So your nose is running? Where’s it going?

Elementary school humor aside, I know what a bothersome thing rhinitis (inflammed nasal passages) can be. The poorly kept secret about allergists is that almost all of us have allergies and so we can empathize really well with our patients. I struggle with allergic rhinitis almost every day of the year (so does Dr. Haberle).

But you didn’t come here to learn about us. Pretty frequently I get to see patients who are really frustrated because their allergic rhinitis isn’t any better on over the counter allergy medications and they want the good stuff.

Fact #1:
The best medicines are all available over the counter. Since July 2013 two different nasal steroid sprays, Triamcinolone (Nasocort) and Fluticasone (Flonase), have become available over the counter (OTC). These OTC versions are the same medication in the same dose that you get when you fill a prescription. It still might be less expensive to get a prescription depending on how your insurance covers these medications, but the OTC versions are just as good.

A concern I often hear: “I’ve tried several nose sprays and every anti-histamine [Diphenhydramine (Benadryl), Loratadine (Claritin), Fexofenadine (Allegra), and Cetirizine (Zyrtec)] and nothing has worked I need allergy shots.”

Not all that drips and runs requires prescriptions.
Not all that drips and runs requires prescriptions.

Fact #2:
Not all that sneezes is allergy. Without getting too technical, “allergy” in the sense that Allergists and Immunologists use the term usually describes a type 1 hypersensitivity reaction involving IgE, mast cell degranulation and histamine. This reaction is really well characterized and it is what we are trying to treat with allergy medications. Unfortunately, there are lots of reasons why your nose may run or be congested that have nothing to do with this reaction. If that is the case allergy medications are generally really not as useful, some are completely useless.

Q: “How do I know if my miserable nose and sinuses are due to allergies?”

A: Your story means a lot to an allergist. It’s why we ask really specific questions when you tell us you have “all the allergic symptoms”.

What are your symptoms? Congestion, runny nose, and post nasal drip are common allergic symptoms, but they are also common non-allergic symptoms. Itching is uncommon to non-allergic causes. Itchy eyes, nose, and ears are big keys for me. If your eyes itch like crazy along with your runny nose then I’m a lot more confident we’re talking allergies. If you nose is really stuffy without itching then I start to wonder.

When did you start having symptoms? – Though not impossible most people develop allergies as children and have been dealing with them most of their lives. It’s not impossible to develop allergic symptoms as an adult, just less likely.

When are your symptoms? – Most people with allergies have a “season”. Common allergens are plant pollens and plants generally pollenate at specific times of the year. Even people who are allergic to “everything”, like me, have different symptoms depending on the season. If your nose knows no season then maybe it’s not allergies.

What makes them better? – Most people end up in my office because “nothing works” or common medications aren’t doing enough. I mentioned before “allergies” are a well characterized sequence of events. Because we know what is happening drug companies have been really aggressive about tracking down ways to stop the reaction itself and the effects of the reaction. The newer anti-histamines [Loratadine (Claritin), Fexofenadine (Allegra), and Cetirizine (Zyrtec)] are very potent and specific for the types of receptors that are key to causing runny nose and itch. Many folks think these medications aren’t doing anything until they stop them. It’s one of the helpful cheats we allergists use. We generally have people stop medications for a week before they see us in case we do skin testing. I’ve had countless patients tell me one of two stories. #1: “I didn’t think Loratadine was doing anything, but this past week has been extra miserable”. Not surprisingly these people are almost always allergic. #2: “Nothing has changed at all since I stopped my medications”. Not surprisingly these folks are very often NOT allergic.

What makes your symptoms worse? – This can be a little tricky. Many patients with allergic noses are also sensitive to irritants as well, but some patients get symptoms that are basically the same as allergies, but they get there through another route of things going wrong. Common culprits are

1) Strong smells: perfumes and cleaning agents.
2) Small particles: dust, cigarette smoke, exhaust fumes, molds, and mildews.
3) Activities: eating spicy foods, or strenuous exercise.
4) Meteorological: does your nose know when the weather is changing?

If these are the main triggers of your symptoms rather than a season I start to think hard about whether or not you are allergic.

Fact #3:
Not being allergic isn’t the end of the world. I say this as a joke because patients often seem disappointed when I tell them they aren’t allergic. We can still figure out how to make you feel better.

If you are allergic, I’m sorry. I really am. We can work on that too.



As my clients get older, especially over the age of 75, it’s vitally important to review the necessity, risks, and side effects of each medication and supplement on a regular basis and stop some of these pills. We call this “deprescribing,” and this may help the elderly life longer, with higher quality lives and functionality.

Below is a video that describes my process for deprescribing perfectly. Ignore the cheesy intro and music.
More from #IM2015 soon!

#IM2015 – ACP Boston – Who’s going?

UnknownJust by way of brief posting before my next blog post, I’m taking poll of anyone who is going to ACP 2015 in Boston this coming week. There are a group of us meeting up. So any tweeps, blog followers, or residency colleagues that are interested in meeting up, please let us know! Comment here, leave a post on my Facebook page, or send me a direct message on Twitter @cheeler.

I’ll be live tweeting and blogging the ACP meeting Thursday – Sunday focusing on geriatric care, preventative medicine, patient-guided/centered care, hospice and palliative medicine, and deprescribing. Remember folks: Less is more… except for exercise.

More soon!

“How hard do I really have to exercise?”

I am frequently asked in my clinic, “How hard do I really have to exercise to have health benefits? Is walking a little every day enough? Or would it be better for me to run really hard on a treadmill, which I can only do a few times a week, if that?”

It’s a very good question, and one that’s sometimes difficult to answer, depending on my client’s/patient’s preferences and goals (I’m starting to not like the word “patient.” Contextually, it feels like the person at the end of the paternalistic treatment-stick). A good study published last month in the Annals of Internal Medicine gives us a little bit more information about the question, “Which is more important, exercise amount (duration) or exercise intensity?”

The people enrolled in the study were all obese. They had large bellies and BMI > 30. Each person was randomly assigned to one of four “treatment” groups:

  1. Keep doing what you’re doing (the control group, basically no exercise).
  2. Do low intensity, low duration exercise (example, walking daily for 30min).
  3. Do low intensity, high duration exercise (example, walking daily for 60min).
  4. Do high intensity, high duration exercise (example, running daily for 40min).

The study lasted for 6 months. The results showed that among all of the exercise groups, there was a similar amount of waistline reduction (about 1.5 inches) and weight loss. Compared to the control group, the exercise groups had all done much better but there really was no difference between the exercise groups. They all benefited about the same.

Current guidelines recommend 75 min weekly of high intensity exercise (biking, jogging, etc) or 150 min of low-intensity exercise.

So, especially for my elderly clients, if it’s not realistic to do any high intensity exercise, try a little walking or light swimming on a more routine basis. Walking 30 minutes a session, 5 days a week appears to be just as good for your weight and waistline than hitting the stair-stepper or running a marathon.

The bottom line? Do what you can do that feels good, and do it regularly. If it’s too much, slow down and do a little less, but do it more often. A little bit of exercise is amazingly better for your health than no exercise at all.

Literature Review: CVID is Variable

I had an interesting case today that prompted me to review some literature from the immunology world. Found a great review on the clinical presentations and treatment courses of over 2000 people with Common Variable Immunodeficiency (CVID) in an article published last month in the Journal of Allergy and Clinical Immunology.

CVID is a heterogenous disorder (or, probably, and in my humble opinion, a group of many disorders stemming from myriad genetic/environmental causes) characterized by 1) Antibody deficiency which leads 2) one or more of the following:

1. Recurrent respiratory infections
2. Enteropathy
3. Autoimmunity
4. Lymphoproliferative disorders

Supposedly, the prevalance in the U.S. is somewhere around 1 in 25,000. This is probably conservative and many cases most likely go undiagnosed. For example, the community where I practice officially has 75,000 residents. I am one of at least 20-30 primary care physicians in town, and I personally have at least 4 clear cut cases of CVID in my practice alone. So, depending on the demographic, the prevalance may be much higher.

To diagnose CVID, your lovely patient must meet the following criteria:

1. Age > 2 years old
2. Hypogammaglobulinemia: Both IgG and IgA OR IgM 2 SD below the mean for age (usually the lower limit of normal on standard test reporting)
3. Absent isohemagglutinins OR Poor vaccine response.

In this report mentioned above, Europeans medical researchers analyzed data on 2212 with confirmed cases of CVID. The most common clinical feature was pneumonia (32%). Interestingly, the next most common feature was autoimmunity (29%), followed by bronchiectasis (23%), enteropathy (9%), solid tumors and lymphomas (8% combined). In my mind, it makes more sense to lump bronchiectasis and pneumonia into the same broad category, which makes lower respiratory infections the most common feature at 55%, which is still much lower than I thought it would be. Upper respiratory infections (sinusitis, etc.) was not a common clinical feature in this analysis.

The mean age of onset was — say it with me now: variable. More than a 3rd of patients were diagnosed before the age of 10, but many were diagnosed into their 70s. Children had more infections; adults had more non-infectious presentations. Maybe a way of rewording this is to say that a large portion of CVID tends to not cause overt infectious disease problems when they are young, and thus the diagnosis is delayed.

I would think that we should all be more aware of this disease and how it can present (or go undiagnosed) for years in patients of all ages. A few take home points for myself:

 – Early diagnosis and lifelong treatment with immunoglobulin replacement has been shown to lead to better outcomes, which makes everyone happy, amirite?

 – Be careful to not forget to exclude secondary causes of recurrent infections like HIV, malignancies, and cystic fibrosis in younger patients.

 – Chronic diarrhea and abdominal cramping is not an uncommon complaint in primary care visits. Maybe immunoglobulins should be included in my routine evaluation for this, considering nearly 1/10 patients with CVID present with this (maybe more, if it weren’t underdiagnosed and called IBS?)

 – The workup: CMP, CBC w/ diff, immunoglobulins, and if IgG+IgA OR IgM is low, check isohemagluttinins and/or pneumococcal vaccine titers.

First Post

Welcome to the “Tough Pills” blog. Here, we’ll be sharing our thoughts about topics both new and old in the world of medicine. The intended audience for this blog is both the clinician/health professional and consumers of the healthcare delivery system in the United States. We hope to inspire people to take more informed choices about their own healthcare and make complex medical topics a little more straightforward for the average person, by using both narrative writing as well as the typical blog-report format. Enjoy!

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