This article is in press and will be published in Annals from the College of Allergy, Asthma, and Immunology next month. I thought the study is very interesting given the “push” for oral desensitization. I just returned from the AAAAI annual meeting and it appears that patients with food allergy can become “desensitized” or cured, however, that comes with a cost of potential anaphylaxis during treatment. Think of it like the use of allergy shots which are very effective, but you can develop anaphylaxis after an allergy shot that will need additional treatment such as epinephrine. The question I have is, “should this therapy with foods be used at home where parents and patients don’t know much about giving epi?”
Here’s the summary–>Asthma patients are at risk for more severe reactions and less likely to reach full desensitization during milk oral immunotherapy, according to a study in Annals of Allergy, Asthma and Immunology. Researchers in Israel studied 194 subjects 6 years and older with IgE-mediated cow’s milk allergy, with and without asthma, undergoing milk oral immunotherapy. Regardless of severity, subjects with asthma had more reactions and injectable epinephrine use during induction, and more home treatments with immunotherapy. Moderate to severe asthma also was associated with a lower likelihood of reaching full desensitization
Without a doubt, driving on ice and snow should be reserved for the experienced drivers only. We don’t need more wrecks on Hwy 169 that what we already have to endure. But when the forecast for a winter storm brings on a run for bread and milk, we may have gone a bit too far. We have our own version of Black Friday…it’s called snow storm panic! Here I was shopping at Target to get a few items I really did need. Usually, my wait at the pharmacy is very short, but last night I guess EVERYONE thought it was important to get their medications filled before the storm arrived in case medications would no longer be available. Come on, pharmacies stay open even in Minnesota. Did you happen to go down the bread aisle? Nothing left and not a snowflake on the ground. No wonder you can’t yell fire in a theatre. The most shocking behavior, however, found in Oklahoma in preparation for a winter storm is to cancel school before it even starts to snow. Will you catch us off guard and unprepared? Not a chance. No wonder our kids have never seen snow or had a chance to make those lovely snow angels. They’re never in it. All joking aside, we did have a pretty nasty snowstorm 2 years ago with almost 20 inches in one night. That amount of snow shut the city of Tulsa down for a week! Could it happen again? Sure could, but the video below is enough for me:
Now, you’re probably wondering if I always pontificate about a totally irrelevant topic such as how Tulsans prepare for snow storms. Fortunately, this can have some relevance to cold weather illness:
- Asthma can be a real problem during the cold weather. Inhaling cold air causes drying of the airway wall and more severe bronchospasm that moderate temperatures. Don’t think that coughing and shortness of breath is just cold air; it may be your asthma getting out of control. Learn how to cover your nose and mouth with a scarf or mask, even if you’re outside for a short period of time. And most of all, use your regular inhaler (controller) during the winter months if cold air or upper respiratory infections are triggers for your asthma.
- Another problem with the winter season is trying to figure out if I have a cold, flu, sinus, or allergy problems. Let me make this much easier for you. Most ragweed is done pollinating by the end of October, so without much pollen in the air, your sneezing and coughing is probably not due to allergy (no exposure). A cold usually lasts < 1 week and any congestion or runny nose that doesn’t resolve from one Saturday to the next is probably a sinus infection. Why does this matter? Sinus infections should be treated with the “all or nothing” approach as any infection left in the sinuses will only result in more infection. Catching the flu makes you feel terrible and you’re already coughing. What could be worse? Add a fever with muscle aches and your diagnosis is most likely some type of influenza. Good motivation to get your flu shot!
- Am I Allergic to the Cold? I’m glad you asked. Cold-induced hives stays hidden for most of the year and comes out with a vengeance during cold weather. Some instances can be life-threatening and this condition is nothing to take lightly. Cold-induced urticaria of course, responds best to a vacation at Key West, but if you don’t have the luxury or flexibility to do that, antihistamines are still the backbone of treatment. Be careful when shoveling snow as shortness of breath and chest tightness may be associated with hives and a cold-induced reaction.
Although you must be careful with cold weather illness, you have to do something outside or you’ll get cabin fever. The link below is from AAAAI on how to control your asthma and still participate in winter activities. It’s a good read in front of the fireplace with a cup of hot chocolate. In the meantime, I’m heading for the slopes!
Asthma and Winter Sports.
It’s not unusual for a doctor to refer a patient to our allergy clinic to answer the question, “what pain medications am I allergic to?” Surgery of any kind is a bit frightening, but add to that an adverse reaction to one of your pain medications and you know what hits the fan! Reactions can include hives, difficulty breathing, headaches and a whole lot more. So what can I do if I’m in a car accident or emergency surgery and I receive a pain medication I’m allergic to? Will it kill me?
Consider the following:
- Most effective pain meds are opioids and release histamine from the body when taken as pain meds. We can’t skin test to medications in this category, so we rely on previous history. That works well for the most part, but “there’s a first time for everything”
- The one exception to the above rule is fentanyl. With this medication, skin testing and treatment for tolerance have been published and offer a good alternative.
- Often a procedure called “drug provocation testing (DPT)” is necessary to determine what you can and cannot take for pain medication. Fortunately, most patients can tolerate the standard protocols used by most hospitals, so no need to worry. If in doubt, DPT will give you VERY small amounts of medication making sure you can tolerate the drug before moving to a higher dose. With a little patience & a long afternoon in the doctor’s office, we can usually find a medication that will work.
- But don’t take my word for it….the American Academy of Allergy Asthma & Immunology has several references on the subject of allergy to pain meds. Check it out with the link below:
Prevention of allergic reactions in a patient scheduled for knee replacement who has a history of pain medication allergy and possible contact dermatitis to chromium.
Schools are quite paranoid about giving any medication on their watch. The liability for giving sunscreen when you don’t need it? Zero. This is very similar to the use of epinephrine in a school aged child with food allergy. You certainly don’t want to withhold epi and risk anaphylaxis or death, when the risk of giving the EpiPen is negligible even if you don’t need the drug. Maybe our policies in schools will change after a large malpractice case gets media attention for NOT giving epinephrine at the appropriate time for peanut allergy.
Ok, another study about the dangers of food allergy (yesterday in USA Today). You would think the occurrence of food allergy to KNOWN allergens (peanut & milk) would decrease given all the attention given to accidental ingestion. Evidently, this is not the case. Explanations? Maybe we’re afraid of giving epinephrine. In my personal experience, giving epinephrine is analogous to “waving the white flag.” It doesn’t have to be nor should it be when treating children with suspected food allergy. As I tell my nurses, “give the epi, then call the doctor!”
So how much can we hear about food allergy? As unfortunate as it is to have a severe food allergy, what bothers patients most is lack of reliable information about their condition and the lack of concern about a potentially fatal reaction. Just look on Facebook to find hundreds of stories about the tragedy of food allergy or anaphylaxis. Here’s an example of the anxiety that results from a child with food allergy—>
If you’re going to treat food allergy, you have to know it’s there–duh. But not so fast….most kids never get the appropriate food challenges to make the diagnosis. Consider this:
- Oral food challenges are the gold standard for diagnosing food allergies in children, but only a small fraction of kids in the United States are getting them.
- At the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting Dr. Gupta reported from her study that oral food challenge was done in just 15.6% of children that really needed the test.
- As a result, it is likely that childhood food allergy is seriously underdiagnosed
“Food allergy guidelines just came out in March of this year from the National Institutes of Health NIAID [National Institute of Allergy and Infectious Diseases] stating that oral food challenge is the proper test to diagnose food allergy, along with medical history and positive skin and blood testing,” Dr. Gupta said.
In Dr Gupta’s study, only 47% had a skin test and 40% had a blood test for food allergy.
“Overall, what this tells us is that food allergy is not being diagnosed optimally and oral food challenges are definitely not being done enough,” she said.
What are your thoughts about food allergy? Have any readers experienced a “misdiagnosis” of food allergy? I’d love to hear from you!