Mometasone Furoate Nasal Spray

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.

A sensitive, heart-cutting, two-dimensional liquid chromatography–tandem mass spectrometry method for the determination of mometasone furoate in human plasma: Application for a bioequivalence study in nasal spray formulations

We developed and validated a sensitive, heart-cutting, two-dimensional liquid chromatography–tandem mass spectrometry (2D-LC‒MS/MS) method to determine the concentration of mometasone furoate in human plasma after nasal spray administration. Isotopically labeled mometasone furoate-13C,d6 was used as an internal standard (IS). Plasma samples were prepared using a solid-phase extraction (SPE) method. With this 2D-LC strategy, the analytes were trapped in the first dimension (1D) column, and only judiciously selected portions of the 1D effluent were transferred to the second dimension (2D) column for further separation to obtain high-resolution information. MS/MS quantification was performed in positive ionization mode via multiple-reaction monitoring (MRM). This analytical method was fully validated according to related regulatory guidance, and the results showed that the method is robust and sensitive enough for pharmacokinetic investigation of mometasone furoate with satisfactory linearity from 0.25 to 30 pg mL−1. This method was successfully applied to a bioequivalence (BE) study of mometasone furoate aqueous nasal sprays in healthy volunteers.

Pharmacokinetic Evidence of Steady and Sustained Drug Release from Long-Acting Implantable Corticosteroid Matrices for Chronic Rhinosinusitis

Background

The efficacy of topical corticosteroids is limited in chronic rhinosinusitis (CRS) due to rapid clearance from the nasal cavity and insufficient drug delivery to inflamed sinonasal passages. LYR-210 is an implantable corticosteroid matrix designed to provide up to 24 weeks of treatment to patients with CRS by locally delivering mometasone furoate (MF) to the sinonasal mucosa. In a randomized, controlled, dose-ranging LANTERN study, LYR-210 (7500 µg) achieved clinically relevant improvement in CRS cardinal symptom composite scores, the 22-item Sinonasal Outcome Test (SNOT-22), ethmoid opacification, and the need for rescue treatment at 24 weeks.

Objective

As the plasma MF concentrations of LYR-210 (2500 µg) and LYR-210 (7500 µg) were evaluated at weeks 4, 12, and 24 in the LANTERN study (data on file at Lyra Therapeutics, Inc.), this study aims to characterize the pharmacokinetic profiles of both doses of LYR-210 at earlier timepoints post-placement in patients with CRS.

Methods

Twenty-four surgically naïve adult patients with CRS were enrolled in an open-label, multicenter study and underwent in-office bilateral administration of LYR-210 (2500 µg) (n = 12 patients) or LYR-210 (7500 µg) (n = 12 patients) into the middle meatus. Plasma MF concentrations were determined pre-placement and 1-h post-placement (day 1), and on days 2, 3, 7, 14, 21, 28, 42, and 56 by liquid chromatography-tandem mass spectrometry.

Results

Both LYR-210 doses were well-tolerated with no serious adverse events. Systemic MF levels were dose-dependent and lower than reported values of other respiratory MF products. Plasma MF concentrations showed steady drug release from LYR-210 (2500 µg) and LYR-210 (7500 µg) that persisted through day 56.

Conclusion

LYR-210 achieved dose-dependent, continuous local MF delivery at a steady rate with low systemic exposure for months.

The Genotoxic Effect of Nasal Steroids on Human Nasal Septal Mucosa and Cartilage Cells In Vitro

OBJECTIVE

To determine whether budesonide (Bud) and triamcinolone acetate (TA) cause DNA fractures in the nasal mucosa and septal cartilage cells through examinations using the comet assay technique.

STUDY DESIGN

Prospective, controlled experimental study.

SETTING

University hospital.

METHODS

Septal mucosal epithelial and cartilage tissue samples were taken from 9 patients. Cell cultures were prepared from these samples. Then, budesonide and triamcinolone acetate active ingredients at 2 different doses of 0.2 and 10 µM were separately applied to the cell cultures formed from both tissues of each patient, except the control cell culture, for 7 days in one group and 14 days in one group. After the applications, genotoxic damage was scored with the comet assay technique and the groups were compared.

RESULTS

In both the budesonide and triamcinolone acetate groups, the comet scores at low and high doses, on the 7th and 14th days were found to be significantly higher in both cartilage and epithelial tissue than in the control group.

CONCLUSION

The study results showed that budesonide and triamcinolone acetate lead to a significantly high rate of genotoxic damage in both epithelial tissue and cartilage tissue.

In Vitro Ciliotoxicity and Cytotoxicity Testing of Repeated Chronic Exposure to Topical Nasal Formulations for Safety Studies

Certain active drugs and excipients of nasal formulations may impair ciliary function and mucociliary clearance. The ciliary beat frequency (CBF) is a key parameter for determining mucociliary clearance rate, and in vitro assessments of CBF have proven to be accurate and reproducible. Since topical nasal formulations are applied with repeated doses, it is essential to elucidate their chronic, as opposed to acute, effect on mucociliary clearance and nasal mucosa. The aim of this study was to assess for the first time the ciliotoxicity and cytotoxicity of nasal sprays intended for chronic treatment (with repeated doses) using a previously designed set-up for CBF measurements. For 2 weeks, the 3D nasal MucilAir™ in vitro models were treated daily with undiluted or clinically relevant doses of mometasone nasal spray, placebo nasal spray, culture medium, or they were untreated. We demonstrated a dose-dependent and time-dependent (cumulative) effect of the nasal sprays on ciliary activity and cytotoxicity using CBF measurements and ultrastructural analysis, respectively. Our results indicate that repeated administration of clinically relevant doses of mometasone nasal spray is safe for in vivo use, which is in good agreement with a previous clinical study. Overall, our study suggests that such in vitro assays have great potential for topical nasal drug screening.

Long-acting implantable corticosteroid matrix for chronic rhinosinusitis: Results of LANTERN Phase 2 randomized controlled study

Background

Topical steroids are first‐line treatment for chronic rhinosinusitis (CRS), but fail to provide adequate symptom control for all patients. Designed for medical treatment failures, LYR‐210 is an implantable matrix that locally elutes mometasone furoate to inflamed sinonasal tissue for up to 24 weeks in CRS patients. In an open‐label phase 1 study, LYR‐210 demonstrated clinically relevant improvement in the 22‐item Sino‐Nasal Outcome Test (SNOT‐22). Safety and efficacy of LYR‐210 in CRS were evaluated in the LANTERN Phase 2 study.

Methods

Sixty‐seven surgically naive adult CRS patients who were inadequately controlled by previous medical management and seeking an alternative treatment enrolled in a multicenter, blinded, controlled, dose‐ranging study. Patients had moderate‐to‐severe disease based on SNOT‐22 and composite 7‐day average scores of the 4 cardinal CRS symptoms (4CS), with diagnosis confirmed by nasal endoscopy and magnetic resonance imaging. Patients were randomized (1:1:1) to saline irrigation–only control or bilateral in‐office administration of LYR‐210 (2500 μg) or LYR‐210 (7500 μg). Safety and efficacy were evaluated over 24 weeks.

Results

Both LYR‐210 doses were safe and well‐tolerated over the 24‐week treatment period. LYR‐210 demonstrated rapid and durable dose‐dependent symptom improvement based on 4CS and SNOT‐22, with LYR‐210 (7500 μg) achieving statistical significance as early as 8 weeks and out to 24 weeks compared with control. LYR‐210 (7500 μg) reduced rescue treatment use and radiographic ethmoid opacification at week 24.

Conclusions

LYR‐210 is the first implantable sinonasal treatment to achieve up to 24 weeks of benefit from a single administration in surgically naive CRS patients with and without nasal polyps.

Adverse Events Associated with Intranasal Sprays: An Analysis of the Food and Drug Administration Database and Literature Review

BACKGROUND

Intranasal sprays (INSs) are commonly used medications for the treatment of many rhinologic conditions. Despite their popularity, an analysis of a nationwide reporting database and comparison to the available literature has never been performed.

METHODS

The Food and Drug Administration Adverse Event Reporting System (FAERS) database was accessed to obtain adverse event (AE) records from 2014 to 2019 for varying INSs, including: 10 corticosteroids, 1 alpha adrenergic, and 3 antihistamines. The Proportional Reporting Ratios (PRR) and Reporting Odds Ratios (ROR) were calculated for dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache. A PRR ≥ 2 or ROR ≥ 1 was considered significant.

RESULTS

Corticosteroids had 98 864 total reported AEs to the database, followed by antihistamines (7011) and alpha adrenergics (2071). In total, dyspnea was reported 5843 times, followed by headache (4230), epistaxis (1205), ageusia/dysgeusia (920), and anosmia (312). Overall, PRR and ROR values for dyspnea ranged from 0.51 to 4.25 and 0.51 to 4.49; for dysgeusia/ageusia from 0.56 to 6.09 and 0.56 to 6.12; and for epistaxis from 1.03 to 27.24 and 1.03 to 30.76, respectively. All medications which listed anosmia within the top AEs had PRR and ROR values exceeding 2 and 1, respectively. The PRR for headache exceeded 2 for 1 medication and the ROR exceeded 1 in 7 medications.

CONCLUSION

The AEs of dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache are reported within the FAERS database for commonly prescribed INSs. When compared against the existing scientific literature, the clinical significance of this reporting tool from the FDA for these classes of medications remains unvalidated.

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.

The Proposed Usage of Intranasal Steroids and Antihistamines for Otitis Media with Effusion

PURPOSE OF REVIEW

To examine the role of allergy medications in the treatment of otitis media with effusion (OME), focusing on use of intranasal steroids and antihistamines.

RECENT FINDINGS

There has been ongoing controversy regarding the role of allergy in the development of OME. Treatment of OME with medications commonly used for allergic symptomatology has been studied. Proposed treatment options include decongestants, mucolytics, oral steroids, topical steroids, antihistamines, and antibiotics. We begin by evaluating the proposed association between allergy and OME, and then evaluate intranasal steroids and oral antihistamine therapy in the treatment of OME. The role of the adenoid and concurrent nasal symptomatology is also addressed. The preponderance of data suggests that neither intranasal steroids nor antihistamines improve the long-term clearance of isolated OME and are therefore not recommended. However, data are notably limited with regard to improvement rates in OME in patients specifically with concurrent allergy and/or adenoid hypertrophy. Future studies of medications for OME would ideally incorporate study designs controlling for both allergic rhinitis and adenoid hypertrophy, to better understand the impact of these medications on OME in these subgroups of patients.

Evaluation of the effects of montelukast, mometasone furoate, and combined therapyon adenoid size: a randomized, prospective, clinical trial with objective data

Background/aim: The incidence of adenoid hypertrophy is 2%-3% in children. Adenoidectomy is a commonly performed procedure in children that may cause complications such as early or late bleeding (4%-5%), recurrence of adenoid tissue (10%-20%), and postoperative respiratory problems (27%). Therefore, medical therapy alternatives to adenoidectomy are important and must be tried before surgery. In this study, we investigated the efficacy of mometasone furoate, montelukast, and a combination of these drugs in pediatric patients with adenoid hypertrophy who were scheduled for reduction with medical therapy after not being recommended for surgery.Materials and methods: The study included 120 children with adenoid hypertrophy aged between 4 and 10 years. The patients were randomized into 4 separate groups, with 30 in each group. Group 1 received 100 μg of mometasone furoate per day, group 2 received 4/5 mg (for age) montelukast per day, and group 3 received mometasone furoate + montelukast. Medical therapy continued for 3 months in the treatment groups. Group 4, which comprised patients with mild symptoms, received no treatment and was the control group. The pre- and posttreatment adenoid tissue ratios in lateral neck radiographs were recorded in the four groups. Results: When radiologic measurements of adenoid-to-air passage were calculated, an improvement of 21.76% was observed in group 1 after treatment. The rate of improvement was 22.51% in group 2. There was a 21.79% reduction in adenoid size in group 3 after 3 months? treatment and 12.46% in the control group. There were statistically significant differences between pre- and posttreatment values in every single group administered corticosteroids, montelukast, and combined therapy (P < 0.05).Conclusion: According to our results, both montelukast and mometasone furoate therapies were similarly successful in treating adenoid hypertrophy. Combined therapy has no superiority over single-therapy treatment.

Comprehensive management of congenital choanal atresia

OBJECTIVES

To present results of a one-stage minimally invasive surgical procedure for congenital choanal atresia (CCA). Seven outcome measures were applied.

MATERIALS AND METHODS

Retrospective study conducted between 1999 and 2015. The same endonasal endoscopic approach with multiflaps and no stenting was used on 36 children. The flaps were attached with fibrine glue. There were 50% unilateral and 50% bilateral cases, 70% primary and 30% secondary surgery. The mean age at primary surgery for bilateral atresia was 10 days and for unilateral atresia 4 years. Associated loco-regional disorders were: hypoplasia of the inferior turbinate, rhinopharyngeal stenosis and rhinopharyngeal web.

RESULTS

The average follow-up time was 6 years, ranging from 1 to 14 years. There was a functionally patent choanae in 94% of children, and 6% showed severe restenosis with a diameter less than 4 mm, which needed one revision surgery each. Charge patients were not associated with worse outcome. There was no external nasal valve stenosis and no permanent Eustachian tube dysfunction. Synechiae occurred in 3 patients with hyperplastic inferior turbinate. No patients showed any disharmonious nasal growth. In neonates with isolated bilateral CCA, breast-suction could be started within 1 day (range 1-2 days), and pain-killers were needed on average for 1.5 days (range 1-4 days). The hospital stay for unilateral isolated CCA was on average 1.5 days (range 1-2 days) and for bilateral isolated CCA, 8 days (range 3-20 days). Postoperative procedures under a short general anesthesia were necessary in 12 cases, 10 of them were infants under 6 months of age.

CONCLUSION

Surgery could be performed safely in the newborn in the early stage of life, even for unilateral atresia. Tendency for restenosis can be minimized by: 1. the construction of an as large as possible uni-neochoanae by removing the posterior part of the vomer and by drilling away the medial pterygoid; 2. in case of rhinopharyngeal stenosis, part of the endochondral clivus bone should be resected; 3. all raw surfaces should be covered by multiple mucosal flaps secured with fibrin glue; 4. no stenting; 5. appropriate postoperative care.

Adverse Effects of Nonsystemic Steroids (Inhaled, Intranasal, and Cutaneous): a Review of the Literature and Suggested Monitoring Tool

Inhaled, intranasal, and cutaneous steroids are prescribed by physicians for a plethora of disease processes including asthma and rhinitis. While the high efficacy of this class of medication is well known, the wide range of adverse effects, both local and systemic, is not well elucidated. It is imperative to monitor total steroid burden in its varied forms as well as tracking for possible side effects that may be caused by a high cumulative dose of steroids. This review article highlights the adverse effects of different steroid modalities as well as suggests a monitoring tool to determine steroid totality and side effects.

Use of intranasal corticosteroids in adenotonsillar hypertrophy

Objectives:

This review examined the efficacy of intranasal corticosteroids for improving adenotonsillar hypertrophy.

Method:

The related literature was searched using PubMed and Proquest Central databases.

Results:

Adenotonsillar hypertrophy causes mouth breathing, nasal congestion, hyponasal speech, snoring, obstructive sleep apnoea, chronic sinusitis and recurrent otitis media. Adenoidal hypertrophy results in the obstruction of nasal passages and Eustachian tubes, and blocks the clearance of nasal mucus. Adenotonsillar hypertrophy and obstructive sleep apnoea are associated with increased expression of various mediators of inflammatory responses in the tonsils, and respond to anti-inflammatory agents such as corticosteroids. Topical nasal steroids most likely affect the anatomical component by decreasing inspiratory upper airway resistance at the nasal, adenoidal or tonsillar levels. Corticosteroids, by their lympholytic or anti-inflammatory effects, might reduce adenotonsillar hypertrophy. Intranasal corticosteroids reduce cellular proliferation and the production of pro-inflammatory cytokines in a tonsil and adenoid mixed-cell culture system.

Conclusion:

Intranasal corticosteroids have been used in adenoidal hypertrophy and adenotonsillar hypertrophy patients, decreasing rates of surgery for adenotonsillar hypertrophy.

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

INTRODUCTION

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

Intranasal Fluticasone Propionate Observational Cohort Safety Studies: Reviewing Evidence from Databases on Two Continents

Purpose

Our objective was to highlight the importance of database selection in observational research and to determine the incidence of corticosteroid-related events in patients exposed to fluticasone propionate intranasal spray (FPNS) compared with other intranasal steroids (INS).

Methods

After a feasibility study using an electronic medical record database in the UK (1990–2002), a retrospective cohort study was conducted using a large administrative claims database in the USA from 1994 to 2002 comparing the incidence and rate ratios of steroid-related events among intermittent, sub-chronic, and chronic FPNS use and other INS use episodes.

Results

Most patients used INS intermittently; power was low to evaluate risk associated with chronic use. Significantly elevated adjusted rate ratios were observed in the US study comparing FPNS with other INS for hypercorticism, sinusitis, abscess, and empyema, as well as a significantly decreased rate ratio for cataracts. The US claims database provided greater granularity on covariates and markers of severity to improve control of confounding for this study and time period, but neither database was able to assess the indication for prescription and the UK study could not address the use of INS without a prescription.

Conclusions

The FPNS results were consistent with the risk profile for INS and did not raise any new safety signals at the time of study conduct, which is consistent with the current safety profile. We were not able to discern the extent of potential off-label use of FPNS or other INS. Differences in the available data and healthcare systems highlight important considerations for database selection in the feasibility phase to assess the precision and limitations prior to formal risk evaluation.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0057-y) contains supplementary material, which is available to authorized users.

Systematic review and meta-analysis of randomized controlled trials on the role of mometasone in adenoid hypertrophy in children

OBJECTIVES

Mometasone has been reported to improve the symptoms of nasal obstruction in children with adenoidal hypertrophy. This systematic review and meta-analysis were conducted to evaluate the role of mometasone on different nasal symptoms, otitis media with effusion, adenoid size, and quality of life in children with adenoidal hypertrophy.

METHODS

A comprehensive search of MEDLINE, EMBASE, CINAHL and COCHRANE Collaboration databases was undertaken. We identified all the randomized controlled trials (RCTs) in children with adenoidal hypertrophy that compared the effects of mometasone nasal spray and normal saline nasal spray on different outcomes. The deadline of the search was April 2015. The search was supplemented by hand searching of cross-references in the studies and reviews and by contacting the authors of various studies. Only English language RCTs were considered for the systematic review. The primary outcomes were improvement in symptoms of nasal obstruction, mouth breathing, rhinorrhea, snoring, cough, and total nasal symptoms. The secondary outcomes were improvement in otitis media with effusion, quality of life, and size of adenoid. Quality assessment of RCTs was performed using SIGN 50 and Cochrane risk of bias tools. Risk ratio (RR), weighted mean differences (WMD) and their 95% confidence intervals (CI) were calculated for dichotomous and continuous data, respectively. Random effects model was used for the analyses. Heterogeneity was measured by using the I(2) statistics and p value <0.05.

RESULTS

Our search generated 87 citations, of which eight RCTs met the inclusion criteria. The methodological quality of all the RCTs was poor. There was no significant difference between mometasone and control groups for the patient's characteristic and grades of different nasal symptoms, otitis media with effusion, obstructive sleep apnea, and quality of life at the basal level. There was also no significant difference in the number of patients with different symptoms at the basal level. After the administration of mometasone, there were significant improvements in grades of nasal obstruction, 0.8±0.5 versus 2.0±0.6, WMD -1.16 [-2.09, -0.23], snoring 0.3±0.4 versus 1.6±0.6, WMD -1.07 [-2.09, -0.05], total nasal symptoms 2.9±1.3 versus 6.9±1.5, WMD -4.09 [-6.64, -1.53], obstructive sleep apnea, 0.6±0.3 versus 1.4±0.4, WMD -0.95 [-1.74, -0.16], as well as the percentage of patients with nasal obstruction, snoring, obstructive sleep apnea, compared to control. There was tendency of improvement in rhinorrhea, and cough with mometasone. Compared to control, mometasone nasal spray significantly improved adenoid size or adenoid/choana ratio 50.9±8.8 versus 74.2±12.6, WMD -21.2 [-34.0, -8.4], change in adenoid/choana obstruction from the basal level (p=0.01), and percentage of patients with adenoid hypertrophy, 26% versus 92%, RR 0.29 [0.18, 0.48]. There was improvement in otitis media with effusion, 40% versus 72%, pure tone audiometry 5.2±11 versus 11.6±11dB, WMD -6.40dB [-12.65, -0.15], and quality of life with mometasone. Subgroup analyses showed that RCTs that followed blinding showed significantly less response compared to RCTs that did not follow it for most of the outcomes.

CONCLUSIONS

Mometasone caused improvements in outcomes of nasal obstruction, snoring, total nasal symptoms, pure tune audiometry, otitis media with effusion, adenoid size, and quality of life. The data is based on meta-analysis of RCTs of poor methodological quality. A high methodological quality, placebo controlled RCT of different doses and duration of administration of mometasone is required to evaluate its clear efficacy and safety in children with adenoid hypertrophy.

Intranasal corticosteroids for mild childhood obstructive sleep apnea--a randomized, placebo-controlled study

BACKGROUND

The use of non-surgical treatment for childhood obstructive sleep apnea (OSA) is gaining popularity, especially in children with mild disease.

OBJECTIVE

To test the hypothesis that intranasal corticosteroids reduce disease severity in children with mild OSA.

STUDY DESIGN

A randomized, double-blinded, placebo-controlled trial of intranasal mometasone furoate (MF) versus placebo in children aged 6 to 18 years with mild OSA. The primary outcome was the change from baseline obstructive apnea hypopnea index (OAHI), as documented by overnight polysomnography, after four months of treatment.

RESULTS

Sixty-two children were recruited but 12 dropped out. This left 24 and 26 children for final analysis in the MF and placebo group, respectively. The OAHI and oxygen desaturation index (ODI) improved significantly in the MF group only. The OAHI decreased from 2.7 ± 0.2 to 1.7 ± 0.3 in the MF group, but increased from 2.5 ± 0.2 to 2.9 ± 0.6 in the placebo group (p = 0.039). The mean changes in ODI in the MF group and placebo group were -0.6 ± 0.5 and +0.7 ± 0.4, respectively (p = 0.037).

CONCLUSION

Four months of treatment with intranasal mometasone furoate effectively reduces the severity of mild OSA in children.

Role of mometasone furoate aqueous nasal spray for management of adenoidal hypertrophy in children

Objectives:

To study the role of mometasone furoate aqueous nasal spray for the management of adenoidal hypertrophy in children with more than 50 per cent obstruction, and to assess its impact on change in quality of life.

Methods:

A prospective, randomised, double-blind, interventional placebo-controlled study was conducted. A total of 100 children aged 2–12 years completed treatment and follow up. The symptoms and degree of obstruction were evaluated by nasopharyngoscopy conducted pre-treatment and 24 weeks post-treatment. Subjects received mometasone furoate nasal spray at a daily dose of 200 µg for 8 weeks, followed by a dose of 200 µg on alternate days for 16 weeks. Results were compared with those of a matched control group who were given saline nasal spray.

Results:

With mometasone treatment, there was an 89.8 per cent reduction in clinical symptom score, and the degree of obstruction dropped from 87 to 72 per cent (p < 0.0001). A statistically significant change in quality of life scores was seen in patients treated with the mometasone nasal spray (score change of 37.47) as compared with those given saline nasal spray (score change of 11.25) (p = 0.0001).

Conclusion:

Mometasone nasal spray appears to be effective in treating children with obstructive adenoids.

A double-blind randomized placebo-controlled trial of topical intranasal mometasone furoate nasal spray in children of adenoidal hypertrophy with otitis media with effusion

PURPOSE

To study the effects of topical intranasal mometasone furoate nasal spray for management of otitis media with effusion in children aged 2-12 years with adenoidal hypertrophy and its impact on change in quality of life.

METHOD

A prospective randomized double blind interventional placebo control study was conducted. Hundred patients of endoscopic grade 3 or 4 adenoidal hypertrophy aged 2-12 years were enrolled in this study. Among these sixty two patients had persistent bilateral otitis media with effusion more than three months. These were randomly divided into two groups, group A and group B. Group A received mometasone nasal spray for six months and group B received saline nasal spray for the same period. Patients were evaluated with symptom, pure tone audiometry wherever possible, pneumatic otoscopic examination and tympanogram at 0, 8 and 24 weeks.

RESULTS

Resolution of otitis media with effusion in study group (28 out of 30) was significantly higher as compared control group (16 out of 32) (p value 0.0004). A significant improvement in hearing and symptoms was seen in the study group (p<0.04). Statistically significant change in quality of life was seen with mometasone nasal spray (37.11) as compared to saline nasal spray (11.02) (p value 0.0001).

CONCLUSION

Mometasone nasal spray appears to be effective for the treatment of otitis media with effusion in patients of adenoidal hypertrophy.

Steroid-eluting sinus implant for in-office treatment of recurrent polyposis: a pharmacokinetic study

BACKGROUND

Long-term use of systemic glucocorticoid therapy has been associated with hypothalamic-pituitary-adrenal axis suppression and other systemic adverse events. This pharmacokinetic study evaluated the systemic safety and performance of a bioabsorbable sinus implant that gradually releases 1350 μg of mometasone furoate directly to the sinus mucosa.

METHODS

A prospective, single-center study treating 5 adult patients with recurrent polyposis after bilateral total ethmoidectomy. Each patient received 2 steroid-releasing implants in-office under local/topical anesthesia. Plasma concentrations of mometasone furoate and cortisol were determined before placement and through 30-day follow-up, which also included endoscopic grading and patient-reported outcomes.

RESULTS

Five patients (mean age 46.2 ± 9.2 standard deviation [SD] years; 60% male) underwent successful placement in all 10 ethmoid sinuses. There were no serious adverse events. The plasma concentrations of mometasone furoate were generally below the lower limit of quantification (LLOQ) of the assay (30 pg/mL). Cortisol concentrations at follow-up ranged from 3.9 to 5.7 mg/dL compared to 4.7 mg/dL at baseline. At 1 month, there was a significant improvement in bilateral polyp grade (p = 0.037), nasal obstruction score (p = 0.002), and 22-item Sino-Nasal Outcome Test (SNOT-22) (p = 0.010) compared to baseline.

CONCLUSION

The reported 100% placement success, negligible systemic exposure to mometasone furoate released over time, lack of adrenal suppression, and the absence of serious adverse events suggest that the implant provides a valid and safe option for the in-office treatment of recurrent polyposis. Randomized, controlled, blinded clinical studies are underway to provide further evidence of safety and efficacy.

Current recommendations and emerging options for the treatment of allergic rhinitis

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

The use of large volume low pressure nasal saline with fluticasone propionate for the treatment of pediatric acute rhinosinusitis

OBJECTIVES

Fluticasone propionate and nasal saline irrigation have been used in the treatment of sinonasal diseases for a long time. Our study investigates the effect of the combination of large volume low pressure nasal saline irrigation and fluticasone propionate for the treatment of pediatric acute rhinosinusitis.

METHODS

Ninety-one pediatric patients with acute rhinosinusitis were included in our study. The patients were randomized into two groups. The first group (n=45) was treated with standard therapy (antibiotherapy+nasal decongestant) for 2 weeks, the second group was treated with the large volume low pressure nasal saline+fluticasone propionate combination for 3 weeks. The clinical scores, radiologic evaluations (X-ray Waters view), peak nasal inspiratory flow (PNIF) measurements, total symptom scores and hematologic parameters (WBC, CRP, ESR) of the patients were evaluated and compared.

RESULTS

There were no significant differences in between the two groups regarding age, gender, height and weight. Even though the clinical scores of Group 2 improved more rapidly, there were no significant differences in between groups regarding clinical scores by the 21st day. There were no significant differences in post treatment radiologic evaluations (Waters graphy). Both groups had significant improvement of their post treatment PNIF values, yet the improvement was more marked in Group 2 than in Group 1. The rhinorrhea, nasal congestion, throat itching and cough symptoms improved more rapidly in Group 2 than in Group 1. Post-treatment nose itching and sneezing symptoms were significantly less in Group 2. The values of hematologic parameters were significantly reduced at the end of the 3rd week in both groups.

CONCLUSIONS

Our study is a first in investigating the combined use of large volume low pressure nasal saline and fluticasone propionate in acute pediatric rhinosinusitis, and the results reveal that the combination therapy was effective. Low pressure large volume nasal saline+fluticasone propionate combination can be employed as a new line of therapy for the treatment of pediatric acute rhinosinusitis, either by itself or combined with standard therapy.

Simultaneous Bilateral Quadriceps Tendon Rupture following Long-Term Low-Dose Nasal Corticosteroid Application

Simultaneous bilateral quadriceps tendon rupture is a very rare injury, which was previously only described in slightly more than 100 cases in the English literature. Occurrence after minor trauma is predominantly associated with certain medical conditions including chronic diseases and long-term use of certain drugs. We report the case of a 61-year-old healthy patient who sustained a simultaneous bilateral quadriceps tendon rupture following minor trauma. Medical history was completely clear except of a long-term nasal corticosteroid medication due to allergic rhinitis.

Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years

OBJECTIVE

To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents.

METHODS

Analysis of the medical literature published since the last version of the guideline (2001).

RESULTS

The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever[temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the firstline treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening(progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.

CONCLUSIONS

Changes in this revision include the addition of a clinical presentation designated as “worsening course,” an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis.

Effect of intranasal steroids on glucose and hemoglobin A1c levels in diabetic patients

BACKGROUND

Intranasal steroids are widely used for the treatment of inflammatory diseases of the nose and sinuses such as rhinosinusitis, allergic rhinitis, and nonallergic rhinitis. Along with the general otherwise healthy population, many diabetic patients use intranasal steroids as well. This study was designed to evaluate the adverse effects of long-term treatment with intranasal corticosteroid preparations in diabetic patients.

METHODS

The study group included all diabetic patients treated with intranasal steroids for at least 3 months at primary care clinics in Clalit Health Services Central District in Israel in 2002-2007. The central database had been reviewed for demographic data, medical history, medications, and laboratory test results.

RESULTS

A total of 1768 diabetic patients were treated with topical nasal steroid sprays during the study period. Data on hemoglobin A1c (HbA1c) levels both before and during steroid treatment was available for 245 patients, and data on fasting serum glucose levels at both time points was available for 163 patients. On statistical analysis, there was no change in either measure from baseline to 3 months after starting treatment (p = 0.104 and p = 0.101, respectively). Treatment with triamcinolone acetonide was associated with a significantly greater increase in fasting serum glucose levels than other preparations (p = 0.006).

CONCLUSION

Intranasal corticosteroids seem to have no adverse effects on HbA1c and serum glucose levels in diabetic patients. Their long-term use appears to be safe, provided that the patients are carefully monitored, especially those receiving triamcinolone acetonide.

Effects of intranasal mometasone furoate on itchy ear and palate in patients with seasonal allergic rhinitis

BACKGROUND

Intranasal steroids relieve nasal symptoms and ocular itch in allergic rhinitis. Itchy ear and palate are also common and bothersome symptoms but have received little attention in clinical trials of allergic rhinitis.

OBJECTIVE

To ascertain the efficacy of mometasone furoate nasal spray in alleviating itchy ear and palate in seasonal allergic rhinitis.

METHODS

Data were pooled from 4 randomized, double-blind, placebo-controlled trials of mometasone furoate nasal spray, 200 μg/d. Participants rated ear and palate itching from baseline through treatment day 15 as follows: 0, none; 1, mild; 2, moderate; and 3, severe.

RESULTS

A total of 962 study participants received mometasone furoate nasal spray or placebo. Baseline least squares mean itchy ear and palate score was 1.81 for participants receiving mometasone furoate nasal spray (n = 480) and 1.85 for participants receiving placebo (n = 482). Mometasone furoate nasal spray was associated with a greater decrease in itchy and ear palate score vs placebo during the 15-day study period (least squares mean change, -0.73 vs -0.45; P < .001). The difference reached significance on day 2 and persisted through day 15 (P ≤ .01 for each day). Results were similar in a subgroup of patients (n = 305) with moderate-to-severe symptoms at baseline. Adverse events with mometasone furoate nasal spray were similar to those observed in other studies of intranasal steroid therapy.

CONCLUSION

These preliminary findings suggest that mometasone furoate nasal spray effectively treats itchy ear and palate in individuals with seasonal allergic rhinitis. Itchy ear and palate is a relevant end point for future clinical trials of allergic rhinitis.

Intranasal steroids in the treatment of allergy-induced rhinorrhea

While nasal congestion has been identified as one of the most bothersome and prevalent symptoms of allergic rhinitis, it is underappreciated that many patients find rhinorrhea also to be bothersome. Rhinorrhea as a symptom of allergic rhinitis virtually never occurs alone; about 97% of patients with allergic rhinitis suffer from at least two symptoms, a finding that underscores the advantage of treating a broad range of symptoms with a single medication. Along with sneezing and nasal obstruction, rhinorrhea is a classic acute symptom of allergic rhinitis; it appears as a late-phase symptom as well. In this review, the characterization and epidemiology of rhinorrhea, the pathophysiology of rhinorrhea in allergic rhinitis, the roles played by mediators in early- and late-phase rhinorrhea, the prevalence and impact of this symptom, and the efficacy and safety of available treatment options are all discussed in context of relevant literature. A review of the clinical studies assessing the efficacy of intranasal corticosteroids (INS) for rhinorrhea is presented. Many clinical studies and several meta-analyses conclusively demonstrate that, in addition to being safe and well-tolerated, INS are more effective than other agents (including oral and intranasal antihistamines) across the spectrum of AR symptoms, including rhinorrhea and nasal congestion.

Effect of nasal mometasone furoate on the nasal and nasopharyngeal flora

OBJECTIVE

Mometasone furoate (MF) is one of the commonly used topical steroids, particularly for patients with allergic rhinitis. However, its effect on the colonization of bacteria that may cause superinfections by suppressing the local immunity is not known. Thus, we investigated the effect of MF use on the nasal and nasopharyngeal microbial flora.

MATERIALS AND METHODS

Swab samples were taken from 35 patients who required MF monotherapy, just before and after one month of the treatment. Samples were maintained in Stuart's medium. Each swab was transferred to 1ml of a sterile saline solution, then into the standard agar. After incubation under 5% carbon dioxide at 37°C, colony number was detected per ml.

RESULTS

Colony counts of nasal or nasopharyngeal microbial flora did not show any statistically significant alteration with one month use of MF. However, an increase in potential pathogens as well as normal flora bacteria was determined in five of the patients and six patients acquired new nasopharyngeal potential pathogens, mostly Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus, following the use of MF.

CONCLUSION

The use of MF for one month did not statistically significantly change the nasal and nasopharyngeal flora. This study indicates that MF could be increase the colonization of the potential pathogens in some of the patients at the subclinical level particularly in the nasopharyngeal area.

Evidence-based management of nasal polyposis by intranasal corticosteroids: from the cause to the clinic

BACKGROUND

Nasal polyposis is an inflammatory disorder involving the mucosa of the nose and paranasal sinuses and affecting approximately 2-4% of the general population.

METHODS

A literature search of Medline and Embase was conducted to obtain an overview of the epidemiology, pathophysiology, and current treatment of nasal polyposis, focusing on evidence-based efficacy of intranasal corticosteroids (INSs) as primary and postoperative therapy. Recent research on INSs in nasal polyp treatment, along with notable historic findings, was reviewed.

RESULTS

Nasal polyps are mostly characterized by eosinophil infiltration, a complex inflammation of nasal mucosa, and possibly production of polyclonal IgE. Current treatment modalities include INSs, oral corticosteroids, and surgery; surgery is generally limited to those with an insufficient response to medical treatment. Because of their effects on eosinophil-dominated inflammation, INSs and oral corticosteroids are the primary medical treatment strategies. The very low (≤1%) systemic bioavailability of newer INSs minimizes the systemic adverse effects seen with oral corticosteroids.

CONCLUSION

Based on randomized, controlled trials, guidelines recommend INSs as first-line therapy for nasal polyps and for care after polypectomy. Clinical data suggest INSs are effective in reducing polyp size and relieving nasal symptoms. INS treatment has also reduced nasal polyp recurrence in patients undergoing functional endoscopic sinus surgery. Treatment with these mainstay options has been found to improve quality of life, which, along with symptom improvement, is a key factor in disease treatment.

Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation

Adenoidal hypertrophy (AH) and adenotonsillar hypertrophy are common disorders in the pediatric population and can cause symptoms such as mouth breathing, nasal congestion, hyponasal speech, snoring, and obstructive sleep apnea (OSA), as well as chronic sinusitis and recurrent otitis media. More serious long-term sequelae, typically secondary to OSA, include neurocognitive abnormalities (e.g. behavioral and learning difficulties, poor attention span, hyperactivity, below average intelligence quotient); cardiovascular morbidity (e.g. decreased right ventricular ejection fraction, left ventricular hypertrophy, elevated diastolic blood pressure); and growth failure. Adenoidectomy (with tonsillectomy in cases of adenotonsillar hypertrophy) is the typical management strategy for patients with AH. Potential complications have prompted the investigation of non-surgical alternatives. Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) in the management of patients with AH. This article reviews the epidemiology and pathophysiology of AH with a particular focus on evidence of its association with allergy and allergic rhinitis. Current treatment options are briefly considered with discussion on the rationale and evidence for the use of INS.

Impact of baseline nasal polyp size and previous surgery on efficacy of fluticasone delivered with a novel device: a subgroup analysis

BACKGROUND

Little information exists on the impact of baseline polyp size and previous nasal surgery on the efficacy of intranasal steroids. This study was designed to investigate whether baseline polyp size and previous nasal surgery influence the efficacy of an intranasal steroid delivered with a novel device.

METHODS

A post hoc analysis of recently published results with intranasal administration using a novel bidirectional delivery device containing fluticasone propionate (Opt-FP) was performed in 109 patients with mild-to-moderate bilateral polyposis. Patients were allocated to subgroups based on summed polyp score at baseline (2, 3, or 4) and on their history of previous sinus surgery.

RESULTS

A highly significant and progressive reduction in summed polyp size was observed for Opt-FP versus placebo in all three polyp size subgroups (p < 0.001). A greater relative reduction in polyp size (p < 0.05) and an increase in peak nasal inspiratory flow (p < 0.001) were observed for Opt-FP at 12 weeks in the 28 patients with a baseline summed score of 3 and 4 compared with the 27 with a summed score of 2. Nevertheless, in patients with small polyps at baseline, the polyps were completely resolved on both sides in 7 of 27 patients. Previous sinus surgery had no impact on efficacy.

CONCLUSION

The highly significant progressive treatment effect of Opt-FP was observed regardless of baseline polyps score. Coupled with the complete removal of polyps in many patients with small polyps, this suggests that improved deposition to target sites achieved with the bidirectional delivery device may translate into true clinical benefits and reduced need for surgery.

Intranasal corticosteroid monotherapy in acute rhinosinusitis: An evidence-based case report

In this evidence-based case report we studied the clinical question: Does intranasal corticosteroid (INCS) monotherapy reduce time to recovery in adults with acute noncomplicated rhinosinusitis? The search yielded 490 papers, of which only two were relevant and had a high validity regarding our clinical question.

Pharmacokinetics in special populations

Pharmacokinetics are typically dependent on a variety of physiological variables (e.g., age, ethnicity, or pregnancy) or pathological conditions (e.g., renal and hepatic insufficiency, cardiac dysfunction, obesity, etc.). The influence of some of these conditions has not always been thoroughly assessed in the clinical studies of antiallergic drugs. However, the knowledge of the physiological grounds of the pharmacokinetics can provide some insight for predicting the potential alterations and guiding the initial prescription strategies. It is important to recognize that both pharmacokinetic and pharmacodynamic differences between populations should be considered. The available information on drugs used for the therapy of allergic diseases is reviewed in this chapter.

Drug metabolism and pharmacokinetics

In this article, aspects of absorption, distribution, metabolism, and excretion have been described bearing in mind the pathogenesis of allergic diseases and their possible therapeutic opportunities. The importance of the routes of administration of the different therapeutic groups has been emphasized. The classical aspects of drug metabolism and disposition related to oral administration have been reviewed, but special emphasis has been given to intranasal, cutaneous, transdermal, and ocular administration as well as to the absorption and the subsequent bioavailability of drugs. Drug-metabolizing enzymes and transporters present in extrahepatic tissues, such as nasal mucosa and the respiratory tract, have been particularly discussed. As marketed antiallergic drugs include both racemates and enantiomers, aspects of stereoselective absorption, distribution, metabolism, and excretion have been discussed. Finally, a new and promising methodology, microdosing, has been presented, although it has not yet been applied to drugs used in the treatment of allergic diseases.

Daily versus self-adjusted dosing of topical mometasone furoate nasal spray in patients with allergic rhinitis: randomised, controlled trial

BACKGROUND

Many patients with allergic rhinitis are reluctant to use daily intranasal steroids for prolonged periods. A self-adjusted regimen which delivers reasonable control of allergic rhinitis may be more acceptable to such patients.

OBJECTIVES

To compare the efficacy of daily use of mometasone furoate nasal spray, versus a self-adjusted regimen, in patients with chronic allergic rhinitis, in terms of symptom control and nasal volume change.

SETTING

Ambulatory visits in an office setting.

PATIENTS AND METHODS

Sixty patients with chronic allergic rhinitis were randomised: 30 were prescribed mometasone furoate nasal spray once daily for six weeks, while 30 were prescribed the same spray daily for one week, every alternate day for one week and then on a self-adjusted regimen for four weeks. Patients kept a symptom diary documenting sneezing, rhinorrhoea, nasal blockage and nasal itching. Acoustic rhinometry was used to measure the total nasal cavity volume at the first visit and at the end of the treatment period.

RESULTS

The total nasal score on treatment days showed an improvement in both groups, compared with baseline measurements. There was no significant difference in total nasal scores between the two groups, except on days 10 (p = 0.043), 20 (p = 0.008), 23 (p = 0.19), 30 (p = 0.008) and 37 (p = 0.000), when the daily group's total nasal score was significantly lower than the self-adjusted group's total nasal score, and on day 8 (p = 0.004), when the self-adjusted group's total nasal score was significantly lower than the daily group's total nasal score. Total nasal cavity volume significantly increased in both groups (p = 0.0001), with no statistically significant difference between the groups.

CONCLUSIONS

Self-adjusted dosage of mometasone furoate nasal spray gives reasonable control of allergic rhinitis (albeit with some 'breakthrough' symptoms). Patients should learn how to control these symptoms with the least number of steroid doses.

Local cytokines and clinical symptoms in children with allergic rhinitis after different treatments

Background

Therapy for allergic rhinitis aims to control symptoms and improve the quality of life. The treatment of allergic rhinitis includes allergen avoidance, environmental controls, pharmacologic treatment, and specific immunotherapy.

Objectives

The aim of this study is to evaluate the clinical changes and the levels of interferon-γ (IFN-γ) and interleukin-5 (IL-5) in nasal lavage fluid from children with allergic rhinitis after different types of pharmacologic treatment (mometasone, montelukast, or desloratadine).

Methods

Twenty-four children aged from six to 12 years with moderate persistent allergic rhinitis were randomized into three groups receiving monotherapy treatment over four weeks: nasal corticosteroid (mometasone), leukotriene modifier (montelukast), or antihistamine (desloratadine). The perception of symptom improvement during the medication use was evaluated at the end of the treatment. Samples of nasal lavage fluid were collected before and after treatment for measuring IFN-γ and IL-5 cytokines by ELISA.

Results

All parents perceived an improvement in symptoms. Significant enhancement was seen in the mometasone group compared to those with montelukast (P = 0.01) and desloratadine (P = 0.02). No significant differences were found among the three groups in the levels of IL-5 and IFN-γ in nasal fluid at baseline or after treatment. Only the group treated with mometasone showed a slight but significant reduction in IL-5 levels after the treatment period as compared with levels before the treatment (P = 0.0469).

Conclusion

The group treated with mometasone showed better improvement of clinical symptoms and a slight reduction in IL-5 levels in the nasal fluid. This may indirectly reflect the relative immunomodulatory effects of the drugs tested.

Pediatric allergy medications: review of currently available formulations

BACKGROUND

Allergy affects about 50% of the pediatric population globally. Allergic rhinitis (AR), one form of allergy, causes considerable impairment in quality of life, including disruption of sleep and, in children, interference with school attendance and performance.

SCOPE

Traditional formulations and delivery systems - tablets, capsules, or intranasal sprays - successfully used by adults for treatment of AR may not be as easily administered in children. Liquid oral medications are more readily taken by children but contain sugars and excipients; they can also be inconvenient with less accurate dosing and are associated with dental caries and gastrointestinal upset.

METHODOLOGY

This review evaluated medications for treatment of AR currently available for pediatric patients and identified the attitudes of parents and health care professionals toward these medications. Guidelines from international organizations and governmental websites were reviewed for recommendations and product labeling requirements. A Medline search was conducted using the terms dyes, excipients, palatability, prescribing habits, sugar, among others.

FINDINGS

In recent years, governmental regulatory agencies and professional organizations in Europe and the United States have recommended avoidance of sugar in pediatric medicines and required stricter labeling of their ingredients. Public awareness about the adverse effects of sugar and some excipients has also increased, and parents more frequently express the desire for safer and more convenient medicines for their children. In response, more sugar-free, dye-free liquid medicines and other formulations, such as granules, filmstrips, chewable tablets, fast-dissolving tablets, and drops, are becoming available for pediatric use.

LIMITATIONS

Data from well-designed trials conducted in children for the treatment of AR are lacking. In addition, the possibility of a social response bias may exist for parents and physicians about sugar and other ingredients in children's medications.

CONCLUSION

Treatment for AR is often long-term, particularly in persistent AR; therefore, safety, tolerability, convenience, and patient/parental acceptance are important considerations when deciding which medication to prescribe.

Long-term study of fluticasone propionate aqueous nasal spray in acute and maintenance therapy of nasal polyposis

BACKGROUND

Topical steroids are first-line medication to control nasal polyposis (NP), a disease with long-term clinical course.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of fluticasone propionate aqueous nasal spray (FPANS) 200 microg twice a day (bd) after 1 month of treatment, and to compare FPANS 200 microg bd and FPANS 200 microg once a day (od) in maintenance and long-term treatment.

METHODS

Double-blind, placebo-controlled, 8-month study with three treatment periods (1-month acute period followed with 1-month maintenance period and 6-month follow-up period) was carried out. Group 1 received FPANS 200 microg bd, during acute, maintenance and follow-up periods, Group 2 received FPANS 200 microg bd during acute period and FPANS 200 microg od during maintenance and follow-up periods, and Group 3 received placebo during acute and maintenance periods and FPANS 200 microg bd during follow-up period. Endpoints were change from baseline in clinic peak nasal inspiratory flow (PNIF), domiciliary evening PNIF, intensity of symptoms and polyposis grade.

RESULTS

After acute period and maintenance periods, FPANS 200 microg bd was significantly more effective than placebo on all endpoints and more effective than FPANS 200 microg od after 1-month maintenance period on clinic PNIF, evening PNIF, obstruction, percentage of days with no sense of smell and percentage of nights with no disturbances. The two doses were similar on other endpoints. After the 6-month follow-up period, there was no difference between the two doses of FPANS at all efficacy endpoints. The safety profile of FPANS did not highlight any new or unanticipated adverse events.

CONCLUSION

The study demonstrated the efficacy of FPANS 200 microg bd in acute treatment and FPANS 200 microg od as a sufficient dose to maintain a long-term efficacy in the treatment for NP.

Using nasal steroids to treat nasal obstruction caused by adenoid hypertrophy: does it work?

OBJECTIVE

To systematically review the evidence for the usage of nasal steroids to improve symptoms of nasal airway obstruction in children with adenoidal hypertrophy.

DATA SOURCES

Published studies indexed in the MEDLINE (1951 to 2008), EMBASE (1974 to 2008), and the Cochrane databases (Issue 3, 2008).

REVIEW METHODS

Data from the included trials were extracted and trial quality was assessed. Meta-analysis was not applicable and data were summarized in a narrative format. Evidence from excluded studies was also discussed.

RESULTS

Seven studies (six randomized controlled trials and one cohort study) met the inclusion criteria of the review, including a total of 493 patients. Six of these studies demonstrated significant efficacy of various nasal steroids (mometasone, beclomethasone, flunisolide) in improving nasal obstruction symptoms and in reducing adenoid size, as measured with symptom scores and fiber-optic nasopharyngeal endoscopy, respectively. The response appeared to be a group effect and may be maintained longer-term by continuing nasal steroids at a lower maintenance dose. The treatment was safe and well-tolerated with few minor adverse events.

CONCLUSION

The available evidence suggests that nasal steroids may significantly improve nasal obstruction symptoms in children with adenoid hypertrophy. This improvement appears to be associated with a reduction of adenoid size. Evidence of long-term efficacy is limited but suggests that in many children maintenance therapy is needed if symptom-relief is to persist. Further studies are required to support the use of nasal steroids as a first-line approach in these children.

Efficacy of mometasone furoate nasal spray in the treatment of allergic rhinitis. Meta-analysis of randomized, double-blind, placebo-controlled, clinical trials

RATIONALE

Several randomized, double-blind, placebo-controlled clinical trials have demonstrated the efficacy of mometasone furoate nasal spray (MFNS) in the treatment of allergic rhinitis (AR) thus allowing for a meta-analysis to determine the overall treatment effect.

METHODS

A comprehensive search of the MEDLINE, LILACS, SCOPUS, and the Cochrane Library databases up to 31 October, 2007 was carried out. Randomized, double-blind, placebo-controlled, clinical trials evaluating the efficacy of MFNS in patients with AR compared to placebo were included. Total nasal symptom scores (TNSS), individual nasal symptoms, total non-nasal symptom scores (TNNSS) and nasal airflow were analysed as the standardized mean difference (SMD). Meta-analysis was performed with the random or the fixed effect models depending on heterogeneity, by using revman 5 software.

DATA SYNTHESIS

Sixteen of the 113 identified articles met the inclusion criteria. For MFNS efficacy on TNSS, 2998 participants were analysed: 1534 received MFNS and 1464 placebo. Mometasone furoate nasal spray was associated with a significant reduction in TNSS (SMD -0.49, 95% CI: -0.60 to -0.38; P < 0.00001; I(2) = 50.1%). A significant effect on SMD for nasal stuffiness/congestion (-0.41; 95% CI: -0.56 to -0.27), rhinorrhoea (-0.44; 95% CI: -0.66 to -0.21), sneezing (-0.40; 95% CI: -0.57 to -0.23) and nasal itching (-0.39; 95% CI: -0.53 to -0.25) was also demonstrated. Mometasone furoate nasal spray treated subjects also showed a significant reduction in TNNSS (-0.30; 95% CI: -0.43 to -0.18). The proportion of patients with adverse events was similar for MFNS and placebo (0.99; 95% CI: 0.81-1.20; P = 0.91).

CONCLUSIONS

This meta-analysis provides a level Ia evidence for the efficacy of MFSN in the treatment of AR vs placebo. Adverse events frequency was similar in both groups.