Apparently buying someone else’s breast milk over the internet is a real thing. I had no idea. The folks at the journal Pediatrics are more on the ball than I and just published a study analyzing human breast milk samples purchased from an unnamed “popular website”. They compared the internet samples to unpasteurized samples from the Human Milk Banking Association of North America, which, apparently, is also a thing. What they found was pretty unsettling. The internet samples were twice as likely to contain significant levels of gram-negative bacteria (72% vs. 35%) and 2.5 times as likely to contain significant amounts of staphylococcus (63% vs. 25%). Their conclusion is that purchasing breast milk online places kids at risk, especially if they are preterm or otherwise medically compromised, and that increased use of lactation support services is needed to address the gap for women who wish to feed their children human milk but who are unable to meet those needs.
Intranasal Steroids (INS) have long been the most effective therapy for nasal allergies, and their use is part of the guidelines for the treatment of both allergic rhinitis and asthma. They’ve been in use since I was a child and have always been available only by prescription. Over the past few years, several other countries have made them available without a prescription, commonly called over-the-counter or OTC. The U.S. has now followed suit. The FDA voted 10-6 in favor of allowing the steroid triamcinalone acetonide (TAA) to be sold OTC as an INS. There has been mixed reaction to this in the allergy community and the AAAAI issued a position paper, which was endorsed by the American Academy of Pediatrics, against allowing TAA to be sold as an INS OTC. Overall, I’m in favor of the move, but I do share some of the AAAAI’s concerns.
The AAAAI spends most of the position paper talking about safety concerns, primarily growth suppression in children. Inhaled corticosteroids for asthma have consistently shown a small reduction in growth with long term use, about the length of my fingernail. The data on INS and growth suppression are less clear, but it is still a reasonable concern. Chronic use of INS has also been linked to cataracts and, less clearly, to glaucoma in adults, though the data here are mixed and the findings less robust. Please note that these concerns are for chronic use, not for episodic use. The TAA packaging will advise users to see a doctor for their symptoms if they have to use the spray for more than a couple of months per year, but if experience with other OTC medications holds true here, many folks will not adhere to this advice.
Another concern with OTC TAA has to do with how INS have to be used. Most OTC medications work well on an as-needed basis. In contrast, INS have to be used regularly for several days in order to work well. If you just use them a day here and a day there, you’re just getting the mechanical effect of squirting something wet up your nose. Product labeling will reflect this need, but, again, there are bound to be folks who don’t read and/or don’t follow the directions, and they will be, essentially, spraying really expensive water up their noses.
The AAAAI position paper leaves out what is, for me, a big issue with bringing TAA OTC: the molecule itself. Off the top of my head, there are seven different steroid molecules being used in INS, two of which are generic: TAA and fluticasone propionate (FP). Of all the molecules, TAA is the worst. It has the lowest topical potency and highest bioavailability (read: potential for side effects). I haven’t written a new prescription for TAA or its former branded equivalent in a decade. Making FP OTC would have been a much better option.
Despite these legitimate concerns, I think the FDA was reassured by the experience other countries have had with OTC INS. If used as directed the potential for significant complications is very low. I’m hopeful that other molecules with better risk/benefit ratios will come to market and that competition will result in cost savings for patients while creating added convenience. When that day arrives, allergists and other physicians will still have an important role in counseling patients as to which OTC INS are best for them, much like we do for OTC antihistamines.
The lead article in the Sunday’s New York Times is ostensibly about medication costs in general, but it focuses on allergy and asthma medication costs. I’ve blogged about this before, several years ago in fact, but the problem persists. Allergy and asthma medications are incredibly expensive in the U.S. when compared to the rest of the world, and the costs are going up, despite the fact that there are multiple options, i.e. competition, in every medication category. It’s a problem we have to deal with every single day in our office and it adversely affects our patients.
I have to say, I was more than a bit disappointed that the article did not mention allergen immunotherapy as a treatment option for some of the patients. It has been shown to be effective and cost-effective in treating allergic asthma and is a part of the asthma treatment guidelines. Yet another reason to see a board-certified allergist for care of your asthma.
This is my first blog! I am excited to share some of my thoughts and opinions on allergies with you and hope the topics will be of interest.
So, it’s the time of year our children start planning their Halloween costumes and begin looking forward to trick-or-treating. I have a 3-year-old girl who is already so excited to wear her pink fairy costume and gather up some treats! Unfortunately, I know that for some of my patients (and their families) with food allergies it can be a scary time for more reasons than one.
If your child has a food allergy, there are some things that you can do to make sure they have a safe Halloween. I would suggest your children collect their treats (as long as they are packaged, not homemade cookies, etc.) and then turn them in at the end of the night for you to review. You could have them trade the candies they can’t eat for some “safe” ones or give them a quarter for each candy they can’t eat and allow them to buy something of their choice. Watch little ones carefully, as you never know when they might decide to bite the candy, even with the wrapper still on! It may be best to carry their trick-or-treat bags if they are too young to understand the risk.
If you are like us and only visit a few homes in your neighborhood, you could always stock them with a few safe candies or small toys/stickers/crayons to be given to food-allergic children. Sometimes just making people aware of the risk of food allergies will have a ripple effect and may help another family with a food-allergic child.
Beware of “fun size” candies. They usually don’t have allergy warnings on them and may have slightly different ingredients than the regular sized versions.
Of course you need to be prepared for an accidental exposure, so have your epinephrine auto-injector available — and easy to access.
Cockroach has long been considered to be the primary allergic trigger for inner-city asthmatics. In that setting, it’s a difficult allergen to avoid, and trials of cockroach immunotherapy in inner-city asthmatics have been disappointing. New data suggests that mouse allergen is actually the biggest problem for inner-city asthmatics. This might be why the cockroach immunotherapy trials failed: we weren’t desensitizing people to the most important trigger. We’ll see lots more about this.
If you’ve read this blog over time, you know I’m a big proponent of vaccination. During my career alone, we have seen huge public health benefits from new vaccines. Now there is data showing that pneumococcal vaccination in kids results in significant reductions in invasive pneumococcal disease. Pneumococcus is the number one cause for bacterial pneumonia in all age groups and can be a very serious, non-trivial infection. The vaccine led to a 60% reduction in invasive pneumococcal disease. That’s huge.
Most treatments in medicine are a balance of safety and effectiveness, risk and benefit. Allergy shots are no different. When done properly, they can be life-changing. They do, however, carry some risk, and they are not a process which should be entered into or performed cavalierly.
Allergy shots work by giving patients injections of the things to which they are allergic. So, if you are allergic to ragweed and cat, your shots will contain ragweed pollen and cat allergens. By starting with a very tiny dose and gradually increasing the dose over time, your body learns to tolerate the allergens in the shots. Numerous studies have shown that allergy shots have a dose threshold that must be reached in order for desensitization to occur. In English, this means that if you don’t put enough allergen in the vials, the shots don’t work. Allergists call this dose the maintenance dose.
Building a patient up to the maintenance dose is a double-edged sword: the higher the dose, the greater the chance of desensitization, but also the greater the chance of having an allergic reaction to the shots. Allergists have learned how to minimize the risk of reactions in a number of ways. First, we use maintenance doses that offer the best combination of effectiveness and risk. Second, we use build-up schedules that mitigate risk while allowing the patient to reach maintenance in a reasonably timely manner. Third, we have dedicated staff and computerized protocols to ensure that patients are getting the right dose every time. Fourth, our staff look for patients having issues with their shots so that appropriate dose adjustments can be made. Finally, we monitor our patients after every shot for signs of a reaction and we treat them promptly and appropriately when they occur.
So what is the chance you’ll have a reaction to your allergy shots and how bad can it be? In broad terms, the risk of systemic reactions is low, but serious reactions, including life-threatening reactions and fatalities, have occurred. Estimates are that 3-5% of patients on a conventional build-up schedule will have a systemic reaction. The majority of these are mild, fortunately. In a review of our practice a few years ago, I calculated that we gave epinephrine to a shot patient for a bad allergic reaction around once a month. This came out to roughly once for every 5000 injections, a rate which is consistent with most large studies looking at systemic reactions in allergy shots. Large, long-term studies estimate the fatality rate at one every 2.5 million injections, which is about the same risk as being in a fatal commercial airline crash, one out of every 2.5 million flights.
If the risk is that low, then why can’t patients get their shots at home? Simply put, the convenience is outweighed by the risk. The reason allergy shots are so safe in the first place is because patients don’t get their allergy shots at home. The expertise, monitoring, and access to prompt evaluation and treatment that prevent mild-to-moderate reactions from progressing to severe, life-threatening reactions are the primary reasons that allergy shots are as safe as they are. If you removed these, then the safety profile of allergy shots would be much worse. This is why the guidelines for allergen immunotherapy set forth by the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology explicitly state that injections must be given in an appropriate clinical setting with a provider on site and the means to diagnose and manage acute allergic reactions, and that patients must be observed for an appropriate length of time after injections. Physicians who allow their patients to receive allergy injections at home are operating outside of published guidelines, are not following the standards of practice in the community, and are placing patients at risk.
Our practice has multiple locations, early and late shot hours and even, in a few offices, weekend hours, all to try and make the shot process as convenient as possible for patients while maintaining the highest degree of safety for you and your children. You should accept nothing less.
It’s that time of year again. The weather is cooling, football season is a month old, and the leaves are starting to turn. It can only mean one thing.
You need your flu shot.
I’m sure that’s the first thing on your mind on a lovely fall day, right? Well, don’t procrastinate too long – influenza can be nasty and the influenza vaccine is your best defense. It’s not perfect and it’s better some years than others, but it is much better than nothing at all.
The technical name for the flu shot is Inactivated Influenza Vaccine, abbreviated IIV. All IIVs will contain at least 3 strains of influenza, IIV3, and some contain 4 strains, IIV4. Strains are chosen based on their prevalence in other parts of the world where flu season occurs earlier in the year. To make the vaccine, the influenza virus is grown on chicken eggs and then killed or inactivated. This means two things. First, IIV cannot give you influenza. Second, people with egg allergy have had concerns about receiving IIV.
There are plenty of data looking at the risk of receiving IIV in egg-allergic patients, and they all point to the same conclusion: IIV is safe to give to egg-allergic patients, even those with severe egg allergy. The 2012 recommendations advised patients with severe egg allergy to receive the IIV in an allergist’s office and to be observed afterwards for a period of time. We are more than happy to provide this service. However, new guidelines advise that IIV may be administered to egg-allergic patients, including those with severe egg allergy, in any appropriate clinical setting. Furthermore, they state that language describing egg-allergic patients as being at increased risk or requiring special precautions should be removed from product labeling.
These are sound recommendations and I hope they clear up what has been a source of confusion for clinicians for some time.
September 18, 2013
by Dr. John Overholt 0 comments
If you’re wondering whether you have allergies, you can be tested two ways: a skin test and a blood test. Most allergists prefer skin tests – the results are immediately available, they are easier to interpret and may be more clinically relevant. That’s not to say that blood tests are bad. In the hands of someone who knows how to properly select the appropriate tests and how to interpret the data, they are an excellent tool. Unfortunately, some practitioners continue to order 1) unnecessary tests or 2) the wrong type of tests in an effort to diagnose allergies in their patients. To better explain this, a little background is necessary.
The immune system makes proteins called antibodies (Ab) or immunoglobulins (Ig) that are designed to help fight off infections. There are four main types and each has a letter name: IgA, IgG, IgM, and IgE. IgA and IgG each have different sub-types: two for IgA and four for IgG. Each of the different types of Ig has a different job. IgA is found on the lining of the airways where it helps to keep bacteria and viruses at bay. IgG circulates in the blood stream where it helps to fight bacteria and viruses that have slipped past the first lines of defense. It is the most important Ig in the overall defense from infection. IgE is the allergy antibody. It sits on the surface of allergy cells, like mast cells and basophils if you really must know, and when it comes into contact with allergens it causes the allergy cells to explode and release all of their nasty contents that make you sneeze and wheeze and blow your nose.
Igs do their work by binding to things like a bacterial cell wall, a viral capsule, or a grain of ragweed pollen. Ig binding is very selective. Each individual Ig will only bind to a very specific 3-dimensional protein structure, much like a lock and key. However, just like there are master keys that can open several locks, there are Igs that can bind to a few very different things. This is called cross-reactivity and it can often cause confusion when trying to interpret blood tests.
So what does all of this have to do with allergy blood tests? Well, when you are doing blood tests for allergies, you are measuring the amount of IgE floating around in the blood that will bind to a specific allergen: ragweed, cat, peanut, etc. Note that I said the amount of IgE, not IgG. IgG does not play a role in the allergy response, measuring the amount of IgG that binds to molds or foods will not tell you one way or the other if you have an allergy to these things. This goes for IgG sub-types such as IgG4 as well. This is a distressingly common mistake – ordering the wrong type of test. Indeed, the AAAAI saw fit to address this specifically as item number one in their Choosing Wisely initiative.
The second common mistake is indiscriminate testing: ordering unnecessary tests. The big problem with this, apart from wasting money, is that blood tests, and particularly blood tests for foods, have a fair degree of false positive tests. Often this is due to cross-reactivity, where people who are very pollen allergic will have positive blood tests to certain foods but will be able to tolerate those foods just fine. In medical parlance, this is called being sensitized but not allergic. The selection of tests should always flow from the patient history. So, if a patient’s history is not consistent with food allergies, then a provider should never order food tests. The use of food tests ordered as part of a “routine allergy panel” when the patient is being evaluated for non-food related problems, such as asthma or hay fever, is a prime example of indiscriminate testing.
So, in summary, IgE testing is the only meaningful allergy blood test and you should only be tested to things that fit with your history. If your provider wants to do blood tests for allergies, make sure it is IgE testing and ask them what you are being tested for and why. Or, better yet, see a board-certified allergist.
A very interesting study attempting to quantify the cost of childhood food allergies. They came up with a staggering total of $25 billion dollars a year. The biggest chunk of this was lost parental revenue at $14 billion. This underscores the need for not only better understanding of the causes of the increasing incidence of food allergies, but also better treatment options.
A recent review of asthma in pregnancy (AiP) confirms the long-held notion that the most important thing to do with AiP is to treat mom’s asthma. The risk to the fetus from a bad asthma exacerbation far outweighs the risks of regular medications. Frequent monitoring is also important.