Question | |
Should intranasal glucocorticosteroids vs. oral H1-antihistamines be used for allergic rhinitis? | |
Population: | Patients with seasonal allergic rhinitis |
Intervention: | intranasal glucocorticosteroids |
Comparison: | oral H1-antihistamines |
Main outcomes: | Nasal symptomsOcular symptomsQuality of lifeAdverse events (any)Serious adverse events |
Setting: | |
Perspective: | Clinical recommendation – patient perspective |
Background: | Intranasal corticosteroids have been described as more efficacious than oral antihistamines. However, oral antihistamines may be more acceptable to some patients, considering their fast onset of action, their adequacy for patients with corticosteroid-phobia, and their affordability. |
Conflict of interests: | AWMF conflict of interest declaration and management policies were applied, the assessment performed by the AWMF with guidance and help from Juan Jose Yepes Nuñez. Due to the CoI assessment results, the following panel members recused from voting (determining the direction and strength of the recommendation): Bousquet, Canonica, Jacomelli, Klimek, Papadopoulos, Pereira and Zuberbier T. The voting members were: Bedbrook, Bognanni, Dykewicz, Gilles, Lourenço, Palamarchuk, Parmelli, Savouré, Schunemann, Sousa-Pinto, Valiulis, Ventura, Vieira, Williams, Yepes Nuñez and Zuberbier J. |
Assessment
ProblemIs the problem a priority? | ||
Judgement | Research evidence | Additional considerations |
Allergic rhinitis (AR) is a common condition affecting 18.1% of the population, and its symptoms can significantly reduce the quality of life and pose a high economic burden (mainly because of indirect costs related to lost school days and workdays). [Savoure] Studies of patients consulting general practitioners for AR reported that 18–48 % had symptoms that were not controlled by pharmacotherapy. [Bousquet, Bhattacharyya, Vandenplas] Despite the bothersome nature of symptoms, AR is often trivialized by the patient – only 45% seek medical advice or treatment for their condition, which results in under-treatment and poor control of symptoms. [Linneberg] Problems related to diseaseEconomic burdenA systematic review performed to estimate the financial burden of AR in European countries [Linneberg] suggests that the GP services bore the majority of the direct costs for AR. However, the majority of the overall cost burden correspond to indirect costs caused by high absenteeism and presenteeism.In the United States, annual costs for medications for rhinitis patients can be estimated at approximately $1.3 billion. In total, direct costs are estimated to be >$4.6 billion for rhinitis management, including treatment, allergy testing, clinical visits and hospital procedures. [Roland]Similar findings were found for Asia. An analysis of the indirect costs associated with insufficiently treated AR and urticaria patients revealed an annual burden of USD 105.4 billion. This translates to a cost ranging from USD 1,137 to USD 2,195 per patient due to absenteeism and presenteeism [Kulthanan] Clinical burden The median prevalence of allergic rhinitis was found to be 18.1%, based on a dataset that included 310 reported prevalences. The prevalence of AR ranged from as low as 1.0% to as high as 54.5%.
These statistics indicate that AR is a relatively common condition affecting a significant portion of the population, with variations in prevalence observed across different regions or studies. [Savouré]Problems related to intervention Based on a conducted rapid review, several barriers and concerns related to the feasibility of intranasal corticosteroids and oral antihistamines for patients with AR have been identified. These barriers are related to safety, knowledge, required resources, acceptability and feasibility. References:
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Desirable EffectsHow substantial are the desirable anticipated effects? | ||
Judgement | Research evidence | Additional considerations |
Nasal symptoms In a systematic review with meta-analysis performed by Torres et al.[1], the improvement of nasal symptoms was assessed in patients under intranasal corticosteroids (INCS) and compared with that registered in patients receiving oral H1-antihistamines (OAH). For patients with seasonal allergic rhinitis, it was possible to meta-analytically pool the total nasal symptom score (TNSS; combination of four nasal symptoms and scale of 0-12) results of 15 randomised controlled trials (RCTs). INCS were associated with a significantly higher improvement in the TNSS when compared to OAH (mean difference=-0.86; 95%CI=-1.20;-0.51). INCS displayed a 68% probability of resulting in a clinically meaningful improvement when compared to OAH, including a 51% probability of resulting in a small improvement and a 17% probability of resulting in a moderate improvement. Considering direct and indirect evidence of a network meta-analysis (NMA) performed based on the studies included in three systematic reviews from our team [1-3], we observed consistent results: INCS resulted in a significantly higher improvement in the TNSS when compared to OAH (mean difference=-0.76; 95%CI=-0.96;-0.57). The certainty of evidence was the same when considering evidence from the NMA. For patients with perennial allergic rhinitis, there were no primary studies directly comparing INCS and OAH. Performing an NMA using classical methods would not be adequate, as it would imply lumping nasal and oral placebo into a single group. The evidence we have suggests that this is not adequate, with nasal placebo being associated with significant differences in outcomes compared to oral placebo. Therefore, performing an NMA using classical methods would lead to an underestimation of the differences between INCS and OAH. As an alternative, we performed an NMA in which we combined studies evaluating patients with seasonal and perennial allergic rhinitis. We then applied a meta-regression model with the type of allergic rhinitis (seasonal vs. perennial) as a covariate. We predicted that, in patients with perennial allergic rhinitis, INCS were associated with a significantly higher improvement in the TNSS when compared to OAH (mean difference=-0.64; 95%CI=-1.15;-0.13). Subgroup considerations: Children and adolescents Following a comprehensive review performed by our team:
Ocular symptoms In a systematic review with meta-analysis performed by Torres et al. [1], the improvement of ocular symptoms was assessed in patients under INCS and compared with that registered in patients receiving OAH. For patients with seasonal allergic rhinitis, it was possible to meta-analytically pool the total ocular symptom score (TOSS; combination of three nasal symptoms and scale of 0-9) results of five RCTs. INCS were associated with a significantly higher improvement in the TOSS when compared to OAH (mean difference=-0.36; 95%CI=-0.56;-0.17). INCS displayed a 21% probability of resulting in a clinically meaningful improvement when compared to oral H1-antihistamines (and a 79% probability of resulting in a trivial effect). Considering direct and indirect evidence of an NMA performed based on the studies included in three systematic reviews from our team [1-3], we observed that INCS and OAH displayed a similar effect in improving the TOSS (mean difference=-0.29; 95%CI=-0.45;-0.12). The certainty of evidence was the same when considering evidence from the NMA. For patients with perennial allergic rhinitis, no RCTs were found either directly comparing INCS vs OAH or evaluating OAH vs placebo (precluding indirect comparisons). Subgroup considerations: Children and adolescents In a comprehensive review performed by our team, no studies were found assessing total ocular symptoms in pediatric patients. Overall symptoms In a systematic review with meta-analysis performed by Torres et al. [1], the improvement of overall rhinitis symptoms was assessed in patients under INCS and compared with that registered in patients receiving OAH. The patient-reported outcome measure used to assess this outcome was the total symptom score (TSS), which includes nasal, ocular and other rhinitis symptoms. The TSS computation method differed among studies, with most considering at least one ocular symptom in addition to nasal symptoms and only one study considering ear or palate itching as part of the score. Four RCTs comparing INCS and OAH reported TSS values for seasonal allergic rhinitis. Two studies, comparing budesonide vs desloratadine and fluticasone propionate vs cetirizine, did not find statistically significant differences in TSS change from baseline. The other two RCTs, though, did report a statistically significant difference in effectiveness favouring INCS over OAH. Both drug classes, however, proved effective in significantly decreasing baseline scores in all four studies. Quality-of-life In a systematic review with meta-analysis performed by Torres et al. [1], the improvement of quality-of-life was assessed in patients under INCS and compared with that registered in patients receiving OAH. For patients with seasonal allergic rhinitis, it was possible to meta-analytically pool the rhinocojunctivitis quality of life questionnaire (RQLQ; scale of 0-6) results of two RCTs. INCS were associated with a significantly higher improvement in the RQLQ when compared to OAH (mean difference=-0.88; 95%CI=-1.15;-0.61). INCS displayed a 100% probability of resulting in a clinically meaningful improvement when compared to OAH. Considering direct and indirect evidence of an NMA performed based on the studies included in three systematic reviews from our team [1-3], we observed consistent results: INCS resulted in a significantly higher improvement in the RQLQ when compared to OAH (mean difference=-0.61; 95%CI=-0.79;-0.44). The certainty of evidence was the same when considering evidence from the NMA. For patients with perennial allergic rhinitis, there were no primary studies directly comparing INCS and OAH. Performing an NMA using classical methods would not be adequate, as it would imply lumping nasal and oral placebo into a single group. The evidence we have suggests that this is not adequate, with nasal placebo being associated with significant differences in outcomes compared to oral placebo. Therefore, performing an NMA using classical methods would lead to an underestimation of the differences between INCS and OAH. As an alternative, we performed an NMA in which we combined studies evaluating patients with seasonal and perennial allergic rhinitis. We then applied a meta-regression model with the type of allergic rhinitis (seasonal vs. perennial) as a covariate. We predicted that, in patients with perennial allergic rhinitis, INCS were associated with a significantly higher improvement in the RQLQ when compared to OAH (mean difference=-0.33; 95%CI=-0.63;-0.03). Subgroup considerations: Children and adolescents Following a comprhensive review of the literature performed by our team:
References: 1. Torres MI, Gil-Mata S, Bognanni A, et al. Intranasal Versus Oral Treatments for Allergic Rhinitis: A Systematic Review With Meta-Analysis. J Allergy Clin Immunol Pract. 2024 Dec;12(12):3404-3418. 2. Sousa-Pinto B, Vieira RJ, Bognanni A, et al. Efficacy and safety of intranasal medications for allergic rhinitis: Network meta-analysis. Allergy. 2025 Jan;80(1):94-105. 3. Vieira RJ, Gil-Mata S, Ferreira A, Riera-Serra P, Bognanni A, Duarte VH, et al. Efficacy and safety of oral antihistamines for allergic rhinitis: Network meta-analysis. 2025 [link with the full results] 4. Fokkens WJ, Scadding GK. Perennial rhinitis in the under 4s: a difficult problem to treat safely and effectively? A comparison of intranasal fluticasone propionate and ketotifen in the treatment of 2-4-year-old children with perennial rhinitis. Pediatr Allergy Immunol. 2004 Jun;15(3):261-6. 5. Bender BG, Milgrom H. Comparison of the effects of fluticasone propionate aqueous nasal spray and loratadine on daytime alertness and performance in children with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2004 Mar;92(3):344-9. The results for the comparisons between intranasal corticosteroids and oral antihistamines and the corresponding evaluations of the certainty of evidence can be found here. | ||
Undesirable EffectsHow substantial are the undesirable anticipated effects? | ||
Judgement | Research evidence | Additional considerations |
Adverse events Following a systematic review with meta-analysis performed by Torres et al. [1], the frequency of patients developing at least one adverse event was assessed in patients under intranasal corticosteroids (INCS) and compared with that registered in patients receiving oral H1-antihistamines (OAH). A total of 18 randomised controlled trials (RCTs) reported data on the number of patients with seasonal allergic rhinitis reporting at least one adverse event. The meta-analytical risk ratio comparing INCS to OAH was of 1.02 (95%CI=0.94;1.10) [six more cases per 1000 persons; 95%CI = 17 fewer cases to 29 more cases per 1000 persons. Trivial difference]. When considering direct and indirect evidence from a network meta-analysis (NMA) performed based on the studies included in three systematic reviews from our team [1-3], consistent results were observed, with the meta-analytical risk ratio for the comparison between INCS and OAH being of 0.97 (95%CI=0.87;1.08) [7 fewer events per 1000 individuals; from 30 fewer events to 18 more events per 1000 individuals]. Considering a threshold of at least 65 events per 1000 individuals to consider an effect to be small, this corresponds to a trivial effect. For patients with perennial allergic rhinitis, there were no primary studies directly comparing INCS and OAH. Performing an NMA using classical methods would not be adequate, as it would imply lumping nasal and oral placebo into a single group. The evidence we have suggests that this is not adequate, with nasal placebo being associated with significant differences in outcomes compared to oral placebo. Therefore, performing an NMA using classical methods would lead to an underestimation of the differences between INCS and OAH. As an alternative, we performed an NMA in which we combined studies evaluating patients with seasonal and perennial allergic rhinitis. We then applied a meta-regression model with the type of allergic rhinitis (seasonal vs. perennial) as a covariate. We predicted that, in patients with perennial allergic rhinitis, INCS were associated with more adverse events than OAH (RR=1.13; 95%CI=0.73;1.75 | 39 more cases; from 81 fewer to 224 more cases per 1000 individuals). This corresponds to small decrease to moderate increase. Most adverse events which were considered to be related to the treatment were mild and self-limited and comprised headache, epistaxis, nasal discomfort or upper respiratory tract infection. Subgroup considerations: Children and adolescents Following a comprehensive review performed by our team:
Serious adverse events Following a systematic review with meta-analysis performed by Torres et al. [1], the frequency of patients developing at least one serious adverse event was assessed in patients under INCS and compared with that registered in patients receiving oral H1-antihistamines. A total of 26 RCTs reported data on the number of patients with seasonal allergic rhinitis reporting at least one serious adverse event. Most studies (20) reported no serious adverse events with either nasal or oral treatments. The frequency of serious adverse events was as following:
In all cases, serious adverse events were deemed unlikely to be related to the interventions. For patients with perennial allergic rhinitis, no data was available. Subgroup considerations: Children and adolescents In a comprehensive review performed by our team, no studies were found reporting serious adverse symptoms in pediatric patients. Pharmacovigilance data When considering pharmacovigilance data, OAH were identified as associated with a disproportionally higher frequency of somnolence (reporting odds ratio [ROR=45.5; 95%CI=37.7; 55.0]) while INCS were identiifed as associated with a disproportionally high frequency of nasal discomfort, anosmia, epistaxis and ageusia. In terms of important adverse events, cataract and glaucoma were disproportionally more frequently reported with INCS than with OAH, even though they were rarely reported. Important adverse events related to exposure to corticosteroids (e.g., Cushing syndrome or candidiasis) were very rarely reported with INCS. On the other hand, QT prolongation was disproportionally more frequently reported with OAH than with INCS, although they were rarely reported and this is specific to some OAH (e.g., astemizole and terfenadine) over others.  References: 1. Torres MI, Gil-Mata S, Bognanni A, et al. Intranasal Versus Oral Treatments for Allergic Rhinitis: A Systematic Review With Meta-Analysis. J Allergy Clin Immunol Pract. 2024 Dec;12(12):3404-3418. 2. Sousa-Pinto B, Vieira RJ, Bognanni A, et al. Efficacy and safety of intranasal medications for allergic rhinitis: Network meta-analysis. Allergy. 2025 Jan;80(1):94-105. 3. Vieira RJ, Gil-Mata S, Ferreira A, Riera-Serra P, Bognanni A, Duarte VH, et al. Efficacy and safety of oral antihistamines for allergic rhinitis: Network meta-analysis. 2025 [link with the full results] 4. Bender BG, Milgrom H. Comparison of the effects of fluticasone propionate aqueous nasal spray and loratadine on daytime alertness and performance in children with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2004 Mar;92(3):344-9. The results for the comparisons between intranasal corticosteroids and oral antihistamines and the corresponding evaluations of the certainty of evidence can be found here. | ||
Certainty of evidenceWhat is the overall certainty of the evidence of effects? | ||
Judgement | Research evidence | Additional considerations |
The certainty of evidence was high for 1 out of 4 analyses, moderate for 2 out of 4 analyses, and very low for 1 out of 4 analyses.
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ValuesIs there important uncertainty about or variability in how much people value the main outcomes? | ||
Judgement | Research evidence | Additional considerations |
Utility values Symptoms Regarding specific symptoms, in two studies, utilities (measured by VAS) were lower for severe nasal congestion and severe rhinorrhea compared to severe sneezing, severe throat itching, and severe itchy eyes (certainty of evidence: low). When utilities were elicited with the standard gamble technique, severe itchy eyes were rated by US patients as the least preferred AR symptom (certainty of evidence: low).  Studies of rating or ranking of outcomes Adults
 Children/caregivers sample Seven studies assessing children or their caregivers were included in the relative importance analysis. Most of these studies only assessed symptom-related attributes. Similarly to the adult population, a nasal symptom was frequently ranked as the most or second most important attribute (certainty of evidence: low). In particular, nasal congestion was identified as the most important attribute in five studies (certainty of evidence: low).  | ||
Balance of effectsDoes the balance between desirable and undesirable effects favor the intervention or the comparison? | ||
Judgement | Research evidence | Additional considerations |
Taking into account both benefits and harms of intranasal corticosteroids (INCS) versus oral H1-antihistamines (OAH), we can consider the following:
Overall, the benefits of INCS over oral H1-antihistamines seem to outweigh the harms. | ||
Resources requiredHow large are the resource requirements (costs)?” | ||
Judgement | Research evidence | Additional considerations |
Cost of drugs We conducted a survey, having received responses from specialists from 51 countries (mostly in Europe, America and Asia). OAH and INCS were available in all 51 countries. The costs of being treated for one year with INCS ranges from 3.4 US Dollars Power Purchase Parity (PPP) [Israel] to 692.0 USD PPP [Argentina] (assuming full adherence to treatment and the choice of the least expensive INCS). This corresponds to weekly costs ranging from 0.1 USD PPP to 13.3 USD PPP. The yearly costs per country associated with the use of INCS are displayed in the following map:  The costs of being treated for one year with OAH ranged from 4.7 US Dollars Power Purchase Parity (PPP) [Hong Kong] to 743.3 USD PPP [Argentina] (assuming full adherence to treatment and the choice of the least expensive OAH). This corresponds to weekly costs ranging from 0.1 USD PPP to 14.3 USD PPP. The yearly costs per country associated with the use of OAH are displayed in the following map:  In 16 out of the 51 countries, INCS were associated with lower costs than OAH:  | ||
Certainty of evidence of required resourcesWhat is the certainty of the evidence of resource requirements (costs)? | ||
Judgement | Research evidence | Additional considerations |
Evidence on the costs of interventions was obtained based on a survey to experts. | ||
Cost effectivenessDoes the cost-effectiveness of the intervention favor the intervention or the comparison? | ||
Judgement | Research evidence | Additional considerations |
Considering the costs reported in the survey alongside the differences in utilities computed using MASK-air data, INCS would be cost-effective in all countries except Mexico and Colombia at a willingness to pay threshold of $50,000/QALY gained. Considering the conservative willingness to pay threshold of 1 time the GDP per capita, INCS would only not be cost-effective in five countries (Chile, Mexico, Mozambique, Syria and Vietnam). | ||
EquityWhat would be the impact on health equity? | ||
Judgement | Research evidence | Additional considerations |
We conducted a survey, having received responses from specialists from 51 countries (mostly in Europe, America and Asia). At least one intranasal corticosteroid (INCS) and one oral antihistamine (OAH) was reported to be available in all 51 countries. Other equity-related aspects  | ||
AcceptabilityIs the intervention acceptable to key interest-holders? | ||
Judgement | Research evidence | Additional considerations |
Compliance We identified one cross-sectional survey [1] that describes compliance among Thai children with allergic rhinitis. Among 250 included patients, compliance to oral antihistamine (72.8%) was better than intranasal glucocorticosteroids (64.8%). Evidence from direct patient data: In complete weeks of MASK-air reporting during the pollen season, there were 36.0% in which INCS were used for 6 or 7 days. This compares with 38.5% for OAH. Satisfaction Evidence from direct patient data: In the MASK-air dataset, there were 6174 days in which INCS were used in monotherapy and for which patients provided information on how satisfied they were with their treatments. The median results of the visual analogue scale were of 86 (higher values indicating higher satisfaction) [IQR=26]. In the MASK-air dataset, there were 7679 days in which OAH were used in monotherapy and for which patients provided information on how satisfied they were with their treatments. The median results of the visual analogue scale were of 84 (higher values indicating higher satisfaction) [IQR=30]. In adjusted multivariable models, INCS was associated with significantly higher VAS satisfaction levels than OAH (mean difference=1.70; 95%CI=0.68;2.72) [2] Co-medication rate Evidence from direct patient data: In the MASK-air dataset, in 56.2% of the days in which INCS have been used, they have been used in comedication. This compares with 50.1% for oral AH. Compared to other rhinitis medication classes, INCS was associated with lower odds of being used in co-medication (OR=0.90; 95%CI=0.86-0.93) in a study using multivariable mixed-effects logistic regression models [3]. The same study found that OAH (OR=0.78; 95%CI=0.75-0.81) were also associated with lower odds of being used in co-medication. Days of monotherapy are associated with better symptoms than those in co-medication. In 6.2% of days with INCS use, more than one INCS was used (that is, patients tried at least two INCS on the same day). This compares to 4.1% of days with OAH use. Comparing the adjusted frequency of use in co-medication, INCS appear to be associated with higher odds of use in co-medication (OR=1.26; 95%CI=[0.99;1.59]) [2]. Onset of action In a rapid review of the literature, the median (min-max) onset of action of OAH was found to be 60 min (1 hrs) [15-150 min (0.25-2.5 hrs)] for improvement in nasal symptoms; and 120 min (2 hrs) [75-120 min (1.25-2 hrs)] for improvement in ocular symptoms. For INCS, we observed a median onset of action of 720 minutes [120-3600 minutes]. References 1. Achararit, Nitchanan & Sungkhanit, Chareenee & Nanthapisal, Sira & Kulalert, Prapasri & Poachanukoon, Orapan. (2019). Allergic rhinitis treatment preference, compliance and adherence in Thai children. Journal of Allergy and Clinical Immunology. 143. AB280. 10.1016/j.jaci.2018.12.854. 2. Sousa-Pinto B, Vieira RJ, Bognanni A, et al. Comparison of allergic rhinitis treatments on patient satisfaction: A MASK-air® and EAACI Methodological Committee Report. Allergy. 2025 (accepted for publication) 3. Sousa-Pinto B, Sá-Sousa A, Vieira RJ, et al. Behavioural patterns in allergic rhinitis medication in Europe: A study using MASK-air® real-world data. Allergy. 2022 Sep;77(9):2699-2711. | From a comparative perspective, INCS and OAH appear to be similar in terms of acceptability. OAH have a faster onset of action but INCS seems to be associated with higher treatment satisfaction. Considering that, we opted to judge this criterion as “varies”, with the most acceptable drug class preferentially representing patients’ preferences. | |
FeasibilityIs the intervention feasible to implement? | ||
Judgement | Research evidence | Additional considerations |
We have included 5 studies that provide data on the feasibility of intranasal steroids (INCS) vs. oral antihistamines (OAH). Most of these studies were surveys. All included studies were published between 2007 and 2023. Barriers Safety-related Europe/North America In an exploratory study assessing patients’ perceived knowledge, expectations, preferences, and concerns regarding INCS and OAH, 48% and 33% of respondents voiced apprehension about potential side effects associated with the treatment of INCS and OAH, respectively [Hellings] Middle East 75.2% of primary healthcare physicians considered INCS as safe medication for AR, in comparison to 59.9% in the case of first-generation oral antihistamines and 82.5% in the case of second-generation oral antihistamines [Almousa] Ease of use Patients generally found INCS easy to use in the provided studies. Ease of use does not appear to be a significant problem in the feasibility of INCS use for AR patients. Considering the results from three studies, most included patients did not find INCS to be challenging in terms of use. – In a randomized trial, almost 90% of patients using beclometasone declared that the beclomethasone nasal aerosol device with an integrated dose counter was “very easy” or “somewhat easy” to use [Gross]. – In a US-based survey (1600 AR patients), 78% of respondents felt confident that they correctly used INCS. The same percentage of patients declared that they reviewed the package insert, and 80% of them stated that it was easy to learn how to apply the drug [Fromer 2014] – In a third study assessing 1544 respondents (including 506 children), 98% found it easy to use mometasone furoate, 96% found the mist from the applicator easy to administer, and 96% reported that the applicator was easy to pump and press [Fromer 2008]. References 1. Almousa H, Alsaad SM, Ismail D, Mahjoub S, Bin Obaid S, Alsaleh S. Allergic rhinitis guidelines knowledge, attitudes, and practices among primary health care physicians: A national multicentre cross-sectional study. Journal of family medicine and primary care. 2023;12(6):1202-1208. 2. Fromer LM, Blaiss MS, Jacob-Nara JA, Long RM, Mannion KM, Lauersen LA. Current Allergic Rhinitis Experiences Survey (CARES): Consumers’ awareness, attitudes and practices. Allergy and asthma proceedings. 2014;35(4):307-315. 3. Fromer LM, Ortiz GR, Dowdee AM. Assessment of Patient Attitudes About Mometasone Furoate Nasal Spray: The Ease-of-Use Patient Survey. World Allergy Organ J. 2008;1(9):156-159. 4. Gross GN, Settipane RA, Ford LB, Kelley L, Tantry SK. Patient satisfaction with beclomethasone dipropionate nasal aerosol device with integrated dose counter during daily use. Allergy and asthma proceedings. 2013;34(6):527-533. 5. Hellings PW, Dobbels F, Denhaerynck K, Piessens M, Ceuppens JL, De Geest S. Explorative study on patient’s perceived knowledge level, expectations, preferences and fear of side effects for treatment for allergic rhinitis. Clin Transl Allergy. 2012;2(1):9 | ||
Planetary healthWhat would be the impact on planetary health? | ||
Judgement | Research evidence | Additional considerations |
To assess planetary health, it is usual to perform lifecycle assessment studies, that is, studies assessing the environmental impact of interventions from cradle-to-grave. In a rapid review of the literature, we were unable to find LCA studies assessing intranasal corticosteroids or oral antihistamines. Additionally, we did not identify any LCA studies comparing devices for intranasal administration of medications against the packaging used in oral medications. The following table presents a qualitative summary of topics which may be considered for the assessment of the planetary impact of intranasal corticosteroids and oral antihistamines across the medication lifecycle.  Quantitative comparison: blisters versus vials Since we found no LCA studies specifically comparing intranasal corticosteroids versus oral antihistamines, we attempted to find LCA studies assessing medications administered as blisters and medications administered via vials. Separate LCA studies were found for aluminum and PVC blisters (for oral medications) and for 1 mL drug vials (polymer and glass). The studies applied different methodologies and therefore their results may not be directly comparable. A summary of the studies may be found below:  An exercise to project estimates of global warming and ozone depletion potential for 30 days of medications was made (considering the patients would use one tablet of oral medication per day, or 2 sprays/nostril qd, considering a 15 mL container with 120 puffs of medication):  In addition, a study by Llano Martinez (2012) favours PVC blisters in regards to global warming potential (although no comparison with intranasal devices was made):  References:
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Summary of judgements
Judgement | |||||||
|---|---|---|---|---|---|---|---|
Problem | No | Probably no | Probably yes | Yes | Varies | Don’t know | |
Desirable Effects | Trivial | Small | Moderate | Large | Varies | Don’t know | |
Undesirable Effects | Trivial | Small | Moderate | Large | Varies | Don’t know | |
Certainty of evidence | Very low | Low | Moderate | High | No included studies | ||
Values | Important uncertainty or variability | Possibly important uncertainty or variability | Probably no important uncertainty or variability | No important uncertainty or variability | |||
Balance of effects | Favors the comparison | Probably favors the comparison | Does not favor either the intervention or the comparison | Probably favors the intervention | Favors the intervention | Varies | Don’t know |
Resources required | Large costs | Moderate costs | Negligible costs and savings | Moderate savings | Large savings | Varies | Don’t know |
Certainty of evidence of required resources | Very low | Low | Moderate | High | No included studies | ||
Cost effectiveness | Favors the comparison | Probably favors the comparison | Does not favor either the intervention or the comparison | Probably favors the intervention | Favors the intervention | Varies | No included studies |
Equity | Reduced | Probably reduced | Probably no impact | Probably increased | Increased | Varies | Don’t know |
Acceptability | No | Probably no | Probably yes | Yes | Varies | Don’t know | |
Feasibility | No | Probably no | Probably yes | Yes | Varies | Don’t know | |
Planetary health | Reduced | Probably reduced | Probably no impact | Probably increased | Increased | Varies | Don’t know |
Type of recommendation
Conclusions
Recommendation |
In adults with allergic rhinitis, the ARIA guideline panel recommends using intranasal corticosteroids over oral H1-antihistamines (strong recommendation based on moderate certainty of evidence). |
Justification |
This recommendation is grounded on the fact that intranasal corticosteroids are more effective than oral antihistamines and display a similar safety profile. In addition, intranasal corticosteroids are cost-effective and do not pose equity concerns. |
Subgroup considerations |
For preschool and school children, the ARIA guideline panel recommends using intranasal corticosteroids over oral H1-antihistamines. However, evidence is more limited in these subgroups. The same applies for pregnant women and for the elderly. However, for pregnant women, there are concerns that triamcinolone may have teratogenic effects (it was associated with a higher rate of congenital respiratory defects in a large Canadian prospective cohort study (Bedard A et al. 2016). Oral antihistamines may be preferrable in patients with mild forms of disease or who particularly value having a fast symptom relief or who have corticosteroid-phobia. |
Implementation considerations |
It should be highlighted that this recommendation considers average class-level evidence. Within each treatment class, there may be some differences across individual medications that should be considered and that have been addressed in different recommendations. |
Monitoring and evaluation |
Research priorities |
Research priorities by domain of the certainty of evidence assessment:
EtD criteria for which research is most needed: In addition to primary studies focused on the desirable and undesirable effects of intranasal corticosteroids versus oral antihistamines (considering the gaps described above and the very low certainty of evidence associated with quality of life), new studies are needed on comparing the planetary health impact of these two classes of medications. In particular, quantitative evidence specific for these interventions is required. |