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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.

 

 

 

March 10
Food Allergy and Product Labeling

Food allergy is estimated to affect 5 to 7% of infants and 1 to 2% of adults. Currently there is no cure for food allergy and patients must adhere to a strict regimen of dietary avoidance of foods to which they are allergic. Despite the best of intentions, accidental exposure to food allergens remains a significant cause of allergic reactions. To avoid such exposure, food allergic patients and their families rely on food package labels to identify possible triggers.

 

The Food Allergy Labeling and Consumer Protection Act of 2004 requires packaged foods sold in the United States to clearly list the eight primary food allergens in plain English on the ingredient label. These 8 foods are milk, egg, wheat, soybean, peanut, tree nuts, fish and shellfish. However, for foods that may accidentally contain small amounts of allergens- such as being produced in a factory that handles the allergen- precautionary labels may be applied to food products as well. Such precautionary labeling is neither consistent nor regulated. Food allergic patients have varying levels of tolerance to allergens and such precautionary labels could lead to confusion and unnecessary risk taking behavior.
 
In January, Medical News Today reported on a study published in the Journal of Allergy and Clinical Immunology (January 2015) by the research team led by Clare Mills, PhD of the Institute of Inflammation and Repair at the University of Manchester in the UK.  Researchers sought to better define the threshold doses of 5 major food allergens (peanut, hazelnut, celery, fish and shrimp) in a European population. What researchers were able to demonstrate was that for these foods there is threshold dose below which only 10% of allergic subjects will react. Though more research is needed, such new data could help better identify allergen doses that are safe versus those doses which may trigger a reaction. This information would help improve patient safety through refined product labeling.
 
These new findings highlight how essential it is for patients with suspected food allergy to be evaluated by an allergist who will not only assess but help minimize the risk for future food reactions.

 

References:

1.       “Study identifies levels at which five foods may trigger allergic reactions” Medical News Today. January 2015.
2.       Mills C et al. How much is too much?: Threshold dose distributions for 5 food allergens. J Allergy Clin Immunol 2014, published online January 2015, abstract.
 

 

March 03
Preventing Peanut Allergy with Early Exposure

Peanut allergy can result in severe, and at times fatal, allergic reactions. Unfortunately, peanut allergy has become more and more common over the years. A new study, however, gives hope that early interventions may decrease the risk of developing peanut allergy.

  

A recent study published in the New England Journal of Medicine suggests that early exposure to peanuts helps to prevent peanut sensitization in high risk children.  The study was performed in response to the significant increase in the incidence of peanut allergy worldwide, especially in westernized countries, such as the United States.  The most recent recommendations by the American Academy of Pediatrics (AAP) came in 2000, in response to outcomes from infant feeding trials conducted in Europe and the United States.  At that time, the AAP recommended refraining from introduction of peanuts to children until age 3.  Despite this recommendation, the incidence of peanut allergy continues to rise, and in 2008, the AAP retracted its recommendation due to insufficient evidence.  Since that time, multiple observational studies have found that early introduction of peanut protein, as well as cow's milk and egg, result in decreased incidence of these food allergies.  
 
In a new study by Du Toit et al., Learning Early about Peanut Allergy (LEAP), investigators studied over 500 infants at high risk of peanut allergy (severe eczema, egg allergy, or both).  Half of the children were randomly selected to consume peanuts and the other half, to avoid peanuts.  At age 5, the children underwent peanut challenge to determine if they were allergic.  Results indicated that the prevalence of peanut allergy in the peanut-avoidance group was significantly higher at 17.2%, compared to 3.2% in the group that consumed peanuts.
 
The trial went on to compare two groups: one group of infants with skin prick test (SPT) that was initially negative to peanut, and another with mildly positive results (wheal of 1-4mm).  Infants with a wheal of >4mm were excluded from the study (about 10%).  In infants with an initially negative SPT, prevalence of peanut allergy was 13.7% in the avoidance group and 1.9% in the consumption group.  For infants with mildly positive SPT, the prevalence of peanut allergy was 35.3% in the avoidance group and 10.6% in the consumption group.  
 
Although many questions still remain, early testing of infants at high risk for peanut allergy in the first 4-8 months of life, along with early introduction of peanut protein or in-office peanut challenge may have the potential to prevent peanut allergy in the future.  
 
Allergy Partners’ board certified allergists are experts in the diagnosis and treatment of food allergies. If you have questions regarding food allergies, contact your local Allergy Partners physician.
 

 

 

 

February 25
The Importance of Using Controller Medicines Daily

Asthma is a condition due to airway inflammation often associated with an allergic component. It is characterized by symptoms that can include chest tightness, cough, shortness of breath and wheezing, which may be intermittent or persistent. Proper diagnosis requires a thorough history, physical examination, appropriate lung function testing and allergy testing.

 
Acute, or severe asthma, can present as a rapid or gradual increase in symptoms resulting in an acute attack or exacerbation. Chronic asthma, or persistent asthma, may present with intermittent symptoms or even nocturnal awakening.
 
Control of asthma is defined as an absence or decrease in asthmatic symptoms and improvement in the quality of life. A 5-question survey known as the ACT defines uncontrolled asthma on the basis of a score of less than 19 out of a possible 25.
 

The key to controlling asthma is through the regular use of asthma controller medications such as inhaled corticosteroids, antileukotrienes, or combination inhalers containing inhaled corticosteroids and long-acting bronchodilators. These drugs treat the underlying cause of asthma, namely airway inflammation. They are most often delivered by inhalers with the exception of the antileukotrienes, which are taken orally. Short-acting bronchodilators such as albuterol, are considered relievers and are meant to be used on an as-needed basis or before exercise.  The need for a reliever inhaler more than 2 days a week or 2 nights a month is a sign of poorly controlled asthma.

 
Recent studies have demonstrated adherence to asthma medications averages only 50%. In other words, one-half of patients do not take their controller medicine regularly. This is extremely important, as improved adherence is associated with less asthma attacks and an improved quality of life and more symptom-free days. Thus non-adherence is associated with a lack of asthma control, poor health outcomes and increased costs.
 
The reasons for the lack of regular use of asthma control drugs are varied. The cost, co-pays and coverage for these drugs varies widely and high costs can be a barrier for many people. Some patients are worried about ‘being dependent’ on daily medications while many people simply find it hard to remember to take medication once or twice a day. Additionally, correct inhaler technique is vital to ensure that the medicine, when taken, is effective.
 
The physician-patient relationship is vital in improving adherence. Understanding, trust and mutual respect are absolutely necessary between a patient and physician. For example, patients should understand the difference between an oral steroid like prednisone  and an inhaled corticosteroid in terms of their safety and efficacy. Patients should feel confident in why they are taking certain medications and in how they are taking it. Regular follow up visits are vital. Asthma can have fluctuations that require adjusting therapy up or down depending on the situation. Thus prescribing or changing an asthma regime requires feedback to insure safety, efficacy and compliance. Adjustments in dosing, if needed,  can be made on subsequent visits, usually 4-6 weeks apart, or as long as 90 days.
 
Newly developed electronic monitoring devices have the potential to be a very important asset to remind and reinforce with patients when to take their medication. Such devices may even provide vocal reminders that the medicines are due. Documenting the regular use of these medications is of great use to physicians as well as to patients.
 

In addition to devices that remind us to take medication, the future of asthma therapy will no doubt include lung function peak flow monitoring via the smart phone. This will allow both patients and physicians to get a much fuller picture of an individual’s asthma and allow far greater individualized care.

 

Managing asthma successfully hinges upon using controller medications, such as inhaled steroid, regularly. Regular use improves symptoms and quality of life and reduces the risk of asthma exacerbations. For many, however, adherence can be challenging. Effecting behavior change is quite difficult and time consuming. It requires reinforcement and even such devices as peak expiratory flow meters to be used by the patient at home. Technology should lead the way in helping patients and physicians alike improve asthma control.  In recent years we have all seen tremendous advances in technology that have not only made our lives better, but improved the quality of our lives. Such an outcome would be welcome in the care of our asthmatic patients. As Leaders in Allergy and Asthma Care, Allergy Partners is actively working to bring this technology to our patients.

 
 
 

February 16
Smart Inhalers

Smart Inhalers

 

 
Remembering to take medications every day can be difficult for many people. For asthma patients, forgetting to take daily controller inhalers can lead to more asthma exacerbations. New technology, however, may help asthmatics remember their medications and keep asthma under better control.
 
On June 3rd, 2014, a New Zealand company, Nexus6, announced it received marketing clearance for SmartTouch, an inhaler monitoring device. In the recent December issue of the Journal of Allergy and Clinical Immunology a study was published titled Inhaler reminders improve adherence with controller treatment in primary care patients with asthma by Foster et al. It used the SmartTouch device to measure asthma medication adherence. The device, which can connect to the internet via smart phones and other devices, records doses and provides reminders for missed doses. At six months, adherence in the reminder group was double (60%) that of the non-reminder group (29%) whose adherence data was collected covertly. The reminder group also had a statistically significant reduction in severe exacerbations (11% versus 28%) compared to the non-reminder group. Such data will help health care providers distinguish patients that are refractory to treatment versus treatment failures due to non-compliance. A similar device appears on their website for nasal sprays.
 
Per the company website, the SmartinhalerAppTM is available on iPad, iPhone and Android devices although it was not found in the iTunes App Store as of January 14. It appears the SmartTouch device is preparing for U.S. markets given the product section of the  company website has a color matching device for most American branded inhaler products available.
 

 

The availability of a "Smart Inhaler" should benefit both patients and physicians. We may eventually see devices that can alert pharmacies when your inhaler is running low. The physician can be alerted if rescue inhaler usage has exceeded the recommended amount. Can't recall if you took your scheduled controller last night? Check the log. No more over or under reporting of medication use based on what a patient thinks the physician wants to hear. Patient reminders and accurate adherence records will help improve asthma control as we continue to become further connected electronically.

 

 

 

February 03
Outdoor Air Quality: How to Protect Yourself from Unhealthy Air

Have you ever wondered what to make of those air quality warnings you hear on the news?  These warnings are intended to help you take action to avoid harmful air, but it is not always clear what they really mean and what actions are reasonable and necessary.  Here is a brief history of the system behind the Air Quality Index (AQI), and education regarding how these warnings can help you breathe better.

 

 
The AQI was developed by the Environmental Protection Agency in 1968.  It measures the levels of 5 major air pollutants regulated by the Clean Air Act: particle pollution, ground-level ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide.   Of these, ozone and particle pollution pose the greatest risk to your health. 
 

 

The AQI is a number from 0-500 for each of these pollutants, and anything below 50 is considered good.  From 50-100 only very sensitive people will be affected.  Above 100 more people will begin to experience problems, especially people with allergies, asthma, COPD, heart disease, the elderly, and children.  Above 150 even healthy people might begin to have problems.
 
Air Quality.png

Health effects of air pollution include irritation of the nose, throat, and lungs, worsening asthma, increased susceptibility to respiratory infections, and even long term damage to these areas if the exposure is high and prolonged.
 
So what action should you take when the AQI is elevated?  The first step is to build awareness of how your own body reacts to air pollution, by keeping track of air quality (www.airnow.gov or the AIRNow app), and seeing what symptoms you experience.  You may find you need to take precautions in the Yellow or Orange range.  Everybody should take precautions once levels are in the Red range or worse.  Precautions include avoiding exercising outdoors when AQI is poor, and limiting your children’s outdoor play.  Go to the gym or walk at the mall instead of jogging outdoors.  Use the air conditioner in your home and auto to help filter the air.  If you have asthma or allergies you may need to take extra precautions.  Discuss this with your Allergy Partners physician and make a plan to maintain optimal health.

 

January 20
Is There A Simple Way to Help Prevent the Onset of Atopic Dermatitis/Eczema in Children?

Atopic dermatitis or atopic eczema is a chronic inflammatory skin condition that causes itching of the skin and chronic or recurrent skin lesions. Atopic dermatitis can significantly impair quality of life due to sleep disturbance, skin changes and scarring, and skin infections.  Treatment may require topical or oral steroids which have potential side effects. Studies that have evaluated allergen avoidance measures as a means to PREVENT atopic dermatitis have not shown much benefit. However, new studies indicate that using inexpensive moisturizing emollients at a very young age may prevent eczema and perhaps even allergies in at risk children.

 

 
Atopic dermatitis is now felt to result from skin barrier defects. Many people with eczema have defects in a protein called filaggrin in the top layers of skin. This protein and lipid layers together help maintain a healthy skin barrier. The outer layers of skin are important to retain skin moisture and act as an effective barrier to environmental allergens and irritants.  The question is whether or not enhancement of the defective skin barrier could prevent or delay the onset of atopic dermatitis. Emollients (hydrating agents) improve the skin barrier by providing extra lipids to the skin. 
 
Recent studies have evaluated the benefit of early application of emollients to the skin of infants at high risk for developing atopic dermatitis and have shown positive results.  In a pilot study done in the United States and in the United Kingdom, daily application of an emollient to the entire body surface, except the scalp, beginning by 3 weeks of age showed a reduction in the incidence of atopic dermatitis at 6 months of age. The emollients used in the US included sunflower seed oil with a high ratio of linoleic acid/oleic acid, Cetaphil cream, and Aquaphor ointment.  Most parents preferred using a cream and there were no adverse effects noted from applying the moisturizers.
 
Allergen sensitization can occur through skin that is not intact and preventing the development of atopic dermatitis may reduce allergic sensitization. For example, studies have identified peanut allergen in dust in homes where peanuts are consumed and skin exposure to this allergen is believed to sensitize some infants and children with eczema to peanut.  Thus, applying an emollient cream such as Cetaphil on a daily basis beginning shortly after an infant is born may prevent the development of atopic dermatitis and sensitization to allergens through the skin.
 

 

Once atopic dermatitis is established, use of emollients remains a mainstay of treatment. In addition, evaluation by an allergist and allergy testing can help identify environmental or dietary allergic sensitivity that may be triggering symptoms. Your Allergy Partners physician will work with you to develop an individualized treatment plan that includes avoidance of allergens and irritants and other skin care recommendations.

 

January 12
Alternative Medicine and Allergy/Asthma: What Really Works

Pharmacy shelves are stocked with herbs and supplements that claim to improve health. Such complementary and alternative medicines (CAM) are part of a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of the conventional medical practices.

 

 
Over 42 percent of people in the US (both adults and children) have used CAM for their allergic disorders. Such treatments are perceived to be natural and safe by patients, but reporting of adverse effects is largely inadequate. But do CAM therapies really help with allergies and asthma? Importantly, are CAM therapies safe?
Chinese Herbal Medicine has been used for centuries in Asia. However, lack of standardization and controlled clinical trials have hampered their use as conventional therapies in Western medicine. There is potential for developing novel therapies for atopic diseases from Chinese herbs. Several herbal formulas show early promise for the treatment of asthma, food allergies, and allergic rhinitis in randomized trials. Work remains to determine the active components of each herb and their mechanisms of action. In addition, issues with consistency of herb quality and standardization still need to be addressed.
 
Other Herbal therapies like Ayurvedic mixes, butterbur, and Tinofend have demonstrated some efficacy but these treatments may have side effects.  These products are not systematically monitored for safety by drug regulatory bodies. Herbal remedies, including teas, made from plants can cause allergic reactions, such as hives, or can induce asthma symptoms. Pregnant and nursing patients should be advised to avoid these herbal therapies.
 
Nasal sprays consisting of dilute solutions of capsaicin or inert, micronized cellulose powder have shown efficacy for allergic rhinitis. Nasal saline lavage, commonly with a nettie pot can be effective in alleviating symptoms of nasal congestion and drainage.
 
A variety of other herbal preparations, homeopathic products, and miscellaneous therapies have been suggested for the treatment of allergic rhinitis or conjunctivitis. However, studies have either been of low quality or failed to show benefit.  Additionally, a number of herbs such as chamomile and Echinacea can cause allergic reactions in people who are allergic to ragweed pollen.
 
Vitamin D deficiency has been increasingly recognized as a health issue, particularly in northern latitudes. Low Vitamin D levels have been associated with increased rates of food allergy. It’s too early to say whether vitamin D can reverse food allergies. Future research is needed to answer that question. However, research is beginning to support the idea that vitamin D can protect against food allergies and vitamin D is important for overall good health.
For most people, the best way to ensure you have enough vitamin D is a combination between sensible sun exposure and adequate intake of foods containing the vitamin. Your doctor can assess your vitamin D status with a simple blood test and recommend a supplement if necessary
 
Non-pharmacologic interventions such as Acupuncture and Acupressure (Stainless steel pellets in adhesive discs are applied to specified points “acupoints” on the ear) show modest benefit in the treatment of allergic rhinitis, although it is difficult to estimate the size of the effect in most studies. 
 

 

With all CAM interventions, it is vitally important to discuss your use of these therapies with your doctor. Additionally, CAM therapies should not be used in place of conventional therapies without first talking to your doctor.

 

November 21
Winter Allergies

Winter Allergies
As the calendar turns to the winter months, many allergy sufferers let out a sigh of relief. No more pollen means no more sneezing and itching. But, for others winter time means winter allergies. Winter allergies? Yes, winter allergies.
 
With colder weather, we close up the house and get out our warm blankets and comforters. Pets come indoors to snuggle. And for those allergic to pets and dust mites, winter means more allergy symptoms.
 
Dust mites are microscopic, eight legged creatures that feed on flakes of dead skin. They absorb moisture from the air as opposed to drinking. Therefore, they like to live where people are and where it is humid. Beds, bedding and carpets provide dust mites the perfect place to live. And no matter how clean your house is, you have dust mites.
 
Allergy to dust mites is one of the most common allergies. Up to 1 in 4 people are allergic to dust mites and over 45% of homes have enough dust mite allergen to trigger asthma and allergies. Symptoms of dust mite allergy tend to be a bit different from pollen triggered allergies. As opposed to sudden fits of sneezing, clear watery runny nose and itchy eyes, dust mite allergy tends to cause more chronic nasal congestion that is worse first thing in the morning. People allergic to dust mites are more prone to ear and sinus infections. Dust mite allergy also worsens other underlying allergies.
 
So what should you do? The first step is to find out if you are dust mite allergic. Allergen skin testing under the direction of your Board Certified Allergy Partners physician remains the best way to diagnose allergies. If you are dust mite allergic, the following can help limit your exposure:
 
1.    Limit dust collectors such as stuffed animals in the bedroom
2.    Wash bedding in hot water (130 degrees)
3.    Vacuum carpets regularly with a HEPA filter vacuum
4.    Consider steam cleaning your carpets yearly
5.    Invest in high quality allergen encasements for your mattress and pillows to put a barrier between you and the dust mites.
 
Treatment of dust mite allergy symptoms can include the use of over the counter and prescription medicines. For those interested in preventing symptoms, allergen immunotherapy (AKA allergy shots) can provide relief without having to take daily medications. Your Allergy Partners physician will work with you to determine the best options for you and your family.
 
To learn more about allergen encasements visit www.allergyguardian.com
 
To learn more about controlling your indoor air quality visit www.O2airpurifier.com
 

To learn more about allergies, asthma and our practice visit

 

September 23
O2 Air Purifier

                The O2 Air Purifier attracts and eliminates not only allergens, but also mold, bacteria, germs and odors.
                Learn more today about how you can truly breathe fresh air at home.  www.o2airpurifier.com/comprehensive

 

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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!


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