CHAPTER 37 • ALLERGIC DISEASES IN ATHLETES 223- The USOC is much more stringent. All sympath-
omimetic-containing medications are banned. Antihi-
stamines are allowed in all but the shooting sports in
which they are completely banned. While the USOC
does not restrict cromolyn or leukotriene receptor block-
ers, written permission should be obtained for nasal or
inhaled steroid use (Fuentes and Rosenberg, 1999).
ALLERGY TESTING
- In patients with a history suggestive of allergic rhini-
tis, indications for referral for skin testing include tar-
geting allergens for avoidance as well as institution of
immunotherapy when medical therapy is failing.
Allergy consultation is recommended prior to drastic
environmental interventions such as pet elimination,
taking up carpets, or purchasing new mattresses, bed-
ding, dust mite covers, and the like. - Antihistamines should be stopped 1 week prior to
testing so as not to blunt the cutaneous response to
skin testing. - Allergy testing is contraindicated in the setting of
severe lung disease or poorly controlled asthma with a
FEV1 (forced expiratory volume in 1 s) less than 70%. - Skin testing is preferred over in vitro radioallergosor-
bent testing(RAST) because it is more sensitive. In
vitro RAST is helpful for validating the diagnosis and
supporting environmental controls. It is a reasonable
alternative when skin testing cannot be performed.
ALLERGEN IMMUNOTHERAPY
- Allergen immunotherapy (AIT) is effective for allergic
rhinitis and allergic asthma. Advantages include long
lasting symptom remission and reducing the risk of
developing new allergies and asthma in children
(Ledford, 2000). Notable symptom relief usually
takes several months of treatment. Three to five years
of AIT is required to sustain symptom remission. Any
individual who cannot fully commit to treatment, has
poorly controlled asthma, or is on a beta-blocker
should not receive AIT. It should be prescribed and
administered by a board certified allergist to ensure a
thorough discussion of the benefits and potential risks
of therapy and to provide ongoing follow-up.ALLERGIC CONJUNCTIVITIS- Etiology is the same as for allergic rhinitis. Symptoms
occur on inoculation of the allergen onto the mucosa
of the eyes. - Symptom control can be achieved with the same meas-
ures as discussed with allergic rhinitis. Persistent eye
symptoms may require targeted ocular medications
(see Table 37-3). Combination mast cell blocker and
antihistamine topical therapy is very effective. Other
options include topical mast cell blockers or antihista-
mine alone, topical decongestants, and topical mast
cell stabilizers. Topical corticosteroids are associated
with significant complications and should only be used
after consultation with an ophthalmologist.
URTICARIA AND ANGIOEDEMAPATHOPHYSIOLOGY- Urticaria is caused by mast cell degranulation in the
superficial dermis and is characterized by pruritic,
erythematous, cutaneous elevations that blanch with
pressure. Hives may appear anywhere on the body, but
occur primarily on the trunk and extremities. Mast
cell mediators involved include: histamine, prostag-
landins, leukotrienes, platelet activating factor, ana-
phylatoxins, bradykinin, and hageman factor. All
cause blood vessel dilation and tissue edema. - Angioedema is similar to urticaria but occurs in the
deeper dermis and subcutaneous tissues. It is more
painful and burning than pruritic and often involves
the face.
TABLE 37-3 Allergic Conjunctivitis Topical Medications
TOPICAL AGENT MECHANISM OF ACTION DOSE
Patanol (Olopatadine) Mast cell blocker/antihistamine 1 drop bid; age > 3
Zaditor (Ketotifen) Mast cell blocker/antihistamine 1 drop bid to tid
Alomide (Lodoxamide) Mast cell blocker 1–2 drops qid
Alamast (Pemirolast) Mast cell blocker 2 drops qid
Alocril (Nedocromil) Inhibits activation and mediator release 1–2 drops bid
from inflammatory cells
Livostin (Levocabastine) Antihistamine 1–2 drops qid
Emadine (Emadastine) Antihistamine 1 drop qid
Optivar (Azelastine) Antihistamine 1 drop bid
Crolom (Cromolyn): Mast cell blocker 1–2 drops 4–6 times/day
Naphcon A, Opcon A, Antihistamine/Decongestants Up to qid
Vasocon A, Visine A