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from WXXI news this is second opinion live on connections I’m Evan Dawson this hour of connections
we’re going to focus on something that many of you can relate to I certainly can it’s drug allergies ten
percent of the u.s. population report being allergic to penicillin with all
the different antibiotics available might not seem like a big deal right
well maybe not so fast it’s important to understand what drug allergies are how
they can impact us and what it all means for us now in studio today we have dr.
Allison Ramsey of allergy and clinical immunology at Rochester Regional Health
she’s also clinical assistant professor of medicine at the University of
Rochester School of Medicine and Dentistry dr. Ramsey welcome to the
program thank you for having me and this hours being produced in association with
a national public television show second opinion which is produced by WXXI public
broadcasting and the University of Rochester Medical Center in rochester
new york and today’s broadcast is part of the second opinion live webcast
series you can watch this program on the web at second opinion dash T V dot org
and you can participate in today’s conversation you’ve got questions about
you your kids rashes questions about drug allergies already have some emails
from you will get to those and you can call the program 844-295-talk tollfree
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this possible let’s get started in i mentioned
myself and you know I’m trying not to overshare here but I had a big rash
when I was in high school amoxicillin rate we related and we
mentioned Dr. Ramsey ten percent of the population allergic to penicillin is
amoxicillin in that umbrella or is it penicillin and it’s you know only has it
work? so there’s a family of medications called the penicillin family and that’s a class of medications of which amoxicillin is a member and when you say ten percent of the
population is allergic there’s a distinction there ten percent
of the population thinks they’re allergic but actually when you look into
it only about ten percent of that population is allergic to ninety percent
of people walking around in our country that think they’re allergic to pop to
penicillin actually are not ok so why would people get the idea that they are
so it’s a similar to story to what you described for yourself so a lot of times
what happens is that kids are given antibiotic when they have an infection
in childhood and they may get a rash from the infection itself or actually an
interplay between the antibiotic and the infection may get a rash and a lot of
times the rash is sort of miss attributed to penicillin or amoxicillin
or a member of the penicillin family it goes on their allergy list and is never
revisited it definitely never in fact for me and it’s been decades now there’s
no amoxicillin that’s ever been anywhere close to me because you put it down on a
form and they just eliminated is that a bad idea so for most people it
doesn’t come up when they’re young and healthy and childhood and moving forward
but what happens is when you get hospitalized or need an antibiotic for
specific infection and there’s some people that sort of run out of options
at times but we know this is an important public health issue because
people with penicillin allergy have been shown to have longer hospital stays when
they are hospitalized they often use sort of less effective second-line
antibiotics and they often get more side effects from the antibiotics because
sort of the first choice one wasn’t available. So what would you would you
tell a patient like me if I said look I think I had a rash or at least that was
the diagnosis back when I was 16 should i avoid amoxicillin for the rest
of my life you know what’s the idea here? So i’m biased because I’m an allergist
and this is an important issue for me so i would say you need to revisit that
first of their primary care physician and then the appropriate person to see
to further evaluate is it is an allergist and our most important tool is
a thorough history what happened what were the circumstances under which were
taking the medication what symptoms did you have and then we decide sort of what next step is appropriate in some cases
it is yeah avoid the medication for life but in most cases it’s not and we have
testing and other ways to sort of reintroduce the drug to you safely. You
have to have people who are really surprised to hear that who probably got
that diagnosis years ago and thanks we I can’t revisit this right I mean that you
probably surprised some paper patients sure so I’ve certainly surprised
patients and you know the general public but i also think so our offices put a
pretty big emphasis on this recently as has our Hospital Rochester General
Hospital and I think we’ve actually even surprised some medical professionals who
kind of think that the allergy label is a black box and you never revisit it
when we know that’s not true it should be revisited just because of the the
other things I mentioned there’s risks associated with avoiding penicillin. Can
you outgrow a legitimate, so let’s say 20 plus years ago for me it was an actual
allergic reaction to the amoxicillin that the diagnosis was correct can I outgrow that you can so they’ve
studied patients who were convincingly convincingly allergic to penicillin or
amoxicillin or a member of the penicillin family and we know a majority
of patients outgrow their drug allergy to the antibiotic in five or ten years
so even if they’re if it were a true reaction if it’s decades ago it’s worth
revisiting again your immune system doesn’t always forget but can forget in
the case of this type of allergy alright this is a total aside here and
very selfishly so because I’ve long suspected that when I was growing up my
mother sold me a bill of goods on my allergies to things like chocolate dairy
I think that she just didn’t want me to consume as much of it so she told me I
was allergic and she says one day you’ll outgrow that can you outgrow food
allergies by the way that’s a good question so maybe she told you you were
allergic to chocolate but right after Halloween but that’s not just definitely
possible and it didn’t work at all by the way that’s actually not a common
thing to be allergic to so i think it’s important to establish that there’s kind
of six most common foods to be allergic to dairy is one of them so cow’s milk
egg wheat soy peanuts tree nuts fish and shellfish are the most common food
allergens and depending on what food you’re allergic to there’s different chances about growing
it so the majority of children outgrow their milk egg wheat and soy
allergies it’s a little bit more difficult to
outgrow peanut only about twenty percent of children outgrow peanuts tree nuts
even worse about ten percent and then fish and shellfish are actually
allergies that can crop up not only in childhood but in adulthood as well and
you’re usually stuck with that one Mom.. I knew it! She may have been acting on poor advice. you have to give her the benefit of the doubt. yeah yeah yeah well I love chocolate today so that
didn’t work either we’re talking to Dr. Ramsey and I think
for parents out there you know hearing about not only outgrowing but revisiting
things like penicillin and the penicillin host penicillin family will
come as a bit of a surprise if you’ve got any questions about that are related
issues again the numbers 844-295-talk tollfree 844 295 8255 or if you’re in
rochester 263 WXXI, 2639 994 ok so if if ten percent of our population thinks
they’re allergic to penicillin but only ten percent of them are that’s roughly
one percent of the population that’s actually allergic to penicillin what’s the most common drug allergy? So
penicillin is the most commonly reported drug allergy so that’s still sort of
leads the pack but it’s just not as common as everybody thinks and that’s actually true for food
allergies as well when you really get down to taking any person in the
population thinks their medication allergic or food allergic and you get
down to actually challenging them to the medication or the food a lot of times
you know if the food or medication is being incorrectly blamed ok so even
though most people who think they’ve got a penicillin allergy don’t have it it’s
still the most commonly reported drug allergies. Is it the most common in
actuality drug allergy you think? Yes. It is, okay, I guess the good news then is
that most of us are not allergic to medications were going to be prescribed –
Correct – doesn’t mean that we shouldn’t be thinking about it was serious but it’s
not that common so I mean I think having an antibiotic or medication allergy is a
common thing that comes up in patients medical histories I think ignoring that and not revisiting that
sort of you know years down the line is probably the wrong thing to do because a
lot of times these things come up when people are already ill they have other
reasons to have symptoms and so it’s not uncommon for things to be falsely or for
medications to be falsely blamed as an explanation for someone symptoms okay speaking of symptoms before I get
to the first couple of phone calls have come in I mentioned the rash that I had
I hear that is common but let’s talk about legit allergic reaction will start
with penicillin well how does it usually present so
penicillin can cause a variety of different reactions and your immune
system has lots of different players so the reaction that people are often quite
worried about is what we call an IGE mediated reaction so don’t want to get
too nitty-gritty with the details but basically that’s the immediate type
reaction that you hear about on that can lead to anaphylaxis so the symptoms that
are on that spectrum include itching, flushing, hives, cough, wheezing, shortness
of breath, sometimes gastrointestinal symptoms like vomiting or nausea and
then in severe cases low blood pressure so hypotension where patients you know
they’re there they go into sort of anaphylactic shock so that’s one type of
reaction somebody could conceivably have to penicillin and that’s the type of
reaction that we actually have testing to evaluate for that’s how we can skin
test to look for that type of reaction another reaction is caused by a
different part of the immune system and that part of the immune system is called
the T-cell and that typically gives a more delayed rash so if you took
penicillin this rash me sort of appear days into your treatment it doesn’t– it
is not accompanied by the other scary or symptoms that I just described in rare
cases it can involve other organ systems but usually a t-cell mediated rashes it
is an itchy flat rash that goes away when you stop the medication so it can
do other things. Ok, and in the population of people who
are allergic to penicillin do most of the symptoms end up in that sort of rash serious but not that serious family or
do most veer toward possibly you know anaphylaxis is a word that scares a lot
of people– Right, so that the true rate of anaphylaxis is rare. It’s like 1 in
10,000 people. So most of the time as symptoms are not on that spectrum but a
lot of times people don’t remember this occurred in childhood or there were a
lot of other things going on with their health at the time so sometimes it’s
difficult even taking a very thorough history to kind of categorize what we’re
where they fall and so I mentioned that we have testing that can evaluate for
that first type of reaction if we rule that out that’s pretty reassuring that you know
the page to say to the patient we can give you with a dose of penicillin after
this negative skin testing we think your risk of having an anaphylactic reaction
is it is exceedingly low and then I can’t say for sure you’re not going to
have another react different type of reaction caused by a different part of
the immune system but the chances of that are low Ok, let’s get to your phone calls on
second opinion live with Dr. Allison Ramsey of allergy and clinical
immunology at Rochester Regional Health we’re talking about drug allergies and
this is Ellen in Greece first up go ahead Ellen hello Evan thank you for taking the
call I didn’t realize it was just drug allergies I read an article in the paper
recently where they’re finding that if they expose babies and young children
the common allergens like peanuts and wheat et cetera that that keeps them from
becoming allergic to them later in life Ellen great question and you are up to
date with our allergy field so there was a very important study that was released
in early 2015 and it was called the leap study and that study sort of
turned on its head what previously had been recommended for children in the
late 90s early 2000s with children at high risk for food allergies that the
highly allergenic foods that I mentioned a few minutes ago be delayed for
introduction into their diet this study did the opposite so they actually took kids at high risk
for peanut allergy so these were kids the eczema and kids with an egg allergy
and they took kids between 4 and 11 months of age and they introduced peanut
into the diet of these children when possible somewhere already allergic but
the majority were not and they found in eighty to ninety percent reduction in
the rate of allergy and the kids that were consuming peanut early versus kids
that had placebo or were not actually given a peanut introduced that who did
not have peanut introduced early in their life so that’s really change what
we recommend two families there’s further study ongoing as to how much
this applies to other foods we think it does but that’s an area of research is
going on right now Well thank you I have a quick little
anecdote i’m a nurse and I work in the pediatric office 40 years ago one of the
pediatrician was an allergist and that’s what he was doing he was
injecting the children with great with week and then stronger doses of allergen
every week and it seemed to nullify the allergies after a while all the other
doctors thought he was nuts! So at you sound like an allergist already Ellen so I’m
that’s that’s really the basis that’s what we do for allergy shots we still do
the same thing today so people with environmental allergies that’s a great
form of treatment for nasal and eye allergies and even asthma so not much
has changed from that perspective well that’s great to know he wasn’t
ecentric he was beyond his years ahead of his time Thank you Ellen, thanks for calling the
program appreciate that and I know there’s some other calls lined up here
gonna get to those in a second you probably Dr. Ramsey can’t go
anywhere without people asking food allergy questions and even though we’re
trying to focus on drug allergies people want to ask general allergy questions so
we’re gonna try to keep it on task as much as we can but the judge will allow
one more counselor question outside the scope here that’s Frank and rochester go
ahead Frank. Hey Evan, so about two years ago I had been eating seafood
my whole life I’m 26 right now about 2- 3 years ago I had some shrimp and I got a big welt on the back
of my head and I mean I’m not it wasn’t really big but it was big enough where I
thought I was allergic I have not eaten any shellfish since that point i’ve been
eating fish, calamari, scallops and stuff in nature and nothing
happens from it what if I wanted to really introduce
that into my diet would that be a bad decision or is there some precaution I
should take? So Frank that’s also a great question comes up commonly I see someone
like you in my office weekly so if you’re interested in
reintroducing a food into your diet that you’re concerned you might be allergic
to you can discuss it first with your primary care physician but you should
see an allergist so there’s no reason to unnecessarily avoid food I can’t
guarantee that you get good news because you may actually be allergic as well but
we have testing to food so we can skin test of foods and decide based on that
testing and sometimes blood testing whether or not yeah we think you’re really allergic you
should avoid the food and if you are avoiding the food because you think
you’re allergic you should have injectable epinephrine and be available
in case your mistakenly exposed but sometimes like I said just like with
penicillin allergy there’s over-reporting of a food allergy in in
the population so sometimes people are unnecessarily avoiding foods like
they’re unnecessarily avoiding penicillins. Yeah okay and I mean that
you know another thing isn’t it happens quite often it if I get like in heat I
get a little bit of a well underneath my right eye and I get it like maybe once
or twice a month I have no idea what it is but I get it all the time so that’s
another reason to potentially be evaluated because there’s a few things
that could be going on there alright well thank you. Thanks Frank good
luck to you there, and I’m going to use food to transition us back to a drug
question because that was the main subject they should but hey you know in
many ways the second opinion live audience takes to share what they want
when they’ve got someone who works in an allergy medication i’m not surprised I
take the point but when we talk allergies but let’s let’s focus on sort
of categories if we can for one second Dr. Ramsey we for your I want to say about say about for a good five years a lot about gluten allergies and that
drove some people crazy because I think a lot of people at least in the
professional world found that it was much more likely to either be a gluten
sensitivity or a gluten well I guess the the difference between
an allergy what is it an intolerance sensitivity or
just something fabricated in your own brain so those are the four categories
what was going on with gluten and I wonder if the same kind of thing
happened well at least I think you’re going to correct me in a second but does
that happen in drugs as well whereas you can have side effect of a drug that’s
not an allergy or intolerance it’s an allergy. So let’s start with gluten and
let’s move it to drugs and I wrong about gluten? For a second I was so scared I
had to answer a lot of questions about gluten I’m just kidding! I mean this has to go
all the time right? So no, so there’s different parts so I was I say touched on this a
little bit there’s different parts of your immune system that can cause
symptoms on and you’re right there’s a good parallel between food allergy and
drug allergy so there are people who are truly allergic to foods and as an
allergist I’m I’m strict about that definition so what I mean when someone
is truly allergic to food they can eat the food when they eat the food they get
all those symptoms I talked about before like that immediate type an anaphylactic
reaction not everybody who’s allergic to food has an anaphylactic reaction but
those this the symptoms are all in the same spectrum so those symptoms you know
everybody knows the example of peanut you know a kid with a peanut allergy
they mistakenly peanuts they may get hives they may get itching, flushing, coughing, etc
so the same thing can happen with drugs as I touched on with penicillin but then
I think what we see with drug allergy is a lot of people lump any symptom or any
new way that they feel after taking a medication as an allergy and the
difference is there’s a lot of drugs antibiotics any medication really that
has sort of predictable known side effects and so there’s that category
drug side effect and then there’s other categories where
you know maybe it’s not routinely reported in the population but people
may get some symptoms when they take a certain drug but they’re not caused by
their immune system those symptoms are not caused by their immune system so you
could label that as an intolerance they’re not able to take the drug
because they have undesirable symptoms that they can’t they can’t deal when they’re
on the medication that’s an intolerance and then an allergy has to be caused by
your immune system so that’s again we’re kind of strict and semantics but for
something to truly be a drug allergy your immune system should be causing the
side effects or that not the side effects the symptoms that you’re
experiencing. Ok what if you have an allergy to a drug are you going to have
a reaction every time you take it? Yes. If you have a drug that creates some
side effects the first time you take it are you likely to get the same side
effects every time? Often yes, it depends on the drug but yeah I’m usually so in a
lot of cases you’re sort of stuck avoiding the drug regardless on but the
difference between those two is the immune system is not necessarily
involved in the side effect or intolerance portion okay and before I
turn go on here to do more people claim they have gluten allergies than people
who actually have gluten allergies? Yes. Ok, just wanted to make sure we had that
officially they’re not Dave Rochester next up, go ahead Dave. Yes Allison, Hi it’s Dave Topa, how are you? Hey I know you How are you? Dr. Topa, how are you? So yeah I’m a
pediatrician on the community and I think one thing to really touch on to
how often viruses cause rashes and so you will be seeing the practice up and
their patients who come in insisting that (inaudible) clearly a viral
illness and then when they go ahead and develop that ranch after its associated
with the virus they mistakenly associated with the antibiotic and so
just a little PSA to remind people that antibiotic consequences not that serious and this is one of the places where they
can find significant issues moving forward from your health they could (inaudible) antibiotics see them and then that also i just that
you could expand upon how a lot of times how stuff that’s foreign gets graphed into
the penicillin allergy where unfortunately I think a lot of people think that is ok I
can’t penicillin well then therefore I can’t take a cephalosporin which is
really distant cousin of penicillin and (inaudible) Allison’s part of an excellent group Dr. Topa, thank you sort of in and out
with the phone quality but I appreciate the phone call go ahead Dr. Ramsey so
Dr. topa who’s fantastic made two fantastic points so their first is I think we
touched upon this a few minutes ago where that’s how a lot of times people kids in particular Dr..Topa is a
pediatrician get labeled with the penicillin allergy they get placed on a
an antibiotic maybe they had a viral infection is you didn’t even need the
antibiotic but it’s the virus that actually causes the rash and the
penicillin or amoxicillin or whatever is in a bit you know incorrectly blamed so
that is an excellent point and that’s how a lot of kids march into adulthood
with the penicillin allergy label the second point that Dr. Topa brought up
was penicillins have this cousin class of antibiotics called cephalosporins and
there is sort of some diehard teaching that still happens even in medical
education that there’s a big cross reactivity between penicillins and
cephalosporins and it’s it’s important to know so the historical teaching was
that the if someone was penicillin allergic maybe ten to fifteen percent of
the time they would also have a reaction to a cephalosporin and that’s actually
not true and it’s relevant because the the penicillin family and the
cephalosporin family are sort of collectively referred to as beta-lactam
antibiotics and they’re really good first line antibiotics for sinus
infections ear infections a lot of the infections that are encountered in the
outpatient setting that you would like affordable and effective antibiotics for
so a lot of times even medical
professionals are reluctant to use cephalosporins in penicillin allergic
patients when probably the true cross reactivity is only around two percent
and that’s in patients who are truly allergic to penicillin which we’ve
already talked about is is not is not most of the people walking around with
the penicillin allergy label so so I think pediatricians as a whole are
actually very good about not doing that they typically will go to a self
selfless porn is it as the next agent if if there’s a question of a penicillin
allergy but it comes up a lot in the hospitalized setting in the hospital
setting and that’s that’s sort of an area where having the penicillin allergy
label can be damaging you know I for the reasons I mentioned before these
patients end up on sort of more costly potentially less effective antibiotics
they may have more side effects in longer length of stay and then
antibiotic resistance is also something to think about where you know we have a
limited amount of antibiotics available and we have to make sure we keep the
powerful ones in reserve for when they’re really needed how concerned
should we be about creating superbugs by over using antibiotics very concerned as
a as in addition to that I mean the CDC has actually made penicillin allergy of
priority recommended skin testing in patients who have a penicillin allergy
because this happens all the time in the hospital where people end up on these
more powerful antibiotics for reactions they can’t even describe that occurred
when they were too and now they’re 82 allegation to make sure i understand
that use the CDC is recommending a skin allergy test for penicillin if you’ve
got a labeled allergy or on your forms to make sure that you do have it in
these patients in these high-risk patients that are in the hospital who
would be better treated by penicillin or one of its cousins yes penicillin is
incredible isn’t it it’s it’s it’s our first antibiotic and still relevant ok let’s get our only break the hour
i’ll come back to more your phone calls you’ve got questions we’re talking
allergies particularly drug allergies 844 295 talk tollfree 844 295 8255 or if
you’re in rochester 263 WXXI 263 994 you can join us by twitter using the
#2NDOP and you can watch this program on the web at second
opinion dash T V dot org so hello if you’re watching on the web will come right back
and continue the discussion on drug allergies next I’m Evan Dawson monday on
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back to second opinion live here on connections second opinion live being
produced in association with the National public television shows second
opinion and today’s broadcast is part of the second opinion live webcast series
in studio today we have dr. Allison Ramsey of allergy and clinical
immunology at rochester regional health and clinical assistant professor of
medicine at the University of Rochester School of Medicine and Dentistry thanks
to the sponsor second opinion the BlueCross and BlueShield Association
their support helps to make second opinion live possible and I want to get
back to some of your questions and phone calls here it’s a 844-295 talk
tollfree 844 2958 255 and we’ve been talking about drug allergies and you
heard Dr. Ramsey talk about in Dr. Toba when he called and talked about when
allergies and rashes may manifest here’s a question right in line with that
from a listener named Kendall she writes Evan my daughter went on antibiotics and 24
hours later she came down with an itchy rash the rash was reddish my husband
thought that she was having an allergic reaction to her medication no I don’t let me read that she says my
husband thought if she was having an allergic reaction to her medication she
would have shown a reaction right away not a full day later i’m concerned about
her getting that medication again should I be how quickly does a reaction
happen that’s a that’s a great question and
that scenario is encountered in pediatricians offices like Dr. Topas on
a daily basis and so in the heat of the reaction so to speak so when that first
occurs there’s really no way to know is that the antibiotic is it a virus was
that was that rash going to happen regardless of whether or not an
antibiotic was on board it’s really hard to say so what generally happens is that
patients say yeah I had a rash with the antibiotic it’s this that you always
want to sort of take the most conservative course the safest course
would be to avoid the antibiotic but what I’m here to say is it’s worth
revisiting not weeks later but maybe years later and sometimes sooner but
most of the time that good news is there’s alternative antibiotics that can
be used but you know for that child that had the rash of day into a course they
should avoid the antibiotic for decades you know maybe a few years and and
revisited and certainly we run into cases where patients end up having
allergies across multiple classes of antibiotics and that’s when it should be
revisited so in terms of the timing which was the
other part of that question that get that which part of your immune system is
causing the reaction so that type of reaction where you get kind of a flat
itchy rash days into therapy is not IGE it’s not the allergy and a body that
causes anaphylaxis or causes you to have an immediate allergic reaction to foods
that if that rash was truly from a drug allergy it’s probably the t cell which
causes a more delayed rash so you can see that days into therapy you can okay
so Kendell first of all thanks for the email and second of all you know your
husband’s concerned that a drug allergy reaction would be right away is so it is
I understand the concern but we’re hearing is that’s not well-founded that
the reaction can be delayed — correct –but it’s also what hearing Kendall is that reaction can
come from multiple things and that your daughter’s possibility of being actually
allergic to penicillin or whatever the medication was is a one in a hundred or
less so you might as well you know at least try to study it a little bit more
not just give up on whatever the medication was the rest of your life so
yeah if I saw if I saw her daughter in the office and the reaction had happened
you know weeks to months ago I’d say let’s sit on it you have other
antibiotics to use I’d give it you know we know that a lot of if this were true
allergy we know that this these the majority of these resolved within five 5
years or so so a lot of times with the kids in this
situation I’ll say wait five years and revisit it but sometimes sooner if if
you if you don’t have other options for any particular infection the good news
is most kids don’t have recurrent infections in some do but most don’t so there’s other options available Mindy
wrote to the programming is asking should kids be tested for medicine
allergies or do we have to find out when they have a reaction also asking about
proactive testing that is a good question so that kind of gets that how
your immune system function so that the funny thing or that I guess the good
thing about your immune system is it has to see something to become allergic to
it so to have a reaction to something you have to have seen it before so
there’s no role for pre preemptively testing on and really for drug allergy
the only good testing me have is for penicillin and we only employ that after
someone in the case of someone having a a possible reaction history
there’s not roll for doing it proactively do men or women boys or
girls get more drug allergies that’s it that’s also a good question so
women tend to have more drug allergies or anything that that women have easier
than men I mean not drug allergy no I
don’t I don’t know maybe they’re trying more medications to
to get through life I don’t know ok so it’s a women more more likely to
be diagnosed with an actual drug allergy is a large number more you know I
wouldn’t know those statistics off the top of my head but it I actually think
it’s probably I don’t know if I’m guessing like 60-40 70-30 something like
that okay and is there any relationship
between food and drug allergies in other words if you’ve got a peanut allergy or
a child with an allergy in the food world are you more likely to end up
seeing an allergy in the drug world not not with the majority of drug allergies
so a lot of my allergic conditions march together so someone with eczema is more
likely to have food allergy someone with eczema and food allergy is more likely
to have environmental allergies someone with environmental allergies is more
likely to have asthma drug allergy really sort of stands alone in that case
but a lot of the other allergic diseases do march together ok my son had eczema for any first
couple you don’t think we’ve seen very much of it is four-and-a-half I don’t
think I honestly don’t recall but that is that an indicator of just be on the
watch for more allergies as he gets older yes so children who have had for infants
who have eczema or the medical term is atopic dermatitis are at higher risk for
food allergy about thirty percent of them end up with a food allergy and then
they kind of march it’s called the atopic march where kids start with
eczema they get food allergies and then they get environmental allergies which
can manifest with either nasal symptoms or asthma or eye symptoms that’s his dad sorry buddy well it’s not
guarantee though, not guarantee lets get back to
the phones this is Patrick in Rochester go ahead Patrick– hello my question is that
because of certain you know your reactions or allergies to two
medications and so forth to find that that frightens people away from getting their
children vaccinated in general you know they just one sort of leads from no we
won’t get any of them you know that the ordinary childhood vaccines that are that are very important? I thank you for
that question and I agree with your statement that childhood vaccines are
very important so in the case of drug allergy I can’t say that I’ve had patients who
have drug allergy or whose children have had a reaction to medication I haven’t
seen them then become concerned about vaccine reactions but I will say that
someone who’s had a drug reaction or suspected drug reaction or they’re
worried that the symptoms experienced were from a drug are very nervous and a
lot of times we’ve talked about testing in my office but a lot of times if I’ve
taken a history and I think someone is not likely to be allergic to a
medication I’ll do something called a graded challenge where I give them a
small dose of the medication wait 30 minutes give him kind of a mid dose and
then wait 30 minutes and give them a full dose I will say people are very
nervous and rightfully so sort of revisiting a medication their whole life
they’ve been avoiding or for X amount of years they’ve been avoiding and if I get
the sense that someone is is really nervous they sort of try and talk them
through the power of the mind and how a lot of times people have symptoms during
these these challenges but the reason that’s the reason we do them in a
monitored medical setting and I only reintroduce or try to reintroduce a
medication when I’m pretty convinced it’s going to be safe on but the mind is
very powerful and and sometimes I’ll say I may trick you at some point during
this challenge and give you a placebo and we’ll see yeah it would they even that the thought
of it I think but my question was this is frightened people so much they don’t
want the kids to get anything you know the it the possibility you know the old
thing you know my mother-in-law came over and the cat died well the cat could have been sick before you know right yeah sure so false association so i think i think
people also are concerned especially when they’re running out of options if
if it’s a child or an adult that’s having or a particular problem with an
infection on they’re all so scared of running out of options but I will say that that
we as allergist you also see children who have had you know the rare allergic
reaction to a vaccine and in the vast majority of cases were also able to
safely vaccinate those children by dividing up those vaccine doses so even
if a child has a true allergic reaction to a vaccine we are are almost always
able to successfully immunize them and I have a few adults even who you know I
can think of a patient off the top of my head right now works in a nursing home
and needs her flu vaccine every year and every year she hangs out in my office
for a few hours and gets it in divided doses so there’s even ways around around
those reactions and I think we as allergist and our nurses are very good
at reassuring patients we do food challenges we do allergy shots so we
know what to look for and I think on patients feel reassured being in a
monitored setting Patrick thanks for that phone call I was curious was it
eventually gonna get around to that so I’ll just follow up real briefly ask you
has this been a harder period for the medical community in dealing with vaccines
because of this concern about side effects or allergies etc for sure I I
can’t speak from I am certainly not on the front lines like the pediatricians
are I mean that is one of the most wonderful parts of modern medicine is
vaccination and I am not you know on the front lines of vaccinating children like
Dr. Topa and you know pediatricians offices across the country on so but I
do think that in general we as as a public have been sort of lulled
into a false sense of security because we don’t see these diseases anymore and
that’s because vaccinations have been so successful on but at the same time I
think you know the the vocal few of have raised questions in people’s heads and
you know I mean I have three children at home they get their vaccines yeah and placebos incredible you
mentioned the power of the mind we you know if we could just harness placebo we
wouldn’t even need any drugs anymore the mind is so powerful! But on the flip
side of that i’m curious to know if somebody has been told they have an
allergy say to wheat allergy and then you eat a
piece of bread you go up you know you almost think yourself into feeling bad
whether it’s GI and rest or whatever it is can you as powerful as placebo can be
to help us in a good way can we convince ourselves through
confirmation bias that something bad is happening to us? For sure and that’s I
think you know like i said just a few minutes ago we give patients allergy
shots every day where we have it we tell people you know there’s a chance of an
allergic reaction that’s the main risk involved with this or we do food
challenges in our office where we say we’re gonna give you this food we think
there’s a 50-50 chance that you’re you’re going to react or I’m going to
give you this medication because you’re running out of antibiotics let’s do a
challenge I think you you should be fine but I can’t say for sure you will be
almost invariably in all of those challenges someone feels a little itchy
or someone has like a funny feeling in their throat but really at the end of
the day when someone’s having a true reaction there should be objective
things that I can tell so you know this skin is actually a great you know
Telegraph of what’s going on so that’s oftentimes where the first symptoms will
come up So it’s very rare that someone’s
having a subtle reaction that I can’t tell objectively but it is very common
for patients to have sort of symptoms that crop up during you know in any of
those scenarios that I mentioned a lot of it is just reassurance you’re ok
you’re in a monitored setting we know how to handle this you know go back to
reading your book. It’s Second Opinion Live and we’re talking to Dr. Allison
Ramsey of allergy and clinical immunology at Rochester Regional Health
and we’re talking about drug allergies in particular here’s an email from a listener named
Tim in pittsford he says my wife says she is allergic to advil more
importantly the coating on the pill she had an allergic reaction to it when she
was a kid she can take ibuprofen but she will not touch advil so two questions Tim says do you think the coding is the
real problem and do you think she has outgrown this Oh Tim I like your question so for
people that don’t know advil is ibuprofen so it sounds like Tim’s wife is avoiding the very
specific brand Advil and that gets that it that this question gets an important
question is how often are you allergic to the sort of inactive part of a
medication and the answer is it’s exceedingly rare to be allergic to the
dye or the filling in a medication, coding or the coating anything that’s not the
active form of the medication so if I saw Tim’s wife in my office you know here’s the thing what’s what’s
the risk-benefit here I mean she has an ibuprofen tablets available that she can
take if she gets a headache or she has something that hurts her but if she
wants to get that off her list that would be that would be a scenario where
I would be comfortable doing a challenge because the the chances of her truly
having an issue with the coding are very very very very small ok so you would say hey next time just
take an advil know I would say if you really want to know you could do that in
my office and I will watch you oh I got you ok but she may say well
didn’t you just say they’re the same exact thing so why would I take an advil
and she might say that and so I have visits like that you know even with
penicillin allergy you can say you have other options available you don’t have
to be tested or you don’t have to undergo a challenge to XYZ drug if you
have alternative so it’s always it’s always fine to use an alternative if you
have one available ok Aleve is not the same though is that right? Aleve is naproxen? Correct ok so I want to move from a second we’ve
been talking so much about penicillin and and its family for good reason that’s it we open the hour by saying
that 10% of the US population reports being allergic to penicillin but
if you’re just joining us Dr. Ramsey telling us only 10% of those
people in other words 1%of the US population has a real allergy to
penicillin right around that number anyway so the point is most people who
think they’re allergic to penicillin are not and let’s move from penicillin to
other drugs and the other other more common or anything else that’s close to
penicillin in terms of actually iliciting an allergic reaction? So, I
don’t think that there the statistics are sort of how they rank I’m actually I
don’t know that off the top of my head but what I do know is what comes up
routinely in practice or things that are that people are worried about so we just
touched upon non-steroidal anti-inflammatories so that is another
important class of medications that do cause allergies we as allergist don’t
have any particular skin testing for matter testing for that but we can take
a good history and sort of come up with a plan if it if it comes up that someone
really needs to take one of those medications mean aspirins a big one that
comes up for you know coronary protection if someone’s had a heart
attack or their risk for a heart attack or their risk for stroke and so
sometimes patients are avoiding a whole class of medications and we can help
them find one in the class that is potentially safe we also have ways of tricking the body
into tolerating the medication if they really even are allergic we start with
really small doses of medication and go up kind of on a scale over minutes to
hours so I think that nsaids are are something that we are commonly referred
particularly in that in the adult population someone needs an aspirin or
someone needs a pain medication they can take that’s a pretty complicated area of
drug allergy there’s a bunch of different ways you can be allergic to
those but we can puzzle through that with a patient and and give them kind of
a clear plan of approach on another class of medications that comes up for
patients is the local anesthetics so a lot of times people had trouble in the
dentist chair or you know in an emergency situation where they needed
stitches and a lot of times patients I say this that I say this to my patients
at local anesthetics are often used when people are stressed out anyway you’re in
the dentistry you can’t be at the dentist or you need stitches or you know
that’s a stressful scenario and a lot of times people have you know what we call
vasovagal events and that’s where you pass out just from sort of that the
emotional feeling overwhelmed and so we we’ll challenge to local anesthetics in
the office to because there’s people any dental work and they’re avoiding all the
local anesthetics don’t they say with anesthetics most people who claim to be
allergic anesthetic say that it makes him vomit?
No, so the local ones I’m talking about like toppling Jeffrey injectable one so
a lot of times people say oh I got injected with that and i passed out or
but a lot of times it’s just because they were worried about the procedure so
that’s that’s important because there’s a lot of people not going to the dentist
for example because they feel like they don’t they won’t have any you know pain
control during the procedures so we see that a fair amount in our office along
with the nsaids antibiotics come up frequently as i mentioned before on and
those are I would say the top three drug allergies there that were referred and
then every once in a while we we see we see patients that have much more
complicated histories of patients with diabetes rarely can get insulin allergy
or patients with really resistant infections need some sort of special
antibiotics in your chemo therapeutic agents come up as well and and we have
ways of evaluating for those two ok back to the phones and this is an in
penfield go ahead and Ojai quick and i’ll hang up the answer i wanted me to
comment I’m two types of reactions to drugs the first would be the serotonin
syndrome reaction strange presence in a second would be a reaction to beta
blocker drugs now hang up so I can listen to your answer thanks very much in so the question was
talking about serotonin syndrome an antidepressant medications so when we
were distinguishing categories of drug reactions the serotonin syndrome is sort
of one of those rare but anticipated side effects to medication that occurs
with the selective serotonin reuptake inhibitors which are you know a lot of
the antidepressants people take. That is not something that I typically would
evaluate as an allergist but it it because it’s not an immune-mediated
reaction it’s it’s sort of an overwhelming response that you can see
to that particular class of medications on so I don’t particularly feel
qualified to comment on that further but I would say that that that sort of falls
into that other category of rare but anticipated
side effects for class of medication on that I would say anybody prescribing
those medications which I don’t routinely– would have to be aware of
how to recognize, treat, and what to what alternative medications would be
available there are certainly antidepressants that are not in that
family that could be could be gone to next in terms of reactions to beta
blockers those are medications that are used for patients with heart disease or
high blood pressure I’m not quite sure those as a class of medications don’t
really are not a common offender in terms of allergic reactions they are
common offender in terms of side effects so a lot of times people say
they feel tired or fatigued or their exercise tolerances and quite as
good but these are very beneficial medications in patients who have a
history of coronary disease or have high blood pressure on but if someone has an
allergic reaction to a beta-blocker really depend on what what scenario how
hard we would try to find an alternative or sort of trick the body into
tolerating that type of medication so without having a specific scenarios
her to know where to take that answer for the caller but those are not as a
family usually common offenders for an allergic reaction ok and using the hashtag 2NDOP Barb
just says how does one go about getting tested for a real penicillin allergy is
something that general a regular GP does that’s a good question so allergist do
this testing so if someone is interested in
revisiting that I think a good place to start would be your general practitioner
or your pediatrician or family doctor internist and just say you know it does
this make sense for me do you think you know I’m someone that would be a good
person for this testing and and whose someone that’s a good person for the
testing well if you have more than one antibiotic allergies it’s nice to get
them off the list because you never know what’s gonna come up in the future in
terms of infections I think kids are great great population
to have a penicillin allergy revisited because those are the kids it become
adults that have a penicillin allergy and God forbid get hospitalized and it’s
nice to have all the classes of antibiotics available so I think as with
most medical concerns starting with your primary care physician is is a good
place to go and you know 30 seconds I was going to ask for your final thoughts
I suspected you were going to loop back to the question on not being afraid to
revisit what you were diagnosed with as a child I think you just put the words
in my mouth so right so I think on a drug allergy in general you get that
label of XYZ drug allergy and it stays on your chart and you don’t revisit it
and I and I sometimes make it sometimes it has to stay there but sometimes it
doesn’t and I think it’s worth asking those questions thanks for being here at
Dr. Ramsey and and so many different questions from listeners on this I we
covered a lot of ground and I hope that it helps you been listening today
wherever you’ve been listening and Finger Lakes public radio WXXI WRUR maybe you’re listening on the mobile app or watching on the webcast and
second opinion live Dr. Ramsey it’s been great having you thank you for taking
the time for the program thank you for having me and that is all the time we
have for second opinion live thanks to our sponsor the BlueCross and BlueShield
Association their support helped to make today’s program possible and thanks to
all of you again listening and watching a second our
thanks to engineer John Andrus thank you John and the great team who produces
second opinion live i’m just here talking there’s so many people who do
the great work to get it all ready for you and of course Megan Mack the
producer of this program have a great weekend and we’ll talk with you monday
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