Posts by Dr. Michael Manning, M.D.:

Allergy Shots or Drops: Besides the Obvious, is there a Difference?

Comments Off on Allergy Shots or Drops: Besides the Obvious, is there a Difference? Written on October 1st, 2014 by
Categories: Allergies, Allergist, Allergy Advice, Allergy Articles, Allergy Shots

What are the treatment options for documented allergic disease?  If you do not know what the facts are, the answers can be very confusing.  When treating hay fever or allergic rhinitis, asthma and sometimes eczema, there are three main categories of treatment options.  First, one should always try and avoid any offending allergy triggers.  Second, there are a variety of medications that may be effective.  Lastly, allergen immunotherapy, also known as allergy shots, can be instituted if the first two options are ineffective.  So where does allergy drops fit in, if at all?


Allergy drops, or more properly known as sublingual immunotherapy (SLIT), are a form of allergen immunotherapy developed in Europe.  The purpose of sublingual immunotherapy is the same as traditional subcutaneous immunotherapy (SCIT) or allergy shots.  Subcutaneous immunotherapy works by readjusting or rebalancing the immune system so that it stops reacting to allergy triggers.


When someone is allergic his or her immune system has made an allergic antibody to a pollen, dander or mold.  This antibody, when exposed to the allergen, starts a reaction that ends with the symptoms of hay fever or asthma, such as runny nose, nasal congestion, and watery itchy eyes, coughing or wheezing.  This is actually an over-active immune system.  Therefore the goal of subcutaneous immunotherapy is to calm down this over-active immune response.  For allergy shots to work, the patient needs to be allergic to substances that are appropriate for allergen immunotherapy.  The allergy shot serum should include the allergens the patient is allergic to and not include the ones that they are not reactive to.  This means the serum should be customized to each patient.  Also, the serum must be mixed correctly in that certain allergens cannot be put together in the same serum as they degrade each other.  This process takes time but is the best long-term solution to control allergies.


Sublingual immunotherapy has the same biological effects as subcutaneous immunotherapy.  This was refined in Europe and has shown excellent benefit when used in the appropriate patient.  Sublingual immunotherapy works best in those individuals that are not allergic to a lot of different allergens.  Currently there are no FDA approved sublingual extracts or serum in the United States. This also means that insurance companies will not cover sublingual immunotherapy. Studies to obtain FDA approval are ongoing.  When FDA approval is obtained, sublingual immunotherapy will be an appropriate treatment option for the control of allergic rhinitis or hay fever and asthma.


So what is the problem?  Unfortunately, there is a lot of misinformation about sublingual immunotherapy.  Many practitioners advertise drops as being safe with no potential for systemic or severe reactions like can be seen with subcutaneous immunotherapy.  This is not true.  Systemic reactions can occur with sublingual treatment therefore care must be taken when sublingual immunotherapy is started and advanced. Local reactions in the mouth, throat and stomach also occur. Sublingual immunotherapy, when it obtains FDA approval, needs to be performed under proper supervision by a physician specifically trained in allergy and immunology.  Also, like subcutaneous immunotherapy, sublingual extracts should be customized for the patient.  There is no one drop fits all.


When sublingual immunotherapy receives FDA approval, it will be an added treatment option for patients with allergic rhinitis or asthma.  If avoidance measures and medications do not adequately control symptoms and the patient is only allergic to a few allergens, then sublingual immunotherapy may be the next step in treatment.  In patients who fail to respond to sublingual immunotherapy or who react to a multitude of allergens, then traditional subcutaneous immunotherapy would be the best option.  Until that point, make sure your treatment program is appropriate and backed by scientific study.



Valley Fever: What In The Haboob Am I Talking About?

Comments Off on Valley Fever: What In The Haboob Am I Talking About? Written on July 22nd, 2014 by
Categories: Allergies, Allergy Advice, Allergy Articles, Asthma, Asthma Articles, Valley Fever

Who can forget the Great Haboob on July 5, 2011? Beyond all the mess that was left behind to clean up, what else did that big dust cloud give us?  It gave the car wash industry a tremendous boost.   The Haboob has also blown in concerns over an upsurge in cases of Valley Fever.  What exactly is Valley Fever and what does the Haboob have to do with it?

Valley Fever is the common name for Coccidioidomycosis, an infection caused by fungi known as Coccidioides.  This fungus is found in the soil in certain lower deserts of the desert southwest including southern Arizona, south and central California, southwestern New Mexico and west Texas.  It can also be found in parts of Mexico and Central and South America.  The name Valley Fever is actually the shortened older name for Coccidioidomycosis, which was San Joaquin Valley Fever.  The association between the disease and the causative agent was made in the San Joaquin Valley in California.

Now what does a dust storm have to do with Valley Fever?  As I mentioned above, Valley Fever is caused by a fungus, or mold, that lives in the ground or soil here in the Valley of the Sun. Coccidioides grows as a mold a few inches below the surface of the desert soil.  During dry conditions the mold becomes fragile. Even slight air disturbances can fracture the mold into single-cell spores that are 3-5 microns in size and can stay suspended in the air for prolonged periods of time. The spores become suspended in air during times of digging such as landscaping, construction of homes and with big dust storms. Humans, and animals such as dogs, may contract the fungus by breathing when the fungal spores are suspended in the air. Once the spores get into the lungs, they change shape and enlarge sometimes as big as 70 microns or more in diameter.  They continue to grow and eventually lead to the clinical infection known as Valley Fever.  Once the spore fragments are in the lungs and change shape, they cannot be spread from person to person.  Therefore, this is not a contagious disease. This disease can occur after inhaling just one of the single cells.  We are expecting to see a dramatic increase in the number of Valley Fever cases following the Haboob-an intense dust storm that surely suspended millions and millions of Coccidioide spores for a prolonged period of time.

The risk of exposure in the endemic areas varies but is highest during dry periods that follow rainy seasons.  In Arizona these periods tend to be from May thru July and then again from October to early December.  It is estimated that 60 percent of the coccidioidal infections in the US occur in Arizona in the counties of Maricopa, Pima and Pinal.

With all this ominous news, how does one know if they have Valley Fever?  Well, the incubation period is typically between 7 and 21 days, meaning clinical disease is apparent 7 to 21 days after exposure.  Thinking back to our recent Haboob, individuals would start experiencing symptoms around July 12th to July 26th.  But symptoms may remain subclinical for weeks or even months.  Many times individuals never even realize they had Valley Fever due to the mild nature of their illness.

Valley Fever typically presents as community-acquired pneumonia with chest pain, fever, difficulty breathing and cough.  However, one may have only a day or two of mild coughing or cold-like symptoms with muscle aches and joint pains.  Two types of rashes can occur, Erythema nodosum and Erythema multiforme.  A common symptom is fatigue that can last for months.  The arthralgias, or joint pains, have lead to an alternate name for Valley Fever, “desert rheumatism.”  Although most patients have a mild form of the disease the does not require treatment, Valley Fever can be very severe and life-threatening; especially in immunocompromised individuals such as those with AIDS, transplant patients, diabetics, pregnant women, cancer patients on chemotherapy, and patients using high-dose prednisone.

The first step in making the diagnosis of Valley Fever is remembering to consider the possibility that Valley Fever might be present. Physicians and patients need to consider the symptoms that are present and if they follow possible exposure to conditions conducive to contracting the spores. Laboratory findings may be unremarkable but an elevated erythrocyte sedimentation rate, an elevated eosinophil count (part of a complete blood count or CBC) and chest x-ray abnormalities are helpful in making the diagnosis.  Serologic testing is available the measures antibody production against the mold.  This testing can also be used to monitor disease activity and duration.

If you suspect that you may have Valley Fever, and not everyone will have it, please contact your physician or you can call our office for more information.  Stay well and remember, there is a fungus among us.


Take Two Asprin and Call Me in the Morning… UNLESS YOU ARE ALLERGIC TO IT

Comments Off on Take Two Asprin and Call Me in the Morning… UNLESS YOU ARE ALLERGIC TO IT Written on May 15th, 2011 by
Categories: Allergies, Allergy Advice, Allergy Articles
Tags: ,

We all know someone who is “allergic” to a medication. Many times that person is not having a
true allergic reaction but either a side effect to the drug or just an adverse reaction. This is also the
case with aspirin or the related non-steroidal anti-inflammatory drugs (NSAlDS) such as ibuprofen
or naproxyn.

There is a special group of individuals that have a unique reaction to aspirin and the NSAlDS. These are a subset of asthmatics. Twenty percent of asthmatics are sensitive to aspirin and NSAIDS. This group of asthmatics have what is called Aspirin Exacerbated Respiratory Disease (AERD). It was originally known as Samter’s Syndrome or Triad Asthma. AERD is a combination of asthma, chronic sinusitis. nasal polyps and then a reaction to aspirin or an NSAlD, This reaction is not a true allergic reaction but an exaggerated response of the body to the biological effect of aspirin or all NSAIDS. This reaction is characterized by watery itchy eyes. runny nose. nasal congestion, sinus-like headache and a severe exacerbation of asthma. An aspirin reaction occurs between twenty minutes and three hours after ingesting the aspirin or NSAlD.

Aspirin-sensitive asthma or AERD occurs in approximately 20 percent of asthmatics. It signifies an aggressive form of inflammatory airways disease mediated by inflammatory chemicals called leukotrienes. Avoiding aspirin or any of the NSAIOS actually does not help the disease. Unfortunately there are many asthmatics avoiding these drugs simply because they have asthma and there is the misconception that all asthmatics may be sensitive to aspirin. By unnecessarily avoiding aspirin or NSAIDS. these patients do not have appropriate medications for pain control, arthritis, and fever reduction or cardio prophylaxis utilizing low dose aspirin.

So, if I am an asthmatic, how can I tell if I have this type of asthma?

Well, it is not as hard as you may think. We first look at the patient’s medical history, The patient must have asthma, chronic sinusitis and nasal polyps. Typically patients describe the onset of their disease as a “cold that never, went away.” Then there must be a history of reacting to aspirin or any of the NSAIDS if all these events are present, it then requires an oral challenge to aspirin to prove if the patient is truly aspirin sensitive. These challenges were formalized at Scripps Clinic and Research Foundation in La Jolla. California, Initially the challenge required a week long hospitalization, The Allergy department at Scripps Clinic has refined the process for the outpatient setting. The safety of the aspirin challenge has also been improved with the development of anti leukotriene medications. After undergoing an aspirin challenge. the patient can be desensitized and take aspirin or an NSAID for an appropriate medical condition. The patient can also be desensitized and take aspirin daily to actually help treat the asthma and sinus disease.

With all this information. who should think about undergoing an aspirin challenge? Asthmatic patients with the appropriate history who need to take aspirin every day for cardiac reasons or those patients that need an anti-inflammatory medication for arthritis or similar condition, Also. those asthmatics with poorly controlled asthma or who have required multiple sinus surgeries to control the sinus disease or polyp formation are excellent candidates for aspirin desensitization.

Having trained at Scripps Clinic. I have been involved in many aspirin challenges and desensitizations, The process of aspirin desensitization is safe under the appropriate supervision and now available in the outpatient setting. Most desensitizations take a minimum of two days to complete.

If you think you or a loved one may be a candidate for this procedure. please feel free to contact our office at 480-949-7377. We would be happy to talk with you to help determine if aspirin desensitization on may be right for you.


Fighting for Air

Comments Off on Fighting for Air Written on February 1st, 2011 by
Categories: Allergy Advice, Asthma, Asthma Articles, COPD
Tags: ,

Struggling to breathe is not a situation that any of us wants to be in but for nearly 800,000 Arizonans that is what they face every day. I would like to take this opportunity to introduce an event and organization that we all can join to help all of us breathe easier.

I, along with one of my partners, Jean Nelson, FNP-C, are the co-chairmans for 2011 Fight For Air Walk put on by the Arizona chapter of the American Lung Association (ALA). This event used to be known as the Asthma Walk but the name has been changed to truly encompass all the respiratory problems that the ALA works to correct, including chronic obstructive lung disease, lung cancer, smoking cessation, air quality issues in addition to asthma. This is one of the largest Lung Association walks in the country. Money raised in the Fight for Air Walk goes to support Camp Not-A-Wheeze, the ALA’s traditional summer camp for children with asthma, research to study asthma, COPD and lung cancer, asthma education, tobacco prevention and cessation along with supporting the fight for clean air.

Money raised in the Fight for Air Walk goes to support Camp Not-A-Wheeze, the ALA's traditional summer camp for children with asthma, research to study asthma, COPD and lung cancer, asthma education, tobacco prevention and cessation along with supporting the fight for clean air.

To help understand the impact of pulmonary disease in Arizona, here are some facts to consider. Arizona has the second highest asthma rate in the country and is the leading cause of school absenteeism for children. COPD is the third leading cause of death in Arizona. The Phoenix-Mesa-Scottsdale area was number 11 on the American Lung Association’s State of the Air report for the most ozone polluted cities. Lung cancer is the second most commonly diagnosed cancer in both men and women.

So why am I taking the time to introduce the ALA’s Fight For Air Walk? I would like to see even more people involved in this very worthwhile event. You may be asking yourself “How can I get involved?” There are three main avenues to becoming involved. First, you or your company could be an event sponsor. There are levels from $1500 and up. This allows your company to be recognized by the community as a leader in the fight for air. Secondly, you can organize a walk team. This can be done with family members, a company team or even a school or athletic team. It is a great way to enjoy a beautiful Saturday morning with friends and colleagues while raising money for a worthy cause. Lastly, you could donate directly to the ALA.

I hope that I have raised some interest in joining Jean and myself in making the 2011 Fight For Air Walk the biggest and best walk yet. The walk will be held at the Scottsdale Civic Center on Saturday, April 2, 2011. For more information go to the American Lung Association’s web site,, or log on to You can also call 602-258-7505. Janelle Tassart or Stacey Mortenson would be more than happy to talk to you about participating or even come to you workplace to help organize a company walk team.

Every day 800,000 individuals in Arizona worry about their next breath. It could be you, a family member or a friend or coworker. There is a good chance that respiratory disease has some impact in your life. Please help us help everyone breathe a little easier. As they have said in the past, “If you can’t breathe, nothing else matters!” See you at the walk.