Ashley Tromblay, PA-C, EVMS ENT Allergy Division, presents an overview of allergic rhinitis, when a PCP should refer for additional treatment, and the services that EVMS Allergy has to offer.
Yeah. So thank you everyone for coming today. Um, and joining me for this presentation and we'll get started. Um, I'm gonna go over uh just a basic overview of allergic rhinitis. Discuss when to consider making a referral as well as go over the allergy services that we offer here at E V MS. So what are allergies? They're an abnormal reaction to an ordinarily harmless substance called an allergen. And patients can be allergic to one or multiple allergens. The most common inhaled allergens are pollens from trees, grasses and weeds as well as molds, cockroaches, dust mites and pet dander and us living in Virginia. Uh, we're unique because we have all of these allergens here with us. Um, whereas in other parts of the world or other parts of the country, um, different allergens may be more predominant than others. But for here, for us here, this is a, a big issue and, and uh, allergies are, are tough for some of our allergy patients. We'll talk about the burden of allergic rhinitis. It affects 10 to 30% of adults and up to 40% of Children worldwide and the prevalence is only increasing. Uh, the impact on quality of life. Patients are losing work days, they're losing school days, they're just not being productive due to their symptom burden. Um And it's also a high cost to individuals in society. It's estimated to be greater than $7 billion in direct costs and greater than $4 billion in indirect costs in the United States each year. So, going over the path of physiology, it's an I G E mediated reaction to an inhaled allergen. The allergen interacts with I G E on the surface of the mast cell and triggers degranulation in the early phases. It releases histamine and we get that sneezing, runny nose symptoms. Whereas in the late phases, it releases the academic acid metabolites, inducing congestion and tissue E S N OS also contribute to the local inflammation and damage. So we're all familiar with the common allergy symptoms. The sneezing, runny nose congestion, itchy nose, postnasal drainage, cough, itchy, watery eyes fatigue. But as providers, it's important for us to differentiate for our patients. Um things like allergies versus the common cold. So both have runny nose, stuffy nose, sneezing, cough fatigue. Whereas the allergies, you're gonna see more of the itchy, watery eyes, itchy nose ears or throat and the symptoms last longer usually goes through a season or multiple seasons or even year round depending on what the patient is allergic to. Whereas with the common cold, they generally have fever chills, body aches, sore, scratchy throat and the symptoms usually resolve within a week or two snow will go over like what antigens or allergens are contributing to seasonal versus um perennial. Um, symptoms. Generally speaking, trees pollinate in the spring grasses in the summer and weeds in the fall. So these are the big things that contribute to those seasonal symptoms that we see. Whereas dust mites, animal dander cockroaches and molds contribute to more of the year round symptoms. And patients can have any combination of these. They could have dust mite and tree allergy where they kind of have symptoms all year long, but they get worse in the springtime. And this just kind of gives us a guide to, you know, correlate with the patient's history. What we think that they might be allergic to the diagnosis of allergic rhinitis is a clinical diagnosis. It's based on the presence of characteristic symptoms and a suggestive clinical history like seasonality duration or symptoms after exposure to animals or dust or something like that. Um And it's also with supportive findings on physical exam like allergic stranding or the swollen nasal mucosa treatment of allergic rhinitis. We do avoidance and environmental controls and it can be helpful to have the allergy testing results to help guide this. Um, we also have pharmacotherapy and immunotherapy and we'll go into these. So for avoidance and environmental controls, patients who are allergic to dust mites, it's important for us to remind them to keep the humidity down make sure they're washing their bedding on a weekly basis in hot water, using covers for their pillows and mattresses. Regular vacuuming with HEPA filters. Patients with cockroach allergies. It's making sure that we clean the reservoirs of cockroach contaminants and then get pest management involved when needed, um, allergies to pets. Although we all love to have our pets in our bedrooms with us and, and everywhere we go, um, it's really important for patients with allergies to pets to keep them out of their bedroom. They wanna keep washing their pets and vacuuming using the HEPA filters. And again, the covers for the pillows and mattresses can be helpful for patients with mold allergies. Um, it's reducing the indoor moisture with good ventilation and considering maybe a dehumidifier, cleaning any hard surfaces with a disinfectant that are affected and also removing affected upholstered furniture, carpets or rugs. And for patients who come in and they say, you know, each year I get symptoms in the spring, summer or fall, we want to remind these patients that even though it's nice outside and they're may be tempted to open up all the windows in their house. They really want to keep the windows closed. Otherwise they're allowing the pollen into their home, which can exacerbate their symptoms. So now moving on to pharmacotherapy, I've kind of listed these here in order of efficacy for the treatment of allergic rhinitis. So, intranasal corticosteroids have been found to be most efficacious for the treatment of allergic rhinitis, followed by the intranasal antihistamines like Astin or Alaine. And then finally, the oral antihistamines and I will say that the nasal saline irrigations and sprays can be really beneficial for patients for just routine nasal hygiene. It helps to remove any mucus or pollen or any inhaled allergens from the nasal cavity and it helps prime the nose so that we can then apply the intranasal medicated medications into their nose and it can then get to where it really needs to go. I also made a note down here about the oral leuco trine antagonist. So that's your Monte Lou cast or singular. It is not recommended for the treatment of allergic rhinitis. It may have some benefit in a subset of patients who have both asthma and allergic rhinitis, but it is not routinely used for the treatment of allergic rhinitis. We created this very basic clinical care pathway that just says in a primary care setting, you know, you're having the patients come in and you're making a clinical diagnosis of allergic rhinitis, you're treating the patients with appropriate pharmacotherapy and then if their symptoms are well controlled, that's great. And they can just continue with pharmacotherapy if their symptoms are not well controlled or they're not tolerating their medications or maybe they don't just don't wanna be on long term allergy medications. These are patients that you may consider a referral um for further allergy evaluation. So this is our team here at E V MS. We work in the E N T department and we work with the allergy patients. Um You heard from Doctor Ha earlier in this presentation, we also have Doctor Lam, Doctor Schroeder and myself, we offer allergy testing, both skin prick testing and immunoassay testing through the blood. And we also do immunotherapy with subcutaneous immunotherapy being the allergy shots and the sublingual immunotherapy. And then I'm also gonna talk to you about fractional exhaled nitric oxide testing, uh which is another service that we offer here. But I'm gonna go into each of these in more detail in the upcoming slides. So for allergy testing, we generally do the skin prick testing. Both uh both the skin prick testing and amino Asay testing have similar efficacy. But with the skin prick testing, it's done in the office, you get the results back quickly. They're done in 20 minutes, you get more antigens. We're currently, I think 39 I believe going to 40 antigens. Um and it costs less the caveat to this is that the patient has to stop all antihistamines seven days prior to testing. So for patients who can't tolerate coming off their antihistamine or maybe patients with dermagraphism who can't do the skin prick testing. These are patients that we would then send for immunoassay testing. It's done through a blood draw at the lab. The results are back within a week. Usually, um you get less antigens. Their panel is 24 antigens. Um And it's more expensive, but we don't have to have them stop their antihistamine. So this can be beneficial for some patients. So how are the allergy test results helpful? Um Knowing what the patient is allergic to, allows us to better tailor avoidance and environmental control measures. It also allows us to make a personalized treatment plan for each individual patient coming into our office. It also helps determine if a patient would be a good candidate for immunotherapy and guide which type of immunotherapy that the patient might benefit from. So allergen specific immunotherapy is repeated administration of allergens to provide protection against I G E mediated disease. It results in immunologic changes such as regulatory T lymphocytes. A shift from type two to type one immunity and eventually a reduction in specific I G E levels. It's an effective therapy for both adults and Children with allergic rhinitis. And we have two FDA approved forms of, of treatment and that's through the allergy shots and the sublingual tablets. So who's a good candidate for immunotherapy and who might not be such a good candidate for immunotherapy? Um, good candidates are patients with known positive allergy testing to clinically relevant allergens. Um Generally patients whose symptoms are not adequately controlled by medications and avoidance measures or maybe they're just experiencing adverse effects from their allergy medications or they're just not tolerating them well, um, or they don't wanna be on their allergy medications. Long term. These are all patients who, who might benefit from immunotherapy. Um, as far as poor candidates for immunotherapy, um, this includes poorly controlled asthmatics. Um, asthma is a increased risk factor for having an anaphylactic reaction. Um, so we would send these patients back to their primary care pulmonologist or whoever's managing their asthma to get their asthma under better control prior to starting immunotherapy. The next group that we'll talk about is beta blockers. So beta blockers are a risk factor for more serious and treatment resistant anaphylaxis and they make the treatment of anaphylaxis with epinephrine more difficult. So if a patient is on a beta blocker, just for routine hypertension, we may have them go back and talk with their primary care and see if maybe they can be switched to another antihypertensive medication. But for patients who need to be on a beta blocker for some other medical condition, um they may not be the best candidate for immunotherapy, but we can always talk about and weigh the risks and benefits with the patient and, and decide from there and then finally pregnancy. So if a patient is on maintenance therapy of their allergy shots, um they can continue and they become pregnant, then they can continue with their, their allergy shots and safely. But we do not start pregnant patients on immunotherapy and we don't escalate immunotherapy for patients who are pregnant. So these patients are always welcome to come back and discuss options for immunotherapy after they've delivered their babies. Now, we're kind of gonna go through the two types of immunotherapy a little bit more. Both usually have a duration of 3 to 5 years. Um, with the allergy shots, there is a build-up phase where the patient is required to come into the office on a weekly basis for their injections. Um, and they, each week they go up in a dose and then and up in concentrations until they reach their maintenance dose, it can take about a year to a year and a half for the patient to reach maintenance. So it is a big commitment for patients. They have to be willing to adhere to the schedule and, and get these weekly injections. Um once they do reach maintenance, we slowly space them out every two weeks, every three weeks and then monthly thereafter and they continue monthly injections for the remainder of their treatment period. The benefit to the subcutaneous immunotherapy is that we can include multiple allergens into the patient's files. So we use the patient's allergy test results, their clinical history and known cross reactivity to formulate a personalized prescription for each individual patient undergoing subcutaneous immunotherapy. For sublingual immunotherapy, there is no escalation dose. So the dose the patient takes on day one is the same dose that they take throughout the remainder of their treatment period. Um The first dose is taken in the office under observation and as long as they tolerate it fine, they can take the remainder of the doses at home. It's taken on a daily basis. The caveat to this type of uh immunotherapy is that it treats a specific allergen. So we currently have three FDA approved um tablets and they are odactra which treats house dust, mites Gras Tech, which treats Timothy grass and rag weech, which treats ragweed. But so in order for a patient to qualify for this, they would have to show that they were allergic to one of these um allergens. And I put in a slide here on pheno testing, which is the fractional exhaled nitric oxide. We're one of the only sites in the area that offer pheno testing. The next closest would be Duke. The test is done in the office. It's very quick. It just takes a few minutes. It's not covered by insurance. So it is a $35 fee collected on the date of service. Um The patient is instructed to slowly and steadily breathe into the mouthpiece attached to the machine and it measures the level of nitric oxide gas exhaled in a sample of the patient's breath. Pheno is a biomarker for airway inflammation and it's used to measure the level of airway inflammation in the patient's lungs. The table here is put out by the American Thoracic Society and these are their defined um pheno cut-off points which we use to help interpret the patient's results. So if they're an adult and they're less than 25 then it's unlikely that they have type two inflammation. Whereas if they're in the 25 to 50 range, it's possible. And if they're in the high range over 50 then it's likely that they do have this inflammation. People are still trying to understand the full application of pheno testing. But what it can do is it helps support the diagnosis of asthma. It tells us the likelihood that a patient will respond to inhaled cortico steroids. Um And so for that, someone who has a high pheno, we would expect to respond well, whereas someone with a low pheno may not respond as well to the inhaled corticosteroids. Um and then it also helps us to tell if a patient is adhering to the use of their inhaled corticosteroids because um inhaled corticosteroids, reduce the level of the pheno levels. So we can kind of monitor that and see how they're doing with the use of their medications. So this is just another service that we offer here at E B MS. And I wanted to make you all aware of. This is just a summary slide again, just quickly summarizing the different services that we offer here at E V MS. And then we do have two locations. We're located in the River Pavilion at Norfolk General, as well as at this entire Princess Ann campus. We have uh these are the addresses for each location and then the contact information for both. And I really just want to thank you all for kind of taking the time out of your day to listen to this lecture. I know it's lunchtime and everyone's busy. But I do appreciate you taking the time to listen to this presentation. I hope you found it helpful and informative and please feel free to email me with any questions. I've left my email here for you.
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