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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
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 8/26/2023, 11:59 PM EST
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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


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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.


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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
THIS ACTIVITY HAS EXPIRED FOR CREDIT

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

Valid for credit through: 8/26/2023, 11:59 PM EST

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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.

 

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