CHARACTERIZATION OF MODERATE AND SEVERE ASTHMA EXACERBATIONS IN THE CAPTAIN STUDY

BACKGROUND

Limited data exist on the relative impact of moderate and severe exacerbations on asthma control and impairment.

OBJECTIVE

To explore data from the CAPTAIN trial to evaluate the relationship between first moderate or severe exacerbation and changes in lung function, symptoms, physical activity limitation scores, and short-acting β2-agonist (SABA) usage to determine the clinical relevance of moderate events.

METHODS

CAPTAIN was a Phase IIIA 24-52-week, multicenter, international, randomized controlled trial evaluating efficacy and safety of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) versus FF/VI in patients with uncontrolled asthma on inhaled corticosteroid/long-acting β2-agonist. Outcomes reportedinclude: first post-randomization exacerbation event by severity (Weeks 1-52), frequency and duration of moderate and severe exacerbations and time course of changes over ±14-day peri-exacerbation period for lung function, symptoms, limitations, and SABA use.

RESULTS

Of the intent-to-treat population (N=2436), 550 patients (23%) continued to 52 weeks. There were 529 moderate and 546 severe exacerbations. Lung function changes were similar, but symptom, physical activity limitation scores, and SABA use were higher, for severe versus moderate exacerbations. Lung function decline preceded increases in symptom, physical activity limitation scores, and SABA use, irrespective of exacerbation severity. Lung function variables, limitation scores, and SABA use returned to pre-exacerbation baseline after ∼8-12 days for both exacerbation severities.

CONCLUSION

While severe events were associated with greater impact on symptoms, physical activity limitations, and SABA use, onset and time to resolution were generally similar for moderate and severe events. Both exacerbation severities represent clinically important deteriorations comprising clinical and functional changes. NCT02924688.

Serious Asthma Outcomes and Asthma Exacerbations with Maintenance on Inhaled Corticosteroid (Mometasone Furoate)/Long-Acting Beta Agonist (Formoterol) Combination Compared to Step Down to Mometasone Monotherapy

BACKGROUND

Because of historical safety concerns with the use of long-acting β-agonists (LABA) in asthma, step-down from inhaled corticosteroid (ICS)/LABA combination therapy to ICS monotherapy is recommended once asthma control is achieved.

OBJECTIVE

To evaluate the benefit/risk question about whether patients with asthma who achieve disease control on fixed-dose ICS/LABA combination therapy, such as mometasone furoate/formoterol fumarate (MF/F), should continue with this therapy or be stepped down to ICS monotherapy, such as MF.

METHODS

Using data from 8447 clinically stable patients with persistent asthma in the Safety Pharma Investigation of Respiratory Outcomes trial who had been receiving a stable dose of ICS/LABA for ≥4 weeks, this post hoc analysis evaluated the risk of serious asthma outcomes (SAOs) (adjudicated hospitalization, intubation, or death) and asthma exacerbation (AEX) (composite of hospitalizations ≥24 hours, emergency visits <24 hours requiring systemic corticosteroid, or systemic corticosteroid for ≥3 consecutive days) in participants randomized to remain on ICS/LABA (MF/F) or step down to ICS (MF) for 26 weeks.

RESULTS

There was no significant difference in SAO risk among patients maintained on ICS/LABA with MF/F compared with those who stepped down from ICS/LABA to MF (hazard ratio [HR], 1.03 [95% confidence interval (CI): 0.61, 1.75], P = .913). The risk of AEX was significantly lower in patients maintained on ICS/LABA with MF/F compared with those who stepped down from ICS/LABA to MF (HR, 0.87 [95% CI: 0.78, 0.98], P = .020).

CONCLUSIONS

In this post hoc analysis of a large clinical trial dataset, maintenance on ICS/LABA with MF/F is not associated with an increased risk of SAOs and also significantly reduces the risk of AEX compared with step-down from ICS/LABA to MF.

Serious asthma events with mometasone furoate plus formoterol compared with mometasone furoate

BACKGROUND

The safety of long-acting β-agonists added to inhaled corticosteroids for the treatment of persistent asthma has been controversial.

OBJECTIVE

We sought to determine whether administering formoterol in combination with mometasone furoate increases the risk of serious asthma outcomes (SAOs) compared with mometasone furoate alone. This clinical trial is registered as NCT01471340.

METHODS

We conducted a 26-week, randomized, double-blind trial in adolescent and adult patients (≥12 years) with persistent asthma in 35 countries with the primary objective of evaluating whether mometasone furoate-formoterol increases the risk of SAOs (adjudicated hospitalization, intubation, or death) compared with mometasone furoate alone. The key efficacy end point was asthma exacerbation (composite of hospitalization of ≥24 hours, emergency department visits of <24 hours requiring systemic corticosteroids, or use of systemic corticosteroids for ≥3 consecutive days).

RESULTS

Among 11,729 patients (mometasone furoate-formoterol, n = 5,868; mometasone furoate, n = 5,861), a total of 81 SAOs, all asthma-related hospitalizations, were observed in 71 patients: 45 events from 39 patients receiving mometasone furoate-formoterol and 36 events from 32 patients receiving mometasone furoate. The hazard ratio for the first SAO in the mometasone furoate-formoterol versus mometasone furoate group was 1.22 (95% CI, 0.76-1.94; P = .411). Asthma exacerbation occurred in 1,487 patients: 708 receiving mometasone furoate-formoterol and 779 receiving mometasone furoate. The hazard ratio for the first asthma exacerbation in the mometasone furoate-formoterol versus mometasone furoate group was 0.89 (95% CI, 0.80-0.98; P = .021).

CONCLUSIONS

The addition of formoterol to mometasone furoate maintenance therapy did not increase the risk of serious asthma-related events and reduced the risk of asthma exacerbation.

Taking Aim at Asthma Around the World: Global Results of the Asthma Insight and Management Survey in the Asia-Pacific Region, Latin America, Europe, Canada, and the United States

BACKGROUND

Asthma, a worldwide health problem, can be controlled if properly diagnosed and managed. Multinational surveys conducted in patients with asthma from 1998 to 2003 indicated that asthma was inadequately controlled. The Asthma Insight and Management (AIM) study represents the largest survey conducted on patients with asthma since 2003.

OBJECTIVE

The objective of this study was to assess findings from the United States (US), Europe and Canada (EUCAN), Latin America (LA), and the Asia-Pacific (AP) region surveys to identify differences and similarities with earlier surveys on patients with asthma.

METHODS

The US, EUCAN, LA, and AP AIM surveys conducted from 2009 to 2011 all used a common set of questions. Responses to these are reported as proportions of patients with asthma for each country individually, and as totals for all regions. Results are presented as mean/median proportions for US, EUCAN, LA, and AP survey populations individually. Global medians and the range of regional response values are also described.

RESULTS

A total of 10,302 patients or parents of adolescents with asthma were interviewed. Approximately one-quarter reported daytime symptoms daily or on most days over the previous 4 weeks. Globally, a median of 67% (range, 27%-88%) of patients perceived their asthma as completely and/or well controlled, but a median of only 9% (range, 0%-29%) of patients had well-controlled asthma using criteria from asthma guidelines. A majority (≥60%) of patients felt that quick-relief medication could be used daily if needed, contrary to guideline recommendations.

CONCLUSIONS

Patients exhibited a lack of knowledge and conviction for treatment recommendations and guidelines that was relatively uniform across the regions, similar to earlier survey findings. These results reveal an ongoing need for improvement in asthma care and education in most populations.

Effect of cetirizine on symptom severity and quality of life in perennial allergic rhinitis

The effect of cetirizine on quality of life (QOL) in subjects with perennial allergic rhinitis (PAR) has been previously evaluated using generic instruments. While generic QOL tools are used across various conditions, disease-specific instruments evaluate the impact of treatment on areas that are affected by that particular condition. This study evaluated the effect of cetirizine on symptom severity and health-related QOL, using a disease-specific instrument, in adults with PAR. This randomized, double-blind, placebo-controlled study was conducted at 15 U.S. centers outside the pollen allergy season. After a 1-week placebo run-in period, qualified subjects aged 18-65 years with PAR were randomized to once-daily cetirizine 10 mg (n = 158) or placebo (n = 163) for 4 weeks. Change from baseline in total symptom severity complex (TSSC) and overall Rhinitis Quality of Life Questionnaire (RQLQ) scores were primary efficacy end points. Cetirizine produced significantly greater improvements in mean TSSC for each treatment week (p < 0.05) and for the entire 4-week treatment period (p = 0.005) compared with placebo. After 4 weeks, cetirizine-treated subjects reported significantly greater overall improvement in RQLQ scores compared with placebo-treated subjects (p = 0.004). After 1 week, cetirizine produced significant improvements in the nasal symptoms, practical problems, and activities RQLQ domain scores compared with placebo (p < 0.05). After 4 weeks, cetirizine-treated subjects reported significant reductions in these RQLQ domain scores and in emotion domain scores compared with placebo-treated subjects (p < 0.05). Cetirizine 10 mg daily produced significant improvements in symptom severity and allergic rhinitis-related QOL compared with placebo in adults with PAR.

Asthma control, cost and race: results from a national survey

OBJECTIVE

Although interventions have been shown to alleviate symptoms in most patients suffering from asthma, only one-third of asthma patients have disease that is well-controlled. The purpose of this study is to investigate whether partly and uncontrolled asthmas are associated with increased costs for asthma-related healthcare utilization compared to well-controlled asthma and to determine whether these associations differed across racial groups.

METHODS

We classified respondents from the Asthma Insights and Management survey into those with well-, partly and uncontrolled asthma and compared utilization of healthcare services and costs among these groups, as well as between whites and non-whites.

RESULTS

Respondents categorized as having asthma that was not well-controlled reported lower income levels, higher rates of unemployment and more trouble paying for healthcare; similar results were found in analyses stratified by race. Patients whose asthma was partly or uncontrolled had greater use of asthma-related medications and medical services compared to patients whose asthma was well-controlled. Total unadjusted and adjusted costs were greater in patients whose asthma was classified as partly and uncontrolled. Similar results were found in analyses stratified on race. Across all levels of asthma control, non-whites had higher rates of utilization of emergency rooms and urgent care facilities and had greater rates of hospitalizations compared to whites.

CONCLUSIONS

Our findings indicate that patients with asthma that is not well-controlled utilized more healthcare resources and had greater medical costs, despite lacking of health insurance which may suggest less access to care.

Safety and efficacy of fluticasone/formoterol combination therapy in adolescent and adult patients with mild-to-moderate asthma: a randomised controlled trial

BACKGROUND

This study investigated the efficacy and safety of a new asthma therapy combining fluticasone propionate and formoterol fumarate (fluticasone/formoterol; flutiform®), administered twice daily (b.i.d.) via a single aerosol inhaler, compared with its individual components administered separately and placebo, in patients with mild-to-moderate asthma.

METHODS

Patients aged ≥ 12 years were evenly randomised to 12 weeks of treatment with fluticasone/formoterol (100/10 μg b.i.d.), fluticasone (100 μg b.i.d.), formoterol (10 μg b.i.d.), or placebo, in this double-blind, parallel group, multicentre study. The three co-primary endpoints were: a) change in forced expiratory volume in the first second (FEV(1)) from morning pre-dose at baseline to pre-dose at week 12 for the comparison with formoterol; b) change in FEV(1) from morning pre-dose at baseline to 2 hours post-dose at week 12 for the comparison with fluticasone, and c) time to discontinuation due to lack of efficacy from baseline to week 12 for the comparison with placebo. Safety was assessed based on adverse events, clinical laboratory tests and vital sign evaluations.

RESULTS

Statistically significant differences were demonstrated for all the three co-primary endpoints. Fluticasone/formoterol combination therapy showed significantly greater improvements from baseline to end of study in the change in pre-dose FEV(1) compared with formoterol (Least Squares (LS) mean treatment difference: 0.101 L; 95% Confidence Interval (CI): 0.002, 0.199; p = 0.045) and the change in pre-dose compared with 2 hours post-dose FEV(1) versus fluticasone (LS mean treatment difference: 0.200 L; 95% CI: 0.109, 0.292; p < 0.001). The time to discontinuation due to lack of efficacy was significantly longer for patients in the combination therapy group compared with those receiving placebo (p = 0.015). Overall, the results from multiple secondary endpoints assessing lung function, asthma symptoms, and rescue medication use supported the superior efficacy of the combination product compared with fluticasone, formoterol, and placebo. The fluticasone/formoterol combination therapy had a good safety and tolerability profile over the 12 week treatment period.

CONCLUSIONS

Fluticasone/formoterol had a good safety and tolerability profile and showed statistically superior efficacy for the three co-primary endpoints compared to fluticasone, formoterol, and placebo, in adolescents and adults with mild-to-moderate asthma. EudraCT number: 2007-002866-36; US NCT number: NCT00393991.

Qualitative Development of the Rhinitis Control Assessment Test (RCAT), an Instrument for Evaluating Rhinitis Symptom Control

BACKGROUND

: Effective management of allergic rhinitis requires ongoing monitoring of its control. This article describes the qualitative phase of development of a patient-completed instrument, the Rhinitis Control Assessment Test (RCAT), designed to assist patients and providers in the detection of problems with rhinitis symptom control.

OBJECTIVE

: To identify concepts to be measured and to develop initial questionnaire items to be tested further in the next phase of development.

METHODS

: A literature review and input from patient focus groups were utilized to generate concepts to be measured in the draft questionnaire. The draft items were subjected to cognitive testing to ensure that the items were understood by patients and to eliminate ambiguity as well as to select an optimal recall period and meaningful response scales. Patients aged ≥18 years self-reporting a rhinitis diagnosis who had experienced rhinitis symptoms in the past 12 months were eligible for participation in the focus groups (n = 39) and the cognitive interviews (n = 23).

RESULTS

: This qualitative process yielded a draft instrument with 26 items assessing five constructs of rhinitis symptom control: frequency and bothersomeness of nasal and non-nasal symptoms, symptom impact, activity interference, symptom control, and medication use. A five-point Likert response scale and a 1-week recall period for each item were adopted based on patient input.

CONCLUSION

: The qualitative phase of development of the RCAT produced constructs and items for an instrument that is anticipated to facilitate accurate assessment of rhinitis control and improve the quality of care for patients with allergic rhinitis.

Asthma burden in the United States: results of the 2009 Asthma Insight and Management survey

Updated guidelines and new treatments for asthma have become available since the last major survey of asthma management in the United States was completed ∼11 years ago. The Asthma Insight and Management (AIM) survey was conducted to assess the current status of asthma burden in the United States. A geographically stratified screening of 60,682 households provided a national sample of 2500 patients with current asthma (2186 adults aged ≥18 years; 314 adolescents aged 12-17 years). A national sample of 1004 adults without current asthma was interviewed for comparison with the adult asthma population, and 309 asthma health care providers were surveyed for their opinions about the burden of asthma. Asthma prevalence in the United States was estimated at 8%. Twice as many adult asthma patients rated their health as "only fair," "poor," or "very poor," or experienced limitations in activity because of health problems, compared with the general population. Asthma also frequently caused negative emotional symptoms in patients. Most patients experienced asthma throughout the year (63%) and symptoms within the 4 weeks before the summer survey (68%). Overall, 41% of patients responded that asthma interfered with their/their child's life "some" or "a lot". During the year before the survey, 69% of patients experienced at least one severe asthma episode. Asthma burden in the United States remains high despite the availability of updated treatment guidelines and new therapies. Asthma care in the United States remains suboptimal, indicating the need for continued improvements in patient management.

Patient and physician asthma deterioration terminology: results from the 2009 Asthma Insight and Management survey

Long-term achievement of asthma control is dependent in part on the use of mutually understandable asthma terminology in all verbal and written patient-physician communications. Using data from the Asthma Insight and Management (AIM) survey, the objective of this analysis is to provide a contemporary depiction of asthma deterioration terminology as used by current asthma patients and physicians in the United States. As part of the 2009 AIM survey, current asthma patients (≥12 years of age; weighted n = 2499) and physicians (n = 309) were queried about their recognition, understanding, and/or use of the terms "asthma attack," "asthma flare-up," and "asthma exacerbation" in telephone interviews. Nearly all patients had heard the term "asthma attack" (97%), but relatively few had heard the term "asthma exacerbation" (24%); 71% had heard "asthma flare-up." In contrast, physicians reported using the term "asthma attack" least (65%) and the term "asthma exacerbation" most (77%) when discussing asthma with their patients; 70% reported using "asthma flare-up." Among patients familiar with "asthma flare-up" and "asthma exacerbation" (n = 502), only 38% said that the terms mean the same thing; nearly all physicians (94%) said that the terms mean the same thing. Collectively, data from the AIM survey suggest that patients and physicians use different asthma deterioration terminology and, more importantly, that they do not necessarily understand each other's terms. Standardizing asthma deterioration terminology may help optimize asthma patient-physician communication to improve patient understanding of written asthma action plans and therefore, enhance patient outcomes.

Asthma management and control in the United States: results of the 2009 Asthma Insight and Management survey

Past asthma surveys have shown suboptimal management and control of asthma in the United States. No major survey of asthma management has been conducted since the Third Expert Panel Report for the National Asthma Education and Prevention Program (NAEPP) guidelines on diagnosis and treatment of asthma (August 2007). This study was designed to report asthma management and control results from the Asthma Insight and Management survey of U.S. patients and physicians. A telephone-based survey was conducted during 2009 in 2500 patients with asthma, aged ≥12 years, and 309 physicians (104 allergists, 54 pulmonologists, 101 family practitioners, and 50 internists). Patients' asthma control perceptions (71% "completely controlled" or "well controlled") were inconsistent with their NAEPP control level as determined by self-reported symptoms (29% well controlled). Patients and physicians had low expectations for effective asthma management; patients considered asthma well managed if rescue medication was used three times per week (46%), urgent care visits occurred twice per year (67%), or emergency department visits occurred once per year (60%). Asthma-related syncope, seizure, intensive care unit admission, and intubation were associated with uncontrolled asthma based on NAEPP guidelines. Respiratory specialists (allergists/pulmonologists) implemented asthma management recommendations more than other physicians surveyed. However, only 22% of patients visited a specialist for usual asthma care and 48% had never visited a specialist. Despite detailed NAEPP guidance, asthma management and control in U.S. patients is unsatisfactory. Improved asthma control assessment (impairment and risk) and implementation of NAEPP management recommendations are needed to improve asthma control and outcomes.

Comparison of the Asthma in America and Asthma Insight and Management surveys: did asthma burden and care improve in the United States between 1998 and 2009?

Significant changes in asthma treatment guidelines and therapies occurred between the period of time in which the Asthma in America (AIA) and Asthma Insight and Management (AIM) surveys were conducted: 1998 and 2009, respectively. This study compares asthma burden and management in 1998 and 2009. Both surveys were telephone based and conducted across the United States. The AIA survey included 2509 patients with asthma (aged <1 year to 89 years old), 512 physicians, and 1000 adults from the general population. The AIM survey included 2500 patients (aged ≥12 years), 309 physicians, and 1090 adults from the general population. Patient responses were weighted to match the entire population of U.S. patients with asthma. The impact of asthma burden and care on the general population and on asthma patients was slightly lower or unchanged in the AIM survey versus the AIA survey. Acute care use (hospitalizations, emergency department visits, or other urgent care visits) was common in AIA (36%) and AIM (34%) surveys. Most physicians were aware of guidelines in AIA (90%) and AIM (96%), but fewer "always" followed them (AIA, 36%; AIM, 28%). Spirometry was often used to aid in diagnosis by asthma care specialists (AIA, 73%; AIM, 76%) but infrequently by nonsubspecialists (AIA, 27%; AIM, 38%). Most physicians prescribed inhaled corticosteroids (ICSs) for mild (AIA, 70%; AIM, 83%) or moderate (AIA, 89%; AIM, 83%) persistent asthma. In the AIM survey, 38% of specialists prescribed ICSs combined with a long-acting β2-agonist for moderate asthma. The state of U.S. asthma care and clinical outcomes changed little from 1998 to 2009.

Intranasal steroids in the treatment of allergy-induced rhinorrhea

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

Patient satisfaction with a pressurized metered-dose inhaler with an integrated dose counter containing a fixed-dose mometasone furoate/formoterol combination

INTRODUCTION

Inhaled delivery devices that are easy to use and facilitate dose tracking may lead to improved patient satisfaction and adherence. Patient satisfaction with a metered-dose inhaler (MDI) with an integrated dose counter containing a fixed-dose mometasone furoate/formoterol combination (MF/F MDI dose counter) was evaluated in subjects with persistent asthma or chronic obstructive pulmonary disease.

METHODS

In this multicenter study (N = 272, age range: 12-92 years), subject experience and satisfaction with MDI devices was evaluated using baseline and poststudy surveys. Subjects responded to the baseline survey based on their previous MDI experience, then received MF/F MDI 100/10 μg with the integrated dose counter for 4 weeks before completing the poststudy survey. This evaluation was part of a broader study objective to assess performance of the MF/F MDI dose counter.

RESULTS

At baseline, 52% of subjects reported being extremely satisfied with their previous MDI. After using the MF/F MDI dose counter, a relative increase of 43% in overall satisfaction was observed. Approximately 90% of subjects agreed the MF/F dose counter helped them track doses and was easy to use; >80% agreed the inhaler was of good quality and well designed. Subjects agreed the dose counter relieved anxiety about running out of medication (68%) or taking a subtherapeutic dose (65%). Nearly 80% of subjects had no reservations about the MF/F MDI dose counter, and most subjects stated they would request it from their physician (66%) and recommend it to a friend (75%).

CONCLUSIONS

The MF/F MDI dose counter was found to be easy to use and have overall high patient satisfaction.

Twenty-six-week efficacy and safety study of mometasone furoate/formoterol 200/10 microg combination treatment in patients with persistent asthma previously receiving medium-dose inhaled corticosteroids

Asthma is a heterogeneous condition characterized by reduced lung function, chronic inflammation, and periodic asthma deteriorations. This study was performed to evaluate the effect of mometasone furoate (MF)/formoterol (F) combination, 200/10 microg, administered twice daily (b.i.d.) on asthma deteriorations and pulmonary function in patients with asthma uncontrolled on medium-dose inhaled corticosteroid (ICS). After 2- to 3-week open-label run-in with MF 200 microg b.i.d., patients (>or=12 years) were randomized to 26 weeks of treatment with MF/F 200/10 microg, MF 200 microg, F 10 microg, or placebo b.i.d. Coprimary end points were time to first asthma deterioration (MF/F versus F) and bronchodilation, assessed by the area under the curve of the change in forced expiratory volume in 1 second 0-12 hours (FEV(1) AUC(0-12h); MF/F versus MF). A total of 781 patients were randomized. Treatment with MF/F 200/10 microg reduced asthma deteriorations and clinically judged deteriorations (i.e., deterioration resulting in emergency treatment, hospitalization, or treatment with additional excluded asthma medication [i.e., systemic corticosteroids]). The proportion of patients experiencing asthma deteriorations was MF/F, 30.4%; MF, 33.9%; F, 54.0%; placebo, 55.6% (p < 0.001, MF/F versus F and placebo). There was a sixfold reduction in clinically judged deteriorations with MF/F versus F and placebo (p < 0.001). Lung function improved more rapidly with MF/F than MF and placebo. Mean change from baseline FEV(1) AUC(0-12h) at week 12 was MF/F, 11.7% versus MF, 5.7%; F, 8.5%; and placebo, 3.9% (p < 0.001). Treatment-related AEs were rare and similar across groups. Treatment with MF/F 200/10 microg was effective in reducing the risk of asthma deteriorations. MF/F was safe and provided rapid and sustained bronchodilation in patients with asthma.

Physician perceptions of the treatment and management of allergic and nonallergic rhinitis

Historically, rhinitis has been perceived by many clinicians in respiratory medicine as an unimportant condition. The purpose of this study was to evaluate physicians' perceptions of the impact of allergic rhinitis and chronic or nonallergic rhinitis on patients' health. This cross-sectional survey involved U.S. physicians identified from a claims database as treating patients with allergic rhinitis or chronic rhinitis during a 13-month period. Responses were stratified by physicians' overall assessment of their patients' rhinitis severity, presence or absence of an allergy specialist at the practice, and agreement or disagreement that allergic rhinitis and nonallergic rhinitis should be managed similarly. Of 2614 physicians invited to participate, 766 responded. Physicians who perceived the majority of their patients as having moderate-to-severe symptoms were more likely to be prescribed more than one class of medication and physicians whose patients had mostly mild symptoms were more likely to recommend nonprescription products. Physicians whose practice included an allergy specialist compared with physicians without an allergy specialist at their practice were more likely to report that higher percentages of their patients were prescribed more than one class of medication, more likely to rate patients' descriptions of symptom severity and quality-of-life-related issues as extremely important in treatment decisions, and less likely to believe that allergic rhinitis and nonallergic rhinitis have the same symptoms. Physicians who did not agree that allergic rhinitis and nonallergic rhinitis should be managed similarly were more likely to prescribe more than one class of medication and to rate patients' descriptions of symptom severity and quality-of-life impact as extremely important in their treatment decisions. This physician survey provides insight into perceptions of the impact of allergic rhinitis and nonallergic rhinitis on patients' quality of life and symptom severity.

The pathophysiology, clinical impact, and management of nasal congestion in allergic rhinitis

BACKGROUND

Nasal congestion is a cardinal symptom of allergic rhinitis (AR). It is difficult to treat and is associated with decreased quality of life.

OBJECTIVE

This article reviews the clinical features of nasal congestion, its complex pathophysiology in the context of AR, its clinical impact, and the strengths and weaknesses of available treatments.

METHODS

Primary studies and reviews in the peer-reviewed, English-language literature were identified through searches of MEDLINE (1966-2008) and the Cochrane Library (1996-2008) using the terms nasal congestion, allergic rhinitis, pathophysiology, quality of life, and burden. Additional references were obtained by searching the reference lists of the identified articles. Abstracts from the 2006 and 2007 meetings of the American Academy of Allergy, Asthma, and Immunology were also searched. Pertinent articles were included in the review if they were recently published and patient-focused, and if their authors were recognized leaders in the field.

RESULTS

A survey of 2355 patients with AR or their guardians found that almost half of respondents rated nasal congestion the most bothersome symptom; in a survey of 2500 adults with AR, 78% rated nasal congestion either extremely or moderately bothersome. Histamine and leukotrienes are major mediators of the allergic inflammation associated with nasal congestion, as indicated by reductions in nasal cross-sectional area in response to histamine challenge (P<0.001) and increases in nasal airway resistance in response to leukotriene challenge (P<0.05).Therapy for nasal congestion in AR is often hampered by limitations associated with the individual agents; for example, decongestants are effective in the control of nasal congestion, but their use is restricted by their adverse-event profiles. A meta-analysis of 16 controlled studies involving 2267 patients with AR found that intranasal corticosteroids provided significantly greater relief of nasal congestion than oral antihistamines (95% CI for combined standardized mean difference, -0.73 to -0.53). The results of several clinical trials have suggested that leukotriene-receptor antagonists may be associated with reduced nasal congestion; however, no agents in this class are currently approved for the treatment of nasal congestion in AR.

CONCLUSION

There is a need for therapies that are well tolerated and effective in relieving nasal congestion in AR.

The prevalence of nasal symptoms attributed to allergies in the United States: findings from the burden of rhinitis in an America survey

Although the annual prevalence of physician-diagnosed hay fever has been previously reported, the prevalence of allergic rhinitis symptoms in the United States is uncertain. The purpose of this study was to estimate the prevalence of allergic rhinitis symptoms in the United States. A self-administered 10-item screening questionnaire regarding nasal symptoms was sent to representative households in the United States in January 2004. A total of 8,708 members (44.3%) reported nasal symptoms on > or =7 days in the past 12 months. The majority of these responders described their symptoms as seasonal or perennial allergies (n = 5,944) compared with cold or flu only (n = 1,841), cold or flu and vasomotor rhinitis (n = 175), or vasomotor rhinitis only (n = 748). The prevalence of self-reported seasonal and perennial allergic rhinitis symptoms on > or =7 days in the past 12 months was 30.2%, which corresponds to 89.6 million persons in the United States. The prevalence of self-reported physician-diagnosed seasonal or perennial allergic rhinitis with symptoms on > or =7 days was 22%, or approximately 65 million persons nationwide. Among responders with a higher burden of nasal symptoms (> or =30 days), the prevalence of physician-diagnosed hay fever, allergic rhinitis, or nasal allergies was 11.9% of the total population. The prevalence of nasal symptoms attributed to rhinitis related to seasonal and perennial allergies in the United States ranged between 11.9 and 30.2% depending on duration of symptoms and physician diagnosis. Almost one-half of Americans experience troublesome nasal symptoms on at least 7 days throughout the year, with most attributing their symptoms to allergies.

Rhinitis symptoms and comorbidities in the United States: burden of rhinitis in America survey

OBJECTIVE

To assess the burden of nasal symptoms in the United States (U.S.) and the comorbid conditions associated with nasal symptoms.

SUBJECTS AND METHODS

A self-administered screening questionnaire and follow-up survey was sent to targeted households from a representative sample of 15,000 households in the U.S. Subjects with comorbid asthma completed the Asthma Control Test (ACT).

RESULTS

Out of 7024 evaluable subjects who responded, 3831 subjects were classified as rhinitis "sufferers." Individuals with active rhinitis symptoms were 1.5 to 4.5 times more likely to suffer from comorbid conditions including asthma, conjunctivitis, otitis media, sinusitis, eczema, food and insect bite allergies, migraine, and depression. Almost half of all respondents with moderate or severe rhinitis symptoms and comorbid asthma had poorly controlled asthma as defined by an ACT score of < or =19.

CONCLUSIONS

A strong relationship exists between rhinitis symptoms and various comorbidities, including asthma, in the U.S. population. Poorly controlled rhinitis contributes to the public health burden of rhinitis and asthma.

Ciclesonide improves health-related quality of life in adults and adolescents with mild-to-moderate persistent asthma

Health-related quality of life (HRQOL) provides information on patients' everyday physical, emotional, and social difficulties that traditional measurements of asthma severity (pulmonary function assessments and asthma symptom scores) may not reflect. Our objective is to evaluate the effect of ciclesonide (CIC) on HRQOL in a combined analysis of two identical, 12-week, multicenter, double-blind, parallel-group, placebo-controlled trials. Patients (N=1015) with mild-to-moderate asthma (aged >or=12 years; forced expiratory volume in 1 s 60-85% predicted at randomization after administration of single-blind placebo during baseline [5-28 days]) were randomized to receive placebo or CIC 80, 160, or 320 microg (ex-actuator) once daily. HRQOL was assessed using the Juniper Asthma Quality-of-Life Questionnaire (AQLQ). The overall AQLQ score and individual domain scores (activity limitation, symptoms, emotional function, and exposure to environmental stimuli) were recorded at baseline, week 4 and week 12. Statistically significant improvements (p<0.0001) in overall AQLQ scores were observed for all CIC groups versus placebo (CIC80, 0.50; CIC160, 0.61; CIC320, 0.69; placebo, 0.14) from baseline to week 12. Similar significant improvements were observed for all CIC groups in the four individual domain scores, except the CIC80 environmental stimuli domain score. A greater proportion of CIC-treated patients achieved a minimally important difference in overall AQLQ score (>or=0.5 improvement) by week 4, which was sustained through to week 12, compared with placebo (week 12: CIC80, 47.1%; CIC160, 50%; CIC320, 50.6%; placebo, 31%). In this combined analysis, once-daily CIC significantly improved HRQOL compared with placebo, in adults/adolescents with mild-to-moderate persistent asthma.

Intranasal mometasone furoate alleviates the ocular symptoms associated with seasonal allergic rhinitis: results of a post hoc analysis

BACKGROUND

Burdensome symptoms of allergic rhinitis (AR) include nasal and ocular symptoms such as itching, tearing and redness. Intranasal corticosteroids are efficacious in the treatment of nasal symptoms of AR.

OBJECTIVE

It was the aim of this study to determine the efficacy of the intranasal corticosteroid mometasone furoate nasal spray (MFNS) in relieving ocular symptoms associated with seasonal AR (SAR).

METHODS

Ocular symptom data were analyzed for subjects >or=12 years of age, randomized to MFNS 200 mug q.d. (n = 176) or placebo (n = 177) in a placebo-controlled, double-blind clinical trial. Post hoc efficacy analysis assessed the mean change from baseline in subject-reported total ocular symptom scores (TOSS) averaged over the treatment period.

RESULTS

Mean baseline TOSS was 4.91 for the MFNS group and comparable (5.05) for the placebo group - combined average for individual symptoms such as itching, tearing and redness ranged from 0 (no symptoms) to 9 (all symptoms, severe). Mean change from baseline in TOSS averaged over days 1-15 was -1.42 for the MFNS group and -0.94 for the placebo group (p = 0.02), for an observed treatment difference of 0.49 (statistical data rounded to 2 decimal positions). Improvement in individual symptoms (eye itching, tearing and redness) contributed to this treatment effect; the greatest improvement occurred with tearing, which decreased -0.52 from the baseline score 1.59 in the MFNS group and -0.31 from 1.67 in those receiving placebo (p < 0.01), for an observed treatment difference of 0.21. Treatment with MFNS was safe and well tolerated.

CONCLUSION

MFNS is effective in reducing ocular symptoms of SAR, in addition to its established efficacy in reducing nasal symptoms of SAR.

Objective monitoring of nasal patency and nasal physiology in rhinitis

Nasal obstruction can be monitored objectively by measurement of nasal airflow, as evaluated by nasal peak flow, or as airways resistance/conductance as evaluated by rhinomanometry. Peak flow can be measured during inspiration or expiration. Of these measurements, nasal inspiratory peak flow is the best validated technique for home monitoring in clinical trials. The equipment is portable, relatively inexpensive, and simple to use. One disadvantage, however, is that nasal inspiratory peak flow is influenced by lower airway as well as upper airway function. Rhinomanometry is a more sensitive technique that is specific for nasal measurements. The equipment, however, requires an operator, is more expensive, and is not portable. Thus, it is applicable only for clinic visit measures in clinical trials. Measurements require patient cooperation and coordination, and not all can achieve repeatable results. Thus, this objective measure is best suited to laboratory challenge studies involving smaller numbers of selected volunteers. A nonphysiological measure of nasal patency is acoustic rhinometry. This sonic echo technique measures internal nasal luminal volume and the minimum cross-sectional area. The derivation of these measures from the reflected sound waves requires complex mathematical transformation and makes several theoretical assumptions. Despite this, however, such measures correlate well with the nasal physiological measures, and the nasal volume measures have been shown to relate well to results obtained by imaging techniques such as computed tomography scanning or magnetic resonance imaging. Like rhinomanometry, acoustic rhinometry is not suitable for home monitoring and can be applied only to clinic visit measures or for laboratory nasal challenge monitoring. It has advantages in being easy to use, in requiring little patient cooperation, and in providing repeatable results. In addition to nasal obstruction, allergic rhinitis is recognized to be associated with impaired mucociliary clearance and altered nasal responsiveness. Measures exist for the monitoring of these aspects of nasal dysfunction. Although measures of mucociliary clearance are simple to perform, they have a poor record of reproducibility. Their incorporation into clinical trials is thus questionable, although positive outcomes from therapeutic intervention have been reported. Measures of nasal responsiveness are at present largely confined to research studies investigating disease mechanisms in allergic and nonallergic rhinitis. The techniques are insufficiently standardized to be applied to multicenter clinical trials but could be used in limited-center studies to gain insight into the regulatory effects of different therapeutic modalities.

The burden of allergic rhinitis

Although formerly regarded as a nuisance disease, allergic rhinitis (AR) has a considerable effect on quality of life and can have significant consequences if left untreated. The total burden of this disease lies not only in impaired physical and social functioning but also in a financial burden made greater when considering evidence that AR is a possible causal factor in comorbid diseases such as asthma or sinusitis. Compared with matched controls, patients with AR have an approximate twofold increase in medication costs and 1.8-fold the number of visits to health practitioners. Hidden direct costs include the treatment of comorbid asthma, chronic sinusitis, otitis media, upper respiratory infection, and nasal polyposis. Nasal congestion, the most prominent symptom in AR, is associated with sleep-disordered breathing, a condition that can have a profound effect on mental health, including increased psychiatric disorders, depression, anxiety, and alcohol abuse. Furthermore, sleep-disordered breathing in childhood and adolescence is associated with increased disorders of learning performance, behavior, and attention. In the United States, AR results in 3.5 million lost workdays and 2 million lost schooldays annually. Patients struggle to alleviate their misery, frequently self-adjusting their treatment regimen of over-the-counter and prescription medications because of lack of efficacy, deterioration of efficacy, lack of 24-hour relief, and bothersome side effects. Ironically, health care providers overestimate patient satisfaction with therapy. Therefore, improvement in patient-practitioner communication may enhance patient adherence with prescribed regimens.

Comparison of cetirizine-pseudoephedrine and placebo in patients with seasonal allergic rhinitis and concomitant mild-to-moderate asthma: randomized, double-blind study

BACKGROUND

Allergic rhinitis (AR) and asthma are common concurrent conditions.

OBJECTIVES

To evaluate the effects of cetirizine hydrochloride (5 mg)-pseudoephedrine hydrochloride (120 mg) (cetirizine-D) twice daily on AR and asthma symptoms, pulmonary function, and asthma-related quality of life in 274 patients with confirmed seasonal AR and concomitant mild-to-moderate asthma.

METHODS

In this multicenter, randomized, double-blind, placebo-controlled study, after a 1-week screening period, patients took cetirizine-D or placebo for 4 weeks. The primary efficacy variable, AR total symptom severity complex score, was derived from patient daily diary ratings of sneezing, runny nose, itchy nose, postnasal drip, and nasal congestion. Asthma symptom severity total scores were derived from twice-daily diary ratings of wheezing, coughing, shortness of breath, and chest tightness. Pulmonary function was tested at clinic visits and by patients each morning and evening. Patients completed the Asthma Quality of Life Questionnaire at each visit. All tests were 2-sided, with statistical significance at the .05 level.

RESULTS

Cetirizine-D reduced total symptom severity complex scores by 42.3% overall vs 23.6% with placebo (P < .001). Asthma symptom severity total scores were significantly improved with cetirizine-D at most times vs placebo. Cetirizine-D treatment was also associated with significantly improved Asthma Quality of Life Questionnaire overall scores. Pulmonary function test results were neutral. Cetirizine-D was well tolerated, with discontinuation and adverse event rates similar to placebo. Somnolence occurred in 8 patients (5.8%) taking cetirizine-D and in 1 (0.7%) taking placebo.

CONCLUSIONS

Treatment with cetirizine-D twice daily significantly reduced rhinitis and asthma symptoms and improved overall asthma quality of life in patients with seasonal AR and concomitant mild-to-moderate asthma.

Efficacy and tolerability of fluticasone propionate/salmeterol administered twice daily via hydrofluoroalkane 134a metered-dose inhaler in adolescent and adult patients with persistent asthma: a randomized, double-blind, placebo-controlled, 12-week study

OBJECTIVE

This study compared the efficacy and tolerability of the combination of fluticasone propionate (FP) and salmeterol (SAL) delivered via a single hydrofluoroalkane (HFA) 134a metered-dose inhaler (MDI) with those of its 2 components alone delivered via a chlorofluorocarbon (CFC) MDI and placebo (PLA) delivered via HFA MDI in adolescent and adult patients with persistent asthma that was not controlled by medium doses (equivalent to FP 440-660 microg/d) of inhaled corticosteroids (ICSs).

METHODS

This was a randomized, double-blind,placebo-controlled, parallel-group study consisting of a 2-week, single-blind, placebo run-in period followed by a 12-week, double-blind treatment period. Participants had to be > or =12 years of age and have a diagnosis of asthma requiring pharmacotherapy for at least 6 months before the study. Patients had to have used ICS therapy for > or =3 months before the study and at a consistent dose for the previous month. Lack of asthma control was defined as a forced expiratory volume in 1 second (FEV(1)) that was 40% to 85% of the predicted value. Patients could not enter the double-blind treatment period if they had 3 days when they required >12 puffs of rescue albuterol per day or >3 nighttime awakenings due to asthma that required treatment with albuterol during the 7 days before the randomization visit. Patients were randomized to receive one of the following treatments delivered via MDI twice daily for 12 weeks: FSC 220/42 microg HFA (2 inhalations of FSC 110/21 microg; 125 microg/21 microg ex-valve); FP 220 microg CFC (2 inhalations of FP 110 microg); SAL 42 microg CFC (2 inhalations of 21 microg); or 2 inhalations of PLA HFA. The primary efficacy end point for FSC versus FP was the mean area under the 12-hour serial FEV(1) curve relative to the prerandomization baseline (FEV(1) AUC(bl)). The primary efficacy end points for FSC versus SAL were the mean change from baseline in morning predose FEV(1) at end point and the probability of not being withdrawn from the study due to worsening asthma. Tolerability assessments included electrocardiograms, routine clinical laboratory tests, vital signs, oropharyngeal examinations, and physical examinations. Adverse events were assessed at each clinic visit.

RESULTS

Thirty-two adolescent and 333 adult patients were randomly assigned to receive double-blind treatment. The treatment groups were comparable at baseline with respect to demographic characteristics (mean age, 38-41 years; white race, 78%-88%) and pulmonary function (mean percent predicted FEV(1), 68%-69%; mean asthma symptom score, 1.6 [scale 0-5]; and mean daily albuterol use, 3.1 puffs). After 12 weeks of treatment, the mean FEV(1) AUC(bl) was significantly greater in patients who received FSC compared with those who received FP, SAL, or PLA (7.0, 3.6, 5.3, and 1.4 L-h, respectively; all comparisons, P < or = 0.020). At end point, the mean change from baseline in morning predose FEV(1) for FSC was significantly greater than that for FP, SAL, and PLA (0.41, 0.19, 0.15, and -0.12 L; all comparisons, P < or = 0.001). During 12 weeks of treatment, 7% of patients receiving FSC were withdrawn due to worsening asthma, compared with 24% of patients receiving SAL and 54% of patients receiving PLA (P < 0.001); 11% of patients receiving FP were withdrawn due to worsening asthma. Treatment with FSC resulted in significant improvements in morning and evening peak expiratory flow compared with FP, SAL, and PLA (both, P < 0.001); need for rescue albuterol compared with FP and PLA (P < or =0.005); and asthma symptom scores compared with PLA (P < 0.001). The tolerability of FSC was similar to that of FP or SAL alone. The incidence of possibly drug-related adverse events was generally similar across treatment groups, and the most common (occurring in > or= 2% of patients) were headache (1%-4%), throat irritation (1%-2%), candidiasis of the mouth/throat (0%-2%), unspecified oropharyngeal plaques (0%-2%), and palpitations (0%-2%).

CONCLUSIONS

In these adolescent and adult patients whose asthma was not controlled by medium doses of an ICS, FSC delivered via HFA 134a MDI (2 inhalations of 110/21-microg strength administered BID) was more effective in improving lung function than FP or SAL monotherapy or PLA. All treatments were well tolerated.

Asthma Control Test: Reliability, validity, and responsiveness in patients not previously followed by asthma specialists

BACKGROUND

The development of the Asthma Control Test (ACT), a short, simple, patient-based tool for identifying patients with poorly controlled asthma, was recently described in patients under the routine care of an asthma specialist.

OBJECTIVES

We sought to evaluate the reliability and validity of the ACT in a longitudinal study of asthmatic patients new to the care of an asthma specialist.

METHODS

Patients (n=313) completed the ACT and the Asthma Control Questionnaire (ACQ) at 2 physician visits (4-12 weeks apart). Pulmonary function was measured, and asthma specialists rated asthma control.

RESULTS

Internal consistency reliability of the ACT was 0.85 (baseline) and 0.79 (follow-up). Test-retest reliability was 0.77. Criterion validity was demonstrated by significant correlations between baseline ACT scores and baseline specialists' ratings of asthma control (r=0.52, P<.001) and ACQ scores (r=-0.89, P<.001). Discriminant validity was demonstrated, with significant (P<.001) differences in mean ACT scores across patients differing in asthma control, pulmonary function, and treatment recommendation. Responsiveness of the ACT to changes in asthma control and lung function was demonstrated with significant correlations between changes in ACT scores and changes in specialists' ratings (r=0.44, P<.001), ACQ scores (r=-0.69, P<.001), and percent predicted FEV1 values (r=0.29, P<.001). An ACT score of 19 or less provided optimum balance of sensitivity (71%) and specificity (71%) for detecting uncontrolled asthma.

CONCLUSIONS

The ACT is reliable, valid, and responsive to changes in asthma control over time in patients new to the care of asthma specialists. A cutoff score of 19 or less identifies patients with poorly controlled asthma.

CLINICAL IMPLICATIONS

In a clinical setting the ACT should be a useful tool to help physicians identify patients with uncontrolled asthma and facilitate their ability to follow patients' progress with treatment.

Fluticasone propionate nasal spray is superior to montelukast for allergic rhinitis while neither affects overall asthma control

BACKGROUND

Asthma and allergic rhinitis are both highly prevalent diseases and often coexist in patients.

OBJECTIVE

To investigate the effect of rhinitis therapy on asthma outcomes in adult and adolescent patients with both seasonal allergic rhinitis (SAR) and persistent asthma.

METHODS

A total of 863 patients (mean baseline FEV1 81% predicted) were randomized to receive open-label fluticasone propionate/salmeterol (FSC), 100/50 microg bid for 4 weeks, plus either blinded fluticasone propionate aqueous nasal spray (FPANS) 200 microg/d, montelukast 10 mg/d, or placebo. Patients kept daily records of peak expiratory flow (PEF), asthma, and rhinitis symptoms and rescue albuterol use.

RESULTS

FPANS added to FSC resulted in superior outcomes for daytime total nasal symptom scores (D-TNSS) and individual daytime nasal specific symptoms (congestion, rhinorrhea, sneezing, and itching) compared with montelukast plus FSC and placebo plus FSC (p < or = 0.001). Montelukast plus FSC was superior to placebo plus FSC only for D-TNSS and itching and sneezing. Morning PEF, asthma symptoms, and rescue albuterol use improved significantly (p < or = 0.001) in all treatment groups, but improvements were comparable across the treatment groups.

CONCLUSION

In patients with persistent asthma treated with FSC, the addition of montelukast or FPANS for the treatment of SAR resulted in no additional improvements in overall asthma control compared with FSC alone. However, FPANS provided superior rhinitis control compared with montelukast. These data suggest that asthma and rhinitis should each be optimally treated.

Treatment for allergic rhinitis and chronic idiopathic urticaria: focus on oral antihistamines

OBJECTIVE

To review the efficacy and safety of first- and newer-generation antihistamines for the management of allergic rhinitis and chronic idiopathic urticaria (CIU), with a focus on management in the pharmacy.

DATA SOURCES

A literature review was performed using MEDLINE (1966-October 2005), with no time or language restrictions. Key words or phrases used were histamine, antihistamine(s), first- and second-generation, allergic rhinitis, chronic idiopathic urticaria, quality of life, impairment, sedation, cost-effectiveness, astemizole, cetirizine, desloratadine, diphenhydramine, fexofenadine, loratadine, hydroxyzine, ketotifen, and mizolastine. Additional references were found in the bibliographies of the articles cited.

STUDY SELECTION AND DATA EXTRACTION

Clinical trials and other experimental studies of the use of antihistamines for the management of allergic rhinitis and CIU were selected. Review papers and guidelines were also included.

DATA SYNTHESIS

First-generation antihistamines are effective at ameliorating the symptoms of allergic rhinitis and CIU; however, they are associated with adverse effects due to a lack of selectivity for the histamine H(1)-receptor and an ability to bind to cerebral H(1)-receptors. Newer-generation agents, in general, possess high H(1)-receptor selectivity and a low tendency to cross the blood-brain barrier, while maintaining efficacy. In general, safety at elevated doses has been demonstrated for the newer antihistamines, although higher rates of sedation and impairment have been reported with increasing doses for some agents.

CONCLUSIONS

Pharmacists can play an important role in the management of allergic rhinitis and CIU by considering the relative advantages of newer-generation agents when reviewing treatment options.

Effect of fluticasone/salmeterol administered via a single device on exercise-induced bronchospasm in patients with persistent asthma

BACKGROUND

Exercise is a common trigger of asthma symptoms in patients with persistent asthma.

OBJECTIVE

To evaluate the protective effect of fluticasone/salmeterol against exercise-induced bronchospasm.

METHODS

Multicenter, randomized, double-blind, parallel-group trial of 192 asthma patients who used moderate-dose inhaled corticosteroids. Patients (aged 12-50 years; mean forced expiratory volume in 1 second [FEV1], 78% of predicted at baseline) were randomized to receive fluticasone/salmeterol (250/50 microg twice daily) or fluticasone alone (250 microg twice daily) via Diskus for 4 weeks. Exercise challenge tests were performed 1 and 8.5 hours after administration of the first (day 1) and last (week 4) doses of blinded study medication.

RESULTS

On day 1 and at week 4, mean +/- SEM values for the maximal percentage decline in FEV1 1 hour after drug administration were 11.4% +/- 1.5% and 10.9% +/- 1.5% for fluticasone/salmeterol compared with 20.0% +/- 1.7% and 18.4% +/- 1.8% for fluticasone (P < .001). At 8.5 hours, mean +/- SEM values on day 1 and at week 4 were 11.6% +/- 1.4% and 8.9% +/1.1%, respectively, for fluticasone/salmeterol and 12.6% +/- 1.6% and 12.9% +/- 1.4%, respectively, for fluticasone (P = .01 at week 4). More fluticasone-treated patients did not complete the 8.5-hour exercise challenges (36% on day 1 and 33% at week 4) compared with the fluticasone/salmeterol group (18% each) (P < or = .01). Improvements in peak expiratory flow rate and albuterol rescue-free days were significantly greater with fluticasone/salmeterol vs fluticasone over weeks 1 to 4 (P < or = .03).

CONCLUSIONS

Consistent with the improvements in other measures of asthma control, long-term fluticasone/salmeterol therapy also provided protection against exercise-induced bronchospasm in patients with persistent asthma.

Effectiveness of immunotherapy for recurring sinusitis associated with allergic rhinitis as assessed by the Sinusitis Outcomes Questionnaire

BACKGROUND

Outcomes measurement is a proficient method for determining the effectiveness of medical therapy. Currently, there are no easy-to-use and inexpensive questionnaires available to evaluate the impact of immunotherapy in the treatment of sinusitis by allergists, given the research constraints of a private practice setting.

OBJECTIVE

To measure the effectiveness of immunotherapy in the overall treatment of atopic patients with associated sinusitis in a private practice setting.

METHODS

A total of 114 patients with a history of rhinitis and sinusitis and positive radiographic evidence of sinus disease were consecutively chosen from 3 private practices nationwide and surveyed for global symptoms and specific symptoms related to the nose, sinuses, eyes, and chest with the Sinusitis Outcomes Questionnaire (SOQ). Their medical history, including prior treatment, was evaluated. This questionnaire was administered twice in one sitting, with the first a recall of symptoms before starting immunotherapy and the second an evaluation of current symptoms.

RESULTS

The data revealed that 99% believed immunotherapy worked, with 1% unsure. Patients experienced a 72% decrease in days lost from work or school and a 26% reduction in the use of medications per year. There was a mean reduction of 51% in the overall symptom score of the patients after receiving immunotherapy.

CONCLUSIONS

This study demonstrates that the user-friendly SOQ can be effectively and inexpensively used in a private practice setting and suggests that immunotherapy is an effective treatment for patients with sinus disease and allergic rhinitis.

Development of the asthma control test: a survey for assessing asthma control

BACKGROUND

Asthma guidelines indicate that the goal of treatment should be optimum asthma control. In a busy clinic practice with limited time and resources, there is need for a simple method for assessing asthma control with or without lung function testing.

OBJECTIVES

The objective of this article was to describe the development of the Asthma Control Test (ACT), a patient-based tool for identifying patients with poorly controlled asthma.

METHODS

A 22-item survey was administered to 471 patients with asthma in the offices of asthma specialists. The specialist's rating of asthma control after spirometry was also collected. Stepwise regression methods were used to select a subset of items that showed the greatest discriminant validity in relation to the specialist's rating of asthma control. Internal consistency reliability was computed, and discriminant validity tests were conducted for ACT scale scores. The performance of ACT was investigated by using logistic regression methods and receiver operating characteristic analyses.

RESULTS

Five items were selected from regression analyses. The internal consistency reliability of the 5-item ACT scale was 0.84. ACT scale scores discriminated between groups of patients differing in the specialist's rating of asthma control (F = 34.5, P <.00001), the need for change in patient's therapy (F = 40.3, P <.00001), and percent predicted FEV(1) (F = 4.3, P =.0052). As a screening tool, the overall agreement between ACT and the specialist's rating ranged from 71% to 78% depending on the cut points used, and the area under the receiver operating characteristic curve was 0.77.

CONCLUSION

Results reinforce the usefulness of a brief, easy to administer, patient-based index of asthma control.

Improved ability to perform strenuous activities after treatment with fluticasone propionate/salmeterol combination in patients with persistent asthma

Patients with asthma experience disruptions in usual activities that can impair their quality of life, and in patients whose daily routine involves an active lifestyle, these disruptions can be severe. We assessed the patient-perceived effect of treatment with fluticasone propionate/salmeterol combination (FSC), compared with fluticasone propionate (FP) or salmeterol (SAL) alone, on activity limitations, particularly strenuous physical activities. The Asthma Quality of Life Questionnaire (AQLQ) was administered in two 12-week, randomized, double-blind, placebo-controlled trials comparing FSC 100/50 or 250/50 microg twice daily vs. the individual components alone in 686 adults and adolescents with asthma. In one study, patients were stratified by prior treatment [low to medium doses of inhaled corticosteroids (ICS) or SAL], and in the other study, all patients were previously treated with medium to high doses of ICS. Patients prospectively identified five activities they performed regularly and were asked how these activities were limited by their asthma. The effect of randomized treatment on strenuous activities (e.g., aerobics, cycling, hiking, and basketball) was assessed. In both studies, treatment with FSC resulted in clinically meaningful improvements (i.e., change in AQLQ of > or = 0.5) and was statistically significantly better than SAL in both studies and FP in one study. Treatment of the two main components of asthma--inflammation and bronchoconstriction--with FSC results in clinically meaningful improvements in the ability of patients with persistent asthma to perform not only their usual activities but also strenuous activities.

Fluticasone propionate aqueous nasal spray improves nasal symptoms of seasonal allergic rhinitis when used as needed (prn)

BACKGROUND

Few published clinical trials document the efficacy of intranasal corticosteroids used as needed for treatment of seasonal allergic rhinitis.

OBJECTIVE

To evaluate the efficacy and safety of 4 weeks' treatment with fluticasone propionate aqueous nasal spray 200 microg used as needed (FP200PRN) in patients with seasonal allergic rhinitis.

METHODS

A randomized, double-blind, placebo-controlled study in 241 patients (> or = 12 years of age) with a positive skin test result to a relevant fall allergen and who were symptomatic at randomization. The primary endpoint was the mean change from baseline in total nasal symptom score (TNSS; the sum of nasal congestion, rhinorrhea, sneezing, and nasal itching, each rated on a 4-point scale from 0 = none to 3 = severe).

RESULTS

The mean percentage of days that patients used the study medications in the FP200PRN and placebo groups was 61.8% (SD = 30.4%) and 70.1% (SD = 28.3%), respectively. Patients treated with FP200PRN had a significantly greater reduction from baseline in TNSS compared with those treated with vehicle placebo (mean +/- SE = -2.02 +/- 0.18 vs -1.06 +/- 0.22, P < 0.001), representing a 91% greater improvement with FP200PRN than vehicle placebo. The FP200PRN group also had a significantly greater (P < 0.001) mean reduction in individual nasal symptoms of rhinorrhea, sneezing, nasal itching, and nasal congestion compared with placebo. FP200PRN was well tolerated, with an incidence of adverse events comparable to vehicle placebo.

CONCLUSIONS

FP200PRN in patients 12 years and older is effective for treatment of nasal symptoms associated with seasonal allergic rhinitis. It has a lower incidence of adverse events than typically associated with regular once-daily use.

Pharmacotherapy for allergic rhinitis: a critical review of leukotriene receptor antagonists compared with other treatments

OBJECTIVE

To review the mechanisms and clinical efficacy of leukotriene receptor antagonists, which are investigational therapies for allergic rhinitis, compared with intranasal corticosteroids and nonsedating antihistamines, which are the most commonly prescribed pharmacotherapies for allergic rhinitis.

DATA SOURCES

Computer-assisted MEDLINE searches for articles and manual searches of conference proceedings on intranasal corticosteroid, antihistamine, leukotriene receptor antagonist, leukotriene modifier, zafirlukast, montelukast, allergic rhinitis, rhinitis, and asthma.

SELECTION

Published articles and pertinent abstracts on the topics identified above were selected. Head-to-head comparator trials as well as data from placebo-controlled trials were selected.

RESULTS AND CONCLUSIONS

The studies published to date demonstrate that leukotriene receptor antagonists are sometimes more effective than placebo, are no more effective than nonsedating antihistamines, and are less effective than intranasal corticosteroids in the treatment of allergic rhinitis. The combination of a leukotriene receptor antagonist and an antihistamine has not been proven to be more effective than either agent alone. This review reveals several inconsistencies that require resolution. First, whereas leukotriene receptor antagonists are predicted on the basis of their mechanism of action to improve nasal congestion significantly, clinical studies reveal leukotriene receptor antagonists to be no better than antihistamines at improving congestion. Second, leukotriene receptor antagonists would not be expected on the basis of their putative mechanism of action or nasal challenge data to improve significantly sneezing, nasal itching, or drainage. However, some studies show improvement in these symptoms during treatment with leukotriene receptor antagonists. Considered in aggregate, the data available to date do not clearly support a unique role of leukotriene receptor antagonists in the treatment of allergic rhinitis whether or not it is accompanied by asthma.

Comprehensive evaluation of cetirizine in the management of seasonal allergic rhinitis: impact on symptoms, quality of life, productivity, and activity impairment

Improvement in patient daily functioning and well-being resulting from disease-related symptom relief is increasingly viewed as a clinically relevant therapeutic outcome. The objective of this study was to evaluate the health-related quality of life (HRQL) effects, safety and efficacy of cetirizine in the treatment of seasonal allergic rhinitis, and impact on self-reported work/school-related productivity and activity impairment (WPAI). This was a double-blind, placebo-controlled, parallel-group study. Adult patients (n = 865) were randomized to daily treatment for 2 weeks with cetirizine or placebo. Patient disease-specific HRQL and WPAI were assessed at baseline and weeks 1 and 2 of treatment using the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and Allergy-Specific Work Productivity and Activity Impairment (WPAI-AS) Instrument, respectively. Treatment with cetirizine resulted in greater (p < 0.001) improvement in overall RQLQ and individual domain scores (activities, sleep, non-nose/eye symptoms, practical problems, nasal symptoms, eye symptoms, emotional), as compared with placebo. Cetirizine therapy produced a 28.9% mean reduction in total symptom severity complex (TSSC) score versus 12.7% with placebo at study end. Work/school productivity and activity impairment were significantly (p < 0.001) decreased from baseline for cetirizine-treated patients compared with placebo. The incidence of treatment-related side effects was similar between groups. Cetirizine provides safe and effective symptomatic relief in adults with SAR while significantly improving HRQL and providing a positive impact on work/school-related productivity and activity impairment. These results provide a more comprehensive assessment of cetirizine, indicating that its benefits extend beyond conventional measures of clinical outcome.