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`2.Salib R:J;Howarth PH-Drug Saf 26(12):pgs.863-93,2003
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`REVIEW ARTICLE
`
`Drug Safely 2003; 26 (12): 863-893
`0114-5916/03/0012-0863/$30.00/0
`
`© Adis Data Information BV 2003. All rights reserved.
`
`Safety and Tolerability Profiles of
`Intranasal Antihistamines and
`Intranasal Corticosteroids in ·the
`Treatment of Allergic Rhinitis
`Rami Jean Salib and Peter Hugo Howarth
`Respiratory Cell and Molecular Biology, Faculty of Medicine, Southampton General Hospital,
`Southampton, United Kingdom
`
`Contents
`
`Abstract ............. , . , .............. , ................................... , ............ , ... , 864
`l . Intranasal Antihistamines: Historical Perspective ............... , ..... , ................. , , .... 866
`2. · Levocabastine: .......................................................................... 866
`2.1 General Overview ...... , ................................... , .... , ........ · ........... 866
`2.2 Tolerability and Safety Profile ......................... , ................................. 867
`2.3 Specific Safety and Tolerability Issues .................................................. 869
`2.3. l Local Tolerability , .............................................................. 869
`2.3.2 CNS Effects ........ , ....................... -.................................... 869
`2.3,3 Cardiovascul.ar Effects ................................................ , ......... 869 ·
`2.3.4 Drug Interactions ............ .' ...................... , ........................... 869 ·
`2.3.5 Use in Pregnancy .............................. : ........... -~ ................... 870
`2.3.6 Other Effects .......................... : ...... , ................. : ................ 870
`-------'-·· Azelc:istlffe .... :·: .. :·.·.·,-; ........ . ·.-.. -.-. >.C;-.- .... .' .... "' .... : ............... a-.. -.-.-.. ·,· .. ·,.,-.., ... -.. -,-. 8-78-
`3.1 General Overview , ... , ... , , , ..... , . , , , .......... , . , . , , . , . , . , ......... , . , , , , , , ..... , . 870
`3.2 Tolerability and Safety Profile, ..... , , , .... , , , , ..... , , , , .... , ........................... 871
`3.3 Specific Safety and Tolerability Issues .................................................. 872
`3.3.l CNS Effects .................................................................... 872
`3.3.2 Cardiovascular Effects ............................................. , , , , , .... , ... 872
`3.3.3 Use in Pregnancy .................. , , .... , . , . , , , . , ......... , , , , , , , , , , , .... , .... 873
`3.3.4 Other Effects . , , , , , . , .... , . , ... , , , : , ...... , ..... , , , , , ..... , , , , . , , , . , ...... , , , , , 873
`Intranasal Corticosteroids , , , , ........ , , . , , , . , ...... , , , . , , , , . , . , ..... , .. , . , ..... , , .... , . , . , 873
`4.1 General Overview , .. , .. , , .... , . , , , , , , ........ , , ...... , .............................. 873
`4.2 Pharmacokinetic Corisiderations , , . , , .......... : .... , ............. : .................... 87 4
`4.3 Tolerability and Safety Profile .......................................................... 877
`21.J.1 Toca1 rnecff .. : . · ....... ~ .................................................. .-.... sn --
`2,-:2~Eff~et-s--eA-Hyf3e-t-A0tamie--Pituit-arv Adrenal-Axis-eAel-GFGWFA-,-,, .. , . , . , .. , .• -. ·, , .. , ... g.7_7-__ ..
`4.3.3,., Other Systemic Effects .. ,,.,.,, .............. , .......... ,,,.,,.,,, ....... , .... ,. 879
`4.3,4 Use in Pregnancy ........ , . , ............ , , , , , , , , ....... , , , , , . , . , , .......... , . , , 879
`5. Specific Corticosteroids , , , .... , .. , ... , , , , , , .. , ... , , . , , , , ............. , . , , ........... , , . , , , 879
`5, l Beclomethasone , , . , ....... , , , , , , . , , . , .... , , , , , ..................................... 879
`5.2 Budesonide ... , . , , , , ....... , , , . , , , . , ................................................ 880
`5.3 Ciclesonide , , , , , , , , , ................................................. : .............. 881
`5.4 Flunisolide ................................................. , ......... , ......... , , , . , , 881
`5.5 Fluticasone Propionate ................... , . , , .. , . , ..... , . , , , . , , , , , , , ... ·.--... _,,,.,.,., 881
`
`4.
`
`

`

`864
`
`Salib & Howarth
`
`5.6 Mometasone ........................................................................ 883
`5.7 Triamcinolone .................................................... -.............. _,.~----... 883
`6. Specific Safety and Tolerability Considerations .....................................• ~, ....... 884
`
`6.1 Paediatric Population ................................................... , . < ......... 884
`
`6:-:z-Pregn·ancy~-- ~ .. : . : ......... -.- ..... -.----:-. · .. --: · ....... ~ :---:---:--~ .......... _. .... '. _.-: . ..... -......... 884'"-
`6.3 The Elderly ................................................. --.. -.-.-. ,.-.-.-.-.-.,--.. ,-.-,-.--.--.. -,-.--.. --.--.88§
`7. Conclusion ............ , , ...... : .. .--.. -........ -... -.- : . -. : .. -.... , ·: ... ., .· ........ -...... : : . -...... -. 885
`-··
`.
`
`Abstract
`
`Intranasal corticosteroids and intranasal antihistamines are efficacious topical
`therapies in the treatment of allergic rhinitis. This review addresses their relative
`roles in the management of this disease, focusing on their safety arid tolerability
`profiles. The intranasal route of administration delivers drug directly to the target
`organ, thereby minimising the potential for the systemic adverse effects that may
`be evrdentwi.th-oraltl:rerapy.· Furi.hermore~Lhe·to-ptcatToute-orde-:ti'v'ery-e.rrn:olesthe
`use of lower doses of medication. Such therapies, predominantly- available as
`aqueous formulations following the ban of chlorofluorocarbon propellants, have
`minimal local adverse effects.
`Intranasal appycation of therapy can induce sneezing _in the hyper-reactive
`nose, and transient local irritation has been described with certain formulations.
`Intranasal administration of corticosteroids is associated with minor nose bleeding
`in a small proportion of recipients. This effect has been attributed to the vasocon(cid:173)
`strictor activity of the corticosteroid molecules, and is considered to accoun~ for
`the very rare occurrence of nasal septa! perforation. Nasal biopsy studies do not
`show any detrimental structural effects within the nasal mucosa with long-term
`administration of intranasal corticosteroids. Much attention has focused on the
`systemic safety of intranasal application. When adinihistered atsfa.ndaid recom~
`mended therapeutic dosage, the intranasal antihistamines do not cause .significant
`sedation or impairment of psychomotor function, effects that would be evident
`when these agents are administeredrorally at a therapeutically relevant dosage.
`The systemic bioavailability of intranasal corticosteroids varies_ from <l % to
`up to 40-50% and influences the risk of systemic adverse effects. Because the
`dose delivered topically is small, this is not a major consideration, and extensive
`studies have not identified significant effects on the hypothalamic-pituitary(cid:173)
`-adrenal axis · with continued treatment. A small effect on growth has been
`reported in one study in children receiving a standard dosage over 1 year,
`however. This has not been found in prospective studies with the intranasal
`corticosteroids that have low systemic bioavailability and therefore the judicious
`choice of intranasal formulation, particularly if there is concurrent corticosteroid
`inhalation for asthma, is prudent. There is no evidence that such considerations are
`relevant to shorter-term use, such as in intermittent or seasonal disease.
`Intranasal therapy, which represents a major mode of drug delivery in allergic
`rhinitis, thus has a very favourable benefit/risk ratio and is the preferred route of
`administration for corticosteroids in the treatment of this disease, as well as an
`important option for antihistaminic therapy, particularly if rapid symptom relief is
`required.
`
`© Adis Data Information BV 2003. All rights reserved.
`
`Drug Safety 2003: 26 (1 2)
`
`

`

`Allergic
`rhinitis
`Intermittent Symptoms are present for <4 days per week or for
`<4 weeks
`Symptoms are present for >4 days per week and
`for >4 weeks
`None of the following items are present: sleep
`disturbance; impairment of daily activities, leisure
`and/or sport; impairment of school or work;
`troublesome symptoms
`One or more of the following items are present:
`impairment of daily activities, leisure and/or sport;
`impairment of school or work; troublesome
`symptoms
`ARIA = allergic rhinitis and its impact on asthma,
`
`Persistent
`
`Mild
`
`Moderate-
`severe
`
`Intranasal Antihistamines and Intranasal Corticosteroids in Allergic Rhinitis
`
`865
`
`Table I. Classification of allergic rhinitis according to ARIA
`guidelines
`
`Parameters
`
`Allergic rhinitis arises following an initial sen(cid:173)
`sitisation phase, in which allergen presentation re(cid:173)
`sults in antibody (IgE) formation and the develop(cid:173)
`ment of atopy. Subsequently, depending upon the
`level of exposure and the -degree of sensitisation,
`allergen can then trigger a humoral response, which
`underlies the clinical disease phase and is manifest(cid:173)
`ed by symptoms such as nasal itching, sneezing,.
`rhinorrhoea and nasal obstruction. Allergic rhinitis
`is a common condition, having increased substan(cid:173)
`tially in prevalence during the 20th century,l1l and
`now represents a global health problem affecting
`10-25% of the world population.l2,3J The socioeco(cid:173)
`nomic impact of allergic rhinitis is consi~erable,
`pa.c-rticularly when not only the direct costs of man-
`the allergen-~duced airway inflammation, which is
`agement but also the indirect costs from reduced
`glucocorticoid-responsive. Furthermore, topical in(cid:173)
`productivity and absenteeism from work are taken
`tranasal therapy allows site-directed treatment with
`into account. These costs do not include the further
`a reduced risk of systemic effects because of the low
`expense of treating conditions associated with aller-
`gic rh,initis, such as asthma, sinusitis, otitis media,
`bioavailability of intranasal antihistamines and in(cid:173)
`tranasal corticosteroids from this site. In blocking
`nasal polyposis, lower respiratory tract infection and
`· dental malocclusion. l4l
`the end-organ effects of histamine intranasal antihis-
`tamines have a rapid onset of effect and can be used
`Previously, based on the timing of exposure,
`allergic rhinitis was subdivided into seasonal and
`as both 'as required' therapy for intermittent disease
`relief and as regular daily therapy in persistent dis(cid:173)
`perennial varieties. Although such a subdivision is
`ease. In general, the clinical profile of therapeutic
`relevant in countries such as UK, this is· not 80 in
`many parts of the world where, because of the nature
`.benefit with intranasal corticosteroids is greater than
`of the. clirnate, typic;:al .se~~onal allergens are in_ fapt
`. with intranasal antihistamines in rhinitis, because of
`tlie more widespread effect ofTiitranasalcorticoster(cid:173)
`perennial. It is also recognised that in those patients
`oids on mucosa! inflammation. Since there is a delay
`who are multisensitised to allergens, such as tree,
`before the anti-inflammatory effect is clinically
`grass and weed pollens, their 'seasonal' disease is
`prolonged. In the recent document on allergic rhini- manifested following initiation of therapy, in(cid:173)
`tis and its impact on asthma (ARIA),l5l the consen-
`tranasal corticosteroids have, until recently, been
`sus was that this classification was no longer ade-
`predominantly used for the treatment of persistent
`disease. The debate is still ongoing, however, con(cid:173)
`quate, and therefore a major change was proposed.
`The ne\Y. classification based on the ARIA guide-
`cerning the safety and tolerability profiles of in(cid:173)
`lines (table I) subdivides <JJJergic rhinitis, in relation
`tranasal antihistamines and intranasal corticoster(cid:173)
`to the duration oLthe .disease, into 'intermittent' or
`oids, particularly in relation to the systemic b10-
`__ _])ey~istent' disease. The severity of aller_gic rhinitis _ . _av~l.a:-_b_iJity of intranasaj_ c;()_rt._i_cost~~9ids and the~
`is also classifiec:l a{'mild' or 'moderate-severe'.
`potential to modify growth in children.
`
`Intranasal"antihistamines and intranasal cortico-
`steroids represent major therapeutic options as
`first-line medications in the management of allergic
`rhinitis because of the prominent role of histamine
`as a mediator of rhinitis and the underlying nature of
`
`This review adopts an evidence-based approach
`to conduct a thorough critical and comparative ana(cid:173)
`lysis of the currently available data, particularly
`concerning the safety and tolerability profiles of
`intranasal antihistamines and intranasal corticoster-
`
`© Adis Data Information BV 2003. All rights reserved.
`
`Drug Safe1Y 2003; 26 ( 12)
`
`

`

`I
`'
`' '
`j : I!
`i I
`I
`
`866
`
`Salib & Howarth
`
`opment of H1 receptor antagonists for clinical use
`aids, in the context of their use as topical therapeutic
`came with the synthesis of the antihistamine,
`agents in allergic rhinitis.
`terfenadine, which, while retainrng peripheral H1
`A computerised literature search of Medline
`receptor antagonist-acti-¥it¾~dici.--n0-t----appgar-t-0-e-rnss~
`(1966-onwards) and .Embase-dat-abases wa&-per-
`the blood-brain hairier_aitdwas.thus devoid of un-.
`formed using the following search terms: allergic
`wanted CNS-antihistarninic effects, such as sedation
`rhinitis, seasonal, perennial, corticosteroids, antihis-
`and impairment of psychomotor functi6n.f 13l Fur(cid:173)
`tamines, intranasal or topical, safety, tolerability. In
`thermore, it had no H2 receptor antagonism, ex- or B-
`addition, abstracts from key meetings have been
`adrenergic receptor antagonism, antiserotoninergic
`i1_1cluded in the search process.
`or antimuscarinic effects.C14l Thus,
`It should be noted, however, that this review is
`in 1981,
`terfenadine was introduced as the first oral non- .
`neither meant to be exhaustive, nor is it intended as a
`sedating antihistamine for the treatment of rhi(cid:173)
`systematic review or meta-analysis. Rather it aims
`noconjunctivitis. This represented a major advance
`to present a balanced perspective, based on the
`in the development of H1 receptor antagonists for
`available evidence in the publishedJiterature, on the
`safety--and-tolera:bility--profiles-ofintranasal -antihis" -~ase-in-- th~-1:fea:tmerJ:t:-ef-rhi:noeonjtm:ctiviti:s:-0ther--:(cid:173)
`tamines and intranasal corticosteroids in the treat-
`orally administered ,non-sedating (second-genera(cid:173)
`tion) H1 receptor antagonists were then launched in
`ment of allergic rhinitis.
`the 1980s and 1990s. Topical H1 receptor antagon(cid:173)
`ists such as levocabastine_ for nasal and ocular ad(cid:173)
`ministration, azelastine for nasal administration, and
`more recently emedastine for ocular administration,
`have subsequently been developed. Topical therapy
`has the advantage of delivering drug effecpvely to
`the target organ while avoiding or minimising sys(cid:173)
`temic adverse effects. Such therapy does have a
`disadvantage, however, in_that if i_t is noHxstemicaj.(cid:173)
`ly bioavailable, .it will modify disease only at that
`site and not disease concurrently manifesting at oth(cid:173)
`er target organ sites. The choice between topical
`therapy and systemic therapy will thus depend upon
`the spectrum of disease and the efficacy to safety
`ratio of therapies.
`
`1. Intranasal Antihistamines:
`Historical Perspective
`
`Histamine H1 receptor antagonists have been the
`mainstay of therapy for allergic rhinitis since they
`were first introduced, following the demonstration
`by Staub and Bovet in 1937 that this class of com(cid:173)
`pounds, newly developed at that time, offers protec(cid:173)
`tion against allergen-induced anaphylaxis.C6l . Al(cid:173)
`though observational studies reported symptomatic
`relief in allergic rhinoconjunctivitis with the earliest
`antihistamines, adverse pharmacological effects,
`such as sedation, dry mouth, and blurred vision,
`limited their widespread acceptance. In addition,
`there was concern that asthma, often associated with
`rhinitis, could be worsened by antihistarninic ther(cid:173)
`apy, C7,8l although this view is no longer held, nor
`indeed is it supported by the available evidence.
`In general, an ethylarnine chain is common to all
`H1 receptor antagonists. Marty of the additional
`properties of this class of compounds, with the ex(cid:173)
`ception of sedation, can be linked to side-chain
`radical structure. Structural engineering of these
`molecules later enabled the synthesis of H1 receptor
`antagonists without the anticholinergic,[9l antiser(cid:173)
`otoninergic,D0l a-adrenergic receptor antagonis(cid:173)
`tic, [l ll or local anaestheticC12l effects evident in earli(cid:173)
`er compounds. The major breakthrough in the devel-
`
`2. Levocabastine
`
`2.1 General Overview
`
`Levocabastine has been reviewed by Noble and
`McTavish.l15l Levocabastine is a potent and selec(cid:173)
`tive H1 receptor antagonist with no appreciable af(cid:173)
`finity in vitro for H2, doparninergic, adrenergic,
`serotoninergic, or cholinergic receptors. The recom(cid:173)
`mended nasal dosage for levocabastine is 0 .1 mg into
`each nostril twice daily and ocular dose is 0.03mg
`administered into each eye twice daily.[16l The nasal
`efficacy of levocabastine has been demonstrated
`
`© Adis Data Information BV 2003. All rights reserved.
`
`Drug Safety 2003; 26 (12)
`
`

`

`al Antihl·stamines and Intranasal Corticosteroids in Allergic Rhinitis
`Jntranas
`
`867
`
`fluticasone propionate was found to be significantly
`more effective than levocabastine in the treatment of
`seasonal allergic rhinitis.l21,281 Another study, which
`assessed nasal nitric oxide levels as a marker of
`underlying nasal inflammation, reported a signif(cid:173)
`icant effect with nasal corticosteroids but not with
`topical levocabastine. 1291 Comparative studies in
`perennial rhinitis are limited. A preliminary 2-week
`study reported improvement in sneezing and rhinor(cid:173)
`rhoea with topical levocabastine compared with pla(cid:173)
`cebo, which could not be further improved by the
`addition of topical nasal beclomethasone dipropion(cid:173)
`ate. l30l Nasal blockage, however, did respond to the
`additional therapy.
`Levocabastine is available as a 0.5 mg/mL
`microsuspension (0.05% levocabastine hydrochlo(cid:173)
`ride) nasal spray and eye drops. The recommended
`dosage in adults and children>9 years of age is two
`sprays into each nostril twice daily and one drop ~to
`each eye twice daily, both of which could be m(cid:173)
`creased to three to four times daily. Given the renal
`route of excretion, levocabastine should be used
`with caution in patients with renal impairment. l3ll
`Dosage recommendations for the elderly population
`are notcurrently available. This is a reflection of the
`relative rarity of allergic rhinitis in this age group.
`
`under challenge conditions.r11,181 It has a rapid onset
`of action (10-15 minutes) and is effective for up to
`12 hours. These findings have been confirmed in the
`+; al hall
`ere r1s,19J
`eye usmg conJuncu v c
`enb .
`•
`•
`Administered topically, levocabastine is most ef(cid:173)
`fective against nasal itching, sneezing, and rhinor(cid:173)
`rhoea. There are a number of published placebo(cid:173)
`controlled trials in seasonal allergic rhinitis, l20·211 but .
`the majority of studies report comparisons with ac(cid:173)
`tive medications, such as oral H1 receptor antagon(cid:173)
`ists,l22,23l sodium cromoglycate (cromolyn sodi(cid:173)
`um),l20,24l or intranasal corticosteroids.[221 One pla(cid:173)
`reported no effect of
`cebo-controlled study
`levocabastine on nasal obstruction in patients with
`seasonal allergic rhinitis due to mountain cedar,
`when used at a dosage of 0.2mg t\Vice daily (1 spray
`into each nostril twice_ daily,), despite clear effects. on
`the neurally-mediated symptoms of itching, sneez(cid:173)
`ing, and rhinorrhoea. l211 Regular therapy with levo(cid:173)
`cabastine is reported to be more effective than a
`_ topical antihistamine/decongestant (naphazoline/
`·a.11tazoline) preparationl221 or topical sodium cromo(cid:173)
`glycateI20,24l in the treatment of allergic rhinoc~n(cid:173)
`junctivitis. A comparative study of levocabastme
`(0.5 mg/mL, two sprays into each nostril four times
`daily) and sodium cromoglycate (20 mg/mL, · two
`2.2 Tolerability and Safety Profile
`sprays into each nostril four times daily) involving
`114patients over a 2-w~e_k period1_found s~nific~t~---- __ -~---- _ -~~--- --'----'--'-'-'---- -----~(cid:173)
`The rationale for the use of a medication for the
`symptomatic improvement in allergic rhinitis with
`levocabastine therapy (76% patients on levocabas-
`treatment of a condition is based on assessing the
`251
`drug's potential for beneficial and adverse effects.
`tine improvingvs 46% on sodium cromoglycate)J
`Similar results with more symptom-free days in the The major advantage of the second-'generation H1
`levocabastine-treated patients were found in another
`receptor antagonists, which significantly improved
`study_[
`1 An open observational study comparing
`their benefit/risk profile, was considerably reduced
`efficacy and the onset of action of topical levocabas-
`or absent CNS sedative effects when used at
`tine nasal spray and eye drops as well as nedocromil
`standard clinical dosages. Not all new H1 receptor
`nasal spray and eye drops showed that >80% of
`antagonists, including levocabastine, exhibited this
`patients--witl1--seasonaLallei:gic_rhinitis reported
`beneficial profile when administered orally. Thus _
`~-symptom relief with both medications wj_ll:J.i°' ?ne _ - levocabastin@,--0n-aGcount of-its relplar-kable potene-y--(cid:173)
`hour, a.mounting to approximately a 50% reductron
`as an Hi receptor antagonist, was subsequently de-
`261
`in symptOIJJ- severity. l
`veloped for topical use. Because of the small volume
`of delivery, only those H1 receptor antagonists with
`While,levocabastine nasal spray has been report-
`ed to be as efficacious as topical nasal corticoster-
`reasonable solubility and high potency are suitable
`oids in allergic rhinitis,l22l the comparative data cur-
`for delivery by topical route. Topical therapy mini(cid:173)
`rently available do not support this view. Intranasal mises the potential for systemic adverse effects
`
`2o
`
`© Adis Data Information BV 2003. All rights reserved.
`
`Drug Safety 2003; 26 (12)
`
`

`

`868
`
`Salib & Howarth
`
`hours.f34l Renal dysfunction may, therefore, be asso(cid:173)
`while preserving the therapeutic benefits. Concern
`ciated with decreased elimination of the d!ug.[ 15,311
`that the effect of topical therapy might be limited by
`The tolerability profile o:( Iev'ocabastine nasal
`rhinorrhoea has not been substantiated. When exper-
`spra.y··has··oeen extensrv-ely evaiuated m clinical
`imentally-indu_c~d .rhinorrho_ea._with .methacholine
`was followed by• intranasal levocabastine adminis-
`trials. The available ·data -suggesnhar topical le Vo- ·
`tration and nasal lavage· · with saline 30 secohds
`cabastine is well tolerated, with an adyerse effect
`profile comparable with that of topit'~ sodium
`following intra.nasal levocabastine administration,
`cromoglycate and placeboJ21,38-41J A review of the
`there was no evidence of reduction in the efficacy of
`adverse events reported in 1758 patients who re(cid:173)
`levocabastine
`in
`inhibiting histamine-induced
`srieezing and rhinorrhoea. [321
`ceived levocabastine nasal spray in clinical trials
`identified that most common adverse events en(cid:173)
`Levocabastine is absorbed following intranasal
`countered were headache (4%), nasal irritation
`administration, with systemic bioavailability typi-
`(3%), somnolence (3%) and fatigue (2%))421 None
`cally ranging between 60-80% after a single-dose
`nasal administration, [331 with peak plasma concen-
`of these occurred more frequently than would hay_e __
`tration (Cmax) reached. after 1-4 hoursJ34,I5T C-m~ax-_,,,__be-::.en·:;;:~ticipated with placebo under· similar.circum(cid:173)
`stances. In a multicentre, double-blind, placebo-con(cid:173)
`values of 0.78 µg/L and 1.76 µg/L were reached 2:9
`and 4.3 hours following nasal application of 0.1mg
`trolled trial evaluating the efficacy and safety of
`and 0.2mg single doses, respectively, in healthy
`levocabastine nasal spray for seasonal allergic rhini(cid:173)
`volunteers.l351 Similar values were obtained follow-
`. tis, the incidence of adverse· events was similar for
`ing repeated ad!ninistration of levocabastine.[361 In
`both the treatment and placebo groups.f21l In this
`another study, administration of levocabastine nasal
`study, most of the adverse events were mild an.d
`spray (0.2mg) to non-atopic volunteers produced a
`linked with the disease process, with the most fre(cid:173)
`peak plasma concentration range of 1.4-2.2 µg/L.f34l
`fo each
`quently reported being sinusitis (17%
`Detailed pharmacokinetic-pharmacodynamic test-
`group), headache (I 7% with placebo, 14% with
`levocabastine), and rhinitis (8% with placebo, 2%
`ing has indicated that the clinical benefits evident
`with levocabastine can be attributed to the local with_levocabastine)_f21l Tliis.profil~ of adverse event
`antihistaminic effects at the site or application. r37l
`reporting is similar to that in numerous other clinical
`trials of topical levocabastine_l23,3941 ,43-47l In sepa(cid:173)
`Coupled with the fact that levocabastine is subject to
`rate studies, the overall incidence of adverse events
`minimal hepatic metabolism, a potential site for
`important drug interactions, these findings suggest
`has been comparable for levocabastine and placebo
`(27% vs 31 %)l42l and (30% vs 32%).[481 A double(cid:173)
`theoretically that the likelihood of systemic adverse
`blind parallel-group study (n = 27) comparing the
`effects with nasal administration of levocabastine is
`extremely low. With repeated doses of intranasal
`safety and efficacy of topical levocabastine with that
`of oral terfenadine over an 8-week treatment period,
`levocabastine in healthy volunteers, steady-state
`plasma concentrations are reached within 7-10
`found the incidence of adverse events lower, at 31 %,
`days. The extent of drug absorption appears to be
`in the levocabastine group compared with-43% in
`the terfenadine groupJ43J Other reports suggest a
`related to the method of administration of top