Song Allergy, Asthma and Immunology Clinic
Patient's Handbook


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3113 Sepulveda Blvd
Suite A
Manhattan Beach, CA 90266
(310) 802-8016 - Phone
(310) 802-8031 - Fax

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Please browse the Handbook by clicking on a topic of interest below.
Definitions and Terminology
Patient Evaluation and Procedures
Basic concepts of Allergy Treatment
Allergy Immunotherapy
Common Allergic and Immunologic Diseases
Asthma

Allergic/Non-Allergic (Vasomotor) Rhinitis

Sinusitis
Atopic Dermatitis (Eczema
Contact Dermatitis
Hives (Urticaria)
Shock (Anaphylaxis)
Food Intolerance/Allergy
Immunodeficiency
Genetics vs Environment
Pregnancy and Allergic Disease
Drug Formulary
Environmental Control
Skin Test Instruction Sheet
Skin Test Panels
Instruction for New Immunotherapy (Allergy Shot) Patients
Normal Peak Flow Values
General Health Tips

Complementary/Alternative Medicine

Definitions and Terminology

Antigen: Any substance that causes immune reactions. Antigens are usually protein-compounds such as pollens, foods, mites, etc.

Allergen: Any antigen that causes allergic reactions such as pollens, mites, foods,etc.

Antibody: People produce these molecules in response to antigen challenge.  They are capable of producing myriad of different antibodies. As a group, they are called immunoglobulins(Ig).  Ig can be sub-grouped into 4 different classes; IgG, IgA, IgM, and IgE.  Antibodies to milk can be produced in any of the 4 classes.

IgE antibodies: Only allergic people can produce IgE antibodies.

 

Mast Cells: Residential cells (reside in the tissues such as nasal cavities and airway) which are involved in allergic reaction. IgE antibodies go to the surface of mast cells.

Hypersensitivity: Hypersensitivity refers to any immunological reaction which may be harmful to the host.  Allergic reaction is one of the 4 classes of hypersensitivity.

Allergic reaction:  Allergic people are genetically programmed to produce a special class of antibodies known as IgE antibodies. IgE antibodies go to the surface of mast cells that are present in various tissues such as nasal cavity. When allergens such as pollens arrive at the tissue (e.g. nasal cavity), mast cells interact with them through IgE antibodies on their surface. Once the interaction takes place, mast cells get activated and produce various mediators.

The best known and most important of all mast cell mediators are histamine and leukotrienes.  These mediators produce allergic reactions; the major components of allergic reactions are;

•  Smooth muscle spasm (as occurs in the airways of the asthmatics).
•  Tissue swelling (as occurs in the nose of the people with hey fever).
•  Mucus secretion (as occurs in the nose of a hey-fever patient.
•  Irritation of the nerve endings causing itchiness as in eczematous skin.
•  Inflammation resulting from the infiltration of other circulating cells.
•  Tissue damage (fibrosis) if inflammation persists.

A different disease state will result depending on where these reactions manifest:

•  Lungs > asthma
•  Nose > allergic rhinitis (hey fever)
•  Skin > atomic dermatitis (eczema) or urticaria(hives)
•  Digestive system > allergic gastroenteritis
•  Anaphylaxis > when allergic reactions occur involving many sites all at once. The blood pressure may fall because of the fluid may leave the circulation to the tissues. This is an emergency which needs to be treated right away.

Triggers of Allergic Reaction:
  • Allergens: Any antigen that causes allergic reactions such as pollens, mites, foods,etc.
  • Irritants: When the tissues get inflamed due to allergic reaction, they respond to non-allergic substances such as smoke, viral infection, and temperature change. People do not produce IgE antibodies to irritants. Therefore, there are no skin test or blood tests that can measure the degree of sensitization to irritants.

Allergy Skin testing: Introducing a small amount of allergen on the skin mast cells will cause swelling, if a person is allergic, i.e., if his/her mast cells produce mediators through IgE-mediated reaction. 

RAST test: If skin testing is not feasible ( e.g., in eczematous skin), a blood test can be done to detect the amount of IgE antibodies. In general skin testing is considered more sensitive.

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Patient Evaluation and Procedures

Patient Evaluation

During the initial visit, Dr. Song will do a complete history /physical  exam and diagnostic procedures which may include spirometry, X-rays, and rhinoscopy.  During the subsequent visits, the skin tests will be done if indicated.  Depending on the age and  the complexity of the symptoms, skin testing may take more than one session. At the completion of the diagnostic procedures, a session will be devoted to summarize and explain the findings and to formulate the treatment plan.

PROCEDURES

Skin Test

This is the most important procedure from which an allergist can obtain useful information on the patient’s condition.  Test allergens include grass pollens, tree pollens, weed pollens, mold spores, dust mites, animal hair/dander, and foods. The most common and relevant allergens are selected and administered in groups on the patient’s back or arms/forearm in one to three separate sessions. Initially prick tests are done using plastic devices. If the test results are negative, more sensitive intradermal tests may be applied. By inspecting the skin swelling from the test sites, Dr. Song will determine to which allergens a patient is sensitive and will apply the information to the therapeutic plan.  Please read the Skin Test Instruction, the Clinical Information section, and Skin Test Panels (appendix) of the guidebook for further information.

Patch Test

This test is done to find out if the patient’s skin rash is caused by contactants such as cosmetics, leather, nickel, etc. This test is especially useful for the patients with hand dermatitis. We use T.R.U.E. Test by Glaxo-Wellcome Inc. Two plastic sheets ( 3” x 5”), each containing 12 aluminum disks of test materials, are taped on the back of the patient and are read in 72 hours

Spirometry

This test is done to assess the lung function of the patients. Many allergic patients have subtle asthma  which  may not be detected by physical exam alone. This test will help  detect the early signs of respiratory compromise and  follow the progress of the disease.  This test is routinely used in our office to follow the patient with respiratory disease.

Exhaled Nitric Oxide(eNO) Test

This test measures the level of nitric oxide from the breath. The increased level suggests the inflammation in the airways as seen in asthmatics and may be present in the absence of spirometric changes. Please ask for the patient education material.

Peak Flow Meter

This is a simple test used for assessing the lung function and may not be as complete as spirometry but is less time consuming. Patients will often be asked to measure the peak flow at home with a portable one.

Rhinoscopy

This procedure is performed to assess the anatomy of the nasal cavity. After the lining of  the nose is numbed with a local anesthetic, a small caliber tube is inserted into the nasal space for inspection. .  The degree of swelling and inflammation of the nasal tissue and the presence of polyps  will be determined. 

Audiogram/Typmanogram

To assess hearing and  to detect abnormal tympanic membrane activities. This test will detect the presence of fluid in the middle ear.

 

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Basic Concepts of Allergy Treatment

For chronic allergic diseases, no matter what they are, the treatment includes the following three components.

Avoidance of allergens: (mites, smoke, molds, foods, drugs, etc.)

Drugs:  Available in inhalers(MDI), tablets, capsules.

Rescue medicines:
•  Beta-agonists(for asthma)
•  Theophylline(for asthma)
•  Antihistamines(for rhinitis)
•  Decongestants( for rhinitis)
•  Anticholinergics(for asthma and rhinitis)
•  Epinephrine(for anaphylaxiss)

Controller medicines:
•  Steroids(asthma, rhinitis,etc)
•  Long acting beta-agonist(asthma)
•  Anti-leukotriene drugs(asthma)
•  Cromolyn (asthma, rhinitis)
•  Nedocramil(asthma)
•  Combination of Steroid MDI and long acting beta-agonist(asthma)
Please do not be afraid of using steroid when necessary!
Many studies have shown that steroid inhalers( MDI) are not associated any long term side effects. On the contrary, most adverse outcomes such as ER visits and hospital admission are associated with the lack of steroid inhaler use.

Allergen Injection Therapy:
To manipulate the immune system into decreasing its allergic tendencies in the long run. Allergen shots have been shown to be effective for many patients with allergic rhinitis and allergic asthma, especially during the early phase.It can improve the condition permanently.
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Allergen Immunotherapy (Allergy Shots)

Currently, There are two methods of delivery; subcutaneous (SCIT) and sublingual(SLIT) Currently in the United States, SCIT is a predominant form of delivery, but in Europe, SLIT is overtaking SCLIT as the major modality of treatment. Dr. Song has added the SLIT approach to the conventional SCIT in 2011.
SUBCUTANEOUS IMMUNOTHERAPY(SCIT)(SHOTS)
Indications
  • High allergen sensitivity
  • Symptoms not controlled by other therapeutic means
  • Desire to “cure” the disease
  • Prevention of allergic diseases
Efficacy
  • Effective for hay fever(allergic rhinitis) and asthma.
  • Most effective for people with bee sting allergy: over 90 % success rate.
  • More effective in early stage of the disease.
  • More effective for people who have fewer allergies.
Adverse Effect
  • About half of the patients experience some injection site swelling.
  • Mild systemic reaction such as sneezing and rash affect ~10% of the patients.
  • Severe reaction such as shock is reported in 1/10,000 patients.
  • Most of these adverse effects can be immediately treated.
Injection Schedule
  • Initially once or twice a week.
  • The doses are increased gradually to a maintenance level over 3 – 6 month period
  • Once the maintenance dose is achieved, the injection interval is increased gradually to 4 weeks.
Injection protocol
  • Patients are observed in the office for a minimum of 20 minutes after receiving the injection so that adverse reactions can be treated.
  • Patients are required to take an antihistamine before coming to an allergy shot appointment.
SUBLINGUAL IMMUNOTHERAPY (SLIT)

Allergen drops are applied under the tongue instead of being given by injection.

How does it work?
The studies show that the sublingual area is one of the most ideal site for effecting the beneficial change in our immune systems (1).  In this area, the allergens are taken up  and retained by  the special cells for up to 48 hrs.  Interaction between allergens and the special cells initially induce the tolerance and eventually (after several months)  permanent decrease or abrogation of allergic response.
Who can benefit from it?
Children and adults with allergic rhinitis and asthma, and possibly with atopic dermatitis, latex allergy, and food allergies (2).

How effective  is it?
There are  more than 60  randomized, double-blind, placebo-controlled trials with SLIT (2). Most studies demonstrated efficacy for allergic rhinitis and asthma.   Both, the Cochran review (accepted way of gauging efficacy) and meta analyses, have demonstrated  that SLIT  is effective way of treating allergic rhinitis , asthma and dermatitis.  

How does it compare to SCIT?
  • Equally efficacious
  • Less side effects.
  • Can be used for young children
  • May be used for food allergies, latex allergy, poison ivy/oak
  • More convenient, Less time consuming
  • Economical

 

SCIT

SLIT

Clinical efficacy : Rhinitis

Ia

Ia

Clinical efficacy: Asthma

Ia

Ia

Clinical efficacy : Rhinitis (children)

Ib

Ia

Prevention of new sensitization

Ib

IIa

Long term effect

Ib

IIa

Prevention of Asthma

Ib

Ib

Evidence based treatment scores of I & II are considered excellent to good. Passalacqua et al , JACI 2007:119(4) 881-891

Is it approved by FDA?
Although used quite commonly in Europe, it is not yet approved in the United States. Clinical trials are still going on.

Is it being used  in USA?
Many ENT and allergist have been using it off label.  Used by early allergists in ~1900 and popularize in 1945 for a short time.  Then the practice of SLIT has re-emerged for the last several years.

How to get started?
Depending on the results of the allergy skin test, Dr.Song will prepare the allergen mix.
Initially the allergen concentration may be low and be increased later.
The patient will be supervised for his first SLIT  administration in the office.

How to follow up. 
Patient needs to see Dr. Song monthly for the first 3 months and then every 3 months thereafter.

How long?
Most studies indicate that one needs to be on it for 4-5 years for the permanent benefit.

What is the cost ?
Currently the insurance companies do not pay the expense since it is an off-label treatment. The cost is  approximately $ 50-100 / month depending on the number of allergens included in the preparation.

Reference:
  1. Frall,  Mucosal immunization approach to allergic diseases. Allergy and Asthma Proceedings, Jan-Feb 2007 Vol 28
  2. Passlacuq,et al, WAO J,  July 2010, p216
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Common Allergic and Immunologic Diseases

Asthma

People with asthma have difficulty breathing due to temporary narrowing of the airways in their lungs.  The symptoms include wheezing, chest tightness, and coughing. Coughing, especially at night time, or exercise intolerance may be the only manifestation at the beginning.  Like in other allergic diseases, the incidence of asthma has been on the rise (why? - see the discussion under separate topic) in the USA and other developed countries of the world. In the USA, 7 -10% of the population have experienced asthma and in Australia ~25% have!! Children growing in developing countries and farms are reported to have less incidences. It affects all ages, ethnicities, and even the physically fit. One out of every five 1998 U.S. winter Olympic athletes have reported using asthma medicines.  There is some evidence suggesting that exposures to virus, other microbes, and animals early in life may prevent the disease. However, later in life, the same exposures may provoke asthma attacks. Although we cannot cure the disease, new medicines have been reported to be much more effective in controlling the disease

Causes: In children, allergies are the predominant cause, but, in adults, allergies are demonstrated in only half of the patients. Allergic tendencies are inherited; maternal transmission rate is ~40%, paternal 30%, and 60-70% from both parents. Research shows  that there are many genes involved.  Some combination of genes probably produces more potent allergic manifestation. Non-allergic causes of asthma are not known. Whether allergic or non-allergic, asthma attacks can be triggered by irritants including smoke, fumes, wind, emotion, and physical exertion.

Evaluation:

  • History, family history, environmental assessment, physical exam
  • Allergen skin test
  • Lab tests including RAST
  • Spirometry:
    • FEV1 (forced expiratory volume at one second): Asthmatics cannot blow out air due to narrowed airway. Therefore, the amount of air one blows out in one second gives a very good measure of asthma severity. When treated with bronchodialater such as albuterol, FEV1 increases at least 12 % in untreated asthmatics.
    • FEV1/FVC: The ratio of FEV1 to functional vital capacity (which approximates lung volume) gives a better picture of lung obstruction. Less than 80% is considered significant.
  • Peak Flow meter: Peak flow (fastest speed with which you blow) is an easy way of measuring lung function since it does not require a spirometer. It approximates FEV1.
  • Nitric oxide measurement: Asthmatics exhale more nitric oxide than non-asthmatics. Studies show that NO measurement may be used as a tool to adjust asthma medications. This test is offered at Dr. Songs office. Some incurance companies do not reimburse the cost.

It is important to realize the value is only as good as the patient’s effort. Therefore the results need to be interpreted with this in mind.

Prognosis
For most adults, the disease activity, unfortunately, tends to stay the same or may get progressively worse. Some children grow out of asthma, but most allergic children don’t.  One study (Martinez, Tuscon) reported that 2-3 yr old children have a 75% chance of continuing to wheeze at the age of 6-13 years when they have met the following criteria (2 major and 1 minor). 

  • Major criteria: parental asthma, eczema
  • Minor criteria: allergic rhinitis (hay fever), wheezing apart from cold, eosinophilia >4%

Another study showed that if a child is wheezing and has positive reactions to an
allergy skin test at the age of  6, there is a greater than 85% chance of wheezing at the age of 11 years.

. Graph 1



Treatment:
Depending on the severity and the causes of asthma, the patient and doctor need to develop a comprehensive treatment plan including the components listed below.  Some patients need to be on controller medicines all the time.

  • Avoidance of triggers
    • Allergens (patient specific): mites, pollens, animal danders, foods, etc.
    • Irritants (patient non-specific): polluted air, air temperature change, draft, wind, fog, laughter, etc.
    • Stress: emotional or physical
  • Drugs: Combination of drugs are used in accordance with the disease severity.
    • Rescue medicines: Albuterol (Proventil, Ventolin), Xopenex, Atrovent
    • Controllers: Inhaled cortico-steroids, anti-leukotriens such as Singulair & Zyflo, Xolair
    • Combination of the two
  • Allergen immunotherapy (allergen injections): Early intervention may modify or eliminate the disease.  Discussed under separate topic.

Trigger avoidance and allergen immunotherapy will be discussed under separate headings.

DRUGS

  • Rescue meds:
    • SABA(short acting beta-agonist): works in minutes and is associated with jitteriness and heart palpitation. Can be delivered by an inhaler (MDI) or a nebulizer. Learn to use the inhaler properly. A spacer (such as Aerochamber) is necessary for children. A nebulizer is primarily used for infants and young children, especially when asthma is severe since more medicine can be delivered that way. Use a Pari nebulizer because it delivers the smallest particle size.  Only a portion of inhaled medicines end up in the lungs. If you use spacers, the amount of aerosol deposits may increase.
      graph 2
      • Albuterol (Proventil, Ventolin): increases wind pipe caliber by relaxing smooth muscles through adrenergic pathway
      • Xopenex (Levalubterol): possibly, more potent and less side effects than albuterol.
      • Atrovent (Ipratropium Bromide): anticholinergic; antagonizes bronchial constriction by blocking cholinergic input. Minimal cardiac effect
      • Spiriva (Tiotropium): Long acting anti-cholinergic
      • Combivent (Ipratropuim + Albuterol)
  • Controller meds:
    • These medicines are used for long term control of the disease. Most studies show that regular use of these medications decreases the symptom fluctuations, emergency room visits, and hospitalization.  For milder asthmatics, the controller medicine may be used at the beginning of an upper respiratory infection to abort the asthma exacerbation.
      • Inhaled cortico-steroids (ICS): Flovent, Pulmicort, Asmanex
        • Most studies show that even the prolonged use of them is not associated with any major side effects. Some studies demonstrated that the growth rate of children'may be decreased if inhaled steroid were to be used regulary for a long time (loss of 0.8cm in adult height).
        • Most common side effects: hoarse voice and oral thrush which go away when the medicine is stopped.
        • Flovent comes in 3 different potencies: 220, 110, 44.  Pulmicort comes either as an inhaler or respules (0.25 mg, 0.5 mg) for nebulizer.  Currently, Pulmicort respule is the only inhaled steroid available for infants.
      • LABA (long acting beta-agonist); Serevent, Foridil
        • Gives broncho-dilating effect for 8-12 hrs.
        • Sole use of the drug is not recommended due to the potential risk of death reported especially among black asthmatics (BLACK BOX WARNING).
      • COMBINATION OF STEROID AND LABA
        • When these medicines are combined, the effects are synergistic and the risk associated with the sole use of LABA decreases.
        • Advair is an inhaler which combines Flovent and Serevent. Comes in 3 different strengths; 500/50, 250/50, 100/50. Approved for asthmatics aged 4 years and above. DO NOT TAKE MORE THAN TWICE A DAY because the effect is cumulative and can become toxic.
        • Symbicort is an inhaler which combines Pulmicort (budesonide) and Oxis (formoterol). Approved for use for asthmatics aged 12 years and above. The dose can be adjusted.
        • Dulera is an inhaler which combines mometasone and formoterol. Approved for patients over 12 years of age. The dose can be adjusted.
      • Leukotriene inhibitors
        • Singulair is a leukotriene receptor antagonist (LTRA ) and is used most widely among its class.
        • Available in 3 strengths: 10 mg for >14yrs of age, 5 mg for 6-14 yrs, and 4 mg for 2-5 years of age.
        • Not as effective as steroid inhalers, but is more convenient to use.
        • Recommended as a solo medicine for mild asthma and in combination with a steroid inhaler for moderate to severe asthma.
        • It has steroid-sparing effect.
        • Minimal side effects. Some patients report sleep disturbance, including nightmares.
      • Oral steroids: used only when there are severe symptoms. They are used for only for a few to several days (burst) to minimize the long term side effects of weight gain, bone loss, cataracts, GI disturbances, immune suppression, etc. The most common short term side effect is mood swings.
      • Anti-IgE (Xolair) may be used as an adjunctive therapy for severe allergic asthmatics. It is supposed to mop up all of  the IgE molecules produced and theoretically eliminate allergic symptoms. Some patients respond dramatically and others improve only minimally. It has to be given every 2  or 4 weeks; the use is restricted to severe asthma and needs prior authorization. Lately, there were reports of delayed anaphylaxis (0.1% of patients).

    The standard guidelines for pharmacotherapy is published every 5 years by then AEPP (National Asthma Education Prevention Program). The current one is from 2002 and the 2007 version is about to be released.

    The 2007 guidelines recommend 6 different steps of treatment, depending on the degree of severity, control, and responsiveness.  Listed below is the summary, which I will follow in general after a full discussion with patients.

     

    Day Sxs

    Night Sxs

    Peak Flow

    Controller Meds

    Rescue Meds

    Intermittent

    < 2 x /wk

    < 2 x / month

    >80%

     

    PRN

    Mild persistent

    > 2 x / wk

    > 2 x / month

    > 80%

    Step 2,

    PRN

    Moderate persistent

    daily

    > 1 x / wk

    >60%,  <80%

    Step 3

    PRN

    Severe peristent

    constant

    frequent

    <60%

    Step 4 or 5  or 6

    PRN

    Normal peak flow rate can be estimated by 30 + 30 x age  from 5 to 16 yrs of age.

    Step1 : SABA
    Step 2: low dose ICS or LTRA
    Step 3: medium dose ICS or low dose comb or low dose steroid inhaler + LTRA
    Step 4: medium combo or med ICS+ LTRA
    Step 5: high combo,  Xolair
    Step 6; high combo + oral steroid, Xolair

    If the symptoms are well controlled for 3 months, consider stepping down or lowering ICS by 25-30% every 3 months until the lowest dose is achieved.

    If the symptoms are not controlled, one needs to step up.

    A written step-wise  written plan, listing medications to be added based on peak flow and symptom parameters, should be prepared for patients. It is essential to work with the doctor on a regular basis. For an acute episode, know when, where and whom to call,and  do not delay!

    Peak Flow

    Condition

    Symptoms

    Treatment

    80-100%

    GREEN: Safe

    Easy breathing
    No cough

    Controller

    60-79%

    YELLOW: caution

    Cough, wheezing, tight chest

    Controller
    Rescue med

    <60%

    RED: Danger

    As above
    Meds not working
    Hard to breath

    Above meds
    Oral meds
    Call MD

    Some patients wheeze only with physical exertion, typically 5-10 minutes into exercise. The symptoms can be controlled with an albuterol inhalation 10-15 minutes before exercise. Other preventive programs may include taking Singulair or Advair 100/50 on a daily basis if one engages in sports every day.

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Allergic(Hay Fever)/Non-Allergic(Vasomotor) Rhinitis

ALLERGIC/NON-ALLERGIC(VASOMOTOR) RHINITIS

Nasal symptoms: Itching, sneezing, clear watery discharge or blockage, post-nasal drainage

Associated Conditions: Coughing secondary to post nasal drip, sore throat, mouth breathing, loss of smell, loss of taste, or poor sleeping patterns (fatigue), nasal polyps, asthma, sinusitis

Evaluation: History and physical, skin testing, rhinoscopy,  spirometry (to rule out the co-existence  of  asthma), X-ray of the sinuses or  Sinus CAT-scan

Triggers:

  • Allergens
  • Irritants: The most common form of non-allergic rhinitis is called “vasomotor rhinitis”.  For these patients, irritants, rather than allergens, are the major triggers.
  • Infections: Chronic sinus infections due to bacteria, viruses, or fungi
  • Gastro-esophageal reflux
Treatment:
  • Avoidance of allergens ( mites, smoke, molds, foods,etc)
  • Rinsing of nasal cavity by salt water solution: Ocean spray, Sinus rinse
  • Drugs:
    • Rescue medicines:  For immediate relief.
      • Antihistamines -Primarily for drying the nose
        • Long acting (Non-sedating): Allegra, Claritin, Clairnex, Zyrtec
        • Short acting (sedating): Benadryl, atarax
        • Nasal spray; Astelin, Patanse
      • Decongestant nose drops or spray: Afrin, Neosinephrine: Frequent use of nasal sprays can cause rebound congestion. Please do not use these sprays more than 3 days a week.
      • Oral decongestant: Sudafed
      • Combination of antihistamines and decongestants: Dymsita
    • Controller: For long term control of the symptoms
      • Nasal steroid inhalers: Flonase, Nasonex, Rhinocort, Vancenase, Qnasal, Zetonna, etc
      • Nasal Cromalyn inhalers
      • Oral steroids: Predinisone tablets, Medral pack
  • Allergen injection therapy :Effective in the majority of patients with allergic rhinitis as a long term therapy


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Sinusitis

Symptoms:

  • Acute sinusitis: facial pain, purulent discharge, cough, fever, lethargy.
  • Chronic sinusitis: Persistent coughing may be the major, sometimes the only symptom. Other symptoms include discolored nasal discharge, tiredness, postnasal discharge worsening of underlying condition such as asthma, loss of smell sensation

Associated conditions: asthma, allergic rhintis, gastro-esophageal entertis, immunodeficiency ( for recurrent sinusitis)

Causes:

  • Bacterial infections of upper airway: Streptococcus Pneumoniae, Hemophilus influenzae, & Moraxella catarrhalis are the most common pathogens. In order to get the organism, one has to get inside the cavity by puncturing it.  Theculture of nasal cavity is useless because they are contaminated by resident bacteria (~25 %-40% of us have Strep. Pneumoniae in our nasal cavity.
  • Viral infection of the nose often lead to bacterial infections
  • Gastro-esophageal reflux can lead to chronic sinusitis
  • In rare cases ( when patients are immunologically compromised), fungi can infect the sinus cavity
  • If patients have frequent or persistent sinusitis, immune deficiency should be ruled out
  • Recent animal studies show that lack of normal bacteria in the nasal linings may be associated with chronic sinusitis (Susan Lynch, UCSF: Microbial spray into the nasal cavity may be beneficial?)

Diagnosis

  • Sinus CAT scan is the gold standard
  • Rhinoscopy: Nose and pharynx can be inspected to see the drainage and inflammatory changes.

Treatment:

  • Nasal rinse:
    •  Salt water solution is sprayed or squirted to the nose, twice a day.
    • ¼-1/2 teaspoonful of sea salt and a pinch of baking soda in 8 oz of warm(body temperature) water.
    • Ready maked salt packages are sold  in pharmacies.
  • Antibiotics:
    • Acute infection: for 2 wks
    • Chronic or recurrent infection: 4-6 wks or until the infection subsides.
  • Steroid: may help decrease the inflammation of sinus and nasal cavity and increase the drainage
  • Surgery: If patients do not respond to medical therapy, sinus surgery may be considered. However without treatment of underlying conditions, sinusitis may recur.


NASAL POLYPS


Symptoms: Nasal congestion and other symptoms of rhinitis. Most often nasal polyps are associated with chronic rhino-sinusitis.  Patient may be allergic, but more commonly not allergic.
Associated conditions: asthma, rhinitis, sinusitis, cystic fibrosis ( in children), aspirin-sensitivity
Treatment:

  • Surgery: If underlying conditions are not treated, polyps tend to grow back
  • Medical treatment:
    • Burst of oral steroid initially
    • Nasal steroid
    • Sinus rinsed: 1 vial of 0.5 mg Pulmicort vials can be mixed with salt pack in 2 oz water. Apply once with the head tilted back while lying flat on the back and let it soak for a few minutes
    • Anti-leukotriene drugs such as Singulair and Ziflo (which is gaining popularity again ) orally
    • Singulair nasal spray; Four of 10 mg tablets are crushed and dissolved into 1 oz of lukewarm water and sprayed once to each nostril every day
    • Omalizumab(Xolair): one to several injections may decrease the polyp size for several months.

ASPRIN(ASA) INDUCED RESPIRATORY ILLNESS
Symptoms: ASA and  other nonsteroidal anti-inflammatory drugs may induce asthma, rhinitis, nasal polyps (Sampter’s Triad), or urticaria. The subject is very complicated and you need to ask Dr. Song for further information.  You may avoid the drugs or may be desensitized at his office over three day period and stay on ASA for long time to have your symptoms under control;


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ATOPIC DERMATITIS (ECZEMA)

Eczema is a descriptive terminology referring to dry, itchy, and scaly skin condition. Atopic dermatitis is a clinical diagnosis in which eczematous skin is a major component. Majority of children with atopic dermatitis are allergic, but many adults are not, indicating that there is an intrinsic defect in the skin itself. It affects up to 20% of children in USA  and the incidence rate is rising. It tends to  improve as  children get older: remits in 17% and less severe in 65%, but may relapse later in life.

Diagnosis:

  • Itchiness plus 3 or more of following
  • Hx of skin fold involvement. Hx of ashma or hay fever. Hx of dry skin in the last year. Visible flexural eczema. Onset < 2 yr

Dianostic test

  • Skin test
  • RAST.  IgE level is higher than in other allergic conditions
  • Complete blood count
  • Triggers:
  • Allergens; foods, dust-mites
  • Irritants to the skin: soap, wool clothing, heat, emotional upsets, and other factors.
  • Microbials (Staph.aureus cultured in 90% of AD patients vs 5% in controls

Treatments:

  • Trigger control;
    • Eliminate dust mites. Keep environment clean
    • Avoid allergic foods, wools
    • Wear cotton underwear
  • Mild soap: Nutragena, Cetaphil, Alveeno
  • Hydration; Bathe briefly in lukewarm water > wrap up the body in a towel for a few minutes and then apply skin emollient
  • Skin emollient : Eucerin, Alveeno, Acquaphore, Cetaphil Restpraderm body lotion, CeraVe moisturizer, Vanicream
  • Steroid cream or ointment
    • Avoid using on the face or use low potency H-cortisone (0.5%) because steroid can thin the skin
    • For body, my favorites are Cutivate(0.05% Fluticasone topical  cream or lotion ) because it has less side effects (adrenal suppression , bone loss etc) and 0.1% triamncilone cream(cheap)
    • Desonide lotion to the head
    • Desonide ointment to the face and neck
  • Wet dressing and Wrapping
    • Wrapping materials:gauze, old socks, stockings,leggings, tights, Tubifast bandage, ski cap
    • Apply thin layer of steroid on the involved skin and emollient on the surrounding areas
    • Wrap the area with wet clean gauze
    • Wrap the gauze with another layer of dry gauze or other wrapping material listed above
    • Do the wrapping for 2 hours twice a day or sleep with it
    • Can be done every day or a few times a week until the rash clears up
    • See You-Tube for ECZEMA WET DRESSING INSTRUCTIONAL VIDEO
  • Antibiotics: Overgrowth of Staph.aureus results in increased amount of Staphlococcal toxins, which can make the skin condition worse. When atopic dermatitis gets worse, antibiotics like Keflex can be used for several weeks ( 2-4x/d) and sometimes for several months in a reduced dose( once a day)
  • Probiotics
    • May reduce the incidence of atopic dermatitis in at-risk infants. There is prelimnary support for treatment of symptoms.  Evidence rating-B

(Krigler, Am Fam Physician 2008 Nov 1: 78(9):1073-8)

  • Immuno-suppressant
    • Protopic or Elidel can be used on the face and body for children  over 2yrs of age
    • Black box warning: in animals it may cause cancers but not in humans so far.
  • Allergy shots; generally not effective. But occasionally dust mite allergen immunotherapy has shown to be effective.
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Contact Dermatitis

A classical example of this condition is the skin rash caused by contact with poison ivy or poison oak.. The condition is not caused by allergic mechanism, but rather by a different immunological mechanism. There are hundreds of different substances we are touching every day and the relationship between the rash and the contactants may not appear obvious. Identifying the contactants by history or patch testing leads to the diagnosis. See the patient evaluation and procedure section for more information on patch testing.

Associated condition
Psoriasis or extremely dry skin condition.
People with atopic dermatitis are less likely to have contact dermatitis.

Causes
Most common contactants include cosmetics, lanolin,nickel, hair dye, and other dyes.

Diagnostic Test

Diagnotic Test

  • True Test (36 patches)
  • North American Series  (42 patches)
  • Patient's own contactants(shampoo, soap,etc) can be applied via Finn chambers. 

Treatment

  • Avoidance of the contactants

  • Steroid cream

  • Oral steroids for severe cases

  • Back to the top

    Hives (Urticaria)

    HIVES (URTICARIA) and ANGIOEDEMA

    Patients with urticaria experience itchy welts of varying size on any part of their skin. This condition affects 15-20% of general population and is accompanied by angioedema (body swelling) up to half of the patients. Angioedema is not itchy but gives burning sensation deep under the skin and involves the tissues where blood supply is ample such as lips, tongue, eye socket, hands, feet, and scrotum.  Angioedema occurring alone without hives deserves special consideration.

    Urticaria may be of a short duration resolving after only a few days spontaneously or in response to elimination of the causative agents or to administration of anti-histamines. However, the symptoms may last much longer sometimes for months or even years. When symptoms persist longer than six weeks, the condition is defined as chronic (versus acute)

    Most common causes for acute disease are drug or food hyper-sensitivities and viral diseases (see the list below).  In chronic disease, the causes cannot be found in majority of the cases. In less than 10% of the cases, one may find causes such as physical stress (pressure, vibration, cold or warmth), hepatitis, or vasculitis (disease of small blood vessels) as in systemic lupus. In vasculitis, the hives tend to stay in one place, often involve hand and feet, and do not blanch when pressed.

    Current thinking is that majority of these “idiopathic” (cause unknown) hives are due to an autoimmune phenomenon. In other words, these patients develop antibodies which attack their own skin!  This may be one reason why in 20-30% of patients, thyroid auto antibodies are found and even thyroid function may be abnormal. This can be tested by doing a skin test using patient’s own serum (Ask the lab technician to draw 0.5 cc of extra serum and put in a test tube and bring it to Dr. Song’s office).

    Although more than 2/3 of patients recover in one year, chronic urticaria is one of the most annoying and frustrating diseases for patients and doctors alike. So patients need patience and tincture of time!

    MAJOR CAUSES OF URTICARIA  AND DIAGNOSES

    • Drug reaction:
    • Food or food additives:
    • Inhalation, ingestion, or contact with antigen
    • Infections; virus, bacteria, mycoplasma, parasite; LAB TEST
    • Insect bites
    • Collagen vasculitis: Lupus, serum sickness, erythema multiforme, etc: LAB TEST
    • Physical urticarias: cold, cholinergic, dermographism, pressure, vibratory, solar, aquatic
    • Malignancy; very rarely: LAB TEST
    • Urticaria pigmentosa: systemic mastocytosis: LAB, SKIN BIOPSY
    • Chronic idiopathic: more than half are auto-immune: SKIN TEST WITH PATIENT’S SERUM

    MAJOR CAUSES OF ANGIOEDEMA

    • Hereditary angioedema (C1 inhibitor deficiency): LAB TEST
    • Acquired angioedema (associated malignancy): LAB TEST
    • Drug induced (ACE inhibitors)
    • Exercise induced?
    • Idiopathic

    TREATMENT

    • Antihistamines are the backbone of the treatment
      • Long acting ; Allegra, Claritin, Clarinex, Zyrtec (combination of the these can be used in higher doses)
      • Short acting: Atarax is a favored one. The dose can be gradually increased up to 50 mg, 4 x/day,  to control the symptoms. Initially patients may feel drowsy, but most get used to them.
      • For nocturnal itching, Doxepen can be used.
    • Steroid: When antihistamines alone do not control symptoms, oral steroid may be employed. Minimal effective dose needs to be used, since long term use of steroid is associated with many side effects such weight gain, cataract, bone loss, GI bleeding, depression, adrenal suppression, etc. Once the control of symptoms is obtained, prednisone needs to be tapered gradually. However if this is not possible, other drugs need to be added
    • Dapsone: This anti-leprosy drug can be a useful adjunctive drug.
    • Immune suppressing drugs: If steroid does not reduce the symptoms or cannot be tapered, these agents need to be used. Most of these drugs are used as anti-cancer drugs and are associated with side effects.  Literature reports the successful use of Cytotoxan, Cyclosporin, Methotrexate, and Cellcept. Of these Cellcept probably has the least side effects.
    • IVIG (intravenous immunoglublin G): There are reportsof  successful use of this product. Although the use of drug is tightly guarded acquiring review process by the insurance companies because of  its limited  availability and expense, it is associated with very little side effects.  The product may be given by a home health nurse at patient’s home (Crescent Home Health Care is a leading agent in our area).
    • Omalizumab (Xolair): Improves the symptoms and signs in patients with chronic idiopathic urticaria  who failed to antihistamine treatment (New England J. of medicine 2/24/2013).

    LAB STUDIES

    Lab tests

    Associated Diseases

    CBC with ESR

    Eosinophila :allergy and parasites.
    ­ESR >infections, immune complex diseases

    UA

    Urobilinogen in hepatitis, blood and/or protein in some vasculitis

    LFT

    ­ in viral hepatitis

    (TFT, thyroid antibodies)

    TFT ­ or ¯ in autoimmune thyroid diseases, anti-thyroglobulin and /or anti-microsomal antibodies in thyroidtis and some euthyroid patients

     

    DIAGNOSTIC CLUES


    By History

    Associated Diseases

    Temporal relationship to drugs, foods, and contactants

    Adverse reactions to, e.g,  penicillin, fish, latex, etc

    Travel History

    Hepatitis, parasites

    History of physical exposure

    Physical urticaria (Cold, heat, pressure, vibratory, aquagenic, solar, etc)

    Induced by exercise

    Cholinergic, exercise-induced urticaria and anaphylaxis

    History of trauma

    Hereditary angioedema

    Systemic illness

    Viral/bacterial/mycoplasma infections, vasculitis including systemic lupus erythematosus and  serum sickness,   Henoch-Schonlein purpura

    Family Hx

    Hereditary angioedema, amyloidosis with deafness and urticaria, C3b inactivator deficiency

    By Physical Exam

     

    Size of urticaria

    Cholinergic, cold-cholinergic ,aquagenic, insect bites, scabies

    Exposed areas

    Physical urticaria (cold, dermatographism, solar, pressure, vibratory, aquagenic)

    Angioedema:

    Hereditary angioedema, acquired angioedema associated with malignancy, drug or contactant –induced angioedema

    Dependent area

    Vasculitis

    Involves palms and soles

    Vasculitis

    Thyroid enlargement

    Thyroiditis

               

    DISEASE MECHANISM

     

    Mechanism

    Hx

    PE

    LAB

    By

     

     

     

     

    By HX

     

     

     

     

     Specific antigen sensitivity

    IgE mediated

    Temporal relationship to ingestants or
    contanctants

     

    ST, RAST

     Physical urticaria
      Dermographic
      Solar
      Aquagenic
     
     

    IgE mediated in some.

    Temporal relationship to application of physical stimuli

    Demonstrable lesions from application of physical stimuli

     

    Dermographic

     

     

    Demonstrated after skin is stroked.

     

    solar

     

     

    Demonstrated after sun light.

     

    Aquatic

     

     

    Demonsrated after water is applied.

     

    Cholinergic

     

    Exercise and heat

    Application of heat
    Small pin head sized wheals  frequently involving the skin of the neck.

    Methacholine challenge is positive in 1/3

    Exercise induced

     

    Wheezing, angioedma, shock

    Exercise challenge test

     

    Cold urticaria

     

     

    Confined to the exposed parts of the body

    Ice cube test
    Passive transfer of IgE

    Contact urticaria

     

    History of exposure to contactants

    Confined to the the exposed parts of the body

    Patch test

    IgG mediated

     

     

     

     

     Cold

     

     

     

     

     Dermographic

     

     

     

     

    Chronic idiopathic

     

    Hx not helpful

     

    IgG ab to IgE or IgE R

    Immune complex

     

     

     

     

     Serum sickness

     

    History of systemic illness

    Erythema, angioedmea

    ¯CH50, ¯C3, ¯C4

     HAE

     

    Family history(AD)
    Abdominal pain

    Angioedma without urticaria

    ¯CH50, ¯C3, ¯C4
    ¯C1esterase

     Acquired abgioedema

     

     

     

     

      Necrotizing vasculits

     

     

     

    Skin biopsy

      Transfusion

     

    Hx of transfusion

    Hematuria

     

      Infection

     

    Especially heaptitis

    May evolve into erythema multiforme

    LFT

      Cold urticaria

     

     

     

     

      Heat urticaria

     

     

     

     

    Non-immunolgical

     

     

     

     

     Direct MC degranulating
       Opiates
       Amphetamines
       Polymyxin
       Curarie
       RCM

     

     

     

     

    Physical Urticaria
      Pressure urticaria
     

     

     

    In the area where physical force is applied such as belted area.

     

    Urticaria pigmentosa

     

    Early childhood

     

     

    Arachdonic acid metabolism altering
      ASA
      Azo dye

     

    Hx of drug ingestion

     

     


    Algorithm


    When the initial history/exam(1) yields a specific diagnosis, such as cholingeric urticaria or food allergy, manage accordingly. When it yields no result, do screening lab tests(2) and start symptomatic treatment. If the screening lab tests indicate a specific diagnosis such as thyroiditis or hepatitis, manage accordingly. If no etiology is found, repeat the evaluation in 6 weeks (3). If still no diagnosis is obtained, manage it as idiopathic urticaria.

    Back to the top

    Shock(Anaphylaxis)

    This is the most dreaded condition in allergy by patients and doctors alike. It often occurs after eating allergic foods such as peanuts or after exposure to insect stings. The patient feels generalized weakness, dizziness, cold sweating, itchiness, chest tightness, and feeling of “impending doom”. The most important aspect of treatment is “quickness” in responding to this potential life-threatening emergency. If you have experienced an episode like this, you must always prepared for another one.

    • Call 911
    • Self-inject Epipenephrine(Epipen, Anakit, Auvi-Q)into the thigh: Please learn how to use the kit. If you do not, ask Dr. Song to demonstrate the usage for you.
    • Quick acting antihistamines: Atarax and Benedryl are preferred. Zyrtec, Allegra, and Claritin can be used, but the onset of action for these medicines is slower.
    Back to the top

    Food Intolerance/Allergy

    Food intolerance (adverse reactions) may be due to allergic or non-allergic cause. However it may be hard to distinguish the two. The symptoms are eczema, hives, gastrointestinal complaints and rarely rhinitis and asthma. Allergic reactions occur immediately (in a few minutes or hours) and caused by IgE mediated mechanism as demonstrated by positive skin test or ImmunoCAP specific IgE blood test.  In contrast non-allergic reactions tend to occur late (in hours to days) and the skin test and ImmunoCAP specific IgE blood test are negative.
    FPIES(food protein-induced enterocolitis syndrome) is a non-allergic GI disorder that present in infancy with severe vomiting and diarrhea. The most common food triggers are cow milk, soy formula, and even solid foods including rice.

    Eosinophilic Eosphagitis is a condition with both allergic and non-allergic (delayed hypersensitivity) components. Symptoms are swallowing difficulty, food impaction, and heart burn. The diagnosis is made by esophageal biopsy showing more than 15 eosinophils per high power field.  The symptoms improve when patients go on a restriction diet of 6 common foods (milk,egg, soy, wheat, nuts, and fish)

    The true incidence rate of food allergies is lower than reported by patients ( ~8 % in children and ~1% in adults). Unfortunately the incidence rate has been rising recently. So is the mortality rate from food anaphylaxis.

    The most common foods associated with food allergy are;
    For young children: milk, egg, soy, wheat, peanut
    For adults: shell fish, peanut, tree nuts, fish, milk, egg

    COMMON ALLERGIC FOODS

    • COW MILK
      • Two major proteins are casein and whey
      • 85% outgrow by 3 yrs of age
      • 30% of children with + ST to milk at 1 yr develop other food allergies
      • Lactose intolerance may be confused with milk allergy
      • Cow milk shares allergen with goat milk
      • For cow milk sensitive infants, milk protein hydrolysate formula is a better choice than soy milk
    • EGG
      • Egg white is more allergenic than yolk
      • Present in mayonnaise, glossy baked goods, pound cakes
      • Flu vaccine-yes. MMR-no
      • Most out grow by 5 yrs
    • SOY
      • 10% of milk allergic children also sensitive to soy
      • Soy milk, powder, tofu, green soybeans
      • 6/7 soy lecithin contain soy protein
      • 3/8 soy oil preparation contain soy protein
    • PEANUT (GROUND NUT)
      • Affect 0.6% of U.S. population: ~ 1.6 million
      • 150 die per year: 50% of food related fatality. Often due to accidental exposure
      • Powder can cause symptoms. Smell-unlikely
      • Only a minority may grow out of it
        • If RAST > 15 KU/L ; permanent
        •                < 15 KU/L: may grow out
    • TREE NUTS
      • Tree nut protein is not related to peanut
      • But 1/3 of peanut sensitive children may develop sensitivity to tree nuts independently
      • Almond, walnut, cashew, pecan, pistachio
      • Sesame seeds are related to tree nut protein
    • SHELL FISH
      • The most common allergic food for adults
      • Mollusks (oyster, clams, oysters, squid)
      • Crustacea (shrimp, lobster, crabs)
      • Topomycin is the responsible protein
      • Dr. Song can order  “ shell fish RAST panel”

    DIAGNOSIS
    SKIN TEST:  If negative, food allergy is unlikely (95%). If positive, only 30-50% may have real manifestation when challenged with the particular food.

    RAST (radio-allergo-sorbent test): The test measures the amount of IgE antibodies to particular foods in the blood. This test is much more reliable than the skin test in predicting food allergy symptoms. However the test is not sensitive enough to be used as a screen tool.

    If  the IgE  levels are above the following value, the patient has greater than 95% chance of experiencing an allergic reaction.
    Egg-7 (kUa/L). Milk-15.  Peanut-14. Fish-20. Tree nuts-15.

    If  the IgE  levels are above the following value, the patient has greater than 75% chance of experiencing an allergic reaction.
    Soybean-30 (kUa/L). wheat-26

    COMPONENT TESTS
    Allergy causing food proteins can be broken down to different components (epitopes).  Allergic (IgE)  reaction to some components may be more predictive of real clinical reaction than other components.  A good example is peanut allergy; a component known as  ‘Ara h2 ‘, increased response to which is predictive of  more severe reaction than other components such as ‘Ara h8’.  This test can be ordered now through Dr.Song’s office (may not be covered by insurance)

    FOOD CHALLENGE 
    Even when skin test is negative or RAST value is low, patient may, in rare instances, experience allergic symptoms. Therefore it is necessary that patient be put to test with real foods.  This can be done in our office before the patient tries the food at home. If the patient reacts to the food adversely in the office, he/she may be treated.  It takes usually ~ 3 hours to perform the test since the amount of the challenge food is increased incrementally.

    PROGNOSIS
    Most infants tend to grow out of milk and egg allergy.
    Most children do not grow out of peanut or tree nut allergy. But some do when they have low level of RAST.
            
    TREATMENT

    • Avoidance of known allergenic foods
    • If foods are suspected as a cause for clinical symptoms, but patient and doctor cannot pin point it, one may try an elemental diet . See below
    • Epinephrine with accidental ingestion of an allergic food when respiratory difficulty occurs or when there is history of anaphylaxis. Keep Epipen at a reachable location at all times. Learn how to administer it.
    • Antihistamine (benadryl is  preferred since it acts faster) whenever accidental ingestion occurs.
    • Prednisone (15 mg to 40 mg ) to prevent delayed reaction.

    AN EXAMPLE OF ELEMENTAL DIET
    FOR INFANTS: amino acid powder such as Vivonex or Neocate may be tried.
    FOR ADULTS.
    Rice, puffed rice, rice flakes, rice krispies
    Pineapple(canned), apricots(canned), 
    Cranberries,peaches, pears, apples : fresh or juice/nectar of these
    Lamb, chicken
    Asparaguss, beets, carrots, lettuce, sweet potato
    Tapioca
    White vinegar, olive oil
    Honey, 2oz a day, cane sugar, salt
    Neocate, Vivonex
    PREVENTION

    • RESTRICTIVE PERINATAL DIET
      • Various large scale studies show
        • Restrictive diet (no milk, egg and peanut) during pregnancy- No benefit to infants
        • Restrictive diet to infants during the 1st year (Breast feeding for 6 months + introduction of potential allergenic foods after one year); Beneficial to infants> decreased incidence of atopic dermatitis (eczema) during the fist one year of life. But no effect on development of asthma or hay fever
    • WHEN DINING OUT
      • Ask about ingredients and the way food is prepared before you order when you dine out.
      • Order simple prepared foods such as baked potates, steamed vegetables, and broiled meat.
      • Avoid creamy sauces and toppings.
      • Avoid buffet salad bars. Often people will use the same spoon in different dishes.
      • Asian, Thai, and African foods often contain peanuts.
      • Peanuts can be finely chopped and baked in cakes and pie crusts.
    • WHEN TRAVELING
      • Get a letter from your allergist that confirm food allergy.
      • Bring your own food.
      • Confirm your peanut-free snak request at the gate and ith the lead flight attendant.
      • Prepare for the unexpected. Bring Epipen and antihistamines.
    • WEAR  BRACELET : MedicAlert:  2323 Colorad Ave. Turlock, CA 95382. 800-432-5378
    • USEFUL WEB LINKS
      • American Academy of Allergy of Asthma and Immunology (AAAAI). Phone: 414-272-6071.  Fax: 414-272-6070. www.aaaai.org
      • Food Allergy Network (FAN): Phone: 703-691-3179. Fax: 703-691-2713. www.foodallergy.org
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    Immunodeficincy

    Symptoms: recurrent infections such as sinusitis(more than one documented infection  /yr), pneumonia(more than one/yr) , ear infections( more than 8x /yr), deep skin infections,  & deep seated infections.

    Causes and Treatment:  Although there are many different kinds, severe ones are rare.

    • RELATIVELY COMMON ONES:
      • Specific Antibody Deficiency: This is the most commonly encountered form of immune deficiency in my practice. Typically they are young children with history of recurrent upper airway infections including otitis, sinusitis, and rhinitis. It is uncommon for them to have serious infections such as pneumonia and meningitis. They have difficulty producing antibodies to common polysaccharide (sugar coated) bacteria such as Pneumococci or Hemophleus Influenza, although they have received vaccinations against these bacteria during the first one year of life.  The immunoglobulins(the sum of  antibodies) are usually normal since the deficiency is limited to a very small number of antibodies. Probably the immune system of these young children was not ready to respond to the vaccinations or real bacteria during early life. As they get older, the immune system matures and responds better to the same vaccines. If specific antibody defects may persist despite Pneumovax vaccination ( which contains 21 killed serotypes), Prevnar (which contains 7 killed serotypes conjugated to protein carrier) is given, because the latter is considered to be more immunogentic.  In the rare events when patients respond to neither vaccines,  prolonged antibiotic treatment ( 6 months, in full therapeutic range) or IVIG (intravenous immunoglobuling G) may be required to control infections.  Of note is many of these patients have also allergic symmtoms such as asthma and rhinitis.
      • Transient Hypogammaglobulinemia of Early Childhood: Some young children (1yr -5yrs of age) may have decreased levels of immunoglobulins (the sum of antibodies). They may have frequent upper air way infections and sometimes lower air way infections (pneumonia). The deficiency is usually transient and majority of these children will grow out of it.  During this period of deficiency, they may need to be on continuous prophylactic antibiotics or even monthly IVIG (intravenous immunoglobulin G)  replacement therapy.
    • RARE ONES
      • Common Variable Immunodeficiency: Usually starts in late childhood or adulthood with mild recurrent infections, but may progress into more severe infections. They cannot produce enough antibodies and may require IVIG.
      • X-linked Immunoglobuline deficiency: Complete absence of antibodies. Most develop frequent upper air way and lower air way infections after infancy ( in some, later in life).  They need to be supported with regular IVIG treatments.
      • There are many other severe forms such Severe Combined Immune Deficiencies
    EVALUATION
                Goal of our immune system is to protect our body from invading micro-organisms. These organisms are destroyed by the cells with the help of antibodies and other components in the blood and tissues. The following are the most commonly ordered lab tests
    • Cells: white cell count, CD4, CD8, NKC
    • Quantitative immunoglobulins (IgG, A, M, E)
    • Specific antibody: If  the antibody level is low, patients are given the vaccination and the blood is drawn after 4 wks to see the response
      • anti-Pneumococcal antibody before and after vaccination
        •  Protective level is  ≥1.3 mg/L  in  greater than 50% of serotypes in 2-5 yr of age, in greater than 70% of serotype after 5 yrs of age
        • Good vaccine response is when antibodies rise 4 x or greater
      • anti-Hemophleus antibody
        • Protective level is ≥ 1.0 mg/L
      • anti-Tenanus antibody
        • Most children have a protective level if they are vaccinated
    • Memory B cells: For those patients who do not respond to vaccinations, number of memory B cells (IgD-, CD27+) are checked.  When memory B cells are lacking, patients’ immune system does not ‘remember’ if he/she received the vaccinations.
    • Complement levels: Complements help antibody and cell to fight infection better

    diagram

    Genetics vs Environment in the Allergic Diseases
    _
    __

    It has been the focus of investigation why the incidence of asthma ---
    The answer seems to be  “probably no”

    Epidemiological evidences suggest that viral infections –

     

    Recent epidemiological studies also suggest that Vitamin D deficiency plays a significant role in the genesis of allergic disorders. Incidence rate of asthma is reported higher in the temperate than the warmer zones of the world.  A survey showed that 35% of asthmatic children were low in Vitamin D in USA (Brehm, Journal of Allergy and Clinical Immunology, 2010)
    A hypothesis is that the vitamin D deficiency leads to a decrease in function and number of regulatory T cells that is important in suppressing allergic potentials

    According to the United States Institute of Medicine, the recommended dietary allowances of vitamin D are 600-800 IU/day (15 ug/day)

    The tolerable upper intake levels are;

    • 0-6 months of age: 1,000 IU
    • 6-12 months: 1,500
    • 1-3 yrs of age: 2500 IU
    • 4-8 yrs of age: 3000 IU
    • 9-71+ years of age: 4000 IU
      Back to Top

    Genetics vs Environment in the Allergic Diseases

    Allergic tendencies are generally inherited. Studies have demonstrated that strongly positive allergy test results are the single most important predictor for the persistence of asthma in childhood. Scientists have been investigating the genes responsible for allergies. Currently many promising genes have been reported and the allergic diseases result most likely from the interaction of these multiple genes and environmental factors. The following information may serve as a useful guide.

    • 20% of the population have allergic tendencies
    • If one parent has allergy, 30-50% of the children are affected.
    • If two parents have allergy, two thirds of the children are affected.

    It has been the focus of investigation why the incidence of asthma has been on the rise in the industrialized countries. Is it due to environmental pollution? The answer seems to be “no”, since the developing countries have the worse pollution, but the lower incidence rate.

    Epidemiological evidences suggest that viral infections during early childhood play a suppressive role against the development of allergies. In other words, children growing up in the developed countries are more vulnerable to the allergic diseases because they are protected against infections by improved vaccines and hygiene

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    Pregnancy and Allergic diseases

    The effects of pregnancy on asthma have been extensively studied. However they vary from one individual to another. The following is the rough estimate of the outcome.

    • 1/3: Asthma worsens
    • 1/3: Asthma does not change
    • 1/3: Asthma improves.

    The pattern present during the first pregnancy tends to repeat itself during the subsequent ones.

    The allergy drugs are classified (see below) according to their tumor-producing effects on the fetus.

    CATEGORY ANIMAL STUDIES HUMAN STUDIES
    A Negative Negative
    B Positive Negative
    C Positive Not done
    D Positive Positive

    During pregnancy, the category A and B are preferred. The C drugs can be used if A and B drugs are not adequate for treatment and the potential benefits outweigh the risks.
    Listed below are the classifications of commonly used allergy medicines

      B C
    Steroid inhalers Pulmicort Vanceril, Azmacort, Flovent
    Oral steroids   Prednisone, Medral
    Anti-leukotrienes Singulair, Accolate  
    Bronchodilators Brethine, Atrovent Proventil, Albuterol, Ventolin, Serevent. Foradil, Slo- Bid, Theo-Dur
    Combination drugs   Advair
    Antihistamines Benedryl, Chlortrimeton,Claritin, Zyrtec Atarax, Allegra, Clarinex

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    Drug Formulary

    Summary of commonly used allergy medications

    MDI =metered dose inhaler

    For Asthma

    • Rescue meds: To open airways before exercise and with acute episodes.
      • Albuteral MDI( Proventil, Ventolin, Maxair): 2 puffs every 4-6 hrs.
    • Controller meds: To heal the airway and prevent symptoms.
      • Steroid MDI
        • Low strength
          • Vanceril /Beclovent MDI:2 puffs x 4/day
          • Azmarcort MDI; 2 puffs x 4/day
          • Flovent 44mg/puff: 2 puff x 2/day
        • Medium strength
          • Aerobid MDI: 2 puffs x 2/day
          • Flovent 110mg/puff x 2/day
        • High Strength
          • Flovent 220mg/puff x 2/day
          • Pulmocort 2 puff x 2/day
      • Steroid, Nebulized
        • Pulmicort respule  0.25mg/2 cc , 0.5mg/2cc, for infants
      • Singular tabs
        • 2-5 years: 4 mg chewable x once evening
        • 6-14 years: 5 mg  x once evening.
        • Over 14 years : 10 mg x once evening.
      • Long acting Beta-agonists
        • Serevent MDI: 2 puffs x 2/day (Do not exceed the recommended dose. It may lead to toxicity)
        •   Foradil MDI: 1 puff x 2/day
      • Combination of steroid and long acting beta-agonist
        • Advair MDI 1 puff x 2/day :  3 strengths available:  low potency- 100/40, medium potency-250/40, high potency-500/40

    For Nasal Symptoms  

    • Rescue Medicines
      • Antihistamines : Primarily for drying the nose
        • Non-sedating
          • Claritin 10mg: either 12 or 24 hr preparations, Available in syrup 5mg/5cc
          • Clarninex 5 mg (24 hrs)
          • Allegra 60mg (12 hrs), or 180mg (24 hrs)
        • Less-sedating
          • Zyrtec 5mg, 10mg, 5 mg/5cc : 24 hr
        • Sedating
          • Benadryl , Atrax, Chlotrimeton, etc: usually every 6 hrs
      • Atrovent Nasal spray: for drying the nose. 2 puffs  x 4/day
      • Decongestants: To open up the nasal passage. Not to dry
        • Afrin or neosinephrine nose spray or drops: use not more than 3 days a week. Long term  use not recommended, because of the nasal congestion may get worse
        • Sudafed: oral decongestant, over the counter. Consult doctor if you have high blood pressure , arrhythmia, prostate problems, etc.
      • Combination of antihistamines and decongestants
        • Claritin-D, Allegra-D, etc.
      • Rinsing agents
        • Ocean Spray, Sinus-Rinse, etc
        • Make it yourself:  1 cup water + 1/2 tsp salt + a pinch of baking soda. Put them in a Mustard Dispenser or other dispenser with a tip.
    • Controller Meds: To heal the nasal passage and prevent the symptoms.
      • Nasal steroid MDI: Flonase, Nasonex, Rhinocort, Zetonna, Qnasal, etc.  To be sprayed to the nasal cavity 2 puffs once or twice a day.  It is important to use regularly at least 4 wks at a time, otherwise the optimal preventive effect is not reached. Use after rinsing. Aim towards the ear on the side of the nostril being sprayed.
      • Combination of nasal steroid & anti-histamine: Dymsita: 1-2p x2/day.

    For the Eyes

    • Rescue  meds: usually one drop x 4/day
      • Decongestants: Vasocon, Naphcon
      • Antihistamines:Livostin
    • Controller meds: heals and prevent allergic eye symptoms
      • Opticrom(Cromolyn): 1-2 drops x 4/day
      • Alomide: 1-2 drops x4/day
      • Patanol : 1-2 drops x 2/day
      • Pataday (olopatadine): 1-2 drop  x 1/day
      • Zaditor(ketotifen):1-2 drops, 2-3x/day
      • Optivar (azelastine): 1 drop , 2x/day
      • Restasis (cyclosporine):1 drop, 2x/day
    • A cool pack to the eyes, plus the liquid tears can be very helpful    

    For the Skin

    • Limit soap exposure as much as possible  because it dries out sensitive skin
    • Put lotion on the skin immediately after toweling down while the skin is still wet, absorption is maximum at that time
    • Antihistamines can help the itch
    • Use steroid ointments ( preferred over cream).  Be careful as the stronger steroids can blanch the skin, and should not be used on the face
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    Environmental Control Measures

    Call 1-800-9-POLLEN for mold/pollen count or click here.

    Dust mite control

    • Encase mattress, box-spring, pillows
    • Wash bed linen in hot water(130F) setting of washing machine
    • Remove carpets and put wood, tile or linoleum on the floor
    • Avoid heavy curtains. Shades or vertical blinds catch less dust
    • Avoid clutter, stuffed toys, dust catchers and upholstered furniture in bedroom
    • Avoid air turbulence caused by fans and forced air heating. Cover hot air vents. Use radiant space/room heaters in winters and AC instead of fans in hot weather
    • Clean surface with wet cloth instead of dry dusting.
    • Use a well fitting face mask with filter when cleaning and stay out of the room for 1 hour after cleaning
    • Use a vacuum cleaner with HEPA filter or multi-layer bag for dust containment
    • Avoid excessive heat and humidity which helps dust mites to grow

    Mold Control

    • Check for mold in bathrooms, basements, closets and behind heavy furniture in North facing rooms during rainy weather. Use dilute bleach solution to clean and spray with Lysol to prevent mold growth
    • Do not keep live potted plants indoors
    • Do not allow foods or produce to get moldy
    • Fresh or dry flower arrangement and potpourris can have mold
    • Avoid heat, humidity and dark areas which encourage mold growth
    • Damp shoes and clothes, if put inside closets without dry, can have mold growth
    • Avoid collection of dead plants /leaves outdoors. If present, either use a mask when clearing them or get someone else to clear it

    Pollen Control

    • Avoid exercising outside during daytime in high pollen season
    • Keep windows and doors closed between 4AM and 4PM
    • Closed bedroom door and start HEPA filter 1-2 hrs before retiring

    Dander Control

    • Avoid having pets you are allergic to. Next best measure is to keep the pet out of the house/bedroom/carpets and furniture
    • Have someone else do the grooming, feeding and walking of the pet. Washing the animal once a week with plain water decreases shedding of dander

    Skin Test Instruction Sheet

    The skin tests are administered either on the forearm/arm or on the back to determine if you have allergic diathesis. Allergen extracts are pricked on the surface of your skin by plastic devices. If the initial prick test results are negative, intradermal skin tests may be injected to your skin using very small gauge needles.

    • Please avoid all antihistamine containing drugs. The following medicines are the common ones.  Actifed, Allegra, Benedryl, Claritin, Contac, Deconamine, Dimetapp, Dramamine, Trinalin, Ornade, Periactin, Phenergan, Rondec, Tavist, Triaminic, Zyrtec
    • If you are on anti-depressants, please call us for instructions
    • Do not stop taking asthma medicines including steroids
    • Continue nasal inhalers
    • If you are taking beta-blocker medicines, please notify us. Examples are some anti-high blood pressure medicines such as Atenolol, Inderal, and Lopressor or eye droppers used for glaucoma such as Timoptic or Betapacdrops
    • We cannot test if your arms or back is sunburned or infected
    • We need to postpone the tests if you are ill

    Although skin testing is generally safe, you may experience skin discomfort and rare systemic reactions such as skin itching, coughing, wheezing or even anaphylaxis. For this reason it is important that we test you under our close observation and you should let us know if you feel any untoward reactions.

    Click Here To Download Skin Test Instruction Sheet.

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    Skin Test Panels

    If you would like copies of the skin test panels, you may down load them here.

    Adult Panel 1
    Adult Panel 2
    Food Allergy Panel
    Infant/Child Panel

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    Instruction for New Immunotherapy (Allergy Shot) Patients

    Information For New Patients Starting Immunotherapy

    1. From your skin test results, we have prepared allergen sets. They have been diluted to a very weak concentration. Each time you come in we will increase your dose, thereby increasing your tolerance to those things you are allergic to. Therefore, it is important for you to come in on a regular schedule. For the first 2-3 months, you will need to come in twice a week. Then the injection frequency will decrease to once a week, every 2 weeks, every 3 weeks, and eventually every 4 wks
    2. Studies have shown that allergen injection therapy, if administered properly, is successful in relieving symptoms in the majority of patients with allergic rhinitis and allergic asthma. The rate and degree of improvement vary with individual patients. For these reasons, you will require visits with the doctor every 3 months to monitor your progress. We will inform you when to schedule these visits.
    3. Local reactions are the reactions occurring in the injection site. Systemic reactions refer to any symptoms (shortness of breath, generalized itchiness, feeling dizzy etc) occurring away from the site of injection. Systemic reactions are rare, but if they occur, they would do so during the first 20 –30 minutes. Therefore, it is mandatory to wait 20 minutes in the office so that we can treat you. To minimize the risk of reactions, you are requested to take an antihistamine such as Allegra or Claritin 1 – 2 hours before your appointment. Please show the nurse your arms before leaving the office so that we can record the extent of your local reaction.
    4. If you have a systemic reaction outside of our practice, please contact our office immediately by phone. If you are in the vicinity, return promptly to our office. In the event that you cannot reach our office, report to the nearest emergency room.
    5. When starting your injections, your first shot may be a skin test (intradermal) to make sure the concentration is not too strong. The doctor must be in the office during your first injection.
    6. Check your injection sites 4 hours later. If there is an area of redness, swelling or both 1 inch diameter or larger, it is important for you to report it to us on your next visit.
    7. No shots can be given if you are running a fever of over 99 degrees, are having an increased asthma symptoms, or you are having an acute allergic episode.
    8. Check with us to see if your current medicines are safe during immunotherapy. If you are pregnant or planning pregnancy, please let us know.
    9. It is important that you do not engage in any strenuous physical activity for 90 minutes before and after injections.
    Click Here To Download Immunotherapy Instruction Sheet

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    Normal Peak Flow Values

    Daily peak flow recording is a very important tool in asthma management and planning. As discussed in asthma treatment section, the drug therapy is partially based on such records. Dr. Song would want to know what your reading is when you call him for an advice on asthma exacerbation. Based on your height and ethnicity, the normal value can be found on the published normograms. There is, however, a practical way of estimating the normal value for patients with average height based on their age.

    • From the ages 6 to 16: 30 x Age + 30
      • For example: The value for 10 year old patient = 30x10 +30=330
    • From the age 17 to 55 : Above 500 for men, Above 450 for women
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    General Health Tips

    NUTRITION

    The full discussion is beyond the scope of this guidebook.  As some say we become what eat. Food is more than calories -  it could harm us or keep us healthy. Most of us lead a sedentary life – we can not live on a menu of bacon and steak meant for hardy life with heavy physical. Work. Some foods harbor many  ingredients that have preventive powers.  Time magazine         (1/21/2002) selects the best 10 foods for their potential benefits.

    FOODS

    BENEFICIAL INGREDIENTS

    PREVENTIVE EFFECTS

    Tomato

    Contains the most powerful anti-oxidant.

    Released best when cooked.

    Prostate CA

    Spinach

    Iron, folate, phytochemicals*

    Heart disease, macular degeneration

    Red wine

    Antioxidant

    Heart disease

    Nuts

    Unsaturated fats

    Heart disease

    Broccoli

    Phytochemicals

    Breast, colon, stomach CA

    Oats

    Fibers, anti-oxidants

    Heart disease

    Salmon

    Omega-3 fat

    Heart disease, rheumatoid arthritis, lupus, Alzheimer’s

    Garlic

    Phytochemicals

    Heart disease, antibacterial, anti fungal

    Green tea

    Phytochemicals

    Stomach, liver, esophageal CA, antibacterial

    Blueberry

    Antioxidants

    Heart disease, cancer, boost brain power.

                * phytochemicals : chemicals produced by plants

    One should also curtail salt consumption, because it is the best way to prevent and lower high blood pressure.

    WEIGHT CONTROL

    Genetics (obesity genes) play a significant role in controlling our body weight. Some of us who are borne with “bad” genes need to try harder to control weight with diet and exercise. Even a few calories of over intake/ a day would eventually result in  a significant weight gain. Studies have shown that short term weight loss programs are not effective. One needs to go on a long term program that includes an appetite control approach.

    •        Eat plenty of fruits and vegetable especially the one listed above.
    •        Good source of protein: nuts, soy, fish, chicken and turkey.
    •        Good source of fat: unsaturated fat such as olive oil.
    •        Use fillers such as celery and carrot sticks.
    •        Avoid junk foods such as cookies, chips, etc.
    •        Learn to control appetite by; meditation, positive thinking, acupuncture, etc.
    •        Exercise every day; Walk for an hour a day: Please read exercise section below.

    EXERCISE

    Time magazine (1/21/2002) lists walking as the perfect exercise, quoting Dr. Manson, chief of preventive medicine at Harvard, “ If everyone walks in the US were to walk briskly 30 minutes a day, we could cut the incidence of chronic disease 30 to40%.”

    Some of the areas where health benefits are demonstrated are;

    • Heart disease: Exercise lowers blood pressure and decrease coronary heart disease.
    • Stroke: One study showed those walking more than 20 hrs/wk decreased their risk of stroke by 40%.
    • Weight control: Waking not only consumes calories but also boosts the metabolic rate for the rest of the day.
    • Weight loss: Walk at least an hour a day:  Exercising too intensely can work against you by interfering with the body’s ability to pull energy from fat cells.
    • Diabetes: Walking may be more effective in preventing diabetes than some medicines.
    • Osteoporosis: Walking during young age can prevent osteoporosis later in life.
    • Arthritis: You may need to exercise every other day to give  joints time to recover.
    • Depression: Walking  may prevent relapse of depression for those on medication.
    • Cancer: May lower the risk of colorectal cancer by facilitating bowel wall movement.

    SMOKING CESSATION

    • Best result is obtained when one stops smoking on will power alone.
    • Nicotine patches may be helpful and are available over the counter.
    • Zyban, oral anti-depressant, is also shown to be effective.
    • Chantix (Varenicline), a new drug, has been also used with success.
    • Facilitator devices such acupuncture needle insertion may be helpful to some people.

    MENTAL HEALTH

    Many studies have shown that mental relaxation and happiness bring good physical health. 

    • Studies have shown that relaxation program can lower blood pressure.
    • Nervous and immune system are shown to be communicating at various levels.
    • Emotion can trigger many chronic diseases including asthma.
    • Prayers and religious experiences have shown to have a healing power
    • We are borne with tremendous healing powers, which can be augmented by positive thinking.
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    COMPLEMENTARY/ALTERNATIVE  MEDICINE

    The complementary or alternative remedies to various medical disorders, including allergy and asthma, are becoming increasingly popular. Dr. Song  is very much interested in any approaches that are helpful to patients, since he is aware of the limitation of  the traditional medicine.  He may be familiar with some of these techniques and  is happy to discuss about them. However, he is of the view that these remedies should be evaluated on the same scientific basis as the traditional remedies. Probably the best way to study these approaches is by DBPC(double blind placebo control) method. For example, a herb extract of interest (treatment) and  sugar(control) are put in the identical capsules and  are given to patients. Doctors and patients do not know which are which. After completion of treatment, the codes are broken and the clinical results are evaluated.

    The following summary table is extracted from the Journal of Allergy and Immunology (10/2000). 

    CLASS

    EXAMPLES

    Herbal, Western

    Herbs, phytochemicals*, botanical

    Herbal, Chinese

    CTM, Kanpo, Jamu

    Nutritional

    Magnesium, selenium, omega-3-fatty acids, antioxidants, teas

    Fruit and vegitable diets

    Homeopathy

    Classical, isopathy

    Exercise

    Breathing technique, yoga, Chinese exercise (e.g, qi gong, tai chi)

    Massage

    Shiatsu, reflexology, etc

    Acupuncture

    Classical, electroacupuncture, acupressure, moxibustion

    * Chemicals produced by plants.

    Chinese herbal therapy

    The typical herbal prescription may contain 10 to 16 herbs, which are boiled and used as a soup.  Although some ingredients including ma huang(ephedra) are shown to be therapeutic for asthma and hay fever, none of these herbs are as efficacious as currently used western drugs.

    Homeopathic Remedies

    Classical homeopathy uses single herbs diluted to the point the final prescribed solution may be totally free of any physical remnants of the original drug. A more recent form, termed isopathy, uses dilution of allergens or drugs that provoke symptoms.  Some studies have shown the efficacy of homeopathic treatment  by DBPC studies. It is a mystery how it works since the homeopathic concentration may be so dilute that it may not contain any molecules of the drugs or allergens.

    Physical manipulation

    Physical manipulations including yoga, breathing exercises, postures, and Chinese qi gong practices may be a helpful adjunctive therapy for asthma.

    Psychological Therapies

    Prayer, biofeedback , transcendental meditation, and related practices help improve autonomic imbalance in diseases such as asthma.

    Acupuncture

    At present, acupuncture is one of the most popular alternative  therapies for asthma in the United States. Acupuncture involves the insertion of thin needles into the skin at specified locations to regulate the flow of energy (Chi). Acupuncture has the appeal offered by a nearly risk-free, relatively low-cost, nonpharmacologic form of treatment.

    Of the 6 double-blind studies for the acupuncture treatment of asthma, 4 were negative, whereas 6 of the 7 single-blinded studies were positive. Although, efficacy of acupuncture has not been convincingly demonstrated, the use of acupuncture as a complementary or adjunctive therapy need to be explored. Dr. Song has been interested in this area for some time and has had some experience in the use of acupuncture for various conditions, including headache and backache.

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