Immunotherapy- A Medication Alternative

Immunotherapy- The Medication Alternative

Pills aren’t working? Are those alternate therapies not doing the trick? Or are you just sick (physically and mentally) of your symptoms being so intense and irritating every day or allergy season?

These are just some of the reasons why many patients venture to the care and treatment of hay fever through immunotherapy.

What even is immunotherapy though?

Immunotherapy is treatment targeted often to type I hypersensitivity, which uses desensitization therapy. Also, usually works best with hay fever patients. How it works is through the involvement of environmental control of external allergens in addition to the titrated pharmacologic exposure to them as well. With environmental control, a plan has to be made to decrease the exposure to the specific allergen(s). The pharmacologic desensitization process involves injections of the allergen (antigen) regularly through a course of time. This usually will last anywhere from months to years depending on the extent and progress. Throughout the time period, the dosages of allergen will be increased as tolerated. This will hopefully cause a change in the immunoglobins so that there will be an increase of IgG and IgA blocking antibodies as opposed to the abundance of IgE..

However immunotherapy doesn’t always work and may not be a complete treatment to allergy symptoms.  Also it has been reported that the relief to certain grasses and pollens usually last about 4-5 years.

Some considerations before getting involved

If you are thinking about getting immunotherapy keep a couple of things in mind. Such as the commitment it will take -the years of having to come in for the shots. Also it is an expensive process- you must weigh the costs of this with the costs of the medications you normally use.  Immunotherapy is not a definitive treatment and does not yield the same results for everyone.  Age is an important consideration- immunotherapy shots are usually not given to children under five and to older adults (65+ depending on medical status). Lastly, there are some medication conditions that may be present to prevent you from receiving immunotherapy. These include immunodeficiency diseases, recent heart attack or unstable angina, current use of beta blockers. 

Remember if you are considering this to ask your physician about any concerns or questions you may have. 

Prevention

Are taking medications not working or just not your thing? What else can you do if the symptoms of hay fever still haunt you? 

For those who are the seasonal allergy sufferers have it easier in the sense that symptoms only last a couple weeks or months. However, prevention of these seasonal sniffles is much harder to avoid, or fix. 

Because seasonal allergies primary cause is pollens the key concept is to stay indoors. It is advised to keep all windows and doors closed and use the air conditioner to stay cool. This also applies for while driving as well; but make sure that the car is in the “recirculation” mode. It’s also important that the air conditioner has a good air filter, which is to be washed weekly during high pollen season. Another thing to keep in mind is to keep in mind is to not have plants indoors.

As for the year round hay fever sufferers, prevention gets a little more difficult. Also, there are a lot more possible sources/causes of the allergens. The most common, which I will focus on are dust, dust mites, pet dander, and mold. For household dust, it’s beneficial to not have carpet and instead have a smooth surface, such as hardwood flooring. This allows dust to settle on top and be cleaned much more effectively and easily. If you are unable to get rid of carpet use a mask while vacuuming. Also limit surfaces, and furniture, for dust to settle on. Clothing could be a big issue when it comes to dust because it’s fabric, has a lot of surface area, and is normally stored in the bedroom. It is advised that clothing be kept out of the bedroom and/or in airtight vinyl clothing bags. Some other small changes that could be made are to use blinds instead of drapes, to keep the air conditioning vent closed in the bedroom, and to make sure there is a clean filter on the air conditioning unit. As for dust mites, these changes also apply in addition with some new ones. It’s key to wash bedding weekly in hot water (at least 130 F). It’s also important to not sleep/lie down on upholstered furniture and to keep the home cool and dry. As for pet dander, the most effective solution would be to remove the pets from the home. This could be keeping them outside or the better solution (in the mindset of relieving hay fever symptoms) is to get rid of the pets altogether. However this is easier said then done, so the next best thing is to make sure to get the home cleaned thoroughly and often, keep the pet out of the bedroom, and make sure that it gets groomed elsewhere regularly.

Mold is perhaps the most potentially dangerous out of the year round hay fever causes.  The three D’s: dampness, darkness and drafts are key to the growth of mold. Therefore the best way to avoid mold is to avoid those three things; however it may be too late and the growth as already begun. Make sure rooms have good ventilation by opening doors and windows. Put lights in dark places, like small closets and the basement. Also avoid places of high humidity. This can include green houses, barns, laundry rooms etc. Because mold can be potentially dangerous to ones healthy it is very important to get the mold checked out by a professional. They may be able to help remove the mold (or at least part of it) regardless of the danger as well.

So overall, what’s the best way to prevent the symptoms of hay fever without medications (or in addition to)? AVOIDANCE. Avoid as much as you can and you will start to feel better.

Some of the Meds

Treatment

How do these medications work?

As stated before, the most common medications used for hay fever are antihistamines, mast cell stabilizers, intranasal corticosteroids, leukotriene receptor antagonists LTRAs and decongestants.

Antihistamines: There are two type of antihistamines which are classified in first generation (sedating) and second generation (non sedating). Common first generation antihistamines are azataine (Optimine), brompheniramine (Dimetane) and diphenhydramine (Benadryl). Common second generation antihistamines are loratadine (Claritin), centirizine (Zyrtec), dexofenadine (Allegra), and desloratadine (Clarinex). Both generations work by binding with the Hò receptors on target cells thus blocking the binding of histamine. Second generation agents have a decreased attraction for the receptors in the brain, which makes them preferable with the less sedating side effects. http://www.claritin.com http://www.benadryl.com

Mast cell stabilizers: The most common use of this is seen as a nasal spray, or cromolyn spray known as NasalCrom. Recall in a previous entry the physiologic process about how mast cells degranulate resulting in the histamine release? Mast cell stabilizers inhibit this degranulation in the first place of these sensitized mast cells. Medications like NasalCrom have minimal side effects, besides occasional nasal irritations however it is important to start treatment regimens prophylactically. This includes 2 weeks before the allergy season or 15 minutes before exposure to a specific allergy, such as a dog. http://www.nasalcrom.com/

Intranasal Corticosteroids: The primary corticosteroids used for hay fever come in the form of nasal sprays. Some of the common medications include budesonide (Rhinocort), ciclesonide (Omnaris), and mometasone (Nasonex). These work by being a locally used corticosteroids for the nasal passageways. Corticosteroids work by inhibiting the inflammatory response- thus decreasing the symptoms that go along with hay fever. Like the mast cell stabilizers, there is just minimal nasal burning or stinging and it should be started 2 weeks before the allergy season. However, because corticosteroids work by surpressing the immune system the body is at risk for increased risk for infections, such as Candida Albicans (a fungal infection where white patches will appear in the mouth and tongue). Also it is to be used on a regular basis, not just as needed. http://www.nasonex.com/nasx/index.jsp http://www.omnaris.com/

Leukotriene Receptor Antagonists (LTRAs): The most common LTRA is montelukast (Singulair). This works by antagonizing or inhibiting leukotriene activity. Normally when leukotrienes are released, they cause a slow-reacting substance of anaphylaxis (SRS-A) leading to many of the respiratory symptoms. These include narrowing of airway and increased edema in the airway. By inhibiting these to be released, these symptoms are able to be avoided.  Unlike many of the other medications listed here, there are many side effects that go along with the use of LTRAs. These include from a range of headaches, and dizziness to altered liver function tests. Therefore it is important to monitor liver function, take on an empty stomach, and not be be used for acute attacks of symptoms. Also, medications such as singular are more common for chronic respiratory conditions such as asthma. This would not be a first round choice for those with hay fever especially with just mild to moderate symptoms. http://www.singulair.com/montelukast_sodium/consumer/asthma/asthma-medication/index.jsp

Decongestants: Perhaps with the antihistamines and intranasal corticosteroids, decongestants are a very popular choice for hay fever, especially for those who have a little more severe sinus/nasal symptoms. The most common decongestant is pseudoephedrine (Sudafed). These decongestants can also be recognized for being added to other medications with the addition of a “D” to the name. Ex: Claritin D. These work by stimulating adrenergic receptors on blood vessels causing them to constrict. As a result congestion decreases from the reduced nasal edema and rhinorrhea. Because it acts on the adrenergic receptors some side effects are from the cardiovascular system such as increased blood pressure, increased heartbeat and excitation/irritability. Another important thing to keep in mind with decongestants is that you have to buy them from the pharmacy counter and purchases marked through your driver’s license. Why? The key ingredient in these decongestants (ephedrine or pseudoephedrine) is used in the production of meth. http://www.sudafed.com/

If you have any questions about what medications you should be taking or about any of the side effects make sure to talk to your doctor and pharmacist. Also check out www.rateadrug.com to evaluate your treatments. Also use it to read about other people’s questions or input on medications you may be taking or thinking about taking.

Some of the Physio

As mentioned before, the overall concept of hay fever is caused by the bodies sensitization to a specific allergen. But how exactly is this caused?

Our immune system is made up of several structures; this includes skin and mucous membranes, the mononuclear phagocyte system, the lymphoid system, and bone marrow which all have different types of white blood cells, also known as leukocytes. Leukocytes help protect the body through inflammation and immunity.  T Lymphocytes (or T cells) are the mediators of specific immunity which act by reacting to the presence of a specific antigen (marker of a foreign substance) body and stimulates B Cells to make antibodies, a protein complex which react to the antigen.

In hay fever this antigen is caused by the presence of an otherwise substance that isn’t harmful. This is an allergen that after repeated exposure causes a hypersensitive reaction. The primary antibody responsible for mediating this reaction is immunoglobin E, or IgE. The IgE binds to receptors on other cells in the immune system known as mast cells. This IgE Mast Cell complex can bind to passing antigens (the specific allergen) and create a crosslink (when two antibody ends attach to an antigen) therefore causing an increase of intracellular calcium in the mast cell. This increase causes local mast cell degranulation resulting in the symptoms of inflammation. This may cause other inflammatory cells, and as for the case of hay fever, basophils to also release chemicals. The primary receptors to these are histamine. (That is why a lot of allergy medications are classified as antihistamines). Histamine causes a variety of symptoms, which may vary in severity. Some of the effects of histamine include bronchoconstriction, vasodilatation, increased mucus secretion, and pruritus (itching).

This however depends how the allergen entered the body and how much. For those with hay fever the most common is the allergic rhinitis (because the allergen enters through the nasal passageway). These symptoms also occur only when the allergen is present (or in high enough levels) for the antibodies to react. That is why for those with seasonal allergies they vary on location and pollen levels and for those with chronic have to make lifestyle changes depending on the cause.