Medical Communicators

Medical Communicators
Patient Teaching Material

This was done as part of the Mercy Caring database for Catholic Healthcare Partners, a group of hospitals based in Ohio. I would like to thank them, as holders of the copyright, for their kind permission to use it.

Research Document
Allergic Rhinitis

Author: Kurt V. Ullman
Topic: Respiratory System
Subject:Allergic Rhinitis

Title: Allergic Rhinitis

Synonyms/Keywords:
hay fever

Introduction:
An allergy is an exaggerated response to substances that, in most individuals, cause no difficulty. Allergies are among the most common diseases experienced by Americans and may complicate the lives of as many as 40 million adults and children in the United States. That means allergies are the country's sixth most prevalent chronic condition.
Allergies may be a seasonal problem that occurs only once or twice a year in the spring and late summer. One of the most common allergic diseases is seasonal allergic rhinitis, sometimes called hay fever. Symptoms can also last year-round (perennial). Perennial allergic rhinitis may be triggered by dust, molds, and animal dander throughout the year.

Symptoms
Sneezing, runny nose, nasal congestion and watery, itchy eyes are all symptoms of an allergy attack. Nasal congestion can be one of the key symptoms of allergies. It is a natural part of the body's response to histamine and other allergens.

Associated diseases
Allergic asthma, with symptoms of wheezing, coughing, and shortness of breath. Allergic conjunctivitis (eye allergy), which produces redness and itching in the eyes and chronic mucus-related discharge. Allergic eczema, an allergic skin rash. Allergic contact dermatitis, for example, poison ivy.

Affected population
Several factors contribute to the development of an allergic sensitivity. You must inherit the genes from your parents. Then, you must be exposed to one or more allergens to which you have a genetically programmed response. Finally, you must be exposed to the allergens at a great enough concentration and for a long enough period of time to trigger a reaction.
Gender and ethnic background do not appear to have an influence on allergies. They tend to develop or worsen when your body's defenses are lowered or weakened--for instance, during puberty or after an infection.

Causes
                There are three components to allergies: mast cells, which contain chemicals like histamine; antibodies, a specific type of protein made by the immune system (known as IgE); and allergens, the substances which trigger the reaction.
               Mast cells are the allergy-causing cells and are found in every tissue throughout the body. They are most heavily concentrated in those tissues that are exposed to the outside world including the skin, linings of the nose and lungs, gastrointestinal tract, and reproductive system.
               The IgE antibody sits on the surface of the mast cells. Each mast cell has about 1,000 histamine-containing granules inside. On its surface are between 100,000 and 1 million receptors for IgE. When the IgE encounters the allergen, it triggers the mast cell to release the histamine and other chemicals. The mediators released then interact with the tissues, causing the allergic symptoms.

Diagnosing the condition
               A number of diseases appear to be allergic but, when the person is examined by a doctor, prove to be otherwise. For example, you may have nasal symptoms related to chronic and repeated infections that seem to be symptoms of allergic rhinitis. It's important to have proof of allergy when it's suspected because treatments for allergic and nonallergic disease are very different.
               Skin testing is usually considered the gold standard in identifying what is causing the allergy. A small amount of the suspected substance is placed on the skin and the skin is gently scratched through the small drop with a special sterile needle.
                If the skin reddens and, more importantly, swells, then allergy to that substance is probable. Skin tests are well tolerated by the youngest of patients and should be the standard for testing.
               More expensive and less reliable blood tests are available. These blood tests are usually only used in people who cannot be skin tested for unusual reasons (e.g. severe eczema). They look for IgE antibodies in the blood which suggests allergy in the tissues. If the allergy testing agrees with the history given by the patient, then a diagnosis of allergic rhinitis can be made.

Standard Treatment
               Avoidance of identified allergens is the most helpful factor in controlling allergy symptoms. Allergy avoidance is often not easy. A thorough discussion with your primary care provider or health advisor is needed and control measures are required daily.
               If avoidance is not possible or does not relieve symptoms, additional treatment is offered. Many patients respond well to antihistamines.
                There are a number of antihistamine products available over-the counter. Most have "allergic" or "allergy" somewhere in their trade name Most of the antihistamines can cause drowsiness and should be used with caution when alertness is important.
               Zyrtec® (cetirizine HCl) is a new medication recently approved for use in the United States. In Europe, Zyrtec is the most widely prescribed antihistamine and is currently used in more than 90 countries Zyrtec is characterized by a fast onset of action, which is important in relieving allergy symptoms that can include sneezing, runny nose and watery eyes. Zyrtec is well tolerated and has no known drug interactions.
               If antihistamines and nasal sprays are not effective or not tolerated by the patient, other therapies are available.
               Decongestants help control allergy symptoms, but not the causes. They work by shrinking the swollen membranes in the nose, widening the air passages and making it easier to breath. Decongestants can be taken orally or by nasal spray.
                Decongestant nasal spray should not be used for more than five days unless directed by a doctor and then usually only when accompanied by a nasal steroid. Decongestant nasal sprays often cause a rebound effect that worsens the symptoms when a drug is discontinued. This is a result of a tissue dependence on the medication.
               Some people with persistent allergy symptoms will need specialized prescription medicines like the corticosteroids (cortisone like), cromolyn, and ipratropium (Atropine like) nasal sprays. These do not cause the rebound effect noticed from decongestant nasal sprays.
               Cortisone nasal sprays work to reduce the inflammation which causes swelling, sneezing and running nose. It can also stop the formation of the many allergy chemicals described above. Many cortisone nasal sprays are on the market through prescription only.
                Cromolyn is also an anti-inflammatory medication. Although not as potent as cortisone, it has fewer side effects. One bad thing is that it must be used well in advance of anticipated allergy symptoms to be useful.
               Ipratropium nasal spray is available for drying a runny nose. It will not prevent allergic reactions. This is an atropine derivative and although usually very safe, a person sensitive to atropine should be cautious.
                Repeated spraying of medication into the nose occasionally causes trauma and sometimes bleeding. This effect can be minimized by directing the tip of the spray applicator directly backward thus avoiding the sensitive middle and outside wall of the inner nose.
               Allergy desensitization or immunotherapy stimulates the immune system with gradually increasing doses of the substances to which a person is allergic. Since the patient is being exposed to the allergy-inducing substance and an allergic reaction can occur, an experienced allergy specialist is advised.
               Although the exact way allergy desensitization works is not completely known, allergy injections appear to reduce the strength of the IgE and its effect on the mast cells. This form of treatment is very effective for allergies to pollen, mites, and cats.
               Rare (1 in 2-5 million injections given), serious allergy reactions can occur while receiving allergy injections. No one can predict who will have a severe reaction. Even after years of receiving allergy shots a patient can experience a reaction.
                Allergy immunotherapy usually takes six months to one year to become effective. Injections are usually required for three to five years and necessitate frequent office visits. The success rate of an allergy desensitization program in significantly reducing symptoms can be up to about 80%. The effect of allergy immunotherapy should last many years, if not a lifetime.

Investigational Treatment
               Doxofylline (Maxivent® , Ventax®; Roberts) is a methylxanthine derivative in Phase III clinical trials for use in the treatment of bronchial asthma. ABC Laboratories (Italy) developed the drug and has since licensed it to Roberts Pharmaceuticals for marketing in the United States. Doxofylline has shown comparable efficacy to the slow-release formulation of theophylline; however, doxofylline is better tolerated than theophylline.
               Oxis Turbuhaler was approved by the Swedish Authorities for the treatment of asthma symptoms. This is the very first approval for this product worldwide. European approval is expected to follow. This new product has significant potential within the fast growing bronchial therapy market for Astra.
                Oxis Turbuhaler is a combination of the long acting beta-agonist formoterol and the leading dry powder inhaler system Turbuhalerâ. Formoterol has advantages over existing long acting bronchodilators such as salmeterol, with a much faster onset of action.
                This medicine is expected to be launched in Sweden in the beginning of 1997. Other European countries will launch during the same year. The product will be available in the USA and Japan in a few years.

Complementary Treatment
If you have severe allergies, you must see a conventional physician. However, because allergies are often hard to diagnose and often are incurable, alternative remedies for them have become popular. Examples of these remedies include acupressure to relieve upper respiratory symptoms, aromatherapy to relieve nasal congestion, and infusions of herbs such as chamomile, eyebright, nettle or yarrow for their anti-mucus and anti-inflammatory effects. Vitamin C and bioflavonoids act as natural antihistamines and vitamins A and B complex are thought be effective stimulants of the immune system.
When a patient already has symptoms of allergic rhinitis, Chinese Traditional Medical treatment principles involve expelling any external pathogens, mainly wind. Once the external pathogenic wind is expelled, the proper balance is restored and the symptoms disappear. To achieve this, Chinese physicians utilize herbal preparations with or without acupuncture. Examples of Chinese herbs that work to expel external pathogenic wind include Cocklebur Fruit, Hogfennel Root, Astragalus Root, Ginseng Root, Magnolia Flower, Peppermint, Wild Chrysanthemum. Honeysuckle Flower, Agastache and Citrus Peel. Chinese medicinal formulas with some of these herbs as ingredients can be very effective in combating allergic rhinitis. Effects of these remedies can be quite dramatic and fast, with symptoms completely resolving as early as hours after ingestion.

Self Care
                Since there are no cures for allergies, care is directed toward the control of symptoms. There are many over-the-counter medicines available, the most popular being the antihistamines. Unfortunately, many antihistamines cause drowsiness as a side effect. Be sure to read labels carefully and take the proper precautions with driving or operating heavy equipment if you are taking the medicines.
                As noted above, be careful not to rely on over-the-counter decongestant nasal sprays, because using these products for more than a few days can cause a "rebound" effect that makes your symptoms worse.
                An important part of self care is taking measures to avoid the allergens as much as is possible. Some ways to reduce exposure to allergens and irritants include:

Remove rugs, carpets and drapes when you can to reduce dust.

Keep animals outside, or at least out of your bedroom.

Wash pillowcases and sheets in hot water at least weekly.

Clean carpets with special chemicals that help reduce dust.

Keep your windows closed and the air conditioning on to avoid pollen and other plant allergens.

Eliminate house plants, since they are often a source of molds.

Wash your hands regularly and try to avoid close contact with people who have any respiratory illness.

You can get more information about controlling allergy symptoms from any of these sources:

Allergic diseases. U.S. Department of Health and Human Services, April 1991 p2(23)Reference # 14022465

Hay fever and other allergies: things you can do to control your symptoms. Pamphlet by: American Academy of Family Physicians, 1993 Reference # 16151094

Understanding the pollen & mold season. Pamphlet by American Academy of Allergy and Immunology 1990Reference # 09258994

Hay Fever, Summer Colds & Allergies. American Academy of Otolaryngology - Head and Neck Surgery, Inc.,

For information on getting these pamphlets and other information, see the Contact Information section below.

Prevention
               To avoid pollens, a person should shower or bathe before bedtime to wash off the pollen and other allergens that may have collected in your hair and on your skin. Avoid going outside, especially on dry, windy days. Keeping the windows and doors shut can be useful, as can using an air conditioner at home, work, and in your car.
               You can reduce the amount of mold in your home by removing houseplants, and by frequently cleaning shower curtains, bathroom windows, damp walls, areas with dry rot and indoor trash cans. Use a mix of water and chlorine bleach to kill mold.
                It is suggested that allergic persons don't carpet bathrooms or other damp rooms and use mold-proof paint instead of wallpaper. Throw away old books, shoes and bedding, which can be a source for mold. Reducing the humidity in your home to 50% or less can also help.
                If you are sensitive to pet dander, avoidance can be more problematic. You may need to give your pets away or at least keep them outside because they bring pollen as well as animal dander in with them. Cat or dog dander is often in house dust and takes four weeks or more to die down, so a short-term trial of removing your pet may not help you find out if this is a problem.
               You can reduce dust mites by removing the places where they like to live and breed, such as carpets, drapes and feather pillows, and by making your home less inviting by lowering the humidity and frequent dusting with a damp cloth. Pay special attention to keeping your bedroom clean. This is where you spend much of your time at home.
               Wear a mask when you clean. Even better, have someone else in your family clean for you or hire someone if possible.

Support Groups
Asthma and Allergy Foundation of America. 220 Boylston St. Chestnut Hill, MA 02167 Telephone: (617) 965-7771 Fax Phone: (617) 965-8886 or toll-free 800-727-8462

Joint Council of Allergy, Asthma and Immunology 50 N. Brockway, Ste 3.3 Palatine, IL 60067 (847) 934-1918 (voice) (847) 934-1820 (fax)

References
Allerdays Website http://www.allerdays.com/season.html

Kaliner, Michael A. Allergic diseases. Pamphlet by U.S. Department of Health and Human Services, April 1991

Hay fever and other allergies: things you can do to control your symptoms. Pamphlet by American Academy of Family Physicians. 1993

The Medical Advisor: The Complete Guide to Alternative and Conventional TreatmentsTime-Life Books, 1996.

For More Information, Contact:
National Allergy Bureau's Hotline 1-800-9-POLLEN

Asthma and Allergy Foundation of America. 220 Boylston St. Chestnut Hill, MA 02167 Telephone: (617) 965-7771 Fax Phone: (617) 965-8886 or toll-free 800-727-8462

Joint Council of Allergy, Asthma and Immunology 50 N. Brockway, Ste 3.3 Palatine, IL 60067 (847) 934-1918 (voice) (847) 934-1820 (fax)

American Academy of Family Physicians 8880 Ward Parkway, Kansas City, MO 64114 (816)333-9700

American Academy of Allergy, Asthma & Immunology, Inc. 611 East Wells Street Milwaukee, Wisconsin 53202

Bill Chan, M.D. and Ming Li The Canadian College of Traditional Chinese Medicine

American Academy of Otolaryngology - Head and Neck Surgery, Inc.,One Prince Street, Alexandria VA 22314-3357

Note:

The information contained herein is provided for informational purposes only and should not be considered as medical advice or medical instruction. You should always consult your health care professional for advice relating to your medical condition.

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