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A cookbook approach to allergies?
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It's that time of year again. Everything's blooming, we're spending more time outdoors and allergies abound. Even though our patients think of spring as the allergy season, we know better. Considering the variety of antigens - plants, pet dander, foods, chemicals - it is no wonder allergies are so widespread.
Indeed, it seems as if allergies have reached an epidemic level. In the United States alone, more than 20 million suffer from allergies and collectively spend billions of dollars on treatment annually. Clearly, allergies are a nuisance for patients, a challenge for pharmaceutical companies and a nemesis for health care providers.
Yes, it is true most allergies are self-limiting. However, they account for a significant number of office visits and consume a fair amount of our time. Additionally, they can be tricky to diagnose. Witness the variable and vague symptoms associated with allergies, as well as the absence of a pathognomonic slit lamp finding.
Furthermore, allergies can be challenging to treat. Given the multifactorial pathogenesis of allergies it is understandable why we occasionally encounter a differential response to therapeusis. Simply put, antihistamines, decongestants, mast-cell stabilizers, nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids all have their place and time. Unfortunately, it isn't always clear as to where and when each agent is indicated! It's no wonder why so many succumb to a broad-spectrum "cookbook" approach to treatment.
While easy and tempting, is the cookbook approach always the best alternative? Not for the patient, and rarely for the clinician, especially those who want to showcase their clinical acumen. For instance, the patient experiencing itching only after playing soccer may simply require a topical antihistamine as needed. This is quite different from the young vernal keratoconjunctivitis sufferer requiring a pulse dose of topical steroids followed by a long-term mast-cell stabilizer.
And what about the chronic over-the-counter antihistamine/decongestant user who is now finding this therapy to be counterproductive? Perhaps the patient is better served by eliminating the decongestant and implementing an NSAID. Finally, consider the contact lens wearer with perennial allergies. Arguably, this is an excellent candidate for a histamine/mast-cell stabilizer.
The common denominator in each case, of course, is the opportunity to tailor your patient's treatment regimen. Just as we would not select the same bifocal eyeglass, contact lens or glaucoma medication for every patient, we should not prescribe the same treatment for every allergy sufferer. To do so fails to utilize the many excellent therapeutic options available, trivializes the decision making process and is often not in the patient's best interest.
My advice? Keep the cookbook at home.