asthma and allergies: how to get relief may 31, 2010 bryna dunaway jennifer...

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Asthma and Allergies: How to Get Relief Webcast May 31, 2010 Bryna Dunaway Jennifer Creaser, A.R.N.P., F.N.P. Thomas Hei Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you. Thomas’ Story: A Lifelong Battle with Allergies Andrew Schorr: When is a cough or a sniffle not just a cold? Persistent congestion could be seasonal allergies or even asthma. Coming up, experts from UW Medicine Neighborhood Clinics will discuss the symptoms and risk factors for asthma and allergies. Learn how to get relief next on Patient Power. Hello and welcome to Patient Power sponsored by UW Medicine. I'm Andrew Schorr. Well, it is late spring as we record this program and millions of people have itchy eyes, runny nose, maybe a cough. Yes, it's allergy season, although many people have allergies in the fall and sometimes other times as well, and some people have asthma. In America we're talking about like 50 million people have allergies and 20 million have asthma, and of course asthma in extreme cases can be fatal when people simply can't breathe and don't get help soon enough. So we're going to talk about that with some UW Medicine experts from the neighborhood clinics. It's interesting that one of the family practice doctors at UW Medicine, like millions of other people, has allergies and asthma himself, and that's Dr. Thomas Hei. Thank you for joining us, Doctor, and I'll call you Thomas as a patient in this case. How long have you had allergies and asthma? Thomas: I've had both as far back as I can remember. Andrew Schorr: And how severe could it be? Thomas: For me at least remembering in childhood, it could be quite severe. It would be completely sleepless nights when I would be lying there gasping for breath and hearing wheezing every time I breathed and coughing all through the night. Andrew Schorr: And as a child, and I know you were growing up in Taiwan, maybe not taking a lot of medicines or even having medicines that you could take, how did that limit your


activities? Thomas: Quite dramatically. I'm been active all my life so I was a pretty active kid as well, but definitely there were days when I couldn't be active because of my symptoms and also if I didn't sleep the night before. Andrew Schorr: So you're 42, and I know you're an active guy now. Let's see, basketball, tennis. You love to play golf? Thomas: Yes. Andrew Schorr: So golf sounds a little problematic with grass. Is that a problem for you? Thomas: Yeah, definitely in the spring. Andrew Schorr: So what do you do? Do you have a pocketful of medicines? Thomas: Pretty much. Pretty much. Starting about March I start my little regimen of several medications to suppress my allergy symptoms so I can keep living my life. Andrew Schorr: All right. So antihistamines. Thomas: Yes. Andrew Schorr: Various things to stop the runny nose. Some things, maybe a steroid, nasal steroid or even one that you would have for your lungs to reduce inflammation? Thomas: Right, so both for allergy symptoms and for asthma symptoms. Andrew Schorr: And then if you get in real trouble with your asthma, a rescue inhaler? Thomas: Right. Exactly. There's a couple that I have that I alternatively use.


Andrew Schorr: Let's meet our providers, both from the UW Medicine Factoria clinic, and that's Jennifer Creaser, did I say it right, family nurse practitioner? Ms. Creaser: Yes. Jennifer Creaser. A Common Problem Andrew Schorr: Okay. And then also Bryna Dunaway who is a physician assistant also at the Factoria clinic. Let me start with you, Jennifer. It is a common problem, correct? Ms. Creaser: Yes, it is a very common problem. Andrew Schorr: All right. So what can people do themselves, let's talk about that, and then we'll find out what they can do with a provider such as you or Bryna. Ms. Creaser: Well, patients who have allergies or suspect they have allergies have many options today. There are a few over-the-counter medications that can be taken, also seeing their primary care provider if their symptoms don't improve over--if they have a cough or a sniffle that doesn't improve over a couple of weeks with over-the-counter medications they can come in and be evaluated for allergies, that type of thing. Andrew Schorr: Now, as I was preparing for this program I had what I thought was a really bad cold a couple of weeks ago. So right in the middle of spring, no temperature, no other symptoms but really runny nose and a bit of a cough and all that. Is it possible even if I've never had allergies before, Jennifer, that this in fact could have been an allergy for me in the springtime? Ms. Creaser: Definitely. Just because you don't have allergies when you're younger doesn't mean that you won't go on to develop them in your adult life. When Should You Go to the Doctor? Andrew Schorr: Bryna, so what about you? So let's say somebody goes to the pharmacy and there's no shortage of medicines for stuffy noses and itchy eyes over the counter, when do you need to see a provider such as you to see do we need more? Ms. Dunaway: So a lot of patients have these annoying allergy symptoms, of course. Itchy eyes, watery eyes, nasal irritation and chronic nasal drip or postnasal drip are common symptoms.


Many people will respond to over-the-counter medications like Benadryl, Claritin and Zyrtec, and if they respond to medications quickly and their symptoms resolve they don't necessarily need to be seen by a provider if their symptoms are relatively short-lived and their symptoms resolve with over-the-counter medications. Andrew Schorr: All right. But if they don't resolve like how long would something persist where you say I need to see Bryna or Jennifer? Ms. Dunaway: Yeah. Often two weeks is a good rule of thumb if the symptoms are mild. Of course, if symptoms are severe or there's anything like shortness of breath we want to see them as soon as possible. Andrew Schorr: Right, because the shortness of breath could be asthma and if your airways are closing, if you're having trouble breathing, that could even be an emergency, right? Ms. Dunaway: Right. Andrew Schorr: All right. Jennifer, so when somebody comes in then how will you evaluate them to see if maybe more needs to be done or even sit down with them and try to get a handle on what may be triggering the problem? Ms. Creaser: Well, certainly asking them a lot about their environment, where they live, when the symptoms started, and if they've tried anything in the past. If they have a family history of allergies or asthma that certainly puts them at greater risk. And then of course doing an assessment, looking in their ears, their nose, listening to their heart and lungs and trying to detect if there's anything that's obviously allergy- or asthma-related through the physical exam. Andrew Schorr: Bryna, how do you know when maybe you'd recommend allergy testing for someone? When does it get to that point? Ms. Dunaway: That's a great question and that's one that we see a lot of in clinics. So a lot of people, in fact the majority of people with mild allergy symptoms will respond to over-the-counter medications or simple prescription medicines like a nasal steroid. Often if patients respond to that they really don't need additional evaluation. Certainly if they want to get allergy testing we can refer them for allergy testing, and certainly if their symptoms don't respond to some of the simpler medications, either the over-the-counter antihistamines or medications like nasal steroids, then we would want to refer them.


Andrew Schorr: Thomas, do you know what triggers your symptoms? Do you know the triggers? Thomas: Yeah, by and large I do. There are triggers I can't avoid certainly without living in some sort of a bubble room or something. Andrew Schorr: Right. Thomas: So there are grass pollens, tree pollens, flower pollens. Those are my main triggers, which is why my symptoms are largely seasonal. I luckily don't have animal triggers so we have three dogs and have had cats, so that's been nice. So, yeah, being aware of triggers was important. However, being aware of triggers doesn't mean you can actually avoid the triggers. Andrew Schorr: Right, although take with allergy testing, that would be the idea to try to understand are there certain things that could be that you could avoid or at least try to be desensitized for. Thomas: Yeah. Desensitization is interesting. I think that there's really only--there is a subset of patients, people, who have allergies and don't respond to conventional either pills or spray medicines, and if they have allergy triggers that are not avoidable, then those are the folks that generally could have desensitization treatments, injections, really, allergy shots, commonly referred to, as an option. But it's a treatment course that is actually quite burdensome. You have to get lots of shots over a period of time, then you have to get maintenance shots over an even longer period of time, and if you fall off that schedule you have to go back to the intense desensitization schedule again and so. Andrew Schorr: Did you ever have shots? Thomas: No. I was able to control my symptoms, albeit with lots of medicines. Andrew Schorr: But you have a strategy. Thomas: Right.


Andrew Schorr: Okay. Now, Bryna, so it sounds like it's got to be really individualized. So if you have many patients who have asthma or allergies in your practice it is not a one-size-fits-all approach, is it? Ms. Dunaway: No. No, often we have patients coming in with mild allergy symptoms, and they may not have tried the over-the-counter treatments yet, so for some patients allergy treatment could be as simple as taking one Benadryl tablet maybe even before they go to bed, as Benadryl can often cause drowsiness, and for some people that will control symptoms for them. Other patients may take something nondrowsy like Claritin or Zyrtec during the day and that will work for them. For patients who have more severe symptoms we often suggest a medication like a nasal steroid such as Flonase spray that can help them get good control of their symptoms. Andrew Schorr: And, Jennifer, just so I get it right, when we're talking about allergies generally usually people have these upper respiratory symptoms. Asthma is particularly in the lungs, correct, and the airway? Ms. Creaser: Yes. Andrew Schorr: Okay. And that can be allergic although less commonly it can be not allergic where it could be just environmental factors, and Thomas talked about pets. Some people could have smoke or mold that triggers it, correct? Ms. Creaser: Yes. Andrew Schorr: Jennifer, what would you advise people as far as first of all recognizing the signs of allergy or asthma? What should they be looking for to say, hmm, it's not a cold, it's an allergy or maybe even it's asthma? Ms. Creaser: Well, typically with allergies you will have symptoms of itchy eyes, watery eyes, itchy throat, and even itchy ears. That can be a runny nose as well and coughing and clearing of the throat that doesn't seem to cause fever. Some people will have coughing because of the drainage down the back of their throat. They can also have shortness of breath and even some wheezing or a whistling sound in their chest if there are asthma symptoms present. I would recommend that if people have those symptoms and especially if they have shortness of breath, wheezing or cough that's persisting beyond one or two weeks to be evaluated by their primary care provider because it may be signs of asthma and certainly allergies.


Andrew Schorr: All right. So then it's a matter sort of peeling the layers of the onion, right, to see what's their individual situation. Is it seasonal, what may trigger it and what of a pretty broad armamentarium could help them feel better, right? Ms. Creaser: Yes. Andrew Schorr: All right. So do people nowadays need to suffer? Treatment Options: Over-the-Counter and More Ms. Creaser: Oh, no. People do not need to suffer. There are over-the-counter medications that are available to treat allergies to help prevent secondary infections like sinus infections or bronchitis from developing. Andrew Schorr: Thomas, let me ask you, related to your own strategy what do you think is the responsibility of the patient to manage their condition and also communicate with their provider so that they work as a team to handle it, you know, seasonally and for life? Thomas: I think the most important thing is about getting familiar, educating yourself on what the condition is, what it involves, what are the symptoms, what are the strategies for both control and rescue, prevention, all of those things because this is a condition--these are conditions that really it's not like your common strep throat, take some antibiotic and it's done. It's something people have for could be as long as their whole, entire life, and if a person doesn't understand this thing that they have well and completely or significantly rely on others to take care of it, it's a very difficult thing to manage. So it's really all about getting yourself educated, getting from either doctors or providers or from books and now internet, and then really asking a lot of questions and being very clear about symptoms and how symptoms change over time and over place and all of that information. Andrew Schorr: Even though your allergies and your asthma can be, and have been in the past, severe at times, do you feel like you can have a full quality of life in what's available to you now, knowing yourself, having a good team on the provider side that you can do what you want to do? Thomas: Absolutely. There really is it no reason why anybody with asthma or allergies can't completely enjoy all parts of their life. Now, there are folks with more significant symptoms that need more stronger medicines, maybe allergy shots or those kind of strategies, but at this time and age it really should not be a life-limiting condition.


Andrew Schorr: Jennifer, you'd agree with that? Ms. Creaser: I do, definitely. Andrew Schorr: All right. So for someone who is suffering they should speak up, right, they don't have to suffer. And then it could vary though year to year, couldn't it, Jennifer? I mean some years could be tougher. Sometimes over-the-counter medicines may not work for them. So it's kind of a moving target, isn't it? Ms. Creaser: It is. Year to year symptoms can wax and wane, and some years over-the-counter medications are not helpful and other years they are. So I think being educated and learning about allergies and asthma, asking your primary care provider if you see them, reading on the internet, that can be a very helpful resource to better understand the condition. Andrew Schorr: What do you really want people to know? So you've seen maybe hundreds of people with this condition, what do you think overall you want to remind people of? Ms. Creaser: I want to remind people that if you know you have allergies and you're taking an over-the-counter medication to help treat your allergies and it's not getting better there are other medicines we can try that can help with your symptoms. You don't have to suffer. You don't have to have this condition that you're suffering from. Andrew Schorr: And if certain medicines worked last year but are not working this year, what should they do then? Ms. Creaser: I would recommend that they see their primary care provider. Andrew Schorr: Thomas, for you, so you probably have friends who have asthma and allergies. They maybe see you with your inhalers or people know you've been living with this for a long time, what do you tell them related to them maybe getting the best care and the best control? Thomas: Just largely I tell them what I said, just know your symptoms well. There are lots of things out there that can help. These are what I do. Yeah, pretty much normalize it as something I have, something I've had all my life, but it's absolutely controllable.


Andrew Schorr: Now, how do you decide--you have a bunch of medicines that are available to you. How do you decide what to do when? How do you kind of stage it in your own daily life? Thomas: That's part of that whole patient self-education process. Of course I have the advantage of having gone through medical school, but I think for a particular condition a person is going to have all their life in a way they need to kind of go to kind of a mini medical school-- Andrew Schorr: For their condition. Thomas: So I generally just start with a very simple generic loratadine, which is the generic for Claritin. They're pretty affordable these days, and if it's the very beginning of the season a single pill generally has essentially no side effects. This is kind of okay for me, and then slowly through the season I start sort of wrapping things up. So usually I would add a nasal steroid spray for nasal symptoms. Occasionally I would use an antihistamine type eye drop, not the ones that shrink the red away, but you can talk to local pharmacists and there's some over-the-counter eye drops just with some antihistamine in it. So I kind of target nasal and eye symptoms if a simple pill doesn't quite do it. I would add those, and then as my asthma symptoms start picking up, sometimes in late March and April, then I usually have an annual visit with my physician right around then too, so to say, you know, got to get back on the inhaled steroid puffer, kind of a spray, and also as needed the rescue inhalers when I do actually still get some wheezing on top of that if I go on a long run or some sort of thing like that. Andrew Schorr: Jennifer, let me ask you, so there are people with asthma who carry the rescue inhalers like Thomas does who really depend upon that, and that's like their go-to medicine regularly. Would that be concerning? Ms. Creaser: I think that it is--that medicine is available to help with coughing and wheezing and feeling short of breath. In situations where people who have allergies or asthma, I would say if that medicine was being used more than a couple times a day for a week or more then they would want to see their primary care provider because they may need additional medicine or a short-term use of a steroid inhaler to help better manage their symptoms. Andrew Schorr: Trying not to get to the rescue point. Ms. Creaser: Right.


Andrew Schorr: On a regular basis. Ms. Creaser: Right. Thomas: Yeah, could I just chime in here? Andrew Schorr: Yeah. Thomas: I not infrequently use how often I need the rescue inhaler as an indication of how I'm doing, because ideally I shouldn't be really using that much. Andrew Schorr: Right. You want to avoid--that's your failsafe. You want to avoid getting to that point. Thomas: Exactly. Andrew Schorr: Now, Jennifer, what about--at least when it comes to asthma, I know you have measurement tools to see how somebody's lungs are doing. Is that something that's done in the clinic from time to time? Ms. Creaser: We have spirometry onsite, and we can check somebody's peak flow as well here in the clinic. Andrew Schorr: So this is where you blow into something and it's measuring your capacity and just how well your lungs are doing, and then that gives you more information on are medicines needed and in what situation. Ms. Creaser: Correct. Andrew Schorr: Bryna, I'd love your take. I was just talking to Jennifer. If somebody is using their rescue medicine frequently would that be something they'd want to talk to their provider about? Ms. Dunaway: Yeah, absolutely. So for asthma medication if someone is using their rescue inhaler, that albuterol inhaler, more than two or three times a week we want to see them to get them on preventive medications. Of course the idea is that we prevent the asthma so that they very rarely have to use the rescue inhaler. And if they're using that rescue inhaler more


frequently that can also be a warning sign for severe asthma symptoms, and we're able to do peak flow testing, which they can also do at home, that can help us spot problem asthma symptoms before they become very severe. Andrew Schorr: So whether it's allergy or asthma it sounds like you need a strong relationship with a provider over time. Some years will be different, some medications will work at different times, and there are new medications fortunately that come on the market as well. So it's kind of an ongoing dialogue, isn't it, Bryna? Ms. Dunaway: Yeah, it is, and primary care providers often see a lot of allergies and asthma, so this is definitely something that is within our scope of practice that we're all very familiar with as primary care providers. Andrew Schorr: Jennifer, what about you? You feel confident the primary care level--it may be pretty severe for somebody, oh, my god, my head is filled or I'm wheezing, but at the neighborhood clinic you can help. Ms. Creaser: Absolutely. We can help for asthma, allergies. Andrew Schorr: All right. So, Thomas, I want to just go back to you. So what advice would you give people as far as knowing themselves because maybe 50 million people with allergies, 20 million with asthma, but it is not, as I said, a one-size-fits-all, getting to know not just the medications but time of year, or environment for them? What advice would you give about just learning about themselves? Thomas: Yeah, I think there's just this need to just be generally aware of one's own symptoms, how long they've been, what's been going on in their life or in their environment, and, like I said, there are so many sources for information and references nowadays that there really shouldn't be anybody who can't find information. And again the primary care providers or others on the healthcare team can serve in that role as well, and beyond knowing when symptoms pop up and what makes symptoms worse but also as they try different things like over-the-counter meds or even with prescribed medications would be important to track how they're doing with that and whether they respond to that or have any side effects. Ms. Dunaway: Another resource that I have given to patients that people often find useful is pollen.com. And you can go to that website, type in your zip code, and it will give you a pollen forecast basically for the next several days.


Andrew Schorr: So how do people use that? We're talking about people having a high quality of life even with a chronic condition or seasonal condition, and yet the pollen counts come out, does that mean don't go outdoors this day, or what do you do with the information, I guess, Bryna? Ms. Dunaway: So especially for people who have mild symptoms and don't need to take an antihistamine on a daily basis may be able to look at the pollen forecast for their zip code and if they see that the pollen counts are going to be much higher they may be able to take some medicines to prevent allergy symptoms. So for instance if you go to pollen.com right now we can type in our zip code and we can see that alder pollen is especially prevalent right now and that Thursday is going to be a higher pollen count day. Andrew Schorr: So it might be a day when you want to self medicate, in other words. Ms. Dunaway: Correct. Andrew Schorr: And, Jennifer, what about the fall? So some people have problems with smoke, right? Ms. Creaser: Yes, from wood-burning fires. Andrew Schorr: Right. Ms. Creaser: People can have allergy symptoms and a flare of asthma as well. Andrew Schorr: And while we're talking about smoke, some people who have asthma or allergies are smokers or around smokers. How do you feel about that? Ms. Creaser: That does not help their situation. Smoking or smoke exposure certainly can cause the lungs to be more inflamed and constrict the airways. Andrew Schorr: And, Thomas, I'm going to ask you a question as a physician too now. So I understand that in asthma if you just don't pay enough attention to it the airway actually can be what they call remodeled, almost like scarred in a way. So this is not something to ignore, is it?


Thomas: No, it isn't, and I'll speak both as a physician and as a patient with asthma. As I alluded to earlier as a child growing up in Taiwan there was really zero medications available for a lot of these things that I had, and I lived through it luckily, but I recall having when we moved to the United States I was a premedical school--premed major in college involved in some research projects as a staffer. And one of them was doing the lung capacity testing, and my professor wanted to just run a test on us just to make sure the equipment was working, and I had some sort of chronic, we call it sort of restrictive type of picture on the pulmonary function test because I think just over time not having had any treatment for my asthma as a kid and to suffer through it had caused some of that. So, yeah, inflammation in the airways is not unlike a red scar on your hand when you get it scratched. If you keep it inflamed for a long time it leaves a scar. Andrew Schorr: So just to recap a couple of things then with all of you, I'm going to see how I get graded on this test. So first of all someone can develop allergies and asthma at any age. We think of asthma and allergies often with kids, but it could be at any age, right? Thomas: Yes. Andrew Schorr: How did I do? Okay. Next thing is that, Jennifer and Bryna, your primary care provider can help, right? Ms. Creaser: Yes. Ms. Dunaway: Yes. Andrew Schorr: And UW Medicine Neighborhood Clinics are dedicated to that, and both of you have many people with these conditions in your practices. And while some people may routinely go to over-the-counter medicines, which is fine if they work, there can be a need in any given year or maybe for that person like Thomas, regularly, where you need something more, and so that ongoing dialogue with your provider, Jennifer, is important, right? How did I do? Ms. Creaser: Great. Flying colors. Andrew Schorr: Okay. Thomas, did I get a good grade? Thomas: You did great.


Andrew Schorr: Okay. So thank you so much for being with us. First of all, Thomas, who is a family physician himself but living with asthma and allergies his whole life. But you've got your strategy, got your plan, but I thought it was interesting what you said, Thomas, is, yes, you've gone to medical school but for someone with a chronic or recurring condition like this they need to be smart themselves about this condition that affects them. I think that's great advice. And, Jennifer Creaser, family nurse practitioner at the Factoria clinic, thanks so much for joining us. We appreciate that. And Bryna Dunaway, physician assistant at the UW Medicine Factoria clinic, thank you too. Ladies, thank you for joining us. Ms. Creaser: Thank you. Ms. Dunaway: Thank you for having me. Andrew Schorr: This is what we do on Patient Power, time after time with experts from UW Medicine, and there's so much that primary care providers can do, and with allergies or asthma you don't have to suffer, but you do have to pay attention to them, and you've got partners certainly at the primary care level and at the UW Medicine Neighborhood Clinics. I'm Andrew Schorr. Thanks for joining us. Remember, knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you.

asthma and allergies: how to get relief may 31, 2010 bryna dunaway jennifer...

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