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Author: Stephen J. Klemawesch, MD

New drug goes after major cause of asthma — eosinophils

New drug goes after major cause of asthma — eosinophils

Maybe you’ve seen the ads on TV lately for Fasenra, also known as Benralizumab, a new monoclonal antibody to help treat asthma. Fasenra blocks the proliferation of asthma-causing bad guys called eosinophils. The decreasing of these white blood cells helps prevent asthmatic inflammation.

The new Fasenra antibody is “selective for interleukin-5 (IL-5),” counteracting this chemical mediator that causes the proliferation of eosinophils — the major cause of asthma.

It is indicated for severe asthmatics 12 years old or older. Clinical trials have resulted in marked improvement in asthma control and in reduction of asthma exacerbations. It is administered as an injection in the arm, thigh or abdomen, and is given every four weeks for the first three doses; then every eight weeks.

Two other monoclonal drugs that also target IL-5 are Nucala and Cinqair. Nucala is also given by injection but every four weeks. Cinqair is given intravenously every four weeks. No head-to-head trials have been conducted comparing these three medicines. Nucala and Cinqair are given more often than Fasenra, but Fasenra is twice as expensive, so all three cost about the same.

Causes clearer for this eczema than relief

Causes clearer for this eczema than relief

Dyshidrotic eczema is a common condition that is still poorly understood. In fact, there is as much confusion with its name(s) as with its etiology.

The condition is a type of eczema that is characterized by pruritic vesicles (itchy, tiny blisters) that erupt in the fingers, palms and sometimes feet. It affects both children and adults, and can range from a rare, self-limiting problem to a chronic, severe and sometimes debilitating one.

Unfortunately, it also tends to be resistant to many forms of treatment.

The term dyshidrotic refers to the hypothesis that sweat glands dysfunction and cause the tiny blisters. But when a research group did biopsies of the palms of affected patients they did not find a problem with the sweat glands. Yet, it is known that people with hyperhidrosis (super-sweaters) are very prone to the condition. Also, Botox injections which help people with hyperhidrosis in their arm pits also help hand/foot eczema if the Botox is administered there.

Two other names for the condition: pompholyx (which means “bubble”), or pedpompholyx (if the rash appears only on the feet); and also, acute and recurrent vesicular hand and foot dermatitis.

The tiny blisters itch intensely, then pop and cause the skin to peel. Over time the skin can become thickened and fissured. About 50% of persons with this condition also have allergic problems. Also shown is a strong familial tendency for the condition.

Certain metals if ingested can cause the problem; most common are nickel and cobalt. Websites can detail the metal content of various foods and beverages.

Emotional stress is a well-recognized aggravator of the misery, but episodes also can be precipitated by environmental factors such as changes in temperature and humidity.

Although resistant to therapies, most people benefit by intensive efforts to moisturize the hands. A simple therapy that often works is Vaseline petroleum jelly applied to the hands, and then covered with white cotton gloves at night.

A variety of OTC and prescription steroid creams, lotions and ointments are effective to speed healing.

Finally, soaking the hands in cool water for 10-15 minutes stops the itch and can re-hydrate the skin.

Diabetes med Metformin quite a multi-tasker

Diabetes med Metformin quite a multi-tasker

Dear Dr. Sasha K: I read that the Metformin I take for my Type II diabetes has an anti-cancer benefit. Is this true?

In a word: yes. Metformin is an old drug that keeps making itself new. Metformin’s origins go back to medieval Europe where the French lilac plant was used to treat diabetes. The lilac contains biguanide, the main component of Metformin.

This drug works for diabetes by reducing the amount of glucose the liver makes by decreasing the amount of glucose the intestines absorb, and by enhancing patients’ sensitivity to their own insulin.

In addition to its anti-diabetic effects, Metformin is good for the cardiovascular system – lowering blood pressure and lipids, and lessening atherosclerosis. Some research centers are using Metformin in nondiabetics for these cardiovascular benefits.

Another application is in polycystic ovarian syndrome (PCOS). This condition is a problem for many women because it causes infertility, a tendency to diabetes and hirsutism (excess hair growth) and acne. Metformin has helped many young women obtain a desired pregnancy, while also helping them lose weight and reduce unwanted hair growth and acne.

Metformin has been found to play a role in the coagulation system; lessening unwanted clotting and improving the endothelium (the inner lining) of blood vessels so plaque does not accumulate as fast. In the brain Metformin can help the insulin resistance of brain cells in patients with Alzheimer’s. It also decreases oxidative stresses on brain cells and therefore, may have value in ALS, Parkinson’s and some cancers.

Finally, to answer your question, it’s Metformin’s potential as an anti-cancer therapy that has researchers most excited. It seems that this is because of its anti-inflammatory and anti-oxidant roles. For instance, Metformin has been shown to cause cancer cells to self-destruct. Of course, much further research is needed.

Pharma companies give free meds for school adrenalin emergencies

Pharma companies give free meds for school adrenalin emergencies

The two pharmaceutical companies that produce the two available forms of auto-injector adrenalin to deal with anaphylactic (allergic) shock are offering a program of free epinephrine doses to schools. The companies are Mylan, which makes the EpiPen, and Kaléo, maker of Auvi-Q.

Epinephrine, as many know, must be on hand to treat food allergy and insect sting emergencies.

Even with insurance coverage, these drugs have become very expensive. For some families this expense limits the purchase of the adrenalin to a single unit at home, but not one at school. Through this program, the medication can be placed in a child’s school, but access would be allowed to any student in peril.

Each company will provide both doses of epinephrine – the .15mg and the .30mg.  Mylan offers the medicine to all schools — public or private — and to all grade levels. Kaléo offers it to public grade schools. To request the medications be placed at your child’s school, visit EpiPen’s site at and you’ll find info on the EpiPen4Schools program. For Auvi-Q:

You’ll need to give the name and address of the school and send a physician’s prescription with the request.

Q – Tips: itchy skin

Q – Tips: itchy skin

Dry skin leads to itchy skin. For people experiencing this combination it might be time to switch to a non-drying soap such as one based on shea-butter. And maybe to stop applying soap to the entire skin surface. A safer but still hygienic approach is to use soap in the key areas: armpits, groin, feet, and let water clean the rest.

Q – Tips: Pets in childhood

Q – Tips: Pets in childhood

A recently published German study about pet exposure in childhood has not only confirmed that there is less allergy in children in pet households, but a new finding shows when these children become adults they are less buffeted by life’s stresses, and less likely to develop anxiety or depression.

Q – Tips: Chlortrimeton

Q – Tips: Chlortrimeton

A new application for an old drug has been found. Chlortrimeton (chlorpheniramine maleate), one of the oldest OTC antihistamines still in use, has been found to be very effective in suppressing a chronic “tickle” cough known as hyperactive cough syndrome.

Allergic conjunctivitis — all kinds of misery

Allergic conjunctivitis — all kinds of misery

Dear Dr. K: My brother has vernal conjunctivitis and I have perennial allergic conjunctivitis. We both use the same eye drops but I seem to do a lot better than he does. What gives?

What gives is that you have a less severe condition than your brother. Let me explain. Allergic eye problems fall into four general types: seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), allergic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC).

IgE (the allergic protein), plays a role in all four, but in ARC and VKG T-lymphocytes (the allergic cells) also contribute to the mischief. (Unlike in the familiar “pink eye,” caused by a virus or bacteria and not by allergy.)

SAC is probably the most common and is seen at all ages and equally in males and females. It is caused by seasonal pollens: ragweed in Fall, trees in Spring and grasses in summer. It responds better to eye drops than to oral antihistamines. The eye drops most commonly used are topical antihistamines or mast-cell stabilizers (mast cells release histamine).

PAC is also very common with the same age and gender distribution as SAC. Because it is perennial, it is usually caused by pet dander allergy, but also by dust mite and mold allergy. It responds to the same treatments as SAC.

In both SAC and PAC, the most common symptom is itching, but the eyes also tear, burn and can turn red. The eyelids can swell, but this is usually caused by unrestrained rubbing of the eyes – especially in young children.

Luckily, AKC is an uncommon allergy as it can be quite severe and adversely affect vision. This one is more frequent in males and more common in middle age. Most of these patients have eczema, and the eye symptoms often wax and wane with their skin symptoms. There can also be eczema surrounding the eyes, as well as other body areas. The eyes itch and tear, but also tend to produce a mucus discharge. The inside of the eyelids – more on the lower lids than the uppers – develop little bumps.

Antihistamine and mast-cell stabilizer drops are helpful. In severe cases, steroid eye drops are sometimes used to gain control of the problem but should only be used short-term. Cyclosporine eye drops and tacrolimus ointment to the external lids are also of benefit. Both medicines work on the T-cell part of the inflammation.

VKC (just as AKC) is perennial but can worsen in Spring — hence the name vernal as in vernal equinox. Eyes itch and turn red. This redness tends to be greatest on the white part of the eye right next to the iris. As in AKC, the inside of the eyelids develops bumps, but these tend to be worse on the upper lids. The eyes tear and also produce a ropey mucus discharge. It is most common in males but at a younger age: pre-teen and teen. It is treated the same way as AKC.

… And now the cat story

… And now the cat story

“Spoiler” alert!

Between 5 and 10% of the human population has an allergy to cat. The major cat allergen is a protein called “Fel-D-1,” which is a protein in the cat’s saliva, sebaceous glands and genitourinary tract. Dried skin particles (dander) contain the protein, even though the protein is not part of the coat itself.

Female cats produce less Fel-D-1 than male cats. Light-colored cats make less than dark-colored cats. Long-haired cats give off less allergen into the environment than short-haired kitties because their long fur holds the protein against the skin.

The Fel-D-1 protein is a very tiny molecule which allows it to stay airborne for a very long time, which in turn makes it easy to inhale. The particles are also very sticky, making it easy for them to cling to furniture, carpet, drapes, bedding and walls — so sticky they can “hang around” six-to-eight months after a cat has left the premises. These particles can also be picked up by shoes and clothing and travel home to abodes that have never housed a cat.

Even “hairless” breeds groom themselves, so the protein ends up on their skin. The only allergic advantage of “hairless” cats is they don’t harbor other allergens such as pollen or dust mites. And even after washing cats, the levels of Fel-D-1 are back up to pre-bath levels within 24 hours.

Child in crisis — Epi-Hug more than affection

Child in crisis — Epi-Hug more than affection

Because of the burgeoning of allergic disorders, more and more children are requiring auto- injectors of epinephrine. These devices are used to stop severe allergic reactions or anaphylaxis.

If the device is required it is obviously at a time of crisis for both the child and the parent, which makes it more likely for mis-adventures to occur. Because it is life-critical that the medication be properly administered, it usually requires some form of child restraint.

Thus has evolved the concept of compassionate restraint known as “the epi-hug.”

The best site to administer the epinephrine is the top side of the child’s thigh. So, try to visualize this: one parent should sit and place the child on his or her lap, with the child sitting on one of that parent’s legs, while the parent’s other leg rests on top of the child’s knees, immobilizing the child’s legs.

The parent should use her non-dominant arm around the child’s back to hold and immobilize the child’s free arm. Have the child place his other arm in a “hug” around the back of the parent. The parent’s dominant arm is then free to use the auto-injector on the child’s thigh.

Trying to administer the epinephrine to a non-restrained or “bucking” child has led to countless episodes of partially administered doses, broken needles and even of the parent accidently being injected.

The advice of “practice makes perfect” applies. If you’ve rehearsed the epi-hug with the “trainer” injector before a true need, it will help ensure all goes well.