Navigating Allergy Management During COVID-19

With COVID-19 in our midst, it’s understandable that patients may be confused about allergy symptoms and treatments in this unique health environment. Patients may be worried about their symptoms and unsure if what they are experiencing is “just allergies” or something else. They may be seeking advice about when to see a healthcare provider or allergist and what treatments are currently available. Healthcare providers who treat allergies may want to inform and reassure their patients about worrisome symptoms and help them plan treatment strategies while COVID-19 and social distancing measures continue.

I got in touch with Jacqueline Eghrari-Sabet, M.D., an allergist-immunologist in metro Washington, D.C., and an ALK paid consultant, to talk about these pressing issues and what patients and physicians need to know during this time. Dr. Eghrari-Sabet is an associate clinical professor at George Washington University and director of telemedicine for the Allergy & Asthma Network, a national education and advocacy organization.

Jorge: Thank you for joining me Dr. Eghrari-Sabet! Can you give everyone reading this a quick overview of environmental allergies? What are they and what causes them?

Dr. Jacqueline Eghrari-Sabet: I am so pleased to participate in this exchange to help people learn more about managing allergies during these trying times. As you mentioned, there is a lot of confusion about allergies and COVID-19 and it’s important to share this information.

Environmental allergies occur when the body’s immune system overreacts to substances in their outdoor and indoor environments, for example grass, pollen or dust mites.[1] Overall, for those who have allergies, when they come into contact with something they’re allergic to, their immune system overreacts by forming antibodies that trigger a chemical response, causing allergic symptoms.1,[2] Common symptoms are runny nose, congestion, itching around the nose, mouth, eyes or throat and sneezing.[3]

Jorge: What are some of the concerns you’ve been hearing from patients regarding their allergies and COVID-19?

Dr. Jacqueline Eghrari-Sabet: In many parts of the U.S., the coronavirus hit just when the spring season began, when we typically see an uptick in pollen, tree and grass allergens. Now that it’s summer, people are spending more time outdoors when they can, or are stuck inside quarantining. For people with dust mite allergies, the quarantine measures have exacerbated symptoms because we’ve been hunkering down inside our homes as “quarantine mates” with our dust mites. So, people with both outdoor and indoor allergies may notice more symptoms, and they may have confusion and question if their symptoms are allergy-related or potentially COVID-19.

There are symptoms and patterns to watch-out for when evaluating allergies versus COVID-19 symptoms. COVID-19 is associated with a fever, while allergies do not cause fever. Also, it’s important to remember allergies are a chronic condition that can occur seasonally or year-round, whereas COVID-19 is an acute illness with a sudden onset. If patients are concerned, they should contact their healthcare provider.

It's important that patients get evaluated if they have allergy symptoms that are bothersome or interfering with their daily lives because there are treatment options that can help. However, there may be concerns about going in-person even with some restrictions easing.

Jorge: If patients have a need to see a healthcare provider or allergy specialist if they suspect they have environmental allergies, or have been diagnosed in the past and have questions, what can they do?

Dr. Jacqueline Eghrari-Sabet: Great questions – patients are always asking me “what am I allergic to?” and they have their own ideas/hunches. Some joke that they are allergic to broccoli, while others will say house cleaning products or being outside for yard work. There are two main ways we allergists evaluate.

First, we ask patients about their medical history and symptom questions including if they typically have symptoms in the summer, fall, winter or spring; if they are a sneezer or a wheezer; and if they are typically stuffy or snore. With these answers, and any past allergy evaluations conducted, we can determine a lot of information.

Second, we conduct testing. There are two ways we go about testing – blood tests or in-office skin prick testing. During skin prick testing, the skin is exposed to tiny amounts of an allergen to watch for signs of an allergic reaction.[4] Either way, we can pinpoint exactly what is triggering their allergic reaction and help to figure out how to manage it.

For symptom management, there are many allergy medicines available to patients as they cruise up and down the over-the-counter (OTC) aisle – antihistamines, decongestants and nasal spray. They work quickly to relieve bothersome symptoms but stop helping once the treatment is stopped and side effects can be a problem for some people. I usually recommend that if patients haven’t tried OTC options yet, they should as a first line treatment, but if these have failed to work in the past, allergy immunotherapy (AIT) is the better way to go. AIT is targeted to the type of allergen patients are allergic to – dust, grass, pollen – and it treats the reason they’re the allergic symptoms by their own immune system as therapy to treat the allergies. With immunotherapy, patients become tolerant of their allergy triggers, and because it trains the immune system, positive effects will continue even after a patient stops taking AIT.

Jorge: For patients who are candidates for, or currently receiving, allergy immunotherapy, what do they need to know?

Dr. Jacqueline Eghrari-Sabet: Allergy immunotherapy (AIT) uses the body’s own immune system as therapy to treat environmental allergies like grass, pollen, ragweed and dust mites. It works by targeting the cause of an allergic reaction and training the body’s immune system to become less sensitive to those triggers (allergens) over time.

There are two AIT types approved by the FDA in the U.S. – Subcutaneous immunotherapy (SCIT) or sublingual immunotherapy tablets (SLIT-tablets).

Shots, or SCIT, are administered in the allergist’s office usually on a weekly basis, and patients need to wait in the office for 30 minutes after the shot in case of a potential allergic reaction. Because of the contact with allergy offices during the pandemic, the American Academy of Allergy, Asthma and Immunology (AAAAI) published guidelines for the administration of allergy shots during COVID-19, which can be accessed here. They recommend not starting patients on immunotherapy shots during the COVID-19 pandemic because of the time commitment inside the doctor’s office. The guidelines also recommend decreasing the frequency of injections for patients who are currently on shots, so they don’t come to the office so often during the pandemic. That’s why I think the SLIT-tablets are a good option for some allergic patients.

SLIT-tablets, or sublingual immunotherapy, are tablets taken once a day at home. The tablets work the same way as shots – targeting the allergy trigger and training the body’s immune system to become less sensitive to those triggers (allergens) over time. However, it is a dissolvable tablet taken once daily instead of an injection often given weekly. The first dose must be supervised in an allergist’s office but after that patients are out of the office and at home. Any follow-up sessions with a doctor can be managed via telemedicine.

Jorge: How can patients with allergies best prepare for an office or telemedicine visit with an allergist or healthcare provider?

Dr. Jacqueline Eghrari-Sabet: I think most people will have noticed that telemedicine is offered by many of their doctors and it’s here to stay. The patient convenience is unbeatable and it’s a great option for managing environmental allergies. As a telemedicine allergist I can talk with patients about any signs and symptoms of allergy – checking out red eyes and drippy nose, and even have the patients use their own hands to feel for swollen glands that are associated with allergy. I can also explain test results and recommend treatment strategies. It’s effective, convenient and safe, giving patients quality care without having to go into an office and risk being exposed to people in waiting areas and exam rooms.

Patients can let the office staff know if they prefer a telemedicine or in-office visit and see what the practitioner recommends based on the reason for the visit.

To prepare for an allergy appointment, patients should be sure to write down all their symptoms and note where and when symptoms occur. It’s also a good idea to make a list of the medications used, including over-the-counter medicines. This information can help the doctor determine what might be triggering the allergy and where the treatment gaps are.

Jorge: Why is it important to keep allergies in check during this time of COVID-19 and before the fall?

Dr. Jacqueline Eghrari-Sabet: Allergies are a chronic health condition that may occur seasonally or year-round, so it’s important that patients are in good respiratory health overall, including lowering inflammation in the lung airways, especially with regard to COVID-19 and to defend against flu symptoms. Fall is ragweed season, so we would want to ensure that patients with ragweed allergy have a treatment plan in place well before the peak. As the weather gets colder, patients may be spending more time indoors and experiencing more symptoms of dust mite allergies. In the U.S., 33% of the population are sensitized to house dust mite allergens, 50-70% are sensitized to grass allergens and 26% are sensitized to short ragweed allergens, all causing allergic rhinitis with or without conjunctivitis (AR/C).[5],[6],[7]

Jorge: Thank you for this incredibly informative discussion, Dr. Eghrari-Sabet. I really appreciate your time. Where can patients learn more?

Dr. Jacqueline Eghrari-Sabet: A terrific resource to learn more about allergies and allergy treatment options, including allergy immunotherapy, is: https://www.understandingait.com/main/home/. There is also an allergy mobile app, Klara, which patients can install on their devices.

- Jorge Alderete, President, ALK, Inc.

[1] Mayo Clinic. Allergies. Available at: https://www.mayoclinic.org/diseases- conditions/allergies/symptoms-causes/syc-20351497. Accessed July 9, 2020.

[2] American Academy of Allergy Asthma & Immunology. Rhinitis (Hayfever) Overview. Available at: https://www.aaaai.org/conditions-and-treatments/allergies/rhinitis. Accessed June 19, 2020.

[3] Mayo Clinic. Hay Fever. Available at: https://www.mayoclinic.org/diseases-conditions/hay-fever/symptoms-causes/syc-20373039. Accessed July 9, 2020.

[4] Mayo Clinic. Allergy skin tests. Available at: https://www.mayoclinic.org/tests-procedures/allergy-tests/about/pac-20392895. Accessed July 9, 2020.

[5] Nolte H, Bernstein D, Nelson H, et al. Efficacy of house dust mite sublingual immunotherapy tablet in North American adolescents and adults in a randomized, placebo-controlled trial. J Allergy Clin Immunol. 2016;138(6):1631-1638.

[6] Maloney J, Bernstein D, Nelson H, et al. Efficacy and safety of grass sublingual immunotherapy tablet, MK-7243: a large randomized controlled trial. Ann Allergy Asthma Immunol. 2014;112(2):146-153.

[7] Nolte H, Hébert J, Berman G, et al. Randomized controlled trial of ragweed allergy immunotherapy tablet efficacy and safety in North American adults. Ann Allergy Asthma Immunol. 2013;110(6):450-456.