Combination Of Antihistamines Research Articles

Expert opinion on the clinical use of a combination of antihistamines with leukotriene receptor antagonists in the management of allergic rhinitis in Indian settings

Background: Various clinical studies have reported that the combination of montelukast and levocetirizine was effective in alleviating residual symptoms and the improvement of quality of life associated with allergic rhinitis. However, there was a dearth of data regarding the prescription practice among clinical practitioners. So, this study aims to gather clinicians' opinion regarding the use of antihistamines, with a special focus on the combined use of antihistamines with leukotriene receptor antagonists for the management of AR in Indian settings. Methods: The multiple-response questionnaire-based survey involving 19 questions gathered information on current recommendations, clinical observations, clinical experience of specialists in AR management, and the use of montelukast with levocetirizine in routine settings. Results: Out of 388 participants, approximately 84% of respondents preferred a combination of antihistamines and leukotriene receptor antagonists for managing AR. Additionally, 36% stated that 26 to 50% of patients presenting to routine practice may require montelukast and antihistamine combination as treatment. Around 61% endorsed the combination of antihistamines with leukotriene receptor antagonists as the preferred AR treatment strategy. In long-term AR management, 65% of clinicians rated montelukast with levocetirizine as excellent, and 78% of respondents reported montelukast confers additive benefits when combined with antihistamines. Conclusions: The significant preference for the combined use of antihistamines and leukotriene receptor antagonists underscores their perceived efficacy in AR treatment. The combination of antihistamines with leukotriene receptor antagonists emerges as the favored strategy for managing AR.

A Perception-Based Survey on Practice Patterns Pertaining to the Diagnosis and Management of Allergic Rhinitis in India.

Allergic rhinitis (AR) is increasingly prevalent in India, affecting a significant portion of the population and adversely impacting their quality of life. This nationwide survey aimed to explore the perceptions and clinical preferences of Indian physicians regarding the perceived prevalence, common symptoms, and various available treatments for AR. This cross-sectional, observational, digital questionnaire-based survey was conducted from September 2022 to March 2023, involving physicians sharing insights on prevalence rates, diagnostic approaches, medication preferences, and immunotherapy practices in AR management. A total of 1608 physicians participated in this survey. The majority of physicians (n=684, 42.5%) reported that the prevalence of AR in routine clinical practice is between 21 and 40%. Physicians also noted a substantial burden of AR with asthma (n=626, around 40%). Total IgE count was reported as a mandatory test for the diagnosis of AR by 47.5% of physicians (n=764). For the management of mild cases of seasonal or perennial AR, 980 (60.9%) physicians preferred fexofenadine as an oral antihistamine of choice. Fluticasone furoate was the preferred intranasal corticosteroid (INCS) option (67.1% of physicians (n=1079)), for the management of patients with moderate to severe AR, the most recommended duration of INCS therapy was two to fourmonths (40.9% of physicians). Doctors recommended a montelukast and antihistamine combination in mild AR (n=152, 9.5%), mild AR not responding to antihistamine alone (n=291, 18.1%), moderate to severe AR along with INCS (n=252, 15.7%), and AR with mild asthma (n=74, 4.6%). The majority of physicians (n=1512, 75.6%) preferred using fexofenadine in combination with montelukast for the management of AR. The majority of physicians (n=839, 52.2%) opined that the efficacy rate of oral montelukast-fexofenadine was 60-90% in the management of mild-moderate AR. Around 55.3% of physicians (n=889) had not used immunotherapy in their clinical practice. These observations offer a holistic view of how Indian physicians perceive the management of AR, a condition highly prevalent in India and often associated with asthma. It also highlights the treatment strategies employed in their day-to-day clinical practice.

Intranasal combo: fixed-dose combination of mometasone furoate and olopatadine hydrochloride in therapeutic strategies for rhinosinusitis.

A novel strategy for the treatment of allergic rhinitis results from the innovative combination of antihistamine and intranasal corticosteroid drugs. By combining two preparations with different mechanism of action, this novel approach facilitates quick and effective controls of all upper respiratory tract allergy symptoms. The article presents the results of a study of olopatadine hydrochloride and mometasone furoate fixed-dose combination (GSP301) administered intranasally from a spray formulation, with an attempt at positioning the treatment within the ARIA and EPOS guidelines.

Intranasal corticosteroid and antihistamine combinations in the treatment of allergic rhinitis: the role of the novel formulation olopatadine/mometasone furoate

ABSTRACT Introduction Allergic rhinitis (AR) is a common disease with an important impact on the quality of life and very high management costs. In many patients, the poor control of rhinitis symptoms often requires the use of different drugs, and polytherapy tends to reduce therapeutic adherence. According to the latest version of ARIA guidelines, the currently recommended drugs for the treatment of moderate-to-severe AR are second-generation antihistamines, intranasal corticosteroids, and their combination, even in a single nasal spray device. A single medication with a rapid onset of action, acting on breakthrough symptoms too, would be advantageous, also in terms of patient compliance. Areas covered GSP301 (olopatadine 600 µg – mometasone furoate 25 µg) is a novel intranasal formulation, combining the second-generation antihistamine olopatadine hydrochloride with mometasone furoate. Here, we review the evidence for GSP301, especially concerning the efficacy and safety profile of this intranasal combination in the treatment of AR. Expert opinion The evidence provided in the current review clearly supports the use of GSP301 as a novel intranasal corticosteroid/antihistamine combination with a well-documented efficacy and safety profile in terms of rapid symptom relief and good tolerability.

The Prescription of Antibiotics in ENT Diseases in the ENT and Surgery Department Cervico-Facial at Sikasso Hospital

Antibiotics are chemical compounds elaborated by a micro-organism or produced by synthesis and whose specific activity manifests itself in doses on the micro-organisms. They are commonly used in the management of infectious pathologies in ENT and Cervico-Facial Surgery. This study aims to evaluate the use of antibiotics in the therapeutic arsenal in the ENT-CCF department of the Sikasso hospital. This is a 4-month prospective study from November 1, 2016 to February 28, 2017 on the prescription of antibiotics in the ENT department of Sikasso hospital. Four hundred (400) patients were included in this study. The following variables were collected: gender, age, occupation, reason for consultation, history, prescription and evolution. During the study period 400 patients were retained. Among which 293 benefited from a prescription of antibiotics that is 73.25% of the cases and (107 cases) 26.75% without antibiotics. The female sex was predominant with 57% of cases, i.e. a sex ratio of 1.32. More than half of the work force were made up of learners and preschoolers. The reasons for consultation were dominated by otalgia with 35.8% followed by odynophagia in 15% of cases. 76.75% of our patients had no history. The prevalence of antibiotic therapy was 73.25%, including 49.83% amoxi+clavulanic acid, 10.92% cephalosporin, 10.60% macrolides, 3.75% sulfonamides, 1.70% amoxicillin and ear drops in 23.2% of cases. Apart from antibiotic therapy, antihistamines were the most prescribed with 32.75% followed by nasal corticosteroids in 23.36% of cases. Non-steroidal anti- inflammatory drugs were associated with the antibiotic in 33.78%, followed by the analgesic-nasal corticosteroid- antihistamine combination in 15.35% of cases. The evolution was favorable in 83.62% of cases, unfavorable in 10.92% of cases and 5.46% of patients did not show up for the check-up appointment on the 7th day. It was a prospective study of four (04) months on the place of antibiotic therapy ......

Adverse reactions to four types of monovalent antivenom used in the treatment of snakebite envenoming in South China

To evaluate the adverse reactions associated with the four types of monovalent antivenom currently used in China, we retrospectively analysed the data of all patients admitted for snakebites who received antivenom treatment at the main institution for the treatment of venomous snakebites in Guangzhou from January 2013 to December 2021. A total of 1658 patients were analysed in our study, and 60.7% (n = 1007) of the snakebite patients received antivenom treatment. The incidence rate of adverse reactions that occurred after the administration of all types of monovalent antivenom was 4.9% (n = 49), and the incidence rate of acute adverse reactions was 2.7% (n = 27). The number of adverse reactions that occurred was 38/744 (5.1%) in patients who received prophylactic application of glucocorticoids alone and 10/217 (4.6%) in those who received a combination of antihistamines and glucocorticoids (P = 0.83). The average doses of the antivenoms used in patients exhibiting acute adverse reactions and serum sickness were 3.31 ± 0.75 vials and 2.36 ± 0.26 vials, respectively (P = 0.28). The antivenom skin test showed high specificity (98.3%, 95% CI: 97.24%–99.01%) but low sensitivity (14.3%, 95% CI: 6.41%–27.86%). Our results showed that the four types of monovalent antivenom were safe. No significant difference was observed between the use of glucocorticoids alone and the use of antihistamines combined with glucocorticoids as premedication for the prevention of adverse reactions. Reducing the dose of antivenoms or reducing the combination of antivenoms did not help to reduce the occurrence of adverse reactions. Skin testing should not be recommended due to its low sensitivity.

Pharmacological Management of Allergic Rhinitis: A Consensus Statement from the Malaysian Society of Allergy and Immunology.

The goal of allergic rhinitis (AR) management is to achieve satisfactory symptom control to ensure good quality of life. Most patients with AR are currently treated with pharmacotherapy. However, knowledge gaps on the use of pharmacotherapy still exist among physicians, particularly in the primary care setting, despite the availability of guideline recommendations. Furthermore, it is common for physicians in the secondary care setting to express uncertainty regarding the use of new combination therapies like intranasal corticosteroid plus antihistamine combinations. Inadequate treatment leads to significant reduction of quality of life that affects daily activities at home, work, and school. With these concerns in mind, a practical consensus statement was developed to complement existing guidelines on the rational use of pharmacotherapy in both the primary and secondary care settings.

Chronic spontaneous urticaria or urticarial vasculitis?

Chronic spontaneous urticaria is the spontaneous appearance of blisters, angioedema, or both for 6 weeks that affects up to 0.5%5% of the population, mainly females. Spontaneous wheals and/or angioedema, severe skin itching that leads to depression and anxiety, sleep disturbances, sexual dysfunction, and activity of daily life and work restrictions. Other diseases sometimes occur under the guise of chronic spontaneous urticaria. Urticarial vasculitis is a vasculitis of the small skin vessels, characterized by the duration of persistent skin rashes in combination with histopathological features of leukocytoclastic vasculitis. Differential diagnosis of chronic spontaneous urticaria and urticarial vasculitis is conducted in the case of an atypical clinical picture of urticaria. Wheals lasted for 24 h, often accompanied by burning and pain, and leaving behind purpura or residual hyperpigmentation. Herein, described a case of urticarial vasculitis in a patient that required a differential diagnosis of chronic spontaneous urticaria and urticarial vasculitis several years after the disease onset. Successful treatment was conducted with a combination of antihistamines, glucocorticosteroids, hydroxychloroquine, and omalizumab.

Treatment pattern and direct medical costs of pediatric outpatients with actuate respiratory infection at X hospital in Jambi

Introduction: Acute respiratory infection is common among the general public. Such disease and its associated symptoms encourage higher consumption of medicine. Varied medications for ARI patients incur different costs of each patient, which eventually lead to higher healthcare costs. Objectives: To identify the treatment patterns and direct medical costs among ARI pediatric patients at X Hospital in Jambi. Methods: This research was an observational study with retrospective data collection. The samples were collected in 2018. Results: The results showed that the most-frequently administered antibiotic for ARI pediatric patients was cefixime (29.17%), while the most-commonly used supportive therapy for ARI pediatric patients was the combination of antihistamines, antipyretics-analgesics, decongestant, and corticosteroid (16.67%). The total direct medical cost to ARI pediatric patients was IDR 191,097. Conclusion: The mean direct medical cost for ARI therapy was IDR 191,097. More administered therapy resulted in higher medical costs. Keywords: ARI, child, antibiotics, direct medical costs

Management of peripheral vertigo with antihistamines: New options on the horizon

Vertigo is associated with a wide range of vestibular pathologies. It increasingly affects the elderly, with a high cost to society. Solutions include vestibular suppressants and vestibular rehabilitation, which form the mainstay of therapy. Antihistamines represent the largest class of agents used to combat vestibular vertigo symptoms. Agents targeting the H1 and H3 receptors have been in clinical use for several decades as single agents. Nonetheless, effective management of vertigo proves elusive as many treatments largely address only associated symptoms, and with questionable efficacy. Additionally, the primary and limiting side effect of sedation is counterproductive to normal functioning and the natural recovery process occurring via central compensation. To address these issues, the timing of administration of betahistine, the mainstay H3 antihistamine, can be fine-tuned, while bioavailability is also being improved. Other approaches include antihistamine combination studies, devices, physical therapy and behavioural interventions. Recently demonstrated expression of H4 receptors in the peripheral vestibular system represents a new potential drug target for treating vestibular disorders. A number of novel selective H4 antagonists are active in vestibular models in vivo. The preclinical potential of SENS-111 (Seliforant), an oral first-in-class selective H4 antagonist is the only such molecule to date to be translated into the clinical setting. With an excellent safety profile and notable absence of sedation, encouraging outcomes in an induced vertigo model in healthy volunteers have led to ongoing clinical studies in acute unilateral vestibulopathy, with the hope that H4 antagonists will offer new effective therapeutic options to patients suffering from vertigo.

Leukotriene receptor antagonists for eczema.

Leukotriene receptor antagonists for eczema.

Mast cell activation disorder masquerading as a nervous breakdown

While mast cells have been implicated in human disease since the early 1900s, mast cell activation syndrome (MCAS) was only recently discovered and recognized as a disorder caused by aberrant release of mast cell mediator enzymes. These mediators trigger a wide variety of symptoms ranging from headache, pruritis and gastrointestinal discomfort to life-threatening anaphylaxis. MCAS is frequently unrecognized and misdiagnosed because symptoms associated with MCAS are often present in other medical conditions and are highly variable among patients. We describe a case of a 62-year-old male who presented to the emergency department (ED) with three days of recurrent flushing, diarrhea, mild edema of his hands bilaterally, and severe emotional lability with recurrent crying. In the ED, he was misdiagnosed with severe anxiety and directly sent to a mental health clinic for assistance. However, he was previously seen in allergy clinic for suspected MCAS. Fortuitously standing labs including plasma histamine, tryptase, and urine studies that were ordered in allergy clinic were drawn concurrently with the initial ED workup. He was found to have elevated histamine level during his ED episode and treatment for MCAS was initiated. In subsequent visits, his symptoms, except for episodes of “brain fog” and emotional lability, improved significantly on a combination of antihistamines, oral cromolyn sodium, and montelukast. Additionally every other day prednisone has substantially cleared the neurocognitive symptoms. This case highlights the difficulty of MCAS diagnosis and the importance of assessing for MCAS, especially in patients who have multisystem complaints.

Correlation between the histopathology of chronic urticaria and its clinical picture

BACKGROUNDChronic urticaria is characterized by transient, pruritic lesions of varying sizes, with central pallor and well-defined edges, with disease duration longer than six weeks. Its cellular infiltrate consists of neutrophils, lymphocytes and eosinophils. There is a subgroup of patients with eosinophilic or neutrophilic urticaria, resistant to the treatment with antihistamines, but that respond to a combination of antihistamine with other drugs.OBJECTIVETo evaluate the present infiltration in chronic urticaria biopsies and correlate it with the clinical disease activity and response to treatment.METHODSForty-one patients with chronic urticaria were classified according to the score of severity of the disease, response to treatment and type of perivascular infiltrate. Inflammatory infiltrates were divided in eosinophilic (46.30%), neutrophilic and mixed.RESULTSAn association was found between the eosinophilic infiltrate and clinical scores of greater severity (p = 0.002).CONCLUSIONThis association shows that the eosinophilic inflammatory infiltrates denote high clinical activity, which means more severe and exuberant clinical pictures of the disease.

Association between desloratadine and prednisolone in the treatment of children with acute symptoms of allergic rhinitis: a double-blind, randomized and controlled clinical trial

IntroductionA combination of antihistamines and oral corticosteroids is often used to treat acute symptoms of allergic rhinitis. ObjectiveTo evaluate safety and efficacy of desloratadine plus prednisolone in the treatment of acute symptoms of children (2–12 years) with allergic rhinitis, and to compare it to dexchlorpheniramine plus betamethasone. MethodsChildren with moderate/severe persistent allergic rhinitis and symptomatic (nasal symptoms score [0–12]≥6) were allocated in a double-blind, randomized fashion to receive dexchlorpheniramine plus betamethasone (n=105; three daily doses) or desloratadine plus prednisolone (n=105; single dose followed by two of placebo) for 7 days. At the beginning and end of the evaluation, the following were obtained: nasal symptoms score, extra nasal symptoms score, peak nasal inspiratory flow, blood biochemistry, and electrocardiogram. Ninety-six children of the dexchlorpheniramine plus betamethasone group and 98 of the desloratadine plus prednisolone group completed the protocol. ResultsThe two groups were similar regarding initial and final nasal symptoms scores, extra nasal symptoms scores and peak nasal inspiratory flow. A drop of 76.4% and 79.1% for nasal symptoms score, 86.0% and 79.2% for extra nasal symptoms score, as well as an increase of 25.2% and 24.3% for peak nasal inspiratory flow occurred for those treated with desloratadine plus prednisolone and dexchlorpheniramine plus betamethasone, respectively. There were no significant changes in blood chemistry. Sinus tachycardia was the most frequent electrocardiogram change, but with no clinical significance. Drowsiness was reported significantly more often among those of dexchlorpheniramine plus betamethasone group (17.14%×8.57%, respectively). ConclusionThe desloratadine plus prednisolone combination was able to effectively control acute symptoms of rhinitis in children, improving symptoms and nasal function. Compared to the dexchlorpheniramine plus betamethasone combination, it showed similar clinical action, but with a lower incidence of adverse events and higher dosing convenience.

Clinical validation of efficacy and safety of herbal cough formulation "Honitus syrup" for symptomatic relief of acute non-productive cough and throat irritation.

Background:Acute cough represents the most common illness evaluated in the outpatient settings. Available remedies for its management are generally allopathic combinations of antihistamines and decongestants that achieve antitussive activity, but often with unpleasant side effects prompting the need to explore safer and effective options. Honitus is an Ayurvedic proprietary herbal cough syrup with benefits of honey, intended to provide relief in acute nonproductive cough and throat irritation without causing drowsiness. This study investigated the safety and efficacy of Honitus in reducing acute nonproductive cough and throat irritation in comparison to a standard marketed allopathic cough syrup intended for use in similar conditions.Materials and Methods:This was a randomized double-blind study conducted in 105 individuals who received orally 2 tsp (10 ml) of either Honitus or marketed cough syrup (MCS) four times a day for 3 days. Response to treatment was evaluated from baseline to the end of treatment period on the basis of changes in day and night frequencies of cough, throat irritation and development of adverse events (AEs).Results:Honitus was found safe and effective in reducing symptoms of acute nonproductive cough, throat irritation, and comparable to MCS in reducing day and night frequencies of cough, the time to relief from cough and throat irritation and the Physician's Global Assessment of cough. Honitus showed comparably better results than MCS on throat irritation, the duration of relief from cough and throat irritation without causing drowsiness. No AEs related to study or study products were reported.Conclusion:Honitus Syrup is safe and effective in reducing the symptoms of acute nonproductive cough and throat irritation without causing drowsiness.

Treatment of solar urticaria using antihistamine and leukotriene receptor antagonist combinations tailored to disease severity.

Solar urticarial (SU) is characterized by erythema, whealing, and/or pruritus occurring minutes after sun exposure. Treatment is difficult and often unsatisfactory. To determine the action spectra and minimal urticaria dose (MUD) and to tailor a treatment regimen graded according to disease severity in a series of patients with SU. Eleven patients (seven females, four males, age range: 5-60 years) with a clinical history suggestive of SU, verified by photo-provocation tests to ultraviolet A (UVA), visible light, and/or UVB, were treated with various combinations of antihistamines and leukotriene receptor antagonist. All patients were sensitive to visible light (median MUD 50 J/cm(2)). Three patients were sensitive to UVA (median MUD 3.75 J/cm(2)), and one patient was sensitive to UVB (MUD of 0.03 J/cm(2)). Two patients experienced a spontaneous remission without treatment. One patient declined treatment. The remaining eight patients were managed by a combination of antihistamines (desloratidine, fexofenadine, cetirizine HCl) and a leukotriene receptor antagonist (montelukast). Seven of the 8 patients experienced a sustained remission of symptoms and signs following treatment. Photoprovocation for SU with determination of action spectra and MUD enables specifically tailored treatment regimens consisting of combinations of antihistamines and leukotriene receptor antagonist.

Seasonal and perennial allergic conjunctivitis.

Seasonal and perennial allergic conjunctivitis are IgE-mediated, hypersensitivity conditions characterized by ocular pruritus, epiphora, and hyperemia. Proper diagnosis is usually made clinically based on history and physical examination. Diagnostic procedures are rarely necessary. Non-pharmacological measures, such as environmental modification and proper eye care, should be considered for all patients with allergic conjunctivitis. Pharmacological interventions may also be required. Milder cases can be treated with short-term topical ophthalmic therapy such as a decongestant/ antihistamine combination, a mast cell stabilizer, or a multi-action agent. Moderate to severe cases may require longer usage of the above agents and/or the addition of an oral antihistamine. Refractory cases may necessitate the use of topical ophthalmic corticosteroids and topical NSAIDs. Immunotherapy, whether via the subcutaneous route or the intranasal route, should be considered in the treatment of persistent severe cases refractory to conventional treatment. Despite all the available therapeutic agents, there continues to be a constant need to discover more effective ways to treat seasonal and perennial allergic conjunctivitis. This article also discusses recent patents related to the field.

The status quo and unmet needs in the management of allergic rhinitis and chronic rhinosinusitis: a Malaysian perspective.

BackgroundAllergic rhinitis and rhinosinusitis, common and debilitating conditions, should be managed in accordance with guideline recommendations. Guideline adherence shows regional differences. As of now, there is little data from Asia and none from Malaysia on the current treatment practices and unmet needs in the management of these conditions.ObjectiveThe objective of this study was to assess the current practice in the management of allergic rhinitis and rhinosinusitis by conducting a survey among ear, nose and throat (ENT) specialists, pharmacists, and general practitioners (GPs) in Malaysia.MethodsWe conducted a survey study among ENT specialists, pharmacists, and GPs in Malaysia, who answered a multiple choice questionnaire focused on the current practice in the management of allergic rhinitis and rhinosinusitis in their respective field. More than 200 ENT specialists, 100 pharmacists, and 200 GPs participated in the survey.ResultsAntihistamines were the most preferred choice for the treatment of mild allergic rhinitis by ENT specialists (45%), pharmacists (78%), and GPs (51%), with the most preferable duration of <2 weeks. In moderate-to-severe allergic rhinitis, a combination of antihistamines and intranasal steroids was the most preferred treatment of choice in 90% of ENT specialists, 72% of pharmacists, and 69% of GPs. Efficacy of antihistamines was the main criteria of choice in 58%, 53%, and 38% of ENT specialists, pharmacists, and GPs, respectively. Notably, complaints of drowsiness associated with nonsedative antihistamines were the major unmet need identified in the survey. For chronic rhinosinusitis, a combination of antihistamines and intranasal steroids was the most preferred treatment. The majority of the respondents preferred a treatment duration of >3 months with antihistamines. Satisfaction with the recommendations in the current Allergic Rhinitis and its Impact on Asthma (ARIA) guideline was high; 66%, 58%, and 89% of the ENT specialists, pharmacists, GPs, respectively, reported that the current ARIA guidelines are sufficient for their clinical/pharmacy practice.ConclusionThe current practices in the management of allergic rhinitis in Malaysia are largely in line with the ARIA guidelines. The majority of physicians and pharmacists are satisfied with the recommendations in the ARIA guidelines.

Interventions for adult Eustachian tube dysfunction: a systematic review.

Eustachian tube dysfunction (ETD) is the inability of the Eustachian tube (ET) to adequately perform at least one of its functions: to protect the middle ear from sources of disease, to ventilate the middle ear, and to help drain secretions away from the middle ear. There are a number of treatment options for ETD, but there is little consensus about management. To determine the clinical effectiveness of interventions for adult ETD and to identify gaps in the evidence to inform future research. Twelve databases were searched up to October 2012 for published and unpublished studies in English (e.g. MEDLINE from 1946, EMBASE from 1974, Biosis Previews from 1969 and Cumulative Index to Nursing and Allied Health Literature from inception). References of included studies, relevant systematic reviews and regulatory agency websites were checked. A systematic review was undertaken. Controlled studies evaluating prespecified treatments for adult patients diagnosed with ETD were eligible. Uncontrolled studies with at least 10 participants were included for interventions where no controlled studies were found. Outcomes included change in symptoms severity/frequency (primary outcome), quality of life, middle ear function, hearing, clearance of middle ear effusion, early ventilation tube extrusion, additional treatment, adverse events and complications. All aspects of the review process were performed using methods to reduce reviewer error and bias. Owing to heterogeneous data, a quantitative synthesis could not be performed, and results were reported in a narrative synthesis. Nineteen studies were included: three randomised controlled trials (RCTs) and two non-RCTs evaluating pharmacological interventions or mechanical devices for middle ear pressure equalisation; and 13 case series and one retrospective controlled before-and-after study evaluating surgical interventions. None was conducted in the UK. All studies were small (11 to 108 participants). Most non-surgical studies reported including mixed populations of adults and children. All except two studies were at high risk of bias, and subject to multiple limitations. Based on a single RCT, nasal steroids showed no improvement in symptoms or middle ear function for patients with otitis media with effusion and/or negative middle ear pressure. Very short-term improvements in middle ear function were observed in patients receiving directly applied topical decongestants or a combination of antihistamine and ephedrine. Single trials found two pressure equalisation devices were each associated with significant short-term improvements in symptoms, middle ear function and/or hearing. Eustachian tuboplasty (seven case series) and balloon dilatation (three case series) were associated with improved outcomes. Positive results were also reported for myringotomy (two case series), directly applied topical steroids (one case series) and laser point coagulation (one controlled before-and-after study). High rates of co-interventions were documented. Minor complications of surgery and pharmacological treatments but no serious adverse effects were reported. The evidence was limited in quantity and overall was of poor quality. No data were identified on several interventions despite extensive searches. It is not possible to draw conclusions regarding the effectiveness of any of the interventions for the treatment of adults with an ETD diagnosis, and there is insufficient evidence to recommend a trial of any particular intervention. Further research is needed to address lack of consensus on several issues, including the definition of ETD in adults, its relation to broader middle ear ventilation problems and clear diagnostic criteria. This study is registered as PROSPERO CRD42012003035. The National Institute for Health Research Health Technology Assessment programme.

Widespread Morbilliform Eruption Associated With Telaprevir

Telaprevir, combined with pegylated interferon alfa and ribavirin, is an efficacious approach to treat hepatitis C virus infection. A morbilliform eruption associated with telaprevir is a common adverse effect experienced by patients. Current guidelines mandate telaprevir discontinuation in any patient with a severe, progressive, or unresponsive cutaneous eruption. Eight patients with a grade 3 (severe) widespread morbilliform eruption associated with telaprevir were referred to dermatology for evaluation and treatment. Each patient received a combination of antihistamines, topical corticosteroids, and thick emollient creams, rendering their eruption tolerable for the duration of treatment. No patients had evidence of a systemic or life-threatening drug reaction, developed a systemic drug eruption, or had to prematurely stop triple therapy secondary to a cutaneous eruption. Patients with an uncomplicated grade 3 (severe) widespread morbilliform eruption associated with telaprevir may be able to continue triple therapy with close monitoring and dermatologic consultation. Given our findings, we propose an additional clinical classification of the telaprevir-associated eruption to better reflect the dermatologic classification of drug eruptions.