Asthma/allergies and asthma
QUESTION: My husband has suffered from allergic rhinitis starting in August this year, 2013. We live in southwestern Colorado,we are in town, but it is a rural town. We live with 2 golden retrievers. Typically he will awaken early each morning with a sneezing attack and then have congestion, nasal drip, watery eyes,etc till noon or so. It was so bad that 2 months ago, the allergies triggered his asthma which he hadn't suffered from for 8 years. He is retired. He is now taking claritin,flunisolide nasal spray,symbicort,singulair,occasional sudafed. Also prilosec and zocor and baby asa. He also does nasal washes each morning and evening. Honestly nothing seems to help. He is now scheduled for allergy testing next week and then a course of allergy drops if indicated. In your opinion, 1) is the allergy testing worthwhile? and 2) are the drops a good alternative to the shots? He is part of the VA health system and there is no allergist in our part of the state, so he is going to the ENT that did his sinus surgery several years ago, and just paying out of pocket. Thank you.
ANSWER: Hi Maria,
There are three things that I look at when evaluating the patient. The environment, both home and work, medications being taken, and, in the case of a delivery device (dry powder inhalers, pressurized metered dose inhalers, nasal sprays), proper technique.
All the different medications will not matter if the home environment is not kept with low allergen levels. With pets, this can be very difficult. Besides their own dander, they are also bringing in dust and pollen from the outside. In addition, a full house evaluation should be done. Checking for mold in the basement, beneath the sinks, and in the attic is critical. There are test kits sold at hardware stores for checking basement and attic areas. If you have forced air heating, replacing the furnace filter every month with a good quality filter is also important. Weekly vacuuming of all the carpeted areas is important, and the areas vacuumed should be gone over about three times with each pass. Having a vacuum with the built-in HEPA filter helps reduce redistributing the dust. And then the final notes for indoor control, is not having the dogs in the bedroom at any time. I know this is difficult, but lung function goes down overnight, and inflammation in the lungs and sinuses increase. This is normal physiology, but is predominantly a problem and only people with allergies or other inflammation issues like rheumatoid arthritis. To give you an idea of how important this is, in my own home, after putting up the gate to keep the dog out of the bedroom, shampooing the carpets, returned the bed back to the bedroom after the shampooing with fresh linens, and cleaning the walls, then that night my wife had no stuffed sinuses at all and her breathing was better. All after one extensive cleaning. She couldn't believe it, and that finally ended a long-standing argument.
Now, regarding the drug therapy! Up to 75% of patients are not properly instructed in using the various inhaler devices. Has any medical provider ever visually demonstrated the proper use of the device and care for cleaning? This is something I review with my patients on each and every filling of the medication. It's amazing how many physicians do not even know how to use them properly! If you'd like, I can send you to a site that covers this.
And finally, no one antihistamine, inhalation steroids, nose spray or eye drop works equally well in all patients. After addressing the Home environment and device technique issues, then we would approach which medication changes might be best suited for your husband. We would only change one at a time, to be assured that were not getting confused which is working and which is not.
And, in addressing your testing for your husband, it's always important to determine what are the triggers bringing at his problems. Then you know specifically what you going to have to target to reduce the issues. It's not foolproof, but it gives a good sense of direction. Then, appropriate immunotherapy can be of tremendous benefit.
I hope this helps!
Any further questions, or the resource for device technique, please feel free to get back to me.
---------- FOLLOW-UP ----------
QUESTION: Hello again,
My husband had allergy testing done today at the ENT's office. He had both forearms done with the needle prick test and his upper arm done with the intradermal. The only thing that reacted was the positive (histamine) control. So,the test was completely negative and yet he still suffering with all the symptoms of allergic rhinitis. The doctor said, maybe it is non allergic rhinitis or vaso vagal rhinitis since it starts about 4am and clears up by 1000am. Do you have any opinion of where we should go from here? He was given yet another nasal spray (Astapro) and sent on his way.
Sorry for the delay.
My questions at this point are, first of all, has the doctor done any blood test? I'm looking at IgE levels and a complete blood count with differential. The second question I have is, what occupation was your husband in through the years? Has he been in contact with different chemicals at all in his work? Adult and said allergy symptoms are not always due to the same kind of triggers. Rather than allergen triggers, they can be irritants triggers. Things like solvents, cleaning agents, fertilizers, etc. can bring on the same issues. The blood work could help point the way. I'd need the results for evaluation. Also, how does he react with a large rainstorm front moving in...where a lot of lightning proceeds it. That contains high levels of ozone, another big trigger. Are you close to a major highway? High particle counts are usually around there, another irritant.
So, get back to me on these. Also, Astepro is an antihistamine, not a steroid.