April 30th, 2009
I was reading an article in this week’s edition of The New England Journal of Medicine and it made me think. The article focused on asthma in pregnancy. While that is a topic for another time, it got me thinking about the treatment of allergies in pregnant women.
Currently, we are nearing the peak of the Spring allergy season. Most of the patients that I am seeing for the first time arrive on prescription or over-the-counter allergy medications. Pregnancy categories for medications include category A, B, C, D, and X. You want to be on medications in pregnancy category A or B and avoid those in pregnancy category D or X. For drugs in pregnancy category C, caution is advised, but the benefits of the medication may outweigh the potential risks.
First, it is important to think about what medications you are taking if you are thinking about becoming pregnant. You cannot wait until you discover that you are pregnant. You may have to modify your medication regimen when you begin trying to become pregnant. The reason for this is to ensure that there are no harmful effects to the baby from medications prior to learning that you are pregnant. The most critical time in a baby’s development that is affected by medication are the first weeks of pregnancy.
Zyrtec and Benadryl represent antihistamines that are pregnancy category B.
Rhinocort is a nasal steroid that is pregnancy category B.
For those patients that are on allergy shots, guidelines recommend continuing with your shots if there are observed benefits. However, the dose should be held and not increased until after delivery of the baby.
If you are considering becoming pregnant and have a question about your allergy options, contact your physician to ensure the safest options for your child.
February 25th, 2009
One of the things that gets my dander up as a allergist is to see the repackaging of older medications which are then marketed as new and improved. Companies try this tactic to gain new patents and extend the profitability of medications. I’ve got nothing against companies making money and I’m fully aware that crass profit motives have driven some great discoveries in medicine. These examples, however, are not great discoveries.
If you haven’t had much chemistry, a bit of background is helpful here. Drug molecules often exist as stereoisomers. This means that they have two different molecular structures which are mirror images of each other, just like your right and left hand. In the body, only one of these molecules will bind to the target receptor and be active. Imagine you just had one right handed glove. Your right hand would fit easily, but your left hand would fit awkwardly or not at all.
Most drugs on the market exist as this mixture of right- and left-handed forms. Now, companies have figured out how to isolate the active form. This allows them to market the molecule as a brand new drug. In reality, people had been taking the drug all along, There’s generally nothing new or exciting about these single-isomer drugs except their branding campaigns. Examples of this practice include, Clarinex(Claritin), Xyzal(Zyrtec), Xopenex(albuterol), and Nexium(Prilosec). Note that all of these medications except albuterol are available OTC for significantly less than their prescription counterparts.
Other tactics include changing the delivery vehicle in a nasal spray (Astelin to Astepro) or gaining a new indication, say for once-daily dosing(Patanol to Pataday).
Generally, these new drugs are significantly more expensive than their older counterparts and their pharmacy co-pays are much higher. To counteract this, the pharmaceutical companies often offer coupons for rebates and try to enlist us physicians in passing them out. This tactic, in particular, irks me. When doctors prescribe more expensive medications, we all pay indirectly.
Part of the job of being a physician is being a responsible steward of the medical dollar. Because of this, I’m often quite blunt with my reps that if their drug offers no significant clinical benefit over older, cheaper medications, then I am very unlikely to prescribe it.
Dr. O
January 22nd, 2009
Most wheezing in young children is due to viral infection of the airways, often termed bronchiolitis. A common cause would be Respiratory Syncitial Virus which you may have heard of as RSV. Essentially all wheezing below the age of 3 and most wheezing between the ages of 3 and 6 falls into this category. The wheezing produced by these infections results from damage and swelling of the airways as a direct result of the viral infection. Traditionally, kids with bad wheezing from such infections have been given steroids to try and reduce the swelling and inflammation.
This week’s New England Journal of Medicine has two interesting studies examining this practice. In the first kids with viral induced wheezing who were sick enough to be hospitalized were randomly given either prednisone or placebo. As it turns out there was no difference in the length of hospital stay or any other outcome between the two groups. In the second study, kids between the ages of 1 and 6 who had strictly viral induced wheezing were given inhaled steroids at the start of an upper respiratory infection to try and prevent wheezing. In this study, inhaled steroids were no better than placebo at preventing viral induced wheezing.
These studies will likely lead to a significant change in the treatment of viral induced wheezing. I would like to stress that these studies do not examine the effects of steroids on asthma or viral induced asthma exacerbations.
January 15th, 2009
A while back, the FDA decided to look into the issue of mood disturbance and drugs like Singulair. Through an extensive review of over 20000 patients, the data show no increase in depression or suicide in patients treated with Singulair. They are still reviewing the data to see if there is a link between Singulair and behavioral issues in kids. My sense is that this will be ok as well, but we’ll await the findings of their review. For now, If you’re on Singulair for control of asthma or allergies, you should feel safe to continue these medications
December 17th, 2008
Lets talk for a bit about common allergy medications. In the interest of time, I’ll focus on meds used to treat nasal symptoms, what doctors call rhinitis.
The most common medications used for rhinitis are antihistamines. Antihistamines work, as their name suggests, by blocking the effects of the chemical histamine. They are particularly good for controlling symptoms of nasal itching, sneezing, runny nose, and itchy eyes. They are not very good at controlling nasal congestion and drainage. Older antihistamines like diphenhydramine (benadryl), chlorpheniramine (chlor-trimeton) , and hydroxyzine (atarax, vistaril) are very potent, but they are also very sedating. Newer antihistamines such as cetirizine (zyrtec), fexofenadine (allegra), and loratidine (claritin) are classified as low- or non-sedating and still have adequate potency. I generally recommend one of the newer medications. Cetirizine and loratidine are available over-the-counter and store brands run only about $10 a month.
Decongestants also do what their name suggests: help control nasal congestion. Some people find they help with symptoms of pressure and pain as well. They work by constricting the blood vessels in the nose which, in turn, shrinks the lining of the nasal passage. Since they are oral medications, they will also constrict the blood vessels in the rest of the body, which can worsen blood pressure, In guys, they can also worsen prostate problems. They cause insomnia in a number of people as well. Because of all these side effects, I avoid decongestants as much as possible and limit their use to short periods of time.
Over-the-counter nasal sprays are a double-edged sword. They are sold under a variety of names, but most contain the drug oxymetazoline. They will open your nose like nothing else, but if used improperly can lead to dependence so be very careful with them and always follow the instructions. Never use them for more than 3 days in a row or more than twice a day. If you do, when you try to stop, your nose will be worse than when it started- a phenomenon called rebound. I see patients every week who have become dependent on these medications to breathe through their nose. Don’t become one of them.
Finally, I’ll talk about saline rinse. This is a great treatment for most nasal symptoms, including drainage. It’s essentially free and devoid of side effects. I’m not referring to “ocean spray” that simply moistens the nose, but rather forcing a large volume of saline through the nose. This can be done with gravity-a neti pot- or with force- a plastic squeeze bottle. Either way, make sure you don’t use plain tap water- it’s too dilute and will irritate the lining of the nose. A simple mix involves using a teaspoon of salt in 8 ounces of water. Some companies try to sell you their mix, claiming that they have “pharmaceutical grade NaCl”. This is ridiculous. Plain table salt is fine and could never make the nose a dirtier place than it already is.
Hope this is helpful.
Dr. O
December 15th, 2008
A few weeks ago, I posted on the recent meta-analysis examining the safety of long acting beta-agonists, LABAs. Going by the names salmeterol (Serevent) and formoterol (Fordil), these medications are components of Advair and Symbicort, which also contain inhaled corticosteroids. The FDA recently convened a special advisory panel regarding the safety of these agents, and, fortunately, there were prominent members of the asthma community to advise them along the way. Following the best available evidence and expert opinion, the panel reaffirmed that combination therapy is the preferred choice for adults and children with persistent asthma.
Additionally, they said that LABAs should not be used in isolation, without the addition of an inhaled steroid. For anyone familiar with the literature and with these medications, this is a glaringly obvious conclusion. The scary part is that the FDA had to convene a special panel to resolve internal disagreements regarding the use of these medications. Thanks to those members of the AAP, ATS, and AAAAI who aided in this important decision.
November 14th, 2008
The most common limiting side effect of nasal steroid sprays (flonase, nasonex, etc.) is nose bleeds. Since doctors have to use obscure names we call this epistaxis. Most epistaxis arises from a specific location in the nose called Kiesselbach’s plexus, where several blood vessels in the septum come together.
Obviously, this area could easily be irritated by using a nasal steroid spray. If you aim the spray nozzle slightly inward, it directs the spray right toward this point. That’s why, when using a nasal steroid spray, you should always aim slightly outward. Try using your right hand for the left side of the nose and vice versa. Often, this simple trick will allow someone who has had difficulty with epistaxis from nasal steroid sprays to use the medications without complication.
Dr. O
