Comparative efficacy and acceptability of licensed dose intranasal corticosteroids for moderate-to-severe allergic rhinitis: a systematic review and network meta-analysis

In perennial allergic rhinitis, RQLQ is improved similarly by Azelastine 0.15 and mometasone furoate

Some double-blind, placebo-controlled trials have shown that Azelastine (Aze) high dose (0.15%) was effective in seasonal (SAR) and perennial allergic rhinitis (PAR). However, there was no long-term comparison between Aze 0.15% and intranasal corticosteroids (INCS) on safety and quality of life in perennial allergic rhinitis.An open-label, active-controlled, parallel-group one-year study comparing mometasone furoate and Aze 0.15% in adults assessed safety over 1 year. Efficacy using the 28-item rhino-conjunctivitis quality of life questionnaire (RQLQ) was a secondary end point.A total of 703 patients were randomized and 687 (97.7%) were included in the intent-to-treat (ITT) population. The present formulation was shown to be safe with long-term use over 12 months, with a mean duration of exposure of 270.7 days.Over the one-year period, there was no significant difference for any RQLQ domains between Aze and mometasone furoate (MF) for all evaluations (baseline, 6, 9, and 12 months). This study suggests that Aze 0.15% and MF display a similar improvement of RQLQ ( 2.80 [2.78] for Aze 0.15% vs 2.81 [2.75] for MF).

Clinical trial registry number

NCT00720382.

Efficacy and safety of intranasal medications for allergic rhinitis: Network meta-analysis

BACKGROUND

Intranasal antihistamines (INAH), corticosteroids (INCS), and their fixed combinations (INAH+INCS) are one of the cornerstones of the treatment of allergic rhinitis (AR). We performed a systematic review and network-meta-analysis comparing the efficacy and safety of INAH, INCS, and INAH+INCS in patients with AR.

METHODS

We searched four electronic bibliographic databases and three clinical trial databases for randomised controlled trials assessing the use of INAH, INCS, and INAH+INCS in adults with seasonal or perennial AR. We performed a network meta-analysis on the Total Nasal Symptom Score, Total Ocular Symptom Score, Rhinoconjunctivitis Quality-of-Life Questionnaire, development of adverse events, and withdrawals due to adverse events. Certainty of evidence was assessed using GRADE-NMA.

RESULTS

We included 167 primary studies, most of which assessed patients with seasonal AR. Among individual medications, azelastine-fluticasone, and fluticasone furoate were the most frequently highest-ranked interventions for efficacy outcomes, being regularly associated with clinically meaningful larger improvements when compared to other active treatments. Considering drug classes, INAH+INCS were the highest-ranked interventions for all outcomes in which they were assessed, followed in most cases by INCS. In 105 out of 184 comparisons in seasonal AR, and 28 out of 97 comparisons in perennial AR, certainty of evidence was considered "high" or "moderate".

CONCLUSION

Intranasal medications for AR display clinically relevant differences in their efficacy, but all show a good safety profile. To our knowledge, this is the first network meta-analysis comparing INAH, INCS, and INAH+INCS in AR, providing relevant evidence for guideline developers and practising physicians on the most efficacious treatments.

Surgical Intervention in Allergic Rhinitis: Stuffy Versus Sneezy Runny Nose

To detect proportion and surgical outcome of adult patients with allergic rhinitis non-responsive to medical treatment. To identify clinical candidacy for submucous turbinoplasty of inferior turbinate resection or soft tissue reduction. A prospective descriptive study of adults with clinical allergic rhinitis was done. Non-responders to medical therapy were identified and outcome of surgical intervention analyzed. There were 393 patients. Eighty-one patients (21%) were refractory to medical therapy. Presenting symptoms were sneezing with watery rhinorrhea among 72% and nasal obstruction in 28% patients All patients in the latter group had hypertrophied inferior turbinates with associated deviated nasal septum in 36.6%. Bony and mucosal inferior turbinate hypertrophy among 73.3% and mucosal hypertrophy among 26.7% were identified by a negative or positive response to on-table local vasoconstrictor application respectively. Submucosal inferior turbinoplasty with turbinate resection in the former and soft tissue reduction in the latter group were done, along with septoplasty among 36%. All patients revealed significant reduction in postoperative SNOT score. Crusting was more during early postoperative period among those with soft tissue reduction and simultaneous septoplasty, necessitating meticulous endoscopic follow-up. Adult allergic rhinitis presenting predominantly with nasal obstruction ('stuffy nose'), could be non-responsive to medical therapy unlike sneezy, runny nose, especially when obstructive symptoms are more than two years among older patients, suggesting presence of hypertrophied inferior turbinates. On-table response to vasoconstrictors is a reliable clinical indicator for submucous inferior turbinoplasty: negative and positive response suggesting turbinate resection among majority and soft tissue reduction among minority respectively.

Budenoside aqueous nasal spray: an updated reappraisal in rhinitis management

Allergic rhinitis (AR) and nonallergic rhinitis are prevalent diseases. In western countries, type 2 inflammation usually characterizes these medical conditions and mainly sustains nasal obstruction. Budesonide aqueous nasal spray (BANS) is an intranasal corticosteroid (INCS) that has been available since the early 1980s. BANS is indicated for treating allergic rhinitis, nonallergic rhinitis, and nasal polyps (both as treatment and prevention after surgery). Consolidated evidence confirms its efficacy in treating seasonal and perennial AR, and nonallergic rhinitis. In addition, BANS is safe with negligible local and systemic side effects. Recent guidelines for patients with AR recommend using INCS as the first line in many situations. In particular, patients may assess the perception of symptoms' severity using the Visual Analog Scale. A score ≥5/10 means uncontrolled symptoms and requires adequate treatment. BANS could appropriately be used in patients with uncontrolled symptoms and/or moderate/severe nasal obstruction. In conclusion, BANS represents a valuable option in managing patients with type 2 inflammation of the nose.

Allergic Rhinitis: A Review

Importance

Allergic rhinitis affects an estimated 15% of the US population (approximately 50 million individuals) and is associated with the presence of asthma, eczema, chronic or recurrent sinusitis, cough, and both tension and migraine headaches.

Observations

Allergic rhinitis occurs when disruption of the epithelial barrier allows allergens to penetrate the mucosal epithelium of nasal passages, inducing a T-helper type 2 inflammatory response and production of allergen-specific IgE. Allergic rhinitis typically presents with symptoms of nasal congestion, rhinorrhea, postnasal drainage, sneezing, and itching of the eyes, nose, and throat. In an international study, the most common symptoms of allergic rhinitis were rhinorrhea (90.38%) and nasal congestion (94.23%). Patients with nonallergic rhinitis present primarily with nasal congestion and postnasal drainage frequently associated with sinus pressure, ear plugging, muffled sounds and pain, and eustachian tube dysfunction that is less responsive to nasal corticosteroids. Patients with seasonal allergic rhinitis typically have physical examination findings of edematous and pale turbinates. Patients with perennial allergic rhinitis typically have erythematous and inflamed turbinates with serous secretions that appear similar to other forms of chronic rhinitis at physical examination. Patients with nonallergic rhinitis have negative test results for specific IgE aeroallergens. Intermittent allergic rhinitis is defined as symptoms occurring less than 4 consecutive days/week or less than 4 consecutive weeks/year. Persistent allergic rhinitis is defined as symptoms occurring more often than 4 consecutive days/week and for more than 4 consecutive weeks/year. Patients with allergic rhinitis should avoid inciting allergens. In addition, first-line treatment for mild intermittent or mild persistent allergic rhinitis may include a second-generation H1 antihistamine (eg, cetirizine, fexofenadine, desloratadine, loratadine) or an intranasal antihistamine (eg, azelastine, olopatadine), whereas patients with persistent moderate to severe allergic rhinitis should be treated initially with an intranasal corticosteroid (eg, fluticasone, triamcinolone, budesonide, mometasone) either alone or in combination with an intranasal antihistamine. In contrast, first-line therapy for patients with nonallergic rhinitis consists of an intranasal antihistamine as monotherapy or in combination with an intranasal corticosteroid.

Conclusions and Relevance

Allergic rhinitis is associated with symptoms of nasal congestion, sneezing, and itching of the eyes, nose, and throat. Patients with allergic rhinitis should be instructed to avoid inciting allergens. Therapies include second-generation H1 antihistamines (eg, cetirizine, fexofenadine, desloratadine, loratadine), intranasal antihistamines (eg, azelastine, olopatadine), and intranasal corticosteroids (eg, fluticasone, triamcinolone, budesonide, mometasone) and should be selected based on the severity and frequency of symptoms and patient preference.