Allergy

Allergies are an overreaction of the immune system. People who have allergies have a hyper-alert immune system that overreacts to a substance in the environment called an allergen. Exposure to what is normally a harmless substance, such as pollen or dust, causes the immune system to react as if the substance is harmful. This can also include certain foods, such as fruits, vegetables, dairy, and certain grains.

• Allergy symptoms can be categorized as mild, moderate, or severe (anaphylactic).
• Mild reactions include those symptoms that affect a specific area of the body such as a rash, itchy eyes (coryza), and nasal congestion. Mild reactions do not spread to other parts of the body.
• Moderate reactions include symptoms that spread to other parts of the body. These may include generalized itchiness or difficulty breathing (wheezing).
• A severe reaction, called anaphylaxis, is a rare, life-threatening emergency in which the response to the allergen is sudden and affects the whole body. Typically, the face or mouth will swell, potentially causing difficulty breathing and swallowing. It may be associated with a sudden drop in blood pressure, which can cause dizziness, fainting, and nausea.
• Untreated allergies can sometimes result in nasal polyps, which are nodular swellings of the lining of the nose and sinus. Given enough time, these can cause nasal and sinus blockage, which result in feelings of sinus pressure, facial pain, post-nasal drip, and difficulty breathing through the nose.

• Our office is capable of testing for both environmental (dust mites, pollen, etc.) and food allergens.
• We offer allergy testing for children as young as 6 years old.
• The two most common types of allergy testing testing are skin prick/scratch testing and intradermal testing. Skin prick testing involves introducing a small amount of allergen into the superficial layers of the skin with a small plastic stick (looks like a toothpick) and assessing for a possible allergic reaction. Intradermal testing introduces the allergens into the deeper layers of the skin using very fine needles, similar to how a tuberculosis test (PPD) is performed. This type of testing is more sensitive, and can detect allergies where skin prick testing may not. Intradermal testing also provides more objective data on allergy sensitivity, which is more helpful when determining a starting point for potential allergy shots.

Over the counter medications

These generally fall into two categories. The first category is oral antihistamines, which includes brand name medications such as Zyrtec, Claritin, Allegra, and Xyzal. Antihistamines help mitigate the acute phase of the allergic response. They usually cause drowsiness as a side effect, but the newer generations tend to be less drowsy-inducing. The second category is nasal steroid sprays, such as Flonase, Nasocort, Rhinocort, and Nasonex. Steroids are a powerful anti-inflammatory. Used topically in the nose, they can help decongest and reduce mucus production. The most common side effects are nasal dryness and occasional nosebleeds.

Prescribed medications

There are several prescription strength medications available for severe allergies. One is montelukast (Singulair), which is an oral medication that helps prevent the allergic response. There are also several nasal sprays (Xhance, Dymista) that have either a larger dose of steroids compared to the over the counter varieties, or are combined with a topical antihistamine for added allergy relief. Patients with a history of anaphylaxis or asthma may be prescribed epinephrine pens for acute allergic reactions, as well as inhaled medications to help decrease airway inflammation in an emergency.

Immunotherapy

Immunotherapy is the gold standard for treatment of severe allergies. This treatment modality is time and effort intensive, taking up to 2-5 years to reach the therapeutic endpoint. However, the results are long lasting or even permanent. This type of treatment involves exposing your body’s immune system to small amounts of the offending allergen(s). Over time, larger amounts are introduced to desensitize your immune system. The goal is to make sure that in the future, your immune system does not over-react to allergic substances. Our office provides both subcutaneous and sublingual immunotherapy (SCIT and SLIT respectively). Subcutaneous immunotherapy (“allergy shots”) usually involves coming back once or twice a week for the initial ramp up period (6-9 months), after which the maintenance level/concentration is reached. The shots can then be spaced out up to once every 4-6 weeks after that. Sublingual immunotherapy must be taken daily, but the maintenance level is reached quite quickly. One advantage to sublingual immunotherapy is that it can be administered at home, but the downside is that it is only effective for certain types of allergies (specific grasses, tree pollens, etc).

Allergy testing guidelines

1. 1. We ask that you please come by yourself, owing to limited space in our allergy testing room. You are allowed to bring a parent/guardian (if under the age of 18) or translator if English is not your primary language.
   2. Please wear short sleeves.
   3. Please stop or avoid the following medications:
      1. Antihistamines, antacids, and sleep aids (7 days prior to testing)
         1. Allegra & Allegra-D
         2. Benadryl or diphenhydramine (commonly found in “PM” versions of pain relievers)
         3. Claritin & Claritin-D
         4. Meclizine
         5. Pepcid or famotidine
         6. Tagamet or cimetidine
         7. Unisom
         8. Xyzal
         9. Zyrtec & Zyrtec-D
      2. MAO inhibitors (5 days prior to testing, and then permanently if starting allergy shots)
         1. Eutonyl (pargyline)
         2. Furoxone (furazolidone)
         3. Matulane (procarbazine)
         4. Nardil (phenelzine)
         5. Parnate (tranylcypromine)
      3. Beta blockers (5 days prior to testing)
         1. Atenolol
         2. Esmolol
         3. Labetalol
         4. Metoprolol
         5. Propranolol
         6. Timolol
      4. Tricyclic antidepressants (3 weeks prior to testing)
         1. Amitriptyline
         2. Doxepin
         3. Imipramine
         4. Nortriptyline
         5. Protriptyline
         6. Trimipramine
      5. Anti-inflammatories (5 days prior to testing)
         1. Aspirin
         2. Celebrex
         3. Ibuprofen (Motrin, Advil)
         4. Naproxen (Aleve)

Allergy shot instructions

1. Notes:
   1. Serums are prepared from test results for your specific allergy combination.
   2. Shots are given once a week to start. The dose is increased over a span of about 6-12 months until reaching the maximum strength/dose. After reaching “maintenance level,” you will be able to space out the shots to every 2-3 weeks, or even longer.
   3. Some patients may notice a change in symptoms after a couple of months, but typically you won’t see changes until the next allergy season.
   4. Therapy typically takes at least 2-3 years. This is to allow adequate time for building up immunity to the allergens, after which most patients will hopefully require little to no medications to control allergy symptoms.
   5. After the second year, you may have repeat allergy testing to see your progress since the initiation of therapy. Please see allergy testing guidelines as above.
2. We advise that you wear clothing that will provide easy access to the upper arms.
3. Most patients will be given 2 shots at each shot visit (one in each arm).
4. Unless it is your first shot with a new vial (“vial test”), you may return to your vehicle after receiving your shot(s).
5. Please wait for 15 minutes prior to departing. If you experience any itching or other adverse reactions, please return to the office for further treatment.
6. Be advised: no shot will be given for patients who are actively ill. This minimizes the chance for an abnormal hyper-activation of the immune system.
7. Patients are required to follow up with their ENT physician every 6 months for routine evaluation.
8. It is common for some patients to feel fatigue after their shots; this usually subsides further into treatment.
9. Please avoid strenuous exercise for 3 hours following shots, as this may induce asthma-like symptoms.