Allergic rhinitis: a growing primary care challenge

PURPOSE: To describe the growing problem of allergic rhinitis (AR) and the latest recommendations on its diagnosis and management for the nurse practitioner (NP) in primary care settings. DATA SOURCES: Recent clinical research, review articles and consensus guidelines, and the author's clinical experience. CONCLUSIONS: The prevalence of AR is increasing, possibly due to increased airborne pollutants, poor ventilation, and rising levels of indoor allergens. Allergic disease is systemic and rarely involves a single symptom. Treatments include reducing exposure to allergens as well as pharmacotherapy. IMPLICATIONS FOR PRACTICE: Patient education is crucial for successful management and includes understanding the allergic basis of symptoms, reducing allergen exposure, understanding proper use of medications, and reassessing the plan on a regular basis.     

Fluticasone propionate aqueous nasal spray compared with oral loratadine in patients with seasonal allergic rhinitis*

The effectiveness and safety of fluticasone propionate aqueous nasal spray (200 μg once daily for 4 weeks) were compared with those of loratadine (10 mg once daily for 4 weeks) in 114 adults and adolescents with seasonal allergic rhinitis in this multicenter, double-blind, double-dummy, randomized, parallel-group study. Patients recorded their nasal symptoms (nighttime and daytime obstruction, sneezing, itching, rhinorrhea, and overall discomfort) using a 4-point scale (0=no symptoms, 3=very frequent symptoms) in daily diaries. Clinicians assessed patients' nasal symptoms (nighttime and daytime obstruction, sneezing, itching, and rhinorrhea) using a 4-point scale at every scheduled visit. Clinicians and patients assessed the overall effectiveness of treatment at the end of the study. Fluticasone propionate improved clinician-rated total nasal symptom scores (defined as the sum of five nasal symptoms) more than loratadine at the 2-week and 4-week assessments (P≥0.008). Clinicians gave fluticasone propionate better global ratings than loratadine (P=0.04). After 4 weeks of treatment, between-group differences in clinician-rated individual nasal symptoms favored fluticasone propionate (P<0.05), with the exception of nasal itching (P=0.11). These findings were confirmed by between-group differences in the percentages of symptom-free days calculated from patient-recorded daily diary-card data. Both treatments were well tolerated. The incidence of adverse events between groups was similar. Fluticasone propionate aqueous nasal spray 200 μg administered once daily in the morning was more effective than loratadine 10 mg administered once daily for the treatment of seasonal allergic rhinitis.     

抗组胺药治疗婴幼儿过敏性鼻炎的临床应用专家共识

<正>1背景过敏性鼻炎(allergic rhinitis,AR)也称变应性鼻炎,是机体暴露于过敏原后,主要由免疫球蛋白E(Ig E)介导的鼻黏膜非感染性慢性炎性疾病,主要症状包括喷嚏、流涕、鼻痒和鼻塞[1-3]。近年来,儿童AR患病率呈总体上升趋势[4-6],已成为困扰儿童的常见疾病,首次发病年龄趋于越来越小[7],平均发病于6月龄[8],严重影响患儿生活质量[9],造成沉重的社会负担。     

Effectiveness of as‐needed antihistamines in chronic spontaneous urticaria patients under omalizumab treatment

The question how second‐generation antihistamines (sgAHs) should be used when chronic spontaneous urticaria (CSU) is under control with omalizumab is still unanswered. This study aimed to investigate the effectiveness of as‐needed sgAHs in patients with well‐controlled urticaria under omalizumab treatment. Patients from four different urticaria centers who were treated with omalizumab 300 mg/4 weeks for at least 3 months, had well‐controlled urticaria (Urticaria Control Test: 16 > UCT≥12) and were using sgAHs only if needed, were included in this study. In order to assess effectiveness of sgAHs, change in the itch, hives, and total itch‐hives scores before and after sgAHs were evaluated using modified urticaria activity score‐twice daily. Fifty‐three patients [38 female (71.7%)] with mean age 41.1 ± 11.4 years were included in this study. Median sgAH intake per patient throughout the 4 week‐intervals was 3 (2–5) tablets. sgAH intake decreased itch, hives and total itch‐hives scores 45.7% ± 52.9, 42.4% ± 39.1, and 50.2% ± 51.1, respectively (P < .001 for all). This decrease was similar in both isolated‐urticaria and urticaria‐and‐angioedema phenotypes. Baseline IgE levels were positively correlated with the decrease of three symptom scores (r = 0.31, P = .05; r = 0.375, P = .017; r = 0.31, P = .05, respectively) that showed in patients with higher baseline total IgE levels, as needed sgAH intake decreased the symptom scores less. Our study showed that sgAHs may still be an effective option for the treatment of the intermittent symptoms in patients with well‐controlled urticaria under omalizumab treatment. Baseline total IgE levels may be used as a potential biomarker for sgAH effectiveness in these patients.     

Chronic idiopathic urticaria and its management

ABSTRACT: Chronic urticaria is defined as the daily or almost daily occurrence of wheals for at least 6 weeks. This disorder affects 0.1% of the general population and is more common in females. Recently a subgroup of patients with chronic urticaria has been found to have circulating autoantibodies directed against the high-affinity IgE receptor (Fc∍RI) or against IgE antibodies. These "autoantibodies" are felt to play a role in mast cell histamine release. Urticaria patients with these circulating antibodies also have a higher prevalence of other autoimmune diseases. The management of patients with chronic urticaria is to identify and eliminate the underlying cause, however, an etiology for chronic urticaria is rarely identified. Thus the approach to treatment usually centers on the use of antihistamines initially with the addition of other immune modulating agents as necessary.     

The apparent volumes of distribution of H1 receptor antagonists

ABSTRACT: The apparent volume of distribution (V_D) of a drug estimates its distribution into the body. Referring to the volume of exchangeable water (0.6 L/kg body weight), it indicates if tissue distribution is extensive when V_D is greater than 0.6 L/kg or poor if V_D is less than 0.6 L/kg. Its interest in the selection of an appropriate drug is found after comparing the map of selected targets (mainly receptors) to be reached by the drug, the accessibility of these targets by the drug, and the V_D necessary and sufficient to reach them. This analysis is here applied to H₁ receptor antagonists, a pharmacologic class, where target cells, endothelial cells such as eosinophils, mastocytes, basophils, and smooth fibers have receptors on the external side of cell membranes and thus are more readily accessible from blood than toxic sites located inside cells (heart, brain, liver). Of the H₁ receptor antagonists marketed today, cetirizine has the lowest V_D, 0.4 L/kg, enough to reach selected targets without extensive distribution in organs where it would be useless. These characteristics are related to its chemical amphoteric structure.