A Functional Approach to Asthma and Allergic Sinusitis: Kara Fitzgerald, ND
Allergy season is in high gear. The trees are budding and pollen is bursting forth in Connecticut. As our winters are warmer, we’re also seeing allergies kick in sooner, perhaps with a higher intensity than in years past. While most of us are cracking our windows open and emerging from the winter cocoon into the welcoming sun, our spring allergy patients step outside or crack their windows and they’re bombarded immediately with an almost invisible (to the non-sufferer) onslaught of antigenic materials, resulting in the oh-so-familiar descent into itchy, watery eyes; runny nose; coughs, wheezes, sneezes and on. Out come: the antihistamines, the steroid inhalers and nasal sprays, the leukotriene inhibitors. And if they are particularly hard hit with allergies, that runny nose evolves into a sinus infection (or rhinosinusitis, more correctly), and chances are good that they are gunning for the oft-repeated steroid taper and antibiotics.
And who can blame them, honestly?
But we’re painfully familiar with the damage caused by repeat steroids and antibiotics. Particularly in the allergy patient, disruption of the precious, delicate microbial ecosystem and damage to the protective barriers over and over (be they gut, lungs, naso/oropharynx or elsewhere) assures that we will indeed see allergies continue and another episode of sinusitis not far behind. And we might see the sinusitis episodes become more virulent, less responsive, than before. Perhaps there are antibiotic resistant strains now present, or a particularly refractory or undiagnosed fungal infection needing treatment. It’s also not terribly uncommon to see adults with chronic steroid exposure develop IgE sensitization to the fungus itself. Ugh.
[Additionally, (and off topic) but an important point none-the-less, I am very concerned about the chronic use of antihistamines in my allergic patients given the well-documented association with dementia.]
What do we do?
Thank God a good, thorough, FxMed approach can offer much to even the most severe allergy sufferer.
In my practice, I think about addressing all allergic disease using a “6R” framework. Yup, the 6R protocol shares much with its famous sibling we use for gut healing, the 5R protocol. In fact, if you’re familiar with the 5R, jump right into it with all of your allergy patients and you’ll take them a good distance. However, there are specific considerations for the allergic patient, and particularly the tough allergic patient, for which the 6R protocol is ideally suited. (By the way, check out our allergy relief program if you have not already). I have a more detailed, cited blog on the 6R approach you can refer to, but simply, it includes:
- Reduce symptoms.Effective palliation is essential for the allergy patient. Yes, medications can absolutely be appropriate, even essential here, especially in the early course of treatment. We also have a great arsenal of natural products that may supplant the need for meds.
- Remove the antigenic load. Don’t fall into the trap of thinking a seasonal allergy sufferer only has to deal with the pollen at hand. Chances are they’re reacting to other environmental antigens and foods. This is especially true for the severely allergic patient. Cast a wide net in your investigations of allergies and sensitivities. Remove also includes the investigation and treatment of toxin exposures, including in our diet. Clean, organic foods are important for the allergy patient.
- Repair barriers.Allergic sensitization requires hyperpermeable barriers, most commonly its gut permeability, but skin, lung, nasal mucosa are all possible sites for sensitization if damaged. Nothing ushers in barrier permeability like high histamine (aforementioned steroids and antibiotics notwithstanding). In allergy season, because of increased permeability, you’re likely to identify other antigens that are not an issue at other times of the year. This is especially true of foods. A good barrier repair protocol is an essential piece of a successful allergy program.
- Restore the microbiome. Dysbiosis is part of the pathogenesis of allergic diseases and needs to be addressed and corrected in everyone. This can be as simple as altering the diet, to completing a full functional stool test and addressing the identified imbalances. Probiotics/fermented foods/prebiotic foods are all important.
- Replace includes correcting nutrient insufficiencies with goals around reducing inflammation and building tolerance. Think about vitamin D, A, omega 3 fatty acids, sublingual immunotherapy or allergy shots. Digestion must be impeccable in the allergy sufferer, as larger protein fragments can become antigenic. Replace HCL or enzymes as indicated.
- Rebalance. Plenty of research demonstrates that a heightened stress response will promote allergic disease. Indeed, adrenalin itself is a mast cell agonist. And high cortisol is a barrier damaging molecule, as exogenous steroids are. Part of the allergy sufferer’s journey, if they are to successfully move to the other side, must include embracing some form of mind/body self-care.
Putting the 6R to the test: A case brief
Denise, a lovely 60 year old woman, arrived at my office in the summer of 2015. An extremely busy business consultant in Manhattan, she came seeking relief from a lifetime of atopic disease, including hay fever, asthma and chronic allergic sinusitis. Indeed, at our first visit, Denise was in the throes of a nasty sinus infection, working her way through a prednisone taper and a 10-day course of the antibiotic amoxicillin and clavulanic acid. This was not a new routine: Denise had sinusitis almost as often as not, and a course of antibiotics with a steroid taper was a common occurrence. Denise symptoms were poorly managed on steroid inhalers and an albuterol rescue inhaler. Denise’s diet was that of a bread and dessert-loving Italian. She didn’t avoid any foods and loved to cook, but did report that certain foods caused her mouth to itch. She reported frequent diarrhea and bilateral knee pain and inflammation.
[Remove antigenic load] In order to identify the antigenic load, I ordered a broad sweep of labs, including IgE inhalants and food allergies, IgG food sensitivity, celiac serology and genetics, and a host of nutrients (Denise did not want to collect specialty tests, so we do not have comprehensive stool testing. All of Denise’s lab testing was completed and was insurance-covered.)
Denise’s IgE data revealed strong positives to: Birch, wheat, milk, egg, and dust mites. We started Denise on a lower carbohydrate/ very low simple sugar elimination diet based on these findings. Because she reported an itchy mouth (evidence of oral allergy syndrome and pollen/food cross reactions), and was positive to Birch (up to 90% of Birch-allergic individuals experience food cross reactions) we pulled her off of the top Birch-associated cross reactions. I also had Denise remove all gluten-containing grains (not just wheat) because she was positive for the celiac gene HLADQ2, although her celiac serology was negative. As I’ve discussed on previous blogs, research suggests that individuals with celiac genetics without positive serology have a higher rate of non-specific GI inflammation and may respond to a gluten elimination. Denise’s vitamin D level was low at 20 ng/mL.
Finally, given Denise’s marked reactivity to dust mites, we initiated our clinic protocol, which involves good HEPA filtration, dust-mite proof bedding, cleaning, and (sometimes) requires carpet and upholstery removal. For Denise, during the removal of her bedroom carpet resulted in multiple, severe asthma attacks, confirming her heightened reactivity to these little devils. [Don’t underestimate dust mite allergy in your patients, you may need to “go the distance” for some with regard to carpet and upholstery removal. I’ve seen dust mite allergy cause refractory migraine, asthma and sinusitis.]
[Reduce symptoms, Replace nutrients and anti-inflammatories] Initially, I started Denise on 5 grams of quercetin with ascorbate, 8000IU of vitamin D3, 3 grams of EPA and DHA, and 2 grams of boswellia all in two divided doses. I also used resolvins early on in our treatment. Called SPMs, or specialized pro-resolving lipid mediators, resolvins are potent, rapid-acting derivative compounds of EPA and DHA. They are incredibly interesting compounds worthy of their own blog or two, with demonstrated anti-allergic, anti-inflammatory properties.
Taken together, all of these nutrients have palliative, anti-inflammatory capability, especially the resolvins, quercetin as a potent antihistamine and boswellia as a LOX inhibitor. [Restore microbiome] We also started a high dose probiotic, in addition to prebiotic/fermented foods. Denise was advised to continue her medications as directed during our first phase of treatment, but I was confident she would lower her reliance on them once we quenched the heightened inflammation. [Remove] Importantly, I also prescribed a nasal irrigation system, and had Denise add 10 drops each of a garlic concentrate and a berberine glycerite into the reservoir along with 16 ounces of sterile water and 1/2 teaspoon of non-iodized salt. (Note that I always advise patients to start with just a few drops of the botanicals, slowly increases as tolerated. While generally fine, these potent antimicrobials are irritating to some.)
With a few tweaks along the way, Denise has responded well to this general approach. She occasionally has asthma flares (such as when the bedroom carpet was removed), which we track down and deal with. We’ve cautiously reintroduced some foods, although she still requires avoidance of gluten and the Birch cross reactive foods. I’ve started her on SLIT (sublingual immunotherapy) to reduce her overall reactivity. Gut rebuilding has been initiated. Diarrhea and knee pain are better with the program, at least in part linked to gluten removal. Since our work started together in the summer of 2015, Denise has not had another episode of sinusitis (or antibiotics, steroid taper), and has been able to stop or reduce her medications. Denise stated that her pulmonologist is thrilled with her progress, and her recent pulmonary function tests were “the best ever!” Go, Denise!
This blog was originally posted on www.drkarafitzgerald.com on May 3, 2017. Posted with permissions.