Symptomatic Treatment of Pollen-Related Allergic Rhinoconjunctivitis in Children: Randomized Controlled Trial

This study aimed to compare the efficacy of daily intranasal corticosteroid, on-demand intranasal corticosteroid, and daily oral antihistamine in decreasing symptoms from grass-pollen allergic rhinoconjunctivitis.This study examined patients who were 6–18 years of age in the Netherlands and had a diagnosis of allergic rhinitis and evidence of grass-pollen sensitization.This was a 3-armed, single-blind, randomized controlled trial occurring for 3 months during the grass-pollen season. Patients were randomized to daily intranasal corticosteroid (INCS) (fluticasone 100 µg per day if <12 years of age; 200 µg per day if >12 years of age), on-demand intranasal corticosteroid (same dosing but only used when needed), or on-demand oral antihistamine (5 mg levocetirizine). Patients recorded their symptoms by using a daily online symptom diary that included questions about nose and eye symptoms.One hundred and fifty children were randomized. There were no statistically significant differences between groups in symptom-free days, although the trend favored on-demand INCS (30% symptom-free days compared with 22% for daily INCS and 15% for on-demand oral antihistamine). Patients randomized to on-demand INCS received 61% less nasal steroid than those randomized to daily INCS.The authors conceded that the study was underpowered to detect significant differences but noted that the on-demand INCS group performed slightly better than the daily INCS group, supporting that on-demand INCS was not inferior to daily INCS and allowed for lower overall corticosteroid exposure.Traditionally, providers have taught that daily intranasal corticosteroids are necessary to keep allergic rhinoconjunctivitis symptoms at bay, and current guidelines recommend daily use. In reality, many patients’ families do not adhere to this approach. Furthermore, some studies of on-demand inhaled corticosteroids for asthma exacerbations do not demonstrate inferiority, leading researchers to wonder if this approach might also have some efficacy in children with allergic conjunctivitis. In this study, researchers attempt to evaluate a strategy of on-demand INCS versus daily INCS versus oral on-demand antihistamine. Unfortunately, due to low recruitment, the study was underpowered to detect a statistically significant difference, although it is unlikely that daily INCS was superior to on-demand INCS given that the data demonstrated that on-demand INCS users had a higher proportion of symptom-free days than daily INCS users. This provides support for the suggestion that there may be a role for on-demand INCS among children with allergic rhinoconjunctivitis. Further research into this dosing strategy should be done, perhaps with a greater diversity of allergic rhinoconjunctivitis triggers.