10 Things to Know About Allergies

Systemic steroids are overused. Physicians often give steroid shots or oral bursts for sinusitis, bronchitis, URI’s, asthma, joint inflammation, skin conditions or other reasons. When a patient seeks treatment from their primary care physician, urgent care, ENT, orthopedist, etc, all of these steroids start adding up without the different physicians being aware. One way to minimize the need for all of those systemic steroids, at least from an allergy/asthma/chronic sinusitis standpoint is to have better day-to-day control of these diseases. This could be a daily corticosteroid or antihistamine nose spray for rhinitis, or a daily-inhaled corticosteroid inhaler for asthma, or immunotherapy for both.
Asthma inhalers are often prescribed without instruction on how to properly use the device. It’s a waste of time and money for someone to use an inhaler incorrectly. Sometimes even with proper coaching, the patient may need a spacer device. Or the patient was told to use a spacer, but the patient (especially an older child) doesn’t bother with the spacer and ends up using the inhaler incorrectly. There are many different inhaler devices on the market now, so teaching how to use a standard “L-shaped” metered-dose-inhaler isn’t enough anymore. Also, patients often give up on their daily controller inhalers because of thrush, but often the patient wasn’t instructed on proper preventative oral hygiene.
Besides inhalers and leukotriene-antagonists as controller meds for asthma, injectable biological agents are useful in cases of moderate-severe asthma. These include anti-IgE omalizumab and soon to be available anti-IL-5 injectables, mepolizumab and reslizumab.
Immunotherapy for environmental allergens saves money, work and school days lost, and improves a patient’s overall quality of life. The cost of five years of immunotherapy for all the environmental things a person is allergic to is far less than the cost of lifetime controller meds, repeated antibiotics and steroids and OTC sinus meds for recurrent sinusitis and asthma flares, and the number of days missed from school/work or having suboptimal performance from school/work due to allergies and asthma.
Venom hypersensitivity to stinging insects and fire ants is a truly life-threatening condition that can be effectively treated with immunotherapy. Immunotherapy eliminates or at least lessens the severity of future stings.
Not enough epinephrine auto injectors are prescribed. And when they are, patients are not given the proper instruction of how and when to use them. Patients might be acutely taken care of in the ER or urgent care, but when discharged, they are often not given a prescription for an auto injector. And even if they are, there is typically no written emergency action plan.
An allergic patient is more likely to implement environmental control measures if they experience a skin test and see the response. No matter how many times a pediatrician tells parents that their child is allergic to their pets or to dust mites, the importance of doing something about it doesn’t really hit home until the family can see the large wheal and flare on their child’s back. At that point, they begin consider environmental control measures, or discuss immunotherapy.
Subcutaneous immunotherapy (SCIT) vs. sublingual immunotherapy (SLIT)? Subcutaneous immunotherapy (traditional allergy shots) is given in a physician’s office due to the risk of anaphylaxis. SCIT is administered over a finite time period with years of long-lasting benefit. SCIT takes care of most environmental allergens, including allergic rhinitis, allergic conjunctivitis, chronic sinusitis or otitis media, atopic dermatitis and asthma. Presently, the only FDA-approved sublingual immunotherapies are tablets for grass or a tablet for ragweed. No SLIT is currently approved for other pollens, pet dander, dust mites, or mold allergy and there are no FDA-approved allergy drops. The advantage of SLIT is that they can be taken at home if the patient compliantly takes the pill daily.
There are many reasons patients have chronic sinusitis – it is important to figure out the root cause to limit antibiotic and steroid use. Allergic rhinitis, non-allergic rhinitis such as vasomotor rhinitis, laryngopharyngeal reflux, and immunodeficiencies can be the root cause of chronic sinusitis. It might help a patient’s chronic headaches and sinusitis if one can find and treat an underlying condition.
Refractory asthma can be conditions other than asthma. Things like GERD, chronic sinusitis, vocal cord dysfunction, cardiac disease, alpha-one antitrypsin disease and COPD can all mimic asthma. Additionally, not all COPD is COPD. Long-term asthmatics who were undertreated with just a rescue albuterol inhaler or never diagnosed and simply treated for repeated bronchitic episodes can develop an obstructive picture that is often misdiagnosed as COPD.