Allergic Rhinitis and ENT Practice: Review and Evidence Emphasis on Fluticasone Furoate

Sequels of Allergic Rhinitis: Around 20% of both adults and children grapple with seasonal or perennial AR, leading to severe complications like asthma, sinusitis, and otitis media with effusion (OME) and respiratory infections. Nearly 37% of patients with seasonal AR are diagnosed with asthma, about 78% of recurrent sinus infections are due to allergy, and 40-50% of pediatric chronic OME present with AR, underscoring the intricate relationship between AR and respiratory conditions (4, 5).

Pharmacological Management of AR: Lacking a single medication capable of rapidly and comprehensively alleviating all symptoms are common pharmacological gap in AR. (6) Antihistamines, Leukotriene receptor antagonists, and corticosteroids are some common pharmacological options that significantly prevent and alleviate nasal symptoms in allergic rhinitis. (7)

Corticosteroids regulate the rate of protein synthesis and increase the synthesis of a protein (lipocortin-1) that inhibits the production of lipid mediators. They reduce the number of circulating T lymphocytes, inhibit T-lymphocyte activation and interleukin production, reduce the circulating numbers of eosinophils and eosinophil influx in the late-phase response, reduce the numbers of circulating macrophages and monocytes, and inhibit the release of cytokines (8).

Fluticasone furoate nasal spray, an FDA-approved glucocorticoid used in AR treatment; exhibits greater potency than others by inhibiting tumour necrosis factor (TNF)-induced Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-ΚB) mediated alkaline phosphatase(ALP) release from human lung epithelial cells and lipopolysaccharide(LPS)-induced tumour necrosis factor(TNF) release from peripheral blood mononuclear cells. (9)

Pharmacokinetically, it has 99.4% plasma-protein binding, and administered once daily at 110 µg, it effectively reduces reflective and instantaneous total nasal and ocular symptom scores (9).

Review of Literature: Clinical Considerations:

Fluticasone Furoate(FF) is More Efficacious than Fluticasone Propionate- Indian Experience: In a comparative, open-label, multicentric clinical trial involving 220 clinically symptomatic adult Indian patients with AR, fluticasone furoate (FF) nasal spray at 110 µg/day was compared to fluticasone propionate (FP) nasal spray at 200 µg/day over a period of 2 weeks. The results demonstrated that FF demonstrated significantly superior efficacy in improving Total Symptom Score (-10.4 ± 3.2) and total nasal symptom score (-7.3 ± 2.2) (including nasal congestion, rhinorrhea, nasal itching, and sneezing) compared to FP with better tolerability than FP. Based on these findings, researchers concluded that FF was not only efficacious but also better tolerated than FP (10).

Fluticasone Furoate(FF) is Superior to Azelastine: In a randomized open-label parallel-group study assessing the efficacy and safety of fluticasone furoate (FF) in clinically diagnosed AR, 150 patients were assigned to receive either FF (27.5 µg/spray) or intranasal Azelastine hydrochloride (0.10%) twice daily. After treatment, by the end of days 7 and 15, FF demonstrated a significant reduction in total nasal symptom score (10.13±0.79 to 2.89±0.70), signs (endoscopic staging) (5.13±0.68 to 1.35±0.55), quality of life scores, eosinophil count, and sensory attributes (34.12±4.23 to 9.74±2.37) compared to azelastine hydrochloride (AH). The study concluded that FF exhibited superior efficacy over azelastine hydrochloride for the treatment of AR. (11).

What Do Guidelines Say?

The Standard Treatment Guidelines Otorhinolaryngology by the Ministry of Health & Family Welfare, Govt. of India (12) suggested using nasal steroid spray, including Fluticasone, on an outpatient basis for AR. The Indian Medical Association (13) also suggested using intranasal corticosteroids (INCS) for moderate-severe intermittent AR, mild persistent, and moderate-severe AR. The Association of Otolaryngologists of India (AOI) (14) also stressed that INCS is the most efficacious medication available for the treatment of AR and non-AR.

The American Family Physician recommended an initiation of INCS, including fluticasone furoate alone for the treatment of AR with symptoms affecting quality of life (15) The Allergic Rhinitis and its Impact on Asthma (ARIA) INCS such as fluticasone furoate for mild intermittent and for moderate/severe intermittent symptoms of AR. (16)

Take-Home Points:

• Allergic Rhinitis (AR) shows an escalating prevalence exacerbated by factors such as urbanization, pollutant exposure, and lifestyle choices, leading to significant economic burdens globally.
• A significant interaction exists between AR and other respiratory conditions due to persistent nasal inflammation and obstruction, often complicating with asthma, sinusitis, and otitis media with effusion.
• Antihistamines, LTRAs are some pharmacological options, significantly preventing and alleviating nasal symptoms in allergic rhinitis
• Fluticasone furoate nasal spray, an FDA-approved glucocorticoid, effectively reduces reflective and instantaneous total nasal and ocular symptom scores.
• Fluticasone Furoate is not only efficacious but also better tolerated than Fluticasone propionate.
• Fluticasone furoate also exhibited superior efficacy over azelastine hydrochloride for the treatment of AR.

References:

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8. LaForce C. Use of nasal steroids in managing allergic rhinitis. Journal of Allergy and Clinical Immunology. 1999 Mar;103(3):S388–94.

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10. Kubavat AH, Pawar P, Mittal R, Sinha V, Shah UB, Ojha T, et al. An open label, active controlled, multicentric clinical trial to assess the efficacy and safety of fluticasone furoate nasal spray in adult Indian patients suffering from allergic rhinitis. PubMed. 2011 Jul 1;59:424–8.

11. Narayana S, Chennakeshavaraju N, M. Mohiyuddin A. Comparative study of the efficacy and safety of intranasal azelastine hydrochloride and fluticasone furoate in the treatment of allergic rhinitis. Journal of Family and Community Medicine. 2020;27(3):186.

12. STANDARD TREATMENT GUIDELINES OTORHINOLARYNGOLOGY (ENT) Ministry of Health & Family Welfare Govt. of India [Internet]. [cited 2024 Feb 26]. Available from: http://www.clinicalestablishments.gov.in/WriteReadData/87.pdf.Indian Medical Association (IMA). (n.d.). Allergic Disorder: Simplify Allergic management in India. Retrieved on 18th March, 2024. Available from: Allergy Booklet Design Final Print Normal Resolution File 230123 (ima-india.org).

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