Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7173.1624 (Published 12 December 1998) Cite this as: BMJ 1998;317:1624
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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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests