Recomendaciones sobre la duraci n optima del tratamiento con corticoesteroides t picos intranasales: Revisi n de la evi

2. Recomendaciones sobre�la duraci�n optima del tratamiento con corticoesteroides t�picos intranasales: Revisi�n de la evidencia � Presentaci�n y debate Jorge F M�spero Buenos Aires Argentina

3. Rinitis Al�rgica Prevalencia elevada ?600.000.000 en el mundo (1/3 con asma) Prevalencia en aumento Causas del aumento de la prevalencia Cambios en el medioambiente sin dudas Hip�tesis higi�nica? Aumento de la poluci�n? Frecuentemente co m�rbida

4. Allergic rhinitis: common, costly, and neglectedLancet 2008;371 Costos en salud de la Rinitis Al�rgica U$d 1.000.000.000 en 2005 (Agency for Healthcare Research Quality, USA, 2005) 1/3 honorarios m�dicos (22.000.000 consultas) Promedio anual de u$d 520/persona Afectaci�n personal y social Gran impacto en la calidad de vida Efectos en la escolaridad Ausentismo laboral Editorial. Allergic rhinitis: common, costly, and neglected 11 billones = mil millones � El doble de lo gastado en 2000.Editorial. Allergic rhinitis: common, costly, and neglected 11 billones = mil millones � El doble de lo gastado en 2000.

5. 1.906 MAP 14.703 pacientes encuestados y 4.335 a-q Frecuencia de RA en asm�ticos 55,2% RA Intermitente 66,5% Persistente 33,5% 81,2% tratados 34,1% con AH 14,2% con ICS A-q = completaron n autocuestionario 14 703 pacientes encuestados y 4335 a-q auto-questionnaires The frequency of AR in asthmatic patients was 55.2% (CI: 95%, 54.4�56.0%), i.e. 8028 patients out of the 4 542 assessable patients. Allergic rhinitis was intermittent for 66.5% of patients (CI: 95%, 65.4�67.6%) and persistent for 33.5% (CI: 95%, 32.4�34.6%). A-q = completaron n autocuestionario 14 703 pacientes encuestados y 4335 a-q auto-questionnaires The frequency of AR in asthmatic patients was 55.2% (CI: 95%, 54.4�56.0%), i.e. 8028 patients out of the 4 542 assessable patients. Allergic rhinitis was intermittent for 66.5% of patients (CI: 95%, 65.4�67.6%) and persistent for 33.5% (CI: 95%, 32.4�34.6%).

6. Cohorte de 453 individuos con AR (SFARq) Evalu� el nivel de conocimiento de la enfermedad y su tratamiento Frente a un episodio de RA 49% espera a que se le pasa sin tratamiento 31% toma una medicaci�n que le hab�an indicado previamente 20 % consulta a un profesional de la salud 59% MAP 26% farmac�utico 13% especialista Seguimiento s�lo en el 42% de los pacientes, principalmente por MAP A cohort of 453 individuals with AR was selected using the Score For Allergic Rhinitis questionnaire. The survey evaluated the level of understanding of allergic rhinitis and its management, including both pharmacotherapy and SIT. A parallel survey was conducted with 400 general practitioners, allergists and nonallergist specialists. When an episode of AR occurred, almost half (49%) the patients did nothing and waited until it was over, while 31% took a previously prescribed medication. At the onset of an episode, 20% of patients consulted a health professional (doctor or pharmacist), and subsequently, two-thirds consulted either a doctor (59%), most frequently their GP, or a pharmacist (26%) or both. The specialist (allergist, ENT specialist or pneumologist) was consulted initially only in 12% of cases. GPs referred patients to a specialist in 42% of cases, and the family circle also played a role by persuading the patient to seek specialist treatment. Postconsultation follow-up was infrequent and was carried out for only 42% of patients, mainly by GPs. A cohort of 453 individuals with AR was selected using the Score For Allergic Rhinitis questionnaire. The survey evaluated the level of understanding of allergic rhinitis and its management, including both pharmacotherapy and SIT. A parallel survey was conducted with 400 general practitioners, allergists and nonallergist specialists. When an episode of AR occurred, almost half (49%) the patients did nothing and waited until it was over, while 31% took a previously prescribed medication. At the onset of an episode, 20% of patients consulted a health professional (doctor or pharmacist), and subsequently, two-thirds consulted either a doctor (59%), most frequently their GP, or a pharmacist (26%) or both. The specialist (allergist, ENT specialist or pneumologist) was consulted initially only in 12% of cases. GPs referred patients to a specialist in 42% of cases, and the family circle also played a role by persuading the patient to seek specialist treatment. Postconsultation follow-up was infrequent and was carried out for only 42% of patients, mainly by GPs.

7. Prevalencia de los distintos tiposde rinitis al�rgica (RA) Prevalencia global de la rinitis al�rgica persistente Prevalencia de los distintos tipos de rinitis al�rgica (RA) Seg�n una encuesta telef�nica en la que participaron 9.646 entrevistados de B�lgica, Francia, Alemania, Italia, Espa�a y el Reino Unido, se estim� que la prevalencia de la RA en la UE era de 22,7%. De este porcentaje, 29% de los pacientes presentaba s�ntomas correspondientes a RA �persistente� seg�n la clasificaci�n de la ARIA, mientras que el resto (71%) presentaba s�ntomas de RA �intermitente�. Prevalencia de los distintos tipos de rinitis al�rgica (RA) Seg�n una encuesta telef�nica en la que participaron 9.646 entrevistados de B�lgica, Francia, Alemania, Italia, Espa�a y el Reino Unido, se estim� que la prevalencia de la RA en la UE era de 22,7%. De este porcentaje, 29% de los pacientes presentaba s�ntomas correspondientes a RA �persistente� seg�n la clasificaci�n de la ARIA, mientras que el resto (71%) presentaba s�ntomas de RA �intermitente�.

8. Presencia de s�ntomas durante el a�o completo en pacientes con RAP El 50% de los pacientes presentan s�ntomas al menos durante 4 meses en el a�o El 20% de los pacientes presentan s�ntomas al menos durante 9 meses en el a�o.

9. Encuesta Enfermedades al�rgicas cr�nica m�s frecuentes en su consulta? RA 35% AB 24% DA 17% U 9% Otra 15% RA � S�ntoma m�s dif�cil de tratar Congesti�n Goteo post nasal

10. Encuesta (cont.) El 74% de los encuestados dijo que 5 de cada 10 pacientes que diagnostican sufren s�ntomas persistentes El 75% de los encuestados dijo que 5 de cada 10 pacientes que diagnostican sufren RA moderada/severa El 52% utiliza ICS <30 d�as en promedio en pacientes con RA moderada severa TODO INDICA SUBTRATAMIENTO TODO INDICA SUBTRATAMIENTO

11. En la encuesta a m�dicosde atenci�n primaria en Latinoam�rica m�s del 75% de los encuestados respondieron que en sus consultas: 50% o m�s de los pacientes son del tipo persistente-moderado-severo cuando se aplican los criterios de clasificaci�n de ARIA Pero no usan el tratamiento sugerido por ARIA m�s de 30 d�as-a�o No hay estudios de largo plazo que eval�en las ventajas del tratamiento continuo vs intermitente de la rinitis persistente

13. Tratamiento de largo plazo con esteroides nasales

14. Qui�n trata la rinitis? INDICE NACIONAL DE TERAPEUTICA Y ENFERMEDADES (INTE) INDICE NACIONAL DE TERAPEUTICA Y ENFERMEDADES (INTE)

15. Uso de las gu�as ARIA � EP3OS Qu� son las gu�as? No las conoce 64% Las conoce 36% Las aplica 60% No las aplica 40% S�lo el 22% las conoce y las aplica

16. �C�mo tratan la rinitis al�rgica?

17. �Existen recursos suficientes? 2.200 ORL � 800 Alergistas2.200 ORL � 800 Alergistas

18. Conclusiones iniciales Los MAP y pediatras son los que mayor n�mero de pacientes con RA atienden Est�n pobremente entrenados en el diagn�stico y tratamiento de �sta enfermedad Existen varias gu�as de tratamiento, pero ninguna que permitan identificar f�cil y r�pidamente a los pacientes que se beneficiar�an con una intervenci�n prolongada o intermitente.

19. �C�mo evaluar el tratamiento de la rinitis al�rgica persistente a largo plazo ?

20. Duraci�n optima del tratamiento con corticoesteroides t�picos intranasales: Mantener la terapia a�n en ausencia de s�ntomas ? (atacar la inflamaci�n m�nima persistente) Buscar el control de los sintomas y luego usar la menor dosis o uso p.r.n? Considerar rapidez de acci�n , costo directo , compliance y aceptaci�n por el paciente vs evoluci�n a largo plazo , complicaciones y costos indirectos

21. Persistent inflammation in allergic rhinitis Prophylactic use of intranasal steroids in seasonal allergic rhinitis Long-term use of intranasal steroids in perennial allergic rhinitis Long-term use in adults Long-term use in children

23. Minimal Persistent Inflammation

24. Evidence of Significant Inflammation During the Days with Low Pollen Count and Low or Absent Symptoms

26. MFNS: Anti-Inflammatory Effect of 12-Month Treatment in Patients With PAR

27. Unretouched Nasal Biopsy Pictures Impact on the Nasal Mucosa Documented reduction of inflammation NASONEX� in PAR - Histology - Results - Patient 2 Again, note the histology prior to the initiation of NASONEX� treatment, and the demonstration of more marked inflammatory changes and even more damage in the superficial mucosa. Note on the right, again after 12 months of therapy with NASONEX�, that the dermis is much improved in terms of inflammatory infiltrate. NOTE: The clinical relevance of these data in the treatment of allergic rhinitis is not known. Minshall E, Ghaffar O, Cameron L, et al. Assessment by nasal biopsy of long-term use of mometasone furoate aqueous nasal spray (NASONEX) in the treatment of perennial rhinitis. Otolaryngol Head Neck Surg. May 1998;118(5):648-654.NASONEX� in PAR - Histology - Results - Patient 2 Again, note the histology prior to the initiation of NASONEX� treatment, and the demonstration of more marked inflammatory changes and even more damage in the superficial mucosa. Note on the right, again after 12 months of therapy with NASONEX�, that the dermis is much improved in terms of inflammatory infiltrate. NOTE: The clinical relevance of these data in the treatment of allergic rhinitis is not known. Minshall E, Ghaffar O, Cameron L, et al. Assessment by nasal biopsy of long-term use of mometasone furoate aqueous nasal spray (NASONEX) in the treatment of perennial rhinitis. Otolaryngol Head Neck Surg. May 1998;118(5):648-654.

28. Persistent Inflammation in Allergic Rhinitis: Summary In patients with seasonal allergic rhinitis, inflammation is present both before and during the season Patients with perennial allergic rhinitis have persistent inflammation Intranasal steroids are effective anti-inflammatory agents What are ,if any, the clinical advantages of long term treatment?

29. �Cuan persistente es la rinitis persistente?

30. Calculation of the �normal range� of nasal symptom scores. Calculation of the �normal range� of nasal symptom scores. The dotted line (- - - -) represents the cut-off for the normal range of symptom scores (mean nasal symptom score of control group + 2SD). Scores below the dotted line are in the normal range. Error bars are 95% CI. The maximum possible symptom score is 9.Calculation of the �normal range� of nasal symptom scores. The dotted line (- - - -) represents the cut-off for the normal range of symptom scores (mean nasal symptom score of control group + 2SD). Scores below the dotted line are in the normal range. Error bars are 95% CI. The maximum possible symptom score is 9.

31. Why did you take your medication?�, �could answer either: 1. To prevent symptoms; 2. As needed because of present symptoms; 3. Doctor�s orders; 4. A habit; 5. Other reason.

33. Conclusions persistent nasal symptoms over a previously unstudied period of 12 months in persistent rhinitic subjects, with pathologically high nasal symptom scores for 65% of the time. The majority of persistent rhinitic subjects used nasal medication intermittently, Increasing nasal symptom scores were a predictor for the use of nasal medications. These findings suggest that, despite continued high allergen exposure, subjects with persistent rhinitis experience some variation in symptom intensity and are able to respond to these changes by taking medication.

34. Prophylactic use of intranasal steroids in seasonal allergic rhinitis

35. MFNS and BDP in Prophylaxis of Nasal Symptoms of SAR: Primary Endpoint�Proportion of Minimal Symptom Days NASONEX in Prophylaxis of Nasal Symptoms of SAR: Primary Endpoint � Proportion of Minimal Symptom Days The proportion of minimal symptom days (days with total nasal symptom score =2), the primary endpoint of the study, was significantly greater (P=0.01) in patients treated with NASONEX� 200 �g once daily than in those receiving placebo, both during the pollen season (83% vs 64%, respectively) and during the entire 8-week study (88% vs 75%, respectively). The proportion of minimal symptom days was also significantly greater (P=0.01) in patients treated with beclomethasone dipropionate (BDP) 168 �g twice daily than in those receiving placebo, both during the pollen season (77% vs 64%, respectively) and during the entire 8-week study (83% vs 75%, respectively). An 8-week multicenter, double-blind, randomized, placebo-controlled study was designed to assess the effects of prophylactic use of NASONEX� when initiated before the anticipated onset of the ragweed pollen season. In this study, a total of 349 patients aged 12 years or older with a history of allergic reactions to ragweed pollen were randomized to receive either NASONEX� 200 �g qd (n=114), beclomethasone dipropionate 168 �g bid (n=112), or placebo (n=104) beginning four weeks before the estimated onset of the ragweed season and continuing for a total of 8 weeks. The primary efficacy variable was the proportion of minimal symptom days (days with total nasal symptom score =2) from the onset of ragweed season to study completion. The recommended dose of NASONEX� for patients aged 12 years and older for the prophylaxis of nasal symptoms of SAR is 200 mcg once a day, when started 2-4 weeks prior to pollen season. Beclomethasone dipropionate is not indicated for the prophylaxis of SAR. NASONEX in Prophylaxis of Nasal Symptoms of SAR: Primary Endpoint � Proportion of Minimal Symptom Days The proportion of minimal symptom days (days with total nasal symptom score =2), the primary endpoint of the study, was significantly greater (P=0.01) in patients treated with NASONEX� 200 �g once daily than in those receiving placebo, both during the pollen season (83% vs 64%, respectively) and during the entire 8-week study (88% vs 75%, respectively). The proportion of minimal symptom days was also significantly greater (P=0.01) in patients treated with beclomethasone dipropionate (BDP) 168 �g twice daily than in those receiving placebo, both during the pollen season (77% vs 64%, respectively) and during the entire 8-week study (83% vs 75%, respectively). An 8-week multicenter, double-blind, randomized, placebo-controlled study was designed to assess the effects of prophylactic use of NASONEX� when initiated before the anticipated onset of the ragweed pollen season. In this study, a total of 349 patients aged 12 years or older with a history of allergic reactions to ragweed pollen were randomized to receive either NASONEX� 200 �g qd (n=114), beclomethasone dipropionate 168 �g bid (n=112), or placebo (n=104) beginning four weeks before the estimated onset of the ragweed season and continuing for a total of 8 weeks. The primary efficacy variable was the proportion of minimal symptom days (days with total nasal symptom score =2) from the onset of ragweed season to study completion. The recommended dose of NASONEX� for patients aged 12 years and older for the prophylaxis of nasal symptoms of SAR is 200 mcg once a day, when started 2-4 weeks prior to pollen season. Beclomethasone dipropionate is not indicated for the prophylaxis of SAR.

37. MFNS and Fluticasone Propionate (FP) for Long-Term Treatment of Patients With PAR: Study Design A 3-month, randomised, double-blind, double dummy, parallel-group study in 474 adolescent and adult patients (age 12-77) with perennial allergic rhinitis Treatment for 3 months MFNS 200 �g od (n=166) Fluticasone propionate (FP) 200 �g od (n=162) Placebo (n=146) Primary efficacy variable Change from baseline in total AM plus PM diary nasal symptom score over the first 15 days of treatment

38. MFNS and FP in Adolescents and Adults With Moderate-to-Severe PAR: Percent Change in Patient-Rated Nasal Congestion NASONEX� in Moderate to Severe PAR: Percent Change in Patient-Rated Nasal Congestion, a Component of TNSS Patient diary data demonstrated that patients receiving NASONEX� 200 �g qd experienced significantly greater percent reductions from baseline in nasal congestion (secondary end point) compared with their counterparts receiving placebo during the entire 12-week study. The difference between NASONEX� and placebo was statistically significant at all time points (P<0.01). Patients receiving FP (fluticasone propionate) 200 �g qd also experienced significantly greater percent reductions from baseline in nasal congestion (secondary end point) compared with their counterparts receiving placebo during the entire 12-week study. The difference between FP and placebo was statistically significant at all time points (P=0.01). This was a 12-week, randomized, double-blind, double-dummy, parallel-group study in 548 patients aged 12 to 77 years. Patients allergic to at least one perennial allergen with a confirmed allergy history, skin test positivity, and moderate to severe symptoms were randomized to receive either NASONEX� 200 �g once daily (n=181), FP 200 �g once daily (n=183), or placebo (n=184). Treatment outcomes were evaluated by both the patients and the physicians. The primary efficacy variable was the mean change from baseline in total reflective AM/PM patient diary nasal symptom score over the first 15 days of treatment.NASONEX� in Moderate to Severe PAR: Percent Change in Patient-Rated Nasal Congestion, a Component of TNSS Patient diary data demonstrated that patients receiving NASONEX� 200 �g qd experienced significantly greater percent reductions from baseline in nasal congestion (secondary end point) compared with their counterparts receiving placebo during the entire 12-week study. The difference between NASONEX� and placebo was statistically significant at all time points (P<0.01). Patients receiving FP (fluticasone propionate) 200 �g qd also experienced significantly greater percent reductions from baseline in nasal congestion (secondary end point) compared with their counterparts receiving placebo during the entire 12-week study. The difference between FP and placebo was statistically significant at all time points (P=0.01). This was a 12-week, randomized, double-blind, double-dummy, parallel-group study in 548 patients aged 12 to 77 years. Patients allergic to at least one perennial allergen with a confirmed allergy history, skin test positivity, and moderate to severe symptoms were randomized to receive either NASONEX� 200 �g once daily (n=181), FP 200 �g once daily (n=183), or placebo (n=184). Treatment outcomes were evaluated by both the patients and the physicians. The primary efficacy variable was the mean change from baseline in total reflective AM/PM patient diary nasal symptom score over the first 15 days of treatment.

39. MFNS and FP in Adolescents and Adults With Moderate to Severe PAR: Percent Change in Patient-Rated Individual Symptom Scores In this survey, patients reported a variety of symptoms, including sneezing, runny nose, itchy nose, blocked nose, itchy/red eyes and watery eyes. Compared with patients with SAR +PAR, patients with PAR or SAR reported fewer symptoms (P< .001). Congestive symptoms (blocked nose) were more commonly reported by patients with SAR + PAR than those diagnosed with either PAR or SAR alone (P< 0.05). By contrast, ocular symptoms ( itchy/red eyes and watery eyes) were more commonly present among patients with SAR and patients with SAR+PAR than in those with PAR (P< .05). According to the physicians� assessment, more patients with asthma than without asthma had moderate to severe disease (73.7% vs 64.3%, P < .001) This study indicates that the burden of AR is greatest in patients with PAR with/without SAR and tended to present more frequent and severe symptoms. These severe symptoms, if not well controlled, may lead to more comorbidities, such as asthma and sinusitis. Canonica GW. Allergy. 2007;62(suppl 85):17In this survey, patients reported a variety of symptoms, including sneezing, runny nose, itchy nose, blocked nose, itchy/red eyes and watery eyes. Compared with patients with SAR +PAR, patients with PAR or SAR reported fewer symptoms (P< .001). Congestive symptoms (blocked nose) were more commonly reported by patients with SAR + PAR than those diagnosed with either PAR or SAR alone (P< 0.05). By contrast, ocular symptoms ( itchy/red eyes and watery eyes) were more commonly present among patients with SAR and patients with SAR+PAR than in those with PAR (P< .05). According to the physicians� assessment, more patients with asthma than without asthma had moderate to severe disease (73.7% vs 64.3%, P < .001) This study indicates that the burden of AR is greatest in patients with PAR with/without SAR and tended to present more frequent and severe symptoms. These severe symptoms, if not well controlled, may lead to more comorbidities, such as asthma and sinusitis. Canonica GW. Allergy. 2007;62(suppl 85):17

40. FUROATO DE MOMETASONA: CAMBIO PORCENTUAL EN LA CONGESTI�N NASAL DE MODERADA A SEVERA EN LA RINITIS AL�RGICA PERENE Baseline congestion scores were 2.0 in all 3 groups (MFNS, FP, and placebo).Baseline congestion scores were 2.0 in all 3 groups (MFNS, FP, and placebo).

42. MFNS in Children With PAR: Design:1-Month Double-Blind and 6-Month Open-Label Study A multicentre, double-blind, randomised study in 381 children aged 3 to 11 years with at least 1-year history of symptoms of PAR Treatment MFNS 100 �g/day for 4 weeks (n=190) Placebo for 4 weeks (n=191) All subjects continued in open-label safety period with MFNS for up to 6 months Efficacy variables Improvement from baseline in the physician-rated TNSS Patient-rated TNSS, TSS, and individual symptoms Physician- and patient-rated overall condition of PAR

43. MFNS in Children With PAR: TNSS Evaluated by Physicians

44. MFNS in Children With PAR: TNSS Evaluated by Patients

45. MFNS in Children With PAR: Overall Condition of PAR Evaluated by Physicians

46. MFNS in Children With PAR: Efficacy in 6-Month Open-Label Study Summary After 4 weeks of double-blind treatment Mean score of overall condition in patients treated with MFNS was better than in patients treated with placebo At week 30 after open-label treatment with MFNS 49% reduction of symptoms vs baseline in patients initially treated with placebo and switched to MFNS

47. MFNS Treatment for up to 6 Months Was Well Tolerated in Children With PAR 5 patients discontinued treatment during the double-blind period 2 in the MFNS group (both unrelated to treatment) 3 in the placebo group (2 unrelated to treatment) Treatment-related adverse events (AEs) 15% during the double-blind period (16% in the placebo group) 17% during the open-label period

48. MFNS Treatment for up to 6 Months Was Well Tolerated in Children With PAR

49. PAR treatment during 12 months

50. PAR treatment during 12 months

51. PAR treatment during 12 months:Mometasone in pediatric PAR ,52 weeks

52. Long-Term Use of Intranasal Steroids in Perennial Allergic Rhinitis: Summary Persistent inflammation is a hallmark of AR INS are potent anti-inflammatory agents INS are effective in the prophylaxis of seasonal allergic rhinitis both before and during the allergen season Significantly more days with minimal or no symptoms Significantly reduced symptom burden

53. Long-Term Use of Intranasal Steroids in Perennial Allergic Rhinitis: Summary In adult and paediatric patients with PAR, long-term use of INS is associated with a significant reduction in Total nasal symptom scores Individual nasal symptom scores, including congestion scores Overall condition of PAR Long-term use of INS is well tolerated in both adult and paediatric patients with PAR Therapeutic implications: Consider long-term therapy with INS in patients with PAR

54. Intranasal SteroidsOnset of Action This section shows data from publicly available sources.This section shows data from publicly available sources.

55. FF in SAR: Onset of Action-Change in iTNSS After First Dose iTNSS improvement with FF seen at 8 and 10 hours was not sustained at 12 hours. This data is derived from a phase III clinical trial and is not based on the chamber or park study, which are typically required by the FDA for a claim about onset of action. Does this have an implication for a drug claiming 24-hour duration of action?iTNSS improvement with FF seen at 8 and 10 hours was not sustained at 12 hours. This data is derived from a phase III clinical trial and is not based on the chamber or park study, which are typically required by the FDA for a claim about onset of action. Does this have an implication for a drug claiming 24-hour duration of action?

56. Ciclesonide in PAR: Onset of Action After the First Dose iTNSS improvement with ciclesonide seen at 9 hours was not sustained at 10, 11, and 12 hours. Ciclesonide label indicates onset of action of 24-48 hours. This data is derived from a phase III clinical trial and is not based on the chamber or park study, which are typically required by the FDA for a claim about onset of action.iTNSS improvement with ciclesonide seen at 9 hours was not sustained at 10, 11, and 12 hours. Ciclesonide label indicates onset of action of 24-48 hours. This data is derived from a phase III clinical trial and is not based on the chamber or park study, which are typically required by the FDA for a claim about onset of action.

57. NASONEX� Onset of Action: Percent Change in Total Symptom Score After Single Dose NASONEX� onset of action, as determined from the time to significant improvement in TNSS (total nasal symptom score) over placebo, in the park study was 7 hours, and was sustained at all subsequent time points, as required.NASONEX� onset of action, as determined from the time to significant improvement in TNSS (total nasal symptom score) over placebo, in the park study was 7 hours, and was sustained at all subsequent time points, as required.

58. NASONEX� Onset of Action: Percent Change in Total Nasal Symptom Score After Single Dose NASONEX� onset of action, as determined from the time to significant improvement in TNSS (total nasal symptom score) over placebo, in the park study was 7 hours, and was sustained at all subsequent time points, as required.NASONEX� onset of action, as determined from the time to significant improvement in TNSS (total nasal symptom score) over placebo, in the park study was 7 hours, and was sustained at all subsequent time points, as required.

59. MFNS Provided Significant Relief of Acute Rhinosinusitis Symptoms on Day One

60. Mean weekly total nasal symptom score throughout the study with 12 months treatment with budesonide (solid red line) and cetirizine (dashed blue line). The arrow indicates the end of treatment and start of the 12-month follow-up period, during which both groups received 14-day courses of budesonide when neededMean weekly total nasal symptom score throughout the study with 12 months treatment with budesonide (solid red line) and cetirizine (dashed blue line). The arrow indicates the end of treatment and start of the 12-month follow-up period, during which both groups received 14-day courses of budesonide when needed

61. Mean nPEF throughout the study with 12 months treatment Mean nPEF throughout the study with 12 months treatment with budesonide (solid red line) and cetirizine (dashed blue line). The arrow indicates the end of treatment and start of the 12- month follow-up period, during which both groups received 14- day courses of budesonide when neededMean nPEF throughout the study with 12 months treatment with budesonide (solid red line) and cetirizine (dashed blue line). The arrow indicates the end of treatment and start of the 12- month follow-up period, during which both groups received 14- day courses of budesonide when needed

62. Proportion of patients free from relapses during the second year of the study after discontinuation of 1 year�s treatment with budesonide or cetirizine Kaplan-Meier plot showing the proportion of patients free from relapses during the second year of the study after discontinuation of 1 year�s treatment with budesonide, 400 �g once daily (solid red line), or cetirizine, 10 mg once daily (dashed blue line).Kaplan-Meier plot showing the proportion of patients free from relapses during the second year of the study after discontinuation of 1 year�s treatment with budesonide, 400 �g once daily (solid red line), or cetirizine, 10 mg once daily (dashed blue line).

63. Conclusions:

64. Conclusions:

65. The diagnosis and management of rhinitis: An updated practice parameter( JACI Aug 2008) Use of certain agents�that is, intranasal corticosteroids� on an as-needed basis Intranasal corticosteroids may provide significant relief of symptoms of seasonal allergic rhinitis when used not only on a regular basis but also on an as-needed basis. B However,as-needed use may not be as effective as continuous use of intranasal corticosteroids. D Consideration of using a Rhinitis Action Plan

68. Propuestas Estudio de vida real sobre la actividad de la rinitis persistente e impacto del tratamiento en LA Comparaci�n del tratamiento permanente vs a demanda en rinitis persistente Poblaci�n a definir: Endpoints: TNSS, QOL,Congestion Screener, Complicaciones y comorbilidades( OME,olfato,sinusitis ,AOS ,asma,etc) productividad , costos , etc?