Nhi Tran never had allergies growing up in Southern California. But when she moved to Connecticut in 2008 at age 30, the symptoms started.
“My husband’s parents had three cats, so anytime we went to their house I would notice allergy-like symptoms,” says Tran, now 43.
At first, it was just a runny nose and itchy eyes. But then it turned into a tight feeling in her chest, and eventually coughing and wheezing. She went to an allergist and learned that she was not only allergic to cats, but also environmental allergens like tree pollen.
“Since I wasn’t exposed to allergens like maple trees growing up, I’d never had a reaction,” Tran says.
Tran’s allergist put her on over-the-counter antihistamine Zyrtec, as well as prescription drug montelukast sodium (Singulair), to treat her allergic asthma. While that worked for day-to-day symptoms, it didn’t stop the flares that occurred at her in-laws’ house. Tran needed a rescue inhaler with albuterol, a type of drug known as a beta-agonist, to help relax airway muscles. And even that wasn’t enough: Tran eventually required oral steroids to get her attacks under control.
“Over the years, my system became more and more sensitive to the cats,” she says. “Initially, I could stay in my in-laws’ house for about an hour without a flare up. But it got to the point where I would hug my mother-in-law outside of her house and I’d have an asthma attack because there was cat dander on her sweater.”
When Tran knew she would see them, she would take the oral steroid prednisone a couple days before the visit, and then wean herself off of them a couple days after the visit.
“We couldn’t just spontaneously drop by their house, even though they lived just an hour away,” she says. “If my husband needed to drop something off for them, I’d have to wait in the car, to avoid a reaction,” she says. “When we did visit them for an extended period of time -- like for the holidays -- we would have to stay in a hotel.”
Tran did try sublingual immunotherapy, a relatively new form of immunotherapy where small doses of certain allergens are given as a tablet under the tongue. But she found it hard to stick to the daily regimen, and she experienced side effects like itching. Her in-laws’ cats passed away several years ago, so that’s no longer an issue. Tran now avoids furry pets and treats her other allergic symptoms with Zyrtec and Singular.
What Treatments Are Best for Allergic Asthma?
The good news is there are better-than-ever treatments for allergic asthma out there, especially for very severe allergies like Tran’s, says Ryan Steele, DO, an allergist-immunologist at Yale Medicine and assistant professor of medicine at Yale School of Medicine in Connecticut. Most people with asthma need two kinds of medications:
Quick-relief medications. Known as bronchodilators, these are inhalers that are taken at the first sign of asthma symptoms to provide immediate relief. They allow more air to move in and out of your lungs to make it easier for you to breathe. There are two main types: short-acting beta2-agonists and anticholinergics.
Long-term control medications. These are the medications you take daily to keep symptoms in check and avoid asthma attacks. They include inhaled steroids like:
Antileukotrienes, or leukotriene modifiers, open narrowed airways while easing inflammation and mucus production. They tend to be less effective than steroids but are sometimes used in addition to inhaled steroids for more severe asthma. These include:
- Montelukast sodium
Long-acting inhaled beta2-agonists that work for at least 12 hours. Some also contain a steroid. These include:
What to Do When You Need More Options
For some people, these medications are enough to keep symptoms in check. But if you turn to your quick-relief medication more than two times a week or wake up at night with asthma symptoms at least two times a month, that’s a sign your asthma isn’t well-controlled, says Stanley Fineman, MD, MBA, an Atlanta allergist and spokesperson for the American College of Allergy, Asthma and Immunology. Other options include immunotherapy and biologics.
Immunotherapy, or allergy shots, may ease symptoms and lower the amount of asthma medication you take. It may be right for you if you have mild to moderate asthma.
“If you have more severe asthma, we don’t recommend it, because you’re at greater risk for an adverse response to the shot like wheezing,” Fineman says.
In that case, you may be a candidate for biologics. They’re considered cutting edge because they treat specific cells that lead to the allergic inflammation that makes it so hard to breathe.
“The hope is we can get a patient’s allergic asthma under good enough control that they then can become a candidate for immunotherapy,” Fineman says.
There are currently five biologic drugs available:
Omalizumab (Xolair). This drug targets a type of protein in the body called immunoglobulin E (IgE) antibodies that are high thanks to allergies. It works best in people who are allergic to year-round allergens like dust mites, mold, or pet dander. It’s given by injection in your doctor's office every 2 to 4 weeks.
Reslizumab (Cinqair), benralizumab (Fasenra), and mepolizumab (Nucala). These drugs work best for people with allergic asthma who have a certain type of severe asthma known as eosinophilic asthma (EA). They target a protein known as interleukin 5 (IL-5) and are given in a doctor’s office via an IV every 4 to 8 weeks.
Dupilumab (Dupixent). This drug is for people with very severe eosinophilic asthma, especially those who require daily steroid pills to control it. It targets two proteins, IL-4 and IL-13, and is given via IV or injection every 2 to 8 weeks.
“Over the last several years, the advent of some of the newer biologic medications has meant that many patients with severe allergic asthma have been able to get the condition under better control, even if they can’t get rid of symptoms entirely,” Steele says.
That’s reassuring news for Tran, whose 9-year-old son also has allergic asthma.
“Even though his symptoms are well-controlled now with Zyrtec and Singulair, it helps to know there are other treatment options if he needs them,” she says.
Nhi Tran, 43, Fairfield, CT.
Ryan Steele, DO, an allergist-immunologist at Yale Medicine and assistant professor of medicine at Yale School of Medicine in New Haven, CT.
Stanley Fineman, MD, MBA, an Atlanta allergist and spokesperson for the American College of Allergy, Asthma & Immunology.
UpToDate: “Patient education: Asthma treatment in adolescents and adults (Beyond the Basics).”
American College of Allergy, Asthma & Immunology: “Medication.”