1Department of Otolaryngology-Head and Neck Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea
2Department of Physiology and Biomedical Engineering, Mayo Clinic
3Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea
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Abstract
Allergic rhinitis (AR) significantly impairs quality of life and often necessitates combination therapies for optimal symptom control. This study aimed to evaluate the efficacy of montelukast–antihistamine combination therapy in patients with AR by using a network meta-analysis. A comprehensive search was conducted using PubMed, Embase, MEDLINE, Scopus, the Cochrane Library, and Google Scholar up to April 2025. The treatment strategies included montelukast alone, antihistamine monotherapies (loratadine, desloratadine, levocetirizine, and fexofenadine), their respective combinations with montelukast, including bilastine. Outcomes included daytime and nighttime symptom scores, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and individual symptoms. Both pairwise and network meta-analyses were conducted. Thirty studies (4,486 patients) were included. Montelukast combinations with desloratadine (standardized mean difference [SMD] = −0.51), levocetirizine (SMD = −0.44), and loratadine (SMD = −0.31) significantly improved daytime nasal symptoms compared to montelukast alone. Only montelukast–levocetirizine improved nighttime symptoms (SMD = −0.21) and RQLQ (SMD = −0.48). The combinations with desloratadine or levocetirizine were superior for nasal obstruction, sneezing, and itching, while nasal discharge improved only with montelukast–levocetirizine. No treatment significantly improved eye symptoms. Surface under the cumulative ranking curve rankings generally favored combination therapies, though trends varied by outcome. Desloratadine monotherapy ranked highest for nasal itching. Although some comparisons require cautious interpretation, montelukast-based combination therapy demonstrated greater efficacy than monotherapy for multiple AR symptoms. These results highlight the importance of selecting therapeutic strategies based on the predominant symptom profile of individual patients.
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