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

H1 Antihistamines-Promising Candidates for Repurposing in the Context of the Development of New Therapeutic Approaches to Cancer Treatment

Despite significant progress in the field of clinical oncology in terms of diagnostic and treatment methods, the results of anticancer therapy are still not fully satisfactory, especially due to limited response and high toxicity. This has forced the need for further research to finding alternative ways to improve success rates in oncological treatment. A good solution to this problem in the context of rapidly obtaining an effective drug that works on multiple levels of cancer and is also safe is the global strategy of repurposing an existing drug. Research into other applications of an existing drug enables a precise assessment of its possible mechanisms of action and, consequently, the broadening of therapeutic indications. This strategy is also supported by the fact that most non-oncological drugs have pleiotropic effects, and most of the diseases for which they were originally intended are multifactorial, which in turn is a very desirable phenomenon due to the heterogeneous and multifaceted biology of cancer. In this review, we will mainly focus on the anticancer potential of H1 antihistamines, especially the new generation that were not originally intended for cancer therapy, to highlight the relevant signaling pathways and discuss the properties of these agents for their judicious use based on the characteristic features of cancer.

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.

Biowaiver Monograph for Immediate-Release Solid Oral Dosage Forms: Fexofenadine

In this monograph, the potential use of methods based on the Biopharmaceutics Classification System (BCS) framework to evaluate the bioequivalence of solid immediate-release (IR) oral dosage forms containing fexofenadine hydrochloride as a substitute for a pharmacokinetic study in human volunteers is investigated. We assessed the solubility, permeability, dissolution, pharmacokinetics, pharmacodynamics, therapeutic index, bioavailability, drug-excipient interaction, and other properties using BCS recommendations from the ICH, FDA and EMA. The findings unequivocally support fexofenadine's classification to BCS Class IV as it is neither highly soluble nor highly permeable. Further impeding the approval of generic equivalents through the BCS-biowaiver pathway is the reference product's inability to release ≥ 85 % of the drug substance within 30 min in pH 1.2 and pH 4.5 media. According to ICH rules, BCS class IV drugs do not qualify for waiving clinical bioequivalence studies based on the BCS, even though fexofenadine has behaved more like a BCS class I/III than a class IV molecule in pharmacokinetic studies to date and has a wide therapeutic index.

Cetirizine for the treatment of allergic diseases in children: A systematic review and meta-analysis

OBJECTIVE

The global prevalence of allergic diseases has led to a negative and extensive impact on the health and lives of a large population of children. This study investigates the efficacy, acceptability, and safety of cetirizine (CTZ) for treating allergic diseases in children and provides evidence-based assertions for decision-making.

METHODS

PubMed, Embase, the Cochrane Library, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and the European Union Clinical Trials Register were systematically searched from inception to April 21, 2022. Randomized controlled trials (RCTs) or quasi-RCTs of children with allergic diseases receiving CTZ compared with those receiving placebo or other drugs were included without language limitations. Two investigators independently identified articles, extracted data, conducted meta-analyses, assessed the Cochrane risk of bias of individual studies, and evaluated the evidence certainty using the Grading of Recommendations Assessment, Development, and Evaluation approach; any discrepancies were resolved by consulting with a third investigator. Primary outcomes included scales that evaluated the recovery of allergic conditions in AR, such as the total symptom score (TSS). Secondary outcomes included laboratory test changes, safety (adverse events, AEs), and quality of life (QOL). Data were pooled using the Cochrane Review Manager 5.4, and a fixed-effects model was used if heterogeneity was evaluated as low (I 2 < 50%); otherwise, a random-effects model was adopted.

RESULTS

A total of 22 studies (5,867 patients) were ultimately included [eight with perennial AR, six with seasonal AR, four with atopic dermatitis (AD), and four with other allergic diseases], most of which had a low or unclear risk of bias. Moderate certainty evidence showed that CTZ was found to benefit allergic symptom control [mean difference (MD) of TSS at 1 week: MD, -0.32 (-0.52, -0.12); at 2 weeks: MD, -0.25 (-0.35, -0.14); at 4 weeks: MD, -4.07 (-4.71, -3.43); at 8 weeks: MD, -4.22 (-4.73, -3.72); at 12 weeks: MD, -5.63 (-6.14, -5.13); all P-values were less than 0.05] and QOL [at 12 weeks: MD, -23.16 (-26.92, -19.39); P < 0.00001] in children with AR. It had similar efficacy compared with other antihistamines (AHs) or montelukast, without showing better control of AD severity in children. Moderate-to-low certainty evidence demonstrated that CTZ was well tolerated and did not increase the risk of severe and overall AEs, cardiotoxicity, damage to the central nervous and digestive systems, or other systems in children, except for the risk of somnolence [risk ratio, 1.62 (1.02, 2.57); P = 0.04, compared with placebo].

CONCLUSION

Moderate-to-low certainty evidence revealed that CTZ could improve clinical improvement and QOL in children with AR and have comparable efficacy with other AHs. CTZ is well tolerated in the pediatric population, except for an increased risk of somnolence.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021262767].

Fexofenadine: review of safety, efficacy and unmet needs in children with allergic rhinitis

Allergic rhinitis (AR) is the most common undiagnosed chronic condition in children. Moderate/severe AR symptoms significantly impair quality of life, and cause sleep disruption, absenteeism and decreased productivity. Additionally, untreated AR predisposes children to asthma and other chronic conditions. Although intranasal corticosteroids are the most effective pharmacologic treatment for AR, oral antihistamines are often preferred. First-generation antihistamines may be chosen to relieve AR symptoms as they are inexpensive and widely available; however, they cause sedative and cardiovascular negative effects due to poor receptor selectivity. Therefore, second-generation antihistamines were developed to reduce adverse effects while retaining efficacy. There are fewer clinical trials in children than adults, therefore, efficacy and safety data is limited, particularly in children under 6 years, highlighting the need to generate these data in young children with AR. Fexofenadine, a highly selective second-generation antihistamine, effectively alleviates symptoms of AR, is non-sedating due to decreased blood-brain barrier permeability, and is devoid of cardiovascular side effects. Importantly, fexofenadine relieves the ocular symptoms of allergic conjunctivitis, which occur concomitantly with AR, improving quality of life. Overall, fexofenadine displays a favorable safety profile and results in greater treatment satisfaction in children compared with other second-generation antihistamines. This review aimed to evaluate and compare the safety and efficacy of fexofenadine with other available first- and second-generation antihistamines in children with AR.

Does Over-the-Counter Purchase of Antihistamines by Residents of Dhaka City, Bangladesh Align with the Prescribing Choices of the Physicians Practicing in That City?

Most current guidelines recommend prescribing second-generation antihistamines (SGAs) over first-generation antihistamines because SGAs are less likely to cause sedation and impairment of heavy work performance. However, common residents who use these antihistamines as over-the-counter (OTC) medicines are less likely to know that. So, this study was designed to compare the over-the-counter use of antihistamines by common residents with the prescribing preferences of physicians residing at Dhaka City, Bangladesh. Between June and August of 2017, a total of 100 Physicians from some of the top medical institutions of the city and 350 randomly selected common residents were directly interviewed with two separate semistructured questionnaires specifically designed for each population. Data was statistically analyzed using Fischer’s exact test, Spearman’s rank correlation test and Kendall’s tau rank correlation test. The data shows that physicians prefer second-generation antihistamines with fexofenadine (48.09% of the total responses), desloratadine (16.03%), and rupatadine (13.74%) taking the top spots. Cetirizine (29.46% of total responses), desloratadine (14.73%), and chlorpheniramine (14.52%) were the most used OTC antihistamines by the common residents. Statistical analysis with Fischer’s exact test revealed that the difference in preference of first-generation antihistamines between physicians and common residents were extremely significant (p<0.0001). Furthermore, cetirizine (which is known to have some degree of sedating activity) and chlorpheniramine are more preferred among common residents than among physicians (extremely significant difference, p<0.0001 in both cases). The study concludes that physicians of Dhaka City are complying with practice guidelines, but sedating antihistamines still retain some popularity among the common residents. Hence, a more engaging community pharmacy is needed to minimize adverse effects that can arise from OTC use of sedating antihistamines.

Clinical management, expectations, and satisfaction of patients with moderate to severe allergic rhinoconjunctivitis treated with SQ-standardized grass-allergen tablet under routine clinical practice conditions in Spain

BACKGROUND

Sublingual immunotherapy has been proven as a well-tolerated and effective treatment for allergic rhinitis. Within this type of treatment, GRAZAX® is the most documented product in terms of safety and efficacy. The objective of this study was to identify the patients' expectations and level of treatment satisfaction, as well as the clinical management of patients with moderate/severe allergic rhinoconjunctivitis treated with GRAZAX®.

METHODS

This was a non-interventional, observational, multi-centre, open-label study involving a total of 131 adult patients aged 18-66 years with confirmed diagnosis of grass-allergy and initiated treatment with GRAZAX® between June 2010 and April 2011.

RESULTS

In the pollen season after starting treatment, 56.6% of patients stated that their symptoms were much less/less intense, 86% needed less symptomatic medication for control of their symptoms, and 74.4% manifested to have improved (quite/a lot) as regards their allergic disease since treatment was initiated as compared with previous grass pollen season. The patient satisfaction with GRAZAX® was measured using a visual analogue scale (VAS) between 0 (minimum satisfaction) and 100 (maximum satisfaction) comprising five different items: effectiveness, tolerability, cost, convenience and overall satisfaction. The results obtained for each item were [mean (SD)]: 74.7 (18.1), 70.3 (36.1), 39.3 (25.8), 86.2 (12.6), 78.4 (15.8) respectively. The patient's level of satisfaction is highly influenced, especially in terms of assessment of effectiveness, tolerability and convenience, by the information provided by the specialist.

CONCLUSIONS

In summary, it can be concluded that improved communication leads to increased patient knowledge, greater patient compliance, and increased patient satisfaction.

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.

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.

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.

Nonruminant Nutrition Symposium: Neurogastroenterology and food allergies

Neurogastroenterology is a subspecialty encompassing relations of the nervous system to the gastrointestinal tract. The central concept is emergence of whole organ behavior from coordinated activity of the musculature, mucosal epithelium, and blood vasculature. Behavior of each effector is determined by the enteric nervous system (ENS). The ENS is a minibrain positioned close to the effectors it controls. The ENS neurophysiology is in the framework of neurogastroenterology. The digestive tract is recognized as the largest lymphoid organ in the body with a unique complement of mast cells. In its position at the "dirtiest" of interfaces between the body and outside world, the mucosal immune system encounters food antigens, bacteria, parasites, viruses, and toxins. Epithelial barriers are insufficient to exclude fully the antigenic load, thereby allowing chronic challenges to the immune system. Observations in antigen-sensitized animals document direct communication between the mucosal immune system and ENS. Communication is functional and results in adaptive responses to circumstances within the lumen that are threatening to the functional integrity of the whole animal. Communication is paracrine and incorporates specialized sensing functions of mast cells for specific antigens together with the capacity of the ENS for intelligent interpretation of the signals. Immuno-neural integration progresses sequentially, beginning with immune detection, followed by signal transfer to the ENS, followed by neural interpretation and then selection of a neural program with coordinated mucosal secretion and a propulsive motor event that quickly clears the threat from the intestinal lumen. Operation of the defense program evokes symptoms of cramping abdominal pain, fecal urgency, and acute watery diarrhea. Investigative approaches to immuno-ENS interactions merge the disciplines of mucosal immunology and ENS neurophysiology into the realm of neurogastroenterology.

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.

Chronic spontaneous urticaria in children: itching for insight

While there is increasing information about the pathogenesis and treatment of chronic spontaneous urticaria (csU) in adults, there is little published information about csU in children. Consequently, most of the recommendations contained in current guidelines for the prevention and treatment of csU in infants and children is based on extrapolation of data obtained in adults. To rectify this, this review points out critical gaps in our knowledge and suggests strategies which may help us to improve our understanding of this condition. How common is csU in children? What do we know about its clinical presentation and the presence of useful biomarkers? What are its common underlying causes? What is the course of csU in children? How does csU affect the everyday life of children? What treatment options are available for children? To answer these questions, two separate types of information are required. The first is information about the prevalence of the condition in the community at large and how csU affects the everyday life of both the child-patient and the parent or carer. Because most csU cases in infants and children do not come to specialists but are treated by general practitioners or by parents using over-the-counter medications, these questions may be answered only by general population surveys or schools programmes. The second is clinical information including family history and disease presentation, the presence of biomarkers and comorbidities, objective measures of severity, frequency and duration of exacerbations, the response to therapy and the time to remission. Targeted questionnaires need to be developed and validated for these investigations. This has already begun in Germany with the establishment of the CU-KID Netzwerk (Email address: cu-kid@charite.de), the aim of which is to identify clinical centres and colleagues who treat children with urticaria and to initiate the information gathering described above.