You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.
 

CME / ABIM MOC / CE

Is Intranasal Antihistamine Plus Corticosteroids Effective in Allergic Rhinitis?

  • Authors: News Author: Lorraine L. Janeczko, MPH; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 8/26/2022
  • Valid for credit through: 8/26/2023
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for pulmonologists, otorhinolaryngology clinicians, family medicine and primary care clinicians, internists, pediatricians, physician assistants, nurses, nurse practitioners pharmacists, neurologists, allergists and clinical immunologists, and other members of the health care team who treat and manage patients with allergic rhinitis.

The goal of this activity is that learners will be better able to compare the safety and efficacy of combination intranasal corticosteroid and intranasal antihistamine therapy for allergic rhinitis with those of intranasal corticosteroid monotherapy, based on findings of a systematic review and meta-analysis of randomized controlled trials.

Upon completion of this activity, participants will:

  • Assess the safety and efficacy of combination intranasal corticosteroid and intranasal antihistamine therapy for allergic rhinitis compared with those of intranasal corticosteroid monotherapy, based on findings of a systematic review and meta-analysis of randomized controlled trials
  • Evaluate the clinical implications of the safety and efficacy of combination intranasal corticosteroid and intranasal antihistamine therapy for allergic rhinitis compared with those of intranasal corticosteroid monotherapy, based on findings of a systematic review and meta-analysis of randomized controlled trials
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Lorraine L. Janeczko, MPH

    Freelance writer, Medscape

    Disclosures

    Lorraine L. Janeczko, MPH, has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.25 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-22-280-H01-P).

    Contact This Provider

  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 8/26/2023. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME / ABIM MOC / CE

Is Intranasal Antihistamine Plus Corticosteroids Effective in Allergic Rhinitis?

Authors: News Author: Lorraine L. Janeczko, MPH; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 8/26/2022

Valid for credit through: 8/26/2023

processing....

Clinical Context

Allergic rhinitis (AR) is a widespread condition associated with rhinitis, upper respiratory symptoms, and ocular symptoms. It is responsible for significant morbidity and reduction in quality of life. US prevalence now ranges from 10% to 30% of adults and children and is increasing.

Combination therapy with intranasal corticosteroid (INCS) and intranasal antihistamine (INAH) has been recommended as an alternative to INCS monotherapy for patients with AR, but studies comparing the safety and efficacy of these treatments are limited. Such comparisons are needed to inform optimal therapeutic regimens.

Study Synopsis and Perspective

Combination INCS and INAH therapy appears to be a more effective treatment for AR than INCS monotherapy, according to results of a systematic review and meta-analysis.[1]

In particular, "INCS/INAH combination therapy was significantly better for alleviating nasal and ocular symptoms and improving quality of life than INCS monotherapy," the study's corresponding author, Sang Min Lee, MD, PhD, from Gachon University College of Medicine in Incheon, Korea, and colleagues wrote in a letter to the editor published online June 18 in Allergy.

To compare the outcomes of both treatment regimens, the investigators searched the standard medical databases for studies that evaluated AR treatments. They analyzed 13 studies, all of which were randomized controlled trials.

They found that compared with monotherapy, combined therapy was linked to significantly improved nasal and ocular symptoms and quality of life. Treatment-related adverse events were not serious and mainly involved dysgeusia, an unpleasant taste in the mouth or throat.

  • Combined INCS and INAH reduced the mean morning and evening 12-hour reflective total nasal symptom score more than did INCS alone (MD [mean deviation], −0.44; 95% confidence interval [CI], −0.61 to −0.27; P<.00001; I [heterogeneity]=8%).
  • Combined therapy reduced the total ocular symptom score more than did INCS alone (MD, −0.62; 95% CI, −1.05 to −-0.19; P=.005; I 2=36%), but combined therapy did not reduce the total symptom score significantly more than did INCS alone.
  • Combined therapy significantly improved the total mean Rhinoconjunctivitis Quality of Life Questionnaire score compared with INCS monotherapy (MD, −0.24; 95% CI, −0.42 to −0.06; P=.009; I 2 = 79%).
  • Adverse events with combined therapy were higher (response rate [RR], 1.52; 95% CI, 1.28-1.81; P<.00001; I 2=1%), with dysgeusia a common experience (RR, 7.40; 95% CI, 3.60-15.23; P<.00001; I 2=0%), but serious adverse events were not elevated.

The authors acknowledge that limitations of the study include possible bias, deviation from the intended intervention, and missing data, and they call for further related research.

Asked by Medscape Medical News for comment, 3 experts who were not involved in the Korean study agreed on the value of combination intranasal therapy. "In addition to the significant economic burden, [AR] is associated with cognitive and psychiatric issues, including lower exam scores during peak pollen seasons and poor concentration," Amanda Lee Pratt, MD, a clinical associate in the Department of Pediatrics at Duke University School of Medicine in Durham, North Carolina, explained.

"[AR] affects a significant proportion of the US population. Estimates vary from 10% to 30% of adults and children, and the condition is increasing in prevalence," she told Medscape Medical News.

"We commonly use combination therapy with an intranasal steroid and an intranasal antihistamine, especially in patients who have difficult-to-control or persistent symptoms," she added.

Dr Pratt said that she considers how adding yet another daily medication is going to affect each patient's quality of life. "What is the feasibility for this person with a busy life to remember 1 more medication? What is the likely adherence going to be?"

Barriers to access, including insurance coverage and other costs that vary and change, also need to be considered.

"Intranasal antihistamines are a versatile and well-tolerated option as add-on or as-needed therapy for my chronic rhinitis patients," Steve Handoyo, MD, a clinical associate of pediatrics at University of Chicago Medicine in Illinois, said.

"While intranasal steroids are the most powerful medication for many chronic rhinitis patients, intranasal antihistamines are also powerful therapeutic options," he added. "This meta-analysis demonstrates significant benefit with combination therapy for oculonasal symptoms compared to steroids alone."

"For patients who are uncontrolled on nasal steroids alone, or who do not tolerate nasal steroids, intranasal antihistamines offer a safe and effective alternative," Dr Handoyo advised.

For Amrita Ray, DO, an otolaryngology specialist at Henry Ford Health in Detroit, Michigan, "this study confirms what we have already seen in the literature--that combination nasal sprays of [INCS and INAH] provide substantive synergistic benefit compared with use of an [INCS] alone.

"These medications are comparatively inexpensive and relatively well tolerated, and they have minimal side effects," she said.

Dr Ray also pointed out that the study "supports the recommendations made in the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis, that combination therapy is more effective for nasal and ocular symptom control. Providers should feel comfortable prescribing them in the appropriate patient population."

The authors, Dr Pratt, Dr Handoyo, and Dr Ray have disclosed no relevant financial relationships. The study was supported by the Korean Academy of Asthma, Allergy, and Clinical Immunology.

Study Highlights

  • Systematic search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and MEDLINE databases identified 13 randomized controlled trials (RCTs) suitable for systematic review and meta-analysis.
  • Ten RCTs evaluated differences in symptom scores, 12 described adverse events, and some studies reported both.
  • Compared with INCS monotherapy, INCS/INAH combination therapy more significantly reduced mean morning and evening 12-hour reflective total nasal symptom score (TNSS; MD, −0.44; 95% CI, −0.61 to −0.27; P<.00001; I 2=8%) and total ocular symptom score (MD, −0.62; 95% CI, −1.05 to −0.19, P=.005; I 2=36%), but not total symptom score (MD, −0.53; 95% CI, −2.83 to 1.77; P=0.65; I 2=99%).
  • Compared with INCS monotherapy, the INCS/INAH combination significantly improved total mean Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score (MD, −0.24; 95% CI, −0.42 to −0.06; P=.009; I 2=79%).
  • Sensitivity analysis showed that the 2 treatments differed significantly in TNSS, TSS, and RQLQ scores.
  • INCS/INAH combination therapy was associated with significantly greater risk for treatment-emergent adverse events (TEAEs) than INCS monotherapy (RR, 1.52; 95% CI, 1.28-1.81; P<.00001; I 2=1%), especially dysgeusia (bad/bitter taste in the mouth/throat; RR, 7.40; 95% CI, 3.60-15.23; P<.00001; I 2=0%), but not serious adverse events (RR, 1.72; 95% CI, 0.47-6.38; P=.42; I 2=0%).
  • In sensitivity analysis excluding studies with uncertain bias, INCS/INAH combination therapy significantly increased risk for TEAEs and dysgeusia.
  • The investigators concluded that INCS/INAH combination therapy was significantly better than INCS monotherapy for treating ocular symptoms and improving quality of life in patients with AR.
  • However, the thresholds of minimal clinically important differences (0.28 for TNSS and 0.5 for RQLQ) were not exceeded, and INCS/INAH combination therapy was associated with higher rates of TEAEs and dysgeusia.
  • Experts contacted by Medscape Medical News agreed on the value of combination intranasal therapy, especially for patients with difficult-to-control or persistent symptoms.
  • AR poses a significant economic burden and cognitive and psychiatric issues, including lower test scores and poor concentration during peak pollen seasons.
  • Clinicians should consider how adding a daily medication may affect quality of life and adherence, as well as barriers to access, including insurance coverage and other fluctuating or variable costs.
  • For patients who are uncontrolled on INCS alone or who do not tolerate INCS, INAH is a safe, effective alternative.
  • Combination therapy with INCS and INAH may offer substantive synergistic benefit over INCS alone, is relatively inexpensive and well tolerated, and has minimal adverse effects.
  • The study findings support 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis recommendations that combination therapy is more effective for nasal and ocular symptom control.

Clinical Implications

  • INCS/INAH combination therapy was significantly better than INCS monotherapy for treating ocular symptoms and improving quality of life in patients with AR.
  • INCS/INAH combination therapy was associated with higher rates of TEAEs and dysgeusia.
  • Implications for the Health Care Team: Combination intranasal therapy may be especially helpful for patients with difficult-to-control or persistent symptoms.

 

Earn Credit