Allergic rhinitis is a common disease characterized by the

Comparison of antileukotrienes and antihistamines in the treatment of allergic rhinitis Ching-Yin Ho,* M.D., Ph.D., and Ching-Ting Tan,# M.D., Ph.D. (Taiwan) ABSTRACT Background: The aim of this study was to compare the effect of antileukotriene (anti-lt), antihistamine, and a combination of anti-lt and antihistamine on the symptoms and nasal resistance in allergic rhinitis patients. Methods: We performed a placebo-controlled study, with 120 persistent, moderate to severe allergic rhinitis patients randomly selected to receive the different treatments for 4 weeks: no treatment, 10 mg of cetirizine once per day, 20 mg of zafirlukast once per day, 20 mg of zafirlukast twice per day, a combination of 20 mg of zafirlukast and 10 mg of cetirizine once per day, or a combination of 20 mg of zafirlukast twice per day and 10 mg cetirizine once per day. The nasal secretion nitric oxide (NO) concentration, nasal symptom score, and nasal resistance were measured before and after treatment. Results: Total symptom scores improved in each treated group compared with the control group (p 0.05). Nasal obstruction significantly improved in the anti-lt treated groups (p 0.05). High-dose anti-lt or the combination of low-dose anti-lt and antihistamine significantly improved allergy symptoms compared with no treatment, low-dose anti-lt, or antihistamine alone (p 0.05). Furthermore, anti-lt decreased NO concentration in nasal secretions (p 0.05), regardless of the dose administered. Conclusion: These results suggest that high-dose anti-lt alone or the combination of low-dose anti-ly and antihistamine can effectively treat allergic rhinitis. (Am J Rhinol 21, 439 443, 2007; doi: 10.2500/ajr.2007.21.3044) Key words: Allergic rhinitis, anterior rhinomanometry, antihistamine, antileukotriene, asthma, cetirizine, nasal resistance, nitric oxide, zafirlukast Allergic rhinitis is a common disease characterized by the infiltration of inflammatory cells into the nasal mucosa. 1,2 Two of the most abundant and potent mediators are histamine and cysteinyl leukotrienes (LTs). 3,4 Histamine has long been implicated as a major mediator of allergic rhinitis, primarily causing sneezing, nasal itching, and rhinorrhea. In contrast to histamine, LTs such as LTC 4 and LTD 4 contribute to vascular permeability and vasodilation resulting in mucosal swelling, which causes rhinorrhea and nasal congestion. 5 7 In addition, the nasal allergen challenge-induced release of cysteinyl LTs has been correlated with allergic symptoms. 8 10 Furthermore, nasal congestion in the early phase and the late phase is accompanied by a significant increase of cysteinyl LTs in nasal lavage fluid from allergic rhinitis patients. 9 Therefore, it is indicated that cysteinyl LTs play an important role in allergic rhinitis. Studies support the possibility that nitric oxide (NO) plays an important role in regulating nasal functions. 11 14 Recent studies in rats showed that the increased vascular permeability induced by a histamine nasal challenge can be blocked by perfusion with an NO synthase (NOS) inhibitor in the nasal cavity contralateral to nasal challenge. 12,13 A rabbit study From the *Department of Otolaryngology, Veterans General Hospital-Taipei and National Yang-Ming University, Taipei, Taiwan, and #Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine Taipei, Taiwan Supported by Grant NSC92-2314-B-075-125 from the National Science Council, Grants VGH 91-213 and VGH 92-204 from the Veterans General Hospital Taipei, and Grants NTUH 92-N005 and NTUH 93-S034 Address correspondence and reprint requests to Ching-Yin Ho, M.D., Ph.D., Department of Otolaryngology, Veterans General Hospital Taipei. Number 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan E-mail address: cyho@vghtpe.gov.tw Copyright 2007, OceanSide Publications, Inc., U.S.A. showed that the nasal application of sodium nitroprusside, an NO donor, increased ciliary beat frequency in vitro and mucociliary activity in vivo. 15,16 The same nasal application of an NO donor also has been shown to increase the mucociliary activity and blood flow in human nasal mucosa. These findings indicated that NO plays an important role in the regulation of vascular permeability, mucociliary activity, and blood flow in nasal mucosa. An elevated level of NO in nasalexhaled air has been found in patients with allergic rhinitis; this elevation decreased after treatment with steroid nasal spray or antihistamine. 17 19 However, the relationship between the NO concentration in the nasal secretion and anti-lt effect remains unknown. This study was conducted for two purposes. First, we designed a randomized trial to compare the effect of anti-lt, antihistamine, and a combination of anti-lt and antihistamine on the symptoms of allergic rhinitis and also on nasal resistance measured by active anterior rhinomanometry (AAR). Second, we investigated the concentration of nasal secretion of NO in the allergic rhinitis patients treated with anti-lt, antihistamine, or a combination of both. MATERIALS AND METHODS This study was approved by the Committee of Clinical Research Studies at the Veterans General Hospital-Taipei. All patients were told the aim of the study, after which each patient provided written informed consent. Patients and Study Design Patients eligible for this study were healthy adult men and women who had a clinical history of allergic rhinitis for at least 2 years and who tested positive only for mite allergy in the multiple allergen simultaneous test. All patients suffered from persistent, moderate to severe allergies according to the American Journal of Rhinology 439

classification of Allergic Rhinitis and Its Impact on Asthma. 20 Patients were excluded if they had any chronic nasal diseases or if they had received corticosteroid nasal spray, oral antihistamine, oral decongestant, or oral corticosteroids in the past 3 months. During a 7-day lead-in period, baseline nasal resistance and NO concentration of the nasal secretions were obtained and diary card assessments were performed on 120 adult allergic rhinitis patients. Then, these patients were randomly selected to receive one of the following six treatments for 4 weeks: no treatment (P group), 10 mg of cetirizine once per day (C group), 20 mg of zafirlukast once per day (Z20 group), 20 mg of zafirlukast twice per day (Z40 group), a combination of 20 mg of zafirlukast and 10 mg of cetirizine once per day (Z20 C group), or a combination of 20 mg of zafirlukast twice per day and 10 mg of cetirizine once per day (Z40 C group). After 4 weeks, the nasal resistance was measured, as well as the NO concentration in the nasal secretions, and the diary card assessments were recorded again. Symptom Scale Score Subjective assessment of nasal symptoms was conducted before and throughout the study; patients assessed their subjective sensations of sneezing, rhinorrhea, and nasal obstruction. Symptoms were graded on a scale of 0 10, with 0 representing no perceived symptoms and 10 representing the greatest severity of symptoms imaginable. This assessment was made both at baseline and after treatment. Measurement of Nasal Resistance Measurements of nasal resistance were made using a Mercury Electronics NR6 rhinomanometry (Instrument Rhinomanometry NR6 2 G. M. Instruments, Ltd., U.K.) for AAR. This rhinomanometry measured the nasal flow rate during tidal breathing, while simultaneously measuring the nasopharyngeal pressure that produced the flow. Airflow was measured using a face mask with a pneumotachograph positioned at the inlet. An integral nasal cannula for measuring nasopharyngeal pressure was placed in the subject s nasal cavity and sealed with the tape. The face mask was placed firmly on the face and the airflow was measured through the other nasal cavity. Inspiration and expiration were measured separately. AAR resistance was measured separately for each side of the nose and the total resistance was calculated by the computer program. Collection of Nasal Secretion A microsuction system, which was designed by the investigators, was used to collect nasal secretions. The applied pressure was 0.04 MPa ( 408 cm H 2 O). Under the rigid scope, we put the suction into patients nasal cavities and aspirated all secretion in the nasal cavity. Nasal fluid was stored on ice and centrifuged for 10 minutes at 1000 g. The supernatant was stored at 80 C until analysis. Concentrations of NO in the nasal secretions were measured using HPLC. Measurement of NO 2 and NO 3 Levels NO 2 and NO 3 levels in the nasal secretions were separated by a reverse-phase separation column packed with polystyrene polymer (NO-PAK, 4.6 50 mm; Eicom, Kyoto, Japan), and NO 3 was reduced to NO 2 in a reduction column packed with copper-plated cadmium filings (NO-RED; Eicom). NO 2 was mixed with a Griess reagent to form purple azo dye I in a reaction coil. The separation and reduction columns and the reaction coil were placed in a column oven that was set at 35 C. The absorbance of the product dye at 540 nm was measured by a flow-through spectrophotometer (NOD-20; Eicom). The mobile phase, which was delivered by a pump at a rate of 0.33 ml/minute, was 10% methanol containing 0.15 M of NaCl/NH 4 Cl and 0.5 g/l of 4Na-EDTA. The Griess reagent, which was 1.25% HCl containing 5 g/l of sulfanilamide with 0.25 g/l of N-naphthlenediamine, was delivered at a rate of 0.1 ml/minute. The contamination of NO 2 and NO 3 in Ringer s solution and the reliability of the reduction column were examined in each experiment. Data and Statistical Analysis All results were analyzed by one-way analysis of variance, which was adjusted for multiple comparison by Duncan s method when appropriate. The value of p 0.05 was considered significant. All data are presented as means SE. RESULTS One hundred twenty allergic rhinitis patients were included in this study. The male-to-female ratio was 74:46, and their ages ranged from 18 to 68 years. Before treatment, the symptom score, nasal resistance, and NO concentration of nasal secretion showed no significant differences between each group. The total symptom score improved after treatment in the treated group (p 0.05; Fig. 1 A). The high-dose anti-lt alone (Z40) and the combination of anti-lt, including low- and high-dose, and antihistamine (Z20 C and Z40 C) caused better results than the low-dose anti-lt (Z20) or antihistamine (C) alone (Fig. 1 A). In the C group, the symptoms of sneezing and rhinorrhea improved significantly (Fig. 1, C and D), but nasal obstruction did not improve (Fig. 1 B). In the Z20 group, rhinorrhea improved, but sneezing and nasal obstruction did not (Fig. 1, B D). All allergic symptoms, including sneezing, rhinorrhea, and nasal obstruction, were significantly reduced after Z40, Z20 C or Z40 C treatment; however, the treatment effect was similar in Z40, Z20 C, and Z40 C groups (Fig. 1, B D). The objective nasal resistance was measured via AAR before and after treatment. Both the P group and the C group showed no change after treatment. Nasal resistance significantly decreased in patients who received Z40, Z20 C, and Z40 C treatment. Nasal resistance did not show significant difference between the Z40, Z20 C, and Z40 C groups (Fig. 2). The baseline nasal NOx concentration was 357 65 pmol, 323 74 pmol, 329 51 pmol, 397 98 pmol, 279 53 pmol, and 412 40 pmol in the P, C, Z20, Z40, Z20 C, and Z40 C groups, respectively, and there was no difference in any of the groups (Fig 3). After treatment, the NOx concentration in nasal secretions did not change in the group receiving antihistamine alone (Fig. 3). However, the concentration of NOx in nasal secretions significantly decreased after anti-lt treatment in either low or high doses. The addition of antihistamine to either low- or high-dose zafirlukast did not further reduce the concentration of NOx (Fig. 3). 440 July August 2007, Vol. 21, No. 4

Figure 1. Symptom score of allergic rhinitis before and after treatment. (A) Total symptom score; (B) nasal obstruction score; (C) sneezing score; (D) rhinorrhea score. *, Significantly different from before treatment; a, significantly different from the posttreatment of C group; b, significantly different from the posttreatment of Z20 group; P, no treatment; C, 10 mg of cetirizine once per day; Z20, 20 mg of zafirlukast once per day; Z40, 20 mg of zafirlukast twice per day; Z20 C, a combination of 20 mg of zafirlukast and 10 mg of cetirizine once per day; Z40 C, a combination of 20 mg of zafirlukast twice per day and 10 mg of cetirizine once per day (p 0.05 was considered significant). DISCUSSION Our results show that the combination of anti-lt and antihistamine improved nasal allergic symptoms significantly compared with treatments of placebo, antihistamine, or low doses of anti-lt alone. Not only did the subjective symptom score improve, but also the objective nasal resistance decreased. In addition, anti-lt decreased the NO concentration in the nasal secretions regardless of the dose administered and regardless of an additional antihistamine. The levels of histamine and cysteinyl LTs were elevated in the nasal secretion of patients with allergic rhinitis when triggered by IgE-mediated reactions. 10 In addition, the release of histamine and LTs contributes to the allergic nasal symptoms by exerting selective effects in the nose. 21,22 Histamine nasal challenge induces neurological responses, such as itching and sneezing, but affects nasal congestion to a lesser degree. Therefore, LTs contribute to the pathophysiology of allergic rhinitis and potentially increase both mucus production and congestion. One recent study examined the possible advantages of a combination of anti-lt and antihistamine for asthma. 23 That study showed that the concomitant use of loratadine and zafirlukast was significantly more effective in diminishing the response to an inhaled allergen challenge than the use of loratadine or zafirlukast alone. Both histamine and LT receptor antagonists have antiallergic and anti-inflammatory properties, including effects on mediator release and the chemoattraction of inflammatory cells. These findings suggested that administering antihistamine and LT modifiers together might result in an amplified effect in the treatment of allergic rhinitis. Our results indicated that sneezing and rhinorrhea significantly improved in C-group patients but no significant change was observed in nasal obstruction, which profoundly affects the nasal obstruction symptom score and nasal resistance. The Z20-group patients improved only in nasal obstruction, and no change was observed in rhinorrhea and sneezing. The Z40, Z20 C, and Z40 C groups showed significant improvement in all allergic nasal symptoms, including sneezing, rhinorrhea, and nasal obstruction, with no difference between each group. This result shows that either high-dose anti-lt or a combination of low-dose anti-lt and antihistamine has the same effect on allergic rhinitis patients. Therefore, the combination of low-dose anti-lt and antihistamine or the use of high-dose anti-lt alone is a good treatment choice for allergic rhinitis patients. As shown in an earlier study, LTD 4 is 5000 times more potent than histamine in inducing increased nasal airway resistance in humans. 24 It is noteworthy that this increase is more prolonged than that induced by histamine and is similar to that induced by antigens. In recent animal studies, nasal LTD 4 challenge was shown to increase nasal airway resistance, 25 and anti-lt can inhibit the antigen-induced increase in nasal resistance. 26 Our results show that both a low dose or high dose of anti-lt, with or without additional antihistamine, can improve subjective nasal obstruction and objective nasal resistance. These results indicate that anti-lts are more powerful in the improvement of nasal congestion than the new generation antihistamine in allergic rhinitis. The relationship between NO and chronic allergic responses has been emphasized, because NO acts as a powerful mediator involved in several atopic diseases. 27 For example, American Journal of Rhinology 441

the function of NO in the nasal mucosa related to the allergic reaction. Kharitonov et al. 31 recently found that nasal NO levels were significantly elevated in patients with untreated rhinitis compared with normal individuals or subjects treated with topical steroids. The previous results showed that the degree of inducible NOS expression by epithelial cells was significantly elevated in an allergic rhinitis group compared with that of the control group. 32 However, the relationship between LTC and NO in allergic rhinitis was not clear. Our study showed that both low-dose or high-dose anti-lt treatment decreased the NO concentration in the nasal secretions of allergic rhinitis patients. Our results also showed that anti- LT significantly improves nasal obstruction and decreases nasal resistance. Therefore, the mechanism of anti-lt may improve nasal congestion by inhibiting NO formation. Figure 2. Total nasal resistance of allergic rhinitis patients before and after treatment, measured by anterior rhinomanometry. (A) Left nasal resistance; (B) right nasal resistance. *, Significantly different from before treatment; a, significantly different from the posttreatment of C group (p 0.05 was considered significant. The grouping was the same as in Fig. 1. Figure 3. NOx concentration of nasal secretion in allergic rhinitis before and after treatment. *, Significantly different from before treatment; a, significantly different from the posttreatment of P group (p 0.05 was considered significant). The grouping was the same as in Fig. 1. patients with bronchial asthma have shown elevated NO levels in exhaled air. 28,29 Hamid et al. 30 reported an increased expression of NOS, which is an enzyme responsible for NO production, in bronchial epithelial cells from untreated asthmatic patients, and suggested its relevance to the pathology of asthma. In contrast to the lower airways, little is known about CONCLUSION High-dose anti-lt, a combination of low-dose anti-lt and antihistamine, or a combination of high-dose anti-lt and antihistamine produce the same treatment results in allergic rhinitis patients, including improved nasal allergic symptoms and nasal resistance, and decreased NO concentrations in nasal secretions. Therefore, our results indicate that two good treatment choices for allergic rhinitis patients are either the combination of low-dose anti-lt and antihistamine or the use of high-dose anti-lt alone. REFERENCES 1. Baraniuk JN. Pathogenesis of allergic rhinitis. J Allergy Clin Immunol 99:S763 S772, 1997. 2. Bascom R, Pipkorn U, Lichtenstein LM, et al. The influx of inflammatory cells into nasal washings during the late response to antigen challenge. Effect of systemic steroid pretreatment. Am Rev Respir Dis 138:406 412, 1988. 3. Miadonna A, Tedeschi A, Leggieri E, et al. Behavior and clinical relevance of histamine and leukotrienes C4 and B4 in grass pollen-induced rhinitis. Am Rev Respir Dis 136:357 362, 1987. 4. Creticos PS, Peters SP, Adkinson NF Jr, et al. Peptide leukotriene release after antigen challenge in patients sensitive to ragweed. N Engl J Med 310:1626 1630, 1984. 5. Howarth PH. Leukotrienes in rhinitis. Am J Respir Crit Care Med 161:S133 S136, 2000. 6. Simon RA. The role of leukotrienes and antileukotriene agents in the pathogenesis and treatment of allergic rhinitis. Clin Rev Allergy Immunol 17:271 275, 1999. 7. Busse W, and Kraft M. Cysteinyl leukotrienes in allergic inflammation: Strategic target for therapy. Chest 127:1312 1326, 2005. 8. Peters-Golden M, and Henderson WR Jr. The role of leukotrienes in allergic rhinitis. Ann Allergy Asthma Immunol 94:609 618, 2005. 9. Naclerio RM, Baroody FM, and Togias AG. The role of leukotrienes in allergic rhinitis: A review. Am Rev Respir Dis 143:S91 S95, 1991. 10. Saito H, Morikawa H, Howie K, et al. Effects of a cysteinyl leukotriene receptor antagonist on eosinophil recruitment in experimental allergic rhinitis. Immunology 113:246 252, 2004. 11. Ferguson EA, and Eccles R. Relationship between nasal nitric oxide concentration and nasal airway resistance. Rhinology 35:120 123, 1997. 442 July August 2007, Vol. 21, No. 4

12. Lane AP, Prazma J, Gibbons PJ, et al. The role of nitric oxide in the neural control of nasal fluid production. Am J Rhinol 11:303 311, 1997. 13. Lane AP, Prazma J, Baggett HC, et al. Nitric oxide is a mediator of neurogenic vascular exudation in the nose. Otolaryngol Head Neck Surg 116:294 300, 1997. 14. Alberty J, August C, Stoll W, et al. The effect of endogenous nitric oxide on cholinergic ciliary stimulation of human nasal mucosa. Laryngoscope 114:1642 1647, 2004. 15. Imada M, Nonaka S, Kobayashi Y, et al. Functional roles of nasal nitric oxide in nasal patency and mucociliary function. Acta Otolaryngol 122:513 519, 2002. 16. Kim JW, Min YG, Rhee CS, et al. Regulation of mucociliary motility by nitric oxide and expression of nitric oxide synthase in the human sinus epithelial cells. Laryngoscope 111: 246 250, 2001. 17. Vural C, and Gungor A. The effect of topical fluticasone on nasal nitric oxide levels in a patient with allergic rhinitis. Ear Nose Throat J 82:592 597, 2003. 18. Gratziou C, Rovina N, Lignos M, et al. Exhaled nitric oxide in seasonal allergic rhinitis: Influence of pollen season and therapy. Clin Exp Allergy 31:409 416, 2001. 19. Wilson AM, Dempsey OJ, Sims EJ, et al. Subjective and objective markers of treatment response in patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol 85:111 114, 2000. 20. Bousquet J, Van CP, and Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 108:S147 S334, 2001. 21. Naclerio RM. Allergic rhinitis. N Engl J Med 325:860 869, 1991. 22. Meltzer EO. Role for cysteinyl leukotriene receptor antagonist therapy in asthma and their potential role in allergic rhinitis based on the concept of one linked airway disease. Ann Allergy Asthma Immunol 84:176 185, 2000. 23. Roquet A, Dahlen B, Kumlin M, et al. Combined antagonism of leukotrienes and histamine produces predominant inhibition of allergen-induced early and late phase airway obstruction in asthmatics. Am J Respir Crit Care Med 155:1856 1863, 1997. 24. White MV, and Kaliner MA. Mediators of allergic rhinitis. J Allergy Clin Immunol 90:699 704, 1992. 25. Fujita M, Nakagawa N, Yonetomi YT, et al. Cysteinyl leukotrienes induce nasal symptoms of allergic rhinitis via a receptor-mediated mechanism in guinea pigs. Jpn J Pharmacol 75:355 362, 1997. 26. Fujita M, Yonetomi Y, Shimouchi K, et al. Involvement of cysteinyl leukotrienes in biphasic increase of nasal airway resistance of antigen-induced rhinitis in guinea pigs. Eur J Pharmacol 369:349 356, 1999. 27. Kharitonov SA, Yates D, Robbins RA, et al. Increased nitric oxide in exhaled air of asthmatic patients. Lancet 343:133 135, 1994. 28. Gill M, Walker S, Khan A, et al. Exhaled nitric oxide levels during acute asthma exacerbation. Acad Emerg Med 12:579 586, 2005. 29. Taylor DR. Nitric oxide as a clinical guide for asthma management. J Allergy Clin Immunol 117:259 262, 2006. 30. Hamid Q, Springall DR, Riveros-Moreno V, et al. Induction of nitric oxide synthase in asthma. Lancet 342:1510 1513, 1993. 31. Kharitonov SA, Rajakulasingam K, O Connor B, et al. Nasal nitric oxide is increased in patients with asthma and allergic rhinitis and may be modulated by nasal glucocorticoids. J Allergy Clin Immunol 99:58 64, 1997. 32. Kawamoto H, Takeno S, and Yajin K. Increased expression of inducible nitric oxide synthase in nasal epithelial cells in patients with allergic rhinitis. Laryngoscope 109:2015 2020, 1999. e American Journal of Rhinology 443