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Second Opinion:
Seasonal Allergies

Hosted by Abigail Trafford
Washington Post columnist

Tuesday, May 8, 2001; 2 p.m. EDT

Welcome to Second Opinion, a weekly column and Live Online discussion with Post Health columnist Abigail Trafford.

Are your eyes itchy and watery? Is your nose runny and do you sneeze often? Do you get tired a lot? You might be suffering allergies this season. Over the past weeks, the region's pollen levels have been high between 8.1 and 12.0. Allergy symptoms become more severe during days with high pollen levels.

Our guest is Dr. Daniel Ein, a clinical professor of Medicine at the George Washington University School of Medicine. He has been in the clinical practice of allergy since 1972 and founded what became Washington Allergy Associates in 1974. He received his M.D. from Albert Einstein College of Medicine in New York. He spent six years at the National Institutes of Medicine where he conducted research and published numerous articles on various aspects of the normal immune system and its diseases.

Dr. Daniel Ein
Dr. Daniel Ein
He is a member of the Board of Regents of the American College of Allergy, Asthma and Immunology. He founded Capitol Physicians Network, a network of D.C. physicians dedicated to providing integrated health care to its patients. Among other activities, he has served on The D.C. State Health Planning and Development Agency and has been a member of an FDA advisory committee.

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.


Abigail Trafford: Hello everybody! Feeling stuffed up? Do you just hate it? Is this the worst season you've ever experienced? Send us your questions and comments.

Abigail Trafford: Dr. Ein, welcome to Health Talk! Tell us, why are allergies so bad this year?

Dr. Daniel Ein: Normally, the heavy season starts at the beginning of April. This year,the first two weeks of April were cold and wet, delaying the pollenation of trees. By mid-month, all the trees burst out at once causing very high pollen levels.

Abigail Trafford: In general, what are the key ways to prevent and treat allergies?

Dr. Daniel Ein: Three main ways ;
Avoidance of the allergen. In pollen season, close your windows, keep the A/C going, drive with closed windows. If you are allergic to dust, clean up.

Medication: over the counter meds(which can make you drowsy) prescription anti-histamines and decongestants which don't cause sleepiness or nasal cortisone sprays
If all else fails, see an allergist and consider getting allergy "shots" to desensitize you.

Abigail Trafford: We refer to pollen counts. What does that mean? What are we counting?

Dr. Daniel Ein: There are standard methods of collecting pollen on specially traeted microscope slides and counting the numberand kinds of pollen grains.

Washington, D.C.: Dr. Ein,

Could you discuss the difference between the "new" antihistimines - Claritin, Zyrtec, Allegra?

I've been taking Claritin for two years, but find that while it relileves the eye irritation, it hasn't been as effective on nasal congestion. Last year I went three solid months with fairly constant congestion...am wondering if another one of them might be more effective.

Dr. Daniel Ein: The new antihistamines represent an advance over the old ones because they cause little to ne drowsiness. They are not necessarily more effective as antihistamines. Zyrtec is slightly more prone to cause this side effect then the others.My rule about the best one antihistamine is: It's the one that gives you (the individual) the greatest relief with the fewest side effects at the lowest price.

Boston, Mass.: Dear Dr. Ein,

I'm 28, and this is the first year I've been noticeably affected by seasonal allergies. Typical symptoms, but it's making me crazy. My question is, how do I know if I should make the switch from over-the-counter medications to a prescription allergy medications? My major complaint with the over-the-counter meds is sleepiness, and I've never tried the prescription versions. Also, on an odd note, my doctor claims that my generation is "overmedicated" and therefore only rarely gives prescriptions. If you advise that I try a prescription medication, any advice on how to convince him that it's a good idea?

Dr. Daniel Ein: Your experience with the drowsiness is not unusual and it can be disabling. Recent studies show that the OTC drugs can impair judgment making driving potentially dangerous. Let your doctor know that you cannot function with the older drugs. Cite the studies I mentioned above

Annandale, Va.: I was taking Allegra (180 mg./day) for seasonal allergies and then, after a few really bad days in a row, found it wasn't working well enough, so my doctor switched me to Zyrtec. The first day I took the Zyrtec I was absolutely in a fog--very sleepy. Ever since then I have been just fine, except for a few drowsy moments. Is it possible that I still had some of the Allegra in my system (I didn't take the Zyrtec until about 30 hours after the last Allegra) on that first day, and the drug interaction caused the severe sleepiness? Or is it normal to build up a tolerance to such reactions? Thanks.

Dr. Daniel Ein: Good question. Zyrtec causes drowsiness in about 10 percent of people who take it but the drosiness wears off if you continue the medicine. ONly less then one percent of people don't tolerate it after a few days. It is clearly working pretty well for you.

Silver Spring, Md.: My son is 18 months old and is showing some signs that he may suffer from pollen and other allergens. He is also at risk for asthma. Is there anything I can do now (besides keeping my house dust free and keeping my son inside on high pollen coutn days) to help prevent allergies or asthma or will they come whether of not I intervene?

Thank you.

Dr. Daniel Ein: Sounds like you have the issue well worked out. You are doing all the right things for now. There is really no good way you can protect your child in the future but you can address the problem down the road if you need to by consulting a specialist.

Montgomery Village, Md.: Hi,

Is it possible for a 15-month-old toddler to have allergies and how can I tell whether its allergies or a persistent cold? Is there anything I can do to help her feel better. My doctor suggested Benadryl but I am hesitant.

Dr. Daniel Ein: It can be very difficult sometimes to tell the difference between allergies and infections. Infections frequentlyu are accompanied by fever, discolored mucus, adn in older kids, complaints of aching,muscles. A trip to the doctor might be helpful to check a blood count which can differentiate the two. A trial of Benadryl might help because allergies respond better to it then do colds,

Abigail Trafford: Claritin, for example, has become the most popular drug, largely because it's been so well marketed. But what's the difference between claritin and an over the counter medication such as benedril? Would you advise patients to start with benedrill first before going to a prescription drug that is so much more expensive?

Dr. Daniel Ein: I used to suggest that people start with Over the counter medication but I am very concerned about the safety problems caused by the drowsiness with Benadryl. I absolutely prefer the newer drugs. Not all my colleagues agree.

Arlington, VA: I realize there a wide variety of reactions by the body to pollen. My problem only occurs with tree pollen, and it makes me very sleepy. I can be outdoors for five minutes, and then become very lethargic and sleepy and nap for an hour. Is this unusual?

Dr. Daniel Ein: Yes but not unheard of. Try some medication or stay indoors more.

Abigail Trafford: What causes people to have allergies? Is it in a person's genetic makeup? Are there genetic tests for allergies? And why does it seem that the incidence of allergies is going up?

Dr. Daniel Ein: Allergy is a combination of two factors:1) genetic make-up or the genetically dtermined ability of your immune system to generate the allergic reaction and 2) exposure to the allergens for whichn you are programmed. There is no current genetic test for allergy but someday I'm sure DNA analysis will give us that tool.
The increasing incidence of allergy is real and may be related to the cleaning up of our envirnment and the conquest of infectious didease so that the immune system , in a way, has nothing better to do then to reacct to pollen instaed of bacteria. That's the current theory.

Sniff, sniff...: I've always had mild alergies, but this year I seem to have the achey, sore-throught thing that seems like a flu. I had a child this winter. Does that make a difference?

Dr. Daniel Ein: It shouldn't if you have totally recovered from the pregnancy and childbirth. You could also, in fact, have an infection. You nmay want to check with your doctor to make sure you aren't carrying something you could give to your baby.

Abigail Trafford: Some basics: how can you tell if you have allergies or just a plan old cold?

Dr. Daniel Ein: Sometimes it is almost impossible to tell. Infections usually have an elevated temperature, achy muscle, fatigue, sore throats and discolored nasal discharge or sputum. Allergies don't frequently have sore throats, there is no measurable fever (although you may feel feverish hence the term "hay fever") and the muscus is clear.
Sometimes I have to treat patients for both because I can't be sure which the patient has.

Washington, D.C.: What are your thoughts on the new anti-IgE antibody for allergy shot patients and who exactly will it be indicated for?

Dr. Daniel Ein: I think this is a very exciting addition to our medication. The antibody is genetically engineered to soak up IgE, which is the antibody fraction responsible for allergies, from the blood.The IgE virtually disappears after several months of injections of this new material. It will be very useful for people who don't respond to ususal medication or who need lote of toxic medication to control serious allergies, especially asthma. It may also pervent severe reactions to medication, like Penicillin. Cost will be a factor, however, so the use may be restricite dto the worst cases. TRhat remains to be seen.

Washington, D.C.: Dr. Ein:

I take Allegra and it seems to work for the most part. However, when I play golf on the weekends, my nose starts running big time. Is there anything I can do besides medication (and staying indoors) which would help me?

Dr. Daniel Ein: Try alternative antihistamines such as Zyrtec also Claritin. Also Astelinwhich is an antihistamine spray that works well. Also try Allegra-D whcih contains Sudafed which is a drying agent.If that doesn't work, ask your doctor for a cortisone nasal spray such as Flonase, Nasonex, Nasacrt and others.

Abigail Trafford: Dr. Ein, something I don't understand. Over-the counter medications make some people drowsy and can cause car accidents. In other words they're not safe. Why are they available without prescription? And the newer drugs are safer but they are NOT available over the counter. This seems exactly backwards for the consumer. You thoughts?

Dr. Daniel Ein: The allergy community is concerned that making these newer medications over the counter will take the physician out of the equation and so patients who may be ill with asthma or other serious disease will not be properly taken care of. There are some residual concerns about the long term safety of these medicines.
I personally think that the older durgs ought to have their OTC status reconsidered.

Alexandria, Va.: Dr. Ein, thanks for taking our questions. Last year I was referred to an ENT to investigate some throat problems I was having. It turns out that the problems were related to GERD and they were eventually treated surgically by another physician. But while under the care of the ENT he decided to test me for allergies even though I had never exhibited any of the classic allergy symptoms. Sure enough I tested positive for just about everything; both inhaled and food allergens. The doctor recommended I begin a special diet and immunotherapy, which I thought strange. Yes I had tested positive, but I had no symptoms! After several months of treatment and diet with no noticeable change in my health I voluntarily withdrew (against the doctors wishes) from the treatment and to this day I feel just fine. I now suspect the doctor was treating me for a condition he knew I didn't have simply to get payments from my insurance company and I further suspect that he has quite a little scam going out of his office doing the same thing to other patients. How do you respond and what do you recommend?

Abigail Trafford: Dr. Ein, a couple of additional uestions. What's GERD? And what is the potential for abuse in allergy desensitization treatments? How can consumers protect themselves?

Dr. Daniel Ein: I think you did the right thing by discontinuing the treatment which was not effective. I don't like to ascribe self-interseted motives to my colleagues in a profession where judgment counts for so much. Certainly, there is a case to be made that some of the throat problems were due to post-nasal drainage which could be secondary tomallergies.
By the Way, GERD is "gastro-esophageal reflux disease" in which stomach acid goes backwards up the esophagus (food Tube) and can cause heartburn, hoarseness (Clinton's hoarseness was due to that) and even asthma.

Abigail Trafford: A lot of people get allergy shots--weekly visits to the doctor's office for years. A few years ago, there was a study that questioned the effectiveness of desensitization therapy. Tell about allergy shots. What are they? Are they effective? For whom? How long do you have to get shots?

Dr. Daniel Ein: Allergy shots or "immunotherapy" is a treastment devised over eighty years ago in which the patient is injected with small amounts of the substances (ususally airborne allergens) she is allergic to. There are many studies, other then the one you cite, which demonstarte its effectiveness for hay fever and, to a lesser extent, for asthma.The traetment is highly effective if you are allergic to bee stings.

Arlington: Although "outside" allergens bother me somewhat, my main problem is dust (and dander, which may exacerbate the reaction to dust in my house). Do the "new" medications like Claritin and Allegra help with dust allergies? Obviously it's less seasonal than other allergens. Is one of the new medicines better than the others for dust?

Dr. Daniel Ein: There is no specificty of the anti histamines in terms of the particular allergen. In other words, if Claritin works for you it will work for pollens, dust -you name it.

Achoo! in Chantilly, Va.:
Dear Doc,

This is the first time I've had a reaction to pollen and in general, everything good that goes with Spring. Immediately upon waking, I begin sneezing. I shutter when I look in the mirror- my eyes are all puffy and red. I can handle looking as if I've been in a fight,
but I'm more concerned with all the meds I'm taking.
Currently taking: 10mg of Zyrtec, 1-2 benedryls (or benehist, made by Safeway), 125 mg of Effexor (anti-depressant) and Celexa, approx 25 mg. Also, Anbutril, an inhaler

Is there any danger mixing anti-depressants and an anti-hystamine??

Dr. Daniel Ein: You are certainly taking a lot of medicines but the good news is that the newer antihistamines, such as Claritin , Allergra and Zyrtec dont have any significant drug interactions. Sounds like your symptomes are not well controlled and I would seek alternatives such as the nasal cortisone sprays.

Gaithersburg, Md.: A few years ago, my doctor prescribed the Beconase inhaler for my allergies and Naphcon A for my eyes (which is now sold over the counter) -- this combination has worked wonders for me! No drowsiness or any other side effects.

I know that Beconase has something to do with steroids, but how exactly does it work?


Dr. Daniel Ein: Beconase is a steroid but like the other steroids in nasal sprays or certain asthma inhalers, it does not get into the bloodstream very well at the doses prescribed and therefore has a very low potential for side efeects in your system. These medicxines are now considered by the medical profession to be a safe as the new antihistamines for treating nasal allergies. They can be used as first line treatment -at the perescribed doses.

Abigail Trafford: A followup question on allergy drug interactions. For OTC allergy drugs, can they be safely taken with all other medications? What drugs should you not take if you are taking OTC allergy remedies? What about alcohol and OTC drugs? And what are the potential drug interactions with prescription drugs such as claritin?

Dr. Daniel Ein: PLease do not, I repeat, do not mix alcohol with the OTC medicines . Taking two drugs at the same time that affect your brain function is a disaster waiting to happen. Claritin does not appear to have any serious interactions at the prescribed dose.

Abigail Trafford: If allergies are going up because we have developed a "lazy" immune system, should we be exposing ourselves to bacteria as therapy to get out immune system back on track? It seems like an increase in allergies is an ironic consequence of the public health advance of cleaning up the environment.

Dr. Daniel Ein: I wouldn't call the problem a "lazy immune system. It's really a system in search of someting to do so it gets redirected to allergic reeacting.
I'll take allergies over pneumonia or diptheria any day.

Arlington, Va.: Do the "new" medicines begin to work immediately to stop an allergy attack (like the OTC ones do) or do they take a couple days to kick in?

Abigail Trafford: I've always wondered: are you supposed to take certain medications to prevent an allergic response. And other kinds of medications once you've succombed? Please explain what they are. Thanks.

Dr. Daniel Ein: The new meds work almost as quickly as the old ones. They are designed to last 12 to 24 hours so they take just a bit longer to kick in. Some folks do better with them if they take the meds regularly for a few days.

21771: My nine yo daughter suffers from Seasonal allergies. She's having an especially rough spring. She takes Claritin redi-tabs and also takes Singular for preventive (asthma). She recently had her adenoids taken out because she was frequently getting sinus infections. She's also had her nose carturized (sp?) twice because of frequent nosebleeds. Since she's sneezing so much lately she flared up the nosebleeds again. Sometimes several times a day for 20 min. I'm planning to have her reevaluated by her dr. this week. She uses neosporne to heal and moisten the inside of her nose. Any tips to help with the nosebleeds. We try to keep the house closed up for the pollen and don't use humidifer because of mold. How do we relieve her suffering! Is Claritin-reditabs the most effective (with no side effects) for someone her age.

Dr. Daniel Ein: Better make sure her nose is not infected. A culture of the nose might help.This is a complicated situation and needs more thoughtful analysis then I can provide online. Consider getting a pediatric allergist to see and evaluate her -both for this year and next

Reston, 20190: What percentage of the population has pollen allergies? I ask because I don't have them. Those days when the pollen count was above 1500 I had the windows open, went for my usual evening walk, and had no problem. The only allergy I have is poison ivy and I've found that after I've had it once in the spring, it's not a problem for the rest of the year.

Abigail Trafford: And I have an opposite response with poison ivy. Each time I've been exposed, it's a worse attack. I now avoid poison ivy like the plague. What's going on here?

Dr. Daniel Ein: Allergies in general affect between 15 and 20 % of the population. Be grateful that you have been spared this year. Sounds like you are desensitized to poisen ivy once exposed. The immune mechanism in poison ivy is completelly different from and unrelated to the one involved in pollen allergies.
Farmers used to chew poisen ivy leaves to get "hardened" Some people do get more sensitive with each exposure and avoidance is the best trewatment.

Bethesda, Md.: Dr. Ein: Thanks for answering our questions. About ten years ago I was getting injections, then stopped after not noticing any difference. I went to another allergist a few years later, who started me up again, but this time I did see a difference. He told me that the difference was that he was using a different base for the allergen which enabled him to administer it in much higher doses w/o instigating a reaction, thus building up immunity much more quickly. He no longer practices in the area and I am trying to find more info on this. Can you tell me what this base might be, or recommend anyplace I can find more info on this?

Dr. Daniel Ein: There are some allergists who use modified allergens that are prepared in media that are diffent from the usual ones, for example alum precipitated extracts. I haven't seen this in a long time. But new approaches are on the way so hang in there.

Washington, D.C.: I am in my first trimester of pregnancy and my allergies are killing me. I stopped taking zertek, but am still taking flonase. I stopped taking most of my asthma meds (pulmicort and singulaire) but am taking proventil as needed. Any advice for pregnant women during this tough allegy season?

Dr. Daniel Ein: This is a real problem bnecause we are all appropritely worried about medication in pregnancy, especially the first trimester. Staying indoors with the windows closed is still the best way to treat for you. If you mudt be outdoors, wash your hair to get rid of the pollen before you go to bed. The older OTC antihistamines -Benadryl and Chlortrimeton -are know to be safe in pregency as is Sudafed. . The newer drugs claritin and Zyrtec probably are also but we are not sure. I would definately avoid allegra in pregancy. Above all, check with your OB

Abigail Trafford: Our time is up. Tis the season. I hope you all feel better. Thank you Dr. Ein. Thank you all for participating. Join us next week, same time same place. We'll talk about emergency contraception.

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