drsamirajeimy

A lot of people assume you only need allergy shots for cats if you live with a cat.

The major cat allergen, Fel d 1, is small and sticky. It binds to clothing and upholstery, and even hair and eyelashes (ew). So, it travels well beyond the home and shows up in schools, offices, public spaces, and even homes without cats.

This is why cat allergy can be difficult to control with avoidance alone. You can remove the cat from your home and still have ongoing symptoms because the allergen lingers and continues to be reintroduced.

Immunotherapy addresses the underlying immune response rather than trying to control every exposure, which is often not realistic. So I consider allergy shots for cat allergy based on symptoms and sensitization, not just whether there is a cat in the home.

Curious how others approach this, especially in patients with intermittent but reproducible symptoms in “cat-free” environments.

Eosinophilic esophagitis is frequently missed, especially in adults.

It is an immune-mediated condition where eosinophils infiltrate the esophagus, leading to inflammation, remodeling, and eventually scarring or strictures.

Over time, the esophagus becomes narrow and less flexible.

Symptoms evolve slowly, so patients sometimes compensate and adapt for many years.

Common clues:
• food impaction
• slow eating, excessive chewing
• drinking liquids with every bite
• avoiding “dense” foods like bread or meat
• reflux symptoms that do not respond to standard therapy
• chest discomfort or pill dysphagia

Early diagnosis is important, as untreated inflammation can lead to scarring/narrowing.

Once that narrowing develops, diet and medication alone may not reverse it. That is when patients need procedural interventions like dilations.

Treatment is targeted and includes:
• proton pump inhibitors
• swallowed topical steroids
• food elimination diets
• biologic therapy such as Dupilumab

Food elimination note: Milk is one of the most common triggers, and milk elimination alone induces remission in a substantial proportion of patients. For some, removing dairy is enough to change the trajectory.

It’s not in your head! Several things converge after sunset.

1) environment - dust mites in bedding and pillows, pet dander on fabrics, maybe mold
2) physiology - Cortisol follows a circadian rhythm. It’s highest in the morning and falls overnight. Cortisol has anti-inflammatory effects, so when it drops, allergic inflammation has more room to surface.

Histamine activity also rises at night, which can amplify itching, sneezing, and congestion.

3) body position. Lying down increases nasal blood flow and congestion and mucus doesn’t drain as easily. Reflux can also creep in and irritate the airway.

If your symptoms peak at bedtime, think about:
• dust mite covers for pillow and mattress
• washing bedding weekly in hot water
• keeping pets out of the bedroom
• HEPA filtration in the bedroom
• taking non-sedating antihistamines or nasal steroids consistently

Before giving up on your nose sprays, watch this video.
3 common mistakes I see:

First, technique.
If you spray straight up the nose and sniff hard, most of it goes down the throat and very little stays where it needs to work. Aim@slightly outward, toward the ear. Don’t sniff hard.

Second, using it only when symptoms are bad.Sprays like Fluticasone, Mometasone, and Budesonide treat inflammation. They’re meant to be used daily and not as needed.
If you stop and start, they’ll always feel like they’re not doing much.

Third, the Goldilocks principle.
Some sprays are steroid alone. Some combine steroid + antihistamine. Some work better for congestion, others for sneezing and itch. If one didn’t help, another option might!

When used with the right technique, consistently, and with the right choice, nasal sprays are often the most effective treatment for allergic rhinitis.

A teenager in Ottawa was just hospitalized after doing the “Benadryl challenge.”

Diphenhydramine (Benadryl) is often treated like a harmless allergy pill or sleep aid.

It’s a first-generation antihistamine that enters the brain, causing sedation, slowed reaction time, confusion, and impaired thinking.

At higher doses it can trigger severe anticholinergic toxicity: agitation, hallucinations, dangerous heart rhythm disturbances, seizures, and coma.

For these reasons, modern allergy guidelines recommend newer antihistamines (cetirizine, loratadine, fexofenadine) as first-line treatment, as they can help allergy symptoms without the same brain effects.

Social media challenges that involve medications are especially dangerous because the line between a normal dose and a toxic dose can be crossed so fast.

Going to have some serious conversations with my own newly minted teenager. Social media has made things so much more complicated.

Ever take a bite of hot soup or spicy food and your nose immediately starts running?

This is gustatory rhinitis.

Gustatory rhinitis is a nerve reflex. Certain foods, especially hot or spicy ones, stimulate the parasympathetic nerves in the nose, which tells the nasal glands to produce watery mucus. The result is sudden onset of your nose dripping during meals.

As the above implies, this is not a food allergy. There’s no IgE involvement and no immune reaction. It’s simply the nervous system activating nasal secretions in response to food stimuli.

Common triggers include chili peppers, hot soups, and strongly spiced dishes. It tends to become more noticeable with age.

If symptoms are bothersome, ipratropium nasal spray used before meals can reduce the glandular secretion and help control the runny nose.