Seasonal allergic conjunctivitis: overview and treatment update.

Seasonal allergic conjunctivitis is rarely associated with permanent vision impairment; however, it is a relatively common condition that may compromise the quality of life. It may, in extreme cases, impair daily activities, including work. Numerous treatment options have become available for the relief of acute symptoms. Avoidance should always be the first line in therapy but, in most cases, is not practical, especially with pollen allergies. The use of saline eyedrops is simple and nontoxic, and it is effective in up to 30% to 35% of cases. It can and should be added to all other remedies to reduce adverse effects and cost by decreasing the need for other therapeutic options. Antihistamines and decongestants are useful treatment choices for the majority of cases. Ketorolac tromethamine may be helpful in relieving pruritus, but it offers little advantage over topical antihistamines. Corticosteroids may be used for severe cases for a limited time. If topical corticosteroids are being considered, an ophthalmologist should be consulted. Cromolyn sodium and lodoxamide ophthalmic solution may be helpful in the prophylaxis of symptoms during the allergy season, but these agents require frequent dosing. Olopatadine hydrochloride is a mast cell stabilizer and antihistamine that can be dosed twice a day. Immunotherapy is effective and should be offered to those who are intolerant or have allergic conjunctivitis refractory to medications.

Asthma and gastroesophageal reflux.

Gastroesophageal reflux and asthma are common diseases in the developed world, and they often coexist in patients. Animal experiments, epidemiologic data, and clinical studies suggest that gastroesophageal reflux may contribute to the pathogenesis of asthma. In addition to classic reflux symptoms, such patients may notice nightly exacerbations of asthma or postprandial worsening of their pulmonary symptoms. Empiric treatment with an acid-suppressive regimen is the most cost-effective approach for asthmatic patients with classic gastroesophageal reflux symptoms, especially if the asthma remains poorly controlled despite conventional treatment. If patients have persistent problems after an adequate duration of acid-suppressive therapy or if they report symptoms indicating complicated reflux disease, such as dysphagia, additional diagnostic studies should be initiated. In most cases, medical therapy should be chosen for the long-term treatment of patients with asthma and gastroesophageal reflux. With the availability of less-invasive laparoscopic surgery, fundoplication may be an alternative in selected, mostly young individuals who have documented reflux and symptoms responsive to appropriate acid-suppressive regimens.

Tricyclic antidepressant use in diabetic neuropathy.

OBJECTIVE: To determine whether all tricyclic antidepressants are equally effective in the treatment of painful diabetic neuropathy. DATA SOURCES: A MEDLINE search for randomized controlled studies was conducted from January 1966 to December 1998. CONCLUSIONS: Amitriptyline, imipramine, and desipramine are superior to placebo in relieving painful diabetic neuropathy. Desipramine has been shown in one small study to have efficacy equal to amitriptyline. Imipramine has been compared with amitriptyline in another small study, but the lack of statistics and adverse effect evaluation did not allow for critical comparison between the two agents. No randomized studies on nortriptyline monotherapy in diabetic neuropathy have been published. Data are insufficient to determine whether all tricyclic antidepressants are equally effective. Amitriptyline and desipramine are reasonable first choices in treating diabetic neuropathy.

Potentiation of warfarin anticoagulation associated with topical methyl salicylate.

OBJECTIVE: To report a case of international normalized ratio (INR) elevation resulting from the administration of topical methyl salicylate in a patient whose INR was previously stable while she received warfarin anticoagulation. CASE SUMMARY: A 22-year-old white woman presented with an INR of 12.2 after applying a topical pain-relieving gel to her knees daily for eight days. The potentiation of the warfarin anticoagulation was attributed to the low-dose methyl salicylate contained in the product. DISCUSSION: Methyl salicylate is systemically absorbed through the skin in measurable amounts, and may increase warfarin action by affecting vitamin K metabolism or by displacing warfarin from protein-binding sites. While several investigators have reported this interaction with use of high-dose methyl salicylate, this case indicates that a significant interaction can occur with the use of lower topical doses of methyl salicylate as well. CONCLUSIONS: Healthcare providers and patients taking warfarin must be aware of the potential hazard of using topical methyl salicylate in combination with warfarin.