Category Archives: Uncategorized

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.

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.

Baked egg diet instructions developed at the Jaffe Food Allergy Institute.

Instructions for introducing baked egg at home – after the physician-supervised OFC (oral food challenge) and when approved by your doctor.

When your child has passed the baked egg challenge, he or she will be able to eat extensively baked products with egg as an ingredient. Should your child develop an allergic reaction to the food that contains baked eggs, please record the offending food, amount eaten, preparation technique and symptoms. Please contact our office at your earliest convenience to review the reaction.

Your child may now eat the following:

  • Store-bought baked products with egg/egg ingredients listed as the third ingredient or further down the list of ingredients.
  • Home-baked products that have no more than one third of a baked egg per serving. For example, a recipe that has 2 eggs/batch of a recipe that yields 6 servings.
  • Remember to check store-bought products and ingredients on the basis of your child’s food allergies to avoid a reaction to other allergens.
  • All baked products must be baked throughout and not wet or soggy in the middle.

Your child should continue to avoid unbaked egg and egg-based foods such as the following:

  • Baked products with egg listed as the first or second ingredient.
  • Caesar salad dressing.
  • Custard.
  • Eggs in any form, such as hard boiled, soft boiled, scrambled or poached.
  • Egg noodles.
  • French toast and pancakes.
  • Homemade waffles.
  • Frosting containing egg.
  • Ice cream.
  • Mayonannaise.
  • Quiche.

Baked milk diet instructions developed at the Jaffe Food Allergy Institute

Instructions for introducing baked milk at home – after the physician-supervised OFC (oral food challenge) and when approved by your doctor:

When your child has passed the baked milk challenge, he or she will be able to eat extensively baked products with CM (cooked milk) as an ingredient.  Should your child develop an allergic reaction to the food that contains baked milk, please record the offending food, amount eaten, preparation technique, and symptoms. Contact our office at your earliest convenience to review the reaction.

Your child may now eat the following:

  • Store-bought baked products with CM/CM ingredient listed as the third ingredient or further down the list of ingredients.
  • Home-baked products that have no more than one-sixth cup of CM per baked milk serving. For example, a recipe that has 1 cup CM per batch of a recipe that yields 6 servings.
  • Remember to check store-bought products and ingredients on the basis of your child’s food allergies to avoid a reaction to other allergens.
  • All baked products must be baked throughout and not wet or soggy in the middle.

Your child should continue to avoid unbaked milk and CM-based foods such as the following:

  • Baked products with CM listed as the first or second ingredient.
  • Product that may have a CM ingredient that has not been baked, such as a CM ingredient containing frosting on a cookie or cupcake, or a cheese flavoring on a cracker that may not have been baked (e.g. flavorings may be applied topically after the product is baked).
  • Milk chocolate chips that will melt during baking but not bake. Please continue to use CM-free chocolate chips.
  • Regular milk or dairy in any form including whole, low-fat, nonfat, or skim CM, lactose-free products, dry milk powder, yogurt, sour cream, butter, hard and soft cheeses, ice cream, sherbet, butter, etc.
  • Frosting with a CM ingredient.
  • French toast and pancakes.
  • Homemade waffles.
  • Cooked milk products that are not baked, such as pudding.

Passive smoke: How does it affect allergies and asthma?

Cigarette smoking is considered the single most preventable cause of death and illness in the United States. Over 400,000 deaths per year are attributable to smoking. Despite this, approximately 20- 25% of adults and adolescents in this country currently smoke.

People who smoke affect themselves (active exposure) as well as people they come in contact with (passive exposure). Environmental tobacco smoke is a combination of mainstream smoke which is inhaled by the smoker, and sidestream smoke that comes from the burning end of a cigarette. Cigarette smoke contains over 7000 chemicals including nicotine, tar, formaldehyde, cyanide, arsenic, carbon monoxide, methane and benzene. 69 of these chemicals are known carcinogens. Secondhand smoke contains twice as much tar and nicotine than smoke inhaled through cigarette filters. The Journal of the American Medical Association in 1996 concluded that more than 40% of children in the United States, age 2 months to 11 years, live in homes with at least one smoker. In 2006 the United States Surgeon General reported that nonsmokers have a 20-30 percent greater chance of developing lung cancer if they are exposed to secondhand smoke at home or work.

Children exposed to second-hand smoke have a statistically significant higher incidence of otitis media (ear infections), tonsillitis, sinusitis, bronchitis, pneumonia and asthma exacerbations than children not exposed. Infants of maternal smokers are three times more likely to die from sudden infant death syndrome (SIDS). Smoking during pregnancy has resulted in documented spontaneous abortions, premature deliveries, lower birth weights and subsequent decreased lung function, with a higher risk for developing asthma during childhood.

A proposed mechanism for smoke-induced disease involves greater production of an allergy antibody known as IgE, which promotes allergies, asthma and increased hyper-responsiveness in the airways. More recently, cigarette smoke has been recognized as a major irritant to mucosal surfaces which adversely affects ciliary function. The cilia line our upper and lower respiratory tracts and are responsible for moving mucus. After active or passive smoke exposure, our cilia become dysfunctional, thus promoting disease. What most people do not realize is that during smoke exposure, the smell of smoke from hair, clothing or the smoker’s breath will affect the cilia.

The New York States Smoker’s Quitline reports that smoking decreases a person’s life expectancy by 13-14 years. The sooner a smoker quits the better chance the lungs have to heal. Nicotine is one of the most addictive chemicals known. Therefore, smoking cessation may be difficult. Many, “Stop Smoking Programs” are available but are only effective when a true commitment to STOP has been undertaken.

Smokers need to consider the effects of continued smoking on their own bodies as well as all people they come in contact with. If this isn’t a good enough reason to quit, consider the cost. At $10.00 per pack (in Western New York as of 2013), a one pack-per-day smoker will spend approximately $3650 a year for cigarettes. Additional other costs include higher health and life insurance premiums as well as health care costs associated with tobacco-related diseases. By contrast it costs the tobacco companies 5 cents to produce a pack of cigarettes.

For help to quit smoking contact the New York State Smoker’s Quitline at 1-866-NY-QUITS  (1-866-697-8487) or their website www.nysmokefree.com.