On April 3, Dr. Mehmet Oz hosted a segment on his TV show called “How to Survive the Allergy Epidemic”. In keeping with many news reports released this spring, Dr. Oz declared: “This year, you’re going to feel even more miserable than ever before.”

New York allergist and Allergic Living contributor Dr. Clifford Bassett was invited to help explain to viewers why this may be. He said that climate change factors, such as warm seasons starting earlier and ending later, are to blame. He also noted that tree pollen and grass pollen seasons can overlap resulting in a “pollen bomb” that can cause misery for allergy sufferers.

Dr. Oz did an excellent job explaining how certain weather patterns can cause what allergy specialists and botanists now call ‘the priming effect’ – where pollen levels rise, fall and rise again in late winter and early spring. When it’s unseasonably warm, plants begin producing pollen early. When the temperature drops again, they stop, and then begin again once the warmer weather returns. In pollen-sensitive individuals, this can cause worsened allergy symptoms that are tougher to control because their immune system has been ‘primed’ for pollen allergens.

The topic of conversation then moved to treatment. Most medications for spring allergies work by blocking histamine receptors, so the histamine in one’s body has nowhere to bind to and cause symptoms. These treatments are effective for most people, but they treat the symptoms but not the underlying allergic disease. Upon each re-exposure, the symptoms will have to be blocked again.

This is why doctors often recommend immunotherapy, or allergy shots, in which a small amount of the allergen (i.e. pollen) is injected into a sensitized individual on multiple occasions over a long period of time. The goal is to allow the patient to build tolerance to the allergen and eventually no longer be sensitized to it.

The trouble with this traditional type of immunotherapy, which Dr. Bassett noted has been available for almost 100 years, is just that – the trouble: injections are required several times before each allergy season for several years, resulting in many, many hours in the allergist’s office.

Fortunately, Dr. Bassett informed Dr. Oz’s audience that sublingual immunotherapy (SLIT), which is a type of immunotherapy that uses under-the-tongue tablets or drops instead of needles, is gaining ground. It is far less invasive: once an allergist determines the proper dosage, a patient can actually conduct this immunotherapy by themselves, at home.

While not yet approved by the FDA, several clinical trials have demonstrated that this type of treatment can be effective, and it has been available in Europe for years. One brand, Oralair, was recently approved for prescription use in Canada.

See the full episode of The Dr. Oz Show here

See also:
Peanut Drops Hold Treatment Promise
Milk OIT Not Lasting
Dr. Oz on Nut Proteins in Olive Oils

One of the tablets, known as Oralair, recently became available by prescription in Canada, but not the United States. This pill has proven effective in international studies, and is now approved by Health Canada.

Another tablet, known as Grazax in Europe, has been submitted to the FDA in the United States for final approval. Unfortunately, the tablet (which will have a different brand name in the U.S.) most likely won’t become available until next year’s grass season at the earliest.

When it comes to grass allergy, taking antihistamines does the job for some people. But allergists have traditionally steered those with more severe symptoms and asthma toward immunotherapy, also known as allergy shots. The tablets are a new form of this therapy – called sublingual immunotherapy, or SLIT, because the dose is taken under the tongue.

Although it’s recommended to begin taking these tablets four months before allergy season begins, they have been known to show significant improvement after being taken for as little as one month. This is far less invasive and time-consuming than traditional immunotherapy: instead of visiting an allergist several times to get your shots, you can simply place a tablet under your tongue and allow it to dissolve.

Sublingual immunotherapy is actually not so new.  For years now, researchers have been studying it, not just for grass allergy but potentially for food allergy as well. It works with the same principle as traditional allergy shots: introduce tiny amounts of the specific allergen into the patient’s system (in this case, via drops), with the goal of building toward tolerance.

See also:

Allergic Living’s Full Report on SLIT for Grass Allergy
Milk OIT Not Lasting

In fact, three to five years after completing an OIT study, Johns Hopkins University researchers said that many participants were more reactive to cow’s milk than they had been early in the course of treatment.

The team presented results from a follow-up study involving 32 children from two clinical trials in which they were fed tiny, then increasingly larger amounts of milk. These patients completed the milk oral immunotherapy, then underwent an oral challenge test for tolerance and were sent home with individualized instructions for daily milk consumption.

It turned out that 38 percent of the test subjects (12 children) who were thought to be desensitized were having frequent symptoms from milk three to five years after the trial had ended, while 22 percent had occasional symptoms. Only 25 percent of the participants were able to consume milk without symptoms. (The other 16 percent had ceased having milk.)

In terms of the type of reactions being experienced, 31 percent reported systemic symptoms (characterized as more than an itchy mouth or stomach ache) and 19 percent had symptoms serious enough to require an epinephrine auto-injector.

At a news conference at the AAAAI meeting, Dr. Robert Wood, director of pediatric allergy and immunology at Johns Hopkins, did not mince words: “Some of the more dramatic failures had looked like absolute successes in the study. They were tolerating huge amounts of milk; they were about as close to ‘cured’ as we could imagine,” he said.

The study shows that 22 percent of the children had returned to either milk avoidance or minimal consumption of it. “The main thing that I’ve come to believe is that they were not as protected as we believed in that they self-restricted [consumption] because they didn’t like the side effects the milk was putting them through,” said Wood.

So have the researchers lost hope? Not at all. It appears more a case of figuring out where the research goes from here for some patients who lose newfound allergy protection easily.

“Learning something that’s disappointing is why it’s called research,” Wood noted about the study. As he told Allergic Living in an interview: “To go from where we were 10 years ago, which was to say that ‘we probably can’t give food to a highly allergic patient safely at all,’ to say now that some patients are having extremely good outcomes, this leaves us with encouragement that the long-term potential is very real.”

Dr. Wesley Burks, one of the leaders on OIT research from the University of North Carolina, summed it up well when he said: “There are a lot of encouraging results, but there’s also a lot of work to be done. This isn’t really ready for treatment – we’re not there yet.”

There are some intriguing bigger questions on where research will head to get “there”. Allergic Living will be examining these issues in the Summer edition in a special report on food allergy treatment research. We hope you and your family will find it enlightening.

Read more news from the AAAAI meeting here.

See Also: Parents Exposing Kids to Their Allergens

Known as sublingual immunotherapy, or SLIT, this treatment works by having study subjects take tiny, daily doses of an allergen – in this case, peanut – in steadily increasing amounts over an extended period of time.

The new study, published in the January edition of the Journal of Allergy and Clinical Immunology, involved 40 peanut-allergic patients between the ages of 12 and 37 in five U.S. cities. The subjects were randomly divided in half, with one group taking liquid drops containing peanut powder under the tongue and the other taking drops with a placebo.

After 44 weeks of the daily doses, 70 percent of those getting the peanut powder could tolerate at least 10 times more peanut in an oral food challenge before showing symptoms than they could have at the outset of the study. In a follow-up challenge at 68 weeks, they could tolerate about twice as much again. (Patients were also to be retested at 88 weeks.)

This suggests that longer treatment could lead to even better results. The end goal is to slowly build up tolerance until the individual is no longer sensitized to the allergen.

“It gives us hope that this type of therapy might be used in the future for some type of treatment,” Dr. Wesley Burks, lead author of the study and Chair of the Department of Pediatrics at The University of North Carolina, told Allergic Living.

But Burks is quick to acknowledge the hurdles that remain. First, the treatment was not effective for 30 percent of the subjects. He believes this has to do with finding the proper dosage for those individuals, which could be related to their specific immune and gastrointestinal systems.

He says it shows that more and larger studies are required before this type of treatment – currently only done with strict medical supervision – becomes widely available.

The second issue is that, after 44 weeks, the average amount of peanut one of the responding allergic patients could consume was still fairly small: 496 milligrams. That equates to about two peanuts (a single peanut typically contains 250 to 300 mg of protein).

The treatment “is not ready for practical day-to-day usage,” says Burks. “There is some efficacy, but it is not the right thing to do right now”.

Even if SLIT’s results are being measured in incremental successes, that is still significant and promising, especially when compared to the sole, current allergy treatment of strict avoidance of peanuts.

An anaphylactic reaction includes more than one of the body’s systems, such as the respiratory tract, gastrointestinal tract, the skin and cardiovascular symptom. Symptoms of an allergic reaction include tingling in the mouth, swelling of the tongue and throat, itchy skin or hives, difficulty breathing, abdominal cramping and vomiting. In a severe anaphylactic reaction, a person may experience a drop of blood pressure, loss of consciousness and even cardiac arrest and death.

One of the issues in managing peanut allergy is that symptoms can vary. A person may have had minor symptoms, only to suffer anaphylaxis on a subsequent exposure.

Because peanut allergy reactions can be severe, it is important that a person with this allergy carry an epinephrine auto-injector (EpiPen or Twinject) with them at all times. Peanut allergy is often considered a lifelong allergy, but research has shown up to 20 per cent of children may outgrow it by the time they reach school-age.*

*Source: 2010 FA primer. JACI

Prevalence

In the United States, the rate of peanut allergy in children increased by 3.5 times from 1997 to 2008, to a rate of 1.4 per cent. In Canada, it is estimated that 1.68 per cent of children and 0.71 per cent of adults have peanut allergy.

More on Peanut Allergy Statistics

Next Page: Not a Nut!

Who Reacts

Even our understanding of the prevalence of pet allergies is fuzzy. Although an estimated 20 to 30 per cent of young adults will react to at least one airborne allergen, studies have shown early exposure to animals (which researchers now suggest can have a protective effect), where you live, and whether you experience asthma, hay fever or both can all influence the development of allergies to animals.

New research from the U.S. National Institutes of Health shows that cats are the single biggest trigger for asthma, causing reactions in 29.3 per cent of asthmatics. A Swedish study, meantime, found 40 per cent of kids with asthma reacted to cats, 34 per cent to dogs, and 28 per cent to horses.

For the kids who got runny noses and itchy eyes, 49 per cent reacted to cats, 33 per cent to dogs, and 37 per cent to horses.

Dr. Jeffrey Davidson, an allergist in San Francisco and a clinical professor at the University of California San Francisco, says it’s fair to expect that as the incidence of allergic disease grows, so does the number of people reacting to animals. And while cat allergies are by far the most prevalent, people can be sensitized to any animals with feathers and fur, including dogs, guinea pigs, mice, birds, and ferrets.

The Symptoms

The range and severity of symptoms is vast, and includes itchy, runny nose and sneezing, irritated, watering eyes, wheezing and shortness of breath, eczema and hives. “Some people say they don’t have a problem unless they touch the pet and touch their eyes,” Davidson said. “And there are other people who walk into a room where there is a cat, or there has been one, and they will have an asthma attack.”

The Allergens

The culprits setting of these reactions are a series of proteins found in concentrated amounts in dander (flakes of dead skin), saliva and oil called sebum that hair follicles secrete to protect fur and skin. In some animals, allergenic proteins that originate in the blood are released through urine. The cat’s most prominent allergenic protein is called Fel d1, and its counterpart in dogs is Can f1.

Dr. James Ransom, an allergist in Topeka, Kansas and clinical instructor at The University of Kansas Medical Center, says cats’ constant grooming and indoor litter boxes mean these allergens are continuously evaporating into indoor air. A pet lover might reason a hairless cat or a short-haired dog should be fine. Not necessarily. Ransom says that, regardless of their fur, pets still emit the allergy-causing proteins from their skin, glands, dander, urine and saliva.

Plan B Solution

Ransom says if a patient has a severe reaction to animals or develops asthma, he’ll advise that the pet has to go. But “getting people to get rid of pets is very difficult.”

His Plan B is to tell the family to minimize the exposure. First, someone not allergic to the animal should wash it once a week. Next, the pet should never be allowed into the allergy sufferer’s bedroom. The pet’s roaming area in the house should be reduced to exclude areas where the allergic person spends much of his or her time. Finally, cloth-covered furniture and carpeting (which Ransom calls the “reservoir of allergens”) must be replaced with leather or vinyl furniture and hard floors such as linoleum or tile.

Although some shampoos and sprays claim to reduce how much allergenic protein your pet totes around, Davidson says washing a pet with water alone is probably just as effective. Wipe down a cat with a damp cloth instead of bathing him, the specialist advises, to avoid “losing your forearms.”

Next Page: The Cat Comes Back

What is immunotherapy?

Immunotherapy is a form of treatment, commonly known as allergy shots, in which a patient with allergic rhinitis gets controlled exposure to allergens through injections. It will not be the first course of treatment. In immunotherapy, a doctor raises the allergen dose in your shots over a number of months and years – the intent is that as the dose rises, you become less sensitive to allergens.

Who should get allergy shots?

First, your allergist will take a history, do an examination including skin-prick tests to determine what you are allergic to, and then will prescribe medications. If you’re still suffering even with medication, allergy shots may be the next step. Candidates for this treatment are usually people who are no longer helped by allergy medications and those who have serious rhinitis symptoms for prolonged periods of time.

If you haven’t had allergies for long, you are more likely to be responsive and experience longer-lasting benefits. Children, however, should have had seasonal symptoms for at least two years before being considered candidates, says Dr. Eric Leith, an allergist based in Oakville, Ontario, and chair of the Canadian Allergy, Asthma and Immunology Foundation. The child should be old enough to understand what’s going on, he says, “and if a reaction occurs, they must be able to express that.”

Allergist Dr. Harold Kim says about 5 to 10 per cent of patients receiving immunotherapy have skin, breathing or gastrointestinal reactions. Only about 1 to 3 per cent have more severe reactions. While anaphylaxis is rare, “immunotherapy can be life-threatening,” cautions Leith. “You should be waiting in the doctor’s office for half an hour [after the treatment] to make sure you are not reacting.” If you have asthma, Leith stresses that it must be under control or the shots “may accentuate the asthma.”

How long does immunotherapy treatment last?

Immunotherapy can take years to carry out. Patients receive one to two shots a week of minimal amounts of their allergen for about six months, until they reach their “maintenance dose,” which means symptoms have improved. Then, a monthly dose is required to keep the allergies under control. Treatment can take up to five years, but the benefit of immunotherapy is that it may have a lasting effect even after the shots have stopped. Leith says there have been cases in which patients have seen their symptoms disappear completely.

Related:
• The Hay Fever Handbook
• 10 Ways to Beat the Pollen
• America’s Top 10 Spring Allergy Capitals

From the Spring 2006 issue of Allergic Living magazine.
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