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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Update on the Management of Allergic Rhinitis With Emphasis on Antihistamines


GOAL
The goal of this issue is to provide physicians with the most current information available for the treatment and management of allergic rhinitis.

TARGET AUDIENCE
This activity is designed for allergists, otolaryngologists, pulmonary specialists, and primary care physicians.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Utilize currently available antihistamines in allergic rhinitis based on their efficacy, safety, and efficiency profiles.
  • Recognize the differences among currently available antihistamines with respect to central nervous system side effects.
  • Evaluate and manage patients with asthma and allergic rhinitis in the context of a syndrome that affects the entire airway tree.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association (AMA) Physicians' Recognition Award. Each physician should only claim those hours of credit that he/she actually spends on this educational activity. Credits are available until the expiration date of November 30, 2004.

This continuing education activity was produced under the supervision of Alkis Togias, MD, Associate Professor, Department of Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

This program is supported by an unrestricted educational grant from Aventis Pharmaceuticals.

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

The contents of this issue of Advanced Studies in Medicine include highlights from the XXI Congress of the European Academy of allergology and Clinical Immunology, Naples, Italy, June 1-5, 2002.

FACULTY ADVISOR

    Alkis Togias, MD
    Associate Professor
    Department of Clinical Immunology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Togias reports receiving grant/research support from GlaxoSmithKline and Schering-Plough; serving as a consultant to Merck and Alcon; and having received honoraria from AstraZeneca, Merck, and Pfizer.

PARTICIPATING FACULTY

    Sergio Bonini, MD
    Professor
    Institute of Neurobiology and Molecular Medicine
    Italian National Research Council
    Rome, Italy
    • Dr Bonini reports receiving grant/research support from ALK-Abell, Merck Sharp & Dohme, and Schering-Plough; serving as a consultant to and on the speakers bureau for Alcon Allergy Therapeutics, AstraZeneca, Aventis, Bioallergy, GlaxoSmithKline, Hitachi, Italian Ministry of Health, Lofarma, Merck Sharp & Dohme, Novartis, Schering-Plough, Stallergenes, UCB Institute of Allergy, and VSL Pharmaceuticals.

    Stephen R. Durham, MD
    Professor
    Upper Respiratory Medicine
    National Heart & Lung Institute
    Royal Brompton Hospital
    Imperial College School of Medicine
    London, United Kingdom
    • Dr Durham reports having received honoraria from Aventis.

    Ian Hindmarch, PhD
    Professor of Human Psychopharmacology
    Head of the Human Psychopharmacology Research Unit
    Medical Research Centre
    University of Surrey
    Guildford, United Kingdom
    • Dr Hindmarch reports receiving grant/research support from Aventis.

    F. Estelle R. Simons, MD
    Professor
    Head, Section of Allergy and Clinical Immunology
    Department of Pediatrics and Child Health
    University of Manitoba
    Winnipeg, Manitoba, Canada
    • Dr Simons reports receiving grant/research support from Almirall, Aventis, Pfizer, Schering-Plough, and UCB Pharma.

    Scott A. Waldman, MD, PhD
    Samuel M.V. Hamilton Family Chair in Medicine
    Department of Medicine, Biochemistry and Molecular Pharmacology
    Thomas Jefferson University
    Philadelphia, Pennsylvania
    • Dr Waldman reports having received honoraria from Aventis.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

 

Unlocking the Full Potential of Antihistamine Therapy
Alkis Togias, MD,* and Sergio Bonini, MD†

The discovery of histamine-1 (H1)-antagonists occurred in the 1940s due to the work of the Italian Nobel Prize winner Daniele Bovet. However, first-generation antihistamines were associated with significant side effects, particularly anticholinergic effects and marked central nervous system (CNS) effects, including sedation at therapeutic doses. Second-generation antihistamines were introduced in the 1980s, and have subsequently been effectively used in the symptomatic relief of allergic rhinitis, conjunctivitis and urticaria. These antihistamines have fewer anticholinergic and sedative side effects, high specificity for the H1-receptor, as well as claimed additional anti-inflammatory benefits. The debate now ongoing is whether we are moving toward a new era in antihistamine treatment and a third generation of antihistamines.

At the clinical level, several different types of treatment guidelines are available, depending on the disease in question—for example, guidelines exist for the treatment of asthma, conjunctivitis, rhinitis and dermatitis, as well as for immunotherapy. However, many patients often suffer from more than one allergic disease, progressing from one allergy to another (the so-called 'allergic march'). Furthermore, the diagnostic and management pathways of patients with allergic disease are often different, depending on the country they live in, and on the specialists they are referred to. However, the link between allergic rhinitis and asthma, championed in the 'one airway, one disease' hypothesis, has led to a new view of allergic diseases, in which there is one disease requiring one diagnosis, one prescription, and one set of guidelines that integrates the various concepts, as stressed in the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines. From this perspective, antihistamines might have a more relevant role in the overall treatment of the allergic patient than they have in the treatment of individual allergic diseases.

Asthma, rhinitis and conjunctivitis are traditionally considered as separate homogeneous diseases. Increasing understanding of their underlying pathophysiology has, however, suggested that these diseases often occur together with different associations, and that even within a single disease the phenotypes are quite heterogeneous. The presence of a specific immunoglobulin E (IgE) response, polyclonal IgE activation, increased numbers of mast cells and increased mediator release, activation of eosinophils, and tissue hyperreactivity all represent distinct variables, differentially expressed in individual allergic patients. In addition to their indicated use in allergic rhinitis and chronic idiopathic urticaria, antihistamines could also be useful for specific phenotypes with a prevalent Type I hypersensitivity mechanism, independent of clinical symptoms. These considerations might represent one aspect towards unlocking the full potential of these important drugs, which suggest that they may be of use in specific phenotypes of patients, including some asthmatics.

This supplement is based on a satellite symposium, involving globally renowned clinicians, held at the 21st Annual Congress of the European Academy of Allergology and Clinical Immunology in Naples, Italy. The aim of this symposium was to highlight the changing view of antihistamine therapy and to provide an update on the most recent advances in antihistamine therapy. As studies have suggested that higher doses than those currently recommended of the newer antihistamines may be necessary for use in new indications, the presentations focused on safety at higher doses. In addition, the potential for antihistamines as a therapy in alternative allergic diseases was also discussed, particularly in consideration of the safety issues previously presented.

The first presentation focused on differentiating efficacy from potency with regard to antihistamines, comparing clinical data with in vitro data and models of allergic diseases. Studies suggest that a more potent drug is not always clinically superior, and that other properties, such as a lack of selectivity for the H1-receptor, may be more important considerations than potency in terms of safety. Subsequent presentations assessed the CNS safety of antihistamines, particularly at supraclinical doses, highlighting the importance of a nonsedating and nonimpairing safety profile. In addition, the need for rigorous safety testing was stressed and the benefits of antihistamines with a wide therapeutic index in terms of safety and efficacy were discussed. The symposium concluded with a review of the ARIA guidelines and the association between upper and lower airway involvement in allergic diseases, reporting on the link between allergic rhinitis and asthma. Antihistamines with benefits in both the early- and late-phase inflammatory reactions were considered to be of potential use in the treatment of some forms of asthma.

*Associate Professor, Department of Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
†Professor, Institute of Neurobiology and Molecular Medicine, Italian National Research Council, Rome, Italy.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.