Nasal Sprays for Allergic Rhinitis
February 1, 1998
Nasal Sprays for Allergic Rhinitis
Nasal steroids are a mainstay of treatment for allergic rhinitis. Mechanisms of symptom relief include vasoconstriction, decreased membrane permeability, and blunted immune responses. Of the available steroids, no clear guidance exists to provide rationale for use of one agent over another, save the standard issues of cost, dose frequency, and cosmetic issues like fragrance or after-taste. This study compared two popular once-daily nasal steroids, triamcinolone acetonide vs. fluticasone propionate, in 233 Spring allergic rhinitis patients. Outcome measurements included rhinorrhea, nasal congestion, sneezing, and itching and a composite of all four symptoms at baseline and three weeks later.
Both products were equally efficacious in individual symptom reduction as well as composite scores. Modest, statistically significant side effect profile differences were detected between the products. Triamcinolone was significantly less likely to be reported as running down the throat or out of the nose. On the other hand, fluticasone was less likely to cause dry nostril sensation or a sensation of a stuffed-up nose. Triamcinolone and fluticasone are equally efficacious in symptom control of allergic rhinitis.
Small P, et al. J Allergy Clin Immunol 1997;100:592-595.
Clinical Scenario: A healthy 30-year-old woman was seen in the office for her "routine city physical." She is found to be surprisingly bradycardic, as shown in the figure below. What is the cause of her "bradycardia?"
Interpretation: On initial inspection, the rhythm in the figure appears to be sinus bradycardia with one early occurring beat (complex #3). The most helpful clue to the true etiology of the rhythm resides in analysis of this early beat. Although widened, it is not a premature ventricular contraction (PVC). Instead, beat #3 is preceded by a telltale premature P wave-that defines this beat as a premature atrial contraction (PAC). The reason the QRS complex of beat #3 is wide is that the impulse is conducted with aberration. Practically speaking, most aberrant beats are conducted with a pattern of either left or right bundle branch block and/or a hemiblock-reflecting whatever part of the conduction system is delayed in recovering and still refractory at the time the electrical impulse arrives at the AV node.
The morphologic appearance of the QRS complex of the PAC in the figure suggests that this beat is conducted with a bifascicular pattern of aberrancy (i.e., the S wave of beat #3 in lead I is consistent with right bundle branch block; the marked negativity in leads II and III is consistent with left anterior hemiblock).
Keeping in mind that when there is one PAC, there will often be more, provides the next clue to the events in this tracing. Close inspection of the T wave, especially in lead III reveals notching after beat #1 and variable peaking after beats #4, 5, and 6. This changing T wave morphology is a result of hidden premature P waves that occur so early in the refractory period that they are not conducted (i.e., "blocked"). Thus, the rhythm is not sinus bradycardia after all-but, instead, reflects atrial bigeminy in which each PAC is either blocked or conducted with aberration. Note how the blocked PACs are less evident in lead II than they are in lead III, and not evident at all in lead I. Clinically, no treatment is needed for a patient with PACs other than to advise about factors that may precipitate this rhythm (i.e., excess caffeine, alcohol, over-the-counter sympathomimetics, diet pills, etc.).
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