Three other studies indicated that intranasal steroids (triamcinolone, fluticasone) relieved eye symptoms more effectively than oral antihistamines (loratadine, fexofenadine) based on mean reductions in TNSS, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Total Ocular Symptom Score (TOSS).4-6 Of these scoring systems, only the RQLQ has been clinically validated.7
One additional study (including 2 RCTs) showed conflicting results.2 TABLE 2 summarizes the results of studies comparing intranasal steroids and oral antihistamines to relieve eye symptoms.
TABLE 2
How intranasal steroids compare with oral antihistamines for reducing eye symptoms
| Study design | Intervention | Outcome | Significance | Harms |
|---|---|---|---|---|
| Systematic review3 | INS vs OAH 11 RCTs reporting ocular symptoms, N=1317 | OR for deterioration or no change of varied scoring systems: –0.043 (CI, –0.157 to 0.072) | No significant difference between INS and OAH scores | Not reported |
| RCT, double blind, double dummy5 | INS (triamcinolone acetonide), N=153 OAH (loratadine), N=152 | Percent reduction from mean baseline TNS ocular score: INS: 59% OAH: 48% Total TNS ocular score: 3 | Changes in INS scores significantly greater than changes in OAH scores (P<.05) | INS: headache (22%), anxiety (<1%), epistaxis (<1%) OAH: headache (18%), increase in rhinitis symptoms (2%), conjunctivitis (<1%) |
| RCT, double blind, double dummy4 | INS (fluticasone propionate), N=150 OAH (loratadine), N=150 INS+OAH, N=150 Placebo, N=150 Duration 2 wk | Mean change in RQLQ ocular score from baseline: INS: –1.9 OAH: –1.3 Total RQLQ ocular score: 6 | Changes in INS scores significantly greater than changes in OAH scores (P<.05; 0.5 change in score is clinically significant) | INS and OAH: blood in mucus (1%-2%), xerostomia (1%-2%), epistaxis (<1%) |
| RCT, double blind, double dummy6 | INS (fluticasone propionate), N=158 OAH (loratadine), N=158 Placebo, N=155 Duration 4 wk | Mean change in TOSS score from baseline: INS: –88.7±5.3 OAH: 72.5±5.4 Total TOSS score: 100 | Changes in INS scores significantly greater than changes in OAH scores (P<.045) | INS: headache (17%) OAH: headache (18%) |
| Two RCTs, double blind, double dummy2 | Study 1: INS (fluticasone furoate), N=312 OAH (fexofenadine), N=311 Study 2: INS (fluticasone furoate), N=224 OAH (fexofenadine), N=227 Duration 2 wk | Least squares mean difference from baseline TOSS2 score: Study 1: TOSS2: –0.3 (95% CI, –0.6 to 0.0; P<.106) Study 2: TOSS2: –0.6 (95% CI, –0.9 to –0.2; P=.002) Total TOSS2 score: 9 | Changes in INS scores significantly greater than changes in OAH scores for Study 2 (P=.002) but not for Study 1 (P<.106) | INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%) |
| CI, confidence interval; INS, intranasal steroids; OAH, oral antihistamines; OR, odds ratio; RCT, randomized controlled trial; RQLQ, rhinoconjunctivitis quality of life questionnaire; TNS, total nasal score; TNSS, total nasal symptom score; TOSS, total ocular symptom score; TOSS2, (variation of) total ocular symptom score. | ||||
Antihistamines cost less than steroids and are available OTC
Oral antihistamines are less expensive than intranasal steroids and are available over the counter. The cost of antihistamines ranges from $5.70 to $21.99 for a month of treatment, whereas the cost of intranasal steroids for the same period varies from $60.99 to $149.99.8
In the studies reviewed here, the 2 interventions showed similar harms, including sore throat, epistaxis, and headache.2,4-6
Recommendations
The American Academy of Allergy, Asthma and Immunology’s 2010 guidelines conclude that intranasal steroids are first-line treatment for allergic rhinitis. If the patient prefers, use oral antihistamines.9
The Joint Task Force on Practice Parameters for Allergy and Immunology also recommends intranasal steroids as the most effective medication class for treating allergic rhinitis; no drug within the class is preferable to another. Daily administration is more effective than administration as needed, although the latter is an option. For treating ocular symptoms, intranasal corticosteroids and oral antihistamines work equally well.10