1
|
Chitsuthipakorn W, Hoang MP, Kanjanawasee D, Seresirikachorn K, Snidvongs K. Combined medical therapy in the treatment of allergic rhinitis: Systematic review and meta-analyses. Int Forum Allergy Rhinol 2022; 12:1480-1502. [PMID: 35446512 DOI: 10.1002/alr.23015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/05/2022] [Accepted: 04/17/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antihistamines (ATH) and intranasal corticosteroids (INCS) are primary treatments for patients with allergic rhinitis (AR). When monotherapy of either primary treatment fails to control symptoms, combined medical therapy is an option. In this meta-analysis we assessed the additional effects of different medical combinations compared with primary treatments. METHODS Systematic searches on PubMed and EMBASE were updated on November 4, 2021. Randomized, controlled trials comparing the effects of combinations with monotherapy were included. There were 7 comparisons: (1) ATH-decongestant vs ATH; (2) ATH-leukotriene receptor antagonist (LTRA) vs ATH; (3) INCS-ATH vs INCS; (4) INCS-LTRA vs INCS; (5) INCS-decongestion vs INCS; (6) INCS-saline irrigation vs INCS; and (7) ATH-saline irrigation vs ATH. Data were pooled for meta-analysis. Outcomes were composite nasal symptom score, composite ocular symptom score, quality of life (QoL), and adverse events. RESULTS Fifty-three studies were included. Compared with ATH alone, the ATH-decongestant combination improved composite nasal symptoms; ATH-LTRA improved nasal symptoms in patients with perennial AR; and ATH-nasal saline improved both symptoms and QoL. Compared with INCS alone, the INCS-intranasal ATH combination improved nasal symptoms, ocular symptoms, and QoL; INCS-LTRA improved ocular symptoms but not nasal symptoms; and INCS-nasal saline improved QoL but not symptoms. There were no additional effects observed from adding oral ATH or topical decongestant to INCS. CONCLUSION After ATH monotherapy fails to control symptoms, addition of decongestant, saline, or LTRA can improve the outcomes. When INCS monotherapy is ineffective, addition of intranasal ATH can improve nasal symptoms; LTRA can improve ocular symptoms, and saline irrigation can improve QoL.
Collapse
Affiliation(s)
- Wirach Chitsuthipakorn
- Center of Excellence in Otolaryngology, Head and Neck Surgery, Rajavithi Hospital, Bangkok, Thailand.,College of Medicine, Rangsit University, Bangkok, Thailand
| | - Minh P Hoang
- Department of Otolaryngology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam.,Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Dichapong Kanjanawasee
- Center of Research Excellence in Allergy and Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Biodesign Innovation Center, Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kachorn Seresirikachorn
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| |
Collapse
|
2
|
Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Dinakar C, Ellis AK, Finegold I, Golden DBK, Greenhawt MJ, Hagan JB, Horner CC, Khan DA, Lang DM, Larenas-Linnemann DES, Lieberman JA, Meltzer EO, Oppenheimer JJ, Rank MA, Shaker MS, Shaw JL, Steven GC, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Dinakar C, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Khan DA, Lang DM, Lieberman JA, Oppenheimer JJ, Rank MA, Shaker MS, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Finegold I, Hagan JB, Larenas-Linnemann DES, Meltzer EO, Shaw JL, Steven GC. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020; 146:721-767. [PMID: 32707227 DOI: 10.1016/j.jaci.2020.07.007] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.
Collapse
Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, School of Medicine, Saint Louis University, St Louis, Mo.
| | - Dana V Wallace
- Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David J Amrol
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Fuad M Baroody
- Department of Otolaryngology-Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Timothy J Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, Pa
| | - Chitra Dinakar
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, Calif
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ira Finegold
- Division of Allergy and Immunology, Department of Medicine, Mount Sinai West, New York, NY
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Md
| | - Matthew J Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colo
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Caroline C Horner
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, School of Medicine, Washington University, St Louis, Mo
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | - Jay A Lieberman
- Division of Pulmonology Allergy and Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Eli O Meltzer
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, University of California, San Diego, Calif; Allergy and Asthma Medical Group and Research Center, San Diego, Calif
| | - John J Oppenheimer
- Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, New Brunswick, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Liu G, Zhou X, Chen J, Liu F. Oral Antihistamines Alone vs in Combination with Leukotriene Receptor Antagonists for Allergic Rhinitis: A Meta-analysis. Otolaryngol Head Neck Surg 2018; 158:450-458. [PMID: 29337654 DOI: 10.1177/0194599817752624] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To evaluate whether an adjuvant therapy of leukotriene receptor antagonists (LTRAs) based on oral H1-antihistamines (H1) can increase efficacy of allergic rhinitis (AR) treatment. Data Sources The search involved databases of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials, from inception up to September 23, 2017. Randomized controlled trials (RCTs) that compared efficacy of LTRAs + H1 vs H1 alone were eligible. Review Methods Pooled comparative effects were measured using weighted mean difference (WMD) and 95% confidence interval (CI). Subgroup analysis comparing seasonal vs perennial AR was prespecified to explore the source of heterogeneity. The evidence quality of each outcome was assessed by the GRADE approach. Results A total of 8 RCTs were included (n = 1886), and all measured outcomes used scaled scores. Compared with H1 alone, H1 + LTRAs were superior to improve overall daytime (WMD, -0.11; 95% CI, -0.19 to -0.03, high quality) and composite (WMD, -0.12; 95% CI, -0.23 to -0.01; low quality) nasal symptoms. Specifically, H1 + LTRAs had better efficacy against composite nasal rhinorrhea, sneezing, and daytime itching but not congestion. The effects were more pronounced in patients with perennial AR compared to those with seasonal AR. There were no significant differences in nighttime nasal symptoms and eye symptoms between the 2 groups. Conclusion The current evidence suggests that LTRAs + H1 can increase the therapeutic efficacy against daytime and composite nasal symptoms, including rhinorrhea, sneezing, and itching; however, it does not affect nighttime nasal symptoms and eye symptoms. The patients with perennial AR may benefit more from the combination therapy.
Collapse
Affiliation(s)
- Guo Liu
- 1 Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xu Zhou
- 2 Evidence-based Medicine Research Center, School of Basic Medical Sciences, Jiangxi University of Traditional Chinese Medicine, Jiangxi, China
| | - Jianrong Chen
- 3 Department of Endocrinology, the Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Feng Liu
- 1 Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
4
|
Abstract
Leukotrienes (LTs) are a family of inflammatory mediators including LTA4, LTB4, LTC4, LTD4, and LTE4. By competitive binding to the cysteinyl LT1 (CysLT1) receptor, LT receptor antagonist drugs, such as montelukast, zafirlukast, and pranlukast, block the effects of CysLTs, improving the symptoms of some chronic respiratory diseases, particularly bronchial asthma and allergic rhinitis. We reviewed the efficacy of antileukotrienes in upper airway inflammatory diseases. An update on the use of antileukotrienes in upper airway diseases in children and adults is presented with a detailed literature survey. Data on LTs, antileukotrienes, and antileukotrienes in chronic rhinosinusitis and nasal polyps, asthma, and allergic rhinitis are presented. Antileukotriene drugs are classified into two groups: CysLT receptor antagonists (zafirlukast, pranlukast, and montelukast) and LT synthesis inhibitors (5-lipoxygenase inhibitors such as zileuton, ZD2138, Bay X 1005, and MK-0591). CysLTs have important proinflammatory and profibrotic effects that contribute to the extensive hyperplastic rhinosinusitis and nasal polyposis (NP) that characterise these disorders. Patients who receive zafirlukast or zileuton tend to show objective improvements in, or at least stabilisation of, NP. Montelukast treatment may lead to clinical subjective improvement in NP. Montelukast treatment after sinus surgery can lead to a significant reduction in eosinophilic cationic protein levels in serum, with a beneficial effect on nasal and pulmonary symptoms and less impact in NP. Combined inhaled corticosteroids and long-acting β-agonists treatments are most effective for preventing exacerbations among paediatric asthma patients. Treatments with medium- or high-dose inhaled corticosteroids, combined inhaled corticosteroids and LT receptor antagonists, and low-dose inhaled corticosteroids have been reported to be equally effective. Antileukotrienes have also been reported to be effective for allergic rhinitis.
Collapse
|
5
|
Bautista AP, Eisenlohr CP, Lanz MJ. Nasal nitric oxide and nasal eosinophils decrease with levocetirizine in subjects with perennial allergic rhinitis. Am J Rhinol Allergy 2012; 25:383-7. [PMID: 22185740 DOI: 10.2500/ajra.2011.25.3668] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Allergic rhinitis is commonly treated with antihistamines. Monitoring improvement of airway inflammation noninvasively using nasal nitric oxide (nNO) would be clinically useful. To determine the anti-inflammatory effect of oral levocetirizine dihydrochloride (LC), we measured nNO and nasal eosinophils (nEos) in perennial allergic rhinitis (PAR) subjects. METHODS A randomized double-blind placebo-controlled crossover design was used. Inclusion criteria consisted of subjects having a PAR history, exam and diary scores consistent with active symptoms, and positive skin testing. Subjects taking allergy medications 1 month before the study were not enrolled. After consenting, 31 subjects (24 female subjects; mean age, 29 years) were randomized to either oral LC (5 mg) or matching placebo for 2 weeks. After 2 week washout, subjects started the other 2-week treatment. At each visit, nNO was measured by aspiration at each nare using a nasal kit from NIOX (Aerocrine, Sweden) in parts per billion; nEos was collected from nasal smears and measured by microscopy using the scoring system (0-4+) and symptoms were self-reported using the allergic Rhinitis Quality of Life Questionnaire (RQLQ). Daily allergy symptom scores (total symptom score [TSS] 4) were collected at each visit. RESULTS During LC, mean baseline nNO was 807 ± 317 parts per billion (ppb; left) and 831 ± 332 ppb (right) and decreased significantly to 688 ± 266 ppb and 702 ± 286 ppb, respectively (p < 0.05). No significance was found during placebo treatment (778 ± 270 ppb, 808 ± 299 ppb to 802 ± 271 ppb, 813 ± 273 ppb). The mean nNO change was also significant compared with placebo (-125 ppb versus +14 ppb; p < 0.05). There was a significant decrease in nEos with LC compared with placebo (3.1-2.5 versus 2.9-2.6; p < 0.05). RQLQ scores were significantly improved with LC only. In TSS-4 scoring, a trend toward improvement during LC and significant worsening during placebo was found. Baseline nNO predicted changes in nasal eosinophils (nEos) and RQLQ. CONCLUSION We showed that oral LC therapy decreased objective markers of rhinitis inflammation, nNO and nEos, in patients with PAR. Improvement in symptom scoring was also found with LC treatment.
Collapse
Affiliation(s)
- Angela P Bautista
- Department of Allergy, Asthma, and Rhinosinusitis, AAADRS Clinical Research Center, Coral Gables, Florida 33134, USA
| | | | | |
Collapse
|