Dec 1, 2015

Interview Transcript

Dr. Miller: Allergies, colds or something else? How do you tell and how do you treat them? That's next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Jeremiah Alt. He is an ENT surgeon. That's an ear, nose and throat surgeon. He's a member of the Department of Surgery here at the University of Utah. Jeremiah, how does one tell the difference between an allergic symptoms of nasal discharge versus a common cold or sinusitis? Is there a way to sort of know if you have one or the other?

Dr. Alt: Yeah. That's very difficult. Even very difficult for the physician to figure that out in many cases and requires a thorough history with the patient to figure some of these things out. In general, allergic rhinitis if it's seasonal will occur during the season, where if you have hay fever, you'll get itchy eyes and a runny nose.

Dr. Miller: I always think of hay fever as being itchy.

Dr. Alt: Right.

Dr. Miller: Right? So people are scratching the corners of their eyes and they're blowing and sneezing.

Dr. Alt: Right.

Dr. Miller: The back of the throat is kind of scratchy. Sometimes when I think of the common cold or sinusitis that doesn't feel very itchy. That's [inaudible 00:01:15].

Dr. Alt: Right. So the common cold will have some of the similar symptoms, as there's definitely overlap where you can have increased congestion and nasal blockage. You'd probably be more likely, though, to have some facial pain and pressure. We commonly talk about the loss of smell occurring with sinusitis. But this can also occur with allergies as the inner lining inside your nose is swollen and angry, and inflamed and it can block off some of the ability to smell.
One of the big differences though, is we commonly think of discharge. So if the discharge is yellow or green, this is more signs that this is more severe than just an allergic reaction.

Dr. Miller: More inflammation, more at that issue of infection in the sinus.

Dr. Alt: Correct.

Dr. Miller: So one goes to the store to self-remedy what they would consider to be a fairly short course of this problem. If they have rhinitis, that is the itchy symptoms, what should they be using to treat that problem with? I think most of the medications now are purchased or can be purchased over the counter.

Dr. Alt: Correct. The oral antihistamines are a great option, and they've been used for many years. The second generation are non-sedating, like the Benadryls were that can make people very tired. Although, the second generations can make some people tired.

Dr. Miller: I've taken Benadryl and it works as an antihistamine. But man, does it knock me out. I think it does the same with some people and some people, they don't seem to have that fatigue that I get or that a number of people will get.

Dr. Alt: Correct.

Dr. Miller: Now, I've heard with Claritin, which is an example that comes generic as loratadine, that it's not sedating. But do you think it works as well as something like Benadryl or diphenhydramine?

Dr. Alt: Well, partly it's also what we're targeting. The itchiness, I think, works great. Another great antihistamine is Zyrtec. So if the patient has the itchiness with the runny, drippy nose, what we call clear rhinorrhea, or clear, drippy nose, the Zyrtec is actually quite more drying than let's say the Claritin. So we would push the patient more towards the Zyrtec, which is a more drying medication.

Dr. Miller: This is also listed as a non-sedating antihistamine.

Dr. Alt: Correct. One thing to consider is even if the second generations make you drowsy or feel a little fatigued, you can also take them at night which is an option.

Dr. Miller: So sleep a little better and maybe get a little bit better coverage for the allergic symptoms.

Dr. Alt: Yeah. A third option that's more recent is a topical spray antihistamine. This is not taken by the mouth and you can spray it in the nose. This type of antihistamine, I've never seen it cause drowsiness or fatigue in patients, and you can use it on contact. So if you know you're going outside you can quick spray it in your nose to reduce the antihistamine response that you have for your allergies.

Dr. Miller: So Jeremiah, does that require a prescription or is that available over the counter?

Dr. Alt: That one is still a prescription medication. So you really need to get that from you allergist or your ENT, or your primary care doctor.

Dr. Miller: Now, there's another class of medication used to treat allergic rhinitis as well, and that would be the nasal steroids.

Dr. Alt: Yeah. So the nasal steroids actually have great evidence to be used both for allergic rhinitis and for many of the diseases that we talked about in some of the other podcasts, including chronic rhinosinusitis or reoccurring acute rhinosinusitis, where there's just an overall inflammation inside the sinonasal cavity. This just calms the inside of the nose down. It's a topical steroid. It's sprayed within the nose, usually dosed once or twice a day. What I like to think of it, it addresses the root of the problem.

Dr. Miller: The inflammation.

Dr. Alt: The inflammation, correct. So it really reduces the overall amount of goblet cells in the nose, the inflammatory, or those mediators in the nose and the immune system that are really creating the immune system to start with to create this inflammation.

Dr. Miller: Now, do you think that a patient with allergic rhinitis could also take the antihistamine orally, antihistamine nasal spray, and a topical steroid nasal spray, or should they use them separately? What's your thought on that?

Dr. Alt: It really depends on the patient's response and the overall diagnosis that you've come up with your doctor and your treatment plan. However, commonly we like to use both and we feel like patients get a good response by both blocking with an antihistamine and using a topical nasal steroid like Flonase or Nasonex.

Dr. Miller: Both of which they could get over the counter.

Dr. Alt: Correct.

Dr. Miller: It's possible that they could start their own treatment and then if things weren't going well they could end up seeing their physician.

Dr. Alt: There is a new medication, Dymista, that has actually combined the two together. So you can get it in a single spray, which patients are noting that they've really enjoyed using just one medication instead of two separate.

Dr. Miller: Now, let's say they have the common cold or sinusitis. Do the same medications work?

Dr. Alt: Yes. In general, though, we don't typically use antihistamines for chronic sinusitis unless they have a comorbidity or that's one other disease process that they also have on top of the chronic sinusitis that we want to help control symptomology. So if they have allergies and we want to help control some of that drippy nose, postnasal drip symptoms, we can add on an antihistamine. But, yeah, the steroids are great, as we talked about. It's really disease of inflammation, so that topical nasal steroid is ideal for helping.

Dr. Miller: Would you recommend using an oral, what we call, sympathomimetic, like pseudoephedrine or Sudafed for someone who has the common cold or sinusitis?

Dr. Alt: Those are really two different diseases and two different applications for that. For an acute onset cold or viral rhinosinusitis or bacterial, this can help make the patient feel better. I don't think it really helps get you over the illness quicker. But it can help improve your overall well-being. Now, in sinusitis it can also improve your overall feel of increasing your ability to breathe through your nose.
But this doesn't get at the root of the cause of the disease itself, and we commonly don't like to think of using these long-term in a disease like chronic rhinosinusitis, which is a chronic condition. You'd have to use this over potentially months and years, which we're concerned about the possibility of hypertension.

Dr. Miller: Now, you could also use the same medication as the nasal spray for a few days, I understand.

Dr. Alt: Afrin or over-the-counter oxymetazoline is a great sympathomimetic, which really reduces the overall swelling inside the nose. We commonly like to really counsel the patient that these are great short-term. So these are two to three-day treatment options, and then they really need to consider trying to come off of them.

Dr. Miller: So to wrap up, it sounds like if one has allergic rhinitis the bottom line there would be to use antihistamines orally and perhaps nasally, and also to use nasal steroids to reduce the inflammation. But when you have the common cold or sinusitis you could use an oral agent that is a medicine like pseudoephedrine or Sudafed. Or you could also use a similar compound as a nasal spray that would come as oxymetolazone [SP] or a similar compound. Then, you could also use the nasal steroids to reduce the inflammation for a short course.

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