Sometimes it’s a zebra.

Thanks for the vote of confidence. Start a webpage? We have already started a blog that is authored by 5 experienced MDs and that is in no way associated with any skeptical group. Its name says it all: science-based medicine. We are hoping that this blog will become the place to go for unbiased medical information.

I also suggest that in order to draw in the greatest number of rational, intelligent consumers, the ones you have the best chance of helping, that you present the site as being that of one or several experienced doctors and in no way associate it with Skeptics or Quackbusters simply because many consumers have already been convinced by the Great American Alt Marketing Machine that such groups are terribly biased and unreliable.

My allergies are not well-controlled, but I’m only allergic to fungi (not cats, trees, dust mites, house dust, etc), so I’ve been told there is no data on whether allergy shots will work for me or not (apparently being only allergic to fungi is rare enough it’s hard to find enough people to do an RCT). I’m also kinda leery about allergy shots because some simple skin testing for various fungi kicked my asthma into overdrive (in addition to leaving me with near golf-ball sized lumps for several weeks for 6/21 fungi). I’m also put completely out by Allegra (much worse than benadryl for me). I guess I’m just a physicians nightmare …

I have a friend who has a nickel allergy.. it sounds pretty nasty and makes it hard to find watches, among other things. Topical steroids, when used occasionally, seem to be pretty safe.

So, I’ve been told. Still, it is nicer that I’ve managed to control my allergies now with avoiding some allergens, and only go through one bottle of prescription allergy meds per year. Though it may have to do with age, and my immune system deciding to not freak out over every bit of pollen.

Though I do use cortisone (sp?) cream on my hands when I react to nickel.

I’m glad to hear GPs aren’t handing out steroid dose packs like candy any more. Avascular necrosis is a nasty thing. I would think even a 0.01% side effect, when pushed to a LOT of patients by GPs could result in a lot of damage (avascular necrosis often leads to total hip replacement).

I guess I’m the flip side of the coin as far as antibiotics are concerned… I always seem to have sinus/throat infections turn into bacterial infections of the lungs without them. My track record (since childhood) is quite awful on this score. It doesn’t matter if I currently have a virus when I go to a doctor… within 1-3 days, I’ll have some nasty bacterial secondary infection and once it has a foothold, it can take 2-3 weeks to go away. I was once sick for a total of two months because a doctor refused to give me a prescription for antibiotics “because you only have a virus” (then the student health clinic shut down and I couldn’t get any antibiotics when I needed them two days later. By the time I got them, it was way too late).

HCN: Newer steroid nasal inhalers use water-based suspensions/colloids and are MUCH easier on the nasal tissues (the solvent-based ones give me nosebleeds).

As a general comment, steroids are powerful, immediate immunosupressives and anti-inflammatories. One of the best reasons to use them is that they are nearly instantaneous (when compared to other stuff like methotrexate, etc.). I have no doubt that steroid nasal sprays begin to suppress your immune system within the first one to two doses.

This issue of antibiotic use for sinusitis is a bit sensitive for me because I had to get antibiotics for a sinus infection 3 weeks ago… Ten days of antibiotics cleared it up… but after being off them for about a week, it was back, with a vengeance. I just don’t seem to do well in clearing bacteria (and I never have). Ugh.

The answer: “People don’t like to leave the doctor’s office without a prescription.”

WTF?! I know it’s hard to deal with cranky people whose sinuses hurt, but isn’t this the kind of thing that brought us antibiotic-resistant staph?

Couldn’t these cases be used as teaching moments?

Very short courses of steroids for asthma, gout, etc are usually quite safe, and have little immune or adrenal suppression associated with them.”

My experience with them for hayfever (allergic rhinitis?) was that they were yucky. It may have been the solvent was irritating, but I could never ever get used to the steroid spray up my nose that was prescribed by the allergy doctor (this was in the late 1970s). I was also told I had to use them consistently over a week for them to work.

FAIL!

Fortunately, my allergies were (and are) of the sort that responded to the weekly shots (yay!… or maybe the two years of getting shots was a placebo), avoiding allergens (sorry, dear spouse, I’m allergic to dusting), and more modern medications (hurray for the ones that don’t knock you out! … and hurray for benadryl for allowing me to sleep during itchy times). Well, for a week in the Spring I do live with puffy eyes, but I can live with that… as long as I don’t have to breathe in those awful steroid inhalers. Ugh.

So I finally went to the clinic. After a cursory inspection and a diagnosis of Viral Infection DKWK*, the resident said he would give me a prescription for antibiotics.

I refused of course because if it really was a virus the antibiotic wouldn’t help the cough, but might educate little baby bacteria about developing immunity. After paying my fee, I went home, grumbling and coughing.

37 years later we’re still at it? Oh dear.

Noni

* Don’t Know What Kind

But inhaled corticosteroids have a very low incidence of systemic side effects. They aren’t associated with significant osteopenia, avn, dm, etc.

Very short courses of steroids for asthma, gout, etc are usually quite safe, and have little immune or adrenal suppression associated with them.

I don’t think it’s any wonder why nasal steroids aren’t useful for sinusitis. I am guessing that a lot of cases of sinusitis are bacterial… and steroids are powerful immunosuppressants in addition to being powerful anti-inflammatories. The benefit of shrinking of the nasal passages may be mitigated or wiped out by the suppression of the immune system. I dunno if this is actually true, but it never made much sense to me to hand out steroids for every little inflammatory condition (as seems to be the practice for at least the last 5-6 years) like asthma (associated with bronchitis/pneumonia) and sinusitis. Because of the immunosuppression inherent in steroids, this seems like it could backfire in many cases. Steroids can be used in cases where the sinus passages are extremely swollen and are can be damned helpful in cases of asthmatic bronchitis, but I think they are over-used these days.

I wonder how many GPs handing out prednisolone dose packs are aware of the small but definitely non-zero risk of avascular necrosis (aware enough to not hand them out willy-nilly, which has been my observation). It’s one thing to be aware of a risk as a statistic on a piece of paper, it’s another thing to know that even 0.1% of patients can easily be one person whose life can be forever altered by a simple steroid dose pack.

LOL! I was completing my PhD in immunology when my wife and I started trying to have a baby. I did a test for HCG (which uses run of the mill immunology techniques) with a kit only available to research and clinical labs – they weren’t available OTC 32 years ago. I found that she was pregnant, but she didn’t believe it until her OB got the results from a commercial lab.

I always make sure they feel free to come back or call me and let me know how they are doing, and that usually gets me by, but honestly, even my own wife doesn’t believe me.

I agree that we shouldn’t over-use antibiotics, but is there any talk in human medicine about the awful over-use of antibiotics in the raising of animals? Massive amounts of antibiotics are used in animals every year, whether they get sick or not, whether they are needed or not, because, statistically, animals get to slaughter weight faster if all of the animals are given antibiotics. This practice is a major source for antibiotic-resistant bacteria.

I strongly believe in using evidence to weed out useless therapies and woo-based crap, but I have often seen doctors use studies such as this one to make their lives easier (come back in a week if your ears/sinuses aren’t better). Things like this take the personal touch out of practicing medicine. Too many physicians I’ve witnessed short-circuit the decision tree completely (or completely ignore the fact that a patient may not fit on a decision tree designed for “average” populations). Having been a victim of this type of “treatment,” I’m very afraid that broad application of relatively simple-minded decision trees will leave those among us that don’t fit into these simple-minded decision trees out in the cold (even more than we are already left out in the cold).

Disclaimer: This fear of the way in which evidence-based medicine is currently being practiced is NOT an excuse for woo-based therapies, nor is it a rejection of using good evidence to make medicine better. It is simply a statement of my experiences with the treatment I get when I would never qualify for any study because my biology is so odd when reacting to most treatments.

Either doctors were intentionally excluding many patients (very unlikely) or this study truly shows how difficult it is to convince patients to “wait and see” and potentially not prescribe an antibiotic. Just 1 patient per year per for any given doctor was willing to enroll in a study wherein they were only 50% less likely to receive an antibiotic.

I advocate a wait and see approach in most cases. I do sometimes write a script and encourage parents to hold off on filling it, as a compromise. For my own daughter I would prefer she not take the antibiotic unless she clearly had an indication, and I’d wager my own family members use antibiotics far below the norm.

That would be an interesting study.

Anecdotally: I was discussing the revised AHA guidelines for antibiotic prophylaxis with my cardiologist when they first came out (antibiotic prophylaxis for infective endocarditis is no longer recommended before dental treatment in most cases). He was somewhat skeptical and his parting comment was “I hope you will continue to premedicate yourself when you get your teeth cleaned (I’ve got MVP with moderate regurgitation – for which the AHA no longer recommends prophylaxis).”

Maybe as part of the paperwork a patient fills out before their appointment they could answer questions like “Do you believe that a drug of some kind is always necessary to help you overcome your health issue?” (clearly the wording could be better, but you get my point).

I’m sure lots of patients (including me?) would see this as an annoyance, but forcing them to actually answer a question like that (rather than just read a pamphlet of facts) might make a difference.