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Wise et al.

Page 95

Kronholm 1250 demonstrated that a single injection of either betamethasone dipropionate/ betamethasone phosphate or methylprednisolone acetate given at the onset of the hay fever season led to a significant reduction of both nasal and ocular symptoms during the 5 weeks of the study, with the betamethasone combination being more effective. Ohlander et al. 1251 compared 3 long-acting corticosteroid injections given at the beginning of the season, and showed that all treatments led to significant reductions in nasal and ocular symptoms during the season with no difference between groups. However, all preparations also suppressed endogenous cortisol, in some cases for more than 14 days after injection, and 2 out of the 3 injections resulted in increases in blood sugar levels. When compared to other agents, injected corticosteroids demonstrated similar effectiveness outcomes. Specifically, there were similar clinical outcomes when comparing preseasonal steroid injections to both daily oral prednisolone 1252 and daily intranasal beclomethasone dipropionate spray. 1253 An adrenal corticotropic hormone (ACTH) test performed at 3 weeks showed significant suppression of adrenal function in the oral steroid treatment group and no evidence of suppression in the corticosteroid injection or topical intranasal corticosteroid groups. 1252 This was probably related to the short duration of adrenal suppression expected after a single injection of corticosteroids compared to continuous administration. When evaluating the timing of injectable corticosteroid therapy, Borum et al. 1254 compared the effects of a single depot injection of methylprednisolone given either at the beginning of the allergy season or later when pollen counts peaked. Compared to placebo, intramuscular methylprednisolone was efficacious against nasal congestion with less pronounced effects against rhinorrhea and sneezing. The authors argue that depot injectable steroids may be considered after other safer medical therapy fails and may provide an effective alternative treatment even if provided late in the allergy season. Injectable corticosteroid preparations may have significant side effects that include adrenal suppression and growth retardation. 1256 In a large retrospective study of Danish National Registries, the relative risk and incidence of both osteoporosis and diabetes were higher in allergic individuals receiving at least 1 depot corticosteroid injection during the allergy season compared to those receiving immunotherapy. 1255 Several early reports detailed significant improvement in symptoms of AR in a large proportion of patients who received intraturbinate injections of cortisone, 1257 hydrocortisone acetate, 1258 or prednisolone. 1259 Similar, noncontrolled, studies showed improvement in AR symptoms after intraturbinate injections. 1260,1261 A more recent randomized, placebo controlled, single-blind trial by Yang et al. 1262 compared the efficacy of intraturbinate injections of either onabotulinum toxin A, triamcinolone, or isotonic saline in patients with PAR. Both onabotulinum toxin A and triamcinolone therapy showed better control of nasal symptoms than placebo with onabotulinum toxin A efficacy lasting longest. Orbital complications have been reported with intraturbinate but not intramuscular injections. Based on a large clinical experience, Mabry cites an estimated incidence of visual loss after intraturbinate injections to be 0.006%. 1263 Other complications have included

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

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