Seasonal allergies are coming fast and furious this year. How do we prepare our patients?
An introduction to the “6R” protocol for Allergies
At this time of year in Connecticu, we’re usually trudging through our last few snow flurries of the year. Roads become muddy and wet, as dirty snow melts into the streets. It’s not the most pleasant time to be in the state. But at least seasonal allergies haven’t kicked in!
With our winter being one of the warmest on record, and having virtually no spring thaw, trees, early flowers and some grasses are bursting forth with new growth. Many patients presented to my office this week with the tell-tale signs: itchy, watery eyes, runny noses and relentless fatigue: blindsided by early allergies.
Figure 1. Pollen count for Sandy Hook, CT 3-14-16 through 3-18-16. We had rain early in the week which cleaned the air and dropped the pollen count on Monday and Tuesday. Top allergens in CT right now are Juniper and Elm. Check out the allergy forecast tool for your area at www.pollen.com.
I was speaking to a patient who recently switched to maintenance care for eosinophilic esophagitis (EoE). EoE is almost always associated with a combination of food and inhalant allergies, and frequently there is some degree of food/inhalant cross reactivity. [Click on the hyperlink to read a basic overview on cross reactivity/oral allergy syndrome written by Romilly Hodges, our staff nutritionist.] To preserve the progress she’s made as we head into allergy season, I decided to bump up her basic treatment protocol short-term to something akin to what we did when we first started working together. I think this protocol is useful for all of our inhalant and food allergy sufferers. When I teach at the Institute for Functional Medicine, I include a “6R” approach to allergic disease that covers the foundational areas needing to be addressed. I’m using this basic approach as a preventative protocol for my EoE patient.
Introduction to the 6R Allergic Disease Protocol
- Reduce symptoms. This is palliation. If someone is full of histamine, they feel lousy. We want to provide some symptom relief as quickly as possible. Tools for consideration include quercetin, nettles, butterbur, vitamin C, boswellia. I use sodium bicarbonate on occasion for acute flares. My EoE patient experiences marked dysphagia as her chief allergy symptom– ¼ to ½ tsp of bicarbonate can increase pH just enough to quickly and temporarily reduce histamine release. For some, we want to be careful about excess sodium exposure. There is a potassium bicarbonate available, too. Antihistamine medications (as well as antileukotrienes, mast cell stabilizers, bronchodilators for asthma) are all fair game during acute flares, if they’re needed. As your patient recovers and underlying imbalances are addressed with the rest of the 6Rs their reliance on these medications will drop. I particularly like hydroxyzine before bed as it seems to have a nice anxiolytic effect with less of the “hung over” feeling that often accompanies Benadryl.
- Remove (or minimize) antigenic load. One of the most powerful leverage points we have as FxMed clinicians is diet. Identify and remove the problem foods such as gluten and dairy (I conduct IgE inhalant and foods testing on my allergy patients, and often look at IgG or IgG4 food testing as well).
As I mentioned above with regard to my EoE patient, inhalant/food cross reactions are common in season. Keep your eyes out for these. For instance: Birch potently cross reacts with a number of different fruits, celery, carrot, nuts and soy. Cross reactions most commonly present with oral allergy syndrome, but not always. Dysphagia associated with EoE can be a manifestation of an inhalant/food cross reaction, and thus onset or worsening of EoE can occur during allergy season. I have also seen very severe soy allergy develop in a birch sensitized patient.
Don’t underestimate the potent inflammatory capacity of sugar and processed foods. Via numerous mechanisms, not the least of which is increased insulin and arachidonic acid, sugar will drive inflammation and heighten an allergic response. My EoE patient reports that sugar always worsens her symptoms. There is a very interesting paper on IgE sensitization to candida (and associated cross reactions) in EoE that may be a piece of what’s occurring with her.
It’s also EXTREMELY important to remove the inhalant antigenic load as much as possible. Neti pots are a great tool for rinsing the sinuses. If the individual is prone to infection, I will often recommend including a small amount of berberine in the rinse. HEPA air filters and screens on the window will help keep the household air cleaner. Air conditioners may be essential during peak allergy season for some folks.
Planting a hypoallergic garden can be essential for some allergy folks. We have significantly overplanted this country with pollen-producing male plants and have increased the antigenic load markedly because of this. Thomas Ogren has done remarkable work in outlining both the problem and solution.
Finally, if an individual has high endogenous production of histamine, it can be a drain on methyl donors, as histamine requires a methyltransferase for metabolism. Include a B complex to support histamine removal. For some, the addition of diamine oxidase (DAO) may also help metabolize histamine.
- (or restore) the microbiome: Allergy patients can be expected to have dysbiosis to varying extents of severity. You can start with a good probiotic, emphasizing D and L-lactate producing bacteria (Lactobacillus and Bifidobacteria, primarily). Of course, using fermented foods is a fabulous option. I personally love fermented sauerkraut and kimchee.
If you are conducting a full FxMed work-up, a comprehensive stool analysis is important and useful for allergy patients.
- Repair barriers: Nothing ushers in barrier permeability in an allergic patient like histamine. Note that by reducing histamine using the above recommendations — especially the botanical approaches — you’ll help minimize damage to the barriers. The faster we can reduce histamine, the better. For my EoE patient, we’ve resumed a glutamine/zinc carnosine supplement for the short term.
- Replace: There is good research out there demonstrating that insufficient stomach acid will highly significantly increase the possibility of food allergy. This is because the larger protein fragments of undigested foods are more likely to appear foreign to the gastrointestinal lymphoid tissue prompting immunological reaction. Thus, we want to ensure our allergy patients are able to break their food down very well. Think about digestive enzymes and HCL as indicated. And remember “rest and digest” allowing the body to move into a parasympathetic state while eating enables production of the various digestive juices to ensure proper digestion/absorption.
“Replace” is also the category where I think about general anti-inflammatory support. Anything that helps inhibit the arachidonic acid (AA) derived eicosanoids will help blunt the allergic response. Reduce omega 6 intake, increase omega 3 intake. Get rid of sugar and processed foods. Consider wonderful botanicals such as curcumin, ginger, boswellia and many others are known to reduce/inhibit the potently pro-inflammatory AA-derived eicosanoids.
Think about improving tolerance in your allergy patients. We want to blunt that heighted Th2/allergic response. Many of the interventions I outline here will help support the establishment of tolerance. Vitamin D and vitamin A have both shown to increase Foxp3+ T-regulatory cells. I use sublingual immunotherapy (SLIT, or low dose exposure to antigens) with many of my patients (also demonstrated to increase Foxp3+ Treg cells). Most commonly I use SLIT for inhalant allergies.
- Rebalance: Anxiety is a major fall-out of allergy sufferers. Allergies are miserable. And adrenalin is a mast cell agonist, thus heightened stress can influence the allergic response. Additionally, cortisol is a potent barrier damaging molecule. Think about meditation, exercise, sufficient sleep. I engage my patients in an ongoing dialogue around what works for them, and we return to this conversation often, as it is fundamental to a successful overall plan.
There is no doubt that a good FxMed approach to allergic disease works. I hope this basic overview of how I work with many of my patients is a useful starting point for you. Of course, structure your thinking of each case into the functional medicine Matrix/Timeline/ATM [read intro to FxMed approach here] format for the best outcome. You’ll find that many longtime allergy sufferers have — in addition to immune upregulation and imbalance — nutrient deficiencies, HPA axis imbalances, energy deficits and gut imbalances. For those of you who find such a structure useful, consider using this 6R approach: Reduce, Remove, Re-inoculate, Repair, Replace and Rebalance. Happy Spring!
If you would like to try out the 6R allergy relief program for yourself, we recommend the following online programs that provide educational materials, resources and supplements to combat your symptoms.
Very clinically useful, thank you!
Fermented foods are off the list if someone is high histamine.