Risk-benefit assessment of fluticasone propionate in the treatment of asthma and allergic rhinitis

Special Considerations in the Treatment of Pregnancy Rhinitis

Pregnancy rhinitis is a common condition that is not yet fully recognized by the public. This form of rhinitis affects approximately one in five pregnant women, can start in almost any gestational week, and disappears after delivery. However, as it reduces quality of life, and also possibly affects the fetus, treatment is often required. Saline irrigations, exercise and mechanical alar dilators are a safe and general means of relieving nasal congestion. Nasal corticosteroids have not been shown to be effective. As nasal decongestants provide good temporary relief, women tend to overuse them. Therefore, to avoid an additional rhinitis medicamentosa, nasal decongestants should be restricted to a few days use. Invasive methods of turbinate reduction may be effective, but are not recommended. The differential diagnosis towards sinusitis is often difficult. Antral irrigation is the ultimate diagnostic for purulent sinusitis and often needs to be repeated for therapeutic reasons. If β-lactam antibiotics are used, an increased dosage is required during pregnancy.

Exogenous interleukin-10 alleviates allergic inflammation but inhibits local interleukin-10 expression in a mouse allergic rhinitis model

Background

Interleukin-10 (IL-10) has an important anti-inflammatory and immunoregulatory function, and its expression is negatively correlated with the development and severity of allergic rhinitis (AR). However, the in vivo effects of exogenous IL-10 on AR have not been studied and the mechanisms underlying the effects of IL-10 have not been fully understood. Here, we investigated the effects of intranasal administration of recombinant mouse (rm) IL-10 on the expression of Th responses and local IL-10 in a mouse model of AR induced by ovalbumin.

Results

Administration of rmIL-10 during challenge significantly reduced the number of eosinophils and mast cells, as well as Type 2 helper T (Th2) and Th17 cell related cytokine and transcription factor levels in the nasal mucosa and nasal lavage fluid in AR mice. The rmIL-10 treatment significantly inhibited the number of IL-10-positive cells and IL-10 mRNA expression in the nasal mucosa in AR mice.

Conclusion

Our results show that exogenous IL-10 administrated in challenge phase alleviates nasal allergic inflammation in AR mice, most likely by inhibiting Th2 and Th17 responses. It can also inhibit local IL-10 levels in the nasal mucosa. Our findings indicate that IL-10 may have the potential as an inhibitor of AR.

The Etiology and Management of Pregnancy Rhinitis

Pregnancy rhinitis is defined as nasal congestion in the last 6 or more weeks of pregnancy, without other signs of respiratory tract infection and with no known allergic cause, with complete resolution of symptoms within 2 weeks after delivery. Pregnancy rhinitis occurs in approximately one-fifth of pregnancies, can appear at almost any gestational week, and affects the woman and possibly also the fetus. The pathogenesis of pregnancy rhinitis is not clear, but placental growth hormone is suggested to be involved. Smoking and sensitization to house dust mites are probable risk factors. It is often difficult to make a differential diagnosis from sinusitis: nasendoscopy of a decongested nose is the diagnostic method of choice. In some cases ultrasound or x-ray may be necessary. Sinusitis should be treated aggressively with increased doses of beta-lactam antibiotics and antral irrigation. Nasal decongestants give good temporary relief from pregnancy rhinitis, but they tend to be overused, leading to the development of rhinitis medicamentosa. Corticosteroids have not been shown to be effective in pregnancy rhinitis, and their systemic administration should be avoided during pregnancy. Nasal corticosteroids may be administered to pregnant women when indicated for other sorts of rhinitis. Nasal alar dilators and saline washings are safe means to relieve nasal congestion, but the ultimate treatment for pregnancy rhinitis remains to be found.

Pregnancy Rhinitis

Pregnancy rhinitis has gained attention as a defined clinical entity that is recognized increasingly by medical professionals and by the public. It affects one in five pregnant women, and as far as we know, it is not caused by one single factor. Pregnant women should be informed about this cause of nasal congestion, and how to handle it. There is no cure known, but symptomatic treatment may be needed, because impaired nasal breathing can reduce quality of life and possibly affect the fetus. Simple measures, such as elevated head end of the bed, physical exercise, nasal saline washings, and nasal alar dilation can improve nasal breathing.

CT assessment of the effect of fluticasone propionate aqueous nasal spray treatment on lower turbinate hypertrophy due to vasomotor rhinitis

CONCLUSION

Fluticasone propionate (FP) aqueous nasal spray was objectively found to be effective and safe for the treatment of lower turbinate enlargement in patients with vasomotor rhinitis.

OBJECTIVE

To assess the efficacy of FP aqueous nasal spray treatment in lower turbinate hypertrophy due to vasomotor rhinitis using CT.

MATERIAL AND METHODS

Of 35 patients with hypertrophic lower turbinates due to vasomotor rhinitis, 20 were treated twice daily with FP aqueous nasal spray (200 microg/day) for 3 months continuously and 15 were treated with placebo vehicle as a control group. The local effect of the nasal spray was studied using CT and visual analog scales.

RESULTS

Treatment with FP provided significantly greater relief from the symptom of nasal obstruction compared with placebo over the entire 3-month treatment period (p < 0.001). When the change from baseline was compared between the two groups, FP produced statistically significant reductions in the mucosal area of the lower turbinates and in the thickness of the nasal mucosa after 3 months (p < 0.05).

Clinical and pathogenetic characteristics of pregnancy rhinitis

Pregnancy rhinitis is a very common condition. Defined as "nasal congestion present during the last 6 or more weeks of pregnancy without other signs of respiratory tract infection, and with no known allergic cause, disappearing completely within 2 wk after delivery," it strikes one in five pregnant women, and it starts in almost any gestational week. The pathogenesis is not clear, but placental growth hormone is suggested to be involved. Smoking and sensitization to house dust mites are probable risk factors. It is often difficult to make a differential diagnosis from sinusitis, which may in pregnancy present with nasal congestion as the only symptom. Antral irrigation is diagnostic for purulent sinusitis and often needs to be repeated, as it should be treated intensively. Because of changes in pharmacokinetics, increased dosage of betalactam antibiotics is needed during pregnancy. As pregnancy rhinitis reduces quality of life and possibly also affects the fetus, there is often need for treatment. Nasal corticosteroid shave not been shown to be effective. Systemic administration should be avoided,but nasal corticosteroids could be used in pregnancy when indicated for other sorts of rhinitis. Nasal decongestants give good temporary relief, so pregnancy rhinitics tend to overuse them, giving an additional rhinitis medicamentosa. Therefore, use of nasal decongestants should be restricted to a few days. Invasive methods of turbinate reduction may be effective but are not recommendable in this self-limiting condition because of side effects. Nasal saline washings, exercise, and mechanical alar dilators are safe general means to relieve nasal congestion, but the ultimate treatment remains to be found.

Techniques of intranasal steroid use

OBJECTIVE

The effectiveness of topical intranasal steroids (INS) sprays for the treatment of allergic and nonallergic rhinitis may be limited by lack of instruction in the optimal spray technique. To determine whether the technique used affects the efficacy and safety of the product, this review of evidence had the goal of identifying and establishing a preferred method of applying INS sprays.

STUDY DESIGN

A MEDLINE search of pertinent literature on 7 INS and 1 intranasal antihistamine spray preparations conducted with the use of appropriate search terms, yielded an initial 121 articles, 29 of which were identified as appropriate for review and grading for quality of evidence.

RESULTS

The analysis provided no definitive evidence regarding how best to instruct patients to use INS or antihistamine spray devices.

CONCLUSIONS

On the basis of a lack of clear evidence regarding instructions to maximize efficacy and safety of these drugs, the panel recommended a 7-step standard technique.

Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis

Intranasal corticosteroids and intranasal antihistamines are efficacious topical therapies in the treatment of allergic rhinitis. This review addresses their relative roles in the management of this disease, focusing on their safety and tolerability profiles. The intranasal route of administration delivers drug directly to the target organ, thereby minimising the potential for the systemic adverse effects that may be evident with oral therapy. Furthermore, the topical route of delivery enables the use of lower doses of medication. Such therapies, predominantly available as aqueous formulations following the ban of chlorofluorocarbon propellants, have minimal local adverse effects. Intranasal application of therapy can induce sneezing in the hyper-reactive nose, and transient local irritation has been described with certain formulations. Intranasal administration of corticosteroids is associated with minor nose bleeding in a small proportion of recipients. This effect has been attributed to the vasoconstrictor activity of the corticosteroid molecules, and is considered to account for the very rare occurrence of nasal septal perforation. Nasal biopsy studies do not show any detrimental structural effects within the nasal mucosa with long-term administration of intranasal corticosteroids. Much attention has focused on the systemic safety of intranasal application. When administered at standard recommended therapeutic dosage, the intranasal antihistamines do not cause significant sedation or impairment of psychomotor function, effects that would be evident when these agents are administered orally at a therapeutically relevant dosage. The systemic bioavailability of intranasal corticosteroids varies from <1% to up to 40-50% and influences the risk of systemic adverse effects. Because the dose delivered topically is small, this is not a major consideration, and extensive studies have not identified significant effects on the hypothalamic-pituitary-adrenal axis with continued treatment. A small effect on growth has been reported in one study in children receiving a standard dosage over 1 year, however. This has not been found in prospective studies with the intranasal corticosteroids that have low systemic bioavailability and therefore the judicious choice of intranasal formulation, particularly if there is concurrent corticosteroid inhalation for asthma, is prudent. There is no evidence that such considerations are relevant to shorter-term use, such as in intermittent or seasonal disease. Intranasal therapy, which represents a major mode of drug delivery in allergic rhinitis, thus has a very favourable benefit/risk ratio and is the preferred route of administration for corticosteroids in the treatment of this disease, as well as an important option for antihistaminic therapy, particularly if rapid symptom relief is required.

Fluticasone propionate spray and betamethasone sodium phosphate mouthrinse: a randomized crossover study for the treatment of symptomatic oral lichen planus

BACKGROUND

Symptomatic oral lichen planus (OLP) has been palliated with a wide spectrum of topical and systemic therapies. Although the majority of management strategies include corticosteroids, few have been evaluated in randomized controlled trials.

OBJECTIVE

We investigated the acceptability and efficacy of topical fluticasone propionate spray (FP) and betamethasone sodium phosphate mouthrinse (BSP) upon the signs and symptoms of OLP, assessing patient quality of life changes as a consequence of these therapies.

METHODS

We implemented a randomized, crossover study in which each drug was administered for a period of 6 weeks with an intervening washout period of 2 weeks at an outpatient oral medicine unit in London, United Kingdom. We treated 48 patients with biopsy-proven symptomatic OLP, and 44 patients (92%) completed the study. The dosage was 50 microg two dose unit sprays and BSP 500 microg, each 4 times daily. Symptomatic improvement was evaluated by means of a visual analogue scale (VAS), the McGill pain score, the Oral Health Impact Profile (OHIP), and Oral Health Quality of Life (OHQoL) questionnaires. The total surface area of the lesions, including all white, erythematous, and ulcerative lesions was measured at each visit. The efficacy, ease of application, and adverse effects associated with each medication were recorded.

RESULTS

Both FP and BSP mouthwash caused both a statistically significant reduction in painful symptoms as measured by the VAS and improvement in quality of life as measured by the OHIP and OHoQL indices. There was no significant difference between the two corticosteroids in their efficacy in reducing painful symptoms (measured by the VAS) or in their effect on patient quality of life. Both FP and BSP significantly reduced the surface area of oral lesions. However, FP was statistically significantly better than BSP in reducing lesion surface area. There was no statistically significant difference between the patient-assessed effects of the 2 therapies.

CONCLUSIONS

FP and BSP are both effective in the short-term clinical management of symptomatic OLP. FP is more acceptable to patients than BSP because of the convenience of the spray form.

Fluticasone propionate aqueous nasal spray in pregnancy rhinitis

Pregnancy rhinitis is a common condition with longstanding nasal congestion; troublesome for the mother, possibly also affecting the fetus. There is need for a safe, effective treatment. Nasal corticosteroids, indisputable in other types of rhinitis, have not been evaluated in pregnancy rhinitis. In this placebo-controlled, randomized, double-blind study with parallel groups, we evaluated the effect of 8 weeks of treatment with fluticasone propionate aqueous nasal spray in 53 women with pregnancy rhinitis. Daily symptom scores and nasal peak expiratory flow, as well as acoustic rhinometry before and after treatment, did not show any difference between the groups. Placebo resulted in 6/27 responders, compared with 5/26 for active treatment. There was no detectable influence on maternal cortisol as measured by morning S-cortisol and overnight 12-h-U-cortisol, or any difference in ultrasound measures of fetal growth or pregnancy outcome. Altogether, our study indicates no significant effects of the treatment described here.

Secretion of adrenocorticotropic hormone induced by allergen inhalation in patients with atopic asthma

Allergen inhalation in atopic patients results in cytokines production or release of preformed cytokines, some of which are known to induce adrenocorticotropic hormone (ACTH) secretion in experimental conditions. We examined whether allergen inhalation can induce ACTH secretion in vivo. A significant elevation of ACTH levels was observed in 2 and 24 hr after allergen inhalation challenge. However, methacholine challenge with the same degree of airflow limitation did not induce ACTH elevation, indicating that this may not be due to bronchoconstriction per se. Our results indicate that allergen inhalation can trigger ACTH secretion in patients with atopic asthma.