Top 7 Reasons Nearly Every Doctor Should Test for Allergies

The allergy skin test is painless, quick and accurate.

The allergy skin test is painless, quick and accurate.

Family practitioners, internists, pediatricians, dermatologists, ENTs, neurologists, pulmonologists, ophthalmologists and nearly all other types of physicians and health care providers come in contact with patients who suffer from allergies virtually every day. That’s because allergies cause symptoms in every organ system. In fact, they cause many more symptoms than the average person realizes, including rashes (dermatitis), sinus infections, migraine headaches, dizziness, conjunctivitis, respiratory problems, fatigue, muscle and joint pain, and the list goes on. So here are our top seven reasons your healthcare provider should offer allergy testing — and treatment — in his or her office.

1) Since nearly every type of doctor comes in contact with patients suffering from allergies, it’s important that they are trained and have the tools to properly diagnose those patients’ allergies, suggest appropriate treatment, and know when to refer to an allergy specialist.

2) Allergies affect A LOT of people. The World Allergy Organization estimates that “30-40% of the world’s population is now affected by one or more allergic conditions.” And those numbers are growing; allergies have reached epidemic status.

3) There aren’t enough allergists to go around. Allergists make up a very small percentage of doctors. Even if there were enough, people often don’t know that their illness/ailment/discomfort is caused by allergies. Their primary care doctors should be able to make that diagnosis and offer first line definitive treatment as they do with most other chronic conditions (like hypertension and diabetes).

4) It’s impossible to be sure exactly what’s causing the allergic symptoms without a proper test. Pollens ride on the wind and cause discomfort for people up to hundreds of miles away from their source. Pet hair gets stuck in furniture and carpeting, causing allergic reactions even if the animal has been away for months. Dust mites float through the air and hide in bedsheets. Cockroaches leave hidden “presents” that trigger allergies. Which of these items cause your symptoms? The only way to find out is to test. AllerVision provides doctors with a program that allows them to test for reactions to a wide range of regional allergens and a variety of foods.

5) The allergy skin test is painless, easy to administer in the doctor’s office, and produces results in just 15 minutes. This convenient test, which is the diagnostic gold standard, helps doctors quickly determine the problem and the select the right course of treatment immediately.

6) Allergies can lead to asthma attacks. Asthma is a serious chronic airway disease that causes coughing, wheezing, and difficulty breathing. It often interferes with quality of life, preventing sufferers from participating in sports and outdoor activities. Severe asthma attacks in a patient without adequate disease control can be fatal.

7) Allergies can cause anaphylaxis, an extreme, life-threatening reaction. Anaphylaxis is usually associated with insect stings and food allergies but other allergens can cause it as well. Simply put, knowing what you’re allergic to can save your life.

Healthcare providers who don’t offer allergy testing should consider taking the time to learn and add the service to their practice. For more information, click here.

If you think that you may suffer from allergies, get an allergy test and evaluation. (Hint: if you’re feeling bad and don’t know why, it could be allergies.) AllerVision can help you find a local doctor who performs the test, or we can contact your provider to help him or her launch an allergy testing and treatment program. Click here to learn more.

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Treating Your Asthma Patients Using NIH guidelines

Inhalers offer significant relief for many asthma sufferers. But they're not the only option.

Inhalers offer significant relief for many asthma sufferers. But they’re not the only option.

In the previous blog post, I discussed assessing control and severity of your asthmatic’s symptoms. Now we will take this stratification and translate it into clinical practice standards.

The NIH guidelines provide an algorithm whereby asthma treatment is guided in a step-wise approach. In many ways this is logical but it is not always practical. Below is a review of their step-wise approach along with commentary for real-world clinicians — not just academicians! — based on my personal experience.

Step 1 treatment (for intermittent asthmatics). This is very straightforward — prescribe a short-acting beta-agonist inhaler. A few key tips: I prefer inhalers that have dose counters so the patient doesn’t have to guess if any medicine is left in the device. For that reason I highly recommend Ventolin HFA. There are few situations more precarious than that of an asthmatic counting on their rescue inhaler only to realize they are holding nothing but air!

Step 2 treatment (for mild, persistent asthmatics). Remember the rule of 2s; two days a week of symptoms, such as wheezing, shortness of breath or coughing. The choices here are as follows: (1) a low-dose inhaled corticosteroid. (2) If you are concerned your patient will have difficulty using the inhaler, or you are concerned about long term use of an inhaled steroid, the other option is the oral monteleukast (Singulair). This is available in both adult and pediatric doses — 10 and 5 mg respectively. When going with option one, I like Flovent Diskus because it comes in two doses: 50 and 100 micrograms. I also like that it also has a dose counter and that the discus is breath activated, meaning coordination is not a factor when it comes to getting the inhaled medicine deep into the lungs.

Step 3 treatment. Here the NIH guidelines give you a few options. The one I use and find works extremely well is the combination of an inhaled corticosteroid with a long-acting beta agonist inhaler. For decades, I have used the Advair Diskus with excellent results. It comes in three strengths: 100/50, 250/50 and 500/50. I most often use the 100/50 in chronic asthmatics, and have experienced good results at that dose. I will up the dose to 250/50 if the patient has an exacerbation due to an infection or allergen exposure. I don’t find much of a need for the 500/50; a patient that severe will likely require oral steroids for control.

Step 4 treatment (for severe asthmatics). These patients have daily symptoms and their normal activities are limited. They will need a high dose inhaled corticosteroid combined with a long-acting beta agonist. A good option is the Advair 250/50 or the newer Dulera 200/50. If you confirm allergic disease, the patient may be considered for the monoclonal antibody injection (Xolair). This is where I recommend you refer to a specialist to manage the complicated disease state and specialized treatment regimen.

The other important thing to remember is the potential benefit of allergy immunotherapy for allergic asthmatics at any of these steps. All forms of allergen immunotherapy have been shown to decrease the inflammation that lies at the root of allergic asthmatics’ disease.

Dr. Dean Mitchell

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Chart Your Patients’ Asthma Visits Like an Expert

Asthma is often triggered by allergies. Determining the allergy source, with a skin test, can help patients avoid extensive treatment.

Asthma is often triggered by allergies. Determining the allergy source, with a skin test, can help patients avoid extensive treatment.

This time of year brings changing weather and an uptick of respiratory viruses. For most physician offices, asthma visits rise with these trends. The diagnosis of asthma is often not the hard part; patients short of breath with coughing and wheezing make for a simple diagnosis. Other patients come in with the elusive and often undiagnosed cough, and a quick run of the spirometry can provide the answer. But navigating the art of managing and charting your asthmatic patients requires some skill.

The experts agree on the need to document two key points: severity and control. The components of severity are: intermittent, mild, moderate and severe. Begin the differentiation by stratifying the patient by the Rule of Twos using the key asthma indicators: nocturnal awakenings, use of short-acting beta-agonists inhalers, and interference in daily activities. If these indicators occur less than twice a week, then the patient is considered to have intermittent asthma; if the patient has these symptoms more than twice a week but not daily, then he/she falls into the mild persistent category. Moderate persistent is used for patients who experience the indicator symptoms daily, and severe persistent asthmatics suffer with symptoms throughout the day. It is critically important to follow and document pulmonary function tests and home peak flow levels in your moderate and severe patients. The moderate persistent asthmatic will demonstrate FEV1 values between 60-80% predicted, while more severe persistent patient values fall consistently under 60%.

The ACT (Asthma Control Test) is a standardized validated questionnaire that serves as another key component to the management process. The questionnaire provides a quick assessment of both severity and control. This form should be downloaded and printed from the back end of the AllerVision website — you will use it often! A score of less than 20 on the ACT signifies poor control, indicating that intervention or change in therapy is in order.

Always keep in mind that asthma is multi-factorial and heterogenetic; meaning there are lots of components at play. The detective work of good medicine means finding that trigger of your patient’s asthma, so the plan can center on avoiding those triggers whenever possible. Respiratory infections, especially viral, are common culprits that prove difficult to avoid. Stress and emotions also affect asthma, leading to exacerbations. However, a main trigger in most asthmatic exacerbations is allergic response. This fact is the impetus behind the NIH guideline stating that all persistent asthmatics be tested to identify their allergic triggers. The AllerVision testing program offers a comprehensive and regionally appropriate assessment. Perform the test, carefully document positive results along with correlation to the careful and detailed history, and take action to help the patient learn how to remove the offending allergen(s) from his or her environment. Because avoidance can be near-impossible, give serious consideration to allergen immunotherapy for your asthmatic patients. SLIT (sublingual immunotherapy) is a fantastic option in this case because it offers the benefits with significantly less risk than SCIT (subcutaneous immunotherapy, aka allergy shots).

Our next blog post will comment on making adjustments to asthma control through medications.

Dr. Dean Mitchell

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Antibiotics and Asthma: A Surprising Relationship

Crying Tears

The longer I practice medicine, the more amazed I am at the reversal of long held medical dogmas. Since the common use of antibiotics began around World War II, the medical profession has seen the effectiveness of antibiotics as evidence that science can prevail over infections. However, we didn’t foresee the downside of that success — the current rise of antibiotic resistance by common bacterial organisms. A similar arena of surprise in the medical field has taken place in the realm of allergy and asthma. We have observed an alarming rise in allergic diseases in Western countries over the past few decades. There are different hypotheses as to the cause of this allergy epidemic, but an article in the May issue of Annals of Allergy Asthma and Immunology seems to shed new light on one potential root of the problem: antibiotics.

Consider this common scenario: A six-month-old infant with a high fever and extreme irritability is brought to the pediatrician. The doctor examines her and sees a red tympanic membrane with fluid. The mother is desperate to relieve her child’s pain and suffering. The pediatrician wants to help and doesn’t want to miss a possible bacterial infection, despite the likelihood that the infection is viral. More often than not, the parent leaves with an antibiotic prescription. In medical practice, we are constantly faced with balancing risks and benefits, as well as attempting to perfect the art of doing good while upholding the oath to “do no harm.”  As we all know, this is a delicate balance. In order to maintain it, we have to keep ourselves constantly informed. The article cited above provides new and valuable information about the risks inherent in the above scenario. Here is the basic rundown …

Drs. Ong and Umetsu conducted a study on infants receiving antibiotics in the first year of life. The result: the antibiotic-receiving infants had double the incidence of asthma before three years of age. In addition, there appeared to be a dose-dependent relationship: the more antibiotic given, the more likely the child would develop asthma. Clearly, antibiotic usage in early infancy comes with risks. The explanation for the results lies in the alteration of the child’s microbiome. Antibiotic-induced biome alteration poses a concern for the development of atopy.

Where does this leave us in terms of treating infants with infections? As is so often the case, the key to the answer is patient/parent education. While effective for bacterial infections, antibiotics have no place in treating a child with viral infections — or allergic asthma. Doctors and parents need to be on the same page realizing that the best therapy for these young patients in the absence of definitive diagnosis of bacterial infection is close observation and supportive care. So many viral illnesses are self-limiting; a few days of rest and fluids go a long way. Powerful, broad-spectrum antibiotics are definitely not the answer to viral infection or allergic disease. Sometimes the parents just need an answer. While the febrile patient is clearly suffering from more than allergic disease, allergic inflammation sets up the ideal environment for infectious proliferation. The best thing you can do is definitively identify allergic children when they are not suffering from an acute infection.

Proper management of allergic disease, including avoidance where possible, appropriate medication use, and immunotherapy when indicated, can keep them well. A patient’s medical history is tremendously important in making the diagnosis of allergy, but a definitive IgE test is an equally important piece of the puzzle. If he or she has allergies or has asthma, if a parents smokes in the home, or if a pet lives in the house, allergies should be considered as the cause of the child’s problems. NIH guidelines indicate that all persistent asthmatics should be tested for allergic triggers and offered immunotherapy if indicated.

A new era in medicine is being ushered in, and the finding that antibiotic use in infancy increases the risk of asthma may be only the tip of the iceberg. Modern doctors must choose our treatments with care.

– Dr. Dean Mitchell

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