Asthma, allergies and the new hope of immunotherapy
CHICAGO — When Lori Feeney's 7-year-old daughter, Allison, suffered a minor asthma attack while playing soccer, the mother knew her attempts at managing her daughter's seasonal allergies weren't working. In fact, she didn't even know her daughter had asthma.
Since the girl was 2, Feeney had been trying to manage her daughter's seemingly innocuous symptoms — simple runny nose, itchy eyes, coughing, constant clearing of her throat, congestion and fatigue — with over-the-counter medications and nasal sprays. She even tried a neti pot, humidifier and steam treatments, spending $30 to $50 a month trying to alleviate symptoms.
"It was at this point that we made an appointment with her pediatrician to get some assistance and direction," the Chicago mother said. "She was officially diagnosed with asthma at that point, prescribed an inhaler and referred to an allergist."
Dr. James Sublett, an allergist-immunologist in Louisville, Ky., and president of the American College of Allergy, Asthma and Immunology, said it's common for people to have asthma and not know it.
"It is estimated that as many as one of four people with asthma have never been told they have asthma," Sublett said. "Asthma is a chronic condition that can flare during a seasonal exposure. Chronic or recurrent cough is the most common symptom." People with asthma often are misdiagnosed as having a sinus and bronchial infection, he said.
The U.S. Centers for Disease Control and Prevention estimates that asthma affects 25.7 million people in this country and that, of those, 7 million are under age 18.
Asthma is a chronic inflammation of the airways of the lungs, Sublett explained. "Symptoms are cough, intermittent wheezing, chest tightness and shortness of breath," he noted. "The most common triggers are allergies and viral infections like the common cold. Air pollutants, especially small particulates from cigarette smoke and diesel exhaust, are also frequent triggers."
Because asthma is a chronic inflammatory disease, it should be managed preventively. "An asthma 'attack' represents poorly controlled asthma and should be able to be prevented with good management," he added.
Identifying and avoiding triggers as much as possible is the first step toward managing asthma, Sublett said. This includes keeping pets out of the bedroom or restricting time around smokers, if those are allergen triggers.
Outside of lifestyle changes, those suffering from asthma have a handful of ways to manage or treat their disease, ranging from antihistamines to nasal steroid sprays, depending on the type and severity of asthma.
Sarah Best-Wilson, 34, from Madison, Wis., has been managing her asthma since she was a child, using her maintenance inhaler (long-term medicine) daily and always carrying her rescue inhaler (fast-acting) for emergencies. "My doctor told me always to err on the side of caution and take a rescue inhaler when I think I might need it," Best-Wilson said. "It's not always easy to tell when I'm having a true attack because sometimes I get lightheaded instead of getting wheezy. So I also have a peak-flow meter (measuring lung capacity) that can help me gauge my symptoms."
Best-Wilson is constantly looking for ways to manage her asthma better, which is why she's keeping close tabs on new GPS-based technology that tracks when patients take medication while providing location data that might reveal allergy problem areas.
When the allergist recommended allergy shots to Feeney for her daughter, she was hopeful because she didn't want her daughter on daily medication.
"We began the process of 'desensitization injections' the following week," she said. The testing revealed that her daughter was allergic to more than 30 foods in addition to ragweed, grass, mold, tree, dust, cat and dog fur. Armed with that information, Feeney adjusted her daughter's diet, and they began the process of giving the girl a "cocktail" of her specific allergens via injections regularly to expose her body to them in a way that she doesn't overreact when exposed naturally.
"The connection between her exposure to allergens and her asthma difficulties is so direct, and we didn't realize it when we were new to the parenting game," Feeney said. "Once her allergies were under control, her asthma issues virtually disappeared."
This type of "cocktail" is a form of immunotherapy, and many patients are finding long-term success using the treatment, eventually being able to stop altogether.
In immunotherapy, small controlled amounts of specific allergens are injected or otherwise introduced into the patient, explained Dr. Sandra Y. Lin, associate professor, Department of Otolaryngology-Head and Neck Surgery at Johns Hopkins University School of Medicine. Over time this leads to greater immune tolerance and decreased allergic symptoms.
Prime candidates for immunotherapy are patients with proven allergic rhinitis (or hay fever) whose seasonal pollen allergies or reactions to other triggers like pet dander, dust mites, cockroaches and mold, are not well controlled with medications or desire treatment that actually changes the underlying disease, according to Lin.
"The majority of patients, after being on immunotherapy, will have significantly improved symptoms and a decreased need for allergy medication," Lin said.
Newer in the patient arsenal is sublingual immunotherapy, approved by the Food and Drug Administration last year. Rather than frequent doctor's office visits for injections, patients who test positive for a specific allergen now can take tablets under the tongue at home. Drops also are available, but currently only the tablets are FDA-approved.
Encouraged by the positive results patients were experiencing with immunotherapy, Lin recently led a panel on sublingual immunotherapy as one of several state-of-the-science treatments for allergic rhinitis. The treatment is being recommended in a new guideline published earlier this year by the American Academy of Otolaryngology — Head and Neck Surgery Foundation.
"Young children may do better with sublingual forms since they tend to not like frequent injections," Lin added. "Immunotherapy shots or sublingual drops are available for environmental allergies (pollens, dust mites, dander, etc). However, there are sublingual tablets in the United States only for ragweed and grass pollen."
Not everyone is a candidate for sublingual immunotherapy, including patients with a past severe allergic reaction to immunotherapy or who are pregnant. "Also patients taking beta-blocker medications may not be good candidates — beta blockers interfere with effectiveness of the medication we give in the case of severe allergic reactions," Lin said.
Another benefit of immunotherapy is cost. "Some studies show that in the long-term, immunotherapy is actually less expensive than medications," Lin added.
"Allergy shots have worked wonders for Allison," Feeney said. "It is a commitment but so worth it for us. She started once a week but now goes once a month."
Sublingual immunotherapy wasn't an option for Feeney at the time her daughter began treatment, but she would prefer having her daughter take drops at home rather than getting shots regularly at a doctor's office. "The most difficult part of the injection process is committing to the regular schedule of injections, so anything that could be less time-consuming would be wonderful," she said. "I'm going to be asking about sublingual immunotherapy now."
FACT BOX
The U.S. allergy capitals:
The Asthma and Allergy Foundation of America has produced a list of the Spring Allergy Capitals of 2015, naming the cities expected to be hardest on allergy/asthma sufferers. The list is based on data such as levels of pollen and mold, plus availability of board-certified allergists. The top 25 are:
1. Jackson, Miss.; 2. Louisville, Ky.; 3. Oklahoma, City, Okla.; 4. Memphis, Tenn.; 5. Knoxville, Tenn.; 6. McAllen, Texas; 7. Wichita, Kan.; 8. Dayton, Ohio; 9. Providence, R.I.; 10. Richmond, Va.; 11. Little Rock, Ark.; 12. Tulsa, Okla.; 13. Baton Rouge, La.; 14. Chattanooga, Tenn.; 15. New Orleans, La.; 16. Columbia, S.C.; 17. Birmingham, Ala.; 18. San Antonio, Texas; 19. Dallas, Texas; 20. Syracuse, N.Y.; 21. Greenville, S.C.; 22. Charleston, S.C.; 23. Nashville, Tenn.; 24. Winston-Salem, N.C.; 25. St. Louis, Mo.
For the complete list, visit http://www.tinyurl.com/allergycities.
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