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

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

Is Fresh Air Making You Sick?

The number of people suffering with allergy symptoms is at an all-time high. Sales of air fresheners are at an all-time high. These two facts may be related.

Stan Fineman, MD, president of the American College of Allergy, Asthma & Immunology, presented the following information at our annual meeting in November, 2011: 80 percent of Americans buy some type of air freshener each year. No one wants their house to smell like cat litter or cigarette smoke; however, the ingredients of those products can include formaldehyde, benzene, other volatile organic compounds (VOC’s), phosphates, and ammonia. This includes sprays and diffusers (wicks). Plug-in deodorizers have over twenty different volatile organic compounds.

Okay, but aren’t “organic” and “green” products safe? Literally, “organic” means it contains carbon. Therefore, my cat’s solid waste contributions to his litter box are “organic”. Organic, “natural” or “unscented” does not equal safe; many of these products contain phthalates. Phthalates, which are industrial chemicals used to make plastics flexible, are thought to cause many endocrine/hormone problems. (SC Johnson is voluntarily phasing out phthalates in its plug-in deodorizers by 2012).

Especially beware of the word, “unscented”. Unscented products can still contain an irritating fragrance. It will also contain a masking fragrance to hide that odor. Instead of unscented, look for “fragrance free”.

What about my scented candles, you ask. 63 percent of scented candles produce soot. Candles often also contain VOC’s, lead, and other non-allergic irritants. A study done at the University of South Florida concluded, “the toxicity characteristics of candle emissions match those of diesel emissions”, and “their size, < 1 micro-meter, allows penetration into lungs”. A 2009 study from the Journal of Environmental Health reported that 20 percent of all people reported health problems from air fresheners, and 30 percent of all people report problems when exposed to certain perfumes, colognes and other scented products. Okay, but what about my potpourri? (You don’t even want to know about potpourri).

Current health claims about aromatherapy may (or may not) be true about emotional well being. I love the way my house smells when we are baking chocolate chip cookies. However, if you think air fresheners are irritating your lungs, nose and throat, you’re probably right. Here are some recommendations for keeping your home smelling clean: Don’t let anyone smoke inside, empty the garbage outside regularly, put baking soda at the bottom of your garbage can, grind up some lemon in the garbage disposal, and open windows to let in fresh air (assuming pollen/mold is not too high outside).

I’m still trying to teach my cats how to clean their own litter box.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

Allegra Going Over-The-Counter

In March 2011, Allegra (fexofenadine) became non-prescription. An antihistamine, it treats runny nose, itchy nose/eyes and sneezing. All forms of Allegra are now over-the-counter, including Children’s Allegra, Allegra-D 12 hour and Allegra-D 24 hour. Allegra-D also contains pseudoephedrine, which is effective for stuffy nose, sinus pressure and headache.

Allegra-D 12 hour and Allegra-D 24 hour are completely different. Besides only working for half as long, the 12 hour version contains 60 mg of Allegra. So twice a day would be 120 mg, right? But Allegra-D 24 hour contains 180 mg. of Allegra. The 24-hour version came out after establishing that 180 mg per day worked better than 120 mg.

Previously prescription-only, Claritin (loratadine) and Zyrtec (cetirizine) went over-the-counter a few years ago.

The plain Allegra is also available in 24 and 12 hour doses, but the 24 hour dose actually contains three-times more medicine than the 12 hour dose (180 mg vs. 60 mg).

Allegra is almost as strong as Zyrtec, but far less sedating. Claritin is the least effective of the three. Claritin may be non-sedating, but is barely more effective than placebo (“The Claritin Effect; Prescription for Profit”. New York Times, March 11, 2001). In order to get Claritin 10 mg. up to Zyrtec’s 10 mg. strength, you need two or three Claritin’s, which would be more sedating than one Zyrtec. Brand-name prescription Xyzal (levocetirizine) and Clarinex (desloratadine) cost much more, but really don’t work better than the drugs they “replaced” – Zyrtec (cetirizine) and Claritin (loratadine). Allegra went generic by prescription several years ago, and 95% of its prescriptions were being filled with generic fexofenadine. Meanwhile, 60% of OTC sales for Claritin and Zyrtec are for the brand-name pills, not generic. Consumers buying OTC meds often think the brand name works better than the generic. No wonder Allegra is going OTC; they want to sell some brand name Allegra. Generic Allegra (fexofenadine) won’t be over the counter for a few more months.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.











 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.




 

Aspirin Allergy, Asthma and Polyps

15 percent of all asthma patients and 40 percent of asthmatics with nasal polyps are allergic to aspirin and other NSAID’s (e.g., Advil, Aleve, Motrin). Often, they need repeated sinus surgeries and oral steroids for asthma. In 1979, researchers showed that desensitizing them to aspirin results in fewer asthma flares, increased sense of smell, and fewer surgeries. For desensitized patients, the need for sinus surgery drops from once every three years to once every ten years.

We also get aspirin allergy referrals from cardiologists. Cardiac stents that could save a patient the risk of open heart surgery recommend that you take aspirin afterwards to keep the stent open. Here’s the thanks from one cardiologist: “You just saved this lady cardiac bypass surgery. Not bad for an allergist.” Arthritis patients often cope better with pain if they can take NSAID’s. When they are allergic to aspirin, it limits their options.

There are two completely distinct ways to be allergic to aspirin. Aspirin triggers asthma and sinus disease in some people, and hives in others. Aspirin desensitization usually takes two days, but then you must continue to take aspirin twice per day to remain desensitized.

In February 2011, a patient drove to Houston from Michigan to get desensitized for his aspirin exacerbated respiratory disease by The Allergy Clinic. He couldn’t smell, had already had six sinus surgeries and often needed steroids for asthma. He found us on the Internet and left his email with our nurses. Emailing back, I asked why he would drive right by Chicago and Memphis to go to Houston since those medical centers perform aspirin desensitization. Or why not go to Scripps Clinic in San Diego where they pioneered this 30 years ago. His answer: I can’t get those guys to answer all my questions the way you have. He probably meant to say that Houston is a much prettier place to visit than La Jolla.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

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 website. 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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.


 

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 website on the mechanism of action. It's a 13-page paper (Adobe Reader required):

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

Car Allergy

Rule #1 in allergy is avoid what you’re allergic to. That includes the automobile. Here are a few tips:

Most every car has carpeting. We walk around outdoors, often in the rain, mud, and pollen, then put our dirty shoes on the floor. When carpet gets wet, mold spores can grow easily. Vacuum and dry the carpeting well, then place down water-proof, grooved, plastic floor mats.

We sit in the seat for extended periods of time, sweating and shedding old skin. That’s a perfect recipe for growth of dust mites. Vacuum the upholstery regularly as well.

Never allow smoking in your car as the irritants penetrate the carpet, upholstery, and the liner above your head.

When the weather is beautiful in Houston, there will be lots of pollen in the air. Allergy sufferers should keep the windows up, with the fan set on recirculate.

Look under the seats for last year’s French fries; don’t ever give mold a chance to grow.

Many newer cars have air filters. When doing maintenance, remember to replace these regularly. Old filters impair fresh air from coming in. Old filters that get moist can produce musty odors.

Air fresheners that hang from the mirror are designed to mask odors, not to remove the source of the odor. Most of them contain chemicals that can irritate your lungs and nose.

Make sure the weather stripping is intact and that all doors shut properly. You may not notice a slow leak until the mold spores become very apparent.

When driving your cat or dog to the vet’s office, place them in an animal carrier. This is not only safer for them, but reduces the amount of pet dander that ends up in the car.

You may love that new car smell, but it’s actually caused by the off-gassing of volatile organic compounds (VOC’s). A brand new car usually needs about 6 months for levels of VOC’s to come down to levels present in an older car.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

Cat Allergy

Most people allergic to cats don't keep a cat in their home. The best treatment for any allergy is avoidance, but many cat lovers do what they can to keep the cat in the house. It is always best to remove a cat from an allergic individual'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 emergency room with brittle asthma.

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 floor. Removing carpet from your home completely is even better.

	3.	Put a HEPA filter in your bedroom and run it 24/7. I usually don't recommend fancy filters because most allergens are heavier than air. Cat allergen is tiny and remains airborne. Thus, it can be captured by a good filter.
	4.	Mild or moderate cat allergy responds very well to allergy shots. When administered correctly, allergy shots actually induce tolerance in the allergic patients so that future encounters with cats produce milder symptoms.
	5.	After playtime with your cat, wash your hands well and change shirts afterwards. Be careful not to touch your eyes.

Often, we are able to bridge the gap between a cat lover and their cat allergy. When all else fails, removing a cherished member of the family, your cat, from your home can be difficult.

One company I no longer recommend is Allerca Lifestyle Pets which claims to have bred non-allergic cats. The internet is full of stories from people who paid up to $10,000 and never received their cat or a refund. In 2006, Time Magazine called the new cats one of the best inventions of the year, but it was too good to be true. The U.S. Better Business Bureau has 14 documented complaints and gives Allerca an "F" rating, the worst grade allowable. Google the words "allerca" and "scam" and you'll find some interesting reading.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

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 and the American Academy of Allergy, Asthma and Immunology.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

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!

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.






 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

Diesel Engines

With gasoline over $3.00 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 have hybrid engines that run on both gasoline and electricity. Mercedes, BMW and Volkswagen, on the other hand, increase fuel economy using diesel engines. Most trucks are available with diesel engines.

Diesel exhaust particles (DEPs) are terrible for people with allergies and asthma; 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. In all fairness, the new Mercedes, VW and BMW diesels have much cleaner as emission-control technologies than they did several years back. However, the cover article from the Febuary, 2005 Journal of Allergy & Clinical Immunology shows diesel fumes driving production of IgE, the allergic antibody. And diesel pick-up trucks still use the older, dirtier diesel engines.

Granted, diesels produce fewer greenhouse gases and are more fuel efficient than their gasoline counterparts. But if you have allergies or asthma, consider a gasoline hybrid before a diesel.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.











 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.






 

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. 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.

We 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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.












 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.






 

Expired Medications – Are They Safe?

What does that expiration date on the medication bottle mean, anyway? The Medical Letter, a well-respected publication, addressed this topic in 2002, then again in 2009. In reading those two reports, it seems the answer to the question is, “it depends”. As a general rule, pills stored in their original, unopened bottle have the best chance of maintaining potency for several years past the expiration date. In fact, the expiration date is basically the date the manufacturer puts on the bottle to say “we guarantee >90% potency up until this date”. After the expiration date, the usual thing that occurs is nothing. Medications don’t suddenly lose all of their potency, nor do they become suddenly dangerous. We don’t recommend using eye drops past their expiration date, but that’s because the preservative that keeps your eye from getting infected may no longer be active.

The military was buying and throwing away millions of unused prescription items every year based on label expiration dates. They hired the FDA to do a study to determine what the actual date should be beyond which not to use them. Even when stored under high heat and humidity, which should lead to breakdown, many medications tested were still good for 2-5 years past their expiration date. Some of them were good 25 years past their expiration date! Another general rule: liquids don’t last as long as powders, pills or capsules. Suspensions are very prone to freezing, which can upset their chemical structure.

We prescribe an EpiPen for each patient on allergy shots, but those EpiPens are only used if the patient has a serious reaction to their allergy shot. Thus, many expire without ever being used. Expired EpiPens have been studied for potency and there is a clear observation that the older the EpiPen is, the less helpful it would be in case of emergency. Bottom line for EpiPens –keep them only until their expiration date, then replace them. But, if all you have is an expired EpiPen, go ahead and use it. Then call 911. Be sure to replace expired eye drops and liquid medicine. As for over-the-counter cold preparations or Tylenol—they're probably safe to use for a few years after the expiration date.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

Flu Vaccine and Egg Allergy

Influenza vaccine (injectable and nasal) is grown on chick embryos. For decades, the thinking was that those allergic to eggs could have allergic reactions to the vaccine. But when you withhold the vaccine, thousands of egg-allergic patients come down with the flu. Yes, we have medicines to treat the flu like Tamiflu, but 1) we have begun seeing flu strains resistant to Tamiflu, and 2) Tamiflu is not a panacea (instead of feeling like you were run over by a truck for five days, you feel that way for four days).

Several years ago, state-of-the-art advice from a board-certified allergist was to get allergy skin tested with the flu vaccine. If the skin test was negative, we would give you a test dose with 10 percent of the flu vaccine. If you were OK 30 minutes later, we would give you a second shot with the other 90 percent of the dose and then observe you for 30 minutes.

That allergy test is no longer necessary. Bottom line – it is almost always safe for those allergic to eggs to get the flu vaccine, even for people who have the most severe reactions to eggs (e.g., anaphylaxis). A 2011 study included 27 young children (under 3 years old) who had anaphylaxis from eggs; none of them had serious reactions to the vaccine. In another 2011 study, 64 egg-allergic children received the vaccine. One got hives, and two had a single hive; none of them had wheezing, shortness of breath, tight throat or more serious reactions. A higher percentage of the control group (kids without egg allergy) got hives after their flu shot.

If you are egg allergic, it is recommended you get your flu shot in a doctor's office; if you have a severe egg allergy, or had a serious reaction after getting a flu shot, it is recommended you get the flu shot in an allergist's office. Remember, there is definitely a risk to not getting immunized – influenza-related illness in the U.S. averages 200,000 hospitalizations per year and 10,000 deaths per year.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

Food Allergies: Will my child become allergic to peanuts?

Laura is one of our patients and is planning her first pregnancy. She has allergies and mild eczema, and her husband has severe peanut allergy. What are the chances that their baby will have peanut allergy?

Very good question, and the answers are different now than they were in 1998.

In 1998, the United Kingdom’s Committee on Toxicity recommended that mothers of at-risk infants avoid eating peanuts during pregnancy and breast-feeding, and that peanut products be withheld from such infants in early life. In 2000, the American Academy of Pediatrics suggested that nursing mothers of at-risk infants eliminate peanuts from their diet and that introduction of peanut be delayed until 3 years of age.

But from 1990 until 2005, the number of children with food allergies went way up. The percentage of American and British children with peanut allergy doubled. An interesting study done in Israel and in the UK looked at groups of Jewish children. Some of them lived in Israel, and the others lived in UK. Genetically and socio-economically they were very similar. The children in England were ten times more likely to develop peanut allergies than the children in Israel. In Israel, they do not delay introduction of solid foods. Babies are often fed peanuts at 4 months of age.

Since that time, some studies confirm their results, but other studies suggest that avoiding the foods protects against the kids getting food allergies. Maybe it was the peanuts themselves—In the USA and UK, most peanuts are dry roasted, but in Israel, most peanuts that infants consume are boiled.

Bottom Line: the answer to Laura’s question is “We don’t know”. That doesn’t sound very intelligent, but that is where the science currently is. Perhaps instead we should say, “The precise mechanisms have not yet fully been elucidated”. It still means we don’t know, but it sounds smarter.

Here is the official advice from the expert panel published in December, 2010:

Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel:

The introduction of solid foods should not be delayed beyond 4 to 6 months of age. Potentially allergenic foods may be introduced at this time as well.

• Rationale: Insufficient evidence exists for delaying introduction of solid foods, including potentially allergenic foods, beyond 4 to 6 months of age, even in infants at risk of developing allergic disease.


• Balance of benefits and harms: Restricting exposure to food antigens during infancy has been hypothesized as a means of preventing development of food allergy. However, restricting developmentally appropriate solid food variety beyond age 6 months can lead to inadequate nutrient intake, growth deficits, and feeding problems.


• Quality of evidence: Low


• Contribution of expert opinion: Significant

Clearly more data are needed. The LEAP study was designed to answer this question. Learn Early about Peanut Allergy (LEAP) started in 2008 and results will start becoming available in 2013. Stay tuned.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

Food Allergy Treatment – An Unmet Need

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 website , 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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.








 

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 website 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 Walk for Food Allergy.

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.






 

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 website 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!

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.





 

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. Other 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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.











 

Humidify Dehumidify?

Sometimes you read that you need a humidifier for your health, then you turn around and read that you need a dehumidifier to prevent the growth of mold, mildew and dust mites. This can be confusing. Before you buy either, find out if there is a problem. You can accurately measure humidity (water content of the air) with a digital humidity gauge. They are widely available and cost ~$20. Many also display the high and low humidity for the past 24 hours. The goal is to keep the humidity between 35 and 50%. Consider a dehumidier if the humidity is above 50%. Dust mites can't drink water; they have to absorb it from the air. Dust mites and mold grow better in higher humidity. High humidity also makes the air feel damp, which can worsen asthma and allergies. Consider a humidifier if the humidity is below 35%. Low humidity, more common in winter months, can cause dry, itchy skin, nosebleeds, sinus headaches and, like high humidity, flare asthma and allergies.

If you get a humidifier, rule #1 is Keep It Clean. They cause more problems than they solve if you start spewing bacteria and mold up into the air. Warm mist humidifiers are easier to keep clean than cool mist humidifiers, but the warm air may burn a child, so be careful. We tell patients that when they are infected, temporary use of a humidifier can reduce coughing and congestion and loosen the mucus. From April to October, your air conditioner probably takes adequate humidity out of the air, so you may only need to use a dehumidifier during Houston's winters.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.













 

Iodine dye allergy

At least once a week, we hear a patient tell us that they are scared to eat fish because they had an allergic reaction to iodine. The next part of the story involves the Radiology procedure they underwent when they had the reaction. Let’s untangle two myths and shed some light on this:

1) Radiocontrast Media (RCM) that contains organic iodine may cause adverse reactions such as urticaria, angioedema, bronchospasm, laryngospasm and shock. These reactions are not truly allergic in origin. Instead, a non-allergic pathway triggers what looks exactly like an allergic reaction. While we don’t know the exact mechanism, it is apparently related to the high osmolarity (concentration of particles) of these agents. If you have had this type of reaction and need another procedure done, your physician will probably recommend a lower osmolar preparation to decrease the risk of another reaction.

The risk can be further decreased by pre-medicating with antihistamines (e.g., Allegra, Claritin/Clarinex or Zyrtec) and steroids (e.g., prednisone). I don’t recommend Benadryl anymore for outpatient pre-medication protocols. The risk of tolerating the procedure just fine, but then falling asleep and crashing your car into a tree on the way home must also be considered. Why would you fall asleep? Don't forget that most over the counter sleeping pills are made of diphenhydramine (the active ingredient in Benadryl).

2) Seafood may contain iodine. However, seafood allergy is not caused by iodine; rather, to specific proteins in fish and shellfish (e.g., parvalbumin, tropomyosin) that also do not contain iodine. Thus, fish or shellfish allergy does not indicate a sensitivity or allergy to iodine.

So how did the two myths get tangled? Allergic reactions tend to occur in people who already have other allergic reactions. So the person who has allergies (e.g., shrimp) is at higher risk to have another unrelated allergic reaction than the person with no history of allergies.

Many thanks to the American Academy of Allergy, Asthma and Immunology for providing this update. Their website is a terrific source for physicians and health consumers.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.








 

Mucinex 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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.


 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.






 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.








 

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!!

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

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 website 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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.









 

Ragweed Pollen

After a long Houston summer, we're all ready for cool evenings. But when nighttime temperatures drop below 70 degrees, and humidity drops below 70%, ragweed starts to grow. Ragweed is the main source of allergic misery for those who suffer in September and October. Ragweed will continue to make pollen until early November unless we get an early freeze.

Interestingly, several foods cross-react with ragweed. If you are allergic to ragweed, you may experience itching or tingling of the lips or tongue when you eat cantaloupe, watermelon or bananas while ragweed pollen counts are high. Interestingly, by cooking the related food, heat will alter the structure of the antigen, usually making it non-allergenic. Drinking chamomile tea may cause a similar reaction.

Ragweed puts out more pollen in the mornings than in the evenings, so if you're allergic to it, save outside activities for late afternoon or after a heavy rain, when pollen levels are lower.

We've been waiting all summer to roll down the windows in our car, but if you're allergic to ragweed, this is asking for trouble. Take advantage of the filtering system in your car's HVAC system to keep symptoms in check. If you have an indoor dog that goes outside to play for a while, consider giving him/her a bath; dog fur has a static charge which acts as a transport mechanism to bring in all sorts of pollen.

Ragweed is named for the raggedy shape of its leaves. It's not a very pretty plant; still, what it lacks in beauty, it makes up for in potency. One ragweed plant can put out over one billion grains of pollen! Its scientific name, Ambrosia, was the delicious food eaten by the mythical Greek gods to make them live forever.

Remember, if you're on one of those preventative steroid nose sprays (e.g., Nasonex, Rhinocort, or Nasacort), start it soon so it will be working when ragweed pollen hits its peak.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.




 

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 website 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

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

The RUSH Room (without Limbaugh)

We have re-decorated 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 got comfortable lounge chairs. All of our locations have wireless internet access (wi-fi).

Allergy shots have to be started at a low, safe dose, but the shots don’t work until you reach a high, effective dose. After RUSH, patients take allergy shots once a week for a short period of time, but our goal is to have our maintenance dose patients at once per month. To give you the best chance to keep feeling better when you stop taking allergy shots, they should be taken for 3 to 5 years.
We have now successfully performed RUSH IT in over 2,000 patients since 1995, performing the procedure hundreds of time each year. We're doing this procedure on Fannin Street, in Pasadena, in Pearland, and at Houston Allergy and Asthma Clinic on the first floor of the 1200 Binz building, just north of Hermann Park.

Our three-day pre-medication results in our lower side effect profile. Previously, pre-medication schedules for RUSH were just for one day.

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.








 

Salt Water Rinse

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 ounces 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 premixed 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 one of the proteins released by the allergic white blood cells that helps protect you from becoming infected by germs. But when not busy fighting germs, too much MBP can also damage the protective lining of the nose and the lungs.

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

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

Saving Money

Healthcare is often expensive, but many times you can get the same good results and spend much less money.

How? With 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.

1. Generic medicines are much less expensive than brand name ones. In allergy and asthma, many brand name expensive drugs are no better than older versions they replaced. For example, Clarinex is “improved” Claritin, or loratadine. Generic loratadine costs 5-10 cents/pill. They work about the same. Xyzal is “improved” Zyrtec, or cetirizine. Cetirizine as a generic costs about 5-10 cents/pill. The nasal steroid, Flonase, is now available as generic fluticasone. It is much less expensive than Veramyst or Nasonex. (However, fluticasone does cause more nosebleeds than the newer sprays). Astelin is now generic azelastine, but we get samples for the new, improved Astepro, which costs more. The difference: they added Splenda to Astelin to help disguise the taste and got a patent for the new drug, Astepro.


2. If you prefer the brand name drug, or if there is no generic, see if there are discounts of some type, either a co-pay voucher or discount card. Nasonex has a $15 discount at www.Nasonex.com. Look for similar savings from other nasal steroids Veramyst and Omnaris. Asthma inhalers such as Advair , Symbicort, and Proventil HFA all have discounts, as do the nasal antihistamines Astepro and Patanase. Check the sites for Singulair, ProAir, Ventolin, and any other brand name medicine you take.


3. Some over-the-counter medicines were the hot, brand-new items a few years back. Prescription Pataday and Bepreve are expensive, but often OTC Alaway works just as well, for about $12 per 60 day bottle. OTC loratadine and cetirizine are the least expensive at Sam’s Club or Costco, around 4 cents per pill.


4. Many pharmacies fill a 30 day supply of certain generics for $4.00. Look for benzonatate, loratadine, promethazine, albuterol nebulizer solution, and others on these lists.


5. Target sells the small version of Ventolin HFA for $8.00; WalMart has it for $9.00. It only has 60 puffs instead of 200 puffs, but the regular ones usually sell for $45-50.


6. 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.

In 1988, when managed care was ramping up, the CEO of Methodist Hospital said: 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. We will work with you to try to get all 3.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

 

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, and again in 2010. 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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.




 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.


 

Thinking Inside the Box

At Houston Allergy and Asthma Clinic, we love seeing a straightforward patient with a routine problem. Probably because that’s an unusual event. Most patients don’t read the textbook before coming, so they don’t present as a “textbook case” of allergies or asthma. Getting an accurate diagnosis is key to getting the proper treatment. Before a doctor comes up with your diagnosis, he or she forms a differential diagnosis. A differential diagnosis is basically a list of the possibilities. It is best to look at things with a broad-angle lens before deciding what to zero in on.

Many patients come to see us because their doctor said we embrace alternative medicine, or that we think outside of the box. Yes, we have made referrals for our patients to start Pilates, acupuncture, probiotics and to see nutritionists. But before you think “outside of the box”, you have to know how to think “inside the box.” It’s exciting to come up with some ingenious or innovative solution to a problem, but many routine approaches work better.

As long as your doctor knows what the routine approaches are.

Over the past 10-15 years, Practice Parameters have been developed to improve patient care. Some call this “cookbook medicine”. If you actually read the parameters, they’re enlightening and educating. If that treatment doesn't work, we document it, then proceed to think outside the box. When you trust us with your allergies, we will think outside of the box. Right after we finish thinking inside the box.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.










 

Throw your mattress away?

“Is your mattress full of dust mites? Then throw it away and come buy a new one from me!” That is not good advice. Buying a new mattress would solve the problem for about 6 months, until new dust mites had made a home for themselves in your new mattress. The dust mites come because you grow new skin; they feed on the old skin that you shed. The salesman would be happy selling you a new mattress every 6 months, but Consumer Reports says that you need to replace your mattress when it is no longer providing you comfort, not when it gathers dust mites.

To keep dust mites from bothering you while you sleep in your bed, here’s what you need to know:

1. Encase the mattress and pillow with a special cover that zips up and keeps the dust mites and their allergen away from you. You then put your sheets and pillow case on top of the covered mattress and pillow. But don’t stop there. That is a good start, but effective treatment means also:


2. Controlling humidity. The growth factors for dust mites are heat, and humidity. Dust mites cannot drink water; rather, they absorb moisture from the air. Relative humidity below 50% helps minimize growth of dust mites.


3. Wash your sheets in HOT water. Wet heat kills dust mites. Once every week should do it.


4. If possible, replace any bedroom carpeting with a hard, washable surface, such as tile, wood, or Pergo. Carpeting provides an ideal home for dust mites.


5. Vacuuming carpet only throws the dust mite allergen up into the air for 30 minutes. Mites cling tightly to carpet fibers, and no vacuum has ever been shown to reduce dust mite levels enough to actually make a patient’s symptoms better. Of course, the Carpet and Rug Institute disagrees on this point, but it seems as though they employ the same Junk Science experts who used to work for The Tobacco Institute. What the Practice Parameters actually say is, “Carpeting is best removed from the bedroom and replaced with smooth finish wood, tile, or vinyl flooring.”

Source: www.allergyparameters.org

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.


 

When Allergy Shots Don’t Work

Claritin, Zyrtec, Xyzal, Allegra, Nasonex, Flonase, Singulair. All treat allergy symptoms, but none actually makes you less allergic. You stop the medicine, it soon stops working. Allergy shots are unique in that if taken at the right dose for at least 3 years, they can continue to provide beneficial immunologic effects after you stop taking them.

Frequently, though, people say allergy shots don’t work. Why is that? Most likely, it’s an inadequate dose. To a point, the higher the dose, the better the protection it gives you. Ask your allergist, “How many micrograms of Der p 1 does my maintenance dose for dust mites contain?” Higher doses are associated with increased side effects, but most reactions are mild—itchy arms, local swelling. Taking antihistamines or applying ice to the site of the shot usually works. Rarely, high effective doses of allergy shots can cause serious reactions—wheezing, hives all over, even anaphylaxis. That’s why we monitor each patient with a digital timer after each shot, and then send each patient out with their own EpiPen to use if they have a late reaction.

Why else don’t allergy shots work? It’s important to split up some components into separate vials. For example, mold extract can digest grass extract. If you are allergic to several things, but your allergy serum is all in just one vial, it is possible that some of its contents are being degraded. There is enormous variability in how allergy shots are formulated, and how they are dosed. Many allergists continue to follow recommendations made 30 or 40 years ago.

At The Allergy Clinic, we base our recipes on guidelines published in 2003 and updated in 2010. Maybe that is why we hear, “these shots have changed my life” more often than “these allergy shots don’t work.”

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.








 

Why Are Allergies So Much Worse These Days?

300 years ago, we didn’t have clean drinking water. Municipal water treatment began in the early 1800’s. Our immune systems were always busy fighting cholera, typhoid, etc. 100 years ago, we didn’t have antibiotics. We spent more time dealing with bacteria and parasites. And, 50 years ago we didn’t all have wall-to-wall carpeting and spend 90 percent of our time indoors. Meanwhile, our immune systems developed over hundreds of thousands of years. 300 years is barely a blink of the eye in that time frame. Our immune systems are suddenly much less busy, and things have gotten “out of balance”.

The word “allergy” did not exist before the year 1920. You will find references to “hay fever” starting in 1831 and “catarrh” in much older publications, but it was uncommon. It certainly didn’t affect 15 to 20 percent of the population in westernized countries. As our environments get cleaner and cleaner, allergy and asthma are becoming much more prevalent. The correlation between the cleaner environment and the increase in allergies and asthma is explained in the Hygiene Hypothesis. Supporting this hypothesis are the facts that allergies are much less common in people who grow up on farms and those who live in non-Westernized countries.

The out-of-balance immune system can usually be helped with allergy shots, which celebrate their 100th birthday this year. The first publication by Drs. Noon and Freeman was in 1911 in The Lancet. Allergy shots (or drops) literally put the immune system back in “balance”. With our cleaner environments, we can mistakenly interpret dust mites or ragweed as a germ, some type of foreign invader. The allergic reaction is an attempt by the body to fight off what is actually a harmless substance. Getting allergy shots (or drops) to the right level basically teaches your immune system how to tolerate, or ignore, the allergen.

Allergies can be a big headache, but they don’t have to be. Get tested, get treated, and get better.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.







 

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.

David B. Engler, MD

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.