For patients with allergic rhinitis whose symptoms aren’t helped by one treatment, adding another may work, according to results of a systematic review and meta-analysis published in a recent issue of International Forum of Allergy and Rhinology.
If monotherapy with either an antihistamine (ATH) or an intranasal corticosteroid (INCS) does not improve symptoms, combined therapy is an option, the authors write.
“After ATH monotherapy fails to control symptoms, addition of decongestant, saline, or LTRA [leukotriene receptor antagonist] can improve the outcomes. When INCS monotherapy is ineffective, addition of intranasal ATH can improve nasal symptoms; LTRA can improve ocular symptoms; and saline irrigation can improve QoL [quality of life],” they explain.
Lead study author Wirach Chitsuthipakorn, MD, of the College of Medicine of Rangsit University in Bangkok, Thailand, and his colleagues searched PubMed and Embase through late 2021 for randomized controlled trials that compared the effects of combined nasal or oral medication therapies with monotherapy for patients with allergic rhinitis.
They searched for studies in all languages that included combinations of any ATH, decongestant, LTRA, INCS, or nasal saline. From the 53 studies that met their search criteria, they pooled data for meta-analysis and found the following:
Compared with an ATH alone, an ATH combined with a decongestant improved composite nasal symptoms.
An ATH combined with an LTRA improved nasal symptoms for patients with perennial allergic rhinitis.
An ATH combined with nasal saline improved symptoms and QoL.
Compared with an INCS alone, an INCS combined with an intranasal ATH improved nasal symptoms, ocular symptoms, and QoL.
An INCS combined with an LTRA improved ocular symptoms but not nasal symptoms.
An INCS combined with nasal saline improved QoL but not symptoms.
Adding an oral ATH or topical decongestant to an INCS had no additional effects.
“Because decongestants are associated with several risks of adverse events, this combination should be used with caution and with the shortest duration possible,” the authors advise.
Dr Aria Jafari
Aria Jafari, MD, an assistant professor and otolaryngology and rhinology surgeon at the University of Washington Medical Center in Seattle, told Medscape Medical News that he welcomed the results.
“Combining certain treatments or adding an additional treatment can often help allergic rhinitis symptoms and improve quality of life,” Jafari, who was not involved in the study, said in an email. “This study provides an evidence-based framework for the treatment of patients with this common condition. The findings allow clinicians to navigate the myriad options available and guide decision-making.
“Systematic reviews to synthesize the available data such as this are helpful to guide treatment decisions,” he added.
However, there are “inherent limitations based on the availability of the published literature. There may also be some heterogeneity in the data, such as the way the data were collected and variability in the outcome measures. This can make the comparisons more difficult to interpret,” he cautioned.
Dr Kara Coffey
Kara E. Coffey, MD, an assistant professor of pediatrics at the University of Pittsburgh School of Medicine in Pennsylvania, said in an email, “Patients with allergic rhinitis have a variety of treatment options to try, and when one option alone has underwhelming benefits, therapies can be combined.
“Even non-medicated therapies such as adding saline nasal irrigation or saline nasal spray can have better symptom control than a steroid nasal spray alone,” she added.
“Oral decongestants have increased risks for undesirable side effects,” noted Coffey, who also was not involved in the study. “So I would favor the use of nasal steroids, nasal antihistamines, and saline sprays or irrigations for long-term allergic rhinitis treatment.”
The study was not funded. The authors and independent experts have disclosed no relevant financial relationships..
Int Forum Allergy Rhinol. Published online April 21, 2022. Abstract
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