I'm thirsty...a drink of water wouldn't hurt, would it? Yet most of us are aware of water intoxication from using water (in a sense) "the wrong way".  Should we therefore regard water with a serious degree of danger? Should we all "just play it safe" and stop drinking water?  

...Such were the thoughts in my mind when I read the report in the August issue of The Journal of Allergy and Clinical Immunology by Cochard & Eigenmann entitled "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy".  

In their article, they present 2 cases of patients who suffered serious consequences when they took undertook SLIT.  Each patient had stopped prior SCIT also because of side effects.  Their conclusion?  "Special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."

hmmm.  And as I showed above, water is not totally safe either...

As some of you know, I've used SLIT for 29 years (this coming Feb), and as someone who has had not inconsiderable experience in treating patients who have experienced prior anaphylaxis from injection immunotherapy, I just have to weigh in on this one. I think the following comments are in order:

First, remember the literature---most of the published European literature is on monosensitized patients.  Both of the patients reported in the article were multiply sensitized.   

Secondly, the literature comments on the use of protocols designed for the stable allergy patient--the protocols weren't specifically designed for highly sensitized patients with prior reactions to SCIT.  

Thirdly, why would one give an ultra-rush protocol to patients previously found so reactive to SCIT that they had to discontinue it.  In short--what's the rush?  Looking for trouble?  

Fourthly, I have a suspicion that the total allergy load of at least one of the patients was not completely addressed. Something was missing.  Here's the story--the first patient (a 14 year old girl) was successsfully able to work up 8 drops a day with no major problem, but then 1 week later--at home--she reported a severe asthma attack together with mouth itchiness immediately after SLIT, lasting several hours.  Well, how come she could handle the SLIT the other 6 days without problems?   Most likely, she has some other stressor affecting her system, and partially limiting her response to the treatment...since she was birch, grass, ragweed, and alternaria sensitive, could she have had a hidden concomitant food reaction going on?  How about a hidden cereal grain allergy since she's grass sensitive?  Or a fruit sensitivity to banana, melon, apple, etc. ??  Furthermore, the authors were not, from my understanding, treating her alternaria allergy--just grasses. What were the Alternaria mold counts on the day of her severe reaction?  Incompletely treating allergy load doesn't help the situation here.  

In my opinion (after nearly 3 decades of experience), these authors would have more likely had a successful outcome with both patients if they used multi-antigen threshold dosing, and perhaps selective preseasonal moderate dose therapy as an add-on, after thoroughly looking for hidden food sensitivies that could make  these patients brittle.  It works for me.  

Indeed, often when I see a patient poorly tolerating SCIT, (like these 2 patients), it's because of usually only 2 reasons:  either the doseage administered was technically a failure, or there was a hidden sensitivity in the patient that hadn't been addressed, and stressed their system, making them "brittle".  More often, it's choice number 2 rather than choice number 1.  Although it could be either.

Soooo, what's the verdict?  I agree with the authors conclusions--"special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."  Yes, and water can be poisonous.  In my opinion, a better title for the article (rather than "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy" would be

"Sublingual immunotherapy  in ultra-rush protocol to multiple sensitized patients who may have other hidden sensitivities is not always a safe alternative to subcutaneous immunotherapy" would be a much better title.   

My real fear is that the typical allergist likely perusing this article will go AHA!  SLIT ISN'T SAFE!  SEE! SEE!  And he/she will settle back comfortably into the complacent shot-giving attitude that is so common now-in-days, making the search for a better form of immunotherapy nonexistant.  And you know what?  The allergist is being bypassed in all this--by the ENT physicians and others who are increasingly using SLIT. Most ENT's  know SLIT can have side effects, and the one's that are friends of mine aren't using ultra-rush protocols on their patients either...

The search for a "universal" dose of SLIT that fits all patients in allconditions is nonsense.  To apply the European protocols for monosensitized patients to multi-sensitized patients with severe SCIT reaction histories should only be done at the doctor's (and patient's) own peril...SLIT is incredibly versabile, and like any oral therapy (antibiotic treatment immediately comes to mind) different dosing protocols, depending on the condition you're faced with, make intuitive sense.  (I won't treat an acne patient and a lyme's patient with the same dose of doxycycline, would I?)

So think about these things, and while you're at it--pour me a glass of water, would ya?

Later, Dude

When I first started to blog, I read a cardinal rule--"post on your blog site regularly"...as those of you who follow my blog are well aware, I have violated this rule repeatedly...and as a result, I've probably lost most of my readers...but such is life.  I blog for myself, and to divulge the innermost secrets--my passions--in the allergy profession I've dedicated my life to.  I've been busy getting lectures ready for our annual allergy meeting, so I suppose that is a meager excuse for my tardiness on my blog site.  But in the process of giving a talk on diagnostic techniques used by the allergist, I once again come back to the critical importance of the history in allergy diagnosis...

It's funny that when I take a past medical history on my patients, so many of them say "I went to an allergist and had skin testing"...but none--and I mean none--have ever said 

"I went to an allergist to get a good allergy history and appropriate testing"

It's as if the procedure of skin testing tells the whole story.

It doesn't.

...I'll be getting a colonoscopy in the near future.  I really don't expect the colonoscopist to know my whole story...he's a technician designed to look at my colon--and to see if anything is abnormal. But he can't put the findings into any clinical context.  That's for my doctor to do...I don't expect him to give me any answers except for what he sees at the moment.  

I saw a patient last week...the man looked absolutely miserable. He had a history of sneezing, congestion, facial swelling initially beginning in the spring, but then building up and getting worse each summer and fall.  The problem had been going on for several years.  He had a nice skin response to a histamine control, but his skin tests were largely negative.  It has been an aphorism of mine that the allergist can stop thinking when the skin tests are strongly positive, but needs to start thinking when the tests are negative in someone with a clinical history of allergic problems. He'll undoubtedly be a delayed reactor to molds on is skin tests in 24-48 hours. I'll be interested in his delayed-reaction report.  

Another patient had seen me recently, with the onset of congestion in the summer of 2008, continuing throughout the winter and into the summer of 2009 when I had seen her.  She was also miserable. My initial impression of possible dust mite sensitivity didn't show up on skin testing--in fact, skin testing failed to reveal anything of importance.  More significantly, further history-taking had revealed she had traveled from Minnesota to Arizona over the winter, with absolutely no improvement in her symptoms.

So it was back to the history, once again...

What was going on last summer 2008 that was "out of the ordinary?" I asked.  "Nothing, she replied, except that I had had diverticulitis and was hospitalized briefly for it", she stated.  "Did anything change after that?" I asked.  "No, except that I began eating very large quantities of yogurt to help my intestine, she said".

It turns out that after additional testing I found out that she was milk protein sensitive, and the dramatic increase in milk protein beginning last summer was enough to cause her problems from that point onward--and would explain why she hadn't improved with a change in climate from Minnesota to Arizona.  

The most important diagnostic tool we have is not the needle we stick in the skin, but the grey matter between our ears.  

Skin testing and colonoscopies are fine, but only tell part of the story.  The rest is up to the doctor and the patient.

Later, Dude

In my last entry, I asked the question "Where are today's Leonardos?" in the allergy community. If I was the head of an allergy training program in a University (which thankfully I am NOT), I would not only (of course) emphasize superior critical analysis and clinical problem solving, but also very unconventional creative thinking sessions among all trainees. Why? Because I firmly believe that the clinical triad of a superior allergist is technical knowledge (i.e., thoroughly knowing disease states we deal with), wisdom (which comes from experience in dealing with patients), and...curiosity (i.e., creative stimulous).

The Book by Von Oech, "A Whack on the Side of the Head" would be mandatory reading for every allergy fellow.

It is my contention that truly creative allergists are in short supply...and that's because of blocks to creativity that every allergist subconsciously "employs" in his or her practice. And these blocks to creativity slow down advances in the allergy community. Advances that are within our reach if we think creatively. How can we have a Renaissance of creative thought in our Allergy Community?

By removing the Roadblocks to Creativity...

Allergy Creativity Roadblock #1: There is only one "right answer".

To quote Von Oech, "Nothing is more dangerous than an idea when it's the only one you have". Example: SCIT works for immunotherapy. Stop there. Don't ask the question--can we deliver immunotherapy more safely, effectively, than with SCIT? We have one idea. SCIT works. Nothing else does. And nothing else is even considered.

Allergy Creativity Roadblock #2: Logic can kill creativity.

As a former engineer, this rule absolutely kills me, but it's still a rule we have to follow for creativity. Simply put, there is a time and a place for logic--I use it minute-by-minute to solve clinical problems daily encountered in my practice--but there is a time and a place for creative thinking as well. What we need as allergists is a "time out" from logic so we can get as many ideas as we can, no matter how crazy--the crazier the better. For the Creative Allergist, it is the patient who "doesn't make sense" that is the patient we can learn the most from.  Last month, I mentioned the recent review by Bahna on food additive sensitivity, in which he concluded that there was not one report in the medical literature on desensitization to food additives (despite of course multiple reports on successful ASA desensitization). Well? Doesn't anyone have a crazy idea?

Allergy Creativity Roadblock #3: Break some Rules

As creative, Renaissance Allergists, we need to ask ourselves the tough question, "What 'unwritten' rules are currently in place in my profession that are stopping me from helping more patients productively?" Here are a few "unwritten rules" in our profession--1. To paraphrase Patrick Henry, "Give me IgE or give me Death", 2. Head, neck, lungs. The allergists domain. Nothing else. We all need to break a few rules, and see where our thinking leads us. The pathetic tragedy is most allergists can't think outside the box, because they don't even realize they are in one.

Allergy Creativity Roadblock #4: Being Creative is 'Not my Job'

The good allergist, we're taught, plays by the rules, and follows the lead of our professional societies--we rely on them to be creative. Nonsense. We can never rely on a professional society to be creative, when it has vested political, financial, and other outside interests which can atrophy any feeble attempts at creativity. As individual allergists, we have to realize that we are NOT fully doing "our job" UNTIL we approach our field in a creative fashion. Creativity starts with the individual allergist, not the professional allergy societies. Not the other way around.

Allergy Creativity Roadblock #5: Fear

I've saved what I feel is the most potent roadblock to allergy creativity to the end: Fear. Face it: It is hard to be creative when you are fearful. And if there is one disease that Allergists suffer from currently, it is a (possible terminal) case of fear:Fear of declining reimbursements from insurance carriers--especially if we use SLIT and not SCIT. Fear of increasing competition from ENT's, Family practitioners, etc for our patients. Fear of SLIT-based pracitioners and pharmaceutical companies making better and better treatments that "take away" the need for an allergy referral and put allergy management back into the hands of the primary practitioner. Fear of "internet educated" patients desiring help with delayed food sensitivities and other areas we aren't really interested in or know how to deal with. In truth, we are a fearful lot. And, as I've said, it's hard to be creative when you're fearful. But there's a cure:

There is no fear in love [dread does not exist], but full-grown (complete, perfect) love turns fear out of doors and expels every trace of terror! For fear brings with it the thought of punishment, and [so] he who is afraid has not reached the full maturity of love [is not yet grown into love's complete perfection]. —1 John 4:18

Simply put, if we love our profession, our patients, and our calling with enough passion, we'll approach creativity without fear.  And then advances in allergy can really be made.

Later, Dude

It is truly rare that I read a newspaper article that resonates with my opinions & beliefs like the article, "Where are Today's Leonardos?" by Dr. Howard Zucker  in USA Today.  Although the article was officially addressed to the graduating class of 2009, it could just as easily have been addressed to our professional allergy community.  In his article, Dr. Zucker (a resident fellow at the Institute of Politics at Harvard University), states

"Perhaps it is time for a rebirth, a time to create a better world through the energies of the Class  of 2009"...The Renaissance was a period when our search to perfect one's worldly knowledge transcended obstacles and bridged intellectual divides.  Students of creative thought--including da Vinci, Michelangelo, Copernicus and Galileo--questioned conventional wisdom...  Just as the Renaissance masters cast away conventional concepts, so too shall we discard friction that creates inertia in our thoughts."

Conventional Wisdom in the allergy community today involves several key underpinnings, which permeate all thinking and research in the field and (in my humble opinion) don't exactly "transcend obstacles and bridge intellectual divides".  Here are 3 key points in allergy Conventional Wisdom:  

1.  Since IgE mediated disease is the only "true" allergy, it is the only sensitivity we should be concerned about. Delayed food reactions, mold reactions, etc. really aren't our concern...so let's sweep them under the rug.  Let them die a death of benign neglect, not flourish in an atmosphere of curiosity...

2.  Asthma and upper respiratory disease should encompass what the allergist is "all about".  Other organ systems (besides pulmonary) should (once again) die a death of benign neglect as it regards interest in them as allergically responsive systems.  

3.  Other chronic disease states--chronic fatigue syndrome, fibromyalgia, migraine headaches, interstitial cystitis, have no allergic component, because everybody knows they don't.  So let's not be curious and study if indeed they DO have an allergy component to them.  

Examples of this "intellectual straightjacket" abound.  You can generally pick up any current issue of any allergy journal and see Conventional Wisdom at work--and trumpeted...Here's just one small example:  In the June issue of Current Opinion in Allergy and Clinical Immunology DRs. Randhawa and Bahna wrote a comprehensive review entitled "Hypersensitivy reactions to Food Additives".  They comprehensively review the protean manifestations of food additive reactions, and I heartily recommend the article for those allergists who see this problem in clinical practice.  However, near the end of their article, they state:

To our knowledge, there are no published reports on successful desensitization procedures.  

What?  You mean there isn't even a single case report in the entire body of medical literature on successful desensitization to food additives, despite multiple articles on successful aspirin desensitization?  Hello--isn't anyone anyone curious & interested?  Where's creative thought?  

It was this form of unconventional thinking that drove me to try oral desensitization to yellow dye #5 in a patient I had seen in my office earlier, who had presented with a history of seasonal allergic rhinitis, and repeated urticarial reactions to foods containing yellow dye.  As with many allergy patients, she wanted help with the "difficult issue" (dye sensitivity), and not the "easy issue" (allergic rhinitis).  As a businesswoman, she frequently went on trips and ate at restaurants, and found it always a risky procedure

We began her on a progressive program of yellow dye oral desensitization, starting with dilution #9 of yellow dye #5, and working progressively up to a dilution #1 without serious problems.  We knew we had successfully desensitized her when she told me she was on a business trip and gulped down a glass of Tang, which she had mistaken for Orange Juice, and had no reaction. Conventional Wisdom would have just treated her for her allergic rhinitis (which she could handle just fine with an OTC antihistamine, thank you).  

So here's the thought for the day--are we graduating Leonardo's from our allergy training programs, or just good Asthmalogists and technicians?

Do allergists think "outside the box"--or inside a straightjacket? 

Later, Dude

It was with bittersweet pleasure that I read the "JAMA Classics" article "Dr. William W. Duke:  Pioneer in Platelet Research" that was just published June 3, 2009.  Dr. Kickler, in his commentary on this classic article (first published in 1910 by Dr. Duke) states:

...when Duke published an article in JAMA on the role of platelets in hemostatis, probably few individuals realized that this report would be judged as one of the outstanding contributions to the science of medicine during the first half of the 20th century...this JAMA Classics article by Duke is historically important for 2 reasons:  it defined the role of platelets in hemostasis and it documented the therapeutic efficacy of blood transfusion in treating thrombocytopenia..."

There is always a danger in "cherry picking" a great physician's body of published work--you might give the erroneous impression that's ALL they really accomplished....  I pointed this out in my earlier commentary on a recent article on Dr. Warren Vaughn, another Renaissance Allergist, published in the JACI that didn't (in my humble opinion) adequately due justice to his contributions to the field of food allergy.  

In truth, I count 97 total publications by Dr. Duke over his lifetime.  Less than 10% of these actually deal with platelets.  Dr. Duke was fascinated by the wide range of symptoms that food sensitivity could cause, and abided by the maxim "one mucosal surface" instead of the mantra "one respiratory tract" (used by so many "allergists" today) to describe the wide range of manifestations that allergic disease could cause.  Here are some articles he also published:

Duke, WW:  Food Allergy as a cause of abdominal pain.  Arch Int Med.  Chicago 28:151, 1921.

Duke, WW:  Food Allergy as a cause of abdominal pain.  South M J Birmingham 15:599, 1922.  

Duke, WW:  Food Allergy as a cause of bladder pain.  Ann Clin Med 1:117, 1922.

Duke, WW:  Food allergy as a cause of irritable bladder.  J Urol, Baltimore 10:173, 1923. 

Duke, WW:  Meniere's syndrome caused by allergy.  JAMA 81:2179-1923.

Duke, WW:  Urticaria caused specifically by the action of physical agents (light, cold, heat, burns, mechanical irritation, and physical and mental exertion) JAMA 83:3, 1924.  

Duke, WW:  Mental and neurologic reactions of asthma patient.  J Lab & Clin Med 13:20, 1927.

Duke, WW:  Allergy as a cause of gastrointestinal disorders.  South M J 24:363, 1931.

Duke, WW:  Rapid and more accurate method of determining pollen count in air.  JAMA 99:1686, 1932.

Duke, WW:  Soybean as a possible important cause of allergy.  J Allergy 5:300, 1934.

Duke, WW:  Wheat miller's asthma.  J Allergy 6:568, 1935.

I stress this is only a fraction of the allergy articles published by Duke--it is by no means a complete list.  It is ironic that the commentator of the article on Duke and platelets (Dr. Thomas Kickler) did not at least reference JAMA's OWN TRIBUTE on Duke's life:

William Waddell Duke 1883-1946, JAMA 130:1185, 1946.  

Duke was obviously a brilliant allergist who made important contributions to the specificity of food allergy, in addition to making important contributions in the field of hematology.  How do I know about Duke?  One of my mentors (Dr. Theron Randolph) recalled seeing Dr. Duke at an allergy conference in 1933 in Atlantic City New Jersey, while he was a senior in Medical School.  He studied Duke's life, and published his bibliography.  I have a copy of that bibliography.  Dr. Randolph stated that  

"Duke's remarkable book published in 1925 really opened up the field of food allergy...Duke related specific foods and simple chemicals to a wide range of allergic symptoms, including headache and bewilderment resembling delirium..."

William H. Duke:  Pioneer in Platelet Research

                             AND...

                    Renaissance Allergist.

Something to think about.

Later, Dude