Doxycycline or oral corticosteroids for nasal polyps

Doxycycline or Oral Corticosteroids for Nasal Polyps Therapeutic Options Beyond our Pages highlights randomized controlled trials published in other journals of novel therapeuticoptions for the conditions treated by allergist-immunologists. Generally written by Editorial Board members with relevantexpertise, this feature summarizes the methods and results of the study and then provides the author’s perspective regarding thepractical use of the information at this time.
The study by Van Zele et al1 reports positive results for either 20 doxycycline group is similar to that reported after 4 weeks of days of doxycycline (200 mg the first day, followed by 100 mg daily) or 20 days of a tapering schedule of methylprednisolone Relative to the secondary outcome of important nasal symptoms, (32 mg on days 1-5; 16 mg on days 6-10, and 8 mg days 11-20) the methylprednisolone group had reduction of postnasal drip, for the treatment of nasal polyps in a randomized, double-blind, smell loss, and nasal congestion, whereas the doxycycline-treated placebo-controlled trial. The primary end point was reduction in group improved only in postnasal drip. Neither group showed nasal polyp score, which was graded 0 to 4 on each side, resulting improvement in anterior rhinorrhea. Improvement in both treat- in a score range of 0 to 8; the score was determined at baseline ment groups was also seen in the secondary outcome of nasal peak and weeks 1, 2, 4, 8, and 12. Entry criteria required that the inspiratory flow, with the methylprednisolone group being better patient either have recurrent polyps after surgery or massive than the doxycycline group. Inflammatory markers were measured polyps (grade 3 or 4); the total polyp score in each of the 3groups averaged approximately 6. The patient population in thisstudy was, therefore, at the severe end of the spectrum; results This trial of 47 patients reported a significant may not be generalizable to patients with milder disease.
reduction in endoscopically graded polyp size in This trial of 47 patients reported a significant reduction in both the doxycycline- and methylprednisolone- endoscopically graded polyp size in both the doxycycline- and treated groups compared with placebo.
methylprednisolone-treated groups compared with placebo. Ashas been reported by others,2 the patients who received a burst ofmethylprednisolone enjoyed a substantive, statistically significant reduction in nasal polyp size (maximum decrease of 2.3 on the in nasal secretions. Compared with placebo, both groups had 8-point scale); unfortunately, the effect was transient with return reduced eosinophilic cationic protein (ECP); the methylpredniso- to baseline score by week 8. In contrast, the doxycycline-treated lone group had reduced IgE and IL-5, whereas the doxycycline group had a less impressive but still statistically significant group had reduced myeloperoxidase and matrix metalloproteinase- reduction (maximum decrease of 0.7) in nasal polyp score that 9. One important aspect of the study design to note is that persisted through the end of the study, week 12. As the supplemental antibiotics, nasal steroids, and oral glucocorticoste- researchers noted, the magnitude of polyp reduction in the roids were disallowed during the study. Therefore, in some nasalsecretion biomarker comparisons, such as ECP, IL-5, and IgE, thedifferences observed were partly because of increases in the placebogroup that occurred because they discontinued nasal steroids.
The study by Van Zele et al1 provides category I evidence in This work is supported by the Ernest S Bazley Trust to Northwestern University and support of an oral glucocorticosteroid burst for improvement in Conflicts of interest: L. C. Grammer has received research and travel support from the signs and symptoms of nasal polyps. Because of the side effect the National Institutes of Health, Food Allergy Network, and S&C Electric; profile of oral glucocorticosteroids, however, the frequency with has received the Bazley Foundation Grant; has received consultancy fees which they can be judiciously administered is limited. It should from Astellas Pharmaceuticals; is employed by Northwestern University and the be emphasized that this is probably the first study to evaluate the Northwestern Medical Faculty Foundation; has received lecture fees from theAAAAI and Beth Israel Hospital; and receives royalties from Lippincott, duration of the effect of a short course of oral glucocorticoste- roids. Unfortunately, the effect is transient, essentially dis- Received for publication April 16, 2013; accepted for publication April 18, 2013.
appearing by 8 weeks after initiation of therapy. In practice, most patients prescribed a short course of oral glucocorticosteroids Cite this article as: Grammer LC. Doxycycline or oral corticosteroids for nasal would also be using nasal steroids, which was not the case in this polyps. J Allergy Clin Immunol: In Practice. http://dx.doi.org/10.1016/j.jaip.2013.04.010.
study. It is possible that the effect would have been longer lasting Corresponding author: Leslie C. Grammer, MD, Northwestern University, 14022 if nasal steroids were concomitantly administered.
Arkes Pavilion; 676 N St Clair St, Chicago, IL 60611. E-mail: [email protected] This study also provides proof of concept for use of doxycycline in the treatment of nasal polyps. The researchers speculate that there is a population of patients whose disease is exacerbated by Ó 2013 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2013.04.010 lococcus aureus enterotoxin.4 Although doxycycline reduced polyp patients with nasal polyps would benefit from the addition of doxycycline, what the best dosage schedule is, and whether there are additive or synergistic effects with other therapies. Inparticular, although both doxycycline and methylprednisolonedecreased ECP, they had different effects on other inflammatory size and symptoms only modestly, it supports the superantigen biomarkers, with doxycycline reducing matrix metalloproteinase- theory of chronic rhinosinusitis with nasal polyposis. The 9 and myeloperoxidase, whereas methylprednisolone reduced IgE researchers speculate that doxycycline has great potential for and IL-5. Because the 2 drugs seem to affect different inflam- extended use. Because of the modest effects observed, this trial matory components, the hypothesis that they could result in does not support the use of doxycycline as monotherapy for nasal additive or synergistic effects seems a reasonable one to test.
polyps. It does suggest that, in some patients, it might be anadditive therapy to currently proven treatments such as nasal steroids.5 Future studies will be needed to determine which 1. Van Zele T, Gevaert P, Holtappels G, Beule A, Wormald PJ, Mayr S, et al. Oral steroids and doxycycline: two different approaches to treat nasal polyps.
J Allergy Clin Immunol 2010;125:1069-1076.e4.
2. Martinez-Devesa P, Patiar S. Oral steroids for nasal polyps. Cochrane Database Future studies will be needed to determine 3. Small CB, Hernandez J, Reyes A, Schenkel E, Damiano A, Stryszak P, et al.
which patients with nasal polyps would benefit Efficacy and safety of mometasone furoate nasal spray in nasal polyposis.
from the addition of doxycycline, what the best J Allergy Clin Immunol 2005;116:1275-81.
dosage schedule is, and whether there are 4. Conley DB, Tripathi A, Seiberling KA, Suh LA, Harris KE, Paniagua MC, et al.
Superantigens and chronic rhinosinusitis; II, analysis of T-cell receptor V beta additive or synergistic effects with other domains in nasal polyps. Am J Rhinol 2006;20:451-5.
5. Kalish L, Snidvongs K, Sivasubramaniam R, Cope D, Harvey RJ. Topical steroids for nasal polyps. Cochrane Database Syst Rev 2012;12:CD006549.

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