ENJOY THE WINTER. SPRING IS COMING.
Looking out the window and seeing snow fall, allergies may be out of sight and out of mind. However, in the Northeastern United States trees will start to bloom in about two months. For those of us allergic to tree pollen this can be a difficult time. Runny nose, sneezing and itchy eyes are more than a nuisance. Before you suffer, miss work or school, make a plan to beat spring allergies.
Step 1. Find out what you are allergic to. Different plants pollinate at different times. For example, birch trees pollinate early in the spring, as soon as mid-March. Grass pollens tend to peak later on, in the early summer.
Step 2. Track pollen counts and do your best to avoid pollen. Here are some tips:
- Pollen is spread by the wind and highest on dry, windy days
- Pollen is also highest in the morning hours (and late afternoon). Limit outdoor activity at dawn and dusk.
- Stay indoors as much as possible when pollen counts are at their peak.
- Keep windows closed at home and in the car. Use an air conditioner to filter the air. Clean or replace air-conditioning filters on a monthly basis with in use. Avoid using window fans that can draw pollens and molds into the house.
- Do not hang clothes outside to dry.
- Wear a pollen mask (such as a NIOSH-rated 95 filter mask) when mowing the lawn, raking leaves or gardening, and take appropriate medication beforehand.
- Wear glasses or sunglasses when outdoors to minimize the amount of pollen getting into your eyes.
- After completing activities, change your clothes to remove pollen. A shower or bath is even better.
Step 3. Start medications early. It is best to get ahead of your symptoms. As the season goes on, your body becomes more sensitive to pollen. This makes it harder to treat.
Step 4. Know your options. Allergy treatments can help reduce symptoms when taken daily (pills, sprays). Other treatments (drops, shots) can help lessen your allergies over time, giving you long lasting improvement and less need for medication.
See your allergist now, before it is too late.
Everyday in our office, we see people suffering with hives. They want to find out what is causing the hives and how to get rid of them. Sometimes the cause is obvious (i.e. a peanut two minutes before the outbreak) but more often there is no answer. The hives are random with no consistent trigger. These people are often diagnosed with Chronic Idiopathic Urticaria (CIU).
Chronic = lasting more than six weeks
Idiopathic = unexplained, spontaneous, random
Urticaria = hives: itchy, red or skin colored welts
- CIU is common. Over a lifetime, there is a 10-20% chance of one episode of hives. The prevalence of chronic hives (lasting 6 weeks or more) is 2%.
- CIU occurs most often between the ages of 20 and 40, affecting women more often than men.
- CIU is often associated with swelling (angioedema).
- Episodes of hives lasting for a short period may be due to allergy, for example, foods or medications. Very often we can make a definitive diagnosis.
- However, the cause for CHRONIC hives remains unknown. Chronic hives are due to poorly understood, non-allergic, immune abnormalities. The leading theory is that CIU is an autoimmune disease. This is when your immune system attacks healthy cells in your body. In this case your own allergy cells (mast cells and basophils) are the target. Evidence includes, a higher incidence of other autoimmune diseases (i.e. thyroid or Celiac disease) and positive allergy testing using a patient’s own (autologous) serum.
- Symptoms are often triggered by benign activities (ie showering), tight clothes, anxiety/stress, certain medications and possibly diet.
- Although we are able to get symptoms under control it often takes multiple medications. For those with difficult to treat hives, Xolair is often effective. However, there is no clear answer how long a patient will need to remain on therapy.
- CIU alone is rarely a sign of another underlying disease.
- CIU is rarely permanent but typically lasts from 1-5 years.
- CIU is not an allergic reaction and rarely puts the patient at any risk of anaphylaxis.
- CIU symptoms can be successfully managed.
Interesting articles from 2017 – SEARCH OF GOOGLE SCHOLAR
- Chronic hives have a significant impact on quality of life.
- Patient-reported impact of chronic urticaria compared with psoriasis in theUnited States. Meryl H. Mendelson, Jonathan A. Bernstein, Susan Gabriel, Maria-Magdalena Balp, Haijun Tian, Jeffrey Vietri & Mark Lebwohl. Journal of Dermatological Treatment Vol. 28, Iss. 3, 2017.
- Conclusion: Patients with chronic urticaria had impaired mental/physical health and work/non-work activities, similar to moderate-to-severe psoriasis patients. This analysis reflects the significant burden of chronic hives.
- Blood tests cannot diagnose chronic hives yet but there is progress.
- Potential blood biomarkers in chronic spontaneous urticaria. Clinical & Experimental Allergy. Volume 47, Issue 1. January 2017. Pages 19–36.
- Conclusion: We identified 10 biomarkers that are supported by strong evidence for distinguishing patients with chronic spontaneous hives from healthy controls, or for measuring chronic spontaneous hives activity. There is a need for further research to identify biomarkers that predict outcome or treatment response in chronic spontaneous urticaria.
- Testing may predict how fast Xolair works.
- Serum autoreactivity predicts time to response to omalizumab therapy in chronic spontaneous urticaria. Gericke, Janine et al. Journal of Allergy and Clinical Immunology, Volume 139, Issue 3, 1059 – 1061.e1
- Conclusion: A positive BHRA (basophil histamine release assay) and ASST (autologous serum skin test) is predictive of a slow response to omalizumab (Xolair).
- Testing may predict how fast hives recur after Xolair is stopped.
- Increased IgE levels are linked to faster relapse in patients with omalizumab-discontinued chronic spontaneous urticaria. Ertas, Ragip et al. Journal of Allergy and Clinical Immunology, Volume 140, Issue 6, 1749 – 1751.
- Conclusion: High IgE levels are linked to fast hives relapse after cessation of omalizumab (Xolair) treatment.
- More info how blood tests predict response to Xolair treatment.
- P154 Biomarkers which may predict response to omalizumab in chronic urticaria: serum IGE and CD203C. Straesser, M. et al. Annals of Allergy, Asthma & Immunology , Volume 119 , Issue 5, S39.
- Conclusions: Patients with chronic urticaria, normal-to-high serum IgE, and negative anti-FcεRI antibodies may respond better to treatment with omalizumab (Xolair). Conversely, those with low serum IgE and positive anti-FcεRI antibodies may respond better to traditional immune-modulator therapy.
- Patients with chronic hives often get misdiagnosed with multiple drug allergies.
- Underlying Chronic Urticaria in Patients With Multiple Drug Allergies: A Call For Screening. Oriel, Roxanne C; Innamorato, Amanda; Kaplan, Blanka M. Journal of Allergy and Clinical Immunology, suppl. S; St. Louis Vol. 139, Iss. 2, (Feb 01, 2017): AB43.
- Patients with chronic hives should be screened for drug allergy AND vice-versa.
- Low vitamin D levels are often found in patients with chronic hives.
- The Relationship Between Chronic Urticaria and Serum Vitamin D Level. Perez, Cecilia; Dozo, Gloria; Ferrero, Paola; Orellana, Julio; Muino, Juan Carlos. Journal of Allergy and Clinical Immunology, suppl. S; St. Louis Vol. 139, Iss. 2, (Feb 01, 2017): AB247.
- Conclusion: Patients with chronic hives should be screened for low vitamin D levels.
- Another antibiotic shows promise in a subset of patients with chronic hives.
- Patients with chronic cold urticaria may benefit from doxycycline therapy. British Journal of Dermatology. Volume 176, Issue 1. January 2017. Pages 259–261.
- Conclusion: In our study, 34% of patients with cold urticaria benefited from the treatment with doxycycline, with half of them showing full remission.
- Adding montelukast to levocetirizine may be better for a subset of patients, compared to doubling the dose of levocetirizine.
- Effectiveness and safety of levocetirizine 10 mg versus a combination of levocetirizine 5 mg and montelukast 10 mg in chronic urticaria resistant to levocetirizine 5 mg: A double-blind, randomized, controlled trial.
- Conclusion: Fifty-two patients on levocetirizine 10 mg group and 51 patients on levocetirizine 5 mg + montelukast 10 mg group were analyzed. Urticaria Activity Scores and Total Symptom Scores were reduced significantly in both treatment groups and reduction of score were comparable in between the groups (P = 0.628, P = 0.824, respectively). Among adverse effects, sedation was noted significantly more (P = 0.013) in levocetirizine 10 mg group. Quality of life was significantly improved in levocetirizine 5 mg + montelukast 10 mg group (P = 0.031).
- Genetics may predict your risk for chronic hives AND your response to treatment.
- Association of ORAI1 gene polymorphisms with chronic spontaneous urticaria and the efficacy of the nonsedating H1 antihistamine desloratadine. Li, Jie et al. Journal of Allergy and Clinical Immunology, Volume 139, Issue 4, 1386 – 1388.e9.
- Conclusion: ORAI1 gene SNPs rs12320939 and rs3741596 are associated with the risk of chronic spontaneous hives by genetic association study and functional study providing biologic plausibility. In addition, this study indicates that rs3741595 is associated with responsiveness to the nonsedating H1 antihistamine desloratadine.
- Novel treatment options are needed.
- Looking forward to new targeted treatments for chronic spontaneous urticaria. Emek Kocatürk, Marcus Maurer, Martin Metz and Clive Grattan. Clinical and Translational Allergy20177:1.
- Conclusion: Chronic spontaneous urticaria (CSU) is a chronic disabling inflammatory skin disease, which is in many cases well-controlled by the existing licensed treatment options. In approximately 1 of 5 CSU patients, these treatment options are not sufficient. Novel drugs are needed and are under development. Ligelizumab, PGD2 receptor antagonists, a topical Syk inhibitor, and canakinumab are promising candidates for future CSU treatment options and are currently being tested in clinical trials for their efficacy and safety in CSU. Substance P antagonists, DARPins, blockers of C5a/C5aR, therapies targeting IL-4, IL-5 and IL-13, and drugs that target inhibitory mast cell receptors should be tested in controlled CSU trials. Many other mediators and receptors are held to be of pathogenic relevance, and this should be explored in skin profiling studies and functional proof of concept studies.
Food allergies are challenging. The risk and fear of allergic reactions make life hard for children and parents. Unfortunately, food allergies are becoming more common and taking longer to outgrow. Oral Immunotherapy (OIT) is a new option that may help to keep your child safe while reducing anxiety, allowing your child to eat out or attend school with less worry.
OIT involves retraining the immune system to tolerate the allergic food (i.e. peanut or milk). This is done by feeding the food allergic person small amounts of the food. The amount increases slowly over time. As the dose goes up, so does the level of protection.
Working as a Nurse Practioner at the food allergy institute of Mount Sinai in NYC, allowed me to gain valuable experience and insights regarding OIT. Historically, food allergy treatment included strict avoidance and carrying emergency medications. That was it, do your best and wait. OIT is a novel option. Studies have shown OIT reduces allergic reactions from cross contamination and increase quality of life.
As the treatment is still new, there are uncertainties. It is currently unknown if OIT leads to long term tolerance and a ‘cure’ for food allergy. Or is the benefit only temporary. Optimal dosing protocols are still being worked out. Also, it is not clear which patients would benefit from addition of adjuvants, like Xolair or probiotics.
OIT can be a great option for some patients. It should only be done in an office that has the training and staff to safely navigate them through the process. The undertaking can be difficult and time consuming and there can be side effects. Despite the unknowns and risks, OIT can have a huge impact on reducing food allergy reactions and increasing quality of life. It can be a great option for families to be less afraid of cross contaminations and to gain the possibility of eventually outgrowing their allergy.
OIT has great potential and I am excited and hopeful to see further success.
Elizabeth (Beth) Strong is a board certified Family Nurse Practitioner. She completed her Bachelor of Science in Nursing at SUNY Buffalo and went on to earn her Masters of Science in Nursing at the University of Rochester. Beth learned world-class allergy care while working closely with and training under top researchers and experts. For the past eleven years, she worked through the Jaffe Food Allergy Institute at Mount Sinai in NYC. She treated patients with food allergies, eczema, seasonal allergies and asthma. She managed several clinical trials studying immunotherapies for food allergy and was highly integral in opening the Food Allergy Treatment and Research Center to treat food allergic patients with an advanced oral desensitization protocol. In her free time, Beth enjoys being outdoors and traveling. Most of all, she loves spending time with her husband and two young children.
The U.S. Food and Drug Administration is alerting consumers to Meridian Medical Technologies’ voluntary recall of 13 lots of Mylan’s EpiPen and EpiPen Jr (epinephrine injection) Auto-Injector products used for emergency treatment of severe allergic reactions. This recall is due to the potential that these devices may contain a defective part that may result in the devices’ failure to activate. The recalled product was manufactured by Meridian Medical Technologies and distributed by Mylan Specialty.
While the number of reported failures is small, EpiPen products that potentially contain a defective part are being recalled because of the potential for life-threatening risk if a severe allergic reaction goes untreated. Consumers should keep and use their current EpiPens if needed until they get a replacement. Consumers should contact Mylan at 800-796-9526 or firstname.lastname@example.org with any questions.
As stated on the product label, consumers should always seek emergency medical help right away after using their EpiPens, particularly if the device did not activate.
At this time, the 13 lots identified – distributed between Dec. 17, 2015, and July 1, 2016 – are the only EpiPen lots impacted by the U.S. recall. Consumers who have EpiPens from lots that are not included in this recall, do not need to replace their EpiPen prior to its expiration date.
|Product/Dosage||NDC Number||Lot Number||Expiration Date|
|EpiPen Jr Auto-Injector, 0.15 mg||49502-501-02||5GN767||April 2017|
|EpiPen Jr Auto-Injector, 0.15 mg||49502-501-02||5GN773||April 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||5GM631||April 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||5GM640||April 2017|
|EpiPen Jr Auto-Injector, 0.15 mg||49502-501-02||6GN215||September 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM082||September 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM072||September 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM081||September 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM088||October 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM199||October 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM091||October 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM198||October 2017|
|EpiPen Auto-Injector, 0.3 mg||49502-500-02||6GM087||October 2017|
The FDA asks health care professionals and consumers to report any adverse reactions or device malfunctions to the FDA’s MedWatch program, by:
- Completing and submitting the report online at www.fda.gov/medwatch/report.htm, or
- Downloading and completing the form, then submitting it via fax at 800-FDA-0178.
The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.
“Sanofi and Regeneron Pharmaceuticals, Inc. announced today that the U.S. Food and Drug Administration (FDA) approved Dupixent® (dupilumab) Injection, the first and only biologic medicine approved for the treatment of adults with moderate-to-severe atopic dermatitis (AD) whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable.”
After much anticipation, dupilumab becomes the first biologic approved for the treatment of atopic dermatitis (a form of eczema). Dupilumab is indicated for adults with moderate to severe eczema that are not well controlled with steroid creams or ointments. The current options for these patients are limited. Most often oral immunosuppressants, like prednisone or cyclosporine, are used. These medications may have several adverse effects. Dupilumab is a biologic that aims to more specifically target the underlying factors driving allergic inflammation. In this case it blocks the signals of two molecules, Il-4 and IL-13.
Approval was based on three studies. The results of these studies showed the medication to be effective for the majority of patients. Additionally, 36-38% of patients achieved clear to almost clear skin.
Dupilumab will come in a pre-filled syringe for self-administration, to be given by subcutaneous injection every other week. A loading dose in your physician’s office may be required.
The wholesale cost was reported $37,000 per year. However, the actual cost to patients is still unknown.
Future directions. Two studies are currently testing safety and effectiveness in children, 6 months to 11 years and 12 to 17 years of age. Other uses under investigation include asthma, nasal polyps and eosinophilic esophagitis.
If you do have atopic dermatitis that is not well controlled, speak to your allergy doctor to see if dupilumab is right for you.
Preventing allergy is a priority for both physicians and parents. There have been many studies attempting to lessen the risk of both food and environmental allergies.
Here are a few examples of possible interventions to decrease the risk of allergy;
- Frequent application of emollients (moisturizers) from birth.
- Breast feeding, hypoallergenic formulas, early introduction of foods.
- Avoiding pets OR adding more pets.
A study, started in 1990 and recently completed and accepted for publication, looked at fish oil supplementation in pregnancy*. Over 500 pregnant mothers were given supplements containing fish oil, olive oil or no oil. The hypothesis was that maternal supplementation with long chain n-3 polyunsaturated fatty acids (PUFAs) may have immunological effects on the developing fetus and decrease allergies and asthma. The children were evaluated when they reached 18 years of age.
The probability of having had asthma medication prescribed was significantly reduced in the fish oil group compared to the olive oil group (HR=0.54, 95% CI: 0.32-0.90, p=0.02). The probability of having had allergic rhinitis medication prescribed was also reduced in the fish oil group compared to the olive oil group (HR=0.70, 95% CI: 0.47-1.05, p=0.09), but the difference was not statistically significant. Self-reported information collected at age 18-19 years supported these findings.
Maternal supplementation with fish oil may have prophylactic potential for long-term prevention of offspring asthma.
Hansen S, Strøm M, Maslova E, Dahl R, Hoffmann HJ, Rytter D, Bech BH, Henriksen TB, Granström C, Halldorsson TI, Chavarro JE, Linneberg A, Olsen SF, Fish oil supplementation during pregnancy and allergic respiratory disease in the adult offspring, Journal of Allergy and Clinical Immunology (2016), doi: 10.1016/j.jaci.2016.02.042.