Managing allergic reactions and anaphylaxis under daily antihistamines

[twinturbo]

I've spent the last... however long it's been, stabilizing DS2 from the steamroll of allergic reactions and narrowly headed off a near future failure to thrive and tube feeding Neocate. If we are even able to find out what allergen(s) were responsible it might not be for quite a while. For now we've had a few weeks without major reactions, he's taking Neocate orally. I'm not going to even go in to DS1 or my brain will explode.

Yesterday the local allergist came through on using daily Zyrtec to help with quality of life for DS2. He personally rewrote the embarrassingly illegible and inaccurate previous EAP that had come from his office via his assistant. He also went over in detail the results from our peanut component test and why it reads that he has had the opportunity to sensitize to peanut yet shows not allergic to it at this point in time.

Which brings me to daily Zyrtec, Benadryl and managing reactions including anaphylaxis. DS2's sensitivity is what the local allergist refers to as outlier, anomalous, he even uses DS2 as a anonymized case study for his in house residents. That surprisingly bummed me out because one of my kids is badly off enough to be an example case of incredibly low threshold, # of allergens, so forth.

Zyrtec could definitely increase his quality of life and I'm going with the idea of protecting skin integrity with a safe, effective, well studied antihistamine with no noticeable side effects in this 2 year old. Our newly clarified EAP calls for daily Zyrtec with the administration of Benadryl and epinephrine unchanged.

Any advice on the use of these specific antihistamines in managing FAs within these parameters? Biggest concern on my part is delaying epinephrine because I don't have experience with daily Zyrtec with my older child. I'm concerned if something makes it through the Zyrtec, e.g. I'm seeing hives, then is it time for epinephrine directly or is it reasonable to use Benadryl and go forth with EAP unchanged? Child is diagnosed speech delay so no help like, "My stomach hurts, lip tingles."

[CMdeux]

We've been down this road.

From a decade out...

yes, it's a worry-- but what we basically found is that it tamps down all of the "noise" sufficiently that it actually serves to metaphorically take a BIG scoop out of the top of that very full-full-full allergy cup.

What that means, basically, is:

a) yes, better quality of life, for sure, but also--

b) reduced need for other intervention meds long-term, since high enough doses of cetirizine have some demonstrated ability to prevent additional sequelae in the so-called allergic march.    Less lifetime need for steroids = excellence, bottom line, no?

c) less reactivity day-to-day, and maybe this could translate into a theoretical decrease in anaphylaxis... but this is putative only, and depends upon the poorly understood link that "priming" plays in triggering major reactions.  I will say that we've seen that be the case.  When we are assiduous about ceterizine, DD experiences vastly improved tolerance of the kinds of casual exposure that (as we both know all too well) are truly unavoidable. 

Oh-- and one more.  Less allergy symptoms daily also means fewer infections.   Strange but true.  Why?  Because sinuses aren't gooped up, fingers aren't wiping at a runny nose or itchy eyes all the time, etc. etc.  So less upper-respiratory and gastrointestinal illness, which ONLY improves one's ability to distinguish between reactions and illness, by the way.  Oh, and reduces the need for inhaled steroids to treat asthma from illness...  It also reduces hand-to-mucosa contact which reduces exposures from ultra-trace contaminated surfaces, I might add.  [Note to others-- the kinds of exposures that I'm talking about are the sort that 99.99% of people with a food allergy never even know are occurring, since they are so far beneath their reaction threshold... this is just NOT a big worry for most people with food allergies.]

We've still seen breakthrough symptoms-- both from contact and from aerosol exposures.  The nice thing, though, is that this basically just clears the noise-noise-noise from that basic signal.  If we SEE allergic symptoms, we KNOW to pay close attention.  It's likely to be something that needs addressing with interventions, if you KWIM.  Before, allergic symptoms were so frequent that the noise level tended to result in a much greater "wait and see" approach simply because we dealt with hives/puffiness/itchies/runny nose/irritated eyes SO often that it could (and often was) pretty much anywhere, any allergen, all the time.

Kids tend to lose peripheral reaction symptoms anyway by the time they are late elementary aged.  At least the super-reactors like yours and mine seem to.   

As for feeling awful because of being an "example to others" I hear ya.  It's not a good feeling to know that you're (or your child is) your highly expert specialist's vision of a "poster child" for the condition.     Got that teeshirt, too.

  On the bright side, when you've been with such a physician for a long time, you have a true partner in management.  That's priceless.  I've been moved to tears by how caring my daughter's allergist is, and how willing he is to help us obtain accommodations for her.  I'm not generally a person that puts other human beings on pedestals-- but I've got one for our allergist.  I openly hero-worship our allergist.     I wish that I could clone him and give him to everyone with food allergies. 

[twinturbo]

I'm going to hug my computer in an emo moment. Thank you, thank you, thank you.

Okay, a little more walkthrough though. Do we essentially do the Benadryl-EpiPen dance as if he hadn't been taking ceterizine? And oh boy how I know exactly what you mean on the endless full cup watch. You may have already answered this but my nerves might be taking over for fear of missing a reaction or not having the mouth streak warning.

Give me a 6 ft. 200+ lb. violent felon and I'm fine. Allergy watch in my baby then I buckle.

[CMdeux]

Yep-- with a kid like this, you just treat what you are observing in the moment.  At that point, OD-ing is the last on the list of concerns, basically.

Throw Zyrtec (nasonex, singulair, etc. etc.) on the "prophylaxis" side of things.

Now, on the "treatment" side, you have emergent meds like diphenhydramine (yes, it's an antihistamine, but the dosing window on antihistamines is VERY, VERY wide-- 'effective and safe' dose for most people is something in the neighborhood of up to 200% of recommended dosing... but obviously no advice is intended with that statement.  I'm just saying that we've done it.  With our physician's knowledge and approval.)

and epinephrine, obviously.  Oh, and bronchodilators. 

SO yes, it's the same basic decision tree as always.  You've just (hopefully) moved the starting blocks a bit.   

[rebekahc]

Yep, we've BTDT, too.  DS was diagnosed FTT at age 4 and had confirmed allergies to many foods with very low threshold on several of them.  We toyed with the idea of an elemental formula, but even that contained his allergens. 

I think part of your concern is that the Zyrtec might keep symptoms at bay so that by the time you see the hives (or other symptom) the reaction is pretty severe?  We have not found that to be the case.  It really helps to pinpoint the truly bad reactions.  If you see hives while on Zyrtec, they're still just hives.  It won't mask the symptoms or hide the onset of a reaction.  It might delay the onset of a reaction or raise DS's threshold and prevent some reactions, but as for treating the symptoms it would be the same as before Zyrtec - just hopefully much less frequently!

[eragon]

my son is currently on a mixture of daily anti histamines, he has been diagnosed with auto immune oedema. which means he randomly swells up, internally or on face.
basically he has a higher than normal amount of differing anti histamine, which dont recognise each other, so theres an ongoing war running through his veins.
Our treatment plan for flare ups is to throw more antihistamine at him. which is fine by us!

certainly his quality of life since he was young has been improved with antihistamines for the reasons CM mentions.  getting control of allergies in this way can  really make a difference with quality of sleep  which has links to growth, and ability to concentrate and learn at school.

antihistamines have a pretty safe record or so I have been told by immunologists.

[joanna5]

D has been on daily Zyrtec for ages and for us, it didn't change anything else in our allergy plan.  We use Epi/Benadryl with no regard for the Zyrtec.  His allergist said what CM2 said- the dosing window is so high that using both Benadryl and Zyrtec is not an issue. 

[twinturbo]

Thank you all, each and every one of you.

[my3guys]

D has been on daily Zyrtec for ages and for us, it didn't change anything else in our allergy plan.  We use Epi/Benadryl with no regard for the Zyrtec.  His allergist said what CM2 said- the dosing window is so high that using both Benadryl and Zyrtec is not an issue.

Two of my kids are in the exact same boat.  They need the daily zyrtec.  One DS has had a few reactions over the years, and they were clearly recognizable with the daily zyrtec.

[candyguru]

My daughter takes 2.5 ml of cetirizine daily as well.  We increase to 5 ml on bad pollen/mould days.  Winter is the only time she does not need daily cetirizine