Clinical Inquiries

Intranasal steroids vs antihistamines: Which is better for seasonal allergies and conjunctivitis?

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INTRANASAL STEROIDS PROVIDE BETTER RELIEF for adult sufferers, according to nonstandardized, nonclinically validated scales. Steroids reduce subjective total nasal symptom scores (TNSS)—representing sneezing, itching, congestion, and rhinorrhea—by about 25% more than placebo, whereas oral antihistamines decrease TNSS by 5% to 10% (strength of recommendation [SOR]: B, systematic review of randomized controlled trials [RCTs], most without clinically validated or standardized outcome measures).

Intranasal steroids improve subjective eye symptom scores as well as (or better than) oral antihistamines in adults who also have allergic conjunctivitis (SOR: A, systematic review, RCTs).

Evidence summary

The most commonly measured outcomes in allergic rhinitis and conjunctivitis trials are symptom scales, which are neither standardized nor clinically validated. Almost all the studies discussed here calculated outcomes as a percentage change from baseline symptom scores but didn’t provide absolute values, so it isn’t clear whether statistical differences are clinically relevant.

Steroids provide more relief of nasal symptoms
A meta-analysis of 21 randomized placebo-controlled trials (total 2821 patients, average age mid-30s) that compared changes in TNSS with intranasal steroids and oral antihistamines among adults with seasonal allergic rhinitis found that steroids reduced TNSS more than antihistamines.1 Most of the patients had had moderate to severe symptoms for several years.

Investigators calculated percent changes from baseline in mean TNSS, which typically included sneezing, itching, congestion, and rhinorrhea, each usually scored on a scale of 0 to 3.1 Individual RCTs compared one of 3 intranasal steroids (fluticasone, triamcinolone, or budesonide) and one of 3 oral antihistamines (cetirizine, loratadine, or fexofenadine) with placebo; no studies compared medications within classes against each other.1

On individual symptom scores, intranasal steroids reduced sneezing, itching, congestion, and rhinorrhea more than placebo by more than 20%. Both intranasal steroids and oral antihistamines decreased itching and rhinorrhea a similar amount, but antihistamines reduced congestion by only 5% to 10% more than placebo.1

This meta-analysis included only studies reporting TNSS as an outcome, and individual studies used varying TNSS scales. Investigators attributed heterogeneity in the studies to intraclass differences between medications.1

Two drug company-sponsored RCTs (1616 patients combined, average age 30s, moderate to severe allergic rhinitis) published before the meta-analysis also demonstrated that the intranasal steroid fluticasone propionate modestly reduced TNSS compared with the oral antihistamine fexofenadine (1 point vs 1.3 on a scale of 0 to 12).2 TABLE 1 summarizes the results of studies comparing intranasal steroids and oral antihistamines to reduce nasal symptoms.

Intranasal steroids vs oral antihistamines for nasal symptom relief

Study designInterventionOutcomeSignificanceHarms
Systematic review of RCTs1INS: 7 RCTs (total N=597)
OAH: 14 RCTs (total N=2224)
Mean percentage change in TNSS from baseline:
INS: –40.7%
OAH: –23.5%
Placebo: –15.0%
Changes in INS scores significantly greater than changes in OAH scores (P<.001)Not reported
Two RCTs, double blind, double dummy2Study 1*
INS (N=312)
OAH (N=311)
Placebo (N=313) Study 2*
INS (N=224)
OAH (N=227)
Placebo (N=229) Duration 2 wk
Least squares mean difference from baseline TNSS score of INS vs OAH:
Study 1:
TNSS: –1.0
(95% CI, –0.7 to –1.4) Study 2:
TNSS: –1.3
(95% CI, –0.9 to –1.7)
Changes in INS scores significantly greater than changes in OAH scores (P<.001)INS: sore throat (2%), urticaria (<1%) OAH: epistaxis (2%), sore throat (<1%), cholecystitis (<1%), upper respiratory infection (<1%), sinusitis (<1%)
CI, confidence interval; INS, inhaled nasal steroids; OAH, oral antihistamine; RCTs, randomized controlled trials; TNSS, total nasal symptom score.
*The INS used was fluticasone furoate; the OAH used was fexofenadine.

Results for eye symptoms are mixed
A meta-analysis of 11 RCTs (1317 patients, average age 32) showed no significant difference in relief of eye symptoms between oral antihistamines (dexchlorpheniramine, terfenadine, and loratadine) and intranasal steroids (budesonide, beclomethasone, fluticasone, and triamcinolone) in patients with seasonal allergies, as measured by various symptom scores.3


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