Regular use of one of the inhalants on the left may reduce the need for one of the two on the right (oral steroid syrup or pills)

See the discussion below.

A Few Examples of Controller Agents That Contain Inhaled Steroid

Top five reasons daily puffs of inhaled steroids are important for control of persistent asthma (asthma symptoms more than 2x/week, or more than 2x/month in the middle of the night, as well as other criteria).

1) Inhaled steroids are the preferred anti-inflammatory medication for asthma control according to national and world health organizations.

2) Inhaled steroids work at the surface of the lungs and have limited systemic effect when inhaled at low to medium doses.

3) There are several decades of experience and research centered around inhaled steroids.

4) Inhaled steroids surpass all other controller agents (for example Cromolyn, Singulair, Nedocromil and Theophylline) in potential for reducing and controlling inflammation in the lungs of asthma patients.

5) One may in fact reduce their exposure to steroids in the long run, by taking daily doses of inhaled steroid at low to medium dose ranges.

Let’s delve into # five a little further.

We will compare a year’s cumulative dose of inhaled steroid to one oral steroid taper (short course of oral steroid gradually reduced over 7 days). An oral steroid taper is often prescribed when an adult or child has a moderate to severe asthma attack. Inhaled steroids (for example, Flovent, Pulmicort, Advair, Qvar, Asmanex, Azmacort etc) are commonly ordered to prevent and control asthma. Patients are encouraged to take inhaled doses for months to years, even when feeling well, in order to stay well. If inhalants are regularly and properly taken, asthma attacks may be avoided and therefore oral steroid courses may be avoided.

A 7 day standard taper of oral steroid, for an older child or adult, may include 40mg by mouth, daily for 3days, 30mg for 2 days and 20mg for 2days and 10mg for 2 days. The total dose adds up to 240mg.

One year of an inhaled steroid, medium daily dose of 440 micrograms (2 puffs twice daily of Flovent 110 for example) adds up to > 160,000 micrograms. It takes 1000 micrograms to make one milligram.

Thus the cumulative inhaled dose is 160 milligrams (the total for the year). Understand that the percentage of inhaled steroid that gets to the lung is at most, about 20% (of a properly inhaled dose). Not all of this 20% gets to the rest of the body. These reductions further decrease the amount inhaled over the course of a year from 160mg to 32mg, regarding systemic impact (the amount the body is exposed to, in addition to the lung).

All pill and syrup forms of steroids reach the body through the systemic circulation after being absorbed from the stomach. Injected or infused forms of steroids also circulate through the body. Such forms are routinely ordered in emergency departments and hospitals, as life saving measures.

So, we compare 32mg inhaled steroid exposure to the body over a course of a year to 240mg in one week, if a severe episode requires oral steroid.

Your body makes about 4mg of steroid daily for natural purposes (if you are an adult). Low to medium doses of inhaled steroid represent only a fraction of this number (remember, microgram quantities are a thousand fold less than milligrams, plus only a fraction of the inhalant dose gets into the system).

A similar relationship can be illustrated in children on inhaled steroids. Parental concerns about medications should be counter balanced by the risk of inadequate asthma treatment which may lead to the need for oral steroid (Prelone, Orapred, Prednisolone etc.). One or more oral steroid courses add up to over a year’s worth of inhaled steroid in most cases.

Concerns about growth and other developmental processes in children may occasionally lead to premature elimination of inhaled steroids by parents. This may put a child at risk for severe asthma (which may be life-threatening) as well as increase the chances of requiring oral steroid for a flare-up. Furthermore, growth and development may be severely impacted by poor asthma control. Controller medications are sometimes reduced or eliminated by the doctor if several months of good control have been established.

Current national guidelines recommend inhaled steroids for control of persistent asthma for people of all ages . Oral syrup and pill forms of steroids are recommended for treatment of severe asthma.

Medications should be adjusted upwards or downwards based on the doctor’s assessment of asthma control. Inhaled steroids are preferred for long term control and may spare a patient from needing oral or injected steroids by reducing asthma attacks and active chest symptoms.

Please discuss any concerns you have about medications with your doctor. Asthma is a highly treatable disease which remains grossly under treated in this country and worldwide.

Want more?

Check out these sites:

 www.sciencedaily.com/releases/2007/01/070123143233.htm 

and : www.asthma.ca/adults/treatment/steroids.php

Next Topic:

Are you ready for ragweed season? It is just 2 weeks away. I will discuss some ways to prepare for ragweed season in the next posting. I'll also show you what this plant looks like.

The high efficiency air filter won't get to the dander before your nose, if it is already in the sheets.

Read about a recent study about asthma, cats and allergy triggers. Cats are wonderful and lovable creatures but if you are allergic..., sad news.  SEE BELOW.

Flo and Teddy

Will you be cuddling Teddy tonight? If you have allergy problems, maybe you shouldn't.

Flo, in the closet (If she can't be near you, how about your clothing?)

There are more than 20 million people that have asthma in the United States. A large percentage of households in America have cats and/or dogs. For years doctors have advised patients and parents to avoid bringing cats and dogs into the house in order to reduce exposure to potential allergy triggers.

I have wondered whether available allergy testing methods (skin testing or blood testing) although very sensitive, misses a number of people with asthma and hayfever that have cat or dog allergy. A number of times patients have had negative skin test results to cat but by history have breathing problems when in the presence of a cat.

If you have asthma, a cat in your house, and are allergic to dust mite, grass or mold, you may have more difficulty controlling your asthma because of the cat. Notice, I did not mention that you needed to be allergic to cat. Your skin test or blood test may be negative, suggesting no cat hypersensitivity. Yet, the presence of a cat in your home may worsen asthma control.

A recent study in the Journal of Respiratory and Critical Care Medicine, Vol. 176, pp 20-26, 2007, concluded that atopic people (allergic people) in general, may have greater lung hypersensitivity, whether allergic to cat or not, if a cat is in their home. The Study was conducted from 1998 to 2002 and involved over 1800 participants in 20 communities across Europe.

Blood tests were done to determine allergic sensitivity to house dust mite, grass, mold and cat. A special breathing test for measuring Bronchial Hyper-responsiveness (BHR) was performed on each patient. BHR reflects the level of twitchiness of the airways in the lung. People with asthma tend to have twitchy airways (more twitchy when the asthma flares up). Indoor triggers (cat and dust mite) were measured in the various households through scientific methods.

Expectations of the researchers were to confirm that people allergic to cat and dust mite (by blood test results) would have greater sensitivity (on breathing test measuring BHR) to these triggers when levels of these specific triggers were higher in their homes. The surprising findings were that people with negative cat allergy tests had more twitchy lungs (increased BHR) if they: 1) were allergic to one or more of the other three allergens (dust mite, grass or mold) and 2) had a cat in their home (especially when cat protein levels measured were moderate to high)

Bottom Line:

This is one study, which needs to have follow-up studies to confirm similar findings before major advisory based on the results is considered. Allergists have suspected their patients would be better off without cats and dogs in their homes, despite negative allergy test results, for decades. There were concerns about becoming allergic over time, and the impact on other family members (usually other members of a family are also allergic). This study provides an explanation for why some people with cats in their home may have trouble with their asthma even though they are not considered cat allergic.

We have to see what further research brings.

Mr. X, several days after the initial severe facial eruption.

We have made it through the worst of what spring and summer pollens have to offer for this year. I hope my spring and summer tips for allergy management have been helpful (see table of contents). July may be pretty uneventful for many pollen allergy sufferers because tree and grass pollens tend to be lower. Mold counts have been moderately high and may explain why some people continue to experience itchy and watery noses and eyes.

July in the Chicago area usually means lots of sunny, hot weather. We have already had a few 95 degree days but the nights and days of rain have cooled us off well, despite the high temperatures.

Now is the time to protect your skin from the harmful rays of the sun. Most of us know to apply sunscreens before spending hours outdoors this time of the year but what if you have sensitive skin?

The above picture of Mr. X is a patient I saw last week that complained of the development of a facial rash, hours after applying sunscreen and swimming with his family. The rash was much more severe before coming to my office and had required urgent treatment.

The rash likely represented a photosensitive reaction to the combination of an ingredient in the topical sunscreen and UV (ultraviolet) rays of the sun. There are two major types of such reactions which are not easy to distinguish by appearance.

Phototoxic reactions are a subtype of photosensitivity that occurs when UV rays react with a medication or chemical rubbed on the skin or taken orally (a drug taken by mouth). The sun rays alter the drug (in the skin) resulting in a chemical which then damages the skin.

Photo-allergic reactions are another type of photosensitivity where UV rays from the sun react with a drug or chemical either rubbed into the skin or ingested (that has been swallowed). The altered drug now causes a type of immune reaction in the skin much like poison ivy (a form of contact dermatitis). The difference is in the involvement of specific immune cells (such as T-lymphocytes) early on in the process. Photoallergic reactions are often delayed by several hours.

Whether the reaction is phototoxic or photoallergic, the treatment is to avoid any further contact with the drug, lotion or spray. Anyone experiencing such a rash, burning or intense itching should see a physician as soon as possible. Topical steroids are often prescribed, as well as other medications.

What is the difference between the photosensitive skin reaction and sunburn? Sunburn is not as severe early on, and does not tend to cause the degree of blistering and inflammation that may be seen with photosensitive reactions. Sunburn is often more widespread involving more sun-exposed areas whereas photosensitive reactions are often localized to the face, neck, arms and hands.

Mr. X only had involvement of the face. I think the swimming activity allowed for less intense exposure of the arms and other areas of the body because of movement and water contact. His face was not submerged in the water.

Mr. X is doing well. He has responded well to prescribed steroid and antihistamine. He is avoiding further contact with his sunscreen. We will be scrutinizing the label to look for PABA (para-aminobenzoic acid) tars, fragrances and other high risk ingredients. We may do patch testing for contact allergy on a follow-up visit. We will carefully select another sunscreen once we have all the information we need.

Sunscreen is important for protection against certain harmful wavelengths from the sun. Fortunately, hypersensitivity to sunscreen is not widespread. We simply have to be aware of it when it occurs and get appropriate treatment.

There is more information on the site provided on this link : www.webmd.com/a-to-z-guides/sun-sensitizing-drugs 

NEXT WEEK: WHY CATS ARE THE ALLERGIST'S PUBLIC ENEMY #1

Allergy Shots Work About 80% of the Time

Who should consider getting allergy shots?

1) Children (five years or older) or adults who fail to adequately respond to allergy medications and environmental controls

2) People who are intolerant of allergy medications. Nasal sprays and antihistamines may be associated with bothersome side effects (although not a frequent issue)

3) If there is a desire to minimize medication needs

4) If nasal allergy problems are accompanied by allergic asthma symptoms

5) If allergy symptoms are very severe causing loss of sleep, fatigue or productivity

6) If there are frequent complications such as sinusitis, ear infections or cough

7) If asthma is triggered by unavoidable allergy triggers

Allergy shots are successful at reducing allergy symptoms about 70-80% of the time. It is the only longstanding treatment that may actually alter the natural course of allergic nasal and lung problems (asthma). This means, the reduction in nasal and asthma symptoms may last long after allergy shots have been stopped.

What’s the downside of allergy shots?

1) They are only given by injection and are inconvenient, especially early on, when weekly visits are required.

2) They may be expensive depending on the type of insurance coverage.

3) They may not help about twenty percent of the time.

4) Local and rarely, systemic reactions (sudden itching, swelling or breathing problems) which can be severe, may occur.

5) Allergy shots take several weeks to months to start working and are not curative.

Bottom Line:

Allergy shots should probably be considered for management of moderate to severe allergic nasal and / or asthma problems based on some of the above points. As allergy pills and nasal sprays escalate in cost, in a time of rising prescription drug co-pays, allergy shots may not only reduce symptoms but also lower medication expenses.

Unavoidable triggers such as outdoor pollens and mold spores often spoil the good weather months in the Midwest for allergy sufferers. Allergy shots have the potential of eliminating the breathing problems that become associated with spring, summer and fall.

More on allergy shots:

-See my posting from April 7th (click the link on April, scroll down to bottom and click “Next Page”)

-See this site: www.acaai.org/public/patients/factSheet.htm

Note the puffiness, darkening, and lines under the eyes

Do you have bothersome ocular allergy symptoms?

If you do, you may have or experience:

-itching of the eyes and skin around the eyes

-watering or tearing of both eyes

-frequent periods of rubbing the upper and lower eye lids

-burning and reddening of the whites of the eyes

-swelling of the whites of the eyes (called chemosis)

-darkening and puffiness under the eyes (shiners- see above pic)

-lines or creases in the lower lids (above pic)

-more eye symptoms when your nasal symptoms are active

Possible allergy triggers include: pollen, mold, dust mite, cat and dog

Possible irritant triggers include: smoke, chemical fumes, pollution, dry air dust particles (and many other factors)

Internet sites and newspapers are filled with articles and ads about nasal allergies (hayfever) and asthma. Ocular (eye) allergies are often overlooked as a serious component of seasonal and perennial (year round) allergies.

People who have ocular allergy are exposed to an allergy trigger which causes mast cells (located in the eyes, nose, skin and other places) to release histamine and other substances which cause inflammation. Antihistamines block the effect of the released histamine.

What helps to relieve ocular allergy?

Many patients have fewer eye allergy symptoms when they regularly take medications for their nasal allergy. Antihistamines (Claritin, Allegra, Zyrtec…) taken by mouth, may help to reduce many of the eye allergy symptoms. Some nasal steroid sprays assist in reducing eye allergy symptoms, although how this actually happens is not certain. A new intranasal steroid, Veramyst has an indication for nasal and eye allergy symptoms. Veramyst requires a prescription from your doctor.

Some clinical studies have shown improvement in eye allergy symptoms after taking Singulair, which is prescribed for asthma and allergic nasal problems.

The medications that directly target eye allergies are pretty well known and have been available over the counter (OTC) and by prescription for several years. Your neighborhood pharmacy or grocer has several brands of eye drops advertised for relief of ocular allergy symptoms. Some are simple wetting solutions that cleanse and moisten the eyes and contain no active medication (Artificial Tears and others). Many of the eye drops are brands of antihistamine which may relieve or prevent itching, burning and watering. Some antihistamine eye drops also contain a vasoconstrictor (a drug that narrows the opening of small blood vessels). Vasoconstrictors rapidly clear up the redness and help to reduce some of the eye swelling. You need to be cautious about the use (and prolonged use) of some of these drops because they may aggravate glaucoma. Glaucoma is an eye disease that occurs when intraocular pressures (inside the eye pressure from eye fluids naturally in the eye) are too high. Severe glaucoma may lead to loss of vision. Many OTC eye drops contain vasoconstrictors, which along with antihistamine, may worsen certain types of glaucoma.

Your doctor may guide you in how to select an eye drop for allergy related symptoms. There are other causes of ocular reddening, burning and watering which should be considered before starting treatment. The top three brands I prescribe for ocular allergy are: Patanol, Optivar and Elestat. A new brand which is a derivative of Patanol but with a once daily dosing is Pataday. The other brands, above, are generally recommended twice daily.

The Tips:

-Know your trigger factors in order to accurately judge when allergy eye drops should be started. If you wait until the onset of symptoms (itching or watering…) the drops may be less effective. We identify trigger factors by doing skin test.

-If you have seasonal allergy symptoms do not ease up or stop your nasal or ocular medications prematurely. A few good days or weeks of minimal symptoms during the season may trick you into believing that you no longer need medication. If climate conditions change (as they often do), trigger factors may escalate and result in a much higher exposure for you. Ask your allergist when and how you should stop your medications.

-Finally, if you are not pleased with your allergy control because of persistent eye symptoms, follow up with your allergist or primary doctor. There may be a small adjustment or change in your medication or environment that may further address the problem.

www.emedicinehealth.com/eye_allergies/article_em.htm

Take your ocular allergy quiz: www.acaai.org/public/eyeALLERGY/eye.htm

Next Topic: When Should Allergy Shots Be Considered?