It's Spring Again and Allergies Are In Bloom

by Food and Drug Administration (FDA)

Chances are that you would just as soon not think about your nose. As long as it lets air in and out fairly easily, sniffs a nice aroma now and then, and keeps eyeglasses in place, a nose is, well, forgettable.

But for 25 million to 30 million Americans who suffer from seasonal allergic rhinitis — better (if inaccurately) known as hay fever — it is sometimes hard to think of anything but their noses. When a hay fever victim's particular nemesis is in the air, he or she is apt to be preoccupied by a constant struggle against the ailment's classic symptoms — watery nasal discharge, runny eyes, violent fits of sneezing, and itching that can affect not just the nose, but the roof of the mouth and even the Eustachian tubes connecting the inner ear to the back of the throat.

If tree pollen is the culprit, this all-out barrage against the nose and its neighbors usually strikes in early spring. Grass pollen tends to be troublesome in late spring and summer, and the deservedly notorious ragweed pollen is most abundant in the fall. Depending on where they live, hay fever victims who react to all three types of pollen may get a respite only in mid-summer and the dead of winter.

On the other hand, a hay fever sufferer who is allergic to molds, house dust, or animals may have to contend with symptoms the year 'round. So do people whose attacks are triggered by industrial pollutants, cigarette smoke, and other airborne irritants and allergens where they live or work. These unfortunate souls have "perennial allergic rhinitis." Their hay fever never lets up.

If that is the bad news, the good news is that a lot can be done to help hay fever sufferers cope with the disease. Better understanding of the complex events involved in an allergic reaction has made possible substantial improvement in the care of allergy patients, whether they have hay fever, asthma, food allergies, or any of a wide range of distressing and sometimes life-threatening allergic diseases. Medical science cannot cure allergies the way it can pneumonia. But advances in treatment and prevention allow millions of people to avoid the torment that can plague anyone unfortunate enough to "have allergies."

Allergies or a Cold

Allergists (physicians who specialize in treating allergies) think that a good deal of allergic disease is unrecognized and therefore untreated. One reason is that seasonal allergies can easily be mistaken for a cold. Careful observation and common sense are useful guides to whether a stuffy, runny nose and sneezing signal a cold or an allergy. If the symptoms last more than a week or so, if they go on virtually all of the time, if they start and stop at the same time every year, flare up around cats or horses (principal causes of animal allergy), or otherwise follow a consistent pattern, allergy ought to be suspected. To be more certain, however, appropriate tests should be done by a physician, preferably an allergist.

The diagnosis of allergic rhinitis — the medical term for the inflamed, runny nose that's the main symptom of "allergies" — is based on a detailed patient history and examination of the nose. But the most critical step is skin testing. Tiny, diluted amounts of suspected allergens are injected under the skin or applied to a small scratch or puncture on the patient's arm or back. Within about 15 minutes, if the patient has IgE antibodies to an allergen being tested, a small raised area surrounded by redness — the "wheal and flare" reaction — will appear at the test site. The size of the skin reaction indicates how sensitive the patient is to the allergen that caused it.

Paul C. Turkeltaub, M.D., of FDA's Center for Biologics Evaluation and Research, and researchers at the National Center for Health Statistics examined information on allergen skin testing collected between 1976 and 1980 in the Second National Health and Nutrition Examination Survey. Among more than 16,000 people aged 6 to 74, about one in five had skin reactions to at least one allergen. Ryegrass and ragweed pollen each produced reactions in over 10 percent of the people tested, 6.2 percent were sensitive to house dust, and 2.3 percent showed a reaction to cats. More than twice as many people reacted to allergens found outdoors than to those found indoors.

Not everyone who tests positive for specific IgE antibodies necessarily has allergy symptoms. Nevertheless, many allergists think that allergic disease of one kind or another — hay fever, asthma, drug allergy, or an allergic reaction to certain foods or insect stings — is likely to appear sooner or later in a person who has no symptoms but who has a positive skin test. About 80 percent of people who develop allergic rhinitis do so before the age of 30. But the disease has also first appeared in people in their 70s or 80s.

Shots and Other Relief

Before the 1940s brought the general availability of antihistamines, hay fever sufferers could get little help from the pharmacy. A hundred and fifty years ago, the English clergyman, wit, and hay fever victim Sydney Smith — he said his sneezes could be heard for six miles — put opium in his nostrils to relieve "this little upstart disease." Today allergic rhinitis can be controlled by more effective and much less dangerous drugs.

Antihistamines, available both over the counter and by prescription, remain the most widely used agents to treat hay fever symptoms. They can be highly effective in controlling itching and sneezing, but do less well in clearing nasal congestion. Antihistamines are most effective when used regularly rather than sporadically. Their chief undesirable side effects are drowsiness and excessive drying of tissues. Newer antihistamines, such as the prescription medication Seldane (terfenadine), are less apt to cause these side effects.

Nonprescription decongestants that shrink blood vessels in and around the nasal passages may help relieve nasal stuffiness. Decongestants are often sold in combination with antihistamines in the form of tablets, capsules, caplets and liquids. Others are sold as nose drops or sprays. While very effective for short-term use — a few days at most — overuse of nose drops and sprays can cause a "rebound" effect in which the congestion comes roaring back worse than ever. Patients can get caught in a vicious circle of use, relapse, and more use. The only solution is to stop using the drug altogether.

Intal or Nasalcrom inhalers (active ingredient cromolyn sodium), available by prescription, were first used against asthma and are proving useful in treating hay fever as well. For most people, inhaled cromolyn has few if any side effects, but must be taken frequently — every four hours — to be of maximum benefit. The corticosteroids, hormone-like drugs that suppress the immune response, may also be useful in relieving allergy symptoms. They are usually administered as sprays, but are sometimes taken by mouth. While long-term use of oral corticosteroids can depress the activity of the adrenal glands, resulting in diminished resistance to infection, and cause other serious side effects, the nasal preparations used to treat allergic rhinitis are not thought to have any effect on the body as a whole. Corticosteroids are available only by prescription.

Allergen immunotherapy — "allergy shots" — offers another effective approach to controlling hay fever symptoms. First employed in the 1920s, immunotherapy consists of injecting gradually larger amounts of the allergens that cause the patient's allergic response. At the beginning of the treatment the dose is intentionally much too small to cause a reaction. The dose is gradually increased to a level that protects the patient from whatever is causing the allergy. It usually takes six to 12 months to reach a protective dose. Once protection has been achieved, patients are given maintenance shots at four- to six-week intervals to keep symptoms under control. Whether or not the patients can successfully stop receiving allergy shots is uncertain. Studies suggest that protection fades if the shots are discontinued. For that reason, some allergy specialists recommend that they be continued indefinitely.

Aiming for Improvements

FDA is actively seeking to standardize the commercially available extracts used in skin testing and immunotherapy to improve their safety and effectiveness. The agency has two main objectives: expanding the availability of single-allergen extracts (individual kinds of pollen, for example, rather than extracts containing mixtures of several allergenic pollens); and standardizing extracts on the basis of how strong a skin reaction they produce. Studies have shown, for example, that weed and grass pollen extracts are more than 10,000 times as potent in producing skin reactions as extracts made from white pine and mountain cedar pollen. The labeling of standardized extracts reflects such differences in terms of "allergy units." Using single-allergen, standardized extracts, physicians are better able to tell precisely what causes a patient's symptoms and to plan, if necessary, the most effective course of allergy shots.

Immunotherapy has proven effective in hay fever sufferers and can be little short of miraculous for some patients who cannot get adequate relief either from avoiding allergens or from medication. Allergy shots are, however, time-consuming and costly and entail a slight risk of causing the kind of reaction they are meant to prevent. Because such a reaction can be serious, doctors like to monitor patients for at least 20 minutes after giving the shot.

The best course of action in treating hay fever is to get a careful diagnosis and discuss treatment options with an allergist. Once a hay fever sufferer's problem has been diagnosed, a doctor often can show how symptoms can be controlled by avoidance of the allergen or allergens involved or by the careful use of over-the-counter antihistamines and decongestants. If prescription drugs or immunotherapy are called for, a physician can recommend the most appropriate course of treatment. The important thing is that virtually every hay fever sufferer can be helped by prevention and treatment.

Noses are remarkable. They filter the air we breathe, warm it when it's too cold, and moisten it when it's too dry. They alert us when food might be unsafe to eat, and some noses can even smell a rain storm coming. Yet, with the possible exception of Bob Hope, we would all be grateful if noses went about their impressive variety of tasks unnoticed. For hay fever victims, that would be a blessing. Thanks to medical science, it's a blessing millions of them can enjoy. ? Ken Flieger is a free-lance writer in Washington, D.C.

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