An Abundance of Remedies but Little Relief


Allergies are a worldwide problem. Skin testing is sometimes helpful as part of a treatment plan.

In Brief:

*Despite dozens of over-the-counter and prescription remedies, millions of allergy sufferers seek better relief.

*Allergies are often overlooked by doctors and patients but can lead to serious health problems, including asthma in children.

*Rush immunotherapy regimens offer a fast response — and hold out hope for long-term relief — but require close monitoring.

*Under-the-tongue remedies offer an alternative for the needle shy but aren’t yet F.D.A.-approved.

*With more than 35 over-the-counter remedies and 28 prescription medications crowding the market, you’d think it would be easy for hay fever sufferers to find relief.

Think again.

Most of the estimated 50 million Americans who suffer the runny noses, raw and itchy eyes, clogged sinuses and hammering headaches of allergic rhinitis, as hay fever is medically known, aren’t getting the relief they seek. According to a 2005 survey conducted by the Asthma and Allergy Foundation of America, more than half say they’re “very interested” in finding a new medication. One in four reports “constantly trying different medications to find one that works for me.”

Why is it so hard to find an effective treatment?

One problem, experts say, is that allergic rhinitis isn’t taken seriously enough, by doctors or allergy sufferers. “Allergic rhinitis is typically a doorknob complaint,” said Dr. Bradley Marple, professor of otolaryngology at the University of Texas Southwestern Medical School in Dallas. “Patients wait until they’re almost out the door before they say, ’Oh, and by the way, my allergies have been acting up.’” Too many doctors quickly write a prescription or recommend an over-the-counter antihistamine but fail to follow up to see if it worked.

Four out of five allergy sufferers never even make it to the doctor’s office, relying instead on over-the-counter remedies, according to the A.A.F.A. survey. “Unfortunately, that usually means there’s no treatment plan in place,” said Dr. Marple. “A patient may try one antihistamine and if it doesn’t work try another, when what they really need is a decongestant, or a drug that targets another part of the allergic reaction, or a corticosteroid nasal spray.”

That’s too bad, and not only because it means needless suffering. Allergies can lead to sleep problems and set sufferers up for more serious respiratory problems. Children with allergic rhinitis are three times more likely than their non-sniffling counterparts to develop asthma. Kids and adults alike are more likely to develop sinus and ear infections, especially if their allergies go untreated.

The strongest argument for taking allergies seriously comes from results of an ongoing experiment called the Preventive Allergy Treatment Study in Denmark. Seven years after completing a course of allergy shots aimed at quieting an overcharged immune response to harmless substances such as pollen, children in the study were more than four times less likely to develop asthma.

“Those results are really remarkable,” said Dr. Harold Nelson, an allergist at the National Jewish Medical and Research Center in Denver. Along with other evidence, he explained, they show that immunotherapy doesn’t just alleviate symptoms but actually changes the immune system of people with allergies, restoring it to normal.

Unfortunately, few studies have been done to compare one course of allergy treatment with another. Instead, physicians must rely not on evidence-based research but what’s referred to as “expert opinion.” And as Dr. Marple said, “experts can disagree.”

Still, a consensus on the basic plan of attack is emerging.

For mild to moderate allergic rhinitis, over-the-counter remedies are a reasonable first step. Decongestants work by constricting tiny blood vessels and shrinking swollen and inflamed tissue in the lining of the sinuses. Antihistamines block one of the biochemical steps of the allergic process.

If over-the-counter medicines don’t work, it’s time to talk to a doctor or allergist. Many prescribe corticosteroid nasal sprays, which suppress the allergic process at the heart of the problem.

Typically, immunotherapy is the last resort. The treatment involves identifying the specific culprit that’s causing the problem through a series of skin tests or, in some cases, a blood test. Tiny doses of allergen are then injected under the skin in a weekly series of allergy shots to desensitize the immune system.

Some doctors now offer an accelerated protocol called rush or cluster immunotherapy, in which patients receive several shots a day, spaced half an hour apart. “Instead of the six to eight months it usually takes with standard immunotherapy, we can get to maintenance levels in four weeks,” said Dr. Nelson. Because this rush procedure can lead to serious immune reactions, including shock, it must be closely monitored. A ragweed vaccine given over six weeks is also currently in testing.

For the needle-shy, another advance is making immunotherapy more attractive: the use of allergens that dissolve under the tongue. Although widely used in Europe, sublingual allergens haven’t yet won F.D.A. approval in the United States. Allergists are free to prescribe them, but insurance companies won’t cover the cost. Another drawback is that sublingual allergens are only about half as effective as injections in desensitizing the immune system. But patients can take them at home, rather than having to make an office visit for each treatment – an important advantage.

For his part, Dr. Nelson thinks more patients should consider immunotherapy, especially those with severe and persistent allergic rhinitis. “Medications work only as long as you keep taking them,” he said. “Immunotherapy is the only treatment we have that alters the immune system, restoring the same response to allergens like ragweed that we see in normal nonallergic people.”

Unlike pills and nasal sprays, in other words, immunotherapy holds out the possibility of something far better: a cure.

Sources:The New York Times: June 10 ’08

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