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Treatments for Seasonal Allergic Rhinitis
Comparative Effectiveness Reviews, No. 120
Investigators: Joan Glacy, MD, Kathleen Putnam, SM, Sarah Godfrey, MPH, Louise Falzon, PGDipInf, Barbara Mauger, PhD, David Samson, MS, and Naomi Aronson, PhD.
Author Information and AffiliationsStructured Abstract
Objectives:
This review compared the effectiveness and common adverse events of medication classes used to treat seasonal allergic rhinitis (SAR) in adolescents and adults, in pregnant women, and in children. We sought to compare the following classes of drugs: oral and nasal antihistamines and decongestants; intranasal corticosteroids, mast cell stabilizers (cromolyn), and anticholinergics (ipratropium); oral leukotriene receptor antagonists (montelukast); and nasal saline.
Data sources:
We identified English-language studies using a peer-reviewed search strategy. The following databases were searched on July 18, 2012, with no date restrictions: MEDLINE® (PubMed® and Ovid), Embase® (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and DARE (Database of Abstracts of Reviews of Effects).
Review methods:
We consulted a Technical Expert Panel to identify the treatment comparisons most relevant to patients and providers. Subpopulations of interest were individuals with asthma or eye symptoms. Outcomes of interest were patient-reported symptom scores, quality of life, and adverse events. Inclusion was limited to studies that reported an outcome of interest and directly compared drugs of interest that were approved by the U.S. Food and Drug Administration (FDA). Two independent reviewers performed study selection and data abstraction. Disagreements were resolved by consensus or a third reviewer.
Results:
We identified 59 trials that addressed 13 of 22 treatment comparisons of interest for adolescents and adults, 0 of 17 comparisons of interest for pregnant women, and 1 of 21 comparisons of interest for children. Across all comparisons, 20 of 39 drugs FDA approved for the treatment of SAR were studied. For adolescents and adults with SAR, evidence was sufficient to form the following conclusions. For the treatment of nasal symptoms, montelukast (oral leukotriene receptor antagonist) and intranasal corticosteroid were similarly effective (high strength of evidence [SOE]). For the treatment of nasal symptoms and eye symptoms, intranasal corticosteroid, nasal antihistamine, and combination intranasal corticosteroid plus nasal antihistamine were similarly effective (high SOE), and montelukast and oral selective antihistamine were similarly effective (moderate SOE). For improved quality of life, montelukast and oral selective antihistamine were similarly effective (moderate SOE), and combination oral selective antihistamine plus intranasal corticosteroid was superior to oral selective antihistamine alone (low SOE). To avoid insomnia, oral selective antihistamine was superior to oral decongestant and to combination oral selective antihistamine plus oral decongestant (moderate SOE). In patients codiagnosed with SAR and asthma, montelukast was superior to oral selective antihistamine for reduced asthma rescue medication use (moderate SOE). In sensitivity analyses using a lower threshold for minimum clinical effectiveness, combination oral selective antihistamine plus oral decongestant was superior to oral selective antihistamine alone for the treatment of nasal symptoms in adolescents and adults with SAR (moderate SOE). In this population, we did not find evidence that any single treatment was both more effective and had lower risk of harms. Evidence for both effectiveness and harms was insufficient regarding the comparison between oral selective and oral nonselective antihistamine in children. All effectiveness and harms outcomes were limited by short trial durations.
Conclusions:
Several effectiveness comparisons demonstrated similarity of treatments for selected outcomes. For most harms comparisons, the evidence was insufficient. Conclusions were limited by (1) lack of comparative evidence for all drugs within each class and (2) lack of evidence on the magnitude of symptom change that constitutes a minimal clinically important difference.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Results of Literature Searches
- Overview
- How This Section Is Organized
- Key Question 1 Comparative Effectiveness of SAR Treatments in Adults and Adolescents 12 Years of Age or Older
- Key Question 2 Comparative Adverse Effects of Treatments in Adults and Adolescents 12 Years of Age or Older
- Key Question 3 Comparative Effectiveness and Adverse Effects of Treatments in Pregnant Women
- Key Question 4 Comparative Effectiveness and Harms of SAR Treatments in Children Younger Than 12 Years of Age
- Discussion
- Key Findings and Strength of Evidence
- Key Question 1 Comparative Effectiveness of SAR Treatments in Adults and Adolescents 12 Years of Age or Older
- Key Question 2 Comparative Harms of SAR Treatments in Adults and Adolescents 12 Years of Age or Older
- Combined Evaluation of Key Questions 1 and 2 Comparative Effectiveness and Harms of Treatments in Adults and Adolescents 12 Years of Age or Older
- Key Question 3 Comparative Effectiveness and Harms of SAR Treatments in Pregnant Women
- Key Question 4 Comparative Effectiveness and Harms of SAR Treatments in Children Younger Than 12 Years of Age
- Findings in Relationship to What Is Already Known
- Applicability
- Implications for Clinical and Policy Decisionmaking
- Limitations of the Comparative Effectiveness Review Process
- Limitations of Evidence Base
- Research Gaps
- Conclusions
- References
- Abbreviations
- Appendix A Search Strategies
- Appendix B Excluded Studies
- Appendix C Evidence Tables
- Appendix D Data Abstraction Form Elements
- Appendix E United States Preventive Services Task Force (USPSTF) Criteria for Randomized Controlled Trials (RCTs)
- Appendix F McMaster Quality Assessment Scale of Harms (McHarm)
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10058-I. Prepared by: Blue Cross and Blue Shield Association Technology Evaluation Center, Evidence-based Practice Center, Chicago, IL
Suggested citation:
Glacy J, Putnam K, Godfrey S, Falzon L, Mauger B, Samson D, Aronson N. Treatments for Seasonal Allergic Rhinitis. Comparative Effectiveness Review No. 120. (Prepared by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center under Contract No. 290-2007-10058-I.) AHRQ Publication No. 13-EHC098-EF. Rockville, MD: Agency for Healthcare Research and Quality; July 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10058-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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