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Strike the Bell

“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. 

5Realize 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. 

Later, Dude. 









Posted on Monday, May 6, 2013 at 05:52PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment

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