Recurrent panniculitis in a man with asthma receiving treatment with leukotriene-modifying agents

Leukotriene-modifying drugs are novel agents introduced recently to treat asthma. Both 5-lipoxygenase inhibitors, such as zileuton, and leukotriene receptor antagonists, such as zafirlukast and montelukast, have proved effective in the treatment of asthma. To our knowledge, there have been no detailed reports regarding dermatologic manifestations of this class of drugs. This article describes an unusual case of erythema nodosum in a 46-year-old asthmatic man who received 2 different leukotriene modifiers.     

Leukotriene modifiers to prevent aspirin-provoked respiratory reactions in asthmatics

OBJECTIVE: To evaluate the use of leukotriene modifiers in preventing aspirin-provoked respiratory reactions in asthmatics. DATA SOURCES: Clinical literature accessed through MEDLINE (1965-February 2001). Key search terms included aspirin, asthma, leukotriene, and treatment. DATA SYNTHESIS: Aspirin-sensitive asthmatics experience a wide variety of symptoms, ranging from rhinitis to life-threatening bronchospasms, after the ingestion of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). The relationship between aspirin sensitivity, asthma, and nasal polyps was first reported in 1922. The exact mechanism of these reactions is not clearly understood. Four studies investigated the use of leukotriene modifiers to prevent aspirin-provoked respiratory reactions. The efficacy of these agents ranged from complete inhibition to no blockade. CONCLUSIONS: Patients who experience aspirin-sensitive asthma should be cautious when taking aspirin and NSAIDs, despite treatment with leukotriene inhibitors.     

孟鲁司特联用布地奈德吸入防治儿童哮喘合并变应性鼻炎

目的：观察在吸入糖皮质激素（布地奈德）的基础上联合应用白三烯受体拮抗剂（孟鲁司特）对儿童哮喘伴变应性鼻炎的防治作用。方法：74例轻、中度支气管哮喘伴变应性鼻炎患儿随机分为治疗组和对照组各37例，进行3个月的治疗，观察组吸入布地奈德每天400μg，一个月后减至每天200μg，治疗组在此基础上加用孟鲁司特每天5mg。记录患儿的哮喘症状评分、变应性鼻炎症状评分、按需吸入β2受体激动剂的次数及测定气道反应性。结果：治疗后两组患儿的哮喘症状评分、变应性鼻炎症状评分及气道高反应性均明显改善。治疗组治疗后夜间哮喘症状评分及变应性鼻炎症状评分为0分及（0.30±0.36）分，对照组治疗后夜间哮喘症状评分及变应性鼻炎症状评分为（0.41±0.36）分及（1.29±0.54）分，两组比较差异有显著意义（P〈0.01）；按需吸入β2受体激动剂的次数治疗组为（1.84±0.04）喷，对照组为（2.97±0.03）喷，两组比较差异有显著性（P〈0.05）。结论：在吸入糖皮质激素的基础上联合应用白三烯受体拮抗剂可显著提高对儿童哮喘伴变应性鼻炎的疗效。     

Review of recent results of montelukast use as a monotherapy in children with mild asthma

Background: Asthma is a chronic disease with a heterogeneous phenotype that is often associated with allergic sensitization in childhood. The earliest definable form of asthma is mild (intermittent or persistent), a severity level that may be characteristic of a majority of children with asthma. Several asthma controllers are indicated for use in children. International guidelines recommend the use of inhaled corticosteroids as the preferred controller therapy in mild persistent asthma. Objective: This article reviewed recent results from randomized, double-blind studies of children with mild asthma treated with montelukast, a leukotriene receptor antagonist that is approved for the treatment of asthma and allergic rhinitis in children and adults. Methods: A literature search of MEDLINE was conducted to gather relevant, English-language articles using search terms such as randomized controlled studies, double-blind studies, montelukast, leukotriene receptor antagonist, pediatric asthma, mild asthma, exercise-induced asthma, and bronchoconstriction. Recent articles (since 1998) that described the use of montelukast as a monotherapy were chosen for this review. Results: Releevant studies included a 48-week, placebo-controlled study of 2- to 5-year-old mild intermittent asthmatics (N = 549); a 12-week, placebo-controlled study of 2- to 5-year-old mild persistent asthmatics (N = 689); an analysis of a mild persistent asthmatic cohort (N = 138) from an 8-week, placebo-controlled study of 6- to 14-year-old asthmatics; a 12-month study comparing montelukast with fluticasone in 6- to 14-year-old mild persistent asthmatics (N = 949); and 3 placebo-controlled studies in children with exercise-induced asthma (N = 123). The results from these studies, encompassing end points measuring lung function and symptoms, found that montelukast provided effective and beneficial asthma control to children aged 2 to 14 years with mild asthma. Conclusion: The evidence suggests that montelukast is an effective monotherapy controller in children with mild asthma.     

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.     

Montelukast in the prophylaxis of migraine: a potential role for leukotriene modifiers

OBJECTIVE: Clinical observation of a decrease in migraine frequency in patients with comorbid asthma taking montelukast, a specific D4 leukotriene receptor antagonist, or zafirlukast, another leukotriene receptor antagonist, prompted us to explore a possible role for leukotriene modifiers in the treatment of migraine. (A further prompt was a pharmacist colleague's observation that a number of patients on these agents reported a decreased sensitivity to perfume triggers and improvement in migraine.) BACKGROUND: Nonsteroidal anti-inflammatory agents have been used widely in the treatment of migraine. Another class of anti-inflammatory agents, known as leukotriene modifiers, have not been studied to date with regard to their possible role in the treatment of migraine. The name "leukotriene is derived both from the parent molecule, which was originally isolated from leukocytes, and from its three double-bond carbon backbone or triene structure. Both prostaglandins and leukotrienes are derived from the metabolism of arachidonic acid, with prostaglandins coming off the cyclooxygenase pathway and leukotrienes derived via the enzyme 5-lipoxygenase. Both prostaglandins and leukotrienes mediate inflammatory responses. The latter have been studied with regard to their role in the pathophysiology of asthma. METHODS: A prospective, open-label study evaluating the efficacy of montelukast, 10 mg or 20 mg, in the prophylaxis of migraine in 17 patients is presented in this paper. All 17 patients completed the study that consisted of a 2-month baseline run-in period and a 3-month treatment phase. RESULTS: Montelukast was extremely well tolerated, and no adverse events were reported by any of the patients. Fifty-three percent showed a reduction of greater than 50% (P<.025) in the frequency of severe attacks, with 41% showing a reduction of greater than 60%. Responders, including modest responders, rated the drug as excellent. CONCLUSIONS: We conclude, given the limitations of an open-label study design and the small sample size, that montelukast shows potential as an effective, well-tolerated prophylactic agent in migraine. Double-blinded, placebo-controlled studies are warranted. In addition, the leukotrienes, as suggested previously in the literature, may play a role in the pathogenesis of migraine.     

Montelukast treatment of urticaria

OBJECTIVE: To review clinical trial data to determine the benefits of using montelukast alone or as combination therapy in the treatment of urticaria. DATA SOURCES: MEDLINE (1966-March 2006) and International Pharmaceutical Abstracts (1970-October 2005) were searched to find clinical trial publications that addressed the use of montelukast in urticaria. DATA SYNTHESIS: Six clinical trials were identified. Montelukast was compared alone and as combination therapy with nonsedating histamine1-receptor antagonists to determine efficacy and safety. Patients had chronic or physical urticaria. The results were mixed. Some studies demonstrated that montelukast can decrease urticarial symptoms with minimal adverse effects, while others found no differences. CONCLUSION: Large-scale, controlled trials are needed to determine which patients would likely benefit from treatment with montelukast.     

Therapeutic modulation of allergic airways disease with leukotriene receptor antagonists

Although asthma is one of the most common chronic respiratory conditions, it often remains unrecognized and undertreated, while patients are often reluctant to comply with regular inhaled anti-inflammatory and bronchodilator therapy. Allergic rhinitis co-exists with asthma in as many as 40% of patients, and can be regarded as a continuum of the same inflammatory disease process. Corticosteroids are the 'gold standard' first-line treatment for both conditions, and have a significant impact upon underlying inflammation, symptoms and long-term outcome. Cysteinyl leukotrienes are potent airway inflammatory mediators, suggesting that treatment antagonizing their effects could play a role in disease management. In recent years, leukotriene receptor antagonists have provided a further therapeutic option in the management of allergic airways disease. These drugs are orally active, can be administered once daily, and provide a systemic approach to the management of patients with asthma and allergic rhinitis. We review the pharmacology of leukotriene receptor antagonists, their potential role in clinical practice in patients with allergic airways disease, and likely areas for further research.     

白三烯受体拮抗剂在慢性咳嗽治疗中的临床价值

目的 探讨白三烯受体拮抗剂在慢性咳嗽临床治疗中的意义.方法 选择81例慢性咳嗽患者(根据慢性咳嗽诊断流程诊断),所有患者均符合咳嗽时间≥8周,不吸烟或戒烟4周以上,无服用血管紧张素转换酶抑制剂类药物史,服用者停药观察4周,X线胸片检查未见异常,并除外胃食管反流性咳嗽、除变应性鼻炎的其他上气道咳嗽综合征、支气管内膜结核等其他慢性咳嗽病因.对诊断为咳嗽变异性哮喘、变应性鼻炎、嗜酸粒细胞性支气管炎及感染后咳嗽的患者给予孟鲁司特钠10 mg,每晚1次进行治疗4周并观察疗效.结果 81例入选患者中咳嗽变异性哮喘36例,变应性鼻炎30例,嗜酸粒细胞性支气管炎5例,感染后咳嗽10例.经孟鲁司特钠治疗后,67例患者咳嗽症状临床控制,12例患者显效,2例无效,有效率97.5%(79/81).结论 气道炎症是慢性咳嗽患者常见的病理特征,白三烯受体拮抗剂孟鲁司特钠有显著的抗炎作用,能明显改善咳嗽变异性哮喘、嗜酸粒细胞性支气管炎、感染后咳嗽、变应性鼻炎等慢性咳嗽患者的气道炎症,减轻咳嗽症状,是治疗慢性咳嗽的重要药物.     

Caring for patients with allergic rhinitis

PURPOSE: Allergic rhinitis (AR) affects up to 40 million Americans, with an estimated cost of $2.7 billion per annum. This review discusses several therapeutic options that reduce the symptoms of AR, including allergen avoidance, antihistamines, intranasal corticosteroids (INS), leukotriene receptor antagonists, and immunotherapy. DATA SOURCES: The articles included in this review were retrieved by a search of Medline literature on the subjects of AR, antihistamines, INS, leukotriene antagonists, and immunotherapy, as well as current published guidelines for the treatment of AR. CONCLUSIONS: Allergen avoidance is recommended for all patients prior to pharmacologic therapy. Oral and nasal H(1)-antihistamines are recommended to alleviate the mild and intermittent symptoms of AR, and INS are recommended as the first-line treatment choice for mild persistent and more moderate-to-severe persistent AR. IMPLICATIONS FOR PRACTICE: There are a number of different types of therapy for the management of AR; with so many options available, successful tailoring of treatment to suit individual requirements is realistically achievable.     

Montelukast: data from clinical trials in the management of asthma

OBJECTIVE: To review the pharmacology, pharmacokinetics, clinical efficacy, and adverse effects of montelukast, a leukotriene receptor antagonist used to treat asthma, and to discuss the therapeutic role of montelukast as long-term medication and difficulties associated with the management of asthma. DATA SOURCES: A MEDLINE search (up to May 1999) was conducted to identify relevant English-language publications, including preclinical studies, clinical trials, and recent reviews. STUDY SELECTION: All available published reports of controlled, clinical trials of montelukast in adults and children with asthma were summarized, including pharmacokinetic and pharmacologic effects of montelukast. DATA EXTRACTION: Information on the safety and efficacy of montelukast was evaluated on the basis of patient selection, study design, methodology, and statistical significance as compared with placebo or inhaled corticosteroid treatment. DATA SYNTHESIS: Montelukast is approved for the prophylaxis and chronic treatment of asthma at a dose of 10 mg once daily for adolescents (> or =15 y) and adults and 5 mg once daily for children (6-14 y). In placebo-controlled clinical trials, montelukast significantly improved pulmonary lung function (as measured by forced expiratory volume in 1 sec), significantly reduced beta2-agonist use, and significantly improved patient-reported end points in adults and children (> or =6 y) with chronic asthma. In adults, a similar magnitude of improvement in lung function is seen with or without inhaled corticosteroid use; the effects of montelukast may be additive to those of inhaled corticosteroids and permit the reduction of the required dose of inhaled corticosteroids. In cases of exercise-induced asthma (adults and children), montelukast treatment attenuates the fall in pulmonary function following exercise. It attenuates both the early- and late-phase responses of asthma after allergen inhalation. Improvements in asthma control are similar in asthmatic patients who are aspirin-sensitive or not aspirin-sensitive and can be seen within one day of treatment. Tolerance does not develop, and the adverse events do not differ from those of placebo. CONCLUSIONS: Montelukast is indicated for the prophylaxis of chronic asthma in adults and children (> or =6 y). It may be considered for use as first-line therapy in patients with mild persistent asthma or for additional control in patients who are still symptomatic while receiving treatment with inhaled corticosteroids. It may also be used for additional control in aspirin-sensitive asthmatic patients. Consideration may be given for using montelukast to allow tapering of the dose of inhaled corticosteroids while maintaining clinical stability. Chronic treatment with montelukast can provide additional control of symptoms during exercise, but inhaled beta2-agonists remain first-line therapy for prophylaxis and treatment.     

Opioid antagonists in the treatment of opioid-induced constipation and pruritus

OBJECTIVE: To describe the role of opioid antagonists in the treatment of opioid-induced constipation and pruritus. DATA SOURCES: A MEDLINE search was performed (1966-February 2000) for narcotics and opioid antagonists. Results were limited to English-language and clinical trials. Background information was obtained from pharmacology and pharmacotherapy references and review articles. Hand searching of selected bibliographies yielded several references. STUDY SELECTION AND DATA EXTRACTION: Studies were reviewed that examined the use of naloxone, naltrexone, and methylnaltrexone for opioid-related constipation and pruritus. Selected citations included various clinical trials and case series. DATA SYNTHESIS: Opioid agents are used for cancer and nonmalignant pain. Peripheral opioid receptor stimulation due to endogenous (i.e., endorphins) or exogenous (i.e., morphine) stimulants may result in negative adverse effects, including constipation and pruritus. Adjuvant agents, such as laxatives and antihistamines, are often used to treat these adverse effects, but are themselves associated with adverse effects and are sometimes ineffective. Opioid antagonists have demonstrated reversal of peripheral opioid receptor stimulation. Clinical trials show adequate maintenance of pain control, as well as decreases in opioid-induced constipation and pruritus. CONCLUSIONS: Opioid antagonists offer a therapeutic alternative to conventional adjuvant agents, with the risk of loss of analgesia at higher doses. Methylnaltrexone offers the advantage of peripheral action only, therefore not reversing analgesia. Results are promising; however, larger clinical trials are necessary before opioid antagonists become the standard of care for opioid-induced constipation and pruritus.     

Calcium-channel antagonists and nitrates in coronary artery bypass patients receiving radial artery grafts

OBJECTIVE: To review the literature assessing the role of vasodilators for the prevention of vasospasm leading to graft failure in patients receiving the radial artery (RA) as a conduit in coronary artery bypass grafting (CABG). DATA SOURCE: A MEDLINE search (January 1966-May 2000) was performed using calcium-channel antagonists, nitrates, radial artery, and coronary artery bypass as key words. English-language articles were identified, and the references of these articles were used to further identify pertinent articles. DATA SYNTHESIS: RAs can be used as conduits in CABG. It has been suggested that failure of these grafts may be due to vasospasm, leading to occlusion observed angiographically. Calcium-channel antagonists and nitrates have been proposed as a means of preventing vasospasm and subsequent graft failure. CONCLUSIONS: Currently published data on the use of calcium-channel antagonist or nitrate therapy as prophylaxis against vasospasm in patients receiving RA grafts are inconclusive. Systematic evaluations of currently available pharmacologic agents are needed to guide clinical practice in this area.     

Recognizing and treating non-infectious rhinitis

PURPOSE: To increase clinicians' familiarity with nonallergic and mixed rhinitis and to differentiate these from allergic rhinitis, thus providing for an accurate diagnosis and facilitating a successful initial treatment program. DATA SOURCES: A Medline search of published journal articles was supplemented with known books and proceedings pertaining to rhinitis. CONCLUSIONS: Although there is significant overlap of symptoms among the three types of rhinitis (i.e., allergic, nonallergic, and mixed), the patient history often contains clues that can aid in establishing a correct diagnosis. The new Patient Rhinitis Screen, a questionnaire developed for use in the primary care arena, facilitates the diagnostic process. IMPLICATIONS FOR PRACTICE: As the most common condition in the outpatient practice of medicine, rhinitis is frequently treated by primary care practitioners. Recent guidelines for the diagnosis and management of rhinitis suggest that a specific diagnosis of allergic, nonallergic, or mixed rhinitis leads to more effective treatment strategies. The result is successful and efficient care utilizing, as appropriate, broad-based and symptom-specific therapies.     

Montelukast-induced generalized urticaria

OBJECTIVE: To report a case of generalized urticaria induced by montelukast treatment. CASE SUMMARY: A 28-year-old man with allergic rhinitis and moderate persistent asthma developed generalized urticaria 5 days after the initiation of montelukast and inhaled fluticasone. Symptoms disappeared within one day after suspension of both drugs. Two months later, after the resumption of montelukast and fluticasone, the patient developed generalized urticaria and eyelid angioedema, which were successfully treated with intravenous betamethasone, achieving complete remission within hours. After 2 days, the patient resumed inhaled fluticasone only and continued this therapy for several months without any adverse reaction. DISCUSSION: We attributed the adverse reaction to montelukast because of the temporal relationship between use of montelukast and urticaria, the absence of other identified causative factors and other explanations for allergic reactions, and the positive dechallenge and rechallenge. The Naranjo probability scale showed a probable relationship between skin manifestations and montelukast treatment. CONCLUSIONS: The use of antileukotrienes is increasing in asthma therapy. In cases of generalized urticaria in asthmatic patients undergoing montelukast therapy, physicians should be aware of a potential adverse reaction to this drug.     

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.     

Use of epidural corticosteroids in low back pain

OBJECTIVE: To review the literature regarding the safety and efficacy of epidural corticosteroid injections in the treatment of low back pain (LBP) of various etiologies. DATA SOURCES: A MEDLINE search (1966-February 1999) of English-language literature pertaining to the use of epidural corticosteroids in LBP was performed. Additional literature was obtained from reference lists of pertinent articles identified through the search. STUDY SELECTION AND DATA EXTRACTION: All articles were considered for the review. The clinical trials included are those that enrolled a larger patient population and were primarily controlled clinical trials. The authors selected pertinent information for further discussion. DATA SYNTHESIS: Nerve root compression and inflammation are thought to be factors contributing to LBP. Corticosteroids act to decrease inflammation and may be of benefit in relieving LBP, especially if administered directly to the affected area via the epidural route. However, data on the efficacy of various corticosteroid agents administered via this route are limited. In addition, there have been reports of significant adverse reactions, thought to be due primarily to the preservative components in the corticosteroid preparations. Therefore, the role of these agents in the therapy of LBP remains to be determined. CONCLUSIONS: Based on the studies reviewed, epidural corticosteroids may be an effective treatment for LBP. Their use is warranted in patients who have failed conservative therapy. Although they contain preservatives, it appears that these agents are relatively safe and do not cause significant neurotoxicities.     

Comparison of oral montelukast and inhaled fluticasone in the treatment of asthma associated with chronic rhinopolyposis: a single-blind, randomized, pilot study

Background: Rhinopolyposis is considered to be a non-immunoglobulin E-mediated inflammatory condition of the nose and sinuses, often associated with chronic rhinitis and asthma. Inhaled corticosteroids are currently the most commonly used anti-inflammatory agents for the chronic treatment of asthma and rhinopolyposis. Recently, montelukast, a selective cysteinyl leukotriene receptor antagonist indicated for the prophylaxis and treatment of asthma, has been shown to be effective in controlling rhinopolyposis and related symptoms.Objective: The aim of this study was to compare the short-term clinical efficacy of montelukast with that of fluticasone propionate in patients with asthma associated with rhinopolyposis.Methods: In this prospective, single-blind, randomized, pilot study, 12 out-patients with asthma associated with rhinopolyposis were given oral montelukast (10 mg once daily) or inhaled fluticasone propionate (intranasal suspension 50 μg and spray 250 μg twice daily). At baseline and after 30 days of treatment, the patients completed an asthma and rhinitis questionnaire and underwent nasal endoscopy, pulmonary function tests, and bronchial provocation testing.Results: Of the 12 study patients (9 men, 3 women), 7 were randomized to the montelukast group and 5 to the fluticasone group. There were no significant differences in baseline characteristics between the 2 treatment groups. After treatment, improvements in nasal and respiratory symptoms and nasal endoscopy results were found in 6 patients, 3 in each treatment group. No significant differences in the peak expiratory flow rate, forced expiratory volume in 1 second, or bronchial hyperresponsiveness changes after treatment were observed between the 2 groups.Conclusions: Our preliminary data show a comparable effect on respiratory and nasal symptoms and pulmonary function test results between oral montelukast and inhaled fluticasone in this small patient population, suggesting that leukotriene-receptor antagonists might be considered an alternative to inhaled corticosteroids in the treatment of asthma associated with rhinopolyposis.     

白三烯受体拮抗剂对毛细支气管炎外周血CD_4~+CD_(25)~+Treg的影响及疗效观察

目的探讨白三烯受体拮抗剂(孟鲁司特)对毛细支气管炎患儿外周血CD4+CD25+调节性T细胞(Treg)的影响并观察其疗效。方法将48例毛细支气管炎患儿按入院顺序分成孟鲁司特干预组和常规治疗组,常规治疗组采取综合治疗,孟鲁司特干预组在综合治疗的基础上加用孟鲁司特4 mg,每晚1次口服。检测2组患者治疗前后外周血中CD4+CD25+Treg的水平,并观察2组患者咳嗽、喘憋、肺部体征的持续时间。结果治疗前2组患儿外周血CD4+CD25+Treg占CD4+T细胞的百分比均明显低于健康对照组,差异有统计学意义(P0.01);治疗后孟鲁司特干预组外周血中CD4+CD25+Treg水平较常规治疗组显著上升(P0.05),同时咳嗽、喘憋、肺部体征持续时间与常规治疗组比较有统计学意义(P0.01)。结论孟鲁斯特纳可缩短病程,提高毛细支气管炎患儿外周血CD4+CD25+Treg的水平,在毛细支气管炎的治疗中起重要作用。     

New competition in the realm of renin-angiotensin axis inhibition; the angiotensin II receptor antagonists in congestive heart failure

OBJECTIVE: To critically review the studies comparing angiotensin II (AgII) receptor antagonists with placebo or angiotensin-converting enzyme (ACE) inhibitors in patients with congestive heart failure (CHF). DATA SOURCES: A MEDLINE search (1988 to January 2000) was used to identify pertinent literature. Additional references were also retrieved from selected articles. STUDY SELECTION: As most published CHF studies were performed with candesartan and losartan, these agents are the main focus of this article. However, all identified comparative clinical studies were reviewed and included, regardless of the agent used. DATA SYNTHESIS: AgII receptor antagonists inhibit the effects of AgII at its sub-type 1 receptor, independently of AgII's synthesis pathway. They present a hemodynamic profile similar to that of ACE inhibitors, without reflex neurohormonal activation. They have been shown to be at least as effective as ACE inhibitors in improving symptoms, exercise capacity, and New York Heart Association functional class in CHF patients. Although the ELITE (Evaluation of Losartan in the Elderly) trial suggested that losartan improved survival compared with captopril, this study was not designed to look at mortality. ELITE-II, an adequately powered study, showed no difference in mortality rates between patients taking captopril and those taking losartan. The combination of AgII receptor antagonists and ACE inhibitors provides additional benefit on blood pressure lowering and prevention of ventricular remodeling. AgII receptor antagonists are well tolerated, with an incidence of adverse effects similar to or lower than that of ACE inhibitors. Their lack of effect on bradykinin degradation might explain their lower incidence of cough. CONCLUSIONS: The data cumulated thus far in patients with CHF highlight that ACE inhibitors must remain the treatment of choice and that AgII receptor antagonists may be considered as an acceptable alternative for patients who are intolerant to ACE inhibitors.