TREATMENTS

In order to better monitor symptoms away from the office, many patients are prescribed a Peak Flow Meter; this device allows patients to keep a record of the level of obstruction being experienced on average, as well as during symptom flares.

The treatment of asthma generally involves two main aspects:

Avoidance: this is helpful for patients whose asthma is triggered either by allergens or irritants.  As with nasal allergies, the ability to avoid certain triggers can be difficult, but strong triggers should be routinely avoided.

Medications: there are several different classes of medications used in order to maintain and treat asthma.

Inhaled corticosteroids: these are often considered the cornerstone of asthma management as they are directed at decreasing the inflammation that is the basis of this disease.  They are available in a variety of types and strengths, and are chosen for patients based on symptom profile.

Inhaled long-acting bronchodilators:  the object of these inhalers is to decrease airway hyper reactivity, or relax smooth muscles of the airways.  As single agents they are rarely used for maintenance therapy, but may be used to prevent exercise- induced symptoms. 

Combination inhalers: these contain both an inhaled corticosteroid and a long-acting bronchodilator, and are generally reserved for patients whose symptoms are not controlled with an inhaled corticosteroid alone. 

Inhaled short-acting bronchodilators: generally these medications are reserved for emergency or rescue use, when a patient’s daily medications are not enough to control symptoms.  They can also be used to prevent symptoms from arising with exposure to specific triggers, such as animal dander or exercise. 

Antileukotrienes: leukotrienes, which contribute to inflammation within the body, are often beneficial to patients with asthma has they help to decrease airway inflammation.  These medications are available in pill or powder forms, as opposed to being inhaled. 

Be aware of problems that are often associated with asthma symptoms, such as rhinitis, reflux disease, vocal cord dysfunction, and sensitivity to aspirin. These conditions may not respond to standard treatment regimens, and could require further evaluation.   

Food Allergies
Whether or not a food reaction is classified as an allergy or intolerance, the best way treat is to strictly avoid the food(s) causing the symptoms.  With certain food intolerances, such as lactose intolerance, reactions are often worse if large amounts of the foods are eaten, but small amounts may be tolerated. 

However, if a patient has been diagnosed with a food allergy, even very small amounts of these foods can cause a life threatening reaction, called anaphylaxis.   For patients who have a definite food allergy, it is best to carry epinephrine, especially when eating away from home, and should know how and when to use it.  Patients should be very comfortable requesting information about food ingredients when dining out, and should read food labels thoroughly. 

At this time, allergen immunotherapy for food allergies is not available.   New methods of allergen immunotherapy for specific foods are currently being studied, but at this time none are approved. 

Insect Allergies
Prevention:  The first step in treatment of insect stings, whether they are mild or severe, is to avoid being stung.  Prevention can be accomplished by wearing protective clothing when outside, such as shoes, long-sleeved shirts and pants, and gloves.  Risks for stings include:

● Summer season

● Involvement in outdoor activities including yard work, bicycling, boating, swimming and camping. 

● Wearing scented perfumes, lotions, soaps, and other personal hygiene products

● Eating or drinking outdoors, or being near or handling garbage

● Rapid or jerking movements.  Remain still when stinging insects are present because insects usually do not sting unless they feel threatened.

Mild reactions:  these reactions are treated mainly to relieve the pain and itching involved.  The area should be cleaned, and if the stinger remains in the skin, it should be flicked off.  Avoid using tweezers for removal.  Ice may be applied to the area, and using topical and/or oral antihistamines for the itch is recommended.  Topical corticosteroid creams may also be used. 

If a large local reaction occurs, treatment with oral steroids may be needed.

Anaphylaxis:  When patients have life-threatening reactions, they must receive in injection of epinephrine to avoid going into shock.  For patients who have a history of severe reactions, carrying epinephrine, or an Epi-pen, is common.  However, even for patients who carry their own epinephrine, medical care should be sought as soon as possible.  Very often, patients will need more medications, and possibly IV fluids and oxygen.  It is also important that even after a reaction resolves, the patient is closely monitored in case symptoms return after several hours. 

If a patient has experienced anaphylaxis, it is strongly recommended that an allergist evaluate them.  This is important so that a thorough history is taken, and that the patient is skin tested. Also during this visit, the patient will need to be educated about risk factors, how to recognize a severe reaction, how and when to use their epinephrine, and discussion of shots (allergen immunotherapy) for insect allergies if the skin tests are positive.

It is important to note that skin testing for insect allergies should not be done within six weeks of the last reaction, because skin tests may be negative during this period.

Allergen Immunotherapy: These are recommended for any patient with a history of previous systemic reactions.  Allergy shots for insects work in the same way that they do for inhalant allergies.  The patient is injected with venom extracts that are determined based on which skin tests were positive during the evaluation.  These injections are extremely successful in the treatment and prevention of severe reactions.  It is generally recommended that injections should be continued indefinitely, although studies have demonstrated that in some patient these may be stopped after five years.

Hives
When an identifiable cause for urticaria and angioedema is involved, avoidance should be the first step in treatment.  This is especially true of triggers that can result significant reactions, such as medications and foods.   When a reaction does occur, however, the treatment of urticaria and angioedema consists primarily of antihistamines.  Often patients will require doses of antihistamines that are greater than what is generally prescribed for other problems such as nasal allergies.  It is also common to have patients with chronic urticaria or angioedema take a regimen of antihistamines for a period of time even after the problem is cleared, in order to be sure that the immune system response to the trigger is decreased.

Urticaria and angioedema, especially when occurring over a long period of time, will often cause significant distress and anxiety.  This is an important aspect for both patients and providers to consider when evaluating and treating these conditions.

Nasel Allergies
Nasal allergies, or allergic rhinitis, involve inflammation of the nasal tissues, called mucous membranes.  This results in a variety of symptoms, including runny nose, sneezing, congestion, and itching of the nose, throat and roof of the mouth, as well as eye itching and watering.  Some patients only experience these symptoms during certain times of the year.  This is called Seasonal Allergic Rhinitis, and generally involves pollens and molds.  Other patients experience symptoms year round, called Perennial Allergic Rhinitis, which can involve animal dander, dust, and cockroaches in addition to pollens and molds.   

In an effort to better maintain nasal allergy symptom relief, there are three main branches of treatment.

 Inhaled Allergen Avoidance: this is a very basic aspect of allergy treatment, but can be especially vital depending on the type of allergy, and particularly if the patient also suffers from asthma that has allergic triggers.

● House dust and dust mites: for those patients with dust allergies, limiting exposure is key.  Covering pillows and mattresses with dust mite covers, and using an air purifier, especially in bedrooms, can accomplish this.  Further recommendations include routine cleaning, use of allergy filters on furnaces, and professional ductwork cleaning.  It may also be recommended that wherever possible, carpeting is limited throughout the home.

● Molds: molds as a group are plentiful throughout the environment, especially with wet weather.  Leaving piles of wet grass clippings or leaves in the yard can promote mold growth around the home.  Any type of water damage within the home can also be very problematic.  Avoidance in this group consists mainly of thorough and timely cleanup of any situation that will lend itself to mold growth, whether indoors or out.

● Pets: avoidance of pets can often be particularly difficult, mainly because parting with them is frequently not an option.  However, limiting them to certain areas of the house can be helpful, and in particular, keeping them out of bedrooms is best.  Again, use of proper furnace filters as well as air purifiers may be recommended.  For those patients with asthma who are also allergic to cats, limited exposure may not be enough to keep asthma flares in check.

● Pollens: these include tree, grass, and weed pollens, and can be the most difficult to avoid as they are plentiful during each of their seasons.  It is recommended, however, that patients avoid sleeping with windows open, driving with car windows down, and avoiding hanging laundry to dry outdoors. 

Medications: there are several different types of medications used for the treatment of inhalant allergies.  These may be used alone or often in combination to help control allergy symptoms. 

● Antihistamines: This group of medications acts to block the release of histamine, the major chemical involved in an allergic reaction, from cells throughout the body.  This in turn helps limit the allergic reaction. Antihistamines are best suited for the treatment of symptoms such as itching of the nose and often the eyes, runny nose, and sneezing.  They are available by prescription as well as over the counter, and are generally well tolerated. 

● Decongestants: These include Sudafed or pseudoephedrine, and phenylephrine.  They are available mainly over the counter, and are often found in combination with antihistamines and/or expectorants.  They effectively shrink back swollen nasal tissues in order to relieve congestion and can often limit post-nasal drainage.  They are not recommended for patients with high blood pressure, glaucoma, enlarged prostate or urinary retention.

● Expectorants/mucolytics: This group is made up mainly of guiafenesin, which is designed to thin mucus secretions, allowing for sinus cavities and nasal passageways to drain more effectively.    They are often used as an add-on therapy to decongestants. 

● Intranasal steroid sprays: This class is often considered one of the most effective treatments for nasal allergy symptoms because they also have the ability to prevent symptoms.  They limit the immune response in the nasal tissues and in turn alleviate and prevent symptoms such as runny nose, sneezing, itching, congestion and post-nasal drainage.  The technique used to apply these sprays is not difficult but should be reviewed, as misuse is the most frequent cause of side effects including sore throat and bleeding. 

● Intranasal antihistamine sprays: These work in much the same way as oral antihistamines, but are applied directly to the nasal tissues.  They are effective against symptoms such as runny nose, sneezing, itching and post-nasal drip.  They may help congestion in some patients. 

● Antileukotrienes: Leukotrienes are chemicals released within the body for several reasons, including allergic responses, and contribute to inflammation.  They are frequently more likely to be involved with asthma, but there are some patients who experience some relief of their nasal symptoms, particularly congestion, with this class of medication.  

● Eye drops: For those patients whose eye symptoms are not well controlled with other medications, allergy eye drops are often recommended.  They are available over the counter and by prescription, and are most beneficial when used prior to allergen exposure, or upon waking.