Combined mediator blockade or topical steroid for treating the unified allergic airway.
BACKGROUND
Asthma and allergic rhinitis are manifestations of a single unified allergic airway, for which the best treatment is uncertain.


OBJECTIVE
To compare the anti-inflammatory efficacy in the unified allergic airway of combined oral mediator antagonism and combined topical steroid.


METHODS
Subjects with asthma and perennial allergic rhinitis entered a randomized double blind crossover study comparing montelukast 10 mg and cetirizine 10 mg to extra-fine inhaled beclomethasone 400 mcg/day and intranasal beclomethasone 200 mcg/day, each taken once daily for 2 months, after 2-week placebo washouts. Measurements were made after each washout and randomized treatment, comprising: methacholine PC20, exhaled and nasal nitric oxide, blood eosinophils and eosinophilic cationic protein, symptoms, lung and nasal function tests.


RESULTS
Seventeen patients completed per protocol. For PC20 and exhaled nitric oxide, only combined topical steroid produced improvements (P < 0.005) from placebo baseline. Combined steroid was superior by a 0.93 (95% CI 0.14-0.93, P < 0.05) doubling dilution difference for PC20 and a 0.99 (95% CI 0.9-15.1, P < 0.01) doubling difference for exhaled nitric oxide. Both treatments attenuated eosinophils and eosinophilic cationic protein, and reduced nasal symptoms (P < 0.05). Only steroid improved nasal nitric oxide (P=0.05) and asthma symptoms (P < 0.05). Neither treatment affected lung or nasal function tests.


CONCLUSIONS
Combined topical steroid and combined mediator antagonism both attenuated systemic inflammation in the unified allergic airway, but only the former reduced bronchial and nasal inflammatory markers. The relevance of this to exacerbations and airway remodelling needs to be defined.
Barnes
M L
ML
Asthma and Allergy Research Group, Department of Medicine and Therapeutics, Ninewells Hospital and Perth Royal Infirmary, University of Dundee, Dundee, UK.
Menzies
D
D
Fardon
T C
TC
Burns
P
P
Wilson
A M
AM
Lipworth
B J
BJ
D000085:Acetates / Q000008:administration & dosage; D000287:Administration, Topical; D000293:Adolescent; D000328:Adult; D000368:Aged; D018926:Anti-Allergic Agents / Q000008:administration & dosage*; D018927:Anti-Asthmatic Agents / Q000008:administration & dosage*; D001249:Asthma / Q000188:drug therapy*; D001507:Beclomethasone / Q000008:administration & dosage; D017332:Cetirizine / Q000008:administration & dosage; D018592:Cross-Over Studies; D003521:Cyclopropanes; D004311:Double-Blind Method; D004333:Drug Administration Routes; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011804:Quinolines / Q000008:administration & dosage; D012221:Rhinitis, Allergic, Perennial / Q000188:drug therapy*; D013440:Sulfides
D000085:Acetates; D018926:Anti-Allergic Agents; D018927:Anti-Asthmatic Agents; D003521:Cyclopropanes; D011804:Quinolines; D013440:Sulfides; D001507:Beclomethasone; C093875:montelukast; D017332:Cetirizine