Allergies; Treatment.

It's important to remember that if you suffer any severe allergic reaction--such as anaphylactic shock or asthma that causes shortness of breath or difficulty breathing, or any other extreme discomfort--you should seek medical attention immediately. In fact, if you've ever had a previous severe allergic reaction, you should ask your health care professional about carrying a kit with you to treat anaphylactic shock and be sure you've been taught to give yourself an injection from the kit. If you have to use the kit, be sure you also get medical help immediately. Until help arrives, lie down and raise your legs above the level of your chest to increase the blood flow to your heart and brain.

The first course of treatment is avoiding the allergen. (For more details, see the section on Prevention.) Your health care professional may also prescribe medications, recommend over-the-counter remedies or suggest allergy shots. Although there is no cure for allergies, one of these strategies or a combination of them can provide varying degrees of relief from allergy symptoms.

Your health care professional may prescribe some medications that can be used alone or in combination. These include:

Antihistamines counter the effects of histamine that is released in response to the allergen. Antihistamines relieve sneezing and itching in the nose, throat and eyes; reduce nasal swelling and drainage; and are used to treat hives. The older drugs (called first-generation antihistamines)--brompheniramine, chlorpheniramine, diphenhydramine, hydroxyzine and triprolidine--cause drowsiness and increase the risk of vehicle and occupational injuries.

Some of the newer (second-generation) antihistamines, such as fexofenadine (Allegra), loratadine (Claritin), desloratadine (Clarinex) and cetirizine (Zyrtec), have fewer side effects. Some people, however, do experience mild side effects including drowsiness, dizziness, headache, nervousness, nausea, diarrhea, abdominal discomfort, dry mouth, dry skin or itchiness, or discoloration of urine with some of these medications. You should always let your health care provider know what other medications you are taking.

In November 2002, the U.S. Food and Drug Administration (FDA) approved Claritin as an over-the-counter (OTC) allergy medication. The product was previously available only as a prescription drug and is indicated for seasonal allergic rhinitis.

Two other second-generation antihistamines are azelastine and ketotifen. Azelastine is approved for use in the nose and eyes, and ketotifen in the eyes.

To treat eye symptoms of allergic conditions, such as inflammation, itching, watering and burning, your health care professional may prescribe antihistamine eyedrops that block histamine release. Don't use any other eyedrops while using these and be sure to remove contact lenses to apply the drops to your eyes. If you wear contacts, you're probably safer switching to glasses during the course of your treatment.

If you are pregnant, keep in mind that some of these antihistamines' effects on an unborn baby are untested; similarly, their effects on breast milk or nursing infants are in some cases not known. Always tell your health care professional if you are, could be or could become pregnant, and discuss your situation with him or her before taking any medications. Both cetirizine and loratadine are category B for pregnancy, meaning they appear to be safe, although they have not been tested specifically in pregnant women.

Topical nasal steroids are anti-inflammatory drugs that stop the allergic reaction. They decrease the number of the histamine-releasing cells in the nose and reduce mucus secretion and nasal swelling. These corticosteroid nasal sprays include mometasone (Nasonex), triamcinolone (Nasacort ), fluticasone (Flonase) and budesonide (Rhinocort). Although they are generally safe when used at recommended doses, side effects of these medications may include:

stinging or burning of the nose

sneezing after application

bleeding nose

perforated septum (inside center of nose), extremely rare

headache or lightheadedness

unpleasant (or loss of) taste or smell.

Once used only to manage acute symptoms, corticosteroids inhalants are now considered the best medications for long-term control of persistent asthma, according to the American Academy of Allergy, Asthma & Immunology.

In June 2003, the FDA approved omalizumab (Xolair), a genetically engineered antibody preparation administered by injection. Omalizumab is in a new class of allergy therapy known as "anti-IgE therapy," and it is indicated for adults and adolescents (12 years of age and older) whose allergy-related asthma symptoms are inadequately controlled with inhaled corticosteroids.

Cromolyn sodium (Nasalcrom) is a nasal spray that in some people helps to prevent allergic reactions from starting. It is in a class of medications known as mast cell stabilizers, which help control inflammation by preventing the release of inflammatory chemicals. Another mast cell stabilizer frequently used to help control allergies is nedocromil (Tilade Inhaler). When administered, cromolyn sodium can safely inhibit the release of chemicals like histamine from the cells. It has few side effects--which may include stinging or burning of the nose, headache, bad taste, runny nose, or postnasal drip--when used as directed and significantly helps some people with allergies. While tests have shown it is unlikely to harm an unborn baby, don't use cromolyn sodium without first talking to your health care professional if you are pregnant. It's not known if this medication passes into breast milk; talk to your health care professional if you are nursing.

Decongestants, such as pseudoephedrine, help reestablish drainage of the nasal passages and relieve symptoms such as congestion, swelling, excess secretions and discomfort in the sinus areas. These over-the-counter and prescription drugs can be taken by mouth or applied directly to the nose. Be careful not to use nasal sprays and drops for more than three or four days, or you might end up even more congested because of a rebound effect. Your health care professional may advise you to take an antihistamine in combination with a decongestant to relieve other allergic symptoms. Decongestants may produce side effects such as nervousness, insomnia, rapid heartbeat and elevated blood pressure.

Some over-the-counter products should not be used by people with high blood pressure, diabetes or other medical conditions, or if they've taken an MAO inhibitor in the last 14 days. If you have any medical conditions, be sure to consult your health care professional before self-treating.

Immunotherapy, also called allergy vaccine therapy, which consists of a series of injections, is the only available treatment that has a chance of reducing allergy symptoms over a longer period of time. Patients receive subcutaneous injections of increasing concentrations of the allergen(s) to which they are sensitive. These injections reduce the amount of antibodies in the blood and cause the body to make a different protective antibody. Many patients with allergic rhinitis (hay fever) will improve within 12 months of starting immunotherapy, but the most noticeable improvement usually takes place in the second year. In addition to seasonal allergies, immunotherapy is commonly used for patients with indoor allergies to dust mites, pets and mold, and stinging insect (Hymenoptera) hypersensitivity. Patients who benefit from immunotherapy may continue it for three to five years and then consider stopping. Although many patients are able to stop the injections with good long-term results, some do get worse again after immunotherapy is stopped.

A recently developed alternative therapy to traditional immunotherapy is sublingual immunotherapy, or allergy drops. Allergy drops work similarly to allergy shots in that they slowly desensitize patients to the substances that cause their allergic reactions. However, instead of being injected, with SLIT, the antigen is placed under the tongue with a dropper. Allergy drops appear to be both more effective and more convenient than traditional immunotherapy (plus, they don't involve the discomfort of an injection), though they are still being tested in the United States and are not yet FDA-approved. They are offered off-label or as part of trials in some medical centers across the country. Ask your doctor if allergy drops are an option for you.

In the cases of food allergies, while antihistamines and decongestants can help alleviate some symptoms, the best course of action is to avoid the trigger food.

The primary treatment for skin eczema is aimed at alleviating symptoms. To relieve itchiness and eczema, your health care professional might recommend initially a room-temperature bath to remove crusted skin, followed by immediate application of a moisturizer, which helps conserve the skin's natural moisture. Two FDA-approved topical medications, tacrolimus (Protopic) and pimecrolimus (Elidel) are available for treatment of eczema. Note: In 2006, the FDA added a black box warning to topical pimecrolimus cream and topical tacrolimus ointment stating that their use may increase the risk of certain cancers, specifically skin cancer and non-Hodgkin's lymphoma. Talk to your health care professional about this risk. Also tell your doctor if you are pregnant or breastfeeding.

Topical coal-tar preparations also work, but they can be messy and smelly. They should not be used by pregnant women, and their prolonged use may increase the risk of skin cancer. If symptoms persist, your health care professional may recommend application of over-the-counter hydrocortisone cream or, in severe cases, oral corticosteroid medication. Although steroid creams or oral steroids may be appropriate for acute outbreaks or severe episodes of eczema, long-term use is not advisable because of the considerable risk of side effects. Topical steroid creams can cause thinning and spotting of the skin, acne, and permanent stretch marks. If used around the eyes, topical steroid medications can, in rare cases, lead to glaucoma. Eczema patients who take oral steroids for longer than the usual two-week cycle and then stop using the drug face the additional risk of severe relapse. For these reasons, long-term steroid therapy is advised only under a health care professional's supervision.

The oils of mackerel, herring and salmon are high in eicosapentaenoic acid (EPA), may reduce skin inflammation and itchiness, but more research is needed. In the meantime, it probably can't hurt to try increasing your intake of EPA to see if it helps. Talk to your doctor about taking cod liver oil or fish oil supplements to boost your EPA intake, and be sure to inquire about possible adverse interactions with other medications you may be taking.

References

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Keywords: allergies, anaphylactic shock, allergen, antihistamine, histamine, allergic reaction, prescription drug, medication