Guideline updates treatment of allergic seasonal rhinitis

To treat seasonal allergic rhinitis, physicians should routinely prescribe monotherapy with an intranasal corticosteroid instead of adding an oral antihistamine, according to a new guideline, which also recommended intranasal corticosteroids over leukotriene receptor antagonists.

The updated guideline, a joint product of the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology, was published online by Annals of Allergy, Asthma, & Immunology on Nov. 2. A synopsis was published online Nov. 28 by Annals of Internal Medicine.

For initial treatment of seasonal allergic rhinitis in patients ages 12 years or older, the guideline recommends that physicians routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine (strong recommendation).

Evidence showed no benefit from adding an oral antihistamine to an intranasal corticosteroid, and oral antihistamines, mainly first generation, may cause sedation and other adverse effects, the authors wrote. There may be a subgroup of patients who experience treatment failure with an intranasal corticosteroid alone and could benefit from adding an oral antihistamine. However, data did not determine whether adding an oral antihistamine would benefit patients with residual symptoms despite appropriately dosed intranasal corticosteroids.

For initial treatment of seasonal allergic rhinitis in patients ages 15 years or older, the guideline recommends an intranasal corticosteroid over a leukotriene receptor antagonist (strong recommendation).

The evidence clearly showed that an intranasal corticosteroid was more effective than montelukast for nasal symptom reduction, the guideline stated. Reductions in nasal symptoms comparing an intranasal corticosteroid versus montelukast were clinically meaningful according to recently published criteria.

Some patients do not tolerate or accept the use of an intranasal corticosteroid and prefer an oral agent, such as montelukast, despite its lesser efficacy, the guideline authors noted. In patients who also have mild persistent asthma, a leukotriene receptor antagonist may be prescribed and may also provide benefit for seasonal allergic rhinitis. The authors acknowledged that there may be subgroups of patients with seasonal allergic rhinitis who are more responsive to a leukotriene receptor antagonist, such as those with asthma.

For treatment of moderate to severe seasonal allergic rhinitis in patients ages 12 years or older, physicians may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment (weak recommendation).

The authors concluded, “When treating patients with seasonal allergic rhinitis, clinicians need to use their expertise to assist patients in evaluating the best treatment choice through shared decision making; consider the potential for benefit as well as the potential for harm, the burden, and the cost of combination therapy; and allow patients to express their values and preferences and participate in the decision-making process.”