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Interviewer: All right. Here's a scenario, Dr. Miller. A patient comes to you because of a runny nose, sneezing, watery eyes, itchy throat. Okay? So you suspect seasonal allergies. What do you do to help them? Maybe I should back up. Are those the symptoms of allergies? Did we hit all of them?

Dr. Miller: Oh, yeah. Absolutely. So runny nose, sneezing, itchy eyes, itchy ears, itchy back of the throat, postnasal drip. Basically, these are, and especially the time of year, so if it's fall and spring when you have a lot of pollen.

Interviewer: That's like bingo.

Dr. Miller: Yeah. Ragweed in the fall, things like that.

Interviewer: Gotcha.

Dr. Miller: People get allergies.

Interviewer: Can you differentiate those symptoms from a cold, generally?

Dr. Miller: Yes. Generally, you can. A cold gives you the scratchy, uncomfortable feeling. You'll have some of the same symptoms, like postnasal drip, but you tend not to get that itchy eyes and itchy nose. And it just feels uncomfortable. Most people can differentiate between an upper respiratory infection versus allergies.

Interviewer: Yeah, I feel that I'm an allergy sufferer. I feel like I can usually when it comes on. So we've hit the signs, right? Those are some of the signs that you're suffering from some sort of a seasonal allergy from your environment.

Dr. Miller: Well, the other thing is you look and you can see the pollen counts, like in the spring and fall, you'll see when they start to go up that more and more people have problems with allergies.

Interviewer: And you see a lot of this sort of thing?

Dr. Miller: We do.

Interviewer: Okay.

Dr. Miller: We do quite a bit.

Interviewer: So, since you see a lot of it, you probably have a routine that you go through to help that patient if they're sick and tired of suffering?

Dr. Miller: Yeah. First of all, you have to make the diagnosis and so you listen to the history. So, just as we were talking about, if they come with those symptoms, it's the right time of year. Yes. You can say these are seasonal allergies and then you begin to talk about treatment. Avoidance is the best treatment. So, if you can stay out of the open where you have a lot of high . . . or you have a high pollen count, stay away from it if that's possible. Many times it's not possible, but that's the best thing.

Also, for people who are out working in the yard or they're out exercising or mowing the lawn, if they start to exhibit symptoms because the antigens from all these pollens, these particles are on their skin, which trigger the allergic reaction, you should go home, change your clothes, take a shower, wash it off, clean off the antigens.

Interviewer: All right.

Dr. Miller: That'll be the first thing to do.

Interviewer: So avoid it if you have to be out in it. Clean it off as soon as is feasible. What about putting one of those masks on?

Dr. Miller: Right. So you'll see gardeners wear those masks sometimes.

Interviewer: They're effective.

Dr. Miller: They are effective. They're partly effective. They're not a 100% effective, but they're better than just breathing in the particles, which will trigger allergic reactions in a lot of people, especially in high amounts like you might expect you would see in gardeners, lawn care people.

Interviewer: Okay. So can allergies possibly get worse over time if I don't do something about them?

Dr. Miller: In fact, they do. So some people will start out, especially when you're younger and you'll have some issues and they can tend to be worse over time as your body becomes more sensitized and produces a more aggressive allergic reaction every time you're exposed to them.

Interviewer: And that's regardless of I do something or not because aren't most treatments revolving around giving you symptom relief? Like there's no cure for allergies.

Dr. Miller: There isn't a cure per se. Although if you end up having desensitization shots, they many times will help reduce the burden of the allergic reaction and sometimes eliminates it completely. And people have very serious allergic reactions due to pollens and other particulates and you can't get away from the triggers. Sometimes these allergy shots which they start them in a low dose and then they increased the dose over time so that your immune system just becomes used to it. That's the theory behind it. That can actually be pretty helpful. So, in that sense, for some people, yes. The treatment can make it go away.

Interviewer: But I think I jumped ahead a little bit, because as a kid I got a lot of shots. I didn't find a lot of success personally with those, although people do. I ignored my symptoms for many, many years, and finally I got so bad I went to a doctor again and the doctor said, "Well, shots is really down the d in treatment options at this point."

Dr. Miller: Down the road. That's right.

Interviewer: There's a lot of stuff you can do before that. So what are some of those things that you would do then?

Dr. Miller: Well, interestingly, there are a number of medications now that are very effective for people who have mild to moderate symptoms of allergic reaction to pollens and particulates. And basically, you can use antihistamines, which are a pill that you take by mouth. And there's a couple of kinds. The older antihistamines have some side effects. They can make people sleepy, drowsy, fatigued. They tend to work pretty well. That is they suppress the itching and the sneezing and the itchy throat and those types of things. But they have a newer class of antihistamines that's non-sedating, and they work pretty well in suppressing the symptoms, and they don't give you that massive fatigue that some people get taking the older antihistamines.

Interviewer: And that's in a pill form?

Dr. Miller: That is in a pill form.

Interviewer: Okay.

Dr. Miller: The other thing that we've moved to, especially for sneezing and rhinitis that most people get with these allergies are nasal sprays, very mild doses of steroids in nasal sprays. And you spray that in on a daily basis, and it basically just cools down the lining of the sinuses and it's pretty effective for preventing sneezing and itching and scratchy throat, that kind of thing. They also have similar drops for the eyes for people who struggle with itching eyes during allergy season.

Interviewer: It didn't occur to me, but so like the nasal sprays, that's what I use. I've had great success with them.

Dr. Miller: They work pretty darn well for most people.

Interviewer: But something you just said earlier intrigued me. It's mainly for the sneezing symptom and maybe some of the itching?

Dr. Miller: Correct. It doesn't really work for the eyes. And so that's the nasal spray that you're talking about. So they make drops. They contain some of the same medicine and you can use those.

Interviewer: And the pills, do they take care of all of the symptoms, the antihistamine pills?

Dr. Miller: Yes. They do.

Interviewer: Okay.

Dr. Miller: So during allergy season for people with moderate symptoms, you'll find that they get relief both with the nasal spray and the oral antihistamine, especially the non-sedating antihistamine on a daily basis. So they just lacquer up, if you will, during that season.

And then also again, trying to stay away from the triggers. This is especially true for people who have allergies to pets. We haven't talked about that yet, but some people are allergic to cats, although they like to scratch the cat when the cat comes by and then the immediately they rub their eyes and all of a sudden they're going crazy. So the key there is avoidance. And for some people, unfortunately, they discover that they are allergic to pets, and in severe cases, they have to send the pet to a relative or somebody else. And that's unfortunate. That's really hard to do when people are attached to their pets. So the next best thing is you wash your hands after you pet the animal. But you have dander around the house and that sets people off.

Interviewer: We talked about some nasal histamines. Do you need to start taking those like, say, my allergies are going to kick in when the grass starts growing. For any of these actually, do I need to start ramping up, or do I just take it as soon as I need it?

Dr. Miller: That's a good question. So, basically, if you're anticipating a spell of allergy coming on with a particular season or if you're going to be out gardening, it's a good idea to get ahead of that a day or two before you head out.

Interviewer: Oh, so just a day or two?

Dr. Miller: Well, especially if you're going to be exposing yourself to high pollen counts. So starting the antihistamines two days before, a day before and then definitely starting the nasal spray probably maybe three, four days before because it does take a few days for the medicine to become maximally effective.

Interviewer: So, for me and my cat allergy and my mother-in-law who has cats, three or four days before I go for a visit that's what I want to do?

Dr. Miller: Either that or . . . well, I won't say don't visit because that's probably not a possibility or have a neutral space that you can visit her where the cats don't come with her.

Interviewer: Sure. That's fair enough. All right. Have we covered everything? I'm trying to think as a person with allergies if I feel that we have.

Dr. Miller: I do want to mention one thing. So some people use decongestants that they buy over-the-counter. Medications that actually dry out the mucosa. They're different than the nasal sprays that I'm talking about. They're steroid-based. So, when you go to the drugstore and buy what's called a decongestant, especially a decongestant nasal spray, we find that if those are used more than three, four days in a row, you can develop a rebound phenomenon that basically addicts you to that medication. So we would advise people not to use decongestant for treating allergy.

Interviewer: Okay.

Dr. Miller: So to stick with the steroid nasal sprays and the first-line antihistamines, if you can tolerate them or perhaps more commonly the non-sedating antihistamines.

Interviewer: Actually, you know what, you triggered another question as an allergy sufferer. Can I go and just get some over-the-counter stuff? I know the Flonase equivalent now is available over-the-counter.

Dr. Miller: Yeah. All the things that I'm talking about are over-the-counter.

Interviewer: So you don't even really need a visit to your physician for those things?

Dr. Miller: No. You can try those. And especially with the internet now you can look online and provided you have a reasonable source to read about what you can treat your allergies with, you can use a combination of a nasal steroid or you could use an antihistamine or you could use both to treat. Again, I think the simple stuff is if you can avoid the triggers, that's the very best thing. But again, many people can't, you have to be outside.

Interviewer: All right. So, if somebody tries over-the-counter stuff and they get relief, great. If not, what's the next step at that point? When do you want to go see a doctor?

Dr. Miller: So, one, if you're having symptoms on a pretty much daily basis and these symptoms are causing fatigue or if you're missing work and also if your sleep is impaired due to these allergies, you're up at night sneezing and you're back and forth to the Kleenex box, it's probably time to go to the physician. And the first thing that they would do is see if you're taking a maximal, not a maximal, but an appropriate number of over-the-counter medications that we talked about earlier, whether you're using them appropriately.

And if that's not working, then the next step would be to use prescription medications, which are a little more potent and could suppress the allergic reaction. Again, you may end up having testing because testing can help you identify the actual allergen triggers that you might want to avoid. Once you know that, it might be a little bit easier to figure out when you're exposed to an allergen and what to do after you're exposed or to prevent exposure.

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