Watch 3 intraoperative videos

• Dissect the appendix
• Resect the appendix
• Remove the specimen

Videos provided by Teresa Tam, MD, and Gerald Harkins, MD

CASE: Should appendectomy be included in total
laparoscopic hysterectomy?

A 39-year-old mother of two continues to experience severe dysmenorrhea and persistent menorrhagia despite undergoing endometrial ablation 2 years earlier. Her obstetric and gynecologic history is remarkable for a diagnosis of chronic pelvic pain, endometriosis, and failed endometrial ablation. Both her children were delivered by cesarean, and she has undergone tubal ligation. She requests hysterectomy to address the dysmenorrhea and menorrhagia once and for all.

A pelvic exam reveals an anteverted, 10-weeks’ size uterus with no adnexal masses or tenderness. After extensive discussion of the surgical procedure, the patient signs a consent for total laparoscopic hysterectomy.

Would you recommend appendectomy, too?

Prophylactic removal of the appendix during a benign gynecologic procedure is known as “elective incidental appendectomy.”¹ Incidental appendectomy at the time of cesarean delivery was reported initially in 1959.² Subsequent studies of removal of a normal-appearing appendix at the time of gynecologic surgery have met with considerable debate. Proponents argue that removal of the appendix at the time of abdominal hysterectomy does not increase operative time or postoperative morbidity. More important, it does prevent future appendicitis.^3-5

Some surgeons disagree, citing an increase in operative time, hospital costs, and patient morbidity as reasonable concerns. They also note that appendectomy requires an additional surgical procedure, which could increase the risk of infection and other complications and lead to adhesion formation.

Advantages of incidental appendectomy include technical ease, low patient morbidity and mortality, and significant diagnostic and protective value.⁶ It also prevents conflicting diagnoses, especially in patients who have chronic pelvic pain, a ruptured ovarian cyst, or endometriosis. Other patients likely to benefit from elective incidental appendectomy are those who are undergoing abdominal radiation or chemotherapy, women unable to communicate health complaints, and those who are planning to undergo complex abdominal or pelvic procedures that are likely to cause extensive adhesions.¹

In this article, we describe the rationale behind this procedure, as well as the technical steps involved.

The laparoscopic approach is preferred

Appendectomy is commonly performed laparoscopically. Semm first described this approach in 1983.⁷ Several studies since have reported that incidental laparoscopic appendectomy is safe, easy to perform, and should be offered to patients undergoing a concomitant gynecologic procedure.^8-10 Laparoscopic removal of a normal appendix does not add morbidity or prolong hospitalization, compared with diagnostic laparoscopy. A large study drawing from the Nationwide Inpatient Sample (NIS) database found laparoscopic removal of the appendix to be associated with lower mortality, fewer complications, shorter hospitalization, and lower mean hospital charges, compared with open appendectomy.¹¹ The same study found laparoscopic appendectomy to be the procedure of choice in both perforated and nonperforated appendicitis.

Overweight and obese patients also may benefit from the laparoscopic approach because it avoids problems associated with an open incision, such as the need for abdominal wall retraction, a longer hospital stay, and a risk of wound infection, compared with smaller incisions—especially in this high-risk population.¹²

Cost is another issue. Any prolonged surgical time and higher medical costs required for incidental appendectomy decrease as surgical proficiency and experience rise. The concomitant performance of endoscopic procedures can also reduce the risk associated with anesthesia for reoperations.

Endometriosis patients stand to benefit from appendectomy

There is compelling evidence that elective appendectomy is beneficial in patients who have endometriosis. Endometriosis of the bowel has been reported in 5.3% of all histologically proven endometriosis cases, with appendiceal endometriosis found in approximately 1% of women with endometriosis.¹³ Despite the low prevalence (2.8%) of appendiceal endometriosis,¹⁴ some studies reported a high incidence of appendiceal endometriosis when incidental appendectomy was performed. Patients who report right lower quadrant (RLQ) pain, chronic pelvic pain, and ovarian endometrioma had the highest incidence of abnormal histopathologic findings.^15-17 Because most women with endometriosis present with these symptoms, it is prudent to counsel patients preoperatively about the incidence of appendiceal endometriosis and to visually examine the appendix during gynecologic surgery to identify incidental appendiceal pathology.

Age may influence the appendectomy decision

The incidence of acute appendicitis is highest among people aged 10 to 19 years. The estimated lifetime risk of appendicitis is 6.7%.¹⁸ The surgical dilemma is whether to perform incidental appendectomy in the nonadolescent population, which is at lower risk for appendicitis, as a preventive measure.

We lack randomized trials on the benefit of incidental appendectomy. A retrospective study of open procedures supported incidental appendectomy in patients younger than 35 years; for patients 35 to 50, the decision was left to the clinical judgment of the surgeon, based on the patient’s clinical condition.⁴ The same study failed to support incidental appendectomy in women older than 50 years.

When the appendix is not easily accessible, or the surgical complexity of the gynecologic procedure prevents the surgeon from safely performing an appendectomy, it is better to complete the planned gynecologic surgery and forgo the appendectomy. It is acceptable to make the decision to refrain from the appendectomy intraoperatively if the risk of complications outweighs the likely benefits. The practice of cautionary discretion demonstrates sound judgment and avoids compromising the safety of the patient.

How to perform appendectomy

1. Maintain at least three laparoscopic sites

• After the laparoscopic gynecologic procedure, maintain three trocar sites—preferably, two 5-mm trocars and one 12-mm trocar.
• The first 5-mm trocar, at the umbilical incision, accommodates the laparoscopic camera. The second 5-mm trocar serves as an accessory port for laparoscopic instruments and is inserted into the RLQ.
• The 12-mm trocar in the left lower quadrant (LLQ) is also used to insert endoscopic instruments. This trocar site will be used at the conclusion of the appendectomy to accommodate the mechanical stapling device and the specimen bag for removal of the excised organ.

FIGURE 1: Visualize the appendix. Identify the cecum and ileocolic junction to locate the appendix.

2. Identify the appendix

• Perform a careful visual exploration of the abdominal contents to exclude other intra-abdominal pathology.
• Identify the cecum and ileocolic junction to locate the appendix (FIGURE 1).
• Visually inspect the appendix and identify any gross appendiceal pathology.

FIGURE 2: Divide the mesoappendix
Isolate, cauterize, and divide the mesoappendix using 5-mm ultrasonic shears.

3. Dissect the appendix (VIDEO 1)

• Insert an atraumatic forceps through the 5-mm right accessory trocar.
• Grasp the fatty tissue at the tip of the appendix and provide some traction.
• Elevate the appendix to facilitate visualization of the mesoappendix.
• Isolate the mesoappendix and cauterize and divide it using 5-mm ultrasonic shears inserted through the RLQ trocar (FIGURE 2).
• Release some of the upward tension from the specimen retraction by dropping the height of the instrument to prevent undue trauma and bleeding.
• Make a window between the mesentery and the base of the appendix to facilitate dissection.
• Skeletonize the mesoappendix at the junction of the appendiceal base and the cecum.
• During skeletonization, pay special attention to the appendiceal artery at the base of the mesoappendix.

FIGURE 3: Apply the stapling device
Apply the stapling device across the base of the appendix.

4. Resect the appendix (VIDEO 2)

• Insert an automatic stapling device through the 12-mm port and apply it across the base of the appendix (FIGURE 3).
• Apply the mechanical stapling device for 15 seconds to crush the base of the appendix and empty its contents.
• Visualize both sides of the stapler to ensure that it is placed at the base of the appendix.
• Always check the tip of the device to ensure that the jaws of the stapling device fully compress the appendix and have not inadvertently grasped other abdominal contents.
• With the stapling device compressing the base of the appendix, release some of the upward tension on the specimen by dropping the height of the retraction.
• Activate the stapling device and completely excise the appendix from its base
  (FIGURE 4).
• Thoroughly inspect the appendiceal stump to ensure hemostasis (FIGURE 5).

FIGURE 4: Excise the appendix
Activate the stapling device and completely excise the appendix from its base.

FIGURE 5: Ensure hemostasis
Thoroughly inspect the appendiceal stump and ensure hemostasis.

5. Remove the specimen (VIDEO 3)

• Remove the stapling device and replace it with a specimen retrieval bag, inserting it through the 12-mm port.
• Place the amputated appendix in the specimen retrieval bag to prevent abdominal contamination (FIGURE 6).
• Close the specimen retrieval bag inside the abdomen.
• Refrain from removing the specimen bag through the trocar or forcefully passing the appendix through a small incision. We usually withdraw the 12-mm trocar, then remove the cinched bag containing the resected appendix under direct visualization. We take all precautionary measures to prevent breakage of the bag, which would leak appendiceal contents into the abdomen.

FIGURE 6: Remove the specimen
Place the amputated appendix in the specimen retrieval bag and remove it, intact, through the patient’s abdomen.

6. Perform a few last measures

• If the surgeon chooses, suction and irrigation can be performed at the completion of the appendectomy procedure.
• Send all surgical specimens to pathology for evaluation.
• Complete the operation in the usual laparoscopic fashion. Remove all instruments, and close the 12-mm trocar port site using the Carter Thomason fascial closure device. Close the remaining port sites using 2-0 interrupted suture (Monocryl). Apply skin adhesive to all laparoscopic incisions.
• For more on surgical technique of appendectomy, see Baggish,¹⁹ Jaffe and Berger,²⁰ and Daniell and colleagues.²¹

Adequate training is essential

Surgical proficiency in laparoscopic appendectomy, like any surgical skill set, requires adequate training to ensure procedural familiarity and expertise and to encourage consistency. This training, preferably undertaken during residency, should be an essential part of obstetrics and gynecology education.

It is important to know which patient populations are at high risk for appendiceal pathology so that they can be assessed and counseled adequately prior to surgery. Among the components of patient counseling is a thorough and impartial discussion of procedural risks and benefits. Risk-benefit considerations should include the patient’s preferences so that she can be an active participant in her own health-care decisions.

Because the risks of appendectomy are minimal, and complications are rare, it is appropriate to offer elective laparoscopic appendectomy to patients scheduled to undergo benign gynecologic procedures, especially in the setting of chronic pelvic pain and endometriosis.

CASE: Resolved

The patient is counseled about the benefits and risks of laparoscopic incidental appendectomy, including the fact that it may be especially beneficial in women who have endometriosis. She consents to undergo the procedure at the time of her total laparoscopic hysterectomy.

Both procedures are performed safely, with no complications, and the patient’s immediate postoperative course is unremarkable. After one night of hospitalization, she is discharged home. The histopathologic report on the appendiceal specimen reveals endometriosis with fibrous obliteration of the lumen.

We want to hear from you! Tell us what you think.

Watch 3 intraoperative videos

• Dissect the appendix
• Resect the appendix
• Remove the specimen

Videos provided by Teresa Tam, MD, and Gerald Harkins, MD

CASE: Should appendectomy be included in total
laparoscopic hysterectomy?

A 39-year-old mother of two continues to experience severe dysmenorrhea and persistent menorrhagia despite undergoing endometrial ablation 2 years earlier. Her obstetric and gynecologic history is remarkable for a diagnosis of chronic pelvic pain, endometriosis, and failed endometrial ablation. Both her children were delivered by cesarean, and she has undergone tubal ligation. She requests hysterectomy to address the dysmenorrhea and menorrhagia once and for all.

A pelvic exam reveals an anteverted, 10-weeks’ size uterus with no adnexal masses or tenderness. After extensive discussion of the surgical procedure, the patient signs a consent for total laparoscopic hysterectomy.

Would you recommend appendectomy, too?

Prophylactic removal of the appendix during a benign gynecologic procedure is known as “elective incidental appendectomy.”¹ Incidental appendectomy at the time of cesarean delivery was reported initially in 1959.² Subsequent studies of removal of a normal-appearing appendix at the time of gynecologic surgery have met with considerable debate. Proponents argue that removal of the appendix at the time of abdominal hysterectomy does not increase operative time or postoperative morbidity. More important, it does prevent future appendicitis.^3-5

Some surgeons disagree, citing an increase in operative time, hospital costs, and patient morbidity as reasonable concerns. They also note that appendectomy requires an additional surgical procedure, which could increase the risk of infection and other complications and lead to adhesion formation.

Advantages of incidental appendectomy include technical ease, low patient morbidity and mortality, and significant diagnostic and protective value.⁶ It also prevents conflicting diagnoses, especially in patients who have chronic pelvic pain, a ruptured ovarian cyst, or endometriosis. Other patients likely to benefit from elective incidental appendectomy are those who are undergoing abdominal radiation or chemotherapy, women unable to communicate health complaints, and those who are planning to undergo complex abdominal or pelvic procedures that are likely to cause extensive adhesions.¹

In this article, we describe the rationale behind this procedure, as well as the technical steps involved.

The laparoscopic approach is preferred

Appendectomy is commonly performed laparoscopically. Semm first described this approach in 1983.⁷ Several studies since have reported that incidental laparoscopic appendectomy is safe, easy to perform, and should be offered to patients undergoing a concomitant gynecologic procedure.^8-10 Laparoscopic removal of a normal appendix does not add morbidity or prolong hospitalization, compared with diagnostic laparoscopy. A large study drawing from the Nationwide Inpatient Sample (NIS) database found laparoscopic removal of the appendix to be associated with lower mortality, fewer complications, shorter hospitalization, and lower mean hospital charges, compared with open appendectomy.¹¹ The same study found laparoscopic appendectomy to be the procedure of choice in both perforated and nonperforated appendicitis.

Overweight and obese patients also may benefit from the laparoscopic approach because it avoids problems associated with an open incision, such as the need for abdominal wall retraction, a longer hospital stay, and a risk of wound infection, compared with smaller incisions—especially in this high-risk population.¹²

Cost is another issue. Any prolonged surgical time and higher medical costs required for incidental appendectomy decrease as surgical proficiency and experience rise. The concomitant performance of endoscopic procedures can also reduce the risk associated with anesthesia for reoperations.

Endometriosis patients stand to benefit from appendectomy

There is compelling evidence that elective appendectomy is beneficial in patients who have endometriosis. Endometriosis of the bowel has been reported in 5.3% of all histologically proven endometriosis cases, with appendiceal endometriosis found in approximately 1% of women with endometriosis.¹³ Despite the low prevalence (2.8%) of appendiceal endometriosis,¹⁴ some studies reported a high incidence of appendiceal endometriosis when incidental appendectomy was performed. Patients who report right lower quadrant (RLQ) pain, chronic pelvic pain, and ovarian endometrioma had the highest incidence of abnormal histopathologic findings.^15-17 Because most women with endometriosis present with these symptoms, it is prudent to counsel patients preoperatively about the incidence of appendiceal endometriosis and to visually examine the appendix during gynecologic surgery to identify incidental appendiceal pathology.

Age may influence the appendectomy decision

The incidence of acute appendicitis is highest among people aged 10 to 19 years. The estimated lifetime risk of appendicitis is 6.7%.¹⁸ The surgical dilemma is whether to perform incidental appendectomy in the nonadolescent population, which is at lower risk for appendicitis, as a preventive measure.

We lack randomized trials on the benefit of incidental appendectomy. A retrospective study of open procedures supported incidental appendectomy in patients younger than 35 years; for patients 35 to 50, the decision was left to the clinical judgment of the surgeon, based on the patient’s clinical condition.⁴ The same study failed to support incidental appendectomy in women older than 50 years.

When the appendix is not easily accessible, or the surgical complexity of the gynecologic procedure prevents the surgeon from safely performing an appendectomy, it is better to complete the planned gynecologic surgery and forgo the appendectomy. It is acceptable to make the decision to refrain from the appendectomy intraoperatively if the risk of complications outweighs the likely benefits. The practice of cautionary discretion demonstrates sound judgment and avoids compromising the safety of the patient.

How to perform appendectomy

1. Maintain at least three laparoscopic sites

• After the laparoscopic gynecologic procedure, maintain three trocar sites—preferably, two 5-mm trocars and one 12-mm trocar.
• The first 5-mm trocar, at the umbilical incision, accommodates the laparoscopic camera. The second 5-mm trocar serves as an accessory port for laparoscopic instruments and is inserted into the RLQ.
• The 12-mm trocar in the left lower quadrant (LLQ) is also used to insert endoscopic instruments. This trocar site will be used at the conclusion of the appendectomy to accommodate the mechanical stapling device and the specimen bag for removal of the excised organ.

FIGURE 1: Visualize the appendix. Identify the cecum and ileocolic junction to locate the appendix.

2. Identify the appendix

• Perform a careful visual exploration of the abdominal contents to exclude other intra-abdominal pathology.
• Identify the cecum and ileocolic junction to locate the appendix (FIGURE 1).
• Visually inspect the appendix and identify any gross appendiceal pathology.

FIGURE 2: Divide the mesoappendix
Isolate, cauterize, and divide the mesoappendix using 5-mm ultrasonic shears.

3. Dissect the appendix (VIDEO 1)

• Insert an atraumatic forceps through the 5-mm right accessory trocar.
• Grasp the fatty tissue at the tip of the appendix and provide some traction.
• Elevate the appendix to facilitate visualization of the mesoappendix.
• Isolate the mesoappendix and cauterize and divide it using 5-mm ultrasonic shears inserted through the RLQ trocar (FIGURE 2).
• Release some of the upward tension from the specimen retraction by dropping the height of the instrument to prevent undue trauma and bleeding.
• Make a window between the mesentery and the base of the appendix to facilitate dissection.
• Skeletonize the mesoappendix at the junction of the appendiceal base and the cecum.
• During skeletonization, pay special attention to the appendiceal artery at the base of the mesoappendix.

FIGURE 3: Apply the stapling device
Apply the stapling device across the base of the appendix.

4. Resect the appendix (VIDEO 2)

• Insert an automatic stapling device through the 12-mm port and apply it across the base of the appendix (FIGURE 3).
• Apply the mechanical stapling device for 15 seconds to crush the base of the appendix and empty its contents.
• Visualize both sides of the stapler to ensure that it is placed at the base of the appendix.
• Always check the tip of the device to ensure that the jaws of the stapling device fully compress the appendix and have not inadvertently grasped other abdominal contents.
• With the stapling device compressing the base of the appendix, release some of the upward tension on the specimen by dropping the height of the retraction.
• Activate the stapling device and completely excise the appendix from its base
  (FIGURE 4).
• Thoroughly inspect the appendiceal stump to ensure hemostasis (FIGURE 5).

FIGURE 4: Excise the appendix
Activate the stapling device and completely excise the appendix from its base.

FIGURE 5: Ensure hemostasis
Thoroughly inspect the appendiceal stump and ensure hemostasis.

5. Remove the specimen (VIDEO 3)

• Remove the stapling device and replace it with a specimen retrieval bag, inserting it through the 12-mm port.
• Place the amputated appendix in the specimen retrieval bag to prevent abdominal contamination (FIGURE 6).
• Close the specimen retrieval bag inside the abdomen.
• Refrain from removing the specimen bag through the trocar or forcefully passing the appendix through a small incision. We usually withdraw the 12-mm trocar, then remove the cinched bag containing the resected appendix under direct visualization. We take all precautionary measures to prevent breakage of the bag, which would leak appendiceal contents into the abdomen.

FIGURE 6: Remove the specimen
Place the amputated appendix in the specimen retrieval bag and remove it, intact, through the patient’s abdomen.

6. Perform a few last measures

• If the surgeon chooses, suction and irrigation can be performed at the completion of the appendectomy procedure.
• Send all surgical specimens to pathology for evaluation.
• Complete the operation in the usual laparoscopic fashion. Remove all instruments, and close the 12-mm trocar port site using the Carter Thomason fascial closure device. Close the remaining port sites using 2-0 interrupted suture (Monocryl). Apply skin adhesive to all laparoscopic incisions.
• For more on surgical technique of appendectomy, see Baggish,¹⁹ Jaffe and Berger,²⁰ and Daniell and colleagues.²¹

Adequate training is essential

Surgical proficiency in laparoscopic appendectomy, like any surgical skill set, requires adequate training to ensure procedural familiarity and expertise and to encourage consistency. This training, preferably undertaken during residency, should be an essential part of obstetrics and gynecology education.

It is important to know which patient populations are at high risk for appendiceal pathology so that they can be assessed and counseled adequately prior to surgery. Among the components of patient counseling is a thorough and impartial discussion of procedural risks and benefits. Risk-benefit considerations should include the patient’s preferences so that she can be an active participant in her own health-care decisions.

Because the risks of appendectomy are minimal, and complications are rare, it is appropriate to offer elective laparoscopic appendectomy to patients scheduled to undergo benign gynecologic procedures, especially in the setting of chronic pelvic pain and endometriosis.

CASE: Resolved

The patient is counseled about the benefits and risks of laparoscopic incidental appendectomy, including the fact that it may be especially beneficial in women who have endometriosis. She consents to undergo the procedure at the time of her total laparoscopic hysterectomy.

Both procedures are performed safely, with no complications, and the patient’s immediate postoperative course is unremarkable. After one night of hospitalization, she is discharged home. The histopathologic report on the appendiceal specimen reveals endometriosis with fibrous obliteration of the lumen.

We want to hear from you! Tell us what you think.

Watch 3 intraoperative videos

• Dissect the appendix
• Resect the appendix
• Remove the specimen

Videos provided by Teresa Tam, MD, and Gerald Harkins, MD

CASE: Should appendectomy be included in total
laparoscopic hysterectomy?

A 39-year-old mother of two continues to experience severe dysmenorrhea and persistent menorrhagia despite undergoing endometrial ablation 2 years earlier. Her obstetric and gynecologic history is remarkable for a diagnosis of chronic pelvic pain, endometriosis, and failed endometrial ablation. Both her children were delivered by cesarean, and she has undergone tubal ligation. She requests hysterectomy to address the dysmenorrhea and menorrhagia once and for all.

A pelvic exam reveals an anteverted, 10-weeks’ size uterus with no adnexal masses or tenderness. After extensive discussion of the surgical procedure, the patient signs a consent for total laparoscopic hysterectomy.

Would you recommend appendectomy, too?

Prophylactic removal of the appendix during a benign gynecologic procedure is known as “elective incidental appendectomy.”¹ Incidental appendectomy at the time of cesarean delivery was reported initially in 1959.² Subsequent studies of removal of a normal-appearing appendix at the time of gynecologic surgery have met with considerable debate. Proponents argue that removal of the appendix at the time of abdominal hysterectomy does not increase operative time or postoperative morbidity. More important, it does prevent future appendicitis.^3-5

Some surgeons disagree, citing an increase in operative time, hospital costs, and patient morbidity as reasonable concerns. They also note that appendectomy requires an additional surgical procedure, which could increase the risk of infection and other complications and lead to adhesion formation.

Advantages of incidental appendectomy include technical ease, low patient morbidity and mortality, and significant diagnostic and protective value.⁶ It also prevents conflicting diagnoses, especially in patients who have chronic pelvic pain, a ruptured ovarian cyst, or endometriosis. Other patients likely to benefit from elective incidental appendectomy are those who are undergoing abdominal radiation or chemotherapy, women unable to communicate health complaints, and those who are planning to undergo complex abdominal or pelvic procedures that are likely to cause extensive adhesions.¹

In this article, we describe the rationale behind this procedure, as well as the technical steps involved.

The laparoscopic approach is preferred

Appendectomy is commonly performed laparoscopically. Semm first described this approach in 1983.⁷ Several studies since have reported that incidental laparoscopic appendectomy is safe, easy to perform, and should be offered to patients undergoing a concomitant gynecologic procedure.^8-10 Laparoscopic removal of a normal appendix does not add morbidity or prolong hospitalization, compared with diagnostic laparoscopy. A large study drawing from the Nationwide Inpatient Sample (NIS) database found laparoscopic removal of the appendix to be associated with lower mortality, fewer complications, shorter hospitalization, and lower mean hospital charges, compared with open appendectomy.¹¹ The same study found laparoscopic appendectomy to be the procedure of choice in both perforated and nonperforated appendicitis.

Overweight and obese patients also may benefit from the laparoscopic approach because it avoids problems associated with an open incision, such as the need for abdominal wall retraction, a longer hospital stay, and a risk of wound infection, compared with smaller incisions—especially in this high-risk population.¹²

Cost is another issue. Any prolonged surgical time and higher medical costs required for incidental appendectomy decrease as surgical proficiency and experience rise. The concomitant performance of endoscopic procedures can also reduce the risk associated with anesthesia for reoperations.

Endometriosis patients stand to benefit from appendectomy

There is compelling evidence that elective appendectomy is beneficial in patients who have endometriosis. Endometriosis of the bowel has been reported in 5.3% of all histologically proven endometriosis cases, with appendiceal endometriosis found in approximately 1% of women with endometriosis.¹³ Despite the low prevalence (2.8%) of appendiceal endometriosis,¹⁴ some studies reported a high incidence of appendiceal endometriosis when incidental appendectomy was performed. Patients who report right lower quadrant (RLQ) pain, chronic pelvic pain, and ovarian endometrioma had the highest incidence of abnormal histopathologic findings.^15-17 Because most women with endometriosis present with these symptoms, it is prudent to counsel patients preoperatively about the incidence of appendiceal endometriosis and to visually examine the appendix during gynecologic surgery to identify incidental appendiceal pathology.

Age may influence the appendectomy decision

The incidence of acute appendicitis is highest among people aged 10 to 19 years. The estimated lifetime risk of appendicitis is 6.7%.¹⁸ The surgical dilemma is whether to perform incidental appendectomy in the nonadolescent population, which is at lower risk for appendicitis, as a preventive measure.

We lack randomized trials on the benefit of incidental appendectomy. A retrospective study of open procedures supported incidental appendectomy in patients younger than 35 years; for patients 35 to 50, the decision was left to the clinical judgment of the surgeon, based on the patient’s clinical condition.⁴ The same study failed to support incidental appendectomy in women older than 50 years.

When the appendix is not easily accessible, or the surgical complexity of the gynecologic procedure prevents the surgeon from safely performing an appendectomy, it is better to complete the planned gynecologic surgery and forgo the appendectomy. It is acceptable to make the decision to refrain from the appendectomy intraoperatively if the risk of complications outweighs the likely benefits. The practice of cautionary discretion demonstrates sound judgment and avoids compromising the safety of the patient.

How to perform appendectomy

1. Maintain at least three laparoscopic sites

• After the laparoscopic gynecologic procedure, maintain three trocar sites—preferably, two 5-mm trocars and one 12-mm trocar.
• The first 5-mm trocar, at the umbilical incision, accommodates the laparoscopic camera. The second 5-mm trocar serves as an accessory port for laparoscopic instruments and is inserted into the RLQ.
• The 12-mm trocar in the left lower quadrant (LLQ) is also used to insert endoscopic instruments. This trocar site will be used at the conclusion of the appendectomy to accommodate the mechanical stapling device and the specimen bag for removal of the excised organ.

FIGURE 1: Visualize the appendix. Identify the cecum and ileocolic junction to locate the appendix.

2. Identify the appendix

• Perform a careful visual exploration of the abdominal contents to exclude other intra-abdominal pathology.
• Identify the cecum and ileocolic junction to locate the appendix (FIGURE 1).
• Visually inspect the appendix and identify any gross appendiceal pathology.

FIGURE 2: Divide the mesoappendix
Isolate, cauterize, and divide the mesoappendix using 5-mm ultrasonic shears.

3. Dissect the appendix (VIDEO 1)

• Insert an atraumatic forceps through the 5-mm right accessory trocar.
• Grasp the fatty tissue at the tip of the appendix and provide some traction.
• Elevate the appendix to facilitate visualization of the mesoappendix.
• Isolate the mesoappendix and cauterize and divide it using 5-mm ultrasonic shears inserted through the RLQ trocar (FIGURE 2).
• Release some of the upward tension from the specimen retraction by dropping the height of the instrument to prevent undue trauma and bleeding.
• Make a window between the mesentery and the base of the appendix to facilitate dissection.
• Skeletonize the mesoappendix at the junction of the appendiceal base and the cecum.
• During skeletonization, pay special attention to the appendiceal artery at the base of the mesoappendix.

FIGURE 3: Apply the stapling device
Apply the stapling device across the base of the appendix.

4. Resect the appendix (VIDEO 2)

• Insert an automatic stapling device through the 12-mm port and apply it across the base of the appendix (FIGURE 3).
• Apply the mechanical stapling device for 15 seconds to crush the base of the appendix and empty its contents.
• Visualize both sides of the stapler to ensure that it is placed at the base of the appendix.
• Always check the tip of the device to ensure that the jaws of the stapling device fully compress the appendix and have not inadvertently grasped other abdominal contents.
• With the stapling device compressing the base of the appendix, release some of the upward tension on the specimen by dropping the height of the retraction.
• Activate the stapling device and completely excise the appendix from its base
  (FIGURE 4).
• Thoroughly inspect the appendiceal stump to ensure hemostasis (FIGURE 5).

FIGURE 4: Excise the appendix
Activate the stapling device and completely excise the appendix from its base.

FIGURE 5: Ensure hemostasis
Thoroughly inspect the appendiceal stump and ensure hemostasis.

5. Remove the specimen (VIDEO 3)

• Remove the stapling device and replace it with a specimen retrieval bag, inserting it through the 12-mm port.
• Place the amputated appendix in the specimen retrieval bag to prevent abdominal contamination (FIGURE 6).
• Close the specimen retrieval bag inside the abdomen.
• Refrain from removing the specimen bag through the trocar or forcefully passing the appendix through a small incision. We usually withdraw the 12-mm trocar, then remove the cinched bag containing the resected appendix under direct visualization. We take all precautionary measures to prevent breakage of the bag, which would leak appendiceal contents into the abdomen.

FIGURE 6: Remove the specimen
Place the amputated appendix in the specimen retrieval bag and remove it, intact, through the patient’s abdomen.

6. Perform a few last measures

• If the surgeon chooses, suction and irrigation can be performed at the completion of the appendectomy procedure.
• Send all surgical specimens to pathology for evaluation.
• Complete the operation in the usual laparoscopic fashion. Remove all instruments, and close the 12-mm trocar port site using the Carter Thomason fascial closure device. Close the remaining port sites using 2-0 interrupted suture (Monocryl). Apply skin adhesive to all laparoscopic incisions.
• For more on surgical technique of appendectomy, see Baggish,¹⁹ Jaffe and Berger,²⁰ and Daniell and colleagues.²¹

Adequate training is essential

Surgical proficiency in laparoscopic appendectomy, like any surgical skill set, requires adequate training to ensure procedural familiarity and expertise and to encourage consistency. This training, preferably undertaken during residency, should be an essential part of obstetrics and gynecology education.

It is important to know which patient populations are at high risk for appendiceal pathology so that they can be assessed and counseled adequately prior to surgery. Among the components of patient counseling is a thorough and impartial discussion of procedural risks and benefits. Risk-benefit considerations should include the patient’s preferences so that she can be an active participant in her own health-care decisions.

Because the risks of appendectomy are minimal, and complications are rare, it is appropriate to offer elective laparoscopic appendectomy to patients scheduled to undergo benign gynecologic procedures, especially in the setting of chronic pelvic pain and endometriosis.

CASE: Resolved

The patient is counseled about the benefits and risks of laparoscopic incidental appendectomy, including the fact that it may be especially beneficial in women who have endometriosis. She consents to undergo the procedure at the time of her total laparoscopic hysterectomy.

Both procedures are performed safely, with no complications, and the patient’s immediate postoperative course is unremarkable. After one night of hospitalization, she is discharged home. The histopathologic report on the appendiceal specimen reveals endometriosis with fibrous obliteration of the lumen.

We want to hear from you! Tell us what you think.

CASE A man in his 30s with allergic rhinitis (AR) at predictable times of the year with high pollen counts reports only modest symptom relief with a nasal steroid preparation after 3 weeks of use. He comes to see you because he’s “tired of feeling lousy all of the time.”

What management options would you consider?

There is a plethora of treatment options for patients like this one, and considerable variation in clinical practice when it comes to AR.¹ The good news is that there are several recent guidelines for treating AR patients, whose symptoms (and underlying cause) can vary widely.

The following review—and accompanying algorithm—provides evidence-based recommendations that can help you refine your approach to AR.

Two guidelines, and several Cochrane reviews

Allergic Rhinitis and its Impact on Asthma (ARIA), a sentinel rhinitis treatment guideline, was published in 2001 and updated in 2008 and 2010.^2-4 The British Society for Allergy and Clinical Immunology Standards of Care Committee (BSACI) published guidelines for rhinitis management in 2008 and guidelines for immunotherapy in 2011.^5,6 In addition, several Cochrane reviews have been performed.^7-12 The ALGORITHM^1-6 combines these recommendations. The TABLE^2-12 itemizes the recommendations made by each guideline.

ALGORITHM
An evidence-based approach to treating allergic rhinitis^1-6
Based on recommendations from ARIA and BSACI guidelines and Cochrane reviews

TABLE
Treatment recommendations/suggestions for allergic rhinitis^2-12

The summary that follows provides a more detailed look at the recommendations, with a review of the pathophysiology of AR (“Phases of allergic rhinitis”^{2,3,5,8,13-15}).

Of note: This summary preserves the terminology used in ARIA 2010. Specifically, the ARIA guideline uses the term suggest for conditional recommendations and recommend for strong recommendations.⁴ That same language is used here.

Nasal steroids: First-line Tx for moderate to severe symptoms

BSACI indicates that nasal steroids (NS) are the treatment of choice for moderate to severe persistent AR (symptoms lasting >4 days per week or >4 weeks per year).⁵ ARIA 2010 suggests NS as first-line treatment rather than oral antihistamines for adults and children with seasonal (related to outdoor allergens such as pollens or molds) and persistent AR.⁴ ARIA 2008 finds NS are the most effective treatment for children.³ Steroids reduce inflammation by decreasing inflammatory cell migration and inhibiting cytokine release.¹⁶ They are the most effective monotherapy for all symptoms of AR, including nasal congestion, which antihistamines do not treat effectively.^13,16 NS also treat ocular symptoms of allergy effectively.^15,17

The ARIA 2010 guideline also recommends using NS rather than nasal antihistamines and leukotriene receptor antagonists.⁴ Combination therapy (eg, NS with the addition of nasal antihistamines) is an option for severe or persistent AR, but it appears to be no more effective than monotherapy with NS.¹⁶ A 2010 Cochrane review determined there is insufficient evidence for or against the use of oral antihistamines plus NS vs NS alone in children with AR.⁷ Intermittent steroid use may be beneficial in children.⁵

Steroids begin working 6 to 8 hours after the first dose, although symptom reduction may take days and maximal effect up to 2 weeks.⁵ Treatment failure may be due to poor technique that can cause local adverse effects (ie, dryness, irritation, epistaxis). Technique-related failure occurs in up to 10% of users.^5,15 Educating patients and families about correct technique with steroid spray may decrease nonadherence due to irritation and epistaxis.¹⁸ Tell them to shake the bottle well, look down, aim the nozzle toward the outside wall of the nostril using the opposite hand, and spray while sniffing lightly.⁵

Any steroid is appropriate for adults. For children ≥2 years of age, consider fluticasone propionate, mometasone furoate, or triamcinolone acetonide.³ These medications have lower systemic bioavailability and a decreased risk of such adverse effects as hypothalamic-pituitary-adrenal axis suppression and growth retardation.¹⁵ Budesonide is appropriate for those ≥6 years.^19-21 Avoid regular use of betamethasone, which has high bioavailability, for >1 year in children, as it may decrease their growth rate.³ Beclomethasone, fluticasone, and budesonide have been used widely and safely for pregnant women with asthma.⁵

Antihistamines are first-line Tx for mild symptoms

ARIA 2010 recommends new-generation oral nonsedating antihistamines that do not affect cytochrome P450 for mild AR,⁴ such as cetirizine, levocetirizine, loratadine, desloratadine, and fexofenadine. First-generation antihistamines can reduce symptoms, but are not first-line treatment as they cause sedation, fatigue, decreased cognitive function, and reduced academic and work performance.^3-5 ARIA 2010 further suggests choosing oral antihistamines over oral leukotriene receptor antagonists in patients with seasonal AR and in preschool children with persistent AR.⁴

BSACI recommends oral or topical antihistamines as first-line treatment for mild to moderate symptoms lasting <4 days per week or <4 weeks per year and moderate persistent AR.⁵ When steroids alone do not control moderate to severe persistent AR, BSACI recommends adding oral or topical antihistamines.⁵ Oral and topical antihistamines decrease histamine-related symptoms of itching, rhinorrhea, and sneezing, but do not significantly decrease nasal congestion.¹⁵

Nasal antihistamines (levocabastine, azelastine) have a rapid onset of action and few adverse effects.³ ARIA 2010 suggests nasal antihistamines over nasal chromones (inhibitors of mast cell degranulation) and notes that the need to use chromones 4 times daily may limit adherence.⁴ The same guidelines suggest nasal antihistamine use for children and adults with seasonal AR and suggest not using nasal antihistamines for patients with persistent AR until more data on efficacy and safety are available.⁴

Alezastine is approved for individuals ≥5 years, and olopatadine is approved for individuals ≥6 years for the treatment of AR.^16,22,23 A pediatric review article noted nasal antihistamine (azelastine) plus nasal fluticasone was more efficacious than NS alone.¹⁵

In children, weigh adverse effects of antihistamines against the general malaise caused by AR.³ Do not use first-generation antihistamines due to the sedation that may interfere with learning.¹⁵ Treatment with once-daily, long-acting antihistamines rather than multiple daily dosing may improve adherence in children.⁵ Continuous administration, rather than as needed, is optimal treatment in children.⁵ Cetirizine, loratadine, and levocetirizine have been studied and are effective and safe in children.³ Levocetirizine has proven safe and efficacious for children ≥2 years.²⁴ Fexofenadine was found to be effective and safe for those ≥6 years.²⁵

For children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones.⁴ Due to the safety of these agents, chromones may be used first, then antihistamines.⁴ Just as with nasal chromones, the need to use intraocular chromones 4 times daily may limit their use in children.⁴

Pregnant patients. Antihistamines do cross the placenta.⁵ Agents that appear to be safe for pregnant patients are chlorphenamine (first-generation), loratadine, and cetirizine.⁵

Leukotriene receptor antagonists: Always pair with antihistamines
As adjunctive therapy for additional symptom control, ARIA 2010 suggests oral leukotriene receptor antagonists for children and adults with seasonal AR, and for preschool children with persistent AR. These agents may also be helpful in children with concurrent asthma.¹⁵ Always pair leukotriene receptor antagonists with antihistamines. Montelukast is approved for seasonal AR in children ≥2 years and for frequent nonseasonal nasal or ocular AR symptoms in children ≥6 months.²⁶

ARIA 2010 recommends against the use of oral leukotriene receptor antagonists in adults with persistent AR.⁴

Decongestants are for limited use only
For adults with severe nasal obstruction, ARIA 2010 suggests a short course (<5 days) of nasal decongestant along with other drugs.⁴ Limiting use of nasal decongestants to <10 days helps prevent rhinitis medicamentosa.^5,27 BSACI notes nasal decongestants may be useful for eustachian tube dysfunction experienced aboard airplanes, for children with acute otitis media with middle ear pain, to relieve congestion after an upper respiratory infection, and to improve nasal patency before NS use.⁵ Both guidelines suggest against regular oral decongestant use.^4,5

Avoid decongestants in pregnant patients.⁵ ARIA 2010 suggests against nasal decongestant use in preschool children.⁴

Chromones may help, but require multiple daily dosing
Chromones inhibit mast cell degranulation, are weakly effective for reducing nasal obstruction in AR, and have a high safety profile.^3-5,28 As noted earlier, they must be used 4 times daily, which may reduce adherence—particularly in children.⁴

ARIA 2008 notes that disodium cromoglycate is less effective than NS or antihistamines.³ The 2010 update suggests nasal antihistamines over nasal chromones.⁴ For adults as well as children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones. BSACI recommends limited use of chromones for children and adults with mild symptoms.⁵

Nasal saline helpful as adjunct to medication
Nasal saline irrigation improves symptoms of AR, clears nasal passages, and is helpful for pregnant patients, for whom medications should be used with caution.^2,3,5 Nasal irrigation using a neti pot or squeeze bottle is efficacious for chronic rhinorrhea, as solo or complementary treatment, and for children.^5,16,27

Oral steroids: Use only rarely
ARIA 2010 suggests a short course of oral glucocorticosteroids for patients with AR and moderate to severe nasal or ocular symptoms not controlled with other treatments.⁴ BSACI notes oral steroids are rarely indicated, but that their use over 5 to 10 days may help with severe nasal congestion, symptoms uncontrolled by conventional pharmacotherapy, or before important social or work events.⁵ Both guidelines recommend against intramuscular steroids.⁴ ARIA 2008 notes oral and depot preparations of steroids affect growth in young children.³

Ipratropium when rhinorrhea is severe
Nasal ipratropium bromide, a topical anticholinergic, is helpful for excessive or refractory rhinorrhea. Consider using ipratropium with NS for patients for whom rhinorrhea is the dominant symptom.^5,16,28 ARIA 2010 suggests using nasal ipratropium to treat rhinorrhea in patients with persistent AR.⁴

Allergen-specific immunotherapy: When other treatments fail

Allergen-specific immunotherapy (ASI) consists of repeated exposure to an allergen to induce immunomodulation, which prevents or reduces allergy symptoms and actually changes the natural course of AR. (For more on identifying the offending agent, see “Time for allergen testing?”^2,5,15,18,29.) This treatment process decreases medication needs, prevents new allergen sensitization, and results in long-lasting improvement.^2,5,6,30 BSACI 2011 notes that ASI is effective for adults and children with severe AR who do not respond to conventional pharmacotherapy and allergen avoidance measures.⁶

ASI methods developed to date use subcutaneous, sublingual, or nasal routes of administration. However, the US Food and Drug Administration has yet to approve commercial sublingual or nasal products for use in the United States.¹⁶

Subcutaneous immunotherapy may cause local adverse reactions (pruritus and swelling) and systemic reactions that can be severe or life threatening (anaphylaxis) and thus must be given in a doctor’s office prepared to treat anaphylaxis.^6,16,30 Adrenaline administration has been necessary in 0.13% of those being treated.⁹ Subcutaneous immunotherapy must be done for 3 to 5 years for sustained effective treatment.¹⁵

ARIA 2010 suggests subcutaneous immunotherapy for adults with seasonal AR and with persistent AR due to house dust mites.⁴ A 2007 Cochrane review found subcutaneous immunotherapy is efficacious for patients with seasonal AR due to pollens, resulting in decreased symptoms and medication use with few significant severe adverse reactions.⁹ A meta-analysis showed subcutaneous immunotherapy is as potent as pharmacotherapy in controlling seasonal AR symptoms as early as the first season of treatment.³¹

What if the patient is pregnant—or a child? BSACI notes that maintenance ASI may be continued in a patient who becomes pregnant, but starting ASI or increasing the dose is contraindicated.⁵

Based on ARIA 2008 and 2010, consider subcutaneous immunotherapy for children—but not for those <5 years.^3,4 Care must be used in selecting patients, as 3 to 5 years of treatment are necessary for sustained benefit.¹⁵

Lifestyle changes: Limited benefit may be achievable
ARIA 2010 recommends mold avoidance and animal dander avoidance for patients so affected.⁴ Allergens from pets can persist in homes for months after pet removal.¹⁵ BSACI found that commercially available nasal filters (filters or screens placed over or within both nares) reduced symptoms of AR during ragweed and grass pollen seasons.⁵ Allergen avoidance for children with persistent AR has not shown consistent benefit.¹⁵ A 2010 Cochrane review concluded that allergen avoidance may decrease AR symptoms, but more research is needed.¹¹

House dust mites. The 2010 Cochrane review also reported on 2 trials that assessed high-efficiency particulate air (HEPA) filters specifically for patients allergic to house dust mites.¹¹ The studies, which had methodological limitations (inconsistent randomization, small sample size, and short duration), concluded that HEPA filters alone will not likely reduce symptoms of house dust mite allergy. But HEPA filters may be beneficial as one component of an extensive bedroom-based environmental control program.¹¹

Impermeable bedding has been shown to reduce dust mite load by 50% to 70%, leaving residual allergen that may still trigger symptoms.¹¹ A 2012 Cochrane review concluded that achieving substantial reductions in house dust mite load using a combination approach of multiple interventions, including acaricides and extensive bedroom-based environmental control programs, may decrease AR symptoms.¹² However, ARIA 2010 recommends against single chemical or physical preventive methods and against combination preventive methods to reduce house dust mite exposure.⁴

Total elimination of house dust mites may be impossible, and recommending use of impermeable covers and HEPA filters, removal of rugs and curtains, and frequent cleaning must take into account a patient’s symptoms and a family’s motivation and finances.^11,18

Complementary and alternative medicine: Too little evidence
ARIA 2010 suggests against patients using homeopathy, acupuncture, butterbur, herbal medicines, or phototherapy for AR.⁴ While one systematic review of acupuncture for AR demonstrated mixed results with no specific effects for seasonal AR and some improvement of frequent nonseasonal symptoms,³² another review concluded evidence was insufficient to make any recommendation.^32,33 The benefit of ear acupressure is unknown, as supporting studies are of low methodological quality, although it appeared to provide some benefit for AR.³⁴

Due to lack of data, probiotics should not be recommended.²⁷ A pediatric review article noted that probiotics may alter cytokine production in patients with seasonal AR and may be more helpful in AR than in asthma, although more research was needed.¹⁵ Another review showed that probiotics may reduce AR symptoms and medication use.³⁵

CASE Since the nasal steroid you prescribed for your patient did not provide adequate relief, you opt to add cetirizine 10 mg to his NS regimen. This step relieved his symptoms within 2 to 3 days. Had his symptoms persisted, the patient would have been a candidate for a one-week course of oral decongestant, such as pseudoephedrine 120 mg orally every 12 hours, as needed; and then for allergen testing, specifically for pollens corresponding to the seasonality of his AR. Appropriate follow-up would be to monitor the patient until his symptoms resolved or became manageable.

CASE A man in his 30s with allergic rhinitis (AR) at predictable times of the year with high pollen counts reports only modest symptom relief with a nasal steroid preparation after 3 weeks of use. He comes to see you because he’s “tired of feeling lousy all of the time.”

What management options would you consider?

There is a plethora of treatment options for patients like this one, and considerable variation in clinical practice when it comes to AR.¹ The good news is that there are several recent guidelines for treating AR patients, whose symptoms (and underlying cause) can vary widely.

The following review—and accompanying algorithm—provides evidence-based recommendations that can help you refine your approach to AR.

Two guidelines, and several Cochrane reviews

Allergic Rhinitis and its Impact on Asthma (ARIA), a sentinel rhinitis treatment guideline, was published in 2001 and updated in 2008 and 2010.^2-4 The British Society for Allergy and Clinical Immunology Standards of Care Committee (BSACI) published guidelines for rhinitis management in 2008 and guidelines for immunotherapy in 2011.^5,6 In addition, several Cochrane reviews have been performed.^7-12 The ALGORITHM^1-6 combines these recommendations. The TABLE^2-12 itemizes the recommendations made by each guideline.

ALGORITHM
An evidence-based approach to treating allergic rhinitis^1-6
Based on recommendations from ARIA and BSACI guidelines and Cochrane reviews

TABLE
Treatment recommendations/suggestions for allergic rhinitis^2-12

The summary that follows provides a more detailed look at the recommendations, with a review of the pathophysiology of AR (“Phases of allergic rhinitis”^{2,3,5,8,13-15}).

Of note: This summary preserves the terminology used in ARIA 2010. Specifically, the ARIA guideline uses the term suggest for conditional recommendations and recommend for strong recommendations.⁴ That same language is used here.

Nasal steroids: First-line Tx for moderate to severe symptoms

BSACI indicates that nasal steroids (NS) are the treatment of choice for moderate to severe persistent AR (symptoms lasting >4 days per week or >4 weeks per year).⁵ ARIA 2010 suggests NS as first-line treatment rather than oral antihistamines for adults and children with seasonal (related to outdoor allergens such as pollens or molds) and persistent AR.⁴ ARIA 2008 finds NS are the most effective treatment for children.³ Steroids reduce inflammation by decreasing inflammatory cell migration and inhibiting cytokine release.¹⁶ They are the most effective monotherapy for all symptoms of AR, including nasal congestion, which antihistamines do not treat effectively.^13,16 NS also treat ocular symptoms of allergy effectively.^15,17

The ARIA 2010 guideline also recommends using NS rather than nasal antihistamines and leukotriene receptor antagonists.⁴ Combination therapy (eg, NS with the addition of nasal antihistamines) is an option for severe or persistent AR, but it appears to be no more effective than monotherapy with NS.¹⁶ A 2010 Cochrane review determined there is insufficient evidence for or against the use of oral antihistamines plus NS vs NS alone in children with AR.⁷ Intermittent steroid use may be beneficial in children.⁵

Steroids begin working 6 to 8 hours after the first dose, although symptom reduction may take days and maximal effect up to 2 weeks.⁵ Treatment failure may be due to poor technique that can cause local adverse effects (ie, dryness, irritation, epistaxis). Technique-related failure occurs in up to 10% of users.^5,15 Educating patients and families about correct technique with steroid spray may decrease nonadherence due to irritation and epistaxis.¹⁸ Tell them to shake the bottle well, look down, aim the nozzle toward the outside wall of the nostril using the opposite hand, and spray while sniffing lightly.⁵

Any steroid is appropriate for adults. For children ≥2 years of age, consider fluticasone propionate, mometasone furoate, or triamcinolone acetonide.³ These medications have lower systemic bioavailability and a decreased risk of such adverse effects as hypothalamic-pituitary-adrenal axis suppression and growth retardation.¹⁵ Budesonide is appropriate for those ≥6 years.^19-21 Avoid regular use of betamethasone, which has high bioavailability, for >1 year in children, as it may decrease their growth rate.³ Beclomethasone, fluticasone, and budesonide have been used widely and safely for pregnant women with asthma.⁵

Antihistamines are first-line Tx for mild symptoms

ARIA 2010 recommends new-generation oral nonsedating antihistamines that do not affect cytochrome P450 for mild AR,⁴ such as cetirizine, levocetirizine, loratadine, desloratadine, and fexofenadine. First-generation antihistamines can reduce symptoms, but are not first-line treatment as they cause sedation, fatigue, decreased cognitive function, and reduced academic and work performance.^3-5 ARIA 2010 further suggests choosing oral antihistamines over oral leukotriene receptor antagonists in patients with seasonal AR and in preschool children with persistent AR.⁴

BSACI recommends oral or topical antihistamines as first-line treatment for mild to moderate symptoms lasting <4 days per week or <4 weeks per year and moderate persistent AR.⁵ When steroids alone do not control moderate to severe persistent AR, BSACI recommends adding oral or topical antihistamines.⁵ Oral and topical antihistamines decrease histamine-related symptoms of itching, rhinorrhea, and sneezing, but do not significantly decrease nasal congestion.¹⁵

Nasal antihistamines (levocabastine, azelastine) have a rapid onset of action and few adverse effects.³ ARIA 2010 suggests nasal antihistamines over nasal chromones (inhibitors of mast cell degranulation) and notes that the need to use chromones 4 times daily may limit adherence.⁴ The same guidelines suggest nasal antihistamine use for children and adults with seasonal AR and suggest not using nasal antihistamines for patients with persistent AR until more data on efficacy and safety are available.⁴

Alezastine is approved for individuals ≥5 years, and olopatadine is approved for individuals ≥6 years for the treatment of AR.^16,22,23 A pediatric review article noted nasal antihistamine (azelastine) plus nasal fluticasone was more efficacious than NS alone.¹⁵

In children, weigh adverse effects of antihistamines against the general malaise caused by AR.³ Do not use first-generation antihistamines due to the sedation that may interfere with learning.¹⁵ Treatment with once-daily, long-acting antihistamines rather than multiple daily dosing may improve adherence in children.⁵ Continuous administration, rather than as needed, is optimal treatment in children.⁵ Cetirizine, loratadine, and levocetirizine have been studied and are effective and safe in children.³ Levocetirizine has proven safe and efficacious for children ≥2 years.²⁴ Fexofenadine was found to be effective and safe for those ≥6 years.²⁵

For children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones.⁴ Due to the safety of these agents, chromones may be used first, then antihistamines.⁴ Just as with nasal chromones, the need to use intraocular chromones 4 times daily may limit their use in children.⁴

Pregnant patients. Antihistamines do cross the placenta.⁵ Agents that appear to be safe for pregnant patients are chlorphenamine (first-generation), loratadine, and cetirizine.⁵

Leukotriene receptor antagonists: Always pair with antihistamines
As adjunctive therapy for additional symptom control, ARIA 2010 suggests oral leukotriene receptor antagonists for children and adults with seasonal AR, and for preschool children with persistent AR. These agents may also be helpful in children with concurrent asthma.¹⁵ Always pair leukotriene receptor antagonists with antihistamines. Montelukast is approved for seasonal AR in children ≥2 years and for frequent nonseasonal nasal or ocular AR symptoms in children ≥6 months.²⁶

ARIA 2010 recommends against the use of oral leukotriene receptor antagonists in adults with persistent AR.⁴

Decongestants are for limited use only
For adults with severe nasal obstruction, ARIA 2010 suggests a short course (<5 days) of nasal decongestant along with other drugs.⁴ Limiting use of nasal decongestants to <10 days helps prevent rhinitis medicamentosa.^5,27 BSACI notes nasal decongestants may be useful for eustachian tube dysfunction experienced aboard airplanes, for children with acute otitis media with middle ear pain, to relieve congestion after an upper respiratory infection, and to improve nasal patency before NS use.⁵ Both guidelines suggest against regular oral decongestant use.^4,5

Avoid decongestants in pregnant patients.⁵ ARIA 2010 suggests against nasal decongestant use in preschool children.⁴

Chromones may help, but require multiple daily dosing
Chromones inhibit mast cell degranulation, are weakly effective for reducing nasal obstruction in AR, and have a high safety profile.^3-5,28 As noted earlier, they must be used 4 times daily, which may reduce adherence—particularly in children.⁴

ARIA 2008 notes that disodium cromoglycate is less effective than NS or antihistamines.³ The 2010 update suggests nasal antihistamines over nasal chromones.⁴ For adults as well as children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones. BSACI recommends limited use of chromones for children and adults with mild symptoms.⁵

Nasal saline helpful as adjunct to medication
Nasal saline irrigation improves symptoms of AR, clears nasal passages, and is helpful for pregnant patients, for whom medications should be used with caution.^2,3,5 Nasal irrigation using a neti pot or squeeze bottle is efficacious for chronic rhinorrhea, as solo or complementary treatment, and for children.^5,16,27

Oral steroids: Use only rarely
ARIA 2010 suggests a short course of oral glucocorticosteroids for patients with AR and moderate to severe nasal or ocular symptoms not controlled with other treatments.⁴ BSACI notes oral steroids are rarely indicated, but that their use over 5 to 10 days may help with severe nasal congestion, symptoms uncontrolled by conventional pharmacotherapy, or before important social or work events.⁵ Both guidelines recommend against intramuscular steroids.⁴ ARIA 2008 notes oral and depot preparations of steroids affect growth in young children.³

Ipratropium when rhinorrhea is severe
Nasal ipratropium bromide, a topical anticholinergic, is helpful for excessive or refractory rhinorrhea. Consider using ipratropium with NS for patients for whom rhinorrhea is the dominant symptom.^5,16,28 ARIA 2010 suggests using nasal ipratropium to treat rhinorrhea in patients with persistent AR.⁴

Allergen-specific immunotherapy: When other treatments fail

Allergen-specific immunotherapy (ASI) consists of repeated exposure to an allergen to induce immunomodulation, which prevents or reduces allergy symptoms and actually changes the natural course of AR. (For more on identifying the offending agent, see “Time for allergen testing?”^2,5,15,18,29.) This treatment process decreases medication needs, prevents new allergen sensitization, and results in long-lasting improvement.^2,5,6,30 BSACI 2011 notes that ASI is effective for adults and children with severe AR who do not respond to conventional pharmacotherapy and allergen avoidance measures.⁶

ASI methods developed to date use subcutaneous, sublingual, or nasal routes of administration. However, the US Food and Drug Administration has yet to approve commercial sublingual or nasal products for use in the United States.¹⁶

Subcutaneous immunotherapy may cause local adverse reactions (pruritus and swelling) and systemic reactions that can be severe or life threatening (anaphylaxis) and thus must be given in a doctor’s office prepared to treat anaphylaxis.^6,16,30 Adrenaline administration has been necessary in 0.13% of those being treated.⁹ Subcutaneous immunotherapy must be done for 3 to 5 years for sustained effective treatment.¹⁵

ARIA 2010 suggests subcutaneous immunotherapy for adults with seasonal AR and with persistent AR due to house dust mites.⁴ A 2007 Cochrane review found subcutaneous immunotherapy is efficacious for patients with seasonal AR due to pollens, resulting in decreased symptoms and medication use with few significant severe adverse reactions.⁹ A meta-analysis showed subcutaneous immunotherapy is as potent as pharmacotherapy in controlling seasonal AR symptoms as early as the first season of treatment.³¹

What if the patient is pregnant—or a child? BSACI notes that maintenance ASI may be continued in a patient who becomes pregnant, but starting ASI or increasing the dose is contraindicated.⁵

Based on ARIA 2008 and 2010, consider subcutaneous immunotherapy for children—but not for those <5 years.^3,4 Care must be used in selecting patients, as 3 to 5 years of treatment are necessary for sustained benefit.¹⁵

Lifestyle changes: Limited benefit may be achievable
ARIA 2010 recommends mold avoidance and animal dander avoidance for patients so affected.⁴ Allergens from pets can persist in homes for months after pet removal.¹⁵ BSACI found that commercially available nasal filters (filters or screens placed over or within both nares) reduced symptoms of AR during ragweed and grass pollen seasons.⁵ Allergen avoidance for children with persistent AR has not shown consistent benefit.¹⁵ A 2010 Cochrane review concluded that allergen avoidance may decrease AR symptoms, but more research is needed.¹¹

House dust mites. The 2010 Cochrane review also reported on 2 trials that assessed high-efficiency particulate air (HEPA) filters specifically for patients allergic to house dust mites.¹¹ The studies, which had methodological limitations (inconsistent randomization, small sample size, and short duration), concluded that HEPA filters alone will not likely reduce symptoms of house dust mite allergy. But HEPA filters may be beneficial as one component of an extensive bedroom-based environmental control program.¹¹

Impermeable bedding has been shown to reduce dust mite load by 50% to 70%, leaving residual allergen that may still trigger symptoms.¹¹ A 2012 Cochrane review concluded that achieving substantial reductions in house dust mite load using a combination approach of multiple interventions, including acaricides and extensive bedroom-based environmental control programs, may decrease AR symptoms.¹² However, ARIA 2010 recommends against single chemical or physical preventive methods and against combination preventive methods to reduce house dust mite exposure.⁴

Total elimination of house dust mites may be impossible, and recommending use of impermeable covers and HEPA filters, removal of rugs and curtains, and frequent cleaning must take into account a patient’s symptoms and a family’s motivation and finances.^11,18

Complementary and alternative medicine: Too little evidence
ARIA 2010 suggests against patients using homeopathy, acupuncture, butterbur, herbal medicines, or phototherapy for AR.⁴ While one systematic review of acupuncture for AR demonstrated mixed results with no specific effects for seasonal AR and some improvement of frequent nonseasonal symptoms,³² another review concluded evidence was insufficient to make any recommendation.^32,33 The benefit of ear acupressure is unknown, as supporting studies are of low methodological quality, although it appeared to provide some benefit for AR.³⁴

Due to lack of data, probiotics should not be recommended.²⁷ A pediatric review article noted that probiotics may alter cytokine production in patients with seasonal AR and may be more helpful in AR than in asthma, although more research was needed.¹⁵ Another review showed that probiotics may reduce AR symptoms and medication use.³⁵

CASE Since the nasal steroid you prescribed for your patient did not provide adequate relief, you opt to add cetirizine 10 mg to his NS regimen. This step relieved his symptoms within 2 to 3 days. Had his symptoms persisted, the patient would have been a candidate for a one-week course of oral decongestant, such as pseudoephedrine 120 mg orally every 12 hours, as needed; and then for allergen testing, specifically for pollens corresponding to the seasonality of his AR. Appropriate follow-up would be to monitor the patient until his symptoms resolved or became manageable.

CASE A man in his 30s with allergic rhinitis (AR) at predictable times of the year with high pollen counts reports only modest symptom relief with a nasal steroid preparation after 3 weeks of use. He comes to see you because he’s “tired of feeling lousy all of the time.”

What management options would you consider?

There is a plethora of treatment options for patients like this one, and considerable variation in clinical practice when it comes to AR.¹ The good news is that there are several recent guidelines for treating AR patients, whose symptoms (and underlying cause) can vary widely.

The following review—and accompanying algorithm—provides evidence-based recommendations that can help you refine your approach to AR.

Two guidelines, and several Cochrane reviews

Allergic Rhinitis and its Impact on Asthma (ARIA), a sentinel rhinitis treatment guideline, was published in 2001 and updated in 2008 and 2010.^2-4 The British Society for Allergy and Clinical Immunology Standards of Care Committee (BSACI) published guidelines for rhinitis management in 2008 and guidelines for immunotherapy in 2011.^5,6 In addition, several Cochrane reviews have been performed.^7-12 The ALGORITHM^1-6 combines these recommendations. The TABLE^2-12 itemizes the recommendations made by each guideline.

ALGORITHM
An evidence-based approach to treating allergic rhinitis^1-6
Based on recommendations from ARIA and BSACI guidelines and Cochrane reviews

TABLE
Treatment recommendations/suggestions for allergic rhinitis^2-12

The summary that follows provides a more detailed look at the recommendations, with a review of the pathophysiology of AR (“Phases of allergic rhinitis”^{2,3,5,8,13-15}).

Of note: This summary preserves the terminology used in ARIA 2010. Specifically, the ARIA guideline uses the term suggest for conditional recommendations and recommend for strong recommendations.⁴ That same language is used here.

Nasal steroids: First-line Tx for moderate to severe symptoms

BSACI indicates that nasal steroids (NS) are the treatment of choice for moderate to severe persistent AR (symptoms lasting >4 days per week or >4 weeks per year).⁵ ARIA 2010 suggests NS as first-line treatment rather than oral antihistamines for adults and children with seasonal (related to outdoor allergens such as pollens or molds) and persistent AR.⁴ ARIA 2008 finds NS are the most effective treatment for children.³ Steroids reduce inflammation by decreasing inflammatory cell migration and inhibiting cytokine release.¹⁶ They are the most effective monotherapy for all symptoms of AR, including nasal congestion, which antihistamines do not treat effectively.^13,16 NS also treat ocular symptoms of allergy effectively.^15,17

The ARIA 2010 guideline also recommends using NS rather than nasal antihistamines and leukotriene receptor antagonists.⁴ Combination therapy (eg, NS with the addition of nasal antihistamines) is an option for severe or persistent AR, but it appears to be no more effective than monotherapy with NS.¹⁶ A 2010 Cochrane review determined there is insufficient evidence for or against the use of oral antihistamines plus NS vs NS alone in children with AR.⁷ Intermittent steroid use may be beneficial in children.⁵

Steroids begin working 6 to 8 hours after the first dose, although symptom reduction may take days and maximal effect up to 2 weeks.⁵ Treatment failure may be due to poor technique that can cause local adverse effects (ie, dryness, irritation, epistaxis). Technique-related failure occurs in up to 10% of users.^5,15 Educating patients and families about correct technique with steroid spray may decrease nonadherence due to irritation and epistaxis.¹⁸ Tell them to shake the bottle well, look down, aim the nozzle toward the outside wall of the nostril using the opposite hand, and spray while sniffing lightly.⁵

Any steroid is appropriate for adults. For children ≥2 years of age, consider fluticasone propionate, mometasone furoate, or triamcinolone acetonide.³ These medications have lower systemic bioavailability and a decreased risk of such adverse effects as hypothalamic-pituitary-adrenal axis suppression and growth retardation.¹⁵ Budesonide is appropriate for those ≥6 years.^19-21 Avoid regular use of betamethasone, which has high bioavailability, for >1 year in children, as it may decrease their growth rate.³ Beclomethasone, fluticasone, and budesonide have been used widely and safely for pregnant women with asthma.⁵

Antihistamines are first-line Tx for mild symptoms

ARIA 2010 recommends new-generation oral nonsedating antihistamines that do not affect cytochrome P450 for mild AR,⁴ such as cetirizine, levocetirizine, loratadine, desloratadine, and fexofenadine. First-generation antihistamines can reduce symptoms, but are not first-line treatment as they cause sedation, fatigue, decreased cognitive function, and reduced academic and work performance.^3-5 ARIA 2010 further suggests choosing oral antihistamines over oral leukotriene receptor antagonists in patients with seasonal AR and in preschool children with persistent AR.⁴

BSACI recommends oral or topical antihistamines as first-line treatment for mild to moderate symptoms lasting <4 days per week or <4 weeks per year and moderate persistent AR.⁵ When steroids alone do not control moderate to severe persistent AR, BSACI recommends adding oral or topical antihistamines.⁵ Oral and topical antihistamines decrease histamine-related symptoms of itching, rhinorrhea, and sneezing, but do not significantly decrease nasal congestion.¹⁵

Nasal antihistamines (levocabastine, azelastine) have a rapid onset of action and few adverse effects.³ ARIA 2010 suggests nasal antihistamines over nasal chromones (inhibitors of mast cell degranulation) and notes that the need to use chromones 4 times daily may limit adherence.⁴ The same guidelines suggest nasal antihistamine use for children and adults with seasonal AR and suggest not using nasal antihistamines for patients with persistent AR until more data on efficacy and safety are available.⁴

Alezastine is approved for individuals ≥5 years, and olopatadine is approved for individuals ≥6 years for the treatment of AR.^16,22,23 A pediatric review article noted nasal antihistamine (azelastine) plus nasal fluticasone was more efficacious than NS alone.¹⁵

In children, weigh adverse effects of antihistamines against the general malaise caused by AR.³ Do not use first-generation antihistamines due to the sedation that may interfere with learning.¹⁵ Treatment with once-daily, long-acting antihistamines rather than multiple daily dosing may improve adherence in children.⁵ Continuous administration, rather than as needed, is optimal treatment in children.⁵ Cetirizine, loratadine, and levocetirizine have been studied and are effective and safe in children.³ Levocetirizine has proven safe and efficacious for children ≥2 years.²⁴ Fexofenadine was found to be effective and safe for those ≥6 years.²⁵

For children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones.⁴ Due to the safety of these agents, chromones may be used first, then antihistamines.⁴ Just as with nasal chromones, the need to use intraocular chromones 4 times daily may limit their use in children.⁴

Pregnant patients. Antihistamines do cross the placenta.⁵ Agents that appear to be safe for pregnant patients are chlorphenamine (first-generation), loratadine, and cetirizine.⁵

Leukotriene receptor antagonists: Always pair with antihistamines
As adjunctive therapy for additional symptom control, ARIA 2010 suggests oral leukotriene receptor antagonists for children and adults with seasonal AR, and for preschool children with persistent AR. These agents may also be helpful in children with concurrent asthma.¹⁵ Always pair leukotriene receptor antagonists with antihistamines. Montelukast is approved for seasonal AR in children ≥2 years and for frequent nonseasonal nasal or ocular AR symptoms in children ≥6 months.²⁶

ARIA 2010 recommends against the use of oral leukotriene receptor antagonists in adults with persistent AR.⁴

Decongestants are for limited use only
For adults with severe nasal obstruction, ARIA 2010 suggests a short course (<5 days) of nasal decongestant along with other drugs.⁴ Limiting use of nasal decongestants to <10 days helps prevent rhinitis medicamentosa.^5,27 BSACI notes nasal decongestants may be useful for eustachian tube dysfunction experienced aboard airplanes, for children with acute otitis media with middle ear pain, to relieve congestion after an upper respiratory infection, and to improve nasal patency before NS use.⁵ Both guidelines suggest against regular oral decongestant use.^4,5

Avoid decongestants in pregnant patients.⁵ ARIA 2010 suggests against nasal decongestant use in preschool children.⁴

Chromones may help, but require multiple daily dosing
Chromones inhibit mast cell degranulation, are weakly effective for reducing nasal obstruction in AR, and have a high safety profile.^3-5,28 As noted earlier, they must be used 4 times daily, which may reduce adherence—particularly in children.⁴

ARIA 2008 notes that disodium cromoglycate is less effective than NS or antihistamines.³ The 2010 update suggests nasal antihistamines over nasal chromones.⁴ For adults as well as children with ocular symptoms, ARIA 2010 suggests intraocular antihistamines or intraocular chromones. BSACI recommends limited use of chromones for children and adults with mild symptoms.⁵

Nasal saline helpful as adjunct to medication
Nasal saline irrigation improves symptoms of AR, clears nasal passages, and is helpful for pregnant patients, for whom medications should be used with caution.^2,3,5 Nasal irrigation using a neti pot or squeeze bottle is efficacious for chronic rhinorrhea, as solo or complementary treatment, and for children.^5,16,27

Oral steroids: Use only rarely
ARIA 2010 suggests a short course of oral glucocorticosteroids for patients with AR and moderate to severe nasal or ocular symptoms not controlled with other treatments.⁴ BSACI notes oral steroids are rarely indicated, but that their use over 5 to 10 days may help with severe nasal congestion, symptoms uncontrolled by conventional pharmacotherapy, or before important social or work events.⁵ Both guidelines recommend against intramuscular steroids.⁴ ARIA 2008 notes oral and depot preparations of steroids affect growth in young children.³

Ipratropium when rhinorrhea is severe
Nasal ipratropium bromide, a topical anticholinergic, is helpful for excessive or refractory rhinorrhea. Consider using ipratropium with NS for patients for whom rhinorrhea is the dominant symptom.^5,16,28 ARIA 2010 suggests using nasal ipratropium to treat rhinorrhea in patients with persistent AR.⁴

Allergen-specific immunotherapy: When other treatments fail

Allergen-specific immunotherapy (ASI) consists of repeated exposure to an allergen to induce immunomodulation, which prevents or reduces allergy symptoms and actually changes the natural course of AR. (For more on identifying the offending agent, see “Time for allergen testing?”^2,5,15,18,29.) This treatment process decreases medication needs, prevents new allergen sensitization, and results in long-lasting improvement.^2,5,6,30 BSACI 2011 notes that ASI is effective for adults and children with severe AR who do not respond to conventional pharmacotherapy and allergen avoidance measures.⁶

ASI methods developed to date use subcutaneous, sublingual, or nasal routes of administration. However, the US Food and Drug Administration has yet to approve commercial sublingual or nasal products for use in the United States.¹⁶

Subcutaneous immunotherapy may cause local adverse reactions (pruritus and swelling) and systemic reactions that can be severe or life threatening (anaphylaxis) and thus must be given in a doctor’s office prepared to treat anaphylaxis.^6,16,30 Adrenaline administration has been necessary in 0.13% of those being treated.⁹ Subcutaneous immunotherapy must be done for 3 to 5 years for sustained effective treatment.¹⁵

ARIA 2010 suggests subcutaneous immunotherapy for adults with seasonal AR and with persistent AR due to house dust mites.⁴ A 2007 Cochrane review found subcutaneous immunotherapy is efficacious for patients with seasonal AR due to pollens, resulting in decreased symptoms and medication use with few significant severe adverse reactions.⁹ A meta-analysis showed subcutaneous immunotherapy is as potent as pharmacotherapy in controlling seasonal AR symptoms as early as the first season of treatment.³¹

What if the patient is pregnant—or a child? BSACI notes that maintenance ASI may be continued in a patient who becomes pregnant, but starting ASI or increasing the dose is contraindicated.⁵

Based on ARIA 2008 and 2010, consider subcutaneous immunotherapy for children—but not for those <5 years.^3,4 Care must be used in selecting patients, as 3 to 5 years of treatment are necessary for sustained benefit.¹⁵

Lifestyle changes: Limited benefit may be achievable
ARIA 2010 recommends mold avoidance and animal dander avoidance for patients so affected.⁴ Allergens from pets can persist in homes for months after pet removal.¹⁵ BSACI found that commercially available nasal filters (filters or screens placed over or within both nares) reduced symptoms of AR during ragweed and grass pollen seasons.⁵ Allergen avoidance for children with persistent AR has not shown consistent benefit.¹⁵ A 2010 Cochrane review concluded that allergen avoidance may decrease AR symptoms, but more research is needed.¹¹

House dust mites. The 2010 Cochrane review also reported on 2 trials that assessed high-efficiency particulate air (HEPA) filters specifically for patients allergic to house dust mites.¹¹ The studies, which had methodological limitations (inconsistent randomization, small sample size, and short duration), concluded that HEPA filters alone will not likely reduce symptoms of house dust mite allergy. But HEPA filters may be beneficial as one component of an extensive bedroom-based environmental control program.¹¹

Impermeable bedding has been shown to reduce dust mite load by 50% to 70%, leaving residual allergen that may still trigger symptoms.¹¹ A 2012 Cochrane review concluded that achieving substantial reductions in house dust mite load using a combination approach of multiple interventions, including acaricides and extensive bedroom-based environmental control programs, may decrease AR symptoms.¹² However, ARIA 2010 recommends against single chemical or physical preventive methods and against combination preventive methods to reduce house dust mite exposure.⁴

Total elimination of house dust mites may be impossible, and recommending use of impermeable covers and HEPA filters, removal of rugs and curtains, and frequent cleaning must take into account a patient’s symptoms and a family’s motivation and finances.^11,18

Complementary and alternative medicine: Too little evidence
ARIA 2010 suggests against patients using homeopathy, acupuncture, butterbur, herbal medicines, or phototherapy for AR.⁴ While one systematic review of acupuncture for AR demonstrated mixed results with no specific effects for seasonal AR and some improvement of frequent nonseasonal symptoms,³² another review concluded evidence was insufficient to make any recommendation.^32,33 The benefit of ear acupressure is unknown, as supporting studies are of low methodological quality, although it appeared to provide some benefit for AR.³⁴

Due to lack of data, probiotics should not be recommended.²⁷ A pediatric review article noted that probiotics may alter cytokine production in patients with seasonal AR and may be more helpful in AR than in asthma, although more research was needed.¹⁵ Another review showed that probiotics may reduce AR symptoms and medication use.³⁵

CASE Since the nasal steroid you prescribed for your patient did not provide adequate relief, you opt to add cetirizine 10 mg to his NS regimen. This step relieved his symptoms within 2 to 3 days. Had his symptoms persisted, the patient would have been a candidate for a one-week course of oral decongestant, such as pseudoephedrine 120 mg orally every 12 hours, as needed; and then for allergen testing, specifically for pollens corresponding to the seasonality of his AR. Appropriate follow-up would be to monitor the patient until his symptoms resolved or became manageable.

Colon cancer screening comes too late

AFTER 14 YEARS OF TREATMENT by her physician, a 73-year-old woman with a medical history that included chronic obstructive pulmonary disease and major depression underwent her first colonoscopy. It revealed colon cancer. The patient died about a year and a half later.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The physician claimed that the patient had declined his recommendations for colon cancer screening many times and that she had failed to return stool samples from a home test kit he had given her. The physician’s medical records, which began in 2001, didn’t reflect his screening recommendations. Earlier records had been destroyed in 2007 in accordance with office policy.

VERDICT $500,000 Massachusetts settlement.

COMMENT Do you routinely document refusal of preventive services by your patients? If not, you, too, may fall victim to a plaintiff’s attorney!

A drug reaction with lasting consequences

AN ALLERGIC REACTION to trimethoprim/ sulfamethoxazole caused skin changes in a 44-year-old woman. Nevertheless, her physician prescribed another regimen of the drug 4 years later. This time, the patient had a full-blown allergic reaction, characterized by red, scaly, weepy skin and elevated liver enzymes, among other symptoms.

After several emergency department visits and a hospital admission, the patient was transferred to the burn unit of a regional medical center, with a presumed diagnosis of Stevens-Johnson syndrome (SJS). After evaluating the patient, however, the director of the burn unit concluded that her symptoms were not severe enough to be SJS; he attributed them to a simple drug reaction and had the patient moved to a medical/surgical floor.

At some point, she developed peripheral sensory neuropathy in her hands and feet. The parties involved disagreed about when the neuropathy began and what caused it.

PLAINTIFF’S CLAIM The patient should not have been transferred to the medical/surgical unit; the higher level of care provided on the burn unit would have prevented the peripheral neuropathy. The patient received inadequate nutrition, which contributed to her injuries.

THE DEFENSE Because the patient didn’t actually have SJS, the medical/surgical floor was the appropriate place to treat her. The patient received proper skin care and nutrition. The patient had complained of numbness and tingling in her hands and feet before she was hospitalized, indicating that the drug-related neuropathy had existed before admission to the regional facility.

VERDICT Defense verdict following confidential settlement with the physician who prescribed trimethoprim/sulfamethoxazole.

COMMENT When prescribing any antibiotic, always confirm that the patient isn’t allergic to it. Have your nurses and medical assistants help you maintain accurate medication and allergy lists in your office chart or electronic medical record.

A colonoscopy, then hepatitis C

AFTER UNDERGOING A COLONOSCOPY, a 44-year-old man was diagnosed with hepatitis C. He claimed that the infection had been transmitted by the anesthetic used during the procedure.

PLAINTIFF’S CLAIM The anesthesiologist drew the anesthetic from a multiple-dose vial that had been used during previous procedures; proper sterile techniques weren’t followed.

THE DEFENSE No information about the defense is available.

VERDICT $675,000 New York settlement.

COMMENT I thought this practice had stopped 20 years ago. Review your office procedures and make sure it doesn’t happen. Don’t use single-dose, single-use vials for more than one patient—ever.

Colon cancer screening comes too late

AFTER 14 YEARS OF TREATMENT by her physician, a 73-year-old woman with a medical history that included chronic obstructive pulmonary disease and major depression underwent her first colonoscopy. It revealed colon cancer. The patient died about a year and a half later.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The physician claimed that the patient had declined his recommendations for colon cancer screening many times and that she had failed to return stool samples from a home test kit he had given her. The physician’s medical records, which began in 2001, didn’t reflect his screening recommendations. Earlier records had been destroyed in 2007 in accordance with office policy.

VERDICT $500,000 Massachusetts settlement.

COMMENT Do you routinely document refusal of preventive services by your patients? If not, you, too, may fall victim to a plaintiff’s attorney!

A drug reaction with lasting consequences

AN ALLERGIC REACTION to trimethoprim/ sulfamethoxazole caused skin changes in a 44-year-old woman. Nevertheless, her physician prescribed another regimen of the drug 4 years later. This time, the patient had a full-blown allergic reaction, characterized by red, scaly, weepy skin and elevated liver enzymes, among other symptoms.

After several emergency department visits and a hospital admission, the patient was transferred to the burn unit of a regional medical center, with a presumed diagnosis of Stevens-Johnson syndrome (SJS). After evaluating the patient, however, the director of the burn unit concluded that her symptoms were not severe enough to be SJS; he attributed them to a simple drug reaction and had the patient moved to a medical/surgical floor.

At some point, she developed peripheral sensory neuropathy in her hands and feet. The parties involved disagreed about when the neuropathy began and what caused it.

PLAINTIFF’S CLAIM The patient should not have been transferred to the medical/surgical unit; the higher level of care provided on the burn unit would have prevented the peripheral neuropathy. The patient received inadequate nutrition, which contributed to her injuries.

THE DEFENSE Because the patient didn’t actually have SJS, the medical/surgical floor was the appropriate place to treat her. The patient received proper skin care and nutrition. The patient had complained of numbness and tingling in her hands and feet before she was hospitalized, indicating that the drug-related neuropathy had existed before admission to the regional facility.

VERDICT Defense verdict following confidential settlement with the physician who prescribed trimethoprim/sulfamethoxazole.

COMMENT When prescribing any antibiotic, always confirm that the patient isn’t allergic to it. Have your nurses and medical assistants help you maintain accurate medication and allergy lists in your office chart or electronic medical record.

A colonoscopy, then hepatitis C

AFTER UNDERGOING A COLONOSCOPY, a 44-year-old man was diagnosed with hepatitis C. He claimed that the infection had been transmitted by the anesthetic used during the procedure.

PLAINTIFF’S CLAIM The anesthesiologist drew the anesthetic from a multiple-dose vial that had been used during previous procedures; proper sterile techniques weren’t followed.

THE DEFENSE No information about the defense is available.

VERDICT $675,000 New York settlement.

COMMENT I thought this practice had stopped 20 years ago. Review your office procedures and make sure it doesn’t happen. Don’t use single-dose, single-use vials for more than one patient—ever.

Colon cancer screening comes too late

AFTER 14 YEARS OF TREATMENT by her physician, a 73-year-old woman with a medical history that included chronic obstructive pulmonary disease and major depression underwent her first colonoscopy. It revealed colon cancer. The patient died about a year and a half later.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The physician claimed that the patient had declined his recommendations for colon cancer screening many times and that she had failed to return stool samples from a home test kit he had given her. The physician’s medical records, which began in 2001, didn’t reflect his screening recommendations. Earlier records had been destroyed in 2007 in accordance with office policy.

VERDICT $500,000 Massachusetts settlement.

COMMENT Do you routinely document refusal of preventive services by your patients? If not, you, too, may fall victim to a plaintiff’s attorney!

A drug reaction with lasting consequences

AN ALLERGIC REACTION to trimethoprim/ sulfamethoxazole caused skin changes in a 44-year-old woman. Nevertheless, her physician prescribed another regimen of the drug 4 years later. This time, the patient had a full-blown allergic reaction, characterized by red, scaly, weepy skin and elevated liver enzymes, among other symptoms.

After several emergency department visits and a hospital admission, the patient was transferred to the burn unit of a regional medical center, with a presumed diagnosis of Stevens-Johnson syndrome (SJS). After evaluating the patient, however, the director of the burn unit concluded that her symptoms were not severe enough to be SJS; he attributed them to a simple drug reaction and had the patient moved to a medical/surgical floor.

At some point, she developed peripheral sensory neuropathy in her hands and feet. The parties involved disagreed about when the neuropathy began and what caused it.

PLAINTIFF’S CLAIM The patient should not have been transferred to the medical/surgical unit; the higher level of care provided on the burn unit would have prevented the peripheral neuropathy. The patient received inadequate nutrition, which contributed to her injuries.

THE DEFENSE Because the patient didn’t actually have SJS, the medical/surgical floor was the appropriate place to treat her. The patient received proper skin care and nutrition. The patient had complained of numbness and tingling in her hands and feet before she was hospitalized, indicating that the drug-related neuropathy had existed before admission to the regional facility.

VERDICT Defense verdict following confidential settlement with the physician who prescribed trimethoprim/sulfamethoxazole.

COMMENT When prescribing any antibiotic, always confirm that the patient isn’t allergic to it. Have your nurses and medical assistants help you maintain accurate medication and allergy lists in your office chart or electronic medical record.

A colonoscopy, then hepatitis C

AFTER UNDERGOING A COLONOSCOPY, a 44-year-old man was diagnosed with hepatitis C. He claimed that the infection had been transmitted by the anesthetic used during the procedure.

PLAINTIFF’S CLAIM The anesthesiologist drew the anesthetic from a multiple-dose vial that had been used during previous procedures; proper sterile techniques weren’t followed.

THE DEFENSE No information about the defense is available.

VERDICT $675,000 New York settlement.

COMMENT I thought this practice had stopped 20 years ago. Review your office procedures and make sure it doesn’t happen. Don’t use single-dose, single-use vials for more than one patient—ever.

ILLUSTRATIVE CASE

When you prescribe an antibiotic for a 45-year-old patient with Helicobacter pylori, he worries that the medication will cause diarrhea. Should you recommend that he take probiotics?

More than a third of patients taking antibiotics develop AAD,² and in 17% of cases, AAD is fatal.^3,4 Although the diarrhea may be the result of increased gastrointestinal (GI) motility in some cases, a disruption of the GI flora that normally acts as a barrier to infection and aids in the digestion of carbohydrates is a far more common cause.

Morbidity and mortality are high
AAD is associated with several pathogens, including Clostridium difficile, Clostridium perfringens, Klebsiella oxytoca, and Staphylococcus aureus,² and varies widely in severity. Pseudomembranous colitis secondary to C difficile is the main cause of AAD-related mortality, which more than doubled from 2002 to 2009.^3,4 C difficile infections cost the US health care system up to $1.3 billion annually.⁵ With such high rates of morbidity and mortality and high health care costs associated with AAD, even a small reduction in the number of cases would have a big impact.

Probiotics replenish the natural GI flora with nonpathogenic organisms. A 2006 meta-analysis of 31 randomized controlled trials (RCTs) assessing the efficacy of probiotics for both the prevention of AAD and treatment of C difficile found a pooled relative risk of 0.43 for AAD in the patients taking probiotics.⁶ However, many of the studies included in that meta-analysis were small. As a result, in 2010, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) recommended against the use of probiotics for the prevention of primary C difficile infection, citing a lack of high-quality evidence.⁷

Nonetheless, that same year, 98% of gastroenterologists surveyed expressed a belief that probiotics had a role in the treatment of GI illness.⁸ And in 2011, the 3rd Yale Working Group on Probiotic Use published recommendations for probiotic use based on expert opinion.⁹ The meta-analysis detailed in this PURL, which included more than 30 trials published since the 2006 meta-analysis, addressed the efficacy of probiotics for prevention and treatment of AAD.

STUDY SUMMARY: Probiotics significantly reduce AAD

Hempel et al reviewed 82 studies and pooled data from 63 RCTs (N=11,811) to identify the relative risk (RR) of AAD among patients who received probiotics during antibiotic treatment compared with those who received no probiotics or were given a placebo.¹ The studies encompassed a variety of antibiotics, taken alone or in combination, and several probiotics, including Lactobacillus, Bifidobacterium, Saccharomyces, and some combinations.

The outcome: The pooled RR for AAD in the probiotics groups was 0.58 (95% confidence interval, 0.50-0.68; P<.001), with a number needed to treat of 13. Although the authors reported that the overall quality of the included trials was poor, a sensitivity analysis of the higher quality studies yielded similar results.

Subgroup analyses by type of probiotic and duration of antibiotic treatment were also consistent with the overall pooled RR. In subgroup analysis by age, a similar decrease in AAD was found among the youngest patients (0-17 years) and those between the ages of 17 and 65 years. Among patients older than 65 years—for whom there were just 3 studies—a non-significant decrease in risk was found. Twenty-three of the studies assessed adverse outcomes, and none was found.

WHAT’S NEW: A reason to pair antibiotics and probiotics

This meta-analysis reached a similar conclusion as the 2006 meta-analysis: Probiotics appear to be effective in preventing and treating AAD in children and adults receiving a wide variety of antibiotics for a number of conditions. The results were also consistent with those of a new meta-analysis that looked specifically at one pathogen—and found a reduction of 66% in C difficile-associated diarrhea in patients taking probiotics with their antibiotics.¹⁰

CAVEATS: Limited data on the safety of probiotics exist

There was some heterogeneity among the studies in the meta-analysis by Hempel et al, and some of the studies were of poor quality. Because of this, the authors used subgroup and sensitivity analysis, which supported their initial conclusion.

Probiotics have generally been considered safe; however, there have been rare reports of sepsis and fungemia associated with probiotic use, especially in immunosuppressed patients.¹ Fifty-nine of the included studies did not assess adverse events, which limited the ability of this meta-analysis to assess safety.¹ Patients taking probiotics should be monitored for adverse effects.

CHALLENGES TO IMPLEMENTATION: Lack of guidance on dosing and duration

Since probiotics are considered food supplements, health insurance will not cover the cost (which will likely be more than $20 per month; www.walgreens.com). No single probiotic strain has high-quality evidence; however, most of the RCTs included in the meta-analysis used combinations of Lactobacillus species, which are usually found in over-the-counter antidiarrheal probiotic supplements. No standard dose exists, but dose ranges in RCTs are 10⁷ to 10¹⁰ colony-forming units per capsule (taken one to 3 times daily);¹ however, product labels have variable accuracy.¹¹ The duration of treatment ranges from one to 3 weeks—or as long as the patient continues to take antibiotics.

Acknowledgement

The PURLs Surveillance System was developed with support from Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

When you prescribe an antibiotic for a 45-year-old patient with Helicobacter pylori, he worries that the medication will cause diarrhea. Should you recommend that he take probiotics?

More than a third of patients taking antibiotics develop AAD,² and in 17% of cases, AAD is fatal.^3,4 Although the diarrhea may be the result of increased gastrointestinal (GI) motility in some cases, a disruption of the GI flora that normally acts as a barrier to infection and aids in the digestion of carbohydrates is a far more common cause.

Morbidity and mortality are high
AAD is associated with several pathogens, including Clostridium difficile, Clostridium perfringens, Klebsiella oxytoca, and Staphylococcus aureus,² and varies widely in severity. Pseudomembranous colitis secondary to C difficile is the main cause of AAD-related mortality, which more than doubled from 2002 to 2009.^3,4 C difficile infections cost the US health care system up to $1.3 billion annually.⁵ With such high rates of morbidity and mortality and high health care costs associated with AAD, even a small reduction in the number of cases would have a big impact.

Probiotics replenish the natural GI flora with nonpathogenic organisms. A 2006 meta-analysis of 31 randomized controlled trials (RCTs) assessing the efficacy of probiotics for both the prevention of AAD and treatment of C difficile found a pooled relative risk of 0.43 for AAD in the patients taking probiotics.⁶ However, many of the studies included in that meta-analysis were small. As a result, in 2010, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) recommended against the use of probiotics for the prevention of primary C difficile infection, citing a lack of high-quality evidence.⁷

Nonetheless, that same year, 98% of gastroenterologists surveyed expressed a belief that probiotics had a role in the treatment of GI illness.⁸ And in 2011, the 3rd Yale Working Group on Probiotic Use published recommendations for probiotic use based on expert opinion.⁹ The meta-analysis detailed in this PURL, which included more than 30 trials published since the 2006 meta-analysis, addressed the efficacy of probiotics for prevention and treatment of AAD.

STUDY SUMMARY: Probiotics significantly reduce AAD

Hempel et al reviewed 82 studies and pooled data from 63 RCTs (N=11,811) to identify the relative risk (RR) of AAD among patients who received probiotics during antibiotic treatment compared with those who received no probiotics or were given a placebo.¹ The studies encompassed a variety of antibiotics, taken alone or in combination, and several probiotics, including Lactobacillus, Bifidobacterium, Saccharomyces, and some combinations.

The outcome: The pooled RR for AAD in the probiotics groups was 0.58 (95% confidence interval, 0.50-0.68; P<.001), with a number needed to treat of 13. Although the authors reported that the overall quality of the included trials was poor, a sensitivity analysis of the higher quality studies yielded similar results.

Subgroup analyses by type of probiotic and duration of antibiotic treatment were also consistent with the overall pooled RR. In subgroup analysis by age, a similar decrease in AAD was found among the youngest patients (0-17 years) and those between the ages of 17 and 65 years. Among patients older than 65 years—for whom there were just 3 studies—a non-significant decrease in risk was found. Twenty-three of the studies assessed adverse outcomes, and none was found.

WHAT’S NEW: A reason to pair antibiotics and probiotics

This meta-analysis reached a similar conclusion as the 2006 meta-analysis: Probiotics appear to be effective in preventing and treating AAD in children and adults receiving a wide variety of antibiotics for a number of conditions. The results were also consistent with those of a new meta-analysis that looked specifically at one pathogen—and found a reduction of 66% in C difficile-associated diarrhea in patients taking probiotics with their antibiotics.¹⁰

CAVEATS: Limited data on the safety of probiotics exist

There was some heterogeneity among the studies in the meta-analysis by Hempel et al, and some of the studies were of poor quality. Because of this, the authors used subgroup and sensitivity analysis, which supported their initial conclusion.

Probiotics have generally been considered safe; however, there have been rare reports of sepsis and fungemia associated with probiotic use, especially in immunosuppressed patients.¹ Fifty-nine of the included studies did not assess adverse events, which limited the ability of this meta-analysis to assess safety.¹ Patients taking probiotics should be monitored for adverse effects.

CHALLENGES TO IMPLEMENTATION: Lack of guidance on dosing and duration

Since probiotics are considered food supplements, health insurance will not cover the cost (which will likely be more than $20 per month; www.walgreens.com). No single probiotic strain has high-quality evidence; however, most of the RCTs included in the meta-analysis used combinations of Lactobacillus species, which are usually found in over-the-counter antidiarrheal probiotic supplements. No standard dose exists, but dose ranges in RCTs are 10⁷ to 10¹⁰ colony-forming units per capsule (taken one to 3 times daily);¹ however, product labels have variable accuracy.¹¹ The duration of treatment ranges from one to 3 weeks—or as long as the patient continues to take antibiotics.

Acknowledgement

The PURLs Surveillance System was developed with support from Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

When you prescribe an antibiotic for a 45-year-old patient with Helicobacter pylori, he worries that the medication will cause diarrhea. Should you recommend that he take probiotics?

More than a third of patients taking antibiotics develop AAD,² and in 17% of cases, AAD is fatal.^3,4 Although the diarrhea may be the result of increased gastrointestinal (GI) motility in some cases, a disruption of the GI flora that normally acts as a barrier to infection and aids in the digestion of carbohydrates is a far more common cause.

Morbidity and mortality are high
AAD is associated with several pathogens, including Clostridium difficile, Clostridium perfringens, Klebsiella oxytoca, and Staphylococcus aureus,² and varies widely in severity. Pseudomembranous colitis secondary to C difficile is the main cause of AAD-related mortality, which more than doubled from 2002 to 2009.^3,4 C difficile infections cost the US health care system up to $1.3 billion annually.⁵ With such high rates of morbidity and mortality and high health care costs associated with AAD, even a small reduction in the number of cases would have a big impact.

Probiotics replenish the natural GI flora with nonpathogenic organisms. A 2006 meta-analysis of 31 randomized controlled trials (RCTs) assessing the efficacy of probiotics for both the prevention of AAD and treatment of C difficile found a pooled relative risk of 0.43 for AAD in the patients taking probiotics.⁶ However, many of the studies included in that meta-analysis were small. As a result, in 2010, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) recommended against the use of probiotics for the prevention of primary C difficile infection, citing a lack of high-quality evidence.⁷

Nonetheless, that same year, 98% of gastroenterologists surveyed expressed a belief that probiotics had a role in the treatment of GI illness.⁸ And in 2011, the 3rd Yale Working Group on Probiotic Use published recommendations for probiotic use based on expert opinion.⁹ The meta-analysis detailed in this PURL, which included more than 30 trials published since the 2006 meta-analysis, addressed the efficacy of probiotics for prevention and treatment of AAD.

STUDY SUMMARY: Probiotics significantly reduce AAD

Hempel et al reviewed 82 studies and pooled data from 63 RCTs (N=11,811) to identify the relative risk (RR) of AAD among patients who received probiotics during antibiotic treatment compared with those who received no probiotics or were given a placebo.¹ The studies encompassed a variety of antibiotics, taken alone or in combination, and several probiotics, including Lactobacillus, Bifidobacterium, Saccharomyces, and some combinations.

The outcome: The pooled RR for AAD in the probiotics groups was 0.58 (95% confidence interval, 0.50-0.68; P<.001), with a number needed to treat of 13. Although the authors reported that the overall quality of the included trials was poor, a sensitivity analysis of the higher quality studies yielded similar results.

Subgroup analyses by type of probiotic and duration of antibiotic treatment were also consistent with the overall pooled RR. In subgroup analysis by age, a similar decrease in AAD was found among the youngest patients (0-17 years) and those between the ages of 17 and 65 years. Among patients older than 65 years—for whom there were just 3 studies—a non-significant decrease in risk was found. Twenty-three of the studies assessed adverse outcomes, and none was found.

WHAT’S NEW: A reason to pair antibiotics and probiotics

This meta-analysis reached a similar conclusion as the 2006 meta-analysis: Probiotics appear to be effective in preventing and treating AAD in children and adults receiving a wide variety of antibiotics for a number of conditions. The results were also consistent with those of a new meta-analysis that looked specifically at one pathogen—and found a reduction of 66% in C difficile-associated diarrhea in patients taking probiotics with their antibiotics.¹⁰

CAVEATS: Limited data on the safety of probiotics exist

There was some heterogeneity among the studies in the meta-analysis by Hempel et al, and some of the studies were of poor quality. Because of this, the authors used subgroup and sensitivity analysis, which supported their initial conclusion.

Probiotics have generally been considered safe; however, there have been rare reports of sepsis and fungemia associated with probiotic use, especially in immunosuppressed patients.¹ Fifty-nine of the included studies did not assess adverse events, which limited the ability of this meta-analysis to assess safety.¹ Patients taking probiotics should be monitored for adverse effects.

CHALLENGES TO IMPLEMENTATION: Lack of guidance on dosing and duration

Since probiotics are considered food supplements, health insurance will not cover the cost (which will likely be more than $20 per month; www.walgreens.com). No single probiotic strain has high-quality evidence; however, most of the RCTs included in the meta-analysis used combinations of Lactobacillus species, which are usually found in over-the-counter antidiarrheal probiotic supplements. No standard dose exists, but dose ranges in RCTs are 10⁷ to 10¹⁰ colony-forming units per capsule (taken one to 3 times daily);¹ however, product labels have variable accuracy.¹¹ The duration of treatment ranges from one to 3 weeks—or as long as the patient continues to take antibiotics.

Acknowledgement

The PURLs Surveillance System was developed with support from Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

The 2013 immunization schedules have been published by the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP).^1,2 Perhaps the most noticeable change is a single schedule for infants, children, and adolescents, instead of the previous 2 schedules (for those ages 0-6 years, and for those ages 7-18 years). Other major new recommendations include the following:

• tetanus-diphtheria-pertussis (Tdap) vaccine for individuals ≥65 years of age
• Tdap for pregnant women during every pregnancy
• meningococcal conjugate vaccine for high-risk infants and children
• pneumococcal conjugate vaccine for high-risk adults.

There are also minor changes in recommendations for the use of measles, mumps, and rubella (MMR) vaccine among those with human immunodeficiency virus (HIV) infection. The new immunization schedules can be found on the CDC’s immunization Web site, at http://www.cdc.gov/vaccines/schedules/index.html.

Previous Practice Alerts have reported on recommendation changes made throughout 2012, including removal of egg allergy as a contraindication for influenza vaccine for those who experience only hives after eating eggs,³ the addition of a simplified algorithm for deciding whether children younger than 9 years need one or 2 doses of influenza vaccine,³ and the addition of human papillomavirus vaccine as a routine recommendation for males ages 11 to 21 years.⁴

Tdap: Some recommendations are off label

Given the continuing elevated rates of pertussis in the United States and our understanding about the duration of protection and safety of the Tdap vaccine, ACIP has made new recommendations for the use of Tdap, including some off-label uses. Two Tdap products are available: Boostrix, approved for individuals ≥10 years, and Adacel, approved for individuals 11 to 64 years (TABLE 1).⁵ ACIP states that those ≥65 years may be vaccinated with Tdap, and that an opportunity for vaccination should not be missed; Adacel can be substituted if it is the only product available. To control the spread of pertussis to the most vulnerable, it is especially important to immunize grandparents, childcare providers, and those who are around infants.

TABLE 1
Available tetanus-diphtheria-pertussis vaccines⁵

Wound management. If a tetanus booster is indicated for wound management in an individual ≥19 years who has never received Tdap, this product is preferred to Td.⁵ There is now no suggested minimum time interval for administering Tdap after Td. Currently only one dose of Tdap is recommended for adults (except for pregnant women, as described in the next section). But this may change as time passes and we learn more about the duration of protection from the acellular pertussis antigen in the vaccine.

Pregnancy. ACIP first recommended the use of Tdap during pregnancy in October 2011, in an attempt to provide protection for newborns through the transfer of maternal antibodies to the fetus.⁶ Recent evidence indicates that the duration of protective antibody levels wanes between pregnancies and may not be high enough to protect a newborn in subsequent pregnancies.⁷ ACIP voted in October 2012 to recommend Tdap for pregnant women during each pregnancy, at the gestational age of 27 through 36 weeks. If a mother does not receive Tdap during pregnancy and has never received it, she should be vaccinated soon after delivery.

The safety data for serial vaccination with Tdap in pregnant women is sparse, and ACIP considered this concern. In the opinion of ACIP, the potential benefits to the newborn, coupled with the high rate of pertussis, outweigh this concern, and efforts will be made to monitor for safety issues. If the rate of pertussis declines, ACIP will likely revisit this recommendation.

Meningococcal vaccine: No routine immunization for infants

A previous Practice Alert described 3 new products to protect infants and children against meningococcal disease, and identified issues that make recommendations about their use difficult at a time when rates of meningococcal disease in this age group are very low.⁸ At its October 2012 meeting, ACIP considered one of these products, HibMenCY (MenHibrix), which contains antigens against meningococcal serogroups C and Y and Haemophilus influenzae B (Hib).

ACIP voted not to recommend routine immunization against meningococcal disease in infants. However, HibMenCY was recommended for high-risk infants, and it was noted that it can be used as an Hib vaccine. The details of the recommendation appear in “When should you use HibMenCY in infants?”.⁹ The current recommendation also includes vaccinating high-risk infants ages 9 through 23 months with 2 doses of MenACWY-D (Menactra) with at least 8 weeks between doses. Only one of these products should be used, and ACIP does not cite a preference between them.

Pneumococcal conjugate vaccine recommended for high-risk adults

There are now 2 products that provide protection for adults against pneumococcal disease: a 23-valent polysaccharide product (PPSV23) and a 13-valent conjugate product (PCV13). PPSV23 is recommended for all adults ≥65 years and for those <65 who are at high risk for pneumococcal disease or complications from pneumococcal disease. While PCV13 is approved by the FDA for all adults ≥50 years, ACIP recommends it only for those at higher risk for pneumococcal disease.¹⁰

ACIP also recommends that those at risk should receive both PCV13 and PPSV23. Give PCV13 first, followed by PPSV23 2 months later.¹⁰ However, if PPSV23 is given first, administer PCV13 12 months later. To complicate matters, for some risk categories it is recommended that patients receive a second dose of PPSV23 5 years after the first one. No more than 2 doses of PPSV23 should be given prior to age 65. This complicated set of recommendations is summarized in TABLE 2.¹⁰

TABLE 2
Indications for using pneumococcal vaccines in adults ≥19 years*¹⁰

MMR for those with HIV and use of IG for measles prevention

The last set of significant changes to the schedules are updated recommendations for the use of MMR vaccine in those who have HIV infection, and the use of immune globulin to prevent measles in those previously unvaccinated who are exposed to the disease. Details of these recommendations can be found at http://www.cdc.gov/vaccines/recs/provisional/downloads/mmr-Oct-2012.pdf.

The 2013 immunization schedules have been published by the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP).^1,2 Perhaps the most noticeable change is a single schedule for infants, children, and adolescents, instead of the previous 2 schedules (for those ages 0-6 years, and for those ages 7-18 years). Other major new recommendations include the following:

• tetanus-diphtheria-pertussis (Tdap) vaccine for individuals ≥65 years of age
• Tdap for pregnant women during every pregnancy
• meningococcal conjugate vaccine for high-risk infants and children
• pneumococcal conjugate vaccine for high-risk adults.

There are also minor changes in recommendations for the use of measles, mumps, and rubella (MMR) vaccine among those with human immunodeficiency virus (HIV) infection. The new immunization schedules can be found on the CDC’s immunization Web site, at http://www.cdc.gov/vaccines/schedules/index.html.

Previous Practice Alerts have reported on recommendation changes made throughout 2012, including removal of egg allergy as a contraindication for influenza vaccine for those who experience only hives after eating eggs,³ the addition of a simplified algorithm for deciding whether children younger than 9 years need one or 2 doses of influenza vaccine,³ and the addition of human papillomavirus vaccine as a routine recommendation for males ages 11 to 21 years.⁴

Tdap: Some recommendations are off label

Given the continuing elevated rates of pertussis in the United States and our understanding about the duration of protection and safety of the Tdap vaccine, ACIP has made new recommendations for the use of Tdap, including some off-label uses. Two Tdap products are available: Boostrix, approved for individuals ≥10 years, and Adacel, approved for individuals 11 to 64 years (TABLE 1).⁵ ACIP states that those ≥65 years may be vaccinated with Tdap, and that an opportunity for vaccination should not be missed; Adacel can be substituted if it is the only product available. To control the spread of pertussis to the most vulnerable, it is especially important to immunize grandparents, childcare providers, and those who are around infants.

TABLE 1
Available tetanus-diphtheria-pertussis vaccines⁵

Wound management. If a tetanus booster is indicated for wound management in an individual ≥19 years who has never received Tdap, this product is preferred to Td.⁵ There is now no suggested minimum time interval for administering Tdap after Td. Currently only one dose of Tdap is recommended for adults (except for pregnant women, as described in the next section). But this may change as time passes and we learn more about the duration of protection from the acellular pertussis antigen in the vaccine.

Pregnancy. ACIP first recommended the use of Tdap during pregnancy in October 2011, in an attempt to provide protection for newborns through the transfer of maternal antibodies to the fetus.⁶ Recent evidence indicates that the duration of protective antibody levels wanes between pregnancies and may not be high enough to protect a newborn in subsequent pregnancies.⁷ ACIP voted in October 2012 to recommend Tdap for pregnant women during each pregnancy, at the gestational age of 27 through 36 weeks. If a mother does not receive Tdap during pregnancy and has never received it, she should be vaccinated soon after delivery.

The safety data for serial vaccination with Tdap in pregnant women is sparse, and ACIP considered this concern. In the opinion of ACIP, the potential benefits to the newborn, coupled with the high rate of pertussis, outweigh this concern, and efforts will be made to monitor for safety issues. If the rate of pertussis declines, ACIP will likely revisit this recommendation.

Meningococcal vaccine: No routine immunization for infants

A previous Practice Alert described 3 new products to protect infants and children against meningococcal disease, and identified issues that make recommendations about their use difficult at a time when rates of meningococcal disease in this age group are very low.⁸ At its October 2012 meeting, ACIP considered one of these products, HibMenCY (MenHibrix), which contains antigens against meningococcal serogroups C and Y and Haemophilus influenzae B (Hib).

ACIP voted not to recommend routine immunization against meningococcal disease in infants. However, HibMenCY was recommended for high-risk infants, and it was noted that it can be used as an Hib vaccine. The details of the recommendation appear in “When should you use HibMenCY in infants?”.⁹ The current recommendation also includes vaccinating high-risk infants ages 9 through 23 months with 2 doses of MenACWY-D (Menactra) with at least 8 weeks between doses. Only one of these products should be used, and ACIP does not cite a preference between them.

Pneumococcal conjugate vaccine recommended for high-risk adults

There are now 2 products that provide protection for adults against pneumococcal disease: a 23-valent polysaccharide product (PPSV23) and a 13-valent conjugate product (PCV13). PPSV23 is recommended for all adults ≥65 years and for those <65 who are at high risk for pneumococcal disease or complications from pneumococcal disease. While PCV13 is approved by the FDA for all adults ≥50 years, ACIP recommends it only for those at higher risk for pneumococcal disease.¹⁰

ACIP also recommends that those at risk should receive both PCV13 and PPSV23. Give PCV13 first, followed by PPSV23 2 months later.¹⁰ However, if PPSV23 is given first, administer PCV13 12 months later. To complicate matters, for some risk categories it is recommended that patients receive a second dose of PPSV23 5 years after the first one. No more than 2 doses of PPSV23 should be given prior to age 65. This complicated set of recommendations is summarized in TABLE 2.¹⁰

TABLE 2
Indications for using pneumococcal vaccines in adults ≥19 years*¹⁰

MMR for those with HIV and use of IG for measles prevention

The last set of significant changes to the schedules are updated recommendations for the use of MMR vaccine in those who have HIV infection, and the use of immune globulin to prevent measles in those previously unvaccinated who are exposed to the disease. Details of these recommendations can be found at http://www.cdc.gov/vaccines/recs/provisional/downloads/mmr-Oct-2012.pdf.

The 2013 immunization schedules have been published by the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP).^1,2 Perhaps the most noticeable change is a single schedule for infants, children, and adolescents, instead of the previous 2 schedules (for those ages 0-6 years, and for those ages 7-18 years). Other major new recommendations include the following:

• tetanus-diphtheria-pertussis (Tdap) vaccine for individuals ≥65 years of age
• Tdap for pregnant women during every pregnancy
• meningococcal conjugate vaccine for high-risk infants and children
• pneumococcal conjugate vaccine for high-risk adults.

There are also minor changes in recommendations for the use of measles, mumps, and rubella (MMR) vaccine among those with human immunodeficiency virus (HIV) infection. The new immunization schedules can be found on the CDC’s immunization Web site, at http://www.cdc.gov/vaccines/schedules/index.html.

Previous Practice Alerts have reported on recommendation changes made throughout 2012, including removal of egg allergy as a contraindication for influenza vaccine for those who experience only hives after eating eggs,³ the addition of a simplified algorithm for deciding whether children younger than 9 years need one or 2 doses of influenza vaccine,³ and the addition of human papillomavirus vaccine as a routine recommendation for males ages 11 to 21 years.⁴

Tdap: Some recommendations are off label

Given the continuing elevated rates of pertussis in the United States and our understanding about the duration of protection and safety of the Tdap vaccine, ACIP has made new recommendations for the use of Tdap, including some off-label uses. Two Tdap products are available: Boostrix, approved for individuals ≥10 years, and Adacel, approved for individuals 11 to 64 years (TABLE 1).⁵ ACIP states that those ≥65 years may be vaccinated with Tdap, and that an opportunity for vaccination should not be missed; Adacel can be substituted if it is the only product available. To control the spread of pertussis to the most vulnerable, it is especially important to immunize grandparents, childcare providers, and those who are around infants.

TABLE 1
Available tetanus-diphtheria-pertussis vaccines⁵

Wound management. If a tetanus booster is indicated for wound management in an individual ≥19 years who has never received Tdap, this product is preferred to Td.⁵ There is now no suggested minimum time interval for administering Tdap after Td. Currently only one dose of Tdap is recommended for adults (except for pregnant women, as described in the next section). But this may change as time passes and we learn more about the duration of protection from the acellular pertussis antigen in the vaccine.

Pregnancy. ACIP first recommended the use of Tdap during pregnancy in October 2011, in an attempt to provide protection for newborns through the transfer of maternal antibodies to the fetus.⁶ Recent evidence indicates that the duration of protective antibody levels wanes between pregnancies and may not be high enough to protect a newborn in subsequent pregnancies.⁷ ACIP voted in October 2012 to recommend Tdap for pregnant women during each pregnancy, at the gestational age of 27 through 36 weeks. If a mother does not receive Tdap during pregnancy and has never received it, she should be vaccinated soon after delivery.

The safety data for serial vaccination with Tdap in pregnant women is sparse, and ACIP considered this concern. In the opinion of ACIP, the potential benefits to the newborn, coupled with the high rate of pertussis, outweigh this concern, and efforts will be made to monitor for safety issues. If the rate of pertussis declines, ACIP will likely revisit this recommendation.

Meningococcal vaccine: No routine immunization for infants

A previous Practice Alert described 3 new products to protect infants and children against meningococcal disease, and identified issues that make recommendations about their use difficult at a time when rates of meningococcal disease in this age group are very low.⁸ At its October 2012 meeting, ACIP considered one of these products, HibMenCY (MenHibrix), which contains antigens against meningococcal serogroups C and Y and Haemophilus influenzae B (Hib).

ACIP voted not to recommend routine immunization against meningococcal disease in infants. However, HibMenCY was recommended for high-risk infants, and it was noted that it can be used as an Hib vaccine. The details of the recommendation appear in “When should you use HibMenCY in infants?”.⁹ The current recommendation also includes vaccinating high-risk infants ages 9 through 23 months with 2 doses of MenACWY-D (Menactra) with at least 8 weeks between doses. Only one of these products should be used, and ACIP does not cite a preference between them.

Pneumococcal conjugate vaccine recommended for high-risk adults

There are now 2 products that provide protection for adults against pneumococcal disease: a 23-valent polysaccharide product (PPSV23) and a 13-valent conjugate product (PCV13). PPSV23 is recommended for all adults ≥65 years and for those <65 who are at high risk for pneumococcal disease or complications from pneumococcal disease. While PCV13 is approved by the FDA for all adults ≥50 years, ACIP recommends it only for those at higher risk for pneumococcal disease.¹⁰

ACIP also recommends that those at risk should receive both PCV13 and PPSV23. Give PCV13 first, followed by PPSV23 2 months later.¹⁰ However, if PPSV23 is given first, administer PCV13 12 months later. To complicate matters, for some risk categories it is recommended that patients receive a second dose of PPSV23 5 years after the first one. No more than 2 doses of PPSV23 should be given prior to age 65. This complicated set of recommendations is summarized in TABLE 2.¹⁰

TABLE 2
Indications for using pneumococcal vaccines in adults ≥19 years*¹⁰

MMR for those with HIV and use of IG for measles prevention

The last set of significant changes to the schedules are updated recommendations for the use of MMR vaccine in those who have HIV infection, and the use of immune globulin to prevent measles in those previously unvaccinated who are exposed to the disease. Details of these recommendations can be found at http://www.cdc.gov/vaccines/recs/provisional/downloads/mmr-Oct-2012.pdf.

CASE Mr. A, a 59-year-old high school science teacher, came into our medical clinic with severe pain (7/10) in his left shoulder and arm and weakness on flexion of his left elbow. A week earlier, he felt a “pop” and experienced sharp pain and immediate “swelling” of the left biceps after throwing a heavy trash bag away while at work. He went to the school nurse for evaluation and was referred to a physician.

Mr. A was healthy, had no chronic diseases, and reported no previous injuries or trauma. He denied smoking, drinking alcohol, using illegal drugs, or taking steroids or other medications. He had worked as a high school teacher for the last 10 years at the time of his clinic visit.

Imaging, physical exam tell the tale. The patient’s physical exam was normal, with one outstanding exception: a “Popeye” deformity in his left biceps (FIGURE), accompanied by severe pain and tenderness to palpation over the proximal aspect of the left biceps. Both active and passive range of motion of the elbow were full and symmetrical, but the patient had prominent pain and weakness on elbow flexion and supination. However, he had good rotator cuff strength without pain and no impingement signs or acromioclavicular joint pain. He had no atrophy or scapular dyskinesia. Similarly, a neurovascular exam of the distal aspect of the extremity was normal.

FIGURE
“Popeye” deformity in left biceps

The magnetic resonance imaging report revealed a complete tendon rupture of the long head of the biceps brachii muscle. The long head muscle was intact and there was a posttraumatic hemorrhage in the region of the tear in the upper arm. The remaining muscle, ligaments, and tendon were intact. There was no evidence of a fracture.

A 3-pronged approach. Once the diagnosis of acute complete rupture of the left long head tendon biceps brachii was reached, we laid out a 3-pronged treatment approach:

• nonsteroidal anti-inflammatory agents and muscle relaxants such as cyclobenzaprine, tizanidine, or metaxalone
• physical therapy (2-3 times per week) and daily home exercise
• modified activities—specifically, no overhead work or lifting of anything >10 lb with the affected arm.

Before we proceeded with this plan, we referred the patient to a specialist for evaluation and a second opinion.

Biceps tendon rupture usually follows a traumatic event

Long head biceps tendon ruptures often involve people between 40 and 60 years of age, with men affected significantly more often than women.^1,2 Tennis players and ballplayers are also affected, as a result of frequent swinging motions.³ As you might expect, a person’s dominant arm is more often affected.³

Excessive weightlifting or rapid stress upon the tendon can cause an acute tendon rupture. As a rule, biceps tendon ruptures are caused by a single traumatic event that typically involves lifting a heavy object while the elbow is bent at a 90-degree angle. Weight lifters who use anabolic steroids are at an increased risk of sustaining a rupture at the tendon, and clinicians may also see such ruptures among patients who have fallen forcefully onto an outstretched arm.^2,3

Keep in mind, however, that rupture can also occur in the absence of a traumatic event. This usually happens in elderly individuals with advanced tendon degeneration.⁴ Smoking, rheumatoid arthritis, steroid medications,^2,5 fluoroquinolones,⁶ and statin therapy⁷ can affect this tendon and increase the risk of spontaneous rupture, as well.

“Popeye” biceps—a telltale sign. Understanding the function of the biceps brachii helps explain at least one of the telltale signs of long head tendon rupture. The biceps muscle enables supination of the forearm and flexion of the elbow. With long head tendon rupture, however, the muscle belly retracts, causing prominent fullness and bulging of the upper arm—what’s called “Popeye” biceps. Because the rupture involves only the long head tendon of the biceps and not the short head tendon, the biceps still functions.⁸

Surgical repair vs conservative management

Whether to pursue surgery or conservative management when caring for a patient with a biceps rupture remains a subject of debate in the medical literature. There are no studies that demonstrate the superiority of one approach over the other.^2,5,9,10

Surgery. The serious complications associated with surgery have led some experts to question whether the risks of surgery outweigh the benefits.¹¹ Equally important is the patient’s individual circumstances. Clinicians need to consider each patient’s occupation, lifestyle, and age when recommending a course of action.

Published clinical guidelines usually recommend surgical repair for young athletes who require maximum supination strength in daily activities. Although the size of the Popeye deformity does diminish after conservative treatment, surgery is often recommended for patients who are unwilling to accept the cosmetic defect seen after the tendon ruptures. And finally, operative treatment is indicated for middle-aged carpenters and manual laborers whose occupations require full supination and arm strength.^2,12-14

The surgical procedure, called tenodesis, involves reattaching the torn section of the tendon to the bone.^5,15 A recent study involving 5 professional wrestlers injured while performing noted that tenodesis restored full biceps function, gave excellent cosmetic results, and allowed all of the young men to return to wrestling.¹⁵

Conservative treatment. A conservative approach is appropriate for older patients when their profession and lifestyle do not demand a high degree of supination and upper arm strength.^5,8,13,14 In addition, the more conservative approach is very well tolerated, which reduces the risk of serious complications and the cost of surgery.¹¹ Avoiding surgery also permits patients to return to work much sooner.

Patients may, however, lose up to 20% of their supination strength with conservative treatment.¹⁴ But this approach does not cause weakness in grip, pronation, or elbow extension. Nor does it affect patients’ activities of daily living,¹⁴ which may explain why more patients are treated conservatively than with surgery.^5,11 Additionally, some experts recommend nonoperative treatment of distal biceps tendon ruptures for people who are wary of surgery or present late with the injury.¹¹

CASE Two orthopedic surgeons examined our patient and both supported our recommendation to pursue conservative treatment for Mr. A.

Over the next 4 to 6 weeks, he received physical therapy 2 to 3 times per week. With the help of the physiotherapist, Mr. A performed joint mobilization and flexibility exercises to improve the range of motion in his shoulder. The therapist also helped him with strengthening and stretching exercises to restore the strength of his biceps and elbow muscle.

At home, our patient’s regimen included elbow bend and straighten movements, elbow supination and pronation movements, and static biceps contractions.

Over time, his pain diminished and the strength in his left arm improved. Mr. A was able to return to work with modified duty, 2 to 3 weeks after his injury. By Week 8, he had full range of motion in his left arm and normal strength. He was able to do his job as a high school science teacher without any restrictions, but continued to have the Popeye deformity.

Our experience treating Mr. A serves as a reminder to physicians that complete long head biceps tendon rupture can be successfully treated conservatively. Patients working in sedentary occupations usually do not need a high degree of supination or physical strength in their upper extremities, making this a worthwhile treatment option for them.

CORRESPONDENCE 
Sofya Pugach, MD, PhD, MPH, Complete Med Care, 8989 Forest Lane, Dallas, TX 75243; [email protected]

CASE Mr. A, a 59-year-old high school science teacher, came into our medical clinic with severe pain (7/10) in his left shoulder and arm and weakness on flexion of his left elbow. A week earlier, he felt a “pop” and experienced sharp pain and immediate “swelling” of the left biceps after throwing a heavy trash bag away while at work. He went to the school nurse for evaluation and was referred to a physician.

Mr. A was healthy, had no chronic diseases, and reported no previous injuries or trauma. He denied smoking, drinking alcohol, using illegal drugs, or taking steroids or other medications. He had worked as a high school teacher for the last 10 years at the time of his clinic visit.

Imaging, physical exam tell the tale. The patient’s physical exam was normal, with one outstanding exception: a “Popeye” deformity in his left biceps (FIGURE), accompanied by severe pain and tenderness to palpation over the proximal aspect of the left biceps. Both active and passive range of motion of the elbow were full and symmetrical, but the patient had prominent pain and weakness on elbow flexion and supination. However, he had good rotator cuff strength without pain and no impingement signs or acromioclavicular joint pain. He had no atrophy or scapular dyskinesia. Similarly, a neurovascular exam of the distal aspect of the extremity was normal.

FIGURE
“Popeye” deformity in left biceps

The magnetic resonance imaging report revealed a complete tendon rupture of the long head of the biceps brachii muscle. The long head muscle was intact and there was a posttraumatic hemorrhage in the region of the tear in the upper arm. The remaining muscle, ligaments, and tendon were intact. There was no evidence of a fracture.

A 3-pronged approach. Once the diagnosis of acute complete rupture of the left long head tendon biceps brachii was reached, we laid out a 3-pronged treatment approach:

• nonsteroidal anti-inflammatory agents and muscle relaxants such as cyclobenzaprine, tizanidine, or metaxalone
• physical therapy (2-3 times per week) and daily home exercise
• modified activities—specifically, no overhead work or lifting of anything >10 lb with the affected arm.

Before we proceeded with this plan, we referred the patient to a specialist for evaluation and a second opinion.

Biceps tendon rupture usually follows a traumatic event

Long head biceps tendon ruptures often involve people between 40 and 60 years of age, with men affected significantly more often than women.^1,2 Tennis players and ballplayers are also affected, as a result of frequent swinging motions.³ As you might expect, a person’s dominant arm is more often affected.³

Excessive weightlifting or rapid stress upon the tendon can cause an acute tendon rupture. As a rule, biceps tendon ruptures are caused by a single traumatic event that typically involves lifting a heavy object while the elbow is bent at a 90-degree angle. Weight lifters who use anabolic steroids are at an increased risk of sustaining a rupture at the tendon, and clinicians may also see such ruptures among patients who have fallen forcefully onto an outstretched arm.^2,3

Keep in mind, however, that rupture can also occur in the absence of a traumatic event. This usually happens in elderly individuals with advanced tendon degeneration.⁴ Smoking, rheumatoid arthritis, steroid medications,^2,5 fluoroquinolones,⁶ and statin therapy⁷ can affect this tendon and increase the risk of spontaneous rupture, as well.

“Popeye” biceps—a telltale sign. Understanding the function of the biceps brachii helps explain at least one of the telltale signs of long head tendon rupture. The biceps muscle enables supination of the forearm and flexion of the elbow. With long head tendon rupture, however, the muscle belly retracts, causing prominent fullness and bulging of the upper arm—what’s called “Popeye” biceps. Because the rupture involves only the long head tendon of the biceps and not the short head tendon, the biceps still functions.⁸

Surgical repair vs conservative management

Whether to pursue surgery or conservative management when caring for a patient with a biceps rupture remains a subject of debate in the medical literature. There are no studies that demonstrate the superiority of one approach over the other.^2,5,9,10

Surgery. The serious complications associated with surgery have led some experts to question whether the risks of surgery outweigh the benefits.¹¹ Equally important is the patient’s individual circumstances. Clinicians need to consider each patient’s occupation, lifestyle, and age when recommending a course of action.

Published clinical guidelines usually recommend surgical repair for young athletes who require maximum supination strength in daily activities. Although the size of the Popeye deformity does diminish after conservative treatment, surgery is often recommended for patients who are unwilling to accept the cosmetic defect seen after the tendon ruptures. And finally, operative treatment is indicated for middle-aged carpenters and manual laborers whose occupations require full supination and arm strength.^2,12-14

The surgical procedure, called tenodesis, involves reattaching the torn section of the tendon to the bone.^5,15 A recent study involving 5 professional wrestlers injured while performing noted that tenodesis restored full biceps function, gave excellent cosmetic results, and allowed all of the young men to return to wrestling.¹⁵

Conservative treatment. A conservative approach is appropriate for older patients when their profession and lifestyle do not demand a high degree of supination and upper arm strength.^5,8,13,14 In addition, the more conservative approach is very well tolerated, which reduces the risk of serious complications and the cost of surgery.¹¹ Avoiding surgery also permits patients to return to work much sooner.

Patients may, however, lose up to 20% of their supination strength with conservative treatment.¹⁴ But this approach does not cause weakness in grip, pronation, or elbow extension. Nor does it affect patients’ activities of daily living,¹⁴ which may explain why more patients are treated conservatively than with surgery.^5,11 Additionally, some experts recommend nonoperative treatment of distal biceps tendon ruptures for people who are wary of surgery or present late with the injury.¹¹

CASE Two orthopedic surgeons examined our patient and both supported our recommendation to pursue conservative treatment for Mr. A.

Over the next 4 to 6 weeks, he received physical therapy 2 to 3 times per week. With the help of the physiotherapist, Mr. A performed joint mobilization and flexibility exercises to improve the range of motion in his shoulder. The therapist also helped him with strengthening and stretching exercises to restore the strength of his biceps and elbow muscle.

At home, our patient’s regimen included elbow bend and straighten movements, elbow supination and pronation movements, and static biceps contractions.

Over time, his pain diminished and the strength in his left arm improved. Mr. A was able to return to work with modified duty, 2 to 3 weeks after his injury. By Week 8, he had full range of motion in his left arm and normal strength. He was able to do his job as a high school science teacher without any restrictions, but continued to have the Popeye deformity.

Our experience treating Mr. A serves as a reminder to physicians that complete long head biceps tendon rupture can be successfully treated conservatively. Patients working in sedentary occupations usually do not need a high degree of supination or physical strength in their upper extremities, making this a worthwhile treatment option for them.

CORRESPONDENCE 
Sofya Pugach, MD, PhD, MPH, Complete Med Care, 8989 Forest Lane, Dallas, TX 75243; [email protected]

CASE Mr. A, a 59-year-old high school science teacher, came into our medical clinic with severe pain (7/10) in his left shoulder and arm and weakness on flexion of his left elbow. A week earlier, he felt a “pop” and experienced sharp pain and immediate “swelling” of the left biceps after throwing a heavy trash bag away while at work. He went to the school nurse for evaluation and was referred to a physician.

Mr. A was healthy, had no chronic diseases, and reported no previous injuries or trauma. He denied smoking, drinking alcohol, using illegal drugs, or taking steroids or other medications. He had worked as a high school teacher for the last 10 years at the time of his clinic visit.

Imaging, physical exam tell the tale. The patient’s physical exam was normal, with one outstanding exception: a “Popeye” deformity in his left biceps (FIGURE), accompanied by severe pain and tenderness to palpation over the proximal aspect of the left biceps. Both active and passive range of motion of the elbow were full and symmetrical, but the patient had prominent pain and weakness on elbow flexion and supination. However, he had good rotator cuff strength without pain and no impingement signs or acromioclavicular joint pain. He had no atrophy or scapular dyskinesia. Similarly, a neurovascular exam of the distal aspect of the extremity was normal.

FIGURE
“Popeye” deformity in left biceps

The magnetic resonance imaging report revealed a complete tendon rupture of the long head of the biceps brachii muscle. The long head muscle was intact and there was a posttraumatic hemorrhage in the region of the tear in the upper arm. The remaining muscle, ligaments, and tendon were intact. There was no evidence of a fracture.

A 3-pronged approach. Once the diagnosis of acute complete rupture of the left long head tendon biceps brachii was reached, we laid out a 3-pronged treatment approach:

• nonsteroidal anti-inflammatory agents and muscle relaxants such as cyclobenzaprine, tizanidine, or metaxalone
• physical therapy (2-3 times per week) and daily home exercise
• modified activities—specifically, no overhead work or lifting of anything >10 lb with the affected arm.

Before we proceeded with this plan, we referred the patient to a specialist for evaluation and a second opinion.

Biceps tendon rupture usually follows a traumatic event

Long head biceps tendon ruptures often involve people between 40 and 60 years of age, with men affected significantly more often than women.^1,2 Tennis players and ballplayers are also affected, as a result of frequent swinging motions.³ As you might expect, a person’s dominant arm is more often affected.³

Excessive weightlifting or rapid stress upon the tendon can cause an acute tendon rupture. As a rule, biceps tendon ruptures are caused by a single traumatic event that typically involves lifting a heavy object while the elbow is bent at a 90-degree angle. Weight lifters who use anabolic steroids are at an increased risk of sustaining a rupture at the tendon, and clinicians may also see such ruptures among patients who have fallen forcefully onto an outstretched arm.^2,3