NEPA Vital Signs - Summer Fall 2018 - 17

SUMMER/ FALL 2018

rhinoconjunctivitis
No special expertise is required by
the testing physician. It can even
be done on people taking antihistamines. There is no concern of a
potentially severe adverse reaction
from the testing. However, this procedure is more expensive, less sensitive, and
more abstract for the patient.

Those affected may notice a stuffy nose and/
or runny nose, a drip in the throat, an itch in
their ears, nose and/or throat. Treatment may
be divided into three components: avoidance,
medication, and immunotherapy.

Some people can have allergic rhinitis
symptoms, even with negative testing.
This may be due to local IgE production
in the eyes, nose and lungs. Since the IgE
production is not systemic (throughout
the body), testing will miss this. However,
exposure to relevant allergens will lead to
symptoms. In addition, many allergens may
intrinsically trigger an immune response.
People may be symptomatic, even if they
do not have IgE and mast cell responses.

Pollen avoidance is often more difficult. During the pollen season, windows
and doors should be kept closed. Air
conditioning, set to recirculated air, can
decrease exposure to pollen. Another
option to consider would be a HEPA (high
efficiency particulate accumulator) filter.
Although expensive, these filters can
remove molds, pollens and pet dander
from the ambient air.

Treatment may be divided into three 2. Oral antihistamines represent a first
components: avoidance, medication,
choice for mild to moderate allergic
and immunotherapy.
rhinitis. Newer antihistamines are
generally recommended, as being less
1. Avoidance measures are the most
sedating, and having less potential for
effective and safest treatment for
anticholinergic side effects. Intranasal
any allergy. Testing can be very
corticosteroids, many available overhelpful, to inform which avoidance
the-counter, are most effective when
strategies to employ. In people allergic to
started prior to the pollen season, and
perennial allergens (such as dust mites,
used regularly. Intranasal antimolds and pets) and to seasonal allergens
histamines used simultaneously
(pollens), avoidance of all allergens is
will give additional therapeutic
more effective than just partial avoidance.
effects. Leukotriene modifiers tend to be most effective
The most important step for avoiding
when used in combination with an
dust mites is to cover all pillows and matantihistamine. Another option would
tress with mite proof encasings. Blankets
be intranasal cromolyn prior to known
and sheets should be washed regularly
allergen exposure, to prevent rhinitis.
in water above 130°F, to kill dust mites.
Anticholinergic agents, such as ipratropiIdeally, pets should be kept out of the
um nasally, are used to dry up secretions,
bedroom, and washed weekly. Removal of
but may not be as effective for congestion,
bedroom carpeting is effective, but someitching and sneezing.
times more difficult to achieve. Forced
air ventilation is a potent source of 3. Patients doing well with minimal mediallergen exposure. Cleaning the
cations need no further therapy. If they
vents, and placing inexpensive filter
continue to be symptomatic, or are unable
material where the vent blows into
to tolerate medications, immunotherthe room, can be successful.
apy (allergy shots) may be indicated.
N E PA

VITAL SIGNS

Subcutaneous immunotherapy, or SCIT,
has been used for over a century. This is
effective for many conditions, including
allergic rhinitis. However, an allergic
reaction due to the injection is possible.
Therefore, a waiting period of 30 minutes
after each injection is recommended.
The injections are given in the
office of a physician, who must
be prepared to immediately treat
anaphylaxis. In patients in whom
epinephrine is contraindicated, SCIT
would also be contraindicated.
A newer alternative is sublingual immunotherapy, or SLIT. The first dose is given
in the physician's office. Subsequently,
patients take the medication at home,
daily. Studies suggest that SLIT is safer
than SCIT, but may be less effective. The
FDA has approved SLIT for grass, ragweed
and dust mite allergens. Data is still
lacking on whether patients with more
than 1 allergen may combine different
SLIT therapies.
In summary, allergic rhinitis is a common
issue for many patients. This can cause
significant symptoms. Allergic rhinitis may
lead to allergic conjunctivitis, sinusitis, otitis
media and asthma. It is important to realize
that safe and effective therapies exist, which
can substantially improve quality of life.
JOEL LAURY, M.D., is an allergistimmunologist in Scranton.

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