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Asthma–The Study of One

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By Dr. Paul Ehrlich
In some ways, the more we learn about asthma, the less we know. To be sure, the science is getting better, but despite the similarities between symptoms that we see in our office, there are crucial differences among patients. Dr. Anthony Gagliardi, a pulmonologist who worked at the late, lamented St. Vincent’s Hospital in New York, says that the study of asthma “is the study of one.” That is, you have to study each patient as an individual to get at the root causes of his condition, and find the right treatment.

Some things that look like asthma are not. As we say in our book, asthma describes a set of symptoms known as “asthma syndrome,” that may be triggered by many allergic or environmental causes, or, by bacterial infection. We have to solve the mysteries, and treat them, one at a time.

I was reminded of this recently when a patient came into my office whose chief complaint was difficulty inhaling; it would bother her for several days and then subside spontaneously. She experienced no wheezing and did not respond to an inhaler prescribed by her primary care physician [PCP]. While she felt this way she did not have any trouble sleeping, and it never woke her up—common symptoms of asthma.

A detailed history revealed a few minor allergies, but I asked her how she felt when taking a deep breath. She said that she felt as if she just “couldn’t quite take a deep enough breath.” Occasionally, she tried to hold her breath because if she let it go she would have the initial problem again.

I drew a graph with a horizontal line, and asked her to consider it a kind of peak for deep breathing when she was anxious. I asked if breathing above that line gave her relief. She got excited saying, “Yes, yes exactly.”

The rest was easy. Her pulmonary function was normal. I asked if she considers herself a Type A personality. She said she had a very stressful job. She is the oldest of four children, always the one who “needed to succeed” and the tough economy was “doing me in.”

I told her that she was quite healthy and had what is called “anxiety breathing.” For the next ten minutes we talked about life, problems at home and work. The fact that anxiety could make her feel this way was totally understandable, and she left with a peak flow meter to be used when she felt this way. I asked her to call me if the test at home was abnormal (I knew that it wouldn’t be). She thanked me for taking the time to ask these questions. So far, so good.

These are tough times. Lots of us are anxious. Misinterpreting symptoms associated with asthma can lead us up blind alleys. People may end up taking inappropriate medications. Inhaled corticosteroids and bronchodilators are literally life saving for people with asthma, but they are powerful drugs that shouldn’t be used when they aren’t warranted.

Good vs. Evil: part deux

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Good vs. Evil: part deux
By Dr. Chiaramonte–

When we left off in the 1880s, Dr. Blackley had traced clues that hinted at the existence of IgE, the allergic antibody, and in 1911, the English Doctors Noon and Freeman were homing in on the blocking antibody IgG. In any war, new intelligence comes in that must be interpreted, and in this one, the scientists could not yet tell the allies from the enemy.
In 1921 Doctors Prausnitz and Küstner found some key phenomena concerning the allergic agents and blocking agents. Küstner had clinical symptoms after eating fish, and developed a positive immediate response to fish when he applied it to his skin. Prausnitz was not allergic to fish and had a negative immediate skin test response. In the spirit of Dr. Jekyll, he injected a small amount of Kustner’s blood serum into Prausnitz’s own skin. Fortunately, the evil Mr. Hyde response after two days was confined to that site and lasted a few weeks. He became, in effect temporarily allergic to fish at that spot. This allergic antibody was not detectable by any other means. This temporary reactivity is now known as a P-K reaction after our two intrepid laboratory adventurers. It can be prevented by moderately heating the serum before injecting.
Some time later, other researchers did a similar experiment with pollen allergy. They found that serum drawn from a subject who had undergone immunotherapy with pollen created a blocking effect on the P-K reaction.
Without going into too much detail—this is after all a website, not an encyclopedia, suffice it to say that when the immune system is involved, we can sometimes only tell when a patient has developed antibodies when we see a known reaction.
In this case, the allergic antibody was called a reaginic, or skin-sensitive antibody, and detectable by only the P-K reaction. It was heat sensitive, and thought to have only one site available to combine with the antigen, which meant it didn’t leave enough evidence of itself to be detected in a test tube. The blocking antibody was heat stable with multiple sites to combine with the antigen; it threw off plenty of evidence. Now at last there was a way of telling the friendlies from the enemy.

Next Time: Good vs. Evil—Where there’s smoke, there’s fire

God Bless Dr. Spock

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By Kathy Franklin–

I had the great luck to read Dr. Spock’s Baby and Child Care before my child was diagnosed with food allergies. His common-sense advice made raising a food-allergic child much, much easier than it might have been.

You’re the Boss

Dr. Spock has strong negative words about kiddie breakfast cereals. He asks what kind of a society allows, even encourages, growing children to eat these nutritionally barren, heavily sugared, dishonorably marketed junk foods that do nothing but promote a lifetime of unhealthy eating? He urges parents to resist all entreaties from their children and never, ever buy them popular sugary cereals. Just tell them, calmly and clearly, that this is how we do things in our family, and we may be different from the kids down the street, and the kids on television, but these are my/our rules because this is what I’ve/we’ve decided is best. The magic words he uses are “be perfectly matter-of-fact about it” and your children will accept it. Now, I personally have nothing against sugared cereals, still enjoy the occasional bowl of Frosted Flakes, and, with apologies to the late, great doctor, have even bought some brightly colored lucky loops and fruity charms for my kids from time to time. My point here is that Dr. Spock encouraged me to make unpopular choices when I felt it best, and to present them matter-of-factly to my child. It worked.

When my son was 3 years old, we’d go to the park with a group of other kids after nursery school. Spring, summer, and fall, the ice cream truck sat next to the park. It struck me that eating ice cream every single day, like all his friends did, was a bad idea for my skinny little boy with a skinny little appetite. Big sugary ice cream bars, if eaten 3 or 4 times a week, would make up too large a percentage of his weekly calories. I made Friday ice cream day, and, other days, we’d get snacks from the deli to take with us. I was calm, unapologetic, matter-of-fact about it, and he was hungry, so the first few choices I offered always sufficed. My son didn’t seem to notice, or care, that he was snacking on melon chunks, popcorn, or pretzels while his friends ate ice cream. A year later, when he landed in the ER in respiratory distress after eating a pistachio nut, we had to carefully limit his diet to nut-free (and egg-free and sesame-free) foods. It just wasn’t that big of a deal for him, because he was already accustomed to eating different foods than his peers. Thank you, Dr. Spock.

By the way, this matter-of-fact thing applies to older kids, too. They may chafe at your curfews and rules, but secretly appreciate the limits you’re setting; they know it comes from concern for their safety, because you love them. And, despite what they say, it is not true that all of their friends are allowed to watch unlimited television, play computer games for hours, or stay out as late as they want.

Allergy to One Antibiotic Doesn’t Rule Out the Rest

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Q: A child comes in with a rash a few days after receiving AMOXICILLIN for an ear infection. It is red, blotchy, and spreads across the body. It appears to be a drug reaction rather than a viral exanthem. Does this mean the child cannot take PENICILLIN in the future? Is the child restricted from trying any other “CILLIN” – DICLOXACILLIN, etc.
— Dr. L

Dear Dr. L,
The majority of side effects observed in AMOXICILLIN clinical trials were of a mild and transient nature and less than 3% of patients discontinued therapy because of drug-related side effects. The most frequently reported adverse effects were diarrhea/loose stools (9%), nausea (3%), skin rashes and urticaria (3%).

This is an “allergic reaction” but it is NOT related to a life threatening one. I think there is little risk if the child takes PENICILLIN in the future and should not be restricted from trying any other “CILLIN”, including DICLOXACILLIN.

The War on (Allergy) Drugs

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By Dr. Paul Ehrlich
I recently realized that I had reached a milestone in my 30 years plus of practice. I went more than a month without prescribing an oral antihistamine. This has implications for the way health care is bought and paid for in the United States.

Let’s review for a moment the old way of doing things. The first antihistamines, including diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton) started out as prescription drugs. They had a side effect: they made you sleepy, so you couldn’t drive or operate heavy machinery after using them, as the labels still warn.

Drug companies had a medical incentive as well as a financial one to develop the next generation of antihistamines, which didn’t knock you out. And so we got the wave of drugs that included loratadine (Claritin) and cetirizine (Zyrtec), which stopped the sneezing and itching without making you long for the couch. As they approached the end of their patent protection, the drug companies that made them started to add a few bells and whistles at the molecular level so they could get premium prices again.

But things have changed. Insurance companies don’t want to pay for new drugs that don’t make a big difference from the old ones and have stopped paying for them. The OTC drugs cost about the same at retail as a standard co-payment. In the meantime, members’ health dollars go for urgent things, including asthma treatment, or cost-efficient measures like immunotherapy and asthma control medications, or so we hope. Regardless, those with chronic allergies should use the OTC drugs as part of a medication strategy, not as a substitute for monitoring and treatment. It’s not that I won’t prescribe the newer medications at all, but I will do so when indicated.

I must also point out that the OTC, self-medicating approach doesn’t work for every allergy or allergy-related condition. For example, as Dr. Chiaramonte describes so movingly in his postscript to our book, many inner-city kids rely dangerously on Primatene, the OTC inhaler, to keep their asthma in check. It gives them a dangerous jolt that’s even worse than the one they would get from prescription albuterol. Both are worse for them in the long run than inhaled therapies like Advair, which with regular conscientious use keeps them from having attacks, arrests inflammation, and halts the dangerous process of airway remodeling.

Those who rely on OTC Neo-Synephrine to keep their sinuses clear would be better off with the prescription drugs like Nasonex or Omnaris (both of which I prescribe regularly) if they have allergic rhinitis. Regular use of Neo-Synephrine can make the sinuses look like hamburger. But they would also be better off with a high-concentration 2-3% saline solution sinus rinse, such as those marketed as SaltAire and Ocean, which come in convenient plastic squeeze bottles. The bargain-minded parent can make this at home: 2 or 3 heaping teaspoons of Kosher or sea salt (no additives) and one level tablespoon of baking soda, mixed in a quart of tap water. You can buy a plastic squeeze bottle or a 30-cc bulb syringe for easy administration.

In the end, the answer to your allergic symptoms will probably lie in a combination of judicious use of drugs, both high-tech and low-tech, changing your behavior, keeping an eye on the weather, perhaps watching what you eat, and generally living right. The most important body part an allergist treats is the brain.

(To read about The Hows and Whys of Allergy Medication, turn to chapter 8, Asthma Allergies Children: a parent’s guide.)

(Note: Dr. Ehrlich has worked for the Claritin Council, sponsored by Claritin. His participation is for information purposes only and he does not, nor does this website, endorse one OTC drug over another. All have characteristics that make them more or less useful than others for certain individuals at different times.)

Step Up or Step Down? The Asthma Treatment Debate

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By Dr. Larry Chiaramonte

One of the persistent discussions in treating asthma is whether to start with smaller, milder dosages of medication and “step up” if they prove ineffective, or start with heavier dosages and “step down.”

In the South Bronx, New York where I practice, and indeed with most asthmatics, patients want to get the condition under control immediately, even if it means taking more medication, as they should. After inflammation is under control, we can take the steps to ratchet down the reliance on high dosages, using peak flows, measuring exhaled nitric oxide, and other means to fine-tune our choice of medications and their dosages.

In this initial treatment, we have three primary weapons:
1.Long-acting beta agonist [LABA]to relax the spasm in the bronchial muscles;
2. Montelukast, a leukotriene-receptor antagonist (LTRA], since leukotrienes are an important cause of allergy.
3. Inhaled corticosteroids [ICS] to thin thick mucous and reduce inflammation.
We try to avoid systemic steroids such as prednisone because they affect the larger immune system instead of just the lungs. (That’s not to say they aren’t effective with asthma. In the days before inhaled steroids, bragging rights went to the doctor who used the least amount of systemic steroids. One of my teachers said at a national meeting he never used steroids to treat
asthma. This was technically true, he transferred from his care all the severe asthmatics to others on his staff, who then used steroids.)

Unfortunately, inhaled corticosteroids still have a vestige of the old stigma attached to them, although it is largely unwarranted. They are central to our NIH asthma guidelines. The NIH states that ICS are safe, necessary for reducing airway inflammation, and prevent the damage of airway remodeling. Add to the historic mistrust of corticosteroids the confusion with testosterone-derived steroids that athletes use and the result is great reluctance to use, or even on the part of primary care doctors to prescribe, these most effective asthma drugs, even after twenty years of safe usage.

While I prefer to step down from aggressive treatment, I don’t have anything against stepping up strategy, unless, as frequently happens, it means avoiding ICS unless nothing else works. Patients suffer in the meantime.

[Note: A different take on this issue “Step-up Therapy for Children with Uncontrolled Asthma” by Robert F. Lemanske, Jr., M.D. appears in the March 18, 2010 issue of the New England Journal of Medicine. There is also a related editorial by Erika von Mutius, M.D., and Jeffrey M. Drazen, M.D.

Train Yourself to Manage Your Child’s Allergic Reactions

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By Sally Noone–

Sally Noone

Watching your child experience an allergic reaction can be frightening for a parent. Instinctively, you want to make your child feel better and use every trick you have to make them better.

It starts with recognizing when something is happening. Allergic reactions to foods can have different types of symptoms. Some involve the skin, with hives or an itchy rash or eczema flare. Others may begin with difficulty breathing. Whatever the symptoms, we must be ready to start treatment quickly.
You might work with your child’s doctor to personalize an emergency treatment plan for every contingency. A cool bath can soothe your child’s skin when there is a rash or itchy hives, but it provides no real treatment for the cause. You must understand the underlying physical process, and treat that. For example, hives are caused by a release of histamine during an allergic reaction, but only focusing on the hives may distract you from other symptoms such as swelling or breathing problems that are potentially very serious. Treating with an antihistamine medication that you doctor has recommended, such as Benadryl or Zyrtec, can help to block this histamine release as you carefully continue to observe for signs of a progressing allergic reaction. Often, the hives and their itchiness begin to resolve within 20 to 30 minutes but it is important to continue to watch for other symptoms.

A food allergy reaction accompanied by difficulty breathing needs to be treated promptly. It is a medical emergency. A steamy shower is an excellent treatment for croup, but breathing problems associated with a food allergic reaction require different treatment. Epinephrine, given by injection, is the medication universally prescribed to treat this type of reaction. This medication is available in auto injectors such as EpiPen, EpiPen Jr. or Twinject, which are available by prescription. Anyone who may be in a position of having to use these devices—you, your child, the babysitter, teachers, grandma and grandpa—should be trained in their use so when the time comes, they don’t panic or hesitate. Other treatments are administered by inhaler or nebulizer. These can make the child feel more comfortable and less panicky. It is best to give epinephrine first, then the inhaler or nebulizer treatment if you suspect a food allergy reaction. Stopping the life-threatening event comes first; comfort comes second. Anytime epinephrine is given, your child needs to be taken to an Emergency Department for further care and observation. Sometimes the symptoms of a reaction can appear to have resolved, and then come back later. If this does occur, it is best to be in the Emergency Department where they know what to do. Don’t be tempted to skip the Emergency Department!

In most cases, it is best to allow 911 to provide transportation to the hospital because you don’t want to drive in an anxious state. When you call, tell the 911 operator that your child has had an allergic reaction and has received epinephrine. This alerts them to send the proper level of responder to meet your child’s needs as they provide transportation to the hospital.
An emergency treatment plan can be very helpful in providing information about allergic reactions and their treatment to anyone who may be in a position of having to look after your child in an emergency. Typically, the plan includes the signs and symptoms of an allergic reaction, along with the correct dosages of medications to be used. Reviewing the plan with your child’s caregivers provides a good opportunity for you to practice with the auto injector trainers.
Is it still scary? Of course it is. This is your child we’re talking about. But knowledge and training will allow you to react like a pro when the time comes.

Sally Noone, R.N., M.S.N., C.C.R.C., conducts clinical research at the Jaffe Food Allergy Institute of the Mt. Sinai School of Medicine in New York City. She was drawn into the field by the case of a girl who was hospitalized after a milk-allergy attack at the age of 4. Read more about Sally and her work with food allergic children in chapter 13 of Asthma Allergies Children: a parent’s guide.

Peanut-Sniffing Dogs: Good Idea or Bad Idea?

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Q: What do you think about using a peanut-sniffing dog for a severely peanut-allergic child?

Dr. Ehrlich replies:
This is a new wrinkle in discussion of what to do when children have life-threatening food allergies, which we write about in chapter 14 of Asthma Allergies Children: a parent’s guide. To summarize what we say there:

Cases where children are sensitive to fleeting exposure, not just ingestion, are extremely rare.

These dogs are really expensive, as are their inspiration—drug- and explosive-sniffing dogs–so it’s not for everyone because of basic economics. It’s not a particularly cost-effective use of the family health-care budget.

I have heard talk of a foundation to raise money to support this approach. I’m not one to question people’s philanthropic impulses–I would certainly donate for training seeing-eye dogs. However, peanut allergy is not blindness. I can think of many areas in the field of pediatric food allergy that will produce more bang for the tax-exempt buck, primarily because the dog approach projects a fundamental misunderstanding of the problem. The seminal study of peanut fatalities by Dr. Hugh Sampson shows that they happen when people are exposed to peanuts far from their normal surroundings and are exposed accidentally, such as mountain climbers whose climbing partners carry energy bars that contain peanuts.

Anyone who expects to encounter peanuts at school or the mall can prepare for it by carrying an epinephrine injector such as Epi-pen or Twinject at far less cost, which they should do even if they have a dog. Epinephrine is safe, even with repeat injections.

A family that expects a dog to create a peanut-free bubble is in for trouble because they will create a false sense of security. It’s not a peanut-free world. I agree with the Food Allergy and Anaphylaxis Network that even schools should not be peanut free. The children should understand their condition, never eat food that mom didn’t give them including birthday cupcakes, and their teachers and nurses ought to be trained to help in the event of anaphylaxis. Their classmates should be taught to respect those who have this condition.

Failing the Test

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By Dr. Ehrlich
Nothing separates “science” from sound medical practice more than the use and misuse of allergy testing. Inappropriate testing leads doctors and their patients down blind alleys and dead ends, wasting time, money, and health. More times than I care to remember a new patient arrives in my office like the one this past week, a twenty-three year old man with eczema who recently moved from Florida to New York City. He told me that he is allergic to some twenty foods from milk to asparagus.

His history included some laboratory results of tests that were performed while he was living in West Palm Beach and he said that his physician advised him to stay away from all these foods. His diet was thus reduced to a narrow spectrum that was making his life miserable and his eczema no better.

With the patient in front of me I called the 800 number of the lab and spoke with a woman about the tests. The first thing she wanted to know was what state I was calling from. When I told her I was from New York, she told me that their lab work would not be covered by my patient’s insurance company. (My patient paid cash up front but this shows where their priorities lie.) I then asked her about the tests performed, and she told me they were IgG4 tests to the various foods. I thanked her for the information, hung up and looked at the young man.

“The tests they performed were phonies, with no redeeming clinical significance,” I said without hesitation. “They only tell me only that you have eaten these foods in the past. You’re probably not allergic to any.”

The remainder of the visit included tests related to IgE antibodies, the ones that count, to various foods as well as a few environmental allergens, and they were all negative, suggesting that he could begin all the foods he had eliminated from his diet. Needless to say, he was thrilled. It turned out his eczema came from exposure to dust mites. The history was obvious to an allergist, which his Florida doctor was not, and in fact had never bothered to take a history. Between his insurance company and his own pocket, the Florida office visit and the tests probably involved an outlay three times what it cost at an allergist (yours truly) with nothing to show it. A patient’s history is everything and the tests performed done usually to substantiate what a trained doctor usually suspects.

A final thought: this kind of misdiagnosis of food allergy is bad enough in an otherwise healthy 23-year old. It’s quite another in very small children. I regularly see very small kids whose diets are needlessly circumscribed for the same bogus reasons who are in fact being malnourished. This falls under the antiseptic but loaded heading “failure to thrive.” [For more on food allergy, see chapter 5 Asthma Allergies Children: A Parent’s Guide.]

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