Intranasal and MDI Budesonide Combination Use:

• Given the relationship between AR and asthma, it can be hypothesized that reducing inflammation in the upper airway with intranasal corticosteroid (INCS) medications may improve asthma outcomes.
• INCS medications include INCS sprays that deliver medication primarily to the nasal mucosa
• nasally inhaled corticosteroids deliver medication to both nasal and lower airway respiratory epithelium
• 2010 Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines recommended management of AR with INCS medications, but did not find enough evidence to indicate a clear clinical benefit from the use of INCS sprays for asthma

Systemic Review on impact of INCS medications on asthma outcomes

• Asthma-specific outcomes from randomized, controlled studies evaluating INCS medications in patients with AR were evaluated, including studies that compared INCS sprays to placebo, INCS sprays plus orally inhaled corticosteroids to orally inhaled corticosteroids alone, and nasally inhaled corticosteroids to placebo.
• Sufficient data for meta-analysis were retrieved for 18 trials with a total of 2162 patients

Outcomes

• INCS spray to placebo had significant improvements in FEV1, bronchial challenge, asthma symptom scores and rescue medication use.
• Nasal inhalation of corticosteroids significantly improved morning and evening peak expiratory flow.
• There were no significant changes in asthma outcomes with the addition of INCS spray to orally inhaled corticosteroids or daily inhaled corticosteroid

Rationale

• improvements noted with nasally inhaled steroids could be due to pulmonary deposition and/ or improvements in upper airway inflammation
• Although this meta-analysis suggests that treatment of the upper airway can improve some lower airway outcome measures, the direct clinical implications are less straightforward

References:

1. S. Lohia, R. J. Schlosser & Z. M. Soler. Impact of intranasal corticosteroids on asthma outcomes in allergic rhinitis: a meta-analysis. http://onlinelibrary.wiley.com/doi/10.1111/all.12124
2. Public Assessment Report for paediatric studies submitted in accordance with Article 45 of Regulation (EC) No1901/2006, as amended