On April 3, Dr. Mehmet Oz hosted a segment on his TV show called “How to Survive the Allergy Epidemic”. In keeping with many news reports released this spring, Dr. Oz declared: “This year, you’re going to feel even more miserable than ever before.”

New York allergist and Allergic Living contributor Dr. Clifford Bassett was invited to help explain to viewers why this may be. He said that climate change factors, such as warm seasons starting earlier and ending later, are to blame. He also noted that tree pollen and grass pollen seasons can overlap resulting in a “pollen bomb” that can cause misery for allergy sufferers.

Dr. Oz did an excellent job explaining how certain weather patterns can cause what allergy specialists and botanists now call ‘the priming effect’ – where pollen levels rise, fall and rise again in late winter and early spring. When it’s unseasonably warm, plants begin producing pollen early. When the temperature drops again, they stop, and then begin again once the warmer weather returns. In pollen-sensitive individuals, this can cause worsened allergy symptoms that are tougher to control because their immune system has been ‘primed’ for pollen allergens.

The topic of conversation then moved to treatment. Most medications for spring allergies work by blocking histamine receptors, so the histamine in one’s body has nowhere to bind to and cause symptoms. These treatments are effective for most people, but they treat the symptoms but not the underlying allergic disease. Upon each re-exposure, the symptoms will have to be blocked again.

This is why doctors often recommend immunotherapy, or allergy shots, in which a small amount of the allergen (i.e. pollen) is injected into a sensitized individual on multiple occasions over a long period of time. The goal is to allow the patient to build tolerance to the allergen and eventually no longer be sensitized to it.

The trouble with this traditional type of immunotherapy, which Dr. Bassett noted has been available for almost 100 years, is just that – the trouble: injections are required several times before each allergy season for several years, resulting in many, many hours in the allergist’s office.

Fortunately, Dr. Bassett informed Dr. Oz’s audience that sublingual immunotherapy (SLIT), which is a type of immunotherapy that uses under-the-tongue tablets or drops instead of needles, is gaining ground. It is far less invasive: once an allergist determines the proper dosage, a patient can actually conduct this immunotherapy by themselves, at home.

While not yet approved by the FDA, several clinical trials have demonstrated that this type of treatment can be effective, and it has been available in Europe for years. One brand, Oralair, was recently approved for prescription use in Canada.

See the full episode of The Dr. Oz Show here

See also:
Peanut Drops Hold Treatment Promise
Milk OIT Not Lasting
Dr. Oz on Nut Proteins in Olive Oils

The discussion around this article has become a wonderful opportunity to explore with our patients their concerns about the real risks of food allergy, their hopes for a cure, and their understanding of where things stand in that search for a cure. Since you may have some of the same questions, allow me to review some key perspectives and hopefully find common ground on which we can all agree.

Those living with food allergy are all too aware of the risks of accidental food allergen ingestion. However, we strive to provide our patients a balanced approach, where we encourage vigilance at reducing those risks, but work to prevent that from evolving into debilitating anxiety. This requires a clear understanding of the real risks of food allergy.

One area fraught with ambiguity for patients is food allergen labeling laws. The Food Allergen Labeling and Consumer Protection Act (FALCPA) does not permit any of the eight major food allergens to go unlabeled as ingredients, regardless of the quantity present. However, what is very troublesome to families is that FALCPA is silent on the issue of cross-contact.

Cross-contact can and does sometimes occur in manufacturing.  There is no guidance given to manufacturers as to when a precautionary label (often referred to as a “may contain” warning) should be included.  Fortunately, efforts are under way by the Food and Drug Administration (FDA) to help reform how manufacturers use these precautionary statements.

Another important point of discussion raised by the Times article is the true risk of anaphylaxis due to skin exposure to food allergens. In the Spring 2013 issue of Allergic Living, Dr. Scott Sicherer addresses this question (pages 24-25), explaining that anaphylaxis from skin exposure is very unlikely because the skin barrier prevents the protein from entering the blood system. So, for most with food allergy, playing a game with a ball that had briefly contacted an allergen would not be expected to pose a significant risk of anaphylaxis.

Also of concern to patients was the reference in the Times article to a mortality rate from food anaphylaxis of 1 per 1,000 for “severely allergic” children. It is critical that patients understand that this figure was derived by comparing the estimated number of food allergy deaths in the U.S. to the number of annual emergency department visits for food anaphylaxis. Another approach favored by many puts the risk at more than 100 times lower, or five to 10 per one million.  This approach has the advantage of making the comparison to the total food allergy population in the U.S.

Undoubtedly, even one death from food allergy is a tragedy because it could have been prevented. For those with food allergy, it is important to understand that this risk can be significantly decreased by exercising vigilance in avoiding food allergens and always having access to epinephrine.

Another area of discussion after the Times article revolved around the emotional toll that food allergies can take on families, particularly when severe allergic reactions have been experienced in the past. Our goal is always to help families work through their fears and arrive at a place where affected children feel safe and in charge of their allergies.

Certainly, the psycho-social impact of food allergy is real and, as research is beginning to demonstrate, often detrimental. But there is help, and fear should not be accepted as the norm for those with food allergy. For times when anxiety becomes overwhelming, a counselor, psychologist, or psychiatrist can teach specific coping mechanisms.

While no one would choose to have a food allergy, some of our young patients have gained great empowerment from their experience – a sense that if I can manage my food allergies, I can do anything. So, as the name “Allergic Living” epitomizes, a balanced approach is important to ensure that having a food allergy does not prevent one from truly living.

Next: Community’s Role in the Quest for a Cure

One of the tablets, known as Oralair, recently became available by prescription in Canada, but not the United States. This pill has proven effective in international studies, and is now approved by Health Canada.

Another tablet, known as Grazax in Europe, has been submitted to the FDA in the United States for final approval. Unfortunately, the tablet (which will have a different brand name in the U.S.) most likely won’t become available until next year’s grass season at the earliest.

When it comes to grass allergy, taking antihistamines does the job for some people. But allergists have traditionally steered those with more severe symptoms and asthma toward immunotherapy, also known as allergy shots. The tablets are a new form of this therapy – called sublingual immunotherapy, or SLIT, because the dose is taken under the tongue.

Although it’s recommended to begin taking these tablets four months before allergy season begins, they have been known to show significant improvement after being taken for as little as one month. This is far less invasive and time-consuming than traditional immunotherapy: instead of visiting an allergist several times to get your shots, you can simply place a tablet under your tongue and allow it to dissolve.

Sublingual immunotherapy is actually not so new.  For years now, researchers have been studying it, not just for grass allergy but potentially for food allergy as well. It works with the same principle as traditional allergy shots: introduce tiny amounts of the specific allergen into the patient’s system (in this case, via drops), with the goal of building toward tolerance.

See also:

Allergic Living’s Full Report on SLIT for Grass Allergy
Milk OIT Not Lasting

Clarke and her colleagues surveyed close to 10,000 Canadians in the Surveying Canadians to Access the Prevalence of Common Food Allergies and Attitudes towards Food Labelling and Risk (SCAAALAR) study. They found that 3.2 per cent were allergic to one or more of peanuts, tree nuts, shellfish, fish and sesame. Of those, “at most, only 38.7 per cent reported receiving epinephrine,” while having a moderate to severe reaction, says Clarke.

It’s not clear whether these individuals had auto-injectors and simply didn’t use them, or if epinephrine wasn’t available to them. Either way, Clarke told Allergic Living that the numbers concerning.

“We certainly know that there is a problem here in the proper management, because one would like to see that almost everybody who is reporting a moderate to severe reaction would receive the epinephrine.”

Clarke says her team has dug into the data a little further to look at what type of people are likely to carry an auto-injector, but results of that analysis are not yet available.

The SCAAALAR study, which is partially funded by the allergy research network AllerGen, also looked at attitudes towards food labeling, particularly precautionary statements on food packages (such as “may contain” advisories), and attitudes of general population toward risk of food allergy in the context of environmental health risks. Results will be available in the coming months.

Highlights from SCAAALAR study

Allergies in the Canadian population

Published in the June 2010  issue of the Journal of Allergy and Clinical Immunology. View here.

Dr. Hugh Sampson, head of the Consortium of Food Allergy Research in the United States, told Allergic Living magazine that U.S. researchers got the idea from French research, in which scientists have developed immunotherapy patches for cow’s milk allergy.

Those researchers placed a milk-containing patch on dairy-allergic patients every other day for three months. The results were that the patients were able to consume, on average, 12 times more milk without a reaction than they could before the treatment.

Armed with this encouraging research, a company formed by the French researchers is now set to begin a safety trial on a comparable peanut patch. If the safety trial is successfully completed, Sampson and the researchers in CoFAR hope to begin the next level of clinical trials: to see if the patch works to desensitize patients allergic to peanut.

Sampson, who is the director of the Jaffe Food Allergy Institute at New York’s Mount Sinai School of Medicine, says it’s unclear why placing an allergen on the skin could lead to an allergic person being able to consume the food in question without reaction. But he says a variety of research done with mice shows that you can both sensitize, and desensitize, through the skin. Part of the work his group will undertake will be to discover more about the immunologic factors at play.

One promising aspect of desensitization through the skin, compared to other methods such as oral immunotherapy (in which patients eat gradually increasing amounts of their allergen) is that so far, reactions have been limited to the area where the patch is applied, and have not affected other systems of the body. However, the French study was done on a small group of patients.

Sampson hopes to begin his trial mid 2011.

From the Fall 2010 issue of Allergic Living magazine.
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Today, Sean Randall, a 43-year-old artist, thinks it’s in a drawer somewhere. I always ask him if he has life insurance since Sean has allergies and asthma, the combination considered the most high risk for life-threatening reactions. A severe asthmatic as a child, he spent time in the oxygen tents, and now takes the controller drug Advair daily.

He has been coping in his own way for years. As a student in boarding school in Winnipeg, he never ate toast because the knives had been in peanut butter as well as jam jars.

“You manage,” he says. “You learn breakfast is cereal, you learn self-discipline.” Sean once ate a peanut by accident in a restaurant with low lighting, and had an anaphylactic reaction. He added to his strategies: “be more vigilant when eating in darkly lit restaurants.”

Rather than carrying an auto-injector, he figures a call to 911 will save him in a crisis. “It’s less of a decision and more of laziness. If you don’t use something for 20 years, it doesn’t seem necessary.”

Largely, he relies on avoidance: no peanuts are allowed in their house in Regina, and he doesn’t go to restaurants, such as Thai eateries, that use peanuts in the kitchen. He also avoids bake sales and has learned “the hard way” which chocolate bars will set off a reaction.

Still, my sister and I hope to wear him down yet, and finally get that prescription refilled.

Reprinted from Allergic Living magazine.

Related Reading:  The Allergy Deniers

There’s just one problem in paradise: Koentges is allergic to tree nuts. While he’ll sometimes let restaurants know that he can’t have nuts in meals he orders, mistakes happen about once or twice a year.

“I think, ‘Oh crap’,” he says of recognizing the flavor of nuts. He knows the next hour or two will be filled with intense stomach pain, hives and swelling.

His strategy? To wait it out. Cautious parents of food allergic children will be stunned to learn that Koentges does not own or carry an epinephrine auto-injector. He admits that if a food looks particularly intriguing and tasty, he’ll take a chance and try it. “It’s a pretty stupid approach to it, I am a stupid person,” says Koentges. “I’m kind of cavalier about things.”

In fact, he’s savvy, talented – and in good company. There are large numbers of adults with potentially life-threatening food allergies who do not carry auto-injectors, are not vigilant food label readers and are unlikely to be found wearing MedicAlert jewelry. Almost everyone knows someone – a colleague, a friend – who has been diagnosed with a food allergy but believes that he or she doesn’t need to carry an auto-injector because the allergy is “mild” or “moderate”.

These people lack the understanding of the disease to appreciate that symptoms are not consistent; that a mild reaction today could mean full-on anaphylaxis the next time (complete with problems breathing and a dangerous drop in blood pressure). So they go about their lives taking few precautions for the condition, blithely ignoring or dismissing the fact that they are standing on the precipice of a few mistaken bites or a sting, and unprepared if a big reaction does arise.

Surveys reveal that adults with food and stinging insect allergies are far more likely to take risks than parents would take with an allergic child. “We don’t see this behavior from parent to child. It seems to be an adult phenomenon,” says Anne Muñoz-Furlong, the former CEO of the Food Allergy & Anaphylaxis Network (FAAN), who has been involved in allergy research. “We often say that teenagers are risk-takers, and they feel like they’re invincible. But I hear more stories of risk-taking from adults than I do from teens.”

New studies on adults with food allergies are telling. The qualitative research firm Fresh Squeezed Ideas Inc. last year examined patient attitudes about anaphylaxis for King Pharmaceuticals, the makers of the EpiPen auto-injector in Canada. The firm surveyed 650 participants, dividing them into two main groups – those a physician had diagnosed as food or sting allergic and those who were labeled “at risk”. The latter group had experienced symptoms clearly consistent with such an allergy, but had not been formally been diagnosed.

In the “at risk” group, only 4 per cent owned and carried an auto-injector, compared to about half of the diagnosed group. As well, 65 per cent of those “at risk” believed an antihistamine would always clear up allergy symptoms.

In FAAN’s 2004 survey of seafood allergy prevalence, auto-injector findings mirrored that “at risk” group. Only 8.6 per cent of those with a seafood allergy, which affects over six million Americans and is largely an adult affliction, had an auto-injector.

Fresh Squeezed Ideas’ research revealed a shortlist of the reasons for not carrying an auto-injector:

• Most of the “at risk” group thought only people with “severe” allergies required one, and distanced themselves from that label;
• A significant majority (in both diagnosed and at risk groups) also believed strongly in their ability to avoid allergens.
• A lot counted on their family physician’s advice and if the doctor hadn’t mention a prescription for an auto-injector, the patient didn’t ask whether one was needed.
• Several also expressed confidence that there was good awareness about food allergies in society in general and at restaurants – and drew the assumption that this was adequate protection.

Next: Life on the edge of a dormant volcano