Hypoallergenic dog or marketing myth?

Dog allergies are very common, up to 20% of the population are affected. This has not limited the popularity and enjoyment of having a dog at home. The ASPCA estimates that 37-47% of all households in the United States have a dog. Patients with dog allergies may have upper respiratory symptoms (sneezing, runny nose, itchy eyes), lower respiratory symptoms (cough, wheezing) or even skin symptoms (itching, rash). An allergist can confirm dog allergy as the cause of these symptoms.

What’s next? What are the options? Removing the dog from the home is an option, but not very pleasing for the owners or their dogs. There are medications that can lessen symptoms. However, patients are looking for  other ideas. Suggestions have included, frequent washing, frequent vacuuming, putting air filters in the house and buying a “hypoallergenic dog.”

What is a “hypoallergnic dog?”  The substance produced by a dog, causing an allergy is an allergen. The word hypoallergenic means less likely to cause allergy. This implies that the dog would produce less allergen. As of today, there have been six identified dog allergens, named Can f 1, 2, 3, 4, 5 and 6. These proteins are found in hair, skin, dander (skin flakes), saliva and urine. Each allergen can be found in each type, or breed of dog. Can f 1 and 5 are considered major allergens, causing allergy in a large percentage of patients. However, patients can be allergic to any single allergen or any combination as well. Interestingly, Can f 5 is found only in male dog urine, suggesting that some patients may be allergic to male dogs only.

These proteins come off the dog and are found throughout the home. For example in carpets, couches and pillows. They can also be found in places without a dog. For example, in a classroom or on an airplane.

A Google search will recommend, if you have allergies buy a hypoallergenic dog. Dogs that do not shed or with wiry hair.

So is there such thing as a hypoallergenic dog? A dog breed that produces less allergen than other breeds? Is there anyone certifying or testing breeds to show that there are real benefits?

Here are a few studies that may answer these questions:

TITLE: Dog factor differences in Can f 1 allergen production. Allergy 2005.

CONCLUSIONS:

  • Allergen levels (Can f 1) were highest for Poodles (17) and Yorkshire Terriers (16) and lowest for the Labrador retriever (2).
  • Males produced less allergen than females.
  • There was no difference according to hair length or hormonal status.
  • Skin seborrhea caused higher allergen levels.

TITLE: Can f1 levels in hair and homes of different dog breeds: Lack of evidence to describe any dog breed as hypoallergenic. JACI 2012.

CONCLUSIONS: Allergen levels in hair and coat samples were higher in breeds considered hypoallergenic. Although there was a lot of variability between dogs of each breed. The amount of allergen in dust samples was similar for hypoallergenic and other breeds. Although certain dog breeds are described and marketed as being “hypoallergenic”, no evidence was found that these breeds are less allergenic.

TITLE: Dog allergen levels in homes with hypoallergenic compared with nonhypoallergenic dogs. American Journal of Rhinology & Allergy 2011.

CONCLUSIONS: Clinicians should advise patients that they cannot rely on breeds deemed to be “hypoallergnic” to in fact disperse less allergen in their environment.

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The evidence is pretty clear, at this time there is no “hypoallergenic” dog breed. Some dogs may produce more allergen than other dogs. Some people may be more allergic to one dog than other dogs. There is no consistency for which breed is best. Here are some tips for patients with dog allergy. Unfortunately, they are based more on common sense then scientific evidence.

Here is some more practical, but no better proven advice, for patients with dog allergies :

  • Choose a small dog. They will shed less dander.
  • Keep the dog out of the bedroom and other rooms in which you spend a lot of time.
  • Keep the dog out of the house. Remember, dogs may bring pollen or other allergens inside with them.
  • Bathe your dog weekly.
  • Remove carpet or other places dog dander may reside.
  • Get a cat.
  • MOST IMPORTANTLY: see an Allergist.

 

Generic Nasonex Now Available

Generic Nasonex will soon be available for allergy sufferers. Apotex, is a generic pharmaceutical company, based in Florida, has successfully gotten FDA approval of the generic Nasonex (mometasone furoate).

Generic Nasonex will still need a prescription. This is different than over the counter nasal steroid sprays that are available without a prescription from your doctor. There are currently 3 over the counter nasal steroid sprays available. Flonase, Nasocort and Rhinocort.

Flonase will go Over the Counter (OTC)

Nasocort is now Over the Counter (OTC)

Rhinocort OTC is now available

Many insurance companies are not covering any prescription nasal steroid sprays because others are available over the counter as we mentioned earlier. Although some patients seem to respond better to one more than another. Recently newer types of nasal steroid sprays have come on the market, Qnasl and Zetonna. These are nasal aerosol sprays that are not in a liquid form, so patients do not get the post nasal drip symptoms.

Generic Nasonex likely won’t be as cost prohibitive as the branded version of Nasonex, making it more affordable for patients. Nasonex is the only nasal steroid spray that has an indication for nasal polyps.

Seasonal and perennial allergic rhinitis is a major problem in the United States. Many allergy sufferers are allergic to allergens such as tree pollen, grass pollen, weed pollen, dust mites, cat dander, dog dander and molds. First line treatment for nasal congestion symptoms are nasal steroid sprays such as Nasonex. Generic Nasonex will be very helpful to many patients who did not insurance coverage for the branded version Nasonex, although it remains to be seen if insurance carriers will cover generic Nasonex or they still may say the patient will have to try over the counter versions of nasal steroid sprays such as Flonase, Nasocort or Rhinocort.

Update: Oralair approved for grass pollen allergy

The FDA has approved the first product for oral immunotherapy! 

Oralair is a tablet containing five grass allergens; Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass. It is manufactured by Stallergenes, a French pharmaceutical company. It will be marketed and sold in the United States by Greer Laboratories.

Allergy immunotherapy is the most effective treatment for environmental (and possibly food) allergies. It is all natural, containing only the allergens you are allergic to, and the only treatment that prevents disease. Immunotherapy can be given as a shot, drop or tablet.

It is no surprise that our first [glossary slug=’sublingual’]sublingual[/glossary] option is coming out of Europe. For many years, allergists in Europe have chosen the sublingual route rahter than subcutaneous (shots). There are other differences in the way allergies are treated here and abroad. Most sublingual products contain only one allergen. For example, grass pollen. However, up to 40% of patients have allergy to more than one substance. Allergists in the United States attempt to treat as many of the patient’s allergies as they can, administering a mix of several allergens in shot form. For example, grass pollen plus dust mites. Here is a more complete discussion, see this article (Allergy Tablet Approval Warrants Caution for Some).

It is not clear which method is better, one allergen or many. Probably there is no one right answer that would apply to everyone. The same is true in the debate, shots vs. drops/tablets. Shots are more effective but drops/tablets are more convenient. In the end, the approval of ORALAIR provides an additional treatment option for allergy specialists and their patients. If more patients get treatment then we all benefit.

UPDATE (2): TOO LATE FOR 2013

For best results, Oralair should be started 2 months prior to the grass pollen season. In the northeast, May and June are the months with peak grass pollen levels. If Oralair is available this May then it would be too late for 2013.

PRESS RELEASE (excerpts):

– Grass allergy is the most common seasonal allergy in the United States and most people are allergic to more than one type of grass. ORALAIR contains a mix of five grass pollens: Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass. The five grass pollens contained in ORALAIR represent those to which most patients in the U.S. are exposed.

– ORALAIR is indicated as immunotherapy for the treatment of grass pollen-induced allergic rhinitis with or without conjunctivitis confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies for any of the five grass species contained in this product. ORALAIR is approved for use in persons 10 through 65 years of age.

– ORALAIR is a tablet that dissolves under the tongue. The first dose is taken in the doctor’s office under medical supervision, and subsequent doses are administered once a day by the patient or the patient’s caregiver. ORALAIR treatment should be started four months before the expected onset of each grass pollen season and continued throughout the season. Allergy symptoms are reduced beginning with the first grass pollen season.

– ORALAIR was originally approved in Europe in 2008 and is currently authorized in 31 countries around the world, including most European countries, Canada, Australia, and Russia for the treatment of grass pollen allergy. In Canada, ORALAIR was launched in 2012, making it the first allergy immunotherapy tablet to be registered and marketed in North America. Worldwide post-marketing experience with ORALAIR includes more than 20 million doses given to more than 110,000 patients.

– ORALAIR has been approved based on results from an extensive clinical development program. ORALAIR has been studied in double-blind, placebo-controlled trials, in both Europe and the United States in over 2,500 adults and children. The results of these trials demonstrated that pre-seasonal and co-seasonal treatment reduces patients’ allergy symptoms and their need for symptom-relieving medication. In the clinical development program, the most common adverse reactions for ORALAIR (reported in >=5% of patients) were oral pruritus, throat irritation, ear pruritus, mouth edema, tongue pruritus, cough, and oropharyngeal pain.

Stress & Allergy

It is clear to those suffering, allergies cause stress. Constant runny nose, decreased quality of sleep, missed days at school and work are among the many reasons why. A new study from Ohio State University* flips this conclusion on its head and asks; can stress cause allergies?

Our bodies immune system is not limited to the nose. It involves organs and cells throughout the body. The inflammatory chemicals produced during an allergic reaction can have wide ranging effects. Likewise, the endocrine system will respond to stress by increasing (or decreasing) hormone levels throughout the body. These two systems do not live in isolation.

In this study, subjects were asked to complete daily diaries. They recorded allergy symptoms, mood and stress levels using a secure website. The data showed that patients with higher stress scores experienced more allergy flares. Also, there was a similar relationship between negative mood and rhinitis symptoms. For most patients, the effect was spread out over time, a stressful day did not occur together with a bad allergy day. However, for a few more sensitive subjects there was a pattern of increased allergy symptoms on stressful days.

The authors conclude that allergic individuals with persistent emotional stress have more frequent allergy symptoms. They recommend stress reduction techneques, such as meditation for the treatment of allergy symptoms. However, it should be noted, this study does not prove cause and effect. There is no evidence that the stress causes the allergy as opposed to the allergy causing the stress. Either way, stress-reduction is a good thing.

 

* Patterson A, Yildiz V, Klatt M, Malarkey W. Perceived stress predicts allergy flares. Ann Allergy Asthma Immunol 112 (2014) 317-321.

Allergy shots, a new source of savings

dollar_icon

dollar_iconAllergies are common and costly. Total costs are in the billions. An increasing proportion of this number is being shifted to the patient, in the form of higher copays and deductibles. The price of health care is now a real part of our health care conversation.

When choosing the most appropriate allergy treatment, doctors and patients should consider efficacy, side effects and cost. The most common treatment options for allergy patients are:

1. Avoidance

2. Medications

3. Immunotherapy (also know as allergy shots)

It is well established that allergy shots provide the most relief but are they worth the cost? A recent study* used an advanced computer model to address this question.  They considered these factors most important in making a decision:

  • patient age
  • life expectancy
  • number of months per year medications are required
  • cost of medications
  • number of allergies
  • duration of immunotherapy (3 vs 5 years)

A virtual allergy patient was put through economic analysis. He was doing well using an intra-nasal steroid, the gold standard in treatment. Unfortunately, nasal sprays do not alter the course of the disease, symptoms recur shortly after they are discontinued. There is no endpoint for the patient.  On the other hand, immunotherapy can induce long term tolerance after only 3-5 years of therapy. This means that the benefits will continue long after your shots are finished. Despite this advantage, allergy shots are usually reserved for patients who fail medical therapy. Economically, younger patients would be better off with 3-5 years of shots, not a lifetime of nasal steroids.

cost_chart

 

 

 

 

 

 

 

 

The attached figure demonstrates a large area where immunotherapy is more cost effective than medical therapy. It must be noted, this figure only represents those patients that are doing well on nasal sprays.  For patients who continue to have symptoms despite medications, the decision would be shifted heavily in favor of allergy shots.

 

* Kennedy J, Robinson D, Christophel J, Borish L, Payne S. Decision-making analysis for allergen immunotherapy versus nasal steroids in the treatment of nasal steroid‐responsive allergic rhinitis. American Journal of Rhinology & Allergy.  2014; 28(1) 59-64.

Probiotics for the prevention and treatment of allergies

 Probiotics are defined as live microorganisms which when administered in adequate amounts confer a health benefit (FAO/WHO 2002). The potential benefits include inhibition of pathogens, improved integrity of the gastrointestinal (GI) barrier and enhanced immune responses. These effects may be useful for the prevention and treatment of multiple allergic conditions.

Rationale:

– Allergies occur more in developed nations. The hygiene hypothesis states that a highly sanitized environment provides insufficient bacterial stimulation at a young age. Without proper ‘training’ the immune system is unable to distinguish harmful bacteria from healthy foods (tolerance).

– As we get older, the GI associated immune system continues to play an important role. Unfortunately, the composition of gut microbiota can be altered by diet, stress, aging, antibiotics or infection.

– The composition and diversity of intestinal microbiota varies in allergic versus non-allergic children.

– Children born via vaginal delivery are less likely to have allergies than those children born via c-section. Exposure to beneficial bacteria in the maternal vaginal tract helps to colonize the child. Also, this benefit may occur in those children who are  breast fed.

Evidence:

– The effectiveness of probiotics for the prevention and treatment of allergies is controversial. There are a large number of published studies with a wide range of results. Several studies show a great benefit and several studies show no benefit at all.

– The variable results are likely the result of variable protocols. The strain of bacteria, the amount of bacteria and the age of the patient are important factors in determining outcome. It is likely that different strains produce different immunologic effects leading to different outcomes. One probiotic may help asthma and another may help eczema. Examples of beneficial probiotics include, Lactobacillus rhamnosus HN001 and Bifidobacterium longum BB536.

– Eczema (atopic dermatitis). Probiotics have shown value for preventing eczema when given to expecting mothers. Probiotics have shown value for treating eczema when given to young children.

– Allergic rhinitis (sneezing). Several studies from Japan have shown decreased allergy symptoms for patients with tree pollen allergy.

– Food allergy. Infant formulas supplemented with probiotics may improve the symptoms of milk allergic colitis. Unfortunately, supplementation did not accelerate cow’s milk tolerance in those infants with milk allergy.

Conclusion:

Probiotics may be a useful adjunct in the fight against allergic disease. They provide a natural way to stimulate the immune system. Most importantly, proper timing may prevent future allergies. Further research is needed to determine which strains are useful and when they should be taken.

FDA committee supports approval of two new sublingual allergy tablets

tabletsLast week, the FDA Allergenic Products Advisory Committee unanimously supported approval for two new sublingual allergy tablets (Oralair and Grastek).  Allergy tablets are an alternative to conventional allergy shots. Both tablets are indicated for the treatment of grass pollen allergy. Oralair is made by a French pharmaceutical company Stallergenes and contains 5 different grasses: Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass. Grastek (aka Grazax in Europe) is made by ALK-Abello and Merck and contains only Timothy Grass.  Although both tablets are available in Europe, FDA approval may not occur for a year or more.

For more than a century, physicians have been using the process of desensitization to treat environmental allergies. Introducing small amounts of allergen (i.e. dust mites, pollens) over and over again, helps to re-educate the immune system. Using current dosing regimens, the results are impressive. Large analyses show a decrease in allergy and asthma symptoms of ~ 75%. Other benefits include a decreased need for medications (60%) and decreased risk of developing new allergies or asthma. Unfortunately, these results require commitment and frequent office visits.

Which is better, allergy tablets or shots? 

1. Effectiveness. There have been few good studies comparing allergy tablets (or drops) with shots. Looking at placebo controlled trials (comparing treatment with a ‘fake’ injection or tablet), allergy shots appear to provide higher levels of relief.

Winner: shots.

2. Convenience. Each and every allergy shot must be given in the allergist’s office.  Although the first dose is given at the allergist’s office, allergy tablets are continued at home.

Winner: tablets.

3. Flexibility.  Those tablets currently available (in Europe) contain only single allergens, such as for grass. Other tablets in development include ragweed or dust mites. Allergy shots are customized by allergists to contain multiple allergens, such as for trees, grasses, weeds, dust mites, animal danders and/or molds.

Winner: shots.

4. Compliance. Without completing a recommended course of allergy tablets or shots, patients will not get their optimal result. Unfortunately, neither treatment route has demonstrated a high completion rate. A recent study from the Netherlands  found that only 7% of those getting allergy tablets (or drops) completed the recommended three years of treatment. Surprisingly, that was even worse than the 23% of patients getting allergy shots. One possible reason, allergy shots may be spread out to once monthly versus daily use of allergy tablets.

Winner: neither.

5. Cost. Producing a high quality allergy tablet (or drop) requires significantly higher amounts of material than allergy shots. However, there are less associated costs, i.e. office visits and injections. Unfortunately, an accurate comparison is not possible at this time, until allergy tablets are approved by the FDA, there is no insurance coverage.

Winner: unknown.

6. Safety. Both tablets and shots are well tolerated. Both have the potential to cause local reactions, either an itchy mouth or an itchy harm. Both have the potential to cause systemic (more severe) reactions. Although the risk is low, it is definitely higher with shots (compared to tablets).

Winners: tablets.

6. Conclusion. The best allergy treatment is one that works quickly and lasts forever. Allergy tablets, drops and shots will continue to get better. For example, four doses of an investigational cat vaccine, given over 12 weeks, had a significant improvement in symptoms two years later. Stay tuned.

 

Dust Mite Avoidance

broomOne in four Americans are sensitive to dust mites. If we include other components of house dust (pollens, animal danders, cockroaches and molds), the number is even higher.

Dust mites are arachnids, like spiders and ticks. They thrive in warm, humid climates; temperatures above 70 degrees Fahrenheit and humidity over 70%. Mites live off water in the air and ingest particles of human skin and animal dander. This is why the concentrations are so high in your mattress and bedding. However, dust mites are not bed bugs, they do not bite nor carry disease. Mites are only harmful to those people who are allergic. Dust mite allergy can result in several allergic conditions:

1. Allergic rhinitis: runny nose, congestion, sneezing and itching.

2. Asthma: cough, wheezing, shortness of breath.

3. Atopic dermatitis: eczema, itching.

People who are allergic to dust mites react to proteins within the bodies and feces of the mites. These particles are found mostly in pillow, mattresses, carpeting and upholstered furniture. They float in the air when anyone vacuums, walks on a carpet or disturbs bedding, but settle out of the air soon after the disturbance is over.

Research has confirmed that targeted avoidance (environmental control aimed at relevant triggers) can be as effective as medications in reducing symptoms. Here are some tips:

• Focus on reducing dust mite levels in the bedroom. Keep indoor humidity below 50%. This may require a dehumidifier. Do not use vaporizers or humidifiers. Use ventilation fans in bathrooms and kitchen. Use a vacuum with a HEPA filter. If you are allergic, wear a N95 filter mask while dusting, sweeping or vacuuming. Even better, find someone else to clean when you are not at home.

◦ Encase mattresses and pillow with ‘mite-proof’ covers.

◦ Wash all bed linens weekly using hot water ( > 130°).

◦ Remove wall-to-wall carpets.

◦ Remove plants, soft toys, cushions and upholstered furniture.

◦ Treat stuffed animals with fire and ice: Dust mites die at freezing temperatures. Put pillows and children’s stuffed animals in plastic bags and put them in the freezer for 24 hours. Alternatively, put toys in a fabric bag and place them in the dryer for 10 minutes. Remember to take off anything that could melt.

• Acaracidal sprays (i.e. tannic acid) can temporarily reduce mite levels in airborne, furniture and carpet dust. Application of liquid nitrogen to the mattress and carpets is slightly more effective and much more dangerous.

• Install a high efficiency media filter with a MERV rating of 11 or 12 in the furnace and air-conditioning unit. Change the filter at least every three months (with the change of the seasons).

• Portable HEPA filter air-cleaners are less effective at reducing dust mite levels. This intervention may be worthwhile for pet allergy (esp. cats).

There are more than 30 trials demonstrating the effectiveness of bed encasings for asthma. Financially, the one time cost is significantly less than a monthly copay. Unfortunately, the clinical benefit of covers alone was small. A complete program, including acaricides and extensive bedroom based environmental control is necessary. Benefits include decreased allergy and asthma symptoms, less medications and more savings.