5 things I would never do as an Allergy and Immune System Expert
Kara Wada, MD: Welcome back everyone. To this episode of the Becoming Immune Confident Podcast. My name is Dr. Kara Wada. I'm a board-certified allergy, immunology, lifestyle medicine doc and systemic Sjogren's patient. Today we are celebrating our 99th episode. I cannot believe how the time has flown by. We have been recording this podcast for nearly three years and I am excited to see where things will be another two years from now. But for today's episode, this is going to be a solo episode and I'm going to share five things that I would never do as an allergy and immune system expert, both personally and professionally.
This, in the last few months has been a trend on social media, both on Tiktok and Instagram, for medical professionals to share all the things that they would never do given their knowledge and expertise. So for instance, it's not surprising that a pediatric ER physician is not so excited about having their kids jump on trampolines. But these are the five things I would never do as a board-certified allergy, immunology and lifestyle medicine physician, who also happens to be an autoimmune patient with systemic Sjogren's. So let's dive in to this countdown of sorts.
We are getting into the weeks towards the end of 2023 when we're recording this. And it's always in that week around Christmas and then New Year that we see all of these countdowns. I remember as a kiddo listening to Casey Qasem go through the top hits from the past year, over the weekends leading up to the new year.
Number 5: I would never rely on a Primatene mist inhaler to treat my asthma or breathing symptoms alone.
Kara Wada, MD: And so this is going to be our version. We'll start with number five. Number five is I would never rely on a Primatene Mist inhaler to treat my asthma or breathing symptoms alone. So Primatene Mist is a controversial over-the-counter epinephrine inhaler. So when we think about the rescue inhalers or the as needed inhalers that we use to treat asthma, typically they include or contain a medication called albuterol. Albuterol is a short acting beta-agonist. Beta-agonist is referring to the receptors that this medication works on and it helps relax any spasm or muscle contraction in those muscles that are surrounding the airways. Epinephrine also works on these same receptors, but they also work on a lot of other receptors as well. And can put more strain on our cardiovascular symptoms. So, Primatene Mist was off the market for many years because, it actually was banned seven years ago. In part, because it relied on propellant that contained ozone damaging ingredients. But in the last couple of years, it came back to the shelves with the safer propellant. But here's the deal epinephrine is actually not considered a safe medication for asthma treatment.
When you look through all of the recommendations from the, academies of allergy, the college of allergy, asthma and immunology, the recommendations from pulmonologists, GINA, which is like the global asthma folks. None of them mentioned using epinephrine. They all say in our guidelines for your rescue inhaler, as needed inhaler to relieve that broncospasm or those muscle contractions that are resulting in coughing, wheezing, chest tightness, albuterol is the way to go, which much safer, more effective, has less potential for really bad cardiac side effects. I very much recall being, I dunno if traumatized is the right word, but remembering, the heyday of the supermodels with Cindy Crawford and Niki Taylor, right by her side, Niki's younger sister who was an up and coming supermodel in her own right really tragically passed away, in part, because of side effects of Primatene Mist.
Asthma. The National Asthma Education and Prevention Program Guidelines recommend, again, another organization, recommend against using epinephrine. In part, because that epinephrine can exacerbate heart symptoms, it can cause vasoconstriction in those heart blood vessels that mimic breathing or asthma symptoms. And if people are relying on self-medication, so they're going to the asthma allergy section of the pharmacy. They're trying to treat things on their own, this can delay much needed emergency care that is going to help decrease inflammation. Asthma is much more a disease of inflammation. Along with that bronchospasm, you need to treat both in order to do the best job of decreasing those symptoms. So asthma is not a do-it-yourself disease. It is primarily due to inflammation or swelling, redness, increased mucus secretion that occurs in the airways and set inflammation that then makes the airways more spastic or twitchy. It's also really common for patients to underestimate the severity of their asthma symptoms. So any patient who has ongoing symptoms requiring the use of these as needed inhalers more than twice a week really should be on an anti-inflammatory medication to treat the underlying or some of the root causes of asthma. Overuse of Bronchodilators or things like epinephrine in the case of Primatene Mist or even albuterol is associated with worse outcomes, increased fatalities. And what happens is essentially the airways become less responsive to these as needed medications if you are using them too often. And unfortunately about 3,500 people will die from asthma that goes untreated each year. So, skip the Primatene Mist, go see either your primary care doctor, your allergist, immunologist, your pulmonary doctor, if you are using your rescue inhaler more than twice a week. Or if you are suspicious that you may have asthma that hasn't been diagnosed.
So that's number five.
Number 4: I would never use food sensitivity tests or food allergy panels to screen for foods that I should not be eating.
Kara Wada, MD: Number four. I would never use food sensitivity tests or food allergy panels to screen for foods that I should not be eating. We've talked about this on the podcast before, along with Jennifer and in one of my original, OG episodes from my backline when I talked about the different types of reactions our bodies can have to the food that we eat. The problem is food sensitivity tests purport and claim to tell folks which foods are contributing to their bloating, their gas, their fatigue, their headaches by seeing which foods the immune system is reacting to. Many of these food sensitivity tests are checking for a type of reaction called IgG. IgG or immunoglobulin G antibody is the type of memory antibody that our body produces. The thing is these reactions, the production of these proteins does not necessarily tell us if it's a good memory or a bad memory.
In fact, there's a certain type of IgG called IgG-4, a subclass of IgG, that actually says that you're tolerant to foods. whAt I see very often is I'll see patients come in, they'll bring in their food sensitivity testing, and they'll say, "Dr. Wada, what am I supposed to eat? This test tells me I'm sensitive, I'm allergic to everything that I'm eating." And I'll say, "Did you read the fine print?" 'Cause the fine print on these tests will say you need to follow up with an elimination diet to really determine if these foods are a problem or not. So my guidelines or advice to patients, if I catch them before they get this testing done is skip the test and let's think about things of from a more holistic kind of point of view. What do I mean by that? Let's think about the symptoms you're having and the physiology that would be going on to cause the symptoms.
Oftentimes the symptoms we have related to foods we eat are not driven by a true immune system response. In our gut, we have a, essentially a symphony going on. And as members of the orchestra, we have the food we eat. We have the microbiome and all the millions of different types of those little buggers that are in there. We have our digestive enzymes that our own cells and those microbes are secreting. We have our own cells, many different types of cells that are there. There's a mucus layer, all sorts of things going on. We also have the tempo. So you think about, know, the different instruments. We have the volume of those instruments, are they in pitch or out of pitch? We also have the pace.
So how well is the gut propelling food through the system as it's being digested. And when we think back to this newer concept called the epithelial barrier hypothesis of just this idea that we are using to understand why we're seeing an increase in allergies auto-immunity. But essentially if there is increased permeability in the gut, If there are breakdowns in that mucus layer, then in, gaps between the cells were more food, more microbial products are being seen by the immune system on the other side, there can be the potential for an immunologic response. There can also be the potential for an irritant response. I think about, you know, there's a lot of our nervous system that is located in the gut and we know hyper responsiveness in our gut nervous system also plays a role in IPS and other things as well. We see that also on the skin with eczema. The skin barrier is leaky, increase in itching, increase in changes in how the nervous system is interacting with our immune system as well.
And this is an area of science that is really only newly, you know, being understood that it's important and that we need to research it more. So, we think through the process, I typically will have patients keep a food and symptom diary. And in addition to taking note of the foods they're eating, how much they're eating when they're having symptoms, I'm also asking how hydrated are you? How's your stress level? How's your sleep the night before? Because we know that all of these also play into how our gut and our microbiome health are doing.
I also want to know, about how things are coming out the other side, too, right? One of the main causes of bloating is actually constipation and you can be constipated even if you're having bowel movements on a daily basis, which a lot of people don't realize. So, I say skip the food sensitivity tests because one, they're not covered by insurance. Two, they're not going to provide much helpful, useful information. And If we think about, things that are kind of switching gears into food allergy panels.
So food allergy panels are going to look for, and this also includes skin testing and blood testing, looking for the presence of IgE antibody. IgE antibody is the allergic antibody. But here's the deal, a lot of people are going to have the presence of that antibody without the symptoms. So when we talk about food allergy is a clinical diagnosis. You need to have symptoms related to ingestion from that food and that in combination with that positive IgE, that then says, "Oh yes, you have an IgE-mediated food allergy." So it's important because what can happen is if you have a positive blood test or positive skin test but you're already tolerating that food. So, say it's a little kiddo with eczema, they have a really high chance of having elevated IgE levels to many foods. They may already be eating a lot of those foods and not having much of an, not having any throwing up, any hives, any wheezing associated with eating those foods. And if you take those foods out of the diet, when there already is tolerance, You run the risk of losing that tolerance and that then becoming a life-threatening food allergy. tHis is why it's important not to go looking for problems if there aren't any. Food allergies are dramatic, they're messy, they're scary and there's no such thing as a hidden food allergy. Now I do find sometimes it's some people will notice improvements in how they feel with more of these food sensitivities that may be a little less dramatic in nature, but food allergies, specifically, are not subtle. Here's my other issue with these. They stoked their fear of food and they increase our anxiety around food. They increase our grocery bills. And I've seen a lot of folks who really severely limit their diets as a result of these test results. If you want to learn more about that, you should listen back to our episode with, Tamara, who is a food allergy counselor. People end up in this constant state of fight or flight. And that is not good for our health. Not having a diverse diet is not good for our health. Diversity in our diet is key in helping support good gut and immune system health. And we know limiting exposure to a diversity of foods in early childhood can, as I said, result in increase risk of developing true life-threatening food allergy. When we think about, evolutionarily speaking, our brains and our bodies, it is deeply ingrained from even prehuman-ness, to associate symptoms that we have in our body with what we've eaten. If you think about even a bear getting into a bad batch of berries. That bear is going to remember, "Ooh, those berries, those killed Bob Bear. I'm not going to go eat those," right?
So I think it's really important that we pause and be conscientious and think through the potential role for foods in our symptoms. And also reassure ourselves that foods are not the cause of all of our symptoms as well. I think one of the things we really talk a lot about but haven't explicitly mentioned in the podcast for a while is this idea of 'And' rather than 'Or'. And sometimes we're holding two thoughts in our mind at the same time that don't always seem like they would go together. And that is actually a technique from certain types of therapy and coaching can be really helpful in us making sense of a complex world.
And in our case, we're talking about really complex physiology as well. All right. Enough on that.
Number 3: I would never ignore recurrent infections, especially repeat sinus infections.
Kara Wada, MD: Let's hop into number three. I would never ignore recurrent infections especially repeat sinus infections. So as an allergist, immunologist, especially working in an academic center, recurrent infections are a red flag for us for many reasons. But in particular, we know that increased use of antibiotics itself is not without risks.
So if these are true infections that you were needing antibiotics, we want to do whatever we can to decrease your need for those because we know that if you need to use more antibiotics, You may have greater exposure, could you develop allergies to those, maybe. We know also there's a change in our microbiome, which can have negative effects on our metabolism resulting in weight gain. I'm sure many of us are very familiar with the diarrheal issues that can come across or come along with using antibiotics.
And in particular, there is a diarrheal infection called C.diff or C difficile diarrhea that's associated with using certain antibiotics. That is one of those things in particular is life-threatening. It's also something you would not wish upon your worst enemy. It's miserable. And needs actually a very specific antibiotics to treat that. But here's the deal. In some instances, recurrent infections may not be infections at all. They could be allergies, which are treated much differently.
Sometimes they are allergies that then lead to bacterial sinus infections because that swelling is causing a lot of trouble in allowing the sinuses and nasal passageways to drain appropriately.
Other times this may signal an immune deficiency or a structural issue in the sinuses that maybe we were born with or developed over time. So if you're someone who goes to the urgent care or the minute clinic for sinus infections more than one to two times every few years, it's worth getting things checked out. Another good reason to talk to your allergist, if you believe you are allergic to penicillin or amoxicillin, there's a really good chance that you aren't anymore. Like a 99 in 100 chance that you aren't anymore. Pretty close to that. And an allergist can help you sort this out pretty easily. Sometimes we'll do a little skin scratch, skin pricks in the office. Many times now I'm just giving folks a dose, a baby dose of amoxicillin and watching them in the clinic. Making sure they do okay and then we're de labeling them on their allergy because just having penicillin or amoxicillin allergy listed on your chart dramatically increases the cost of your care, especially if you end up hospitalized. And if you end up needing a surgery or have other things going on, it increased the risks of surgical site infections, so like a post-op infection, increases the risk of that C.diff I was talking about that you really don't want. And the reality is penicillin and amoxicillin are actually still really great drugs for things like ear infections, pneumonia, in certain urinary infections as well.
All right. We're getting down to the end.
Number 2: I would never use personal products with fragrance as an ingredient.
Kara Wada, MD: Number two. I would never use personal care products with fragrance listed as an ingredient.
I also would extend this to using those plugin
little room freshener things. They do anything but freshen the room. They actually decrease the air quality overall. So here's why. Let's dig in. So when we go back to that epithelial barrier hypothesis, this idea that our bodies have interfaces with the outside world. Our skin is our largest organ, so that's one place. It functions as a barrier, but absorbs a lot of what we put on it. The same ideas happening in our respiratory track as well. Okay. So when we see this in all those like wonderful, fresh smelling things, "fresh." For those listening, I did some air quotes, because we don't need something to smell like flowers or spring rain in order for it to be clean. Okay? So here's the deal. Fragrance is a catch-all term that is used to describe a mix of chemicals that are proprietary, meaning the companies get an out from listing each of those ingredients on what that product includes, whether it's a skin lotion or whatever's in that plugin.
Unfortunately, there's a loophole in US law that doesn't require companies to disclose what's exactly in that mix because they say, "Oh, someone may steal it." Okay. Roll eyes. We know though that these substances are associated with numerous health problems. Specifically within my purview as an allergist immunologist, fragrance, especially in personal care products is one of the top skin allergens and irritants that we see.
So if anyone has eczema, a kiddo with eczema has sensitive skin, you need to be skipping fragrance.
Kara Wada, MD: And stop.
It was the contact allergen of the year, back in 2007. And it's the third, most common allergen that will be positive on allergy testing that looks for specific triggers for like cosmetic type allergens. So this is particularly problematic for anyone, as I said, with sensitive skin, eczema, rosacea, or even hives.
These are also really irritating to her respiratory track as well. So, anyone who has runny nose, allergies, non allergic rhinitis, commonly gets colds.
Anyone who has asthma really should not have these things floating around in your homes or your work. Just really avoiding them is the best medicine. Some folks will find that they do tolerate maybe a little bit of diffuse, essential oils. But I also say, dip your toes in if you want something that kind of has a fragrance, but really trying to minimize our exposure to candles, to these plugins, all these things, are so much better for our respiratory health.
And this is super important for our little ones because their airways are smaller. We think about, know, the fires we had in the smoke kind from the fires in Canada this summer. We had a lot of that blowing down our way in Columbus this summer and we were keeping our little kiddos indoors, right? And at levels that were lower than maybe what was recommended for adults. Because their airways are more sensitive, they're more vulnerable. Also the case for those Osteo PD, Pulmonary fibrosis, other breathing issues. So get rid of them. Our noses are a way for us to interact with our outside world. At first, smelling something that smells a little icky or foul, it's kind of part of life. It's also a good reminder that maybe, we, you know, need to take the trash out more often or do other things to keep things tidy. It's a kind of a warning system. We don't need to muck up or mess up our warning systems ability to work with these products.
The other thing that I think is really concerning is that many of these chemicals found in fragrance are also considered endocrine disruptors. So these chemicals can mimic the hormones in our body. Things like our thyroid hormone, and so forth. And even very small amounts of these endocrine disruptors can have really big effects on how our body functions. EDCs and exposures have been associated with issues with kidney and nervous system. Again, respiratory system problems. They're also implicated in fertility, premature puberty and birth defects.
Again, just skip them. Save yourself some money. Fragrance free. Oh, and one quick note to mention. Unscented does not equal fragrance-free. Sometimes companies will use other fragrances to mask the natural smell of a product and they'll call it unscented.
Number 1: I would never rely on Benadryl to treat my severe allergic reaction.
Kara Wada, MD: Yup. Okay. Last, but not least, our number one. We do a little drumroll.
I would never rely on Benadryl to treat my severe allergic reaction. All right, I'm going to say that again. Our number one is I would never rely on Benadryl to treat my severe allergic reaction. So epinephrine is the first-line treatment for anaphylaxis. Anaphylaxis is a severe system-wide allergic reaction. It means you have more than one body system. That is, having symptoms related to that allergic reaction. Benadryl and other anti-histamines like Sirtex or Allegra's are bandaids. They only treat the symptoms, but epinephrine is needed. It's an extra dose of our fight or flight hormone that we need to shut down the reaction at the root of the problem.
Fatalities associated with severe allergic anaphylactic reactions are associated with the delay in administering Epi. If you are worried that you're having a severe life threatening reaction, use Epi and use it early. Also another word on Benadryl. Us allergists? We don't like it. We're on our soap box with this in the last couple years. It doesn't work any faster than second generation anti-histamines like Cetirizine, Fexofenadine, Loratadine. It also has a lot more side effects. So it tends to make people either really sleepy or for a minority of people, it make some bounce off the walls. We don't want either of those things if you're having a severe allergic reaction because we want to know like what your mental status is doing.
That's one of the ways that we make sure that you're doing okay how we check in. Making sure you're getting blood flow to your brain.
All right. So. Skip the Benadryl. Pick up either generics. Sirtex, Cetirizine, Fexofenadine or Loratadine, and keep that on hand in your, your emergency kit. The other thing, you will see sometimes Benadryl cream or diphenhydramine cream, these topical formulations. They can and it tends to be pretty helpful with like bug bites, in that itch you get. The problem is there are really common contact allergen. So a lot of times after you've used it for a little bit, your immune system will recognize that topical Benadryl cream and we'll start reacting to the cream. So instead you're better off getting a little mild like prescription grade steroid cream, like a triamcinolone, something from your primary care doctor, allergist, dermatologist to help with those really itchy bug bites and stuff. Or if you're in a pinch, you can also use an ice pack on those areas as long as you don't have them all over. Ice can actually help decrease the itch quite a bit in a pinch.
I Would love to hear your feedback from these five things I would never do as an allergy immune system expert, both personally and professionally. I'd love to hear your thoughts. Is there anything you thought was missing? Things that you would add? Things that surprised you. Let's keep the conversation going. And, if you found this to be helpful, you are going to want to make sure you're subscribed to the Becoming Immune Confident newsletter. We have a weekly email that goes out, and includes all things on the topics of allergies, auto-immunity, anti-inflammatory living and, a sprinkle of some of that mindfulness and work, internal work that really is the self-care that we all are craving and need. I hope you all are having a lovely holiday season for those that are listening kind of when this is released and for those that are listening after the fact, thanks for joining us. If you love the podcast, we would so appreciate it if you would consider leaving us a five star review on your favorite podcast app. It's those are views that really allow others to help discover the podcast along with you talking about it. We are so excited to be embarking on next week, our hundredth episode and going into our third year of bringing all of this empowering educational content to you. And I look forward to what the future is going to bring. I hope you all take care and have a great week ahead.
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