Nasal sinus rinses with saline solution

Before we discuss using nasal sinus rinses with saline solution, I think it would better to review the anatomy and physiology of the nose and sinuses. I'm going to try something new, using Youtube videos that I have screened, and also not reinvent the wheel. The nose normally makes some mucus: to protect the mucosal lining from being too dry; to wash off particles, allergens, viruses, and bacteria off of the mucosal lining; and to protect the mucosal lining against infections. When the mucosal lining of the nose is irritated, we call this rhinitis. If the cause is from allergies, we call this allergic rhinitis. The sinuses are bony caves branching off from the nose. Here is a good review of sinusitis. This video says almost the same thing.

Saline solution introduced into the nose and sinus cavities will wash mucus and anything in the mucus off the mucosal lining. Here is a good video demonstrating nasal rinses on Youtube for an adult and another for a child. Some prefer to use the Netipot. Either work for me. Any product that works for you and is cost-effective is an acceptable product. It's based on personal preference. In the top 3 photos to the right, I am demonstrating what I consider to be optimal technique: head down with chin above the eyes, saline solution being squeezed gently but persistently into the upper nostril, allowing the saline to drain out the lower nostril, mouth breathing. There is no downside when done gently. The three products (Nasaline, Ayr, NeilMed) in the bottom right photos were chosen simply because I had a sample in my office.

I am frequently asked about how much saline solution to use and how often. Mucus by its very nature is sticky, like syrup. So for the saline solution to effectively loosen the mucus up, it generally takes at least 8 ounces or 240 ml per session in my experience. I habitually rinse my nose and sinuses out at least four times per day. Why? I have several reasons. First, I am exposed on a daily weekday basis to many people. Rinsing is simply good hygiene. I have a family history of allergies, plus there's my wife with very severe allergies, and I do not want my mucosal immune system to develop allergies, so I never let the allergens build up in my nose or sinuses. Think of it as constant spring pollen cleaning. Next, I find it refreshing, like splashing cool water on your face. Finally I am exposed to patient every weekday with respiratory infections. Some of them look pretty miserable. Some of the little twerps (or to be politically correct unhappy little children) cough or sneeze point blank right in my face as I try to examine them. Whatever they have, virus or allergy or bacteria, I DON'T WANT IT. So, once I have finished their office visit, I go straight over to the bathroom for handwashing + nasal sinus rinsing.

How much saline solution is safe to use? Remember what happens when you go swimming in either a pool or the ocean. Lots of water goes up your nose. Your nose and sinuses are getting washed out very thoroughly. Think about how your nose feels after a swim. Usually it is very clear for a few hours. Why? Your nose and sinuses have most of the mucus and anything in the mucus removed. Since mucus is produced normally, the clear feeling does not last forever.

I hope this discussion tells you how I feel about nasal sinus rinsing. As my friend Linus reminded me about Chicago voters each election, they vote early and vote often. Here I recommend rinse with lots of saline and rinse often.

2008 Center for Diseases Control and Prevention (C.D.C.) Influenza Vaccine Recommendations

The Centers for Disease Control and Prevention have released their guidelines for 2008. The major change is the recommendation that children from age 5 years old to 18 years old should also get the flu vaccine, unless they have serious egg allergy. Previously, only children from age 6 months to 5 years old were recommended to receive the flu vaccine. Research has shown that school age children have higher rates of flu than the vaccinated people older and younger than they are plus these children are likely to spread flu to the general population. The new recommendation plugs this hole in our general protection wall.

Why should I be concerned about influenza? A viral infection initially of the respiratory tract which can cause severe illness in some people. The people prone to this outcome include the very young, elderly, those with respiratory or heart diseases, and those with compromised immune systems, such as with cancer. About 200,000 people are hospitalized and about 36,000 people die each year from flu infection.

When do influenza infections occur? The season may range from October until May, based on historical records. Typically the peak is in February.

When should I get vaccinated? As soon as possible. Some facts: after vaccination, it may take up to two weeks for protective levels of antibodies to be generated. Epidemics take time to be detected and it could be too late to protect you because of the time delay. Once an epidemic is detected, there is inevitably a rush for vaccinations, resulting in a local shortage, and once again no protection. Our office just got our shipment of the trivalent flu vaccine (FYI $25 - the same price as everywhere else - which you must prepay because most insurances do NOT cover this. (Bad preventative medicine.) Personal advice: check with your employer. They may subsidize this price, because they are practicing good preventative medicine for their employees. Our office provides the flu vaccination free to our employees. We're a medical office focusing on respiratory diseases. Make sense?) I plan on getting vaccinated and by this weekend ALL of my family will be vaccinated, except my 11-year-old daughter. She gets hysterical from injections, so we have compromised and will get her the nasal vaccination. This is officially called the live, intranasal influenza vaccine. It is a nasal spray. This is significantly more expensive, (I was quoted prices from $40-70 for FluMist by local providers), and not covered by insurance either. (More bad preventative medicine.) The trivalent vaccine, which most people will receive, is a live vaccine and given as an injection into the muscle, usually of the deltoid, which covers your shoulder. People may have soreness in their arm for 1-2 days. I usually have this, but it's a small price to pay for not getting an influenza infection. I had been vaccinated for flu each year since 1984, when I entered medical school. So far, there are no long-term adverse effects. Here is the CDC's information sheet on the inactivated vaccine.

Here's a tangent, mercury-free trivalent vaccine costs about $35 and is given by injection. Mercury can be and usually is used in the preparation process. People have speculated that mercury causes autism in children. There is no evidence that this is true. Otherwise we would ban mercury use altogether.

By the way, what IS a "serious egg allergy"? As an allergist, I define this as a life-threatening allergic reaction after touching or eating a food product containing egg. Life-threatening means: throat closing, trouble breathing in the chest, and/or lightheadedness or fainting. Historical information eliminates the vast majority of concerns, because it turns out it was not an allergic reaction or they have eaten eggs without any reaction. If patients have a concern, then we can skin test patients for egg allergy or the flu vaccine. It takes about 60 minutes, most of which is waiting and watching. If you have a question about this, ask your doctor before proceeding.

Age of patient	Dose of vaccine	Frequency
Children 6 months old - 35 months old, first time	0.25 ml IM	twice, 4 weeks apart
Children 6 months old - 35 months old, second or more time	0.25 ml IM	once
Children 36 months old - 8 years old, first time	0.50 ml IM	twice, 4 weeks apart
Children 36 months old - 8 years old, second or more time	0.50 ml IM	once
Children >9 years old and adults, any time	0.50 ml IM	once

This information comes from the package insert of the Fluzone vaccine, which is the only approved vaccine by injection for children.

SUMMARY: every one 6 months and older should proceed in a calm and orderly fashion to get a influenza vacation, unless they have a serious egg allergy (Cut to scene of a riot in the streets because a shipment of Wii have arrived on Christmas Eve at Toys'R Us).

More facts at http://kaoallergyasthma.blogspot.com/2008/11/importance-of-getting-influenza.html

Food Allergies: more information and the Food Allergy Initiative (FAI)

The Food Allergy Initiative is a non-profit organization founded in 1998 whose main goal is to support research to find a cure for life-threatening food allergies. Useful information can be found on their website. I find the lists of synonyms for various foods to be particularly helpful. For example, if your child has an allergy to soy, consider printing this list. The American Academy of Allergy, Asthma, and Immunology has recently recognized this organization as a partner. Congratulations. The other partners are listed in the "Websites" link in the top left corner of the blog's home page.

For those interested in how schools could care for children with food allergies and anaphylaxis could go to New York State's resource guide: Making a difference: caring for students with life-threatening allergies. This guide was developed because N.Y. state law mandated public schools have a policy for managing anaphylaxis. The guide is pretty comprehensive. What I like best is how the guide is written from the perspective of various members of the school staff. For example, the role of food service personnel and coaches, and how to prepare for field trips are discussed. Six other states have passed legislation similarly requiring policies for management of food allergies and anaphylaxis in public schools. The states are Connecticut, Massachusetts, New Jersey, Tennessee, Vermont, and Washington. To my knowledge, South Carolina has not had any proposed legislation.

Evaluation of Chloraseptic "Allergen Block"

Jennifer Lashley, a physician's assistant at our office, gave me a coupon from the newspaper (thank you!) for Chloraseptic's "Allergen Block." This product is advertised as a "drug-free way to help prevent nasal allergy symptoms by blocking indoor and outdoor allergens. Chloraseptic™ Allergen Block is a clear topical gel containing petrolatum, glycerin and other ingredients. A patented formulation process creates a positively-charged gel which blocks negatively-charged allergens on contact." [blue and italics by me.] I searched its website for more information http://www.allergenblock.com/product.html. There was no information about this "process". I do not know of any process that allows "positively-charged gel" to be kept in a tube and then spread on skin. This is physically impossible. By the way, who says that allergens are negatively charged? Otherwise, it is simply petroleum mixed with glycerin. Frankly, it sounds like a gimmick. As a professional health care advocate, I would like to see objective evidence demonstrating efficacy and safety before I recommend using any product. Therefore, I can not recommend this product.

If you have questions about this product, ask your doctor and do your own research.

ADDENDUM: 10/28/08. This is my evaluation of a similar product: Little Allergies Allergen Block.

Are all albuterol HFA inhalers created equal?

Short answer: NO. The active chemical compound (albuterol) and the propellant (HFA) are the same, but the devices are not the same. Because of the Montreal Protocol, HFA has become the preferred propellant. The albuterol HFA inhalers do work the same. They have the same number of puffs of albuterol - 200. Photos of the inhalers can be seen here. As can be seen, the inhalers differ in (1) appearance. The American College of Allergy, Asthma and Immunology created this table to highlight the other differences. (2) The excipient alcohol is not is every inhaler. (3) The taste varies because some contain oleic acid, a monounsaturated omega fatty acid. (This is found in high concentrations in olive oil and Brazilian açaí fruit.) (4) Ventolin HFA's device is the only one with a counter for the number of sprays. (5) Finally, albuterol HFA inhalers differ in price. Which is the most cost effective? This depends on what tier your insurance classifies the products, how much each product in that tier costs (consult your drug formulary handbook), and if you have any discount coupons. Be sure to ask your doctor and the pharmacist about coupons. Currently with the switch to HFA occurring, (only about 60% of patients have switched to HFA so far), there are a lot of promotions, time-limited and quantity-limited of course. I can say they all cost about cash $35-$45 before insurance kicks in.

A word of caution. There is NO generic albuterol HFA inhaler. It does not exist. If your prescription is for albuterol HFA inhaler, do not accept it. If you want an albuterol HFA inhaler, you have to choose one of these four brand-name products. Remember Maxair Autohaler is a dry-powder inhaler that is available and equally effective. Be careful and ask questions!

Epinephrine Auto-injector Holders or Carriers

I saw two men yesterday who develop anaphylaxis from insect stings. They work outside and enjoy outdoors activities. Unfortunately, neither man carried an epinephrine auto-injector, but at least they owned up to this when we spoke about their action plan. For them and others, I have listed below some links to websites for epinephrine auto-injector holders or carriers. I do not endorse any one product, since each person will have to decide for themselves the answers to questions like what color, what type of pouch, and how plus where will the auto-injectors be attached to themselves. Happy shopping and PLEASE REMEMBER TO CARRY YOUR EPINEPHRINE AUTO-INJECTOR AT ALL TIMES! Thank you.

http://www.achooallergy.com/acc-ana-tote.asp
http://www.achooallergy.com/acc-anatotetwin.asp
http://www.activeaide.com/us/
http://www.allergyhaven.com/c/epi-pen
http://www.allergypack.com/anaphylaxis/pen.html
http://www.allergypack.com/anaphylaxis/penpalcombo.html
http://www.allergypack.com/anaphylaxis/penpouch.html
http://www.kozyepi.com/faq.htm
http://www.medipouch.com/
http://www.omaxcare.com/
http://www.takeincase.com/

Food Allergy Lecture for Piedmont Dietetic Association

Here is my presentation for the Piedmont Dietetic Association on September 11, 2008. They are the Upstate Chapter of the Americian Dietetic Association. These professionals help us focus on better nutrition through research, education, and advocacy. I think that excellent nutrition is one of the pillars for a healthy life.

Smoke-free Workplace Ordinances: Cities and Counties

This map shows the state for public smoking in SC. This map is not yet available on DHEC's website, but I thought it was important to share to raise awareness. Three counties and fifteen cities have smoke-free workplace ordinances. Let's work to increase these numbers!!

Greenville's Magnificent Mile

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I propose the name "The Magnificent Mile" for the portion of Greenville's Main Street from the West End Field to the Hyatt Regency. This is an inspired suggestion. As a native of Chicago, born and educated there, I have walked many times up and down Michigan Avenue in downtown Chicago. It was dubbed the Magnificent Mile because of the many prestigious restaurants, stores, new and historic buildings, views of the Lake Michigan, and hotels that lined the avenue. I have lived in Greenville since 2000 and I consider it my home. Like Chicago's Magnificent Mile, Greenville's Magnificent Mile in just this short one mile stretch also has fine restaurants, Piazza Bergamo and Court Square, City Hall, the Peace Center, views of the Reedy River and Reedy Falls Park's Liberty Bridge, fine hotels (the Hyatt and historic Westin Poinsett), and a new baseball stadium. Show me another downtown that has so much in so little a distance. Let's hear it for Greenville's own Magnificent Mile!!

(This does not have anything to do allergies, but we had a nice walk downtown yesterday and it is MY blog ;-)If you want to learn more about South Carolina through websites of all types, go to South Carolina Blogs at Sciway.

What is the atopic march?

The atopic march refers to the natural history of atopic diseases. They include eczema (or atopic dermatitis), food allergies, allergic rhinitis (or hay fever), and asthma. There is a typical progression when you look at the prevalence of these diseases over time in a large population. (Photo from reference 4.) In genetically predisposed infants, usually eczema is the first manifestation of allergic diseases. Food allergies may also be present. Both peak by age 2 years of age and then fall off. Respiratory diseases rise and persist. 2/3 of patients with atopic dermatitis develop allergic rhinitis later in life. 1/2 of patients with atopic dermatitis develop asthma later in life. The stronger the family history of allergic diseases, particularly in the parents and grandparents, the greater likelihood one of their offspring will be affected. It's chance. The stronger one parent is affected by allergic diseases, any or all of atopic dermatitis, food allergies, allergic rhinitis, and asthma, the greater chance that each offspring will be affected similarly. Finally, to see yours or your child's future, look into the crystal ball, our own parents and grandparents health. If they have had severe or lifelong allergies and the same allergic genes have been passed on, the odds favor history repeating itself. If you can forsee this happening to yourself or your children, take preventative action now!!! Do whatever you can to reduce your or your children's allergic reactions. Consider avoidance and allergen immunotherapy. Regretably, at this point in time, medications have not been shown to alter the natural history of allergic diseases. Medications can very effectively minimize the signs and symptoms, but the underlying fire of atopy still burns on.

References:
1. Saarinen UM, Kajosaari M. Lancet 1995; 346:1065–1069.
2. Spergel JM, Paller AS. J Allergy Clin Immunol 2003; 112 (suppl 6): S118-S127.
3. Homburger HA. Arch Pathol Lab Med 2004; 128: 1028-1031.
4. Wahn U. What drives the allergic march? Allergy 2000 Jul;55(7):591-9 or http://www.worldallergy.org/professional/allergic_diseases_center/allergic_march/

When will generics become available for Singulair and Clarinex?

I gave prescription refills for a mother of a child with seasonal allergies. She asked me, "When will generics be available for Singulair and Clarinex?" Good question. I had to look the dates up - please see the table below. The dates will include when the last patent and exclusivity expires, as drugs can be approved for more than one indication and in multiple age groups. To read up on the difference between patent and exclusivity, read this. I did not include any dates for nasal sprays and inhalers for asthma because their situation is more complicated. The inhaler devices must be replicated and demonstrate that they can deliver the medication within the tolerances required. This is a difficult and expensive task. The drugs below are just either coated pills of medications or solutions, not devices + medications. Having said this, with one indication already expired, I wonder when generic drug manufacturers will attack Singulair. It is approved for the treatment of both allergic rhinitis and asthma - one of few medications to be able prove itself capable in clinical trials. It has no real competitors in its class in the marketplace. In the U.S. alone, sales totaled $3.4 billion for 2007. That's good enough for sixth place. (See my earlier post of the rising cost of medications in the U.S.) This is a very large and tempting target. Merck's annual profits are dependent on a blockbuster (defined as greater than $1 billion per year in sales in the U.S. alone) like Singulair. Fortunately for Merck, there was little downside to Singulair until recently. (Please see my post on Singulair and the risk of depression). Recall that sales of Vioxx have ceased and no blockbuster drugs are in Merck's pipeline at present. We shall see what happens during the next four years.

Back to the original question. For patients, it will be several years before generics are available, so if you need the medication, you'll have to pay. Don't forget to read how to get medications less expensively and efficiently.

Medication	Expiration date	Sales rank 2007
Singulair: allergic rhinitis	8/27/08	6
Singulair: exercise-induced asthma	4/13/10	6
Singulair: asthma	8/3/12	6
Clarinex	1/7/20	117
Clarinex-D 12 Hour and 24 Hour	1/7/20	?
Xyzal	9/24/12	?
Allegra-D 12 Hour	12/25/20	110
Allegra-D 24 Hour	5/29/18	193
Optivar	5/1/11	?
Patanol	6/10/15	129

The effect of smoking on loss of lung function over time

Today's column is dedicated to smokers. I just saw a patient that I have been seeing for the past 5 years. As my responsibility requires, I pointed out again, as I have at each visit, that her increasing symptoms, her declining lung function, and her increasing medication use are all the direct result of her smoking. Her health becomes increasingly and irreversibly affected. Her response was angrily to ask me why couldn't I give her better and less expensive medications to reduce her symptoms.

To the left is a very famous study of the effects of lung function with increasing age in groups of people who did or did not smoke. Every medical student had to memorize this chart, because we were tested on it. Even non-smokers have a mild decline in lung function over time, because their lungs are getting older. Regular smokers have a much accelerated rate of loss of lung function, resulting in a much higher chance of symptoms, disability and finally death at an early age. Interestingly, if smokers stop, the rate of decline decreases to that of the non-smokers. That's good news. The bad news is that lung function that is lost remains lost. The comment above is also stunning and true in my practice.

Conclusions: stop smoking or using tobacco products ASAP. Try not even get exposed to second-hand smoke from any tobacco products. These are inflammatory comments, especially since I'm writing this from South Carolina, whose economy is in part dependent on growing tobacco. But it's the truth.

Soon smokers at least employed by the state of South Carolina will be paying higher premiums. It's their choice.

If you have questions about smoking and accelerated loss of lung function, ask your doctor.

Guidelines for Ear Wax Removal

Today's I am writing about a very practical problem: ear wax removal. This plagues my family and many of my patients too. Fortunately, this problem has been examined by independent and well respected organizations. First, let's review some background facts. Cerumen (ear wax) occurs naturally and is actually a defense mechanism to prevent infections in the outer ear canal. The composition of cerumen varies between people and races. Cerumen should not automatically be removed unless it is causing a problem. Two examples would be interfering with drainage of water from the outer ear canal and causing reduced hearing. According a Cochrane Review,"Using ear drops to remove impacted ear wax is better than no treatment, but no particular sort of drops can be recommended over any other." Further,"water and saline drops appear to be as good as more costly commercial products." The ear, nose, throat organization, American Academy of Otolaryngology, reviewed this problem and produced a guideline, which agreed with the Cochrane Review. Use of water irrigation was most effective when done 15-30 minutes after instilling a wax removing agent into the outer ear canal. If these two steps are ineffective, then seeking medical care should be the next step, because this may involve manually removing the cerumen. There is a risk of infection or ear drum perforation, then hearing loss. They did not recommend using a Q-tip, an oral irrigator with a special tip, or ear candling. Another good summary by the American Hearing Research Foundation for this problem with good pictures can be found at here. Although this predates the AAO Guidelines, they generally agree. One more point, I like their prevention method of regularly instilling some sterile olive oil or baby oil into outer ear canals. This will soften up ear wax. I have heard this tip from several ENT doctors and I recommend it to my patients routinely.

If you have questions about removing ear wax, ask your doctor.

New medications and devices update September 2008

1. Alvesco is ciclesonide in a metered-dose inhaler that uses HFA as the propellent. NycoMed's product was approved by the F.D.A. on 1/10/08. This fall, their U.S. partner Sepracor will begin marketing Alvesco in the U.S. Alvesco has 2 dose strengths: 80 mcg and 160 mcg 1-2 puffs twice per day. Alvesco is indicated for the maintenance treatment of asthma in patients 12 years old and in adults. Alvesco's device has a dose counter built-in, starting at 120.

2. Tilade (nedocromil sodium) will no longer be available. Tilade uses CFC as the propellent and the sale of CFC products will be banned on 1/1/09. No inhaler using HFA as a propellent is planned.

3. The F.D.A. has issued an advisory in response to reports that patients have mistakenly swallowed the capsules of medication containing Spiriva and Foradil, rather than put the capsules of medication in the devices and then inhaled the medication. No one suffered any harm, nor did the patients get any benefit from swallowing the medications. Please instruct your patients carefully in the use of devices and then check routinely for their understanding.

4. Three devices using HFA as a propellent for albuterol are approved. There is no generic equivalent. The devices and package inserts are not the same, despite using the same propellent and having the same medication. No data that I am aware of that indicates any have safety issues nor one has proven superiority.

5. Verus, the manufacturer of Twinject, declared bankruptcy during early 2008. Twinject was sold to and is promoted now by Sciele. The device is unchanged. (Medical offices may already be familiar with Sciele from their other products - Rondec and Orapred ODT.) To my knowledge, the price is unchanged also.

6. My preliminary research shows that insurance companies are beginning to recognize the code 95012, which is measurement of exhaled nitric oxide, to measure airway inflammation caused by asthma. There are two devices approved for sale by the F.D.A. in the U.S. (See prior posts.) More to follow later.