A new study published in the New England Journal of Medicine, Oct 17th 2007, demonstrated that early treatment with steroids, not acyclovir, provided a greater chance for a patient’s full recovery at 3 and 9 months.

 

Bell’s Palsy (idiopathic facial paralysis) usually resolves in the majority of cases, but up to 30% of patients afflicted continue to experience pain and associated facial paralysis.

 

Both steroids and antiviral medications are commonly utilized to treat the early presenting signs and symptoms of Bell’s Palsy. The effectiveness of the treatments alone or in combination remains unclear.

 

Researchers reported the results from a double-blind, randomized trial evaluating the effectiveness of steroids and acylovir in the early treatment of Bell’s Palsy. Adults who presented within the first 72 hours of symptoms were randomized to receive either prednisolone (50 mg/day) & acyclovir (2g/day) both or placebo for 10 consecutive days. The primary outcome measure was recovery of facial nerve function at both 3 and 9 months. Investigators also examined other outcomes including facial appearance, pain, along with quality of life.

 

Results of the study show that at both 3 and 9 months, recovery rates were significantly higher among patients randomized to prednisolone than among those who did not receive prednisolone. (83% vs 64% at 3 months, 94% vs 82% at 9 months, p<0.001) .

 

Recovery rates, however, were similar between patients randomized to acyclovir and those randomized to no acyclovir (85% vs 91% at 9 months (p=0.1). Acyclovir provided no additional benefit when taken together with prednisolone. There were no serious adverse effects of treatment noted in any group, according to the study authors.

 

DR 911 : This study provides clear evidence that prescribing steroids alone early in the course of Bell’s Palsy increase the chance of complete recovery by 9 months. Acyclovir, however demonstrated no benefit. It is important to note that these findings only apply to acyclovir, as described by many editorialists who reviewed the article. Other antivirals (including valcylovir) which have much greater absorption must be investigated before one can conclude that antivirals are not indicated in treatment of Bell’s Palsy.

 

References:

 

1. Sullivan FM et al. Early treatment with prednisolone or acyclovir in Bell’s      Palsy. N Engl J Med 2007 Oct 18; 357:1598.

 

2. Gilden DH, Tyler KL. Bell’s Palsy-Is glucocorticoid treatment enough? N       Engl J Med 2007. Oct 18; 357:1653.

 

 

A recent study published in the Annals of Emergency Medicine in September, 2007 examined reasons why emergency physicians prescribed antibiotics for a majority of patients with upper respiratory infections when the likely etiology was presumed to be viral in origin.

 

The consequences of overprescribing antibiotics include the potential for adverse drug reactions, as well as increased drug resistance. Physicians often overprescribe as a perceived response to patient demand, as well as a way to increase the turnover of patients in the emergency department (ED). Physician error may also contribute to inappropriate prescribing of antibiotics in this particular setting.

 

The study, examining 272 adult and pediatric patients who presented to 10 academic emergency departments with a diagnosis of uncomplicated bronchitis or upper respiratory tract infection, was prospective in design and addressed factors associated with antibiotic prescribing. Patients were interviewed prior to meeting with the physician regarding expectations for their care in the ED, immediately after completion of the exam, and 2 weeks later. They were asked about waiting time to see the physician, actual time spent with the physician, general satisfaction, and whether the encounter changed their understanding of their illness. After seeing and examining the patients in the ED, physicians were asked whether they believed the patient expected a prescription for an antibiotic, whether the patient had asked for antibiotics, and the final diagnosis.

 

Results of the aforementioned study demonstrated that overall, about one-third of patients received antibiotic prescriptions. Physicians were more likely to prescribe antibiotics to patients they believed expected them, although they were only able to correctly identify 27% of patients who actually expected antibiotics, based on physician survey data. Patient satisfaction was not related to receiving a prescription for antibiotics; instead, it was related to a belief they had a greater understanding of their illness after the ED visit.

 

DR 911 : This study clearly demonstrates that patients value a physician’s clinical judgment. Importantly, they want an explanation of their presenting symptoms and illness, as opposed to a quick prescription to expedite an emergency department visit. Since overprescribing of antibiotics is a growing public health concern, physicians should be cautious for prescribing antibiotics for conditions that they are not known to derive a benefit. The concept that the patient expected an antibiotic is contradicted by this and other studies. Patients truly want an explanation of their ailment, what they should expect to feel, and measures to follow to achieve relief of their symptoms.

 

References:

 

Ong S. et al. Antibiotic use for emergency department patients with upper respiratory infections. Prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med 2007 Sep; 50:213.