Can Allergy Drops Improve Nasal Symptoms?

Dual-action medications and combination regimens can make life easier for patients.

BY OPHTHALMOLOGY MANAGEMENT STAFF

For allergy patients, April is indeed the cruelest month. Expect to see your appointment book start to fill up over the next several weeks with visits from people who dread rather than welcome this time of year. Is there anything ophthalmologists can tell them that might lift their spirits? Yes, actually. Some drops for ocular allergy relief provide an added benefit: efficacy against nasal symptoms. Though likely not as robust as that from a nasal spray, any extra bit of relief is always welcome.

In its phase 3 clinical trials of the ocular allergy treatment bepotastine 1.5% (Bepreve), Ista Pharmaceuticals also assessed the medication's effects on nasal allergy symptoms. In two seven-week, masked, randomized, placebo-control led studies (n=157), the conjunctival allergen challenge (CAC) model of allergic conjunctivitis was used to evaluate patients' total non-ocular composite symptom score (TNSS) as a secondary endpoint. TNSS was defined as the sum of nasal congestion, rhinorrhea, nasal pruritis and ear and/or palate itching.

The consolidated results from the two studies have not been published yet, but Ista says that bepotastine demonstrated a 77% reduction from baseline in TNSS within seven minutes after dosing [clinical and statistical significance vs. placebo (p ≤ 0.001)]. In addition, bepotastine demonstrated an 82% reduction from baseline in TNSS at eight hours after dosing [clinical and statistical significance vs. placebo (p ≤ 0.001)].

“It's important to study any drug's effects on all body systems,” explains Gregg J. Berdy M., an ophthalmologist in St. Louis. “Also, Ista knew bepotastine is a potent molecule that would likely have an impact on both ocular and nasal symptoms. Millions of prescriptions have been written for the oral form in Japan (Talion, Tanabe Seiyaku Co., Ltd.), which for several years has been approved to treat allergic rhinitis and itching associated with certain skin conditions.”

Ophthalmology Management asked Dr. Berdy and other physicians how the new information about bepotastine and other agents fits with the current thinking about treating patients with seasonal and perennial allergy symptoms.

A Concept Worth Exploring

The nasal effects of prescription ocular allergy medications in the same class as bepotastine — antihistamine/mast-cell stabilizers — have also been studied. (See “Ocular Antihistamine/Mast-Cell Stabilizers and Nasal Symptoms.”) According to Peter D'Arienzo, MD, an ophthalmologist in Manhasset, NY, “all of these drops will have some nasal effect due to their antihistaminic activity. We know allergic rhinitis goes hand in hand with eye allergy problems.^1-3 So if an allergy drop can get into the nasolacrimal system and reduce nasal symptoms, it may allow for less use of nasal medications.”

Warner Carr, MD, an allergist in Mission Viejo, Calif., agrees that reducing the number of medications patients need to take, whenever possible, is a desirable goal. “Socio-economic issues are also important in today's world,” he says. “We should be conscious of the cost of multiple prescriptions and the time it takes for patients when they have to see multiple doctors.”

Additional Evidence to Consider

Based on the currently available research about the nasal effects of ocular allergy medications, Michael S. Blaiss, MD, an allergist in Memphis, cautions doctors not to expect a “magic bullet” for effective relief of both eye and nose symptoms. In his opinion, “there are better data showing that steroid nasal sprays positively impact ocular symptoms.”^4,5 One such spray, fluticasone furoate (Veramyst, Glaxo-SmithKline), is FDA approved to treat the nasal symptoms of seasonal allergy as well as red, itchy and watery eyes.

Even so, Dr. Blaiss says, when treating patients with ocular and nasal allergy symptoms, several factors need to be taken into account. These include convenience/compliance issues, patient preferences and, most importantly, severity of symptoms. “Some patients will need specific treatment for both their eyes and nose,” he explains.

Judging by both the published research and his clinical experience, Dr. D'Arienzo finds site-specific therapy is often the most effective for ocular allergy relief. “Nasal sprays decrease nasal congestion, so perhaps that also improves tear flow and the washing away of allergic mediators,” he says. “But there is no physical way a nasal spray can get to the surface of the eye to help ocular symptoms. Allergy patients come to see us because their eyes itch. For that, they need an antihistamine on the eye.”

Furthermore, Dr. D'Arienzo continues, it is well-established that the oral antihistamines often prescribed to allergy patients by their primary care doctors tend to dry the eyes, which only serves to exacerbate ocular symptoms. “Unless patients have asthma or another condition that requires oral medication, I'd much rather have them use an eye drop for their eyes and a nasal spray for their nose if they need it.”

Dr. D'Arienzo participated in a study that supports the site-specific treatment approach. In the study, concomitant use of the intranasal steroid spray fluticasone propionate (Flonase, GlaxoSmithKline) and the eye drop olopatadine (Pataday, Alcon Laboratories, Inc.) was more effective than concomitant use of fluticasone and oral fexofenadine (Allegra, Sanofi-Aventis) for overall treatment of the signs and symptoms of allergic rhinoconjunctivitis.⁶

Several other studies of nasal symptom reduction have reached similar conclusions. For example, in a study by Spangler et al.⁷ comparing olopatadine 0.1% (Patanol, Alcon Laboratories, Inc.), intranasal mometasone fumarate (Nasonex, Schering-Plough) and oral fexofenadine, both topical medications provided more relief to the targeted tissues than the oral medication. Also, in a study by Rosenwasser et al., olopatadine 0.2% (Pataday) was shown to be “statistically and clinically superior to fluticasone nasal spray (Veramyst) for the relief of signs and symptoms of allergic conjunctivitis.”⁸

Patients Need Eye and Nose Relief

Taking the relevant research into account, Dr. Berdy says “there is likely a role” for the newest antihistamine/mast-cell stabilizing eye drop, bepotastine, in providing nasal symptom relief “but we don't yet know how it will play out.” Greater clinical experience and confirming studies will further elucidate how effective it will be for controlling symptoms beyond the ocular.

The take-home message for ophthalmologists, according to Dr. Berdy, is that “the dual-action eye drops are our armamentarium workhorses.” From a safety and efficacy standpoint, he says, they should be the first line of treatment for patients' ocular symptoms. “For those who also present with nasal symptoms, a drop may help. If not, we can also prescribe a nasal treatment or refer to an allergist for further evaluation.” OM

References

1. Nathan RA, Meltzer EO, Seiner JC, Storms W. Prevalence of allergic rhinitis in the United States. J Allergy Clin Immunol 1997;99(6):S808-S814.
2. Kosrirukvongs P, Visitsunthorn N, Vichyanond P, Bunnag C. Allergic conjunctivitis. Asian Pac J Allergy Immunol 2001:19(4):237-44.
3. Schulman, Ronca and Bucuvalas, Inc. (SRBI). Allergies in America: A Landmark Survey of Nasal Allergy Sufferers. Available at www.myallergiesinamerica.com. Accessed Jan. 5, 2010.
4. Blaiss MS. Evolving paradigm in the management of allergic rhinitis-associated ocular symptoms: role of intranasal corticosteroids. Curr Med Res Opin 2008; 24(3):821-836.
5. Origlieri C, Bielory L. Intranasal corticosteroids: do they improve ocular allergy? Curr Allergy Asthma Rep 2009;9(4):304-10.
6. Lanier BQ, Abelson MB, Berger WE, et al. Comparison of the efficacy of combined fluticasone propionate and olopatadine versus combined fluticasone propionate and fexofenadine for the treatment of allergic rhinoconjunctivitis induced by conjunctival allergen challenge. Clin Ther 2002;24(7):1161-74.
7. Spangler DL, Abelson MB, Ober A, Gomes PJ. Randomized, double-masked cmparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models. Clin Ther 2003;25:2245-67.
8. Rosenwasser LJ, Mahr T, Abelson MB, et al. A comparison of olopatadine 0.2% ophthalmic solution versus fluticasone furoate nasal spray for the treatment of allergic conjunctivitis. Allergy Asthma Proc 2008;29:644-653.