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Evidence-based answers from the Family Physicians Inquiries Network HELP DESK ANSWERS [To Your Clinical Inquiries]

Sean Schulz, DO; Patricia Adam, MD, MSPH What is the most effective University of Minnesota, Department of Family topical treatment Medicine, Minneapolis EDITOR Corey Lyon, DO for ? University of Colorado Family Medicine Residency, Denver

Evidence-Based Answer to 24 hours. A meta-analysis wasn’t possible Topical and top- because most studies didn’t tabulate the A ical mast cell stabilizers appear mean scores and error associated with these to reduce conjunctival injection and itching scores. Most individual studies, however, effectively. Topical nonsteroidal anti-inflam- showed improvement in the cardinal symp- matory drugs (NSAIDs) are also effective, but tom of itchiness. may sting on application (strength of recom- Finally, 8 RCTs compared topical mast mendation: B, meta-analysis of randomized cell stabilizers (sodium cromoglycate, lo- controlled trials [RCTs]). doxamide, and nedocromil sodium) with , a topical . Two Both of these treatments RCTs with 74 patients had follow-up peri- relieve redness and itching ods of 15 minutes to 4 hours; the remain- A 2004 systematic review of 40 RCTs (total N ing 6 RCTs with 473 patients had follow-up not provided) assessed the efficacy of topical periods of 14 days to 4 months. Subjective treatment with mast cell stabilizers and anti­ scoring of symptoms was done in 7 of the , comparing each with the other 8 studies. and placebo.1 Eleven trials that included Scores between treatment groups were 899 children and adults compared mast cell reported as not statistically significant in the stabilizers (sodium cromoglycate, nedocro- 6 longer-term studies. Meta-analysis wasn’t Digital Weekly Summaries of mil, and lodoxamide tromethamine) with possible because most studies didn’t tabulate placebo. Follow-up periods ranged from 4 to the mean scores and error associated with Must-Read Clinical Literature, 9 weeks. measures. The 2 short-term studies reported Guidelines, and FDA Actions Because of study heterogeneity, a ran- a statistically significant reduction in itching dom-effects model was used and showed and redness (P<.05) in patients treated with that topical mast cell stabilizers relieved the antihistamine (data not provided). ClinicalEdge is what you, the busy clinician, have asked for—5 to 10 succinct symptoms (ocular itching, burning, and lacrimation) 4.9 times more effectively NSAIDs relieve itching summaries of “must-read” news and clinical content with KOL commentary. than placebo (95% confidence interval [CI], but may sting when applied 2.5-9.6). Possible publication bias was cited A 2007 meta-analysis of 8 RCTs compared ClinicalEdge also provides you with: as a limitation. topical NSAIDs (ketorolac, diclofenac, aspi- Summaries archived by date and disease state Links to related articles, Clinician-IQ quizzes, In the same systematic review, 9 RCTs rin, or steroid) with placebo for treating isolat- with 313 patients compared topical anti- ed allergic conjunctivitis in 712 children and and more Clinical summaries and practice guidelines histamines (levocabastine, hy- adults.2 Primary outcomes were measured as “Easy advance” scrolling and navigation features FDA actions of interest to primary care HCPs drochloride, emedastine, and subjective reductions in conjunctival injec- phosphate) with placebo. Signs and symp- tion and itching measured at 2 to 6 weeks us- toms (itching, redness, burning, and swell- ing a 0-to-3 severity scale. ClinicalEdge is updated weekly at ing) were graded using symptom severity Topical NSAIDs produced significantly www.jfponline.com/clinicaledge Brought to you by scales. Follow-up ranged from 30 minutes greater relief of conjunctival itching (4 trials, continued on page 321 Log on today!

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N=231; mean difference [MD]=-0.54; 95% Guideline recommends topical CI, -0.84 to -0.24) and conjunctival injection antihistamines or mast cell stabilizers (4 trials, N=208; MD=-0.51; 95% CI, -0.97 to The American Academy of Ophthalmology’s -0.05). NSAIDs weren’t superior to placebo 2012 evidence-based guideline recommends in treating other ocular symptoms of eye- treating allergic conjunctivitis with topical an- lid swelling, ocular burning, photophobia, tihistamines (Level A-1 evidence, defined as or foreign body sensation, and they had a important evidence supported by at least one higher rate of stinging on application (odds RCT or a meta-analysis) and using topical mast ratio=4.0; 95% CI, 2.7-5.9). cell stabilizers if the condition is recurrent.3 JFP

References 1. Owen CG, Shah A, Henshaw K, et al. Topical treatments 2007;14:311–319. for seasonal allergic conjunctivitis: systematic review and 3. American Academy of Ophthalmology. Conjunctivitis Sum- meta-analysis of efficacy and effectiveness. Br J Gen Pract. mary Benchmarks for Preferred Practice Pattern Guidelines. 2004;54:451-456. American Academy of Ophthalmology Web site. Available at: 2. Swamy BN, Chilov M, McClellan K, et al. Topical non-steroidal http://one.aao.org/summary-benchmark-detail/conjuncti- anti-inflammatory drugs in allergic conjunctivitis: meta- vitis-summary-benchmark--october-2012. Accessed October analysis of randomized trial data. Ophthalmic Epidemiol. 18, 2013.

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