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Wise et al.

Page 112

Several RCTs have examined the efficacy of combination therapy utilizing both an oral antihistamine and INCS and demonstrated no added benefit of combination therapy (Table IX.B.10.b). In 2000, Wilson et al. 1469 demonstrated that oral cetirizine and intranasal mometasone were effective at improving nasal peak inspiratory flow rates as well as nasal symptoms and total daily symptoms after 4 weeks of use. However, the combination was not significantly better than cetirizine and placebo or cetirizine and montelukast. In a double blinded crossover study, Barnes et al. 1470 compared the combination of fluticasone and levocetirizine vs fluticasone and placebo and found, in most patients, that the benefits of an additional oral antihistamine to an effective nasal steroid regimen were not significant. Additionally, Ratner et al. 1471 found that fluticasone monotherapy compared to fluticasone plus loratadine had comparable efficacy in nearly all clinician and patient rated symptoms. Finally, Di Lorenzo et al. 1472 demonstrated similar results in patients with SAR, noting that combination therapy did not appear to offer substantial improvement in daily nasal symptom scores or in reduction of nasal lavage inflammatory markers. In contrast, a 2008 study by Pinar et al. 1473 compared mometasone spray monotherapy to mometasone plus desloratadine and found that the combination therapy group had significantly better nasal symptom scores at the end of study week 2 and better QOL scores throughout the study. A recent systematic review and meta-analysis by Feng et al. 1474 summarized the efficacy of the combination therapy of an oral antihistamine and INCS as compared to either therapy independently. They concluded that the combination demonstrated significant improvement in symptom scores in AR when compared to an oral antihistamine alone, but do not provide significant additional benefit when compared to monotherapy with an effective INCS. 1474 Limitations to this data include the fact that the studies did not control for variations in the specific oral antihistamines or INCS utilized and that the studies predominantly evaluated patients with SAR, excluding patients with PAR. Additionally, the conclusions of this meta-analysis are supported by the updated 2010 ARIA guidelines, which also do not recommend the addition of an oral antihistamine to an effective INCS, in contrast to prior recommendations. 1167 It should also be noted that adverse effects of oral antihistamine and INCS combination therapies include drowsiness and dry mouth (from oral antihistamines) as well as epistaxis and nasal irritation (from INCS). • Aggregate Grade of Evidence: B (Level 1b: 5 studies; Table IX.B.10.b). • Benefit: Reduction of nasal congestion with combination of oral antihistamines and INCS compared to oral antihistamines alone. • Harm: Side effects include sedative properties of antihistamines, although significantly decreased with the newer second-generation agents. Side effects of topical INCS include nasal dryness and epistaxis, burning in the nose, and with prolonged usage, possible growth suppression in the pediatric population. • Cost: Low. • Benefits-Harm Assessment: Harm likely outweighs benefit of adding the oral antihistamine unless treating symptoms other than nasal symptoms.

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