Immunise yourself against allergens

SINGAPORE - Recently, I saw the youngest of three brothers with allergic rhinitis (AR).

Before seeing me, they had received intranasal steroids and antihistamines - first-line conventional medication for AR.

For the two older brothers, the symptoms were still present and they had given up on the medication.

The youngest brother had not even tried the medication long enough for it to work.

There are two issues at play here. The first is for patients to have an understanding of the important aspects of the medication. Someone had to explain and ensure that the rest of the family understood too.

The second issue is the treatment itself. Conventional pharmacotherapy (drugs) is often used for AR. This comprises oral medication and intranasal steroids. In addition, taking measures to avoid dust mites can help.

Allergen immunotherapy - a treatment which desensitises the body to an allergen over time - is another effective treatment option.

It involves giving the patient the allergens which cause the medical problem, starting with tiny doses and slowly increasing the doses over time.

Immunotherapy alters the body's response to the allergens to ease the symptoms and inflammation.

This method can reduce the need for standard medication as well.

Two of the brothers also had asthma, which made adequate treatment of AR all the more important.

Therefore, I suggested allergen immunotherapy for the brothers.

After undergoing skin-prick tests, all three of them were started on immunotherapy using extracts of house dust mites.

Benefits of immunotherapy

Benefits of immunotherapy

Immunotherapy holds several advantages over conventional pharmacotherapy.

Firstly, its beneficial effects may last long after the treatment is stopped. A study showed that the benefits lasted seven to eight years after stopping immunotherapy.

Pharmacotherapy wears off within hours, at most a few weeks, after stopping the treatment.

Another advantage is, if conventional pharmacotherapy fails to control the symptoms, immunotherapy can be added to the treatment regimen.

The third advantage is long-term cost-effectiveness. The time and financial commitment during the treatment period is considerable and these factors usually cause many patients to recoil from immunotherapy.

But going the traditional route - which requires regular doctor's visits and medication - may end up being even more time-consuming and costly, especially as AR can last several years and often for life.

However, immunotherapy requires patience. The patient must complete the treatment course to enjoy its full benefits.

It also takes a longer time to work, compared with intranasal steroids and antihistamines. Many patients see a significant response only after three to six months.

For this reason, conventional treatment, including dust-mite avoidance measures, often needs to continue while a person undergoes immunotherapy.

It seems counter-productive to avoid dust mites while also administering dust mites via immunotherapy at the same time.

Don't sneeze at the condition

However, the amount of dust mites administered during immunotherapy, especially in the initial stages, is very small, and is aimed at altering the body's response to dust mites.

Avoiding dust mites in one's environment is still required because items, such as bedding, contain far more dust than the amount in immunotherapy vials.

This amount of dust exposure will worsen symptoms in people with AR.

In Singapore, immunotherapy is available at various allergy specialist clinics for adults and children.

In the paediatric allergy clinics at National University Hospital, sublingual immunotherapy - the administration of an allergen via a spray into the mouth - is an option for AR, especially for those who find that conventional medication is not enough.

Don't sneeze at the condition

Not only is AR often undiagnosed, it is also frequently under-treated.

About half of the patients suffering from it self-medicate and among the remainder who see a doctor, many end up skipping their medication.

People often trivialise AR but, unfortunately, the condition is not something to be sneezed at.

Under-treatment is a great concern, especially in those with other medical problems which are caused or worsened by AR.

For instance, 60 to 85 per cent of patients with allergic asthma (including children below two years of age) have AR as well.

In these cases, good control of AR symptoms is important in managing the underlying asthma.

Patients have several reasons for not taking their medication.

Fears, myths and unaddressed expectations account for the majority.

Common myths and fears

Common myths and fears

The most common myth is that intranasal steroids have severe side effects which can affect the rest of the body.

Another common fear is that one may become addicted or dependent on the medication.

Again, this fear is unwarranted. The medication is neither addictive nor does it induce dependence.

A third barrier is the expectation that the medication will work instantly. This, unfortunately, does not hold true for intranasal steroids.

Many patients have to use it daily for one to two weeks before they start to see any improvement.

Patients who see me for the first time often say they stopped using intranasal steroids because they did not work after one to two days.

Due to the reasons listed above, half of my consultation time with each patient is often spent explaining the medication, dispelling myths and fears, and emphasising exactly how long it takes for the medication to work.

In this day and age, with so many types of medicine and conflicting (or false) sources of information

online, the role of good, clear communication by the doctor is more essential than ever in patient care.

jian_yi_soh@nuhs.edu.sg

Dr Soh is an associate consultant at the division of paediatric allergy, immunology and rheumatology at National University Hospital.

This article was first published on MONTH DAY, 2014.
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