Ashok Patel, MD
Board Certified Allergist
Academy Allergy, Asthma & Sinus Center
3220 N. Academy Suite 2
Colorado Springs, CO 80917
719-637-1222
Research studies are conducted on a regular basis at Academy Allergy, Asthma, Sinus & Immunology Center. We are currently taking volunteers for our asthma and allergy studies.
3116 North Elizabeth, Suite A
Pueblo, CO 81008
ACUTE SINUSITIS BY ASHOK PATEL, MD
“Dr. Patel, Sara has a sinus infection†Beth, Sara’s mother, stated. “Will you please prescribe an antibiotic? By the way, amoxicillin doesn’t work for her.†Sara is a 15-year-old pleasant, adolescent girl with moderate asthma. I have asked her and her mother to report to me when she develops a cold because it usually worsens her asthma. “Before I prescribe an antibiotic for her, I have some questions for you,†I responded. How do doctors decide if a patient has a sinus infection and needs an antibiotic? The question seems very simple; I thought I could answer the question in my sleep. However, recently I did a presentation on the evaluation of the treatment of sinusitis to a group of doctors and performed extensive research. I had difficulty finding an answer for the simple questions—When does a cold turn into a bacterial sinus infection, and when should a doctor prescribe antibiotics? During my interactions with numerous doctors over the years, I have found that doctors’ practices differ widely regarding diagnosis and treatment of acute sinusitis. In my practice, I have found that sometimes patients who carry the diagnosis of “sinusitis†in reality are having symptoms because of another medical condition. These symptoms should be explored before any treatment is prescribed. In this column, I share my views on the diagnosis and treatment of acute sinusitis. Your doctor may or may not agree with me. “I know what you’re going to ask, Dr. Patel,†Beth retorted. “Sarah has yellow nasal discharge.†“How much and for how long?†I asked. “A small amount for the last 3 days,†Beth murmured. Yellow nasal discharge–As soon as a patient’s nasal discharge turns green or yellow, she calls the doctor’s office requesting antibiotics. Yellow or green nasal discharge does not automatically mean that she has a bacterial infection and needs an antibiotic. A change in the color or characteristic of the nasal discharge is not a specific sign of a bacterial infection. “Sara needs an antibiotic because she complains of sinus pressure!†Beth emphasized. Sinus pressure–When some patients feel sinus pressure, they think they have a sinus infection and request an antibiotic. With the common cold, a patient can have sinus congestion and sinus pressure. “I’m not convinced that Sara needs an antibiotic,†I expressed my opinion. “Why don’t you order sinus x-rays, Dr. Patel?†Beth intervened. “Sinus x-rays will tell you whether she has a sinus infection or not.†“In my opinion, sinus x-rays are not very helpful in deciding if a patient needs an antibiotic or not,†I replied. “Why?†Beth quizzed me. Need for sinus x-ray–Many patients, especially children, used to or still do, undergo numerous sinus x-rays for diagnosis of acute sinusitis. Personally, I do not order sinus x-rays to diagnose acute sinusitis—why? I read a research study, which in my opinion, is not widely known. As a part of the study, the doctors ordered a CT scan of the sinuses for volunteers who were suffering from a common cold. To the doctors’ great surprise, they found severe abnormalities in the CT scan of the sinuses. The bottom line is that a simple cold can cause severe abnormalities on a CT scan and plain sinus x-rays. Why order sinus x-rays if they do not help in differentiating a common cold from bacterial sinus infection? “My friend, Monica, called her doctor and she got an antibiotic called in, Dr. Patel.†Beth claimed, “Why are you not prescribing Sara an antibiotic?†I examined Sara. The examination was unremarkable except for a small amount of white mucus in the nostrils. “Beth, Sara has a viral infection.†I counseled. “She does not need antibiotics.†“Oh,†Beth mumbled. Seeing the frustration on Beth’s face, to lighten up the situation I declared, “If all else fails, I recommend that the two of you go to Hawaii for 2 weeks. Lying down on the beach and exposing her sinuses to the warm moist ocean air can help.†When should a doctor prescribe antibiotics?–After reviewing medical literature extensively, I realized this question does not have a simple answer. A recent and very well-designed study published in a medical journal, Pediatrics, concluded: “Neither amoxicillin nor amoxicillin-clavulanate offers any clinical benefit compared with a placebo for children with clinically diagnosed acute sinusitis.†In simple words, antibiotics were as good as a placebo, a sugar pill. Another study published in Lancet, a respected medical journal, compared a placebo to an antibiotic in treatment of acute sinusitis and concluded: “Antibiotic treatment did not alter the clinical course of sinusitis, nor the number of relapses in the following year.†Duration of symptoms–Symptoms of the common cold can last for several days. The younger the child, the longer the symptoms will last. In children less than 1 year old, symptoms of a cold can last up to 9 days. According to one research study, symptoms of the common cold lasted as long as 15 days in 13% of children attending daycare centers. An expert group of physicians comprised of infectious disease specialists, pediatricians, and allergists concluded: “The diagnosis of bacterial sinusitis is made too frequently…patients with viral illnesses of only a few days’ duration are inappropriately labeled as having bacterial disease.†In the absence of evidence-based data, the group recommended that a physician may consider a course of antibiotics if the patient is “no better or worse after 10 days.†Your doctor will work with you to decide whether you need an antibiotic or not. So, when you are seeking relief from sinus pressure and congestion, work with your doctor to do the thing that is best for you, which may not always be the old standby antibiotic. By the way, evaluation and treatment of “sinusitis†costs the nation billions of dollars annually—a lot of money, some of which we may be able to save.
FDA official’s criticism of Severent is only partially right
By ASHOK PATEL, MD
Are you confused when a prominent doctor from the FDA alleges that five drugs are dangerous to your health, while another doctor speaking on behalf of the FDA rejects the allegations as hysterical? Recently, during his testimony in the Senate, Dr. David Graham, associate science director of the Office of Drug Safety at the Food and Drug Administration, alleged that Accutane, Meridia, Bextra, Crestor and Serevent might not be safe to take. Dr. Graham is right on the mark regarding concerns on Serevent (salmeterol), but in my humble opinion, only partially. How? To understand the issue, first you have to know what goes wrong in asthma. In simple terms, in asthma the bronchial tubes are in spasm and inflamed. To relieve the spasm or constriction of bronchial tubes, doctors prescribe bronchodilator medications, which dilate the bronchial tubes. You may be familiar with a very widely used bronchodilator – albuterol, also available as Proventil and Ventolin brands. The bronchodilator effect typically lasts for 4-6 hours. Albuterol is a short-acting bronchodilator. To prolong the bronchodilating effect, pharmaceutical companies developed long-acting bronchodilators, two of them are salmeterol (Serevent) and formoterol (Foradil). If doctors prescribe only bronchodilators, they are correcting only one part of the problem, bronchoconstriction. To heal the inflammation, they have to prescribe anti-inflammatory medications. The mainstay anti-inflammatory medications for chronic use are inhaled glucocorticosteroids. Some of the commonly used ones are: 1. Flovent Inhaler (fluticasone). 2. Pulmicort Inhaler (budesonide). 3. QVAR, Beclovent, Vanceril, (beclomethasone). 4. AeroBid (flunisolide). 5. Azmacort (triamcinolone). Patients with asthma should definitely be taking an anti-inflammatory inhaler and possibly a long-acting bronchodilator. Why? Numerous studies have shown that when doctors combine an anti-inflammatory inhaler and a long-acting bronchodilator, the asthma is much better controlled. No wonder GlaxoSmithKline (GSK) came out with a combination product, Advair – a combination of fluticasone, an anti-inflammatory medication, and Serevent Inhaler, a long-acting bronchodilator. Tens of thousands of doctors prescribe Advair everyday, and millions of patients love it to control their asthma. As far as I know, nobody has raised a safety alarm for Advair Inhaler, even though it contains Serevent. Why? When patients are using Advair, they are addressing the two components of asthma – bronchoconstriction and inflammation. On the other side of the coin, when they are using only a Serevent Inhaler, the inflammation keeps simmering, their asthma gradually worsens, and they may suffer a bad outcome. The bad outcome is not the side effect of a Serevent Inhaler but the consequence of unchecked inflammation, which the doctor has not addressed with anti-inflammatory medication. Consequently, I do not recommend my patients use a Serevent Inhaler by itself. The silver lining of the controversy is patients and doctors will review their use of Serevent. If they are using only Serevent, in my opinion, they shall consider adding an anti-inflammatory medication. As an allergist, I have extensively studied Serevent. Not only am I extremely familiar with it, but also I have done consulting work for GSK. Even though you may consider me GSK’s hired gun, you will find the information herein valuable and helpful. Based on my observations on how GSK has acted in our region, I give credit to GSK for promoting the correct use of a Serevent Inhaler. The FDA has also approved Serevent for COPD. Unfortunately, we do not have a magic cure for COPD. Almost all doctors recommend stop smoking, stop smoking, stop smoking! If your doctor has recommended you supplemental oxygen because your oxygen saturation is less than 88 percent, don’t be bashful, use the oxygen as per your doctor’s advice. Besides stopping smoking and supplemental oxygen, doctors recommend numerous medications and measures, most of which I consider just a Band-Aid. If you are concerned about the safety of Serevent, your doctor may change Serevent to another bronchodilator, or he may substitute Advair in place of Serevent. Why? Some COPD patients benefit from the anti-inflammatory medication. As said above, Advair contains both – an inhaled corticosteroid and a bronchodilator. By the way, the FDA has approved Advair 250/50 mcg 1 puff twice a day for the treatment of COPD. As there is a widespread steroid phobia, in my opinion, to discuss the side effects of inhaled corticosteroids will require another lecture. I feel at home in delivering another lecture as I have extensive experience with inhaled corticosteroids. In the past 16 years, like legions of other doctors, I have prescribed thousands of patients inhaled corticosteroids. Like “McDonald’s”, pharmaceutical companies marketing inhaled corticosteroids can have a slogan “More than _______ millions served.†Ashok Patel, M.D., Allergist, Academy Allergy, Asthma, Sinus & Immunology Center
DREADING SPRING
April, 2003 While her friends are excitedly looking forward to the arrival of spring, Rachel dreads the springtime. Spring brings her misery during which she suffers from annoying fits of sneezing. Nasal congestion, which worsens at nighttime, does not allow restful sleep. She is miserable from itching in the nose, roof of the mouth, and throat. Her eyes itch and water. No wonder she is not looking forward to springtime. Rachel is suffering from hayfever. Hayfever is a misnomer because patients do not develop fever. The medical name for hayfever is allergic rhinitis. Typically, Rachel’s symptoms start in March. In some years, her symptoms start in late February. Frustrated, Rachel asked, “What is in the air?†During spring, pollens of trees cause allergic symptoms. In our region pollens of Rocky Mountain Juniper, Cottonwood, American and Chinese Elm, Ash, etc., are the culprits. Chopping them down is not the solution as their pollens float into the air and can get carried away by wind for miles. “Dr. Patel, what time of day should I not venture outdoors?†Rachel inquired. Besides closing the windows and turning an air conditioning on in the house and car, I do not recommended drastic lifestyle altering measures because they are not practical and most are minimally effective. With modern treatment programs, doctors can relieve the suffering. “Initially, for the first few days, Claritin, which I purchased over the counter, seemed to help somewhat; but, it doesn’t work anymore,†Rachel reported. Now Claritin, an antihistamine, has become over the counter; of course, it is fairly expensive. Antihistamines, as a group, have been around for many years; names such as Benadryl, Chlor-Trimeton, Tavist-1 and many others are very familiar Oral antihistamines may reduce sneezing, itching, and runny nose in addition to watery, itchy eyes. Typically, antihistamines do not help nasal congestion. So, pharmaceutical companies combined antihistamines with oral decongestants such as pseudoephedrine — Sudafed being the popular brand name. Older antihistamines such as Benadryl and Tavist are sedating and may affect cognitive and motor function, even without obvious sedation. Newer antihistamines such as Claritin, Clarinex, and Allegra are non-sedating. Antihistamines may cause bladder retention in persons with enlarged prostate. With the availability of Claritin over the counter, some insurance companies are asking patients to try Claritin first before approving other antihistamines such as Allegra, Clarinex, or Zyrtec. Some insurance companies are asking patients to pay substantially high co-pays for prescription antihistamines. “Dr. Patel, should I try something else over the counter? I cannot decide what to choose, as a plethora of products are available over the counter for treatment of nasal and sinus symptoms,†Rachel inquired. Grouping the available over-the-counter medications as follows will help in the selection of appropriate medication: Pure antihistamine a. Over-the-counter: Benadryl, Tavist-1, Claritin and many others. b. Prescription: Allegra, Clarinex, Zyrtec and others. Pure oral decongestants such as pseudoephedrine, Sudafed, and phenylephrine. Patients with high blood pressure should check with their doctors before using oral decongestants. Combination of oral antihistamine and decongestant such as Allegra-D, Claritin-D, Zyrtec-D and others. Addition of acetaminophen, Tylenol, to antihistamine and decongestant. For example, Dimetapp Cold and Allergy Tablets contain acetaminophen, a pain reliever, chlorophenamine, an antihistamine, and phenylephrine, a decongestant. Guaifenesin is supposed to help with mucous, and drug companies combine it with antihistamines and/or decongestants. For example, Dimetapp Cold and Congestion Caplets contain dextromethorphan, a supposed cough suppressant, guaifenesin, supposedly an expectorant, and pseudoephedrine, a nasal decongestant. Dextromethorphan: Companies add it to combination products to reduce the cough. I am not sure how much dextromethorphan helps the cough. As I am discussing, antihistamines let me mention an intranasal antihistamine, Astelin, which is available only by prescription. It can cause sedation in some and has an unpleasant taste. Of course, many more options are available for treatment of hayfever. In future columns, I will address cortisone nasal sprays and the role of a leukotrine modifier, Singulair, which has been recently approved for treatment of allergic rhinitis. By the way, cromolyn, NasalCrom, is available over the counter. NasalCrom may help mild hayfever symptoms, but a patient has to use it 4-6 times per day for it to be effective. I, myself, would have difficulty in using a medication 4-6 times a day, every day. I advise my patients not to use nasal decongestant sprays such as Afrin, which when stopped can cause rebound nasal congestion and eventually are habit-forming. Ashok Patel, MD, Allergist, Academy Allergy, Asthma, Sinus & Immunology Center
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