Episode 46: Precision Medicine, Biomarkers and Genitourinary Cancers

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Episode Summary:

Biomarkers are windows into health, like a cholesterol or PSA test. Precision medicine biomarkers enable us to refine clinical targets and identify more precise cancer risks, diagnosis & treatments. This new health care trend translates into better cancer care & reduced collateral damage, especially for prostate cancer.

Guest:

Jeffrey J. Tosoian, MD, MPH Assistant Professor and Director of Translational Cancer Research, Department of Urology, Vanderbilt University Medical Center, Nashville TN. Dr. Tosoian’s research is focused on the development and clinical application of diagnostic and prognostic tools, including blood-, urine-, and tissue-based biomarkers, to guide detection and management of genitourinary cancers.

During This Episode We Discuss:

  1. Precision medicine addresses some of the limits of current diagnostic tools. For example, an elevated PSA (prostate specific antigen)  level is not a very specific indicator of cancer—high PSA can be a result of several different things. A more specific test that follows up the PSA test can be a blood or urine test for specific cancer biomarkers, instead of an invasive biopsy.
  2. Using biomarkers to provide better and more targeted medical care is an example of translational research: taking new discoveries from the lab bench to the patient bedside. For example, identification of abnormal/cancerous genes in the lab gets ‘translated’ to the bedside as a reliable, effective, and less invasive(blood or urine) test for those faulty genes, which can be used by the medical system for diagnostic purposes.
  3. Biomarkers and precision medicine target several phases of cancer health care. There are biomarkers that can indicate and monitor: cancer susceptibility, specific cancer diagnosis, prognosis, and cancer growth or recession.
  4. Official Guidelines may recognize these diagnostic and monitoring tests as approved and providing an equal or higher standard of care, but there may be temporal and structural disconnects between use of these new tools and what health insurances may cover. 

Quotes (Tweetables):

— “[Precision medicine is]  a superior way of treating a cancer when you can target something specifically. Again, I’ve used the analogy before, [the old way is] dropping a bomb on a cancer versus a missile strike at a specific area.”

Dr. Pelman 

—“Our National Institutes of Health define a biomarker as a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic or abnormal processes, or our responses to a therapeutic intervention.”

Dr. Tosoian

—“Many men will have an elevated PSA that do not have a harmful or a significant prostate cancer. And so our current aim is to use newer noninvasive tools to look at that group of men with an elevated PSA and identify who among them really does need a biopsy…” Dr. Tosoian

—“Translational research ….. takes the discoveries made in the laboratory or at the bench and figures out how they can be applied to best helping our patients at the bedside.  It really does lead to better outcomes for our patients. And so that term bench to bedside is often used.”

Dr. Tosoian

— “When we think about these things, most of us aren’t reading about biomarkers at night, right before you go to bed. Most people aren’t doing that. And so, I think it’s finding that medium through which, you know, we are reaching everyone, or as many people as possible. That’s why I mentioned this podcast as a way to reach a lot of people.” 

Dr. Tosoian

— “You know, you don’t want to be providing medical advice by Twitter, but pointing someone in the right direction [is needed], pointing them toward the resources that they can then take to their doctor and talk about in more detail…..finding those various avenues to connect with our larger population, our friends and families….”

Dr. Tosoian


Episode Transcript:

Dr. Pelman (00:00):

The Original Guide to Men’s Health is moving to a monthly release schedule. We will be releasing new episodes the first Wednesday of each month. We really appreciate you listening, and we hope you enjoy this episode.

Dr. Pelman (00:18):

Whatever you do, whatever you enjoy, you need your help. Welcome The Original Guide to Men’s Health,  a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy, maintenance and prevention strategies, along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.

Dr. Pelman (01:07):

On this episode of The Original Guide to Men’s Health, we’ll be exploring allergy and immunology. What does immunology or your immune system have to do with allergies*? Everything! Our guests on this episode are Dr. Lahari Rampur, physician allergy and immunology, Kaiser Permanente, Washington. Dr. Rampur treats allergic disorders and immunodeficiencies and practices at Capitol Hill, Seattle, and in Everett, Washington with Kaiser Permanente. Additionally, we have Dr. Andrew Ayars. Dr. Ayars is an associate professor, department of medicine, division of allergy and infectious diseases, University of Washington School of Medicine. He serves as director of allergy and immunology training program at the University of Washington School of Medicine. Dr. Ayars, Dr. Rampur, welcome and thank you for joining us. Many people have concepts about allergies, have allergies, but I’d like to go into a little background about why our immune systems are involved in the allergic response. Dr. Rampur, why don’t you take this first? And then Dr. Harris, we’ll ask you to fill in.

*Allergies and Immune System: https://www.hopkinsmedicine.org/health/conditions-and-diseases/allergies-and-the-immune-system 

Dr. Rampur (02:24):

Thank you. Thank you, Dr. Pelman for having me here. And yeah, that’s an important question. So allergies are typically genetically predisposed. There is nothing much that you can do. However, there is certainly an environmental influence on development of allergies. For example, kids who are exposed to dogs or cats at home, you know, they can develop allergies to cats or dogs. But basically they are genetically predisposed with family history of allergies with parents and history of eczema* can also predispose you to develop allergies as well. 

*Eczema: https://www.mayoclinic.org/diseases-conditions/atopic-dermatitis-eczema/symptoms-causes/syc-20353273 

Dr. Pelman (03:00):

So in looking at, you know, just going into some basics of the immune system, Dr. Ayars, just give us a little background. What is the immune system? How does it work as far as allergic response?

Dr. Ayars (03:11):

The immune system is actually amazing. If you think about how many bacteria, viruses, parasites we have to fight off, not as much parasites in the developed world. But we’re constantly bombarded with, you know, organisms that we have to fight off and your body has to be able to see what’s a friend and what’s a foe. And that can be very difficult. And frankly, our body’s really good at it. It’s incredible. I’m actually amazed by the immune system all the time that we’re able to pick out what’s a threat, fight it off, you know, form the immune response, which is extremely complex. Now I kind of think the immune system, or the immune problems and the multiple categories, there’s immunodeficiency*, meaning your body just can’t fight off infection. We see people like that every day in our clinics, people without immune system can’t fight off infection.

*Immunodeficiency: https://medlineplus.gov/ency/article/000818.htm 

Dr. Ayars (03:51):

Now there’s mistakes in the immune system and they can manifest in different ways, either rheumatologic* or allergic. And rheumatologic, your body accidentally goes after yourself. You can go after a lot of different things and that can present in a lot of different ways. And that’s more of a rheumatology talk. Whereas allergy is a body goes after something that’s benign in the immune system like a food, a pollen, you know that’s not a threat. But our body for whatever reason, and we I’m sure we’ll go into that later, sees that as a threat and forms, you know, an immune response. So things like pollen or cat dander or things like that. Or foods, you know, we’re constantly eating foods and it’s amazing how our body can pick out what’s a friend and what’s a foe. But you know the immune system, if it’s off sees that food as a threat and amounts an  immediate immune response** to an or delayed immune response. It’s our immune system almost working too well, meaning it’s going after things that shouldn’t in the allergic. And with allergy it’s things external, with rheumatologic it’s things internal. So that’s kind of a simplistic way to think about it.

*Rheumatologic/Rheumatic: https://www.mayoclinichealthsystem.org/locations/mankato/services-and-treatments/rheumatology/rheumatic-diseases 

**Allergic reactions: https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/allergic-reactions 

Dr. Pelman (04:48):

So Rampur, wet components are part of our immune system? I mean in our blood, what else? And what is in our blood that helps mount the immune response?

Dr. Rampur (04:59):

So the immune system consists of basically cells. So that are T-cells* and B-cells*, they’re mainly white blood cells. I would look at them as sort of the leaders of the immune system, which drive all the other cells. So depending on what is being exposed, different categories of cells get activated. For example, if there is an infection, let’s say there is an exposure to bacteria. So the bacteria has components that is recognized by specific types of immune cells, which then release other types of chemicals and molecules** to attract specific component of the immune system. So if you are exposed to allergens that are different set of cells that are attracted. And if there are viruses, different type of cells are brought to the area of infection. And depending on the severity of infection, most of the time they are able to take care of the threat with some basic immune response that’s called innate immunity***.

*T cells and B cells: https://www.genome.gov/genetics-glossary/Lymphocyte 

**Cytokines: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/immunotherapy/cytokines.html 

***Innate immunity: https://medlineplus.gov/ency/article/000821.htm#:~:text=Innate%2C%20or%20nonspecific%2C%20immunity%20is,defense%20in%20the%20immune%20response

Dr. Rampur (05:56):

However, if the innate immune response is not able to destroy the pathogen, or the threat, then the specialized forms of cells get activated. And they mount antibody response or long-term memory cells like memory T cells*, B cells, which then come into picture. So the next time if you’re exposed to a similar threat, the body can recognize easily. For example, in vaccination** so you’re given an inactive virus and the body forms antibodies to these viruses. And there are also long-term memory cells. So the next time you are exposed to this specific virus, the body is able to recognize the threat immediately and form the antibodies in an effective manner and take care of it efficiently.

*Memory T cells: https://www.nature.com/articles/d41586-017-08280-8 

**How vaccines work: https://www.cdc.gov/vaccines/hcp/conversations/understanding-vacc-work.html 

Dr. Pelman (06:43):

And the antibodies are actually what type of cells?

Dr. Rampur (06:47):

So B cells are the cells which produce the antibodies. So antibodies are not cells. They are molecules or some sort of protein that are produced from the B-cells.

Dr. Pelman (06:58):

Okay. And Dr. Ayars, when we look at response and the immune response, we talked a moment ago about different types of cells from a bacteria or virus to an allergic response. What are those type of blood components that we see that respond?

Dr. Ayars (07:19):

I mean, there’s a lot of different types of reactions. The classic allergy is something called IgE-mediated*. That’s, you know, seasonal allergies. That you watery eyes, runny nose, can cause asthma, can cause food allergies. And that’s something called IgE. Dr. Rampur mentioned the antibodies, and they’re basically little smart bombs. They have to see something. The body has to form the appropriate immune response. And then they have to be able to glom** on and neutralize things like bacteria and viruses. And there’s different types of antibodies. The most important is IgG***. That’s the one we form that they can help fight off bacteria, viruses, very much essential to us to help fight off these organisms. There’s different ones called IgA. There’s one called IgE that historically helps us find out things like parasitic infections. Whereas historically, we were always bombarded by parasites and things like that.

*IgE-Mediated Reaction: https://www.rch.org.au/uploadedFiles/Main/Content/allergy/Non%20IgE%20Food%20Allergy.pdf 

**Glom: https://www.merriam-webster.com/dictionary/glom 

***Immunoglobulin G: https://www.uofmhealth.org/health-library/hw41342 

Dr. Ayars (08:09):

We’re not exposed to them as much anymore. And IgE, basically we in developed countries oftentimes we don’t need IgE. But this type of antibody is what causes a lot of different allergies. It sits on these things called mass cells* that we all have in the skin, GI tract**, respiratory tract, and they’re preloaded with all these different inflammatory mediators. And if they are preloaded with IgE, meaning they are predisposed to react to a pollen or a food, they will rapidly release their contents, release things like histamine***, inflammatory mediators like prostaglandins****. I won’t get too far into it, but someone walks into a room with a cat. If it’s preloaded those mast cells, you know, if you get the cat in your nose that causes it to rapidly release their content. So things like histamine, and causes congestion, itchy, watery eyes, runny nose for those predisposed.

*Mass cells: https://www.aaaai.org/conditions-treatments/related-conditions/mcas 

**Gastrointestinal (GI) tract: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrointestinal-tract 

***Histamine: https://medlineplus.gov/medlineplus-videos/histamine-the-stuff-allergies-are-made-of/

****Prostaglandins: https://www.yourhormones.info/hormones/prostaglandins/#:~:text=The%20prostaglandins%20are%20a%20group,All%20Hormones%20Resources%20for%20Hormones 

Dr. Ayars (08:57):

If you breathe it in, you can have asthma*: wheezing, chest tightness, mucus production. You know people have food allergies, you know, if they’re predisposed and they have that IgE say to peanut. When they consume the peanut, it causes wheezing, chest tightness and the upper airway congestion, you know, things like that, nausea, vomiting. So if you’re predisposed and have that allergic antibody, that’s what causes a lot of the allergies that we deal with. Things like allergic rhinitis** or like seasonal allergies, things like asthma and things like food allergies. So we’ll talk about this later, I’m sure. But when we do like skin testing or blood testing, we test to look and see if patients have those antibodies and little smart bombs. The things that they shouldn’t like, foods and medications or aeroallergens and things like that.

*Asthma: https://www.mayoclinic.org/diseases-conditions/asthma/symptoms-causes/syc-20369653 

**Allergic rhinitis: https://medlineplus.gov/ency/article/000813.htm 

Dr. Pelman (09:42):

So in looking at a allergic response, which is based in our immune system, it would be fair to say there is a cascade of events that take place with a recognition of an allergen, and then the response. And the response is trying to contain the allergen, but also a mediated response that involves cells that release certain things that cause our body to have reactions?

Dr. Ayars (10:15):

Yep. It’s called the adaptive immune response* meaning say we’re exposed to a virus or bacteria, our body has to see that and it has to process it, and know it’s a threat and it forms different types of cells. Body has to see something first, react to it and then form the appropriate immune response. That’s why if you see a cold for the first time, it takes a while to get over it because your body’s giving mounting the appropriate immune response. But if you’ve seen that cold before, you can fight it off much easier. So same with foods and aeroallergens, your body has to see it. And it has to see it as a threat, and that’s inappropriate threat but it sees it as a threat and makes that immune response and forms things like T cell response. But the big one, we were about an allergy, is B cells which make antibodies.

*Adaptive immune response: https://www.ncbi.nlm.nih.gov/books/NBK21070/

Dr. Ayars (11:00):

And again that IgE, sometimes we call it the allergic antibody, which classically fights off parasites and things like that. But now it’s just kind of more of a nuisance cause it’s one of the underlying causes or that one of the major ones for, you know, food allergies or seasonal or allergic asthma. So again, your body has to see it, mount an immune response, and then it becomes predisposed to, you know, in best case scenario, fight off a bacteria or virus, you know. The worst case scenario, it affects things that are benign like a pollen or a food, or like rheumatologic disease even like rheumatoid arthritis, goes after our joints and things like that. So again, when the immune system is functioning appropriate it’s very efficient. It sees it, processes it and has a memory. So it can fight it off if it sees it again. But in the inappropriate response, it either goes after itself in the body, or it goes after something that’s benign, again like a pollen or a food.

Dr. Pelman (11:51):

So going back, before we talk about various types of responses and where they’re manifest in the body and how they’re manifested, Dr. Rampur had said that a lot of this is genetically predetermined. That your immune system is going to turn itself on when it sees something based on sort of genetic code that you were born with. Dr. Rampur?

Dr. Rampur (12:12):

Yes, that is true. So if you’re genetically predisposed, you are more likely to have allergic conditions like eczema, seasonal allergies, sort of environmental allergies, as well as food allergies. So here’s an interesting thing about how kids with eczema may develop food allergies later on. So eczema is mainly a condition where the barrier, the skin barrier, is affected. So normal skin when it is exposed to food allergens or some other irritants, it has a good barrier. It doesn’t react. However, kids with eczema has an issue with a barrier. So if the food is exposed through the skin, the skin can, the body gets sensitized to that allergen and can cause allergic reaction. So they may develop antibodies, which may recognize these allergens in the future as a threat. For example, a kid with horrible eczema is constantly exposed to peanut dust or peanuts at home. So their body processes that peanut as a threat. So normally when you eat peanuts, you may not become allergic. However, if there is an issue with the skin, if it’s exposed through a different route, it can become allergic. The next time the body’s exposed to the peanuts, these antibodies can attack the peanut molecules, and they go and tell the mast cells to release the histamine. And that’s when you start having the reactions like itching or hives or anaphylactic type of reaction. So these are genetically predetermined, you know, parents with history of asthma, parents with history of eczema, or seasonal allergy type of history.

Dr. Pelman (13:48):

So let’s look a little bit at some of the common type of allergic responses. We just talked about eczema. And again, a lot of this is based upon what you’re being exposed to, what you’re allergic to, and we’ll go into some of those in a little bit. But generally, you might classify allergic responses in the skin and where else?

Dr. Ayars (14:12):

So itchy, watery eyes, runny nose, rash and post-nasal drip, sneezing are kind of the classic. And that can be, do a lot of different aeroallergens, things like dust, dust, mites, pets, grasses, aeroallergens, grasses, trees, molds, things like that. So classically upper airway. And the lower airway, you know, asthma causes, you know, wheezing, chest tightness, shortness of breath. You know, historically it’s been called hay fever*. That’s kind of a misnomer cause you don’t get a fever with it. You felt sick. So that’s why they got that name again. The fever is a misnomer, but you kind of feel like you have a cold basically when you’re exposed to those aeroallergen,  either a certain time of the year or if you’re in an environment with dust mites or you have a pet allergy. That’s kind of how the upper airway manifestations present. 

*Hay fever: https://www.mayoclinic.org/diseases-conditions/hay-fever/smptoms-causes/syc-20373039 

Dr. Pelman (14:57):

Yeah. You mentioned asthma. A lot of people think of asthma as a pulmonary disease, but asthma is really based in a allergic response?

Dr. Ayars (15:07):

Asthma is like arthritis. There’s a lot of different types of asthma, and allergic asthma is certainly one of those types. Basically just like it causes inflammation in the upper airway and those that are genetically predisposed, it can cause lower airway inflammation. And classically, it seems like wheezing, chest tightness, shortness of breath. So we always ask patients, you know, you get asthma symptoms when you’re in a room with a cat? You get at a certain time of the year? What are your certain triggers? So it’s a broad question, and there’s a lot of different types of asthma. But allergic asthma is what we see a lot of, especially in young kiddos. We see that a fair amount.

Dr. Pelman (15:41):

Okay. So let’s take a look at some of the more common allergens in categories. So I’m going to throw out drugs. We have people who are allergic to medication, Dr. Rampur, what happens there?

Dr. Rampur (15:58):

So there are different types of allergic or hypersensitivity responses to medications as a broad category. It could be immediate or delayed type of responses. Immediate responses are, you know, as soon as you take a medication. For example, penicillin is one of the most common drug allergies. So the moment you take it, within like 15 minutes or half an hour, in most of the cases it happens within a few minutes of taking, you may feel itchy, flushed red, or hives all over your body or lip swelling or tongue swelling, throat closing type of sensation or wheezing or asthma type of response. Those are immediate type of allergic reactions. And this is where testing is most helpful. There’s another type of reaction where when you take a medicine, initially nothing happens. But after seven days of taking, you may start to notice the rashes all over your body.

Dr. Rampur (16:48):

So most of the delayed rashes are benign. They just go away on their own after a few days after stopping the medicine. However, there are other types of delayed responses where it can be pretty severe. So where your internal organs may get affected, or you may have massive skin peeling type of response. Meanwhile, your internal organs or mucus membranes like mouth or gastrointestinal tract is called severe cutaneous drug responses. So like these, there are several different kinds, but you know, we often get asked about them. This patient had vomiting type of reaction to a medication. Can you test them? So vomiting by itself without any other symptoms is not an allergic response. It could be some kind of an intolerance and testing is not indicated. In studies have shown that more than 90% of the time, allergic response to any medication, you know, does involve a skin response like itching or hives. If somebody has a subjective breathing difficulty without any objective evidence of wheezing or anything, it’s less likely to be a true allergic response.

Dr. Pelman (17:55):

And because we have people concerned currently about COVID vaccination and drug reactions. Dr. Ayars, I know that the reaction to the current vaccines as far as allergic response are rare, but can you go through a little bit about people who are concerned about that? What the risk? I know it’s small and also how you might mitigate it. If say you’ve had allergic responses to other medications, does that necessarily make you more at risk for a COVID vaccine reaction?

Dr. Ayars (18:31):

The reactions are exceedingly rare. You can get, like Dr. Rampurl talked about, immediate type reactions: immediate wheezing, chest tightness, shortness of breath, lightheadedness. Those are very rare, but you can see them. So evaluate this all the time. And frankly, most of the time we’re able to clear that to get the second vaccine or their booster. So, you know, even if there’s a, you know, a fairly immediate reaction, oftentimes we can clear them and there’s different components in the vaccine. But again, for the most part, it’s very well-tolerated. Now there are delayed reactions that have been described, but again, those are exceedingly rare as well. You know, delayed rashes, a few other things that can happen after a few days. But for the most part they’re really safe and really well-tolerated in almost anybody. You know, what we always ask people, “Have you had a reaction to a vaccine in the past?” And we try to characterize that. Drug allergy can be pretty tricky cause we don’t have a lot of tools to diagnose it.

Dr. Ayars (19:24):

So it comes down to the history. What happened and what type of immune response do we think it was? So, you know, with the COVID vaccine, I always ask, “Have you reacted to any other vaccines? If so, was it immediate? Was there immediate wheezing, chest tightness, shortness of breath?” And if it was more mild, we’ve usually cleared them to get it. And we oftentimes will tell them to take a few anti-histamines. And instead of waiting around the average 15 minutes, we usually say, just stay about a half hour instead just to make sure nothing severe happens. But you know, I’ve seen, I’m sure Dr Rampur is the same,  I’ve seen hundreds and hundreds of hundreds of these type of reactions. And most of them were able to clear. Most of them were able to tolerate the vaccine moving forward.

Dr. Pelman (20:01):

So when you say clear, do you mean you giving a medication to treat them or they just resolve spontaneously?

Dr. Ayars (20:07):

They clear them to get their second vaccination. They had a, you know, some chest tightness during the first vaccine. You know, we always ask about other symptoms. Did you feel like you’re going to pass out? Did you have, you know, skin symptoms? And if they didn’t usually we, again, clear them so that you can have that vaccine, but you might want to pretreat with some anti-histamines. I usually say Zyrtec, Allegra, or something like that. And then just wait a half hour instead of the standard 15 minutes that most facilities require. So there are people that have had a severe reaction to the first vaccine and that’s where it can get tricky. But if there is a severe reaction to the first vaccine, that’s when we always recommend see an allergist, an immunologist, and tease it out. And they can kind of have risk stratify if you will. So even if they’ve reacted to a different vaccine in the past, that’s not a contraindication to getting COVID. And even if it’s a mild reaction to the first COVID vaccine, oftentimes they’re able to receive their back second vaccine or booster without an issue.

Dr. Pelman (21:01):

Dr. Rampur. So if you had a patient who is hesitant about receiving any COVID vaccination because of prior allergic reactions, would you pre-treat them? Or just monitor them and say, “We can treat you on the spot if something happens.”

Dr. Rampur (21:17):

So I have never recommended pre-treating any patients. I would ask them to take the vaccine and we monitor them, depending on the anxiety level, half an hour to 60 minutes. Yeah. I mean, it’s out of abundance of caution. You know, of course people with history of severe anaphylaxis to, as you know, some of the medications and food, according to CDC guidelines, we monitor them for 30 minutes. But we don’t necessarily know that they’re actually at increased risk of having severe reactions to COVID vaccine. So there is a lot of anxiety. Of course, I do see a lot of patients with these concerns. So another aspect that I wanted to touch upon is that patients with previous history of severe reactions to another vaccine, we consider that a little bit more serious. We, first of all, true allergic reactions are extremely rare. However, if somebody said they had hives or low blood pressure, hypertension, chest tightness type symptoms with a, you know, let’s say diptheria, tetanus vaccine. Some of the vaccines do contain similar components as COVID-19 vaccines. And that’s when we also consider testing for, let’s say polyethylene glycol*, which is present in Pfizer and Moderna vaccines, and polysorbate**, which is presented in Johnson & Johnson vaccine. And polysorbate and polyethylene glycol, they cross-react with each other. And that’s when we also consider testing to make sure.

*Polyethylene glycol: https://medlineplus.gov/druginfo/meds/a603032.html#:~:text=Polyethylene%20glycol%203350%20is%20used,it%20is%20easier%20to%20pass

**Polysorbate (polysorbate-80): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015121/#:~:text=Polysorbate%2080%2C%20also%20known%20as,surfactants%20%5B1%2C%204%5D

Dr. Pelman (22:43):

So as Dr. Ayres suggested, first of all reactions are extremely rare to the COVID vaccines. Two, If somebody does have a true allergic reaction to a different type of vaccination, they should see an allergist, immunologist, be tested and sort that out. And they still could potentially be a candidate to receive a vaccine, but they would go in having been evaluated. Dr. Ayars?

Dr. Ayars (23:09):

Certainly. We get a lot of referrals for people that have reacted to even a different vaccine. So with drug allergy, the biggest thing is the history. What happened? You know, what was the timing? What were the symptoms? And that really helps us risk stratify, you know, who is at risk for having a more severe reaction to the COVID vaccine, who isn’t. So again, it comes down to the history. And if there’s any question we always recommend seeing an allergist and immunologist for evaluation. Whether testing is necessary, that really depends on the history. But again, the biggest thing, we just need to sit down with them. What was the previous reaction? And that helps us risk stratify. You know, who is it likely to react to the COVID vaccine? 

Dr. Pelman (23:46):

Well, let’s go now to the common allergies. We talked about drugs. Let’s talk about food. Now food is a very general term. We need food to sustain us. And it seems like, how can somebody be allergic food? But we know gluten. So let’s review gluten for a sec., gluten allergy. What happens there?

Dr. Rampur (24:07):

Gluten allergy is a very broad term, and people kind of misuse gluten allergy, pretty much for all kinds of symptoms. You know, I do hear a lot of patients complain that they do have gluten sensitivity. So sensitivities, allergies there’s is a huge difference*, what can be tested and what cannot be tested. So gluten is a broad term for, you know, grains that contain gluten. But allergic response is typically to a specific allergen, not broadly to the gluten. For example, people can be allergic to wheat, contains gluten, but you are not allergic to the gluten component. When somebody say allergic response to an allergist, we think that the true allergic responses are itching, hives, slips, filling sort of immediate responses. And that happens because of preformed antibodies. Let’s say you’re allergic to wheat. You should have IgE antibodies, which can be tested. But when people say that I feel bloated and crampy after eating some gluten containing food, is this an allergic response? May not be. It could be some kind of an intolerance, or it could be gluten sensitivity, which is another immunological disorder. It’s nothing to do with allergic response. It is because of antibodies to like they are  called celiac antibodies, anti TTG* antibodies, basically. And that’s what we test them for. But this is not an allergic response.

*Food allergy vs food intolerance: https://www.mayoclinic.org/diseases-conditions/food-allergy/expert-answers/food-allergy/faq-20058538 

**Anti Tissue Transglutaminase (TTG) antibodies: https://celiac.org/about-celiac-disease/screening-and-diagnosis/screening/ 

Dr. Pelman (25:33):

Dr. Ayars? 

Dr. Ayars (25:34):

Yeah. I kind of categorized quote unquote, gluten or wheat allergy, or I say, quote, unquote allergy and the three categories. Ones, you can be allergic to wheat in form the classic immediate wheezing, chest tightness, lightheadedness, nausea like we talked about Dr. Rampur with the IgE. Actually that’s pretty darn rare, especially in adults. I don’t never see a true wheat allergy. Then there’s celiac disease* with Dr. Rampur also talked about. That’s a different type of immune response to the gluten, which causes inflammation in the gut. And that usually presents with weight loss, you know, abdominal pain, diarrhea, things like that. And the way you test for that is actually do have to do a biopsy in the gut is the gold standard. And that’s somewhat rare. Although a lot of people do have celiac disease. And then the most common is basically non-celiac gluten sensitivity, which is kind of a wastebasket term.

*Celiac disease: https://medlineplus.gov/celiacdisease.html#:~:text=Celiac%20disease%20is%20an%20immune,wheat%2C%20rye%2C%20and%20barley

Dr. Ayars (26:24):

You haven’t a reaction to it. It’s not an immune one. And classically it’s, abdominal pain, nausea, bloating, things like that. So again, there’s the classic allergy, which IgE or the immediate reaction, which is very rare. Or celiac disease, which has the delayed reaction, which again in the gut causes diarrhea, abdominal pain, things like that. And then again, the most common is non-celiac gluten sensitivity. And I always tell you, say sensitivity is very real. It’s just not an allergy. We don’t have testing for it. So if you rule out the other two, the immediate reaction and celiac, basically it goes into this non-celiac gluten sensitivity. So people generally just don’t feel well. And mainly GI symptoms with gluten.

Dr. Rampur (27:04):

I would also like to add that a lot of people have chronic abdominal bloating and gastrointestinal symptoms. They sort of think that they could be allergic to many different foods and they start avoiding these foods. You know, when somebody has symptoms chronically and they feel like they’re reacting to everything, they’re less likely to be allergic to the food. But there might be something wrong with their gut itself. So I would recommend gastroenterology evaluation rather than, you know, allergy evaluation at that point to see if that is some kind of an inflammatory bowel condition or an intestinal condition.

Dr. Pelman (27:38):

Thank you. Well, let’s look at crustacean or shellfish. That’s a common food allergy that some people have. Do you want to break that down a little bit? Dr. Ayars?

Dr. Ayars (27:48):

Yeah. So as kids, a lot of kids have developed food allergies. And the reason for that is very complex. And we can talk about that later if you want, but kids can be allergic to a lot of different things. You know, wheat, dairy, eggs, things like that. Most of the time they grow out of those allergies. There’s a few that hang onto that into adulthood. But the more common ones that go into adulthood are about peanuts and shellfish allergy, you know, shrimp, lobster, crab, You can be allergic to finfish as well, salmon, cod, things like that. So yeah, that is, it’s a very common and especially me seeing mainly adults. That’s the most common allergy, that along with peanuts and other nuts that can cause that type of reaction. So it is one of the more common types of allergens. And so what we do see a lot of that, especially me seeing mainly adults, that’s the most common that again and peanut or the most common ones that we see. Again, the other ones that a lot of kids can be allergic to like wheat, milk, you know, things like that, most of the time they grow out of that by the time they hit adulthood,

Dr. Pelman (28:46):

Dr. Rampur, when people have shellfish allergy, I’ve heard people say, “I can eat one type of shellfish, but not the other.” If somebody has a reaction, should they stay away from all shellfish? Or how do you distinguish what kind of crustaceans they can consume?

Dr. Rampur (29:02):

So generally I would categorize shellfish allergy as shellfish, as crustacean and mollusks. Examples for crustaceans are shrimp lobster, crab, and mollusks are clam oysters and scallops. So crustaceans have, you know, they’re more than 50% cross-reactive. So if you’re allergic to shrimp, you could also be allergic to crab, but I’ve also seen patients who can just be allergic to shrimp, but not allergic to crab n’ lobster. It kind of depends on the history, but if they are allergic to shrimp, I generally ask them to avoid all types of crustaceans. Because if you eat at a restaurant, that is a significant chance of cross-contamination. But the patients with crustacean allergy are not necessarily allergic to mollusks. Some people are, but that cross reactivity is lower compared to the cross-reactivity among the crustaceans. So when they are eating at a restaurant, I asked them to avoid all types of shellfish, but if they’re pretty short at home and if they are re recently eaten clams, if they had an allergic reaction to shrimp, and if they’re doing okay with the molluks, I would let them eat if they are a hundred percent sure. Yeah.

Dr. Pelman(30:10):

And you know, a common question is have people had this all their lives or can people develop these sort of shellfish allergies or mollusk reactions later in life?

Dr. Ayars (30:23):

You can develop an allergy at any time. Most commonly it occurs when they’re younger, when they’re a kid, when they are first introduced. The foods are seen in teens, twenties, it’s very rare, but I see people develop it later in life. We don’t know why that is. We’re not entirely sure. So most commonly people develop allergies when they’re fairly young and initially close to the foods, just kind of step back. I know it’s a little off topic, but you know, say like peanut allergy, their old dogma used to be wait and don’t administer it. Don’t give the kid if you’re predisposed to allergies until they’re four or five. But there was a study a few years ago called the Leap Study where peanuts, where they randomized the groups into either early introductions, around six months versus three or four years. And the difference is totally different. The people that introduced early had a much lower incidence of allergies. So I remember sitting in a room as a fellow and people argue back and forth early versus late introduction. Now it’s clear, introduce it as early as possible around six months. And that significantly decreases the risk of developing a reaction, specifically to peanuts. But you can associate that with other foods as well.

Dr. Pelman (31:26):

So An infant at six months, won’t be able to chew a peanut, bu peanut butter?

Dr. Rampur (31:31):

Yeah. One of the reasons they realize this is in Israel, there’s a food called Bamba that a lot of parents will give their kids. It’s a peanut base, but it can really melt in the mouth. Actually, my kids loved it as well. And they introduced that earlier and they had a lower incidence of peanut allergy and that’s one of the reasons they started this study. So there’s a lot of different forms of peanuts that you can introduce. But the classic is Bamba, which is a very common, you can see it in most supermarkets. And that’s what I gave my kids when they were around six months.

Dr. Pelman( (31:58):

And looking at the concern. I know that even if peanuts are in the air, the airlines have stopped circulating peanuts. If somebody has a definitive peanut allergy, what steps should they take to protect themselves?

Dr. Rampur (32:11):

So basically I advise no touching or eating. You know, if somebody next to you is eating, usually it’s not a problem. It’s not like inhaled in the air. And it’s very less likely that they develop an allergic reaction without touching or eating. If you have a history of allergic reaction, make sure you read the labels of everything that you’re eating or coming in contact with, and also carry an EpiPen. And never forget too, that’s life saving. So everybody who has a food allergy should carry an EpiPen. 

Dr. Pelman

Dr. Ayars?

Dr. Ayars (32:42):

I agree completely. The biggest thing is epinephrine and always having that available. Early epinephrine is life saving. You know, we do studies where again, to the studies and testings, you have to actually put, you know, kids or adults into reactions. We know the earlier we give epinephrin, they do much better. So there’s a stigma about epinephrin and it’s actually a very safe medication. So I tell patients if you’re on the fence, you think you may be going into reaction, just take it and we’ll tease it out later. So I agree with Dr. Rampur. The biggest thing is having an epinephrine. obviously reading labels and things like that is very important, but you know, having a strategy and things like Benadryl don’t cut it. So, you know, epinephrine is by far and away the best treatment. So for those who have a severe allergy to anything, you know, shellfish peanuts, the biggest thing is having an epinephrine auto injector available at all times.

Dr. Rampur (33:29):

For when someone is in doubt, its always important to use epinephrin, rather than not using it. And one of the biggest causes of severe reactions, which turned out really bad, is that delay in using epinephrine. That’s one. So when you’re having a severe allergic reaction, people can have low blood pressure. And during this time, if you don’t use epinephrine, but you stand up too quickly, or walk around, people can collapse and even die. So that’s when severe reactions can happen. So when you’re having a severe reaction take epinephrine, go call for help, call 9 1 1, because that’s not the complete treatment, they still need to be monitored. EpiPen, lay down quickly, there where you are, and then call for help.

Dr. Pelman( (34:10):

Excellent. And we touched briefly on egg and milk. Do any of these travel together or do they distinctly separate the egg and milk allergies? Dr. Ayars?.

Dr. Ayars (34:19):

I mean, people that are predisposed to allergies, you’re more likely to have multiple allergies, but there’s no cross-reactivity between the two. It’s just people who are predisposed to develop food allergies are more likely to develop it to multiple allergens like Dr. Rampur, you know, discussed, you know, crustaceans and things like that. That’s much more likely to react to one versus the other, whereas like milk and peanuts, soy they’re unrelated. Just those people are predisposed to develop that reaction.

Dr. Pelman (34:45):

And you said earlier that kids who have milk allergies can outgrow them.

Dr Ayars (34:50):

Yeah. It’s very common in milk. So, things like that and egg. they’re most likely able to grow out of those. It’s the ones like peanuts, tree nuts and shellfish that people are much less likely to grow out as they get into adulthood. Now it’s important to establish with an allergist and they test annually often, depending on the patient, just see whether they have the skin test positivity or the blood test positivity. So we just monitor that. Okay.

Dr. Pelman (35:15):

And before we leave, food’s just one last. Sulfites? How do people present with sulfite? Where do they find those?

Dr. Rampur  (35:21):

So sulfite in wines and certain types of food, like lettuce, can cause primarily asthma type of reaction. I haven’t seen this commonly, but it’s less likely to cause anaphylactic type of reactions. But there is no way to test this. You know, some people believe that they’re allergic to sulfites in wine and alcohol, but there’s no way to test them or prove.

Dr. Ayars (35:45):

Yeah, it’s a distinct mechanism from the classic allergy. So it’s much easier to diagnose, and usually the reactions much less severe with sulfides.

Dr. Pelman (35:54):

Well, let’s look at moving off of foods to things that are common here in the Northwest. Mold. So I hear a lot about, you know, have your house suspect from mold. What happens? What’s the manifestation of mold in your environment?

Dr. Rampur (36:10):

So, typically more allergies can cause now chronic sinus issues, inflammation inside your nose, and asthma, wheezing and chest tightness. And it can also cause a chronic hypersensitivity condition called ABP, called allergic bronchopulmonary aspergillosis*. It’s a condition where it presents like asthma, but the routine asthma treatment not work. So they present as difficult to treat asthma. And that’s when we do the blood testing and also do a CT** scan of their chest to diagnose. Apart from this, you know, I also hear people say, you know, toxic mold syndrome and some of weigh other symptoms, but there is no evidence that molds are actually causing the problems. And there are many types of molds in that environment. Not everything is harmful. Just because somebody is able to visualize it, easy to attribute their symptoms to the mold. But many of them do not even cause symptoms. There are a variety of toxins produced, but some are totally harmless. So there are some of them which can cause, in which can commonly cause respiratory issue, are aspergillus***, alternaria, penicillium, cladosporium. These are some of the common ones that we do test. And if they’re positive, we can do allergy shots and things like that. But not every mold is harmful. I have to say.

*Allergic Bronchopulmonary Aspergillosis (ABP): https://www.aaaai.org/Conditions-Treatments/Related-Conditions/allergic-bronchopulmonary-aspergillosis 

**CT scans: https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac-20393675 

***Aspergillus: https://www.mayoclinic.org/diseases-conditions/aspergillosis/symptoms-causes/syc-20369619 

Dr. Pelman (37:26):

Another source for allergies would be pet dander. So what happens there? What kind of reactions do we see?

Dr. Ayars (37:36):

Pet danders, you know, like I mentioned cat, you know, think over 50% of the country in the households have a dog now. And our mantra is, you know, even if you’re allergic people get rid of their allergists before their animals, you know. You know, dogs and cats are family. So they do manifest, you know, upper airway, itchy, watery eyes, runny nose, congestion, asthma. Where people predispose, wheezing, chest tightness, shortness of breath, things like that. And classically it’s when you’re exposed, although specifically cat allergen is a very sticky allergen. So it’s very difficult to get out of the house. You know, with dogs, there’s some evidence to say, you know, if you’re washing your dog or keeping it clean, that can help somewhat. But cats, it’s very difficult. And I do want to step aside and say, there’s actually no such thing as a hypoallergenic breed. I hear that all the time. They did a study a few years ago, it looked at this. What they found is actually the individual dogs themselves have vastly different amounts of allergic protein. So it’s actually not the breed itself, it’s the individual. Actually in that study, the lowest was labs, which is not quote unquote hypoallergenic. So yeah, there is no such thing as a hypoallergenic breed but some dogs seem to be more allergenic than others.

Dr. Pelman (38:44):

Interesting. So looking at somebody who, like you said, they’ll get rid of their allergist before they get rid of their pet. I want to keep my dog. I want to keep my cat. What do we do?

Dr. Ayars (38:55):

Medical therapies are where we always start. You know, for upper airway, topical steroids, things like flonase*, nasonex**, anti-histamines things like Zyrtec, Allegra, things like that. So there’s medical therapies, you know. Like I talked about, there’s some evidence that bathing them twice a week can decrease the allergenic protein but that’s somewhat controversial. And the final thing that I’m sure we’ll touch on this is allergy shots. That’s the one thing that changes your body’s underlying immune response to those. So a lot of my patients who say get a dog and obviously they don’t want to get rid of their pet, they’ll come to us. One for medical therapy, you know, obviously we diagnose that with skin testing or a blood test. And if the medical therapy isn’t cutting it, that’s when we often times go to allergy shots, which work fairly well for most people, but they’re a lot of work. So we kind of saved them for last line.

*Flonase: https://www.flonase.com/allergies/what-is-fluticasone-propionate/ 

**Nasonex: https://www.rxlist.com/nasonex-drug.htm 

Dr. Pelman (39:42):

Dr. Rampur, any thoughts on pet allergies?

Dr. Rampur (39:45):

So there are also certain things that you can do at home to reduce the pet dander. HEPA air purifiers have shown to reduce dander exposure. And we also ask people not to expose or not to allow pets inside their bedrooms, especially when they have severe allergies or asthma. Yeah. These are some of the things that you do. And yes, allergy shots, as Dr. Ayars mentioned is a way to go if you still have persistent symptoms

Dr. Pelman (40:11):

And do people have carpeting versus a bare wood floors do better or linoleum floors without carpeting who have pets? Are there any tricks that way?

Dr. Ayars (40:21):

Yeah, no. The carpet is certainly a reservoir. The bedroom is as well. We have people that cover their sheets if they have dust mites, which is one of the most common allergens at least in this part of the country, the Pacific Northwest. Dust mites are basically our dominant year round allergen other than pets. So you can get dust mite covers, cover the sheets, mattress, things like that. Yeah. So there are strategies to limit it. A lot of patients, if they can, tell them to get rid of the carpet in the bedroom specifically. But that’s not always an option for people, you know, other reservoirs for things like dust mites or stuffed animals or old, you know, old carpets in the bedroom or things like that. So I tell them to try and get rid of it, specifically with dust mites, to get rid of as many reservoirs as they can.

Dr. Pelman (41:02):

So deep cleaning HEPA filters; try to get rid of reservoirs; topical treatments that you can take; all will help mitigate responses to things like dust mites. Let’s talk briefly about insect because that can be, I know people have certain bee allergies and reactions. Dr. Rampur, you want to take that?

Dr. Rampur (41:25):

Sure. You know, the common types of stinging insects are honeybee, yellow jackets, white faced hornets, yellow faced hornets, wasps, and fire ants. People can have pretty severe reactions to these. They can have anaphylaxis hypertension, people can collapse. Or they can also have local reactions like itching and swelling, localized swelling. So how we can do allergy shots or venom immunotherapy shots for these as well, especially for people who’ve had severe reactions. So studies have shown that people who have a severe reaction to a stinging insect are more likely to develop future severe reactions. And for these people, we recommend testing as well as allergy shots. So there are some people who get large local reactions, meaning they get stung and the entire limb gets swollen. So this is also some type of an allergic response. Generally, they may not be at a very high risk of developing severe reactions. However, if you are a beekeeper and you are constantly at risk of exposing yourself, we do recommend testing and they can consider allergy shots as well.

Dr. Pelman (42:35):

You mentioned fire ants. They have a friend who had never been subjected to a fire ant bites. It was out in the garden and did, and got severely systemically, really, almost an anaphylactic type of reaction. Would you advise that person then to have allergy shots or, you know, for a rare fire ant? Or could just carry an EpiPen? Or what sort of things should they do?

*EpiPen: https://www.epipen.com/en 

Dr. Ayars (43:01):

Dr. Rampur brought up a nice distinction there. There’s that large local rash, which I get. If I’m stung my upper arm might swell all the way down to my hand. Now I’ve never been tested. I don’t need an EpiPen. I don’t eat allergy shots cause I’m not much higher risk than the general population to react. We always distinguish that from immediate wheezing, chest tightness, whole body hives, lightheadedness. That’s a different story. Those patients are at a much higher risk. If they’re stung, they’re at a 50% chance to react. Now if we get them an allergy shot, that gets down closer to around 5%. So it’s an incredibly effective therapy for it. Obviously we always have them carry an epinephrine auto injector, but if your friend had a severe, immediate reaction, you know, we don’t see fire ants around here, but down south, you know, when fire ants answer native, yes, we do recommend that they at least consider starting allergy shots. And certainly we recommend they carry an epinephrine auto injector.

Dr. Pelman (43:50):

Excellent. And I want to touch on latex allergies, which we see a bit. How would that manifest and how does somebody know if they had a latex allergy?

Dr. Ayars (44:00):

So latex allergy can be IgE mediated, meaning they can have antibodies to latex. So when they come in contact with latex, they can have immediate onset hives or swelling or anaphylactic type of reactions. Latex allergy, these days, is very rare and testing is also not greatly sensitive. We can do blood tests or we can do skin tests, but I’ve never seen a positive latex allergy. And there are also certain types of food like fruits, like banana and avocado, can cross-react with latex. You know, people with latex allergy can have reactions to these fruits, and people with reactions to these fruits may have maybe a higher risk of reacting to latex. But I’ve never seen a positive latex, truly positive latex study.

Dr. Ayars (44:46):

And latex was a big issue in the nineties, late eighties, mainly because people started wearing gloves more mainly because of the HIV epidemic. So they used to see it a lot. Or not a lot, but it used to be much more common. I agree with Dr. Rampur, I very, very rarely see a true allergic reaction you know, to latex.  It can be an irritant, especially if you’re breathing it in and it can cause irritation. But you know, most of the products we use, especially in the medical field, are not latex based. So it’s a much less common problem than it was, you know, 20, 30 years ago. 

Dr. Pelman (45:18):

And lastly, let’s look at plants, you know, weeds, grasses, and hardwood, deciduous trees a far as seasonal allergies that a lot of people suffer from and the pollen counts are up. Let’s talk a little bit about what would somebody do? Spring allergies, fall allergies, summer allergies. What do you see? What do you advise? What do we do?

Dr. Rampur (45:40):

We treat pollen allergy, grasses and weed pollens, as you said. Trees are common in the spring season; grasses in the summer season between May and July. And weed pollens are common between June, July, and they go on up until September, October. So if somebody has severe allergy seasonal allergy, we would treat them consistently with antihistamines or nasal sprays. If they have sporadic, once in a while type of symptoms, they can just take medicines as needed. However, if they have persistent severe symptoms, I would ask. Let’s say their symptoms are starting in February. I would start end of January or beginning of February, start the medication to prepare your respiratory system. Better to take on that allergen lower and stay on that consistently. But if you feel like your quality of life is being affected with symptoms every year, I would recommend allergy shots for them.

Dr. Pelman (46:35):

Dr. Ayars?

Dr. Ayars (46:36):

It depends on where you’re listening to those podcasts. There’s different pollen seasons, depending on where you are in the country. So, you know, if they are bothering you, most people, you know, we don’t see most people with seasonal allergies cause most of the time now that a lot of these medications are over the counter, like Zyrtec, Claritin, Allegra, Flonase. Most of the time they can control it, but we see the more severe cases. And if that’s the case, it is a good idea to get tested. You know, what I do is test all our allergens and I know what our pollen seasons are in this part of the country. So I say around this part of the year, start taking, you know, this nasal spray or this anti-histamine. And stop it, you know, at the end of the grass season, whenever that is, where they are in the country. 

Dr. Ayars (47:14):

So it depends on where they are, but if you’re not getting by with medications, you know, again, and that’s why we test for things like dust mites, where you can do environmental controls, things like that. We usually try environmental controls, medications. And if that doesn’t cut it, then that’s oftentimes when we’ll talk about allergy shots, which again, work very well, but are very labor intensive. So we try to, you know, environmental controls and medications first. And again, the classics are the anti-histamines and the nasal sprays like Flonase, Nasonex, Nasacort, things like that.

Dr. Pelman (47:43):

These are over-the-counter now as long= as well as a lot of the common anti-histamines right?

Dr. Ayars (47:48):

Yes. And they’re very accessible. They’re very cheap. So yeah, most of the time people can get by just doing those. But if they’re not, that’s usually when we say see an allergist get tested, cause we can come up with other strategies as far as what time of the year. Again, dust mites around here are the major allergen. So there’s things we do as far as environmental control. So if you’re not getting by with those medications, that’s usually what I recommend getting tested.

Dr. Rampur (48:10):

So if you’re allergic to just grasses, you can take grass tablets. They are a sublingual form of immunotherapy. It’s easier that you can take it at home. Usually the first dose is given in the allergy clinic and we monitor to make sure there’s no allergic reaction. But you can take the rest of the doses at home every day. So it’s easier for people who are just sensitized to process.

Dr. Pelman (48:33):

And we spoke a lot about allergy testing. Dr. Ayars, do you want to just explain what happens? Because a lot of people don’t know. They go, well, how do you get allergy tested? Is it a patch test or what is modern allergy testing look like?

Dr. Ayars (48:47):

That’s a great question. And it depends on what type of reaction you have. For things like asthma, you know, seasonal year round allergies, what we most often do as allergists is a skin prick test*. Basically it’s just purified allergen. We put it on the skin, exposed to those things called mast cells that we all have. And if it forms basically a bump or a hive, that means you’re positive. So that’s most commonly what we do as allergists cause it’s done in 15, 20 minutes and you have your results. We can go over them in real time. There’s also a blood test to look for like we talked about that IgE or the allergic antibody, and that gives us similar information just not readily available. So either of those look for things like seasonal allergies, asthma, food allergies, that’s another way to do it as well. So that’s the most common way to look at that. Now there’s other types of allergic reaction. I won’t get into things like contact dermatitis, like poison ivy, things like that. That’s called a patch test where we leave the individual allergens on a skin for several days, and then look to see if there’s a reaction. By far and away, the most common tests, if you do go see an allergist, is a skin prick test, which again takes 15 to 20 minutes and you have your answers.

*Allergy Skin Tests: https://www.mayoclinic.org/tests-procedures/allergy-tests/about/pac-20392895 

Dr. Pelman (49:50):

And then desensitization we talked about. Is this allergy shots that we’re talking about?

Dr. Rampur (49:56):

Yes. So desensitization is a broad term which can be done for environmental allergens, but it doesn’t mean that your allergies are going to completely resolve. So once you stop the allergy shot, some people may have recurrence of symptoms up to sometime as well. So we do desensitization for medications as well. For example, somebody has a history of allergic reaction to penicillin, and we do the skin testing and the skin test is positive. That means that they are allergic. So what we do is slowly introduce penicillin and with a very small dose, and we keep increasing the dose every 15 to 20 minutes to reach the maximum level. That’s also called us desensitization, a drug desensitization

Dr. Pelman (50:42):

As we wrap up, I always like to give our listening audience the opportunity to look towards some resources that are available. So if either of you have some favorite resources for allergies that you would give patients or put out there, let us know, go ahead and just list them. Dr. Ayars, do you have some favorite resources?

Dr. Ayars (51:03):

Not really. I have my group of, you know, handouts that I give patients. The biggest one is dust mite control measures. Again in this part of the country, and a lot of the country that’s the major year-round allergen. So, you know, things like dust mite covers, you know, washing the bedding at a certain temperature, things like that. But the American Academy of Allergy Asthma and Immunology is a great resource as well. Same with the American College of Allergy Asthma and Immunology. Those are our two big groups and they put out great information for patients. I’ve gone to that website is another great spot.

Dr. Pelman (51:32):

So say those again, the?

Dr. Ayars (51:34):

We call it the quad AI, American Academy of Allergy Asthma and Immunology (AAAAI). And the other one is the college,  American College of Allergy Asthma and Immunology (ACAAI). So AAAI, ACAAI are great resources.

Dr. Pelman (51:48):

Excellent. And people can find those online?

Dr. Ayars (51:51):

Yup. 

Dr. Pelman (51:52):

Dr. Rampur, do you have any other favorite resources?

Dr. Rampur (51:55):

I agree with Dr. Ayars and you know, one of the things that my patients find helpful allergyfreeskin.com. So this is recommended by one of the contact dermatitis specialists. So contact allergies are due to like preservatives and creams or personal care products that you use. They can cause chronic allergy type of symptoms. And we do something called patch testing that goes on their back. And this is not like an immediate skin prick testing that we do for other allergens. So once we find what they’re allergic to, I typically give them the handout from the website on what they’re allergic to and what they have to award. They can also find the allergen free products in this website called allergyfreeskin.com, which is recommended by a national expert as well. Obviously they have to verify before using the products, but they generally find this helpful.

Dr. Pelman (52:47):

And resources for their patients public out there would be primary care physician, family, doc, and then referral to allergy immunology as necessary.

Dr. Ayars (52:59):

Yeah. Most of the patients go to their primary doctor first, who are, but most of them are very good at managing this and, you know, go through the initial therapies. The anti-histamines like we talked about, the nasal steroids, things like that. But you know, still having symptoms despite that, that’s when we usually recommend a referral to an allergist.

Dr. Pelman (53:17):

Excellent. Well, I think we covered a lot of ground. Anything else that either of you wanted to contribute that we forgot to mention or go through?

Dr. Ayars (53:25):

One thing I find fascinating is Dr. Rampur mentioned genetics in allergy. Allergy is actually a relatively new phenomenon. You know, the first case of seasonal allergies or quote unquote hay fever was diagnosed in England in the 1870s, and in the U S around that same time before that. It wasn’t really an issue. And it’s in industrialized places, classically was in the big cities where they’d see this. It wouldn’t be out in the country. So we know not only our genetics in play, but the environment is as well as the early life exposures. We find that people that have the least amount of allergies actually live on farms and are exposed to the most species of animals. There’s a great study with the Amish and the Hutterites, which are very similar lifestyle. Everyone knows how the Amish live, you know, right next to their animals and things like that.

Dr. Ayars (54:12):

Whereas the Hutterites actually practice differently where they have industrialized farming. So they’re not as close to the animals. So the Amish have, I think seven fold increase in asthma as opposed to that genetically like almost identical population. So we know that early exposure along with genetics, so what predisposes people to allergies. And that’s why we’ve seen such an increase over the past hundred, hundred years or so. So I find that fascinating, it’s called a hygiene hypothesis. So you have to be genetically predisposed, but early life exposures also play a major role as to whether you’re going to develop allergies or not.

Dr. Pelman (54:46):

But then we want to get peanut exposure early.

Dr. Ayars (54:51):

No, it is, it’s fascinating. There’s a lot of interplay with this. You know, again, antibiotics are some of the greatest inventions in human history, but you know, we get early antibiotics in life and you know, that does change your gut flora. Or, you know, the makeup of the things in your gut that are associated with immunity. So I find it fascinating that not only genetics, but early life exposures kind of shape your immune system and predispose you to allergies depending on your early exposures.

Dr. Pelman (55:18):

Yeah. We’ll make a plug for an earlier episode. Listen to the episode, part two on your microbiome. Dr. Rampur, any other final thoughts?

Dr. Rampur (55:28):

I think we touched upon everything. Thank you for the great questions, but I just want to add something that I commonly see in clinics. It’s called chronic idiopathic urticaria*. Idiopathic, meaning nobody knows why it’s happening. And urticaria means hives. Hives that come and go randomly without a clear trigger. And a lot of my patients believe that they’re allergic to pretty much everything. They stop eating. Some of them get horrified and they’re itchy and hivey all the time. And I would like to say that this is mainly an immunological condition. Basically mast cells become twitchy and they start releasing histamine randomly without a clear trigger. It can happen anytime during their life. And they’re typically treated with anti-histamines and no need to get concerned about allergies if it’s happening repeated without a clear trigger. And they can also be triggered by heat or temperature changes, alcohol, pain medications. And I’ve seen people go on a cleaning spree, they changed their diet, change all their products. They spent hundreds of dollars cleaning their vents and everything, but nothing really helps. It’s an internal phenomenon.

*Chronic Idiopathic Urticaria: https://allergyasthmanetwork.org/health-a-z/chronic-idiopathic-urticaria-ciu/ 

Dr. Pelman (56:36):

Interesting. Well, I’m sure we could spend hours going over other immunologic and allergic phenomena, but I think we’ve covered a lot of basics for people. And thank you so much for staying late in the office and allowing us to go through some of the basics here. Thank you so much.

Dr. Ayars (56:54):

Thanks for having us. 

Dr. Rampur (56:54):

Thank you for having us.

Dr. Pelman (56:58):

This completes another episode of The Original Guide to Men’s Health podcast. We wish to thank all guests who volunteered their time and knowledge. The information presented is the opinion of the speakers. The show’s recordings are engineered and edited by Sean Fox. Episode titles and descriptions, as well as editing assistance, are provided by Dr. Kathleen O’Connor, PhD. Music for our show is San Juan Bell’s, written and performed by Dr. David Whiting. The podcast is sponsored and published by the Washington State Urology Society.  The Original Guide to Men’s Health is an original publication of the Washington State Urology Society. Reproduction and use without the express written consent of the society is prohibited. For more information about men’s health and previous episodes, as well as additional recommended resources, visit us online at https://theoriginalguidetomenshealth.org/ . This is Dr. Richard Pellman thanking you for listening, and reminding you to take care of yourself.

(Part B starts at the 40 minute 30 second mark). Early life exposure to foods and allergens can influence a person’s lifetime gut microbiome and allergy risk.

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