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Wise et al.

Page 104

IX.B.6. Intranasal anticholinergics— Ipratropium bromide (IPB) nasal spray acts by controlling watery nasal secretory output from seromucous glands. IPB is used primarily to reduce rhinorrhea and is effective in adults and children with perennial rhinitis and common cold. 1378,1379 It has a quick onset of action and short half-life administered up to 6 times per day, with less than 10% absorption over a range of 84 μ g/day to 336 μ g/day. 1380 Local side effects include nasal dryness, irritation, epistaxis, and burning. Systemic side effects have not been observed with therapeutic dosing, as plasma concentrations of greater than 1.8 ng/mL are needed to produce systemic anticholinergic effects. 1380 However, care should be taken to avoid over-dosage that could lead to high serum concentrations of ipratropium. All studies have shown that the use of IPB significantly controls rhinorrhea in children and adults with PAR (Table IX.B.6). The combined use with INCS have also been shown to be more effective than either agent alone, suggesting a role of IPB for patients with persistent rhinorrhea. 1381 • Aggregate Grade of Evidence: B (Level 1b: 9 studies; Level 2b: 5 studies; Table IX.B.6). • Benefit: Reduction of rhinorrhea with topical anticholinergics. • Harm: Local side effects include nasopharyngeal irritation, burning, headache, pharyngitis, epistaxis, nasal dryness, nasal congestion, and dry mouth. Care should be taken to avoid over-dosage leading to systemic side effects. • Cost: Low to moderate. • Benefits-Harm Assessment: Preponderance of benefit over harm in PAR patients with rhinorrhea. • Value Judgments: No significant benefits in controlling symptoms other than rhinorrhea. Evidence for combined use with INCS is limited but encouraging for patients with persistent rhinorrhea. • Policy Level: Option. • Intervention: IPB nasal spray may be considered as an adjunct medication to INCS in PAR patients with uncontrolled rhinorrhea. IX.B.7. Biologics (omalizumab)— Biologics have been studied in the treatment of AR, specifically omalizumab, either alone or in combination with specific AIT. Omalizumab is a humanized antibody that binds to human IgE. No biologic is currently approved by the FDA for the treatment of AR. One systematic review and meta-analysis of RCTs has demonstrated reduced symptoms, reduced rescue medication use, and improved QOL in patients treated with omalizumab. 1391 However, the cost of omalizumab is very high, estimated to be over $18,000 year in the United States. Systematic review identified 5 level 1 evidence studies examining the use of omalizumab in AR (Table IX.B.7). Four RCTs 1392-1395 demonstrated that omalizumab monotherapy was superior to placebo at improving patient symptoms and QOL. The first RCT evaluating different delivery routes and dose-ranges did not show efficacy against ragweed-induced

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