Posts Tagged ‘sensitivity’

Type of Drug
Cephalosporin Antibiotics
(CEF-uh-loe-SPOR-in)
Brand Names
Cefaclor 91 Raniclor
Cefadroxil Duricef
Cefdinir Omnicef
Cefditoren Pivoxil
Spectracef
Cefixime Suprax
Cefpodoxime Proxetil 91 Vantin
Cefprozil Cefzil
Ceffibuten Cedax
Cefuroxime Axetil 90 Ceftin
Generic Ingredient: Cephalexin 91 Panixine Disperdose    Keflex
Prescribed For  Bacterial infections.
General Information
These antibiotics are related to cephalosporin C, which is similar to penicillin and is isolated from the Cephalosporium acremonium fungus. Of the more than 20 different antibiotic drugs derived from cephalosporin C, only those that are taken by mouth are included in The Pill Book. Most common infections can be treated with these antibiotics, but they are not interchangeable. Your doctor must select the appropriate antibiotic for a particular infection.
Cautions and Warnings
Do not take cephalosporin antibiotics if you are allergic or sensitive to any of their ingredients. Up to 15% of people allergic to penicillin may also be allergic to cephalosporins. The most common cephalosporin allergic reaction is a hive-like rash condition with redness over large aceas 0 the body. Other sensitivity reac161011S Include general rash, fever, and joint aches or pain. Such reactions generally begin after a few days of taking the antibiotic and resolve within a few days after the antibiotic is stopped.
Prolonged or repeated use of a cephalosporin may lead to a secondary infection not susceptible to the antibiotic.
Occasionally, people taking a cephalosporin develop colitis. Call your doctor if you develop severe diarrhea while taking one of these drugs.
People with poor kidney function may require less medicine to treat their infections. Rarely, people taking a cephalosporin have had a seizure, especially those with kidney disease whose dose was not reduced.
Some injectable cephalosporins have caused blood-clotting problems. This has not occurred in people taking an oral drug.
Rarely, severe anemia occurs in people taking cephalosporin antibiotics. Report any signs of anemia (such as pale skin color, weakness, tiredness, difficulty breathing, and abnormal heart rhythms) to your doctor.
Cefprozil oral suspension contains phenylalanine and cannot be taken by people with phenylketonuria (PKU disease).
Possible Side Effects
Most side effects are mild.
✓    Most common: diarrhea, headache, abdominal pain, constipation, gas, upset stomach, nausea, vomiting, itching, and rash.
✓    Less common: dizziness, tiredness, weakness, tingling in the hands or feet, confusion, appetite loss, changes in taste perception, and genital and anal itching. Colitis may develop.
Cefaclor may cause serum sickness (symptoms include fever, joint pain, and rash). cephalosporins may cause changes in blood cells, kidney problems, liver inflammation, and jaundice, but these side effects are rarely a problem with oral cephalosporins.
Drug Interactions
•    Antacids can reduce the amounts of cefaclor, cefdinir, cefditoren pivoxil, and cefpodoxime proxetil in the blood. Do not take antacids within 2 hours of these antibiotics.
•    Cimetidine, famotidine, ranitidine, or nizatidine can reduce the effectiveness of cefpodoxime proxetil, cefditoren pivoxil, and cefuroxime axetil—do not combine these drugs.
•    Iron and iron-fortified foods may interfere with the absorption of cefdinir. Separate your iron dose from the antibiotic by at least 2 hours. Iron-fortified infant formula does not have this effect.
•    Probenecid may increase blood levels of some cephalosporins.
•    Potent (loop-type) diuretics can lead to kidney damage if mixed with a cephalosporin antibiotic.
Food  Interactions
Generally, cephalosporins may be taken with food or milk if they upset your stomach. Cefditoren pivoxil should be taken with a meal. Food increases the absorption of cefpodoxime proxetil and cefuroxime axetil.
Usual Dose
Ceftibuten
Adult and Child (age 12 and over): 400 mg once a day for 10 days. Child: 4 mg per lb. of body weight, up to 400 mg, once a day.
Cefuroxime Axetil
Adult and Child (age 13 and over): 250-1000 mg a day in 1-2 doses.
Child (age 3 months-12 years): tablets-125-250 mg every
12 hours. Liquid-9-13 mg per lb. of body weight every 12 hours.
Cephalexin
Adult: 1000-4000 mg a day in divided doses, usually 250 mg every 6 hours, or 500 mg every 12 hours.
Child: 11-23 mg per lb. of body weight a day in divided doses. The dose may be increased to 46 mg per lb. of body weight for middle-ear infections.
Overdosage
Common symptoms of overdose are nausea, vomiting, and upset stomach. These can often be treated with milk or an antacid. Cephalosporin overdoses are generally not serious; contact a hospital emergency room or local poison control center for more information. If you seek treatment, ALWAYS bring the prescription bottle or container.
Special Information
Call your doctor if you develop severe abdominal cramps or diarrhea. Stop taking this drug and immediately call your doctor if you experience fever, chest tightness, breathing difficulties, redness, muscle aches, or swelling.
You must take the full course of treatment prescribed—even if you feel better in 2 or 3 days—to obtain the maximum benefit from any antibiotic.
Proper diagnosis is key to the effectiveness of an antibiotic: Do not take any antibiotic without consulting your doctor.
You should be aware that all cephalosporins may cause false results for certain urine tests for sugar. Cefuroxime may cause false results for blood sugar. Diabetics taking cephradine should not change their diet or diabetes medication without consulting their doctor.
If you miss a dose that you take once a day, take it as soon as you remember. If it is almost time for your next dose, take the dose you forgot right away and your next one 10-12 hours later. Then go back to your regular schedule. If you take the medication twice a day, take the dose you forgot right away and the next dose 5-6 hours later. Then go back to your regular schedule. If you take the medication 3 or more times a day, take the dose you missed right away and your next dose 2-4 hours later. Then go back to your regular schedule.
Most cephalosporin liquids must be kept in the refrigerator to maintain their strength. Only cefixime liquid does not require refrigeration. All of the liquid cephalosporins have a very limited shelf life. Do not keep any of these liquids beyond the 10 days-2 weeks specified on the label. Follow your pharmacist’s storage instructions.
Special Populations
Pregnancy/Breast-feeding: These drugs are considered relatively safe during pregnancy, though small amounts pass into the fetus. Little information is available about the newer members of the group. Also, cephalosporins pass more quickly out of the bodies of pregnant women. cephalosporins should only be used during pregnancy after carefully weighing their potential benefits against their risks.
Small amounts of most cephalosporin antibiotics pass into breast milk. Nursing mothers who must take a cephalosporin should use infant formula.
Seniors: Seniors may require a lower dosage if they have reduced kidney function.
Cefaclor
250 mg every 8 hours, or 375-500 mg every 12 hours.  9 mg per lb. of body weight a day, in 2-3 equal doses.
Cefadroxil
1-2 g a day. in 1-2 doses.
13 mg per lb. of body weight a day, in 1-2 doses.
Cefdinir
Adult and Child (age 13 and over): 600 mg a day, in 1-2 doses. Child (age 6 months-12 years): 6.5 mg per lb. of body weight a day in 1-2 doses.
Cefditoren Pivoxil
Adult and Child (age 12 and over): 200-400 mg twice a day for 10 days.
Cefixime
400 mg a day, in 1-2 doses.
3.5 mg per lb. of body weight a day, in 1-2 doses.
cefpodoxime Proxetil
Adult and Child (age 13 and over): 200-400 mg a day, in 1-2 doses. Child (age 5 months-12 years): 5 mg per Yo. of body weight a day
in 1-2 (dvsin. Maximum daily dose for middle-ear infections is
400 mg; 200 mg for sore throat or tonsillitis.
Cefprozil
Adult and Child (age 13 and over): 500-1000 mg a day.
Child (age 6 months-12 years): 7-13 mg per lb. of body weight a day in 1-2 doses.

oxitropium An anticholinergic bronchodilator similar to ipratropium, and used by aerosol inhalation in stable chronic asthma and related conditions.
Dose: 200-300pg (4-6 puffs) daily. . See page 118 and Table 6.

Dose: 1-3 mega-units/min by i.v. infu,ion only, with monitoring. Excessive doses may cause severe uterine contractions with the risk of fetal asphyxiation. (Syntocinon).

oxpentity1fine An aminophyline-like drug used mainly as a vasodilator in periphei at vascular disorders.
Dose: 800-1200 mg. It may cause nausea, flushing and dizziness. Care is necessary in hypotensive states. (Trental).
oxprenoW A beta- ad renoceptor blocking agent with the actions, uses and side-effects of propranolol. It also has anxiolytic properties, and may reduce the symptoms of transient stress such as tremor and palpitations.
Dose: 60-480 mg daily. (Slow- Trasicor). See page 148 and Table 21.
oxybuprocaine A local anaesthetic for ophthalmic use, including tonometry, as a 0.4% solution.
oxybutynin An anticholinergic antispasmodic that promotes relaxation of the detrusor muscle of the bladder.
Dose: in urinary incontinence, 10-20 ing daily; 10 mg daily for children with neurogenic bladder instability. Side-effects are those of anticholinergic drugs generally. (Cystrin; Ditropan). See page 174.
toxycodone A powerful narcotic analgesic with a prolonged action. Used as suppositories of 30 mg in terminal care.
oxypertine A tranquillizer with a chlorpromazine-like action, and used in anxiety neuroses, psychoses and schizophrenic states.
Dose: 30-60 mg daily in anxiety states; up to 300 nig daily in schizophrenia.In higher doses it may cause nausea, dizziness and drowsiness. See page 168 and Table 30.
paclitaxelk’ A new cytotoxic agent originally obtained from the bark of the Pacific Yew. It prevents mitosis and inhibits cell growth by stabilizing microtubule production. It is used by specialists for metastatic ovarian cancer not responding to platinum therapy. Premedication is necessary to prevent severe hypersensitivity reactions. (Taxol). See page 122 and,rable 8.
pamidronate disodium A bisphosphonate with the actions and uses of etidronate. It is used mainly in the hypercalcaemia of malignancy, as it inhibits the development of active osteoclasts.
Dose: by i.v. infusion 10-90 mg or more according to the degree of hypercalcaemia. The initial response may occur within 24-48 hours. Dose in Paget’s disease of bone, 30 nig weekly. Care is necessary in marked renal impairment. (Aredia).
pancreatin A preparation containing the pancreatic enzymes, trypsin, lipase and amylase. It is used to aid the digestion of fats, proteins and carbohydrates in cystic fibrosis and pancreatitis. Some high-strength products have caused fibrotic strictures of the large bowel.
pancuronium A non-depolarizing or competitive muscle relaxant that has little histamine-releasing or cardiovascular action.
Dose: 50-100 pg/kg i.v. initially with Supplementary doses of 10-20 pg/kg as required. (Pavulon).
oxytetracycline (Terramycin). See tetracv-
oxytocin The oxytocic fraction of pituitary extract, but now made synthetically. Used for the induction and maintenance of labour, and to control post-partum haemorrhage, either alone or in association with ergometrinc.
pantoprazoleV A proton pump inhibitor similar to omeprazole, used in peptic ulcer and reflex oesophagitis.
Dose: 40 mg daily with breakfast. The tablets must be swallowed whole with water, and not chewed or crushed. (Proteunfl. See page 162 and Table 27.
papaveretum A preparation of the alkaloids of opium, containing approximately 50% of morphine together with papaverine and codeine. Used mainly by injection, often in association with hyoscine (scopolamine) for premedication. Dose: 7.7-15.4 nig repeated as required.
papaverine One of the alkaloids of opium. It has little analgesic action, and has been used mainly as a smooth muscle relaxant in peripheral vascular diseases. More recently it has been used by intracavernosal injection in the treatment of impotence.
paracetamol A widely used mild analgesic with few side-effects except in large doses. It differs from aspirin in the absence of any anti-inflammatory action.
Dose: 2-4 g daily. Paediatric suppositories of 125 mg are available. Overdose may cause severe liver damage (see acetylcysIcinc).
paraffin A generic name for hydrocarbon mixtures. Soft paraffin is the common ointment base; liquid paraffin is a lubricant laxative. Hard paraffin was used in the wax bath treatment of rheumatic conditions.
paraldehyde A colourless liquid with a strong characteristic odour. It was once used as a chloral-like sedative causing little respiratory depression; now given by deep i.m. injection in status asthinaticus. Dose: 5-10 nil. Occasionally given in similar doses by rectUril, diluted with saline or arachis oil. Discoloured paraldehyde must not be used.
paroxetine A selective inhibitor of sero(011111 uptake in the central nervous system, and indicated in the treatment of depression.
Dose: 20 ing daily, initially in the morning, with food, slowly increased as required to 50 mg daily. It should not be given with any other drug likely to increase serotonin uptake. Side-effects are nausea, drowsiness and insomnia. Extrapyramidal reactions may occur more often with paroxetine. (Seroxat). See page 128 and Table i I.
penciclovir An antiviral agent used as a 1% cream for cold sores (Herpes kabialis). Treatment should be started as soon as possible by applying the cream every 2 hours for 4 days. (Vectavir). See page 144 anti Table 19.
penicillarnine A breakdown product of penicillin which has the power of combining with certain metals to form a water-soluble, non-toxic complex that is excreted in the urine. It is used in Wilson’s disease, which is due to the retention of copper in the body, in poisoning by lead and mercury, in chronic active hepatitis (after the condition has been controlled), in cystinuria, and in severe rheumatoid arthritis in which it has an action similar to that of gold.
Dose: in Wilson’s disease, 1.5-2 g daily before food for sonic months. In chronic hepatitis, 500 mg daily initially, slowly increased over some weeks to 1.25g daily. In rheumatoid arthritis, 125-250 trig daily initially before food, slowly increased at monthly intervals with maintenance doses of 500-750 mg daily. Patients should be warned that the response in rheumatoid arthritis is slow. In cystinuria, 1-3 g daily with adequate fluids, ad iusted later to maintain the urinary cysteine level below 200 mg/I. Dose in heavy metal poisoning, 2g daily. Side-effects include nausea, loss of taste, rash and thrombocytopenia. Blood Counts during treatment are essential and patients should be advised to report most side-effects. A late onset rash may require cessation of treatment. (Distarnine; Pendramine). See page 165 and Table 29.
penicillin, benzyl penicillin, penicillin G I lie first of the antibiotics. It acts by pre venting the development of the bacterial cell wall, but some groups of organisms vary widely in the degree of sensitivity to penicillin, and it is inactivated by penicillinase-producing organisms. Penicillin is inactive orally, and so is given by i.m. injection, but as it is rapidly excreted the action is relatively brief. Derivatives such as procaine-penicillin have a longer action (penicillin V is an orally active derivative). The main side-effect is hypersensitivity, and sensitivity to one penicillin extends to any other penicillin, and may also include sensitivity to the related cephalosporins. High doses of penicillin, especially in patients with renal insufficiency, may occasionally cause cerebral irritation and encephalopathy. Cloxacillin and amoxycillin are derivatives of penicillin active against resistant staphylococci; ampicillin has a wide range of activity against Gram-positive and Gram-negative organisms; piperacillin and ticarcillin are active against Pseudomottas acruginosa.

pentaerythitol tetranitrate A vasodilator with properties resembling those of glyceryl trinitrate, but with a more prolonged action. Used mainly in the prophylaxis of angina as side-effects are relatively infrequent.
Dose: 60-240 mg daily. (Mycardol). See page 114 and Table 4.
pentamidine A synthetic drug used in the treatment ofPneutnocystiscarinii pneumonia in AIDS and other immunocompromised patients, as an alternative to co-trimoxazole.
Dose: 4 nig/kg daily by i.v. infusion for 14 clays or more, or by inhalation of a nebulized solution. Other dosage schemes are used in the treatment of’trypaiiosomiasis and leislunaniasis. Severe reactions, particularly hypotension, may occur, and pentamidine should be used only under expert supervision. (Pentacarinao.
pentastarch A starch-derived plasma substitute used as a 10% solution in burns and septicaemia.
Dose: by i.v. infusion 500 nil-21.. (Haes.
See hetastarch.
tpentazocine A powerful analgesic of the morphine type, but less likely to cause addiction, although dependence may occur with long treatment.
Dose: 100 -400 nig daily after food, up to 360 nig daily by injection. Suppositories of 50 mg are available. Hallucinations ions are an occasional side-effect. It should be
avoided after myocardial infarction as it may increase the cardiac load. Other side effects include dizziness, nausea, tachycardia and rash. It should be avoided in opioid-dependent patients. (Fortral).
pentostatin A potent cytotoxic agent used in hairy cell leukaemia. It is an inhibitor of adenosine deaminase, and may affect RNA synthesis and cause DNA breakdown.
Dose: i.v. under specialist supervision, 4 ing/ni’every other week, continued up to 6 months unless a remission has been achieved. Side-effects include myelosuppression, leukopenia, renal and liver toxicity and rash. Blood counts are necessary during treatment. (Nipent). See page 122.
peppermint oil Aromatic carminative. Dose: 0.2 -0.4 ml. (Colpermin; Nlintec).
pergolide A dopamine agonist with a stimulating action on both D, and D, receptors. It is used in the auxiliary treatment of parkinsonism, and combined treatment may permit a reduction in the dose of levodopa and its side-effects. Dose: 100 jig daily initially, slowly increased at 3-day intervals according to response, with care taken to avoid initial hypotension. Other side-effects include nausea, diarrhoea, confusion and hallucinations. (Celance). See page 160 and
pericyazine A tranquillizer of the chlorpromazine type with similar uses and side-effects. It is used mainly in schizophrenia and severe anxiety states.
Dose: 15-75ingdaily, slowly Y increased according to need up to 300 111g. ( Neulactil). See page 168 and Table 30.
perindopril A long-acting ACE inhibitor used in the control of essential hypertension not responding to other drugs. Dose: initially, it single daily dose of 2 mg (before food), subsequently adjusted up to a maximum of 8 nig daily. Diuretic therapy should first be withdrawn for 2-3 days, and renal function should be assessed before and during treatment. It is also used as supplementary therapy in heart failure in doses of 2-4 ing. (Coversyl). See page H8 and Table 21.
permethrin An insecticide used as 1% cream for head lice, and 5% cream for scabies. (Lyclear).
perphenazine A tranquillizer with the actions, uses and side-effects of chlorpromazine, but it is less sedating, and effective in lower doses.
Dose: psychiatric and antiemetic, 12-24 nig daily. It is sometimes useful in the control of, intractable hiccup. (Fentazin). See page 168 and Table 30.
pethidine A synthetic analgesic with spasmolytic properties. Widely employed as an alternative to morphine for pre- and post-operative use. Of value in obstetrics as it has a less depressant action than morphine on the respiration.

co-fluampicil -tablets of flucloxacillin and ampicillin
co-flumactone Tablets of spironolactone and hydrochlorothiazide.
colchicine The alkaloid obtained from meadow saffron. It is used in acute gout. Dose: 500mg every 2 hours until relief is obtained. A total dose of 10mg should not be exceeded, but relief of pain or the onset of vomiting or diarrhoea usually renders full doses unnecessary. It is also used prophylactically in doses ol’500pg 2 or 3 times a day during early treatment with allopurinol, probericcid and sulphiripyrazone. Gire is necessary in the elderly, and in renal impairment. See page 140 and’I'able 17.
corticotrophin The adrenocorticotrophic hormone of the anterior pituitary gland. It stimulates the production of corticosteroid hormones by the adrenal cortex. It is now used mainly as a test of adrenocortical function. See tetracosactrin.
Hydrocortisone.
cortisone one of the corticosteroids secreted by the adrenal cortex. Although it is rapidly absorbed orally, it is inactive until converted in the liver to hydrocortisone. It therefore has the actions, uses and side-effects of hydrocortisone, which is often the preferred corticosteroid. It should be noted that cortisone is of no value for topical application. See hydrocortisone, page 250 and Table 36.
colestipol An exchange resin used in hyperlipidaemia that acts by binding with bile salts in the gut and preventing their reabsorption, and so indirectly lowers the plasma level of cholesterol.
Dose: 10-30g daily. May interfere with the absorption of many drugs. (Colostid). See page 146 and Table 20.
colfoseeril A pulmonary surfactant used in the respiratory distress syndrome of the new-born. (Exosurf). See beractant.
colistin An antibiotic used mainly for bowel sterilization.
Dose: 4.5-9 mega-units daily. In systemic gram-negative infections 2 mega-units 8-hourly by injection have been used, but less toxic antibiotics are now preferred. Colonlycin).
collodion When applied to the skin, it dries to form a flexible film, and is used as a vehicle for the extended local application of drugs such as salicylic acid.
co-phenotrope tablets of diphenoxylate
and atropine. (Lomotil; Tropergen).
co-prenozide Tablets of oxprenolol and cyclopenthiazide. (Trasidex).
co-proxamol Tablets  and paracetamol. (Distalgesic).
corticosteroids Hormones secreted by the cortex of the suprarenal gland. The principal hormone is hydrocortisone but more potent synthetic derivatives such as dexamethasone are also in use.
co-tenidone Tablets of atenolol and chlorthaliclone. (Tenoretic).
co-triamterzide Tablets of hydrochlorothiazide and triannerine. (Diazide).
co-trimoxazole A mixture of trimethoprini and sulpliaiiietlioxazole. Trimethoprim, like the sulphonamides, interferes with the folic acid cycle of bacterial metabolism, but at a different point, and the mixture has an increased antibacterial action. It was once widely used, but is now advised only for Prieunjocystis carinii pneumonia. Occasionally given in acute bronchitis and urinary infections when no other drug is acceptable.
Dose: 120 nig/kf; daily lot- 14 days; 960 ing 12-hourly by i.v. infusion. (Bactrin); Septrin).
coumarins Compounds that depress the formation in the liver of prothrombin and other blood coagulation factors. See warfarin and phenindione.
counter-irritants Substances, also referred to as rubifacients, that, when applied to the skin, produce a mild, local irritation and inflammation, and give symptomatic relief in painful conditions of the muscles and joints. Creams and liniments containing methyl salicylate, turpentine, capsicum resin and menthol are examples of rubifacients.
crisantaspase Asparagine is an aminoacid essential for the development of some malignant cells. Crisantaspase is an enzyme, also known as asparaginase, that breaks down asparagine, and so has an indirect cytotoxic action. It is used to induce remission in acute lymphoblastic leukaemia in children.
Dose: (after pre-treatment with other drugs): 1000 units/kg by slow i.v. injection daily for 10 days. Side-effects include anaphylactic reactions, and skin tests to detect hypersensitivity
are essential before initial and re-treatment. (Erwinase).
crotamiton An ascaricide and antipruritiL. Used by local application as cream or lotion (10%) in the treatment of scabies and itching conditions. (Eurax).
crystal violet A dyestuffwith a selective action against Gram-positive organisms and yeasts. Used as a 0.5% solution for infected skin conditions, and for skin
preparation.
cyanocobalamin The anti-anaemic factor present III liver. It is specific in the treatment of pernicious anaemia and its neurological complications, and of value in some other anaernias due to nutritional deficiencies.
Dose: in pernicious anaemia, I Ing by i.m. injection at monthly intervals. It has been largely replaced by hydroxocobalamin, which has a more prolonged action. (Cytanien). See page 112 and’I'able 3.
cyclizine An antihistamine, used mainly in I ravel sickness and nausea generally. Also useful in vertigo.
Dose: 100-150 mg daily. Side-effects include dryness of the mouth, headache and drowsiness. (%Ialoid).
cyclopenthiazide A thiazide diuretic with the actions, uses and side-effects of bend roll tiazide.
Dose: I mg initially, 250-500mg daily or on alternate days, in the morning, according to need. (Navidrex). See page 148 and Table 21.
cyclopentolate An anticholinergic agent use(] to produce cycloplegia and mydriasis. The action is more rapid and less prolonged than atropine, particularly in children. (Mydrilate).
cyclophosphamide A widely used alkylating
cytotoxic agent, active orally and by injec-
tion. Used in I lodgkin’s disease, chronic
lymphocytic leukaemia and lymphomas. Dose: 100-300 Ing daily, orally or i.v., or 300 mg-1 g weekly. A high fluid intake is necessary, as a metabolite may cause hacm- ( )rrhagic cystitis, and it is sometimes used with mesna to reduce the risk of such cystitis. Nausea and vomiting are common side-effects, as is epilation with high doses. (Endoxana). See page 122 and Table 8.
cyclopropane An inhalation anaesthetic of high potency with which induction and recovery are rapid. It causes some respiratory depression and cardiac irregularities, and its administration requires care. It is used with closed-circuit apparatus as it forms an explosive mixture with air and oxygen. Supplied in orange-coloured cylinders.
cycloserine An antibiotic used in
pulmonary tuberculosis when standard drugs are ineffective. Occasionally used in urinary infections.
Dose: 250-750 mg daily. Side-effects include drowsiness, vertigo and rash. See page 170 and Table 31.
cyclosporin An antibiotic with a powerful inuininosuppressant action. It is used under expert control to prevent graft rejection in organ and bone marrow transplantation, and in the prevention of graft-versus-host disease (GVI-ID). Prolonged therapy over some months may be required. Side-effects may include tremor, gastrointestinal disturbance, hypertrichosis and nephrotoxicity (Neural; Sandinimun).
cyproheptadine A compound with antihistamine and antiserotonin properties. Sonic allergic reactions are due not only to histamine, but also to serotonin, and cyproheptadine is useful in conditions not responding completely to an antihistamine. Dose: 4-20 ing daily. It has been used as an appetile stimulant in doses of 12 mg daily and in refractory migraine. (11criactin). See page 110 and Table 2.
cyproterone An anti-androgen used to reduce libido in sexual deviants. Dose: 50-100 nig daily. It is also used in the palliative treatment of prostatic carcinoma, particularly in advanced cases that have become resistant to other therapy. Dose: 300 mg daily.

Allergens in Food
Anyone with true food allergy or coeliac disease needs to be very careful about avoiding certain foods. The information given here is aimed mainly at such people, rather than those with food intolerance (see p. 74), who can usually tolerate small amounts of their offending foods. However, some of the basic information given here is relevant to those with food intolerance as well.
There are different levels of sensitivity even among those with true food allergy. The ‘exquisitely sensitive’ can react to unbelievably minute traces of the food, and for them life is especially difficult. The same is true of some coelicacs, who can be affected by the tiniest quantity of gluten.
These people are a small minority. The level of vigilance required of such people will not be necessary for most people reading this book, so don’t get things out of proportion. While it is vital to be sensible about avoiding your problem food, it is also important not to become over-anxious.
Buying basic ingredients
Cooking for yourself is the safest way to eat for those with true food allergy and coeliac disease. There are relatively few hazards, but do beware of well-meaning assistants in health-food shops who try to sell you some exotic package of grain or flour – spelt or kamut or triticale, for example – reassuring
you that it is ‘definitely not wheat’. Be well informed about the different forms of your problem food and the names under which it is sold (see pp. 172-5).
Oils made from foods such as corn or peanut sometimes cause concern. Ordinary refined oils have been so thoroughly processed that they actually contain no allergenic proteins, so you can safely use these. Bottles of gourmet walnut oil and almond oil are a different story however, and should be avoided if you have nut allergies. Sesame oil is not purified either and can provoke serious reactions. With any oil, if you are unsure how safe it might be, go by the smell. Oils that smell or taste like the food from which they are made could well contain allergens.
Those with allergy to tuna can usually eat tinned tuna because the processing makes it safe. The allergens in fresh fruit and vegetables are generally inactivated by cooking too, so jams and tinned fruits tend to be safe – but test very cautiously. Cooking does not have much effect on other food allergens, apart from eggs. In rare cases, cooking can create allergens (see box on p. 186).
If you share your kitchen with others, and are highly sensitive, check that all cooking utensils are truly clean before use. Coeliac should watch out for breadcrumbs in the butter dish, jam or toaster. Where small children are allergic to a food, it may be best to keep the culprit out of the house entirely.
Genetic engineering and food allergy
Many people with food allergies are very concerned about the possibility that genetic engineering could introduce allergens from one plant species into another. This concern seems to be shared by government officials and those in the food industry, who are being extremely vigilant and cautious at present. As long as this attitude continues, there should be little danger to food allergy sufferers.
Finding food in funny places
If you are suffering some inexplicable reactions to non-food items, it might, just possibly, be a food reaction. Some latex gloves contain the milk protein casein, for example, added as a manufacturing aid.
Buying packaged foods
There are several different issues here:
• the need to read labels carefully for allergenic ingredients described by unfamiliar names (see p. 172)
• errors in the packaging used (see pp. 174-5)
• contamination by minute traces of a food substance due to processing machinery not being cleaned adequately. Cartons of fruit drink have occasionally been contaminated with traces of milk because the same production lines were used for packaging milk drinks. Tofu desserts made in ice-cream factories can also become contaminated with milk. These tiny traces of a food will only affect the most highly sensitive individuals, but contamination by nuts can involve large pieces and affect anyone with nut allergy (see p. 174).
• foodstuffs which are used as part of the production process
and leave a tiny residue in the finished item (see p. 174).
Be very cautious indeed about ready-made food that is unlabelled, such as that from bakeries and home-made stalls. Egg is frequently used as a glaze on baked products, nuts may lurk within, and milk or wheat can turn up in the most unlikely places.
Restaurants, cafes and takeaways
The majority of fatal and near-fatal incidents involving people with true food allergy are due to restaurants, cafeterias and canteens. Takeaways can also be a problem except in the case of the large chains such as McDonald’s, where ingredients are standardised. It is alarming that highly allergenic foods (e.g. peanut) are sometimes used – yet far from obvious – in recipes and sandwich fillings where they would simply not be expected. Anyone with peanut or shellfish allergy should be ultra-cautious about Chinese, Thai or Malaysian cooking – but those with milk allergy should find a haven here, because milk is not part of these culinary traditions.
The simplest solution is to eat very plainly when you go out –steak and salad, for example. Steer clear of casseroles and thick soups, where you can’t see what’s in it (the occasional chef throws in peanut butter to thicken the mix…). Food wrapped in pastry is best avoided for the same reason. Desserts and cakes are risky for anyone with nut, egg or milk allergy.
You must insist on accurate information about the food before you taste it. If the counter staff, the waiter or the waitress
is unsure of the ingredients, ask them to check with the chef, or with the label on pre-packaged food. Be persistent and never eat anything unless you are sure. Make eye contact with the person concerned, and learn to be a good judge of character. Your life could depend on telling the difference between the waiter who knows the facts about the food and the waiter who is being blandly reassuring for the sake of a quiet life.
It is a great mistake to pick out the pieces of offending food – kiwi fruit from a fruit salad for example – and eat the rest. There is often enough allergen left behind to cause anaphylaxis in the highly allergic individual.
Those who are extremely sensitive to the offending food must also consider the problem of contamination in the kitchen. Grills and fryers in restaurants and canteens can become contaminated with fish allergens or nut allergens (e.g. from nut cutlets) and these can be transferred to fried potatoes or other foods, provoking anaphylaxis in the highly allergic individual. One person with fish allergy died in this way. Sesame seeds can also contaminate equipment, work-surfaces or bakery counters.
Parties and buffets
Milk, egg, shellfish or nut allergies can make it especially hazardous to eat buffet or party food. Regard everything with suspicion. Cocktail snacks with nuts or peanut paste hidden inside are a particular problem.
When fish allergy isn’t fish allergy
Anisakis is a parasitic worm that infests fish and can sometimes survive the
cooking process to infect humans. The worms are easily thrown off by the human immune system, but the body is primed to make IgE antibodies should
it ever encounter Anisakis again. Another meal of parasitised fish – even if the Anisakis worms are all dead this time, and only the allergens remain
will provoke a massive IgE-mediated reaction, leading to anaphylactic shock. This problem is usually misdiagnosed as allergy to fish itself.
Other inconsistent reactions to food can be due to contaminants such as antibiotics, preservatives, other food additives or (especially in the case of shellfish) naturally occuring toxins.

Skin-prick tests
This is an indirect method of detecting true allergic reactions. It is one of a family of skin tests that use a similar approach. The three different tests in this family are known as: skin-prick tests or prick tests, puncture tests, and scratch tests.
For the skin-prick test - the technique used in Britain - a small drop of liquid containing an allergen, such as grass pollen, is placed on the arm. The doctor makes a small prick in the skin, under the drop of liquid, allowing a minuscule amount of the allergen to get into the skin. A positive reaction is recorded if a red bump develops soon afterwards. For accuracy, the bump must be compared to positive and negative controls (see below).
The puncture method is very similar to the skin-prick test but uses a slightly different technique for breaking the skin. The term prick-puncture test covers both techniques.
With the scratch method, the skin is scratched lightly, and the allergen solution is then applied over the scratch. This method gives less consistent results than prick-puncture testing.
It is important to include a negative control in the test - a skin-prick test with plain salt water (saline). This should not produce much of a bump - if it does, the skin is clearly over-reactive and the tests more difficult to assess. The doctor should also include a positive control - a skin-prick test with histamine, the substance that plays a central role in allergic reactions. This should always produce a bump. If it does not, the skin is decidedly under-reactive, and the tests are invalid.
Taking antihistamines will make the skin under-reactive, and you should stop taking them before the testing, for a period ranging from a day to several weeks - it varies depending on the particular antihistamine. Ask your doctor for specific instructions about stopping these and other drugs before testing.
Skin tends to be over-reactive to testing in people with dermatographism (see p. 52). Blood tests for specific IgE,
such as RASTs (see p. 92), are needed for anyone who has this condition. Eczema sufferers with a rash over large areas of the body may also require blood tests, if there is too little clear skin for testing.
Skin-prick tests can produce both false positives and false negatives (see box below). Some allergic diseases will give a lot of false negatives and relatively few false positives, while for others the reverse is true. The allergen itself influences the rates of misleading reactions: for example, tests for soya allergy are notoriously unreliable, whereas those for peanut are far more accurate. The age of the person being tested also makes a difference. With all these influences at work, interpreting the test responses is a real art, and the doctor’s experience counts for a lot.
All sorts of people offer skin-prick tests, including alternative practitioners. Get them done by a qualified doctor, preferably by an allergist, who will know how to make sense of the reactions.
Note that the purpose of these tests, and of blood tests for specific IgE, is to identify the allergens that are bringing on your symptoms, not to predict how strongly you will react to those allergens. The tests may give some indication of the intensity of your reaction, but they cannot be regarded as a good guide to how you will respond to the allergen in the future.
The safety record of skin-prick tests is very good. Occasionally a systemic reaction (anaphylaxis) occurs with these tests, but there are no records of any deaths. Nevertheless, if you suffer from severe asthma or have experienced anaphylactic shock in the past, it is advisable for the doctor to have adrenaline and resuscitation equipment available. Those with strong allergic reactions to latex may also react badly if they are tested with an allergen that cross-reacts with latex (e.g. cypress pollen), not just when tested with latex itself. Taking beta-Mockers (see box on p. 150) increases the risk of a life-threatening reaction for anyone in these higher-risk categories.
False positives and false negatives
Apart from challenge tests, none of the tests used for allergy works with 100% accuracy. Most give both false positives and false negatives.
A false positive means that there is a positive test but no actual reaction when the allergen is encountered (e.g. eaten or inhaled). A false negative means that there is a negative test result despite a genuine reaction (as shown by a challenge test, for example).
A test that gives relatively few false positives has good positive predictive value - in other words, if it suggests you are allergic to something, you probably are.
A test that gives relatively few false negatives has good negative predictive value. If it comes up negative, you are probably not allergic to that allergen.
Some tests for allergic reactions show good positive predictive value but poor negative predictive value, while for other tests the reverse is true.
Fresh is best
The fruit and vegetable allergens that provoke Oral Allergy Syndrome (see p. 63) are chemically unstable, so commercially produced extracts for skin-prick testing quickly lose their potency and give false-negative results. Most allergists now favour using a drop of fresh juice from the fruit or vegetable concerned.
Intradermal tests
These tests (also called ‘intracutaneous tests’) put allergen more deeply into the skin than prick-puncture tests. The skin tends to react more when penetrated to this depth, so there are more false positives. There is also a greater risk of a serious reaction which may require emergency resuscitation. Don’t undergo these tests if you are taking beta-Mockers (see box on p. 150).
Blood tests for IgE
There are blood tests that look at the total amount of IgE (the allergy antibody), which is sometimes useful in diagnosis. But more important are blood tests for specific IgE – against egg or grass pollen or latex, for example. There are different ways of measuring the IgE in the blood, the most commonly used being a radio-allergosorbent test or RAST.
Research shows that RASTs are no more accurate than skin-prick tests in confirming real-life allergic reactions. However, they are useful for patients who can’t discontinue their antihistamines without developing severe symptoms, and for those with dermatographism or very severe eczema (see p. 91).
Patch tests
These tests, used primarily for contact dermatitis, are similar to straightforward challenge tests, because the suspect substances are applied directly to the skin.
The test substances are placed on the skin – usually on your back – in small chambers. They are held in place with sticky tape, and left there for several days. Ideally, the reaction of the skin should be checked three times: after two days, again the next day, and again the day after that. It really is worth going back for all these separate visits, because the accuracy of the test increases greatly with repeated checking.
The substances chosen for testing are a standard set of antigens that most commonly cause contact dermatitis. This standard set will pick up 60-80% of all sensitivity reactions in contact dermatitis. If you have substances that you suspect may be causing symptoms, such as cosmetics, the doctor can usually test for these too.
You should not be tested while you still have a rash, as the testing will probably make the existing rash flare up, even though the test patches are applied well away from the rash.
Use of steroid creams and any light treatments (including exposure of the test area to ordinary sunlight) must stop at least a week before testing starts, or the results will not be accurate.
Interpreting patch tests requires a huge amount of skill, plus extensive knowledge of the finicky details of the different test substances. You need a dermatologist with considerable experience in this area.
False positives (see box on p. 91) can occur, especially if you react very strongly to one of the substances tested – some people develop what dermatologists call an ‘angry back’, and this generates false positives to various other substances being tested at the same time. Should you be told that you are sensitive to a great many different things, you may want to query this reading of the test. Ernest N. Charlesworth, an allergist and dermatologist at the University of Texas, describes patients who ‘develop into environmental cripples’ after being told that they are definitely sensitive to multiple antigens, on the basis of misinterpreted false-positive patch tests.
False negatives (see box on p. 91) are also possible, even with very careful testing. Should this occur, a type of challenge test known as a ROAT (Repeat Open Application Test) is possible. The suspect substance is applied to the inner fold of the elbow twice a day for a week. Get your doctor’s agreement before trying this test.
Endoscopy and biopsy
Miniaturised cameras and sophisticated fibre-optics have allowed modern doctors to do something that their predecessors could never have imagined possible – look right inside the human body. This procedure is called endoscopy, and it has a useful role in a few sensitivity reactions.
Looking inside the sinus cavities can assist in understanding exactly what is going wrong in chronic sinusitis. Inspecting the digestive tract can be valuable in several of the non-IgE immune reactions to food, such as coeliac disease (see p. 70) and eosinophilic gastroenteritis (see p. 72).
A biopsy is often carried out at the same time as endoscopy.
s involves taking a small sample from the affected area, such as
I ning of the gut, and studying it in detail under a microscope.
One purpose of a gut biopsy is to look for characteristic :goes of damage to the lining of the gut – such as the distinctive charges produced by untreated coeliac disease. A biopsy can also reveal what kind of immune cells are present. Abnormal numbers of certain immune cells, for example, eosinophils (see p 19), may suggest a particular diagnosis.
Another way of looking at what kind of immune reactions are going on, used for lung diseases, is a bronchoalveolar lavage – iterally a ‘washing out’ of the airways and lungs, allowing immune cells to be collected and studied. This diagnostic technique is lased for Heiner’s Syndrome (see p. 72).
Tests for food intolerance
The only really effective way of testing for food intolerance is an el ruination diet (see pp. 194-7). This is the gold standard. However, it is neither easy nor quick – which has led to a constant search for alternative tests.
The proposed alternatives are all indirect tests, that is to say, non-dietary. The results of the tests are used as a basis for an avoidance diet. In other words, the foods that give a positive test result are avoided.
Some of these tests use samples of hair or blood, others use pulse testing, pendulums, or muscle strength tests (’applied kinesiology’). A few of these tests do show some promise. Pulse tests, and a blood test called the ‘lymphocyte transformation test’. for example, can give a general indication of sensitivity reactions – sometimes. However, even in the most expert hands, these do not give a result that is accurate enough to be useful.
Of the other tests that are available, most have not been evaluated at all objectively.
Many of them are advertised directly to the public, and one of the problems with this approach is that the testing company starts by assuming that food is the problem. The same is usually true of ‘dietary therapists’ and others in the alternative health field offering tests of this kind.
Almost everyone who undertakes such tests is given a fairly long list of foods which have come up positive in the tests. This does not fit with the evidence from medical trials in which a group of people with irritable bowel or migraine (typical food intolerance symptoms) undertake an elimination diet. A significant proportion of them always find that they do not have food intolerance. Of the rest. many find that they react to one or two foods only. The long lists of foods produced by the commercial tests are, to put it mildly, implausible.
With tests that require a sample of blood, sending off two blood samples from the same person, under different names, is a simple way of assessing the tests’ validity. This exercise has been tried several times with different testing companies, and every time two completely different lists of foods have been sent back.
Covert studies of this kind have also shown that the tests overlook genuine reactions. In one alarming case, a woman with a true allergy to peanuts was assured by a ‘dietary therapist’ that she really could eat peanuts safely.
Many people with food intolerance will tell you that they did well after following a diet based on such tests – and they may well have done. Given that common foods such as wheat and milk are regular offenders in food intolerance, and that these foods very frequently feature on the lists of positive test results generated by commercial testing companies, quite a few people should do well. The problem is that these people may also be avoiding many other foods quite unnecessarily.
Furthermore, if people have sensitivities to some other foods that are not on the list, they will be missing out. They could enjoy a far better level of health if all the foods causing symptoms were Identified and removed from their diet.
In the end, an elimination diet is both cheaper and far more likely to give the right answers.
Testing for IgG antibodies
In diagnosing food intolerance, a few doctors offer tests for a type of antibody called IgG. This antibody is formed to any food molecules that get Into the bloodstream after a meal – and some do, even in entirely healthy people. So finding IgG antibodies to food molecules is not indicative of any disease at all. It occurs in everyone and is perfectly normal.
Nevertheless, some doctors feel that by measuring the level of IgG antibodies to foods, they can get a general idea of the permeability of the gut wall (which might possibly be true) and of particular foods that could be causing intolerance reactions (very doubtful – the tests just tell you what you eat most, and you know that already).
This test does measure something real, unlike some of the alternative tests for food intolerance. But the relevance of what it measures to the health of the individual concerned is partial and indefinite. A recent study of IgG testing for irritable bowel syndrome has confirmed this view.
In short, blood tests for IgG antibodies to food molecules seem like very poor value for money, and potentially misleading, whereas an elimination diet is a far more precise way of pinpointing food intolerances.

Using inhalers
The value of using an inhaler rather than taking tablets or syrup is explained on p. 141 for steroids. The same principle applies to all drugs.
The oldest type of inhaler is the ‘puffer’ or aerosol inhaler, properly called a ‘pressurised metered-dose inhaler’ or MDI. It delivers the drug as a fine, moist, spray. In addition, there are now many devices that deliver drugs in dry-powder form.
If you or your child find the aerosol inhalers difficult, you may do better with a dry-powder inhaler. Your doctor should have several different inhalers available for you to try out, to see which one suits you best.
When you are given an inhaler you must be shown how to use it by a doctor or asthma nurse. A great many asthma patients have a ‘poor inhaler technique’, and get too little of the drug as a result. This often leads to their asthma getting out of control. The advice given here for using inhalers is no substitute for proper training, and should only be used to supplement what your doctor or asthma nurse has told you.
When using an aerosol inhaler or MDI, remember to shake the inhaler well or you will not get the right dose. Your in-breath must coincide exactly with pressing the canister down: this is the part that many people find difficult. You must breathe in slowly and deeply, otherwise you do not get much of the drug into your airways.
Many asthmatics stop inhaling the moment the
spray from the aerosol inhaler hits the back of the
throat. The spray contains a propellant, which
makes it very cold, and there is a natural reflex
response to this cold liquid which stops inhalation.
This response may be impossible to control. If so,
you need a dry-powder inhaler (see right), or a
spacer to use with your aerosol inhaler (see p. 162).
Breath-operated aerosol inhalers such as the
Autohaler can be useful for those who find ordinary
aerosol inhalers too hard to use. With these devices, you do not have to push the canister down because your in-breath triggers the release of the drug. Take care not to block the air-intake holes with your hands and don’t stop breathing when you hear the inhaler click. (If there is no click, start again and breathe in more forcefully this time.)
One hazard with aerosol inhalers is that, when almost empty, they produce no drug – just the propellant. Although they still ‘puff’ normally, they are not effective. It may be hard to tell when your inhaler is running low. Ask your doctor or asthma nurse for advice about this.
Many asthmatics find dry-powder inhalers such as the Spinhaler, Rotahaler, Diskhaler, Accuhaler, Clickhaler and Turbohaler are the easiest to use. They have no aerosol device, so none of the problems associated with the coldness of the propellant.
On the other hand, nothing pushes the drug into your mouth and lungs with a dry-powder inhaler: you have to do all the work yourself. This means you have to breathe in quite hard and fast. During a severe asthma attack you may not be able to breathe in hard enough to get a good dose of the drug. Some asthmatics have an aerosol inhaler as well, often combined with a spacer (see p. 162), for use during severe attacks.
For the parents of asthmatics, who want to keep an eye on how much of a drug is being used, most of the dry-powder inhalers allow you to do so.
Arthritis and inhalers
Those who suffer from arthritis in their hands often find inhalers difficult to use. There are several aids now available to help with this problem – ask your doctor or asthma nurse about these.
Do hold your breath
Whichever type of inhaler you use, it is important to give the drugs a chance to do their work. After inhaling, and when your lungs are full, you should hold your breath for at least ten seconds. Then breathe out, but wait at least another 30 seconds before breathing in again.
Side effects from non-drug ingredients
There are other ingredients in inhalers, besides the drug, and they occasionally cause side effects.
Aerosol inhalers are the worst offenders. They can contain up to five non-drug ingredients, such as propellants and surfactants. Some asthmatics are sensitive to one of these, and respond with coughing or bronchospasm when they inhale them.
If inhaled in large amounts, the propellants in aerosol inhalers can give a mild ‘high’, and asthmatic teenagers and their friends may - very rarely - begin abusing inhaled beta-2 relievers. Parents should be alert for the possibility of such problems, but not worry unduly.
Dry-powder inhalers do not need propellants or surfactants, so they are suitable for anyone who develops a sensitivity to these. However, they may contain lactose, or milk sugar, in addition to the drug. Enough lactose is deposited in the mouth and swallowed to provoke symptoms, such as diarrhoea and wind, in people who suffer from severe lactose intolerance (see box on p. 79). Trace amounts of milk proteins in the lactose may be a problem for people with severe milk allergy.
CFCs and inhalers
Aerosol inhalers have long contained CFCs, which are very inert gases (at ground level) and perfectly safe to inhale. Unfortunately, they cause serious damage when they reach the ozone layer high above the earth, so they are being phased out in asthma inhalers, as they are in all aerosols. Other propellants, called hydrofluoroalkanes (HFAs), are being introduced to take their place. The spray from an HFA inhaler may taste and feel different, but it should do exactly the same job as a CFC inhaler: the drug it contains remains the same. Research suggests that these new propellants are very safe, but tell your doctor if your reaction to your inhaler seems to change suddenly.
These new propellants deliver medication more efficiently into the lungs, so that usually only half the previous dose is required. Unlike CFC-type inhalers, they will deliver a constant dose until empty. In addition, they are not affected as much by below-freezing temperatures.
Inhale - then clean your teeth
Asthmatic children are more prone to dental decay than other children, and inhalers are suspected of causing the problem. No one knows, as yet, exactly which ingredient of the inhalers is the culprit - it could be a drug, or a non-drug additive such as a propellant. Alternatively, the fact that the spray from some inhalers is slightly acidic could explain this side effect. Brushing the teeth after using the inhaler, or just rinsing out the mouth with water, is recommended as a preventive measure.
Using spacers
A spacer is a large empty chamber that can be fitted to an aerosol inhaler (a puffer or MIDI). to make it more effective and easier to use. The aerosol spray goes into one end of the spacer, and the asthmatic breathes it in from the other end.
When using a spacer, you can breathe normally: you don’t have to take all the drug in at once. or hold your breath after you’ve inhaled. But you should try to breathe as deeply as possible, and hold your breath for up to ten seconds if you can.
Note that spacers are for use with aerosol inhalers only. Spacers allow the aerosol propellant (see p. 161) to evaporate, leaving tiny airborne droplets of the drug to be inhaled. Once the propellant has evaporated, these droplets are no longer cold, so the reflex response that stops inhalation is avoided.
During an asthma attack, spacers are immensely valuable because they allow you to get some of the drug into your airways even though you are unable to take a deep breath. There is a collapsible spacer, called the E-Z Spacer, which folds up into a plastic case small enough to be slipped into a pocket. In a severe asthma attack, having such a spacer could save your life.
In an emergency, if no spacer is available, you can improvise one (see p. 100).
Babies and small children, who cannot yet coordinate the in-breath with pushing the aerosol canister down, need spacers for everyday use. There are spacers designed for children under two years, with masks that fit over the nose and mouth.
When using a spacer, shake the inhaler and then spray it into the spacer once only. Inhale within five seconds. During an asthma attack, you can add another dose from the inhaler every ten seconds, until the attack begins to subside, but keep a count of how many puffs you use (see p. 100).
For a young child, shake the inhaler well, and fit it to the spacer. Put the mouthpiece into the child’s mouth, or put the mask on. Tell the child to breathe in and out steadily. Listen for the clicking of the valve on the spacer - this shows that it is opening and closing. When the child’s breathing is regular, puff a single dose into the spacer. The child should breathe in and out 5-8 times.
Priming a spacer
Prime a new spacer, or one that has been washed, by firing the inhaler into it about five times. Do this before you actually need to use the spacer.
The drug will coat the spacer walls, due to an electrostatic charge on the plastic. You won’t be able to see the drug as it forms a very thin coating.
When you come to use the spacer, no more of the drug will stick to the spacer walls, because they are already coated, so the full dose will be available for you or your child to inhale.
Priming new spacers is particularly important when the asthmatic is a young child, because there may be some delay between firing the inhaler and the child actually getting a proper lungful of the drug. The longer the delay, the more chance the drug has to stick to the unprimed spacer walls.
A spacer can be used on a baby while it is asleep, which may make life easier for you both. If you need to use the spacer while the baby or toddler is awake, stroke the mask against the child’s cheek first. Keep smiling and talking so that the situation doesn’t seem so frightening. If the baby does start to cry, keep the mask in place: crying will bring on a deep in-breath which is just what is needed.
For an older child, decorating the spacer with coloured stickers can make it appear less daunting. Try to make using the spacer seem like a game. If this fails, don’t get into a battle with the child – leave it a while and try again later.
Playing with the spacer when feeling well will help the child to see it as something familiar, not as a frightening piece of equipment associated with asthma attacks.
Nebulisers
A nebuliser delivers high doses of asthma drugs in an easily inhaled form. It is generally used for severe asthma only, or in an emergency to relieve asthma attacks.
A nebuliser can be attached to an oxygen cylinder, which enriches the air–drug mixture with oxygen. This is useful in severe asthma.
The only people who need to have a nebuliser at home for emergencies are those with brittle asthma, whose condition can deteriorate very suddenly and sharply.
For routine use, only a very small minority of asthmatics require a nebuliser. They include:
• Those with such severe asthma that they depend on large doses of drugs to control their symptoms
• Very small children or elderly people with severe asthma, who have difficulty using inhalers. For them, a nebuliser may be the easiest way to take their drugs.
The fact that the hospital’s nebuliser is so effective in an emergency gives it a special mystique for many people, who assume that nebulisers are a magical cure for asthma. Nebulisers are widely advertised in specialist publications for asthmatics and, while they are expensive, they can look like the answer to a prayer. Many asthmatics, or their parents, mistakenly believe that owning a nebuliser would be the answer to all their problems. In fact the nebuliser only works so well because it delivers a much higher dose of the reliever drug – a dose which also carries a higher risk of side effects. This high-dose treatment should not be used on a regular basis unless it is absolutely essential. No one should buy a nebuliser without first discussing the matter with their doctor.
Asthmatics who own a nebuliser should have detailed written instructions from a doctor about when and how to use it, and how much of the drug to put in. One hazard of owning a nebuliser is that it may give you a false sense of security during emergencies, and delay you from getting expert medical help when you need it. If the nebuliser is for emergency use you should be told the exact signs that indicate a need to use it and – no less important – the signs that show the attack is out of control and needs hospital treatment.
Take care, when using a nebuliser, not to allow the mist to escape and settle on the face or eyes. Regular exposure to steroid mist can cause cataracts in the eyes, and thinning of the skin on the face. Anti-cholinergics (see p. 156) can cause glaucoma if they come into contact with the eye. The mask must fit very tightly. As an additional precaution, place a scarf around the upper edge of the mask to cover any gaps. Wash the face after using the nebuliser for steroids.
Keep off the cough mixture
Coughing can be a useful reaction in asthma, evicting mucus from the lungs. But in some asthmatics the cough does not produce mucus and seems to be no more than a reflex reaction to the airway inflammation. This type of cough can be debilitating, but it is not a good idea to treat it with cough mixture which has no benefit and may mask the seriousness of the asthma. Tackling the airway inflammation with preventer drugs such as steroids is the best course. Simple expectorants, which loosen mucus, may be of value – ask your pharmacist about these.

Candidal Spores of the Fungus, Candida Albicans.
`As a small child Jason was plagued with ear infections which led to many courses of antibiotics,’ Hannah Mitchell recalls. ‘Eventually he started to get symptoms such as an upset stomach, itchy bottom, flu-like symptoms and extremely itchy eyes. The GP prescribed eye drops and when I put them in Jason screamed his head off. In the morning every single eyelash had fallen out. Jason’s health deteriorated and a few months later his eyebrows started to itch. Within two days every single eyebrow hair had fallen out. His eyes were worse and I was offered steroid eye drops again. Reluctantly I accepted.’
‘Putting the drops in caused Jason extreme pain. The red patches of skin around his eyes spread and the itching increased. I was at the end of my tether when I came across a book in the library about food-related illness…
What Hannah discovered from her reading was that, for many with diarrhoea, bloating, wind and an itchy bottom, the cause can be an overgrowth of yeasts in the gut, caused in part by repeated courses of antibiotics which kill off friendly gut bacteria in the gut flora (see p. 204) and allow yeasts to flourish. This is not mainstream medicine, which is why none of the doctors who had seen Jason mentioned the possibility of yeast overgrowth.
Yeasts are microscopic fungi, so anti-fungal drugs are needed to kill them. However, reducing the intake of sugar in the diet is also very effective because yeasts living in the gut thrive on sugar. Hannah took matters into her own hands, and tried out a diet containing no sugar and no yeast. (The reason for avoiding yeast in food is discussed below.) There was some improvement and, encouraged, she went back to the doctor and asked for anti-fungal drugs.
The doctor agreed, and to Hannah’s immense relief, the combination of diet and drug treatment worked for Jason – it cleared the diarrhoea, wind and itching, and eventually allowed his eyelashes and eyebrows to grow back. (Note that few other patients with yeast problems suffer hair-loss – this is a very exotic symptom – but yeast overgrowth can produce some other quite unusual reactions.)
The elusive culprit
So far, you will notice, I have not mentioned Candida. Among those doctors who study and treat this condition, this particular yeast was once considered the prime suspect. Indeed, the disease itself was called ‘candidiasis’. But the role of Candida is now considered doubtful by many.
Researchers such as Dr John Hunter, of Addenbrooke’s Hospital in Cambridge, have tried to find Candida in their patients without success. ‘I think now we have to reject the idea of Candida causing the symptoms,’ says Dr Hunter. ‘But I do believe that there is an imbalance in the gut flora – the micro-organisms that live in the gut. I believe that’s at the root of so-called “candidiasis”.’ This new evidence has not yet affected beliefs about candidiasis’ and ‘Candida’ in the complementary health field.
The fact remains that anti-fungal drugs have proved very helpful to many patients with the typical cluster of symptoms –diarrhoea, wind, bloating and an itchy anus – that were previously attributed to Candida. Given the effectiveness of these drugs, it seems probable that yeasts of some kind are playing a large part in this condition. So the term ‘yeast overgrowth’ is being used, rather tentatively at the moment, as a label for this condition. The yeasts concerned have not, as yet, been identified.
The facts about Candida
This box is about Candida as understood by conventional medicine, rather than ‘Candida’ and ‘candidiasis’ as understood by alternative medicine.
The yeast known as Candida lives naturally in the gut, usually causing no trouble. Problems are usually caused by Candida only when it sets up home in the throat, vagina or penis (’thrush’ infections). Such localised infections have well-defined symptoms and, in most cases, are easily treated with anti-fungal drugs. Patients with damaged immune systems, caused by anti-cancer drugs or AIDS, often develop more widespread Candida infections, but this never happens to people with a normal immune system.
Inhaling steroids and not rinsing out the mouth afterwards can make asthma sufferers more susceptible to Candida infections in the throat (see p. 145).
Other symptoms that have been linked to yeast overgrowth are:
• fatigue
• poor concentration
• irritability, depression and confusion
• headache or migraine
• severe premenstrual problems
• recurrent cystitis
• skin rashes
• aching muscles
• chronic urticaria.
Sometimes there is constipation rather than diarrhoea. Recurrent thrush – a genuine Candida infection in the vagina – can also be a feature of this problem. Occasionally allergic symptoms such as asthma seem to get worse with yeast overgrowth.
Is there an allergic reaction to the yeast?
Those with symptoms typical of yeast overgrowth may give a positive skin-prick test to Candida, but what this means is debatable. For one thing, not everyone with this condition gives a positive test. For another, some entirely healthy people give a positive skin-prick test to Candida. To complicate matters, there are a lot of cross-reactions (see p. 14) between different kinds of yeasts and moulds, due to similarities in their chemical constituents. So the positive skin-prick test does not mean that Candida itself triggered the original IgE-response.
The question of whether some kind of sensitivity reaction to yeasts is occurring in those with yeast overgrowth, and contributing to their symptoms, is an interesting one. The benefits from avoiding yeast in food (see Diagnosis and treatment) suggest that it may be – but this is a question that cannot be answered at present.
Diagnosis and treatment
Unfortunately, this is one of those ’suck-it-and-see’ conditions, where diagnosis and treatment are the same – you try the treatment for yeast overgrowth, and if it works you assume that the disease is, or was, yeast overgrowth. This is far from satisfactory, but is the best that can be done at present.
It is only worth trying this treatment if you have quite a number of the symptoms listed. Bowel problems and an itchy anus are characteristic, and if you have neither of these it is unlikely the treatment will help you.
A key part of the treatment is a no-yeast-no-sugar diet (see p. 205). This diet has been developed on a largely pragmatic basis, and seems to work – but why? The rationale for cutting out sugar is clear – it feeds yeasts in the gut. But why avoiding foods containing yeast should help is uncertain. Possibly the yeasty food supplies some special nutrient that benefits the yeasts living in the gut. Alternatively, there might, for some people, be a sensitivity reaction to the yeast in food (see left).
If it seems that you are on the right track, because there is some improvement with this diet, ask your doctor for anti-fungal drugs. You should take these in addition to the diet. Nystatin (see box below) is very safe for most people, since it is not absorbed from the gut. Bacterial replacers (see p. 205) may also be useful.
You may need a referral to a doctor who is knowledgeable about yeast overgrowth but try to avoid those doctors and alternative therapists who are part of the ‘Candida’ craze, and think that ‘candidiasis’ explains a huge variety of illnesses. You may not have yeast overgrowth at all, so you need someone with an open mind.
Eczema and yeasts?
Doctors have found that some children whose eczema looks very red, and is not responding to treatment, have IgE in the blood against a range of yeasts and other fungi (Candida, Trichophyton, Saccharomyces and Pityrosporum). Given the tendency to cross-reactions among fungi (see main text) it is not clear exactly what these reactions indicate. A proportion of these children get much better on anti-fungal drugs, including a drug called nystatin, which is not absorbed through the gut wall – so cannot reach the skin. The eczema improves, and at the same time there is a fall in levels of anti-fungal IgE in the blood. In other words, a treatment that can only affect fungi living in the gut benefits the skin. Exactly what is going on here is unknown, but the important point is that the treatment seems to work. This is a controversial topic, but since nystatin is an extremely safe drug, your doctor may be prepared to try it out. A course of 3-4 weeks is the minimum needed.

FOOD SENSITIVITY IN ASTHMA, ECZEMA AND OTHER ALLERGIC DISEASES
In 1995, medical researchers in North Carolina, USA, asked over a hundred dermatologists how they treated atopic eczema. All used standard treatments such as moisturisers and steroid creams, but only 14% mentioned the possible role of food to the parents of children with eczema.
Between them, the dermatologists in this study treated about 17,000 children with atopic eczema per year. Using the most widely accepted estimates for food sensitivity in atopic eczema –38% of eczematous children are sensitive to food – one can calculate that there were over 5000 children in this study area who might perhaps have benefited from avoiding a problem food, but whose parents were never told about this treatment option.
North Carolina is by no means unique. The situation is much the same in other parts of the world, which adds up to millions of children and parents not even being told about a treatment that is frequently effective.
Other allergic diseases (see right) can also be triggered by food, although the percentage of patients affected is much lower than for atopic eczema. Here too, many doctors are unaware of (or sceptical about) the possible role of food.
These reactions are best described as ‘food sensitivity’. They cannot be called food allergy (see p. 62) if there are no symptoms in the mouth or gut and if skin-prick tests are negative – as is often the case. Negative skin tests suggest that the reaction is not IgEmediated (see box on p. 12).
However, in some children with atopic eczema. the skin-prick tests to culprit foods are positive. When these foods are eaten after a period of avoidance, such children sometimes suffer an
immediate reaction, with symptoms typical of true food allergy. For these individuals, their atopic eczema seems to be a symptom of IgE-mediated food allergy.
How can an atopic eczema reaction in response to food be IgE-mediated in one individual and not in another? Research is finally beginning to answer this question (see pp. 18-19).
The allergic conditions that may sometimes be induced, or simply aggravated, by a non-immediate reaction to food are:
• atopic eczema (atopic dermatitis)
• asthma
• perennial allergic rhinitis (constantly blocked or runny nose)
• chronic sinusitis
• secretory otitis media (’glue ear’).
In all of these conditions, many other causes exist. Except in the case of eczema, the other causes are far more likely than sensitivity to food. This fact will weigh heavily with your doctor, whose instinct, quite sensibly, is to look for likely causes first.
Taking asthma as an example, food sensitivity is relatively unusual as a primary cause, whereas allergy to airborne items. such as pollen or house-dust mite, is very common. Food probably affects only 8-10% of asthmatics overall, but is much more important for those with brittle asthma (the most severe and unstable form), affecting as many as 60% in a recent study.
The pollen connection
People who suffer from both birch-pollen allergy and atopic eczema may have worsening eczema when they eat certain fruits and vegetables, e.g. apples and carrots. These same foods cause Oral Allergy Syndrome (see box on p. 63) in some with birch-pollen hayfever, but they can aggravate eczema without causing Oral Allergy Syndrome.
Diagnosis
Consider other likely allergens first. Look at p. 28 for the airborne allergens that could play a part in perennial allergic rhinitis, chronic sinusitis, secretory otitis media (’glue ear’), and asthma. Only in the case of children with atopic eczema is food a prime suspect (between 38% and 69% of children with atopic eczema are affected by food), but even here there are a lot of other factors to consider (see pp. 43-4).
If you do decide to investigate the role of food, don’t abandon basic treatments in the meantime. By neglecting these. you could make the whole problem a great deal worse.
There are various clues that food is at fault:
• If you have other symptoms that suggest food intolerance (see p. 76). These problems often seem to go together with food-induced asthma or rhinitis.
• If you have noticed that a particular food makes your symptoms worse. Where there is intolerance to one food, there could well be intolerance to another, which you have not noticed.
• If you have exercise-induced asthma (see p. 41) and sometimes respond severely to exercise but sometimes have little or no reaction. Sensitivity to a food or foods may be instrumental in changing the response to exercise.
• If you have brittle asthma – but you must get your doctor’s consent for an elimination diet. Foods must be tested under medical supervision as severe life- threatening asthmatic reactions can occur on testing.
• If there are also digestive problems such as diarrhoea, vomiting or belching. This is a strong clue in the case of children with atopic eczema. Symptoms such as diarrhoea frequently precede atopic eczema, and it seems likely that a reaction to food in the gut increases the leakiness of the gut wall, allowing more food molecules through to the blood.
• If there is pronounced eczema around the mouth in children (but this can also be due to constant licking),
• For adults with atopic eczema, if there is a persistent rash on the hands, or the lips. Where there is a blistering rash on the hands that erupts at regular intervals, food is often the problem – or it may be metal contaminants of food such as nickel (see pp. 55-6). In general, food sensitivity is rarer among adults with atopic eczema than it is among children.
Skin-prick tests (see p. 91) for commonly eaten foods are worth
trying in all the diseases – if they give a positive result, they should
be noted, but if they give a negative one, they should be disre-
garded. The many alternative tests being marketed (see p. 93) are
highly inaccurate and unlikely to help.
Research from Tampere University Hospital in Finland suggests that babies are much more likely to give false-negative skin-prick tests for food than older children and adults with atopic eczema. The Finnish researchers found that 52% of babies with atopic eczema give a negative skin-prick test despite having a genuine reaction when tested by food challenge. In an attempt to tackle this problem, they have devised a patch test, similar to those used for contact dermatitis. The patch test, in which food is applied to intact skin and left there for two days, gives false negatives in only 39% of babies.
The best way to detect food-sensitive eczema, according to Dr Erika Isolauri. who heads the Finnish research team, is to use both tests, and take note of a positive reaction to either. This detects 80-90% of eczema-causing food reactions in infants.
Few other doctors are currently using patch tests for atopic eczema; because so much controversy surrounds this topic, and no standardised method has yet been devised. You may be lucky and find a specialist who does these tests.
To confirm the role of particular foods in atopic eczema, a food challenge test is essential, having first avoided the food carefully for two weeks. Great care is needed in testing (see p. 198).
If you cannot get suitable tests done. a simple elimination diet will be needed (see p. 198).
Treatment
There is a choice here, between avoiding the offending food, or eating normally and controlling the symptoms with drugs.
The difficulty comes when parents have to make this decision on behalf of their children. Unfortunately, there is insufficient evidence as regards the consequences of this decision. Treating food sensitivity can reduce the eczema symptoms substantially in the short term, but it does not necessarily improve the long-term prospects for the child. Orthodox doctors tend to think that eating a normal diet is much better for a child nutritionally and socially, and they have a point.
Doctors with a special interest in food sensitivity generally believe that treating the problem at source, rather than just suppressing the symptoms with drugs, must take the pressure off the child’s immune system, and give the child a better chance of growing out of sensitivity reactions in the long run.
The decision is yours – but it is vital that the diet is not more of an encumbrance than the disease itself, and that the child’s interests come first (see pp. 170-71). Whatever you do, don’t allow a child to become malnourished (see p. 198).

A blocked or runny nose in Allergy
THAT LASTS ALL YEAR
`Everyone has heard of hayfever, but it’s news to most people that you can have this sort of problem all year round,’ complains Elizabeth. ‘Before we got the treatment sorted out, Benny was “the kid with the constant cold”, and I did notice other mothers looking less than enchanted at the prospect of his coming over to play.’
Benny suffers from allergic reactions to house-dust mites and cats which cause hayfever-style symptoms (26) all year round. This condition doesn’t even have a common name – the medical one is perennial allergic rhinitis – yet it is one of the most common allergic diseases.
Any airborne allergen that is found in the air all year round can cause perennial allergic rhinitis:
• House-dust mite is the number one suspect in most parts of the world. Particles from other insects, such as midges and mosquitoes outdoors, and cockroaches, house flies, bloodworms (used for fish food) or carpet beetles indoors, can also cause nasal allergies.
• Mould spores can be the problem: they are found both indoors and out.
• In some regions, certain types of pollen are airborne all year round (27).
• All pets other than fish produce allergenic particles (even snakes).
• Allergens encountered at work (133) can also produce symptoms in the nose. This is a warning sign gn you should not ignore – it often means that occupational asthma is on its way (132).
Occasionally, the offending substance is being eaten not inhaled. This is less common, so you should investigate inhaled allergens first, before trying an elimination diet (29).
Skin-prick tests (91) will help to identify any airborne allergens that are responsible, but where food is the culprit, skin-prick tests are often negative (69)
Triad and NARES
Diagnosis of perennial allergic rhinitis is complicated by the fact that there are two other conditions – called triad and NARES – which produce similar symptoms and involve the immune system but are not, strictly speaking, allergies.
Triad is so called because it involves three distinct symptoms:
• perennial rhinitis
• polyps in the nose – little fleshy growths that can kill your sense of smell
• asthma.
People with triad tend to collect all three symptoms gradually, in no fixed order, over a period of years or even decades. Many are sensitive to aspirin and related drugs, and almost everyone with triad develops this sensitivity eventually.
Aspirin sensitivity can come on very suddenly and produces a reaction akin to anaphylaxis (101). This can be fatal, so it is probably best to avoid all aspirin-like drugs if you have triad, even though you have not reacted to aspirin in the past Aspirin-like drugs are found in painkillers, arthritis drugs and cold remedies – check with a pharmacist before you buy (151).
If you have asthma, think twice about operations on the nose to remove polyps – they can make the asthma much worse.
The initial letters of Non-Allergic Rhinitis with Eosinophilia have been stretched a bit to get NARES. (This is a medical joke –the Latin word Hares means nostrils.) The problem is caused by eosinophils (19), which flock into the nose and cause severe inflammation. Some people with NARES go on to develop triad.
Collateral damage
Having the nose swamped with mucus can lead to knock-on problems in the ears, sinuses and airways.
If the tube that leads from the ear to the nose (the Eustachian tube) becomes blocked, then fluid cannot drain away from the middle ear. This is called secretory otitis media, or glue ear - it dulls the hearing and causes an unpleasant ‘popping’ sensation. The ears may also feel blocked and itchy, but if children have had this problem since they were tiny they may not complain because they assume that’s just the way ears are supposed to feel. Deafness is often the first sign anyone notices.
Sinusitis is another possible complication, because fluid from the sinuses should also drain into the nasal cavity. With the ouflow blocked, mucus builds up in the sinuses and can become infected by bacteria (30).
Post-nasal drip can also occur with perennial allergic rhinitis. The over-abundant mucus runs down the back of the nose, into the throat and then the airways. This produces a persistent phlegmy cough, which may occasionally be mistaken for asthma.
When the rhinitis is treated effectively, all these problems should sort themselves out, although additional treatment is usually necessary in the case of persistent sinusitis (33).
Treatment
Where an allergen such as house-dust mite or mould spores has been identified as the source of the problem, eradicating it from your house (see Chapter 4) will make a huge difference, and may avoid the need for drugs. If the allergen is unavoidable, immunotherapy (see pp. 164-8) or some alternative form of desensitisation (see pp. 210-13) could be very helpful.
Where drugs are needed, nose drops are best. They get the drugs right to the target so doses are minimal, which means very few side effects. The drugs used are:
• cromoglycate to prevent the allergic reaction before it starts (148)
• antihistamines to block the allergic reaction before it produces inflammation (138)
• steroids to calm down inflammation (144). Steroid nose drops are also useful for NARES and triad. If you are taking steroid drops continuously, your doctor should check the membranes inside your nose every six months. Make sure you put the drops in correctly, especially if you have polyps (144).
If you suffer stinging, burning or dryness, it might be due to preservatives in the drops, not the drug itself (see box on p. 33), so talk to your doctor about a different formulation.
Don’t use over-the-counter decongestant drops: they do nothing to treat the allergy or inflammation, and are little more than a ‘chemical crowbar’ to open up the nose. Your nose gets addicted to them in a few days, and when you stop using them you get ‘rebound congestion’ - absolute and total blockage. It does wear off eventually, but is unpleasant meanwhile. If you are suffering this problem at this very moment, don’t put more decongestant drops in - your nose needs to go ‘cold turkey’ to recover, not have its addiction fed!
If none of the anti-allergy drugs work, but decongestant drops do, then you probably have a non-allergic disease called vasomotor rhinitis. The symptoms are very similar to allergic rhinitis, but without the sneezing and itching. See your doctor again, because there is an effective treatment that uses anticholinergic drugs (see box on p. 156). Acupuncture (see below) can also be helpful.
An elimination diet (194) will diagnose any food reactions. It works wonders for some people with severe and unexplained perennial rhinitis, Including people with such a flood of mucus that they can scarcely work or live normally. You should certainly give this diagnostic diet a try if there are clues that suggest food is the culprit (69) or if no airborne allergen can be identified. Yeast - found in bread, beer and B-vitamin tablets -is quite often the culprit in rhinitis, but it could be any food.
Acupuncture is worth trying, to reduce the blockage in the nose and stem the flow of mucus, because the autonomic nervous system (see box on p. 235) plays some part in the symptoms of allergic rhinitis (and is the sole cause of the symptoms for those with vasomotor rhinitis). For those with severe sinusitis, osteopathy can be good for draining mucus from the sinuses.
Very occasionally, psychological or emotional reactions play a part in perennial allergic rhinitis, with symptoms getting significantly worse during stressful events. One possible manifestation of this is post-coital rhinitis, where sex brings on rhinitis (and sometimes asthma as well). In such cases, psychotherapy should be considered. (But check you are not just allergic to the dust mites in your bed first…)
A nose by any other name…
Rhinitis means inflammation (-itis) of the nose (rhin-). The same Greek word gives us rhinoceros - ‘nose-horn’.