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Wise et al.

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It is likely because of this significant risk of adverse events and propensity for interactions with other medications that the ARIA 2010 guidelines recommended against the routine treatment of AR with a combination oral decongestant and oral antihistamine. 1167 The 2010 ARIA document suggested that oral decongestants only be added in patients who are not controlled by antihistamines alone and are less averse to side effects or adverse reactions. Additionally, they suggested that oral decongestants be limited to utilization primarily as a rescue medication during periods of significant symptom exacerbations. Overall, despite the available evidence verifying the efficacy of combination oral antihistamines and oral decongestants in improving AR symptoms, caution should still be exercised when prescribing this treatment, particularly in patients with cardiovascular or urologic comorbidities. • Aggregate Grade of Evidence: A (Level 1b: 21 studies; Table IX.B.10.a). • Benefit: Improved control of nasal congestion with combination of oral antihistamines and oral decongestants. • Harm: Oral decongestants can cause significant adverse effects, particularly in patients with hypertension, cardiovascular disease, or benign prostatic hypertrophy. Additionally, these medications should not be used in children under 4 years of age or pregnant patients. This should be weighed against the potential benefits prior to prescribing. • Cost: Low. • Benefits-Harm Assessment: Harm likely outweighs benefit when used on a routine basis. • Value Judgments: Combination therapy of oral antihistamines and oral decongestants can be helpful for relief of an acute exacerbation of AR, especially nasal symptoms, when exposed to triggers. Caution should be exercised regarding long-term use given the possibility of significant adverse effects. • Policy Level: Option, particularly for acute exacerbations of nasal congestion. • Intervention: Combination therapy with oral antihistamine and oral decongestant can provide effective reduction of nasal congestion symptoms in patients with AR; however, recommend against chronic use given the significant side effect profile of oral decongestants. IX.B.10.b Oral antihistamine and intranasal corticosteroid.: A combination of an oral antihistamine and INCS is often used in clinical practice for the treatment of AR. As previously mentioned, oral antihistamines function as a reversible competitive antagonist of the histamine H 1 receptor and thereby prevent the binding of histamine that is present in the circulation. The newer, second-generation agents, such as fexofenadine and cetirizine, are less sedating, have fewer adverse effects, and provide good control of sneezing, rhinorrhea, and nasal itching, but with less effect on nasal congestion. 1448 Additionally, INCSs, such as fluticasone or beclomethasone, have repeatedly been validated as an effective treatment option for AR while offering a good safety profile and low systemic absorption. 1448

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