5 things this allergist-immunologist will never do [PODCAST]

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“Jumping on the recent TikTok trend of medical professionals sharing the things they would never do given their knowledge and expertise, I am sharing the five things I would never do as a board-certified allergist-immunologist.”

Kara Wada is an allergist-immunologist.

She shares her story and discusses her KevinMD article, “5 things I would never do as an allergy and immune system expert.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today we welcome back on the show Kara Wada. She’s an allergist-immunologist, and her latest KevinMD article is titled “5 things I would never do as an allergy and immune system expert.” Kara, welcome back to the show.

Kara Wada: Thank you so much for having me on, Kevin. I appreciate it.

Kevin Pho: Now, for those of you who listened to our first episode together, that was, we were talking offline, almost a year ago. Time flies. Just briefly share your story and journey to where we are today.

Kara Wada: So I am an academic allergist-immunologist. I work at The Ohio State in Columbus, Ohio. I joke a little bit about the “the,” because I still feel somewhat like a transplant here, even though I’ve been here about 12 years. And as we were talking offline, we just started our fellowship recruitment season.

But how I ended up in allergy and immunology, and really writing this article, was through mentorship. I mentored Dr. Dave Stukus, who I think you’ve had on the show as well, and some of the work that we have done together was really looking at the role of myths and misperceptions that are really pervasive, especially in social media, about medicine. And so when I saw this TikTok trend looking at, you know, what are five things I would never do, I thought, “Oh goodness, I need to jump on board with this,” and kind of do the video. But then I thought, I tend to like a little longer form. Allergist-immunologists, we’re not always the shortest in our notes or in our interactions. We tend to be kind of long-winded. And so I thought that this would be a great additional way to share this information with everyone that comes to your site.

Kevin Pho: Now, before we get into that, for those who don’t know what you do on a daily basis, just give us a sample of some typical cases or common cases that you would see every day.

Kara Wada: Yeah, so in the clinic, I see the real breadth of allergy-immunology: everything from runny noses, nasal polyps, food allergies or suspected food allergies, chronic hives, and asthma. And then, being at the university, we see a fair bit of immunologic issues too. So on the immune system side, we tend to see more of things that are immune deficiency.

But I think one of the common misperceptions for a lot of folks is that if your immune system is low or underactive, immune deficient, that means that you would not necessarily have allergies or autoimmunity. But actually, the reverse is true. We see that more often: When the immune system is misbehaving, it tends to misbehave in more than one way. And so we will share a lot of patients with the rheumatology department or infectious disease, you know, some of these other medical specialties we interact with all the time.

Kevin Pho: All right, let’s go straight into that most recent KevinMD article. And like you said, this was started by one of those TikTok memes, and your article is titled “5 things I would never do as an allergy and immune system expert.” Now, tell us some of those five things that you would never do.

Kara Wada: Yeah, so we can kind of quickly run through them. One is I would never use a Primatene Mist inhaler. These are the epinephrine inhalers that are back on the market. They were off the market for around a decade, and in part, all of our national asthma, allergy, and pulmonary organizations were pretty upset that they came back on the market. They are not first-line treatment for bronchospasm. They will help relax those airways, but they also have impacts on our cardiovascular system.

And so when we see over 3,500 people every year die from asthma, in part this can be related to overuse of bronchodilators. Our worry is that these folks aren’t necessarily getting the full scope of care. Asthma is an inflammatory disease. We need to treat the inflammation, not just the muscle spasms that are a result of that inflammation.

Kevin Pho: So what are some of those cardiovascular risks that you mentioned that were associated with Primatene Mist?

Kara Wada: Yeah, so we see increased strain on the heart, increased blood pressure, and increased heart rate. And if you are increasing the heart rate and the blood pressure, that is essentially increasing your heart’s metabolic demand, and that’s when you see things like heart attacks.

Kevin Pho: All right, so no Primatene Mist.

Kara Wada: The next is I would never use food sensitivity testing or food allergy panels to decide what I should or should not be eating. First of all, food sensitivity tests, although they sound like a great way to figure out what foods you may tolerate or not tolerate, that, you know, may cause bloating or gas, are looking for something called IgG. IgG is our immune system memory protein. And the problem is that these reactions that we kind of term food sensitivities are more of an interaction between our body, our microbiome, and our digestion process. The immune system is not as involved, at least not in this way. And we’re actually using these IgG tests, and many times, especially in patients with true anaphylactic-type food allergy, we see that they are a sign of tolerance.

So if you read the fine print on these test kits that you can pick up at Target or online, they’ll say you need to follow up with an elimination challenge. And so I tell folks, “Save your money.” If you’re worried about a food giving you trouble, keep a journal of it. You know, write down how you’re feeling after. And if you need some help, work with a registered dietitian or your allergist, or someone who is well-versed in digestion and nutrition, rather than using these tests that are not approved, and really, the science is not what they try to market it as.

The other thing I’d like to always mention along with this is food allergy testing is not a good screening test. It’s a much better test to confirm our suspicion that a food is an allergen or is a problem. And so the reason for this is there are a lot of false-positive tests. So what that means is there are a lot of us walking around that, if I did a food allergy panel, I’d see a lot of things pop up, and they’re foods that you’re eating and tolerating perfectly fine. And so to take some of those foods out of our diet, especially in kiddos whose immune systems are still evolving and developing tolerance, we can lose tolerance to those foods. So we can actually see the potential for causing food allergy.

Kevin Pho: So if I get a patient and they come to me and say, “Dr. Pho, I think I’m allergic to X food,” then I normally would send them off to you guys in terms of what to do next. So you’re saying that there’s no real definitive test to see whether someone is allergic to a specific food, other than eliminating that food from the diet and observing?

Kara Wada: So the gold standard for food allergy is a double-blind, placebo-controlled, you know, food challenge. Now, the reality is, in many instances, the risk of doing this, like if someone has had a reaction to peanut or egg or milk, we may not want to take that risk. And that’s where food allergy testing is helpful, to confirm that someone is making, in this case, IgE, so a little different than the IgG, allergic protein to that particular food.

And there are a few other instances, you know. With everything, medicine is filled with nuance, and so there are circumstances where someone maybe has other conditions where we will use the testing or the modalities we have in other ways. But when we do these big panels or try to use it as a screening test, much more often than not, we’re seeing the potential for harm rather than help.

Kevin Pho: All right, so what’s the third thing that you would never do?

Kara Wada: The third thing is I would never ignore recurrent infections: recurrent sinus infections, pneumonias. In some cases, this may be a sign that someone has inadequately treated or undiagnosed allergies, but it’s also not terribly uncommon to have an immune deficiency. About one in 500 folks in North America will have IgA deficiency. About one in maybe 50,000 or so will have common variable immune deficiency. So although these things are not the most common cause, they occur, and we find them.

You know, granted, I see these patients all the time, and I’m seeing patients with sinus issues. But if someone is going to the urgent care, MinuteClinic, they’re getting antibiotics, maybe antibiotics are helping or not, there usually are either better treatments to try to avoid the need for antibiotics all the time, or perhaps there is a more serious underlying cause that needs to be investigated and treated appropriately as well.

Kevin Pho: So in the primary care setting, if I did see someone with, say, recurrent sinus infections, is there a basic workup that you would recommend we do in the primary care setting?

Kara Wada: Yeah, so something I would think about, especially if you don’t have good access to an allergist nearby, is getting just a basic idea of whether they’re allergic or not. So in this case, one of the environmental panels may actually be kind of helpful: a serum IgE panel for your local pollens, pets if they’re around them, and dust mites. Usually that’s a pretty easy test to obtain.

The other thing you could think about is just grabbing a blood count, a CBC, making sure their white cells and platelets and everything are looking fine. And then immunoglobulins, so quantitative immunoglobulins. We talked a little bit about the different flavors, but there’s IgG, A, M, and E. The ones I worry most about when it comes to immune deficiency would be a low level of G, A, and M. So those would be other things to think about.

Kevin Pho: So the fourth thing that you would never do, you write, “I would never rely on Benadryl to treat my severe allergic reaction.” Why not?

Kara Wada: Yes, because epinephrine is what is going to treat that root cause of anaphylaxis. That is what is going to shut down that reaction. Benadryl is just a Band-Aid. And so it may help with, you know, treating some of the itching. It is also probably going to cause that patient, more likely than not, to be sedated, which makes assessing their level of consciousness more problematic. Or, in some cases, a little less common, some people have this idiosyncratic reaction to Benadryl where they end up hyperreactive, bouncing off the wall.

And really, you want to use epinephrine early. Edge on the side of using epinephrine more liberally, because we know the earlier you use epinephrine, the less likely we are to have a rebound reaction four to six hours after that initial anaphylactic or systemic allergic reaction. So that’s going to shut those mast cells down.

Kevin Pho: Give us typical scenarios where an allergist like yourself would need to use epinephrine, just say, in an everyday setting.

Kara Wada: Yeah, so we commonly give allergy shots in our office. That is a treatment that is great for treating asthma, allergic rhinitis, and eczema, but it comes with some risk. About one in about 200 patients or so will have a more significant reaction, sometimes a systemic reaction, so we will commonly use epinephrine to treat those reactions.

The other situation is, especially in more pediatric-heavy instances, we’re doing food challenges, and sometimes those food challenges fail. Someone will have a systemic reaction to the food that we think they’ve maybe outgrown an allergy to, and so we would administer it in those instances as well.

Kevin Pho: And then in the outpatient setting, would that epinephrine be in the form of an EpiPen, say?

Kara Wada: Correct. Yeah, EpiPen, Auvi-Q, any of the generics. And ideally, you want to administer it in the big thigh muscle. If you do have either the EpiPen or the Mylan generic, it has a blue cap on the top and an orange cap on the bottom. And so we say, “Blue to the sky, orange to the thigh,” is kind of the way that you can remember. And always hold those devices like a microphone, so that you can avoid poking your finger by accidentally putting your finger where the needle deploys.

Kevin Pho: And what’s the last thing that you would never do as an allergist-immunologist?

Kara Wada: I avoid personal care products with fragrance. Our skin is our largest organ. It is one that functions very intimately with our immune system. It in part is a physical barrier, but it also is permeable. And so, in particular, if someone has sensitive skin or is prone to eczema, fragrance is a very common contact allergen. Contact allergy is a little different than that anaphylactic-type reaction. It occurs as a result of our T cells, one of our white blood cells, becoming too familiar with particular substances, and many times these are things like preservatives and nickel. Fragrance is another.

What I really did not understand at all growing up, as a fan of, you know, all the lovely scented body sprays and lotions and potions and everything, is that fragrance is actually a catch-all term used by personal care products, perfumes, and so forth. And there’s actually kind of a loophole in U.S. law that allows these companies just to write “fragrance” on the packaging, but fragrance is actually a list of many different substances to make that nice-smelling substance. And many of these chemicals that make that substance are contact allergens, but we’re also increasingly understanding that they have other physiologic effects. Many of them mimic some of our hormones in our body and are called endocrine-disrupting chemicals.

And so in addition to seeing it being a big trigger for eczema, rosacea, and sometimes hives, you know, one of the more concerning things is this: How are these impacting our metabolism, our thyroid health, and human development? So there are many reasons, but those are reasons I try to avoid fragrance.

Kevin Pho: And when you talk about personal products, give us a scope. Are we talking about just soaps, moisturizers, and deodorant? Does it go to anything that touches your skin, like detergents and fabric softeners? So give us a scope of what you mean by personal products.

Kara Wada: I would challenge you or your listeners to just take a little tour around your house and look at all the things that you’ll find fragrance in: your dish soap, as you mentioned, laundry products, everything in the bathroom. Fragrance is everywhere. It’s in our candles. It’s in our air fresheners in the bathroom, the little plug-ins. It really is quite pervasive.

And I would just, you know, caution: Some would counter, you know, maybe we should be thinking about using essential oils as an alternative. And I do occasionally like to diffuse a little or use a little, because smell is lovely. It has some physiologic effects and can be beneficial. But with everything, we just have to realize that not everything is perfect, and there have been studies that have shown, for instance, that lavender essential oil has also been associated with premature puberty and contact allergy. So not everything that is natural is necessarily safe, and not everything that is synthetic is necessarily harmful. But broad scope, I try to avoid fragrance.

Kevin Pho: We’re talking to Kara Wada. She’s an allergist-immunologist, and her latest KevinMD article, which we’re talking about today, is titled “5 things I would never do as an allergy and immune system expert.” Kara, what are some of your take-home messages that you want to leave with the KevinMD audience?

Kara Wada: I think one of the take-home messages is having some appreciation that there are broad strokes. There are some things we can do that can be beneficial for allergy and our immune system health, but, you know, the devil is always in the details, and nuance is really important. And so although these five tips are things that I say I would never do, of course there are always exceptions to the rule. And that’s when it can be really helpful to work with your colleagues and your specialist team to dig into those details, to realize that each of us is a unique individual and has different things that make us the human that we are.

And so, although there are these broad strokes, it really is important to have those relationships and to be able to communicate effectively with one another in conveying those things, as we just try to do the best we can for our patients and our own health as well.

Kevin Pho: Kara, thank you so much for sharing your time and insight. Thanks again for being on the show.

Kara Wada: Thank you so much, Kevin. Take care.

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