The Burden and Treatment of Allergic Rhinitis in the 21st Century Jee YK Dankook University, College of Medicine 1
AGENDA 1 The Epidemiology of Allergic Rhinitis 2 The Impact of Rhinitis on Health Economics and Quality of Life 3 Treatment Approaches to Allergic Rhinitis 4 Unmet Needs and formulation considerations in AR Treatment 6 Ciclesonide; A New Intranasal Corticosteroid
Classification of Rhinitis Allergic Rhinitis IgE-mediated response Previous Classification Seasonal allergic rhinitis (SAR) Perennial allergic rhinitis (PAR) ARIA Classification Intermittent allergic rhinitis (IAR) Persistent allergic rhinitis (PER) Nonallergic Rhinitis Infectious Idiopathic or Vasomotor Eosinophilic Drug-induced Rhinitis Medicamentosa Hormonal Anatomical Quillen D. Am Fam Physician. 2006;73:1583-1590. Settipane RA. Allergy Asthma Proc. 2003;24:147-154. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008
Increasing Prevalence of Allergic Rhinitis in Developed Countries* Subjects (%) 40 34 30 28 23 20 13 10 0 1990 1998 Positive Skin-Prick Test 1990 1998 Allergic Rhinitis *A cross-sectional study of 15- to 41-year-olds in Copenhagen, Denmark. ** Self-reported diagnosis Adjusted odds ratio = 1.94, 95% CI 1.30 2.90. Δ 75% Linneberg A et al. Allergy. 2000;55:767.
Epidemiology and Current Status of Allergic Rhinitis, Asthma in KOREA Subjects (%) Prevalence of Allergic Rhinitis in Korea 30 24.7 21.7 20 16.4 10 0 35 36-50 51 Age (Years) Park HS et al. Asian Pac J Allergy Immunol 2009; 27: 167-171 *A cross-sectional study of 2,467 adults over 20 yr in Korea. ** Self-reported diagnosis p=0.02
Subjects with Allergic rhinitis (%) Prevalence of Allergic rhinitis in patients with bronchial asthma in KOREA Age Asthma Severity 100 100 80 60 82.8 79.4 69.0 59.1 80 60 76.4 75.3 65.7 59.1 40 40 20 20 0 16-29 yrs 30-49 yrs 50-64 yrs 65 yrs 0 Int Mild Per. Mod Per. Sev Per. *A cross-sectional study of 460 patients over 16 yr in Korea. Kim CW et al. Korean J Asthma Allergy Clin Immunol 2007; 27: 248-256
The Impact of Rhinitis on Health Economics and Quality of Life 9
Subjects (%) Degree of Discomfort from Nasal Allergies 60 93% OF SUBJECTS 55 40 38 20 0 6 Can totally ignore Can tolerate but symptoms are noticeable Can not tolerate 1 Not sure Allergies in America Executive Summary. Available at: http://www.mmcpub.com/scsaia/adultsummary.pdf
Most Bothersome of Symptoms Associated With Allergic Rhinitis* Subjects (%) 25 20 22 15 14 14 10 5 10 10 9 7 5 4 4 0 Stuffed up nose Headache Postnasal drip Red, itching eyes Runny Nose Repeated Sneezing Facial Pain Watering Eyes Ear Pain Itching Allergies in America Executive Summary. Available at: http://www.mmcpub.com/scsaia/adultsummary.pdf *Characterized as most bothersome
The Magnitude of the Impact on Daily Life of Nasal Allergies Subjects (%) 30 85% OF SUBJECTS 26 25 20 19 14 15 10 1 0 Symptoms did not Impact daily life Slight Some Moderate Large Extent of Interference with daily life Not Sure Allergies in America Executive Summary. Available at: http://www.mmcpub.com/scsaia/adultsummary.pdf
The Frequency of Impairment of Sleep by Allergic Rhinitis Parameter Wake-up during night Unable to get to sleep Lack of good night sleep 64 75 78 (0%) (100%) Subjects Rhinitis and poor sleep lead to.. daytime somnolence quality of life psychiatric disorders depression, anxiety, or alcohol abuse disorders of learning, behavior, or attention in childhood or adolescence cognitive functioning Juniper EF. J Allergy Clin Immunol. 1994;93:413-423. Craig TJ et al. J Allergy Clin Immunol. 2004;114(suppl 5):S139-S145; Young T et al. J Allergy Clin Immunol. 1999;99(suppl):S757-S762; Stuck BA et al. J Allergy Clin Immunol. 2004;113:663-668; Breslau N et al. Biol Psychiatry. 1996;39:411-418; Chang PP et al. Am J Epidemiol. 1997;146:105-114; Gozal D. Pediatrics. 1998;102:616-620; Owens J et al. Pediatrics. 1998;102:1178-1184.
Subjects with asthma relate symptoms (%) Comparison of Asthma related Symptoms between asthmatics with AR or without AR in KOREA 100 80 60 40 20 P<0.01 61.9 77.3 Asthma alone (n=126) Asthma with AR (n=334) NS 69 68 NS 54 49.4 NS 20.7 26.3 0 Night-time asthma Symptoms Exercise induced asthma symptoms Absent day due to asthma symptoms Speech limitation due to asthma symptoms *A cross-sectional study of 460 patients over 16 yr in Korea. Kim CW et al. Korean J Asthma Allergy Clin Immunol 2007; 27: 248-256
Annual cost / patient ($) Allergy is the 5 th Most Costly Physical and Mental Health Condition 450 Inpatient Outpatient ER Rx 400 Absence STD Presenteeism 350 300 250 200 150 100 50 0 HTN Heart Disease Mental Illness Arthritis Allergy Diabetes Migraine /Headac he Any Cancer Resp. Infec. Asthma Goetzel RZ. J Occup Environ Med. 2004;46:398-412. *Assuming a $23.15/hour wage estimate Depression, sadness, mental illness HTN: hypertension; Resp.: respiratory; STD: short-term disability In United States *
Economic Burden of Allergic rhinitis in KOREA Direct cost Indirect cost Total (in 2007, Mil. Won) In- Patient Out- Patient 244,408 54,027 298,435 5,059 2,610 7,669 Total 249,467 56,637 306,104 Direct cost= direct medical care cost + direct non-medical care cost (transportation cost, nursing cost) Indirect cost: Loss of productivity Report of the Korea Centers for Disease Control and Prevention (KCDC) 2009 A study on Research Methodology and Long-term Planning regarding Estimating of Economic Burden of Major Diseases in Korea.
Treatment Approaches to Allergic Rhinitis 18
ARIA Classification Intermittent < 4 days per week or < 4 weeks Persistent 4 days per week and 4 weeks Mild (all of the following) normal sleep no impairment of daily activities, sport, leisure normal work and school no troublesome symptoms Moderate-severe (one or more items) abnormal sleep impairment of daily activities, sport, leisure abnormal work and school troublesome symptoms Allergic Rhinitis and its Impact on Asthma (ARIA) 2008.
Treatment of Allergic Rhinitis (ARIA) Mild intermittent Moderate -severe intermittent Mild persistent Intranasal corticosteroids Local chromone Moderate -severe persistent Oral or local non-sedative H1-blocker Intra-nasal decongestant (<10 days) or oral decongestant Leukotriene receptor antagonists Allergen and irritant avoidance Immunotherapy Allergic Rhinitis and its Impact on Asthma (ARIA) 2008.
Rhinitis Management Diagnosis of allergic rhinitis Intermittent symptoms Persistent symptoms Check for asthma especially in patients with severe and/or persistent rhinitis Mild Moderate - severe Mild Moderate- severe Not in preferred order oral H 1 -blocker or intranasal H 1 -blocker and/or decongestant or LTRA* Not in preferred order oral H 1 -blocker or intranasal H 1 -blocker and/or decongestant or intranasal CS or LTRA (or cromone) In persistent rhinitis review the patient after 2-4 weeks In preferred order Intranasal CS, H 1 -blocker or LTRA Review the patient after 2-4 weeks Improved Step-down and continue treatment for >1 month Failure Review diagnosis Review compliance Query infections or other cause If failure: step-up If improved: continue for 1 month Add or increase intranasal CS dose Rhinorrhea add ipratropium Blockage add decongestant or oral CS (short term) Failure referral to specialist *LTRA, leukotriene receptor antagonists Allergic Rhinitis and its Impact on Asthma (ARIA) 2008.
Pharmacologic Options for Allergic Rhinitis Agent Sneezing Itching Congestion Rhinorrhea Ocular Oral Antihistamine Nasal Antihistamine Intranasal Corticosteroid Oral Decongestant ++ ++ +/- ++ ++ + + +/- + ++ ++ ++ ++ + + Intranasal Decongestant ++ Intranasal Mast Cell Stabilizer + + + + Topical Anticholinergic ++ provides no benefit + provides modest benefit +/- provides minimal benefit ++ provides substantial benefit Adapted with permission from The AAAAI Allergy Report. Vol. 2, page 19.
Study Intranasal CS vs. oral H1-Antihistamines TOTAL NASAL SYMPTOM SCORE Géhanno Bronsky Munch Favors intranasal CS Favors antihistamine Schoenwetter Van Bavel Berrnstein Beswick Vervloet Wood Overall effect -0.423 (-0.531 to -0.315) -1.5-1.0-0.5 0.0 0.5 1.0 Standardized mean difference (95% CI) Weiner JM et al. BMJ. 1998;317:1624-9. Χ 2 = 26.82; df = 8; P < 0.001
Study Intranasal CS vs. oral H1-Antihistamines NASAL BLOCKAGE Bunnag Simpson Brooks Bernstein Schoenwetter Vervloet Bronsky Munch Géhanno Juniper Darnell Beswick Wood Robinson Favors intranasal CS Favors antihistamine Overall effect -0.628 (-0.729 to -0.527) -1.5-1.0-0.5 0.0 0.5 1.0 Standardized mean difference (95% CI) Weiner JM et al. BMJ. 1998;317:1624-9. Χ2 = 11.76; df = 13; NS
Unmet Needs and formulation considerations in AR Treatment 25
Reasons for Dissatisfaction With AR Medications Wasn't effective 66 Bothersome side effects 21 Effectiveness wore off 12 Didn't provide 24 hour relief Not covered Cost/co-pay Hard to administer Other 1 1 1 2 4 10 Not sure Patients (%) (0) (80) Allergies in America Executive Summary. Available at: http://www.mmcpub.com/scsaia/adultsummary.pdf AR: allergic rhinitis
Perception of Loss of Effectiveness With Chronic Use Not sure 6% No 40% Yes, more than one 38% Yes, one 15% Yes, not sure how many 2% Allergies in America Executive Summary. Available at: http://www.mmcpub.com/scsaia/adultsummary.pdf
Perception of 24-Hour Coverage With Intranasal CS Patients (%) 60 48 46 40 20 6 0 Loses effectiveness Loses effectiveness Does not lose effectiveness Does not lose effectiveness Not sure Not sure Allergies in America Executive Summary. Available at: http://www.mmcpub.com/scsaia/adultsummary.pdf
Commonly Reported Side Effects of Allergy Medicines Occurrence frequency 40 Moderately Extremely 30 20 10 0 11 15 7 7 13 Burning Bad taste Headaches Drowsiness 21 20 22 12 12 13 12 Dripping down throat Drying feeling Allergies in America Executive Summary. Available at: http://www.mmcpub.com/scsaia/adultsummary.pdf
Patients Needs for AR Medications Experience relief within an hour after taking medication Maintains its effectiveness to the designated time you are to take another dose Non-drowsy Lets you wake up with symptoms under control Provides relief all day and into the next morning Fewer doses of medication needed to control allergy symptoms Comes in various forms Total allergy sufferers (n=1,000) 69 68 67 63 62 45 23 (0%) (80%) Long AA. Clin Ther 2007; 29:342-51. online interviews (16-item questionnaire) Adults (aged _>18 years) with physician-diagnosed allergic rhinitis in the United States
Ciclesonide A New Intranasal Corticosteroid 32
Mechanisms of GCS
Mechanisms of GCS
Mechanisms of GCS Inflammatory cells Eosinophil Numbers (apoptosis) T-lymphocyte Cytokines Structural cells Epithelial cell Cytokines Mediators Endothelial cell Leak Numbers Mast cell GCS Airway smooth muscle β2-receptor Macrophage Cytokines Cytokines Dendritic cell Numbers Mucus gland Mucus secretion
System brain bone endocrine eyes gastrointestinal muscle psychological sexual, female sexual, male skin others Side effect loss of brain tissue, loss of cognition avascular necrosis of the bone, osteoporosis, osteonecrosis suppression of adrenal response, widespread endocrine dysfunction, Cushing's Syndrome, diabetes, fluid retention cataracts, glaucoma, range of other side effects, gastrointestinal hemorrhage, indigestion, worsening of peptic ulcer loss of skeletal muscle, myopathy (muscle weakness) dementia, changes in mood menstruation disturbance decrease testosterone skin atrophy, thinning, bruising impaired healing, weight gain, increased risk of infection
Directions of development Development of new drugs Developments of new steroid-changes of structures Effectiveness Binding affinity Delivery ADR Route of administration Less mineralocorticoid action Rapid systemic metabolism Low oral bioavailability Proactive forms
Requirements for New AR Medications Effective Fast acting 24-hour coverage No tachyphylaxis Minimal side effects Little burning, drying, and bad taste No systemic side effects Comfortable to use Less run out of nose Less drip down throat Meltzer EO. Ann Allergy Asthma Immunol. 2007;98:12-21.
Hydrocortisone Prednisolone Fluticasone propionate Budosonide Ciclesonide
Bioactivation of Ciclesonide and Fatty Acid Lipid Conjugation of Des-Ciclesonide HO CH 3 CH 3 O O O O O H Intracellular airway esterases HO CH 3 CH 3 OH O O O H O Ciclesonide (Inactive Parent Compound) O O Des-Ciclesonide (Active Metabolite) O-fatty acid esters O-fatty acid esters HO CH 3 O O H CH 3 O O C-21-lipid conjugates des-cic: desisobutyryl-ciclesonide Sato et al. Biopharm. Drug Dispos 2007;28: 59 64.
Steroid concentration in rinsing solution, nmol/l CIC, Des-CIC vs Fluticasone Oropharyngeal Deposition 4,000 CIC des-cic FP 3,000 2,000 1,000 0 0.0 0.2 0.4 0.6 0.8 1.0 Time, hours Richter K, et al. Am J Respir Crit Care Med. 2002;165:A189. Abstract A48.
Drug R Binding Affinity Lung dilivery (%) Protein binding (%) Oral Bioavailibility (%) Systemic Clearance (L/h) Distributti-on (L) IV Half-life (h) Inhlaed Beclomethasone dipropionate/17- monopropionate b 0.4/13.5 50 60 87 20/40 150/120 20/424 0.5/2.7 UK/2.7 Budesonide 9.4 15 30 c 88 11 84 280 2.8 2.0 Ciclesonide/de sciclesonide b 0.12/ 12.0 50 99/99 <1/<1 152/228 207/897 0.36/ 3.4 0.5/4.8 Flunisolide 1.8 68 80 20 58 96 1.6 1.6 Fluticasone propionate Mometasone furoate 18 20 c 90 1 66 318 859 7.8 14.4 23 d 11 d 99 <1 53 152 5.0 UK Triamcinolone acetonide 3.6 22 71 23 45 69 103 2.0 3.6
Metabolism of Ciclesonide in Human Nasal Epithelial Cells Amount (pmol/dish) 30 Ciclesonide Des-ciclesonide 20 10 0 0.5 3.0 6.0 24.0 (hrs) Sato et al. Biopharm. Drug Dispos. 2007;28: 59 64.
Formulation Aspect of INCS ; Hypotonic Intranasal Delivery System Sato et al. BMC Pharmacology 2007;7:7-14. Hypotonic suspension Isotonic suspension Shrinking matrix H 2 O H 2 O Water diffuses with drug H 2 O H 2 O H 2 O H 2 O H 2 O Adherence to nasal mucosa Collapse of matrix Powder like Longer retardation of ciclesonide on mucosa High local ciclesonide concentration and increased its absorption into mucosal tissue Increased des-cic in mucosal tissue Rapid clearance into esophagus with drug diffusion Insufficient ciclesonide absorption Lower concentration of ciclesonide and des-cic in mucosal tissue
Persistence of Hypotonic Ciclesonide Formulation in Rabbit Nasal Mucosa % of Dose administered 50 40 30 min 30 20 120 min 30 min 10 120 min 0 Hypotonic suspension Isotonic suspension Wingertzahn MA. J Allergy Clin Immunol. 2006;117(suppl):S260.
Formulation-Dependent Run-off Into the Rabbit Esophagus Percent of original dose in esophagus 100 80 60 40 20 0 Isotonic suspending formulation (n = 6) Hypotonic suspending formulation (n = 4) 0 5 15 30 Time (min) Wingertzahn MA. J Allergy Clin Immunol. 2006;117(suppl):S260. Statistical analysis not performed
Formulation Aspect of INCS ; Formulation Comparisons Intranasal CS BKC Potassium Sorbate Alcohol Polysorbate Propyleneglycol CMC Ciclesonide (Omnaris) Fluticasone propionate (Flixonase) Triamcinolone acetonide (Nasacort AQ) Mometasone furoate (Nasonex) Budesonide (Rhinocort Aqua) Fluticasone furoate (Avamys) - + - - - + + - +* + - + + - - + - + + - - + - + - + - + - + + - - + - + BKC, benzalkonium chloride; CMC, carboxymethylcellulose * Phenylethyl alcohol Adapted with permission from Meltzer EO. Ann Allergy Asthma Immunol. 2007;98:12-21. Veramyst [Avamys; in Korea] FDA label. GlaxoSmithKline.; 2010.
Clinical Studies 1 Pivotal SAR Study 48
Efficacy and Safety of Ciclesonide Nasal Spray for the Treatment of Seasonal Allergic Rhinitis (SAR) RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, MULTI-CENTER, PARALLEL-GROUP STUDY SAR patients Baseline Period (Day -10 ~ -1) Placebo (n=163) Ciclesonide 200 μg/d QD (n=164) Treatment Period (Day 1 ~ 28) Patient-assessed total nasal symptom score (TNSS) Physician-Assessed overall Nasal signs and symptoms Severity (PANS) Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ) Adverse events Ratner et al. J Allergy Clin. Immunol. 2006;118:1142-1148.
Change from Baseline in the Average of AM and PM reflective TNSS (Day1-28) Change from baseline in the average of AM + PM reflective TNSS Significantly Improved rtnss in SAR 0.0 Placebo Ciclesonide 200μg/d -1.87-2.69 * -1.0-2.0-3.0 *P < 0.001 vs placebo Ratner et al. J Allergy Clin. Immunol. 2006;118:1142-1148. TNSS: Total Nasal Symptom Score (Runny nose, Congestion, Sneezing, Itching)
Changes in Individual components of the TNSS Improvement in Individual Symptom Parameter Ciclesonide Placebo Treatment difference P - value Congestion -0.58 (0.04) -0.32 (0.04) 0.26 <0.001 Itching -0.61 (0.04) -0.41 (0.04) 0.20 0.002 Sneezing -0.61 (0.05) -0.41 (0.05) 0.20 0.003 Runny Nose -0.63 (0.05) -0.41 (0.05) 0.24 <0.001 Ratner et al. J Allergy Clin. Immunol. 2006;118:1142-1148. TNSS: Total Nasal Symptom Score
Clinical Studies 2 Pivotal PAR Study 52
Efficacy and Safety of Ciclesonide for the treatment of perennial allergic rhinitis (PAR) RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, MULTI-CENTER, PARALLEL-GROUP STUDY PAR patients Baseline Period (Day -14 ~ -1) Placebo (n=233) Ciclesonide 200 μg/d QD (n=238) Treatment Period (Day 1 ~ 42) Patient-assessed total nasal symptom score (TNSS) Physician-assessed overall nasal signs and symptoms severity (PANS) Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ) Adverse events Meltzer et al. Ann Allergy Asthma Immunol. 2007;98:175-181.
Change From Baseline in the Avg. of AM and PM Reflective TNSS (Days 1-42, ITT Population) Change from baseline in the average of AM + PM reflective TNSS Significantly Improved reflective TNSS in PAR 0.0 Placebo Ciclesonide 200μg/d -1.89-2.51 * -1.0-2.0-3.0 *P < 0.001 vs. placebo Meltzer et al. Ann Allergy Asthma Immunol. 2007;98:175-181. TNSS: Total nasal symptom score.
Changes in Individual Components of the TNSS Improvement in Individual Symptom Parameter Ciclesonide Placebo Treatment difference P - value Congestion -0.55 (0.04) -0.47 (0.04) 0.09 0.09 Itching -0.64 (0.04) -0.46 (0.04) 0.18 <0.001 Sneezing -0.65 (0.03) -0.46 (0.03) 0.20 <0.001 Runny Nose -0.68 (0.04) -0.50 (0.04) 0.17 0.001 Meltzer et al. Ann Allergy Asthma Immunol. 2007;98:175-181. TNSS: Total nasal symptom score.
Clinical Studies 3 Onset of Action 56
Onset of Action of Ciclesonide in SAR Treatment RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, SINGLE-CENTER, PARALLEL-GROUP STUDY Environmental Exposure Chamber (EEC) Single treatment Screening Phase Priming Phase Placebo (n=251) Ciclesonide 200μg/d QD (n=251) itnss assessed at hourly intervals for 12hrs Patel P et al. Ear Nose Throat J. 2008;87:340-353. * itnss: instantaneous Total Nasal Symptom Score
LS Mean change from baseline in itnss Time to Onset of Action Significant difference vs. placebo at 1 hour after administration 0.0 Ciclesonide (200 µg/day) Placebo -0.5-1.0-1.5-2.0 * * * * * * * * * * * * -2.5 0 1 2 3 4 5 6 7 8 9 10 11 12 Time (hours) Patel P et al. Ear Nose Throat J. 2008;87:340-353. *One-sided P 0.025 versus placebo itnss: instantaneous Total Nasal Symptom Score
Clinical Studies 4 Long-term Safety and Efficacy 59
Need for Long Term Safety and Efficacy Study Intranasal steroids: mainstay treatment for moderate-severe AR Dissatisfaction with AR medication - Long-term effectiveness and concern for tachyphylaxis - Concern for adverse effect, especially to intranasal steroids Intranasal Ciclesonide - Safe and effective in SAR and PAR up to 6 week duration - No long term safety, tolerability and efficacy data Chervinsky P et al. Ann Allergy Asthma Immunol. 2007;99:69-76.
Long Term Safety and Efficacy of Intranasal Ciclesonide RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, MULTI-CENTER, PARALLEL-GROUP STUDY Placebo (n=222) Baseline Period (7-14 days) Ciclesonide 200 μg/d (n=441) Treatment Period (Day 1 to Week 48/52) Treatment-emergent adverse events Ocular exam: IOP, lens opacification 24-hour urine and plasma cortisol 24-hour reflective TNSS, PANS, RQOL Chervinsky P et al. Ann Allergy Asthma Immunol. 2007;99:69-76. IOP: intraocular pressure, TNSS: total nasal symptom score PANS: physician assessed nasal symptom RQLQ: rhinoconjunctivitis quality of life questionnaire
LS Mean change from baseline in the average of 24-Hour reflective TNSS LS Mean change from baseline Improvement of rtnss and QOL 24-Hr Reflective TNSS Over Days 2-365 RQLQ Assessment 0.0 Placebo Ciclesonide 200μg/d -1.8-2.3 Placebo Ciclesonide 200μg/d 0.0 * * -0.88-1.07-1.0-0.5-2.0-1.0-3.0-1.5 *P < 0.001 vs placebo *P = 0.003 vs placebo Chervinsky P et al. Ann Allergy Asthma Immunol. 2007;99:69-76. ITT Analysis
LS Mean change from baseline in 24-hr reflective TNSS Long-term Efficacy of Intranasal Ciclesonide No Evidence of Tachyphylaxis 0.0 Placebo Ciclesonide 200 μg OD -0.5-1.0-1.5-2.0-2.5-3.0 0 4 8 12 16 20 24 28 32 36 40 44 48 52 Time (week) Chervinsky P et al. Ann Allergy Asthma Immunol. 2007;99:69-76. *One-sided P 0.025 versus placebo itnss: instantaneous Total Nasal Symptom Score
Change from baseline in 24-hour urinary free cortisol (mg/day) Change from baseline in plasma cortisol (mcg/dl) No Clinically Relevant Effects on HPA axis 24-Hour Urinary Free Cortisol at Endpoint AM Spot Plasma Cortisol at Endpoint Placebo Ciclesonide 200μg/d Placebo Ciclesonide 200μg/d 4.0 1.0 3.0 2.0 0.0 1.0 0.0-1.0-1.0-2.0-2.0 * No significant difference between treatment groups Chervinsky P et al. Ann Allergy Asthma Immunol. 2007;99:69-76. ITT Analysis
Lens Opacity Findings* with Long Term Ciclesonide Nasal Spray No Treatment Differences in Lens Opacity Findings Parameter Placebo Ciclesonide Treatment Difference (95%CI) Intraocular Pressure -0.10 (0.16) -0.00 (0.12) -0.10 (-0.50,0.30) Nuclear Color 0.14 (0.03) 0.14 (0.02) 0.00 (-0.06,0.06) Nuclear Opalescence 0.08 (0.03) 0.11 (0.02) -0.03 (-0.09,0.03) Posterior Subcapsular Cataract 0.02 (0.01) 0.01 (0.01) 0.01 (-0.01,0.02) Cortical Cataract 0.00 (0.02) -0.01 (0.01) 0.01 (-0.02,0.05) *LS mean changes Chervinsky P et al. Ann Allergy Asthma Immunol. 2007;99:69-76.
Clinical Studies 5 ICS/INCS HPA-Axis Data 66
Intranasal Ciclesonide Co-aministration with Inhaled FP- SAL in Allergic Rhinitis Patients RANDOMIZED, DOUBLE-BLIND, PARALLEL-GROUP, PLACEBO- AND ACTIVE-CONTROLLED NON-INFERIORITY STUDY pre-ics 24-hr cortisol profiles post-ics 24-hr cortisol profiles post-nasal spray + ICS 24-hr cortisol profiles Screening Phase Placebo nasal spray ICS (FP/SAL) Placebo nasal spray + ICS (n=75) Ciclesonide nasal spray +ICS (n=75) post-dexa 24-hr cortisol profiles Change in plasma cortisol AUC (0-24 hr) Kim K et al. J Asthma. 2007;44:515-520. ICS: inhaled corticosteroid FP/SAL: fluticasone propionate/ salmeterol
Plasma cortisol AUC 0 24h μg h/d Mean Plasma Cortisol AUC (0, 24h) No Additive Inhibitory Effects on the HPA axis 250 Ciclesonide (200 μg/day) Placebo 200 150 100 50 0 Baseline Post FP-SAL Run-in Post FP-SAL + INCS Post Dexamethasone Tx Period Treatment (Day1;S1) (Day 1 to 10;B1) (Day 10 to 52; T2) (Day 52 to 53; T3) Kim K et al. J Asthma. 2007;44:515-520. FP-SAL, fluticasone propionate-salmeterol
Adverse Events reported by 2% or more of patients in any treatment group Adverse Event Preferred Term Placebo (n = 163) Ciclesonide 200 g/d (n = 164) Headache 8.0% 5.3% Increased White Blood Cell Count 0.0% 4.0% Increased Blood Glucose 0.0% 2.7% Epistaxis 2.7% 0.0% Pharyngolaryngeal Pain 2.7% 0.0% Kim et al. J Asthma. 2007;44:515-520.
Summary : Intranasal Ciclesonide Effective relief of rhinitis symptoms and quality of life Maintained effectiveness over the full 24-hour dosing interval Onset of action as early as 1 hr after administration Decreased run-off into esophagus, less drying feeling and bad taste No evidence of tachyphylaxis over 1 year treatment period No clinically relevant differences in adverse events, systemic safety, and ocular examination No additive effects on cortisol suppression when coadministered with [ICS+LABA] Kim et al. J Asthma. 2007;44:515-520.
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