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).
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.) www.drugstore.com. 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
Medicine, University of Washington, Tacoma
Leilani St. Anna, MLIS, AHIP
University of Washington
Janelle Guirguis-Blake, MD
Medicine, University of Washington, Tacoma
TABLE 1 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% N=2224) 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. TABLE 2 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 0.072) RCT, double blind, INS (triamcinolone Percent reduction from double dummy (5) acetonide), N=153 mean baseline TNS OAH (loratadine), ocular score: N=152 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: N=150 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; P<.106) 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 clinically significant) 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 score.
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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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