University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• 11y/o girl presents for management of seasonal allergic rhinitis. For children with intermittent seasonal allergic rhinitis, is the use of as-needed nasal corticosteroid more effective than the use of as-needed oral antihistamine?

Clinical Bottom Lines

1. The use of as-needed intranasal corticosteroids provides more effective symptom relief and more reduction of allergic inflammation compared to the use of as-needed oral antihistamines in patients with seasonal allergic rhinitis.
   
2. Only published studies are with data from adult patients. Difficult to know if conclusions can be applied to children.

Summary of Key Evidence

1. Randomized, open-label, parallel-group study comparing the use of as-needed intranasal Flonase vs. oral Claritin.¹
2. Study design:
   · 88 patients with seasonal allergic rhinitis and positive skin test to ragweed.
   · Exclusion criteria: perennial rhinitis; cardiovascular disease; nasal polyps; deviated nasal septum; use of corticosteroids, antihistamines, decongestants, or cromolyn within 2 weeks; immunotherapy within 2 years.
   · Patients randomized to use either Flonase nasal spray (100mcg each nostril) or Claritin (10mg po) on an as-needed basis.
   · No rescue medications allowed.
   · Patients were evaluated at start of study, 2 weeks, and 4 weeks. At each visit, they completed the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and underwent nasal lavage to measure total eosinophil count and eosinophil cationic protein (ECP). Patients also recorded symptoms (rhinorrhea, congestion, sneezing, itchy eyes on scale of 0 to 3) in a diary twice daily throughout the study.
3. Outcome measures: RQLQ score, daily symptom diary scores, number of eosinophils and level of ECP in nasal lavage samples.
4. Results: In comparison to those taking Claritin, patients taking Flonase had:
   · Better scores in the activity, sleep, practical, nasal, and overall categories of the RQLQ (P < 0.05).
   · Lower median total daily symptom scores (4.0 vs. 7.0, P < 0.01).
   · Fewer eosinophils and lower ECP levels in their nasal lavages (P = 0.001).¹
5. Validity:
   · Randomized clinical trial, groups similar at baseline, sufficient follow-up.
   · However, was not double-blinded and unclear if intention to treat analysis used.
6. Limitations:
   · No actual numbers provided for RQLQ scores.
   · Only number provided for daily symptom scores was the median total symptom score at day 28.
   · Possibility of individual bias because patients were not blinded.

Additional Comments

• Intranasal corticosteroids are the most effective medication class controlling symptoms of allergic rhinitis.²
• Topical nasal steroids are more effective than cromolyn and second generation antihistamines in treating allergic rhinitis.³
• It is well-established that regular use (or initiation of use several days prior to known exposure) is superior to as-needed use of intranasal steroids, however patients with mild or episodic allergic rhinitis may choose to medicate only on an as-needed basis.¹
• Patients who take medications for their allergies as needed (i.e. after the initial onset of symptoms) are essentially treating the late phase of the allergic response, for which corticosteroids are superior compared to antihistamines.⁴
• Onset of action for intranasal corticosteroids typically around 12 hours, so may still need to combine with oral antihistamine at least on day 1 of symptoms.
• More cost effective to use intranasal corticosteroids, as they are less expensive than antihistamines.¹
• Patients all > 18 y/o. However, Allergy is a combined pediatric and adult subspecialty, and data from adult studies is frequently extrapolated to the pediatric population. In addition, a previous study in adolescents with seasonal allergic rhinitis found that regular, daily use of Flonase was more efficacious than regular, daily use of Claritin.⁵
• Study partially funded by Glaxo Wellcome, manufacturer of Flonase.
  

Citation

1. Kaszuba SM, et al. Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis. Arch Int Med 2001; 161: 2581-7.
2. Dykewicz MS, Fineman S, Skoner DP. Joint Task Force Summary Statements on Diagnosis and Management of Rhinitis. Joint Council of Allergy, Asthma and Immunology. November 1998.
3. deShazo RD, Kemp SF. Management of Allergic Rhinitis. UpToDate, May 2002.
4. Naclerio RM. Allergic rhinitis. N Engl J Med 1991; 325(12): 860-9.
5. Jordana G, et al. Intranasal fluticasone proprionate versus loratadine in the treatment of adolescent patients with seasonal allergic rhinitis. Journal of Allergy and Clinical Immunology 1996; 97(2): 588-97.
   

CAT Author: Emily Chou, MD

CAT Appraisers: John G. Frohna, MD, MPH and Robert Schumacher, MD

Date appraised: August 12, 2002