Non-interventional study comparing treatment satisfaction in patients treated with antihistamines

Efficacy and perceived satisfaction of 3-year SLIT in children with allergic rhinitis and asthma: a pilot study

BACKGROUND

Despite the presence of robust evidence, there is very limited data on the efficacy of allergen immunotherapy (AIT) for selected patients. Accordingly, we aimed to evaluate the efficacy and perceived satisfaction of a 3-year course of sublingual immunotherapy (SLIT) in a paediatric population with allergic rhinitis and/or asthma.

METHODS

A pilot, monocentre, retrospective cohort study was performed. One hundred fifty-three children who fulfilled the criteria for allergic rhinitis and asthma and were either mono- or poly-sensitized were enrolled. A standardized questionnaire assessing perceived efficacy, use of rescue medication, disease control, number of exacerbations, quality of life, and perceived satisfaction was administered to each patient.

RESULTS

Seventy patients (49 males, 21 females; mean age, 14.3±1.9 years) were included in the final analysis. All 70 patients received SLIT for up to 3 years, with 100% adherence to the treatment throughout the study. Significant improvements in symptoms and quality of life were reported (p<0.01). There was also a significant decrease in disease severity, use of rescue medication, and sleep disturbances (p<0.01). Additionally, a significant improvement in school performance was also recorded (p<0.01). Of the enrolled patients, 60 out of 70 (85.7%) reported being very satisfied, 6 out of 70 (8.57%) were much satisfied, and 4 out of 60 (5.71%) were satisfied.

CONCLUSIONS

We were the first to demonstrate the efficacy and perceived satisfaction of a 3-year SLIT in a paediatric population, with 100% treatment adherence throughout the study.

Unintentional cetirizine overdose causing anticholinergic syndrome: A case report

The incidence of anticholinergic syndrome due to second generation antihistamines is infrequently reported. Largely due to their decreased affinity for central nervous system (CNS) receptors, second generation antihistamines are rarely associated with anticholinergic symptoms, though toxicity is still possible particularly when taken in excess. We report a case of a six year old boy who presented with agitation, hallucinations, fixed and dilated pupils, tachycardia, and hyperthermia consistent with anticholinergic toxicity several hours after accidental overdose of a second generation antihistamine, cetirizine. Early identification of this rare phenomenon is important not only for appropriate emergency management but also for avoidance of potentially invasive and unnecessary tests which may further increase patient morbidity.

Impact of increasing treatment rates on cost-effectiveness of subcutaneous immunotherapy (SCIT) in respiratory allergy: a decision analytic modelling approach

BACKGROUND

Specific immunotherapy is the only causal treatment in respiratory allergy. Due to high treatment cost and possible severe side effects subcutaneous immunotherapy (SCIT) is not indicated in all patients. Nevertheless, reported treatment rates seem to be low. This study aims to analyze the effects of increasing treatment rates of SCIT in respiratory allergy in terms of costs and quality-adjusted life years (QALYs).

METHODS

A state-transition Markov model simulates the course of disease of patients with allergic rhinitis, allergic asthma and both diseases over 10 years including a symptom-free state and death. Treatment comprises symptomatic pharmacotherapy alone or combined with SCIT. The model compares two strategies of increased and status quo treatment rates. Transition probabilities are based on routine data. Costs are calculated from the societal perspective applying German unit costs to literature-derived resource consumption. QALYs are determined by translating the mean change in non-preference-based quality of life scores to a change in utility. Key parameters are subjected to deterministic sensitivity analyses.

RESULTS

Increasing treatment rates is a cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of 3484€/QALY compared to the status quo. The most influential parameters are SCIT discontinuation rates, treatment effects on the transition probabilities and cost of SCIT. Across all parameter variations, the best case leads to dominance of increased treatment rates while the worst case ICER is 34,315€/QALY. Excluding indirect cost leads to a twofold increase in the ICER.

CONCLUSIONS

Measures to increase SCIT initiation rates should be implemented and also address improving adherence.

Intranasal exposure to monoclonal antibody Fab fragments to Japanese cedar pollen Cry j1 suppresses Japanese cedar pollen-induced allergic rhinitis

BACKGROUND AND PURPOSE

Fab fragments (Fabs) of antibodies have the ability to bind to specific allergens but lack the Fc portion that exerts effector functions via binding to receptors including FcεR1 on mast cells. In the present study, we investigated whether intranasal administration of the effector function-lacking Fabs of a monoclonal antibody IgG1 (mAb, P1-8) to the major allergen Cry j1 of Japanese cedar pollen (JCP) suppressed JCP-induced allergic rhinitis in mice.

EXPERIMENTAL APPROACH

Balb/c mice sensitized with JCP on days 0 and 14 were challenged intranasally with the pollen on days 28, 29, 30 and 35. Fabs prepared by the digestion of P1-8 with papain were also administered intranasally 15 min before each JCP challenge.

KEY RESULTS

Intranasal administration of P1-8 Fabs was followed by marked suppression of sneezing and nasal rubbing in mice with JCP-induced allergic rhinitis. The suppression of these allergic symptoms by P1-8 Fabs was associated with decreases in mast cells and eosinophils and decreased hyperplasia of goblet cells in the nasal mucosa.

CONCLUSIONS AND IMPLICATIONS

These results demonstrated that intranasal exposure to P1-8 Fabs was effective in suppressing JCP-induced allergic rhinitis in mice, suggesting that allergen-specific mAb Fabs might be used as a tool to regulate allergic pollinosis.

Brain histamine H1 receptor occupancy measured by PET after oral administration of levocetirizine, a non-sedating antihistamine

OBJECTIVE

Histamine H1 receptor (H1R) antagonists often have sedative side effects, which are caused by the blockade of the neural transmission of the histaminergic neurons. We examined the brain H1R occupancy (H1RO) and the subjective sleepiness of levocetirizine, a new second-generation antihistamine, comparing fexofenadine, another non-sedating antihistamine, as a negative active control.

METHODS

Eight healthy volunteers underwent positron emission tomography (PET) imaging with [(11)C]doxepin, a PET tracer that specifically binds to H1Rs, after a single oral administration of levocetirizine (5 mg), fexofenadine (60 mg) or placebo in a double-blind crossover study. Binding potential ratios and H1ROs in the cerebral cortices regions were calculated using placebo. Subjective sleepiness was assessed with the Line Analogue Rating Scale and the Stanford Sleepiness Scale.

RESULTS

There was no significant difference between the mean brain H1RO after levocetirizine administration (8.1%; 95% CI: -9.8 to 26.0%) and fexofenadine administration (-8.0%; 95% CI: -26.7 to 10.6%). Similarly, subjective sleepiness was not significantly different between the two antihistamines and placebo. Neither subjective sleepiness nor plasma concentrations was significantly correlated with the brain H1RO of the two antihistamines.

CONCLUSION

At therapeutic dose, levocetirizine does not bind significantly to the brain H1Rs and does not induce significant sedation.

A survey of clinical features of allergic rhinitis in adults

BACKGROUND

Allergic rhinitis (AR) has high prevalence and substantial socio-economic burden.

MATERIAL/METHODS

The study included 35 Italian Centers recruiting an overall number of 3383 adult patients with rhinitis (48% males, 52% females, mean age 29.1, range 18-45 years). For each patient, the attending physician had to fill in a standardized questionnaire, covering, in particular, some issues such as the ARIA classification of allergic rhinitis (AR), the results of skin prick test (SPT), the kind of treatment, the response to treatment, and the satisfaction with treatment.

RESULTS

Out of the 3383 patients with rhinitis, 2788 (82.4%) had AR: 311 (11.5%) had a mild intermittent, 229 (8.8%) a mild persistent, 636 (23.5%) a moderate-severe intermittent, and 1518 (56.1%) a moderate-severe persistent form. The most frequently used drugs were oral antihistamines (77.1%) and topical corticosteroids (60.8%). The response to treatment was judged as excellent in 12.2%, good in 41.3%, fair in 31.2%, poor in 14.5%, and very bad in 0.8% of subjects. The rate of treatment dissatisfaction was significantly higher in patients with moderate-to-severe AR than in patients with mild AR (p<0.0001). Indication to allergen immunotherapy (AIT) was significantly more frequent (p<0.01) in patients with severe AR than with mild AR.

CONCLUSIONS

These findings confirm the appropriateness of ARIA guidelines in classifying the AR patients and the association of severe symptoms with unsuccessful drug treatment. The optimal targeting of patients to be treated with AIT needs to be reassessed.

Comparison of levocetirizine pharmacokinetics after single doses of levocetirizine oral solution and cetirizine dry syrup in healthy Japanese male subjects

Objective

Levocetirizine, the R-enantiomer of cetirizine, is classified as a second generation antihistamine used for the treatment of allergic disorders. This study aimed to compare exposure to levocetirizine when given as levocetirizine oral solution (OS) 5 mg to that when given as cetirizine dry syrup (DS) 10 mg, which contains equal proportions of levocetirizine and dextrocetirizine, in healthy Japanese male subjects.

Methods

The study was conducted in an open-label, single dose, randomized and two-way cross-over design. Eligible subjects were allocated to one of two groups and received either levocetirizine OS 5 mg or cetirizine DS 10 mg under fasting conditions, and the alternate treatment after a 7-days washout period. Serial blood samples were taken after each administration, and plasma levocetirizine concentrations were determined using a validated LC-MS/MS method. Pharmacokinetic parameters were calculated by using non-compartmental analysis. Comparisons of levocetirizine pharmacokinetics were conducted with maximum concentration (C_max) and the area under the plasma concentration-time curve from dosing until 48 h post-dose (AUC_0–48) after each treatment.

Clinical Trial registration number

ClinicalTrials.gov identifier is NCT01622283

Results

The mean C_max and AUC_0–48 of levocetirizine after a single dose of levocetirizine OS 5 mg and cetirizine DS 10 mg were 203.3 ± 42.49 ng/mL and 1814.9 ± 304.22 ng.hr/mL, and 196.5 ± 31.31 ng/mL and 1710.5 ± 263.31 ng hr/mL, respectively. The ratios and the 90% CIs of the geometric least squares means ratios of C_max and AUC_0–48 were 1.027 (0.968–1.091) and 1.059 (1.024–1.094), respectively.

Limitation

The small sample size and single dose design of this study prevent definitive conclusions regarding the pharmacokinetics and safety of levocetirizine OS in a Japanese patient population being made. Study limitations include conducting the study in adult males, not in children.

Conclusions

Levocetirizine exposure in plasma was equivalent when given as levocetirizine OS 5 mg and as cetirizine DS 10 mg. Both preparations were safe and well-tolerated in healthy Japanese male subjects.

Pharmacology of antihistamines

H1-antihistamines, the mainstay of treatment for urticaria, were developed from anticholinergic drugs more than 70 years ago. They act as inverse agonists rather than antagonists of histamine H1-receptors which are members of the G-protein family. The older first generation H1-antihistamines penetrate readily into the brain to cause sedation, drowsiness, fatigue and impaired concentration and memory causing detrimental effects on learning and examination performance in children and on impairment of the ability of adults to work and drive. Their use should be discouraged. The newer second-generation H1-antihistamines are safer, cause less sedation and are more efficacious. Three drugs widely used for symptomatic relief in urticaria, desloratadine, levocetirizine and fexofenadine are highlighted in this review. Of these levocetirizine and fexofenadine are the most potent in humans in vivo. However, levocetirizine may cause somnolence in susceptible individuals, whereas fexofenadine has a relatively short duration of action and may be required to be given twice daily for all round daily protection. Although desloratadine is less potent, it has the advantages of rarely causing somnolence and having a long duration of action.

A survey on features of allergic rhinitis in children

OBJECTIVE

A number of epidemiologic studies evaluated the prevalence of allergic rhinitis (AR), but few data are available on its different clinical presentations. We addressed this survey to assess the features of AR in children and adolescents.

METHODS

Thirty-five centers in Italy included 2623 pediatric patients with rhinitis, of whom 2319 suffered from AR, while 304 had other kinds of rhinitis. For each patient a standardized questionnaire was filled in, including ARIA classification, the duration of symptoms, the allergen identified as clinically relevant, the co-morbidities, the kind of treatment, the response to treatment, the satisfaction with the treatment, and the feasibility of allergen immunotherapy (AIT).

RESULTS

Of the 2319 patients, 597 (25.7%) had mild intermittent, 701 (30.2%) mild persistent, 174 (7.5%) moderate-severe intermittent, and 773 (33.3%) moderate-severe persistent AR. The allergens most relevant were grass pollen and dust mites. The most frequently used drugs were oral antihistamines (83.1%) and topical corticosteroids (63.5%). The response to treatment was judged as excellent in 13.5%, good in 45.1%, fair in 30.8%, poor in 10%, and very bad in 0.6% of cases. The satisfaction with treatment was judged as very satisfactory in 15.2%, satisfactory in 61.8%, unsatisfactory in 22.4%, and very unsatisfactory in 0.5% of cases. AIT was considered indicated in 53.1% of patients with mild intermittent, 79.2% of moderate-severe intermittent, 72.6% of mild persistent, and 82.7% of moderate-severe persistent AR.

CONCLUSIONS

The limitation of this study is that the population was not unselected and this prevents epidemiological significance. These results offer confirmation of the adequacy of ARIA guidelines in classifying patients with AR and of the association of severe phenotype with lack of success of drug treatment.

Pharmacology of antihistamines

This article reviews the molecular biology of the interaction of histamine with its H1-receptor and describes the concept that H1-antihistamines are not receptor antagonists but are inverse agonists i.e. they produce the opposite effect on the receptor to histamine. It then discourages the use of first-generation H1-antihistamines in clinical practice today for two main reasons. First, they are less effective than second generation H1-antihistamines. Second, they have unwanted side effects, particularly central nervous system and anti-cholinergic effects, and have the potential for causing severe toxic reactions which are not shared by second-generation H1-antihistamines. There are many efficacious and safe second-generation H1-antihistamines on the market for the treatment of allergic disease. Of the three drugs highlighted in this review, levocetirizine and fexofenadine are the most efficacious in humans in vivo. However, levocetirizine may cause somnolence in susceptible individuals while fexofenadine has a relatively short duration of action requiring twice daily administration for full all round daily protection. While desloratadine is less efficacious, it has the advantages of rarely causing somnolence and having a long duration of action. Lastly, all H1-antihistamines have anti-inflammatory effects but it requires regular daily dosing rather than dosing 'on-demand' for this effect to be clinically demonstrable.

Pharmacology of antihistamines

This article reviews the molecular biology of the interaction of histamine with its H₁-receptor and describes the concept that H₁-antihistamines are not receptor antagonists but are inverse agonists i.e. they produce the opposite effect on the receptor to histamine. It then discourages the use of first-generation H₁-antihistamines in clinical practice today for two main reasons. First, they are less effective than second generation H₁-antihistamines. Second, they have unwanted side effects, particularly central nervous system and anti-cholinergic effects, and have the potential for causing severe toxic reactions which are not shared by second-generation H₁-antihistamines. There are many efficacious and safe second-generation H₁-antihistamines on the market for the treatment of allergic disease. Of the three drugs highlighted in this review, levocetirizine and fexofenadine are the most efficacious in humans in vivo. However, levocetirizine may cause somnolence in susceptible individuals while fexofenadine has a relatively short duration of action requiring twice daily administration for full all round daily protection. While desloratadine is less efficacious, it has the advantages of rarely causing somnolence and having a long duration of action. Lastly, all H₁-antihistamines have anti-inflammatory effects but it requires regular daily dosing rather than dosing 'on-demand' for this effect to be clinically demonstrable.

Emerging drugs for perennial allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) is a high-prevalence disease, sustained by an IgE-triggered reaction with histamine release, followed by an inflammatory response which involves cells, mediators, cytokines and adhesion molecules. According to its duration, AR can be either intermittent or persistent. In the persistent form, the inflammatory component usually predominates.

AREAS COVERED

The current therapeutic strategy is based on antihistamines, antileukotrienes and on corticosteroids (which broadly act on inflammation). Allergen-specific immunotherapy is a biological response modifier that affects the immune response to allergens in a broad sense. The available pharmacotherapy is overall effective in controlling symptoms and inflammation, but safety concerns may be present (especially for prolonged treatments), and a proportion of patients remain uncontrolled. The available therapeutic innovations, as derived from the most recent literature are reviewed herein.

EXPERT OPINION

In the last years there have been very few innovative approaches to optimize the management of AR. These include new histamine receptor antagonists, combination therapy and strategies to selectively block relevant signaling pathways of the allergic reaction. Some more promising advances have been shown for allergen immunotherapy, where a number of new strategies are currently under development.

Comparison of the sedating effects of levocetirizine and cetirizine: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Compared with placebo, levocetirizine has been found to be less sedating than cetirizine in separate trials. However, whether levocetirizine is less sedating than its parent drug cetirizine has not yet been studied in a randomized trial.

OBJECTIVE

To determine whether levocetirizine is less sedating than cetirizine.

METHODS

We conducted a randomized, double-blind, crossover, placebo-controlled trial examining sedation and allergy symptoms in patients with perennial allergic rhinitis who had previously reported significant sedation with cetirizine. Enrollment ran from January 28, 2009, to February 25, 2009. All patients completed the study by April 17, 2009. Thirty patients enrolled, and 29 patients completed the study (1 patient did not return her questionnaire). In a double-blind fashion, the 29 study participants received levocetirizine, 5 mg daily for 1 week, cetirizine, 10 mg daily for 1 week, and an equivalent placebo pill for 1 week in randomized order with washout periods before each treatment arm. At the end of each washout period and each treatment period, participants completed a 1-page questionnaire. This questionnaire included questions about sedation or sleepiness in the form of a modified Epworth Sleepiness Scale, a Likert scale measuring general or global sedation, and allergy symptoms as measured by the total rhinitis symptom score.

RESULTS

Sedation as measured by both the modified Epworth Sleepiness Scale and the Likert scale was not significantly different between the levocetirizine and cetirizine treatments.

CONCLUSIONS

In patients with a perceived history of sedation with cetirizine, most were able to tolerate levocetirizine. However, this controlled trial also suggests that many of these patients would tolerate cetirizine if given in a masked manner. Therefore, patients with a history of mild to moderate sedation with cetirizine are unlikely to experience a different sedation profile with levocetirizine.

Patient-related factors in rhinitis and asthma: the satisfaction with allergy treatment survey

BACKGROUND

Patient satisfaction with the prescribed treatments represents a crucial issue that may have clinical relevance as it may significantly affect treatment compliance. We designed an observational study to evaluate the satisfaction level concerning different pharmacological treatments for allergic rhinitis (AR) and asthma in a real-life setting.

METHODS

The study was conducted in 21 allergy centres homogeneously distributed in Italy. Three hundred and one patients (46.8% males; 53.2% females; mean [SD] age, 33.1 [13.8] years) with AR and/or asthma were consecutively evaluated. Diagnosis, classification, symptom severity, and satisfaction degree (assessed by a questionnaire) were the parameters considered.

RESULTS

Only 33.5% of the AR patients were satisfied with the rhinitis treatments. Only 40.7% of the asthmatic patients were satisfied with the asthma treatments. Some factors associated with treatment dissatisfaction are as follows: female gender (odds ratio [OR] 2.36; p < 0.01), co-morbidity (OR 2.39; p < 0.05), rhinitis severity (OR 1.39; p < 0.05), asthma severity (OR 2.04; p < 0.05), and antihistamine use (OR 2.53); however, the use of bronchodilators had a favourable impact (OR 0.28; p < 0.05). The relatively low number of subjects prevented performing stratification of patients by treatment classes.

CONCLUSION

The findings of this real-life study strengthen the concept that AR is particularly troublesome and that most allergic patients suffering from both rhinitis and asthma are dissatisfied with prescribed drugs.

Evaluation of treatment satisfaction in children with allergic disease treated with an antihistamine: an international, non-interventional, retrospective study

BACKGROUND AND OBJECTIVES

Histamine H(1)-receptor antagonists (antihistamines) have been shown to be efficacious and safe in children and are recommended as first-line treatment for the symptoms of allergic rhinitis and urticaria. No published study to date has directly compared satisfaction with the different antihistamines in children in a real-life clinical setting. This study aimed to investigate parent and physician satisfaction with the efficacy and tolerability of oral antihistamine treatment in children and to compare satisfaction between levocetirizine and the other antihistamines used by children in this cohort.

METHODS

This was an international Observational Survey in Children with Allergic Rhinitis (OSCAR). Children aged 2-12 years, with a history of an allergic condition leading to a consultation, were enrolled from 424 primary-care/specialist allergy clinics across Bulgaria, India, Portugal, Romania, Russia, South Korea and Spain. At the consultation, parents and physicians of eligible children completed questionnaires evaluating their satisfaction with specific antihistamines currently employed for management of the child's allergic condition, as well as their intention for future use of that treatment. Parents' satisfaction scores for efficacy, tolerability and global satisfaction with the antihistamine used were primary study outcomes, while physicians' satisfaction scores for the same measures were secondary outcomes. Other secondary outcomes were parents' rating of the impact of the antihistamine treatment on their child's sleep and school performance, and parents' and physicians' willingness to use/recommend the same antihistamine in the future.

RESULTS

A total of 4581 patients were enrolled; 3048 (66.5%) had allergic rhinitis (55.9% persistent allergic rhinitis and 44.1% intermittent allergic rhinitis), and 663 (14.5%) had urticaria as primary conditions. Additionally, 2465 patients (53.8%) suffered from other allergic diseases, including allergic asthma (33.3%), atopic dermatitis (17.6%), food allergy (5.3%), other allergies (5.0%) and drug hypersensitivity (2.0%). Parents' and physicians' satisfaction scores were closely concordant and demonstrated significantly greater global satisfaction for the second-generation antihistamines than for the first-generation antihistamines. Levocetirizine (n = 2339) and fexofenadine (n = 42) generally scored highest for efficacy, tolerability and global satisfaction, as well as for impact on the child's ability to function at school, quality of school activities and quality of sleep. Furthermore, >97% of parents and physicians indicated their desire to continue or recommend the use of levocetirizine in the future. Somnolence, the most commonly reported adverse event in this survey, was observed predominantly in patients treated with first-generation antihistamines. Among second-generation antihistamines, reports of somnolence were most frequent in the cetirizine group.

CONCLUSION

Second-generation antihistamines have a better risk:benefit ratio than first-generation antihistamines, indicating that the latter should be avoided or their use limited in children whenever possible. Levocetirizine and fexofenadine were perceived by parents and physicians to produce significantly higher treatment satisfaction than the majority of the other antihistamines with respect to overall efficacy and tolerability, and impact on the child's sleep and school activities. The newer antihistamine levocetirizine seems to be a preferred and appropriate future treatment choice for children with allergic diseases.

Allergic rhinitis in family practice: the role of levocetirizine in clinical care

Allergic rhinitis is one of the most common presentations of allergic disorders in the United States, affecting more than 20% of the population. Chronic rhinitis affects patients' quality of life and exacerbates comorbid conditions. Its widespread burden affects society by substantially decreasing worker and scholastic productivity. Allergic rhinitis is typically managed with pharmacotherapy to alleviate symptoms and control comorbid conditions, yet many of these agents carry their own burden due to bothersome and sometimes severe side effects that can compromise patient safety. A new generation of non- or less-sedating antihistamines has recently emerged. These agents offer the promise of enhanced efficacy and tolerability. Of these agents, levocetirizine is the latest antihistamine introduced in the United States. It appears to be safe and effective for the treatment of allergic rhinitis. In addition to covering the above topics, this article reviews the value of levocetirizine for the treatment of allergic rhinitis based on its pharmacologic and pharmacokinetic profile, its efficacy compared with placebo and other new-generation antihistamines, and its safety and tolerability.