Dr. Haase & Mr. Why

Did you know there is a therapy that can profoundly improve not only the symptoms of allergy, but can re-educate the body to no longer be allergic? Crazy, but true.

The amazing therapy is called SLIT (Sub-Lingual Immuno-Therapy) and is essentially allergy shots administered as custom-formulated drops under the tongue at home, not in an allergist’s practice.

• They are cheaper than allergy shots.
• They are safer than allergy shots.
• They are very useful for treating molds – this is tough with allergy shots.
• They are VERY useful for treating food allergies – again, tough with allergy shots.
• Allergy drops can be administered at home, not taking time out of one’s busy schedule to go to the doctor’s office and sit there for 20 minutes after the shot is given.

Here is a comparison of shots vs. drops that I wrote last year.  And here is a piece describing just who can benefit from allergy drops.

We love to see our patients at the MaxWell Clinic start to enjoy the freedom and vitality that occur when allergies no longer occupy a major part of their life.   SLIT works to provide more healthy days.. and after all isn’t that a major goal of the profession of medicine…. it should be.

Yet, many established allergists do not utilize this remarkable therapy?   Why?  WHY don’t more allergists use this therapy? Dr. George Kroker the formerly angry allergist explains why dollars and pride are outweighing sense and practicality in his excellent 2 part blog on the adoption of SLIT by allergists – Liberally excerpted here…..  Thanks George!

On Accepting Sublingual Immunotherapy–A Denial of Reality…

In my last entry, I’ve written about the extensive history of SLIT–going back over one century…many, many years prior to the European literature,which largely began in the 1980s…Invariably, in any discussion about SLIT the one key question that arises is…

Why has recognition of this technique as a safe and efficacious treatment for allergic disease taken so long?

To my knowledge, there has never been a medical article that addresses that question…and it seems to be a perfect blog topic…so here goes…

Lack of American acceptance of SLIT as a viable treatment modality is probably because of several factors:

1. The “turf wars” between ENT’s and Allergists: Face it. The majority of early proponents of SLIT were not allergists. They were ENT physicians (Hansel, Pfeiffer), or non-ENT non-allergists (Dickey–a urologist by training). Medical history has a tendency to repeat itself…when Edward Jenner discovered vaccination for smallpox, his discovery was unrewarded by the medical establishment, largely because of bias against him–he was a rural general physician and his 1798 paper was rejected and never published by the medical establishment. Similarly, why would a board-certified allergist look kindly on a technique condoned–and discovered–as effective by his non-board certified colleagues??

2. The profound implications of SLIT–it’s potential to revolutionize the office practice of allergic disease: Let’s face it. As allergists, we can rapidly incorporate a new medication into our practice with minimal problems…but incorporation of SLIT into an office practice would take far more work, and (according to conventional wisdom), considerable financial risk. Technicians would have to be trained, and a doctor would have to be educated and confident of his success in using it…in the face of non-insurance coverage. The American allergist, before he/she dives into a SLIT-based practice, simply wants iron-clad, irrefutable, American-based evidence that SLIT is safe and effective. Anything less is simply unacceptable…Money can be made with SCIT, and with SLIT…well, insurance coverage just isn’t there…yet…so “let’s wait and see”, right?

3.The “tomato effect”. Allergists were trained during fellowship to believe that SLIT didn’t work, because…everyone knew it didn’t work. This is an example of “The Tomato Effect”, written about by Goodwin, JS & Goodwin JM, JAMA 251: 2387-2390, 1984. Briefly put, the tomato effect is defined whereby a potentially efficacious medical therapy is discounted because “it doesn’t make sense”. The conventional wisdom–common knowledge–is that “it just doesn’t work”. In 1560, the tomato was becoming a staple of the European diet, having been brought back from Peru. As the Goodwins put it,

“Of interest is that while this exotic fruit from South America was revolutionizing European eating habits, at the same time it was ignored/actively shunned in America.

“The reason tomatoes were not accepted until relatively recently in North America is simple: they were poisonous. Everyone knew they were poisonous, at least everyone in North America. “Not until 1820, when Robert Gibbon Johnson ate a tomato on the steps of the courthouse in Salem, New Jersey, and survived, did the people of America begin, grudgingly, we suspect, to consume tomatoes…”

4. If SLIT is accepted, we have a technique safe enough that potentially even non-allergists will do it and create increased competition for the allergist. This gets into my “hidden agenda” blog post from earlier. To the trained allergist using SCIT, there is only one solution to the dilemma of having a form of immunotherapy that is simply “too safe”…and that is to “spin” SLIT to make it as dangerous as possible…this benefits the allergist–since it keeps the treatment “in his camp”. No one but the board-certified allergist would dare to do it (pretty much like injection immunotherapy presently). Presentations and studies by American allergists will therefore be overly cautious and negative in their portrayal of the benefits of SLIT…

In short, the American allergist (unlike their European counterpart), comes with psychological “baggage” of years past regarding inherent bias against SLIT (a technique largely proposed by non-allergists), and a fear about maintaining financial security when adopting this technique and giving up SCIT. Instead of objectively looking at European studies and aggressively pursuing SLIT, we employ a strong “denial of reality”–a defensive, fearful posture–we think “if we just don’t think about SLIT, it’ll go away”…And we employ tired, worn arguments (i.e., “it’s not FDA approved, we don’t have American studies…”) that don’t even make rational sense (after all those of us who use SLIT use FDA approved extracts in an off-label useage–something perfectly legal).

It’s hard to be creative and innovative when you’re fearful, and that’s just the place where the American Allergist is…now, more than any other time in our history, the American Allergist needs to be resourceful, creative, and innovative. Not fearful. Our attitude with SLIT is but one example of something that needs to be changed…and soon.

Later, Dude

Thanks, George!   Keep up the great work & keep answering the question of “WHY?”

Did you know that withdrawal from many drugs CAUSES the same symptoms the drugs were prescribed to TREAT?

• Anti-depressant medication withdrawal often cause acute depression and all kinds of other wacky symptoms.
• Anti-anxiety medication withdrawal often causes severe anxiety – even worse than the initial symptoms.
• AND Anti-ACID drugs used to treat GERD or heartburn – upon withdrawal – will often cause WORSE heartburn than what the person originally experienced when starting the medications.

This has been an observation of mine for years, and the reason I harp that we must look for, and address the underlying CAUSES of dysfunction and disease as opposed to suppressing meaningful symptoms with powerful new-to-nature drugs on a regular basis.     Drugs often blow away the “smoke” of the symptom while letting the “fire” of the underlying abnormality rage on.

A study in Gastroenterology has deeply vindicated my position.     It showed concvincingly that a Proton-Pump Inhibitor (PPI) , or “purple pill” or specifically in this case esomeprazole (Nexium) when given to HEALTHY people without any heartburn whatsoever for an 8 week period caused often severe heartburn, dyspepsia, and GERD symptom in 44% of these people when the medication was stopped!    In most of these individuals the symptoms persisted for greater than the 4 week follow-up period!   There is no reason that other PPI’s such as Prilosec, Protonix, Aciphex, or Prevacid would be expected to act any differently.

This means HEALTHY people now have a new long-term problem due to taking this medication (some forms are now over the counter).    That sounds like a problem to me.  This opinion article reflects my concerns and gives a nice review of the full scope of the problem.  Now, it is certain that these drugs truly benefit some individuals long term (meaning that the benefit they provide over-weighs the detriments they induce) , and I am also certain they are massively overused.  Especially since there are so many effective cause-focused approaches available.

So what has occurred is the rise of a highly profitable class of  medications that help initially, but now we know that many patients are assured of feeling even worse when they stop that medication.    Sounds like a great business plan. 

Another problem is that in real life healthy people don’t take medications – sick people do.   People with heartburn and reflux.       But allow me to ask…  WHY do they have these symptoms?    The presence of these powerful drugs that so quickly and completely removes symptoms have seduced patients into thinking that the problem is that they have a “purple pill” deficiency as a cause of their symptoms, and has equally seduced doctors into believing they are doing the best for their patient because the symptoms go away.

This twin seduction of  doctor and patient closing their eyes to a bigger problem because of a quick fix is the same problem that leads to narcotic addiction, stimulant addiction, sleeping pill addiction, etc.    I currently live in the state that has had the dubious honor of prescribing the most lortab (a potent narcotic) per capita of any state in the union.   Is that because Tennesseans hurt more than people in other states…. obviously not.   The answer is complex … like most truths, but at the center of the problem is the culture we have together developed that cure comes in the form of a drug that will block, inhibit, or short-circuit a normal function of the body.

On the national scale this situation presents a larger problem because 5% of the developed world is taking this EXPENSIVE medication class.  That is a lot of health-care dollars that you and I needlessly pay.

So what are some causes of the severe reflux and heartburn that some people encounter?   My fingers don’t go fast enough to cover all I want to say, but let’s think of some big-bucket causes.   Certain foods can loosen the sphincter that separates the stomach from the esophagus – coffee, chocolate, milk, and sugar are the biggest culprits in the scientific literature, but I can tell you many foods can cause it.   Many foods can cause sensitivities or allergies that will have as a symptom heartburn (remember another class of medications used to treat acid issues are H-2 blockers… the “H” stands for histamine which is a major chemical in the allergy cascade).  Emotional stress both chronic and acute definitely contributes,  Small bowel bacterial overgrowth,  yeast overgrowth or sensitivity, parasite infection, Poor diet leading to inflammation, recent anti-biotic use, recent viral infections, Hiatal hernia (which I have witnessed respond to visceral manipulation in several of my patients), hormone imbalance, Celiac disease, some toxins, some commonly used medications.

WHY is the most important question we can ask when we have a symptom… our body is giving us an early warning that something is not right, and we then get the opportunity to investigate, address the cause and potentially gain side-benefits in other areas of our health from our cause-focused intervention.

WHY may find the cause is actually a LACK of adequate stomach acid leading to poor digestion, bloating, and all kinds of skin problems.    WHY may lead to the understanding that eating machine-poop instead of real-food does not adequately fuel our lives and help in the attainment of our highest life purposes.   WHY may give the bravery to re-claim your life choices as your own, and give the opportunity for you to start living your life your way.   WHY may lead to you seek a comprehensive evaluation which could identify that weak link in your chain that would shorten your life otherwise.  WHY could get you to the cause of persistent weight gain… and lead to remarkable weight loss.   I have witnessed all these things.   Good stuff that WHY.

Find the Root Cause and give the Right Treatment.

It is my opinion that with the exceptions of acute ulcer healing, erosive esophagitis and Zollinger-Ellis Syndrome we should be very cautions in prescribing these Proton Pump Inhibitors for anything over 1-2 weeks.  Now that rebound acid secretion has been demonstrated to induce symptoms, we are probably obliged to inform patients about rebound acid hyper-secretion and its potential effects.   There is evidence for these meds contributing to dysfunctional long-term gut function, osteoporosis, mal-digestion of  proteins, inhibition of vitamin B12 absorption, and significantly thinning your pocketbook if you take them personally, or if you pay taxes for other individuals to unnecessarily take them life-long.