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...
“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.
A Half-truth is a whole lie
--Old Yiddish Proverb
Cindy sat across from me in my office and shyly smiled. This 8 year old girl was being brought in by her parents for allergy assessment...
But with a twist.
"We want Cindy checked for food allergies" her mother said, "but nothing else--she's had all the routine blood work." Their finances were limited, she explained, and Cindy's asthma was "being taken care of" by her other allergist. As I looked over the enclosed ELISA IgE antibody report from Cindy's other allergist, I found astoundingly high IgE values for dog, as well as for dust. And...yes, she had a dog at home. Furthermore, she had seasonal hayfever in the springtime. And what, you might ask, was her treatment for her allergies?
Flovent 110 2 puffs bid.
Her mother explained that Cindy's asthma really "wasn't an issue", but she had been scared the preceeding week when Cindy had an acute anaphylaxis episode after eating. It didn't surprise me that Cindy's anaphylactic episode might occur during the spring allergy season. Her seasonal springtime hayfever told me she was probably tree pollen sensitive. A recent article By Vetander et al published online March 15 in Clinical & Experimental Allergy found that "our study suggests an associated risk for anaphylaxis during leaf tree pollen season among 35 pollen-allergic individuals." And clinically I see this all the time in patients. For example, I can recall one girl who had 6 episodes of anaphylaxis, all clustered around the ragweed season. In her case a combination of ragweed and food sensitivities would reach a "critical mass" and trigger a severe reaction.
When we did intradermal skin testing on Cindy, she had strongly positive reactions to dust, dog, multiple spring & fall pollens, and alternaria mold.
And here she was, her parents only wanting her to be assessed only for food allergy, because her asthma "was just fine" on Flovent, and her hayfever "was being taken care of" with antihistamines.
Cindy's parents had unknowingly bought into The Big Lie.
Somehow, somewhere, the message we Allergists have given our patients is that symptom-controlling medication is all we can--and should--offer most of our them. In truth, Cindy's immunological reactivity was spreading--first hayfever, then asthma, and now anaphylaxis. In essence, although her asthma was "controlled" most days, her allergic reactivity wasn't.
But if we look further, we can find what's really behind The Big Lie --And that's The Big Secret.
The Big Secret is we indeed have a potentially disease-modifying treatment at our disposal: immunotherapy. However, as allergists, we don't talk about it enough, educate patients enough, and use it enough. Period. Think I'm wrong? Check out the recent USA Today Allergy Supplement. There you will find a semi-comprehensive guide to asthma. Why do I refer to it as semi-comprehensive? Because there is no mention of immunotherapy as an option. None! And yet, there is a nice write-up about Cystic Fibrosis--a non-allergic disease!
Let's get back to the basics: As allergists, we discover allergies and then try to induce tolerance with immunotherapy. To a large extent, the ability to do immunotherapy defines who we are and what we do. In that regard, we are like surgeons, only we do "knifeless surgery" on the immune system. What would your reaction be if you read a USA Today Supplement on Surgery and only medications and "control" of illness was discussed, and not actually surgery? Would something be missing?
Of course, I have some understanding why immunotherapy is not "shouted from the rooftops" by my colleagues--and that's because subcutaneous immunotherapy (SCIT) can of course be dangerous. The beauty of sublingual immunotherapy (SLIT) is it's safety and effectiveness. It has the chance to breathe new life into our specialty. And for someone like Cindy, who began SLIT the day I saw her, it gives her hope of a better future.
Often I can't help suffering when I really want to.
Bob sat across from me in the office. He was seeing me for chronic sinusitis, and he was feeling better. But his eyes told a different story. Since I had last seen him, I found out that tragically, one of his children was accidentally killed. But the truly horrifying thing was it was the second child in his family that had been accidentally killed....
As an allergist, I am of course primarily interested in finding out the allergic problems my patients face, and alleviating their suffering. But my allergy textbooks take a sterile, clean approach to allergic disease, and you won't find the word "suffering" in any of them. Furthermore, in the course of talking to many patients over thirty-one years, I have found out the disappointing truth that, in reality, I help a very, very small amount of Suffering. And even more disappointing was the realization that I often don't have an effective way to alleviate their greatest suffering.
But I have a story.
When my children were little, they came to me and implored me to build a playground. Bright, anxious voices bubbled with excitement telling me how blissfully happy they'd be if only I would get this for them. And, of course, since I loved them so much, I had a playground built. And I have to admit, if I say so myself, it was a beautiful one. I mean I really think it had everything my children would want. (And apparently it did, judging by their reaction...!) But I knew one thing, and I dreaded it:
They'd get hurt while playing. Gravity, force, and mass were impartial to wishes on the playground.
As it turned out, one day Lizzy came in, screaming. She had fallen and hurt her knee. And it was a pretty bloody mess. And of course, she said,
"Daddy, make the pain go away...now!"
And, honestly, I think she thought I could.
Because, up to this point, she thought I could do everything. After all, I was her Father, a Doctor for goodness sake, and soooo old and wise that I could really work magic. After all, I'd made the playground, right? And she had heard stories of me helping many people in the office, right? So why couldn't I help her when she really needed it? When she was suddenly, against her will, engulfed in a world of pain?
And, frankly to me, having decades of life on this world, I looked at her pain as a "small thing in the big picture". But I cared for her. And so her pain wasn't really "small" at all, but important to me. But as I cleaned her knee and put ice on it, the funny thing was she didn't feel my arms around her, or my love, because she was hysterical with pain. And she wanted it gone. Now. She was oblivious to me and the love and sympathy I had for her pain. She was angry. But I wasn't angry at her even though she shouted at me. I made the playground, and now I wasn't going to help her take away her pain? Behind her tears, she really was saying,
Life was so unfair. And disappointing. And painful.
As I said before, I can't take away many of my patients' suffering. And I don't have an easy, pat answer for most of it. But I remember my experience with my daughter. And my role as Creator of a playground for her. And I knew that someday, when she was much older and no longer playing on that playground, but in a different world, a world more mature, the bruised knee-- and more importantly, the memory of that bruised knee--