Comparing Superiority of Add-On Therapies in Allergic Rhinitis

allergies, rhinitis
allergies, rhinitis
In allergic rhinitis, combination therapy with oral H1-antihistamines plus intranasal corticosteroids demonstrated a similar effect to intranasal corticosteroid monotherapy.

In patients with allergic rhinitis, with the exception of the remission of rhinorrhea, combination therapy with oral H1-antihistamines (OAH) plus intranasal corticosteroids (INCS) demonstrated a similar effect to INCS monotherapy, according to study results published in the Annals of Allergy, Asthma & Immunology. In addition, combination therapy with intranasal H1-antihistamine (INAH) and INCS was superior to INCS alone or combination therapy with OAH and INCS.

Researchers conducted a literature review followed by meta-analyses of total nasal symptom scores (TNSS) and individual NSS. They included randomized controlled trials comparing combination OAH and INCS therapy or combination INAH and INCS with INCS monotherapy.

Recognizing that the pharmacotherapy for allergic rhinitis aims to control disease severity, investigators sought to identify the superior of the 2 therapeutic strategies. In the meta-analyses, TNSS and individual NSS were pooled according to studies that compared concomitant OAHs plus INCS with INCS monotherapy for the treatment of allergic rhinitis.

Pooled results were expressed as weighted mean differences (WMDs) between treatments. For each of the selected studies, the researchers calculated the relative clinical impact (RCI) based on TNSS: 100 x (Score Monotherapy – score Combined therapy)/Score Monotherapy. All of the included studies recorded TNSS and adverse events. The TNSS comprised 4 individual component nasal symptom scores: rhinorrhea, nasal congestion, sneezing, and nasal itching. The symptom scores were rated on a 4-point scale, with 0=absent, 1=mild, 2=moderate, and 3=severe.

Overall, 13 publications met selection criteria for the meta-analyses. These studies involved a total of 5066 patients. Pooled results demonstrated no significant WMD on total nasal symptom scores in the OAH plus INCS group compared with the INCS alone group. Regarding participants’ individual symptoms, the most common symptom to demonstrate remission was rhinorrhea, which was observed following the use of OAH in combination with INCS. Additionally, the combination therapy of INAH plus INCS was superior to treatment with INCS alone. An indirect comparison showed that the weighted mean RCI for INAH plus INCS was significantly higher than that for OAH plus INCS (P <.01).

Some study limitations included small sample sizes (eg, 3 of 5 randomized controlled trials contained a sample size <100), the funnel plot was skewed in the meta-analysis of the INAH and INCS, and using TNSS as the single outcome measure may have contributed to the decreased heterogeneity of the study.

“This is the first meta-analysis to confirm that INAH was superior to OAH as an add-on therapy to INCS with regard to improvement in TNSS and individual NSS,” the researchers wrote. “However, no significant difference in improvement of TNSS was found between the concomitant OAH plus INCS and the INCS alone.”


Du K, Qing H, Zheng M, Wang X, Zhang L. Intranasal antihistamine is superior to oral H1-antihistamine as an add-on therapy to intranasal corticosteroid for treating allergic rhinitis [published online July 7, 2020]. Ann Allergy Asthma Immunol. doi:10.1016/j.anai.2020.06.038