, lack of treatment, ineffective treatment, poor medication adherence, and associated comorbidities. Many patients who have AR turn to over-the-counter medications for relief but often find themselves dissatisfied with the results. Determining the correct diagnosis, followed by initiation of the most-effective treatment(s), is essential to provide patients with better symptomatic management and quality of life. Although there are many options, currently available combination therapies, e.g., azelastine with fluticasone and intranasal corticosteroids with nasal decongestants, offer distinct advantages for the management of complex rhinitis phenotypes. Further research is required to investigate the pathomechanisms and biomarkers for mixed rhinitis and nonallergic vasomotor rhinitis subtypes that will lead to novel targeted therapies for these conditions.

Does oxymetazoline increase the efficacy of nasal steroids in treating nasal polyposis?

BACKGROUND

Although nasal steroids are the mainstay treatments in nasal polyposis, up to one-half of patients do not respond and need surgical treatment. This study aimed to evaluate whether oxymetazoline administration produces any additive effect on nasal steroid therapy and whether rebound congestion develops after oxymetazoline treatment.

METHODS

Sixty-eight patients with nasal polyposis were randomly assigned in a 1:1 ratio to receive either oxymetazoline plus mometasone furoate nasal spray (MFNS) or placebo plus MFNS, 2 sprays per nostril twice daily, with an interval of 5 minutes between each medication for 4 weeks. All the patients were then treated with MFNS, 2 sprays per nostril twice daily for 2 weeks. The nasal symptoms score, peak inspiratory flow index, nasal mucociliary clearance time (NMCCT), and total nasal polyps score were used to evaluate treatment outcomes. An intention-to-treat analysis was performed, and a worst case sensitivity analysis was applied to missing cases.

RESULTS

Thirty-four patients were allocated to the oxymetazoline-MFNS group, and 34 to the placebo-MFNS group. One patient in each group was lost to last-visit follow-up. At 4 weeks after beginning treatment, the oxymetazoline-MFNS group showed significantly greater improvement in blocked nose, hyposmia, peak flow, NMCCT, and total nasal polyps score than the placebo-MFNS group. During the nasal steroid phase, both groups showed continuing improvement in all outcome variables. However, the oxymetazoline-MFNS group still showed significantly greater improvement in blocked nose, hyposmia, NMCCT, and total nasal polyps score, but not peak flow, than the placebo-MFNS group at the end of the study.

CONCLUSION

The use of nasal steroids with oxymetazoline was more effective over 6 weeks than nasal steroids alone in improving blocked nose, hyposmia, nasal mucociliary clearance, and polyp size in treatment of nasal polyposis. There was no evidence of rebound congestion after 4 weeks of oxymetazoline treatment.

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

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

A 45-Year-Old Man With Delayed Onset of OSA Events During Polysomnography

A 45-year-old man with a medical history that included asthma and chronic nasal congestion presented for an evaluation of possible OSA. He reported loud snoring, witnessed apneas in sleep, and daytime sleepiness. The patient's score on the Epworth Sleepiness Scale was 12 of 24, indicating excessive sleepiness. His nasal congestion had been treated with frequent use of an over-the-counter nasal decongestant.

Effects of the inverse alpha-agonist doxazosin in allergic rhinitis

BACKGROUND

We examined the paradoxical hypothesis that the alpha-receptor inverse agonist doxazosin might produce beneficial effects in allergic rhinitis.

OBJECTIVES

To evaluate single and chronic dosing effects of doxazosin on nasal airflow and symptoms in allergic rhinitis.

METHODS

Fifteen patients randomized to receive 3-5 weeks of oral doxazosin 4 mg daily or placebo in crossover fashion. Measurements were taken at baseline and after first and last doses.

RESULTS

There was a fall in peak nasal inspiratory flow (PNIF) between baseline vs. first dose of doxazosin: mean difference -19 L/min (95% CI -35 to -2) P = 0.03, with recovery between first and last doses: 21 L/min (95% CI 7-34) P = 0.006. Nasal visual analogue scale (VAS) and blockage scores were worse between baseline vs. first dose of doxazosin: mean difference VAS -10 mm (95% CI -18 to -2) P = 0.02, blockage -0.7 (95% CI -1.3 to -0.1) P = 0.02, with recovery between first and last doses: VAS 15 mm (95% CI 4-25) P = 0.009, blockage 1.1 (95% CI 0.5-1.6) P = 0.001. The oxymetazoline dose-response for PNIF was blunted after single vs chronic dosing with doxazosin: mean difference -17 L/min (95% CI -30 to -4) P = 0.01. Heart rate and diastolic blood pressure showed the same pattern. There was a significant difference between doxazosin and placebo for nasal blockage score and heart rate after single but not chronic dosing.

CONCLUSIONS

There was a disconnect between single and chronic dosing effects of doxazosin for nasal symptoms, oxymetazoline response and cardiovascular outcomes, in turn suggesting alpha-1 receptor up-regulation.

Clinically relevant outcome measures of novel pharmacotherapy for nonallergic rhinitis

PURPOSE OF REVIEW

The purpose of this review is to briefly provide the current understanding of the pathogenesis of nonallergic rhinitis (NAR), currently available pharmacotherapies as well as some recent advancement in pharmacotherapy for this condition. With this background on NAR, we then describe and contrast outcome measures used in previous NAR and allergic rhinitis clinical trials. Finally, we conclude with a brief discussion on which of these outcomes might be most suitable for future NAR clinical trials.

RECENT FINDINGS

NAR is a heterogeneous condition in which multiple mechanisms have been postulated to be involved. Patients with NAR commonly experience chronic nasal congestion and anterior and/or posterior drainage, which significantly affects their quality of life. Current standard of care is primarily symptom based, as specific therapies that target the underlying mechanisms of this condition are lacking. As there are no current treatment algorithms for NAR, clinical response and outcomes can vary widely between patients. Intranasal corticosteroids and intranasal antihistamines have been found to be effective in well designed clinical trials in the treatment of NAR and are therefore considered first-line therapies. Recently, studies investigating a combination of intranasal antihistamine/corticosteroid and an intranasal decongestant and with an intranasal corticosteroid have shown promise for allergic rhinitis and may also be more effective than monotherapy for NAR. Multiple outcome measures have been used in previous NAR trials, the most common being variations of nasal symptoms scores. Given the differences in prominent symptoms typically experienced by allergic rhinitis and NAR, accurate clinical outcomes used to evaluate new treatments for these two patient groups will likely differ. Further studies specifically designed to investigate the efficacy of various therapeutic agents in NAR are required to improve the management and outcomes of this chronic condition.

SUMMARY

Further research is required to expand our understanding of the pathobiology of NAR that should lead to novel therapeutic approaches for managing this condition. It will be necessary to have well established validated NAR outcomes that can be used to study these novel therapies.

Allergic Rhinitis: Mechanisms and Treatment

The prevalence of allergic rhinitis (AR) has been estimated at 10% to 40%, and its economic burden is substantial. AR patients develop specific immunoglobulin E (IgE) antibody responses to indoor and outdoor environmental allergens with exposure over time. These specific IgE antibodies bind to high-affinity IgE receptors on mast cells and basophils. Key outcome measures of therapeutic interventions include rhinitis symptom control, rescue medication requirements, and quality-of-life measures. A comprehensive multiple modality treatment plan customized to the individual patient can optimize outcomes.

Rhinitis Subtypes, Endotypes, and Definitions

Rhinitis is often seen as posing a small burden. However, rhinitis is a complex disease that is underpinned by a plethora of different mechanisms and causes. Rhinitis is frequently associated with other comorbid conditions but, by itself, is a source of considerable morbidity for patients and creates a significant financial burden on health systems worldwide. This article approaches this condition from both a phenotypic and mechanistic standpoint, focusing on the complexity of characterizing these subtypes. Developing a clearer demarcation of the currently obscure rhinitis phenotypes and endotypes will substantially improve their future prevention and treatment.

Nonallergic Rhinitis: Treatment

Chronic nonallergic rhinitis (NAR) is a syndrome rather than a specific disease. A lack of understanding of the pathogenesis of this condition has led to imprecise terminology with several alternate names for the condition, including vasomotor rhinitis, nonallergic rhinopathy, and idiopathic rhinitis. The therapy for NAR is best based on the underlying pathology, which typically exists in a form whereby an abnormality of the autonomic nervous system is dominant or a form in which inflammation seems to be the cause of symptoms. In general the most effective therapy is the combination of an intranasal antihistamine and an intranasal corticosteroid.