Clinical approach to diagnosis and treatment of nonallergic rhinitis.
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Endoscopy↗
Biomedical subjects
Mark S Dykewicz
Publications and source records attributed to Mark S Dykewicz.
Efficacy of montelukast during the allergy season in patients with chronic asthma and seasonal aeroallergen sensitivity.
BACKGROUND: Montelukast has proven efficacy in the treatment of chronic asthma and seasonal allergic rhinitis, but it has not been evaluated in the subpopulation of asthmatic patients with seasonal asthma symptoms. OBJECTIVE: To determine the effectiveness of montelukast treatment in improving the control of asthma symptoms during the allergy season in patients with active asthma and seasonal aeroallergen sensitivity. METHODS: Adults with a history of chronic asthma who are also symptomatic during the allergy season and with skin test sensitivity to seasonal aeroallergens were enrolled in a randomized, parallel-group, multicenter study with a 1-week, single-blind, placebo run-in period followed by 3 weeks of double-blind treatment during the spring of 2004. After the run-in period, eligible patients were randomly assigned to receive either oral montelukast (10 mg) or placebo. Daytime and nighttime asthma symptom scores, beta-agonist use, and morning and evening peak expiratory flow rates were recorded daily using an electronic diary. The primary end point was mean change from baseline to week 3 in the daytime asthma symptom score. RESULTS: Of 455 randomized patients, 433 completed the study. Compared with placebo, treatment with montelukast resulted in a significant improvement from baseline in the daytime asthma symptom score (-0.54 vs -0.34; P = .002) and in beta-agonist use, nighttime symptoms, and peak expiratory flow rates. Few patients in the montelukast and placebo groups discontinued study participation because of asthma (1.3% and 3.0%, respectively). CONCLUSION: In patients with chronic asthma and seasonal aeroallergen sensitivity, montelukast treatment provided significant asthma control during the allergy season compared with placebo.
Acetates↗
Role of intradermal skin tests in the evaluation of clinically relevant respiratory allergy assessed using patient history and nasal challenges.
BACKGROUND: Skin testing, correlated with patient history, is the accepted method of identifying clinically relevant aeroallergen sensitivity. Traditionally, intradermal tests are believed to be more sensitive in identifying aeroallergen sensitivity than the epicutaneous and percutaneous methods. Therefore, many allergy practitioners use the epicutaneous or percutaneous method first and, if the results are negative, follow up with intradermal tests. OBJECTIVES: To compare the epicutaneous, percutaneous, and intradermal methods to determine their sensitivity to patient history and to evaluate the value of intradermal tests when epicutaneous and percutaneous test results are negative. METHODS: Participants were evaluated for rhinoconjunctivitis symptoms and then were skin tested using the prick and Multi-Test II (MTII) methods. Intradermal tests were performed when prick and MTII test results were negative to an aeroallergen. Participants with negative prick and MTII test results and corresponding positive intradermal test results underwent nasal challenges with evaluation by anterior rhinomanometry. RESULTS: Compared with patient history, average sensitivity for MTII was 77% and for the prick method was 62%. When MTII results were negative, 17% of intradermal tests corresponded with probable patient histories of allergy but none with positive nasal challenge results. Nasal challenge results were similar to those of the negative control group and significantly different from those of the positive control group (P < .001). CONCLUSIONS: The MTII tests are more sensitive and equally specific compared with the prick method. When MTII results are negative, positive intradermal test results are unlikely to identify clinically relevant aeroallergen sensitivity. Routine performance of intradermal tests when MTII results are negative is likely to be of low clinical yield.
Adolescent↗
Fresh frozen plasma in the treatment of resistant angiotensin-converting enzyme inhibitor angioedema.
BACKGROUND: Angioedema, particularly of the head and neck, is a well-recognized adverse effect of angiotensin-converting enzyme (ACE) inhibitors. Most cases respond to conventional therapy, including antihistamines and corticosteroids. Severe episodes may require epinephrine and intubation. OBJECTIVE: To report the case of a patient with ACE inhibitor-induced angioedema treated with fresh frozen plasma (FFP). METHODS: The patient is a 43-year-old, white woman who first received the ACE inhibitor ramipril in March 2002. After 3 weeks, she developed angioedema of her lips and fingers, which resolved with antihistamines, corticosteroids, and one dose of epinephrine. A low dose of ramipril was restarted 4 days later, which was increased throughout 4 days. In late August 2002, she developed severe upper lip and tongue edema recalcitrant to conventional therapy. Her C1 esterase inhibitor level was normal. RESULTS: After 4 days of treatment with antihistamines, corticosteroids, epinephrine, antileukotrienes, cyclosporine, and intravenous immunoglobulins, the patient's tongue swelling continued to recur and became more severe. Two units of intravenous FFP was given, with rapid improvement and no further recurrence of tongue swelling. CONCLUSIONS: In our patient, FFP was highly successful in the treatment of resistant, life-threatening angioedema due to an ACE inhibitor. The benefit of FFP in this setting might be due to the effect of kininase II in breaking down accumulated bradykinin.
Adult↗
Clinical implications of the allergic rhinitis-asthma link.
A possible link between allergic rhinitis (AR) and allergic asthma has long been a subject of debate. Surveys report that up to 78% of asthma patients have AR and 38% of patients with AR have asthma. Evidence points to a causal or coincidental relation between these upper and lower airway diseases. Various agents used to manage one entity have shown benefit in treating the other. The 2001 Allergic Rhinitis and Its Impact on Asthma guidelines call for patients with either condition to be assessed for the other. Medical therapy for AR or asthma should be chosen with awareness of the probable coexistence of these diseases. We present the case for and against the united airway theory proposed to explain the association between these diseases. The roles of various therapies for dually afflicted patients are evaluated, including topical corticosteroids, antihistamines, leukotriene modifiers, anti-immunoglobulin E monoclonal antibody, theophylline, and immunotherapy.
Adolescent↗
Cough and angioedema from angiotensin-converting enzyme inhibitors: new insights into mechanisms and management.
PURPOSE OF REVIEW: Angiotensin-converting enzyme inhibitors are widely prescribed for hypertension and heart failure. These drugs are commonly associated with cough, and are less commonly associated with angioedema, which may be potentially life threatening. This review describes data that extend our understanding of the mechanisms of these reactions, and provides guidance about clinical management. RECENT FINDINGS: For patients who develop angioedema from angiotensin-converting enzyme inhibitors, recent data are reassuring that the majority of such patients can tolerate angiotensin-II receptor blockers. These data support earlier conclusions that most patients with angiotensin-converting enzyme inhibitor-induced cough can tolerate angiotensin-II receptor blockers. Limited case reports suggest that in acute angioedema induced by angiotensin-converting enzyme inhibitors, patients refractory to standard treatment may benefit from the infusion of fresh frozen plasma. SUMMARY: Although data are incomplete, it appears that angiotensin-converting enzyme inhibitors cause cough and angioedema through a cascade of effects that begins with the accumulation of kinins, and then involves arachidonic acid metabolism and nitric oxide generation. Most patients who develop either cough or angioedema from angiotensin-converting enzyme inhibitors can tolerate angiotensin-II receptor blocking agents.
Angioedema↗
Fluticasone propionate aqueous nasal spray improves nasal symptoms of seasonal allergic rhinitis when used as needed (prn).
BACKGROUND: Few published clinical trials document the efficacy of intranasal corticosteroids used as needed for treatment of seasonal allergic rhinitis. OBJECTIVE: To evaluate the efficacy and safety of 4 weeks' treatment with fluticasone propionate aqueous nasal spray 200 microg used as needed (FP200PRN) in patients with seasonal allergic rhinitis. METHODS: A randomized, double-blind, placebo-controlled study in 241 patients (> or = 12 years of age) with a positive skin test result to a relevant fall allergen and who were symptomatic at randomization. The primary endpoint was the mean change from baseline in total nasal symptom score (TNSS; the sum of nasal congestion, rhinorrhea, sneezing, and nasal itching, each rated on a 4-point scale from 0 = none to 3 = severe). RESULTS: The mean percentage of days that patients used the study medications in the FP200PRN and placebo groups was 61.8% (SD = 30.4%) and 70.1% (SD = 28.3%), respectively. Patients treated with FP200PRN had a significantly greater reduction from baseline in TNSS compared with those treated with vehicle placebo (mean +/- SE = -2.02 +/- 0.18 vs -1.06 +/- 0.22, P < 0.001), representing a 91% greater improvement with FP200PRN than vehicle placebo. The FP200PRN group also had a significantly greater (P < 0.001) mean reduction in individual nasal symptoms of rhinorrhea, sneezing, nasal itching, and nasal congestion compared with placebo. FP200PRN was well tolerated, with an incidence of adverse events comparable to vehicle placebo. CONCLUSIONS: FP200PRN in patients 12 years and older is effective for treatment of nasal symptoms associated with seasonal allergic rhinitis. It has a lower incidence of adverse events than typically associated with regular once-daily use.
Administration, Intranasal↗
Symptom severity assessment of allergic rhinitis: part 1.
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Humans↗
7. Rhinitis and sinusitis.
Rhinitis and sinusitis are prevalent medical conditions that are often associated with each other and may result in significant morbidity and medical costs. They can cause systemic symptoms, decrease quality of life, and result in reduced workplace productivity and missed school days. Appropriate management of rhinitis or sinusitis may be an important component in effective management of coexisting or complicating conditions, such as asthma, allergic conjunctivitis, or chronic otitis media. Rhinitis may be caused by allergic, non-allergic, infectious, hormonal, occupational, and other factors. Defining the basis for rhinitis in an individual is important in selection of therapeutic options. Rhinitis and sinusitis may be difficult to distinguish from each other on the basis of history alone. Although most acute upper respiratory infections are viral and do not require antibiotic treatment, persistence of symptoms for > or =7 days makes acute bacterial sinusitis more likely and antibiotics an appropriate consideration. Radiographic imaging is not required for diagnosis of acute, uncomplicated sinusitis, although CT scans are indicated in evaluation of suspected chronic sinusitis or treatment failures. Chronic sinusitis may have an infectious or non-infectious basis. Underlying disorders that predispose to chronic sinusitis should be identified and treated as part of the treatment of chronic sinusitis.
Anti-Bacterial Agents↗
Anaphylaxis and inflammation.
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Anaphylaxis↗