- Email: [email protected]
Intranasal corticosteroids reduce ocular symptoms of allergic rhinitis as a class effect
538 CORRESPONDENCE
J ALLERGY CLIN IMMUNOL FEBRUARY 2008
pollen was a risk factor for an asthma epidemic during the thunderstorm in Naples, with a close temporal association between the arrival of the thunderstorm, a major increase in the concentration of Parietaria species pollen grains, and the onset of the epidemic. We completely agree with Marks and Bush2 about the ‘‘4 necessary conditions’’ for asthma epidemics, but more than fungal spores and grass pollen have to be taken into consideration. The same mechanisms might involve other pollen grains in different geographic areas, depending on the seasonality of thunderstorms and allergenic pollen. Gennaro D’Amato, MDa Lorenzo Cecchi, MDb Gennaro Liccardi, MDa From athe Division of Respiratory and Allergic Diseases, Department of Respiratory Diseases, High Specialty Hospital A. Cardarelli, Naples, Italy, and bthe Interdepartmental Centre of Bioclimatology, University of Florence, Florence, Italy. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest. REFERENCES 1. Pulimood TB, Corden JM, Bryden C, Sharples L, Nasser SM. Epidemic asthma and the role of the fungal mold Alternaria alternata. J Allergy Clin Immunol 2007;120: 610-7. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. 3. D’Amato G, Liccardi G, Viegi G, Baldacci S. Thunderstorm-associated asthma in pollinosis patients. Available at: http://bmj.bmjjournals.com/cgi/eletters/309/6947/131/c. Accessed December 7, 2007. 4. D’Amato G, Liccardi G, Frenguelli G. Thunderstorm-associated asthma in pollinosis patients. Allergy 2007;62:11-6. 5. D’Amato G, Ruffilli A, Ortolani C. Allergenic significance of Parietaria (pellitoryof-the-wall) pollen. In: D’Amato G, Spieksma F, Bonini S, editors. Allergenic pollen and pollinosis in Europe. Oxford: Blackwell Scientific Publications; 1991. p. 113-8. 6. D’Amato G, Cecchi L, Bonini S, Nunes C, Annesi-Maesano I, Behrendt H, et al. Allergenic pollen and pollen allergy in Europe. Allergy 2007;62:976-90. Available online January 3, 2008. doi:10.1016/j.jaci.2007.10.046
Reply To the Editor: We thank D’Amato et al1 for drawing our attention to a thunderstorm-related asthma outbreak that was associated with another pollen, in this case the weed pollen Parietaria species. We agree that the 4 conditions we outlined in our editorial2 need not only apply to grass pollens, although most previous reports do appear to have been linked to this form of pollen. However, any pollen grains, grass, weed, or tree, that are abundant and can rupture and release respirable allergenic starch granules would be expected to behave in a similar way in the presence of a thunderstorm outflow. Guy B. Marks, MBBS, PhDa Robert K. Bush, MDb From athe Woolcock Institute of Medical Research, Sydney, New South Wales, Australia, and bthe William S. Middleton VA Hospital, Madison, Wis. E-mail: G.Marks@unsw. edu.au. Disclosure of potential conflict of interest: R. K. Bush has consulting arrangements with Greer Laboratories and has received grant support from the National Institutes of Health. G. B. Marks has declared that he has no conflict of interest. REFERENCES 1. D’Amato G, Cecchi L, Liccardi G. Thunderstorm-related asthma: not only grass pollen and spores. J Allergy Clin Immunol 2008;121:537-8. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. Available online January 21, 2008. doi:10.1016/j.jaci.2007.10.047
Intranasal corticosteroids reduce ocular symptoms of allergic rhinitis as a class effect To the Editor: In their study of fluticasone furoate nasal spray, Kaiser et al1 make an important but possibly underappreciated contribution to the growing amount of evidence demonstrating that intranasal corticosteroids (INSs), as a class, reduce the ocular symptoms associated with allergic rhinitis (AR). Unfortunately, the authors concluded that ‘‘older INSs failed to show consistent efficacy for ocular symptoms in adult subjects with SAR’’ (seasonal allergic rhinitis), and characterized fluticasone propionate (FP) and mometasone furoate (MF) nasal sprays as ‘‘older’’ INSs. However, the literature supports the positive effect on ocular allergy symptoms of older INS agents as a class effect. One possible reason that older studies may not have consistently shown a positive effect for ocular symptoms is that those studies did not focus on the ocular domain of allergy symptoms, but combined all symptoms into a single component of the total nonnasal symptom score. However, studies published over the past 5 years with FP, MF, budesonide, triamcinolone acetonide, and beclomethasone dipropionate have collected and reported ocular allergy signs and symptoms separately. In the article by Bernstein et al2 cited by Kaiser et al,1 a 28-day study comparing FP, oral loratadine, and placebo found that subjects treated with FP had statistically significant decreases compared with placebo in the total ocular symptom score, which was the sum of scores for the symptoms of itching (pruritus), tearing (epiphora), and redness (erythema). The data also suggested that FP had reduced ocular symptoms more than or comparable to oral loratadine. The positive effect of MF on ocular allergy symptoms was seen in an analysis of pooled data from 4 randomized blind studies. Subjects who received MF had significantly greater reductions in total ocular symptom score and the component symptoms of itching, tearing, and redness than those who received placebo over the entire 2-week course of the study, which was similar to the study by Kaiser et al.3,4 Mometasone furoate had an onset of effect starting at 24 hours of initiation of treatment.4 Ocular symptom scores also decreased significantly in pediatric patients with perennial AR after 1 year of treatment with budesonide,5 adolescents and adults with seasonal allergic rhinitis who received triamcinolone acetonide,6 and patients with chronic rhinosinusitis with and without allergy given beclomethasone dipropionate, which significantly improved ocular tearing, itching, and redness as well as blepharedema.7 In conclusion, these clinical studies have demonstrated that many of the INSs have a positive effect on the ocular symptoms of AR. The positive effect appears to be a class effect of INSs, and not, as Kaiser et al1 imply, solely an attribute of fluticasone furoate. The results of the studies conducted with the other older INSs and the results of the study by Kaiser et al1 indicate that all of these agents may have a similar positive effect on the ocular symptoms of AR. Leonard Bielory, MD From the Departments of Medicine, Pediatrics, Ophthalmology, and Visual Sciences, Division of Allergy, Immunology and Rheumatology, New Jersey Medical School, Newark, NJ. E-mail: [email protected]. Disclosure of potential conflict of interest: L. Bielory has consulting arrangements with Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis, Genentech, UCB Pharma, MedPointe, Inspire, and Vistakon and has received grant support from Pfizer, Forest, Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis,
J ALLERGY CLIN IMMUNOL VOLUME 121, NUMBER 2
Genentech, UCB Pharma, Alcon, MedPointe, Ciba-Vision (Novartis), Inspire, Lev Pharmaceuticals, Abbott, Vistakon, and Dyax. Editor’s note: There is no accompanying reply to this correspondence. REFERENCES 1. Kaiser HB, Naclerio RM, Given J, Toler TN, Ellsworth A, Philpot EE. Fluticasone furoate nasal spray: a single treatment option for the symptoms of seasonal allergic rhinitis. J Allergy Clin Immunol 2007;119:1430-7. 2. Bernstein DI, Levy AL, Hampel FC, Baidoo CA, Cook CK, Philpot EE, Rickard KA. Treatment with intranasal fluticasone propionate significantly improves ocular symptoms in patients with seasonal allergic rhinitis. Clin Exp Allergy 2004;34: 952-7. 3. Schenkel E, LaForce C, Gates D. Mometasone furoate nasal spray in seasonal allergic rhinitis: effective in relieving ocular symptoms. Allergy Clin Immunol Int 2007; 19:50-3.
CORRESPONDENCE 539
4. Bielory L. Ocular symptom reduction in patients with seasonal rhinitis treated with the intranasal corticosteroid mometasone fuorate. Ann Allergy Asthma Immunol 2008. In press. 5. Moller C, Ahlstrom H, Henricson KA, Malmqvist LA, Akerlund A, Hildebrand H. Safety of nasal budesonide in the long-term treatment of children with perennial rhinitis. Clin Exp Allergy 2003;33:816-22. 6. Condemi J, Schulz R, Lim J. Triamcinolone acetonide aqueous nasal spray versus loratadine in seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2000;84: 533-8. 7. Giger R, Pasche P, Cheseaux C, Cantini L, Rossetti A, Landis BN, Lacroix JS. Comparison of once- versus twice-daily use of beclomethasone dipropionate aqueous nasal spray in the treatment of allergic and non-allergic chronic rhinosinusitis. Eur Arch Otorhinolaryngol 2003;260:135-40. Available online January 3, 2008. doi:10.1016/j.jaci.2007.10.013
J ALLERGY CLIN IMMUNOL FEBRUARY 2008
pollen was a risk factor for an asthma epidemic during the thunderstorm in Naples, with a close temporal association between the arrival of the thunderstorm, a major increase in the concentration of Parietaria species pollen grains, and the onset of the epidemic. We completely agree with Marks and Bush2 about the ‘‘4 necessary conditions’’ for asthma epidemics, but more than fungal spores and grass pollen have to be taken into consideration. The same mechanisms might involve other pollen grains in different geographic areas, depending on the seasonality of thunderstorms and allergenic pollen. Gennaro D’Amato, MDa Lorenzo Cecchi, MDb Gennaro Liccardi, MDa From athe Division of Respiratory and Allergic Diseases, Department of Respiratory Diseases, High Specialty Hospital A. Cardarelli, Naples, Italy, and bthe Interdepartmental Centre of Bioclimatology, University of Florence, Florence, Italy. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest. REFERENCES 1. Pulimood TB, Corden JM, Bryden C, Sharples L, Nasser SM. Epidemic asthma and the role of the fungal mold Alternaria alternata. J Allergy Clin Immunol 2007;120: 610-7. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. 3. D’Amato G, Liccardi G, Viegi G, Baldacci S. Thunderstorm-associated asthma in pollinosis patients. Available at: http://bmj.bmjjournals.com/cgi/eletters/309/6947/131/c. Accessed December 7, 2007. 4. D’Amato G, Liccardi G, Frenguelli G. Thunderstorm-associated asthma in pollinosis patients. Allergy 2007;62:11-6. 5. D’Amato G, Ruffilli A, Ortolani C. Allergenic significance of Parietaria (pellitoryof-the-wall) pollen. In: D’Amato G, Spieksma F, Bonini S, editors. Allergenic pollen and pollinosis in Europe. Oxford: Blackwell Scientific Publications; 1991. p. 113-8. 6. D’Amato G, Cecchi L, Bonini S, Nunes C, Annesi-Maesano I, Behrendt H, et al. Allergenic pollen and pollen allergy in Europe. Allergy 2007;62:976-90. Available online January 3, 2008. doi:10.1016/j.jaci.2007.10.046
Reply To the Editor: We thank D’Amato et al1 for drawing our attention to a thunderstorm-related asthma outbreak that was associated with another pollen, in this case the weed pollen Parietaria species. We agree that the 4 conditions we outlined in our editorial2 need not only apply to grass pollens, although most previous reports do appear to have been linked to this form of pollen. However, any pollen grains, grass, weed, or tree, that are abundant and can rupture and release respirable allergenic starch granules would be expected to behave in a similar way in the presence of a thunderstorm outflow. Guy B. Marks, MBBS, PhDa Robert K. Bush, MDb From athe Woolcock Institute of Medical Research, Sydney, New South Wales, Australia, and bthe William S. Middleton VA Hospital, Madison, Wis. E-mail: G.Marks@unsw. edu.au. Disclosure of potential conflict of interest: R. K. Bush has consulting arrangements with Greer Laboratories and has received grant support from the National Institutes of Health. G. B. Marks has declared that he has no conflict of interest. REFERENCES 1. D’Amato G, Cecchi L, Liccardi G. Thunderstorm-related asthma: not only grass pollen and spores. J Allergy Clin Immunol 2008;121:537-8. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. Available online January 21, 2008. doi:10.1016/j.jaci.2007.10.047
Intranasal corticosteroids reduce ocular symptoms of allergic rhinitis as a class effect To the Editor: In their study of fluticasone furoate nasal spray, Kaiser et al1 make an important but possibly underappreciated contribution to the growing amount of evidence demonstrating that intranasal corticosteroids (INSs), as a class, reduce the ocular symptoms associated with allergic rhinitis (AR). Unfortunately, the authors concluded that ‘‘older INSs failed to show consistent efficacy for ocular symptoms in adult subjects with SAR’’ (seasonal allergic rhinitis), and characterized fluticasone propionate (FP) and mometasone furoate (MF) nasal sprays as ‘‘older’’ INSs. However, the literature supports the positive effect on ocular allergy symptoms of older INS agents as a class effect. One possible reason that older studies may not have consistently shown a positive effect for ocular symptoms is that those studies did not focus on the ocular domain of allergy symptoms, but combined all symptoms into a single component of the total nonnasal symptom score. However, studies published over the past 5 years with FP, MF, budesonide, triamcinolone acetonide, and beclomethasone dipropionate have collected and reported ocular allergy signs and symptoms separately. In the article by Bernstein et al2 cited by Kaiser et al,1 a 28-day study comparing FP, oral loratadine, and placebo found that subjects treated with FP had statistically significant decreases compared with placebo in the total ocular symptom score, which was the sum of scores for the symptoms of itching (pruritus), tearing (epiphora), and redness (erythema). The data also suggested that FP had reduced ocular symptoms more than or comparable to oral loratadine. The positive effect of MF on ocular allergy symptoms was seen in an analysis of pooled data from 4 randomized blind studies. Subjects who received MF had significantly greater reductions in total ocular symptom score and the component symptoms of itching, tearing, and redness than those who received placebo over the entire 2-week course of the study, which was similar to the study by Kaiser et al.3,4 Mometasone furoate had an onset of effect starting at 24 hours of initiation of treatment.4 Ocular symptom scores also decreased significantly in pediatric patients with perennial AR after 1 year of treatment with budesonide,5 adolescents and adults with seasonal allergic rhinitis who received triamcinolone acetonide,6 and patients with chronic rhinosinusitis with and without allergy given beclomethasone dipropionate, which significantly improved ocular tearing, itching, and redness as well as blepharedema.7 In conclusion, these clinical studies have demonstrated that many of the INSs have a positive effect on the ocular symptoms of AR. The positive effect appears to be a class effect of INSs, and not, as Kaiser et al1 imply, solely an attribute of fluticasone furoate. The results of the studies conducted with the other older INSs and the results of the study by Kaiser et al1 indicate that all of these agents may have a similar positive effect on the ocular symptoms of AR. Leonard Bielory, MD From the Departments of Medicine, Pediatrics, Ophthalmology, and Visual Sciences, Division of Allergy, Immunology and Rheumatology, New Jersey Medical School, Newark, NJ. E-mail: [email protected]. Disclosure of potential conflict of interest: L. Bielory has consulting arrangements with Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis, Genentech, UCB Pharma, MedPointe, Inspire, and Vistakon and has received grant support from Pfizer, Forest, Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis,
J ALLERGY CLIN IMMUNOL VOLUME 121, NUMBER 2
Genentech, UCB Pharma, Alcon, MedPointe, Ciba-Vision (Novartis), Inspire, Lev Pharmaceuticals, Abbott, Vistakon, and Dyax. Editor’s note: There is no accompanying reply to this correspondence. REFERENCES 1. Kaiser HB, Naclerio RM, Given J, Toler TN, Ellsworth A, Philpot EE. Fluticasone furoate nasal spray: a single treatment option for the symptoms of seasonal allergic rhinitis. J Allergy Clin Immunol 2007;119:1430-7. 2. Bernstein DI, Levy AL, Hampel FC, Baidoo CA, Cook CK, Philpot EE, Rickard KA. Treatment with intranasal fluticasone propionate significantly improves ocular symptoms in patients with seasonal allergic rhinitis. Clin Exp Allergy 2004;34: 952-7. 3. Schenkel E, LaForce C, Gates D. Mometasone furoate nasal spray in seasonal allergic rhinitis: effective in relieving ocular symptoms. Allergy Clin Immunol Int 2007; 19:50-3.
CORRESPONDENCE 539
4. Bielory L. Ocular symptom reduction in patients with seasonal rhinitis treated with the intranasal corticosteroid mometasone fuorate. Ann Allergy Asthma Immunol 2008. In press. 5. Moller C, Ahlstrom H, Henricson KA, Malmqvist LA, Akerlund A, Hildebrand H. Safety of nasal budesonide in the long-term treatment of children with perennial rhinitis. Clin Exp Allergy 2003;33:816-22. 6. Condemi J, Schulz R, Lim J. Triamcinolone acetonide aqueous nasal spray versus loratadine in seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2000;84: 533-8. 7. Giger R, Pasche P, Cheseaux C, Cantini L, Rossetti A, Landis BN, Lacroix JS. Comparison of once- versus twice-daily use of beclomethasone dipropionate aqueous nasal spray in the treatment of allergic and non-allergic chronic rhinosinusitis. Eur Arch Otorhinolaryngol 2003;260:135-40. Available online January 3, 2008. doi:10.1016/j.jaci.2007.10.013