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Allergic Reactions


Allergic reactions (hypersensitivity reactions) are inappropriate responses of the immune system to a normally harmless substance. Usually, allergies make the eyes water and itch, the nose run, the skin itch, rashes develop, and people sneeze. Some symptoms, called anaphylactic reactions, are life threatening. Symptoms suggest the diagnosis, and skin tests can help identify the allergy trigger. People who have had severe reactions should always carry a self-injecting syringe of epinephrine Some Trade Names ADRENALIN and antihistamines. Avoiding the trigger is best, but if it is impossible, allergy shots can sometimes desensitize the person. Severe reactions require emergency treatment in the hospital.

Normally, the immune system—which includes antibodies, white blood cells, mast cells, complement proteins, and other substances—defends the body against foreign substances (called antigens). However, in susceptible people, the immune system can overreact when exposed to certain chemicals (allergens) in the environment, foods, or drugs, which are harmless in most people. The result is an allergic reaction. Some people are allergic to only one substance. Others are allergic to many. About one third of the people in the United States have an allergy.

Allergens may cause an allergic reaction when they land on the skin or in the eye, are inhaled, are eaten, or are injected. An allergic reaction can occur in several ways: As part of a seasonal allergy (such as hay fever), caused by exposure to such substances as grass or ragweed pollen Triggered by taking a drug (see Adverse Drug Reactions: Allergies to Drugs ) Triggered by eating certain foods Triggered by breathing in dust or animal dander

In many allergic reactions, the immune system, when first exposed to an allergen, produces a type of antibody called immunoglobulin E (IgE). IgE binds to a type of white blood cell called basophils in the bloodstream and to a similar type of cell called mast cells in the tissues. The first exposure may make people sensitive to the allergen but does not cause symptoms. When sensitized people subsequently encounter the allergen, the basophils and mast cells with IgE on their surface release substances (such as histamine, prostaglandins, and leukotrienes) that cause swelling or inflammation in the surrounding tissues. Such substances begin a cascade of reactions that continue to irritate and harm tissues. These reactions range from mild to severe.

Symptoms

Most allergic reactions are mild, consisting of watery and itchy eyes, a runny nose, itchy skin, and some sneezing. Rashes (including hives) are common and often itch. Hives are small, pale, slightly elevated areas of swelling (wheals) that are surrounded by a red area. Swelling may occur in larger areas under the skin (as angioedema—see Allergic Reactions: Hives and Angioedema ). Swelling is caused by fluids leaking from blood vessels. Depending on which areas of the body are affected, angioedema may be serious. Allergies may trigger attacks of asthma.

Certain allergic reactions, called anaphylactic reactions (see Allergic Reactions: Anaphylactic Reactions ), can be life threatening. The airways can narrow (constrict), causing wheezing, and the lining of the throat and airways may swell, interfering with breathing. Blood vessels can widen (dilate), causing a dangerous fall in blood pressure.

Diagnosis

Doctors first determine whether a reaction is allergic. They may ask whether the person has close relatives with allergies because a reaction is more likely to be allergic in such cases. Blood tests are usually done to detect a type of white blood cell called eosinophils. Eosinophils are produced in large numbers when an allergic reaction occurs.

Because each allergic reaction is triggered by a specific allergen, the main goal of diagnosis is to identify that allergen. Often, the person and doctor can identify the allergen based on when the allergy started and when and how often the reaction occurs (for example, during certain seasons or after eating certain foods).

Skin tests are the most useful way to identify specific allergens. Usually, a skin prick test is done first. Dilute solutions are made from extracts of pollens (from trees, grasses, weeds, or fungal spores), dust, animal dander, insect venom, foods, and some drugs. A drop of each solution is placed on the person's skin, which is then pricked with a needle. If the person is allergic to one or more of these substances, the person has a wheal and flare reaction: A pale, slightly elevated swelling—the wheal—appears at the pinprick site within 15 to 20 minutes. The wheal is surrounded by a well-defined red area—the flare. The resulting area is about 1 / 2 inch in diameter.

The skin prick test can identify most allergens. If no allergen is identified, a tiny amount of each solution can be injected into the person's skin. This type of skin test is more likely to detect a reaction to an allergen. Antihistamines should not be taken before skin tests because they may suppress a reaction to the tests.

The radioallergosorbent test (RAST) is used when skin tests cannot be used—for example, when a skin rash is widespread. This test measures blood levels of different types of IgE that are specific to particular allergens. If a large amount of one type of IgE is detected, the immune system is mounting an allergic reaction against that allergen. Thus, this test helps doctors identify the allergen. People may be asked to stop taking certain drugs a few days to a week before the test. These drugs, which include over-the-counter and prescription antihistamines, tricyclic antidepressants, and monoamine oxidase inhibitors (also antidepressants), can interfere with test results. People who are taking beta-blockers are not tested.

Prevention

Environmental Measures: Avoiding an allergen, if possible, is the best approach. Avoiding an allergen may involve the following: Stopping a drug Keeping a pet out of the house Installing high-efficiency air filters Not eating a particular food For people with severe seasonal allergies, possibly moving to an area that does not have the allergen Removing items that collect dust, such as upholstered furniture and carpets Covering mattresses and pillows with finely woven fabrics that cannot be penetrated by dust mites and allergen particles Using synthetic-fiber pillows Washing bed sheets, pillowcases, and blankets in hot water frequently Using dehumidifiers in basements and other damp rooms Treating homes with heat-steam

Allergen Immunotherapy: Because some allergens, especially airborne allergens, cannot be avoided, allergen immunotherapy (also called desensitization), usually allergy shots or injections, can be given to desensitize people to the allergen. With allergen immunotherapy, allergic reactions can be prevented or reduced in number or severity. However, allergen immunotherapy is not always effective. Some people and some allergies tend to respond better than others.

Immunotherapy is used most often for allergies to pollens, house dust mites, molds, and venom of stinging insects. When people are allergic to unavoidable allergens, such as insect venom, immunotherapy helps prevent anaphylactic reactions (see Allergic Reactions: Anaphylactic Reactions ). Sometimes it is used for allergies to animal dander, but such treatment is unlikely to be useful. Immunotherapy for food allergies is usually not advised because it can cause severe reactions and is less effective. Also, foods can usually be avoided.

Immunotherapy is not used when the allergen, such as penicillin and other drugs, can be avoided. However, if people need to take a drug that they are allergic to, immunotherapy, closely monitored by a doctor, can be done to desensitize them.

In immunotherapy, tiny amounts of the allergen are usually injected under the skin. The dose is gradually increased until a dose adequate to control symptoms (maintenance dose) is reached. A gradual increase is necessary because exposure to a high dose of the allergen too soon can cause an allergic reaction. Injections are usually given once or twice a week until the maintenance dose is reached. Then injections are usually given every 2 to 6 weeks. The procedure is most effective when maintenance injections are continued throughout the year, even for seasonal allergies.

Alternatively, high doses of the allergen may be placed under the tongue (sublingual) and held there for a few minutes, then swallowed. The dose is gradually increased, as for injections. The sublingual technique is relatively new, and how often the dose should be given has not been established. It ranges from every day to 3 times a week.

Allergen immunotherapy may take 3 to 4 years to complete.

Because immunotherapy injections occasionally cause dangerous allergic reactions, people remain in the doctor's office for at least 30 minutes afterward. If they have mild reactions to immunotherapy (such as sneezing, coughing, flushing, tingling sensations, itching, chest tightness, wheezing, and hives), a drug—usually an antihistamine, such as diphenhydramine Some Trade Names BENADRYL NYTOL SOMINEX or loratadine Some Trade Names CLARITIN —may help. For more severe reactions, epinephrine Some Trade Names ADRENALIN (adrenaline) is injected.

Treatment

Avoiding the allergen is the best way to treat as well as prevent allergies. If mild symptoms occur, antihistamines are often all that is needed. If they are ineffective, other drugs, such as mast cell stabilizers and corticosteroids may help. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not useful. Severe symptoms, such as those involving the airways (including anaphylactic reactions), require emergency treatment.

Pregnant women with allergies should avoid allergens in order to control their symptoms whenever possible. If symptoms are severe, then pregnant women should use inhaled antihistamines rather than oral antihistamines unless they cannot obtain adequate relief. Breastfeeding women should also try to avoid antihistamines, but if they are necessary then inhaled antihistamines are preferred to oral antihistamines. If oral antihistamines are essential for controlling symptoms, they should be taken immediately after feeding the baby.

Antihistamines: The drugs most commonly used to relieve the symptoms of allergies are antihistamines. Antihistamines block the effects of histamine rather than stop its production. Taking antihistamines partially relieves the runny nose, watery eyes, and itching and reduces the swelling due to hives or mild angioedema. But antihistamines do not ease breathing when airways are constricted.

Antihistamines are available as tablets, capsules, or liquid solutions to be taken by mouth or as nasal sprays, eye drops, or lotions or creams. Which is used depends on the type of allergic reaction. Some antihistamines are available without a prescription (over-the-counter), and some require a prescription.

Antihistamines have anticholinergic effects, such as drowsiness, dry mouth, blurred vision, constipation, difficulty with urination, confusion, and light-headedness (particularly after a person stands up), as well as drowsiness. Often, prescription antihistamines have fewer of these effects.

Some antihistamines are more likely to cause drowsiness (sedation) than others. Sedating antihistamines are widely available over the counter. People should not take sedating antihistamines if they are going to drive, operate heavy equipment, or do other activities that require alertness. Sedating antihistamines should not be given to children under 2 years of age because they may have serious or life-threatening side effects. Over-the-counter antihistamines are also a particular problem for older people (see Aging and Drugs: Anticholinergic: What Does It Mean? ) and for people with glaucoma, benign prostatic hyperplasia, or dementia because of the drugs' anticholinergic effects. In general, doctors use antihistamines cautiously in people with cardiovascular disease.

Not everyone reacts the same way to antihistamines. For example, Asians seem to be less susceptible to the sedative effects of diphenhydramine Some Trade Names BENADRYL NYTOL SOMINEX than are people of Western European origin. Also, antihistamines cause the opposite (paradoxical) reaction in some people, making them feel nervous, restless, and agitated.

Some Antihistamines

Drug Degree of Anticholinergic Effects * Degree of Drowsiness†

Nonprescription

Brompheniramine Some Trade Names DIMETANE

Moderate

Some

Cetirizine Some Trade Names ZYRTEC

Few to none

Little to none in most people and moderate in some people

Chlorpheniramine Some Trade Names CHLOR-TRIMETON TELDRIN

Moderate

Some

Clemastine Some Trade Names TAVIST

Strong

Moderate

Desloratadine

Few to none

Little to none

Diphenhydramine Some Trade Names BENADRYL NYTOL SOMINEX

Strong

Extreme

Loratadine Some Trade Names CLARITIN

Few to none

Little to none

Prescription ‡

Azatadine Some Trade Names OPTIMINE

Moderate

Moderate

Azelastine Some Trade Names OPTIVAR

Few to none

Some

Cyproheptadine Some Trade Names PERIACTIN

Moderate

Some

Dexchlorpheniramine Some Trade Names POLARAMINE

Moderate

Some

Fexofenadine Some Trade Names ALLEGRA

Few to none

Little to none

Hydroxyzine Some Trade Names ATARAX VISTARIL

Moderate

Extreme

Levocetirizine

Few to none

Little to none

Promethazine Some Trade Names PHENERGAN

Strong

Extreme

*Anticholinergic effects include confusion, dry mouth, blurred vision, constipation, difficulty with urination, confusion, and light-headedness (particularly after a person stands up). Older people are particularly susceptible to these effects.

† The degree of drowsiness varies, depending on the dose, other active ingredients in the formulation (as in decongestants), and the person.

‡ Some formerly prescription-only antihistamines are now also available over the counter.

Mast Cell Stabilizers: Mast cell stabilizers inhibit mast cells from releasing histamines and other substances that cause swelling and inflammation. These drugs include cromolyn Some Trade Names CROLOM INTAL NASALCROM and nedocromil Some Trade Names TILADE . They are taken when antihistamines and other drugs are not effective or have bothersome side effects. These drugs may help control allergic symptoms.

Cromolyn Some Trade Names CROLOM INTAL NASALCROM is available by prescription for use with an inhaler or nebulizer (which delivers the drug in aerosol form to the lungs), as eye drops, or in forms to be taken by mouth. It is available without a prescription as a nasal spray. Cromolyn Some Trade Names CROLOM INTAL NASALCROM usually affects only the areas where it is applied, such as the back of the throat, lungs, eyes, or nose. When taken by mouth, cromolyn Some Trade Names CROLOM INTAL NASALCROM is not absorbed into the bloodstream, but it can relieve the digestive symptoms of mastocytosis (see Allergic Reactions: Mastocytosis ).

Nedocromil Some Trade Names TILADE is available by prescription as eye drops.

Corticosteroids: When antihistamines and mast cell stabilizers cannot control allergy symptoms, a corticosteroid may help. Corticosteroids can be taken as a nasal spray to treat nasal symptoms or through an inhaler, usually to treat asthma. Doctors prescribe a corticosteroid (such as prednisone Some Trade Names DELTASONE METICORTEN ) to be taken by mouth only when symptoms are very severe or widespread and all other treatments are ineffective. If taken by mouth for more than 3 to 4 weeks, corticosteroids have many, sometimes serious side effects (see Joint Disorders: Corticosteroids: Uses and Side Effects ). Therefore, corticosteroids taken by mouth are used for as short a time as possible.

Creams, and ointments that contain corticosteroids can help relieve the itching associated with allergic skin rashes. One corticosteroid, hydrocortisone Some Trade Names See Cortisol , is available over the counter.

Other Drugs: Leukotriene modifiers , such as montelukast Some Trade Names SINGULAIR , are anti-inflammatory drugs used to treat mild persistent asthma and seasonal allergic rhinitis. They inhibit leukotrienes, which contribute to inflammation and cause airways to constrict.

Omalizumab is a monoclonal antibody (which is a manufactured (synthetic) antibody designed to interact with a specific substance). Omalizumab binds to IgE, an antibody that is produced in large amounts during an allergic reaction, and prevents the IgE from binding to mast cells and basophils and triggering an allergic reaction. Omalizumab may be used to treat allergic rhinitis or persistent or severe asthma when other treatments are ineffective. When it is used, the dose of a corticosteroid can be reduced. It is given by injection under the skin (subcutaneously).

Emergency Treatment: Severe allergic reactions, such as an anaphylactic reaction, require prompt emergency treatment. People who have severe allergic reactions should always carry a self-injecting syringe of epinephrine. Many of these people also carry antihistamine tablets. If a severe reaction occurs, these treatments should be used as quickly as possible. Usually, the combination of epinephrine and an antihistamine stops the reaction. Nonetheless, people who have had a severe allergic reaction should go to the hospital emergency department, where they can be closely monitored and treatment can be repeated or adjusted as needed.

Source: The Merck Manual Home Edition