the versatility of lcm slit: approaching the complex allergy patient george f. kroker md facaai
TRANSCRIPT
The Versatility of LCM SLIT: Approaching the Complex Allergy Patient
George F. Kroker MD FACAAI
Copyright 2011. Allergy Associates of La Crosse
Case Presentation T.D., a 49 y/o Wal-Mart employee from Iron
Mountain Michigan presented 3/25/04 with multiple complaints: ENT: conjunctivitis, peri-orbital swelling,
rhinitis, sinus pressure/congestion, otic pruritis PULMONARY: occasional nocturnal cough GI: urgency & diarrhea after meals, multiple
food reactions SYSTEMIC: chronic fatigue, weight gain,
suboptimal memory & cognitive functioning, headaches
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.) PMH:
Eczema from eggs/dairy as infant Allergic rhinitis as young adult Recurrent sinusitis, vaginitis As young adult began having acute episodes
of angioedema, urticaria & diarrhea from multiple foods
Episodes increased in frequency/intensity and required increasing ER visits
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.) Comment:
“during both of my emergency room visits, I was asked if I was having my period—yes both times…I was asked if I was under heavy stress—yes both times…my husband was in the Navy and both times we were actually moving cross-country”
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.) PMH:
Prior injection immunotherapy in Idaho for multiple inhalant sensitivities
Prior allergy w/u in 1986, 1989, 2001 Recent trials of Clarinex, Flonase, elimination
diets (“pork and rice”) failed to provide significant relief
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.) Environmental History
Seasonal congestion spring & fall Work: store remodeling at Wal-Mart, much
dust exposure, while painting noted ENT SSX flared
Home: has dog; knows cats bother her; yard work aggravates symptoms
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.) Dietary History:
Throat irritation, mouth swelling from multiple foods(especially raw): potatoes, tomatoes, melons, rutabaga, raw carrots & celery, raw cucumber, garlic, apple, oranges, banana, cabbage
“Sugar & bread are what I can eat” Breakfast: eggs & toast Lunch: sandwich Supper: meat, canned vegetable Snacks: 3 Pepsi per day, cupcake, craves
chocolate
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.) Medications:
Up to 8 Sudafed/day for congestion; OTC antihistamines
Epi pen for emergencies
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.)
“Help my energy, and mental functioning” “Keep me from having ER visits—I have to
carry an epi pen everywhere I go…” “I don’t want to be on 8 Sudafed a day…” “Help my food tolerance; I can’t eat the foods
I want to…and I overeat other foods and am gaining weight”
Patient Goals
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont)Now what?What do you do??How do I understand what’s really going on??
How can you utilize LCM SLIT to help this patient?
Copyright 2011. Allergy Associates of La Crosse
Copyright 2011. Allergy Associates of La Crosse
How to approach the complex patient Approaching the complex patient with chronic
illness requires a different paradigm than the acutely sick patient with recent illness
In order to approach complex allergy patients, a specific set of concepts are of help to the practicing allergist
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation
Copyright 2011. Allergy Associates of La Crosse
Concept One: Multiple Causation Acute illness: often one cause Chronic illness: multiple causation is the rule Ask two questions:
1. What is this patient getting too much of, that is not good for them?
2. What is this patient not getting enough of, that is good for them?
AllergensStressChemicalsEtc.
NutrientsExerciseDietSLIT
Copyright 2011. Allergy Associates of La Crosse
Concept Two: Total Load Corollary: Treatment of only one isolated
factor in the multiply-sensitized patient may not result in improvement; the erroneous conclusion is “that factor isn’t important because removal/treatment didn’t help”
“Wood sliver analogy” helpful for patients Multiple causation is applied to the complex
patient through the principle of the total load concept
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load
Copyright 2011. Allergy Associates of La Crosse
Total Load Concept
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Total Load Concept
Copyright 2011. Allergy Associates of La Crosse
Total Load Concept: “Critical Mass”
Time
Allergic Threshold(“Critical Mass”)
Copyright 2011. Allergy Associates of La Crosse
Total Load/Critical Mass Concepts
Time (in months or years)
“Onset of Current Illness”
AllergicThreshold
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Critical Mass Concepts
Time (in days)
“Bad Day”AllergicThreshold
“Bad Day”
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Critical Mass Concepts
Time
“Bad Day”AllergicThreshold
“Bad Day”
The “Sometimes” Patient
Copyright 2011. Allergy Associates of La Crosse
The Complex Patient: Natural History of Treatment Course
Time
AllergicThreshold
Stage I“Illness”
“bad days” >>”good days”
Stage 2“Transition”
“bad days”&”good days”
Stage 3
“Recovery”“good days” >>”bad days”
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load Target organ variability
Copyright 2011. Allergy Associates of La Crosse
Concept Three: Target Organ Variability Different allergenic triggers may “target” different end
organ systems in the same patient Disease “labels” are largely irrelevant (!)
Triggers
MED IATORS
“TargetOrgans”
Disease“Labels”
SAR
IBS
Eczema,Urticaria
ENT
GI
DERM
CNSChronicFatigue Syndrome
Trigger 2
Trigger
1
Trigger 3
Disease-ModifyingTreatment--SLIT
Drugs &SymptomaticTreatment
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load Target organ variability Altered intestinal permeability
Copyright 2011. Allergy Associates of La Crosse
Concept Four: Altered Intestinal Permeability
The “screen inthe window”
metaphor
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Concept Four: Altered Intestinal Permeability
Copyright 2011. Allergy Associates of La Crosse
Concept Four: Altered Intestinal Permeability Increased intestinal permeability can be
responsible for increased “spread” and severity of food reactions
Causes of increased intestinal permeability include: Acute infectious illness: Viral gastroenteritis, food
poisoning Chronic infectious illness: Protozoal infections, fungal
overgrowth secondary to antibiotics Chronic ingestion of food allergen(s) Drugs: Chronic NSAIDs, alcohol ingestion Acute anaphylactic reaction
Copyright 2011. Allergy Associates of La Crosse
Concept Four: Altered Intestinal Permeability Multiple clinical presentations:
White male with prior history of hay fever, --had acute GI bleed secondary to overdose of NSAIDs; shortly afterwards began having multiple food reactions
Alcoholic male with increasing food reactions as drinking increased
White female with chronic antibiotic use for acne, developing yeast vaginitis infections recurrently and simultaneous multiple food reactions
White female with all prior food allergens under good control with SLIT, until trip to California when contracted food poisoning and developed immediate loss of tolerance to all former food allergens
Copyright 2011. Allergy Associates of La Crosse
Concept Four: Altered Intestinal Permeability & Chronic Antibiotic Use
Hygiene Hypothesis—infectious disease at early, opportune moments in immunologic development provides protection from atopic disease
“Extended Hygiene Hypothesis”—intestinal microbial flora exposure outweighs that of infections in providing maturational signals
Note: Oral tolerance is defective in germ-free animals
Copyright 2011. Allergy Associates of La Crosse
Role of Antibiotics & Fungal Microbiota in Driving Pulmonary Allergic Responses Noverr Et al. Infec & Immunity Sept 2004 pp 4996-5003
Mouse model of antibiotic-induced GI microbial disruption with C. albicans bias; followed by nasal challenge to mold
Mice easily developed CD4 T cell mediated allergic airway response in lungs to subsequent nasal mold exposure without previous systemic antigen priming
Effect is absent in mice challenged with mold not receiving chronic antibiotic administration
Copyright 2011. Allergy Associates of La Crosse
Role of Antibiotics & Fungal Microbiota in Driving Pulmonary Allergic Responses Noverr Et al. Infec & Immunity Sept 2004 pp 4996-5003
“These studies indicate that increased numbers of yeast cells in the microbiota can be a contributing factor in up-regulating Th2 responses to antigen exposure in the lungs. In these studies, Candida was never isolated from the lungs…these studies highlight the concept that events in distal mucosal sites such as the GI tract can play an important role in regulating immune responses in the lungs”
“We have presented a model of a clinically feasible, common scenario that occurs for a number of humans: Antibiotic treatment followed by a non-life-threatening low grade increase in fungal microbiota…”
Copyright 2011. Allergy Associates of La Crosse
Role of Antibiotics & Fungal Microbiota in Driving Pulmonary Allergic Responses Noverr Et al. Infec & Immunity Sept 2004 pp 4996-5003
Question: What happens to an allergic patient with an immune
system that is already up-regulated in Th2 bias, who becomes the recipient of chronic antibiotic usage and Candida overgrowth?
Diagnostic & Therapeutic Implications: Excessive Candida carriage promotes heightened
reaction to mold Excessive mold exposure heightens reaction to
previously asymptomatic Candida carriage
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load Target organ variability Altered intestinal permeability Food allergen reactivation
Copyright 2011. Allergy Associates of La Crosse
Concept Five: Food Allergy Reactivation “Once an allergen, always a potential
allergen” An allergen early in life causing an acute
reaction (hives, eczema, asthma) may go into remission and then “resurface” in adulthood, causing symptoms once again—often more insidious—and often in a different target organ
Note: Reactivation of an allergen is often a non-IgE mediated, delayed onset sensitivity
Copyright 2011. Allergy Associates of La Crosse
Concept Five: Food Allergy Reactivation
Infant with colic & recurrent otitison Cow’s Milk Formula
Changed formula to soy; symptoms resolve
Asymptomatic remission period
New target organ involvement
Dairy re-introduced into diet again; no acute rxn
Reactivated dairy allergy
Allergic/stress load increases
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load Target organ variability Altered intestinal permeability Food allergen reactivation Hidden food sensitivities
Copyright 2011. Allergy Associates of La Crosse
Concept Six: Hidden Food Sensitivities Frequently eaten foods may be responsible
for chronic, fluctuating symptoms in allergic patients
No immediate reaction consistently reported after eating these foods
Common hidden food sensitivities include milk, wheat, corn, soy, egg, yeast
Diagnostic tests: low or negative titer IgE, may show up with IgG RAST, ALCAT, MRT
Copyright 2011. Allergy Associates of La Crosse
Concept Six: Hidden Food Sensitivities Important principle of negative feedback loop:
Hidden food sensitivities worsen intestinal permeability AND increased intestinal permeability worsens hidden food sensitivities!
Food Sensitivities Intestinal Permeability
Copyright 2011. Allergy Associates of La Crosse
Concept Six: Hidden Food Sensitivities
Two types of Hidden Food Sensitivities: Delayed onset food allergy Low level IgE mediated food allergy
Copyright 2011. Allergy Associates of La Crosse
Concept Six: Hidden Food Sensitivities
Day Number
2 3 4 5 61
Initial Food Ingestion
Total CumulativeFood Allergen Load
AllergicThreshold
Copyright 2011. Allergy Associates of La Crosse
Critical Mass Concepts Revisited
Time
“Bad Day”AllergicThreshold
“Bad Day”
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load Target organ variability Altered intestinal permeability Food allergen reactivation Hidden food sensitivities “The formula”
Copyright 2011. Allergy Associates of La Crosse
Concept Seven: “The Formula” When you do a “test” for “allergies,” you are
only measuring one of the two essential items that determine an allergic reaction:
Allergic Reaction =
Our testing Patient’s exposure
Allergic LoadAllergic Sensitivity x
Copyright 2011. Allergy Associates of La Crosse
Concept Seven: “The Formula” A corollary: the highly sensitized patient with
a low allergic load may be less in need of treatment than the minimally sensitized patient with a high allergic load!
Example: An bookkeeper with severe mold sensitivity on testing may be less symptomatic than a farmer with mild mold sensitivity on testing
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load Target organ variability Altered intestinal permeability Food allergen reactivation Hidden food sensitivities “The formula” The “allergy/nonallergy interface"
Copyright 2011. Allergy Associates of La Crosse
Concept Eight: The “allergy/nonallergy interface”
AllergicDiseases
Other Diseases
Insect anaphylaxisUrticariaSeasonal allergicrhinitis,Etc.
Celiac DiseaseFibromyalgiaChronic FatigueIrritable Bowel SyndromeMigraine headachesADD, ADHDEtc.
Aggravation ofChronic Conditions:FibromyalgiaChronic FatigueADD, ADHDIBS“Targeting” effect
Copyright 2011. Allergy Associates of La Crosse
The Complex Allergy Patient…Revisited
Let’s reconsider our patient’s history…
Copyright 2011. Allergy Associates of La Crosse
Concepts in Chronic Illness Multiple causation Total load Target organ variability Altered intestinal permeability Food allergen reactivation Hidden food sensitivities “The formula” The “allergy/nonallergy interface"
Copyright 2011. Allergy Associates of La Crosse
Case Presentation…Revisited T.D., a 49 y/o Wal-Mart employee from Iron
Mountain, Michigan presented 3/25/04 with multiple complaints: ENT: Conjunctivitis, periorbital swelling, rhinitis,
sinus pressure/congestion, otic pruritis PULMONARY: Occasional nocturnal cough GI: Urgency after meals, multiple food reactions SYSTEMIC: Chronic fatigue, weight gain,
suboptimal memory & cognitive functioning, headaches
Multiple Symptoms…Multiple targets…Think Total Load
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: (cont.) Comment:
“during both of my emergency room visits, I was asked if I was having my period—yes both times…I was asked if I was under heavy stress—yes both times…my husband was in the Navy and both times we were actually moving cross-country”
Total Allergy Load—hormonal, allergy, stress
Copyright 2011. Allergy Associates of La Crosse
Case Presentation, Revisited: PMH:
Eczema from eggs/dairy as infant Allergic rhinitis as young adult Recurrent sinusitis, vaginitis began to develop As young adult began having acute episodes
of angioedema, urticaria & diarrhea from multiple foods,
Episodes increased in frequency/intensity and required increasing ER visits
Reactivated??
Candida load up…
Increased intestinal permeability
Copyright 2011. Allergy Associates of La Crosse
Case Presentation, Revisited: PMH: (cont)
Prior injection immunotherapy in Idaho for multiple inhalant sensitivities
Prior allergy w/u in 1986, 1989, 2001 Recent trials of Clarinex, Flonase, “pork and
rice” diet failed to provide significant relief in symptoms
Single approaches fail withMultiple causation…“wood sliver effect”
Copyright 2011. Allergy Associates of La Crosse
Case Presentation, Revisited: Environmental History
Seasonal congestion spring & fall Work: Store remodeling at Wal-Mart, much
dust exposure, while painting noted ENT SSX flared
Home: Has dog; knows cats bother her; yard work aggravates symptoms
Big dust exposure…Raises load
Check out dog
Copyright 2011. Allergy Associates of La Crosse
Case Presentation, Revisited: Dietary history:
Throat irritation, mouth swelling from multiple foods: potatoes, tomatoes, melons, rutabaga, raw carrots & celery, raw cucumber, garlic, apple, oranges, banana, cabbage
“Sugar & bread are what I can eat” Breakfst: Eggs & toast Lunch: Sandwich Supper: Meat, canned vegetable Snacks: 3 Pepsi per day, cupcake, craves
chocolate
OASPR-10, profilinsConsider ISAC
Narrowed diet..New hidden food rxns??Daily eggs!
Copyright 2011. Allergy Associates of La Crosse
Case Presentation, Revisited:
“Help my energy, and mental functioning” “Keep me from having ER visits—I have to
carry an epi pen everywhere I go…” “I don’t want to be on 8 Sudafed a day…” “Help my food tolerance; I can’t eat the foods
I want to…and I overeat other foods and am gaining weight”
Patient Goals
“the allergy/nonallergy Interface”
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: IDT TestingDilution # 5 4 3 2 1
Ragweed
Birch
16mm
10mm
Oak
11mm9mm
Grass
10mm
Go after Birch—Bet v 1OAS
Go after RagweedProfilin OAS
Copyright 2011. Allergy Associates of La Crosse
Oral Allergy Syndrome (OAS)
Copyright 2011. Allergy Associates of La Crosse
Bet v 1 & Profilin (Bet v2) : Cross- Reactivity Pattern in Oral Allergy Syndrome
Wensing, et al. JACI , 435-442, Sept 2002
Birch
Correlations between specificIgE titers of Bet v1, profilin, and 14 plant-derived foods calculated bySpearman rank test
Daily in diet
Daily in diet
Pt’s Oral AllergySyndrome Foods
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: IDT TestingDilution # 5 4 3 2 1
Dog
Candida
9mm
7mm
Dust Mite
7mm 9mm
Alternaria
7mm 10mm
9mm 11mm
7mm
Conclusion:Heavy multiple inhalant load:Pollens,dust,dander,molds
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: IgE ELISA TestingAntigen Conc IgE
IU/ml(nl<.05)Class
Dust Mite .20 II
Egg White .00 Neg
Wheat .07 I
Corn .07 I
Tomato .14 I
Carrot .01 Neg
Milk .03 Neg
Orange .10 I
Potato .09 I
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: IgE ELISA Testing (cont.)Antigen Conc IgE IU/ml
(nl<.05)Class
Yeast .05 Neg
Garlic .11 I
Apple .21 II
Celery .07 I
Melon .05 Neg
Banana .10 I
Milk .03 Neg
Pineapple .01 Neg
Cabbage .07 I
Multiple low grade IgE rxns
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: Challenge Testing
Antigen Symptoms Elicited
Egg Fatigue, fell asleep, eye itching
Wheat Eye itching, arm rash
Candida Fatigue, yawning, eye watering
Corn Very fatigued, eye watering, ears flushed
Multiple hidden food sensitivities
Candida Sensitivity
Copyright 2011. Allergy Associates of La Crosse
Total Load Concept
Inhalant Allergens
Food Allergens
Nutritional Stressors
Hormonal Stressors
Chemical /toxin stressors
Emotional Stressors
Infectious Stressors
AllergicThreshold
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: The Total Load
Oral Allergy Syndrome Foods
Microbial Disruption &Candida Sensitivity
Seasonal Pollen/Mold
Perennial Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
Copyright 2011. Allergy Associates of La Crosse
Case Presentation
Time
Milk/eggeczema
Childhood Adulthood
Stress
Dust&Mold PollenAllergy
OralAllergySyndr
NarrowsDiet
Increased
Intestinal Permeability
CandidaAntigenicLoad
FoodAllergy
TotalAllergyLoad
SYMPTOMS
RecurrentSinusitis
Copyright 2011. Allergy Associates of La Crosse
LCM SLIT and the Complex PtPrinciples of Administration Utilize multi-antigen threshold dosing initially Always administer SLIT in conjunction with
reduction in Total Allergy Load Advance dose carefully, based on:
Prioritizing advancing “key” allergens Compliance in reduction in allergy load
Later, “Mop up” residual seasonal symptoms with pre-seasonal high dose protocol
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: The Total Load
Oral Allergy Syndrome
Microbial Disruption &Candida Sensitivity
Seasonal Pollen/Mold
Perennial Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
= Load x Sensitivity
Copyright 2011. Allergy Associates of La Crosse
Consult 3/15/04
Oral Allergy Syndrome
Microbial Disruption &Candida Sensitivity
Seasonal Pollen/Mold
Perennial Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
= Load x Sensitivity
Fix Dust Barrier Covers SLIT
Rx Diflucan, probioticsRefined sugar restriction
SLIT
SLIT
SLITa/c, environ control
“reassurance & hope”
avoidance
Encourage diversificationInto other “safe” food grps
SLIT
Copyright 2011. Allergy Associates of La Crosse
Consult 4/14/04 Update
Oral Allergy Syndrome
Microbial Disruption &Candida Sensitivity
Seasonal Pollen/Mold
Perennial Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
= Load x Sensitivity
Fix Dust Barrier Covers SLIT
Rx Diflucan, probioticsRefined sugar restriction
SLIT
SLIT
SLITa/c, environ control
Interval Change:Transient cong as SLIT begunNo ER/ visits for angioedema/urticaria/sinusitisLost 13 lb; more energy; diarrhea much improvedMuch personal stress; father killed
SLIT
RDD minus egg, corn,Wheat, refined sugar
Rotate carefully!
Copyright 2011. Allergy Associates of La Crosse
Consult 7/9/04 Update
Oral Allergy Syndrome
Microbial Disruption &Candida Sensitivity
Seasonal Pollen/Mold
Perennial Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
= Load x Sensitivity
Fix Dust Barrier Covers SLIT
Rx Diflucan, probioticsRefined sugar restriction
SLIT
SLIT
SLITa/c,environcontrolcontrol
SLIT
RDD minus egg,corn,Wheat, refined sugar Rotate!
Interval ChangeSpring resp ssx much betterNo chronic sinus congestion, rare SudafedDiarrhea in remissionNo urticaria,angioedemaExcellent Energy; Lost 26 poundsTolerating melon, bananas for “first time in years”
Rx Diflucan dc’edProbiotics con’t
Off strict RDD, diversification,restrict eggs, corn, wheatRefined sugars
Copyright 2011. Allergy Associates of La Crosse
Consult 8/24/04 Update
Oral Allergy Syndrome
Microbial Disruption &Candida Sensitivity
Seasonal Pollen/Mold
Perennial Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
= Load x Sensitivity
Fix Dust Barrier Covers
SLIT
ProbioticsRefined sugar restriction SLIT
SLIT
SLITa/c, environ control
SLIT
Restricting egg, corn,Wheat, refined sugar
Rotate carefully!
Interval ChangeDoing well except for 1 acute attack of angioedema requiring emergency room visit— “Why did this happen?”
Occurred Sunday 8/22—Weekend spent outdoorsAte cheeseburger & coleslawJust before episode
Copyright 2011. Allergy Associates of La Crosse
Consult 1/14/05 Update
Oral Allergy Syndrome
Microbial Disruption &Candida Sensitivity
Seasonal Pollen/Mold
Perennial Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
= Load x Sensitivity
Fix Dust Barrier Covers
SLIT
ProbioticsRefined sugar restriction
SLIT
SLIT
SLITa/c, environ control
SLIT
Restricting egg, corn,wheat, refined sugar
Rotate carefully!
Interval ChangeNo urticaria/angioedema x 5 monthsNo sudafedLost 30# total; good energyMild PND when ate thanksgiving mealWith raw apple; no hives or angioedema!
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: Further f/u Office consult 5/12/05:
“I’ve been great…everyone carries a Kleenex at work but not me…no need for my epi pen; stomach good…can sit out on my deck in spring & fall and enjoy myself without sudafed!”
Office consult 11/21/05: “I did well over the fall, no need for regular sudafed or
antihistamines…no epipen needed…I cheat occasionally on foods with no significant reactions”
Office consult 5/30/06: “No oral allergy problems with fruits provided I don’t overeat
them; no epi pen needed; I need a rare sudafed when I ride my 4-wheeler during allergy seasons! 6 sudafed last year!”
Copyright 2011. Allergy Associates of La Crosse
Case Presentation: Further f/u Office consult 5/14/07
“Another good year”…no sudafed needed this spring, outdoors biking…no epi pen needed”
Office consult 8/11/08: “I selectively eat food allergens without reactions…on
picnics I have hotdogs, buns, ice cream, fruits and I’m ok”…I have had no need for my epi-pen or sudafed…my intestines are working fine…”
Copyright 2011. Allergy Associates of La Crosse
Treatment Strategy Summary: Lower Total Allergy Load
Oral Allergy Syndrome
MicrobialDisruptionCandida Sensitivity
Seasonal Pollen/Mold
Dust/Dog
Hidden Food Allergy
Stress
Reaction
AllergicThreshold
= Load x Sensitivity
Dust Barrier Covers SLIT
Rx Diflucan, probioticsSugar restriction SLIT
Rotate Carefully SLIT
RDD minus egg, corn,Wheat, refined sugar SLIT
a/c; environ ctrl SLIT
Reassurance:“A plan for recovery”
Copyright 2011. Allergy Associates of La Crosse
Copyright 2011. Allergy Associates of La Crosse
Thank you
Next: Exploring the Broader Implications
Of Allergy & Immunity
Vijay Sabnis MD, Benoit Tano MD, Kathryn McMullan MD