🎙 Two Docs Talk Allergies & Asthma Part 2 Prevention, Testing, and Treatment Ep 107

Welcome to MedEvidence: Two Docs Talk Allergies and Asthma Part 2, Prevention, Testing and Treatment.  In this episode, Dr. Michael Koren and Dr. Sunil Joshi explore the importance of prevention before treatment and the different testing and treatment options available for pollen allergies. They also cover clinical treatments, such as immunotherapy, and how they can help manage symptoms.

This series is the perfect resource for learning about allergies and asthma. Tune in to gain a deeper understanding of these important healthcare topics.

Listen to the whole series:
Two Docs Talk: Allergies and Asthma Pt 1 - Pollen Season & Symptoms Associated with Pollen Allergies
Two Docs Talk: Allergies and Asthma Pt 2 - Prevention, Testing & Treatment
Two Docs Talk: Allergies and Asthma Pt 3 - The Evil Eosinophils
Two Docs Talk: Allergies and Asthma Pt 4 - Eosinophil Asthma Research & Treatment

Common medications:

• The anti-IL5 products that affect eosinophil survival are mepolizumab (Nucala), benralizumab (Fasenra), reslizumab (Cinqair). 
• The anti-IL4/IL13 product is dupilumab (Dupixent)
• The anti-IgE agent is omalizumab (Xolair)
• The anti-TSLP agent is Tezepelumab. (Teszpire) 

Sunil Joshi, MD, is the President and Managing Partner of Family Allergy Asthma Consultants in Jacksonville, Florida. The Past-President of the Duval County Medical Society (the largest and oldest Medical Society in Florida) and a graduate for the University of Florida College of Medicine. Dr. Joshi received his Allergy/Immunology fellowship training at the University of Rochester in New York.  He truly enjoys treating patients with allergic disorders and believes that education about these disease processes can bring better care to the public.

Michael J. Koren, MD, is a practicing cardiologist and Chief Executive Officer at Jacksonville Center for Clinical Research, which conducts clinical trials at 7 locations in Florida. He received his medical degree cum laude at Harvard Medical School and completed his residency in internal medicine and fellowship in cardiology at New York Hospital/Memorial Sloan-Kettering Cancer Center/Cornell Medical Cent

Be a part of advancing science by participating in clinical research.

Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com

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Music: Storyblocks - Corporate Inspired

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Transcript

Transcript
Two Docs Talk Allergies and Asthma Part 2 Prevention, Testing and Treatment
Recorded Date: April 14, 2023

[Narrator] Welcome to MedEvidence where we help you navigate the truth behind medical research with unbiased, evidence-proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher Dr. Michael Koren.
[Dr. Koren] Hello I'm Dr. Michael Koren, returning for our next episode of MedEvidence, where we discover the Truth Behind the Data. Again, I have the great pleasure of being with my guest Dr. Sunil Joshi who is an allergist-immunologist and who is also a very well-known person in our community because of his work at the Duval County Medical Society and the foundation. We do appreciate that work very much.
[Dr. Joshi] Thank you, thank you!
[Dr. Koren] Terrific stuff! He's involved in organized medicine and also involved in clinical research. For all these reasons we have a great connection and we're having this really fabulous discussion about pollen and allergies. During our last segment, I talked about this “theoretical patient” who turns out to be me! This was somebody that had no problem with allergies as a teenager - in fact, he thought his friends were making up stories about allergies. Then during residency, while attending a graduation in Massachusetts, he developed symptoms for the first time: watery eyes, running nose, facial swelling, and saying “What the heck is going on here?” and not really feeling sick. We're going to start with that. Now, I admitted that this was me, so let's go back to my 26 or 27 year old self and I show up in your office and how do you help me?
[Dr. Joshi] Well, number one: if those symptoms were just a one-time thing we talk about other potential things that triggered it. But if it became a chronic illness for you then of course we're going to start looking into potential causes for your allergy symptoms. The way we do that is through allergy testing. Allergy testing is actually not as difficult as people make it out to be.
[Dr. Koren] It sounds very complicated.
[Dr. Joshi] (laughing) It's something we call skin testing. What we do with the skin testing is we take the allergen. For instance, the things that are outdoors that you may be allergic to - the different tree pollen and the protein that's associated with that tree pollen - comes from an extract company. It’s basically mixed with nothing but salt water.
[Dr. Koren] How many allergens are you testing?
[Dr. Joshi] For trees we have about 14 in Northeast Florida that can cause allergies. They're very prevalent in this area. Keep in mind that the whole Western panhandle of Florida is nothing but trees, it still really isn't developed. A lot of that pollen is coming into the Jacksonville area that's where all the fronts come from and the wind comes that way as well.
[Dr. Koren] We're here in Northeast Florida as we speak; for those listening to us from outside of our area.
[Dr. Joshi] That's right! We do have pollen from a lot of different parts of the country that come down here. So we will test for those, and the way we test is that a little bit of fluid is in a vial with a toothpick, basically. It's what we call technically a Derma pick but it looks like a toothpick. We pull out the toothpick - it has some of that fluid attached to it - and we drop that on the person's forearm. Then we use that same toothpick and scratch the skin with it. We wait for 15 minutes. A positive test is a hive like a mosquito bite and a negative test, nothing happens. That's what we call prick testing for environmental allergies. Very easy! Within 15 minutes we have an answer in terms of whether you're allergic to Oak Tree Pollen or not.
[Dr. Koren] Interesting! Now again, you obviously didn't do the testing on me back then, but given my story what would you anticipate to find?
[Dr. Joshi] Yeah so in Massachusetts at that time of the year, and since that was really kind of an isolated incident, I would expect to see a potential combination of tree pollen and grass pollen. Grass starts to pollinate in the summer so depending on what kind of season they were having you could start to expect to see grass pollinating in that June/July time period. Late May might have had a little crossover there. If it was an outdoor graduation and you're outside in grass pollen, you can expect that as well. I would have expected to see something in that tree/grass realm.
[Dr. Koren] Interesting. Any particular species of trees?
[Dr. Joshi] Up in the Northeast birch tree pollen is a very common one that causes allergies up there. They also have pine trees and oak trees, but Birch is probably the most common.
[Dr. Koren] Does that really matter from a practical standpoint?
[Dr. Joshi]  It matters in the sense of how you treat it. Of course, there are medications to treat allergies, and they can treat all kinds of allergies with antihistamines and topical nasal sprays. But if you were going to do targeted immunotherapy, then we do need to know exactly what you're allergic to because each of those proteins are different. If we're going to get you to the point where you are no longer allergic or significantly less allergic or desensitized, we would need to know if it's a birch tree versus an oak tree versus a pine tree. This is so we get the right tree pollen in there in the mix.
[Dr. Koren] Makes sense. Talk a little bit more about this desensitization process.
[Dr. Joshi] Okay! To be desensitized basically… I think there's a misnomer. People think if you're desensitized, you're no longer allergic to something. That's the ultimate goal; to develop tolerance so that you no longer react to oak trees. The reality is that what we're trying to do is minimize your symptoms, improve your quality of life, and decrease your need for medication. This is so that you can be outside during the spring pollen season and not suffer. First, we’d find out what you're allergic to: it could be your dog or cat or other things in the environment. Then we would start treatment. If you're doing allergy shots, for instance, you'd be introduced to a very small amount of that allergen mixed with salt water. It's very natural, to be honest. It starts off with such a low dose it's almost like you're getting a placebo injection initially. Each time you come in you get a little bit more of what you're allergic to until you get up to a dose that's high enough to turn off your allergies but not so high to cause an allergic reaction. If we do that in weekly increments, in our practice, it takes about 24 to 25 weeks to get up to your top dose. It takes about six months of the year, so there's a little time commitment. Once you get up to your top dose, then you don't come once a week anymore. You ultimately just come once a month for your shot and we leave the dose the same. The goal, of course, is to see how you're doing the NEXT pollen season, and then pollen season after that. It's a five-year course typically. That's not because it takes five years for the patient to feel better; instead, it takes five years for us to get as close to tolerance as possible. Anything more than that doesn't necessarily give you any more chance of tolerance, so we typically stop at five years. At that point, 85 percent of the patients are able to go forward without shots, need less medications, and have less quality of life issues.
[Dr. Koren] For life?
[Dr. Joshi] At least for the next five to ten years. These studies don't go on for too long but we know that for an extended period after stopping shots, they're able to tolerate that environment.
[Dr. Koren] So getting back to our hypothetical patients um how would you treat me?
[Dr. Joshi] In that particular case it was a one-time episode and maybe if it was persistent…
[Dr. Koren] We didn't get the whole history! It did happen periodically after that. Very seasonally and in very specific circumstances. So again, it always seemed to be in May and always during outdoor events that happened to be in bucolic grassy places.
[Dr. Joshi] Okay, got it. So this is someone, in your case you, who's suffering with late spring pollinosis or allergies. In this particular case obviously, we'd give you some information about common sense ways to avoid the allergen: taking showers when you come home, washing your hair, putting on a new pair of clothes, that type of thing. If we were looking at medications (what most of our patients want a prevention strategy) and we know that this is something that's typically going to happen to you in that May/June/July time period, we would want to pre-treat you. We would preempt your symptoms and get you on a preventative plan, in particular with topical nasal steroid spray. Some are available over the counter and some are prescription. They can be used to prevent symptoms before they start. The worst thing people do with allergies is they wait till their symptoms begin. It's much easier for us to prevent symptoms than it is for us to treat symptoms.
[Dr. Koren] It's a great point, a very very important point.
[Dr. Joshi] In all of medicine, right? In cardiology, it’s much better to prevent heart disease and treat heart disease and an allergy is the same thing. Once the proverbial cat is out of the bag (that's an allergy term, cat out of the bag)..
[Dr. Koren] (laughing)
[Dr. Joshi] Right, so once the cat is out of the bag, it's very hard to get it back in. So our goal is always when we're seeing our patients, if this is clearly a seasonal allergy sufferer, we want to get in front of the story. We want to get him controlled so that during the season they have a good quality of life. That's what my plan for you would be: to say “let's do a topical nasal steroid before the season and then have an antihistamine to use as needed kind of as your rescue through that season, and let's see how we do.”
[Dr. Koren] Yeah! I'm going to reiterate that point about early and preventative treatment because it's so important throughout medicine. There's a Chinese proverb from traditional Chinese medicine that states that a weak physician waits until the end stage of the disease before the physician treats the patient, a good physician treats people in the early stages of disease, but the BEST physicians treat people before they have the disease.
[Dr. Joshi] Absolutely, absolutely!
[Dr. Koren] I think that's a really key point. One of the crazy theories I had back then, and I love your comments on this, is that because I never had any problems whatsoever until I was a medical resident, I wondered if there was some exposure that I had during my medical training that led me to develop allergies. In particular, as a medical student or as an intern or resident you got pricked by a needle that was in a patient or got exposed to people with various diseases and you might just wonder if that was what predisposed me to this problem and why I developed it later in life. I’d be curious about your perspective.
[Dr. Joshi] It's a really good question actually and it actually gets down to the Immunology of how we fight off infections or fight off allergies. Actually, what happens a lot to us in in residency or in medical schools is that we get exposed to communicable diseases, right? Viruses, bacterial diseases, things of that sort. What happens is that our immune system develops a reaction to it, just like when you get a vaccine or you get the flu. Your immune system reacts in such a way to protect you and to protect you from the next time you get infected by that. That's what it's supposed to do, so theoretically what would happen is that if you're getting exposed to these viruses or other substances, you should actually be less likely to develop allergies because our immune system as it's developing has a fork in the road. That fork is to go forward into fighting off viruses and to developing that protective part of our immune system, or if they're not seeing viruses - like if our society is too clean and we're not exposed to viruses or parasites - then it doesn't have anything to fight here. In that case, it starts to push more towards the direction in which we fight off things that are ubiquitous in the environment; that are normally there such as dust mites, such as dog allergens, such as oak tree pollen, or even peanut allergen. Now you're starting to develop more allergies to these proteins that you're getting exposed to because you're not getting exposed to the others. The Hygiene Hypothesis states that if you are getting exposed to viruses at certain times in your life then you're less likely to develop allergies. You may have allergy symptoms because your nose runs and your eyes itch and water, but you're pushed away from that allergy phenotype.
[Dr. Koren] Wow, that is fascinating stuff! We're going to really dig into that, but one of the things I want to talk about before we dig into that is defining what an eosinophil is and where that particular cell fits into this whole hypothesis
[Dr. Joshi] The eosinophil through our training here in the United States is considered the allergy cell. Eosinophils actually through most of the world and through evolution fight off parasitic infections, in particular in developing countries. We just don't see parasites here. Eosinophils are produced in the bone marrow. They come out into the bloodstream and then they get into tissue. Here in the westernized world as they get into tissue, they release certain mediators inside of the cells that cause scar tissue to form and also bring other immune cells into the environment. This can either help heal a process or destroy the tissue. It depends on why it's there for it to have its effect. If you fall off your bike and you have scar tissue in your and you're open here (indicates arm) and you need scar tissue to form and the eosinophils come in there at that point that's doing a good thing. It's protecting you. But if it's coming into your lungs after you got exposed to diesel exhaust fumes or cigarette smoke or an allergen and it puts down scar tissue that's a bad thing. It really depends on where they're going and what they're doing in terms of whether they're positive or negative.
[Dr. Koren] Interesting! Eosinophils have this interesting way of bringing different specialists together. Here in our clinical research center, we've done studies in eosinophilic esophagitis. As a cardiologist, I've seen patients that have eosinophilic heart disease. We think that asthma is often driven by eosinophils. All these different organs are affected by eosinophils, so I really want to explore this hypothesis with you in the next segment and also how docs can work together on these things
[Dr. Joshi] Absolutely!
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