Greg E. Sharon, M.D. Priya J. Bansal, M.D.

ADULT ASTHMA basic rule of asthma therapy is that the intensity of treatment CONTROLLING TRIGGERS & should match the severity of asthmatic symptoms. Therefore, CONTRIBUTING CONDITIONS: historyA is essential in determining if your disease is mild, moderate, or The identification and avoidance of asthma triggers is a critical severe and whether the asthma is intermittent or persistent. Asthma component of successful asthma management. is associated with a chronic allergic irritation of the chest that in some Inhaled allergens- The patient should be aware of symptoms patients can progress to permanent changes. This can lead to irreversible triggered by common inhaled allergens, at home, daycare, school, or obstruction which is called Chronic Obstructive Pulmonary Disease, or work. Indoor allergens, such as dust mites, animal dander, , and COPD. This is why it is important to recognize and treat asthma. The cockroaches, are of particular importance. Food allergy rarely causes primary goals of treatment are relief of patient symptoms, prevention of isolated asthma symptoms, although wheezing and cough can be acute asthmatic attacks, and an improved quality of life. symptoms of food-induced anaphylaxis. If your history suggests these allergic triggers, basic avoidance measures will be advised. The successful management of patients with asthma includes four Respiratory irritants- Inhaled irritants include tobacco smoke, essential components: wood smoke from stoves or fireplaces, strong perfumes and odors, chlorine-based cleaning products, and air pollutants. Patients should be cognizant of avoiding irritants, and avoid exertion outdoors on days • Routine monitoring of symptoms and lung function when levels of air pollution are elevated • Patient education to create a partnership between clinician Contributing conditions- In adults, these conditions include and patient leading to reduction of symptoms chronic obstructive pulmonary disease/emphysema (COPD), allergic bronchopulmonary , gastroesophageal reflux, obesity, • Controlling environmental factors (trigger factors) and obstructive sleep apnea, rhinitis/sinusitis, vocal cord dysfunction, and co-morbid (two or more co-existing conditions or diseases) depression/chronic stress. that contribute to asthma severity Aspirin and non-steroidal anti-inflammatory drugs can trigger • Pharmacologic therapy to reduce damage to the lungs and asthma symptoms in approximately 3 to 5 percent of adult asthmatic inflammation patients. The incidence of aspirin-exacerbated respiratory disease is higher among asthmatic patients with nasal polyposis (constituting “triad asthma” or Samter’s triad). Aspirin-sensitive asthma is uncommon in children. MONITORING PATIENTS WITH ASTHMA: Complications of influenza- Annual administration of the Currently, the majority of medical visits for asthma are for urgent influenza vaccine is recommended for patients with asthma because care. Effective asthma management, however, requires a preventative they are at risk for complications of infection. However, vaccination approach, similar to the treatment of hypertension or diabetes. Routine does not reduce the number or severity of asthma exacerbations during follow-up visits for patients with asthma are recommended, at a the influenza season. frequency of every one to six months, depending upon the severity of Dietary sulfites- Sulfite compounds are used in the food industry asthma. These visits should be used to assess multiple aspects of the to prevent discoloration. As many as 5 percent of patients with asthma patient’s asthma. Even if you’re well today you need to keep your may note significant and reproducible exacerbations following ingestion appointments and seek further education and reduction of risk of of sulfite-treated foods and beverages, such as beer, wine, processed asthma flare. Some therapies and monitoring can only be done when potatoes, dried fruit, sauerkraut, or shrimp. you are healthy, i.e. skin testing. We ask at each visit the following: signs and symptoms of your asthma, how you’re functioning, quality of life, asthma exacerbations, adherence with treatment and medication SUMMARY AND RECOMMENDATIONS: side effects. We want to know about nighttime symptoms, use of Effective asthma management requires a preventative approach, with short acting inhaled beta agonists (SABAs) to relieve symptoms, and regularly scheduled visits during which symptoms are assessed, pulmonary difficulty in performing normal activities and exercise. Well-controlled function is monitored, medications are adjusted, and ongoing education is performed. Patients should learn to monitor asthma control at home (e.g., asthma is our goal. frequency and severity of dyspnea, cough, chest tightness, and albuterol use). Patients with moderate to severe asthma and those with poor perception of ASTHMA ACTION PLAN: increasing asthma symptoms may also benefit from assessment of their peak The patient’s normal Peak Flow Meter PEFR value can be used to expiratory flow rate at home. A personalized asthma action plan should be construct a personalized “asthma action plan.” The asthma action plan provided with detailed instructions on how to adjust asthma medications provides specific directions for daily management and for adjusting based upon changes in symptoms and/or lung function. Environmental medications in response to increasing symptoms or decreasing PEFR. triggers and co-existing conditions that interfere with asthma management Instructions and forms for asthma action plans are important tools. should be identified and addressed for each patient.

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com Greg E. Sharon, M.D. Priya J. Bansal, M.D.

DRUG ALLERGY drug allergy, or an allergic drug reaction, is an unexpected drug PENICILLIN: reaction that results from a specific immune system response Penicillin is the most prevalent allergy causing medication, with toA a medication. Past tolerance to a medication is no guarantee that approximately 10% of patients reporting being penicillin-allergic. treatment with that drug will not cause an allergic reaction next time. However, when patients with a history of penicillin allergy are evaluated, People who who have allergies have a higher risk of drug reactions. time has lead to a cure. Many patients are candidates for Penicillin skin Certain families may have a higher than normal risk of drug reactions. testing because they have lost their allergy to Penicillin. This is because 80% of such individuals lose their sensitivity over a period of 10 years. In DRUG ALLERGY HISTORY some cases, patients or doctors are unwilling to trust a negative skin test A thorough history is an essential component of the evaluation of result. To alleviate everyone’s apprehension and prove the medication’s patients with suspected drug allergies. The most important components safety unequivocally, most experts recommend a negative skin test be of a drug allergy history are as follows: followed by an elective oral challenge to Penicillin. CEPHALOSPORIN: These are cousins to penicillin and can cross-react in a penicillin What is the name of the medication? allergic person. This means if you’re allergic to penicillin and have never Although it may be obvious that a drug allergy history starts with the taken one of the cephalosporins before the body may have learned an name of the implicated medication, frequently patients are unable to allergy from the prior penicillin reaction. So now you can react to the give this basic piece of information. class of antibiotics called Cephalosporins. This cross-reaction cannot be predicted by history alone. The rate of cross-reaction ranges from How long ago did the reaction occur? The time elapsed since the reaction is important, because some allergies, ten percent to fifteen percent. Cephalosporins share a common four- such as penicillin allergy, are known to wane over time. member beta-lactam ring with penicillin. Cephalosporins appear to be less allergenic than penicillins, particularly in causing IgE-mediated Which systems (eg, cutaneous, respiratory, gastrointestinal) reactions. The incidence of anaphylaxis as a reaction to cephalosporins were involved in the reaction, and what was the time course? is also lower. Unlike penicillin, cephalosporin has no validated diagnostic skin test reagents available. Skin testing using non-irritating What illness was occurring when the medication prescribed? concentrations of native cephalosporins is usually performed, but its predictive value is less well studied. Was the patient taking concurrent medications at the time of QUINOLONES: the reaction? Cipro, Levaquin, and Avelox can cause a reaction with the first dose you take in your life. They are a very strong and important class of Had the patient taken the same or a cross-reacting medication medication and should not be used for minor infections. before the reaction? SULFA: These older medications can commonly cause a delayed, often Have you taken a similar medication since the reaction and very itchy reaction. They can also lead to a very severe reaction, and tolerated it? are sometimes fatal. Higher incidence is seen in AIDS patients and leukemics. Once you react to a sulfa you may never take one again. Sulfa Has the patient experienced symptoms similar to his or her allergic patients are more likely then normal’s to react to Penicillin. reaction in the absence of drug treatment?

Erythromycin Biaxin, Zpak, and Ketek are usually well-tolerated ALLERGIC REACTIONS: and are the drugs of choice for Penicillin allergic patients. Immediate (within one hour of a dose) allergic reactions occur when Tetracycline Minocin, and Doryx are not commonly used except the body has developed a specific hypersensitivity (allergy) to a drug. for acne patients They can lead to severe reactions and are mostly The body will make a certain antibody called IgE. The IgE antibody a problem when combined with sun’s UVB radiation. only reacts with allergic cells. These allergic cells will release chemicals, like histamine, responsible for causing stuffy nose, sneezing, itching, hives, and asthmatic reactions. Delayed Reactions: Reactions appearing after one hour are classified as delayed, although most delayed reactions begin after six hours, and typically not until days after treatment.

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com Greg E. Sharon, M.D. Priya J. Bansal, M.D.

DRUG ALLERGY LOCAL ANESTHETICS: These medications are used by the dentist or surgeon to freeze or numb your teeth or skin. Reactions can either be allergic or a side effect alone. We can perform a skin test to find safe alternate medications for your doctor or dentist to use.

PROSTAGLANDIN INHIBITORS: Aspirin and like medications are more likely to react if you have asthma, recurrent sinusitis or nasal polyps. These drugs are in the group of medications that are used for the treatment of minor pains. Aspirin is the main problem, but other over the counter medications like Advil or Aleve also cause trouble. A pain reliever that is often safe in Aspirin allergic patients is Tylenol. Interestingly, if you react to aspirin, you might react to a common food dye called Tartrazine or yellow dye #5.

NON-ALLERGIC REACTIONS: Reactions to medications come in several forms, and not all are allergic. Some examples of non-allergic reactions include these: Side effects of medications: Nausea and vomiting. Drug interactions: Medications taken together can cause toxicity. Concurrent viral infections: Medications taken during viral infections can cause reactions. Delayed destruction of drugs: A build up of medicines can cause intolerance. Non-Drug induced symptoms: Patients who receive local anesthetics to numb a tooth sometimes complain that the drugs made them faint or feel ill when in fact the fear (pain) of the dental surgery is causing the reaction. Psychological effects: Stress, pain, fear are powerful enough to induce fainting, hives, nausea and vomiting.

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com Greg E. Sharon, M.D. Priya J. Bansal, M.D.

ALLERGIC REACTIONS ALLERGIC AND ASTHMATIC MODERATE CONTENT REACTIONS TO FOOD ADDITIVES • Corn starch, Frozen potatoes, Maple syrup, Fresh mushrooms, he list of additives used in the food industry is extensive and Malt vinegar, Dried cod, Beer, Gelatin includes thousands of flavorings and coloring substances, preservatives,T sweeteners, antioxidants, and thickeners, etc. However, • Dry soup mix, Maraschino cherries, Pectin, Pickles/relishes, only a small number of additives have been implicated in IgE-mediated Imported jams and jellies or other (immunological or non-immunological) adverse reactions. Some studies concluded that sensitivity to the following food additives • Gravies, Sauces, Soft drinks, Instant tea, Pizza dough (frozen), in patients with chronic urticaria/angioedema is rare, but can occur: Pie dough

•MSG •TARTRAZINE • Coconut, Fresh fruit salad, High fructose corn syrup, Canned •BENZOATES (FD&C YELLOW potatoes, Hominy •PARABENS #5, E102) •SULFITES •SUNSET YELLOW •BHA (FD&C YELLOW Hyperactivity and behavioral changes in children are sometimes •BHT #6, E110) seen from food additive and a trial of avoidance and rechallenge is often useful. Migraine patients may react to Tryamine containing foods which In asthmatics and allergic patients the risk of reaction is greater. is not an additive but an Amino Acid that can affect their headaches. While any asthmatic may develop sulfite sensitivity, these sulfite sensitive asthmatics have more severe asthma and are often steroid dependent.

SULFITE-CONTAINING FOODS:

HIGH CONTENT

• Dried fruit (excluding dark raisins and prunes), Lemon juice (nonfrozen), Limejuice (nonfrozen)

• Wine, Molasses, Sauerkraut juice, Grape juice (white, white sparkling, pink sparkling, red sparkling)

• Dried potatoes, Wine vinegar, Fruit topping, Shrimp (fresh), Pickled peppers, Pickled cocktail onions

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com Greg E. Sharon, M.D. Priya J. Bansal, M.D.

IMMUNOTHERAPY ALLERGEN IMMUNOTHERAPY FOR WE OFTEN SUGGEST SCIT IF WE SEE: ALLERGIC DISEASE • An inadequate or partial • Cost burden associated with llergen immunotherapy (SCIT) or allergy shots treats allergic response to environmental chronic medication use. diseases. The process involves gradually administering increasing control and medications. amountsA of allergens (the proteins your allergic to) leading to reduced • Non-compliance with reactions to allergens (immunologic change called tolerance). SCIT is • Medication resistant maintenance medication currently the only treatment that alters the allergic immune response symptoms. regimens (i.e. teens) causing allergic disease. Medications only cover up symptoms of allergy. After several months of SCIT, patients undergo less nasal • Patients with side effects reaction to allergen challenges and see an improvement in symptoms related to medication use. of allergic rhinitis or asthma.

The allergic antibody (IgE) typically increases after your worse At present, there is consensus that an initial course of allergy season. This post-seasonal spike can be eliminated by SCIT. immunotherapy should consist of three to five years of maintenance The body uses an allergic blocking antibody called IgG to do this. treatment. After this, the clinician and patient should meet to review Levels of this good blocking antibody may continue to rise over many overall impact on quality of life, and based upon these factors, decide months of SCIT and elevated levels may persist for many years after if treatment will be continued. We believe two allergy seasons free of immunotherapy is completed. Immunotherapy also results in several symptoms suggests the discontinuation of SCIT. changes in white blood T cell responses to allergens. These changes may contribute to immunologic tolerance to the allergen. Changes in another allergic white blood cell called basophils is also affected. The ability of basophils to fully release histamine in response to the allergen is reduced.

Allergic Rhinitis, Allergic Asthma, and Atopic Dermatitis respond to SCIT. The administration of SCIT to children with allergic rhinitis can help prevent the subsequent development of allergic asthma. SCIT is not usually initiated during pregnancy, although it may be continued in women who were receiving the therapy prior to becoming pregnant. SCIT is appropriate for both adults and children, and there are no defined age limits for its administration. When proposing SCIT for pediatric patients, most clinicians wait until a child is at least five years of age so that they are mature enough to cooperate with repeated injections. Children are believed to derive potentially greater benefit from immunotherapy, due to the potential of SCIT to prevent progression to more severe disease and allergic asthma. For this reason, therapy will occasionally be started in very young children.

SCIT is usually recommended for the treatment of allergies and respiratory disease only after a trial of medications. Medications are relatively easy for most patients to use and, when effective, provide relief more rapidly than immunotherapy, however they never lead to a “cure” of allergy.

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com Greg E. Sharon, M.D. Priya J. Bansal, M.D.

ORAL ALLERGY ORAL ALLERGY SYNDROME (POLLEN-FOOD ALLERGY SYNDROME) ollen-food allergy syndrome (OAS) describes allergic reactions, Sensitization to inhaled pollen proteins via the respiratory tract is limited to the mouth, tongue, lips and occasionally throat, which believed to be the initial event. The pollen-specific IgE generated by Poccur upon ingestion of certain fresh fruits, nuts, or vegetables by this mechanism then binds to the surface of mast cells and basophils individuals who are sensitized to plant pollens (Hay Fever). These throughout the body, including those in the mouth and throat. reactions are a form of localized allergy-mediated immediate hypersensitivity. The allergens in these foods are similar to plant Upon eating a related food, these allergic molecules recognize allergens leading to cross-reactivity. The symptoms of OAS result similar proteins in the food, triggering localized release of from contact urticaria, or hives, of the mouth and throat. inflammatory mediators and the symptoms of OAS. In most cases, the allergens are subsequently destroyed in the stomach, limiting any Symptoms are usually limited to the mouth and throat and are only further reaction. observed with raw forms of the food because the causative allergens are rapidly destroyed by cooking and digestion, although this is not uniformly true. Systemic reactions, as well as reactions to cooked foods, are observed in a small proportion of patients (~5-10%).

ALLERGY PLANT | CROSS REACTING FOOD

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com Greg E. Sharon, M.D. Priya J. Bansal, M.D.

PROBIOTICS he intestinal tract is host to groups of different bacteria, many of which are necessary for health but also can do great harm. TheseT small bacteria have the potential to affect the development of diseases by a variety of mechanisms. Changes in our intestinal lining may affect the barrier function which is what separates us from them. Changes in bacteria may trigger our bodies to start immune bacterial killing, which can lead to an inflammatory response. This inflammation means that healthy cells can take damage as an innocent bystander. Inflammation damages the barrier of our intestines, this leads to increased uptake of bacterial and food particles that stimulate the immune system. This can lead to , Atopic Dermatitis, Crohns disease or Ulcerative colitis. Probiotics are healthy microorganisms that have beneficial properties for us. Most commercial products are derived from food sources, especially cultured milk products. The list of such microorganisms continues to grow and includes strains of lactic acid bacilli (eg, Lactobacillus and Bifidobacterium), a nonpathogenic strain of E. coli (eg, E. coli Nissle 1917), Clostridium butyricum, Streptococcus salivarius, and HOWO D PROBIOTICS WORK? boulardii (a nonpathogenic strain of sold as Probiotics don’t allow growth or epithelial binding or invasion Florastor). by bad bacteria. Probiotics lead to improvement of intestinal barrier function making our GI tract healthier and more effective. Some Also under development are strains of bacteria that have been Lactobacillus strains appear to induce expression of micro-opioid genetically engineered to secrete immunomodulators (such as (pain pills) and cannabinoid receptors in intestinal epithelial cells interleukin-10 or trefoil factors), which have the potential to and help with an analgesic function in the gut in a manner similar favorably influence the immune system. More recently, the concept to the effects of morphine. Probiotics differ in their ability to resist of restoring levels of normal bacterial species that are diminished gastric acid and bile acids, colonize the intestinal tract, and influence in certain disorders, such as Crohn’s disease, has been developed. cytokines secreted by intestinal epithelial cells. Thus, not all probiotics Therapeutic benefit has also been seen in several disorders including are alike; as a result, benefits observed clinically with one species or the inflammatory bowel diseases, antibiotic-related diarrhea, a combination of species are not necessarily the same with another Clostridium difficile toxin-induced colitis, infectious diarrhea, hepatic . You may need to try several types and brands of Probiotic encephalopathy, irritable bowel syndrome, and allergy. to find one that agrees with you.

For Inflammatory Bowel disease we recommend: E.Cole 1917 Nissle, Lactobacillus GG or culturelle, Probiotics VSL#3 or Metagenics Ultra Flora IB. These have been shown to block cell activation and prevent destruction of epithelial cells. In the treatment and prevention of antibiotic-associated diarrhea we suggest Florastor. Several studies have evaluated a variety of probiotics in the treatment of infectious diarrhea and Culturelle was the best. However, for the prevention of traveler’s diarrhea they concluded that several products, including Saccharomyces boulardii (Florastor) and a combination of Lactobacillus acidophilus and Bifidobacterium bifidum worked well. In recovery from acute diarrhea in children VSL#3 significantly improved stool frequency. Probiotics generally do not have significant side effects but mild temporary changes in your bowels may be noted. If one type of Probiotic fails to give the desired effect try another one.

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com Greg E. Sharon, M.D. Priya J. Bansal, M.D.

VASOMOTOR RHINITIS VASOMOTOR RHINITIS asomotor Rhinitis is a disease of unknown causes more common with age. It can follow an increase in our weight, after head TREATMENT Vtrauma, after severe sinusitis, pregnancy or severe stress. It is usually associated with a loss of control of the nose’s function. The healthy A. AVOIDANCE nose will swell and secrete fluid in response to air that is dirty or very The home environment must be modified to avoid factors that cold. In vasomotor rhinitis, the nose swells and secretes mucus and initiate or exacerbate the rhinitis, e.g., smells, dust, fungi, insects, or fluid to minor irritations. Clear, runny, nasal congestion and postnasal cigarette smoke. Control of humidity and temperature can lessen drainage are the usual complaints. Irritating triggers can include: nasal instability or vasomotor hyperactivity. smoke, dust, sprays, smells, perfume, alcohol, chemicals, wind or a fan blowing in the face, rapid chilling or heating of the body, newsprint, B. MEDICATIONS and perfumes. This can presents with profuse, watery runny nose or 1. Irrigations with normal saline solutions using a bulb syringe or congestion in association with eating hot or spicy foods. Laying down commercial saline spray can help liquify mucus, moisturize mucosal increases nasal stuffiness, in contrast, exercise reverses nasal congestion surfaces, and wash away allergens. temporarily. Seventy percent develop the condition after age 20; by 2. Specific pharmacologic agents are usually required to control comparison, the onset of allergic rhinitis usually occurs before age 20. symptoms. As with acute allergic rhinitis, start with drugs with fewer The majority are female, with a reported predominance between 55 side effects and advance to additional agents if control is not achieved. and 71 percent. Usually symptoms are all year and without specific Intranasal steroids can be effective 50% of the time. I also use an anti- allergic triggers. irritant or antihistamine drug in a nasal spray that can give relief in up to 80% of the patients. Anti-cholinergics can also help.

C. EXERCISE Exercise can help reduce nasal obstruction by stimulating sympathetic nerve discharge, which produces vasoconstriction and lasts for 15-30 minutes. Weight loss can be crucial in some patients.

D. IMMUNOTHERAPY Allergy shots for allergic rhinitis may not be as effective as it is for acute seasonal allergic rhinitis if vasomotor rhinitis is also present.

E. SURGICAL TREATMENT Because breathing through each nostril normally alternates every 1 or 2 hours, a deviated septum can present additional complications to the patient with vasomotor rhinitis. Varying degrees of septal deviation occur in about one-third of all patients with rhinitis. Mild septal deviation without unilateral congestion need not seek surgical evaluation.

Chronic nonallergic rhinitis or vasomotor rhinitis is a persistent condition in the majority of patients. In one study, 180 patients with nonallergic rhinitis were reevaluated three to seven years after diagnosis. Fifty-two percent reported worsening symptoms over time.

303 East Army Trail Rd, Ste 403, Bloomingdale, IL 60108 • (630) 894-7083 • www.asthmaallergycenter.com