Intranasal versus oral treatments for allergic rhinitis: A systematic review with meta-analysis

Torres MI, Gil-Mata S, Bognanni A et al. J Allergy Clin Immunol Pract. 2024 Sep 7:S2213-2198(24)00888-2. doi: 10.1016/j.jaip.2024.09.001. 

Abstract

Background

Treatments for allergic rhinitis include intranasal or oral medications.

Objective

To perform a systematic review with meta-analysis comparing the effectiveness of intranasal corticosteroids or antihistamines versus oral antihistamines or leukotriene receptor antagonists in improving allergic rhinitis symptoms and quality of life.

Methods

We searched four bibliographic databases and three clinical trial datasets for randomised controlled trials (i) assessing patients ≥12 years old with seasonal or perennial allergic rhinitis, and (ii) comparing intranasal corticosteroids or antihistamines versus oral antihistamines or leukotriene receptor antagonists. We performed a meta-analysis of the Total Nasal Symptom Score (TNSS), Total Ocular Symptom Score (TOSS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), development of adverse events, and withdrawals due to adverse events. Certainty of evidence was assessed using GRADE.

Results

We included 35 studies, most of which assessed patients with seasonal allergic rhinitis and displayed an unclear risk of bias. Superiority of intranasal treatments was found for all assessed outcomes. Intranasal corticosteroids were more effective than oral antihistamines at improving the TNSS (MD=-0.86; 95%CI=-1.21;-0.51; I2=70%), TOSS (MD=-0.36; 95%CI=-0.56;-0.17; I2=0%) and RQLQ (MD=-0.88; 95%CI=-1.15;-0.61; I2=0%), being mostly associated with clinically meaningful improvements.

Superiority of intranasal corticosteroids at improving the TNSS was also found against oral leukotriene receptor antagonists (MD=-1.05; 95%CI=-1.33;-0.77). Intranasal antihistamines were more effective than oral antihistamines at improving the TNSS (MD=-0.47; 95%CI=-0.81;-0.14; I2=0%) and RQLQ (MD=-0.31; 95%CI=-0.56;-0.06; I2=0%).

Conclusions

Randomized controlled trials suggest that intranasal treatments are more effective than oral treatments at improving symptoms and quality of life in seasonal allergic rhinitis.

Highlights

What is already known about this topic?

Intranasal and oral medications are part of the mainstay for the treatment of allergic rhinitis. Although intranasal medications are usually recommended, for most of these recommendations, certainty in the evidence was “low” or “very low”.

What does this article add to our knowledge?

We assessed intranasal corticosteroids or antihistamines versus oral antihistamines or leukotriene receptor antagonists. We found intranasal treatments to be superior to oral interventions at improving nasal and oral symptoms and quality-of-life.

How does this study impact current management guidelines?

This systematic review could help future guideline developers issue recommendations for allergic rhinitis, particularly as the evidence certainty for most comparisons was deemed “moderate” or “high”.

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