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Q/intranasal steroids vs antihistamines: which is better for seasonal allergies and conjunctivitis?


A/ INTRANASAL STEROIDS PROVIDE BETTER RELIEF for adult sufferers, according to nonstandardized, nonclinically validated scales. Steroids reduce subjective total nasal symptom scores (TNSS)--representing sneezing, itching, congestion, and rhinorrhea--by about 25% more than placebo, whereas oral antihistamines decrease TNSS by 5% to 10% (strength of recommendation [SOR]: B, systematic review of randomized controlled trials [RCTs], most without clinically validated or standardized outcome measures).

Intranasal steroids improve subjective eye symptom scores as well as (or better than) oral antihistamines in adults who also have allergic conjunctivitis (SOR: A, systematic review, RCTs).

Evidence summary

The most commonly measured outcomes in allergic rhinitis and conjunctivitis trials are symptom scales, which are neither standardized nor clinically validated. Almost all the studies discussed here calculated outcomes as a percentage change from baseline symptom scores but didn't provide absolute values, so it isn't clear whether statistical differences are clinically relevant.

Steroids provide more relief of nasal symptoms

A meta-analysis of 21 randomized placebo-controlled trials (total 2821 patients, average age mid-30s) that compared changes in TNSS with intranasal steroids and oral antihistamines among adults with seasonal allergic rhinitis found that steroids reduced TNSS more than antihistamines. (1) Most of the patients had had moderate to severe symptoms for several years.

Investigators calculated percent changes from baseline in mean TNSS, which typically included sneezing, itching, congestion, and rhinorrhea, each usually scored on a scale of 0 to 3. (1) Individual RCTs compared one of 3 intranasal steroids (fluticasone, triamcinolone, or budesonide) and one of 3 oral antihistamines (cetirizine, loratadine, or fexofenadine) with placebo; no studies compared medications within classes against each other)

On individual symptom scores, intranasal steroids reduced sneezing, itching, congestion, and rhinorrhea more than placebo by more than 20%. Both intranasal steroids and oral antihistamines decreased itching and rhinorrhea a similar amount, but antihistamines reduced congestion by only 5% to 10% more than placebo. (1)

This meta-analysis included only studies reporting TNSS as an outcome, and individual studies used varying TNSS scales. Investigators attributed heterogeneity in the studies to intraclass differences between medications. (1)

Two drug company-sponsored RCTs (1616 patients combined, average age 30s, moderate to severe allergic rhinitis) published

before the meta-analysis also demonstrated that the intranasal steroid fluticasone propionate modestly reduced TNSS compared with the oral antihistamine fexofenadine (1 point vs 1.3 on a scale of 0 to 12). (2) TABLE 1 summarizes the results of studies comparing intranasal steroids and oral antihistamines to reduce nasal symptoms.

Results for eye symptoms are mixed

A meta-analysis of 11 RCTs (1317 patients, average age 32) showed no significant difference in relief of eye symptoms between oral antihistamines (dexchlorpheniramine, terfenadine, and loratadine) and intranasal steroids (budesonide, beclomethasone, fluticasone, and triamcinolone) in patients with seasonal allergies, as measured by various symptom scores?

Three other studies indicated that intranasal steroids (triamcinolone, fluticasone) relieved eye symptoms more effectively than oral antihistamines (loratadine, fexofenadine) based on mean reductions in TNSS, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Total Ocular Symptom Score (TOSS). (4-6) Of these scoring systems, only the RQLQ has been clinically validated. (7)

One additional study (including 2 RCTs) showed conflicting results. (2) TABLE 2 summarizes the results of studies comparing intranasal steroids and oral antihistamines to relieve eye symptoms.

Antihistamines cost less than steroids and are available OTC

Oral antihistamines are less expensive than intranasal steroids and are available over the counter. The cost of antihistamines ranges from $5.70 to $21.99 for a month of treatment, whereas the cost of intranasal steroids for the same period varies from $60.99 to $149.99. (8)

In the studies reviewed here, the 2 interventions showed similar harms, including sore throat, epistaxis, and headache. (2,4-6)


The American Academy of Allergy, Asthma and Immunology's 2010 guidelines conclude that intranasal steroids are first-line treatment for allergic rhinitis. If the patient prefers, use oral antihistamines. (9)

The Joint Task Force on Practice Parameters for Allergy and Immunology also recommends intranasal steroids as the most effective medication class for treating allergic rhinitis; no drug within the class is preferable to another. Daily administration is more effective than administration as needed, although the latter is an option. For treating ocular symptoms, intranasal corticosteroids and oral antihistamines work equally well. (10)


(1.) Benninger M, Farrar JR, Blaiss M, et al. Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class. Ann Allergy Asthma Immunol. 2010; 104:13-29.

(2.) Andrews CP, Martin BG, Jacobs RL, et al. Fluticasone furoate nasal spray is more effective than fexofenadine for nighttime symptoms of seasonal allergy. Allergy Asthma Proc. 2009;30:128-138.

(3.) Weiner JM, Abramson MI, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ. 1998;317:1624-1629.

(4.) Ramer PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47:110-125.

(5.) Gawchik SM, Lim I. Comparison of intranasal triamcinolone acetonide with oral loratadine in the treatment of seasonal ragweed-induced allergic rhinitis. Am J Manag Care. 1997;3:1052-1058.

(6.) Bernstein DI, Levy AL, Hampel FC, et al. Treatment with intranasal fluticasone propionate significantly improves ocular symptoms in patients with seasonal allergic rhinitis. Clin Exp Allergy. 2004;34:952-957.

(7.) Juniper EF. Measuring health-related quality of life in rhinitis. J Allergy Clin Immunol. 1997;99:S742-S749.

(8.) Accessed March 20, 2012.

(9.) Brozek JL, Bousquet L Baena-Cagnani CE, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126:466-476.

(10.) Wallace DV, Dykewicz MS, Bernstein DI, et al; Joint Task Force on Practice, American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(suppl 2):S1-S84.

Suzanna Parle-Pechera, MD; Laurel Powers, MD

Tacoma Family

Medicine, University of Washington, Tacoma

Leilani St. Anna, MLIS, AHIP

University of Washington

Health Sciences

Library, Seattle


Janelle Guirguis-Blake, MD

Tacoma Family

Medicine, University of Washington, Tacoma
Intranasal steroids vs oral antihistamines for nasal symptom relief

Study design        Intervention          Outcome

Systematic review   INS: 7 RCTs (total    Mean percentage change
of RCTs (1)         N=597)                in TNSS from baseline:

                    OAH: 14 RCTs (total   INS: -40.7%
                                          OAH: -23.5%

                                          Placebo: -15.0%

Two RCTs, double    Study 1 *             Least squares mean
blind, double                             difference from
dummy (2)           INS (N=312)           baseline TNSS score
                                          of INS vs OAH:
                    OAH (N=311)
                                          Study 1:
                    Placebo (N=313)
                                          TNSS: -1.0
                    Study 2 *
                                          (95% CI, -0.7 to -1.4)
                    INS (N=224)
                                          Study 2:
                    OAH (N=227)
                                          TNSS: -1.3
                    Placebo (N=229)
                                          (95% CI, -0.9 to -1.7)
                    Duration 2 wk

Study design        Significance            Harms

Systematic review   Changes in INS scores   Not reported
of RCTs (1)         significantly greater
                    than changes in
                    OAH scores (P<.001)

Two RCTs, double    Changes in INS scores   INS: sore throat (2%),
blind, double       significantly greater   urticaria (<1 %)
dummy (2)           than changes in
                    OAH scores (P<.001)     OAH: epistaxis (2%),
                                            sore throat (<1 %),
                                            cholecystitis (<1 %),
                                            upper respiratory
                                            infection (<1%),
                                            sinusitis (<1 %)

CI, confidence interval; INS, inhaled nasal steroids; OAH, oral
antihistamine; RCTs, randomized controlled trials; TNSS, total
nasal symptom score.

* The INS used was fluticasone furoate; the OAH used was fexofenadine.


How intranasal steroids compare with oral antihistamines
for reducing eye symptoms

Study design         Intervention          Outcome

Systematic           INS vs OAH            OR for deterioration
review (3)           11 RCTs reporting     or no change of varied
                     ocular symptoms,      scoring systems:
                     N=1317                -0.043 (CI, -0.157 to

RCT, double blind,   INS (triamcinolone    Percent reduction from
double dummy (5)     acetonide), N=153     mean baseline TNS
                     OAH (loratadine),     ocular score:
                                           INS: 59%

                                           OAH: 48%

                                           Total TNS ocular
                                           score: 3

RCT, double blind,   INS (fluticasone      Mean change in RQLQ
double dummy (4)     propionate), N=150    ocular score from
                     OAH (loratadine),     baseline:
                                           INS: -1.9
                     INS+OAH, N=150
                                           OAH: -1.3
                     Placebo, N=150
                                           Total RQLQ ocular
                     Duration 2 wk         score: 6

RCT, double blind,   INS (fluticasone      Mean change in TOSS
double dummy (6)     propionate), N=158    score from baseline:

                     OAH (loratadine),     INS: -88.7 [+ or -]
                     N=158                 5.3
                     Placebo, N=155
                                           OAH: 72.5 [+ or -] 5.4
                     Duration 4 wk
                                           Total TOSS score: 100

Two RCTs, double     Study 1:              Least squares mean
blind, double        INS (fluticasone      difference from
dummy (2)            furoate), N=312       baseline TOSS2 score:
                     OAH (fexofenadine),
                     N=311                 Study 1:

                     Study 2:              TOSS2: -0.3
                     INS (fluticasone
                     furoate), N=224       (95% CI, -0.6 to 0.0;
                     OAH (fexofenadine),
                     N=227                 Study 2:
                     Duration 2 wk
                                           TOSS2: -0.6 (95% CI,
                                           -0.9 to -0.2; P=,002)

                                           Total TOSS2 score: 9

Study design         Significance             Harms

Systematic           No significant           Not reported
review (3)           difference between
                     INS and OAH scores

RCT, double blind,   Changes in INS scores    INS: headache (22%),
double dummy (5)     significantly greater    anxiety (<1 %),
                     than changes in          epistaxis (<1 %)
                     OAH scores (P<.05)
                                              OAH: headache (18%
                                              increase in rhinitis
                                              symptoms (2%),
                                              conjunctivitis (<1 %)

RCT, double blind,   Changes in INS scores    INS and OAH: blood
double dummy (4)     significantly greater    in mucus (1%-2%),
                     than changes in          xerostomia (1 %-2%),
                     OAH scores (P<.05;       epistaxis (<1 %)
                     0.5 change in score is

RCT, double blind,   Changes in INS scores    INS: headache (17%)
double dummy (6)     significantly greater
                     than changes in          OAH: headache (18%
                     OAH scores (P<.045)

Two RCTs, double     Changes in INS scores    INS: sore throat (2%),
blind, double        significantly greater    urticaria (<1%)
dummy (2)            than changes in
                     OAH scores for           OAH: epistaxis (2%),
                     Study 2 (P=.002)         sore throat (<1 %),
                     but not for Study 1      cholecystitis (<1 %),
                     (P<.106)                 upper respiratory
                                              infection (<1%),
                                              sinusitis (<1 %)

CI, confidence interval; INS, intranasal steroids; OAH, oral
antihistamines; OR, odds ratio; RCT, randomized controlled trial;
RQLQ, rhinoconjunctivitis quality  of life questionnaire; TNS,
total nasal score; TNSS, total nasal symptom score; TOSS, total
ocular symptom score; TOS52, (variation of) total ocular symptom
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Title Annotation:CLINICAL INQUIRIES: Evidence-based answers from the Family Physicians Inquiries Network
Author:Parle-Pechera, Suzanna; Powers, Laurel; St. Anna, Leilani
Publication:Journal of Family Practice
Date:Jul 1, 2012
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