Treatment options for seasonal allergic rhinitis

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Background:Seasonal Allergic Rhinitis (SAR) or ‘hay fever’ is a common, complex disorder resulting in nasal and ocular symptoms. Treatments for SAR aim to minimise symptoms, improve quality of life and reduce the risk of developing any co-existent disease. Improving the evidence-base for treatment decisions in primary care is now a priority for the NHS.Methods:We used standard systematic review methods to conduct a systematic review of all randomised control studies (1990-2002) evaluating the effectiveness of treatments for SAR. For a study to be included all patients had to be at least 12 years with a physician confirmed diagnosis of hay fever. The minimum length of follow-up was stipulated as being 2 weeks. The interventions and comparisons analysed were those including topical or systemic antihistamines, decongestants, leukotriene antagonists and ipratropium bromide. Steroids were not included as they are preventative rather than curative. Our primary outcome measure was rhinitis quality of life using the validated Juniper Rhinitis Quality of Life Questionnaire. Secondary parameters of effectiveness included visual analogue rhinitis symptom score completed by the doctor and/or patient, medication usage and medication usage scores, days off school or work and adverse events.Results:We found 68 trials satisfying our inclusion criteria, although only four of these had used formally validated outcome measures (Juniper-RQLQ) to assess clinical effectiveness. Because of the heterogeneous nature of the studies identified, we used a narrative overview to summarise data. Three trials have shown that oral fexofenadine significantly improves disease specific quality of life and evidence from one trial indicates that a combination of oral monteleukast and loratadine is also clinically effective. Numerous trials indicate that a number of oral antihistamines with/without oral decongestants improve rhinitis symptoms. Topical levocabastine is also of benefit in reducing rhinitis symptoms but there is at present confliciting evidence on the usefulness of other topical treatments (azelastine and ipratropium bromide).Conclusions:Fexofenadine and a combination of oral monteleukast/loratadine should be regarded as first line interventions for the medical treatment of SAR. There is evidence to suggest that other oral antihistamines and intranasal levocabastine are also likely to be of clinical benefit.