AIR FILTERS

"What kind of air filter should I buy for my allergy?" I hear that question on a daily basis. In general, the answer is "it depends on what you're allergic to." If you are allergic to cat dander and grass pollen, and you have a cat in your home, I recommend investing in some sort of advanced filter. That's because these allergens are small; thus they are lighter than air and stay airborne indefinitely. That means they can actually be filtered out of the air. Now, let's compare that to dust mite allergy. Dust mite allergen is relatively large, staying airborne for about 15 to 20 minutes after being disturbed (such as making the bed). There's no way a filter can catch much dust mite allergen once it has settled back onto the bed or into the carpet.

Electrostatic filters are an interesting idea. You get a permanent metal filter that takes the place of your disposable fiberglass filter. The metal electrostatic filter is better at trapping allergens than the less expensive fiberglass model. However, consider these tips before you decide to go with electrostatic. First, you should run your air conditioning system using "ON" rather than "AUTOMATIC". You just paid for a good filter, and you want it filtering 24/7, right? Not just when your thermostat tells the compressor to blow cold air in the summer or tells the furnace to blow warm air in the winter. Second, be sure to clean the filter regularly with a strong flow of water. Most recommendations say to wash off the electrostatic filter once or twice a month, but it depends somewhat on how dusty your home is. If you don't keep an electrostatic filter clean, it will become less effective. It will also increase the drag on your entire HVAC system, making the system work harder. The company that services the air conditioners in my home doesn't like electrostatic filters at all, saying they reduce the life of the entire system. That company, AireServ, recommends that allergy patients consider an in-system High Efficiency Particulate Air (HEPA) filter. They sell the Lennox Healthy Climate, which is excellent, but expensive.

If you do get a filter, should you get a free-standing HEPA filter, a Sharper Image Ionic Breeze, or electro-static filters that replace your furnace filters in your home's air conditioning system? This depends somewhat on budget and noise tolerance. The HEPA filters have fans that make some noise. If you buy one, I recommend you get a Honeywell. After all, it's "the brand that doctors recommend most." Gag!! Actually, since it's a big seller, you'll be able to find the filters for it at any hardware store 15 years from now. Who is going to sell you the replacement filter for that Whirlpool or Vornado HEPA you bought 4 years ago? I don't know. I have a Honeywell in my bedroom, and we keep it on low speed when we're in there, and on high speed when we leave for the day. You have to change the pre-filter every 2 or 3 months. It's very easy to change, but take the unit outside before you disassemble it so the dust doesn't get messy. Changing the main filter is almost as easy, and only has to be done every couple of years.

The Sharper Image Ionic Breeze, with its huge advertising budget, has made quite an impact on the public, as well as the allergy community. With the professional marketing behind it, it is now thought by consumers to be the "best" filter out there. At least that's what it implies in its commercials. And besides, the Asthma and Allergy Foundation of America has given the Ionic Breeze its Seal of Truth. But what does that really mean?

AAFA does not endorse, recommend or advocate the purchase of any specific products, but AAFA will grant a "Seal of Truth" to products that meet scientific criteria determined by an independent panel of scientists including MDs, PhDs, MPHs and other medical, scientific and research experts. The AAFA Seal has been awarded to a variety of consumer products in many categories including vacuum cleaners, air filters, cleaning products and more.

To translate that last bit to English, if you have a product that works, and you pay AAFA $5000.00, they will allow you to use their Seal of Truth. Also, the seal states that the filter can "reduce airborne allergens and irritants..." As with most filters, it does NOT say it will reduce your symptoms, make you feel better, or allow you to use fewer medications. Currently, Sharper Image is giving dozens of my allergy colleagues large research grants to prove that their Ionic Breeze is an effective air cleaner AND can reduce symptoms scores. Sharper Image has certainly gotten its money's worth from that $5000.00 investment; however, I believe AAFA's sterling reputation has suffered. Both the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology have sent their members letters distancing themselves from that endorsement. That was a necessary step since both the College and the Academy have provided financial support to AAFA for many years. Stay tuned – this is exciting!

FULL DISCLOSURE – I own an Ionic Breeze GP model. We keep it in the room where our dogs, Spike and Rosie-Toes, sleep. A couple of my patients got one and raved about it, so I decided to give it a try. It does gather dust – we can see the dust every time we remove the filter to clean it. But, as Consumer Reports points out, my coffee table also gathers dust out of the air. That doesn't make it an air cleaner.

Lastly, the Ionic Breeze is NOT silent, as Sharper Image claims. Several of my patients agree with me that it hisses and pops whenever a tiny speck of dust hits the grid.

So what's the bottom line? If you're interested, get one if you can afford it and try it for 60 days. But keep all the packing materials, the box, and your receipt. If your symptoms aren't better after 59 days, pack everything up (including the receipt) in the box, take it back to The Sharper Image, and get your money back.

"No matter what filter you buy, you have to remember that a filter is just one step in a long process of allergen avoidance. If recommended by your doctor, you should also cover your mattress and pillow with impermeable covers; you should wash the sheets in hot water, remove the carpet from your bedroom, and keep the humidity in your home low enough to discourage growth of dust mites and mold." – David B. Engler, MD

 
AN ARMY OF PLACEBOS

Often, a patient comes in with allergy complaints that require a certain medication for relief, only to have an underlying medical condition which prevents him/her from being able to take that medication. Instead, we are left treating the allergic condition with another, less effective remedy. The classic example is the patient who has high blood pressure and a very stuffy nose. The best drug for the stuffy nose, Sudafed, often worsens the hypertension; thus, we have to choose the best alternatives. Interestingly, several allergy medicines have been shown to treat stuffy nose (nasal congestion) "better than placebo". That's good, right? Not necessarily. Remember the football coach who said that a game ending in a tie is like kissing your cousin? That's what "better than placebo" sounds like to me. Treating the stuffy nose with "better than placebo" means no Claritin-D, Allegra-D, Zyrtec-D, or any other oral decongestants. Still, we have prescription drugs like Astelin, Singulair, Clarinex, Flonase and Nasonex all bringing us evidence that they relieve nasal congestion "better than placebo". Usually, I would say, "big deal better than placebo ain't worth much more than getting hit in the face with a wet mop".

All the same, if our hypertensive patient with the stuffy nose takes Clarinex, which is great for runny nose and itching, and "better than placebo" for nasal congestion; and also takes Nasonex nose spray, which is wonderful for allergic drainage and sneezing, and "better than placebo" for nasal congestion, and maybe Singulair, the leukotriene blocker that is "better than placebo" for nasal congestion-well, you get the idea. It may take a few building blocks, but we often are able to relieve difficult-to-treat symptoms without bothering underlying medical conditions by recruiting this Army of Placebo's.

For one last tip on helping stuffy noses, read this page about Breathe Right® strips.




 
AND YOU'RE A CAT LOVER?

If you love cats, but you're allergic to them, hope may be on the way. The major protein responsible for cat allergen has long been known: it is called Fel d I. It is found in the dander of the cat after being produced in the cat's sebaceous glands. The gene responsible for producing Fel d I has been identified, and a company called Allerca has bred kittens after silencing this gene. Kittens were available for purchase for $4,000.00, but demand drove the price up to $5,950.00 with an additional $2,000.00 fee if you wanted to go to the top of the waiting list. But they sold too many kittens, and have now stopped selling them until their own supply is replenished.

If you wish to keep Fluffy and it's driving your allergies nuts, here's some advice:

First, it is always best to remove the cat from the allergic person's home. Having said that, most patients I counsel want to reserve cat relocation as the last option. I'm okay with that as long as the cat is not sending you to the E.R. with brittle asthma. So, assuming Fluffy will not be evicted, here's what may help:

	1.	Keep the cat out of your bedroom at all times, even when you're not home.
	2.	Remove carpeting from your bedroom (removal from the whole house is even better).
	3.	Cover your mattress and pillow with true allergy-proof covers. My favorites are from Mission Allergy. They'll give you a 15% discount on pillow and mattress barriers if you ask nicely and say we referred you.
	4.	Put a HEPA filter in your bedroom and run it 24/7. I usually don't recommend fancy filters; that's because most allergens are heavier than air. Cat allergen is tiny and remains airborne; thus, it can actually be captured by a good filter.
	5.	Mild or moderate cat allergy responds very well to allergy shots. Allergy Shots, when administered correctly, actually induce tolerance in the allergic patients so that future encounters with cats produce milder symptoms.
	6.	Consider getting a light-colored, neutered cat. Some researchers believe they produce less Fel d I than their darker cousins. A black male cat, therefore, may be a bad choice for the allergic patient.
	7.	If you play with your cat, wash your hands well and change shirts afterwards. Take care not to touch your eyes.

Removing a cherished member of the family from the home can be difficult. Often, we are able to bridge the gap between a cat lover and their cat allergy.

 
AN UNMET NEED – FOOD ALLERGY TREATMENT

For the most part, treatment of allergies and asthma is much easier, and much more effective, than when my father was in my shoes as a 48-year-old allergist. The year was 1972. We didn't have Seldane, much less Claritin or Allegra, the non-sedating antihistamines. We didn't have Advair, much less Pulmicort or Asmanex, the state-of-the-art asthma maintenance inhalers. Triple therapy for asthma was Theo-Dur, albuterol tablets, and an Alupent inhaler.

We also didn't have any help for patients with severe food allergies except: avoid eating that food, and here's a prescription for injectable epinephrine in case some pieces of allergic food slip into your meals. Guess what? That's still the treatment guidelines for severe food allergies. I don't mean eating chocolate gives you a headache. I mean eating peanuts gives you a tight throat and drops your blood pressure to zero. What's worse, the number of people with true food allergies is getting bigger every month. We clearly have an unmet need in the treatment of food allergy.

But we're close. Every year, those of us in the field hear about how research protocols for food allergy treatment have been successful. Basically, the treatments are like allergy shots, but the immunotherapy is taken under the tongue rather than an injection. Much of the funding for these important studies comes from the Food Allergy & Anaphylaxis Network. That's one of the reasons why my wife and I are big supporters of FAAN.

I invite you to check out their web site , and to participate in the Food Allergy Walk at Sam Houston Park on September 12, 2009. Details are available at Walk for Food Allergy. Several of us will be there at our booth since our sister practice, The Allergy Clinic, is the original platinum sponsor for this walk. So, let's hope for great weather, and we'll see you there.





 
ASK YOUR DOCTOR TO OPT OUT

We can have excellent quality healthcare. We can have universal coverage. And we can make it affordable. Now choose which two you want. The problem is when you try to fit all three into one model it's impossible. I wish I had the solution, but there is one thing all physicians can do to decrease the acceleration of healthcare spending — restrict your prescribing data from drug companies.

Starting in October 2007, my Allegra drug rep came in the office selling Xyzal, the new antihistamine that is derived from Zyrtec. Wait, you mean the Allegra rep, who spent the last 10 years criticizing Zyrtec is now promoting the new, improved Zyrtec? Yep.

In December 2007, Zyrtec went generic and then over-the-counter. Allegra went generic last year. Generic drugs can save you money, and they save your insurance company even more money. But every allergist, ENT, internist, and family practitioner is going to get a visit from the Xyzal rep. They will try to convince us that Xyzal, at $3 a pill, is better than generic Allegra or generic Zyrtec, both available at a fraction of the cost.

For a few of my tough-to-treat patients with hives, they're right. Xyzal will be an absolute blessing. But, Xyzal has no business being promoted to doctors as the next blockbuster allergy medicine. Drug companies purchase physician prescribing data and tell their drug reps which doctors are prescribing what medicine at what rate. That way, they can zero in on doctors who are “underperforming.” New Hampshire and other states are suing to outlaw the practice, but the drug companies are hiding behind the First Amendment.

Here's how we can fight back. Ask your doctor to opt out by having their prescribing data restricted. They can easily register and opt out at AMA. They'll need to register, but there's a link to set up an account. If enough doctors opt out, drug companies will have a harder time driving up the cost of American healthcare.

 
BACK TO SCHOOL

	1.	#2 Pencils
	2.	Notebooks
	3.	School Uniform
	4.	Allergy Medicine...

Wait – allergy medicine? That's right. Adequately treating your child's allergies may be just as important to ensuring their academic success as new school supplies. Allergies affect the whole body, not just the nose. In a recent survey conducted by the American College of Allergy, Asthma, and Immunology, 94 % of the respondents stated that their allergy symptoms affected their quality of life, including their performance and school and work. Allergy symptoms often lead to difficulty sleeping, fatigue, and daytime drowsiness, all of which may make it difficult for your child to perform well in school. Children dealing with untreated allergy symptoms, such as runny or stuffy nose, itchy eyes, and sneezing often find it difficult to concentrate and may have behavioral problems such as increased irritability or hyperactivity. Your child's allergies may also affect activities outside of the classroom, diminishing activity, interest, and performance in extracurricular activities such as sports.

Many children with allergies also have asthma which, if untreated, may also affect performance in school and leisure activities. Like the nasal symptoms of allergies, the shortness of breath, wheezing and nighttime cough associated with asthma can impair sleep leading to fatigue and decreased concentration. Asthma attacks may also impair athletic performance and the fear of having an attack is enough to discourage some children from even attempting participation.

The good news is that help is available. Many treatments are available for allergy and asthma symptoms, freeing your child to excel both in and out of the classroom. Unlike many older medications which have a high incidence of sedation, current regimens will allow your to be awake and alert during the day and sleep well and night. Irritability may decrease when the child is no longer suffering from constant running nose, sneezing or stuffiness, and involvement in extracurricular activities may be easier when they can breathe freely. Immunotherapy treatments (i.e. allergy shots) are also available and treat the underlying allergy process, potentially making it possible to be symptom free with minimal or no medications.

Remember, a child who does not feel well may not learn well. If your child has allergies or asthma, make sure they are getting all the tools needed for academic success. In addition to pencils, pens, and notebooks, allergy and asthma treatment may be just the thing.

 
BANNED IN BOSTON (AND THE REST OF THE USA)


Many patients with asthma have had trouble getting their generic albuterol inhalers filled lately. The propellant of the generic albuterol is chlorofluorocarbons, and all CFC-containing albuterol inhalers in the United States must be withdrawn by the end of 2008.

Replacing them are albuterol HFA products. The HFA propellant does not damage the ozone like CFCs do. Further, the albuterol dissolves better in a HFA, and penetrates deeper into the lungs, which allows for better dilatation of the breathing tubes.

Since no HFA albuterol is generic, they are more expensive to buy; however, the ProAir HFA brand has a $15 discount voucher you can print from its web site. Temporarily, there is also a link there to get a whole prescription of ProAir HFA for free.

HFAs feel different from CFC inhalers. They're not as cold, and they come out much slower. That makes it easier to inhale them into the lungs instead of having most of it whack into the back of your throat. You do have to rinse out your HFA device every few weeks or it may clog up.

Instructions are available online at Proventil®HFA. Their site also has a $15 rebate you can print and temporarily has a free transition kit that includes a voucher for a whole prescription of Proventil HFA.

Some patients really prefer the old inhalers. For them, I recommend asking their doctors to prescribe Maxair Autohaler or the Alupent inhaler. Unlike albuterol, neither of those asthma rescue medications is affected by the 2008 deadline. According to the March 29, 2007 New England Journal of Medicine, they are “subject to withdrawal in the future”.

No matter which asthma rescue drug you use, if you're using it more than once or twice a week, ask your doctor if you would benefit from an asthma controller inhaler. These wonderful additions prevent the swelling and inflammation that causes asthma in the first place.

 
BREATHE RIGHT® STRIPS

In An Army of Placebos we talked about how it sometimes takes a few tries to relieve a stuffy nose when we're not allowed to use strong drugs like Sudafed (pseudoephedrine). That article failed to mention Breathe Right® nasal strips as a helpful adjunctive treatment for stuffy nose. These adhesive strips stick to the outside of your nose, and pull it open just a little bit to partially relieve the congestion.

Poiseulle" Law determined that the laminar flow rate of an incompressible fluid along a pipe is proportional to the fourth power of the pipe's radius. In other words, you need sixteen tubes to pass as much fluid as one tube twice their diameter. In the case of the Breathe Right nasal strip, we're not doubling the radius of your nasal passage; just increasing it a bit.

But consider the example of a 7 mm passage that increases to 8 mm. 7 to the 4th power is 2401.

7x7x7x7=2401

8 to the 4th power is 4096!

8x8x8x8=4096

In other words, you almost doubled the amount of air that can flow through your congested nostril just by increasing the diameter 1 millimeter.

Sorry for all that math, but I love to point out that staying awake in high school physics class does have a point, after all. A few tips from veteran users of Breathe Right nasal strips. First, the adhesive is good, but not great. So clean the oil off your nose well before application so the adhesive will stay put. Second, you need the strip sticky at its ends, but not in the middle. Some patients put a little dab of Kleenex in the middle of the strip before application so it doesn't stick to the bridge of your nose. Then, removing it doesn't peel off your skin. Ouch!

Here is a link from their web site on the mechanism of action. It's a 13-page paper (Adobe Reader required):



 
CALL ME A SKEPTIC

With gasoline over $2.00 per gallon, automobile manufacturers are trying to figure out how to let Americans have their cake, and eat it too. We want luxury, safety, and of course, fuel efficiency. Honda, Ford, Lexus, GM and Toyota are bringing out hybrid engines that run on both gasoline and electricity. Mercedes, on the other hand, is featuring the diesel engine in its new E320CDI. Until now, Volkswagen had the only diesel automobiles in American automobile showrooms. Most trucks are available with diesel engines.

Diesel exhaust particles (DEPs) are terrible for people with allergies and asthma; to tell you the truth, they even raise the allergic antibody (IgE) levels in people who do not even have allergies. According to the Environmental Protection Agency (EPA), diesel exhaust particles may be the component of air pollution most responsible for the huge increase in allergies throughout the western world. The exhaust that these soot-filled tailpipes release into your lungs make the immune system produce chemicals, called cytokines, which worsen allergic inflammation. According to Mercedes, its new diesel will be clean , burning its diesel fuel at higher temperatures and higher compression ratios. This will produce less noise and pollution per Mercedes. As a recent Wall St Journal article points out, though, the CDI is so new there are no emission statistics available on the car. Meanwhile, cover articles from the Journal of Allergy & Clinical Immunology from 2005 show diesel fumes driving production of IgE, the allergic antibody.

Granted, diesels produce fewer greenhouse gases and are more fuel efficient than their gasoline counterparts. But if you want to have your cake and eat it too, I recommend a gasoline hybrid. Not a diesel. Not even a Mercedes diesel. Nose Still Stuffy?






 
CAVEAT EMPTOR

The Carpet and Rug Institute (CRI) used to advertise to doctors in physician journals claiming that carpeted rooms are actually better for the allergic patient than hard floors. I thought they would extend these ads to the public, but that has not happened yet. Dozens of scientific studies have been published in peer-reviewed, prestigious medical journals on the value of avoiding what you're allergic to. Almost all of them recommend removing carpeted surfaces and putting down tile, wood or linoleum instead. The references provided by the CRI that support carpeting being less allergenic than hard floors come down to one medical abstract; it was not accepted for publication in any peer-reviewed journal.

Their argument goes like this: when you walk on hard floors, you kick up pollen, dust mites particles, etc, that get into your "breathing zone". On the other hand, according to CRI, carpet traps these particles, thus protecting you from breathing them in.

This is just not true.

By cleaning hard surfaces, you remove the allergens entirely. Carpeting, which provides dust mites with a nice, warm, moist environment to live, can never be totally cleaned of allergenic particles. Not even close. So keep your carpeting if you can control your allergy symptoms in spite of it, but don't install it because you think it will help with your allergies.

So, while the Carpet and Rug Institute puts its opinion all over the internet (including Wikipedia, unfortunately, claiming that carpet helps allergies and asthma, almost all researchers disagree:

Here are some examples: from BBC News, DrGreen.com and the American Academy of Allergy, Asthma and Immunology.



 
CHRISTMAS TREE ALLERGY – NOTHING TO SNEEZE AT

The Christmas tree you buy each year is at the end of its long journey. Having grown up in Oregon, it is harvested and placed on a flat bed truck for its cross country journey. Once every few stops, the trees are watered down to keep them moist and fresh. Just make sure that the beautiful Tannenbaum you invite into your living room doesn't make your allergies worse! Although an artificial tree is best (if you rinse off the attic dust!), here are some tips if you decide to go with a real tree:

That continual watering promotes mold growth. Make sure to spray your tree with a garden hose before bringing it inside. This also helps rinse the pollen off the tree. Although pine trees aren't a major source of tree pollen, they can trigger hay fever if you get a big dose of the powder right in your face. Rinsing the tree off, plus using your allergy medicines before you enjoy trimming the tree, may prevent your Christmas-time allergy. Speaking of trimming the tree, your ornaments may have spent the off-season in the attic with dust mites and mold. Carefully clean them off in a well-ventilated area. After Christmas, pack the ornaments carefully in sealed plastic bags to make next year's job a bit easier.

Keep the living room well-ventilated. The aromatic resins that impart the pine scent can act as non-allergic irritants. Our Texas Aggie buddies suggest the Leyland Cypress tree since, as a true hybrid, it cannot produce pollen. Fewer resins on the Leyland Cypress mean fewer odors.

Along with cheerful holiday gatherings come colds and flu. How does your doctor keep from getting all those bugs? We wash our hands with hot soapy water or Purell about 753 times a day. Careful hand washing can prevent transmission of respiratory viruses.

Stay well and Happy Holidays from Houston Allergy and Asthma Clinic, your allergy and asthma specialists!



 
CONTACT DERMATITIS

Itchy, scaly rash on your hands? Dry, cracked lips and rash around the mouth? Scales and rashes under the eyelids? Rashes anywhere else on your body? This all could be a condition known as contact dermatitis. Contact dermatitis can cause discomfort and embarrassment and is the most common skin condition among workers' compensation claims.

Contact dermatitis refers to any dermatitis arising from direct skin exposure to an exogenous substance. The dermatitis may either be allergic or irritant-induced. Irritant-induced contact dermatitis accounts for 80% of cases of contact dermatitis, and allergic-induced contact dermatitis accounts for 20% of cases. In allergic contact dermatitis, an allergen induces an immune response, while in irritant contact dermatitis the trigger substance itself directly damages the skin. Contact dermatitis is a common cause of occupational disease, accounting for 30%-40% of all occupational illnesses and 90% of occupational skin diseases. The most common sensitizer in North America is the plant oleoresin urushiol found in poison ivy, poison oak, and poison sumac. Other common sensitizers in the US include nickel (jewelry), formaldehyde (clothing, nail polish), fragrances (perfume, cosmetics), preservatives (topical medications, cosmetics), rubber, and chemicals in shoes (both leather and synthetic). Hypersensitivity to a number of medications may also occur.

Tracing its relation to causative factors is difficult. However, here at Houston Allergy and Asthma Clinic, our expert physicians with detailed knowledge about this disease process can perform special customized tests using your cosmetics, perfumes, hair products, etc, to see if these agents are causing your symptoms of contact allergy. Patch testing can help identify or confirm contact allergens and is the gold standard for contact allergen identification. Our medical staff will take a detailed history, and then you will have one on one physician consultation to come up with the best identification and treatment plan that is right for you.





 
CONTROL YOUR ASTHMA BETTER

Patients with an allergy can have 20 times the risk of developing asthma as those who do not have allergies. But what steps can we take to monitor patients with asthma and give them the best possible outcome?

We are excited to announce a new medical device called the Insight™ eNO. This test actually measures airway inflammation. Medical studies have shown that patients who are monitored with this test and spirometry frequently have better outcomes with less medication.

Common symptoms of asthma include shortness of breath, wheezing, cough, and chest tightness. The standard treatment for asthma – there is no cure – is regular use of inhaled steroids, like Pulmicort or Asmanex, or combination drugs, like Advair or Symbicort. In addition, “rescue medications,” such as albuterol, help relieve immediate symptoms.

It has been know for over 10 years that quantifying the amount of exhaled nitric oxide is an accepted and trusted method of measuring bronchial airway inflammation. Unfortunately, until now, there has been no practical way of utilizing this knowledge in the treatment of asthmatics. That has now been remedied with the Insight™ eNO. This new device is easy to use and allows accurate measurements of airway inflammation. One important benefit to the patient is that the dose of medication necessary for successful treatment can be prescribed in far more precise amounts. In some patients, the treatment plan may lead to more aggressive treatment efforts, while in many others the amount of the maintenance inhaler can be reduced, without resulting in increased symptoms of asthma. The test is hygienic, safe, pain-free and economical.

It is rare that a new device is introduced that provides this level of advancement in patient care at such a small price. The Insight™ eNO is just that, and we are excited to be the first allergy office in Harris County to offer this important test to our patients.



 
DOCTORS YOU CAN UNDERSTAND

A couple years ago, we wrote one of these columns as an April Fool's prank. On behalf of People for the Ethical Treatment of Dust Mites, we asked patients to boycott Houston Allergy and Asthma Clinic because we recommended ways that patients could reduce their allergy symptoms by reducing their exposure to dust mites. Well, it's April again, and we doubt you'll fall for that same trick.

Our approach this year is how to understand your doctor if he talks too much like a scientist. Here's one: If you go to the hospital and wind up getting much sicker with some horrible infection because someone never washed their hands before examining you, expect to hear, something about “…an iatrogenic nosocomial infection.” To translate, that means an illness acquired in the hospital and caused by the hospital staff or the doctor. If your doctor says that your allergies or asthma are “exacerbated by a multifarious interaction among proinflammatory cells, mediators and cytokines resulting in abnormal airways hyperresponsiveness,” well, that just means that evaluation and management of allergies are complicated; indeed, they are. But that doesn't mean we can't explain things in a straightforward way. How about, “the immune response to respiratory syncytial virus causes a predisposition toward an intense inflammatory reaction manifest as eosinophilic desquamative obstructive bronchitis”? I would rather tell you that asthma often flares up when you catch a cold.

Wouldn't it be nice if you got lucky and ended up with a doctor you could actually understand? When you choose Houston Allergy and Asthma Clinic, you're assured of a complete allergy evaluation by nationally recognized experts who listen to you. If there is something you're confused about, we will carefully explain it to you—in language you can understand. And if the answer to the question you ask is, “Probiotics have the potential to reduce intestinal permeability and the generation of proinflammatory cytokines that are elevated in patients with rhinitis, atopic dermatitis, and food allergy,” then I would say that eating yogurt may help improve your allergies.




 
DROPS OR SHOTS

Recently, I wrote about how it is now possible to stimulate the immune system with allergy drops for the long-term treatment of allergies or asthma. As such, we have had several people start treatment with our allergy drops, which are supervised by Michael Flanagan, PhD, PA-C. Dr. Flanagan has a PhD in immunology, plus he went to medical school to become a physician assistant. Michael is on a first-name basis with Dr. Robert Esch, PhD of Greer Laboratories, the company working on getting allergy drops approved by the FDA in the USA. Though not FDA approved, allergy drops are safe, effective, and legal.

Still 75 percent of people who have come to us asking about allergy drops have decided to take allergy shots. Why? Two big reasons: first, allergy drops are not covered by your medical insurance. Second, we're in our 14th year of performing rush immunotherapy, where we give someone the first six months of their allergy shots in one day. One day! That means you go straight to getting maintenance allergy shots once a month and not much “once a week” allergy shots at all. And the best part of all: once you're on once-a-month shots, you take them for three to five years, and then you're done! The best part about high dosed allergy shots is that they continue to provide their immunologic benefit for years after you stop taking them.

Houston Allergy and Asthma Clinic, our sister practice in Park Plaza, would like to thank Dr. Ramon Garrido, who retired in September 2008, for over 40 years of practice. And, our clinic welcomes Dr. Sunil Saraf, a board certified allergist who has been practicing in The Woodlands. Dr. Saraf will see patients in our Fannin and Pearland offices for now, and then begin seeing patients in our Park Plaza office. We are highly selective when choosing our doctors, and hope you enjoy getting to know Dr. Saraf as much as we have.






 
ENSURE ACADEMIC SUCCESS – ALLERGY MEDICATIONS CAN HELP

Treating your child's allergies may be just as essential to ensuring academic success as starting them off each morning with a good breakfast. In a recent survey, 94 percent of the respondents stated that their allergy symptoms affected their quality of life, including their performance at school and work.

Allergy symptoms often lead to difficulty sleeping, fatigue, and daytime drowsiness—all of which may make it difficult for your child to perform well in school. Children dealing with untreated allergy symptoms often find it difficult to concentrate and may have behavioral problems such as increased irritability or hyperactivity. Your child's allergies may also affect activities outside of the classroom, with a diminished activity, interest, and performance in extracurricular activities such as sports.

Many children with allergies also have asthma that, if untreated, may also affect performance in school and leisure activities. The shortness of breath, wheezing, and nighttime cough associated with asthma can impair sleep, leading to fatigue and decreased concentration. “Asthma attacks” may also impair athletic performance and the fear of having an attack is enough to discourage some children from participating.

The good news is that many treatments are available for allergy and asthma symptoms. Unlike many older medications, which have a high incidence of sedation, current regimens will allow your child to be awake and alert during the day and sleep well at night. Irritability may decrease when the child is no longer suffering from constant allergy symptoms, and involvement in extracurricular activities may be easier when they can breathe freely.

Remember, a child who does not feel well may not learn well. If your child has allergies or asthma, make sure they are getting the essentials needed for academic success.



 
FOOD ALLERGY TREATMENT – WORKING TO MAKE IT EASIER

Part of the reason I love practicing allergy is that we have so many successful ways to handle the problems that come up. Those allergic to dust mites find successful relief with avoidance of dust, treatment of symptoms with pills, or prevention of symptoms with nose sprays. Airborne allergy can even be changed with allergy shots, which are designed to make you less allergic. Things are not so easy with food allergies. The only effective treatment is avoiding what you're allergic to.

If a severe reaction occurs, we try to prepare our patients ahead of time to carry injectable epinephrine, either an EpiPen or Twinject. There are no effective allergy shots that can fix a food allergy. Try being allergic to peanuts and scheduling an evening flight on Southwest Airlines. Or enjoying a meal at a nice restaurant if you experience anaphylaxis when eating pecans, almonds, or shellfish. Luckily, a tremendous asset exists for those with food allergies: the Food Allergy & Anaphylaxis Network.

The difficulties in living with food allergies are made easier by their practical tips. Check out the Downloads section of the web site for School Guidelines for Managing Food Allergy, or How to Read a Food Label.

On September 12,2009, Walk for Food Allergy: Moving Toward a Cure comes to Sam Houston Park. Our sister practice, The Allergy Clinic, is a platinum sponsor of the walk and invites all of our patients (as well as the whole community) to participate. Sign up at Food Allergy Walk.

Unfortunately, the incidence of severe food allergy keeps increasing. We are trying to raise awareness about what it's like to live with food allergies and support NIH funding so that, one day, treatment of food allergy will be no more difficult than treatment of dust mite allergy.



 
FOOD ALLERGIES IN CHILDREN

Laura is one of our patients and is planning her first pregnancy. She has allergies and mild eczema, and her husband has food allergies. They came to see me and asked what advice I had to decrease the chances that their baby will have allergies.

First of all, there is no good evidence that avoiding specific foods during pregnancy will prevent the baby from developing allergies, except maybe in the case of peanuts. The literature is inconclusive, but we now recommend our pregnant patients with allergies to avoid eating peanut products while they’re pregnant. But what about a food that has no peanuts but whose label says “this product may contain peanuts.” With the new food allergy rules passed recently by Congress, some manufacturers put that label on everything they make; probably on the advice of their legal department. Anyway, that would be a trace amount, so it would be OK for Laura to eat that food.

After delivery, the most important intervention is exclusive breastfeeding for the first four to six months of life. While breastfeeding, Laura has been advised not to eat peanuts or tree nuts (e.g. walnuts, pecans, cashews). Some advise eliminating eggs, milk, fish, and shellfish, but the evidence for avoiding those is sketchy. When foods are introduced to the infant, dairy products should be delayed until 12 months; eggs until two; and peanuts, tree nuts, fish, and shellfish until three.

Breastfeeding while eating a restricted diet doesn’t always prevent food allergies in the infant, but it probably does decrease the chance of the baby developing eczema. Some research has shown that young children with A.D. develop allergic rhinitis and, subsequently, asthma much more frequently than young children without childhood A.D. This phenomenon is called the Atopic March. Laura and her family are hoping that following these recommendations prevent the misery of allergies in their children.




 
GARDENING AND ALLERGIES

A couple of years ago, National Public Radio aired a review of a book called, Safe Sex in the Garden: And Other Propositions for an Allergy-Free World. What a title! The premise of the book is that how you garden, and what you plant, can have a big impact on how your allergies bother you. Gardening is a wonderful activity, but what you plant might make you sneeze, wheeze or itch. The author, Thomas Ogren, has been hired to advise on pollen-free landscapes at schools, businesses, even the Virginia headquarters of the American Lung Association.

Basically, avoid male plants because they make pollen. Female plants do not make pollen. By choosing plants with colorful flowers, you do yourself a huge favor. These plants rely on insects to pollinate them, not the wind. So they are less likely to bother your allergies. (If you are allergic to the insects, like honeybees, however, then disregard what I just said!)

It's a good idea to use your antihistamine pill or nose spray before you start your outdoor activities. Even though Claritin, Allegra and Zyrtec treat allergy symptoms, they work even better at preventing allergic reactions. I also advise my horticulturally-inclined patients to wear gloves, goggles and respiratory masks to reduce exposure to pollen and other irritants while enjoying this hobby. When done working outdoors, it's a great idea to shower and wash your hair to remove excess dust and pollen. Also, place your clothes in a covered hamper until you get a chance to wash them.

Pick up a copy of Tom Ogren's book or visit his web site for more tips. He has great chapters on plants that cause skin rashes, and a great discussion on poisonous plants. At $14.95, it's probably less expensive than your co-pay to go see the doctor!


 
GET THE DROP ON YOUR ALLERGIES

Perhaps because I am board certified in internal medicine, I tend to get many referrals from doctors who are also board certified in internal medicine. My father was trained in pediatrics before he did his allergy and immunology fellowship. Oher doctors have done a combined internal medicine and pediatrics residency. That would have been too difficult for me; I barely survived the three years of internal medicine residency at Baylor College of Medicine's teaching hospitals.

The American Board of Allergy & Immunology is a conjoint board of the American Board of Internal Medicine and the American Board of Pediatrics. So every board certified allergist is also board certified in either internal medicine or pediatrics. Most of these boards require their members, or “diplomates,” to re-certify with another examination every six to 10 years. My board certification in allergy and immunology expires in 2011, and I'm already studying!

These medical specialty boards require high standards of training and performance and ensure them by rigid examinations. On the other hand, there are other board certified doctors whose specialty is not recognized by the American Board of Medical Specialties. According to www.quackwatch.com, there are more than 75 boards not affiliated with the ABMS. Most of these boards do not require a residency, which usually takes three to five years. Some of these boards only require a weekend course. Among some examples of these boards is the American Board of Chelation Therapy, or Clinical Ecology, or Environmental Medicine.

Houston Allergy and Asthma Clinic strives to practice evidence-based medicine, even when we delve into complimentary and alternative medicine. With this in mind, we will start offering high-quality, high-dose allergy drops for our patients who prefer drops to shots. If you're interested, please call 713.522.9911.




 
GOT A CHRONIC COUGH?

What's causing that chronic cough, anyway? When doctors evaluate a complaint, they form a "differential diagnosis", which is a list of possible diagnoses that should be ruled out. Complaints of cough are most likely due to sinusitis or bronchitis, but can also be caused by allergic drainage dripping down the throat. Sometimes, cough may be the only symptom we see when we make the diagnosis of asthma (called 'cough-variant asthma'). Once in a while, gastro-esophageal reflux presents as chronic dry cough. Many different medicines have cough as a side effect, but ACE inhibitors, used to treat high blood pressure, are some of the worst offenders.

Names of some ACE inhibitors include Vasotec (enalapril), Prinivil or Zestril (lisinopril), and Altace (ramipril).

Successful treatment of a cough depends on the underlying cause. I mentioned above that reflux can present as cough. Sometimes, the cough is present in the total absence of heartburn. Nevertheless, modifying the diet and taking one of the proton-pump inhibitors, such as Prilosec, Prevacid, Nexium, Protonix or Aciphex can provide relief. When post nasal drip is a factor, we can try antihistamines, anticholinergics and nasal steroids to get rid of the drip, thus decreasing the cough. Often, though, the best way to stop the cough is by not coughing. Wait, that's not as stupid an idea as it sounds. The more you cough, the more you irritate your airways, making you more susceptible to further cough. I often recommend that a combination of cough suppressants be taken around the clock for a week or two to totally stop the cough.








 
IS ADVAIR SAFE TO USE?

Advair has a black box warning and an editorial in a recent New England Journal of Medicine by Fernando D. Martinez, MD, that says other drugs should be used first (and second). This continues to cause concern in our patients with asthma who benefit from using Advair.

However, it is still the belief of the doctors of Houston Allergy and Asthma Clinic that Advair is safe when used as recommended. The Journal of Allergy and Clinical Immunology has an editorial by Harold Nelson, MD, the most respected allergist in the country in its December, 2005 issue. In it, Dr. Nelson defends Advair, stating that "these outcomes (deaths) were not a direct toxic effect of the drugs and increases the possibility that they resulted from an interaction between relief of symptoms by ²2-agonists and delay in seeking medical care."

In other words, it was not the combination drug, Advair, increasing the risk of death. Rather, it was use of Advair's component half, Serevent, without also using an inhaled steroid. Plus, because stimulant drugs like Serevent and albuterol make your asthma feel better for a little while, you may postpone the necessary doctor visit to get appropriate treatment.

An advisory panel of the FDA met in 2006 to consider taking Advair off of the market. You can imagine the scare this put into our patients who are taking that medication, particularly those who are receiving such benefit from it. Bottom line: If you are on Advair, Do Not Worry! Do Not Stop the drug unless your doctor advises it. The FDA advisory panel unanimously decided not to remove Advair, Serevent or Foradil from the market.

A little background on this: Advair is actually a combination of two drugs: salmeterol and fluticasone. Each of these was sold alone as, respectively, Serevent and Flovent. Flovent is an inhaled steroid, and no one is worried about that drug. Serevent, on the other hand, is a mixed blessing, particularly if it is being used by itself. Serevent is a bronchodilator, similar to albuterol (Ventolin, Proventil). Serevent has a longer duration of action than albuterol, though. It works for 12 hours instead of 3 or 4 hours. The way that bronchodilators work is by relaxing the smooth muscle on the outside of the airway. That relaxation allows the airway to open wider and let more air come through. The relaxation actually takes place because albuterol and salmeterol are beta agonists and they stimulate beta receptors. The problem with salmeterol by itself is that when you over-stimulate a beta receptor, your body responds by down-regulating (decreasing) the production of the beta receptors. Thus, you end up with fewer receptors for those beta agonists to attach themselves to.

Luckily, that problem doesn't happen when you use an inhaled steroid at the same time you use salmeterol. Advair contains salmeterol and fluticasone, an inhaled steroid. One important benefit of inhaled steroids is that they up-regulate (increase) the production of beta receptors. That up-regulation more than offsets the detrimental down-regulation that salmeterol by itself can cause.

Whenever Houston Allergy and Asthma Clinic prescribes a long-acting beta agonist such as salmeterol (Serevent) or formoterol (Foradil), we also prescribe an inhaled steroid to prevent any possible worsening of asthma symptoms. Advair has that beneficial inhaled steroid built in, so there is usually no need to worry about Advair worsening your asthma.

In summary, Advair has been a wonderful addition in the treatment of asthma. Patients on it should continue using it, but please contact your medical provider if you have questions. Patients on Serevent or Foradil who are not also using an inhaled steroid should contact their medical provider as soon as possible to have their condition re-assessed.

 
KNOCK YOUR ECZEMA – WITH NOXZEMA

Yes, it's true that the name, Noxzema, is derived from “Knocks Eczema”. In the early 20th century, this concoction was marketed as a sunburn remedy. The pharmacist who compounded it was complimented by a grateful customer who exclaimed, “You knocked my eczema”. Patients with eczema, or atopic dermatitis, are often spoiled by Houston's high humidity. But this time of year, our version of winter, the humidity drops and everyone's skin gets a bit drier.

Excellent care of eczema, according to fellow Texan and fellow allergist, Ernest Charlesworth, MD, begins with keeping the skin well moisturized. This time of year, that may require using your Eucerin, Lubriderm or Aveeno lotion 4 or 5 times each day. Step two is to prevent the skin from itching. According to Dr. Charlesworth, “Eczema is the Itch that Rashes, not the Rash that Itches.” That means that you often don't see the rash until you start scratching the skin. If you can prevent scratching the itch, you often prevent the rash. The hard part is not scratching the itch once the skin gets itchy. So how do we keep the skin itch-free? Unfortunately, many well-designed scientific studies have shown that antihistamines do little to relieve the itch of eczema.

So, what does work? Well, keeping the skin well moisturized is a good start, since dry skin itches. What else? Creams available with counter-irritants, like, well . . . Noxzema Original Cleansing Cream. And at $5 for a 10.75-ounce jar, it's a lot cheaper than some of the anti-itch eczema lotions out there. For instance, Sarna Original contains similar ingredients, but costs over twice as much. If your skin is badly irritated from the eczema, then Sarna Original and Noxzema may be too strong. Start with Sarna Sensitive or Aveeno Eczema Care for a couple weeks first. Allergies are the main trigger for eczema. Dust Mites cause eczema more frequently than any other allergen. The National Eczema Association is a wonderful patient resource.





 
MUSINEX VS. BROMELAIN

We have all seen the commercials for Mucinex: Mr. Mucus losing the battle to Mucinex, resulting in his eviction from the nose. Yes, this stuff really works, if used as directed, which is 2 pills, twice a day, with plenty of water.

Guaifenesin works by increasing the water content of your mucus, making it thin and easier to clear out. Mucinex contains time-released guaifenesin, so it only has to be taken every 12 hours. The generics also work, but not when taken twice a day. Walgreen’s Mucus Relief contains immediate-release guaifenesin, and should be taken 1 pill every 4 hours. There’s a big difference between remembering to take something twice a day vs. remembering to take something four times a day. Even though Mucinex is more expensive than the generic, it may be worth it if you can only remember to take a pill twice a day. Guaifenesin’s main side effect is stomach upset.

For people who get stomach upset with guaifenesin, I often recommend bromelain. Bromelain is basically pineapple enzyme. You know how they say you can mix jell-o with fruit, as long as that fruit isn’t pineapple? That’s because the bromelain prevents the protein in the jell-o from setting, or clotting. Same thing with your mucus, which is partially made of protein. Bromelain prevents the mucus from getting thick and stuck.

The German Commission E, which is roughly Germany’s Food & Drug Administration, has approved bromelain for “treatment of sinus and nasal swelling”. The trick with bromelain is to take it an hour before you eat; otherwise it will simply digest the protein in the meal you just ate. Rather than milligrams, the potency of bromelain is measured in “GDU’s”, or gelatin-dissolving units. That makes sense, right, because bromelain works by digesting protein. Many of my patients have gotten some good quality bromelain at Whole Food’s that worked well. Each capsule contains 2400 GDU’s, and I recommended one capsule, one hour before breakfast, lunch, and dinner.

What’s not worth the price? Mucinex Full Force nose spray, which contains the exact same oxymetazoline as Afrin or 4-Way nasal spray. But Afrin costs about 5 bucks, and Mucinex Full Force Nasal Spray is more than twice that. Meanwhile, generic Afrin can be had at Sam’s Club, 3 double-size bottles for less than $5.00.

 
NEW MATH

2 + 2 + 2 = 200

We had our winter. It even snowed Christmas Eve! Followed by a quick return to Houston Summer Redux, with 75 or 80 degrees. Through it all, our patients showed up at Houston Allergy and Asthma Clinic needing relief. The quick changes from cold to hot, and high humidity to low humidity worsened sinus symptoms in all people, not just those with allergies.

I was reminded of the explanation that Dr. Andy Grant used to give University clinic patients back when Dr. Malick and I were post-doc allergy fellows at U.T.M.B. Galveston. Dr. Grant would say that when you' re allergic to more than one thing, it's more than just adding up the sensitivities. Regarding allergy testing, he would tell patients, "Your 2+ sensitivity to molds, plus your 2+ sensitivity to ragweed, plus your 2+ sensitivity to dust mites add up to 200!" That's because of the priming effect. Remember priming a ground water pump at a farm? Getting it to pump water by cranking it a few times? Then, the water flows just fine. Well, the mold, which was high all summer, primed many of us into moderate misery – it only took a little bit of ragweed to send your allergy symptoms into the stratosphere.

Then the non-allergic weather changes played havoc with our heads and noses. Talk about adding insult to injury. What to do? As always, put out the fire with a continual coating of low dose nasal corticosteroids if recommended by your physician. Add on antihistamines to help immediate symptoms, and do your best to stay away from what you're allergic to.

When necessary, get to the doctor's office sooner rather than later so you're still being treated for allergies instead of for a sinus infection or for bronchitis. Lastly, prevention beats treatment in the long run. Prevention of symptoms usually means the prescription nose sprays. Prevention of the allergy itself is accomplished with allergy shots.



 
NO PRESCRIPTION, NO RISK?

Use of the wide array of over-the-counter (OTC) allergy and asthma medications is becoming increasing popular. OTC medications are convenient, fairly inexpensive, and can be picked up right at the grocery store along with some milk and bread; so they must be safe, right? Not so fast. OTC medications are not free from side effects or interactions. Decongestants are a prime example of this. Most OTC decongestants contain pseudoephedrine or phenylephrine, potent decongestants that can also be very stimulating. This can lead to increased blood pressure, a dangerous situation if you high blood pressure. Even patients with normal or borderline blood pressure can experience hypertension while taking decongestants. They can also cause insomnia. The fast acting decongestant nasal sprays, like Afrin and Neo-Synephrine, also have risks. Long term use of these sprays can result in your nasal lining becoming addicted to them. This leads to rebound swelling of the nasal lining which leads to worse congestion than you were treating in the first place and an increasing need to use the medication. These nose sprays are useful, but should not be used more than 3-5 days without medical supervision.

Herbal remedies can have their own risks. Echinacea is a popular herbal supplement readily available in forms ranging from teas to lozenges. Its most common use is as a treatment for colds and an immune booster. While it is generally regarded as safe, allergy sufferers beware. Echinacea is related to ragweed, the bane of the allergy sufferers existence in the fall. If you are allergic to ragweed, you may actually get allergy symptoms from Echinacea. Some patients who are allergic to grasses, a spring allergen, also get symptoms from Echinacea.

The message is not that OTC medications are bad. But you cannot assume that they are free from risk just because they do not require a prescription. These medications are best used in consultation with a medical professional.





 
P.E.T.D.M.

The People for the Ethical Treatment of Dust Mites (P.E.T.D.M.) request a boycott of Houston Allergy and Asthma Clinic because they continually advise their allergic patients to murder innocent dust mites. People allergic to dust mites have been advised to place barriers over their pillow cases and mattresses to reduce exposure to them.

Well, guess what? That deprives them of their food, starving them to death. Even worse, these allergy doctors counsel patients to wash their bed sheets and blankets in hot water. Wet heat KILLS dust mites. Dust mites have never intentionally caused any problems for humans. Trapping them in high filtration vacuum cleaner bags is absolutely UNETHICAL! How can they enjoy life inside a vacuum cleaner bag? Wouldn't it be more humane if the allergist advised patients to relocate dust mites to a special shelter where they could live in peace, without fear of deadly human hunters? Maybe even a reservation on a large farm put aside just for them. You could leave all your old carpets there so the dust mites would sleep comfortably, and have trucks bring in human skin cells for them to feast upon.

Allergists at Houston Allergy and Asthma Clinic have advised patients allergic to dust mites to keep household humidity between 35% and 50% to inhibit their growth. (You don't want it much lower than 35% or you may get dry skin or even a bloody nose). That dry air causes dust mites to shrivel up and prevents them from making baby mites! Masks don't kill dust mites and wearing one while vacuuming keeps the allergen out of your nose while the vacuum cleaner is stirring dust up. Yes, we know that you have a super-duper Dyson, or Kirby, or Rainbow vacuum. Keep in mind, though, that the expensive vacuum cleaner with the perfect exhaust system may keep allergens in the bag instead of just recirculating them into the air like old vacuums; but, the brush at the vacuum's entrance stirs up more dust than it sucks in and propels allergens into the air – right into the operator's nose!

So, yes, we agree, wear a mask. But other measures that kill dust mites? Is that really how you want to treat these beautiful creatures? Well, maybe not beautiful; but, please feel obligated to rescue these creatures from being slaughtered just so the allergic can breathe easier.

Finally, one last thing...JUST KIDDING!!

 
QUITTING SMOKING IS EASY

"Mark Twain once said, 'Quitting smoking is easy. I've done it a thousand times'." Quitting smoking for a short period of time is relatively easy; still, not giving in to the urge to pick up a pack of cigarettes during a time of unusually bad stress is extremely difficult. Every smoker I know wants to quit. It's what comes after you smoke your last cigarette that determines whether you are a permanent quitter or an intermittent quitter.

Here's the interesting part, though: Consider how many of us are afraid to make a New Year's resolution because we might fail? I hate trying something just to fail at it. What if the paradigm were turned on its head, and you got quite a bit of partial credit for being an intermittent quitter? An article published in the Annals of Internal Medicine in 2005 looked at the effects of smoking cessation on death. Not surprisingly, the permanent quitters had much lower death rates (6.04 deaths per 1000 person-years) than the permanent smokers (11.09 deaths per 1000 person-years). The intermittent quitters, though, had death rates much closer to the permanent quitters (7.77 deaths per 1000 person-years) even though they started smoking again. In other words, quitting smoking helps your health even if you re-start a few weeks later.

Your doctor (and you) would prefer that you not re-start at all; however, that's often not compatible with reality. So take advantage of the proven methods offered by the American Cancer Society. Go to their web site and search for the word, "quit". You'll be able to get every little advantage on your side to help make the next effort to quit more successful.

The great news: even if you are an intermittent quitter, you've still done yourself a whole lot of good.






 
REFLUX IN THE THROAT

A patient goes to the doctor. The doctor says, “you’re fat”. The patient says, “I want a second opinion”. The doctor says, “OK, you’re ugly, too.” The old joke has a point. Just because you have one ailment does not mean you can’t have another going on at the same time.

We often see patients with complaints of sore throat, the frequent need to clear their throat, and chronic cough. Many have allergies. The allergic rhinitis (literally, inflammation of the nose) causes excess mucus to be produced in the nose. Gravity drains the mucus down the throat, where it irritates cough receptors, and the coughing starts. Constantly clearing your throat is not only bothersome, it also worsens your sore throat. Delicate muscles designed to swallow are not built to clear mucus all day long, so you can literally “pull a muscle” in your throat. Treatment of the allergy usually helps, but doesn’t always improve things 100 percent.

Why not? Many people also have some reflux of stomach acid going on. Maybe it’s just a teeny, tiny bit of acid, not even enough to cause symptoms of heartburn. Even so, if the acid reaches up to the throat, the exact same symptoms can occur: sore throat, too much mucus in the throat, a continual need to clear the throat, and cough, cough, cough. Believe it or not, treating Laryngo-Pharygeal Reflux (LPR) is more difficult than treating Gastroesophageal Reflux Disease (GERD). Those acid blocking medicines, like Nexium, Prevacid and Aciphex, do a great job at relieving GERD when taken once a day, with or without meals.

Frequently, though, they need to be taken twice a day to work for LPR, and often only work if taken 60 minutes before meals. Why is that? I guess that a moderate degree of acid reduction makes your esophagus feel better; it lives next door to the stomach and is built for heavy duty use. But your throat is very delicate, and can tolerate only a very small amount of acid before crying out for help. Also, Nexium makes your heartburn feel better within a few days, but twice daily Nexium can take months of regular use before LPR symptoms of constant throat clearing, cough, and sore throat improve.

Here are some tips from the American Academy of Otolaryngology's web site on reducing reflux:

	Adult Lifestyle Changes To Prevent GERD And LPR
	•     Avoid eating and drinking within two to three hours prior to bedtime
	•     Do not drink alcohol
	•     Eat small meals and slowly
	•     Limit problem foods:
		•     Caffeine
		•     Carbonated drinks
		•     Chocolate
		•     Peppermint
		•     Tomato and citrus foods
		•     Fatty and fried foods
	•      Lose weight
	•     Quit smoking
	•     Wear loose clothing

Table Courtesy of American Academy of Otolaryngology – Head and Neck Surgery

 
SAFER ASTHMA TREATMENT

Dianne has moderate to severe asthma. She has been a patient of Houston Allergy and Asthma Clinic for the past 17 years. During that time, we have maintained her on a high dose of inhaled steroids, most recently Flovent. Now, at age 43, she has developed osteoporosis. One of the risks of long-term use of inhaled steroids is thinning of the bones, or osteoporosis. For 25 years, doctors have used inhaled steroids to treat asthma. While these drugs were certainly an improvement over the previous generations of asthma treatment, they have their own side effects. In addition to osteopenia, we have worried that long-term use of inhaled steroids can contribute to cataracts and glaucoma. After use of these drugs, patients are also instructed to rinse their mouths with water to prevent formation of thrush, basically a yeast infection inside the mouth.

In September 2008, a new inhaled steroid became available in the United States. Ciclesonide, sold as Alvesco, seems to have been developed with Dianne in mind. It is not actually an inhaled steroid; rather, it is a steroid precursor. Ciclesonide, needs to be metabolized to des-ciclesonide before it is an active steroid. The good news is that the enzymes required to activate ciclesonide are only present in the lungs and the nose. Classic steroid inhalers deliver their steroid side effects whether they reach the lungs or the stomach. With ciclesonide, though, only the activated component will be available to form the side effects, and that is less than 20 percent of the total dose. We are hoping that use of ciclesonide will significantly decrease the incidence of steroid side effects in patients who need high doses of inhaled steroids. It will be interesting to follow Dianne's future bone density tests to see how quickly use of Alvesco reverses her osteoporosis.

I want to emphasize that the great majority of patients on routine inhaled steroids are not at risk to develop bone problems, and no one should stop using their asthma medications without advice from their doctor.





 
SAVING MONEY

In 1988, when managed care was ramping up, the health care crisis was explained to me as follows: You can have excellent quality health care, it can be affordable, and you can have universal coverage. Now pick any two you want; you can never have all three.

As humble physicians, we limit our efforts to making sure that Houston Allergy and Asthma Clinic's patients are well cared for. Still, the targets are constantly moving, particularly with insurance coverage for prescription drugs. Co-pays have been rising annually, and formularies are becoming more restrictive. There are, however, several tactics we recommend to cope with these challenges.

One is the combination of information and communication. By knowing your plan's formulary and sharing it with your physician, you both win. You get your prescription more quickly and for a lower co-pay; your doctor's office gets fewer phone calls to return.

Another idea is taking advantage of rebate programs. Nasonex currently has an offer to get a FREE 30 day supply for new users, and a $10.00 discount voucher for current users. That's the quickest way to turn a $35 co-pay into a $25 co-pay. Similar programs are also available for Nasacort, except that you get a $20.00 discount voucher. Veramyst, the "new, improved" version of Flonase, has you sign up for its program. They email or snail mail you a voucher for a free 30 day supply or a $25.00 discount voucher. Astelin, the nasal antihistamine, has a $10.00 mail-in rebate. Allegra has gone generic, but Allegra D 12 hour and Allegra D 24 hour each has a $24.00 mail-in rebate.

Singulair just started its Asthma Information Resources (A.I.R.), which includes a $10.00 discount.

Another favorite is the free Advair program. Advair, an asthma inhaler, is used regularly to prevent symptoms. Go to Advair's web site and look for the "Save on Advair" link. As you fill out the information, it will offer you the opportunity to print out a coupon for a free Advair if your doctor has never prescribed Advair. If you have been on Advair, it will offer you a $10 coupon instead.

As for generics, sure they save money. But sometimes they save BIG MONEY. My advice for self-pay patients is to fill their generics at Costco or Sam's Club pharmacy. You don't have to have a Costco or Sam's membership to use their pharmacy, and it's often worth your while to compare their price to CVS or Walgreen's. If you are one of the lucky folks for whom Claritin is helpful, the Sam's Club and Costco generics of loratadine are incredibly inexpensive. You can buy 2 bottles of 150 pills for about $11.00! That's about 3 cents/pill. Remember, though, that Claritin is only non-sedating at 10 mg/day. Many people require 2 or 3 Claritins to achieve adequate relief of their symptoms. At that dose, it may make you sleepy. And don't forget about the $4.00 generic prescription list at Wal-Mart.

If you shop at Mission Allergy, here's how to save a little money: Mention Code: "DM5" before ordering. You'll get a 15% discount on Premium Microfiber encasings, or a 10% discount on Barrier Fabric II.

 
SCIENCE VS. TRADITION

Just 10 years ago, allergy shots were very different. In 2003, clearly defined practice parameters were published by the Joint Council of Allergy, Asthma & Immunology. They were updated in 2007. Our sister practice, The Allergy Clinic, invested tens of thousands of dollars in 2003 and 2004 to totally update their approach to allergy shots.

Now, with Rush, we are able to make allergy shots work to block your symptoms within two weeks of starting. More importantly, we are often able to stop your allergy shots after three to five years and have the immunologic benefit continue thereafter.

Meanwhile, the bootleg allergists, those not board certified by the American Board of Allergy & Immunology, continue to provide the same allergy shots they did 50 years ago. Does your “allergist” also prescribe bio-identical hormones? Do they take out tonsils and have a nurse who runs the shot room with zero input from the doctors? If so, you're not seeing a board certified allergist. Maybe they are board certified in another specialty, like family practice or ear, nose, and throat. Although they are appropriately trained professionals in their respective fields of expertise, allergy shots are best prescribed by board certified allergists. The family practitioners as well as the ear, nose and throat doctors who send their allergy patients to us don't do their own allergy, because they know that we do it better.

The bottom line is that we base our allergy shot contents on current scientific research. Bootleg allergists base their recipes on tradition; still practicing the same methods they did 50 years ago. Study after study has shown that these obsolete techniques are no more effective than a placebo (sugar pill).

Did you quit taking allergy shots because they just didn't work? Unlike nose sprays and pills, wouldn't it be great to achieve the unique benefit that only allergen immunotherapy provides? Maybe it's time to try allergy shots again. But this time, leave it to the experts.


 
STARVE A COLD (OF ANTIBIOTICS)

As we head into cold and flu season, many of us will catch a viral infection that will give us symptoms of a common cold: runny and/or stuffy nose, sore throat, cough, headache, and yellow mucus. So if we’re infected, we should take an antibiotic, right? Wrong! Antibiotics don't work on viruses, and viruses cause colds. A review of sinus infections from the New England Journal of Medicine recommends against using antibiotics until the mucus has been yellow or green for at least 7 or 10 days (N Engl J Med 2004;351:902-910).

Many of the patients we treat for allergy to multiple antibiotics develop those allergies when their antibiotic is changed over and over again. It gets changed because they take the first antibiotic when the cold first appears. “Amazingly”, the antibiotic does nothing to treat the virus, which continues to run it course. The patient, not feeling any better, asks for another antibiotic. And sometimes another. While the last antibiotic gets credit for curing the infection, the patient may become more likely to develop drug allergies.

For years, the line about chicken soup was, “Will it help?” “Well, it couldn’t hurt”. Scientific evidence now suggests why chicken soup helps. It contains the amino acid, cysteine, which has been shown to thin out thick mucus secretions and help relieve congestion. A similar mechanism of action helps Mucinex, available over the counter without a prescription, treat colds and sinus infections; basically increasing the water content of mucus to thin it out, so you can get rid of it.

What about “feed a cold, starve a fever”. It’s actually not a bad idea. A fever without cold symptoms may be the flu (influenza), another viral infection often manifest by nausea and vomiting. Starving the fever by temporarily withholding solid food is reasonable if one is vomiting. But make sure you’re drinking plenty of Gatorade or Pedialyte so you don’t get dehydrated.

What else works when you have a cold? Rinsing your nose out with a salt water solution a couple times a day makes many people feel much better. Go to NeilMed® for details; it's available at Walgreen's and CVS.

Just skip the antibiotics until the mucus has been yellow or green for at least a week.

 
THE GOOD, THE BAD, AND THE MUCUS

Treatment of allergies can be divided into three options: avoiding what you’re allergic to, taking medications, and getting allergy shots. I'm not sure if rinsing your nose with salt water is avoidance or if it's medication, but, either way, it's one of the most under-utilized treatments in chronic sinusitis and chronic rhinitis.

To get started, try dissolving a level teaspoon of salt and a pinch of baking soda in 8 oz. of distilled water, then rinsing the inside of your nose with this mixture. An infant’s bulb syringe is an easy device to rinse with, but remember: with an infant, the purpose is to pull mucus out of the nose; with this adult salt water rinse technique, the purpose is to spray saline into your nose in order to irrigate mucus out.

You can also buy pre-packaged salt envelopes including an 8 ounce rinse bottle at Walgreen’s under the name “Sinus Rinse”, or get the easiest to use pre-mixed form called “Simply Saline” at any pharmacy. Either way, you receive many benefits. Obviously, you moisten your nasal membranes and rinse away thickened secretions, which may cause obstruction. You also rinse out pollen or other allergens which you may have inhaled, lessening the chance of their promoting further allergic reactions.

Interestingly, though, you also rinse away some of the major basic protein (MBP). OK, what is MBP? It’s the protein released by the allergic white blood cells involved in immunity against germs. But if there are no germs to be seen, MBP can also play a harmful role: damaging the lining of the nose and the lungs.

If you have chronic allergy or sinus symptoms, rinsing your nose with salt water can reduce the amount of MBP in your nose. Studies have shown that this simple, low-tech procedure, if done regularly, will reduce symptoms and decrease the frequency of sinus infections.



 
THE RUSH ROOM (WITHOUT LIMBAUGH)

We have been busy re-decorating the Rush room in each of locations; the Rush room is where we perform the Rush procedure. That's where you get the first six months of allergy shots all in one day. We installed flat screen TVs with built-in DVD players, and got satellite or cable so you can surf the channels while the nurse gets you desensitized to those dust mites and cats. Since you're sitting down from 8:30 am until 3 or 4 pm, we even got comfortable lounge chairs. We are still working on wireless Internet access, but we have several small lap desks so you can comfortably balance your laptop as you're seated.

Our sister practice, The Allergy Clinic, has now successfully performed Rush IT in over 1,200 patients since 1995, with 600 procedures done just the past couple years. In a few months, we'll be doing it at Houston Allergy and Asthma Clinic on the first floor of the 1200 Binz building, just north of Hermann Park. The three-day pre-medication results in a low side effect profile. The Allergy Clinic began using the three-day pre-medication schedule in 2003 after successfully treating an inpatient at St. Luke's who was quite allergic to the cardiac cath dye.

So, if you want to achieve the unique benefit that only allergy shots provide, but you don't want to put up with six months of co-pays, inconvenience, and needle sticks, give us a call. Even if you see another board certified allergist, we can Rush you using their serum, then send you back to them for your maintenance allergy shots. But I'll bet you'll want to stay with us after you experience our customer service. After all, "no one nose allergies like we do."








 
YOU ARE WHAT YOU DRINK

In the Allergy specialty, we prescribe steroids on a daily basis. Usually, they are just inhaled corticosteroids, where we can delivery microgram amounts directly the nose or the lungs. I've been worried, though, that decades of daily use of these steroids may contribute to osteoporosis. Steroids taken by mouth are notorious for causing osteoporosis. The whole point of the "topical" steroids is to deliver a much smaller dose of the medicine directly to the target organ (e.g., the nose or the lung). After all, there are 1000 micrograms in each milligram.

We encourage our patients on Flonase, Nasacort, Advair and Pulmicort to eat a calcium-rich diet and to take calcium supplements. We've heard that calcium citrate (e.g., Citracal) is better absorbed than calcium carbonate (e.g., TUMS). What worries me, though, is what else is being consumed in the diet.

We have suspected that there was a link between reduced bone density and soda consumption; now, it seems that facts back up this hypothesis. Phosphoric acid in soft drinks may be the culprit. The excess phosphoric acid in Coke, Pepsi or Dr. Pepper binds to calcium in the gut, which may keep calcium from being absorbed. Why do I pick on Diet Coke instead of Coca-Cola? Because Diet Coke drinkers think they're helping their health by drinking it instead of its sugary sibling. Some dieticians think it's the calcium-phosphorus ratio in the diet that's critical: a ratio of one part calcium to one part phosphorous promotes the highest level of calcium. Sodas can have ratios in excess of one part calcium to 30 parts phosphorus, draining calcium from bones and teeth. Not surprisingly, the National Soft Drink Association denies any risk of osteopenia (thinning of the bones) from drinking soda. On the other hand, the Carpet and Rug Institute claims that a carpeted room is better for the dust-mite allergic patient than a wooden or tile floor. Yet I digress.

Phosphorous may just be a red herring. Perhaps the connection to bone weakening and osteoporosis is the result of a lifestyle that includes soda drinking. Soda drinkers often are guilty of skipping meals, downing a soda instead of milk, and avoiding high calcium foods such as spinach, beans, or corn tortillas.

Regardless of dietary habits, we encourage all of our patients to participate in regular weight-bearing exercise. That doesn't have to mean pumping iron; walking at a brisk pace is the perfect "weight-bearing exercise". Another wonderful way to exercise if you hate gyms is gardening! Gardening can be a real workout, says Bottom Line Health. You can even plan your garden to minimize its impact on your allergies.

Long-term studies on the effects of inhaled steroids on bone density are still being done. Rather than assuming inhaled steroids are harmless to bones, I'd hedge my bets: more calcium, fewer Diet Cokes.

That doesn't mean no sodas – just fewer.