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Environmental Control for Indoor Allergens

Patients Educational Materials Environmental Control

Environmental Control for Indoor Allergens

House dust contains a variety of allergens such as insect parts, animal dander, and dust mites. Furthermore, mold may also be present in homes. It is important to eliminate as much allergen as possible from the home in order to derive maximum benefit from your treatment.

House Dust Mite is probably the most important allergen in most homes. Controlling house dust mite exposure will decrease symptoms in allergic patients and may decrease the risk of developing dust mite allergy in patients not yet sensitized. Dust mites are tiny microscopic creatures that thrive in warm, moist climates. Upholstery (particularly the bed) is the ideal habitat for dust mites because they need the protection of the padding and a food supply (shed human skin) to survive. They cannot thrive on non-porous surfaces or in cool dry climates.

There are simple things you can do to minimize dust mite exposure:

  • You should concentrate on the bedroom (particularly the bed) because this is where you spend most of your time. In fact, when you are sleeping, you are breathing with your mouth and nose inches from a whole army of dust mites. The bedroom should be clutter free.
  • Dusting should be done frequently with a damp cloth.
  • The humidity in the bedroom should be kept below 50%. In Central Oklahoma this generally requires only air condition, but may require a de-humidifier. Humidifiers encourage dust mite and mold growth and should be avoided.
  • The mattress, box spring and pillow should be encased in dust mite proof encasements. All items on the bed should be washed in hot water (140 degrees) every one to two weeks. Stuffed animals should be removed from the bed.
  • Upholstered furniture and wall to wall carpet contain dust mites and should be avoided if possible, but these are not nearly as important as the bed.
  • Air filters, expensive vacuum cleaners, and duct cleaning help only minimally. When vacuuming, a HEPA filter or double bag should be used to minimize dust mites being stirred up and released into the air.

Cockroaches are now recognized as important indoor allergens. Other insects such as lady bugs, spiders, and crickets have recently been implicated. Keep the home clean and dry and fix any leaks or drips. It may be necessary to have an exterminator treat the home periodically.

Animal dander, generally from cats and dogs (but sometimes from gerbils, hamster, guinea pigs, mice, etc.) is a very important source of allergen in dust. Contrary to popular belief, animal hair is not the problem. Rather, it is a protein in the urine, saliva and dander of animal that provokes allergy. There are no “nonallergenic” furred pets. Some individual animals produce more allergen than others but there are no “safe” breeds.

  • The best thing you can do if you are allergic is to eliminate the pet.
  • Keeping the animal outside is only a partial solution because people who handle the animals outside will bring the allergen in on their clothes.
  • If you cannot eliminate the pet, try to keep the pet in non-upholstered areas and never let the pet in the bedroom. A HEPA filter in the bedroom may provide some protection.
  • Bathing the animals weekly may decrease the amount of allergen they produce.
  • After the animal has been removed, it can take as long as a year for allergen levels in the home to drop significantly, so a good thorough cleaning of the home is necessary after eliminating the animal.

Recently some information has come to light which suggests that if you are not already allergic it may actually be helpful to have cats or dogs in the home. However, if you are already pet allergic having the pets around will only worsen your allergic symptoms.

Indoor Mold can also cause significant allergic respiratory symptoms. Homes with high humidity and/or leaks have a high likelihood of having significant indoor molds. Once these issues have been fixed, it is generally easy to eliminate molds, but if you continue to have problems with water leaks or high humidity, you will have a hard time cleaning up your mold. Use a cleaning solution containing 5% bleach and a small amount of detergent to clean up moldy areas. Performing house dust control measures will help as well.

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The Current State of Oral Immunotherapy

Food Allergies and OIT

From the American Academy of Allergy, Asthma & Immunology
https://www.aaaai.org/

What is oral immunotherapy for food allergy?
Oral immunotherapy (OIT) refers to feeding an allergic individual an increasing amount of an allergen with the goal of increasing the threshold that triggers a reaction. For example, a person allergic to peanuts may be given very small amounts of peanut protein that would not trigger a reaction. This small amount is gradually increased in the allergist’s office or a clinical research setting over a period of months. The goal of therapy is to raise the threshold that may trigger a reaction and provide the allergic individual protection against accidental ingestion of the allergen. OIT is not a curative therapy.  Individuals who receive OIT will continue to carry epinephrine, read labels closely, etc., and it is not expected that OIT will lead to ingestion of the allergen without limitation.

What is the current standard of care for treatment of food allergy?
The current standard of care for treatment of food allergy is avoidance of the allergen and treatment of anaphylaxis with auto-injectable epinephrine. While many food allergy treatments, including OIT and epicutaneous immunotherapy (EPIT, or a skin patch), have been considered investigational by professional allergy societies and other key stakeholders, the Allergenic Products Advisory Committee of the Food and Drug Administration (FDA) voted to support approval of a standardized oral immunotherapy (OIT) product for peanut allergy, called PalforziaTM. The indication is for treatment to reduce the incidence and severity of allergic reactions, including anaphylaxis, after accidental exposure to peanut in patients aged 4 to 17 years with a confirmed diagnosis of peanut allergy.

How effective is OIT?
Efficacy in clinical trials has typically been defined by induction of a desensitized state. “Desensitization” refers to the improvement in food challenge outcomes after therapy and relies on ongoing exposure to the allergen. Peanut, egg and milk OIT have been shown to desensitize approximately 60 to 80% of patients studied. Desensitization rates for other foods have not been as closely studied and some evidence suggests OIT may not be equally efficacious for every food allergy. It is important to note that because efficacy has been measured using oral food challenges in trials, it is not yet definitively known whether desensitization can protect patients from real-world accidental exposures (e.g. prevent hospitalization or death).

Some studies have looked at “sustained unresponsiveness” which refers to retention of the protective benefit achieved through therapy and is not reliant on ongoing exposure. Sustained unresponsiveness has not been adequately studied to provide definitive data. Peanut and milk OIT have been reported to induce sustained unresponsiveness in approximately 30 to 70+% of individuals, though a number of variables make broad interpretation of this data difficult, including age of participants in the studies, length of time on therapy, and length of time off therapy at the time the sustained unresponsiveness was assessed. It is assumed that ongoing exposure will be required for the majority of individuals receiving OIT or EPIT; the therapies in their current form are unlikely to produce a permanent, long-standing immunologic change.

What are the side effects of OIT?
The most common side effects involve the gastrointestinal (GI) tract. Typical symptoms include abdominal pain, vomiting and cramping. Some patients have developed eosinophilic esophagitis (EoE), an allergic disease of the esophagus that causes difficulty swallowing, vomiting and abdominal pain, but it is not always clear that EoE was caused by the therapy. EoE typically resolves when therapy is discontinued. Other commonly reported side effects include oral itching, rash, hives, swelling, wheezing and anaphylaxis.

What are some “real-life” considerations with OIT?
Studies thus far have brought to light several “real-life” considerations that will be important to understand as treatment with OIT becomes available. OIT involves a long-term commitment with daily dosing during the up-dosing and maintenance phases which occur over several months to years and possibly indefinitely. Bi-weekly office visits are required to safely assess the tolerability of each consecutive dose level. When dosing at home, certain precautions increase safety but also place restrictions on daily life, such as a home monitoring period after dosing and avoiding an elevation in body temperature (e.g. with exercise, hot showers, etc.) for 2to 4 hours after dosing. In addition, aversion to the taste and smell of the product can be tough to overcome for those who have practiced lifelong avoidance.

What is unknown about OIT?
There are many important questions about OIT that require ongoing study. The precise degree of protection is a topic of active investigation. Will OIT allow individuals to reliably eat products with precautionary labels? The length of treatment and doses used have varied in published studies. The “best” dose to give for any particular allergen is unknown. How to predict which individuals would respond to treatment and those at highest risk of side effects is also unknown. Do treatments have long-term safety risks different from those observed in clinical trials? Is there a way to measure benefit without performing an oral food challenge? Is long-term treatment sustainable? What are the effects of long-term treatment on quality of life and family dynamics? What are the effects of suboptimal adherence on safety and efficacy? Could OIT be combined with another therapy to improve safety and efficacy?

What OIT has been approved for the treatment of food allergy?
The only FDA approved treatment for food allergy is the aforementioned peanut OIT product, PalforziaTM. Other programs for egg and walnut allergies have been announced. There are also a relatively small number of allergists around the country who use commercial food products to offer OIT as a service in their offices, a clinical practice which is not currently and will not be “approved” by the FDA. Only REMS certified providers will be able to prescribe PalforziaTM.

What else should individuals affected by food allergy and their families be aware of when considering OIT?
OIT is a leading investigational and now, marketed treatment, offering the hope of protection from food allergy reactions. However, like most chronic diseases, food allergy treatment will not be a “one size fits all” approach. Thus far, OIT has primarily targeted allergy to single foods; further study is required to determine if multiallergen OIT will be beneficial. Other investigational therapies may become available and carry different risks and benefits. In addition to the safety profile, important considerations will include likelihood of outgrowing an allergy naturally, prevalence of food in the diet/culture, severity of allergy, and risk of exposure. Ultimately, the choice of treatment, including that of active non-intervention, will be based on individual and family factors after careful discussion with one’s physician.

The post The Current State of Oral Immunotherapy appeared first on Oklahoma Allergy and Asthma Clinic.

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