Combined Intranasal AR Treatment Better Than Monotherapy

Combination intranasal corticosteroid (INCS) and intranasal antihistamine (INAH) therapy appears to be a more effective treatment for allergic rhinitis (AR) than INCS monotherapy, according to results of a systematic review and meta-analysis.

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, of Gachon University College of Medicine in Incheon, Korea, and colleagues wrote in a letter to the editor in Allergy.

To compare the outcomes of both treatment regimens, the investigators searched the standard medical databases for studies that evaluated allergic rhinitis treatments. They analyzed 13 studies, all of them 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% CI, -0.61 to -0.27; P < .00001; I² [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; I² = 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; I² = 79%).

• Adverse events with combined therapy were higher (response rate [RR], 1.52; 95% CI, 1.28-1.81; P < 0.00001; I² = 1%), with dysgeusia a common experience (RR, 7.40; 95% CI, 3.60-15.23; P < .00001; I² = 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.

Amanda Lee Pratt, MD

Asked by Medscape for comment, three experts who were not involved in the Korean study agreed on the value of combination intranasal therapy. “In addition to the significant economic burden, allergic rhinitis 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.

“Allergic rhinitis 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 in an email.

“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.

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 one 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.

Steve Handoyo, MD

“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, said in an email.

“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,” Handoyo advised.

Amrita Ray, DO

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 intranasal corticosteroids and intranasal antihistamines provide substantive synergistic benefit compared with use of an intranasal corticosteroid alone.

“These medications are comparatively inexpensive and relatively well tolerated, and they have minimal side effects,” she said in an email.

And Dr Ray 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, Pratt, Handoyo, and Ray, report no relevant financial relationships. The study was supported by the Korean Academy of Asthma, Allergy, and Clinical Immunology (KAAACI).

Allergy. Published online June 18, 2022. Full text

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