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Wise et al.

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review evaluated the efficacy of INCS on asthma outcomes in patients with coexistent rhinitis, finding no significant improvement in asthma outcomes with the use of INCS. 1295 Heterogeneity in study designs may have limited the findings of this meta-analysis and explain the discrepancy of the results compared to high-quality RCTs. Alternatively, a 2013 systematic review and meta-analysis of the efficacy of INCS for asthmatics with concomitant AR demonstrated improvements in asthma outcomes with the use of INCS compared to placebo, but a lack of further improvement with INCS as an addition to inhaled corticosteroids. 1296 Interestingly, patients with concomitant AR and asthma who received training on the proper use of INCS and education on the relationship of AR and asthma demonstrated significant reductions in asthma symptoms and albuterol use compared to patients receiving INCS without additional education. 1812 This demonstrates the importance of patient instruction for both therapy evaluation and future trial design. (See section IX.B.2.a. Management – Pharmacotherapy – Corticosteroids – Intranasal corticosteroids (INCSs) for additional information on this topic.) Pharmacotherapy: leukotriene receptor antagonists.— LTRAs (montelukast and zafirlukast) have demonstrated benefit for the treatment of both asthma and AR, consistent with efficacy in addressing inflammation in the “unified airway” 1813 (Table X.A.4-3). In 2008, the ARIA group reviewed the evidence for effectiveness of montelukast in treating patients with asthma and AR, finding improvement of both nasal and bronchial symptoms as well as reduction of β -agonist use. 101 In fact, the LTRAs are the only class of medications specifically described in the 2008 AR management guide for primary care physicians, and in the full ARIA report, as effective for both asthma and AR. 101,1814 The 2010 ARIA update further supports the recommendation of LTRAs for both AR and asthma, but specifies that LTRAs are not recommended over other first-line therapies for the respective conditions (ie, it is better to treat asthma and AR with both a nasal and inhaled steroid, than try to treat both with an LTRA). A more recent review in 2015 also identified some utility of LTRAs for patients with concomitant AR and asthma. 1802 Despite this evidence, the limited additional benefit and added cost leads to a strong recommendation (based on moderate quality evidence) for inhaled glucocorticoids over LTRAs for single-modality treatment of asthma in patients with comorbid AR. 1167 Based on the summarized RCTs, an evidence-based recommendation is made for LTRAs not to be used as monotherapy for AR, but LTRAs may be considered as part of the treatment of comorbid asthma and AR (See section IX.B.4. Management – Pharmacotherapy – Leukotriene receptor antagonists (LTRAs) for additional information on this topic) (Table X.A.4-3). Pharmacotherapy recommendations for the treatment of AR with coexisting asthma. • Aggregate Grade of Evidence: A (Level 1a: 2 studies; Level 1b: 23 studies). Antihistamines (Level 1b: 6 studies; Table X.A.4-1). INCS (Level 1a: 2 studies; Level 1b: 12 studies; Table X.A.4-2). LTRAs (Level 1b: 5 studies; Table X.A.4-3). • Benefit: Pharmacotherapy improves subjective and objective severity of asthma in patients with coexistent AR. Patient education and training on medication use

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