Expert: Marc Rubin, RPh Asthma Educator - 5/4/2008

Question
QUESTION: In January, I was helping my son clean a water bowl for his rabbit.  I have been around the rabbits numerous times and do know that they cause me to have itchy eyes, cough, etc.  However,this was just a bowl and no rabbit was near me.  I experienced what I thought was the beginning of an asthma episode.  I took a couple of puffs of my rescue inhaler and got no relief.  It was like three seconds and I could not move any air.  My son called a neighbor who came immediately to take me to the ER.  (We live in a rural area.) He called 911 enroute to the hospital.  Although I walked to the neighbor's car, I immediately lost consciousness.  The ambulance met us between my home and the hospital.  They performed CPR, then transported me to the local hospital where I was stabilized and then life flighted to a trauma center.  This happened on a Wednesday morning and I remember nothing until Friday a.m. when I woke up in the ICU.  Initially the medical team thought I had experienced a heart attack, but my enzymes did not indicate this.  After numerous EKGs, echocardiograms, CAT scan (or was it an MRI) of my heart, and a heart catherization, it was determined that I had takotsubo syndrome or broken heart syndrome brought on by stress.  A week ago I visited my cardiologist and my heart is indeed healing.  When I left the hospital, I had an ejection fracture of 28% and now I have one of 50%.  The cardiologist still wanted me to see and asthama specialist which I did just a couple of days ago.  She believes that I have anaphylactic asthma and wants me begin taking shots of Zoltor or Zoltair?  I am not sure what the name of the drug is exactly, but the shots are very very expensive and apparently will be required for the remainder of my life.  This is after four hours in her office.  Is this the only course of action?  Are there other things we can do to get my asthma under control?  I realize my asthma was not under control at the time of the incident in January.  Are there more tests that should be done rather than some skin testing and a sprirometry?  I return to this specialist in three weeks and would like to ask some informed questions.  Can you please help me?

ANSWER: Sorry for what you had to go through. You would be a great candidate for advertising why it is so important to keep the inflammation of asthma constantly under control.

The determinations are made, as you know, by skin testing and spirometry, but they would also be looking at your immunoglobulin levels, specifically, your IgE levels. This would be a significant factor. Also, Xolair is a product used in moderate-severe asthma that is not adequately controlled with inhalation corticosteroids, such as Flovent, Pulmicort, Advair, etc.

A significant point that you made was that your asthma was not adequately under control at the time of the incident. So, I have some questions for you: 1) Have you been through any asthma education programs to thoroughly teach you about the disease? 2) How frequently were you being followed by the specialist while you were not under good control? 3) How good are you about a)taking your medications on a regular basis and b)monitoring your status, e.g.: with s peak flow meter? 4)Has the specialist reviewed your device technique (how you use your rescue inhaler, steroid inhaler, etc.)? 5)Did the specialist create an "Action Plan" for you which describes how you should self-adjust your medications based upon peak flow/symptom presentation? These are extremely important factors to look at prior to going to Xolair. So get back to me on it as soon as you can so I can assess what may prove to be the best route for you with the options you have.

Tuesday evening and Wednesday afternoon are the best for me this week to respond. I'll be giving presentations all day and evening Thursday, so I'll be out of the loop then.

Looking forward to hearing from you.

Sincerely,

Marc

---------- FOLLOW-UP ----------

QUESTION: Thanks so much for your reply.  In answer to the questions you posed.
1.  No, I have not been through any asthma education programs to teach me about the disease. When I visited the asthma specialist, she gave me a folder of information to read, and I also watched a video in her office about things to do at home to control asthma triggers.  This is the extent of my education.
2.  I was not being followed by a specialist at all before the major episode in January.  I saw a PA or GP as needed.  I was taking Singular although I must admit, I was not taking it very regularly.  I also took Advair, but at the PA's suggestion, just took it when I knew I was going to be around a known trigger such as cats.
3.  Prior to the episode in January, I did not do a very good job of taking my medications regularly.  Since the episode in January, I am very good about taking my medications!!!  Prior to January, I did not monitor the status of my asthma with a peak flow meter.  I now do this too.
4.  Yes, the specialist did review how to use a rescue inhaler and the Advair diskus.
5.  I now have an action plan in place for asthma.  I did not in January.

Since I emailed you, I have also spoken to another doctor.  He is not an asthma specialist, but a general practitioner.  He of course does not claim to be an expert about asthma, but he thought Xolair was a fairly drastic first step to take.  He was under the impression that Xolair was for asthma that could not be controlled by some other drug(s). I do return to the specialist next week (May 1).  I have a couple of more questions I would like your opinion on before I return to her.
1.  What is IgE?
2.  Will my IgE levels determine if Xolair is needed?  Can other medications such as Singular and Advair be used instead?  Will the blood work indicate that Xolair is the best course of action?
3.  The skin testing showed that I am highly allergic to rabbits, cats, and cattle.  The specialist is thinking that the rabbit's water bowl triggered this episode of anaphylactic asthma.  I have been around the rabbits before and know that I am allergic to them.  Why was this reaction so much more severe?  I know that people who eat peanuts can experience anaphylactic shock.  However, I was under the impression that this would happen each and every time they might eat peanuts.  Therefore they avoid them at all costs.  Would I suddenly develop an anaphylactic reaction to rabbits?  Will this happen every time I encounter a rabbit?  Will an EPI pen work in emergency situations?
4.  I do plan to seek a second opinion.  Do you have any suggestions for finding another qualified asthma specialist?  

Thank you again for your reply to my previous question.  I feel as though I will be able to ask better questions of my specialist.

ANSWER: Hi Dawn,

IgE is one of the antibodies in your immune system that under normal circumstances protects your body. In allergic individuals, the levels are much higher, and the body over-responds. Very high levels are a strong indicator that you'd be a good candidate for Xolair, but your GP is correct. It is usually reserved for those who do not adequately respond to normal therapy. The fact that you were not previously well educated about your condition, and therefore, did not properly take your medication was a significant reason for your treatment failure. Also, the PA does not understand the proper use of Advair. It is not for flare-ups, but a maintenance medication for continuous use.

For a deeper education, follow this link to the patient education website of the allergy organization I belong to: http://www.aaaai.org/patients/gallery/
It is an excellent resource for patients.

In regard to you going in the direction of Xolair, it would be a balance between your following your therapy and action plan (sounds like your doing great in that regard!), and the risk of another episode of anaphylaxis. Because of the previous episode, I assume the physician also gave you a prescription that you filled for an EpiPen (a rescue injection of epinephrine). This should always be kept with you, and preferable, have a twin pack, since you don't live close to emergency medical help. Yes, it is for emergency medial situations, and read the EpiPen directions fully now, if you haven't already, so you don't have to hesitate when you need to use it. You should have the twin pack, since a single injection may not last long enough until you are under professional care. Xolair is not without risks, including anaphylactic reactions to the injection itself (it must be administered in the allergists office, and you must stay and be observed for a while to make sure that if it does happen, you'd get immediate care. But...it really works great at bringing your IgE levels to normalcy, and having a normal life, without all the other medication. You'd still carry your rescue meds, but would probably not need all the other allergy drugs. The fact that you live in a rural area, not close to an ER, would make me lean towards its use, but the final decision would be between you and the specialist.

Singulair and Advair do not have an effect on reducing IgE levels, and therefore, if the IgE is very high, which correlates with increased risk of another severe reaction, the Xolair would be a preferential approach.

In regards to your past exposure to rabbits, etc., when your immune system develops a reaction to the allergen, in this case rabbits, each exposure will generate a stronger, and much more rapid response. You didn't suddenly develop the anaphlactic reaction..it is just that each exposure increased your immune systems response until you attained the level of a very rapid and intense response.

To find specialists in your area, go to 2 web sites: 1) the American Academy of Allergy, Asthma and Immunology> http://www.aaaai.org/physref/
and 2)the American College of Allergy, Asthma and Immunology> http://www.acaai.org/LocateAllergist/

The physicians with these organizations are board certified specialists trained in this field of medicine.

Good Luck!

Sincerely,

Marc

---------- FOLLOW-UP ----------

QUESTION: I visited my specialist's office again this past week.  The specialist was out of town, so I saw an associate of hers who is a PA.  The results from the blood test for IgE were in.  My level was a 223.  The PA said this is indeed high, but since Advair and Singulair seem to be controlling my asthma, we will continue with that for now and not the Xolair.  I am also doing some trial and error tests with different allergy meds.  This may change when the doctor is back in town.  The PA also said that IgE levels can fluctuate depending on the season and allergens in the air.  I am also allergic to some grasses and trees.  What would you consider to be a "high" IgE level?  When would you consider the level of IgE high enough to indicate Xolair?  

I really do appreciate you answering my questions.  I feel like I am able to ask more informed questions at my office visits and be more informed and in charge of my asthma plan.  I visit with the specialist again in about three weeks.  Thank you!

Dawn

Answer
Hi Dawn,

The indication for Xolair evaluation is when IgE is in the range of 30 to 700 IU/ml. Specifically, and this is from the manufacturers web site:

To assess if XOLAIR is right for your patients:

Confirm that these patients are 12 years of age or older with:

   * IgE levels 30-700 IU/mL
   * Positive skin test of in vitro reactivity to a perennial aeroallergen (year-round/ airbourne)
   * Moderate-to-severe persistent asthma
   * Symptoms inadequately controlled with ICS

XOLAIR might be right for these patients, especially those:

   * Symptomatic on ICS (Inhaled Corticosteroids)
   * With nighttime symptoms
   * With IgE levels as low as 30 IU/mL, and
   * With exacerbations (severe attacks)

Needless to say, on the IgE front, you are there. While the PA may feel comfortable with this, my concern is should you have a severe attack,  you are not close to immediate assistance. Hindsight is 20/20. Since your specialist is out of town, it is a great opportunity to get a second opinion from anther specialist, especially now that you are armed with your IgE level.

I will say this, not all allergists practices like going to Xolair due to the cost and preparation. An allergist I work with specifically started her own practice for this reason. The previous groups business model was giving shots to reduce reactions to allergens. While that is a major therapeutic approach, one should ALWAYS have the PATIENTS best interest in mind, not the business model.

If a second specialist concurs that Xolair is not appropriate for your particular case, at this point, then as you have learned, it is imperative to stay compliant with your therapy, and learn all you can about asthma and your personal triggers. It is all about taking control.

Good work! Keep me posted!

Marc