Musty Mold, Pesky Pests, or Stinky Stenches in Your Home?

Jeff May's Healthy Home Tips, a new paperback book, provides many hundreds of tips on how to detect the source of these indoor air quality problems and then eliminate them. His wife, Connie, a former English teacher, provides practical comments and true short stories throughout the book, adding some humor and making her Harvard graduate husband's science more palatable. Jeff is probably the most experienced indoor air quality expert in the United States, and certainly the most widely published. This is Jeff's fourth book on the topic, but my favorite remains My House Is Killing Me, published in 2001, when I began working on indoor air quality projects for the National Institute for Occupational Safety and Health (NIOSH).

If you have an allergic nose or allergic asthma (or both), you will find dozens of practical ideas for sleuthing inside and outside your sick home, apartment, or office. Most people who've become sensitized to aero-allergens are allergic to both outdoor allergens (such as pollens) and indoor allergens, such as molds, house dust mites, cockroaches, and perhaps cats or dogs. Molds, mites, and roaches proliferate in moist buildings, so Healthy Home Tips concentrates on finding and fixing the sources of moisture in your indoor environments. An expensive book from the National Academy of Sciences in 2004 exhaustively reviewed the evidence that "damp indoor spaces" often worsens nasal allergies, sinusitis, and asthma, so Jeff and Connie don't spend much time discussing the "cause and effect" relationships - they assume that you bought the book because you are suffering from the effects.

Much of the book is devoted to handy guys who enjoy weekly trips to the Home Depot or Lowe's, and many of the solutions and repairs (aka remediations) are expensive, such as adding a layer of concrete to a basement or crawl space floor which is currently covered in dirt. Some are inexpensive, such as buying a better quality of air filter; many are free, such as always running the exhaust fan in the bathroom when you take a shower; and a few save you money, like "don't buy electrostatic or electronic room air cleaners" and don't pay to have your air ducts "sanitized."

The diagrams provided by Mr. Fix-It (Tom Fezia) were superb, and I would like dozens more. All of the case-studies were fascinating, such as the stinking dead squirrel in the hot water heater vent pipe of a gourmet cook. However, I found the workbook style formatting difficult to read. There are "Do" and "Don't" checklists on most pages, and redundancy within and between chapters. Candid reviews of the resources, supplies, equipment, other books, and websites would have been a great addition. Perhaps Jeff can add these to his website.

In summary, if your nose gets congested, you develop a sinus headache, or your asthma often gets worse after an hour or two at home or at work, buy one of Jeff's books to find the cause and a way fix it (and he didn't pay me to say this).

Related Topics:

• Environmental Illness - Toxins in Our Environment
• Allergy-Proof Your Home

Technorati Tags: Jeff May, Healthy Home Tips, indoor air quality, allergies, asthma

Smoke Gets In My Eyes...and Lungs!

If you have asthma or COPD, which is worse:

• smoke from 4th of July fireworks
• smog from automotive exhaust
• smoke from a nearby wildfire
• ash from a volcano
• living with a smoker

When a person with asthma or COPD inhales smoke and fumes from any of these products of combustion, their airways will become more inflamed for at least 24 yours after the exposure is over. Bronchospasm, or airway narrowing, will begin with the first breath of smoke, and will last for at least an hour. Airway inflammation, with mucus production and airway swelling will begin within a few hours, and will last for up to two days without treatment.

Starion, who frequents the WebMD asthma message board, and her family all have asthma. If they stay in Honolulu during New Year's Eve celebrations, they all experience asthma exacerbations due to the heavy smoke from Chinese fireworks in the city, so they stay in a motel in rural Oahu or Kauai. It's common for emergency department physicians to treat a larger number of patients with asthma or COPD on the 4th or July or New Year's Day due to inhalation of smoke from fireworks. If you must go to see the fireworks, make sure that you have taken your asthma controller inhalers, stay upwind from the fireworks displays, and keep your albuterol rescue inhaler handy.

Wildland fires usually rage during the summertime throughout the United States. Some occur near the urban-forest interface, so the smoke and fumes from the fires are often blown over highly populated areas. Those with asthma or COPD (or both) have "twitchy" airways which are more sensitive than others to the effect of smoke inhalation. The Department of Environmental Quality (DEQ) in most states operates air quality monitors. When the concentration of respirable particles in the air (PM-10, PM2.5, or simply smoke) exceeds thresholds, they issue health alerts to the media. If your nose isn't congested, go outside and you can often smell the smoke, and see it in the air.

While most of us who fly frequently have become accustomed to a Code Orange terrorist "alert," if you (or a child or grandparent for whom you are the caretaker) has asthma or COPD, Code Orange or Code Red air quality notices are alerts from the government that you should take seriously. Use the media to determine the source of the smoke. The National Weather Service can track the direction of the smoke plume, so find out if it's headed in your direction.

If your asthma is poorly controlled that day, strongly consider a mini-vacation to stay with friends or relatives, or even a motel, in a location away from the smoke. If you must stay in the smoky area, start taking those inhalers faithfully again. Refill those prescriptions if you've run out again. Find the written asthma action plan that your doctor gave to you. Consider asking that she call a prescription for five days of prednisone (for example, twenty 20mg pills) in case your asthma control falls from the green zone into the yellow, orange, or red zones.

If you must stay in a smoky area outdoors, consider wearing an N-95 respirator (NIOSH-approved dust mask). When worn appropriately, these will remove 95% of the smoke particles from the air that you are inhaling. If you are staying indoors (or in a newer model vehicle), run the air conditioner on recirculate (which does not introduce outside air). Many new cars and SUVs have a HEPA air cleaner "for the cabin" (like those used in modern aircraft). The standard air filters for home air conditioners are designed to merely keep dust and hair from clogging the motor and coils, but you can retrofit them with better filters which will remove some smoke particles. Better yet, buy a large and quiet HEPA room air cleaner and run it continuously in the room in which you are working or sleeping. These filters remove almost all of the smoke in a room every six minutes. If air is blowing from them, they are working.

To finish answering my original question, studies following the Mt. Saint Helens volcano eruption found that inhaling the cool grey ash was relatively harmless. Dozens of studies of urban smog caused by vehicles in the United States show only a modest effect on children with asthma. Of course, smog levels in many developing countries are much worse than those now experienced in the U.S. At the other end of the spectrum, living with a smoker is without a doubt, the worst - probably because the second-hand exposure is constant for many hours day and night, for many years. It's nearly impossible to escape if you are an infant or child. Whenever I see a baby in a car seat with a smoker at the wheel, I feel like calling Child Protection Services, because it ought to be a crime.

Related Topics:

• WebMD Video: Asthma Triggers in Children
• Smoking and Asthma

Technorati Tags: asthma, COPD, smoke, wildfire, cigarettes, smog, fireworks, ash

The Best Antihistamines for Sneezing and Nasal Congestion

Photo Credit: Jon Lebkowsky

About 1 in every 5 people suffer from hay fever, also known as allergic rhinosinusitis by doctors, and I am one of them. Some people suffer all the time (perennial, persistent, constant), usually due to allergies to indoor allergens such as dust mites, molds, animal dander, or cockroaches. Others have allergic symptoms only during certain seasons, because they have become sensitized to grass, tree, or weed pollens. I've had hay fever since preschool days -- a rather typical case.

When we lived in Minnesota, I only had symptoms during the summer, especially when I cut grass or raked leaves, but after moving to southern Arizona, I now have perennial allergic rhinitis (PAR), since weeds release pollen into the air almost any time of the year. After I get a cold or after I am exposed to a high dose of allergens (such as using a line-trimmer to cut weeds), my allergic rhinitis often worsens to include sinusitis.

As a child, my mom gave me Benadryl or Chlor-Trimeton pills. They worked for a few hours to suppress my sneezing, stuffy nose, and itchy eyes, but made me drowsy -- probably a good side-effect from the viewpoint of my mother, considering my hyperactivity. In fact, these first generation antihistamines are also sold OTC (over-the-counter) as sleeping pills. I also got allergy shots and injections of my own urine (from a quack allergist), which "cured me" from complaining anymore about my allergies. I did avoid exposure to grass and weeds (also called secondary prevention) by not playing field sports (baseball, football, soccer) and by refusing to cut the grass.

I can't tell you "what 9 out of 10 doctors recommend for hay fever," but I can tell you what I've done, and tell you what's been published from research studies (controlled clinical trials) of antihistamines. For many years, I got prescriptions for a second-generation, once-a-day, non-sedating antihistamine. They cost about 3 dollars per pill and even with insurance, the co-pay was over $100 per year, so I took them only when I had symptoms. Many others must have done the same, since the U.S. market for prescription antihistamines was then over 4 billion dollars per year.

Everything changed around Christmas, 2002 when the patent for Claritin expired and Wellpoint successfully petitioned the FDA to switch non-sedating antihistamines to OTC. Since then, I've taken generic loratidine every morning; and it only costs $20 a year (for a small bottle of 300 little white pills). Despite the doom and gloom prophecies of allergists and big pharma in 2001, it became a win-win situation. The quality of my life and others improved because we rarely have allergy symptoms anymore, and the profits of the manufacturers of loratidine improved (with 30% market share and 1.4 billion dollars in annual sales).

Allergy sufferers got another Christmas present in 2007 when the patent on Zyrtec, another non-sedating antihistamine, expired. Zertec is now available OTC for about a dollar a pill for the brand name product, while the generic cetirizine costs only $15 to $45 for a bottle of 90 tablets -- enough to get through 3 months of the allergy season for those with seasonal allergic rhinitis. It's also available as a chewable tablet or liquid for children (at a lower dose) and combined with a Decongestant in a capsule.

As an allergy sufferer in the United States, your choices have now been expanded: You can buy generic Claritin OTC, generic Zyrtec OTC, or ask your doctor for a prescription for Clarinex, Allegra, or Xyzal. To determine which is best antihistamine, I read the most recent studies, which are summarized in an excellent review by Doctors Lehman and Blaiss from the University of Tennessee (in the journal Drugs 2006), and a similar review, written for physician assistants, which you can download without cost.

In summary, second-generation antihistamines are the first-line therapy for both seasonal and perennial allergic rhinitis (SAR and PAR). They are very effective, very safe, and last for more than 24 hours. They are much less likely to cause sedation (drowsiness or fatigue) when compared to the old first generation antihistamines. For any of these drugs, the higher the dose, the more likely sedation will be noticed. At the recommended doses for adults, Zyrtec and its twin brother Xyzal are more likely to cause sedation (5-10%) when compared to the others (1-2%).

A small advantage for Zyrtec and Xyzal is that their onset of action may be shorter (about an hour) when compared to the others (1-3 hours). However, a somewhat slower onset of action is not a problem when these drugs are taken every morning (when you brush your teeth) to PREVENT the release of histamine in your nose and eyes later in the day. Antihistamines are much less effective if you wait to take them until you have symptoms.

Allegra (fexofenadine, still by prescription only) is slightly more effective in relieving itchy, watery, red eyes, and less likely to cause sedation at higher (off-label) doses, when compared to Claritin and Clarinex. Blood levels of Allegra are increased by about 40% if you take it with grapefruit juice, erythromycin (an antibiotic), or ketoconazole (an antifungal), but these drug-drug interactions are unlikely to significantly increase the risk of sedation from Allegra.

Bottom line, I will continue to take generic Claritin every morning, because it's effective, doesn't cause sedation at the recommended dose, and cheap. I may try generic Zyrtec when the cost drops towards that of generic Claritin. I will still keep a bottle of generic Benedryl for insect stings and severe allergic reactions, realizing that after taking it I will feel like a space cadet or sleepy. Despite heavy advertising, I personally see no reason to ask my doctor for a prescription for Clarinex, Allergra, or Xyzal, but I am sure that a few patients will feel that these expensive antihistamines are more effective.

Related Topics:

• Plagued by Pollen
• WebMD Video: The Truth About Allergies

Technorati Tags: hay fever, pollen, allergic rhinitis, sinusitis, Benedryl, Chlor-Trimeton, antihistamines, Claritin, Zyrtec, Clarinex, Allegra, Xyzal, allergies

Are Chantix Side Effects Worth the Risk?

The risks of continuing to smoke far outweigh the risks of trying to quit. Consider these facts:

• One billion people will die from smoking in this century.
• Half of persistent cigarette smokers are killed by their habit.
• Smoking cessation at age 50 cuts this risk in half.
• Smoking cessation before age 30 avoids almost all of the risk.
• The success of smoking cessation improves by using nicotine gum; improves more by using Xyban; and improves even more by using Chantix.
• About half of those who take Chantix remain non-smokers one year later.

Before Chantix (varenicline) was released by the FDA in the United States (in June 2006), it was clear that it caused minor side effects such as nausea, mood alterations, drowsiness, vivid dreams, or an allergic rash in up to one-third of patients. Many patients have reported these symptoms on Internet message boards. Now, after about 4 million smokers have taken Chantix, about 40 suicides have been reported to the FDA associated with Chantix and about 400 cases of suicidal thinking or behavior. In industry talk, these are called SAEs (serious adverse events), but individuals who experience an SAE (or their loved ones) appropriately use much stronger words.

All drugs have side effects, so doctors and patients considering starting a drug must always weigh the potential benefits against the risk of side-effects. (You can do the math using the above statistics.) Once you notice a side effect (or one is found by your doctor using laboratory tests), the severity of your side effects must be weighed against the benefit obtained by continuing the drug. Sometimes you and your doctor compromise by lowering the dose of the drug or switching to a different drug.

If you are an adult and feel blue (depressed), switching from Chantix to Zyban may be a good idea since Zyban is a low dose of an antidepressant (bupropion). If you get an itchy rash while taking Chantix, stop taking it until you can discuss this with your local pharmacist (free) or physician (good luck). Allergic reactions to drugs can become life-threatening if you ignore them and keep taking the drug.

This week, an FDA spokesperson said that "health care professionals should closely monitor patients for behavior and mood changes if they are are taking this drug." However, in my opinion, it is much more reasonable to advise the patient and their family and friends about this risk. The press and legal community have already done an excellent job of warning people (judging from their websites). It is encouraging that the FDA has responded much more rapidly in releasing the preliminary results of "post-marketing surveillance" for newly released drugs (such as Chantix) since the Vioxx/Celebrex fiasco.

However, their surveillance system is passive, waiting for doctors and patients to report drug side effects. This means that the SAE rates are probably seriously underreported. Perhaps only 1% of SAEs which occur are reported to the FDA after a drug is approved for sale.

Many experts believe that to better protect the public, surveillance should be proactive, with costs and responsibilities to be shared by the FDA and the company which profits from sales of the drug. In my opinion, in the case of Chantix, pro-active surveillance could easily have been paid for by spending a small fraction of the 25% profit from the $681 million in 2007 sales of Chantix.

Smoking cessation is a process for most smokers, who are addicted to nicotine. Before turning to drug therapy, I suggest trying to quit with the help of a support group. Call the smoking cessation helpline in your state or country, such as 1-800-QUITNOW in the United States.

Now for some interesting disclosures. Most of the smoking statistics I listed at the top are from a research paper which you can download for free and read. The renowned first author of this paper, Sir Richard Doll, died at age 92, one year after it was published in the British Medical Journal. After his death, it was disclosed that he had received, but not reported, large consulting fees from chemical companies during his career.

Over the past 3 years, I have been paid a total of about $20,000 by Pfizer for reviewing the quality of spirometry tests done for a study of the effectiveness of Chantix in patients with COPD. My consulting for them on this project continues. Last year, Pfizer also paid me about $4,000 for helping them to produce educational videos to describe how spirometry should be used to evaluate diabetic patients for whom Exubera was being considered. To learn more about the fate of Exubera, click here.

Related Topics:

• How to Quit Smoking
• WebMD Video: Quit Smoking for Good

Technorati Tags: chantix, smoking, quit smoking, FDA, side effects

A New Study of Inhalers to Prevent COPD: Flies in the Ointment

The treatment of chronic obstructive pulmonary disease (COPD, formerly known as emphysema or chronic bronchitis with airway obstruction) is a rapidly expanding 5 billion dollar per year market for inhaler manufacturers. Large COPD public awareness (promotional) campaigns were started in 2007 by the U.S. National Heart, Lung, and Blood Institute (NHLBI), and the manufacturers of the two inhalers which have been approved by the FDA for COPD: Spiriva (tiotropium) and high dose Advair (a combination of 500 mcg fluticasone and 50mcg salmeterol).

The results of INSPIRE, the second of three very large, international COPD treatment studies were published in the January 2008 issue of the most prestigious pulmonary journal (AJRCCM, aka “the blue journal”). INSPIRE directly compared the effectiveness and safety of these two inhalers in over 1300 patients with severe treated COPD for two years.

Twice as many patients randomly selected to take Spiriva died during the two years of the study when compared to those randomly selected to take Advair. In the patients who also had some type of heart disease or hypertension when they started the study (about half of them), there were 24 deaths in those taking Spiriva, but only 9 deaths in those taking Advair. The higher death rate in those taking Spiriva was apparent just three months into the study. Unfortunately, sudden death from heart disease in individual patients with COPD is rarely even considered as possibly due to a side-effect of their inhalers, because smoking is the most common cause of death from heart disease.

Over 8 million patients with COPD have been prescribed Spiriva since it became available five years ago. Spiriva temporarily relieves shortness of breath in about half of patients with severe COPD, and may slightly reduce the risk of a subsequent exacerbation in those who have previously required hospitalization for a COPD exacerbation. Some adults with asthma are prescribed Spiriva, but the evidence that it helps them is so scanty that the FDA has not approved it for asthma.

More than 15 years ago, I was an investigator of the NHLBI-sponsored Lung Health Study in which 5000 smokers with mild to moderate COPD were randomized to take Atrovent (ipratropium) or a placebo for five years. We reported that study participants taking Atrovent were twice as likely to die, and more likely to be hospitalized with a serious cardiac arrhythmia (heart rhythm disturbance) than those taking the placebo inhaler. Since then, other investigators have also reported that patients with COPD taking Spiriva were more likely to experience a cardiac arrhythmia. Spiriva and Atrovent are both anticholinergic bronchodilator inhalers, but Spiriva is ultra long-acting.

More than one-third of the patients who were enrolled into the INSPIRE study were current cigarette smokers -- the cause of their severe lung disease. The study sponsors apparently did nothing to help them to stop smoking, although smoking cessation is the only treatment proven to halt the rapid progression of COPD. On the other hand, the study investigators did not include a placebo comparison group because "it was deemed unethical to withhold known effective therapies."

I worry that prescribing expensive inhalers for patients with COPD who continue to smoke makes them think that they are “getting the cure” and don’t need to quit. All smokers should be helped with the process of smoking cessation.

Related Topics:

• Living with COPD
• WebMD Video: A Breath of Fresh Air for Emphysema Patients

Technorati Tags: COPD, smoking cessation, Advair, Spiriva, health, wellness, heart disease, lung disease