Recent pharmacological developments in the treatment of perennial and persistent allergic rhinitis

ABSTRACT

Introduction: Allergic rhinitis (AR) has a major negative impact on patients’ quality of life (QoL) and carries a high socio economic burden. This is particularly the case for patients who experience symptoms for extended periods of time (i.e. those with perennial (PAR) or persistent AR (PER), depending on the classification system used). This review covers available pharmacological advances and recent developments in the treatment of PAR or PER.

Areas covered: Pharmacological AR treatment is used to reduce symptom burden and help restore patients’ normal daily routine. Traditionally, non-sedating antihistamines and intranasal corticosteroids (INS) were the two drug classes recommended for use first line. These, along with antileukotrienes, decongestants, mast cell stabilizers and anticholinergics, constituted the bulk of the AR treatment arsenal. MP-AzeFlu (Dymista®, Meda, Solna, Sweden) is the most recent addition to that arsenal. It is a novel intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP) delivered in a single spray and has surpassed available therapies in terms of symptom control and treatment response. Other relatively new treatments for PAR or PER include H₃ antihistamines, toll-like receptor (TLR) agonists, cellulose powders and micro-emulsions, novel biomolecular formulations and omalizumab. Each of these new additions is reviewed here.

Expert opinion: A new AR drug class has recently been introduced (i.e. RO1AD58). Currently MP-AzeFlu is the only treatment option within this drug class. It can be estimated that combination treatments like MP-AzeFlu will become the mainstay of PAR and PER therapy since use will result in better compliance, improved efficacy over INS and a faster response together with good levels of tolerability. The challenge is to find other equally, or more effective, combination treatments, as has been the therapeutic standard in bronchial asthma for decades. The potential of biologics, as well as TLR-agonists and other new treatment options needs to be further evaluated.

KEYWORDS:

• Antihistamines
• MP-AzeFlu
• glucocorticosteroids
• perennial allergic rhinitis
• persistent allergic rhinitis

Article highlights

• Depending on the classification system used, about 40% of allergic rhinitis (AR) patients suffer from perennial allergic rhinitis (PAR) and about one-third suffer from persistent rhinitis (PER).

• Treatment costs associated with PAR are higher than in seasonal allergic rhinitis patients.

• Second-generation antihistamines and intranasal corticosteroids (INS) form the two pillars of classical PAR or PER treatment strategy. Additional pharmacological treatments include leukotriene receptor antagonists, anticholinergics, nasal decongestants and mast cell stabilizers.

• Allergen-specific immunotherapy administered via subcutaneous or sublingual routes is recommended for patients that do not respond to other pharmacological interventions.

• New advances include MP-AzeFlu, H₃ antihistamines, toll-like receptor (TLR) agonists, cellulose powders and microemulsions, as well as the IgE inhibiting recombinant humanized monoclonal antibody, omalizumab.

• MP-AzeFlu is a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate delivered as a single spray.

• MP-AzeFlu is the first drug to exceed the efficacy of INS, providing faster and more complete symptom control in PAR patients.

• The potential of biologics, as well as TLR-agonists and other new treatment options, needs to be further evaluated.

This box summarizes key points contained in the article.

Declaration of interest

This paper has been supported by an unrestricted educational grant from Meda Pharmaceuticals. L. Klimek has received research grants from ALK-Abelló, Allergopharma, Bionorica, Dr. Pfleger, Stallergenes, HAL, Artu Biologicals, Allergy Therapeutics/Bencard, Hartington, Lofarma, MEDA Pharmaceuticals, Merck Sharp & Dohme, Novartis/Leti, ROXALL, GlaxoSmithKline, Essex-Pharma, Cytos, Curalogic, and has served on the speaker’s bureau for the above mentioned pharmaceutical companies. J. Mullol is or has been member of national and international scientific advisory Boards (consulting), received fees for lectures, or grants for research projects from ALK-Abelló, Boheringer-Ingelheim, Crucell, Esteve, FAES Farma, GlaxoSmithKline, Hartington Pharmaceuticals, Johnson & Johnson, MEDA Pharmaceuticals, Merck Sharp & Dohme, Novartis, Pierre Fabre, Sanofi-Aventis, Schering Plough, UCB Pharma, Uriach Group, Zambon. P. Hellings has received research grants and/or has been lecturing for GlaxoSmithKline, Merck, Stallergenes and ALK. R. Mösges reports personal fees from ALK-Abello, personal fees from Allergy Therapeutics, personal fees from Allergopharma, grants and personal fees from Bencard, grants and personal fees from BiotechTools, personal fees from Bayer, personal fees from GlaxoSmithKline, grants from HAL, personal fees from Johnson & Johnson, grants and personal fees from Lofarma, personal fees from Merck Sharp & Dohme, personal fees from Menarini, personal fees from FAES farma, personal fees from Novartis, personal fees from Leti, grants from Optima, non-financial support from Greer, non-financial support from Roxall, grants from AIPrevent, personal fees from Servier, personal fees from Stada, grants and personal fees from Stallergènes, personal fees and non-financial support from UCB Pharma, grants from Ursapharm, grants from Bitop, grants from Hulka, non-financial support from Atmos, grants and personal fees from Arthrocare, personal fees from Meda Pharmaceuticals, personal fees from Ohropax, outside the submitted work; and Ralph Mösges is a member of the guidelines task force of the German Academy of Otorhinolaryngology, he is the chairman of ISCOANA, the International Standardisation Committee of the European Rhinologic Society (ERS), the chairman of the ENT-Section of the European Academy of Allergy, Asthma and Clinical Immunology (EAACI), and a vice-president of INTERASMA. W. Fokkens has received an educational grant from Meda Pharmaceuticals and research grants from GlaxoSmithKline and Biopharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Writing assistance from Ruth Murray, MedScript Communications Ltd, and Nidhi Nair, MedScript Communications Ltd, was utilized in the production of this manuscript and funded by MEDA Pharmaceuticals.