The future of allergies
Allergist Tina Sindher acknowledges that allergies may be affecting more people worldwide, influenced by a combination of factors such as environmental changes, modern lifestyles, urbanization, and evolving dietary habits.
Prevention is playing catch-up, and promising new strategies include earlier food introduction than was popular only a few years ago. On the treatment front, hopes are rising for immunotherapies and a new prescription medicine, omalizumab, that addresses multiple allergens at once. While no single approach helps all, these strategies could allow millions worldwide to better manage their allergies, Sindher tells host Russ Altman on this episode of Stanford Engineering’s The Future of Everything podcast.
Transcript
[00:00:00] Russ Altman: This is Stanford Engineering's The Future of Everything, and I'm your host Russ Altman. I thought it would be good to revisit the original intent of this show. In 2017 when we started, we wanted to create a forum to dive into and discuss the motivations and the research that my colleagues do across the campus in science, technology, engineering, medicine, and other topics. Stanford University and all universities, for the most part, have a long history of doing important work that impacts the world. And it's a joy to share with you how this work is motivated by humans who are working hard to create a better future for everybody. In that spirit, I hope you will walk away from every episode with a deeper understanding of the work that's in progress here, and that you'll share it with your friends, family, neighbors, coworkers as well.
[00:00:48] Tina Sindher: What we're finding is in this warming climate, where the temperatures are rising and there's increased CO2, what we're seeing is that the pollen seasons are actually getting longer and longer. And with the high CO2 and the high temperature, the allergenicity of the pollen is stronger, so you're getting longer pollen seasons with stronger allergens that are really causing much more severe symptoms and more individuals are impacted.
[00:01:22] Russ Altman: This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. If you're enjoying the show or if it's helped you in any way, please consider sharing it with friends, family, and colleagues. Word of mouth is one of the best ways to spread news about the future of everything. Today, Tina Sindher will tell us that allergies are on the rise globally. That's bad news. But our ability to prevent, diagnose and treat them is getting better. So that's good news. It's the future of allergies. Before we get started, a reminder to tell your friends, family, and colleagues about The Future of Everything. That word-of-mouth spread is what helps the show grow.
[00:02:06] So we're all aware of allergies. In general, they come in two types. There's allergies to food. That means you have to worry about exposures to peanuts or seafood or a variety of other things. It means when you go out to dinner or to lunch or to breakfast, you have to make sure that you're not being exposed to the wrong kinds of food. And then there's allergies to the environment. Pollen, hay fever, flowers, the forest, people can have very different relationships to both food and to their environment if every time they're exposed, they get itchy eyes, trouble breathing, rashes, eczema. So allergies are a big deal, and one of the parts of that big deal is that they're on the rise. It turns out that climate change, as we will learn, is affecting the rates of allergies. On the other hand, our ability to prevent, diagnose and treat is also getting better. Tina Sindher is a professor of medicine, pediatrics, and allergy at Stanford University, and an expert especially on food allergies, but really all allergies. She's gonna tell us that it's a problem, but we're starting to find good solutions.
[00:03:16] Tina, you're an expert on allergies. Why do allergies happen and why do so many of us suffer from them?
[00:03:23] Tina Sindher: Oh my gosh. That, that is, that is a great question. It is, it is something we think about all the time. So when, my emphasis is mostly on food allergy, so I'll come at it from that angle, but really that can be extrapolated to any type of allergy. So essentially what happens is that our immune system, when we get exposed to allergens for the first time, our antigen presenting cells take up that antigen, or let's say peanut, and it breaks it up into little proteins and exposes our Naive T cells to those proteins or epitopes. And in an environment where there's already a predisposition to allergy, we call this an atopic milieu or a Th2-skewed system that, uh, exposure to the allergen causes our, um, our B cell antibodies to produce allergen specific, um, IgE antibodies, uh, which are, uh, bound on our mast cells and basophils. So the next time your body recognizes the protein, let's say the child is eating peanut for the first time, or uh, you know, it's the third or fourth time, those allergen specific IgE antibodies recognize the peanut and cause the mast cells and basophils to degranulate, which release the histamine, the leukotrienes, all that inflammatory cells that are associated with an allergic response. And that's what you end up seeing.
[00:04:57] Russ Altman: Okay, so let me go back because, um, you, you had a lot. There, but one of the things you just said is it you, you have that first exposure to the peanut and you said it, it depends a little bit about the environment. And when you say environment, do you mean the bigger environment that the individual is living in and their previous kind of life exposures? Or do you mean their internal biology environment and like how they're genetically made up and, and what, how, which of those two are both are, are important factors?
[00:05:25] Tina Sindher: It is actually both. So that is in one of our studies, it's called the SUNBEAM Study, where we are enrolling pregnant moms and then watching the, um, the growth of the child until three years of age. That is one of the things we're trying to understand. Is it just the immune environment inside, and when is that environment changing, as well as the external environment, what is their diet like? Is there a pet in the home? What kind of medications or exposures have they had? What genetic factors are involved? Are there, we have testing for parents, both father and mother, to get a sense of what is their, um, you know, what are their risk factors or genetic features that play a role in it. So, it really is a combination of all of the above, which makes it such a complicated disease to study.
[00:06:18] Russ Altman: Yes. So, so I, but from what you just said, it sounds to me that one of the initial conclusions is that allergies can like, kind of run in the family. It can, it can be genetic. And so, if grandma and mom or dad, if they have allergies, it might not be a completely done deal, but it might improve, uh, increase the chances that you have an allergy. Is, is that correct?
[00:06:38] Tina Sindher: That's absolutely right. And the first degree relative that is allergic increases the risk of the child. For instance, when we're evaluating young children in our clinic to suss out, are they allergic, are they not? What kind of, you know, intervention plans should we undertake? One of the first things we ask is, do you have an older, or we ask the parent, do they have another child who is also food allergic? Is the parent food allergic? 'Cause all of those things kind of play into your decision plan for the individual in front of you.
[00:07:09] Russ Altman: Yes. And, and when, when there is a genetic connection, do they tend to have the same allergies? So like I have suffered in the past, and I think, I think I talked about it on this show, from a shrimp, crab, lobster allergy. Um, does it mean that my children or my siblings might have that same allergy? Or does it just raise the chances that they have some allergy of some kind?
[00:07:31] Tina Sindher: So, it is the latter. It is that it raises their risk for having a form of allergy. And this, I know we, we say allergy for food allergy, but really it could be asthma, eczema, um, and food allergy, environmental allergies as well as a condition we see a lot, um, it's eosinophilic esophagitis where it's almost like eczema in your esophagus. So, all of those fall into this allergic phenotype. And having one or more of any of those, um, conditions can increase your risk for food allergy.
[00:08:05] Russ Altman: Great. And then the other thing I would have to ask you about is there was, there has been a theory, and, and I don't know if it's still the one that drives the field that, um, part of the problem was that we were keeping our children too clean, that we were worried about, like, don't, don't let them, um, you know, don't let them hug the cat. Don't let them walk on the dirty floor. Make sure they eat, uh, everything, including things that are not really food, but like sand and dirt. Is that still part of the equation?
[00:08:34] Tina Sindher: That, yes, absolutely. As we learn more and we're learning about our environment, we're understanding that microbiome plays a huge role in effective functioning of our immune system. Um, so as my mentor Kari Nadeau, um, used to say, um, really food allergy or allergy prevention were the six D's. So, you gotta focus on, uh, dry skin, diet, playing out in the dirt, having exposure to dogs or pets that kind of bring in allergies from the outside, Vitamin D exposure, so being out in the sun. And then minimizing detergent use, which can also, um, cause barrier, uh, function on your skin, dysfunction on your skin.
[00:09:17] Russ Altman: Well, that will be our future of, our future of everything quiz will be, can you recall Tina's, and then Kari's, six D's. Um, now I know that you've also written and thought about climate change, which is a little bit surprising, but does climate change actually, uh, factor into this equation?
[00:09:34] Tina Sindher: Yes. So actually, you know, we were talking about, before we started this recording, you were talking about your allergy to flowers and pollen allergy. And what we're finding is in this warming climate where the temperatures are rising and there's increased CO2, what we're seeing is that the pollen seasons are actually getting longer and longer. And, and with the high CO2 and the high temperature, the allergenicity of the pollen is stronger. So, you're getting longer pollen seasons with stronger allergens that are impacting, you know, that are really causing much more severe symptoms and more individuals are impacted.
[00:10:17] Russ Altman: I, I must say climate change comes up all the time and it's, it's rare, it's rarely good news. And even for allergies, it's, it's taking its toll. Um, that, thinking about the global, and, you know, as climate change is a global phenomenon, um, are allergies a global phenomenon? Are, are do different cultures have different allergies or do you, or do you see the kind of same types of things across the board?
[00:10:39] Tina Sindher: Yes. You know, it really is a global phenomenon. We did, our team did a review a few years ago. We were trying to find data from really every continent, um, and we did find that across the globe, ER visits related to, um, food allergic reactions or anaphylaxis were rising up. More and more individuals are being impacted. Um, in Australia where they've actually followed, um, entire cohorts in categorizing food allergy, it has been rising despite, um, some early intervention strategies. Um, so it really is a global phenomenon. And in terms of what allergen we see, it really is much more area dependent for, generally the same allergens pop up everywhere, meaning the peanuts, the tree nuts, shellfish, um, but kind of the distribution of each of the allergens there is some variability. For instance, um, we see a lot of peanut and hazelnut, but in Italy, hazelnut is much more prevalent than peanut, even though both of them are, um, high up there. And it really kind of ties into the processing of the foods, how the child is exposed, and how much of that allergen they have in their environment.
[00:11:56] Russ Altman: So, let me, let me just ask about this, you, you mentioned these two allergies, uh, the, the nut allergies and the, uh, seafood allergies. Do we have any idea what it is about those two types of food? Um, I know that you can see allergies of, of anything across the board, but those ones just pop up so much. Do we understand what it is?
[00:12:14] Tina Sindher: You know, that we, and even within those allergens, we see that some of the nuts are more potent, as in they trigger reactions at a much lower dose.
[00:12:25] Russ Altman: Yeah. I saw you had a, a paper on the difference between cashew and peanut. And I thought that was amazing. Like, wow, she's really splitting hairs here, but I, I guess it matters.
[00:12:35] Tina Sindher: It does matter. And you know, it, i, this is anecdotal, but in our outpatient clinic and research clinic, and in research, we are blinded, so we don't always know what they're getting. But if it's a severe reaction and they keep having symptoms, we're like, oh, I bet that was a cashew challenge. And then when we're unblind, more often than not we are correct. And in our outpatient clinic where we do a lot of food challenges and oral immunotherapy, the second our team hears cashew, they're on higher alert than usual, um, just because we, between, among the allergens, we do see some variation in how patients are reacting and at what, um, dose they're reacting.
[00:13:18] Russ Altman: That's that, that's just amazing. And I was so surprised to see the cashews, uh, come up 'cause I hadn't been aware of a cashew allergy. Of course, um, I have been treated for allergies, and it was me and a bunch of little kids who had peanut allergies and a lot of fun stories there, which I, I won't go into. But basically, they were very impressed at how much I could breathe because of course I was three times their size. Even though I'm not such a great breather, compared to a 7-year-old, I have a good, uh, lung capacity. And so, we were all be getting very competitive about our ability to blow into the machine.
[00:13:49] Um, I did want to ask about an, a thing that just recently gotten on my radar and I know that you're a food specialist, but I suspect that you're aware of this syndrome called Beta gal which, uh, has started to pop up and, uh, I have a relative actually who has it, and I know it's very debilitating. Um, it manifests as, um, and this doesn't really capture the whole thing, but as basically like a meat allergy. And I'm wondering if you can just tell me about that and what is known. It seems to have just popped up recently, but maybe that's wrong.
[00:14:19] Tina Sindher: No, no, you are right. Alpha Gal, um, syndrome,
[00:14:22] Russ Altman: Alpha Gal, I'm sorry, not Beta gal.
[00:14:24] Tina Sindher: No, no. It's almost, um, it starts off, I, I will preface this with saying we don't see a lot of Alpha gal in our area and being pediatrics focused, I, I haven't, um, done a lot of work or research in that area. In fact, I don't even really test for it unless I have a really strong suspicion. But certain areas, and we have collaborators who are working on this, um, in, in Arkansas, um, and where it's, it's a tick borne, um, condition that you basically start, you get sensitized, um, to this protein, and then it cross reacts with different meats. And then, when you eat the meat, you, and this can pop up out of the blue, similar to your shrimp or your shellfish allergy where you, you are totally fine and then all of a sudden you start having symptoms. And you have anaphylaxis. It happens quickly, and it's just hard to diagnose because it can cross-react among different meats. And, um, and it, it, there are some studies going on right now that are led by the NIH. It's an area of special interest for the NIH where they are trying to further categorize this condition. It's hard to test for, it's, um, just very unusual and you are right, it is popping up more and more.
[00:15:47] Russ Altman: Yeah, so the family member that I, that, that I'm thinking of, um, lives in Kansas. Uh, and um, is thirty something, you know, a young mom and all of a sudden, uh, the anaphylaxis and they kind of narrowed it down that whenever, and, uh, an exquisite sensitivity. So, we had a family, uh, gathering, um, and she had to stay outside, and she had to ask that none of the meat, even the, um, smell of the meat on the barbecue, she said could have triggered her symptoms. So, it was very disabling and it's having a big effect. And we're gonna, obviously, we're gonna be talking about treatments because that's, you know, you, you're an allergist MD and your whole, your whole, um, thing is to, to try to treat these folks. But I know that that's been a very big challenge for them. So, so, uh, before we go to treatment, I did want to ask about, um, multiple allergies. Um, so, um, sometimes you have a single person, like, um, my main problem was shrimp and seafood. Uh, but other people have kind of across the board, and I know you've written a lot about multi-food allergies. Um, is this the same deal or do you think these people, uh, who suffer from this have special features that makes it kind of different from the, the people who have single allergies?
[00:17:02] Tina Sindher: Yes. You know that, so the majority of patients, maybe not majority, but a lot of the patients we are seeing in our research unit who are coming in for severe, uh, treatment or uh, treatment of their severe allergies tend to be multi-allergic. In the literature, up to forty-five percent of food allergic individuals have multi-food allergies. One of the things we are trying to better understand, there's so much unknown about food allergy, is the phenotypic differences between those that are just mono-allergic versus multi-food allergic. And at this time, it's, we, we are not seeing, uh, obvious differences between these individuals. Also, we're trying to better understand, you know, children who outgrow their food allergies, right? What is different about them and their immune response versus the kids who don't outgrow their food allergies. Um, so all of these are areas of better research. At this time, from the clinical perspective, when a patient's in front of you, the reason whether it's one food or multiple food comes into play is you shared decision making on how best to treat it. Um, because if it's multiple foods, it might change your decision making on how to treat it versus just a single food.
[00:18:19] Russ Altman: This is The Future of Everything. And I'm Russ Altman. We'll have more with Tina Sindher next. Welcome back to The Future of Everything. I'm Russ Altman and I'm speaking with Tina Sindher from Stanford University. In the last segment, we learned a lot about allergies, the rates are going up, the difference between food allergies and environmental allergies, and the different ways that we can start to understand how allergies form and what we can do to stop them. In this segment, we're gonna specifically focus on prevention, diagnosis, and treatment, of course. There's some new drugs that are very exciting.
[00:19:02] I want to talk about prevention. We don't, I don't think about prevention of allergies 'cause usually it's kind of a surprise and like the game's over, we already have it. But I know that you've been doing work on prevention. What could be the strategy for preventing allergies?
[00:19:16] Tina Sindher: Yes. So, one of the ways, uh, that we are thinking that we can prevent food allergy is early introduction of food and a diversity of food introduction. And this all came about, um, around 2015. So ahead of that time, the American Academy of Pediatrics would recommend that you delay introduction of allergenic food. So peanut, tree nuts, uh, till beyond one year of age. In fact, fish and shellfish were at three years of age. So, it really was pushing out the introduction. And then the LEAP trial was published, um, out of UK where they found that children who were sensitized to peanut, so testing was positive, if they introduced peanut into their diet, um, they were less likely to develop peanut allergy down the line.
[00:20:03] And so there were two groups. Ones who avoided peanut and ones who didn't. And the children who avoided peanut were five times more likely to develop peanut allergy later in life. So, with that study, and then subsequent other studies showing similar uh, findings, the AAP reversed its guidance in 2017 and started recommending early introduction of peanut, and now that has really been expanded across the globe. Different societies and academic, um, uh, committees have put out guidance on early introduction. Um, there is still a lot of, I won't say controversy is the right word, um, but it's hard to get consensus of which allergens, how often, how early. So, there are some continued discussions on the exact timing.
[00:20:54] Russ Altman: Oh, so it's possible that some things, some things might be best early, some things you might wanna wait, and so people are trying to sort that all out and there's a lot of different foods. So that's a lot of different decisions.
[00:21:04] Tina Sindher: Right. Because a lot of times you give a baby a little bite and it's hard to keep it in their diet 'cause they might develop taste for something else. So, so there is a lot of research ongoing in that front. Um, and it really is a global effort trying to find the right balance. Um, so that's one strategy. Another strategy is through the skin. Um, so early, other studies have found. That when you have dry skin or eczema at a very young age, so maybe from the time you're born before two months of age, if you have moderate to severe eczema, you are at a much higher risk of developing food allergy.
[00:21:41] Russ Altman: Oh, interesting.
[00:21:41] Tina Sindher: And so, studies have shown that if you treat that eczema early, it can, it may reduce your risk of food allergy. So, one of our studies, um, it's called the SEAL trial, um, it's different than the SUNBEAM trial.
[00:21:56] Russ Altman: You have very beautifully named trials, I must say.
[00:22:00] Tina Sindher: Um, we are enrolling babies less than two months of age who have dry skin and eczema, and there were one group is getting standard of care, no treatment. The other group is getting aggressive, moisturization along with, um, steroid treatment for their skin. And then we're following to see who develops food allergy and who doesn't, to see if really aggressively treating the skin will lead to a lower, um, incidence of food allergy. And the reason the, the two of these play a role is there's a hypothesis out there called the dual allergen exposure hypothesis, and essentially what folks are thinking is that you are getting sensitized when the allergen is entering in, interacting with your immune system through the skin. And usually, the skin provides a beautiful barrier, but in the setting of dry skin and eczema, that barrier doesn't work as well. So, the allergens are entering, they're interacting with your immune system in a way, in an aberrant way, triggering that. Um, you know, in the beginning I talked about this allergic milieu and Th2-skewed immune system. So, it's kind of driving that skewed immune system and causing you to develop the allergen specific um, antibody. So, the first time you eat peanut, you are already sensitized because you got it through the skin.
[00:23:24] Russ Altman: Wow. That's, that's exciting. That's exciting. And who would think that the, the skin of a two-month-old, which of course we always talk about a baby's bottom and a baby's skin. But they're not always perfectly intact. And that, uh, barrier is very important early on.
[00:23:38] Tina Sindher: That's right.
[00:23:39] Russ Altman: So, well, well, that leads us very naturally into, um, from prevention to diagnosis. Now, um, I, as, as I've intimated, I, I have suffered from allergies and, um, I think twice in my life I've been laying, you know, belly down on a table where they gave me like sixty different pin pricks with, with had sixty different little samples. Um, I know for one of them, uh, fifty-eight out of sixty were positive. Um, and, but is that the state of the art or have we been able to get a little bit better at making these diagnoses?
[00:24:10] Tina Sindher: Oh, you know, I am sad to stay that we still doing that method, that's skin prick testing and essentially whatever we suspect you're allergic to, we take that extract and we prick your skin essentially to, um, get your mast cells activated. So, if you have allergen specific antibodies on those mast cells, they react and cause a wheel that looks like a mosquito bite. Um, we have ways of measuring that, uh, specific antibodies, uh, through IgE testing, but both of these have a fifty-percent false positive rate. So they are, they are not, they're not great diagnostic features. If they're negative, we feel confident. If they're positive without a clinical history, let's say, it's a baby who's never eaten the foods before, we don't know how to interpret it. Um, so the gold standard of treatment is actually food challenges, where we bring you into clinic and feed you the food you're allergic to, to see at what level you develop, um, a reaction to.
[00:25:13] Russ Altman: Wow. Yes. And so, and, and that cannot be, that can be not fun depending on how the reaction goes. And, um, of course, I'm sure people come in very nervous because they've had bad experiences. Um, uh, so just to make sure I understand, when you are doing these pinpricks, this is literally ground up stuff. Like this is not high-tech bio-engineered molecules. This is, I took some peanuts, I mashed them up into be, you know, like a powder and maybe put 'em in some water or oil, and that's what you're injecting. And it's, and it's uh, uh, is there a standard, so there must be standards that people, that somebody makes?
[00:25:48] Tina Sindher: Um, there is, we do use, uh, a step above that. We do use standardized product through, um, a company where it follows strict guidance through the FDA. So, we are getting very, um, well characterized extracts so we know exactly how much protein is in there. Um, it is reconstituted in, um, you know, liquid formulation. So that it is, standardized across the board, but when folks bring it, folks come in with allergies to uncommon things that you don't have extracts to, you, what you describe is exactly what we do. We call it a fresh prick to prick testing, and we have them bring in the food, we crush it up, add in some glycerin, and then we, um,
[00:26:35] Russ Altman: I kind of love it. It's kind of like old fashioned medicine, like what they did. And, but, but let me ask you, you talk about the gold standard was an oral challenge, but some people have allergies, like hay fever, like, uh, to pollens. You're not having them eat the, is there a gold standard for them? Um, 'cause you can do the pin prick, but if you're not sure what is the equivalent of having them swallow some or do you have them swallow pollen?
[00:26:57] Tina Sindher: No. No. So, in research trials, um, we actually do something called a nasal allergen test, where we insert small incremental doses of the allergen through the nose. It is not pleasant for anyone, in our clinical practice, we don't do that. We do the, we focus on symptoms. Um, and then with the testing, it helps us guide how to prepare the immunotherapy regimen that we come up with.
[00:27:28] Russ Altman: Great. Great. And then, and, and I didn't wanna leave of course, because there's been a revolution in treatment. So, I wanna give you some time to tell me, uh, and us, uh, about, uh, what are the, uh, frontiers of, uh, new treatments and what is kind of coming down the pike that you're excited about.
[00:27:45] Tina Sindher: Oh, yes. Um, it actually has been a very exciting time and when it comes to treatment of food allergies. Um, so prior to 2020, the standard of care was avoidance. If you come into clinic, we diagnose you we're like, okay, you have food allergy, and just don't eat it. Good luck. Here's some Epi in case you have reaction. But really, we had no, um, approved treatment option. So, the first medication that was approved is peanut oral immunotherapy, where you take incremental doses of peanut, um, and it desensitizes you, so that over time if you come across a bite of a cookie, you're not having severe anaphylaxis and ending up in the emergency room. Um,
[00:28:27] Russ Altman: I think it's worth pausing here. This idea of desensitization, so they have a peanut allergy, but if you give them tiny amounts, and then like increase it, you can maybe avoid these big reactions and get them to kind of tolerate the peanuts. It's kind of a, kind of good news. Uh, and does it always work? And can you get that initial dose small enough so that it doesn't set off a big reaction?
[00:28:50] Tina Sindher: That is right. We start at a very low dose. So, to put into perspective, let's say, one peanut is approximately three hundred milligrams of protein. We start at three milligrams of protein, so one hundredth. And in our outpatient clinic, if someone were to react at that dose, I just go down even lower. So, you can titrate it to a lower dose where you don't induce severe reactions at that early.
[00:29:15] Russ Altman: Okay. I'm sorry I interrupted, but that's the desensitization.
[00:29:17] Tina Sindher: Oh no, I always tell families to think, I don't know if you're, um, if you watch the Princess Bride, but it's, it's the poison, you know, the poison in the cups where he's desensitized himself to the poison, which is exactly how,
[00:29:31] Russ Altman: Iocane powder.
[00:29:32] Tina Sindher: Yeah. So that's exactly oral immunotherapy. So, and, and the downside is that you have to dose every day, and if you stop dosing for a few weeks or a few months, you may go right back up to your prior sensitized state. And as children, it's, I don't, I don't know if it's ever easy, but when they're little, parents can really be a part of this. But as they get older, pre-teens, teens in college, it is very hard to accomplish. And then, um, children and adults come across dosing fatigue when you're having to eat the same food every day. And we're just talking about peanut, but for the multi-allergic kids, that's so many foods that they're having to eat every day. So, it's not easy. Kids have reactions, they can still have allergic reactions. Um, so we have, we, um, need better ways. And that's where the next drug, um, which actually just got approved for food allergy in 2024, Omalizumab, And this,
[00:30:35] Russ Altman: That's a mouthful.
[00:30:36] Tina Sindher: That's, that's a mouthful. Um, and Omalizumab is an IgE blocker, so it's an injection. Um, and you receive it every two weeks or every month depending your, on your total IgE level and your weight. And it, it binds to IgE and takes it out of circulation.
[00:30:54] Russ Altman: And IgE is the molecule that recognizes the thing that you're allergic to. So, no IgE, no reaction.
[00:31:01] Tina Sindher: That's right. That's right. So, it takes it outta circulation. So, kids and adults are able to ingest that food in small amounts. There is a threshold level. It's not like you can eat the food as if you're non-food allergic. Um, but they just have, don't have reactions at a level they would previously have reactions to.
[00:31:20] Russ Altman: Do they have to keep taking that medication or is it a one time or two time thing?
[00:31:25] Tina Sindher: So, what we found, and that is really what's been an issue in the food allergy therapy, is that your immune system is, is very robust and the second you take away whatever the treatment is, your body goes right back to being allergic. Um, so it, it'll take six months to a year for the full effects of the Xolair to leave your body. Um, and at that point you may revert back to your allergic state.
[00:31:50] Russ Altman: Does having the IgE wiped out by the mouthful, also known as Xolair, but that's the, uh, brand name. And we like to keep things generic. But is it possible that you could then desensitize somebody in the old-fashioned way and then, um, with regular exposure to the food, they might not need more of the, of the, uh, Xolair.
[00:32:09] Tina Sindher: That's exactly right. We, so we, and these were studies led by Kari Nadeau in the very beginning and then followed up on by Dr. Sharon Chinthrajah, um, where we actually did, through the NIH and the Consortium of Food Allergy Research, a multi-site study where it was Xolair plus oral immunotherapy, and then the Xolair is taken away and the, the food introduction continues, to really do what you, what you suggested. The Xolair takes the IgE out of circulation. You get up on all the foods that you're starting to eat in a safe way, and you keep going on that. So, you continue the desensitization, um, with lower risk levels, without having to take an injectable for a long period of time.
[00:32:54] Russ Altman: Great. So, I have two questions, uh, as we come up to the end of our time, but the first question is, um, can you get, get, can you calibrate me for how exciting Xolair is for somebody who's suffering from allergies? Should, should they think like, okay, this could really solve my allergies. Or is it, or, or should we temper their expectations and say, this will help, but it might not be the full answer. So where are we in terms of the excitement about this new drug?
[00:33:20] Tina Sindher: Oh, so I, you know, what I tell my patients and my families is that we have yet to come across a one drug that fits all and every, and there are differences in individuals. So, I hesitate to say, this will solve all your problems. Um, but I have seen really good results. For instance, um, I've had, you know, preteen teenagers who've been very successful with OIT. However, when Xolair came about, they, they started Xolair. And what's great is that he goes to camp without having to worry about dosing, or travel. And he, you know, told me how he went to an ice cream shop with his friend, which in the past, he would never have done. So outside of, you know, eating the food, it really improves quality of life and just the psychological burden of having a food allergy. So, and it actually can help because it's, it takes all IgE out of circulation, it can help a, you know, not just one allergen, but multi allergens.
[00:34:19] Russ Altman: Right. And we were talking about the multi-food allergies. Great.
[00:34:22] Tina Sindher: So, this particular child, also avid baseball player, had severe grass allergies. After Xolair, his symptoms went away for that as well, so, it works really well for some.
[00:34:33] Russ Altman: Good. So that's a great, that's a great calibration, that it can be almost like a miracle, but it's not guaranteed. And we have to try and we'll, and we'll do our best. The final question I have is just for those people who are not suffering so much from food allergies, but from environmental pollen, uh, I know that you've written about things that they can do at home, simple task, and we always love to finish our episodes with kind of take home, good knowledge for people. So, what would you recommend for somebody who is struggling with, um, seasonal allergies about, um, things that they can do at home to kind of help manage those allergies?
[00:35:07] Tina Sindher: Oh, yes, absolutely. I, I think step one for all of this is just knowledge. Knowledge is power. So, if you're able to really pinpoint which seasons you have the most symptoms, what has worked, what has not worked, and if you're able to get allergy tested so you know what your panel, you know, what you're allergic to. Because one of the things you can do is kind of track pollen reports. It's very easy to access through apps, you know, weather, um, apps. And if you know what you're allergic to, you can track it and right before it spikes, you can start your allergy medicines. So, you're kind of, you hit the ground running. If you have a lot of, um, outdoor allergens, you know, during that season, keeping your windows closed as best as you can. Um, if you know you are cat or dog allergic, if you're going to visit someone, maybe making sure you're, you know, medicated and well kind of ready to enter the home. What I tell our pediatric patients is if you've been outside all day and you're grass allergic, come home, rinse off, take off your clothes.
[00:36:11] Russ Altman: Right. Because we learned about the importance of skin earlier.
[00:36:13] Tina Sindher: That's right. So, get it, get it off of you, because the longer exposure will trigger symptoms and keeping your bedroom as clear of these allergens as possible.
[00:36:23] Russ Altman: Do the air, uh, so there's been a lot of marketing for air purifiers. Uh, what's your sense of their utility in this situation?
[00:36:31] Tina Sindher: The air purifiers actually, especially now with more and more, um, wildfire related pollution, we do think kind of monitoring their air quality in your home is, it has, we do think has, is beneficial. Um, and then keeping a filter really in your bedroom where you spend a lot of time, um, can help reduce symptoms. I will say all of these are risk mitigation. They're not gonna take away your symptoms altogether. Um, so after someone has tried all this, I would say if these are not working, we can do more for you. Please, please go see your allergist.
[00:37:08] Russ Altman: Thanks to Tina Sindher. That was the future of allergies. Thank you for listening to The Future of Everything. Don't forget, we have nearly 300 episodes in our back catalog, and they're all available for you to binge listen on the future of almost anything. Please remember to rate and review. We love to get a 5.0 if we deserve it, and we love your comments. Think about rating and reviewing in whatever app you're listening to right now. In addition, you can connect with me on many social media. I'm on LinkedIn, Threads, Mastodon and Bluesky @RBAltman or @RussBAltman. You can also follow Stanford School of Engineering @StanfordSchoolOfEngineering, or more simply @StanfordENG.
