Spring 2020 is here. After a mild winter in the Northeast, high pollen levels are expected. How will the Coronavirus (COVID-19) impact the allergy season?
The majority of Tri-state area residents are quarantined in their homes. However, social distance rules are not enough to keep them indoors. To relieve stress and confinement, people are increasingly heading outdoors. Walking, running and biking, families are filling streets, parks and trails. Sneezing and itching are sure to follow. Don’t head back inside, get help.
At my office we are trying to balance the health and safety of our patients and our staff. We have temporarily limited hours and in-office visit types. However, we continue important treatments for those in need. This includes injectable medications for chronic hives or asthma, oral immunotherapy for children with peanut allergy and allergy shots for pollens, pets, dust and molds.
For those patients who cannot be seen in the office we are now offering Telehealth visits. It is amazing how much can be done over a Zoom meeting. Here are a few accomplishments this week;
- Optimized medications and provided much needed refills for patients with asthma.
- Treated eczema with an iPhone.
- Helped patients with immunodeficiency minimize their risk of COVID infection.
In the next month, I am expecting many calls from patients suffering with spring allergies. Telehealth is a great way to help. A typical discussion may include the following;
- Current symptoms; timing, severity.
- Current and past medications.
- Associated conditions (ie asthma, fruit allergy).
- Avoidance advice.
- Review of the most appropriate and effective treatment options; including over-the-counter medications, prescription medications, sublingual drops or tablets and allergy shots.
Do you know which common allergy symptoms are not treated by Claritin, Zyrtec or Allegra? Schedule a Telehealth visit to find out, 203-374-6103.
[3/24/2020] FDA is alerting patients, caregivers and health care professionals that EpiPen 0.3mg and EpiPen Jr 0.15mg auto-injectors, and the authorized generic versions, may potentially have delayed injection or be prevented from properly injecting due to:
- Device failure from spontaneous activation caused by using sideways force to remove the blue safety release
- Device failure from inadvertent or spontaneous activation due to a raised blue safety release
- Difficulty removing the device from the carrier tube
- User errors
In a letter to health care professionals from Pfizer, the manufacturer of the EpiPen, and Mylan, detailed how these devices may activate prematurely if the blue safety release is removed using a sideway force. For example, a user may try to hold a device with only one hand and try to remove the blue safety release with their thumb in a sideways force. Prior to use, the blue safety release should be removed by pulling straight up with one hand and holding the device with the other hand.
A very limited number of EpiPen devices also may have a blue safety release that is slightly raised. If the blue safety release is raised, the device may activate prematurely, which could potentially delay or prevent emergency treatment when needed.
Additionally, in some cases EpiPen devices may not slide out of their carrier tube easily, or potentially at all, due to a slight deformation on the rim of the carrier tube. The carrier tube is the immediate package in which the auto-injector is contained. In some cases, the patient or caregiver may not be able to quickly remove the auto-injector from the carrier tube.
The letter also describes specific user errors that can delay or prevent the administration of the intended dose of epinephrine. For example:
- The device will not activate if the blue safety release is in place
- Ensure the needle end (orange end of the device) is in contact with the outer thigh (upper leg) prior to and during activation. The EpiPen device should be administered by swinging and pushing firmly against the outer thigh until it “clicks.” This signals that injection has started.
- Ensure the device is held in place for a minimum of three seconds following activation.
It is important for health care providers, patients and caregivers to periodically review the EpiPen user instructions and practice using the EpiPen trainer to ensure proper understanding and utilization of the EpiPen auto-injector.
It is vital for lifesaving products to work as designed in an emergency situation, and patients and caregivers should inspect their epinephrine auto-injector prior to needing it to ensure the blue safety release is not raised and that the device can be easily removed from the carrier tube.
Patients should contact Mylan Customer Relations at 800-796-9526 if they find an issue with their auto-injector and to obtain a replacement at no additional cost. Pharmacists should inspect the products before dispensing them to patients to ensure quick access to the auto-injector and should not dispense any product which does not easily slide out of its carrier tube or has a raised blue safety release. As stated on the product label, consumers should always seek emergency medical help right away after using their epinephrine auto-injector.
FDA is aware of adverse event reports associated with EpiPen products. FDA asks health care professionals and consumers to report any adverse reactions or quality problems to the FDA’s MedWatch program.
||fatigue, body aches|
||shortness of breath**|
||travel or exposure|
* Viral infections include influenza and coronavirus.
** Overlapping symptom of asthma and viral infection.
Beware the Ides of March, as tree buds appear, temperatures rise and winter hibernation ends.
Connecticut’s spring pollen season typically begins in mid-March. However, this week we will seeing temperatures in the 40s and 50s. This warm weather should bring an early start to the pollen season.
Why so early? Global changes in climate may be to blame. Here are a few reasons why:
- With increasing temperatures there are more days above freezing, leading to a longer allergy season. Per climatecentral.org the growing season in Hartford, CT has increased by 18.4 days from 1970 to 2018.
- Increasing levels of CO2 (aka plant food), produce increasing quantities of plants and plant pollens. For example, higher ragweed biomass and ragweed pollen levels. Not only do numbers rise but pollens become stronger (more potent or allergenic). This has been demonstrated for grass pollens as well as mold spores (Aspergillus fumigatus).
Spring season is upon us, be prepared.
Spring is in the air and that means pollen, mold spores and other airborne allergens are going to bring on sneezing and wheezing for an estimated 50 million Americans.
The spring season can be especially bothersome with so much conflicting information on how to find relief. To help you better understand spring allergies and combat symptoms this sneezing season, the American College of Allergy, Asthma and Immunology (ACAAI), has answered some of the most frequently asked questions.
1. Why does it seem like more and more people have spring allergies?This is likely due to increased awareness and more people taking the steps to being properly tested and diagnosed. According to a recent study published in the Annals of Allergy, Asthma and Immunology, pollen counts are gradually increasing every year, which can cause heightened symptoms.
2. Do spring allergy symptoms only last during the spring months?The length of the season can help determine the severity of symptoms. For many areas of the country, spring allergies begin in February and last until the early summer. Mild winter temperatures can cause plants to pollenate early. A rainy spring can also promote rapid plant growth and lead to an increase in mold, causing symptoms to last well into the fall months. Allergists recommend starting medications to alleviate symptoms two weeks before they begin. If you have a history of prior seasonal problems, start your medication at the first sign of any symptoms.
3. Will eating local honey cure allergies?A common myth is that eating a spoonful of local honey a day can build allergy immunity. The idea is that bees pick up pollen spores from flowers, transfer them to their honey and help you better tolerate pollen. Seasonal allergies are usually triggered by windborne pollen, not pollen spread by insects. There is no scientific evidence that honey will provide any benefit or reduce allergy symptoms. Your best bet? Talk to your allergist about ways to avoid allergy triggers, the best medications to treat symptoms and whether immunotherapy (allergy shots) could be beneficial.
4. Is there such a thing as spring asthma?Allergies and asthma are often worse during different times of the year due to environmental allergens. An estimated 75 to 85 percent of asthma patients have allergies. These allergic responses in the lung can lead to symptoms of asthma. If you have spring allergies, this can be why you have more asthma symptoms during the season. Those that believe they may have symptoms of nasal allergy or asthma can find a free screening program in their area by visiting www.acaai.org/nasp.
5. Can you suddenly develop seasonal allergies in adulthood?Yes. Although allergies are common in children, they can occur at any time and any age. Sometimes allergies go away, but they also can come back years later. If you suspect you have an allergy, you should keep track of your symptoms with MyNasalAllergyJournal.org and see an allergist to find relief.
By understanding what allergens trigger your symptoms and how to avoid them, you can find relief from spring allergies this season, says Dr. Richard Weber, an allergist and ACAAI president. An allergist can help you find the source of your suffering and stop it, not just treat the symptoms.
Allergies and asthma are serious diseases during every season of the year and that s nothing to sneeze at. Misdiagnosis and inappropriate treatment can be dangerous.
- 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.
- 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.
- 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.