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Wise et al.

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Cost: Increased cost associated with H 2 antagonist.

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Benefits-Harm Assessment: Unclear benefit and possible harm.

• Value judgments: No studies evaluating efficacy of H 2 antihistamines in context of topical nasal corticosteroids. • Policy Level: No recommendation. The data available does not adequately address the question as to the benefit of H 2 antihistamines in clinical AR as part of modern treatment protocols. • Intervention: Addition of an oral H 2 antagonist to an oral H 1 antagonist may improve symptom control in AR; however, the evidence to support this is not strong. IX.B.1.c. Intranasal antihistamines.: The use of intranasal antihistamine spray for AR has been well studied. Two agents are currently available in North America for intranasal use as a topical spray, azelastine hydrochloride and olopatadine hydrochloride. A systematic review of the English-language literature was performed for clinical trials of azelastine or olopatadine for the treatment of AR. A total of 44 papers were identified that reported results of RCTs of intranasal antihistamine monotherapy against either placebo or active control 1046,1199-1241 (Table IX.B.1.c). Of these, 11 studies included comparison of different doses of intranasal antihistamine 1204,1205,1207,1211,1212,1216,1218,1219,1231,1235 , 1237 and 29 studies utilized inactive placebo. 1201,1202,1204,1205,1207-1209,1211-1214,1216,1218-1222,1224,1225,1227-1231,1233,1235,1237-1239 Overall, there were 38 studies of azelastine 1046,1199-1201,1203,1205,1207-1213,1215,1217,1220-1241 and 10 studies of olopatadine 1202 , 1204 , 1206 , 1208 , 1210 , 1211 , 1214 , 1216,1218,1219 as monotherapy. Outcome measures were predominantly patient-reported symptom scores or QOL assessments. The most common outcome measure was the TNSS (23 studies), which records the severity of runny nose, sneezing, itching, and congestion. Other outcome measures included the RQLQ (7 studies), the Total Ocular Symptom Score (TOSS, 5 studies), the Caregiver Treatment Satisfaction Questionnaire (2 studies), the Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (1 study), the Short Form-36 (1 study), the Epworth Sleepiness Scale (ESS, 1 study), the Rhinitis Severity Score (1 study), and a Subjective Global Assessment (1 study). Multiple studies, particularly those published prior to 2002, used a variety of nonvalidated symptom scoring systems ranging from 5 to 13 items each (19 studies). Objective measures included nasal lavage (3 studies), response to methacholine challenge (2 studies), nasal flow rate (2 studies), and rhinomanometry (1 study). Study duration ranged from 2 days to 8 weeks, with the most frequent duration being 14 days of treatment. The number of subjects in each study ranged from 20 to 1188. Intranasal antihistamine was compared to placebo in 29 studies, 1201,1202,1204,1205,1207-1209,1211-1214,1216,1218-1222,1224,1225,1227-1231,1233,1235,1237-1239 with primary outcomes showing superiority to placebo in all studies. Intranasal antihistamine was trialed against an active treatment comparator of a different medication class in 24 studies. 1046,1199,1203,1206,1213-1215,1217,1220,1221,1224,1226 , 1227,1229,1231-1236,1238-1241 Although not reported in all studies, the intranasal antihistamine spray consistently had a more rapid onset

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.