Managing Fall Allergies and Asthma

Dareen D. Siri, MD, FAAAAI, FACAAI

Allergy, Asthma, and Immunology

Springfield Clinic

What is Hay-Fever?

• = Allergic Rhinitis and Conjunctivitis

– Refers to the “Haying” season or Fall

• Affects 40 million Americans

• Misnomer: Allergies do not cause fever

• Airborne particles, i.e. pollen and dust, cause symptoms in allergic people

• Implicated plants are primarily anemophilus

– Pollen is spread by wind and air currents, not spread by insects

Allergies

• The immune system overreacts to substances that are normally harmless

• Occurs in susceptible persons, “atopic” persons

– Predisposition to allergies is inherited

• Contact with allergens to our eyes, nose, sinuses, lungs, and skin cause inflammation

– Immune cell in the body are responsible for swelling, redness, congestion, and mucus

• Symptoms: itchy eyes, runny nose, congestion, sneezing, itchy throat, and mucus production

Asthma

• Affects lower airways in the lungs

• Characterized by airway inflammation, mucus over-production, and spasms of muscles around airways

• Symptoms: Wheezing, cough, shortness of breath, chest tightness or heaviness, problems with activity, laughing, and sleep

• Commonly provoked by mold, dust, pollen, animal dander, airborne irritants, tobacco

Ragweed

• Where: Midwest, Northeast, South

– Can be found in every state in the US (except Alaska) and in parts of Canada

• When: Mid-August until frost

– Most pollination occurs 10am to 4pm

• What: The most prevalent fall allergen and the foremost cause of “hay fever”

– Contact with the plant may cause skin rash

Sourced from: National Allergy Bureau (AAAAI)

Common and Giant RagweedAmbrosia artemisiifolia & trifida

1 billion grains = ragweed pollen produced in an allergy season

High Pollen State

• Pollen can travel hundreds of miles and be airborne for days (2 miles up and 400 miles out)

• Pollen is best released on dry windy and hot days (humidity less than 70%)

• A preceding wet season increases plant production

• Global warming and increased CO2 levels increase pollen production

• Goldenrod is often mistaken for ragweed, which blooms at the same time

Can we get rid of ragweed?

• Large-scale control: Impossible

– Uncultivated and wild areas are abundant with ragweed

– Construction sites, fields, river banks, woods, etc.

• Local control: Landscaping, herbicides, weeding, reaping and mowing bi-monthly

– Ragweed plants are best manually uprooted in spring

Other Weeds

Sorrel/Dock

Kochia/Goosefoot

Amaranth/Pigweed

Thistle

Other Weeds

Cocklebur

Lambs Quarters

English Plantain

Mugwort

Grasses

• Pollination in late spring through the late summer

• Direct contact with grass barbs to the skin can cause allergic skin rashes

• Allergenic grasses

– Blue / Kentucky, Brome, Canary, Timothy, Meadow/Fescue, Redtop, Orchard, Rye, Velvet, Sweet Vernal

– Bermuda

– Johnson

Fungus Among Us

• = Fungi, Mold, Yeasts• Very abundant around plant materials• Alternaria, Cladosporium, Penicillium,

Aspergillus, Smut and Rusts, etc.• Can cause skin, respiratory, sinus, and

nail, as well as opportunisitic infections

Alternaria

• Abundant in the summer and early fall

• Present on dead plant materials, especially cereals and grasses

• Contributes to 1/3 of agricultural spoilage

• Cause of tomato and potato blights

• Harvesting corn causes spore release into the air which can drift for many miles

• Important allergen in provoking asthma

• May be a cause of September asthma epidemics

• Allergies to fresh fruits and vegetables

• Occurs in the 10% most allergic persons

• Mouth and tongue itching, swelling, and numbness upon contact with food

• Foods can be tolerated if they are peeled then washed well, or cooked or processed (such as in a pie)

• Caused by bodies’ confusion with food proteins that are similar to proteins in allergenic plants

Ragweed pollen = bananas, cucumbers, zucchini, melons, chamomile, sunflower seeds, echinacea, dandelion, hibiscus, artichoke

Birch tree pollen = apples, cherry, almonds, avocado, banana, carrot, celery, chickory, coriander, fennel, fig, hazelnut, kiwi, nectarine, parsley, parsnip, peach, pear, plum, potato, walnut

Grass pollen = melons, tomato, orange, kiwi, peanut

Food-Pollen SyndromeOral Allergy Syndrome

Diagnosis

• A Board-certified Allergist and Immunologist is the most qualified physician to diagnosis and treat allergic diseases

• History of symptoms

• Physical Examination

• Skin testing

• Blood testing

• Imaging

• Formulation of a treatment plan

Skin Testing

• Why is allergy testing important?

– Knowledge is the first step to effective solutions and treatments for your allergies.

– Identifies the specific things that trigger your reactions.

– Modern allergy tests are more convenient and accurate.

• Who can be tested?

– Children and adults of any age

– Allergies can develop at any age

• Is skin testing painful?

– Mild discomfort can be expected, but there is usually minimal if any pain.

• What can be tested?

– Pollen, dust mites, animal dander, insects, foods, some chemicals and medicines

• Are there risks to skin testing?

– An allergic reaction to the skin test is extremely rare.

– Pain, bleeding, rashes at the skin test site is uncommon.

– A few people faint due to being nervous.

Skin Testing

• Prick skin tests

– Needle-free testing to test inhalant allergens, food, medicines, insect venom

– Application of allergen extracts to the skin with a plastic pick which is used to lightly “prick” the skin

– 20 to 30 minute wait time for skin reactions to the allergens

• Intra-dermal skin tests

– Application of allergens under the skin by a small needle

• Patch testing

– Application of chemicals, metals, cosmetics, foods, and other materials to the skin with a light adhesive

– 2-3 days wait time for skin reactions to the allergens

•Blood tests for true allergy should be IgE tests (such as ImmunoCap), not IgG tests.

•IgG tests do not reflect true allergies and have false positive results.

•Many insurance plans will not pay for IgG “allergy” tests as they are considered unconventional.

Blood tests

Negatives

•More expensive than skin tests

•Takes longer to get results

•Blood draw can be painful

•Not as sensitive as skin testing

•Negative blood tests cannot guarantee that no allergy is present

•Lack of accuracy in young children

•False positives can be present in highly allergic people

•Blood tests for true allergy should be IgE tests (such as ImmunoCap), not IgG tests.

•IgG tests do not reflect true allergies and have false positive results.

•Many insurance plans will not pay for IgG “allergy” tests as they are considered unconventional.

Blood tests

Positives

•Useful in those with severe skin conditions that can’t be improved for skin testing

•Can be helpful in people with very dark skin due to difficulty in reading skin tests

•An alternative for people who can’t get off of medicines that interfere with skin testing

•Helpful in monitoring of food allergies

Testing

• Allergen, food and drug challenge

– Regimented administration of a food or drug to diagnose allergy with close observation

• Breathing tests

– Spirometry = measuring force and volume of breathing to diagnose asthma, emphysema/COPD and other lung conditions

– Exhaled nitric oxide = direct measure of nitric oxide chemical released from the lung during inflammation in asthma

Imaging

Normal Sinus CT Scan Abnormal Sinus CT Scan

Control and Treatment

• Managing the allergies– Allergen avoidance– Medications

• Curing the allergies– Allergy shots (immunotherapy)

Allergen Avoidance - The Outdoors

• Avoid fields, farms, woods, railroad tracks, vacant lots, construction sites

• Limit activities by

– being out during early mornings or late evenings

– staying in on dry and windy days

• Follow pollen counts and weather patterns

– www.aaai.org/nab

– www.pollen.com

– www.weatherchannel.com

Allergen Avoidance - The Outdoors

• Reassign outdoor work

• Wear protective gear when doing mowing or yard work

– Wear long-sleeved clothing

– Wear a mask

– Wear protective glasses

• Weed in the spring

• Don’t hang laundry out to dry

• Shower and rinse your nose after being outdoors

Allergen Avoidance - The Indoors

• Limit pollen-laden clothes, shoes, and pets from the bedroom

• Use a HEPA filter-containing vacuum frequently

• Close all windows and bedroom doors and use air-conditioning

• Purchase good furnace/air filters and change them monthly

• Use allergen-proof pillow and bed covers

• Removal of carpeting or use of low pile carpeting in bedrooms and other frequently used rooms

• Keep clutter low and dust often

Quick Relief Medicines

• Anti-histamines

– Sedating: Benadryl, Chlortrimeton, Hydroxyzine

– Non-sedating: Claritin, Zyrtec, Allegra

– Nasal sprays: Astelin, Astepro, Patanase

– Eye drops: Zaditor, Patanol, Pataday, Optivar, Bepreve

• Bronchodilators

– Oral: albuterol, theophylline

– Inhalers: Albuterol (ProAir, Ventolin, Proventil), Levalbuterol (Xopenex), Pirbuterol (MaxAir), Ipatroprium (Atrovent)

• Decongestants

– Oral: Pseudoephedrine (Sudafed), Phenylephrine (Sudafed PE)

– Nasal Spray: Oxymetolazone (Vicks 44, Afrin, Mucinex, Zicam), Phenylephrine (Neo-synephrine), Xylometolazone (4Way)

• Other

– NasalCrom, expectorants, mucolytics, cough suppressants

Maintenance Medicines

• Anti-inflammatories

– Anti-leukotrienes: Singulair, Accolate, Zyflo

– Mast-cell Stabilizer: cromolyn

• Immunosuppressants

– Oral: prednisone, prednisolone, cortisone

– Inhalers: Flovent, QVar, Asmanex, Pulmicort

– Nasal Sprays: Flonase, Nasonex, Nasacort, Veramyst, Omnaris, Rhinocort

– Eye drops and Creams

• Bronchodilators

• Combination Inhalers: Advair, Symbicort, Dulera

• Theophylline

Non-medicine Treatments

• Allergy shots and desensitization

• Biologic medicines (Xolair)

• Surgery and Micro-surgery

• State-of-the-Art Research

– Vaccines for pollen and food allergies

– Food desensitization

• Natural and herbal remedies

– Nasal saline (salt-water)

– Traditional Chinese Medicine

– Acupuncture and chiropractics

– Homeopathic drugs, e.g. Zicam, capsaicin pepper

Allergy Shots

• Who should consider them?

– Desire for long-term relief

– Treatment for the cause of allergy, not just symptoms

– Difficulty in avoiding allergens

– Trouble with medicines or their side effects

– Medicines are a burden

– Benefits of shots outweigh the costs

– Having severe allergic disease or having asthma in addition to hay-fever

– Prevention of asthma

• How old should you be to get shots?

– 5 years + (some mature 3 and 4 year-olds)

• What is in the shots?

– Allergy extracts customized to what a person is found to be allergic to after skin testing

• How long to the shots take?

– A person must build up to a maximum tolerated dose by getting shots weekly or more frequently.

– After the maximum tolerated dose is achieved, monthly maintenance shots are done for 3 to 5 years.

• How long to the effects of the shots last?

– Unsure, most experts agree about 5 to 10 years or longer

• Are there risks to getting shots?

– Local reactions: swelling, heat, redness of the arms

– Systemic reactions: anaphylaxis (rate less than 0.5%)

Allergy Shots

Questions ?