Hay fever: therapy

Hay fever therapy: Symptomatic treatment

The annoying symptoms of hay fever can be effectively alleviated in most cases with medication. The drugs used target the inflammatory messengers histamine and leukotrienes, which are released as part of the allergic reaction of the so-called mast cells and trigger the hay fever symptoms: hay fever drugs block the effect of the inflammatory messengers or their release from the mast cells.

The following medicines are used in symptomatic hay fever therapy:

antihistamines: Antihistamines block the docking sites (receptors) of the inflammatory messenger histamine, so that it can no longer develop its effect. The drugs work very fast, usually already after about an hour. Therefore, they are suitable for the relief of existing hay fever complaints.

Antihistamines can be used for both local hayfever therapy in the form of nasal sprays (such as levocabastine) or as eye drops (such as azelastine) or as whole body tablets (such as levocetirizine, loratadine, fexofenadine). In the past, antihistamines were often tiresome, which was very dangerous especially on the road. The presented here “new antihistamines” have this side effect barely, so they do not or almost not tired. Nevertheless, as a precaution, doctors recommend that you take the antihistamines in the evening before going to bed. Their effect usually lasts around 24 hours. Antihistamines are also available without a prescription at the pharmacy.

Decongestant nasal sprays and nasal rinses: Decongestant nasal sprays provide quick help with hay fever when the nose is swollen. However, they should be applied for a maximum of one week. Otherwise, there is a risk that the nasal mucous membranes dry out, which can aggravate the allergic reactions. In addition, decongestants can even trigger inflammation (drug-induced colds, rhinitis medicamentosa).

Nasal rinses are also part of the symptomatic hay fever therapy: they cleanse the nasal mucosa from the pollen. Nasal sprays with saline are very convenient during the day. Much more effective, however, is the flushing of the nose with a nasal douche, which is available in drugstores and pharmacies. The allergic complaints can thus be significantly alleviated.

Also, a dexpanthenol-containing ointment for the care of irritated nasal (mucus) skin is recommended.

Cortisone: Cortisone is an endogenous hormone that performs many functions in the body. Its strong anti-inflammatory effect is also used in hay fever therapy. For this purpose, cortisone-related substances (glucocorticoids) are used either locally (as nasal sprays) or systemically (as tablets). In the locally acting cortisone preparations (such as beclomethasone nasal spray) hardly any side effects are to be expected. Since the glucocorticoids have a very strong effect, they are usually used in hay fever therapy only for very pronounced symptoms.

Mast cell stabilizers: The drug group of the so-called Cromone “stabilizes” the mast cells so that they release no more inflammatory messengers. Mast cell stabilizers (cromoglizic acid or nedocromil) do not work immediately and do not relieve any allergic reaction that has already occurred. Rather, they should be taken about a week before the expected pollen count. In addition, the duration of action is relatively short, which is why Cromone must be applied several times a day. Their antiallergic effect is not always sufficient, so they are often used in addition to the antihistamines in hay fever therapy. Cromones are not absorbed by the digestive system, which is why they only work locally. They are available in various preparation forms (nasal spray, eye drops, metered dose inhaler). Cromoglizic acid capsules also only act locally on the intestinal mucosa, as they are not absorbed.

Leukotriene receptor antagonists: This substance group blocks the action of leukotrienes (inflammatory messengers). Leukotriene receptor antagonists (such as montelukast) are mainly used in allergic asthma, but are also suitable for hay fever therapy. They are available by prescription and available as tablets or chewable tablets.

Hay fever therapy: Specific immunotherapy (SIT, “Desensitization”)

The specific immunotherapy (SIT) is currently the only option of hay fever treatment, which mitigates the mechanism of the discomfort – the excessive immune response. Physicians therefore also speak of causal (causal) hay fever therapy. The procedure itself, the specific immunotherapy, is also called hay fever hyposensitization, hay fever desensitization or hay fever vaccine, because it is the immune system gradually accustomed to the actually harmless allergens (pollen), so that it ultimately less “sensitive” to respond.

Desensitizing hay fever therapy can greatly reduce the symptoms of pollen allergy in the majority of people treated, so that either no antiallergic drugs are needed at all, or at least significantly less. However, specific immunotherapy can be used not only for hay fever, but also, for example, for allergies to pets or insect bites. Their application in the context of hay fever therapy is particularly useful for three reasons:

1. The effect of desensitization is very good for hay fever, as proven by several large scientific studies.
2. With hay fever, it is difficult to avoid the allergy-causing substance (allergy avoidance), as the pollen often fly hundreds of kilometers through the air and those affected can hardly protect themselves from it. A desensitization can thus increase the quality of life of allergy sufferers enormously.
3. Meanwhile, it is believed that a hay fever after some time in an allergic asthma can pass. Through hay fever desensitization this so-called floor changes can be avoided.

Desensitizing hay fever: How does it work?

The principle of hay fever desensitization is to introduce the allergenic substance (allergen) in an increasing dose in the body, so that the immune system in a sense gets used to the allergen and it no longer fights. How exactly it comes to this habituation is not clear so far. The success of desensitization in hay fever is undisputed.

Basically, the allergen can be injected under the skin (subcutaneous immunotherapy = SCIT) or in the form of tablets or drops under the tongue (sublingual immunotherapy = SLIT). SCIT is considered to be more effective, but also poses a greater potential for potential adverse drug reactions. If the SCIT is not possible for a variety of reasons or if the patient desires, the SLIT will be used. For hay fever therapy, both methods have been proven effective.

Desensitization of hay fever: who carries it out?

Hay fever desensitization is done by specially trained physicians. Most of these are dermatologists, ear nose and throat doctors (ENT) or internists specializing in pulmonary medicine. The treatment is usually performed on an outpatient basis in practice. In case of particularly severe allergies or for short-term treatment (see below), in-patient treatment may be necessary. Since specific immunotherapy may very rarely lead to life-threatening allergic reactions (anaphylactic reactions), the physician must have appropriate knowledge and medicines to treat such an emergency.

Desensitizing hay fever: When and how long will it be performed?

With the hay fever desensitization one begins a few months before the actual Allergensaison (= preseasonal) and therefore usually already in the autumn. In some cases, desensitization also takes place throughout the year (= perennial). When exactly hyposensitization starts depends on which type of pollen you are allergic to. The various plants release their pollen at different times of the year, which must be taken into account in this form of hay fever therapy.

In the weeks leading up to the individual allergen season, the allergens are usually given once a week at an increasing dosage (increase dose) up to a maximum dose. During the actual hay fever season, the allergen is given only once a month (maintenance dose). Overall, the duration of this hay fever therapy is at least three years.

Desensitizing hay fever: who is it suitable for?

The desensitization as hay fever therapy is possible in principle at any age. For practical reasons, it is usually used in children from the age of six years. Especially in childhood, hay-fever desensitization is very effective. However, some people develop hay fever only in older age. There is no strict upper age limit for hay fever desensitization. It is important, a generally good physical condition. If in doubt, the doctor will provide information on whether a specific immunotherapy in individual cases is possible.

Desensitizing hay fever: Who is it not suitable for?

In various situations, hayfever desensitization should not be performed better because the potential risk of causal hay fever therapy outweighs the benefit of treatment:

• During pregnancy
• For serious diseases of the cardiovascular system
• For serious cancer
• In severe diseases of the immune system (autoimmune diseases or acquired immune disorders caused by drugs or diseases such as AIDS)
• For very severe asthma
• If so-called “beta-blockers” have to be taken for the treatment of another disease

In some cases (except pregnancy), hayfever desensitization may still be performed under certain circumstances. Decisive here is an individual benefit-risk balance by the physician.

Desensitizing hay fever: How exactly is the treatment?

Before a desensitization of hay fever is even in question, it must be ensured that the symptoms are really allergic. A prick test (or patch test, if applicable) is used to determine which pollen people are allergic to.

Before the causal hay fever therapy, the doctor clarifies the patient about possible risks and side effects. Although desensitization is a low-risk procedure, an allergic overreaction (anaphylactic reaction) can occur in very rare cases. During the discussion, the doctor will also ask the patient about his medical history (anamnesis), so that he can assess whether the desensitization to hay fever therapy in a specific case is safe. After the interview, the patient must sign a form confirming that the doctor has informed him about the treatment and its potential side effects.

Now, the allergen can be injected under the skin (subcutaneous immunotherapy = SCIT) or given as a tablet or a drop under the tongue (sublingual immunotherapy = SLIT). Both procedures are carried out for three years:

• The SCIT uses a very fine needle (26G needle) syringe. After disinfecting the skin area, the doctor injects the allergen into a skin fold on the back upper arm. The puncture hurts only very briefly, during the injection one feels at most a slight feeling of pressure. Most people described the injection as little painful. For safety reasons, patients must remain in the office for at least 30 minutes after the injection if there is an allergic overreaction. Local redness and swelling at the injection site are normal. But if you feel noticeably uncomfortable, you should tell the doctor or the staff immediately. After the 30 minutes, the doctor checks the puncture site again before the patient is allowed to go home. These injections are usually about once a week for several months. How many injections are needed depends on the preparation used.
• With SLIT, the allergen is placed in the form of drops or as tablets under the tongue. There it should stay for two to three minutes, that is, as long as should not be swallowed. Thereafter, patients should not drink for at least five minutes. The first application should be under the supervision of the doctor. Subsequently, the SLIT can then be performed by the patient himself. Incompatibility reactions should be reported to the treating physician immediately. In case of illness (especially if there is a fever) the intake should be interrupted. In addition, the instructions of the drug manufacturer should generally be observed.

Desensitization of hay fever: What should be considered after treatment?

In the pre-hay desensitization hours and for the remainder of the day after allergen administration, patients should refrain from alcohol and strenuous exercise (for example, sports, sauna, etc.) because it may trigger or exacerbate allergic reactions. If someone wants to have a vaccination during the hayfever treatment, the vaccination appointment should not take place during the increase phase (weekly allergen administration with the SCIT), but during the maintenance phase (about monthly allergen administration). At least one week should pass between vaccination and desensitization sessions. Immediately necessary vaccinations (for example tetanus vaccine after injury) can be done at any time.

Desensitization in hay fever: short-term therapy

For hay fever therapy, the specific immunotherapy can also be done in a very short period of time. This so-called short-term therapy is not yet sufficiently assessable in terms of its long-term effect, since it is a relatively new process. The dose buildup is very fast in about four to eight injections before the pollen season. Even variants in which multiple injections take place in one day are possible. However, these so-called RUSH or Ultra-RUSH procedures are not standard and are not offered by all doctors or clinics.

Alternative therapy for hay fever: homeopathy

Many people see homeopathy as an effective alternative or supplement to the classic hay fever therapy. From a scientific point of view, the effectiveness of homeopathy in hay fever has so far been rather controversial. Although in recent decades, numerous studies on the efficacy of homeopathy in hay fever were performed, but usually were not objective target values ​​measured as a result, but the subjects questioned after their subjective perception of the therapy. The results were therefore often doubted because subjective impressions are hardly verifiable and depend on a wide variety of influencing factors.

Another approach followed a study from India (Gosh et al., 2013): It not only showed that homeopathy can alleviate hay fever, but above all it was able to detect verifiable changes in laboratory values ​​through homeopathy treatment. In this study with 34 subjects, the concentration of so-called Ig-E antibodies and eosinophilic granulocytes in the blood was measured. By a one-year hay fever therapy with various homeopathic medicines there was a statistically significant reduction of these values, which are usually increased in allergic diseases such as hay fever. Among other things were used Natrum muriaticum, Histaminum, Psorinum, Lachesis muta, Allium cepa and Euphrasia officinalis, Homeopathy not only changed the laboratory values, but also significantly improved the symptoms. In order to further increase the acceptance of homeopathy in hay fever, further scientific studies with a larger number of subjects are needed.

Organotropic homeopathy

Some doctors see hay fever therapy as a suitable field of application for so-called organotropic homeopathy (indication-related homeopathy). In this direction of homeopathy is largely dispensed with the otherwise very elaborate collection of medical history (anamnesis). Instead, homeopathic medicines are administered, which generally help with a certain illness. On the one hand, the treatment is thus far less individualized for each patient – on the other hand, this direction of homeopathy enables rapid treatment. A self-treatment is also possible sooner. Basically, homeopathy should not be used on hay fever without the advice of a doctor or homeopath.

Homeopathy in hay fever: Commonly used preparations

Homeopathic medicine	operation area
Galphimia glauca	With watery, itchy eyes and violent sneezing attacks. Can also be taken preventively – starting six to eight weeks before the pollen season.
Allium cepa (onion)	Complaints, especially on the nose: Burning, watery runny nose
Euphrasia (Augentrost)	Complaints, especially on the eyes: Burning, watery eyes.
Wyethia helenoides	Itching in the throat or deep in the throat
Arundo mauritanica (water pipe)	Itching in the ears

These homeopathic remedies are usually in the Potentiation D6 or D12 used. In this case, five globules are to be taken about three to five times a day. If the symptoms are very severe, five globules can be taken every hour for six to ten hours. From the second day, the dosage is then reduced back to the usual level (three to five times a day, five globules each). Attention: This information is only a rough guide for the homeopathic Hay fever therapy and in no case replace the advice of a doctor or homeopath.