* Surgery (taking out the cancer)
* Chemotherapy (using drugs to fight the cancer)
* Radiation Therapy (using high-dose x-rays or other high-energy rays to kill cancer cells)

The vote does not mean the two drugs, Serevent and Foradil, will be pulled from the market. Instead, the panel strongly urged the FDA to tell doctors not to prescribe the drugs to children or adults as a standalone asthma treatment .

The drugs are also widely prescribed for chronic obstructive pulmonary disease. That use was not affected by Thursday’s deliberations of a 27-member FDA advisory committee.

At the same time, the experts backed two other popular asthma drugs , saying their benefits outweigh their risks.

Serevent and Foradil are in a class of drugs known as beta-agonists. They help control and prevent airway spasms during asthma attacks . But the drugs have also been associated with a small but significant increase in the risk of hospitalization and death from asthma.

Medical guidelines and the drugs’ labeling recommend that beta-agonists only be used in combination with inhaled steroids that cut down on airway inflammation leading to attacks. The combination lowers the risks to a level most experts believed is justified by their benefits.

But studies show that many patients do not use inhaled steroids as directed when taking them separately from beta-agonists. At the same time, patients often feel physical relief from labored breathing when they use their beta-agonist inhaler. The difference can lead to many patients using the beta-agonist alone (called monotherapy), which raises the risk of dangerous side effects, according to FDA analyses presented this week.

“I think the label should be greatly strengthened to say that monotherapy for asthma should basically be contraindicated” for Serevent and Foradil, said Daniel Notterman, MD, a member of the advisory panel from the department of molecular biology at Princeton University.

The rest of the advisors agreed. In a 17-to-10 vote, the panel said the risks of long-term Serevent and Foradil use outweigh the benefits when used alone. The panel cast a similar vote for adolescents with asthma and voted unanimously that the drugs are not worth the risk in children 4 to 11 years old.

“The data is that single use is dangerous,” said David Schoenfeld, PhD, a panelist and professor of medicine from Massachusetts General Hospital.

The panel gave broad backing to two other asthma drugs, Advair and Symbicort, in adults. Those products contain a combination of beta-agonist and steroid drugs, thus guaranteeing that patients get both drugs each time they take a puff.

The group was split on whether Advair should be used in children. Thirteen panelists said Advair’s benefits outweigh its risks in children, while 11 said they did not. Three abstained.

Experts said they were uneasy with how few studies had been performed showing Advair’s safety and efficacy in children.

“I think there’s a paucity of data,” Notterman said.

Symbicort is generally not used in children.

John Jenkins, MD, who heads FDA’s Office of New Drugs, said the agency would consider ordering manufacturers to conduct more safety studies in children, which it can do under new authority granted by Congress.

Ellen Strahlman, MD, the chief medical officer of GlaxoSmithKline, which makes both Advair and Serevent, said the company was pleased with the committee’s backing of Advair. But she also said the company was “concerned” that the panel’s vote to restrict Serevent could “deny patients needed treatment for optimal care of their asthma.”

A statement from Novartis and Schering-Plough said the companies “strongly disagree” with the panel’s rejection of Foradil, which they market in a joint venture.

“We believe this opinion is inconsistent with clinical evidence supporting the benefit/risk profile of Foradil in patients not adequately controlled on other asthma-controller treatments,” the statement read.

The FDA now has to go back and consider whether to change product labeling or indicated uses for Serevent and Foradil. It will also consider ordering new safety studies, Jenkins said.

Jenkins emphasized that patients currently taking Serevent or Foradil “should not stop taking your asthma medications without talking to your physician.”

SOURCES:Daniel Notterman, MD, department of molecular biology, Princeton University; member, FDA advisory panel.David Schoenfeld, PhD, professor of medicine, Massachusetts General Hospital; member, FDA advisory panel.John Jenkins, MD, director, FDA Office of New Drugs.Ellen Strahlman, MD, chief medical officer, GlaxoSmithKline.News release, Novartis Pharmaceuticals Corp. and Schering-Plough.

For this most recent study, published in Chest, researchers analyzed absences for children with asthma. The children, who were in fourth, fifth, and sixth grades, attended 19 schools in the Dallas Independent School District. Researchers compared the absence rates of children with asthma to fourth- through sixth-grade absence rates at the 19 schools and to absence rates district-wide.

All absence rates were between 2% and 3%. The study authors conclude, “In the DISD, children with asthma do not miss more school days than their peers without asthma.”

The study’s authors say there could be several possible explanations for the results. One is that the overall management of childhood asthma improved between the last study (done in 1995) and the current study (done in 2003). This improvement could be attributed to the acceptance of NAEPP (National Asthma Education and Prevention Program) guidelines by the medical community, authors say.

Also, the method by which children were identified as having asthma may have affected results. Past studies have relied on self-reported asthma and asthma identified by school nurses. This study screened a large pool of students with lung function tests, thereby identifying a larger number of students with asthma. The absence rates of the students with abnormal lung function tests vs. healthy students in the 19 schools and the entire district were not significantly different.

Another important note: More than 90% of schools in the Dallas Independent School District have their own full-time registered nurses. These nurses prepare asthma management plans for every child known to have asthma and provide urgent care during school hours for children with symptomatic asthma.

As part of the conclusion, the authors argue that school nurse salaries are money well spent. “Allocation of limited school resources to school nurse salaries may be more cost-effective and produce better asthma control outcomes than district-wide efforts at testing for asthma,” they write.

SOURCE:Millard, M., Chest, February 2009; vol 135: pp 303-306.

The city earned the dubious honor of being named the worst of the worst on the latest list of “The 100 Most Challenging Places to Live with Spring Allergies.” Los Angeles, much maligned for its air pollution, ranked far better — number 86 on the 2008 list. San Francisco was 99, and Spokane came in at number 100. (See full list at the end of this article)

What do the worst allergy cities have in common? What makes a city good for people with allergies?  Unfortunately, there are no easy answers. But allergy experts say there are key factors to look for.

How the ‘Worst’ Allergy Cities Are Computed

Unveiling the worst spring allergy cities in America has become an annual tradition. The lists are released by the Asthma and Allergy Foundation of America, in Washington, D.C., and many factors are plugged in to figure out which cities will get the dubious honor each year, says Mike Tringale, a spokesman for the foundation.

The foundation experts look at the most populated cities and take into account factors such as the region’s pollen score (pollen count and other factors), along with the number of allergy medications prescribed and the number of board-certified allergists practicing there. Each city gets a score and then the list of 100 cities is drawn up.

While Lexington got a score of 100, the average score was about 40.  And the top 10 is a bit overloaded with southern cities: Greensboro, N.C.; Johnson City, Tenn.; Augusta, Ga.; Jackson, Miss.; Knoxville, Tenn.; Birmingham, Ala.; New Orleans; and Little Rock, Ark.

But San Diego is also in the top 10 worst allergy list — debunking the myth that ocean breezes get rid of pollen.

Why Are Some Cities Worse for Allergies Than Others?

“The fundamental issue with cities is the type of plant or grasses, trees or weeds that grow in the area,” says Daniel Waggoner, MD, an allergist in Mystic, Conn., who is not affiliated with the list creation but is familiar with it.

Cities with an exceptionally high concentration of trees, grass, or weeds may have more pollen in the air, he says. Local environmental factors such as wind, humidity, typical temperatures — and air pollution — also play a role in allergies, notes Miguel Wolbert, MD, an allergist in Evansville, Ind. and a certified pollen counter.

What if you don’t live in a major city? How can you tell if your region is especially bad for allergies? Here’s what the experts have to say.

Allergy Risks by Region

Near River Basins
“If you are around certain river basins, such as in Ohio or Mississippi, higher pollen counts occur due to high humidity levels,” says Wolbert.

In the middle of Mississippi, everything sits, Wolbert says, so pollen is likely to be worse.

In the Mountains
In the mountains, there are fewer plants that pollinate, Wolbert say, perhaps explaining why West Virginia and other hilly locales are absent from the 2008 list.

Near the Coast

While some seaside towns made the list, in general a sea breeze helps reduce allergens, Leftwich says. The closer to the sea the better. “If you can afford to live in that first quarter mile from the beach, it’s great. Pollens are not so much a problem there.”

The Midwest
The Midwest, known for its ragweed pollen, has several cities on the list including South Bend, Ind. and St. Louis. Some experts believe global warming is making the ragweed season longer, Wolbert says, so pollen may just get worse.

The West

“West of the Rockies, there is no ragweed but there is lots of grass pollen,” Leftwich says.

The South

And allergy wise, he says, “Tennessee is where everything comes together,” noting there are several different types of pollen flourishing there. His town, Nashville, Tenn., made No. 18 on the list.

Putting the Worst Allergy Cities List Into Perspective

Waggoner and other allergists caution that the list of worst cities for springtime allergies may not be that scientific. “The worst city for one person is the best city for another person,” Leftwich agrees. “It depends on what you are allergic to.”

“Being allergic to one tree pollen doesn’t mean you are allergic to another.” The city that has the worst tree pollen count may not have the worst grass pollen count, he says. “It is a common misconception that pollens are pollens. They are not.”

No scientific studies have thoroughly compared allergy risks in different cities, Leftwich says. Instead, we turn to the annual list almost for bragging rights.

So how can we use the annual list of worst allergy cities? Well, don’t use the list to pick one place to live over another, allergy experts say. Instead, get allergy testing to be sure you know what triggers your allergies. And if you must move, find out whether your pollen triggers grow widely in the area and neighborhood you’re considering.

What if you love your home, but you’re in a bad allergy community?  Talk to your doctor. There are preventive treatments you can start before allergy season to help you stay home and healthy.

Complete List of 2008 Spring Allergy Capitals

1. Lexington, Ky.
2. Greensboro, N.C.
3. Johnson City, Tenn.
4. Augusta, Ga.
5. Jackson, Miss.
6. Knoxville, Tenn.
7. Birmingham, Ala.
8. New Orleans
9. Little Rock, Ark.
10. San Diego
11. Oklahoma City
12. Mobile, Ala.
13. South Bend, Ind.
14. Omaha, Neb.
15. Stockton, Calif.
16. McAllen, Texas
17. Greenville, S.C.
18. Nashville, Tenn.
19. Tulsa, Okla.
20. Harrisburg, Pa.
21. Louisville, Ky.
22. Dallas-Fort Worth
23. Charlotte, N.C.
24. Tampa, Fla.
25. Philadelphia
26. St. Louis
27. Scranton, Pa.
28. Lansing, Mich.
29. Madison, Wis.
30. Rochester, N.Y.
31. Daytona Beach, Fla.
32. Memphis
33. Milwaukee, Wis.
34. Norfolk, Va.
35. Pensacola, Fla.
36. Charleston, S.C.
37. Cleveland
38. Indianapolis
39. Houston
40. Lakeland, Fla.
41. Baltimore
42. Sacramento, Calif.
43. Columbia, S.C.
44. Kansas City, Mo.
45. New York
46. San Antonio
47. Allentown, Pa.
48. Wichita, Kan.
49. Albuquerque, N.M.
50. Baton Rouge, La.
51. Washington, D.C.
52. Providence, R.I.
53. Fort Wayne, Ind.
54. Austin, Texas
55. Canton, Ohio
56. Atlanta
57. Kalamazoo, Mich.
58. Chattanooga, Tenn.
59. Boston
60. Detroit
61. Grand Rapids, Mich.
62. Hartford, Conn.
63. Denver
64. Dayton, Ohio
65. Tucson, Ariz.
66. Buffalo, N.Y.
67. Des Moines, Iowa
68. Syracuse, N.Y.
69. Salt Lake City
70. Minneapolis-St. Paul
71. Cincinnati
72. Columbus, Ohio
73. Chicago
74. Boise City, Idaho
75. Albany, N.Y.
76. El Paso, Texas
77. Richmond, Va.
78. Raleigh-Durham-Chapel Hill, N.C.
79. Las Vegas
80. Jacksonville, Fla.
81. Melbourne, Fla.
82. Pittsburgh
83. Miami
84. Toledo, Ohio
85. Modesto, Calif.
86. Los Angeles
87. Springfield, Mass.
88. Youngstown, Ohio
89. Colorado Springs, Colo.
90. Seattle
91. Phoenix-Mesa, Ariz.
92. Fresno, Calif.
93. Portland, Ore.
94. Fort Myers, Fla.
95. Orlando, Fla.
96. Lancaster, Pa.
97. Sarasota, Fla.
98. Bakersfield, Calif.
99. San Francisco
100. Spokane, Wash.

SOURCES: American Academy of Asthma Allergy & Immunology: “Outdoor Allergens,” “National Allergy Bureau.” Asthma and Allergy Foundation of America: “Pollen and Mold Counts.” National Institutes of Health: “Airborne Allergens: Something in the Air.” Daniel Waggoner, MD, allergist, Mystic, Conn. Miguel P. Wolbert, MD, allergist, Evansville, Ind. Russell Leftwich, MD, allergist, Nashville, Tenn. WebMD Health News: “Worst Spring Allergy Cities?”

Reviewed by Brunilda Nazario, MD on 2/25/2009

There’s not much you can do to avoid pollen altogether — after all, it’s produced by grasses, trees, flowers and weeds — but you can minimize the misery. Here’s your springtime pollen survival guide.

Can You Really Avoid Pollen?

Be realistic. “Complete avoidance of pollen is impractical,” says Daniel Waggoner, MD, an allergist in Mystic, Conn., tells his patients. “In Connecticut, spring brings tree pollens. Late spring and summer brings grass pollens. Late summer and fall brings weed pollen.”

“That in general holds true across the country,” he says. However, if you travel south, some types of pollen may linger year round, with the warmer temperatures.

But there’s a lot you can do to minimize the fallout from pollen — from simple measures you can take around the house to seeing an allergist for treatment.

First, Know Your Pollen Count

Pollen is the invisible annoyance. The average pollen particle is smaller than the width of an average human hair, according to the American Academy of Allergy Asthma & Immunology.

But once pollen reaches your nose and throat, it can trigger an allergic reaction if you are the sensitive type. And about 35 million Americans are sensitive to pollen, according to National Institutes of Health estimates.

It’s easy enough to check the pollen count in your locale through the National Allergy Bureau, a section of the American Academy of Allergy Asthma and Immunology, which maintains an online site for pollen counts.

Pollen counts calculate a given pollen in a specific amount of air during a particular period, such as 24 hours, according to the Asthma and Allergy Foundation of America.

Ask your allergist exactly what you are allergic to, and when that pollen peaks, so you can be ready to take action before the pollen triggers bad allergic reactions, says Russell B. Leftwich, MD, an allergist in Nashville, Tenn.

Second, Stay Indoors When Pollen Counts Are High

When pollen counts are high, shut the windows and use the air conditioner, suggests Leftwich.

“The biggest problem pollen-sensitive patients have are the times when the pollen is heaviest and outside temperatures are the nicest,” he says. “People are tempted to sleep with the windows open.”

Big mistake, he tells them. “Normally with the windows shut and the air conditioner on there is very little pollen in your house.”

Third, Plan Outdoor Time Wisely

It’s best to avoid the outdoors during high pollen counts, but that’s not always practical.

“Most plants pollinate from 5 a.m. to 9 a.m., says Miguel P. Wolbert, MD, an allergist in Evansville, Ind. Wolbert is certified in pollen counting for the National Allergy Bureau. “If you are outside then, going for a jog, you pick up the pollen on your hair, face, and clothes,” he says.

Windy days can be worse than calm days. “Windy days stir the pollen around,” he says.

If a dog is jogging with you, he’s a pollen-carrier, too, Wolbert says. “Often people blame the dog for an allergy, and it might be the pollen on the pet.”

When possible, avoid early morning outings with the dog on high pollen days, especially if it’s windy.

Fourth, Protect Yourself From Pollen When You Go Outdoors

“When people do have to be outside at a high pollen time, wearing a mask is a good filter,” says Leftwich. He suggests getting a painter’s mask at your local hardware store or home improvement center.

“If you have bad pollen allergies and you are the one who has to do the yard work, wearing a mask is a good idea,” he says. They don’t look fashionable, he admits, but reminds his patients: “It’s not a social occasion.”

When you’re outside, minimize your exposure to pollutants and other allergens as well, suggests Wolbert. If you go jogging later in the day when pollen tends to die down, pick a residential street instead of a thoroughfare to avoid car exhaust.

Also, adds Leftwich: “Take your allergy medicines before you go outside. People wait until they are miserable and then take it. For some reason they think [an allergy attack] is not going to happen this time.”

Fifth, Keep Pollen From Following You Into the House

As soon as you arrive home — even if you’ve just been in the backyard — change your clothes and take a shower to rid your body of as much pollen as possible, Leftwich says.

Don’t forget your hair, especially if it is long, Leftwich says. “Just rinsing your hair would do.”

Sixth, Treat Your Pollen Allergies

A variety of over-the-counter and prescription medications can help your allergy symptoms such as runny nose, itchy eyes, congestion, and coughing.

Get an evaluation from an allergist to help find the best allergy remedy for you, Wolbert says. The doctor may recommend an antihistamine, other allergy pills, inhaled allergy treatments, or even allergy shots.

Beware of overusing decongestant nasal sprays. Using decongestant sprays for more than three days in a row, he says, can lead to a “rebound” effect. Your allergy symptoms may become worse than before you started the medicine.

If your pollen allergies are bad, talk to your doctor about preventive treatment with antihistamines or inhaled steroids. Start taking the treatment before pollen season starts.

You might also consider allergy shots (allergy immunotherapy) if you suffer severe allergies. The doctor injects a small amount of the allergen that affects you, building up your immunity over time. Typically, the injection is given once a week or once a month. “It usually takes three to five years of allergy shots,” Wolbert says, to build up immunity to the allergen.

“Most people get good results, if they stick with the recommended number of injections,” he says.

Seventh, Take an Allergy Vacation

If pollen still drags you down after taking all the six steps above, consider taking an allergy vacation.

When pollen season is in full swing, take a trip to an area less affected by pollen, such as the beach or the seashore nearest to your hometown. Relax! You deserve it.

SOURCES: Daniel Waggoner, MD, allergist, Mystic, Conn. Miguel P. Wolbert, MD, allergist, Evansville, Ind. Russell Leftwich, MD, allergist, Nashville, Tenn. American Academy of Asthma Allergy & Immunology: “Outdoor Allergens,” “National Allergy Bureau.” Asthma and Allergy Foundation of America: “Pollen and Mold Counts.” National Institutes of Health: “Airborne Allergens: Something in the Air.”

Reviewed by Brunilda Nazario, MD on 2/25/2009