A)  GENERAL:

1) The continued importance of the Medical/Allergy History.  Take time - your time, assisted by questionaires>>>>gets relevant data, establishes rapport, is satisfying.

2) Do a good physical exam, not just a focused exam>>>(see above).

3) Lab work: Don’t forget the sed rate.  Skin Tests:  Intradermal skin tests remain the gold standard, for both identification and degree of sensitivity.

4)  Diagnosis:  Better to write “etiology undetermined” in your chart than to guess.  What was - and still is - allergy may not be ONLY allergy any more, through  the action of decades of recurrent infections>>>chronic rhinitis/sinusitis, chronic bronchitis...  A complete diagnosis is important for treatment and also for prognosis:  if only “allergy”>>?cure; if combined diseases>>>management, stabilization, slow improvement.  A complete diagnosis of all existing medical conditions is important for both pathophysiologic and drug interactions: eg., hypertension, GERD, sleep apnea, diabetes mellitis, ...

5)Environmental Control: General; Smoking; Pets; Occupation; Avocation...

B) SPECIFICS

1) Medications:

Hydration Antihistamines: Use only the newer non-sedating, non-drying  agents (Allegra, Claritin).   N.B.  Zyrtec is not in this category.
Mucolytics Bronchodilators:  For inhalation therapy, Xopenex (1.25 mg) is better than albuterol.  Dry powder inhalers.  Brand Proventil vs albuterol in some patients.  Avoid the overuse of Serevent and all beta bronchodilators in general.  Remember Atrovent, a good medication.

Intal/Tilade:  Should always be considered and should often be part of regular therapy.
Nasalcrom nasal spray:  Excellent as a baseline treatment,  and  sometimes as the only treatment.
Steroid nasal sprays: Look for more hydration, less perfumes and preservatives: Nasarelle, Rhinocort aqua, Nasonex...
Steroid oral inhalers: Pulmocort, Aerobid, Asmacort>>>Vanceril
Oral steroids:  Remember Celestone when patient appears to  be “steroid resistant”.
GI meds: Prilosec, prevacid>>>zantac, etc.
Eye medications”Patanol/alomide/alocril, but not with contact lenses.
Leucotriene inhibitors: Singulair>>>Accolate (not Zyflo).

STOP THE SMOKING!  Much better results now with combined nicoderm patches ( 7 mg., three weeks maximum) and Welbutrin (150 mg BID).  An Asthmatic MUST stop all smoking, within a month and permanently, or must find a new doctor - my position.

TIME:  M.D. time, and some R.N. time.  “There is no such thing as ‘quality time’, just TIME”.  FOR A PATIENT, THE THREE MOST IMPORTANT ATTRIBUTES OF A PHYSICIAN ARE ABILITY, AFFABILITY, AND AVAILABILITY..........IN REVERSE ORDER.

2)  ALLERGY IMMUNOTHERAPY:  For both upper and lower (asthma) respiratory allergies, IT WORKS: clinically, by relieving symptoms and signs; pathophysiologically, by reversing the mechansms of disease and thereby avoiding “remodeling”- scarring; by immunomodulation - desensitization.  It is SAFE in the hands of experts.  By this time in medical education, training, experience and research,  anyone who does not recognise and acknowledge these facts is either ignorant of the facts, or has a self-serving agenda.

C) FASCINOMAS
Chronic Fatigue Snydrome: Look for a substantially increased tendency to concomitant allergies,  and treat the allergies...you may be surprised.
TH2>>>TH1  issues.   “Could pets in the house be good for kids??”  NO, BUT......Also, the role of recurrent respiratory tract infections in producing immunomodulation away from IgE  production.  IS THIS THE REASON FOR THE  EFFCTIVENESS  OF  “STOCK BACTERIAL VACCINE” USE THROUGH THE LAST SIX DECADES??  “Is ‘Intrinsic Asthma’ also really dependent on IgE?  Atopic Dermatitis: two types>  Cox inhibitors (ASA, NSAIDS) for treatment of Asthma?
But remember the most severe Asthma - ASA - sensitive Asthma!!!

G.S., July 15, 2000