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      Management of persistent allergic rhinitis: evidence-based treatment with levocetirizine

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          Abstract

          Allergic rhinitis (AR) is a major health problem that can significantly impair quality of life (QoL). The former classification of AR comprises seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR), which do not adequately reflect the clinical course and presentation of AR. The Allergic Rhinitis and its Impact on Asthma (ARIA) classification is based on the duration of symptoms and their severity. Persistent AR (PER) is experienced for periods longer than 4 days/week and for more than 4 consecutive weeks, and may feature mild or moderate-to-severe disease based on the impairment of QoL and symptom severity. Oral antihistamines are a standard treatment option in AR. New second generation antihistamines have a rapid onset of action, are highly effective on AR symptoms, and some were even shown to relieve nasal congestion. Levocetirizine is a potent histamine H 1-receptor antagonist with proven efficacy in both SAR and PAR, and it is the best studied therapeutic option in persistent AR. The Xyzal in Persistent Rhinitis Trial (XPERT™) studied 551 patients with PER, showing that levocetirizine (5 mg/day compared with placebo) significantly improved nasal symptoms as early as the first week and for the 6 months of study, with significant improvement in nasal congestion after 6 weeks of treatment. Levocetirizine also improved QoL, was well tolerated, and produced substantial societal and employer cost savings. Thus, levocetirizine is the first tested standard treatment for PER using ARIA classification, and shows prompt short-term and long-term relief of symptoms, improves patients' QoL, and provides economic benefits to employers and the society.

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          Most cited references 52

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          Prevalence and rate of diagnosis of allergic rhinitis in Europe.

           S E Durham,  V Bauchau (2004)
          To measure the prevalence of allergic rhinitis among European adults and the proportion of undiagnosed subjects, a two-step, cross-sectional, population-based survey in Belgium, France, Germany, Italy, Spain, and the UK was undertaken. Step one of the study involved screening for allergic rhinitis by telephone interview, based on history of symptoms and/or self-awareness of the condition. Step two undertook confirmation of allergic rhinitis in a subset of the subjects screened positive; this was performed by a clinical diagnosis conducted in three to five clinical centres per country, including specific immunoglobulin E tests and a disease-specific questionnaire. A total of 9,646 telephone interviews were conducted between February and April 2001. Self-awareness of allergic rhinitis was reported by 19% of the subjects. Physician-based diagnosis of allergic rhinitis was reported by 13% of the subjects. In step two, 725 clinical assessments were conducted between May and August 2001. A total of 411 of patients, who underwent step two, had investigator-confirmed allergic rhinitis. Among patients with investigator-confirmed allergic rhinitis, 45% had not reported a previous diagnosis by a physician. Prevalence of subjects with clinically confirmable allergic rhinitis estimated by combining step one and step two data ranged from 17% in Italy to 29% in Belgium with an overall value of 23%. This large-scale study confirms that allergic rhinitis has a high prevalence in western Europe and is frequently undiagnosed.
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            Long-term clinical efficacy of grass-pollen immunotherapy.

            Pollen immunotherapy is effective in selected patients with IgE-mediated seasonal allergic rhinitis, although it is questionable whether there is long-term benefit after the discontinuation of treatment. We conducted a randomized, double-blind, placebo-controlled trial of the discontinuation of immunotherapy for grass-pollen allergy in patients in whom three to four years of this treatment had previously been shown to be effective. During the three years of this trial, primary outcome measures were scores for seasonal symptoms and the use of rescue medication. Objective measures included the immediate conjunctival response and the immediate and late skin responses to allergen challenge. Cutaneous-biopsy specimens obtained 24 hours after intradermal allergen challenge were examined for T-cell infiltration and the presence of cytokine-producing T helper cells (TH2 cells) (as evidenced by the presence of interleukin-4 messenger RNA). A matched group of patients with hay fever who had not received immunotherapy was followed as a control for the natural course of the disease. Scores for seasonal symptoms and the use of rescue antiallergic medication, which included short courses of prednisolone, remained low after the discontinuation of immunotherapy, and there was no significant difference between patients who continued immunotherapy and those who discontinued it. Symptom scores in both treatment groups (median areas under the curve in 1995, 921 for continuation of immunotherapy and 504 for discontinuation of immunotherapy; P=0.60) were markedly lower than those in the group that had not received immunotherapy (median value in 1995, 2863). Although there was a tendency for immediate sensitivity to allergen to return late after discontinuation, there was a sustained reduction in the late skin response and associated CD3+ T-cell infiltration and interleukin-4 messenger RNA expression. Immunotherapy for grass-pollen allergy for three to four years induces prolonged clinical remission accompanied by a persistent alteration in immunologic reactivity.
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              Advances in H1-antihistamines.

               F Simons (2004)
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                December 2005
                December 2005
                : 1
                : 4
                : 265-271
                Affiliations
                [1 ]Unitat de Rinologia, Servei d'Otorinolaringologia, ICEMEQ, Hospital Clinic, IDIBAPS Barcelona, Spain
                [2 ]Department of Oto-Rhino-Laryngology, University Hospital Ghent, Belgium
                [3 ]Clinique des Maladies Respiratoires, University Hospital and INSERM U454, Hospital Arnaud de Villeneuve CHU Montpellier, France
                Author notes
                Correspondence: Joaquim Mullol Unitat de Rinologia, Servei d'Otorinolaringologia, Hospital Clinic, Barcelona, Spain Tel + 34 93 227 9872 Fax + 34 93 451 5272 Email jmullol@ 123456clinic.ub.es
                Article
                1661632
                18360569
                © 2005 Dove Medical Press Limited. All rights reserved
                Categories
                Review

                Medicine

                antihistamines, allergic rhinitis, levocetirizine, quality of life, societal costs

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