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Patient Handbook Questions

  How do we treat allergic diseases?

  • Avoid the allergen(s) - The most direct and effective treatment is   avoidance of the offending allergen or allergens. Although many allergens, cannot   be completely avoided, even a decreased exposure may be helpful. Furthermore,   avoidance of one allergen may increase tolerance of other, less easily avoided   allergens.
  • Medication - A variety of specific and effective medication is now available.   When taken in proper dosage according to a specific schedule, these medications   offer relief to a large number of allergic patients.
  • Specific Immunotherapy (allergy shots, desensitization): The only treatment   which modifies the underlying allergic inflammatory response and can alter the   natural history of allergy. Immunotherapy may improve allergy sx as well as   induce a tolerance to the specific allergens. This tolerance persists even after   immunotherapy is discontinued. Immunotherapy is considered when avoidance measures   and medications do not provide adequate relief.


  What is involved in an Allergy Evaluation?

We will conduct a thorough interview to examine your history of symptoms and conditions. After the interview the visit may include skin testing to evaluate for specific allergens that may be relevant to you. If you have breathing problems we may conduct a specialized lung function test called spirometry. We will then discuss these findings and outline with you a plan to address your condition and concerns.

  How do allergens cause allergic symptoms?

Allergic inpiduals have a genetic predilection to develop an allergic inflammatory   response on exposure to specific allergens in their environment or diet. This   includes production of allergic antibody (called immunoglobin E, or IgE). Subsequent   exposure to the same allergen results in binding of the allergen with the IgE   antibody found on cells in the skin, eyes, nose, sinuses, lungs and gut. This   triggers release of chemicals called mediators, such as histamine, from these   cells within the body. These mediators then cause the allergic symptoms seen   in allergic inpiduals. With ongoing stimulation a chronic inflammation occurs.

  What can cause or aggravate asthma and allergic conditions?

  • Airborne (inhalant) allergens
    • Pollens
    • Animal danders
    • Molds
    • Dust Mites
  • Infection – usually viral or the "common cold"
  • Exercise
  • Non-specific irritants
  • Cold air, tobacco smoke, strong odors or fumes, dust, newsprint
  • Medications
  • Insect stings
  • Foods

  What diseases and conditions may be caused or aggravated by Allergy?

  • Asthma or asthmatic bronchitis -  wheezing and coughing, shortness of breath, tight chest
  • Allergic rhinitis or hayfever – sneezing, itching of eyes and nose, nasal congestion
  • Urticaria (hives) and Angioedema (swelling)
  • Eczema
  • Intestinal allergy - diarrhea, vomiting, or cramps from foods
  • Recurrent respiratory infections, such as recurrent ear infections and sinusitis
  • Sinus headaches
  • Recurrent pneumonia or bronchitis
  • Insect sting reactions
  • Drug allergies
  • Food allergies
  • Generalized allergic reactions (anaphylaxis)

  Why an Allergist?

If you have an allergic condition, it means that your immune system responds to certain substances or situations with an allergic inflammatory response rather than the normal response seen in the population without allergy. Allergic symptoms may result from exposure to pollens, animal danders, insect stings, foods, drugs, as well as other allergens. This response may result in conditions affecting your eyes, nose, sinuses, skin, and lungs.  An Allergist is uniquely trained to evaluate and treat both the underlying conditions and identify the triggers aggravating or causing them.

General

  Should immunization be any different for the allergic child?

Smallpox vaccination is no longer recommended. It did cause serious problems in some children with eczema. Measles, mumps, and rubella vaccines are grown in chicken tissue, and were avoided in egg sensitive individuals. Now we realize that the amount of egg in these vaccines is to small to produce a reaction and can be given to individuals who are egg-sensitive. Influenza vaccines, and several others are grown on egg protein and should not be given to individuals who are highly sensitive to egg. Please consult your physician before administration of any of these vaccines.

  Should exercise be avoided if it produces or aggravates wheezing or coughing?

No. Many people with asthma have some wheezing with exercise. The amount of difficulty varies with the inpidual and the duration of exercise. This "exercise-induced bronchospasm," is generally prevented by the use of medication before anticipated exercise. Conditioning may also play some role. Specific medicines for this problem should be reviewed with us to avoid unnecessary restriction of physical activity.

  Are there any medications which make allergy problems worse?

"Beta-blocking" agents, such as those used to control high blood   pressure, can aggravate asthma, and potentiate allergic reactions. Please tell   us all the medications you are taking so that we can be certain there are no  issues.

  Should aspirin be avoided by people with allergies?

Aspirin can cause reactions in some people, including asthmas, hives, and nasal   congestion. Aspirin should be avoided if there is any suspicion that symptoms   are aggravated by this medication. Many aspirin substitutes (e.g., ibuprofen)   can cause similar reactions, and should also be avoided in aspirin-sensitive individuals.

  Why do such things as perfumes, strong odors, and aerosol sprays seem to cause "allergic" symptoms"

Most people with allergies have unusually sensitive airways. Factors that may   cause only mild irritation in non-allergic people can cause a great deal of   aggravation and discomfort in those with allergies, and can actually reproduce   their allergic symptoms. Avoidance of these irritants is the best treatment,   but good control of the underlying allergy may improve tolerance.

  Do people outgrow their allergies?

The allergic diseases, especially in children, tend to eventually become more   easily controlled, or even seem to be "outgrown" or dormant. This   may take years, however, so that allergy treatment may be necessary for prolonged   periods. Asthma may occur in childhood, resolve, then recur as an older adult.

  Are Allergies inherited?

The allergic tendency is inherited but the mechanism is not as yet well-defined.   The stronger the family history of allergy, the more likely it will be that   other family members will be allergic.

Treatment of Allergic Disease

  Will a humidifier help?

Humidification of the air, especially in the winter, will sometimes help the   allergic patient. However, some patients are made worse by humidification if   excessive, particularly those who are mold or mite sensitive. Ideal humidity   for respiration is 25-50%

  Will a fan help my allergy?

Fans potentially make respiratory allergies worse. Anything which circulates   air and allergy particles without filtering tends to make allergy sufferers   have more trouble. This same principle applies to riding around in open cars   in pollen season, walking in fields or wood on dry, windy days, etc.

Allergy Shots

  How effective are allergy injections?

The amount of relief depends in part upon the disease being treated, the age   of the patient, and the allergen involved. Most patients do derive significant   relief from their symptoms and some become completely free of symptoms. Unfortunately,   a few patients derive no benefit and other means of therapy must be found.

  Are there any side effects of allergy immunotherapy?

Since the shots contain materials to which the patients is allergic, it is   possible to produce allergic symptoms with the injections. Many patients experience   short term itching or swelling at the injection site. Taking an antihistamine   on the day of the injection can minimize this reaction. Rarely hives, trouble   breathing, or a generalized allergic reaction may occur. A reaction is more   common if the injection is given in a setting of active asthma symptoms. Always   report any breathing difficulties before receiving allergy immunotherapy. A   30 minute observation period following an allergy injection is necessary so   that in the unlikely event of a reaction it can be treated promptly.

  How long must the shots be continued?

This varies with the allergy being treated and the response of the patient.   In general, patients require injections at regular intervals for three to five   years. This will vary with the allergies being treated, and the response of   the patient.

  Must the injections be given regularly?

Since development of tolerance is a slow process, and since very low doses   of the allergenic substances must be used at the start, the injections should   be given at the prescribed intervals. If injections are given irregularly, control   of symptoms may be reduced or delayed, and risk of allergic reactions to the   injections is increased.

  How often must injections be given?

In general, allergy shots are given at intervals which can be as often as twice   a week, to as little as once a month. Most schedules require injections once   or twice a week at the start, until the desired maintenance dose is achieved, then extending to monthly for the duration of therapy.

  What is the allergy shot?

Allergy injections contain small amounts of the substances (allergens) to which   the particular patients is allergic. Allergy injections may be prescribed for   stinging insects, pollens, mites, molds and animal danders. Food allergy cannot   be treated with allergy immunotherapy.

  Does it "cure" the allergy?

No, but a tolerance is induced which can be long lasting, even after the injections   are discontinued.

  What is allergy immunotherapy?

A series of injections to the allergens to which the patient is allergic, a   tolerance to these allergens is gradually build up so that exposure to the allergen   can occur without developing the same degree of allergic symptoms.

Skin Testing

  How accurate is skin testing?

In general, skin test results correlate very well with clinical sensitivity.   As is true in all of medicine, however, there are some patients who do not follow   the rule, and correlation with the clinical history is, therefore, a very important   part of allergy evaluation.

  How is skin testing done?

In this office, two methods are generally used. A majority of tests are done   by "prick" method. Drops of the skin test material are applied in   rows across the back as tiny pricks are made through each drop, pressing the   allergen into the skin. Results are usually read in 10 to 20 minutes. Also,   some "intradermal" tests are may done. These involve a small injection   into the superficial layers of the skin of the arm. "Patch" tests   are used to identify materials causing skin reactions on contact. Small amounts   of these materials or gauze patches are taped on the skin and left for 48 to   72 hours before being read.

  What is "skin testing"?

Skin testing is performed to detect the presence of allergic antibody to an   allergen by introducing the allergen to the allergy cells in the area of the   back or arm. If allergic antibody is present, a small wheal and flare (hive)   will occur at the skin test site.

Specific Allergens

  Urticaria

Urticaria (hives) are itchy welts which can occur anywhere on the skin. Acute   hives can be due to an allergic reaction to any of a variety of agents (foods,   infections, drugs, insect stings, allergy injections, etc.). They may also be   of non-allergic origin.

Hives can also become a more chronic problem and often are not due to allergy.   An exact cause may remain undetermined in spite of extensive investigations.   Even then, it is usually possible to control symptoms with medications.

  Eczema

There are allergic inflammatory cells which are permanent residents in the   skin, and this leads to the chronic dry itchy red skin seen in eczema. Routine   treatment to minimize further inflammation is necessary to control the symptoms.

Swimming and bathing are useful to reduce the bacterial burden found in eczematous   skin. However this does tend to dry out the skin. Therefore bathing should be   followed immediately by lubrication. Creams or ointment are preferable to lotions.   Children's faces may be irritated by wiping with a damp cloth after meals.   To avoid this, vaseline can be applied to the child's face before meals.   The food can then be easily removed after meals without using soap and water.

Overheating and sweating can cause itching. Clothing should be selected which   will not cause overheating. For the same reason, nylon leotards and sneakers   or rubber packs should not be worn for long intervals. Wool is very irritating   and should not be worn next to the skin. Cotton or soft corduroy are good materials   to select.

Skin testing may reveal food and other sensitivities which contribute to the   inflammation underlying eczema. Topical steroid creams or ointments, and some   non steroidal anti-inflammatory agents (elidel, protopic) used on the skin help   control the eczema by decreasing inflammation and controlling infection.

There is no question that much effort and continuing care are required to help   the patient with eczema, but the results can be gratifying and long-lasting.

  Stinging Insects

The venom of yellow jackets, hornets, honeybees, and wasps is a very potent   allergen and can cause serious allergic reactions in sensitized inpiduals.   Inpiduals who have had an allergic reaction to a sting should be evaluated   by an allergist for consideration of allergy testing and immunotherapy. Immunotherapy   for stinging insects is highly successful in preventing serious allergic reaction   on subsequent stings.

  Pets in the home

Indoor warm blooded pets are frequent allergens. Efforts to reduce dander levels   while the pet remains in the home are uniformly unsuccessful. Many products   are marketed with claims they will help a patients allergies; but the only proven   effective means to reduce allergen levels below those which trigger allergic   inflammatory responses is to remove the animal from the home environment. Preventing   the animal from entering the bedroom area, use of HEPA filters, removing carpeting,   and "mite control" measures may be of some limited benefit.

  Molds

Molds are fungi. They produce seeds, or spores, which are even smaller than   pollen and are found in the air in large numbers at certain times of the year.   For most inpiduals outdoor molds are the primary source of mold problems.

Outdoors they are abundant in soil, grass, dead leaves, haystacks, barns, and   stables. Indoors, they are prevalent in areas with moisture. They are responsible   for the familiar musty smell noticeable in such places. Areas of visible mold   or areas with flooding are the most problematic.

It is quite difficult to eliminate molds from the home environment. Special   attention to ventilation and drainage may help decrease indoor molds.

  Dust Mites

Dust mites are a major part of household dust in most homes in our climate.   They live on human dander and are therefore found largely in areas where dander   accumulates. This includes bedding (mattresses, pillows, blankets, and carpets   in bedrooms). It is very important therefore to cover mattresses, and pillows   with dust proof, air tight encasings. These covers should be cleaned with a   damp sponge with each bedding change. All bedding should be laundered in hot   (rather than warm or cold) water to remove dust mites. Comforters or quilts   that are not easily laundered are therefore not recommended.

  House Dust

Ordinary house dust represents one of the most troublesome materials to which   allergic patients are exposed. House dust is made up of many tiny organic and   inorganic particles. These organic particles may include house dust mites, animal   and human danders, pollens, and molds. Therefore, house dust control is an important   part of the overall treatment of many allergic people. Since a person spends   more time breathing the air of his bedroom than of any other room–in fact   one-half of his time in childhood-the focus centers largely in the bedroom.

General Info. for Allergy Patients

  Insurance and Billing

  • The Business Office is available on Monday, Tuesday, Wednesday and Thursday to assist patients with insurance and billing questions or problems.  We are closed on Friday.  We encourage patients to speak directly with their insurance company for questions specific to their policy.
  • Our office participates and accepts assignment with the following  insurance companies. Blue Cross/Blue Shield of Vermont,  Vermont Managed Care, CIGNA , Medicare, MVP, Catamount Health Plan, One Health Plan, CBA, Vermont Medicaid and New York Medicaid.  We ask all patients to contact their insurance company before receiving services in our office to be sure that the services will be covered. 
  • If you have coverage with an insurance company that was not listed  above, we will be happy to submit the claim to your insurance company, however, you will be responsible for full payment to our office.  Please be prepared to pay on the day of the visit. Any problems that arise with your claim should be taken up directly with your   insurance company.   
  • If your insurance requires a referral, it is the patient's responsibility to obtain a referral before each appointment from their primary care physician. Please stop in the Business Office to confirm a referral is in place for allergy vaccines and injections as well as office visits.
  • All patients covered under any Medical Assistance Program (Medicaid)  should present their Medicaid Card in the Business Office for each appointment including patients receiving allergy injections in our office.   In the event your Medicaid coverage expires, please notify our Business Office  immediately (802)863-4887.
  • All patients should be prepared to pay their copayments on the day of the visit.  Patients on allergy immunotherapy should be prepared to pay their copayment, coinsurance and/or deductible balances on the day of the injection.

  Primary Medical care

We encourage all our patients to initiate or continue care with a primary care   physician (pediatric, family physician, internist). Your medical care, including   that involving allergic problems, will best be coordinated in this fashion.

A summary of your allergy evaluation and our specific recommendations will   be sent to your physician. You should therefore, contact your personal physician   for any ongoing care (medications, prescriptions, etc.) and for treatment of   any immediate problems.

  Medications containing antihistamines

Medications containing antihistamines can suppress skin tests reactions.   Antihistamines are present in many cold remedies, allergy medicines, and motion sickness pills. Most antihistamines must be stopped at least forty-eight to seventy-two hours prior to skin testing. Some antidepressants also have anti   histamine activity and may interfere with skin tests. If you cannot go without   these medications, or question whether or not your particular medication should   be stopped, check with your doctor or have them call our office.

~Common Antihistamine Medications : Discontinue 7 days before skin testing
~Fexofenadine (Allegra Hydroxyzine (Atarax)
~Loratidine (Claritin, Alavert)
~Chlorpheniramine (Chlortrimaton)
~Cetirizine (Zyrtec)
~Diphenhydramine (Benadryl)
~Desloratidine (Clarinex)

ASTHMA MEDICATIONS SHOULD BE CONTINUED
 
Aspirin, prednisone, inhaled steroids, bronchodilators, and most other medications   – including allergy shots – do not interfere with allergy test results,   and can be continued.

  • Unless otherwise stated, allergy patients on injection therapy should   be re-evaluated every six to twelve months.
  • Allergy solutions for injection therapy will be mailed directly to your physicians office.  Dosage schedules and instructions are included with the solutions.

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