Question | |
Should intranasal glucocorticosteroids vs. intranasal H1-antihistamines be used for allergic rhinitis? | |
Population: | Patients with allergic rhinitis |
Intervention: | intranasal glucocorticosteroids |
Comparison: | intranasal H1-antihistamines |
Main outcomes: | Nasal symptoms Ocular symptoms Quality of life Adverse events (any) Serious adverse events |
Setting: | |
Perspective: | |
Background: | Intranasal corticosteroids and intranasal antihistamines are two of the most commonly used classes for the treatment of allergic rhinitis. These two treatment classes have different profiles in terms of acceptability and affordability, among others. |
Conflict of interests: | AWMF conflict of interest declaration and management policies were applied, the assessment performed by the AWMF with guidance and help from Juan Jose Yepes Nuñez. Due to the CoI assessment results, the following panel members recused from voting (determining the direction and strength of the recommendation): Bousquet, Canonica, Jacomelli, Klimek, Papadopoulos, Pereira and Zuberbier T. The voting members were: Bedbrook, Bognanni, Dykewicz, Gilles, Lourenço, Neves, Palamarchuk, Parmelli, Savouré, Schunemann, Sousa-Pinto, Valiulis, Ventura, Vieira, Williams, Yepes Nuñez and Zuberbier J. |
Assessment
ProblemIs the problem a priority? | ||
Judgement | Research evidence | Additional considerations |
Allergic rhinitis (AR) is a common condition affecting 18.1% of the population, and its symptoms can significantly reduce the quality of life and pose a high economic burden (mainly because of indirect costs related to lost school days and workdays). [Savoure] Studies of patients consulting general practitioners for AR reported that 18–48 % had symptoms that were not controlled by pharmacotherapy. [Bousquet, Bhattacharyya, Vandenplas] Despite the bothersome nature of symptoms, AR is often trivialized by the patient - only 45% seek medical advice or treatment for their condition, which results in under-treatment and poor control of symptoms. [Linneberg] Problems related to diseaseEconomic burdenA systematic review performed to estimate the financial burden of AR in European countries [Linneberg] suggests that the GP services bore the majority of the direct costs for AR. However, the majority of the overall cost burden correspond to indirect costs caused by high absenteeism and presenteeism.In the United States, annual costs for medications for rhinitis patients can be estimated at approximately $1.3 billion. In total, direct costs are estimated to be >$4.6 billion for rhinitis management, including treatment, allergy testing, clinical visits and hospital procedures. [Roland]Similar findings were found for Asia. An analysis of the indirect costs associated with insufficiently treated AR and urticaria patients revealed an annual burden of USD 105.4 billion. This translates to a cost ranging from USD 1,137 to USD 2,195 per patient due to absenteeism and presenteeism [ Kulthanan]Clinical burden The median prevalence of allergic rhinitis was found to be 18.1%, based on a dataset that included 310 reported prevalences. The prevalence of AR ranged from as low as 1.0% to as high as 54.5%.
These statistics indicate that AR is a relatively common condition affecting a significant portion of the population, with variations in prevalence observed across different regions or studies. [Savouré] References:
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Desirable EffectsHow substantial are the desirable anticipated effects? | ||
Judgement | Research evidence | Additional considerations |
Nasal symptoms In a systematic review with network meta-analysis performed by Sousa-Pinto et al., the improvement of quality-of-life was assessed in patients under intranasal corticosteroids (INCS) and compared with that registered in patients receiving intranasal antihistamines (INAH). For patients with seasonal allergic rhinitis, it was possible to meta-analytically pool the total nasal symptom score (TNSS; combination of four nasal symptoms and scale of 0-12) results of 82 randomised controlled trials (RCTs). INCS were associated with a significantly higher improvement in the TNSS when compared to INAH (mean difference=-0.34; 95%CI=-0.52;-0.16). INCS displayed a 4% probability of resulting in a clinically meaningful improvement when compared to INAH. [Low certainty of evidence]. For patients with perennial allergic rhinitis, it was possible to meta-analytically pool the four symptom TNSS results of 27 RCTs. INCS were associated with a significantly higher improvement in the TNSS when compared to INAH (mean difference=-0.46; 95%CI=-0.89;-0.03). INCS displayed a 26% probability of resulting in a clinically meaningful improvement when compared to INAH. [High certainty of evidence]. Subgroup considerations: Studies including vs. not including patients with asthma A subsequent subgroup analysis of the network meta-analysis performed by Sousa-Pinto et al. was performed, grouping trials according to whether they had excluded patients with asthma. The following results were found:  Subgroup considerations: Children and adolescents In a systematic review with network meta-analysis performed by Sousa-Pinto et al., for patients with seasonal allergic rhinitis, there were no primary studies assessing INAH (therefore, INCS cannot be compared with INAH). For patients with perennial allergic rhinitis, it was possible to meta-analytically pool the four symptom TNSS results of 12 RCTs. INCS were not associated with a significant difference compared to INAH on changes to TNSS (mean difference=0.07; 95%CI=-0.37;0.51). Ocular symptoms In a systematic review with network meta-analysis performed by Sousa-Pinto et al., the improvement of ocular symptoms was assessed in patients under INCS and compared with that registered in patients receiving INAH. For patients with seasonal allergic rhinitis, it was possible to meta-analytically pool the total ocular symptom score (TOSS; combination of three nasal symptoms and scale of 0-9) results of 24 RCTs. INCS were not associated with a significant difference in changes in TOSS when compared to INAH (mean difference=0.02; 95%CI=-0.10;0.14). INCS displayed a 0% probability of resulting in a clinically meaningful improvement when compared to INAH. [Moderate certainty of evidence]. For patients with perennial allergic rhinitis, no RCTs were found assessing INAH. Subgroup considerations: Studies including vs. not including patients with asthma A subsequent subgroup analysis of the network meta-analysis performed by Sousa-Pinto et al. was performed, grouping trials according to whether they had excluded patients with asthma. The following results were found:  Subgroup considerations: Children and adolescents In a systematic review with network meta-analysis performed by Sousa-Pinto et al., there were no primary studies assessing the TOSS in patients receiving INAH (therefore, INCS cannot be compared with INAH). Overall symptoms In a systematic review with network meta-analysis performed by Sousa-Pinto et al., the improvement on allergic rhinitis overall symptoms was assessed in patients under intranasal corticosteroids (INCS) and compared with that registered in patients receiving intranasal antihistamines (INAH). The patient-reported outcome measure used to assess this outcome was the total symptom score (TSS), which includes nasal, ocular and other rhinitis symptoms. The TSS computing method differed among studies, and while in most it consisted of the sum of nasal and ocular symptoms, in other RCTs ear and/or palatal itching, post-nasal drip or cough were part of the TSS. No studies directly comparing the effectiveness of INCS vs INAH measured by the TSS were identified. For seasonal allergic rhinitis (SAR), there were six primary studies comparing INAH (azelastine and levocabastine) to placebo which reported TSS. A significant improvement in this score favouring INAH was observed in all studies and for three of them – which compared azelastine to placebo - it was possible to obtain a pooled mean difference of -1.9 (95%CI=-3.0;-0.8). There were no RCTs comparing INAH to placebo for perennial allergic rhinitis (PAR). Ten RCTs reported TSS values for INCS: 8 for SAR and 2 for PAR. Most studies found a statistically significant difference in the change from baseline TSS, favouring INCS over placebo for the treatment of SAR. Only 2 out of the 8 included RCTs reported a non-significant difference between the INCS group and placebo. For PAR, a study assessing the TSS reported a significant improvement in this score for triamcinolone vs placebo while for mometasone, according to other study, the improvement did not reach statistical significance. Quality-of-life In a systematic review with network meta-analysis performed by Sousa-Pinto et al., the improvement of quality-of-life was assessed in patients under INCS and compared with that registered in patients receiving INAH. For patients with seasonal allergic rhinitis, it was possible to meta-analytically pool the rhinocojunctivitis quality of life questionnaire (RQLQ; scale of 0-6) results of 35 RCTs. INCS were associated with a significantly higher improvement in the RQLQ when compared to INAH (mean difference=-0.21; 95%CI=-0.32;-0.11). INCS displayed a 10% probability of resulting in a clinically meaningful improvement when compared to INAH. [High certainty of evidence]. For patients with perennial allergic rhinitis, it was possible to meta-analytically pool the RQLQ results of 15 RCTs. INCS were not associated with a significant difference in RQLQ changes when compared to INAH (mean difference=-0.08; 95%CI=-0.30;0.14). INCS displayed a 6% probability of resulting in a clinically meaningful improvement when compared to INAH. [Low certainty of evidence]. Subgroup considerations: Studies including vs. not including patients with asthma A subsequent subgroup analysis of the network meta-analysis performed by Sousa-Pinto et al. was performed, grouping trials according to whether they had excluded patients with asthma. The following results were found:  Subgroup considerations: Children and adolescents In a systematic review with network meta-analysis performed by Sousa-Pinto et al., for patients with seasonal allergic rhinitis, it was possible to meta-analytically pool the RQLQ results of 4 RCTs. INCS were not associated with a significant difference compared to INAH on changes to RQLQ (mean difference=-0.15; 95%CI=-0.33;0.03). For patients with perennial allergic rhinitis, it was possible to meta-analytically pool the RQLQ results of 3 RCTs. INCS were not associated with a significant difference compared to INAH on changes to RQLQ (mean difference=0.10; 95%CI=-0.11;0.31). | ||
Undesirable EffectsHow substantial are the undesirable anticipated effects? | ||
Judgement | Research evidence | Additional considerations |
Adverse events Following the systematic review performed by Sousa-Pinto et al., the frequency of patients developing at least one adverse event was assessed in patients under intranasal corticosteroids (INCS) and compared with that registered in patients receiving intranasal antihistamines (INAH). The summary of findings table is presented below. A total of 89 randomised controlled trials (RCTs) reported data on the number of patients with seasonal allergic rhinitis reporting at least one adverse event. The meta-analytical risk ratio was of 0.63 (95% confidence interval=0.53-0.76) [INCS was associated to 43 fewer cases per 1000 patients than INAH; 95%CI = 55 fewer cases to 28 fewer cases per 1000 patients. Trivial difference] [Moderate certainty of evidence]. A total of 38 RCTs reported data on the number of patients with perennial allergic rhinitis reporting at least one adverse event. The meta-analytical risk ratio was of 0.84 (95% confidence interval=0.60-1.19) [INCS was associated to 25 fewer cases per 1000 patients than INAH; 95%CI = 61 fewer cases to 29 more cases per 1000 patients. Trivial difference] [Moderate certainty of evidence]. Most adverse events which were considered to be related to the treatment were mild and self-limited and comprised headache, epistaxis, nasal discomfort, upper respiratory tract infection and – for INAH – bitter taste. In an additional analysis of pharmacovigilance data on patients under INAH or INCS (regardless of allergic rhinitis diagnosis), the following results were found:  Subgroup considerations: Studies including vs. not including patients with asthma A subsequent subgroup analysis of the network meta-analysis performed by Sousa-Pinto et al. was performed, grouping trials according to whether they had excluded patients with asthma. The following results were found:  Subgroup considerations: Children and adolescents In a systematic review performed by Sousa-Pinto et al., a total of 11 RCTs reported data on the number of patients with seasonal allergic rhinitis reporting at least one adverse event. The meta-analytical risk ratio was of 1.01 (95%CI=0.60-1.69) [INCS was associated with 1 more case per 1000 individuals than INAH; from 46 fewer cases to 80 more cases per 1000 individuals. Trivial difference]. A total of 15 RCTs reported data on the number of patients with perennial allergic rhinitis reporting at least one adverse event. The meta-analytical risk ratio was of 1.00 (95%CI=0.70-1.42) [INCS was associated with a difference of 0 cases per 1000 individuals compared to INAH; from 46 fewer cases to 64 more cases per 1000 individuals. Trivial difference]. Serious adverse events Following the systematic review performed by Sousa-Pinto et al., the frequency of patients developing at least one serious adverse event was assessed both in patients under INCS and in patients receiving INAH. The following results were observed for seasonal allergic rhinitis:  The following results were observed for perennial allergic rhinitis:  Only one serious adverse event was considered likely to be related to the treatment (increased intra-ocular pressure in a patient with perennial allergic rhinitis). In an additional analysis of pharmacovigilance data on patients under INAH or INCS (regardless of allergic rhinitis diagnosis), important adverse events were 1.9 times (95%CI = 1.5; 2.4) more common with INCS than with INAH. Although they are very rare events, cataract and glaucoma were particularly more associated with INCS than INAH. Subgroup considerations: Children and adolescents In a systematic review performed by Sousa-Pinto et al., a total of 7 RCTs reported data on the number of patients with seasonal allergic rhinitis reporting at least one serious adverse event. Four serious adverse events were reported in a total of 2012 children treated with INCS. This compares to 0 serious adverse events in 694 children treated with INAH. A total of 13 RCTs reported data on the number of patients with perennial allergic rhinitis reporting at least one serious adverse event. 11 serious adverse events were reported in a total of 2985 children treated with INCS. This compares to 0 serious adverse events in 327 children treated with INAH. | The panel noted that INAH may be recommended for patients who have epistaxis secondary to INCS. On the other hand, INCS may be recommended for patients with dysgeusia. | |
Certainty of evidenceWhat is the overall certainty of the evidence of effects? | ||
Judgement | Research evidence | Additional considerations |
The certainty of evidence was moderate for 5 out of 9 analyses, high for 2 out of 9 analyses, and low for 2 out of 9 analyses.
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ValuesIs there important uncertainty about or variability in how much people value the main outcomes? | ||
Judgement | Research evidence | Additional considerations |
Utility values Symptoms Regarding specific symptoms, in two studies, utilities (measured by VAS) were lower for severe nasal congestion and severe rhinorrhea compared to severe sneezing, severe throat itching, and severe itchy eyes (certainty of evidence: low). When utilities were elicited with the standard gamble technique, severe itchy eyes were rated by US patients as the least preferred AR symptom (certainty of evidence: low).  Inc - Certainty of evidence was lowered due to inconsistency; R- Certainty of evidence was lowered due to risk of bias; Ind- Certainty of evidence was lowered due to indirectness; Imp- Certainty of evidence was lowered due to imprecision, ⨁⨁⨁⨁ high certainty of evidence, ⨁⨁⨁◯ moderate certainty of evidence, ⨁⨁◯◯ low certainty of evidence 4 We rated down the certainty of evidence for indirectness because an indirect measurement tool was used to elicit the utility of outcomes with scale of 0 to 1, where 0 indicated the worst symptom(s) and 1 represented no symptom(s).5 Small sample size of the included study.Studies of rating or ranking of outcomes Adults
 Children/caregivers sample Seven studies assessing children or their caregivers were included in the relative importance analysis. Most of these studies only assessed symptom-related attributes. Similarly to the adult population, a nasal symptom was frequently ranked as the most or second most important attribute (certainty of evidence: low). In particular, nasal congestion was identified as the most important attribute in five studies (certainty of evidence: low).  | ||
Balance of effectsDoes the balance between desirable and undesirable effects favor the intervention or the comparison? | ||
Judgement | Research evidence | Additional considerations |
Taking into account both benefits and harms of intranasal corticosteroids (INCS) versus those of intranasal antihistamines (INAH), we can consider the following:
Overall, the benefits of INCS seem to marginally outweigh the benefits of INAH. In addition, the harms of INCS seem to be lower than those of INAH. However, these differences in benefits and harms are probably not being clinically meaningful. | ||
Resources requiredHow large are the resource requirements (costs)?" | ||
Judgement | Research evidence | Additional considerations |
Cost of drugs We conducted a survey, having received responses from specialists from 41 countries (mostly in Europe, America and Asia). In 29 of these countries, both intranasal corticosteroids (INCS) and intranasal antihistamines (INAH) were available. The costs of being treated for one year with INCS ranged from 3.4 US Dollars Power Purchase Parity (PPP) [Israel] to 692.0 USD PPP [Argentina] (assuming full adherence to treatment and the choice of the least expensive INCS). This corresponds to weekly costs ranging from 0.07 USD PPP to 14.4 USD PPP. The yearly costs per country associated with the use of INCS are displayed in the following map:  The costs of being treated for one year with INAH ranged from 18.0 US Dollars Power Purchase Parity (PPP) [Bangladesh] to 856.4 USD PPP [Colombia] (assuming full adherence to treatment and the choice of the least expensive INAH). This corresponds to weekly costs ranging from 0.35 USD PPP to 16.5 USD PPP. The yearly costs per country associated with the use of INCS are displayed in the following map:  In 21 out of the 29 countries where both INCS and INAH were reported to be available, INCS were associated with lower costs than INAH:  | ||
Certainty of evidence of required resourcesWhat is the certainty of the evidence of resource requirements (costs)? | ||
Judgement | Research evidence | Additional considerations |
Given that intranasal steroids and antihistamines and has been around for a long time, there is a reasonably high degree of certainty about the general costs. However, it should be noted that: 1. Available evidence comes from a survey of experts 2. There is substantial difference in costs for specific interventions | ||
Cost effectivenessDoes the cost-effectiveness of the intervention favor the intervention or the comparison? | ||
Judgement | Research evidence | Additional considerations |
In cost effectiveness within trial study medication cost per treatment success (global evaluation of efficacy: very good or good) was lowest with mometasone furoate use and highest with levocabastine use: 11.52 vs 42.82€ [Lange 2005]. Through a supplementary search conducted on the INAHTA database and the HTA agency websites, one reimbursement recommendation (specifically for Azelastine/Fluticasone) was found on the CADTH website, which included cost-effectiveness data for Fluticasone Propionate (FP) and Azelastine (comparators for Azelastine-Fluticasone fixed combination). The manufacturer’s economic submission for drug Azelastine-Fluticasone informed that azelastine (comparator in economic analysis) was dominated by FP (more costly, fewer QALY gains), in treatment patients with moderate to severe SAR in Canada. The manufacturer's submission had several limitations, that were noted in CDR PHARMACOECONOMIC REVIEW REPORT such as the source of input data (efficacy data), the time horizon of the analysis, the assessment of adverse events' impact on quality of life, and adjustments of QALY. However there are no difference in ICUR values between base case scenario [submission model] and re-analysis [CDR multi-way reanalysis]. Considering the costs reported in the survey alongside the differences in QALYs reported in the CDR Pharmacoeconomic Review Report, INAH would be dominated by INCS in 21 out of 29 countries (more expensive and associated with lower gains QALYs; assumption of full adherence to treatment and the choice of the least expensive medication of each class). In all remaining countries, INCS would be cost-effective at a willingness to pay threshold of $50,000/QALY gained. Considering the willingness to pay threshold of 1 time the GDP per capita, INCS would only not be cost-effective in one country (Egypt). Similar results would be obtained considering differences in VAS EQ-5D assessed using MASK-air data (inverse probability weighting methods were used to account for confounding), but in that case INCS would be cost-effective in Egypt.
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EquityWhat would be the impact on health equity? | ||
Judgement | Research evidence | Additional considerations |
Availability We conducted a survey, having received responses from specialists from 41 countries (mostly in Europe, America and Asia). Intranasal corticosteroids (INCS) were reported to be available in all assessed countries. All respondents reported availability of at least three different INCS in their respective country. Intranasal antihistamines (INAH) were reported to be available in 29 out of 41 countries. In 13 countries, only one INAH was available.  Other equity-related aspects  | ||
AcceptabilityIs the intervention acceptable to key interest-holders? | ||
Judgement | Research evidence | Additional considerations |
Switching rate Switching to another intranasal therapy occurred less often in patients doing intranasal corticosteroids (6.12%) compared with 10.15% for intranasal antihistamines. Augmentation with a prescription oral antihistamine or another intranasal therapy occurred in 22.52% of patients taking intranasal antihistamines, in comparison to 27.64% of patients taking intranasal corticosteroids. [Fairchild] Evidence from direct patient data: In the MASK-air dataset, in 84.8% of the days in which INAH have been used, they have been used in comedication. This compares with 50.1% for oral antihistamines, 51.0% for the fixed combination of INAH+intranasal corticosteroids, 56.2% for intranasal corticosteroids, and 83.0% for antagonists of leukotriene receptors. Compared to other rhinitis medication classes, INAH was associated with higher odds of being used in co-medication (OR=2.41; 95%CI=2.07-2.81) in a study using multivariable mixed-effects logistic regression models [Sousa-Pinto]. In 54.8% of days with INAH use, more than one INAH was used (that is, patients tried at least two INAH on the same day). This compares to 6.2% of days with intransal corticosteroids use, 4.1% of days with oral antihistamine use, 0.3% of days with fixed combination of INAH+intranasal corticosteroids use, and 0.4% of days with antagonists of leukotriene receptors use. In multivariable linear regression models adjusted for the CSMS of the previous day (a proxy variable of the rhinitis control level before medication use) and for the patients’ ARIA score (an indicator of disease severity), INAH were associated with higher odds of being used of co-medication than INCS (OR=1.88; 95%CI=0.87;4.03). Compliance (patient) Evidence from direct patient data: In complete weeks of MASK-air reporting during the pollen season, there were 36.0% in which INCS were used for 6 or 7 days. This compares with 38.5% for OAH, 12.2% for INAH, and 31.7% for fixed combinations of INAH+INCS. Satisfaction Evidence from direct patient data: In the MASK-air dataset, there were 6174 days in which INCS were used in monotherapy and for which patients provided information on how satisfied they were with their treatments. The median results of the visual analogue scale were of 86 (higher values indicating higher satisfaction) [IQR=26]. In the MASK-air dataset, there were only 81 days in which INAH were used in monotherapy and for which patients provided information on how satisfied they were with their treatments. The median results of the visual analogue scale were of 60 (higher values indicating higher satisfaction) [IQR=57]. In multivariable linear regression models adjusted for the CSMS of the previous day (a proxy variable of the rhinitis control level before medication use) and for the patients’ ARIA score (an indicator of disease severity), INAH were associated with lower VAS satisfaction than INCS (average difference: -2.07; 95%CI=-6.99;2.85). Onset of action A rapid review of the literature on the onset of action of intranasal corticosteroids and H1-antihistamines was carried out. The following results were found: 
| The panel noted that, except for onset of action, INCS were superior to INAH (in terms of adherence, satisfaction, and comedication rate). On the other hand, INAH had a faster onset of action (median 30 min. vs 120 min.). | |
FeasibilityIs the intervention feasible to implement? | ||
Judgement | Research evidence | Additional considerations |
We have included 2 studies that provided data on the feasibility of intranasal antihistamines vs. intranasal corticosteroids. Data comes from surveys conducted in Asia-Pacific, Middle East, and South America regions, published after 2015. Barriers-safety related 75,2% of primary health care physicians considered intranasal corticosteroids as a safe medication for AR in comparison to 58.6% of physicians who indicate intranasal antihistamines as a safe option. [Almousa] Adherence with guidelines In an online survey conducted to identify speciality-specific knowledge gaps, 66% of GPs, 88% of otolaringologists, 92% of pulmonologists, 90% of paediatricians and 92% of allergists agreed that intranasal glucocorticosteroids should be used in patients with AR in comparicon to the intranasal antihistamines. [Larenas Linnemann]
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Planetary healthWhat would be the impact on planetary health? | ||
Judgement | Research evidence | Additional considerations |
There is currently no evidence on the comparative impact of intranasal glucocorticosteroids and intranasal H1-antihistamines on planetary health. Key considerations include the availability of locally produced medications, as well as medication effectiveness in reducing healthcare resource utilization. | ||
Summary of judgements
Judgement | |||||||
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Problem | No | Probably no | Probably yes | Yes | Varies | Don't know | |
Desirable Effects | Trivial | Small | Moderate | Large | Varies | Don't know | |
Undesirable Effects | Trivial | Small | Moderate | Large | Varies | Don't know | |
Certainty of evidence | Very low | Low | Moderate | High | No included studies | ||
Values | Important uncertainty or variability | Possibly important uncertainty or variability | Probably no important uncertainty or variability | No important uncertainty or variability | |||
Balance of effects | Favors the comparison | Probably favors the comparison | Does not favor either the intervention or the comparison | Probably favors the intervention | Favors the intervention | Varies | Don't know |
Resources required | Large costs | Moderate costs | Negligible costs and savings | Moderate savings | Large savings | Varies | Don't know |
Certainty of evidence of required resources | Very low | Low | Moderate | High | No included studies | ||
Cost effectiveness | Favors the comparison | Probably favors the comparison | Does not favor either the intervention or the comparison | Probably favors the intervention | Favors the intervention | Varies | No included studies |
Equity | Reduced | Probably reduced | Probably no impact | Probably increased | Increased | Varies | Don't know |
Acceptability | No | Probably no | Probably yes | Yes | Varies | Don't know | |
Feasibility | No | Probably no | Probably yes | Yes | Varies | Don't know | |
Planetary health | Reduced | Probably reduced | Probably no impact | Probably increased | Increased | Varies | Don't know |
Type of recommendation
Conclusions
Recommendation |
In patients with allergic rhinitis, the ARIA guideline panel suggests using intranasal corticosteroids over intranasal antihistamines (conditional recommendation based on moderate certainty of evidence). |
Justification |
This decision is mostly grounded on advantages in terms of cost-effectiveness, equity, and acceptability as evidenced by MASK-air direct patient data. Desirable effects were marginally in favour of INCS (trivial differences) |
Subgroup considerations |
For preschool and school children, the ARIA guideline panel suggests using intranasal corticosteroids over intranasal antihistamines. For patients with asthma, there were no trials specifically comparing patients with and without asthma. However, those trials which included patients with asthma found similar results to those which excluded patients with asthma. |
Implementation considerations |
For patients with corticosteroid-phobia, or in those with poor adherence or with epistaxis or glaucoma, INAH may be a more adequate intervention (this may be something particularly to take into account in patients with asthma under inhaled corticosteroids). For patients experiencing bitter taste with INAH, INCS may be a more adequate intervention. |
Monitoring and evaluation |
Research priorities |
- Need for studies in specific subgroups of participants or presentation of results by subgroup. Such subgroups include: children and adolescents (perennial allergic rhinitis), older patients, patients with multimorbidity (asthma and conjunctivitis), and patients from ethnic minorities. - Need for studies - particularly randomised controlled trials - evaluating participants with mild allergic rhinitis. - Need for studies evaluating the planetary health impact of the intervention. |