Antihistamines Should Be Used Properly

Pacific Ocean. (Dr. Noorali Bharwani)
Pacific Ocean. (Dr. Noorali Bharwani)

Antihistamines are used to treat hay fever and other allergies. They work by preventing the effects of histamine, which is produced by the body. Histamine can cause itching, sneezing, runny nose, and watery eyes.

Allergic reaction occurs when our body’s immune system mistakes a harmless substance for a harmful one, and the body releases chemicals to fight it. This reaction is what causes the symptoms.

Hay fever is an allergic reaction to substances in the air like pollen. This can be indoors or outdoors. Besides pollen, one can have allergy to dust mites, or tiny flecks of skin and saliva shed by cats, dogs, and other animals with fur or feathers.

Allergic rhinitis refers to inflammation of the nasal passages due to the release of histamine and other mediators in the nose. Allergy testing helps with the diagnosis. Allergic rhinitis may be seasonal (usually due to grass, tree or weed pollens) or perennial (due to triggers such as pet hair, house dust mite or mould). Allergic rhinitis can lead to increased asthma symptoms.

Allergic conjunctivitis is another condition similar to allergic rhinitis. It can be seasonal due to pollens or perennial due to allergens present all year.

An article titled “How to use antihistamines,” was published in the Canadian Medical Association Journal (CMAJ April 6, 2021) which says, “Antihistamines are among the most commonly and incorrectly used medicines worldwide.”

The article says antihistamine use is most strongly supported for treating allergic rhino-conjunctivitis (hay fever) and urticaria (hives). It says we should not use antihistamines for conditions where antihistamines have questionable utility, such as in managing asthma, eczema, or cough.

Older (first generation) antihistamines are associated with substantial and sometimes fatal adverse effects. They cause sedation, injury and impairment in sleep. They interfere with mental and cognitive function, including impaired performance at school.

Older antihistamines should be avoided in the elderly. Overdose can result in death. Examples of older antihistamines are: Benadryl, Chlor-Tripolon, and Atarax.

The CMAJ article says, “Newer antihistamines are safer, as affordable and as efficacious as first-generation antihistamines.”

Compared with first-generation antihistamines, systematic reviews of randomized controlled trials have found newer antihistamines to be safer, longer lasting (12–24 hours) and faster acting. Their effect is felt in 50 minutes compared to 80 minutes for the first-generation antihistamines.

Warning – no antihistamine should be consumed with alcohol. And antihistamines should not be used for anaphylaxis. For this purpose, epinephrine is the drug of choice.

What you should know about second generation antihistamines.

Second generation antihistamines are newer medicines. Many treat allergy symptoms without causing sleepiness. The CMAJ article gives a summary of preferred antihistamines for allergy and urticaria: Bilastine, Cetirizine (Reactine), Desloratadine (Aerius), Fexofenadine (Allegra), Loratadine (Claritin), Rupatadine (Rupall).

It is important to remember some antihistamines are mixed with other medicines. These could include pain relievers or decongestants. These are meant to treat many symptoms at the same time. It is a good idea to treat just the symptoms that you have. If you have only a runny nose, don’t choose a medicine that also treats headache and fever.

There are other uses of antihistamines. For example: to prevent motion sickness, nausea, vomiting, and dizziness. In addition, since antihistamines may cause drowsiness as a side effect, some of them may be used to help people go to sleep, relieve anxiety, and produce sleep before surgery.

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Benefits and risks of COVID-19 vaccines.

Cactus in Arizona. (Dr. Noorali Bharwani)
Cactus in Arizona. (Dr. Noorali Bharwani)

“There is solid medical and scientific evidence that the benefits of vaccines far outweigh the risks. Despite this, there have been concerns about the safety of vaccines for as long as they have been available in the U.S,” says Centre for Disease Control and Prevention (CDC) on its website under the title of Vaccine Safety.

“Vaccine risks are rare,” according to Dr. Supirya Sharma. She said this last year. She is a senior medical advisor for Canada’s health department. “The benefits outweigh the potential risks, but it is still a drug and still a vaccine and there are potential risks even if they’re rare,” Sharma said. “That’s why we continue to monitor it.”

Sharma has said that the three vaccines authorized in Canada so far offer excellent protection and, along with public health measures, can help slow the spread of the virus and potentially help stop it from mutating even further.

“We knew this was going to happen, that we would have variants,” she said, in an interview with The Canadian Press.

There is still a lot we are learning about COVID-19 vaccines.

We know that COVID-19 has caused very serious illness and death for a lot of people.

The biggest benefit is vaccines vastly reduce your chances of getting COVID-19. They also to an even greater degree protect against hospitalisation and death. We don’t know how long protection lasts for those who are vaccinated. It’s concerning seeing breakthrough infections, and the worry is that they might increase if vaccine protection does, as suspected, fall over time.

The US Centers for Disease Control and Prevention led a nationwide study of vaccination involving more than 3,600 adults hospitalized for Covid-19 between March and August.

The study found Pfizer vaccine provided 88 per cent protection against hospitalization, and Moderna was 93 per cent effective. Johnson & Johnson’s Janssen vaccine comes in third, but still provides 71 per cent protection.

Vaccine failure

According to an article in The Conversation Canada (September 9, 2021) titled “Four factors that increase the risk of vaccinated people getting COVID” are:

  1. Vaccine type
  2. Time since vaccination
  3. Variants
  4. Your immune system

Two weeks after your second COVID-19 vaccine dose, the protective effects of vaccination will be at their highest. At this point, you’re fully vaccinated. If you still get COVID-19 after this point, you’ve suffered a “breakthrough” infection.

In the UK, research has found that 0.2 per cent of the population – or one person in every 500 – experiences a breakthrough infection once fully vaccinated. But not everyone is at the same risk. Four things appear to contribute to how well you are protected by vaccination.

1. Vaccine type

The first is the specific vaccine type you received and the relative risk reduction that each type offers. Relative risk reductions for the Moderna vaccine reduced a person’s risk of developing symptomatic COVID-19 by 94 per cent, while the Pfizer vaccine reduced this risk by 95 per cent. The Johnson & Johnson and AstraZeneca vaccines performed less well, reducing this risk by about 66 pr cent and 70 per cent respectively.

2. Time since vaccination

It’s becoming increasingly evident that length of time since vaccination is also important and is one of the reasons why the debate over booster immunisations is growing in intensity.

Some reports suggests that the Pfizer vaccine’s protection wanes over the six months following vaccination. Report from Israel also suggests that this is the case. It’s too soon to know what happens to vaccine efficacy beyond six months in the double vaccinated, but it’s likely to reduce further.

3. Variants

Current information suggests the vaccines are slightly less protective against variants.

4. Your immune system

If your immunity is compromise due to your age or other medical conditions, you will have lower levels of vaccine-induced protection against COVID-19. This raises the question – who should get a booster shot?

There is solid medical and scientific evidence that the benefits of vaccines far outweigh the risks. Get your shot and don’t forget the importance of wearing your mask, washing your hands and maintaining social distance.

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Are we taking good care of our doctors, nurses and other healthcare professionals?

"Without a sense of caring, there can be no sense of community." Anthony J. D'Angelo
"Without a sense of caring, there can be no sense of community." Anthony J. D'Angelo

Dr. Scott Malmberg, a physician in Medicine Hat, Alberta recently posted a blog about his experience in COVID-19 ward at the local regional hospital. He was on duty for 48 hours. He had 16 admissions, two ICU transfers, four discharges and four deaths. He didn’t get much sleep.

Ninety per cent of these patients were not vaccinated. Most of these patients did not expect to be very sick with COVID-19. But many of these patients rapidly went into pulmonary failure requiring ventilators. You wonder, “Why would eligible individuals refuse to have lifesaving vaccines?”

Malmberg says hospitals are clogged up by unvaccinated sick people requiring life saving measures like ICU beds and use of high flow oxygen units. These patients use up all lifesaving drugs and services of demoralised over stretched doctors, nurses and other hospital staff. This leads to cancellation of urgent surgeries. It is hard to find beds for patients who come with stroke, heart attack and severe trauma. Cancer patients have to wait longer for surgery.

Another blog was brought to my attention recently. This was written by Dr. Peter Brindley, Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton.

He wrote an open letter to the unvaccinated individuals. It was published in The BMJ Opinion (September 3, 2021). In part he says, “Many healthcare professionals are at a loss for words. Not only because we are exhausted, but because we simply cannot understand why so many of our fellow citizens refuse to get a simple vaccine.”

President of the Alberta Medical Association recently wrote, “Recent anti-vaccine protests that have blocked access to hospitals, along with bullying and threats, have added to the distress many of us are feeling. Alberta health care workers have experienced harassment and intimidation, both online and while going about the business of caring for patients.” He called this unacceptable behaviour.

Now we are into the fourth wave of COVID-19 pandemic. According to the World Health Organisation, so far 221 million people worldwide have contracted the disease and 4.5 million people have died from the illness. In Alberta and rest of Canada the number of people with COVID-19 are increasing. And majority of the people are unvaccinated individuals. Many of these patients die.

Alberta Government has provided general guidance to help Albertans and businesses follow “best practices” to prevent the spread of COVID-19.

Alberta Health website says, “COVID-19 transmission is increasing and hospital admissions are rising, largely in unvaccinated Albertans. Alberta is taking temporary measured steps to reduce transmission and prevent the health care system from being overwhelmed. These temporary measures came into effect September 4 at 8 am.”

Few days ago, the premier of Alberta acknowledged the ongoing risk of exposure. He advised people to “use common sense and exercise personal responsibility” when enjoying their new freedom.

The premier is reported to have said, “People will get infected. Some people will get sick. Regrettably, a few people likely will pass away, as has been the case forever with influenza, but we don’t shut down society to deal with that kind of limited and controllable risk. We manage the risk. The vaccines give us a superpower to manage it. Let’s embrace that.” Is this the right approach?

The fourth wave is hitting us hard. The numbers are rising every day. One way to take care of our doctors, nurses, hospital staff, our seniors, our brothers, sisters and children is to get vaccinated, wear a mask and maintain safe distance from others.

This is not over yet. Our health care professionals need our help.

Take care.

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Should Canada offer a booster (third) shot of COVID-19 vaccine to general public?

The Golden Gate Bridge in San Francisco, California. (Dr. Noorali Bharwani)
The Golden Gate Bridge in San Francisco, California. (Dr. Noorali Bharwani)

Majority of the Canadians have had one or two shots of COVID-19 vaccine.

As we know vaccination protects us from getting seriously ill and dying from COVID-19.

For two-dose vaccines, both doses are needed to achieve the highest level of immunity. This high level of protection is achieved two weeks after the second dose.

Common question is – Can we stop taking precautions after receiving two doses of vaccine?

No, you cannot. No vaccine is 100 per cent effective and breakthrough infections are expected.

Evidence shows COVID-19 vaccine will protect you from serious illness and death but there are exceptions to the rule. You cannot lower your guard. Public health officials are calling for more mask-wearing. There is clear evidence that breakthrough COVID-19 infections can occur in people who are fully vaccinated. This is particularly true with various kinds of emerging variants.

COVID-19 booster shots

Recently, U.S. has announced it will offer third shot of COVID-19 vaccine in September to boost up protection against more transmissible variants.

Americans will be eligible to receive a third shot of the Pfizer or Moderna vaccines eight months after receiving their second dose. Why? They noted that COVID-19 vaccines are still highly effective, but their protection against infection appears to be waning as time goes by. According to President Joe Biden, this is the best way to protect ourselves from new variants that could arise.

As of August 15, Israel reported 31 per cent rise in severe or critical COVID-19 cases. Nearly three in five of those patients were fully vaccinated. That country is now offering booster shots to people over age 50. Germany and France recently authorized booster shots for the elderly and vulnerable. Health officials in Canada, meanwhile, have yet to authorize a third dose for the immunocompromised.

A study in Israel has shown third dose of Pfizer’s COVID-19 vaccine has significantly improved protection from infection and serious illness among people aged 60 and older.

One study published in the Centers for Diseases Control and Prevention weekly report (August 27, 2021) found the protection against infection offered by the Pfizer and Moderna vaccines dropped from 74 per cent in the spring to 53 per cent this summer.

A New York study showed people who received the Johnson & Johnson vaccine likewise reported a drop in protection against lab-confirmed infection from 92 per cent in early May to 80 per cent in late July.

Where does Canada stand on booster shots?

Health Canada has not authorized a three-dose regimen for any of the COVID-19 vaccines.

Canada’s National Advisory Committee on Immunization has not yet made a formal recommendation on COVID-19 booster shots.

Ontario is going to offer third dose of vaccine to individuals whose immune systems are compromised and for individuals in high-risk retirement homes.

Many experts feel third dose should be offered to venerable people only. Not to the general public. In Canada, it would be premature to offer third shot to the general population. The aim should be to improve overall vaccine uptake. That would offer greater community protection than giving third booster shots to vaccinated healthy people.

I am sure vaccine experts and people helping governments make vaccine decisions are struggling with this question: Is it ethical for rich countries to offer third dose of vaccine to their citizens while the poor countries are waiting to get vaccines for their people? What do you think?

Take care. Be safe. Besides being fully vaccinated, wearing a mask and washing your hands regularly continues to be important.

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