Written on December 14, 2012 at 1:22 am, by Neil Gershman, MD
Even though I am no videographer, I think you will get a lot out of watching this video. Just a couple of disclaimers: 1. Watching this video should not take the place of the care and advice of your physician or pharmacist 2. This is some disagreement on the “proper” use of inhalers. The video does not depict the perfect techniques. It demonstrates what I believe are adequate techniques that the majority of people are able and willing to perform.
Written on April 17, 2012 at 12:28 am, by Neil Gershman, MD
Sublingual drops, or tablets for allergen immunotherapy (SLIT), have received a lot of attention lately. Even though there are no FDA approved products, many US physicians are offering this treatment to their patients. We, at Asthma & Allergy Associates of Florida, have chosen to carefully consider using this therapy as an alternative to conventional subcutaneous immunotherapy (SCIT) or allergy shots.
There were several studies at 2012 American Academy of Allergy, Asthma and Immunology that showed the effectiveness of SLIT. However, high doses of allergen are required. This may be due to much of the allergen is being broken down by saliva and other factors. On average, the DAILY dose of SLIT is about twice the MONTHLY dose of SCIT. One study using dust mite sublingually used 70 micrograms of allergen daily, whereas the effective injection dose is around 5-10 micrograms per month. If you look at a variety of studies, you see that the total dose of SLIT is about 30 to 200 times the total injection dose.
So, the result is that the cost of the allergen extract can become prohibitive if the patient is being treated for more than a few allergens. A very rough estimate would be that for year-round type allergens (dust mite, cat, for example), the cost would be $100 per allergen per month. Seasonal pollens would cost about $10-20 each per month.
So, if someone was allergic to dust mite, cat, and a few pollens pollens, the extract or “sublingual drops” would cost about $300 per month just to purchase the extract from the manufacturer (this is not even accounting for the administrative costs). So, it would get quite expensive. In addition, until a product is approved by the FDA, SLIT won’t likely be covered by insurance plans. That is, the entire cost would be out-of-pocket. If you look at Grazax, a sublingual tablet for grass pollen that is approved for use in Canada and Europe, it costs about $200 per month just to treat grass pollen allergy.
Although there are few studies that compare SLIT to SCIT, the general consensus is that SCIT is more effective. On average, SCIT (shots) studies show a 40% improvement in symptom scores, where SLIT (drops or tablets) improve symptoms by 20%. However, SLIT is appealing in that the patients can treat themselves mostly at home, and that no needles are involved. Plus, SLIT drops have been associated with less allergic reactions than SCIT shots.
In summary, the question is not whether sublingual allergen immunotherapy works (it apparently does), it is whether physicians are using adequate doses. For unclear reasons, allergic individuals in the US tend to be allergic to multiple allergens. This results in sublingual therapy being an expensive proposition.
I foresee that SLIT will have a place in certain situations (small children, patients allergic to one or two allergens). We are still in the process of deciding whether to begin using this method of allergy treatment. I would advise, however, that any potential patients ask their doctor about whether they are receiving an adequate dose of each allergen. Otherwise, that patient might be receiving a very expensive placebo.
Neil Gershman, MD
Vocal Cord Dysfunction or Paradoxical Vocal Cord Movement….. vocal fold motion, vocal cord dysfunction
Written on January 18, 2012 at 1:09 am, by Neil Gershman, MD
This is a very common problem which is very under appreciated. I will make a bold statement here. I believe most of the asthma ER visits in affluent areas (I’ll explain in a second) have as much to do with Vocal Cord Dysfunction (VCD) as the actual asthma.
What I mean is that if you are actually take your asthma medicines appropriately (using the inhalers correctly and as often as your doctor recommends), it is very unlikely that you end up in the ER with an asthma attack. The medicines are VERY effective these days. It’s people who can’t afford the medications or those who don’t get the proper medical advice (or won’t take or understand the advice) who end up in the ER for the most part.
So, if the asthma aren’t working, we think of VCD. I should mention that part of the recognition problem is that different medical professionals call this problem different things. I mentioned “VCD” to an ENT specialist, and he looked at me blankly. When we started talking about it, he said “oh yeah, that’s blah, blah, blah (I forgot what he called it!). So, you see the problem.
In any case, once it is recognized we can start to look for a solution. I find that most patients can learn to control it on there own with yoga and meditation breathing techniques. In more difficult cases, speech pathology therapists can help.
I found this nice video on youtube.com demonstrating the problem. I should warn you that it might be a little gross to some.
I am going to try and work with a speech therapist to make a more comprehensive video.
Written on January 16, 2012 at 3:28 pm, by Neil Gershman, MD
It’s essentially impossible to get topical medication into the sinuses. Here’s a video showing how to get the medicine from the nasal spray into the form of a sinus irrigation. Obviously, you must talk to your doctor before trying any new sinus or polyp treatment.
Written on May 15, 2011 at 3:12 pm, by Neil Gershman, MD
Before the expo, Dr. Gershman went with some of the staff to NBC studios.
Written on April 28, 2011 at 2:54 pm, by Neil Gershman, MD
We had a fulfilling weekend at the NBC Health & Fitness Expo. We met so many nice people and were happy to tell them about our practice. Please check out the video below.
Written on April 25, 2011 at 12:19 pm, by Neil Gershman, MD
Hello again from Allergyweb.com’s blog. I have always thought that pollen seasons weren’t that dramatic in South Florida since we don’t really have seasons here. But looking at our patient logs, we saw many more people this March versus last March. There is no official pollen counting station in South Florida (the nearest is in Orlando), so it’s hard to know for sure… but I believe this tree season (mostly from Oak tree) might have been the worst in many years.
Dr. Neil Gershman
Written on October 13, 2010 at 3:15 pm, by Neil Gershman, MD
Written on October 13, 2010 at 2:59 pm, by Neil Gershman, MD
We had a great day at this year’s American Lung Association’s Fught for Air Run/Walk. The purpose of the Run/Walk is to raise awareness about lung diseases and support many of the programs the ALA provides. The weather, the food, the camaraderie, and the activities were fantastic. Close to $80,000 was raised.
This year, like every year, Asthma & Allergy Associates of Florida was a major sponsor of the event. Our practice has worked closely with the American Lung Association – Dr. Miller and I are Advisory Board members for two of the South Florida Chapters. The next major event is the Fight for Air Climb in downtown Ft. Lauderdale on December 11th.
Neil Gershman, MD
Written on September 29, 2010 at 1:02 am, by Neil Gershman, MD
Should we be telling moms to avoid common allergy-causing foods for the first few years of life?
Conventional wisdom among pediatricians was to tell moms to hold off on feeding kids certain foods until the children were “old enough.” This came from allergy researchers who thought avoiding these foods would make the child less likely to develop an allergy to peanut, for instance. Unfortunately, it looks like this advice to parents is probably folklore. That is, there was no real hard science behind this advice. It turns out that the opposite advice is might be better. Researchers are starting to feel that children should be exposed to allergenic foods (peanut, shrimp, tree nuts, for example) early and often.
Studies looking at the effectiveness of government-based guidelines seeking to decrease peanut allergy by later introduction of peanuts found them at the very least to be ineffective, and possibly detrimental. Early feeding of allergenic foods may lead to tolerance. Tolerance is the response where the immune system learns to ignore a substance – or to not react in an allergic way.
I must clarify one important point. If a person is already allergic to a food, the only current recommended treatment is strict avoidance and that the patient should carry a self-injectable epinephrine device in case of accidental ingestion. What I am talking about here is trying to prevent children from becoming allergic to a food in the first place.
Food allergy continues to be a problem which seems to be on the increase despite the measures we take. We as doctors and parents must take the recommendations of the past with “a grain of salt.”