On Halloween morning, this popped up on our Twitter feed:
“One of my clinical hates is when patients are told that they have been saved from anaphylactic death by paramedics or ED staff – and ‘oh and by the way – your next reaction is going to be worse!’ It understandably creates great stress and angst and is not factually correct.”
Dr. Smith has contributed to this website before, discussing the False Alarm Hypothesis to account for the rise in food allergies. Another time we tracked him down after reading his work on fatal anaphylaxis. So after seeing his Halloween Tweet, we asked him to catch up and ask a few questions about his “clinical hate.”
AAC: Welcome back to our website. How often do you hear this story about escalating reactions?
Pete: Once every couple of weeks. This is too much, as it really compounds an already distressing situation.
AAC: You say this is one of your clinical hates. What are some others, and what do you hate about them? How do they affect your patients?
Pete: Okay, hate is a strong work – “peeve” might be better. I don’t like the upper airways being forgotten (it is such an easy thing to manage) and also the eyes. Seeing someone spend over $400 on glasses because of blinking and squinting when the problem is allergic conjunctivitis is frustrating. Having patients being diagnosed with EoE and discharged on a PPI with no follow up is also frustrating.
AAC: The field of allergies is replete with mythology that passes for fact just because no one ever bothers to find out the truth. (The number of food allergy fatalities is a major example.) This one is insidious because it generates anxiety, as you said. Why is it so hard to dispel? Do you have any ideas about how to get the word out?
Pete: Patients often see the dose required to elicit a reaction decrease before an allergy is diagnosed or may see an escalation in symptoms with venom reactions before they seek medical review. There are many co-factors that determine if you have a severe reaction or not. Sites like yours get the word out. Awareness of research and publications help. For example, risk factors that multiply reactions and Now we have sleep deprivation as well
AAC: You are a busy practitioner in what if I’m not mistaken is the most allergic, asthmatic nation in the world. We came across a new paper showing that cost of asthma medication is a big factor for non-compliance. Can you reflect for a moment on why this is (apart from the taste for barbecued food) and what can be done about it? What are some of the other factors you see in your practice?
Pete: Compliance is an issue for many reasons. 20% of patients do not obtain their medications because of the word steroid. If you have allergies – your immune system is too effective and your body makes steroids to counteract this – but you can make less if you focally treat the afflicted area such as the lungs in the case of asthma. It is important to understand why medications are being used. We have reported that 40% of eye drops and 20% of nasal sprays* purchased over the counter are alpha-agonists that may provide temporary relief but may allow rebound effects that will make things worse. Other compliance factors may be side effects such as throat symptoms (made worse by not using a spacer and not rinsing) or nose bleeds (more common with poor technique).
AAC: Finally, the False Alarm Hypothesis is one of the most interesting things we have covered on this website. Can you tell us how it has been received among your colleagues? I know there was one study in Europe that seemed to bear out some of your observations. Can you tell us about that and perhaps some others?
Pete: It was a very heavily accessed paper in JACI in 2017. A study in South Africa also looked at this and found trends to high glycation foods. A paper was presented a couple of weeks ago in Florence at the PAAM meeting – some research came in from Naples that reinforced the AGEs-in-diet paper.
AAC: The False Alarm Hypothesis was so novel and interesting. You came to a team at Mount Sinai to investigate the underlying science for reasons you explained in our earlier interview. Do you farm out other ideas?
Pete: The Mt Sinai team had already shown that isoflavones/genestin in soy stopped the development of food allergy in an animal model. They had a working food allergy model, but were not aware of advanced glycation end products. It made sense to work with a team with an existing model. I share ideas though.
AAC: Thanks for your time.
*An example of such a nasal spray is oxymetazoline hydrochloride, sold as Afrin among other brand names. As we reported in Asthma Allergies Children: a parent’s guide, it “provides profound relief as swollen blood vessels in the nasal passages shrink, restricting the painful flow of fluids into the nose and sinuses.But when the effect wears off it makes the patient feel miserable. The vessels dilate to more than their previous diameter, literally becoming engorged; the congestion increases.” After prolonged use, it “makes the nasal blood vessels and tissues look like raw hamburger.”
Dr. Pete Smith is a Professor in Clinical Medicine at Griffith University in Queensland Australia. He trained in Pediatrics and did his PhD in molecular immunology at Flinders University South Australia and has worked as a Senior Lecturer at the Institute of Child Health London and an Honorary Consultant in Allergy at Great Ormond St Hospital London. He consults in Clinical Medicine in Southport Queensland and is Medical Director of Allergy Medical Group in Brisbane and Sydney. Current research includes AGEs and allergy, molecular ion channels in hypersensitivity and allergy, molecular activation pathways in allergic rhinitis and clinical studies in food allergy and rhinitis. He can be found on Twitter @ProfPeteSmith.