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Month: April 2023

SMART Asthma Therapy

Asthma is a chronic inflammatory disease of the airways that causes frequent symptoms of coughing, chest tightness, wheezing and/or shortness of breath.

If the symptoms are less frequent than twice a week during the daytime and less than twice a month during the nights, it is termed “intermittent” asthma. If the symptoms are more frequent than twice a week during the daytime and more than twice a month during the nights, it is called “persistent” asthma. Persistent asthma is further subdivided into mild, moderate, and severe based on the severity and frequency of the asthma symptoms as well as lung function measurements obtained by pulmonary function tests.

Intermittent asthma is traditionally treated with an as needed “rescue” inhaler medication, which is usually an albuterol (e.g., ProAir, Proventil, Ventolin) inhaler. Albuterol is a short-acting beta 2 agonist bronchodilator medication which acts as a dilator of the bronchial tubes of the lungs. It provides quick relief for the wheezing, chest tightness, coughing, and shortness of breath that plagues asthma sufferers. The usual dose is 2 puffs from the inhaler every 4 to 6 hours as needed for symptom relief. Albuterol can also be used prior to exertion for the prevention of exercise-induced asthma symptoms.

Persistent asthma, on the other hand, needs a daily scheduled maintenance medication in order to control the inflammation that occurs in asthmatics. The daily maintenance medication helps prevent symptoms and preserve the lung function in the long term. The maintenance medication usually consists of a corticosteroid in the form of an inhaler [Flovent (fluticasone), QVAR Redihaler (beclomethasone), Asmanex (mometasone), Pulmicort (budesonide), Arnuity (fluticasone), Alvesco (ciclesonide), Aerobid (flunisolide)] which is usually taken either once or twice a day. There is also another maintenance therapy that does not include a corticosteroid. Such non-steroid maintenance medications typically are known as leukotriene antagonists [e.g., Singulair (montelukast), Accolate (zafirlukast), Zyflo (zileuton)]. It is up to the allergist and patient to decide which type of maintenance therapy is best for that patient.

Since a maintenance medication is needed in most persistent asthmatic patients, usually 2 different types of inhalers are needed in total – one for the daily preventive maintenance and the other for the as needed quick relief for asthma symptoms. Though it is an effective way of treating asthma, it can sometimes lead to confusion for some patients, so it is necessary for the board certified allergist to explain how and when to use both types of medications.

There has been a recent update in the recommendations for asthma management from the National Asthma Education and Prevention Program. The newer guidelines recommend one inhaler both for prevention and rescue therapy. This new recommendation is termed Single Maintenance And Reliever Therapy (SMART).

The recommended inhaler contains a combination of a corticosteroid (anti-inflammatory agent) and a short-acting beta 2 agonist bronchodilator to open the airways quickly. In addition to using it once or twice a day on a regular daily basis for maintenance, the patient can take one or two puffs from the same inhaler as needed for the rapid relief of the symptoms. SMART therapy is approved for children who are 5 years old and above.

Clinical studies have shown that SMART therapy reduces acute flare-ups, emergency healthcare visits, and hospitalizations compared to the traditional therapy in patients with moderate and severe persistent asthma. However, If the patient’s current therapy is controlling their asthma well and they are not having side effects, there is no need to make a change.

There are 2 main corticosteroid medications recommended for SMART therapy: budesonide and mometasone. These 2 corticosteroids can be used as the preventive component. Formoterol is a faster acting long-acting beta 2 agonist that is used as the rescue component. Only formoterol-containing formulations should be used. Formoterol has a more rapid onset bronchodilator effect than other long-acting beta 2 agonists, similar to albuterol. Budesonide/formoterol (i.e., Symbicort) is the most commonly used formulation for SMART therapy, but mometasone/formoterol (i.e., Dulera) may also be used.

The board certified allergy specialists at Black & Kletz Allergy have been treating asthma in pediatric and adult patients for more than 5 decades. We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area which are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. If you or someone you know has asthma or any other allergic or immunologic condition, please make an appointment so that we may help you. Alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy have been treating patients in the Washington, DC metropolitan area for allergies, asthma, sinus disease, and immunologic disorders for more than 50 years. We would be pleased to provide allergy and asthma relief for you and your family in a relaxed, caring, and professional environment.

Hives, Itching, and Swelling

Of all the ailments that people seek an allergist’s care for, one of the most bothersome conditions is hives (i.e., urticaria). A hive can be described as an itchy red blotch or welt that can occur anywhere on the skin. A hive can be flush with the skin or it can be a raised bump. Usually, there are a multitude of hives that occur as opposed to just one hive, although a single hive may occur. The size and shape of a hive is variable as it can be large or small and it can take any shape. Although hives usually itch, they can occur without itching. Hives can also occur internally such as the gastrointestinal system. If the hives occur in the stomach, the individual may experience abdominal pain, abdominal cramping, nausea, and/or vomiting as a result of internal hives. If the hives occur in the throat, the person may feel a tightening of their throat.

There are 2 basic criteria for hives. If one has hives on and off for less than 6 weeks, that person is said to have “acute” urticaria. If, however, the hives last 6 or more weeks, that individual is said to have “chronic” urticaria. Acute urticaria is more common than chronic urticaria and it is not uncommon. Approximately 20-25% of Americans will have hives at some point in their lives. Hives generally last less than 24 hours, but may last longer. They may occur very frequently (i.e., multiple times a day) or occur very rarely, (i.e., one isolated episode). Hives tend to be intermittent (i.e., come and go) as opposed to remaining on the skin for days, weeks, or months like eczema (i.e., atopic dermatitis). Chronic urticaria acts the same as acute urticaria except that the duration of the hives is 6 weeks or greater.

There are many causes of hives. Some of the common causes of hives may include an allergy to a food (e.g., peanuts, tree nuts, milk, egg, soy, wheat, fish, shellfish), medication [e.g., antibiotic, aspirin, nonsteroidal anti-inflammatory drugs (ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve, Anaprox), indomethacin (Indocin), salsalate (Disalcid), diclofenac (Arthrotec, Voltaren, Cataflam), ketorolac (Toradol), celecoxib (Celebrex), meloxicam (Mobic), nabumetone (Relafen), tolmetin (Tolectin), fenoprofen (Asaid), etodolac (Lodine), sulindac (Clinoril), piroxicam (Feldene), and oxaprozin (Daypro)], or flying insect sting (e.g., bee sting). Other common causes may include an infection (i.e., viral, bacterial, fungal, or parasitic), autoimmune disorders (i.e., the immune system fights against an individual’s body instead of fighting against outside invaders), inflammatory conditions (i.e., vasculitis), and/or rarely cancers. In addition to the forementioned causes, physical stimuli such as heat, cold, exercise, pressure, vibration, sun exposure, and/or even water exposure can cause hives in sensitive individuals.

If someone has chronic urticaria, it is important to find out if there is an underlying condition present that is causing that individual to have the hives. The diagnosis of hives begins with a comprehensive history and physical examination. Allergy skin testing or blood testing may be needed depending on the patient’s unique situation with respect to their hives. For patients with chronic urticaria, blood testing and a urinalysis are obtained in order to look for an underlying condition that may be causing the hives. It is interesting to note that despite doing a thorough workup for chronic urticaria with blood and urine tests, 95% of the time no cause is identified. In these cases, the chronic urticaria is designated as “idiopathic” which is basically saying that we know what is not causing the hives, but we still do not know what is causing them. These patients are labeled as having chronic idiopathic urticaria (CIU) or chronic spontaneous urticaria (CSU).

The treatment of hives usually begins with oral antihistamines or H1 blockers [e.g., Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine), Xyzal (levocetirizine)]. In some cases, H2 blockers such as Pepcid (famotidine) may be used in combination with the H1 blocker (antihistamine). Leukotriene antagonists [e.g., Singulair (monteleukast)] may also be used if needed. Occasionally corticosteroids may be necessary to treat recalcitrant cases. In addition to the above medications, patients with chronic spontaneous urticaria (i.e., chronic idiopathic urticaria) may benefit greatly with Xolair (omalizumab), a biologic injectable medication which is usually administered monthly.

There are 2 other conditions that are related to hives that should be discussed since they can occur without hives or with hives. They are as follows:

Pruritus: Even though pruritus technically means “to itch,” it should be noted that some individuals just itch without having associated hives while as mentioned above, some itch with associated hives. For the purposes of this blog, pruritus means the former, itching without hives or a rash. The diagnosis and management are essentially the same as with hives except Xolair is not used in patients with just pruritus alone.

Swelling (i.e., angioedema): Similar to pruritus, swelling (i.e., angioedema) may occur simultaneously with hives or the swelling can occur without associated hives. One can think of angioedema as a large hive, so in essence it is not really different from a hive, except it can be scarier to the individual with the swelling. Of course if the swelling is in the throat for example, it can be life-threatening. The diagnosis and treatment are also basically the same as with hives except there is an added blood test (i.e., C1 esterase inhibitor level) that is obtained and like with the treatment of pruritus, Xolair is not used with just angioedema alone.

The board certified allergy doctors at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding hives (i.e., urticarial), itching (i.e., pruritus), swelling (i.e., angioedema) or any other allergic condition. We have 3 offices with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer on-site parking. In addition, the Washington, DC and McLean, VA offices are accessible by Metro. There is also a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please make an appointment by calling any one of our 3 offices, or alternatively, you can click Request an Appointment and we will answer you within 24 hours by the next business day. Black & Kletz Allergy diagnoses and treats both children and adults and we are proud to serve the Washington, DC metro area residents for which we have done for more than 5 decades.