Oral methylprednisolone acetate (Medrol Tablets) for seasonal rhinitis: examination of dose and symptom response

Allergic Rhinitis and Its Effect on Sleep

Allergic rhinitis (AR) is associated with increased sleep disturbances in adults and children. Pathogenesis is multifactorial, with nasal obstruction playing a large role. Intranasal corticosteroids, antihistamines, leukotriene inhibitors, and allergen immunotherapy have been demonstrated to relieve self-reported symptoms of sleep impairment. Given the high prevalence of sleep impairment in AR, providers should consider evaluating any patient with AR for sleep disturbances and sleep-disordered breathing.

Limited beneficial effects of systemic steroids when added to standard of care treatment of seasonal allergic rhinitis

Intramuscular injections with methylprednisolone treating allergic rhinitis (AR) have a long history. Modern guidelines are designed to dissuade this treatment, but it´s frequently used, especially in primary care. This despite of concern for side effects and lack of modern placebo-controlled studies. This study was designed to evaluate if methylprednisolone, could significantly improve symptoms of birch pollen induced AR and reduce the concomitant use of standard of care medication. Forty-two patients with birch pollen induced AR were randomized to treatment with methylprednisolone (80 mg) or placebo (NaCl 0.9%). Daily symptom- and medication scores was registered for 3 weeks. Quality of life questionnaires Sino-nasal Outcome Test-22 (SNOT-22) and Juniper Rhinoconjunctivitis Quality of Life Questionaire (Juniper RQLQ) were registered at trial start and at the end of the 3 weeks period. The combined symptom- and medication scores indicate that the methylprednisolone treated group [mean Area Under the Curve (AUC) 37.1 (SD 16.2 (95% CI 29.9-44.6))] was significantly better off than the placebo group [mean AUC 49.1 (SD 10.1 (95% CI 44.5-53.7))], p = 0.008. No significant difference between the groups were found in the SNOT-22 and Juniper RQLQ analysis. Registered side effects were few and mild. The limited beneficial effects of systemic steroids when added to standard of care in combination of its potential risk for side effects, speaks against its use for treatment of severe seasonal allergic rhinitis. The lack of difference in quality-of-life further underscores this result.

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians

OBJECTIVE

To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders.

DATA SOURCES

PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines.

REVIEW METHODS

A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings.

CONCLUSIONS

Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss.

IMPLICATIONS FOR PRACTICE

Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Pharmacological Management of Allergic Rhinitis: A Consensus Statement from the Malaysian Society of Allergy and Immunology

The goal of allergic rhinitis (AR) management is to achieve satisfactory symptom control to ensure good quality of life. Most patients with AR are currently treated with pharmacotherapy. However, knowledge gaps on the use of pharmacotherapy still exist among physicians, particularly in the primary care setting, despite the availability of guideline recommendations. Furthermore, it is common for physicians in the secondary care setting to express uncertainty regarding the use of new combination therapies like intranasal corticosteroid plus antihistamine combinations. Inadequate treatment leads to significant reduction of quality of life that affects daily activities at home, work, and school. With these concerns in mind, a practical consensus statement was developed to complement existing guidelines on the rational use of pharmacotherapy in both the primary and secondary care settings.

Benefits and harm of systemic steroids for short- and long-term use in rhinitis and rhinosinusitis: an EAACI position paper

Because of the inflammatory mechanisms of most chronic upper airway diseases such as rhinitis and chronic rhinosinusitis, systemic steroids have been used for their treatment for decades. However, it has been very well documented that—potentially severe—side-effects can occur with the accumulation of systemic steroid courses over the years. A consensus document summarizing the benefits of systemic steroids for each upper airway disease type, as well as highlighting the potential harms of this treatment is currently lacking. Therefore, a panel of international experts in the field of Rhinology reviewed the available literature with the aim of providing recommendations for the use of systemic steroids in treating upper airway disease.

Current therapeutical strategies for allergic rhinitis

INTRODUCTION

Allergic rhinitis is a common condition with increasing prevalence and is associated with several comorbid disorders such as bronchial asthma and atopic dermatitis. If allergen avoidance is not possible, allergen-specific immunotherapy is the only causal treatment option.

AREAS COVERED

This review focuses on current treatments and the future outlook for allergic rhinitis. Pharmacotherapy includes mast cell stabilizers, antihistamines, glucocorticosteroids (GCSs), leukotriene receptor antagonists, and nasal decongestants. Nasal GCSs are currently regarded as the most effective treatment and are considered first-line therapy together with non-sedating antihistamines. The new formulation MP29-02 combines the nasal GCS fluticasone propionate with azelastine in one single spray and has achieved greater improvements than those under monotherapy with modern GCSs or antihistamines. Furthermore, this review discusses allergen immunotherapy alone and in combination with modern monoclonal antibodies.

EXPERT OPINION

Despite the variety of medications for allergic rhinitis, ranging from general symptomatic agents like GCSs or decongestants, to more specific ones like histamine receptor or leukotriene blockers, to causal therapy like immunotherapy, many patients still experience treatment failures or unsatisfactory results. The ultimate goal may be to endotype every downstream pathway separately in order to offer patients individualized, targeted therapy with specific antibodies against the respective pathway.

Spectrum of Seasonal Allergic Rhinitis Symptom Relief with Topical Corticoid and Oral Antihistamine Given Singly or in Combination

Sixty ragweed-sensitive volunteers participated in a 2-week study that compared symptom profiles during treatment with antihistamine (loratadine, LOR) alone, topical corticoid (beclomethasone, BEC) alone, or the two drugs combined. For 5 days commencing shortly after the beginning of the ragweed bloom, patients took no treatment while we collected baseline data. They were then randomized to one of the three treatments, receiving that treatment for the balance of the 2-week study term. Twice each day they recorded the severity of congestion, eye symptoms, running and blowing, itching, and sneezing. At the end of the study they provided an estimate of overall symptom relief, which favored combined treatment (vs LOR P = 0.001, vs BEC P = 0.042). To gain an estimate of disease severity and treatment effectiveness over time, and to smooth out day-to-day variation, we divided symptom diary reports into three segments (days 2–4, 5–7, and 8–10) for analysis. Combined treatment controlled symptoms better than antihistamine alone in nearly all study segments. Corticoid alone or combined with antihistamine provided similar control of congestion, running and blowing, and eye complaints. Combination therapy controlled itching and sneezing better, especially through the study segments 1 and 2. Patient preference for combined treatment seems to relate to control of itching and sneezing and rapid onset of effect.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

[Mechanism of action of nasal glucocorticosteroids in the treatment of allergic rhinitis. Part 2: Practical aspects of application]

Allergic rhinitis (AR) is the single most common allergic disease and one of the most common chronic diseases. It affects approximately 25-30% of the population, and can substantially worsen patients' medical conditions, reduce quality of life, and contribute to absenteeism from work or school. It is also responsible for substantial direct and indirect economic burdens on the health care system. The medical management of allergic rhinitis includes several available pharmacotherapies, such as α-sympathomimetics, anticholinergic drugs, natural saline or other nasal rinses, mast cell-stabilizing agents, topical and systemic antihistamines, topical and systemic glucocorticosteroids, leukotriene-receptor antagonists and the new monoclonal antibodies following a stepwise approach. Allergen-specific immunotherapy is the only treatment option that interferes with the natural course of the disease and, besides allergen elimination, is thought to be the only causative treatment option. Nasal glucocorticosteroids (nGCS) are thought to be the most effective treatment choice for controlling the symptoms of AR. Double-blind, randomized clinical trials have demonstrated greater efficacy of nGCSs versus placebo, antihistamines or montelukast for relief of all nasal symptoms, especially congestion. Therefore, especially in the management of AR-related nasal inflammation and congestion, nGCSs are considered the most appropriate treatment. Patients should be informed that symptom improvement can be expected after 2-4 days for intermittent rhinitis and after up to 2-3 weeks for persistent rhinitis. The medication has to be taken regularly and not as "on-demand" treatment. Adherence to treatment also affects outcomes, and this may be influenced by patient preferences for the sensory attributes of an individual drug and the awareness of possible side effects. More recently, safety studies have shown that the newer nGCS agents have improved safety profiles compared with older nGCS agents. The newer nGCS drugs have been found to have minimal adverse effects on growth and hypothalamic-pituitary-adrenal-axis function in children. This review will discuss the pathophysiology of allergic inflammation in the nasal mucosa and the mechanism of action of nGCSs; also the efficacy and safety of nGCSs will be discussed by focusing on clinical evidence.

Effect of betamethasone-loratadine combination therapy on severe exacerbations of allergic rhinitis : a randomised, controlled trial

OBJECTIVE

Corticosteroids are effective in controlling the inflammatory component of allergic rhinitis; however, evidence for the clinical efficacy of systemic corticosteroids in this disease is sparse. It is further common practice to combine oral corticosteroids with antihistamines in the treatment of acute exacerbations of allergic rhinitis. The aim of this study was to investigate the effect of low-dose oral betamethasone alone and in combination with loratadine in a group of patients with allergic rhinitis with clinically significant obstruction.

METHODS

In this parallel, double-blind, active controlled multicentre study, 299 patients with severe allergic rhinitis were randomly allocated to either betamethasone 1.0mg or betamethasone 1.0mg plus loratadine 10mg or betamethasone 0.5mg plus loratadine 10mg or loratadine 10mg alone for 5-7 days. Total symptom scores, nasal obstruction, and doctor and patient perception of improvement were measured as markers of disease severity.

RESULTS

Although not statistically significant, both betamethasone 1.0mg regimens resulted in a total symptom score difference of at least 1 or more from loratadine (i.e. mean [SD] change in total symptom score of 4.10 [3.10] and 4.40 [3.62] vs 3.10 [3.30], respectively, for betamethasone 1.0 mg plus loratadine, betamethasone 1.0 mg and loratadine). All corticosteroid-containing regimens were significantly better than loratadine alone with regard to the patients' (p < 0.013) and doctors' (p < 0.009) perceptions of improvement. They significantly favoured loratadine in combination with betamethasone over single-drug therapy (i.e. odds ratio: investigator ratings 0.49, 0.36 and 0.45, and patient ratings 0.47, 0.40 and 0.43, respectively, for 0.5 mg and 1.0 mg betamethasone plus loratadine and betamethasone 1.0 mg alone vs loratadine alone). Betamethasone 1.0mg plus loratadine also resulted in significant reduction of the relapse rate compared with the other therapies.

CONCLUSIONS

This study demonstrated the benefit of a short course of a systemic low dosage of corticosteroids with and without antihistamine therapy during acute severe exacerbations of allergic rhinitis. Combination treatment with betamethasone 1.0mg and loratadine 10mg was significantly better in relieving symptoms of hayfever as experienced by patients. This was the first study to give evidence of benefit of systemic low-dose corticosteroids with and without an antihistamine in patients with acute exacerbations of allergic rhinitis.

Treatment of congestion in upper respiratory diseases

Congestion, as a symptom of upper respiratory tract diseases including seasonal and perennial allergic rhinitis, acute and chronic rhinosinusitis, and nasal polyposis, is principally caused by mucosal inflammation. Though effective pharmacotherapy options exist, no agent is universally efficacious; therapeutic decisions must account for individual patient preferences. Oral H₁-antihistamines, though effective for the common symptoms of allergic rhinitis, have modest decongestant action, as do leukotriene receptor antagonists. Intranasal antihistamines appear to improve congestion better than oral forms. Topical decongestants reduce congestion associated with allergic rhinitis, but local adverse effects make them unsuitable for long-term use. Oral decongestants show some efficacy against congestion in allergic rhinitis and the common cold, and can be combined with oral antihistamines. Intranasal corticosteroids have broad anti-inflammatory activities, are the most potent long-term pharmacologic treatment of congestion associated with allergic rhinitis, and show some congestion relief in rhinosinusitis and nasal polyposis. Immunotherapy and surgery may be used in some cases refractory to pharmacotherapy. Steps in congestion management include (1) diagnosis of the cause(s), (2) patient education and monitoring, (3) avoidance of environmental triggers where possible, (4) pharmacotherapy, and (5) immunotherapy (for patients with allergic rhinitis) or surgery for patients whose condition is otherwise uncontrolled.

Mechanisms and clinical implications of glucocorticosteroids in the treatment of allergic rhinitis

Allergic rhinitis is a common airway disease characterized by hypersensitivity, exudation, hypersecretion, inflammatory cell infiltration and remodelling. Intranasal glucocorticosteroids are the most effective drugs for controlling the inflammation caused by allergic rhinitis. Glucocorticosteroids exert anti-inflammatory effects through at least two pathways: the transactivation pathway and the transrepression pathway. Glucocorticosteroids also exert regulatory functions by inducing regulatory cytokines and forkhead box P3 (FoxP3(+)) regulatory T cells. Evidence suggests that intranasal glucocorticosteroids control not only nasal symptoms but also ocular symptoms. In contrast to sedating H1 receptor antagonists, intranasal glucocorticosteroids can improve impaired performance symptoms, such as daytime sleepiness, associated with allergic rhinitis. Recent studies suggest that intranasal glucocorticosteroids might also be useful for the prophylactic treatment of pollinosis; this possibility is supported by the molecular mechanism of the anti-inflammatory action of glucocorticosteroids. These findings suggest that intranasal glucocorticosteroids might be positioned as first-line drugs for the treatment of both perennial and seasonal allergic rhinitis.

The effect of Gencydo injections on hayfever symptoms: a therapeutic causality report

OBJECTIVES

The aim of this study was to study the effect of Gencydo (Weleda AG, Arlesheim, Switzerland) injections on hayfever symptoms.

DESIGN

This is a therapeutic causality report based on the practices of 13 Dutch general practitioners.

SUBJECTS

Thirteen (13) patients with a mean history of hayfever with grass pollen allergy of 9 years duration, who in previous years used conventional hayfever medication because of the severity of symptoms during the pollen season.

INTERVENTIONS

Gencydo injections were given in 12 patients before the onset of and during the grass pollen season, and in one patient during the grass pollen season only.

OUTCOME MEASURES

Nasal and non-nasal hayfever symptom severity, use of rescue medication (antihistamines or corticosteroids), and subjective experiences of patients were used as outcome measures.

RESULTS

Nine (9) of 13 patients showed no increase of symptom severity during the so-called pollen season. Both the mean maximal total nasal symptom score per patient and the mean total nasal symptom score for the entire study group during the days with a grass pollen count >100 were mild. Percentages of individual "strong" or "severe" nasal symptom scores were low. There was no statistically significant difference in mean total nasal symptom score between the period when the pollen count was <100 and the period when it was >100. Conventional rescue medication for hayfever was used only eight times, all by one person. Nine (9) patients (69%) reported an improvement of symptoms (eight patients cited strong improvement and one patient noted slight improvement).

CONCLUSIONS

There are clear indications that Gencydo treatment was effective in a large subgroup of the research population.

Acoustic rhinometry, rhinomanometry and spirometry of the asthmatics patients with rhinitis symptoms before and after oral corticoid

INTRODUCTION

Asthma and rhinitis frequently co-exist in the same patient. It may exist a specific condition witch affects the general respiratory activity and also able to produce symptoms into upper and/ or lower airways.

PURPOSE

To analyze the alteration and functional burst of upper and lower airways before and after oral corticoid.

METHODS

From July of 2000 to August of 2002, sixteen (69 % was female ), acute asthmatics patients with rhinitis symptom assisted in the pneumology department, were analyzed through cross-sectional study using: symptoms questionnaire, physical examination, radiogram, spirometry, acoustic rhinometry, and rhinomanometry.

RESULTS

Sixteen patients presented compromising symptoms of the upper airways. In the spirometry, FEV1, FEV1/FVC e FEF25-75%, presented major statistically differences. The acoustic rhinometry presented important statistical differences in the minimal cross- sectional area 1 e 2 in the left side and total nasal volume, after medicine intervention.

CONCLUSIONS

The functional evaluations upon lower and upper airways, improvements in FEV1, FEV1/FVC e FEF25-75%, were observed through spirometry and total nasal volume, analyzing the acoustic rhinometry after oral corticoid.

Glucocorticosteroids in allergic inflammation: clinical benefits in allergic rhinitis, rhinosinusitis, and otitis media

Allergic rhinitis, rhinosinusitis, and otitis media are among the most common health problems encountered in general practice. Although frequently trivialized, they affect the quality of life, represent a significant socioeconomic burden, and are associated with some serious complications. In addition, allergic rhinitis, rhinosinusitis, and otitis media are often considered as comorbidities. These disorders involve an inflammatory process of the respiratory mucosa of the nose, paranasal sinuses, or middle ear. Because of their well-known anti-inflammatory effects, the role of glucocorticosteroids in the management of these three disorders has been questioned, evaluated, and, in some cases, established.