Episode transcript
Time stamps
1:23 - Dr. Golden's Background in Insect Allergy Research
3:29 - Evolution of Dr. Golden's Expertise to Anaphylaxis
4:56 - Key Takeaways from the Anaphylaxis Practice Parameter Updates
6:22 - Importance of Prompt Epinephrine Use
7:54 - The Underreporting of Insect Sting Reactions
12:25 - Venom Immunotherapy and Testing with Allergen Components
14:52 - Effectiveness of Venom Immunotherapy
16:52 - Testing with Allergen Components for Venom Allergies
19:52 - Importance of Baseline Tryptase Testing
22:56 - New Options for Epinephrine Administration
25:15 - Changing Perspectives on Anaphylaxis Management
26:37 - Key Messages for Primary Care Providers
Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems.
Gary Falcetano:
I'm Gary Falcetano, a licensed and board-certified PA with over 12 years experience in allergy and immunology.
Luke Lemons:
And I'm Luke Lemons with over 6 years experience writing for healthcare providers and educating on allergies. You're listening to ImmunoCAST, your source for medically and scientifically-backed allergy insights.
Hello, welcome to ImmunoCAST. We are here, live at the moment, at the American College of Allergy, Asthma and Immunology, and we have a very special guest today, Dr. David Golden.
Gary Falcetano:
We're very excited to have you with us today, David. I'll let you discuss a little of your background, but Dr. Golden almost needs no introduction, certainly among the allergy community, and he really is an icon, especially when it comes to stinging insect and venom allergies. He is a past chair of the Practice Parameter Task Force, and recently the lead author on the Anaphylaxis Practice Parameters that were published last year, and just an all-around, great guy to talk to, especially when we're talking about insects and anaphylaxis.
Dr. David Golden:
My favorite subject.
Gary Falcetano:
Yeah. So Dr. Golden, just tell us a little bit about how you got to this point. You've had a pretty interesting life.
Dr. David Golden:
Yeah, it has been fabulous. But of course, as things happen, you never know how things are going to happen, right? As a first-year allergy fellow at Johns Hopkins, that first summer, aside from the fact that it was like 110 degrees and I told my wife, "Forget this, we're moving back to Canada." Our car wasn't air-conditioned, right?
Gary Falcetano:
Sure.
Dr. David Golden:
That changed very quickly. In the summer, the fellows just hang out and look at what's going on in the allergy division and decide what kind of project they want to get involved in. We were all sitting in the fellows' office, and Larry Lichtenstein, the chair of the allergy division, came in and looked around and said, "You, Golden, go over and help them with the insect project." So that's how I got to be the insect-
Luke Lemons:
Yeah. And then now look at fast-forward and give the practice parameters, too.
Dr. David Golden:
Right. So, things just happen. But it's just something that... It's a challenge that I took on and ran with the ball, and it's been a wonderful trip along the way. Because when he said, "Go out and help them," what he meant is that was the summer and they were doing sting challenges in one of the early studies of venom immunotherapy. And I was just supposed to hang out and take care of the people who went into anaphylaxis. But there was a beekeeper who was supposed to supply the insects, which he did, usually. But there was the day he didn't arrive, we had patients lying there with their IVs, they're ready for the challenge, and there's no insects. So the study coordinator and I had to go out in the courtyard with a coke and a doughnut and catch yellowjackets, and that's another day I went home and I said to my wife, "This is not in my job description. We're going home."
Luke Lemons:
Well now, it might not be in your job description now to go out to the field with coke and doughnuts, but stinging insect allergy and venom allergies, definitely in your job description now. You are actually here at the college presenting on practice parameters for stinging insect venom allergy, or I'm sorry-
Dr. David Golden:
For anaphylaxis.
Luke Lemons:
... here for anaphylaxis, which is highly related to [inaudible 00:03:30]
Dr. David Golden:
Well, that's the evolution.
Luke Lemons:
Yeah.
Dr. David Golden:
For many years, I became the expert having done so much work and becoming familiar with the field and insect allergy and working closely over the years with the late Bob Reisman from Buffalo, who was an expert in insect allergy. But that's, of course, it involves anaphylaxis and I got to be de facto, I guess, an expert in anaphylaxis.
And in more recent years, we're still working on practice parameters and insect allergy. I think a lot of allergists would say, "Oh, well that's old hat. We know everything we need to know."
Well, if we need everything we need to know. How come I get about a hundred emails a year from allergists saying, "I don't know what to do?" So there's still work to be done. We're actually starting work right now on the next update on the Insect Allergy Practice Parameter.
Luke Lemons:
Oh, wow.
Dr. David Golden:
We hope to publish that in 2026. But that brought me into the world of anaphylaxis, where I became friendly with the amazing Dr. Phil Lieberman, who was the lead author of the Anaphylaxis Practice Parameter. And when the next one came along, he suggested that maybe I should take that over from him. He's no longer doing any writing and leading. It's a lot of work to do that kind of stuff.
Luke Lemons:
Sure.
Dr. David Golden:
And he thought he would rather me do the work than him. Although his son, of course, Jay Lieberman, is really the heir apparent to this work in anaphylaxis, and I'm sure he'll be the next person to take it over.
Luke Lemons:
Pass the torch down?
Dr. David Golden:
Right.
Gary Falcetano:
So, speaking of the Practice Parameter, as you know, we have formulated this podcast to really be primary care focused, although more and more allergists are telling us they're listening and enjoying the podcast. But for our primary care colleagues, what would you say are some of the take-homes from the new Practice Parameter, and just maybe some of those lesser known things that I think the level that a lot of clinicians are practicing may not be where we need to be.
Dr. David Golden:
Well, in the Anaphylaxis Practice Parameter update that was published in January of this year, it's a focused update. So there were seven areas that we really focused on, and some of them are very, I think, targeted to the specialist.
Gary Falcetano:
Sure.
Dr. David Golden:
But the parts that dealt with diagnosis of anaphylaxis, which is not at all straightforward-
Gary Falcetano:
And I think as clinicians we often think we know anaphylaxis when we see it, right? I mean, it's not a difficult diagnosis, but it actually can be.
Dr. David Golden:
It can be, but it also ties in with, why do you need criteria? When you see a patient in anaphylaxis, are you thinking, "Well, let me count the criteria." Does this patient meet the criteria for anaphylaxis?" No. One of the main messages in that Practice Parameter was that you don't need a diagnosis of anaphylaxis to give epinephrine.
Gary Falcetano:
You need to repeat that one more time.
Dr. David Golden:
Yeah, you don't need a diagnosis of anaphylaxis to give epinephrine.
Gary Falcetano:
Exactly.
Dr. David Golden:
And conversely, just because you gave epinephrine doesn't prove it was anaphylaxis. So, I think that was one important-
Gary Falcetano:
And you should actually be okay with that.
Dr. David Golden:
Absolutely. That's right. Epinephrine, I don't know if I should say epinephrine is harmless, but it almost is. Really, it's amazing how much of a therapeutic window we have with epinephrine. You would think there'd be potentially dangerous side effects and cardiac, actually, it's amazing how little there is. I could go into a lot of the details, but it's just reassuring to know that it's actually pretty safe. So we really urge people and doctors to don't think twice, think once.
Gary Falcetano:
Exactly.
Dr. David Golden:
If you think this patient may be having anaphylaxis, one of the worst things that patients do and doctors do also is to say, "Well, I'll just wait a little bit and see if it gets worse."
Gary Falcetano:
Or, take an antihistamine
Dr. David Golden:
Or take an antihistamine. That's the second-worst thing to do. So those are also messages in the Practice Parameter. On the other hand, another recommendation in our Practice Parameter was that we don't recommend, or we recommend against the giving of epinephrine preemptively. So in other words, before the reaction starts, "Oh, I think I ate something with peanut and I know I'm allergic, I'm going to use my epinephrine." No, actually. On the other hand, at the first sign of symptoms, yes, don't wait until you're sure you're having anaphylaxis because it's never too late, but sometimes it is.
Luke Lemons:
You mentioned patients, they're like, "Am I having a reaction?" So they take [inaudible 00:07:59] antihistamine. But a lot of patients will have a severe reaction and then they won't go to the doctor, but then when they go to the doctor, they don't report it to, let's say, a primary care doctor, that they got stung by a bee and had a reaction. Why do you think that is? And how common do you think that is that when a primary care is sitting in front of a patient that they may have been stung and had a reaction?
Dr. David Golden:
One of the first things I did so many years ago was an epidemiologic study of insect sting allergy, and we learned a lot of things from that. That's actually where we learned, for example, which we'll come back to, I'm sure, 20% or more of adults have a positive test for insect allergy.
Gary Falcetano:
Just in the general population?
Dr. David Golden:
In the general population. And we'll come back to why that is so. But the other thing we found is that 9 out of 10 people who had a systemic allergic reaction to an insect sting never told their doctor. And the number one reason they tell us is they thought it was a fluke. We hear this all the time.
Luke Lemons:
It was just an accident?
Dr. David Golden:
Well, because typically, they've been stung many times in their life with no problem. It's kind of like adults getting seafood allergy. "Oh, I've eaten shrimp so many times with no problem." And then they get a reaction. You see the same thing in penicillin allergy for that matter.
This is a common picture, that frequent exposure with no problem, and then they have a reaction. So they think, "Oh, well, that was a fluke. It'll never happen again."
When it happens a second or a third time... On the controlled, as long as we're telling stories, and I won't name names, although I don't know if he's still with us, but one patient in the controlled trial of venom immunotherapy, this was in the summer of 1976, and the controlled trial meant that some patients got placebo. And there's a whole separate paper published about the people who got placebo and the reactions that they had. But there was this one gentleman in particular who had this story. He was a telephone lineman and he was on the top of the telephone pole, got stung by an insect, had anaphylactic shock, fell to the ground, lay there for a couple of hours, woke up and went home and never told his doctor.
Luke Lemons:
What?
Dr. David Golden:
It happened a second time, he still didn't tell his doctor.
Luke Lemons:
Did he fall to the ground the second time, too?
Dr. David Golden:
Yes.
Luke Lemons:
Two times, you're not telling your doctor you're falling to the ground?
Dr. David Golden:
Yes.
Luke Lemons:
And you're-
Dr. David Golden:
The third time he thought, "I guess it's not a fluke. Maybe I'll tell my doctor about this." And he landed up in the clinical trial. And needless to say, he was one of the guys who got placebo. So when we did the sting challenge, he landed up in intensive care and the study was stopped at that point.
Gary Falcetano:
So we mentioned sting challenge a couple of times already, and that's not in common practice right now, right?
Dr. David Golden:
We do food challenges these days and drug challenges, but well, there are practical issues in doing a sting challenge. You can't just pull the food or the medicine out of the cabinet and give it, although it's easier than you think. I've told many allergists that if they want to do a sting challenge, I can tell them exactly...
There was an entomologist that we worked with for many years at University of Maryland, actually after that insect escaped, she invented a device that's actually a syringe with a wire mesh on the end, so it's self-enclosed. And then when you want to sting... You actually keep it in the fridge overnight, and then when you want to sting, you just warm it up in your hands until you hear the buzzing, and then you put the wire mesh on the skin and you plunge the plunger gently until you convince the insect to sting. And then, it's disposable.
So, there's no escapees. And we found that we can ship this overnight. So if you want to do sting challenge, it's actually doable. But, no, it's certainly not routine. Well, first of all, you can't do a graded dose challenge. It's either a sting or no sting.
Luke Lemons:
Yeah. [inaudible 00:11:34]
Dr. David Golden:
You can't do half a sting.
Gary Falcetano:
I think you've done research on that it often varies, the amount of venom that's introduced in a sting?
Dr. David Golden:
It does. That's right. So you can't define the dose. A sting is a sting, but yellowjackets deliver between 2 and 20 micrograms of venom protein per sting. So that's a ten-fold difference. And patients would always tell us, "Oh, that was a light sting," or, "That was a strong sting."
In fact, in the sting challenge studies, the patients finally rebelled. They said, "We want two stings because one sting, it wasn't enough.
Luke Lemons:
It wasn't enough, yeah.
Dr. David Golden:
Interesting people that we see. "I want more stings."
Luke Lemons:
Yeah, yeah, that is... Going more into that same... that these different types of vespids or bees have different types of venom that they put into patients. There's also different types of testing, too, that can correlate with which type of insect may have stung an individual, correct?
Dr. David Golden:
So to go back to that, honey bees on the other hand, deliver 50 micrograms of venom per sting every sting, and that's because they lose their stinger along with the venom sac. So the entire contents of the venom sac are injected.
Gary Falcetano:
So they're a lot more standardized.
Dr. David Golden:
Right. And they sting once and that's it. Whereas vespids, you know... What if the yellowjacket that's stinging you just stung someone else 20 minutes ago and doesn't have any venom left?
Luke Lemons:
Oh, yeah.
Dr. David Golden:
So there are a lot of possible reasons for that. And the testing, it is like testing for different foods. There's a test for yellowjacket, there's a test for honey bee venom. These are purified venoms, the same materials that are used for immunotherapy. So we can test specifically by skin test or blood test for the IgE allergic antibodies to the specific venoms and see what you're allergic to. And then there are more specifics that we were able to do now to really fine-tune that. But before we go into that, I want to go back to maybe the beginning and say, well, what's in this Anaphylaxis Practice Parameter that would be interesting to-
Gary Falcetano:
We did kind of go down a-
Luke Lemons:
Yeah.
Dr. David Golden:
It's easy to do, and there's so many fun things to talk about with this to me. Yeah, anaphylaxis is fun as long as it's not me having the anaphylaxis reaction.
Luke Lemons:
And there's some interesting things in there, too, about alpha-gal as well.
Dr. David Golden:
Yes, for sure.
Luke Lemons:
The whole Practice Parameters, if you're listening and you haven't had a chance to read these 2023 Practice Parameters for anaphylaxis, for diagnosing and managing, there's a lot of interesting stuff in there.
Dr. David Golden:
It's a big read, but there's an executive summary at the beginning if you want the short read. And then, if you're interested in specific sections, you can go on to the full section. But I think from a primary care point of view, just that diagnosis of anaphylaxis, there was a specific section on infants and toddlers. Because the diagnosis of anaphylaxis in infants and toddlers is not the same. First of all, they can't tell you, "My throat feels funny." They can't tell you, "I can't breathe," or, "I feel dizzy."
And so, we look at more behavioral things in infants and children. If they're fussy and crying for no reason and they're itchy and scratching, we're going to call that anaphylaxis actually. So there's a whole section. And as a follow-up to that, Mike Pisner actually headed that up and has worked to... Just recently, there was a paper that he published with a group to help define more the diagnostic criteria when you need criteria, which you don't when the patient is actually having a reaction. But when you do want it, actually, "Was this really anaphylaxis? There are now some improved criteria for infants and toddlers, and that was one of the sections I think pediatricians and a lot of primary care physicians might really want to take a look at.
Luke Lemons:
Going towards venom, again, venom allergy, you had mentioned venom immunotherapy. And one of the things that I really wanted to ask you is that in the primary care setting, somebody might diagnose somebody with having, let's say, an insect allergy. But when do they refer? Because I think that maybe some people might not know the impact and how effective venom immunotherapy can be.
Gary Falcetano:
We need to discuss that for sure.
Dr. David Golden:
That's still a sore point with me, and it's a failure of public and professional education, even though we've tried really hard for 30-plus years now, I don't know why we can't get this message through, but we can't, that venom immunotherapy exists. That means just let's start with that statement. There is allergy shots, immunotherapy, for purified insect venoms. The first point is, that even exists. Because there's so many patients who are told right there in the emergency room that... First of all, they've made progress. They actually prescribe EpiPens now, which they didn't use to, but they don't refer to allergists.
Luke Lemons:
Yeah.
Dr. David Golden:
They'll routinely tell patients, "Well, there's no point going to an allergist. There's nothing else they can do about it. Just carry, your EpiPen."
Gary Falcetano:
"You have your EpiPen," right?
Dr. David Golden:
Yeah. And not to dis primary care. I think it's, like I said, a failure of professional education, that they're just not aware that venom immunotherapy exists, it was approved by the FDA in 1979, and that it is the most effective form of immunotherapy that exists. We can't just cut down the sneezes or reduce the reaction, we can completely block anaphylaxis from happening.
Luke Lemons:
That's incredible.
Dr. David Golden:
People get stung by a bee and they don't even have one hive. Our definition of success, was zero systemic reaction. A little bit of local swelling, okay. No systemic reaction. If they get even one hive, we call that a treatment failure.
Luke Lemons:
Yeah.
Dr. David Golden:
That's crazy. But it's that effective in more than 95% of patients.
Gary Falcetano:
And yet, so many primary care providers-
Dr. David Golden:
And, it's safe.
Gary Falcetano:
... aren't aware.
Dr. David Golden:
And they figure, "Oh, well, this has to be dangerous if it's..."
Luke Lemons:
No, no.
Dr. David Golden:
No, it's actually... I see more reactions to cat or grass immunotherapy than to venom immunotherapy.
Luke Lemons:
Could you speak a little bit about components when it comes to tailoring correct venom immunotherapy procedures? Because you had said it was, I forget the exact year, it was the seventies that they started doing venom immunotherapy, and a lot has changed. We now have allergen component testing for specifically stinging insect venom, and that can affect how this therapy is done. Correct?
Dr. David Golden:
Definitely. For all those years until just three years ago?
Gary Falcetano:
Yeah, something like that.
Dr. David Golden:
Something... Three, four years. That's right, that we would test a patient. So we would do skin tests or blood tests for these purified venoms, and whatever was positive honey bee, yellowjacket, hornet, wasp, we would recommend treatment, because we should cover all the bases and make sure they're not going to react to anything.
Gary Falcetano:
And that's exactly what the Practice Parameter says.
Dr. David Golden:
The last Insect Parameter was in 2016, published in January 2017. And that's what it says, "We should treat with every venom to which they're positive." And that leads to people getting two or three injections every week for a few months, then every month or two for some years. That reminds me to point that the venom immunotherapy is also curative in the majority of it.
Gary Falcetano:
[inaudible 00:18:02]
Dr. David Golden:
This is also kind of unique. They can stop treatment after four or five years, and they're no more at risk than the general population.
So components, every allergen has a number of proteins in it, allergen meaning, let's say, peanut. Peanut has a dozen different components. And we come to appreciate when we can dissect that out and say, "Well, if they're allergic to Ara h 2, then they're going to probably anaphylax. And if they're allergic to Ara h 8, one of the other components, then there's much less chance." So we can use venoms, not so much in that way, now, components, not so much to say the chance of reaction, but to dissect which exact venom they're allergic to.
Because half of our patients when we test them, are positive to both honeybee and yellowjacket. Are they really allergic to both? And they might be. But on the other hand, there are reasons that they could cross-react. They might be allergic to honeybee, but the test for yellowjacket shows positive, often because of carbohydrates cross-reacting carbohydrate determinants in the venoms, for example. Or simply because there are venom proteins that cross-react. But they may not actually have a true yellowjacket allergy, unique allergy. The components are individual proteins from honeybee venom or yellowjacket venom, and we can test with those proteins.
Luke Lemons:
And, they're CCD-free.
Dr. David Golden:
And they're CCD-free, that's right. Because of the way they're expressed in the lab, they don't have that carbohydrate component. And so, we can test and get rid of that cross-reactivity. And we know that there are certain components that are unique to honeybee or unique to yellowjacket. If they show positive to Api m 1, they're allergic to honeybee. If they're allergic to Ves V1, they're allergic to yellow jacket. If they're positive to both, they're allergic to both.
Gary Falcetano:
And then you're doing immunotherapy for both.
Dr. David Golden:
Right. But in half the patients or more, we find out that they don't need both. So we can reduce the burden both as far as how many shots they have to get and the cost and the utilization of venoms, which are a rare resource these days. So the availability of component testing has really helped the allergy community to zero in on the exact venom that they're allergic to and tailor the therapy accordingly.
Luke Lemons:
And I think, again, just to anybody who's listening, to hammer home that point, venom immunotherapy exists. It works. This testing has made it easier for venom, or not easier, but has made venom immunotherapy much more impactful.
Gary Falcetano:
More precise.
Luke Lemons:
More precise.
Dr. David Golden:
It's more precise, right.
Luke Lemons:
Yes.
Gary Falcetano:
The other part of the venom immunotherapy, just to echo the last point that you made, it's really successful, and we need to be referring patients and really encouraging them to get it because it's a disease modifier. It's basically a cure after four or five years.
Dr. David Golden:
It is in the great majority. There are some exceptions we've identified from experience the hard way. Some patients have high risk factors that would make them need to actually remain on venom immunotherapy possibly for life.
Gary Falcetano:
So that kind of brings us to tryptase, right, and the requirement. And that's in the new Practice Parameters as well. Maybe speak to that in the setting of insect sting.
Dr. David Golden:
The measurement of serum tryptase, and we're really talking about baseline serum tryptase here, baseline meaning what you're walking around every day with.
Gary Falcetano:
Right.
Dr. David Golden:
And we all have a certain level of tryptase. Tryptase is one of the many factors released from mast cells. So in an allergic reaction, for example, they release histamine and other factors, and tryptase. Tryptase happens to be one of the easiest to measure. And we know what the normal level is for the average person, but there are people with inherent mast cell abnormality conditions like mastocytosis or the more recently described, hereditary alpha tryptasemia.
Gary Falcetano:
Right.
Dr. David Golden:
And that's important, because people who have those mast cell conditions are at increased risk for anaphylaxis and for severe, life-threatening anaphylaxis. So in the case of insect allergy, and anaphylaxis in general, among the recommendations in our Practice Parameter is that you should measure the baseline serum tryptase in any patient who's had severe anaphylaxis or insect sting anaphylaxis or idiopathic anaphylaxis, because they may have an underlying mast cell condition that puts them at risk for more severe and dangerous anaphylactic reactions. So if we measure the tryptase and it's higher than the average, then we need to look into that and see what condition they have and manage them accordingly.
Gary Falcetano:
Exactly, maybe do a workup for mastocytosis or mast cell activation?
Dr. David Golden:
Right. So that's now part of the workup for severe anaphylaxis.
Gary Falcetano:
And that's a stronger recommendation than it used to be. It was always mentioned, right, but now it's-
Dr. David Golden:
It is. It's actually one of the few strong recommendations, because in these guidelines, we now make strong and conditional recommendations. That's a strong recommendation.
Luke Lemons:
Going back, we had mentioned epinephrine, epinephrine auto-injectors, and now there's inhaled epinephrine, nasal. Can you talk more about that?
Dr. David Golden:
Sure. And we're so excited to have this new option, and there will be more coming along. We're aware of other nasal epinephrines and even sublingual film of epinephrine that we're hoping to see in the future. Does it work? Well, there are no clinical trials. It's unethical and infeasible, they say, to do a controlled trial.
Luke Lemons:
Yes.
Dr. David Golden:
In other words, giving a placebo to someone who's having anaphylaxis.
Gary Falcetano:
Because the trials were really in healthy adults and just measured blood levels.
Dr. David Golden:
That's right.
Luke Lemons:
Yeah.
Dr. David Golden:
So the FDA agreed to an alternative pathway to approval, bracketing. It's comparing by pharmacokinetics, measuring how much gets into the blood, how fast it gets into the blood, how high does it go. We know the characteristics of the intramuscular injections, the approved treatments. So if a new treatment can show that they get into the blood at a level and rapidity-
Gary Falcetano:
Similar efficacy.
Dr. David Golden:
... that is somewhere in that range between the different available approved products, then that's a pathway to approval. So the nasal spray showed that within 8 to 10 minutes, they're at the same level or within the range of different products that are used for intramuscular epinephrine. And pharmacodynamics, meaning the physiologic effect, did the blood pressure go up? Did the pulse rate go up? Did it do the things that you wanted to do to save someone's life when they're having anaphylaxis? The answer is, yes, it did the same thing as intramuscular epinephrine. So that was enough to get it approved. Is it enough to convince allergists to prescribe it? Is it enough to convince patients to accept that this is what's going to save their life?
Luke Lemons:
Yeah.
Dr. David Golden:
And actually, I've said that twice already, and I'll go right back to saying, the real purpose of epinephrine is not to save lives. The fatality rate... I think this is a really important message to clinicians about the mortality, fatality rate from anaphylaxis. It's 0.1%.
Luke Lemons:
Oh, wow.
Dr. David Golden:
You have 99.9% chance you are not going to die from your peanut allergy or your insect allergy. So this culture of fear with anaphylaxis is really detrimental in so many ways.
Luke Lemons:
Yes.
Gary Falcetano:
Anaphylaxis equals near death.
Luke Lemons:
Yes.
Gary Falcetano:
And it often isn't.
Dr. David Golden:
So we're trying to re-educate professionals and patients that, number one, stop being afraid of dying. It's ruining your life.
Luke Lemons:
That is a very philosophical way of looking at it, too.
Dr. David Golden:
And number two, use the epinephrine not to save your life, but because you're having a nasty reaction, and you don't want to land up in the emergency room.
Luke Lemons:
Yes.
Dr. David Golden:
And that's the other important thing in the Anaphylaxis Practice Parameter now, there's a pathway to not calling 911. We said that if you use your epinephrine promptly, and you get a good response and you stay better, you don't need to go to the emergency room.
Gary Falcetano:
Wow. And again, that's another shared decision-making, right?
Dr. David Golden:
But it is shared decision-making. And in that guideline, it says that if you're not comfortable with not going to the emergency room, then go to the emergency.
Gary Falcetano:
Or maybe you have a history of biphasic reactions or more complex-
Dr. David Golden:
Probably because you waited too long, but yes. So, that's another important message. And having easier, faster methods of using epinephrine, I hope will change a lot of those things.
Luke Lemons:
So we've talked about a lot today from anaphylaxis to stinging insects and the way in which you can, well, you used to administer it. I just want to say for our listeners, who are our primary care clinicians, what would be the take-home of these Practice Parameters and of stinging insects in general, the [inaudible 00:26:28]
Gary Falcetano:
What do we want them to [inaudible 00:26:28]
Luke Lemons:
When the primary care audience turns off this podcast at the end, what do you want to tell them right now? This is your chance to literally get in their ear.
Dr. David Golden:
Number one, and I'm sure every specialist has something like this, they can say, a complete medical history is not complete if you do not ask the patient, "Have you ever had a severe reaction to an insect sting,"
Gary Falcetano:
Mic drop.
Dr. David Golden:
Because, they didn't tell you. They probably have had a reaction, but they don't tell their doctors, right? We discussed that. So you will be surprised how many people will say, "Oh, yeah, I had a dangerous reaction 10 years ago, but I know it was a fluke, so I'm not worried about it." Alarm bells.
Luke Lemons:
Yeah.
Dr. David Golden:
Ask every patient at least once, "Have you ever had a severe reaction?" And if the answer is yes, refer them to an allergist.
Again, you can take on some of the discussion and counseling that we've talked about. But what those patients need to hear often has to come from an expert trained in the-
Luke Lemons:
[inaudible 00:27:27]
Dr. David Golden:
... board-certified allergy, immunology, Because there is a lot of shared decision-making, and a lot of counseling and risk stratification about who should really worry and who shouldn't worry. We didn't really talk about people who get huge swellings and are scared, or people who break out in hives. Just try telling, I've done this, try telling a mother that their child who got stung and was covered in hives and their face was swollen and they rushed into the emergency room, and the emergency room doctor of course said, "The next one will kill you." They always say that, "The next one will kill you." Well, I just said, there's a 99.9% chance that's not true. And that's why they need to see someone who can counsel them and re-educate them, and who's in danger and who's not.
Gary Falcetano:
And not all allergists are comfortable with venom immunotherapy as well, right?
Dr. David Golden:
That's true. That's true. So sometimes, it requires a secondary referral, but it's really a matter... Because what I didn't say is that those people with those non-anaphylactic reactions, having hives and swollen faces, actually non-anaphylaxis. If you didn't have trouble breathing or low blood pressure, it's not an anaphylaxis. And, they're low risk. Their chance of having anaphylaxis is 1 or 2%, barely more than the general population. They don't need venom immunotherapy, but they were told they're going to die.
Luke Lemons:
Yeah.
Dr. David Golden:
So again, there's a lot of counseling and risk stratification and management. So ask the question, refer the patient, advise, educate. If any of the things that I've said resonate, and you can offer them to the patient, I think that's really helpful to the patient, because we want to prevent impaired quality of life, and we also want to prevent dangerous reactions.
Gary Falcetano:
What about around epinephrine? You probably have at least two absolute take-home messages for epinephrine for primary care, which, also for patients.
Dr. David Golden:
Again, it's risk stratification, because a prescription for epinephrine is a prescription for fear. There was a fabulous study by my friends in the Netherlands who randomized insect allergy patients to either venom immunotherapy or epinephrine injector. And after a year... They have a validated quality of life instrument. And first of all, people with insect sting allergy have a significantly impaired quality of life, because they live in fear.
Gary Falcetano:
Right.
Dr. David Golden:
And they limit their activities. They don't go to picnics. After a year, the people on venom immunotherapy had dramatically improved quality of life. The people who were given the epinephrine injector had a further impairment in quality of life.
Luke Lemons:
Wow.
Dr. David Golden:
They were not reassured by having their epinephrine injector. In fact, they were more scared than they were before. So think about that. I think doctors reflexly, and per medical legal reasons, prescribe epinephrine because they've done their duty. Now, it's in the patient's... "What if I don't prescribe epinephrine and this patient has a severe reaction?"
Well, that's a decision that the patient can be involved in. This is shared decision-making. We need to hear the patient's values and preferences. We can communicate what we know and who's high risk and who's low risk, and what does it mean to be low risk? But the patient may say, "Oh, that's not so bad. I don't need treatment." Or the patient may say, "Oh, that low risk doesn't sound very good to me. I want to be treated." And then, we can respect that because patients are experts on their values and preferences. So these are some of the aspects that we now try to incorporate into our management of insect allergy and anaphylaxis in general.
Luke Lemons:
Well, thank you so much. I was going to just thank you so much for being on the show. We talked about so much, and there's a lot of knowledge that you shared.
Gary Falcetano:
Always a wealth of knowledge. Always a pleasure speaking to. Thank everyone out there for tuning in, and see you next time.
Luke Lemons:
Yeah. Thank you for listening.
Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific creators of ImmunoCAP Specific IgE Diagnostics and Phadia Laboratory Systems. For more information on allergies and specific IgE testing, please visit ThermoFisher.com/immunocast. Specific IGE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy. Clinical history alongside specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be, and should not be interpreted as or substitute, professional medical advice, diagnosis, or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
