September Newletter

Asthma Action Plans

With the fall season underway, the staff at Baker Allergy, Asthma and Dermatology Center have been preparing our patients for the upcoming school year with regard to asthma and allergy education. As fall is upon us, so is the cold and flu season. If you or your child has a diagnosis of asthma that is triggered by upper respiratory infections it is important to have the tools to detect increase in asthma symptoms (coughing, wheezing, shortness of breath and chest retractions), along with the medications to treat these signs and symptoms.

An asthma action plan can be very helpful with treating patients who have asthma symptoms with upper respiratory infections by temporarily increasing or adding an extra medication for a few weeks to prevent complications. Additional asthma triggers that are often seen with the fall and winter seasons are dust and mold allergies, exercise and cold air exposure. If you feel an asthma action plan would be beneficial for you or your child, please contact us at 503 636-9011.

You can find more information about environmental controls for allergies to dust and mold on our website, http://www.bakeraad.com/ or http://www.AAAAI.org.

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Psoriasis Study

Psoriasis is an autoimmune disease that typically affects the outside of the elbows, knees or scalp, however it may appear on any location. One of the most common forms of psoriasis is called plaque psoriasis. It causes raised, red patches covered with a silvery white layer of dead skin cells. Some people report that psoriasis itches, burns and stings[1].

It is reported that at least 10 percent of the general population inherits one or more of the genes that create a predisposition to psoriasis. However, only 2 percent to 3 percent of this population develops the disease. Researchers believe that for a person to develop psoriasis, the individual must have a combination of the genes that cause psoriasis and be exposed to specific external factors known as "triggers". These triggers can include; stress, injury or trauma to the skin and some types of medications. Psoriasis can also flare following a strep throat infection, earache, bronchitis, tonsillitis or a respiratory infection. Basically, anything that can affect the immune system can affect psoriasis[1].

The severity of psoriasis is not only measured by how much area of the body is affected, but also by how psoriasis affects a person's quality of life. There are a variety of ways to treat psoriasis, including; topical medications, systemic medications, biologic drugs, phototherapy treatment and alternatives therapies[1].

The Baker Research Center is currently offering a study to research a topical medication that has been found to be beneficial in the treatment of psoriasis in adults 18 years or older. If you or someone you know has had psoriasis for over 6 months and would like more information regarding this study please notify Emily Widen or Angie Johnson at 503 534-2622.

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1. National Psoriasis Foundation (n.d.). Retrieved November 26, 2013 from https://www.psoriasis.org/about-psoriasis

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Cat Allergy Study

Allergy to cat dander is one of the most common forms of allergic rhinitis. In the United States alone, over 26 million people suffer from cat allergies[1]. Those with a cat allergy who live with cats may experience many unpleasant symptoms, such as itching, sneezing, nasal congestion, and watery eyes. One of the most effective forms of treatment for cat allergies is specific immunotherapy. Specific immunotherapy for cat allergies provides a long term benefit by boosting the immune system against cat specific proteins.

One of the largest downsides of immunotherapy is the potential risk of allergic reaction or anaphylaxis. The Baker Research Center is participating in a study that looks to overcome this risk by using an alternate formula for immunotherapy. This new study drug improves upon traditional immunotherapy by using molecules significantly smaller than those found in regular immunotherapy. Essentially, they are little fragments of the normal allergen. These fragments, called peptides, are too small to contain multiple allergy antibody binding sites. Thus, only a single allergy antibody can bind them. This prevents cross-bridging, which may lead to anaphylaxis. Since they can still be bound by an allergy antibody but not cross-bridged, the peptides boost the immune system without large risk of an adverse reaction.

The goal of the cat allergy study is to prove that use of the new investigational immunotherapy drug helps safely reduce symptoms of cat allergy and reduces dependence on allergy medication. The study lasts for approximately one year. During this time, study subjects will receive 8 doses of study drug, placebo, or both. Study subjects will record their symptoms and medication use for a few weeks during the year, and the results will be compared between placebo and non-placebo groups. In order to qualify for the study, patients must be 12-65 years of age, experience symptoms when exposed to cats, live with a cat that is indoors for more than 8 hours each day, and not have any severe asthma, food allergies, or dust and mold allergies.

If you or someone you know is interested in learning more about this study, please contact our research department at 503 534-2622.

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1. World Allergy Organization. The global epidemiology of allergy. White Book on Allergy, 2011.

July Newsletter

Itch Study

Pruritus is the sensation of an itch and can be either localized or generalized. It is triggered by an irritation to a specific type of nerve that leads to an itch sensation and the desire to scratch the skin. Itching can result from skin conditions, such as eczema, medication reactions

[1] or systemic illness[2]. It is defined as chronic when the symptoms of itching have been present for six weeks or longer, according to the International Society for the Study of Pruritus. The incidence of a chronic itch has been found to increase with age[3].


People who have itching often times seek medical care from their dermatologist, as it can contribute to a decrease in quality of life, including difficulty functioning and sleeping [4]. The Baker Allergy, Asthma and Dermatology Research Center is currently involved in a study researching an investigational treatment for chronic itching. If you or someone you know has chronic itching, are 18 years or older and would like additional information about the research study, please contact either Emily Widen, research coordinator or Erin Flamiatos, FNP in our research center at (503) 534-2622


1. Reich A, Stander S, Szepietowski JC. Drug-induced pruritus: a review. Acta dermatovenereologica. 2009;89(3):236-244.

2. Grundmann S, Stander S. Chronic pruritus: clinic and treatment. Annals of dermatology. Feb 2011;23(1):1-11.

3. Thaipisuttikul Y. Pruritic skin diseases in the elderly.  The Journal of dermatology. Mar 1998;25(3):153-157.

4. Dalgerd F, Stevensson A, Holm JO, Sundby J. Self-reported skin morbidity in Oslo. Associations with socioeconomic factors among adults in a cross-sectional study. The British journal of dermatology. Aug 2004;151(2):452-457.

Controlling Medication Costs

There is a reliable cost comparison website available online to assist with keeping medication costs down. It is called www.Goodrx.com and easily and efficiently compares costs of prescription medications between pharmacies in your local area. It has been evaluated by Consumer Reports and is recommended as the most effective and reliable website.

When medication deductibles are high or patients are paying out of pocket for medication, it is beneficial to shop around and compare prices. Pharmacies all have different prescription prices and are not required to have the same prices on prescription medications as their competitors do. Even pharmacies that are located close to each other may have widely varying prices, so it is wise to compare.

Visit: www.Goodrx.com

Nasacort AQ -  Now Available Over-the-counter!

Nasacort AQ (triamcinolone nasal) has been approved by the FDA to be sold over-the-counter at pharmacies in the United States now. The approval was given in February this year. Nasacort is an intranasal steroid spray that is approved for treatment of allergic rhinitis. It decreases nasal tissue swelling; therefore relieves congestion, along with nasal discharge and sneezing. It provides the most effective relief when used consistently through pollen season or year round for patients with indoor and outdoor allergies. 

When using a nasal spray, it is improtant to aim the spray toward the outside wall of the nose and avoid spraying toward the middle of the nose (nasal septum). 

The over-the-counter price for Nasacort ranges from $15-$20 depending on the pharmacy. It is available at Costo in a bulk package of 3 bottles for $34.49.

http://www.fda.gov/drugs/newsevents/ucm370973.htm

Testing for Food Allergies

We often times see pediatric patients for possible food allergies, who have already had ImmunoCAP blood testing performed for several foods that have varying degrees of positive IgE levels. These food allergy blood tests may come in panel forms that include testing to many foods the child consumes without any adverse reactions. The clinical challenge with having multiple foods tested with the blood test or skin prick test is that the false positive rates are up to 50% for food allergy testing [1]. Often times these false positive results can lead to significant amounts of confusion for the provider, the patient and the patient's parents. In addition, the results are challenging to interpret and a slightly elevated food IgE level may not be relevant with regard to true food allergy, but we see this reported commonly, even though a patient may tolerate the food and enjoy it. Although a patient may have IgE to a food protein present, it doesn't always mean that they cannot tolerate this food or should avoid it. The clinical picture must be taken into consideration.

In a 2010 study of 79 children who had smaller skin test results or mildly elevated blood tests to peanut protein, only 22.4% of the children reacted clinically to an oral challenge to peanut [2]. This helps confirm that sensitization doesn't always mean patients have a true food allergy.

In clinic we don't practice using blanket or panel allergy testing for this reason and we recommend skin prick testing over ImmunoCAP testing if possible. We prefer to test only the foods that a patient has reacted to and possibly additional foods that cross react with the allergenic food group. Overall, the patient's story of his or her personal reaction to the food trumps the food allergy testing results and the skin prick test trumps the ImmunoCAP blood test.

1. American College of Allergy, Asthma, & Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol 2006; 96:S1.

2. Maloney JM, Rudengren M, Ahlstedt S, et al. The use of serum-specific IgE measurements for the diagnosis of peanut, tree nut, and seed allergy. J Allergy Clin Immunol 2008; 122:145.

Asthma Research Center Studies - Accepting Patients

Asthma Research Center Studies 

Asthma is a chronic inflammatory airway disease characterized by airway inflammation, hyperresponsiveness and remodeling. Together, these features can cause wheezing, breathlessness, chest tightness and coughing. While typically more prevalent during the morning and night and in younger individuals, asthma exists with a variety of triggers and impairs the daily lives of over 25 million individuals in the United States [1].

The physiology of asthma involves the activity of multiple types of cells, including white blood cells, mast cells and macrophages. Long term treatment of the disease is commonly achieved by controlling the populations of these cell types through maintenance inhalers or antibody injections. Overall, the goal of treatment is to reduce the prevalence of asthma attacks and to diminish the need for rescue medication.

The Baker Research Center is currently accepting patients into studies for asthma control.
Those 12 and older who have suffered from asthma may be eligible to enroll in an asthma study and receive free standardized treatment.

To Qualify:

• Patient must be 12 years of age or older.
• Patients must be on a stable dose of asthma medication without the use of prednisone in the past month.
• Patients must also meet criteria for uncontrolled asthma and show lung function improvement when given albuterol.

For more information on these studies or to see if you qualify, contact Julie Anderson or Michelle Walsh at 503-534-2622.

[1] Akinbami LJ, Moorman JE, Bailey C, Zahran HS, King M, Johnson CA, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010. NCHS Data Brief. 2012 May;(94):1-8





Pollen Season Has Arrived

If you suffer from allergic rhinitis you may have already noticed the arrival of the pollen this spring. The pollen count for Oregon is based out of Eugene and is published on The American Academy of Allergy, Asthma and Immunology website:

https://www.aaaai.org/global/nab-pollen-counts.aspx

The most recent count on 4/3/14 showed tree pollen ranking high and grass low. Tree pollen was first posted in early February and grass has been posted intermittently at low counts since late March.

Allergies may be treated by avoiding the allergen trigger, taking medication to treatment symptoms and/or treatment with immunotherapy [1]. We offer immunotherapy in the forms of allergy injections (subcutaneous immunotherapy) and allergy drops (sublingual immunotherapy). Sublingual immunotherapy (SLIT) is administered in the form of drops under the tongue on a daily basis.

Over-the-counter antihistamines are commonly used to treat allergic rhinitis and may relieve a runny nose and itchy eyes. However, if you are experiencing nasal congestion, you may need to add in an intranasal steroid spray in order to decrease the congestion. If you take Zyrtec daily, we recommend using Allertec, which is found at Costco for $15.99 for an entire year supply.

If you need an updated allergy care plan or testing to determine the type of treatment best for you, please schedule an appointment at 503 636-9011.

[1] Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998; 81:478.

Proper Epipen Use
Epinephrine is a medication that is used for anaphylaxis related to various causes. We most commonly prescribe it for treatment of food or bee sting allergies. Epinephrine temporarily increased blood pressure, which helps ensure blood is delivered to vital organs and decreased mucosal swelling in the skin, throat and bronchioles. It also acts as a bronchodilator, which opens of the bronchioles and decreases activation of mast cells, which are responsible for releasing histamine, a key component in anaphylaxis. There are no absolute contraindications to the use of epinephrine for anaphylaxis [1]. Therefore, all patients who are at risk for anaphylaxis should have access to epinephrine for self-treatment.

We prescribe two types of epinephrine devices:
• Auvi-Q: containing 0.15mg or 0.3 mg per dose(provides audible directions to guide user)
• Epipen: containing 0.15mg or 0.3 mg per dose

Anaphylaxis Reactions
Anaphylaxis is highly unpredictable [2]. One exposure to an allergen may result in mild symptoms, like hives and/or slight swelling, while the next causes a life-threatening reaction. It is not fully understood why reactions in the same patient can be so different. Anaphylaxis can sometime occur in two phases, called biphasic. Retrospective studies of anaphylaxis have found that a second dose was necessary in up to 35 percent of cases due to this biphasic reaction [3].

 Indications for use of Epinephrine
Epinephrine is the most effective treatment available for anaphylaxis and having an autoinjector enables patient to safely treat themselves immediately. Studies that have looked into reasons for fatal anaphylaxis show an association with lack of availability of epinephrine or failure to inject it at the onset of anaphylaxis symptoms [4]. Antihistamines and albuterol cannot reverse throat swelling or hypotension and are too slow-acting to be effective in anaphylaxis that develops quickly [5]. It is vital that epinephrine autoinjectors be carried at all times so the medication is available when the drug is needed. Autoinjectors should be taken everywhere, without exception.


In the setting of an allergic reaction, patients should use the epinephrine autoinjector immediately if they:
 Are having trouble breathing or asthma symptoms
 Feel tightness in the throat or difficulty swallowing
 Feel lightheaded, dizzy or think they might pass out

If treating a child with an allergic reaction, also use the autoinjector if the child:
 Is not improving or has a decrease in consciousness during an allergic reaction
 Has food allergies and is vomiting repeatedly shortly after eating, especially if these symptoms are accompanied by flushing or hives
 Is coughing repeatedly during an allergic reaction (indicating bronchospasm)
 Had previous anaphylaxis and develops widespread hives after a suspected or known ingestion of the allergen.

Administering Epinephrine
Epinephrine is most effective when given within the first few minutes of an allergic reaction and should be injected into the mid-outer part of the thigh, into the underlying muscle [2]. The autoinjector should be held with a closed fist (like a baton, with fingers away from either end) [6]. The autoinjector can be used through clothes, as the needles are designed to penetrate clothing. A second dose may be needed if symptoms do not appear to be stabilizing or improving, and this may be given 5 to 15 minutes after the first injection [2]. If patients become lightheaded they should lie down with their legs elevated, if possible, in order to increase blood flow to vital organs. Patients should never be propped up during anaphylaxis.

Patients should stay with other people if possible during an allergic reaction. If alone, epinephrine should be self-administered first, and then the patient should call for help and be transported to the nearest emergency department as soon as possible, in case the symptoms of anaphylaxis worsen or recur without further exposure to the trigger (biphasic reaction). The reason for proceeding to the emergency department is because of the possibility of worsening or recurrent symptoms. It is important to inform and educate appropriate friends, family, colleagues, and food providers about their allergic condition.

Storing Epinephrine
Epinephrine autoinjectors have a limited shelf life and need to be replaced annually. It is recommended to use an out-of-date autoinjector, if that is all that is available, rather than not injecting epinephrine at all [7]. Autoinjectors should not be refrigerated. They should be stored in locations with neutral temperatures (work bag, purse, cabinets) rather than locations where the unit may overheat or freeze (glove compartment of a car, in an uninsulated bag on the beach).

References
1. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477.
2. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117:391.
3. Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospective study of epinephrine administration for anaphylaxis: how many doses are needed? Allergy Asthma Proc 1999; 20:383.
4. Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119:1016.
5. Simons FE. Anaphylaxis: evidence-based long-term risk reduction in the community. Immunol Allergy Clin North Am 2007; 27:231.
6. Simons FE, Lieberman PL, Read EJ Jr, Edwards ES. Hazards of unintentional injection of epinephrine from autoinjectors: a systematic review. Ann Allergy Asthma Immunol 2009; 102:282.
7. Simons KJ, Simons FE. Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol 2010; 10:354.
8. Simons FE, Gu X, Simons KJ. Outdated EpiPen and EpiPen Jr autoinjectors: past their prime? J Allergy Clin Immunol 2000; 105:1025.

Psoriasis Study
Psoriasis is an autoimmune disease that typically affects the outside of the elbows, knees or scalp, however it may appear on any location. One of the most common forms of psoriasis is called plaque psoriasis. It causes raised, red patches covered with a silvery white layer of dead skin cells. Some people report that psoriasis itches, burns and stings .

It is reported that at least 10 percent of the general population inherits one or more of the genes that create a predisposition to psoriasis. However, only 2 percent to 3 percent of this population develops the disease. Researchers believe that for a person to develop psoriasis, the individual must have a combination of the genes that cause psoriasis and be exposed to specific external factors known as "triggers". These triggers can include; stress, injury or trauma to the skin and some types of medications. Psoriasis can also flare following a strep throat infection, earache, bronchitis, tonsillitis or a respiratory infection. Basically, anything that can affect the immune system can affect psoriasis[1].

The severity of psoriasis is not only measured by how much area of the body is affected, but also by how psoriasis affects a person's quality of life. There are a variety of ways to treat psoriasis, including; topical medications, systemic medications, biologic drugs, phototherapy treatment and alternatives therapies1.
The Baker Research Center is currently offering a study to research a topical medication that has been found to be beneficial in the treatment of psoriasis in adults 18 years or older. If you or someone you know has had psoriasis for over 6 months and would like more information regarding this study please notify Emily Widen, Erin Flamiatos, FNP or Angie Johnson at 503 534-2622.

References
1. National Psoriasis Foundation (n.d.). Retrieved November 26, 2013 from https://www.psoriasis.org/about-psoriasis