Seasonal Allergies: Optimizing Treatment for Each Patient (Recording)
This webinar was recorded on August 27, 2024
As many as 60 million Americans live with seasonal allergies. Tree pollen is active in the spring, grasses and hay are active in the summer and fall brings ragweed. In this webinar, learn how to diagnose and treat your seasonal allergy patients.
Speaker:
- Anne Maitland, MD, PhD
Director, Allergy & Immunology Services
Metrodora Institute
Asst. Professor, Icahn School of Medicine at Mt Sinai
Department of Medicine- Allergy & Clinical Immunology Division
Dr. Maitland was named one of New York Times 2011 Super Doctors and one of America’s Top 21 Women’s Doctors by Lifescript.com in 2009. She is a Fellow of the American College of Allergy, Asthma and Immunology and a member of the American Academy of Allergy, Asthma and Immunology.
Dr. Maitland is very active in local societies and the surrounding communities, to increase awareness of immune mediated disorders. She is also involved with research to continually improve the treatment of allergies, asthma and recurrent infections. Her clinical focus includes the diagnosis and treatment of allergic skin disorders, allergic rhinitis (hayfever), drug allergies, food allergies/sensitivities, asthma and recurrent infections.
This Advances webinar is in partnership with the American College of Allergy, Asthma & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for Advances webinars.
All attendees will be offered a certificate of attendance. No other continuing education credit is provided.
CME is available through ACAAI for this webinar.
Sponsored by the American College of Allergy, Asthma and Immunology
Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Catherine: We still have a lot of folks trying to get in. In the meantime, if you would be so kind, put where you are from, we are calling from in the chat, so we can get started in just a minute or so. OK. We are going to get started. Hello, everyone, and welcome welcome welcome. My name is Catherine Blackwell, and I’m the chief health equity officer for the allergy and asthma network. Wanted to take a minute to say thank you so much for joining us. We are in for a real treat today with Dr. Anne Maitland as our today’s presenter. We have a few housekeeping rules before we start today’s program. First come we are going to be muted for the webinar, and we are going to record today’s webinar and post it on our website within a few days. You will be able to find our recorded webinars on our website at allergyasthmanetwork.org. Scroll to the bottom and you will find our recorded webinars and then the other webinars you would like to attend. This webinar is going to be about an hour, and that includes time for questions. We are going to take those questions at the end of the webinar. You can put your questions in the Q&A box at any time, and that is located at the bottom of your screen. We are going to have somebody monitoring the chat if you have questions or you need some help. We’re going to get to as many questions as we can before we conclude today’s webinar. This advances webinar is in partnership with the American College of allergy, asthma, and immunology. ACAAI offers attendance credits. You can get a free ACAAI account and obtain credits for Advances webinars. A few days after the webinar you will receive an NML with additional information and a link to download the certificate of attendance. We are going to try to add the link into the certificate and the chat. Let’s get started. Today’s topic is “Seasonal Allergies – Optimizing Treatment for Each Patient.” As many as 60 million Americans live with seasonal allergies. Tree pollen is active in the spring. Grasses and hay are active in the summer. And fall brings ragweed. In this webinar we are going to learn how to diagnose and treat your seasonal allergy patients. It is my esteemed pleasure to introduce our speaker, Dr. Anne Maitland. Dr. Maitland was named one of New York Times 2011 super doctors and one of America’s top 21 women’s doctors in 2009. She is a fellow of the American College of allergy, asthma, and immunology, and a member of the American Academy of allergy, asthma, and immunology. Dr. Maitland is very active in local societies, in the surrounding communities, to increase awareness of immune-mediated disorders. She is involved with research to continually improve the treatment of allergies, asthma, and recurrent infections. Her clinical focus includes the diagnosis and treatment of allergic skin disorders, allergic — hayfever, drug allergies, food allergies, sensitivities, asthma, and recurrent infections. Thank you so much for being with us today, I’m going to turn it over to you now.
Dr. Maitland: I want to thank you again for this very kind invitation. If you can contact my brother, because he wanted when I was going to get a real job. Does she wondered when I was going to get a real job. Just kidding. Absolutely delighted to talk about a condition that a lot of people describe as a nuisance, but I’m hoping to show you this is more of a menacing condition that shouldn’t be underestimated regarding what it can do to your vitality and wellness. This again is the mission of the allergy and that’s my network, the need to finish a needless death and suffering associated with allergic conditions through outreach, education, advocacy, as well as research. This is me, and I’m currently the director for allergy and immunology services in Selleck city. By also retained my assistant professorship in New York. These are my disclosures. This has nothing pertaining to what we are going to talk about regarding the diagnosis and management of allergic rhinitis. We are talking about the burden of allergic rhinitis, unmet needs on an individual basis, and the need to create an individualized treatment plan for those who suffer with allergic rhinitis. Please understand with climate change it used to be April showers, May flowers. We now see individuals suffering tree pollen starting in February and grass pollen at the beginning of June and then ragweed and other sufferers late fall trees until the first frost. What is rhinitis? It is inflammation of the upper airway, tip of the nose to the back of the throat. It is commonly review her to as allergies, but allergies means you have information that can impact any system. Allergic rhinitis focuses on the fact that you are making inappropriate immune responses, taking away from how your body functions to send inappropriate energy to fight against things that are completely innocent. They have a tendency to cause the following symptoms. You have sneezing fits, runny nose, itchy eyes committee throat, your fullness and pain, susceptibility to sinus headaches, throat pain is welcome the infamous postnasal drip. You wonder, if this condition is so common, why isn’t it considered it menacing? I want to point out why it might be the case. It can really impact your quality of life, but also impact other comorbid disorders that are quite common, including individuals that may have hypertension, susceptibility to sleep disorders, and I will show you that this is an extremely prevalent condition where when I first entered into clinical practice, less than 10% of the population were impacted by having a positive allergy test. The latest assessment shows that one out of three adults are impacted by conditions including over 25% having seasonal allergy and as as was previously stated, 60 million children, adults, and seniors suffered this chronic upper airway inflammation. To the point that we estimate 40% of the population are affected. This is an article from “time” magazine back in the early 1990’s showing that this epidemic was just starting to get on the rise. In many ways having allergic rhinitis is nothing to sneeze at. Up to 30% of adults, 40% of children. If you ask the patients who are dealing with these symptoms, nearly 60% of them reported that their symptoms are moderate or severe, meaning it is interfering with other aspects of their life, whether you are talking about participation in school, participation in work, or frankly missing time in the form of absenteeism as well. Interestingly enough, for employers and schools, it is the second leading cause of chronic disease in the United States. Up to 60 million persons are affected and nearly half of them have had symptoms for more than 10 years. You can imagine how Spring doesn’t bring joy, but suffering in the form of upper airway inflammation that can also impact other organ systems. Some of the conditions that commonly travel with allergic green-itis are sleeping — allergic rhinitis are sleep disorders, including snoring, increased susceptibility to infections, whether in her ear throat infections, or sinus infections.
It can cause you draft cough postnasal drip. Nearly 80% of patients who have asthma have upper airway inflammation with the seasonal component. And then you have individuals that are susceptible to vertigo, and if you have ever had this condition, you know how devastating it is to have your world spin every time you move. One thing that a lot of primary care may not appreciate is having upper airway inflammation contributes to psychiatric illnesses including mood disorders, depression, anxiety, as well as neurodevelopmental disorders. It is not uncommon for children to have issues with attention deficit because they are not sleeping well, the ongoing inflammation can impact how the brain functions as well. So those are the indirect costs that are associated with having not well-controlled rhinitis. The direct cost is astronomical. We are talking hundreds of millions of dollars a year being lost not only in treatments that may not be as effective as they should be, but also ending up in the emergency department are frequent visits to a doctor because now you are getting sinus infections, asthma exacerbations. The latest illness is esophagitis, which is associated with inflammation impacting the upper G.I. tract. We have some individuals who are even at risk for having seasonal allergic rhinitis associated with anaphylaxis. Very common symptoms is not only ocular issues — can you imagine trying to drive when you are having all of this inflammation? Fatigue as well as asthma exacerbations. This is just to highlight that in addition to other disorders that are known to prevent people from participating work fully, including diabetes or hypertension, allergic rhinitis is the second in causing lost productivity at work. As you can see, this so-called nuisance of a disorder is quite menacing in that it causes quite a few problems. So it is prevalent, it causes a lot of disorders, and it contributes to a lot of disorders, but one out of eight individuals impacted by chronic rhinitis have these issues. Talk to the doctor about trying to improve the symptomatology associated with chronic upper airway inflammation. And the reason for that is many times people don’t think you need a medical home for this chronic disorder, but that is the case. I like to drill down a little bit more about the need to your primary care, primary care to recognize that this is a condition that might need a specialist’s attention, and for the specialist to be thoughtful and mindful about educating on how to improve therapy that make it the symptoms under control.
Let’s talk about delayed diagnosis and management of seasonal allergic rhinitis when it comes to the patient, when it comes to the general practitioner, when it comes to the specialist. When it comes to the patient, a lot of patients don’t know that they should present it to their pediatrician or their general practitioner. One thing I like to point out is many women rely on their gynecologist for their primary care, but realize that is not the focus of the gynecologist could I do strongly recommend that women should align themselves with a person who is trained and has much experience in adult medicine beyond the exposures — beyond the training of a gynecologist. A family physician, an internist , would be a lot more helpful in providing medical home to get these conditions under control. Because patients don’t think that they can present it can they end up trying to self-manage with over-the-counter medications, including decongestants. There is reason why decongestants are behind the counter. They have a tendency to raise blood pressure come can be misused in the form of illicit use, and can drive hypertension and make other disorders much worse. Another reason why patients might not bring attention to their doctor, they might not want to take time away from work or school, they might not want to pay the co-pay. They don’t want to make that investment. That investment might be necessary for not only improving her upper respiratory health, but improving your mental health , improving your lung health, and potentially contributions to other disorders you might be dealing with including hypertension, diabetes, or other inflammatory disorders. I would like to also point out that it is really important if you have nasal congestion, if you have sleep disorders, if you have a diagnosis of asthma, you should be tested to see whether or not you have another trick component, because there are really good therapies available that if you get the rhinitis under control, you reduce your susceptibility to these other disorders, including euro psychiatric illnesses. Let’s move over to the general practitioner. Again, a lot of patients don’t believe that a general practitioner would be open to discussing how to treat this, and also the way this is taught in training, whether you are talking family medicine, pediatrics, or internal medicine, maybe not enough attention is given to the need to screen for this disorder and educate patients on how it can contribute to other conditions besides the nasal congestion or postnasal drip. Again, just like the patient might not know that these other comorbid disorders run with allergic rhinitis, it is very possible that the family medicine practitioner, the internist, and the pediatrician doesn’t know the Association, for instance, with pediatrics, not having well-controlled rhinitis can contribute to attention deficit disorder or mood disorders. Or the internist might not recognize that not -well-controlled airway inflammation contributes to sleep disorders or fatigue. If you have these other conditions, you should be screened for upper airway inflammation and screened to see whether or not there is a seasonal component. Let’s move over to the primary care making the appropriate referral. If you have ongoing upper airway inflammation you go to an ENT specialist, also referred to as otorhinolaryngologist, or in immunology specialist?
There overlapping, but there are key differences to appreciate. The air, nose, and throat specialist can diagnose the front part of the nose but also the back part of the nose as well as the lower aspect of the throat evened out to the vocal cords. If they see that you have inflammation that is suggested of an allergic component, they might make recommendations and prescribe antihistamines, where we have a first-generation antihistamines that work better and dry out the mucus but have a tendency to make you sleepy. They made second-generation antihistamines, which are less likely to make you sleepy but can also last 24 hours. I have to tell you, straight antihistamines don’t take care of the major presentation in individuals that have not-well-controlled allergic when I just dished allergic rhinitis, and — not-well-controlled allergic Renee does. If you have diabetes, hypertension, a history of stroke, history of abnormal cardiac rhythms, you cannot take these medications, because you are going to trade in one problem for another. One other thing that the ENTs can do but may not be a common procedure would be called a radiofrequency ablation, where they scar down the tissue so it is less likely to become inflamed. That technique hasn’t taken suit and a lot of ENT specialist practices. They might not necessarily order the tests that are necessary to identify what you might be having allergic inflammation to regarding common environmental allergies. I would like to pivot to what allergy Manella just specialists have been doing for 100 years. Finally in 1989 we had a biological basis for why the positive skin tests were causing problems.
During the blood testing we are looking for in antibody, IGE, that prior to the allergy epidemic actually was the antibody that was used to detect and fight off parasites. Outside of industrialized nations, there is a huge burden of parasites that contribute to illness in individuals that don’t have protected water or protected food or sanitation that picks up refuse every Tuesdays and Thursdays. The allergists have the ability to do the skin testing. Whether you are talking drops on the skin or minute amount being injected in the skin. I have to tell you, I prefer doing the allergy testing, because then I can show you every time you breathe in the substance, this is what is happening on your respiratory linings. This is what happens when you have the cats sleep in the room with you. This is what happens when you decide to cut the grass. This is what happens when he started dust and you don’t use a vacuum that has happened filter or you are not wearing a mask. That type of inflammation will flare up. I can tell you, if you have allergic inflammation, it reduces a nonallergic trigger like airborne chemicals from perfumes or personal toiletries or cleaning agents to make your congestion or your symptoms associated with rhinitis worse. The allergists will have the opportunity to tell the difference between someone who has an allergic component, meaning your body has made antibody and every time it sees it it will increase the amount of inflammation that is going to be recruited to the airways, as opposed to a nonallergic component. I would also like to, for those that work in an environment where they are constantly exposed to airborne antigens, such as if you are working in the mail industry or cosmetologist, or you are working in maintenance, or you are working in outdoor — running a nursery — you are at increased risk of being exposed to both irritants that can prompt developing an allergic component and the allergic component would then allow these nonallergic components to make your congestion even worse. Much more easily. I find that allergists have a tendency to not only identify what you are allergic to third skin testing or blood testing. They will also make an effort to educate you on how to use methods to reduce your exposures to your environment, how to use your medications, and if your medications are not available or you might not find the medications are working for you, it might be important to think about allergen immunotherapy, which I will get you. I have to tell you that there is a huge issue about having access to immunology specialists. When it comes to medical schools and nursing schools, less than a month the first year of graduate education is focused on allergy and immunology education. In this country there is only one allergy immunologist specialist for 1000 residents pit that is a problem if you have 60 million people impacted by the condition. Also there is limited opportunities, only 80 training programs in the country, which means there is very few allergy immunologist specialist that are available, and also general practitioners can internists, surgeons don’t get enough exposure to understanding the basis of this chronic condition and how to get it under control.
This is a statement that was made back in 2007 that there is just not good allergy, knowledge management and practices, hospitals, clinics. It is minimal or nonexistent which is a huge issue. Just to give you an idea, this is trying to identify and immunology specialist not only in urban centers where I can tell you in one of the communities in Manhattan with its over 250,000 people living, there is not a single allergist between 90th Street and 160th Street East to West. You can look at this map and depending on the darker brown colors shows that you have an allergy — a huge number of allergy immunologist specialist. As the color gets lighter, these are individuals who make drive up to 50 to 100 miles to get an evaluation by an immunologist specialist. We have to do a better job of educating general practitioners and specialists on the recognition of allergic night and comorbid disorders, but we also need to educate the general population that this is not a condition that you need to just live with and actually acclimate down to, but there is an opportunity to make you feel better. What is up with the specialists? Besides not enough of us around, many of them have a tendency to just focus on the three-minute visit in order to be able to keep their clinic open. As a former practitioner, where I was seeing close to 25 patients a day, the patient’s story, we do the allergy testing, do you want allergy shots, and repeat. But there is more to it, and you might need a number of visits just to get the appropriate testing, try the recommended therapies, get a written action plan on how you should use those therapies, and then come back in a few weeks to a few months and save is this working for you or not. Secured the diagnosis, get therapies, see if the therapies work for you and you are not having adverse reactions. This is what we use in our practices. We have a tendency to use allergy action plans. But that is after I tried to understand how well-controlled or not well-controlled allergic rhinitis is. If you are just having upper airway symptoms that just come and go less than four days a week from it is called intermittent, or you can do away with using oral antihistamines. But if it is more persistent, meaning we are now in the middle of ragweed season, if you are having postnasal drip, itchy eyes come every day for a few weeks, now the question is is it wild persistence such that you are able to go to school and pay attention, not having any sleep issues, able to participate in activities, now considered mild persistent where you might warrant the use of a nasal corticosteroid, and there are plenty of them over the counter as well as prescriptions. And there is also nasal antihistamines can which I find to be a lot more effective in controlling the congestion symptoms compared to the oral antihistamines. Over-the-counter now have dish with a prescription — they have combination sprays where you get the benefits of the nasal corticosteroids and the nasal corticosteroids can take up to a week to start work, but the nasal antihistamines start working in 15 minutes and work 12 hours. Havingtogether in one medication, you could potentially use them as needed, which you will have a better chance to get the symptoms under better control.
Other medications , if the oral medications, avoidance measures, nasal preparations don’t work for you, you have the opportunity of considering allergen immunotherapy. This is the action plan that I typically provide where we identify what you are allergic to and we let you know how to use the medication. A lot of patients don’t use the medication properly. I just tell people to lean down a little bit and aim the spray at 1:00 and 11:00. You want to make sure that you aim away from the nasal septum. The sprays easily three to four inches high. It will make its way up there. There are oral antihistamines. You have the leukotriene antagonist could one thing I have a tendency to lean on the most is nasal saline. Plenty of preparations over-the-counter. You can do your own DIY version. Literally washing your nose out at night is a good way to reduce the inflammation after you have breathing 18 times per minute throughout the day in a pollen-filled environment. Formal. One tip to show whether you are pollen-allergic or multi— mold if an allergic is pollen is worse when it is sunny. Mold picks up after rain could one of the major mold allergens is Alternaria, which we call blitzkrieg rhinitis as well as blitzkrieg asthma. Some people have problems when the day is nice in some have problems when the day is what. — wet. We will lean into more about the medications that then we will talk about other therapies, especially the use of allergen immunotherapy. Avoidance measures. Believe it or not, the covert pandemic not only helped individuals reduce their exposure to breathing in SARS-CoV-2 to cause a viral infection, it actually helps control a lot of asthmatics and allergic night’s patients, because those dish allergic rhinitis patient — allergic night’s patients, because those masks were good at keeping out more than pollen. If you need to use nasal saline commit is less likely to have inflammation. Closer windows when you are driving. I know it is kind of a lot of fun driving with your car top down, but guess what you are breathing in, all the pollen that is settling in, especially if you are out westward down south. You can use these filter guards if you have the windows that go up. This will that she will get — you will get a nice breeze without the pollen coming in. So you don’t end up sleeping with the enemy. It is a good idea if you have been outside either exercising or walking to take a shower and wash that off so it doesn’t land in your hair. And then you transferred to your pillow. And using air-conditioning. It is really important that you have appropriate folders and air conditioning units so you are not kicking out: Mold that is a committed overtime. These are general recommendations for how to do avoidance measures.
Keep your windows close, use air conditioning, try to stay indoors as much as possible. If you go outside, where I had. — where I had. W — wear a hat. Let somebody cut the grass or doesn’t have seasonal allergies, and healthy they are wearing a mask when they are doing it. Consider vacationing by the beach where you are less likely to — salt air will be a natural rinse of your airway. When traveling by car, it is important to keep your windows closed and user conditioning. — use air conditioning. Let’s talk about the medications that are available. You want to time — this is the advantage of identifying when you are allergic to — this is an old calendar talking about when tree pollen starts popping up. Some people are now suffering since we no longer have a white Christmas. I know that Christmas Day a few years ago was beautiful and balmy and people were feeling it from the pine trees that they would bring in for Christmas. Tree pollen is active from February till about June. We have grass pollen that kicks up into April and early May and continues to the first trust. Ragweed is now along with other weeds such as Mug Ward. Some individuals who have pollen allergies also have problems with fresh fruits and vegetables. Individuals that have tree pollen allergies will have problems with cherries and peaches and apples. People with grass allergies will have possibly problems with watermelon. That will cause each with fresh fruit and vegetables. If you cook it, less likely to have that type of reaction. Ragweed cross-reacts with chamomile. You have your-route allergens dish year-route allergens. — you have year-around allergens. Multiple kick up when it is raining outside. If you have medications and you have the treating grass allergy can be will be what did these medications for six months, starting in February and going through the summer. Or if you have grass allergy, you are done from April until September or October. It is important to know when you should start your medications. Nasal steroids need to start at least a week before the season. And iced means are used dish antihistamines are used as needed but don’t do good for congestion — antihistamines are used as needed but don’t do good for congestion issues. The nasal sprays are the best one comes to topical medications and keeping not only the itch under control but the congestion as well. What I wanted to show you is that it is not the easiest thing to take a vitamin on a daily basis. Taking an oral advice to mean dish oral entities demean and — taking an oral antihistamine every day is difficult.
These are individuals who were given medications. Less than 10% of them are using sprays correctly. There were not getting the full benefit of the medication. They are paying for the product, got the prescription, went and bought it, now they are not getting optimal relief. The other thing they found is that the predictors for individuals that were not very good at rhinitis control — I will raise my hand as a working mother who makes sure everybody else is taken care of and then I think about myself and by that time I’m too tired at night to do what I need to do besides just use the nasal spray just before I brush my teeth. Individuals that have active asthma have a tendency to not focus on keeping the upper airway under control bit a lot of individuals have a tendency to depend on intranasal decongestants come which can be used up to one or two days but then you end up with chronic written ideas condition — chronic rhinitis condition due to the medication that is meant to help clear the symptoms in the first place. How do we get your seasonal allergic rhinitis under control? It is a personalized decision. Once you get the diagnosis, understand what you are allergic to. See what you can use, given what fits your lifestyle, which is going to be effective, and not cause side effects. Again, I want to emphasize that over the past decade, climate change has led to increased pollen release. Not only the pollen count is starting earlier in the year and they are much higher, so people are terribly people static with the changes of season — terribly symptomatic with the changes of seasons. Also you need some type of therapy including oral antihistamine, vitamin C, vitamin D, omega-3. Or are using nail — nasal saline, antihistamines. That cost a lot of money just from co-pays from three different medications can $100 a month. What is another option? I want to talk about the three forms of allergen immunotherapy. We have what has been done for over a decade — over a century come allergy shots. That requires you going into the office and being monitored. They have allergy tablets for which we have at least four allergens that are prescription. And then we have allergy drops. I want to lay this out a little bit. Let’s talk about allergy shots. The pro is it has been done for over a century. We know how much to give you, how long to give you, we can give you multiple allergens, perennial allergens such as mold and components of dust. We know that it reduces the risk of developing other hypersensitivity disorders such as asthma, and with allergic eczema. Once you complete a three-year course, they show that the efficacy of the allergy shots can last 10 years.
The downsides are left upfront costs, you have to go into the doctor’s office, you have to pay the co-pay can you are paying for medications that are keeping her symptoms under control, but in many ways I would urge you to think about investing yourself. Not only do allergy shots address the allergens you are sensitive to, it reduces the risk of you developing sensitivities to other airborne environmental allergens as well. It requires time. You have to take time from work or school, you have to go into a doctor’s office who knows how to administer the serums. The thing I’m most worried about, having a reaction besides a local reaction, including anaphylaxis, meaning I give you a shot and start clearing your throat. It needs to be treated. I already talked about the pros and cons of allergy shots. Let me talk about allergy tablets. We have allergy tablets, standard dose for ragweed, grass pollen, as well as dust mites. It can be taken at home. There is no needles or injections. There is a lower risk of anaphylaxis. And no need for you to go to a doctor’s office, sit there for 30 minutes, and return to normal activities. The cons are you can only do one allergen tablet at a time. There are some individuals that will do to at a time. I’m reluctant to do that because if you have a reaction, I don’t know that you would have done it. We don’t know the long-term safety. We know it helps to reduce symptoms and reduces your dependence on medications. We don’t know whether or not once you stop there is long-term therapy available. The first time you get the tablet computer would in the office because there is a risk of an allergic reaction such as anaphylaxis. And welcome to the battle of the century, getting insurance companies to pay for this type of immunotherapy. The one thing I might’ve mentioned before, I had one patient who I started on the allergy tablets and within two weeks he started complaining of irritation in his throat which identify he actually had esophagitis, so the medication had to be stopped. The last form of immunotherapy like to talk about his subliminal immunotherapy. These are jobs that really haven’t been voiced in the United States except some pockets, but it has been frequently used in Canada, Europe, as well as southern Americas. It does require injections. It does not require an epinephrine autoinjector. It can be taken at home. My practice is predominantly with drops. It is put under your tongue can one drop in the morning, to drops in the evening. It is shown to reduce the need for medications. You can do it pre-seasonally or year-round.
It can be used in children as young as five years of age. It helps to reduce dependence of other medic agents such as the nasal corticosteroids and the and iced means dish antihistamines — and the antihistamines. If you stop the drops, how long does the therapeutic benefit last? We don’t know the impact on other conditions. We know that it helps to reduce the risk of asthma exacerbations . We don’t know if you discontinue having to take drops for two years how long the therapy lasts. We don’t know the efficacy — the efficacy is clear with some of these antigens such as pollens. We are not sure how effective they are for mold. To kind of sum up, I would lean into the argument that allergic rhinitis is a menace. ” or of the population is impacted — close to a quarter of the population is impacted. Not only does because upper airway symptoms such as itchy eyes and conjunctivitis. It can increase the risk for infections and headache disorders and contribute to sleep disorders as well. It is associated with neuropsychiatric illnesses including mood issues as well as attention deficit disorders. And it is a major contributor to absenteeism at school and work as well as presentism, meaning you are at work but you cannot focus because you nose and sinuses are awry. The issue when it comes to poorly controlled rhinitis is that patients have a tendency not to go not to tell — don’t think that this might be a problem, so they try to self medicate or suffer through. And then a lot of doctors don’t necessarily pay attention to the fact that rhinitis may be contributing to other things, or it is quite bothersome. I had a minister come through and his wife called me saying “my husband is suffering,” and one of the nurses I was speaking to was saying you can suffer — you can suffer from rhinitis, this is his livelihood. He wants to speak clearly, he doesn’t want to risk of vertigo, he doesn’t want to risk of sinus infections. This interferes with his livelihood, and we need to lean into that. You have to make sure that the health care provider is listening to your concerns as well. And then refers you out so you can get — you can secure the diagnosis and whether you have allergic rhinitis, nonallergic rhinitis, or both come and write out a therapy plan that works for you. Better health requires for this chronic condition of patient practitioner partnership for optimal rhinitis care. It starts with identifying a practitioner who is going to listen to you, starting with your general practitioner, pediatrician, family medicine specialist, internist, and for the ladies, your OB/GYN. And then they need to assess you and there’s a straightforward questionnaire to identify whether or not you have issues. If you answer it any of these questions, it warrants an evaluation whether you get the blood test or the allergy skin testing.
The blood testing is twice as much allergen and then skin testing. Skin testing you get the answer in less than a few minutes. Blood tests, it has to go into the lab, they have to the tests and come back. You can understand why some insurance companies may not want to pay for so many allergens to be tested. Primary care should have this question available, especially if you are patients with sleep disorders, evidence of asthma, food allergies, eaqr fullness — ear fullness and pain, vertigo, susceptibility to developing polyps. The medical practitioner needs to emphasize dish I gave electric many years ago and this little boy was being — I gave a lecture menus ago and this little boy was being restricted to special ed because he had behavioral issues. His tonsils were contributing to a sleep disorder. Once he had his tonsils and but he was able to rejoin the normal class. His attention deficit disorder came under better control. You want an accurate diagnosis. The best set of working diagnoses, so that you get the optimal therapy. Can you get away with avoidance? Do you need oral antihistamines? Do you need combination spray of antihistamines as well as corticosteroids? If all of these are ineffective, costly, having side effects, or you want to prevent the development of other disorders, allergen immunotherapy should be considered. That is the action plan. Readily available. You can download it and bring it to your primary care or general practitioner. They should refer you to a specialist so you can get the avoidance measures and get a plan of the medications and consider immunotherapy. It starts with educating yourself about this chronic condition that is quite prevalent. Educating your general practitioner. You may not know that this something that are important not only for you but for the patients in the practice. And then partnering with a specialist that understands the impact different ideas on health and — the impact of rhinitis on health and wellness. I’m going to Vinita the conversation here in Moco any questions. — I’m going to end the conversation here and welcome any questions.
Catherine: Thank you, Dr. Maitland. Wow, that was a great presentation. A lot of information. There are a couple of questions, and I’m going to do my best to try to combine it. I think you already addressed to the wine, because someone asked about — addressed to the one, because someone asked about allergy shots and medication and how insurance-family they are. You want to just speak to that?
Dr. Maitland: So that would be a great conversation with — air, nose, and throat physicians normally don’t do allergy shots. It would be important to have a conversation with an allergist in network, and they are able to analyze whether or not you are able to go on to allergy shots. Most insurances have a tendency to limit your testing. But they typically will — the first year they know to build up to frequent visits. 20 to 26 weeks. They are more than happy for you to go on a set of injections once a month because now you pay the co-pay once a month and you are not taking three medications that were not pumping you get your symptoms undercontrol in the first place. Leaning into the patient practitioner partnership, that is a conversation you need to have with the practitioner who understands her condition knows how to listen to you, and translate that into meaningful action to get symptoms undercontrol.
Catherine: There is another question about if you have allergic rhinitis, are there certain foods you should avoid it there is one, that the majority of people that the person encountered had fewer or milder symptoms when they switched to a low-carb diet. Do you have commentary about that?
Dr. Maitland: A low-carb diet goes with using vegetables that have a vitamin C in it. Vitamin C has a tendency to be very good at stabilizing mast cells. There are other nutraceuticals that can be helpful for that as well that can be obtained from food. Carbohydrates, getting away from carbohydrates means you are a better risk of having issues with diabetes, not good for anyone with inflammatory issues. It also reduces the risk of increased BMI, becoming heavier. The more fat you have on your body, the more likely you will have an allergic-type reaction to these antigens. It is not a good combination. Depending on how you change your diet, leaning into more fruits and vegetables, vitamin C can be very helpful. And leaning away from foods that will increase your susceptibility to developing diabetes as well as becoming more heavy.
Catherine: Is there any correlation between vertigo and allergic redeye does? nine — allergic rhinitis?
Dr. Maitland: There is a two from your inner ear that goes to the top of her throat. If you have ever been on a plane and then you swallow, you pump your ears, that is the chief that connects directly to your nose in the back of your sinuses . When you breathe and stuff, that inflammation will involve all of the upper airway, so not only is there a link to vertigo, there is also a link to children that keep on getting recurrent interviewer infections, or children — and adults the end up with large adenoids and tonsils that contribute to sleep disorders. If you are pumping your ears and your user itching, that is because you have been breathing in an antigen like mold or pollen or dust that is getting up there. And the two gets blocked and then the fluid gets trapped in there. A very special apparatus is responsible for maintaining your balance that is not able to equilibrate properly. Ringing in the years compared his full disk ringing in the ears, — ringing in the ears, which is full tonight’s, or vertigo, dizziness as well.
Catherine: We have a school nurse on the line and she sees a lot of students with allergy symptoms and asks if you have recommendations for allergy management in a school setting.
Dr. Maitland: Well, one, you want to make sure the classrooms keep the windows closed during the spring and summer days. Or have the air conditioning on. Some schools can afford to do that. Also it is really important — it was identified a long time ago, you want to make sure the school buses are not parked up against the building and the fumes are getting in. That will aggravate the allergic night’s as well. — allergic rhinitis as well. I would pull the parent aside and say, hey, Jamie is doing the allergic salute and going like this. That is assigned that they should go to the pediatrician and get a plan to get the symptoms undercontrol. A lot of parents sometimes don’t necessarily want to spend the money to go for a doctor’s visit and will rely on over-the-counter. If they’re going to start using over-the-counter medications, they should understand if the child does not get any better at taking whatever prescription or over-the-counter antihistamines, it is not going to work and they shouldn’t double it. They shouldn’t double the amount of loratadine, they shouldn’t double the amount of facts offended in they should invest in the office visit so that they get originated and out plan of what to take for what — a written-out plan of what to take for what. You have to use a drop. Or using nasal cortical steroid spray that is used properly in children. And sometimes just pointing it out to the parent and saying this is happening every time she goes out to the playground, she comes backwards, I think she has seasonal allergies, bringing it to the parents attention so the parents are educated out of their busy schedule to make the time to go to the pediatrician or potentially scheduled to see a specialist. Catherine: And then one other question — they asked if a blood test, is it as effective as skin testing, and does a test for multiple allergens.
Dr. Maitland: So there are pluses and minuses. It is not as sensitive as one form of skin testing. There is two forms of skin testing, prick test and injection. And yes, you can test for a lot of that, but insurance committees prefer to pay for allergy testing because it is a lot less expensive. If you do a panel of 30 or 40 allergens, you were going to run up a bill and insurance may or may not cover all of those allergens that are being tested. And then also there are false negatives. You won’t miss it. Are there some conditions that I will lean into a blood test is a post was contest? no and yes — blood test as opposed to a skin test? Yes. I would go to a blood test. For the most part I think it is a good educational tool for the parents to see whether patient to see that the — if you can keep Kitty in the bed with you or you’re going to go walk in at the height of pollen flying around, which is between seven and 10:00 a.m. in the morning and 4:00 to 4:00 and 7:00 p.m. at night, you will be a lot more symptomatic. There is ways of giving guidance for avoidance measures also both for the blood test and for the skin testing. But I think skin testing is more expensive. I think there are false-negative spirit and sometimes whoever orders the test, because it might be primary care, they might not understand how to interpret those tests.
Catherine: We have time for one more question. Someone asked what age is it OK to take a decongestant.
Dr. Maitland: In my opinion, never.
[LAUGHTER]
Catherine: I understand.
Dr. Maitland: The reason why I said that — all right, if most people don’t know this, the reason why they put certain decongestants behind the counter is they were made into amphetamines. OK? If anybody saw “Breaking Bad,” that’s what they were using. That medication is not good for you. Every once in a while it’s fine, but you want to make your you don’t have a history of stroke, arrhythmia, hypertension , because that can make things worse. And then also for women in childbearing years, that decongestant and good for the baby. — ain’t good for the baby. I prefer that you use medications that are safer, especially with people running around with conditions they don’t know. And then I can tell you the nasal decongestants, you can only use them for one or two days. I can’t tell you how many patients have to go on a 12-step down procedure to get off of their addiction to the nasal decongestants. It ends up causing another problem. If you are going to use the decongestants, be very mindful that you put yourself at risk. If you are going to use a decongestant, I would use the one that is not behind the counter, because it is less likely to be so stimulating. That’s another thing, it will interfere with your sleep. Taking 120 or 240 milligrams of pseudoephedrine, it’s crazy. Your blood pressure is going to be — and then the nasal decongestant, do the Sailing, you can use it for one or two days, but after that you need to stop. Otherwise you are going to be one that has a bottle on both sides of the bedstand, in your car, in your purse.
Catherine: I understand. Dr. Maitland, we are at the top of the hour. Thank you so much. This has been so informative. We have a few webinars coming up in September. First up is updates on a topic, dermatitis treatment options, September 18 at 12:00 p.m. Eastern standard Time. Then we will welcome Melissa page from the national Association for medication Access and patient advocacy to discuss the new medication Access coordinator training program on September 24 at noon. You are going to receive an email for Zoom in a few days with a link to the recording and an evaluation and supplemental resources. Thank you again for attending from all of us at allergy and asthma network come and join us as we work every day to breathe better together. Thank you very much. Have a good afternoon. Bye-bye.
