128 Allergy, Asthma, and Clinical Immunology, Volume 4, Number 3, 2008 the development of glaucoma and/or cataracts. Therefore, close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts. Specific data with CIC suggest minimal ocular effects. The risk of glaucoma was evaluated by assessments of intraocular pressure in three studies, including 943 patients. Of these, 390 adolescents or adults were treated for up to 52 weeks and 186 children ages 2 to 11 years received treatment for up to 12 weeks. In these trials, no significant differences in intraocular pressure changes were observed. Additionally, no significant ophthalmologic differences between CIC nasal spray 200 mg and placebo- treated patients were noted during the 52-week study of adults and adolescent patients in whom thorough ophthalmologic assessments were performed, including evaluation of cataract formation using slit lamp examina- tions.16 Glaucoma and cataract formation with FF was evaluated using intraocular pressure measurements and slit lamp examinations in one controlled 12-month study in 806 adolescent and adult patients aged 12 years and older and in one controlled 12-week study in 558 children aged 2 to 11 years.20 Intraocular pressure remained within the normal range (, 21 mm Hg) in $ 98% of the patients in any treatment group in both studies. However, in the 12-month study in adolescents and adults, 12 patients, all treated with FF, had isolated intraocular pressure mea- surements that increased above normal levels ($ 21 mm Hg). In the same study, which had a 3:1 (FF to placebo) randomization schedule, seven patients (six treated with FF and one treated with placebo) had cataracts identified during the study that were not present at baseline.20 Further longer-term (more than 1 year) studies are needed with regard to ocular safety. Concurrent Use of Inhaled and Intranasal Corticosteroids Given that many patients with AR also have asthma, another potential concern is the use of INCs with concomitant therapy for asthma such as inhaled steroids. Few studies have examined this specific question. Sheth and colleagues reported that the concurrent use of intranasal FP with orally inhaled FP for the treatment of rhinitis and asthma does not increase the risk of HPA axis abnormalities.22 This analysis of two double-blind, rando- mized, placebo-controlled, parallel-group safety and effi- cacy studies included evaluation of the HPA axis effects of concurrent treatment with intranasal and orally inhaled FP. In the first study, patients with asthma who were $ 12 years of age were assigned randomly to receive twice-daily doses (either 88 or 220 mg) of orally inhaled FP delivered from a metered-dose inhaler (MDI). In the second study, patients were assigned randomly to receive either orally inhaled FP 250 mg or orally inhaled FP 250 mg/salmeterol 50 mg delivered via the Diskus device. In both studies, patients with rhinitis were allowed to continue the use of intranasal FP at their usual dosing. Treatment periods were 26 weeks and 12 weeks for the MDI and Diskus studies, respectively. HPA axis effects were assessed using response to short cosyntropin stimulation testing. The number and percentage of patients with an abnormal cortisol response, defined as a morning plasma cortisol of , 5 mg/dL, a poststimulation peak of , 18 mg/dL, or a poststimulation rise of , 7 mg/dL, were summarized in two subgroups: patients who used intranasal FP and those who did not. The concurrent administration of intranasal FP and orally inhaled FP via an MDI or Diskus or via Diskus with salmeterol was not associated with HPA axis effects compared with orally inhaled FP alone. Conclusion INCs are first-line therapy for treatment of AR in both children and adults. Safety concerns with the use of INCs were examined in this article. As newer-generation INCs are developed, more sophisticated studies examining safety have been performed. As all clinicians are aware, each patient can have individual responses to both efficacy and safety; however, the data reviewed suggest that the benefits outweigh the potential risks. Based on many of the articles reviewed in this article, INCs appear to be safe to use in appropriate patients. As newer-generation INCs become available, they, too, will need to meet or exceed the safety standards set by the currently available therapies for AR. Understanding the potential concerns and the data behind these concerns should give clinicians the information to be able to discuss this with patients and parents to incorporate appropriate therapy for those with AR. References 1. Statistical Report on the Health of Canadians. https://www. phac-aspc.gc.ca/ph-sp/phdd/pdf/report/stab/eng64-77.pdf (accessed December 8, 2007). 2. Bousquet J, Van Cauwenberge P, Khaltaev N, Aria Workshop Group, World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108(5 Suppl):S147–334.