Deborah Brauser

November 11, 2009

November 11, 2009 (San Diego, California) — Daily long-term use of nasal saline irrigation (NSI) by patients with recurrent rhinosinusitis (RS) can increase the frequency of acute infection by as much as 60%, according to a new study presented here at the American College of Allergy, Asthma & Immunology (ACAAI) 2009 Annual Scientific Meeting. Many called the study "important."

"We have a serious problem with many patients who suffer with chronic sinus disease thinking that the best treatment is daily [NSI]. They think it isn't harmful and so use it all the time," said lead investigator Talal M. Nsouli, MD, clinical professor of pediatrics and allergy/immunology at Georgetown University Hospital School of Medicine and medical director at the Watergate and Burke Allergy and Asthma Research Centers in Virginia. He presented the results during a podium session.

Afterward, Dr. Nsouli told Medscape Allergy & Clinical Immunology that he has no problems with the use of NSI over a short term, and that previous studies have shown that it can improve nasal mucociliary clearance. However, "despite the common use of [NSI], or neti pots, in the treatment of sinus disease over a long period of time, there has been little evidence to confirm its success."

For this study, the investigators hypothesized that the "long-term use of NSI may deplete the nose of its immune blanket of mucus, resulting in recurrent RS."

To test this theory, they enrolled 68 patients with RS (mean age, 29.3 years) who were regular users of NSI. Patients continued using the treatment twice a day every day and were then monitored for the frequency of RS episodes over 12 months. That was followed by an additional 12 months of monitoring during complete treatment discontinuation.

In addition, a parallel noninterventive control group, consisting of 24 patients (mean age, 34.2 years) using NSI daily for 12 months, had the frequency of their RS episodes monitored.

All patients continued taking the same medication previously prescribed to them by their allergists or other physicians.

Episodes Decreased at Discontinuation

Study results showed that 544 episodes of acute RS were experienced by the patients in the NSI phase (each patient averaging 8 episodes a year), with only 204 in the discontinuation phase (averaging 3 episodes per year), a statistically significant decrease in frequency of 62.5% (< .001).

Similarly, the control group's average frequency of RS was 50% higher than that found in the discontinuation group, which was also a statistically significant difference (P < .001).

"This happens because nasal mucus acts as a first line of respiratory defense against infections due to its composition," explained Dr. Nsouli. "When we wash away the good mucus, we might be depleting nasal secretions from its immune elements."

"Treating bad mucus with [NSI] for 1 week to 10 days is fine and patients can use it for 6 to 8 weeks after surgery," continued Dr. Nsouli. "But if the bad mucus is present all the time, it means that that person has an infection and needs to be treated with other medication."

He reported that his team will next be conducting a larger study. "We're expecting to find the same results, but this will increase the power."

"The bottom line is that long-term use of [NSI] is harmful for patients. We need to tell them to go back to using these devices for coffee and tea!" concluded Dr. Nsouli.

Always Ask Questions

"This is a simple but important study," said ACAAI abstract review committee chair John J. Oppenheimer, MD, associate clinical professor of medicine at New Jersey Medical School in Newark, during a press conference on key research findings. Dr. Oppenheimer was not involved with this study.

"These patients had worse outcomes with the long-term treatment than when using nothing at all. This doesn't mean that this isn't an appropriate medication to consider when you have a cold. But using it daily may not have as good outcomes as we thought it did," said Dr. Oppenheimer.

He added that "it reinforces to me that, as doctors, it's always important for us to ask questions. Just because we may have done something for years doesn't necessarily make it right."

At the same press conference, Gailen D. Marshall, MD, PhD, editor-in-chief of the Annals of Allergy, Asthma and Immunology, from the Division of Allergy/Immunology at the University of Mississippi Medical Center in Jackson, said that "it is still a good idea to get rid of mucus through a saline wash when a patient has a cold."

"But as with anything else, you can overdo it. This abstract addresses that fact in a clear fashion and makes a good argument for maybe giving the treatment a 'drug holiday'." Dr. Marshall was also not involved with this study.

He continued: "I think this is a wonderful study because it points out the idea that simple things can be harmful. But simple things can also be very good if used in the proper context. I think it's important to take a few extra minutes to explain all of this to patients and to give them the rationale for our suggestions."

When asked what the next step should be, Dr. Oppenheimer replied: "I think we need to look at the same evidence acutely. I would feel more comforted to see it replicated to see if there are any differences. But it's the right direction and it tells us that sometimes something that makes sense empirically may not make sense in real practice."

Dr. Nsouli and Dr. Marshall have disclosed no relevant financial relationships. Dr. Oppenheimer reports being a consultant and doing research for Glaxo, AstraZeneca, Schering, Merck, Novartis, and Genentech.

American College of Allergy, Asthma & Immunology (ACAAI) 2009 Annual Scientific Meeting: Abstract 32. Presented November 8, 2009.