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ALLERGY, ALLERGIC RHINITIS, AND ASTHMA
By: Joram S. Seggev, MD, FACP

ALLERGY
Allergy is a specific reaction between the immune system and a substance that is harmless for most people. In a way, allergy is like a vaccination, in which first contact with an allergen causes no harm, but a second time is harmful. Upon initial contact with an allergen (e.g., a patient inhales a neighbor's mulberry tree pollen), specific antibodies that are called immunoglobulin E (IgE), are formed. Those antibodies bind to special cells in the bloodstream and stay there. Upon repeated exposure to the same allergen (inhaling the neighbor's mulberry tree pollen the following year), that allergen attaches to the antibodies that were formed during the previous season. This attachment starts a chain of reactions that leads to the release of chemical substances, which causes the symptoms of allergy. Allergens can be pollen, molds, foods, drugs, insect venoms and even metals. Allergic symptoms may occur on the skin, in the nose and lungs, in the gut, and less frequently in other organs. There is a clear hereditary factor to allergy, but we still do not fully understand why some patients suffer from allergy in one body part (e.g. the nose), while others from suffer from allergy in another body part or several body parts.

For diagnosis of allergy, we need to obtain the patient's history, examine him/her and perform skin tests. Skin testing involves applying a drop of an extract of an allergen to the skin, and the skin is lightly pierced with a needle. There needs to be correlation between the skin tests, the medical history and the patient's environment (Sensitivity to mulberry pollen and having symptoms when mulberry trees pollinates). Blood tests for allergy are available, but they are less sensitive than skin tests.

ALLERGIC RHINITIS
Seasonal allergic rhinitis, commonly referred to as hay fever, is due to sensitivity to pollen and / or fungi. Year-round allergic rhinitis is usually due to domestic pets, molds and the house dust mite. The house dust mite is not a major problem in Las Vegas, but lawns (grass) can lead to year-round problems. Symptoms include bouts of sneezing, runny nose and eyes, nasal congestion and itching of the nose and soft palate (roof of the mouth). Approximately 20 million Americans suffer from allergic rhinitis and 45.5 million suffer from upper respiratory tract allergies. A family history of allergy predisposes a person to an increased risk of allergic rhinitis that usually begins during childhood or adolescence. The major complications of untreated allergic rhinitis are ear infections, sinusitis and poorly controlled asthma. The economic impact of allergic rhinitis is also enormous. Americans spend $1.8 billion for medications and medical treatment of rhinitis. Allergic rhinitis also costs $3.8 billion in lost wages, lost school and workdays each year. Treatment includes avoidance, and if insufficient, medication. Complete avoidance is obviously impossible, but there are several measures of common sense, which include: Using air conditioning in the house and while driving; special filters on the air conditioning/heating unit; using special vacuum bags on the vacuum cleaner; excluding pet animals from the bedroom, and on occasion also covering pillows, blankets and mattresses with air-tight covers. People with mild symptoms may need only an occasional over the counter antihistamine or a preventive nasal spray such as Nasalcrom. Patients with more severe symptoms may need continuous medication, which includes non-sedating, long acting antihistamines, available only by prescription, occasionally oral decongestants, antihistamine or cortisone derivative nasal spray, or immunotherapy (allergy shots). Over the counter antihistamines (all) cause mental impairment to varying extent and reduce ability to learn, work and drive. The choice between the various medications needs to be made by the physician in collaboration with the patient's preference and tolerance, depending on severity of symptoms. Adequate treatment allows patients to lead a normal life with minimal side effects.

BRONCHIAL ASTHMA
Asthma is a chronic lung condition with ongoing inflammation of the airways leading to the lungs, spasm of the muscle of the airways and intolerance of irritating substances. Allergy is a major factor in asthma, but not the only one. The symptoms of asthma are coughing, wheezing, and trouble breathing. Symptoms are usually intermittent, but may be continuous during attacks or in patients with severe asthma. Acute symptoms (attacks) can be brought about by allergens or other factors (e.g. exercise, reflux of acid from the stomach, and exposure to irritating factors such as dust, smoking, certain chemicals). Depending on one's sensitivities, asthma may act up only during certain seasons or all year.

Asthma may appear at any age and even infants and persons past middle life can get signs of asthma. However, studies show that asthma is more common in children than adults.

Asthma can cause severe attacks, which can cause someone to stop breathing, and account for 5,000 deaths in the United States each year, and cost about 6 billion Dollars per year in direct and indirect costs. African?Americans of both sexes are almost three times more likely to die from asthma compared to whites.

A diagnosis has to be made, based on a patient's history, examination, and breathing tests. Because asthma affects the lungs; breathing tests tell us how well they work; actually, breathing tests are the equivalent of measuring one's blood pressure in patients with high blood pressure.

Treatment consists of medication, environmental control, patient education, and in the case of allergic asthma, also of immunotherapy (allergy shots).

There are two classes of medications, one that treats the inflammation in the airways and acts slowly, but leads to long-term control of the disease. The other group gives immediate, short-lived relief ("rescue"), but does not treat the underlying inflammation. Asthma is divided into mild, moderate and severe, based on the severity of symptoms, limitation of daily activities, and the need for rescue medication. With the exception of those patients that need immediate relief medication no more than twice weekly, all other patients have to be treated with an anti-inflammatory medication. Selected patients may require allergy shots (immunotherapy).

Patients need to be taught about medication and how to use it; what to do if asthma gets worse, or if expecting to encounter known triggers; having written instructions. Again, with adequate treatment patients may lead a nearly normal life.

Joram S. Seggev, MD, FACP
Joram S. Seggev, MD, FACP is a Fellow with the American Academy of Allergy, Asthma & Immunology and Certified with the American Board of Allergy/Immunology.