Arecent study in Archives of Otolaryngology-Head and Neck Surgery on the potential side effects of nasal zinc therapies is the newest staging ground in the debate over how otolaryngologists can advise patients on the benefits of homeopathic treatments in the context of the common cold.
The study reported that the use of over-the-counter, homeopathic nasal zinc gel and spray “can and does cause anosmia” (Arch Otolaryngol Head Neck Surg. 2010:136(7);673-676). The results are the latest data in the back-and-forth on the efficacy of intranasal zinc gluconate, which drew attention last year when the U.S. Food and Drug Administration (FDA) warned customers that three Zicam intranasal zinc treatments were associated with anosmia. Still, the FDA continues to label the therapy as “generally regarded as safe (GRAS)” on its consumer website.
“These things can come to market and don’t need to go through the same rigors and trials other treatments need to go through,” said Karen Fong, MD, co-director of California Sinus Centers (CSC) Advanced Sinus Surgery and Rhinology Fellowship in Walnut Creek, Calif. “Just because it’s over the counter doesn’t mean it doesn’t have any issues.”
Honesty Is Key
According to the study authors, increased FDA scrutiny and oversight of homeopathic medicines, “especially ones with limited proven therapeutic benefit,” are needed to monitor the safety of such treatments. In an interview, however, lead author Terence M. Davidson, MD, FACS, added that such a proposal would likely draw criticism from the producers of such treatments and the pharmacies that profit by selling them. He also questioned the amount of money and time spent scrutinizing treatments that may not prove medically beneficial in most patients, but that have no side effects and may be beneficial to certain patients.
Either way, Dr. Davidson and other otolaryngologists interviewed for this story agreed that candor is the best way to handle questions about the topic of alternative treatments.
“The single most important thing a physician can do is be honest,” said Dr. Davidson, professor of otolaryngology-head and neck surgery and associate dean for Continuing Medical Education at the University of California, San Diego School of Medicine. “When a patient asks about a homeopathic treatment, sometimes you have to say ‘I don’t know.’”
The usefulness of alternative treatments in treating the common cold adds a layer of uncertainty because of the condition’s self-limiting nature. The patient’s symptoms may dissipate in a matter of days as the illness runs its course, leaving both the physician and the patient unsure of whether any of the alternative treatments used, such as zinc therapies, nasal irrigation and oversized doses of vitamin C, had a measurable impact on recovery time.
Michael Stewart, MD, MPH, professor and chairman of otorhinolaryngology and senior associate dean for clinical affairs at Weill Cornell Medical College, uses questions about nasal zinc therapies and other alternative treatments as educational opportunities. He discusses available studies with patients and gives them all the facts he can present and then recommends against using any treatments for which available evidence shows that potential downsides outweigh potential benefits. He can only recommend options to patients, he said.
“If I have a stockbroker and I feel like I have to veto every point he makes, then why do I have a stockbroker?” said Dr. Stewart, an ENT Today editorial board member. “You need to have the same sort of relationship with your physician. You have to question and, ultimately, it’s your call, but if [a patient is] questioning everything, then maybe you should find another doctor.”
Dr. Stewart was quick to point out, though, that physicians should not be dismissive of alternative treatments out of hand, especially when many doctors have techniques or treatments that they may rely on despite a lack of evidence-based data.
“I do think there’s a role for homeopathic treatment and being open-minded to these things,” he added. “The reality is there’s a lot about what we do that is not ‘scientifically proven.’ We have to be careful in making sure not to have a double standard.”
Ask the Right Questions
One of the first steps in that process is identifying the homeopathic treatments that a patient may have used in the past, or is currently using, to treat a common cold. Dr. Fong has a category on her patient questionnaire about alternative treatments.
“People will tell you they are not using any medication,” said Dr. Fong, who is also adjunct clinical assistant professor of otolaryngology-head and neck surgery at Stanford University in Palo Alto, Calif. “But if you ask them to list it out, they might tell you 20 supplements, vitamins and over-the-counter medications they are taking.”
This is the point in the process when patients’ preconceived notions of the safety of homeopathic treatments can run counter to a physician’s training and education, said Eric Holbrook, MD, an otolaryngologist at the Massachusetts Eye and Ear Infirmary in Boston.
“It always strikes me as surprising, because they have some belief, for whatever reason, that homeopathic medicines…are safer than conventional medicine,” he added. “But, in reality, a lot of those supplements have not been thoroughly studied and we don’t know what effects they can have.”
Dr. Holbrook said physicians can only be so aggressive about how they educate their patients. An overly aggressive approach “can be counterproductive.” To that end, Dr. Stewart talks with his patients about their desire to use treatments, their personal experience with such alternatives and the accumulation of research on a given topic, what he calls the “three-legged stool of evidence-based treatment.”
Dr. Stewart noted, however, that the discussion occurs more often with younger patients, a generational issue he attributes to the information age. Whereas patients 20 years ago would take a physician’s advice without question, technologically savvy patients now come to appointments armed with printouts from alternative medicine websites and WebMD.
“Everybody’s looking for that magic that will cure the common cold, make it pass faster and less severe,” Dr. Fong said. “That really doesn’t exist.”