Nasal Steroid Best First Treatment for Seasonal Allergic Rhinitis
By Reuters Staff
NEW YORK (Reuters Health) - For people age 12 or older who suffer from seasonal allergic rhinitis, an intranasal corticosteroid alone is the best initial treatment, a joint task force of the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) advises in evidence-based guidelines.
In their review of the most current relevant data, the task force found no evidence to prove a benefit of adding an oral antihistamine to an intranasal corticosteroid and “recognized that oral antihistamines, mainly first-generation, may cause sedation and other adverse effects,” according to their synopsis of the guidelines published online November 27 Annals of Internal Medicine.
Seasonal allergic rhinitis affects up to 14% of U.S. adults. “Most patients who consult an allergy and immunology specialist have already tried many over-the-counter monotherapies without success and are seeking more effective treatment. No consensus exists about whether a particular medication should be used for initial treatment or about the benefit of using two or more medications concurrently for initial treatment,” the task force writes.
They offer three recommendations in their report, two “strong” and one “weak.”
The first, as mentioned, is to “routinely prescribe” monotherapy with an intranasal corticosteroid rather than the combination of an intranasal steroid and oral antihistamine in patients 12 or older. This is a “strong” recommendation.
The second "strong" recommendation is for initial treatment of people age 15 or older with seasonal allergic rhinitis. For this group, the task force advises treatment with an intranasal corticosteroid over a leukotriene receptor antagonist such as oral montelukast. Overall, the task force judged the evidence as “clearly showing that an intranasal corticosteroid was more effective than montelukast for nasal symptom reduction.”
The third recommendation involves treatment of moderate to severe seasonal allergies in people age 12 or older. The task force says physicians “may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment.” The available evidence shows that adding an intranasal antihistamine to an intranasal corticosteroid in patients with moderate-to-severe seasonal allergic rhinitis “provides additional benefit, in contrast to combination therapy with an intranasal corticosteroid and an oral antihistamine,” according to the report. This recommendation, however, is “weak.”
“Our weak recommendation for combination therapy was based on concerns about potential bias in the critically appraised studies and the greater potential for adverse effects associated with combination therapy, including dysgeusia and somnolence,” the task force explains.
They further advise, “When treating patients with seasonal allergic rhinitis, clinicians need to use their expertise to assist patients in evaluating the best treatment choice through shared decision making; consider the potential for benefit as well as the potential for harm, the burden, and the cost of combination therapy; and allow patients to express their values and preferences and participate in the decision-making process.”
SOURCE: https://bit.ly/2n6w0r0
Ann Intern Med 2017.
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