All posts by Jeffrey Rockoff, M.D.

IT’S HERE: ORAL IMMUNOTHERAPY(OIT)

OIT has been successful at decreasing food allergic sensitivity. This was originally designed to make food allergic patients less sensitive so cross contamination from a factory or food exposure would be less likely to cause a severe allergic reaction known as anaphylaxis. Additional research has proven that many patients desensitize enough where they become tolerant to their allergens and can ingest without any risk of anaphylaxis.

Step 1 of OIT involves appropriate history and lab work to determine which patients may be eligible. This can occur during an initial office visit or follow up for our existing patients.

Step 2 of OIT patients will receive rapid desensitization over a 4-6 hour visit. During this time incremental increasing amount of an allergen is ingested while patients are closely monitored for evidence of a reaction. The patients are then discharged to home while maintaining their daily dose for at least 7days.

Step 3 is referred to as “up dosing”. Patients will have their maintenance dose increased during this 45-60 minute office visit.

Step 4 is maintenance when the desired top dosage is achieved. Patients will then be followed and appropriate labs will be monitored. A second food allergen can be introduced    after this time.

OIT success rates are above 80%. Potential side effects are mild to more severe allergic reactions. Less than 5% of patients develop Eosinophilic Esophagitis(EOE) which would be criteria to discontinue this desensitization. Patients who have their environmental allergens, asthma and atopic dermatitis poorly controlled are not candidates for OIT. Additional contraindications include idiopathic anaphylaxis, MAST cell disease, FPIES and poorly controlled GERD or existing EOE.

We have being doing successful up dosing in our practice  for over 1 year from Drs Mayer and Silver from Michigan and Cleveland, respectively. We will be following strict criteria for advancing OIT.

As of October 8TH, 2018 we will be booking patients for OIT. Call to schedule an appointment (Step 1). We are looking forward to seeing many smiles on our patient’s and families faces.

NEWIST ADDITION TO OUR PRACTICE

Dr Rockoff and his entire staff are proud and excited to announce that Matthew Mavissakalian, D.O. has joined our practice as of mid-July/2018. Dr Matt obtained his undergraduate degree from University of Rochester. He then graduated from Touro College of Osteopathy medicine in N.Y.C. Dr Matt completed 5 years of residency in Internal Medicine and Allergy/Immunology at the University at Buffalo.

Dr Matt has been part time with us for the last 2-3 months. He will start full time in early October, 2018. He will help to expand our practice with his exceptional knowledge of Allergy and clinical Immunology. We have already received tremendous feedback on his ability to work with our new and follow up patients as well as our office staff.

DUPIXENT THERAPY FOR MODERATE TO SEVERE AD

DUPILUMAB(DUPIXENT) has been approved for moderate to severe atopic dermatitis. This drug is an Interleukin(IL)-4 inhibitor. These patients have failed topical aggressive moisturizers,corticosteroids and  immunomodulators(Elidel/Protopic). Eligible patients are >18years of age and have had an insurance prior approval. This subcutaneous injection is initially given at 600mg, then 300mg every 2 wks. The 1ST dose is administered in our office and subsequent dosages are self injected at home. Contraindications include allergic reactions to any of the ingredients in Dupixent. No live vaccines should be administered when patients are on this medication. It is also not approved for pregnancy/breastfeeding. The most common side effects include site reactions and inflammation/redness of the eyes and eyelids. Dr Rockoff and his staff will determine which patients are eligible for this new monoclonal therapy.

Omalizumab(Xolair) therapy for Chronic Urticaria/Hives

Omalizumab(Xolair) has been approved for >12 year olds with chronic idiopathic urticaria(hives). These patients have failed multiple H1 antihistamines(ie. Atarax, Benadryl, Allegra, Claritin, Zyrtec and Xyzal) and H2 antihistamines(ie. Pepcid, Tagamet and Zantac) combinations. H1 antihistamines block ~80% of our itch receptors, where H2 block ~20%. When treatment failure occurs despite H1/H2 therapy we will attempt additional medications which include montelukast and aggressive systemic corticosteroids. Common triggers for hives includes underlying infections, foods , medication and stress. Labs are drawn to rule out other potential triggers. When all triggers are eliminated patients are classified as having idiopathic hives. This patients may then be eligible for Xolair therapy. After insurance prior authorization is approved our patients are started on 150-300mg subcutaneously every 4 weeks. Most patients show a clinical response within the 1ST 2-3 dosages.

BIOLOGIC THERAPY FOR ASTHMA/2018

Omalizumab(Xolair) has been approved for moderate-severe asthma in patients >6 years of age. This drug binds free serum IgE in allergic asthma patients that have failed aggressive therapy. This includes inhaled corticosteroids, short and long acting bronchodilators, anticholinergics, montelukast and frequent bursts of systemic corticosteroids. Xolair is given subcutaneously in our office every 2-4 weeks. The dose and interval depends on the patient’s weight and IgE level.

IN 2017, 3 new biologic monoclonal antibodies became available to treat moderate to severe persistent asthma. They all target Interleukin-5(IL-5) as inhibitors to decrease production of an inflammatory white blood cell called eosinophils.
1. Mepolizumab(Nucala) was approved for >12 years of age in patients with peripheral eosinophil counts > 150mg/dL. Patients are given 100mg subcutaneously in our office every 4 weeks. (See previous blog from Feb/’17).
2. Reslizumab(Cinqair) was the 2nd IL-5 inhibitor approved for >18 year old asthmatics by the FDA in 2017. A peripheral eosinophilic count of >400mg/dL is required. This drug is given at 3mg/kg IV every 4 weeks. We use Dent Infusion center for administration of this drug.
3. Benralizumab(Fasenra) was the latest IL-5 inhibitors approved. This drug targets the IL-5 receptor and is also given subcutaneously in >12 year old asthmatics. The dosage is 30mg every 4 weeks x 3, then every 8 weeks. It is also given in our office.

Dr Rockoff and his staff will determine which patients are eligible for IL-5 inhibitor therapy. Side effects are rare, but reported. All patients receiving these meds will be given epinephrine injectors for potential anaphylactic reactions. All side effects and appropriate therapy will be reviewed prior to initiating monoclonal therapy. Prior authorization from the patient’s insurance is also mandatory. Significant clinical improvements including decrease asthma flares, nocturnal awakenings, use of rescue and systemic corticosteroids should be seen within 6-12 months. Many of our patients have seen a tremendous improvement within the 1st 3 injections. The future of IL-5 inhibition may also include treating nasal polyps and other eosinophilic diseases such as eosinophil esophagitis.

JR

Early Peanut Introduction

Recent data from Israel showed a much lower incidence of Israeli children developing peanut allergy than here in the US. Further research revealed their infants were fed peanut products much earlier in life. Studies now confirm when peanut products are ingested by 6 months of age, these children are much less prone to develop peanut allergies. Patients with egg allergies and severe eczema are high risk for peanut allergy. These children should have peanut skin tests and/or a blood test(Immunocap RAST) to determine if they are allergic. If their test are negative, peanuts should be introduced between 4-6 months of age. Mild to moderate eczema patients should have peanuts introduced by 6 months after a few solids(cereals/fruits and vegetables) have been tolerated. We recommend using Bamba which is a peanut containing puff. Some practices use peanut butter mixed with milk(breast or formula) or hot water. We do not recommend direct peanut butter or actual peanuts because of obvious choking potential. Avoid peanut introduction to patients who are sick.
With the above knowledge we can hopefully look forward to reversing the surging trend towards increase peanut allergies in young children especially over the past 2 decades.
More to come…. JR

NUCALA THERAPY

Nucala (mepolizumab) is a new drug used as an anti-Interleukin 5(IL-5) therapy for severe persistent asthma. It targets eosinophils which are major inflammatory cells in our bodies contributing to asthma and asthma flareups.

Nucala is approved for 12 years of age and above. It is not indicated for relief of bronchospasm during an asthma exacerbation. It is also not indicated for other eosinophilic diseases such as Allergic Rhinitis, Nasal Polyps, Gastroesophageal diseases, Hypereosinophilia, etc.

Patients must meet certain criteria to have this drug prior approved by their insurance. Documentation of multiple asthma flares despite compliance with a maintenance high dose inhaled corticosteroid as well as adjunct therapy including oral/systemic steroid bursts must be reported. Pre-therapy CBC/Differential labs must show a total eosinophilic count of >150.

The approved dose of Nucala is 100mg subcutaneously every 4 weeks. It is given in our office under supervision of our staff. Patients are observed for 1 hour after their first injection and 30 minutes after each subsequent injection. Beneficial clinical responses with decreased asthma flares, use of rescue inhalers, ER/Hospital visits and Prednisone bursts should be noted within a few months. However, some studies suggest 6-12 month trials before noted benefit is seen.

Common side effects include local site reactions with redness, itching and swelling. Headaches, back pain, fatigue and itchy(non site ) reactions have been less commonly noted. Rare systemic reactions have also been reported. All patients are given and trained on use of either Epipen, Auvi-Q or Adrenaclick which should be carried for 24 hours after each injection.

Whether patients are candidates for Nucala(mepolizumab), Cinqair(Reslizumab) or Xolair(Omalizumab) should be discussed with Dr Rockoff.

Eosinophilic Esophagitis(EOE)

Eosinophilic Esophagitis(EOE) is a condition where eosinophils (allergic/inflammatory cells) appear in the esophagus of patients. These cells are normally found in the eyes and nose especially in patients with allergies, in the lungs in patients with asthma, on the skin in patients with atopic dermatitis(eczema) and in the gastrointestinal tract from the stomach down to the lower intestines. These cell can also appear in patient that are healthy without any atopic disease. Eosinophils are not normal when found in the esophagus. The etiology(cause) of EOE is currently unknown.

EOE will occasionally run in families and can present in pediatrics as well as adults. Children will often experience recurrent nausea and vomiting, abdominal pains and feeding problems especially refusing to eat solid foods. Adolescents and adults usually present with a history of dysphagia(trouble swallowing) especially solid foods. They will also report food getting stuck, heartburn as well as abdominal or chest pains.

This condition can be diagnosed by Gastroenterologist(GI specialist) after endoscopy where biopsies of esophageal inflamed tissue reveal eosinophils.

Treatment involves a very strict diet and medications. EOE patients should avoid 4 common foods: eggs/milk/soy and gluten(barley/oats/rye and wheat). There are some reports that show that peanuts/tree nuts and shellfish may also promote eosinophils in certain patients. An initial diet avoiding all these foods can be very challenging, but lead to significant improvement in patient’s symptoms. A repeat endoscopy should reveal decreasing eosinophils if patient’s comply with this diet. Nuts and shellfish may be added back into the diet slowly after several months of improvement if the re-introduction does not result in increasing symptoms and/or increasing eosinophils on repeat biopsies.

Medications include proton pump inhibitors(PIP’s) such as: Prilosec (Omeprazole), Prevacid (Lansoprazole), Nexium( Esomeprazole), Aciphex( Rabeprazole), Dexilant (Dexlansoprazole), Protonix (pantoprazole) and Zegerid(Omeprazole/sodium bicarbonate). PPI’s are usually given to patients with gastroesophageal reflux qd(daily), however in EOE these meds are started bid(2x/day). Inhaled corticosteroids are also used. Flovent 220 and more recently budesonide are also swallowed bid, not inhaled. These meds provide topical anti-inflammatory effects.

Complications include anemia,weight loss and fatigue from poor caloric content as well as gastrointestinal strictures just to name a few. The differential diagnoses includes true food allergies, food protein-induced enterocolitis syndrome(FPIES),celiac disease and many other GI diagnoses. Your primary care, allergist and gastroenterologist should all work together with these patients and their families to provide a better outcome.

Differential Diagnosis for Hoarseness

Common acute causes of hoarseness include: voice abuse (especially after cheering for your favorite team) and as part of a viral infection (laryngitis). Both of these cases will resolve within a few days or weeks. Chronic hoarseness may be caused by the following:

#1. Chronic voice abuse (children or adults who abuse their vocal cords).
#2. Recurrent sinusitis with thick purulent post nasal drip.
#3. Gastroesophageal reflux (GERD) where gastric acid irritates the vocal cords.
#4. Anatomic: most lesions are benign(nodules/cysts/polyps), malignancies are rare.
#5. Inhaled corticosteroid to treat asthma may cause vocal cord myopathy(weakness).
#6. Trauma: from neck injury or post intubation during surgery(vc paralysis).

A good medical history will help decipher which of the above etiologies may be the cause. Flexible Fiberoptic Rhinoscopy can be performed in our office to determine whether further work ups are necessary. An otolaryngologist (ENT) evaluation and potential voice therapy may be indicated.

Sublingual Immunotherapy (SLIT)

Sublingual (under the tongue) immunotherapy has recently been approved by the FDA for grass and ragweed.

Grastek tablets from Merck and Oralair tablets from Greer are both grass tablets which may be given to grass allergic patients(documented by + skin or blood tests). Grastek is for patients 5-65yo and Oralair is for 10-65yo. This treatment plan should be started ~3 months prior to grass season(Feb/March) and taken daily till the end of grass season(mid-July). The 1st dose will be administered in our office by placing the tablet under the tongue. After 1 minute, patients may swallow and food/liquids can be consumed after 10 minutes. Patients are observed in our office for 30 minutes. Common side effects include mild swelling and itching under the tongue, palate and throat or itchy ears. These symptoms resolve usually within 10 minutes. More severe reactions include: flushing, tightness or difficulty swallowing/breathing, dizziness,GI cramping, hives and feeling faint. For any of these symptoms patients will be appropriately treated and SLIT will be discontinued.

Ragwitek tablets have also been approved by Merck for Ragweed allergic patients from 18-65 yo. This tablet should be started in May and continued till the 1st frost(~mid-October). Similar treatment plans and side effect profile stated above apply.

If you or your children are interested in SLIT please feel free to discuss this with our medical staff.