Skin Patch Immunotherapy for Allergy Cure

Over the years, there have been a variety of systems via which physicians and researchers have attempted to cure patients of their inhalant allergies.

These include (click here for a description of each):

• Allergy shots
• Under the tongue allergy drops (SLIT)
• Intra-Lymphatic Injections (ILIT)
• Allergy Tablets
• Epicutaneous Immunotherapy (EPIT)
• Intra-Nasal Spray
• Bronchial Inhalers

Well… we can now add skin patches to the list.

European researchers conducted a placebo-controlled, double-blinded trial involving 132 patients with grass pollen allergies. The patients were randomly divided into one of four groups: placebo, low-dose, medium-dose or high-dose patches. Patients applied six weekly patches prepared with grass allergens prior to and during the 2008 grass season and ALL reported improvement in their symptoms (30% in 2008) though one year later, there was a dose-dependent improvement with essentially no improvement in low-dose and placebo groups.

Unfortunately, higher-dose patches had higher rates of adverse events including pruritus, erythema, wheal, or eczema leading to an overall drop-out rate of 8.3% from the study.

This all may sound good and promising, but two of the study’s authors hold patents on patch-based immunotherapy which may lead to study bias.

My take? More study is needed…

Reference:
Epicutaneous allergen-specific immunotherapy ameliorates grass pollen–induced rhinoconjunctivitis: A double-blind, placebo-controlled dose escalation study. The Journal of Allergy and Clinical Immunology
Volume 129, Issue 1 , Pages 128-135, January 2012

Food Allergy Reaction Video

So the other day, I was watching the movie Hitchstarring Will Smith and Eva Mendes during which there is this one scene where Hitch suffers an allergic reaction from a food he ate during a dinner date. Watch video.

It’s actually a pretty good depiction of a reaction due to a food allergy.

However, given the throat-clearing suggesting airway swelling which extends to his face, he really should have called 911 as this not uncommonly leads to death if the airway swelling is severe enough to obstruct his breathing. Along with facial and airway swelling, his blood pressure probably dropped and his heart rate increased to point he could have passed out due to insufficient blood flow to the brain. Of course, it was a movie and none of that happened, but don’t think for a second that benadryl alone is adequate.

It is a little unusual for an adult to have a previously unknown food allergy with this severe a reaction in someone as old as Hitch, but not impossible.

Treatment was appropriately given with benadrylin the movie, but in reality Hitch additionally should have gone to the ER where epinephrine and steroids also would have been administered followed by several hours of observation.

After recovery, he should ALWAYS carry an epipen with him. He should also probably see an allergist to determine what it was he reacted to so that he can avoid it in the future.

On another note, in the movie, Hitch literally chugs down an entire bottle of liquid benadryl and acts drunk from it. That wouldn’t have happened… rather, he would have gotten extremely drowsy and fallen asleep fairly quickly.

http://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B005CPM23Qhttp://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B000I8G5C6

Laryngospasm and Vocal Cord Dysfunction Video

A new video has been uploaded showing what happens inside the throat when a patient suffering from laryngospasm or vocal cord dysfunction suffers from a breathing attack.

For more information on this condition, click here.

If you are unable to watch the video below, click here to watch it on YouTube.

Why Does the Nose Whistle in Some People?

Though most people like the professional nose whistler shown here require an instrument to enable the nose to whistle, in others it occurs naturally due to unique anatomic features within the nose.

Why might someone’s nose whistle?

Septal Perforation

The most common reason it may occur constantly is due to a hole in the septum (septal perforation). The septum is a wall that divides the right nasal cavity from the left side. Normally, it should be straight and without any openings.

However, when a hole is present in the septum and it is in just the right size and place, whenever air is breathed in and out the nose, it will whistle. In this situation, the hole is the “window” of the whistle and the nose itself is the mouthpiece.

Correction of this problem is by either closing the hole (septal button or surgery) or making it bigger such that the aerodynamics eliminate the conditions conducive to nasal whistling. As an FYI, surgical correction of a septal perforation is quite difficult.

Septal Deviation and Some Nasal Congestion

The other situation when the nose may whistle, but only intermittently, is when there is a deviated septum. In this scenario, the septum rather than being straight, it is slightly crooked to one side making one side more narrow than the other.

Add some slight swelling of the nasal lining such that the opening of the nose is restricted to just right size and shape, and it may whistle.

This type of nasal whistling is akin to grass whistling (blowing between two thumbs holding a blade of grass).

Thankfully, the nasal conditions that lead to nasal whistling is quite rare and requires the perfect storm of just the right amount of septal deviation with just the right amount of nasal congestion.

As such, correction of this problem is fairly easy as one needs to change either the congestion causing the nasal lining to swell with a nasal spray or anti-histamine OR fix the deviated septum. If the inferior turbinates are enlarged, they can be reduced in size as well.

Of course, one can take this unusual condition and make it a positive feature worthy of a concert hall… WITHOUT the assistance of any instrument!

Carbon Dioxide Helps with Nasal Allergies

MSNBC reported recently that a shot of carbon dioxide gas into the nose can help with allergies based on preliminary findings funded by Capnia, a company that makes the product.

Upside:
Symptoms of nasal allergies improved within 30 minutes.
No liquid is involved… just carbon dioxide gas.

Downside:
Lasts only 4 hours
80% has nasal discomfort after use
25% became teary eyed
14-20% developed headaches

My take?
I’ll pass on this drug… There are already good drugs with minimal side effects that lasts up to 24 hours already on the market .

Read the story here.

Of note, some readers may point out that there is an older study that had better results. With two one-minute carbon dioxide treatments into the nose resulted in symptom relief within 10 minutes and lasted for 24 hours. Even with these results, I’ll still pass… not sure how many people will go with 2 one-minute treatments when a 1 second swallow with an allergy pill or nasal spray use works just as good.

Reference:
Nasal carbon dioxide for the symptomatic treatment of perennial allergic rhinitis. Annals of Allergy, Asthma & Immunology – 19 August 2011 (10.1016/j.anai.2011.07.014)

Intranasal noninhaled carbon dioxide for the symptomatic relief treatment of seasonal allergic rhinitis. J Allergy Clin Immunol. Volume 121, Issue 1, Pages 105-109 (January 2008).

Kids Exposed to Fido or Fluffy in the First Year of Life Decreases Risk of Becoming Allergic to Them

There have been a number of studies in the past investigating whether it is healthy for a baby to be around pets and whether such exposure increases or decreases risk of becoming allergic to them later in life.

In a recent study (published online June 2011), the researchers found that among males, those with an indoor dog during the first year of life had half the risk of becoming allergic to dogs at age 18 compared with those who did not have an indoor dog in the first year of life regardless whether born by C-section or vaginally. Also, teens with an indoor cat in the first year of life also had a decreased risk of becoming allergic to cats. Neither cumulative exposure nor exposure at any other particular age was associated with either outcome. So it appears that the FIRST year of life is key to whether a child develops pet allergies or not.

Although in this study, cat and dog ownership appears to be beneficial in kids, prior studies have suggested that for at least cats, it increases risk of overall allergies in children by 13 times! Dog exposure, however, reduces overall allergy by 4 times.

Reference:
Lifetime dog and cat exposure and dog- and cat-specific sensitization at age 18 years. Clinical & Experimental Allergy Volume 41, Issue 7, pages 979–986, July 2011

Genetic and environmental risk factors for childhood eczema development and allergic sensitization in the CCAAPS cohort. J Invest Dermatol. 2010 Feb;130(2):430-7. Epub 2009 Sep 17

Opposing Effects of Cat and Dog Ownership and Allergic Sensitization on Eczema in an Atopic Birth Cohort. J Pediatr. 2011 Feb;158(2):265-71.e1-5.

Anti-Histamine Eye Drops

Allergies often cause eye symptoms of itching, swelling, redness, and tearing.

If other allergy symptoms are also present involving the nose and skin, it is best to try an oral anti-histamine as a first step.

This one oral drug may be able to resolve all these symptoms. As I am fond of telling patients, oral medications affect the whole body as the medication goes to the stomach after swallow, gets digested, and spreads to the big toe just as much as the skin, nose, and eyes.

However, if symptoms are limited to just the eye, it is best to use topical medications like eye drops rather than an oral medication which goes everywhere (where it is not needed).

There are in essence two anti-histamine eye drops available over-the-counter.

The first is the combination of naphazoline and pheniramine found in NaphCon-A and Visine-A (formerly called Ocuhist). Naphazoline is a decongestant that helps eliminate the red eyes whereas pheniramine is an anti-histamine to help eliminate itching. It can be used up to 4X per day for relief.

The other contains the active ingredient ketotifen and has 3 modes of action: anti-histamine, mast cell stabilizer, and eosinophil inhibition. All three actions in essence help resolve current as well as future allergy eye symptoms. It’s also why it can be used only twice a day opposed to 4X per day required with naphazoline/pheniramine.

There are three main brands of ketotifen that basically are the same thing:

- Zaditor

- Alaway

- Zyrtec Eye Drops

- Claritin Eye Drops

The “zyrtec” and “claritin” eye drops names are quite misleading in that the eye drops do NOT contain the same ingredient as that found in the oral medication by the same name.

Personally, I prefer ketotifen over naphazoline/pheniramine due to longer-lasting relief per use, 2X per day dosing, and less risk (glaucoma and hypertension specifically). Ketotifen can be used from the age of 3 years (age 6 years for the other).

Of course, if these eye drops don’t work, there are prescription antihistamine eye drops that work quite well including pataday/patanol (olopatadine), bepreve (bepotastine),  and lastacaft (alcaftadine). Of course, most insurance companies require trial of OTC eye drops first before they will authorize these prescriptions.

On a final note, there is one steroid nasal spray called Veramyst that has an FDA indication for eye allergies though I suspect all steroid nasal sprays can help similarly. As such, if a patient has only ocular and nasal allergy symptoms, it may be worth trying a steroid nasal spray, though I’m not sure how often this is practiced in reality.

http://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B004AI345Ghttp://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B001ET7D4Whttp://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B001G7PMU4http://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B001CCUC3U

Patients with Iodine or Seafood Allergy CAN Receive Contrast During CT Scans

It is a prevalent belief out in the medical (and lay public) community that patients with iodine or seafood allergy can not receive contrast when undergoing certain radiological tests like CT or MRI scans. The concern is that contrast contains minute amounts of free iodide and as such, IV administration of this material puts the patient at risk of a life-threatening anaphylactic reaction.

Contrast is often given in these tests as it traces out bloodflow enabling the physician to see organ and mass architecture much more clearly allowing for improved accuracy in seeing anything abnormal.

Well… rest assured that patients with iodine and seafood allergy CAN receive contrast without any significant increased risk of an allergic reaction as compared to other allergies.

In a large study encompassing 112,003 patients, only 5% had a reaction. The relative risk of a reaction in patients with seafood allergy was 3.0 compared with 2.9 for those with allergy to eggs, milk, or chocolate; 2.6 for those with allergy to fruit and strawberries; and 2.2 for those with asthma [7]. In other words, a seafood allergy increases the risk of a contrast reaction by about the same factor as does any other allergy. At least 85% of patients with seafood allergy receiving IV contrast material will not have an adverse reaction.

Reference:
Formation of potential antigens from radiographic contrast media. Acta Radiol 1987; 28:473-77
Immunologic basis for adverse reactions to radiographic contrast media. Acta Radial 1990; 31:605-612
Contrast media reactions: experimental evidence against the allergy theory. Br J Radiol 1984;57: 469-173
Adverse reactions to intravascularly administered contrast media. AJR 1975;24: 145-152

New and Only Over-The-Counter Anti-Histamine Nasal Spray

Up until now, there has been three anti-histamine nasal sprays in the United States market available only by prescription… Astelin, Astepro, and Patanase.

However, in May 2011, Meda Pharma announced a new anti-histamine nasal spray Rhinolast Allergy that is available over-the-counter.

The active ingredient is azelastine, the same one as found in the prescription nasal spray Astelin and Astepro.

Azelastine has a triple mode of action: anti-histamine effect, m,ast-cell stabilizing effect, and anti-inflammatory effect. Azelastine has a rapid onset of action of 15 minutes.

It can be used from the age of 5 years.

This nasal spray can be used in combination with other over-the-counter anti-histamines medications taken orally like zyrtec, claritin, allegra, and benadryl.

Read more about this new nasal spray here.

Read more about allergy medications in general here.

Generic Singulair Expected in August 2012

Why August 2012? That’s when the patent for singulair, an allergy and asthma medication, goes off-patent. Generic versions of singulair should be expected soon after the patent expires.

For those who don’t know… generic versions of medications are much cheaper than brand name medications, but contain the same active ingredient. Here’s a list of a few brand name medications relevant in the ENT world with generic names in parentheses.

Flonase (fluticasone)
Prilosec (omeprazole)
Prevacid (lansoprazole)
Claritin (loratidine)
Zyrtec (cetirizine)
Benadryl (diphenhydramine)