Environmental Allergy

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Allergy shots, a new source of savings

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.