Preventing nose bleeds from nasal steroids

Having periodic allergic rhinitis, I have used nasal steroids with good effect. However, I am one of the 15-20% who develop nose bleeds from nasal steroids (in fact the only 2 nose bleeds of my life came from nasal steroids). This study tells me that I can try them again, just change my technique!! Nasal Steroids: Contralateral Hand-Nostril Technique Curbs Epistaxis

With the aim of pinpointing the source of the bleeding and whether it could be prevented, Dr. Nsouli’s team studied 19 patients with perennial and seasonal allergic rhinitis who were using various nasal steroid sprays and experienced recurrent episodes of mild epistaxis.

“Nasal flexible fiberoptic rhinoscopy showed that the bleeding was coming from the septum–the middle cartilage of the nose that contains a lot of blood vessels,” Dr. Nsouli explained.

This made sense, he said, because the conventional technique for delivering nasal spray–using the right hand to spray in the right nostril and vice versa–deposits much of the drug the septum. “This causes irritation and erosion of the lining of the nose reaching to the blood vessel complex and leading to bleeding,” Dr. Nsouli said.

Using an alternate hand technique–the right hand to spray in the left nostril and the left hand to spray in the right nostril–aims the medicine to the outer part of the nose, avoiding the septum and dramatically reducing epistaxis, according to the results of a 2-week test in 13 of the study subjects.

“No patient had epistaxis when they used this contralateral hand-nostril spray technique,” Dr. Nsouli, who is with Georgetown University Medical Center in Washington, D.C., said. “Now we advise all of our patients to use this contralateral technique in order to prevent bleeding and improve compliance and symptoms of allergic rhinitis.”

Now I must see if I have sufficient coordination to use the technique!!

The downside of universal care

Universal care has a big price: patients wait.

Now I must throw in a brief rant before the commenters go crazy! The article points out that Canadians have a higher life expectancy than those in the US. This statistic may or may not have relevance. We would really like to understand the difference in demographics. We would need to know the causes of death. Unadjusted life expectancy is like unadjusted surgical mortality. Extrapolating from these data are hazardous.

A potential difference between statins

We know that some statins lower LDL more than others. Some raise HDL more than others. What we do not know is whether those differences matter. This study suggests that the differences may be important. Study of Two Cholesterol Drugs Finds One Halts Heart Disease

In patients taking pravastatin, or Pravachol, made by Bristol-Myers Squibb, atherosclerosis worsened slowly over 18 months. But the disease was halted in those who took the highest dose of atorvastatin, or Lipitor, the drug made by Pfizer.

“We saw something extraordinary,” said Dr. Steven Nissen, the cardiologist at the Cleveland Clinic who directed the study of 502 patients.

“All statins are not alike,” Dr. Nissen said, adding that with pravastatin, heart atherosclerosis will worsen, but with the highest dose of atorvastatin, that is unlikely.

At the study’s start, the middle-aged, mostly male heart disease patients in the study had levels of low density lipoproteins, or L.D.L., of 150, on average. L.D.L. carries cholesterol to arteries. Atorvastatin lowered participants’ L.D.L. levels to 79, while those taking pravastatin had an average level of 110.

After 18 months, the atorvastatin patients had no change in the plaque in their arteries. But plaque increased by 2.7 percent in pravastatin patients. The study did not assess patient outcomes like heart attacks and deaths, which would have required 8,000 patients and taken five or more years.

One can also read more details on this study at theheart.org (no direct linking of articles, but it appears in the November 12th entries). This important study deserves several caveats.

• The study compares high dose 80 mg atorvastatin (Lipitor) with moderate dose 40 mg pravastatin (Pravachol). Why do they do this? Why not compare equivalent dosing?
• The maker of Lipitor funded the study. This does not bother me as much as the dosing selection.
• The study measured an intermediate endpoint – atherosclerotic plaque – not clinical outcomes. We must always urge caution from such studies, as the intermediate outcomes will not necessarily result in clinical improvements.
• I cannot find data on HDL in the descriptions of this study (from either the NY Times or theheart.org). Perhaps atorvastatin raises HDL more, thus explaining the effect. I would like to know those data.
• The data show that atorvastatin 80 mg lowers CRP levels greater than pravastatin 40 mg. Since accumulating data have convinced me of the importance of CRP, this information is fascinating.

As most good research does, this study raises as many questions as it attempts to answer. We must always remember that we rarely have definitive answers based on a single study. Rather, we must view clinical knowledge growing in fits and starts, with data accumulating over time.

If I had coronary artery disease, I would probably take atorvastatin 80 mg a day. I can afford it, and it just might help.

I will finish this rant with these quotes from theheart.org.

More information on whether the REVERSAL data do have an effect on clinical outcome will become available soon, with the results of the PROVE-IT study. This trial, in which Cannon and Braunwald are both involved, is comparing the exact same two regimens in REVERSAL but in 4000 ACS patients and has a clinical outcome as the primary end point. Results are expected at the American College of Cardiology meeting next March.

Several other clinical-end-point trials comparing high-dose vs moderate- or low-dose statin treatment are also under way. These include TNT (atorvastatin 80 mg vs atorvastatin 10 mg), IDEAL (atorvastatin 80 mg vs simvastatin 20 mg), and SEARCH (low-dose vs high-dose simvastatin).

Another reminder on drinking and marathons

I know, I have beat this horse to death. However, I just might help one person but redundantly blogging about this issue. If so, I will have done something important – Too much H20 may be a no-no

Fear of HIPAA

Read Overlawyered’s take on how physicians are responding to HIPAA. Medical privacy madness, cont’d

… Silly doctors, to be so spooked by the prospect of $10,000 fines for overstepping hundreds of pages of guidelines.