Intranasal antihistamines and corticosteroids in allergic rhinitis: A systematic review and meta-analysis

Bernardo Sousa-Pinto; Rafael José Vieira; Jan Brozek; António Cardoso-Fernandes; Nuno Lourenço-Silva; Renato Ferreira-da-Silva; André Ferreira; Sara Gil-Mata; Anna Bedbrook; Ludger Klimek; João A Fonseca; Torsten Zuberbier; Holger J Schünemann; Jean Bousquet

doi:10.1016/j.jaci.2024.04.016

Intranasal antihistamines and corticosteroids in allergic rhinitis: A systematic review and meta-analysis

J Allergy Clin Immunol. 2024 Apr 27:S0091-6749(24)00419-6. doi: 10.1016/j.jaci.2024.04.016. Online ahead of print.

Authors

Affiliations

¹ MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences; Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS@RISE - Health Research Network, MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.
² Department of Health Research Methods, Evidence, and Impact & Department of Medicine, McMaster University, Hamilton, ON, Canada.
³ CINTESIS@RISE - Health Research Network, MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal; Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Ophthalmology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
⁴ MASK-air SAS, Montpellier, France.
⁵ Department of Otolaryngology, Head and Neck Surgery, Universitätsmedizin Mainz, Mainz, Germany; Center for Rhinology and Allergology, Wiesbaden, Germany.
⁶ Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
⁷ Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; ARIA, Montpellier, France. Electronic address: jean.bousquet@orange.fr.

PMID: 38685482
DOI: 10.1016/j.jaci.2024.04.016

Abstract

Background: There is insufficient systematised evidence on the effectiveness of individual intranasal medications in allergic rhinitis (AR).

Objective: To perform a systematic review to compare the efficacy of individual intranasal corticosteroids and antihistamines against placebo in improving the nasal and ocular symptoms and the rhinoconjunctivitis-related quality-of-life of patients with perennial or seasonal AR.

Methods: We searched four electronic bibliographic databases and three clinical trials databases for randomised controlled trials (i) assessing adult patients with seasonal or perennial AR and (ii) comparing the use of intranasal corticosteroids or antihistamines versus placebo. Assessed outcomes included the Total Nasal Symptom Score (TNSS), the Total Ocular Symptom Score (TOSS) and the Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ). We performed random-effects meta-analyses of mean differences for each medication and outcome. We assessed evidence certainty using the GRADE approach.

Results: We included 151 primary studies, most of which assessed patients with seasonal AR and displayed unclear or high risk of bias. Both in perennial and seasonal AR, most assessed treatments were more effective than placebo. In seasonal AR, azelastine-fluticasone, fluticasone furoate and fluticasone propionate were the medications with the highest probability of resulting in moderate or large improvements in the TNSS and RQLQ. Azelastine-fluticasone displayed the highest probability of resulting in moderate or large improvements of TOSS. Overall, evidence certainty was considered "high" in 6/46 analyses, "moderate" in 23/46 analyses, and "low"/"very low" in 17/46 analyses.

Conclusion: Most intranasal medications are effective in improving rhinitis symptoms and quality-of-life. However, there are relevant differences in the associated evidence certainty.

Keywords: Allergic rhinitis; Intranasal antihistamines; Intranasal corticosteroids; Meta-analysis; Systematic review.