How to improve diagnosis and treatment of allergy

If you think more allergy patients are landing in your chair every year, you’re absolutely correct. The prevalence of allergy is rising worldwide to near epidemic proportions and carries a significant burden for both the individual patient as well as healthcare systems globally.

Astoundingly in 2012, over 17 million adults and 6.6 million children in the United States were diagnosed with allergic rhinitis, and 11.1 million medical examinations were performed resulting in a primary diagnosis of allergic rhinitis (AR).¹

Ocular manifestations of allergy-like conjunctivitis are among the comorbidities of AR, and the prevalence of ocular allergy is increasing. The World Allergy Organization (WAO) reports that allergic conjunctivitis carries with same “clinical gravity as allergic asthma and allergic rhinitis.”²

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In spite of the overwhelming statistics, allergy often goes undiagnosed and untreated. Many physicians and patients consider the condition to be more of an annoyance and aggravation than a chronic and potentially progressive, and in some cases, life-threatening disease. However, “it’s just my allergies acting up” affects the patient’s ability to live, work, and play, and costs just under $8 billion annually in the United States.³

Unfortunately, doctors are falling short. They often fail to properly diagnose and educate patients on the allergic conditions, but perhaps the greatest shortfall is they assume their patients are satisfied with the care and treatment they have been given.

Allergy patients tend to suffer in silence, dripping and sniffing in cubicles and classrooms across the country. Doctors, mistakenly, assume that because a patient doesn’t return after a prescription has been written that he is satisfied, but this isn’t necessarily the case.

Some patients fail to find relief because the drug prescribed is ineffective or loses efficacy throughout the day. They may also be burdened by high cost or unwelcome side effects. Many allergy patients have little faith that a “cure” is available, so they just don’t return to the doctor or, worse yet, bounce from practitioner to practitioner.³

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The WAO identifies the need for increased training of a doctors focusing on properly caring for patients with allergic disease.² Gatekeepers like primary eyecare providers are essential in identifying and treating the majority of patients with ocular sequelae. The sheer volume of patients necessitates that providers across the board, not just specialists, must play a role. Allergists are indispensable partners in caring for these patients. Developing an interdisciplinary approach will best serve patients and keep specialist waiting rooms from overflowing with easily managed cases.

If many doctors are making the grade, where can improvements be made?

Next: Patient education

Patient education
This is often overlooked and undervalued. The patient needs to understand the chronicity of the condition. Most know that it “comes and goes,” but they don’t really understand why or when symptoms will exacerbate and remit. Identifying triggers and practicing avoidance of specific offending allergens can make a large impact (see below) and take some of the mystery out of the condition. Without that awareness, patients may elect to self-prescribe over-the-counter (OTC) medications and take a “shotgun” approach.

OTCs can feel harmless to patients because no doctor’s Rx is required, but they aren’t without dangers. Commonly used allergy relievers like antihistamines can cause dry eye/mouth, drowsiness, dizziness, and trouble urinating. Decongestants may cause headaches, anxiety, insomnia, and a slew of other untoward complications. Side effects are possible for anyone taking a drug, but some groups are more vulnerable.

Pediatric and geriatric populations can be less predictable. Children metabolize drugs differently than adults, and their dosing may be inexact. OTC packaging often gives a large range of ages or weights for pediatric medications, and caregivers dispense liquid forms of medications from ordinary teaspoons rather than cylindrical measuring spoon or oral syringe. For the elderly, side effects such as dizziness may increase the likelihood of falls and broken bones. Perhaps the greatest danger of OTCs is the potential for drug interactions.

Thorough review of patient medications is essential in guiding safe and effective use of OTC allergy medications. Many patients don’t know when to seek medical advice and often elect to just live with manifestations or take matters into their own hands.⁴

Next: Diagnostics

Diagnostics

Allergic conjunctivitis is the leading cause of red eye and affects more than 1 billion people worldwide.² Classic symptoms include itching, redness, photophobia, and epiphora. However, those same symptoms bring to mind a plethora of differential diagnoses that may lead to eyecare providers following the wrong path. Basing a treatment plan on symptoms and clinical experience isn’t using poor judgment, but it fails to drill down to the root of problem and may leave the patient unsatisfied and ultimately another long-suffering allergy victim.

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Skin (in vivo) and blood (in vitro) allergy testing properly identify allergens. Commonly, skin tests are performed because of their speed, sensitivity, and economy. They can evaluate aero, food, and industrial allergens.⁵ Quality of allergen extracts are critical to accuracy of testing and can be variable affecting both in vivo and in vitro testing. While most benefit from skin testing, in vitro may be necessary if patients are uncooperative, unable to discontinue allergy medications before testing, or anaphylaxis is distinct risk.⁶

More point-of-care testing is available in eye care than ever before. Ranging from RPS Inflammadry and AdenoPlus to TearLab Osmolarity System, doctors can save their patients time, money, and frustration by accurately pinpointing the diagnosis.

Allergy skin testing is readily available and can be performed in many primary care optometry settings. Doctor’s Allergy Formula acquired by Bausch + Lomb in October 2015 gives eyecare providers an FDA-approved in-office test that can identify regionally specific allergens. Naming the particular offending agents aids in customizing the patient’s treatment.

Next: Therapy 

Therapy
Certainly one could argue, if ODs aren’t prescribing allergen immunotherapy, why bother with allergy testing in their offices? However, one of the most powerful allergy treatment with virtually no side effects is the practice of avoidance. Both allergic asthmatics and occupational allergy sufferers have reported significant symptom relief by avoidance alone.

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Avoidance may include covering bedding (mattress and pillows), or reducing humidity levels to make the home less hospitable to allergens or replacing carpet with solid-surface flooring like hardwood or tile. Making adjustments in the home or work environment can prove to be very beneficial but may not eliminate all triggers.²

If avoidance alone fails to yield relief, other non-pharmaceutical (cold compresses, artificial tears) and pharmaceuticals (ophthalmic and oral allergy medications) are prescribed. Should symptoms persist or worsen, referral to an allergist may be warranted.

With allergy on the rise, diagnostic precision best serves patients and differentiates practices from those doing only the status quo. Offering patients the basics may not satisfy their needs or relieve their symptoms. Adding allergy testing to your diagnostic armament may be just what the doctor ordered.

References

1. Allergy Statistics. American Academy of Allergy, Asthma, and Immunology. Available at: http://www.aaaai.org/about-the-aaaai/newsroom/allergy-statistics.aspx. Accessed 1/1/16.

2. WAO: White Book on Allergy." Ed. Rudy Pawankar, Giorgio Canonica, Stephen Colgate, and Richard Lockey. 2011. Web. 2016. http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf. Accessed 1/1/16.

3. Emanuel IA, Parker MJ, Traub O. Undertreatment of allergy: exploring the utility of sublingual immunotherapy. Otolaryngol Head Neck Surg. 2009 May;140(5):615-21.

4. Hussar DA. Precautions with Over-the-Counter Drugs. Merck Manuals Consumer Version. Available at: https://www.merckmanuals.com/home/drugs/over-the-counter-drugs/precautions-with-over-the-counter-drugs. Accessed 1/1/16.

5. Rusznak C, Davies RJ. Diagnosing Allergy. BMJ. 1998 Feb 28; 316(7132): 686. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1112683/. Accessed 1/1/16.

6. Owenby, DR. Allergy Testing: In vivo versus in vitro. Pediatric Clinics of North America 1988, 35(5): 995-1009.