What do seasonal allergies look like? 

Symptoms include sneezing, nasal discharge, cough, congestion, itchy eyes, watery eyes, red eyes, throat pain, and throat itching, to name a few. Symptoms may also include poor sleep, malaise, mouth betaking, snoring, nocturnal cough, and poor school performance. 

Besides that, these symptoms are uncomfortable. Allergic rhinitis can cause poor sleep, leading to school performance problems. Additional chronic cough may lead to facial change and malocclusions. 

What are the mainstays of allergy treatment? 

1. Avoidance
2. Medications 
3. Immunotherapy 

First-line therapy is really now considered to be an intranasal steroid spray. They have been safely used in the long term to manage allergic rhinitis. Topical nasal antihistamines are approved for use in children >6 months. Combination nasal histamines & steroids are more efficacious than either on its own. 

The second line is adding either a second-generation antihistamine or an intranasal steroid spray. First-generation antihistamines are more sedating and equally efficacious for allergenic rhinitis as second-generation. 

First Generation: (used to treat eczema)

• Benadryl (diphenhydramine) 
• Hydroxyzine 

Second generation: 

• Loratadine (Claritin) – the weakest 
• Cetirizine (Zyrtec) 
• Fexofenadine (Allegra) – least sedating 

Before moving to the third line, consider switching between brands of second-generation antihistamines and intranasal steroids. For reasons we do not yet know, some patients respond better to one over the other. 

The third line is the addition of leukotriene modifies (Montelukast). Guidelines suggest using intranasal stewards first, as Montelukast is less effective (Dykewicz et al., 2017). It is worth noting that the FDA put a black fox for serious mental health side effects on Montelukast for suicidal ideations or actions. They are recommending that montelukast should only be used for allergic rhinitis in patients who have an inadequate response or intolerance to alternative therapies.

Do you need to use these medications every day?

No, there is evidence to support that fluticasone nasal spray works about as well, used as needed versus regularly after 1 week of regular use.

What if you are on multiple medications and still have symptoms? 

Immunotherapy, which includes subcutaneous or sublingual immunotherapy, maybe the best option. 

How do they work?

Typically an allergen enters through the nose and then travels to the Lower respiratory tract, eventually leading to an increase in the immune cells IgE, which cause mast cells to release something called histamines. Histamines cause swelling, itching, and increased secretions. 

With allergy shots, a higher antigen dose is given under the skin to an antigen-presenting cell, which leads to the production of IgG4 and T Regs that down-regulate (decrease) IgE and, therefore, mast cell histamine release.

Can I use sublingual instead of shots? 

Sublingual-only FDA forms approved are for ragweed, grasses, and dust mites. Peanut allergy trials are ongoing. So if you have allergies ONLY to these things, then sublingual may be an option. They are dissolvable tablets you give under the mouth once a day at home. Allergy shots are slightly more effective than sublingual therapy. 

What do allergy shots work for? 

The shots work best for insect stings, pollen, dust mites, and pet dander 

Note on pet dander and hypoallergenic breeds – no research to confirm allergy comes from animal fur but rather from salvia, skin, and urine. 

Are there any Risks? 

Risks include allergic reactions. Life-threatening allergic reactions have occurred, mainly in those with unstable asthma. 

What can you expect with allergy shots? What is the process? 

First, either the allergist/immunologist or I will order either skin or blood testing. Skin is slightly more sensitive. Then the allergist/immunologist will develop a shot or shots depending on your allergies. They are administered using a very small needle. The shots must be given in the physician’s office, and you must stay for up to an hour after to monitor for allergic reactions so the physician can treat them if they develop. 

Sessions start weekly and then monthly. Usually, 30 weekly sessions, then maintenance (monthly) for 3-5 years.

Do the shots work? 

This type of immunotherapy is effective in 80-85% of patients. It also may reduce de-novo (new) allergies as well as asthma. 

Compared with 14% at the start of the study. No moderate or severe adverse events were reported.

References: 

1. PMID 28441993.
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5. Protocols for drug allergy desensitization in children. Diaferio L, et al. Expert Rev Clin Immunol. 2020 Jan;16(1):91-100. doi: 10.1080/1744666X.2019.1698294. Epub 2019 Dec 8.PMID: 31771366
6. EAACI Allergen Immunotherapy User’s Guide.Alvaro-Lozano M, et al. Pediatr Allergy Immunol. 2020 May;31 Suppl 25(Suppl 25):1-101. doi: 10.1111/pai.13189. PMID: 32436290
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8. Allergen Immunotherapy in Young Children.Phomakay V et al.  Allergy Asthma Rep. 2022 Aug;22(8):93-99. doi: 10.1007/s11882-022-01035-0. Epub 2022 Apr 25. PMID: 35467180