What Went Wrong-

Why Do We Have Allergies 2: What Went Wrong?

We Are Not Alone

If you are looking for a trendy term to impress your friends or co-workers, try microbiome. The microbiome refers to the fascinating world of microorganisms (bacteria, viruses and fungi) that not only fill every nook and cranny of the planet we live on but also every nook and cranny of our own bodies.

By some estimates, we have as many microbes living in our bodies as we do our own cells. (Wouldn’t that be a cool fact to throw out at a dinner party?) For the most part, those microbes living in and on our bodies share a symbiotic relationship with us, meaning they help us and we help them. Supposedly, my dog and I share a symbiotic relationship: I provide him food and shelter and he, well… he hangs around the house looking cute and chewing up my shoes and socks.  (Come to think of it, this may be more indicative of a parasitic relationship.)

Not only do the microorganisms in our body help us digest our food, produce vitamins and help fight off infection, they play an important role in regulating our immune system. From infancy on, these single-celled animals communicate with our immune system and explain the ways of the world to it. It is believed that this early-life education is essential for our immune system to grow up and act appropriately: attacking bad guys – like the measles virus – and not reacting with good things like breakfast or the dander from the sock eating dog.

Of course, the process of this early-life microbial education can involve infection.  And yet, these are usually not life threatening infections, and the end result is a strong, wise and well behaved immune system.What Went Wrong- (1) 2

We No Longer Live in the Garden

Getting back to the question of what went wrong to cause us to have allergies, one of the theories is the hygiene hypothesis which proposes that our immune system is adapted to an environment that – at least for people living in Ahwatukee and most of the westernized world- no longer exists.   At one time in our history, our environment was much more complex and diverse from a microbial point of view with exposure to farm animals and other elements of a farming environment as well as large families with lots of runny-nosed siblings to play with. The hygiene hypothesis was proposed in 1989 when researchers noticed that children who grew up on farms or who came from large families with lots of siblings had fewer allergies.

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The explanation? Progress and myriad changes associated with modern life such as a decrease in natural birth deliveries, antibiotic use, lack of breast-feeding, pasteurization, Lysol in every kitchen and bathroom, and antimicrobial everything (hand wipes, mouth wash, soaps, detergents) – not to mention a noticeable lack of cows, chickens, and pigs in the yard -reduce an infant’s exposure to the wise microbe masters that once kept or immune system from going down the path of the dark side.Untitled design (58)

Just as children who grow up in an overly protective, sterile, and restrictive parental environment may have difficulty coping with challenges later in life, our pampered undirected immune system may react inappropriately.

The unintended consequence of our quest to control everything has been the emergence of allergy and other chronic inflammatory diseases.  Who knew?

Now that we are beginning to understand why we develop allergies, the big question is how to fix it.  Allergy immunotherapy or desensitization is essentially a way of re-educating the immune system to behave more appropriately towards our environment.   It is not a quick fix, but the end result can be life-long immunity to things we are allergic to.  New forms of immunotherapy are in the works that combine conventional immunotherapy with elements of the microbiome to mimic the type of early-life training that has been lost (along with paradise).

Brian Millhollon, MD

 

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Why Do We Have Allergies?

When scientists set out to understand a challenging and complicated problem they frequently construct models to help the process of discovery. Models help us to visualize the big picture, and to see how individual pieces of information fit together. This is true when we try to understand allergy.

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Our immune system is a particularly complex bit of machinery. Its job is to monitor our internal and external environment, and when it detects a problem, eliminate the danger.   It vigilantly looks out for an attack from pathogenic microbes such as bacteria and viruses, injury from various toxic substances, and cancer cells trying to get a foot hold.

When the immune system finds a problem it deals with it through a process called inflammation. Inflammation is what we experience when our immune system is doing its job; or at least believes that it is doing its job.

When we get a fever, snotty nose, and cough with a cold, these symptoms are not caused by the virus but by our immune system fighting the virus. Good thing too, because without that snotty nose the only thing we may feel is the virus eating our brain.

BaileyBio.com

When we get a thorn in our foot, the irritation, itching, redness and swelling in the area is a result of inflammation. Inflammation increases the blood supply to the area and makes the blood vessels leaky so that antibodies, blood clotting chemicals, and white blood cells can rapidly move in. The pain and itching we feel is to alert us to the thorn so that we will stop walking on it and try to get it out.

We would not last long without our immune system doing its job through inflammation, but sometimes our immune system does things that appear to have no point and seem to cause more harm than good.

The reality is, a significant percentage of the chronic medical conditions we suffer from fall under the category of chronic inflammation of unknown cause or, put another way, unknown purpose. What is our immune system thinking?

A variety of devastating autoimmune diseases such as rheumatoid arthritis and lupus certainly fit into the category of chronic inflammation with unknown purpose, but so does some neuro psychiatric and neuro degenerative diseases (such as muscular sclerosis) and of course, allergy.

What But Not Why

In medicine we are pretty good at answering the “what” questions, such as: “What chemical in the skin causes the itching and swelling when you break our in hives?” Or, “What white blood cells cause an asthma attack?”  In fact, I have many big textbooks with pages of explanations and diagrams showing how our immune system reacts with harmless things like breakfast or the family dog to cause allergy misery. TEXT HERE (1)
But to many, myself included, the more pressing question is “why?”.  Why hives?   Why asthma?  Why lupus?  Our sophisticated, highly developed immune system reacts, at times violently, to things that we eat, breathe or touch.  Things that are, to the best of our knowledge, harmless.

A simple answer to these  “why?”questions about the elusive and baffling world of chronic inflammatory disease would be to say that it is a mistake.

A very big mistake.

Millions of dollars spent on medications and doctor visits, time lost from school, work, and play, and even lives lost because of an error?

What Went Wrong and Who is To Blame?

We don’t have clear answers but we do have a large body of emerging data from research that presents some intriguing clues. In the next post (here) I will discuss a few of the current theories and models that are being proposed  that will hopefully help us to unlock the mystery of “why?”.

Brian Millhollon, MD

Picachu

Pokemon Allergy

It is not every day that a physician from a small town like Ahwatukee gets to discover a new disease.  But this is just such a day and I would like to take this opportunity to announce the first reported case of Pokemon Allergy ©.

The discovery began when a young man came to our allergy clinic complaining of itching and rash of the lower legs.  The rash was not severe but the itching was quite annoying and he found himself scratching his lower legs so much that the thin skin above the shins was raw and bleeding.

My first thought was a contact allergy and so I questioned. “Have you been exposed to any new products?   Sun screens, lotions, soaps, chemicals?”

He had not.

“How about something where you work?”

He worked in an office, sitting most of the day at a desk entering data in a computer and nothing in that environment had changed recently.

“Do you have any new hobbies or participate in sports?”

Like a lot of young adults, his primary hobby (and sport for that matter) was playing computer games.  He was good at it and spent a great deal of his free time indoors on the computer. That environment had not changed either.

That’s when a chance comment about his gaming activities caught my attention.

“I have started playing a new game.  It’s called Pokemon Go.”

“Actually it’s not new.  My brothers and I used to play it all the time as kids. Back then our parents would drive us all over town to buy packs of cards that had pictures of these mythical, cartoon-like characters called Pokemon. The point was to collect all the characters, but some were rare and took a long time and a lot of work (and gas) to collect.

Pokemon Desert Foothills park ahwatukee

Pokemon Hunting Desert Foothills Park Ahwatukee

Now the game is played with a smart phone and the characters are virtually located all over the place –  parks, parking lots,  stores, on the side of the road; even in people’s houses. The most popular place to find them is in community parks.   I would go out to Desert Foothills Park to hunt for Pokemon at 11:00 at night and see hundreds of kids and adults walking around the park, staring at their phones like zombies.”

“Wait. You said walking around in the grass at night for hours.  Did the rash start before or after you started playing Pokemon Go?”

“About the same time.”  He said.  “Could it be related?  How?”

“Well, Bermuda grass causes a lot of allergy problems.

Bermuda Grass flower

Bermuda Grass flower

It is the most common grass grown in Arizona in the summer and likes to release pollen from it’s whirlybird-like pollen stalks during the cooler temperatures at night and early morning.  Although most people who are allergic to the grass will have respiratory symptoms such as sneezing, itchy, watery eyes, nasal congestion and even asthma, high levels of skin exposure  – which could occur when walking in the grass in shorts and sandals – can also cause a contact allergy with itching and rash.  I think this may be it”

It was.

The treatment for Pokemon Allergy?

Although strict Pokemon Go avoidance would no doubt bring about a rapid cure, the substantial health benefits derived from playing the game (spending time out of doors, regular exercise, face-to-face social interaction) in my opinion, make this option less desirable.   Instead, I recommended wearing shoes and long pants and showering after sessions, at least until the winter.

On a recent follow-up visit, the rash had resolved.  He was enjoying his new found life out of his room in front of a computer so much that he started running and hiking for exercise, entered triathlon races, quit his boring job, and enrolled in optometry school.  I never dreamed there would be an app for that.

Brian Millhollon, MD

 

 

Nairo Quintana 2

Loosing the Tour de France Because of Allergies

I could not pass up the opportunity to comment on a news item that combines two of my favorite subjects: allergy and cycling.

The Tour de France – arguable the hardest endurance sporting event in the history of particularly hard sporting events – concluded this week.  “The Tour” is a three week long cycling race.  Participants ride more than 4-5 hours a day, distancing more than 100 miles, up and down mountains, in freezing rain and gale force winds, at a pace that burns a mind boggling 8000 calories each day. Most adults would consider any work-out that consumes more than 500 calories to be an exhausting challenge.   Needless to say the event includes some of the strongest athletes in the world.Untitled design (53) 2

Two men were favored to win the tour this year: Chris Froom (two-time winner and defending champion) and a young columbian rider, Nairo Quintana.  Unfortunately, although eventually taking third overall  (Chris Froom finished first), it was clear that Nairo was struggling and riding well below his -and his fan’s-expectations.

When asked about his difficulties, this is what Nairo had to say:

“It’s not fatigue that I’m feeling, but still, the body isn’t responding. It could be some sort of allergy I’ve got at the moment because my legs aren’t getting enough oxygen. “It could be some sort of allergen in the area that’s been affecting me these last few days. I hope with the rain that is coming in these next days I can keep it at bay.”

Although some may find watching a four hour bike race a bit boring, I am mesmerized by the scenery as the cyclists sale through the countryside of France and into the alps or the Pyrenees mountains bordering Spain.   Untitled design (54) (1)The dreamy state of captivated longing as the peloton winds through river valleys, past medieval castles,  across fields of sunflowers and mountain meadows, is acutely enhanced by the fact that the tour takes place in July. In July the “countryside” of Phoenix is looking a bit scorched after more than a month of  115 + degree days and 100 degree nights with very little rain.

With the record-breaking heat comes very low pollen counts – the plants have a hard enough time surviving much less reproducing – but you could image a very different story in the spring like weather in the mountains of France.  In fact, it is likely that these areas are experiencing their peak allergy season.  Which is why I think Nairo Quintana’s assessment of the source of his struggles has merit.

So how can allergies adversely affect an athlete’s performance?  Here are a few thoughts:

  • Allergy is the primary risk factor for asthma and asthma can certainly have a significant negative impact on any athlete participating in an aerobic sport.
  • Allergies can disrupt sleep and if there is anything that a Tour de France rider needs during a month long bike race is adequate sleep.
  • Energy that the body spends dealing with allergies means less energy available to ride your bike up mountains and sprint to the finish line.
  • Mouth breathing because your nose is congested from allergies means that you loose the conditioning and filtering affect of the nose.  This can lead to increased irritation of the upper and lower airways as well as the  lungs
  • Medications taken for allergy symptoms such as antihistamines and decongestants can negatively impact performance.

Possible the best treatment option for athletes who suffer from allergies (besides staying home) is allergy immunotherapy.  Immunotherapy prevents the allergic response from occurring (rather than treating symptoms after the fact) so that the risk of asthma is reduced, sleep disruption, energy loss, and mouth breathing do not occur and the need for medications is eliminated or significantly reduced.

Hopefully, Nairo Quintana will look up a good allergist when he gets home to Columbia so that he can give Chris Froom a run for his money next year.

Brian Millhollon,MD

 

apocalypse gas mask

Brown Cloud of the Apocalypse

It’s monsoon season in Arizona and this is what my phone screen has looked like for the past several days.

Dust Storm Alert

 

 

 

 

 

 

 

 

 

 

 

And this is what all the fuss is about.
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From an allergy perspective, monsoon season is a mixed bag.

On the positive side, monsoon moisture and rain removes the dust and pollen that tends to hang in the air forever when the air is dry.  Also, the damp ground is less likely to be picked up by a dust storm, carried across the valley and dumped in your pool (and lungs).

On the negative side, monsoon storms pick up an incredible amount of dust which is carried across the valley and dumped in your pool (and lungs).

Ozone and particulates are the primary contributors to air pollution in Phoenix and both can reach unhealthy levels in the summer.  Particles of organic and inorganic mater small enough to stay suspended in the air and also small enough to travel deep into the lungs when inhaled are the visible danger when dust storms blow through the valley.  Ozone is more insidious but a serious risk for people with heart and lung disease.

This is an excerpt from the Arizona Department of Air Quality forecast for today and yesterday showing the ozone and particulate levels and a comment:Untitled design (50) (1)

“Circling back to ozone…lack of daytime cloud cover and light winds, until outflows from the north came, gave ozone a serious boost in the afternoon hours Wednesday. Seven monitors did exceed. An Ozone High Pollution Advisory remains in effect today and will be extended through Friday” .

The air quality forecast warning suggests that “sensitive groups” (which would be most of our patients) and active children and adults (which is most everyone else) should limit time spent out of doors, particularly if your activity calls for breathing.

If you would like to learn more about air pollution and ozone in Arizona you can find it here and here.  Information about air pollution and exercise in Arizona can be found here.

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Food Allergy for Beginners: Sugars

What is a Sugar?

Sugar is one those loaded words that can have a variety of  meanings.  For example sugar can mean sucrose, the white granules you put in your coffee, or it can refer to the level of glucose in your blood, as in: “I need to up my insulin because my blood sugar is sky high after putting all that sugar in my coffee”.

Sugar can also refer to carbohydrates (“carbs”), one of the three categories of chemicals, along with fats and proteins, which make up the food we eat.

Carbohydrates can be single molecules or joined together to form large chains.  Single molecules are called monosaccarides and include glucose, galactose and fructose. Any two of these simple sugars combined are called disaccharides. For example, sucrose (table sugar) is a disaccharide combing the two simple sugars glucose and fructose. Lactose is a disaccharide containing glucose and galactose. Polysaccharides are long chains of monosaccharide joined together and are used in plants and animals for structure and storage. Sugar is stored as starch in plants and as glycogen in animals.

Monosaccaride - glucose

Monosaccharide – glucose

Disaccharide Sucrose

Disaccharide Sucrose

Polysaccharide

Polysaccharide Starch

Sugars can combine with proteins to form glycoproteins and with fats to form glycolipids.

It’s All About Glucose

Glucose is our body’s primary source of energy and also the primary product of photosynthesis, the process in plants that turns sunlight into food.  Most of the carbohydrates that we eat are converted to glucose during digestion. We crave sweet things because they usually contain lots of simple sugars that require very little or no work to convert to glucose. Most of the cells in our body can run on either glucose, fats, or proteins but the brain needs glucose to work.Glucose metabolism

Can You Be Allergic to Sugar?

The short answer is no. Simple sugars and disaccharides such as sucrose and lactose are not allergens and cannot cause true allergic reactions.

However, people have become allergic to glycoproteins, sugars combined with proteins. An example of this is allergy to galactose-alpha-1,3-galactose, also know as alpha-gal.   Alpha-gal is a common glycoprotein found on all animal cells except humans and primates and those sensitized can have allergic reactions to a variety of meats including beef, pork, and lamb.   Interestingly, a large number of alpha-gal allergic patients developed symptoms after being bitten by a tick, particularly the lone star tick found in the Southern and Eastern United States. Skin testing to meat and a blood test for allergic antibodies to alpha-gal can make the diagnosis.

Lactose Intolerance

Although sugars rarely cause true allergic reactions, they are a common cause of food intolerance. Because the cells in our body can only use glucose for fuel, all complex sugars (disaccharides and polysaccharides) have to be chopped-up or digested to make the glucose available. To do this, we produce enzymes that make the process of digesting the complex sugars possible.   Many of these enzymes are specific for a particular type of sugar. For example lactase is the enzyme that facilitates the break down of cows milk sugar (lactose) to yield glucose and galactose that is then easily absorbed into circulation to be used as fuel.

Without lactase the milk sugar passes intact into the colon where it provides nutrition for colonies of fermenting bacteria. These bacteria feed on the sugar and as a by-product, produce a large amount of methane gas and fluid retention causing intestinal bloating, cramping, and gas.   Treatment is avoidance of all mammalian milk and/or taking supplemental lactase (Lactaid) whenever milk products are consumed.

In summary, true allergic reactions to carbohydrates are rare while food intolerance, such as lactose intolerance, are more common.  Other problems associated with sugar (i.e., how to say,  “No thank you” to that cheese cake) is an important topic, although – except as a fellow victim- a bit out of my area of expertise.

Brian Millhollon, MD

chick-fil-a peanut

Food Allergy for Beginners: Fats and Oils

As discussed in the previous article (Food Allergy for Beginners: Proteins), primarily it is protein in foods that causes the majority of allergic food reactions. Our diet also contains fat (oils) carbohydrates (sugars), and minerals but these rarely cause true allergic reactions.   This is an important point because many oils, such as peanut oil, are made from very allergenic nuts or seeds.

Is peanut oil safe to eat if you have a peanut allergy?

The answer to this question depends on the type of processing used to extract the oil.

Most vegetable oils used for cooking are produced using an extensive multistep mechanical and chemical process that begins by heating and crushing the seed or nut.   The oil is then extracted using the chemical hexane. Additional steps may include adding acids and steam distillation. The final product contains so little protein that the FDA does not require oils processed this way to be listed as a potential cause of allergic reactions.

Chick-fil-a, a fast food chicken chain, uses peanut oil and posts the following information about food allergies:

     “Chick-fil-A(r) cooks in 100% refined peanut oil. According to the FDA, highly refined oils such as highly refined soybean and peanut oil are not considered major food           allergens and therefore are not listed here”

Oils may also be extracted from nuts and seeds using only mechanical press without heat or chemicals.   This method produces much smaller amounts of oil but the oil produced retains more of the natural flavor and also may contain significant amounts of protein.  For this reason, contact with cold pressed oils can cause allergic reactions if you are allergic to the nut or seed used to produce the oil.Untitled design (42) (1)Untitled design (43) (1)

Storm Trooper Food Allergy

Food Allergy for Beginners: Proteins

A Few Introductory Facts

  • Living things, including you and the food you eat, are made up of proteins, fats, sugars (carbohydrates) and minerals.
  • For the most part proteins – not sugars, fats, or minerals- cause food allergies.
  • Proteins are like Lego creations. They are large, complex structures made up of a slew of small, simple units (amino acids) stuck together.
    Amino Acid

    Single Amino Acid

    Protein Structure

    Protein Structure containing hundreds of amino acids.

     

  • A Millennium Falcon made out of red, green, yellow, blue, and white Lego pieces put together in a particular way “looks” like a Millennium Falcon.

Mellinium falcon lego

 

  • A pile of colorful, unconnected Lego pieces does not.

 

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  • Our immune system “sees” protein like we see a Lego-block Millennium Falcon, It does not recognize unconnected amino acids.
  • To stay healthy your body needs amino acids from the food you eat. It does not need intact proteins.
  • If your immune system decides that proteins looking like the Millennium Falcon are a threat, it may launch an attack with sophisticated weapons that go off when in contact with any Millennium falcon-looking food taking you down the dark path to… Allergy!

 

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Steroid Devil

Steroids: Angel or Demon?

Steroids Everywhere

If you have suffered with allergies or asthma for any time, you have likely been prescribed a steroid medication of some kind, either as a steroid nasal spray, a steroid inhaler, a steroid eye drop, a steroid cream, or even a steroid tablet or injection.

Are all these steroids safe?   Don’t they have a lot of side effects, cause woman to grow beards, athletes to hit home runs or go berserk, and make you fat?

A Brief Biochemistry Review

Steroids are a class of chemicals produced naturally by plants and animals.  There are hundreds of different steroids but in humans they fall into three general categories:  sex hormones, corticosteroids, and anabolic steroids.

The sex hormones include testosterone and estrogen and orchestrate much of our lives, often without us knowing it.

The anabolic steroids are a class of synthetic (man made) chemicals with properties similar to testosterone – both the good and the bad.

The corticosteroids include chemicals related to cortisol, an important hormone produced naturally by our adrenal glands and the only steroid class used to treat allergies.

Dealing with a Bad Day

Cortisol is a stress hormone; it’s job is to help us deal with stressful events in life. This stress response begins in a part of the brain called the hypothalamus.  When it senses stress or believes that it needs to get you ready for something stressful, the hypothalamus produces corticotrophin releasing hormone or CRH.  CRH tells the pituitary gland (the master control gland) to wake the adrenal gland up and get to work making more cortisol.   This link between our brain and adrenal gland is called the HPA or hypothalamus-pituitary-adrenal axis.

The HPA plays a very important role in helping us deal with life, from the day-to-day stress of just getting up in the morning to facing the trauma of a major illness or injury.

Cortisol To The Rescue

In fact, one of the most important jobs for cortisol is to regulate our immune system’s response to a serious illness.  Inflammation is the body’s way of dealing with injury and infection.  When we are fighting an infection, the inflammatory response recruits a powerful army of weaponized cells that search out and destroy an invading pathogen with an arsenal of deadly chemicals.  In injury, inflammation increases blood flow to the injured area and allows healing and clotting factors in the blood to move to the injured part (this is why an sprained ankle gets red and swollen). We could not survive without the armed forces of our immune defense and yet these same weapons can injure us if not carefully kept in check.  This is the role of cortisol.

Cortisol keeps inflammation from getting out of hand.   Inflammation that is inappropriate and gets out of hand is a pretty good definition for allergy. Wouldn’t it be nice if we had a medicine that could control this inappropriate inflammation?    Once we realized that our bodies were already making the perfect treatment for the problem of allergy, it was not long before the world of steroid medications was born.

The good news is that because our immune system is designed to be regulated by cortisol, corticosteroids are some of the most powerful medications currently available for the treatment of allergies and asthma.

The bad news is that our bodies are not designed to experience high levels of corticosteroids for more than a few days.  Some of the effects of cortisol that are likely beneficial during brief periods of extreme stress, such as regulation of fat and sugar metabolism, can cause excessive weight gain and problems with diabetes if used in high dose on a daily bases to control a chronic disease.

Topical use of a corticosteroid such as in a nasal spray, asthma inhaler, or cream, can have the same beneficial anti-inflammatory effect with minimal systemic  side effects.  High doses of topical steroids can still be a concern in some individuals, particularly children, were even small amounts of absorbed corticosteroid can have an effect on growth.  In all cases, the minimal amount of steroid for the shortest amount of time required to control symptoms is the goal.

Sneezing

Over The Counter Allergy Medications

You feel miserable!

Your eyes are so itchy that you have rubbed them raw and you have fits of sneezing so violent you are afraid you have permanently damaged your ears.  Mucous drips on your keyboard while you try to work and you can’t sleep or taste your food because your nose is plugged shut.   Your mouth is so dry from mouth breathing that it feels like a small furry mammal has taken up residence.

You need relief but you are too busy to get in to see a doctor or the next available appointment is not until the allergy season will be long over.

You might be asking: “What can I get at a local Walgreens, CVS, or Costco that will give some relief?”

Here are a few suggestions:

Antihistamines

Get Zyrtec 10 mg (cetirizine) or Allegra 180mg (fexofendine).  Do not get the “D” version of either.

Zyrtec is best but can make you a little drowsy so be careful at work or school or if you will be driving.  Allegra works well and will not make you drowsy but is a pretty big pill to swallow.  These will help the sneezing and itching and to some degree the dripping.   They will not unstuff your nose.

Nasal Steroids

Yes it’s a steroid…however it is topical with very little systemic side        effects, and is the only thing that will safely unplug your nose.   (Read more about steroids)

No nasal steroid works quickly; it will be several days to a week before you see improvement and you have to use them every day.   Flonase (fluticasone) and now Rhinocort (budesonide) are the best.  They both have a smell but neither is deal breaker.  All nasal steroids can cause burning and possible a bloody nose with regular use.  They should not be used in children under 12 without checking with a doctor first.

Eye Drops

Naphcon A works quickly and will temporarily relieve the itching and redness.  Any topical medication with a decongestant (like Naphcon) can cause rebound issues if you use it daily for more than about a week.   For symptoms lasting longer than that, you are much better off getting a prescription eye drop.

Oral Decongestants

Decongestants have issues.  For any but short term, as needed use, the side effects can outweigh the benefits.   There are only two decongestants still on the market: pseudoephedrine and phenylephrine. Pseudoephedrine (Sudafed) is considerable more effective than phenylephrine, which many believe to be so under dosed in the OTC products that it is not much better than placebo.  Pseudoephedrine is now a controlled medication so you can only get a few at a time and you have to sign for what you get.  Oral decongestants can cause cottonmouth, raise your blood pressure and heart rate, keep you up at night, and make it hard to pee (particularly if you happen to have a prostate).

In my opinion, decongestants are more helpful for cold and sinus symptoms.  In fact, OTC medications that use the words, “cold and sinus”, typically contain a decongestant and medications that use the word “allergy” usually contain an antihistamine.

If medications are not helping or if you are wondering if there is an alternative to having to take medications (OTC or otherwise) for the rest of your life, it is time to make an appointment with an allergist.

I just might know one to recommend.