To begin his presentation for the April 7th Eye & Ear Foundation webinar entitled, “Breathing Easier: Sinonasal and Allergies,” Mikhaylo Szczupak, MD, shared an iconic image of Pittsburgh with one of its many bridges framed by cherry blossoms.
“This is an image of what many probably imagine when you think of this wonderful city during the spring, with trees and beautiful flowers,” said the Assistant Professor of Otolaryngology and a General Otolaryngologist in the Department of Otolaryngology at the University of Pittsburgh. “Unfortunately, these cause some bothersome allergy symptoms.”
In the webinar, Dr. Szczupak said he would share the Department’s approach to allergies and highlight specific research discoveries that faculty have made thanks to the Eye & Ear Foundation.
Dr. Szczupak showed a Venn diagram of Allergic, Nonallergic, and Infectious rhinitis. Chronic rhinitis is “not as accurately diagnosed as we would like,” he said, calling it a tricky subject and a catchall umbrella term. Separating it into three different etiologies shows how they all overlap. The challenge is the significant amount of overlap.
Therefore, diagnosis comes down to the diagnostic workup, which includes a thorough history, looking in the nose with a camera (called a nasal endoscopy, done in the office), and allergy testing.
The focus of this webinar was on allergic rhinitis, which is the most common chronic disease in children and the fifth most common chronic disease in adults. It results in significant annual health expenditure and impairs quality of life.
Allergic rhinitis is an inflammatory disease that can be seasonal, perennial (year-round), or episodic. It can be intermittent or persistent, and mild or severe. Symptoms can include runny or stuffy nose, sneezing, itchy nose, swelling around the eyes, and red and watery eyes.
The Atopic “March”
Longitudinal studies on eczema, rhinitis, asthma, and food allergy showed that rhinitis increases later in childhood and plateaus around age 12. There is a hygiene hypothesis, which states that exposure to certain microorganisms in early childhood protects against allergic disease by contributing to the development of the immune system. “Does growing up on a farm growing up and sitting in a really clean environment make a difference?” Dr. Szczupak asked. “We think it does.” This is partly why allergies are so common today.
Impact on Sleep
In 2004, Berrylin J. Ferguson, MD, FACS, FAAOA, Professor in the Department of Otolaryngology at the University of Pittsburgh, published her work on the influence of allergy symptoms on sleep. She looked at four symptoms, tracked them over time, and had patients grade them. She found that symptoms were most severe in the morning and really increased from midnight to six in the morning due to a combination of lying flat and variations in the circadian rhythm.
The immune system can be separated into innate immunity and adaptive immunity. Part of the innate immune system includes physical barriers that our body has, like the mouth, GI tract, stomach acid, to help protect us. Looking at the cellular levels in the blood, the immune system can be separated into innate (cells that respond to antigens based on what they have been programmed to do) vs. adaptive (more of a learned response through antibody production and having memory of past exposure).
Immune equilibrium is critical to fight, but it is a fine balance that can be thrown off when encountering many things throughout a normal day.
A landmark paper in the New England Journal of Medicine in 2001 looked at factors and interleukins (chemicals that cells produce) involving the allergy immune response. Isolating immune cells became more of a possibility.
Oral Allergy Syndrome
In 2005, Jenkins et al investigated oral allergy syndrome. Some foods and pollen have structural similarity. There is a cross-reactivity between inhaled allergens and food. A chart was shown with a list of pollens and how allergies to those pollens may trigger symptoms in corresponding foods. For example, an allergy to birch might mean a reaction to eating raw apples and apricots. Ragweed is linked to bananas, cantaloupe, honeydew, and watermelon.
The most common indoor aeroallergens are dust mites. Dust mite feces are actually the most allergic components.
The most common outdoor aeroallergens depend on the season. In spring, it is the trees. In summer, grass. Fall, weeds. Molds torment people year round.
Allergy Treatment Ladder
Picture a ladder. The bottom rung is the first mode of action: avoidance and environmental controls. The middle rung is medications/nasal sprays and pills. At the top is immunotherapy/allergy shots and drops – the only chance for a “cure.”
The overall goal is symptom control.
The problem with medications is there is no exit strategy. Often, the medications are lifelong, which can create a sense of anxiety in some people. The last option is sublingual drops, which addresses the root of the issue.
Environmental Control Approach
Several landmark clinical practice guidelines have our best evidence-based recommendations to utilize. The Environmental Control Approach, for example, means removing the subject from the allergen environment, reducing allergens in the subject’s environment, or preventing sensitization before the allergy develops.
Many patients benefit when they go on vacation and are away from their typical inhaled allergy exposures, Dr. Szczupak said. Even altitude makes a difference in symptoms. Moving from a sea level climate to a high-altitude area can do that, since many allergens are not present at higher altitudes.
When it comes to environmental controls, patient preference is a factor. Other things to consider are shared decision making, practicality, cost, and efficacy of treatments.
Because there is such limited data on environmental controls, the strongest recommendation is only to “advise avoidance.”
Techniques to Reduce Allergens
- Impermeable mattress covers
- Wash bedding
- Dehumidifiers – goal is to get humidity to less than 50 percent
- Acaricides (general term for pesticides) – can reduce dust mites up to 70 percent by using chemicals in the house. Some can stain furniture if not used correctly, which makes use challenging.
- Reduce fabrics – carpets, curtains, etc.
- Introducing natural sunlight
Physical measures to get rid of dust mites include:
- Wash bedding in hot water (>130 F)
- Impermeable bedding covers
- Air filtration (HEPA)
“Antigen reduction does not always equal symptom reduction,” Dr. Szczupak said.
Physical measures to get rid of cockroaches include insecticide bait traps and house cleaning.
Other than complete avoidance, strategies include:
- Keeping pets out of the bedroom
- Removal of carpet
- HEPA filters
Fewer people develop allergies to dogs, Dr. Szczupak said. Complete avoidance is impossible because most people are not willing to part ways with their pet.
The first line of medications includes Flonase nasal spray, Allegra, Azelastine nasal spray, and NeilMed sinus rinses. There is a whole range of different topical nasal steroid sprays.
The next option is oral medication. There are a few different options that are non-sedating oral antihistamines.
Other second line medication options are Singulair, Sudafed, Nasalcrom nasal spray, and Atrovent nasal spray.
Medications that are not recommended are oral steroids, nasal steroid injections, and topical nasal decongestants. There are risks with oral steroids, including insomnia, elevated blood pressure, elevated blood sugar, fluid retention, and bone density changes with long-term use.
The goal of immunotherapy is to create an immune system tolerance, reduce medication use, and avoid local (or systemic) reactions. Success in reducing symptoms depends upon direct antigen dose and continuous treatment. This means it can generally take three to five years. Premature withdrawal decreases effectiveness.
Risks are injection site swelling and anaphylactic reaction (shortness of breath, rash or hives, wheezing, and throat swelling). In a paper from the Department of Otolaryngology at the University of Pittsburgh on immunotherapy safety, errors are extremely rare and typically are from patient identification, vial mixing, and dosing errors. Anaphylaxis is a rare event, occurring only in 1 in every 10,000 injections.
- Beta blockers
- Contraindication to epinephrine
- Patient non-adherence
- Autoimmune disease
- Pregnancy – may continue but do not start
- Uncontrolled asthma
We know allergy shots work. Subjectively, they work by symptom resolution, medication reduction, and quality of life improvement. Objectively, we have demonstrated immunologic changes, decreased skin test reactivity, and improved lung function parameters with allergic asthma, Dr. Szczupak said.
Allergy testing is done by skin or blood testing, where approximately 30-40 different environmental allergens are tested. Providers tend to have their own preference; both provide equivalent data.
Regarding time to maintenance therapy, there is no difference between blood testing and skin prick testing, nor is there a correlation with overall symptom improvement.
Allergy Shots and Sublingual Drops/Tablets
Testing will determine how allergic someone is and where to start with treatment. The buildup phase when doing allergy shots depends on how sensitive the person is. There is a slow advancement over four to six months in which the dosage is increased. Once the highest dose is reached, this is the maintenance phase, which means receiving shots once a week for at least a year. They can be more spaced out in the second year, and in the third year, shots can be given every three weeks or so. Many people will not have any symptoms after stopping three years in, though it is always possible to develop symptoms years later.
Sublingual drops are an alternative means of treatment without injections. There are always pros and cons in the discussions with patients, Dr. Szczupak said. These involve a small dose under the tongue daily at home. The first dose is given in the office to make sure there is not a severe reaction. Technically, this is not FDA approved, so there is some cost consideration involved. While there are some local and mild reactions, the dose is then adjusted, and most have no issues. Some literature shows that this is a bit safer. “But it is still very rare to get a severe reaction with allergy shots,” Dr. Szczupak said.
There are also newer FDA approved sublingual tablets: Grastek (Timothy grass pollen, approved for kids five and up), Ragwitek (short ragweed pollen), Oralair (grass pollen), and Odactra (dust mite).
When it comes to allergic rhinitis, the unified airway theory and recent treatment innovations have helped to advance care. A multi-disciplinary team approach helps patients. UPMC ENT Allergy has several locations: Mercy, Shadyside, Monroeville, and Horizon.
When asked about acaracides being harmful to pets or young children, Dr. Szczupak said there are definitely some concerns about pesticides in the house. He is not familiar with individual chemicals and encourages people to read the packaging.
Bedding and clothing worn to sleep should be washed weekly for dust mites. Strategies can be employed for pillows and comforters, since they are hard to wash items. They can be placed in the dryer on high heat. Dr. Szczupak has not seen a lot of research showing that any detergent is more effective than another, so it is better to focus on high temperature water.
A most common reaction to using nasal spray long term is a nosebleed. A lot of nasal sprays are dependent on how they are used. Dr. Szczupak demonstrated a technique called using the opposite hand. Rather than spraying into the middle of the nose, spray outward toward the ear. Hold the spray bottle in your right hand to spray the left side of your nose, and vice versa. This can help prevent nosebleeds. There are other strategies as well. Dr. Szczupak has patients on nasal sprays long term, and the benefit is that this is not medication absorbed significantly into the bloodstream, so it is inherently safer than an oral steroid. This is why nasal sprays and topical medications are preferred; the risks are pretty low.
It is okay to take an oral medication like Allegra daily if you experience symptoms year-round. Overall, the risks are pretty low. Oral antihistamines can cause some dryness, especially in the mouth. If patients are having symptoms outside the nose (watery eyes, throat symptoms), allergy pills are a good option. They can take several hours to start working and reach maximal effect.
Dr. Szczupak tends to be a little more cautious in using nasal sprays in patients with a history of glaucoma. A risk-benefit discussion is had with patients.