Download Adventures in Rhinorrhea

Adventures in Rhinorrhea
A Review of Sinusitis and Common Cold
Peter Adler, MD
Attending Physician UPMC Passavant
2/12/2015
Who Am I?
•
•
•
•
Graduated from UPMC EM residency in 2009
Worked at Shadyside from 2009-2013
Worked in North Carolina from 2013-2014
Now work at UPMC Passavant
Purpose of this talk
• Explain typical course of Acute Bacterial
Sinusitis (ABS) and Common Cold (CC)
• Explain evidence behind our therapeutic
options
• Reduce your internal dread when a patient
asks for an inappropriate antibiotic
Patient #1
• 35 y/o male
• 3 days of feeling “sick”
• C/o sore throat initially
– Fever yesterday to 102
– Bilateral facial pain and headache
– Nonproductive cough
• Rhinorrhea x 1 day, ST improving
• AFVSS
• Physical exam essentially WNL
Should this patient receive an
antibiotic?
1. Yes
2. No
50%
1
50%
2
Patient #2
• 30 y/o female with 7 days of rhinorrhea
– Sore throat on days 1-3, now gone
– Fever days 2-4, improved, now fever again x 1 day
– No improvement in rhinorrhea
• Facial pain is “getting worse”
– More on left than right
• Rhinorrhea is “green-colored”
• Now with dental pain
Should you prescribe this patient an
antibiotic? (1 of 2)
1. Yes
2. No
0 of
30
50%
1
50%
2
What first-line antibiotic should you
choose (assume NKDA)? (2 of 2)
1.
2.
3.
4.
5.
0 of
30
Amoxicillin
Cefinidir
Levofloxacin
Macrodantin
Linezolid
20%
1
20%
20%
2
3
20%
4
20%
5
Epidemiology of ABS/CC
• ABS costs $5.8 billion/yr
– Including all patients given the diagnosis of
sinusitis
– 11-16% of all adults will be diagnosed / yr
• Common cold costs $40 billion/yr
– Average kid gets 8-12x/yr
– Average adult gets 2-3x/yr
Ray et al. J Allergy and Clinical Immunology, Mar 1999.
What % of all antibiotics prescribed in
the US are for sinusitis?
1.
2.
3.
4.
0 of
30
5%
10%
20%
30%
25%
1
25%
25%
2
3
25%
4
Rhinorrhea Syndromes
• Rhinitis
– Involves nasal passages only
• Rhinosinusitis (Sinusitis)
– Involves nasal passages and sinuses
• 4 sinuses
– Maxillary
– Sphenoid
– Ethmoid
– Frontal
Image from http://ilmukedokterangigi.com/?p=336
dresdenplates.blogspot.com
Pathogenesis of Sinusitis
• Inflammatory response to bacterial/viral/
fungal/allergic challenge
– Increased mucus buildup and viscosity
– Ciliary paralysis or hypokinesis
– Nasal conchae become obstructed and swollen
– Mucus stagnates in sinuses
– Further infectious contamination leads to primary
or secondary infection
Risk factors
• Allergic rhinitis
• Asthma
• Nasal obstruction
– Polyps
– Foreign body
– Nasal intubation
•
•
•
•
Immunodeficiency
Tobacco smoke
Pollution
GERD?
Definitions of Sinusitis
• Acute
– Symptoms less than 4 weeks
• Subacute
– 4-8 weeks
• Chronic
– More than 8-12 weeks
• Recurrent
– 3+ episodes of acute sinusits / yr
Causes of Acute Infectious Sinusitis
• Viral
– 98-99.5% estimated
• Bacterial
• Fungal
–
–
–
–
–
Aspergillus
Candida
Histoplasma
Coccidioides
Cryptococcus
• Allergic*
What’s a cold and what’s bacterial
sinusitis?
The $$$$$$$$$$$$$$$$ Question………………………..
http://theallergypage.com/page_18.html
Time Course of URI
• Time to onset 1-3 days after exposure
• Total course of illness: 5-14 days
– Should be improving by day 7
• Clear->yellow->green phlegm color typical
• Green color of sputum DOES NOT EQUAL
BACTERIA
– But may be suggestive….like WBC for appendicitis
Uncomplicated URI vs Sinusitis
• Symptoms frequently indistinguishable from
bacterial sinusitis on days 1-5!
Clinical Features of Acute Bacterial
Sinusitis (ABS) vs Common Cold (CC)
Symptom or Sign
Sensitivity
Specificity
+ Likelihood Ratio
Maxillary toothache
18
93
2.5
No improvement with decongestants
41
80
2.1
Purulent secretion
51
76
2.1
Abnormal transillumination
73
54
1.6
Sinus tenderness
48
65
1.4
Cough
70
44
1.3
Sore throat
52
56
1.2
Headache
68
30
1.0
Prospective study, n=247 males, gold standard was x-rays, 92% sensitivity if all redhighlighted criteria present
Williams JW et al. Clinical Evaluation for Sinusitis: Making the diagnosis by history and physical
examination. Annals of Internal Medicine. 1992; 117:705-710.
Classical Guidelines for Diagnosis of
Acute Bacterial Sinusitis
• Symptoms of Viral URI for >10 days
– Or acute worsening after 5-7 days
•
•
•
•
Unilateral facial pain
Maxillary dental pain
“Moderate to Severe symptoms”
“Double sickening”
http://www.aafp.org/afp/2006/0915/p956.html
“Official Diagnosis” of ABS
• Major criteria
–
–
–
–
–
–
Facial pain/pressure
Purulent nasal discharge
Fever
Nasal congestion
Nasal obstruction
Hyposmia/anosmia
• Minor criteria
–
–
–
–
–
–
Headache
Cough
Fatigue
Halitosis
Dental pain
Ear pressure
*In a patient >7 days of symptoms.
**2 major or 1 major and 2 minor criteria.
From: Task force on rhinosinusitis: in Haro et al. Sinusitis and Rhinitis.
Harwood Nuss’ Clinical Practice of Emergency Medicine, 2005
My Strategy…….. ABS if:
• Days 1-5
– Fever, unilateral sinus tenderness, maxillary pain,
purulent discharge (if early)
• Consider delayed Abx script to start day 5-7 if trustworthy
• Days 6-14ish
– Abx if patient got better and then worsened
– If above symptoms present and not improving
• More than 2/3 weeks
– Not ABS…..consider recurrent ABS or chronic
Of course…………
• There are some patients who you can’t convince they
have a virus
• Try and educate but know when to quit
– Kids are exception
http://www.gponlin
e.com/consultationskills-staying-calmangrypatients/article/105
1676
Diagnostic tests
• Imaging?
– X-ray
– CT
– MRI
• Rhinorrhea culture
– Typically contaminated
– Reserved for refractory sinusitis
• Done by trained ENT, not us
Imaging
• Xrays
– AP view (Caldwell)
– Occipitomental 4-view (Waters)
– Complete sinus opacification
– Mucosal thickening >4mm
– Air fluid level
• CT – mucosal thickening
• Ultrasound?
– “back wall echo”
Ghorayeb.com
Imaging
• X-rays
– Poor specificity and sensitivity
– No longer routinely used
• CT
– Test of choice but…..
• Mucosal thickening seen in 40% of asymptomatic patients
– Best test to evaluate for sinusitis complications
• MRV
– Test of choice to rule out Cavernous sinus thrombosis
Cavernous Sinus Thrombosis
http://doctorspiller.com/cavernoussinus.htm
Complications
•
•
•
•
•
•
Periorbital/orbital cellulitis/abscess
Meningitis
Cavernous sinus thrombosis
Epidural/subdural empyema
Brain abscess
Maxillary sinusitis as a complication of dental
abscess
Chronic Sinusitis
•
•
•
•
Greater than 8 weeks of symptoms
Nasal steroids have shown benefit
Antihistamines helpful
Oral steroids also possibly beneficial but
studies mixed
– Seems more useful if nasal polyps present
• Saline irrigation also helpful
– Not well-studied in acute sinusitis
Treatment of ABS/URI
• Antibiotics?
– Do we need them?
– Which ones?
– How long?
•
•
•
•
•
H1 antagonists?
Alpha agonists?
Nasal Saline?
Vitamin C?
Zinc?
You diagnose ABS. What is the role of
an antibiotic in your management?
1. None, you don’t
need to give one
2. Patient will get
better anyway, just
faster with abx
3. The disease will
spread or not
improve w/o abx
33%
1
33%
2
33%
3
Are antibiotics necessary at all?
• Let’s look at the data.......
Abx vs Placebo at 7-15d
Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW, Mäkelä
M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews
2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2
From: Rosenfeld et al. Clinical Practice Guideline: Adult Sinusitis.
Otolaryngology-Head and Neck Surgery. 137, S1-S31. 2007.
Conclusions: Abx for ABS
• Antibiotics seem to decrease time to cure
– Avg. 12 days with placebo
– Avg. 8 days with antibioitic
– No change at 2 weeks
• No change in complication rates in
immunocompetent patients
• Adverse side effects (RR=1.75, ARR=0.11)
– Diarrhea
– GI upset
– Allergic reaction
Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M.
Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews
2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2
Duration of antibiotic
• Classical teaching = 10 days
– Allows for extra time for antibiotic to penetrate
nasal mucosa and into mucus
• Meta-analysis………
Falagas et al. Effectiveness and safety, etc. British Journal of Clinical Pharmacology.
2008. 67:2, 161-171
Meta-analysis of clinical success for short course (3-7 days) vs. long course (7-14
days)
Adapted from: Falagas et al. Effectiveness and safety, etc. British Journal of Clinical Pharmacology.
2008. 67:2, 161-171
Conclusion
• Duration from 3-14 days doesn’t seem to
matter
• Studies indicate 7 day course may give optimal
treatment
So antibiotics may be somewhat
helpful….which one(s) should I use?
Which antibiotic should NOT be used
for first-line therapy
1.
2.
3.
4.
5.
Azithromycin
TMP/SMX
Amoxicillin
Moxifloxacin
Clarithromycin
20%
1
20%
20%
2
3
20%
4
20%
5
Bacteria in Sinusitis
Organism
% isolates/ Adults
% isolates / Children
Streptococcus pneumoniae
41
41
Haemophilus influenzae
35
27
Anaerobes
7
0
Streptococcal species
7
7
Moraxella catarrhalis
4
22
Staphylococcus aureus
3
0
Other
4
4
Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed. 2009. “Sinuisitis”
First line antibiotics
• Amoxicillin
– Amoxicillin/Clavulanate?
• Bactrim
• If allergic:
– Azithromycin
– Clarithromycin
Rosenfeld et al. Clinical Practice Guideline: Adult Sinusitis. OtolaryngologyHead and Neck Surgery. 137, S1-S31. 2007.
Second line antibiotics
• Use if patient failed a 1st line antibiotic in past
month
– Wait at least 7 days before diagnosing treatment
failure*
– Amoxicillin/Clavulanate
– Quinolones
– Doxycycline
– 2nd/3rd generation cephalosporins
Rosenfeld et al. Clinical Practice Guideline: Adult Sinusitis. Otolaryngology-Head and
Neck Surgery. 137, S1-S31. 2007.
Antibiotics for Common Cold (CC)
• Cochrane Review 2013; abx vs placebo for CC
– Pooled RR of .95; (95%CI 0.59-1.51); N=1047
– RR of 2.62 (95%CI 1.32-3.21) for side effects with
antibiotics
– “Routine use of antibiotics for common cold not
recommended”
Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis.
Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD000247. DOI:
10.1002/14651858.CD000247.pub3.
Non-antibiotic therapies
• Will focus on CC, but most therapies hold for
ABS as well……..
Treatment options for Common Cold
(CC) and adjuncts to ABS therapy
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•
•
NSAIDs
Antihistamines
Decongestants
Complementary and Alternative Medicine (CAM) options
–
–
–
–
–
Echinacea
Garlic
Vitamin C
Zinc
Steam
• Ipratropium IN
• Others
NSAIDs for CC
• 9 RCTs, n=1069
– No significant change in symptom score
– No significant change in CC length
– No significant change in cough, rhinorrhea
• Significant benefit in headache, ear pain,
myalgias (as expected)
– Significant benefit in sneezing
– OR 2.94 (95%CI 0.51-17.03….2 studies) for side
effects
Kim SY, Chang YJ, Cho HM, Hwang YW, Moon YS. Non-steroidal anti-inflammatory
drugs for the common cold. Cochrane Database of Systematic Reviews 2013, Issue 6.
Art. No.: CD006362. DOI: 10.1002/14651858.CD006362.pub3.
Analgesics for cough
• DCRCT in 1992, n=79 with CC, Naproxen vs
placebo
– 29% reduction in 5 day symptom score (95%CI 1642%)
– Pooled symptoms include headache, myalgia, malaise,
and cough
– Some texts will cite this study to say Naproxen is good
for cough
• No good data on NSAIDs for cough
• CR: No good data on codeine or opioids for
cough/congestion
Sperber SJ, Hendley JO, Hayden FG, Riker DK, Sorrentino JV, Gwaltney JM. Effects
of Naproxen on Experimental Rhinovirus Colds: A Randomized, Double-Blind,
Controlled Trial. Ann Intern Med. 1992;117:37-41.
Antihistamines for CC/ABS
• Monotherapy provides no benefit at any age (12
trials as of 2003, 1 showed marginal benefit)
• Side effects of dry mouth, thicker nasal mucus
• 2nd generation antihistamines also ineffective in
monotherapy
• Last review from 2003, multiple endpoints
De Sutter AIM, Lemiengre M, Campbell H. Antihistamines for the common cold. Cochrane
Database of Systematic Reviews 2003, Issue 3. Art. No.: CD001267. DOI:
10.1002/14651858.CD001267.
Decongestants
• Pseudoephedrine
– Behind counter, limited availability
• Phenylephrine
– Similar to, but weaker than, pseudoephedrine
• Oxymetazoline (aka Afrin)
– IN only
• All are alpha-agonists
– Cause vasoconstriction to nasal mucosa
Oxymetazoline (Afrin) IN
• No Cochrane review, looked at PubMed
• German trial 2005, n=247, Afrin vs placebo
– Duration of rhinitis decrease from 6->4 days
– 84% treatment arm vs 44% placebo arm reported
“very good” reduction of symptoms
– Effect most pronounced on day 2
• Surprisingly that’s all I could find for placebo
controlled trials for non-allergic rhinitis!
• Rhinitis medicamentosa….3 days only for spray
Oral decongestants Alone
• 6 studies, n=643, (MD -.24)
– 2 studies with benefit, 4 without
– Benefit marginal at best
• Side effects (OR 1.43):
– HTN, insomnia, headache
Taverner D, Latte GJ. Nasal decongestants for the common cold. Cochrane
Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001953. DOI:
10.1002/14651858.CD001953.pub3.
Antihistamine-Decongestant Combos
• Not helpful by themselves, but when their
effects combine……..
Antihistamine-Decongestant combos
• Pooled data on 6 trials, n=309
– For severity of symptoms OR 0.27 (95%CI 0.15-0.50)
• NNT=4.4 (95%CI 3-5.6)
• Studies in adults and “older children” only
– No similar effects in young children
• Side effects (OR 1.58)
–
–
–
–
Dry mouth
Somnolence
Dizziness
Hypertension
Taverner D, Latte GJ. Nasal decongestants for the common cold. Cochrane Database of
Systematic Reviews 2007, Issue 1. Art. No.: CD001953. DOI:
10.1002/14651858.CD001953.pub3.
Antihistamine-Decongestant Severity
De Sutter AIM, van Driel ML, Kumar AA, Lesslar O, Skrt A. Oral antihistamine-decongestantanalgesic combinations for the common cold. Cochrane Database of Systematic Reviews 2012,
Issue 2. Art. No.: CD004976. DOI: 10.1002/14651858.CD004976.pub3.
Antihistamine-Decongestant Side
Effects
De Sutter AIM, van Driel ML, Kumar AA, Lesslar O, Skrt A. Oral antihistaminedecongestant-analgesic combinations for the common cold. Cochrane Database of
Systematic Reviews 2012, Issue 2. Art. No.: CD004976. DOI:
10.1002/14651858.CD004976.pub3.
Antihistamine/Decongestant combo
• Actually works!
• Side effects (OR 1.58)
– Dry mouth
– Somnolence
– Dizziness
– Hypertension
Taverner D, Latte GJ. Nasal decongestants for the common cold. Cochrane Database
of Systematic Reviews 2007, Issue 1. Art. No.: CD001953. DOI:
10.1002/14651858.CD001953.pub3.
Ipratropium Bromide (Atrovent) IN
• Cochrane Review (CR) 2013
– Metaanalysis of 7 trials, n=2144, all adults
– Can improve rhinorrhea by 15% on average
– No effect on “nasal stuffiness”
– Side effect profile (OR 2.09)
• Epistaxis
• Nasal dryness
– No studies I could find on nebulized Atrovent
AlBalawi ZH, Othman SS, AlFaleh K. Intranasal ipratropium bromide for the common
cold. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD008231.
DOI: 10.1002/14651858.CD008231.pub3.
Complementary and Alternative
Medicine (CAM) Options
•
•
•
•
•
•
•
Echinacea
Garlic
Steam
Honey
Vitamin C
Zinc
Will focus on illness incidence, severity, and
duration
– Ratio of efficacy to side effects important
Echinacea vs Placebo for CC: Incidence
Karsch-Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.:
CD000530. DOI: 10.1002/14651858.CD000530.pub3.
People dropping out of Echinacea
trials due to side effects
Karsch-Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea for
preventing and treating the common cold. Cochrane Database of Systematic Reviews
2014, Issue 2. Art. No.: CD000530. DOI: 10.1002/14651858.CD000530.pub3.
Echinacea vs placebo for CC: Severity
Karsch-Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea
for preventing and treating the common cold. Cochrane Database of Systematic
Reviews 2014, Issue 2. Art. No.: CD000530. DOI: 10.1002/14651858.CD000530.pub3.
Echinacea
• 24 DBRCTs, n=4631
– 12 trials on prevention……most showed some benefit
– Post hoc pooling of data showed 10-20% RRR
• 2 trials on CC (common cold) cure showed no
benefit for therapeutics
• Many people drop out of trial due to side effects
– 7% have allergic rash, rare anaphylaxis
• CR authors: Not recommended at this time
– Never for kids<12
Karsch-Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea for
preventing and treating the common cold. Cochrane Database of Systematic Reviews 2014,
Issue 2. Art. No.: CD000530. DOI: 10.1002/14651858.CD000530.pub3.
Herbals/CAM
• Garlic
– 1 trial met inclusion criteria for Cochrane, n=146
– Prevention trial for 12 weeks
– 24 got CC in tx arm, 65 in placebo
– No reliable treatment trials
Lissiman E, Bhasale AL, Cohen M. Garlic for the common cold. Cochrane Database
of Systematic Reviews 2014, Issue 11. Art. No.: CD006206. DOI:
10.1002/14651858.CD006206.pub4.
Steam
• Warm, Humidifed air
– 6 trials, n=394
– Overall symptom relief for CC; OR 0.31 (95%CI
0.16-.60)
• No change when specific symptoms evaluated directly
– No change in viral shedding
– Minor side effects
– CR authors: No enough data to recommend
Singh M, Singh M. Heated, humidified air for the common cold. Cochrane
Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001728. DOI:
10.1002/14651858.CD001728.pub5.
Nasal Saline
• No good trials
– CR: No evidence to give recommendation
• I recommend it because there is essentially no
risk and it’s something we can do
Vapor Rub
• (1 study, n=138) shows Likert scale change of 1
for multiple markers compared to placebo
– 12/44 “skin burning” side effects
– Marginal benefit in all markers EXCEPT rhinorrhea
Honey for cough
• Study in 2007, DBRCT, kids age 2-18, n=105, 3
tx arms (honey, DM, placebo), patients with
URI
– No improvement in DM arm
– Average around 1 point Likert scale improvement
with honey
Ian M. Paul, MD, MSc; Jessica
Beiler, MPH; Amyee McMonagle,
RN; Michele L. Shaffer, PhD;
Laura Duda, MD; Cheston M.
Berlin Jr, MD
Effect of Honey,
Dextromethorphan, and No
Treatment on Nocturnal Cough
and Sleep Quality for Coughing
Children and Their Parents
Arch Pediatr Adolesc Med.
2007;161(12):1140-1146.
doi:10.1001/archpedi.161.12.11
40.
Honey
• Honey (particularly Buckwheat) for cough
– Cochrane review based on 2 studies, n=154
– 1-2 tsp PO qhs
– No effect on rhinorrhea
– Significant effect on cough, better sleep for child
and parent
Honey vs Placebo for cough in kids
Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE. Honey for acute cough in
children. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.:
CD007094. DOI: 10.1002/14651858.CD007094.pub4.
Vitamin C
• 29 RCTs, N=11306 (!) for prevention/incidence
– Pooled RRR of 0.97% (95%CI 0.94-1.00)
• May be better for those doing distance training in cold
weather…… RRR of 0.48
• 31 RCTs on cold duration, n=9745
– Adult duration decreased 8% (95%CI 3-12%)
– Children’s duration decreased 14% (95%CI 7-21%)
Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold.
Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000980.
DOI: 10.1002/14651858.CD000980.pub4.
*Note the following 3 slides were also taken from this article
Incidence; Taking
chronically
Incidence: Taking chronically,
exposed to physical
stress/cold
Duration; Taking Vit C
chronically; adults
Duration; Taking Vit C
chronically; children
Severity: Taking Vitamin C Chronically
Duration: Taking Vitamin C when sick
Severity: Taking vitamin C when sick
Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane
Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000980. DOI:
10.1002/14651858.CD000980.pub4.
Vitamin C Conclusions
• Vitamin C works well, if taken chronically, to
decrease severity and duration of colds, but
not their incidence
• May work slightly better in kids
• Data less clear if you start it when sick
• Few side effects
• Cochrane authors: CC patients should test on
an individual basis whether or not to take
Vitamin C
Vitamin C caveats
• For some reason, better in really cold climates
– Canadian studies show more benefit than
American
• Also better in times of severe physical stress
– Trying to mitigate your cold before a sporting
event
• May not be generalizable to our population
Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane
Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000980. DOI:
10.1002/14651858.CD000980.pub4.
Zinc
• Comes in many forms
– Losenge, tablet, nasal spray, etc.
• 16 treatment trials n=1387
• 2 prevention trials n=394
Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews
2013, Issue 6. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub4.
Zinc vs Placebo: Incidence
Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic
Reviews 2013, Issue 6. Art. No.: CD001364. DOI:
10.1002/14651858.CD001364.pub4.
Zinc vs placebo: duration
Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2013,
Issue 6. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub4.
Zinc vs Placebo: Severity
Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews
2013, Issue 6. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub4.
Zinc
• Marginal effect on Duration of symptoms
– Average of -1.03 days (95%CI -1.72 to -0.34)
– Studies about 50-50 as to showing benefit at all
• Trend toward improvement of severity, but
not significant
• Incidence is lower if taken chronically RRR
0.64 (95%CI 0.47-0.88)
– Based on 2 small studies
Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews
2013, Issue 6. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub4.
Zinc
• Side effects OR 1.58 (95%CI 1.19-2.09)
– Most benign (GI, etc.)
• 2 major effects
– Disrupts copper metabolism-> can lead to
elevated saturated fat levels
– Can cause permanent anosmia (FDA warning,
2009)
• More common in intranasal form (DO NOT USE)
Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews
2013, Issue 6. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub4.
Zinc Conclusions
• 50/50 chance will decrease CC duration by
average of 1 day
• Non-significant trend towards decreased
severity of CC symptoms
• Must take within 24 hours of symptom onset
to have effect
• Take >75mg/day for full effect
Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews
2013, Issue 6. Art. No.: CD001364. DOI: 10.1002/14651858.CD001364.pub4.
A Comment about Dextromethorphan
and Guaifenesin
• Most trials on these are industry sponsored
• CR: No clear evidence one way or another
• UTD: Common cough medicine ingredients include
guaifenesin and dextromethorphan; these are often
combined with other medications in over-the-counter cold
formulas. However, the benefit of cough medicines is likely to
be small to non-existent. In clinical trials, cough suppressants
were no more effective in reducing the duration or severity of
coughing due to cold than a placebo (a non-drug substitute).
• Translation: they may work but have not been proven
Sexton et al. Patient information: The common cold in adults (Beyond the Basics).
http://www.uptodate.com/contents/the-common-cold-in-adults-beyond-the-basics.
Jan 2015
Things that DON’T work for CC
treatment in adults
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•
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•
•
•
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•
•
Steam
Vitamin E
Oral Steroids
Antibiotics
Antihistamine monotherapy
Codeine
Albuterol (unless wheezing)
Nasal Steroids
Nasal irrigation (1 RCT, therapeutics only)
Vitamin C
Dextromethorphan (mixed outcomes…..cough only)
Guaifenesin (mixed outcomes….cough only)
Things that MAY work in CC in adults
• Ipratropium Bromide
– IN (well-studied) or inhaled/NEB (not well studied)
• NSAIDs
– Only for pain/fever symptoms
• Decongestants alone (marginal)
– Topical seems ok for 3 days
• Zinc (may decrease duration by 1 day)
– Take 75mg/day within 24 hours for 5 days
• Vitamin C
– Better in certain subgroups
Things that DO work in CC in adults
• Antihistamine/decongestant combos
– NNT=4.4
– Caution side effects
• HTN
• Rhinitis medicamentosa with oxymetazoline
Important Information about kids
• They are not little adults…….
– When it comes to cold meds
• Any kid under 4 should not be given any OTC
oral med for cough/cold
– Exception: NSAIDs/Tylenol
– Honey ok for age>1yr
– Some studies indicate<age 6
Things that don’t work for kids to treat
CC/ABS
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•
•
•
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Fluids
Antibiotics
Dextromethorphan
Antihistamines
Decongestants
Antihistamine/decongestant combos
All Steroids (unless asthmatic/wheezing)
Echinacea
All OTC Antitussives
JULIA FASHNER, MD; KEVIN ERICSON, MD; and SARAH WERNER, DO.
Treatment of the Common Cold in Children and Adults. Am Fam Physician.
2012 Jul 15;86(2):153-159.
Things that MAY work in kids
• Saline irrigation/nasal spray
– No good studies on therapeutics
• NSAIDs
– For pain and fever
• Ipratropium bromide IN
– Not well studied in kids, beneficial in adults
• Zinc
– 14% severity improvement in kids vs 8% improvement in
adults if taken within 24 hours
• Honey – 1-2tsp qhs for 3-5 days
• Vapor Rub – one application
What I would have said before this talk
(adults and kids)
•
•
•
•
Suck it up
Drink plenty of fluids
Nasal saline PRN
7-10 days to get better
– 10-14 days for bronchitis
• OTC meds don’t work
What I will offer now (adults)
• Antibiotic for ABS only if diagnosis highly
suggestive
• If you feel the need to give something for CC
– Antihistamine/decongestant combo if not
contraindicated
• Or Afrin IN for 3 days
– NSAIDs for pain or fever
• If you feel the need to do more
– Ipratropium bromide IN for rhinorrhea
– Nasal Saline
– Zinc lozenge if for 5 days if sx <24hours
What I will offer now (kids>4)
• ABS is rare, abx only if highly suggestive
• If you feel the need to do something for CC
– NSAIDs for pain/fever
– Buckwheat honey (2 tsp qhs)
– Saline nasal spray
• If you feel the need to do more
– Ipratropium bromide IN for rhonorrhea
– Zinc lozenges for 5 days (if presenting within 24
hours)
What I will offer now (kids<4)
•
•
•
•
ABS basically nonexistent
Bulb suctioning +/- nasal saline
NSAIDs for fever
If you feel the need to do something:
– Honey (if age>1)
• If you feel the need to do more:
– No recommendations
Overall conclusions
• 98-99.5% of acute infectious rhinorrhea is viral
• A common cold getting worse after day 5 may
be acute bacterial sinusitis
• Be specific with use and choice of antibiotic
– Patient may be better 4 days faster with correct
abx if correct diagnosis of bacterial sinusitis made
• Consider use of adjunctive therapy
– Especially antihistamine-decongestant combos
References
• Ray NF et al. Healthcare expenditures for sinusitis in 1996:
contributions of asthma, rhinitis, and other airway disorders. J
of Allergy and Clinical Immunology, 1999 March; 103: 408-14.
• http://www.aafp.org/afp/2006/0915/p956.html
• Falagas et al. Effectiveness and safety, etc. British Journal of
Clinical Pharmacology. 2008. 67:2, 161-171
• Williams JW et al. Clinical Evaluation for Sinusitis: Making the
diagnosis by history and physical examination. Annals of
Internal Medicine. 1992; 117:705-710.
• Mandell: Mandell, Douglas, and Bennett's Principles and
Practice of Infectious Diseases, 7th ed. 2009. “Sinuisitis”
References
• Varonen et al. Comparison of ultrasound, radiography,
and clinical examination in the diagnosis of acute
maxillary sinusitis: a systematic review. Journal of Clinical
Epidemiology. 53: 940-948. 2000
• Rosenfeld et al. Clinical Practice Guideline: Adult
Sinusitis. Otolaryngology-Head and Neck Surgery. 137,
S1-S31. 2007.
• Williams et al. Does this Patient have Acute Sinusitis?
JAMA 270;10. 1242-46. 1993.
• Leung RS, Katial R. The Diagnosis and Management of
Acute Sinusitis. Primary Care: Clinics in Office Practice.
35:11-24. 2008.
References
• Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW,
Mäkelä M. Antibiotics for acute maxillary sinusitis. Cochrane Database of
Systematic Reviews 2008, Issue 2. Art. No.: CD000243. DOI:
10.1002/14651858.CD000243.pub2
• Marx et al. Sinusitis. Rosen’s Emergency Medicine. (online) 2011
References
• The rest are scattered throughout the talk and
cited accordingly