A new type of inhaler is now available to deliver albuterol
for patients with asthma or reversible COPD. The inhaler is called
ProairRespiclick and is available for patients 12 years or older to treat acute
symptoms of airway constriction (bronchospasm) or as prevention of exercise
induced asthma symptoms. Most patients refer to albuterol inhaler as the
“rescue” or “emergency” inhaler.
Current albuterol inhalers (Ventolin, Proventil, Proair HFA)
are all aerosol propelled meter dosed inhalers that most patients need a spacer
or holding chamber to deliver medicine effectively. Respiclick inhaler is
a dry powder inhaler and requires no spacer. The medicine is released and
delivered into your lungs by your own breath effort (breath-actuated).
This eliminates the need to coordinate dispensing the medicine with breathing
in the medicine. This step frequently results in poor delivery of the
medicine from traditional inhaler into your lungs.
There are 200 doses per inhaler with dose counter to track
doses remaining. No priming is required that would result in lost
doses. Respiclick must stay dry at all times. Patients with severe
cow’s milk allergy may not be candidate for this inhaler. Consult your
Allergist to see if dry powder albuterol inhaler is right for you. Dosing
directions and training on how to use this new style inhaler will be necessary
to discuss with your doctor. Opening the mouth piece guard will generate
a “click” and load the albuterol to inhale from the Respiclick. Educating
patients with asthma on how and when to use their inhalers is a critical
feature to a successful asthma management plan developed by Allergy Partners
physicians, nurses, and asthma educators.
Inspired by one
of our favorite television shows, Allergy Myth Busters looks at a number of
popularly held beliefs about allergy. But are these myths just urban legends or
are they true?
Myth: Some breeds of dogs are hypoallergenic,
so dog allergic patients can tolerate having these dogs in the home.
For many of us dog
allergies interfere with our love for these furry companions. Exposure to the
allergens from our beloved pets can lead to nasal, eye, skin and breathing
symptoms which can make life miserable. That makes the innovation of the
“hypoallergenic” dog an amazing breakthrough! Unfortunately what is well known
to allergists is that the existence of a hypoallergenic dog is a MYTH.
In a study
published in 2012, investigators from the Utrecht University in the Netherlands
compared Can f 1 levels (the major dog allergen) in the pet hair/coat samples
and the home environment of various alleged hypoallergenic (Labradoodle,
poodle, Spanish Waterdog, and Airedale terrier) and non-hypoallergenic dogs
(Labrador retriever and a control group composed of 47 different
non-hypoallergenic dog breeds and several crossbreeds.)They found that that Can
f 1 levels in hair and coat samples were related to the breed, BUT there was a
high variability within individual breeds. Can f 1 levels were significantly
higher in hair and coat samples in dog breeds considered hypoallergenic thus
they are not less allergenic than any other dogs. Similar findings were
published in another study from 2011 which examined dog allergen levels in
homes of hypoallergenic versus non-hypoallergenic dogs. It, too, showed that
there was no evidence of decreased shedding of allergens by dogs grouped as
The myth of the
hypoallergenic dog has been debunked. For those people who do suffer from dog
allergy, this does not mean that they have to get rid of their pet. Those
people who don’t want to give up “man’s best friends” can always try allergy
medications or be evaluated for immunotherapy/ allergy shots. If you
suffer from allergies to your pets, Allergy Partners can help you find relief.
Vredegoor DW, Willemse T, Chapman MD, Heederik DJJ, Krop EJM. Can f1 levels in
hair and homes of different dog breeds: lack of evidence to describeany dog
breed as hypoallergenic. J Allergy ClinImmunol 2012;130:904-9.
Nicholas CE, Wegienka GR, Havstad SL, Zoratti EM, Ownby DR, Johnson CC.Dog
allergen levels in homes with hypoallergenic compared with nonhypoallergenic
dogs. Am J Rhinol Allergy 2011;25:252-6.
Inspired by one of our favorite television shows, Allergy Myth Busters looks at a number of popularly held beliefs about allergy. But are these myths just urban legends or are they true?
Radiocontrast media reactions are related to shellfish allergy.
Patients with a history of allergy to shellfish are not at increased risk for anaphylaxis from iodinated contrast media. This myth stems from the false assumption that an iodine allergy is the common cause of contrast media and shellfish allergy. In fact, iodine is not an allergen and is structurally unrelated to the tropomyosin proteins which can cause anaphylactic reactions to shellfish. Although it is clear that contrast media can cause a variety of reactions, the mechanism of most of these is poorly understood and is not due to ‘iodine allergy’. Individuals with any allergic condition are at higher risk of contrast media reactions, regardless of a history of allergy to seafood. Fortunately, reactions to contrast media are quite low.
In some patients scheduled for procedures using contrast dye, precautions should be taken, such as premedication with antihistamines or steroids or using low osmolal contrast material (LOCM) agents. So who deserves these precautions? Empiric use of LOCM agents for all intravascular procedures has become widespread and has largely eliminated the need for premedication. In settings where LOCM agents are not routine, nonionic LOCMs or iso-osmolal agents should be considered for patients with asthma and patients taking beta-blockers, interleukin-2, or NSAIDS (eg. Aspirin, ibuprofen). In addition, nonionic LOCM agents should be considered in patients with a previous history of serious reactions to radiocontrast media, patients receiving contrast by power injector, or any other circumstance in which the clinician believes that it is indicated. In the absence of a history of immediate hypersensitivity reactions to contrast media in the past, empiric premedication with antihistamines and steroids is generally not indicated.
American College of Radiology Committee on Drugs and Contrast Media. ACR Manual on Contrast Media, 5th ed, American College of Radiology, Reston VA 2004. p.5.
Solensky R, Khan DA. Drug Allergy: an updated parameter. Ann Allergy Asthma Immunol. 2010 Oct;105(5):259-73.
Greenberger P. Prophylaxis against repeated radio contrast media reaction in 857 cases. Arch Intern Med. 1085;145:2197-200.
Lang DM, Alpern MB, Visintainer PF, Smith ST. Elevated risk for anaphylactoid reaction from radiographic contrast media associated with both beta blocker exposure and cardiovascular disorders. Arch Intern Med. 1993;153:2033-40.
Allergy immunotherapy, more commonly referred to as
allergy shots, is the most effective treatment available for environmental
allergies. By reducing your reactions to pollens, pet dander, molds and dust
mites, allergy shots reduce symptoms and your need for medication. While
it is a highly effective treatment, immunotherapy does not contain medication
and is composed of natural protein extracts from allergens. By giving gradually
increasing doses of the allergen, immunotherapy teaches your immune system to
tolerate exposure to the allergens in the environment. It is highly effective
in treating sinus and eye symptoms along with asthma, sinusitis and allergy
induced eczema. To assure that proper treatment is provided, immunotherapy
should always be prescribed by a board certified allergist. Certification by
the American Board of Allergy, Asthma and Immunology assures that your doctor
has received at least 2 years of additional training specifically in treating
allergic diseases. Only through this intense training can a doctor gain
full knowledge of immunotherapy treatment.
While immunotherapy is the cornerstone of the allergy
specialty, not all allergy shots are created equally. Allergy Partners strives
to provide the most effective, safe and cost effective care possible.
Allergy Partners was founded on a simple premise: by working together, allergists
can identify and implement best practices, which will result in improved
patient care. By following this premise we have grown to over 100 allergists
across the United States, and our shared knowledge and experience is
unsurpassed in allergy and asthma care. We have applied this knowledge to
create a state of the art immunotherapy program. To produce optimal results,
immunotherapy protocols must follow national guidelines which are based on the
latest research. These guidelines include proper patient selection, allergy
testing, and immunotherapy dosing. As the leader in allergy and asthma
care, Allergy Partners has compiled the largest collection of data and
information about allergy shots in the world. We are continually utilizing this
experience to further improve patient care. Furthermore, our Clinical
Excellence committee continually reviews the medical literature and assures
that our treatment program is state of the art.
The Allergy Partners immunotherapy protocols strictly
adhere to national practice guidelines and were developed in collaboration with
nationally recognized experts. To maintain the highest quality standards
throughout the immunotherapy treatment process, we compound our immunotherapy
extract at our centralized lab in Asheville, NC. Our lab was planned and
built in collaboration with industry experts and the FDA Center for Biologics
Evaluation and Research. Today we produce over a quarter of a million vials
annually of the highest quality allergy extract possible. Allergy
Partners extract labs strictly follows USP 797 guidelines for sterile
allergenic extract processing, and it is through this attention to detail that
we can provide you will be provided safe and effective treatment.
We invite you to learn more about
Allergy Partners, the conditions we treat and our immunotherapy treatment
program by browsing our website or contacting your local Allergy Partners
Previous research indicates that women tend to experience
more severe allergic reactions - anaphylaxis – than men. The reason behind this
has remained somewhat of a mystery, however, a new study published in The
Journal of Allergy and Clinical Immunology suggests estrogen could be to
blame. Researchers from the National Institute of Allergy and Infectious
Diseases have explored sex-dependent differences in a mouse model of
anaphylaxis to explore how female sex hormones, estrogen, may be involved.
In this study, anaphylaxis was induced in both female and
male mice by using histamine, as well as Immunoglobulin E (IgE) and
Immunoglobulin G (IgG) receptor aggregation. Anaphylaxis was assessed by
monitoring body temperature, release of mast cell mediators, and lung weight.
Researchers were able to observe that female mice experienced
anaphylaxis that was more severe and lasted longer compared to their male
counterparts. This enhanced severity was eliminated after pretreatment with an
estrogen receptor antagonist or ovariectomy. They found that estrogen
influenced blood vessels and enhanced the levels and activity of endothelial
nitric oxide synthase (eNOS), an enzyme that drives anaphylaxis. When eNOS
activity was blocked, the gender difference disappeared. When they blocked
estrogen in female mice, this decreased the severity of their allergic
This study demonstrates a link between estrogen and eNOS in
severe allergic reactions in female mice. The results may shed light on why
women have more severe allergic reactions than men, however, further research
is needed to determine whether there is a similar effect in humans.
Estrogen increases the severity of anaphylaxis in female mice
through enhanced endothelial nitric oxide synthase expression and nitric oxide
production, Valerie Hox, et.al.,The Journal of Allergy and Clinical
Immunology, doi:https://dx.doi.org/10.1016/j.jaci.2014.11.003, published 29
Partners physician would likely respond to the above statement with a cautious
“maybe.” Hives, like many of the responses of the body, can be caused by
many stimuli, not just allergies. Take, for instance, the similar example
of sneezing. Sneezing is a common allergic symptom; however, we all know
that non-allergic stimuli can cause sneezing, from infections due to the common
cold to irritants in the air (pepper, for example). In a likewise fashion,
hives can be due to allergic and non-allergic causes.
Partners doctor will take a careful history and perform a thorough examination
when considering whether your hives are due to an allergic reaction. Be
prepared to answer questions on how long your symptoms have lasted, any recent
exposures to new foods or medications, and whether you have experienced any
If you have had
hives almost daily for six weeks or more, your allergist may use the term
“chronic” to describe your condition. Hives lasting less than six weeks
are called “acute”. The distinction between “acute” and “chronic” is
important, as acute hives are more frequently associated with identifiable
causes. If supported by the details of your history, allergy testing may
be helpful in identifying causes of acute hives.
non-allergic conditions have been reported to be associated with chronic hives,
including various infections, connective tissue diseases, thyroid dysfunction,
and endocrine disorders. If your symptoms do not readily suggest one of
these conditions, extensive laboratory testing is not typically warranted or
necessary. Extensive testing is not cost-effective and does not appear to
improve patient outcomes. In light of an unremarkable clinical history
and physical examination, laboratory evaluation and allergy testing rarely identifies
a cause for chronic hives.
Hives can be
incredibly uncomfortable and frustrating. Hives typically improve with a
regimen of antihistamines, regardless of the cause. For cases of chronic
hives that do not respond to antihistamines, alternative treatments are
available. A newly approved approach to chronic hives utilizes the medication
Xolair (omalizumab). This medication was initially developed for patients
suffering from moderate to severe allergic asthma, but has shown to be
effective in chronic hives. With your input, your Allergy Partners physician
can decide what testing and treatment options are best for you.
Nobody likes getting a shot, especially children.
However, US health guidelines recommend annual influenza vaccination of
children, especially those with asthma, and including those with egg allergy.
Live attenuated influenza vaccine (LAIV) is an intranasal vaccine administered
via the nose licensed for use in children. However, this vaccine contains egg
protein and it is currently suggested that it not be used on children with egg
allergy. Furthermore, North American guidelines recommend against its use in
children with asthma. Thus, asthmatic or egg allergic children receive a
traditional flu shot.
In a study recently published online by The Journal of Allergy and Clinical
Immunology (JACI), Turner and colleagues present the results of the
SNIFFLE-1 Study. In this study, 433 doses of LAIV intranasal flu
vaccine were administered to 282 children with egg allergy. Two thirds of
the children also had a physician diagnosis of asthma/recurrent wheezing and
41% had experienced a prior anaphylactic (severe allergic) reaction to egg.
The study found that influenza vaccination using LAIV was safe in egg-allergic
children – including those with a prior history of anaphylaxis – with no
systemic allergic manifestations seen. Eight children experienced mild short
lived symptoms, which may have been due to an IgE-mediated allergic
reaction. However, noting the intranasal reaction thresholds to egg, the
authors suggest these reactions were not likely to have been caused by egg
protein and were probably due to other ingredients in the vaccine.
Importantly, in those children with a history of asthma or recurrent wheezing,
there was no significant increase in respiratory symptoms requiring medical
treatment in the 72 hours following vaccination with LAIV. This suggests that
the current guidelines may be unnecessarily over-restrictive in terms of this
vaccine’s use in patients with asthma or egg-allergy. This study may help lead
to changes in the current guidelines and make an annual flu vaccine more
pleasant for kids with asthma and egg allergy.
have become an increasing public health issue. Recent studies now indicate that
nearly 1 in 13 children are diagnosed with food allergy. Food allergies are
triggered when the immune system make a special type of antibody, called IgE,
directed against foods. On re-exposure to the food, the IgE antibody can
trigger severe, even life threatening allergic reactions.
The diagnosis of
food allergy is typically done through a combination of a detailed medical
history coupled with specific food allergy testing. Classically, such testing
is through skin prick testing where a small amount of the food is applied to
the skin and the skin is then pricked with a small sterile probe, allowing the
liquid to seep under the skin. After about 20 minutes, a hive (a bump similar
to a mosquito bite) may form indicating allergy. More recently, a blood based
test commonly referred to as RAST or Immunocap testing has grown increasingly
popular. Unfortunately, these blood based tests can be overly sensitive and
have false positive results. This can lead to misdiagnosis of food allergy
which leads to unnecessary food avoidance, unnecessary medication
prescriptions, and increased cost.
In a recent
study in Journal of Pediatrics, Bird and colleagues at the University of
Texas Southwestern Medical Center and Dell Children’s Medical Center in Dallas
reviewed the charts of 797 patients referred for evaluation of possible food
allergy. They selected patients in whom the primary care provider had ordered a
standard panel of food-specific IgE tests. Such a panel was done in 284 (35%)
of all patients. Of these, only 90 patients (32.8%) had a history that
warranted such testing.
altered in 126 of patients based on the initial testing. Of these, 72 did not
have histories suggestive of food allergy and all of these individuals were
found to not have food allergy. In total, 112 (88.9%) of the 126 patients who
were avoiding foods were able to reintroduce at least one food. It was
estimated that the cost associated with those patients whose history did not
warrant food allergy testing was $79, 412.
The diagnosis of
food allergy hinges on a detailed history and physical exam. Food-specific IgE
testing is a vital tool used to confirm food allergy. This study, however,
highlights that panels of food specific IgE tests have little utility as a
screening tool. Such panels often result in the over-diagnosis of food allergy.
A ‘positive’ test does not automatically translate into clinical food allergy,
as a significant proportion of individuals with a positive test are not
Partners physicians are Board Certified Allergist-Immunologists. This means
that they have undergone two to three years of specialized training in the
diagnosis, treatment and management of allergic diseases, including food
allergy. They have expertise in the interpretation of food allergy test results
and are equipped to offer food challenges which are the definitive test for the
diagnosis of food allergy. If you are concerned about food allergy, contact
your Allergy Partners physician.
Source: Bird JA,
Crain M, Varshney P. Food Allergen Panel Testing Often Results in Misdiagnosis
of Food Allergy. J Pediatrics 2014:166(1):97-100.
Sleep apnea is a common disorder in which you have one or more pauses in
breathing or shallow breaths while you sleep. Breathing pauses can last from a
few seconds to minutes and they may occur 30 times or more an hour. Typically,
normal breathing then starts again, sometimes with a loud snort or choking sound.
Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep.
As a result, the quality of your sleep is poor, which makes you tired during
the day. Sleep apnea is a leading cause of excessive daytime sleepiness. More
importantly, sleep apnea can increase your risk of high blood pressure, heart
attack, stroke, diabetes and obesity.
There is evidence
suggesting that a relationship exists between asthma and obstructive sleep
apnea. A recent study in the Journal of the American Medical Association
investigated if having asthma increased the risk of developing obstructive
sleep apnea (The
Association between Asthma and Risk of Developing Obstructive Sleep Apnea. JAMA
2015: 313 (2):156-164.).
This study used a population that consisted
of adults who had overnight sleep studies completed at 4 year intervals
starting in 1988 (The Wisconsin Sleep Cohort Study). Asthma and additional
information was assessed during these studies through March 2013.
The results found that participants with
bronchial asthma had a significantly higher incidence of developing obstructive
sleep apnea (27%) at their first 4 year follow up interval sleep study, versus
16% of the participants without asthma who developed sleep apnea at that
interval. Using all 4 year interval studies, there was also a significantly
higher percentage of participants with bronchial asthma who developed
obstructive sleep apnea (27% ), versus 17% of non-asthmatic participants who
developed obstructive sleep apnea.
In summary this study found that
preexistent asthma was a risk factor for an asthmatic patient developing
clinically relevant obstructive sleep apnea over a 4 year period. It was also
found that the longer the time a patient had bronchial asthma, the more likely
that the patient would develop obstructive sleep apnea.
Therefore, obstructive sleep apnea should
be considered in asthmatic patients with symptoms suggestive of sleep apnea,
and especially those patients who have a history of long-standing bronchial
asthma. Symptoms of sleep apnea include snoring, choking or gasping while
sleeping, daytime sleepiness, or not feeling well rested after sleep.
Identifying and treating obstructive sleep apnea in asthmatic patients has been
found to be beneficial, since another study has shown that treating obstructive
sleep apnea in patients with asthma leads to improvement in asthma symptoms,
improved air movement and improved quality of life.
If you think you have a sleep problem, consider keeping a
sleep diary for 1 to 2 weeks. Bring the diary with you to your next doctor’s
appointment. Write down when you go to sleep, wake up, and take naps. Also
write down how much you sleep each night, how alert and rested you feel in the
morning, and how sleepy you feel at various times during the day. This
information can help your doctor figure out whether you have a sleep disorder.
SLIT is an alternative method of allergen desensitization in the management of atopic conditions such as asthma and allergic rhinitis, which does not involve a series of injections. The protocol for SLIT involves an allergist determining a patient’s sensitizing allergens, typically by skin testing, followed by small doses of these allergens placed under the tongue daily in the form of tablets or drops. This causes a decrease in the body’s natural production of specific allergic antibody, called IgE.
Though SLIT is widely accepted and standard in Europe, not all SLIT therapy is approved in the US by the Food and Drug Administration (FDA). A tablet form of SLIT for patients with grass and ragweed allergy (GRASTEK, ORALAIR, RAGWITEK) has been FDA approved and is currently available for physicians to prescribe. While yet to be approved by the FDA, sublingual drop therapy formulated by your Allergy Partners physician is available for “off label” use.
Does it Work?
There is mounting evidence that SLIT is an effective treatment strategy in the management of allergic conditions. A recent systematic review in the Journal of the American Medical Association states: “The overall evidence provides a moderate grade level of evidence to support the effectiveness of sublingual immunotherapy for the treatment of allergic rhinitis and asthma, but high-quality studies are still needed to answer questions regarding optimal dosing strategies.”1Though evidence supports SLIT being more efficacious compared to some traditional treatment strategies, it is very clear that subcutaneous injection immunotherapy (allergy shots) is favorable to SLIT in reducing allergy symptoms.
What Are the Side Effects?
In general, SLIT is well tolerated. Patients may have oral itching or mild tongue swelling after the first 3-4 doses. However, these symptoms typically subside. Other potential side effects include: trouble breathing, throat tightness, throat swelling, dizziness, rapid heartbeat, severe stomach cramps, vomiting, diarrhea, and severe flushing of the skin. As there is risk for anaphylaxis, all patients on SLIT therapy should have access to an epinephrine pen and be trained on its use and the first dose of SLIT is administered in a physician’s office.
Is it For Me?
There are certainly advantages to SLIT. Published data does demonstrate clinical efficacy and you can expect to see improvement in your allergy symptoms. For patients with busy schedules, SLIT makes immunotherapy less cumbersome as treatment can be given at home. For children with “needle phobia,” SLIT provides an alternative option to avoid weekly injections. Although allergy shots are the most efficacious form of immunotherapy, there undoubtedly is a role for SLIT in the management of allergic disease. Talk to your Allergy Partners physician about whether SLIT is the best option for management of your allergy symptoms.
1. Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review. JAMA. 2013 Mar 27;309(12):1278-88.
Welcome to our blog site! Stay tuned to get the latest news. We will share tips and techniques for living with and managing your Allergies & Asthma. We look forward to sharing useful resources with our patients!