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COVID-19 Vaccine

We have received numerous questions over the past several weeks regarding the Covid vaccines, and we will try to address most of them in this post. We have compiled this information from different sources which are listed at the end of this piece. Please note, the Pfizer and Moderna COVID-19 vaccines are some of the safest and most effective vaccines for an infectious disease. These vaccines will end this pandemic if almost every human around the world is inoculated.

 

Will our practice (Allergy, Asthma & Food Allergy Centers) receive vaccines to immunize our patients?

As of 4/28/21, we will NOT as the mRNA approved vaccines require extremely cold temperatures (-70°C or -94°F for Pfizer; -20°C or -4°F for Moderna) for storage, and there is now good access for the general population (except most kids) to receive all 3 approved vaccines.

 

I have allergies (to foods, drugs, pollens, etc.). Am I at risk for a severe allergic reaction to the vaccine?

If you have an allergy to polyethylene glycol or some injectable medications, you may be at risk, but food allergies, drug allergies to oral medications, and environmental allergies do not put you at any significant risk over the general population. You will also be monitored for at least 15-30 minutes after vaccination, and vaccination sites should have epinephrine on hand on the off chance you have a reaction. Remember, no one has died from Covid vaccination despite millions of doses and as of this post, over 400,000 people have died due to COVID in the US.

There was a recent CDC  report with 71% of anaphylaxis cases being in the first 15 min. Anyone with an anaphylactic history can and should wait 30 mins. 

There is currently no validated testing for suspected allergy to polyethylene glycol or for other components of the vaccine. You can find more information here: American College of Allergy, Asthma & Immunology (ACAAI) Guidance on Risk of Allergic Reactions to mRNA COVID-19 Vaccines.

Remember, allergic reactions to the vaccine are relatively infrequent; roughly one in every hundred thousand injections — more than 100 times less common than allergic reactions to penicillin. Reactions are being observed because so many people are being immunized. Importantly, everyone who has had a reaction has been effectively treated and stabilized without any long-term problems.

Large local reactions have been reported, especially after Moderna vaccines, including:

  • Itching, redness, and swallowing are not uncommon. This comes on late (>5 days from vaccination) and can last for weeks. Treatment is symptomatic: antihistamine, NSAIDs (like ibuprofen)/Tylenol, ice. You CAN still get the second dose! In the Moderna vaccine trial, delayed large locals like these occurred 4 times less with the 2nd dose than the 1st dose.
  • Consider switching to the other arm for the second dose if you had a local reaction to the first dose.
  • These large local rxns are all very delayed in onset (often after day 8) so mechanistically they are different from immediate reactions.

 

I’ve heard that the vaccines are made from fetal tissue. Is this true?

NO, the Pfizer and Moderna vaccines are synthetic- made from chemicals. The AstraZeneca (AZ) vaccine (not approved as of 1/25/21) does use an immortalized cell line (HEK 293) derived from an abortive fetus from the 1960s for vaccine production. Here is a commentary that discusses this.

 

Where can I get information on how to get the Covid vaccination?

 

How do the Covid vaccines work?

COVID-19 vaccines help boost the immune system against the pandemic-causing SARS-CoV-2 virus. As of 1/25/21, two COVID-19 vaccines are available in the U.S. One by Pfizer/BioNTech and the other by Moderna.  Both of these utilize messenger RNA (mRNA) to make the spike protein found in the SARS-CoV-2 virus, which attaches to human cells leading to infection. The spike protein stimulates the immune system to make antibodies against this virus, making a person less susceptible to contracting it. Having antibodies against the spike protein can prevent the virus from attaching and infecting human cells.  Both vaccines require two doses, three or four weeks apart in order to achieve an optimal immune response.

 

Are there any safety concerns with the new technologies (mRNA and nanotechnology) being used in the development of COVID-19 vaccines?

There are no known additional risks of mRNA vaccines or lipid nanoparticles. Live attenuated viral vaccines, such as the measles vaccine, induce an immune response that is similar to natural infection. mRNA vaccines, on the other hand, simply give the body instructions to produce one very specific part of a virus – in this case the spike protein – to then induce an immune response.  Because mRNA is broken down very quickly in the human body, it is wrapped in a lipid nanoparticle to be able to get into our cells to do its work. Once it gets into the cells to deliver the instructions, the mRNA breaks down very quickly. There are rumors that mRNA vaccines will alter DNA because the RNA molecule can convert information stored in DNA into proteins. That is not true. It is important to note that the mRNA vaccines never enter the nucleus of the cell, where DNA is stored. After injection, the mRNA from the vaccine is released into the cytoplasm of the cells. Once the viral protein is made and on the surface of the cell, mRNA is broken down and the body permanently gets rid of it, making it impossible to change DNA.

This is a nice set of tweets from Andrew Nowalk, MD, Ph.D., a pediatric infectious disease specialist in Pittsburgh. He presents some information on the vaccines that may alleviate some concerns people have about the speed at which the vaccines were developed. They are presented below (but here is a link to his tweets).

  • This is NOT a vaccine created in 9 months. The origin goes back many years.
  • The first reports of an mRNA vector in a lipid particle used as a transfer vehicle go back to 1989 at the Salk Institute. Vaccines were considered using this in the 1990s. Kariko and Weissman made a big leap forward in 2005.
  • They modified the nucleosides of the mRNA, the building blocks that encode the viral protein so that they would be recognized as host RNA and properly translated.
  • Moderna (ever notice the last 3 letters) started in 2010 to expressly use this technology.
  • The first vaccines of this variety are NOT against #COVID it was MERS and OG SARS. Those trials are more than 3 years old.
  • The real analog here is 2009. That’s when we took the pandemic H1N1 strain and made a vaccine with it in 6 months. That’s a good analogy.
  • When this vaccine technology and development started, REM and Nirvana were the big bands, Clinton was president, and an i-anything from Apple was more than half a decade away.

Risk of Covid vaccine in context by Aaron E. Carrol, M.D., who is a professor of pediatrics at Indiana University.

 

What about Covid-19 vaccination in pregnancy?

Please contact your OBGYN to see what his/her current recommendations are.  Most OBs are recommending it for pregnant and nursing mothers.  The Centers for Disease Control and Prevention (CDC), the American College of Obstetrics and Gynecology (ACOG), and the Society for Maternal-Fetal Medicine agree that the new mRNA COVID-19 vaccines should be offered to pregnant and breastfeeding individuals who are eligible for the vaccine. Here is a piece on the Covid vaccine in pregnancy.

More recently, preliminary findings of a study published in the New England Journal of Medicine on 4/21/21 find COVID-19 mRNA vaccines made by Pfizer and Moderna are safe for pregnant women. A study in JAMA Pediatrics found pregnant women who became infected with the virus were at increased risk for maternal mortality, preeclampsia and preterm birth. Therefore, it is particularly important for those who are pregnant to receive the COVID vaccine, and the CDC now recommends that all pregnant women be vaccinated.

 

What if I have already had COVID, do I still need the vaccine?

Yes, you should still receive the vaccine. Due to the severe health risks associated with COVID-19 and the fact that reinfection with COVID-19 is possible, you should still be vaccinated.

 

How soon after being infected from COVID should I get the vaccine?

 Current CDC guidelines state you can receive the vaccine as soon as you are fully recovered from symptoms and out of the quarantine period.  However, reinfection within 90 days of illness is uncommon, so it may be less critical to get the dose right away.  They can wait until closer to the end of the 90 days if they want.

If you were treated for COVID-19 symptoms with monoclonal antibodies or convalescent plasma, you should wait 90 days before getting a COVID-19 vaccine. 

 

The vaccines are not 100% effective, so why should I take them? 

The mRNA vaccines are nearly 100% effective against severe illness from COVID-19. Of the 32,000 people in the Pfizer trial, only one developed COVID-19 severe enough to require hospitalization. Beyond the 95% prevention of any clinical COVID-19 infection, the 5% that got the illness had a very minimal illness. So these vaccines are almost totally effective in preventing COVID-19 illness in all qualifying age groups.

 

If I can still spread the disease after I’ve received the vaccines, why should I take them? 

Disease spread was not a specific endpoint in the clinical trials, but if the clinical illness is reduced by 95%, the spread of the virus should also be reduced by 95%. In the Moderna trial, the asymptomatic disease appeared to be as reduced as significantly as symptomatic diseases.

 

Will the vaccines protect me against the new variants of Covid?

The current data suggest that the vaccines offer varying amounts of protection against the known mutant strains of Covid. While the protection may not reach 95%, it is still very significant.

 

There are (or will be) different Covid vaccines approved. Which one should I get?

The simplest answer is take whatever vaccine you can get as soon as you can get it since all of the approved (or likely to be approved) vaccines essentially eliminate the risk of a severe Covid infection that will lead to death.

 

Does the vaccine contain toxic chemicals that will make me sterile?

NO! There are no toxic chemicals in the vaccine. The lipid component is in many foods and cosmetics. The amount of this material you are exposed to every day is hundreds of times more than in the vaccine. All these substances have been shown to be safe in large studies because they are in food and cosmetics. Therefore, it is unlikely that anything in the vaccine would cause a toxic effect.

There are many false rumors about the Covid vaccines, specifically targeting women. Some of them are debunked here.

 

The information above was compiled from different sources, including:

Here are more links to frequently asked questions: 


Seasonal and Year-Round Allergies (Allergic Rhinoconjunctivitis)

Outdoor Allergens 

Seasonal allergic rhinitis, commonly referred to as hay fever, affects millions of people worldwide. Symptoms include sneezing, nasal congestion, runny nose, and itchiness in your nose, the roof of your mouth, throat, eyes, or ears. The most common seasonal triggers are pollen and mold spores in the air, which trigger a chain reaction in your immune system.

Your immune system controls how your body defends itself. For instance, if you have an allergy to pollen, the immune system identifies pollen as an invader or allergen. Your immune system overreacts by producing antibodies called Immunoglobulin E (IgE). These antibodies travel to cells that release chemicals, causing an allergic reaction.

Pollen

Pollen consists of tiny grains needed to fertilize many kinds of plants. Pollen from plants with colorful flowers, like roses, usually do not cause allergies. These plants rely on insects to transport the pollen for fertilization. On the other hand, many plants have flowers that produce powdery pollen that is easily spread by wind. These culprits cause allergy symptoms.

Each plant has a period of pollination that does not vary much from year to year. Trees pollinate in the spring, grasses in the early summer, and weeds in the late summer/fall. In the St. Louis area, major trees causing symptoms in the spring are oak, ash, and mulberry. Ragweed is a major fall allergen, which typically causes symptoms around Labor Day. The weather can affect the amount of pollen in the air at any time. In warmer places, pollination can be year-round.

Molds

Molds are tiny fungi related to mushrooms but without stems, roots or leaves. Molds can be almost anywhere, including soil, plants, and rotting wood. Their spores float in the air, much like pollen. Outdoor mold spores begin to increase as temperatures rise in the spring. In the United States, mold spores reach their peak in July in warmer states and October in the colder states. They can be found year-round in the South and on the West Coast.

Pollen and Mold Levels

Pollen and mold count measures the number of allergens present in the air. The National Allergy Bureau is the nation’s only pollen and mold counting network certified by the American Academy of Allergy, Asthma & Immunology (AAAAI). The NAB compiles pollen and mold levels from certified stations across the nation. You can find these counts for different geographic areas here. Counts for St. Louis can be found at the St. Louis County Pollen and Mold Center.

Effects of Weather and Location

The severity of your symptoms may be affected by recent contact with other allergens, the amount of pollen exposure, and your sensitivity to pollen and mold. Hay fever symptoms are often less prominent on rainy, cloudy, or windless days because pollen does not move around during these conditions. Pollen tends to travel more with hot, dry, and windy weather, which can increase your allergy symptoms.

Treatment

If your seasonal symptoms are making you miserable, we can help!

As board-certified allergists, we have the background and experience to determine which allergens, if any, are causing your symptoms. This information will form the basis of a personalized treatment plan to help alleviate your symptoms, including recommendations on how to avoid or minimize contact with your allergens where possible.

If your symptoms continue or if you have them for many months of the year, you may benefit from allergy immunotherapy (allergy shots). This treatment involves receiving regular injections given in gradually increasing doses. This helps your immune system become more resistant to the specific allergen and lessen your symptoms as well as the need for medications.

There are also simple steps you can take to limit your exposure to the pollen or molds that cause your symptoms:

Tips

  • Keep your windows closed at night and if possible, use air conditioning, which cleans, cools, and dries the air.
  • Try to stay indoors when the pollen or mold counts are high. If your symptoms are severe, wear a pollen mask if long periods of exposure are unavoidable. When you return indoors, take a shower, shampoo your hair and change clothes.
  • Avoid being responsible for mowing lawns or raking leaves. This stirs up pollen and molds. Also, avoid hanging sheets or clothes outside to dry.
  • When traveling by car, keep your windows closed.
  • Take any medications as prescribed.
  • Avoiding exposure during times of high pollen and mold counts will help ease symptoms.
  • The majority of hay fever medications work best if started before a pollen season begins. For spring allergies, we typically recommend starting medications around Valentine’s Day.
  • Allergy shots can often provide long-term relief of hay fever symptoms.

Source: aaaai.org/conditions-and-treatments/library/allergy-library/outdoor-allergens

 

Indoor Allergens

Millions of people suffer year-round from allergy symptoms caused by indoor allergens. These culprits include dust mite droppings, animal dander, cockroach droppings, and molds.

When allergy symptoms occur year-round, the condition is called perennial allergic rhinitis. In addition to causing allergy symptoms, allergens can also trigger asthma flare-ups in people with allergic asthma.

Dust mites

Dust mite allergens are a common trigger of allergy and asthma symptoms. While they can be found throughout the house, these microscopic creatures thrive in warm, humid environments such as bedding, upholstered furniture, and carpeting.

Because so much time is spent in the bedroom, it is essential to reduce mite levels there. Encase mattresses, box springs, and pillows in special allergen-proof fabric covers or airtight, zippered plastic covers. Bedding should be washed weekly in hot water (130° F) and dried in a hot dryer. Allergen-proof covers are available for comforters and pillows that can’t be regularly washed.

Keep humidity low by using a dehumidifier or air conditioning. Wall-to-wall carpeting should be removed as much as possible. Instead, throw rugs may be used if they are regularly washed or dry cleaned.

Pet Allergens

There are no truly “hypoallergenic” breeds of dogs or cats. That is because people are not allergic to an animal’s hair, but to an allergen found in the saliva, dander (dead skin flakes), or urine of an animal with fur. While there are no cats and dogs that do not produce allergens, the amount of allergen exposure from pets may vary somewhat depending on the breed.

Pet allergy symptoms typically occur within minutes, with short-term exposure. With more chronic exposure symptoms may occur more chronically and not as acutely. For some people, symptoms build and become most severe 8 to 12 hours after contact with the animal. People with severe allergies can experience reactions in public places if dander has been transported on pet owner’s clothing.

If you have a pet that you are allergic to, try to minimize contact and keep the pet out of the bedroom and other rooms where you spend a great deal of time. As with dust mites, vacuum carpets often or replace carpet with a hardwood floor, tile, or linoleum. Keeping an animal outdoors is only a partial solution since homes with pets in the yard still have higher concentrations of animal allergens. If you have a cat allergy, there is a specific cat food that can decrease to some extent the amount of allergen produced by cats. You can read about that here Pro Plan LiveClear Allergen Reducing Cat Food.

While dander and saliva are the sources of cat and dog allergens, urine is the source of allergens from rabbits, hamsters, mice, and guinea pigs; so ask a non-allergic family member to clean the animal’s cage.

If you have a pet allergy, allergy immunotherapy (allergy shots) could be a great option! This strategy can often provide significant and long-term relief.

Cockroaches

Cockroaches are often found in the homes of densely populated urban areas, schools, or commercial buildings, but these creatures can lurk almost anywhere. This does not mean that you have a dirty house or living area.

Block all areas where roaches can enter the home. This includes crevices, wall cracks, and windows. Cockroaches need water to survive, so fix and seal all leaky faucets and pipes. Have an exterminator go through the house when your family and pets are gone to eliminate any remaining roaches.

Keep food in lidded containers and put pet food dishes away after your pets are done eating. Vacuum and sweep the floor after meals, and take out garbage and recyclables. Use lidded garbage containers in the kitchen. Wash dishes immediately after use and clean under stoves, refrigerators, or toasters where crumbs can accumulate. Wipe off the stove and other kitchen surfaces and cupboards regularly.

Indoor Molds

Indoor molds and mildew need dampness typically found in basements, bathrooms, or anywhere with leaks. Get rid of mold growth on hard surfaces with water, detergent and, if necessary, 5% bleach (do not mix with other cleaners). Then dry the area completely. If mold covers an area of more than 10 square feet, consider hiring an indoor environmental professional. For clothing, washing with soap and water is best. If moldy items cannot be cleaned and dried, throw them away.

Repair and seal leaking roofs or pipes. Using dehumidifiers in damp basements may be helpful, but empty the water and clean units regularly to prevent mildew from forming. All rooms, especially basements, bathrooms, and kitchens, require ventilation and cleaning to deter mold and mildew growth. Avoid carpeting on concrete or damp floors, and storing items in damp areas.

Source: aaaai.org/conditions-and-treatments/library/allergy-library/indoor-allergens


Welcome patients of Dr. Esswein to Allergy, Asthma & Food Allergy Centers!

Dear Dr. Esswein Patients,

We are delighted to welcome you to our practice! While we did not anticipate this particularly trying time, we aim to make your transition as smooth as possible. 

If you are on allergy injections, we should now have your vials. Once we have entered your vials into our electronic system and have you registered in the practice, we will call to let you know that you can come for your injections.  Please wait for this call before you come to our office, but in the meantime, please download the new patient paperwork from this page and allergy shot treatment consent and financial consent. Email the completed new patient paperwork, consent forms, copies of the front and back of your insurance card, and driver’s license to info@aascare.com. Please include in the subject line “transferring Dr. Esswein patient”. If you have not received a phone call in the next 1-2 weeks, please call us. Please also schedule a telemedicine visit at your earliest convenience in order to become further established in our practice. You will need to have that visit before we can refill medications and answer medical questions. The first telemedicine visit will be with Dr. Esswein or one of our advanced practice providers (Lauren Davis, PA-C, Laura Kahle, PA-C, or Dani Loftus FNP-BC) so we can get you established as soon as possible. You can read more about telemedicine visits here.

  • Allergy injections are administered:
    •  8:30AM – 4:30PM Mon-Thur
    •  8:30AM – 2:30PM Fri
    • You will notice we have shot hours on Tue evenings (not currently offered during the COVID-19 pandemic) and Sat mornings. We ask that you kindly avoid these times until further notice, as they are typically our busiest times with the longest wait periods. 
  • We follow the guidelines from our professional allergy societies  that all allergy injection patients will need to wait in the office for 30 minutes after their injections.
  • During this time of concern for COVID-19, we will not escalate your dose. This is to help minimize the risk of an adverse reaction, particularly as we are now in the spring season. We will also allow you an extra week “grace period” where you will not be considered late. 

If you are on a biologic for asthma or hives (ex. Xolair, Fasenra, Nucala, Cinqair, or Dupixent), please call to schedule a telemedicine visit at your earliest convenience. This will allow us to get you registered in the practice and enable us to go through the necessary prior authorization process to obtain your medications. When you are due for your injection(s), and we have verified that we have your medication, we will schedule an in person visit in the office. Please note that our policy is that you will need an office visit for each biologic injection administered in the office. New Patient paperwork is available on this page and information on telemedicine visits is available here. Email the completed new patient paperwork, consent forms, copies of the front and back of your insurance card, and driver’s license to info@aascare.com. Please include in the subject line “transferring Dr. Esswein patient”.

For all other patients, we request that you please schedule a telemedicine visit at your earliest convenience to become established in our practice. We will need to see you for the telemedicine visit in order to refill medications or answer any medical questions. This is also an excellent time to do an annual visit. We can provide updated food allergy and asthma action plans at the time of the visit if needed. New Patient paperwork is available on this page and information on telemedicine visits is available here. Email the completed new patient paperwork, consent forms, copies of the front and back of your insurance card, and driver’s license to info@aascare.com. Please include in the subject line “transferring Dr. Esswein patient”.

We recommend that you follow us on Facebook. We will be posting practice updates, particularly as we do our best to navigate the challenges posed by COVID-19. 

It is our pleasure to play a role in keeping you well. We look forward to meeting you!


Telemedicine Services Available!

Allergy, Asthma & Food Allergy Centers has been using the doxy.me platform for telemedicine visits since Thursday, March 19, 2020, and this has been working very well for patients at all of our current locations (Swansea, Illinois; Bloomsdale/Ste. Genevieve, Missouri, and south county). Telemdicine appointments can also be done for those currently scheduled to be seen in our Chesterfield (west county) location at 16216 Baxter Rd. Suite 299, Chesterfield, MO 63017. As you know, we have moved most of our patients to telemedicine visits in the interest of public safety to decrease the spread of COVID-19 in our community while continuing to provide essential medical care.

If you are scheduled for any upcoming office visits, other than for biologic medication administration, our staff will continue to contact you before your appointment to convert your appointment to a telemedicine visit. The telemedicine visits enable new and established patients to keep their originally scheduled visits to discuss medical problems, treatment plans, allergy shots, and prescription medications while following the “stay at home” rules. These visits will be increasingly important for patients and families as the spring tree pollen season ramps up. The spring pollen season gets busy, and appointments can be scarce in the greater St. Louis area, but Allergy, Asthma & Food Allergy Centers has 8 active providers who are able to see patients via telemedicine even during these troubled times. Call 314-849-8700 or 618-233-8700 to schedule your telemedicine visit to help you stay healthy during this allergy season.

Telemedicine Frequently Asked Questions:

  1. How does telemedicine work?
    1. A staff member will call you in the morning on the day of your scheduled appointment to collect insurance information and copays.
    2. You will receive a text in most cases (an email if you cannot receive texts or prefer to do the visit using a computer/laptop/tablet) with a link from doxy.me. You can watch a brief instructional video here and/or review this document.
    3. Open the link through your phone or use Chrome browser when on a computer/laptop. You will need a strong internet connection and will need to give permission for the website to use your camera and microphone.
    4. Sign in with the patient’s first and last name and click the “Check In” box, which will place you in the virtual waiting room. You can also review the telemedicine consent and test your connection while in the waiting room.
    5. Once the visit has started, your provider will be able to see you, and you will be able to see them. Your provider may not always be looking at the camera, because they will have another screen open with your medical record so they can document and review your information. Please be assured that if the provider looks away, they are not being distracted from the visit, and your medical care is their sole focus during your appointment.
  2. Do I need to download any program or application?
    1. No, because the doxy.me platform is web-based, you can access it from a browser on an internet connected device.
  3. What type of device do I need?
    1. You need an internet connected smartphone, tablet, computer, or laptop that has a camera and microphone. You will have to give the camera and microphone permission to access your web browser, which you should be able to do in the settings of your device, and we recommend you confirm this before your appointment.
  4. What else should I do to prepare for the visit?
    1. If you have a thermometer, please take your temperature before the visit to let the provider know so they can document it in your chart.
    2. Please take your pulse manually (instructions here) or with an apple watch, fitbit, or other device before the visit and let your provider know so they can document it in your chart.
    3. You can also review the telemedicine consent form here.
  5. Is the telemedicine visit secure?
    1. Yes, the doxy.me telemedicine platform is secure and HIPAA compliant. 
  6. What if I do not receive a text or an email?
    1. If it is 5 minutes past your scheduled appointment and you have not received a text or email, please call our office.
  7. Is telemedicine more expensive than an office visit?
    1. No, you will have the same copay as you would with an in person office visit, but you do not have to leave the comfort of your home.
  8. I have read that insurance companies are waiving copays for telemedicine visits, so why do I have a copay?
    1. Insurance policies vary on this. If your insurance pays for the telemedicine visit, including the cost of the copay, you will receive a refund. You should be able to determine this by the explanation of benefits (EOB) that you will eventually receive from your insurance company.
  9. What if my primary allergist is not available for a telemedicine visit?
    1. Do not worry! Our fantastic advanced practice providers, Lauren Davis, PA-C, Laura Kahle, PA-C, or Dani Loftus, FNP-BC can see you if your primary allergist is not available.

Allergy, Asthma & Food Allergy Centers Telemedicine COVID-19 update 3/20/20

Dear Allergy, Asthma & Food Allergy Centers Patients and Families,

As we informed you a couple of days ago, our professional societies released COVID-19 Pandemic Contingency Planning for Allergy and Immunology on Tuesday, March 17, 2020. We implemented the guidelines in order to continue providing essential medical care for our patients while keeping our community safe. Social distancing remains one of the centerpieces of prevention, and we are minimizing the amount of time patients may have to spend outside the home. We have updated the information regarding telemedicine visits from the blog posted on Wednesday March 18, 2020. 

  1. Anyone who is currently scheduled for a new patient office visit or a follow up office visit through April 3, 2020, will have the option of converting the in person office visit to a telemedicine visit or rescheduling the in person visit to a later date. The telemedicine platform we are using is https://doxy.me/. You do not have to sign up for an account. You will receive a link to the virtual appointment via text message or email, which you should access through your mobile phone, tablet, or a computer with a video camera and microphone.  Starting on Saturday, March 21, 2020, the telemedicine visits will be billed to your insurance carrier and appropriate copays (depending on your insurance) will be collected over the phone. We will also read you a verbal consent form, which you can review here (informed consent).
  2. If you are on biologic injections (ex. Xolair, Nucala, Fasensra), you should keep your appointment as long as you are not acutely ill with any symptoms suggestive of an infection. However, there may be issues with delivery of the biologic medications, so please confirm with our office on the morning of your appointment to make sure we have received the shipment of the medication.
  3. If you are on allergy shots and have an annual visit coming up at which time you planned on receiving your allergy shots, you can keep that in person office visit.
  4. Patients currently on allergy shots may also continue to receive their injections in our office. However, if you have been building up once weekly, you may start coming every 2 weeks for your buildup phase during this time period. If you are currently on maintenance dosing receiving injections every 2 or every 3 weeks, you may increase your interval to every 4 weeks.
  5. If you are having acute environmental allergy or asthma symptoms, please contact the office to schedule an acute telemedicine visit with one of our providers.
  6. Office based food challenges, oral immunotherapy (OIT) new starts, and OIT dose escalations will need to be rescheduled. Our staff will be contacting families regarding this, so there is no need to call our office. However, if you need more capsules, please make sure to inform the staff member who calls.
  7. If you are ill with fever, cough, and shortness of breath, have any possible COVID-19 exposures, or have traveled (domestic or international) in the past 2 weeks,  please do not come to the office. If you suspect you need testing, please check with the following screening resources:
    1. MO hotline:  877.435.8411
    2. IL hotline:  800.889.3931
    3. Mercy screening:  314.251.0500
    4. SSM Virtual screening:  www.ssmhealth.com

 

For more information regarding COVID-19, please see the CDC website: http://bit.ly/CDC-COVID-19_info 

While COVID-19 is appropriately on all of our minds, allergy season is also upon us. If you have not already started your seasonal allergy medications, you should do so ASAP. In addition, remember to follow routine environmental controls:

  • Keep doors and windows closed in your home to prevent pollen from coming inside.
  • Keep sunroofs and windows on vehicles closed and use recirculation mode for the vehicle’s air conditioner.
  • Bathe or shower and change your clothes after spending time outside during the spring pollen allergy season, because pollen can settle into your clothing and hair. This will also decrease the spread of pollen throughout the home.

We will continue to post updates on Facebook in this evolving situation. Stay safe and healthy. 


Allergy, Asthma & Food Allergy Centers COVID-19 Update 3/18/20

Dear Allergy, Asthma & Food Allergy Centers Patients and Families,

Our professional societies released COVID-19 Pandemic Contingency Planning for Allergy and Immunology on Tuesday, March 17, 2020. We are implementing these guidelines in order to continue providing essential medical care for our patients while keeping our community safe. As the virus spreads through our community, social distancing remains one of the centerpieces of prevention. Therefore, we are looking to minimize the amount of time patients may have to spend outside the home and are instituting the following:

 

  1. All food challenges and oral immunotherapy (OIT) new starts currently scheduled through April 3, 2020, will be rescheduled. Our staff will be contacting families regarding this, so there is no need to call our office at this time.
  2. All OIT dose escalations (updosing) currently scheduled through April 3, 2020, will need to be rescheduled. Our staff will be contacting families regarding this, so there is no need to call our office at this time. However, if you need more capsules, please make sure to inform the staff member who calls.
  3. Patients currently on allergy shots may continue to receive their injections. However, if you have been building up once weekly, you may start coming every 2 weeks for your buildup phase. If you are currently on maintenance dosing receiving injections every 2 or every 3 weeks, you may increase your interval to every 4 weeks. In the spirit of social distancing, if you have flexibility, please try to avoid any peak times to minimize the number of people in the waiting room. We have decreased the seating capacity in the waiting room. However, if you are uncomfortable coming into the office, you may skip injections during this period of social distancing.
  4. If you are on biologic injections (ex. Xolair, Nucala, Fasensra), you should keep your appointment as long as you are not acutely ill with any type of infection.
  5. Anyone who is currently scheduled for a new patient office visit through April 3, 2020,  will have the option of converting the in person office visit to a telemedicine visit or rescheduling the in person visit to a later date. The cost for the telemedicine visit will be $200 for the new patient appointment. We will collect payment at the time of service. Please contact your insurance company to see about reimbursement for your out of pocket costs.
  6. Anyone who is currently scheduled for a follow up visit through April 3, 2020, will also have the option of converting the in person office visit to a telemedicine visit or rescheduling the in person visit to a later date. The cost will be $50-$100 out of pocket depending on the complexity and duration of the telemedicine visit. This amount may be less than an in person office visit copay for some patients depending on their insurance.
  7. If you are having acute environmental allergy or asthma symptoms, please contact the office to schedule an acute telemedicine visit with one of our providers.
  8. If you are ill with fever, cough, and shortness of breath, have any possible COVID-19 exposures, or have traveled (domestic or international) in the past 2 weeks,  please do not come to the office. If you suspect you need testing, please check with the following screening resources:
    1. MO hotline:  877.435.8411
    2. IL hotline:  800.889.3931
    3. Mercy screening:  314.251.0500
    4. SSM Virtual screening:  www.ssmhealth.com

 

For more information regarding COVID-19, please see the CDC website: http://bit.ly/CDC-COVID-19_info 

We as a practice will continue to follow the precautionary measures recommended by the CDC and our professional societies to keep our office as safe as possible for our patients, families, and staff. Please continue to monitor our Facebook page for updates. Thank you for your understanding and continuing to partner with us to improve health outcomes. Working together in our local community and as a nation, we will overcome this crisis. Stay safe and healthy.


Singulair (montelukast) Black Box Warning

On March 4, 2020 the U.S. Food & Drug Administration (FDA) decided to add a “Boxed Warning” to the oral medication montelukast (brand name, Singulair) due to an elevated concern regarding the risk of neuropsychiatric events, including suicidal thoughts and actions. Because of this new warning, the FDA is now recommending that montelukast only be used to treat patients with allergic rhinitis and asthma that do not tolerate or do not respond to alternative medications.

Montelukast is a leukotriene receptor antagonist that has been used to treat patients with asthma, allergic rhinitis and other conditions such as chronic urticaria (hives) since the drug was approved in the U.S. in 1998. There were no major reported safety concerns with this drug until 2007, when the manufacturer of Singulair updated the prescribing information and patient information to include post-marketing adverse events such as behavior/mood changes (i.e. agitation, anxiety, depression) and suicidality (suicidal thinking and behavior). 

Data collected by the FDA between 1998 and 2019 through their Adverse Event Reporting System identified 82 cases of completed suicide in patients taking montelukast, with 19 cases in patients under age 18. Interestingly, further data from the FDA’s Sentinel System collected between 2010 and 2015 did not show an increased risk of neuropsychiatric events in approximately 450,000 asthmatics older than age 6 taking montelukast vs. inhaled corticosteroids. Other observational studies also did not find an increased risk of mental health side effects. That being said, the reports of suicide along with evidence that montelukast crosses the blood-brain barrier in animal models persuaded the FDA to strengthen their warning.

Our medical providers at Allergy, Asthma & Food Allergy Centers are dedicated to providing the best possible treatment options for our patients while also keeping their safety in mind. Although the overall prevalence of severe neuropsychiatric events including suicide appears to be extremely low given the number of patients in the U.S. taking montelukast, we understand that our patients and caregivers may be hesitant to start or continue taking this medication. If you are already taking this medication it is safe to stop immediately, if you are not comfortable continuing it. However, we strongly advise that you contact our office to schedule an appointment to discuss alternative treatment options. As with any medication, either prescription or over-the-counter, we are more than happy to discuss the risks and benefits with you. If you are not having any problems while on montelukast, it is likely safe to continue the medication.


Dr. Laura Esswein is joining our practice!

A warm welcome by Dr. Vitale & the team at Allergy, Asthma & Food Allergy Centers:

Shortly after graduating from medical school and returning to St. Louis, a family friend recommended I connect with Dr. Laura Esswein. I was not particularly familiar with the field of Allergy/Immunology at the time. I called Dr. Esswein, having never met her. She generously allowed me to shadow her in her office. She took the time to teach me about the field. Invaluably, she also shared her experiences as a working mother and “woman in medicine.” Her example and mentoring stayed with me and were pivotal in my own decision to pursue Allergy/Immunology. It is a true honor to welcome Dr. Laura Esswein to our practice!

Dr. Esswein graduated from the University of Missouri School of Medicine. She completed her residency at St. Louis Children’s and her fellowship in Allergy/Immunology at Washington University Medical Center. She joins us after an illustrious 23 years with Mercy.

In addition to establishing herself as a leading Allergist/Immunologist in St. Louis, she and her husband have raised 6 children – two of which have followed their mother’s footsteps into medicine and one is in dental school.

She will be joining us this April. She will see patients in our Sunset Hills office and new West/Chesterfield office. We have a lot to look forward to!


FDA Approves Palforzia for Treatment of Peanut Allergy

Our providers and staff at Allergy, Asthma & Food Allergy Centers are excited to learn of the FDA’s decision to approve Palforzia as the first “drug” for the treatment of peanut allergy, as this signifies greater acceptance of oral immunotherapy (OIT) as mainstream treatment for life-threatening food allergies.

Based on our 3+ years of direct experience treating peanut-allergic patients with OIT and the collective 10+ years of experience from other private practice OIT centers across the country, the safety and efficacy data of the Palforzia “drug” is comparable to our method of using readily available sources of peanut protein to perform oral desensitization. This is where the similarities end.

First, the highest treatment dose of Palforzia is 300 mg of peanut protein, about the equivalent of 1 whole peanut or 1/4 teaspoon of peanut butter. Thus, the primary goal of this drug is to raise the threshold of having an allergic reaction to an accidental ingestion of peanut protein (“bite-proof”), which in itself can be a remarkable achievement for peanut allergy sufferers. On the other hand, our protocol is designed to allow patients to reach a daily maintenance dose of 2000 mg (2 grams) of peanut protein, equal to 8 whole peanuts or 2 teaspoons of peanut butter. Furthermore, this maintenance dose actually allows them to safely ingest at least 6000 mg (6 grams) of peanut protein, equal to 24 whole peanuts or 2 tablespoons of peanut butter. This provides the majority of our patients the freedom to eat any amount of peanut protein they wish. That being said, each patient and family may have a different safety goal in mind, and our OIT protocol also provides the flexibility to achieve this goal.

Second, Palforzia is only approved for the treatment of peanut-allergic patients between the ages of 4 and 17 years. Our OIT program has no age limits. In fact, some of our most impressive outcomes have been seen in our infants with peanut allergy!

Additionally, there is no OIT “drug” close to FDA approval for the treatment of food allergies other than peanut. We currently have patients undergoing OIT for egg, milk, tree nuts, wheat, soy and sesame.

Finally, the company that makes Palforzia has set the annual price for their “drug” at $10,680 (or $890 per month) with no guarantee of health insurance coverage at this point. Our current OIT patients/families will spend on average less than $200 in total for peanut flour capsules supplied by a local compounding pharmacy. Beyond that, they are using store-bought roasted peanuts or peanut butter. Palforzia may simply not be a cost-effective option, especially for the level of protection it will provide for those with peanut allergy.

For those of you interested in learning more about all treatment options for peanut allergy, please call our office to schedule an appointment with one of our board-certified allergists. As always, Drs. Borts, Warrier and Vitale are accepting new patients in our main (Sunset Hills, MO) office. Furthermore, Dr. Palis primarily sees new patients in our Swansea, IL office, only 15 miles east of downtown St. Louis.


Peanut oral immunotherapy (OIT)- one step closer to FDA approval

Many people or families affected by peanut allergy are likely aware that on Friday, September 13, 2019, an FDA advisory panel voted 7 to 2 to recommend Aimmune’s peanut oral immunotherapy (OIT) product originally identified as AR101 (now with the brand name Palforzia). Here is a link to a New York Times article regarding this. While the vote is non-binding, the FDA usually follows their advisory panel’s recommendation. If approved, Palforzia will be indicated as a treatment to reduce the incidence and severity of allergic reactions after accidental exposure to peanut in those aged 4 to 17 years of age with a confirmed diagnosis of peanut allergy. 

The data reviewed by the panel showed a 9.1% risk of anaphylaxis with Palforzia compared to 3.5% risk for placebo with dose escalations (updosing). There was an 8.7% risk of anaphylaxis with Palforzia compared to 1.7% risk for placebo while on maintenance dosing. Epinephrine use during dose escalations was 10.4% for Palforzia compared to 4.8% for placebo, and 7.7% for Palforzia compared to 3.4% for placebo while in the maintenance phase. 

Now let’s review the projected cost for the FDA approved product. Analysts have estimated the cost for Palforzia to be $4,200 a year for an individual patient. This is the cost of the standardized peanut flour alone and does not take into account the cost for office visits. Currently, the cost for peanut allergic patients going through our customized OIT program at Allergy, Asthma & Food Allergy Centers (AAFAC) is approximately $2/capsule, which would total $730/year IF TAKING IT DAILY FOR THE ENTIRE YEAR. As our peanut OIT patients know, if things are going smoothly, after approximately 16 weeks (112 day), our patients have transitioned to actual peanuts (sometimes this transition occurs sooner) for a cost of ~$224, which is obviously much, much lower than the cost of the “drug” Palforzia. Additionally, there is no recurring annual cost since patients are consuming regular store bought peanut products for their maintenance doses.  Some other practices just starting OIT this summer (2019) in the greater St. Louis area are taking another approach. Instead of billing insurance, they offer peanut OIT on a cash basis. At Allergy, Asthma & Food Allergy Centers, the typical expense to reach a maintenance dose is less than $2500, though this depends on an individual’s insurance plan (insurance companies set the amount for office visit copays and deductibles), so the out of pocket expenses could be significantly lower. Our practice goal is to ensure as much access to OIT as we can by making it as affordable as reasonably possible for our community. We know what it is like to have food allergies in our own families- the fear, the insecurity, the near constant worry when our kids with food allergies are in an environment we cannot control- which is the main reason we pioneered OIT in the St. Louis area. We have now expanded to Illinois to give even more patients and families suffering with food allergies additional options for treatment. Our office there is located at 510 Fullerton Road, Swansea, IL 62226.

So what exactly is the “drug” Palforzia (AR101)? While the FDA classifies it as a drug, it is basically standardized peanut flour in a capsule. The standardization is necessary for clinical trials and FDA approval, but there is no evidence that using Palforzia is superior to using regular peanut flour that is commercially available for OIT (as practices across the country have been doing for more than a decade). Nevertheless, we at Allergy, Asthma & Food Allergy Centers are very excited that at least some form of OIT will soon achieve FDA approval. This is a big step in giving more people a choice when it comes to managing peanut allergy, though as mentioned above, people in the greater St. Louis region have had the option of OIT through our practice since 2016, and we currently have patients going through OIT not only for peanut but also for cow’s milk/dairy, egg, wheat, soy, sesame, and tree nuts.

Oral immunotherapy is not for the faint of heart. It takes a lot of dedication and courage from patients and their families. While there are real risks, including both anaphylaxis, eosinophilic esophagitis, and lack of tolerability due to gastrointestinal issues for some patients, some of the concerns regarding anaphylaxis with OIT have been a bit sensationalized. The risk of having a serious reaction when purposely exposed to an allergen is of course higher than when trying to just avoid the allergen, JUST AS IT IS WITH ALLERGY SHOTS for seasonal/environmental allergens. However, both with allergy shots and with OIT, treatment is administered in a controlled fashion, so individuals know exactly what triggered the reaction and how much they consumed compared to accidental exposures to a food allergy. Many people have died from accidental exposures, but there are no known deaths in the U.S. associated with OIT. In fact, when a life threatening reaction occurs with OIT, there is usually an associated underlying circumstance (illness, exercise, hot showers, etc) that led to the reaction.

Going back to the example of allergy shots, you do not hear investigators, the press, or other individuals saying that allergy shots should not be administered due to the increased risk of anaphylaxis. There are generally risks with any form of medical treatment, but the potential improvement in the quality of life for an individual and family after either allergy shots (also done at AAFAC) or OIT can be HUGE, even LIFE CHANGING, as people who have been through these treatments in our office (and other places) can readily attest. While some investigators suggest that there is no evidence of an improved quality of life with OIT, we strongly disagree and address it in a previous post https://aascare.com/food-oit-and-quality-of-life/

Food allergy and OIT have become somewhat of a sub-specialty for allergists, and not all allergy offices will be equipped or even have an interest in offering this treatment. There are reasons for this, and this blog post from OIT 101 addresses this issue.

We at Allergy, Asthma & Food Allergy Centers look forward to continuing to partner with our patients and their families to improve health outcomes for environmental allergies, asthma, and food allergies! Thank-you for your trust and dedication!