December 18, 2013
by Dr. John Overholt
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FDA Advisory Committee Supports Two New Sublingual Grass Tablets

The FDA advisory committee has recommended approval of two new sublingual tablets for the treatment of grass allergy.  The FDA is not bound to follow the recommendation of the advisory committee, but it usually does. So, what does this mean for you, dear reader?

First off, the word sublingual means “under the tongue”. These new treatments are a form of sublingual immunotherapy, or SLIT. I’ve blogged about the pros and cons of SLIT before and they still hold true today. In short, subcutaneous immunotherapy, aka SCIT, aka allergy shots, is probably more effective, works quicker, lasts longer and is better at preventing new allergies and complications. SLIT is more convenient and safer. Compliance is pretty poor for both.

The big drawback for the new grass SLIT tablets is their lack of flexibility and their narrow focus. One tablet contains only Timothy grass – a representative pasture grass – and the other contains a mixture of pasture grasses. This is great if all you have is pasture grass allergy; but if you have hot-weather grass allergy, like Bermuda and Bahia, or if you’re allergic to any of the other myriad allergens, like trees, weeds, dust mites, cats, dogs, cockroaches or molds, then you’re out of luck. In my practice, I would estimate that less than 1% of my allergic rhinitis patients are sensitive to only pasture grass. Allergy is regional, so this might be different elsewhere.

Perhaps more important than the individual tablet approvals is the fact that the FDA might approve SLIT at all. Up until now, SLIT has been a strictly off-label practice in the U.S. and, because it lacks FDA approval, it has not been covered by insurance. This certainly won’t lead to wholesale SLIT approval across the board, but it does get a foot in the door. For SLIT to be a meaningful treatment for most allergy sufferers it will have to be individualized and the approval process for that will be more complicated.

Stay Tuned.

Dr. O

December 17, 2013
by Dr. John Overholt
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In a Lather Over Soaps

Doctor:
What is it she does now? Look how she rubs her hands.

Gentlewoman:
It is an accustom’d action with her, to seem thus
washing her hands. I have known her continue in this a quarter of
an hour.

Lady Macbeth:
Yet here’s a spot.

Doctor:
Hark, she speaks. I will set down what comes from her, to
satisfy my remembrance the more strongly.

Lady Macbeth:
Out, damn’d spot! out, I say!

-Macbeth, Act V, Scene i

Germophobes rejoice! Or revolt! I’m not sure which, but the FDA is now going to require that manufacturers of anti-bacterial soaps prove that their products are safe over time and that they work better than plain soap and water. Your hand sanitizer is still safe, for now.  A bit more from Jeff Bezos’ Washington Post.

Dr. O

December 17, 2013
by Dr. John Overholt
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Dogs and Allergies, More on Multivitamins

In the interest of full disclosure on this topic: I’m a dog person.  I have a huge Golden Retriever and his boss, a French Bulldog, so I may be a bit biased.  Even if I am biased, I hope the researchers at the University of Michigan (Hail!) weren’t.  They just published a study showing that exposure to dust from dog owners’ homes led to less asthma in laboratory mice.  Interestingly, the primary change they found in the mice was not in their airways but in their guts.  The dog-exposed mice had higher levels of Lactobacillus johnsonii in their GI tracts, suggesting a link between gut flora and the development of allergic disease.  It’s just mice, but it’s still interesting.  Read more here.

 

This month’s Annals of Internal Medicine, probably the most respected Internal Medicine journal, has three scholarly papers dealing with vitamin supplementation and health.  One looks at cognitive decline, one at cardiovascular mortality after a heart attack, and the other at primary prevention of cancer and heart disease.  The accompanying editorial doesn’t mince words in its title, “Enough is Enough: Stop Wasting Money on Vitamin and Mineral Supplements“.  Suffice to say that none of the trials showed any benefit and they join a long line of similar trial outcomes that failed to show benefit, or even showed possible harm, from vitamin supplementation.  Supplements are a 30 billion dollar a year business in the U.S., and it’s time they were held to the same standards as medications.  The New York Times has a good summary here.

 

Dr. O

December 3, 2013
by Dr. John Overholt
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The Post-Antibiotic Era: Sinusitis

Part III of the appropriate antibiotic use series will deal with one of the most common diagnoses seen by allergists: sinusitis. Here are some staggering statistics.

  • Sinusitis remains one of the top reasons for seeing a doctor in the U.S., accounting for almost 14 million physician visits annually.
  • Overall, 1 in 5  antibiotic prescriptions in the U.S. are written for presumed sinusitis, and most of these are unnecessary.
  • Despite studies showing that antibiotics don’t help for acute sinusitis, 86% of patients who sought treatment for acute sinusitis received antibiotics.

So what is sinusitis? Sinusitis is usually taken to mean infection of the sinus cavities.  It is broadly divided into acute sinusitis and chronic sinusitis. Acute sinusitis is mostly due to the common cold virus (rhinovirus) and can present with low-grade fever, pain, pressure, and discolored secretions. It usually lasts 7-10 days and resolves on its own. Bacterial infections complicate less than 5% of cases of acute sinusitis. Chronic sinusitis can present with similar symptoms, though they are usually less severe, and also may cause significant fatigue, cough and occasionally drainage. Unlike acute sinusitis, it is frequently bacterial.

The biggest problem in managing chronic sinusitis is making a diagnosis. The symptoms are non-specific and don’t correlate well with the gold standard diagnostic test, a sinus CT. Indeed, the exact same symptoms can be infectious, allergic, both or neither.   This illustrates the importance of allergy testing and sinus imaging in the management of chronic sinusitis. In general, if you’re having persistent sinus symptoms or have required antibiotics three or more times in a year, it’s time to see an allergist. They can find out precisely what’s wrong with you and come up with a treatment plan to get you better.

Dr. O

November 22, 2013
by Dr. Megan Stauffer
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Epinephrine in Schools

Last week President Obama signed into law the “School Access to Emergency Epinephrine Act,” which was passed by the House and Senate at the end of October. This is definitely a step in the right direction in addressing the growing epidemic of food allergies. It has been recognized that about 25% of first-time allergic reactions to foods occur at school, and this law helps increase access to the life-saving drug epinephrine for school students and staff. Through financial incentives states are encouraged to stock epinephrine auto injectors (EpiPen or Auvi-Q) in schools for use by any student or staff member experiencing a life-threatening allergic reaction. The law also encourages training of school staff in recognizing and treating allergic reactions. Currently only four states require stock epinephrine in schools (Maryland, Nebraska, Nevada and Virginia) and many more states (including Tennessee) now allow schools to stock it if they so choose. Hopefully with more federal incentives, access to epinephrine in schools will increase and more states will require epinephrine auto injectors in all schools.

Another recent promising development in the management of food allergies at schools is the publication of the “Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs”, which was recently released by the CDC. These guidelines help schools implement food allergy management strategies or improve existing practices. By working to prevent food reactions in students with known food allergies and by improving emergency treatment should reactions occur, schools can make a safer environment for all students. More details about both of these developments can be found at FARE.

Dr. Megan

 

 

November 21, 2013
by Dr. John Overholt
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The Post-Antibiotic Era: Bronchitis

Part II of the when-not-to-use-antibiotics post will deal with another common ailment:  Bronchitis. We’ll be dealing with acute bronchitis, not chronic bronchitis due to long-term smoking, which is a different animal altogether.

The term bronchitis is fairly non-specific. It simply means inflammation of the bronchial tubes or airways. This inflammation can occur for several different reasons, most commonly viruses or irritants, but rarely from bacteria. Viruses that cause bronchitis include influenza, parainfluinza, adenovirus and respiratory syncitial virus (RSV).  Non-infectious causes of bronchitis include pollutants, chemicals, second-hand cigarette smoke and the like.

The hallmark of bronchitis is a cough, with or without mucus production. Depending on the cause, there may be fever, aches, headache and sore throat as well. The acute symptoms typically last less than two weeks, but the cough may linger  for several weeks after. You should call your healthcare provider for high fever, thick or bloody mucus, or trouble breathing, but otherwise seek simple symptomatic treatment. Lots of great ideas are on this CDC web page.

Note that I did not mention antibiotics as a treatment. Since the vast majority of acute bronchitis is viral-or irritant-induced, antibiotics will not improve symptoms or shorten the duration of illness. (Anti-viral treatments for influenza can help if started early). Treating bronchitis with antibiotics simply adds to the cost, exposes people to the potential for adverse reactions, and adds to the growing rates of antibiotic resistance.

The one exception is pertussis, aka whooping cough. It is bacterial and responds to certain antibiotics. It also has an excellent vaccine that you and your children should all be up-to-date on. It had virtually disappeared from the U.S., but recent drops in vaccination rates and changes in vaccine composition have led to its reemergence. It causes a very characteristic, severe cough that can last for months, hence its old name, the 100-day cough.

So what can you do to prevent bronchitis? Avoid smoking and second-hand smoke for you and your kids, practice good hand hygiene, and stay current on your vaccinations, including pertussis and the yearly influenza vaccination.

I’ve borrowed liberally from the CDC website in writing this post. They have a ton of great information for the interested reader.  I highly recommend it.

Dr. O

November 13, 2013
by Dr. Megan Stauffer
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Acetaminophen and Asthma

No parents want their child to suffer. When your child is sick, especially with a fever, he or she can feel miserable, which in turn makes you feel miserable, too! Fever-reducing medications, such as acetaminophen (Tylenol) and ibuprophen (Motrin) have long been known to improve symptoms associated with infections. Pediatricians recommend, however, that these medications only be used if the fever is affecting the child’s behavior (except in youg infants) or if it is extremely high. The fever itself is not harmful and is in fact a way the immune system fights the infection.

A study recently published in the Annals of Allergy, Asthma and Immunology by Kang et al., examined the association between acetaminophen exposure in the first year of life and the risk of developing asthma. The researchers found that those preschool children (3-7 years old) who used acetaminophen for more than three days during the first year of life, especially if they have a family history of asthma, were significantly more likely to have asthma.  Similar results have been seen in other studies, but this study controlled for lung infections associated with an increased risk of asthma. At this point, these are only associations, and the results cannot clarify cause and effect. Also, it is unknown whether or not this risk remained as the children got older. More studies are needed to help clarify this risk, but the results are quite intriguing and would certainly lead me to recommend that those families with a history of asthma should limit the use of acetaminophen during the first year of life.

Dr. Megan

 

November 13, 2013
by Dr. John Overholt
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The Post-Antibiotic Era: Adult Upper Respiratory Infections

It’s no secret that antibiotics are becoming less and less effective. The Centers for Disease Control has launched a campaign to educate both doctors and the general public about antibiotic use and to cajole them into actually doing the right thing. I think this is a hugely important issue, so I’m going to devote a few posts to it. I’ll start with the one I see most: upper respiratory infections, or URIs.

In the general population, virtually all sporadic infections of the upper respiratory tract are self-limited viral infections, usually the common cold. Since antibiotics don’t treat viruses, you’d think doctors wouldn’t prescribe them for such problems, but they do. Alot. In fact, doctors prescribed $1.1 billion worth of antibiotics for URIs last year, and nearly all of those were unnecessary. Aside from the waste of money, the biggest problem for overprescribing antibiotics is resistance. The more we use antibiotics, the more bacteria become resistant to them. So, if we want them to work when we need them, we need to use them only when we need to. For more in-depth info on antibiotic resistance, I highly recommend this page from the CDC.

Here are some helpful facts about URIs and antibiotics.

  • More than 200 different viruses can cause the common cold.
  • Cold symptoms include runny nose, sneezing, sore throat and cough.
  • Cold symptoms typically last ten days to two weeks.
  • When nasal discharge turns yellow or green, it does not mean there is a bacterial infection.  It simply means the immune system is fighting the virus.
  • Bacterial infections only complicate 1 out of every 50 colds.
  • Call your doctor if symptoms last more than 10 days or if you have a fever of greater than 100.4.
  • If you go to the doctor, let them know you’re ok with not taking antibiotics.  Doctors are ten times more likely to prescribe antibiotics if they feel that’s what the patient wants.

Even though nothing will get rid of or shorten the duration of a cold, medications and other strategies can give symptomatic relief.

  • Take acetaminophen, ibuprofen or naproxen to relieve pain or fever. Always use these as directed.
  • Soothe a sore throat with ice chips, lozenges or a sore throat spray
  • For sinus pain and pressure, use a decongestant or saline nasal spray, or breath in steam from a bowl of hot water or shower.
  • For a cough, try a cool mist vaporizer or humidifier.

Next time, I’ll discuss some other common infections like bronchitis and sinusitis.

Dr. O

 

 

October 31, 2013
by Dr. John Overholt
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Rapid Oral Peanut Desensitization Using Omalizumab

I don’t need to tell you, dear reader, that peanut allergy is a big problem. It’s incidence is increasing for unclear reasons, avoidance is difficult, reactions can be severe, even life-threatening, and there is no treatment available for general clinical use. Yet.

Oral desensitization is being done in research settings, as well as by some maverick allergists, and it works for some folks. It is, however, very time consuming and systemic reactions are common. Indeed, many people are unable to complete the desensitization because of reactions.

If we had a way to reduce or eliminate the reactions during desensitization, we could make the process safer and allow more people to be desensitized. Enter omalizumab. Omalizumab is an injectable medication that essentially eliminates the body’s ability to have an acute allergic reaction. (For more on omalizumab and its mechanism, see my old blog post here.)

Studies have shown that omalizumab can protect peanut allergic patients from having reactions to peanuts. The big question has been: If you use omalizumab during a peanut desensitization to prevent allergic reactions, what happens when you stop the omalizumab. A new study in the JACI helps answer this.

This is a small, pilot study with only 13 participants, all of whom had clinical peanut allergy. By pretreating with omalizumab, they were able to have patients tolerate a cumulative dose of almost 1g of peanut flour, about the weight of a peanut, within 8 hours. They then underwent an 8-week dose escalation while continuing the omalizumab, up to 4g of peanut flour per day. During this phase there were a few mild reactions. Then they stopped the omalizumab.

I’ve got to say that takes some guts. I would guess that you really had no idea how the patients would respond off omalizumab, but they did fine, for the most part. Once the omalizumab was stopped, the participants kept taking 4g of peanut flour daily for the next 12 weeks. During this phase, there were more reactions and a couple of patients required epinephrine, but there were some extenuating circumstances. In the end, 11 of the 13 patients continued with regular peanut ingestion, from 10 to 20 peanuts a day.

This is a very promising study. IMHO, this will be the way peanut desensitization makes it in to general clinical use. It also has implications for desensitization of other food allergies.

As usual, there are some caveats. First, the doses of omalizumab used were, in some cases, much higher than those used for the treatment of allergic asthma. Omalizumab is still an incredibly expensive medication and the doses some patients received in this study would be upwards of $5,000 a month or $25,000 for the total study period. Also, some patients still had reactions off omalizumab. Granted, these were not 100% linked to peanut ingestion, but it still does give one pause. Finally, this is a very small study. Fortunately, larger studies are underway to help refine this process. I am looking forward to seeing the results.

Dr. O

October 30, 2013
by Dr. Megan Stauffer
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Asthma in Tennessee

Asthma can affect people at any time of year, but the fall seems to be an especially bad time of year for patients. The combination of respiratory viruses, fall pollen, and cooler weather can all trigger asthma. In fact, children are more likely to end up in the ER with an asthma attack during the month of September than at any other time of year.

The Asthma and Allergy Foundation of America recently reported the top 15 worst cities in America for asthma. This year, three of the top 15 cities listed were in Tennessee:  Knoxville (#10), Memphis (#3), and Chattanooga (#2). Asthma patients in our state need to be especially mindful of triggers for their asthma and follow their doctor’s orders about using asthma medications regularly so that they don’t end up in the ER due to asthma.

Dr. Megan