The term “biologics” is the name of a new class of medical treatment. They are highly targeted medicines, often modified antibodies, designed to perform a very specific action in the body, usually by blocking a very specific function. In the field of Allergy, some of the new biologics have become extremely useful tools for treating conditions in people for whom traditional medications have not worked. The conditions Allergists treat with biologics include asthma, eczema (atopic dermatitis), and chronic hives (urticaria). Prior to biologics, these conditions often required frequent or long-term treatment with oral steroids or other harsh medications which can cause many and serious side effects. Of course, biologics have their own side-effects but they are much rarer and treatment with them is generally well-tolerated.
The goal of treating these conditions with biologics is to achieve good control over the symptoms without needing oral steroids. For asthma, the currently available biologics include Omalizumab (Xolair), Mepolizumab (Nucala), Reslizumab (Cinqair), and Benralizumab (Fasenra). Depending on the specifics of one’s asthma, one biologic might be more appropriate than another. For eczema, the only available biologic is Dupilumab (Dupixent). As with asthma, treatment with this biologic could cut down the need for oral steroids as well as even topical steroids to maintain control of eczema symptoms. For chronic hives, the same biologic used to treat asthma, Omalizumab, has also been shown to be effective in reducing symptoms in about 70% of people.
Biologics are also a big step forward toward the lofty goal of personalized medicine. Medical research is showing that not all asthmatics have the same exact type of inflammation when one “looks under the hood.” By using the correct biologic in the correct scenario, better control of symptoms can be achieved without resorting to frequent or long-term use of harsher medications. While asthma has multiple options, eczema and chronic hives currently have only one biologic option each. The good news is that more biologics are on the way. To see if a biologic treatment is a correct option for you, make an appointment to see one of our Allergists today.
Yoram Padeh, M.D.
Board-Certified in Allergy & Immunology (ABAI)
Asthma & Allergy Associates of FL
Food allergies are growing food safety and public health concern. They affect 4%–6% of children and up to 4 % of adults in the United States. Food allergy symptoms are most common in babies and children, but they can appear at any age. Though less common; one can develop an allergy to foods eaten for years without a problem.
Why do food allergies happen?
The body’s immune system keeps one healthy by fighting off infections and other dangers to good health. A food allergy reaction occurs when the immune system overreacts to a food or a substance in a food, identifying it as a danger and triggering a protective response.
Which foods can be involved?
While any food can cause an adverse reaction, eight types of food account for about 90 % of the reactions; Milk, Eggs, Wheat, Soy, Peanuts, Tree nuts, Fish and Shellfish.
What are the symptoms of food allergies?
Symptoms of food allergy can range from mild to severe. They can present with one or more of the following: vomiting, abdominal pain, hives, tongue or throat swelling causing hoarseness or difficulty talking, inability to breathe, repetitive cough, wheezing, dizziness or feeling faint, weak pulse. Anaphylaxis is the most severe presentation of food allergy in which 2 or more of the above described symptoms happen together. This can be life threatening and has to be treated immediately. One should call 911 in case of having a life threatening reaction.
A food allergy will usually cause some sort of reaction every time the trigger food is eaten. The symptoms may be the same or different every time. The symptoms might even worsen with each exposure.
What is the timing of the reaction in relation to food?
Most food-related symptoms occur within two hours of ingestion; often they start within minutes.
Is there other kind of reaction related to food allergy?
There are some delayed reactions in the form of worsening eczema in some individuals. There are also some gastrointestinal conditions involving delayed allergies to foods; namely Eosinophilic Esophagitis. There is also a delayed food allergic condition called FPIES (food protein induced enterocolitis syndrome) which is usually seen in babies. It involves severe vomiting and diarrhea which can lead to dehydration and shock.
What is the amount of food which can trigger a reaction?
The amount of food needed to trigger an allergic reaction is different for everyone. Some people react to just a tiny exposure of food and some react after ingest a larger amount.
How is food allergy diagnosed?
You should talk about your symptoms with your primary doctor and discuss about seeing a specialist who deals with allergies. An allergist is a specialist doctor who is trained to diagnose and manage food allergies.
To make a diagnosis, the allergist will ask detailed questions about your medical history and your symptoms. They will also order skin testing and/or blood tests to arrive at a diagnosis. Skin testing involves pricking the skin with an allergen extract and a control and monitoring the area for a wheal/flare reaction (looks like a mosquito bite) . The test is not painful but the skin can be itchy where the extract is placed. A positive test does not always mean an allergy but a negative test is helpful in ruling it out. The blood tests are less accurate than the skin tests. Your allergist might use one or both types of tests to diagnose food allergies.
How is food allergy treated?
The primary way to manage a food allergy is to avoid consuming the food that triggers the allergy. There is currently no cure for food allergies; nor are there medicines to prevent reactions.
Read food labels to ensure that you don’t eat foods that contain ingredients which you are allergic to. Many ingredients have alternative names which can be confusing. Always ask about ingredients when eating at restaurants or when you are eating foods prepared by family or friends.
In case you have severe food allergy; carry an epinephrine auto injector which is prescribed by your doctor. It is a lifesaving medication which is injected into the thigh muscle in case you are having anaphylaxis. Antihistamines like Benadryl can also be used in case of mild symptoms. Talk to your allergist about having an anaphylaxis action plan and discuss treatment approach for mild symptoms.
It is especially important for children with severe food allergies in day care and school to have well documented list of food to be avoided and have an epinephrine auto injector available at all times. School personnel should know how to handle emergency situations.
What is difference between food allergy and food intolerance?
Many people who think they are allergic to a food may actually be intolerant to it. Some of the symptoms of food intolerance and food allergy are similar, but the differences between the two are very important. Proper diagnosis and distinction between food allergies and intolerance is important which can be done by an allergist.
Can I outgrow my food allergies?
It is possible for children with food allergies to grow out of them; this is especially true for foods like milk, eggs, wheat and soy. Peanut and tree nut allergies tend to be more persistent. Allergies which develop later in life tend to be lifelong. Your allergist can help in figuring this out.
I am allerigic to peanuts, is my child allergic to it?
Not necessarily, though immediate family members may be at an increased risk for food allergies. Your allergist can do simple tests to figure this out.
Where can get more information?
Before discussing allergies, we should first understand what the word “allergy” means. Allergy is basically a mistake of the immune system, where the body is trying to defend itself against a harmless substance. So, instead of the body normally ignoring a cat dander particle, an immune response is set up to fight it off as if it were an infectious organism. In this example, chronic exposure to cat dander leads to a cold-type syndrome that never seems to go away.
When allergens are airborne and are inhaled, they lead to syndromes such as allergic rhinitis (sneezing, nasal congestion, etc.) or asthma. When allergens are ingested, they lead to the symptoms of food allergy and drug allergy. Later in this article, we will discuss the particular case of preventing peanut allergy.
So why are allergies becoming more common? One theory is that the clean living in our modern society, leading to lesser exposure to invading organisms, contributes to this “allergic” mistake of the immune system. Also, the overuse of antibiotics in children probably leads to the same result. In addition, pollution, by unknown mechanisms, seems to lead to allergy. Lastly, as far as food allergies go, it appears that delaying infant feeding of certain “allergenic” foods leads to more allergies.
Science has provided a few hints on the “primary” prevention of allergy – that is, not becoming allergic in the first place.
First, having more children at home, and consequently having them share more viral infections, leads to fewer of the children having respiratory allergies. Also, likely from exposure to animal waste, being born on a farm or being exposed to pets at birth appears to lead to fewer allergies (note that once you are allergic to an animal, the animal is best removed). Also, fresh air, exercise, sunlight (Vitamin D) and healthy fats in the diet appear to lead to fewer allergies. Here you can see why children in modern industrialized societies are more allergic.
Exposure to dust mites in infancy, however, seems to lead to more respiratory allergy. Dust mites are microscopic creatures that live indoors, especially in moist and warm environments. Since our children spend more time indoors than they have in the past, this is another reason allergies are on the rise. Studies have shown that less dust mite exposure in infancy leads to less asthma, for instance.
As to the primary prevention of food allergies, studies over the last few years have told a fascinating story. About 20 years ago, allergy researchers noted an increase in food allergy, especially to milk, eggs, and peanuts. A theory developed that by delaying infant exposure to these foods until the “immune system matured,” we could reverse the trend. As it turned out, the opposite occurred. Essentially, a food allergy epidemic came into existence.
This is where the story gets interesting. Some very smart researchers noted that different countries and cultures had different rates of food allergy. Peanut allergy, for instance, seemed to be almost nonexistent in Israel compared to other Western countries. So, one group of scientists decided to compare the Israeli infant feeding habits to a genetically similar group of children in another country (Jewish children in Israel versus Jewish children in England). What they found was that Israeli children were being fed peanut-containing snacks starting at only a few months of age. Whereas, like the United States, English parents (following national guidelines) were not giving their children peanuts until about two years of age or later. So, they came up with the hypothesis that delayed feeding of peanuts was leading to an increase in allergy.
As good scientists do, they decided to test their theory. They enlisted a group of parents who agreed to have their babies enter a study where some were given peanut-containing snacks at about four months of age, whereas the others were not given peanuts until they were five years old. They then followed these children for several years to see who developed a peanut allergy. They studied only children with severe eczema or pre-existing egg allergy, as they thought that this group was at the highest risk for peanut allergy.
The results of this study (the “LEAP” trial – Learning Early About Peanut allergy) were published in 2015 in the New England Journal of Medicine. They found that early peanut introduction led to a dramatic decrease of peanut allergy at five years of age – 2% in the early group, versus 14% in those with the delayed introduction of peanuts. A study following this by the same researchers found that the effect was long-lasting.
As a result of this, US feeding guidelines for infants have recently changed. The new guidelines, issued by the National Institute of Allergy and Infectious Diseases in January 2017, recommend giving babies puréed food or finger food containing peanut protein before they are 6 months old, and even earlier if a child is prone to allergies and doctors say it is safe to do so. They caution to never give a baby whole peanuts or peanut bits because they can be a choking hazard. So, new and future parents should be asking their pediatricians about when to start peanut-containing foods in infants. Studies are ongoing regarding other foods such as milk and egg, but no answers are available yet regarding the best strategy for these foods.
“Secondary prevention,” or what to do when you are already allergic.
As far as food allergies are concerned, there is no secondary prevention besides strict avoidance of the food, as well as carrying an epinephrine self-injectable device for accidental ingestions. Studies on the elimination of existing food allergies are being done, but specific treatments are likely a few years away. It should be noted that many children outgrow their food allergies, so food-allergic children should be followed by an allergy specialist to see if and when certain foods can be safely introduced.
If one is allergic to airborne allergens, there are strategies to avoid exposure. Animal dander exposure can be lessened by rinsing the animal with water twice a week and with the use of HEPA air room filters. Obviously, if someone is allergic, the removal of the animal from the home is the best strategy. Dust mite exposure can be decreased by frequent washing of bedding, removal of carpeting, and placing dust mite-proof encasements around pillows and mattresses. Also, weather permitting, allowing fresh air into the home decreases dust mite exposure. Mold growth in the home can be especially problematic for those with allergies, so the removal of any water-damaged materials in the house is important. As far as pollens, there is no particular ideal way to avoid these allergens since being outside is so healthy otherwise. However, avoiding being outside on particularly windy days is a reasonable idea.
Lastly, another prevention strategy for existing airborne allergies is allergen immunotherapy injections or allergy shots. This treatment has been around for many decades and is still the only effective method for actually decreasing the immune allergic response of an individual. Unlike medications that only treat the symptoms, allergy shots get to the core of the problem and alter the patient’s immune system to make them less allergic.
Pollen allergy sufferers may experience relief during winter months as most outdoor allergens disappear until spring. But our South Florida winters are mild and brief with tree pollination starting in February and people with seasonal allergic rhinitis (hay fever) sensitive to tree pollen may experience bothersome episodes of recurrent sneezing and runny nose early in the year.
Indoor allergy sufferers, those allergic to house dust mites, dog or cat dander, may experience increased symptoms because we tend to spend more time indoors during winter months. Also, holiday decorations, travel and stress can all present challenges for people with allergies and asthma; for instance, Christmas trees can make some people sneeze or experience shortness of breath. It is unlikely that they are allergic to the tree itself, but the fragrance may be irritating and some trees harbor mold spores that trigger asthma and allergies that cause sneezing, itchy nose or wheezing. Ideally, use an artificial tree but, if you must have a real tree, let it dry in a garage or enclosed room for a week and have a non-allergic person give it a good shake prior to bringing it inside. Be sure to follow directions carefully when spraying artificial snow or flocking. Inhaling these sprays can irritate your lungs and trigger asthma symptoms.
In addition, during winter months, dry indoor air may cause chapped lips, dry skin, and irritated sinus passages. The moisture from a humidifier can help dry sinus passages, but for people with indoor allergies, dust and mold from the humidifier may cause problems. The number one indoor allergen is the dust mite which thrives in high humidity. Keep the humidity level in your house between 30-45% if possible. You can monitor the level with a hygrometer.
Food allergies during the holidays are also an important concern. If you have a food allergy, holiday gatherings may be difficult to navigate. Be sure to ask about the ingredients used to make each dish. Be aware of cross-contamination that can occur during preparation. If you do not feel comfortable eating foods prepared by others, bring your own snacks or eat before you arrive. And of course, have your epinephrine auto-injector handy at all times.
Cold weather activities such as cross-country skiing and other winter sports are more likely to cause exercise-induced bronchoconstriction. Symptoms include wheezing, tight chest, cough, shortness of breath and, in rare cases, chest pain which usually begins within 5 to 20 minutes of exercising. Strenuous exercise, particularly in cold air, may cause these symptoms in most asthmatics. Some people with exercise-induced bronchoconstriction do not otherwise have asthma, and people with allergies may also have trouble breathing during exercise. To cope with this condition, the first step is to develop a treatment plan with your physician. Exercise-induced bronchoconstriction may be prevented with controller medications taken regularly or by using the medicine before exercise. Once symptoms occur, they can be treated with rescue medications such as albuterol. In addition, warm-ups and cool-downs may prevent or lessen symptoms.
People with asthma should receive the yearly influenza vaccine as respiratory infections and viral respiratory infections, in particular, may exacerbate asthma symptoms. They should also strictly comply with prescribed controller asthma medications as winter months are associated with an increased incidence of asthma exacerbations.
People with atopic dermatitis or eczema may also experience winter-related flare-ups of eczema. Dry winter air may dry the skin which triggers the itch/scratch cycle typical of atopic dermatitis. People so affected should keep their skin hydrated with daily application of emollient creams immediately after bathing and more frequently as needed. Of interest, some recent studies provide strong support for the benefit of vitamin D supplementation in children with winter-related atopic dermatitis.
Some of the information provided in this article has been obtained from the allergy-library from the American Academy of Allergy Asthma and Immunology. For more information please visit aaaai.org
La estación de otoño por ser temporada de cosechas y acopio, es también, de antaño, época de grandes fiestas, verbenas, ferias y romerías que celebran la abundancia y prosperidad con amplio despliegue de manjares y golosinas. La naturaleza suavizada y vestida de oro, nos ofrece la merecida recompensa por nuestra ardua faena. Es ocasión de plenitud y satisfacción, cuando familia y amigos se reúnen alrededor de la mesa a deleitar recetas de la abuela a prueba del más exigente comensal. Para los que vivimos en el sur de la Florida, los festejos comienzan con Halloween seguidos rápidamente por el Día de los Difuntos luego por el Día de Acción de Gracia, culminan con las fiestas Navideñas, Año Nuevo y terminan con Los Reyes Magos. Se suceden tan deprisa que tal parece que al repartir las golosinas a los niños disfrazados, ya se terminó el año. Es una vertiginosa cadena de fiestas culinarias envuelta en el caluroso reencuentro con seres queridos. Es sin duda, la temporada más hermosa. Es también sin duda, la época de recetas más elaboradas y complicadas; platos fuertes con salsas contundentes, embutidos, postres con nueces, pescados, mariscos, vinos y champaña. En fin, toda una explosión gastronómica. Cabe recordar, sin deslucir las fiestas, y por razones obvias, que en esta temporada se producen la mayoría de reacciones alérgicas alimenticias. La incidencia de reacciones alérgicas en adultos se estima alrededor del 1 % de la población y en niños, algo mayor, abarcando hasta un 6 a 8 % en niños menores de 3 años. Por razones aún desconocidas, la incidencia de reacciones alérgicas alimenticias está incrementando. Por ejemplo, la alergia al maní o cacahuete ha aumentado en algunos países como Estados Unidos. Cualquier alimento es capaz de desencadenar una reacción alérgica, pero los alimentos comúnmente implicados en la gran mayoría de las reacciones alérgicas son la leche de vaca, la clara de huevo, el maní o cacahuete, las nueces, el trigo, el pescado y los mariscos. La reacción alérgica propiamente dicha es una reacción inmunológica a la proteína del alimento que casi siempre ocurre súbitamente después de la ingesta del alimento y va acompañada de urticaria o ronchas en la piel, edema o hinchazón, dificultad respiratoria y hasta descenso de presión arterial con pérdida de conocimiento. Esta reacción puede ser muy peligrosa y hasta fatal. La persona así afectada debe acudir a un especialista de alergias para confirmar la alergia a través de prueba de sangre o prueba cutáneas, debe además evitar la ingesta del alimento en cuestión y llevar consigo la adrenalina autoinyectable para usarla en caso de reacción alérgicas causada por la ingesta accidental del alimento. Existen otros tipos de reacciones alérgicas inmunológicas, como el eczema o dermatitis atópica, condición dermatológica especialmente frecuente en niños que se manifiesta con picazón y erupciones recurrentes de la piel. La dermatitis atópica a veces está relacionada con la ingesta de ciertos alimentos. Las reacciones alérgicas deben diferenciarse de otras reacciones relacionadas con ingesta de alimentos como la intolerancia alimenticia, las reacciones tóxicas, infecciosas y las indigestiones. Por ejemplo, la intolerancia a la lactosa, un carbohidrato de la leche, es una condición muy corriente que se manifiesta con dolor abdominal, flatulencia y diarrea después de ingerir leche. Las reacciones tóxicas como la ciguatera que se produce por la ingesta de pescado contaminado por la toxina o la escombriosis que se produce por la ingesta de pescado descompuesto, pueden confundirse a primera vista con reacciones alérgicas. Afortunadamente, las indigestiones que son las aflicciones más frecuentes en general y en esta época festiva en particular, en su gran mayoría, no tienen importancia. De modo que a disfrutar las fiestas con moderación y ojo con el invitado alérgico, sobre todo si es un niño. Buen provecho!
Summer means fun – school vacation and long lazy days filled with outdoor family outings, cookouts and adventure. Here in South Florida it likely includes days of sunny sandy beaches, sunscreens, pollens and insects. If you have allergies, take these simple precautions and make them part of your summer routine. Remember, an ounce of prevention is worth a pound of cure.
For most people insect stings are just a nuisance as most people are not allergic. Red and black Imported Fire Ants are common in Florida particularly during the summer months and are members of the same family as bees and wasps. Allergic reactions to these insects can be severe with immediate onset of dizziness, weakness, unconsciousness, throat tightness, difficulty breathing, wheezing or hives. People with severe allergy should carry an epinephrine auto injector (EpiPen) to be used immediately, also, the emergency medical team should be called to the scene to continue medical surveillance as soon as possible because a severe reaction may be fatal.
Insect stings can also cause local reactions that may involve a large, painful, swollen area around the sting site. Local reactions are not a major concern as they do not pose a significant risk of life-threatening reactions. Also, remember that a normal or non-allergic reaction to Fire Ants includes redness and a postule at the sting site. Fire Ants build mounds in the fields and insect repellent does not work against them, therefore, be vigilant, avoid mounds, do not wear sandals or walk barefoot in the grass.
If you have experienced a severe reaction to an insect sting, talk to your doctor for a consultation with an allergist. Your allergist will likely perform skin tests or blood tests to confirm the allergy to the specific insect and recommend a preventative program of desensitization using venom immunotherapy or allergy injection which is close to 100% effective in preventing a subsequent reaction to stings of that insect. Your allergist will prescribe an EpiPen and advise you to carry it with you at all times.
Sunscreens are a common cause of both contact dermatitis and photo contact dermatitis. Sunscreens are products applied to the skin that absorb or reflect ultraviolet (UV) radiation. One can develop an allergic reaction to the active ingredient or to the fragrances and preservatives present in the sunscreen. If you experience an allergic reaction to a sunscreen, remove the sunscreen, wash the skin with soap and water and apply a cortisone cream. Follow up with your doctor for possible referral to an allergist or dermatologist to determine a safe UV protection alternative sunscreen. It is important to identify the chemical responsible for the allergic reaction so you can avoid using a skin product containing such a chemical in the future. Contact allergy tends to persist indefinitely and avoidance is the only preventive treatment available at this time.
Large amounts of pollen are released into the air by some plants for the purpose of fertilization. These pollen when inhaled by an allergic person trigger an inflammatory reaction in the mucosa of their nose, bronchial tree and conjunctiva which in turn causes sneezing, runny nose, itchy eyes, cough, wheezing and even asthma.
People with seasonal allergies experience symptoms during a specific season. Here in Florida people allergic to grass pollen experience more severe symptoms during the summer months when our grasses are pollinating. Those allergic to tree pollen are affected during the spring and those allergic to weed pollen are affected during the fall.
Most pollens are released into the air during early morning hours, so avoid being outdoors during the early mornings. Wear sunglasses to protect your eyes, avoid gardening and yard work especially during the morning hours, and change clothing, wash your hands and hair when you come home. Monitor the daily pollen and mold counts at allergyweb.com
Immunotherapy or allergy injection is a safe and effective preventive treatment that can significantly reduce allergy symptoms. Your allergist will perform skin or blood testing to accurately identify your specific sensitivities to aero-allergens such as pollen, house dust mites, and mold spores. Once your specific allergies are identified, your allergist may recommend immunotherapy or allergy shot which is a treatment program to desensitize you to your specific allergies. Immunotherapy should enable you to inhale the allergens in their natural environment with greatly reduced inflammation of the respiratory tract and therefore significant reduction of symptoms.
Food Allergy is relatively rare, it affects approximately 1% of the adult population and up to 6 to 8 % of children under 3 years. For reasons not well understood, the incidence of food allergy is increasing and peanut allergy is particularly increasing in some countries such as the United States. Any food can cause an allergic reaction but the foods implicated in the great majority of reactions are cow’s milk, egg peanut, tree nuts, wheat, fish and shellfish.
The allergic reaction is an immunologic reaction to a protein in the food. The reaction occurs shortly, usually within 4 hours but sometimes immediately after the ingestion of the food and can cause itchy hives in the skin, swelling, a lump in the throat, difficulty breathing, wheezing, tight chest, dizziness, loss of consciousness and even death. People with food allergies, like people with insect allergies, should always carry an epinephrine auto-injector or EpiPen to be used immediately after a reaction to accidental food ingestion. Also, Fire Rescue should be called to the scene to continue medical management as the duration of the effects of EpiPen is only about 15 min.
If you have a food allergy ask your doctor to refer you to an allergist. Your allergist will confirm the allergy to the suspected food by performing skin tests or blood tests. You should strictly avoid the culprit food, read all food labels and be vigilant of hidden sources of the food in restaurants and friend’s homes. Always carry the EpiPen and familiarize yourself with its proper use. Tell your friends that you are allergic and to which specific food. Make sure to inform teachers, camp supervisors, babysitters and anyone responsible for the care of your child that your child is allergic to a specific food or family of foods. Some people are allergic to peanut and all tree nuts or to all fish or all shellfish. Also, teachers and caregivers should have an EpiPen and be taught when and how to use it.
Prepare and make a checklist to not forget the necessary medications, sprays, and inhalers. If allergic to insects or foods, be vigilant of flying insects, Fire Ant mounds and inform everyone that you have a food allergy. And always, always bring your EpiPen. Have a wonderful and safe summer!
by Dr. Ubals
An allergy is a peculiar reaction to a substance that is not harmful to normal, non-allergic people. “Allergy,” however, is an often misunderstood term. Most people believe that an allergy refers to any uncomfortable reaction to a substance that is inhaled, eaten, or that touches the skin. Symptoms that are attributed to allergy include sneezing, wheezing, nasal irritation, cough, runny and/or stuffy nose, heartburn, bloating, diarrhea, and a variety of skin rashes.
The main confusion is that some substances can cause these symptoms in a non-allergic way. Examples of non-allergic reactions would be inhaling perfume (causing sneezing because of simple irritation) and ingesting milk (causing bloating because of a deficiency of an enzyme that helps digest sugars in the milk). Further complicating the issue is that a substance like milk can also cause true allergic reactions including hives and wheezing.
In fact, “allergy” implies that the body’s immune system is responding to a substance, or allergen, in such a way that it leads to some of the symptoms mentioned above. This occurs when the immune system sends white blood cells (as well as other cells and chemical mediators) to the site of the body where it encounters an allergen. These cells and chemicals cause changes in the tissues that lead to allergic-type symptoms. Examples of allergens include tree pollen, cat dander, dust mites, and several foods.
A requirement of such an allergic immune response is that the immune system is able to recognize a substance as being foreign – not normally present in the body. Put simply, the substance must contain molecules with certain characteristics (having a protein or large carbohydrate structure, for example) to enable it to be recognized by the immune system and give rise to an allergic response. This explains why the runny nose caused by cold air in some is not a true allergic phenomenon. People with allergic inflammation in their noses, however, are often more troubled by irritants such as smoke. A useful analogy is the following: Salt poured on intact, healthy skin causes no discomfort, but if you pour salt on an open wound it is quite painful.
Why allergy occurs in the first place is still a mystery. Some believe that allergy is simply a mistake of the immune system. That is, the immune system may “believe” that an allergen is an infectious organism such as bacteria or virus. Consequently, the immune system sends those white blood cells (such as lymphocytes) and chemicals to the tissues to ward off this false infection. Nasal congestion, for instance, might represent the immune system’s attempt to restrict the allergen (thinking it’s a virus or bacteria) from gaining deeper entry into the body.
Researchers have noted that there is an increase in the proportion of people suffering from allergies. Some believe that air pollution and heavier exposure to indoor allergens (spending more time inside tightly insulated homes) is to blame. Another interesting theory is that allergies are our society’s trade-off for being so sanitary. That is, our immune system is not as busy fighting off genuine infections as much as before, with the consequence being more frequent mistaken allergic immune responses. This theory is interesting in light of the lower incidence of allergy seen in poorer parts of the world with more exposure to parasitic infections.
Another very interesting development of the past few years has been the rise in food allergy. It turns out that the medical establishment apparently got this one wrong. They figured that having infants avoid allergy-causing foods until they were older would lead to a decrease in food allergy. So, several years ago, there were recommendations that suggested that children avoid peanuts, for instance, until they were one or two years of age. The result of these recommendations likely leads to an increase in peanut allergy. Recent studies from Israel and England have shown that exposing children to peanuts very early in life led to a decrease in the incidence of peanut allergy.
Finally, the question is what to do about treating allergic symptoms? First, it is important to determine what a person may be allergic to. The diagnosis can sometimes be made by the patient’s history alone, but allergy skin tests are needed to confirm the diagnosis. The next step is to avoid exposure to allergens. For food allergies, this is the only scientifically proven treatment. But for airborne allergens, medications can be very helpful since it may be impossible to totally avoid exposure. In addition to medications, immunotherapy (allergen injections) can be an effective remedy.
I was going to write a blog entry about this exciting new asthma drug that should be available for use very soon. But then, Dr. Alan Khadavi, an Allergy/Immunology Specialist from Los Angeles beat me to it. So, as I always say, “Don’t reinvent the wheel.” The drug appears to be very safe and effective, and will be in the form of an injection and probably given in a doctor’s office once a month. It will be for adults with asthma who are still having troublesome symptoms despite the proper use of daily maintenance inhalers such as Advair, Symbicort, Dulera, Flovent, and Qvar.
I read several of the articles on Dr. Khadavi’s blog, and they are all excellent – so check them out at:
Neil Gershman, MD
The US FDA has recently unanimously recommended Nucala (Mepolizumab) for add on maintenance treatment in patients 18 years older with severe eosinophilic asthma. The panel recommended against Nucala (mepolizumab) for children aged 12 to 17 years old. Severe eosinophilic asthma is defined as a blood eosinophil count greater than 150 cells/microliters at the start of treatment or greater than 300 anytime the past 12 months.
There are currently no approved treatments for patients with severe asthma with predefined eosinophil levels.
Nucala or Mepolizumab is a humanized monoclonal antibody to human interleukin 5 (IL-5). IL-5 is primarily involved in the regulation of blood and tissue eosinophils. Eosinophils are responsible for airway inflammation in asthma. Thereby by using Nucala (Mepolizumab) which blocks IL-5, this would reduce expression of eosinophils in the blood and tissue.
Nucala (Mepolizumab) is proposed to be administered subcutaneously every 4 weeks. Clinical studies showed a significant reduction in asthma exacerbations in treatment groups receiving Nucala (mepolizumab). The rate of hospitalizations or ER visits was lower in the treatment groups of Nucala (mepolizumab) than the placebo groups.
Side effects seen were local injection site reactions and possibly hypersensitivity reactions with Nucala (mepolizumab). Long term side effects remain to be seen as this drug still hasn’t come out on the market yet.
This would be the second monoclonal antibody drug to come out in the market for severe asthma. Xolair (omalizumab) has been on the market for years and it is used to treat severe persistent asthma. It blocks IgE receptors in the blood and it also has an indication for chronic idiopathic urticaria. It works well in patients who have allergic asthma, but it is very cost prohibitive, in some cases, it can be thousands of dollars a month. There is currently no price yet on Nucala (mepolizumab), but most likely it won’t be inexpensive.
But for the patients who have severe persistent eosinophilic asthma, who do not respond to conventional asthma medications, Nucala (mepolizumab) may be a good treatment option in the future. You should speak with your allergist or allergy doctor to see if Nucala (mepolizumab) is right for you.
This story reminds me of the movie, “Sleeper.” The Woody Allen movie from the 70s focuses on a man who was put into a cryogenic freeze when he died after a simple operation in a New York hospital. He woke up 200 years later and found that the world was very different. He was surprised that everyone was smoking cigarettes. This future scientist told him that research had determined that tobacco was extremely healthy for the lungs.
Of course, this is silly, but one thing rings true. As science moves forward, some old dogma turns out to be very wrong. This is the case with the thought of restricting allergenic foods until later in life. Pediatricians have been taught to tell parents that they shouldn’t give their children such foods as milk, egg, peanuts, and shellfish until the child is much older. That advice is likely the opposite of good advice.
The idea about peanut introduction early in life came from an observation that children in Israel were less likely to develop a peanut allergy than children in other parts of the world. Israeli children are fed, at a very early age, treats that contain fairly large amounts of peanuts, whereas children in England, for instance, aren’t supposed to eat peanuts until much later.
So British researchers started a study looking at the very early introduction of peanuts into the diet of infants. They found that there was a dramatic decrease (80% less peanut allergy) in the incidence of peanut allergy as children grew up. I imagine that, in the very near future, the recommendations for when to introduce allergenic foods will be drastically different than in the past. To learn more information, contact at https://allergyweb.com/
Subcutaneous allergen immunotherapy (SCIT), or “allergy shot therapy,” has been around since the early 1900s. It is considered a well-accepted therapy for allergic rhinitis and asthma. Sublingual immunotherapy (SLIT) has garnered a great deal of attention lately since two sublingual tablet formulations to treat grass allergy were reviewed by an FDA advisory committee. The advisory committee recommended approval of Oralair™ and Grastek™ tablets, which are meant to treat grass pollen allergy symptoms. Although the FDA is not bound by the committee’s guidance, typically approval of the products follows soon afterwards.
While we at the Asthma & Allergy Associates of Florida are always excited about new therapies for allergic disease, we are concerned about what is starting to unfold in the medical community. It is clear that these pharmaceutical company manufactured sublingual tablets are effective, but it is not at all certain that compounded sublingual or under-the-tongue “allergy drops” (liquid treatments made up from allergen extracts that are only approved for injection therapy) will benefit patients. We fear that these drops will gain popularity in that they will be offered as treatment for a larger variety of allergens versus conventional injection therapy. Patients may ask, “Why should I only get treated for grass allergy, when I am allergic to so many things such as dust mite, animal dander, and mold?” There are two main issues regarding sublingual therapy. First, the “devil is in the dosing.” Secondly, there is no good data supporting sublingual therapy for more than one allergen at a time. Thirdly, the delivery system, a tablet versus a liquid, can make a big difference in effectiveness.
Subcutaneous immunotherapy (SCIT), or injection therapy, has been shown in several studies to be a very cost-effective option for treating allergic rhinitis and asthma. It may be a different story for sublingual therapy(SLIT).
As far as the dosing, the most conservative estimates are that the dose needed for effective SLIT is 30 times more than that needed for injection therapy. This can lead to a very high cost to treat a patient effectively. While the raw extract cost for injection therapy may only be a few dollars a month (the majority of the cost being due to the need for administrative staff, nurses, and supervision by the physician), the extract costs for sublingual therapy will end up being extremely high when more one or two allergens is being treated. A ballpark estimate, based on controlled studies of sublingual therapy, would be that the cost of extract alone in treating year-round allergens such as dust mite, cat and dog allergy would be $50-$100 for each allergen. Treating pollens would be slightly less per allergen. The consequence is that the extract costs would be prohibitive for most American patients who are usually allergic to multiple allergens. To this point, in Europe, where sublingual therapy is most popular, patients are typically treated for one allergen. Another hint as to the potential the high cost of this therapy is that the estimate for the cost upcoming grass tablets will be approximately $150 per month, and this is only to treat one allergen.
As far as the second point, there is really no good data to support treating more than one allergen at a time with sublingual therapy, as very few studies have been done. Lastly, as was mentioned above, there may be differences in effectiveness when the allergen is given in different formats (tablet vs liquid). The products on the horizon to be approved in the United States are mostly tablets.
Also concerning to us are claims that sublingual therapy is more effective than injection therapy for allergies. There is absolutely no basis in fact for this. There are some studies showing similar benefit, but the majority of the evidence suggests a greater benefit with injection therapy.
There is no question that the idea of sublingual therapy allergy is an attractive one. Because of the lower incidence of allergic reactions with sublingual therapy, patients would be able to treat themselves at home as opposed to getting therapy in a doctor’s office. Also, because of the lower chance of reactions, very young children can be treated. Plus, no needles are involved.
In summary, the question is not whether sublingual allergen immunotherapy works (it apparently does), it is whether physicians are going to use adequate doses in the proper format. For unclear reasons, allergic individuals in the US tend to be allergic to multiple allergens. This results in sublingual therapy being an expensive proposition.
We foresee that SLIT will have a place in certain situations (small children, patients allergic to one or two allergens, moderate to severe asthmatics). Asthma and Allergy Associates of Florida is in the process of deciding the best situations in which to use this type of therapy. We strongly suggest to the public that the be very aware of the limitations of sublingual therapy. For example, we would advise any patient being offered this therapy to specifically ask their physician whether they will be receiving an adequate dose of each allergen.
There is an detailed and referenced review of this topic at the following address: http://www.asthmacenter.com/index.php/News/details/sublingual_immunotherapy/
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