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August 20
New Rescue Inhaler Available

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.

July 16
Allergy Myth Busters!

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.
 
Busted! 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 hypoallergenic.
 
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.
 
References
1. 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.
2. 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.

July 15
Our very own Allergy Myth Busters!

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:
Radiocontrast media reactions are related to shellfish allergy.
 
Busted! 
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.
 
References:
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.

June 12
Immunotherapy (Allergy Shots): The Allergy Partners Way

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 practice.

May 11
Increased severity of allergic reactions in women: Is estrogen to blame?

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 responses.
 
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.
 
Reference
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 December 2014.

May 01
Ask the Expert: "I have hives. I must have allergies."

Your Allergy 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. 
 
Your Allergy 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 other symptoms. 
 
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. 
 
Many 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. 

April 28
Intranasal influenza vaccination is well-tolerated in egg allergic children with asthma or recurrent wheeze

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.

April 14
Food Allergen Panel Testing Often Results in Misdiagnosis of Food Allergy

Food allergies 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.
 
Diets were 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 clinically allergic.
 
All Allergy 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.

April 02
Sleep Apnea and Asthma

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.

March 18
What is Sublingual Immunotherapy (SLIT)?

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. 
 
Reference

1.       Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review. JAMA. 2013 Mar 27;309(12):1278-88.

 

 

 

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