Options on allergies
Here’s what I think everyone needs to know about nasal allergies. (If you’re looking for information on food allergies, begin here.)
Symptoms:
Many allergy symptoms are well known: “runny” nose, sneezing, itching of the eyes, nose, or throat, and nasal congestion. However, nasal allergy can lead to other less obvious problems. These include ear pain, ear pressure, tinnitus, hearing loss, cough, sore throat, chronic fatigue, hoarseness, decreased sense of smell and taste, and globus sensation (that “something in the back of my throat” feeling).
Testing:
There are two types of allergy tests: skin tests and blood tests. Skin tests are more accurate but are also more irritating. If you are going to be desensitized to a particular allergen, testing is a necessary prerequisite.
Testing is also very helpful for devising avoidance strategies. Avoidance is difficult if you don’t know what to avoid.
Avoidance:
Avoidance is usually the most effective treatment strategy for dealing with nasal allergies. There are two problems with avoidance. First, avoidance is only effective if you have full knowledge of your allergies. Testing is helpful in this regard, but allergy tests aren’t perfect. Second, avoidance is only effective if you are willing to practice avoidance. A common example is the cat owner who will not give up her cats (many pet owners are not even willing to bar their pets from the bedroom).
Avoidance may also be impractical: if you live in the Pacific Northwest and are allergic to redwood pollen, the only way to practice avoidance is to leave the area. Some folks are willing and able to do this, but many are not. Even if you cannot leave the area, however, you can still minimize your exposure to local allergens.
Certain avoidance strategies are useful to adopt even in the absence of testing:
*Frequent laundering of bedding.
*Frequent vacuuming of the bedroom (including underneath the bed), and all carpeted floors. Ideally, have someone else do the vacuuming! Avoid using carpets whenever possible.
*Keep your bedroom windows closed at night.
*Use a HEPA filter in your bedroom throughout the night. HEPA filters clean the air of pollen, dust, and other particulate matter. The HEPA filter must be elevated off the ground (otherwise, it will tend to blow dust into the air, and this is counterproductive!) HEPA filters large enough to filter one room usually cost about $100 to $120. When you buy the HEPA filter, make sure that replacement filters are also available. There’s a charcoal prefilter as well as the HEPA filter itself. If you find the HEPA filter to be helpful, you should consider purchasing replacement filters early, since models seem to change on a semiannual basis. In other words, you may not be able to find replacement filters if you shop for them in 6 months. That’s planned obsolescence for you.
Drugs:
Before discussing drugs to treat allergy, let’s talk about other drugs. Tobacco, marijuana and other inhaled drugs (such as cocaine or crack) are injurious to the tissues lining the nose (mucosa). Obviously, these drugs (and other inhaled irritants, such as cleaning fluids or chemical fumes) should be avoided as much as possible.
Alcohol is dehydrating. Poor hydration leads to thickening of nasal mucus. We all produce about 4 cups of mucus per day, but we usually don’t notice the mucus; that’s because it is usually quite thin. The thicker the mucus, the more noticeable (and obnoxious) it will be to you.
What about drugs to treat allergy?
If there’s any chance you’re pregnant, discuss a drug with your obstetrician before taking it — that goes for over the counter as well as prescription medications.
Most over the counter drugs are “combination” drugs. These should be avoided, since you may not need all components of the combination. In general, decongestants (sprays such as Afrin or Neosynephrine, or pills containing pseudoephedrine – such as Sudafed) should be used only to treat acute congestion due to a cold or brief exposure to an allergen. Long-term use of decongestants often thickens nasal mucus; long-term use of decongestant sprays (longer than 3 or 4 days) leads to dependency. In other words, you could find yourself using the spray with increasing frequency, and the spray could worsen your problems with congestion.
One last warning about decongestants: these drugs are hazardous for patients with particular health conditions such as high blood pressure. If you have any doubts, ask your doctor whether that particular drug is safe for you.
Antihistamines (examples include Benadryl, Chlortrimeton, Allegra, Claritin and Zyrtec) can be effective for allergy treatment. Sedation is the most frequent side effect, even for the so-called “non-sedating” antihistamines (Allegra, Claritin, Zyrtec). In recent years, a spray antihistamine (Astelin/azelastine) has proven quite promising, as it provides the benefits of antihistamines without fewer side effects. It’s expensive, unfortunately.
As with decongestants, antihistamines are potentially harmful for folks with other medical problems, including glaucoma, high blood pressure, enlarged prostate, heart disease, and thyroid disease. If you’re not sure whether antihistamines are safe for you, ask your doctor.
Nasal steroid sprays (examples include Flonase, Rhinocort, Nasacort, Nasarel, and Nasonex) blunt the allergic response and reduce inflammation. If you have any eye problems, you should discuss the use of nasal steroid sprays with your eye doctor, as they are sometimes problematic in patients with glaucoma or cataracts. Additionally, nasal steroid sprays can cause excessive nasal dryness and nose bleeds.
Cromalyn sodium spray (Nasalcrom) is, in my opinion, an excellent over the counter medication for allergy sufferers. It must be used regularly and, if your allergy problems are severe, frequently (see package instructions). Nasalcrom has minimal side effects, and adverse interactions with other medications are rare.
Singulair (montelukast) is another medication often used for patients with asthma or nasal allergies. In my experience, it is a poor “solo” drug, but is sometimes useful in combination with other medications.
Desensitization:
Desensitization — also known as immunotherapy, but more commonly referred to as “allergy shots” — has been demonstrated in many well-executed, carefully controlled clinical studies to be a safe and effective treatment for nasal allergies. It is particularly useful for patients with severe allergies who are unable to avoid their allergens.
Desensitization may take many months (a 12 to 18 month course of therapy is not unusual) and is not always effective. If the patient responds poorly to desensitization, there are three common possible explanations. First, testing may not have revealed the full range of allergens to which you are sensitive. To take a very obvious example, let’s say you own 6 cats, are allergic to cats, and yet you have not been tested for an allergy to cat dander. If you weren’t tested for it, it is very unlikely that your course of desensitization covered this particular allergy.
A second reason for failure is the development of new allergies during the course of therapy. You can develop new allergies throughout life.
Finally, your problems may not be due to allergy at all. Some nasal complaints are due to chronic sinusitis, which may be thought of as chronic inflammation (often with bacterial or fungal infection) of the tissues lining the sinuses. While many patients with chronic sinusitis improve with desensitization, many do not; presumably, the individuals who do not improve have little or no underlying problems with allergies.
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