Categories
Change Password!
Reset Password!
Cetirizine, ebastine, and rupatadine perform better for nasal symptoms, while loratadine and desloratadine show relatively better effects on ocular symptoms and quality of life in allergic rhinitis patients.
A large network meta-analysis explored the efficacy and safety of oral H1-antihistamines in allergic rhinitis (AR) by synthesizing evidence from 74 randomized controlled trials. The dataset incorporated 53 studies in seasonal allergic rhinitis (SAR) and 21 studies in perennial allergic rhinitis (PAR). These studies covered multiple outcomes, including total nasal symptom score (TNSS), total ocular symptom score (TOSS), rhinoconjunctivitis quality of life questionnaire (RQLQ), and various safety endpoints.
The evidence base was substantial, starting from 6,209 records and 27 trial registry entries, with 410 full texts screened and 74 RCTs included. Participants were mainly young adults (mean age ~34 years) with a slight female predominance (~56%). Study sizes ranged from 27 to over 1,000 participants, with an average of ~437 per trial. Methodological quality was moderate to low overall, with only 8% of studies at low risk of bias and most rated unclear or high.
Efficacy results across outcomes
For nasal symptoms (TNSS), all or most antihistamines were superior to placebo, but differences between drugs were generally small. In PAR (13 studies; 4,762 participants), heterogeneity was moderate. Cetirizine, ebastine, and rupatadine consistently ranked among the most effective treatments. Rupatadine exhibited a statistically better effect than loratadine (mean difference [MD] −0.53). In SAR (38 studies; 14,925 participants), results were more variable, but cetirizine and ebastine again performed well, while rupatadine depicted strong comparative advantages over desloratadine (MD −1.56) and levocetirizine (MD −1.53).
Lower-performing agents were fexofenadine, levocetirizine, and terfenadine in several comparisons. For ocular symptoms (TOSS), assessed only in SAR (12 studies; 5,675 participants), most drugs improved symptoms when compared with placebo. Loratadine and desloratadine tended to rank highest overall, while fexofenadine illustrated weaker performance. Several agents—including cetirizine, bilastine, levocetirizine, loratadine, and rupatadine—had more than a 50% probability of clinically meaningful benefit over fexofenadine.
For quality of life (RQLQ), all antihistamines improved outcomes when compared with placebo. In PAR (6 studies; 2,586 participants), differences between active drugs were minimal, although levocetirizine and desloratadine ranked slightly higher. In SAR (25 studies; 11,409 participants), rupatadine and desloratadine showed stronger effects overall, with rupatadine outperforming levocetirizine (MD −0.36), although inconsistency reduced certainty in rankings.
Safety results
Safety profiles were broadly similar across all second-generation antihistamines. In both PAR (16 studies; 7,330 participants) and SAR (38 studies; 15,568 participants), no drug showed a meaningful rise in adverse events when compared with placebo. Small differences appeared in isolated comparisons, such as slightly lower adverse event risk with ebastine vs. rupatadine in PAR, and trends suggesting better tolerability with bilastine or levocetirizine in SAR, but these were not clinically significant.
Withdrawal due to adverse events was rare and exhibited no differences between drugs or placebo in either PAR or SAR. Serious adverse events were extremely uncommon across all treatments, occurring sporadically in both active and placebo groups, with no clear drug-related safety signal for modern antihistamines.
Overall, oral antihistamines remain effective and safe options for AR, but their comparative differences are modest. The choice of agent is therefore better guided by individual patient factors such as symptom pattern, response variability, tolerability, cost, and availability rather than clear superiority of one drug over another.
The Journal of Allergy and Clinical Immunology: In Practice
Efficacy and Safety of Oral Antihistamines for Allergic Rhinitis: Network Meta-Analysis
Rafael José Vieira et al.
Comments (0)