Research ArticleTools for Practice

Antihistamines for allergic rhinosinusitis

Betsy Thomas, Anthony Train and G. Michael Allan
Canadian Family Physician September 2022, 68 (9) 670; DOI: https://doi.org/10.46747/cfp.6809670

Clinical question

Do oral antihistamines (AHs) improve symptoms in adults with allergic rhinosinusitis?

Bottom line

Oral AHs reduce rhinosinusitis symptoms by 10% to 30% versus placebo over 2 to 12 weeks. Individual AHs appear to have comparable efficacy. More patients attain moderate improvement or better with intranasal corticosteroids (ICs) (about 80%) versus AHs (about 60%). There appear to be no meaningful differences between AHs and leukotriene receptor antagonists or when adding AHs to IC use.

Evidence

Results were statistically significant unless noted.

  • Antihistamines versus placebo over 2 to 12 weeks:

    • - Systematic review (7 RCTs, 1218 patients)1 found that for patient-rated nasal obstruction scores (scale 0 to 3), baseline=1.65; placebo improved symptoms 16% and AHs 48%.

    • - Systematic review (5 RCTs, 3329 patients)2 of bilastine (newer AH) found total symptom score effect size=0.28, similar to improving symptoms 10% to 16% over placebo.3

  • Antihistamines versus other AHs:

    • - Systematic reviews showed no statistical or clinical differences in total or nasal symptom scores.2,4

  • Antihistamines versus other agents:

    • - Two systematic reviews (5 to 16 RCTs, 990 to 2267 patients) compared ICs with AHs over 2 to 8 weeks.5,6 Total nasal symptom scores improved more with ICs (51% vs 31%). Proportion attaining moderate control or better7 was higher with intranasal steroids (78%) versus AHs (58%); number needed to treat=5.

    • - Systematic review (13 RCTs, 5066 patients)8 of AHs plus ICs versus ICs alone over 2 to 6 weeks found antihistamines did not add clinically meaningful benefit.

    • - Two systematic reviews (9 to 14 mixed-design studies, 4458 to 5781 patients) of AHs versus leukotriene receptor antagonist over 1 to 12 weeks found no clinically meaningful differences.9,10

Context

  • Adverse event data are reported infrequently and difficult to interpret.11 Some AHs may have less of a sedative effect: eg, bilastine (3%) versus cetirizine (7%).2

  • Estimated cost for 30-day supply: cetirizine 10 mg, desloratadine 5 mg, or fexofenadine 120 mg, $25; bilastine 20 mg, $45; mometasone 50 μg or beclomethasone 50 μg, $25; fluticasone 50 μg, $40.12

Implementation

Antihistamines have comparable efficacy, so choice should be based on cost and adverse event profile. Patients presenting in primary care typically have moderate to severe rhinosinusitis symptoms and more patients are likely to benefit from nasal steroids versus AHs.13 Improvement with nasal steroids may take several days and full effect can take up to 2 weeks.13

Notes

Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice{at}cfpc.ca.

Footnotes

  • Competing interests

    None declared

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.

  • La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de septembre 2022 à la page e268.

References

  1. 1.↵
    1. Hore I,
    2. Georgalas C,
    3. Scadding G.
    Oral antihistamines for the symptom of nasal obstruction in persistent allergic rhinitis—a systematic review of randomized controlled trials. Clin Exp Allergy 2005;35(2):207–12. Erratum in: Clin Exp Allergy 2005;35(4):547.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Singh Randhawa A,
    2. Mohd Noor N,
    3. Md Daud MK,
    4. Abdullah B.
    Efficacy and safety of bilastine in the treatment of allergic rhinitis: a systematic review and meta-analysis. Front Pharmacol 2022;12:731201.
    OpenUrl
  3. 3.↵
    1. Bachert C,
    2. Kuna P,
    3. Sanquer F,
    4. Ivan P,
    5. Dimitrov V,
    6. Gorina MM, et al.
    Comparison of the efficacy and safety of bilastine 20 mg vs desloratadine 5 mg in seasonal allergic rhinitis patients. Allergy 2009;64(1):158–65.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Xiao J,
    2. Wu WX,
    3. Ye YY,
    4. Lin WJ,
    5. Wang L.
    A network meta-analysis of randomized controlled trials focusing on different allergic rhinitis medications. Am J Ther 2016;23(6):e1568–78.
    OpenUrl
  5. 5.↵
    1. Juel-Berg N,
    2. Darling P,
    3. Bolvig J,
    4. Foss-Skiftesvik MH,
    5. Halken S,
    6. Winther L, et al.
    Intranasal corticosteroids compared with oral antihistamines in allergic rhinitis: a systematic review and meta-analysis. Am J Rhinol Allergy 2017;31(1):19–28.
    OpenUrl
  6. 6.↵
    1. Weiner JM,
    2. Abramson MJ,
    3. Puy RM.
    Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998;317(7173):1624–9.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    1. Schoenwetter W,
    2. Lim J.
    Comparison of intranasal triamcinolone acetonide with oral loratadine for the treatment of patients with seasonal allergic rhinitis. Clin Ther 1995;17(3):479–92.
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Du K,
    2. Qing H,
    3. Zheng M,
    4. Wang X,
    5. Zhang L.
    Intranasal antihistamine is superior to oral H1antihistamine as an add-on therapy to intranasal corticosteroid for treating allergic rhinitis. Ann Allergy Asthma Immunol 2020;125(5):589–96.e3. Epub 2020 Jul 7.
    OpenUrl
  9. 9.↵
    1. Xu Y,
    2. Zhang J,
    3. Wang J.
    The efficacy and safety of selective H1-antihistamine versus leukotriene receptor antagonist for seasonal allergic rhinitis: a meta-analysis. PLoS One 2014;9(11):e112815.
    OpenUrl
  10. 10.↵
    1. Feng Y,
    2. Meng YP,
    3. Dong YY,
    4. Qui CY,
    5. Cheng L.
    Management of allergic rhinitis with leukotriene receptor antagonists versus selective H1-antihistamines: a meta-analysis of current evidence. Allergy Asthma Clin Immunol 2021;17(1):62.
    OpenUrl
  11. 11.↵
    1. Bender BG,
    2. Berning S,
    3. Dudden R,
    4. Milgrom H,
    5. Tran ZV.
    Sedation and performance impairment of diphenhydramine and second-generation antihistamines: a meta-analysis. J Allergy Clin Immunol 2003;111(4):770–6.
    OpenUrlCrossRefPubMed
  12. 12.↵
    Allergy & sinus. Toronto, ON: Shoppers Drug Mart Corporation; 2022. Available from: https://shop.shoppersdrugmart.ca/. Accessed 2022 Jul 28.
  13. 13.↵
    1. Small P,
    2. Keith PK,
    3. Kim H.
    Allergic rhinitis. Allergy Asthma Clin Immunol 2018;14(Suppl 2):51.
    OpenUrl
Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools
Respond to this article
Antihistamines for allergic rhinosinusitis
Betsy Thomas, Anthony Train, G. Michael Allan
Canadian Family Physician Sep 2022, 68 (9) 670; DOI: 10.46747/cfp.6809670
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo

Jump to section