Rhinitis Options: Fast Relief or Delayed Long-term Effect

Ingrid Hein

November 24, 2020

Within an hour, a single dose of a combination antihistamine that consists of loratadine and pseudoephedrine (Claritin D) delivers more than twice the rhinitis relief as a fluticasone nasal spray (Flonase), results from a head-to-head comparison show.

"If patients want rapid relief, they need to use an antihistamine decongestant tablet. Don't expect rapid benefit from a nasal spray; the benefit only kicks in after 3 to 5 days, not right away," said Anne Ellis, MD, from Queen's University, Kingston, Ontario, Canada.

"Normally when I prescribe a nasal steroid spray, I tell the patient it won't kick in for 3 or 4 days," Ellis told Medscape Medical News. "This confirms that the nasal spray needs to be used for a longer period of time to take effect."

For their study, Ellis and her colleagues used a "uniquely objective" peak nasal inspiratory flow (PNIF) measurement device to assess how quickly over-the-counter drugs offer patients relief.

Multiple studies have shown that the loratadine and pseudoephedrine combination is superior to placebo, and it is common knowledge that nasal spray takes a long time to work, but no head-to-head comparisons had been conducted.

So Ellis and her colleagues designed a double-blind four-group crossover study to evaluate nasal airflow in adults sensitized to ragweed pollen after a single dose of the loratadine and pseudoephedrine combination or a single dose of fluticasone nasal spray. Ellis presented the findings at the American College of Allergy, Asthma & Immunology (ACAAI) 2020 Annual Scientific Meeting.

Four Blinded Treatments

After exposure to ragweed pollen in an environmental exposure unit for 3 hours, the 84 study participants had a Total Symptom Score of at least 7, an individual nasal congestion score of at least 2, and a reduction of at least 15% in nasal airflow measurement.

All participants were taught to use the PNIF measurement device, and were monitored to validate flow before and after readings. "We were happy to get consistent readings," Ellis reported.

Each participant did a ragweed pollen challenge and then was randomized to one of the four treatments: the combination tablet consisting of loratadine 5 mg and pseudoephedrine 120 mg; a placebo tablet; two sprays per nostril of fluticasone propionate nasal spray 50 μg; or placebo nasal spray.

Each of the four treatments was administered during a 1-day visit to the study site, and there was a 14-day interval between each treatment. During each visit, a treatment was administered to the patient and PNIF was recorded at 30, 60, 120, 180, and 240 minutes.

The average percent decrease in PNIF over 4 hours with the combination was 31.3%, which was higher than the 14.8% decrease (P < .001) with the fluticasone nasal spray and the 11.6% decrease (P < .001) with the placebo tablet.

One hour after administration, the decrease in PNIF was significantly greater with the combination than with the nasal spray (30.7% vs 8.6%; P < .001). However, the decrease in PNIF was not significantly different between the nasal spray and the placebo spray (14.8% vs 9.7%; P = .195).

"Based on a one-time single dose, there's faster onset with the oral medication," Ellis said.

For Long-term Effect, Squirt Your Nose

"I tell my patients that it takes 7 to 10 days for the nasal spray to start working and a month to have the full effect," said Allen Meadows, MD, immediate past president of the ACAAI.

"There are some studies that show a short-term benefit for topical fluticasone, but you really need to use it daily for up to a month for it to take effect; patients don't understand this," he told Medscape Medical News.

The combination tablet works quickly but loses its effect after a couple of days, he explained. "Fourteen days from now, the spray effectiveness will be a 10, the tablet will be a one," he said.

"When you're lying in bed, remind yourself, squirt your nose," he tells his patients. Or, leave it beside your toothbrush so you’ll remember before bed.

Only about 20% of patients use the treatment correctly, "and that's probably a high estimate," Meadows said. "They squirt once and think it doesn't work. Well of course it didn't."

So if you want relief for the next 3 days, "take a pill." But if you want relief 14 days from now, "use the nose spray."

The study was funded by Bayer. Ellis has disclosed no relevant financial relationships. Meadows has accepted speaker fees from Optinose.

American College of Allergy, Asthma & Immunology (ACAAI) 2020 Annual Scientific Meeting: Abstract A070.

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