Two medicines not always better than one for seasonal allergic rhinitis : Guidelines

In a newly updated clinical practice guideline, published in Annals of Allergy, Asthma, and Immunology, allergists offer practical advice on the best types and amounts of medications to treat seasonal allergic rhinitis. Annals is the scientific publication of the American College of Allergy, Asthma, and Immunology (ACAAI).

"The Joint Task Force on Practice Parameters (JTFPP) formed a workgroup to develop a focused, systematic review to provide guidance to healthcare providers for the treatment of seasonal allergic rhinitis (SAR) in patients under the age of 12," says allergist Dana Wallace, MD, past ACAAI president and co-author of the guideline.

According to Dr. Wallace, the guidelines focus on three key clinical statements:

1. For initial treatment of Seasonal Allergic Rhinitis in adults, clinicians should routinely prescribe monotherapy with an intranasal corticosteroid (INCS) rather than INCS in combination with an oral antihistamine.


2. For initial treatment of Seasonal Allergic Rhinitis in adults, clinicians should recommend an INCS over a leukotriene receptor antagonist.


3. For treatment of moderate to severe Seasonal Allergic Rhinitis in adults, clinicians may recommend the combination of an INCS and an intranasal antihistamine for initial treatment.

"There is a strong message in the guidelines promoting the importance of shared decision-making with patients," said St. Louis University allergist Mark Dykewicz, MD, ACAAI member and lead author of the guidelines. "The guideline encourages physicians to make patients aware that taking two medications, e.g., using a combination of drugs, such as an oral antihistamine and INCS, is not always better than using a single drug such as an INCS. In contrast, the combination of an intranasal antihistamine and an intranasal corticosteroid does lead to greater relief than use of either medication by itself. Yet, using the two types of drugs in a combination nose spray product will likely be more expensive than using either a single nose spray such as an INCS or using two individual medication sprays to deliver the combination." Dr. Dykewicz stressed that using both medications, either combined or separately, may increase side effects such as the bad taste described by some patients, attributed to the nasal antihistamine component.

This is the first JTFPP guideline that was developed using a GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology, a very rigorous, systematic, evidence-based approach to making clinical recommendations. "We want physicians to know it is a very different type of guideline than our previous practice parameters," said Dr. Wallace. "We believe the first and third recommendations will confirm the experience of most allergists. Physicians will likely consider using the combination recommended in #3 more quickly if not initially for moderate-to-severe patients."