Allergies are much more than just a runny nose. We all know they can cause the acute misery of sneezing, itchy eyes and nasal congestion, but they affect people in numerous other ways. One of the most common complications of allergies is an increase in upper respiratory infections. URIs include sinusitis, pharyngitis (sore throat), tonsillitis, and the common cold.
Multiple studies have shown that allergy shots will reduce the direct symptoms of allergies, and now a recent study has helped quantify exactly how much we can expect them to help with the complications. Data presented at this year’s AAAAI meeting show that patients who take allergy shots are overall three times as likely to have fewer URIs than patients who do not. The study used a large medicare database from florida and compared several thousand allergy shot patients with matched controls. The study found that allergy shot patients were
twice as likely to have fewer sinus infections
four times as likely to have fewer episodes of tonsillitis
eight times as likely to have fewer sore throats and
35 times as likely to have improvement in nasal polyps
This confirms what we’ve been saying all along- If you’re having complications from allergies you need to see a board certified allergist so you can get tested, get treated, and get better.
The tree pollen is out, say both the pollen counters and my nose. Time to start back on your allergy medications. Remember- it’s much more effective to prevent allergies than to treat them when they are in full force.
Can a pregnant woman do something to prevent her child from having food allergies? There has been much debate surrounding this question over the years. In the past, allergists recommended pregnant women try to avoid nuts during pregnancy; however, current recommendations are that maternal avoidance diets are unsucessful in preventing the development of an allergy and are therefore not recommended.
A new Harvard study published in JAMA Pediatrics provides some new insight. This study examined the association between maternal comsumption of nuts and the risk of having children with a nut allergy. They found that mothers who were not allergic and who ate nut products more than five times per month were significantly less likely to have a child with a nut allergy. This finding is consistent with new recommendations about introducing highly allergenic foods earlier in life as a way to help prevent the development of food allergies, and it suggests that early exposure to allergens may help promote tolerance to these allergens.
The FDA advisory committee has recommended approval of two new sublingual tablets for the treatment of grass allergy. The FDA is not bound to follow the recommendation of the advisory committee, but it usually does. So, what does this mean for you, dear reader?
First off, the word sublingualmeans “under the tongue”. These new treatments are a form of sublingual immunotherapy, or SLIT. I’ve blogged about the pros and cons of SLIT before and they still hold true today. In short, subcutaneous immunotherapy, aka SCIT, aka allergy shots, is probably more effective, works quicker, lasts longer and is better at preventing new allergies and complications. SLIT is more convenient and safer. Compliance is pretty poor for both.
The big drawback for the new grass SLIT tablets is their lack of flexibility and their narrow focus. One tablet contains only Timothy grass – a representative pasture grass – and the other contains a mixture of pasture grasses. This is great if all you have is pasture grass allergy; but if you have hot-weather grass allergy, like Bermuda and Bahia, or if you’re allergic to any of the other myriad allergens, like trees, weeds, dust mites, cats, dogs, cockroaches or molds, then you’re out of luck. In my practice, I would estimate that less than 1% of my allergic rhinitis patients are sensitive to only pasture grass. Allergy is regional, so this might be different elsewhere.
Perhaps more important than the individual tablet approvals is the fact that the FDA might approve SLIT at all. Up until now, SLIT has been a strictly off-label practice in the U.S. and, because it lacks FDA approval, it has not been covered by insurance. This certainly won’t lead to wholesale SLIT approval across the board, but it does get a foot in the door. For SLIT to be a meaningful treatment for most allergy sufferers it will have to be individualized and the approval process for that will be more complicated.
Doctor: What is it she does now? Look how she rubs her hands.
Gentlewoman: It is an accustom’d action with her, to seem thus washing her hands. I have known her continue in this a quarter of an hour.
Lady Macbeth: Yet here’s a spot.
Doctor: Hark, she speaks. I will set down what comes from her, to satisfy my remembrance the more strongly.
Lady Macbeth: Out, damn’d spot! out, I say!
-Macbeth, Act V, Scene i
Germophobes rejoice! Or revolt! I’m not sure which, but the FDA is now going to require that manufacturers of anti-bacterial soaps prove that their products are safe over time and that they work better than plain soap and water. Your hand sanitizer is still safe, for now. A bit more from Jeff Bezos’ Washington Post.
In the interest of full disclosure on this topic: I’m a dog person. I have a huge Golden Retriever and his boss, a French Bulldog, so I may be a bit biased. Even if I am biased, I hope the researchers at the University of Michigan (Hail!) weren’t. They just published a study showing that exposure to dust from dog owners’ homes led to less asthma in laboratory mice. Interestingly, the primary change they found in the mice was not in their airways but in their guts. The dog-exposed mice had higher levels of Lactobacillus johnsonii in their GI tracts, suggesting a link between gut flora and the development of allergic disease. It’s just mice, but it’s still interesting. Read more here.
This month’s Annals of Internal Medicine, probably the most respected Internal Medicine journal, has three scholarly papers dealing with vitamin supplementation and health. One looks at cognitive decline, one at cardiovascular mortality after a heart attack, and the other at primary prevention of cancer and heart disease. The accompanying editorial doesn’t mince words in its title, “Enough is Enough: Stop Wasting Money on Vitamin and Mineral Supplements“. Suffice to say that none of the trials showed any benefit and they join a long line of similar trial outcomes that failed to show benefit, or even showed possible harm, from vitamin supplementation. Supplements are a 30 billion dollar a year business in the U.S., and it’s time they were held to the same standards as medications. The New York Times has a good summary here.
Part III of the appropriate antibiotic use series will deal with one of the most common diagnoses seen by allergists: sinusitis. Here are some staggering statistics.
Sinusitis remains one of the top reasons for seeing a doctor in the U.S., accounting for almost 14 million physician visits annually.
Overall, 1 in 5 antibiotic prescriptions in the U.S. are written for presumed sinusitis, and most of these are unnecessary.
Despite studies showing that antibiotics don’t help for acute sinusitis, 86% of patients who sought treatment for acute sinusitis received antibiotics.
So what is sinusitis? Sinusitis is usually taken to mean infection of the sinus cavities. It is broadly divided into acute sinusitis and chronic sinusitis. Acute sinusitis is mostly due to the common cold virus (rhinovirus) and can present with low-grade fever, pain, pressure, and discolored secretions. It usually lasts 7-10 days and resolves on its own. Bacterial infections complicate less than 5% of cases of acute sinusitis. Chronic sinusitis can present with similar symptoms, though they are usually less severe, and also may cause significant fatigue, cough and occasionally drainage. Unlike acute sinusitis, it is frequently bacterial.
The biggest problem in managing chronic sinusitis is making a diagnosis. The symptoms are non-specific and don’t correlate well with the gold standard diagnostic test, a sinus CT. Indeed, the exact same symptoms can be infectious, allergic, both or neither. This illustrates the importance of allergy testing and sinus imaging in the management of chronic sinusitis. In general, if you’re having persistent sinus symptoms or have required antibiotics three or more times in a year, it’s time to see an allergist. They can find out precisely what’s wrong with you and come up with a treatment plan to get you better.
Last week President Obama signed into law the “School Access to Emergency Epinephrine Act,” which was passed by the House and Senate at the end of October. This is definitely a step in the right direction in addressing the growing epidemic of food allergies. It has been recognized that about 25% of first-time allergic reactions to foods occur at school, and this law helps increase access to the life-saving drug epinephrine for school students and staff. Through financial incentives states are encouraged to stock epinephrine auto injectors (EpiPen or Auvi-Q) in schools for use by any student or staff member experiencing a life-threatening allergic reaction. The law also encourages training of school staff in recognizing and treating allergic reactions. Currently only four states require stock epinephrine in schools (Maryland, Nebraska, Nevada and Virginia) and many more states (including Tennessee) now allow schools to stock it if they so choose. Hopefully with more federal incentives, access to epinephrine in schools will increase and more states will require epinephrine auto injectors in all schools.
Another recent promising development in the management of food allergies at schools is the publication of the “Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs”, which was recently released by the CDC. These guidelines help schools implement food allergy management strategies or improve existing practices. By working to prevent food reactions in students with known food allergies and by improving emergency treatment should reactions occur, schools can make a safer environment for all students. More details about both of these developments can be found at FARE.
Part II of the when-not-to-use-antibiotics post will deal with another common ailment: Bronchitis. We’ll be dealing with acute bronchitis, not chronic bronchitis due to long-term smoking, which is a different animal altogether.
The term bronchitis is fairly non-specific. It simply means inflammation of the bronchial tubes or airways. This inflammation can occur for several different reasons, most commonly viruses or irritants, but rarely from bacteria. Viruses that cause bronchitis include influenza, parainfluinza, adenovirus and respiratory syncitial virus (RSV). Non-infectious causes of bronchitis include pollutants, chemicals, second-hand cigarette smoke and the like.
The hallmark of bronchitis is a cough, with or without mucus production. Depending on the cause, there may be fever, aches, headache and sore throat as well. The acute symptoms typically last less than two weeks, but the cough may linger for several weeks after. You should call your healthcare provider for high fever, thick or bloody mucus, or trouble breathing, but otherwise seek simple symptomatic treatment. Lots of great ideas are on this CDC web page.
Note that I did not mention antibiotics as a treatment. Since the vast majority of acute bronchitis is viral-or irritant-induced, antibiotics will not improve symptoms or shorten the duration of illness. (Anti-viral treatments for influenza can help if started early). Treating bronchitis with antibiotics simply adds to the cost, exposes people to the potential for adverse reactions, and adds to the growing rates of antibiotic resistance.
The one exception is pertussis, aka whooping cough. It is bacterial and responds to certain antibiotics. It also has an excellent vaccine that you and your children should all be up-to-date on. It had virtually disappeared from the U.S., but recent drops in vaccination rates and changes in vaccine composition have led to its reemergence. It causes a very characteristic, severe cough that can last for months, hence its old name, the 100-day cough.
So what can you do to prevent bronchitis? Avoid smoking and second-hand smoke for you and your kids, practice good hand hygiene, and stay current on your vaccinations, including pertussis and the yearly influenza vaccination.
I’ve borrowed liberally from the CDC website in writing this post. They have a ton of great information for the interested reader. I highly recommend it.
No parents want their child to suffer. When your child is sick, especially with a fever, he or she can feel miserable, which in turn makes you feel miserable, too! Fever-reducing medications, such as acetaminophen (Tylenol) and ibuprophen (Motrin) have long been known to improve symptoms associated with infections. Pediatricians recommend, however, that these medications only be used if the fever is affecting the child’s behavior (except in youg infants) or if it is extremely high. The fever itself is not harmful and is in fact a way the immune system fights the infection.
A study recently published in the Annals of Allergy, Asthma and Immunology by Kang et al., examined the association between acetaminophen exposure in the first year of life and the risk of developing asthma. The researchers found that those preschool children (3-7 years old) who used acetaminophen for more than three days during the first year of life, especially if they have a family history of asthma, were significantly more likely to have asthma. Similar results have been seen in other studies, but this study controlled for lung infections associated with an increased risk of asthma. At this point, these are only associations, and the results cannot clarify cause and effect. Also, it is unknown whether or not this risk remained as the children got older. More studies are needed to help clarify this risk, but the results are quite intriguing and would certainly lead me to recommend that those families with a history of asthma should limit the use of acetaminophen during the first year of life.