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Evaluating montelukast-second-generation antihistamine combinations versus monotherapy in allergic rhinitis: A
Angelina Wandana1, Joyceline Chika Tanely2, Robby Malik Chandra Sudrajat3
1Department of Internal Medicine, Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia.
Background:
Allergic rhinitis (AR) is an atopic condition affecting over 400 million people worldwide, impairing quality of life and often leading to complications such as asthma and sinusitis. Montelukast, a leukotriene receptor antagonist, is often used in combination with second-generation antihistamines (sgAHs) to enhance symptom control. However, the relative efficacy of different montelukast-sgAH combinations remains unclear.
Objective:
To evaluate and compare the efficacy of montelukast combined with various sgAHs versus montelukast monotherapy in patients with AR.
Methods:
Randomized controlled trials (RCTs) comparing montelukast-sgAH combinations to montelukast alone were identified from 5 electronic databases up to 2025. Outcomes included Total Nasal Symptom Score (TNSS; 0-12), Daytime and Nighttime Nasal Symptom Scores (DNSS, NNSS; 0-3), and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ; 0-6). Risk of bias (RoB) was assessed using Cochrane RoB 2.0. A frequentist network meta-analysis with subgroup analysis and meta-regression was performed using RStudio and Jeffreys's Amazing Statistics Program.
Results:
Seventeen RCTs involving 2,655 participants were included. For TNSS improvement, montelukast + desloratadine combination is significantly better than monotherapy in adults (mean difference [MD] = -0.92 [-1.15 to -0.69]) and children (MD = -1.95 [-3.46 to -0.44]). Effects on RQLQ and DNSS were inconsistent, while NNSS improved with montelukast-levocetirizine (P = 0.0384). Heterogeneity was high, but most studies showed low risk of bias. No serious adverse events were reported.
Conclusion:
Montelukast-sgAH combinations may improve symptoms over monotherapy, especially with desloratadine in both adults and children. However, variability across outcomes and high heterogeneity warrant cautious interpretation and further research.
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