Epistaxis Risk Associated with Intranasal Corticosteroid Sprays: A Systematic Review and Meta-analysis

• Published in: Otolaryngology-head and neck surgery Vol. 161; no. 1; pp. 18 - 27
• Main Authors: Wu, Eric L., Harris, William C., Babcock, Casey M., Alexander, Bailin H., Riley, Charles A., McCoul, Edward D.
• Format: Book Review Journal Article
• Language: English
• Published: Los Angeles, CA SAGE Publications 01-07-2019
• Subjects: Administration, Intranasal; Adrenal Cortex Hormones - administration & dosage; Adrenal Cortex Hormones - adverse effects; allergic rhinitis; corticosteroid; epistaxis; Epistaxis - chemically induced; Humans; meta‐analysis; nasal spray; Nasal Sprays; Rhinitis, Allergic - drug therapy; Risk; corticosteroid; meta-analysis; allergic rhinitis; nasal spray; epistaxis
• ISSN: 0194-5998; 1097-6817
• DOI: 10.1177/0194599819832277

Objective
Intranasal corticosteroids (INCSs) are widely utilized for the treatment of allergic rhinitis. Epistaxis is a known adverse effect of INCSs, but it is not known if the risk of epistaxis differs among INCSs.
Data Sources
Systematic review of primary studies identified through Medline, Embase, Web of Science, PubMed Central, and Cochrane databases.
Review Methods
Systematic review was conducted according to the PRISMA standard. English-language studies were queried through February 1, 2018. The search identified randomized controlled trials of INCSs for treatment of allergic rhinitis that reported incidence of epistaxis. An itemized assessment of the risk of bias was conducted for each included study, and meta-analysis was performed of the relative risk of epistaxis for each INCS.
Results
Of 949 identified studies, 72 met the criteria for analysis. Meta-analysis demonstrated an overall relative risk of epistaxis of 1.48 (95% CI, 1.32-1.67) for all INCSs. The INCSs associated with the highest risk of epistaxis were beclomethasone hydrofluoroalkane, fluticasone furoate, mometasone furoate, and fluticasone propionate. Beclomethasone aqueous, ciclesonide hydrofluoroalkane, and ciclesonide aqueous were associated with the lowest risk of epistaxis. Conclusions about epistaxis with use of budesonide, triamcinolone, and flunisolide are limited due to the low number of studies and high heterogeneity.
Conclusions
While a differential effect on epistaxis among INCS agents is not clearly demonstrated, this meta-analysis does confirm an increased risk of epistaxis for patients using INCSs as compared with placebo for treatment of allergic rhinitis.