Short communication
`
`Effect of cetirizine, levocetirizine, and dextrocetirizine on
`histamine-induced nasal response in healthy adult volunteers
`
`Copyright © Munksgaard 2003
`SSW 0105-4538
`
`Background: Cetirizine, an effective H,-receptor antagonist, is a racemate
`mixture of two enantiomers; levocetirizine (R enantiomer) and dextrocetirizine
`(5 enantiomer).
`Methods: To investigate the pharmacologic activity of the two enantiomers of
`cetirizine, we conducted a randomized, double-blind, four-way, crossover study
`to assess the effect of treatment with 5 mg levocetirizine, 5 mg dextrocetirizine,
`and 10 mg cetirizine and matched placebo, on histamine-induced changes in the
`nasal airways of 24 healthy volunteers. Four hours after a single oral intake,all
`subjects were Se Fae see eS eSes
`concentrations (from 0,25 ta 32 mg/ml) of
`in both nostrils. Nasal
`resistance was measured by passive anterior rhinomanometry (PAR), and
`i
`calculated together with the absolute
`Both levocetirizine and cetirizine ae attenuated the histamine-
`induced increase in nasal airway resistance by nearly 50% (from a median
`resistanceof2.51 salon 1,29and 1.31 Papercm°ls,respectively)at the
`ee setteeonlContaxHomer: Sneezing
`was also attenuated by bot
`Jevocetirizine and
`However, these
`SSUIUIEtucktcyreeversinssatenyof
`boccetiskGagan
`
`maximal concentration, and they concomitantly increased the histamine
`
`the inhibition of histamine-induced increase in nasal resistance, indicating that
`the antihistaminic properties of cetirizine are probably attributable to
`levocetirizine.
`
`D. Y. Wi
`
`C.DeViterSmeg
`ENTDeparwnart,Vie Universitet Busse, Brussel,
`
`threshold; sevocetirizine; nasal resistance,
`Christine De Vas, PhO
`UCS Phere
`‘Alida de la Recherche 80
`B-1070 Brussals
`Baigiem
`
`Accepted for publication 23 November 2000
`
`
`
`The role of histamine has been well documented in the
`ao ebauee cole ofhistamine in allergic diseases has
`been associated with the development of specific and
`highly efficacious H,-receptor antagonists for sympto-
`Ly seasonal and
`
`gencration antihistamines have been associated with
`central nervous system and anticholinergic side-effects,
`particularly sedation and impaired psychomotoractiv-
`ity (7), and are therefore not much used currently. In
`contrast, the newer second-generation antihistamines,
`such as cetirizine, loratadine, and fexofenadine, exhibit
`fewer sedative and anticholinergic effects and have a
`rapid onset of action, making them ideal for sympto-
`matic relief of the allergic disease.
`
`Controlled trials in patients with seasonal and
`rhinitis have demonstrated that cetirizine is
`effective in attenuating nasal and/or ocular symptoms
`resulting from experimental or natural allergen expo-
`sure (8-11). However,cetirizine is a racemate mixture of
`two enantiomers:
`levocetirizme (R enantiomer) and
`dextrocetirizine (5 enantiomer). The aim of this study
`was to investigate the activity of these two enantiomers
`on histamine-induced changes in nasal resistance and
`sneezing in healthy volunteers, and then to compare
`these effects with those of cetirizine and placebo.
`
`Material and metheds
`
`Twenty-eight healthy nonallergic volunteers were enrolled in this
`study, Of them, 24 subjects (nine males and 15 fernales) aged 20-38
`aneeee ee tes
`had normal
`findings on routine hematologic and
`Elochnelont Kload bon parieustera: Nea of ta volswieacs waeiad
`539
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`Apotex, Inc. (IPR2019-00400), Ex. 1005, p. 001
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`

`

`Wang et al.
`
`more than five cigarettes a day or had a history of allergy of
`hypersensitivity to piperazines. They did not take any medication,
`except oral contraceptives during the 2 weeks preceding enrollment.
`Allwohaniceregave written informed consent prior to the study. This
`study waswas approved by the ethics committee of the university
`hospital, Free University of Brussels (Academisch Ziekenhuia, Vrije
`Universiteit Brussel), Belgium.:
`
`Study design
`This was a randomized, double-blind, placebo-vontrolled, four-way,
`crossover study. Each volupteer was entered into a randomized
`schedule to receive a single dose of 5 mg levocetirizine, 5 mg
`
`events before and after nasal provocation, and, all being well, they
`were given appointments to attend the clinic for the next visit after a
`washout period of 7-14 days.
`
`Measurement of nasal resistance
`Nasal resistance was measured by PAR (Heyer, Bad Ems, Germany),
`ipentsees 00 Oeee
`blown through a nozzle into one nostril. The pressure induced by the
`nasal airway resistance to this airflow at a given level of the nozzle
`wos measured. The meseurements were expressed in Pa per cm*/s, as
`recommended by the International Committee on Standardization of
`Rhinomanometry (15). In this study, nasal airway
`measured in each nostril | min and 5 min after cach challenge, and
`the mean value of the two time measurements wes calculated, The
`higher value of mean resistance from one of the nostrils was
`subsequently used in the final efficacy analysis.
`
`Histamine nasal provocation test
`pune (om HALAB Alergy ‘Serve,Bruns, Begum) ed
`solution (diluent of histamine
`Heber tangerndepeg ye 13.1 mg),
`ae ce mg), sodium phosphate (1.2 mg), human
`ere aneae (HEA‘U3 com: und pueselit igsLeal ener toe
`injection.
`‘Nasal provocation
`application
`with a Heyer nebulizer (Heyer, Bad Ems, agefb 13). The
`nebulizer contained the challenge solution and was aerosolized for
`introduction into the volunteer's nostrils through a nozzle, The nasal
`
`any treatment visit, they were withdrawn from this study.
`Volunteers were assessed for general well-being and any adverse
`
`procedures with increasing concentrations of histamine were
`
`Table 1. Comperison of effect of treatment for 4h with 10 my catirizing, 6 mg levncatirizin, and 5 mg dexarocatirizine compared with placebo on histarsine-indured changes in nasal
`alrvray resistance (unit==Pa por coils; nm24 healthy volunteers}
`Nasal airway resistance Pa per omt'/s
`
`
`
` Histamine concentration (mg/l) Placebo (median) Cotirizine (radian) Lovovatirizina (median) Destrocetirizina (median) Friaderean: test” P
`4
`O78
`0.79
`76
`0.84
`0.831
`2
`os
`O83
`15
`om
`bie9
`4
`112
`0.88
`O87
`142
`a7
`
`
`
`
`
`a
`
`18
`
`+0)
`
`
`
`1.26
`
`1.38
`
`2.08
`
`edi
`
`0.002
`
`agoz
`
`‘Global evalustion with Friedman test.
`When
`qiobal evaluetion wee statistically significant (°<0,05), two-by-two comparison of treatment wea done. Only comparisons with P< 0.10 are mentioned in tables:
`+005 <Pef.10
`0005< P05
`001 < Pc8025
`79.00) <P.
`
`340
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`Apotex, Inc. (IPR2019-00400), Ex. 1005, p. 002
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`Apotex, Inc. (IPR2019-00400), Ex. 1005, p. 002
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`

`

`Antihistaminic properties of levocetirizine
`‘i 2, Gomperisonofeffectafrrestmentfor4hwith10 mgcetirizine,5 mglevacetinzine,and5 mgdextrocetirizinecomparedwithplacebo onhistaminethrasholdconcentration,based
`on frequency of volunteers demonstrating 100% increase in moan nase! resistance (n=24 healthy volunteers!
`
`peer”|
`
`Catirizina ve placebo 0.026 < P< 0.05,
`
`performed, allowing an interval of i min after the inst PAR
`measurement (which was 5 min after the beginning of the previous
`histamine administration).
`
`Statistical analysis
`The sample size was estimated by a power catculation done on the
`
`“MwOo
`
`ga
`
`Sewmme
`
`Effect of treatment on nasal resistance
`
`Measurement of nasal airway resistance under placebo
`demonstrated that this was increased by histamine
`administration in a
`manner (Tabie J},
`Treatment with both cetirizine and levocetirizine
`significantly attenuated the histamine-induced increases
`in nasal airway resistance at the maximal concentration
`of 32 mg/ml with almost 50% reduction over placebo
`(Table 1). Both cetirizine and levocetirizine were found
`90% power level with an errorof5%; consequently, 28 eligible
`
`to attenuate significantly the effects of histamine at
`individuals were recruited
`the study to allow for dropouts.
`All data were
`as
`values, and the overall
`concentrations of >3 and = 16 mg/ml, respectively. In
`of
`in histamine
`contrast, treatment with dextrocetirizine did not show
`any significant effect on histamine-induced increase in
`nasal airway resistance as compared to placebo.
`
`iple comparison procedure
`
`(1.AltintswepeerediteSAsata
`package (Version 6.08) on an IBM-compatible microcom
`ae ae oc. od aie ci Patawe eedme
`significant.
`
`Results
`
`Of the 28 volunteers recruited into the study, results for
`four subjects were not included in the overall efficacy
`analysis. One subject suffered from an episode of
`bronchitis after visit 4 and prior to receiving the last
`treatment at visit 5, and therefore did not complete the
`entire study protocol. The other three subjects, despite
`the fact that they were eligible, failed to react
`to
`histamine, showing a histamine threshold concentration
`of >32 mg/ml at every treatment visit. Their results
`were therefore considered to be not evaluable, and these
`volunteers were replaced,
`
`Effect of treatment on histamine threshold concentration
`
`After treatment with placebo, 16/24 (67%) subjects
`demonstrated a histamine threshold concentration of
`<8 mg/ml. Treatment with cetirizine,
`levocetirizine,
`and dextrocetirizine decreased the number of subjects
`demonstrating a histamine threshold concentration of
`<8 mg/ml tooe (29%), 5/24 (21%), and 13/24 (54%),
`respectively. The histamine threshold concentration
`was significantly increased fourfold from a median
`value of 8 mg/ml after treatment with placebo to a
`median value of 32 mg/m] after
`treatment with
`cetirizine
`(P<0.05) or
`levocetirizine
`(P<0.025)
`(Table 2). In contrast, dextrocetirizine was not found
`to alter significantly the histamine threshold concentra-
`tion as compared to placebo, as the number of subjects
`with a threshold concentration below 8 mg/ml was 13
`out of 24, Levocetirizine was found to be significantly
`341
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`Apotex,Inc. (IPR2019-00400), Ex. 1005, p. 003
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`Apotex, Inc. (IPR2019-00400), Ex. 1005, p. 003
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`

`

`Wang et al.
`
`
`
`Totalnumberofsnpezes
`
`-S
`
`eons
`eeecis
`SeeHRrESOTeSeOECsSe:=Sreessecemsceemmonens
`
`Cetirizi
`Levocetirizine
` Dextrocetirizine
`
`*eone subject
`Figure 1. Effect of treatment for 4h with placebo, 10 mg cetirizine, 5 mg levocetirizine, and 5 mg dextrocetirizine on histamine-
`induced sneezes.
`
`(P<0,05) more effective than dextrocetirizine in
`increasing the histamine threshold concentration. A
`comparison between cetirizine and levocetirizine, how-
`ever, did not show a significant difference between them
`(Table 2).
`
`induced increases in nasal airway resistance by almost
`50% over placebo at the maximal concentration of
`32 mg/ml. Concomitantly,
`the histamine threshold
`concentration was
`increased fourfold from 8 to
`32 mg/ml. The number of sneszes induced by histamine
`
`Effect of treatment on sneezing
`Fig. 1 me eeee
`number of sneezes induced by histamine
`Treatment with either cetirizme or levocetirizine sig-
`nificantly (P <).01) reduced histamine-induced sneezes,
`but not treatment with dextrocetirizine as compared to
`placebo (P> 0.10).
`
`Evaluation of safety
`There was no special report on health-related problems
`or discomfort (i.e., drowsiness, fatigue, and dry mouth)
`caused by study medications among the volunteers.
`Only one subject
`an adverse event of
`bronchitis, which occurred $ days after treatment
`with levocetirizine and was not judged to be a direct
`result of the study drug. However, this was a single-dose
`study, and the volunteers were interviewed 4h after
`each intake of the study medication.
`
`Discussion
`In this study, levocetirizine 5 mg and cetirizine 10 mg
`a ney aleerable in their antihistaminic
`
`tly attenuated histamine-
`
`They
`
`treatment with dextrocetirizine did not show a similar
`‘protective’ effect as compared to placebo.
`Our findings are in accordance with the findings of
`several studies investigating the effects of cetirizine in
`patients with seasonal and perennial allergic rhinitis.
`Frossard et al, have recently conducted two studies to
`investigate the effects of treatment with 10 mg cetirizine
`on changes in the nasal airway resistance of asympto-
`matic seasonal allergic rhinitics c
`with increas-
`ing doubling doses of histamine (17, 18). These authors
`showed that cetirizine significantly attenuated hista-
`mine-induced increases
`in nasal airway resistance
`(NAR) only 1.5 h after administration (17), and that
`these effects were prevalent even 24 h after treatment
`
`0,when comparedwith placebo.
`
`Thisis thefirst study to investigate thespecificeffects of
`each enantiomer of cetirizine on the histamine-induced
`nasal
`response. In view of the similarity of the
`antihistaminic cifects observed for cetirizine and levoce-
`tirizine and the lack of any significant effects for
`dextrocetirizine in this study,it is likely that the effects
`ofcetirizineinthemanagementofallergicrhinitisare due
`to levocetirizine. Since cetirizine is composed of equal
`quartilesartictes“omuticorsnrs,curateomnestact
`
`M2
`
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`Apotex, Inc. (IPR2019-00400), Ex. 1005, p. 004
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`

`

`preparations of levocetirizine at a dose of 5 mg may be
`useful in the management of seasonal and perennial
`allergic rhinitis in the future.
`In addition to its
`antihistaminic property,
`levocetirizine at
`the single
`dose of 5 mg was well tolerated by the voluntests, whe
`did not suffer from any side-effects in this study.
`the
`In conclusion,
`this study demonstrates that
`antihistaminie properties noted for cetirizine in the
`saarmamnensofsaeontlindpore!See uuitis
`
`are probably due: to the .levocotitinis
`
`Antihistaminic properties of levocetirizine
`
`Further ‘ studies are required to substantiate these
`findings in patients with ongoing seasonal and perennial
`allergic rhinitis.
`
`Acknowledgments
`We thank Marie-Paule Derde and Léon Kaufmann of DICE and
`VUB, Brussels, Belgium, 23 well as Christian Otoul of UCB-Pharma,
`for bringing us their expertise in biostatistics. We also thank Pascale
`Segers for preparing the figures. This study was sponsored by UCB-
`Pharma, Brussels, Belgium.
`
`References
`
`1. Wooo-Baxzr R. Histamine and its
`receptors. In: Buss WW, Hovoate ST,
`editors. Asthma and rhinitis. London:
`Blackwell Scientific, 1995;:791-800,
`2, Pircoan U. Mediators and nasal allergy.
`Clin Exp Allergy 1989;26:585-589.
`3, Wurrs MV, SLater JE, Katiner MA.
`Histaraine and asthma. Am Rev Respir
`Dig 1987+135:1165-1176.
`4, Scanpne GK. Clinical assessment of
`entihistamines in rhinitis. Clin Exp
`Allergy 1995;29 Supp! 3:77-81.
`5, Howaar PH. Assessment of
`antihistamine efficacy end potency. Clin
`Exp Allergy 1999:29 Suppl 3:87-97.
`
`” effects of antihistamines (H,-receptor
`ists). Clin Exp Allergy 1999:29
`Sopp! 3:125-132.
`
`8. Day JH, Briscoe M, Wipurz MD.
`Cetirizine, loratadine, or placebo in
`subjects with seasonal allergic rhinitis:
`effects after controlled ragweed pollen
`challenge in an environmental exposure
`unit. J Allergy Clin Immunol
`1998;101:638-645.
`9, Mexrzta EO, Weer JM, Woourz MD.
`Comparative outdoor study of the
`efficacy, onset and duration of action,
`and safety of cetirizine, loratadine, and
`placebo for seasonal allergic rhinitis. J
`Allergy Clin Immunol 1996;97:617-626,
`10. Lockey RF, Wiotoz MD, Mrvenet
`DQ,et al. Comparative study of
`cetirizine and terfenadine versus
`symptomatic
`management of seasonal allergic
`rhinitis. Ann Allergy Asthma Immunol
`
`1h,
`
`14.
`
`Gonors F, Cizment PAR, Denne MP.
`the comparison
`the threshold of the activity by three
`methods of
`Rhinology 1989;27;263-269.
`Wana D, Cuamenr P. Assessment of
`early and late phase nasal obstruction in
`atopic patients after nasal allergen
`challenge. Clin Otolaryngol
`1995;20-368-373.
`. Clement PAR, Committee report on
`standardization of rhinomanometry.
`
`i
`parametric
`York: Wiley Interscience, 1973:503.
`. Frossanp N, LACRONIQUE J, MeLac M,
`et al. Onset of action in the nasal
`antihistaminic effect of cetirizineand
`
`18.
`
`M, Gtassen'N, Lacronique J, Pauul G.
`Nasal effect ofcetirizine and loratadine
`at 24 hours in patients with allergic
`thinitis, Am J Ther 1998;8;307-311.
`
`hyperreactivityinnon-specific allergic
`thinopathy. Rhinology 1985;23:35~42.
`
`Apotex,Inc. (IPR2019-00400), Ex. 1005, p. 005
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`Apotex, Inc. (IPR2019-00400), Ex. 1005, p. 005
`
`

`

`Apotex,Inc. (IPR2019-00400), Ex. 1005, p. 006
`
`Apotex, Inc. (IPR2019-00400), Ex. 1005, p. 006
`
`