Blowin’ in the Wind
Why are allergies so bad in Texas? What causes an allergic reaction? How do you choose an allergist? And what’s the best treatment: drugs or shots? The Answers, my friend, are Blowin’ in the Wind.
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Antihistamines are for runny noses, sneezing, postnasal drip, watery eyes, and itchy noses and throats. Antihistamines suppress or block altogether the release of histamine from mast cells during an allergic reaction. Histamine, you’ll recall, is what provokes allergic symptoms through receptors located in nasal and bronchial tissue. Antihistamines compete for the receptors most responsible for allergic symptoms; when they occupy the receptors, the receptors, which can handle only one agent at a time, are forced to ignore the histamine. No receptor response; no symptoms.
Not all antihistamines are created equal. To begin with, there are “old” antihistamines, which cause drowsiness, and “new” antihistamines, which don’t. The latter are available by prescription only and are wildly popular, yet they may or may not be safe: The U.S. Food and Drug Administration recently determined that one such antihistamine, Seldane, has potentially life-threatening side effects when taken in combination with some antibiotic and antifungal drugs. Of course, the old antihistamines can cause cardiovascular irregularities too, as well as gastrointestinal problems and allergic reactions (including hives, eczema, shock, and swelling of the limbs, skin, and voice box). But there are at least seven chemical classes of antihistamines, and the extent of the side effects varies from class to class. It’s worth asking your doctor or pharmacist which ones cause the fewest unintended consequences; they will likely tell you that the antihistamines that provide sustained relief and not much drowsiness are those containing brompheniramine, chlorpheniramine, and clemastine—for example, Dimetane Extentabs, Tavist-1, and Chlor-Trimeton Repetabs.
Decongestants combat congestion and the swelling of air passages. They open the nose by constricting blood vessels that have been made to dilate and ooze by the release of histamine. Their side effects tend to be insomnia, higher blood pressure, nervousness, and difficulty urinating. Some topical decongestants, such as nose drops, can also cause rebound swelling in your nasal passages if you overuse them—that is, if you consistently use more of the drops than the lowest recommended dosage, if you use them for more than three to five days, or if you continue to use them when they aren’t working. There is no such rebound effect in systemic decongestants—that is, capsules and pills—and those that contain the generic substance pseudoephedrin (Sudafed) have less of an effect on your blood pressure, but the other side effects remain.
Start with topical decongestants; then, if they don’t work, move on to systemic decongestants. The reason for this is that the side effects of topical decongestants tend to be less invasive on the whole than those of systemic decongestants. So if your problem is primarily nasal congestion, try an over-the-counter spray such as Afrin regular or menthol sprays or Allerest 12-Hour Spray before trying capsules or pills. If the sprays don’t work, the best capsule decongestants are sustained-release products like Sudafed 12-Hour and Afrinol tablets. Such products are also more convenient, as they call for doses twice a day rather than four or six times.
Antitussives and expectorants are for coughing. The former are designed to stop a cough; the latter loosen mucus and bring up phlegm.
Combination drugs aren’t necessarily better. Many are available both by prescription and over the counter, a market-driven response to the fact that most allergy sufferers sustain multiple symptoms. Yet allergists say drugs that promise to suppress all symptoms can increase the chances of an unintended side effect—so it’s always best to treat the main symptom with the appropriate medication. If the problem is a runny nose, stick with antihistamines; if it’s sinus swelling, stay with decongestants. And if you decide to use a combination product, limit the possibility of side effects by making sure it contains only one antihistamine and one decongestant.
Contrary to popular belief, many over-the-counter medications are just as strong as the prescription varieties. Yet even though you don’t need a prescription, you still have to heed the dosage guidelines. As with any medication: When it’s not working, stop taking it.
Also contrary to popular belief, over-the-counter medications can be as expensive as prescription drugs. For example, the prescription antihistamine Extendryl costs $13 for thirty capsules at my neighborhood Eckerd Drugs; over-the-counter Drixoral costs between $15 and $17 for thirty capsules.
If the first line of defense doesn’t work, ask your doctor about corticosteroid or cromolyn sodium sprays. These products don’t act as quickly as over-the-counter decongestant sprays, but they can provide more sustained relief because they address both histamine activity and the chronic in�ammation that accompanies long-term allergies. For many allergy sufferers, the real problem is the ongoing tenderness and hypersensitivity of their nasal and bronchial passages. They’re sensitive not only to specific allergens but also to a wide host of other irritants. When administered on a regular basis, corticosteroid and cromolyn sodium sprays can reduce the number of in�ammatory cells swimming about in the mucosa and diminish the hypersensitivity of nasal nerves.
And if that doesn’t work—or even if it does, but you want a more global allergy treatment—there’s only one thing to do: Forget about going after the symptoms and go after the cause.
Immunotherapy Allergy shots have always had a bad name. At best, they’re seen by much of the public as overpriced placebos for an essentially incurable condition; at worst, they’re the latter-day witchcraft of quacks. As it has with the rest of allergy science, respect for immunotherapy as a safe, effective treatment for allergies has come slowly and uncertainly. Over time, skeptics have tried such questionable approaches as homeopathy, detoxification, autogenous urine therapy, neutralization therapy, and vitamin and nutrient supplements. Yet if administered properly by an allergist and adhered to prudently and patiently by the allergy sufferer, immunotherapy can yield a higher success rate than any of these alternatives—more than 70 percent, according to UT-Southwestern’s Kennerly, who not only administers the treatment but has undergone it himself.
Immunotherapy starts with allergy skin testing, a procedure in which doctors use plastic probes to gently scratch tiny doses of the extracts of as many as fifty antigens (such as pollens, grasses, weeds, molds, dust) into the skin on your back. After a fifteen- to twenty-minute wait, the allergist inspects the scratch sites for reddening and swelling known as �are and wheal reactions; the antigens that cause them become the basis of treatment.
If the offending allergens are, say, the pollens of certain trees, you’re placed on a weekly protocol of shots containing the extract of those pollens—the idea being that you’ll develop a resistance to the allergy. The initial dosages are small and highly diluted, so the therapy itself doesn’t cause an allergic reaction. As your system displays more tolerance, the size and potency of the doses are increased over a three- to six-month period, until you’re ready to receive a so-called maintenance dose, whose concentration is about 10,000 times as strong as the initial dose. “This is generally the dose that can produce the therapeutic results we want and can also be tolerated by the patient,” says Kennerly. By this time, your symptoms should be much improved or in remission. If so, the maintenance dose is adhered to from then on, with shots scaled back to twice a month, then once a month. “The whole process generally will take about three years,” Kennerly says. “There’s a lot of art to it, as well as science. Sometimes a person can be so sensitive that it takes much longer than the three to six months to establish the maintenance dose. In my case, that alone took about two years. It just depends on your specific sensitivity. It is a gradual process of the immune system building a kind of tolerance to the allergen.”
The inner scientific workings of immunotherapy aren’t completely clear, but allergists know a bit about what happens when your tolerance develops. When you receive a shot of the extract of the offending allergen, your immune system begins to produce more and more of the IgE antibody until the supply, in essence, begins to wane. At the same time the remaining IgE antibodies are gradually retrained not to initiate the allergic response. In a sense, the immune system, guilty of a well-intentioned error to begin with, makes amends by policing itself.
Of course, allergy shots aren’t for everyone. “In general,” says Kennerly, “they tend to work better on highly allergic individuals like me. Lesser degrees of sensitivity don’t get as good a response.” In any case, someone looking for such relief should be careful in selecting an allergist, he says, because some doctors may practice according to outdated treatment paradigms that dictate you don’t “dose up” a patient quickly or intensely. “We’ve only really known for about fifteen years that aggressive high-dosing is what works,” he says. “The cautious approach puts the patient through a lot of trouble for nothing.” Case in point: Jim Hicks, a Dallas labor and employment lawyer who began receiving immunotherapy shots from one doctor in the late eighties but didn’t really begin to feel improvement until 1994, when he switched to an allergist who favored the high-dose protocol. “I breezed through that fall of 1995, which was awful for pollen,” says Hicks, who was especially sensitive to fall pigweed. “Whatever he did, it sure has worked. It used to be that I really only had a ten-month year. This therapy has given me back two months. I can go hunting again in the fall.”
In addition to being symptom-effective, immunotherapy can be cost-effective as well. “Compared to what you might pay for antihistamine and corticosteroidal nasal sprays over a lifetime, it can actually represent a savings,” Kennerly says. Typically, immunotherapy shots run from between $5 and $20 apiece, not counting the fee for a visit to your doctor’s office. But because the number of shots required each month can be gradually decreased, and at some point the treatment ends altogether, immunotherapy still saves you money in the long run.
For his part, eight years after beginning immunotherapy, Kennerly still takes a monthly maintenance dose “as an insurance policy.” But he rarely needs to take an antihistamine or a decongestant. “It isn’t an absolute cure,” he says, “but it can send an allergy into complete remission.”
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