From the AAAI Rhinitis Tips:
Do you have bouts of sneezing and itching, or a runny or stuffy nose that do not seem to go away? If so, you may have rhinitis.
Rhinitis is one of the most common illnesses in the United States , affecting more than 50 million people. It often coexists with other respiratory disorders, such as asthma. Rhinitis has a significant impact on the quality of life of those who suffer from it. In addition, it can contribute to other conditions such as sinus problems, ear problems, sleep problems, and learning problems. In patients with asthma, uncontrolled rhinitis seems to make asthma worse.
Allergic rhinitis
Allergic rhinitis is caused by substances that we breathe called allergens. Allergens are usually harmless substances that can cause problems only in some people. These problems are caused because the immune system of people with allergic rhinitis mistakenly identifies these substances as intruders and generates a reaction against them. During this reaction, the immune system cells release substances such as histamine and leukotrienes that cause the symptoms of allergic rhinitis; these and other substances also cause inflammation in the nasal lining that makes the nose very sensitive to irritants such as smoke and strong odors or to changes in the temperature and humidity of the air.
Causes:
1. When allergic rhinitis is caused by common outdoor allergens, such as airborne tree, grass and weed pollens or mold, it is called seasonal allergic rhinitis, or “hay fever.”
2. Allergic rhinitis is also triggered by common indoor allergens, such as animal dander (dried skin flakes and saliva), indoor mold, droppings from dust mites and cockroach particles. This is called perennial allergic rhinitis.
Symptoms
Sneezing
Stuffy nose (congestion)
Runny nose
Itching in the nose, roof of the mouth, throat, eyes and ears
Diagnosis
If you have symptoms of allergic rhinitis, an allergist/immunologist can help determine which specific allergens are triggering your illness. He or she will take a thorough health history, and then test use to determine if you have allergies. Skin tests or blood tests are the most common methods for determining your allergic rhinitis triggers.
What to Do During Pollen Season:
When outdoor pollens are high, remain indoors, particularly in the late morning. Pollen grains can cause significant allergic symptoms like asthma and allergic rhinitis, particularly during the spring and the fall. It is difficult to avoid pollen because it is windborne and can cover wide distances. Short of moving to a different location, here are some tips for avoiding pollen during the season.
1. The pollen count is usually highest in the late morning and early afternoon particularly during sunny, windy days. The pollen count measures the concentration of a specific pollen like birch tree pollen, in the area in a specific area and time. A pollen count is a useful guide for when it is advisable to stay indoors and avoid contact with pollen.
2. Keep the windows and doors closed during the allergy season.
3. Install a room air conditioner with a special filter.The special filter (High Efficiency Particulate Air or HEPA filter) traps airborne allergens. If the house does not have central air, the best spot to put the air conditioner and filter would be the bedroom. Change the filters frequently. An allergic person should also use the car air conditioner to decrease pollen exposure when commuting. Pollen allergic persons should not have a window fan blowing into their bedroom as this will maintain outdoor pollen exposure all night.
4. Avoid working outdoors, if you must wear a special face mask. The face mask is designed to filter pollen out of the air and keep it from reaching the nasal passages.
5. Consider taking a vacation at the height of the pollen season. Preferably at a location where the pollen exposure is minimal, like the seashore.
The EPFX’s slick and sophisticated graphics may impress, but no scientific research shows that energy machines can diagnose or cure medical problems. Still, clients may pay hundreds or thousands of dollars for treatments with practitioners. This session was at the Puyallup Fair.
They can cure cancer, reduce cholesterol, end allergies, treat cavities, kill parasites and even eliminate AIDS.
“Energy medicine” devices can be as small as a television remote control, or as large as a steamer trunk.
Their operators say the devices work by transmitting radio frequencies or electromagnetic waves through the body, identifying problems, then “zapping” them.
Their claims are a fraud — the 21st-century version of snake oil. But a Seattle Times investigation has discovered that thousands of these unproven devices — many of them illegal or dangerous — are found in hundreds of venues nationwide, from the Puyallup Fair, to health-care clinics in Florida, to an 866-bed regional hospital in Missouri.
These are not the devices in wide use by medical doctors, such as electrical stimulators used for sports injuries. Nor are they the biofeedback devices used at respected alternative-medicine centers such as Seattle’s Bastyr University. Rather, these are boxes of wires purported to perform miracles. Their manufacturers and operators capitalize on weak government oversight and the nation’s hunger for alternative therapies to reap millions of dollars in profits while exploiting desperate people:
• In Tulsa, Okla., a woman suffering from unexplained joint pain was persuaded to avoid doctors and rely on an energy device for treatment. Seven months later, her son took her to a hospital. She died within hours from undiagnosed leukemia.
• In Los Angeles, a mother pulled her 5-month-old son out of chemotherapy for cancer and took him to a clinic where a 260-pound machine pulsed electromagnetic waves through his tiny body. The baby died within months.
• In Seattle, a retiree with cancer emptied her bank account to buy an energy machine. Shortly before she died, her husband, a retired Microsoft manager, examined its software, finding that it appeared to generate results randomly — “a complete fraud,” he said.
Over the past year, The Times investigated these machines and the people behind them.
The investigation took us to where the manufacturers of some of these machines are based, in Hungary and Greece. We found the operators — including a cross-dressing federal fugitive who moonlights as a cabaret singer — making outrageous claims as they peddled their wares. We discovered that the U.S. regulatory system has allowed them to flood this nation with an estimated 40,000 devices.
And we learned that many operators consider our state a safe haven for these “miracle machines.”
A device just coming to America from Australia claims to end allergy symptoms in as few as two treatments with the use of lasers. Can it stand up to rigorous scientific testing?There are a lot of potential patients. It’s estimated that one in five Americans suffers with allergies. Adult allergy sufferers spend more than $500 each per year on treatments, according to 2005 numbers from the U.S. Department of Health and Human Services.The report also showed that spending to fight allergies nearly doubled in the five years from 2000 to 2005 to $11.2 billion.David Tucker was among life-long sufferers looking for a cure.”It all stems back from when I was at Ohio State,” Tucker said. “On Saturday, everybody would wake up and go to football games. Because that’s when pollen season was, I’d spend time in the shower because I couldn’t breathe.”Later in life, he was selling electrodes to the chiropractic industry in Florida and suffering hay fever and allergies to cats and dust.Tucker said one chiropractor client turned him onto a device he’d seen in Australia.
Computer Diagnoses
“He’d been treated for his dairy allergy while on holiday. After 72 hours — he hadn’t drunk milk in 15 years — he had a full glass of milk and it had no effect,” Tucker said. “He set it up to have the equipment treat me for dust mites and, 48 hours later, I was fine. I’d always had to stay in a hotel at my mother-in-law’s because of cats. Now I can have cats on my lap.”Tucker said the device works based on biofeedback. The allergy sufferer wears a sensing clip on his finger for testing, and the computer simulates the bio-frequency for 10,000 known allergens. As the body responds to those stimuli, the computer lists which substances are irritants.”This digitized allergen actually matches the harmonic frequency of the actual allergen, making the body believe it is in contact with the real substance,” Tucker said. “The body will react if it is allergic to the particular substance.”The assessment takes about 20 minutes and can cost up to $250.
Curing Allergies
Once the allergens are identified, a laser stimulates biomeridian points on the body — the same points used in acupuncture and acupressure. Tucker said the idea is to strengthen organs to act properly the next time they encounter the allergen — that is, to treat them as harmless.Treatments are about $100, and Tucker said most people need two to 10 treatments to recondition the body’s response. After that, they’re done.Tucker said his own suffering, combined with his business experience, led him to bring the device to American chiropractors.He admits he doesn’t know all the science behind the device. But, he said, he thinks back on all the money he spent on shots and meds, and all the time getting jabbed, and he wonders why he didn’t have access to something so simple.
No Science Backs Device
So far, there is no science to prove the devices work, but Tucker claims a 70 percent positive response rate. He said he has patients filling out questionnaires so that researchers can begin scientific testing of the product.After opening his own AllergiCare Relief Center in Tampa, Tucker franchised the equipment to 11 more U.S. locations and two in Canada. More are planned.
PENN AND TELLER B@#$S&*#$ EPISODES ON ALTERNATIVE MEDICINE
Get Educated, don’t get ripped off! For further info on dubious medical devices go to www.quackwatch.org
from The New York Times
By TARA PARKER-POPE
Published: February 2, 2009
For Ingelisa Keeling, a Houston mother of three children with multiple allergies, mealtime was a struggle. Nuts, eggs, wheat, beef, peas and rice were all off limits — banned by the children’s allergist.
But recently, Mrs. Keeling learned that her family’s diet need not be so restrictive. Although her children do have real allergies — to peanuts, milk and eggs, among other foods — extensive testing at a major allergy center showed that they were not in fact allergic to many of the foods they had been avoiding. Her 2-year-old son, who had been living on a diet primarily of potatoes, fruit and hypoallergenic formula, has resumed eating wheat, bananas, beef, peas, rice and corn.
“His diet had become so, so restricted that nutrition had become a real concern,” said Mrs. Keeling, who traveled to specialists at National Jewish Health in Denver last summer for answers about her children’s diet and eczema problems. Among other findings, she learned that neither of her younger children was really allergic to wheat.
“That’s the big one,” she said. “Wheat is in everything, so it makes life a whole lot easier.”
Doctors say that misdiagnosed food allergies appear to be on the rise, and countless families are needlessly avoiding certain foods and spending hundreds of dollars on costly nonallergenic supplements. In extreme cases, misdiagnosed allergies have put children at risk for malnutrition.
And avoiding food in the mistaken fear of allergy may be making the overall problem worse — by making children more sensitive to certain foods when they finally do eat them.
More than 11 million Americans, including 3 million children, are estimated to have food allergies, most commonly to milk, eggs, peanuts and soy. The prevalence among children has risen 18 percent in the past decade, according to the Centers for Disease Control and Prevention. While the increase appears to be real, so does the increase in misdiagnosis.
The culprit appears to be the widespread use of simple blood tests for antibodies that could signal a reaction to food. The tests have emerged as a quick, convenient alternative to uncomfortable skin testing and time-consuming “food challenge” tests, which measure a child’s reaction to eating certain foods under a doctor’s supervision.
While the blood tests can help doctors identify potentially risky foods, they aren’t always reliable. A 2007 issue of The Annals of Asthma, Allergy & Immunology reported on research at Johns Hopkins Children’s Center, finding that blood allergy tests could both under- and overestimate the body’s immune response. A 2003 report in Pediatrics said a positive result on a blood allergy test correlated with a real-world food allergy in fewer than half the cases.
“The only true test of whether you’re allergic to a food or not is whether you can eat it and not react to it,” said Dr. David Fleischer, an assistant professor of pediatrics at National Jewish Health. In one recent case there, doctors treated a young boy who had been given a feeding tube because blood tests indicated he was allergic to virtually every food. Food challenge testing allowed doctors to quickly reintroduce 20 foods into his diet, and they expect more to be added.
Blood tests may be unreliable because they fail to distinguish between similar proteins in different foods. A child who is allergic to peanuts, for instance, might test positive for allergies to soy, green beans, peas and kidney beans. Children with milk allergies may test positive for beef allergy.
The most important question in diagnosing food allergy is whether the child has tolerated the food in the past, Dr. Fleischer says. While some severe allergies are obvious, parents given a positive blood test result should seek advice from an experienced allergist who performs medically supervised food challenge testing.
Even when a food allergy has been confirmed, parents should have children retested, because many allergies are outgrown, particularly in the cases of milk, eggs, soy and wheat.
Doctors’ groups are also starting to acknowledge that some of their own policies may have contributed to overtesting and misdiagnoses. A committee for the American Academy of Asthma Allergy and Immunology is considering revised guidelines recommending earlier introduction of foods like eggs, peanuts and shellfish, which in the past have been delayed until age 2 or 3. A 2008 study of 10,000 British children, reported in The Journal of Allergy and Clinical Immunology, found that early exposure to peanuts lowered allergy risk.
Just as an allergy indicates oversensitivity to certain foods, it may be that doctors and parents have become oversensitive to food allergies. In an essay in The British Medical Journal in December, Dr. Nicholas A. Christakis, a professor at Harvard Medical School, argues that an “overreaction” to allergy is leading to unnecessary testing and false positives.
“If the kid has been doing fine, I would advise parents not to get allergy testing, because the results are more likely to be false positives than true positives,” Dr. Christakis said in an interview. “If they do think they need allergy testing, be extremely measured and go to reputable people.”
Pfaar O, Klimek L. Efficacy and safety of specific immunotherapy with a high-dose sublingual grass pollen preparation: a double-blind, placebo-controlled trial.
Ann Allergy Asthma Immunol. 2008 Mar;100(3):256-63.
BACKGROUND: Sublingual immunotherapy (SLIT) is increasingly being used for the treatment of allergic rhinitis, but there are conflicting study results demonstrating clinically relevant efficacy. OBJECTIVE: To show clinical efficacy and safety of a new high-dose grass pollen preparation for SLIT. METHODS: In a 2-year, double-blind, placebo-controlled trial, 185 subjects with rhinitis or rhinoconjunctivitis, with or without asthma, were treated with a recently developed, high-dose, 6-grass pollen mixture for SLIT once daily. RESULTS: The primary end point, a combined symptom-medication score, showed almost no change in the placebo group during a 42-day evaluation period in the grass pollen season from 2003 to 2005, whereas active treatment was associated with a significant and clinically relevant improvement (full analysis set, P = .01; main data set, P = .002). The effect was irrespective of asthma diagnosis. Allergen-specific IgE showed no difference in both groups, and specific IgG4 and IgG1 increased with active treatment in the first and second study years compared with placebo, clearly indicating the immunogenic effect of the active treatment. The SLIT was well tolerated. No serious adverse drug reactions occurred. CONCLUSIONS: High-dose, sublingual, specific immunotherapy with an extract of a 6-grass pollen mixture showed a significant and clinically relevant improvement in subjects with grass pollen-associated rhinitis or rhinoconjunctivitis, with or without asthma. The treatment with the sublingual solution was well tolerated.
Cox L. Sublingual immunotherapy and allergic rhinitis.
Curr Allergy Asthma Rep. 2008 Apr;8(2):102-10.
This paper reviews the safety and efficacy of sublingual immunotherapy (SLIT) in the treatment of allergic rhinitis. The literature from 1986 through 2007 shows approximately a 6000-fold range in doses found to be effective with SLIT. However, recent studies in large patient populations have demonstrated a clear dose response with an effective dose range that appears to be equivalent to one to two times the monthly subcutaneous immunotherapy dose administered daily or weekly (ie, 15 to 30 microg of major allergen). Further study is needed to establish the optimal dose and dosing schedule for each formulation. Local reactions (eg, oral itchiness) are common, and serious adverse reactions, although rare, have been reported. Cost-effective analysis cannot be made until the effective dose is established. SLIT appears to be a promising treatment for allergic rhinitis, but it is currently considered investigational in the United States until a formulation approved by the US Food and Drug Administration is available.
Landmark “Pediatric Allergies in America” Survey Uncovered Negative Impact of Allergy Symptoms on Children
from the ACAAI
PHILADELPHIA, Penn.—March 17, 2008—Data from the largest survey of its kind suggested there’s a silent epidemic among our nation’s children. U.S. children are suffering with allergies and not getting the treatment they need, according to the Pediatric Allergies in America survey, which is the largest and most comprehensive national survey of parents of children under the age of 18 who suffer from allergic rhinitis. The survey results were presented today at the American Academy of Allergy, Asthma and Immunology 2008 Annual Meeting in Philadelphia. More than 500 parents who had a child with allergies were interviewed about severity and effects of allergies on their child’s life, and their responses were compared to more than 500 parents of children without allergies.
“We have known anecdotally that children are affected by allergy symptoms similarly to adults, but Pediatric Allergies in America offers the first data quantifying the scope of how allergies interrupt a child’s productivity, sleep cycle, and daily functioning,” said Jay M. Portnoy, MD, President of the American College of Allergy, Asthma and Immunology.
Quality of Life Findings
More than three quarters of parents (76 percent) reported Spring to be the worst time of year for their children’s nasal allergies. Allergy symptoms cause children to feel tired, miserable and irritable. Many children with allergies reported experiencing symptoms every day this time of year. Key findings included:
Allergy symptoms are interfering with children’s sleep. Forty percent of parents indicated that their child’s allergies interfere a lot or somewhat with their sleep. Only eight percent of parents of children without allergies indicated their child’s health interferes with their sleep.
Allergy symptoms are limiting children’s activities. Twice as many parents (21 percent) said allergies limit their children’s activities, compared with only 11 percent of parents whose child did not suffer from allergies.
Allergy symptoms interfere with children’s education. Forty percent of parents of children with allergic rhinitis report their condition interferes with their performance at school compared to only 10 percent of parents of children without allergic rhinitis who attribute lower performance at school to health issues.
Although the most bothersome symptom is a stuffed up nose (27 percent), almost half (46 percent) of parents of children with allergic rhinitis reported serious symptoms – such as headache and ear and facial pain.
Treatment Experience Findings
The survey found that there is room for improvement in the management of allergic rhinitis and that new therapies could help fill some of the current treatment needs. Healthcare professionals overestimate their patients’ satisfaction with allergy medicines.
“Similar to what we have learned about adults, many children with nasal allergies are not satisfied with current treatments. This dissatisfaction is one reason why nasal allergy sufferers sometimes discontinue or switch medications,” said Michael Blaiss, MD, Clinical Professor of Pediatrics and Medicine at the University of Tennessee. “We have information that tells us how, in fact, children suffer with this condition, how it truly affects their quality of life and that there is a need out there for better treatments to control allergies in the pediatric population.”
Nearly half (48 percent) of the children in the study are currently using prescription medication to treat their nasal allergy symptoms; but of those, more than half (57 percent) have changed their medication, with parents citing the medication was not effective enough as the number one reason for the switch. Patients’ dissatisfaction with effectiveness of nasal allergy medicines caused them to ask their doctor to change medication (26 percent) or to simply stop taking them (15 percent).
Bothersome side effects of prescription nasal allergy sprays were a key reason reported when parents were asked why their child is not satisfied with their medication. Cited most often are products dripping down the throat and bad taste, which were also seen as most bothersome when compared to other side effects including burning (15 percent), drying feeling (14 percent), and headaches (13 percent).
Allergic Rhinitis
Allergic rhinitis is a chronic inflammatory disease of the nasal mucosa causing sneezing, itching, nasal congestion and discharge. Some patients with allergic rhinitis have systemic symptoms, including malaise, irritability, fatigue, difficulty concentrating and decreased appetite.
Allergic rhinitis is the most common allergic disease in the U.S. affecting about 40 million people, specifically 10 percent to 30 percent of adults and up to 40 percent of children. It is associated with direct costs of about $4.5 billion annually and indirect costs that reflect approximately four million days of lost time and productivity at work and school.
Seasonal allergic rhinitis is caused by substances typically outdoors (i.e., pollen) that set off allergies and is sometimes referred to as “hay fever.” Symptoms may vary in occurrence and intensity during the day or from season to season. Symptoms are often worse in the morning even when the exposure occurred on the previous day.
Perennial allergic rhinitis is a chronic condition caused by triggers such as pet dander and dust. Symptoms of perennial allergic rhinitis are very similar to those of seasonal allergic rhinitis, yet perennial is persistent and chronic.
About the Survey
A national probability sample of 500 adults, aged 18 and older, who had at least one child who had been diagnosed with allergic rhinitis, nasal allergies or hay fever, and who had nasal allergy symptoms or had taken prescription medicine for allergies in the past 12 months, were interviewed by telephone about their condition and treatment.
More than 35,000 households in the United States were screened to identify nasal allergy sufferers between ages 4 and 17. Individual screening was conducted with a parent in the household to confirm that their child had been diagnosed with nasal allergies and suffered from them or been treated for them in the past 12 months. Parents of children without allergies (N=504) were also interviewed as a comparison group. A third parallel survey was conducted among 501 healthcare practitioners, including a national sample of 401 doctors in direct patient care in outpatient settings: 100 in family practice specialties, 101 allergists, 100 otolaryngologists, and 100 pediatricians. In addition, 50 nurse practitioners and 50 physician assistants were interviewed as part of the survey.
The survey was conducted by the national public opinion research organization, Schulman, Ronca and Bucuvalas, Inc. (SRBI) and made public by Sepracor Inc, a leading manufacturer and distributor of respiratory pharmaceutical products.
I was recently embroiled in an online discussion with several pulmonary and primary care colleagues regarding the efficacy of Allergen Immunotherapy in the treatment of asthma and the future of sublingual immunotherapy, which I think is worth sharing. Let’s start off with some Frequently Asked Questions: Whare are “Allergy Shots”?
Allergen immunotherapy or “allergy shots” is a form of treatment aimed at decreasing sensitivity to substances called allergens which were identified by allergy testing. Allergen immunotherapy involves injecting increasing amounts of these allergens to a patient over a period of time to decrease the patient’s sensitivity to the allergens, prevent development of new allergies, and in children, prevent progression from allergic rhinitis to asthma. Allergen immunotherapy can lead to long-lasting relief of allergy symptoms after treatment is discontinued.
How does Allergen Immunotherapy work?
Allergen immunotherapy works like a vaccine. Your body responds to injected amounts of a specific allergen by developing immunity or tolerance. There are two phases to immunotherapy: a build-up phase and a maintenance phase.
When will the allergy shots start working and when can I stop my meds?
The benefits of allergen immunotherapy, in terms of reduced allergy symptoms, can begin during the build-up phase but may take as long as 12 months on the maintenance doses. It is important to continue taking allergy medications as prescribed together with the allergy shots during the build-up phase. Later, when your symptoms improve, you may discuss with your doctor whether you can discontinue some of your allergy medications. If you do not get your allergy shots on schedule, it will take longer to reach the maintenance dose and longer for the allergy shots to work effectively.
How long do I have to take the Allergy shots?
With currently available allergen extracts, maintenance treatment is generally continued for 3 to 5 years after the build-up phase, which can take up to 6 to 9 months. The majority of inidividuals experience lasting remission but a minority may relapse after discontinuing immunotherapy, therefore the decision to stop must be individualized.
How effective is allergen immunotherapy?
Immunotherapy is successful in up to 90-95% of patients with seasonal allergies and up to 85% of patients with year-round allergies.
Asthma is a multifactorial disease. Allergic rhinitis/ sinusitis has definitively been shown to contribute to the severity of asthma in patients. One of the modalities used to treat allergic rhinitis/ sinusitis and asthma is allergen immunotherapy (IT). By no means is anyone suggesting that allergen immunotherapy be used INSTEAD OF inhaled steroids, however allergen IT does have solid data to show its efficacy when used in conjunction with other modalities.
This is topic has been addressed by the American College of Allergy, Asthma, and Immunology in its position paper on the Cost Effectiveness of Immunotherapy for Asthma.
Regarding sublingual immunotherapy, there is considerable evidence that sublingual immunotherapy for allergic rhino-conjunctivitis has been effective using high doses of grass extract. This is commercially available and used in Europe, but has yet to have FDA approval in the USA. Some studies showing efficacy are cited below:
1. Calderon M, Essendrop M. Specific immunotherapy with high dose SO standardized grass allergen tablets was safe and well tolerated. J Investig Allergol Clin Immunol. 2006;16(6):338-44. 2. Nelson HS. Advances in upper airway diseases and allergen immunotherapy. J Allergy Clin Immunol. 2007 Feb 8; [Epub ahead of print]
That being said, appropriate dosing and efficacy with multiple SL allergen combinations are still an issue.
The “sublingual immunotherapy” that is pure quackery has been used to treat “idiopathic environmental intolerance” (IEI) by means of “neutralizing” extracts administered as sublingual drops usually at such a miniscule dose that it is really only placebo. See the AAAAI position statement on this.
For a tragic example of the use of these “neutralizing sublingual drops” for treatment of IEI or “multiple chemical sensitivity syndrome” see the “Tragic Example” post on this blog.
HAPPY MOTHER’S DAY! Classic Mr. T video: “Treat Your Mother Right”
from the AAAAI 60th Annual Meeting: NAEPP Expert Panel Report:
Asthma reportedly affects about 7% of pregnant women, and some research has suggested that these women are at an increased risk of preeclampsia or having a child suffer perinatal mortality, preterm birth, or low birth weight.
However, by controlling asthma, those risks are thought to be decreased, noted Michael Schatz, MD, chief of the Allergy Department at Kaiser-Permanente Medical Center in San Diego, California, and coleader of the panel committee. “We can do something about what medicines we use,” Dr. Schatz said during his presentation. “How you control the asthma makes a difference.”
The new guidelines discuss the need to intensely monitor women with asthma once a month during pregnancy, reduce any triggers such as allergens and smoke, and educate patients on the importance of asthma control.
Caution must also be taken in step-down therapy, Dr. Nelson said, with more care taken than usual in preventing flare-ups, or even postponing step-down therapy until the pregnancy is completed.
The new recommendations primarily focus on the pharmacologic treatment of asthma. Researchers reviewed a total of 6,113 articles in the medical literature published between 1990 and May 2003, analyzing 44 in depth.
The new recommendations are as follows:
For mild intermittent asthma, pregnant women should be prescribed short-acting inhaled beta2-agonists, preferably albuterol.; Previously, the recommended drug was terbutaline.
For mild persistent asthma, pregnant women should be prescribed low-dose inhaled corticosteroids (ICS), preferably budesonide. Previously, cromolyn was the initial preferred treatment; now that is an alternative recommended treatment, as well as leukotriene receptor antagonists or theophylline.
“Budesonide is the preferred ICS because safety studies in pregnancy are available and reassuring,” Dr. Nelson said. “There are few or no data on other formulations during pregnancy, but no data indicate they are unsafe, and they may be continued in well-controlled patients.”
If a patient is doing well on a different ICS, the investigators advised against switching to budesonide. “If a person is controlled, that’s important,” Dr. Schatz said. “But for starting on a medication in pregnancy, or for women of childbearing age, you may use this data to make some choices.”
For moderate asthma, there are two equal recommendations: either a low dose of an ICS plus a long-acting inhaled beta2-agonist such as salmeterol, or a medium-dose ICS. Previous recommendations of cromolyn and oral beta2-agonists are no longer recommended.
For persistent severe asthma, pregnant women should be prescribed a high dose of an ICS, preferably budesonide, and oral prednisone as a last resort at a maximum of 60 mg. The risks of not treating severe asthma need to be weighed against the indication that oral corticosteroid use during the first trimester was associated with an increased risk in cleft palate and with preterm birth and low birth weight.
The researchers also made no recommendations regarding omalizumab, an asthma medication approved last June by the U.S. Food and Drug Administration, which has no published data regarding use among pregnant women. “This is the problem with a newer drug, it takes a while to get data,” Dr. Schatz said.
In the past, some physicians stopped asthma medications during pregnancy, but that’s not necessary, said William W. Busse, MD, a professor of medicine and allergy at the University of Wisconsin at Madison, who moderated the session. “There are good and safe treatments.”
from the AAAAI Tips to Remember:
During pregnancy, mothers-to-be may feel uneasy taking medications. However, if a pregnant woman has asthma, it is doubly important that her symptoms be well-managed to increase both her health and her baby’s health. Uncontrolled asthma can be a threat to maternal well-being and fetal growth and survival. The goals of asthma management and treatment during pregnancy are the same as for other patients-to prevent hospitalization, emergency room visits, work loss and chronic disability.
Pregnant women, like others with asthma, should avoid asthma triggers, including specific allergens such as house dust mites and animal dander, and irritants such as cigarette smoke. After discovering you are pregnant, see your allergist/immunologist soon after to discuss the best way to manage your asthma and what medications to take. He or she will be able to prescribe effective asthma and allergy medications that are appropriate to use during pregnancy, and will continue to work with you throughout your pregnancy to ensure your treatment is effective, without side effects.
If you are pregnant and have asthma, you may have questions regarding the best care for both your asthma symptoms and your baby. Following are some common questions and answers to assist you.
Common questions
Can women with asthma have safe, full-term pregnancies?
Studies show maternal asthma that is well-managed during pregnancy does not increase the risk of maternal or infant complications. With appropriate asthma management, you can have a healthy baby. Conversely, there is a direct relationship between lower birth weight and uncontrolled asthma. So, it benefits you and your baby to control asthma symptoms.
Why would uncontrolled asthma affect the fetus?
Uncontrolled asthma causes a decrease in the amount of oxygen in the mother’s blood. Since the fetus receives its oxygen from the mother’s blood, decreased oxygen in her blood can lead to decreased oxygen in the fetal blood. This, in turn, can lead to impaired fetal growth and survival, since a fetus requires a constant supply of oxygen for normal growth and development.
How do asthma medications affect the fetus?
Studies and observations of hundreds of pregnant women with asthma have demonstrated that most inhaled asthma medications are appropriate for patients to use while pregnant. The risks of uncontrolled asthma appear to be greater than the risks of necessary asthma medications. However, oral medications (pills) should be avoided unless necessary to control symptoms.
What effect does pregnancy have on asthma?
Pregnancy may affect the severity of asthma. One study showed that asthma symptoms worsened in 35% of pregnant women, improved in 28% and remained the same in 33% of the pregnant women. These changes in severity are another reason to stay in close contact with your allergist/immunologist so he or she can monitor your condition and alter your medications or dosages if necessary.
During what part of pregnancy will asthma change?
Asthma has a tendency to worsen during pregnancy in the late second and early third trimesters; however, women may experience fewer symptoms during the last four weeks of pregnancy. Troublesome asthma during labor and delivery is extremely rare in women whose asthma has been adequately controlled during pregnancy.
Why does asthma improve for some women during pregnancy?
The exact reason is unknown. Higher levels of cortisone in the body during pregnancy may be an important cause of this improvement.
Why does asthma worsen for some women during pregnancy?
Again, the exact reasons are not known. Because the stomach area is compacted during pregnancy, some women may experience gastroesophageal reflux, a condition that causes heartburn and other symptoms. This reflux can worsen asthma symptoms. Other conditions, such as sinus infections, viral respiratory infections and increased stress, may also aggravate asthma during pregnancy.
Can I continue to receive allergy shots during pregnancy?
Immunotherapy or “allergy shots,” do not have an adverse effect on pregnancy, so they can be continued. As always, your allergist/immunologist will monitor your dose to reduce the risk of an allergic reaction to the shots. These reactions are rare; however, such a reaction could be harmful to the fetus. And, allergy shot treatments should not be started for the first time during pregnancy.
Can women with asthma perform Lamaze?
Most women with asthma are able to perform Lamaze breathing techniques without difficulty.
Can I breast feed if I have asthma?
Breast feeding is a good way to increase your child’s immunity, and is encouraged. The transfer of most drugs into breast milk has not been precisely evaluated; however, there appears to be no evidence that asthma medications adversely affect nursing infants. (However, some infants may become irritable from theophylline transferred by breast milk.) Also, if you have allergy symptoms while nursing, it is appropriate to treat these as well. Again, make sure to see your allergist/immunologist for the best treatment of allergies and asthma while nursing.
Although these are common questions during pregnancy, each patient’s individual treatment varies. Managing asthma and avoiding asthma flare-ups during pregnancy is important to the health of the mother and fetus. It is best if women see their allergist/immunologist regularly during pregnancy so that any worsening of asthma can be countered by appropriate changes in the management program. Make sure to discuss any specific concerns with your doctor to ensure the healthiest pregnancy-for your well-being and that of your baby.
When to see an allergy/asthma specialist
The AAAAI’s How the Allergist/Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence provide information to assist patients and health care professionals in determining when a patient may need consultation or ongoing specialty care by the allergist/immunologist. Patients should see an allergist/immunologist if they:
Have a family history of allergies and are interested in identifying prevention strategies for their infant.
Have moderate-severe or uncontrolled asthma.
Your allergist/immunologist can provide you with more information on asthma and pregnancy.
Tips to Remember are created by the Public Education Committee of the American Academy of Allergy, Asthma and Immunology.
From the AAAI Rhinitis Tips:
Do you have bouts of sneezing and itching, or a runny or stuffy nose that do not seem to go away? If so, you may have rhinitis.
Rhinitis is one of the most common illnesses in the United States , affecting more than 50 million people. It often coexists with other respiratory disorders, such as asthma. Rhinitis has a significant impact on the quality of life of those who suffer from it. In addition, it can contribute to other conditions such as sinus problems, ear problems, sleep problems, and learning problems. In patients with asthma, uncontrolled rhinitis seems to make asthma worse.
Allergic rhinitis
Allergic rhinitis is caused by substances that we breathe called allergens. Allergens are usually harmless substances that can cause problems only in some people. These problems are caused because the immune system of people with allergic rhinitis mistakenly identifies these substances as intruders and generates a reaction against them. During this reaction, the immune system cells release substances such as histamine and leukotrienes that cause the symptoms of allergic rhinitis; these and other substances also cause inflammation in the nasal lining that makes the nose very sensitive to irritants such as smoke and strong odors or to changes in the temperature and humidity of the air.
Causes:
1. When allergic rhinitis is caused by common outdoor allergens, such as airborne tree, grass and weed pollens or mold, it is called seasonal allergic rhinitis, or “hay fever.”
2. Allergic rhinitis is also triggered by common indoor allergens, such as animal dander (dried skin flakes and saliva), indoor mold, droppings from dust mites and cockroach particles. This is called perennial allergic rhinitis.
Symptoms
Sneezing
Stuffy nose (congestion)
Runny nose
Itching in the nose, roof of the mouth, throat, eyes and ears
Diagnosis
If you have symptoms of allergic rhinitis, an allergist/immunologist can help determine which specific allergens are triggering your illness. He or she will take a thorough health history, and then test use to determine if you have allergies. Skin tests or blood tests are the most common methods for determining your allergic rhinitis triggers.
What to Do During Pollen Season:
When outdoor pollens are high, remain indoors, particularly in the late morning. Pollen grains can cause significant allergic symptoms like asthma and allergic rhinitis, particularly during the spring and the fall. It is difficult to avoid pollen because it is windborne and can cover wide distances. Short of moving to a different location, here are some tips for avoiding pollen during the season.
1. The pollen count is usually highest in the late morning and early afternoon particularly during sunny, windy days. The pollen count measures the concentration of a specific pollen like birch tree pollen, in the area in a specific area and time. A pollen count is a useful guide for when it is advisable to stay indoors and avoid contact with pollen.
2. Keep the windows and doors closed during the allergy season.
3. Install a room air conditioner with a special filter.The special filter (High Efficiency Particulate Air or HEPA filter) traps airborne allergens. If the house does not have central air, the best spot to put the air conditioner and filter would be the bedroom. Change the filters frequently. An allergic person should also use the car air conditioner to decrease pollen exposure when commuting. Pollen allergic persons should not have a window fan blowing into their bedroom as this will maintain outdoor pollen exposure all night.
4. Avoid working outdoors, if you must wear a special face mask. The face mask is designed to filter pollen out of the air and keep it from reaching the nasal passages.
5. Consider taking a vacation at the height of the pollen season. Preferably at a location where the pollen exposure is minimal, like the seashore.
From the American Academy of Allergy, Asthma, and Immunology patient tips: Atopic dermatitis/eczema
Also see: Allergic Contact Dermatitis
A common allergic reaction often affecting the face, elbows and knees is atopic dermatitis, also known as eczema. This red, scaly, itchy rash is usually seen in young infants, but can occur later in life in individuals with personal or family histories of atopy, meaning asthma or allergic rhinitis (“hay fever”). Eczema may at times ooze, or at times may look very dry. A physician will rarely have difficulty diagnosing atopic dermatitis, based on three factors: an 1) itchy, 2) “eczematous” or bubbly rash in an 3) atopic individual. If one of these three features is missing, your physician should consider other causes.
Identifying the cause of the itch is essential in managing symptoms. Common triggers include overheating or sweating, and contact with irritants such as wool, pets or soaps. In older individuals, emotional stress can cause a flare-up. For some patients, usually children, food can also trigger eczema. Secondary staph infections also can cause a flare-up in children. These patients usually have very dry skin and “allergic shiners”-an extra crease, called a Dennie’s line, across their lower eyelids. They are also more susceptible to other skin infections.
Preventing the eczema itch is the primary goal of treatment. The patient must stop scratching and rubbing the rash. Applying cold compresses is helpful, and lubricating the dry skin with cream or ointment, especially during dry seasons, is essential. Patients should remove all “irritants” that aggravate the condition from their environments. If a food is identified as the culprit, it must be eliminated from the diet.
* Addendum: Recent studies have shown that patients with eczema lack a lipid known as ceramide in their skin and treatment with ceramide containing moisturizers helps heal eczema and dry skin faster.
Topical corticosteroid cream medications are most effective in treating the rash once all preventative measures are taken. Rarely, antihistamines or oral corticosteroids are also prescribed, and if a secondary infection has been introduced by scratching, antibiotics are required.
When to see an allergy/asthma specialist
Whenever you have an unusual rash, make sure to contact your allergist, who will work with you to determine its cause-whether allergies, irritants, or another trigger. Most importantly, your physician and other health care providers can offer a support system and assist you in managing your skin condition.
The AAAAI’s How the Allergist/Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence provide information to assist patients and health care professionals in determining when a patient may need consultation or ongoing specialty care by the allergist/immunologist. Patients should see an allergist/immunologist if they:
Need to confirm the diagnosis of atopic dermatitis or contact dermatitis in a patient with dermatitis.
Need to identify the origin of contact dermatitis.
Have atopic dermatitis that responds poorly to treatment.
Need to identify the role of mite allergy in patients with atopic dermatitis.
Need to identify the role of food allergy in patients with atopic dermatitis.
Your allergist/immunologist can provide you with more information on allergic skin conditions.
