[Allergy & Asthma Corner]

Seven Allergy Tips for Spring Seasonal Allergic Rhinitis (SAR)

If you have SAR you may already be sneezing, blowing (your nose), and rubbing your eyes. Trees have been waiting for a warm spell to explode their pollen into the air and create a hazardous environment for millions of allergy sufferers in the Midwest and other areas of the United States.

Allergic Rhinitis (also called Hayfever, Sinus, Summer Cold…) may be a transient annoyance, or incapacitating. You may have wonderful prescription medication but if they are not started at the right time, and taken regularly (depending on the type of medication) you may find them very ineffective.

Here are seven tips to assist you in managing your SAR.

1) Most prescribed antihistamines (Allegra, Clarinex…) should be started early in the season or preseason to optimize your response. For seasonal allergy, antihistamine medication should not be stopped for several weeks.

2) If you have a nasal spray steroid (Flonase, Nasonex, Nasacort, Rhinocort etc.) start it early (1-2 weeks before you typically start having symptoms) and use proper nasal spray technique (see my article: How Good is Your Nasal Spray Technique, March 16th--scroll down). Take the nasal spray daily for most or all of the season (avoid the quick acting over the counter sprays).

3) Prescription allergy eye drops (antihistamine type), if you are on them, should be taken at least thirty minutes before outdoor exposure, and each day during the active season.

4) Keep your home windows (especially bedroom) down and your car windows up. This reduces pollen allergy exposure. Run your a/c sooner if necessary.

If your car allows you to recycle the inner compartment air, do it!

5) Change the filters on your heating/cooling system if overdue. This should usually be done monthly based on the specifications of your system.

6) Avoid environmental irritants such as tobacco smoke, strong perfumes and odors. Indoor and outdoor pollutants (irritants) may amplify allergy symptoms.

7) Keep some nasal saline (salt water) spray around to rinse out your nasal passages 2-3 times a day. Avoid nasal saline rinses within an hour of taking a medicated nasal spray. Nasal saline is not medication. It may further enhance your management of allergy symptoms when taking other allergy medications.

If you find that you still feel miserable despite the above recommendations, or you perhaps started treatment too late, see your allergist or primary doctor.

Inadequately treated nasal allergies leave you vulnerable to complications which include sinusitis, cough, headache, fatigue and worsening asthma (if you have a history of asthma).

DID YOU KNOW ?

-More than 17 million Americans have asthma.

-More than 60% of people with the diagnosis of asthma also have sinus problems.

-Asthma affects more than 5 million children under 18 in the U.S.

-Asthma has increased by 75% from 1980 to 1994.

-Asthma death rates have decreased over the last 5 years

-Updated NIH (National Institute of Health) guidelines for managing asthma are being finalized.

-More emphasis is being placed on measuring asthma control by utilizing validated questionnaires (for example the Asthma Control Test), reviewing periodic pulmonary function tests (PFTs) and achieving minimal need for reliever inhaler (such as Albuterol).

The goals of asthma management are:

No chest symptoms (cough, wheezing. shortness of breath and chest tightness)

No night time awakenings because of chest symptoms

No limitations at work, home or school, normal lung function

Minimal need for reliever inhaler

No asthma attacks

No side effects from asthma medication

Meet the needs of the patient or parent regarding asthma concerns.

Are you taking a controller medication?

Controllers are prescribed for people that have asthma symptoms more than twice weekly, or night time awakenings because of asthma more than twice a month.

How many times a week do you miss taking a dose?

Is your inhaler technique up to par?

How do you know if you have flaws in your inhaler technique?

80% of patients on inhalers that I see for the first time have flaws in their inhaler technique.

Don’t you think an asthma checklist would be helpful?

Here is one for you:

1) I know what my reliever medication is, when to use it and when I am using it too much.

2) My inhaler technique has been reviewed by a doctor or nurse within the last 6 months. I know about spacers.

3) I know about controller medication and why it is needed and that I must take it every day until instructed to stop.

4) Possible side-effects of my medications have been discussed.

5) Environmental trigger factors have been identified and I know how to reduce my exposure to some of them (especially indoor triggers)

6) I understand how often I need to follow up with my doctor and the importance of visits even when I am doing well (to prevent problems)

7) I have a written plan of action to assist in getting my asthma back in control when it flares up. I have a Peak Flow Meter.

8) I am aware of the signals that should tell me to seek emergency care or urgent care when the asthma is worsening.

9) I am up to date on my screening test- Asthma Control Test (ACT) and Pulmonary Function Test (PFT) which is usually done at least once a year.

10) I have discussed my concerns and my personal goals with my physician regarding asthma care.

Realize that successful asthma management requires a partnership between you and your physician. Medications over time may be reduced or eliminated if goals are being met. Your doctor will guide you through medication adjustments. There will likely be periods where medications need to be increased, but hopefully this will be followed by a step down of medications after achieving better control.

There is no cure for asthma. Most people will require some medications, life long, or for many years. The good news is that asthma may be controlled, allowing for normal growth and development and normal activity levels. The risk of side effects from years of taking controller medications for asthma is far outweighed by the risk of poor asthma control. Poor control has been associated with less productivity, poor self-esteem and abnormal growth patterns.

Don’t let asthma or fears of asthma treatment control your life. Take control of your asthma (or your child’s asthma) by learning more about this highly treatable disease which when under treated, may be life threatening.

Comments about this article?

Leave them here or email them to: AllergyQA@aol.com

Spring is in the air. Soon we will be able to put away the coats, sweaters and long underwear for another three seasons. Unfortunately, the bad news is pollens and molds are poised to explode into the air and spoil the fun for millions of people in the upper half of the United States. Trees are the first to pollinate in the mid-west, as early as February if a warm spell hits. There was too much cold weather and snow to allow for pollen generation in February this year, but a few spurts have already occurred this month (March).

How can you prepare for the pollen and mold season of 2007? The key is, to attempt to prepare. Many people let their allergy season catch them by surprise. They find themselves with outdated medicine or empty bottles of antihistamines and nasal sprays (prescribed kind). Of course with the peak allergy season, it takes weeks to get in to see your allergist. Out of desperation, over the counter medications are purchased for short term relief. Are you familiar with this scenario?

Well, if you were fortunate enough to have planned ahead, you had your pre-spring follow-up appointment (in January or February) and discussed how and when to start medications with your doctor. I have patients that are allergic to trees begin their prescribed allergy medications March 15th, if they are allergic to certain types of trees (such as elm or cottonwood). I warn them to start earlier, if the forecast is for warm weather in February (not this year huh?).

I also review nasal spray technique with all my patients. Many allergy sufferers have prescriptions for nasal steroid sprays (for example Flonase, Nasacort, Nasonex, Rhinocort and others). If your technique is poor, you will not fully respond to the nasal spray. Seasonal allergy nasal symptoms require regular (daily) nasal spray use for most of these preparations. If you use them only as needed, you may not approach the level of relief achieved with regular use.

I also emphasize the importance of timing. Using these nasal sprays first thing in the morning or at the end of the day may limit your response because the nose is not clear at the time. The nose has many functions, one of which is to filter the air (for the lung). The nose is most clear after a shower or bath. If one clears there nose after the bath or shower (blow into tissue) the inner surface is better prepared to receive the medicated spray. Isn't your nose kind of congested and cluttered when you first awaken? Not a good time to do nasal sprays my friends.

What about your technique? Do you lean your head back and spray the medication into the nose (basically down your throat)? This terrible technique if you do that. I advise patients to more properly position the nasal spray by placing just the tip (not the entire nose piece) of the nozzle into the nose aiming slightly away from the nasal septum (the midline wall that divides your nostrils into left and right sides). See the pic below, illustrating good positioning of the nasal spray. It is important not to spray these medications into your nasal septum. This reduces the effectiveness and may cause irritation and bleeding from the nose. If you use your left hand to spray into the right nostril (palm facing the face), it is easier to spray the medicine properly. Have your allergist check your procedure on follow-up visits. It is not real easy to pick up this technique by written instruction which is why most people are not properly using their nasal sprays.

Realize that intranasal steroids take several days to weeks to reach a peak effect. Do not stop too soon (under 3-4 weeks) thinking it will never work. If you got a late start (began the medication after starting to have allergy symptoms) it takes longer to respond. Often the combination of antihistamine and intranasal steroid is recommended for more moderate to severe hayfever. Your allergist is aware of a number of other alternatives (medications and procedures such as nasal saline rinses) and will also review environmental controls.

Finally, avoid the over the counter, quick acting nasal sprays formulated for rapid decongestion of the nose. These tend to be habit forming and are very rough on the inner surface of the nose when used too long (more than three days at a time). Did you know there is a diagnosis for people that overuse such nasal sprays? It is called Rhinitis Medicamentosa. I see about ten patients a year, that have this problem and it is not easy to treat.

Intranasal steroids are not addictive and are often used, along with other medications, to treat patients with Rhinitis Medicamentosa (patients addicted to over the counter nasal spray decongestants). Of course, intranasal steroid sprays require a prescription. Your doctor should periodically check your inner nasal passages to make sure there are no signs of irritation. The intranasal steroids are generallly well tolerated. Many formulations may be used in children down to age 6 (some formulations to age 4 and 2).

Intranasal steroids have become cornerstone to managing seasonal and perennial allergic rhinitis (hayfever). Consistency, timing and proper technique are keys to a successful outcome. Follow-up with your prescribing doctor for maintenance checks.

Did you know that certain inhalers for asthma presently used to relieve symptoms are being phased out? Inhalers such as generic Albuterol will no longer be available for asthma treatment after current inventories run out.

In September of 1987 the U.S. and more than 20 other nations signed a treaty called the Montreal Protocol, to reduce and eventually eliminate man-made chlorines, primarily chlorofluorocarbons (CFCs). Major products containing CFCs are refrigerator units, aerosol hair sprays and metered dose inhalers (MDIs). CFCs in inhalers are propellants which mix (when the canister is shaken) with the active drug to facilitate expulsion from the canister.

CFCs travel from the earth’s surface to the stratosphere where light rays from the sun lead to a chemical reaction which results in the formation a radical form of chlorine (an ion) which may erode the ozone layer surrounding the earth. The ozone layer above the polar regions of earth is particularly vulnerable. A hole was first noted in the polar ozone layer in the 1970’s. This hole has been widening over the years. It is believed that more damaging ultraviolet light rays pass through to the earth surface as a result of the deficiency of the ozone layer.

The U. S. Environmental Protection Agency (EPA) established that by year 2075 the ultraviolet rays could result in 150 million new cases of skin cancer nation wide. Three million deaths may result from these cancers. Other health problems such as cataracts and impairment of the immune system may also result from excessive ultraviolet light exposure.

Since the Montreal Protocol addressing the formation of man-made CFCs and other possible ozone depleting gases took place, subsequent meetings have established several more amendments. Asthma inhalers containing CFCs were initially exempt from being banned because of the lack of alternative medications. Over the last ten years a number of non-CFC containing inhalers have become available. Hydrofluoroalkane (HFA) containing aerosol inhalers are now available. A number of dry powder inhalers (not requiring a propellant) have been formulated. Very soon only these alternatives will be available for asthma treatment. Only brands of the above medications (HFA and dry powder inhalers) will be prescribed once supplies of generic Albuterol are depleted.

There are no generic forms of these alternative agents. Proventil HFA, ProAir HFA, Ventolin HFA and Xopenex HFA inhalers are currently available for relieving symptoms of asthma and for preventing exercise induced asthma.

For more info.: www.aaaai.org/patients/inhalertransition/for_patients.asp

Assessment of asthma control has become a main theme of many publications and seminars on asthma across the United States. For many years we have lacked an effective and practical guideline for measuring  response to asthma treatment. In the last ten years a number of questionnaires have been formulated to evaluate the success or failure of asthma treatment. Many of them are too long for everyday use in a busy office or clinic.

The ACT recently became available for doctors to use along with the physical exam and pulmonary function testing (PFT). Guidelines published by the NIH (National Institute of Health) and WHO (World Health Organization) recommend periodic assessment of asthma control. Pulmonary function testing should be done every 1-2 years.

The Asthma Control Test is based on answering five questions which reflect on how often there are chest symptoms, shortness of breath, limitations on activity, interruption of sleep and overall impression of asthma control. The answers are based on a 5 point scale for each question. The numbers are added up to determine whether there is adequate control, by scoring greater than 19 out of 25 possible points. There is a slightly different ACT for children under 12 years of age (age 4 to 11).

Ask your doctor about the Asthma Control Test. You can find more information on several web sites that discuss asthma management (try keyword: "Asthma Control Test" ). Remember, the ACT is a tool for doctors to assess control of their patients. Decisions on medication changes should be made by your doctor. If you have concerns about your asthma control talk to your doctor.