Dosing

Cromolyn is available for use in allergic disease and asthma as a single-dose vial for oral nebulization, metered dose inhaler (oral and nasal), and ophthalmic preparation. Oral cromolyn, although poorly absorbed from the GI tract, has been used in the treatment of mastocytosis, chronic idiopathic urticaria, and GI-associated anaphylaxis with anecdotal success.

CS for oral inhalation is available as 1 and 5 mg per actuation MDI, 20 mg 1% aqueous solution, and 20 mg capsules for use with the Spinhaler or E-haler (Eclipse) (7). The 1 mg per actuation MDI and 20 mg 1% aqueous solution are available in the United States.

Intranasal cromolyn is available over the counter as a 4% solution. The recommended dosage is one spray per nostril four times daily.

When cromolyn was first developed it was combined with isoprenaline to prevent the bronchoconstriction associated with the inhalation of the sodium salt (2). The blood levels of cromolyn can be increased by the addition of a p2-agonist (15). Furthermore, the clinical response of cromolyn is improved with addition of a p2-agonist (114). In light of the favorable outcomes with ICS compared to cromolyn alone, new research may be needed to compare the use of cromolyn in combination with a p2-agonist compared to ICS to ascertain the correct circumstances and delivery method in asthma therapy.

Nedocromil sodium is available as a 2 mg MDI. Two studies on the nedocromil dosing frequencies reported no overall difference, but Wells (130) reported that patients in the higher dose frequency required few courses of oral steroids (127,130). The CAMP study evaluated long-term use of nedocromil and reported a reduction in urgent care visits and fewer courses of prednisone (129). However, another study with short-term use of nedocromil reported significant differences compared with placebo (136).

Compliance with medication regimens remains an issue with all patients. Traditionally, inhaled cromolyn is dosed four times daily while nedocromil is dosed twice daily. Furukawa et al. studied the same children on cromolyn four, three, or twice daily for one-month intervals. They reported that pulmonary function during the twice-daily use for a month showed a trend toward deterioration compared with the month of dosing three times daily (153). In a similar study with adults, no difference in those patients allowed to reduce their cromolyn dose (2.5 doses/day) compared to those on four daily doses was seen (154). In general, cromolyn is started four times daily and is often reduced to twice daily when asthma has been controlled. Whether there would be equal efficacy if the same total mg dose was delivered twice daily versus four times daily is unclear.

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