Posts Tagged ‘hayfever’

‘I get ill if I do a long coach journey - six or seven hours say. I usually feel sick by the end of the journey, and have a headache. The funny thing is, if I’m walking along

the street and I happen to see a coach of the kind that I do long trips on, I feel a bit sick then too, just for a short while. It seems crazy, but I get ill just from seeing

the coach.’
What Jake is observing is the powerful effect of the mind on the body, in the reaction known as conditioning. Some people are more susceptible to it than others, but no one is

completely immune.
The Russian scientist Ivan Petrovich Pavlov first demonstrated conditioning in 1889, with his famous dog-and-dinner-bell experiment. Pavlov rang a bell every time he fed the

dog, and eventually the dog would salivate each time it heard the bell, whether dinner was being served or not. Its stomach would also begin to secrete acid, in anticipation of

the meal, simply on hearing the bell.
Modern-day experiments have shown that conditioning works with immune reactions too. For example, rats can be conditioned by repeatedly giving them an immunosuppressive drug and

always adding saccharin to their drinking water on the day the drug is given. Subsequently, just the taste of saccharin in the water is enough to- suppress their immune

responses.
This surprising discovery is partially explained by the finding that there are nerves running to the lymph nodes – key areas where the immune responses are coordinated. In other

words, the immune system and the nervous system, once thought of as completely separate domains, are in conversation with each other. In fact this is a three-way discussion,

because the hormones are also involved. The study of these complex interactions,
which we are only just beginning to understand, is known as psychoneuroimmunology.
Even before Pavlov carried out his classic experiment, Dr John MacKenzie of Baltimore had discovered that an artificial rose, in the vase on his desk, would bring on an attack

of rhinitis and asthma in one of his patients who believed that she was allergic to roses. (In fact such an allergy is unlikely –see box on p. 127. It is usually the strong

scent that triggers symptoms, the allergy being to something else, often grass pollen, which is in the air when roses flower.)
Much more recently, something similar happened – this time unintentionally – when a boy with severe hayfever and pollen asthma was undergoing hypnosis aimed at helping him

relax. Part of the hypnotist’s standard technique was to describe an idyllic scene in an alpine meadow, and ask the subject to imagine being there. For this boy, it worked all

too well – the thought of the grass pollen in the meadow brought on a severe asthma attack. The hypnotist, with great presence of mind, asked him to imagine a helicopter

suddenly appearing in the sky and rescuing him from the meadow – and the asthma attack subsided. How allergies affect the mind
In studying the psychological aspects of allergy, researchers have discovered that some patients frequently have thoughts that catastrophise the situation. In the case of atopic

eczema, these thoughts might go along the lines of ‘this terrible itching will never end’ or ‘none of the treatment really makes much difference’.
Such thoughts may be just below the surface of the conscious mind most of the time, and it is only by developing the ability to notice what is going on internally that the

allergy sufferer can become aware of them.
Researchers have also found that, when negative thoughts such as these arise, eczema sufferers are far more likely to scratch their skin and so make the eczema worse. Thus the

thought becomes a reality – a self-fulfilling prophecy.
The tendency to catastrophise difficult situations is something that most people develop (or acquire from others) at a very young age, and it may take some effort to even become

aware of this mental habit, let alone change it. Yet it is possible to start thinking about illness, and about life in general, in a different way – for example, as a difficult

challenge but one that can usually be overcome.
Allergies are in no sense unique. Any long-term disease that causes intense discomfort, makes life unpredictable or limits your activities, is bound to have profound effects on

the personality. However strong a person you are, it affects your life, and influences you in a very deep way – shaping you as a thinking and feeling individual. This is

especially true if illness begins at an early age, becoming part of your formative interactions with your parents (see box on p. 233) or marking you out as different from other

children.
This shaping can have both positive and negative aspects, and it is important to recognise that there is a choice about which aspect you emphasise. It is never too late to try

to change the emphasis. Counselling or psychotherapy (see p. 225) may help with this, especially if the counter-productive attitudes to the illness are deeply rooted in family

experiences.
The role of the mind in asthma
The diagnosis of intrinsic asthma has long since been abandoned. This diagnosis, which was commonplace in the 1950s and 1960s, technically meant ‘asthma with no external cause’.

But the widespread assumption was that the cause was psychological. As older asthmatics will tell you, this made their lives particularly miserable, because they were held

responsible for their disease. Families were often ashamed of having an asthmatic child.
The injustice of this sweeping assumption is clear today. Modern research shows that an external stimulus which initiated the asthma, such as an allergen, can usually be found.

Among asthmatic children, an allergic cause exists in 80-90% of cases. Even where no specific stimulus can be found, there is still a clear-cut state of inflammation in the

airways. No one with any knowledge of asthma would now claim that it is an entirely psychosomatic disease, nor even that it is predominantly psychosomatic.
Nevertheless, once asthma has begun, the mind may play an important role in bringing on attacks, or making them worse, as many asthmatics know from their own experience. This is

entirely understandable when you think how closely breathing is tied up with our emotional lives – fear, sadness, excitement and anger all alter the usual breathing pattern in

different ways, and any of these reactions may trigger an asthma attack.
The interactions between the mind and the airways are complex in the extreme, and vary from one person to another. Anxiety and tension can make asthma a great deal worse for

some people, while others only suffer an asthma attack when the stress is over. A few people actually have less trouble with their asthma when under stress and, oddly enough,

this is the reaction that is easiest to explain. Stress activates the sympathetic nervous system (see box on p.235), which produces adrenaline, and the adrenaline opens up the

airways.
For stress to make asthma worse, as it frequently does, there must be some other reaction going on which overrides the effect of the adrenaline. Doctors don’t know exactly what

this is, but asthmatics who get worse when stressed could be hyperventilating (see p. 226) just a little – not enough for it to be obvious, but enough to make their airway

muscles contract.
Breathing through the mouth, rather than the nose, can also occur under intense stress, and this is bad for the airways because the air they receive tends to be drier, dustier

and possibly colder, for not having passed through the nose first. This raw air may irritate the sensitive airway linings of an asthmatic, and so make the airway muscles

tighten. Small local nerves, that run directly from the airway linings to the airway muscles, could cause this reaction.
Scientific tests, carried out in a laboratory, back up these casual observations. For example, many people who are allergic to grass pollen will suffer an asthma attack if the

experimenter says they are inhaling grass pollen through a mouthpiece – even though they are actually inhaling fresh air.
It can work the other way as well. Telling the same asthmatics that they are now inhaling a reliever drug will stop the attack, even though they are still breathing the same air

as before. This is the basis of placebo effect, the benefit that tends to occur with any treatment, even a dummy pill, as long as patients believe that the treatment will work.
Note that it is not necessarily the immune system producing all these reactions. There are also direct effects of the mind on the skin, in atopic eczema, on the airway muscles,

in the case of asthma, and on the nose, in rhinitis. Some of these are due to the autonomic nervous system (see box on p. 235) while others are much less well understood.
The findings described above should be reassuring for anyone who has noticed that their allergy or asthma symptoms are sometimes affected by their thoughts and feelings. There

is no need to feel bad about this, and it certainly doesn’t mean that your allergies are ‘all in the mind’. Conditioning, and other psychological responses, are an entirely

natural reaction to a very real illness.
However, if you suspect that psychological reactions are making a big contribution to your symptoms, you could try to address the problem directly. Hypnotherapy (see p. 223) can

be particularly useful in this regard, because those who are most susceptible to conditioning are also very responsive to hypnotic suggestion – which can counteract the

conditioning messages. Hypnotherapy can also help those asthmatics who
become psychologically dependent on their inhalers – something that happens quite often, especially in people with severe asthma. In the words of one asthmatic ‘If I found that

I’d left my Ventolin at home, that would sometimes start me off wheezing straight away. I was so afraid of being without it.’ Of course, it is important to carry your reliever

inhaler with you at all times, but this kind of excessive psychological dependence is distinctly unhealthy. At worst, it can lead you to over-use your reliever inhaler, which

can increase your risk of a life-threatening asthma attack (see pp. 153-4).
Sometimes the psychological effects involved in allergies and asthma are far more complex and deep-rooted than this, not just a matter of simple conditioning. It is not uncommon

for asthma attacks, in particular, to be provoked by family tensions and anxieties, or by suppressed memories from childhood. This can occur even though the asthma also has a

clear-cut physical cause, such as an allergy to house-dust mite. Some people find that their asthma always gets worse when they are in a certain place, with a certain person, or

in a particular situation. These problems are usually helped by psychotherapy (see p. 225).
While hypnotherapy and psychological treatments can sometimes be valuable, it is vital to remember that the mental factors in allergic reactions are always operating in

combination with purely physical responses – such as the triggering of mast cells by allergens (see box on p.12). Using psychological treatments alone is as much of a mistake as

ignoring the mental and emotional dimension of ill-health completely. The two aspects of treatment – physical and psychological – should always go hand in hand. Be very wary of

alternative therapists who overemphasise the psychological aspects (see p. 209).
Under the skin
To see a baby with severe eczema is heart-breaking for any parent – tormented by something it cannot understand, the child often experiences touch, not as a comforting and

pleasurable contact, but as a further irritation. According to some psychologists who have studied eczema in depth, suffering from severely itchy skin in the early years of life

may create long-lasting psychological problems. They believe that the discomfort associated with the skin, and especially with being touched, interferes with normal processes of

relating to the world and developing loving relationships with others. That is why it is so important to get the skin symptoms under control, with the proper use of steroid

creams, skin care, dietary changes if appropriate, and an anti-scratching programme (see p. 47).
Psychological symptoms from sensitivity reactions
‘People thought that because the hospital couldn’t find anything wrong with me, and because I wasn’t terminally ill, there was nothing wrong with me at all. No one could

understand how I was feeling, or even believed me. My friends and family lost patience with me. I overheard one member of my family saying they thought I was just

attention-seeking. This hurt me so much. I hated being ill all the time. I wanted to go out and enjoy myself and do the things I’d always done, but I couldn’t because I felt so

bad.’
Josey, who is now 27, was ill in this way for seven years, and her symptoms were so incapacitating that she had to give up work and abandon any sort of social life. Now, as she

puts it, ‘I have my life back again.’
The cause of her symptoms – dizziness, confusion, panic attacks, depression, shortness of breath, and a conviction that she was dying – turned out to be a sensitivity to

caffeine which was inducing hyperventilation (see p. 226). Giving up tea, coffee
and cola drinks restored her to normality very promptly, and she has not relapsed since, except on one occasion, when she unwittingly took a headache remedy that contained

caffeine.
What is clear from Josey’s story is how much the disbelief of those around her added to her problems. She felt trapped by her symptoms, which she could not overcome, while

everyone around her assumed that the whole problem was in her head, and that she could ’snap out of it’ if she chose to.
The suffering of patients like Josey could easily be avoided if more GPs knew how to recognise hyperventilation. This is one of those conditions that is well described in the

medical literature, but does not always get onto the curriculum in medical schools. As a result, many hyperventilating patients go through a lot of expensive and time-wasting

investigations, and may not get a proper diagnosis even then. This is especially sad when hyperventilation is so easy to diagnose and treat (see p. 228).
While the symptoms of hyperventilation are easy to spot, once you know what to look for, this is certainly not true of all
The autonomic nervous system
The autonomic nervous system is a kind of ‘auto-pilot’ – a set of controls that generally keeps you well adjusted to your external circumstances without you having to think

consciously about the situation at all.
The autonomic nervous system controls all the involuntary muscles – those in the heart, around the digestive system, and around the airways. It also controls the state of the

blood vessels, including those in the skin. The autonomic nervous system does its work by issuing two different sets of signals – one set that gears the body up for action and

one set that calms the body down.
Two completely separate nerve networks, the sympathetic nervous system and the parasympathetic nervous system, issue these different signals. The target organs – the airways,

heart, skin, and so on – all receive input from both networks.
The ‘get active’ signals are issued by the sympathetic nervous system, which comes into play at times of stress, excitement, fear or anger. When you can hear your heart pounding

or feel your pulse race, that is your sympathetic nervous system at work. It also makes your nasal passages and airways open up, because extra oxygen is needed for intense

physical activity, and it tightens the muscles around the blood vessels, which raises your blood pressure.
‘Chill out’ messages are delivered by the parasympathetic nervous system. This network comes on-stream when you know you can afford to relax. It slows down the heart, lowers the

blood pressure, encourages the digestive system to do its work, and makes the airways grow narrower because less air is needed when you are less active.
Adrenaline (epinephrine) is the messenger substance released by the sympathetic nervous system. Its action in tightening the muscles around the blood vessels allows adrenaline

to be employed as a drug, which saves the lives of people affected by anaphylaxis (see p. 150). During anaphylaxis, there is a massive fall in blood pressure produced by

histamine (see box on p. 12), but an injection of adrenaline can reverse this.
Both adrenaline and its derivatives, the beta-2 relievers such as Ventolin (see p. 152), also help in asthma attacks. They do this by making the muscles around the airways

relax.
The messenger substance of the parasympathetic nervous system is acetylcholine. Drugs which oppose its action – the
anti-cholinergics – can also help relieve an asthma attack (see p. 156) by blocking the airway-narrowing action of the parasympathetic.
One of the ways in which acupuncture appears to work is by adjusting the activity of the autonomic nervous system. When
acupuncture is used to deal with the immediate symptoms of an asthma attack, this is probably how it makes the airways open up.
sensitivity reactions. Food sensitivity can occasionally cause some unexpected psychological symptoms, such as bouts of hysterical crying (see p. 80) that no conventional doctor

would ever associate with food.
Inevitably, patients with sensitivity problems such as these will initially be diagnosed as having a psychological illness rather than a physical one. It may be a very long time

before the correct diagnosis is established.
Even if the patient works out the link between eating the food and experiencing the psychological response, the doctor may well remain unconvinced. What complicates matters for

doctors is that quite a few people with genuine psychological problems would prefer to think that these have a non-psychological cause, such as a sensitivity to food. (In the

opinion of most doctors, patients of this kind are far more common than patients with psychological problems that are genuinely caused by food or chemical intolerance.) For such

patients, accepting that their problems have a psychological cause means thinking about what that cause might be – and it is often something deeply distressing which the person

would rather forget.
Unfortunately, for people who get into this situation, the phoney explanation doesn’t actually help at all, though it can provide a temporary distraction. Ignoring unpleasant

hidden memories is not the answer – the problem does not go away, it just festers. Facing up to the real underlying problem is the only way to get rid of the distress (see p.

225).
If you have psychological symptoms of any kind, bear in mind that psychological causes are by far the most likely. Such causes can include difficult life circumstances, damaging

experiences during childhood, loss of close relationships, or extremely traumatic incidents in the more recent past. Where there are longstanding problems, neurological factors

(damage to the nerves or brain) or metabolic factors (something affecting the balance of chemicals in the brain), might also play a part, or sometimes be the sole cause.
For a busy doctor, without much time to spare, it is immensely difficult to distinguish patients who really do have psychological symptoms due to food or chemical intolerance,

from patients with psychological problems that they have mistakenly attributed to an intolerance reaction.
What adds to the difficulty is that, with time, psychological causes can sometimes be grafted onto a straightforward intolerance problem. This occurs because illness of any kind

can produce some psychological problems of its own, especially if the person affected cannot lead a normal life. The psychological effects of the illness invariably get worse if

the person concerned has been treated with disbelief by doctors, family or friends – as
is frequently the case when a person has indefinite long-term symptoms that are due to food or chemical intolerance. Separating the secondary psychological reactions to the

illness (or to the scepticism of others) from the primary psychological symptoms that are genuinely produced by the intolerance reactions is far from easy.
Hyperventilation and chemical intolerance
Hyperventilation (see pp. 226-9) and chemical intolerance (see p. 84) often go hand in hand. A person who is sensitive to airborne items which they cannot avoid inhaling, such

as perfume or petrol fumes, may well feel apprehensive when they catch a whiff of these, and unconsciously alter their breathing in response. They may hyperventilate.
If they do, this can both aggravate the sensitivity symptoms, and increase their anxious feelings – because one key symptom of hyperventilation is anxiety (see p. 227). In this

way the problem begins to feed upon itself, and can spiral out of control.
Hyperventilation, pure and simple, may also masquerade as chemical intolerance. In these cases, a deep underlying anxiety probably exists in the person concerned, and one way in

which this expresses itself is as a fear of synthetic chemicals. The person’s fear triggers hyperventilation, which is the initial cause of symptoms. That is not how the person

interprets those symptoms however – because the person was anticipating a reaction to synthetic chemicals, the symptoms seem to confirm that a reaction has occurred. Again, a

vicious circle has been started which is hard to break.
Another possible scenario is that someone with a few sensitivity reactions – for example, a reaction to perfume and cigarette smoke – starts to feel concerned about other

chemical sub-
‘ and to suspect that these might also cause problems. If an anxious reaction to the presence of these substances develops into hyperventilation, symptoms will ensue from the

hyperventilation. These symptoms will appear to confirm the person’s fears about yet more sensitivity reactions. In this way, people with relatively mild chemical intolerance

can begin to believe that their chemical intolerance reactions are far more extensive and disabling than they actually are.
Where the symptoms of hyperventilation are all tangled up with symptoms due to genuine chemical intolerance, opinions tend to split. Some doctors will interpret all the symptoms

as psychological, while other doctors will attribute them all to the intolerance. Both are over-simplifying the problem, and missing a crucial ingredient – hyperventilation.

Recognising and treating hyperventilation (see p. 228) can help a great deal to alleviate the illness.
The psychologisation of illness
‘From the moment Joanna was born, she was never hungry’ Sandra recalls. ‘It took all day to force an ounce of milk down, and she seemed to have terrible stomach pains. At six

months old, after countless trips to the doctor, she was admitted to hospital. The hospital doctors couldn’t work out what was wrong, and in the end they said that she was just

very independent and that she wouldn’t eat until she could feed herself. I couldn’t believe my ears – what a thing to say about a six-month-old baby!’ But as far as the doctors

were concerned, that was that.
As Joanna got older, the symptoms got worse. She developed severe constipation, opening her bowels only once every four weeks. Because her over-full bowel put so much pressure

on her bladder, she wet herself several times a day.
‘She hated school, because the other children teased her, saying she smelled. And she had such awful stomach pains that she couldn’t bend down to tie her shoelaces. When she was

six she was admitted to hospital for a second time.
‘Again they said there was nothing physically wrong with her and it was all in her head, and this time they decided that it must be because something traumatic had happened at

home. They wanted her to see a psychiatrist. It was terrible. I knew nothing like that had happened to her at home, but it was impossible to convince them.’ There was talk of

Joanna being taken away from her parents, because of suspicions about child abuse.
Two weeks before seeing the psychiatrist, something happened to change Joanna’s life. Sandra saw an item on television about a book on food allergies. She bought the book and,

remembering how fiercely Joanna had rejected milk as a baby, she hazarded a guess that milk was the problem. She immediately took all dairy products out of Joanna’s diet.
The effect was astonishing. ‘Within 12 hours her tummy ache had gone, and after six weeks she began opening her bowels almost every day. She stopped wetting herself, and was so

much happier and healthier.’ In fact, all of Joanna’s symptoms went away. and she has remained well on a milk-free diet.
Psychologisation is most frequently encountered by patients %vith medical problems that are unrecognised by conventional medicine – Joanna is a typical example of such a

patient. Occasionally, however, those with true allergies find themselves in the same situation. Take, for example, someone who has collapsed after being stung by a wasp but

gives a negative skin-test result to wasp venom. In the case of insect-sting allergy, skin-tests are supposed to give very few false negatives – so the doctor may be sceptical

about the patient’s observation of what happened. A PAST test (see p. 92) may be ordered, but sometimes this too gives a false negative.
Doctors are – not unreasonably – more inclined to believe that the patient is an unreliable witness (there was never any insect involved), or that the patient has a

psychological problem that has led to this consultation, than that both these tests gave a false-negative result. A patient in this position may need to be quite persistent to

get proper treatment. The same goes for anyone else with unusual allergic reactions that are initially labelled ‘psychological’ by their doctor. In such cases, good

communication is everything.
Good communication with your doctor
Given the intense pressure under which they work, doctors often react badly to symptoms that don’t fit into a neat diagnostic pigeonhole, or don’t respond to standard treatment.

They simply do not have the time for unravelling complex problems and there is a common tendency to ‘psychologise’ such symptoms automatically. This often does great damage to

the patients concerned, boxing them into a corner from which it is impossible to escape – the more they try to convince the doctor their symptoms are genuine, and request

further tests or treatment, the more the doctor views them as difficult, demanding patients with psychological problems. Unfortunately, it is part of the dogma about

psychosomatic illness that patients affected by it will object vehemently to such a diagnosis. So the more you insist that the symptoms are not psychological, the more this

confirms the diagnosis as far as many doctors are concerned.
The psychologisation of illness becomes a real nightmare where the patient is a child, and parents are accused of actually causing the symptoms in some way (see Joanna’s story,

left). This has happened more than once to children with unusual sensitivity reactions.
Good communication skills may stop you from sliding into this situation with your doctor. Firstly, whatever else you do, stay very very calm. Getting emotional, agitated or

angry always causes doctors to suspect a psychological cause for your symptoms.
Secondly, be very open with the doctor, and don’t conceal anything. Be clear about describing symptoms, and accurate about times, the intensity of the reaction and any other

details. Never, ever exaggerate. If you are given to describing things quite colourfully in everyday life, tone it down as much as possible for your doctor’s benefit.
Thirdly, don’t make your own diagnosis – doctors are taught to believe that patients who diagnose themselves may well be suffering from hypochondria. Present any medical

knowledge you have acquired from books or the Internet as tactfully as possible. Finally, it will probably help a lot to use the appropriate words to describe your illness when

talking with the doctor.

Acupuncture
Acupuncture shot to fame in the West in 1972, when James Reston, a correspondent for the New York Times, fell ill with appendicitis while covering President Nixon’s historic

trip to China. Following the removal of his appendix, he received acupuncture treatment for pain, and was highly impressed with its effects.
His Chinese doctor invited Reston to witness the use of acupuncture in anaesthesia, and he reported the remarkable fact that patients undergoing surgery could be free from pain

with just a few tiny needles inserted into carefully chosen points on the body. They remained alert and talkative throughout the operation.
Traditional Chinese medicine has enjoyed a good reputation in the West ever since, but what few people realise is that acupuncture anaesthesia is a very new invention. Surgery

was not traditionally practised in China and it was only in the 1950s, after Chairman Mao had urged Chinese doctors to unify Western and Chinese medicine, that the anaesthetic

potential of acupuncture was discovered.
The remarkable effects of acupuncture anaesthesia made a huge impression on doctors in the West – a high-profile success that has had both good and bad results. On the positive

side, conventional medicine has been prepared to take acupuncture seriously, and to undertake some research into its effects. On the negative side, most
of that research has concerned pain control – the effects of acupuncture on the endorphins. These are natural painkilling compounds produced by the body (their effects are

mimicked by opiate drugs such as morphine and heroin).
Western researchers have paid little attention to how acupuncture affects most other aspects of health, including the immune system and allergic diseases. One exception to this

is asthma, where certain nerves do play a large part in producing the symptoms (see box on p. 235).
Treating the person
Diagnosis and treatment are far more orientated towards the individual patient-, in traditional Chinese medicine, and diagnostic labels such as ‘allergy’ or `hayfever’ are less

important than the particular character of a person’s Qi (see box on p. 215), as detected by the acupuncturist. A traditional Chinese acupuncturist pays great attention to the

quality of the different pulses and takes them at the start of every appointment, and at intervals during treatment, to check how the Qi flow has changed. Each treatment session

is unique and tailored to the individual’s condition at that particular moment.
This makes it very difficult to carry out conventional scientific research into traditional acupuncture.
In an effort to make acupuncture accessible to research, a more Westernised and formulaic approach has been developed, using orthodox medical diagnosis and needling a set of

acupuncture points that are prescribed for that medical condition. Experts in traditional acupuncture feel that this approach – first name the disease, then apply a standard

remedy – will often fail, and is missing the whole point of acupuncture.
That is not the only problem with Westernised acupuncture, as Dr David Eisenberg of Harvard University, a leading expert on acupuncture, points out. He describes a typical

acupuncture session in China: ‘Each time the acupuncturist inserts a needle, he or she asks the patient, “Do you have it or not?” referring to the patient’s “obtaining the Qi”

(de Qi). The question asks whether the patient has felt a sensation of fullness, distension, pins and needles, or the like, from the insertion of the needle in the spot being

used… Most Chinese have experienced acupuncture and they understand the phenomenon of de Qi… By contrast, most Western patients seeking acupuncture therapy know nothing of

the phenomenon of de Qi. Not knowing what sensations they should anticipate, they cannot tell the acupuncturist whether a needle is in the right place. When both therapist and

patient know little about de Qi, as frequently occurs in Western acupuncture clinics, the result is bound to be disappointing.’ Fortunately it is possible to find acupuncturists

who have been properly trained, and the sensation of ‘obtaining the Qi’ is perfectly detectable, even to a sceptical Westerner, so look for someone who pays attention to this.
There can be emotional and psychological reactions to acupuncture, so make sure that you also feel relaxed with your acupuncturist and that there is a certain empathy between

you.
Does acupuncture work for allergies?
According to Chinese theories, acupuncture can have some benefits in any illness – if you are ill, your flow of Qi must be disturbed, and it will help to put that right. Indeed,

most people do feel a sense of well-being after an acupuncture session.
To look at this from a Western scientific perspective, acupuncture can stimulate your body to increase its production of endorphins (see p. 214). This gives you a mild high,

similar to that you’d get from running for a couple of hours. Feeling relaxed and confident helps most people to cope better, and gives them a new perspective on life’s

problems. Since the mind plays some part in almost all illness (if only to aggravate the effects of an underlying physical problem), inducing a more positive state of mind can

be of benefit.
As regards more specific effects, several studies show that acupuncture can have a small, short-term effect in opening up the airways of asthmatics. This is not surprising

because acupuncture affects the autonomic nervous system, the ‘auto-pilot’ section of the nervous system (see box on p. 235) which can tighten or relax the muscles around the

airways. A short-term effect is just that – it doesn’t treat the real problem. What matters more in asthma is the long-term impact of any treatment on the underlying

inflammation of the airways (see p. 36). Although some studies of acupuncture treatment have found a reduction in inflammation, other studies have not. However, only one study

to date used an individualised approach to acupuncture, as opposed to a same-for-everyone formula. It is interesting that this study did find good long-term effects on airway

inflammation.
The larger picture
Acupuncture is just one element of Chinese medicine, which has several other techniques available. In China (and in some Chinese clinics in the West) these techniques are used

together, as different ways of tackling the same problem. No traditional Chinese doctor would dream of trying to treat every patient with acupuncture alone and, in the case of a

patient with allergies, herbal remedies would usually be a central part of the treatment.
A recent and very careful scientific study from Germany took this combined approach with hayfever, and showed some benefit. The patients were treated with both acupuncture and

herbal treatment, using a standardised regime but with additional acupuncture points and herbs chosen to suit the individual. Those treated reported a substantial improvement in

how they felt generally –but not in the specific symptoms of hayfever.
The flow of energy
Acupuncture is rooted in ancient Chinese ideas of the human body. which are radically different from those of Western medicine:
•    Vital energy. called Oi or Chi (and always pronounced ‘thee’). is what distinguishes living bodies from dead ones. It should flow easily and harmoniously thrOLIC11011i

the body nourishing and protecting the organs. When the flow of Qi is blocked, or becomes unbalanced. then illness develops. - Channels called meridians are the conduits for Qi

in the body. They mostly run vertically (i.e. from head to toe) and the points where acupuncture needles are inserted all lie on these meridians.
•    The flow of Qi can be measured by carefully taking pulses — not just one pulse as in Western medicine, but several different kinds of pulse.
•    By detecting disturbances in the flow of Qi, and correcting them, existing illness can be cured, and incipient illness prevented, before there are any obvious symptoms.
The nature of the meridians and the acupuncture points remains a mystery to Western doctors. Some parts of the meridians run roughly along the lines of certain nerves or blood

vessels, but they do not follow them exactly. The acupuncture points have no anatomical reality — there is nothing to see either on the surface or under the skin. However, many

are located near major nerve endings or over deep pressure receptors.

Air Pollution and Allergy

Air pollution plays a variety of roles in allergic reactions. Some pollutants irritate the nose and airways (and sometimes the skin) making them more sensitive to allergens. These pollutants can worsen existing allergic symptoms and may promote the development of allergies in children, by making the airway membranes more permeable. Other chemical pollutants may affect the immune system directly, increasing any existing tendency to allergic reactions.
Indoor pollution
For many of us, the air in our houses is much more polluted than any outdoor air. Several of the indoor pollutants irritate the nose and airways, and some can trigger asthma attacks. A few of the pollutants found indoors can also make allergies and asthma more likely to develop in young children.
Background pollution
One of the worst irritants in indoor air is tobacco smoke. Other people’s cigarette or pipe smoke can trigger asthma attacks in the short term, and makes asthmatics generally worse in the long run. Passive smoking might also affect the immune system making allergies more likely to develop, though this is not proven. Do whatever you can to eliminate tobacco smoke from your home.
Everyone is different
This article considers air pollution from the point of view of someone with classical allergies (e.g. hayfever or asthma). Those with chemical intolerance (see p. 84) may well be more severely affected by air pollution.
If you smoke yourself, there are many good reasons for giving up:
• If individuals from atopic families (see p. smoke, they have a far greater chance of developing allergies and/or asthma when exposed to an allergen in the air.
• For those who had asthma as children and have since grown out of it, cigarette smoking doubles the chance of it coming back.
• Parents of asthmatic children who smoke indoors make their children’s asthma worse. Teenagers can be just as badly affected by passive smoking as young children.
• Smoking during pregnancy significantly increases the risk of a woman’s baby developing allergies and asthma. (Smoking also leads to more prematurity, still-births and cot deaths.)
If possible, have an electric cooking stove rather than a gas one –or fit a powerful extractor fan. Cooking with a gas stove generates a lot of nitrogen dioxide, a gas that you can’t smell or see but which affects the airways. This same gas also comes from motor traffic, but peak levels of nitrogen dioxide in kitchens with gas cookers are often ten times the average level on city streets, and frequently exceed standards for outdoor air set by the world Health Organisation. Other sources of nitrogen dioxide include cigarettes, gas fires and kerosene-burning stoves.
For some people with allergies, nitrogen dioxide enhances their response to the allergen. So if you inhale dust-mite allergen together with nitrogen dioxide, it may have more effect than the Smoke screen
Smoke particles from coal or wood do not seem to make allergies more likely to develop - in fact, quite the reverse. In rural areas of Germany, researchers have found that children with coal or wood stoves in their homes were less likely to have allergies or asthma. An Australian study made a similar finding. Bronchitis and pneumonia are more common in those children with wood and coal stoves and these infections may stimulate the immune system in such a way that allergies are less likely to develop later. However, wood smoke may be a cause when asthma begins in an adult.
allergen alone. Breathing sulphur dioxide (see below) and nitrogen dioxide together boosts the reaction to allergen more powerfully than either gas alone.
Nitrogen dioxide might also make asthma attacks more likely, but the evidence on this is conflicting.
For young children, a high level of nitrogen dioxide at home may make the development of allergic reactions more likely. A recent Canadian study showed that children exposed to high levels of nitrogen dioxide in the home - usually from gas cookers - were ten times as likely to develop asthma as those breathing low levels of nitrogen dioxide. If a dog, cat or other furry pet was kept, and there were high nitrogen dioxide levels, the risk of developing asthma shot up even higher, to 25 times that of children with low nitrogen dioxide and no pets. (Other studies have not produced the same spectacular results, but their methods of measuring nitrogen dioxide exposure were less precise.)
Try to eliminate materials that produce formaldehyde fumes, or seal the items with a good coat of paint. Formaldehyde is given off by chipboard and to a lesser extent by MDF (medium-density fibreboard). Injected cavity wall insulation can also produce persistent formaldehyde fumes, and is very difficult to get rid of -moving out is often the only option. A recent study from Australia showed that children exposed to formaldehyde, especially in the bedroom, were more likely to develop allergic reactions: the higher the level of formaldehyde exposure, the more severe the child’s allergic sensitisation.
Those with asthma have more frequent symptoms if exposed to high formaldehyde levels. A recent study from Finland shows that easy-to-clean plastic wall-covering and flooring increases the risk of asthma in children.
A Canadian study found that children whose first home was less than 20-30 years old were 50% more likely to develop asthma than children living in older houses. One possible explanation for this lies with the materials used in the construction and fitting of new houses, especially the plastics, wood preservatives and insulation materials. Solvents, and chemicals such as formaldehyde, are still being given off by these materials some years later.
Air fresheners provoke asthma attacks in some people. For a few individuals they can cause general symptoms of ill-health that are similar to those described for mild chemical intolerance (see p. 84). Those affected generally don’t realise that the air freshener is the source of the trouble. This malign effect is not entirely surprising, since air fresheners work by giving off a chemical that targets part of the brain - the part involved in processing sensory input from your nose. The chemical ‘freshens the air’ by partially disabling your sense of smell. Better to open a window.
Cleaning products, furniture polish and deodorant were never intended to go into the nose and airways, but that’s what happens when they are sprayed from an aerosol, and they can trigger asthma attacks. Steer clear of aerosols as much as possible - there are usually alternatives.
Pollution peaks
Read the instructions and ingredients lists on all products carefully. It is not just a question of what’s in them, but also what gases they might give off when used. One asthmatic died within minutes when the de-rusting agent she was using on her dishwasher produced a large amount of sulphur dioxide gas: her airways tightened up so much that she couldn’t even use an inhaler to save herself. ‘Sulphuric’, ’sulphate’ or ’sulphite’ in the list of ingredients should ring warning bells if you have asthma: sulphur dioxide gas could be given off by this product.
Bleach, and other chlorine-based cleaning products, such as toilet cleaner and scouring powder, should be used sparingly, and with plenty of ventilation. These products release chlorine gas which, in large amounts, can irritate the airways of asthmatics. Never allow bleach or toilet cleaner to become mixed with any other product. Take care with any product containing hypechlorte, chloramine, ammonia, acids or morpholine and with the chemicals used for swimming pool water. All these can trigger asthma attacks.
If doing repairs or DIY work about the house, take special care. Always ventilate the work area well, and wear a dust mask if sawing or drilling.
The smell of paint is due to solvents, and these can act as irritants to the nose and airways. When decorating, ventilate well, and use low-odour water-based paint. Some of the best low-odour paints, tested and shown to be safe for paint-sensitive asthmatics, are only available by mall order: see p. 255.
‘Instant foam’ kits sold for DIY insulation can provoke asthma in those who were not asthmatic previously. Two different substances are mixed to create the polyurethane foam, and during the mixing process, isocyanate is released – this is one of the most powerful asthmagens known (see box on p. 132). The level of isocyanate can breach the safety limit set for factories.
Avoid using fly spray or other insecticides: look for other methods of pest control. A study from Ethiopia showed that people using an insecticide in their houses were twice as likely to develop allergies. A study of Canadian farmers suggested that asthma might be linked to the use of carbamate insecticides (e.g. carbofuran). The sprays used for cockroaches can act as irritants for those with allergic rhinitis or chronic sinusitis.
If advised that your house needs spraying with insecticide, for woodworm or other wood-boring pests, ask for more information before you go ahead. Is the spraying really necessary? What will happen if the house isn’t sprayed? How quickly will it happen? Is there any other method of eradicating the pest? Spraying is often done when it is not really essential – houses remain standing even with woodworm holes all over them. Unless you have a heavy infestation that is threatening the structure of the house, you are probably better off not having the house sprayed. The heavy and ongoing exposure to insecticide that spraying of a house involves is something you and your family should avoid if at all possible. All the sprays used are toxic to some extent – don’t believe those who tell you otherwise. A heavy exposure to pesticides can sometimes make allergic symptoms worse or precipitate chemical intolerance (see p. 85).
The garage, workshop or garden shed can also be very polluted. Petrol, kerosene and paraffin can affect some people with rhinitis or asthma, and can bring on their symptoms. These fuels should always be kept in airtight containers. Paints sold for cars often contain isocyanates, among the most common causes
of work-related asthma (see box on p. 132). If using such paint, wear a mask with an activated carbon filter and make sure the area is well ventilated. Avoid prolonged or repeated exposure.
Outdoor pollution
Some of the pollutants in outdoor air can make allergic reactions worse and can trigger asthma attacks in people who are already asthmatic. A study of hospital admissions in London, Paris. Barcelona and Helsinki found that high levels of pollution increased hospital admissions for asthma by about 3%.
The pollutants that matter to those with allergies are:
• ozone, which soars to high levels on sunny days, mainly in country areas that are near large cities. The reason for this is a chemical reaction which occurs when car exhaust fumes are exposed to sunlight, producing ozone, a highly reactive form of oxygen. Further chemical reactions, involving another ingredient of exhaust fumes, then break the ozone down again. Thanks to this second reaction, there is usually little ozone in city air. But in a relatively rural area 20 miles or so upwind of the city, the pollutants are too dispersed for the second reaction to occur, and the ozone from the urban traffic can accumulate.
Ozone levels in the air tend to peak in the late afternoon and early evening – but it takes 4-24 hours for ozone to produce its effects on the airways. Indoors, ozone breaks down very quickly because of contact with other gases inside the house.
Ozone can increase the effects of allergens, such as pollen, on the nose and airways.
In addition, ozone makes the airway muscles contract, even for people without asthma. Healthy people tend not to notice these effects, whereas some asthmatics may have more symptoms, and may need more drugs, on days when ozone levels are unusually high.
• diesel particulates, which can become a problem in town centres, and close to main roads used by vans and lorries. Unlike ordinary petrol, diesel fuel contains oil, so when it burns it produces tiny black particles. These consist of flakes of carbon (soot), coated with complex chemicals that are produced by the
But what about the ozone layer…?
Is ozone good for us or bad for us? People often get confused about this, because of all the discussion about
‘the destruction of the ozone layer’. But that ozone layer (which screens us from harmful ultraviolet light) is a natural phenomenon and it is thousands of feet up, well away from our lungs. At ground level, in the air we breathe, ozone is unnatural and potentially damaging .
The size of the particles
Diesel particles are 1-10 microns in size, with most smaller than 2.5 microns. Tobacco smoke, coal smoke, fumes from oil-burning boilers, and the smoke from frying food all contain very much smaller particles, down to a hundredth of a micron (.01 microns) in size. (A micron is a thousandth of a millimetre.)
In pollution reports, counts for particles in the air (mostly diesel particles these days, except in heavily industrialised areas) will often appear as ‘PM1 0′, meaning ‘Particulate Matter less than 10 microns in diameter’. This particle size is chosen because larger particles tend to settle in the nose and throat, and not reach the airways of the lungs. The term ‘Small Particles’ is sometimes used to mean PM10.
To deal with air pollution, you need a really good mask with two filters: a dust filter that can take out very small particles and an activated carbon filter that absorbs irritant fumes and gases. Note that while activated carbon filters remove most pollutants, they do not take out nitrogen dioxide unless they have been specially treated.
partial combustion of the oil. It is probably these surface chemicals, rather than the soot particles themselves, that have such bad effects on the nose and airways.
Some research suggests that diesel particulates might increase the risk of allergies developing – to pollen for example. Additionally, when levels of diesel particulates are high, asthmatics tend to have more symptoms. If levels rise above 50 micrograms per cubic metre there is a sharp increase in asthma attacks – and a recent study in Birmingham showed that such levels are regularly reached at roadsides.
• sulphur dioxide, which often reaches high levels in areas of heavy industry, particularly near coal-fired power stations and coking plants. It acts as an irritant to the airways and can trigger attacks in asthmatics, who are far more sensitive to sulphur dioxide than healthy people (see box on p. 207). However, at the sort of concentrations normally encountered, even in quite polluted air, sulphur dioxide does not have any effect on most asthmatics.
• nitrogen dioxide, which is produced by all types of vehicles, and by power stations and some factories. In towns and cities with heavy traffic, nitrogen dioxide can build up to high levels. This gas is also found indoors (see p, 128) – often at far higher levels.
Oil refineries and cement works
In addition to these widespread pollutants, there are localised areas of air pollution, around industrial sites, that are frequently accused of causing health problems, including high rates of asthma. The kinds of industrial sites regularly mentioned include:
• oil refineries and oil-burning power stations
• cement works that use waste solvents for fuel
• dock areas where oil is loaded into tankers.
None of these accusations has been investigated in any detail, so it is impossible to say if there is a real link with asthma.
Avoiding outdoor air pollution
If you live in the kind of area that experiences high levels of ozone (see p. 130), plan your outdoor activities, especially jogging or playing sport, to avoid summer afternoons and early evenings.
Those who live very close to a main road, with a lot of lorries going past, would probably improve their own health, and reduce the chance of their children developing allergies and asthma, by fitting air conditioning or high-quality HEPA air filters – or by moving house. However, the benefits, in terms of decreased risk, are not enormous, and it is important to take other preventive measures as well (see Chapter 8).
When driving, if you stop behind a lorry or bus, keep your distance, close the window and turn off the fan. Diesel vehicles often emit a thick cloud of particles as they set off, and this can come straight into your car, setting off severe attacks for some asthmatics.
A car with air conditioning will reduce your exposure to diesel particulates while driving. When buying a new car, you can make a contribution to air quality by choosing a non-diesel vehicle, preferably one with a catalytic converter fitted. Alternatively, buy a diesel vehicle with a particle filter on the exhaust (now fitted as standard in Germany).
In Britain, the Vehicles Inspectorate of the Department of Transport encourages the public to report lorries and buses seen pumping out black smoke (look in the phone book for the number).
If you are asthmatic, breathing through your nose may help as this can filter out some damaging pollutants before they reach the airways in your lungs. (If your nose is usually blocked, try the exercises on pp. 230-31).
When levels of ozone or sulphur dioxide are high, taking a supplement of Vitamin C and eating plenty of foods that contain Vitamin E and beta-carotene (see p. 207) can protect your airways.

Pollen

Do you ever wake up in the middle of the night with an attack of hayfever or pollen asthma? And do you ever wonder why this should happen? The explanation is that warm air, rising up from ground level on a summer’s day, takes pollen with it high into the Earth’s atmosphere. When the air cools down after sunset, this pollen slowly descends again — an invisible ‘pollen shower’.
This pollen shower falls quite quickly in the countryside, reaching ground level between 8 p.m. and 10 p.m., but hot city pavements and buildings keep upward air currents going, and pollen stays aloft for longer. Most pollen lands on the city between about midnight and 2 a.m. That’s why you wake up sneezing or wheezing – especially if you sleep with the windows open.
Understanding facts like these about pollen can help you to reduce exposure substantially. Pollen is by far the most difficult allergen to avoid, but don’t believe the defeatists who tell you ‘You can’t do anything about pollen.’
Pollen counts and forecasts
Pollen counts are based on the amounts of pollen collected at specific sites earlier in the day, or on the previous day.
Forecasts for the coming day are really just informed guesswork, based on the present pollen count, the time of year, the temperature and rainfall over the last few days, and the weather forecast for the next day. At best, pollen forecasts are only as good as the weather forecast.
Forecasts of pollen can be useful in deciding when to start taking antihistamines for hayfever or when to Increase your asthma preventer drugs (steroid or cromoglycate inhalers). The start of the grass-pollen season is now predicted quite accurately.
Avoiding pollen outdoors
One thing that really can help here is an air-conditioned car. In an ordinary car, closing the windows (and perhaps fitting a filter to the air intake) helps a lot, but the heat is terrible.
The size of the allergen particles
The pollen grains that cause allergies are between 10 and 40 microns in size, with the majority between 20 and 35 microns. An ordinary dust mask takes out particles larger than 5 microns, so it will be adequate for most pollens. However, a few plants — including rye grass — produce tiny allergenic fragments, some no bigger than half a micron. These are about the same size as cat allergen and will therefore need much better masks. For these fragments, it is worth using a HEPA air filter, and getting a high-quality vacuum cleaner.
A cycle mask, or special nose filters sold for hayfever, will keep out pollen at peak pollen times. Just wearing a scarf over the mouth and nose will also give some protection. Another option is to smear a little Vaseline just inside each nostril and breathe through your nose only. Much of the pollen coming into your nose will stick to the Vaseline. If you ’suffer symptoms in the eyes, sun- glasses will keep some pollen out. Even better are wrap-around shades, or safety goggles with side panels sold in DIY stores.
Pollen release occurs at different times of day for different plants. Grasses release pollen from about 7.30 a.m, onwards, but if the ground is damp the release will be delayed until the moisture has evaporated. Unfortunately, a few grass species wait until the afternoon, so there will be some pollen entering the air all day. If you get up at 6 a.m. for a walk or run, you can be safely home by 7.30 a.m. Alternatively, go out In the early evening, after grasses have finished releasing pollen, and before the ‘pollen shower’.
Birch is an afternoon pollen: release peaks between noon and 6 p.m. Unfortunately, there is no information at present for other types of plants.
All types of plants favour warm sunny days for releasing pollen, and they all avoid rainy weather. On cloudy days there is a build-up of pollen in the flowers, so a massive release of pollen occurs on the next day of good weather.
Avoiding pollen indoors
Pollen grains have one huge point in their favour: compared to other allergenic particles, they are big and heavy. This means that they settle more quickly from the air. In a room with 3m- (1 Oft-) high ceilings, all the pollen will settle within four minutes, as long as the air is completely still. In other words, if you close all the doors and windows, block off any draughts, and sit fairly still, within four minutes you will be breathing pollen-free air.
This does not mean that all your symptoms will instantly vanish, because the ‘Late Phase Reaction’ (see p. 13) can go on for up to 24 hours. But you should feel better and, by not starting a new cycle of allergic reaction, you are improving the prospects for the next day. Escaping from pollen for a few hours every day should produce a general improvement in the long run, with your nose and airways becoming less inflamed.
The bad news is that some plants produce allergenic fragments much smaller than the pollen grains themselves. Various grasses do this, as do birch trees and certain plants not generally found in Britain, such as ragweed. These tiny particles take much longer – up to six hours – to settle from the air.
Some plants even produce ‘volatiles’ – airborne chemicals that provoke symptoms. Birch trees release volatiles from their buds in early spring, weeks before the pollen itself is released, and they affect a great many people, including some who are not allergic to birch pollen. Volatiles can only be removed by masks or air filters if they contain an activated carbon filter (see p. 109).
The notorious effects of oil-seed rape on the nose are also due to volatiles, not pollen. These volatiles are simply irritants and there is no allergic reaction.
To cut down on the amount of pollen you inhale at home:
• Dry all your laundry indoors during the pollen season, to stop it collecting pollen.
• Pets bring in pollen on their fur, so keep them outdoors during the pollen season, and avoid stroking them or getting too close. Brushing them thoroughly before they come in is another option, but the allergic individual should not do this.
• Close the windows when your offending pollen is being released, and during the evening ‘pollen shower’ (see p. 126).
• Change your clothes when you arrive home, since they will be coated with pollen, and wash or rinse your hair. Keep some clothes for indoor use only.
• Aim for still air (no draughts, no fans and no vigorous movement) in the rooms where the allergic individual studies, sits or sleeps. Air currents stir up pollen from the floor and furnishings. (No draughts means poor ventilation, of course, which is acceptable during the pollen season – but ventilate again afterwards, to discourage moulds and dust mites.)
• If tranquil air is an impossibility, consider getting a high quality air cleaner, or air conditioning. Alternatively, wet-dust and vacuum every day (using a vacuum cleaner that keeps allergen particles in – see pp. 116-17) to reduce the amount of pollen residue. Those who are very sensitive may need to do this as well as having an air cleaner.
• Cover your armchair and bed with a dust sheet during the day. In the evening, fold this up very gently and wash it. This removes the layer of pollen that accumulates on furniture during the day, before it is disturbed and inhaled. If you are studying, cover your desk and books when not working.
Places to go, places to avoid
• For the grass-sensitive, mown grass is usually fine (it won’t flower) although some people react to skin contact with grass (see p. 43). Unmown grass does flower, and will cause symptoms. Wheat, barley and oats, although they are grasses, release little pollen and rarely cause problems. Rye and sugarcane do release pollen, and may affect some people, but maize (corn) has heavy pollen that does not travel far, so it rarely causes much trouble.
• The levels of most pollens do not differ much between town and country. In fact, high up in a tower-block may be one of the worst places, because of pollen rising on warm air.
• The seaside is often pollen-free thanks to onshore breezes. Mountain peaks and ridges are also good, but deep mountain valleys can be pollen traps.
Roses are not the problem
The pollens that cause allergic reactions almost all come from plants with inconspicuous greenish flowers. These plants are pollinated by the wind, which is why there is so much of their pollen wafting about in the air. Colourful and scented flowers are pollinated by insects and have big sticky pollen grains that don’t float about and rarely cause allergies. However, strong scents can irritate the nose of those who already have hayfever, and make their symptoms worse.

Many countries have special schools for children with severe asthma and other allergies. Italian children are sent to one in the Italian Alps, where there is no trace of pollen, house-dust mite, or animal allergens. After nine months these children are a great deal healthier and more active - all their lung function tests are vastly improved. Blood tests show that they are actually less allergic to common allergens than before.
You may not be able to do quite this well at home, but all allergens and irritants can be avoided to some extent. Even if you can’t eliminate them completely, you can certainly reduce your exposure.
Before you start, it is important to be clear about exactly what affects you, otherwise you will be wasting a lot of effort. For example, people who are allergic to dust mite often think that a dusty house will necessarily be worse for them than an apparently clean house, but this is not so (see p. 115). Or they may say ‘Oh, I got asthma on holiday, because the roads were so dusty and I’m allergic to dust,’ forgetting that only house dust contains dust mites. The road dust may have acted as an irritant, and helped to spark the asthma attacks, or it may have contained pollen or mould spores - but it does not contain dust mites or their allergens. Blaming the wrong thing for the asthma attack means that the real culprit is not identified.
If you are not absolutely sure what causes your allergies, skin-prick tests (see p. 91) can identify the allergen. These are especially recommended if your reactions to the presumed allergen are inconsistent, or you don’t respond to the anti-allergen programmes described here. For example, a few people who react to house dust are not allergic to dust mites, but to something else in the dust such as wool fibres or mould spores, or particles from cockroaches, house
flies, carpet beetles or a long-departed cat. Even pollen that has accumulated in house dust can provoke allergic reactions - if you are not an over-keen duster, it can still be there long after the pollen season.
If you have hayfever, knowing which pollens cause your symptoms (and learning to recognise the plants concerned) is useful. You will probably need skin-prick tests to be sure. ‘Hayfever’ can even be a seasonal mould allergy in some people (see p. 27).
Tackling allergens is now big business. There are a lot of people out there competing for your money and false claims are common, especially for anti-mite products. Only a few manufacturers are deliberately misleading, and most false claims probably stem from ignorance or wishful thinking, but be very sure you know the facts about your allergen before you buy.
Air cleaners are a good example. A really good quality air cleaner (which uses a HEPA filter - a High Efficiency Particulate Air filter) is an expensive purchase and, as the advertising tells you, it takes out very small particles with staggering efficiency. But this is entirely irrelevant if the source of those particles is no distance at all from your nose - your mite-infested pillow, for example, or the cat on your lap.
Something else that advertisements for air cleaners rarely mention is that unless you reduce allergen production - tackling mould growth in the house, for example, or keeping the dog outside - the filter can’t help much. In short, air cleaners do have their uses for some allergens, but they can’t work miracles.
The products mentioned here, if not available in your locality, can be bought mail-order from specialist suppliers of anti-allergy products (see p. 255). Note that some offer both very good products and distinctly doubtful products, so judge each item on its individual merits. Ask to see scientific evidence that it works.
Don’t be taken in by vague statements such as anti-allergenic’ - get the facts. This label is often used on pillows with synthetic filling, for example, and people assume that it refers to dust-mite allergy, whereas it simply means that the pillow does not contain feathers. But unless you are allergic to feathers, there is no reason to avoid feather pillows. (In fact, if not covered with mite-proof covers, synthetic pillows collect more dust-mites than feather pillows, because the fabric used for the cover is less tightly woven and the mites and skin particles get in more easily.)
Bad advice is also a hazard. Some of it just wastes your time and effort, but some could actually increase your exposure to the allergen. Advice to vacuum floors daily, or to vacuum beds, is commonplace but this achieves little and it means breathing much more allergen unless you have the right kind of vacuum cleaner. One health magazine even advised its readers with dust-mite allergy to ‘air mattresses by regularly turning them’. This will not affect mite numbers at all, but it will shoot massive amounts of mite allergen out of the mattress and into the nose and lungs.
Ridding your house of allergens and irritants is, in itself, a hazardous procedure because more of the offending substances will be released into the air during the work. If you take up carpets or remove mattresses, dust-mite allergens and mould spores will be churned up in their millions. Just bundling up a duvet will produce invisible clouds of dust mite allergen - and cat allergen, if your pet once slept on the bed.
Ideally, the allergic individual should not do the work, nor be in the house until it is 100% complete and the house has been very thoroughly aired. This is particularly important for those with chronic sinusitis and mould growth in the house, because of the risk of fungal infections in the sinuses (see p. 32).
If you are an allergy sufferer and have absolutely no choice but to do the work yourself, or to be present, then you should get a good quality dust mask and wear it throughout - only take it off when you go outdoors. Those with atopic eczema and sensitivity to airborne allergens should cover their skin carefully -with clothing, not barrier cream.
An ordinary hardware-shop dust mask is not adequate for most allergens - it only takes out really big particles and lets through all the common airborne allergens except pollen. You need a more serious sort of mask, designed for workplace use and conforming to official standards. Before buying one, ask what is the smallest size of particle that it filters out (at 90% efficiency, or better). Compare this with the particle size of your allergen (given in the articles that follow).
You must be able to breathe well through the mask when physically active, and it must fit tightly against your face, forming a seal at all edges. Beards and moustaches tend to prevent this - as does stubble.
Masks that combine an activated carbon filter with a dust filter will take out gases and chemical vapours as well as particles. Cycle shops now sell such masks -or try an industrial supplier. Such a mask can be useful if you are affected by traffic exhaust or industrial pollution as well as an allergen, for example, or if you are exposed temporarily to wet paint or other fumes at home. Activated carbon masks should also filter out the irritant substances from oil-seed rape plants.
Some people who try the anti-allergen programmes feel much better quite fast. But generally these are long-term strategies - you may not reap any benefits for a few weeks, and the improvement may be small at first. Sometimes it takes several months for the full effects to be felt, so be persistent.

Tony had suffered from hayfever since childhood but rarely took any medicines. Outside the grass-pollen season, he was fine, free of allergies and very fit. Then, when he was 35 he bought a run-down cottage in the country. The cottage was very damp and dirty.
The previous owner of the cottage, an elderly man, had died, and everything was much as he had left it. Tony moved in with his wife in late summer, and they began pulling out all the old carpets and furniture. Many of the windows would not open and there were dank musty cupboards and attics to be cleared. Dust filled the air – and Tony’s nose. He began to sneeze a little and within a few days he had a strange and unfamiliar feeling of tightness in his chest. During the following weeks, harvesting began in the surrounding fields, with several huge combine-harvesters working away all day and night. Tony noticed that, when out of doors, his eyes began to stream and the tightness in his chest became more noticeable. A few more days passed, and Tony found it harder to breathe, so he reluctantly went to see the doctor. The diagnosis was asthma. Skin-prick tests showed that Tony had allergic reactions to house-dust mite and moulds.
Tony’s case shows how someone who is already sensitised to an allergen – pollen in this case – may be vulnerable to developing new sensitivities, and new symptoms. It was almost certainly the dust mite and mould spores in the cottage that sparked off the trouble, followed by the mould spores from the cereal leaves, dispersed during harvesting.
For people with a tendency to allergies, the dangers of heavy exposure to potential allergens are something to bear in mind. It is surprising how many people with asthma had their first major attack while away from home, sleeping on an old sofa or in a friend’s dusty spare room. The dose of dust-mite allergen that you get from an ancient mattress or eiderdown can be massive.
Managing your allergy symptoms
As well as avoiding the development of new allergies, you need to manage your existing symptoms, and make sure that they interfere with your life as little as possible. For this you need good information and advice, support from your doctor, optimal drug treatment, and careful avoidance of your allergens.
Quite often people have all the information and drug treatment they need, but they still don’t stay on top of their health problems. There can be two distinct reasons for this: either they are not wholehearted about wanting to be well (ambivalence) – or they have never really accepted that they are ill (denial).
Ambivalence
Sometimes being ill has certain benefits – or being entirely well has certain disadvantages. Our state of health determines how people treat us, especially within the family, and the expectations people have of us. It may be comforting to be ill because others are more supportive then, or it may be less risky, because we are not forced to try things (such as sports or other physical activities) at which we might fail or look foolish. Being ill as a child often sets up a pattern for how we interact with the world, which revolves around caution, the comforts of familiarity, and holding back from new situations.
These habitual patterns can survive in the mind long after any real advantages have evaporated. Many people become stuck with a way of thinking and living where ill-health is a cornerstone of their existence. Doctors at the Chelsea and Westminster Hospital in London, who have developed a radical programme for treating atopic eczema (see pp. 46-8), have noticed this in their patients. ‘Old habits die hard and living with a little bit of eczema is a very tempting prospect for many patients, rather than clearing the skin completely…. As atopic skin disease begins for many in the first year of life, causing sometimes understandable alarm and despondency in the parents, the child learns how relevant their condition can be in their relationship with the external world, and with their parents in particular. Before they are able to speak, they have a powerful means of gaining parental attention which can have long-standing effects in the development of their personality. For some, to live without eczema is understandably a daunting prospect. This can be consciously appreciated and spontaneous-y referred to by some patients, while for others the issue will be buried from view, deep in their unconscious.’
If any of this rings bells with you, try to tackle the problem at source. Such mental blocks are not immovable. Indeed, simply recognising that the block is there can start to change things for some people.
Others may need professional help to overcome these longstanding habits of mind. Counselling or cognitive therapy can be very valuable, and your doctor may be able to help in locating a suitably qualified person for this.
Denial
At the opposite end of the spectrum are those who want to deny that they have any kind of health problem. Often these people cannot quite accept that they have a long-term disease, such as eczema or asthma, so they forget to take their drugs, apply creams to their skin, or carry their inhalers. Ironically, these people frequently wind up having far more trouble with their allergies than they need to, and a very poor quality of life, simply because they neglect preventive treatments.
To be really well, you first have to admit that you do have allergies, and then sort out your conflicting feelings about what this means. Again, counselling, cognitive therapy or some other kind of psychotherapy can be helpful.
Dealing with doctors
The decisions that your doctor makes about your treatment are ones in which you should be fully involved. Quite a few allergy patients don’t feel happy about their doctor’s treatment plan, but they never say so to the doctor’s face.
The usual pattern is to accept what the doctor prescribes without any argument, but then halve the dose of tablets, or only put the cream on once a day instead of twice, or not use the Inhaler at all. Some people stop and start their drugs in a random way because they never quite make up their minds about whether drugs are a good thing or not.
This approach to allergies invariably leads to worsening symptoms. The risks are greatest with complex problems such as
atopic eczema or chronic sinusitis, where a vicious circle can easily be set up if the disease is not brought under control, and for those with a life-threatening condition such as asthma. In the case of asthma, neglecting preventative treatment can be fatal.
It is far better to say what you think in the surgery, and discuss any misgivings you may have about drugs with the doctor. That way you can agree on a treatment regime that you are prepared to stick to – which may or may not involve drugs. Most doctors would far prefer a little plain speaking at the outset to having a patient who is half-hearted about following the treatment plan and never really improves.
A more serious form of communication breakdown occurs when a doctor stops believing what a particular patient says. This usually occurs because the doctor has decided that some or all of a patient’s symptoms are due to psychological rather than physical causes. (This is far more likely to happen to those with intolerance or unusual forms of allergic reaction than to those with classical allergic diseases.) Sometimes doctors say what they think, but often they don’t – they just start treating the symptoms in a different way, or acting impatiently, or saying rather puzzling things that leave the patient trying to guess what is going on.
If you find yourself in such a situation, the main thing to do is stay very calm and be very rational. Getting upset, or challenging the doctor’s opinion in a manner that seems at all aggressive, instantly confirms the ‘psychological’ diagnosis. Unfortunately, insisting firmly that the symptoms are not psychological also confirms the diagnosis as far as many doctors are concerned (see p. 237) which can be extremely frustrating. To begin with, deal with the situation by informing yourself about your illness. Be tactful and patient but persistent with the doctor, trying all the time to keep the relationship pleasant and the channels of communication open. If, after giving it a fair try for some weeks or months, this approach isn’t working, you should look into the possibility of changing doctors (see p. 88).
Emergency alerts
An emergency alert bracelet or pendant should be worn by anyone who:
• is allergic to latex rubber, or to drugs such as penicillin
• has a severe allergy to insect stings
• suffers from exercise-induced anaphylaxis, or anaphylactic shock as a result of food allergy
• has very severe asthma attacks.
Key information is engraved on the bracelet, along with a telephone number which gives medical staff access to a computer database containing vital medical data about you. This valuable service is provided by a non-profit-making company called Medic Alert.
As everyone knows, a little knowledge is a dangerous thing. You can use the information in this book to help yourself, but it’s important to remember that there is no substitute for the comprehensive understanding of the human body that your doctor gained during many long years at medical school. Always check with your doctor before changing your diet, stopping your drugs, practising breathing exercises, taking a non-prescription medicine or trying any other experimental treatment.
The information about disease, diagnosis and treatment in this book falls into four categories:
• basic information about the disease that no doctor would disagree with
• the findings of new research, or research that has not become widely known, but which falls within the accepted medical model of the disease concerned. Your doctor may not know about some of this research (there is a terrifying amount of new information bombarding doctors every week, and no one can keep up with it all) but he or she won’t find it unbelievable.
• evidence from research that is entirely valid, but which is widely ignored or dismissed because it falls outside the accepted medical model of the disease concerned (see pp. 86-7)
• information based on the repeated observations of doctors, or of patients – this does not amount to scientifically valid evidence, but it’s included here if it seems plausible and if it could be useful to some readers.
You should be able to tell, from the context in which it is presented, which category any item of information falls into. When talking to your doctor about items that belong in the last two categories above, be prepared for a certain amount of scepticism or possibly outright dismissal.
The important thing to ask the doctor is if there is good reason why you should not try the suggested measures, in addition to your usual treatment – is there any risk involved, given your particular state of health? Make it clear that you want to try the additional treatment with an open mind and will drop it if it is not helping. Ask for the doctor’s help in assessing the effects of the treatment objectively.
Managing asthma
Of all the diseases described in this book, asthma is among the most difficult to live with, especially severe asthma. Learn to recognise asthma symptoms before they get out of hand, and take immediate action.
Studies of patients who die from asthma attacks find that the deaths could, in almost all cases, have been prevented. Factors contributing to fatal attacks include:
• heavy exposure to allergens just before the asthma attack
• cigarette smoking
• failure to use preventer drugs
• repeat prescriptions for inhalers being given without the patient seeing a doctor
• delays in seeing an asthma specialist
• depression in the asthmatic leading to neglect of treatment.
For the day-to-day management of asthma, you should have a written management plan prepared by your doctor or asthma nurse.
This should tell you how often to take your drugs under normal circumstances, and what to do if your symptoms change or you develop a cold or chest infection. The actual brand names of your drugs (or the colour of the inhaler) should be included on the management plan. Assuming you have a peak-flow meter – and you really should have one –specific peak-flow values should be included on your management plan, with instructions for how to respond if your peak flow falls to these levels.
Your plan should tell you how to recognise a severe attack coming on, and what to do at the various stages of the attack. (This personal management plan is specifically geared to you or your child. Although pp. 100-101 give generalised advice, your own plan is invaluable.)
Be sure that you know exactly how the advice in the plan relates to the sort of real-life situations you experience. No matter how good your plan, real life can sometimes be far more complex than anyone anticipates, so there may be times when it is difficult to know what to do. When this occurs, make a note of the situation, and the reasons why you are unsure how to implement the plan. Call your doctor immediately if your asthma is getting worse, and get the asthma attack under control. Save your notes and, at the next opportunity, check with the doctor what you should have done in those circumstances. This will help you to build up your detailed knowledge of how to manage your asthma, or that of your child.
Research shows that asthmatics can, with training, develop a greater awareness of how narrow their airways are – this helps you to detect worsening asthma before things get too serious. You can train yourself in this art by guessing what your peak flow will be and writing your guess down before you use your peak-flow meter (see right) each day. Over a period of weeks, you should find your guesses getting closer to the true value.
A key part of asthma control is having everything with you that you need in case of an attack. It’s tedious, but you have to do it. You should take your reliever inhaler with you wherever you go. Those with severe asthma can also benefit from carrying a collapsible spacer (ask your pharmacist or see p. 255 for contact details of suppliers).
For a long day out, or a stay away from home, check that you also have:
• your management plan
• your peak-flow meter
• your preventer inhaler
• steroid tablets, if you sometimes need these
• your doctor’s phone number.
A little lateral thinking may be needed regarding the problem of carrying all this kit around. One asthmatic friend of mine carries his inhalers in a trendy-looking camera bag that goes everywhere with him. Mothers of asthmatic children have solved the problem by making an ‘inhaler pouch’ from a sunglasses case and attaching it to a favourite belt or by enlarging the pocket in a teenager’s jacket to accommodate inhalers.
Anyone with severe allergies to food or insect stings should take similar steps, so that carrying their auto-injector everywhere is a simple matter.
Peak-flow meters
A peak-flow meter can detect narrowing of your airways – the beginnings of an asthma attack – before there are any obvious symptoms. It measures the maximum speed at which you can force air out of your lungs. The signs of worsening asthma include:
• a morning reading which is less than 75% of the evening reading
• average readings less than 75% of your best-ever reading. (If they get to less than 50% of your best reading, this is a severe and possibly life-threatening attack.)
To use a peak-flow meter:
• push the pointer to zero and hold the meter horizontally
• keep your fingers away from the scale and the pointer
• breathe normally before you start
• stand up and take a deep breath, but don’t puff your cheeks out and don’t hold your breath before you blow
• seal your lips tightly around the mouthpiece
• blow hard into the meter, as if blowing out candles on a birthday cake; don’t move your tongue while doing this
• repeat three times, and record the highest reading of the three.
You must learn how to use a peak-flow meter from your doctor or asthma nurse, who should also check your technique regularly – it is very easy to get into bad habits.

Allergy and Your Immune System
`The summer used to be such a miserable time for me because I’m allergic to grass pollen. For most of

my life I have had dreadful hayfever, and my asthma would get worse during the summer as well.

Antihistamines knocked me for six, and although there were nose drops that helped a little, they

certainly did not resolve the problem completely. Exam time was always a nightmare when I was a student

- then, as now, it coincided exactly with the pollen season.’
‘Getting a job in Chicago was a turning point in my health. My colleagues were amazed to see me

snuffling through the summer and just accepting that nothing could be done to improve matters. The

whole approach to treating allergies is different there. Eventually someone marched me off to see her

allergist, who said that I should have “allergy shots” and that my health insurance would cover it. The

process was very time-consuming at first, and it took a while to work, but the change is remarkable.

I’ve never regretted having the treatment. Summer is a time I can actually enjoy now.’
Not everyone responds this well to immunotherapy, but for those allergy sufferers who do benefit, this

is an excellent treatment. It tackles allergies right at their source, by teaching the immune system to

react differently to the allergen.
Also known as Specific Immunotherapy (SIT), Incremental Immunotherapy (11T) or simply as

hyposensitisation, this form of treatment was devised by two English medical researchers, Leonard Noon

and John Freeman, who reported their successes with hayfever patients in 1911. Ironically, their

treatment is now less readily available in Britain than in any other industrialised nation. Only a

small minority of British allergy patients receive immunotherapy. The cause of this strange situation

is a ruling made in 1986 by the Committee on the Safety of Medicines (CSM). This states that

immunotherapy must only be given where there is resuscitation equipment available, and that all

patients must wait for an hour after each injection, in case of
side effects. In addition, immunotherapy cannot be used for severe asthma.
The requirement for resuscitation equipment rules out most GP surgeries, and this effectively puts

immunotherapy beyond the reach of many allergic individuals in Britain, owing to the extreme shortage

of allergists and hospital allergy clinics (see p. 89). (In the past, the lack of allergy specialists

meant that most immunotherapy in Britain was given by GPs.)
The CSM ruling was triggered by a number of deaths due to immunotherapy: there were eleven fatalities

between 1980 and 1986, with five of these in the eighteen months just before the report. But almost all

these deaths were due to very basic errors in the way the injections were given – tragic as the deaths

were, the official response to them was inappropriate. Fatal reactions to immunotherapy can be avoided

with close attention to ordinary safeguards (see p. 166-7).
Allergen immunotherapy is still freely available elsewhere in the world, and is regarded as a key part

of allergy treatment. Britain is now out of step with all other developed countries, and most doctors

feel that British restrictions are far too strict.
There are hopes that this situation may change within the next few years, and that more allergy

sufferers may be able to take advantage of this valuable treatment. This could be achieved, in part, by

investing more National Health Service money in allergy clinics and allergy specialists. In addition,

there should be a relaxation of the regulations, so that properly trained GPs can give immunotherapy to

patients who are not at high risk of a fatal reaction. For people whose lives are affected by

allergies, the reintroduction of this treatment (with appropriate safeguards) would be a huge boon.
The uses of immunotherapy
Immunotherapy is mainly used for airborne allergens such as pollen, house-dust mite and mould spores.

Allergies to animals can also be treated with immunotherapy, but the treatment cannot work miracles –

if a cat-allergic person decides to keep the cat, the high dose of allergen inhaled every day limits

the impact of immunotherapy treatment.
People with straightforward allergic reactions affecting the nose and eyes (allergic rhinitis and

conjunctivitis) respond well to immunotherapy. In patients with hayfever, for example, the success rate

(patients showing some degree of improvement) is about 80-90%. When nasal allergies are complicated by

chronic sinusitis or nasal polyps, the chance of success is a little lower.
Some studies of the long-term effects of immunotherapy suggest that, if it is given to children with

hayfever or perennial rhinitis, those children are less likely to develop asthma.
The benefits of using immunotherapy to treat established asthma are less certain. Asthma is a more

complex disease than hayfever, and allergies are only one factor among many (see p. 36), which may

limit the impact that immunotherapy can make. Experience suggests that immunotherapy can be a great

help for an asthmatic with a strong allergic reaction to a single airborne allergen, such as grass

pollen or house-dust mite, but not for other asthmatics. Asthmatics with aspirin sensitivity or chronic

sinusitis are unlikely to benefit.
The value of immunotherapy to children with asthma is a subject of great debate among doctors in the

United States. Some studies suggest that it is of little real benefit, while others are more positive.

One interesting study, that followed asthmatic children for 15 years or more, found that if they were

given a full five-year course of immunotherapy when young, they tended to have fewer asthma symptoms

and need less medication in their late teens and early twenties.
Chronic urticaria (nettle rash) is occasionally due to airborne allergens, in which case immunotherapy

may help. However, immunotherapy is not recommended for atopic eczema. When people with both eczema and

rhinitis try immunotherapy for their nasal allergies, some find that their eczema gets worse.
Insect-sting allergy is a prime candidate for immunotherapy (see pp. 167-8) but food allergy is a

different matter, and is not treated with immunotherapy at present (see p. 168).
Who can get immunotherapy?
As a result of the CSM ruling (see p. 164) remarkably few allergy sufferers in Britain receive

immunotherapy.
Those with insect-sting allergy, who have suffered anaphylaxis (see p. 58), are the most likely to be

offered this treatment. However, even with this frightening and life-threatening problem, which can be

treated with almost 100% success by immunotherapy (see p. 167-8), such treatment is not automatically

available.
A few people with severe hayfever that does not respond well to drug treatment may also be given

immunotherapy. It is worth asking your doctor about such treatment if you feel you would benefit.
How immunotherapy works
Immunotherapy consists of a series of small injections, just under the skin. The liquid that is

injected contains an extract of the offending allergen, for example house-dust mite. The injections are

given at regular intervals, usually once a week, although other schedules are possible (see p. 167-8).
At the outset, a very dilute version of the allergen extract is used, way below the threshold for an

allergic reaction. People who seem highly sensitive, on the basis of their skin tests, start on an

extract that is even more dilute.
For the next injection, a slightly higher concentration of the allergen extract is used, and the

concentration goes on increasing with each successive injection. The idea is to habituate the immune

system to the offending allergen, by very gradually raising the dose. Eventually, when the dose reaches

a level which generally gives beneficial effects, no further increases are made.
If an allergy sufferer reacts badly to immunotherapy injections (see p. 166) on several successive

occasions, the dose may be levelled off before the ideal maximum dose is reached. However, a good

allergist will persist for some time in trying to increase the dose because stopping at a lower level

often results in the treatment being ineffective.
The first stage of immunotherapy, when the concentration of allergen is being increased week by week,

is referred to as the build-up stage. The second stage, when the dose is being kept at the same level,

is called maintenance therapy, and the dose used is the maintenance dose.
There is sometimes an obvious improvement by the time the build-up stage is complete, but not always.

The benefits of the treatment generally appear within six months of reaching the maintenance dose, but

some people have to wait a year or even two before things improve. As the immunotherapy begins to take

effect, symptoms decline and there is often less need for drugs.
A great deal of research effort has gone into finding out what lies behind these changes – in other

words, what is actually happening to the immune system when immunotherapy is effective. The answer is

that a surprising number of different changes may occur and no two allergy sufferers react to

immunotherapy in quite the same way. Frequently there is a shift in the kinds of antibodies the body

produces against the offending allergen. Levels of IgG antibodies (which help to block the allergic

reaction) go up, while levels of the allergy antibody, IgE, tend to stabilise and eventually go down.

The numbers of mast cells (see box on p. 12) may also decline, and they can become less responsive to

the allergen. The balance of power between Th1 cells and Th2 cells may also shift, with the pro-allergy

Th2 cells (see p. 11) becoming less influential.
What can go wrong
The secret of safe immunotherapy is to go at exactly the right speed for the immune system of the

individual being treated. The doctor should look for feedback from the immune system – signs that show

how well it is coping with the steadily increasing dose of allergen – and use these to pace the

immunotherapy schedule.
Going too fast – getting ahead of the immune system’s ability to cope – is hazardous. A major allergic

reaction, called anaphylaxis (see p. 58), can occur, and this is the cause of deaths during

immunotherapy. However, as long as there is injectable adrenaline (see p. 150) and resuscitation

equipment available, even such an extreme crisis can be dealt with safely.
Serious reactions to immunotherapy usually occur:
•    during the initial build-up phase; maintenance therapy is much safer
•    during the pollen season, for those with pollen allergy
•    when a new vial of allergen extract is first being used, because of variations in concentration

(see p. 168-9).
Those most vulnerable to severe reactions are:
•    people with asthma, especially severe or unstable asthma
•    those who have experienced systemic allergic reactions in the past
•    anyone who appears to be extremely allergic, on the basis of skin tests
•    anyone taking beta-Mockers (see box on p. 150).
With care, these fatalities can be avoided. Patients who are given immunotherapy can ensure their own

safety by being well informed about the procedure (see p. 167).
The timing of immunotherapy
There are various different approaches to the timing of immurotherapy. The basic method (which has a

good safety record in the United States where it is very commonly used) starts with injections once a

week. After the maintenance dose has been reached, maintenance injections are given once every 2-4

weeks. The frequency of these may be increased during the pollen season, for people with pollen

allergies.
It is the regularity of the injection schedule that gradually creates, and then sustains, immune

tolerance, so the treatment is only of value to patients who can reliably keep their appointments.
When immunotherapy is successful, it can eventually be discontinued without any reappearance of the

allergic reaction. It usually takes 4-5 years of regular therapy, from the time of the first injection,

to get to this point. The benefits then persist for many years, perhaps indefinitely in some people,

even without any further injections.
Rush immunotherapy
Trying to speed up the process of immunotherapy greatly increases the risk of a severe reaction

(anaphylaxis). However, there are some situations where fast results are needed, and in such cases rush

immunotherapy, also called accelerated immunotherapy, may be used.
During the build-up stage of rush immunotherapy, injections are given every day, or even several times

a day. All the usual safety procedures (see below) are observed with particular care, to reduce the

chance of a severe reaction.
In semi-rush immunotherapy, the build-up injections are given twice a week, and the risks are lower

than with daily injections, but still higher than with weekly injections.
Minimising the risks
If you are lucky enough to be offered immunotherapy treatment under the National Health Service, you

should not feel concerned about accepting the offer. There is very little risk of a bad reaction

because safety procedures are now so stringent.
To minimise the risk of suffering a severe reaction, the doctor will ask you, at each visit, about any

reactions that occurred after your previous injection. Reactions might include redness, itching or

swelling around the injection site, or (more seriously) symptoms elsewhere on the body, such as nettle

rash (urticaria), itchy skin, sneezing, a runny nose, red or itchy eyes, tightness in the throat or

chest, coughing or wheezing. Always make a note of such symptoms, so that you don’t forget to mention

them at the next visit. This is crucially important, as such reactions can indicate that the immune

system is being hurried along too fast.
The doctor will also ask if you have an infection of any kind, as this can alter your reaction. You

should also tell the doctor about any new medicines being taken, as some, such as betablockers (see box

on p. 150), can make a bad reaction to the injection more likely to occur.
Asthmatics can expect the doctor to ask about current asthma symptoms, and to check their peak flow

both before and after an injection. If there are any symptoms, or if the peak flow is less than 70% of

the best-ever value, the injection won’t be given.
Severe reactions can sometimes begin several hours after the injection, so stay within reach of a phone

for about 24 hours. Among United States allergists (who don’t require their patients to wait after the

injection for more than 20-30 minutes) there are some who believe that everyone undergoing

immunotherapy should carry an adrenaline (epinephrine) auto-injector (see p. 150) on the day an

injection has been given, for use in the event of a severe reaction. Anyone who has suffered

anaphylaxis in response to an insect sting will probably have an adrenaline auto-injector anyway, and

this can certainly be used to treat anaphylaxis following immunotherapy. Note, however, that using the

adrenaline is just the first step in treating anaphylaxis (see p. 98) and you must then go back to your

allergist, or to the nearest hospital emergency department, without any delay.
It is sensible to avoid exercise for two hours after an injection. Be extra-cautious during the pollen

season if you are receiving immunotherapy for pollen allergies.
Immunotherapy for insect-sting allergy
`Our daughter has had two really bad reactions from being stung by a wasp. After the second one, the

doctor at the accident and emergency department told us that she nearly died. We got so anxious about

it that we worried every time we left the house in the summer, and it was even worse if she went out

without us. My wife got so upset about it that she wasn’t sleeping well. It was affecting the whole

family badly.
‘Then we heard about desensitisation treatment, and asked our GP, but he said he couldn’t do it.

According to him, they might be able to do it at the hospital, but it might not work, and it was risky

too. We accepted that at first, but then I started doing some research on the Internet, and discovered

that in America and Germany this treatment is absolutely standard – someone like our daughter would

automatically be given it. We felt very angry when we found this out, and went back to the doctor.

Eventually Ann was referred to the allergy department at a hospital, and now she is getting this

desensitisation treatment. I’m pleased about that, obviously, but I still think it shouldn’t have been

such a fight to get it.’
Immunotherapy provides highly effective protection for those with insect-sting allergy, and should be

given to anyone who has had a severe systemic reaction (see p. 60). Some United States allergists also

recommend it for adults who have had a cutaneous systemic reaction (see p. 60), on the basis that they

may well progress to a severe systemic reaction with the next sting.
Studies of people who have suffered severe systemic reactions, and are then treated with immunotherapy,

show that 97% have no systemic reaction to future insect stings. For the 3% who are not fully

protected, the severity of the reaction is much reduced and far less likely to be life-threatening. In

other words, this is an excellent treatment which can save lives.
Targeting the treatment
Choosing the right venom for immunotherapy can sometimes be difficult. Not everyone with insect-sting

allergy sees the insect that caused the reaction. Skin tests may not give the answer either, because

there are often positive reactions to several different venoms. Some of these may be false positives

(see box on p. 91) and it is impossible for the allergist to say which one(s) are actually relevant.

Most allergists will recommend immunotherapy for all of them, using a mixture of venom extracts.
Where the guilty insect was seen and identified, but other venoms also give positive skin tests, a more

difficult decision has to be made. Many allergists carry out immunotherapy for all the venoms that gave

a positive skin test, on a ‘better safe than sorry’ basis. Since there are cross-reactions between

venoms (see box on p. 113), there is some sense in this. Other allergists just give immunotherapy for

the insect that did the deed.
Will immunotherapy against one insect protect against a related insect? With two closely related

insects such as wasps and hornets, which have many allergens in common, it might do – but there is no

guarantee. The problem is that, as well as the shared allergens, each venom also has its own unique

ingredients. It’s impossible to say, with the kind of tests available at present, if an allergic

reaction was to shared allergens or unique ones. So immunotherapy against wasp venom may give

protection against hornet venom, but it will not necessarily do so – and vice versa.
In the case of bumblebee allergy (seen almost exclusively in those, such as horticulturalists, whose

work involves handling bumblebees) a more definite answer can be given – honeybee immunotherapy does

not work. Immunotherapy with bumblebee venom does work, fortunately. The bumblebee extract has to be

obtained from specialist sources.
Injections are given weekly during the build-up phase, unless protection is needed urgently, as with

work-related sting allergy, in which case rush immunotherapy may be used. Once the maximum dose has

been reached, a maintenance injection is needed every four weeks. After a year, this maintenance dose

can be given every 6-8 weeks.
After 3-5 years of immunotherapy, skin tests with insect venoms are usually tried again. If the results

are negative, the immunotherapy will stop. Research now shows that, even if skin tests are still

positive when immunotherapy ends, there’s an 8090% chance that no systemic reaction will occur to

future stings. Some people are not reassured by this, and prefer to continue with immunotherapy for

their own peace of mind. Indeed, research shows that a near-fatal systemic reaction has a long-lasting

psychological impact, and that many people continue to feel anxious despite completing immunotherapy

and reacting negatively to skin tests.
At one time, challenge stings with live insects were given to check whether immunotherapy had actually

worked. Few doctors do this now, but your allergist may be prepared to do a challenge test if you ask.

Adrenaline and resuscitation equipment would be available if a challenge test were used, so any severe

reaction could be dealt with promptly and effectively. The fact that the psychological consequences of

insect-sting allergy are so persistent suggests that challenge tests with live insects may have a

particular value, in demonstrating that immunotherapy has worked. Challenge tests are also helpful for

those who work with stinging insects, such as honeybees and bumblebees, and who need to be sure that

they can go back to work safely.
Immunotherapy for food allergy?
Attempts to use standard immunotherapy for food allergy have been made repeatedly, but without success.

The process of giving the injections is nerve-racking because of the constant risk of a severe

reaction. The risks prevent the dose of allergen being increased very much, so the beneficial effects

are small. While there may be some reduction insensitivity, it is not enough – or not reliable enough –

to be of any practical value.
What doctors are aiming for here, incidentally, is simply to protect against the effects of

accidentally eating a tiny amount of the food – no one is expecting that someone with peanut allergy

will be able to eat peanut butter sandwiches as a result.
Some of the new developments in immunotherapy may be useful for food allergy, as described in the next

section.
The future of immunotherapy
Many different research teams are working on ways of improving immunotherapy – making it more

effective, safer to give, and less time-consuming.
One approach involves altering the allergen, so that it only interacts with those parts of the immune

system whose job is to control allergic reactions (and therefore bring about tolerance). The changes

made to the allergen are designed to make it ‘invisible’ to the parts of the immune system that

actually attack the allergen. The idea is to inject something that can’t cause a bad reaction, and is

therefore 100% safe.
The modified allergens are called allergoids. Another term often used is peptide immunotherapy – this

describes a technique in which the allergens are chopped up into small pieces to make them safe

(allergens are proteins, and a fragment of a protein is called a peptide).
Already, researchers in Germany have made an allergoid from birch pollen that can reduce hayfever

symptoms with a series of just seven injections given before the pollen season.
Meanwhile, a research team in London is working on peptides made from cat allergen, with encouraging

results so far. In a group of asthmatics who were allergic to cats, a series of 4-10 injections, over a

period of 2-8 weeks, produced benefits in about half those treated. The researchers believe that they

can improve on this and help the majority of people with cat allergy, at least enough to survive

temporary exposure to cat allergen (when visiting cat-owning friends, for example). They hope to refine

the treatment sufficiently to enable some cat-allergic people to keep their pet, rather than finding it

a new home. This is a relatively safe treatment that might be given by a GP, rather than only by

specialists. The research team hopes the treatment will be available by about 2009.
Could this kind of technique work for food allergy? Doctors believe that it can, and a great deal of

research work is being done, in both Britain and the United States. A major focus of this effort is

peanut allergy, since this puts so many young lives at risk. Even if the research is successful, It

will be several years before such treatments become available.
Researchers are also working hard to produce standardised allergen extracts – in other words, allergen

extracts that always contain a standard amount of the allergen. The aim is not only to reduce the

number of treatment failures (which can occur if the extract does not contain enough allergen) but also

to avoid mishaps when a new vial of allergen extract is used (differences in strength, between one vial

and another, are sometimes a cause of anaphylactic reactions).
Standardisation is difficult, because the starting materials –skin particles from horses, for example,

or dust-mite droppings –are natural materials and therefore variable. Some samples contain far more of

a particular allergenic ingredient than others.
One way around this problem is to develop accurate methods of measuring the amount of allergen in the

extract. Another approach is to abandon the whole business of making extracts, and produce allergens

artificially, in a laboratory. This is done by inserting the gene for the allergen – the gene for the

Der p1 allergen of house-dust mite, for example – into bacteria. These bacteria then act as production

units, manufacturing large amounts of the allergen every day. With this high-tech approach, the exact

content of the allergen preparations can be controlled.
These high-tech allergen preparations are extremely pure, and therefore very effective – as long as the

person receiving immunotherapy really is sensitised to the particular allergen that is included.

Unfortunately, most natural allergenic materials contain two, three or even more separate allergens. In

house-dust mite droppings, for example, while Der p1 is the allergen that affects most people, there is

also an allergen called Der p2, and a few people are more sensitive to this than to Der pl.
Artificially produced allergen preparations usually include the main allergen only. For the minority of

people who are more severely allergic to one of the other allergens, this extract will not work.

Eventually this problem will no doubt be circumvented by means of more precise skin testing before

immunotherapy begins – skin tests with individual allergens, rather than with allergen extract

containing a mix of allergens.
A third approach is to change from injections to oral immunotherapy – giving the allergen extracts by

mouth. The best results are obtained when the allergen is held under the tongue for a while and then

swallowed. This is known as Sub-lingual immunotherapy or SLIT, and has become very popular in Italy and

France, where it is a common treatment for hayfever. A recent pilot trial among GPs in Britain suggests

that it may be useful, but is not a miracle cure. Overall, the group treated with SLIT had fewer

symptoms during the pollen season, but antihistamines were still needed. There is some evidence from

Italy that SLIT might reduce the likelihood of children with hayfever going on to develop asthma, and

reduce the chance of new sensitivities.
Side effects are unusual with this treatment, and those that do occur are mostly mild – itching in the

mouth, for example. The treatment is safe enough for routine use in children.
Might oral immunotherapy work for food allergy? Other Italian studies suggest that it could. The

objective of these studies is to reduce the risk to children with cow’s-milk allergy from accidental

encounters with ‘hidden milk’ in prepared food or drink. The immunotherapy treatment begins with

miniscule amounts of milk – the doctors start with a single drop diluted in water, each day for a week

– and increase the dose extremely slowly. Antihistamines are given to minimise the risk of a reaction.
The whole process requires enormous patience, but after seven months, the majority of the children

involved can tolerate some milk – between three tablespoonfuls and a small cupful each day.
This is a very encouraging study that should be repeated by doctors in Britain. Because of the risks of

anaphylaxis – which can, of course, be fatal – it does require full medical supervision, and you should

not attempt it at home. Whether this method would work for allergens other than milk is something that

nobody has yet investigated.
A great many other approaches to immunotherapy are currently being tried for food allergy. Many of the

new techniques are highly experimental, and some show great promise, but it will be many years before

they are in use.
One innovation that is closer to being in general use in the United States involves giving the anti-IgE

drug omalizumab (see p. 149) alongside immunotherapy injections. The drug maximises the benefits from

the immunotherapy, and may make the build-up stage (see p. 165) safer, by lowering the risk of

anaphylaxis. For British allergy sufferers, who cannot yet get omalizumab, and whose chances of getting

immunotherapy are vanishingly small, it may seem unkind even to mention such treatments, but we can

only hope that things will improve here in the near future. You might take some comfort from the

thought that, by the time immunotherapy is available again in Britain, there will be a whole host of

highly effective new techniques available for doctors to try.
All the methods described above are forms of specific immunotherapy – they treat an allergy to dust

mites or to grass pollen or some other specific allergen.
A far more radical and ambitious approach to immunotherapy is now the aim of some medical researchers:

blocking the tendency to allergies as a whole.The underlying idea here is to reverse the basic shift in

the immune response, from Th1 cells to Th2 cells. It is this shift to Th2 cells which produces the

allergic tendency (see pp. 11 –13).
Some interesting findings have already been made in this area, including the surprising discovery that

the balance of Th1 cells and Th2 cells can be adjusted even in people with longstanding allergies.

Inspired by discoveries about hygiene and allergy (see p. 21), British researchers have made a vaccine

containing inactivated cells of a harmless bacterium found in the soil, Mycobacterium vaccae. This is

given as a single injection just under the surface of the skin. It has been used for adult patients

with asthma, and for children with severe atopic eczema, with some improvement in both groups. If the

treatment proves as useful as the preliminary studies suggest, this could be a common treatment in a

few years’ time.

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

Antihistamines and Allergy

Antihistamines were first introduced in 1947, and are very widely used, so their safety — at least in the case of the older antihistamines — is beyond doubt. Most of the antihistamines have no major ill effects, and no one should feel concerned about taking them. At worst they produce some rather annoying minor side effects, such as drowsiness, which often wear off in time.

These drugs are particularly valuable for hayfever and other allergies in the nose (perennial allergic rhinitis). They are also used for chronic urticaria, sometimes in combination with anotherhistamine-blocking drug — see p. 53.

Antihistamines are not much used for asthma. They have relatively little effect, probably because so many other messenger chemicals are involved in an asthma attack. However, doctors in Japan do use antihistamines for asthma, and it is possible that people of Asiatic origin react differently to them.

Only one antihistamine, ketotifen, is widely used for asthma in the West, and this has other effects besides blocking histamine (see p. 159). A new role may soon develop for antihistamines in thetreatment of asthma, combined with anti-leukotriene drugs (see p. 159).

If you suffer from anaphylaxis you might be given antihistamines in a liquid or chewable form, for use in an emergency. These are not enough in themselves to treat this dangerous condition - you must have an adrenaline injector (see p. 150).

In the past, some doctors prescribed antihistamines for atopic eczema, mainly for their sedative effect(see p. 139) which was thought to help children to sleep better and scratch less at night. This treatment has largely gone out of favour, because its value is in doubt. But a recent study has revealed that the non-sedating antihistamine cetirizine may be useful for very young children with atopic eczema, not only in treating their skin, but also in reducing the chance of them developing asthma (see p. 249).

Most people take their antihistamines in tablet or capsule form. Syrups and sugar-free elixirs areavailable for children.

Antihistamines can also be applied directly, in the form of nasal sprays or eye drops. These are mainlyused to treat hayfever and the conjunctivitis (inflammation of the eye) which often accompanies it.Levocabastine (brand name Livostin) is particularly effective for the eyes.

Antihistamine creams are also sold, without prescription, for the treatment of insect bites - i.e. thenormal non-allergic reaction to such bites. These creams are not recommended for atopic eczema or otherallergic conditions affecting the skin. Not only are they unlikely to help, but they may make mattersworse because, with regular use, skin sensitisation to the antihistamine occurs very readily (see pp.54-5).
Some common brand names

Common brand names include: non-sedating antihistamines - Clarityn, Semprex, Zirtek; Mistamine, Mizollen, Telfast, Terfenadine. Thefirst three are available without prescription.

older (sedating) antihistamines — Atarax, Dimotane, Optimine, Periactin, Piriton, Tavegil, Vallergan eye drops — Emadine, Livostin, Optilast nasal sprays — Livostin, Rhinolast

How antihistamines work
Of the messenger chemicals released when an allergic reaction occurs, the most important is histamine.

This does its work by attaching to specialised receptors in certain parts of the body, and so

triggering various reactions (see box on p. 12). The action of antihistamines is very simple: they bind

to the same receptors as histamine, but they do not trigger any reaction. Histamine cannot bind to the

receptor because the antihistamine is already there.
Unfortunately, the reverse is also true: if the histamine is already there, the antihistamine cannot

elbow it off the receptor, which is why it is important to take the antihistamine well before the

allergen is encountered. Taking antihistamines at the first sign of a snuffle or itch can also work,

but the effects will not be nearly as good as taking them in anticipation of an exposure.
The best approach to treating hayfever, for example, is to start taking the antihistamines at least a

week before the pollen season begins, and preferably two to three weeks before. You should then take

them continuously until it is over. This will make a huge difference to the degree of symptom control

you achieve.
Side effects
The older types of antihistamine, such as chlorphenamine (brand name, Rriton) are relatively

non-specific in their effects – they bind to several different kinds of receptors, not just those for

histamine. As a result they can have some unwanted effects, such as causing drowsiness and poor

coordination. While these sedative effects are no cause for concern in themselves, they can, of course,

be hazardous if you work with dangerous machinery or drive. Avoid both until you are sure how you react

to the antihistamine. Note that the effects of alcohol may be increased.
Very occasionally antihistamines have the opposite effect, causing stimulation rather than sedation;

this is most likely to occur in children and old people. Lowering the dose may solve the problem.
The other possible side effects of the older antihistamines –all of which are minor ones – are

headache, dry mouth, blurred vision, difficulty in passing urine, nervousness, shaky hands, upset

stomach or diarrhoea. A few men suffer impotence while taking antihistamines, but this disappears when

the drug is stopped.
The minor side effects of antihistamines, including drowsiness, often wear off after a while, although

the benefits of the drug remain. So it is worthwhile persisting with an antihistamine, even if it

causes some problems at first. Many people experience side effects from certain antihistamines but not

from others, so try several different types to find one that suits you.
The problem of drowsiness has been reduced, in recent years, thanks to the development of new drugs

that are far more
specific for histamine receptors, the non-sedating antihistamines. A few people do get drowsy even with

these drugs. Again, the effects vary from one drug to another, so if the first one disagrees with you,

try a different one.
It is worth noting – since some people may still have the odd packet in their medicine cabinet – that

two of the non-sedating antihistamines that were available without prescription a few years ago proved

to be unsafe for a small minority of people. One was astemizole (brand names: Hismanal, Pollon-eze),

which has now been withdrawn from use altogether in Britain. The other was terfenadine (brand names:

Triludan, Seldane, Terfenadine) which is still available, but only on prescription.
There are several special precautions relating to terfenadine:
• Never exceed the correct dose.
• If you have ever had any kind of heart problem, talk to your doctor before taking terfenadine.
• Stop taking the drug if you have palpitations, or if you feel faint; see your doctor promptly.
• Do not take terfenadine if you are taking the antibiotic erythromycin, or anti-fungal drugs

such as ketoconazole (Nizoral) or fluconazole (Diflucan), used to treat vaginal thrush.
• Do not take terfenadine if you have liver disease.
• Do not drink grapefruit juice while taking terfenadine: something found naturally in grapefruit

interacts unpleasantly with this antihistamine.
In addition to these special precautions concerning terfenadine, any antihistamine should be treated

with caution by those suffering from epilepsy, Parkinson’s disease, glaucoma, prostate enlargement,

kidney problems, urinary retention, a gastric ulcer, a thyroid disorder, porphyria or liver disease.

Check with your doctor before taking antihistamines if you have any of these conditions.
It may be inadvisable to use antihistamines if you are taking sleeping tablets, anti-depressants or

anti-anxiety drugs – again, see your doctor.
Stop taking antihistamines if you suffer any unusual kind of rash, or if your skin becomes more

sensitive to sunlight.
If you are breast-feeding, note that, because they go through into the milk, the older antihistamines

may make the baby sleepy. However, they do no harm.
Rescue treatment
Most antihistamines perform very badly if you take them once the allergic reaction has set in, but

acrivastine (Semprex) can be good in these circumstances and is non-sedating. No prescription is

required for this drug.
possibly identify all major side effects. We vary in our response to drugs, because we are all so

different at the chemical and cellular level. A drug might have a serious side effect that only affects

one person in 10,000, and no safety trial can hope to identify such a rare response. Only when a drug

is released, and becomes widely used, do such side effects come to light. Other unanticipated side

effects can sometimes arise when people taking the new drug are much older than those in the safety

trials, or belong to a different ethnic group with different susceptibilities. Combining the drug with

certain other drugs can also be a potential source of trouble, although pharmaceutical experts can

often predict such problems from a detailed knowledge of the chemistry of drugs and how they are broken

down in the body. Side effects that take several years to develop - more than the timespan of most

safety trials - will also fail to show up until the drug has been released.
All this may sound very alarming, but in fact severe reactions to new drugs are not that common. And

there are various safety nets in place - doctors keep a close eye on patients taking new drugs, and a

special reporting system ensures that, if unexpected side effects do show up, the information is

quickly shared with others in the medical community.
In order to relate the information here to a particular medicine that you take, you need to know what

drug category it belongs to. Does your inhaler contain a beta-2 reliever, a steroid, a cromoglycatetype

drug or an anti-cholinergic, for example? If you are not sure, ask your pharmacist.
Those are the category names for drugs: they denote families of drugs which are similar chemically
and work in roughly the same way. Within each category, or family, there are a number of individual

drugs. The individual drugs should, ideally, have a standard internationally agreed name - this is

known as the generic name. Unfortunately, a few of the drugs used for allergies and asthma have more

than one generic name - salbutamol is known as albuterol in some parts of the world, and adrenaline is called epinephrine.

Finally there are the brand names, which are the ones most patients are familiar with. These are always

shown with a capital letter, unlike the generic names. Long-established drugs are usually made by

several different pharmaceutical companies, and therefore marketed under several different brand names.

A newer drug, which is still covered by the patent of the pharmaceutical company that developed it,

will be sold under only one brand name.

The issue of brand names is important, because a different brand name might make you think you are taking a different drug, when in fact it is exactly the same drug being marketed in a different guise.If you have suffered side effects from a particular drug in the past, and wish to avoid it in future, take note of its generic name, rather than its brand name. Sometimes the generic name is used as the brand name, in what are called generic drugs. These arerelatively inexpensive copies of popular drug brands -they are just the same chemically, but they costless because there is no advertising of the brand to doctors, and profit margins have been cut to aminimum. In order to reduce National Health Service costs, doctors are now asked to prescribe generic drugs whenever possible.