Allergies A Rite of Spring - Part III

In the last two articles, we explored various triggers for allergic rhinitis and how to avoid them. In this article, we will look at different treatment modalities that are available to treat nasal allergies.
Histamine is your enemy, but antihistamines may not be your friend!

Histamine is a chemical that is released in your body following allergic reactions. It causes allergic symptoms. Antihistamines block the effects of histamine. Antihistamine tablets are effective in relieving symptoms such as itchy eyes, nostrils and skin, runny nose and sneezing. They are not effective in controlling nasal congestion and stuffiness. Older antihistamines such as Benadryl, Hydroxyzine (Atarax) and Chlor-Trimeton are useful but can cause significant sedation and tiredness in some people. A study looking at the effectiveness of Benadryl concluded that it could hinder driving similar to alcohol and could slow down your reflexes while driving. Some States consider driving with antihistamines on board as DUI (Driving Under the Influence) which is a punishable offense. Therefore do not drive or handle machinery after taking antihistamines especially if they cause sedation.

Another common complaint with antihistamines is that previously effective doses of antihistamines are no longer efficient, and patients believe that they have become “immune” to them. There is no scientific evidence to support this notion. Antihistamines can also cause dryness of mouth and eyes. If you already suffer from these complaints, you should avoid taking antihistamines. In older men with enlarged prostate, antihistamines sometimes could cause worsening of the urinary block and make it difficult for them to urinate. However, newer antihistamines such as fexofenadine (Allegra), Clarinex (Desloratadine) and loratadine (Claritin or Alavert) are tolerated better by most patients.

Avoid Afrin and beware of decongestants!

Medications such as Cromolyn (Intal) and Ketotifen (Zaditor) prevent the release of histamine in the body during allergic reactions. They are safe. However they are weak in their effectiveness, have to be taken 3-4 times daily, and their usefulness may not become evident for up to 2 weeks after starting treatment. For these reasons, they are not often recommended by doctors. Afrin and other OTC decongestant nasal sprays are immediately useful. However prolonged use (for more than four days) could make them addictive and causes a condition known as Rhinitis Medicamentosa- where your nasal symptoms get worse instead of better with their continued use. Therefore, they should be avoided if you intend to use them over extended periods of time. Similarly nasal decongestant medications such as pseudoephedrine (Sudafed) and phenylephrine sold OTC are effective immediately when used; they could cause anxiety, nervousness, tremors, sweating, urinary retention and palpitations, elevation of blood pressure and eye pressure and difficulty sleeping. Therefore, you should avoid such medications if you have anxiety, hypertension, glaucoma, heart disease and urinary retention. The side effects equally apply to Claritin-D, Zyrtec-D, and Allegra-D. Phenylpropanolamine is another decongestant medication that is no longer available in this country. It caused hemorrhagic stroke in older female patients.

New kids on the block- Watch Out!

Newer medications such as Singulair (Montelukast) and Accolate (Zafirlukast) are used for the treatment of allergic rhinitis and asthma. Since 90% of asthma in children and 50% of adults are allergy induced, they are often effective when you have both conditions. Recently Singulair hit the headlines because of the FDA concern about its potential for causing anxiety, depression, hand tremors and suicidal tendencies. These allegations are largely unproven but warrant closer scrutiny. Until more information becomes available, consult with your doctor if you are concerned about these issues, and you are taking one of these medications. Accolate also has the potential to cause liver damage and, therefore, monitor your liver function every six months at least if you are taking the drug. You must report to your doctor if you develop yellow jaundice, pale stools, dark urine and nausea, vomiting, stomach pain and loss of appetite while taking Accolate (Zafirlukast).

Do not be afraid of steroid nasal sprays!

(INCS) Intranasal corticosteroid sprays (fluticasone, Flonase, Nasacort AQ, Rhinocort Aqua, Nasonex, and Omnaris) are available by prescription only. They are safe. They do not cause addiction (in fact they have to be used daily to exert any benefit and allowances may not be noticeable for up to 7 days after beginning treatment!). Some are approved for use even in young children because of their excellent safety profile! A study in England showed that nasal corticosteroids do not cause cataracts. If used correctly (pointing to ears with your head looking down), their tendency to cause nosebleeds can be reduced. Occasionally they can cause headaches. Consult with your eye doctor if you have glaucoma before using them. The INCS are effective if you have nasal congestion and stuffiness as chief complaints. Their regular use with Sinus Rinse may help with your snoring and sleep apnea.
In the next and final article, we will read about allergen immunotherapy (allergy injections).
In the last three articles, we looked at common triggers for hay fever (allergic rhinitis), how to avoid them and various medication choices for allergic rhinitis and their pitfalls. In this article, we will look at specific Allergen Immunotherapy (SIT), commonly known as allergy injections as a choice of treatment for allergy sufferers. Leonard Noon, a British doctor, introduced allergen immunotherapy in 1911. His student, John Freeman, popularized the idea subsequently. Now, this is practiced all over the world, and millions of adults and children have benefited from it. It is a time-tested and proven tactics for allergy sufferers!

How are allergy injections different from medications?

Allergic diseases are caused by interaction between allergy-causing genes that you have inherited from your parents and your environment. Once developed, the allergic diseases cause allergy and asthma symptoms. Allergy medications help relieve the symptoms only; the underlying disease remains active. Therefore, the symptoms often return soon after stopping allergy medications. Besides, drugs are expensive, cause side effects and patients may not always be compliant with their use. This often results in patient frustration and suffering. This is where allergy injections come in. Allergy injections, unlike medications, make the underlying disease milder and by it make the symptoms better. The benefits usually outlast the injections. In a study of grass-allergic patients who received allergy injections for 3-5 years, 60% of patients still felt better three years after stopping them. This is not possible with allergy medications.

The proof of the pudding is in the eating!

Allergen immunotherapy is suggested for treating allergic rhinitis and asthma. Many studies over the years, here and abroad have decided it helps 70-90% of allergy sufferers. Studies have shown it helps prevent the development of new allergies in children, makes the existing allergies better and improves the quality of life, sleep and work for patients. A study involving over two hundred children with allergic rhinitis over ten years decided that allergy injections might have even prevented asthma in these children. It is a common knowledge that allergy sufferers on allergen immunotherapy suffer less from complications such as sinus and ear infections. Doctors and patients agree the allergy injections reduce the cost of treatment for allergic rhinitis and asthma in the end.

How do allergy injections work?

It is not clear how allergy injections work. Your immune system has two arms- TH1 and TH2 arms. TH1 arm helps fight infections. TH2 arm promotes the development of allergies. In people with allergies, the TH2 arm predominates. Allergy injections are believed to strengthen the TH1 arm and subdue the TH2 arm by re-educating your immune system. The improved immune system learns to ignore allergens (pollen, dander, and mold) when faced. Naturally, it takes the time to do this; do not expect a good outcome from allergy injections for at least 6-12 months after starting them. For several reasons, pollen and animal dander immunotherapy work better than mold immunotherapy.

Are there any risks?

Allergy injections are administered as injections under the skin- initially twice weekly or weekly. Once maintenance doses are reached, the injections are spaced out- every two weeks to once a month. For best benefits, you should receive injections for 3-5 years. Depending on how severe your allergies are, you may receive from one to three doses each time. Allergy injections are not without risk. One in hundred doses could cause life-threatening allergic reactions affecting the whole body (anaphylaxis). Two-thirds of these reactions happen in the first 30 minutes after the injections. One-third could occur up to 3 hours after the injections. Current recommendations demand that you wait in the doctor’s office for 30 minutes after receiving the injections. If allergic symptoms appear after you leave the office, you should immediately contact your doctor by phone, call 911 and go to hospital emergency room by ambulance (not by car!). If you have asthma, take beta-blocker medications or experienced anaphylaxis before- then you are at higher risk for later reactions, and you should take suitable precautions in consultation with your doctor. You should avoid exercise and sports for 3 hours after receiving allergy injections.

If you have questions, please call our office for clarification at 928-681-5800