Allergy

by Harissios Vliagoftis, MD

Allergic diseases affect more than 1 of every 4 individuals in Canada. The most common condition is allergic rhinitis or hay fever. Asthma, food allergies and skin allergies including hives and various rashes are also very common diseases that have a large impact on the quality of life of sufferers. Drug allergies may be less common but are quite serious conditions that can limit the ability to treat patients with the appropriate medications.

People have the tendency to call “allergy” every reaction that they associate with environmental exposures or exposures to foods and drugs as well as many other conditions of unknown etiology that mystify them and their doctors. The definition of allergy however is very specific. Certain people that have a predisposition to develop allergies react to environmental exposures, to foods or to drugs with production of IgE antibodies. IgE molecules are produced by cells of our immune system, circulate in our blood and reach peripheral tissues where they bind to cells called “mast cells”. When this individual later inhales the same protein or eats the same food or takes the same drug, these “allergens” (pollens, animal dander, foods, drugs) bind to the IgE that is found on mast cells and activate mast cells to release substances that cause symptoms of allergies. The most common and one of the most potent of these substances is histamine. Histamine is responsible for many of the symptoms we develop with allergic reactions and that is the reason that antihistamines are very useful as treatment of allergic diseases.

If you suspect you have an allergy a visit to your doctor can help. Your doctor can take a detailed history and do an appropriate physical exam. If allergy is a concern your doctor may also obtain certain tests to identify the specific exposure responsible for your symptoms or he may refer you to an allergist. Your doctor may also refer you to a respirologist if your main problem is respiratory allergies or a dermatologist if you suffer primarily from skin allergies.

Effective drugs to fight allergies exist and your doctor can prescribe them. The most commonly used drugs are antihistamines and those you can buy without a doctor’s prescription. Your family doctor but also your pharmacist can help you identify one that will work for your symptoms.

Food allergies are a large problem in our communities. However, we should keep in mind that the majority of reactions that develop soon after we ingest certain foods are not food allergy. Because we come in contact with foods multiple times a day, it is easy to associate any reaction we develop with food consumption. Many reactions to food can be the result of toxic substances in the foods. However, the majority of reactions are the result of “intolerance” to foods and although these reactions are very irritating they are less dangerous than true allergic reactions. If you suspect you have food allergies talk to your doctor and, if needed, get a referral for an allergist.

Naturopaths and other non-medical health care providers in many instances favor tests that are unproven and generally not helpful for diagnosis of allergies. Discuss your concerns with your family doctor before seeing an alternative practitioner and before you spend money on these unproven tests.

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Alpha – 1 Antitrypsin Deficiency

By Dr. Irvin Mayers, MD

Approximately 8% of Canadian adults have clinically significant chronic obstructive pulmonary disease (COPD). The most common cause of COPD in Canadians is long-term cigarette smoking. There are other less common causes and one of these is a deficiency of a normal blood protein that protects the lung against permanent injury from smoke and other infections. This protein deficiency known as alpha-1 antitrypsin deficiency can result in severe COPD occurring at a younger age than is typical for COPD. There are estimated to be about 6,000 people in Canada with alpha-1 antitrypsin deficiency but the majority of people remain undiagnosed.

Diagnosis of alpha-1 antitrypsin deficiency can be made by a simple blood test or by genetic analysis. It should be very strongly considered in:

1. COPD in young adults (before the age of 45 y)

2. COPD without typical risk factors, such as cigarette smoking or work exposure.

3. Family history of COPD or emphysema at a young age.

This disorder should be considered in anyone already diagnosed with COPD or with severe, difficult to treat asthma. Treatment for COPD due to alpha-1 antitrypsin deficiency is similar to the usual treatment for COPD. Inhalers to improve lung function along with influenza immunization are standard treatments. In addition, it is imperative that patients stop smoking. The difference in life span for smokers compared with those who quit can be more than 10 years. There is an option for alpha-1 antitrypsin replacement therapy. This is given as an intravenous treatment every one to weeks and is continued indefinitely. In the setting where the patient has quit smoking this treatment can prevent the further loss of lung function. It is important to start this form of treatment early in the disease since once lung function is lost it cannot be recovered.

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Severe Asthma

By Dr. Irvin Mayers, MD

Asthma in general affects about 10% of Canadian adults. Approximately 10% of adults with asthma have severe asthma.  Understanding how to treat severe asthma has improved greatly over the last five years. Our clinic has now joined a cross-Canadian effort at further improving the care of patients with severe asthma.

All patients with asthma need careful assessment to make a clear diagnosis. This should always include measuring breathing capacity (Pulmonary Function Testing) in addition to a thorough history and physical examination. Once a diagnosis of asthma is firmly made, treatment can be started. For most adults treatment of asthma will require the use of a class of drugs known as inhaled corticosteroids (ICS). These drugs have been available in Canada since the 1970’s and they revolutionized the treatment of asthma. If symptoms of asthma are not controlled on low doses of ICS, then usually additional drugs are added and the dose of ICS increased. Severe asthma is diagnosed for those people who are still having significant symptoms of asthma despite being on high dose ICS therapy. Patients with severe asthma in our clinic are then re-evaluated for possible causes.

  1. Cigarettes: Inhaling tobacco smoke inactivates ICS therapy. Treatment is focused on helping with quitting smoking and then asthma control is re-evaluated.
  2. Chronic sinus inflammation or infection: Treating sinus inflammation separately can help reduce the severity of asthma.
  3. Heartburn: Uncontrolled stomach acids flow back into the esophagus can worsen asthma control.
  4. Pets: If people are allergic to their pets, medication alone is often not enough. The most common problem pets are cats.

There are other specialized tests we can do to help better understand the causes of severe asthma to then help focus treatment better. We can look for ongoing evidence of airway inflammation using an Induced Sputum test. This test allows sampling of phlegm from deep in the airways to sort out the specific type of inflammation that is causing symptoms. A simpler test we can also perform is known as Exhaled Nitric Oxide and measures for inflammation in the exhaled air from a patient. There are additional ways of helping define the problem to find a solution.

There are new drugs used to treat severe asthma with many more under development. The newest drug is called omiluzimab (Xolair). This drugs blocks one of the antibodies responsible for developing some of the allergic symptoms in severe asthma. It is given as an injection every 2 to 4 weeks. Our clinic currently follows over 40 patients on this type of treatment.

There are many reasons why one person has mild asthma while another person has severe asthma. Understanding the underlying causes of the disease that are unique to each person helps to personalize treatment to get the best outcomes possible.

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MOLDS AND YOUR HEALTH

by Harissios Vliagoftis, MD

Molds are ubiquitous organisms found in both outdoor and indoor environments. Molds belong to the fungal family along with other organisms such as mildews, mushrooms, rusts, smuts, truffles, and yeast. Molds are generally beneficial in the outside environment, but overgrowth can cause various problems to humans that vary from allergies, to immune and toxic reactions.

The most common health effect of molds in humans is allergic rhinitis, a condition characterized by runny or stuffy nose, sneezing and itching of the nose. Positive skin tests to certain molds may indicate that they are the cause of these symptoms. Effective medications are available for allergic rhinitis; these are mostly nasal corticosteroid sprays and antihistamines. In Edmonton, molds are common in early spring as soon as snow melts. We call it snow mold, and it is a mixture of a variety of molds including alternaria and cladosporium species. The same molds can also cause asthma exacerbations in patients with allergic asthma.

It is likely that exposure to damp indoor environments with high mold levels can induce nasal and throat symptoms, wheeze and/or cough and increased symptoms in people who suffer from asthma. However, there is no sufficient evidence to indicate that these environments lead to the development of asthma or emphysema or development of respiratory symptoms in normal individuals. Unfortunately, there are no reliable laboratory tests to positively identify molds as the cause for any health problems. Any positive test indicates previous exposure to the mold, but there is no way to tell how recent this exposure has been and if the mold is associated with any current problems.

One kind of mold that has generated a lot of concern over the last few years has been black molds, or stachybotrys species. These molds release toxic products that can cause severe problems if inhaled in high doses. There are no reliable tests to evaluate exposure of individuals to toxins of black mold. Presence of antibodies against these molds indicates that the individual came in contact at some point in the past and does not correlate with presence of disease. The only reliable test at this time is a good clinical history taken by a physician.

Unfortunately, a number of alternative practitioners promote ideas that are untested and not based on credible literature and may be more harmful than helpful. If you feel that you have symptoms because of exposure to moldy environments talk to your family physician. If he/she cannot answer all your questions, ask for a referral to an allergist or if you are suspecting your work environment, a referral to an occupational medicine doctor.

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