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The Big Lie 

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.

Later, Dude 




 

 

Posted on Monday, May 28, 2012 at 04:58PM by Registered CommenterGeorge F Kroker MD FACAAI | Comments1 Comment

The Creator's Playground

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--

would heal.

Later, Dude

 

 

 

Posted on Saturday, May 5, 2012 at 05:24PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment

Food Intolerance Testing--Investigate or Denigrate?  

I sat across from Ellen in the exam room.  Her once-tired face had been replaced by a vibrant smile.  "I feel better than I have in years", said Ellen.  Her energy, stamina had returned and her constant gastrointestinal complaints had vanished.  

She handed me an article, and somewhat sheepishly said, "I think you might want to see this".  It was an article from the StarTribune Lifestyle section, called "Doubts cast on food intolerance testing."   

"I know your advice has worked for me", she said.  "But what can I tell other peope after they've read this article?"

Indeed.

Through a combination of detailed history-taking, open- challenge testing here at our office, AND IgG testing, I had diagnosed Ellen as having delayed-type food sensitivities. 

The article mentioned casts doubt on the utility of IgG testing in the diagnosis of delayed-onset of food sensitivity.  But in doing so, I think it misses a few key points. As an allergist with 30 years of experience in diagnosing and treating this troublesome problem, and with extensive experience in looking over hundreds of IgG food tests,  let me weigh in with a caveats:

In Vitro Food Tests should never be utilized alone  to diagnose food sensitivities.  Results should  only be interpreted in conjunction with a thorough history taken by an experienced clinician.  Period.  

False positives occur with IgG food allergy testing.  In reviewing hundreds of these tests, and comparing them to later open food challenges, false positives do indeed occur.  The experienced clinician will often be able to spot these on an initial review of the test results.  

Despite the above, the IgG food testing results often give an excellent "starting point" to begin to look for delayed food sensitivities in a chronically ill patient.  It is an excellent screening tool.

The IgG ELISA/RAST can be cost-effective if done properly.  In our lab, we run a "targeted" IgG RAST to selected foods, based upon the patient's history AND the experienced physician's impressions.  Why check for blueberry allergy, for example, if the patient doesn't even know what a blueberry IS?     

It is the height of hypocrisy for the allergy community to criticize this test, when not admitting they don't have a diagnostic solution to the problem, and aren't even interested in pursuing it.  Hiding behind the IgE food-allergy mantra is a smokescreen to distract us from a much bigger problem--and that is that delayed onset food sensitivities are (in my humble opinion) at least as important in scope as IgE mediated food sensitivities.  Just because a food makes a patient sick hours after eating it, and not immediately, and just because the food sensitivity is non-IgE mediated, should we be uninterested?  As part of the Renaissance in our profession, we need to be the masters of ALL food reactions.  

In truth, the patient who doesn't know about delayed-onset food allergy is uninformed, and the patient who sees the allergist and asks about dellayed-onset food allergy usually leaves misinformed.

Delayed-onset food allergy.  IgG testing.  Something to investigate.  Not denigrate.

Later, Dude

 

 

 

Posted on Sunday, April 29, 2012 at 05:55PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment

Of Allergists, Emperors, and SLIT

History repeats itself, first as tragedy, second as farce.
Karl Marx


In the absolutely superb book Abundance: The Future is Better Than You Think  by Diamandis & Kotler, is an interesting story...going back two millenia.  

In the first chapter of their book, the authors relate a fascinating story told by Pliny the Elder, who was a brilliant Roman naturalist who wrote a 37 volume tome Naturalis Historia. In one of his later volumes, Earth, book XXXV, he tells the following story:  

A goldsmith brought a unique dinner plate to the court of Emperor Tiberius. It was a show-stopper: light, shiny, and gorgeous.  The goldsmith claimed he'd extracted it from clay using a secret technique and formula known only to himself.  Upon seeing this beautiful plate, however, Tiberius became very concerned.   He feared the value of his treasure trove of gold would seriously decline if people suddenly had access to a new metal rarer than gold.  "Therefore", recounts Pliny, "instead of giving the goldsmith the regard he expected, he ordered him to be beheaded."

And thus, aluminum was lost for nearly 2000 years.

My point?  New innovation is not always welcomed by the powers-that-be. And SLIT (sublingual immunotherapy) is a new innovation. And is it being welcomed with open arms by our American Allergy Establishment?  And if not, why not?    

The practicing Allergist is hungry to know more about SLIT.  One of the absolutely most common "search hits" I have on my Blog Site is searching for information on SLIT.  I see searches on my site for "SLIT"  "SLIT protocols", "sublingual immunotherapy" etc. etc. etc.  

But what about the "Allergy Establishment"?  What can we expect in the next few years?  I'll hazard a guess:  more defensive posturing.     Here are some examples we've already seen:  

1.  "It's not FDA-approved"  This is the tired, stalling tactic that has become our mantra as American Allergists. What isn't stated by the Allergy Establishment is that using extracts that are FDA approved in an off-label manner is perfectly legal and is consistent with historical medical practice.   And let's use common sense here--what's the difference between getting an extract into our body by injecting it or by giving it under the tongue?  It's still the same extract, right? Why would we not be enthusiastic about exploiting this route of administration, especially if the current literature attests to its overwhelmingly favorable safety profile?   

2.  More studies highlighting the "danger" of sublingual immunotherapy:  this has major benefits for the Allergy Establishment.  It  "packages" the treatment as something that should only be done by the board-certified allergist, and away from the domain of the ENT, and family practitioner who would consider using it.

3.  Glacial movement towards a protocol for treatment, while attempting to marginalize the fact that an effective protocol for treatment already exists and has published data regarding efficacy.  Yes, that's right. The La Crosse Method of SLIT.  Check out the Feb Issue of the Journal of Allergy:  Quality of Life Improvement with Sublingual Immunotherapy:  A Prospective Study of Efficacy by Morris, Lowery, Theodoropoulos, Duquette, and Morris.  Then check out my lecture on SLIT protocols to compare the La Crosse Method with others.  

As allergists, we've served up the shining, beautiful "plate" of SLIT---to our patients, AND to our allergy establishment.  How are each of them receiving it?  

Something to think about.

Later, Dude

Posted on Monday, March 19, 2012 at 01:38PM by Registered CommenterGeorge F Kroker MD FACAAI in | CommentsPost a Comment

Candida Related Illness and Sublingual Immunotherapy--Similar Struggles

This week on Thursday I'll be giving a Webinar on the Spectrum of Candida Related Disorders (the lecture is available for download). In preparing the lecture, I've reflected on my journey over the last 33 years in looking at this mysterious illness.  The journey began in 1978 when I was an allergy Fellow in Training in Chicago.  I received an unexpected phone call from a patient of mine who told me she had not gotten better with my treatment, but had gotten dramatically better after receiving treatment with antifungal medication from Dr. Orion Truss in Birmingham Alabama.

And so my journey began.  And, after 33 years, I am still on it.

But I am on another journey too.  A journey involving the use of Sublingual Immunotherapy (SLIT) and probing it's depths to determine how best to treat my allergy patients.

Candida related illness is a disease in search of a pathogenic mechanism and diagnostic test.  SLIT is a therapy in search of a mechanism of action and therapeutic efficacy. 

However, in reflecting on these two journeys I've been on, it occurred to me thathe struggles for Candida-related illness to gain acceptance has striking parallels in the struggles for sublingual immunotherapy (SLIT) to gain acceptance

  Consider these points:  

1.  Both concepts were developed outside mainstream academia.

2.  Both concepts suffered from "The Tomato Effect".  As described by Goodwin & Goodwin in their landmark article in JAMA in 1984, the tomato effect is derived from the true story that no one in America ate tomatoes in the early 19th century because "everyone knew it was poisonous".  Why?  Because "we just knew it".  Never mind that Europeans were eating this New World Fruit (imported from Peru) by the bushelbasketful! Finally, in 1820 Robert Gibbon Johnson sat down at the Courthouse steps in Salem, New Jersey and shocked the townspeople by eating a tomato and not dying.  The contention of Goodwin & Goodwin is that the Tomato Effect retards progress in medicine when a treatment doesn't "make sense" in the prevailing medical atmosphere.   

In the case of SLIT, allergists knew it didn't work because "they just knew it".  In the case of Candida, the same thing happened--Candida just causes infections and not allergic disease, because, well, "we just knew it".  

3.  In both cases, rather perfunctory, negative studies were done by academia which dismissed Candida and SLIT as not being worthy of further study. (think about the Dismukes study on Candida in the NEJM in 1990 and the studies by Nelson et al in 1993 on SLIT for cat antigen as good examples)

4.  In both cases, later studies showed efficacy but American academia was still reluctant to enthusiastically endorse either of these concepts.  They just "didn't make sense".  

5.  In both cases, despite academic resistance, general practitioners found the efficacy of antifungal treatment for Candida-sensitive patients and SLIT treatment for allergy patients was just too good to ignore.  Regarding SLIT, our European colleagues have begun utilizing  this form of treatment more and more extensively.  Regarding Candida and antifungal treatment, our Alternative Medicine colleagues have also utilized this form of treatment more and more extensively.  

6.  In both cases, of course, (as to be expected), insurance problems exist with both issues--both reimburse as well as coding problems.   

And what about the future?  Here again, there are similarities with both Candida Related Illness and Sublingual Immunotherapy:

1.  In both cases, much more study is needed in area of mechanisms--in the area of SLIT, we need to further research the  mechanisms of therapeutic action, and in the area of Candida related illness, we need studies in the mechanism of disease pathogenesis.  

2. In both cases, we need to encourage American Academic Institutions to perform studies in these two areas.

And the biggest similarity in the struggle for SLIT and Candida-related illness to gain credence?  Easy answer:  

They both highlight the glaring deficiencies in the mind-set of our general American Allergy Community.

As a group, we have had a myopic, restricted drug-oriented, immunotherapy-minimizing, one-organ system (respiratory tract) viewpoint that frankly embarrasses me.  We need to enlarge considerably and (yes)  embrace and welcome  different viewpoints and new ideas and concepts.  Let's quit our intellectually  lazy "business as usual" mindset, and broaden our horizon beyond the respiratory tract and IgE mediated sensitization states.  We need to open our eyes to new ideas and treatments.  SLIT?  Bring it on!  Candida related illness--let's check it out!

So joint me on my journey.  And trust me:  It's worth it.  

Later, Dude

 

 

Posted on Sunday, March 4, 2012 at 05:17PM by Registered CommenterGeorge F Kroker MD FACAAI | Comments1 Comment | References2 References