May 11th, 2009
During Spring, many people find that their asthma gets worse. They experience tightness in their chest, shortness of breath, and an increased cough. Albuterol use increases. Patients experience this secondary to the increased tree and grass pollen.
If you think your asthma may be poorly controlled, go to www.asthmacontrol.com and take the Asthma Control Test. There are 5 questions with a max point total of 5, minimum of 0. If your total score is less than 20 then your asthma may not be controlled and you should call your doctor for further evaluation. You can print off your test and bring it with you to your appointment. This saves time and may provide quicker treatment which could result in less ER visits and less aggressive therapies.
Dr. Norvell
April 30th, 2009
I was reading an article in this week’s edition of The New England Journal of Medicine and it made me think. The article focused on asthma in pregnancy. While that is a topic for another time, it got me thinking about the treatment of allergies in pregnant women.
Currently, we are nearing the peak of the Spring allergy season. Most of the patients that I am seeing for the first time arrive on prescription or over-the-counter allergy medications. Pregnancy categories for medications include category A, B, C, D, and X. You want to be on medications in pregnancy category A or B and avoid those in pregnancy category D or X. For drugs in pregnancy category C, caution is advised, but the benefits of the medication may outweigh the potential risks.
First, it is important to think about what medications you are taking if you are thinking about becoming pregnant. You cannot wait until you discover that you are pregnant. You may have to modify your medication regimen when you begin trying to become pregnant. The reason for this is to ensure that there are no harmful effects to the baby from medications prior to learning that you are pregnant. The most critical time in a baby’s development that is affected by medication are the first weeks of pregnancy.
Zyrtec and Benadryl represent antihistamines that are pregnancy category B.
Rhinocort is a nasal steroid that is pregnancy category B.
For those patients that are on allergy shots, guidelines recommend continuing with your shots if there are observed benefits. However, the dose should be held and not increased until after delivery of the baby.
If you are considering becoming pregnant and have a question about your allergy options, contact your physician to ensure the safest options for your child.
March 11th, 2009
If your nose hasn’t told you already, it’s officially tree pollen season in Middle Tennessee. The puddles in my driveway this morning had the telltale yellow sheen of pine pollen. Pine pollen granules are relatively large and so they’re easier to see. They’re also what gives your car that yellow, dusty haze.
If you live in Middle Tennessee, you don’t have to guess what the pollen count is. You can check for yourself at the Nashville Metro Government’s pollen count and air quality website. As you can see, the predominant early season tree pollens of cedar and pine are present at levels deemed heavy.
If you’re suffering from tree pollen allergies, try to avoid prolonged outdoor activity during the morning hours when pollen counts are the highest. If you must be outside, a mask can be helpful especially when mowing or gardening. If medications and avoidance aren’t controlling your miserable itchy, watery eyes, sneezing and runny nose, then it’s time to see your local allergist, get tested, and see if immunotherapy can let you enjoy springtime again.
Dr. O
January 15th, 2009
A while back, the FDA decided to look into the issue of mood disturbance and drugs like Singulair. Through an extensive review of over 20000 patients, the data show no increase in depression or suicide in patients treated with Singulair. They are still reviewing the data to see if there is a link between Singulair and behavioral issues in kids. My sense is that this will be ok as well, but we’ll await the findings of their review. For now, If you’re on Singulair for control of asthma or allergies, you should feel safe to continue these medications
January 15th, 2009
Loss of the sense of smell, a problem called anosmia (an-OWES-me-uh), is a common complaint seen by allergists. Smell actually makes up a significant portion of the sense of taste as well, so anosmia not only affects the ability to enjoy smells like coffee, but also significantly lessens one’s ability to enjoy food. Ugh.
In the image above, the olfactory nerve is the yellow structure at the roof of the nasal cavity. The olfactory nerve is responsible for the sense of smell. Anosmia can occur if the olfactory nerve is blocked by swelling from allergies or by nasal polyps. This usually results in gradual, partial loss of smell. Both of these causes can be treated and the ability to smell restored. Total, sudden loss of smell, especially when accompanied by an upper respiratory infection, suggests viral damage to the olfactory nerve. This may be irreversible.
If you have trouble smelling, an allergist can help you determine the cause and may be able to restore your ability to smell
Dr. O
December 31st, 2008
Traditional allergy testing is done via skin tests, where a small device often resembling a plastic toothpick is dipped in a well containing an allergen, like ragweed pollen. The skin is then scratched or pricked and observed to see if the area gets red and raised. Most allergists still feel this is the preferred method of testing, but in some cases skin tests just wont work. In these situations, blood tests are a good alternative.
Most people refer to allergy blood tests as “RAST” tests. The term “RAST” is sort of like kleenex or band-aid. It started as a specific term, but has come to be generalized for all allergy blood tests. RAST stands for Radio Allergosorbant Test. This form of testing is actually seldom done, anymore. These days, allergy blood tests are done via Enzyme-Linked Immunosorbant Assay, which goes by the much-easier-to-pronounce acronym, ELISA (ee-LYE-zuh).
To understand these, a little background is needed. ELISA tests measure antibody levels. Antibodies are proteins your body makes to help fight off infection. There are 4 main types, IgG, IgA, IgM, and IgE. The first three are there to help fight off bacteria and viruses. IgE is the allergy antibody.
Each individual antibody is designed to match up with one specific thing, like a lock and key. For example, an IgG antibody might bind to a specific part of the wall of a strep bacterium or cold virus. In allergic people, there are IgE antibodies that bind to ragweed pollen or peanut protein. ELISA tests measure the amount of such antibodies that are present in the blood stream. These are reported as a concentration (kU/L) and as a class or level, arbitrarily class 0-6.
This all brings us to a couple of important points. First, allergy blood tests should be IgE ELISA, not IgG ELISA. Serum IgG testing has no role in the evaluation or management of allergies, be they inhalant, food, or otherwise. I commonly see patients who have been told they have food allergies on the basis of serum IgG tests. Most often, physicians utilizing such tests are also touting non-standard therapies like yeast elimination, detoxification regimens or unproven expensive supplements. Avoid these at all costs.
The second point deals with the interpretation of serum allergy tests. The tests are easy to order- you just draw the blood and check a box. What’s difficult is how to interpret the information. Every test in medicine has false positives and false negatives. With serum allergy tests, the false negative rate is very low, so they are very good at ruling out allergies. The false positive rate is in the range of 5-10%, which is pretty good. So, if you test to 60 different things and get 5 or 6 low level positives, what does that mean? Are they real allergies or not? For Americans used to a black-or-white, yes-or-no, give-it-to-me-straight-Doc world, this ambiguity can be difficult to internalize. A good allergist should be able to interpret these tests correctly and relay the information in a manner which is easy to understand.
Dr. O
December 17th, 2008
Lets talk for a bit about common allergy medications. In the interest of time, I’ll focus on meds used to treat nasal symptoms, what doctors call rhinitis.
The most common medications used for rhinitis are antihistamines. Antihistamines work, as their name suggests, by blocking the effects of the chemical histamine. They are particularly good for controlling symptoms of nasal itching, sneezing, runny nose, and itchy eyes. They are not very good at controlling nasal congestion and drainage. Older antihistamines like diphenhydramine (benadryl), chlorpheniramine (chlor-trimeton) , and hydroxyzine (atarax, vistaril) are very potent, but they are also very sedating. Newer antihistamines such as cetirizine (zyrtec), fexofenadine (allegra), and loratidine (claritin) are classified as low- or non-sedating and still have adequate potency. I generally recommend one of the newer medications. Cetirizine and loratidine are available over-the-counter and store brands run only about $10 a month.
Decongestants also do what their name suggests: help control nasal congestion. Some people find they help with symptoms of pressure and pain as well. They work by constricting the blood vessels in the nose which, in turn, shrinks the lining of the nasal passage. Since they are oral medications, they will also constrict the blood vessels in the rest of the body, which can worsen blood pressure, In guys, they can also worsen prostate problems. They cause insomnia in a number of people as well. Because of all these side effects, I avoid decongestants as much as possible and limit their use to short periods of time.
Over-the-counter nasal sprays are a double-edged sword. They are sold under a variety of names, but most contain the drug oxymetazoline. They will open your nose like nothing else, but if used improperly can lead to dependence so be very careful with them and always follow the instructions. Never use them for more than 3 days in a row or more than twice a day. If you do, when you try to stop, your nose will be worse than when it started- a phenomenon called rebound. I see patients every week who have become dependent on these medications to breathe through their nose. Don’t become one of them.
Finally, I’ll talk about saline rinse. This is a great treatment for most nasal symptoms, including drainage. It’s essentially free and devoid of side effects. I’m not referring to “ocean spray” that simply moistens the nose, but rather forcing a large volume of saline through the nose. This can be done with gravity-a neti pot- or with force- a plastic squeeze bottle. Either way, make sure you don’t use plain tap water- it’s too dilute and will irritate the lining of the nose. A simple mix involves using a teaspoon of salt in 8 ounces of water. Some companies try to sell you their mix, claiming that they have “pharmaceutical grade NaCl”. This is ridiculous. Plain table salt is fine and could never make the nose a dirtier place than it already is.
Hope this is helpful.
Dr. O
December 10th, 2008
This week’s installment of bogus allergy treatment will focus on the commonly touted remedy of local bee honey. The theory goes something like this: Bees collect nectar to make honey and along the way carry local pollens with them which are then transferred to the honey. Ingesting these small amounts of pollens over time will desensitize the body to them. Sounds great on a superficial level, but this theory is full of holes.
First, most of the pollen bees collect comes from flowering plants, which play little if any role in nasal allergies. Second, many people are allergic to a range of seasonal pollens- tree(spring), grass(summer),and weed(fall) are the three main categories. Honey produced during an individual season may contain pollen present during that time but will not contain other pollen varieties. So if was made in the summer and you took it in the fall, it would not contain fall pollens. Third, oral immunotherapy doesn’t work. (This is distinct from sublingual immunotherapy.) Numerous studies looking at a variety of dosing levels have shown swallowing allergens to have no effect on allergic symptoms.
So maybe its not the pollen at all. Maybe there is something special in bee honey that reduces allergy symptoms. A randomized, placebo controlled trial from a few years ago asked this exact question. They compared treatment with local honey, a national brand, and placebo and found no difference in several allergy symptoms during a 6 month treatment period. So in the end, honey is exactly what it’s supposed to be: a sugar pill.
Dr. O
December 4th, 2008
“I love cats. They keep me in business.”- Anonymous allergist
Cat dander is probably the single most potent sensitizer of the airways. Felis domesticus, the common house cat, secretes a protein in its saliva and skin glands that is very tenacious in an indoor environment. Even with removal of a cat from a home, it can take months for cat dander levels to fall to normal background levels.
It’s not just homes with cats that are the problem, however. Cat dander is much more prevalent than most people realize. Studies have shown significant cat dander levels in subways, department stores, and even in brand new plastic-wrapped mattresses. Cat dander is the number one cause of asthma exacerbations at schools, where kids with cat sensitivity are forced into close proximity with kids toting large amounts of cat dander on their clothes.
So what can we do about cat dander? In my decade or so of practicing allergy, I can count on the fingers of one hand the number of people who got rid of their cat. And why would you? Pets are an integral part of many families, mine included. It’s the allergists job to fix the problem so you can live the life you want rather than requiring you to change your lifestyle to fit the problem!
Many people laugh at the idea of washing the cat regularly. Apparently cats have claws and many are not afraid to use them when confronted with water. Nevertheless, washing a cat with regualrity is the most effective method of reducing indoor cat dander levels. A HEPA filter in the bedroom can also reduce cat dander levels in the place where you spend the most time.
The reality is, though, that most cat-allergic cat owners wind up going on allergy shots to reduce their sensitivity. Even though the shots work less well when the cat remains in the home, they still are more effective than medications at reducing the sensitivity to cats.
Dr. O
December 3rd, 2008
The other day, a flier sent by a local chiropractor came across my office fax machine. Its 32-point tag line read, “Did you know that allergies are not caused by things in your environment, but by misalignment of the spine?” Actually, despite my 4 years of medical school, 3 years of residency, 3 years of fellowship, and 7 years of private practice, I was fully unaware of this! Apparently, this whole “immune system” scam has finally been debunked. I briefly considered walking the 4 doors down to his office to have him enlighten me, but I reasoned that most people who read that particular flier would see it for what it was: hogwash. I have nothing against chiropractors treating musculoskeletal problems- I see one myself from time to time- but this statement clearly showed either ignorance of or willing disregard for the truth.
This is but one example of numerous dubious practices relating to allergy. There are so many, in fact, that it would be impractical for me to list them all here. I’ll start with one that was highlighted in this week’s “Medical Letter”, an independent, non-profit publication that reviews drugs and medical devices. The reviewers examined low-voltage electronic diagnostic devices, which are essentially galvanometers- devices that measure resistance to electrical current. One such device, the Electroacupunctue According to Voll (EAV), requires the patient to hold a metal probe in one hand while the practitioner places a second probe on various “acupuncture points” on the patients other hand or foot. This completes an electrical circuit and the subsequent reading of current is said to reveal organ inflammation if the reading is high and “stagnation” if the reading is low. Certain “acupuncture points” are said to correspond to allergic inflammation. The Vegatest and Biomeridian are two devices which utilize EAV.
The FDA classifies low-voltage diagnostic devices as Class III, meaning they must have FDA approval prior to marketing. Since no EAV devices are FDA approved for diagnosing and managing disease, I’m not sure why they’re allowed to be used in the community. The Medical Letter reviewers summarize their look at these devices by saying, “Patients should be told that low-voltage electronic devices claimed to diagnose or treat a wide variety of health problems lack a scientifically plausible rationale and should be regarded as bogus.” I concur.
Dr. O
