xRead - September 2022

Wise et al.

Page 101

• Benefits-Harm Assessment: Harm likely outweighs benefit if used more than 3 days. • Value Judgments: Topical decongestants can be helpful for short-term relief of nasal congestion. • Policy Level: Option. • Intervention: Topical decongestants can provide effective short-term nasal decongestion in patients with AR, but recommend against chronic use due to risk for RM. IX.B.4. Leukotriene receptor antagonists (LTRAs)— LTRAs have been studied and used in the treatment of AR. Montelukast is approved by the FDA for the treatment of SAR in adults and children over 2 years of age, and for PAR in adults and children over 6 months of age. Several systematic reviews and meta-analyses of RCTs have demonstrated symptom reduction and improved QOL in patients treated with LTRA monotherapy compared to placebo. 1300,1332-1335 Nevertheless, in a clinical practice guideline on AR from the AAO HNS there was a recommendation against LTRA monotherapy, citing decreased effectiveness compared to other first-line agents. 761 Systematic review identified 28 studies, of which 19 were considered level 1 evidence, examining the use of LTRA monotherapy in AR (Table IX.B.4). Multiple systematic reviews 1300,1332-1335 and RCTs 1336-1344 demonstrated that LTRA monotherapy was superior to placebo at improving patient symptoms and QOL. This effect was consistent in studies of SAR, 1340-1344 PAR, 1339 and artificial allergen exposure. 1336-1338 Furthermore, in a double blind RCT by Philip et al. 1341 montelukast improved both AR and asthma disease-specific QOL in patients with concurrent SAR and asthma. Despite multiple studies demonstrating superior effect of LTRA monotherapy over placebo in the treatment of AR, there is consistent evidence that LTRA is inferior to INCS. 1300,1333-1335,1345,1346 Multiple systematic reviews and meta-analyses have shown that INCS result in greater symptom reduction and QOL improvement compared to LTRA. 1300,1333-1335 A double-blinded RCT by Pullerits et al. 1346 showed decreased numbers of activated tissue eosinophils in nasal mucosa biopsies in patients treated with intranasal beclomethasone compared to zafirlukast and placebo. There is conflicting evidence on the relative effect of LTRA compared to oral antihistamines, with 2 systematic reviews demonstrating that oral antihistamines have superior symptom reduction and QOL improvement 1300,1333 and a third study indicating equivalent effect. 1334 Moreover, a double blind RCT by Mucha et al. 1321 indicated that montelukast and pseudoephedrine yielded equivalent symptom reduction and QOL improvement. In that study, objective measurement of nasal peak inspiratory flow was not different between the montelukast and pseudoephedrine treatment groups. In addition to less relative effectiveness compared to other agents, the AAO-HNS clinical practice guideline on AR cited increased costs of LTRA in the recommendation against this drug class as monotherapy in patients with AR without asthma. 761 Goodman et al. 1347 examined the relative cost effectiveness of montelukast compared to several second

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

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