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Author: Stephen J. Klemawesch, MD

Gut microbiome and good immune function

Gut microbiome and good immune function

 

Previous issues of this newsletter have contained articles about the importance of the gut microbiome and human health in general and more specifically in good immune function.  In this regard the use (and overuse) of antibiotics has come under intense scrutiny.  This includes therapeutic antibiotics and those used in our food production.  The premise here is that the antibiotics kill off some of our healthy microbiome and can lead to an overgrowth of “undesirables”.

 

A recent article published in “Nature” details research on the impact of non-antibiotic medications on the healthy microbiome.  The investigators screened over 1,000 different medicines and found that 24% of them alter the healthy microbiome.  The drugs that seemed to be the worst were antipsychotics and other psychoactive drugs, proton pump inhibitors, anti-cancer drugs and hormones.

 

What is a bit unsettling, is that this same research group has found preliminary evidence that an altered microbiome can promote some psychiatric and neurological diseases.  So, the concern is that maybe the treatment that is supposed to help the condition might also contribute to it.

 

The researchers say more studies are needed to clarify these issues.

Dear Dr. K.; My ophthalmologist recently diagnosed me with dry eye syndrome. Is that being caused by my allergy?

Dear Dr. K.; My ophthalmologist recently diagnosed me with dry eye syndrome. Is that being caused by my allergy?

The answer is no, yes, or maybe so.  I’m not trying to be obtuse, but the answer is different for different people.

 

Let’s start with the dry eye syndrome.  It is very common and affects millions of Americans.  Also, it can vary in severity from a mild nuisance to a vision altering severe condition.  The common denominator for all people with dry eye syndrome, is compromised ocular lubrication.  But, the condition has many causes which can overlap and interact.

 

Our tears are made by two different tear glands:  the lacrimal glands which make the salt water component and the meibomian glands which make the oil component.  Dry eye syndrome can be due to inadequate oil production.  This imbalance can actually be worsened when the lacrimal glands over-produce the salt water which ends up diluting the oil further.  And paradoxically someone with dry eyes might be “tearful”.

 

Dry eye syndrome can also be due to inadequate lacrimal output.  The most common cause for this is certain rheumatologic syndromes especially Sjogren’s Syndrome.  But lacrimal deficiency can also occur due to aging, contact lenses, and the drying effect of certain medications such as antihistamines.

 

Allergic individuals may not have ocular allergy until they develop dry eye syndrome, which leads to a paucity of tears and therefore impedes the natural removal process of allergens from the eye.  Then if they take antihistamines to help their allergies they can worsen the drying of the eyes.  Other medicines that can contribute to dry eyes include: diuretics, beta – blockers, some antidepressants, birth control pills and some herbal supplements, especially echinacea.

 

Finally, people who have a reduced blink rate (most commonly seen in Parkinson’s disease) don’t renew the protective tear film on the eyes and experience dry eye issues.

Shocking News

Shocking News

The immune system was once considered an independent, self-regulated system.  But research over the past ten years has found that like most of the rest of the human body, it too is under the control of our nervous system.

 

Some of the early research in this regard was designed to understand why we seem more prone to get sick if we are under stress or depressed.  As it turns out the brain does have significant control over certain aspects of the immune system.  The brain uses the autonomic (also called automatic) nervous system to exert this influence.  One of the main autonomic nerves is the vagus.  Japanese scientists at Osaka University have discovered that using mild electrostimulation of the vagus nerve reduces immune mediated inflammation.  Preliminary studies in rheumatoid arthritis and Crohn’s disease have shown improvement in both diseases with this therapy.  Studies are also underway to determine benefit in reducing the inflammation that causes asthma.

 

One reason this research is so exciting is that unlike most anti-inflammatory drugs in current use, electrostimulation does not cause immune suppression and therefore avoids the increased risk of infection due to drug therapy.

Monoclonal Antibodies for Migraine

Monoclonal Antibodies for Migraine

The FDA has recently approved Aimovig (Erenumab) a once-a-month injection to prevent migraines.  Aimovig is a monoclonal antibody that targets the calcitonin gene-related peptide receptor (CGRP).  CGRP is a neurotransmitter that dilates blood vessels and stimulates pain.  It was discovered that levels of CGRP go way up in people experiencing migraines.  By blocking the receptor for CGRP the Aimovig is able to prevent headaches.

 

Since Aimovig is a preventative agent, it is currently only recommended for patients with frequent severe migraines or with chronic migraines.  The cost of each injection is $600.00.

Q – Tips: asthma

Q – Tips: asthma

A recent study in Europe was done on people with mild-persistent asthma.  The study compared daily use of a combination inhaler with long lasting bronchodilator and steroid versus just using the inhaler when the asthma started to flare up.  The rate of severe exacerbation of the asthma requiring either an ER visit or treatment with oral steroids was the same in both groups.

Q – Tips: Auvi Q

Q – Tips: Auvi Q

Auvi–Q, a form of adrenaline auto injector has recently come out with a lower dose injector for emergency treatment of anaphylaxis in children weighing less than 33 pounds.  It contains .1 mg of epinephrine and has a shorter needle (to avoid hitting the bone when injected).  Previous to this the only other available doses were .15 mg for people 30 to 60 pounds and .30 mg for people over 60 pounds.

Bronchodilators evolve better and safer

Bronchodilators evolve better and safer

Dear Dr. K:  I recently heard that the “black-box” warnings on LABAs (long-lasting bronchodilators) has been removed.  Is that true, and are LABAs safe?

These are two great questions.  The answer to both is “yes”.  It’s best, however, that we explain a few things.  The two most common of these bronchodilators are Formoterol and Salmeterol.  They are basically long-acting forms of Albuterol.  When they first became available about 20 years ago they could be used as a single agent to treat asthma.  It soon became apparent this was not a good idea in moderate-to-severe asthmatics because they don’t treat the underlying inflammation that causes the asthma in the first place.

Until this was understood there were some asthmatics who were hospitalized or even died because of severe exacerbation of their asthma.  This led the FDA to do two things:  No. 1. To require the black-box labeling, and No. 2. To issue specific guidelines never to use LABAs by themselves, but only in combination with an inhaled steroid.

Once these guidelines were instituted, a number of academic studies have shown that these medications not only help control moderate and severe asthma, but also reduce hospitalizations and mortality.

It is for this reason that the FDA decided to do what is rarely done, and that is to remove the black-box warning.  Their rationale for doing so is to eliminate patients’ fear of taking a medicine that could truly help (and not harm) them.

An allergy shot for Alzheimer’s? In the pipeline. . .

An allergy shot for Alzheimer’s? In the pipeline. . .

By:  Sasha Klemawesch, RN, MD

Well…sort of.  Alzheimer’s has been and continues to be one of the most frustrating diseases for researchers, patients, and caregivers alike.  But there may be hope on the horizon.

A new immune therapy called Aducanumab – an antibody against B-Amyloid – is undergoing human testing right now.  B-Amyloid leads to plaque creation and deposition in the brain, and those plaques, along with neurofibrillary tangles  caused by the Tau protein, are the two key pathologic findings in the neuro-degeneration seen in Alzheimer’s.

The early data is promising; the drug has shown to significantly decrease plaque burden in the recipients’ brains, and many of those same patients showed delay in cognitive decline based on a simple mental status test.  However, they did not have similar clinical improvements in cognition scores on more complex/comprehensive testing.  It is also not known whether this drug may be able  to prevent high-risk populations from developing the disease in the first place.

Obviously, more testing needs to be done, but this drug has been hailed by many Alzheimer’s researchers as “very exciting”  and overall, the best news we’ve had in 25 years of Alzheimer’s clinical research.

In the meantime, there are a few basic things you can do that have already been proven to help decrease your risk for dementia:

Exercise: Staying active helps in several ways; angiogenesis neurogenesis, and synaptogenesis.  In lay terms, exercise improves blood flow (and therefore oxygen) to and in the brain, helps prevent brain cell loss and improves the connection between brain cells.

Sleep:  The B-Amyloid we just talked about?  The body normally clears it out while you sleep, and studies have shown that even one night of sleep deprivation can lead to an increase in that protein.

Wear a helmet:  sustaining certain types of traumatic brain injuries may increase the risk for developing Alzheimer’s and other forms of dementia.

Eat right:  heart healthy diets like the DASH or Mediterranean diets are good, not only for your heart, but evidence has shown they can protect the brain as well.

Don’t worry, be happy:  multiple studies have shown that older adults who are depressed are more than 50% more likely to develop dementia.

Eczema med Dupixent may also offer major benefits to asthmatics

Eczema med Dupixent may also offer major benefits to asthmatics

In a previous newsletter we discussed the new biologic drug Dupixent (Dupilumab) as a true “Godsend” for severe eczema.  By way of reminder, it is a monoclonal antibody that blocks the interleukin-4 receptor, and thereby prevents the inflammation that causes eczema.  This medicine has proven to be both safe and effective, and the injections can be done at home.

Because interleukin-4 also plays a big role in asthmatic inflammation, researchers at Washington University have studied its benefits in severe steroid-dependent asthmatics.  Their study showed it to be both safe and effective for this disease also.

Dupixent use saw a 70% decrease in need for systemic steroids, and 59% fewer asthmatic attacks.

If other scientists confirm these finding it might allow the FDA to approve Dupixent for asthma therapy.  At present the monoclonal antibodies for severe asthma (Xolair, Fasenra, Cinqair and Nucala) work very well, but must be administered in a doctor’s office.  Dupixent may offer an at-home alternative.

Summer means lots of swimming fun, but remember to stay alert and aware

Summer means lots of swimming fun, but remember to stay alert and aware

Bathing in warm sulfur spring water has been touted for its potential health benefits, but some susceptible individuals – especially allergic people who may tend to have dry skin or eczema – may turn up with a severe skin rash from exposure to this water.

Typically, the rash appears suddenly about 24 hours after the water exposure.  The rash is red with a look of “punched out” ulcers and pits.  It is caused by the acidic nature of the hydrogen sulfide, sulfate and sulfur that are in the water.

Many of the aquifers here in Florida are rich in these natural sulfur compounds.

Care also needs to be taken if area health authorities post warnings of bacteria risks if warm, shallow lake water gets inhaled.

Just be cautious and enjoy those summer splashes!