This webinar was recorded on March 14, 2024

Spring is on its way and that means sunnier days and allergies! Learn about ways that seasonal allergies may trigger asthma symptoms and how you can manage it.


  • Alice Hoyt, MD FAAAAI
    Hoyt Institute of Food Allergy

Dr. Hoyt is the Chief Allergist at the Hoyt Institute of Food Allergy in New Orleans, LA. She has been practicing academic, evidence-based medicine for over a decade. Dr. Hoyt is board certified in internal medicine, pediatrics and allergy & immunology. During her fellowship at the University of Virginia, Dr. Hoyt launched a now national allergy-focused non-profit organization, The Teal Schoolhouse supporting the Code Ana Program which teaches medical and non-medical school personnel and child care providers about medical emergencies.

At Vanderbilt University, Dr. Hoyt continued her food allergy-focused efforts before transitioning to Cleveland Clinic where she helped launch its Food Allergy Center of Excellence. Dr. Hoyt decided to bring her food allergy knowledge to families in her home state and launched the Hoyt Institute of Food Allergy. In addition to leading the institute, Dr. Hoyt hosts the top-ranked food allergy podcast Food Allergy and Your Kiddo and chairs Code Ana.

CE is not available for this webinar.

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.

Lynda Mitchell: Welcome to this afternoon’s webinar where we’re in for a real treat with Dr. Alice Hoyt here to talk to us about allergies and as but during the spring. We have a few housekeeping items that I’d like to start off with today’s program. First, all participants will be on mute for this webinar. We will be recording this webinar and we will be sharing the link to the recording and some other resources in a day or 2 after this webinar is concluded. Regardless, you can find all of our recorded webinars on the allergy asthma network. Dot org website. If you just go to our homepage, scroll down, you’ll see all the upcoming webinars and then links to the recordings. You can find all of our webinars on the asthma allergy website and you can find all of the upcoming webinars and links to the recordings that have preceded it. We have assistance available to use you can put in questions you may have in the questions box or any other questions you might have about technical assistance in the chat box. We will not be offering continuing education credits for this webinar but we have a significant of attendance available. We will try to add a link to the certificate in the chat box so you can try to access this during the presentation. Let’s get started.

Today’s topic is spring allergies and asthma. Spring is on its way. In this webinar we will learn about the ways seasonal allergies may trigger allergy symptoms and how you can manage that proactively. It is my pleasure to introduce doctor Alice Hoyt. He has been practicing academic medicine for over a decade. Dr. Hoyt’s Boyd certified in internal medicine. During her fellowship at the University of Virginia she launched a new and at the time national allergy focused nonprofit organization supporting the program which teaches medical and nonmedical school personnel and childcare providers about medical emergencies. Adventure about University she continued her food allergy focused efforts before transitioning to the Cleveland clinic where she helped launch the food allergy Center of excellence. She decided to bring her food allergy expertise to families in her home state of Louisiana and launched the Hoyt Institute of food allergy. She hosts a top-ranked food allergy podcasts and chairs the nonprofit organization. Dr. Hoyt was recently named practice champion of the year. Congratulations. I know that is a big deal and a big honor. With that I will hit it over to you to get started. Thank you so much.

Dr. Hoyt: Thank you, Lynda. I see someone is from Zachary, Louisiana. Thank you so much for having me. This is just such a perfect topic for right now and I was getting in my car and it is covered in pollen. I will go ahead and share my screen and we will get going. Are we good? Are we sharing the screen in a good way?

Lynda: I think you have to put it on slideshow format but it is working.

Dr. Hoyt: Thank you so much for having me today and for that wonderful introduction. Today we are talking about. I’m trying to move the zoom bar. You know how it is. We’ll be talking about allergies and asthma. Put what your interest is, are you a patient, or are you a parent or what type of health care professional, or something else and also put the name of your state and that will become relevant in a little bit. I wanted to start this presentation buys something that when I learned it as a fellow it was kind of a no-brainer but it has stuck with me and I love how Barry: and just last year — I love how Barrie Cohen took this and put it a beautiful quote. Untreated allergic rhinitis in children increases the risk for poor asthma control, increased asthma severity, and exacerbations. Let me say that again. “Untreated allergic Untreated allergic rhinitis and ultimately worsen asthma. That is why it is so important we are talking about this topic so we can respect those allergies. Sometimes I feel like the itchy, drippy, sneezy does not get the respect it deserves. If we can get that under control it helps our lungs.

After today’s session you will be able to do the following three things. Number one is you will define seasonal allergies and allergic at a summa. Number — and allergic asthma. You will be able to describe how these allergies impact asthma. Number three, you will be able to discuss management strategies for seasonal allergies and allergic asthma. This is important whether you are a patient or a provider or somewhere in between. Let’s start with a case. I think we all learn better if there is some sort of clinical case we are tuned into. Here is Daniel, a six-year-old boy from New Orleans who has no chronic medical issues and he will present to an allergist this time of year with the following symptoms. Ronnie, itchy nose, nasal congestion. His systems — his symptoms are worse in the spring and at his friends house. His friend has a cat. The allergic salute is present. The allergic salute, you see the arrows pointing, or you get a little line from your nose running so much you keep updating and it forms a little line. That is the allergic salute. He was seen by the allergist .

What is allergist — what is his diagnosis? Seasonal allergies. What are allergies? They can include runny nose, nasal congestion, itchy nose, sneezing, and also fatigue due to poor rest. Allergic conjunctivitis is allergic inflation of the eyes. Allergic rhino conjunctivitis is a mixture of those things. Look at how many people have this. 25.7% of adults and 18.9% of children have seasonal allergies. That is bonkers. That is a lot of people. When we think about seasonal allergies or allergic rhinitis in general, one of the questions I often get is how do you know it is allergies and not just a cold? The biggest component is the itch component. When you have seasonal allergies and you are being exposed to pollen, breathing that in, whichever pollen it is, when you breathe that in it activates your allergy cells, specifically mast cells. Those cells get activated and release histamine, a very itchy chemical. Your vessels open up and that is where the runny nose comes from. When you have that itchy, drippy, sneezy, that is allergies. What are common allergens in allergic rhinitis, whatever we want to call it. The allergen is a protein and binds to the allergen anti-bodies hanging out on the allergy cells. That binding triggers allergic information . Allergens can include pollen, mold, dust, dander, and cockroach. There we have a beautiful cockroach. Why I included the rainbow color poo poo is because the allergen of a dust mite is their poop, and I thought that was the loveliest way to depict that. If any comments come in and you want interrupt me feel three to do so — feel free to do so.

I love maps so I like having this depiction . Here we are in March. It is pi day, 3.14. In Louisiana we are having grass pollen already. We are welling into our tree pollens. You can see what type of pollens are we dealing with at one time of — there can be lots of different therapies. Some work better for lots of different people which is why it is important to have a board-certified allergist to talk you through which therapies could be best for you. The first type of therapy would be behavioral modification. Trying to avoid certain allergens. If you are outside with a lot of pollen, taking a shower, getting a lot of that off of you, especially if you’re doing yard work. Also using air filters. There filters remove allergens from the air. Avoidance can be pretty difficult. It is my job as an allergist to help my patients live their lives how they want to and I help control the allergies and that brings us into medications. Medications can be over the counter or there can be prescription medications. We can talk about nasal and eye rinses. Rinsing out our eyes, rinsing the pollens out of the eyes, rinsing the allergens out of our eyes and clearing our nose. One of the most important parts of our nose is it tries to stop allergens up — it tries to stop allergens here before it can go into our lungs. Rinsing our nose with stair I’ll water or saline, I like the sprays. That can help clear stuff out. Next, nasal steroid spray. Nasal steroid sprays are first-line treatments for allergic rhinitis. A lot of people think an anti-histamine is, but these steroid sprays are superpowerful. People are thinking how can a nasal spray be superpowerful. It is because it is a steroid, and the reason because it is a nasal spray’s steroids are incredibly potent at decreasing inflammation.

We know if you take story relates by mouth they can — if you take steroids by now they have a lot of bad side effects. They can affect your bones, they can affect your weight, they can affect your body, how your body looks, your attitude, your appetite. They can do pretty nasty things. It was super high tech and futuristic when steroids were put into a nasal spray. Then they go right to the side of the inflammation. I will take a moment to show you guys how to use the nasal spray by looking at this image on your screen. One of the downside of nasal sprays is the steroids are super potent. If you spare a steroid — if you spray steroid on the bone inside your nose, than it can cause a lot of irritation and even perforation and nosebleeds. When you use a nasal spray you can use it like this woman on the picture is using it when you’re not pointing it to the bone, you’re actually pointing it to the ear on that side. Pointing it more towards your right ear, not the middle. Some of the sprays are more of a mist and less of a squirt and those are the ones I recommend. Moving right along to oral and eyedropper antihistamines, they can also be very helpful with the receptor antagonists and also eyedrops that stabilize those allergy cells so they do not become activated. When they become activated is one the blood vessels get read and you have curing and it is itchy.

I also get questions about how do I know whether I have dry or allergies. Dry eye is more of a gritty eye and with dry eye you can have curing. One of the causes of dry eye is you get tears that have more water and not enough of the lubricant part so if you’re not lubricating you are eyes that is why you get the gritty part. Your tears are not doing that. That grittiness is very different than the itchiness that is felt when the allergy cells become activated. The third type of therapy we should talk about is subcutaneous immunotherapy. You are making changes to the immune system to grow tolerance to the allergens. Subcutaneous is allergy thoughts and sublingual is drops under the tongue. Let’s get back to Daniel. What we decided to do for his allergic rhinitis was start nasal rinses. He was on board with this. He is a six-year-old. We have to get him on board. The rinses with the saline mist to rinse out all of the yucky stuff — then the steroid is getting where it needs to go. We talked about doing an antihistamine and he can do that more as needed or do it for the first week while starting the nasal steroid spray because the nasal steroid spray is not an immediate fix. The immediate fix nasal sprays you want to stay away from because those cause immediate constriction. I cannot member the generic name. It causes immediate constriction to stop the runny nose. Then when it wears off you can get worse runny nose and you can become addicted to those types of nasal steroid sprays. We want to limit the use of those. Maybe put him on an antihistamine, non-drowsy anti-histamine, we do not see a use for those anymore because we have other antihistamines like Zyrtec, Claritin, Allegra, that can work very well. That can work very well without causing so much grogginess. Zyrtec can cause some grogginess but not as much as Benadryl. Some kids do not respond well to Benadryl and can have some rebound hyper in us. Also going down our list we have to counsel our patients on having vivid dreams. You can see how when I’m thinking about my treatment plan for a patient with seasonal allergies I am not just thinking what is the most potent medication I can use? I am thinking can the patient do this? If I have a patient who will not put anything up there knows I have to accept that and work with the family through shared decision-making and go through all of these options. I am thinking of what will best improve their quality of life while also treating their condition. That brings us down to SCIT, our shots, or SLIT, the sublingual therapy. What is nice about it is it is not shots. It might not be as potent. They teach the immune system to tolerate the allergen so in many cases if you are in allergy shots for three to five years, if you stop the allergy shot were tolerant to the allergen so you’re not eating nearly as much if any of the medications anymore. — you are not needing nearly as much or any of the medications anymore. Now let’s go into allergic asthma. I told you when you started that if we get the allergies under control that would really help the asthma.

What really is asthma? Asthma is kind of a catchall term for conditions that cause reversible airway obstruction. I say reversible because ultimately, if asthma persists without getting the condition under better control, that it can have less and less reversibility. In general asthma is reversible, meaning if someone has asthma they start wheezing and they can take a dilator and that will open up their airways. It is reversible. Asthma symptoms can include coughing, wheezing, chest tightness, shortness of breath. I do not want to underplay coughing as a symptom of asthma. I know a lot of families that sometimes do not realize their child is having an asthma flare until they are wheezing but they’ve been coughing for the last two days and suddenly they are wheezing and having worsening shortness of breath. Kids have asthma. What is allergic asthma? Allergic asthma is when an allergen is triggering the asthma. There are some forms of asthma — for my Pullin G colleagues to tease out that can differentiate what type of therapy I will prioritize for that patient — what type of therapies I will prioritize for my patient. Allergic asthma can also be triggered by viral infections like rhinovirus. Rhinovirus, for most people, for people who do not have asthma, is typically just the common cold or runny nose. Rhino meeting knows. And people who — rhino meeting nose. In people with mild asthma, if they get rhinovirus, they can have significant asthma exacerbation.

Asthma exacerbations are all too common. The national prevalence of asthma attacks — an asthma exacerbation to me indicates that a person’s asthma is not well-controlled and management does not need — needs to be stepped up. How can we prevent those asthma exacerbations? Most asthma exacerbations can be prevented if we have good control of the asthma. That sounds like a no-brainer statement. Of course if your asthma is well-controlled he will not have an exacerbation. Unless you get in the weeds talking with families about a patient’s asthma, you might not realize they are having breakthrough symptoms or are they — or they are having more severe asthma than what you think they do. That is why thinking about things like coughing at night is limited due to shortness of breath that you are not realizing. Controlling asthma should include these four things and this was in the Journal of asthma in practice in 2017. The first is patient education. I’ve talked so much about the importance of talking with families and for families to share all of the potential symptoms. I have had patients not realizing the coughing was a part of asthma. They thought it was just wheezing. Monitoring and of course pharmacological therapy. When we are thinking about asthma medications, we have a slew of medications. Inhaled short acting beta, basically albuterol or medications that open up those smooth muscles in the lungs. Inhaled steroids help palm down information in the lungs — as Lynda and I were talking about before we came on the session about a new medication that is an inhaled steroid that is short acting or there is albuterol. Then also allergen immunotherapies. I talked about shots for seasonal allergies but I also talk about allergy shots for asthma because if a patient has allergic asthma meaning they have asthma flared by seasonal allergens or a cat, whatever the case may be, if you teach your immune system to tolerate your allergens and if you calm down the allergic information .

Then moving into Biologics, there are seemingly a ton of them now. When I started in allergy there were not nearly this many. I remember when Xolair was just approved for children and we were able to start a little boy and it was life-changing for him. He had severe asthma. He had significant seasonal and perennial allergies and he loves soccer. He was not able to keep up with his friends and enjoy his soccer because he would get so out of breath and sneeze and cough and it would flare his asthma — we started him on Xolair and within months he was running around loving soccer and it was awesome. I want to take a minute and talk about smart therapy. Let’s be smart with asthma. I love on allergy asthma there is a beautiful article written on smart therapy and probably if you are a school nurse and you are tuning into the session or an allergy nurse or any health care provider, if you’ve not looked at this you should look at this article. Why I really like it is because it is written in a way that is very easy to understand and it makes so much sense and lays it all out.

What is smart therapy? Smart stands for single maintenance and reliever therapy. If you have asthma or you know someone who has asthma, you might know that someone might have one inhaler, they might have mild intermittent asthma and they might need albuterol every now and then. Or they might have moderate persistent asthma and they might have that albuterol inhaler. They might also have another inhaler or a disk where they might be on a biologic medication. That can get to be a lot. Having multiple inhalers can be one of the most confusing things. What smart therapy is is moving away from that two inhaler approach and using what we typically term a maintenance medication like Symbicort as a rescue. In this case with smart therapy, formoterol is a long acting fusion of albuterol, but what is nice about formoterol’s formoterol starts working quickly, just like albuterol starts working quickly. Just last longer. Why smart therapy is so nice is because you can get rid of your albuterol, just like you can get rid of your Benadryl, and just use your maintenance inhaler. This can be very helpful. This can help with adherence to the providers intended medical plan because it is not confusing. It is also adherence because you are more likely to have the medication with you. Anyone who has kids with asthma needs to know you need to have the medication with them because you never know when they will start having shortness of breath or coughing or a flare of their asthma. You want to have everything you need. As you see on the screen, if you have kids, that is not just the inhaler. It will also be the spacer and the mask. Using that spacer without the mouthpiece helps you get the medication you need into your lungs, as opposed to trying to use the inhaler and coordinate the breathe. That is too much. Use the spacer. It is much more effective. The medication will not be effective if you do not use it properly, but two if you do not have it at all. Smart therapy can simplify the asthma regimen. Also love that allergy and asthma network has this action plan. As somebody who sees lots of kids and kids who have asthma and want their school to be well informed and up-to-date on what their plan is should they start having any mild flare of asthma at school, I love that this asthma action plan is for smart therapy. You can find this on the allergy and asthma network website. If it is you, you still need this type of plan. It is easier if you ever written down plan from your doctor. It is nice to sit down with your doctor and do this. It is a way for me as opposed to the email from mom and passing it on. I like the closed loop of communication where we are going through each step of this to make sure everyone is well aware of what and why to use what medication. This is also very important. I call this a tangent on my podcast.

This is very important when we are thinking about the transition from the pediatric care model to the adult peer model. When he was a patient or a doctor — when you as a patient are talking through this and talking with a child, making sure they are understanding when and how to use their medications, that can start as early as preschool. Making sure they know that if they start feeling badly to ask for their medication. My daughter is three and she will ask for her medication when she feels like she needs it. We can teach kids to recognize symptoms and ask for help and start to know what will help them. A big plug for this type of action plan and this specific action plan for a health care provider. Now let’s fast-forward to Daniel seven years later. He is now 13 years old and he continues to have allergic rhinitis and he developed asthma four years ago. He presents for follow with his pediatrician, for he went to the ER recently for an asthma exacerbation on Easter. His medications include the combined inhaled steroid and as needed albuterol. This is not smart therapy. He just completed a steroid burst that he was given in the emergency room. He occasionally uses nasal steroid spray and he tried allergy shots is a busy dude, a munition, super involved in school. A total bummer. He had asthma exacerbation on Easter. That is not what he planned for spring breaks. What might be the primary reason for the inflammation. He lives in New Orleans. Here he is, the red circle circling the Louisiana. Easter this year, let’s say March and April. You can pinpoint what could be triggering his asthma. You also want to ask about any illnesses, has anyone else been sick, because this conclude us in to is the kid having rhinovirus or did they have RSV and is that tipping over there asthma here the allergens. That is no good down here.

To drive this point home, it is all one airway. Simply stated, allergic inflammation in the nose can trigger that information in the lungs. On the screen is a fancy scientific way to demonstrate that. There are complex mechanisms that do this. What treatments may work well for teenage Daniel? I want to go back to that quote we had at the beginning. Untreated allergic rhinitis in children increases the risk for poor asthma control, increased asthma severity, and exacerbations. One of the easiest things we can do for Daniel is to treat his allergies too. Let’s discuss that. Let’s discuss management strategies for seasonal allergies and allergic asthma. What really should we use? I love tables. Here is a nice table comparing what we use for allergic rhinitis, seasonal and perennial come and what we use for allergic asthma, severe, persistent, poorly controlled. For that allergic rhinitis, we can do the nasal saline rinse. Rinse all of the pollen out, all of the cockroach stuff, all of the cat dander, rinse it all out. Cap dander, for those who — cat and her reminds me of pigpen from peanuts. — cat dander reminds me of pigpen from peanuts with all of that stuff floating around. It is weaponized because it is all around as opposed to dog dander, which falls to the ground. It can be found in house dust. That cat, that is why you can tell if you’re allergic to cats you can tell if one of your friends has a cat and you have a sweater and start sneezing, is because they have been snuggling the cat. Now they have that cat dander crown all around them. You want to rinse all of this stuff out because you breathe it in. You can do that with the saline rinse. Whenever you doing any sort of nasal rinse, if you are using tapwater, you definitely want to have boiled the tapwater, let it cool before you use it to do rinses. You do not want to have a potential infection from that. Nasal steroid spray, he is only kind of using it sometimes. Allergy shots for him, maybe. Allergen avoidance, you cannot always avoid some of this stuff. That is for allergic rhinitis. Let’s think about allergic asthma. The smart therapy for him, he needs smart therapy. Maybe he would be interested in allergy shots. Then also potentially a biologic for him. I do not like to downplay any sort of emergency room visit for asthma, especially not — Daniel does not necessarily have food allergies. If Daniel did have food allergies, we want to be very mindful of those patients who have food allergies and asthma because if they were to have an accidental injection of an allergen — if they want to have asthma on top of that reaction puts them up for a bad outcome. Asthma is a risk factor for a bad outcome and people that have food allergies.

We want to look at him as comprehensively as possible and make a treatment plan that is going to be — that he is going to inherit these recommendations. Also that will best treat his conditions. OK. What if — bonus — Daniel told you that biting into fresh apples caused a tingly sensation in his mouth and he develops mild lip swelling? What could this be? This could be what is called oral allergy syndrome. Oral allergy syndrome is a type of pollen food allergy syndrome. Pollen food allergy syndrome is when you are allergic to a specific pollen, but that Pauline protein — but that pollen protein looks a lot like other food proteins so when you ingest the other food protein your body thinks you are ingesting the allergen and you have an allergic reaction. This is a supercool update or you can see if you are allergic to birch pollen, he is having sneezing at a time when trees are blooming so the tree pollen is floating through the air, he is breathing it in, triggering his seasonal allergies, it is not surprising that if he bites into a fresh apple that has proteins that look a lot like birch pollen he will have a local itchy, unpleasant sensation, and that the enzymes in his saliva and ultimately gastric juices sort of breakdown that protein enough where it is not causing anaphylaxis. Oral allergy syndrome is limited to the mouth and so you’re not having anaphylaxis from oral allergy syndrome. The treatment for oral allergy syndrome is to avoid the food, but really these people tend to like the foods that are triggering. Their reactions, since this is oral allergy syndrome you can allow them to continue to eat it or they can avoid it or they can cook the food where they can take an anti-histamine. There is not a double-blind placebo-controlled study, but patients have told me that swish and spit antihistamine can help pretty promptly. Wrapping up, you should now be able to define seasonal allergies and allergic asthma. Describe how allergies impact asthma. And discuss management strategies for seasonal allergies and asthma. I want to thank you all so much for having me. I love the allergy and asthma network. Their resources are fantastic. Here’s my social stuff. The next webinar will be insect venom and I will turn it back over to Lynda.

Lynda: Thank you. Just wonderful. I have a bunch of questions. Someone just asked for the link to your podcast. Can you put that up again?

Dr. Hoyt: “Food allergy and your kiddo.” We are on all of the podcast things.

Lynda: Can you explain mist versus spray and is one better than the other?

Dr. Hoyt: Mist versus spray, and I could just talk about the real names of the drugs?

Lynda: Here.

Dr. Hoyt: Sometimes with Dr. things they get funny about us using brand names. Basically when you go to the allergy I’ll — the allergy aisle is overwhelming. You can see Flonase, which is more of a green and white packaging, and then you can see Flonase missed which is blue-and-white packaging. Regular Flonase is more of a squirt and it has an interesting taste and smell to it and you can kind of feel it trickling down the back of your throat as opposed to mist, which is a very similar inhaled steroid so the medication is incredibly similar but it is more of a mist when you squeeze the device. It is more of a puff, a missed Clout in your nose. It does not have nearly the taste or smell thing going on. It stays more where you want it to go. We feel it is more effective because it is getting where it needs to be, staying where it needs to be, people are more likely to use it. People are more likely to use it because it is less abrasive. We find there are less adverse effects, less nosebleeds because it is more of a puff as opposed to a squirting steroid.

Lynda: I switched myself so I know what you are referring to. It stays where it is supposed to as opposed to running down.

Dr. Hoyt: Right.

Lynda: The next question was about nosebleeds but I think you address that. I don’t know if there’s anything else you want to say about avoiding nosebleeds.

Dr. Hoyt: Even though these medications are over-the-counter , talk with your allergist before starting one of these meds.

Lynda: We have a lot of school nurses on the zoom webinar today. I know you love school nurses. In terms of them supporting their students and the students families in terms of education or whatever, can you give some tips about what they could do as a school nurse to help kids who have allergic asthma and they know this is allergy season and they are suffering? I will let you take it from here.

Dr. Hoyt: A lot of families and a lot of health care professionals, internists, do not recognize how strong the connection is between seasonal allergies and asthma. If at any point you as a school nurse are calling a parent about an asthma exacerbation, wheezing, then definitely it is allergy season and seasonal allergies can trigger asthma. This might be time to consider what you are doing. Data shows getting the allergies under control can help the asthma that can put the bug in their ear to ask their doctor about that.

Dr. Hoyt: Thank you so much — Lynda: Thank you so much. Does a Xyzal cause drowsiness?

Dr. Hoyt: Only a few of them have the non-sedating label. I do not think Xyzal has the nonsedating label. It is less sedating, but it is non-sedating. It is the actual — I will have to check with the label says. Sometimes they change these things.

How long does — Lynda: How long to Symbicort take to work compared to other combination inhalers. If you can explain that to everyone?

Dr. Hoyt: Let me go back. I am sorry if Symbicort has for motor all in it. It will work pretty promptly regarding opening up the airways. It has the inhaled steroid so it will help calm inflammation. That is different than the long acting I have an Advair — if we are talking about how quickly will Symbicort open the airways compared to albuterol it is pretty equivalent. Advair does not have that equivalent. Advair is long-acting albuterol takes longer to work. That is why he did not want to use Advair for smart therapy because you will not get that rescue you get from albuterol or formoterol.

Lynda: Thank you. This was an interesting question. For kids that have exercise-induced bronchospasm’s, what to they do for needing to pretreat before exercising if they are using smart therapy. To they just use that or is there another way it is handled?

Dr. Hoyt: If you are limited to exercise-induced bronchospasm or exercise-induced asthma and you have no other asthma, then this is the time where you can consider continuing your albuterol or you can consider the new albuterol and steroid, but he really only get exercise-induced bronchospasm’s and are not thinking there is a lot of information there in your lungs, it is a different mechanism of action so you do not necessarily need that steroid. That comes to smart therapy like you need that steroid? Not necessarily. This is a time when you if you are dealing with exercise-induced bronchospasm’s, it is a great time to get back in and talk with your allergist and be very detailed about your symptoms, when your symptoms are. Also a lot of exercise and sports are in the spring, in the fall. Symptoms can change along the way. As he therapies come up, get plugged back in with your allergist and talk through is this a good treatment option for you?

Lynda: MEC. Dude — let me see. Do children need to watch their mouths after using albuterol. The nurse as she knows about steroids but what about albuterol?

Dr. Hoyt: The reason we like kids and adults to it rinse their mouths or brush their teeth after using an inhaled steroid is because the steroid — there can be residual steroid in the mouth and that can promote the developing of thrush and we do not want that. We do not see the same effects with albuterol because it does not have the steroid in it.

Lynda: Great. Our products like Nevada, Nettie Potts and other sinus products recommended to deal with allergic rhinitis?

Dr. Hoyt: Yes. My three-step, there is still an old Facebook video from when I was at Vanderbilt about this. Number one is rinse your nose out. Number three, the anti-histamine is third. Number one is rinsing your nose out. Doing the Nettie pot, you have to use terror I’ll water. Not just put water under the sink and do it because there is still a risk of severe infection if the water as any sort of bacteria in it. You want to use terror I’ll water and you can use those devices. Some people feel like those devices, like they are drowning in some people do not have the time to deal with the water. They want something they can take on the go. That is where those aerosol sprays — simply saline is the brand name to just spray a bunch of it in in the shower or over the sink and then you let it all come out and it helps get all of the yucky stuff out and get the pollen count, get the dander out. If the pollen and the dander are not there they will not keep triggering those allergy cells. You want to rinse that out and then you have a clean surface to then put that nasal steroid spray that then helps calm the inflammation. I think those types of devices, when used properly, can be helpful.

Lynda: You brought up the reference to Benadryl. A question is should we be staying away from Benadryl altogether or is it still recommended for allergy flareups when taking a daily med?

Dr. Hoyt: I do not see a need for Benadryl at all anymore. It served a good purpose before we had a longer acting and less sedating or nonsedating antihistamines. Now that we have medications that work just as well from anti-histamine standpoint without the adverse effects, I do not see a role for Benadryl. If you mean you are doing your nasal wrenches and on a nasal steroid and you’ve already taken a Zyrtec that day, can you take another Zyrtec if you are at your friend’s house and the cat is driving you crazy? You can take another Zyrtec. For chronic hives, we double does more than that sometimes for patients who have chronic hives for anti-histamines. Once you are getting into that type of significant symptomology and you need more advanced therapy and you need more help to help control the symptoms you want to customize your plan with your allergist.

Lynda: What has been your experience on getting smart therapy paid for by insurance? Has that been adopted as acceptable in the payment tiers for insurances or are you finding it is spotty?

Dr. Hoyt: The inhaler situation is ever-changing regardless of what your insurance is. Something can be approved today and it is not the next. I have not found significant issues with it. I am a more recent adopter. I have not heard my colleagues saying they are not getting that approved.

Lynda: We do a lot of advocacy and we have a link on website if we cannot afford your asthma medications. One is a link to the AstraZeneca website regarding Symbicort. We could include that in the follow-up email as well. One is on our website. You can scroll down and find Symbicort. I will try to put the link in the chat so you can see that as well. Let me see if I can find it.

Dr. Hoyt: The allergy asthma network website has so much very good information.

Lynda: Thank you for that. I really appreciate it. I should let everybody know we’re in the process of developing one-page handouts written at the grade five and six reading level on all sorts of topics regarding asthma, allergies, and related conditions. They will also be in Spanish. When we get them finished we will put them in our online store as free downloads so you can print them out and use them with your students or families so they can have that information readily available.

Dr. Hoyt: To go back to the school nurse question, that is a great way to get that information into the hands of parents.

Lynda: Thank you, Kris, he just put the link in the chat. — she just put the link in the chat. If you scroll down you’ll find information about Symbicort. I have seen someone posting I have seen a nasal antihistamines pray. How they factor into streaming — into treating allergic rhinitis?

Dr. Hoyt: Anti-histamine once it has been released by the allergy cell. That is why we do not say give anti-histamine if you are having anti-full access. There’s a lot more going on in into flexes than just histamine being released. Is the same thing in seasonal allergies. It is more than just the histamine. Using more than just an anti-will give you the best of fact and that is why the nasal steroid spray is the first line. That steroid columns all of the inflammation, not just the histamine.

Lynda: I will give you one last question. What is the deal if you treat allergic rhinitis and it helps with eye allergies .

Dr. Hoyt: That is a good question. You are calming down all of the inflammation up sometime some of the medication can traverse to help calm inflation. It calms down the allergy inflammation throughout.

Lynda: This was wonderful. I wish we had more time with you but we are at the top of the hour. I will quickly say thank you so much. And wonderful presentation.

Dr. Hoyt: Thank you all.

Lynda: We have two upcoming webinars for those who would like to join us on new non-May 2, we will have — on new on May 2 — at noon on May 2 we will have a doctor join us, and then we will have a doctor for venom allergy and insect sting allergies on March 21. They are both big experts in their fields so I hope you will join us. Thank you again Dr. Hoyt, it was wonderful having you. Hope to have you again sometime soon.

Dr. Hoyt: Thank you. Have a good one.