Is the Pollen Count Helpful in Medical Practice? Yes and No.

Millions of grains of pollen, in this case from a cottonwood tree, can easily fill the air and travel great distances when picked up by the wind.

Now that the weather has turned warmer and more pleasant, TV news anchors and meteorologists need something other than the weekly snow fall and deep freeze to grab your attention. Enter the pollen count. During the spring months, when trees and grasses release their pollen, official pollen counts get a lot of attention. This isn’t news to you. What you may not know is that in most areas of the country, the publicized pollen counts may be at least partially inaccurate.

In fact, the graphs and numbers reported on television, radio and the internet might actually be yesterday’s news. That’s because, in many cases, the pollen stations report collections from the previous 24-72 hours. You might then ask yourself “why would I read yesterday’s news?” The answer is two-fold. (1) As with weather forecasts, history is used to forecast changes in pollen concentration.(2) Yesterday’s pollen may be at the root of today’s sick visits. That said, you should always remember that a forecast is nothing more than an educated guess. That guess is not only as variable as the weather forecast, but it is highly affected by frequent and unexpected fluctuations in weather.

Pollen.com allows you to type in your zip code and retrieve just such a forecast. Whether or not the forecast is completely accurate, the site does do a nice job of revealing individual pollens that are prevalent in your area. It also provides excellent graphics that reveal pollen sources. Both are valuable features. Reviewing the individual tree pollens is particularly interesting, as the data indicates that while many trees cause allergic symptoms, not all achieve high pollen counts.

For even more specific — and potentially more accurate — data, find out if hospitals in your community have a certified pollen and mold counting station. In my area — New York/New Jersey — we have an excellent one, www.nynjpollen.com, which reports daily on weekdays. Like pollen.com, they provide ranges of pollen units classified as low, medium or high to make it easy for patients to understand the basic pollen outlook for the day.

So what is the best way for you to use the pollen count in your office? It is a good idea to print pollen counts from reliable sources and post them in your office each day where they are easily viewed by both patients and staff. This “in-your-face” technique can often help everyone connect the dots. Once the patients understand the connection between their symptoms and the pollen counts, they are less likely to come to you with the complaint of “sinus infection” in search of an antibiotic, and more likely to come with the expectation of a diagnosis and treatment plan for their allergic disease.

I’m sure you have some of those super-sensitive allergic patients whose nose and eyes seem like radar detectors for increased pollen levels. The moment the levels rise, these patients are at your doorstep with their rhinorrhea, conjunctivitis, sinusitis and tight chests. In my practice, these canary-in-the-coal-mine patients serve as my own reminder to begin collecting information from my local pollen count stations to see if they match up with each patients’ specific allergy test results. If a patient’s tests results indicate allergy to Birch, Oak, Maple and Elm trees, for example, and the pollen count is high for one or more of these trees, then I know targeting her treatment will be relatively easy. However, it is important to figure in the potential combination of that tree allergy with grass allergy, along with the other allergenic elements affecting the patient. The person who has been suffering with tree pollen allergy in April and then gets hit with the double whammy of grass pollen on top of that in May is one you know you will see repeatedly with multiple allergy-related issues…. until you get her or him on immunotherapy.

Pollen is not just pollen — it’s important to identify the real culprit. Targeted allergen immunotherapy, with either shots or drops, can prevent future seasons of suffering. The AllerVision program is designed to help you test for all of the relevant pollens in your area of the country and then to order a treatment set that provides relief and protection.

Again, an accurate pollen report posted daily in clear view can serve as a valuable resource in your practice. For most patients, it’s an education tool. But some patients tend to go into a panic immediately upon report of high pollen counts. I hear them cry, “I’m moving to another state to get away from this pollen.” Unfortunately, as we have all learned, there is almost nowhere left to run. Even Arizona, once a haven for allergy sufferers, has become a massive pollen breeding ground. Sufferers migrating from the southern and eastern states brought their allergenic plants with them and turned wide open spaces into golf courses. Therefore, a more sound recommendation for these patients is to plant only female trees around their home because they do not produce pollen. Of course, allergy sufferers have no control over the neighbors’ yards. The best advice: give serious thought to allergy immunotherapy for a lifetime of protection.

– Dr. Dean Mitchell

When Allergy Season Peaks, Do You Have a Plan? My Tips for Your Worst Patients

With pollen counts skyrocketing, this could be the worst allergy season in years. Be prepared to help your patients.

It’s happening already: TV stations, newspapers and radio are hyping the severe spring pollen season ahead. As we know, long winters with lots of snow are springboards for high pollen counts. Every year when spring arrives my office phone starts ringing and patients can’t wait one day to be seen. My new patients, that is. I’ll explain the difference below. These new patients’ developing allergy “emergency” can be handled effectively with proper management, but more importantly, the crisis can turn into an opportunity to make sure these patients can enjoy spring without interruption next year. Here’s what I’ve learned about allergy peaks over the past 20 years…

They bring a lot of allergic inflammation! Patients come in with their eyes and noses red and swollen. They’ll tell you they feel miserable – like they have a terrible cold. They’ll also tell you they’re tired but can’t sleep at night. Many will complain that their head feels so heavy and their sinuses so painful. These are the ones with the self-diagnosis of “sinusitis.” And they’re right —their sinus passages ARE definitely inflamed. While we know from our training that the inflammatory process is often the result of allergic response, many patients equate sinusitis with infection. And all of them want solutions. So what should you do?

You reach for your prescription pad to put out the fire. But before you do that, it’s critically important that you make a definitive diagnosis. Allergy skin testing is the gold standard for diagnosing IgE mediated allergic disease. When skin test is contraindicated, IgE blood test is an acceptable alternative. Once you know what you’re dealing with, you can begin the management process. Of course, a positive skin or blood test doesn’t rule out infection but if you know there’s an underlying allergic process, you can’t go wrong by attacking it from that angle. Only a sinus tap confirms infection but if you clear up the inflammation, you can bet that this will rarely be necessary.

The medicine that works best in acute inflammatory situations isn’t the antibiotic that the patient often desires. And once your patient sees and feels the results of an allergy test, he/she will understand this concept. Many of us go straight to oral cortisone because it’s effective! However, there’s an art to prescribing oral cortisone so that it works while minimizing side effects and patient concerns. I’ve found Prednisone at a low dose is the key to quick relief. The dosage is weight-dependent but, as a general rule, 20mg is an effective therapeutic dose for adults and children over 60 lbs. You could increase that for patients over 170 kg, but higher doses usually aren’t necessary. Prednisone, like all oral cortisone, should be taken in the morning to synchronize with the patient’s circadian rhythm. It should always be taken with some food to minimize gastrointestinal upset.

One week of Prednisone is usually enough to quell the acute allergic inflammation caused by the eosinophils in the tissue. This gets the ball rolling to reverse patients’ most severe symptoms but you should complement it with topical sustainable medications as well. For nasal congestion, sneezing and rhinorrhea, there is nothing better than topical cortisone nasal spray. Nasacort is the first one of these sprays available over-the-counter. Your patient can use the 24 hour preparation once each morning.

What the patient may not capture from their over-the-counter purchase is the understanding that correct administration technique is vital for effectiveness and safety. It is important that you and your staff demonstrate and educate on the cross-hand technique; show patients how to spray one pump at a time into the lateral aspect of the nostril using the opposite hand.Using opposite hand makes it easier to avoid accidentally spraying medially towards the septum, which diminishes effectiveness, potentially inspires a bloody nose, and ultimately puts the patient at risk for long term septal damage. Nasal steroids are proven superior to antihistamines in terms of both symptom relief and side-effect profile in head-to-head comparison studies.

Many patients don’t like nasal sprays or worry that they’ll “get hooked” on them. My answer: They work. And, no, you don’t get addicted to cortisone nasal sprays as you might after weeks of consecutive use of decongestant sprays like Afrin. That said, decongestant sprays can be incredibly useful for short term treatment of acute inflammation and can sometimes forestall the need for Prednisone.

Eye symptoms such as redness, itching and tearing can be very debilitating. The best short term treatment for acute allergic conjunctivitis is topical antihistamines. I have several favorites in this area, but you need to check with your patient’s insurance coverage. I’ve had patients call up in a panic that the antihistamine eye drop I prescribed cost over $100 for a tiny bottle. I call them “liquid gold” because they’re very effective but the cost is sometimes precious-metal caliber. A nice trick for enhancing relief is storing the eye drops in the refrigerator to ease the burning sensation. Most eye drops should be administered twice each day. Instruct your patients not to use the typical red-out over the counter eye drops. They contain decongestants which may indeed get the red out but also prove quite addicting. Finally, even while using the Prednisone and topical treatments, I recommend my patients take an antihistamine at night. I prefer Allegra(fenofexidine) or Zyrtec (cetirizine) equivalents because they last for 24 hours and are generally more effective and often less sedating than Benedryl (diphenhydramine).

Now that we’ve successfully weathered the initial storm, it’s time for education. This reminds me of an age old saying: “Never waste a good crisis.” In medicine, I take this to mean that when the patient is really suffering, you have an opportunity to explain that they can avoid this same scenario next year with proper diagnosis and treatment! Sometimes it’s necessary to wait for the crisis to pass before definitively diagnosing. This happens when a patient is too symptomatic and miserable to undergo the test. Either way, once we obtain positive results, I explain that allergen immunotherapy — shots or drops — is the only way to minimize or eliminate their regular allergy crises.

No other tools in our bag can actually change the course of the disease. Keep in mind that symptom treatment must continue and even increase in the early weeks of immunotherapy ramp-up, but at the first quarterly visit you’ll discuss tapering meds -for good! For most patients, the choice is simple: a lifetime of meds with side effects and potential interactions vs four years of using elements from the environment to teach the immune system not to overreact to nature. Imagine if we had such a solution for diabetes or hypertension!

In the end, patients relate well to successful results. It brings a smile to my face when I tell the acute patient: “my waiting room used to be filled with sniffles and watery eyes just like yours. Now I have a waiting room mostly full of patients feeling great and just stopping by to pick up their allergy drops.”

– Dr. Dean Mitchell