Which Allergy Treatment is Best for You?

There are a lot of options for treating your allergies but only immunotherapy can keep your symptoms from returning.

There are a lot of options for treating your allergies but only immunotherapy can keep your symptoms from returning.

Fall is hay fever season so there is a good chance you are experiencing some allergy symptoms. After all, over a quarter of Americans suffer from significant allergies. And for many, the symptoms begin in adulthood. So the question is, what should you do about them? To a large degree, that depends on their severity and your tolerance for discomfort.

Officially, the first course of action is avoidance, which means keeping away from your allergy triggers. In theory that makes sense but it’s often undesirable and all but impossible. For instance, say you’re allergic to the family pet. Are you going to get rid of it even though everyone in the family — including you — loves it? Now consider tree, weed and grass pollen. Even if you move far away from the source of the pollen that’s bothering you, a good stiff breeze will send it flying right to you — tree pollens travel hundreds of miles. 

When symptoms start, a majority of people turn to the next courses of action: over-the-counter medications and natural remedies, including nasal irrigation products. Sometimes these measures work very well at relieving symptoms short term. The key here is “short term.” What these products do is overcome your current reaction to allergens. That’s great if you get occasional and/or mild symptoms. There are two “howevers,” though.

The first is the side effect “price tag.” Medications often cause side effects, like drowsiness, that can significant reduce your productivity. And they may not work right away, if at all; doctors now recommend you start taking medications weeks before your symptoms normally start for maximum effectiveness. Even if you do that, the only potential benefit is symptom relief. So you are supposed to take meds in anticipation of symptoms you don’t have yet just to get temporary relief from this year’s onslaught.

The second “however” is even bigger. Let’s say, best case scenario, the medication or natural remedy overcomes your symptoms today. Excellent. But tomorrow when you encounter your allergy trigger — be it pollen, pet dander, mold, etc. — the symptoms start up all over again. You’ll be taking the medication, or using the remedy, for the rest of your life. That’s a lifelong commitment to meds.

There is another option: immunotherapy. This natural treatment exposes your immune system to small amounts of the pollen — or other allergens that your body thinks are enemies — until your immune system learns to accept those allergens as normal. When the body stops trying to fight them off, your allergy symptoms decline and often disappear. In other words, immunotherapy actually makes you better. Every day on immunotherapy is a step towards an allergy-free life.

Immunotherapy doesn’t work overnight. It typically takes a few weeks to two months for treatment to start working. For best long term results, you should continue treatment for three to five years. There are three types of immunotherapy: allergy drops, allergy shots and tablets.

Allergy drops have been popular throughout the world for over 60 years. In the comfort of your home, you simply place a few drops of serum (which is composed of the allergens that trigger your symptoms) under your tongue every day. The drops are convenient, easy, safe, nearly side-effect-free and suitable for allergy sufferers of all ages. The best drops formulations are ones that are designed specifically for you. You start with a low dose and ramp up to a higher dose when your body is ready.

Allergy Shots have been used successfully in the U.S. for decades. Healthcare providers administer the shots to you in their offices on a regular basis, often weekly or bi-weekly. Health insurance policies usually cover many of the out-of-pocket costs associated with allergy shots. Both shots and drops can be formulated to address multiple allergies at once. So, for instance, if you’re allergic to cat dander and tree pollen, you can be treated for both at the same time. Like drops, shots start at a low dose and ramp up.

Tablets are a new form of immunotherapy. Each one is made to combat a single allergen. Unfortunately, most people are allergic to more than one thing. But the companies that makes these tablets have targeted the most severe allergens, like ragweed and grass pollen. Tablets start at full dose, so you get a large amount of allergen under your tongue from day one, ready or not.

So which sounds right for you? If you’re symptoms are mild and very sporadic, and over the counter medications do a good job of hiding them for you without too many side effects, you may choose to go that route. But if they’re more severe, you’re tired of the recurring battle with symptoms, you have side effects with the drugs, or you just don’t want to take medication for the rest of your life, immunotherapy might be your best bet. Either way, you should ask your doctor for an allergy evaluation. You should always be armed with information and a definite diagnosis of allergies before taking even the stuff you can buy over the counter.  Once you have answers about the cause, you and your doctor can discuss the right treatment.

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Allergy Perils Await Your Child This Fall – What to Watch Out For and What to Do

Back-to-school season can bring stress and allergies.

Back-to-school season can expose your child to a wide variety of allergens.

It’s almost September — time for school, football, cross-country, marching band and soccer. There are lots of allergy traps for your child out there. Read on to find out what to look for — and what to do about it.

At school, three immediate threats come to mind. Number one is dust. Most classrooms sit empty over the summer, giving dust plenty of time to settle on tables, books, window frames, etc. Dust mites find a way of hiding inside of window coverings and light fixtures and lurking deep in hidden corners. When teachers return to those rooms to prepare for a new crop of students, dust may be among the last things they consider — if they have time to think about it at all. Once activity returns to the classroom, that dust gets stirred up and fills the air, wreaking havoc for allergy sufferers.

The second potential problem is food allergies. Depending on the severity of your child’s allergies, simply sitting next to someone eating a peanut butter sandwich could be cause for serious alarm. And peanuts aren’t the only risky allergen out there; for some food-allergic kids, a trip to the cafeteria could be like walking through a mine field. While it may be simple to avoid a specific allergen that appears on a plate in its whole form, that same trigger could be an unsuspected ingredient in another dish. Or a trace amount in the kitchen from a previous day’s meal could wind up in the food by accident. The safest course to avoid problems for allergic children is to pack their lunch at home with known ingredients.

And last but certainly not least, there’s good old pollen. It can affect your child at school both on and off the sports field. Grass and weeds are the serious troublemakers in late summer and fall. Football players, runners, marching band members, and soccer players will spend a lot of time rolling around on — and kicking up — grass and weeds. Their parents, you, will likely find yourself at parks and fields for hours where mown grass will take to the air with the slightest breeze. Even the kids who plays sports themselves are surrounded by the allergens floating in the air and drifting off their classmates’ clothing. Aside from the sniffling and wheezing that affects athletic and musical performance, allergy symptoms have a significant effect on attention and concentration in school, and, consequently, on grades. Unfortunately, while antihistamine use may curb the symptoms, side effects from the meds also tend to negatively impact performance.

So what to do about it all? The first step is to take showers and/or change clothes after spending a lot of time outdoors. For the here and now, it may be necessary to take allergy medications to get a handle on immediate symptoms. But equally important, prepare for the next phase of allergen invasion (for instance, winter mold and spring trees) and get way ahead of the curve for next fall by teaching your children’s bodies to stop overreacting to environmental allergens. Immunotherapy is the only fix, and it is all natural with no medication. It trains your child’s body to ignore the allergens that trigger their symptoms so the allergies go into remission for many, many back-to-school seasons.

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Allergy Testing, Immunotherapy Boost Medical Practice and its Patients

Allergy immunotherapy has helped the patients and the practice of Dr. Stephen Sisselman, of Sisselman Medical Group in New York.

Allergy immunotherapy has helped the patients and the practice of Dr. Stephen Sisselman, of Sisselman Medical Group in New York.

This post, from guest blogger Dr. Stephen Sisselman, looks at allergy testing and treatment from the general practitioner’s point of view

Sara V is a patient I’ve known for a long time. She comes in every few months with assorted respiratory complaints including runny nose, cough, congestion and excessive mucus production. I typically tell her she has rhinitis and that antibiotics are ineffective. Nevertheless, she usually requests an antibiotic. Recently, we began offering allergy testing at my office so I told Sara that I wanted to test her to see if allergies might be the cause for her respiratory complaints.

I started allergy testing as a way to offer more services to my patients and enhance the ancillary testing in my practice. It takes just five minutes to prep a patient and about five more to complete the test. In another 15 minutes the test results are ready to read. About half the patients we test each week show significant allergies to trees, weeds, molds, grasses or other environmental allergens. Patients love the idea of in-office testing where they get immediate results and don’t have to schlep to an allergist.

Getting back to Sara V… I thought that maybe seasonal allergies play a role in her frequent respiratory complaints. I performed an allergy test and we were both surprised by her results; she was positive for trees, weeds, grasses and indoor perennials such as dust mites. After a discussion of appropriate therapy, she decided that allergy shots — subcutaneous immunotherapy (SCIT) —were the best choice for her. Now, three months into the program, she already has fewer symptoms and respiratory complaints. And Sara is just one of many of my patients now experiencing a greater quality of life.

Sara chose allergy shots but those aren’t the only treatment option. I help patients with positive test results choose the treatment that’s right for them. Some prefer oral antihistamines and steroid nasal sprays. Others, like Sara, choose immunotherapy because it doesn’t just cover up symptoms, it trains the body to ignore the allergens that trigger the symptoms.

I administer allergy shots in my office. Based on insurance coverage, patients may have just a small copay, or none at all. Some patients prefer the freedom of treating themselves with immunotherapy at home. For them, we offer sublingual immunotherapy (SLIT), also known as allergy drops. SLIT drops from AllerVision are customized to the patient based on the results of their allergy test. The patients simply place three drops under their tongue and hold them there for three minutes each day. Drops usually cost about $70/month. They’re not covered by insurance but for those who choose them, the convenience easily outweighs the cost. Both shots and drops start working within a few weeks to a few months and treatment is complete in four years.

The allergy program has been a great addition to my practice. I enjoy the increased reimbursements for allergy testing and shots administration while my patients love the convenience of getting needed testing and treatment in my office. My staff also loves the program because it’s easy and we can better diagnose and treat patients with frequent or chronic upper respiratory complaints. It’s a win-win for everybody.

Stephen G. Sisselman, D.O., F.A.C.P.

Dr. Stephen Sisselman is Board Certified in Internal Medicine. His practice, Sisselman Medical Group, in Massapequa NY and Commack, NY cares for patients ages 12 and up.

Acute vs. Chronic Urticaria: What You Need to Know

Urticaria can be both painful and unsightly.

Urticaria can be both painful and unsightly.

Urticaria can be a debilitating condition. Patients suffer with a sometimes diffuse rash along with pruritus that can drive a person crazy. Dermatology offices are often the first referral destination for urticarial patients, but the complex issues surrounding these patients extend beneath the skin. The latest research brings insight to the underlying cause of urticarial lesions.

Getting to the bottom of acute urticaria usually involves basic medical detective work. A good history will usually lead you to the diagnosis. The most common culprits are foods (especially in children), medications and even infections. The patient usually identifies the source with a recounting of occurrences over the several hours or even days prior to the onset of the hives.

Among medications, common triggers include antibiotics like Penicillins, Cephalosporins and Sulfa-based drugs as well as over-the-counter NSAIDS or antipyretics like Advil, Alleve and aspirin. With that in mind, I check carefully in the patient’s history for meds first. Patients sometimes don’t realize that a simple antibiotic or OTC medication can cause a reaction so it’s important to ask specific questions. An infection can trigger an urticarial outbreak in highly allergic patients since they have an excess of histamine and infection facilitates the release of that histamine from skin mast cells. The treatment for acute urticaria is often simple: antihistamines for a week and avoidance of the allergic trigger.

Chronic urticaria is another story. These patients have hives that never seem to go away no matter which combination of antihistamines you throw at them. For many years, doctors tended to blame stress and psychological problems for the condition but the latest research points to an autoimmune disorder as the culprit. The mechanism of disease appears to be based in the production of autoantibody to the patient’s own IgE molecules. Just this year, the FDA approved the use of Xolair — the monoclonal antibody injection that was previously approved only for allergic asthma — for chronic urticaria. The new indication for Xolair is an exciting breakthrough for chronic urticaria as long-time sufferers may be symptom-free with just a few injections… and the results last for months!

In summary, urticaria has been a vexing condition that requires some patience on the part of both the sufferer and the physician. With good diagnostic evaluation along with advances in treatment options, the future may be looking much brighter.

Dr. Dean Mitchell

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Drug Allergy: The Most Dangerous Reactions You Can’t Miss! Part 2

800px-Pills_MC_inverseIn Part 1 of this series I discussed the immediate hypersensitivity reactions that occur from a few minutes to a couple of hours after a patient takes a medication. Today, I am covering drug reactions that can occur up to two weeks after a medication is given. These reactions are tricky and dangerous for the clinician. A patient you may have seen for a sore throat and a cough two weeks ago now calls you up and tells you he has sores in his mouth and his eyes are red. What should you do? If it’s a Friday afternoon, don’t tell him you will  see him first thing Monday morning — it might be too late!

The drug reaction I’m describing is well known as the Stevens-Johnson Syndrome. Stevens and Johnson described this reaction back in 1922 in two children who developed extensive skin necrosis, fever, conjunctivitis and stomatitis. The syndrome that bears their name is a potentially life-threatening disease with a sudden onset of erythema and bulbous lesions on the skin; there is epidermal detachment involving less than 10% of the skin, which is accompanied by involvement of two mucosal areas. This syndrome is usually mentioned in the same breath as Toxic Epidermal Necrolysis, which has the same presentation, except here there is 10-30% skin involvement. I have seen just two cases of this in my career — when I was a resident in Internal Medicine. It was very frightening; the patients looked like burn victims. I was also horrified to hear that the son of a medical colleague developed this after a course of antibiotics and has been struggling to recover since.

Most cases of Stevens-Johnson syndrome are linked to specific medications: anticonvulsants such as phenytoin, antibiotics such as sulfonamides and tetracyclines, and widely used non-steroidal anti-inflammatory drugs. Why are some individuals more prone to this syndrome? The answer is probably genetic predisposition — individuals with the HLA types B*1502, B*5701, B*5801, Bw44 and DQB1*0601. Of course, as clinicians we will never know in advance that a patient has these HLA types. However, I would be very cautious in a patient that has told you they seem to get reactions to many different medications. These are not hypochondriacs, there is sufficient medical literature to document individuals with multiple drug reactions. It is only recently that we’ve begun understanding the connection to a person’s genetic-immune make-up.

So, if you get the call or see a patient in the office who is developing a severe desquamating rash along with red eyes and sores in their mouth send them immediately to the hospital. In fact, it’s important that it be a tertiary care hospital that can place this patient in an ICU isolation room. An infection on top of this reaction can be lethal for the patient that is now immune compromised—similar to a burn victim.

I would also suggest that the patient see a good dermatologist and an immunologist who is familiar with drug reactions. The recent medical literature supports using IV gamma globulin to ameliorate the intensity of the disease, and it also helps boost the patient’s immune system.

Today, in our busy practices, most doctors prescribe lots of medications and see just the occasional adverse reactions. It’s important to have your antenna on high alert if you hear a story like the one we just described.

– Dr. Dean Mitchell

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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.

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

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Wheezing and Sneezing are Not Always Signs of Allergy

The obvious underlying cause of sneezing may not necessarily be the right one.

The obvious underlying cause of sneezing may not necessarily be the right one.

In medicine it’s all too easy to assume that a certain symptom is representative of a specific diagnosis. Since allergic symptoms are so common, this is a pitfall we need to be wary of. There’s an old adage, “All that wheezes isn’t asthma.” I’ll add to that “all that sneezes isn’t allergic rhinitis.” Often the only way to establish a definitive diagnosis is through diagnostic testing.

A patient’s history is, of course, the foundation of a correct diagnosis for any medical condition. However diagnostic testing, when available, is invaluable in either supporting a presumptive diagnosis or showing us where we’ve been misled. It’s generally believed that 80% of asthma is extrinsic (allergic) in nature, so one cannot fault a clinician for assuming asthma is due to inflammatory bronchoconstriction, and that an inhaled steroid plus a beta-agonist inhaler should be an effective treatment. But that assumption may be incorrect and the treatment regimen ineffective. I would strongly suggest obtaining a pulmonary function test (PFT) in these patients. A PFT can differentiate between an obstruction due to temporary airway constriction, which may be quickly reversible, and a restriction, which indicates that the fundamental problem is not asthma but another airway disease.

Chapter 8 of my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006), addresses “Diseases that Masquerade as Asthma and Allergies.” The following case is typical of those in the book… The patient was a 60-year-old black African American female. She had been experiencing “a whistle in her chest” for about two months. She had coughing episodes and sometimes wiped a couple of drops of blood from her mouth. Her son, a patient of mine, insisted his mom come to see me to be tested for allergies. I knew her son had a lot of allergies however I found it strange that she had no history of allergies or asthma until her seventh decade. Late-onset asthma always alerts me to look for an underlying cause. I tested her for allergies which revealed positives for ragweed and dust mites, similar to her son — but I was still uneasy. I ran a PFT, which revealed a low FEV1 of 70%. While this result could be consistent with the diagnosis of asthma, she also had a low FVC, indicating some restriction. So I ordered a chest-X ray which demonstrated some fluid in the left lower lung field. I reviewed these findings with the radiologist and he recommended a CT scan. The findings on the CT scan unfortunately indicated an endobronchial adenocarcinoma which was blocking her airway and causing the wheezing. In my 22-years in practice, this was the only such case, but it was unforgettable.

Another case I’ll never forget involved a patient with chronic rhinitis. This case was not a patient of mine, but the story was delivered by a staffer who shared office space with me. The staffer’s father had chronic nasal congestion and was “addicted” to Afrin. He couldn’t go a day without it, yet he didn’t feel it was necessary to seek care from a physician. In his late 50s he developed heart problems and the doctors determined that he needed coronary bypass surgery. At age 61, he developed acute shortness of breath. An emergency room chest-X ray revealed bilateral pleural fluid. The cause of the fluid was renal failure—his BUN was over 100! Evaluation of his kidney disease led to the diagnosis of Wegener’s Granulomatosis; a condition of vasculitis in which the immune system attacks the blood vessels. Interestingly, Wegener’s patients typically have chronic rhinitis or sinusitis as the initial presentation. If you have a rhinitis patient that has negative allergy skin testing, and the cause is unclear, a simple Erythrocyte Sedimentation Rate (ESR) (or “sed rate”) to identify an underlying inflammatory process can be a valuable clue to a more serious condition.

I like to teach medical students that when “you hear hoof beats, you don’t usually think of zebras.” In real world practice there are a lot more horses. But keep those striped animals in mind because every so often one will gallop your way, and your ability to recognize it can make all the difference in your patient’s life.

– Dr. Dean Mitchell

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Anaphylaxis, The True Allergic Emergency – What You Need to Know

Anaphylaxis, which comes from the Greek term “reverse protection,” is the most

There are many possible signs of anaphylaxis...

There are many possible signs of anaphylaxis…

dangerous type of allergic reaction. It is described as a type 1 Hypersensitivity reaction that involves release of IgE triggered, most often, by a food, medication or insect sting. Anaphylaxis is a frightening reaction where a patient, who moments before appeared fine and healthy, almost within seconds can be wheezing, hypotensive, and covered with hives.

The foods most commonly associated with anaphylaxis in children are peanuts and tree nuts; in their adult counterparts it’s usually shellfish. The confusing part for patients and clinicians is that a food allergy can develop after eating a particular food on many occasions. However, once that threshold has been crossed, even a minute amount of that food can cause an explosive reaction. If a food is the suspected cause of anaphylaxis, but the specific food unclear, it’s wise to evaluate the patient through several steps.

Initially, I would recommend a panel of food allergy blood tests. ImmunoCap is a common one used by most labs to evaluate IgE reactions to specific foods. The results range from zero to six, with a score of at least two indicating a positive reaction. If there is a positive reaction to peanut, the allergy should be further explored by ordering a UKnow Peanut test which analyzes the proteins Ara h1,2&3, as well as Ara h8. My article in Consultant for Pediatricians, “Pinpointing the Proteins in Peanut Allergy,” explains why these proteins are important to predict the severity of peanut allergy. If, for some reason, the blood test is negative, I would recommend referral to an allergist for skin testing and/or oral challenge in case there is a hidden allergen that requires more extensive testing.

Any medication can cause an anaphylactic reaction however the common culprits are antibiotics and non-steroidal anti-inflammatory drugs. Many antibiotics are mold-based, which may be part of the reason for their allergenicity. In the past, beta-lactam antibiotics such as penicillin and related cephalosporins were the most likely offenders but today we also see anaphylaxis to the widely used category of quinolone antibiotics. To complicate matters, it is not unusual for a patient to have multiple antibiotic sensitivities; there is a genetic component to this reaction. While Pre Pen can be used to diagnose penicillin allergy (talk to your AllerVision representative for more information), there is no such test for most antibiotics, and a drug challenge may be required for conclusive diagnosis.

Non-steroidal medications, such as Advil, Motrin and Alleve, work by blocking the cyclo-oxygenase pathway and trigger release of leukotrienes which are potent mediators of anaphylaxis. In my experience, patients allergic to NSAIDS are usually unaware of the source of reaction until they suffer several episodes of anaphylaxis. Be on high alert for NSAID hypersensitivity when evaluating a patient for anaphylaxis or urticaria. Unfortunately, a drug challenge is the only conclusive test NSAID hypersensitivity.

The clinical diagnosis of anaphylaxis can be complicated. The World Allergy Organization recently came out with new criteria. Essentially, it includes exposure to a possible or known allergen and the finding of two or more clinical signs: urticarial, bronchospasm, gastrointestinal distress and cardiovascular collapse. In case of cardiovascular collapse, no additional signs are needed — call 911 and immediately transport the patient to the hospital.

While anaphylaxis is fairly rare with allergy injections, and exceedingly rare with allergy skin testing, it is important that you and your staff be prepared just in case. When a patient is in your office, the question of whether or not to treat a potential reaction is simplified, and doesn’t include an extensive review of the clinical findings nor consideration about number of signs. If you place an allergenic substance on the patient’s skin, or inject them with a substance you know they are allergic to, and they have a reaction anywhere other than the local site of exposure, TREAT THEM! Common signs to look out for are itching of hands and feet, or clearing of throat that wasn’t happening when the patient came in to the office. If you apply antigen to one area of the body, and the patient has symptoms somewhere else, you have to assume that the reaction has gone systemic and you should treat accordingly.

The initial treatment of anaphylaxis is unambiguous: epinephrine intramuscularly into the lateral thigh. Don’t play around with Benedryl! Don’t give a cortisone shot! Anaphylaxis progresses immediately, and neither antihistamine nor steroid drugs act on the spot to reverse the severe pathophysiological reaction. Deaths resulting from anaphylaxis happen when epinephrine is not administered in under 3o minutes from the onset of symptoms. If you are giving allergy injections in your office, you MUST have the patient wait 20 minutes in the office to make sure they don’t have an immediate allergic reaction. If they develop ANY sign or symptom within that time, administer epinephrine. The EpiPen is convenient for an office because it contains the 0.3 ml of epinephrine with the needle size for an intramuscular injection. It also comes as the EpiPen Jr. for children or infants less than 66 lbs. Once epinephrine has been given, the patient must be monitored for several hours to make sure there isn’t a biphasic reaction; this usually takes place in a hospital.

Anaphylaxis can be the most frightening of clinical reactions. The good news is with quick recognition and prompt treatment with epinephrine, you can be a real hero!

– Dr. Dean Mitchell

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The Keys to Successful Allergy Treatment in ’14: Compliance, Compliance, Compliance

A provider explains the benefits of allergy drops to to a patient and demonstrates their use.

A provider explains the benefits of allergy drops to to a patient and demonstrates their use.

The new year is beginning and with it comes resolutions. I want to put this challenge out there — 2014 will be the year that doctors who treat allergies make a promise of clinical improvement for their patients… and inspire patients to do their own part in fulfilling that promise! The common ground required for this achievement: compliance.

Compliance is an important building block in the success of almost any endeavor. In medicine, it’s the key to reaching maximum therapeutic results. With allergy treatment specifically, patients must be disciplined because their symptoms are sometimes periodic, but to attain the highest level of success possible, allergy immunotherapy requires year ’round application. The struggles here are similar to those with hypertension meds where the overall wellness of the patient depends on their adherence to medication protocols even in the absence of symptoms. Studies show that compliance for allergy injection therapy is in the low 30% in most situations. Allergy drops compliance has been reported to be as high as 90% or as low as 20%. II have been fortunate in my medical practice to attain closer to 90% compliance with my immunotherapy programs and I’ll share what I’ve learned to make this possible for your clinic.

The key to compliance with allergy immunotherapy is motivation. Of course it may be easier to motivate patients at the beginning of treatment if they are diagnosed when the misery of allergies is clear in their mind. The hard part is inspiring them when they are asymptomatic, and then maintaining the course when they are feeling good. I’ve found that there are two important “up-front” times to motivate a patient: 1) At the visit when test results show their specific allergies, whether they be to pollen, dust mites, mold or animal dander. 2) At the point of informed consent. You will clearly have the patient’s attention when they are able to visually confront the allergens that have been causing them to sneeze, wheeze and itch. But to parlay that into successful treatment takes effort by both the patient and your practice. If the patient has positive allergy tests that correlate with clinical symptoms and immunotherapy is being discussed, the informed consent process is a vital opportunity to discuss the keys to successful outcome and motivate my patients to invest their time for long-term success.

Informed consent can be accomplished many ways in medicine. It is possible to unknowingly scare a patient out of a treatment with extensive lists of possible adverse events, but if you emphasize the positives in comparison to the potential negatives then you have an interested patient. Fortunately with allergy drops, the advantages far outweigh the few negatives. As always, the goal is to make the patient an equal partner in the decision-making process.

In discussing informed consent for immunotherapy, I start off with the many advantages. First, immunotherapy is a program that’s directed at the patient’s specific allergens (not a generic mix that all patients get). Second, the goal is to not only decrease their allergy symptoms, but to reverse the disease. Third, I explain that the allergens used are not drugs but elements from the environment (such as pollens) designed to train their bodies to accept their normal surroundings. Fourth, I let my patients know that studies indicate that immunotherapy is safe and effective. I also explain that the process of desensitization to allergies is similar to working out with weights: “in your workouts, it’s best to start at a low weight and gradually build up. Of course, everyone wants to see immediate results, but with time you will — you just have to visualize yourself on the road to getting there.” The final clincher with the allergy drops is convenience. When the patient realizes what they are taking is good for them and easy to use, they feel the responsibility to be an active participant.

I always ask  patients, “Do you brush your teeth everyday?” They look at me like I’m crazy; they swear they wouldn’t leave the house or go to sleep without brushing their teeth. Well, I tell them, leave your allergy drops by your toothbrush and you’ll never forget to take them either! My patients who regularly take their allergy drops see significant improvement when pollen seasons hit or when they visit a friend’s home with cats and dogs that they couldn’t tolerate in the past.

In the long term, the true key to successful compliance is the relationship between doctor and patient. Studies show that physicians can significantly increase adherence to treatment protocols through consistent follow-up visits. As much as patients know in the back of their minds that they should stay the course, nothing replaces the impact of checking in with their providers for a reminder that they have a partner in their quest for wellness.

Remember, in Latin, doctor stands for teacher. I take it another step further: as doctors we are our patient’s coaches and need to encourage them in the right direction. My best days in practice are when I see my patient at a follow-up visit during a high pollen day and I ask them what’s bothering them and they answer “Nothing!” We both celebrate!

-Dr. Dean Mitchell

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Treating Allergies With Tablets or Drops: What Every Allergy Patient and Doctor Should Know

Girl taking drops

Sublingual allergy drops have been available for a while. New sublingual tablets by pharmaceutical companies are poised to bring FDA approval to sublingual treatment. There are important differences between drops and tablets.

Last week, the FDA advisory committee reviewed two sublingual allergy tablets. Both tablets gained acceptance by the advisory committee, meaning that they will be recommended for approval by the FDA. While the tablets will be new to the U.S. market, they have been available in Europe and Canada for some time. The Sublingual method is an exciting alternative for allergy sufferers who have been waiting for decades for a definitive but shot-free solution to their allergies. Though the tablets present a new answer to that dilemma, physicians in the United States have long been successful in utilizing sublingual immunotherapy drops to help reverse their patients’ allergies. The drops are generally composed of FDA approved antigen in an “off label” route of administration.

While most physicians prescribe “off label” many times per day as part of their regular practice (such as offering a Beta Blocker for performance anxiety, or prescribing Albuterol for young children), FDA approval of the new tablets will provide physicians and patients an added level of comfort with sublingual route. Like many ENTs and several other allergists, I have been prescribing sublingual immunotherapy to treat my patients’ allergic disease for 15 years. In my book, Dr. Dean Mitchell’s Allergy and Asthma Solution, I dedicate a full chapter to discussing numerous medical studies which show that sublingual allergy drops reverse allergies and asthma and prevent future allergies from developing. Most of those studies are available for your review on the AllerVision website http://www.AllerVision.com.

There’s a Big Difference Between Tablets and Drops

The question patients and their doctors will be asking is “What’s the difference between these new sublingual tablets made by the pharmaceutical companies, and the liquid drops I get from my physician?” The answer: there is a big difference. The new sublingual tablets developed my Merck and Stallergenes are high dose allergy tablets covering only a single allergen or allergen category—grass. And, in fact, they only cover the grass(es) for a specific region of the country. The new tablets are clearly effective for patients in those regions who are allergic to only grasses. I have a concern, however, about side-effects with such a concentrated tablet which is taken at full dose from day 1 as opposed to utilizing the build-up phase that defines true immunotherapy. There will be many patients who are highly sensitive to grass pollen and the tablet may cause itching in the throat, rashes or difficulty breathing. In contrast, the sublingual drops available through AllerVision-affiliated providers, are custom-made for each patient to cover the categories affecting that specific patient. The treatment program includes a progressive ramp-up phase. This is important for several reasons…

First, the customized liquid drops enable you to treat multiple allergens simultaneously; most allergy patients suffer from several airborne allergens in multiple categories (most are poly-sensitized.) Interestingly, the cost might be more favorable with the drops compared to the pharmaceutical tablets, which will likely command a third-tier copay when they arrive on the market. Second, proper allergy desensitization protocol dictates starting with a low dose of allergen and carefully building the strength up over time while monitoring patient response. This is the way allergy desensitization has been practiced for decades, and the process accomplishes the goal of modulating the immune system by easing the body into acceptance.

Allergy treatment with the sublingual method may never have been as easy or as effective as it is today; and certainly it is fast becoming more widely available. Remember, not all sublingual options are equal. As always, it is important to do your research and educate yourself so you can rest assured that you are making the right choice.

– Dr. Dean Mitchell

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