On the Rebound

My Twitter feed has recently been subject to a series of promoted tweets from a company that sells decongestant nasal sprays. The brand behind these advertisements shall remain nameless (other decongestant nasal sprays are available), but I have been compelled to take to the keyboard because the spray is being recommended for the relief of symptoms of hay fever – which is just bad medicine.

I must make it clear that the company is doing nothing wrong – the spray is licensed for the treatment of hay fever and it is available without prescription, so they are well within their rights to advertise it in this way. That doesn’t mean I have to agree with them, though.

 

On the face of it, it seems reasonable to use a decongestant for hay fever – one of the symptoms is nasal congestion, after all. The problem lies in the issue of rebound congestion – sometimes known as rhinitis medicamentosa (medical speak for your medicines made your nose run). The decongestants might make you feel dramatically better in the short-term – as they reduce the blood flow, and hence the swelling, in your nasal passages within minutes – but they don’t do anything about the underlying cause. Worse than that, within a few days your nose can start getting ‘addicted’ to these sprays so that the congestion returns with a vengeance, requiring more of the spray to relieve the symptoms, leading to further rebound congestion and so on.

For this reason all decongestants have strict warnings on them that they are not to be used for more than 7 days. They are mostly used for treating colds, and since these last only a week or so that is not too problematic. For treating acute sinus pain, or relieving earache on a flight, they are fantastic, since these are short-term problems. Hay fever, on the other hand, will last as long as the pollen you are allergic to – April and March for tree pollens, May, June and half of July for grasses. So the adverts promote something that should never be used for more than a week, to treat a condition that will usually last at least 2 months. Even for those patients who have only very intermittent symptoms on high pollen days there are more effective treatments out there, in the form of antihistamines and steroid nasal sprays.

While the ‘S’ word can cause people concern, I sometimes describe steroid nasal sprays as being the polar opposite of decongestants. The latter make you feel better straight away, but do nothing for the underlying condition and will make it worse in the long-term, while steroid sprays do absolutely nothing straight away, but treat the underlying inflammation that is the problem in hay fever and will usually solve the problem in the longer term. The steroid dose is extremely low so that there are no side effects due to absorption into the blood stream. It’s better not to use them all year round if you can help it, due to thinning of the lining of the nose and nose bleeds, but then hay fever is seasonal so most people can have prolonged breaks from treatment.

As a doctor I feel especially powerless to stop people becoming dependent on decongestant nasal sprays; and some do become truly hooked – I have had some patients rely on them for decades. I know that my pharmacy colleagues are very good at warning patients not to take them for more than 7 days, and I can’t imagine any pharmacist recommending them for hay fever, but patients don’t have to speak to any health care professional to buy these products. They are categorised under General Sales Licence, which means that you can just drop them in your basket from the shelves of a supermarket and take them to the checkout – no-one will notice that you buy them every week, or advise you that it might be causing you such a problem.

How such a product was ever made so readily available, or achieved a licence for hay fever, I shall never know. There is no prospect of changing this, but perhaps by writing about it I can steer one or two people away from turning their seasonal allergy into a year-round problem of rebound congestion.

Quick Post – Peanut Butter Back on the Menu for Pregnant Women

Thanks to research published this week, Pregnant women can breathe a sigh of relief, give in to the cravings and indulge in a bit of peanut butter, should they so desire, without worrying about causing allergic disease in their baby.

Previous advice to avoid nuts in pregnancy has been controversial and based on poor evidence, but this latest research is a large study of over 60 000 pregnant women which found no association between eating peanuts in pregnancy and allergic disease (asthma or hay fever). In fact, they found that women who had eaten nuts were actually less likely to have children with asthma. We should avoid drawing the conclusions made by The Telegraph, however, which wrongly advised women to actively try to eat nuts in the hope of reducing the risk of asthma: This study has shown an association between eating nuts and a lower incidence of asthma, and that does not show cause and effect. It may be that there is another explanation for the findings – for instance, that women who had asthma themselves might be less likely to eat nuts and more likely to have children who develop asthma.

So in a nutshell? Eat sensibly and healthily in pregnancy, and don’t think too much about allergies!

Warning: Written on a computer also used for completing homework, may contain traces of GCSE English

When the manufacturer of a packet of peanuts feels obliged to print the allergy information: Contains nuts we know we are living in a world that has lost touch with basic common sense. That another food producer considers that they are doing their customers a service with a label such as: Ingredients: No nuts; Factory: No nuts; Cannot guarantee nut free nearly completes the ridiculous confusion that is food labelling. I say nearly because the natural conclusion of such a defensive, litigation-fearing attitude to food labelling is to include such comments as: Workers’ canteen: No nuts; Workers’ packed lunch boxes: Cannot guarantee nut free; Company policy on workers’ lunch boxes: Should be nut free.

We can all laugh at this, but if you are at risk of anaphylactic shock from exposure to even a small quantity of peanut then you are unlikely to appreciate the joke. What are we to make of these labels? The British Medical Journal published a helpful analysis of the situation last year, which makes interesting, if sobering, reading. The link to the article is here, although you will need to be a subscriber in order to access it.

The first thing is to realise the important difference between the labelling requirements of raw ingredients and that of possible contaminants. Under EU law there is a legal requirement to list any of 14 ingredients that are commonly associated with allergy if they are one of the raw ingredients in the product. The full list of these allergens is as follows: Cereals containing gluten (wheat, rye, barley, oats, spelt and kamut), crustaceans, egg, fish, peanuts, milk, tree nuts (e.g. hazelnut, walnut etc), soy, sesame, celery, mustard, lupin (a type of bean rather than the garden flower – I had to look this up!), molluscs and sulphur dioxide or sulphites. On the other hand, allergy information about possible contaminants is entirely voluntary, with no clear guidelines for manufacturers.

Whether or not manufacturers place these advisory labels, and the wording that is used, appears to be alarmingly arbitrary. A 2010 European study published in the journal Food Additives Contaminants – a niche publication if ever there was one! – looked at the presence of peanuts and hazelnuts in cookies and chocolates that did not have either listed as an ingredient. Approximately 60% of the 500 or so products tested carried an advisory label about the possible presence of the nuts. For peanuts the presence of the label was associated with a 33% incidence of detectable quantities of peanut in the product – and for those with no label the figure was 25% – which makes using the label as your guide only marginally better than lucky dip. For Hazelnut the figures were slightly more favourable with the labelled products containing hazelnut in 60% of cases compared with 31% of unlabeled products, although this is hardly a ringing endorsement of our present system.

All of these figures seem very high, which may in part be because this study involved confectionary and biscuits, which are associated with a much higher incidence of cross contamination than other products. A further study in the Journal of Allergy and Clinical Immunology found peanut to be present in 8% of confectionary items labelled with an advisory warning, but in none of 64 non-confectionary products studied, despite the presence of a similar warning. Some caution is needed here, however, as this was a US based study and manufacturing conditions may be very different across the Atlantic.

Despite the problems with interpreting these labels we find it very difficult to ignore warning labels. For many of us it is akin to breaking the rules, or tempting fate. A survey of parents with children with nut allergies published in Paediatric Allergy and Immunology found that 80% of parents avoided products that stated May contain nuts, but only 50% avoided products with the label May contain traces of nuts. This is understandable, but worrying as there is no correlation between the wording on such labels and the chance of finding nuts in the product, or the quantity of nut that could be present.

The answer to sorting out this mess is not easy. If allergy advice labels became compulsory this could greatly restrict consumer choice for those who suffer from allergies – unnecessary advice labels could become even more commonplace as companies try to protect themselves. If the arbitrary placement of advice labels was outlawed you could even find companies adding a small quantity of an allergen to the ingredients so that they can legitimately declare it – the market share commanded by allergy sufferers is likely to be so small that they could easily take the hit, and at least they would know that they could not be sued. The amount of allergen that could cause problems is also very difficult to quantify. For most sufferers there needs to be a clearly detectable level of allergen exposure before they will suffer a reaction, but there will always be individuals who are so sensitive that even the smallest quantities will result in potentially life-threatening anaphylaxis.

Probably the best attempt to find a way forward is the incorporation of a standard risk assessment took called VITAL which has been used in Australia and New Zealand, and has some prospect of being incorporated across Europe in time. VITAL defines a threshold for allergens, with a ten-fold safety factor, and companies are advised to issue a label if their product is found to exceed this level. While this may not help the extreme anaphylaxis sufferer, it will at least give some clarity to the majority who are affected, and help for companies as well who are probably as anxious as consumers in this whole situation.

Ultimately this issue exposes yet again the difficulty in finding real facts and clear evidence when it comes to medicine – which is what motivates me to continue writing this blog. You might call it the pursuit of Truth, but as Oscar Wilde said: ‘The truth is rarely pure, and never simple.’

Dang! There’s that GCSE English – I knew it might contaminate this somehow!