Written on July 20, 2013 at 3:54 pm, by Neil Gershman, MD
We are very proud to announce that Dr. Neil Gershman has been elected to be the President of the Florida Allergy, Asthma & Immunology Society!
Dr. Neil Gershman is a graduate of the University of Miami School of Medicine. He did his Internal Medicine training at Montefiore Medical Center of the Albert Einstein College of Medicine and his Allergy/Immunology fellowship at the University of California, San Francisco.
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.
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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
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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.
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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 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
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