Latest / Voices of Otolaryngology / Earlier Intervention, Better Options: The Changing Landscape of Pediatric Allergy

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Earlier Intervention, Better Options: The Changing Landscape of Pediatric Allergy · Voices of Otolaryngology

• 0:01
  Welcome to the Voices of Otolaryngology.
• 0:03
  I'm your host, Rahul Shah, CEO of the American Academy of Otolaryngology
• 0:08
  Head and Neck Surgery.
• 0:10
  Each episode I bring people from our specialty together
• 0:13
  to talk about the work, the questions and the ideas that move us forward.
• 0:17
  Let's get into it.
• 0:21
  Welcome to the Voices of Otolaryngology.
• 0:23
  I'm super excited.
• 0:24
  Today we have two international experts helping us
• 0:28
  think about what's cutting edge in pediatric allergy.
• 0:32
  I'm going to let my colleagues introduce themselves.
• 0:34
  And thank you, Doctor Marzouk.
• 0:36
  How about we start with you? Sure.
• 0:38
  My name is Haidy Marzouk.
• 0:40
  I practice in Syracuse, New York, under Trinity Health at Saint Joseph Medical Group
• 0:45
  I am also voluntary faculty at Suny Upstate Medical Center,
• 0:49
  and I am also secretary of the American Academy of Otolaryngologic
• 0:53
  Allergy and part of the Allergy Immunology Committee for the Academy.
• 0:57
  Fantastic.
• 0:58
  Thank you, Doctor Christine Francis.
• 1:01
  Hi, I am Christine Franzese, I am a professor and the Director
• 1:05
  of Allergy at the University of Missouri Medical Center in Columbia.
• 1:10
  I'm also one of the members at large academic
• 1:15
  on the board of directors for the American Academy of Otolaryngology
• 1:18
  Head/Neck surgery, as well as the outgoing chair
• 1:21
  of the Asthma, Allergy and Immunology Committee.
• 1:26
  Well, thank you both very much.
• 1:28
  I am in the DMV area, District/Maryland/Virginia,
• 1:31
  and they have pretty bad allergies.
• 1:33
  So I have a little bit of a red eye and a little bit of cough.
• 1:36
  Maybe y'all can help me.
• 1:37
  Thank you and congratulations on your accomplishments.
• 1:40
  Awesome to have two leaders of national societies.
• 1:42
  What an honor.
• 1:44
  We're going to talk about four things today if we can.
• 1:47
  And our members have asked for this.
• 1:49
  And you both are experts on this: subcutaneous
• 1:52
  versus slit, What's cutting edge for children?
• 1:55
  Needle-less anaphylaxis.
• 1:57
  I can't believe that.
• 1:58
  That's super cool.
• 1:59
  Food allergy and then EOE.
• 2:02
  Does that sound great? Perfect. All right.
• 2:05
  My job is to drive, interrupt and keep it interactive.
• 2:08
  Let's start with subcutaneous slit.
• 2:10
  What's cutting edge for children? All that. You both duke it out.
• 2:12
  Who will go first? But what's what's on the horizon?
• 2:15
  And maybe if you could start with the primer for those maybe
• 2:18
  residents or students that sometimes aren't up to speed - or myself.
• 2:22
  So as we know, allergies in kids is epidemiologically on the rise.
• 2:27
  This includes both you know, pollen sensitization
• 2:30
  for rhinitis as well as asthma and things of that nature.
• 2:34
  So atopy is a big issue in children.
• 2:37
  But needles scare kids.
• 2:39
  And for a long time sublingual
• 2:43
  aqueous drops or what have you were used off label.
• 2:46
  And then we got approval for the sublingual tablets
• 2:50
  right of the approval for grass, weeds and dust.
• 2:56
  But they were approved, you know, first in adults.
• 2:59
  And slowly but surely we've been dropping the education, sorry, in the indication.
• 3:04
  And now we have
• 3:06
  sublingual tablets
• 3:08
  FDA approved down to age five, which I think
• 3:12
  is going to be a game changer for kids with atopy,
• 3:16
  especially with concurrent asthma and what have you, that we can start
• 3:20
  desensitizing them younger and younger with a needle free technique
• 3:26
  And so we know
• 3:27
  and we have data in the literature that if you start desensitizing children
• 3:32
  younger, their propensity towards additional sensitization drops.
• 3:37
  So hitting that atopy early in life I think is really important.
• 3:42
  And the fact that we have sublingual tablets approved down to age five
• 3:45
  I think is going to be wonderful for them.
• 3:48
  Doctor Marzouk, back up a second.
• 3:50
  You said something about getting on this earlier is important for atopy.
• 3:55
  Can you explain that for our audience?
• 3:56
  And then we'll go to Doctor Franzese to add to it.
• 3:59
  Sure.
• 4:00
  So if we take, you know, even in infancy,
• 4:03
  right, early at birth, sensitization can happen, right?
• 4:07
  Your TH2, TH1 balance can be altered or shifted.
• 4:12
  And so more literatures coming out
• 4:15
  about things like skin barrier, things like your microbiome
• 4:20
  and things like, you know, early exposure to allergens.
• 4:25
  So all of these things have been at play in the medical research
• 4:29
  regarding how to influence your atopic cascade,
• 4:34
  or we call it the atopic march in children
• 4:38
  and those early influences in life.
• 4:41
  And so all of those have been hot
• 4:45
  in the research with regards to pediatric allergy.
• 4:48
  And so we have a body of literature with regards
• 4:51
  to desensitization, specifically showing that if you desensitize early,
• 4:57
  your propensity to become allergic to more things actually drops. Yes.
• 5:02
  And so for our for preventing further allergies,
• 5:08
  I mean, one of the big things that children with asthma
• 5:13
  or tendencies toward asthma tend to be sensitized to is dust mites.
• 5:17
  And the fact that now we have this dust mite tablet that you can take at home
• 5:22
  is really kind of a game changer for them,
• 5:25
  because with therapy, you can reduce that
• 5:30
  potential toward sensitization in the development of severe asthma.
• 5:33
  So that is a huge thing.
• 5:35
  The other thing is there are some data with the dust mite tablets in particular.
• 5:39
  So one of the thoughts is okay well we have patients.
• 5:43
  Our population tends to be multi sensitized.
• 5:46
  We tend to not be allergic to just one thing.
• 5:48
  And there's data with the dust mite tablets that
• 5:51
  although really just has major dust mite allergen in them.
• 5:55
  They do seem to be somewhat protective against symptoms
• 5:59
  for our tree pollens and our grass pollens.
• 6:01
  So you can help your patients reassure them, saying, you know,
• 6:04
  if you're going to take this tablet, you may also benefit
• 6:07
  if you have tree pollen allergies or grass allergy symptoms as well.
• 6:11
  And for if you've never used them, if you're a little reluctant
• 6:15
  to start, you do have to initiate them.
• 6:18
  You know, for the first time in the office,
• 6:20
  observe them, you know, during 30 minutes to make sure they do okay.
• 6:24
  But then all of the other tablets the patients can take at home.
• 6:27
  And if you've never had one, if you're not sure,
• 6:29
  like I've actually taken the dust mite
• 6:31
  tablets, they dissolve under your tongue in a few seconds.
• 6:35
  There's no taste you can reach because kids can be very fussy.
• 6:38
  You no taste can be a big thing, texture, but literally dissolve in a few seconds.
• 6:43
  And that's it.
• 6:44
  You've got your therapy instead of a shot.
• 6:47
  Yeah, I think it's helpful.
• 6:49
  I don't know if you agree, Doctor Franzese?
• 6:51
  Sometimes they're in that first visit,
• 6:52
  coaching them through some of the itching they'll have under the tongue,
• 6:56
  reassuring them that that's normal, especially for the parents and the kids.
• 7:00
  I think that first session for education does help, that, you know, that
• 7:05
  30 minutes, the nurse can do a lot in terms of teaching.
• 7:09
  Oh I agree.
• 7:10
  Oh, please, one more comment on this then I'm going to move this
• 7:12
  to needle-less anaphylaxis.
• 7:14
  Doctor Franzese, you want to close this?
• 7:16
  I agree. Coaching is very important.
• 7:18
  You want them to wash their hands before and after.
• 7:20
  Kids are not always great about that.
• 7:22
  And then people expect like if you get a shot there's going to be redness.
• 7:25
  Swelling. Oh yeah it means the shot is working.
• 7:27
  Same sort of thing.
• 7:28
  Like there's going to be some of these side effects.
• 7:31
  They usually go away within the first month.
• 7:33
  But reassurance and coaching is very important with your nursing staff.
• 7:37
  You all are awesome.
• 7:38
  I wish
• 7:39
  I mean I'm going to get your cell phones and call you when I'm in the office.
• 7:42
  I'm so mad at myself.
• 7:43
  As a pediatric otolaryngologist in an academic center, what have I missed?
• 7:48
  Like, you know,
• 7:48
  it seems like there's kids out there that we really could be helping.
• 7:51
  And you mentioned Game Changer.
• 7:53
  So thank you all for that.
• 7:55
  Let's talk about needle-less anaphylaxis.
• 7:58
  Doctor Franzese, do you want to start about what's exciting?
• 8:00
  Then we'll go to Doctor Marzouk.
• 8:01
  We'll just keep flipping back and forth.
• 8:04
  Yeah.
• 8:04
  So the exciting thing is reducing the barriers to epinephrine.
• 8:08
  I mean, you'll see this in the E.R.
• 8:11
  patients where there's a lot of fear either
• 8:14
  injecting or what I'll frequently here is, is my anaphylaxis bad enough
• 8:19
  that I need to use my injectable epinephrine?
• 8:23
  Like the goal really is early exposure to epinephrine, the earlier the better.
• 8:29
  And so with now the advent of a needle-less intranasal
• 8:33
  spray like this is amazing.
• 8:35
  So it's one spray.
• 8:37
  It comes in an injector.
• 8:38
  And and the thing to educate your patients are is the demos no longer
• 8:42
  come with either the intranasal or the injectable.
• 8:45
  So it's really important to get in touch with the manufacturer.
• 8:48
  The reps will bring some demo kits to the office, but
• 8:51
  there is a little resistance with this particular one.
• 8:55
  So you want the child to feel it.
• 8:58
  So they get an idea of how hard it is to push,
• 9:01
  which it isn't that hard, but it requires some pressure and it's a single squirt.
• 9:05
  They don't have to sniff, and it'll come in a two pack.
• 9:09
  If you have to use a second spray the manufacturer recommends.
• 9:13
  And this has been followed up with data pharmacokinetics
• 9:17
  that this this second spray should be in the same nostril.
• 9:21
  But there you have early treatment without a needle of anaphylaxis,
• 9:26
  and the data is good for it - including some of the real world data
• 9:29
  that's coming out.
• 9:30
  Doctor Marzouk, can I ask some clarifying questions?
• 9:34
  Sure.
• 9:34
  Because I'm getting excited.
• 9:35
  So really important.
• 9:38
  The second one needs to be on the same side.
• 9:40
  I always say the other side,
• 9:42
  but I would have done the other because you just vaso constricted.
• 9:45
  I don't want to confuse anybody.
• 9:46
  But you said the pharmacokinetics show that. Yep.
• 9:49
  Then that's what the manufacturer recommends.
• 9:51
  And this is reaffirmed by they just did a study
• 9:55
  with people with severe allergic rhinitis because the concern was
• 9:58
  what if my nose is super congested and I can't get the medicine in there?
• 10:04
  Even people with severe allergic rhinitis
• 10:07
  responded, particularly the first and the second spray.
• 10:11
  But in that study, they reaffirmed
• 10:13
  that if you sprayed the second spray in the same nostril,
• 10:18
  your pharmacokinetics were even better than an injectable epinephrine.
• 10:21
  But if you did it on the other side, it also worked.
• 10:25
  It just wasn't quite as good.
• 10:26
  So they recommend the same side. Amazing, amazing.
• 10:29
  So I don't want to confuse people with my ignorance.
• 10:31
  Second spray, same side?
• 10:35
  Yes, if needed. If needed. If needed. Yes.
• 10:38
  And then you said something.
• 10:40
  Then I want to give it to Doctor Marzouk.
• 10:41
  You said with epinephrine we are learning the earlier the better.
• 10:45
  Yes, yes.
• 10:46
  What did you mean by that?
• 10:47
  Either of you? That's absolutely fascinating. Go ahead.
• 10:50
  And when we look at root cause analysis of complications
• 10:54
  or deaths related to anaphylaxis, we find that one of the biggest things
• 11:00
  that could be done differently is early administration of epinephrine.
• 11:05
  And we know that especially adolescence, right.
• 11:08
  A lot of people are infamous for not carrying their EpiPen,
• 11:12
  whether it be because of needles
• 11:14
  or because of the bulk size of your traditional EpiPen,
• 11:18
  you know, so having a needle free and it's a very small device.
• 11:23
  You know how this big, okay,
• 11:26
  needle free, small option that you can carry in your little wristlet
• 11:31
  or in your pocket is really helpful for our pediatric population.
• 11:37
  We've also done studies about why epinephrine might be delayed,
• 11:41
  and there's a lot of needle or technique phobia, so to speak.
• 11:47
  You know, you hear these stories about teachers injecting the wrong way
• 11:51
  and they get a vascularization to their finger or, you know,
• 11:55
  parents afraid to to, you know, give an injection to their child.
• 11:59
  So these sorts of options really will hopefully diminish
• 12:04
  some of the apprehension towards early epinephrine administration.
• 12:08
  How long has it been out?
• 12:10
  So approval for the higher dose two milligram came out in August of 2024.
• 12:16
  That's the greater than 30kg weight.
• 12:18
  And then in March of 2025, they approved the one milligram dose for children
• 12:24
  greater than or equal to four and between 15 and 30 kilos.
• 12:29
  So again above 30 kilos.
• 12:31
  The regular dose two milligrams 15 to 30 kilos
• 12:35
  and greater than or equal to four years old the one milligram dose.
• 12:39
  Doctor Franzese, anything to add on that?
• 12:41
  Because I'm going to ask you then in your practice, what are you seeing?
• 12:45
  How much, how many parents say I want the spray versus I want the needle.
• 12:50
  What are you out there and what are you writing for?
• 12:53
  Oh, yeah, I'm I'm writing for both.
• 12:56
  Mainly because particularly
• 12:59
  during the first year, until they use it and see how they respond,
• 13:03
  I make
• 13:04
  sure they have a backup because that is what's recommended with an injectable.
• 13:08
  But but all pretty much not just kids, but adults are very interested in this
• 13:13
  because it seems more accessible, more approachable,
• 13:16
  and there's a lot less fear with it.
• 13:20
  Like, oh, this is easy.
• 13:21
  If my kid is alone, they can do this.
• 13:24
  It's so much easier to carry.
• 13:26
  So I have actually been writing it. We have.
• 13:29
  We actually have it in our clinic for use when we are allergy testing.
• 13:32
  If we have anaphylaxis, we have actually used it in our clinic
• 13:36
  and been successful to treat anaphylaxis.
• 13:40
  Yeah.
• 13:40
  Doctor Marzouk, your colleague, Doctor Franzese, mentioned
• 13:44
  that you have to get used to how much pressure to put.
• 13:48
  Could you describe that?
• 13:49
  I'm worried that a four year old,
• 13:51
  I mean a four year old should never be alone,
• 13:52
  but maybe 5 or 6 year old can can do it or a seven year old.
• 13:56
  Is it that hard or you just need to get used to it?
• 13:58
  It is not.
• 13:59
  But what I will say with when you do
• 14:02
  it, there's like almost like a little pop that you hear
• 14:05
  once you've deployed the medication or it's actually got deployed.
• 14:09
  So you just want to hear that,
• 14:11
  you know, you want to make sure that they put enough pressure
• 14:14
  so that they hear that little snap or pop, and that means the meds got in.
• 14:19
  So that's kind of the the little bit of the learning curve.
• 14:22
  This is such a game changer.
• 14:24
  Shouldn't it be everywhere.
• 14:25
  So you see “break this glass box for an electronic
• 14:30
  defibrillator.” I'm not kidding.
• 14:31
  Like why is it not on airplanes.
• 14:33
  Why is it not in stadiums? Seriously?
• 14:35
  Do you envision a world where it's just sitting there?
• 14:38
  Nobody should have any kind of peanut allergy or restaurant allergy.
• 14:41
  Am I being
• 14:44
  just too blue ocean?
• 14:45
  No. I think that's really important.
• 14:48
  And in fact, there was a recent update for food allergy treatment in schools,
• 14:52
  and there was a study, like a survey done,
• 14:55
  that over 30% of epinephrine
• 14:59
  like epinephrine uses when children had unexpected anaphylaxis,
• 15:03
  like even kids with no known food allergies over 30% of the time.
• 15:07
  And unassigned auto injector was used like either
• 15:11
  someone left theirs behind or they had a donation.
• 15:14
  And how critical that was that schools had access
• 15:18
  to this unassigned injector to use in an emergency.
• 15:22
  So I think it should be everywhere.
• 15:24
  How should our colleagues, how do you how do you prescribe it?
• 15:28
  Let's let's actually get brass tacks.
• 15:30
  You said. Well, Doctor Marzouk, why don't you answer it?
• 15:33
  You give two prescriptions.
• 15:34
  Explain what y'all just said about the injectable as well as the nasal.
• 15:39
  So again, just like Doctor Franzese mentioned,
• 15:41
  it comes in a two pack, just like your regular EpiPen.
• 15:45
  You have the pediatric version and kind of the adult dose version, right.
• 15:48
  The 1 million.
• 15:49
  So you're going to write it exactly the same.
• 15:51
  You know, one spray.
• 15:53
  If second spray needed 5 to 10 minutes later
• 15:56
  you're going to put it in the same nostril okay.
• 15:59
  And then, you know, the nuance of the backup auto injectable.
• 16:03
  You know, you have to put a little bit more of a, you know, additional like line
• 16:07
  there should, you know, anaphylactic symptoms persist despite
• 16:11
  two doses of intranasal epinephrine administer I.M.
• 16:16
  you know, times one, etc..
• 16:19
  Thank you.
• 16:19
  This is awesome.
• 16:20
  It's like my own little instructional course at the Academy.
• 16:22
  Amazing is a plug for an annual meeting in LA.
• 16:25
  Doctor Franzese, there's some exciting stuff in food allergy.
• 16:29
  You want to talk about that?
• 16:31
  Then Doctor Marzouk is going to end with EOE.
• 16:33
  But talk to you about what's what's
• 16:35
  what's a good breakthrough in kids for food allergies.
• 16:37
  So so we're exciting is like
• 16:40
  the fact that now we have some treatment options.
• 16:43
  Now granted they don't, you know, cure, but the fact that we're reducing
• 16:48
  the severity, the potential severity of anaphylaxis
• 16:52
  when you have an accidental exposure is really important.
• 16:55
  So we we've got
• 16:56
  Omalizumab, which is very exciting because it's for any food allergy.
• 17:00
  And it's really helpful for our pediatric patients
• 17:03
  that tend to be multi food allergic.
• 17:06
  So the fact that you can treat your patients with Omalizumab
• 17:10
  and they may have like several different allergies is very reassuring.
• 17:15
  I also have a number of patients who are either starting school
• 17:19
  or really one of the big areas I've seen is kids going to college
• 17:23
  that have peanut allergy, where there is a lot of fear
• 17:26
  because now they're going to be in a dining hall and it's kind of
• 17:30
  it's like the Wild West, you know, mad Max Road Warrior
• 17:34
  just there's a lot of fear of exposure and there's this.
• 17:37
  So relief of anxiety by starting this to help protect against,
• 17:43
  you know, severe allergic reaction or anaphylaxis.
• 17:47
  And then there is
• 17:49
  Palforzia, which is available for the treatment of peanut
• 17:52
  allergy between the ages of one and 17
• 17:56
  that is available if you are peanut allergic.
• 17:59
  And it's a essentially peanut powder
• 18:02
  that you mix with a vehicle like yogurt or applesauce, whatever the patient likes.
• 18:06
  And it does the same thing.
• 18:08
  The goal is to reduce the risk of having severe allergic reactions.
• 18:12
  If you have accidental exposure to peanuts,
• 18:15
  which is and there's a lot of things on the horizon,
• 18:18
  if you look at ClinicalTrials.gov, there's research on a peanut tablet.
• 18:23
  There are some monoclonal antibodies that are being studied for this.
• 18:27
  There are some JAK tyrosine kinase inhibitors that are being studied.
• 18:31
  So there's a lot of things on the horizon for food allergy.
• 18:36
  This is like mind blowing.
• 18:38
  When I had my immunology class in med school,
• 18:41
  it was literally like 17 pages typed out.
• 18:45
  I mean, there was no textbook.
• 18:46
  It's it's so yeah, it's amazing.
• 18:48
  Doctor Marzouk, anything to add?
• 18:50
  And are these given daily or are they given as needed?
• 18:53
  Can you talk a little bit about that Doctor Marzouk or Doctor Franzese.
• 18:56
  Doctor Marzouk yeah.
• 18:58
  So in terms of Omalizumab, that is a
• 19:02
  I believe it's a 2-4 week injection for food allergy.
• 19:06
  It's the same, Doctor Franzese?
• 19:09
  It can be 2 or 4 weeks.
• 19:10
  So it's it's weight based and IGE based.
• 19:13
  But the vast majority of the time particularly for kids it's
• 19:16
  going to be four weeks because of the weight.
• 19:19
  But that's it.
• 19:19
  It's a four week course. Or do you do it every.
• 19:22
  Oh no. You continue it.
• 19:24
  You continue it like every 2 to 4 weeks, depending on their dose.
• 19:28
  And the first three are generally done in the office.
• 19:33
  And then after that, if their insurance allows them,
• 19:37
  they're able to actually do it at home.
• 19:39
  Correct. Got it. Understood.
• 19:41
  With the peanut tablets or powders, those are daily.
• 19:47
  Yes. Those are daily.
• 19:48
  And you do the you'll start the initiation in the office
• 19:51
  like also very similar to a food challenge.
• 19:53
  And then generally up
• 19:55
  dosing is roughly every two weeks depending on how the patient's doing.
• 19:59
  But in between those up dosing the patient will be taking this daily at home.
• 20:04
  What are you seeing an uptake?
• 20:06
  Parents asking for it?
• 20:08
  Well how much are you prescribing this?
• 20:10
  I know that's a very tough question, but are a lot of your families
• 20:13
  asking for it or give us some context of of how much
• 20:16
  you all are using this in your practices or what you're seeing across the country.
• 20:21
  So I, I by far and away
• 20:23
  have a lot more Omalizumab patients than Palforzia patients.
• 20:28
  And mainly it's because you don't have to do it every day,
• 20:32
  but also the fact that it can protect against multiple multiple foods,
• 20:37
  because that does seem to be a trend that's becoming more common.
• 20:41
  It's it is an injection.
• 20:44
  So that's like the downside of it.
• 20:47
  But the side effect profile is really good.
• 20:49
  It's safe.
• 20:50
  Omalizumab has been out for over 25 years and has a published pregnancy registry.
• 20:55
  So that's also reassuring.
• 20:57
  And then again, like I usually the biggest ask for
• 21:02
  this are kids starting school or daycare or college
• 21:08
  because that can be really anxiety reducing.
• 21:14
  Doctor Marzouk, any comments in your practice
• 21:16
  or in New York, what you see in that in that area with uptake?
• 21:21
  Yeah.
• 21:21
  So I agree that monoclonal antibodies in general, because are becoming
• 21:27
  a little bit favored again because of the poly sensitization.
• 21:31
  And the other thing is when we talk about atopic
• 21:34
  kids, it's usually not just food allergy, right.
• 21:38
  They have eczema, they have asthma, they have rhinitis.
• 21:42
  And so a lot of times when we talk about kind of the pathophysiology,
• 21:47
  when a lot of these monoclonal antibodies are treating
• 21:51
  atopy a little bit more broadly.
• 21:54
  And so when parents kind of know that there's multiple indications
• 21:59
  that it might help with sometimes they try to, you know, they start to favor
• 22:04
  the monoclonal antibodies. And the fact that you're
• 22:07
  not giving the child something that they are allergic to.
• 22:11
  You know, when we talk about or when you talk about it, you know,
• 22:14
  you're just augmenting their atopic pathway a little bit.
• 22:17
  I think psychologically for the parents, that comforts them a little bit.
• 22:22
  It's really well said.
• 22:24
  This is, again, it's life changing.
• 22:26
  Somebody in college or in a preschool setting
• 22:29
  or elementary school that has a peanut allergy, it's a complete game changer.
• 22:34
  I mean, that's just blowing my mind.
• 22:36
  Is that right? Is that how you approach it?
• 22:38
  And keep in mind that when you do the peanut tablets or powders, you're
• 22:43
  not that kids are not going to be able to eat a Reese's Peanut Butter Cup.
• 22:46
  It's really.
• 22:47
  Protective.
• 22:48
  Of minor small amount exposure.
• 22:52
  It doesn't mean that they can consume peanut regularly.
• 22:55
  So that's another thing to keep in mind.
• 22:56
  Also, when you're counseling parents is that it's really
• 23:00
  to help mitigate accidental small amount exposure.
• 23:05
  It's not to really, truly desensitize them
• 23:08
  that they can eat peanut butter and things of that nature regularly.
• 23:12
  Dr. Marzouk:
• 23:13
  Eosinophilic esophagitis.
• 23:15
  There's some good stuff going on there. Great.
• 23:16
  Great breakthroughs. Could you talk about it?
• 23:18
  And then we'll have our colleague weigh in? Sure.
• 23:21
  So just like monoclonal antibodies are becoming popular for multi sensitized
• 23:26
  food allergy, we do have Dupilumab, a monoclonal antibody.
• 23:31
  Right IL-4, IL-13 monoclonal antibody approved for Eosinophilic Esophagitis.
• 23:37
  So when we think of
• 23:39
  Dupilumab in ENT, we think of nasal polyps or chronic sinusitis type two endo type.
• 23:43
  But actually Dupilumab is approved
• 23:47
  down to six months old for atopic dermatitis.
• 23:50
  And it's approved down to one year old for Eosinophilic Esophagitis.
• 23:55
  So for children who have failed, you know, acid suppression therapy,
• 23:59
  elimination, diet, things like that, Dupilumab is an option.
• 24:04
  It's a subcutaneous injection every two weeks.
• 24:07
  And again, we talk about that kind of broad atopy.
• 24:11
  Right?
• 24:12
  Dupilumab has so many atopic indications.
• 24:14
  Many of these children have multiple atopic diagnoses.
• 24:19
  And so having something available again early to kind of augment
• 24:24
  their atopic pathways is really helpful.
• 24:28
  And there's been a lot of nice data showing remission from Eosinophilic Esophagitis
• 24:33
  for kids on Dupilumab.
• 24:37
  Doctor Franzese?
• 24:38
  Yeah, I would agree.
• 24:39
  This has been really a game changer, particularly for children,
• 24:43
  because this can be a progressive disorder.
• 24:46
  If it presents in childhood, you're generally going to see it
• 24:49
  vomiting and it's frequently
• 24:51
  it will get a lot of food allergy referrals because it's confused
• 24:55
  and you think, oh, this vomiting, this nausea, the stomach pain is coming
• 24:59
  from food allergy, but we can't figure out what food they're allergic to.
• 25:03
  This is.
• 25:05
  And so we'll get like a lot of random elimination diets or
• 25:09
  or there is a food component.
• 25:10
  And kids have to avoid a lot of stuff.
• 25:12
  And so with treatment we see, you know, a lot of that reverse and,
• 25:17
  you know, into adulthood,
• 25:18
  it goes from this inflammatory stage to a more fibrotic stage.
• 25:22
  So you get scarring of the esophagus, you get stenosis, strictures,
• 25:26
  dysmotility disorders.
• 25:28
  And if you can prevent that, that's that is kind of amazing.
• 25:31
  So that's the goal here.
• 25:33
  I do use this in my practice there.
• 25:37
  I do use it a little bit off label with a dosing schedule sometimes.
• 25:40
  But I've had it really open up
• 25:43
  kids diets and see instead of where they were like failing to thrive
• 25:47
  and they were struggling to grow, like just completely change their life.
• 25:51
  How is it prescribed?
• 25:53
  Is it what's the modality?
• 25:55
  Is it a pill?
• 25:56
  How often is it a shot?
• 25:57
  It's it's it's an injection.
• 26:00
  It comes in an auto injector and a syringe.
• 26:02
  It is on label.
• 26:04
  Every week, however, I will disclose that off label.
• 26:07
  I will frequently use it every other week with great success.
• 26:11
  And some of my patients, strangely, even the children
• 26:18
  prefer the syringe rather than the auto injector.
• 26:23
  Interesting.
• 26:24
  How long has it been out
• 26:27
  for this indication, folks?
• 26:28
  For EOE.
• 26:30
  I'm going to say the last few years.
• 26:32
  And I hold you to it.
• 26:34
  You don't have to give me a date.
• 26:36
  Doctor Marzouk.
• 26:37
  Don't worry, Doctor Franzese, you don't have to give me a date a couple of years.
• 26:40
  Yeah, I think that least 2 or 3 years that's
• 26:42
  been out for Eosinophilic Esophagitis, I think initially
• 26:46
  it was approved for, like, you know, adolescence.
• 26:50
  And now more recently, they've dropped the indication down to one year old.
• 26:54
  To Doctor Franzese's point, the higher like weekly dosing
• 26:59
  has been shown to have a little bit better efficacy than every other week dosing.
• 27:03
  And so, you know, people have been
• 27:06
  kind of modifying the the frequency as well.
• 27:09
  I love that you're seeing a decrease in complications.
• 27:14
  Yeah. Can you talk about it.
• 27:16
  I actually didn't make that connection.
• 27:18
  The strictures etc.. Either of you please.
• 27:21
  Yeah. It's a huge quality of life issue.
• 27:24
  People with Eosinophilic Esophagitis,
• 27:27
  you know, to see a kid in college is supposed to feel they're invincible.
• 27:30
  Having food impaction and going to the E.R..
• 27:33
  It's really unfortunate.
• 27:34
  You see children who have, like, not even just elimination diet.
• 27:39
  They start to have food aversion because they have so many symptoms.
• 27:42
  And so it becomes a huge issue.
• 27:45
  And so being able to kind of help them kind of lead a normal life
• 27:50
  and a normal quality of life and preventing these long term, you know,
• 27:54
  scarring and having to go for esophageal dilations,
• 27:58
  all of these things - it is really wonderful to to be able to help them.
• 28:02
  And like I said, these kids often have multiple atopic conditions.
• 28:06
  And so, you know,
• 28:08
  sometimes you get a little tricky in the office where you see a kid who's,
• 28:12
  you know, not quite 12 or 18
• 28:15
  and you see they're just horrible rhinitis,
• 28:18
  not true polyps, you know, they're asthmatic but not as magic enough.
• 28:23
  And I'm like, do you have any rashes, you know, or you know, do you have.
• 28:27
  So a lot of times these monoclonal antibodies really come in
• 28:30
  handy for broad use.
• 28:32
  And so for kids that can be approved
• 28:36
  down to age one for Eosinophilic Esophagitis, I really do
• 28:39
  think it's going to help them in multiple ways for their quality of life.
• 28:45
  Doctor Franzese, anything to add to that?
• 28:47
  Yeah. So it's it's been a game changer.
• 28:49
  I've I've seen it.
• 28:51
  I had a patient, one of my first ones who was limited to essentially four foods.
• 28:55
  He was super skinny kid.
• 28:57
  And his goal in starting it was on his birthday.
• 29:01
  He wanted to be able to eat pizza and cake because he could not eat them
• 29:04
  without vomiting.
• 29:05
  And at the end of the year, for his birthday,
• 29:07
  he got to celebrate it with pizza and cake.
• 29:10
  And I do want to make sure people understand that this is
• 29:13
  an incredibly safe medication, but it does potentially have some side effects.
• 29:17
  So you want to watch for not just injection site reactions,
• 29:20
  but there's conjunctivitis or eye inflammation.
• 29:23
  You'll honestly see that more with atopic dermatitis.
• 29:26
  And then joint issues.
• 29:28
  There can be new onset arthralgia.
• 29:30
  They're uncommon.
• 29:31
  But I've the youngest person that I have had
• 29:34
  have that arthralgia was 18 months old.
• 29:36
  So you do want to watch for it. It can happen.
• 29:38
  And then new onset psoriasis, even in patients
• 29:41
  that have no family history or personal history of psoriasis,
• 29:45
  again, very uncommon, but things you want to watch for.
• 29:49
  Wow. Awesome.
• 29:50
  A couple more questions.
• 29:52
  This is amazing. I've learned so much.
• 29:54
  What's on the horizon?
• 29:56
  What do you all
• 29:57
  see out there in the next couple of years that might be experimental?
• 30:01
  That might be an early trials.
• 30:03
  Anything we should get super excited about?
• 30:04
  These are tremendous breakthroughs for pediatrics.
• 30:07
  But anything why don't we have Doctor Marzouk first and Doctor Franzese?
• 30:11
  So, you know, I think a lot of the research
• 30:15
  going on is going to have to do with barrier function,
• 30:19
  whether it be through skin or through intestinal barrier function.
• 30:24
  I think we're learning more and more about atopic
• 30:29
  kind of programing, I would say, during infancy.
• 30:33
  And so I think that we're going to get a lot more knowledge in terms
• 30:38
  of how you're setting up kind of your life in terms of your atopic pathway
• 30:42
  through barrier function research and things
• 30:46
  on microbiome and intestinal barrier research to kind of
• 30:50
  because what we know is that there is an influence.
• 30:53
  But the earlier in life you get that different kind of tweaking.
• 30:57
  It kind of sets you up, you know, your protoplasm.
• 31:00
  And so I think some of the literature that's going to come out
• 31:03
  in the next few years on the horizon for that is going to be very interesting.
• 31:09
  Yeah, I would I would piggyback on that
• 31:11
  because that's going to be very important, particularly with EOE.
• 31:14
  This is a new disease. It did not exist in the past.
• 31:17
  There have been a study that went back and looked
• 31:19
  at esophageal biopsies from the 80s to now,
• 31:22
  and it wasn't that this was missed or not recognized, it just wasn't there.
• 31:26
  And then I think monoclonal antibodies are also going to be.
• 31:30
  So currently
• 31:33
  Lilly has a study on going for perennial allergic rhinitis.
• 31:36
  Like all all perennial allergens currently in phase three trials.
• 31:42
  There's also an upcoming study with Regeneron and Sanofi
• 31:47
  for a birch and cat allergy.
• 31:49
  They're looking at it for allergic rhinitis,
• 31:52
  but also allergic conjunctivitis.
• 31:54
  And of course, like the most exciting is going to be our Crispr technology.
• 31:59
  The potential to that's again in its infancy.
• 32:03
  It's early on but really exciting.
• 32:06
  You know, novel technologies that we like harness.
• 32:11
  I'm so embarrassed.
• 32:12
  I mean, I'm board certified.
• 32:13
  I take my M.O.C., but I do the general tract.
• 32:16
  Maybe I need to do something else or I need to take some allergy refreshers.
• 32:21
  So you both said, and I promise we'll end soon.
• 32:24
  EOE is new.
• 32:26
  It wasn't that it was missed.
• 32:28
  So can one of you go a little bit deeper on that?
• 32:31
  When did the incident start increasing and what do we think
• 32:34
  are some causative factors?
• 32:35
  I know that's a lot, but it's very important.
• 32:39
  It first started to be recognized around the 2000
• 32:42
  wouldn't you say, Doctor Marzouk?
• 32:45
  Yeah, that's what we began to go ahead.
• 32:47
  So I would say kind of like during my training,
• 32:51
  it started to be a new thing
• 32:52
  and we're starting to say, oh, we got to look for the Eosinophils.
• 32:55
  And so I would say right around the early 2000s and in 2000,
• 33:00
  we started to get really revved up about it and start to look for it.
• 33:04
  And why why we weren't missing them in
• 33:08
  the 1980s is just now we have the Eosinophils.
• 33:11
  And what what do they postulate is they cause it
• 33:13
  a factor that it started 26 years ago?
• 33:16
  So there's a lot of hypotheticals why this is happening.
• 33:22
  Some of it has been like microplastics.
• 33:25
  Some of the thoughts have been the ultra processing of food.
• 33:27
  Some of it has been, it seems like in the 1950s and 60s,
• 33:32
  when there were changes in the additives
• 33:35
  to different bleaches and detergents
• 33:38
  and what was allowed to be in cleaning products, that seemed to be
• 33:42
  where there was a big uptick in atopic disorders in general.
• 33:46
  So there's some of the thoughts that perhaps it is some of these forever
• 33:49
  chemicals in the water, some of the things
• 33:51
  in these additive detergents, but we really don't know
• 33:55
  right now other than there seems to be a genetic predisposition.
• 33:58
  But it's more than that. Yeah.
• 34:01
  So if you look at the graphs, right, it's not a flat line.
• 34:04
  It's not even a linear line.
• 34:06
  It's an exponential curve with the amount of atopy in children over time.
• 34:11
  And so, you know, people throw around hygiene hypothesis food additives.
• 34:16
  There's a lot of theoretical.
• 34:17
  It's probably some of all of that if if we had to guess.
• 34:22
  Wow. Before I conclude any conflicts of interest
• 34:26
  or disclosures, we can always access it online at the Academy.
• 34:30
  But if you just want to rattle them off,
• 34:31
  I think it's fair.
• 34:32
  But Doctor Franzese then Doctor Marzouk...
• 34:32
  I have conflicts. Yeah.
• 34:33
  I have conflicts
• 34:34
  with with Sanofi, Regeneron, Novartis,
• 34:37
  GSK, AstraZeneca and then Eli Lilly.
• 34:43
  That's those are my main ones.
• 34:47
  And your thoughts today were all your own.
• 34:49
  Yes, they're on my own and I use these in my practice.
• 34:53
  Thank you for that. I appreciate Doctor Marzouk.
• 34:55
  Yeah, I'm on the advisory board for Sanofi Regeneron, the makers of
• 35:01
  Dupilumab.
• 35:01
  And I'll ask you the same question.
• 35:02
  There were all your thoughts and all what you do in your practice.
• 35:05
  Yes. Great, great.
• 35:07
  Why don't I each have you give a concluding thought
• 35:09
  and I just end with gratitude. This was awesome.
• 35:11
  It won a little bit longer.
• 35:12
  So thank you all for carving out time from your practices.
• 35:16
  Any concluding thoughts?
• 35:17
  Doctor Franzese, we’ll have you go first and Doctor Marzouk, you'll bring us home?
• 35:21
  Yeah. I'd strongly encourage my colleagues.
• 35:23
  If you're not in allergy to
• 35:24
  get an allergy, there's a lot of good you can do for patients.
• 35:28
  If you're not sure about immunotherapy,
• 35:30
  using the sublingual tablets is a great way to dip your toe in the water.
• 35:34
  And then it's the gateway drug to the rest of allergies.
• 35:38
  But it's one of the ways you can make a huge difference in people's lives.
• 35:42
  And and the monoclonal antibodies seem
• 35:44
  very intimidating, particularly the prior auth process.
• 35:48
  But you can always reach out to us because they again,
• 35:52
  they can open up a lot of doors for your patients
• 35:55
  and be a great additive for your practice.
• 35:59
  Yeah.
• 36:00
  I'm sitting here saying, why have I not done this for some of my patients?
• 36:03
  So Doctor Franzese, riff on that a second.
• 36:06
  I'm intimidated. How do I get into allergy?
• 36:09
  Are there courses that I could learn from or talks?
• 36:14
  I mean, it is intimidating and you know, you all are just throwing these words out
• 36:18
  eloquently.
• 36:19
  I couldn't even use them in a sentence barrier.
• 36:22
  Monoclonal all that.
• 36:23
  Doctor Franzese, where can a member go to learn and expand our horizons?
• 36:27
  Then Doctor Marzouk will give you the mic to bring us home.
• 36:31
  I feel like I have to disclose this conflict because I
• 36:34
  give a course at the annual meeting called Adding Allergy to Your Practice.
• 36:39
  And that's okay. That's right. Yeah.
• 36:42
  So and then there's always the AAOA, they have courses as well.
• 36:48
  So the Academy has resources.
• 36:52
  Other organizations have resources.
• 36:54
  But reach out to also your fellow members.
• 36:56
  I think getting yourself education first before you start.
• 37:00
  And then you can always observe a practice.
• 37:02
  I will frequently have my colleagues come.
• 37:06
  I've had them come from other states to go through.
• 37:09
  See what your allergy nurses are doing.
• 37:11
  How does your flow work? How are you billing?
• 37:14
  What are you doing?
• 37:15
  Do you do spirometry?
• 37:17
  So going and observing
• 37:19
  and active successful practice can be incredibly helpful too.
• 37:23
  Yeah. Thank you for that.
• 37:24
  Perfect segue Doctor Marzouk with the AAOA.
• 37:27
  We believe that we all work together.
• 37:29
  So if you want to talk about
• 37:30
  maybe some of their offerings and then give us some final words.
• 37:34
  Yeah.
• 37:34
  So in the AAOA, we have kind of almost every level of education from resident
• 37:40
  training all the way to advanced practice providers,
• 37:45
  as well as people who are very well established in practice.
• 37:49
  Along with partnering with the Academy, we discuss the billing, the workflow,
• 37:54
  the efficiency, the prior auth processes, as well as the clinical
• 37:59
  basic science and really, you know, cheat sheet,
• 38:03
  almost a way of kind of getting into allergy early
• 38:06
  because to be honest, you know, when we're early in career, you know,
• 38:10
  you want to be a good surgeon, you want to be busy and practice.
• 38:14
  But what I realize over time is that having great allergy
• 38:18
  fundamentals and great allergy practice, I'm a generalist.
• 38:23
  You know, I've been in both private practice and academia.
• 38:26
  Having those tools made me a better surgeon.
• 38:29
  It made my results better.
• 38:31
  It gave me more options for my patients, which they appreciate.
• 38:35
  And so it's really something now I can't do without even if I'm not doing,
• 38:40
  you know, crazy polyp cases or things like that, just in general,
• 38:44
  you know, bread and butter practice.
• 38:46
  It's a huge tool in my toolbox that's made me better.
• 38:48
  So why not get into it? It's not hard.
• 38:52
  It really isn't.
• 38:53
  You can do it.
• 38:55
  Well, thank you both very much for sharing of your incredible
• 38:59
  knowledge, experience, but also welcoming our members.
• 39:02
  Right.
• 39:03
  You're not hiding behind an ivory tower or your practice.
• 39:06
  You're saying, come join. Let's help our patients.
• 39:09
  Thank you both very much. Very inspiring.
• 39:11
  Doctor Franzese, Doctor Marzouk, thank you.
• 39:13
  Thank you.
• 39:16
  Thank you for listening
• 39:17
  to this episode of Voices of Otolaryngology.
• 39:20
  Subscribe to listen to more of these episodes
• 39:24
  wherever you listen to your podcasts.
• 39:26
  and definitely join us next time
• 39:27
  as we continue these crucial conversations.