Dr. Neil Kao ("The Allergy Dude's") Allergy and Asthma Website

Drug Update: Patent expirations of Levaquin, Singulair, Avelox and Xyzal

2012-01-05T09:21:00.000-08:00

Happy New Year to all of the Allergy Dude's readers!

Let's review 2011 first. No branded products were removed from the market, which is good. Due to an earlier decision by the F.D.A., generic combinations of antihistamines and decongestants will not be available by prescription in the U.S. The Allergy Dude can not vouch for medications bought outside of the U.S. since there may be issues about "who is responsible quality control of the product?".

Two quiet changes are that first Levaquin's patent expired on 6/20/11. This is now available as a generic. Second, Avelox's patent expired on 12/18/11. This is not available as a generic to my research as of today yet. This may change.

A reminder that Xyzal has been available as a generic in the 5mg pill (only) since December of 2010. So this left only Clarinex as the only branded antihistamine on the market.

A gigantic change is coming in 2012 because Singulair's final patent will be expiring on 8/3/12, as I outlined in an earlier post. This is spell financial relief for many patients and their families. Note there has been no discussion about Singulair going over-the-counter.

One final note, Xopenex will be a branded product until the last of its 5 patents expires in 8/13.

Have a good year!!!

Greenville (South Carolina's) Rank as an Allergy Capital Fall 2011

2011-12-13T17:20:00.000-08:00

Here is how Greenville, South Carolina has been ranked in the Asthma and Allergy Foundation of America's lists of the top 100 most challenging places to live in the U.S. for: Spring Allergies, Fall Allergies, or Asthma.

Year	Spring Allergy rank	Fall Allergy rank	Asthma rank
2003	13	24	not done
2004	19	34	54
2005	6	32	58
2006*	2	1	68
2007	53	45	34
2008	17	2	8
2009	25	96	49
2010	28	44	59
2011	20	31	83

updated 12/13/11.

* = A good or bad year for us, depending on your perspective!

Commentary: Most of the top 50 cities in the Allergy Capitals lists are in the Southeastern U.S. The likely explanation is the highest pollen counts occur in the Southeastern U.S., because of the longer and warmer climate + greater vegetation which cause more allergies and so more medication use. These are two of three criteria used to determine the rankings. The table above can not be found in this format anywhere else on the internet.

If you are curious about how other cities were ranked this year only, go to the Allergy and Asthma Foundation of America's website or click on the link in the top left corner of this website. Prior year's rankings can be found by searching the internet. To see graphs of this years' pollen and mold counts, click here.

Addendum: 4/24/11
I disagree with the 3 measurements used to determine their rankings of Allergy Capitals:

Pollen scores (airborne grass/tree/weed pollen and mold spores)*
Number of allergy medications used per patient
Number of allergy specialists per patient.

Many of the cities in the rankings do not have any pollen counting stations. How then are their pollen scores calculated? They must be estimated. This is 33% of their score. This greatly affects the rankings. Physicians are humans also and so tend to live in larger cities and nicer areas. This may boost the rankings of these cities.
Separately, Greenville ranks about 20th in the spring and about 42nd in the fall fairly consistently.The pollen counts are higher in the spring than in the fall, as it is for most of the SE US.
12/13/11 My other objection to the list is: how are the pollen and mold counts determined? My office has been responsible for the pollen counts in Greenville since 2000. We don't publish mold counts, because we use a Rotorod sampler, which does not count mold spores accurately. Almost every site listed in the National Allergy Bureau's website uses the same sampler (private communication). I also know the NAB does not monitor 100 other pollen and mold counting stations. So where does the certified data come from? I happen to have lived in Dayton, OH and I know the pollen counts weren't as high as Greenville's. Perhaps the climate and vegetation has changed.

Influenza Vaccination for the 2011-12 Season

2011-10-23T15:18:00.000-07:00

The Centers for Disease Control and Prevention published their guidelines for administration of the influenza vaccination for the 2011-2 season. So The Allergy Dude will just summarize.

1. The vaccine is the same as the vaccine from 2010-1, because they thought the flu strains were going to be the same.

2. The vaccine contains 3 strains of influenza, one of which is H1N1 or swine flu.

3. One vaccination is expected to provide immunologic protection for the entire flu season, so a booster is not necessary.

4. Any patient aged 6 months old or more should consider receiving the vaccine, unless they previously had a life-threatening adverse reaction to a prior flu vaccine.

5. Patients with a history of an egg allergy should have the diagnosis confirmed. The influenza vaccine may still be given, however the setting must be where the medical staff can provide medications needed for life-threatening reactions. The odds of a life-threatening allergic reaction to the very tiny amounts of egg protein in influenza vaccines is very low.

Just in case you are wondering if I practice what I preach, here I am getting my own medical advice.

Food Allergy and Adverse Reactions: More Information

2011-10-13T14:05:00.000-07:00

The combination of seeing some patients recently with suspected allergies to additives and recently published articles have led me to dedicate this entry to further education about food allergies.

1. What is "natural"? The United States Department of Agriculture Food Safety and Information Service have a good list of definitions. For meat and poultry, "A product containing no artificial ingredient or added color and is only minimally processed."

2. What about "hypoallergenic"? The F.D.A.'s only statement on its definition applies to cosmetics, not foods. There are "no Federal standards or definitions. "The term means whatever a particular company wants it to mean." So the careful reader should become wary when reading this term.

3. Can I rely on food labels? Short answer: no, may be. The FDA does have general guidelines. In 2006, the Food Allergen Labeling and Consumer Protection Act became in effect. Eight of the commonest allergens were required to be listed on the labels if those eight allergens were even potentially present at any stage in the manufacturing of any ingredient in that food. The intent was to help patients avoid them. The eight allergens are: milk, eggs, fish, shellfish, tree nuts, nuts, wheat, and soybeans. This has been effective. BUT if a patient is allergic or has adverse reactions to other substances in foods, food labels can NOT be relied on. Items for food processing, such as gelatin, do NOT have to be listed on labels, per the FDA, because they are deemed to have no effect on the food or be present in only trace amounts. Unfortunately, trace amounts can be enough to trigger allergic reactions in highly sensitive individuals.

This is not to say that processing aids are not regulated. They are and are defined clearly by such bodies as the European Union, FDA, and the Canadian government.

4. What else are in foods, besides foods? Lots. The FDA maintains a list of over 3,000 approved ingredients. The categories include: preservatives, sweeteners, color additives (commonly called dyes), flavors and spices, flavor enhancers, fat replacers, nutrients, emulsifiers, stabilizers and thickeners, binders, texturizers, pH control agents and acidulants, levening agents, anti-caking agents, humectants, yeast nutrients, dough strengtheners and conditioners, firming agents, enzyme preparations, and gases.

5. Have food dyes been linked to behavior problems in kids? The short: no, but suspected. This is a common topic in the media. Here's a story on National Public Radio. The FDA's stance is that food dyes, for they refer to them as color additives, are regulated and generally very safe. In researching this, I learned some interesting facts. There are only 7 artificial colorings approved plus 2 more for limited indications, in foods. There are 2-3 dozen approved color additives for drugs, cosmetics, and medical devices.

6. Is it completely safe to eat in restaurants if they post or list all of their ingredients? No, and this is not a knock against restaurants or food preparers. The issue is called cross contamination, which means the transfer of harmful substances to foods. This is inadvertent, but still a risk that depending on the severity of reactions must be considered.

What is the Difference between the Cold Desserts: Ice Cream, Gelato, Sorbet, Sherbet, Italian Ice?

2011-10-09T13:07:00.000-07:00

The Allergy Dude was asked by the mother of a patient today since he has egg and milk allergies what kind of cold desserts he could eat? What about gelato? Good questions. The Allergy Dude confessed he did not know the exact differences between cold desserts (ice cream, gelato, sorbet, sherbet, Italian ice). Do you?

Here's the answers, courtesy of Wikipedia:

Let's start with what is (1) ice cream. It is a mixture of milk and cream, salt, flavors, sweeteners, sometimes fruits, a small amount of egg yolks. Note, the exact definitions of each dessert depends on the country. For example, in the U.S., the Food and Drug Adminstration has a strict guideline to distinguish between ice cream and (2) frozen custard. (Yes, believe it!) The latter "must contain at least 10 percent fat milk fat and 1.4 percent egg yolk solids. If it has fewer egg yolk solid, then it is considered ice cream."

Now for the rest of the field. (3) Gelato originated from Italy and is similar to ice cream. Two differences are gelato typically contains lower 4–8% butterfat, versus 14% for ice cream in the United States, and dairy based gelato contains 16–24% sugar whereas most ice cream in the United States contains 12-16% sugar.

(4) Sorbet contains the same ingredients as gelato except no diary products.

(5) Granita is a "semi-frozen Italian dessert made from sugar, water, and various toppings". It is very similar to

(6) Sherbet is "a fizzy powder, containing sugar and flavoring, and an edible acidic and base." When the powder comes into contact with water from a mixing or from saliva, the acid and base react and produce the gassy bubbles. Examples on the U.S. include Pixy Stix and Pop Rocks.

(7) "Italian ice, or water ice, is a sweetened frozen dessert made with fruit (often from concentrates, juices or purées) or other natural or artificial food flavorings." The ingredients are frozen while mixing them, like ice cream. It does not contain diary or egg yolk, which sherbet may.

(8) Shaved ice is fine ice crystals with a topping added . In North America, this is also called a (9) snow cone.

(10) Slush is "a flavored frozen drink". It is a name for a group of desserts made by freezing a liquid. Examples include Slurpee and ICEE.

(11) "Semifreddo (Italian: "half cold") is a class of semi-frozen desserts, typically ice-cream cakes, semi-frozen custards, and certain fruit tarts." Gelato is often used.

(12) "Frozen yogurt is a frozen dessert containing yogurt or other dairy products. It is slightly more tart than ice cream, as well as lower in fat (due to the use of milk (only 0.5-6.0%) instead of cream)."

(13) "Soft serve is generally lower in milk-fat (3% to 6%) than ice cream (10% to 18%) and is produced at a temperature of about −4 °C compared to ice cream, which is stored at −15 °C. Soft serve contains air, between 33% and 45% of volume, introduced at the time of freezing and which affects the taste of the finished product. More than this and the product loses taste, tends to shrink as it loses air and melts more quickly than that with less air."

(14) "Dessert mousse is a form of dessert typically made from egg and cream (classically no cream, separated eggs, sugar, and chocolate or other flavorings), usually in combination with other flavors such as chocolate or puréed fruit."

For me, fine dining will never be the same. As for the mom, she and her daughter will have to be careful about which cold dessert she eats. Are you ready for the Allergy Dude's quiz?

Nasal endoscopy

2011-09-02T11:58:00.000-07:00

The Allergy Dude may recommend nasal endoscopy for some patients to better examine the nasal cavity and throat. Some times directly looking with the eye and a small magnifying glass is insufficient. Having a brighter light that can be directed around corners is very useful. The nasal endoscope is about the size of a small black spaghetti noodle. About 10-15 minutes after an anesthetic and decongestant is sprayed into the nose (read Afrin + Lidocaine), the endoscope can be easily introduced into the noses of most people. It's quite tolerable. I should know. I was the guinea pig for my allergy program that every one practiced on. I even had to practice on myself. The Allergy Dude has found two good videos on youtube that demonstrate nasal endoscopy 1, 2.

(Endoscopes are very useful and come in larger sizes. They may also be used to look inside of the stomach or into the colon.) Endoscopes also allow us to look at the throat and vocal cords. Hypothetically, you should have a nasopharyngeal endoscopy at least at the initial visit and at followup visits when needed. Why are they done? Patients refuse or the physicians do not think the detailed exam is indicated. But keep this in mind if regular medical treatments fail to provide relief.

What does it mean to be Red Flagged for a Prescription?

2011-08-29T12:39:00.000-07:00

Today, the Allergy Dude will write about a potentially delicate topic: being red flagged for a prescription at your pharmacy. Since 2002, the U.S. Department of Justice has offered a grant to states to support the planning, implementation, and enhancement of a prescription drug monitoring program (PDMP). According to the Drug Enforcement Agency (DEA), as of May of 2011, 35 states have established their own PDMP and the remaining states territories are planning to have a PDMP. South Carolina happens to be in the former group. The website providing information is part of the Department of Health and Environmental Control. The express purpose is to monitor prescriptions of controlled medications. Pharmacies and physicians now have a source to check that patients who request prescriptions of controlled substances, especially for either large quantities or frequent refills, are not abusing the health care system. If there is suspicion, then those patients have a "red flag" placed next to their name, to warn the providers and pharmacists. This is not literal, since every one uses computers these days. Unfortunately, abuse of controlled medications is a fact of life. This mechanism helps to reduce this unpleasant problem. Even in my office, an allergist's, there is occasional need to access that website to check up the patient's history of prescriptions and from which doctor and pharmacy.

The purpose of Allergy Dude's entry today is to provide more facts to those that are searching for answers on the internet about "red flags". I had to do some searching myself for documented answers.

Should I eat white rice or brown rice?

2011-08-28T16:58:00.000-07:00

The Allergy Dude will write about which kind of rice is preferred to eat: white or brown. First, I'll tell you what I do not think you should eat: any fried rice from restaurants. Normally restaurants use animal lard for the cooking oil. This overwhelms any nutritional benefit from eating rice.

Next what is brown rice? Starting with a rice grain, once the husk is removed, you have brown rice. Then after the bran and germ are removed, what remains is the white endosperm. This is the white rice you buy in stores and eat. The endosperm has nutritional value, however so do the bran and germ. The nutrients in the latter include rice bran oil, fiber, vitamins, and minerals. Thus brown rice has more nutritional value than white rice. If you compare labels, remember that white rice has nutrients added back into the package.

A large study of almost 200,000 people in the U.S. by Qi Sun concluded that "eating two or more servings of brown rice weekly seems to be associated with a lower risk of developing type 2 diabetes". On the other hand, they reported, "eating five or more servings of white rice per week is associated with an increased risk." White rice has a higher glycemic index than brown rice, which means that blood sugar levels rise faster after eating white rice than brown rice. This is thought to be from the greater fiber content of brown rice. A 2011 small study from China did not find any difference in rate of developing metabolic risk factors for type 2 diabetes.

Here are some other aspects of brown rice. Since brown rice contains more grain than white rice, brown rice takes longer to cook. Brown rice has to be stored more carefully, because the oil in the husk can age and produce a rancid taste. Brown rice has more calories than white rice, but remember the calories come from higher fiber content.

Lastly, brown rice costs paradoxically about twice as much as white rice. You might think that since brown rice is less processed than white rice, which also has nutrients artificially added, that brown rice should cost less than white rice. The simple reason is economics and habits. Just like with white bread and wheat bread, nearly the entire universe prefers to eat white rice, so the demand has shaped the system to produce white rice inexpensively.

The Allergy Dude therefore recommends his readers avoid eating fried rice from restaurants and when possible try to eat brown rice versus white rice. And yes the Allergy Dude puts his money where his mouth is and also tries to eat brown rice whenever possible rather than white rice. It is not easy, since the Allergy Dude was raised eating white rice, but free will and intelligence decide that active energy must be expended to have a better outcome.

Indacterol Approved for COPD

2011-07-26T07:40:00.000-07:00

Indacaterol was approved by the U.S. F.D.A. for the treatment of COPD on 7/1/11. The trade name is Arcapta Neohaler (photo). In Europe, the trade name is Onbrez (photo). Functionly, the delivery device is essentially the same as Foradil's delivery device. This should not too surprising, since Foradil was originally a product from the same manufacturer - Novartis. Indacaterol is a once-daily long-acting bronchodilating agent (LABA), which puts it in the same class of drugs including formoterol (Foradil) and salmeterol (Serevent). Recent controversy regarding the safety of LABAs for asthmatics has stalled Novartis' efforts to get Indacaterol approved for asthma. Novartis has optioned Indacaterol's rights for asthma to another pharmaceutical company, however then it will be that company's burden to satisfy the FDA's safety concerns with LABA (see prior posts), before the FDA grants approval. This could be lengthy and definitely expensive hurdle. The Allergy Dude predicts that it will be quite some time until Indacaterol is approved in any product for asthma.

Food Allergy and Adverse Reactions to Foods: a Classification System

2011-07-24T14:20:00.000-07:00

The Allergy Dude sees so many patients with adverse reactions to foods, he thought it would be a good idea to list his classification of the types of adverse reactions to foods. I want to give credit to both the Guidelines on the Diagnosis and Management of Food Allergies in the U.S. and World Allergy Organization, whose classification systems the Allergy Dude has modified. I think for the better (below). Comments and examples are in parenthesis.

I. Food Allergy

A. IgE-mediated: urticaria, angioedema, oral allergy syndrome, acute rhinitis, acute asthma, anaphylaxis

B. Mixed IgE-mediated and non-IgE-mediated: atopic dermatitis, eosinophilic esophagitis, eosinophilic gastroenteritis

C. non-IgE-mediated: contact dermatitis, protocolitis, food protein-induced enteropathy syndrome, celiac disease, Heiner's syndrome

II. Food Intolerance (not an allergy nor immune mediated)

A. Food characteristics

1. Pharmacologic (caffeine, tyramine)

2. Toxin (bacterial, scromboid fish poisoning)

B. Host characteristics

1. Metabolic (lactase or fructase deficiency)

a. Congenital

b. Environmental (temporary following GI infection)

2. Psychological (aversion, panic disorder)

C. Idiopathic/undefined (sulphites)

D. Excessive intake (from excess intake: greasy, spicy, hot foods) [D-F = NK modifications]

E. GI disease (all may affect normal functioning)

F. GI dysfunction (not outright nor clear cut disease)

1. Congenital (Irritable bowel syndrome)

2. Senile (old age)

Are Blueberries a Good Source of Antioxidants?

2011-07-09T16:59:00.000-07:00

Your Allergy Dude attended the Blueberry Festival at Roper Mountain Science Center today. One of the vendors said to me, "Remember, blueberries are a great source of antioxidants." I also remember reading this on a bag of dried fruits. So I asked myself, has this been measured objectively and what does this really mean?
Yes, blueberries are very high in antioxidants. The highest fruit, and second only to beans. The theory is that aging and diseases result from oxidation of naturally and normally functioning chemicals in the body. So something that reduces or prevents oxidation would be a good thing. The amount of antioxidant activity is measured in vitro, that is, in the laboratory using oxygen radical absorbance capacity (ORAC). This sounds good, however, the Allergy Dude must point out that the numbers produced have unfortunately never been shown to be clinically significant. I would like some further justification for trying to eat a healthy diet.
Photo 2 reminded me, in their garden, but not their spice garden because I forgot to take a picture there, that spices have been measured using ORAC to have antioxidant activity also. However the minute amounts used in regular cooking translate into little net antioxidant activity.
Like your Allergy Dude has said before, eat a healthy diet, because you are what you eat.

New Sunscreen Labeling by the FDA

2011-07-05T17:29:00.000-07:00

Because the Allergy Dude want his readers to practice excellent preventative care medicine, I have linked to three websites that provide useful information. Each site makes good points.

Medscape FDA interview with Dr. Tan: the major points: new labeling is mandatory; and look for products that are broad spectrum, at least SPF 15, and consider water resistant.

FDA Sunscreen: lots of information, may be too much. The range of SPF will now be from 0-50 only.

American Academy of Dermatology Sunscreens: the major points: look for products that are broad spectrum, at least SPF 30 no matter what your skin type, water resistant, use enough volume to cover all exposed skin, and re-apply completely in two hours.

The Allergy Dude is very careful about direct sunlight exposure. All of his readers should be careful also.

What's difference between jam, jelly, and marmalade?

2011-07-03T13:56:00.000-07:00

Well, here goes the Allergy Dude again, down another rabbit hole. I was in the store, doing my usual Sunday morning grocery shopping for my family, when I stopped to buy a jar of grape jelly. I noted there were many choices. I realized I did not know the difference between jelly, jam, and a marmalade. Actually, add to that list: (apple) butter, preserves, and spread. So here we go, into the world wide web for information.

Next time, I've got to remind myself not to ask these types of questions.

The best summary is on wikipedia, again. Surprisingly, there was scant other actual articles with references available. Briefly...

Jelly is translucent with pectin added.

Jam is fruit juice with pulp and pectin added. Sometimes called preserves. Spreads are jams with no added sugar.

Marmalade is a mixture of fruit juice, sometimes pulp, sugar, water, and pectin.

Apple butter is a highly concentrated form of apple sauce, from long and slow heating, until the sugar carmelizes. No real butter is added.

That's it, right? Not so fast, the Allergy Dude's interest is piqued. I saw this product in the store - Welch's Natural Concord Grape Spread. What's this about concord grapes? According to the U.S. Department of Agriculture (USDA)'s Grading Manual for Fruit Jelly Fruit Preserves (dated May 1980), "Concord jelly is considered the top-of-the-line" (page 11 top). This document lists the standards for the product's essence ( the volatile flavoring materials added to their product to enhance the flavor and odor. It adds a "bouquet."), non-carbohydrate artificial sweeteners, carbohydrate sweeteners, consistency [grade A or B], color, and flavor [grade A or B]. For more on grading manuals, go to the USDA's website. The grades do not appear to be listed on the nutritional labels, so the Allergy Dude is not sure if we consumers should hope that we are being sold only grade A food products.

So, to get back to the main track, the Allergy Dude recommends reading those nutritional labels! Avoid all products with high fructose corn syrup and preservatives. It does not have to organic, but may be. Bon appetit!

Have a healthy outing to Toccoa Falls, Georgia

2011-07-02T16:43:00.000-07:00

This holiday weekend's healthy lifestyle outing was to Toccoa Falls, GA. Toccoa Falls is 90 minutes away from Greenville. There is a 5 minute walk up to the path from the parking lot. So actually it was easier and faster to go see Toccoa Falls in GA than it was to see Rainbow Falls in SC. For the latter, once you get to Jones Gap's parking lot, there is still a 1-hour hike up a winding path up and another 45-minute hike back down. Toccoa Falls is 186 feet high, whereas Rainbow Falls is about 90-100 feet. Not that I'm putting down the latter. Both are beautiful. It's great getting up to the base of the falls. There's a strong cool breeze and fine mist, while the sun is hot. I felt like I was in the boat visiting Niagra Falls again. Please get out, be active this holiday weekend, and be safe!

From your Allergy Dude

Smoking Cessation Aids

2011-06-14T17:25:00.001-07:00

The Allergy Dude would like the list some sites for free assistance with quitting smoking. He has been asked by many patients, as well as recommending the sites unsolicited to patients or caregivers.

1. American Lung Association

2. South Carolina Department of Health and Environmental Control (SC DHEC)

3. National Cancer Institute

4. Centers for Disease Control and Prevention

5. others can be found by a simple web search.

The main thing is to want really, really to stop now. It's motivation and determination. Cause and effect. The Allergy Dude has known people to quit without any aids, cold turkey, after having had a heart attack. That should be major league motivation. About 80% of people quit cold turkey. Some patients ask The Allergy Dude about using other methods. He can't say that his patients have had greater success with one particular method. The Allergy Dude offers a choice to smokers and work with them. Reality check: meds cost money and usually not covered by insurance companies. [Commentary: The Allergy Dude thinks this is very short-sighted and greedy of insurance companies, putting profit over patient care. Insurance companies rely on non-profits or government to provide help quitting smoking.] Hopefully, your physicians are trying to get the smokers to stop smoking at every insistence. For example, The Allergy Dude's patients know that they should expect at least 1 minute of every office visit will be spent discussing the evils of smoking and be harassed into quitting smoking.

If you've managed to quit, congratulations. If you're trying to quit, read up about all types of cancer, lung disease, and heart disease. Consider how much money you're wasting every day, total every year. Get motivated and quit now!!

Swimming and the Development of Asthma

2011-06-12T07:30:00.000-07:00

The Allergy Dude strongly recommends everyone get routine aerobic exercise, provided they do not have a medical condition that prevents this. For example, if you have asthma, this should be under tight and good control before attempting exercise. Thus, when I see new patients or ill followup patients, I may restrict their exercise levels, until tight control is achieved. Then they should slowly and consistently increase the amount of their aerobic exercise.

The types of aerobic exercises that The Allergy Dude recommends include running, rowing, hiking, biking, and swimming. Basically, triathlon type of exercise. The medical literature has examined the issue of whether regular swimming indoors, which involves prolonged exposure to chlorinated water, can increase the rate of allergies and asthma in patients (see PubMed search for example of studies). There is disagreement in the literature. Some studies suggest yes and others suggest no. The latest study The Allergy Dude is aware of is reassuring. Laia Font-Ribera and associates examined this issue in their article "Swimming Pool Attendance, Asthma, Allergies, and Lung Function in the Avon Longitudinal Study of Parents and Children Cohort", which was published in the American Journal of Respiratory and Critical Care Medicine Vol 183. pp. 582-588, (2011). "Swimming did not increase the risk of asthma or allergic symptoms in British children. Swimming was associated with increased lung function and lower risk of asthma symptoms, especially among children with preexisting respiratory conditions." The Allergy Dude's opinion is that the benefits from swimming far outweigh the minimal risks.

The Allergy Dude acknowledges that exercise-induced asthma is more common during swimming and other aerobic sports. However this is usually the result of individuals pushing themselves beyond their anaerobic threshold. This is beyond their body's limits to cope with the lactic acid produced by exercise and so it builds up. Muscles feel pain and won't work. Hyperventilating causes chest symptoms, such as shortness of breath and wheezing. Note that slowing the rate of the aerobic exercise, without stopping, will allow lactic acid to be sufficiently processed. But this slowing when our mind wants to go faster causes psychological distress and unhappiness. With regular practice, the anaerobic threshold will rise. So keep up with regular workouts!

Which Grass is the Safest for Allergy Patients? What about Zyosia?

2011-05-31T16:49:00.000-07:00

The Allergy Dude was asked this by a patient who was re-seeding their lawn. Interesting and relevant question. I searched pubMed and all of my allergy journals and texts for an answer. Short answer: there is no answer. Long answer: keeping reading.

Pollen from trees, grasses, and weeds is small enough to be spread by normal wind, unlike the too-heavy pollen from bright flowers, which rely on insects (bees) and birds to be spread. So what you plant in your yard does not matter too much, since there is an ocean of all types of grass producing pollen surrounding you. That being said, under the "reduce your exposure to prevent symptoms" section, I do recommend patients with allergies should know what triggers their allergies. For example, if it is grass, then know too that in South Carolina, based on my 13 years of records as a pollen counter, the season is typically from mid-April until the end of June. Wear a N95 mask outside!! Don't worry about looking stupid. Pretend you're an intern on House. Focus on knowing that for the 1-3 hours you suffocated wearing the mask, in exchange, you will enjoy many more hours of comfort, free from sneezing, congestion, runny nose, and especially a sinus infection. (Do nasal sinus rinses with water or saline when you get inside, too!)

Grass is the most common plant allergen and the most common of all allergens that cause hay fever. The U.S. government funds the National Health and Nutrition Examination Survey. Data was published in the Journal of Allergy and Clinical Immunology 2011; 127: 1226-35 in an article by Salo P et al entitled "Allergy-related outcomes in relation to serum IgE: Results from the National Health and Nutrition Examination Survey 2005-6." They tested blood samples, rather than skin tests, for 19 common aeroallergens. The two grasses selected were Bermuda and rye. Of all 19 aeroallergens, both grasses were found to have the highest prevalence in those patients with current hay fever and current allergies (figure 1 in article). Rye antibodies were detected in 44.2% of those with hay fever. Bermuda was about 35%. In those with current allergy, antibodies to rye were found in about 29% and to Bermuda in about 24%.

In conclusion, The Allergy Dude recommends grass-allergy patients plant whatever type of grass that will grow in their yard, regardless of allergies. Because wind spreads grass pollen thoroughly throughout the air currents across the earth, allergy patients can never completely avoid one specific type of grass pollen.

What is the Asthma Predictive Index?

2011-05-30T06:38:00.000-07:00

The seeds for writing about the Asthma Predictive Index (API) were planted in a blog post The Allergy Dude wrote about 2 years ago. After reading my 2011 issues of the Journal of Allergy and Clinical Immunology, my interest was nurtured. Many researchers have tried to produce a clinical prediction rule to help physicians and patients with asthma know how long their asthma would persist. Researchers in Arizona, led by Jose A. Castro-Rodriguez, M.D., proposed the API in an article published in the year 2000. The API was based on the patient's historical clinical facts, such as family history. Note that the API should be applied to children ages 2 to 3 years old and tries to predict those with a high risk of persistence of asthma. In 2007, the National Heart, Lung, Blood Institute (NHLBI)'s Expert Panel Report promoted use of the API. Here is the Modified API:

High risk children (under age three) who have had four or more wheezing episodes in the past year that lasted more than one day, and affected sleep, are much more likely to have persistent (i.e. lifelong) asthma after the age of five, if they ALSO have either of the following:

One major criteria

~ Parent with asthma

~ Physician diagnosis of atopic dermatitis (often called eczema)

~ Evidence of sensitization to allergens in the air (i.e., positive skin tests or blood tests to allergens such as trees, grasses, weeds, molds, or dust mites)

Two minor criteria

~ Evidence of food allergies

~ >4 percent blood eosinophilia (Increased numbers of white blood cells called eosinophils are made by the body to fight off allergic disease. They can collect in tissues and cause damage to the airways of the lung.)

~ Wheezing apart from colds.

If a child has 1 major criterion or 2 minor criteria, he or she has a 75% chance of having persistent asthma. Alternatively, if the child has a negative Modified Asthma Predictive Index, he or she has a 68% chance of not having persistent asthma past the early school-age years. In the April issue of the Journal of Allergy and Clinical Immunology, Dr. Castro-Rodriguez wrote about the API's "simplicity and relatively good likelihood ratio." The Allergy Dude thinks this is a good start and agrees that there is always room for improvement. We'd like the chances to be well above 50%, or 50-50.

The API was mentioned again in the NHLBI's Strategic Plan 11/30/09 (page 10). The plan points out that young children with recurrent wheezing are a treatment dilemma, as just 1/3 have persistent asthma after age 6:

Would daily therapy be appropriate for these children?
How can you identify and avoid unnecessary treatments for the remaining 2/3?

These are good questions.

There is no universal answers currently. The Allergy Dude weighs the risks and benefits of continuing to treat children who wheeze intermittantly and usually opts to continue treatment, based on symptom control and spirometry data, until a prolonged period without symptoms and normal spirometry have occurred, before tapering treatment. If you have questions, ask your doctor...

Falls Creek Falls

2011-05-29T12:40:00.000-07:00

The Allergy Dude wishes every one a Happy Memorial Day. A long weekend wouldn't be complete without a hike to a waterfall. I have to thank Ivey Knight, R.N., for her recommendation to see Falls Creek Falls. More pictures and directions can be found here. I recommend seeing this waterfalls. The trail has a few short stretches of difficult but is mostly a moderate trail. The cool, fresh air rushing over the waterfalls is refreshing at the top. Furthermore, with the recent rainfall, the streams are full. (photo 1 = upper half, photo 2 = lower half).

Get out and get active! I may get over to the 2011 USA Cycling Pro Championships.

Vitamin D and Allergic Diseases

2011-05-22T07:46:00.000-07:00

Low levels of vitamin D have been increasingly associated with the presence of an allergic disease (atopic dermatitis, allergic rhinitis, asthma) and obesity. These observations have been noted in many studies. The most recent I'd like to highlight is by Sharief S et al in the May 2011 issue of the Journal of Allergy and Clincial Immunology 2011; 127: 1295-1202. The title is "Vitamin D level and food and environmental allergies in the United States: Results from the National Health and Nutrition Examination Survey 2005-2006". Children, not adults, were found to be 2-3x more likely to have an allergic disease. The nature of the association is unclear, meaning there is not sufficient proof yet that low vitamin D levels cause or contribute to development of allergic diseases. The mechanism is unclear also. The general hypothesis is that vitamin D some how interacts with the immune system and improves its normal functioning, leaving the person less likely to have abnormal immune functioning and so less allergic or autoimmune diseases.
So you can see where this is going. Should we take more vitamin D to prevent or treat allergic diseases? There is no definitive answer yet. Researchers are working on this.

The same issue [Journal of Allergy and Clinical Immunology 2011; 127: 1294-6.] also had a study by Majak P et al entitled "Vitamin D supplementation in children may prevent asthma exacerbation triggered by acute respiratory infection". The study gave one group a dose of vitamin D for children of 500 I.U., which is slightly more than the the Institute of Medicine's recommended daily dose of 400 I.U. The control group did not receive vitamin D. They found, they state for the first time in the published literature, that vitamin D supplementation did significantly reduce the number of asthma exacerbations. The study was very small, 48 subjects total, and will have to be repeated in multiple other studies, but it is a hopeful sign.

What's your Allergy Dude's take on all of this? There have been a lot more studies and discussion that I have not highlighted here as of yet. I am closer to the tipping point of recommending further vitamin D supplementation, but right now I am sticking with my recommendation for all of my patients to have a balanced, very low salt, low animal fat diet that should contain vitamins and minerals. If people are unsure of the content, it would not hurt them to take a daily multivitamin. This was also recommended by the Institute of Medicine to the U.S. and Canadian governments.

Intranasal Corticosteroids and Bone Mineral Density in Children

2011-05-10T11:57:00.000-07:00

The Allergy Dude has written earlier about growth and corticosteroids, based mainly on studies from 1990-2000. This topic is being actively investigated and within the U.S., the FDA has provided guidance as to how they recommend growth studies be done (3/07). This is quantity of bone, now how about quality of bone?

I'd like to highlight a recent article on a separate aspect of bones in children using intranasal corticosteroids (INS), which is their density, scientifically called the bone mineral density (BMD). Do INS cause weakening of the bones in children? Excellent question.

The Journal of Bone and Mineral Metabolism just published a study by Ozkaya E, et al. titled "Lack of bone metabolism side effects after 3 years of nasal topical steroids in children with allergic rhinitis." The INS used was budesonide (trade name Rhinocort AQ) 1-2 puffs per day. The subjects were 7 to 11 years old and compared to a placebo group. They concluded "long-term intermittent treatment with intranasal budesonide spray has no negative effects on BMD and associated bone health parameters."

Parents should feel reassured that high quality studies are being done and that the conclusions are most favorable. Still my goals are to control nasal inflammation and prevent or reduce nasal symptoms on as little medication as possible.

The Latest Data on Asthma 2011

2011-05-08T10:15:00.000-07:00

The Allergy Dude would like to highlight a report I recently read that summarizes the latest available data on the status of asthma in the U.S. from 2009. The source is the CDC, by Akinbami et al.

* In 2009, the prevalence for the entire U.S.with asthma is 8.2% (=24.6 million people). In 2001, the prevalence was 7.3%, with a increase of 12.3%. The prevalence for all adults (7.7), women (9.7%), and children (9.6%), other groups, and even men (5.5%) has increased since 2001. For example, in 2001 the prevalence for all children was 8.7%.

* In 2008, persons with asthma missed 10.5 million school days and 14.2 million work days due to their asthma.

* In 2007, there were 1.75 million asthma-related emergency department visits and 456,000 asthma hospitalizations. Asthma emergency visit and hospitalization rates were higher among females than males, among children than adults, and among black than white persons.

If you're interested, go to the link to read the article and look at the graphs and tables. Table 5 on page 10 shows the Healthy People 2010 objectives they used to assess asthma. You can see the Healthy Peoples 2020 objectives in a prior post.

FDA requires post-market safety trials for Long-Acting Beta-Agonists (LABAs)

2011-05-07T17:54:00.000-07:00

The Allergy Dude found this during his daily searching for information on the internet about asthma. The title above is the FDA's summary calling for information from the 4 manufacturers of LABA products in the U.S. The four products (manufacturer in parenthesis) are Advair (GlaxoSmithKline), Dulera (Merck), Foradil (Novartis), and Symbicort (AstraZeneca). Each company was required to do a phase 4 trial in adults including 11,800 subjects each (!). In addition, GlaxoSmithKline was required to do a trial for 6,200 children with Advair. The total of the five studies is 53,000. The FDA expects to have the results during 2017.

The Allergy Dude's commentary: for perspective, the average phase 3 trial includes about 500-2,000 subjects, depending on the disease state. At least 2 pivotal trials are needed for FDA approval. Then there are smaller phase 1 and phase 2 trials, plus throw in 1 non-pivotal phase 3 trial. The total may be 6,000 subjects. Many phase 3 or 4 trials I have participated in required less than 500 subjects. So every one of these trials in a word will be GIGANTIC. My next word will be EXPENSIVE. My next word will be KILLER MIGRAINE HEADACHE. The Allergy Dude certainly favors safety over efficacy and my previously posts documented my stance on the issue of safety of LABAs. To reinterate, LABAs are safe when used as directed currently by the FDA. The issue then is that with an enormous amount of time, effort, and money, we hope to be reassured that the status quo concerning LABA safety still holds whenever the FDA finally finishes analyzing the data. Let's call it 2018 at the earliest, 7 years out. Staggering.

What are the 2020 Healthy Peoples Objectives for Asthma?

2011-05-05T12:42:00.000-07:00

The Allergy Dude is always striving to do his part to improve the quality and quantity of the lives of those with asthma. The 2020 Healthy Peoples Objectives for Asthma are reprinted below for ease of reading and speed (due to the slow loading pages from the CDC). These objectives were established in 1979 and then renewed in 1980 as 10-year objectives. Note that as I provide my efficient care for my patients with asthma, part 7, this directly contributes to goals 1-6 on an individual basis and for general society. I am also going to make yet another unsolicited plus for a healthy lifestyle and body weight. Keep these (part 7) in mind when you assess the quality of your asthma care.

1. Reduce asthma deaths for all age groups

2. Reduce hospitalizations for asthma for all age groups

3. Reduce hospital emergency department visits for asthma for all age groups

4. Reduce activity limitations among persons with current asthma

5. Reduce the proportion of persons with asthma who miss school or work days

6. Increase the proportion of persons with current asthma who receive formal patient education.

7.0 Increase the proportion of persons with current asthma who receive appropriate asthma care according to National Asthma Education and Prevention Program (NAEPP) guidelines:

7.1 Persons with current asthma who receive written asthma management plans from their health care provider

7.2 Persons with current asthma with prescribed inhalers who receive instruction on their use

7.3 Persons with current asthma who receive education about appropriate response to an asthma episode, including recognizing early signs and symptoms or monitoring peak flow results

7.4 Increase the proportion of persons with current asthma who do not use more than one canister of short-acting inhaled beta agonist per month.

7.5 Persons with current asthma who have been advised by a health professional to change things in their home, school, and work environments to reduce exposure to irritants or allergens to which they are sensitive.

7.6 Persons with current asthma who have had at least one routine follow-up visit in the past 12 months.

7.7 Persons with current asthma whose doctor assessed their asthma control in the past 12 months.

7.8 Adults with current asthma who have discussed with a doctor or other health professional whether their asthma was work related.

8. Increase the numbers of States, Territories, and the District of Columbia with a comprehensive asthma surveillance system for tracking asthma cases, illness, and disability at the State level.

Wilderness First Aid courses at the Annual South Carolina Medical Association Meeting

2011-05-01T14:07:00.000-07:00

I attended the South Carolina Medical Association's Annual Meeting this weekend. On Saturday, I learned more about the Electronic Health Records that ObamaCare has mandated and then spoke with many of the physicians, administrators, and vendors present. I was more pleased to see the afternoon sessions were about Wilderness First Aid. Even though I'm a physician, every little bit helps to prevent and treat a medical injury as well as possible. I have been Wilderness First Aid certified since 2006. From 2011 forward, members of Boy Scout Troops are required to have certified Wilderness First Aid adults present. I think this is a good thing. The classroom portion is 16-24 hours long, like we all have that much time lying around. Give a big hand to those that get certified. The Association's Delegates meeting was on Sunday. I felt "congressional."

The Allergy Dude recommends you get certified in Wilderness First Aid, especially if you do outdoor activities. There's lots of good stuff to learn. You never know when you are going to need to give Wilderness First Aid. If you need Wilderness First Aid, who is going to give it? [The Allergy Dude's wife sat through and passed the same certifying course.]

Drugs sales data and controlled substances 2010

2011-04-29T09:44:00.000-07:00

IMS Health, a healthcare information, has released its data for 2010. This article on Medscape by Daniel J. DiNoon is a good summary of IMS' data with commentary. I was surprised to see that the number 1 prescribed medication, by a large margin, was hydrocodone (with acetaminophen), which is a Class III controlled substance used for pain relief. The amount of use and abuse is staggering. In 2010, 131 million prescriptions for hydrocodone were written, with the current U.S. population of 310 million. This means on average just under half (42%) of all people, adults and children, would have had a prescription for hydrocodone. This is sad commentary on our society. Do we really have that much pain and demand for relief in the U.S.?

Note, over-the-counter meds are not listed, so acetaminophen or pseudoephedrine is not included. (You can read the link why we have to show government identification to purchase pseudoephedrine.)

The Allergy Dude strongly encourages everyone to eat nutritious food daily and get regular exercise.

Outdoor (Easter) Adventures April 24, 2011

2011-04-24T11:00:00.000-07:00

Cedar Falls Entrance

I can't get out there.

Once your allergies and asthma are under control, I strongly recommend to all of my patients and blog followers to get exercise. The weather happened to be just right, so following the recommendation of another new patient 2 days ago, my family and I ventured to the new Cedar Falls Park of the Grenville County Recreation District. This has been open for 2-3 months. I strongly recommend the drive (only 40 minutes from Greer) to the tiny, tiny town of Fork Shoals, SC (west of Fountain Inn) to see this beautiful part of the Reedy River. I definitely think this is more beautiful than the down town Reedy River Falls. No offense intended. The river is wider, has several falls and shoals. This place is going to be crowded once people find out about Cedar Falls and all of the paths get finished.

Sunscreen Allergy

2011-04-21T14:47:00.000-07:00

I just saw a mom who asked me a good question concerning her 5 year-old daughter. Could she be allergic to the sunscreen? It turns out that the daycare started putting sunscreen on the kids' faces and arms for the past month for recess outside. Once they come in, they wash those areas with a scented wet wipe.Her daughter has developed a fine bumpy red rash on her cheeks and arms during the past 2-3 weeks.

The Allergy Dude's answer: affirmative! There are many possible causes, by category, the preservatives, fragrances, and actual ultraviolet-blocking agents. A search for information netted many anecdotal sites and stories. The Auckland Allergy Clinic, Baker Allergy Clinic, and Medscape (page 7) (page 8) provided the best information, so I won't reinvent the wheel by repeating their words. If you are very interested in this topic, you may consider reading after downloading the "Clinical Guide to Sunscreens and Photoprotection." [Disclaimer: I have not read this book.]

Back to my patient, I advised mom to read this article for education, then carefully apply a different sunscreen (physical-type) that does not contain any fragrances, preservatives, or PABA. Once recess is over, wash the sunscreen off with water and an unscented tissue. I certainly applaud the daycare's efforts to protect their young wards' health. Sometimes, you just can't win. So be as careful as you can.

The Allergy Dude's final words: please protect your skin from damage from ultraviolet light (and say no to tanning salons).

List of Online Sites for Safer Eating

2011-04-18T08:52:00.000-07:00

The Allergy Dude was asked by concerned parents this morning,"Where can we go out to eat, since my child has severe food allergies?" Below are some websites that list restaurants. I appreciate all of the effort that went into preparing these lists. I would add with all due respect to the restaurants and interviewers that being listed is still not an absolute guarantee of safety. Patients and/or their caregivers should always be constantly ready to deal with an anaphylactic reaction.

AllerDine.com is based on reported reviews

AllergyEats.com interviews restaurants

GlutenFreeRestaurants.org is a paid listing

TheCeliacScene.com is for Canada

SpecialGourmet.com aims to be global guide

Greenville (South Carolina)'s Rank as an Allergy and Asthma Capital April 2011

2011-04-18T06:23:00.000-07:00

Year	Spring Allergy rank	Fall Allergy rank	Asthma rank
2003	13	24	not done
2004	19	34	54
2005	6	32	58
2006*	2	1	68
2007	53	45	34
2008	17	2	8
2009	25	96	49
2010	28	44	59
2011	20	pending	83

updated 4/18/11. Spring 2011 list was just released 1 week ago.

* = A good or bad year for us, depending on your perspective!

Pollen scores (airborne grass/tree/weed pollen and mold spores)*
Number of allergy medications used per patient
Number of allergy specialists per patient.

Alcohol Content of Cold Medications

2011-04-13T13:39:00.000-07:00

I saw a man yesterday, whom I diagnosed with an acute bacterial sinus infection. His symptoms were nasal/sinus congestion, clear drainage, sinus headaches, loud coughing and sore throat. I prescribed an antibiotic and reminded him to use his allergy medications as recommended, not if needed, at this time of the year. As for his cough, he declined any medications. He said,"I know just what to take for that...Rock & Rye [Joaquin's brand has 40% = 80 proof] with some lemon juice and honey." I informed him the higher alcohol content is the reason this seems to work. (I know I've written about this before.)

I'd like to point out several good sites (1, 2, 3 again) that list the alcohol content of some cough medications. Use these products with caution, because of their high (25%) alcohol content: Contact Nighttime, Dristan Ultra, and Vicks Nyquil. Listerine Original contains 26.9% alcohol. I didn't realize it was so high. No wonder it cuts through mucus so well. Personally, The Allergy Dude tries to use Listerine mixed with an equal amount of water to reduce the burning sensation while trying to remove postnasal drip.

Topical Corticosteroid Potency Chart

2011-04-10T12:54:00.000-07:00

Not all topical corticosteroids are created equally!

I saw a patient 2 days ago, with poorly-controlled allergic eczema, who commented the "creams were all the same. None of them work!" Hence my reply above. After we determined which topical steroids she had used, I noted that she used products in the classes of 5, 6, and 7 - the lower end of potency. To get relief, I stressed: general skin care (no tanning!, less soaps, more unscented oil-based lotions), avoiding irritants (perfumes, no scratching), routine use of a stronger topical steroid (class 4) + antihistamines to reduce itching. I think this will help her.

Here is a good chart of many topical corticosteroids currently available. Note: the greater the oil content, the greater the potency usually. Watch the concentration (%) carefully also. The exact rules are more complex and will be discussed in a later blog entry by The Allergy Dude.

Addendum: (4/23/11). The Allergy Dude apologizes, but he tried for 3 hours yesterday night to make the best chart of topical steroids available on the entire internet. However, the ghosts in the machine kept messing up the chart and have won. So I would like to make some points.
1. Lotions contain alcohol and are drying. Creams are a mixture of water and oil and the most preferred. Ointments are oil-based. Potency increases as more oil is used, because the oil helps the medicine penetrate into the deeper skin where it has more effect.
2. Foam, mousse, and shampoos are usually used on the scalp.
3. Solutions and gels are like lotions.
4. The table above is not complete. There are other steroids that are: available in outside of the U.S. or simply not listed.
5. Class 1 are up to 600x more potent than Class 7.
6. After much digging, the FDA has defined topical dosage forms.

The Burden of Adult Asthma in the U.S. from 2005 Data

2011-04-10T12:07:00.000-07:00

Here's a snapshot of adults with asthma from a recently published study by Sullivan PW et al in the February 2011 issue of the Journal of Allergy and Clinical Immunology (127; 363-9) on "The burden of adult asthma in the U.S." The article had the following findings (from 2003 & 2005 data):

1. they were significantly less likely to be employed

2. spent 1.4 days more sick days in bed

3. significantly more likely to have activity limitations or to be unable to work

4. additional $1,907 annually for asthma care

5. national medical expenditure for adult asthma $18 billion

6. the largest contributors for expenditures: prescription drugs, inpatient hospitalizations, home health care.

7. more likely to have coverage from Medicaid (30%) then the general adult population (10%)

Conclusions from The Allergy Dude:

1. get properly diagnosed as soon as possible. (What is the cause of the symptoms?)
2. get treatment appropriate to the severity of the symptoms (Don't over- or under- treat.)
3. maintain long-term & tight control of the inflammation that causes the symptoms (Put the fire out and keep it out!)

ALA Fight for Air Climb Greenville 2011

2011-04-10T11:50:00.000-07:00

I helped to raise funds for the Upstate Region's branch of American Lung Association by competing in the Fight for Air Climb Greenville 2011 on April 9 Saturday. My office did a free screening for asthma using spirometry also (photo 1). After getting sponsors for me to race (fund raising), I got to be timed as I climbed up both of the Liberty One and Two towers, located next to the BiLo Center. The combined total was 30 flights of stairs. The weather was warm and sunny. The stairwells were cold and increasingly steep.
At the 30th story, I was some what out of breath, but not so bad as last year (photo 2).

Keisha Kirkland, Tiffany Haney and I had the honor of presenting awards to the best fundraisers and best times (based on sex, age, teams, fireman with no mask on, fireman with mask on, firemen teams) (photo 3).
Celebrity runner, Levon Kirkland, former football player at Clemson University and for the Pittsburgh Steelers, with a fan, our pollen counter and head nurse, Janice Allen (photo 4).
Addendum 5/5/11
The results are on the American Lung Association's website and in detail here.

Size of Tubes of Medicine

2011-04-07T07:08:00.000-07:00

Today's note makes a practical point about the size of tubes of medicine. My goal is to help people and health care professionals correctly describe how much dermatologic medicine they have. Pictured right is a 100g tube of a medicine. Note this is 15 cm or 6 inches long. Not pictured are sample sized tubes, which typically range in the 2g to 5g of medicine (about 1/8th oz.), and are about 2 inches or 5-6 cm long. When people are prescribed 300g of medicine, often they receive three 100g tubes. The mid-sized tubes are problematic to me, because they are 5 inches or 11 cm long, 3 cm wide, and usually contain 25-30g (1 oz.) of medicine. Because of their length, they can be confused with the 100g tubes.
I hope this helps all. This is not something to ask your Allergy Dude about.

Cat Allergy from the Allergen Fel d 1

2011-04-05T17:05:00.000-07:00

In response to a patient's question, what is Fel d 1?

Let's go backwards a few steps. People with allergies to cats are specifically allergic to compounds produced by cats. The World Health Organization and the International Union of Immunologic Societies (IUIS) have classified the known allergens from cats by the group name Fel d (an abbreviation for Felis domesticus or house cats) with the specific allergens numbered from 1 to 8 currently. Fel d 1 has been determined to be the major cause of symptoms in most patients with clinical allergy to cats. Fel d 4 is another allergen, but very little has been written about it. A PubMed search showed only 1 article with Fel d 4 in the article's title. An overview of cat allergy can be found on Wikipedia. I caution readers, though because about half of the references are to lay journals, and not to be a snob, but not from scientific journals.

I'd like to emphasize some facts about Fel d 1.

First, the major source of Fel d 1 is skin's sebaceous glands then cat saliva.

Second, with a cat in the home, the size of particles found in the air ranges from greater than 9 microns (49%) to less than 4.7 microns (23%). The latter is significant for 2 reasons. First, any particles less than 5 microns are light enough to float in the air currents in a room almost indefinitely. Second, any particles less than 5 microns can reach almost to the deepest parts of the lungs with even normal respiration. This could cause a lot of inflammation and asthma. HEPA filters are very effective at reducing the allergen levels, once the cat is removed.

Third, Tovoy et al (J Allergy Clin Immunol 2001) had an article published titled "Effectiveness of laundry washing agents and conditions in the removal of cat and dust mite allergen from bedding dust". They concluded washing the bedding in warm water (25 degrees Celsius), with any type of detergent, with no benefit from added "enzymes", for more than 5 minutes was sufficient to remove most cat allergens, although hot water (60 degrees C) was more effective.

Now for some unwanted advice for my patients and critics, please get rid of your indoor pets and wash your bedding once per week in hot water.

This has been a quickie summary from The Allergy Dude.

My report on the American Academy of Allergy, Asthma, and Immunology's 2011 meeting

2011-04-02T17:29:00.000-07:00

I attended the AAAAI's (for short!) 2011 meeting in March. I thought this was a productive meeting for me. This is an international meeting of allergists from around the world.

I got to investigate a number of Electronic Medical Record (EMR) systems firsthand. This helped to crystallize my thoughts of the current status of EMR currently available.

Mannitol challenges seem to have replaced methacholine challenges to test for bronchial hyper-reactivity. I do not see my practice using them often.

The general plenary sessions were interesting. (photo 1). Some of the interesting topics: nanotechnology, asthma, studies on sublingual (under-the tongue) immunotherapy, safety of long-acting bronchodilating agents, food allergy, mold exposure.

There were no new medications debuting.

I spoke with allergists from around the world: Japanese, German, Turkey, Finland, Italy, and the U.S. My conclusion: medical practices and health care systems differ widely, not only within the U.S., but in many countries.

I think there will be some subtle changes in my practice, which should improve my patient's disease outcomes.

Incidentally, while in California, I visited the Ira F. Brilliant Center for Beethoven Studies, in the San Jose Public Library. An ultra-fast visit is here and here. You can see Beethoven's hair. A sample was used to discover that high lead levels probably contributed to his death.

The next weekend, I attended the Allergy, Asthma, and Immunology Society of South Carolina's annual meeting. This was a smaller scale meeting of allergists from South Carolina with 4 nationally known speakers. The topics included immunodeficiencies, EMR, drug allergies, food allergies, and occupational asthma. The above comments apply here also. Both meetings were intellectually stimulating and I think they will benefit my patients.

World Allergy Organization Anaphylaxis Guidelines

2011-03-31T11:46:00.000-07:00

The World Allergy Organization has released its Guidelines for the Assessment and Management of Anaphylaxis. The 24-page report can be viewed on the World Allergy Organization's website or the Journal of Allergy and Clinical Immunology's website. What's even more helpful are the teaching slides, which can be seen in a slide show (click on "Figure 1 Image Tools", then "Open in slideshow"). I encourage all patients with anaphylaxis and their care givers to read the slides.

FDA List of Unapproved Prescription Cough, Cold, and Allergy Products

2011-03-06T16:42:00.000-08:00

On March 2, 2011, the FDA announced that certain unapproved prescription cough, cold, and allergy products will be removed from the market. Here is the official notice in the Federal Register. There are three general categories of products: "products in extended release form, products that contain tannates salts (e.g., phenylephrine tannate) as active ingredients, and certain immediate release products. Today’s action does not affect OTC cough, cold, and allergy products." It is clearest to simply quote the FDA website page. The list of over 500 prescription medications is here. If you are confused and unsure about your prescription, check this list. Here is the FDA's relevant Q&A page. Their rationale is review again here.

I think this will affect many of my patients. Why? There was always a medical need for these medications . Here, things getting very muddled, for multiple potential reasons. Some times, medications on this list were selected by patients because there was a desire to have a prescription medication, not over-the-counter, with few choices being available on their insurance company's formulary, thinking that other options have been tried already. Sometimes, the pharmacy switched patients over. Sometimes, this medication was the least inexpensive option available. Sometimes, the medication works very effectively, but now the FDA has questions about the quality of the manufacturing process.

What is the time line? Manufacture must stop within 90 days of 3/2/11. Shipping of meds must stop by 180 days. So supplies won't be affected for probably 270 days. I already feel the ripples. Drug reps have come to me to clarify the situation. (Thank you, I'm on it already.) Many are worried about their jobs. Pharmacies and their suppliers right now are trying to reduce their inventories. Some patients are already at the fork in the road and being pressed to discuss alternatives.

I promise to work with my patients, if affected, to find a safe, effective, and cost-effective alternative as soon as possible. I predict many patients will end up buying the few remaining OTC combination products for relief. There are very, very few prescription medication alternatives.

Updated 3/31/11 NK

Food Allergy Guidelines 2011

2011-02-10T12:00:00.000-08:00

The National Institute of Allergy and Infectious Diseases has just published

Guidelines for the Diagnosis and Management of Food Allergy in the United States. I am pleased to see this. Thirty-four professional organizations, federal agencies, and patient advocacy groups were consulted in the course of drafting this document. I encourage those with food allergies or concerns about food allergies to start off reading the Summary for Patients and Families.

Drug Sales 2010 update

2011-02-08T16:28:00.000-08:00

This update is for 2009 actually, the latest data available. I'm told final 2010 data won't be out for 2 more months. There hasn't been much change compared to 2008. Here are the rankings:

#4 Advair Diskus, #7 Singulair, #21 Levaquan, #23 Spiriva, #39 Proair HFA, #42 Nasonex, #58 Advair HFA, #61 Pulmicort Respules, #76 Symbicort, #97 Avelox, #102 Xopenex neb, #114 Ventolin HFA, #127 Proventil HFA, #131 Allegra-D, #139 Nasacort AQ, #156 Asmanex, #169 Patanol, #170 Xyzal, #173 Clarinex, #175 Astelin, #183 Allegra-D 24HR, #192 Veramyst, #194 Xopenex HFA, #197 Epipen.

A lot of names that you should recognize if you've been buying allergy or asthma meds for some time. This is not the order of meds that I would have predicted, but that goes to show I'm only 1 person.

Xyzal generic is FDA approved 101126

2011-02-05T17:51:00.000-08:00

More good news for allergy sufferers. Actually I should have apologized first to my readers, since I dropped the ball. I read about this two months ago. A generic equivalent for Xyzal 5 mg tablets was approved by the FDA on November 17, 2010. Note this not every form of Xyzal yet.

This leaves Clarinex as the only antihistamine drug not available in any form currently. I expect insurance formularies to begin to adjust which tier they place Xyzal in the near future.

Allegra Over-The-Counter

2011-02-05T06:37:00.000-08:00

Finally, Allegra has been approved for over-the-counter status on 1/25/11. The manufacturer has set a target date of 3/25/11 to have Allegra available in most pharmacies. All forms of Allegra products will be sold over-the-counter: Allegra 180 mg tablet, Allegra 60 mg tablet, Allegra 30 mg tablet, Allegra 30 mg oral dissolving tablet, Allegra 30 mg suspension, Allegra-D 24 hour tablet, Allegra-D 12 hour tablet.

There are other generic manufacturers that will be selling the generic compound fexofenadine. The price has not been announced and I'm sure it will fall.

This is good news for consumers and insurances companies.

What are cotton linters, kapok, and pyrethrum?

2011-02-01T18:12:00.000-08:00

Some allergists may test for cotton linters, kapok, and pyrethrum. These items may be found in some homes and cause allergic symptoms in susceptible individuals.

For information on cotton linters, go down to chapter 6 Uses, 4th paragraph. My conception of this is the "lint" from cotton fabrics. This is not found near as often as more than 30 years ago.

Kapok trees produces a fiber which may be used as stuffing in household items in place of down stuffing.

Sometimes these fibers can cause allergic reactions.

Pyrethrum is the name for a group of flowers, that may have been used for decoration in homes.

What is an Allergist?

2011-01-31T09:32:00.000-08:00

1. An allergist is a physician specially trained, skilled, and experienced in the diagnosis and treatment of allergies, asthma, and related immunologic diseases - for example, hay fever, hives, and eczema.
2. The effective treatment of allergic disorders must be solidly based on advanced training. The training of an allergist involves at least 9 years of intense study - 4 years of medical school, followed by 3 years of training in internal medicine or pediatrics, plus 2 more years of specialized training in allergy and immunology. The specialty of allergy and immunology is recognized by the American Board of Medical Specialties.
3. To be a board certified as an allergist, a physician must be first be certified by the American Board of Internal Medicine or the American Board of Pediatrics and then certified again by the American Board of Allergy and Immunology, which requires both passing an 8-hour written examination on the anatomy, physiology, pathology, biochemistry, diagnosis, and treatment of allergic and immunologic disorders plus completion of a program named Maintenance of Certification.
4. Continuing medical education (CME) is required by South Carolina state law for a minimum of 25 hours per year of studying approved material. Every state has a a similar requirement for physicians to maintain their license to practice medicine.

The Allergy Dude has been a board certified allergist continuously since 1993, the first year I was eligible to take the qualifying exam.

Respitrol

2011-01-29T14:48:00.000-08:00

Respitrol is an over-the-counter mixture of homeopathic products that claims to treat asthma. I heard about this from one of the readers of this blog. I had never heard of Respitrol before. A search through reliable databases did not show anything. Even the manufacturer, Micronutra's, own website does not list its products nor provide online information about the ingredients or references to controlled studies demonstrating efficacy and safety. This website claims to be the official website of Respitrol. No safety nor efficacy information is available, just testimonials. Therefore, with no information available, I can not recommend Respitrol to any of my patients.

Influenza Update 1/27/11

2011-01-29T14:36:00.000-08:00

Empirically, I agree with the data displayed on FluTrends. I have noted an increase in patients being seen with classic flu-like symptoms. Remember:

1. Prevention is the name of the game. Get a flu shot. It's still not too late. Be careful what you touch and what you breathe. Sorry, to be anti-social in church, but move to another pew. All children are a breeding ground for contagious infections. Teach them good hygiene habits.

2. Historically, the incidence of flu will go up for another 3-4 weeks, before starting to decline. Don't let your guard down just because you've been healthy this winter. The war isn't over yet. You might be surprised about the attitudes of many of my patients. Despite me carrying on about the-sky-is-falling-from-influenza, many patients and parents do not cover up for the cooler weather, nor take their preventative meds (since they're not suffering now), nor take simple precautions like routine saline nasal rinses.
3. If you strongly suspect you or a loved one has influenza, contact or see your physician ASAP, because the window for use of Tamiflu is only 48 hours from the onset of symptoms.

Juice definitions

2011-01-25T16:59:00.000-08:00

While researching and checking my updated food families, I came across the idea of juices. I have been skeptical about labeling of juices for some time. Some definitions will help.

Fruit juice: the percentage of juice must be stated on the label. Preferably you'd like 100% fruit juice.

Fruit cocktail or drink: any beverage that contains 1-99% and whose label includes the word "juice", must also include the modifiers "beverage", "cocktail", or "drink".

Blend: indicates that is more than one juice present.

Nectar: "a diluted juice beverage that contains fruit juice or puree, water, and may contain sweetener"

If you want to read the FDA's food labeling guide, click here. I didn't find this government document to be helpful.

The simplest thing is to read the list of ingredients. That's what I (the one and only Allergy Dude) do and what I've tried to teach my kids to do.

Recent information on milk allergy

2011-01-18T17:55:00.000-08:00

The World Allergy Organization's Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines is an excellent summary of the world's literature. To simplify this 105 page document, read through the gray-shaded boxes at the beginning of each section. I'm not going to reprint the information. However I am going to strongly encourage interested people to read this article. It was published in 2010 and so the latest published articles through 2009 have been included.

Cheers, from your Allergy Dude!

Revised food familes

2011-01-11T09:44:00.000-08:00

This is a temporary notice that I have revised and vastly improved the post "Food families." (I'm pleased to say that you can;t find this list anywhere else on the internet, that I've looked, which is why I spent so much time making it.)

Interesting factoid questions:
1. What is the most commonly eaten fruit in the world?
2. Is a tomato a fruit, nut, or vegetable?

More questions from some of my patients...

3. Which fruit is used to give gin its distinctive flavor?
4. Which vegetable is named after a part of male anatomy?
5. Which fruit has the seeds on the outside, not the inside?
6. What is called "food of the gods?"
7. Which vegetables are never frozen nor canned?

Want more questions? Go to this trivia site.

Answers:
1. Mangoes are by far the most commonly eaten fruit in the world. They are eaten three times more than the number two fruit, bananas, and ten times more than the number three fruit, apples.
2. Tomatoes are actually a fruit. However based on a 1897 decision by the U.S. Supreme Court, tomatoes were classified as a vegetable, based on usage at meals.
3. Juniper berry.
4. Avocado is derived from the word for testicle, due to it's similar appearance.
5. Strawberry.
6. Cocao (source for cocoa and coffee).
7. Lettuce or cucumber.

Just for experimentation fun some ads from amazon.....

Asthma prevalence and statistics

2011-01-02T16:31:00.000-08:00

While preparing for a lecture on asthma to primary care physicians, I had to update my slides. There are many different statistics on all sorts of facets of asthma. Here are links to some I found interesting:

1. Asthma Prevalence, Health Care Use and Mortality: United States, 2003-05 by Akinbami. Go down to the charts at the bottom. Children have far more at risk and likelihood of diagnosis 8.9% versus adults 7.2%.

2. AAAAI list of statistics. Nice assortment.

3. Prevalence of asthma by state. SC was ranked 48th for all ages in 2004 at 6.6%. Seems very low to me. Range 4.2%-10.6%

4. CDC surveillance data reported in 2006 for adults >18 years old having been told they have asthma = 7.7%. Moving up to table 54, Greenville County has an obesity rate of 24.0%, which is well below most of the state. So, on this note, I'll end with my refrain of (low salt, low fat, vegetable) diet and (aerobic) exercise.
5. The latest CDC data on asthma prevalence in 2008. (There's always a 2-year lag in data due to collection and analysis.) Children 9.4%, adults 7.3%, females 8.5%, males 7.1%, white 7.8%, black 10.3%, hispanic 5.8%.

Project Rx: Drop off your unwanted medications for proper disposal

2010-11-14T19:04:00.000-08:00

Every year, countless medications are disposed of by flushing them down the toilet. This contaminates our water supply. Project Rx was at Greenville Tech, collecting unwanted and expired meds this Saturday. So was I with the minivan's cabin and seats full of medications. There will be another opportunity in the future. Please take your medications as prescribed and if unused or unwanted or expired, then dispose of those medications through proper waste management.

It's time to get your annual influenza vaccination!

2010-10-20T18:22:00.000-07:00

Step right up and get it. See one, feel one, volunteer some one else to share the pain! Why suffer alone?

Outdoor activity at the Carolina Renaissance Festival in Huntersville NC

2010-10-17T18:31:00.000-07:00

For my outdoor exercise this weekend, my family and I went to the Annual Carolina Renaissance Festival. It was a lot of fun. The weather was terrific. After walking back and forth in the fairly warm weather for 6 hours, I felt like I had gotten a fair amount of exercise today. There's a lot of live action shows and demonstrations, that I was not expecting, like jousting and glass blowing.

Enjoy the outdoors. If you have allergies, you'll have to take some precautions. Mainly, use saline nasal rinses and take your allergy meds.

See you later,

Your Allergy Dude

What about the Super Flu Shot?

2010-10-05T11:46:00.000-07:00

A patient of mine declined to receive a flu shot yesterday. He said,"Doc I want that new Super flu shot I heard about in the news. I really want to avoid getting the flu this year." Hmmm. I think he meant the Fluzone High-dose seasonal influenza vaccine. I am going to summarize the highlights from an already good article from the CDC.

1. This is approved for people 65 years old and older.

2. The ingredients of regular dose Fluzone and High-Dose are the same. The dose is 0.5 ml for both, so the High-Dose is more concentrated.

3. Older adults do not mount as strong an immune response. The intent of this vaccine is to overcome this by giving a four times larger dose of antigen in the vaccine. Preliminary data indicate that higher antibody levels are produced. However it is unknown if this means clinically older adults have greater protection.

4. The safety profile is similar for normal dose Fluzone, although slightly more local reactions have been reported (red, warmth, tenderness, swelling, fatigue).

5. If you have a severe allergy to chicken eggs or have had a prior reaction to influenza vaccines, you should consult with your doctor before receiving either Fluzone vaccine.

6. The CDC does not recommend either vaccine over the other.

Now an important, extra fact. This vaccine costs more, but Medicare does pay more. So I doubt most places will carry the vaccine, because they would be taking a loss, unless the patients paid for this with out-of-pocket cash.

Get motivated, get treated, get protected!

Your Allergy Dude

Elimination Diets

2010-09-26T14:22:00.000-07:00

I saw a man with severe hives (medical terminology: urticaria) 4 days ago. His wife and he wanted to talk about the possibility of him having a food allergy. After evaluating him by history, physical exam, allergy prick skin tests, we agreed on him beginning an elimination diet. This term means to me to not only remove the food suspected of causing the hives, but go to an extreme of restricting the diet a short list of foods. These foods are organic and known not to cause hives even rarely. A common group of foods is rice, lamb, and pineapple. This diet is maintained for 2 to 4 weeks. Wait and see if the symptoms resolve slowly. A new food may be added every 2 days. Read label very carefully, because there are many ways to hide foods.

More information can be found at: the Food Allergy and Anaphylaxis Network, WebMD, and the Dieticians Association of Australia.

If you want to avoid a particular food in your diet, don't forget this entry.

This entry is an improvement of a post on 2/9/09 on the same topic, because it was not good enough. I hope this helps more.

Your Allergy Dude

Can vaccines cause autism?

2010-09-26T11:49:00.000-07:00

Two days ago, a mother of 3 kids asked me what I thought vaccines causing autism? It turns out that she had read articles on the internet stating that data supporting the position that vaccines containing thimerosal can cause autism was being suppressed. She had not allowed any of her kids to be vaccinated. This entry is for her and the many other parents who have asked me the same great and very important question. (This is an update to an entry 2/19/09.)

There is NO proof that vaccines cause autism. I shall provide references from: Master Hastings in Federal Claims Court, the Institute of Medicine, the World Health Organization, Centers for Disease Control and Prevention, the National Institute of Health, and the American Academy of Pediatrics. There are other solid references. The story is detailed on Wikipedia nicely.

Meanwhile, there is proof that we all get vaccinated, there is protection from your individual immune response as well as herd immunity. My family, meaning my 4 kids, spouse, and I, have all been vaccinated per the CDC guidelines. By the way, this includes the Gardisil vaccine for all 3 of my daughters, to protect against Human Papilloma Virus and potential subsequent cancer. I hope this answers where I stand.

Your Allergy Dude

American Lung Association 2010 Upstate Oxygen Ball

2010-09-22T18:53:00.000-07:00

I'd like to take a moment to promote the American Lung Association's 2010 Upstate Oxygen Ball, which will be held on 11/12/10. I know there are many worthy causes out there. This represents one of the two that I try to channel my resources. I am looking forward to the entertain. My wife is looking forward to bidding on the silent auction items. If you can, please come to support the American Lung Association in any way, shape, form, or donation. Thank you.

Your Allergy Dude

USA Cycling Pro Championships Road Race in Greenville

2010-09-19T18:26:00.000-07:00

In keeping with my theme of having a healthy lifestyle and getting aerobic exercise, I went to the USA Cycling Pro Championship Road Race today in downtown Greenville. The course was 112 miles long. Here I am right in front of the finish line. The race ended with three 4.2 mile laps ending there, just over the Reedy River bridge. Man, they were going fast, about 25 miles per hour on the regular streets. They covered 1 mile in about 2 minutes + 30 seconds, overall. On the flat areas, their rate more like 1 mile per 2 minutes. I watched them from my vantage point for about 3 hours. Could be the closest I ever get to seeing the Tour de France. George Hincapie, a resident of Greenville, is pedaling past, on the left, wearing a red jersey, in the second picture. The winners are on the podium. I am motivated to move myself up and down the hallways even faster. Congratulations to all, even who finished this hot day, from Your Allergy Dude. Exercise!!

Should Adults get the Pneumococcal Vaccine and This Year's Influenza Vaccines?

2010-09-10T18:49:00.000-07:00

I have been asked this more than one dozen times in the past week. So, short answer: yes for the influenza vaccination, based on the CDC's 2010 guidelines. There are factors that should be taken into consideration: age of patient, age of first influenza vaccination, history of reaction to prior vaccinations, health conditions like asthma. Yes for the pneumococcal vaccinations from age 19 years old on up, based on Sept 2010 CDC guidelines. From 19-64 years old, the presence of "underlying medical conditions that put them at greater risk of serious pneumococcal diseases"...now include smoking and asthma." Our office will be giving influenza vaccinations later this month. Then during the next two months as part of our outreach using preventative medicine, my office will provide influenza vaccinations at a variety of places. Of course there will be other companies offering influenza vaccinations. Usually the price is about the same. Get them both if you are a candidate. I will and you'll see Your Allergy Dude getting his later this month.

Product Tidbits September 2010

2010-09-06T17:51:00.000-07:00

1. Sepracor announced on June 30, 2010 that the second phase 3 trial for Omnaris HFA showed positive results. There are currently no nasal corticosteroids using aerosol, due to the Montreal Protocol. SanofiAventis received approved for Nasacort HFA several years ago, but declined to manufacture and market this product.

2. SkyePharma's combination asthma product, Flutiform, containing fluticasone and formoterol (sound familiar?), was essentially denied approval on June 24, 2010 from the F.D.A. because even more information was required. This could stop the company from continuing to seek approval in the U.S.

3. Sepracor has not announced plans for a combination product made from 2 products it currently markets: ciclesonide + R-formoterol. Combination products are coming under intense scrutiny by the F.D.A. in the past few years due to their long-acting bronchodilating agents.

Nasal sinus rinses with saline solution part 2

2010-09-06T15:55:00.000-07:00

I am writing about nasal sinus rinses using saline solution or water because I have been thinking about this for a long time. (It's been almost 2 years since my original post on this topic. Thank you, loyal readers!) I get lots of questions about the optimal frequency, the best technique and which preparation to use. Here are my answers.....
1. I recommend doing nasal sinus rinses at least twice per day. The best time is to do it while you are brushing your teeth. You are already at the sink. If you have been exposed to allergens (pollen, etc.) or irritants (perfumes or mowed grass) or some one with an infection, then you should rinse as soon as possible. Don't leave these things lying on your nasal and sinus mucosa. Remove them as soon as possible. How long would you leave dirt on your hands before washing them?
2. After watching some U.S. Open tennis, the serves in particular, I can tell you my definition of the best technique for nasal sinus rinses. Lean forward so your head is even with your lower back. Turn your head sideways, so your nose is about 45 degrees from vertical. Insert the saline solution or water in the upper nostril, gently but firmly. I had never had water enter my ear. Water has entered my throat when I was not leaning forward enough. Let the water drip out by itself. Brush your teeth in the mean time. Don't forget to use all of the water in the bottle to rinse that side and then switch and rinse from the other side.

3. There are more preparations trying to cash in on the market, not that I blame them (photo). The Nasopure (blue, photo) worked fine. The ActiveSinus bottle (orange capped bottle, photo) was the only product I tested where the bottle consistently leaked when I squeezed. Water went on my face, but not into my nose. Sorry, but I rate this as a "Fail." There are several products in a can pressurized with air (photo). When the nozzle is depressed, either a fine mist (photo) or a squirt of water comes out. The pressure within the canister is sufficient to spray the water about 3 feet vertically. If you use a canister, be careful not to scrape against the nasal septum, because you may get a nose bleed. The nozzles don't form a complete seal, so there is a strong tendency for the water to leak back out the same nostril in which it was introduced. Yet this is gentler and may be preferred by kids. If this is the case, I prefer the spray canisters not the mist.

And now for the bonus feature: a video on youtube of your Allergy Dude demonstrating his technique for nasal sinus rinsing.
Go, go, nasal rinsing!!

Labor Day Adventure 2010

2010-09-06T07:48:00.000-07:00

Today, my daughters and I hiked up to the lookout platform to see the Lower Whitewater Falls of SC. The hike is about 1.8 miles and mild to moderate in difficulty. I wish the platform was closer to the base of the falls, but then I realized I was spoiled seeing Looking Glass Falls in Pisgah, Rainbow Falls in Jones Gap State Park, and the grandmother of them all Niagara Falls. There's nothing like standing near the foot of a falls and feeling the cool breeze, hearing the sound of rushing water, and having spray on your face. And what's this got to do with allergies and asthma? Get active outdoors and appreciate the great beauty of our state! Your Allergy Dude

What can I do about mold?

2010-08-29T16:17:00.000-07:00

I saw a mom 2 days ago, who was concerned about her three children's mold exposure from their home. This research is for her and for the many previously seen patients with the same question. I apologize about the delay in finding a good neutral site. The best objective site I have found is the AAAAI's glossary of sites. It includes the EPA's website, of which I have referred previously (look under mold on this website).

Your Allergy Dude

Affording Medications: Partnership for Prescription Assistance

2010-08-29T15:45:00.000-07:00

I was waiting in a local free medical clinic paying a courtesy call when I saw a brochure for the Partnership for Prescription Assistance. Some comments: The website is updated frequently. The site is sponsored by the Pharmaceutical Research and Manufacturers of America (PhRMA), which is composed of drug companies in the U.S. This is their lobbying organization in Washington, D.C. For the asthma and allergy medications I prescribe, it still seems quicker and easier to me to go to the drug's own website and print off the savings cards, or coupons, or patient assistance forms. I listed an analogous site on 5/16/10 for coupons which leads to coupons. All may help. My strategy would be to attack from all sides, because there is no one website I've found that can help all of my patients. I hope this helps clear up some of the confusion.

I am the Coupon King! Ask for them, download them, & use them.

Your Allergy Dude

Lectures on Allergic Rhinitis and Asthma

2010-08-29T14:52:00.000-07:00

I spoke for the Upstate Nurse Practitioner's Association yesterday 8/28/10. The slides for my lectures on allergic rhinitis and asthma are posted here on Slideshare.net. I'd like to thank each of the attendees for the opportunity to speak with them.

Hopefully ;- ) ,
Your Allergy Dude

Cataracts from Asthma Medications

2010-08-22T15:51:00.000-07:00

This is another important topic. Parents frequently ask me if the inhaled steroid medications will hurt their children. As a parent of four children, I agree this is a very good question. Quite a few parents stop their children's controller medications because their concern about adverse effects is greater than the perceived benefits from taking the medication. The controller medications include inhaled corticosteroids, inhaled long-acting bronchodilating agents (LABA), and Singulair. A recent study was published in the July 2010 issue of the Journal of Allergy and Clinical Immunology. The investigators of the Childhood Asthma Management Group (CAMP) followed children with asthma for a median duration of 12 years. The median duration of using inhaled cataracts was 4 years. The question was do children have an increased risk of developing posterior subcapsular cataracts after using inhaled corticosteroids? No, based on dilated slit lamp examinations. I find this result highly reassuring. The study will be become one of a number of studies in mind supporting my position that the benefits outweigh the risks, patients must be watched carefully with regular office visits, and the minimum necessary doses of inhaled corticosteroids to maintain control should be used.
News from your Allergy Dude

Systemic reactions to allergen immunotherapy

2010-08-12T10:43:00.000-07:00

Systemic reactions of allergen immunotherapy is a topic of great importance in our field. I have been compelled to write about this topic because of my team leader nurse Erin. Systemic reactions can be simply understood as a reaction to immunotherapy that occurs more than 5 cm beyond the local area where the allergen immunotherapy injection was given. Until recently, the definition and grading of severity has not been well standardized. A Task Force of the AAAAI/ACAAI proposed a draft of recommendations, that was published in March of 2010. I read them and agree with them. Even more instructive were the comments that have been sent it to the publisher's webpage. Once the final guidelines are endorsed by the member societies, I plan to have our operations reviewed to make sure we have minimized the chances of a systemic reaction. Generally immunotherapy has become safer with time. The published abstract of this article is on PubMed here.

My practice has been both fortunate and careful, in that I have had no fatalities related to immunotherapy since I began practicing allergy in 1991. This is a start on this difficult topic.

Your Allergy Dude

Donation of Expired Medications

2010-07-31T16:11:00.000-07:00

I wanted to donate our expired prescription and over-the-counter medications to our local Greenville or Taylors free medical clinics or a missionary group bound for overseas. After a winding journey, the final answer is that I can't. This was an unpleasant surprise to me. I am forbidden by U.S. law and the World Health Organization's guidelines. No one anywhere can. Despite good intentions, there is too much potential for misuse for any agency to accept expired medications. This is an important point. Millions of expired medication pills are wasted each year being donated. Many dollars also are spent safely disposing of expired medications by relief agencies. Here's a story from the British Red Cross for Haiti. So rather than compound the problem, here are directions on how to safely dispose of your expired medications by U.S. F.D.A. and internationally from the World Health Organization. If you do want to donate unexpired medications, see the first WHO link above.

That's a look at an eye opening problem. Nothing is simple in life.

Your Allergy Dude

News: Dulera approved

2010-07-29T17:56:00.000-07:00

Dulera is a combination product of an inhaled corticosteroid (mometasone furoate, which is the same as Asmanex) and a long-acting bronchodilating agent (LABA) for asthma. I've written about this earlier. The FDA approved Merck's Dulera on June 24, 2010. Here is the FDA's medication guide. Dulera became the third combined product available, following Advair and Symbicort. I was privileged to assist with the trials to approve Dulera. I personally noted no problems, but much more importantly, the FDA did not find particular problems with Dulera. I think it will compete in the market place with other asthma products as simply another option to treat asthma. Note the LABA (formoterol) in Dulera is the same as in Symbicort, Foradil, Perforomist, and Brovanna. There are no comparative trials available nor planned to my knowledge.

Congratulations to Merck and asthmatics,

from your Allergy Dude

addendum: 8/12/10. Samples were delivered to my office. This is the only sky blue inhaler available (see photo). There is a counter on the back side to measure the number of puffs produced from the inhaler. The only difference between the two strengths, 100 versus 200, is the barely visible yellow label and light purple label respectively on the top of the canister. Being environmentally conscious, I am happy to report that the propellant is HFA. Each canister contains enough medication for 120 puffs. Cost is unknown. Insurance coverage is likely to be non-existent, because it typically takes about 1 year for a new medication to get on an insurance company's drug formulary and being covered at an acceptable level. Due to my sensitivity for my patient's spending on medications, not discomfort with Dulera itself, I predict that some time will occur before I am commonly prescribing Dulera for properly indicated patients.
Your Allergy Dude

addendum: 8/20/10. Some physicians offices may have coupons for Dulera. The initial offer is for 1 free month's supply, meaning 1 cannister. Both doses are being priced the same, with an AWP of $188. The cash price at the pharmacy will be about $200 then.
Your Allergy Dude

What does the "Organic label" mean on foods?

2010-07-22T18:36:00.000-07:00

I support having an organic diet, as many of my patients and coworkers know. However, when I decided to learn the strict definition of "organic" food per the U.S. government, I went on another goose chase. Here are the results.

A search will get you to this government page on "Organic Food." The orginal bill was passed in 1990. Go down to paragraph label "3." for the definition of organic. I like it. Unfortunately, it's always something. There are FOUR different levels of organic foods and these may be reflected in the labels. The gold standard, top level states "100% organic." Look out for it, since use of the label is optional technically, although it wouldn't be clear to me why a manufacturer would go through all the trouble to produce 100% organic food and then not use the label. I'm going to read my labels more thoroughly, especially my produce.

I hope you learned something too.

Your Allergy Dude.

What do Insurance Companies Think about Allergy Skin Testing?

2010-06-11T19:09:00.000-07:00

Ever wonder what insurances think about tests for diseases and various treatments? They are called "Clinical Policies". Every insurance company has them. They do not publicize them. I know for a fact that 99.99% of even doctors have never read them and 99% don't even know what they are.

Here are links pertaining to the all-important field of allergy and asthma for some companies:

1) Aetna Allergy Testing and Allergy Immunotherapy, Peak Flow Meters, Airway Clearance Devices, Outpatient Medical Self-care Programs such as Pulmonary Rehabilitation

2) Cigna (calls them coverage policies) Allergy Testing, Allergen Immunotherapy,Pulmonary Rehabilitation, Airway Clearance Devices,

3) Humana Allergy Testing and Allergy Treatment, Pulmonary Rehabilitation, Airway Clearance Devices

4) United Healthcare: Adult Asthma, Pediatric Asthma, Allergy Diagnosis and Treatment (go to page 5), Pulmonary Rehabilitation, Respiratory Devices (page 7 Flutter valves).
5) Wellpoint for the Blue Choice Managed Medicaid Plan of South Carolina: Allergy Testing,

Have a question about your medical benefits? Look it up! Know your rights. Actually, virtually every person I have met doesn't realize that pharmacies, doctors, hospitals, and pharmaceutical companies all have the exact same vote with insurance companies, which is exactly zero. Patients who pay their premiums have a say and more than all the rest of the above. So, if you don't like your benefits, WRITE to your insurance company. The squeaky wheel gets the oil. Haven't you seen people with cancer who need an operation negotiate their insurance companies into paying for the procedure?

Your Allergy Dude

Greenville's Rank as an Allergy and Asthma Capital in the U.S. June 2010

2010-06-10T08:29:00.000-07:00

Year	Spring Allergy rank	Fall Allergy rank	Asthma rank
2003	13	24	not done
2004	19	34	54
2005	6	32	58
2006*	2	1	68
2007	53	45	34
2008	17	2	8
2009	25	96	49
2010	28	?	59

updated 6/10/10. Spring 2010 list was just released 1 week ago.

* = A good or bad year for us, depending on your perspective!

Commentary: Most of the top 50 cities in the Allergy Capitals lists are in the Southeastern U.S. The likely explanation is the highest pollen counts occur in the Southeastern U.S., because of the longer and warmer climate + greater vegetation which cause more allergies and so more medication use. These are two of three criteria used to determine the rankings. The data above can not be found in this format anywhere else on the internet.

If you are curious about how other cities were ranked this year only, go to http://www.aafa.org/display.cfm?id=9&sub=33 or click on the link in the top left corner of this website. Prior year's rankings can be found by searching the internet. To see graphs of this years' pollen and mold counts, click here.

What's the latest on Generic Epinephrine auto-injectors?

2010-06-01T18:26:00.000-07:00

I think this letter summarizes the situation well. Now for some practical comments. This generic is identical to the Adrenaclick. Note the instructions for use are not the same as with Epi-pen. What are relative prices? I don't know and to date I haven't been asked even once. If there were a significant savings at least to the insurance companies, then I'd expect them to be pushing as hard as they do with all other medications, which is to say, very hard. Pharmacies may feel the chance for a profit also. Time will tell. We are all subject to the laws of economics.

Are Elidel and Protopic safe?

2010-05-23T17:01:00.000-07:00

A mother asked me 2 days ago about the safety of Elidel and Protopic, because of a story in the media. I am not aware of the story, but I am aware of the issue. These two medications are indicated for the treatment of eczema or atopic dermatitis for children from age 2 years old and on up. There was a concern about users of these medications being at higher risk for lymphoma. There is no proof of this. If you want further information, please read the American Academy of Allergy, Asthma, and Immunology with the American College of Allergy, Asthma, and Immunology's Report. The American Academy of Dermatology agreed, although I can't find an online version of the report, only this reference. I use these products when indicated for my patients.

Your Allergy Dude

If I have Food Allergies, What else should I avoid? What are Food Cross-Reactivities?

2010-05-22T15:04:00.000-07:00

Here's my answer. This is a great table from an article by Scott Sicherer. This is used with permission from the AAAAI and JACI. The citation is "Sicherer SH. Clinical implications of cross-reactive food allergens. J Allergy Clin Immunol. 2001 Dec;108(6):881-90". I apologize for the blurriness. I got the image from this page. Depending on what you've been found allergic to, check the chart and be careful. Primary prevention always works better than the best secondary treatments.

Your Allergy Dude

How to Reduce the Invasion of Dust Mites Into Your Homes

2010-05-22T14:51:00.000-07:00

Here's some more about dust mites, for those wanting some new, fresher meaty facts to chew on. Go down this page to dust mites and then fungi (molds). Notice there are more than two species of dust mites. However, we can't test for many of the species identified, although we suspect or have evidence that there species cause disease in humans. It's a deficiency in our diagnostic abilities + a tribute to our government's bureaucracy which won't approve some tests. Here's a very good summary of facts about dust mites. I love the pictures. Read the section entitled, "What can you do?" I'm not going to re-invent the wheel.

Your Allergy Dude

ADAC Goes Greener and The Allergy Dude speaks out about Ozone

2010-05-22T14:18:00.000-07:00

Your Allergy Dude has been doing his bit for the environment. Though I think I was a born recycler, doing Boy Scouts and the Leave No Trace Program has heightened my awareness of being good to our environment. Yesterday, I set up green bins for recycling plastic bottles and aluminum cans at my offices. This is part of the iRecycle program. I encourage all businesses and homes to do the same. In Illinois, if you did not separate your recycleable items from general garbage, you can be fined. I hear the same about California and Pennsylvania also. So what's my educational message today? Take care of the Earth, because it takes good care of you. On the right, today I spoke at the Upstate Forever's Spartanburg meeting at Hub-Bub Showroom for "The Air We Breath" Program as part of "The Impacts of Air Quality Part 3:AIR is Everywhere." I focused on the relationship between asthma and ozone. Watch those high counts during the summer time.

Cawthorne's Head Exercises for Dizziness

2010-05-22T06:07:00.000-07:00

Dizziness is actually one of the commonest reasons to visit a doctor. Dizziness can be maddening and incapacitating, and yet thankfully not fatal. I've had to deal with my mother-in-laws episodes of dizziness for at least 10 years. She's had to sit down in Walmart on the floor at the checkout line for 15 minutes, while we waited for the spell to pass. Oh yes and get out of the way. Because I couldn't do much to help her, I called it: idiopathic, chronic, recurrent, relapsing vertigo. The name sounds very scientific, yes? Let's interpret medicalese. Idiopathic means we can't find the cause. Chronic means the disease or symptoms have occurred usually for over 3 months. Recurrent means the disease or symptoms keep coming back. Relapsing means the disease or symptoms come back after periods of wellness with worsening. I am not writing as an expert on vertigo, a.k.a. dizziness. Dizziness is a vague term and it's not medicalese, so I won't use it. Therapeutically, an English ear-nose-throat physician specialist, named Cawthorne, came up with exercises to ease vertigo. I've tried them myself and they seem to help. When I test myself by spinning, I seem to tolerate more spinning with less vertigo after using the exercises. So there's my personal testimonial. By the way, I can't say about my mother-in-law, she won't do the exercises. Here are 2 links to websites that have already written out the levels of exercise. The first link has a shorter description. The second link has a longer description. The key is persistence - daily, monotonous practice. Just do it!

Your less-vertiginous Allergy Dude

Greenville Chinese Cultural Association

2010-05-16T16:58:00.000-07:00

I've been asked enough times about my heritage and if I know about the local Chinese society to provide this written answer. Yes, I am a member and I joined when I came here in 2000. Greenville Chinese Cultural Association's website is the location to find information about it and the GCCA's Chinese School of Greenville. Tuition information, registration forms, and answers to FAQ can be found here. Come and experience some Chinese culture. They are very friendly people.
Your Allergy Dude

Coupons on the Internet

2010-05-16T13:49:00.000-07:00

Go to Internet Drug Coupons for printable coupons. I just read about this in one of my journals. Go and remember to bring your coupons to the pharmacy. Very few coupons are kept there.

The Cigarette Tax in South Carolina has been raised 50 cents!!

2010-05-13T12:00:00.000-07:00

Let's hear it for both Houses of State Government in South Carolina! In a rare sign of unity and common snese, they both overrode the governor's veto and raised the cigarette tax by 50 cents. Yesterday's Spartanburg Herald Journal Editorial called for permanently indexing the tax to the price of a pack of cigarettes. In 1977, 33 years ago, when the tax was raised to 7 cents, a pack cost 49 cents, for a 14% tax rate. Today the average price is $4.83, meaning the price has risen about 900%. I wholeheartedly support this principle. Tax is indexed for practically everything else. Why not, considering the burden that caring for the diseases caused by smoking. They don't take care of themselves, otherwise they would stop smoking. I call on both Houses to support this idea and make it state law. Please for us and our children.

Your Allergy Dude

How many people on the U.S. have food allergies?

2010-05-13T09:53:00.000-07:00

I was asked this by a reported for ABC News for a story. Good question. The latest data from the Report of the NIH Expert Panel on Food Allergy Research is that 6-8% of children under four years old and 3.7% of adults have a food allergy. If you are interested in what research the U.S. government is doing or planning on food allergy, read the report. I was actually pleased to learn about the items in the report.

Your Allergy Dude

American Lung Association Big Ride Across America 2010

2010-05-04T08:10:00.000-07:00

Today, I'd like to highlight a worthy cause called the American Lung Association Big Ride Across America 2010. I had the opportunity to meet Kristin Snyders, who is from Greer. What a tremendous gift to others! She has been training for the ride, in addition to doing the Ride itself. The latter begins in Seattle on June 21 and ends 48 days and 3,300 miles later in Washington, D.C on August 7. I am a proud sponsor of her and her cause. I hope others will help her. Her Facebook information is here and you can access her fundraising page here.
Good luck, thank you, and safe travel!

Your Allergy Dude

Liquid Zyrtec, Benedryl, Tylenol, Advil Recall

2010-05-04T07:45:00.000-07:00

A mom just asked me about the Zyrtec recall. Her son took Zyrtec 10 mg pills. What's the situation?

A quick check brought me to McNeil Product's special website on the product recall. Only liquid preparations of Zyrtec, Benedryl, Tylenol, and Advil are being recalled. Go to the website to check on the lot numbers of the recalled products. Do not just throw away the product, because the website has an option for a refund or high value coupon. Just don't use the product. Safety first.

This has been a late breaking news flash from...

Your Allergy Dude

When is World Allergy Day?

2010-05-02T16:21:00.000-07:00

First, what is World Allergy Day? This is a day selected by the World Allergy Organization to get allergic diseases to be recognized as a world-wide problem. This was also to encourage awareness of and education in allergies, particularly Childhood Asthma, within your country. The physicians who focus their time and energies to treat these diseases belong to the specialty of allergy and immunology.

Where? The WAO meets biennially for the World Allergy Congress during December. The proclamation originates during this meeting.

When? The first World Allergy Day was 7/8/05, then moved to occur during the World Allergy Congress on 12/4/07 and 12/9/09. There have been only 3. This is all the history on this special Day, which is not written up anywhere else on the WWW that I could find. Some historical trivia.

Your Allergy Dude

Patient Instructions for Inhaled Devices

2010-05-02T15:53:00.000-07:00

1) While I am no longer a Member of the American College of Chest Physicians, it did publish some terrific patient instructions for inhaled devices. So being the equal-opportunity type of Allergy Dude that I am, I am pointing patients to there.
2) The AAAAI has videos on general allergy and asthma topics.
3) Don't forget there are video clips on youtube also.

Your Allergy Dude

Celebrate World Asthma Day 2010 on May 4th

2010-05-02T15:36:00.000-07:00

World Asthma Day is an annual awareness-raising event organized and sponsored by the Global Initiative for Asthma (GINA). For more information please visit World Asthma Day. This year, it is on May 4, 2010.

The first World Asthma Day was celebrated in 1999. Since then, World Asthma Day has been celebrated annually on the first Tuesday in May. Next year, the date is May 3, 2011.

My office did a lung screening for asthma at the Climb Greenville event on 4/10/10. If you or a loved one has asthma, take care of it please!

Your Allergy Dude

Goal of Allergic Rhinitis Management

2010-05-02T13:27:00.000-07:00

This was inspired by the NAEPP's Goal of Asthma Management, which can be seen elsewhere on this website here. This is my own drawing. It can't be found anywhere else on the entire WWW. Kind of satisfying to know that at least once on this website, there is at least one unique piece of content! My patients should recall how I grill (gently, medium-well done) my patients to make sure their Allergic Rhinitis is under good control. Expect the same from your physicians.
Your Allergy Dude

What is the Relationship between Allergies and Migraine Headaches?

2010-04-27T07:55:00.000-07:00

I have had a headache for the past two days. It feels like some one at unpredictable times is hitting the right side of my skull with a chisel about every 10-15 minutes. The pounding has continued, despite taking Tylenol, Advil and resting lots. I went to bed at 8:45 pm (very early for me). I tossed and turned all night, because I kept waking up with the same headache. This leads me to my topic for the day: headaches.
The black box is your body. The red circle is allergies, which is present in 20-25% of the general population. The green circle is migraine headaches, which is present in 10-20% of the general population. Both are common disorders, so it is common for one person to have both. But are they related? The short answer is: sometimes, as represented by the yellow area. What I can't demonstrate in this diagram, because I am such a tool with using programs, is that there are some important variables. First, the area of overlap can be small or very large. In the latter case, allergies and migraines are highly related. This is important to know, because treatment of one disorder could by "killing two birds with one stone" improve both disorders. Second, the sizes of either circle can vary, representing the size of the person's problem. For example a person may have a small circle for allergies and a large throbbing circle for headaches. Third, the causative nature can't be indicated on the diagram. For example, often I am asked if allergies can cause migraine headaches. Sometimes. Then by treating allergies, the migraines are reduced or prevented without using specific headache medications. This situation is actually preferred because the "kill two big and closely related birds with one stone" situation really exists. Some patients I have seen with this situation effectively prevented migraines with firm and persistent allergy treatment. Their medication use, symptoms, and missed work or school were all decreased.

Back to me. More ibuprofen and rest until this passes.

Your Fatigued Allergy Dude

Raise the Cigarette Tax in South Carolina!

2010-04-22T09:11:00.000-07:00

I am using today's article to urge the Governor, Mark Sanford, to sign legislation for a 50-cent per pack increase in taxes on cigarettes. We have gone over the logic time and again. To whit, smoking is bad for smokers and non-smokers. Higher taxes cause fewer people to smoke. We are in an economic depression, with insufficientto pay for vital services. The income from this tax will be used transparently to help pay for these services. Every other state has seen fit to raise cigarette taxes well beyond 57-cents per pack several years ago. This is not an issue where Governor Sanford should be concerned about not raising taxes overall. The need is clearly there, even though I am generally against raising taxes. Please support this legislation.

Which Inhalers are being Phased out by the FDA?

2010-04-18T18:13:00.000-07:00

The speed at which information and misinformation from the Web continues to amaze me. 2 days ago, an elderly patient asked me what new medication will I be prescribing for her, since she had just read that the FDA was banning her current inhaler - Combivent mdi.
The FDA did indeed issue a Consumer Update on 4/13/10. There is a lot of confusion, that actually the article can help sort out. It helped me. I will summarize the article. All of the following 7 metered dose inhalers use CFC as a propellant. The first 4 are not being manufactured any more. By the end of this year, it will be illegal to sell them. The next 3 (#5-7) are to have manufacturing stopped in the future. The date that each medication can be sold is listed in parenthesis.
1. Tilade (6/14/10)
2. Alupent (6/14/10)
3. Azmacort (12/31/10)
4. Intal (12/31/10)
5. Aerobid (6/30/11)
6. Combivent (12/31/13)
7. Maxiair Autohaler (12/31/13)
The latter 2 are still actively prescribed. Don't worry about the supply for now.
Your Allergy Dude

Insurance Mandated Limits on Prick and Intradermal Skin Testing

2010-04-15T18:52:00.000-07:00

The best way to determine if a patient has allergies to a substance is to directly challenge the subject with allergens on the suspected tissue. For example, to determine if a patient has anaphylactic reactions to peanuts, we would feed the patient some peanuts and see what happens next. This is called a food challenge. Another example, to determine how allergic a patient is to oak pollen, we place drops of oak pollen into the patient's eye and measure the results. This is called a conjunctival challenge. Neither are practical for testing more than one substance at a time and then there's the danger and discomfort to the patient. Thus, we rarely use challenges to diagnose patients with allergies.

Skin tests are the second best way of: determining the presence of allergic antibodies to a substance and providing some guidance as to the amount of antibodies present. Skin tests can provide evidence as to: 1) does the patient have allergies? yes or no; 2) to what substances (allergens) is the patient allergic?; 3) how badly is the patient allergic to those allergens? The skin's immune system responds about 80-95% of the time just like the respiratory and gastrointestinal tracts. This is the practical standard used by all board certified medical allergists. Blood tests, called RAST or PRIST, are not as accurate.

Let's define the two types of skin testing. First, prick skin tests involve gently pressing on the skin with a plastic device. The device has a drop of an allergen on the end. There is no bleeding and minimal discomfort. Second, intradermal skin tests involve using a 25-gauge needle, which at about 0.5 mm diameter is nearly the smallest diameter needle used in medicine, to place a small amount of allergen under the skin, to see if a small and measureable allergic reaction occurs.

Every insurance companies has placed limits on the amount of skin testing, so I consider this when I order skin tests. I try to keep the number of tests below the mandated limits and rarely exceed this number. Below is some examples I have researched for some major insurance companies.

Insurance	Prick Tests	Intradermal Tests	Comments
Medicare	80	No limit
Super Med	99	No limit
BC BS of Alabama	any +	any: to a maximum of	65 total (terrible)
Medicaid (straight, not HMO)	143	No limit
United Health Care (UHC)	75 per day	75 per day

This table isn't meant to be law. I excluded Aetna, Cigna, and Humana, because there is no discernable pattern to my eyes anyways of how many tests are covered. Check your individual insurance benefits before you have skin testing. What is law now is that everyone's benefit's are made as incomprehensible as possible, and yet you are responsible for your own health. I am just giving some examples to help patients to prepare for a productive visit to their board certified medical allergist. (Note 1: hopefully me. Note 2: always verify that your physicians are board certified. I can tell you every physician makes sure the physician they see is board certified. This means it is important to us!)

Readers, you'll be hard pressed to ever find a post like this on the WWW. I couldn't. I hope this helps you understand the process better.

Your Allergy Dude