Spring is in the Air ... Along with other things!

Spring is in the air... along with other things! 

By: Lisa Mathis FNP-BC

As the cold winter bids us ado, the colorful array of spring flowers greets us with the beauty and aroma of a new season. As grasses, flowers and weeds start to bloom and share their beauty they also share pollen and dander. It can make it difficult to enjoy the warm weather and the spring breezes when you have seasonal allergies. As healthcare providers we encourage patients to be outdoors, exercise and enjoy nature. However, for allergy sufferers this is indeed difficult. Thirty percent of adults in the U.S. have allergies and 40 % of children, resulting in more than 50 million Americans sufferers yearly.¹ This is a staggering statistic with overwhelming impact on patients. Impact includes missed workdays, school absences, and both ER and urgent care visits. One cost estimate of impact to U.S. healthcare and business is 18 million dollars annually.¹

Is simply informing patients in trigger avoidance or staying indoors the answer? When a family cookout can make patients ill, the healthcare provider needs to step in.

In the simplest pathophysiology review, the human immune system makes protective proteins called antibodies to attack foreign invaders. The immune system’s prime purpose is to identify self from non-self and mount a protection. In seasonal allergies, the immune system makes antibodies marking a specific outdoor allergen as harmful, even though it isn’t. Coming into contact with the allergen causes an immune system reaction which can inflame the skin, sinuses, airways, or digestive system. Allergic reactions vary from person to person ranging from minor irritation to life-threatening emergency or anaphylaxis. While most allergies cannot be cured, treatments can help relieve allergy symptoms.²

Before reaching for the prescription pad on the first visit, a detailed history and appropriate labs can be beneficial. An allergy panel, RAST and IGE and if the patient has allergic asthma, a complete blood count with differential to eval eosinophilia can be helpful. Review of lab is an excellent time to incorporate education on housekeeping and trigger avoidance tips, helping grant full beneficial impact of any medications.

Ask about:

• Pets, indoor and outdoor habits and where they sleep.
• Mattress coverings and type of comforter and pillow
• Curtains and large hanging draperies
• Outdoor sports and activities
• Smoking, vaping, and exposure to smoke or irritants
• Flooring types

Answers to a full home assessment can have great impact on success with simple home changes like, having pets stop sleeping in the bed with the patient. Or getting rid of older or uncleaned draperies or carpet. Undertaking home assessment and environmental changes may make medications unnecessary. If medications are needed and household assessment and action is incomplete, medications will prove less to ineffective if home assessment and allergen limiting steps are not taken. Resulting in frustration for patient and provider. Create a questionnaire for the patient to complete as part of the initial assessment and with each follow up to determine allergy control and treatment progress. If symptoms persist after making environmental changes and patients continue with significant symptoms then pharmacotherapeutics are needed. Depending on lab results the patient may need referral to an allergist for immunotherapy.

For patients at least 12 years of age presenting with seasonal allergic rhinitis, intranasal corticosteroid therapy should initially be prescribed over combined intranasal corticosteroid and oral antihistamine therapy to treat nasal symptoms, because moderate-quality data did not show a benefit associated with adding the antihistamine. With this regimen, adherence and convenience were shown to be improved and adverse effects reduced (e.g., sedation with oral antihistamines). By supporting monotherapy, providers can reduce variations in care and improve quality of life, including performance at work or school and sleep. In addition, there is no increased risk of harm of monotherapy vs. combination therapy. Although intranasal corticosteroid monotherapy may not be effective in some patients, the data was inadequate to determine if additional therapy with oral antihistamines is beneficial to treat persistent symptoms.

For patients 12 years and older, combined intranasal corticosteroid and intranasal antihistamine therapy may be considered for nasal symptoms, because they can be better controlled with combination therapy than with either therapy alone. High-quality evidence indicates the combination was beneficial, having greatest effect on symptoms compared with either agent alone. Although using a single spray may be more convenient, it has a greater cost and possibly no benefit over separate sprays. Adverse effects of combination treatment include sedation, unpleasant taste, and nosebleeds.

For patients 15 years and older, an intranasal corticosteroid is preferred over a leukotriene receptor antagonist, such as montelukast. Intranasal corticosteroids are more effective, with increased benefits, and decreased treatment variation. In addition, there is no significant difference in adverse effect rates. Montelukast is associated with headaches and rare neuropsychiatric events. Some patients may prefer oral montelukast or another leukotriene receptor antagonist, even though these therapies are less effective than intranasal corticosteroids. These alternatives may be beneficial in some patients, particularly those who also have mild persistent asthma.³

If there is a component of allergic asthma, following a stepwise approach to therapy with guidelines is recommended.⁴ This involves treating the allergy symptoms as well as the airway disease which is imperative in this patient. More aggressive immunotherapy may be needed to obtain symptom relief in this patient population.

After treatment is initiated, continue administering the allergy questionnaire at each office visit to evaluate treatment effectiveness. Having severe allergies can very much impact the lives of children and adults, causing not only recurrent illness but depression, anxiety and financial distress. This spring, be aggressive and attentive when treating allergies. The patients will be thankful and happy to enjoy those lovely outdoor events. Sunshine and the warmth of the new season will be better than any prescription written!

Keep your face always toward the sunshine — and shadows will fall behind you. -Walt Whitman

1-Allergy Statistics and Allergy Facts

2-Allergies - Symptoms and causes - Mayo Clinic

3- https://www.aafp.org/pubs/afp/issues/2018/0601/p756.html

4- https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf