Baptist Hospital

Top Doctors 2015: Allergy And Immunology

Matthew C. Altman, M.D., Allergy, Asthma and Immunology Clinic at UWMC, 1959 Pacific St., Seattle, 206.598.4615; UW Medical Center; Harvard University, 2009 Andrew (Drew) Ayars, M.D., immunodeficiency, mast cell disease; Allergy, Asthma and Immunology Clinic at UWMC, 1959 Pacific St., Seattle, 206.598.4615; Allergy Clinic at Eastside Specialty Center, 3100 Northup Way, Bellevue, 425 646.7777; UW…

Matthew C. Altman, M.D., Allergy, Asthma and Immunology Clinic at UWMC, 1959 Pacific St., Seattle, 206.598.4615; UW Medical Center; Harvard University, 2009

Andrew (Drew) Ayars, M.D., immunodeficiency, mast cell disease; Allergy, Asthma and Immunology Clinic at UWMC, 1959 Pacific St., Seattle, 206.598.4615; Allergy Clinic at Eastside Specialty Center, 3100 Northup Way, Bellevue, 425 646.7777; UW Medical Center, Seattle Children's; Saint Louis University, 2006

William Butler, M.D., asthma, allergic rhinitis, immunodeficiency; Group Health Allergy Clinic, 125 16th Ave. E, Seattle, 206.326.2391; Group Health Cooperative, Virginia Mason Medical Center; Ohio State University, 1973

Vinod Doreswamy, M.D., asthma/chronic cough, all allergies, hives/urticarial; The Polyclinic, 11011 Meridian Ave. N., Suite 200, Seattle, 206.860.4454; Swedish Medical Center, Northwest Hospital & Medical Center; Mysore Medical College, India, 1994

William R. Henderson, M.D., asthma, urticaria, anaphylaxis; Allergy, Asthma and Immunology Clinic at UWMC, 1959 Pacific St., Seattle, 206.598.4615; UW Medical Center; University of California, San Francisco, 1973

Paul McBride, M.D., asthma, anaphylaxis, sinus disease; The Everett Clinic, 3901 Hoyt Ave., Everett, 425.339.5412; Providence Everett Medical Center; University of Utah, 1982

Arvinder Mokha, M.D., allergic rhinitis, asthma, food allergy; The Polyclinic, 904 Seventh Ave., Seattle, 206.860.4487; Swedish Medical Center; University of Maryland, 1995

David M. Robinson, M.D., urticaria and angioedema (hives and swelling), primary immune deficiency; Virginia Mason Medical Center, Lindeman Pavilion, 1201 Terry Ave., Seattle, 206.223.6822; Virginia Mason, UW Medical Center; Saint Louis University, 1983

Allergy and Immunology, Pediatric

David K. Jeong, M.D., pediatric and adult food allergy, asthma; Virginia Mason Issaquah Medical Center, 100 NE Gilman Blvd., 425.557.8000; Virginia Mason Lynnwood Medical Center, 19116 33rd Ave. W, 425.712.7900; Virginia Mason Medical Center, 1100 Ninth Ave., Seattle, 206.223.6173; Virginia Mason; University of Iowa, 2005

Mary Farrington, M.D., pediatric allergy and immunology, immune deficiency, food allergy; Virginia Mason Medical Center, Lindeman Pavilion, 1201 Terry Ave., 206.223.6173; Virginia Mason University Village Medical Center, 2671 NE 46th St., 206.525.8000; Virginia Mason, Seattle Children's Hospital; Indiana University, 1987

It's That Time Of Year Again — Is It A Virus Or Is It Environmental?

With the return of students to the classroom, there is also a return to runny noses, teary eyes, coughing and generally feeling unwell. That is almost a certainty.

But what is not a certainty is how to know if those symptoms could be the sign of something more serious that requires medical intervention.

If other family members are experiencing symptoms of something like a typical head cold, but without a fever, then it's a good bet that it could be treated with an over-the-counter medication and, according to Dr. Nathaniel David Hare, UPMC Allergy and Immunology, you "don't necessarily need to take them to the doctor."

But for anything that's beyond those nasal type symptoms, eye symptoms, things like that, if they're having more extensive symptoms or rashes or trouble breathing, Hare suggested that they be evaluated.

It's hard to know, though, this time of year, because everywhere there are still pollen-producing plants sending out those irritants.

"There are the main outdoor ones at this point. You've got weed pollens and wheat pollens which tend to run through the first hard frost. So generally they're, the end of September into the first week of October. The first hard frost is kind of when they start settling down," he said. "Same thing outside. Molds are an issue this time of year with harvest season, and they can run through kind of the first hard frost, if there's no snow cover. They never quite completely disappear, but they're at a lower level," he said.

There are also seasonal allergens indoors.

"Occasionally people have what is called a multi-colored Asian lady beetle, but basically it's a type of invasive ladybug species that in some older houses, will go invade the house, and if you get hundreds or thousands in your house, occasionally, people can become allergic to them," he explained.

"It's an unusual seasonal fall indoor allergen, since the ladybugs come into the house that time of year. But for most people, they don't get that issue with their houses, it won't usually be an issue," he added.

Hare also cautioned people to be aware of insect stings before the first hard frost occurs. Honey bees, yellow jackets, hornets, wasps and things like that tend to be more active this time of year because the weather is becoming cooler.

Allergens can also be a problem once people start hunkering down for the winter, even though allergies tend to be less of an issue when a house is closed up.

"The outside allergies are probably less of an issue at that point, and probably done for the year, but if you're allergic to stuff that's indoors, like dust mites or animal danders that can sometimes get worse when you close up the house for the winter because you're spending more time indoors," he said.

It's usually easy to know that these symptoms are caused by an allergic reaction and not by a virus.

"It's an easy one, if you have a fever, you know, you're not dealing with allergies," Hare said.

"It's harder sometimes, if you have a virus without a fever — it's mainly just eyes and nose, like itchy, sneezy, stuffy, runny type stuff, that's a little bit harder to tell. If it's gone on more than probably a week or so, the chances of it being an allergy are probably a little bit higher, especially if nobody else in the family is getting it," he said.

For allergies, basically the treatment is dictated by the symptom. If your eyes are affected, Hare suggested eye drops or some type of allergy pill in the case of older children or adults, or a liquid allergy medicine for children. For nasal symptoms, an allergy medicine or a nose spray is appropriate.

For people who chronically suffer from allergies, the same treatments are appropriate, but if that doesn't work, Hare said, "you can see an allergy doctor, get allergy testing. And if it's appropriate, you have the option of doing allergy shots to retrain your immune system, and they work for about 80% of people — they average about a 50 to 70% drop in symptoms."

If you want to enjoy the last days of summer but suffer from allergies, Hare suggested going out later in the day when the pollen counts are lower.

"Otherwise you're looking at, can you control symptoms with medication, or do you need to do allergy shots at that point if it's something outdoors? The other thing to keep in mind is, during this time of year when there's outdoor allergies present, if you're using window air conditioning units, the filters on those aren't good enough, the pollen is too small," he said, explaining that a HEPA filter would alleviate that problem.

Doctors' Knowledge, Attitudes About Cannabis Impact Allergy Treatment

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Knowledge about and attitudes toward cannabis use vary among allergists, with significant impacts on the way these clinicians approach the care of those who use it, according to a study published in Annals of Allergy, Asthma & Immunology.

"Physician knowledge regarding cannabis has been shown in the literature to be lacking. Until recently, there hasn't been a conduit for learning about cannabis," Joanna S. Zeiger, MS, PhD, CEO of the Canna Research Foundation, told Healio.

Data were derived from Zeiger JS, et al. Ann Allergy Asthma Immunol. 2022;doi:10.116/j.Anai.2022.04.021.

Joanna S. Zeiger

"We wanted to identify the deficits in knowledge and determine what kind of knowledge system would be of interest to allergists," Zeiger said.

Prior work by the researchers had found that 18% of people with allergies and asthma had used cannabis within the previous 2 weeks, and more than 50% of them consumed it via inhalation methods.

"This could potentially exacerbate asthma symptoms of coughing and wheezing for those with asthma, especially if their asthma is not well controlled," Zeiger said.

Many of these respondents reported beneficial effects on sleep, pain and anxiety from using cannabis, Zeiger continued. Only 19% of these patients wanted to discuss cannabis with their physicians, while only 34% of physicians asked about cannabis use.

"We wanted to understand if knowledge and attitudes regarding cannabis influenced physician comfort speaking to patients about cannabis, whether they counseled cessation of inhaling cannabis, whether they asked patients how often they used cannabis and their preferred route of administration," said Zeiger.

As part of the Cannabis Allergy KAP (Knowledge, Attitudes, Practice) Collaboration, the researchers surveyed 207 members of the American College of Allergy, Asthma and Immunology, 47 members of the Canadian Society of Allergy and Clinical Immunology (CSACI) and 191 members of the European Academy of Allergy and Clinical Immunology (EAACI).

The cohort was 49.7% female, with 65.2% born between 1946 and 1964. Also, 54.4% had less than 20 years of experience, 54.9% practiced in nonacademic or research settings and 93.1% had Doctor of Medicine, Doctor of Osteopathic Medicine or Doctor of Philosophy degrees.

The survey included seven items about cannabis knowledge related to allergy care, 13 items pertaining to attitudes toward cannabis and four questions addressing practice approaches to cannabis.

According to the survey, 51.2% of respondents had fielded patient complaints of cannabis allergy, with the highest percentage at 74.5% of the CSACI members and the lowest percentage at 36.2% of the ACAAI members (P < .001).

Also, 84.5% of the respondents had seen between one and nine patients with suspected cannabis allergy, with symptoms including urticaria/angioedema (27.1%), nasal congestion (24.6%), rhinitis (23.2%), cough (23%) and anaphylaxis (14.9%).

Skin prick testing for cannabis sensitization was performed by 71.4% of CSACI members, 35.4% of EAACI members and 25.3% of ACAAI members. Also, only 5.3% performed in vitro testing for cannabis sensitization.

On a scale of 0 to 7, with 0 indicating no correct responses and 7 indicating all correct responses, the researchers found an overall mean of 3 (standard deviation [SD], 1.7) for knowledge. The ACAAI respondents had a mean of 3.5 (SD, 1.6), the CSACI respondents had a mean of 3.3 (SD, 1.6) and the EAACI respondents had a mean of 2.4 (SD, 1.6).

Analysis also led the researchers to classify attitudes toward cannabis as traditional (n = 138; 31%), progressive (n = 215; 48.3%) or unsure (n = 92; 20.7%). The ACAAI respondents included 22.7% traditional, 60.4% progressive and 16.9% unsure. The CSACI respondents included 10.6% traditional, 66% progressive and 23.4% unsure. The EAACI respondents included 45% traditional, 30.9% progressive and 24.1% unsure.

Overall, 70.1% of respondents said they were comfortable talking to patients about cannabis, including 67.6% for the ACAAI, 76.6% for the CSACI and 66% for the EAACI, yet only 35.5% said they verbally queried patients about cannabis use or did so on their intake form.

Similarly, only 28.9% had verbally asked patients about cannabis use in the previous month even though 46.2% said they had noticed an increase in cannabis use among their patients. Queries most often involved how often and how patients used it (56.8% and 51.2%, respectively).

When patients indicated that they smoked or vaporized cannabis, 30.9% of the doctors said they always counseled cessation, and 29.1% said they sometimes counseled cessation.

Further, there were differences in the discussion of cannabis by the three allergy societies, as 28.6% of EAACI members, 13.5% of ACAAI members and 4.3% of CSACI members did not discuss cannabis with their patients.

Doctors who were more knowledgeable about cannabis were more likely to be comfortable discussing it with their patients, asking patients about how and how frequently it was used, and counseling patients about cessation (P < .001), the researchers said.

However, doctors classified with unsure attitudes toward cannabis were less comfortable in speaking to patients about it, while those with progressive attitudes were the most comfortable (P < .001). In fact, 37% of those with unsure attitudes did not discuss cannabis with their patients at all, compared with 15% of those with traditional attitudes and 14% of those with progressive attitudes.

Knowledge and attitudes may supersede demographics, location and legality in approach to care, the researchers said, adding that knowledge impacts attitudes, which then impact care.

"We found that allergists who had more knowledge about cannabis tended to have more progressive attitudes regarding cannabis, and this led to more comfort speaking to patients about cannabis and asking patients about how often they used cannabis and what method of consumption they used," Zeiger said.

Conversely, doctors with unsure attitudes had the lowest knowledge and were least likely to discuss cannabis with their patients. The researchers indicated that a lack of training in cannabis and the endocannabinoid system is one of the most common barriers to knowledge and willingness to consult with patients.

"Patients with all types of conditions are using cannabis. Thus, it is important that physicians learn about cannabis so they can ask their patients the right questions, either verbally or on intake forms — or both — about their cannabis use and discuss cannabis without judgement," Zeiger said.

Though cannabis can be beneficial in many situations, it has adverse effects as well, Zeiger cautioned. Patients need to be educated by reputable sources to maximize the positive effects of cannabis while minimizing its harm, she continued, and they are looking for guidance.

"Right now, dosing, frequency of use and cannabinoid ratios are difficult to address since scant research has been done, and these parameters likely differ depending on the symptoms/conditions being treated," Zeiger said.

The researchers called on professional societies to create cannabis content that provide general information geared toward their specialty. Also, the researchers said, doctors need to understand the laws regarding cannabis use where they practice.

The survey indicated that 48.5% of allergists want didactic learning, 46.7% would like pro/con learning and 41.1% said modules would meet their needs, with 68.8% preferring webinars and 56.4% favoring national meetings.

"The more physicians engaged in this type of discourse, the better, because this will help grow the knowledge base in a real-world setting," Zeiger said.

"Physicians can help destigmatize cannabis and make access easier for those who need to use it medically and perhaps even provide influence to make cannabis federally legal, which will make the study of cannabis much more feasible," she said.

The researchers plan to continue similar surveys in other physician and patient groups.

"Additionally, we will be creating educational materials to help allergists learn about many facets of cannabis to aid them in their patient interactions regarding cannabis," Zeiger said.

"The more physicians know about cannabis, the more likely they are to discuss it with patients, and this engenders a safer and potentially more effective situation for cannabis use."

For more information:

Joanna S. Zeiger, MS, PhD, can be reached at joannazeiger@comcast.Net.

Sources/DisclosuresCollapse Disclosures: Zeiger reports being the CEO of Canna Research Foundation and receiving funds from ACCAI, CSACI, EAACI and Allergists for Israel. Please see the study for all other authors' relevant financial disclosures.

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