This Can’t Be Right

So what is going on with persistent allergy symptoms when the pollens are NOT very high? This patient is using the term “allergies” to describe “symptoms” of allergy that may not be IgE-mediated allergy at all. Doesn’t mention skin testing, but this testing can be completely negative in this scenario. How frustrating!

Positive skin tests look like this….


In fact, often I am tested for allergy and had no reactions even though I sneeze my head off during the fall season?
You cannot assume that pollens are the only cause of persistent rhinitis. Various conditions are called infectious rhinitis, vasomotor rhinitis, that have nothing to do with allergy but still because lots of nasal drainage and congestion.
In fact we are now entering into the time of year (late fall and winter) when many symptoms of sneezing, coughing, asthma are thought to be due to allergy but are really due to infection or cold air. Your body does not tell you when triggers change, but that is actually what is happening.
This writer from Reddit also complained of more symptoms that would suggest asthma during the fall pollen season, but yet low allergy counts.
Again, allergies are not the only cause of asthma even though the highest time of admissions for asthma occurred during the third week of September. Certainly, not all these patients have allergy. We have been inundated with COVID-19, and this virus shares many similarities with the common cold–do not be surprised if sneezing congestion, nasal drainage during the winter makes you think of Covid-19, but is actually rhinovirus induced asthma.

Look at the examples of sinus infection below. Slide a is the only normal CT scan as all of the others have some evidence of sinusitis. Any sinus infection is bound to cause problems with PND, congestion, and even sneezing–allergy can be involved, but many patients with chronic sinusitis have no allergy on skin testing. Asthma during the winter is often exacerbated by sinus infections just like the ones shown below.

What to do with this conundrum?

  1. Take your regular medications as prescribed by your doctor–do not stop using your inhaled corticosteroids just because the seasons change.
  2. It may even be beneficial to increase your dose of inhaled corticosteroids to 2 puffs 4 times a day when you are ill
  3. Always use a spacer device for your asthma
  4. Be open to “nonallergic” trigger for your nasal congestion sneezing, coughing. It is not unusual for patients to have both allergy and sinus infection for instance.
  5. Treating sinus infections may require oral corticosteroids and antibiotics for up to 1 month at a time. 10 days just won’t do it with chronic sinusitis
  6. Take your regular medications as prescribed by your doctor–do not stop using your inhaled corticosteroids just because the seasons change.
  7. It may even be beneficial to increase your dose of inhaled corticosteroids to 2 puffs 4 times a day when you are ill
  8. Always use a spacer device for your asthma
  9. Be open to “nonallergic” trigger for your nasal congestion sneezing, coughing. It is not unusual for patients to have both allergy and sinus infection for instance.
  10. Treating sinus infections may require oral corticosteroids and antibiotics for up to 1 month at a time. 10 days just won’t do it with chronic sinusitis

#allergies, #allergy, #respiratory-disorders

More Reason to Consider Allergy Shots if your hayfever isn’t controlled by medications.

Click here for Christmas Greeting from Dr. Wiens! https://youtu.be/i020Y_gEunU

Huge Growth of Allergy Shots Market by 2028 with Top Key Players – ALK Abello, Stallergenes Greer, Allergy Therapeutics

I have been telling patients for years that allergy immunotherapy (#allergy shots) are very helpful for controlling the sniffles, sneezing and coughing that patients experience particularly during the fall and spring. This is a very interesting market research report on allergy shots that analyzes marked growth of allergy immunotherapy, uses cost structures and various other statistical tools to make their predictions. If AIT does not work, my reasoning is why would the market increase over the next 5 years? I have referenced the research report if you are interested in pursuing a more detailed analysis. Just so you know, our clinic uses Greer extracts and they are one of the top companies in the report.
I’ll provide some specific answers from a clinical standpoint to questions that this research report discusses. They are found at the bottom of the blog. Thanks to data analytics, many industries are now converting a “gut instinct” into mathematical equations–I do not know if this is really good, but “just the facts”

A2Z Market Research announces the release of Allergy Shots Market research report. The market is predictable to grow at a healthy pace in the coming years. Allergy Shots Market 2021 research report presents analysis of market size, share, and growth, trends, cost structure, statistical and comprehensive data of the global market.

The top companies in this report include:

ALK Abello, Stallergenes Greer, Allergy Therapeutics, Aimmune Therapeutics, Anergis, Arrayit Corporation, Biomay AG, HAL Allergy Group, DBV Technologies.

Get Sample Report with Latest Industry Trends Analysis: https://www.a2zmarketresearch.com/sample-request/568899

As analytics have become an inherent part of every business activity and role, form a central role in the decision-making process of companies these days is mentioned in this report. In the next few years, the demand for the market is expected to substantially rise globally, enabling healthy growth of the Allergy Shots Market is also detailed in the report. This report highlights the manufacturing cost structure includes the cost of the materials, labor cost, depreciation cost, and the cost of manufacturing procedures. Price analysis and analysis of equipment suppliers are also done by the analysts in the report.

This research report represents a 360-degree overview of the competitive landscape of the Allergy Shots Market. Furthermore, it offers massive data relating to recent trends, technological advancements, tools, and methodologies. The research report analyzes the Allergy Shots Market in a detailed and concise manner for better insights into the businesses.

The report, with the assistance of nitty-gritty business profiles, project practicality analysis, SWOT examination, and a few different insights about the key organizations working in the Allergy Shots Market, exhibits a point-by-point scientific record of the market’s competitive scenario. The report likewise displays a review of the effect of recent developments in the market on market’s future development prospects.

Global Allergy Shots Market Segmentation:

Market Segmentation: By Type

Allergic Rhinitis
Allergic Asthma
Food Allergy
Atopic Dermatitis
Others

Market Segmentation: By Application

Allergic Rhinitis
Allergic Asthma
Food Allergy
Atopic Dermatitis
Others

Geographic analysis:

The global Allergy Shots market has been spread across North America, Europe, Asia-Pacific, the Middle East and Africa, and the rest of the world.

Get Exclusive Discount on this Premium Report: https://www.a2zmarketresearch.com/discount/568899

COVID-19 Impact Analysis

The pandemic of COVID-19 has emerged in lockdown across regions, line limitations, and breakdown of transportation organizations. Furthermore, the financial vulnerability Allergy Shots Market is a lot higher than past flare-ups like the extreme intense respiratory condition (SARS), avian influenza, pig influenza, bird influenza, and Ebola, inferable from the rising number of contaminated individuals and the vulnerability about the finish of the crisis. With the rapid rising cases, the worldwide Allergy Shots refreshments market is getting influenced from multiple points of view.

The accessibility of the labor force is by all accounts disturbing the inventory network of the worldwide Allergy Shots market as the lockdown and the spread of the infection are pushing individuals to remain inside. The presentation of the Allergy Shots makers and the transportation of the products are associated. If the assembling movement is stopped, transportation and, likewise, the store network additionally stops. The stacking and dumping of the items, i.e., crude materials and results (fixings), which require a ton of labor, is likewise vigorously affected because of the pandemic. From the assembling plant entryway to the stockroom or from the distribution center to the end clients, i.e., application ventures, the whole Allergy Shots inventory network is seriously compromised because of the episode.

The research provides answers to the following key questions:

  • What is the projected market size of the Allergy Shots market by 2027? **As you probably guessed, it’s going up. One of the favorable features of AIT is the frequency of injections–once you complete the build-up phase, allergy shots are given once monthly and it’s hard to beat this “convenience factor”.
  • What will be the normal portion of the overall industry for impending years?
  • What is the significant development driving components and restrictions of the worldwide Allergy Shots market across different geographics? **This is more FYI than anything. I was very surprised that world-wide use of allergy shots is predicted to increase. In previous years, the use of allergy shots around the world had been decreasing–why? AIT involves some risk (albeit small) of anaphylaxis and even death from allergy immunotherapy. In recent years, we’ve been able to reduce this risk by better selection of patients for AIT, more standardized allergen extracts, and more appropriate clinical setting (minimize home shots) for giving shots in order to treat any anaphylaxis quickly with appropriate back-up (urgent care and ER in this case). It’s working as there have been zero deaths from AIT in the United States for the past number of years–wahoo, that’s progress!
  • Who are the key sellers expected to lead the market for the appraisal time frame 2021 to 2027? ** We’ll find out in 5 years. Obviously, this is a very profitable market for companies making allergy extracts. Twenty years ago a gallon of pure dust mite extracts sold for $10,000–I wonder what inflation has done to that cost today?
  • What are the moving and arising advances expected to influence the advancement of the worldwide Allergy Shots market? **Currently, we inject the entire allergen (say ragweed) under your skin to induce tolerance. Researchers have been looking for years at the possibility of injecting only the important parts of the allergen that retains immunogenicity, but reduces the risk of anaphylaxis. This “Holy Grail” is not far off.
  • What are the development techniques received by the significant market sellers to remain ahead on the lookout?

Buy Exclusive Report: https://www.a2zmarketresearch.com/checkout

Contact Us:

Roger Smith

1887 WHITNEY MESA DR HENDERSON, NV 89014

sales@a2zmarketresearch.com

#allergy-immunotherapy, #allergy-shots-2

Is Tomato a fruit or vegetable?

Click the link below for a message from Dr. Wiens himself!

https://www.youtube.com/shorts/dBWo3TZcHK8

https://allergylosangeles.com/allergy-blog/tomato-allergy-can-come-in-many-flavors/

Dr. Alan Khadavi from southern California.

I appreciate the blog from Dr. Khadavi as the question of “citrus acid allergy” often comes up in my daily allergy practice here in Tulsa. Tomato is just one more food that can cause an intolerance that often is confused with a food allergy. As listed below, mucosal irritation is an intolerance, while oral allergy syndrome and anaphylaxis represent two examples of “IgE-mediated” or true allergy.

Tomato allergy is not commonly reported, but it can cause adverse reactions.  Hypersensitivity reactions to other fruits are commonly reported, particularly apples, stone fruits and bananas. Tomato (Solanum lycopersicum) is derived from two wild ancestor species, Solanum pimpinellifolium and Solanum cerasiforme. Tomato flavor is a balance of acid and sugar recognized by the tongue and the effect of volatile compounds within the fruit that cause aroma recognized by the nose. Tomato flavor is commonly described as sweet, tart, tangy or balanced.

Tomato is classified as a fruit because they contain seeds and grow from the flower of the tomato plant. But many people still classify it as a vegetable based on its culinary applications. (how we cook with it!)

Credits to Dr. Alan Khadavi

Types of reactions to Tomato:

  1. Mucosal irritation-Tomato has been implicated in an array of adverse reactions, including uncomfortable mucosal irritation due to acidic pH. The tomato plant can also cause itching of the skin when touched which is a form of allergic contact dermatitis.
  2. Oral allergy syndrome-symptoms typically occur with mouth itching and swelling of lips and tongue.  Patients allergic to grass pollen can describe symptoms of oral allergy syndrome to tomato.  This is not a true tomato allergy, but a cross reactivity of the proteins to the grass pollen.  Treatment is heating the fruit or just avoiding it. Other foods in the same category are kiwi, melon, peach and celery.
  3. Anaphylaxis-symptoms that occur are hives, swelling, wheezing, coughing, vomiting, diarrhea and low blood pressure. This is from IgE mast cell degranulation. Allergy skin testing, specific IgE lab testing and fresh food skin testing with tomato all can be used to test for tomato allergy.

Reactions to tomato can thus come in different forms.  With a severe reaction to tomatoes, patients will often avoid altogether and the problematic reactions are usually the mucosal irritation or food intolerance. An allergy doctor can help decipher what type of reaction one is having to tomato and to do the appropriate tests for establishing or ruling out a diagnosis of clinical allergy.

In the news a couple of years ago, Ariana Grande was diagnosed with a true tomato allergy. She joked that there was “nothing more unfair than an Italian woman developing an allergy to tomatoes in her mid-twenties.” But food allergies are a serious matter and should be taken seriously.  All precautions should be taken place and patients should carry around an injectable epinephrine in case of an accidental exposure.

Not only should patients be aware of tomato allergy, but doctors should also recognize that rare food allergies aren’t so rare if you have the sensitivity. What to do?

  • Make sure you have injectable epinephrine
  • Skin testing or blood testing can be performed to many foods that cause rare allergies.
  • Even if you don’t perform testing, please avoid the food (s) that cause problems, as the reaction may get worse with subsequent exposures.

#tomato-allergy

Will peanut allergy always be with us?

https://www.usatoday.com/story/sponsor-story/aimmune-therapeutics/2021/09/13/back-school-peanut-allergy-6-steps-parents-consider/5459643001/?utm_source=taboola&utm_medium=exchange&tblci=GiArXsoPmR6TKXGp2LlCIMdXds8I3gAGYdlTYUi6Ch-OGSDqyz0o88jezYjn_fI2#tblciGiArXsoPmR6TKXGp2LlCIMdXds8I3gAGYdlTYUi6Ch-OGSDqyz0o88jezYjn_fI2

Back-to-school with peanut allergy: 6 steps for parents to consider

What families living with peanut allergy need to know to help care for their kids at school

Aimmune Therapeutics

Parents of children with peanut allergy can consider these 6 steps when returning to in-person learning.

For families living with peanut allergy, the most common food allergy among children in the U.S.1, managing the allergy can require constant vigilance and supervision. This includes diligently reading food labels and, for some, avoiding social gatherings, such as birthday parties and summer camp, in fear of accidental exposure. Practicing a strict peanut-free diet alone might not be enough, as even a small amount of exposure to the allergen can prompt an allergic reaction.2

With many schools reopening for in-person learning this fall, parents of children with peanut allergy may be feeling nervous to send their kids back to school. This may be particularly true for those with young children starting school in-person for the first time who are not accustomed to the independence and level of vigilance required. 

Here are six proactive steps that parents can take when sending children with peanut allergy back into the classroom: 

1. Speak to the child’s allergist

Before the school year begins, parents should make an appointment to speak to their child’s allergist. At this time, parents can work with the allergist to update their Emergency Care Plan, which details the child’s allergies and what to do in case of an allergic reaction. During this appointment, parents can also discuss treatment options with their allergist.

2. Inform the school

Parents should share their Emergency Care Plan with school administrators and explain how they can help prevent accidental exposure to peanut. Many schools have protocols in place, but it’s important to have open conversations to ensure comfort with those protocols and to put other protocols in place as needed. The school may even have information about a food allergy support group for parents whose children attend local schools, which could offer useful tips.

Parents should make a complete list of the foods their child is allergic to and share emergency contact information, along with how and where their child’s medication will be stored. Additionally, they should confirm that the school staff is trained to administer injectable epinephrine.

3. Educate, educate, educate

Parents may want to meet with teachers, health professionals, cafeteria staff and other parents to educate them about the child’s peanut allergy and what to do in case of an allergic reaction. An educational session, in collaboration with the child’s teacher, could be offered to classmates during which students can ask questions and better understand what it means to avoid even the tiniest traces of peanut.

4. Reduce transportation concerns

Because of the exposure risk posed by school buses, it’s important to understand the schools' transportation protocols for food allergy management.

The school bus may pose a risk for accidental peanut exposure as buses are used for daily transportation and for class field trips. Parents should talk to their child’s school to understand school bus rules and protocols for food allergy management.

5. Prepare lunch or learn about substitute meal options

Preparing lunch at home may offer some parents assurance, while others may prefer that their child uses the school cafeteria. The U.S. Department of Agriculture (USDA) requires schools to offer substitute meals for students with life-threatening food allergies. This may require written instructions from the child’s healthcare provider and is another reason that speaking with the school’s food service director in advance of the school year is suggested.

Once thought to be a permanent condition, peanut allergy is now a treatable condition with the use of Oral Immunotherapy or desensitization to peanuts. Granted, this article is sponsored by the maker of Palforzia, Aimmune, but it is a good option for kids with peanut allergy.

  • Why should I consider the use of an “expensive” protocol for peanut desensitization? (Palforzia)
  • Using a FDA approved protocol simply means that researchers have agreed upon the dose escalation that minimizes adverse reactions such as anaphylaxis during the procedure. After all, you are giving your child a food that they are allergic to!
  • The amount of peanut protein is standardized between doses, meaning during the “up-days” and escalation phase, your child will always get the anticipated dose, making anaphylaxis less likely to occur.
  • In order to start using “peanut desensitization”, parents and physicians must verify that they have completed the appropriate education on how to use Palforzia and not “shoot from the hip.” If it were my child, I would always want to use a product that’s been tested and standardized for best results done safely.

6. Find out if treatment could be the right option

Some families living with peanut allergy may not be aware that there is a U.S. Food and Drug Administration (FDA)-approved treatment for children aged 4 through 17 years with peanut allergy. This might be an option for families who want to help take the power back from peanuts.

PALFORZIA® [Peanut (Arachis hypogaea) Allergen Powder-dnfp] is intended to gradually decrease your child’s sensitivity to small amounts of peanuts that may be hidden in foods. As children go back to school, parents may want to speak to their child’s allergist to see if PALFORZIA may be the right choice for them.

WHAT IS PALFORZIA?

PALFORZIA is a treatment for people who are allergic to peanuts. PALFORZIA can help reduce the severity of allergic reactions, including anaphylaxis, that may occur with accidental exposure to peanut. PALFORZIA may be started in patients aged 4 through 17 years old. If you turn 18 years of age while on PALFORZIA treatment you should continue taking PALFORZIA unless otherwise instructed by your doctor.

#food-allergy, #food-desensitization, #peanut-allergy

Fishing for allergy

Who doesn’t like to fish during this time of the year? Doesn’t matter if it’s catfish on the local pond, or trout at Roaring River, there’s nothing like feeling the tug on your line before you set the hook. And I have relatives that are experts at catching any type of fish you want. Fish allergy can be divided into 2 groups: the white fish and shellfish. You are usually not allergic to both groups and testing for sensitivity can be very helpful to avoid anaphylaxis and give you the tools to avoid the wrong kind of fish. Shellfish allergy to shrimp, crab, and lobster isn’t the focus of this writing, so we’ll discuss only allergy to “white fish” today. At times, I enjoy searching the medical literature for other allergist’s opinions on food allergy and this is no exception. What is most important for the white fish allergy, is can you outgrow this condition?

The data of whether someone can outgrow fish allergy is scarce. Fish allergy is one of the most common causes of food allergy, especially in children and young adults, with rates from 0.1 to 0.5%. The major fish allergen identified is beta-parvalbumin, it is resistant to heat and digestion. Many patients with an allergic reaction to one fish will also react upon ingestion of other fish. Sharks and rays mainly contain alpha-parvalbumin which has been shown to be less allergic.

Journal of Allergy and Clinical Immunology: In Practice.

Previous studies have shown that 15% of children can outgrow fish allergy within a period of 2-5 years, whereas telephone studies have shown it to be 3.5% in the United States.

A recent study called “Natural History of IgE-Mediated Fish Allergy in Children” published in The Journal of Allergy and Clinical Immmunology: In Practice, aimed to describe the natural history of fish allergy.

Children in the study ranged from 4 to 18 years who were previously diagnosed with fish allergy. The results showed:

  • 22% of children tolerated all fish tested, the average timeframe was 8 years after their first reaction.
  • Complete tolerance to fish increased with age, from 3.4% in preschool children to over 45% in adolescents.
  • Most children were able to tolerate swordfish (94%) and tuna (95%).
  • The best predictor of fish allergy was the IgE test to cod greater than 4.87 kUA/L.

The study has shown that fish allergy in children starts early, mostly during the first 2 years of life and a considerable proportion of children will outgrow fish allergy.  Particularly those with less sever reactions and a lower level of sensitization (skin prick and IgE testing). Those who continue being allergic may still tolerate several fish species, such as tuna and swordfish. This probably is a reflection of their parvalbumin content and/or composition.

Tolerance to at least 1 fish can be important for allergic children because fish has beneficial effects on health owing to the high omega-3 content and it is associated with a lower risk of coronary heart disease.

  • So what’s the take away from fish allergy, so you can fantasize what the “big fish” is doing underwater before you set the hook?
  • Most children will outgrow fish allergy and this applies particularly to swordfish and tuna. A definite must is to have testing performed to determine the level of IgE (or skin testing) to white fish that will prevent an allergic reaction that can spoil your next great fishing trip.
  • Tolerating fish to include at least one species can have clinical benefit due to omega-3 content to reduce heart disease and stroke.

#allergy, #fish-allergy, #food-allergy

Capsaicin for Nonallergic Rhinitis

February 5, 2021 by Alan Khadavi

Here’s the full update and thank-you Alan for sharing

Capsaicin nasal spray may be an effective treatment for patients who have nonallergic rhinitis. A significant proportion (25-30%) of patients suffering from rhinitis have nasal symptoms without an infection or allergies, this is referred to nonallergic rhinitis. Up to 50% of these patients have idiopathic #rhinitis after excluding work, elderly, gustatory, hormonal and drug induced rhinitis. Nasal steroid sprays are ineffective for this condition. Astelin, Atrovent are nasal sprays that have also been used for this condition and they have showed some improvement. But for others, these treatment options have failed. Capsaicin is the active ingredient of chili peppers. It is available as an over-the-counter nasal spray (ei, Sinus Buster, Sinus Plumber, others).

Capsaicin is another treatment option available for patients with idiopathic rhinitis. This treatment has limitations though, it can be uncomfortable, time consuming and incompletely understood in terms of its working mechanism. Research for better capsaicin treatment is needed.

A recent study looked at 2 different dosing of #capsaicin nasal sprays to see if it could suppress nasal symptoms. Daily nasal administration of low-dose capsaicin was well tolerated and reduced nasal symptoms. The study also evaluated the levels of Substance P which has been shown to be higher in patients with idiopathic rhinitis.

Symptom reduction was seen between 70-80% of patients with idiopathic rhinitis. Daily administration of low dose capsaicin was well tolerated and reduced nasal symptoms. Levels of Substance P were reduced and there was a positive correlation between Substance P and nasal obstruction, suggesting that rhinitis symptoms result from abnormally increased Substance P levels. As Substance P increases mucus secretion, suppressing it might represent a novel approach.

This study looked at different concentrations of Capsaicin nasal spray. There are various different manufacturers of Capsaicin spray, although the exact concentration isn’t well defined. As always speak to your doctor before beginning any treatment.  Patients who participated in this study were excluded from any allergies or infections prior to beginning treatment.

In conclusion, capsaicin low dose is effective in suppressing nasal symptoms and it may be a good, novel option for patients with non-allergic rhintis.

I have several reasons to write about “non-allergic” rhinitis.

  • Granted, this is the allergy season, but not everything that sneezes is allergy. Patients are always confused when skin testing is negative, yet they have consistent “allergy symptoms”. Heck, I even use the term “allergy” when I’m writing about non-allergic rhinitis.
  • Allergy has to have IgE (that’s the molecule binding to both allergens and subsequently to the mast cell causing histamine release). No IgE, no allergies and unfortunately, no allergy shots will work.
  • As Alan has mentioned, the typical nasal sprays such as Flonase and other nasal steroids don’t work well for this condition. Much of what you see advertised on TV is designed to encourage you to buy intranasal steroids, but many of those conditions are “non-allergic” rhinitis and listening to the TV ads won’t do you a bit of good.
  • I would disagree with the incidence of “non-allergic” rhinitis @ 30%–it’s more like the majority of rhinitis sufferers at ~70% and maybe more during the winter.
  • It is true that treatment of “non-allergic” rhinitis is frustrating because of lack of good nasal sprays, but PLEASE don’t give yourself capsaicin or hot pepper sauce in the nose before getting a prescription to dilute those hot babies down or you’ll be swearing at me all the way to the ER. Pepper spray will reduce that runny nose only if you compound the formula by an experienced pharmacist and deliver it into the nose carefully. Police grade pepper spray will get you into a whole lot of trouble!
  • As a research project, I’m looking into using nasal challenges for patients who have local allergic rhinitis and this may provide some additional use of desensitization even though skin testing and blood work is all negative for IgE. More on that later.
  • Bottom line: Not all that sneezes is allergy and a significant number of patients have runny nose, sneezing and sinus infections without having the opportunity to use allergy shots for desensitization.
  • If this is you, there is hope. See your local allergist for discussion about Astelin, Atrovent (hardly ever used), and if needed, I can work in conjunction with a local compounding pharmacy to get some capscaicin spray to help with that sneezing.

In the meantime, enjoy your tacos!

#if-not-allergy

Reddit Has It All

Not sure I want to rinse my nose everyday for sinus problems, but here goes. I advise rinsing the nose for chronic sinusitis every day, but patients initially turn their nose up at this suggestion (pun intended). I find myself intrigued at the interest in nasal irrigation, flushing, or whatever else you want to call it. So who did I turn to but #Reddit Allergy. So what to my wondering eyes did appear, but questions abound for the right sinus rinse! Google search for sinus rinse yields > 7,000,000 hits and searching PubMed 750–you think there might be a problem there? Misinformation abounds and of course every advertiser/company has the best product! Who do you believe? I’m about to give you some guidelines that you can rest assured have at least been studied in one published article. And by the way, to answer your question below, if the water doesn’t come out the other side, you’ve got nasal congestion that needs further evaluation by your allergist or ENT. My comments are highlighted in RED in the lists after each article. There is no test at the end, but maybe next time….

For the Reddit Junkies
One of the few articles published on the true effects of nasal irrigation!
  • Budesonide is a steroid that can always be added to ANY device you use to flush the nose
  • When you hear “double-blind, placebo-controlled, randomized clinical trial” you’re on the right track to some real (and reliable) research. In this study participants didn’t know if they were getting budesonide or placebo; now remember, in any study the placebo effect can be as high as 30-40% and this is why you can’t make recommendations only based on your treatment “experience”.
  • SNOT-22 score–really? Let me know if you want more information on this one. No takers yet!
  • The results? Budesonide was better than saline for the sinuses, but it’s difficult to measure clinically meaningful benefits to sinus treatment. And who’s going to admit to a better SNOT score?
  • The good news: no side effects noted with the irrigation; so it may look bad, but won’t hurt you!

Here’s the abstract from the above study–>

IMPORTANCE: Recent studies suggest that budesonide added to saline nasal lavage can be an effective treatment for patients with chronic rhinosinusitis (CRS). PARTICIPANTS: This double-blind, placebo-controlled, randomized clinical trial was conducted at a quaternary care academic medical center between January 1, 2016, and February 16, 2017. A total of 80 adult patients with CRS were enrolled; 74 completed baseline assessments; and 61 remained in the trial to complete all analyses. Data analysis was conducted from March 2017 to August 2017. INTERVENTIONS: All study participants were provided with a sinus rinse kit including saline and identical-appearing capsules that contained either budesonide (treatment group) or lactose (control group). MAIN OUTCOMES AND MEASURES: The primary outcome measure was the change in Sino-Nasal Outcome Test (SNOT-22) scores, pretreatment to posttreatment, in the budesonide group compared with the control group. Secondary outcome measures included patient-reported response to treatment, as measured with a modification of the Clinical Global Impressions scale, and endoscopic examination scored by the Lund-Kennedy grading system. RESULTS: Of the 74 participants who completed baseline assessments (37 in each study arm), mean (SD) age, 51 (14.7) years, 50 (68%) were women. Of the 61 who remained in the trial to complete all analyses, 29 were randomized to budesonide treatment, and 32 to saline alone. The average change in SNOT-22 scores was 20.7 points for those in the budesonide group and 13.6 points for those in the control group, for a mean difference of 7 points in favor of the budesonide group (95% CI, -2 to 16). A total of 23 participants (79%) in the budesonide group experienced a clinically meaningful reduction in their SNOT-22 scores compared with 19 (59%) in the control group, for a difference of 20% (95% CI, -2.5% to 42.5%). The average change in endoscopic scores was 3.4 points for the budesonide group and 2.7 points for the control group. There were no related adverse events. CONCLUSIONS AND RELEVANCE: This study shows that budesonide in saline nasal lavage results in clinically meaningful benefits beyond the benefits of saline alone for patients with CRS. Given the imprecision in the treatment effect, further research is warranted to define the true effect of budesonide in saline nasal lavage.

Adults have chronic sinusitis too!
  • Inflammation is once again the key to sinus problems even in the adult population.
  • 1-2% of total physician visits, not just allergists or ENTs. Very impressive.
  • Evidence-based approach to assist in optimizing patient care is the “Holy Grail” of being a doctor. If only we had this for COVID-19. Truth of the matter is, it takes years to analyze and accumulate enough data to make statements about evidence-based medicine, so for some issues, you’ll just have to wait.
  • I won’t bore you with the details, but these results come from HUUGE databases such as MEDLINE and Cochrane. It’s nice to be able to “mine the database” and combine multiple studies in the analysis of your final conclusion.
  • Compared with no treatment, saline irrigation was good, “add-in” topical steroids were better; leukotriene antagonists (Singulair) and oral antibiotics also showed improvement in not just sinusitis, but also resolution of nasal polyps.
  • And now let me introduce DUPIXENT! Approved for use in treatment of nasal polyps even without steroids. That is the problem with research–shelf life isn’t the greatest.

I’ve included the abstract below for easier reading–>

IMPORTANCE: Chronic sinusitis is a common inflammatory condition defined by persistent symptomatic inflammation of the Sino nasal cavities lasting longer than 3 months. It accounts for 1% to 2% of total physician encounters and is associated with large health care expenditures. OBJECTIVE: To summarize the highest-quality evidence on medical therapies for adult chronic sinusitis and provide an evidence-based approach to assist in optimizing patient care. EVIDENCE REVIEW: A systematic review searched Ovid MEDLINE (1947-January 30, 2015), EMBASE, and Cochrane Databases. FINDINGS: Twenty-nine studies met inclusion criteria: 12 meta-analyses (>60 RCTs), 13 systematic reviews, and 4 RCTs that were not included in any of the meta-analyses. Saline irrigation improved symptom scores compared with no treatment (standardized mean difference [SMD], 1.42 [95% CI, 1.01 to 1.84]; a positive SMD indicates improvement). Topical corticosteroid therapy improved overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]; a negative SMD indicates improvement), improved polyp scores (SMD, -0.73 [95% CI, -1.0 to -0.46]; a negative SMD indicates improvement), and reduced polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]). Systemic corticosteroids and oral doxycycline (both for 3 weeks) reduced polyp size compared with placebo for 3 months after treatment (P < .001). Leukotriene antagonists improved nasal symptoms compared with placebo in patients with nasal polyps (P < .01). Macrolide antibiotic for 3 months was associated with improved QOL at a single time point (24 weeks after therapy) compared with placebo for patients without polyps (SMD, -0.43 [95% CI, -0.82 to -0.05]). CONCLUSIONS AND RELEVANCE: Evidence supports daily high-volume saline irrigation with topical corticosteroid therapy as a first-line therapy for chronic sinusitis. A short course of systemic corticosteroids (1-3 weeks), short course of doxycycline (3 weeks), or a leukotriene antagonist may be considered in patients with nasal polyps. A prolonged course (3 months) of macrolide antibiotic may be considered for patients without polyps.

  • Fungus among us–we don’t think very often about fungal sinus infections, but in this study, symptoms improved with antifungal treatment. Fortunately, this is topical amphotericin B as the IV route was called “amphoterrible” for good reason.
  • IgE is an antibody used for diagnosis and treatment of allergic rhinitis (one of the biological measurement of IgE is skin testing), but can also be used to measure inflammation due to infection.
  • In this study, almost 25% of ALL participants had recurrence of chronic sinusitis, but it was improved in the amphotericin B rinse group. IgE went down as well. It’s nice to know that something works for sinus problems, but now that we have DUPIXENT, the results are probably even more of a game changer!

OBJECTIVE: To determine the effect of topical antifungal irrigation fluid containing amphotericin B on nasal polyp and their recurrence pattern, and to study the association of serum IgE in predicting the presence of fungus along with the nasal polyps. METHODOLOGY: All adult patients having nasal polyps, who had not undergone any previous nasal surgery, were included in the study. Patients aged under 18 years, history of granulomatous diseases, immunosuppression, invasive fungal sinusitis, and pregnant ladies were excluded from the study. The ratio was kept as 1:2; one receiving irrigation with amphotericin B and the other only saline nasal irrigation without the medicine. Serum IgE level of more than 250 ng/ml was taken as a high value. RESULTS: A total of 87 patients were inducted. Overall 22 (25.3%) patients had recurrence of symptoms at six-month followup visit. Twelve (13.7%) of these were in the placebo group and 10 (11.5%) were in the amphotericin B nasal irrigation group. Serum IgE level preoperatively ranged between 52 – 9344 ng/dl; postoperatively it ranged from 13-1050 ng/dl. CONCLUSION: Amphotericin B improved the CT scan score of the patients. The nasal irrigation of amphotericin B did not show significant change in the recurrence pattern of chronic sinuses with polyps. Serum IgE can be used as marker for the presence and response to treatment for non-invasive fungal sinusitis.

  • Bacteria have evolved sneaky ways to protect themselves from death by antibiotics. Thus, bacterial infections in the form of adherent biofilms are frequently implicated in the pathogenesis and recalcitrance of chronic rhinosinusitis. You dirty rat! That’s for you Jimmie Cagney from “Taxi” (actually a misquote, but that’s for another time!)
  • Lots of methods to suck out your boogers from battery powered to suction from your own mouth into a separate “trap”. Oh parents will do anything to suck out moist mucous!
  • Who would be recruited for this study? Yuck
  • We are left with that SNOT score again to measure any benefit from our treatment with the Snot Sucker.
  • Battery powered nasal irrigation (snot suckers) came up with 2.5 million hits on Google–it’s popular.

I copied parts of the above abstract for details–>

The Hydrodebrider, a disposable powered irrigation and suction device, has been developed specifically to remove biofilm from the paranasal sinuses. We conducted a prospective study to evaluate the tolerability and efficacy of the Hydrodebrider in the office setting with the use of local anesthesia. Of the original 13 adults we recruited, 10 completed the entire study protocol. All enrolled patients had previously undergone sinus surgery that involved the creation of a maxillary antrostomy large enough to allow placement of a Hydrodebrider device, and the endoscopic findings in all patients were consistent with chronic sinusitis. In conclusion, powered irrigation with suction is a well-tolerated procedure in the office setting and might be a useful short-term adjunct in the management of recalcitrant chronic sinusitis.

Surely, there has to be some conclusions from all this?

  • Don’t get overwhelmed with all of the choices for cleaning out your nose.
  • Using nasal irrigation can include antibiotics, topical steroids, anti-fungal medication, baby shampoo just to name a few. Every doctor who deals with this has their own cocktail.
  • Although clinical research shows that nasal irrigation has a place in the treatment of chronic sinusitis & nasal polyps, you may just want to see your allergist for more aggressive measures such as allergy immunotherapy (AIT), Dupixent, Fasenra, Xolair or many of the other biologics available to treat nasal polyps and chronic sinusitis without using all of those steroids.

#chronic-sinusitis, #nasal-flush, #neil-med-irrigation, #netti-pot, #sinus-irrigation

The Cat’s Out of the Bag!

As the holidays approach, our travel will be limited by #COVID-19, but we still may visit relatives with #cats, and you’re allergic! Researchers from Nestle Purina Research in St Louis MO may have part of the answer. As cats groom (which they do all the time), Fel d 1 is distributed within the hair coat and can then be shed with the #cat hair and dander. Not good news if you suffer from cat allergy. And worse news for your relatives!

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It’s a scam to our patients

Much of my medical office day is explaining to patients what they DON’T have rather than treating #allergy. Allergy has become the explanation for all medical disease. For instance, it’s rare for allergy to cause lack of attention, abdominal cramping (because of food allergy), or even constipation, but patients want allergy testing nonetheless. What are some “non-allergy” conditions that you’re likely to spend money you don’t need because of excessive testing?

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#allergy-shots-2, #food-allergy, #myths, #sinus-infections

Scientists “Speak” on Mold Allergy

Background

  • Allergic bronchopulmonary aspergillosis is a pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus, and rarely other Aspergillus species, and is characterized by chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis.
  • An ABPA-like syndrome called allergic bronchopulmonary mycosis is indistinguishable from ABPA but is caused by other fungi.
  • The condition occurs almost exclusively in patients with cystic fibrosis (CF) or asthma.
  • The global prevalence of allergic bronchopulmonary aspergillosis is reported to be 2.5% (range 0.7%-3.5%) among adults with asthma and reported to be 2%-15% in patients with cystic fibrosis.

Evaluation

  • Suspect allergic bronchopulmonary aspergillosis (ABPA) in patients with asthma or cystic fibrosis who have symptoms consistent with ABPA, such as:
    • difficult-to-control asthma
    • new or worsening cough
    • dyspnea
    • increased sputum production
    • expectoration of brown-black mucus plugs
    • wheezing
    • hemoptysis
  • ABPA may also be suspected in patients with computed tomography (CT) findings of bronchiectasis, especially central bronchiectasis.
  • Multiple sets of diagnostic criteria exist, all of which include a combination of clinical signs, imaging findings, and serologic features.
    • Rosenberg-Patterson diagnostic criteria for patients without cystic fibrosis (most commonly used):
      • major criteria for diagnosis (at least 6 required for diagnosis):
        • asthma
        • transient pulmonary opacities on imaging (fleeting shadows)
        • positive skin test for Aspergillus (type 1 immediate hypersensitivity)
        • peripheral blood eosinophilia (> 1,000 cells/mcL)
        • precipitating antibodies (immunoglobulin [Ig] G) against Aspergillus fumigatus in serum
        • elevated total IgE > 1,000 units/mL
        • central/peripheral bronchiectasis with normal tapering of distal bronchi
        • elevated A. fumigatus-specific IgG and IgE
      • minor criteria:
        • Aspergillus in sputum
        • brownish black mucus plugs in expectorate
        • delayed type III skin reaction to Aspergillus
    • Cystic Fibrosis Foundation diagnostic criteria for patients with cystic fibrosis:
      • classic case (all criteria required):
        • acute or subacute clinical deterioration (cough, wheeze, exercise intolerance, increased sputum, decrease in pulmonary function, exercise-induced asthma) not attributable to other cause
        • serum total IgE > 1,000 units/mL (2,400 ng/mL) in patient not on corticosteroids
        • immediate skin reaction to Aspergillus (wheal > 3 mm diameter with erythema in patient not on antihistamines) or positive serum IgE antibody to A. fumigatus
        • precipitating antibodies to A. fumigatus or serum IgG antibody to A. fumigatus
        • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest computed tomography (CT) that does not clear with antibiotics or chest physiotherapy
      • minimal diagnostic criteria:
        • acute or subacute clinical deterioration not attributable to other cause
        • serum total IgE > 500 units/mL (1,200 ng/mL) (if disease suspected and serum total IgE is 200-500 units/mL, repeat testing in 1-3 months)
        • immediate skin reaction to Aspergillus or positive serum IgE antibody to A. fumigatus
        • 1 of following:
          • precipitins to A. fumigatus or IgE antibody to A. fumigatus
          • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest CT that does not clear with antibiotics and standard chest physiotherapy
      • diagnosis of ABPA in cystic fibrosis should not be based in serology and skin tests only(2)

Management

  • Treatment goals include:
    • control of symptoms of asthma and cystic fibrosis
    • prevention or treatment of pulmonary exacerbations of allergic bronchopulmonary aspergillosis (ABPA)
    • reducing or remitting pulmonary inflammation
    • avoiding progression to end-stage fibrotic or cavitary disease
  • No large randomized trials have evaluated efficacy of various treatment options as of September 20, 2017.
  • Refer patients with suspected or known ABPA to a pulmonologist or an allergist-immunologist.
  • Systemic corticosteroids are considered the cornerstone of therapy for ABPA.
    • In patients with asthma:
      • typical initial therapy is prednisone 0.5 mg/kg/day (or equivalent) with tapering dose as symptoms improve
      • for patients with mild exacerbation – inhaled corticosteroids and bronchodilators may help control symptoms
      • for patients with acute exacerbation – prednisone 0.5-1 mg/kg/day for 1-2 weeks, then 0.5 mg/kg every other day for 6-12 weeks following remission, then tapering dose to preexacerbation dose
      • for patients with refractory disease with multiple asthmatic exacerbations – chronic corticosteroid therapy suggested, usually > 7.5 mg/day
      • dosing may be increased based on findings from routine monitoring of serum immunoglobulin E (IgE) levels, pulmonary function tests, and chest imaging, such as:
        • significant increase of IgE levels (such as doubling of baseline IgE level)
        • imaging evidence of infiltrates, mucoid impaction, fibrosis, worsening bronchiectasis, or worsening physiology
    • In patients with cystic fibrosis:
      • oral corticosteroids indicated for all patients except those with corticosteroid toxicity
      • typical initial dose prednisone (or equivalent) is 0.5-2 mg/kg/day orally to maximum 60 mg/day for 1-2 weeks, tapering to 0.5-2 mg/day every other day for 1-2 weeks with attempt to taper completely within 2-3 months
      • in patients with relapse, increase corticosteroid dose, add itraconazole, and taper corticosteroids when clinical status improves
  • Inhaled corticosteroids and methylprednisolone IV pulses may be used in some situations.
  • Consider antifungal agents in adults with severe, poorly controlled asthma and ABPA (Weak recommendation).
  • Combination antifungal/corticosteroid (nebulized amphotericin B and nebulized budesonide) may reduce the incidence of exacerbations.
  • Omalizumab may reduce exacerbations but may not improve or affect lung function or quality of life.
  • For refractory cases, consider evaluating the patient’s environment for significant mold exposure that can be modified (Weak recommendation).
  • Consider adjunct leukotriene antagonists for some patients (Weak recommendation).
  • Follow-up could include imaging at 4-8 weeks and total serum IgE monitoring.
 2017 Aug;13(8):823-835. doi: 10.1080/1744666X.2017.1324298. Epub 2017 May 17.

Mold allergy: is it real and what do we do about it?

 

Abstract

fungi produce substances that contain pathogen-associated molecular patterns (pamps) and damage-associated molecular patterns (damps) which bind to pattern recognition receptors, stimulating innate immune responses in humans. they also produce allergens that induce production of specific ige. Areas covered: In this review we cover both innate and adaptive immune responses to fungi. Some fungal products can activate both innate and adaptive responses and in doing so, cause an intense and complex health effects. Methods of testing for fungal allergy and evidence for clinical treatment including environmental control are also discussed. In addition, we describe controversial issues including the role of Stachybotrys and mycotoxins in adverse health effects. Expert commentary: Concerns about long-term exposure to fungi have led some patients, attorneys and fungus advocates to promote fears about a condition that has been termed toxic mold syndrome. This syndrome is associated with vague symptoms and is believed to be due to exposure to mycotoxins, though this connection has not been proven. Ultimately, more precise methods are needed to measure both fungal exposure and the resulting health effects. Once that such methods become available, much of the speculation will be replaced by knowledge.