September 4, 2014
by johnoverholt

Ragweed Allergy and the New Ragweed Tablet

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.

Dr. O

August 27, 2014
by Megan Stauffer

Back to School with Food Allergies

It’s that time of year again, when we pack our children’s backpacks and start a new school year. For parents of children with food allergies it can be a particularly stressful time, as they worry about their children having a reaction while at school. Food allergies have become more common in the past 20 years. Most of us grew up not knowing anyone with a food allergy. That’s not true these days. It seems most classrooms have at least one food allergic child.

What can parents do to prepare for the upcoming school year? It is very important to meet with the school nurse and the child’s teacher to review his or her food allergy. You should find out what protocols are already  in place at the school to prevent and to treat accidental exposures. Fortunately, most schools already have protocols in place. You should also have a Food Allergy Action Plan on file at the school that tells the staff about the child’s food allergy, what symptoms he or she might develop, what treatment to give, and contact information on whom to call after treatment has been initiated.

Be aware of field trips or other times your child might be exposed to an allergen, such as a class party or class project. Discuss with the teacher how these activities will be handled.

It’s also important to teach your child how to talk about symptoms he or she might experience during an allergic reaction and what to do if he/she has a reaction. Help your child get in the habit of asking if the food allergen is in the food before taking any food from an adult or other child.

More information on sending your food allergic child to school can be found on the FARE website under “Tools and Resources” for parents.

Have a safe year!

-Dr. Megan

June 20, 2014
by johnoverholt

Local Honey for Allergies: Sweet Relief or Just Sweet?

Local honey is very tasty. I love it on a bagel with peanut butter or in a good marinade. But should it be on your menu of allergy treatments, too?

The notion that local honey can be utilized to treat allergies is not new. In fact, it has been a common topic of conversation with my patients since my days as an allergy fellow. The idea is that a small amount of pollen carried by bees makes its way into the honey and that regular ingestion of the pollen leads to desensitization. It’s a tempting notion, to think that you could treat your allergies with a natural, sweet treat, but the reality is slightly bitter.

First, the pollens that bees carry are not significant allergens. To make honey, bees collect nectar from flowering plants and in the process become coated with the pollen from these plants. As they buzz from plant to plant, they spread the pollen, which allows the flowering plants to reproduce. Since these pollens are carried largely by bees and not the wind, the pollens rarely come into contact with the human nose and eyes and, hence, do not cause allergy symptoms. Conversely, plants whose pollens cause allergies are wind-pollenated and are not major sources for nectar and bee pollen.

Second, oral immunotherapy doesn’t work for nasal allergies. Numerous clinical trials have looked at oral immunotherapy (swallowed allergens) as a possible treatment for this problem. These trials used large doses of purified allergens, far more than would ever be found in bee pollen, and still failed to show a benefit. (Note: this is different from sublingual immunotherapy where the allergen is held under the tongue). So, even if  allergy-causing pollens are found in honey, the act of swallowing them is unlikely to improve allergies.

What if there’s something about honey itself that is beneficial for allergies? This final question was answered over a decade ago by researchers in Connecticut who did a blind, randomized trial comparing the effects of local, unfiltered, unpasteurized honey, commercial honey, and honey-flavored corn syrup on seasonal allergies. They found no benefit for either honey group compared to the corn syrup group. In other words, honey is literally and figuratively, a simple sugar pill.

Dr. O

June 2, 2014
by Megan Stauffer

Allergy tablets

You may have heard that there are some new allergy treatments available. The FDA just recently approved 2 different grass tablets (Grastek and Oralair) and a tablet for ragweed allergy (Ragwitek). There are differences between these tablets, including allergens contained in each, age restrictions and dosing schedule. However, all three of them provide a sublingual (“under the tongue”) form of immunotherapy. Certainly, these products are not right for everyone, but for the right patient there is a new treatment that may be worth discussing with your allergy provider.

-Dr. Megan


April 16, 2014
by Megan Stauffer

Stress and Allergies

We all know stress isn’t good for our health. It increases the risk of developing high blood pressure and diabetes and contributes to increased levels of anxiety and depression.

Now a study in the Annals of Allergy, Asthma and Immunology shows that people who are experiencing stress are more likely to have a flare of their allergies. Many of the patients in the study reported an allergic flare within days of the increased stress. Additionally, allergy suffers with more chronic stress experienced allergy flares more often.

The authors recommend ways to alleviate stress, such as meditating, making time for relaxing and adopting a healthy lifestyle. Certainly decreasing stress is good for your overall health, but be sure to see a board-certified allergist to get a comprehensive plan for managing your allergies.

-Dr. Megan


April 10, 2014
by johnoverholt

The Science of a Sneeze

I love science:  chemistry, physics, engineering, math. It’s a big reason I became a doctor. So when scientists at Massachusetts Institute of Technology published a paper in the Journal of Fluid Mechanics on sneezing, I got pretty excited. How nerdy is that? Anyway, regardless of your level of nerd-cred, the article had some important and interesting new findings — and it has a high-speed video of a sneeze.

What you’re seeing there is not just a simple sneeze, it’s a multiphase turbulent buoyant cloud. That means that when you sneeze, the gasses you emit mix with the surrounding air (“multiphase”) in a violent, roiling fashion (“turbulent”) that results in a floating (“buoyant”) cloud. We used to think that the distance a germ could travel in a sneeze was limited to the distance the large droplet particles could travel, essentially the spray that you can see and feel from a sneeze. We also thought that larger particles traveled the farthest due to their greater momentum. The new gas cloud model turns that understanding on its ear. It tells us that the smaller particles travel the farthest because the cloud keeps them suspended in the air while the larger particles fall out. In fact, these small particles can travel five to 200 times farther than we previously thought! Some very small particles even had the potential to reach air ventilation intakes that could then circulate them elsewhere in an indoor environment.

In practical terms, this might change the way ventilation systems are designed, especially for higher risk locales like hospitals, schools and airplanes. Better air systems with less germ transmission could result in real gains in public health:  fewer cases of hospital-acquired pneumonia, fewer influenza outbreaks in schools, and less anxiety about the guy three rows behind you on the plane coughing his head off. For now, though, the CDC still recommends that we sneeze into our elbow and wash our hands after sneezing — very good recommendations.

If you want to dig a little deeper and read about it from the people who really know what they are talking about, try this press release from MIT. If you read it, let me know what you think, and I’ll put your official nerd certificate in the mail.

Dr. O

April 8, 2014
by johnoverholt

A New Treatment For Hives

Chronic hives make people miserable. They affect all facets of life — work, sleep, relationships, mood — and they can be relentless. Most folks who suffer from persistent hives can get adequate relief with simple, long-acting antihistamines like cetirizine (Zyrtec) or fexofenadine (Allegra) if taken in adequate doses (sometimes two to three times the usual daily dose). If these don’t work, then super-potent antihistamines like hydroxyzine or doxepin are the next step, but both are very sedating.

Sometimes even these very strong medications don’t work or the side effects are just intolerable. In the past, severe patients had very limited treatment options, usually potent immune suppressants like cyclosporine; but now there’s a new option in the form of a not-so-new medication:  omalizumab (Xolair).

I’ve blogged about omalizumab a couple of times, and I gave a rundown of how it works way back in 2009. In simplest terms, it disarms the body’s allergy cells, making it nearly impossible for them to mount an allergic reaction. Because these cells are responsible in large part for causing hives, it makes sense that omalizumab would work in such cases, and now there are good studies to show that it is, indeed, effective when antihistamines fail.

So how effective is it? I would say moderately effective. Studies show that only about a third of folks who took omalizumab injections once a month got total relief and about two-thirds had a good response. It took up to two weeks to see improvement, and once they stopped taking omalizumab, the hives came back. On the good side, omalizumab is very well tolerated.

The important message here is this:  you needn’t be miserable from chronic hives. Numerous good treatment options exist. To find which is most appropriate for you, go see your local board-certified allergist and get better.

March 13, 2014
by johnoverholt

Allergies are Universal in the U.S.

No matter where you go, there you are. – Buckaroo Banzai

Spring allergy season is upon us, and in Middle Tennessee it’s the time of year with the most acute allergy misery. All the sneezy, itchy, runny noses drive many patients to the allergist where they often wonder aloud, “I never had problems like this until I moved here. Would it simply be better for me to move somewhere else?” One recent study suggests the answer to that question is “No.”

No one is born with allergies. Whether people develop them, like most medical problems, depends on the combination of genetics and environment, nature and nurture. Certain people are born with a tendency – the genetic component – to develop allergies.  At some point they become exposed to allergens like tree pollen, cat dander or peanuts – the environmental component. If a person’s genetic tendency is strong and the exposure has the right amount, timing and route of administration, then a clinical allergy may develop.

The genetic side of this formula is set in stone. You can’t pick your parents. The exposure side, however, is variable. Tennessee has more tree pollen than Phoenix. Humid areas (Mississippi) have more dust mites than arid climates (Colorado). Urban areas (Baltimore) have more cockroaches and cat dander than rural areas (Beaver Dam, KY).  So you would think that the prevalence of allergies would be higher in areas with a greater environmental allergy loads. But, you’d be wrong.

A recent study looked at the prevalence of positive allergy tests in all areas of the U.S. and found that the numbers were pretty much the same wherever you live. A whopping 44.6%(!) of U.S. adults are sensitive to at least one allergen. In kids ages 1-5, that number is 36%. Interestingly, the rates didn’t vary from region to region, though they were a little higher in urban areas, 50%, vs. rural areas, 40%. Rates of sensitization to individual allergens did differ. For example, the South had more dust mite allergy and the West had more pollen allergy, but the overall rates remained constant.

So what does this all mean? It suggests that the genetic component of allergies is much more important than the environment. If your body has an allergic tendency, it’s going to find an allergen to react to no matter where you live or what you try to avoid. You can avoid specific allergens, but you can’t avoid all of them, and you can’t run from your genetics.

This is where the allergist comes in. We actually have the tools to make you less allergic to your specific allergens. We can teach your immune system to ignore your triggers, which will shut off your allergies at the source and give you systemic relief, fewer symptoms and fewer complications while using fewer or no medications. So before you pack up for Denver, try giving you local, board-certified allergist a visit first.

Dr. O

March 5, 2014
by johnoverholt

Allergy Shots Reduce Sinus Infections, Sore Throats

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.

These findings confirm 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.


Dr. O