Nasal sprays are commonly used to treat sinus and allergy issues and generally fall into one of three categories.
The most commonly used nasal spray to treat nasal allergies is the intranasal steroid. It works over several days to decrease swelling of the nasal/sinus tissue and mucous production. It must be used every day to really work. Examples include: Flonase, Nasacort AQ, Qnasl and Nasonex.
Nasal antihistamines work in a different way to decrease swelling and mucous production. Symptomatic improvement can occur starting within about 30 minutes and this class of medications can be used as needed in many cases. Examples include: Patanase and azelastine.
The 3rd class of nasal sprays are the over-the-counter nasal decongestants (ie. Afrin). These are the blessing and a curse for patients (and allergists!). They work very rapidly to decrease stuffiness, but if used more than 3 days in a row have the potential to cause “rebound congestion”. When this happens the patient feels they need more and more of the spray to attain the same results and essentially become “addicted” to their nose spray. This happens only with the nasal decongestants and we often have to use the nasal steroids (ie. Flonase) to get patients off these nasal decongestants. As much as nasal decongestants are a life saver during a cold, they can stir up many more problems if not used correctly.
Kids and adults alike are generally hesitant to use nasal sprays. Reasons for the hesitancy to use nasal sprays include; patients just don’t like spraying something up their nose, they are afraid of “rebound congestion”, they don’t like the way the spray tastes or smells, they dislike the spray dripping down the back of their throat, or they get nose bleeds. Although some patients are really unable to use nasal sprays, we can typically come up with something that works with minimal symptoms.
So as the fall allergy season starts, keep in mind that the right nasal spray can help make the season tolerable, but the wrong one can end up making it even more miserable!
“I am so itchy!”, is a common complaint in the allergy clinic. Chronic itching can be very bothersome and can significantly affect a person’s quality of life. It is typically defined as itching lasting longer than 6 weeks. By the time a patient gets to the allergy clinic, they are frustrated, often sleep deprived and looking for answers.
The causes of chronic itching are vast and although we see many of these patients in the allergy clinic, allergy is often not the cause of chronic itching. Causes of itching may be divided into those associated with a rash and those without a rash. Itching with a rash, may be caused by conditions such as ezcema, contact dermatitis, medications, psoriasis, insect bites or chronic hives. Itching without a rash is more likely related to an underlying systemic issue, such as a liver, kidney or blood disorder. Dry skin is a common cause of itching, particularly in the winter. On occasion, the chronic itching will eventually result in a rash typically sparing the back and often triggered by an underlying neurological or psychological cause.
Testing will depend on the results of history and physical exam findings, but may include blood work, allergy testing by prick skin testing or patch testing, and X-ray studies. Treatment also depends on the underlying cause of the rash. Antihistamines, cool baths, nonfragrant moisturizers and topical steroids may be recommended. Often times the primary care physician must work together with an Allergist and/or a Dermatologist to diagnose and manage this frustrating condition.
Spring is over. Summer is here! For many people with springtime allergies, this is a relief. Unfortunately, the summer offers allergy issues of its own.
While tree pollen is mostly gone, grass pollen is here and can cause all the same symptoms triggered by tree pollen: itchy/watery eyes, sneezing and stuffy/runny nose. In the late summer, weed pollen (ragweed) blooms and can cause similar allergy issues.
Pollen can also trigger a specific type of food allergy called Oral Allergy Syndrome (OAS). OAS is a reaction to the fresh fruits and vegetables that we love to eat during the summer. It is caused by a cross reaction between proteins found in pollen that are similar to proteins in specific fruits and vegetables. For instance, people with a birch tree allergy may get an itchy mouth after eating fresh apples, peaches and cherries, but they are able to tolerate cooked forms of these foods.
Since we are spending more time outdoors during the summer months, we are more likely to come in contact with a stinging insect, such as a wasp or a bee. Fortunately, most people only have local reactions to insect stings, typically swelling, redness and pain at the site. However, less than 5% of the population will have a severe allergic reaction to a bee sting, which can be life threatening. Allergists are able to test for a bee sting allergy and can offer allergy shots that are 98% effective in preventing a severe reaction to a future sting.
During the recent American Thoracic Society meeting a study was presented that has caused a bit of a stir in the press. Headlines have included: “Many children with asthma have reaction to peanuts but don’t know it,” “The connection between peanut allergies(sic) and asthma,” and “Asthma symptoms in children may be a sign of peanut allergies(sic).” The authors of the study suggest that children with asthma should be routinely tested for peanut allergy. I think this is a bad idea and the ACAAI agrees with me. Let’s look a bit at the study and the author’s incorrect conclusion.
This study, conducted by Dr. Robert Cohn from Mercy Children’s in Toledo, Ohio, looked at about 1,500 children who were actively followed in their clinic for asthma. They did a chart review and found that about 11% of the kids had a “documented history” of peanut allergy. They then looked at the 650 or so kids who had peanut tests and found that 22% of them had positive tests. They go on to say that 50% of the families were unaware of the peanut sensitivity and that, “We speculate that children with asthma might benefit from peanut sensitivity screening especially when control is difficult to achieve.”
This conclusion is wrong for several reasons.
First, a positive peanut test does NOT indicate peanut allergy. Peanut testing has a high false positive rate, especially in children who are otherwise allergic. Indeed, some studies have suggested that 80% of positive peanut tests are false positives. A positive test indicates sensitization, which is not the same as allergy.
Second, food allergies do not play a role in asthma. Though food allergies can cause respiratory symptoms, usually in conjunction with hives and swelling, these symptoms occur within minutes of exposure to the offending food. They do not cause chronic, ongoing symptoms as found in asthma. Furthermore, they do not have any role in the ongoing inflammation that underlies asthma.
Finally, routine testing for foods is never indicated without a history that is consistent with food allergy. This sort of “fishing expedition” leads to incorrect diagnoses, false positive tests, and unnecessary anxiety and lifestyle modification. It causes more questions than it answers.
Though food allergy testing is not useful in asthma, testing for aeroallergens like pollen, animals and dust mites can be very helpful in guiding avoidance of specific triggers and, in some cases, utilizing specific immunotherapy. If you or your child has allergies and asthma, contact a board-certified allergist in your area.
Imagine you are cooking dinner for a big family get-together at Thanksgiving. Roast turkey with stuffing, green bean casserole, rolls and pie for dessert. It’s a big undertaking. Now imagine doing it without an oven thermometer.
Think about playing a round on your favorite golf course ever. You’ve got a long shot over the water to a tiny green. Now imagine that shot without yard markers or a range finder. Golf is hard enough already.
Numbers are important. Data and objective information help guide us through our daily lives. They let us know the true measure of things so we do not have to rely on intuition or guesswork.
Numbers are important in asthma, too. Often there is a large disconnect between how people perceive their asthma severity and what the objective numbers tell us. Lung function in asthma is measured with a test called spirometry. Spirometry measures the bellows function of the lungs- how well we move air in and out. Spirometry can be used to diagnose asthma, to help us gauge asthma severity, and to monitor response to asthma therapy. Spirometry is critical to the diagnosis and management of asthma. It is so important that the AAAAI lists it as one of their most important recommendations to physicians in their Choosing Wisely initiative.
At The Allergy, Asthma & Sinus Center, all of our locations have the ability to perform spirometry and all of our board-certified physicians are trained in using it to diagnose and manage asthma. If you have asthma or have symptoms such as cough, chest tightness, wheezing or shortness of breath, a simple spirometry test might provide you with valuable information to help improve or maintain your health.
“At what age can my child get tested for allergies?” This is a question I often get asked by parents of young children. Many parents and some healthcare providers believe that allergy testing cannot be done until 3 years of age. This is not true. This belief comes from the fact that most children begin developing seasonal allergies around age 3. However, many children have already developed allergies to other things (ie. indoor allergens and/or foods) by then.
Allergy skin testing is a technique that can detect allergic antibodies present in the blood by placing a small amount of the allergen on the skin and monitoring the response. Allergic antibodies can develop at any age. So if symptoms are consistent with an allergic process, allergy testing can be done. Although I prefer to wait to do a skin test around 1 year of age, many infants particularly those with severe eczema or a possible food allergy need to have some form of allergy testing done much earlier-and it can be done!
Many parents (myself included!) have found it very helpful to know what specifically their child is allergic to, even if they aren’t ready to start on allergy shots. This information can help clarify what time of year it is critical to give allergy medications daily, and when they may used on an as needed basis. Also, if a child is allergic to indoor allergens (ie. dust mite or dog) we can work on ways to decrease exposure to those allergens, thereby decreasing symptoms, which may then decrease the need for allergy medications- which is always desirable, especially for little ones!
An exciting new study on food allergy was recently published in the New England Journal of Medicine. This study, called the LEAP (Learning Early about Peanut Allergy) study, has been much anticipated in the allergy world. It basically reinforces recent recommendations about how we introduce highly allergic foods to our children. In the past, delaying introduction of milk, eggs and peanuts was the norm. Newer information has suggested that we should not delay introduction of these highly allergenic foods in most infants, and this study confirms these recommendations.
The LEAP study involved over 600 children who were considered high risk for peanut allergy (moderate-severe eczema and/or egg allergy). After skin testing these children and performing oral challenges, they were placed into two groups; one group ate high dose peanut products (equivalent of about 8 peanuts) 3 times per week and the other group avoided peanut completely. They then re-evaluated the prevalence of peanut allergy at age 5. There was a remarkable difference in the prevalence of peanut allergy between these 2 groups, with the group eating peanut regularly having significantly less peanut allergy (13.7% in the avoidance group and 1.9% in the consumption group). Some of these children even had evidence of allergic antibodies to peanut at the beginning of the study, but no clinical reaction (sensitization). Those children sensitized to peanut, but who regularly ate peanut over the course of the study had a 70% reduction in the prevalence of peanut allergy as compared to those children sensitized to peanut, but who completely avoided peanut. This indicates that we may be able to prevent the development of peanut allergy in children who have no evidence of peanut allergy, as well as in children who have evidence of allergic antibodies to peanut, but no clinical reaction.
This study should still be interpreted with caution for several reasons. Oral food challenges were done prior to introducing peanut and some kids had reactions. Also, it was limited to children with eczema and/or egg allergy. What about children with other food allergies or other risk factors? Do kids have to eat high dose peanut or can lower doses less frequently provide the same benefit? What happens down the road over the next several years? There is another study in the works, LEAP-On, to answer some of these questions. For now, it is important to remember this this study does not promise a cure for peanut allergy, but shows that we may be able to prevent the development of peanut allergy, at least in some patients. Very exciting stuff!
It appears that this may be a “bad” season for influenza. Every year the flu vaccine is made months ahead of the flu season. Experts must try and predict the influenza strains that will circulate in the upcoming flu season based on trends seen in other parts of the world. Although it is still early in the season, samples collected from people infected with the flu this fall show only about 50% of the strains detected were included in this year’s vaccine, indicating the virus has mutated. The director of the CDC, Dr. Thomas Frieden, has said that the most prevent strain this year (H3N2) has in the past been associated with severe infections, particularly for high risk patients. However, it is still important to get the flu shot, if you haven’t already. Even if you are infected with a strain not covered in this year’s flu shot, your symptoms are likely to be less severe if you have gotten the flu shot.
It is also important this year in particular to call your doctor if you think you have the flu, so you can start on anti-viral medications. These medications may help decrease the severity of the infection and reduce the chance of complications related to influenza.
This year Halloween will likely be different for many kids with food allergies. The Teal Pumpkin Project is an awareness project promoted by FARE. It was actually started by a group in East Tennessee, but this is the first year it has gone national! The idea is to place a teal pumpkin that is visible to trick-or-treaters indicating that “allergy-free” items are available. On their website FARE states “The Teal Pumpkin Project is designed to promote safety, inclusion and respect of individuals managing food allergies – and to keep Halloween a fun, positive experience for all.” FARE has a list of candy alternatives on their website. Ideas include glow bracelets, stickers, pencils, erasers and spider rings. The traditional Halloween candy is still available, but there is also a safe alternative for children with food allergies. More information can be found on the FARE website.
Fall in Tennessee means ragweed pollen season is upon us. Next to tree pollen in the springtime, ragweed is the outdoor allergen that causes the most acute misery in our area. Treatment options for ragweed allergy, just like other allergies, include avoidance, medications and immunotherapy — either sublingually (under the tongue) or via injection. Until recently there have been no FDA-approved products for sublingual use. Now, as we have blogged about before, there are a couple of new options that have been approved by the FDA. I’ve written about the grass tablets specifically, so in this post I’ll tackle the ragweed tablet, Ragwitek, and try to lay out the pros and cons as I see them.
When evaluating a new treatment, the two questions you must answer are 1) Is it safe? and 2) Does it work? In the case of the new ragweed tablet, the answers to those questions are 1) Yes. and 2) Yes, but…. First off, all forms of sublingual immunotherapy (SLIT) are generally safer than shots. Though SLIT reactions are rare, they are not unheard of and the package insert for Ragwitek clearly states that it has the potential to cause severe reactions. Because of this, the first dose of Ragwitek must be given in a physician’s office and the patient must be observed for 30 minutes afterward. Though the risk for severe systemic reactions is low, studies reported significant local side effects, including itching of the ears, tongue, mouth and throat, in 5-20% of patients. One study reported tongue swelling in 19% of patients, swelling of the upper airway in 5%, and irritation of the throat in almost 30%. Most of these side effects get better over time, and while the majority of patients were able to complete the studies, a significant minority of patients (25-30%) did not complete the trials for various reasons, including side effects and adverse events.
The effectiveness question is a bit more complicated. Study patients using Ragwitek generally showed around a 25% reduction in symptoms when compared with placebo. That’s a great number, but it is not clear whether the response seen in the study patients is applicable to the average ragweed allergic patient. The problem is, these studies excluded patients who had non-ragweed allergies that required treatment during the ragweed allergy season. Since patients requiring ongoing treatment for cat or dog allergy, allergies to dust mites or molds, or allergies to other weeds were excluded from the study, it is unclear whether such patients would derive any benefit from Ragwitek. Because it is so rare to find a patient who has ragweed as his or her only significant allergen during ragweed season, it is difficult to draw conclusions from these studies that apply to the general allergy population. In selected patients, however, Ragwitek does appear to have benefits in both reducing symptoms and medication usage.
Another hurdle for Ragwitek is the timing of administration. The effectiveness of Ragwitek when started during ragweed season has not been established. Instead, it has to be started 12 weeks prior to ragweed season and continued during the season. In Tennessee that means starting some time in May and continuing daily treatment until the first frost, which is usually in late October or early November. This adds up to around 6 months of daily therapy. So if you’re looking for relief this season, you’re out of luck.
Finally, a word about cost. Ragwitek is an expensive product. Each pill wholesales for $8.25, so for 180 days of therapy the cost comes out to $1,485.00. And that’s just for a single season of allergies related to just ragweed. This, of course, represents the cost to the insurance company, not the patient who will, however, have to bear the top-tier pharmacy co-payment for each monthly prescription. Since allergy shots are covered by insurance without a co-paymant, treat all of a patient’s allergies, and give long-term desensitization, they are a comparative bargain.
In summary, Ragwitek has been shown to be safe enough for home administration and has been shown to be effective at reducing allergies due to ragweed in a very select patient population. It does have frequent, significant side effects and the cost is not inconsequential. Because of the numerous complexities surrounding Ragwitek, I would strongly recommend consulting with a board-certified allergist if you are considering this potential therapy.