All posts by Stephen J. Klemawesch, MD

Perhaps shared therapies can ease double suffering

What’s known as the Asthma-COPD overlap syndrome was reviewed recently in the Allergy and Asthma Proceedings.

The authors adroitly point out that even though physicians try to pigeon-hole diagnoses, many times people’s health problems don’t fit neatly into a single diagnostic category. This is especially true in the spectrum of chronic airway disorders.

More and more people are being seen by physicians who have both asthma and COPD. The conditions are both similar and different.

In general, asthma (also called reversible airways disease — RADS) is completely reversible with therapies, while COPD (chronic obstructive pulmonary disease) is never (by definition) completely reversible; hence, the adjective “chronic.”

Both conditions are caused by inflammation in the airways. In asthma, the inflammatory cell is the eosinophil, while in COPD it is the neutrophil.

Both conditions tend to have genetic links. In asthma it is the genes that cause allergy. In COPD it is the genes that control alpha-1-antitrypsin (an enzyme that protects the lungs from oxidative stresses).

In general, asthma tends to have onset in childhood, whereas COPD occurs in adults.

Asthma is caused primarily by allergy to inhaled pollens, molds, danders and dust mites. COPD is caused primarily by cigarette smoke and biomass pollutants.

Finally, diffusion capacity is normal or high in asthma, but always reduced in COPD. Diffusion capacity is a measurement of the transfer of oxygen from the lungs into the blood stream.

The most important take-home message is that therapies that were previously used exclusively for one diagnosis may work in both because of the overlap. For instance, inhaled steroids which are a mainstay in the treatment of asthma often benefit patients with COPD.

Also, anticholinergics such as Atrovent, Combivent and Spiriva – originally designed exclusively for COPD – may also benefit people with the overlap syndrome. The bottom line is for patients and physicians to be aware of the overlap, and to look for therapies that are individually stylized to a given person’s need.

Dear Doc: Will oral doses replace allergy shots?

Dear Dr. K:

I’ve read about the newly available oral drops for allergy. Could that replace my current allergy shot?

A quick answer for you is “no;” a longer answer to your question is “perhaps in the future.”

The reason I say “no” is that your current allergy shot contains extracts for nine different grasses, including, Bahia; seven different molds, ragweed and three other Florida weeds; plus seven different trees, including oak.

Right now drop therapy is only available for single allergens and these are extremely limited in their spectrum. For instance, the only serum for grass is for Timothy grass. We have Timothy grass in Florida, but it is a minor contributor to our grass pollen burden, as opposed to the Bahia Grass family and Bermuda grass. The only weed extract available is for short ragweed, one type we have in Florida. More prominent, however, are the giant and southern ragweed plants. And so it goes . . .

It has been known for more than 100 years that allergy immunotherapy works best when all the relevant allergens are addressed.

Another issue is cost. At present, the oral therapy is quite expensive and is not being covered by insurance companies. Part of the reason for the expense is that drug therapy must be done daily requiring a lot of allergy serum.

Finally, like any new modality “the bugs need to be worked out.” One “bug” is that up to 50 percent of people taking oral treatments have unpleasant side effects of mouth and tongue itching, along with stomach upset. These side effects are occurring with just one allergen in the serum so when multiple allergens are available, these problems could become greater nuisances.

Technology always seems to improve current standards, so I have no doubt oral therapy will eventually join allergy shot therapy and perhaps replace it, but there is a long way to go.

GI Tract – gut flora’s humble abode


A recent review article in the Journal of Allergy and Clinical Immunology addressed the role of gut microbiota in health and illness.

The author pointed out that the GI tract serves two main functions: 1. Digestion and absorption of foods and nutrients; 2. Immune function. He also pointed out that these don’t operate independently, but rather, are fully intertwined.

The GI tract is the home for the majority of our immune system cells and proteins. This is so because the GI tract is home to billions of microbes that require immune surveillance. Disruptions in these microbes can impact both digestion and immune function.

One example is celiac disease. It is an inherited condition caused by autoimmunity directed against gluten. New research is finding that despite the inherited tendency, many individuals won’t develop the disease if their gut bacteria are normal.

On the other hand, the more disrupted the gut flora, the more likely that the immune system will cause the inflammation that leads to the disease. Sadly, once the disease starts, it leads to greater alteration in the gut flora, which in turn leads to more inflammation – a bad synergism.

Another example is obesity and metabolic syndrome (insulin resistance and high lipids). Two broad observations are relevant: 1. Children who receive multiple courses of antibiotics are more likely to become obese than children who don’t (antibiotics alter gut flora.) 2. Societies whose cows, beef, chickens and pigs receive antibiotics with their food are also more likely to become obese than those who don’t.

In a similar vein, gastric bypass surgery is more effective at both weight loss and improvement in metabolic syndrome than is lap-band surgery. The former leads to a positive improvement in gut flora not seen with lap-banding.

Even more interesting is the fact that in gastric bypass, patients the metabolic syndrome improves even before there is any noticeable weight loss. The bad gut bacteria breakdown fats into more easy-to-absorb particles, hence greater weight gain and higher cholesterol levels.

Finally, in mice experiments: Transfer of healthy gut bacteria from lean mice to obese mice leads to weight reduction in the latter without reduction in caloric content.  

Q – Tips: Exercise as important as medication

  • An editorial in the American Journal of Medicine was titled “Exercise is Just as Important as Your Medication.”

The article was very detailed in extolling the numerous health benefits of exercise, but one comment struck me most of all: The editorialist pointed out that unfortunately, physicians or patients themselves set too high a benchmark for the activities. He recommended an approach that was moderate in nature and stylized for each person’s health constraints and abilities.

Q – Tips: broccoli

  • Broccoli is a natural source of glucoraphanin, a compound that generates sulforaphone. The latter is an excellent mechanism to remove and detoxify air pollution that we breathe into our bodies. Hence it has been shown to reduce cancer risk, especially in heavily polluted industrial environments.

Possible summertime peril: Be aware

Bathing in warm sulfur spring water has been practiced for centuries for its potential health benefits, but a newly recognized cause for a sudden skin rash is exposure to this water. Unfortunately, it can cause a severe rash in some susceptible individuals.

This is especially true in allergic people who may tend to have dry skin or eczema.

Typically the rash appears suddenly about 24 hours after the water exposure. The rash is red with “punched out” ulcers and pits. The rash 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.

Allergy ties to additives studied

The University of Maryland recently published data about increased incidence of allergy in children correlating with the amount of residues of triclosan and paraben found in their urine.

Triclosan is a chemical that has been added to many personal care and medical products, including soap and toothpaste. It is added for its antimicrobial properties. Paraben is added to food, pharmaceuticals and personal care products, also for its antimicrobial properties.

Both have been previously shown to have immune-modulating properties (in addition to their antimicrobial property). In this particular study there was a strong relationship between urinary levels of these chemicals and the development of a variety of allergies: asthma, eczema and food allergy.

The unstated — but implied – recommendation is to limit childhood exposure to these chemicals

Promising asthma drug in pipeline

A research study of a new drug given to steroid-dependent asthmatics has produced exciting results.

Reported in a recent article in The New England Journal of Medicine, the new asthma drug, Mepolizamab, was tested at various medical centers around the globe, including the University of Pittsburgh.

Mepolizamab is a humanized monoclonal antibody that inactivates interleukin– 5. Interleukin– 5 is a cell communicator that recruits eosinophils (allergic cells) into the lungs.

The eosinophil is a form of white blood cell that causes airway inflammation — asthma’s hallmark.

The remarkable outcome of this study revealed the participants enjoying a marked reduction or cessation of steroid medication, while having improvement in their asthma, along with fewer flare-ups.

The drug was administered by injection once a month and was relatively free of side effects. The main ones were headache and sore throat.

The drug has not finished all its clinical trials for FDA approval, but it should soon. For now the only other monoclonal asthma therapy is Xolair, which binds to the allergic antibody IgE.

Dear Doc: Explain sprue/celiac disease immune reactions

Dear Dr. K: My gastroenterologist said that my blood pressure pill, Benicar, caused me to develop sprue. Can this be true?

To answer your question in a broad sense: “Yes;” but in a strict sense, “No.”

To better understand this yes/no scenario a few definitions would be helpful.

Sprue (also known as celiac disease) is a form of GI upset with diarrhea caused by an immune reaction to gluten. The immune reaction leads to inflammation in the intestinal wall, with resultant atrophy of the villi.

The villi are critical for properly digesting food (due to enzymes found on the villi), and for properly absorbing food (due to increasing absorptive surface area).

Benicar (Olmesartan) is one of a family of anti-hypertensives known as angiotensin receptor blockers. It has been implicated in a number of cases of chronic diarrhea, with biopsies that show villous atrophy.

However, unlike in sprue, there is no inflammation and also unlike in sprue, the illness does not improve with avoiding gluten. It does however, improve with going off the Benicar which allows the villi to regrow.

The Mayo Clinic has had a keen interest in this issue, and has even found some patients on Benicar with mild villous atrophy, but no symptoms.

What is reassuring about this research is that treatable conditions are being discovered for a large group of individuals previously labeled with “IBS” (Irritable bowel syndrome). The term syndrome means no known cause, but does not imply a cause can’t be found.

Even tiny whiff enough to trigger allergic reaction

A review of food reactions in children from inhalation was recently published in an issue of Allergy and Asthma Proceedings.

As an introduction, the authors remind readers we are able to smell foods because of tiny aerosolized particles of food. In some children, even this tiny amount of exposure can lead to allergic symptoms.

The foods most commonly implicated in this mischief are: fish, nuts, legumes, grains and cow milk.

Up to 10 percent of children allergic to fish will have some type of allergic response to seafood odors or fumes. Typically, this is eye itching, sneezing or wheezing.

Of interest, shellfish were much less likely to cause inhalation problems than “swimming” fish.

The incidence of airborne nut allergy was smaller with three percent of children with tree nut allergy reacting to the smell, and one percent of peanut-allergic children reacting. (Even though peanut is a legume, it was studied in the nut category because there are so many children with peanut allergy.)

Again, common symptoms seen were eye itch, sneezing and wheezing. But some children suffer hives and even anaphylaxis from nut odor inhalation.

The most common legumes to cause inhalation allergy are soy, chick peas, peanut-like lupines and green beans. The spectrum of symptoms: eye itch, sneezing and wheezing, but also intense itching in the mouth and throat in some children.

The cereal grains most likely to cause problems are rice, buckwheat and wheat. Buckwheat is more common a cause than expected because many children have ongoing exposure from buckwheat chaff being used in stuffed animals.

And while cow milk is a common cause for inhalation allergy, some children are sensitized from powdered formulas being mixed in their presence.

Also, as mentioned in a previous newsletter, some asthma inhalers contain small amounts of milk protein as a stabilizer.