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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

 

September 18
Don't miss out! Asthma webinar

Dr. Heather Gutekunst, Allergy Partners of Raleigh, hosted a great webinar last night on the symptoms and treatment options for Asthma.  Her colleagues, Dr. Vaishali Mankad, Allergy Partners of Raleigh, and Dr. Ananth Thyagarajan, Allergy Partners of Richmond, joined in for a live Q&A session after the presentation.  If you were not able to attend, please view the recording now on our YouTube Channel, www.youtube.com/MyAllergyPartners.  You can also watch many other useful webinar and ‘how-to’ videos on various topics as it relates to allergies and asthma.

 

September 09
Fall Allergies

 

Ahh Fall. Ahh, cooler weather. Ahh Ragweed?  Ahh CHOO! Yes, Fall has its own pollen season, and the important pollen is ragweed, which pollinates from August to October. The main two varieties in our area are Giant ragweed and Short ragweed.  There are other weeds whose pollen may provoke allergic reactions, but ragweed produces pollen in quantities which put these other weeds to shame.  Other weeds which produce allergenic pollen in our area during the fall are:
Of these, English plantain has the longest pollinating season.  None of those minor weeds above can match Ragweed's production, but are still important contributors to fall allergy symptoms.
 
Many people think that they are allergic to goldenrod, which they see growing in large quantities in open fields in the fall. In fact, the pollens of most flowering plants do not provoke allergy for the simple reason that flowering plants have flowers in order to attract bees which are required to transfer the heavy, sticky pollen from the male to the female plant. Since the pollen requires bees for transfer, it isn't blown aloft where it can be inhaled into the respiratory tract or get into the eyes of allergy sufferers. Those plants which are wind pollinated generally have small and unspectacular flowers or florets, and light, aerodynamically shaped pollen. So when you sneeze next to a field bursting with yellow flowers, it's probably the ragweed, not the goldenrod.
 
Ragweed comes in several varieties, but the important ones in our area are giant ragweed and short ragweed. In the delta region of the Mississippi river, vast stands of giant ragweed may grow to reach as much as 15 feet in height! Let that be a warning to those who are ragweed-sensitive not to visit that area of the country during the fall pollinating season! Many people ask if there is a better place to live if they have ragweed allergies.  Last year, the Asthma and Allergy Foundation of America compiled a list of the worst cities to live for those with ragweed allergies. Top on the list was Louisville, KY.  But don’t think about moving right away.  In general, studies have shown that when people move to another city, 50% have worse allergy symptoms and only 50% get better.
 
In the past, many ragweed-sensitive subjects have taken late summer or fall vacations in the upper peninsula of Michigan or the northern tip of Maine because these areas have traditionally been free of ragweed. People hiking in carrying pollen and seeds on their clothing have unfortunately introduced some ragweed.
 
Many people who are sensitive to ragweed will complain of itching of the throat and/or nasal congestion after eating cantaloupe, watermelon or bananas. This is due to a cross-reacting protein present in these foods and the syndrome is called oral allergy syndrome.
 
A publication from the United States Department of Agriculture found data that indicate a significant increase in the length of the ragweed pollen season by as much as 13–27 days at latitudes above 44°N since 1995 compared to before that time (this latitude crosses states in the northern part of the U.S.)  This is not good news for those people who suffer from ragweed allergy. The pollen is highest during the morning hours, on windy days or shortly after a rainstorm when the plant is drying out. However, rain “washes the pollen out of the air,” so going out during the rain generally causes fewer symptoms.
 
Common symptoms of allergic rhinitis are sneezing, runny nose and nasal congestion. Eye symptoms include itchy, watery, red and, at times, swollen eyes. The ears and roof of the mouth may itch as well. In asthmatic patients, allergen exposure can trigger cough, wheeze and shortness of breath. Importantly, up to 70% of asthmatics have underlying allergies. People with allergies are also more prone to ear and sinus infections.
 
As with other allergic conditions, the mainstays of treatment include avoidance, medications and allergy shots.  Some basic avoidance tips include:
  • Keep windows closed to prevent pollens from drifting into your home. 
  • Keep air conditioning on as that filters out 95% of the pollen.
  • Minimize early morning activity when pollen is generally at its maximum -- between 5:00 and 10:00 a.m.
  • Keep your car windows closed when traveling.
  • Stay indoors during high pollen counts (which are available on our home page) and on windy days when pollen may be present in higher amounts in the air.
  • Machine dry bedding and clothing. Pollen may collect in laundry if it is hung outside to dry.
  • When you come home for the day, change your clothes and take a shower to remove the pollen that is attached to your clothes and hair. Also consider washing out your eyes with contact lens saline solution or artificial tears and rinsing out your nose with saline nasal spray to wash the pollen out of those areas.
As always, you can also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook and “Share” the article.
  
Dr. Elaine S. Turner, MD

September 04
Dr. T was interviewed on CBS6's Virginia this Morning
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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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