S. H. Mandy:
`Chest and Back Acne: A Retrospective Review
`
`S. M. H. Qadri, Y. Ueno, P. Domenico, B. A. Cunha:
`Activity of Ticarcillin/Clavulanic Acid Against
`Gram-Negative Nosocomial Isolates
`
`M.A. Drouin, W. H. Yang, F. Horak,
`P.H. van de Heyning, G. H. Kunkel,
`C. I. Backhouse, M. R. Danzig:
`Adding Loratadine to Topical Nasal Steroid Therapy
`Improves Moderately Severe Seasonal Allergic
`Rhinoconjunctivitis
`
`B. Wiita, J. G. Young, L. J. Downey:
`Esterified Estrogens or Estrogen Plus Androgen:
`Effective Postmenopausal Hormone-Replacement
`Therapy
`
`A.H. Agha, J.B. Roy, D. J. Culkin, K. Lyon:
`The Impact of 5-Alpha-Reductase Inhibitors on the
`Number of Prostatectomies for RPnie:n __ e_rostatic
`Hyperplasia
`
`Index
`
`AR
`·. -
`,•
`
`321
`
`333
`
`340
`
`350
`
`361
`
`367
`
`

`

`Advances
`In Therapy®
`
`The International Journal of
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`-·
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`

`

`FE O 1 '96
`
`vances
`
`CONTENTS
`
`S.H.Mandy:
`Chest and Back Acne: A Retrospective Review
`
`S. M. H. Qadri, Y. Ueno, P. Domenico, B. A. Cunha:
`Activity of Ticarcillin/Clavulanic Acid Against
`Gram-Negative Nosocomial Isolates
`
`M. A. Drouin, W. H. Yang, F. Horak,
`P. H. van de Heyning, G. H. Kunkel,
`C. I. Backhouse, M. R. Danzig:
`Adding Loratadine to Topical Nasal Steroid Therapy
`Improves Moderately Severe Seasonal Allergic
`Rhinoconjunctivitis
`
`B. Wiita, J. G. Young, L. J. Downey:
`Esterified Estrogens or Estrogen Plus Androgen:
`Effectiv~ Postmenopausal Hormone-Replacement
`Therapy
`
`A.H. Agha, J.B. Roy, D. J. Culkin, K. Lyon:
`The Impact of 5-Alpha-Reductase Inhibitors on the
`Number of Prostatectomies for Benign Prostatic
`Hyperplasia
`
`Index
`
`321
`
`333
`
`340
`
`350
`
`361
`
`367
`
`HCi
`
`HEALTH
`COMMUNI(cid:173)
`CATIONS
`INC-
`
`

`

`Advances I Volume 12 No. 6
`
`In Therap~ November/December 1995
`
`Adding Loratadine to Topical
`Nasal Steroid Therapy
`Improves Moderately
`Severe Seasonal Allergic
`Rhinocon j unctivi tis
`
`Michel A. Drouin, M.D. ·
`William H. Yang, M.D.
`Section of Allergy and Clinical
`Immunology
`Ottawa Civic Hospital
`University of Ottawa
`Ottawa, Canada
`Friedrich Horak, M.D.
`HNO University Clinic
`University of Vienna
`Vienna, Austria
`Paul H. van de Heyning, M.D.
`Department of ENT and Head
`and Neck Surgery
`University Clinic of Antwerp
`Antwerp, Belgium
`Gert H. Kunkel, M.D.
`Department of Clinical Immunology
`and Asthma O.P.D.
`University Clinic Charlottenburg of
`the Free University of Berlin
`Berlin, Germany
`Charles I. Backhouse, M.D.
`The Medical Centre
`East Horsley, Surrey, England
`Melvyn R. Danzig, Ph.D.
`Schering-Plough Research Institute
`Kenilworth, New Jersey
`
`ABSTRACT
`
`This study assessed the efficacy of add ing the nonsedating selective H, anti(cid:173)
`histamine loratadine to topical intranasal beclomethasone dipropionate (BDP)
`
`0 1995 Health Communications Inc.
`Transmission and reproduction of this material in whole
`or part without prior written approval are prohibited.
`
`0422
`
`340
`
`Address rc>print requ~s to
`Melvyn R. Danzig, Ph.D.
`Schering-Plough Research Institute
`2015 Galloping Hill Road
`Kenilworth, NJ 07033-0539
`
`

`

`to treat patients with seasonal allergic rhinoconjunctivitis (SAR). In a double-blind, ran(cid:173)
`domized, parallel-group trial, 154 patients, ages 18 to 65, with moderately symptomatic
`SAR were treated with intranasal B_DP (100 µ.g in each nostril twice daily) combined with
`10 mg of loratadine or placebo for 7 days. Four nasal and four non-nasal symptoms were
`evaluated following 3 and Tdays of treatment, and patients recorded daily symptoms and
`possible adverse effects in a diary. BDP alone improved the symptoms of SAR; however,
`BDP plus loratadine provided further improvement. Patients treated with BDP plus
`loratadine achieved significantly greater (P<.05) relief of both nasal and non-nasal symp(cid:173)
`toms than those treated with BDP plus placebo. No differences were noted in the
`incidence or type of adverse effects in the two treatment groups. Loratadine plus topical
`intranasal BDP controls SAR more effectively than does BDP alone, without any increase
`in adverse effects.
`
`Keywords: I antihistamine; topical corticosteroid; loratadine; beclomethasone
`
`dipropionate; allergic rhinitis
`
`INTRODUCTION
`Current pharmacologic management of rhinitis provides less than complete
`relief of symptoms and may be associated with variable degrees of adverse effects.1
`Because many of the drugs currently available affect different components of the
`allergic response, combinations of drugs with complementary effects can maximize
`therapeutic efficacy.
`Loratadiile is an orally effective and long-acting antihistamine.2 It has a high
`selectivity for peripheral histamine HI receptors and a low affinity for central
`nervous system HI, cholinergic, or alpha-adrenergic receptors in vitro or in vivo.3,4
`Loratadine does not readily cross the blood-brain barrier and has an incidence of
`sedation equal to that of placebo.5 Loratadine is rapidly absorbed, with peak
`concentrations in serum reached within 2 hours, an effect consistent with its rapid
`onset of action.6 Loratadine relieves most of the symptoms related to SAR2 and is as
`effective as terfenadine,7·9 astemizole,10,11 and cetirizine.I2
`The nasal response to allergen challenge can be divided into an early reaction
`(occurring within minutes of allergen exposure) and a late-phase reaction
`(occurring 4 to 10 hours after allergen challenge in about half of patients). A
`rechallenge reaction may occur with :a second exposure to allergen 10 hours after
`the first challenge, resulting in increased symptoms and associated physiologic
`effects. I3 Systemic corticosteroids reduce symptoms and mediator release in the late
`and rechallenge phases of the process but have little effect on the early phase.
`Intranasally applied steroids are effective in all three phases of the response,
`however_I,I4 Studies on their mode of action have shown that they reduce the
`number of eosinophils, the presence of eosinophil cationic protein, and the number
`of mast-cell progenitors in the nasal mucosa.I
`Topical steroids, including BDP, flunisolide, budesonide, triamcinolone acetonide,
`fluticasone propionate, and mometasone furoate, are efficacious agents for all the
`nasal symptoms of SAR.I H 1-receptor antagonists relieve the ocular symptoms that
`
`Advances In Therapy<'
`Volume 12 No. 6, November/December 1995
`
`341
`
`

`

`accompany SAR15-18 and help prevent and relieve sneezing, nasal itching, and
`rhinorrhea; however, they do not relieve nasal blockage. 19 In a recent report,
`Frolund20 compared the effects of loratadine with those of intranasal BDP and
`concluded that although both medications· were effective in patients with SAR, the
`two drugs controlled different symptoms. Patients treated with BDP had signifi(cid:173)
`cantly less nasal blockage; those treated with loratadine had more relief of ocular
`symptoms. This study attempts to determine whether combination treatment with
`BDP and loratadine maximizes clinical efficacy.
`
`PATIENTS
`Five medical centers participated in this double-blind, randomized, parallel(cid:173)
`group study designed to determine the efficacy of adding 1 week of loratadine
`treatment to therapy with topical nasal steroids to alleviate the signs and symp(cid:173)
`toms of SAR. The centers were located in Austria, Belgium, Canada, Germany, and
`England. An institutional review committee at each center approved the study
`protocol and statement of informed consent, and each study participant gave
`written informed consent.
`
`Study Design
`Outpatients between 18 and 65 years of age with a history of moderately severe
`SAR were admitted to the study. IgE-mediated hypersensitivity was confirmed by a
`positive skin prick or an intradermal test with relevant seasonal allergens.
`Patients were excluded from the study if they were pregnant, lactating, or not
`using medically accepted birth control; had severe asthma or chronic obstructive
`pulmonary disease; had nasal polyps or significant nasal structural abnormalities;
`or had any significant current disease that might interfere with treatment evalua(cid:173)
`tion. Anyone undergoing immunotherapy with pollen extracts must have been
`receiving a stable dose for at least 1 month before beginning the study.
`Before dosage, patients were required to stop taking oral antihistamines (for
`48 hours, except astemizole for 1 month), oral decongestants (for 24 hours),
`systemic and orally inhaled steroids. (for 1 month), nasally inhaled steroids (for
`72 hours), cromolyn sodium (for 1 week), and topical decongestants (for 24 hours).
`Before beginning the study, patients had to have at least moderately severe SAR
`symptoms. They were evaluated for nasal, ocular, and ear/palate symptoms
`according to the following rating scale: 0 = none (not visible to physician or patient);
`1 = mild (noticed by physician or patient or both but not disturbing); 2 = moderate
`(definitely present and disturbing to the patient some of the time); and 3 = seve:r:_e
`(very disturbing most of the time). Nasal symptoms evaluated included rhinorrhea,
`stuffiness, itching, and sneezing. Ocular symptoms evaluated were itching, tearing,
`and redness. Ear/palate itching was also assessed. To be included in the study,
`patients had to demonstrate a nasal score of at least 6 (including nasal discharge and
`one other nasal symptom of moderate severity) and an ocular score of at least 5.
`Individual symptoms were summed, creating nasal, ocular, and total scores.
`Patients were randomly assigned to treatment with ,either intranasal BDP plus
`loratadine or intranasal BDP plus placeqo. Patients _were instructed to take one
`
`342
`
`M. A. Drouin et al
`Loratadine plus Nasal Steroids in SAR
`
`

`

`tablet of loratadine (10 mg) or matched placebo daily in the morning and two sprays
`(50 µg/spray) of BDP in each nostril every morning and evening for 7 days. All
`patients kept a daily diary of symptom severity and adverse effects between visits.
`After 3 and 7 days of treatment, patients were evaluated by the investigator. In
`addition to scoring individual symptoms at each visit, the patient and physician
`made an overall global assessment of response to treatment on day 7 (or on the last
`day of treatment if a patient discontinued earlier than day 7), using a rating scale of 1
`to 5 (1, excellent; 5, treatment failure). Adverse events were also elicited.
`
`Statistical Analysis
`- Continuous demographic variables (age, weight, duration of condition, and
`duration of episode) were evaluated by means of a two-way analysis of variance
`model. Fisher's Exact Test was used to assess the comparability of sex and race. A
`two-way analysis of variance was used to analyze total symptom scores, which
`were confirmed with the Wilcoxon rank-sum test. The incidence of adverse events
`(total and specific) was analyzed with Fisher's Exact Test.
`
`RESULTS
`The study emolled 156 patients. One patient from each group was dropp~d from
`the study for failure to return for follow-up evaluation after the initial visit. Table 1
`lists the demographic information for the two study groups. Race, age, weight, and
`baseline total symptom scores were comparable (P~.27). Sex had significant
`treatment-by-center interaction (P = .03) but was determined to have no major
`impact on overall efficacy comparisons.
`
`Table 1. Demographic Information
`
`No. of patients
`
`Sex, M/F
`
`Mean age, y
`Mean weight, kg
`Mean duration of SAR, y
`Mean duration of current episode, wk
`Baseline scores (mean value)
`Total symptoms
`Nasal symptoms
`Ocular symptoms
`
`Loratadine + BDP
`
`Placebo + BDP
`
`76
`48/33
`31
`70
`9
`3
`
`14.9
`8.4
`5.5
`
`78
`38/40
`32
`68
`12
`4
`
`15.1
`8.6
`5.6
`
`Advances In Therapy•
`Volume 12 No. 6, November/December 1995
`
`343
`
`

`

`Efficacy
`In general, patients treated with loratadine plus BDP showed greater clinical
`improvement in most symptoms of SAR than those treated with placebo plus BDP
`(Table.2).
`
`Table 2. Improvement in Symptom Scores at Days 3 and 7
`
`Evaluation
`Day
`
`Loratadine +
`BOP,%
`
`Placebo+
`BOP,%
`
`PValue
`
`Total symptom score
`
`Total nasal score
`
`Nasal discharge
`
`Nasal stuffiness
`
`Nasal itching
`
`Sneezing
`
`Total ocular score
`
`lt.ching
`
`Tearing
`
`Redness
`
`Ear/palate itching
`
`NS = not significant.
`
`3
`7
`
`3
`7
`3
`7
`3
`7
`3
`7
`3
`7
`
`3
`7
`3
`7
`3
`7
`3
`7
`
`3
`7
`
`54
`68
`
`55
`66
`58
`67
`43
`62
`61
`72
`57
`67
`
`53
`70
`48
`65
`56
`72
`53
`73
`
`60
`80
`
`46
`58
`
`48
`59
`52
`65
`40
`55
`48
`62
`46
`59
`
`45
`57
`39
`52
`52
`61
`46
`54
`
`38
`50
`
`.08
`<.05
`
`<.05
`NS
`NS
`NS
`NS
`NS
`<.05
`<.05
`<.05
`.07
`
`NS
`<.05
`NS
`<.05
`NS
`<.05
`NS
`.07
`
`<.05
`<.05
`
`Patients receiving loratadine plus BDP showed significantly greater improve(cid:173)
`ment in total symptom score at day 7 (Fig 1), total nasal score at day 3, and total
`ocular score at day 7 (P<.05). Greater improvement with loratadine plus BDP was
`also noted in several individual symptoms. These included less nasal itching on
`days 3 and 7, less sneezing on day 3, less eye itching and tearing on day 7 (P<.05),
`and decreased eye redness on day 7 (P = .07). The two groups did not differ in
`effects on nasal discharge or nasal stuffiness;
`
`344
`
`M, A. Drouin et al
`Loratadine plus Nasal Steroids in SAR
`
`

`

`0 Placebo + BDP
`Iii Loratadine + BDP
`
`*
`
`Fig 1. TotaJ symptom score.
`
`... C
`
`G)
`E
`G)
`>
`0 ...
`a.
`.E
`~ 0
`
`80
`
`60
`
`40 -
`
`20 -
`
`0
`
`3
`
`7
`
`Evaluation Day
`
`"P<.05.
`
`The last non-nasal score, ear/palate itching, was considerably different-between
`the two groups at both evaluation days (P<.05). At day 7, this symptom had
`improved 80% in the loratadine plus BDP group, compared with 50% in the
`placebo plus BDP group.
`Figs 2 and 3 illustrate the physicians' and patients' global evaluation at the
`endpoint of the study. Physician evaluation showed that 84% of patients in the
`loratadine plus BDP group had a good to excellent response, compared with 71 % of
`patients in the placebo plus BDP group (P<.05). In ·the loratadine plus BDP group
`34% of patients had an excellent response, ~ompared with only 17% _in the placebo
`plus BDP group. Similarly, patient evaluation showed that 90% of patients in the
`loratadine plus BDP group had a good to excellent response, compared with 73% of
`those receiving placebo plus BDP (P<.05). Again, the percentage of patients who
`rated the treatment effect as excellent was substantially greater in the loratadine
`plus BDP group than in the placebo plus BDP group (39% vs 19%, respectively).
`
`Safety
`Both groups reported similar incidence and types of adverse effects (Table 3).
`Twenty-three (30%) patients in the loratadine plus BDP group and 20 (26%) patients
`in the placebo plus BDP group reported treatment-related adverse events. Somnol(cid:173)
`ence was reported by 4 (5%) patients receiving loratadine and 5 (6%) patients
`receiving placebo. No patient dropped out of the study because of adverse effects.
`
`Advances In Therapy-
`Volume 12 No. 6, November/December 1995
`
`345
`
`

`

`Fig 2. Physicians' global evaluation at endpoint·
`
`Loratadine + BOP
`
`Placebo + BOP
`
`Good
`50%
`
`Good
`54%
`
`Fair
`11%
`
`· P<.05 for comparison.
`
`Fig 3. Patients' global evaluation at endpoint.•
`
`Loratadine + BOP
`
`Placebo + BOP
`
`Good
`51 %
`
`Excellent
`39%
`
`Good
`54%
`
`Excellent
`17%
`
`Poor+ Failure
`5%
`
`Fair
`24%
`
`Excellent
`19%
`
`Poor+ Failure
`9%
`
`18%
`
`Fair
`3%
`
`7%
`
`'P<.05 for comparison.
`
`346
`
`M. A: Drouin ct al
`Loratadinc plus Nasal Steroids in SAR
`
`

`

`Table 3. Adverse Experiences·
`
`Dry mouth
`Fatigue
`Headache
`Nasal burning
`Nasal irritation
`Rhinitis
`Sneezing
`Somnolence
`
`No. (%) of Patients
`Placebo+ BOP
`loratadine + BOP
`(n = 78)
`(n = 77)
`
`(1)
`3 (4)
`2 (3)
`4 (5)
`3 (4)
`4 (5)
`2 (3)
`4 (5)
`
`3 (4)
`4 (5)
`1 (1)
`4 (5)
`1 ( 1)
`1 (1)
`1 (1 )
`5 (6)
`
`'Treatment-related adverse experiences reported by more than one patient.
`
`DISCUSSION
`·21 studies in
`Although some authors have found no difference in effectiveness,17
`which an intranasal corticosteroid has been directly compared with a nonsedating
`antihistamine have generally shown that steroid nasal sprays control nasal symptoms
`more effectively.15•18•22•23 Clinically, patients respond differently following treatment
`of allergic rhinitis with antihistamines or .intranasal steroids. Antihistamines relieve
`p.ruritus, sneezing, rhinorrhea, and ocular symptoms but do not control nasal stuff(cid:173)
`iness. Intranasal steroids can attenuate all nasal symptoms but are most effective
`against stuffiness and rhinorrhea. Thus, treatment that combines an antihistamine
`and a steroid nasal spray may maximize clinical efficacy.
`Backhouse and colleagues24 found that terfenadine reduced SAR symptoms but
`that terfenadine plus flunisolide nasal spray relieved symptoms more effectively
`than did terfenadine alone. Wihl et al25 showed that astemizole improved rhinitis
`symptoms but that asternizole p]us BDP nasal spray was more effective. Juniper
`et al18 showed that sneezing, nasal obstn1ction, and rhinorrhea were significantly
`improved in patients taking only BDP over those taking only astemizole; BDP plus
`astemizole did not control rhinitis better than did BDP alone. Individuals taking
`astemizole alone or with BDP had fewer ocula~ symptoms and used fewer eye
`drops than those taking BDP alone; eye symptoms were best controlled when
`patients took both medications.
`This study demonstrates that the addition of an antihistamine to topical intra(cid:173)
`nasal steroid therapy improved the control of most SAR symptoms. Loratadine plus
`intranasal BDP improved the symptoms of moderately severe SAR to a greater
`degree than did BDP plus placebo. Patients had significantly improved responses in
`total symptom score as well as in overall nasal and ear/ palate itching scores when
`the two agents were combined. The addition of loratadine also improved ocular
`symptoms. This is not surprising, as nasally administered steroids, because of their
`
`Adv.mct!s In Therapy•
`Volume ·12 No. 6, November/December 1995
`
`347
`
`

`

`localized site of action, cannot be expected to provide control of conjunctivitis, even
`if some studies of intranasal steroids have revealed partial relief of eye symptoms.26
`Patients using BDP plus loratadine had increased symptomatic control of SAR but
`had no more adverse effects than did patients using only BDP.
`
`CONCLUSION
`Oral loratadine added to intranasal BDP improves the treatment of patients with
`SAR. Each drug apparently compensates for the other's shortcomings and enhances
`therapeutic outcome without producing any limiting adverse effects.
`
`REFERENCES
`
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`allergic rhinitis. J Int Med Res. 1989;17:150-156.
`9. Del Carpio J, Kabbash L, Turenne Y, et al. Efficacy and safety of loratadine (10 mg once daily),
`terfenadine (60 mg twice daily), and placebo in the treatment of seasonal allergic rhinitis.
`J Allergy Clin Immunol. 1989;84:741-746.
`10. Oei HD. Double-blind comparison of loratadine (SCH29851), astemizole, and placebo in hay
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`Advances In Therapy-
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