Published in Ezyhealth August 2007 by Louisa Koh

Head to toe

Say Goodbye to Allergic Rhinitis
The answer for all sufferers may lie in sublingual immunotherapy. By Louisa Koh

Allergy can be defined as a hypersensitivity of an individual to one or more substances in his/her environment, which may be harmless or possibly beneficial to an average individual. An allergy may manifest as symptoms that affect various parts of the body, including but not limited to the eyes (as in conjunctivitis), nose (rhinitis or sinusitis), skin (eczema, dermatitis or hives), lungs (asthma) and fatigue or general malaise. Due to this reason, it is sometimes difficult to trace the root of an ailment to an allergy, especially if a medical specialist approached either does not suspect the cause to be an allergy or is not trained to diagnose or treat allergies.

What then is allergic rhinitis? Allergic rhinitis refers to the inflammation of the mucous membrane of the nose, displaying symptoms of runny nose, nasal congestion and itching, and/or sneezing. Additional symptoms may include a headache, impairment of taste and smell, and itching and redness of eyes. Related to allergic rhinitis are sinusitis and asthma. Sinusitis is the inflammation of the mucous membrane of the sinuses, the spaces between the facial bones where air passes and mucus drains into the nose. Sinusitis sufferers usually also have rhinitis, a combined condition called rhinosinusitis. According to Dr Pang Yoke Teen, Medical Director and Senior Consultant, and Ear, Nose and Throat (ENT) Surgeon for the Centre for ENT, Allergy and Snoring (CENTAS) at HealthSense Specialists, Paragon Medical Suites children whose allergic rhinitis is not well managed may develop allergic asthma as a result. And having to cope with asthma will certainly be more costly and inconvenient than just allergic rhinitis alone.

According to a study recorded in the Annals of the Academy of Medicine, Singapore, in 1994 by the Department of Community, Occupational and Family Medicine of the National University of Singapore, the estimated general population prevalence of chronic rhinitis in a cluster random sample of 2,868 adults aged 20 to 74 years was 10.8 per cent; in 2001, the World Health Organisation (WHO) stated that allergic rhinitis affected at least 10 to 25 per cent of the population worldwide and its prevalence was increasing. These figures refer only to allergic rhinitis. Needless to say, there is a large socio-economic cost due to allergies and their unwelcome effects. In particular, allergic rhinitis causes time off work, tiredness, loss of concentration, and restriction of participation in certain sports and co-curricular activities for students, while allergic asthma can lead to hospitalisation.

Testing 1, 2, 3…
First and foremost, consult an allergist. “He or she will first find out more about your medical background and family allergy history, what you suspect may be the allergens you are reacting to, the symptoms bothering you and what you want to achieve out of the treatment,” says Dr Pang. He could not overemphasise the importance of the initial consultation. From this, according to Dr Pang, your allergist can then decide on which test to perform: a skin prick test or blood test, depending on the number and type of allergens he/she is testing. “Both tests are accurate, however, the number of allergens tested is fewer for the skin prick test, and some medicines such as tl antihistamine, as well as cold and flu medicines can interfere with skin tests. Hence, one needs to stop taking these medicines one week prior to the skin test. I prefer skin prick tests, as they show results within 15 to 20 minutes, compared to blood tests which require two to three weeks for the results. This means my patients will have to come back to see me,” he adds.

Manage your options
What are the current methods used to manage allergic rhinitis? Contrary to the widespread belief of medical personnel and the rest of the community, we no longer have to grin and bear with allergies for life. According to Dr Pang, what used to control allergies now give way to the possibility of ridding allergic symptoms for life.

The identified allergen may be avoided in some cases, or relief of symptoms may be sought via inhalers, steroid nasal sprays or oral antihistamines. However, treating the cause of the allergy, rather than its symptoms, actually exists: immunotherapy – in the form of injections or drops administered under the tongue (sublingual). “Immunotherapy works by the principle of desensitising the body to the allergen, or re-training it to not react or react differently, and not manifest as symptoms. Both methods are just as effective, although sublingual immunotherapy (SLIT) would be the preferred choice as it does away with the need for weekly or monthly visits to the doctor for injections. This helps patients save time and money,” says Dr Pang.

Is SLIT the cure?
Immunotherapy is the only cure for allergies, as endorsed by the World Health Organisation (WHO). By what mechanism does SLIT desensitise the body to its identified allergen(s)? According to Dr Pang, as the drops are placed under the tongue for two minutes before swallowing, the allergen enters the bloodstream via the numerous blood vessels under the tongue to the surrounding lymph nodes, where the immune response of the individual to the allergen is slowly modified over time. “The beauty of this treatment is there are no drugs involved – it works like a vaccine,” he says.

The sublingual drops used contain engineered protein based on the identified allergen(s). This method of immunotherapy has been a rousing success in treating allergies caused by inhalants such as dust mites, pet dander or pollen – this extends to symptoms other than rhinitis, especially asthma. “Data over the last 10 years have shown that in two groups of asthmatic sufferers allergic to dust mites, the SLIT-treated group has continued to suffer very few asthmatic attacks compared to the control group, even after 10 years with no treatment in-between” explains Dr Pang.

What does it involve?
So how do you prepare, in terms of cost, adherence to the programme and frequency of visits to your specialist, if you decide to give SLIT a shot? One of Dr Pang’s patients, lawyer Belinda Koh, 42, shares her personal experience: “I’d never known life without allergic asthma and rhinitis. I was always suffering from runny nose, watery eyes, asthmatic attacks and itchiness, due to allergies to dust mites and pollen. My parents tried everything they could think of – Western medicine treatment of inhalers, antihistamines and nasal sprays, and traditional Chinese medicine of herbs and acupuncture that actually relieved my symptoms temporarily, but nothing really worked [long-term].” Belinda goes on to explain: “It got increasingly difficult and stressful to live with or be around people who were untidy, and if I visited friends with pets, they had to keep their pets away from me lest I started wheezing, coughing and sneezing within half an hour.”

In January 2006, Belinda decided to begin SLIT with Dr Pang. “The treatment, to me, was affordable – my investment was $500 every three months, and I was on the therapy for about 15 months in total. It was a very simple treatment; I only had to apply the drops every morning. Every three months, I’d see Dr Pang for a review as SLIT was provided on a quarterly basis. I was even able to take the vial with me when I travelled. I didn’t experience any side effects at all from SLIT, and I haven’t had an asthmatic attack for eight months now. I’ve also stopped using nasal sprays and carrying an inhaler with me, and have very little problems even when I’m hanging out with my friends and their pets now!”

Sound simple and effective enough? Dr Pang certainly thinks so, “Most patients start seeing improvements within four to six months of starting SLIT. After one to one and a half years, most of them are symptom-free, or their symptoms are so significantly reduced, they are no longer a major issue. The short-term cost of SLIT may sound high, but the long-term cost is low, when you add up the amount you could be spending on seeing doctors for allergic rhinitis and/or asthma over the years!” ♥

The estimated cost is now $180 to $250 per month depending on the allergens treated

Book an appointment with HealthSense Specialist Dr. YT Pang to look at your ENT problems and get cured.