Treating asthma alone doesn’t work
Experts say you must treat allergies, too
It doesn’t surprise asthma specialists that the Healthy People/Productive Community survey conducted by two Tampa, FL-based firms found allergies cost employers more than any other medical condition. (See p. 96 for survey details.)
"There is a high prevalence of allergy in the United States," notes James L. Sublett, MD, national medical director of Vivra Asthma and Allergy in Plantation, FL. "There is also certainly a recognition by the National Heart, Lung and Blood Institute that allergy plays a significant role in persistent asthma. You have to look at asthma patients as allergy patients with different manifestations of disease state, including asthma. The focus of asthma management programs up until now has been on the train wrecks. The patients who end up in the emergency rooms or hospitals get lots of attention. But there’s a lot of money being spent on allergy patients whose asthma has not been properly identified."
Asthma management programs that fail to assess patients for allergy may never succeed in controlling asthma symptoms, agrees Michael C. Blaiss, MD, an allergist and associate professor of pediatrics and medicine at the University of Tennessee in Memphis. "The majority of patients with asthma have an element of allergic rhinitis, much of which is not realized or treated. No allergy control means no asthma control in a majority of patients."
Most asthma management programs obtain a complete asthma profile and medical history from patients, he says. "But they should also include a complete history of the patient’s allergy symptoms." Questions case managers and providers should ask their asthma patients include these:
• Does your nose run or itch when you are having asthma symptoms?
• Do you sneeze when you are having asthma symptoms?
• Do you have a family history of allergy?
When Blaiss discusses asthma with other providers, he always explains the "united airways" theory that there is such a strong connection between the upper airways of the nose and the lower airways of the lungs that to think of them as separate is not accurate.
Allergies should be assessed and treated because the most cost-effective, noninvasive treatment for asthma is avoidance of triggers, Blaiss adds. "Too many physicians just tell patients to give the family cat away without testing for allergy to cat dander. Many times the patient is reluctant to give away their pet, and without proof that the cat may be a cause of their asthma symptoms, it’s an even harder sell. If you test for allergies, you can point to their arm and say, See that big reaction on your arm? That’s what happens when you breathe cat dander.’ By testing, you show patients the cause of their symptoms, and they buy into their treatment much better."
However, just as often, allergy testing doesn’t provide a clear cause for a patient’s asthma symptoms. "In the meantime, the patient’s primary care physician has convinced him to give his pets away, and now you find that animal dander is not a trigger for that patient. You have one angry, dissatisfied patient," says Blaiss.
You also may have a noncompliant patient, notes Sublett. "The patient says, Hey, I got rid of two cats, and I’m still wheezing.’ They end up failing to comply with their whole treatment plan due to their frustration."
To vaccinate or not . . .
Asthmatics who react strongly to allergy testing also may benefit from allergy vaccines, say Sublett and Blaiss. "There are different ranges of allergic reaction," Sublett says. "Individ uals who have very strong allergies generally respond well to immunotherapy or allergy vaccines."
"For certain patients, vaccine therapy significantly decreases all allergy symptoms. It doesn’t affect a cure,’ but it can bring almost complete remission of asthma and allergy symptoms in responsive patients," Blaiss adds, "and allergy vaccines are easy for patients to understand. We vaccinate for tetanus, we vaccinate for hepatitis, why not allergies?"
Of course, allergy testing and allergy vaccines can come with a significant price tag, Sublett says. "If you take a short-term approach, immediate allergy testing and treatment is expensive. But if you look at total quality of life and long-term benefits, you put those costs into perspective. Studies like the Healthy People/Produc tive Community study illustrate the socioeconomic impact of allergies. We must begin to place more emphasis on the total patient who wants to be able to garden or play soccer or golf."
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