April 10, 2025 • 21 mins
In this episode of ImmunoCAST, we share an example of impactful patient education from our friends at Allergy Insider (@allergyinsider). They hosted Dr. Zachary Rubin (@rubin_allergy), a double board-certified pediatrician and allergist and internet sensation, and ImmunoCAST’s own Gary Falcetano, PA, on their recent Instagram Live segment “Ask the Insider” to discuss the allergy symptom threshold.
Because Allergy Insider aims to provide patients with evidence-based, educational information about their allergic conditions, helping them feel more empowered and informed about their health, Allergy Insider is a perfect source to refer your patients to if they want to learn more about their allergic conditions. Tune in and discover some helpful tips you can share with your patients when discussing reducing exposure to their allergic triggers.
Episode resources and references available at https://www.thermofisher.com/phadia/us/en/resources/immunocast/understanding-allergy-symptom-threshold-dr-zachary-rubin.html?cid=0ct_3pc_05032024_9SGOV4
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
ImmunoCAST is brought to you byThermo Fisher Scientific, creators
(00:03):
of ImmunoCAP Specific IgEdiagnostics and Phadia Laboratory
Systems. I'm Gary Falcetano, alicensed and board certified PA
with over 12 years experience inallergy and immunology. And I'm
Luke Lemons, with over 6 yearsexperience writing for healthcare
providers and educating onallergies. You're listening to
(00:28):
ImmunoCAST, your source formedically and scientifically
backed allergy insights. Welcometo ImmunoCAST. As many clinicians
know, patient education is anextremely valuable tool when it
comes to helping a patient notonly understand their condition,
but also to ensure that they havecredible and factual information.
(00:50):
That's why in this episode we'regoing to share a patient education
conversation that happenedbetween Gary Falcetano and Dr.
Zachary Rubin. This conversationtook place on Allergy Insider's
Instagram and if you're notfamiliar with Allergy Insider,
there are friends who are morepatient facing. They have
(01:13):
conversations that are moreaccessible to patients around
allergies. They have a website,but they also have an Instagram
page. And on this Instagram pagethey'll go live with an expert
and talk through some topicrelated to allergies for patients
who are interested in learning.We've had Dr. Rubin before on
(01:35):
ImmunoCAST. That was an episode24 where he discusses navigating
social media as a clinician andit's a great episode. I recommend
checking it out. This episodespecifically is a recording of an
Ask the Insider Live. So onAllergy Insider they went live
with Dr. Rubin and Gary serves ashost who discusses the symptom
(01:58):
threshold of allergies, which isthe idea that allergies actually
stack and it may not be onetrigger that is contributing to
these symptoms. It's a greatconversation and it's also a great
example of the type of patientfacing education our friends at
Allergy Insider provide. So enjoythis episode and don't forget to
(02:20):
check Allergy Insider out onInstagram as well on their homepage,
which will be linked in theepisode page in the description
below.
I want to welcome everyone tothis episode of Ask the Insider.
This is inside Spring Allergies.Totally appropriate for the first
(02:43):
day of spring and we're going tobe discussing the allergy symptom
threshold. I'm Gary Falcetano,your host. I've been a PA for over
28 years, currently the USScientific Affairs Manager for
Allergy at Thermo FisherScientific. Joining me today is my
special guest, Dr. Zachary Rubin.He's a double board certified
(03:05):
allergist, a bit of an Internetsensation with millions of
followers on Insta and TikTok.We're going to dive deep, as we
were saying, into the concept ofthe allergy symptom threshold and
how understanding it can helpmanage allergic reactions a little
bit more effectively. So welcome,Dr. Rubin.
(03:28):
Thank you so much for having me.And I've had some chats with you
before. It's been fun getting toknow each other and talk about
what I'm really passionate about.And this is one topic that I
actually haven't talked about in awhile. So I think a lot of the
people here are going to learnsomething new today.
(03:50):
Absolutely. I'm so happy to haveyou. As you were saying, it's been
great in our past experiences andthis is one of my passions as
well. I love talking aboutallergy. I love talking about how
we can really empower patients toreally take control of their
disease and better manage theirsymptoms. So, you know what, let's
(04:13):
start out kind of with the basicstoday. So it is the first day of
spring. Spring allergies, treepollen, are already major issues
in many parts of the country.Although in Chicago, I understand
it's snowing today. So maybeyou've got a few day reprieve.
Maybe discuss this concept ofallergy symptom threshold and why
(04:35):
it's so important and why it maynot just be tree pollen that's
driving symptoms this time ofyear.
Exactly. So when you developallergies to pretty much any
substance, your immune system hasthis abnormal response that will
generate different substances.The ones that we normally think
(04:58):
of are called a type 1hypersensitivity activity
reaction. So you make theseantibodies, these proteins called
immunoglobulin E or IGE for short.And so if you develop an allergy
to tree pollen, to dogs, food, etcetera, if you are exposed to
that, there's a certainthreshold, we were calling it the
(05:20):
symptom threshold, where you needto have a certain amount of
exposure before the symptomsdevelop. So think of it like you
have a cup and you fill it witheither water or marbles, right?
And so if you're allergic tomultiple issues and you get
exposed to all them at the sametime, same time, you're filling
(05:43):
that cup up until you reach thatthreshold. And once you start
having more exposure, it spillsover and leads to symptoms. Now,
that threshold can change overtime and it can have different
situations where, let's say youhave a viral illness that could
potentially lower your threshold.You Have a fever. That could
(06:05):
lower your threshold and increasethe risk of having more severe
symptoms. Same thing withexercise or consuming alcohol.
These different issues can lowerthe threshold before you start to
have symptoms. And it's notalways these specific allergic
triggers. They could be nonallergic in nature. Like just the
(06:28):
sheer fact that we're havingchange in weather. Where I'm at
right now, we had a bigthunderstorm yesterday. The
temperature was in the 50s andit's dropped to below freezing.
And now we have a snowstorm, andthere's about 1 to 2 inches of
snow on the ground on the firstday of spring. So that change in
(06:50):
temperature in barometricpressure can also fill up the
cup, so to speak, and lead tosymptoms getting worse.
Exactly. And it's not justrhinitis or upper airway symptoms
that are so common in the spring,but this also leads into other
even lower respiratory symptoms,like asthma. We know that a large
(07:13):
majority of patients with asthmahave allergic triggers, and those
that don't even sometimes havenon allergic triggers that
contribute to that inflammation.Right, Right, exactly. There's so
many different ways that ourimmune system interacts with our
environment and food. As anexample, there's something called
(07:35):
oral allergy syndrome, where youhave this allergy to pollen from
birch tree is the classic examplebecause it's got protein
structures similar to peaches,pears, plums, apricots, all these
different fresh fruits that whenyou eat it, your immune system
gets confused and thinks, oh mygosh, I think I'm eating a bunch
(07:58):
of pollen. And if you do that,especially in pollen season, that
threshold is going to get filledup very quickly and you're gonna
develop itchy mouth, mildswelling, and in rare cases can
become more systemic and lead toanaphylaxis. And this is true
with food allergies as well,where a small amount for some
(08:20):
people may not hit that thresholdbefore having symptoms. Maybe
it's a couple milligrams ofprotein before you start having
symptoms. But if you're sick,lowers that threshold, increased
risk of having hives, swelling,problems, breathing. It's all
sorts of other symptoms that arenot necessarily related to your
(08:43):
nose. Absolutely. And thesethresholds, as you mentioned,
they change. They can differ atdifferent times of the year for
patients. Again, depending onwhat a patient is experiencing,
like a viral illness. But we alsosee patients who are experiencing
symptoms this time of year. Ithink our fallback. Right. Is to
(09:05):
say, well, especially in areaswhere we know tree pollen is
prevalent, it must be the treepollen. But what can we do? And
I'm thinking about testing here.Right. To actually understand all
of the things someone may besensitized to on the allergic
side. Right. Non allergic is alittle more history dependent.
(09:28):
Exactly. So when I evaluate apatient and thinking about, okay,
what are the potential triggersfor their symptoms of rhinitis,
we do a full panel ofenvironmental testing. And so
that test, whether it's skin orblood testing, can give us a good
idea of what amount of allergyantibody is present that could
(09:50):
bind to that particular substanceand lead to symptoms. And then
you can look at the history,correlate it to the testing to
determine. Okay, I find thatactually you're not only having
symptoms to treat pollen, butmold. And when it gets very humid
outside, or maybe there's waterdamage in the home, they're
(10:13):
getting exposed to mold on top ofthe pollen exposure. So those
multiple exposures can lead tosymptoms. So if we do targeted
environmental reductionstrategies, like saying, okay,
let's go through the house, makesure there's no mold, let's make
sure we keep the humidity under50%. Right. Or hey, you've got a
(10:35):
tree pollen allergy. Let's makesure when you come home, you leave
your shoes in one place, changeyour clothes when you get home,
don't put those clothes on yourbed where you sleep. Make sure
you're cleaning off at nighttime,you know, showering or bathing
and rinsing your nose to removeall of those pollen grains and
(10:58):
potentially irritants too,depending on where you live, you
may have more air pollution. Andso when there's more travel as we
get to warmer months, that meansthere's going to be more air
pollution. That's a non allergictrigger. That could feed into the
other allergies that you'reexperiencing that can lead to
(11:20):
these sinus problems. Exactly.And I think, I think, you know, a
lot of people think, well, pollenis everywhere, it's ubiquitous.
Like how do we. And you mentionedsome of the techniques that we
use, but it's really about theconcept of a safe sleep space.
Right. And if we can protect thatspot where we spend eight, nine,
(11:43):
ten hours a day. Right. Thebedroom, it can really have a
dramatic impact on symptoms.Absolutely. The bedroom is one of
the most important places thatyou have to reduce these
different environmental triggers.And some of these triggers, as
you mentioned, you know, we thinkabout the pollens, the grasses,
(12:05):
trees and weeds in a minute. I'llask you to maybe speak to when we
see tree pollen, grass pollen,weed pollen. But then there's
these indoor triggers, we callthem perennial triggers. Right.
And those are, you mentioned moldthat can be present year round,
but also things like dust mites,things like your pets. Right.
(12:28):
Whether you live urban orsuburban mice can be a big issue.
And we know that can also drive alot of the symptoms we're talking
about. So maybe speak to how,once we identify through testing,
what specifically were sensitizedto, how can we address that
holistically to reduce symptoms?Right, Right. So, as we mentioned
(12:50):
earlier, the bedroom is the firstplace to start because that's
actually where you spend most ofyour time. So I always tell
people, make sure you havedustproof covers for your mattress
and pillow. If you havecarpeting, it's a good idea to
remove that if you can afford toand put hardwood floors. If not,
(13:13):
you've got to vacuum it at leastonce a week. And whenever you're
dusting, wearing a mask and eyeprotection can be very helpful
because anytime you disturbsurfaces, it's going to aerosolize
some of those particles that youcould be sensitive to. So in the
short term, you're trying to helpyourself feel better, but then you
(13:35):
get, you get some of thesesymptoms when you're trying to fix
that. Another way to reduce thatis to have wet dusting cloths
rather than dry. The moisturewill help trap some of that.
Getting portable HEPA aircleaners or air purifiers for
rooms that you spend most of yourtime in is a good idea. That's
(13:58):
especially helpful for thingslike pet dander. And I have three
dogs. I love my dogs to death,but they do not sleep with me.
And I think it's important thatpeople keep their pets out of the
bedroom. And I know people don'talways like hearing that, but I'd
rather say that than say, well,we should be getting rid of your
(14:20):
animal. And I never recommendthat to my patients. I always say,
let's find strategies to reducethat. We could say, hey, let's
bathe your animal regularly. Thatcould actually reduce the amount
of allergens that they have. Wedo want to make sure that when
they come from outside, you gotto wipe down their paws because
(14:43):
they do track a lot of theseirritating substances and
allergens into the home. It's notjust people with a dog or a cat
allergy. Right. But they actuallycan bring in the pollens from
outside or bring in the mold.Exactly. So you have to think
about all the potential point ofcontact that come into your home,
(15:05):
especially in the bedroom, tomitigate that. And then the one
fun thing I like to tell peopleis if you Have a dust mite
allergy. There's actually someevidence to show that if you don't
make your bed right away, it mayhelp. Because when you make your
bed immediately after getting upin the morning, you maintain some
(15:28):
of that moisture that your bodyhas generated, and it traps it in
the bed and increases the dustmite count. So I always say, okay,
it's okay. If you don't make yourbed right away, you could do it
later. That's recommended by thedoctor. Exactly. Let it air out.
Right, Let it air out. Exactly.That actually brings us to
(15:50):
something that's very common,especially with children,
Especially children that do haveasthma. I think a lot of times
parents want to put a humidifierin bedrooms to help them breathe
a little easier. But if they havea dust mite sensitization or
there's mold issues in the house,it's actually like a drinking
(16:13):
fountain. Right. For the dustmites, because that's how they
drink. They absorb water from theair. Right. Dust mites are
roughly, what, 80% made of water.They are so reliant on humidity
that that's why I was mentioningearlier, keeping the humidity
under 50% will decrease the dustmite counts, but at the same
(16:35):
time, dry air can irritate theairways, too. So it is a
balancing act. In the case ofillness, you have to make sure
you're cleaning your humidifiersregularly every other day. It
depends on the manufacturer'sguidelines on the specific device
that you have. But you've got tobe cleaning it, otherwise it's
(16:58):
going to be an area where mold'sgoing to grow or it's going to
allow dust mites to accumulate.But if you also have those
dustproof covers, if you arechanging sheets regularly and
you're vacuuming and dusting,that will help decrease some of
those dust mite counts as well.Yeah, exactly. And things like
(17:20):
maybe not having carpet in thebedroom or washing stuffed
animals on a regular basis, orI've even heard putting the
stuffed animals in the freezer.Yeah. My mentor at fellowship, he
taught me that trick a long timeago. You basically put them in
bags. These are stuffed animals.Leave it in the freezer overnight
(17:43):
once a month, and it'll kill offthe adult dust mites. But the eggs
that they lay, which nobody canreally see, that will stay behind.
So that's why you'd have to dothat regularly. It is one way to
reduce dust mite counts instuffed animals. If for some
reason you can't get rid of them.A lot of kids are very attached
(18:05):
to Their stuffed animals. That'sone way to safely do that,
granted. Do you have the freezerspace? You know, that's always a
challenge, but it is. It issomething that could be
potentially helpful. Yeah, yeah.I mentioned the other pollens,
tree pollen this time of year,but what about grasses and weeds
(18:28):
and what can we expect as we gothrough the year? When I talk
about these things, I'm talkingabout because I'm in the
Chicagoland area. So everyregion's a little bit different.
You look at Texas, they havecedar fever in December, January,
and that tree pollen from ashjuniper is coming out. And people
(18:50):
are miserable in the wintertime.But for a lot of other parts of
the country, you start seeingpollen being released in March.
So that's tree pollen, March,April, May, and then as we
transition from May into June, itgoes into the grass pollen month,
which is the shortest season outof the three. So that's usually
(19:13):
around June, July, and then as weget into late July, August, the
weed pollens come out up untilthat first hard frost in your
area. Once that hard frosthappens, the pollen will stop.
And we're starting to see someoverlap. It's kind of
controversial, right, to talkabout the warming climates, but
(19:35):
we're starting to see overlapswhere spring tree pollen season
may be starting a little earlier,extending into or overlapping
with grass pollen. So sometimesit's hard, just based on the time
of the year, to figure out whatexactly you're sensitized. Yeah.
That's why it's important to lookat the pollen counters in your
(19:58):
area. As an example, the AmericanAcademy of Allergy, Asthma and
Immunology, or Quad AI, they havea pollen counter in many major
cities that you can subscribe to,and they'll give you morning
emails to tell you what's goingon. I'm hoping in the future
we'll have better technology toget more real time estimates,
(20:20):
because really, you gotta handcount a lot of this and these
manual counters. It's very laborintensive. I know there's a lot
of work done into making moreaccurate automated systems so
that we know more in real timewhat's going on. But as a rule of
thumb, if it's dry and windy, yousee that in the forecast, the
(20:43):
pollen counts are likely gonna behigher. If it's going to be
raining, the pollen counts willbe lower, but the mold counts
will be higher. Right, becausemold follows moisture. So those
are some general rules of thumbfor people to think about when
trying to manage their allergies.Yeah, absolutely. So, you know,
(21:05):
we've talked about thepreventative medicine exposure
reduction techniques that we canuse when we're sensitized. But we
also probably should talk alittle bit about medications and
maybe can speak to that conceptof priming. Right. And
identifying when we think basedupon our sensitizations and when
(21:28):
pollen counts are going to behigh, how we can prevent kind of
getting into the thick ofsymptoms. Right, exactly. So this
is especially true for pollenallergies, the seasonal allergic
rhinitis patients. If you don'tstart your medications early
enough, it's harder to treatbecause once you start getting
(21:50):
that exposure, the inflammationthat occurs will just keep
getting worse, worse, worse andworse and worse. That's the basic
concept of what you mean bypriming in that sense. And so, so
if you know that pollen season isgoing to start roughly the first
couple of weeks in March, youshould be starting your medicine
(22:13):
two to four weeks before thenbecause that gives your body
enough time to get used to themedication. It builds up in your
system, especially for nasalsteroid sprays like fluticasone,
mometasone, triamcinolone, yourflonase, nasal cord, Nasonex, over
the counter sprays. If you'redoing that two to four weeks
(22:35):
ahead of time, then you havereally helped cut off that
potential priming stage to reducethe chances of having significant
symptoms. If you start yourmedicine in April, you are playing
a lot of catch up and it's goingto take so much more time and
you're higher risk of havingsinus infections, ear infections,
(22:58):
problems sleeping at night, whichsleep is such a premium and such
an important part of our health.We can't concentrate as well, our
blood pressure goes up if wedon't sleep well, our weight goes
up, cholesterol issues. So sleepis so important. That's why I'm
so passionate about my specialtyis because we're a type of niche
(23:20):
specialty that helps peopleimprove not only their quality of
life, but indirectly theirquantity of life as well. Yeah,
absolutely. So we have a coupleof questions coming in and I
think we answered one of them.But this is probably a Nobel
Prize winning, if you can answerthis right, we know allergies
(23:43):
change over time. What's thehypothesis there on why
particularly young children willdevelop more allergies, they'll
develop tolerance to foodallergies as they age. Why do our
allergic responses really change?Yeah, so the short end of it is
we don't know, obviously. I mean,as you said, this would win a
(24:05):
Nobel prize if we could fullyunderstand this because there are
people out there who will have acat allergy and randomly one day
not be allergic. And we have noidea what was the trigger that
caused that to happen. We havebits and pieces of the story put
together in terms of. We knowthat like I mentioned in the
(24:28):
beginning of our sessiontogether, is that IG antibodies
are produced. They're produced byspecific cell called B cells, and
there's a whole process calledsensitization happening. But we
don't know sometimes what theinitial inciting factor is. It's
probably a complex interplaybetween genetics and environment
(24:50):
that's doing this. And so theenvironmental triggers of how
that happens is not fullyunderstood. But we know that
there are more and more peopledeveloping these problems over
time, starting in childhood andgoing into adulthood. Especially
correlating with, we have higherpollen counts, we have more air
(25:13):
pollution in certain areas. Thereare certain exposures that we
know have increased over time andthat's correlated positively with
more people being diagnosed withthese problems. It's why I hear
every single year, why are myallergies worse this time than
last year? Why is it the worstthis year compared to any other
(25:35):
year? Well, you're exposed moreto these problems that are
causing the allergic symptoms.Part of why people later in life
may see less allergy symptoms isthe immune system just gets
weaker as we age. So we know thatimmune senescence, right? I
believe. Exactly, exactly. Yes.But not everybody does that. And
(25:58):
then on the flip side too, youmay lose your allergic rhinitis
where your immune system issensitized and that allergy
antibody is present, but then theanatomy changes and some of the
immune system changes and youdevelop non allergic rhinitis. So
as you get older, a lot of timespeople will have a runny nose
(26:20):
that's running like a faucet andthat's more of a structural
mechanical problem rather than animmune system problem. And you
need to rule out. Right. Allergyfirst, what we mentioned called
phenotyping. Right. Is this anallergic mechanism or is it a non
allergic and then when it's nonallergic, going down that clinical
(26:43):
pathway to figure out exactlywhat it is. Exactly. Yeah. Thank
you for listening today and Ihope you enjoyed this conversation
with Dr. Rubin on allergyInsider. Again, they're great
patient education. They've gotarticles on their webpage around
specific allergies. They have abunch of content on their
(27:05):
Instagram. And the goal really isto make sure that patients are
getting the most medicallyaccurate allergy information out
there online. If you want tolearn more about some of the
pitfalls of online education andsocial media. Dr. Rubin again
does a great episode on this onImmunoCAST. That's episode 24
(27:28):
called Navigating Social Media asa Clinician. And if you want to
hear Gary and I talk through thesymptom threshold with more of a
clinician lens, we have anepisode around that as well. That
is Episode two. All this will belinked on this episode's page via
the link in the description.Thank you for listening.
(27:50):
ImmunoCAST is brought to you byThermo Fisher scientific, creators
of ImmunoCAP Specific IgEdiagnostics and Phadia Laboratory
Systems. For more information onallergies and Specific IgE testing,
please visit thermofisher.comImmunoCAP Specific IgE testing is
an aid to healthcare providers inthe diagnosis of allergy and cannot
(28:13):
alone diagnose a clinical allergy.Clinical history alongside specific
IGE testing is needed to diagnosea clinical allergy. The content of
this podcast is not intended to beand should not be interpreted as or
substitute professional medicaladvice, diagnosis or treatment. Any
medical questions pertaining toone's own health should be discussed
(28:35):
with a healthcare provider.
ImmunoCAST is brought to you byThermo Fisher Scientific, creators
(00:03):
of ImmunoCAP Specific IgEdiagnostics and Phadia Laboratory
Systems. I'm Gary Falcetano, alicensed and board certified PA
with over 12 years experience inallergy and immunology. And I'm
Luke Lemons, with over 6 yearsexperience writing for healthcare
providers and educating onallergies. You're listening to
(00:28):
ImmunoCAST, your source formedically and scientifically
backed allergy insights. Welcometo ImmunoCAST. As many clinicians
know, patient education is anextremely valuable tool when it
comes to helping a patient notonly understand their condition,
but also to ensure that they havecredible and factual information.
(00:50):
That's why in this episode we'regoing to share a patient education
conversation that happenedbetween Gary Falcetano and Dr.
Zachary Rubin. This conversationtook place on Allergy Insider's
Instagram and if you're notfamiliar with Allergy Insider,
there are friends who are morepatient facing. They have
(01:13):
conversations that are moreaccessible to patients around
allergies. They have a website,but they also have an Instagram
page. And on this Instagram pagethey'll go live with an expert
and talk through some topicrelated to allergies for patients
who are interested in learning.We've had Dr. Rubin before on
(01:35):
ImmunoCAST. That was an episode24 where he discusses navigating
social media as a clinician andit's a great episode. I recommend
checking it out. This episodespecifically is a recording of an
Ask the Insider Live. So onAllergy Insider they went live
with Dr. Rubin and Gary serves ashost who discusses the symptom
(01:58):
threshold of allergies, which isthe idea that allergies actually
stack and it may not be onetrigger that is contributing to
these symptoms. It's a greatconversation and it's also a great
example of the type of patientfacing education our friends at
Allergy Insider provide. So enjoythis episode and don't forget to
(02:20):
check Allergy Insider out onInstagram as well on their homepage,
which will be linked in theepisode page in the description
below.
I want to welcome everyone tothis episode of Ask the Insider.
This is inside Spring Allergies.Totally appropriate for the first
(02:43):
day of spring and we're going tobe discussing the allergy symptom
threshold. I'm Gary Falcetano,your host. I've been a PA for over
28 years, currently the USScientific Affairs Manager for
Allergy at Thermo FisherScientific. Joining me today is my
special guest, Dr. Zachary Rubin.He's a double board certified
(03:05):
allergist, a bit of an Internetsensation with millions of
followers on Insta and TikTok.We're going to dive deep, as we
were saying, into the concept ofthe allergy symptom threshold and
how understanding it can helpmanage allergic reactions a little
bit more effectively. So welcome,Dr. Rubin.
(03:28):
Thank you so much for having me.And I've had some chats with you
before. It's been fun getting toknow each other and talk about
what I'm really passionate about.And this is one topic that I
actually haven't talked about in awhile. So I think a lot of the
people here are going to learnsomething new today.
(03:50):
Absolutely. I'm so happy to haveyou. As you were saying, it's been
great in our past experiences andthis is one of my passions as
well. I love talking aboutallergy. I love talking about how
we can really empower patients toreally take control of their
disease and better manage theirsymptoms. So, you know what, let's
(04:13):
start out kind of with the basicstoday. So it is the first day of
spring. Spring allergies, treepollen, are already major issues
in many parts of the country.Although in Chicago, I understand
it's snowing today. So maybeyou've got a few day reprieve.
Maybe discuss this concept ofallergy symptom threshold and why
(04:35):
it's so important and why it maynot just be tree pollen that's
driving symptoms this time ofyear.
Exactly. So when you developallergies to pretty much any
substance, your immune system hasthis abnormal response that will
generate different substances.The ones that we normally think
(04:58):
of are called a type 1hypersensitivity activity
reaction. So you make theseantibodies, these proteins called
immunoglobulin E or IGE for short.And so if you develop an allergy
to tree pollen, to dogs, food, etcetera, if you are exposed to
that, there's a certainthreshold, we were calling it the
(05:20):
symptom threshold, where you needto have a certain amount of
exposure before the symptomsdevelop. So think of it like you
have a cup and you fill it witheither water or marbles, right?
And so if you're allergic tomultiple issues and you get
exposed to all them at the sametime, same time, you're filling
(05:43):
that cup up until you reach thatthreshold. And once you start
having more exposure, it spillsover and leads to symptoms. Now,
that threshold can change overtime and it can have different
situations where, let's say youhave a viral illness that could
potentially lower your threshold.You Have a fever. That could
(06:05):
lower your threshold and increasethe risk of having more severe
symptoms. Same thing withexercise or consuming alcohol.
These different issues can lowerthe threshold before you start to
have symptoms. And it's notalways these specific allergic
triggers. They could be nonallergic in nature. Like just the
(06:28):
sheer fact that we're havingchange in weather. Where I'm at
right now, we had a bigthunderstorm yesterday. The
temperature was in the 50s andit's dropped to below freezing.
And now we have a snowstorm, andthere's about 1 to 2 inches of
snow on the ground on the firstday of spring. So that change in
(06:50):
temperature in barometricpressure can also fill up the
cup, so to speak, and lead tosymptoms getting worse.
Exactly. And it's not justrhinitis or upper airway symptoms
that are so common in the spring,but this also leads into other
even lower respiratory symptoms,like asthma. We know that a large
(07:13):
majority of patients with asthmahave allergic triggers, and those
that don't even sometimes havenon allergic triggers that
contribute to that inflammation.Right, Right, exactly. There's so
many different ways that ourimmune system interacts with our
environment and food. As anexample, there's something called
(07:35):
oral allergy syndrome, where youhave this allergy to pollen from
birch tree is the classic examplebecause it's got protein
structures similar to peaches,pears, plums, apricots, all these
different fresh fruits that whenyou eat it, your immune system
gets confused and thinks, oh mygosh, I think I'm eating a bunch
(07:58):
of pollen. And if you do that,especially in pollen season, that
threshold is going to get filledup very quickly and you're gonna
develop itchy mouth, mildswelling, and in rare cases can
become more systemic and lead toanaphylaxis. And this is true
with food allergies as well,where a small amount for some
(08:20):
people may not hit that thresholdbefore having symptoms. Maybe
it's a couple milligrams ofprotein before you start having
symptoms. But if you're sick,lowers that threshold, increased
risk of having hives, swelling,problems, breathing. It's all
sorts of other symptoms that arenot necessarily related to your
(08:43):
nose. Absolutely. And thesethresholds, as you mentioned,
they change. They can differ atdifferent times of the year for
patients. Again, depending onwhat a patient is experiencing,
like a viral illness. But we alsosee patients who are experiencing
symptoms this time of year. Ithink our fallback. Right. Is to
(09:05):
say, well, especially in areaswhere we know tree pollen is
prevalent, it must be the treepollen. But what can we do? And
I'm thinking about testing here.Right. To actually understand all
of the things someone may besensitized to on the allergic
side. Right. Non allergic is alittle more history dependent.
(09:28):
Exactly. So when I evaluate apatient and thinking about, okay,
what are the potential triggersfor their symptoms of rhinitis,
we do a full panel ofenvironmental testing. And so
that test, whether it's skin orblood testing, can give us a good
idea of what amount of allergyantibody is present that could
(09:50):
bind to that particular substanceand lead to symptoms. And then
you can look at the history,correlate it to the testing to
determine. Okay, I find thatactually you're not only having
symptoms to treat pollen, butmold. And when it gets very humid
outside, or maybe there's waterdamage in the home, they're
(10:13):
getting exposed to mold on top ofthe pollen exposure. So those
multiple exposures can lead tosymptoms. So if we do targeted
environmental reductionstrategies, like saying, okay,
let's go through the house, makesure there's no mold, let's make
sure we keep the humidity under50%. Right. Or hey, you've got a
(10:35):
tree pollen allergy. Let's makesure when you come home, you leave
your shoes in one place, changeyour clothes when you get home,
don't put those clothes on yourbed where you sleep. Make sure
you're cleaning off at nighttime,you know, showering or bathing
and rinsing your nose to removeall of those pollen grains and
(10:58):
potentially irritants too,depending on where you live, you
may have more air pollution. Andso when there's more travel as we
get to warmer months, that meansthere's going to be more air
pollution. That's a non allergictrigger. That could feed into the
other allergies that you'reexperiencing that can lead to
(11:20):
these sinus problems. Exactly.And I think, I think, you know, a
lot of people think, well, pollenis everywhere, it's ubiquitous.
Like how do we. And you mentionedsome of the techniques that we
use, but it's really about theconcept of a safe sleep space.
Right. And if we can protect thatspot where we spend eight, nine,
(11:43):
ten hours a day. Right. Thebedroom, it can really have a
dramatic impact on symptoms.Absolutely. The bedroom is one of
the most important places thatyou have to reduce these
different environmental triggers.And some of these triggers, as
you mentioned, you know, we thinkabout the pollens, the grasses,
(12:05):
trees and weeds in a minute. I'llask you to maybe speak to when we
see tree pollen, grass pollen,weed pollen. But then there's
these indoor triggers, we callthem perennial triggers. Right.
And those are, you mentioned moldthat can be present year round,
but also things like dust mites,things like your pets. Right.
(12:28):
Whether you live urban orsuburban mice can be a big issue.
And we know that can also drive alot of the symptoms we're talking
about. So maybe speak to how,once we identify through testing,
what specifically were sensitizedto, how can we address that
holistically to reduce symptoms?Right, Right. So, as we mentioned
(12:50):
earlier, the bedroom is the firstplace to start because that's
actually where you spend most ofyour time. So I always tell
people, make sure you havedustproof covers for your mattress
and pillow. If you havecarpeting, it's a good idea to
remove that if you can afford toand put hardwood floors. If not,
(13:13):
you've got to vacuum it at leastonce a week. And whenever you're
dusting, wearing a mask and eyeprotection can be very helpful
because anytime you disturbsurfaces, it's going to aerosolize
some of those particles that youcould be sensitive to. So in the
short term, you're trying to helpyourself feel better, but then you
(13:35):
get, you get some of thesesymptoms when you're trying to fix
that. Another way to reduce thatis to have wet dusting cloths
rather than dry. The moisturewill help trap some of that.
Getting portable HEPA aircleaners or air purifiers for
rooms that you spend most of yourtime in is a good idea. That's
(13:58):
especially helpful for thingslike pet dander. And I have three
dogs. I love my dogs to death,but they do not sleep with me.
And I think it's important thatpeople keep their pets out of the
bedroom. And I know people don'talways like hearing that, but I'd
rather say that than say, well,we should be getting rid of your
(14:20):
animal. And I never recommendthat to my patients. I always say,
let's find strategies to reducethat. We could say, hey, let's
bathe your animal regularly. Thatcould actually reduce the amount
of allergens that they have. Wedo want to make sure that when
they come from outside, you gotto wipe down their paws because
(14:43):
they do track a lot of theseirritating substances and
allergens into the home. It's notjust people with a dog or a cat
allergy. Right. But they actuallycan bring in the pollens from
outside or bring in the mold.Exactly. So you have to think
about all the potential point ofcontact that come into your home,
(15:05):
especially in the bedroom, tomitigate that. And then the one
fun thing I like to tell peopleis if you Have a dust mite
allergy. There's actually someevidence to show that if you don't
make your bed right away, it mayhelp. Because when you make your
bed immediately after getting upin the morning, you maintain some
(15:28):
of that moisture that your bodyhas generated, and it traps it in
the bed and increases the dustmite count. So I always say, okay,
it's okay. If you don't make yourbed right away, you could do it
later. That's recommended by thedoctor. Exactly. Let it air out.
Right, Let it air out. Exactly.That actually brings us to
(15:50):
something that's very common,especially with children,
Especially children that do haveasthma. I think a lot of times
parents want to put a humidifierin bedrooms to help them breathe
a little easier. But if they havea dust mite sensitization or
there's mold issues in the house,it's actually like a drinking
(16:13):
fountain. Right. For the dustmites, because that's how they
drink. They absorb water from theair. Right. Dust mites are
roughly, what, 80% made of water.They are so reliant on humidity
that that's why I was mentioningearlier, keeping the humidity
under 50% will decrease the dustmite counts, but at the same
(16:35):
time, dry air can irritate theairways, too. So it is a
balancing act. In the case ofillness, you have to make sure
you're cleaning your humidifiersregularly every other day. It
depends on the manufacturer'sguidelines on the specific device
that you have. But you've got tobe cleaning it, otherwise it's
(16:58):
going to be an area where mold'sgoing to grow or it's going to
allow dust mites to accumulate.But if you also have those
dustproof covers, if you arechanging sheets regularly and
you're vacuuming and dusting,that will help decrease some of
those dust mite counts as well.Yeah, exactly. And things like
(17:20):
maybe not having carpet in thebedroom or washing stuffed
animals on a regular basis, orI've even heard putting the
stuffed animals in the freezer.Yeah. My mentor at fellowship, he
taught me that trick a long timeago. You basically put them in
bags. These are stuffed animals.Leave it in the freezer overnight
(17:43):
once a month, and it'll kill offthe adult dust mites. But the eggs
that they lay, which nobody canreally see, that will stay behind.
So that's why you'd have to dothat regularly. It is one way to
reduce dust mite counts instuffed animals. If for some
reason you can't get rid of them.A lot of kids are very attached
(18:05):
to Their stuffed animals. That'sone way to safely do that,
granted. Do you have the freezerspace? You know, that's always a
challenge, but it is. It issomething that could be
potentially helpful. Yeah, yeah.I mentioned the other pollens,
tree pollen this time of year,but what about grasses and weeds
(18:28):
and what can we expect as we gothrough the year? When I talk
about these things, I'm talkingabout because I'm in the
Chicagoland area. So everyregion's a little bit different.
You look at Texas, they havecedar fever in December, January,
and that tree pollen from ashjuniper is coming out. And people
(18:50):
are miserable in the wintertime.But for a lot of other parts of
the country, you start seeingpollen being released in March.
So that's tree pollen, March,April, May, and then as we
transition from May into June, itgoes into the grass pollen month,
which is the shortest season outof the three. So that's usually
(19:13):
around June, July, and then as weget into late July, August, the
weed pollens come out up untilthat first hard frost in your
area. Once that hard frosthappens, the pollen will stop.
And we're starting to see someoverlap. It's kind of
controversial, right, to talkabout the warming climates, but
(19:35):
we're starting to see overlapswhere spring tree pollen season
may be starting a little earlier,extending into or overlapping
with grass pollen. So sometimesit's hard, just based on the time
of the year, to figure out whatexactly you're sensitized. Yeah.
That's why it's important to lookat the pollen counters in your
(19:58):
area. As an example, the AmericanAcademy of Allergy, Asthma and
Immunology, or Quad AI, they havea pollen counter in many major
cities that you can subscribe to,and they'll give you morning
emails to tell you what's goingon. I'm hoping in the future
we'll have better technology toget more real time estimates,
(20:20):
because really, you gotta handcount a lot of this and these
manual counters. It's very laborintensive. I know there's a lot
of work done into making moreaccurate automated systems so
that we know more in real timewhat's going on. But as a rule of
thumb, if it's dry and windy, yousee that in the forecast, the
(20:43):
pollen counts are likely gonna behigher. If it's going to be
raining, the pollen counts willbe lower, but the mold counts
will be higher. Right, becausemold follows moisture. So those
are some general rules of thumbfor people to think about when
trying to manage their allergies.Yeah, absolutely. So, you know,
(21:05):
we've talked about thepreventative medicine exposure
reduction techniques that we canuse when we're sensitized. But we
also probably should talk alittle bit about medications and
maybe can speak to that conceptof priming. Right. And
identifying when we think basedupon our sensitizations and when
(21:28):
pollen counts are going to behigh, how we can prevent kind of
getting into the thick ofsymptoms. Right, exactly. So this
is especially true for pollenallergies, the seasonal allergic
rhinitis patients. If you don'tstart your medications early
enough, it's harder to treatbecause once you start getting
(21:50):
that exposure, the inflammationthat occurs will just keep
getting worse, worse, worse andworse and worse. That's the basic
concept of what you mean bypriming in that sense. And so, so
if you know that pollen season isgoing to start roughly the first
couple of weeks in March, youshould be starting your medicine
(22:13):
two to four weeks before thenbecause that gives your body
enough time to get used to themedication. It builds up in your
system, especially for nasalsteroid sprays like fluticasone,
mometasone, triamcinolone, yourflonase, nasal cord, Nasonex, over
the counter sprays. If you'redoing that two to four weeks
(22:35):
ahead of time, then you havereally helped cut off that
potential priming stage to reducethe chances of having significant
symptoms. If you start yourmedicine in April, you are playing
a lot of catch up and it's goingto take so much more time and
you're higher risk of havingsinus infections, ear infections,
(22:58):
problems sleeping at night, whichsleep is such a premium and such
an important part of our health.We can't concentrate as well, our
blood pressure goes up if wedon't sleep well, our weight goes
up, cholesterol issues. So sleepis so important. That's why I'm
so passionate about my specialtyis because we're a type of niche
(23:20):
specialty that helps peopleimprove not only their quality of
life, but indirectly theirquantity of life as well. Yeah,
absolutely. So we have a coupleof questions coming in and I
think we answered one of them.But this is probably a Nobel
Prize winning, if you can answerthis right, we know allergies
(23:43):
change over time. What's thehypothesis there on why
particularly young children willdevelop more allergies, they'll
develop tolerance to foodallergies as they age. Why do our
allergic responses really change?Yeah, so the short end of it is
we don't know, obviously. I mean,as you said, this would win a
(24:05):
Nobel prize if we could fullyunderstand this because there are
people out there who will have acat allergy and randomly one day
not be allergic. And we have noidea what was the trigger that
caused that to happen. We havebits and pieces of the story put
together in terms of. We knowthat like I mentioned in the
(24:28):
beginning of our sessiontogether, is that IG antibodies
are produced. They're produced byspecific cell called B cells, and
there's a whole process calledsensitization happening. But we
don't know sometimes what theinitial inciting factor is. It's
probably a complex interplaybetween genetics and environment
(24:50):
that's doing this. And so theenvironmental triggers of how
that happens is not fullyunderstood. But we know that
there are more and more peopledeveloping these problems over
time, starting in childhood andgoing into adulthood. Especially
correlating with, we have higherpollen counts, we have more air
(25:13):
pollution in certain areas. Thereare certain exposures that we
know have increased over time andthat's correlated positively with
more people being diagnosed withthese problems. It's why I hear
every single year, why are myallergies worse this time than
last year? Why is it the worstthis year compared to any other
(25:35):
year? Well, you're exposed moreto these problems that are
causing the allergic symptoms.Part of why people later in life
may see less allergy symptoms isthe immune system just gets
weaker as we age. So we know thatimmune senescence, right? I
believe. Exactly, exactly. Yes.But not everybody does that. And
(25:58):
then on the flip side too, youmay lose your allergic rhinitis
where your immune system issensitized and that allergy
antibody is present, but then theanatomy changes and some of the
immune system changes and youdevelop non allergic rhinitis. So
as you get older, a lot of timespeople will have a runny nose
(26:20):
that's running like a faucet andthat's more of a structural
mechanical problem rather than animmune system problem. And you
need to rule out. Right. Allergyfirst, what we mentioned called
phenotyping. Right. Is this anallergic mechanism or is it a non
allergic and then when it's nonallergic, going down that clinical
(26:43):
pathway to figure out exactlywhat it is. Exactly. Yeah. Thank
you for listening today and Ihope you enjoyed this conversation
with Dr. Rubin on allergyInsider. Again, they're great
patient education. They've gotarticles on their webpage around
specific allergies. They have abunch of content on their
(27:05):
Instagram. And the goal really isto make sure that patients are
getting the most medicallyaccurate allergy information out
there online. If you want tolearn more about some of the
pitfalls of online education andsocial media. Dr. Rubin again
does a great episode on this onImmunoCAST. That's episode 24
(27:28):
called Navigating Social Media asa Clinician. And if you want to
hear Gary and I talk through thesymptom threshold with more of a
clinician lens, we have anepisode around that as well. That
is Episode two. All this will belinked on this episode's page via
the link in the description.Thank you for listening.
(27:50):
ImmunoCAST is brought to you byThermo Fisher scientific, creators
of ImmunoCAP Specific IgEdiagnostics and Phadia Laboratory
Systems. For more information onallergies and Specific IgE testing,
please visit thermofisher.comImmunoCAP Specific IgE testing is
an aid to healthcare providers inthe diagnosis of allergy and cannot
(28:13):
alone diagnose a clinical allergy.Clinical history alongside specific
IGE testing is needed to diagnosea clinical allergy. The content of
this podcast is not intended to beand should not be interpreted as or
substitute professional medicaladvice, diagnosis or treatment. Any
medical questions pertaining toone's own health should be discussed
(28:35):
with a healthcare provider.
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