DocTalk Podcast: Seasonal Allergies and Asthma with Dr. Wright

While the changing of seasons may mean little to clinicians and some specialties, for allergists, immunologists, and asthma specialists it is one of the most worrisome times of the year.

With asthma peak week in September and pollen levels peaking, the start of the fall season can wreak havoc on patients and increase the workload of clinicians. Fortunately, these same clinicians have developed effective means at combatting the impact this time of year has on patients with allergies or asthma.

To learn more about how the weather, air quality, and the current state of asthma in the US, MD Magazine® recently invited Lakiea Wright, MD, a board-certified allergist with Brigham and Women’s Hospital and medical director of US clinical affairs at Thermo Fisher Scientific, to take part in an episode of the DocTalk Podcast.

For more on that discussion, check out the audio below.

MD Mag: Hello everybody and welcome to the DocTalk Podcast. I’m Patrick Campbell, associate editor of MD Magazine, and I will be your host for this edition of DocTalk as we discuss allergies and asthma with Dr. Lakiea Wright, of Brigham and Women’s Hospital. Welcome to the DocTalk, Dr. Wright.

Before we begin, if you could just give our listeners a little bit of background on who you are, your experience, and any relevant disclosures you may have then we can dive into our chat.

Wright: Okay. Hi, I'm Dr. Lakiea Wright, MD. I'm a board-certified allergist. I'm also a practicing clinician, and I also serve as medical director of US clinical affairs at Thermo-Fisher Scientific.

MD Mag: All right, thank you for that Dr. Wright. Now, just to start, I guess the first question would be, what is the current state of asthma in the United States? Are we seeing asthma rates continue to rise—and what would you point to as the main causes of this rise or potential decline, in your opinion?

Wright: Asthma is still a major public health issue. According to the CDC, there are about 32 million people that have been diagnosed with asthma at some point in their lifetime. Then about 22 million, but I've seen as high as 26 million have current asthma—so, active symptoms. And I would say that it's hard to say, but it looks like it may be on the rise. And it's hard to say because many people with asthma may remain undiagnosed, or may or may not be diagnosed properly.

So, it's really important to dive in a little bit deeper if your patient is talking about any sort of respiratory symptoms and this is particularly important, because, they may not mentioned having wheeze, because you can just have sort of shortness of breath, and cough and it could potentially asthma.

So, we definitely want to keep that diagnosis on our radar. And it may be on the rise because of all these exposures that we're having, particularly when it comes to air pollution and in the quality of our air.

MD Mag: Backtracking a little bit to the end half of your answer how is air quality affecting respiratory health in the US right now? And what are some solutions to this? Obviously, the everyday patient can't always completely avoid going outside and exposing themselves to harmful air. So, what are some simple solutions that physicians can recommend to patients?

Wright: So when it comes to air quality, it's sort of like 2 really big buckets, I like to think about it. There's air pollution and then it's outdoor/indoor. So, when it comes to outdoor air pollution, ozone, being sort of a major contributor and then also particulate matter. So, that's when, like my air, they're the small particles, and then there's like dusting, feel that to contribute to the composition of these small particles and they can really serve as irritants for the lungs and really trigger asthma.

Then when it comes to indoor air quality, you have things like cooking. Cooking produces a lot of fuels that can be at your attend. Also, tobacco smoke is really a major contributor to indoor air quality. See, you always want to make sure you're asking questions about not only is the patient smoking, but is there anyone smoking in the home. And then there's even this issue with third-hand exposure.

So, even if you're not directly exposed to smoke within your home—even if you have someone who does smoke—even having their clothes in home, even though they may not be physically smoking, that can even trigger something. So, it's really important to get the history and then things like smoke from candles or fireplaces that can contribute. And then the other part about air quality is actually things like allergens. And that can be a huge contributor to the air quality.

So, you have things like dust, mold, even pollens cause if you keep your windows open, the pollen can seep from outdoors to indoors, and it can be a major contributor to symptoms. And so what I'll say about allergies is that it's really important to take a good history to determine if your patients are having seasonal allergy symptoms, because again, asthma can be allergic and actually majority of asthma is allergic with kids estimated to have about 80% allergic asthma as high as 80% of the allergic asthma.

Then with adults, it's about estimated up to 60% of their asthma can be allergic and so you want to take a good history. There also is blood testing available for common environmental allergens, dust, mite, mold, pet dander, pollens, and that can help you, along with the history, help to identify triggers and then that way you can have a targeted treatment plan.

So, when it comes to air quality, there are some simple solutions. For example, it's hard to avoid the outdoors, but you can tell your patients to monitor because we often are listening to the weather or we look at it on our phones, they'll often mention what the ozone level is or what air pollution is like or particulate matter and things like that—if it's high in the air. Then you want to minimize going outdoors during that time so you can give your patients that tip and then also they will mention the pollen levels.

So, if your patient is in fact allergic to pollen and you've confirmed it with a history of testing, then you can give them specific advice about seasons and in which seasons in which they want to try to minimize exposure. For example, in the spring, we have trees, tree-pollen that's high.

In summer we have grasses and right now in the fall, we have weeds, particularly ragweed, that can be very high. So, you can tell them to try to minimize the exposure and then as far as when they're coming from outdoors to indoors, you should tell them to remove their clothing because you can get some of the pollen on your clothing and they can still trigger symptoms.

You should keep your windows closed, because, again, that pollen can seep in. Then you should also shower before bed, because you want to remove all that pollen from you. There are things like HEPA filters that can filter out the allergens from the air. And there are things for example, when I was talking about fumes—you really want to remind them that they should have carbon monoxide detectors in their home and they should be tested on a regular basis to make sure that they are in fact working. Things like avoiding using like scented candles or air fresheners. All these things with helps improve the air quality and are great tips for patients.

Oh, and one more that I forgot, if you're patient lives in a humid environment and this is particularly if they have perhaps a basement apartment, or if their their apartment may be humid and they can get a dehumidifier as well. So, all these tips can help improve the quality for your patients.

MD Mag: Okay, and now sort of staying on topic of climate and changing seasons. What are some ways that physicians can better connect or inform patients on the impact of changing seasons, or the impact of changing weather on allergies and asthma and what may or may not constitute a serious event for them?

Wright: So, I think that going through the history in detail, and trying to identify those triggers and trying to understand. Or some people with their asthma, they can sort of predict when it would flare. So, for example, we're in as a peak week, if you get a good history that would suggest that your patient really suffers during peak week and they're typically having asthma attacks and then perhaps, preventively, you can sort of increase their medications, make sure that you go over all those tips that I mentioned about how to reduce their exposure, you can make sure that you've tested them for environmental allergens, if their history suggests that.

All of these things would help to try to help the patient understand when the asthma could get really bad. I'm a big fan of providing asthma action plans and so the way that will work is they would know when they're in the danger zone. So, for example, if you're using their short-acting inhaler albuterol frequently, then they know that they're in the danger zone and, depending on how you structure your asthma plan—if they're using it a lot, then they may need to go up on their inhaler, or if it's really bad attack and they may need to go to the ER—but you can put all of this in a plan, or they may need to call you.

So, you can structure this in the plan and have them posted on their refrigerator, so that they can understand for example, if they have symptoms, 2 or more times a week. We say it's the "rule of 2", 2 or more times in a week during the day, or two or more times at night, in a month, those are all alarm symptoms, that the asthma may not be well-controlled. In addition to giving a history and trying to understand is there a pattern to when they're having asthma attacks and that can help define the serious events and try to get ahead of a serious events.

I also like giving my patients of peak flow, so they can breathe into it when they're feeling good and then breathe into it when they're in the office that they can get a sense of what is my lung function? How well am I breathing? Because, sometimes, it can be hard for them to articulate when the symptoms are getting bad. But then as they have something like a tube, like a peak flow that they're breathing into, and actually getting a number, then that can make it more objective and it's more about empowering the patient to understand when they're getting into the danger zone. I think getting a good history, identifying those triggers, combining it with testing for allergens—if you're getting the medical history that allergies may be a trigger—and, then, making sure that you have that asthma action plan and peak flow.

Then we want to make sure that physicians are actually monitoring the lung function too. I mentioned peak flow, but there's also spirometry, it is recommended, at least annually in asthmatics and some people do it even more frequently, depending on the patient's symptoms.

So, I think a combination of all of those elements can be combined into an asthma action plan. Then when you're seeing the patient in the office having an asthma control test—and that's available online. Asthma control tests can make things very objective, because sometimes patients do have a hard time articulating their symptoms, but they have a questionnaire that's been well-validated in front of them. You can tell controlled or not—18 or higher would suggest that their asthma is controlled and if it's less then it's likely that their asthma isn't controlled. So, it's a way to quantify their symptoms and then take action based on the asthma control test in a more objective way.

MD Mag: All right, thank you for that. And now, just lastly, you had a recent approval for a biologic indicated for pediatric patients between the ages of 6-11 with severe eosinophilic asthma, do you think we'll continue to see biologics and other individualized treatments reach younger and younger asthmatic populations?

Wright: I think that it's likely that we will see the use of or see more biologics being approved for children and I think that because children are twice as likely as adults to have asthma. In some of those children with asthma, it can be moderate to severe and they don't do as well. Some children will not do as well with conventional therapies like inhaled steroids and you really want to try to minimize putting children on chronic steroids or giving them multiple bursts of steroids.

So, that's where biologics fit in, but it's actually like a smaller portion of children with asthma that would actually need it, and it is very targeted therapy, but it's targeted for those that are really moderate to severe and other conventional treatments have not worked in. So, typically, you'll see it approved around age 6 because that's when it's the asthma sort of clears itself. It's likely that based on the history that the diagnosis of asthma is made.

I mean, children can have some wheeze and they can have wheeze with viral illness, and they can be diagnosed with asthma younger, but at age 6 or higher, it's more clear if you're going to have the asthma on a more chronic basis and, if they're exhibiting sort of moderate to severe severity and in their asthma, then if the asthma isn't well-controlled, then a biologic may be appropriate. But the thing about biologics is that while it may help to control your asthma, you have to be very selective in the one that you're choosing because it is targeted therapy.

So for example, with omalizumab you have to have a total IgE level that's in a certain range. And then the patient has demonstrate that they have a year-round allergy to something like dust, mold, dust mites, or pet dander—something that's year round and so you would investigate that patient's history and blood testing with a total IgE level and a specific IgE to the perennial allergen.

So, you want to be very selective about which patients would be appropriate for a biologic, because it is sort of altering their immune system and we don't know all of the long-term consequences of that and so that's why we want to be selective about choosing the patients and choosing them appropriately and in using the more conventional therapies first, and then when those do not work, and we turn to the biologics.

So, it's much more selective and targeted, based on biomarkers and the blood testing to see if that patient is eligible for that particular biologic. But as we use more and more biologics, we'll understand the long-term consequences and the safety profile better. So, I think it is definitely a promising therapy, but it's a very selective population in which we should use it for children with really moderate to severe asthma that have failed traditional therapy.

MD Mag: Okay, that was about it on my questions. Was there anything else you wanted to add related to anything we touched on today?

Wright: A good resource for allergy information is AllergyInsider.com and we have a lot of educational information on our website about asthma and allergies. So, that is also a good resource.

MD Mag: Thank you once again, Dr. Wright, for taking part in our DocTalk Podcast this week and thank you to all of our listeners for tuning. For the latest in allergy and asthma news, be sure to head to MDMagazine.com. Thanks for listening.