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Am Fam Physician. 2003;67(12):2626-2629

AHRQ Report on Allergic Rhinitis

Allergic rhinitis affects more than 19 million U.S. workers annually, and some patients can take steps to relieve symptoms, according to a new evidence report released by the Agency for Healthcare Research and Quality (AHRQ). “Management of Allergic Rhinitis in the Working-Age Population” is available online at or by calling the AHRQ at 800-358-9295.

Researchers specifically studied management of allergic rhinitis in working adults and did not find much evidence on the direct association between allergic rhinitis and work performance. However, physical symptoms of allergies such as sneezing, nasal congestion, headache, poor concentration, and fatigue may cause problems on the job for workers affected by the condition. Treatments that improve symptoms while minimizing side effects will likely improve work performance.

Some patients may find relief with simple steps. For example, selected patients allergic to dust mites can reduce their symptoms by using bedding specifically designed to keep out the mites or by cleaning their homes more often. Immunotherapy can help reduce or eliminate symptoms for seasonal causes, such as trees and pollen, and year-round causes, such as dust mites and cat dander. The researchers found no evidence to support the use of air filtration systems for reduction of mite exposure in patients who have asthma and are mite-sensitive.

Combination treatment with antihistamines plus decongestants is more effective than either agent alone. While the combination of antihistamines plus steroid nasal sprays works better than using antihistamines alone, antihistamines are no more effective than steroid nasal sprays alone. Adding ophthalmic antihistamines to oral antihistamines reduces eye itching, and adding ipratropium improves rhinitis symptoms.

Direct medical costs for common allergies caused by pollen, dust mites, and pet dander can range from $1.2 billion to $4.5 billion, with an additional $3.2 billion spent indirectly, including the cost of lost work productivity.

AAP Statement on Home Apnea Monitors

Home apnea monitors should not be prescribed to prevent sudden infant death syndrome (SIDS), according to a policy statement from the American Academy of Pediatrics (AAP). “Apnea, Sudden Infant Death Syndrome, and Home Monitoring” appears in the April 2003 issue of Pediatrics.

The AAP says the theory that apnea (defined in infants as cessation of breathing for 20 seconds or longer) is a precursor to SIDS has never been proved, despite extensive independent research. Yet, an estimated $24 million is spent yearly to send premature infants home with apnea monitors, whether or not they have risk factors for SIDS. The AAP says physicians should focus on educating new parents about proven practices that decrease the risk of SIDS—including back-sleeping, safe sleeping environments, and elimination of secondhand smoke. Home apnea monitoring may be warranted for infants with certain medical conditions for limited periods of time.

AHRQ Report on Ineffective Treatment of Bronchiolitis

Although physicians commonly use a wide array of medications to treat bronchiolitis—the most common lower respiratory tract disease among infants and toddlers—there is currently no compelling evidence to support these treatments, according to an evidence report released by the Agency for Healthcare Research and Quality (AHRQ). “Management of Bronchiolitis in Infants and Children” is available online at or by calling 800-358-9295.

Bronchiolitis is part of a family of diseases that affect airways in the lungs. It differs significantly from the more commonly diagnosed bronchitis, which can affect adults as well as children and is usually a complication of a viral infection, such as a cold or influenza, or in chronic cases found mostly in smokers.

In addition to good supportive care, physicians often use medications such as inhaled, oral, or intravenous corticosteroids; inhaled epinephrine; and nebulized bronchodilators to treat bronchiolitis. But, whether the medications actually work will not be known until they are studied in well-designed, adequately sized randomized clinical trials. The researchers found some support from adequately designed studies for the use of nebulized epinephrine, nebulized salbutamol plus ipratropium bromide, nebulized ipratropium bromide, oral or parenteral corticosteroids, and inhaled corticosteroids (especially budesonide). However, they cautioned that physicians should be aware of adverse events associated with the use of inhaled budesonide in previous research. They found no evidence to support the use of aerosolized ribavirin, antibiotics, nebulized furosemide, inhaled interferon alfa, and nebulized recombinant human deoxyribonuclease (rhDNase) to treat bronchiolitis, and recommended against their routine use.

In addition, the researchers found no evidence that laboratory tests, complete blood cell counts, or chest radiographs, which are sometimes used to diagnose bronchiolitis, are superior to a carefully conducted medical history and physical examination. However, they did find evidence that supports the use of palivizumab as a preventive medicine, administered once a month intra-muscularly, to protect high-risk infants and children who have underlying bronchopulmonary dysplasia—a chronic lung disease—or who were born prematurely and are under six months of age.

FDA Approvals

  • Pegvisomant. The U.S. Food and Drug Administration (FDA) has approved pegvisomant (Somavert) for the treatment of acromegaly in patients who have had an inadequate response to existing therapies.

Pegvisomant is the first in a new class of medications called growth hormone receptor antagonists. In clinical trials, it normalized concentrations of IGF-I in more than 90 percent of patients by blocking the effects of growth hormone. The most common side effects were injection site reactions, sweating, headache, and fatigue. Patients should have tests to monitor their liver function during the first six months of therapy.

  • Enfuvirtide. The FDA has approved enfuvirtide (Fuzeon) for use in combination with other anti-human immunodeficiency virus (HIV) medications to treat advanced HIV infection in adults and children ages six years and older.

Enfuvirtide is the first in a new class of medications called fusion inhibitors. It interferes with the entry of HIV into cells by inhibiting the fusion of viral and cellular membranes. This inhibition blocks the virus from infecting certain components of the immune system.

Because HIV infection must be treated with a combination of medications to be effective, enfuvirtide can be used as part of a medication regimen in patients for whom there are limited options. It should only be used in patients who have previously used other anti-HIV medications and have ongoing evidence of viral replication. It is administered as a subcutaneous injection.

Physicians should carefully monitor patients for signs and symptoms of pneumonia. Although bacterial pneumonia was uncommon in clinical study participants, more patients treated with enfuvirtide developed bacterial pneumonia than did patients who did not receive enfuvirtide. Patients are advised to seek medical evaluation immediately if they develop signs or symptoms suggestive of pneumonia, such as cough with fever, rapid breathing, and shortness of breath.

In addition, enfuvirtide can cause both serious systemic allergic reactions and local skin reactions at the site of injection. Patients taking enfuvirtide should contact their physician immediately if they develop any of the following symptoms of an allergic reaction: trouble breathing, fever, skin rash, chills, vomiting, and low blood pressure.

Local skin reactions from enfuvirtide injections are common, occur in almost all patients, and may be painful. Patients must be careful that their skin does not become infected at the injection site.

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Copyright © 2003 by the American Academy of Family Physicians.

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