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Join Kara Wada, a board-certified academic adult and pediatric allergy, immunology, and lifestyle medicine physician. We’ll delve into the world of ragweed allergies, exploring their prevalence, causes, and practical tips for managing symptoms. Discover how factors like climate change and urban environments impact allergies and learn about effective treatments.

Kara Wada is a board-certified academic adult and pediatric allergy, immunology, and lifestyle medicine physician, Sjogren’s patient, certified life coach, TEDx speaker, and Dr. Midwest 2023. She can be reached at Dr. Kara Wada and on Instagram, YouTube, Facebook, and LinkedIn. She is a national expert, sought-after speaker, advisor, and host of the Becoming Immune Confident Podcast. She is CEO and founder, The Crunchy Allergist and the Demystifying Inflammation Summit, and serves as the director of clinical content for Aila Health.

She discusses the KevinMD article, “Ragweed allergy peaks during college football season.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Kara Wada. She’s an adult and pediatric allergy, immunology and lifestyle medicine physician. Today’s KevinMD article is titled “Ragweed allergy peaks during college football season.” Kara, welcome back to the show.

Kara Wada: Thanks so much for having me today, Kevin. How are you?

Kevin Pho: I’m doing well, and we’re here to talk about ragweed allergies. Kara’s been on multiple times. Go to KevinMD.com/podcast; in the upper right-hand corner there’s a search icon, and you can search for her name and hear her story. But let’s jump right into your article, “Ragweed allergy peaks during college football season.” Why did you decide to write it?

Kara Wada: Well, I felt very inspired. I practice clinically at Ohio State in Columbus, Ohio, and having been here for about 14 years now, you have to sip the Kool-Aid at least a little bit when it comes to the excitement of the lifers and those who are very excited about the Buckeyes and college football. I thought it was really interesting that I had increasingly realized I was talking with patients about how they needed to start their allergy medications around the time the football team was starting practice, if they had fall allergy symptoms, and I thought it would be a fun article to write.

Kevin Pho: All right, so let’s get everyone on the same page. Tell us what ragweed is and how common an allergen it is.

Kara Wada: Ragweed is one of the key species that affect us in the fall, with fall allergies, or hay fever. Ragweed is a pretty nondescript plant. A lot of people will confuse it with goldenrod, which has that really pretty gold color, but usually ragweed is its not-so-attractive cousin that’s right next to it. And it is incredibly prevalent. It is found in nearly all of the 50 states; it is even found in Hawaii. I think Alaska is the only state where it has not been found.

It tends to thrive in both urban and rural areas. It was kind of surprising to me when I did my training as an allergist. I grew up in a more rural area, surrounded by farms, and I figured we had a lot of pollen and a lot of dust. But it turns out that ragweed specifically has much higher counts in urban areas, because of urban heat islands: areas that are warmer because heat is retained in our concrete and our buildings. These ragweed plants are very, very hardy. They will take root in abandoned parking lots, along roadways and in areas that don’t get mowed. One plant can produce over 1 billion pollen grains, and those grains can stay airborne for up to 400 miles. So they are prevalent and persistent.

Kevin Pho: So how do patients who have allergies to ragweed present to you in clinic, or to a primary care physician like myself?

Kara Wada: Typically, around the middle of August in most parts of the U.S., we start to see the onset of fall allergy season. In part, that’s because the pollination of ragweed and many of its fall allergen counterparts is cued by the length of daylight rather than by temperature. When we think about spring pollen season, we’re waiting for the snow to melt, and that signals to the plants that it’s time to reproduce. Ragweed and weeds are more reliant on the length of daylight, so the start time is pretty consistent. Around the time school is getting back in session, people will notice that they may be having itchy, watery eyes, runny noses, itchy noses, sneezing and an increase in their asthma symptoms, so cough, chest tightness or wheezing. All of that is suspicious for fall allergies, or ragweed allergy.

Kevin Pho: Now, is there a particular demographic that may be more susceptible to ragweed allergies?

Kara Wada: Typically, on the younger end, people tend to need to have been exposed to the pollen for at least one season, so we would say it would be incredibly rare to see a child have seasonal allergies before they’re about two years old. They need to live through a season and then come back to that season again. But we can continue to see seasonal allergies throughout the lifespan. Most often, as you’re getting toward retirement age, the immune system tends to be less likely to make new allergies, but I still meet patients on occasion who are well into their golden years and are still having significant issues.

Kevin Pho: Now, over the past few years, have you noticed that the fall ragweed season has been progressively getting worse?

Kara Wada: When we think about what ragweed needs to thrive, and really what most plants need to thrive, they need sunshine, water, carbon dioxide and warmth. Where I live, for instance, Columbus is a relatively young city. We had tremendous growth in our metropolitan area even before I got here, and in the 14 years I’ve been here, we have continued to see an upward trend. This year in particular, on September 5, we had ragweed counts that were nearly twice as high as they got at any point during last year’s season.

Kevin Pho: Now, does climate change have anything to do with the worsening ragweed counts?

Kara Wada: It does, in a couple of ways. One, we have more of the fuel to promote ragweed growth, but we also see a lengthening of the pollen season, and the farther you get from the equator, the greater that change is. So listeners who are in Canada, for example, may see a longer pollen season, or a greater increase, than those of us in Columbus, compared with those down in Texas.

Kevin Pho: So I want to talk about a couple of different case scenarios: number one, someone who presents to me or you with acute symptoms that may suggest a ragweed allergy, and second, someone who has a previously diagnosed ragweed allergy and wants to inquire about more preventive options. Let’s talk about the first scenario. Someone comes to you or me with acute symptoms that may be suggestive of a ragweed allergy. What’s your approach?

Kara Wada: In that situation, we’re trying to put out the fire. We’re trying to help that patient get back some quality of life and be able to think better and breathe better. One of the things I’m going to key in on is which symptoms are really driving most of their suffering. If it’s itchy, watery eyes or eye swelling, then eye drops may be really beneficial. If it’s nasal congestion, then most often I’m going to recommend a combination of things: maybe some saltwater rinses if there’s a lot of mucus production, a nasal corticosteroid if there’s significant stuffiness or tissue swelling, and then one of the medications that’s newer to our over-the-counter options, intranasal azelastine, which is an intranasal antihistamine. That tends to work quite rapidly and quite well at drying up drainage and helping with the itching as well.

Kevin Pho: So when making that choice between an intranasal corticosteroid like Flonase or Nasacort and intranasal azelastine, do you have a preference? What kind of advice can we share with patients who are confronted with a million nasal medications at the drugstore?

Kara Wada: Yeah, you go to the allergy aisle and you’re inundated. I would say that if you’re having the most trouble with stuffiness, getting air in and out of your nose, you probably need an intranasal corticosteroid on board. That’s going to work best at shrinking those tissues. That being said, people will notice some differences between brands, and some people may tolerate different brands better, so if you’ve tried one and haven’t found it terribly helpful, it may be worth trying another.

The other little sticking point with intranasal corticosteroids is that they take two to four weeks to reach their full effect, and you really need to use them the way you would a blood pressure medicine, on a regular basis, even if you don’t feel like they’re doing much. The improvement is gradual, and that’s where I think a combination, adding in azelastine, can be helpful, because azelastine is a little quicker in its onset of action. It may not help shrink the tissues as quickly or as well, but you may get a little more of the effect you need to stick with it. So often, by the time people reach my office, we’re talking about using a combination of both, so we’re hitting things hard to get that inflammation turned down.

Kevin Pho: Patients sometimes ask me about Afrin, which is also available in that area. Contrast Afrin with the corticosteroid and azelastine.

Kara Wada: Afrin can feel like a magic wand when you use it. It is quite immediate in its onset. It’s a decongestant, and it tends to work very well, but like everything in life, there are sometimes consequences when we take the easy road. So Afrin can at times be incredibly helpful, especially if you are totally congested and obstructed, but if it’s used for a prolonged period of time, and we say more than three or even five days in a row, those tissues in the nose can become accustomed to it. The receptors change, and your nasal tissue can essentially become almost addicted to needing it to stay open.

So I always tell patients, if you find yourself in a pickle because you’ve been overusing Afrin, don’t feel ashamed. Come see me, we’ll get you off it and we’ll get you feeling better. I don’t blame you, because feeling open and clear feels much better than being stuffy. But at the same time, it is not a good long-term solution. Our worry over time is that it can cause damage to the tissues and the vasculature in the nose, and it can cause issues with the septum. So it’s helpful in a pinch, for short use, but you need to think about those other nasal sprays, which are much more effective and safer for the long term.

Kevin Pho: Now, what role do oral antihistamines play, like Claritin, Zyrtec or Allegra, in this scenario?

Kara Wada: They’re a fantastic first-line agent, but I will say they have their limitations. They’re not the best at keeping tissue swelling or congestion under control, so if you are really stuffed up, they likely won’t be sufficient. When we’ve looked at head-to-head trials between oral antihistamines and medications like the intranasal corticosteroids, the nasal sprays win.

Kevin Pho: Early on you mentioned eye drops for those with eye symptoms. Go into more detail about what patients should be looking for at the drugstore.

Kara Wada: You’re going to run into issues similar to the ones we talked about with nose sprays. There are quite a few products that have agents that constrict the blood vessels to take the red out, so if it says something about red eyes, you probably don’t want that particular product. Some of the ingredients I tell patients to look for are, again, azelastine, which we talked about in the nose spray and which comes in an eye drop too, under several different brands, and olopatadine, which is another mainstay of eye drops. These eye drops will occasionally burn when you first put them in, so keeping them in the refrigerator can help mitigate that and give a little more cooling relief. And if you wear contacts, it’s important to put the eye drops in first, wait about 15 minutes and then put your contacts in, or wait until the end of the day, when you take your contacts out, to put the eye drops in.

Kevin Pho: And what’s the reason for that?

Kara Wada: Just so that they’re actually effective and not mucking up the contacts.

Kevin Pho: So let’s talk about that second scenario: someone with a known ragweed allergy who wants to prevent symptoms going into ragweed season. What’s your approach there?

Kara Wada: I applaud them. When we think about inflammation, I think about horses in a barn. If you can keep inflammation from getting out of control, it’s a lot easier, and you can usually use less medication over time. One way we can do that is to start medications early. If this season was particularly bad, maybe you set a calendar alert for August 1 of next year: “Oh, I’ve got to start my Flonase or Nasacort early.”

The other option you can consider is to meet with a board-certified allergist-immunologist. We have other tools in our tool belt, like immunotherapy, which desensitizes your immune system so that it doesn’t respond to ragweed as the enemy; it starts to ignore it. Those treatments do have a bit of a lag time, though. If we’re starting shots, for instance, it may take six months or so to get up to your target dose and see that effectiveness before the next pollen season. If I’m using sublingual, or under-the-tongue, treatments, which come in tablets and occasionally in liquid form, we usually say those take about three months to reach their full effect.

And then there are some newer options that are increasingly becoming available, such as something called intralymphatic immunotherapy, which essentially shrinks the treatment course. Traditional allergy shots were a three- to five-year endeavor, and sublingual treatment is similar, but intralymphatic immunotherapy shrinks that down to just a couple of months. So if you’ve explored these options in the past, I think it’s helpful to know that there are some new things out there that can provide relief, knowing that, especially with climate change, this is going to continue to be an issue over the long term.

Kevin Pho: So regarding that intralymphatic option, talk about it in more detail. What exactly would it entail?

Kara Wada: There’s a small group of allergists providing this. Intralymphatic immunotherapy takes about one one-hundredth of the amount of allergen we would use in traditional allergy shots. We inject that allergen under ultrasound guidance into an inguinal lymph node. What is really neat about using the lymph node specifically is this: When we do a typical allergy shot in the back of the arm, we are relying on our immune system cells, or white blood cells, to capture that allergen and bring it back to the lymph node. The lymph node is essentially the factory where that immune system change occurs, so we’re delivering the allergen directly to the factory, and you need less of it.

The other thing that’s really amazing about lymph nodes is that the cells that have the potential to create anaphylaxis, mast cells, are not present in lymph nodes. When we talk with potential allergy shot patients, we’re also assessing their risk. Are they on medications like beta blockers, or other things that may make it harder to treat anaphylaxis? What are the safety concerns? Because we say that about one in 200 patients may have a more significant reaction to their allergy shots, there’s a lot around that aspect of care as well. In the studies that have been done, it’s a series of three injections into that lymph node, at week zero, week four and week eight, and we’re seeing improvements comparable to those we’ve seen with other types of immunotherapy, under that accelerated course.

Kevin Pho: Now, give us an example, or case studies, of the types of patients that I, as a primary care physician, should consider sending to you for some of these more involved treatments.

Kara Wada: I think the perfect candidate is someone who has tried all the different medications, or perhaps is not tolerating medications well and has a lot of side effects, and continues to have symptoms. The other patients I see often are those looking for a more natural, longer-term approach to care, and those folks are really excited about immunotherapy and the benefits it offers in needing less medication over the long term and having better symptom control. The other group of folks that I think have the best long-term potential are our younger patients. When we look at some of the data for immunotherapy in kids and teens, there is data to suggest that we see less progression of allergies into asthma and less formation of new allergies over the long term, because it changes the milieu of what is going on in the immune system. So those are the other group of patients that I think can really benefit from long-term treatment options.

Kevin Pho: We’re talking to Kara Wada. She’s an adult and pediatric allergy, immunology and lifestyle medicine physician. Today’s KevinMD article is titled “Ragweed allergy peaks during college football season.” Kara, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Kara Wada: First and foremost, you don’t have to suffer through allergy season. Using a combination of trigger avoidance, like keeping your windows closed, medications and/or immunotherapy, we really can get significant improvement and relief of your symptoms. I think that is the take-home message, and if you are having ongoing symptoms, we’re here to help.

Kevin Pho: Kara, thanks once again for coming back on the show and sharing your time and insight.

Kara Wada: Thanks so much, Kevin. Take care.