2008
Welcome to my first attempt ‘blogging’. My daughter and her husband have been doing this for years and it has been most enjoyable. I thought it may have some utility as a supplement to my clinical practice of allergy/clinical immunology. Here goes……..
FAST FORWARD
2023 —
And that was how this began. That young lady is now 15 years old.
Imagine going out on a boat. Trouble begins and the boat starts to sink. You are some distance from shore. You think about how good a swimmer you are which leads you to consider a few other options. Where is that life preserver? The recommendations (and hopes) are that it be within reach or that you are wearing it. That life preserver would be of little use if it was left on the dock.
Now think about asthma. You are out there and because this is an unpredictable condition, trouble starts. Where is your life preserver? Where is your inhaler? Should it be on your person just as that life jacket? This is a real concern and an issue that affects life and the quality of that life for those with asthma.
In the world of managing asthma we have two basic categories of medications: the long-term controller medications and fast-acting rescue medications. I like the use of the term ‘rescue’. These agents work fast and when used in a rescue fashion they help open the airways. The rescue medication will work usually within 15 minutes of application. A few examples of what would be considered asthma rescue medications frequently used for children include:
These agents can be effectively given by a metered dose inhaler (puffer) or through nebulization. Everyone who has asthma, regardless if it is intermittent or one of the three types of persistent asthma (mild, moderate, or severe), must have a rescue inhaler! This has been spelled out since the first edition of asthma guidelines (1991) and is an important part of the most recent NHLBI Guidelines for the Diagnosis and Management of Asthma. This is a well established recommendation, but how do we see it in real life situations?
I have always wondered where the rescue medication is kept, and how long it would take for someone to find and use their rescue medication when symptoms began. Recently, I had a chance to investigate that question.
I just finished a Masters in Public Health program at Indiana University Purdue University Indianapolis (IUPUI). (As an aside, anyone interested in conditions that affect the health of the population would find the pursuit of this type of a masters program most rewarding.) Some courses required doing field projects, especially in the epidemiology and biostatistics courses. I decided to do a project that involved the use of rescue medications by children with asthma.
In biostatistics you need to have a hypothesis, i.e., a statement that will be supported or found to not be true. My hypothesis was that all children with asthma have a rescue medication with them (or have immediate access). I was also interested whether or not a number of variables such as age, severity, or duration of asthma had any relationship to rescue medication availability. The questionnaire was answered by 124 children with asthma. I found that only 28% either carried their inhaler with them or had immediate (within 2-3 minutes) access to rescue medication. That means 72%, over two-thirds may have had to hustle to find rescue medication.
I asked this question of children who were about 10 years old. Just over half were boys. The group was representative of a suburban population. They severity of the asthma was as follows:
These children were asthma-experienced: the duration of having asthma was 6.6 years. This is where the inhalers were with this asthma-savvy group:
The next question was how long would it take to find and use your rescue medication?
The perfectionist in me felt that 5 minutes may be a concern, however there is a real issue with the 32% that needed 15 or more minutes.
There are a number of possible reasons for what I would consider a delay in rescue medication application. Our habits are that when things are going well, we tend to not be as vigilant. A well-controlled child with asthma would have very little additional need for a rescue medication so the lack of immediate access may be due to the success of other therapies. In fact, only 25% had used their rescue inhaler within the preceding month.
I was surprised by the results of my biostatistics project (not the grade, but the findings). As a specialist in the area of asthma care I learned something new and something that will help me to help my patients with asthma. I did not have to read this in a journal about some other population of children, this was a group of kids here at home, in my own backyard. My lesson learned is to be sure to ask the question and to use that basic principle of pediatrics- prevention. Prevent disasters but emphasize the concept of rescue and support any opportunity for the easy and quick access of that life preserver. I do not hesitate in writing those permission slips so medications can be carried at school. Yes there is concern about ‘medications’ and the possibility of misuse/abuse I fully understand that. I also hear about and see children who are very scared with these sudden, acute attacks of respiratory distress. Acute asthma events are not predictable, they are serious, and they need to be addressed urgently. The rescue inhaler needs to be readily available.
Respectfully submitted,
Fred Leickly
I recently attended the 2009 annual meeting of the American Academy of Allergy, Asthma, and Immunology(AAAAI) in Washington, DC. There were five days of extraordinary educational activities (March 13-17, 2009). I thought that while I could still read my notes I would share with you a few things I observed, heard, and learned in the ever evolving world of allergy. I plan to adopt many of these changes in my practice.
The meeting’s agenda covered a wide variety of clinical conditions. It would have been impossible to attend every session. I chose sessions on the allergic environment, eczema, immunotherapy, food allergy, re-certification, headaches, and asthma. There are a number of ideas that are evolving and a number of things currently done in allergy/asthma care that need to change. Each and every one of these topics is truly worthy of more extensive review. I would be happy to use this blog to delve into topics in more detail (per request).
Atopic Dermatitis (aka Eczema)
I still need to be convinced regarding what to call this condition. Dr. Jeff Travers (chief of Dermatology at the IU School of Medicine) and I go back and forth on this topic. During the meeting I heard the concept of extrinsic and intrinsic atopic dermatitis. Extrinsic means from the outside and intrinsic from the inside. These terms have also been used for years to describe two presentations of asthma: extrinsic asthma due to allergy, and intrinsic asthma when no allergy is found. The word atopic means 1) the tendency to come from families with allergy, 2) to make the antibody seen with allergy (IgE, which would be elevated) and 3) to have positive allergy tests. Thus, Intrinsic AtopicDermatitis means no allergy demonstrated (intrinsic) in a condition associated with allergic sensitization (atopic). This blending of terms leads to confusion–why not stick with the simpler term of eczema?
I learned about the use of silver impregnated clothing to decrease the amount of bacteria on the skin. Skin bacteria can cause flaring of atopic dermatitis.
A number of genes associated with atopic dermatitis have been discovered. These discoveries should increase our understanding on how this condition starts and hopefully how we can manage it better.
There was information on allergens that contain enzymes called proteases and how these protease containing allergens aggravate the skin.
Probiotics have been used to treat allergic conditions especially conditions related to food allergy. A review of studies on probiotics have not shown them to be effective in preventing or treating atopic dermatitis.
I listened to debates about being proactive in skin care therapy vs. being reactive. Proactive would be trying to prevent and reactive being treating only when there is a problem. This idea was particularly interesting. Atopic Dermatitis Guidelines and package inserts for a variety of medications used for atopic dermatitis treatment stress short courses of use, the reactive approach. The proactive debater posed the problem of a chronic disease that will have episodic flaring. The abnormality of the skin is there all the time requiring the need for medication to be used perhaps twice a week to avoid flares (those times when the skin is more itchy, more inflamed, and more broken down). Pediatrics deals extensively with disease prevention. My pediatric perspectives are preventative- proactive. All too often we (as patients) tend to be crisis-oriented or reactive to chronic conditions. I am obviously on the proactive side of this argument.
Therapies emphasized moisture and more moisture. Keep these kids wet! This is clearly a major step that is contrary to previous approaches that recommended the avoidance of frequent soaking/bathing. The avoidance of baths is clearly one of those long established principles of atopic skin care that has fallen by the wayside in contemporary skin care.
Foods are an issue in atopic dermatitis. The protease containing allergens such as molds, pets, and mites may have a role in triggering flares.
In Boston a program that has had success includes insuring compliance with the medications (taking them as prescribed), addressing the parents concerns about medication side-effects (helps with compliance), decreasing the itch, and increasing sleep. These are all essential elements to help with control of the condition.
Of note, we need to re-think the role of a specific therapy and make adjustments. Antihistamines are frequently used in atopic dermatitis. In allergic rhinitis and in hives, these products help control itch. However, in atopic dermatitis, the antihistamines have little effect on itch. The role of the anti-histamine is to sedate. Most of the scratching happens at night. A sedating antihistamine used at night works best.
Asthma
There were a number of new ideas regarding asthma. Look for vitamin D to have a possible role in treatment.
Current recommendations from evidenced-based asthma guidelines point out a difference between adults and children and the use of the long-acting bronchodilators in the two populations. These agents are called long-acting broncho-dilators (LABAs). In children, we should increase the dose of the inhaled corticosteroid before adding a LABA. This recommendation appears in two major asthma guidelines with type A evidence used to support the recommendation. This type of evidence (A) means that there are a substantial number of studies that support this statement.
Asthma may be related to bacterial colonization at birth and to the occurrence of the common cold virus later in life. Evidence was also presented regarding the observation from large population studies that the process of airway inflammation starts well before actual symptoms. We heard about diet, viruses, stress, ozone, and endotoxin having a role in the development of asthma. The gene or genes for asthma need to be present. These genes then need to be activated or expressed for the child to show the signs and symptoms of disease. Bacterial colonization and a variety viruses may have a role in activating the genes.
Headaches
This was a great session. The audience heard from an ENT surgeon, an allergist, and a neurologist regarding their approach to headaches. The consensus was that migraine is the biggest player in these situations. The connection of allergy to headache has always been a concern. However, headache is not a manifestation of allergy. There are many studies that have looked at this. People with headaches can have positive allergy tests but does that make the allergen the cause of the headache? Think about other conditions or associations. Could there be an allergic cause for an appendicitis?
I heard of the concept of ‘allergic appendicitis’ during this presentation. It was very odd to hear about this in a headache session, but a valid point was made. This concept of the allergic appendix was compared to allergic headaches. Follow along; data from a national health survey from 1994 indicated that 50% of the population reported that they had allergy. So if someone who had problems with the appendix was allergy tested, the chances are very high that allergy would be found. This however does not make the inflammation of the appendix due to allergy. You can find a significant number of positive allergy tests, be sure of why the tests are being ordered. Think migraine more often as a reason for headache. Allergy is not a major reason for headaches.
Food Allergy
The biggest news from the meeting was the work done by Wes Burks at Duke on peanut allergy. This is exciting and long awaited for those who have peanut allergy and for the families who have someone with peanut allergy. Immunotherapy for peanut trials have allowed the equivalent of about 12 peanuts to be eaten without any problems/reactions. This would certainly take the fear from accidental exposure to peanut especially from tabletops at school cafeterias. I have to check my note again, but I had written down the treatment would be a suppository(?).
There was a very popular abstract (a quick presentation of work in progress prior to it being published in a journal) on food allergy and the over- use of panels for food allergy (pet peeve). A New York Times article a few months ago reported that food allergies were being over diagnosed. Dr. Sears at National Jewish Hospital in Denver, Colorado reported on over one hundred children seen at their center who had food allergy as determined by blood test panels. The average number of food allergies reported were six. After undergoing food challenges the number decreased to only 2 foods. 88% of the foods this group of children were told to avoid based on RA ST panels were added back into the diet. Using a food challenge, no one with meat ‘allergy’ had a positive food challenge (where meat caused a problem), 88% of the grain ‘allergic’ children were negative on challenge, and 83% of the fruit and vegetable group were also negative after a food challenge. Bottom line- the use of these panels is giving falsely positive information and leading to a misdiagnosis of food allergy.
Allergy Testing
I learned that I should no longer use the word RAST. The term is outdated and refers to a technology not used. The blood tests for allergens should no longer have a 0-6 grading scale and should only be reported in what is actually measured kU/l of serum. The test measures a concentration of a specific antibody in the blood. The relationship of that concentration to clinical activity needs to be determined by the clinician. I predict that the interpretation of the blood test results may be a huge issue.
A new in vitro or blood test for specific IgE in the blood is called an ISAC chip. This technology will help with cross-reacting proteins. We see the problem of cross-reactivity with multiple positive allergy tests to legumes (peanut, soy, beans, and peas). I think this will be a very worthwhile test in allergy.
There are three blood tests out there for detecting specific IgE. These are the Immunolite, ImmunoCap, and Hytec. Each of these measure something different. They measure a different population of IgE antibodies and may not be comparable. Caution was advised regarding the blood tests for specific IgE. The physician should know the method used, the validity of the assay, the performance of the laboratory in doing the assay, and realize that no test for allergy is infallible.
Conclusions
Each and every one of these topics could stand alone for more detail and interpretation and I would be most happy to elaborate in more detail. Let me know if you would like more information by adding a comment. If there continues to be an increase in the use of specific IgE panels (as advocated by those who market these tests) we will be doing significantly more food challenges in our office. Usually we are doing food challenges for those who may have outgrown a food allergy. We certainly can offer a food challenge for a child who has been told that food allergy exists based on blood test results. One of my tasks upon my return to the office is to look at our track record of doing food challenges. I hope to report on our successes and failures for our food challenge experience with milk, egg, soy,wheat, and of course peanut.
Respectfully submitted,
Fred Leickly
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