Posts Tagged ‘allergic rhinitis’

When Leonard Noon reported his first tentative experiments with immunotherapy for hayfever, in 1911 (see p. 164), he believed that pollen contained a toxin. Most people were

‘immune’ to this toxin, he said, in the same way that people might be immune to measles or diphtheria, but hayfever sufferers lacked this immunity. Noon thought that his

steadily increasing doses of pollen, injected just under the skin, were inducing immunity to the pollen toxin, in the same way that a smallpox vaccine could induce immunity to

smallpox.
Noon’s theory was all wrong, as we now know, but the important thing was that the treatment seemed to work. In fact it transformed the lives of some patients, especially those

who were very severely affected by hayfever. One spoke of a ‘marvellous cure’, another of going for walks to kick my old enemy the hay’.
So doctors kept using Noon’s treatment, and in time — when it became clear that Noon’s theory was flawed — medical researchers began trying to figure out how the injections

really worked.
Surprisingly, they have still not succeeded, even though a great deal is now known about the changes that can occur in people undergoing immunotherapy. Despite a wealth of

detailed knowledge (see p. 166), it remains impossible to say exactly how conventional immunotherapy reduces allergic reactions. Surprising discoveries about the effects of

conventional immunotherapy are being made all the time.
New methods of immunotherapy are still being devised today, and there are three different approaches being taken.
Firstly, there are doctors experimenting with modifications of the technique devised by Noon. For example, instead of injecting the allergen extract, some doctors are giving it

to their patients in capsule form. to be swallowed. Others are giving it as a liquid, to be placed under the tongue and held there for a few minutes, then swallowed (see p.

169). Sound scientific trials show that both these methods work well, at least with some allergens.
There are also experiments with speeded-up immunotherapy
(see p. 166), called ultrarush techniques — at the outset, injections are given at hourly intervals, or even more frequently (in hospital, of course, where severe reactions can

be dealt with immediately). Doctors have found that they can induce a remarkably rapid tolerance of the allergen in this way.
The second approach is to apply modern medical knowledge about allergic reactions and so develop entirely new methods of immunotherapy (see p. 168-9). Such research involves

working out, from first principles, novel ways of modifying the immune response in general, or the reaction to one allergen in particular.
This theory-led approach is certainly successful for classical allergies such as hayfever and perennial allergic rhinitis, where there is a good understanding of the basic

mechanism (i.e. the malfunctions of the immune system that produce the disease). But for those diseases where the underlying mechanism is only partially understood, such as

atopic eczema, this approach is not necessarily the best one. And for diseases such as food intolerance, where the cause of the illness remains largely unknown, it is a complete

non-starter.
The third type of approach is to devise a technique by trial and error, and then puzzle out the ‘how’ question later. This is the same sort of path as Noon originally took, and

some believe that this kind of pragmatic experimental approach — practising a method which seems to be effective, even though it’s a mystery how it works — is as valid now as it

was in 1911. Others disagree.
210 complementary therapies The two most widely used methods that have been developed in this way are Provocation-Neutralisation and Enzyme- Potentiated Desensitisation.

Although these techniques are practised by doctors with a conventional medical training, they remain ‘outside the pale’ as far as orthodox medicine is concerned. The

controversies that surround them are discussed below.
Enzyme- Potentiated Desensitisation (EPD)
This technique has been developed by a British doctor, Dr Len McEwen, who began work on it in the 1960s. It is now practised in many parts of the world, as well as Britain,

including the United States, Germany and Italy.
EPD is used for a far wider range of problems than conventional immunotherapy, being given to people with food intolerance and chemical intolerance, as well as to those with

true allergies. This — along with the fact that it is unclear how it works —contributes to the controversies that surround it, because these conditions do not have the same

basic causes.
Dr McEwen began with the observation that, when immune cells are aroused during inflammation — whether caused by allergy or some other stimulus — they release large amounts of

an enzyme called beta-glucuronidase. This enzyme increases the immune response to the allergen or antigen that provoked the inflammation.
Dr McEwen experimented with injecting beta-glucuronidase into the skin, along with very small amounts of allergen, believing that in such circumstances the enzyme might have the

opposite effect, and reduce the immune reaction to the allergen. Eventually he discovered a combination of enzyme and allergen which seemed to have the desired effect.
EPD has been tested, in a rigorous scientific manner, and the results suggest that it can work for hayfever and asthma, as well as for childhood migraine and hyperactivity in

children when these are triggered by foods.
In one trial with hayfever patients, researchers measured the levels of anti-pollen IgE following EPD treatment, and it did not rise during the pollen season as it normally does

in those with hayfever. This kind of finding is impressive because it is unlikely to be due to placebo effect. Not all studies have produced positive results, however.
In addition, doctors using EPD claim that it is very effective for patients with allergies who have not done well on the standard course of immunotherapy injections (see p.

164). This fits in with other studies suggesting that the immune changes brought about by EPD are fundamentally different from those induced by traditional immunotherapy.
Patients with true food allergy have been given EPD, and while it does not enable them to eat their culprit food, it does
seem to reduce their reaction to accidental exposures.
Doctors in the Netherlands are using EPD as a treatment for people with Chronic Fatigue Syndrome (CFS), and report that it helps about 50% of patients.
One point in favour of EPD is that it uses very small amounts of allergen, and is therefore very safe — anaphylaxis has never occurred with this technique.
Provocation-Neutralisation
‘After following conventional methods [of immunotherapy] for thirteen years, I heard Carleton H. Lee deliver a paper on provocative testing in 1965, at a meeting of the American

College of Allergists in Chicago. I was naturally sceptical, but tried his suggestions when I returned to my office. The results can only be described as astounding. Many

patients with unresolved allergic problems responded markedly and rapidly. Many with resistant asthma or perennial allergic rhinitis improved greatly or cleared completely when

food injection therapy was added to their inhalant injection therapy.’ So wrote Dr Joseph B. Miller — a distinguished allergist and paediatrician, and a Professor of Medicine at

the University of Alabama, in 1972.
The technique which he learned from Carleton H. Lee was controversial then and, although Miller developed it with great care and precision during the years that followed, it

remains controversial now.
There are two elements in provocation - neutralisation: testing and treatment. Both are used for a wide range of problems — not just classical allergic diseases, but also food

intolerance and chemical intolerance. As with EPD (see left), this is one of the controversial aspects of the technique.
Although provocation-neutralisation involves an injection technique that looks, superficially, very much like conventional immunotherapy (see p. 164), there are several

important differences. Firstly, the allergen extract used (in the case of true allergies) is a very dilute extract, so that far less of the allergen is injected than in

conventional immunotherapy. Likewise, in the case of food intolerance and chemical intolerance, the extracts of the offending substance are used in highly dilute form.
Secondly, the idea of the neutralising dose — which is the central plank of provocation-neutralisation — is quite different from anything in conventional immunotherapy. Broadly

speaking, the conventional technique (see pp. 165-6) works by slowly reeducating the immune system with a gradually increasing dose of the allergen. Only after a succession of

injections does the immune system start to behave differently on encountering the allergen. By contrast, in provocation-neutralisation treatment, the neutralising dose is

claimed to have an instantaneous and direct effect on the body, ‘turning off’ symptoms that have already begun. This is the neutralisation aspect of the technique. The doctors

who practise this technique do not claim to know how the neutralising dose might work.
According to the theory of provocation-neutralisation, the strength of the extract that acts as a neutralising dose is specific for a particular allergen and a particular

person. It can only be worked out by a rather slow procedure involving a series of injections. These are intradermal injections – they place the allergen extract in the skin, at

a slightly deeper level than a skin-prick test. (For treatment, rather than testing, subcutaneous injections are used – these go deeper than intradermal injections, placing the

allergen extract just underneath the skin. Neither hurts very much.)
Ideally, the neutralising dose should be decided on by measuring the size of the wheal (a raised area of skin around the injection site), and whether it grows, stays the same

size, or disappears. The doctor or nurse carrying out the procedure can, in theory, work out the neutralising dose just by careful examination of the skin wheals.
However, it is part of the tradition of provocation-neutralisation techniques that verbal feedback from the patient is also taken into account – so if the patient says that an

injection has turned off the symptoms, that reinforces the belief that the neutralising dose has been found.
The problem with this aspect of provocation-neutralisation is that expectations, and the power of suggestion, can become involved. So if the doctor or nurse says ‘you may find

that this next injection makes the symptoms go away’, that is often exactly what happens – because the forces of placebo effect (see p. 233) come into play. Unfortunately,

verbal interactions such as this are a key aspect of the provocation-neutralisation procedure in many clinics.
Just the same hazard besets provocation - neutralisation if it is used to test for the existence of allergy or intolerance, because it is quite common for practitioners to tell

patients which allergen (or other offending substance) is being injected and to ask if any symptoms are provoked by the injection. This is not good practice – if someone expects

to react to a particular substance, they are quite likely to produce symptoms through purely psychological mechanisms (see pp. 232-3).
Quite apart from this, the question of allergy testing with provocation-neutralisation techniques is contentious, because the pioneers of the technique, such as Professor

Miller, never advocated using provocation - neutralisation in this way. Using it as a routine test for sensitivity reactions was a later development, and there are many doctors

today who, while they practise provocation-neutralisation as a treatment, say that it does not work well as a test for sensitivity reactions. While they agree that injecting a

dose
which is either stronger or weaker than the neutralising dose may provoke actual symptoms (this is the provocation aspect of the technique) they don’t think the reaction is

reliable enough to form the basis of a test for allergies. Nor do they think that using skin-wheal measurements alone (i.e. silent testing) turns the technique into an accurate

test for allergies. That is not what the provocation-neutralisation technique was designed for – it is about treatment, not testing.
The evidence from research
Recent research from the Nova Scotia Environmental Health Centre in Canada confirms that testing by provocation injections is not reliable. The subjects in this study were all

suffering fr= multiple chemical intolerance, a condition which – for one reasor or another – makes patients liable to develop symptoms at an,, time. No less than 70% of these

patients experienced symptoms in response to a dummy injection which contained none of the offending substance. Indeed, 15% of patients also produced a skin wheal in response to

some of the dummy injections, confirming that even this reaction may be subject to the power of suggestion (see pp. 232-3).
Looking just at the patients who did not react to the placebo injection (i.e. those least susceptible to suggestion) the test still did not yield any reliable result – a person

might react to one injection with a particular substance, but fail to react to a subsequent injection with the same substance. The authors concluded that their patients were ‘in

a state of heightened sensitivity as the result of the chronic irritation by various environmental components and other external and internal stressors’. In this state of

sensitivity. patients are so close to the brink all the time that the smallest thing can trigger symptoms. So the apparent reactions to the test injections were actually

determined by other factors – some psychological factors (including a psychological response to the prick of the needle) and some external ones, such as exposure to smells or

very small amounts of airborne chemicals.
Another recent research study, carried out by scientists at the University of California, confirmed the finding of the Nova Scotia team as regards testing. Although this study

did not set out to look at the use of the neutralising dose for treatment, some of the patients were given neutralising doses during the testing process and the researchers

observed that ‘in most cases a single neutralising injection relieved the symptoms’. This casual observation clearly needs to be confirmed by more rigorous testing. Oddly

enough, despite this positive observation about the neutralising doses, the overall conclusion of the researchers was to completely dismiss all aspects of

provocation-neutralisation as ‘the result of suggestion and chance’. This conclusion has been widely publicised in the United States as part of a general campaign against

provocation-neutralisation and doctors who practise it.
Other researchers have looked at treatment with neutralising doses, using stringent scientific methods (a double-blind placebo-controlled trial — see p. 90), and found that they

do work. In one such trial, patients with asthma. and allergies to dogs or cats, were treated with injections of the neutralising dose. They showed a reduction in the

sensitivity of their airways, as measured by objective tests. In another experiment, patients with perennial allergic rhinitis and an allergy to house-dust mite were studied,

and the neutralising dose was given as drops of allergen extract placed under the tongue (sublingual drops) – an alternative to injections. The blockage of the nose, as measured

by scientific tests, was reduced by the neutralising dose.
A great many more trials of this kind would be required to convince most doctors that provocation-neutralisation works.
Furthermore, the recent study from California – which observed a number of practitioners of provocation-neutralisation at work with their patients — showed that these

practitioners need to be a lot more rigorous and objective in their approach. However, the fact that provocation-neutralisation is often practised badly does not necessarily

mean that the basic technique is without any value. There are a great many level-headed doctors and patients who, while initially very sceptical about

provocation-neutralisation, have found it surprisingly effective – just as Professor Miller did back in 1965.
Deciding for yourself
So is provocation-neutralisation an option that is worth trying for your condition?
As regards testing, the answer is probably ‘no’. The most reliable tests are skin-prick tests or FAST blood tests for true allergies (see pp. 91-2), an elimination diet for food

intolerance (see p. 194), and avoidance followed by re-exposure (a challenge test) for chemical intolerance.
As regards treatment for true allergies, conventional immunotherapy has been far more thoroughly tested and, if you can get it (not easy in Britain — see p. 164), is probably a

better bet. It is definitely the best treatment for allergy to insect stings.
The major advantage that provocation-neutralisation has over conventional immunotherapy, in the case of true allergies, is that it is far safer. Because such small amounts of

allergen are used, anaphylactic reactions (see p. 58) don’t occur.
When it comes to treatment for food intolerance, complete avoidance of the problem food(s), for a period of a year or two, is usually a very effective treatment (see p. 77).

Other forms of treatment are only needed for people who find that they have
intolerance to a great many different foods (on the basis of an elimination diet, not kinesiology, blood tests and the like — see p. 93) and cannot devise an adequate diet from

the foods they are able to eat. For such people, provocation-neutralisation may be worth a try. Many patients feel that they have gained considerable help from this treatment.

They report suffering fewer symptoms and being able to return to a more nutritionally balanced diet.
In the case of chemical intolerance, the first line of treatment should be to avoid the substances concerned as far as possible, eat a good balanced diet, and take a vitamin and

mineral supplement if nutritional deficiencies are suspected. Treating any underlying hyperventilation (see pp. 226-9) can also help considerably. Only if there are persistent

symptoms, and you are sure these are not due to psychological causes, might provocation-neutralisation be worth a try. Some people with chemical intolerance do find it is

helpful, but whether this is a real effect, or simply placebo, remains uncertain.
If you decide to give provocation-neutralisation a try, find a practitioner who has good medical qualifications, who seems objective and sensible in their approach, and who

doesn’t make implausible claims for the technique. Take note of what other treatments the practitioner offers, and whether these seem rational or not – this is often a good

guide to the care and objectivity with which provocation - neutralisation is carried out.
Ask the doctor how he or she assesses the neutralising dose. and avoid anyone who does not use the traditional method of a series of injections combined with wheal measurement.

When the neutralising dose is being assessed, say that you would like it to be done ’single-blind’ – that is, you don’t want to be told anything about what is being injected.

Reporting how you feel to the doctor or nurse during the assessment is fine, but only mention really significant symptoms, or a very definite clearance of the symptoms, if this

occurs. These precautions will help you to be sure that you are getting something which is of genuine benefit, rather than just a very expensive form of placebo treatment.
I always wanted to be a doctor, and I enjoyed
medical school immensely, but once I became a
ell GP, I no longer felt quite so sure about what I was doing. It seemed clear to me that there were a lot of people coming to my surgery who I couldn’t do much for. And there

were others who, while I could treat their obvious medical problems with some success, remained distressed and were not coping well with life. Once I became a senior partner in

this practice, I experimented with having a counsellor come in for one session a week, and then an osteopath for the bad backs. It was popular with the patients, and I saw some

people improve enormously. Now we have stress-management classes too, and one of my colleagues has trained in acupuncture, which he uses for selected patients. We also use

elimination diets for patients with a lot of long-term problems like migraine. Overall, I think of it in terms of having more tools at our disposal - being able to tackle things

from a different angle when standard medicine isn’t hitting the spot.’
Geoffrey, a GP in the north of England, is typical of the reconciliation that is now beginning to occur between conventional medicine and alternative medicine. But he also has

plenty of criticisms to make of the alternative scene. ‘The idea that alternative medicine is “holistic” while conventional medicine isn’t, really raises my hackles. Most GPs

could be magnificently holistic if they had an hour with each patient as alternative therapists usually do. We have just 15 minutes, on average, and we have to pack a lot into

that - including our basic duty to eliminate the possibility of serious organic disease such as cancer. Time pressure is everything now, and it has squeezed the humanity out of

medicine, to a very large extent. But the potential for a holistic approach is there - most doctors have a tremendous store of wisdom and life
experience at their disposal, which could form the basis of a holistic approach to treatment if only there were more time to spend with each patient.’
It is in search of a more unhurried and all-embracing approach to treatment that many people turn to alternative medicine. Frequently, what they get out of the therapy has less

to do with the actual methods used, and still less with the theories behind those methods, but everything to do with spending a quiet hour with someone supportive and caring who

listens to all the complex concerns that surround any illness, gives reassurance or advice, or just offers a `safe space’ in which to talk about life’s difficulties.
Other people turn to alternative therapies due to a more serious disillusionment with orthodox medicine. When patients with inscrutable medical problems -such as persistent

unexplained diarrhoea, joint pain or chronic urticaria - are given a succession of different diagnoses by different doctors, they often lose faith entirely in modern medicine

and reject orthodox treatment in favour of alternatives. This is a great mistake. Modern medicine isn’t perfect, but that is only to be expected, because it is not a fixed body

of knowledge but a process - a continuing journey of questioning, investigation, discovery and improvement. Scientific medicine has come a tremendously long way from the state

of ignorance that prevailed two centuries ago, and it will undoubtedly go farther.
Conventional medicine has a great deal going for it - ask anyone over 50, with severe life-long asthma, what they think of treatment now compared to treatment in the 1950s or

early 1960s. You will hear a hymn of praise to the improvements in both drugs and drug delivery systems. Asthma is just one example -conventional medicine has a lot to offer for

all the classical allergic diseases. Alternative medicine should always be regarded as an adjunct to conventional treatment, not a replacement. That is why many doctors prefer

the term complementary medicine.
A third reason for using alternative medicine is a more philosophical one, a need to understand illness in some larger sense, often part of a general search for meaning in life.

Some types of alternative treatment attempt to offer metaphysical reasons for allergy -rather than the mundane explanations of antibodies and immune cells that are given in this

book - and this can be attractive to some people. There is no harm in this approach, which can prompt you to make a critical review of your life, look at unresolved emotional

issues, or reassess choices that are making you unhappy.
But not all illness, or worsening symptoms, can be explained by emotional causes, and the rigid belief that every illness must have a meaning can be damaging. It easily

degenerates into the wholesale psychologisation of illness, the kind of blame-the-victim mentality which can attribute hayfever to ‘Emotional congestion; fear of the calendar; a

belief in persecution; guilt’ and asthma in babies to ‘Fear of life; not wanting to be here’. Both these diagnoses are taken from the best-selling You
can Heal your Life by Louise Hay, which is very influential among some alternative therapists. This compulsive psychologisation of illness can be profoundly damaging, and if

your complementary therapist is preoccupied by ideas of this kind, you could find yourself on a very long guilt trip indeed.
Apart from the psychological aspects of alternative medicine, there is the question of whether it actually works in a practical sense - whether it provides more than just

emotional support and placebo effect (the benefit that comes from any treatment which you believe in). This is always the central question for scientific medicine in relation to

its own treatments,
and conventional doctors naturally apply the same criteria to alternative medicine. Most of this chapter is concerned with trying to answer that question.
Unfortunately, there are so many different kinds of alternative therapy available today that it is impossible to cover all of them in this book. To complicate matters further,

many complementary therapists now practise two or more different techniques, mixing them to
produce their own unique cocktail of diagnosis and treatment. This eclectic approach can span a remarkable range - you may find a therapist doing distinctly whacky stuff such as

iridology (looking at the eye to diagnose all illness - it has been tested and definitely doesn’t work), combined with something perfectly rational such as an elimination diet.

(The elimination diet might be presented as a ‘detox diet’, but it is actually being used to detect food intolerances.)
With new forms of therapy springing up all over the place, a healthy scepticism is a distinct asset for the consumer. Be sceptical about any diagnostic test or treatment that is

only being practised by one person in the country, or in the world - when doctors hit on something that works, they want other doctors to try it out. World exclusives in

medicine are usually suspect.
Avoid any practitioner who tells you to stop using your drugs without your doctor’s consent. Likewise, avoid those with a messianic gleam in their eye, an evident disregard for

logic or reasonable discussion, or an amazing cure that fixes everything from acne to AIDS. Very few of those who sell bogus cures and phoney diagnostic tests are complete

rogues. Most are nice people who are quite genuinely convinced that they have indeed found the answer to people’s problems. The powers of placebo effect (see p. 233) can sustain

such a conviction for a very long time.

Allergens and irritants at work
Some workplaces have very high concentrations of allergens in the air, especially if proper safety procedures are not being followed. Occupational allergies can begin with symptoms in the nose, such as sneezing, blockage or constant streaming (allergic rhinitis). You may also suffer with itchy or watery eyes (conjunctivitis), a cough, sweating and a feverish feeling. Alternatively, direct contact with the allergen can produce a skin rash (dermatitis) or itchiness and swelling (contact urticaria/nettle rash and angioedema).
If you work somewhere with an allergy risk (see pp. 133-4), be vigilant for such symptoms and see your doctor immediately. These symptoms can be the forerunners of occupational asthma, which is a serious and potentially irreversible problem. Some allergens, such as latex, can even produce anaphylactic shock (a life-threatening allergic collapse).
Skin-prick tests (see p. 91) can show if you have an allergy to a substance encountered at work.
Acting promptly gives you the best possible chance of recovery and is vital if you have occupational asthma. Only if exposure to the allergen stops promptly do you have a good chance of shaking off the asthma. See your doctor as soon as possible and ask for a referral to a chest specialist, so that a definite diagnosis can be made. This is essential if you are going to make a claim for compensation.
Far too many people with occupational asthma are just sent off with an inhaler when they first see their doctor. By delaying the moment when work is identified as the source of the problem, and the exposure to the allergen is stopped, drug treatment can turn occupational asthma into a disabling lifelong problem. Although drugs can be helpful in speeding your recovery once exposure to the allergen
Latex allergy
Sensitisation to latex usually occurs at work (see pp. 133-4), or as a result of having many surgical operations. But latex allergy sometimes occurs in allergy-prone people even though they don’t work in a high-risk job and haven’t had many operations. Some doctors think that if a child with severe allergies needs surgery, this should be done in latex-free conditions, even though the child has no allergy to latex, because of the risk that the operation will sensitise.
Latex can cause either contact dermatitis (see p. 55) or a Type I allergy, whose symptoms can include urticaria, asthma and anaphylaxis. Latex allergy often goes undiagnosed. Once sensitised, you may react to balloons, elastic bands, condoms and household gloves. Latex in the air,
due to powdered latex gloves being used, can be a hazard for someone who is highly sensitive, as can latex traces in food (see box on p. 175). Medical treatment may be problematic (see p. 98 and box on p. 249). Cross-reactions to certain foods can occur (see p. 15 and p. 51).
For those avoiding latex, there are non-latex gloves (see p. 57), and non-latex condoms. Immunotherapy (see pp. 164-9) may be useful in severe cases: it can reduce sensitivity and eliminate cross-reactions to foods.
Other hazards
This article (pp. 132-5) deals mainly with allergens at work, that is, substances which provoke classical allergies (Type I reactions). In addition, there are skin irritants and antigens in workplaces which can provoke contact dermatitis (see p. 56) or contact urticaria (see p.50).
Some of the most dangerous workplace substances are those that bring on asthma but are not allergens. These are usually called low-molecular-weight asthmagens. The most notorious of these are platinum salts, isocyanates (used in cement, in the manufacture of foam, plastics and varnishes, and for spray-painting cars, aeroplanes and boats), colophony (used as a solder in electronics), glutaraldehyde (used in hospitals for sterilisation procedures), and persulphate (used in hairdressing). Powerful respiratory equipment, supplying air from outside the area (see p. 135) is needed if you work with some of these substances, e.g. isocyanates for spray-painting cars.
has ended, they should not be seen as a way of allowing you to go on working with the offending allergen or asthmagen.
If it seems plausible that your allergies or your asthma are related to your work, your doctor should be able to give you a sickness certificate, so that you can have some time away from the workplace, to see if you recover. The medical service at your workplace may be better at diagnosing occupational asthma than your own doctor, but be cautious. In some workplaces they do operate as they should and offer genuinely confidential treatment. But there have also been cases of information being passed to the management, and workers with the early signs of occupational allergies and/or asthma being dismissed on a pretext, or made redundant, to avoid a possible compensation claim. Most occupational health services claim to be independent, but they actually have to earn the trust of the workforce. Before you make any move, ask your colleagues for their views, especially those who have worked there for many years.
Choosing a job
If you have any tendency to allergies, or come from an allergy-prone family, you should be very choosy about where you work. Try to avoid workplaces where there is heavy exposure to allergens, especially airborne allergens which can provoke asthma:
• Bakeries and flour mills, where the allergens concerned may be wheat proteins in the flour, or enzymes added to the flour mix. These allergies can take years to begin.
• Other food-processing works, particularly those dealing with tea, soyabeans, other beans (e.g. gram flour), shellfish and fish (especially if automated gutting machines are used without adequate ventilation). Food preparation and sandwich-making can cause contact urticaria, if there is prolonged contact with a particular foodstuff (e.g. tomatoes).
• Farms, docks and cotton mills – or any other workplace generating dust from plant products. On farms, it is the dust from grain and hay that is often responsible, although mould spores (see p. 121) can also be the culprit. Allergies to mites (found in hay, grain and flour) sometimes occur and eczema is the most common symptom – often called simply ‘grain itch’.
• Saw mills and joineries, because of the wood dust, especially that from hardwoods and from red cedar (Thuja plicata).
• Paper recycling plants, if there is a lot of paper dust in the air.
• Detergent and pharmaceutical factories handling enzymes – these are added to ‘biological’ washing powders and are potential allergens. The risks are less these days, as the enzymes are in granule form rather than powder.
• Factories processing natural products such as psyllium or ispaghula, which are used as laxatives. Anyone who has been sensitised should avoid taking medicines containing the offending substance in the future, because these can sometimes provoke a dangerous anaphylactic reaction.
• Hospitals, clinics and dental surgeries, mainly due to latex rubber, used in gloves and equipment. Although nursing staff and surgeons are most susceptible, other staff including hospital administrative workers can occasionally be affected. Fears about the spread of the HIV virus has led to a huge increase in the use of latex gloves in medicine and dentistry, and a consequent epidemic of latex allergy. The main problem is with powdered latex gloves, which release 15,000 times as much allergen into the air as unpowdered gloves. Unpowdered, low-allergen gloves greatly reduce the risk of latex allergy developing, and non-latex gloves are even better. There are moves to ban the import of powdered latex gloves into Britain. They are already being phased out in hospitals and other medical facilities, but progress is slow in some areas.
• Other workplaces where powdered latex gloves are used, including
Making the workplace safe for everyone
Note that these choices about employment are for the individual employees to make for their own protection - an employer cannot refuse to take anyone on because they have allergies or come from an atopic (allergy-prone) family.
The reasoning behind this is that the workplace should be safe for everyone, as far as possible. As many as one in three of the population may be susceptible to allergies, and it is clearly wrong to bar all such people from major industries. Current thinking, in most countries, is that the focus should be on getting allergens and asthmagens out of the air, not keeping the more vulnerable workers out of the workplace.
hairdressers, dental surgeries, pathology laboratories and police stations. Construction workers wearing rubber gloves are also at risk. Someone who has been sensitised by powdered latex gloves may then react to other items (see box on p.132). Those severely affected can have great problems in daily life and with medical treatment, so anyone with a strong tendency to allergy should strenuously avoid becoming sensitised.
• Factories making or using rubber items may also expose workers to the risk of latex allergy. Anything made by the ‘dipping method’ (e.g. balloons, condoms, elastic bands and gloves) is highly allergenic. Moulded rubber items, such as tyres, are much less of a problem. Neoprene and other synthetic rubber items are not allergenic.
• Chiropody and podiatry clinics, where there is a risk of allergic reactions to the fungus that causes athlete’s foot. It is inhaled on skin flakes from the patients’ feet.
• Laboratories and other workplaces where animals are kept. In the case of mice, rats and other rodents, the allergen is found in the animals’ urine, and becomes airborne as the urine dries. Insects and spiders (e.g, those reared for biological pest control), are also allergenic due to small airborne particles from their bodies. Those working closely with bees (either honeybees or bumblebees, now reared for pollinating glasshouse crops) are liable to be stung frequently, and this can lead to sting allergy (see pp. 60-61).
• Hairdressing salons, where many different items are used that are potentially allergenic, including latex gloves (see above), permanent-wave solutions and henna. The risks of contact dermatitis are also high (see p. 55).
• Greenhouses, where the enclosed conditions can lead to high levels of allergens from plants, moulds and insect pests. There may also be exposure to pesticide sprays or their residues, which can greatly aggravate any underlying tendency to allergies.
If you have ever suffered from atopic eczema, work situations that can bring on contact dermatitis should also be avoided (see p. 55).
Taking a risky job
If circumstances force you to take a job with an allergy risk, observe all the safety procedures that are in place, and where you have the option of turning on extractor fans, wearing protective gear, or simply opening doors and windows, always do so. If the safety procedures seem inadequate, talk to your trade union Safety Representative, or the local Health and Safety Executive which can run a check on safety procedures in your workplace. This will be presented to the employer as a routine check, so they need never know that a member of the workforce has contacted the HSE.
Whatever you do, if you are in a risky job, don’t smoke. At a salmon processing plant in Scotland, 40% of the smokers developed allergies (resulting in asthma) to the fish allergens in the spray from the fish-gutting machine. Non-smokers - who formed the overwhelming majority of the workers - were not affected at all. In United States cotton mills, smokers are affected by levels of cotton dust in the air that are legally defined as ’safe’, while nonsmokers remain unaffected.
Passive smoking at work is also an important issue. A recent US study showed that non-smokers were more likely to develop asthma if they worked alongside a smoker. Your employer has a duty to provide you with clean air. This includes ensuring that other employees do not impose their cigarette smoke on you.
Respiratory equipment
Where respiratory equipment is needed, your employer must provide this, and it must be the right equipment for the job. It should be inspected, tested, cleaned and repaired after each use, and filters should be replaced regularly. All this is your employer’s responsibility, but check that it is being done, and always look the mask over before you put it on.
Two different types of respiratory equipment are currently in use:
• Those that give you a supply of air from outside the work area, either from a compressed-air cylinder, or via an air-hose (airline) supplied with fresh air. In Britain these are called breathing apparatus.
• Those that use the surrounding air but filter it to remove allergens and asthmagens. In Britain these are called respirators. (In some countries this term describes any kind of respiratory equipment.) Ordinary respirators may pose problems for some asthmatics because they cannot breathe in strongly enough to draw sufficient air through the filter. Powered respirators can be the answer: they have a battery-powered unit to help with pulling in the air.
There are government regulations concerning the type of equipment required for each type of allergen and asthmagen. Large companies generally follow these regulations, but small businesses, such as local sawmills, joineries and car-repainting workshops, may not even know about them.
Any respiratory equipment that has a face mask must form a tight seal with your face. Facial hair will prevent this, and so will stubble, so shave carefully. Faces vary enormously in shape, and if your face mask does not fit, ask for a different type of mask or a different type of respiratory equipment. Persist until you get one that’s right for you.
Carry out a ‘fit check’ each and every time you wear the mask. For example, with respirators, you can check the fit by covering the air intake completely with your hand and breathing in sharply: if the mask fits properly, it should collapse onto your face, and remain stuck to your face for several seconds. Look at the manufacturer’s instruction booklet as there may be a specific fit check recommended for the equipment you are using.
If there is any difficulty in breathing through the respiratory equipment, the replaceable filter cartridge or the equipment itself should be replaced. You should also take action immediately if you can smell the substance being handled – but never rely on this as a danger sign, because an extremely small amount, way beyond the detection capacity of the human nose, may be very damaging indeed to your health.
Keep your mask on throughout the work period. If you find this impossible, talk to your employer or
line manager about getting a different kind of respiratory equipment – a powered device, for example, that assists the inflow of air.
No form of respiratory equipment provides complete protection against allergens and asthmagens: there is always the chance of some small amount getting through. This is why respiratory equipment should not be used by those who have already developed occupational asthma but want to stay in their job.
Those who really cannot change jobs (e.g, farmers) are sometimes able to use a powered respirator helmet, which allows them to go on working despite the allergen. But this is not an ideal solution from a purely health point of view. Farmers can also improve matters, where moulds are the source of allergens, by keeping all harvested crops dry and thoroughly ventilated.
A lasting problem
As long as you catch the problem early, and are no longer anywhere near the allergen, your symptoms should disappear completely, but remember that you may still be highly sensitive to the allergen, even years afterwards. For a year or two at least, avoid contact with it again, even in tiny amounts. If someone else in your family works at the same place, they may bring home traces of the allergen on their clothes and hair: ask them to leave their workclothes outside the house and shower on arriving home.
With occupational allergies to airborne food particles, it is possible that the affected individual will later react to the same food when eaten. Experiment very cautiously, especially if the allergen is fish or shellfish.
The allergy may persist long after the job has ended. In one case, doctors found that a woman who had developed ‘baker’s asthma’, while working briefly in a bakery when young, was still allergic to the enzyme additive in bread 20 years later. She suffered an asthma attack whenever she ate bread.

Drugs for Asthma
The drug treatment of asthma is far more complex than for any other allergic disease. Drugs prescribed for asthma fall into two basic categories: those that open up the airways by relaxing the airway muscles, called relievers, and those that treat the inflammation in the lining of the airways, called preventers. The former offer a ‘quick fix’ - like taking an aspirin when you have a headache. Just as the actual cause of the headache is not treated by an aspirin, so the actual cause of the asthma attack is not addressed by relievers. Preventers, on the other hand, tackle the basic problem - the inflammation that triggers the contraction of the airway muscles (see p. 36).
In the past ten years, there has been a quiet revolution in asthma treatment, with far more people being given preventer inhalers, usually low-dose steroids. The aim is to get the airways in better condition, with the inflammation thoroughly damped down, so that the airway muscles don’t go into spasm. The ultimate objective is to make people far less reliant on reliever inhalers, because the potential hazards of over-using them are now realised.
The details of modern asthma management, and the different approaches used, are described on p. 160, following the discussion of the main types of drug used for asthma treatment.
Beta-2 relievers (beta-agonists)
Our airways open up when we produce adrenaline. This is the body’s natural response to feeling angry or frightened. The adrenaline widens the airways so that we can run faster or fight more vigorously.
Adrenaline (epinephrine), given as a drug, was among the earliest treatments for asthma. However, it also stimulates the heart to beat faster and raises
the blood pressure. While it is useful for emergency treatment (see p. 155) the side effects make it too hazardous for routine use.
The beta-2 relievers work by mimicking adrenaline – they bind to the same receptors in the airways, the beta-2 receptors. Binding to these receptors stimulates the airway muscles to relax, so that the airways open up.
In other respects, the beta-2 relievers are not like adrenaline. Clever chemical manipulation has made them sufficiently different from adrenaline to have little effect on the heart and other organs, when taken at normal doses.
Beta-2 relievers are best taken by inhalation. Although tablets and syrup are available these are far more likely to bring on side effects, because the dose needed is so much bigger.
Inhaled beta-2 relievers target the drug directly on the airways, so the dose can be smaller. They also have the great advantage of taking effect soon after being inhaled, and giving full relief from airway narrowing within 10-15 minutes.
There are two different kinds of beta-2 relievers:
•    the traditional short-acting beta-2 relievers whose effects last for 3-6 hours (usually about four). The modern consensus is that these should be used only when needed, not taken routinely.
•    the newer long-acting beta-2 relievers, which last up to 12 hours. These drugs are prescribed for more severe forms of asthma (see p. 154), and are generally used routinely, twice a day.
A key question for asthma sufferers is: How often can short-acting beta-2 relievers be used? Ideas about this have changed considerably over the last 20 years, and no doctor would now want to have patients using a Ventolin inhaler five, six or more times a day - something that was quite common in the past. This level of need for beta-2 relievers indicates that the asthma is poorly controlled and requires treatment with a preventer, to quell the inflammation in the airways.
Detailed policy on beta-2 relievers still varies from one part of the world to another. British guidelines state that anyone who needs to use a short-acting beta-2 reliever more than once a day, or who suffers from nocturnal asthma, should be given a preventer as well. The international guideline is more stringent: if a short-acting beta-2 reliever is needed more than three times a week, a preventer should also be prescribed.
How safe are these drugs in the long term? The cause of the big re-think on beta-2 relievers was an epidemic of asthma-related deaths in New Zealand between 1976 and 1988. The death rate from severe asthma attacks was 2-4 times its previous level for a while, and over a thousand New Zealanders died in the epidemic.
There has been a huge controversy over what exactly caused these deaths. Most researchers now agree that the main cause was a new brand of inhaler that delivered a double dose of the drug fenoterol, a short-acting beta-2 reliever with a very powerful effect on the airways and quite high levels of side effects involving the heart. The same brand of inhaler may have been linked to increased death rates in Canada and Germany.
Research suggests that the problem was greatest in New Zealand because sales of the new inhaler were highest there, and because many patients got their inhalers through repeat prescriptions. As a result, people whose asthma was deteriorating badly were not seen by a doctor and were using large amounts of beta-2 reliever, rather than taking preventer drugs. This is now believed to be a major cause of asthma deaths. There are three separate factors involved:
•    The beta-2 reliever covers up the effects of the severe inflammation of the airways. People feel reasonably well, because the reliever is opening up their airways, and don’t realise just how bad their asthma really is. The untreated inflammation in the airways can eventually lead to a very serious, and potentially fatal, asthma attack.
•    The short-acting beta-2 reliever, used regularly, makes the airways more sensitive to exercise, and to allergens such as dust mite or pollen. This means that an asthmatic who is already allergic to these allergens reacts to them at much lower levels in the air.
•    The airways become less and less responsive to the beta-2 reliever itself, so that when a serious attack occurs, requiring hospital treatment, huge doses of beta-2 reliever are needed to open up the airways. These massive doses carry a risk of serious side effects involving the heart.
The details of the New Zealand epidemic still evoke controversy. Was fenoterol itself, which is stronger than other beta-2 relievers, the cause of the deaths? Or was it just that the inhaler delivered a double dose - would any short-acting beta-2 reliever be dangerous at twice the normal dose? Or was it over-use of all beta-2 relievers and lack of preventer drugs?
Some common brand names
Common brand names include:
short-acting beta-2 relievers in inhalers - Aerolin, Airomir, Bricanyl, Ventolin short-acting beta-2 relievers in tablets - Bambec, Bricanyl, Volmax short-acting beta-2 relievers in syrup - Monovent, Ventolin
long-acting beta-2 relievers in inhalers - Bambec, Foradil, Oxis, Serevent
Until this is resolved, safety-conscious asthmatics may want to assume that any of these possibilities could be correct. An ultra-cautious approach would include:
•    Avoiding fenoterol (it is no longer available in Britain, except in the Duovent inhaler, combined with an anti -choli nerg ic drug)
•    Not using double-dose inhalers of any beta-2 reliever (i.e. inhalers that deliver 200mcg/ micrograms per puff)
•    Not routinely taking two puffs of a single-dose inhaler (check with your doctor if you have been told to take two puffs)
•    Using any short-acting beta-2 reliever only I as needed’ – which should be once a day or less according to British guidelines. Note that, with this level of use, there is absolutely no risk from these drugs: it is only regular over-use that is damaging and dangerous.
•    Using a peak-flow meter and ensuring that you are assessed regularly by your doctor
•    Always taking your preventer medication as prescribed.
Since about 1990, the death rate from asthma has been falling, particularly in countries with a policy of reducing use of beta-2 relievers, and increasing inhaled steroids. The death rate in New Zealand is now the lowest it has been for 50 years, and at the same level as in other Western countries.
Unnecessary alarm
While investigating the causes of the New Zealand epidemic, medical researchers discovered that patients inhaling a short-acting beta-2 reliever four times a day had more irritable airways after just two weeks. Their airways were also less responsive to the drug, even after this brief period of use.
Some researchers began to ask if the asthma epidemic itself – the increasing number of cases of asthma – could actually be due to these drugs. Maybe children with mild wheezing, which might have cleared up if left untreated (and which would have gone untreated in the past) were becoming full-blown asthmatics because they were now using beta-2 inhalers?
Many doctors became very concerned about these questions, and a leading medical journal
published an article with the provocative title: ‘Worldwide worsening wheezing – is the cure the cause?’ That was in 1992. Since then, much more research has been done, and it is clear that this particular fear about beta-2 relievers was unfounded.
Unfortunately, there are a few books and other publications around that are spreading unnecessary alarm about these drugs by reporting the debate as it was in 1992. They have taken up that question ‘Is the cure the cause?’, assumed that the answer is ‘yes’, and ignored all the subsequent research, which shows the opposite.
Beta-2 relievers in severe asthma
A few patients with severe asthma remain breathless and wheezy, even though they are inhaling moderate doses of a steroid preventer every day. Increasing the dose of inhaled steroids does not make a huge difference to their symptoms, and it substantially raises the risk of steroid side effects.
Taking a long-acting beta-2 reliever often works wonders for such patients. These relatively new drugs relax the airway muscles, and go on working for 12 hours or more.
There has obviously been concern about long-acting beta-2 relievers having the same sort of insidious side effects as their short-acting colleagues (see p. 153), and so increasing the likelihood of deaths from asthma. However, studies of people taking these drugs suggest that the risks are minimal. Certainly, long-acting drugs taken twice a day are very much safer than short-acting drugs taken four times a day.
Other studies show that the chemical differences of the long-acting drugs, as well as prolonging their effects, also give them a more complex set of actions in the body. For example, they improve the effect of steroids in calming inflammation, and may even have some small anti-inflammatory effect of their own.
Doctors believe that, for patients with troublesome asthma, the benefits of long-acting beta-2 relievers greatly outweigh the risks. But they should only be used in combination with inhaled steroids. Various other options, such as allergen avoidance and the new anti - leukotriene drugs (see p. 159), should probably be investigated as well.
If you are taking long-acting beta-2 relievers, do use them regularly, once every 12 hours – the good effect gradually builds up with consistent use.
Generally speaking, you should not take additional doses in between. These are not intended for use if you have a sudden asthma attack – your doctor will prescribe a short-acting beta-2 reliever for this. This limitation on the use of long-acting beta-2 relievers is certainly appropriate for salmeterol (which was the first of the long-acting beta-2 relievers to be developed) because it is very slow to take effect on the airways. However, one of the newer long-acting beta-2 relievers, called formoterol, begins to work just as quickly as a short-acting beta-2 reliever. Formoterol could, in theory, be used on an ‘as-needed’ basis to combat asthma attacks. You may want to discuss this possibility with your doctor.
Finally, don’t stop taking your preventer drug (e.g. inhaled steroid or cromoglycate), even if you feel a lot better. Long-acting beta-2 relievers are not a substitute for preventers.
Some patients with very severe asthma need to take regular doses of short-acting beta-2 relievers as well as long-acting beta-2 relievers. You should obviously follow the advice of your asthma specialist closely if you are on this kind of drug regime, and not change anything without approval. However, it might be worth discussing other options, such as anti -leukotriene drugs. In addition, do all you can to combat your asthma in other ways – by reducing allergen exposure, avoiding asthma triggers (see p. 39), and employing various other self-help measures (see p. 41).
Immediate side effects of beta-2 relievers
Minor immediate side effects of these drugs include:
•    headache
•    nervousness, trembling, restlessness, anxiety; children may become more excitable, and some are badly behaved or even aggressive.
•    flushing
•    dry mouth
•    muscle cramps.
These side effects – all of which are due to the resemblance of beta-2 relievers to adrenaline – usually wear off relatively quickly. Some long-acting beta-2 relievers may cause nausea and vomiting.
A pounding heart is usually a relatively minor side effect, but it can be more serious, and should be reported to your doctor.
A few asthmatics find that their airways tighten up when these drugs are inhaled, rather than opening. This is called paradoxical bronchoconstriction. If this happens, stop using the inhaler and see your doctor as soon as you can.
Even more rarely, asthmatics can develop allergic reactions to the drugs, or suffer hallucinations or seizures. Obviously you should stop using the inhaler immediately if you experience side effects of this kind, and should see your doctor.
There can be an interaction between beta-2 relievers and other drugs or medical conditions. Should you need a diuretic, tell the doctor or pharmacist that you are also taking a beta-2 reliever, and ask which diuretics are safe. If you have high blood pressure, a heart problem, or a thyroid condition, make sure the doctor remembers this when prescribing beta-2 relievers.
Adrenaline inhalers
Adrenaline inhalers are for use in emergencies. Technically, they are not available in Britain, but they can be imported under special licence, and your doctor may be persuaded to obtain one for you if he or she thinks it might be useful. They are given to people who have asthma and have sometimes had attacks of anaphylaxis (see p. 58), for example in reaction to food, latex or an insect sting. The inhaler provides prompt emergency treatment for the kind of severe asthma attack that you may experience during anaphylaxis.
You should probably be carrying an adrenaline auto-injector as well, as you may need to use both (see p. 98). Those who usually have fairly mild reactions to their allergen can use the inhaler first, to treat symptoms in the mouth, throat and airways. If other symptoms develop, such as faintness or widespread nettle rash,
Asthma alert
If you ever find that your short-acting beta-2 reliever has no effect within ten minutes, or is needed more than once every four hours, this indicates a serious asthma attack and you need urgent medical help (see p. 100).
During a severe asthma attack, while getting to hospital or waiting for a doctor to arrive, up to 30 puffs of a short-acting beta-2 reliever should be taken as an emergency treatment, to get the airways open. There is a risk of death if you don’t use the reliever fully in this situation. (This emergency dose is safe for almost everyone, but there may be risks if you have a heart condition – get detailed advice from your doctor in advance.)
then the adrenaline injector can be used. Those with a history of more severe reactions should start with the adrenaline injector and then use the inhaler if there are still symptoms in the mouth or airways.
Don’t exceed the maximum number of puffs stated on the canister, as the propellant can cause problems. If you have a heart condition, your doctor will advise you about using this kind of treatment safely - adrenaline can affect the heart.
Ephedrine
Ephedrine and orciprenaline (brand name Alupent) belong to the previous generation of reliever drugs. They are chemically very similar to adrenaline and therefore cause a lot of side effects, especially involving the heart.
These drugs are no longer recommended, and will soon be phased out completely. Some older asthmatics may still be using them, just because they have been on them for years and no one has reviewed their treatment.
If you are taking such drugs, ask your doctor about switching to a newer form of reliever - it will be more effective in treating your asthma, as well as having fewer side effects.
Anti -cho linerg ics
These drugs, also known as anti-muscarinics, are relievers. However, they work in a completely different way from the beta-2 relievers. They block the action of the parasympathetic nervous system, a set of nerves that are the biological equivalent of auto-pilot - working without the intervention of conscious thought. The parasympathetic nervous system has many effects on the body, including keeping the airway muscles nicely toned (see box on p. 235). By blocking the parasympathetic, anticholinergics help the airway muscles to relax.
Anti-cholinergics are taken by inhaler, and require 30-90 minutes to achieve their full effects. They should continue working for 3-6 hours.
Some common brand names
Common brand names of anti-cholinergics include: inhalers – Atrovent, Oxivent
nasal spray - Rinatec
For most asthmatics, especially those with a strong allergic component to their asthma, anti-cholinergics are generally less effective than beta-2 relievers. But they are useful to children under one year, who may not respond to beta-2 relievers. They also have a role where asthma is combined with chronic bronchitis -here the anti -choli nerg ics can sometimes be more effective than beta-2 relievers - and they are particularly useful for asthma with a lot of mucus, because blocking the parasympathetic tends to reduce mucus production. For severe asthmatics, anticholinergics may be combined with beta-2 relievers.
Anti -choli nerg ics should be taken only when needed, not regularly several times a day. If used regularly, they can make the airways more sensitive, just as short-acting beta-2 relievers can (see p. 153).
Side effects
Minor side effects of anti-cholinergics may include a dry mouth, blurred vision, constipation, and irritation of the mouth and throat. A few people suffer nausea or difficulty in passing urine.
Serious side effects are rare. Any increase in the stickiness of the sputum coughed up may be a cause for concern, especially in children. If there is an increase in wheezing or coughing, stop taking the drug and see your doctor.
If you already have glaucoma or prostate problems you should be monitored carefully by your doctor, as these conditions can get worse with anti -choli nerg ic drugs.
When anti -choli nerg ics are used in a nebuliser, it is vital that the mask fits well (see p. 163).
Anti-cholinergics for the nose
Another use for anti-cholinergics is in nasal sprays, for the treatment of vasomotor rhinitis, a non-allergic condition that is frequently mistaken for allergic rhinitis (see p. 29). In this disorder, the constant flow of mucus is caused by a malfunction of the parasympathetic nervous system, which is why anti-cholinergics work well.

Various anti-allergy drugs
An allergic reaction is a lengthy, complex process, and the various anti-allergy drugs all work on different stages of that process. That is why it often makes sense to use several different drugs for the same allergic condition: they each tackle the problem in their own way.
Steroids (see p. 140) intervene at a very late stage, quelling the inflammation that follows on from an allergic reaction. Using a steroid is rather like calling the fire brigade to put out a fire, whereas using an antihistamine (see p. 138) is like having fire-proof doors, to prevent the fire spreading at an early stage. Cromoglycate-type drugs (see below) intervene at an even earlier stage. They are like basic fire prevention - teaching children not to play with matches, or fitting smoke detectors.
Anti - leukotnene drugs (see p. 149) work at roughly the same stage of the process as anti-histamines but tackle an entirely different aspect of the allergic reaction.
Cromoglycate-type drugs
These drugs are also referred to as mast-cell stabilisers or mast-cell Mockers.
There are three drugs in this group, sodium cromoglycate (also spelled cromoglicate), nedocromil sodium, and lodoxamide. All operate at an early stage of the allergic reaction, stopping it before it actually starts. They stabilise the outer membrane of the mast cells (see box on p. 12), which prevents the allergic response from occurring.
Some common brand names
Common brand names of cromoglycate-type drugs include:
inhalers - Cromogen Easi-Breathe, Intal, Tilade
eye drops - Hay-Crom, Opticrom, Rapitil, Vividrin, Viz-on nose sprays - Rynacrom, Vividrin
capsules - Nalcrom
This is a far more satisfactory way of dealing with an allergic reaction than trying to tackle it after the reaction has occurred. But from a purely practical point of view, it has a drawback. I order to work at all, these drugs must reach the mast cells in advance of the allergen. They are of very little use if taken after the allergic reaction has begun.
For those who are taking cromoglycate-type drugs on a regular schedule, several times a day, it is very important to be conscientious about taking them on time. This maintains the protective effect of the drug, without any gaps.
If you are using these drugs on an ‘as-needed’ basis, you should take them 30 minutes before an allergen is encountered. or 30 minutes before a bout of exercise, if they are being prescribed for exercise-induced asthma. (Note that children sometimes respond differently, getting protection from these drugs immediately.)
The effect of these drugs takes time to build up. You should take them regularly for at least four weeks before deciding whether they are helping you or not.
One point in favour of cromoglycate-type drugs is that they are extremely safe, with few or no side effects in most people. Sadly, they do not work for everyone. A fairly high percentage of children respond well to them, but the response rate is much lower for adults. Nevertheless, adult allergy sufferers, especially those who need steroids to control their symptoms, should always be given the opportunity to try out these drugs. When cromoglycate-type drugs do work, they are very effective and almost always trouble-free, so they are a good alternative to steroids.
Both sodium cromoglycate and nedocromil sodium are available in inhaler form for asthma (see p. 157). Sodium cromoglycate is also available as nose drops for hayfever and other nasal allergies.
All three drugs are available as eye drops. Recent evidence suggests that sodium cromoglycate drops are less effective than the other two, particularly for the treatment of severe allergic conjunctivitis (inflammation of the eye).
Sodium cromoglycate is available in capsule form for food allergy. Note that these capsules are of very limited value in food allergy, and are certainly not a substitute for food avoidance. They do reduce sensitivity a little and can sometimes be helpful for those with multiple food allergies (see p. 67).
Side effects
There are no serious side effects at all for nedocromil sodium. cromoglycate can, very rarely, cause joint pain and swelling. An allergic reaction to the drug itself is even more uncommon. Stop taking the drug and see your doctor promptly if either of these occurs.
The only other side effects that have occasionally been reported are headache, nausea and vomiting. None of these indicates any damaging effect by the drugs – they are all minor side effects.
Eye drops containing these drugs may cause stinging and burning when inserted, but this is a minor side effect and usually wears off. Flushing and dizziness have sometimes been reported with lodoxamide eye drops.
Nose drops may also cause local irritation. This could be due to the drug itself, in which case it is a minor side effect. Alternatively, the irritation may be due to the preservative used or some other non-drug ingredient (see box on p. 33).
Occasionally cromoglycate nose drops cause bronchospasm – contraction of the airway muscles – but this tends to wear off quite quickly. Bronchospasm can also occur when cromoglycate-type drugs are inhaled (see p. 157).
Anti - leu kotriene drugs
These drugs, which have a set of very specific effects (see p. 159), were originally designed to treat asthma. Their potential for treating other allergic diseases is currently being explored:
•    Several studies show that they work well for perennial allergic rhinitis brought on by allergens such as house-dust mite. They also have some effect on hayfever, but standard treatment (such as antihistamines plus a steroid spray for the nose) is more effective.
•    They are especially useful for both rhinitis and asthma in patients suffering from triad (see box on p. 28). Research shows that they also reduce asthmatic reactions to very small test doses of aspirin, but they don’t give protection against anaphylaxis brought on by normal doses.
•    They have also been used successfully in cases of chronic urticaria and for some patients with delayed pressure urticaria. It seems plausible that they would also be helpful for chronic urticarla linked to aspirin sensitivity.
•    Preliminary trials suggest that these drugs might be useful in atopic eczema. Some studies show a very good response that allows a reduction in steroid creams.
•    Montelukast works very well for eosinophilic gastroenteritis and eosinophilic oesophagitis (see p. 72), according to some new studies.
For side effects of these drugs see pp. 159-60.
Anti-IgE drugs
Since the antibody IgE (see box on p. 12) is such a crucial player in allergic reactions, developing drugs that disable this antibody should help allergy sufferers. The first such drug is omalizumab (brand name Xolair) which was licensed for use in the United States in 2003. It is expected to become available in Britain some time in the next few years.
Omalizumab binds to IgE antibodies and stops them from interacting with mast cells, so blocking any allergic reaction. The drug is given as a ‘depot injection’, just under the skin, every 2-4 weeks. It is gradually released from the injection site and moves around the body in the blood, mopping up IgE molecules.
At present, omalizumab is used for severe hayfever and for people with asthma who are not responding well to the usual treatments. It is only worth using if there is clear evidence that allergies play a part in the asthma. Patients who use omalizumab are often able to reduce their dose of inhaled steroids – and they suffer fewer serious asthma attacks and have better lung function. Some patients can even stop using steroids completely.
Other anti-IgE drugs are in the pipeline. Pilot studies show that one works very well for peanut allergy: after just four injections, sensitivity to the allergen falls sharply, reducing the risk of anaphylaxis from traces of peanut eaten accidentally.
More powerful anti-allergy drugs
Occasionally people with severe allergies, who are on constant high doses of steroid tablets, or who fail to respond to steroids, need treatment with powerful anti-inflammatory drugs, such as methotrexate or cyclosporin. These suppress the immune system, and extremely careful monitoring for side effects is needed.
Adrenaline (epinephrine)
Anyone who has suffered anaphylactic shock (see p. 58) should be carrying a special syringe, called an auto-injector, loaded with adrenaline. The injector is very simple to operate and is designed for emergencies. Most allergy sufferers, even children, can give themselves the injection – or a parent or other adult can give it.
Some asthmatics, and those with food allergy who suffer swelling of the throat, may be given adrenaline in inhaler form as well (see pp. 155-6). This can be useful as an additional treatment but it’s definitely not a substitute for an injector.
See pp. 98-9 for instructions on using adrenaline in a crisis.
Wherever you go, take your injector with you. Always keep it close at hand: you need to be able to use it within minutes of the allergic reaction starting. You may be unable to speak (and therefore unable to ask someone else to fetch it) quite soon after the attack begins. The injector must never be refrigerated. It can also be damaged by sunlight and excess heat.
If you live in the countryside or in an area with a poor ambulance sevice, or if you are going camping or hiking somewhere remote, ask your doctor for a second injector, or one that can deliver multiple injections. Also ask about the maximum number of injections that can be given, and never exceed this total. Some doctors believe everyone should have two injectors, just in case the first dose doesn’t do the trick and help is slow in coming.
It is vital that you are shown exactly how to use the auto-injector. Canadian researchers discovered that only one in four
Some common brand names
Common brand names of adrenaline preparations include: auto-injectors – Anapen, EpiPen
inhalers – AsthmaHaler Mist, Bronkaid, Epiphrine
health professionals got the technique correct when demonstrating how to use an auto-injector In this study, pharmacists were much the best as regards accurate instructions. Dummy injectors are useful for training purposes and most pharmacies have them.
When the adrenaline auto-injectors expire, they can be very useful for practising with, or for showing a new baby-sitter or teacher – practise on an orange or grapefruit.
If you are taking beta-blockers (e.g. for a heart condition or anxiety), adrenaline may not have much effect.
Heavy daily use of beta-2 relievers for asthma (see p. 152) will also make adrenaline less effective when you need it.
Side effects
The important side effects of adrenaline involve the heart. Anyone with a heart condition should be given special advice in advance by their doctor about using adrenaline. The same goes for people with diabetes, hyperthyroidism or high blood pressure, and anyone taking tricyclic anti-depressants. There are quite a few minor side effects from adrenaline, such as anxiety, trembling, nausea. sweating, dizziness and cold extremities. These soon wear off.
Drugs that can make you worse
Aspirin and its relatives have a very bad effect on some people with rhinitis and/or asthma (see box on p. 151). Unfortunately, recent research shows that paracetamol is not safe either. It makes asthma more likely to develop in those who do not yet have the disease, and increases the severity of asthma symptoms for those who do. Unlike aspirin, paracetamol affects everyone, because it lowers the levels of a natural antioxidant, called glutathione, which the body makes to protect the lungs from oxidants. The greatest effects are seen in people who take paracetamol regularly (once a week or more), but even an occasional dose makes some difference.
All the other drugs that can make you worse are prescription drugs, and your doctor should be alert to the dangers. But doctors are overworked and sometimes forget, so it is sensible to know about the risks for yourself. If you have any doubt about the drugs you are taking, ask a pharmacist.
Beta-blockers are a major hazard for people with allergies. They can make the airways contract, and can bring on a serious asthma attack. They also make anaphylaxis more likely in someone who already has allergic reactions (see p. 59) and they increase the risk of a severe reaction to
immunotherapy (see p. 166) or skin-prick tests (see p. 91). Beta-blockers are prescribed for high blood pressure, angina and other heart problems, migraine and thyroid disease. There are alternative drugs in all cases. Sometimes asthma develops in people who have been taking beta-blockers for years. The beta-blockers are not responsible for this, but once asthma has begun, they will make symptoms worse. Eye drops for the treatment of glaucoma may also contain beta-blockers and can have a bad effect on asthmatics.
ACE inhibitors, used for heart conditions, may cause a cough and airway narrowing. They may also increase the risk of a severe reaction to immunotherapy.
Female hormones affect asthmatics, so taking the contraceptive pill or hormone replacement therapy (HRT) may make asthma worse. Progesterone-only contraceptive pills tend to cause fewer problems.
The drug isoniazid (INH), prescribed for tuberculosis, makes the body far more susceptible to histamine in foods (see p. 200).
An allergic reaction to a specific drug (e.g. penicillin) can also occur in some people, resulting in urticaria, or even anaphylactic shock.
Aspirin sensitivity
Aspirin sensitivity is not an allergic reaction, because neither IgE nor mast cells are involved. What causes this problem is a metabolic abnormality — a malfunction in one aspect of the body’s chemistry. The details of this are very complicated: you may want to skip the next three paragraphs and
simply read about how to cope with the problem.
The exact nature of aspirin sensitivity is still far from clear, but it seems to involve a relatively poor production of prostaglandins, combined with a plentiful production of leukotrienes. Both these substances are messenger chemicals which, broadly speaking, promote inflammation. But the details of their pro-inflammatory activities differ. It seems that, ideally, the body should have a harmonious balance between the two, and an imbalance produces problems.
Both prostaglandins and leukotrienes are manufactured from certain fats that are found in the diet. These fats, the raw materials, are worked on initially by two different enzymes — one that leads to the production of prostaglandins and another that leads to the production of leukotrienes.
If one of these enzymes is defective, it may mean that the other is oversupplied with raw materials, resulting in a serious imbalance between prostaglandins and leukotrienes. In those with aspirin sensitivity, or at risk of developing aspirin sensitivity, the enzyme that produces prostaglandins seems to be defective.
Even in the absence of aspirin, this imbalance in the production of prostaglandins and leukotrienes causes problems. It leads to symptoms such as chronic urticaria (see p. 51) or rhinitis, nasal polyps and asthma (a cluster of symptoms that is commonly called triad — see box on p. 28).
Taking aspirin can make the imbalance between prostaglandins and leukotrienes even worse in a person with this underlying abnormality. Aspirin exerts its painkilling effects by disabling the main prostaglandin-making enzyme — the enzyme that is already defective.
When someone with aspirin sensitivity takes aspirin, they may suffer worsening asthma, a severe asthma attack or — the worst-case scenario —collapse. This is a potentially fatal reaction, similar to anaphylaxis, requiring emergency medical treatment (see p. 101).
The greatest puzzle about aspirin sensitivity is why it often takes so long to develop in someone who already has the symptoms of triad —indicating the basic metabolic abnormality. It may be as much as 20 years from when someone has their first triad symptoms to when they begin reacting badly to aspirin.
If you have triad symptoms already, but no aspirin sensitivity yet, what should you do? Unfortunately, there are no safe tests for aspirin sensitivity at present — taking a small dose of aspirin and seeing what happens is very hazardous. It is probably best to assume that you are going to become sensitive to aspirin at some stage, and avoid all aspirin and aspirin-like drugs. Caution is the best plan here because aspirin sensitivity can come on very suddenly, and be life-threatening the very first time it occurs. Note
that some triad sufferers have polyps and rhinitis but no asthma until they actually develop aspirin sensitivity — a dose of aspirin suddenly brings on their first asthma attack plus other symptoms of aspirin sensitivity.
Avoiding aspirin itself is not difficult, but aspirin-like drugs pose more of a problem. Every year there are a number of deaths from these drugs. Some cases occur because a busy doctor momentarily forgets that a patient should not take these drugs. The drugs that need to be avoided are all known as non-steroidal anti-inflammatory drugs (NSAIDs), COX-1 inhibitors or COX-2 inhibitors. However you will not see any of these names on the packet. These drugs are very widely used for pain relief (e.g. in headache and backache remedies such as Nurofen), for the treatment of arthritis, and for several other inflammatory diseases.
There are dozens of non-steroidal anti-inflammatory drugs available, and many are sold under several different brand names. The list grows every year, as new drugs or new brands are launched. The only way to avoid these drugs is to be very cautious:
•    When buying any cold- or flu-remedies, painkillers, medicines for sprains or sports injuries (including those you apply directly to the skin), headache tablets or migraine tablets, always buy them at a chemist’s shop rather than a supermarket, and check with the pharmacist that they do not contain aspirin or aspirin-like drugs.
•    Be cautious also about remedies for an upset stomach. A few (e.g. Alka-Seltzer) contain aspirin.
•    Don’t take any drugs unless you are 100% sure of what they contain. Remember that the ingredients of a familiar brand name can sometimes change — read the label every time.
•    When a doctor prescribes any new drug, always mention that you are sensitive to aspirin, or that you have triad symptoms. Alternatively, check with the pharmacist when the prescription is filled.
•    Aspirin-free painkillers almost always contain paracetamol, a drug which can cause a severe reaction (similar to the collapse induced by aspirin itself) in about 5% of those with aspirin sensitivity. If you are taking paracetamol for the first time, start with half a tablet. Be sure that, for the next 2-3 hours, you have a way of getting to hospital quickly should you start to feel ill. (Note that paracetamol has another entirely separate effect, increasing the severity of asthma, and it is best not to take it too often — see box on p. 150.)
Avoiding all aspirin-like drugs will prevent you having anaphylaxis or severe attacks of asthma. Unfortunately, triad symptoms will not go away however careful you are about avoiding aspirin.
It is well worth trying the new anti-leukotriene drugs (see p. 149), especially if you have aspirin-induced asthma. They seem to help with triad symptoms by curtailing the activities of leukotrienes and so redressing the balance between leukotrienes and prostaglandins.

Few drugs create quite so much alarm as corticosteroids. To some extent, this alarm is justified — if

over-used, they have dangerous side effects. But rejecting them entirely is a great mistake, because

they are safe at the right dose, and immensely useful for a variety of allergic symptoms. With the

information given here, you can use steroids as safely and effectively as possible.
Although their proper name is corticosteroids, these drugs are commonly — and rather inaccurately —

called steroids. This name adds to their doubtful reputation by confusing them with the notorious

anabolic steroids (see box on p. 142). However, the term ’steroids’ is used for corticosteroids in this

book, simply because that is the name most people recognise.
Steroids do not deal with the allergic reaction itself, unlike antihistamines (see p. 138) or

cromoglycate (see p. 148). Instead, they tackle the consequences of the allergic reaction,

inflammation.
What exactly is inflammation? The visible features of this phenomenon – for example, if it occurs in

the skin, around a scratch or cut – are redness and slight swelling. There is also soreness, and some

warmth. All these effects are produced by an influx of immune cells, intent on protecting the broken

skin from infection. These immune cells generate messenger chemicals (see box on p. 10) which boost the

inflammation, as well as attracting yet more immune cells to the area. When inflammation affects

delicate membranes, as when you suffer a sore throat for example, there can be a great deal more

swelling and discomfort.
The inflammation that follows allergic reactions is very similar to that provoked by infection,

although the balance of immune cells and messenger chemicals is slightly different. Eosinophils (see p.

19) play a particularly important role in sustaining the inflammation produced by allergies.
This influx of eosinophils and other immune cells, which lights the fires of inflammation, occurs some

hours after the allergic response itself. It is known as the Late Phase Reaction (see p. 13). Steroids

work well for allergies because they curtail the Late Phase Reaction and have a calming effect on

various immune cells, especially the eosinophils.
Steroid phobia
So many patients have a profound objection to taking steroids that doctors call it, half-jokingly,

’steroid phobia’. One of the hazards of giving information about potential side effects – as in this

book – is that it may encourage ’steroid phobia’. That would be a tragedy, because steroids really are

useful drugs that can do you a lot of good and very little harm, if used correctly. The risks are very

small when the steroids are used at low to medium doses, and targeted directly onto the inflammation.

Even with high doses, the serious side effects can generally be avoided. Please don’t use the

information here to scare yourself – instead, use it to protect yourself while getting the most from

steroid treatment.
A few effects on other body processes remain, even with the new steroids:
•    Raised blood pressure – this can occur even with short-term use of steroids.
•    Children may stop growing, or grow more slowly. Usually they make up for this later.
•    Quite commonly, there is increased hunger (though you don’t actually need more food, and will

put on weight if you eat more than usual). Insomnia and an agitated, edgy feeling during the day may

occur. These are minor side effects, and no cause for concern.
•    Side effects in the eye can occur: there is an increased risk of glaucoma and, with prolonged

use, cataracts.
•    Long-term use can also result in loss of minerals from the bones, leading to thinning and

fragility (osteoporosis).
•    Psychological changes may occur. Some people experi- ece euphoria or greatly increased energy

levels – with the opposite effects occurring when the course of steroids ends. At worst, steroids can

trigger paranoia or severe depression and suicidal feelings. (These effects are more likely to occur in

those with a history of mental illness. If you are concerned about this aspect, discuss the possible

risks with your doctor before taking steroid tablets.)
•    Epileptics may suffer more frequent or more severe seizures.
•    Very rarely, stomach ulcers develop, or other side effects in the digestive system.
•    The skin may become thin, and the small blood vessels beneath it more fragile, leading to easy

bruising and stretch marks (striae). This is also a potential problem with steroid creams (see p. 146).

Elderly patients are much more susceptible to this side effect.
•    Some diabetics need more insulin. in addition, anyone with the potential to develop diabetes is

more likely to do so, but only if taking steroid tablets long term. The diabetes usually goes when the

steroids are stopped.
•    A few men suffer impotence, but only with long-term use of tablets. This can be treated, so see

your doctor. Women may have irregular periods.
•    Damage to the hip bones may rarely occur, usually with excessive doses of steroid tablets. This

is called avascular necrosis and may require hip replacement.
In addition to these effects on other body processes, there are also some side effects that arise from

the steroids’ suppression of the inflammation. These can occur even with short courses. Again, however,

these problems can almost always be prevented, or treated, or reversed if detected at an early stage.
•    Skin wounds may be slow to heal, and are more likely to become infected because of reduced

immunity. This is not a serious problem – just keep all cuts as clean as possible.
•    Infections by viruses and fungi (e.g. Candida – see box on p. 83), may occur more readily.
•    Some infections may be masked initially because fever is suppressed by the steroids.
•    Chickenpox and measles can be far more serious – even fatal – if steroid tablets are being

taken, or have been taken for more than three weeks within the last three months. This is something to

be very careful about (see item 15 on p. 143).
•    Prolonged use can increase the risk of chest infections.
•    Vaccination with live vaccines can cause problems.
•    Older people who once suffered from tuberculosis (TB) may find it comes back.
•    Steroids can lead to pregnancy if using an IUD, because IUDs work by inducing mild inflammation

in the womb.
The most insidious effect of steroids – and remember again that this is only a hazard of prolonged

high-dose treatment – is adrenal suppression. When steroid tablets are taken for more than three weeks,

the adrenal glands’ own ability to produce cortisol (see p. 141) starts to be slightly suppressed. The

longer the course of steroids, the greater the effect. Stopping the steroids abruptly leaves the body

without enough cortisol to protect itself, which, in the very worst cases, can lead to collapse. Less

obviously, there may be greater vulnerability to the effects of accidents, serious illnesses, surgery

or childbirth – demanding events that would normally stimulate a rise in cortisol production to help

the body cope with the stress.
If you take a short course of steroid tablets during this period, there is more risk of side effects

than normal. Adrenal suppression can last for 6-12 months after steroid treatment ends. It may be two

years before the body can cope with surgery unaided and you will need low doses of steroids to get you

through stress of this kind.
Will I look like a weight-lifter?
Absolutely not. The steroids taken by unscrupulous athletes to pump up their muscles artificially are

anabolic steroids. They are entirely different from the corticosteroids used to treat allergies.
Mimicking nature
All corticosteroids are chemically very similar to a substance known as cortisol that is produced

naturally by the body. Cortisol – which is a hormone made in the adrenal glands, located near the

kidneys – has a great number of different effects, apart from damping down inflammation. It regulates

the action of the kidneys, moves proteins out of the muscles and bones, and alters the pattern of fat

distribution.
Like other hormones and chemical messengers that the body produces, cortisol achieves its effects by

binding to receptors on target cells (e.g. immune cells, muscle cells and the cells that make up the

kidneys). These receptors vary a little, which gives researchers scope for making a synthetic version

of the hormone, cunningly modified so that it binds well to one kind of receptor (the one on the immune

cells, for example) but not so well to another (the one on the kidneys).
Hydrocortisone, the original steroid drug, is identical to cortisol, but the newer steroids have been

modified chemically to have the maximum effect on inflammation and minimal effects on other body

processes. While hydrocortisone can only be used for allergies at very low doses (as in

non-prescription hydrocortisone cream), the modified steroids can be used at higher doses.
The side effects of steroid drugs are of two basic kinds:
•    those due to suppression of inflammation (the desired effect of the drugs) because this

partially reduces immunity to disease
•    those due to the effects of steroids on other body processes – undesirable effects which have,

as far as possible, been designed out of the modern drugs.
These different side effects are discussed in more detail on p. 142. First, it is important to look at

the crucial difference between taking steroids in tablet form and applying them directly to the

affected area. Much unnecessary anxiety can be avoided by understanding this difference.
Targeting steroids
The risks of steroids fall dramatically if, instead of taking them in tablet form, you put them exactly

where they are needed: that means drops for the nose or eyes, inhalers to get the drug into the

airways, or creams and ointments to target the skin.
The medical term for this is topical application, and it is infinitely preferable to taking steroid

tablets. When a drug is swallowed, it does its job by being absorbed through the stomach lining into

the bloodstream, and then being carried around the body in the blood. This is called systemic treatment

because it reaches the whole body-system via the blood.
The areas that need the drug – the itchy skin or inflamed airways – get their dose, but so does every

other part of the body. In order to get a useful amount to the afflicted parts, a fairly large total

dose has to be taken which inevitably affects the rest of the body, making the drug far more hazardous.
When a drug is targeted precisely, in sprays, drops, creams or inhalers, the dose used can be very much

smaller. Some of the drug does get into the bloodstream, by penetrating the skin or the membranes of

the nose or airways, and entering the tiny blood vessels that lie just below. But the amount reaching

the bloodstream is usually minuscule compared with the amount in the blood when you take steroid

tablets. Systemic side effects –those due to the drug going round in the blood (see below) – are

usually avoided, although there may be some local side effects, where the drug is applied.
Only with very powerful doses – as in the steroid inhalers used for severe asthma, or high-potency

creams for eczema – do topical steroids reach the bloodstream in sufficient amounts to cause systemic

side effects. You have to be on these treatments for a long time, or be overdoing the dose (a possible

hazard with creams for eczema), to run the risk of systemic side effects.
Steroid tablets
Short courses of steroid tablets – which means three weeks or less – are pretty safe. They are usually

sufficient to get the inflammation under control, and can be taken three or four times a year without

creating any problems.
Even if you have no choice but to take steroid tablets on a long-term basis, remember that the serious

side effects can usually be avoided, or reversed if caught early (see p. 143).
Side effects
Apart from changes that may (rarely) occur in the stomach lining, the side effects of steroid tablets

are all systemic side effects.
In the early days of steroid use, a set of side effects that resemble a disease known as Cushing’s

Syndrome were frequently seen. The side effects included deposits of fat on the shoulders and abdomen,

and around the face, producing a ,moon face’, water retention resulting in puffiness, weakening of the

bones, easy bruising, acne and muscle wasting. All these changes are due to the unwanted effects of

steroids on other body processes, not to any effect on inflammation.
With the new and improved steroids (see left), plus a much more watchful approach by doctors, these

severe side effects have become very rare, but they can still occur in those on high-dose steroid

tablets. As long as they are noticed in good time (see p. 143) the problem can be reversed.
Using steroid tablets safely
Those taking steroid tablets for more than three weeks, or taking a lot of short courses, can protect

themselves from serious side effects in the following ways:
1. Weigh yourself every day. Should your weight suddenly start to rise, despite eating normally,

consult your doctor: this may be a sign of water retention.
2. If you develop hip pain, swollen ankles, muscle weakness or acne tell your doctor.
3. Get your blood pressure checked regularly by the doctor.
4. Get your eyes checked regularly by an optician, who can detect any problems before there is

irreversible damage.
5. In the case of children, make sure the child’s growth is being monitored carefully by the doctor.
6. Stay as active as possible, with plenty of vigorous exercise, to protect against osteoporosis. Avoid

getting too thin, as this is also a risk factor for osteoporosis. Reduce your salt intake and don’t

drink too much alcohol. Ask your doctor to order a bone-density measurement periodically. Following the

menopause, women on steroid tablets should consider taking hormone replacement therapy (HRT) as this

protects against osteoporosis.
7. Persistent unexplained back pain must be reported to your doctor: this can be a sign of

osteoporosis. If you fracture your wrist in a fall (a Colles’ fracture) make sure your doctor knows

about this, and prescribes urgent drug treatment for osteoporosis.
8. See your doctor if you are over-tired, thirsty, or need to pass urine much more frequently – these

can sometimes be signs of diabetes.
9. Take your tablets after food to protect the stomach. See your doctor if you have persistent

indigestion: coated forms of the tablets may help.
10. If you ever produce black, tarry stools, call your doctor immediately. This is generally a sign of

bleeding from the digestive tract.
11. With your doctor’s permission, take all your daily steroids as a single dose in the morning. The

long gap between one dose and the next stimulates the body to maintain its own steroid-making abilities

and so reduces the risk of adrenal suppression. It can also protect against growth problems in

children. Even greater protection comes from taking steroids on alternate days – one day on, one day

off – although not everyone can keep their symptoms under control with this regime. Obviously, you must

consult your doctor before you try. Your dose may need adjusting.
12. Adrenal suppression puts you at risk during any medical procedure. Tell your doctor, dentist, and

anyone treating you in an emergency – even if you stopped taking steroids up to two years earlier. You

should also carry a Steroid Card at all times, in case you are unconscious. These cards are available

from your doctor.
13. Ask the doctor what you should do if you develop any kind of infection or suffer an accident. It is

often necessary to increase the dose of steroid tablets.
14. Tell your doctor if you have ever had tuberculosis, as this can recur.
15. If you or your child have not had measles or chickenpox, avoid contact with anyone suffering from

these diseases – or from shingles (herpes zoster) which is caused by the chickenpox virus. See your

doctor promptly if there is any contact with someone infected. Emergency treatment to combat the virus

must be started promptly.
16. When being vaccinated, remind the doctor or nurse that you are taking steroid tablets.
17. Never stop taking steroid tablets abruptly if you have been taking them for more than three weeks,

as some degree of adrenal suppression may already have begun. Your body needs time to recover its

natural level of activity, so reduce the dosage gradually. Get precise instructions from your doctor

about how to do this.
18. If you are asthmatic, at the end of any course of steroid tablets lasting more than three weeks, be

extra careful about exposure to allergens and asthma triggers. You may be more vulnerable to severe

asthma attacks for as much as a year after long-term steroid tablets are stopped, or the dosage

reduced.
Watch out for adrenal suppression
If you develop any of the following symptoms after stopping steroids,
or while reducing the dose, call your doctor as soon as possible:
•    muscle weakness; muscle and joint pain
•    feeling ‘under the weather’
•    mental changes
•    scaly or flaking skin
•    breathlessness
•    lack of appetite; or nausea and vomiting
•    fever and weight loss
•    painful itchy lumps on the skin.
Note that, very rarely, withdrawal of steroid tablets, or lowering the dose, can unmask a disease

called Churg-Strauss Syndrome (see p. 160).
Steroid nose drops and sprays
Most steroid nose drops and nasal sprays contain very low doses of the drug, and produce no significant

side effects when used for short periods of time. The safety of these preparations is such that several

are available without prescription.
Steroid drops and sprays for the nose are a very effective way of treating hayfever and perennial

allergic rhinitis. They can be used after the symptoms have begun, or in advance of encountering the

allergen.
Steroid nose drops are also useful in reducing the size of nasal polyps (see p. 30) but only if the

drops are inserted correctly. Kneel down and, bending your neck forward as much as possible, put the

crown of your head on the floor. Now put the drops in and stay in this position for several minutes

while the drops reach their target. Once the polyps have shrunk, the drops can be replaced by a steroid

spray which will keep them under control.
Always stick to the stated dose, as with any drugs – don’t use the drops or spray more often than you

should. If you have a cold or other infection in the nose, stop using steroid drops and sprays until it

is better. Following surgical operations on the nose, ask your doctor’s advice before using steroid

drops or sprays.
Side effects
Minor short-term side effects may include dryness and irritation in the nose and throat, and

disturbances of smell and taste. Nosebleeds might occur and should be reported to your doctor. When

inserting the drops, try to keep them away from the central partition of the nose (the septum), as this

is
the part most vulnerable to bleeding. If you are a long-term user of steroid nose drops, your doctor

should check the membranes in your nose regularly, to be sure that they are not becoming thinned. Eye

checks may also be advisable with long-term use, as glaucoma can occur.
Allergic reactions to the steroid are possible, and they can cause bronchospasm (contraction of the

airway muscles) though this is unusual. You should obviously stop using the drops and see your doctor

if this occurs.
With very high doses of steroids in the nose, or prolonged treatment, some systemic side effects might

occur. The main cause for concern is children’s growth (see box on p. 145) – their height should be

checked regularly.
Steroid eye drops
Steroid eye drops are sometimes given for severe inflammation of the eye during the hayfever season.

However, the eye is vulnerable to infections if treated with steroid drops, and such treatment requires

close medical supervision.
Side effects
Be extremely careful about infections – don’t rub your eyes with your fingers, for example, or dry

around your eyes with a towel unless it is absolutely clean. Follow your doctor’s instructions very

carefully, and go back immediately if your eyes become more uncomfortable, if redness increases, or if

you have any other cause for concern.
Steroid eye drops are rarely used for more than a few weeks. With prolonged use, there is a risk of two

serious side effects, glaucoma and cataract.
Using two lots of steroid
Allergy sufferers who need steroid nose drops or a nasal spray, as well as a steroid inhaler, often

worry that they are getting too much steroid overall.
In fact there is no cause for concern, unless you are taking very high doses of inhaled steroid, in

which case talk the matter over with your doctor. The amount in most nose drops and sprays is quite

small and the same is true of steroid eye drops. In all cases, relatively little gets into the

bloodstream.
If you have allergies in the nose, this may well be making your asthma worse, and using steroid nose

drops can be very helpful for the asthma symptoms (see p. 39).
Inhaled steroids and children’s growth
If an asthmatic child inhales relatively high doses of steroids for many years, his or her growth can

be stunted. However, only a small number of children need these high doses, and with low to moderate

doses most children’s growth is unaffected. They may experience a short-term slow-down in growth, but

their eventual height should be normal.
Unfortunately, there are a few children whose growth is stunted even by relatively low doses of inhaled

steroids - and it is impossible to predict which children will respond in this way. However, if it is

noticed in good time, and if the steroids can be withdrawn safely, the child’s growth rate will almost

certainly recover.
Your GP or paediatrician should be monitoring your child’s growth. You can also measure this yourself,

and go back to the doctor if you are concerned. Keep the risks in perspective - uncontrolled severe

asthma also stunts children’s growth, as well as endangering the child in far more serious ways, so

don’t stop using the steroid inhaler.
Steroid inhalers
Inhaled steroids are a key part of the modern treatment of asthma (see p. 157). As with other topical

treatments, inhaled steroids are a great deal safer than steroid tablets. However, some of the drug

does get into the bloodstream, and with high-dose inhaled steroids taken for several years, the levels

can be high enough to cause systemic side effects such as osteoporosis (see p. 142).
The dose is the crucial factor here. The packaging or information leaflet that comes with your inhaler

will tell you how much of the drug is delivered with each inhalation. To interpret the information

about side effects correctly, you need to know your total daily consumption of inhaled steroid, and

whether this corresponds to a low, medium or high dose:
•    For budesonide or beclomethasone, two of the more common steroids, less than 400mcg

(micrograms) per day counts as a low dose for adults and children over the age of five. A moderate dose

is 500-800mcg per day, and more than 800mcg a day is a high dose.
•    For fluticasone (Flixotide), halve these figures (i.e. more than 400mcg a day is a high dose).
•    In the case of children under five, all these figures should be halved (e.g. a high dose of

beclomethasone is more than 400mcg a day).
•    For other steroids, check with your pharmacist.
Anyone taking a low or moderate dose has very little to worry about as regards systemic side effects.

Only those inhaling high-dose steroids for many years need feel concerned.
If you may be at risk of systemic side effects, follow the protective measures described for steroid

tablets on p. 143. Apart from growth suppression in children (see box above) the most likely effects

are osteoporosis, adrenal suppression, and a recurrence of tuberculosis.
You can minimise the risk of systemic side effects from
steroid inhalers by swallowing as little as possible of the steroid. Always rinse out your mouth,

gargle, and spit out the water after using your inhaler. Using your steroid inhaler morning and

evening, just before brushing your teeth, will make it much easier to remember to do this.
Bear in mind that inhaling steroids regularly will help you avoid the need for steroid tablets.

Asthmatics who are worried about side effects sometimes skip doses of their inhaled steroids, then find

their asthma is much worse and that they need a course of steroid tablets. Frequent courses of tablets

increase the risk of serious side effects.
Minor local side effects of inhaled steroids include hoarseness and short-lived coughing due to direct

irritation of the throat. These are no cause for concern.
If you are regularly inhaling steroids from a nebuliser, make sure the mask fits really well (see p.

163).
Because steroids reduce the immune defences a little, one common side effect of inhaling them is a

throat infection by Candida (see upper box on p. 83). Oesophageal infections with Candida can also

happen but these are rare; the symptoms are heartburn and indigestion. Gargling with warm water after

each inhalation will help prevent Candida infections. There are also anti-fungal lozenges, if you are

still having trouble.
Keep inhaled steroids away from your lips if you suffer from cold sores (herpes infections around the

mouth). These can be made worse with steroids.
Fortunately, other infections are no more common when using inhaled steroids. This includes chest

infections.
Recent research has found other side effects in children using high doses of inhaled steroids. Cough

and thirst are common, while hoarseness and loss of voice affect quite a few. Behavioural problems also

occur, including hyperactivity, mood swings, excitability, sleep disturbances, depression, and even

hallucinations.
Steroid creams and ointments
Steroid creams and ointments are used for both atopic eczema and contact dermatitis. By delivering the

drug to the place where it is needed, they reduce the dose required to an absolute minimum and, if used

correctly, are very safe. Dr Ernst Epstein, a dermatologist at the University of California, observes

‘All too often I encounter children who are miserable with uncontrolled atopic dermatitis because of

their parents’ unjustified fears of steroid side effects. It is cruel to the child and the family to

forgo topical medication.’
It is very important to use a steroid cream of the right strength. For example, applying a 1%

hydrocortisone cream (available without prescription) to severe atopic eczema will be of no value.

Similarly, only applying a prescribed cream occasionally, or only once a day when the doctor said three

times a day, will mean that the rash never really succumbs to the treatment.
Keeping old tubes of steroid cream in the bathroom cabinet, and using these rather than the newly

prescribed cream, is another frequent mistake. If the earlier prescription was for a weaker steroid

cream, that is not quite up to the job, you won’t get the symptoms under control.
Inadequate treatment means that the rash goes on longer, so you probably apply more steroid in the long

run – which exposes you to a greater risk of local side effects. It is far better to use a moderately

strong steroid cream for a short period of time and get the inflammation fully under control.
Remember that steroid creams are absorbed far more effectively immediately after a bath or shower, so

this is a good time to apply them (see p. 48).
Don’t stop using steroid creams too soon. The skin looks healthy and happy long before it is completely

healed underneath. You must continue until the ‘hidden healing’ has occurred. As a rough guide, the

point when the skin looks good is just the halfway point: so the steroid creams should be continued for

the same length of time again. If it took three weeks to get to the point where the skin looks fine,

then you should go on applying the steroid creams for another three weeks after that.
Generally speaking, it is a good idea to phase out steroid creams slowly, especially after using them

for a long period of time. Stopping abruptly may cause the rash to flare up again –this is called a

rebound effect.
Once you have atopic eczema under good control, you will still need some steroid cream at home for

dealing with relapses. As soon as you notice any rough, itchy skin, apply the cream twice daily for

three days, then once daily for another three days. This should be enough to curb the outbreak of

eczema before it really gets going.
Side effects
To assess the risk of side effects from your steroid cream or oirtment, you need to know how strong it

is. Four grades are recognised: mild (corresponding to non-prescription hydrocortisone cream),

moderately potent, potent and very potent. Ask your doctor or pharmacist which grade corresponds to

your cream, so that you can make sense of the information given below.
Unfortunately, if steroid creams are not used correctly, there are some quite serious local side

effects. Any steroid cream that is strong enough to work is also strong enough to produce side effects

if over-used, so this is a delicate balancing act. The main local side effects are thinning of the skin

and striae (stretch marks). Teenagers and pregnant women are particularly susceptible to stretch marks

if using steroid creams.
It is important to take care because these side effects can be irreversible. The stretch marks, for

example, may fade in time but never entirely disappear. Sustained over-use of steroid creams can

produce permanent thinning of the skin. Thinning of the ski on the face may produce redness, with small

blood vessels shoving through. The fingertips may develop painful cracks.
Note that these side effects can come on very gradually.. Some may be mistaken for symptoms of the

disease itself.
Other local side effects may include an outbreak of spots that look rather like acne. Increased

hairiness or change in skin colour are also possible. Fortunately these effects are reversible.
To avoid side effects, follow the instructions for using steroid creams carefully, and don’t apply too

much or too often. If you have not been given clear instructions by your doctor on the quantity to use,

go back and ask for more information. Ideally, you should actually be shown the correct amount of the

cream to use each time. Remember to wash your fingers after applying steroid creams
If potent or very potent steroid creams are slapped on W& abandon, enough is absorbed into the

bloodstream to produce systemic side effects, comparable to those that can occur with steroid tablets

(see p. 142).
With very potent steroid creams, used for a long period of time, there is some risk of slight systemic

side effects even though the instructions for use are carefully followed. Young children more

susceptible. Bear in mind that covering the skin with cages after applying the cream increases the

amount absorbed into the bloodstream. The degree of adrenal suppression caused by using the cream (see

p. 142) is probably going to remain unnoticed in everyday life, but a major illness, accident,

childbirth or a surgical operation might reveal the problem – so tell medical what you have been using.
Different areas of the body respond differently to steroids creams. The skin of the face, and within

skin folds.
sensitive and generally requires a lower-strength cream, while the palms of the hands and the soles of

the feet require a higher strength. The genitals and the area around the anus are particularly

sensitive, and can become permanently damaged (and then a source of intense discomfort) by strong

steroid creams: some dermatologists recommend using nothing stronger than 1 % hydrocortisone.
Make sure you see your doctor regularly when using steroid creams continuously, especially if:
•    you are using very potent steroid cream
•    you are applying potent or moderately potent steroid cream over more than 20% of your body for

more than a month
•    you are applying potent steroid cream to a baby or young child.
The vehicle – the cream or ointment base in which the steroid is carried – is important because

sensitivity reactions can occur to certain of its ingredients (see p. 45). Eczema sufferers can even

become sensitised to the steroid itself, and this problem is difficult to diagnose because patch tests

with steroids often give false negatives (see box on p. 91). If you are not getting better, ask the

doctor if this could be the explanation. (If a rash gets worse and starts to spread when you begin

using steroid creams, go back and see the doctor very promptly – you may have an infection called

tinea, or ringworm, which flourishes all the more when steroid creams are applied.)
Tacrolimus and pimecrolimus
These are new treatments for atopic eczema. They are not steroids, but are covered here because they

are an alternative to steroid creams and ointments, and if you are comparing the two treatments it may

help to have the information on them side-by-side.
Tacrolimus ointment (brand name Protopic) is for the treatment of moderate to severe atopic eczema, and

pimecrolimus ointment (brand name Elidel) is for milder atopic eczema, especially in children.
These drugs are immunomodulatory rather than immune-suppressive – they adjust the balance of immune

reactions in the
skin. Unlike with steroid creams, there is no risk of thinning the skin, so they can be used on

delicate areas like the face and eyelids.
These treatments are generally used for patients who are not getting better with moisturisers and

steroid creams. Because they cost so much more (about ten times as much as topical steroid treatment),

and since much of the fear of steroid creams is unfounded, doctors are reluctant to prescribe

tacrolimus ointment ,on demand’. With time, the cost of these treatments may fall.
One important advantage of tacrolimus and pimecrolimus ointments is that they may have good effects

that persist after you have stopped using them. And the benefits are cumulative: in one trial where

babies with atopic eczema were treated with pimecrolimus ointment on an as-needed basis, most had fewer

and fewer flare-ups as the months went by. This was not true of babies being treated with steroid

cream.
As with topical steroids, the effect of tacrolimus and pimecrolimus on infections such as

Staphylococcus aureus is surprisingly beneficial: the enormous improvement in the surface structure of

the skin keeps bacteria out. But heavily infected skin should be thoroughly treated with antibiotics

before you start. While using the ointment, watch out for any signs of infection, especially herpes

(see p. 44), and see your doctor immediately.
Minimise your exposure to UV light – in sunlight and sunlamps – because of the tendency of UV to

provoke skin cancers. With the dampening effect that tacrolimus has on the immune system, the risk of

skin cancers may be a little higher.
Don’t apply anything else to the skin (not even moisturisers) within two hours of putting on the

tacrolimus ointment – they dilute the treatment too much. And don’t apply tacrolimus ointment

underneath bandages or other dressings.
Side effects
A few patients find that, while using tacrolimus ointment, skin in areas not being treated actually

gets worse. Talk to your doctor if this happens. Other possible side effects include stinging and

burning when applied, or redness. These are nothing to worry about, and usually lessen with time.
Some common brand names
Common brand names of steroids include:
nose drops – Betnesol, Vista-Methasone
nasal sprays – Beclometasone, Beconase, Flixonase, Nasacort, Nasonex, Rhinocort Aqua, Syntaris eye

drops – Betnesol, Cloburate, Maxidex, Predsol, Vista-Methasone
inhalers – Aerobec, Becloforte, Beclometasone, Becotide, Flixotide, Pulmicort
tablets – Betnesol, Cortisyl, Dexamethasone, Medrone, Prednesol, Prednisolone,
creams – Adcortyl, Betnovate, Dermovate, Fucibet, Synalar