Friday, September 22, 2023
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.
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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.
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.
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.
