Hot inquiries last week Novermber 06, 2009

Here are the top 5 inquiries I fielded for this week:

1. Swine flu! Should I or my child get it? Yes. This vaccine is made the same way that regular influenza vaccines are made. The H1N1 vaccine is beneficial and as safe as the regular influenza vaccine.


2. Where can I get it? Ask your local public health department. In SC, check here.


3. Are you getting it? Yes, if it ever becomes available for adults. Worldwide supply problems and prioritizing children, then adolescents, then adults will greatly delay when I can actually get vaccinated. I want my 4 kids to get vaccinated too.


4. What's in the air now causing my sinuses to act up? Mold spores, dust mites, dry air inside buildings, viruses, weather changes, not pollen. I supervise the pollen counts at our office, which is the only certified pollen counting station by the National Allergy Bureau in South Carolina. Counts can be viewed here. The factors above are not insignificant.


5. What can be done about them? They can be countered in the following ways:
keep the humidity about 30-50%, temperatures 70-74 degrees, wash all bedding in hot water once per week, use saline rinses and water gargles at least 2x/day, more if ill..

A day at work: seeing drug reps

I'd like to share with my readers a side of work that rarely gets mentioned or shown on any move or television show about medicine - seeing drug reps. It's like they don't exist in the video world. Reps are well dressed, articulate, friendly, and frankly often attractive. They are sales people, after all. Their job is to increase the number of prescriptions, new and old, of their company's product. They do this be being likeable, by bringing the all important drug samples, and some times goodies to eat. Current PhRMA guidelines limit them to basically food - either a snack or meal. They remind actually everyone in the office, patients, and health care providers alike, that their products are available and would like to be prescribed. It's standard salesmanship.

So what's the problem? Things are never as simple as they seem. 99% of the time, drug reps show up without an appointment. Time spent with staff equals more prescriptions, so they start talking with everyone that will listen. This behavior disrupts the already late care for waiting patients. Some reps do not respect this intrusion and attempt to prolong discussions with the doctor. They may try to go over their approved advertising sales aids or studies. Some try pressure tactics and attempt to extract a promise from the doctors that they will "just try" the product out. The worst is when their manager is spending the day observing the new hire's job performance. Then there's the sheer variety. Allergy has a very narrow range of diseases and drugs that are prescribed. Nonetheless, there are at least 16 major drug companies and at least 5-10 smaller drug companies. Each has reps. The larger companies have 2-3 reps covering one of our offices.  We have 3 offices, so that means during any given week, I may see a rep from the same company several times during the same week.  On average, I see 5-10 reps each day. It's a lot of extra names, faces, and talking.  Some reps take the tack of comparing their product to their competitor. Unfortunately, for every "pro" study, the doctor or competitor rep can list a "con" study. It's confusing. I understand they have a job to do and I'm not saying I'm a better human being than them (because I'm not), but on busy days, I'm happier when I don't have to talk to any drug reps. because I've got lots else to do concerning direct patient care.

How much does my medication cost?

I found a site that lists the retail costs of meds rxusa.  I am sure there may be others on the internet, but this was enough for me.

What is "Asthmatx?" and Bronchial Thermoplasty?

One of my patients asked me,"What is Asthmatx?" today.  I said its one name for people who have asthma, thinking she said "asthmatics."  No, no, she said it's device to treat asthma.  I had no idea what she was inquiring about.  Thank you to the internet for highlighting the potential for a new treatment.  So, here's the results of my latest research project.

Bronchial thermoplasty is a procedure that is being investigated to treat asthma.  Lungs have increasingly smaller tubes that deliver air to and from the alveoli, where oxygen and carbon dioxide are actively exchanged.  Those tubes are called bronchioles.  They are surrounded by rings of muscle.  When they constrict, the diameter of the airway is markedly decreased, which in turn causes great difficulty in breathing air in and out.  Normally, the bronchioles constrict and relax by less than 10%.  When this constriction is greater than 15% generally, this can be diagnostic of asthma.  Researchers have shown that when this muscle is heated using energy from radio waves, the amount of muscles is reduced, producing less symptoms.  There is less asthma.  Asthmatx is the name of the company that is developing a device called the "Alair Bronchial Thermoplasty System."  One advisory panel of the FDA has voted for approval, however the FDA's overseeing panel must vote for approval.

What do I think?  Not much yet.  Of course, I don't get to play bridge with Bill Gates and Warren Buffett either.  There's very, very little data, meaning number of patients is very small, length of observation about 1 year only, the degree of improvement compared to currently approved treatments, and only a few other immunologic studies, such as have been done with corticosteroids and asthma.  This is a complex disease.  We know the immune system is involved.  It's exciting.  They are backing their way onto the market place, by aiming for severe, adults with asthma.  With time, the potential to treat many, many more patients may become realized.  This seems like treating the end result of the inflammation causing smooth muscle contraction.  Other anti-inflammatory therapies work earlier in the process.  Who's to say that since the root of the problem and the immune system have not been treated that the problem will simply recur?  New technologies sound great and I'm glad we are spending resources on this disease.  But let me and the rest of the scientific community have a little more time before this proves that it really is the Next Great Treatment.

Just little bit of midwestern skepticism from your Allergy Dude....

What's Really in My Food?

Does any one really know what they are eating?  Barely.  Don't be fooled by your eyes, your nose, or the label.  It's the chemicals in your foods that you should concerned about for health and disease.  Why?  The U.S. Food and Drug Administration has a list of over 2,000 additives, generally recognized as safe (GRAS), and color additives.  Once chemicals are on this list, they are not monitored as closely, because they are by definition regarded as safe.  However, large quantities of anything, even water, can cause disease in humans.  Then there's the group of people with immunologic hypersensitivity to chemicals.  In an earlier blog entry, I reviewed the definition of hypersensitivity as "causing objectively reproducible symptoms or signs, initiated by exposure to a defined stimulus at a dose tolerated by normal subjects."  As an allergist, I see patients who are having symptoms consistent with hypersensitivity to a chemical or compound.  The problems then are trying to identify and confirm which chemicals or compounds are causing the disease.  This is often difficult and frustrating, due to strict limitations in the number of FDA approved tests, lack of understanding, lack of knowledge if the compound is present since the compound may not be listed on the food ingredients.  If a food additivie or other compound is suspected, then often recommend the patient consider eating organically grown foods for at least one month, to see if their immune system can recover.
I hope this helps some patients understand the potential size of the difficulty in identifying which compound in their food may be causing their symptoms.

Kao's Allergy Treatment Pyramid

This is how I think every person with an allergic disease should think of their treatment plan, above.  Please see the picture to the left.  Full credit goes to the USDA. When I saw it, I had a revelation, I thought "YES!!!" that is how we should be treating allergic diseases also.  I never liked the older pyramid on the right.  Likewise, the traditional treatment pyramid for allergic disease is avoidance, then medications, then immunotherapy on top.  I've been struggling with this for fifteen years.  This is too simplistic and not valid for many patients.

Here's my labeling of the components:

1. mental attitude: empathy, hope, courage, take an active role in your health;
2. everyone should exercise at least 30 minutes per day, get enough sleep;
3. eat healthy foods: Mediterranean diet;
4. educate yourself about your allergic disease;
5. avoid triggers of your allergic disease and do not use tobacco products;
6. medications: take them as prescribed to prevent disease symptoms;
7. disease modifying anti-allergic treatments: immunotherapy to reduce long-term inflammation;
8. complementary and alternative medical treatments: saline nasal rinses, physiotherapy (daily deep breathing exercises), massages to relieve stress, , aroma (menthol, eucalyptus, camphor).

Now the size of the pyramid may vary with severity of disease, but the same treatment options are available for every patient with an allergic disease - mild, or moderate, or severe.   Each person's treatment will be an individualized combination of these treatment options.

These are what I think help my patients with any allergic disease.  These are what I do for my own family.  I hope this helps, the "Allergy Dude."

Definitions of Hypersensitivity, Allergy, and Atopy

There are three terms have been used, often interchangeably, but this causes confusion. Below are definitions from the European Academy of Allergy, Asthma and Immunology (EAACI) Position Statement on Nomenclature.  I try to stick with these when I write, lecture, or speak with patients. I think definitions must be agreed upon, because they are the building blocks we use to communicate ideas.  Their meaning can change, but we should still agree on the meaning, otherwise we will automatically be miscommunicating.


1. Hypersensitivity causes objectively reproducible symptoms or signs, initiated by exposure to a defined stimulus at a dose tolerated by normal subjects.  There are allergic and non-allergic subtypes (e.g. aspirin reactions).  This definition does not accommodate classical responses to infection, autoimmunity, or toxic reactions.  

2. Allergy is a hypersensitivity reaction initiated by immunologic mechanisms. Allergy can be antibody- or cell-mediated. In most patients, the antibody typically responsible for an allergic reaction belongs to the IgE isotype and these patients may be said to suffer from IgE-mediated allergy.  In a minority of patients, the reactions may be either IgG antibody-mediated (e.g. hypersensitivity pneumonitis), or T-cell mediated (e.g. contact dermatitis), or other cells (lymphocytes cause many disorders: e.g. some eczema, celiac disease).


3.  Atopy is a personal or familial tendency to produce IgE antibodies in response to low doses of allergens, usually proteins, and to develop typical symptoms such as asthma, rhinoconjunctivitis, or eczema/dermatitis.  It is not always possible to demonstrate a person is ‘‘IgE sensitized’’ or ‘‘skin prick test positive,’’ because of their age (infants), or the discomfort of in depth testing, or the wrong allergens were tested, or the skin prick tests are simply not good enough or numerous enough to detect the IgE antibodies (some dust and mold allergies).

I hope these help, the "Allergy Dude."

Have an Anaphylaxis Allergy Action Plan

It is very important to have a written plan to help remind and guide your caregivers if an allergic or life-threatening anaphylactic reaction should occur.  There are many plans available online.  Most are from school districts.  Naturally much of the burden falls upon schools during the day time.  I have searched and reviewed a number of them.  I recommend either this personal anaphylaxis action plan or this "Food allergy action plan."  Most other plans are variations of these two forms.  I thank both organizations for making them available to the public.  Both forms make good points and have areas for improvements.  My personal preference is for the first form, because there are levels and it shows the steps for giving the epinephrine.  I don't like branding, but Twinject may not be available in Australia.  I may alter the forms in the future with my own "improvements."