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PAPERS: John M Weiner, Michael J Abramson, and Robert M Puy Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials BMJ 1998; 317: 1624-1629 [Abstract] [Full text]

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Intranasal corticosteroids can cause systemic side effects

Pradeep Morar, Shon Williams   (16 December 1998)

Safe in the context of trials

M B Lewis   (17 December 1998)

Evidence of efficacy is useful, but only a start.

Charlotte Paterson   (22 December 1998)

Intranasal corticosteroids can cause systemic side effects 16 December 1998
Pradeep Morar, Lecturer, Specialist registrar Department of Otolaryngology, Royal Liverpool University Hospital, Liverpool, Shon Williams Send response to journal: Re: Intranasal corticosteroids can cause systemic side effects	EDITOR- Weiner et al conclude that the use of intranasal steroids is safe as far as systemic side effects are concerned. An argument they base upon the work of only one group of workers.2 Though we agree on the cost effectiveness of the use of intranasal steroids, it must be clarified that when laboratory assays of adrenal function, bone formation, or urinary cortisol levels are measured, inhaled corticosteroids can be shown to cause suppression of these markers, especially at high doses.3,4 Though evidence of corresponding clinical adverse effects may be lacking, case reports do exist on the systemic clinical side effects from significant hypothalamic-pituitary-adrenal suppression. 5 These are usually in relation to the use of topical steroid nasal drops, where proper administration of the drops is lacking. To be safe it is required that metered sprays be prescribed at the smallest effective dose, for the shortest possible time. 1 Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998; 317: 1624-9. (12 December.) 2 Brannan MD, Herron JM, Reidenberg P, Affrime MB. Lack of hypothalamic-pituitary-adrenal axis suppression with once-daily or twice-daily beclomethasone dipropionate acqueous nasal spray administered to patients with allergic rhinitis. Clin Ther 1995; 17: 637-47. 3 Wihl JA, Andersson KE, Johansson SA. Systemic effects of two nasally administered glucocorticosteroids. Allergy 1997;52(6):620-6. 4 Storms WW. Risk-benefit assessment of fluticasone propionate in the treatment of asthma and allergic rhinitis. J Asthma 1998;35(4):313-36. 5 Flynn MD, Beasley P, Tooke JE. Adrenal suppression with intranasal betamethasone drops. J Laryngol Otol 1992;106(9):827-8.
Safe in the context of trials 17 December 1998
M B Lewis, Neurology SpR St. James's University Hospital, Leeds Send response to journal: Re: Safe in the context of trials	Editor, Weiner et al make a convincing case for the more widespread use of intranasal corticosteroids in the treatment of allergic rhinitis (1). However, I would take issue with their assertion that they are safe, and I feel their article underplays the potential hazards of over prescribing, particularly outside the tight constraints of randomised controlled trials. In a recent article in the BMJ, Findlay et al describe two cases of childhood Cushing’s syndrome induced by intranasal steroids (2) and suggest that this may be the tip of an iceberg. In addition I have seen a case of invasive intracranial aspergillosis induced by intranasal corticosteroids and I am sure other clinicians have come across similar serious complications. Yes steroids have a role to play in the management of allergic rhinitis, but as always they should be prescribed with caution. Yours truly, M B Lewis, Specialist Registrar in Neurology 1. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998;317:1624-9. 2. Findlay CA, Macdonald JF, Wallace AM, Geddes N, Donaldson MDC. Childhood Cushing’s syndrome induced by betamethasone nose drops, and repeat prescriptions. BMJ 1998;317:739-40.
Evidence of efficacy is useful, but only a start. 22 December 1998
Charlotte Paterson, general practitioner Warwick House Medical Centre, Taunton. Send response to journal: Re: Evidence of efficacy is useful, but only a start.	21 December 1998 Dear Editor The headline ‘Intranasal corticosteroids should be used for allergic rhinitis', published in ‘This week in the BMJ' would seem to be a useful evidence based message for busy practitioners. Unfortunately it is not a message that can properly be concluded from the paper concerned, which is a systematic review of randomised controlled trials comparing the efficacy and cost-effectiveness of intranasal steroids and oral antihistamines 1. The evidence from this thorough review is useful but evidence on several other issues needs weighing up before we can conclude that intranasal steroids ‘should be used'. Patient centred consultations, in which therapeutic decisions are the result of negotiation between the health professional's expert medical knowledge and the patient's expert knowledge about him or her self, also require evidence about other treatment options and about adverse effects. Other treatment options for allergic rhinitis include allergen avoidance measures, allergen immunotherapy, and homeopathy. Although these non- pharmaceutical alternatives may have slower and less powerful treatment effects they may be chosen by patients who wish to avoid the risks inherent in drug therapy, or they may be used alongside drug therapy thereby reducing the dose required. The issue of adverse effects is of central concern to many patients but is often treated dismissively by health professionals, as it is in Weiner's paper which introduces the topic with the statement ‘ Intranasal steroids are considered safe.'. Considered safe by whom we might ask? Certainly not by patients, who often have deep seated anxieties about corticosteroids, nor by the Committee on Safety of Medicines and the Medicine Control Agency2. They concluded that clinically important systemic adverse effects can occur and they identified five main areas of concern: adrenal suppression, osteoporosis or changes in bone mineral density, growth retardation in children, cataracts, and glaucoma. Though this was published as an unreferenced report the authors were able to supply me with the list of 123 references on which it was based. Some case reports which illustrate these problems have also been published 3 recently. To suggest that evidence from a systematic review of the efficacy of two treatment options is sufficient for evidence-based therapeutic decision making is a dangerous oversimplification, and is not in keeping with the concordance model of prescribing4. Patients and their doctors need a wide range of evidence for their problem solving 5, and even then factual knowledge will only be one of many inputs which guide their decisions. Yours sincerely Dr Charlotte Paterson General practitioner Warwick House Medical Centre, Upper Holway Road, Taunton, Somerset. TA1 2YJ. Email: c.paterson@dial.pipex.com 1.Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials, BMJ 1998;317:1624-9. 2. CSM/MCA. The safety of inhaled and nasal corticosteroids. Current Problems in Pharmacovigilance 1998;24:8. 3. Findlay CA, Macdonald JF, Wallace AM, Geddes N, Donaldson MDC. Lesson of the week: Childhood Cushing's syndrome induced by betamethasone nose drops, and repeat prescriptions. BMJ 1998;317:739-40. 4. Royal Pharmaceutical Society of Great Britain. From compliance to concordance: towards shared goals in medicine taking. London: Royal Pharmaceutical Society, 1997. 5. Paterson C. Problem setting and problem solving: the role of evidence- based medicine. J R Soc Med 1997;90:304-6.