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A Mayo Clinic podcast for laboratory professionals, physicians, and students, hosted by Justin Kreuter, M.D., assistant professor of laboratory medicine and pathology at Mayo Clinic, featuring educational topics and insightful takeaways to apply in your practice.
- This is Lab Medicine
Rounds, a curated podcast
for physicians, laboratory
professionals and students.
I'm your host, Justin Kreuter,
a transfusion medicine pathologist
and assistant professor
of Laboratory Medicine
and Pathology at Mayo Clinic.
Today we're rounding with
Dr. Douglas McMahon from the
Allergy and Asthma Center
of Minnesota in honor
of May being national, a Asthma
and Allergy Awareness month.
Dr. McMahon is a board
certified in allergy
and asthma doctor
and is a frequent lecturer
at national medical meetings
for food allergies and asthma.
He's also proud to have
served as the director
of outpatient allergy at
the University of Minnesota
for four years,
and the president of the
Minnesota Allergy Society.
He is also the only allergy trained member
of the Twin Cities
Children's Asthma Committee,
and he's a member of the Food Allergy
and Anaphylaxis Network, anaphylaxis
and Food Allergy Association of Minnesota,
Minnesota Medical Society,
and the American Academy of
Allergy, asthma and Immunology.
So we're definitely joined
by an expert to talk
with us now on National Asthma
and Allergy and Awareness Month.
Thanks for joining us, Dr. McMahon.
- Well, thanks for having me.
- Well, it,
it's awesome to have you here.
And for our audience, you know,
I think we have a quite a diverse audience
that are listening and
chime into this podcast
since it's allergy and
asthma awareness month.
Why is it maybe, maybe to take a beat
and say, why is it important
for people to, to kind
of recognize asthma and allergy,
to bring it front of mind?
- Yeah, so asthma is something
that's very important
because unfortunately
people die of asthma.
You know, a lot of people kind
of think about asthma as, oh,
you know, I have some
troubles here or there,
but, you know, people
unfortunately die die of asthma.
So it's definitely something
to take, take serious
and to make sure you're under
good control all the time,
because you never know when the
exacerbation's gonna be severe.
But also, which is more
hits home to more people is
that asthma affects
everyday quality of life.
So I grew up with severe asthma,
and that's kind of why I
went into this field is that,
you know, there just small activities
that people don't even think about.
You know, little kids sleeping
over at a friend's house,
going on a camping trip, playing sports.
All these things can be
impacted if you do have asthma.
So it's important to be under
really good control for that.
And then allergic rhinitis, you know,
a lot allergic rhinitis is something
that affects millions
and millions of people.
Probably one of the most common disorders
in the United States.
And you know, a lot of people
right now are seeing it,
you know, spring, spring
allergens, the tree pollens.
Some of the molds are
really affecting people
and it, it just affects your
quality of life where they're,
you know, not sleeping well,
having trouble, you know,
with sinus infections, having
to skip school, skip work,
just uncomfortable.
'cause they're having
a runny nose, sneezing,
itchy eyes all the time.
And so it, it's definitely
impactful on people.
- Well, I hadn't really considered about,
and I, I appreciate you kind
of bringing this front of mind,
highlighting, I mean, both
the, you know, profound aspect
that some patients can die from asthma,
but then also impacting
kind of the every day
how this can really kind
of impact those around me.
You know, I may not have this diagnosed,
but maybe there might be
other people around me
that are affected.
Maybe this is a good time
for me to ask then, you know,
are there maybe just for
awareness, are there simple things
that, that I might be able to do
that makes it a little easier?
Who people from people that may suffer
from asthma allergies around me?
- Yeah. So one of the, the big
ones is, you know, smoking,
you know, people that
fortunately don't smoke in public
places as much anymore.
So that's a big one. One
thing that's interesting
that we are seeing that a lot
of people probably don't
think about is, you know,
how pets people are bringing their pets
around a lot more places
right now, you know,
and their airlines and you know, the,
the shopping stores and all this.
And, and people, you know,
they, they like their pets
or they want emotional support animals,
but they don't really think
about the, the patients
that are allergic to these animals.
And some people have asthma
that is flared by that.
And so all of a sudden now you're,
you're inducing these responses.
And so that's kind of
a, an interesting thing
that probably a lot of
people don't even think
about that have them.
- That's a, a great point.
I imagine, you know, it's, it may,
it sounds like it's probably
independent of like, you know,
it might be a, an animal that
you're, is, is cleaned and,
and you know, healthy,
but still can set off
exacerbations and those around you.
And so I guess that it brings a mind
of maybe just highlighting if
you're gonna bring an animal
by to kind of talk
with people first instead of the surprise.
- Yeah, yeah. If, yeah.
Especially if you're gonna
be in some close quarters.
Yeah, for sure.
- So transitioning, one
of the things I wanted
to ask you about in kind of talking
before this episode is to understand some
of the newer oral immunotherapy
options that are coming out.
We thought this would
be a great way to kind
of update listeners in
our community to something
that seems very relevant to
patients for asthma allergy.
What should our audience
understand about these neural new
oral immunotherapy options?
- Yeah, so, so there's,
there's two different aspects of this.
One is for environmental allergies, one is
for food allergies.
They both work on the same
premise that giving small amounts
of the allergen.
If you start small enough over
time, giving more and more
and more, your body can
alter the immune response.
So, so basically the,
the two response is
what a lot of the people who
have an allergic response are
in this two realm.
And the notion is, is can we
switch that back to, you know,
either a lower response or
possibly one response.
And so a lot of this is, seems
to be actually the
younger the patients are,
the better it works because
the immune immune system is
probably more malleable at that time.
And so what we're doing right now,
I'll talk about the foods
first, is we are doing a lot
of food, oral immunotherapy
where we are taking these patients
with severe food allergies,
basically life-threatening to,
you know, peanut for example,
we are giving them about one
50000th of a peanut orally,
slowly increasing that over time.
And it's pretty, pretty amazing.
You can see the immune response
pretty quickly like this IgG
four increasing pretty
quickly after taking it.
And then you can see the IgE slowly coming
over down over time.
And, and so you'll, you'll
notice these levels are changing.
And so this is something that
is really on the horizon,
newer, newer therapies that we're doing.
And it works really well,
especially the younger they are.
It works in adults too, but
definitely better than kids.
And so, and then I can talk
about environmental as well,
but do you have some questions
about the food allergies? Yeah,
- I, I just wanted to hop in
and maybe ask for our audience,
'cause people maybe a little
bit, you know, have a kind
of a broad base of understanding and,
and you know, as you're
talking through th one,
th two response, just, I was
wondering if we could kind
of paraphrase that for our
listeners to kind of pick up,
I guess, do you think it's
fair to say that, you know,
the body in some of our
patients have learned to respond
with this sort of allergic
anaphylaxis response
and with this strategy
of giving small doses
over long periods of time
is kind of reprogramming that response,
so it does not respond in that way?
- Yes, yes. Basically, so IgE is,
so you can think of the like th two arm,
we really don't need
the th two arm anymore.
And it's, it's a, it's a
hyperimmune response, the IgE.
And, but unfortunately some people are,
are starting off at a
young age going that route.
I mean, we have theories,
hypothesis why they're going that way.
Some, some genetic, some
other exposures possibly.
But if they're starting to
veer off that way, can we
decrease that, that allergic response?
And it looks like possibly we
are, at least for the foods,
able to kind of revert that
strong allergic response back
to a kind of a more normalized response.
And so that's kind of what
this oral immunotherapy is.
- Excellent. And is there
anything else that needs
to be given to kind of
reprogram that response?
Or is it just kind of the, the
frequent low dose that seems
to allow the body to have a, a reset
- Yep.
Frequent low dose with
increasing, increasing amounts.
So eventually you'll get up to a higher
amount, but yeah, it normal.
I mean, they, there's people
that looked at studies,
do you need to add other things?
You know, there was initial
some data, some herbal,
herbal supplements maybe helped,
but subsequent studies haven't
shown that to be beneficial.
You know, people are looking
at other factors with it.
- Wow. So this sounds like something,
and I know we're gonna transition
and talk about environmental
antigens in a second,
but this sounds like something
that, you know, unlike, a lot
of times we read about new
advancements that are being made,
it sounds like, you know,
it's like stuff that is very,
very costly access to
this is very limited.
Are some of these same challenges
true when you're talking
about these kinds of therapies?
- Yeah, so in interestingly, so
the FDA, you know, needs to
review things to see, you know,
are these safe and, and everything.
And, and the FDA process
is long and it's expensive.
And so companies need to
recuperate those costs.
So a company studied peanut flour
through processes
and they, they market
it now called Peoria.
And so I, I was actually on
the advisory board of them
and myself and some other doctors.
You know, we say, well, why,
why are these patients paying
a thousand dollars when this
is just peanut flour?
You know? And some people want
that prepackaged flour, you know,
we can measure it
ourselves a small amount,
but some, some institutions
only allow FDA approved
products, and so they need
that prepackaged dose.
And so some people will, will,
you know, go through this
for peanut called palor expensive,
but it's, it works, but,
or you can do, you know what
we measure out the doses.
- Hmm. Now if as we transition
to environmental antigens
or allergies, is that,
is it very similar story
or is it more problematic
because we maybe have less control over
our environment than, than what we eat?
- Yeah, so, so the, the food
allergens, it's pretty, I mean,
you can see clear as day, you
know, a patient, you know,
we challenge 'em to, you
know, a one liter of milk
and they have anaphylaxis
and we give 'em these small amounts and
after six months they're
drinking a glass of milk.
We can see 'em in front
of our face, say, Hey,
you, well, you're fine.
You know, you can go eat ice cream,
you can go eat cheese pizza.
You do what you want. You know,
whereas environmental is,
you know, it's different.
You know, people have,
you know, there's sneeze,
it's your eyes, we, you know,
we can't, we can somewhat see,
see it, but it's not, you know,
black and white difference.
We can see with that.
So with the environmental, it's,
it's an something called
sublingual immunotherapy is
typically what is done
with the oral route.
So same concept,
but basically giving small
amounts of the, the food,
or sorry, the environmental
pollen animal dust
mite under the tongue.
So there's a couple options to do.
Some companies have
made them for dust mite,
a tablet called ra, two
grass tablets, grass tech
and oral air, and then a
ragweed tablet, rag tech.
Or you could go to some special
compounding pharmacies like
our facility, or there's other
ones that do compound these,
and they, you can get
'em underneath the tongue
and do those at home.
They, they work well.
Normally reduce symptoms by
about, you know, depending on
what, what study look at maybe
50% reduction in symptoms.
So it's not, you know,
a hundred percent, but,
- And what's the Venn diagram look like?
If we're talking about
people that have allergies
to food allergens
and then people that have
allergies to environmental, is
that, is that pretty overlapping
or is that, is that kind
of more of a separate,
- Seems to be like eczema
seems to be possibly like the,
the middle starting point of those, A lot
of kids have eczema and we think,
- So dry, dry skin,
- Dry open, rough skin.
We think because it all starts with
that maybe these allergens, food
and environmental are
coming through that skin
and citing this th two process
that's starting this allergic pathway is
kind of where we think.
And so that's why we always
try to tell this patient
with eczema, try to get
a real good skin barrier
early, prevent that.
But there's some patients
that have no eczema
and all of a sudden get
environmental allergies,
get food allergies, get asthma.
But I mean, my specialty is
asthma, environmental allergies,
food allergies, and eczema.
And I see a lot of
patients with all of it.
A lot of patients have more
than one of 'em, not everybody,
but a lot of 'em have a couple
of those conditions together.
- And is, is your treating
one is, is it a true saving
to say like, you know, if I'm having,
if I have a milk allergy and
you're desensitizing the,
or retraining my th two response,
and I also have other allergies,
like maybe environmental
allergies d does that,
is there a crosstalk there where I'm kind
of decreasing my overall
th two allergic response?
Or is this something that the body has
to learn like per allergen?
- So it is a good, good question.
Typically for the foods,
it's per allergen.
Interesting though, along that line,
so allergy shots have been
around for over a hundred years,
and same concept, give
injection of a little bit of
what you're allergic to for
environmental allergens, not
for foods, but environmental
allergens give a little
bit more and more, more.
In the United States, we typically try
to find everything you're
allergic to, like Timothy grass,
short, ragweed, birch, and
we put that in the shots,
and then you get shots of those.
However, what I hear is in Europe,
they just say, okay, you're
allergic to 30 things,
we're gonna put the five major things in
because your overall allergic
response is gonna drop.
Hmm. So, so there is,
there's definitely some data
that shows yeah, your total
overall allergic response is
gonna drop even if you don't
target those for environmental.
But foods, we aren't
seeing that right now.
- Well, it's interesting
to see that separation.
You know, I, I really
appreciate you highlighting this
for our, our audience.
And as you know, we
have a, a strong number
of audience members that
are joining us from the lab
medicine perspective.
And this podcast is really about kind
of creating these bridges
and helping laboratory medicine
in the clinical practice,
sort of understand how each other works.
And I was wondering if
you might share, you know,
maybe some ways that in
your practice you rely upon
or use lab testing to
support the, the care
of your patients.
- Yeah, so one big thing is,
is there's a condition
called oral allergy syndrome,
otherwise known as food pollen syndrome.
It's very common. I guarantee you
that some people listening
here have it, I have it myself.
People probably have
it, and they don't even,
didn't even realize it.
But it basically is people who eat
like raw apples or raw carrots,
raw celery, raw cherries,
and they eat 'em in their
mouth kind of itches,
or they might get a little bit
of swelling of their tongue
or, or their, their lips
or maybe a few hives.
And the next time they eat
it, they don't notice it,
and then next time they do.
And so they're very confused
and they're saying, you know what, what
is going on with this?
And normally what that is, is,
the way I explain it is
if people are allergic
to certain pollens, if you
looked under a microscope
at those pollens, they have
certain molecules in them
in those fruits
and vegetables, they
also have the exact same
molecules in them.
And because of that, then
your body is saying, Hey,
you just ate some pollen
and cause the itchy mouth,
but the molecules are weaker.
And so when the acid and
stomach breaks 'em down,
you don't have those full body
reactions and also cooking it.
So somebody might eat like a,
a applesauce and they're fine,
but a raw apple, they have problems.
And so in interestingly,
the lab is very helpful in,
in telling us it's
called component testing.
So we can do IgE component
testing, which is very useful in,
in helping us identify
whether these reactions would
be severe or not.
The particularly peanut
and tree nut is a big one
where patients come in
and they say, you know,
I've never had a peanut,
and all of a sudden I had it
and my lip felt funny, my
tongue thinks was swelling.
And we say, okay, can, can
we tell, can we tell if
that is gonna be a severe reaction or not?
And yes, we can through,
through the lab medicine,
and so you can do those tests
- Phenomenal.
So you don't have to actually
expose somebody to it again,
you can kind of, I guess,
look in a more safe way, it sounds like.
- Yes, there is.
Speaking of that, I have
not done much of this,
but there is a lab test called a a, a
basophil activation test, BAT.
Only certain labs have it,
but basically it's basically supposed to
see if a patient would have a
severe reaction to a, a food.
So let's say you did a IgE to egg before
and level was, you know, 0.4 or five
and you say, gosh, I I don't really
wanna challenge this kid.
This kid is, you know,
not a very healthy kid.
I don't really wanna challenge
him, but I don't wanna
make all these avoidance.
There is a way to do this
where you basically mix
the patient's blood with
the food agen
and you can see if these
basal fills are activated.
I know only certain places have that test,
but that is, is something that's
probably gonna become more,
more useful as, as the
studies go on to see how, how,
how beneficial this test is.
- Yeah, it's wonderful to see And,
and to highlight for our,
our listeners, I wanna kind
of close out this interview,
maybe just asking again,
in recognition of, of this being asthma
and allergy month, like
what do you think kind
of what's just over the
horizon in your field?
You know, like, in other words, h
how do you think you'll be practicing
differently in 10 years?
- Yes, so the biologics medicine,
all the monoclonal antibodies is really,
really taking over our space,
very targeted medicine.
And so, you know, lab medicine
will be useful in that,
that aspect in that, you
know, we need to find which,
which are the biomarkers
that we're targeting.
And so I think that's
really gonna be, continue
to be the wave of the future.
- That's awesome to hear.
And I mean, yeah, absolutely.
That's something that
we're familiar with in,
in laboratory medicine
and how we think about
different interferences
or what does that mean for the other tests
that we're looking at and measuring.
So thanks for rounding
with us, Dr. McMahon.
- You're welcome.
- And thank you
to listeners for joining us today.
We invite you to share your thoughts
and suggestions via email.
Please direct any suggestions
to MCLeducation@mayo.edu
and reference this podcast.
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Rounds, please subscribe
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