A voice for reform in the field of allergy...You're entering the no-spin zone of the Renaissance Allergist...Straight talk by an allergist seeking reform in his profession and a renaissance in the field of allergy...
"I'm a big fan of the misunderstood, the vilified, the underdog, the breaking of myths..."
"In the French language, Renaissance means "rebirth". In medicine, I am convinced that a rebirth--like birth--is inherently a painful process. It involves giving up many cherished ideas; abandoning comfortable ideas and embracing others that may be closer to The Truth. In my field of allergy, we have many old ideas that need re-addressing. And the worst "old ideas" are actually myths. Here are the Top Ten, written in no particular order which permeate our field:
1. Candida is only a harmless commensal organism...it doesn't cause allergic disease.
2. Irritable bowel syndrome is unrelated to food sensitivity.
3. Vaginitis can never have an allergic component.
4. High-doses are needed for sublingual immunotherapy (SLIT) to be effective.
5. Delayed food allergy (if it even exists) is a rare event, mainly confined to FPIES in pediatric patients.
6. Delayed skin test reactions are of uncertain or minimal significance.
7. Rheumatic syndromes such as fibromyalgia and idiopathic polyarthralgia have no potential allergic input.
8. Eosinophilic esophagitis is exclusively triggered by foods.
9. An allergy workup for chronic urticaria is unnecessary and generally unfruitful.
10. The Total Load Theory in allergy does not apply to allergy patients.
Next month I will celebrate my 40thy year as a physician. Over those 40 years, I have given up many cherished ideas and undergone a "rebirth". Significantly, this rebirth has been done largely without the aid of our major allergy professional societies (of which I am either a Member or Fellow). Why is this? Because our professional societies continue to focus almost exclusively on IgE mediated respiratory disease. There are however, occasional "Bright Spots", such as the discovery of alpha-gal allergic disease. I am convinced that if we had the same level of curiosity brought to gastrointestinal and rheumatic fields in general, we could make enormous strides. However, we have made two extraordinary mistakes which exceed all others:
We have taken a field of medicine (allergic reactivity) and have artificially constrained it in two areas:
1. Anatomically demarcating our field, when no anatomic demarkation should exist. I have said before that our field most closely resembles that of Infectious Disease. Infections can involve virtually any part of the body, and our colleagues in this field don't limit themselves to the respiratory tract. Imagine how ridiculous it would be if the Infectious Diseases Society of America had changed their name to "Infectious Diseases and Bronchitis Society of America? Now what would that imply? Yet, both of our major allergy professional societies have tagged the word "Asthma" in their name. As a result, we have moved from becoming Allergists to....Asthma doctors. Only. What a tragedy.
2. Immunologically demarcating our field to IgE-mediated allergy. Delayed food sensitivity is conveniently not really explored in many potentially breakthrough areas--like gastrointestinal and rheumatic illness. Oh sure, we give Lip Service to the idea when discussing certain illnesses like EoE or FPIES but do we really pursue study in the broader context I have mentioned above--Irritable Bowel Disease or Polyarthralgia? I think not. After all, we're "asthma doctors"...
So where does that leave us? With professional societies still overtly--or tacitly--perpetuating the Top Ten myths listed above, largely through anatomical and immunological self-constraints. Our professional societies are in desperate need of Rebirth. Our self-imposed and arbitrary constraints need to be ruptured. And unless we go through a painful Rebirth, our field can expect atrophy and decay in the future.
And that's not a Myth--that's The Truth.
36 Years ago, as a young allergist, I began a fateful journey which took me hundreds of miles away from my Chicago appartment...It was the dead of winter, and I was freezing and tired…I had journeyed hundreds of miles, and was almost at my destination—a small snow-covered Canadian town. The reason for my trip? I wanted to meet—and briefly study under-- a legendary allergist. As I found the house, I knocked on the door, and a grey haired, elderly man answered. He had the treasure I was seeking:
The trite saying “nothing beats experience” has a ring of truth to it. And nowhere in the allergy field is this more true than in the area of Sublingual Immunotherapy (SLIT). At our upcoming meeting in Tampa Florida “Advancing Allergy Treatment Through SLIT” those attending will have the benefit of learning a program of SLIT administration—The La Crosse Method-- that is based upon a synthesis of decades of clinical experience combined with the latest scientific research. It is the only SLIT protocol based on over four decades of experience with over 120,000 patients.
Nothing can compare to it.
Need further convincing? For a quick overview of how the La Crosse Method compares to other SLIT "protocols", download the powerpoint slide presentation here.
Dr. Mary Morris and myself together share over 60 years of experience in utilizing SLIT, and modifying The La Crosse Method SLIT protocols based on our experience as well as the latest scientific research.
SLIT is the wave of the future. But at the meeting you can learn a protocol that gives you the benefit of that experience, and apply it to your patients. Now.
So join us in Tampa Florida--your journey for SLIT experience will be a lot warmer and easier to get to than the Canadian town I traveled to years ago!
“Make your choice, adventurous Stranger,
Strike the bell and bide the danger,
Or wonder, till it drives you mad,
What would have followed if you had.”
C.S. Lewis from "The Magician's Nephew"
The field of allergy is at a crossroads. As a profession, we need to adapt--or perish. Dr. Richard Weber, ACAAI President, in his "message from the President" put it nicely:
"The message which will guarantee our survival as a specialty is that our knowledge is broader than the atopic diatheses, and we have exptertise that is of value in the management of other intersecting medical arenas. This is what gives us value and viability"
So where do we start? I would have a few suggestions--
1. Our mantra for should be "one mucosal system" as it pertains to our areas of interest. We're not asthma doctors...we're allergists.
2. Become educated in allied areas of "intersecting medical arenas" such as irritable bowel disease, eosinophilic esophagitis, and allergic vaginitis, and even chronic fatigue syndrome (to name a few)
3. Become educated in newer, safer, and more convenient forms of immunotherapy delivery--i.e., SLIT. SLIT can be a game-changer for the practicing allergist, and those I have taught to use it have never, ever looked back...
4. Switch our treatment paradigm from "drugs first, environmental control second, and immunotherapy last (and, I might add for a select few!) to the following: "immunotherapy first, environmental control second, and drugs last. Disease-modifying treatment should always be our first priority.
5. Realize that non-atopic food sensitivity and chemical sensitivity exist, and become interested and gain knowledge about those, even if they do not involve IgE...
What does the allergy consult of the future look like? I'll give you an example:
After multiple disappointing gynecological evaluations, a teenage girl finally presents to a University-based gynecologist with intractable vaginal pruritis. Workup is again negative for infections, contact irritants, etc. The gynecologist notes that vaginal pruritis flares in the summer, coinciding with her tree and grass allergic rhinitis. It is even slightly better on cetirizine. She suspects that the girl may have an allergic component to her disease, so she is refered to an allergist. Testing confirms sensitivity to outside aeroallergens, and ISAC molecular testing confirms a strong Bet v 1 and Betv 2 sensitivity. The allergist was aware of Bet v 2 correlating with latex sensitivity. She was also highly sensitive to grass pollen, and the allergist was aware that timothy grass pollen and latex share IgE epitopes. She has been sexually active, noted intense pruritis after intercourse, and it was noted that a latex condom has been used routinely. The diagnosis of allergic rhinitis complicated by allergic vaginitis is made. Latex condom use is discontinued, SLIT is administered for birch and grass , and her seasonal allergic rhinitis significantly improves, but more importantly her allergic vaginitis resolves--completely.
This case--I was the treating allergist-- illustrates several important points of where I think the allergy field needs to grow:
1 A cooperative relationship has been established between the allergist and the gynecologist, each one realizing that the other has specific areas of incomplete knowledge in "an intersecting medical arena". This was not the first referral from this gynecologist, and we have had a mutually satisfying relationship.
2. SLIT is readily employed as a safe effective treatment by the allergist, instead of simply drug support. Drugs alone weren't working in this patient. "Been there, done that". In short--disease modification with immunotherapy is the treatment of choice in this new paradigm.
3. Molecular component testing is employed to give insight into molecular allergens giving a hint of potential cross-reactivity.
So...we're at a crossroads. We can either begin to change...or forever wonder how grand our profession would have become if only we had....
It's time. Let's take the big step and broaden our horizons. Let's not wait.
Let's strike the bell.
I was recently talking with a friend who mentioned she had a conversation with an ENT allergy nurse who was utilizing the La Crosse method for treating her allergy patients, and she was very pleased with the results she was getting. However, the doctor who headed her department had recently attended some of the AAOA courses and now believed that shey should be using the AAOA Method for sublingual allergy treatment. His reason? He told her that the La Crosse method was "old and antiquated".
I have already given a powerpoint lecture comparing current sulbingual protocols so I won't go into all the technical details as to why the La Crosse method is clearly superior. You can find out why it's superior by downloading the lecture, available here as "SLIT protocols". Enough said on that.
Rather, what I want to do is to address the rather interesting and puzzling issue of why some people (like the young doctor mentioned above) gravitate to the AAOA protocol despite the clear superiority of the La Crosse method. Why is this?
I would suggest that it has less to do with objectively reviewing the comparative merits of both protocols, and more on relying subconsciously on a more subjective "belief system" which I believe is pervasive in the allergy professional culture today.
And this "belief system" is not strictly scientific and rational. Rather, "it is what it is"--a belief system--utilized subconsciously by many allergists today. Like most "belief systems" it has certain tenants, and one of them is the thought that "newer is always better".
Nothing could be further from the truth.
Sometimes when we jump on the "newer is always better' bandwagon we can get thrown off the bandwagon--rather rudely. Two quick examples: Remember that glorious "new" antihistamine Seldane, the first real non-sedating antihistamine that the allergist had to use? It was withdrawn from the market because of serious cardiac arrhythmias. Remember most allergists contention in the 1990's that sublingual immunotherapy just "didn't work" because the ""latest studies" (and I'm referring here to prior studies done years ago ) showed no significant improvement with treatment? We've certainly changed our tune on that one! New meds and new studies--just because they're new doesn't mean they're "better".
The "flip side" of the "newer is always better" philosophy is the "old methods are always antiquated methods" viewpoint. Again--not necessarily. Older methods may have a rich and highly successful empirical history behind them and just "make common sense." to continue to use. Should the La Crosse method be considered "old and antiquated" because it was built upon a rich clinical history utilizing concepts of quantified titration and multi-antigen customized threshold dosing first utilized decades ago? I think not. In truth, rather than being "old and antiquated" the protocol fuses the best of both worlds--rich historical concepts of treatment combined with the latest European research. "Old and antiquated"? I think not. How about "versatile and effective, consisting of a family of protocols that are effective for multiple clinical situations?" Now that's more like it.
But there is more to this belief system than just "newer is better" and "older is antiquated". Another unspoken tenant is that if an allergy organization endorses a position/product, it must be the best approach.
My answer to that? Not necessarily. Again, using my earlier non-sedating antihistamine as an example, I remember when the "position" of my official allergy organization was against the introduction of non-sedating antihistamines as over-the-counter medications. In fact, I remember giving a television interview on this issue, and said it really made no sense to me why Benadryl could be over-the-counter (with all of its potential side effects) but non-sedating antihistamines could not. I was "going against the establishment" with that position. Unfortunately, allergy organizations and their positions are not necessarily always exempt of contamination by economic and political considerations. Buyer beware!
Finally, I think that many allergists are tempted to utilize the AAOA protocol because of a false sense of security that they are using a "society sponsored" method of treatment, which somehow will be "more acceptable" to colleagues and associates. But the point is moot if an alternative protocol is more versatile, robust, and effective for their patients.
In conclusion, it is wise for any young, prospective allergist contemplating incorporating sublingual immunotherapy to put aside his or her preconceived "belief system" and have a cold, objective look at the sublingual protocols available.
And one of the questions the young allergist should ask, is whether or not the protocol has been studied in a "real world" clinical setting. And the La Crosse method has. Check out the Quality of Life Improvement with Sublingual Immunotherapy article by Morris, Lowery, et al.
I am confident if protocols are graded on their merits, and not on a preconceived "belief system" the choice will be obvious as to which one to use.
The La Crosse Method. We've been modifying and honing our family of protocols for 30 plus years now, and simply put
Allergists love to talk about...allergic disease. We discuss scientific papers, present lectures, and of course treat patients. But the proverbial "elephant in the room" that we really don't talk about is....how much personal satisfaction do we really have in our profession? When a patient comes to see an allergist, they can't know the answer to that question. So I'll be honest and tell you:
Being an allergist brings me great Joy.
I take joy in having allergies myself so I can appreciate the problems my own patients have. Each day in the office, I feel like I am "coming home" to kindred spirits traveling down the (often painful!) Road of Allergies. I have personally suffered from allergies, so I know the terrible itching that generalized hives can bring, the incapacitating pain of a migraine headache, and the terrible aching and fatigue from a food reaction. In short, "I can relate". And I take joy in this.
I take joy in being in a fascinating field with continual variety: The field of Allergy is the Queen of Specialties. It deals with multiple organ systems (not just the respiratory tract) and the rich variety of presenting problems and breathtaking patient responses to allergic disease is a joy for the physician who loves a diagnostic or therapeutic challenge and wants to help people. I've always loved puzzles and strategy games, and with Allergy I'm never--ever--bored!
I take joy in the fact I have experience in using an effective immunotherapy available that's safe, painless, and affordable: Sublingual immunotherapy (SLIT) is the wave of the future for allergists, and it's here. Now. And we use it. And it's a joy to see someone tell me of the recent exposure they've had to a prior allergen, and how they didn't notice any significant reaction.
I take joy in "growing old" as an allergist. As I have aged and practiced over 3 decades, I have seen patients with severe allergies grow up and live productive lives. For example, several of the young people I have treated are now doctors, helping others with illness. I also see children of my former allergy patients. Their parents, educated in the signs of early allergy and knowing the benefit of SLIT, have brought their children in at an early age for treatment to prevent further problems down the road. The dreaded "Allergic March" of exploding progressive allergic disease doesn't happen with their offspring because they are treated with a disease-modifying modality (SLIT) And I take great joy in that!
I take joy in teaching. Truth be told, I love to teach. Just love it. And I have a willing, motivated, and eager audience in my patients. And I take joy in that!
Something to think about. Something we all should have as physicians and allergists. And I'm very, very grateful to have it.