New Treatments for Asthma

Well, one of the things that’s always been of interest to most allergy and asthma specialists is trying to find the cause of the allergic response. Why are people having this problem? With the medications that we have available now are treating the symptoms. In other words, inflammation is the end result of an allergic reaction.

Now, allergic reactions occur because, as we mentioned before, you are genetically predetermined to develop certain kinds of antibodies. Antibodies, for example, give us our individual characteristics. They determine our blood type and our tissue type. They also determine the type of allergies we have.

The antibody that’s associated with allergy is called IgE, which is a short acronym for immunoglobulin type E, and it’s called E because the other ones also have letters in them, and so this is the letter that they’ve assigned to this antibody. And when you produce these antibodies, they hook onto cells that are located in your respiratory tract – in your nose, in your sinuses, in your throat and your chest, even sometimes in your gut – and they sensitize the cells. In other words, they give the cell the signal that if you come in contact with the specific thing that we’re sensitizing you to, you’re going to have a reaction.

And so when you breathe in pollen, or when you breathe in dander, or when you eat a food that you’re allergic to, these cells, which we refer to as mast cells, get sensitized. And as a result there’s a lock and key mechanism where the antibody, which is the IgE antibody, and the antigen, which is an allergen, get together, and it unlocks the cell, and it releases a lot of chemicals. Many people are aware of one of the chemicals called histamine, which causes redness and swelling and itching and congestion, but there are many other chemicals, such as leukotrienes that cause constriction in the airways. And as a result, you get the allergic or asthma response, and then we give people their medications.

So, what we’ve been looking for, in a sense, is to try and block the allergic response from actually taking place, kind of like if you have a high fever, I certainly can give you Tylenol for your fever, but I need to know what’s causing your fever. If your appendix ruptured, for example, I need to take care of that. Tylenol is not the problem. The getting rid of the affected appendix is. And it’s the same thing here. We certainly can give medications, but if we can control the allergic response so you don’t need to have the medications, that certainly is very exciting. We have now a new compound called an anti-IgE. In other words, we have an antibody against the antibody that we produce, and what it does, it kind of acts as jet fighters that go through the blood stream looking for IgEs and kind of zap them. They hook onto these IgEs before they can hook on and sensitize the mast cells that cause the allergic reaction, and then you eliminate them and you do not have an allergic reaction.

Dick:

It immediately sounds better than treating symptoms. Is it a step in the direction of prevention, would you say?

Dr. Berger:

I think that it is a giant step towards treating the causes of diseases. I think that we certainly are aware of the fact that they’re talking about now genetic therapy, trying to get to the root of the problem. This is about as close as you can get to treating the root of the problem as we’ve had since we’ve really been aware of these diseases. And because it’s non-specific – by that, I mean it blocks any IgE whether it is an IgE that’s directed towards your lungs, or directed towards your nose, or directed towards your throat, it can block all allergic reactions. So, in a sense, it is a single medication that can take care of both your nasal symptoms and your asthma symptoms at the same time.

Dick:

Okay. And a new approach newer and different from anything that’s been tried before.

Dr. Berger:

Certainly the first time we’ve ever been able to block IgE. We have had allergy shots, what we call immunotherapy, that most people who have been to an allergist are very aware of, where the allergist does allergy skin testing. You get a little redness and swelling, and a doctor determines what you’re allergic to and then develops a serum against that particular substance. But the problem is that when you are being treated for this, you are getting small amounts of what you actually are allergic to. So there is a potential, and that’s why it’s so important that you stay in the doctor’s office, after you get the allergy shot there is a potential to actually have a reaction. And so, it has to be done very carefully and requires several months, and in some cases several years of therapy.

With the anti-IgE you’re not giving an active allergen such as grass or tree or wheat. What you’re doing is you’re just giving an antibody against their antibodies. So you don’t have to be as concerned about having allergic reaction from this anti-IgE injection.

Dick:

I can just hear our listeners asking now, “So, are these treatments available generally at the moment?”

Dr. Berger:

Well, here’s the problem. We are not at the point yet where it has been approved. It is still in clinical trials. I think that the approval process is certainly on the horizon. There are sites, including ours, around the country who are doing studies for asthma and for allergic rhinitis, which is the medical term for hay fever, but I think we’re going to see this drug in the next year or two on the market.

Dick:

Okay. Now, aside from medication, are there now or are we becoming aware of better ways for controlling and monitoring asthma than, say, five years ago?

Dr. Berger:

I think we’re far better in our ability, certainly, to control asthma. The NHLBI, which is the National Heart, Lung and Blood Institute, has come out with guidelines last published in 1997 that basically help us to understand asthma; to classify it as being mild intermittent, mild, moderate or severe persistent based on symptoms, based on history, based on physical exam, and based on lung function tests. And then, once that diagnosis is properly made, giving us guidelines as to what medications can be used. I think the strongest statement in these guidelines is that asthma is an inflammatory disease and, similar to what we just talked about a few minutes ago is that anti-inflammatory therapy is critical for anybody who has persistent asthma. The second thing it talks about is monitoring, which I think also is very important in that we have what we refer to as peak flow meters, and these are little devices that a patient can use at home. They can blow into it, and it basically measures their peak flow, their highest flow. And it’s a quantitative way – in other words, you can actually objectively measure how you’re feeling instead of just saying, “I’m not feeling good” or “I am feeling good.” And by following those numbers and graphing them, in a sense it becomes an early detection that things are going badly, and you can then be treated earlier before these symptoms get out of control.

Dick:

Can a patient become more aware of the things that may trigger asthma?

Dr. Berger:

Yes, and I think that in any evaluation that it’s important for a physician to review these in detail. Certainly, we know that most asthmatics will have symptoms after exercise. I was particularly pleased to see that exercise didn’t stop Amy van Dyken from winning a gold medal recently, and Tom Dolen, and a friend of mine who is well known, Jackie Joyner-Kersee, another asthmatic, all who have been able to achieve great accomplishments in terms of gold medals in the Olympics despite their asthma. And if there’s any one thing that I think we need to really let asthmatics know is that you don’t in this point, in the way we treat asthma, have to sit on the sidelines. Asthmatics can lead perfectly normal, active, and in some cases achieve incredible goals despite their asthma if they’re properly diagnosed and treated. So, we know exercise is a precipitant, but we can treat that.

We know, for example, infection, especially in very young children, is a major precipitant, and it’s important that the diagnosis be made. In very young children, very often there is this hesitancy to call them asthmatic. They call them “wheezy bronchitis” or “recurrent bronchitis” or “twitchy lungs,” instead of really making the diagnosis of asthma. And of course, proper diagnosis will then lead to proper treatment.