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PURPOSE: The purpose of this manuscript is to review the recent literature on exercise-induced asthma (EIA) and summarize the pathogenesis, diagnosis, and treatment of this condition. METHOD: A review of the English language medical literature was performed to obtain articles on EIA. RESULTS: The pathophysiology of EIA is not fully understood, but there are two theories: 1) the hyperosmolar theory and 2) the airway rewarming theory. In addition, there have been data to show that airway inflammation is present in some elite athletes, especially in cold weather sports. The diagnosis of EIA is usually straightforward in most patients, but a number of patients may have atypical symptoms and may be more difficult to diagnose. They may well need exercise testing or eucapnic voluntary ventilation testing. Most people respond to treatment with an inhaled beta agonist and or cromolyn before exercise, but some patients will also need other medications, including daily medications such as inhaled steroids. When treatment does not control the problem, then further diagnostic evaluation should be done to rule out conditions other than EIA, such as vocal cord dysfunction or cardiac or pulmonary problems. CONCLUSIONS: EIA is a condition that may occur in schoolchildren in gym class and also in Olympic athletes. The diagnosis and treatment is usually fairly straightforward, but at times it may be challenging. However, all patients should be followed to make sure that the correct diagnosis is made and to make sure that treatment is effective. [ABSTRACT FROM AUTHOR]

Exercise-induced asthma (EIA) can be easily overlooked and underdiagnosed, especially in school children or recreational athletes. It affects individuals of all levels of activity, from recreational sports to competition. This article summarizes the results of the Olympic Exercise Asthma Summit Conference, organized by the Sports Medicine Division of the US Olympic Committee. Making the correct diagnosis of EIA is very important and usually requires some form of pulmonary function testing. Because effective pharmacologic and nonpharmacologic treatment is available for this condition, patients should be followed until the condition is controlled. [ABSTRACT FROM AUTHOR]

Background: Despite the available treatments, asthma remains a serious illness, with a considerable socioeconomic burden associated with a high number of unscheduled visits to the emergency department (ED). Poor adherence and inadequate inhaler technique are contributing factors to poor asthma management and control., Objective: The Asthma Inhaler Design Survey assessed the behaviors, attitudes, needs, and preferences of patients with asthma and their caregivers with regard to quick-relief inhaler usage and device design., Methods: The Asthma and Allergy Foundation of America invited 19,157 adult patients and parents of children with asthma to take part in an online survey that focused on previous asthma diagnosis, symptom severity, and quick-relief and controller medication use. Opinions were also collected., Results: Data from 590 respondents (366 adults; 224 children) were included in the final analysis. Relief inhalers were needed and found to be past the expiration date by 284 of 561 (50.6%) and relief inhalers were found to be empty by 270 of 560 (48.2%). Of the empty inhaler group, 28 of 270 (10.4%) had to visit the ED for treatment, 18 of 270 (6.7%) missed work or school for an unscheduled physician office visit, and 54 of 270 (20%) went without treatment. Although 78.5% indicated that they had at least two quick-relief inhalers nearby, these were not always easily accessible. Few respondents (194/578 [33.6%]) indicated that they and/or their child were very confident that they were using their inhaler properly, even though the majority had received some instruction. When asked what they would do to improve satisfaction with their quick-relief inhalers, 173 of 558 (31%) responded that they would add a dose counter., Conclusion: Unnecessary health care utilization and avoidable loss of time at work or school were associated with the lack of full availability of properly functioning quick-relief inhalers when needed. Adding a dose counter was the most frequently cited response for improving satisfaction with quick-relief inhalers. Confidence about proper inhaler use was low, despite previous instruction.

Allergic rhinitis (AR) affects at least 60 million people in the United States each year, resulting in a major impact on patient quality of life, productivity, and direct and indirect costs. As new therapies, data, and literature emerge in the management of AR, there is a need to communicate and disseminate important information to health care professionals to advance the practice of medicine and lessen the disease burden from AR. Treatment recommendations for AR have not been updated since the 2012 Food and Drug Administration approval of nonaqueous intranasal aerosol agents using hydrofluoroalkane propellants and the first aqueous intranasal combination product. Here, we present an updated algorithm for the pharmacologic treatment of AR that includes these new treatment options. Treatment recommendations are categorized by disease severity (mild versus moderate/severe) and duration of symptoms (episodic versus nonepisodic, with episodic defined as <3 days/wk or for <3 weeks). Preferred treatments are suggested, as well as alternative options for consideration by clinicians in the context of individual patient needs. This recommendation article also outlines the importance of treatment monitoring, which can be conducted using the recently developed Rhinitis Control Assessment Test. Successful therapeutic outcomes depend on multiple factors, including use of the most effective pharmacologic agents as well as patient adherence to therapy. Therefore, it is imperative that rhinitis patients not only receive the most effective therapeutic options, but that they also understand and are able to adhere to the comprehensive treatment regimen. Successful treatment, with all of these considerations in mind, results in better disease outcomes, improved quality of life for patients, and greater economic productivity in the home and workplace.

This article summarizes the findings of an expert panel of nationally recognized allergists and pulmonologists who met to discuss how to improve detection and diagnosis of exercise-induced bronchoconstriction (EIB), a transient airway narrowing that occurs during and most often after exercise in people with and without underlying asthma. EIB is both commonly underdiagnosed and overdiagnosed. EIB underdiagnosis may result in habitual avoidance of sports and physical activity, chronic deconditioning, weight gain, poor asthma control, low self-esteem, and reduced quality of life. Routine use of a reliable and valid self-administered EIB screening questionnaire by professionals best positioned to screen large numbers of people could substantially improve the detection of EIB. The authors conducted a systematic review of the literature that evaluated the accuracy of EIB screening questionnaires that might be adopted for widespread EIB screening in the general population. Results of this review indicated that no existing EIB screening questionnaire had adequate sensitivity and specificity for this purpose. The authors present a call to action to develop a new EIB screening questionnaire, and discuss the rigorous qualitative and quantitative research necessary to develop and validate such an instrument, including key methodological pitfalls that must be avoided., (Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Intranasal corticosteroids (INSs) have been effectively used for >40 years for the treatment of seasonal allergic rhinitis (SAR) and perennial AR (PAR). Following the Montreal Protocol, the initial aerosol formulations using chlorofluorocarbon (CFC) propellants were phased out. For the past 20 years, aqueous solutions have been the only available option for INS treatment. In 2012, the U.S. Food and Drug Administration approved two new nonaqueous aerosol AR treatments that use a hydrofluoroalkane (HFA) propellant. In 2012, the first intranasal aqueous combination product was also approved. This article reviews the clinical profiles of HFA beclomethasone dipropionate (BDP) and HFA ciclesonide (CIC) and the aqueous combination intranasal antihistamine (INA)/INS formulation of azelastine hydrochloride/fluticasone propionate (AZE/FP). The medical literature was searched for clinical trials investigating the use of BDP, CIC, and AZE/FP in SAR and PAR. Clinical trials involving aqueous solutions and CFC propellant or HFA propellant delivery were included. Data from prescribing information and published efficacy and safety data were presented as part of the clinical profile for the reviewed agents. AZE/FP has shown efficacy and safety comparable or greater with the current AR treatment options. Although efficacy comparisons of new HFA formulations have not been investigated in head-to-head clinical trials with aqueous formulations, HFA formulations have shown similar efficacy rates. Furthermore, HFA formulations may have some additional benefits, including a preferable sensory profile for some patients. These new formulations will provide additional options for clinicians and patients to better individualize therapy for control of AR.

Background: Aerosolized intranasal corticosteroid formulations are desirable for many patients with allergic rhinitis (AR), especially children, who wish to avoid the "wet feeling" and "drip down the throat" associated with aqueous formulations. Beclomethasone dipropionate (BDP) hydrofluoroalkane nasal aerosol has been shown to be safe and effective in adolescents and adults with AR., Objective: To evaluate the efficacy and safety of BDP nasal aerosol in pediatric patients with moderate to severe seasonal AR., Methods: In this double-blinded, placebo-controlled study, children (6-11 years of age) with seasonal AR were randomized to once-daily treatment with BDP nasal aerosol 80 μg (n = 239) or 160 μg (n = 242) or placebo (n = 234). The primary end point was change from baseline in average morning and evening reflective total nasal symptom score over the 2-week treatment period., Results: Treatment with BDP nasal aerosol showed significantly greater improvements in average morning and evening reflective total nasal symptom score vs placebo (80 μg, -0.71; 160 μg, -0.76; P < .001 for the 2 comparisons). Similarly, significantly greater improvements in average morning and evening instantaneous total nasal symptom score were seen with BDP nasal aerosol vs placebo (80 μg, -0.63; 160 μg, -0.73; P < .001 for the 2 comparisons). The incidence of adverse events from BDP nasal aerosol was comparable to that from placebo., Conclusion: BDP nasal aerosol (80 or 160 μg/d) provided significant and clinically meaningful nasal symptom relief and an established overall safety profile similar to that of placebo, suggesting that it is an effective and well-tolerated treatment option for pediatric patients with moderate to severe seasonal AR., Trial Registration: clinicaltrials.gov Identifier: NCT012073190., (Copyright © 2013 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Exercise-induced bronchoconstriction (EIB) describes acute airway narrowing that occurs as a result of exercise. EIB occurs in a substantial proportion of patients with asthma, but may also occur in individuals without known asthma., Methods: To provide clinicians with practical guidance, a multidisciplinary panel of stakeholders was convened to review the pathogenesis of EIB and to develop evidence-based guidelines for the diagnosis and treatment of EIB. The evidence was appraised and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach., Results: Recommendations for the treatment of EIB were developed. The quality of evidence supporting the recommendations was variable, ranging from low to high. A strong recommendation was made for using a short-acting β(2)-agonist before exercise in all patients with EIB. For patients who continue to have symptoms of EIB despite the administration of a short-acting β(2)-agonist before exercise, strong recommendations were made for a daily inhaled corticosteroid, a daily leukotriene receptor antagonist, or a mast cell stabilizing agent before exercise., Conclusions: The recommendations in this Guideline reflect the currently available evidence. New clinical research data will necessitate a revision and update in the future.

Exercise-induced bronchospasm (EIB) is a relatively common condition that affects both recreational and elite athletes. The latest data suggest that it is an inflammatory process, especially in elite athletes. Proper diagnosis is important to differentiate EIB from other respiratory conditions. Effective treatment usually controls this condition.

The Joint Task Force for the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology was charged with formulating a position paper regarding the potential release of intranasal corticosteroids for over-the-counter use. We took the position that safety issues regarding this proposal would be our sole concern. We reviewed the literature to evaluate the frequency and severity of potential adverse events related to the administration of intranasal corticosteroids. We limited this review to 5 areas: (1) effects on growth, (2) ocular effects, (3) effects on bone, (4) effects on the hypothalamic-pituitary-adrenal axis, and (5) local adverse effects. After review of the available data, we concluded that intranasal corticosteroids should remain prescription-only drugs. Patients receiving an intranasal corticosteroid should be instructed in its use and that use should be monitored by a physician or an appropriately trained medical provider (eg, nurse practitioner or physician assistant) under the direct supervision of a physician. This conclusion was reached based on the evidence that corticosteroids administered by any route, including the intranasal route, have the potential to cause adverse effects in all the areas noted herein. Our conclusion was strengthened by the fact that these adverse effects can be insidious and therefore not evident for many years; there is the potential for overuse; patients could also have access to other forms of topically administered corticosteroids, thus increasing their total dose; and individuals vary in their susceptibility to corticosteroid-induced adverse effects. We were also influenced to take this position knowing that generally reassuring data regarding the use of respiratory tract-administered corticosteroids are based on mean data and that all such studies have shown outliers in whom adverse effects were evident. Thus, as stated, we recommend that intranasal corticosteroids remain prescription-only drugs.

Exercise is a potent stimulus to asthma. The diagnosis is not always straightforward, and health care providers should have a high index of suspicion. Treatment usually controls exercise-induced asthma but usually requires therapy tailored for each individual patient.

Allergic rhinitis is associated with sleep disturbances, daytime somnolence, and fatigue. The exact relationship between rhinitis and sleep disturbance is unknown; however, both the symptoms and underlying pathology of allergic rhinitis can interfere with sleep quality. Nasal congestion, which has been shown to cause sleep-disordered breathing, is thought to be primarily responsible for rhinitis-related sleep disorders. The severity of nasal congestion follows a circadian rhythm, being worst at night and in the early morning. Chronotherapy is the study of the effects of administration time on the safety and efficacy of drug therapy based on circadian influences on the pharmacokinetics and pharmacodynamics of medications. Chronotherapy studies in allergic rhinitis suggest there are benefits to nighttime dosing of antiallergy medications. For example, the antihistamine mequitazine has shown improved efficacy when administered in the evening compared with morning dosing. More study is needed to determine whether this is a class effect. Leukotriene receptor antagonists are indicated for evening administration; these drugs significantly improve nighttime rhinitis symptoms. Intranasal corticosteroids administered in the morning have demonstrated efficacy in improving nighttime symptoms; however, it is unknown whether evening administration would improve their effects on nocturnal rhinitis symptoms. Because of the significant detrimental effects of nocturnal rhinitis symptoms on quality of life, allergic rhinitis therapies should be evaluated for efficacy in ameliorating nighttime symptoms.

Objective: To provide a review of the current status of the treatment of asthma and introduce new and developing forms of therapy by means of a review of published literature on asthma and publications on new and emerging therapies. Increased public awareness of asthma, improved patient and provider education, implementation of national treatment guidelines, and availability of safe and effective therapies have combined to provide an effective response to the increase in asthma prevalence. However, the number of persons with poorly controlled asthma and asthma-related complications remains unacceptably high. This is particularly true for the relatively small cohort of patients with moderateto- severe asthma that is poorly controlled with inhaled corticosteroids and other standard-of-care medications. Consequently, these patients often experience frequent exacerbations, leading to a disproportionate consumption of asthma health care resources and a poor quality of life. The National Committee on Quality Assurance suggests that the negative impact of asthma can be minimized if health care providers implement aggressive asthma management programs that include patient education and appropriate medications. Newer therapies such as injectable anti-IgE may provide a benefit for many patients., Summary: Currently available asthma medications have been proven to be generally safe and effective for most asthma patients. However, the subset of patients with difficult-to-treat asthma who experience frequent exacerbations requiring emergency department visits or hospitalizations may benefit from novel therapies designed to target specific mechanisms underlying airway inflammation., Conclusions: New therapies may help in the treatment of patients whose asthma is not controlled. These include anti-immunoglobulin E (IgE) antibodies, cytokine modulators, and DNA vaccinations. Future research will determine if these targeted biologic therapies are a cost-effective means to improve the clinical and economic outcomes of asthma management.

Objective: To review the emerging concept of minimal persistent inflammation in allergic rhinitis and its implications for therapy., Data Sources: Relevant clinical studies in the English language were reviewed., Study Selection: Material was taken from academic/scholarly journals., Results: Accumulating evidence suggests that allergic rhinitis is a chronic inflammatory disease instead of a disease of acute symptoms. An approach to the therapy for allergic rhinitis should consider that even when symptoms are absent, a minimal level of persistent inflammation may persist. To prevent unexpected exacerbations, the treatment strategy may need to include managing subclinical persistent inflammation. Therapeutic options addressing the major inflammatory elements in allergic rhinitis, including eosinophils, the cysteinyl leukotrienes, and histamine, must be evaluated as management strategies that can achieve effective control. Traditional medications include intranasal corticosteroids, antihistamines, and immunotherapy. Recently, a leukotriene receptor antagonist has been approved for major rhinitis symptoms (congestion, rhinorrhea, sneezing, and pruritus), suggesting a new option for the treatment of allergic rhinitis., Conclusions: Because of the possible presence of a minimal persistent inflammation during rhinitis patients' asymptomatic periods, it is important to consider a prophylactic approach to treating allergic rhinitis to prevent or reduce exacerbations during an acute increase in allergen. In light of the advances in the understanding of the pathogenesis of allergic rhinitis, agents must be considered based on their safety, efficacy, and ability to deal with underlying inflammation as well as symptom relief.

Objective: This article reviews the recommendations by the World Health Organization's new guidelines, "Allergic Rhinitis and Its Impact on Asthma" (ARIA), and the paradigm for treating allergic rhinitis based on disease classification. After reading this article, readers should understand the ARIA guidelines and the salient issues involving the challenges inherent in the management of allergic rhinitis., Data Sources: Relevant and appropriately controlled clinical studies and results of patient surveys were used. Only literature in the English language was reviewed., Study Selection: Material was taken from academic/scholarly journals, published abstracts, and presentations at a major congress., Results: The ARIA guidelines' new classification categorizes patients' allergic rhinitis as either intermittent or persistent with gradations from mild to moderate-severe. These guidelines propose a stepwise approach to management guided by symptom severity and evaluation of treatment response, with the underlying concept for treatment being to select therapies that address individual patients' symptoms. Although few data were available at the time of their inception, the guidelines recognize that antileukotriene medications may play an important role in the treatment of allergic rhinitis. Results of recent clinical trials support the use of antileukotriene medications in allergic rhinitis, alone or concomitantly with an antihistamine., Conclusions: Targeting specific and multiple mechanisms of allergic rhinitis and individualizing all available and effective treatments to each patient, with specific medications for specific symptoms, will be of particular benefit to patients with allergic rhinitis.

Objective: Intranasal beclomethasone dipropionate (BDP) has generally been considered to have no systemic activity at recommended doses, but the potential for long-term effects on growth has not previously been evaluated. This study was undertaken to assess the effects of 1 year of treatment with intranasal BDP on growth in children., Study Design: In this double-blind, randomized, parallel-group study, 100 prepubertal children 6 to 9 years old with perennial allergic rhinitis were treated with aqueous BDP 168 microg twice daily (n = 51) or placebo (n = 49) for 1 year. Subjects' baseline heights were required to be between the 5th and 95th percentile, and skeletal age as determined by left wrist radiograph was required to be within 2 years of chronological age. Washout periods for medications known to affect growth, including other forms of corticosteroids, were established, and these medications were prohibited during the study. However, short courses of oral prednisolone lasting no more than 7 days, and short courses of dermatologic corticosteroids lasting no more than 10 days, were allowed. Height was measured with a stadiometer after 1, 2, 4, 6, 8, 10, and 12 months of treatment. The hypothalamic-pituitary-adrenocortical axis was assessed by measurements of 8 AM basal cortisol concentrations and response to. 25 mg cosyntropin stimulation. The primary safety parameter was the rate of change in standing height. Statistical analyses were based on all randomized subjects who received at least 1 dose of medication (intent-to-treat principle). The rate of change in standing height was analyzed for all subjects who entered the study and for those completing the full 12 months of treatment (n = 80). The rate of change in standing height over the 1-year study was calculated as the slope of a linear regression line fitted to each subject's height measurements over time. Because there was a statistically significant between-group difference in standing height at baseline, an analysis of covariance was performed for all analyses of standing height data., Results: Of the 100 subjects enrolled, 90 completed the study. The 2 treatment groups were generally comparable at baseline; however, at baseline, mean age and mean height were significantly greater in the BDP treatment group that the in placebo treatment group. In both analyses, overall growth rate was significantly slower in BDP-treated subjects than placebo-treated subjects. The mean change in standing height after 1 year was 5.0 cm in the BDP-treated subjects compared with 5.9 cm in the placebo-treated subjects. The difference in growth rates was evident as early as the 1-month treatment visit, suggesting that the effect on growth occurred initially. The growth-suppressive effect of BDP remained consistent across all age and gender subgroups, and among subjects with and without a previous history of corticosteroid use. Use of additional exogenous corticosteroids during the study was similar in both groups and did not affect the results. Because there was a baseline imbalance in height, a supplemental analysis of the differences in prestudy growth rates was performed. This analysis found no baseline imbalance in prestudy growth rates. To determine whether the difference in growth rates during the study could be attributed to preexisting growth rates, a z score analysis was performed. The heights of both groups were normalized at baseline and at the end of the study using the US National Center for Health Statistics data for mean and standard deviations of height. This analysis confirmed that the difference in growth rates between the 2 groups was primarily attributable to the treatment rather than to any preexisting difference in growth. Additional analyses confirmed that the results were not influenced by outlier values. No significant between-group difference were found in the hypothalamic-pituitary-adrenocortical axis assessments. No unusual adverse events were observed. (ABSTRACT

Background: Optimal management of chronic, mild-to-moderate asthma with inhaled steroids may include use of the lowest possible doses, as recommended in guidelines, and a reduction in the frequency of daily administration for greater convenience. Lower doses and once daily treatment with inhaled steroids must be rigorously evaluated in controlled clinical trials., Objectives: The objective of this study was to assess the efficacy and safety of once daily treatment with budesonide in subjects with stable asthma., Methods: Once daily budesonide was assessed in 309 adult subjects, including those who were and were not using an inhaled steroid at baseline. The subjects were stratified by inhaled steroid use and randomly assigned to one of 3 treatments: 200 microgram budesonide, 400 microgram budesonide, or placebo administered by means of Turbuhaler once daily in the morning for 6 weeks. Beyond this point, treatment was continued unchanged for another 12 weeks (maintenance) in those receiving 200 microgram budesonide once daily and placebo. In those who received 400 microgram budesonide once daily, the dose was reduced to 200 microgram once daily at week 6 and held constant for the remaining 12 weeks (400/200 microgram group). Primary efficacy endpoints were mean change from baseline in FEV1 and morning peak expiratory flow., Results: Once daily budesonide was well tolerated and resulted in significant improvements in all efficacy endpoints, even though baselines were well stabilized. Baseline lung function was elevated with little room for improvement; however, mean increases in FEV1 during the maintenance period were 0.10 L and 0.11 L in the 200 microgram and 400/200 microgram groups, respectively, versus a decrease of -0.09 L in the placebo arm (P <.001). Results for peak expiratory flow were similar. Significant improvements in secondary endpoints, including symptoms, beta-agonist use, and quality of life, also developed with budesonide 200 and 400 microgram once daily., Conclusion: Inhaled budesonide, in doses as low as 200 microgram, may be an appropriate introductory or maintenance dose in subjects with stable, mild-to-moderate asthma.

Exercise-induced asthma: diagnosis and treatment for the recreational or elite athlete. Med. Sci. Sports Exerc., Vol. 31, No. 1 (Suppl.), pp. S33-S38, 1999. Exercise-induced asthma (EIA) is found in 10-50% of recreational and elite athletes, depending on the population studied. The diagnosis may be made with symptoms (cough, wheeze, chest tightness, etc. with exercise) and with pulmonary function measurements (spirometry or peak flow measurements) before and after exercise. Most patients respond well to pre-exercise treatment with an inhaled quick-acting beta agonist. Some patients require additional therapy such as pre-exercise inhaled cromolyn, daily inhaled steroids, salmeterol, theophylline, leukotriene modifiers, or other agents. An occasional patient presents with the symptoms of EIA but responds poorly to treatment. Further investigation may lead to a totally different diagnosis such as vocal cord dysfunction. For most athletes with EIA, proper diagnosis and treatment will allow them to complete at any level.

Background: Inhaled corticosteroids are recognized as the mainstay of prophylactic anti-inflammatory therapy in patients with persistent asthma. In large multiclinic trials, the clinical adverse event profiles have been not significantly different than patients treated with placebo or other medications; however, in small studies evaluating very sensitive in vitro measurements of the hypothalamic pituitary adrenal axis there have been adverse laboratory events noted with moderate and high doses of inhaled steroids., Objective: To survey asthma specialists in North America with regard to their personal clinical experience of adverse events with the use of inhaled corticosteroids., Methods: Two hundred thirteen physicians specializing in the treatment of asthma responded to questionnaires asking their experiences with specific adverse clinical events that have the potential to occur after the use of inhaled corticosteroids (see appendix A for questionnaire)., Results: There was a 67% response rate for the questionnaire. Eighty percent of the respondents were allergists/immunologists and 20% were pulmonologists. The average length of time they had been in practice was 16 years. In general, side effects from inhaled steroids were seen very infrequently in the hands of these physicians in spite of the fact that they were primarily secondary or tertiary referral physicians for the treatment of asthma. The local oropharyngeal adverse events were seen 48% of the time on an occasional basis but only 3% of the time on a frequent basis. When spacers were used the oropharyngeal symptoms were reduced significantly. Skin changes such as bruising or thin skin were seen frequently 6% of the time and occasionally 24% of the time only. In general, these skin changes were found in elderly or middle-aged individuals. Weight gain was very unusually seen, as were adverse effects on bone (osteoporosis, fractures, growth problems, etc.). Hypothalamic pituitary axis abnormalities were seen quite infrequently and primarily in patients who had also received oral corticosteroids., Conclusions: This study shows that inhaled corticosteroids are generally safe in the treatment of asthma and are rarely associated with systemic side effects, as detected in routine clinical practice.

Objective: To determine the ability of budesonide via an inhaler (Pulmicort Turbuhaler; Astra Draco AB) to replace oral glucocorticosteroids (GCSs) in adult subjects with moderate-to-severe asthma., Design: Double-blind, randomized, and placebo-controlled study, with parallel groups., Setting: Multicenter study in outpatient setting., Participants: Eighty men and 79 women, aged 20 to 69 years, with moderate-to-severe asthma and a mean FEV1 of 58.3% predicted normal. All subjects were receiving oral GCS treatment and 79% of subjects were also receiving inhaled beclomethasone dipropionate (BDP). The mean daily doses of prednisone at baseline, including converted dose of BDP, for the placebo, budesonide 400 microg, and budesonide 800 microg, respectively, were 19.7 mg, 19.5 mg, and 18.7 mg., Measurements and Interventions: After a 2-week baseline period, subjects entered a 20-week treatment period, during which the oral dose of prednisone was reduced by forced down-titration at 2-weekly intervals., Results: Subjects receiving 400 microg or 800 microg bid of budesonide achieved a significantly greater reduction (82.9% and 79.0% respectively) in oral GCS dose compared with placebo-treated subjects (27%; p<0.001). Two thirds of the subjects receiving budesonide were able to achieve sustained oral corticosteroid cessation, compared with 8% in the placebo group. Additionally, both doses of budesonide resulted in significant improvement in results of pulmonary function tests and asthma symptoms scores, and a significant decrease in the use of bronchodilator therapy. The mean plasma cortisol levels before and after adrenocorticotropic hormone stimulation increased most toward the normal range in the budesonide-treated groups compared with placebo-treated subjects., Conclusion: Budesonide administered via Turbuhaler has a significant oral GCS-sparing capacity with maintained or improved asthma control in adult subjects with moderate-to-severe asthma.

Benefits: Fluticasone propionate (FP) is a new topical corticosteroid spray for the treatment of allergic rhinitis and asthma. FP has been shown to be effective for the treatment of adult and pediatric asthma, even at rather low doses (25 microg twice daily [b.i.d.]); many studies in asthma have shown clinical efficacy of fluticasone at half the dose of the comparison steroid (such as beclomethasone dipropionate [BDP] or budesonide [BUD]). However, exact dose comparisons cannot be made because dose-ranging comparison studies have not been done. Studies in allergic rhinitis in children and adults have shown good efficacy in FP-treated patients at a dose of 200 microg once daily (o.d.), intranasally. In summary, FP is effective in both asthma and allergic rhinitis., Risks: FP has minimal systemic activity because the portion of drug that is swallowed is not absorbed from the gut. Thus, the amount available for systemic activity is only that which is absorbed through the nasal mucosa (in the treatment of rhinitis) or through the alveoli of the lungs (in the treatment of asthma). When laboratory assays of adrenal function or bone formation are measured, FP and other inhaled corticosteroids can be shown to cause suppression of these markers, especially at high doses. There have been no consistent reports of clinical adrenal suppression or osteoporosis caused by FP. In summary, the risk-benefit ratio of FP at the usual doses (therapeutic ratio) is very favorable. High doses may show evidence of suppression of the hypothalamic pituitary axis as measured by in vitro tests, but evidence of corresponding clinical adverse effects is lacking.

Background: Salmeterol xinafoate is a new aerosol inhalant that is used in the treatment of asthma. It is currently banned by the International Olympic Committee because of the concern that it may lend an unfair competitive advantage to the user., Objective: The purpose of this study was to determine whether salmeterol improves short-term anaerobic performance in elite nonasthmatic track cyclists., Methods: Eleven elite track cyclists volunteered to perform a 30-second all-out cycle ergometer test 3 hours after receiving either 42 micrograms of salmeterol xinafoate or placebo applied in a double-blind crossover procedure. During the ergometer test, peak power output, total work, time to peak power, and percent fatigue (decline in power output) were measured. Pulmonary measurements were also taken before and at various time points after inhalation and the ergometer test. A methacholine challenge was administered to each subject before participation in the study to ensure that none of the subjects had any reactive airway diseases., Results: There were no significant differences (p > 0.05) between the placebo and salmeterol trials for peak power output, total work performed during the 30-second test, percent fatigue, and time to peak power. No differences between trials were observed for the pulmonary function test variables at any of the time points. Blood lactate concentrations before and after administration of drug or placebo were also not significantly different between trials. Additionally, salmeterol did not affect the maximal heart rate achieved during the test as compared with the placebo., Conclusions: Short-term salmeterol use within the prescribed dosage was not shown to increase short-term power output in nonasthmatic cyclists.

Antihistamines are the most commonly used drugs for allergic rhinitis, and many antihistamines may cause subclinical side effects which are not noticeable by the patient. These include impaired driving performance, impaired work performance, reduced coordination, reduced motor skills, sleepiness and impaired information processing (arithmetic, verbal, and office skills). The newer nonsedating antihistamines should be used for the treatment of allergic rhinitis because they do not produce these effects. Recent studies have shown that children's learning in school may also be negatively affected by traditional antihistamines, and therefore, school children should definitely be given the nonsedating antihistamines. Not only does the treatment cause some impaired performance, but allergic rhinitis itself may result in changes in the patient's mood affect, and other aspects of personality. Physicians who treat allergic rhinitis should be aware of the potential performance effects of medications that they prescribe and the potential effects of the disease itself on the patient's personality.

396 adult and adolescent patients with seasonal allergic rhinitis participated in this randomised double-blind parallel-group study in which the efficacy and tolerability of ebastine 10 or 20mg administered once daily in the morning or evening for 3 weeks were compared with those of placebo. Clinical efficacy was assessed by measuring improvement in rhinitis symptoms (nasal discharge, nasal stuffiness, sneezing, itchy nose and itchy/watery eyes) recorded by patients twice daily on diary cards. The improvement in individual and total symptom scores at the end of the 3-week treatment period in patients treated with ebastine 10mg in the morning or ebastine 20mg in the morning or evening was significantly greater than the improvement in placebo recipients. The 20mg dose of ebastine administered in the morning was associated with the greatest improvement in symptom scores. There was no significant effect with the 10mg evening dose compared with placebo. Ebastine was well tolerated by the majority of patients - the incidence of adverse events, including headache, dry mouth, somnolence and asthenia being similar to that reported in placebo recipients. Electrocardiograms showed no evidence of any clinically relevant changes in QTc intervals. In a subsequent nonblinded 4-month study that included 230 patients from the initial study, global evaluations at monthly intervals showed overall symptom improvement in > or = 72% of patients who received ebastine 10mg or 20mg once daily. The drug was well tolerated during prolonged therapy, with adverse events being similar in nature and incidence to those reported in the 3-week double-blind study. In conclusion, ebastine 10mg once daily in the morning is an appropriate starting dose for the treatment of rhinitis, and this can be increased to 20mg as required.

Nocturnal asthma is a major problem in many asthma patients and it is important to recognize and treat it. We previously reported the incidence of nocturnal asthma in our practice (1); the current study was done to try to improve upon the incidence of nocturnal asthma in our patients. After our previous survey, which indicated a 67% incidence of nocturnal asthma in our practice, we instituted a previsit questionnaire regarding nocturnal asthma to be filled out by all follow-up asthma patients in our office. After a period of time, we mailed a nocturnal asthma questionnaire to all asthma patients to see if the intervention had improved our incidence of nocturnal asthma. This questionnaire was identical to the one used in our prior study and was mailed to 2019 patients. We had 602 responders, 560 of whom had asthma. A total of 328 of these patients (59%) had nocturnal asthma. This was similar to the results of our previous survey, and our initial conclusion was that the new in-office questionnaire that we instituted had not improved the situation. Then we discovered that the in-office questionnaire had inadvertently been distributed only to the patients of one or our physicians (Dr. A). His patients were then compared with those of the other two doctors (Drs. B and C), and it was found that Dr. A's patients had fewer nocturnal symptoms than did the patients of the other doctors. The percent of asthmatics with nocturnal asthma 4-7 nights per week (more than half the nights in a week) for Dr. A was 16%, for Dr. B 47%, and for Dr. C 39%. The use of a short office questinnaire for asthma patients before they see the doctor for follow-up visits leads to greater recognition and better treatment of nocturnal asthma.

The purpose of this study was to evaluate the effect of the beta 2-agonist albuterol (salbutamol) at twice the normal dosage (360 micrograms) on power output during a 30-second Wingate test and pulmonary function in highly trained cyclists (4 category 1 and 10 category II U.S.C.F. track cyclists). The cyclists did not have a history of exercise induced bronchial spasms, and a 5 step methacholine challenge confirmed all subjects to be non-asthmatic. The project was performed in a random block, double blind design. Twenty minutes before the 30-second Wingate cycle ergometer exercise, albuterol (90 micrograms per dose) or a saline placebo was administered by inhaler in 4 metered doses. Pulmonary function tests were performed at rest, 20 minutes post-inhalation, and 5, 10, 15 minutes post-exercise. After a standard warm-up, a 30-second Wingate anaerobic power test was performed on a cycle ergometer at a resistance of 0.10 kg (kg body mass)-1. Multi-variate ANOVA revealed no significant difference between the albuterol and placebo treatment for the anaerobic power measures: peak power (1,136.7 +/- 40.9 vs 1,124.8 +/- 39.8 W, mean +/- s.e.), total work (27,213.6 +/- 653.1 vs 27,093.3 +/- 677.4j), time to peak power (4.5 +/- 0.2 vs 4.8 +/- 0.5 s), and fatigue index (16.5 +/- 1.8 vs 16.6 +/- 1.8 W.s-1). Peak heart rate (181.6 +/- 3.7 vs 181.4 +/- 3.8 bpm), or blood lactate (14.0 +/- 0.9 vs 13.8 +/- 0.8 mmol.l-1) 3 min after the exercise bout were not significantly different between treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies have been conducted in the USA comparing fluticasone propionate aqueous nasal spray 200 micrograms once daily with beclomethasone dipropionate aqueous nasal spray 168 micrograms twice daily, oral terfenadine 60 mg twice daily, or oral astemizole 10 mg once daily given for 2 or 4 weeks during tree, grass or ragweed pollen seasons. All six were multicentre, randomised, placebo-controlled, double-blind, parallel-group studies. Efficacy was evaluated by patient and clinician assessments of individual nasal symptoms and overall response to therapy. Fluticasone propionate was superior to beclomethasone dipropionate in one trial according to patient evaluations of symptoms, but response to fluticasone propionate and beclomethasone dipropionate was similar in the second study. Comparisons with antihistamines showed fluticasone propionate to have greater efficacy. It was more effective than terfenadine in both trials according to evaluations by clinicians and patients. Similar findings were observed in the first astemizole trial. The second astemizole study showed superiority of fluticasone propionate over astemizole in terms of patient and clinician evaluations of overall response to therapy and occasionally in terms of symptom evaluations. There were no significant adverse effects, including effects on plasma cortisol concentrations, noted in any of these comparator studies.

Azelastine is a novel antiallergy medication currently under investigation for the treatment of allergic rhinitis and asthma. Pharmacologic studies in laboratory animals and in vitro model systems indicate that azelastine exerts multiple actions including modulation of airways smooth muscle response, interference with inflammatory processes, and inhibition of allergic reactions. In a previous controlled clinical trial, azelastine nasal solution (ASTELIN N.S.) demonstrated effectiveness in controlling symptoms of seasonal allergic rhinitis (SAR). The objective of this 2-week double-blind, parallel-group study was to further assess the effectiveness of azelastine nasal solution in improving allergic rhinitis symptoms. Two hundred forty-seven patients (> or = 12 years) with symptomatic SAR who satisfied a minimum symptoms score during a 1-week, single-blind, baseline evaluation period were randomized to receive azelastine 2 sprays per nostril bid, azelastine 2 sprays per nostril qd, chlorpheniramine 12 mg bid, or placebo using a double-dummy technique to insure blinding. The primary efficacy variables were changes in Major Symptom Complex (nose blows, sneezes, runny nose/sniffles, itch nose, and watery eyes) and Total Symptom Complex (Major plus itchy eyes/ears/throat/palate, cough, and postnasal drip) severity scores. Patients treated with azelastine nasal solution qd and bid had mean percent improvements in the Total and Major Symptom Complex severity scores that were clinically significant (> or = 50% improvement over placebo) after both weeks, at endpoint, and overall. The improvements for the azelastine bid group were statistically significant (P < or = .05) at all evaluation points. Adverse experiences occurred infrequently, and none was considered serious or potentially limiting to the clinical utility of the nasal solution.(ABSTRACT TRUNCATED AT 250 WORDS)

A 1-year, open-label extension of a 12-week, double-blind clinical trial was conducted to evaluate the long-term safety and efficacy of once-daily therapy with triamcinolone acetonide nasal aerosol (110, 220, or 440 micrograms) in 93 patients with perennial allergic rhinitis. All three doses of triamcinolone acetonide were associated with sustained improvement in allergic rhinitis symptoms over the course of 1 year, as evidenced by physicians' and patients' global evaluations, ratings of the nasal environment (appearance and color of the nasal mucosa, as well as the quality of nasal secretions), nasal eosinophil counts, and requirement for escape medication. Among patients who reported adverse clinical experiences, most were considered unrelated or remotely related to therapy. Few patients experienced nasal irritation or throat discomfort, and no serious adverse experiences were attributed to treatment. Among 6 patients who withdrew from the study because of adverse experiences, a possible drug relationship was cited in 2 individuals (1 with headache and 1 with nasal blood) and a remote relationship in 1 (with acne). No clinically meaningful changes in vital signs, physical examinations, or laboratory values were noted, and mean serum cortisol levels were not suppressed during long-term treatment. These findings demonstrate that both safety and efficacy are maintained during long-term once-daily therapy with triamcinolone acetonide nasal aerosol in patients with perennial allergic rhinitis.

We evaluated the prevalence of nocturnal asthma in our subspecialty allergy clinic to see whether it was significantly different than the prevalence in a previous study (3). A questionnaire was sent to 1258 patients, and there were 325 responses. Of the 325, 304 patients had asthma. A total of 204 (67%) of these had nocturnal symptoms of asthma. Eleven percent of the total population awakened every night, 16% awakened three to six nights per week, 20% one or two nights per week, 20% one night per month, and 33% not at all. We discovered that patients had a rather nonchalant view of their asthma and frequently did not report nocturnal symptoms to their doctors. We conclude that even in a specialty allergy and asthma practice, nocturnal asthma symptoms may be more prevalent than suspected. The reason for this is unclear but may be related to a problem with patient perception and possibly to a lack of diligence in physician history taking.

The acute effects of inhaled albuterol, a selective beta-2 adrenergic agonist, on measures of endurance cycling performance and pulmonary function were assessed in 21 competitive road cyclists. A 5 step methacholine challenge revealed all cyclists to be non-asthmatic. Albuterol (A) total dose 360 micrograms or a saline placebo (P) was administered by inhaler, in 4 metered doses of 90 micrograms each, 15 minutes before cycle ergometry exercise. Heart rate, whole blood lactate, perceived exertion and VO2 were determined at the submaximal workloads of 150, 200, 225, 250, 275, 300 watts and at max. Pulmonary function tests determining forced vital capacity, forced expiratory volume during the first second of expiration, forced mid-expiratory flow and maximal voluntary ventilation were performed prior to and 10 minutes after inhalation; and 5, 10 and 15 minutes after termination of the exercise protocol. Heart rate was significantly greater during the A compared to the P treatment at 200 (150.8 +/- 2.5 vs 146.7 +/- 2.8 beats per minute), 225 (159.7 +/- 2.4 vs 154.6 +/- 2.7 beats per minute) and 250 watts (166.9 +/- 2.4 vs 164.4 +/- 2.6 beats per minute). Whole blood lactate was significantly greater during the A compared to the P treatment at 275 watts (4.7 +/- 0.3 vs 4.2 +/- 0.4 mmol.l-1). No other significant differences were found between the 2 treatments at any time point. These data indicate that the acute effect of albuterol inhalation at twice the recommended dosage has no positive effect on endurance performance measures or pulmonary function in athletes who are not asthmatic.