Jul 24, 2020

Transcript

Interviewer: You've tried the sprays and the pills for your seasonal allergies, but they just don't seem to work. So what are the next steps to finding allergy relief?

Dr. Gretchen Mae Oakley is a nose and sinus expert at U of U Health. She's really good with allergies too. So in our previous conversation with Dr. Oakley, we talked about managing those symptoms with prescription and over-the-counter sprays and other medications. If you haven't listened to that podcast, be sure to check that out first. But Dr. Oakley, if those sprays and pills aren't working, what are the next steps that you would take with a patient?

Dr. Oakley: The main next step that we generally talk about with patients is allergy testing, and that is identifying what the patient is specifically allergic to or the things, you know, they're specifically allergic to. And the goal behind doing that allergy testing and the reason we don't necessarily do that upfront is because the main goal is kind of a step towards the immunotherapy option. And this is a treatment for allergies that can be very effective for a lot of patients who, you know, are still struggling after medical therapy. And the idea behind it is basically desensitizing your immune system to the allergies, so it's less reactive to that allergen or those allergens.

Interviewer: And it seems like most people I talked to that have allergies, they'll be like, "Oh, I need to go get my allergies tested." In their mind, it's the first thing that you do. Do you find that to be common?

Dr. Oakley: I do. Yeah. I get that question actually a lot, "Should I be allergy tested?" And it's certainly satisfies our curiosity in many cases of, you know, what we're allergic to, but it doesn't necessarily change the treatment if we haven't done those medical management steps yet, because if, you know, whether you're allergic to this specific pollen or that specific, you know, weed, or this tree, or that grass, you're still going to be using those as, you know, your earlier steps. You're still going to be using, you know, those nasal steroids sprays first or the oral antihistamines first and the antihistamine sprays first, because that has, you know, a broader effect, you know, on all of those.

So that's what we generally don't do that upfront, because it doesn't necessarily change our first couple steps and, you know, the treatment. But it does affect, you know, our later steps. If we're thinking of immunotherapy, we need to know what we're specifically treating for that to work. And so that's kind of where it comes in and the point behind the testing, you know, at that stage generally.

Interviewer: Yeah, so your patients that you take at that point to the testing stage, I'd imagine they're just not finding any sort of relief from the first steps, or their allergies are just so terrible. I mean, what kind of patient then makes it to the testing stage usually? You're able to . . . I would imagine the medical things that you do first, the sprays and the pills take care of a lot of what patients experience.

Dr. Oakley: Yeah. I would say the patients that generally get to that next stage are those that are getting either really severe or really bothersome seasonal allergies that are refractory to the medical therapy. And they just don't want to, you know, suffer every summer, all summer or every spring, all spring. Those are good candidates for immunotherapy. They're getting breakthrough symptoms despite those, you know, medical treatments.

Other patients will have year-long allergies because they may be allergic to, you know, dust mite, and it's all around them. It's in their house. And, you know, there are things they can do, like, you know, try cleaning their house really well. However, we've not seen that those things will fix the problem in a noticeable way. They'll still get their symptoms. And so, you know, those patients are suffering all year, and, you know, there are immunotherapies that can help with those perennial allergies.

An additional option, for example, would be a patient who has a cat that they're allergic to, but they're very, you know, emotionally connected to their cat. It would be distressing for them to get rid of their cat, or it's a partner's cat and, you know, they can't necessarily avoid it. It's not so easy to always get rid of a pet. So that'd be another case where immunotherapy may, you know, play a good role for that patient.

Interviewer: When you get to that point, you do some of the testing, and then after you get the results, how do you proceed to the immunotherapy and how does that work?

Dr. Oakley: So generally, we're identifying the allergies that are causing, you know, the sensitivities that the patients have based on how they respond to, for example, skin prick testing, which would be the most commonly used allergy testing upfront. It can be done, you know, in the office. Patients are tested for multiple allergies at once usually on their arm. You're using a grid system to see what skin responses are the most significant to determine what they're, you know, most allergic to. And those are the allergies that you target, you know, their worst reactions with the immunotherapy. And the idea behind the immunotherapy is giving them very small but ramping up doses of that thing that they're allergic to, to just gradually desensitize the immune system to it.

Interviewer: I remember getting those as a kid. I've had more success with the first line of defense in later life, with some of the new medications that came out, I don't know, probably 20 years ago now, but I say new. So like my experience was the immunotherapy didn't really help me. Do a lot of people experience success with it?

Dr. Oakley: It's generally considered to be 80% to 90% effective. But, you know, it's not 100% effective, as you said. So some people don't get that response. It's generally very effective, but it is a commitment. It's very much a time commitment. You know, it's a three to five-year treatment where patients are coming in anywhere from a weekly to a . . . or I should say anywhere from a twice weekly to a monthly basis for injections, you know, to get that benefit.

Interviewer: Yeah. I remember it was twice a week I'd go in and get those allergy shots. So if immunotherapy doesn't work then, then it sounds like the last option is surgery, and I didn't even know there were surgical methods for allergies. Talk about that.

Dr. Oakley: Well, I should clarify because surgery is more of an assistive option.

Interviewer: Oh, okay.

Dr. Oakley: So not so much a treatment. It doesn't specifically cure or treat allergies. It helps with the symptoms, but in and of itself would not be sufficient. It goes along with these other treatments. So surgery can address some of the more bothersome nasal obstruction symptoms. For example, well, let's just say specifically from anatomical factors, like a deviated septum or enlarged turbinates, which are, you know, shelves of tissue in the nose that warm and humidify the air but can get quite enlarged with allergies. So treating some of those anatomic, you know, factors can improve symptoms of nasal congestion, but you need to treat the trigger as well, the ongoing allergy trigger. So that's that medical management or immunotherapy as well. So the surgery helps, but it's not a treatment in and of itself.

Interviewer: If somebody is listening to this and you just would want them to take away one thing after we're done with our conversation, what would that be?

Dr. Oakley: The main thing I would say is don't suffer in silence. This is a really common problem with many options for treating it. We know from, you know, research study after research study that there is a significant improvement in quality of life when these allergies are managed appropriately in patients rather than just struggling with really bothersome and really distressing, you know, symptoms on a day-to-day or seasonal or yearly basis. You know, try some of these easier steps. Don't hesitate to come in and get some, you know, formal consultation and talk about other options that can really, really benefit you.

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