IMMUNOTHERAPY ( ALLERGY SHOTS)

Allergy shots (patient information)

Allergen immunotherapy was introduced by Leonard Noon 100 years ago and is the only disease-modifying treatment for allergic individuals (Allergy, 2012).

If you have allergies, you may be wondering if allergy shots are the best treatment for you. Here are the answers to some commonly asked questions.

What exactly is there in the allergy shots?

Allergen extracts are manufactured from natural substances, such as pollens, insect venoms, animal hair, and foods. More than 1,200 extracts are licensed by FDA.

How do allergy shots work? 

After allergy testing, typically by skin testing to detect what allergens you or your child may react to, a health care professional injects the child with “extracts” - small amounts of the allergens that trigger a reaction. The doses are gradually increased so that the body builds up immunity to these allergens. Allergy shots work like a vaccine.

There are two phases of administration of allergy shots (immunotherapy): build-up and maintenance.

The build-up phase, ranges from 3 to 6 months, and involves injections with increasing amounts of the allergens. The frequency of injections is once or twice a week. Sometime more rapid build-up schedules are used.

The maintenance phase begins when the most effective dose is reached (maintenance dose). Once the maintenance dose is reached, there are longer periods between injections, typically every 2-4 weeks.

Who administers the allergy shots?

An allergist / immunologist, often referred to as an allergist, is the most qualified physician to test which allergy you have and tell you if allergy shots are right for you. The safest approach is to be seen and treated by a board-certified allergist. You can find an allergist here:http://www.acaai.org/allergist/Pages/locate_an_allergist.aspx

Who needs allergy shots?

Children or adults who don't respond to either over-the-counter (OTC) or prescription medications, or who suffer from frequent complications of allergic rhinitis, may be candidates for allergen immunotherapy - commonly known as allergy shots.

Allergy shots are recommended for patients with allergic asthma, allergic rhinitis/conjunctivitis and stinging insect allergy. They are not recommended for food allergies.

Before a decision is made to begin allergy shots, the following issues must be considered:

- Length of allergy season and the severity of your symptoms
- Whether medications and/or changes to your environment can control your allergy symptoms
- Your desire to avoid long-term medication use
- Time: allergy shots require a major time commitment. The duration is typically 3-5 years, and the shots often require brief clinic visits every 2-4 weeks.
- Cost: may vary depending on your state and insurance coverage

Immunotherapy for children is effective and well tolerated. It prevents the onset of new allergies. Allergy shots are the only treatment that prevents the progression from allergic rhinitis to asthma.

How effective are allergy shots?

According to the National Institute of Allergy and Infectious Diseases (NIAID), about 80-90% of people with allergic rhinitis will see their symptoms and need for medications drop significantly within a year of starting allergy shots.

How quickly will I feel better?

For many people, a decrease in symptoms is seen during the build-up phase, within 3-6 months. For others, it may take as long as 12 months on the maintenance dose.

How long should I stay on allergy shots?

Once the maintenance dose is reached (it takes 3-6 months), allergy shots are continued for 3-5 years. The decision to stop should be discussed with your board-certified allergist. Some people may have a permanent reduction of their allergy symptoms (the best outcome). Others may relapse and then a longer course of allergy shots can be considered.

What are the risks of allergy shots?

There are two types of adverse reactions that can occur with allergy shots.

Local reactions are common and are described as temporary redness and swelling at the injection site. This can happen immediately, or several hours after the treatment.

Systemic reactions are not common, and are usually mild and respond quickly to medications. Signs of a systemic reaction include increased allergy symptoms such as sneezing, stuffy nose or hives. Rarely, a serious systemic reaction called anaphylaxis (an-a-fi-LAK-sis) can develop, with swelling in the throat, wheezing, a feeling of tightness in the chest, nausea or dizziness. This reequires treatment with epinephrine (EpiPen).

Most systemic reactions develop within 30 minutes of giving allergy shots. You should you wait in your allergist office for 30 minutes after your injections.

Is there an alternative to allergy shots such as drops, etc.?

Some doctors are buying extracts licensed for injection and instructing the parents to administer the extracts using a dropper under the adult or child’s tongue. While FDA considers this the practice of medicine (and the agency does not regulate the practice of medicine), parents and patients should be aware that there are no allergenic extracts currently licensed by FDA for oral use.

Can you treat food allergy with allergy shots?

Allergy shots are never appropriate for food allergies. However, it is common to use extracts to test for food allergies so the child or adult can avoid those foods.

References

Allergy Immunotherapy, Allergy Shots. ACAAI.
Allergy Relief for Your Child - FDA Consumer Info.
Allergy Shots: Tips to Remember. AAAAI.
Allergen-specific immunotherapy. Allergy, Asthma & Clinical Immunology 2011, 7(Suppl 1):S5. 
Image source: Pollen from a variety of common plants. Dartmouth Electron Microscope Facility, Dartmouth College.

TIPS TO FIGHT SEVERE SEASONAL ALLERGY!!!

Allergy season is coming and you shouldn't let yourself or anyone else in your family become victims.  Here are seven ways you can help reduce the misery.

Take your antihistamine daily

If you are already taking a long-lasting antihistamine, make sure to take those meds daily, not just when your symptoms flare up. Regular daily dosing may better block the effect of histamine release when allergy triggers are inhaled.

Get a prescribed nasal spray

A prescribed intranasal spray steroid is a cornerstone to seasonal allergy management. Ask your doctor for a prescription if you don't have one. An alternative would be an antihistamine based nasal spray. Occasionally both types of nasal sprays are recommended.

Check your nasal spray technique

Have your nasal spray technique checked with your doctor at least twice a year. Flaws in the use of nasal sprays can considerably impact the effectiveness of the medication

Review your skin test results

Review the results of allergy skin test with your doctor in order to ensure that you have taken adequate steps to reduce the impact of indoor triggers, such as dust mites, mold and pet dander. If you have not had allergy tests, ask your doctor about getting them.

Keep windows closed

Keep your windows at home closed at all times. Turn on your air conditioner early in order to keep humidity levels in your home from rising. This may reduce dust mite and mold growth as well as filter some of the allergens in your indoor environment.

Check your filters

Check to see if the filter on your cooling system needs changing. If you use an indoor air cleaner device, determine if filters or other maintenance matters need to be addressed.

Do a saline rinse

Many people have been aided by rinsing their nasal passages with nasal saline spray during peak periods of the allergy season. Simple flushing of the nose with a saline mist or buying a Neti pot can make a big difference.

6 Tips for Asthmatics to Manage Allergies During Springs!!!!

• After the winter we have had-- like most of you-- we are ready for the warmer spring weather.  After a week of our wish being granted we remembered some of the pitfalls of the gorgeous spring temperatures: pollen, pollen and more pollen.  If you have asthma and allergies this can mean a huge increase in asthma symptoms.
  
  Early in the spring tree pollens can wreak havoc on asthma symptoms.  Some of the most common include ash, birch, cypress, elm, hickory, maple, oak, poplar, sycamore, walnut and western red cedar.  In later spring the grass pollens like bermuda grass, orchard grass, red top grass and timothy grass kick in and trigger flare ups in people allergic to grasses.
  
  Allergies can result in additional inflammation in the airway of asthmatic patients, which is why most emergency rooms see an increase in visits due to asthma complications in the spring.  Additional symptoms of spring allergies can include: sneezing, runny nose, itchy nose or throat, watery eyes, wheezing, coughing and difficulty breathing.  While allergies are not contagious, they can definitely make you feel like you have a nasty illness.
  
  If allergies are aggravating your asthma it is important to treat and prevent those reactions to decrease your airway inflammation.  Here are a few tips to get your spring allergies under control.
  
  Keep up with your asthma medications.
  
  If winter doesn't produce any issues for your asthma, you may need to hit the pharmacy and refill your asthma medications in preparation for spring.  Be sure to have a rescue inhaler on hand in case it is needed.  Reducing airway inflammation with the use of a maintenance medication like Flovent, QVAR or Advair can help prevent asthma attacks.
  
  Get tested for allergies.
  
  If you suspect that allergies might be a trigger for your asthma you may want to consider being tested.  An allergist can help you to determine exactly what you are allergic to and tailor treatments to those specific issues.  Allergy tests may include blood tests or skin testing.
  
  Take allergy medications.
  
  If you have spring allergies your physician may recommend that you start taking an allergy medication a week or so before the season begins and continue it throughout the allergy season.  Antihistamines like Claritin or Zyrtec can be taken daily to prevent reactions.  Some people may also do well with steroid nasal spays to reduce the sneezing, coughing and sinus drainage that can aggravate asthma.
  
  
  Consider allergy shots.
  
  Once you have been tested for allergies your physician may decide to start you on an immunotherapy shot to reduce your body's reaction to allergens.  This therapy can take some time -- up to three or more years--so it is best to start it as soon as possible.
  
  Avoid high pollen hours.
  
  The morning tends to have the highest pollen counts.  It is best to avoid being outdoors between those peak hours of 5 a.m. to 10 a.m.  Staying inside in the air conditioning and recycling the air in your vehicle can help limit your exposure to pollen during those peak hours.  Check out the Weather Channel's allergy tracker tool to determine the pollen levels in your specific area.
• 
  Shower at night.
  
  While it may seem small, showering at night can make a big difference in your allergies.  During the day pollen and other triggers latch on to your skin, clothing and hair.  Taking those clothes off immediately upon returning inside and showering-- including washing your hair-- can dramatically reduce the allergens on your body.  If you don't shower at night those allergens will be in your bed to cause reactions while you sleep and even on future nights.
  
  Allergy season can be miserable, but with a few of these tips you can make it through with the least amount of symptoms and irritation to your asthma.

REMEMBER THIS FESTIVAL, THE CRACKERS YOU BURN IS WHAT YOU BREATH IN!!!

As sure as Diwali ( or any festival /new year) is a festival of lights, sweets, gaiety, splendor & fireworks, it is also one of deafening noise, blinding light, risky fire & suspended particles. And this has direct effects on our health & environment. When the entire nation looks forward to Diwali as a celebration of life, patients suffering from Asthma & COPD (Chronic Obstructive Pulmonary Disease) begin readying there lifesavers – Inhalers, nebulizers or whatever gives them a breath of life. For these people Diwali is not a festival of light & gaiety but that of smoke, coughing & wheezing.

Fireworks are sources of some of the highly toxic inhalants produced during Diwali celebrations. Firecrackers are “power packed” with potassium nitrate, carbon & sulfur. Apart from this they also contain toxic contents like copper, cadmium, lead, manganese, magnesium, zinc, sodium, potassium, and aluminum powder & barium nitrate.  When ignited, the crackers burst allowing these powerful chemicals to come in contact with atmosphere and the smoke thus generated contains increased amounts of carbon monoxide, carbon dioxide, nitrogen dioxide, hydrocarbons, hydrogen sulfide & particulate matter which worsen the quality of Diwali air. The suspended particles hog like a thick blanket reducing visibility and suffocating the atmosphere. In fact studies have demonstrated that during Diwali festival the concentration of sulfur dioxide increased by 10 times & that of nitrogen dioxide, PM10(Particulate matter of size less than 10 microns) & TSP(Total Suspended Particles) increased by 2 to 3 times. The Overall air pollution during Diwali increases by about 200 %. The biggest culprits among firecrackers are the colour sparkles (“Phuljari”), “Anar”, “Chakri”, Fire pencils, Snake tablets & “Hydrogen” bomb.

A special mention may be made of PM10. With the average PM10 charge, we inhale millions of fine particles with each breath. The larger particles( 5 to 10 microns) are filtered in the nose & throat, smaller particles (3 to 5 microns) arrive in the bronchial tube, bronchi (2 to 3 microns), bronchioles (1 to 2 microns) & in alveoli (0.1 to 2 microns) & finally in the blood. These particles can no longer be coughed up & as deposits lead in long term to inflammation, particularly in asthmatics, & also with healthy people, although they may not notice the immediate irritant effects.

When we inhale such a highly toxic and polluted air during Diwali, how can escape from its ill effects? The harmful oxides present in the Diwali fumes come into contact with the moisture while passage from the nostrils to the lungs & form acids which cause immense damage to the body.

The Diwali smoke potentially leads to development of various respiratory ailments like –Allergic bronchitis, acute exacerbation of bronchial asthma & COPD (Chronic Obstructive Pulmonary Disease), allergic rhinitis, laryngitis, sinusitis, pharyngitis, common cold, acute eosinophilic pneumonia, reactive airway dysfunction syndrome, etc.

Children, pregnant women, asthmatics & senior citizens are highly prone to these potentially harmful effects of Diwali smoke.

Here is a list of precautions that need to be followed during Diwali celebrations.

Precautions to be followed by asthmatics:

1.      Stay away from people burning crackers.

2.      Keep the inhalers and other medicines ready beforehand (both maintenance & reliever medications).

3.      Consult your doctor and start maintenance dose of inhalers a few days before the festival & continue the same two days after Diwali.

4.      In severe cases rescue medications need to be taken & if not relieved contact your doctor immediately.

5.      Better do not venture out in the evening of Diwali. Stay in company of friends and family members in house.

6.      If need to venture outside use masks (N95 masks have been technically recommended).

7.      Consult your doctor regarding pulmonary vaccination in advance.

8.      Stay away during colouring and white washing of house before Diwali because these also act as “triggers” of an asthma attack.

9.      If possible plan a visit to some hill-station / ecoclean place (which is not much crowded) during Diwali festival.

Precautions to be followed by every one of us during Diwali festival:

1.      Avoid /decrease the firework celebrations & play “ecosafe” Diwali.

2.      Enjoy Diwali with lamp, lanterns & diyas.

3.      Fireworks if carried out should be done in open grounds, away from residential areas & during fixed time limits.

We should remember that one person’s idea of fun could be an asthma patient’s nightmare. Asthma patients have as much right as us to stick around and enjoy Diwali. And ultimately for our own benefit we should not forget that “what we burn is what we breathe”, this Diwali.

Green areas around homes reduce atopic sensitization in children!!!

Green areas around homes reduce atopic sensitization in children

Western lifestyle is associated with high prevalence of allergy, asthma and other chronic inflammatory disorders. ‘Biodiversity hypothesis’ suggests that reduced contact of children with environmental biodiversity, including environmental microbiota in natural habitats, has adverse consequences on the assembly of human commensal microbiota and its contribution to immune tolerance.

This study analysed 4 cohorts from Finland and Estonia with 1,000 children and adolescents aged 0.5–20 yrs. The prevalence of atopic sensitization was assessed by measuring serum IgE specific to inhalant allergens. WProportion of 5 land-use types—forest, agricultural land, built areas, wetlands, and water bodies—in the landscape around the homes was calculated using the CORINE2006 classification.

The cover of forest and agricultural land within 2–5 km from the home was inversely associated with atopic sensitization. This relationship was observed for children 6 years of age and older.

Land-use pattern explained 20% of the variation in the relative abundance of Proteobacteria on the skin of healthy individuals, supporting the hypothesis of a strong environmental effect on the commensal microbiota.

The amount of green environment (forest and agricultural land) around home was inversely associated with the risk of atopic sensitization in children. Early life exposure to green environments is especially important. The environmental effect may be mediated via the effect of environmental microbiota on the commensal microbiota influencing immunotolerance.

References:

Green areas around homes reduce atopic sensitization in children. Lasse Ruokolainen et al. Allergy, 2014, DOI: 10.1111/all.12545.
http://onlinelibrary.wiley.com/doi/10.1111/all.12545/abstract

How to use a nose spray

How to use a nose spray

1. Gently blow your nose to clear it of mucus before using the medication.

2. Remove the cap and shake the bottle.

3. Hold the pump bottle with your thumb at the bottom and your index and middle fingers on top.

4. The first time you use the pump spray each day, you may have to prime it by squirting a few times into the air until a fine mist comes out.

5. Tilt your head forward slightly. Breathe out slowly.

6. Insert into the nostril and aim the nozzle toward the outside of the nose and away from the nasal septum (the cartiledge which divides our nose in half).

7. Squeeze the pump as you begin to breathe in slowly through your nose.

8. Repeat these steps for the other nostril. If you are using more than one spray in each nostril, follow all these steps again. Try not to sneeze or blow your nose just after using the spray.

Nosebleeds are among the most commonly reported adverse effect of intranasal corticosteroid sprays. However, they tend to result from incorrect positioning of the device ("hitting" the septum in the middle), rather than an adverse reaction to the medication.

Common errors to avoid when using a nose spray include the following:

- forgetting to prime the spray device;

- skipping doses

- wrong head position (should be tilted forward, not back)

- pushing nozzle too hard or too far into the nose;

- blowing nose hard after spraying (the medicine is lost)

- sniffing hard after spraying (the medicine is deposited in the throat instead of the nose)

- using saline sprays or irrigations after using corticosteroid spray, instead of before

How to use Nasonex intranasal spray correctly

Demonstration of how to use Avamys  intranasal spray correctly 

Demonstration of how to use Rhinocort intranasal spray correctly (video):

Saline Sinus Rinse/Flush - Patient Education Videos

Saline nasal irrigation bathes the nasal cavity with liquid by instilling saline into 1 nostril and allowing it to drain out of the other nostril (typically, it drains from both nostrils and the mouth). Only use sterile, distilled, filtered water (using a filter with an absolute pore size of 1 μm or smaller), or previously boiled water for nasal irrigation.

Adult Nasal Wash (video)

The Centers for Disease Control (CDC) has guidelines for the proper preparation of the water used in the nasal wash. View the guidelines at http://njhealth.org/nasalwash. Here is a video demonstration of how to perform a nasal wash for adults:

Pediatric Nasal Wash (video)

A demonstration of how to perform a nasal wash for children: 

Techniques and devices

Techniques and devices include:

- low positive pressure from a spray or squirt bottle
- gravity-based pressure using a neti pot or other vessel with a nasal spout

Indications

A range of conditions may respond to saline nasal 
irrigation but the evidence supporting its use is less conclusive:

- allergic rhinitis
- acute upper respiratory tract infections (URTI)
- rhinitis of pregnancy
- acute rhinosinusitis

The exact mechanism of action of saline nasal irrigation is unknown. Saline nasal irrigation may improve nasal mucosa function through direct cleansing; removal of inflammatory mediators, and improved mucociliary function, as suggested by 
increased ciliary beat frequency.

Adverse effects

Fewer than 10% of patients reported adverse effects:


- self-limited sensation of ear fullness
- "stinging" of the nasal mucosa
- rarely epistaxis
-infections.  Louisiana Department of Health and Hospitals warned against improper use following the deaths of two people who were infected with Naegleria fowleri after using tap water to irrigate their sinuses. Read more here: Is Rinsing Your Sinuses Safe?


Contraindications

Contraindications for saline nasal irrigation include:

- incompletely healed facial trauma
- increased risk for aspiration, such as intention tremor or other neurologic or musculoskeletal problems.

Recommendations

- For chronic rhinosinusitis, nasal irrigation is an effective adjunctive therapy (level of evidence, A).

- Limited evidence for effective adjunctive treatment of irritant or allergic rhinitis, viral upper respiratory tract infection, and postoperative care after endoscopic sinus surgery (level of evidence, B).

- rhinitis of pregnancy, acute rhinosinusitis, sinonasal sarcoidosis, and Wegener's granulomatosis (level of evidence, C).

Mayo Clinic: What can you do about that runny nose and nasal congestion? Medications are one option, but so is nasal cleansing.