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Wise et al.

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generation oral antihistamines. Montelukast was determined to have increased cost for relative effectiveness compared to levocetirizine, desloratadine, and branded and generic fexofenadine. The annual drug and incurred medical costs for montelukast were estimated to be $631. LTRA monotherapy may be a useful alternative in rare patients with contraindications for both INCS and oral antihistamines, but this limits recommendations or options for these agents in general. In patients with concurrent AR and asthma, LTRA can contribute to symptom management of both respiratory diseases. LTRA monotherapy is not recommended as first-line treatment for patients with concurrent AR and asthma, although this may be a consideration in patients with contraindications to INCS. • Aggregate Grade of Evidence: A (Level 1a: 6 studies; Level 1b: 17 studies; Level 2a: 2 studies; Level 2b: 3 studies; Level 4: 3 studies; Table IX.B.4). • Benefit: Consistent reduction in symptoms and improvement in QOL compared to placebo, as demonstrated in RCTs and systematic review of RCTs. • Harm: Consistently inferior compared to INCS at symptom reduction and improvement in QOL in RCTs and systematic reviews of RCTs. Equivalent-to inferior effect compared to oral antihistamines in symptom reduction and improvement of QOL. • Cost: Annual incurred drug and medical costs estimated to be $631 for generic montelukast. • Benefits-Harm Assessment: Preponderance of benefit over harm. LTRAs are effective as monotherapy compared to placebo. However, there is a consistently inferior or equivalent effect to other, less expensive agents used as monotherapy. • Value Judgments: LTRAs are equivalent to oral antihistamine alone and more effective than placebo at controlling both asthma and AR symptoms in patients with both conditions. Control of AR symptoms with LTRAs, however, is less effective than INCS, and inferior or equivalent to oral antihistamines. Therefore, evidence is lacking to recommend LTRAs as first-line or second-line monotherapy in the management of AR alone or in combination with asthma. • Policy Level: Recommendation against as first-line therapy for AR. • Intervention: LTRAs should not be used as monotherapy in the treatment of AR but can be considered as second-line therapy, such as when INCSs are contraindicated. IX.B.5. Cromolyn— Disodium cromoglycate (DSCG) [synonyms: cromolyn sodium, sodium cromoglycate, disodium 4,4 ′ -dioxo-5,5 ′ -(2-hydroxytrimethylenedioxy)-di(4H chromene-2-carboxylate)] was first used by ancient Egyptians for its spasmolytic properties. It is derived from the plant Ammi visnaga . DSCG is a mast cell stabilizer that prevents histamine release. It impedes the function of chloride channels important in regulating cell volume and prevents extracellular calcium influx into the cytoplasm of the mast cell, thus preventing the degranulation of sensitized cells. 1349,1350 DSCG is best used prophylactically

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