36 Chapter 2 The certainty of the evidence was very low due to very serious risk of bias and imprecision. Antihistamines Two systematic reviews were included [25, 26]. The first review included eight doubleblind placebo-controlled RCTs in 3,532 children and adolescents with seasonal AR and compared fexofenadine (different dosages) to placebo [25]. The second review included ten double-blind placebo-controlled RCTs in 2,418 children and adults with AR (seasonal and perennial) and compared rupatadine to placebo [26]. There was moderate-quality evidence that fexofenadine had a moderate effect on total symptoms (SMD -0.42 (95%CI: -0.49 to -0.35)) and that rupatadine had a small effect on total symptoms (SMD -0.36 (95%CI: -0.48 to -0.25)) and ocular symptoms (SMD -0.29 (95%CI: -0.45 to -0.14)). No evidence was found for the other outcome measures. The certainty of the evidence was moderate because of serious risk of bias. Corticosteroids Three systematic reviews about corticosteroids were included [27-29]. The first was a Cochrane review involving three placebo-controlled RCTs in 79 children with perennial AR. It compared beclomethasone dipropionate or flunisolide to placebo, without metaanalysis [27]. The second review included 16 double-blind placebo-controlled RCTs in 2,998 children and adults with seasonal or persistent AR. It compared mometasone furoate to placebo and reported symptom scores [28]. The third review included 16 double-blind placebo-controlled RCTs in 5,348 children and adults with seasonal or perennial AR [29]. It compared fluticasone furoate to placebo and ocular and reported nasal symptoms. There was moderate certainty of evidence that mometasone had a moderate effect on nasal symptoms (SMD -0.56 (95%CI: -0.71 to -0.41)) and a small effect on non-nasal symptoms (SMD -0.30 (95%CI: -0.43 to -0.18)). There was lowquality evidence that fluticasone furoate had a moderate effect on ocular symptoms in patients with seasonal AR (SMD -0.54 (95%CI: -0.70 to -0.37)) and a small effect in patients with perennial AR (SMD: -0.33 (95%CI: -0.61 to -0.05)). No evidence was found for the other pre-defined outcome measures. Overall, the certainty of the evidence varied from low to moderate due to risk of bias and indirectness. Clinical management may result in a small to moderate reduction of symptoms of AR. Natural course We included seven studies reporting the natural course of AR [30-36]. All studies reported on remission, while two also described the combined outcome measure
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