Colds vs Allergies: how I tell the difference

Despite the cold winter breezes,

The patient complained of some sneezes

Then I said, “Golley,

If they comes in a volley,

I’ll treat them as allergies-ez.”

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Summers used to bring me a large allergy practice, generally 4 or 5 patients a day. In those days, I carried in my memory the 5 classes of antihistamines.   If one agent failed a patient, either through ineffectiveness or through side effects, I would choose a drug from a different class.  Then came the generation of non-sedating antihistamines.  The first two, Seldane and Hismanal, upstaged dozens of older agents but in a few years got pulled from the market for serious side effects.  Within a few years, if I made the diagnosis of allergies, I’d give three days samples each of Allegra, Claritin, and Zyrtec to the patient, saying, “Call us and tell us which works best.  Even if the problem is gone, we want to know what to prescribe for you next year.”

Zyrtec emerged the clear winner; when Allegra went from 60 mg to 180 mg it went from a distant to a respectable second. A few patients responded better to Claritin, but not many.  And when Zyrtec went over the counter, I bid my summer allergy business goodbye and good riddance.

In the intervening years we’ve found out that steroid sprayed up the nose work better than antihistamines, even for eye symptoms. Now that no one needs a prescription for Flonase, I shouldn’t have any allergy business at all.

But I do, as allergies come masquerading as colds, especially in the winter . I look for the triad of itchy-watery eyes, itchy-watery nose, and volley sneezes to distinguish allergy from viral infection.  (Occasionally someone will have none of those but still respond to allergy treatment; then seasonal recurrence of symptoms tips me off.  In another clinic, in another state, a young woman had spring joint pains which responded to antihistamines.)  The first frost takes most of the pollen out of the air.

But not all of the allergens. Some people have allergies even in the winter.  Last week I took care of a patient (who gave permission to write more than I have) with allergies that didn’t start till the first freeze.  As the snow started to fall outside, I talked about how we close our houses up in the winter and some molds produce more spores.  I recommended Zyrtec and the Flonase, and, as always, I said, “If it doesn’t work, call.”


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