Reactions to ecallantide (Kalbitor) in some HAE patients decreased hopes that the drug could be used at home

From MedPage Today:

Some patients with hereditary angioedema (HAE) have suffered severe reactions to ecallantide (Kalbitor) in treating acute attacks, thus decreasing the hopes that the drug could be used at home.


New therapies for hereditary angioedema (HAE) (click to enlarge the image).

Unlike the other FDA-approved product for treating HAE attacks - a replacement protein that must be infused intravenously - ecallantide can be administered by subcutaneous injection. That had raised hopes that patients could keep syringes of the drug with them to use immediately in case of an attack.

But the anaphylactic reactions led the FDA to require a boxed warning on the product label, requiring that ecallantide be administered by a healthcare professional prepared to manage such reactions.

Another product, icatibant, is also making its way toward U.S. approval. That drug is a peptide-based selective bradykinin receptor antagonist -- like ecallantide, given by subcutaneous injection -- and is now available in Europe, but the FDA rejected an initial application in 2008.

Updated, 2011: Icatibant is approved for home use. Ecallantide must be administered in a physician-monitored environment.

References:

AAAAI: Study Continues of HAE Drug Reactions. MedPage Today.

Virtually No Relapses After Ecallantide for Acute HAE attacks, despite short half-life. Medscape, 2011.

Hizentra is 20% immunoglobulin for subcutaneous therapy (SCIG) of immunodeficiency

CSL Behring, the maker of Vivaglobin (Immune Globulin Subcutaneous [Human]) announced that Hizentra is now commercially available. Hizentra is the first and currently only subcutaneous 20% liquid immunoglobulin (Ig) therapy indicated for the treatment of patients with primary immunodeficiency disease (PIDD).

This high-concentration product is stabilized with L-proline, a naturally-occurring amino acid. L-proline allows Hizentra to be stored at room temperature (up to 25°C [77°F]) - no refrigeration is necessary.

Hizentra can be self-administered by patients under a physician's care.

Safety Information

Because it contains the stabilizer L-proline, Hizentra is contraindicated in patients with hyperprolinemia. Hizentra is also contraindicated in patients with immunoglobulin A deficiency who have known antibody against IgA and a history of hypersensitivity.

Hizentra is derived from human plasma. The risk of transmission of infectious agents, including viruses and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent, cannot be completely eliminated.

The most common drug-related adverse reactions (observed in 5% or more of subjects in the clinical trial) were local reactions (ie, swelling, redness, heat, pain, and itching at the injection site), headache, vomiting, pain, and fatigue.

Ig administration can transiently impair the efficacy of live attenuated virus vaccines, such as measles, mumps and rubella. It can also lead to misinterpretation of serologic testing.

Coding Information

ICD-9-CM Diagnosis Codes

279.0 Deficiency of humoral immunity

279.00 Hypogammaglobulinemia, unspecified

- Agammaglobulinemia NOS

279.01 Selective IgA immunodeficiency

279.02 Selective IgM immunodeficiency

279.03 Other selective immunoglobulin defi ciency

279.04* Congenital hypogammaglobulinemia

- Agammaglobulinemia: Bruton’s type; X-linked

279.05* Immunodeficiency with increased IgM

- Immunodeficiency with hyper-IgM: autosomal recessive; X-linked

279.06* Common variable immunodeficiency

- Dysgammaglobulinemia: acquired, congenital, primary

- Hypogammaglobulinemia: acquired, primary

- Congenital non-sex linked

- Sporadic

279.09 Transient hypogammaglobulinemia of infancy

279.1 Deficiency of cell-mediated immunity

279.10 Immunodeficiency with predominant T-cell defect, unspecified

279.11 DiGeorge syndrome with thymic hypoplasia

279.12* Wiskott-Aldrich syndrome

279.13 Nezelof’s syndrome

- Cellular immunodeficiency with abnormal immunoglobulin deficiency

279.2* Combined immunity deficiency

Agammaglobulinemia:

Autosomal recessive

Swiss-type

X-linked recessive

Severe combined immunodefi ciency (SCID)

Thymic: Alymphoplasia, aplasia, or dysplasia with immunodeficiency

*All Medicare-approved codes.

Here are some helpful links regarding SCIG and Hizentra specifically:

Hizentra Dosage Calculator
http://www.hizentra.com/professional/about-hizentra/hizentra-dosage-calculator.aspx

Nurse Locator helps yo find nurse agencies that staff nurses who completed the SHARE training program for SCIG:
http://www.hizentra.com/professional/initiating-hizentra/sub-q-therapy-nurse-locator.aspx

References

CSL Behring Receives FDA Approval of Hizentra™, First 20 Percent Subcutaneous Immunoglobulin Therapy
HyQvia combines IgG Infusion 10% and hyaluronidase, packaged as a kit for treatment of primary immunodeficiency. Baxter, 2012.

Difference between Hizentra and Vivaglobin (PDF).

Coding Information (PDF).

Related reading

Possible association between a subcutaneous immune globulin (Vivaglobin) and thrombotic events - ongoing FDA review (PDF).
http://reference.medscape.com/drug/hizentra-immune-globulin-sc-343219

Rates of food sensitivity vary by country, hazelnuts are the most common cause

Nations varied in the rate of people who were sensitive to at least one food (via specific IgE) -- ranging from about 25% of those in Portland, Oregon, to just under 8% of those in Reykjavik, Iceland.

Certain foods that people commonly view as potential allergy triggers -- namely, milk, eggs and fish -- were among the least common causes of food sensitivity.

Along with the U.S., Germany, Italy and Norway had the highest prevalence of food sensitivity -- 22%.

The lowest rates were seen in Iceland (11%), Spain (11%), France and the UK (each around 14%).

Hazelnuts, peaches, shrimp, wheat and apples were the most common allergens. At the other end of the spectrum, fish, eggs and cow's milk were the least common causes of sensitivity.

7% of people across the nations had sensitivity to hazelnuts but U.S., Germany, Norway and Sweden had a prevalence of 12-15%. The next most common causes of sensitivity were peaches, shrimp and wheat, which each affected about 5% of people across countries.

"Sensitivity", as defined in this study, does not predict clinical reactivity. Sensitivity is not the same as food allergy.

References:
Rates of food sensitivity vary by country: study. Reuters, 2010.

Image source: Wikipedia, GNU Free Documentation License.

Poem by an allergy patient

Voice

Each spring my voice changes
As the trees, oaks and pines, begin to leaf,
Taking on qualities of Lauren Bacall’s
Or leaving me soundless.
“What? I can’t hear you.” the caller says.
“Sorry, it’s allergies,” I reply into the receiver, trying for more volume.


Spring through the eyes of someone having an allergy (click to enlarge the image). The author of the picture is Splashi on Flickr: "Shot with the help of a brave mate of mine sitting in our more or less crowded city, sweating. But he did a great job to show the flipside of spring and flowering nature." All rights reserved. Reproduced under fair use license.

It should not be this way. Please see an allergist today to get immediate relief and long-term control: Locate an Allergist - ACAAI

References:

Suture for a Living: Voice, 2010.

Intranasal corticosteroids may reverse rhinitis medicamentosa

Chronic use of intranasal decongestants like oxymetazoline leads to tachyphylaxis of response and rebound congestion, due to alpha-adrenoceptor mediated down-regulation and desensitization of response

In a randomized, double-blind, placebo-controlled trial 19 healthy subjects received intranasal oxymetazoline tid for 14 days, followed by addition of fluticasone bid for a further 3 days.

Oxymetazoline-induced tachyphylaxis and rebound congestion was reversed by intranasal fluticasone.

References:
Fluticasone Reverses Oxymetazoline Induced Tachyphylaxis of Response and Rebound Congestion. Vaidyanathan S, Williamson P, Clearie K, Khan F, Lipworth B. Am J Respir Crit Care Med. 2010 Mar 4. Link via @wheezemd

Pseudoephedrine used in allergic rhinitis improved stuffy nose but decreased sexual activity http://goo.gl/1uLxb

Oxymetazoline for 1 month adds to nasal steroid effect in perennial allergic rhinitis, without development of rhinitis medicamentosa. JACI, 2011.
Image source: Amazon, used for illustrative purposes only - NOT a suggestion to purchase any medications.


Afrin - Costco.

Increased risk of pneumococcal disease in patients with atopic conditions

The same research group has previously reported an increased risk of serious pneumococcal disease (SPD) among patients with asthma.

The study subjects were residents of Rochester, Minn, who developed SPD between 1964 and 1983 and their matched matched controls.

All individuals with atopic conditions were identified by the physician diagnoses including atopic dermatitis or eczema, allergic rhinitis, and hay fever. A total of 3941 records were reviewed and 174 SPD cases identified.

14.9% of the SPD cases and 8.3% of the controls had atopy.

Atopic conditions other than asthma were associated with an increased risk of SPD (odds ratio, 2.13).

The study authors concluded that like asthma, other atopic conditions, particularly atopic dermatitis, are associated with an increased risk of SPD. There may be a common immunogenetic mechanism underlying increased risk of SPD.

References:
Increased risk of serious pneumococcal disease in patients with atopic conditions other than asthma. Jung JA, Kita H, Yawn BP, Boyce TG, Yoo KH, McGree ME, Weaver AL, Wollan P, Jacobson RM, Juhn YJ. J Allergy Clin Immunol. 2010 Jan;125(1):217-221.
http://www.ncbi.nlm.nih.gov/pubmed/20109748?dopt=Abstract

Image source: SEM micrograph of S. pneumoniae. Wikipedia, public domain.

How useful are prebiotics, probiotics and synbiotics in allergic diseases?

With the advent of the hygiene hypothesis, probiotics have provided an avenue of hope in curbing the allergic epidemic. The initial enthusiasm has been tempered by the complexities of this approach.

Definitions of probiotics, prebiotics, and synbiotics

Probiotic: "A preparation of or a product containing viable, defined microorganisms in sufficient numbers, which alter the microflora (by implantation or colonization) in a compartment of the host and by that exert beneficial health effects in this host."

Prebiotic: "a non-digestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon." This definition more or less overlaps with the definition of dietary fiber, with the exception of its selectivity for certain species.

Synbiotic: a product contains both probiotics and prebiotics.

Probiotics have shown limited promise in the prevention of allergic disease rather than in the treatment of established disease. These effects have been limited to the prevention of early childhood conditions such as eczema.

At this stage, the effects of prebiotics, synbiotics and postbiotics are even less clear.

Microbiota modulate immune development and can prevent the allergic phenotype but the optimal way of achieving this is unclear. Supplementation with a single probiotic strain may be oversimplistic.

Given the current level of evidence, it is not appropriate to recommend prebiotics/probiotics/synbiotics or postbiotics as a part of standard therapy or for the prevention of any allergic conditions.

This 2012 study found beneficial effects: Protective effect of Lactobacillus probiotic against eczema in infants persists up to age 4, including for rhinitis.

References:

Practical prebiotics, probiotics and synbiotics for allergists: how useful are they? Johannsen H, Prescott SL. Clin Exp Allergy. 2009 Dec;39(12):1801-14.
Probiotics, prebiotics, and synbiotics--approaching a definition. Schrezenmeir J, de Vrese M. Am J Clin Nutr. 2001 Feb;73(2 Suppl):361S-364S.
Synbiotics prevent asthma-like symptoms in infants with atopic dermatitis http://goo.gl/izEI
Weak efficacy of probiotic Lactobacillus GG for prevention of allergic sensitization and asthma in infants at risk http://goo.gl/jYxPNew evidence relates prebiotics to reduced occurrence of AD. JACI Journal Club http://goo.gl/qUyE
Probiotics given to pregnant women reduced incidence of atopic dermatitis, but had no effect on atopic sensitization. http://goo.gl/xcQiProbiotics and Prebiotics in Pediatrics http://goo.gl/daCiz
Probiotics may down modulate key parameters of allergic rhinitis. Clin Exp Allergy 2011.
"The Office" misinterprets the hygiene hypothesis (video) http://goo.gl/9YhwL
Probiotics and Prebiotics in Pediatrics. PEDIATRICS Vol. 126 No. 6 December 2010, pp. 1217-1231 (doi:10.1542/peds.2010-2548).
Probiotics do not have an established role in the prevention or treatment of allergy http://buff.ly/YBewzd
Image source: Cacık, a Turkish cold appetiser yoghurt variety, Wikipedia, Creative Commons Attribution ShareAlike 3.0 License.

51% of adult patients with asthma have clinically significant anxiety

Of these only 21% had already been diagnosed and were receiving treatment.

Females reported significantly higher scores than males. More females (66.3%) registered clinically significant levels of anxiety as compared with males.

There was a positive correlation between the Beck Anxiety Inventory (BAI) score and the prescribed dose of inhaled glucocorticoids. There was also a positive correlation between anxiety and the number of medicines taken by patients.

Physicians treating patients with asthma should be aware of the association between asthma and anxiety. Always assess patients for the possibility of anxiety disorders as part of asthma management plans.

References:

Anxiety and the Management of Asthma in an Adult Outpatient Population. Medscape, 2010.

The burden of adult asthma in the United States: patients with asthma less likely to be employed (odds ratio, 0.78) http://goo.gl/eCNuu

Increased prevalence of behavioral problems in children with asthma. http://goo.gl/qz3Bm
Individuals with allergic rhinitis appear to be at a higher risk for developing anxiety and mood disorders - study http://goo.gl/hIwq9

Sad in the spring? Allergy-mood link is real - CNN, 2011.

Image source: Openclipart.org, public domain.

The most cost effective oral antihistamine?

The most cost effective oral antihistamine is probably cetirizine (Zyrtec) at Costco Wholesale Club - it costs $15.49 for one year supply of 365 tablets.







Related reading:

Allergy drug recommendations for patients on a budget. KevinMD, 2010.

Patient response to different antihistamines will vary http://goo.gl/Q2PiV
Costco Still Rocks for Allergy meds - generic alternatives to brand name OTC medications at very reasonable prices
Treatment approaches to seasonal allergies reviewed by an allergist on Dr. Oz show (video). 

1 in 5 seasonal allergy sufferers misses work because of their symptoms

Researchers found pollen was the most commonly cited source of seasonal allergies (79%), followed by grasses (59%), ragweed (54%), and trees (52%).

Only 40% of spring allergy sufferers said they were completely or very successful at managing their allergy symptoms in the previous allergy season. Itchy eyes were the most common symptom (87%), followed by sneezing (80%), runny nose (77%), and watery eyes (73%).

Treatment

Avoidance was the most popular type of treatment tried (74%), followed by over-the-counter medicines (70%) and prescription drugs (59%).

The most popular prescription medications mentioned in the survey were:

- steroid nasal sprays, such as Flonase and Nasonex

- Singulair pill

The over-the-counter allergy medications taken most often by people with spring allergies were the antihistamines Benadryl Allergy, Claritin, and Zyrtec, and the decongestant Sudafed.


Oral Antihistamines (click to enlarge the image).

References:

Seasonal Allergy Relief Can Be Hard to Find. WebMD.

Image source: Wikipedia, a Creative Commons license.

Neomycin is the Allergen of the Year 2010

Neomycin is the Contact Allergen of the Year 2010. It is widely present in topical OTC medications such as Neosporin (shown above at Costco Wholesale Club).

References:
Allergen of the Year: Neomycin

European allergen extracts have at least 50% lower potency than US extracts

The most important allergen manufacturers are based in Europe and in the US. In some countries local products are also sold.

The aim of this study was to to determine total protein content and total specific IgE binding capacity or major allergen content of diagnostic extracts from European, US and Mexican origins for Dermatophagoides pteronyssinus (Dpt), Bermuda grass and cat (Fel d 1) (10,000 BAU/mL).

Total protein content of US reference extracts was higher than all other extracts.

Locally produced Mexican products were almost all below 1,000 BAU/mL.

Three diagnostic extracts from European manufacturers and from Mexican providers have a less than 50% relative potency compared to 10,000 BAU/mL of the US extracts. Locally produced Mexican extracts have much lower total protein content and specific IgE binding capacity.

References:
A comparison of in vitro potency between European and Mexican allergen extracts and US (CBER/FDA) reference extracts. Larenas-Linnemann D, Esch RE, Guidos-Fogelbach G, Rodriguez-Pérez N. Allergol Immunopathol (Madr). 2010 Mar 23.

Diagnostic extracts of dust mite used in Europe and Mexico are less potent than those used in the United States. http://www.ncbi.nlm.nih.gov/pubmed/20486333

Image source: Life expectancy around the world. Wikipedia, GNU Free Documentation License.

Epinephrine autoinjectors in order of patient preference: INT prototypes, then EpiPen followed by TwinJect

Prefilled epinephrine autoinjectors are sometimes improperly used by patients, caregivers, and physicians.

A user-centered design process led to the development of 2 prototype epinephrine autoinjectors (INT01 and INT02) that have:

- unidirectional perceived injection end

- self-retracting needle

- voice instructions to assist in guiding users through administration (INT02)

48 participants were divided equally among 3 age groups: 7 to 10, 11 to 15, and 16 to 55 years.

In each group, half had prior TwinJect or EpiPen training. In 1-hour sessions, without training, participants performed simulated-use testing under observation for all 4 epinephrine delivery systems.

More participants correctly followed all device instructions with INT02 (46%) than with INT01 (27%), EpiPen (12%), or TwinJect (0%). The youngest age group [those aged 7-10 years] performed significantly worse.

The first choice of overall preference was greater for INT02 (73%) vs. INT01 (15%), EpiPen (10%), and TwinJect (2%).

The user-centered device design may have a significant impact on correct epinephrine autoinjector use and patient preference.

Accidental Injection of Epinephrine Into Finger (click to enlarge the image).

References:
A comparison of 4 epinephrine autoinjector delivery systems: usability and patient preference.
Guerlain S, Hugine A, Wang L. Ann Allergy Asthma Immunol. 2010 Feb;104(2):172-7.

What are the ‘ideal’ features of an adrenaline (epinephrine) auto-injector in the treatment of anaphylaxis? http://goo.gl/lxCh

Figure: Design overview of currently available auto-injectors for emergency self-administration of adrenaline in the treatment of anaphylaxis.

Free Rhinoscopy Teaching Videos

Dr. William Dolan reviews the principles and practice of performing fiberoptic rhinolaryngoscopy, ACAAI COLA video, Jan 27, 2012:



Free Rhinoscopy Teaching Videos are available from Selner's Rhinolaryngoscopy Online:

http://www.mcg.edu/pediatrics/allergy/rhino/index.html

Dr. John Selner, former ACAAI President, conducted rhinolaryngoscopy workshops at the ACAAI annual meeting for many years.

A new website is now open for medical professionals to view and learn from these materials. The Medical College of Georgia will be offering CME programs based upon this information. These videos, slides, annotations, and text have been endorsed by the ACAAI Board or Regents.


Nose and nasal cavities. Image source: Wikipedia, public domain.

Intravenous montelukast not helpful in children with acute asthma

Up to 30% of patients require hospitalization for acute asthma despite standard therapy in the emergency department. In adults, intravenous montelukast added to standard therapy significantly improved forced expiratory volume in 1 second (FEV1) and reduced hospital admissions.

This was a randomized, double-blind, placebo-controlled, multicenter study of children aged 6 to 14 years. Patients with an FEV1 of 75% or less of the predicted value after 2 hours of standard therapy (e.g., oxygen, albuterol, inhaled anticholinergics, and systemic oral corticosteroids) were randomized to intravenous montelukast, 5.25 mg or placebo. Montelukast is available in the U.S. in oral form as Singulair.

Montelukast was not significantly more effective than placebo for FEV1 when added to standard therapy (0.08 vs. 0.07 L).

In this study of children with acute asthma, intravenous montelukast was not significantly better than placebo in improving FEV1, symptoms, or overall hospital course.

References:
A randomized, placebo-controlled study of intravenous montelukast in children with acute asthma. Morris CR, Becker AB, Piñieiro A, Massaad R, Green SA, Smugar SS, Gurner DM. Ann Allergy Asthma Immunol. 2010 Feb;104(2):161-71.

Intravenous montelukast may be effective as treatment for acute asthma

Urinary leukotriene E(4)/exhaled nitric oxide ratio predicts montelukast response in childhood asthma http://goo.gl/i5cG

Image source: Montelukast, from Wikipedia, the free encyclopedia, public domain.

Food Allergy in the Media: Misdiagnosed and Misunderstood

From the NYTimes and JAMA:

Many who think they have food allergies actually do not. The true incidence of food allergies is about 8 percent for children and less than 5 percent for adults. Yet about 30 percent of the population believe they have food allergies. Even people who had food allergies as children may not have them as adults. People often shed allergies, though no one knows why.

50% of the patients coming to the allergy clinics because they had been told they had afood allergy did not really have one.

People who receive a diagnosis after one of the two tests most often used — pricking the skin and looking in blood for IgE antibodies, the type associated with allergies — have less than a 50 percent chance actually having a food allergy.

One of the biggest misconceptions some doctors have is that a positive test for IgE antibodies to a food means a person is allergic to that food.

During development, the immune system tends to react to certain food proteins, producing IgE antibodies. These antibodies can be transient and even inconsequential. There are plenty of individuals with IgE antibodies to various foods who don’t react to those foods at all.

Summary receiver operating characteristic curves comparing skin prick tests (area under the curve [AUC], 0.87) and serum food-specific IgE (AUC, 0.84) to food challenge showed no statistical superiority for either test. Elimination diets are the mainstay of therapy but have been rarely studied. Immunotherapy is promising but data are insufficient to recommend use. In high-risk infants, hydrolyzed formulas may prevent cow's milk allergy but standardized definitions of high risk and hydrolyzed formula do not exist.

What is the solution?

See a board-certified allergist for correct diagnosis and treatment - you can find an allergist in your area here: http://www.acaai.org/patients/Pages/locate-an-allergist.aspx

References:
Food Allergies Less Common Than Believed, Study Say. NYTimes.
Schneider Chafen JJ, et al. Diagnosis and managing common food allergies. JAMA 2010; 303(18): 1848-56.
What Is a Food Allergy? No One Is Sure. MedPageToday.

Image source: Roasted peanuts as snack food, Wikipedia, public domain.

Thaumatin-like protein is new allergen associated with baker's asthma

Baker's asthma and rhinitis are among the most common occupational diseases. Inhaled cereal flours, such as wheat, especially cause this disease. Prevalence of wheat allergy in Japan is 0.2% - the assessment was based on questionnaire-based exam, skin prick test, and omega-5 gliadin sIgE (http://goo.gl/Mp4nW).

Potential wheat allergens were purified using chromatographic methods from protein extracts of wheat flour and were used in skin prick tests.

10 patients with baker's rhinitis, asthma, or both participated in this study. All the patients had positive skin prick test reactions and specific IgE antibodies to wheat flour. The series included 10 control patients.

Allergen concentrations of 0.3-0.5 mg/mL revealed that:

- 12 patients reacted to a-amylase inhibitor (alpha-AI)

- 9 to peroxidase I (PI)

- 9 to thaumatin-like protein (TLP)

- 6 to lipid transfer protein 2G (LTP2G)

Of these, TLP and LTP2G are now observed to be new allergens associated with baker's asthma.

In addition to the earlier-described alpha-AI and PI, TLP and LTP2G are important in vivo wheat allergens in baker's allergies.

Thaumatin is a low-calorie protein sweetener and flavor modifier. The thaumatins were first found as a mixture of proteins isolated from the katemfe fruit (Thaumatococcus daniellii Bennett) of west Africa.

References:
Thaumatin-like protein and baker's respiratory allergy. Lehto M, Airaksinen L, Puustinen A, Tillander S, Hannula S, Nyman T, Toskala E, Alenius H, Lauerma A. Ann Allergy Asthma Immunol. 2010 Feb;104(2):139-46.

Celiac Disease: Small bowel biopsy remains the gold standard for diagnosis, gluten-free diet the only treatment option. Medscape, 2011.

Occupational sensitization to soy allergens in workers at a processing facility, high molecular weight allergens Gly m 5 and Gly m 6 may be the respiratory sensitizers http://goo.gl/6oXYd
Workforce occupational asthma in New Zealand. The highest risks: printer/baker/sawmill labourer/metal processing. Ann Occup Hyg. 2010.

Image source: Wheat flour, Wikipedia, R. Wampers, Creative Commons Attribution-Share Alike 2.0 Belgium license.

Herbal remedies in asthma associated with lower adherence to inhaled steroids and worse outcomes

Complementary and alternative medicines (CAM), such as herbal remedies, are widely used by patients with chronic diseases, such as asthma.

The researchers surveyed 326 adults with persistent asthma who received care at 2 inner-city outpatient clinics. Patients were asked about CAM use (teas, herbs, and rubs) for the treatment of asthma in the prior 6 months.

25.4% of patients reported herbal remedy use. Herbal remedy use was associated with decreased inhaled corticosteroids (ICSs) adherence and increased asthma morbidity. Herbal remedy users were also more likely to worry about the adverse effects of ICSs.

The use of herbal remedies was associated with lower adherence to ICSs and worse outcomes among inner-city asthmatic patients. Medication beliefs, such as worry about ICS adverse effects, may in part mediate this relationship. Physicians should routinely ask patients with asthma about CAM use, especially those whose asthma is poorly controlled.

A 2012 study suggested that complementary and alternative medicine (CAM) and adherence with pediatric asthma treatment were not necessarily “competitive” http://goo.gl/HPUJR

References:

Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients. Roy A, Lurslurchachai L, Halm EA, Li XM, Leventhal H, Wisnivesky JP. Ann Allergy Asthma Immunol. 2010 Feb;104(2):132-8.

Nearly all of the herbal dietary supplements tested contained trace amounts of lead, pesticides and other contaminants. NYTimes, 2010.

No Chinese manufacturer has successfully registered herbal medicinal products in the EU - all will be banned in May. The Lancet, 2011.
"Traditional Chinese herbal remedy kampo relieved asthma symptoms in nearly all patients in Japanese study". WebMD, 2012.

Image source: Wikipedia, public domain.

Oral allergy syndrome may progress to systemic symptoms in 8.7% and anaphylactic shock in 1.7%

Oral allergy syndrome (OAS) occurs in patients with a prior cross-reactive aeroallergen sensitization and clinically presents with oralpharyngeal symptoms after ingestion of a triggering fruit or vegetable.

Although controversial, these symptoms may progress to systemic symptoms outside the gastrointestinal tract in 8.7% of patients and anaphylactic shock in 1.7%.

OAS's underlying pathophysiology may play a role in clinical presentation and outcome, depending on whether the cross-reactive protein is a heat-labile PR-10 protein, a partially labile profilin, or a relatively heat-stable lipid transfer protein. Profilin is an actin-binding protein involved in the restructuring of the actin cytoskeleton. It is found in all eukaryotic organisms in most cells.

Diagnostic testing is variable based on the underlying food tested, but fresh food skin prick test typically has the highest sensitivity.


Cross-reactivity in Pollen-Food Allergy Syndrome (PFAS) or Oral Allergy Syndrome (OAS) (click to enlarge the image).

Treatment centers on avoidance and the consideration of self-injectable epinephrine. Because of its relationship with a cross-reactive aeroallergen sensitization, subcutaneous immunotherapy and sublingual immunotherapy have also been therapeutically tried with mixed results.

Which allergen cross-reacts with Bet v1 (birch)?

(A) Ara h1 (peanut)

(B) Mal d 1 (apple)

(C) Ara h3 (peanut)

(D) Bos d (milk)

(E) Gal d (egg)

(F) Hev b2 (latex)

Answer: B, apple. Pollen sensitizations linked to food allergies was first reported with birch pollen and apples 50 years ago.

For patients:

Do raw or fresh fruits leave you sneezing, sniffling and with an itchy mouth, lips and throat? You may have oral allergy syndrome.

References:

Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge. Webber CM, England RW. Ann Allergy Asthma Immunol. 2010 Feb;104(2):101-8; quiz 109-10, 117.

Profilin may be a pan-allergen among plants that crossreacts between pollen, fruits, vegetables and latex http://goo.gl/ZUPRQ

Flavored Coffee May Trigger Seasonal Allergies - due to oral allergy syndrome. Fox News, 2011.

Birch-Apple Syndrome Treated with Birch Pollen Immunotherapy (Oral Allergy Syndrome) http://goo.gl/4cASx
In birch-apple syndrome (oral allergy syndrome), eating apple does not affect the respiratory tract. Annals of Allergy, Asthma and Immunology, 2011.

Image source: Head and neck. Wikipedia, public domain.

Spring through the eyes of someone having an allergy

Spring through the eyes of someone having an allergy (click to enlarge the image).

Author is Splashi on Flickr: "Shot with the help of a brave mate of mine sitting in our more or less crowded city, sweating. But he did a great job to show the flipside of spring and flowering nature." All rights reserved. Reproduced under fair use license.

It should not be this way. Please see an allergist today to get immediate relief and long-term control: Locate an Allergist - ACAAI

50% of children with soy allergy outgrew their allergy by age 7 years

Soy allergy is very common, affecting approximately 0.4% of children. It is generally thought that the majority of children with soy allergy develop tolerance in early childhood.

The records of patients with soy allergy seen in a tertiary referral clinic were reviewed and 133 patients were studied (96 male and 37 female patients):

- 64% had asthma

- 71% had allergic rhinitis

- 85% had atopic dermatitis

- 88% had concomitant peanut allergy

The median age at the initial visit was 1 year and the median duration of follow-up was 5 years.

Kaplan-Meier analysis predicted resolution of soy allergy in 25% by age 4 years, 45% by age 6 years, and 69% by age 10 years.

50% of children with soy allergy outgrew their allergy by age 7 years. Absolute soy IgE levels were useful predictors of outgrowing soy allergy.

References:
The natural history of soy allergy. Savage JH, Kaeding AJ, Matsui EC, Wood RA. J Allergy Clin Immunol. 2010 Mar;125(3):683-686.

Image source: Amazon.com, used for illustrative purposes only - NOT a suggestion to purchase any medications.

Doctor shortage, or not?

From Twitter:

@amednews: The Assn. of American Medical Colleges predicts a shortage of at least 125,000 physicians by 2025. http://bit.ly/cIAslO

@DoctorMac: I feel like there have been doctor shortage predictions since I was in med school. Haven't seen it yet, esp when job hunting.

@MatthewBowdish: Really? I've looked at 'overrepresented markets' like SoCal. Nml ratio allergist/gen pop 1:45K. In LA 1:178K, OC 1:91K, SD 1:78K. Part of problem is distribution, part is small turnover in tiny field of a/i. But look how long Walla Walla, WA has been recruiting. We also have several rural monthly/bimonthly clinics that are booked for 5-8 months.

Related:

Starting a new medical school can cost $100 million to $150 million. Many private medical schools have 5,000 or more applicants for a class of 100 students.

http://www.ama-assn.org/amednews/2010/03/29/prl20329.htm

Where America needs doctors, in one map - The Washington Post http://goo.gl/iL6TY and http://goo.gl/MiimZ

Image source: OpenClipArt.org, public domain.

Adiposity is associated with poorer asthma control in women but not in men

368 adolescents with moderate-to-severe asthma (ages 12-20 years) living in 10 urban areas were prospectively followed for 1 year.

More than 60% of female subjects and 50% of male subjects were above the 85th percentile of BMI for age. Higher BMI was associated with more symptom days and exacerbations among female subjects only.

Adiponectin was inversely related to asthma symptoms and exacerbations and positively with FEV(1)/forced vital capacity ratio in male subjects only, independent of body size.

There was no relationship between adiposity or adipokines and total IgE levels, blood eosinophil counts, and exhaled nitric oxide levels.

Adiposity is associated with poorer asthma control in female subjects. Adiponectin is associated with improved asthma control in male subjects.

Higher body mass index may decrease response to inhaled corticosteroids in persistent asthma (http://goo.gl/Xt6eP).

References:

Asthma control, adiposity, and adipokines among inner-city adolescents. Kattan M, Kumar R, Bloomberg GR, Mitchell HE, Calatroni A, Gergen PJ, Kercsmar CM, Visness CM, Matsui EC, Steinbach SF, Szefler SJ, Sorkness CA, Morgan WJ, Teach SJ, Gan VN. J Allergy Clin Immunol. 2010 Mar;125(3):584-92.

Women are more likely to be diagnosed with asthma and suffer greater morbidity than men. Medscape, 2011.

Decreased response to inhaled steroids in overweight and obese asthmatic children. JACI, 2011.

Image source: Wikipedia, public domain.

Log cabin out of expired Epi-Pens

From Flickr user leah.claire: "i made a log cabin out of expired epi-pens and twinjects! oh the life of a kid with food allergies... =]"

References:

What are the ‘ideal’ features of an adrenaline (epinephrine) auto-injector in the treatment of anaphylaxis? http://goo.gl/lxCh

Figure: Design overview of currently available auto-injectors for emergency self-administration of adrenaline in the treatment of anaphylaxis.

Allergist offers desensitization to food allergic children: "There you go. Hit it"

View more videos at: http://www.nbcdfw.com.

"Allergist Dr. Richard Wasserman started this food desensitization program 18 months ago. It's a rigorous, risky treatment that can last up to six months.

Dr. Wasserman admits there are allergists who think this treatment is too risky, exposes patients to much potential harm. Another allergist said that this is promising, but has not been studied enough.

Dr. Wasserman says the program costs about 5-thousand-dollars if all goes smoothly. Some insurance companies do pay for it."

What is the difference between desensitization and tolerance in food allergy?

Oral immunotherapy (OIT) successfully induced desensitization in peanut allergy. Can OIT induce tolerance too?

Desensitization is an increase in threshold of ingested food antigen needed to cause allergic symptoms (achieved w OIT).

Tolerance is the induction of long-term immunologic changes with the ability to ingest food without symptoms and WITHOUT ongoing THERAPY.

Oral immunotherapy (OIT) is not read for prime time yet, according to the leading food allergy experts from Mount Sinai, Duke University, and Johns Hopkins.

References:

Food Allergies. WRCBtv.
http://www.wrcbtv.com/Global/story.asp?S=12421640

NBC5

What is the difference between desensitization and tolerance in food allergy?

Peanut oral immunotherapy in peanut allergy: symptoms more likely during initial escalation day

Adverse reactions during peanut oral immunotherapy home dosing. JACI, Volume 124, Issue 6, Pages 1351-1352 (December 2009).

Office-based oral immunotherapy for food allergy is safe and effective - according to the Texas allergist group that uses it http://goo.gl/S4N8W

Peanut oral immunotherapy (20 peanuts) induces desensitization, however questions about long-term tolerance remain. JACI, 2011.

Oral immunotherapy for peanut allergy - interview with Dr. Wesley Burks: clearly 15-20% will not tolerate the treatment http://goo.gl/U45UB
Oral immunotherapy for food allergy in the news: "Girl sneaks peanuts past her allergy" http://goo.gl/oRLbj - Still experimental.
Sublingual and oral immunotherapy for milk allergy. Desensitization was lost in some cases within 1 week off therapy. JACI, 2011.
The place of oral desensitization in the practice of allergy at this time is in flux - see why: http://goo.gl/gNKLD