Clinical Briefs in Primary Care
Seasonal Allergic Rhinitis
Source: Meltzer EO, et al. J Allergy Clin Immunol 2000;105:917-922.
Seasonal allergic rhinitis sufferers often choose histamine blockade as their preferred treatment, usually a second-generation nonsedating agent. Recent data suggest that leukotriene modulation is also effective in allergic rhinitis. This report details the outcome of a study comparing loratadine, montelukast, the combination, or placebo in a large (n = 460), double-blind, randomized, parallel-group trial.
Subjects were assigned to receive montelukast 10 or 20 mg PO, loratadine 10 mg PO, or the combination of montelukast 10 mg + loratadine 10 mg (or placebo) each morning for two weeks. Each subject was required to have positive skin tests to at least one of eight allergens (Bermuda grass, Johnson grass, rye grass, olive tree, oak tree, elm tree, sycamore tree, or walnut tree). Daily allergic rhinitis symptom scores were calculated based upon nasal stuffiness, runny nose, itch, sneeze, teary eyes, itchy, red, or puffy eyes, and sleep difficulties related to allergic rhinitis manifestations.
Montelukast 20 mg was not more effective than 10 mg. All active treatments were more effective than placebo for rhinoconjuntivitis quality-of-life scores. The combination of montelukast and loratadine concomitantly were at least additive in efficacy scores when compared with either agent alone. Combining leukotriene modulation with antihistamine therapy may provide a logical therapeutic choice for patients who respond inadequately to either agent alone.
Does Acute Bronchitis Really Exist?
Source: Hueston WJ, et al. J Fam Pract 2000;49:401-406.
Upper respiratory infections (URIs) occupy a prominent role in the ambulatory caseload of most primary care physicians. It has been suggested that the diagnosis of acute bronchitis may be stimulated by such factors as clinician desire to justify antibiotic administration, difficult differentiation between acute bronchitis and other URIs, and variable criteria by which the diagnosis is made. The current study was devised to ascertain if any particular clinical signs or symptoms differentiate or predict acute bronchitis rather than URI. Hueston and colleagues hypothesized that there would not be clinical differentiation of bronchitis from other URIs, except that those designated as acute bronchitis would receive antibiotics with significantly greater frequency.
Study subjects comprised the 48,000 population of ambulatory visits at the Medical University of South Carolina Family Medicine Department. ICD-9-CM coding identified subjects.
Analysis of the patients identified as having either acute bronchitis or URI indicated a significant overlap for such signs as cough, chest pain, shortness of breath, runny nose, sore throat, and wheezing. When considering all factors, cough and wheezing were the strongest independent predictors of acute bronchitis. Hueston et al conclude that the respiratory infection entities might be more simply reconceptualized under a single diagnostic umbrella as acute viral respiratory infections, rather than trying to distinguish anatomically distinct disorders.
White-Coat Normotension
Source: Selenta C, et al. Arch Fam Med 2000;9:533-540.
White coat hypertension is a well-recognized phenomenon consisting of abnormal blood pressure (BP) measurements in the office setting, in the face of normal measurements by ambulatory or home monitoring. Conventional wisdom ascribes such medical setting-associated BP increases to anxiety induced in the office setting. Whether there exists a cohort of individuals whose BP elevations might be pathologic on ambulatory monitoring, yet normal in the office setting (i.e., white-coat normotension), has not been examined.
To this end, Selenta and colleagues measured (by ambulatory monitoring) the BP of 319 individuals and compared this with office BP measurements in the same persons. All subjects were ostensibly in good health, not known to have or have had any BP problems, and were excluded if they were taking any medications known to have cardiovascular impact.
Using a definition of hypertension on ambulatory monitoring as greater than 135/85, 23% of the subjects manifest systolic hypertension, and 24% diastolic hypertension that was not captured by office BP measurement (5 office BP measurements were taken for comparison).
Office BP measurement may not be sufficient to address all those at risk of consequences of hypertension. As yet, there is no easily accessible application of ambulatory monitoring in office settings with sufficient economic feasibility that we can routinely use such monitoring to reduce white-coat hypertension and white-coat normotension.
Is There a Persian Gulf War Syndrome?
Source: Doebbeling BN, et al. Am J Med 2000;108:695-704.
A diversity of symptoms, including myalgia, fatigue, cognitive difficulty, and mood dysfunction, have been reported among persons returning from Gulf War deployment. There has been some suggestion that a Gulf War syndrome, representing a new disorder, accounts for some of these symptoms, but much controversy exists about the veracity of such a syndrome. Doebbeling and colleagues use a statistical technique called factor analysis on a large population (n = 29,010) of Iowa National Guard or Reserve soldiers, comparing data on those deployed to the Persian Gulf, with those not so deployed.
A survey research group used computer-assisted telephone surveys to assess almost 80 different symptoms and the severity of such symptoms. Ultimately, interviews included 3695 subjects, approximately half who had been deployed to the Persian Gulf. Demographic data indicated no substantial differences between the groups, including race, income, smoking, etc.
Half of the deployed veterans, vs. 14% of nondeployed controls, reported current health problems. Polyarthralgia, fatigue, joint stiffness, headaches, and memory problems were the symptoms reported differentially most frequently by deployed veterans. Factor analysis did not demonstrate the existence of a unique Gulf War syndrome. Additionally, the diversity of symptoms reported by deployed Gulf War personnel reduces the likelihood of a single disorder explanation. Though the inability to distinguish a distinct Gulf War syndrome may present frustration to those suffering a variety of symptom-complexes, it should provide reassurance that the likelihood of some new "mystery illness" is small.
Treatment of Low Back Pain with Willow Bark Extract
Source: Chrubasik S, et al. Am J Med 2000;109:9-14.
Salicin, a prodrug for salicylate, appears to be the primary active ingredient of willow bark extract (WBE). It has been used to treat fever, rheumatologic symptoms, headache, and other pain. European data about optimum dosing are unclear, as doses ranging from less than 120 mg up to 240 mg of salicin per day have been suggested. Chrubasik and associates tried two different doses of WBE in acute exacerbations of chronic low back pain. Rescue analgesia was allowed with tramadol. The measured outcome was proportion of persons free of pain without rescue medication for at least five days at the final week of treatment. Secondary outcomes included number of persons requiring rescue medication, and score on a back pain index.
The study was placebo controlled. An analysis of 110 features analyzed during the trial indicated little in the way of clinically relevant demographic differences in the three groups (placebo, low-dose WBE, and high-dose WBE) at baseline. Areas in which there were detectable differences would tend to minimize the benefit of active drug (e.g., duration of persistent pain and higher back pain scores were more often found in recipients of active drug).
There was a statistically significant difference between groups for the primary outcome of pain-free status with no rescue tramadol: 6% in the placebo group, 21% in the low-dose group, and 39% in the high-dose group. In the group of patients with baseline neurological deficits, differences between placebo and WBE were intensified: one of 18 placebo recipients vs. 25 of 43 active WBE recipients had a favorable response.
The active agent was well tolerated with few side effects. Traditional agents used to treat low back pain are not without risk, adverse events, and substantial cost. Chrubasik et al suggest that WBE may be an effective alternative to such traditional therapies.
Intermediate Doses of Aspirin Can Suppress ACEI-Induced Cough
Source: Tenenbaum A, et al. Am J Hypertens 2000;13:776-782.
The most frequent, and arguably troublesome, side effect of angiotensin-converting enzyme inhibitors (ACEIs) is cough. Changing to another class of agents resolves cough promptly, but clinicians would enjoy a tool to reduce or resolve ACEI-induced cough, short of drug discontinuation.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and thromboxane antagonists have been found to attenuate or resolve ACEI cough, but optimum dosing has been unclear. The current study evaluated aspirin (ASA) in doses of either 100 mg or 500 mg daily for nonsmoking persons suffering ACEI cough (n = 14). In order to ensure other primary disease processes were not responsible for cough, exclusion criteria included asthma, heart failure, or pre-existing NSAID treatment.
Cough was rated on a 4-point scale, from no cough to severe cough. Subjects underwent discontinuation of ACEI, upon which cough disappeared, and then rechallenge, which did again induce cough.
Low-dose ASA (100 mg) did not affect cough. Higher dose ASA (500 mg) reduced cough in all patients, resolving it in all but one. Beneficial effects occurred as quickly as 24 hours and persisted unabated through the two weeks of the trial. Though this study was brief, Tenenbaum and associates include commentary on six patients with successful cough-control enduring up to one year.
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