Contraindications for Immunotherapy

Allergies are not always clear cut and simple to understand. A person may assume that a certain food or substance is the cause of their symptoms and relate it to allergies, or they may not see the complete picture. We know allergy testing is extremely beneficial in allowing a provider to determine precisely what is or is not causing troublesome symptoms. Accurate diagnosis of the allergy, along with insights into any current medications that have failed to improve or control symptoms, avoidance measures taken, and impact on daily life enables your provider to determine the best treatment program which often includes immunotherapy.

When a provider is considering allergy testing and immunotherapy, it is important to take into consideration potential contraindications that may warrant a different approach including potentially refraining to utilize United Allergy protocol in a particular patient. A contraindication in our instance is a particular condition which makes allergy testing or allergen immunotherapy potentially inadvisable. A contraindication may be absolute meaning that is any situation that this condition is present it is definitely not advised allergy testing or immunotherapy is utilized. The majority of contraindications applicable to allergy testing and immunotherapy, however, are relative. A relative contraindication means a certain condition can drive concern and could increase risks making it possibly inadvisable. Risk vs benefit assessment needs to take place.

Patients that present with one or more of the following contraindications should be screened thoroughly by the provider and the benefits for testing and treating patients with immunotherapy must be weighed against the risks associated. This important assessment and determination on how to proceed will always rest with the ordering provider directly supervising the care of the patient.

  • Beta Blockers: We highly recommend providers that have patients on beta-blockers consider switching them to another medication if appropriate prior to initiating immunotherapy. A beta-blocker may mask cardiac signs or symptoms related to anaphylaxis. Also, if a patient has an adverse event, they may not respond to the epinephrine needed to counteract the life-threatening reaction. There is currently limited data available to support holding beta blockers for a short time period such as 24 hours prior to an allergy test or immunotherapy dose to increase a patient’s safety.
  • ACE Inhibitors: ACE inhibitors have been another cardiac medication thought to pose a risk if utilized with immunotherapy. ACE Inhibitors are considered due to their mechanism of action although whether they pose a significant risk as always been a major topic in academia. During an adverse reaction, it is thought that an ACE inhibitor can block the endogenous compensatory response manifested by the increased secretion of angiotensin-converting enzymes and prevent the destruction of kinins produced during the anaphylactic episode. The evidence regarding a true increased risk has not been clearly proven with environmental allergen immunotherapy and so is not currently included on our list of potential contraindications. Currently, data supports increased risk in venom allergen immunotherapy which is not offered under UAS protocol.
  • Cardiac conditions: Patients with historic and current cardiac issues such as congestive heart failure, myocardial infarction, labile arrhythmias, uncontrolled hypertension, or other significant cardiac problems could be negatively challenged clinically if they experience anaphylaxis due to allergy testing or immunotherapy. Furthermore, many of these patients may not successfully tolerate the consequences of epinephrine injections if required to treat anaphylaxis.
  • Previous history of anaphylaxis to aero allergens: Patients that have a history of previous reactions are much more likely to have a repeat reaction, oftentimes more severe than the initial reaction.
  • Pregnancy: Pregnant patients must remain at the same concentration level of immunotherapy throughout the pregnancy and should not increase the dosage volume or concentration. This is because repeating the same positively tolerated dose, protects the expectant mother and developing fetus from potential harmful effects of epinephrine should a significant systemic reaction occur. It is beneficial for patients that become pregnant or plan to become pregnant at prior to testing, or at low dosage/concentration, delay allergy testing and immunotherapy until the pregnancy has concluded.
  • HIV positive/ AIDS patients: AIDS or AIDS associated disorders are absolute contraindications to immunotherapy, however HIV+ status only is not always contraindicated according to literature. UAS currently recommends providers with patients with a positive HIV + status consider seeking an alternative protocol with an opportunity for closer and more consistent in office monitoring. However, despite this advisement, it is important to share there is no current absolute contraindication for a patient with a positive HIV status to begin allergen immunotherapy. There also are no large, controlled studies that can provide validity to the risks or to the benefits of allergen immunotherapy in HIV positive patients. There have been citations in recent literature to demonstrate both a negative response to initiation of immunotherapy (in which T-cell proliferation and RNA viral load increase occurred) and a positive response (a 3.5-year course of immunotherapy reduced symptoms and medication use, as well as provided well controlled symptoms 3 years port IT, without significant impact to HIV disease).  Each patient must be closely assessed on an individual basis.
  • Immunocompromised patients/ chemotherapy patients (including AIDS patients as mentioned above): Immunocompromised patients have not been shown in the literature to receive benefit from immunotherapy. Immunotherapy works by changing the T-cell repertoire. In immunocompromised patients T-cells are often altered. Thus, patients with an immunocompromised state are not recommended as candidates for immunotherapy.
  • Patients with autoimmune diseases or utilizing immunosuppressant medications: As quoted from the AAAAI “Although concern about the safety of allergen immunotherapy in patients with autoimmune disorders has been raised in the past, there is no substantive evidence that such treatment is harmful in patients with these diseases.” Due to the variation in these different disease states and individual patient situations, it is recommended the benefits and risks are assessed on an individual basis. When a patient is utilizing an immunosuppressant medication there are theoretical concerns that immunotherapy's benefit could be lessened, however there is no overarching body of evidence in literature that provides clear evidence of this regard. The best guidance I can provide for the ordering provider is to have full transparency with the patient regarding the theoretical concern of decreased efficacy of IT and considering holding immunotherapy during active exacerbations of autoimmune diseases.
  • Uncontrolled asthma/severe asthma/severe COPD: The group of patients with the highest risk of severe reactions to allergy testing or allergen immunotherapy are asthmatics, particularly those that have uncontrolled or severe asthma. This can apply to anyone with impairment, obstruction, or restriction of their airways. To protect against a negative outcome of a severe systemic reaction it is strongly recommended providers do not test, initiate immunotherapy, or continue immunotherapy while a patient is in a compromised respiratory state.
  • Eosinophilic Esophagitis (EoE) or Gastroenteritis: This is a concern that applies to sublingual immunotherapy ONLY and does not pertain to subcutaneous immunotherapy.  In sublingual immunotherapy, the allergen is swallowed and has direct contact with the esophagus. Swallowed food, and an allergic response to the food or allergen is presumed to be important in the development or worsening of EoE. Therefore, it is thought that exposure of an aeroallergen with the esophagus can produce the same effects. Package inserts for the FDA approved SLIT tablets indicate that eosinophilic esophagitis is a contraindication for use.
  • Inability to communicate: Patients undergoing allergy testing or allergen immunotherapy need to possess the ability to both mentally and physically participate in their diagnostic and/or treatment plan. The ability to clearly express and communicate active symptoms is crucial should an adverse reaction occur. Patients also need to possess the mental ability to understand the procedure or treatment ordered for them, be cooperative during the process, and understand the importance of their compliance.

United Allergy Services believes in appropriate patient selection (taking into consideration relative and absolute contraindications), doses building in a low, slow deliberate manner, and treatment in compliance with the relevant standards of practice guidelines. The proven safety results and efficacy of the self-administered subcutaneous immunotherapy protocol developed by United Allergy Services is based on a pre-selection of low-risk patients.  If there are additional questions or any additional information requested, please contact the Clinical Support Team. We are here to support providers and provide guidance as they provide excellent allergy care to their patients.

 

Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, PA. After spending 8 years in clinical practice, she joined United Allergy Services where she is currently the Vice President of Clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology. 

United Allergy Services is also on FacebookLinkedInor TwitterSee other interesting and related articles on the UAS Blog.


2022 - New Year, New You!

Happy New Year, and welcome 2022! The start of a new year arrives for many with guilt-laden resolutions to improve things like personal health goals. Resolutions to improve health can seem overwhelming and cause anxiety if they are unrealistic in the end goal or timeframe. Allergy and asthma sufferers do not have to overhaul an entire health plan to see some solid results. A few simple tweaks could make a big difference in easing sniffling, sneezing, and wheezing.

⦁ Adding Exercise – Is it even a New Year’s resolution if it doesn’t involve adding exercise or physical activity – and it’s an especially good goal for those with asthma! It is a common misconception, and one that can be detrimental to overall health, that those with asthma should not exercise. It is true that when asthmatics exercise in certain places or conditions, such as  in cold weather, it can make asthma symptoms worse, so avoid exercising outside if it’s cold and windy (or hot and humid). Air pollution – both indoor and outdoor – as well as high pollen counts, can also cause symptoms during exercise. Consider sports that typically require shorter bursts of exertion or activity like volleyball, gymnastics, baseball, wrestling, golf, and swimming. Using an inhaler before exercising and as needed during exercise can further help. If asthma limits your ability to exercise, talk to your provider to discuss a possible adjustment to your asthma medication routine, or better control of your allergies through testing and allergen immunotherapy.

⦁ Decrease stress – Numerous studies have shown that stress can cause negative health effects, including increased or worse symptoms for allergy and asthma sufferers. Consider downloading a meditation or relaxation app to use at night before bed. Soothing music can also be beneficial, as can doing activities you enjoy that lift your spirit.

⦁ Stop smoking or ban it from your surroundings – Quitting smoking and making your house a smoke-free environment could easily be the single best resolution to make as an asthma and allergy sufferer. This resolution should be on the top of your list. Direct smoke and secondhand smoke is extremely damaging and harmful to many parts of the body, but particularly the lungs. Studies have shown children with asthma who are exposed to secondhand smoke at home have nearly double the risk of being hospitalized than children with asthma who aren’t exposed. If you or your kids have asthma you should also try to avoid fireplace fires and campfires.

⦁ Protect yourself - It's important to do all you can to protect yourself against respiratory viruses like influenza, RSV, and COVID-19 because people with asthma and allergies can be at an increased risk for severe illness. For viruses like the flu and COVID-19, get vaccinated, or get a booster shot, wear a mask when appropriate and social distance.

⦁ Watch what you eat – but wait, this has nothing to do with dreaded dieting! -  For those with food allergies, remain diligent in avoiding the foods you are allergic to. This year, double down on making sure those you love, especially teens or college students, are being vigilant. Older kids sometimes believe not mentioning food allergies helps them not stick out among their peers. Encourage them to courageously educate their friends and enlist their help in the battle to stay allergen-free. Help them take control of their food allergies by urging them to be aware of what’s on the menu wherever they eat. Also, resolve to make sure epinephrine auto injectors are current and up to date, and that two sperate doses or injections are always available to be utilized within 60 seconds of need.

⦁ Proactively see your provider – Each year people wait to discuss their allergies and asthma with their provider and be evaluated when pollen season and allergy symptoms are at their worst. Avoid reaching that level of suffering, the allergy season rush, and the inability to be allergy tested due to need for allergy medications by proactively seeing your provider now. Your provider can help you determine what is causing symptoms and show you how to avoid triggers.

 

Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, PA. After spending 8 years in clinical practice, she joined United Allergy Services where she is currently the Vice President of Clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology. 

United Allergy Services is also on FacebookLinkedInor TwitterSee other interesting and related articles on the UAS Blog.


Helpful Hints for the Holidays

The holidays are here! Holidays mean family centered fun, festive meals, and usually sweet treats to enjoy. For allergy suffers, however, holidays like Christmas, Hanukkah, and Kwanza can be challenging.  First, traditional holiday foods containing hidden allergies may be present. Also at risk is high dust mite exposure as more Americans are finding themselves gathering indoors together. Add in holiday décor from the attic, household pets, a freshly cut Christmas tree, and even scented candles and you’ve got a holiday wreck wreaking havoc on the nose and chest. Not to worry! Amanda Hofmann, PA, and VP of Clinical at United Allergy Services is here to share tips so that you and your family have a safe and happy holiday.

Food Allergy Aware

Traditional holiday meals are at the cornerstone of most holidays, especially winter holidays. Plan the meals in advance and be mindful of any guests that may have a food allergy. Flexibility is key! Try solutions such as switching ingredients or prepping allergy-friendly dishes separately from the other meals. Not sure whether guests have a food allergy? Consider printing recipes for each dish and display them next to it.

These winter holidays typically mean chocolate and sweet treats to younger members of the family, or those young at heart. Try to again consider those guest and family members that may have allergies to things like chocolate, so they are not left sitting on the sidelines. Allergy to chocolate itself, or the cacao bean, is incredibly rare, however more commonly the offenders are milk, peanuts, tree nuts, soy, and corn. A little research will provide an array of options of dairy free or peanut/tree nut free brands of treats. Always check labels to see if the offending food is contained in the ingredients list, or mentions it was produced in a facility that also processes other allergen containing foods putting your loved one at risk of cross contamination. Keep in mind most chocolate does contain soy in the form of soy lecithin to keep it solid at room temperature, and white chocolate commonly contains corn in the form of corn syrup. If the treats offered are of the homemade variety, it can be even more challenging for a food allergy sufferer due to lack of label to research ingredients. If you suffer from food allergies, a good rule to follow is “If you can’t read it, don’t eat it”. Plan to bring some of your own safe snack or goodies, unless you can make sure your host prepared foods allergen free, safely away from other allergen containing food, and on a separate and thoroughly cleaned surface. In lieu of store bought or homemade edible treats, consider offering nonfood items for younger guests such as books, sporting goods, stickers, novelty items, or toys.

If the above-mentioned allergies are life threatening for you or a loved one, always make sure to carry a minimum of two epinephrine auto injectors if it is prescribed. Make sure the epinephrine autoinjector is carried in a way it can be accessed and administered within 60 seconds of a need arising. If you or a loved one does have life threatening allergies, it is always a good idea to check with your health insurance and ensure you know where to seek medical care should the need arise if celebrating the winter holidays out of town.

Asthma Risks

Food allergens typically are the easiest to keep front of mind during the holidays, however equally as difficult for allergy suffers and arguably more difficult to avoid are the scents like pine, baking cookies, holly leaves and seasonal berries spreading plentifully from a scented candle. Unfortunately, scented candles can lead to asthma attacks. It’s even possible for a person with allergies to be agitated by the smell of candles. Candles, especially scented ones, can release toxic soot and petrochemicals that can aggravate the respiratory tract. Think about making the switch to unscented candles. These are a visually appealing alternative to create ambiance without any scents. If scented candles are used, always light them in well-ventilated areas. This way, the smell of the candle isn’t as prevalent. Try to avoid lighting scented candles in areas where guests are forced to gather or remain in close quarters like the meal table or bathroom. And finally, also try to avoid burning wood in the fireplace during gatherings where loved ones may have allergies or asthma. The smoke can irritate allergic and asthmatic airways. Hosting the fire outdoors if possible, or utilizing an electric fireplace, may allow the holiday cheer to stay without the difficult side effects.

Environmental Allergy Traps

If you celebrate Christmas this holiday season, then no decorating is complete without the home’s centerpiece: the Christmas tree. Many allergy sufferers tend to see an increase in symptoms around their beloved fresh cut pine tree, however you may be surprised to hear, pine isn’t the culprit. It is likely the dust mites and mold that is triggering the allergy attack. The strong evergreen smell can also be problematic. If getting an artificial alternative is out of the question to fulfill the holiday ritual (this goes for wreaths or garland as well), then consider allowing it to dry out on an enclosed porch or garage. If you are allergic to mold you can also spray with a fungicide (be aware of a chemical odor). Also, an air purifier in the same room as the tree is a welcome addition that can help reduce mold levels.

If a switch has been made to decorate an artificial tree, make sure to be diligent about cleaning the tree of all dust before setting it up year after year. The artificial tree, and any other holiday décor kept in the attic, garage or basement should be thoroughly cleaned as they can gather mold and dust while in storage. Consider wearing  a mask when getting it out every year if you are especially sensitive to those allergens and also have asthma. When considering your holiday décor, it helps to remember that plastic, metal, or glass decorations that cannot trap dust mites, and storing decorations in plastic boxes rather than cardboard can significantly reduce allergens like mold.

Pet Friendly Families

We cannot forget about the cherished furry family members that may be in attendance for the winter holiday celebration, as well as the propensity to give the gift of puppies or kitties this time of year. Dander, saliva, sweat, and urine from adorable dogs, cats, and even bunnies can trigger an allergic response in some people. If possible, try to keep pets confirmed to only a certain area of the celebration so that those that wish to enjoy them can, while those that are unable can find refuge elsewhere. Make sure to thoroughly wash your hands before returning to an animal free area of the celebration, before partaking in shared food items, or before touching your face, mouth, or eyes. Also, make sure the recipient of a new pet is not triggered by them. Although recent literature has shown us a true allergy to bird feathers is rare, there are substantial amounts of dust mites found in feathers that can trigger unwanted allergy symptoms as well. So given feathered friends careful consideration as well.

If you or a loved are unsure whether food allergens, mold spores, dust mites, or animal dander are potential allergy triggers and the cause of the nasal congestion, runny nose, postnasal drip, sneezing, and itchy watery eyes you have been suffering with, seeing your provider for an allergy test may provide the clarity you are looking for! And if you are already aware of true allergy triggers, but your current allergy medication and avoidance measures are just not cutting it, there is still time to see your provider and discuss starting allergen immunotherapy before the holidays!

 

Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, PA. After spending 8 years in clinical practice, she joined United Allergy Services where she is currently the Vice President of Clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology. 

United Allergy Services is also on FacebookLinkedInor TwitterSee other interesting and related articles on the UAS Blog.


Eczema and Atopic Dermatitis

We have made it to the highly anticipated holiday season! We ate more than our share of turkey, taken down the last of the fall décor, have started trimming the tree, and are double down on the holiday gift lists. With winter weather upon us or in the near future, and personal care products a favorite stocking stuffer, this is a perfect opportunity to think about proper skin care, especially if eczema or atopic dermatitis is present.

It is common for patients and even healthcare providers to use the terms ‘eczema’ and ‘atopic dermatitis’ interchangeably. All atopic dermatitis is a form of eczema, however not all eczema is atopic dermatitis. Atopic dermatitis is the most common form of eczema and typically begins in childhood. Someone suffering from atopic dermatitis typically has dry, itchy skin, as well as potential rashes that range from red/purple to brown/gray. The skin becomes so dry, itchy, and inflamed due to the immune systems hyperactivity, and loss of or lack of a protective protein called filaggrin that allow our skin to produce and maintain a strong skin barrier. Without a strong skin barrier, it is easy for moisture to quickly escape and bacteria carried by fingernails scratching the skin’s surface to get in.

Atopic dermatitis can be triggered by allergen exposure, stress, infection, or commonly weather changes. Atopic dermatitis can unfortunately worsen drastically in the winter, with this month being the start of the season in the US. The cold, dry air outside as well as the dry indoor heat cause the moisture to escape from the skins surface leading to dry skin. Issues with dry skin are further compounded by the tendency to layer up clothing and blankets, or taking lengthy and hot baths or showers.

If the itching keeps on giving this holiday and winter season, here are some helpful hints on how to help the skin survive and get some much-needed relief:

  • Dress in soft, breathable clothing and avoid itchy fabrics like wool that can further irritate the skin.
  • Despite the persistent itch, try not to scratch or rub the skin. This will cause additional damage and irritation as well as cause more heat on the surface of the skin which innately leads to more intense itching. By refusing to scratch, the itching cycle is broken and the skin is protected from virus and bacteria carried by fingernails.
  • For relentless itching sensations, apply cool, damp cloths to affected areas to cool the skin down. Also useful are cold compresses, ice packs, or even that bag of frozen peas in the back of the freezer. Just make sure to always place a towel or barrier between very cold or frozen items and bare skin.
  • Although hot showers and baths go hand in hand with winter weather, aim for lukewarm water bathing lasting for no more than 10 minutes.
  • When bathing, skip the harsh washcloths and loofahs. Instead use your hands to lather up with a good cleanser. (A cleanser is different than soap or body washes. Soaps and body washes typically contain sodium lauryl sulfate which is a skin irritant, and are not as moisturizing or hydrating as a cleanser)
  • Make sure cleansers, moisturizers, detergents, and skin hygiene products are fragrance free and dye free. (Look for the National Eczema Association Seal of Acceptance on products to guarantee they are free of fragrance, dyes and other common allergens.)
  • When done bathing, pat the skin dry rather than harshly rubbing.
  • Replace moisture in the skin by applying a moisturizer immediately after taking a bath or shower. Try to aim for moisturizing to occur within the first 3 minutes.
  • Moisturizers can be classified as an ointment, cream, or lotion based on the amount of oil and water they contain. The more oil in a moisturizer, the better it usually is at providing relief and even treating atopic dermatitis. Ointments have the highest oil content and are the best line of defense for atopic dermatitis.
  • Try using a humidifier.  Make sure to change the water in the humidifier and clean the machine every three days. Consider using distilled or demineralized water.

The National Eczema Association is a great resource for learning more about eczema, atopic dermatitis, causes, symptoms, and treatment options. There is a wealth of information on their website: https://nationaleczema.org/


Dust Mite Allergy

Halloween may be over, but there are certain creepy creatures that diligently remain year-round and commonly trigger allergy and asthma symptoms. Dust mites are eight-legged relatives ticks and spiders, have no eyes, have translucent bodies, and are microscopic, or too small to see with the unaided eye. These tiny creatures love to make their home on human and pet bedding, mattresses, carpets, curtains, toys and upholstered furniture. They love to choose these locations for their homes because of the plentiful food supply. Dust mites regularly feed on the dead flakes of skin that people and pets shed daily and gain their water from moisture found in their environment (think humidity and sweat!). They live somewhere between 60 and 100 days.

Dust mites are well adapted, and currently inhabit every continent except Antarctica. There are two main species of dust mites, the American house dust mite (Dermatophagoides farinae) and the European House dust mite (Dermatophagoides pteronyssinus). Providers utilizing United Allergy Services for their patients’ allergy needs can safely test and treat their patients to both species of mite. Dust mites, as opposed to bed bugs or other parasites, will not and cannot bite you. Dust mites are extremely lightweight and cannot be felt crawling on the skin. They can cause allergic or asthma symptoms in some when those sensitive to them inhale the microscopic fecal matter and shed skins of the mite.

As with any allergen, the goal is to first identify the allergen as troublesome to the individual person and develop a treatment plan. A treatment plan should always include how to reduce the exposures to the offending allergen. However, if your home has humans or pets living in it, there are dust mites present, and it is impossible to avoid them completely. There are several things that can help diminish their food supply and create less of a welcoming environment. The best approach with dust mites is trying to convince them that their current environment will be too much work to maintain their existence. Trying to kill them is almost impossible, there is no spray or pesticide currently labeled in the United States for the destruction of dust mites, and dead dust mites still shed the problem causing protein that triggers allergy and asthma symptoms.

Hard surfaces such as vinyl, wood, or tile, and other hard surface blinds instead of curtains or draperies are helpful in decreasing the dust mite colonization in a home. It is also beneficial to select leather furniture as opposed to upholstered and remove things like books, lamps, knick-knacks, and dust catching items from a room. These steps, although beneficial to a home, can be challenging if home renovations are not in the budget. And who plans to live in a home without any type of lamp, picture frames, or other décor? There are other steps to reduce the dust mite colonization of a home.

First and foremost, a regular and thorough cleaning of the surfaces and regions that dust mites are most likely to dwell is an easy front-line approach to sending dust mites searching for another place to call home. It is especially important to focus on where someone will sleep as this is when a person can spend upwards of 8 hours a day breathing in potential allergens. Cleaning and washing all bedding such as sheets, blankets, and pillowcases in a hot, sanitary cycle is recommended once weekly. Sleeping quarters can further be protected from dust mites by using special covers and encasements to keep out these unwanted visitors. An encasement should be placed on each mattress and sleeping pillow in the home. As well as cleaning and covering areas in which sleeping occurs, it can be beneficial to keep pets and copious amounts of dust collecting stuffed toys out of sleeping areas and off beds as well.

Dust mite body casings are lightweight and can easily become airborne and travel through the air. Ceiling fan blades can harbor dust and dust mites and allow dust to become easily airborne. It is imperative to regularly dust fans, especially before turning on.  Air quality can also be improved by using a high-energy particulate absorption (HEPA) air purifiers on the air conditioning and heating units, as well as the vacuum to remove many allergens, especially dust mites, from the air. A dehumidifier can also be helpful as it helps to create a less favorable environment for the dust mites to survive. Remember, dust mites get their water supply from the humidity in the air as well as human and pet moisture, aka sweat, left behind! Just make sure to regularly clean the dehumidifier unit to prevent mold growth. And finally, wearing a mask can be beneficial to allergy and asthma sufferers when cleaning the home, removing bedding or drapery for washing, or taking out and putting away things from storage spaces like holiday decorations.


Respiratory Care Week, October 24-30

As we settle into this final week of October and prepare for some frightful fun at the end of the week, let’s all take a big deep breath in before the end of the year holiday season is upon us! Speaking of that big dep breath, October is Healthy Lung Month and this week, October 24-30 is Respiratory Care Week. This week we focus on the importance of protecting our lungs against infections like bronchitis, allergens such as mold, air pollution and smoking because if we take care of our lungs, our lungs will take care of us.

One of the more impactful allergens on the lungs specifically, is mold. Mold is a type of fungi, and the seeds or spores of the mold travel easily through the air to reproduce and grow. There are many different types of molds, and some spores thrive in dry, windy weather while other spores need damp, humid environments. Although there are many different types of molds, not all mold is responsible for allergic reactions. The most common allergy-causing molds include Alternaria, Aspergillus, Cladosporium and Penicillium.

Mold is unfortunately everywhere, indoors, and outdoors, and is a year-round allergen, although is typically at its highest from July through October or November. Some of the most favorable places for mold growth are on rotting logs or plants, piles of fallen leaves, compost piles, and on grasses or grains. Mold also tends to grow in cool, damp environments indoors such as basements, kitchens, and bathrooms. Tracking symptoms along with exactly where someone has been, can be extremely helpful to a provider trying to determine if mold is an allergen for their patient and the culprit for the troublesome symptoms the patient might be experiencing. Everyone breathes in mold spores on a regular basis, however, those that have an allergy to mold can experience itchy nose, mouth and lips, sneezing, itchy, watery eyes, and nasal symptoms. Those allergic to mold with underlying allergic asthma are especially susceptible to increased wheezing, coughing, chest tightness, or shortness of breath.

With molds living indoors, outdoors, and year-round it might seem overwhelming to figure out how to avoid this troublesome allergen. Similar to pollen counts, mold spore levels in the air are regularly tracked and reported so it is important to check the allergen forecasts and try to limit time outdoors when counts are high. Planning for indoor exposures can be a bit more challenging, however, some spots like greenhouses, farms, flower shops, construction sites, and antique shops are bound to have higher mold spore counts. Plan to take additional allergy medication, avoid during symptom exacerbations or bring a mask to help lower exposures.

Large fields of grains and grasses, and piles of dead, damp leaves are prime places for mold. Avoiding those places is beneficial, and if planning for the young or young at heart to jump in their fall leaf piles, try to plan for a day with low outdoor mold counts if possible. It is important to try to immediately shower after outdoor activities like mowing, or jumping in leaves, especially before crawling into bed. This will help to wash away any allergens that have adhered themselves to your skin or hair and are hoping to enjoy your comfortable accommodations right alongside you. This is especially important before allowing them to have access to your pillow or sheets and being in the immediate space and air you breath in all night.

Finally, and possibly the most important, let’s focus on how to minimize mold existence and exposure in the home environment. As discussed previously, indoor mold tends to prefer damp, humid environments, and areas with high levels of moisture in the air. Consider using a dehumidifier and air conditioners/heating units fitted with high-efficiency particulate air (HEPA) filters. It is best to try to keep humidity below 60%, ideally between 35% and 50%, and that can be easily tracked with a humidity meter available at a low cost at most hardware stores. Mold can thrive in warm, damp bathrooms and humid kitchens. If the kitchen or bathroom has an exhaust fan, use it, especially when taking a shower or bath. This will help to further reduce humidity in these rooms.

Clean surfaces do not provide a conducive environment for mold spore attachment and reproduction however soap scum in the bathroom or grease in the kitchen do provide an inviting area for mold growth. Aside from regular cleaning, it helps to closely monitor counters, and more importantly refrigerators, drip pans, door seals, showers/baths, AC drain lines, dryer vents and garbage pails. If the kitchen and bathroom have proven to be difficult areas to control mold growth, consider removing carpeting from kitchens, bathrooms, and basements, and replacing with linoleum or concrete flooring to inhibit floor mold growth as these surfaces do not hold moisture. Finally store things like old schoolwork, projects, paper, and clothing in plastic, airtight containers as opposed to plastic bags.


football, food, and fall allergies

Football, Food, and Fall Allergies

Fall has arrived and so have shorter days, cooler weather, and football season! Unfortunately for some, football, food and fall allergies go hand in hand. This is especially true in the southern and western regions of the US where some weed allergens peak in the fall. The idea of sneezing and wheezing with itchy, watery eyes while watching a game or practice can be dreadful. Perhaps more concerning is visiting major sports venues if you or a loved one have food allergies.

Outdoor Allergies

It is common to check the weather forecast to plan for warm or cool temperatures when attending sporting events. . A good habit may be to also check the local pollen counts in the area. Keep in mind that peak pollen times are typically in the first half of the day (specifically 5am 10am). Attending practices or games midday, in the afternoon, or in the evening may help to reduce exposures.

Avoidance for Fall Allergies

If you have a future MVP of your own, packing some wet wipes could be helpful. Wiping down their hands, face and neck can combat those distracting allergy symptoms when out on the field. Also, verify any allergy medication they take will not make them drowsy during their practice or game. Non-sedating medication options or allergen immunotherapy may be worth discussing with their provider.

After practices or games, changing out of the clothing worn while participating or spectating can help alleviate allergy symptoms. Also helpful is an immediate shower, particularly before crawling into bed. Showering will help to wash away any allergens that have adhered themselves to your skin or hair. This is especially important to keep them out of the immediate space and air you breath in all night.

Food Allergies

If food allergies are a concern, planning ahead can alleviate a lot of anxiety and allow for a smooth trip. Always make sure to carry a minimum of two epinephrine auto injectors if one is prescribed to you or a loved one. Make sure the epinephrine autoinjector is carried in a way it can be accessed and administered within 60 seconds of a need arising. The Food Allergy Research and Education (FARE) organization recommends “to reach out directly to the venue to learn more about their efforts” in regard to additional steps they may be taking to ensure your family’s safety at the game.

Food Allergy TipsFootball and Food Allergies

Some suggested topics to cover when you contact the venues are:

  • Availability of allergy friendly games, sections, or suites
  • Is power washing utilized for seating, and traffic pathways at the stadium?
  • Are ingredient lists available upon request at the concessions?
  • Policy for bringing in safe meals and snacks
  • Locations for emergency responders

Planning and communication make it possible to avoid fall allergies and enjoy football season. Communicate with family, friends, coaches, players, and venues, and create a plan that is right for your family. However, missing out on football season does not have to be part of that plan. If you or your loved ones are not quite sure if allergies are playing a roll, or if the allergy medication is just is not cutting it, consider contacting your provider and discussing allergy testing and starting allergen immunotherapy.

 

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Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, PA. After spending 8 years in clinical practice, she joined United Allergy Services where she is currently the Vice President of Clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology. 

United Allergy Services is also on FacebookLinkedInor TwitterSee other interesting and related articles on the UAS Blog.

 


Flu, Allergies, Cold, or COVID?

With the approaching fall season, we typically witness flu and viral season quickly arrive as well. Simultaneously weed pollen, dust mite, and mold allergy sufferers are preparing for an intense time of year. This year however, the ongoing spread of COVID-19 and reputable variants adds an additional concern to patients’ minds. There is quite a lot to navigate!

Currently, the recommendations continue to spend time outdoors or hold event outdoors where social distancing is easier and coronavirus transmission is less effective. For fall allergy sufferers, however, the recommendation to spend more time outdoors can sound like a no-win situation. Not to mention a cough, runny nose, or sneeze seems to send the average person into a state of anxiety, concern, and confusion these days, and those around you running for cover. This fall, more than ever, we have the opportunity to assist providers in determining if their patients’ symptoms are typical for this time of year or signs of something more serious.

Allergy symptoms can occur seasonally or continuously year-round when someone is sensitive to particles such as pollen, animal dander or dust mites. When allergies are to blame, symptoms commonly include itchy, watery eyes, itchy, runny nose, sneezing, nasal congestion, post-nasal drip, and itchy throat or ears. Did I mention itching was common for allergy sufferers? I absolutely mentioned itching, however what I made sure not to mention was fever. Fever, muscle aches, and weakness are three big differentiators as they are absent with allergies. Similarly, as differentiators, sneezing, itching, and clear, watery nasal discharge are always present with allergies but not flu or COVID19.

Some other overlapping symptoms can be fatigue, headache, or sore throat. Again, focusing on time of onset is important. Coronavirus (COVID-19) signs and symptoms tend to be more sudden or rapid than allergies and result in rapid onset fatigue coupled with fever, chills, muscle pain, headache, weakness and potentially also dry cough, sore throat and loss of taste and smell. Allergies can be associated with a cough and can make breathing difficult, and trigger wheezing and/or shortness of breath. Unfortunately, these symptoms can also be associated with COVID-19. However, with allergies expect that these symptoms will come on slowly, and respiratory symptoms will be “wet” in nature. If mucus is being produced, especially clear mucus, and onset is slow allergies are likely the culprit.

Patients that have already been diagnosed with allergies and asthma may be concerned with whether they have a greater risk of contracting COVID-19 or if it is safe for them to continue immunotherapy at this time. It is important to support your provider in assuring these patients there is currently no data to support that patients with allergies are at an increased risk for contracting COVID-19, and similarly there is no data demonstrating that concomitant allergen immunotherapy poses any risk.

Patients with allergies should continue wearing a protective face covering, however if they have been outside for significant time periods or during high pollen or mold count days there are some important mask recommendations to consider. A onetime use, disposable, non-cloth mask is the best option for outdoor pollen sufferers. If allergy sufferers are wearing a cloth mask, please make sure to recommend the mask is washed in the sterile or sanitation cycle after a day’s use. Also, those with allergies can more commonly have sensitive skin or history of contact dermatitis may need to wash the mask more frequently than non-allergy sufferers. One final reminder, if coughing or sneezing strikes- make sure that you encourage patients to carry additional masks, change their masks frequently, however, do not remove masks in public when a cough or sneeze occurs.


Ragweed and Fall Pollen Allergies

Back to school season is here! Shorter days, crisp, cool evenings, and beautiful fall foliage are on the horizon. This time also marks the onset of weed pollination and the resurgence of allergy symptoms that may have taken a vacation in the hot, dry July heat. The meteorological calendar says fall begins September 22nd, but weed pollen, the main culprit of the sniffles and sneezes during fall allergy season, is already here!

Pollen Offenders

Towards the close of summer, weeds start to pollinate. Weeds grow all summer, but their pollen is usually not released until later in the growing season. This can vary year to year but typically starts mid to late August.  Ragweed, cocklebur, lamb’s quarters, pigweed, dock sorrel, English plantain, and sagebrush can all cause fall allergy symptoms and are widely spread across the U.S.

Specifically ragweed pollen is the predominate culprit of allergy symptoms from August through October, peaking on average in mid-September. Ragweed is one of the major drivers of allergy symptoms and releases huge amounts of pollen each and every day. The pollen produced by ragweed is small and light. It is released in large quantities into the air and carried for miles by the wind. Nasal congestion, runny nose, and itchy eyes are typically caused by wind-blown pollen which is easily spread for miles and miles.

Other Pollen Types

Goldenrod, which blooms at the same time that ragweed does, is instead insect-pollinated and therefore is not a significant allergen for most individuals. Insect carried pollen is produced by plants that have bright and attractive flowers. This kind of pollen is typically large and heavy, sticks to insects, and is transported during flight fertilizing other plants. These bright flowers are commonly thought to be allergy offenders, however because they do not release much pollen into the air they are not as likely the culprit of allergy symptoms.

Ragweed and Fall Pollen Allergies
Ragweed and Fall Pollen Allergies

Manage Symptoms

Checking local pollen counts is helpful to anticipate the level of exposure on any given day. Pollen counts are determined by collecting pollen on special rods. The pollen is then counted under a microscope and calculated in grains per cubic meter of air. Pollen counts tend to be the highest early in the day, or often when the wind picks up just before a large rainstorm. If you like dancing in the fall rain, or jumping in rain puddles, however, you are in luck. During a rainstorm and immediately following, pollen becomes still and dormant because the rain makes it damp and heavy. As the air becomes warmer and drier following the storm, however, the pollen count will rise again.

Pollen Avoidance

Those with weed pollen allergies should try to avoid heavily dense wooded areas or those with brush and shrubbery. These areas should be especially avoided in late August when pollen is the most dense and abundant. Pollen counts are never zero, nor will an allergy sufferer truly be able to avoid weed pollen in the late summer and early fall. However, contact may be lessened by taking simple steps to avoid pollen overload:

  • Utilizing the air conditioner or heater
  • Keeping the windows and doors at home and in the car closed
  • Utilizing the dryer rather than the fresh breeze to dry clothing
  • Changing clothes after coming in from being outdoors
  • Shower prior to getting into bed or laying on upholstered furniture

These easy steps will help to decrease pollen exposures. Also, one benefit COVID-19 may bring allergy sufferers, is that wearing of some masks will help to minimize the amount of pollen reaching the nasal passages if being worn in outdoor settings.

Get Tested

If someone is unsure whether weed pollen is a trigger for their back-to-school nasal congestion, runny nose, post nasal drip, sneezing, and itchy watery eyes, seeing their provider for an allergy test may provide the clarity they are looking for!

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Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, PA. After spending 8 years in clinical practice, she joined United Allergy Services where she is currently the Vice President of Clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology. 

United Allergy Services is also on FacebookLinkedInor TwitterSee other interesting and related articles on the UAS Blog.


Back to School Action Plan for Allergies and Asthma

Back to School Action Plan for Allergies and Asthma

As the final days of summer break come to a close, families everywhere are preparing for children to return to school. Whether this is the first year a child is heading to school or the last, it is an exciting time for both children and parents. It can, however, also be a time of anxiety for a parent worried about a child’s asthma or allergy conditions. Below are some ways to prepare and communicate these concerns, and  back to school excitement.

Make a Plan

Schedule an appointment with your child’s healthcare provider in the weeks leading up to the first day of school. During this appointment, discuss overall heath as well as specifics regarding allergies, food allergies, or asthma. This is also a great opportunity to request that the healthcare provider refill any asthma or allergy medications. The provider can complete medication permission forms required by the school nurse during your visit. It is important the school nurse can quickly and easily confirm the medication you provide is:

  • non-expired
  • prescribed for your child
  • has clear directions on when, how, and how much to take

This is also the time to request your provider complete any additional forms required by the school. Examples are asthma action plans, anaphylaxis action plans, and food allergy alert plans with avoidance and substitution information. If your child is in their first year or is entering a new school, it is important to contact the school nurse directly. Also, if your child has complex requirements or action plans, you should visit with the school nurse yearly about their daily requirements. The nurse can discuss accommodation options available for children at the school. Other important policies to discuss include asthma inhalers, epinephrine auto injectors, classroom parties, field trips, and cafeteria rules.

Classroom Action

Back to School with Allergies and Asthma
Back to School with Allergies and Asthma

The classroom can be a source of exposure for children with allergies to dust mites, mold, and animal dander. Communicate with your child’s teacher about allergy triggers for their symptoms and what common symptoms to look out for. Don’t forget to ask if the classroom will have a resident pet. If so, what type of animal and any requirements that the pet come home with your child may be important. It is also important to understand if the school has air conditioning or if windows are typically opened on nicer days. If windows must be opened, then you can prepare your child accordingly with additional symptom control medication.

During your initial meeting with the teacher, you can begin setting appropriate expectations. Discuss things such as asthma action plans and any potential limitations for recess or physical education. Also, anaphylaxis action plans for food or stinging insects and any food avoidance requirements should be covered. You will feel confident knowing both the school nurse and teacher are fully informed of your child’s needs. The school nurse and teacher should have a consistent plan for where inhalers and epinephrine auto injectors are stored. Also confirm that there is a plan for administration of medication in a time of need. It is a good idea to ask about substitutes or classroom aides/parent volunteers confirm they are made aware of your child’s needs.

When to Stay Home

During a regular year it is often a challenge to decide when it is or is not appropriate to send a child to school with cold-like symptoms. That can be even more complex for a parent if your child has allergies or asthma. In this unique time when COVID-19 is still a major focus, another layer of complexity is added.

For children with asthma, it is safe to attend school with mild wheezing that occurs infrequently and is quickly resolving with the use of albuterol. However, it is appropriate to keep your child home from school if:

  • they experience difficulty sleeping due to respiratory symptoms
  • require albuterol every 4 hours to relieve them of things like wheezing, shortness of breath, or chest tightness
  • have respiratory symptoms that are failing to resolve with albuterol use

Make sure to always inform the school nurse and the child’s teacher of any recent asthma exacerbations and how it was treated. Communicate any continued treatment if applicable.

If your child has an allergic reaction, make sure to inform the nurse. Also update the nurse on the allergen trigger if known, how the reaction was treated, and any ongoing treatment.

Wishing all the children a safe, healthy, and prosperous new school year!

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Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, PA. After spending 8 years in clinical practice, she joined United Allergy Services where she is currently the Vice President of Clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology. 

United Allergy Services is also on FacebookLinkedInor TwitterSee other interesting and related articles on the UAS Blog.