Asthma and Peanut Allergy

A recent abstract promoted at the American Thoracic Society meeting on the topic of children with asthma being prone to peanut sensitization. The authors suggest children who do have asthma are more likely to be sensitive to peanuts and therefore kids with asthma should be tested for peanut allergy. This abstract was received with a lot of controversy. If there is no clinical history of peanut allergy in a child that has asthma, no there is no indication to test for peanut allergy, but environmental testing may be helpful. There is no evidence in diagnosing peanut allergy helps treat asthma. Chronic asthma is not a manifestation of peanut allergy or peanut sensitization. The diagnosis of food allergy results in symptoms of cough, wheezing, hives, swelling, vomiting etc. Without a history of this, food testing is not indicated. These reactions usually occur within 2 hours after ingesting a food, and usually it occurs much sooner. Besides peanuts, the most common food allergies are tree nuts, shellfish, fish, wheat, milk, soy and eggs. Chronic and poorly uncontrolled asthma is not a result of a hidden food (peanut) allergy. There is no reason to do food allergy testing in these patients unless the clinical history indicates it as above. But asthmatic children who have asthma could benefit from inhalant (environmental testing). i.e. pollen, animal dander, dust mites. Food allergy testing from a blood test or a skin test is insufficient to diagnose a food allergy. Many patients on food testing show up positive to a food and there is no clinical history after eating the food in question. Positive food testing results should always be interpreted with a clinical history. If a patient has no history of any allergic reactions after eating a certain food, then allergy testing for that food is not necessary. While children who have food allergy have a higher risk of asthma, and children who have asthma have a higher risk of food allergies, food allergy testing every asthmatic child is not indicated. What is more worthwhile is environmental allergy testing. Many children with asthma are triggered by allergens in the environmental such as trees, grass, weeds, dust mite, molds, dogs and cats. Knowing which inhalant allergens a child is allergic to can help manage asthma. So in conclusion if your child has asthma it is not necessary to do allergy tests for foods (especially peanut), but allergy testing for inhalant allergens is actually more beneficial. Your local allergy doctor or allergist can perform allergy testing in the office for you. ORIGINAL TEXT AVAILABLE AT http://allergylosangeles.com

Antibiotics and food allergy induction

The hygiene hypothesis is the most common theory for increased food allergy. It begins with a lack of  early childhood exposure to infections. Without proper stimuli the immune system does not receive necessary education. When presented with food proteins, the normal response (tolerance) is replaced by hypersensitivity. A recent article, in the early edition of Proceedings of the National Academy of Science*, adds further support for a revised hygiene hypothesis, with emphasis on symbiotic microorganisms living in the gastrointestinal tract. The authors identified a common bacteria found in the gut (aka probiotic) that may prevent development of food allergy, specifically peanut. Much research is needed but here is another potential pathway to a cure for peanut allergy.

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    * Commensal bacteria protect against food allergen sensitization; Stefka et al.

Allergic reactions without answers

Chronic hives are a common problem in the general population and in my practice. Children and adults can suffer daily itching and hives for months or years without explanation. However, symptoms often resolve spontaneously and most importantly, the risk of a severe reaction is very low. On the other hand, there is a separate condition called idiopathic anaphylaxis. People with this condition will have more severe allergic reactions; symptoms may include hives and swelling but there may also be upper airway obstruction, wheezing, shortness of breath, decreased blood pressure or fainting. If a patient presents to the office after having a severe reaction, my primary goal is to identify what caused the reaction. Subsequent avoidance can prevent future problems. The most common (known) causes include foods, medications and stings. Unfortunately, a thorough history and physical exam may night identify a cause (or even a suspect). This situation occurs in 30-60% of adults and up to 10% of children. Risk factors include female gender and reported penicillin allergy. Here are some possible explanations for idiopathic anaphylaxis:
  • Hidden food allergens. Expanding testing to include a large food panel may help to identify the cause. Unfortunately studies have shown little success, finding a cause in only 7% of cases. Other studies have ruled out food preservatives as causes of idiopathic anaphylaxis, including sulfites, MSG and aspartame.
  • Female hormones.
  • Immune abnormalities.
  • Increased sensitivity to histamine.
  • Autoimmune disease.
  • Delayed allergy to beef, pork or lamb. An allergic reaction to the oligosaccharide alpha-gal. Transmitted by the Lone Star tick.
  • Conditions which mimic anaphylaxis: somatoform disorder, scromboidosis (poisoning form “spoiled” fish).
Here are some tests that may be done:
  • Skin (or blood) testing to foods and/or medications.
  • Serum anti-alpha-gal IgE.
  • Tryptase level. Prostaglandin D2.
  • Urinary histamine metabolites.
  • Genetic analysis.
Here are possible treatments:
  • Anti-histamines.
  • Oral Steroids.
  • Oral albuterol.
 

Food allergy resources

A new diagnosis of food allergy is life-changing. The questions are endless. I am putting together a new section on the website for parents and patients with food allergy, new and old. I will include links, recipes, diet sheets and school forms. If you have a valuable resource that you would like to share, please let me know. Check it out.

Update: Oralair approved for grass pollen allergy

The FDA has approved the first product for oral immunotherapy!  Oralair is a tablet containing five grass allergens; Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass. It is manufactured by Stallergenes, a French pharmaceutical company. It will be marketed and sold in the United States by Greer Laboratories. Allergy immunotherapy is the most effective treatment for environmental (and possibly food) allergies. It is all natural, containing only the allergens you are allergic to, and the only treatment that prevents disease. Immunotherapy can be given as a shot, drop or tablet. It is no surprise that our first [glossary slug=’sublingual’]sublingual[/glossary] option is coming out of Europe. For many years, allergists in Europe have chosen the sublingual route rahter than subcutaneous (shots). There are other differences in the way allergies are treated here and abroad. Most sublingual products contain only one allergen. For example, grass pollen. However, up to 40% of patients have allergy to more than one substance. Allergists in the United States attempt to treat as many of the patient’s allergies as they can, administering a mix of several allergens in shot form. For example, grass pollen plus dust mites. Here is a more complete discussion, see this article (Allergy Tablet Approval Warrants Caution for Some). It is not clear which method is better, one allergen or many. Probably there is no one right answer that would apply to everyone. The same is true in the debate, shots vs. drops/tablets. Shots are more effective but drops/tablets are more convenient. In the end, the approval of ORALAIR provides an additional treatment option for allergy specialists and their patients. If more patients get treatment then we all benefit. UPDATE (2): TOO LATE FOR 2013 For best results, Oralair should be started 2 months prior to the grass pollen season. In the northeast, May and June are the months with peak grass pollen levels. If Oralair is available this May then it would be too late for 2013.
PRESS RELEASE (excerpts):
– Grass allergy is the most common seasonal allergy in the United States and most people are allergic to more than one type of grass. ORALAIR contains a mix of five grass pollens: Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass. The five grass pollens contained in ORALAIR represent those to which most patients in the U.S. are exposed. – ORALAIR is indicated as immunotherapy for the treatment of grass pollen-induced allergic rhinitis with or without conjunctivitis confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies for any of the five grass species contained in this product. ORALAIR is approved for use in persons 10 through 65 years of age. – ORALAIR is a tablet that dissolves under the tongue. The first dose is taken in the doctor’s office under medical supervision, and subsequent doses are administered once a day by the patient or the patient’s caregiver. ORALAIR treatment should be started four months before the expected onset of each grass pollen season and continued throughout the season. Allergy symptoms are reduced beginning with the first grass pollen season. – ORALAIR was originally approved in Europe in 2008 and is currently authorized in 31 countries around the world, including most European countries, Canada, Australia, and Russia for the treatment of grass pollen allergy. In Canada, ORALAIR was launched in 2012, making it the first allergy immunotherapy tablet to be registered and marketed in North America. Worldwide post-marketing experience with ORALAIR includes more than 20 million doses given to more than 110,000 patients. – ORALAIR has been approved based on results from an extensive clinical development program. ORALAIR has been studied in double-blind, placebo-controlled trials, in both Europe and the United States in over 2,500 adults and children. The results of these trials demonstrated that pre-seasonal and co-seasonal treatment reduces patients’ allergy symptoms and their need for symptom-relieving medication. In the clinical development program, the most common adverse reactions for ORALAIR (reported in >=5% of patients) were oral pruritus, throat irritation, ear pruritus, mouth edema, tongue pruritus, cough, and oropharyngeal pain.

Stress & Allergy

It is clear to those suffering, allergies cause stress. Constant runny nose, decreased quality of sleep, missed days at school and work are among the many reasons why. A new study from Ohio State University* flips this conclusion on its head and asks; can stress cause allergies? Our bodies immune system is not limited to the nose. It involves organs and cells throughout the body. The inflammatory chemicals produced during an allergic reaction can have wide ranging effects. Likewise, the endocrine system will respond to stress by increasing (or decreasing) hormone levels throughout the body. These two systems do not live in isolation. In this study, subjects were asked to complete daily diaries. They recorded allergy symptoms, mood and stress levels using a secure website. The data showed that patients with higher stress scores experienced more allergy flares. Also, there was a similar relationship between negative mood and rhinitis symptoms. For most patients, the effect was spread out over time, a stressful day did not occur together with a bad allergy day. However, for a few more sensitive subjects there was a pattern of increased allergy symptoms on stressful days. The authors conclude that allergic individuals with persistent emotional stress have more frequent allergy symptoms. They recommend stress reduction techneques, such as meditation for the treatment of allergy symptoms. However, it should be noted, this study does not prove cause and effect. There is no evidence that the stress causes the allergy as opposed to the allergy causing the stress. Either way, stress-reduction is a good thing.   * Patterson A, Yildiz V, Klatt M, Malarkey W. Perceived stress predicts allergy flares. Ann Allergy Asthma Immunol 112 (2014) 317-321.

What is Eosinophilic Esophagitis?

Eosinophilic esophagitis (EoE) is an inflammatory condition affecting the esophagus (the tube that connects the throat with the stomach). The esophagus contains too high a number of eosinophils, an allergic white blood cell. This causes several gastrointestinal symptoms, including difficulty swallowing, nausea,vomiting and reflux. Diagnosis: To confirm the diagnosis requires an upper endoscopy and biopsy. Unfortunately, no less invasive procedures are available to diagnose or monitor EoE. The Role of Allergies: The majority of individuals with EoE have family histories of allergies and symptoms of one or more allergic disorders such as asthma, nasal allergies, atopic dermatitis or food allergy. Food allergy is a major cause of EoE in children, and a less probable factor in adult EoE. Environmental allergies such as dust mites, animals, pollens and molds may also play a role. Treatment of EE: – Diet. Avoidance of common allergens (milk, egg, soy, wheat, nuts and fish) may eliminate the symptoms and underlying inflammation of EoE. Atopy patch testing may help to guide food choices. – Medications. Steroids are effective at shutting down inflammation and eosinophil production. Local delivery helps to lessen side effects. This is achieved by swallowing those steroids indicated for asthma (either a fluticasone inhaler or budesonide for the nebulizer machine). The initial diagnosis of EoE can be overwhelming. Working closely with your healthcare team is the best way to assure you are receiving proper care. Additionally, families often benefit from participation in support groups, such as the American Partnership for Eosinophilic Disorders (APFED) at www.apfed.org.

Xolair approved for chronic hives

The FDA has approved omalizumab (Xolair) for the treatment of chronic hives. This is the first medication with a specific indication for [glossary slug=’chronic-idiopathic-urticaria’ /] (CIU). There are many patients with CIU that remain symptomatic, covered in hives and itchy despite multiple medications. The addition of Xolair may help these patients get their symptoms under control. The good: – Current treatment options are limited and often ineffective. – Convenience. Xolair is given as an injection on a monthly basis. Current medication regimens may include up to 20 pills per day. The bad: – Xolair is expensive and will require pre-approval. – Several clinical studies have demonstrated a high degree of safety. However, there are concerns that Xolair use may increase the risk of cardiac events and severe allergic reactions. The ugly: – Xolair, like other available medications, suppresses the hives but does not fix the underlying problem. Optimally, a cause can be identified and corrected or avoided.  
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Allergy shots, a new source of savings

dollar_iconAllergies are common and costly. Total costs are in the billions. An increasing proportion of this number is being shifted to the patient, in the form of higher copays and deductibles. The price of health care is now a real part of our health care conversation. When choosing the most appropriate allergy treatment, doctors and patients should consider efficacy, side effects and cost. The most common treatment options for allergy patients are: 1. Avoidance 2. Medications 3. Immunotherapy (also know as allergy shots) It is well established that allergy shots provide the most relief but are they worth the cost? A recent study* used an advanced computer model to address this question.  They considered these factors most important in making a decision:
  • patient age
  • life expectancy
  • number of months per year medications are required
  • cost of medications
  • number of allergies
  • duration of immunotherapy (3 vs 5 years)
A virtual allergy patient was put through economic analysis. He was doing well using an intra-nasal steroid, the gold standard in treatment. Unfortunately, nasal sprays do not alter the course of the disease, symptoms recur shortly after they are discontinued. There is no endpoint for the patient.  On the other hand, immunotherapy can induce long term tolerance after only 3-5 years of therapy. This means that the benefits will continue long after your shots are finished. Despite this advantage, allergy shots are usually reserved for patients who fail medical therapy. Economically, younger patients would be better off with 3-5 years of shots, not a lifetime of nasal steroids. cost_chart                 The attached figure demonstrates a large area where immunotherapy is more cost effective than medical therapy. It must be noted, this figure only represents those patients that are doing well on nasal sprays.  For patients who continue to have symptoms despite medications, the decision would be shifted heavily in favor of allergy shots.   * Kennedy J, Robinson D, Christophel J, Borish L, Payne S. Decision-making analysis for allergen immunotherapy versus nasal steroids in the treatment of nasal steroid‐responsive allergic rhinitis. American Journal of Rhinology & Allergy.  2014; 28(1) 59-64.

Difficult to treat eczema: a review of medications

Sometimes moisturizers and steroid creams aren’t enough. Many patients with severe eczema (atopic dermatitis, AD) require oral medications to keep their skin clear and itching under control. A recent article out of Amsterdam and Germany, reviewed the risks and benefits of several systemic therapies*. Here are the recommendations:
  • Cyclosporin A: first-line short term treatment option for moderate to severe AD. Higher doses (5 mg/kg/day) lead to a more rapid response and higher efficacy.
  • Azathioprine: second-line treatment option.
  • Methotrexate: third-line treatment option for adults.
  • IFN-γ: third-line treatment option.
  • Systemic steroids: not recommended.
  • Intravenous immunoglobulin: not recommended.
  • Montelukast (Singulair): not recommended.
  • Traditional Chinese herbal medicine (TCHM): not recommended.
  • [glossary slug=’mycobacterium-vaccae’ /]: not recommended.
  • Thympopentin-5 (an immunostimulant): not recommended.
What was not included: What needs to be stated:
  • All of these medications can have significant side effects.
  • It is important to maximize topical treatments, including moisturizers and medications.
  • It is important to identify and minimize exposure to triggers, including foods and contact allergens.
  * Roekevisch E, Spuls PI, Kuester D, Limpens J. Efficacy and safety of systemic treatments for moderate-to-severe atopic dermatitis: A systematic review. Journal of Allergy and Clinical Immunology 2014; 133(2) 429-438.