Lessons Learned in 35 Years of Experience George F. Kroker MD FACAAI

Lessons Learned in 35 Years of Experience

George F. Kroker MD FACAAI

Copyright 2015 Allergy Associates of La Crosse

On Experience…

Experience: that most brutal of teachers. But you learn, my God do you learn…C.S. Lewis

Experience is the best teacher, but the tuition is high…Old Norwegian Proverb

Experience is simply the name we give our mistakes…Oscar Wilde


David Morris M.D.


General Tips


“It’s not about the car, …it’s about the driver” SLIT is one technique for treatment Use of SLIT does not compensate for a

lack of addressing the Total Allergy Load in a patient

Corollary: SLIT doesn’t make you a good allergist, it allows you to be a better allergist


The Clinical History

“The best diagnostic tool an allergist can wield is not the skin test needle between his fingers, but the grey matter between his ears…never forget that the single best allergy test is a thorough clinical history taken by an experienced allergist…”


The Clinical History Take the history yourself, and learn to ask

questions other doctors don’t ask! Find out what the patient’s chief goal is,

not just their “chief complaint” Take the history before reviewing outside

lab data..be unbiased! Read “How Doctor’s Think” by Jerome

Groopman


The Clinical History--learn to ask questions other doctors don’t…one example Have you taken a trip and if so, noticed

a change in how you felt?Example: the woman who traveled to

ThailandExample: the woman with rhinitis, s/p

colonoscopyExample: the man who went Elk Hunting


Approaching the established patient who’s relapsed

Review chart and find a spot where they were doing well—review what they were doing at that time

Possible causes:Poor complianceNew/ Higher allergy load at work or home New medication reactionNew medical conditionMore stress


“Stress” can profoundly affect the allergic condition A stressful period in life may herald the

onset of allergic diseaseExample: woman observing death of 2 sons

and then developing asthmaExample: woman with urticaria developing

the day of a funeral, and continuing yrs after

May be helpful for a patient to understand “why their allergy started now”.


Stress & Response to SLIT

“Psychological stress affects response to sublingual immunotherapy in asthmatic children allergic to dust mites” Ippoliti F., et. Al. Pediatr Allergy Immmunol

Vol 17(5):337-45, 2006



40 dust-mite sensitive asthmatics were treated with SLIT

Divided after 6 months into 2 groups (low & high stress) based on results of stress integrated measure (SIM)

Asthmatic symptom score, PEF and ECP showed greater improvement in non-stressed patients



Authors conclusions:“Our findings show that psychological stress

can affect response to SLIT Rx in allergic subjects and are consistent with data recently reported showing a correlation between stress and poor response to antimicrobial vaccines. Our data also suggest that stress evaluation may become a useful prognostic factor in immunotherapy.”


“Stress” can significantly affect response to SLIT and relapse risk going off SLIT Clinically, highly stressed patients may

take longer to respond to SLIT than the typical patient

Be cautious about discontinuing SLIT in a highly stressed patient—even if they are doing well. They are at an increased risk of relapse going off of treatment


In the new patient who failed a course of SCIT, consider the following: Technical failure of treatment (i.e., all

antigens found, but not treated well, lack of compliance, etc.) esp dust or mold

Failure due to lack of addressing another hidden allergen (i.e., all allergens not found)

Failure due to overwhelming allergic load


The patient unresponsive to your SLIT treatment:

Technical failure: “treating the right allergens, but doses insufficient” or compliance issue

Diagnostic failure: other allergens undiscovered and unaddressed

Failure due to overwhelming allergic load


The “Total Allergy Load” is your friend


Use metaphors to help patients understand the role of SLIT andThe Total Allergy Load

“Teeter-totter” metaphor “Physical Therapy” metaphor “Overloaded boat” metaphor The “child with the building blocks”

metaphor


Remember the Teeter-Totter

Tolerance Allergic Load

The Untreated Patient

Lower Allergic Load

SLIT


The “Physical Therapy” Metaphor

Having a musculoskeletal sprain is like having a “sprained” immune system

Treatment of the sprain and allergy is very similarRest (“reduce allergy load”)Antiinflammatory meds in both casesPhysical therapy (SLIT)


The “Overloaded Boat” Metaphor

“Throw cargo overboard” (allergens you can do without)

“Get boat to dry dock” (safe environ)

Fix the hole(s) (SLIT)


The “Child with the Building Blocks” Metaphor

AllergicThreshold

For my “sometimes” patients


Prior sites of trauma can be “target organs” for reactions: SLIT can help Patient with herpes zoster & corn allergy Patient with ear trauma & wheat allergy The patient stung by a jellyfish who had

a drug reaction The former football player who had knee

pain in the fall allergy season


A new and strange symptom in an established allergy patient is a drug reaction until proven otherwise

Patients with a new symptom unlike their “usual rxns” may be having a drug rxnExample: pt with chlortrimeton-diarrheaExample: pt hosp with asthma, eosinophiliaExample: pt with chronic cough from fosamax

Corollary: Any pt can react to any medicine at any time with any symptom


Inhalant AllergyTips


Skin test Remember the skin test is a “surrogate

marker” for reaction in other parts of the body

Some patients (allergic conjunctivitis) may have minimal skin test reactivity but still react in the eyes


Skin testing Remember skin test sites have a

“memory” (resident T memory cells) An allergenic exposure may trigger a

reaction at prior skin test sites Most often caused by molds Example: A boy who mows the lawn


Skin testing An unexpected increase in a skin test

reaction to a pollen is often because of a coexisting cross-reactive food ingested

Especially common with birch and ragweed patients

If patient had a recent skin test to a pollen, ingestion of the fruit may cause the skin to itch at the test site


Food AllergyTips


SLIT for inhalants helps cross reacting food allergens

Treating a tree allergic patient can help them tolerate fruits causing OAS

Usually requires pre-seasonal dosing coupled with increasing threshold dosing of offending pollen


A “fixed eruption site” triggered by foods can be helped with SLIT

Patients may have a unique site sensitized by contact that is subsequently triggered with foods and sometimes inhalantsExample: pharmacist with PCN & corn

allergyExample: patient with cosmetic reaction &

milk allergy


A mold sensitive patient is also allergic to food yeast and Candida until proven otherwise

Airborne molds

FoodYeast

CandidaAlbicans


Pearls for Candida Related Illness

Candida Related Illness= high colonization + high sensitivity

Best diagnostic test is observing skin test for inappropriate immediate & late rxns

Treatment should always include SLIT Antifungal medication “dependency” can

usually be helped with SLIT for Candida


Pearls for Candida Related Illness

Candida patient may have trouble tolerating mold SLIT Rx until Candida reduced in body

Mold and Candida often give same symptoms

Heavy mold exposure makes pt more reactive to Candida

Heavy Candida exposure makes pt more reactive to mold


Modify treatment with acute viral gastroenteritis

Patient at short-term risk of reacting more to prior food allergens

Advise temporarily resuming hypoallergenic diet & reducing SLIT to once dailyExample: patient with food poisoningExample: wheat allergic patient with GI flu


The inhalant allergy patient with “GERD” has a food sensitivity until proven otherwise

Food allergy may aggravate “GERD” Dairy and gluten most common culprits Often these patients have not

responded to traditional anti-GERD rx


The allergy patient with “treatment resistant GERD” may have eosinophilic esophagitis Food allergy may aggravate both

“GERD” and eosinophilic esophagitis Remember that eosinophilic esophagitis

may be triggered by inhalants—”seasonal esophagitis” Example: Boy mowing lawn with GERDExample: Woman with acute attack in

summer


Treatment Tips


Treatment Observations

In the multi-sensitized patient with active allergy symptoms and a high Total Load, start with the optimized threshold dose and consider a “mini-buildup”:1 pump /d x 1 week2 pumps/d x 1 week3 pumps/d thereafter


Treatment Observations (cont)

The motto is “Go Slow” when you begin SLIT Rx for molds in a patient with mold overload in their home

Higher incidence of side effects Pre-treatment with antifungal

medications in the above situation may help patient better tolerate SLIT


Treatment Observations (cont) SLIT Rx may help a patient with a

physical urticaria to have improved tolerance to cold, heat, or pressure

Lowering the total allergy load has the same positive effectExample: “the baseball player”Example: “the wildlife and fishery worker”


Treatment Observations (cont)

If a patient has side effects from inhalant and food treatment bottles, and the side effects are identical, they are glycerin sensitive until proven otherwise

Corollary: be careful about using glycerin containing extracts in a patient highly sensitive to multiple soaps, shampoos, creams, etc.


Preseasonal Treatment

Preseasonal treatment poses less risk of side effects when used in a mono- rather than multi-sensitized patient

Be careful with multi-sensitized patients—consider #3 instead of #2 dil

Example: Patients “primed” with Alternaria may have trouble handling preseasonal grass treatment


Tip #1: Restated“The best diagnostic tool an allergist can wield is not the skin test needle between his fingers, but the grey matter between his ears…never forget that the single best allergy test is a thorough clinical history taken by an experienced allergist…”

“The best therapeutic tool an allergist can wield is LCM SLIT given in an appropriate protocol by an experienced allergist”


Thank you

Next: Wrap up Q & A

Mary Morris MD and George Kroker MD

Documents

Lessons Learned in 35 Years of Experience George F. Kroker MD FACAAI