A Holistic Approach to Mast Cell Disorders
Kara Wada, MD: Welcome back everyone to this episode of the Becoming Immune Confident podcast. Hello, my name is Dr. Kara Wada. I am a pediatric and adult allergy, immunology, lifestyle medicine physician, and an autoimmune patient. And I am really excited to talk about a topic today that is near and dear to my clinical work at The Ohio State University, where I see patients three days per week and train medical students, residents, fellows. I am really excited to talk about mast cell disorders. I am gearing up to give a presentation to my colleagues. It's called a Grand Rounds presentation. These are weekly meetings where we get together and learn about a particular topic that either one of our internal faculty or a guest faculty has expertise in and my upcoming talk is entitled, A Holistic Approach to mast Cell Disorders: Bridging Academia with the lived experiences of Our Patients. And I'm going to give a version of that talk, get some practice here, in sharing this information that I've pulled together to share with my colleagues, with you all as listeners.
If you are tuning in on your favorite podcast app, know that this presentation is also available on our YouTube channel, which is the @drkarawada and over there, you'll be able to see the slides that I will be using so I'm gonna do my best to describe those for those that are listening, but if you do want that visual cue you can go over, make sure to subscribe while you're over there so you don't miss any of our videos, podcast episodes, all of this great, empowering education that is really geared to helping you feel confident in navigating life's ups and downs with chronic illness, and also learning about the science of our immune system and how that plays a large part in our health and healing.
So let's jump in to mast cell disorders.
What is a Mast Cell?
Kara Wada, MD: Let's learn about what they are. What are mast cells? And when I'm talking about mast cells, if you aren't looking, I'm reading it's M A S T, like the mast of a ship. Why should we care about these little immune system cells? How do they misbehave? And then what can we do about it when they are a problem?
So let's start off and jump in with what exactly is a mast cell. So we currently understand these cells as allergy cells. That's what we call them. And we call allergy cells a few different types of white blood cells. We'll refer to mast cells, to eosinophils, and sometimes to basophils.
We're going to really focus in on this one cell type called mast cells today. These white blood cells evolved over 500 million years ago. So these little white blood cells predate dinosaurs. And actually we know that lizards and frogs have mast cells. So we would anticipate the dinosaurs would have had mast cells as well, but they're even found in animals that don't have a backbone, so invertebrates. So these are really quite ancient white blood cells.
What makes them somewhat unique along with basophils is that they express antibodies or proteins, IgE type. And these we currently know as allergy antibodies or allergy proteins. They provide our immune system memory or a certain type of immune system memory and these cells express those proteins on their surface, and those act like receptors. We'll talk a little bit more about that in a few minutes, but that's something that makes them unique. The reality is though, when we think all the way back to 500 million years ago, or maybe a little more recent, when our ancestors were sitting around the campfire in the cave. These cells were really tasked with protecting us from parasite infections. So parasite infections, things like worm infections, intestinal worms, hookworm, all those sorts of creepy crawly things that we don't want to think about. And I think it's really helpful to think about how we envision immune system cells fighting off infection. Typically, we would think of this white blood cell acting like Pac-Man, gobbling up that bacteria that's much smaller than the white blood cell. That white blood cell will gobble up multiple bacteria at a certain point it gets so full that it self destructs. And that is what we then learn or see as pus.
Now, let's think about this little white blood cell, this little mast cell, and compare that to the size of an intestinal worm or a hookworm. It's like David and Goliath, right? So the worm is relatively large compared to this little white blood cell. It can't do the Pac-Man action to gobble it up. Instead, it evolved to have pre-formed packets or granules of different toxic chemicals.
So things like tryptase and histamine are two of the most common, but there are actually over 100 different chemical mediators that these mast cells are able to produce and to secrete or essentially eject out of their cells when they become activated or turned on. And that is then what we experience or the symptoms we see when we have mast cells that are triggered.
Alright, so let's go way back. We think about how our immune system is set up. If you want to learn more about how the immune system works, go back to the episodes from January of 2023. We have a whole 4 or 5 part series called Immunology 101, but when we think about where these white blood cells come from, they all start with these, this word 'stem cell' that is a multi potential stem cell. It has the ability to become any type of white blood cell. It also can become a red blood cell or a platelet. So it starts off as the stem cell and then it divides and it can go one of two ways. It can go the way of the lymphocytes or the lymphoid cells, which then go on to become natural killer cells, T cells, B cells, plasma cells or it can go the myeloid lineage, which is what we're going to talk about today. And that's where the mast cells evolved. Those are the same line that have those red blood cells. It has the cells that will form platelets or megakaryocytes. And then we also have basophils, neutrophils, eosinophils, monocytes, macrophages, and dendritic Cells. So those are all in their own element of the family tree.
Clinical Sign & Symptoms of Mast Cells
Kara Wada, MD: When we think about mast cells and the symptoms that they are able to create when they are activated, when they're activated by allergies, infections, other immune cell chemical mediators called cytokines, medications, toxins. We have a series of symptoms that we now, in our brains, associate with allergy. But it's a little bit broader than that, and those symptoms can vary based on the location of where these cells are triggered or activated. When we think about mast cells degranulating or becoming activated in our respiratory tract, not surprising that we're going to think of stuffy, runny noses, itchy noses, feeling short of breath or wheezy, and throat swelling.
We think about the skin, we think about hives and angioedema, or swelling of the eyes, the lips, the tongue, the fingers and toes and the genital area. But we also can see flushing or even itching sometimes without a rash. Now I want to have a little asterisk that not all itching is the result of mast cell symptoms. I think of itching in a much more broad context, and I think about it in the same way I think about pain. It's a symptom we can experience. Oftentimes it can be related to mast cells, but not always. Think about our digestive tract: abdominal cramping, reflux, nausea, vomiting, diarrhea, thinking of ways that our body when these cells were activated if we had a parasite infection in that area of our body was trying to purge those things out, "Get them out". Because that was the only way that we were able to really fight them off well.
The other more serious symptoms we think about with allergic reactions affect our cardiovascular system. So low blood pressure, passing out or almost passing out, feeling lightheaded, fast heart rate. These are symptoms that can result in really severe anaphylaxis. Now, if we have too many mast cells or ongoing chronic inflammation, it's not surprising that you would see whole body symptoms like fatigue, generally just feeling malaised or cruddy, weight loss, bone pain, if you have too many of these mast cells, especially in the bone marrow, and you can see bone weakness like osteopenia and osteoporosis as well.
So there are two main flavors of mast cells that we talk about. We have ones that are found in our mucosal surfaces. So our gut, our respiratory tract, our GU or our Genital Urinary tract. And then we have connective tissue mast cells, which we attribute more or think about more in our skin and kind of in those areas near our blood vessels as well especially in the skin and other connective tissues. And these mast cells have a variety of differences. If you are watching this on YouTube then you can see it. We have two complicated looking little cell diagrams here, cute little cartoons. And it reminds me of those picture puzzles that you would see in an old Highlights magazine, where they have the two pictures that look similar, but you have to circle the things that are different.
And so what are different between the gut or the mucosal mast cells and the skin or the connective tissue mast cells? One thing you'll notice right away is that mucosal mast cells, they make tryptase, and the skin mast cells or connective tissue ones make tryptase and chymase. So they have a little bit different chemical mediators that they are able to secrete when they're activated.
Not surprisingly with different chemical mediators that are being released, you also see a difference in the types of cells that are being triggered downstream. Once these mast cells are activated or triggered. Then you see other immune system cells that are brought into the mix like T-cells, eosinophils, dendritic cells, neutrophils, but there are some differences depending on what type of mast cell is activated and what these downstream effects are.
Upstream, when we think about how they're activated, I think it's really interesting and important to note that we mentioned that the IgE antibodies, those allergic antibodies, those act as receptors. Those are missing from these diagrams, but those would be other receptors that would be on the cell surface. Especially, if you are someone who is an allergic person, you make allergic type antibody. But the other types of receptors we see that are shared are toll like receptors, integrins of varying types. And then on the skin mast cells, we also see a really fascinating receptor that is really relatively recently discovered called the MRGPRX2 receptor. Goodness, that's a mouthful.
But this is the receptor that we have realized in the last few years is what many medications work through. So there are medications like opioids. Folks who are more sensitive to these medications may have itching, flushing, hives type symptoms when they're exposed to these medications. It'll look and feel all the world to them like an allergic reaction, maybe even an anaphylactic reaction. But when you get to the nitty gritty of how these cells are being triggered, we technically, as an allergist immunologist, would term this an anaphylactoid reaction. So it's anaphylaxis really referring to when mast cells are triggered specifically by an IgE type mechanism, usually. So it's splitting hairs, but just helpful to know that there are some different ways that these cells can get turned on. Not all mast cell activation is related directly to allergy.
So that's why it's actually quite common for me to see folks with mast cell related symptoms and they may have totally normal allergy testing. So that's not abnormal or odd for me, although it may seem that way if you know, didn't know that.
Why should we care about Mast Cells?
Kara Wada, MD: So why should we care about this? The reality is we're continuing to evolve as humans and we have had a lot of environmental pressures and changes to see changes in how our genes and the proteins our genes are encoded for are expressed.
So if we think about the changes even, you can think back to how we evolved. To live in small tribes, we are hunter gatherer societies, maybe doing a little bit of farming early on. And now, we live in these comfy, cozy environments surrounded by our couches and carpets and warm beverages and artificial heating. And we don't have parasite infections and goodness, I love my creature comforts, but we can really see that there's a huge contrast in how we live now compared to even how we were living 200 years ago. And really, we have seen this huge increase in allergies and autoimmune diseases, too, over the last several hundred years.
So in the U. S. alone, over a quarter of adults are affected by an allergic disease. where mast cells would be implicated, and around 20 percent of children. And we also have seen that these diseases have changed over time as well. So going back to the mid 1800s, you really see this big increase in folks dealing with hay fever or seasonal allergies like: runny noses, itchy, watery eyes.
Into the 1900s, more of the airway affected with asthma. And then into the late 1900s, the 2000s, where you're seeing a lot more food allergy, eosinophilic esophagitis, and I really am quite concerned that we are seeing an ongoing evolution of how these cells misbehave. It really has only been in my lifetime, I'll be 40 in April, that we have even known about the condition eosinophilic esophagitis, which I now see someone in the office at least once or twice a week with this condition that is driven by the another type of allergy cell called eosinophils, but that really wasn't an issue before the 1980s and 90s.
Spectrum of Misbehaving Mast Cells
Kara Wada, MD: So when we think about mast cells, there's a spectrum with how they can misbehave or how they can be problematic, how they can be triggered and cause symptoms. And if you're watching on YouTube you'll be able to see this this diagram that I recreated from one of the papers cited in doing my research for this talk. But we have the all encompassing circle of all mast cell disorders where mast cells are implicated. In a smaller circle, which is not drawn to scale, we have allergic conditions. So we certainly know that mast cells are implicated in allergic disease. They may not be the driving factor, but they're playing some sort of role in that problematic physiology, or how our bodies are not working quite well as they should.
There's also an overlapping circle that is mastocytosis. Mastocytosis is a condition where we have very kinda strict diagnostic criteria where you can check the boxes, where mast cells are in greater numbers and they have a little bit different look about them. Oftentimes, there's a mutation that affects how they behave.
And some of those people have some allergies, some do not. Some have anaphylaxis, some do not. Some have a bad bee sting, and that's actually how we find out that they have this condition. They otherwise feel pretty okay.
We also know that mast cells are a huge driving force in how anaphylaxis occurs. So mast cell degranulation, if it occurs in enough quantity, will result in anaphylaxis, and so we also have idiopathic anaphylaxis as a smaller subset on here as well, where we don't know why certain people are having these reactions, and then we have mast cell activation, which again, we have some criteria as to how that is diagnosed, but the reality is, and what's missing from this diagram, is a group of individuals that I am increasingly I have been seeing in my clinics day in and day out, week after week, that have symptoms that would suggest that mast cells may be not behaving normally and yet they don't fit or check the boxes specifically for mastocytosis.
They don't have allergies necessarily that are a driving factor, which are positive on either skin testing or blood testing and they don't fit the exact criteria for mast cell activation syndrome either. And so that is where there is this disconnect between what is discussed in academic journals and at our meetings and what I am clinically seeing and hearing as the lived experiences from my patients. And that's where we need to continue to do a lot of work.
Mimickers of Mast Cell
Kara Wada, MD: So some of that work is being familiar and thinking about what are the things that may look and sound or act like mast cell related symptoms or disease. What are the things that I can't miss or that we want to think could maybe be masquerading as this mast cell disorder that doesn't have a specific set of criteria.
So some things we would think about are eosinophilic diseases, so EOE or Eosinophilic Esophagitis or EGIN, which is Eosinophilic Gastroenteritis. Sometimes I will have patients who have vocal cord dysfunction. And the reality with vocal cord dysfunction is you can also see that along with mast cell or food allergy, other things.
So just because you have one doesn't mean you don't have the other. Bad reflux, celiac disease can masquerade as many different things. Autoimmune diseases like multiple sclerosis, scleroderma, Sjogren's, certain types of tumors that secrete hormones like pheochromocytomas or parathyroid or carcinoid type tumors.
And there actually are some immune deficiencies that even with that increased susceptibility for infection, there also is inappropriate inflammation that can sometimes masquerade as well.
Mast Cell Adjacent
Kara Wada, MD: There also are a list of conditions that I consider mast cell adjacent. So these may have the potential to masquerade as mast cell, but they also may be found and diagnosed in the same individuals as well, similar to what I mentioned with vocal cord dysfunction.
But those include dysautonomia or POTS. So other types of dysautonomia where the automatic neurologic system is having difficulty with functioning correctly and communicating with our cardiovascular system or our ability to regulate temperature.
Folks who are hypermobile, it may turn out that folks who are hypermobile are more prone to mast cell disorders and or it looks like they are more prone to dysautonomia. There's also a lot of emerging data and interest in our microbiome and what happens when our microbiome is in a bad spot. So this can be described as dysbiosis. So when our gut bugs are just not in a good number amount, you don't have good gut health, so to speak and one of the diagnoses related to that is SIBO, or Small Intestinal Bacterial Overgrowth, when certain bacteria or fungi are in excess amounts. These sorts of issues can result in more food intolerance issues, so more difficulty digesting. So if you eat too much of a certain food or substance chemical mediator that is found in foods like histamine or salicylates or some of the FODMAPs, which are the fermentable oligosaccharides, you end up really bloated, uncomfortable, just feeling miserable.
There also are some other allergic conditions. and inherited conditions that can result in mast cell related symptoms. So hereditary alpha tryptassemia or chronic urticaria and angioedema, Alpha-gal allergy. We have to have an episode still. I have to reach out to my colleague. Dr. Kahwash, he had a great article that was in the New York Times not that long ago talking about a patient he cured for down in Vanderbilt who had Alpha-gal allergy that was resulting in significant symptoms.
So Alpha-gal allergy, for those who are not familiar in certain areas of the United States and elsewhere in the world as well. If you are bitten by a Lone Star Tick, these are the same ticks that can give you Rocky Mountain Spotted Fever and a few other tick borne illnesses. You can develop an allergy to mammal-based meat or mammalian meat. Four legged meat. So that would be beef, venison, pork, goat, lamb, bison, any of those red meats or meats that would come from four legged friends. And what's different about this as a food allergy is you're not having symptoms within minutes of eating the food but typically hours after that food is digested and then essentially becomes what we're allergic to during that digestion process.
There also are conditions that are thought to be related to mast cell exuberance, like interstitial cystitis where you have difficulty with bladder issues. It may seem like you're having a lot of bladder infections when the reality is it's not an infection, but just inappropriate inflammation.
Autoimmune diseases and then multiple chemical sensitivity, which is still a diagnosis that we really don't fully understand. But can look and sound or come along with sometimes mast cell adjacent.
Making the Diagnosis
Kara Wada, MD: So what do we do if someone comes to see me in the office? What are we talking about? What are we doing to try to figure out what the diagnosis may be because the reality is having some way to characterize or understand what's going on with your body really helps us one feel validated in our experience but also gives us a path forward.
Okay, what are we going to try? What are we going to do? It helps delineate that. It also helps us just feel like we're part of a community of other folks who are dealing with similar things too. So the most important thing we can do is sit down and take a comprehensive history and do a physical exam. The reality is this takes time, especially if you maybe have seen lots of other doctors before. You've had symptoms going on for a long time. Oftentimes, I would say 99 percent of the time, I am talking with folks who have had experiences within the healthcare system that have not been ideal. Far from it, in fact. And it takes time to sit down and to feel comfortable and to build that trust with me, especially if we're just meeting. So this is my call to you. If you are someone who is in Ohio and you're wanting to come see me or you're going to come to Ohio to see me, make sure that we know that you're coming to be evaluated for these conditions so we can make sure you're in the right appointment slot. We really try our best to make sure we have an hour blocked out for patients that are concerned about mast cell disorders because we know it takes time to go through the records, it takes time to get the story. And it's not something that can really be rushed.
All right, so what else are we looking for on physical exam? We're looking for, are there any signs or symptoms of rashes or cutaneous manifestations or skin manifestations of mastocytosis? There's a particular type of mastocytosis that will have certain skin rash and skin findings. We're also looking, have you had any blood work? Have you had your tryptase checked? And if not, usually we're thinking about checking that. Tryptase is one of those substances our mast cells create. It is one of the diagnostic criteria for systemic mastocytosis and will be elevated in those individuals.
It's also helpful, and this can be a little challenging at times, if you are someone who's having significant symptoms that are episodic, so maybe more anaphylaxis-like symptoms from time to time, to check tryptase level within four hours of that event.
Now, sometimes it can be hard to get the emergency department on board with drawing that level. Something we're working on from the inside to try to help streamline that. But looking for an elevation from baseline can also be helpful. So that's something else we're thinking about talking about, thinking how we might be able to capture that.
Other things we may think about, depending on the situation, we may be thinking about allergy testing. We may be thinking about testing for a particular mutation called a KIT mutation, which would occur in mastocytosis. And then we also may think about checking a 24 hour urine collection. It's not the most pleasant, but it's also not the worst.
You have to pee into a container, collect all your urine for 24 hours, it has to be kept refrigerated, and then that is sent to be evaluated for some other mediators that mast cells release that are not able to be captured in the blood. And again, sometimes we'll do this at a baseline, sometimes we'll also do this when the symptoms are flared up. These are lab and blood evaluations that help us determine what category condition may fall under. We also are going to be thinking about do we need to test for some of those things that can be the mimickers or go along with mast cell related disorders as well.
So really having to think about your story, your exam, and making a case by case personalized approach, using these frameworks as our guides.
So what's left? Say your labs are normal, your urine studies are normal, but your symptoms aren't normal. And maybe you improve when we try some therapies that are directed towards mast cells. That's the group of individuals that we really need to understand better and to have a better framework for knowing how best to help them. That's what I'm particularly interested in.
What can we do about it?
Kara Wada, MD: So what can we do about it? If you have mast cells that are misbehaving, if you have mastocytosis, mast cell activation that meets criteria, maybe you fall into this other category as well. There really are four ways I think about how we can approach this.
One, first and foremost, we need to have trauma informed, compassionate care. Talk a little bit more about that in a minute. We need to think about symptom relief. What are some ways that we can use lifestyle and trigger avoidance to help improve symptoms as well? And then what are some treatments that are under investigation that we may think about trying, depending on those individual patient physician conversations. that you're having with your health care team, or if I'm your doctor in clinic, what we may be thinking about trying, depending on that shared decision making approach. So that's where we work together as a team to figure out the path forward.
So what does trauma informed care look like? It's active listening. It's understanding that I can never fully walk in your shoes. but I can listen and we can let you know that you're being heard even if we can't fully explain your lived experience through the science that we currently have. It's that human to human connection that mitigates the trauma and what I've realized in, especially in my years of taking care of patients I've been in clinical practice now, graduated med school in 2010. Well over 10 years and almost half of that time I have spent now, both as a patient and as a physician, I've really realized how key validation is. Feeling seen, heard, and believed is paramount to that therapeutic trust. It's also really important, I think, to understand from the patient and the healthcare professional side of things that as a healthcare professional, I am human. As a doctor, I am human. And I am going to do my best to set some boundaries so that we understand and communicate in a way that's respectful and also helps me to let you know that I am human and have limitations as well. So it's setting the stage that we can avoid some of the the hiccups that can happen with medical care. We do our best to let patients know the length of our appointments. I will do my best if we need to try to block additional time within the capacity that we have, if we think that's necessary.
Try to let people know, what are the ground rules for communication between visits. And we talk about, if we're doing lab testing, how we're going to follow up on that after you leave the office, what that's going to look like. And that kind of depends on the situation. It's also rethinking.
So Adam Grant, he is a psychologist. He is a professor at University of Pennsylvania. He is a New York Times best selling author. I love his advice. It's staying humble, maintaining a healthy dose of skepticism, and approaching the world with curiosity. Really, the reality is, despite knowing now more than we ever have about the human body, about physiology, our work isn't done. We still continue to learn and we still continue to evolve. And the thing that I share with my colleagues and I'm excited to share when I talk with them that remind them it's okay for us not to have all the answers. I think that's hard for folks that are generally helpers. We want to solve problems. We want to help people feel better. And when we don't have the answer, we feel pretty crappy and out of sorts. And sometimes we don't always respond in the best way or the most productive way when we're in those circumstances.
So what can myself and my colleagues, what can we do when we don't have the answers? We can try to connect you with a colleague who may have better answers. We can connect you with good other online resources we may know about. We can explain our biases, our goals and values that we would have, in your care when we're thinking about shared decision making, and we can talk about alternatives, working together or maybe not being a good fit as well.
Alright, so we've covered the trauma informed care part, which I think is critical.
What can we do about symptoms?
Kara Wada, MD: We also can work on symptom control and see if symptom control, if we're really working on controlling mast cell mediators and directing therapy that way, is it helpful or not? That is really instructive as we're thinking about what may be driving symptoms so we can try a combination of different antihistamines or mast cell stabilizers. Someone's having anaphylaxis episodes, they need epinephrine. Occasionally, we will use corticosteroids like prednisone. It's not something we like to use all that often, and we definitely don't like to use it long term, but sometimes can be really helpful to put fire out. And then for folks who have especially systemic mastocytosis, some of those KIT mutations I remarked on earlier, there are specific medications called tyrosine kinase inhibitors that are really helpful.
Kara Wada, MD: It's also important to learn and become expert in your body, and that can include avoiding triggers.
I call this kind of a trigger warning page. One of the areas I'm also really keen to continue to learn about and study in the coming years is the brain-body connection as to how we react to potential triggers as well, and understanding kind of the implications of trauma responses and how that may play a role in how we perceive our exposures to certain things over time as well.
But we do know mast cells and certain people's mast cells can be particularly troublesome or twitchy is how sometimes used in the clinic space to temperature changes. To stressors, that includes emotional, physical, like pain or environmental stressors, like huge weather shifts or coming through pollution, pollen, exercise, especially very vigorous exercise, fatigue, certain foods and beverages but alcohol is really one of the key ones that would be recommended to avoid. And then certain medications, so opioids, NSAIDs for some folks, certain antibiotics, local anesthetics, and contrast dyes. Now, it's really important to note that not everyone is going to have all of these be triggers. And so it's really important that we do our best to avoid always being this very hypervigilant or fight or flight state but to be conscientious that these could be triggers if you're dealing with mast cells that are not behaving. And so these are things I mentioned to my folks with chronic hives as well and other kind of mast cell related conditions. But certain perfumes, scents, odors, venom, as I mentioned, sometimes a sting is how we actually diagnose mastocytosis and some mast cell disorders. Certain infections, mechanical irritation, like friction, like a rough wool sweater vibration and then sunlight for some folks as well.
Kara Wada, MD: So what are some of the treatments that are being investigated that may be helpful, but we don't have enough evidence to say that these are FDA approved or that everyone should try them? But are things that we're thinking about that have been some case studies that would say that quite possibly they may be helpful for some folks. Low dose naltrexone. Naltrexone, at its standard doses, is used to help prevent folks from relapsing with alcohol or opioid addiction. At much lower doses, though, we can use it for modulation of chronic itching, inflammation and so a lot of research going on naltrexone. Interestingly, for many years, a low dose naltrexone was sometimes used for folks on pain pumps to help mitigate some of the itching related to the opioids they were using to help treat their pain. So this is an older treatment kind of taking on a new use and in a new way that I think has some exciting promise.
The other area that I am fascinated to learn more about and to see where things pan out is vagal nerve stimulation and brain retraining. How do we see improvement in modulating inflammation through our nervous system? Mast cells and our nervous system are intimately connected. They are in very close proximity to one another, especially around our blood vessels. And so is this a way that we can help turn down the inflammation? I think this is an exciting area that I'm beaded breath waiting to see what the research ends up showing.
For folks who have gut health issues, who are dealing maybe with histamine intolerance issues, there are a portion of folks that may benefit from taking a supplement of DAO, which is what breaks down histamine. So that for some people may be helpful. And quercetin, which is an antioxidant. Often it's found in good concentrations in apples. That may also be helpful for some individuals as well.
I think really the lingering questions that we're left with and really have room for growth, these are growth edges, what is this, is there truly a chronic form of mast cell activation? What are some criteria that encompass these people in this group of individuals? How can we best treat them? Are there other blood tests or urine tests that would be more helpful in capturing mast cell activity and misbehaving mast cells, knowing that there are some blind spots or some spots we very well are missing when we're looking just at tryptase and the urine studies that are available?
How helpful or is it helpful to use omalizumab or Xolair? Really helpful for my chronic hives patients, my patients with idiopathic anaphylaxis. How helpful is this? And is it tolerated well by these folks who have other mast cell disorders? And then what is this relationship? Or can we understand more about this possible relationship between hypermobility, POTS, and mast cell?
Because that is something that really, although we hear and so much talked about in the patient community, the scientific evidence is still like needing some work in that area to really flesh that out and understand what's going on there. So I hope you found this helpful. I hope this helps generate some questions.
Again, reminder, as we say at the beginning of every episode, this is for educational purposes only. Not engaging in patient-physician relationship through podcasts or through YouTube but really want to stimulate conversation, get the word out about these conditions that we were not taught in med school, still not really being taught much about in med school, and really providing that education, that empowerment, and a path forward.
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If you would like to come see me in Columbus, Ohio at Ohio State, we will have the link where you can find information to get scheduled. I also work with a group in coaching, in the Becoming Immune Confident community, which is community, it's coaching, it's a course, it's like everything that I wish I had as I was embarking on my journey as a patient.
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Hey there, amazing listeners. Before we wrap up today's episode, I want to take a quick moment to ask for your support. If you're enjoying the content of the Becoming Immune Confident Podcast, we're bringing you week after week, there's a simple, but incredibly impactful way you can show your appreciation.
You see, leaving a review is like giving us a virtual high five and it helps our podcast to reach even more people who could benefit from the valuable insights, entertainment, and inspiration we strive to provide week after week. So if you're finding value in what you hear, here's what you can do. Open up your podcast app, whether you're on Apple podcasts, Spotify, or any other platform, and give us a glowing five star review we're dedicated to bringing you the best and your feedback helps us fine tune our content to suit your interests and needs.
But, hey, don't stop there. If you have a moment leaving a few kind words in the review section goes a long way too.
Share what you love about the podcast, your favorite episodes, or how it's made a positive impact on your life. Your words, not only brighten our day, but they also encourage others to join our incredible community.
Remember every five star review and every word of encouragement counts, it's like fuel to keep us creating, innovating and striving to make your listening experience even better. So if you're up for it, show us some love by leaving us that virtual high five in the form of a five star review today.
And a huge shout out to all of you who have already taken the time to do so.
Thank you for being a part of our podcast journey and we can't wait to keep bringing you more amazing episodes in the future.
Until next time, keep shining and keep listening and keep on building that confidence in yourself and your immune system health.