ASK THE GP: Should I use steroid spray to get a good night’s sleep?

A childhood accident left me with a deviated septum, severely affecting my sleep throughout my life. Now in my 40s, I find myself tired and yawning in the day and nodding off early in the evening. A consultant gave me a steroid nasal spray called Avamys. I don’t really want to take a steroid for the rest of my life but every day I seem to read an article on the damaging effects of lack of sleep.

Fiona Steele, by email.

As anyone who’s had a heavy cold will know, nasal congestion can affect sleep — but unfortunately for many people, including you, it becomes an enduring problem that can cause a great deal of distress.

In fact, nasal blockage and symptoms related to the nose and sinuses are among the most common reasons for patients to consult GPs, ear, nose and throat specialists and allergists.

There are a number of potential causes, and often they occur in combination. These include allergies, pregnancy and some medications, such as the drugs used to treat erectile dysfunction.

Structural abnormalities such as a deviation of the nasal septum — where the bone and cartilage that divides the nasal cavity is off-centre or crooked — can also be to blame. 

As well as injury, this can be due to the way the nose and face form in the womb, or injury during passage through the birth canal.

In your case it seems the deviation was not severe enough to require surgery to straighten the septum, although it has caused you difficulties over the years.

A common problem linked to a deviated septum is hypertrophy, where the wall of the nasal lining on the side opposite the deviated septum becomes thickened.

Normally the lining of the nose fluctuates in thickness depending on the quantity of blood flowing through it: at times the airway will be clear, while at other times it will be compromised, giving the sensation of a blockage (which can be enough to interrupt the quality of your sleep).

Many factors affect blood flow including allergies, posture (it’s worse when horizontal), mood (such as anger and chronic anxiety) and warmth and humidity (excessive warmth or very dry atmospheres mean the lining is more likely to swell).

The steroid spray you’ve been prescribed can calm an irritated nasal lining, although it might take weeks or more to see the benefits.

In your longer letter you spell out your concerns about long-term use of steroid nasal spray, which has been linked to stunted growth in children.

While this is not a concern for adults, there are other potential side-effects such as nosebleeds and excessive nasal dryness.

If you’re still concerned about side-effects, one option is ‘pulsing’ the treatment — using it for a couple of months and then having a month off, for example.

This may improve the air flow sufficiently in your upper airway to improve your sleep.

You say in your letter that you’ve had difficulties sleeping from the age of 12 — not getting to sleep until the early hours whatever time you go to bed, and waking in the night.

Although you say this insomnia is much better, I think there’s much to be gained from asking your GP for a referral to a sleep clinic, where you can have what’s known as a sleep study. 

This would provide a full assessment of exactly what’s happening physiologically when you’re asleep, and so could reveal if factors other than your nasal airway are causing your sleep problems.

My husband is a very healthy, active 82-year-old but some years ago he was told that he was diabetic. He had one high sugar reading and his father was diabetic, but no medication was advised. He has yearly checks with our practice nurse and all his results have been good. Two further blood tests in the past six months were within the acceptable range for blood sugar. He also has a yearly eye test for diabetic retinopathy: these results have also all come back unchanged. We’ve queried his ‘diabetic status’ with our GP who says it can’t be changed once it’s on the system. But now this label is having a detrimental effect on the cost of our travel insurance.

Maureen Davies, Cardiff.

There’s no doubt a family history is a risk factor for developing type 2 diabetes — your risk is between five and ten times higher if you have a first-degree relative (parent, sister, brother, son or daughter) with diabetes.

But I agree, your husband’s situation is puzzling as the recent tests, including those for diabetic retinopathy (where they check the retina at the back of the eye for damage related to diabetes) have been normal. I wonder if he was correctly diagnosed with type 2 in the first place.

Even if the diagnosis was correct, his normal blood tests could mean the condition is in remission — we do not say ‘cured’, as it’s always still there in the background.

Did you know? Recent studies on patients with type 2 have shown that a low-calorie diet can push diabetes into remission

Recent studies on patients with type 2 have shown that a low-calorie diet can push diabetes into remission. The key is getting down to a healthy weight, with a body mass index (BMI) below 25.

However, the diabetes can still come back — for example, if the weight goes back up, blood sugar levels will, once again, be above the normal thresholds.

In your husband’s case, I would suggest that a good strategy would be to go back to his GP or seek a referral to a specialist for a more sophisticated test (a glucose load test).

If the results of this are normal, he is not diabetic and the notes could be amended to state that there was a previous diagnostic error. If it turns out he is in remission, his notes would not be changed as he’s still diabetic, albeit the condition is controlled.

In either case the relevant information can be transferred via a broker to your travel insurance company.

IN MY OPINION…PATIENTS ARE RIGHT TO BE FED-UP  

Public satisfaction with GP services has fallen to its lowest recorded level, it was revealed last week.

The news was received with sadness and disappointment by many GPs, but I know from talking to my colleagues that, frankly, few were surprised.

Winston Churchill famously said in 1941: ‘Give us the tools and we will finish the job.’ In general practice the most important tool that’s been taken away is time — the time to spend with each patient.

Since the NHS was founded in 1948, what we can achieve medically, and the expectations of the public, have grown massively. This has coincided with a growing population and a workforce that has not increased to meet those expanding demands.

GPs’ frustration at not being able to provide the service they would wish for was underlined by a survey for the British Medical Association last October, which revealed that 50 per cent feel that their workload is excessive, impacting on the quality and safety of care.

The ever-increasing workload pressure was a major reason that GPs opted to withdraw from providing 24-hour care when the chance arose with the new contract introduced by the Labour government in 2004. Stepping away from being available out of hours did untold damage to the relationship between GPs and their patients.

Another nail in the coffin of that relationship has been the change in the way patients are registered with a GP surgery: they are no longer allocated to a named GP, but registered with the entire practice.

With that move we lost the sense that we had a personal doctor who knew our history, would take care of us, fight our corner, and make things happen.

And so we have it: GPs are frustrated, and so, too, are patients. I fear that it’s only going to get worse.