I CLINICAL INQUJHJES I
`
`How effective are nasal steroids combined
`with nonsc:wrtrnt~
`
`For treating seasonal
`allergic rhinitis, inhaled nasal corticosteroids are supe(cid:173)
`rior to nonsedating antihistamines (Grade of recom(cid:173)
`mendation: A, based on a large meta-analysis of ran(cid:173)
`domized controlled trials [RCT~]). Combining nasal
`steroids and nonsedating antihistamines yields no
`additional benefits (Grade of recommendation: A,
`based on several RCT~l. Unless patient preference lim(cid:173)
`its their use, nasal steroids should be first-line therapy.
`
`A meta-analysis of 16 RCTs
`Sl
`compared the efficacy of intranasal steroids and oral
`antihistamines for alleviating nasal, eye, and global
`allert-,:ry symptoms.' Intranasal steroids were superior
`to oral antihistamines for all patient-oriented nasal
`symptom and global symptom ratings. Eye symptom
`scores and adverse events were similar in each treat(cid:173)
`ment group.
`Several large HCTs have addressed whether com(cid:173)
`bining the 2 classes of drugs would achieve greater
`symptom control. Only 1 study' found combination
`therapy
`to be superior. This HCT compared
`beclomethasone dipropionate with
`loratadine or
`placebo
`in 154 patients 2 Total symptom scores
`were better for the combination group rnainly due
`to improved relief from ocular symptoms.
`Fluticasone propionate aqueous nasal spray
`(FPANS) was evaluated alone and in combination
`with cetirizine in a multicenter double-blind study of
`454 patients.) The 1ucan sy1nptom scores for nasal
`and eye symptoms were not significantly different
`
`Intranasal steroids for treating allergic rhinitis
`
`Beconase AQ
`Vancenase AO
`Budesonide
`Rhinocort AO
`Flunisolide
`Nasa rei
`Nasal ide
`Fluticasone propionate
`Flonase
`Mometasone furoate
`Nason ex
`Triamcinolone acetonide
`Nasacort AQ
`
`2 sprays/nostril qd
`2 sprays/nostril qd
`
`2 sprays/nostril bid
`
`2 sprays/nostril bid
`2 sprays/nostril bid
`
`2 sprays/nostril qd
`
`2 sprays/nostril qd
`
`2 sprays/nostril qd
`
`Data, 2001.
`
`month*
`
`$44
`$40
`
`$48
`
`$44
`$46
`
`$53
`
`$56
`
`$56
`
`between the 2 groups. A more recent RCT had sim(cid:173)
`ilar results when comparing FPANS with loratadine
`and with combined therapy.' This double-blinded
`placebo-controlled
`trial, which
`included 600
`patients, measured patient- and clinician-rated total
`symptom scores, individual nasal symptom scores,
`and overall evaluations after 7 and 14 clays of thera(cid:173)
`py. Although the symptom scores for the FPANS
`group were significantly lower than those in the
`loratacline and placebo groups, no significant differ(cid:173)
`ence in scores was found between the FPANS and
`combined groups. The results were the same for the
`quality-of-life questionnaire scores. In an HCT of 106
`patients, budesonide nasal
`efficacy was test(cid:173)
`ed against terfenadine alone and in combination; the
`nasal steroid alone was more dlectivc than the his(cid:173)
`tamine.' Combining the 2 drugs yielded no signit1-
`cant improvements.
`The newer nasal steroids such as fluticasone may
`be more effective because of their stronger affinities
`to glucocorticoid receptors, but no clinical evidence
`confirms this hypothesis."
`
`The Joint
`1~tsk Force on Practice Parameters in Allergy, Asthma,
`and Immunology recommends second-generation
`oral antihistamines for first-line therapy, but notes that
`nasal steroids are the most effective medication class
`for controlling allert-,:ry symptoms.' The task force
`states that combination drug therapy may be tried. A
`monograph from the American Academy of Family
`Physicians notes the lack of consensus guidelines for
`first-line therapy and recommencb that treatment be
`individualized.' It states that combination therapy may
`be tried if inonothcrapy fails.
`
`Moses Cone
`
`MD
`Practice Residency Program
`Greensboro, North Carolina
`
`Ann Tl.1ering, MLS
`Practice Inquiries Network
`JVli.ssouri
`
`Clinical Commentalies by Tsveti Markova, MD, and
`John W. Tipton, MD, at http:/ /www.FPIN.org.
`
`REFEI\ENCES
`RM. Br Med .J 199i1; 317:1(>24-9.
`I. \'Vdner .JM, Abramson Mj.
`F. ct al. Allergy 1992: 12(suppll:17:1.
`2. Drouin MA, Yang WH,
`3. Benincasa C, Lloyd 1\S. Drug Invest 1994; 1l:22'i-33.
`4. R:ltner PH, V:m Bavel JH, Mal1in BG, et :li. ] Fam Pmct 1991l;
`47:118-Z'i.
`5. Simpson RJ. Ann Allergy 1994; 7::\:497-502.
`6. Lumrv J. Allergy Clin
`lmmunol 2000; 105:394. ] Allergy Clin
`Jmmunol 1999; 104(4 Pt 1):S1'i0--B.
`7. Dyke\vicz M, Fineman S. Ann Allergy Asthma Immunol 199H;
`HlA(>3-'5Hl.
`
`American Family
`
`61 6
`
`Ill
`
`• JULY 2002
`
`• VOL. 51. NO.
`
`MEDA_APTX03504783
`
`1
`
`CIP2162
`Argentum Pharmaceuticals v. Cipla Ltd.
`IPR2017-00807
`
`