Dr. Friedman, Allergy Partners of Arizona, was featured on Wake
Click to listen to Dr. David Friedman discuss allergies,
treatment and prevention with callers on Wake Up! Tucson 1030 KVOI The Voice
Patients that suffer from occupational asthma (asthma caused
by breathing in hazardous substances in the workplace) may not realize their
symptoms are work-related. It can also affect their ability to work, overall
quality of life, and even threaten their lives.
What is Occupational Asthma?
Asthma caused by breathing in hazardous substances in the
workplace is called "occupational asthma." Asthma can affect your
ability to work and overall quality of life. It can even threaten your
How Does it Work?
Patients suffering from occupational asthma often may not
realize their symptoms are work-related. Symptoms of occupational asthma are
the same as regular asthma and may include any or all these chest symptoms:
cough, shortness of breath, wheezing and chest tightness. An asthmatic patient
my fail to recognize the work relationship to their asthma as symptoms often
begin several hours after exposure. Occupational asthma symptoms usually become
worse during the workday and throughout the work week. Symptoms may be
immediate (less than 1 hour), delayed (more commonly, 2 to 8 hours after
exposure), or nocturnal. They usually decrease over the weekend, or days off
and during vacations, but may take a week or more. However, workplace exposure
to sensitizing chemicals or dusts can induce asthma often persisting after the
exposure has stopped. Initial symptoms may occur after high-level exposure
What Causes It?
Several hundred substances found in the workplace have been
found to be respiratory sensitizers with more being identified all the time.
The list below is a broad indication of substances known to be respiratory
sensitizers and their common work activities. It is not exhaustive and
many known sensitizers are not identified here:
Substance Groups Common
Vehicle spray painting, foam manufacture
grain at docks, milling, malting, baking
electronic assembly, computer manufacturing
Gloves in health care, laboratories
Laboratory animal work
Saw milling, woodworking, and furniture manufacture
Curing glues and epoxy resins in joinery and construction
Welding stainless steel
Hard metal production, diamond polishing
What Should I Do If I Have Occupational Asthma?
If you are having work-related air flow limitation make an
appointment with your Allergy Partners Physician telling him/her your symptoms,
where you work, what your job is and what chemicals and materials you work with
daily. Take chemical fact sheets to your Allergy Partners Physician. Lung
function monitoring may include serial charting with a peak flow meter for 2 to
3 weeks (2 weeks at work and up to 1week off work as needed to identify or
exclude work-related changes in peak expiratory flow.) Record when symptoms and
exposures occur and when a rescue inhaled bronchodilator is used. Measure and
record peak flows every 2 hours at work and away from work.
What is the Treatment?
Allergy Partners Physicians are trained in additional,
specialized evaluations to include immunologic testing and confirmatory
evaluations such as detailed pulmonary function testing and bronchial
The patient is encouraged to work with on-site health
providers or managers/supervisors discussing avoidance of the initiating agent,
ventilation, respiratory protection, and tobacco smoke-free environments.
If your Allergy Partners Physician tells you that you have
occupational asthma, you should be removed from the work area or job to prevent
it from getting worse. Occupational asthma is a serious illness. Lack of
appropriate treatment can lead to permanent disability. Early recognition
and treatment are paramount in keeping this illness from getting worse.
Patient confidentiality issues are particularly important in
work-related asthma. As even general inquires about the potential adverse
health effects of work exposures may occasionally result in reprisals such as
job loss, occupational asthma patients need to be informed of this possibility
and be full partners in the decision to approach management regarding the
effects or control of workplace exposures.
Dr. Brian Dantzler
Allergy Partners of Charleston
Inspired by one of our favorite television shows, Allergy
Myth Busters looks at a number of popularly held beliefs about allergy. But are
these myths just urban legends or are they true?
MYTH: Children less than 4 years of age can’t be skin tested
First introduced in 1865, allergy skin testing remains the
gold standard for diagnosing allergic sensitization. There are two types of
skin testing. Skin prick testing involves placing a drop of a suspected
allergen (or extract) on the skin and scratching or pricking the surface of the
skin. Intradermal testing involves injecting a small amount of extract just
under the skin, similar to how a Tuberculin skin test is performed. A positive
reaction to either test will appear as a small, slightly raised red bump.
Allergy skin testing has a number of positives:
Quick – Many allergens can be tested at the same
time and results are read in 10-15 minutes.
Comfortable – Both skin prick and intradermal
testing involve very minimal discomfort, although positive test can be itchy
for several minutes.
Accurate – When performed with high quality
extracts and by a trained technician, allergy skin testing is the most accurate
test for allergy diagnosis.
Although the results of allergy tests are not affected by a
person’s age, sex, or race independent, certain age (children younger than 2
years and adults older than 65 years) and racial (African American children)
factors may affect their interpretation. This fact may explain why some people
believe that children need to be a certain age before they can be skin tested.
Generally speaking, skin testing can be performed even in infancy, and as young
as one month of age. However, the skin of very young children may not be as
reactive as older children and adults, and therefore the results need to be
interpreted more carefully.
The reason for skin testing is probably more important than
the age at which a child is tested.
In infants and toddlers, allergic disease most commonly
occurs as food allergy and atopic dermatitis. In school-age children, allergic
disease occurs more commonly as allergic rhinitis. Asthma can occur at any age,
but occurs most commonly in adolescent boys and teenage girls. Because of this,
skin testing should be aimed at identifying allergic triggers appropriate to
the age of the child.
Skin testing, particularly prick skin testing, is virtually
painless. There is no bleeding involved, as the needle only pricks the skin to
the depth of a scratch. The worst part of skin testing is that the skin test
sites may be quite itchy when positive results occur.
Allergy skin testing is a safe, accurate and virtually
painless means of diagnosing allergy at all ages. All Allergy Partners
physicians are Board-Certified and experts in the diagnosis, treatment, and
management of allergies and asthma at any age. Learn more at
Maternal asthma during pregnancy has been associated with
increased risks of several adverse outcomes, emphasizing the need for optimal
asthma control during pregnancy.
Maternal asthma in pregnancy has been associated with an
increased risk of adverse outcomes, including preeclampsia, low birth weight,
preterm birth and congenital abnormalities. This, compounded with the
increasing prevalence of asthma in the general population, emphasizes the need
for optimal asthma control during pregnancy. Of the associated adverse risks,
there has not been a clear consensus as to whether the increased risk of
congenital abnormalities is related to asthma itself or the medications used to
treat asthma. A recent study in the Journal of Allergy and Clinical
Immunology sought to identify whether this risk is associated with asthma
medications in the first trimester.1
What is the underlying cause?
The study did find that there was an increased chance of
congenital abnormalities including cleft palate and gastroschisis in those with
exposure to inhaled B2 agonists (e.g. albuterol), the drug typically
found in rescue inhalers. Though there is an increased risk, the individual risk
remains low – less than 1 in 100 births. There was no increased risk seen with
inhaled corticosteroids, which are often used in controller inhalers.
Despite these findings, both maternal asthma and asthma exacerbations during the
first trimester of pregnancy have been found to increase the risk of congenital
anomalies as well. http://www.jacionline.org/article/S0091-6749(08)00521-6/pdf
asthma exacerbations during pregnancy have been associated with other
unfavorable pregnancy outcomes for both the mother and infant. The study
highlights these facts as the risks of uncontrolled asthma might be much
greater than the studied specific risks. Ultimately, the study suggests that
the use of prophylactic inhaled steroids seems to be the best approach for
treating asthma in pregnancy to prevent asthma exacerbations and to reduce the
need for β2-agonists. For this reason, both those pregnant or
considering pregnancy that have asthma would benefit from being followed by an
Garne et al. Use of asthma medication during pregnancy and risk
of specific congenital anomalies: A European case-malformed control study. J Allergy Clin Imuno.
Vol 136, Number 6. pp 1496-1502.
By Dr. Michael Alvares
Allergy Partners of Dallas-Fort Worth
There has been mounting evidence connecting exposure to
secondhand smoke to illness and diseases due to the irritating nature of
tobacco smoke on the non-smoker.
Despite significant educational efforts, epidemiologic
evidence, and reports from the United States Surgeon General, smoking and
smoking-related conditions are a major health concern. The irritating
nature of tobacco smoke on the non-smoker has long been recognized. Since the
1960’s, there has been mounting evidence connecting exposure to secondhand
smoke to illness and disease.
Secondhand smoke is a term used for the involuntary exposure
of nonsmokers to tobacco smoke from smokers. Another commonly used term
is Environmental Tobacco Smoke. Secondhand smoke is a mixture of side
stream smoke given off by the smoldering cigarette, pipe, or cigar and
mainstream smoke exhaled into the air by active smokers. Third hand smoke
refers to smoke components deposited on surfaces.
In the News.
The Global Burden of Disease Study done in 2010 estimated
that exposure to secondhand smoke is responsible for 601.000 premature deaths
annually worldwide. It is estimated that 28% of the mortality and 61% of
the morbidity is seen in children. Secondhand smoke has been found to be a
cause of lung cancer by several epidemiologic studies. Cardiac disease
has also been causally associated with secondhand smoke exposure in
adults. Mounting evidence also points to secondhand smoke exposure as a
cause or aggravator of a variety of adverse respiratory conditions including
asthma, pneumonia, bronchitis, reduced lung function, sinusitis, and
COPD. Secondhand smoke exposure is also implicated as a cause of middle
ear disease, sensorineural hearing loss, sudden infant death syndrome,
prematurity, impaired fetal growth and development, dental caries, cancers in
locations other than the lungs, renal disease, and atherogenesis.
How it can affect your family.
The level of tobacco exposure of the fetus of a mother who
smokes is the same as the level for an active smoker. There is a higher
risk of stillbirth and neonatal deaths among newborns of smoking mothers.
Maternal smoking during pregnancy reduces birth weight on an average of 200
grams. Active smoking of the mother during pregnancy is also associated
with an increase in a large variety of non-chromosomal birth defects.
Cognitive deficits tend to be more prevalent in children whose mothers smoked
during pregnancy. Exposure of the non-smoking mother to secondhand smoke
during pregnancy has been associated with an increased incidence of low birth
weight, stillbirth, and congenital malformations.
The Global Study of Disease Burden from exposure to
secondhand smoke estimates that 165,000 children under the age of 5 worldwide
die annually because of lower respiratory infections attributed to secondhand
smoke exposure. Chronic exposure to secondhand smoke is linked to an
increased prevalence and severity of asthma. There is also evidence that
secondhand smoke exposure promotes and facilitates allergic sensitization.
Children with chronic secondhand smoke exposure enter adulthood with less
pulmonary reserve and decreased lung function.
Exposure of children and adolescents to parental smoking has
been associated with advancement of the vascular age by 3.3 years by
measurement of carotid artery thickness. This increases the risk of
developing carotid atherosclerotic plaques in adulthood even with adjustments
being made for other risk factors such as blood pressure, lipid levels, and
personal smoking status. There is growing concern about increased risks
of coronary artery disease in adults and children exposed to secondhand smoke.
What can I do?
Reducing and preferably eliminating secondhand smoke in the
home and in vehicles is critical since these are the major locations of
exposure for children and non-smoking adults. Secondhand smoke cannot be
controlled by air cleaning and filtration, or building ventilation. These
findings on the effects of secondhand smoke are the foundation for the drive
for smoke-free indoor environments and for educating parents and the community
on the adverse health effects. Policies that ban all indoor smoking in
workplaces and public places are highly effective in reducing smoke exposure.
Only complete bans of smoking in indoor environments are effective.
Segregation of smokers and non-smokers within the same indoor environment may
reduce some of the exposure, but does not eliminate it.
The myth: Regular use of inhaled corticosteroids to treat
asthma will weaken my lungs.
Systemic corticosteroids were first shown to be effective
in the treatment of acute asthma in 1956. Since the 1970s the use of
inhaled corticosteroids (applied directly to the lungs with inhaler devices)
has been proven to treat asthma with fewer side effects than systemic
corticosteroids. Inhaled corticosteroids have consistently been shown in
studies to decrease asthma symptoms, improve lung function, reduce asthma
exacerbations (resulting in less emergency department visits and
hospitalizations), decrease risk of death and reduce the need for rescue asthma
medications and oral corticosteroids. Inhaled corticosteroids are the preferred
medications for managing persistent asthma in all ages, and the dose is based
on the severity of the asthma.
When used appropriately, inhaled corticosteroids have few
adverse effects at low and medium doses. The most common side effects include
hoarseness of voice and oral thrush, both of which can be reduced with proper
inhaler technique and rinsing of mouth after use. The higher dosages of inhaled
corticosteroids can have more important side effects, including the ability to
suppress the adrenal axis and even have long term effects on height when used
in childhood (approximately 1.2 centimeters in the best study). However,
the higher dosages of inhaled corticosteroids are used to treat only severe
asthmatics, who would often require repeated doses of oral corticosteroids to
open their airways and the risk to benefit ratio may still be in favor of the
use of inhaled corticosteroids. Each patient is always unique and asthma
is best cared for by a physician who specializes in asthma care.
is the myth busted or true?
Thankfully though, there is no dose of inhaled
corticosteroid that has been shown to weaken lungs.
Do you ever wonder how a new medication comes to market?
Ever hear someone claim that a new drug literally changed their life? The
answers stem from the results of clinical research trials … which are quite
important for drug development, and something that you may want to consider
participating in, if asked at some point in the future.
What is a Clinic Trial?
A clinical research trial, or “drug study,” is a scientific
study that has been carefully designed to answer a very specific medical
question. Typically, the maker of the drug, usually a pharmaceutical company
and commonly referred to as the “sponsor,” generates the research question.
Some studies test medications that are currently unavailable for treatment,
referred to as investigational new drugs, whereas others examine medications
that can be prescribed today. The sponsor develops a set of guidelines, or
protocol, that research sites must follow in order to answer the question.
How Does it Work?
The US Food & Drug Administration (FDA) oversees all
research activities in the US. Its goal is to ensure that medications available
to the public are both safe and effective. The FDA works closely with the
sponsor to ensure that the protocol is appropriately designed to answer the
question(s). Typically, the FDA will request results from several studies, each
answering a different question, before approving a new medication for release.
All new medications are tested first in animals, then healthy human volunteers,
and finally in patients with a specific disease.
Can I help?
Most clinical trials need large numbers of patients to answer
the research question. Sponsors, however, do not have direct access to
patients, so they ask medical practices with research experience, or
investigative sites, to help. Depending on the number of patients needed for a
trial, some studies require hundreds of sites located all across the US, and in
some studies all over the globe.
Participating in a trial is a partnership or commitment
between you and the study team. It requires more time and effort than just
“going to the doctor” for a check-up. Patient volunteers are typically asked to
keep careful record of their symptoms along with other conditions that might
develop while in the trial. Most protocols require periodic visits to the site
for exams, lab tests, and to receive new supplies of study medications. In
short, patient volunteers receive a great deal of personalized medical
attention, while at the same time, learning a fair amount about their underlying
Patients participate in
clinical research trials for different reasons. Most appreciate the detailed
medical attention. Others do so to in order to potentially receive a new
medication that others with the same condition are unable to receive today.
Some do so solely for altruistic reasons – to be a part of advancing medical
science. In addition, study-related medical care is provided at no cost, and
for most protocols, patient volunteers are compensated for their time and
Is It Safe?
Many people who consider
participating in a clinical research trial will ask, “Is it safe?” In a
nutshell, yes. With any investigational medication, however, where clinical
experience is limited, extra safeguards are in place. First, most protocols
require careful patient monitoring, which often involves serial lab tests, EKGs,
breathing tests and physical exams. For many protocols with electronic
recording systems, the site can even track your progress on-line between
scheduled visits. Patient volunteers are not allowed to continue in a trial if
any worrisome changes occur. Second, an independent group called an
institutional review board, or IRB, ensures that all patients’ rights and
welfare, are protected. The IRB approves the protocol, the site, and the
consent form for the trial. The site will report any serious adverse events to
both the sponsor and the IRB, whether felt related to the study medication or
not. For events that are felt to be related, the sponsor must distribute the
report to all sites participating in the trial. In addition, the IRB has the
authority to immediately suspend any research activities if they have concerns
regarding patient safety.
With the evolution of electronic medical records and the
development of sophisticated databases, there is a good chance that you may be
asked to participate in a clinical research trial at some point in the future.
Think it over carefully.
What is Sublingual Immunotherapy (SLIT)?
There has been a lot of press recently as well as television
and print advertisements touting the availability of sublingual immunotherapy
(SLIT). Unlike traditional allergy shots (called Subcutaneous
Immunotherapy or SCIT), SLIT is taken as either drops or tablets under the
Does it Work?
A recent meta-analysis (a study that statistically analyzes
multiple other studies to identify trends and confirm positive effects) of SLIT
for seasonal allergies show that it may offer only small benefit. Danilo Di
Bona and colleagues looked at 13 studies enrolling over 4000 patients and in 7
of 13 studies the group taking the immunotherapy reported improved symptoms
with decreased use of medications. In six of the thirteen studies there
was no more improvement than in the placebo (no medication) group. The
conclusion was that while some patients will benefit, many may not, and it is
not possible to identify those that will respond prior to initiating therapy.
What Are the Side Effects?
Over half of the patients in the treatment group reported
either oral or GI/stomach side effects. Seven patients had allergic reactions
SCIT vs. SLIT
In the not so recent past, immunotherapy or “allergy shots”
was a fairly narrow topic for discussion. Those patients with nasal
allergy and allergic asthma who were not well controlled on medications were
offered subcutaneous immunotherapy (SCIT) as a better alternative to medication
and a potentially disease modifying intervention. The injection therapy
works directly on the patient’s response to allergens which results in short
term symptom control, reduced medication requirement, and a durable long term
improvement. The downside was a significant commitment to receiving
injections in a medical setting on a regular basis.
Fast forward to the past few years. Sublingual
immunotherapy (SLIT) utilizes allergen as drops or dissolving tablet under the
tongue. This approach has been common in Europe for a number of years for
patients symptomatic from a single allergen. It is also available off label in
the United States for single or multiple allergens using conventional allergen
extracts. Tablets for grass and ragweed have become available by prescription.
These require at least pre-seasonal therapy beginning three months prior to the
pollen season and may be more effective if continued all year. The major
advantage of SLIT is that the allergens can be self-administered at home with
the availability of epinephrine as the risk of serious systemic reactions is
Traditional subcutaneous immunotherapy allows the inclusion
of multiple allergens in a single injection, and in the large majority of
studies, has been shown to be more or equally efficacious when compared to the
sublingual program. Since many of our patients are allergic to multiple
environmental allergens, this may be their best choice.
Fortunately, Allergy Partners physicians are able to offer
sublingual and injection therapy and select the type of immunotherapy that best
serves your individual needs.
Our very own Allergy Myth
Inspired by one of our
favorite television shows, Allergy Myth Busters looks at a number of popularly
held beliefs about allergy. But are these myths just urban legends or are they
IgG RAST testing is an
effective means to identify food allergies.
What does science say?
It is estimated that 15
million people in the United States have food allergies. This includes up
to 1 in 13 children. Therefore, appropriate evaluation and treatment of
these allergies are essential. Various methods have been described to
test for food allergies since the 1970s. These include skin prick testing
to possible offending foods, ImmunoCAP IgE blood testing, and IgG RAST blood
So is the myth busted or
Detection of IgG
antibodies has been discredited as a reliable diagnostic tool since the
1980s. Unlike IgE antibodies, which are responsible for allergies, IgG
antibodies can be found in allergic and non-allergic people regardless of
whether they are healthy or sick. IgG antibodies are the normal
antibodies made by the body to fight off infections. Increase in levels of IgG
antibodies present in the circulating blood is thought to be a normal response
to the ingestion of food. In fact, IgG antibodies have actually been
found to go up during successful research studies on food immunotherapy.
Also, allergy testing to foods using IgG RAST testing has been shown to lack
clinical relevance. These tests are not validated and lack sufficient
These unproven tests may
lead to false diagnoses, increased anxiety, and a useless strict avoidance
diet. If a food allergy is suspected, evaluation, diagnosis, and
treatment should be performed by a board certified allergist. The
evaluation should include a thorough medical history and a physical exam.
The allergist may perform tests including skin prick tests and ImmunoCAP IgE
blood tests to help identify a food allergy. Both methods are highly
sensitive and useful to help exclude a diagnosis of food allergy. An oral
food challenge or even a trial elimination diet may be necessary. These
tests have all been proven to be effective diagnostic methods which the board
certified allergist may use in conjunction with the information from the
clinical history and physical to provide a diagnosis of a food allergy.
rhinitis, better known as hay fever, is one of the most common chronic
illnesses and is estimated to affect 20% or more individuals at some point in
time. An allergy can be considered an exaggerated immune response where the
body is trying so hard to keep the allergens out that undesirable symptoms such
as sneezing, rhinitis, congestion, and wheezing occur. Allergic
triggers include seasonal pollens and year-round allergens such as house dust
mites, mold, and animal dander.
sufferers also suffer from asthma. Upwards of 70% of all asthmatics have
underlying allergies. In children, the numbers are even more staggering as
80-90% of asthmatic children are allergic. Conversely, allergic children have a
40-60% risk of asthma. Allergies also can negatively impact quality of
life with malaise, fatigue, loss of sleep, and loss of school and work
days. The resulting expenses for treatment and lost wages are very
substantial, ranking high on the list with medical expenditures.
many allergy and asthma patients respond well to symptomatic treatment and
avoidance. Education about allergen avoidance and control and the ongoing
use of an effective medication can lead to excellent results for many.
patients for whom conservative treatment proves inadequate because of severity,
chronicity, and complications, an evaluation by a board certified allergist is
in order. An allergist will use a thorough history and exam to establish
the best available options for treatment. When indicated, allergy skin
tests identify specific sensitivities to seasonal and perennial
allergens. Such testing provides the most cost effective answers, which
can then be correlated with that particular patients’ history and physical
In a patient
with such severe chronic respiratory allergy, subcutaneous immunotherapy (SCIT)
or “allergy shots” may offer the best opportunity to modify, in a sustained
fashion, the underlying problems. SCIT helps up to 80% of pollen allergic
and 60-65% of environmentally allergic patients. By a variety of
mechanisms, SCIT teaches the body to “block” or decrease the exaggerated immune
In the office,
this process takes place by formulating an allergen vaccine targeted against a
person’s allergy triggers. Initial doses are very small and administered in
increasing doses. As the dose is increased, the immune response begins to
change. After a build- up period, immunotherapy is continued at a targeted
optimized dose every 2-4 weeks for a 3-5 year course.
have been shown to result in less symptoms, severity, and complications of both
asthma and allergies over time. Additionally, successful SCIT leads to less
need for medication and less need for medical attention.
medications for allergies and asthma are very effective in treating the
symptoms and preventing asthma flares. However, they do not alter the
underlying cause of asthma. When the medicines are stopped, allergy and asthma
This is one of
the key differences between immunotherapy and other treatments. By
fundamentally changing the immune process to underlying allergies and asthma,
immunotherapy can change the disease process. After 3-5 years of immunotherapy,
many patients are able to stop allergy shots and their symptoms remain
controlled without more medication.
children, allergy shots may also prevent the development of new allergies and
asthma. One study by DeRoches, et al showed that children on SCIT were much
less likely to develop new allergies after 3 years. The Prevention of Asthma by
Immunotherapy (PAT) study also showed that immunotherapy can prevent the
development of asthma in allergic, at-risk children. Children receiving
immunotherapy were 48% and 60% less likely to have developed asthma at 3 and 5
years respectively than the children who did not receive SCIT.
By its nature,
immunotherapy carries with it the risk of allergic reactions. While most
reactions are localized with some swelling, itching and pain, more severe
allergic reactions can occur. Immunotherapy, therefore, should always be
administered in a doctor’s office and patients should be monitored for 30
minutes after all injections. Fortunately, these reactions are rare and Allergy
Partners strives to ensure the safety of all patients.
Learn more about
immunotherapy by contacting your trusted Allergy Partners Allergist.
Welcome to our blog site! Stay tuned to get the latest news. We
will share tips and techniques for living with and managing your Allergies &
Asthma. We look forward to sharing useful resources with our patients!