Clinical Blind Spots: Alpha-Gal, Asthma, and COPD in 2026

TRANSCRIPT for Webinar with the title: Clinical blind spots Alpha-gal, asthma, and COPD in 2026

0:01
Hi everyone, it's, it's good to see you all and thank you for joining us this this morning, afternoon, late afternoon, depending on the time zone you're in, Gary Felsatano and I are really delighted to be with you all and discussing some very active conditions.

0:18
3, Really asthma alpha Gal syndrome, which will be led by Gary and myself, run asthma and COPDN.

0:25
We're going to talk about some of the allergic drivers of these conditions, the way to test for them, particularly within the Quest laboratory diagnostic system.

0:32
And then particularly for asthma and COPD.

0:35
There are a couple of quality measure changes as well, which are these Heatus measure changes.

0:39
So we'll kind of talk about that and how allergy testing or other it creates this opportunity, I think to look along around for triggers.

0:48
So I'll just before handing it over to Gary, just briefly introduce myself.

0:51
I'm a lung doctor, a pulmonologist.

0:53
I really spend my life specializing in Airways disease and asthma and COPD and kind of split my focus between caring for patients clinically, which kind of drives everything else that we do.

1:05
But also I spend a lot of time doing research and education and hoping in forms like this to kind of continue to move along what we do more globally.

1:14
And with that, I'll turn over to my my partner in crime here, Gary Falcitano, who I'm delighted to be with for an introduction and an Alpha Gale overview.

1:23
Yeah, thanks so much, Doctor Tejwani.

1:25
So this is me, Gary Falcitano.

1:27
I'm a physician assistant associate by by training.

1:32
I've been board certified, licensed for approaching 30 years now.

1:36
Background in emergency medicine, primary care, disaster medicine, but for the last 14 years really focusing on allergy and immunology.

1:44
Currently the senior manager for global medical and scientific affairs for allergy at Thermo Fisher Scientific.

1:51
One of the best things about my role, aside from doing, you know, educations like this is actually working with researchers and really experts from around the country and around the world, like my co-host, doctor Tajwani.

2:05
So very happy that quest has has invited us to, to do this presentation.

2:10
You might let's kick it off with some objectives.

2:14
We, we always have to have objectives, right?

2:16
So I think, you know, I, I think doctor Tajwani really covered kind of kind of this somewhat right.

2:23
But we're going to take a bit of a deep dive into alpha gal, alpha gal syndrome and really kind of best practices for kind of having a higher index of suspicion, diagnosing the syndrome and, and a little bit around treatment as well.

2:41
And then we'll, you know, I'll hand things over to my to my co-host and we'll talk about things like quality measures and both in asthma and COPD and how, you know, as we mentioned, specific IGE testing and assessment of allergic triggers can really be an opportunity, right, with the new, with the new Heatus measures to improve patients quality of life, improve their symptoms and really take that an opportunity like that to kind of assess their overall health status and hopefully prevent future exacerbations.

3:14
So let's get started with alpha gal and this, this guy's right in my face here.

3:20
And I say, God, but it's, it's actually a, a female tick, right?

3:23
This so this is the number one identified vector for transmission of alpha gal from the tick right from this Amblyoma Americana or Lone Star tick to its human victims if you will.

3:42
And that transfer of alpha gal causes sensitization to, to alpha gal and this delayed mammalian meat or red meat allergy.

3:53
And you know, we'll talk about it's not just a food allergy, but what is alpha gal?

3:57
So, and you know, the, it, it's really short for galactose, A13 galactose.

4:02
It is a sugar molecule or really an, excuse me, an oligosaccharide that causes this allergy.

4:10
And what's different about this is that sugars typically and, and, and carbohydrates aren't typically sensitizers that cause clinical allergy.

4:21
Typically it's the proteins in foods, whether it be plant foods or mammalian foods that you know, are responsible for people developing a specific IG E sensitization having clinical symptoms.

4:33
But in this case, this carbohydrate or oligosaccharide is responsible and it is responsible for a whole spectrum of symptoms, which are known as alpha gal syndrome.

4:43
So if we'll go to the next slide, you know it is, it is a syndrome, right.

4:48
So it is an allergy, but it does have a constellation of symptoms and those can range from things like chronic urticaria, chronic GI distress if and you know, especially in someone who's ingesting mammalian products on a regular basis all the way up to and including systemic reactions, including anaphylaxis when it was first identified.

5:08
And we'll see that on the on the timeline on the next slide, there was a term kind of bandied about it was known as midnight anaphylaxis because of the delay.

5:17
So, you know, with Alphagal, unlike a lot of other food allergies, protein mediated food allergies, where we see, you know, almost instantaneous symptoms or within two hours of ingestion of the culprit food, with Alphagal, we see this delay at two to six hours or even 8 hours.

5:34
And that makes diagnosis difficult.

5:37
And it, it really makes it differ right from the standard food allergy.

5:41
If we go back kind of to how this was, you know, initially identified, we knew that there were cases that people thought were related to, to tick bites and, and red meat allergy back.

5:54
And you know, as far as the, the 80s or the 90s, but there really wasn't anything reported in, in the literature until the very early 2000s.

6:03
And then it started becoming more and more prevalent at the same time we started seeing hypersensitivity reactions to initial infusions of cetuximab, so an antineoplastic that was in clinical trials for colon cancer at the time.

6:18
And what was interesting is these red meat allergies and these cetuximab reactions were very prevalent in the Southeastern United States.

6:29
So the investigators that were trying to figure out both of these things kind of started doing some detective work and figuring out, you know, why would this geographic, you know, area be so, you know, highly prevalent with these two things.

6:44
And they started looking at tics as vectors.

6:46
And that's when they identified, you know, that tics are the primary vector, that alpha gal is the epitope both in cetuximab and also in red meats that is causing the reactions.

6:59
So, you know, we've seen it in certainly in the US, that's where it was first identified.

7:06
But almost at the same time it was being identified in Australia.

7:10
It's been identified in Europe.

7:11
Actually every continent in the in the world it's been identified on with the exception of Antarctica, probably with the highest concentration of cases being Australia, the US and Europe, places like Germany and Sweden.

7:25
In the US, as I said, you can see that heat map on the left.

7:28
It was predominantly a southeastern, you know, disorder.

7:32
But we're seeing it now spread throughout the entire country, both because people travel, you know, they spend time in different areas of the country where they can get a tick bite, but also because the range of the Lone Star tick, which we'll see in a second is, is moving on.

7:45
Before we look at that, I do want to talk about kind of the prevalence.

7:48
So recent CDC estimates are somewhere around 450,000.

7:54
Probably by now about 1/2 a million individuals within the US are potentially affected.

8:00
We're seeing about 15,000 new cases every year and that that's actually increasing as well.

8:05
And it really based upon all the current data is the 10th most common food allergy.

8:12
And as you may know, currently the top 9 food allergens, you know, things like peanut, tree nuts, soy, milk, you know, weed, etcetera are all required labels, right?

8:25
Required allergen labels.

8:26
So we have 9 required foods or food types that are required allergen labels.

8:30
There's actually legislation in before Congress right now to make alpha gal the 10th required food label.

8:37
So we'll, we'll see, hopefully that will occur.

8:40
And then one other thing, you know, while the this data, this 42% of clinicians who were unaware of Alpha Gal syndrome is from 2023, we're still hearing that awareness among clinicians is still not where it needs to be.

8:57
That same MMWR report also, you know, reported that while 42% were unaware of Alpha Gal syndrome, 35% that had heard about it did not know how to diagnose or treat it.

9:08
So hopefully we'll address both of that today.

9:10
So the next slide, if we take a look at the Lone Star tick and this is the primary vector for alpha gal, we're seeing its range really spread, you know, throughout the, the eastern part of the country.

9:23
But it's not the only tick that will that has been conclusively identified as potentially spreading alpha gal syndrome.

9:29
So there's been a case in Maine that was conclusively linked to Exodi Scapularis or the eastern black legged tick or deer tick.

9:40
And a similar case in the Pacific Northwest in Washington state with Exodus Pacific it's or the western black legged tick.

9:49
So again, usually the Lone Star tick.

9:52
What we have seen identified as these other Exodus ticks and the Exodus ticks on other continents are what have been seen as responsible as well.

10:00
So what does the journey look like?

10:02
So you know, typically what we, you know, the, the common story or history for a patient is they're bitten by a tick.

10:11
That tick bite is exceptionally itchy, which is a little bit unusual from a lot of tick bites.

10:17
That's that's one of the kind of prototypical symptoms that we see once they're bitten at the period of about one to three months occurs where they're, they're sensitization levels increase.

10:29
So there's specific IG E to alpha gal increases.

10:32
And then after that.

10:34
They start developing symptoms whenever they're exposed to both mammalian foods or potentially as in the case of sutuximab and some other medications, you know, medical products or other products that are derived from 1,000,000 foods.

10:48
So it's not just a food allergy.

10:50
And as I mentioned, this isn't a typical food reaction.

10:52
So we typically see a 2 to 6 hour delay and then what happens?

10:57
And you know, like, like with a lot of allergy, we know that exposure drives sensitization, but it's been clearly documented with Alfa Gal syndrome that each subsequent tick bite drives specific Ige levels higher and those higher levels often are responsible for more infrequent symptoms.

11:17
The, you know, the silver lining here is that as you know, time goes by if, if the patient does not have subsequent tick bites, their levels start to decrease again.

11:29
And we have seen cases where you know, clinicians especially that, that deal with a lot of alpha gal.

11:33
I've seen a lot of patients that after a certain period of time, 2-3 years, their levels get down low enough that they can reintroduce a million products.

11:42
Next slide.

11:45
And as I mentioned you know the symptoms it are a constellation, right.

11:49
So yes, that initial midnight anaphylaxis was a, you know, was the term that was bandied around.

11:54
But we often see some of these symptoms in isolation, especially urticaria, especially GI symptoms.

12:02
I'm not a big Morning News watcher, but I saw CBS Morning News this morning.

12:07
They, they did a 3 minute feature on a woman from Pennsylvania who was having really severe postprandial abdominal issues, was worked up for gallstones.

12:20
Wasn't until her friend suggested she might have alpha Gall syndrome that they went down that diagnostic path and that's what she was diagnosed with.

12:26
So we often see isolated GI symptoms and that's both in adults and in children.

12:31
We are seeing and again increasing prevalence in children.

12:34
Initially it was it was pretty much an adult disease, you know, especially because they had been there the kind of, you know, been exposed to multiple tick bites throughout their lifetime.

12:44
But we are seeing more and more cases in children.

12:48
So next slide, not every mammalian product contains the same amount of alpha gal.

12:55
So what you know, if we look at foods, things like gelatin containing foods, gummy bears, etcetera, contain low amounts.

13:02
But some people who are exceptionally reactive may respond with symptoms, you know, up up to and including severe symptoms even from gelatin containing foods.

13:11
Then as we go up, dairy contains more and beef, beef, pork, all the, all the, you know, the mammalian meats contain the most with innards or, or organ meats really being highly decorated without, without fagal.

13:26
And the same thing is true with medications and biologics.

13:29
If we start down at the, at the bottom, you know, gel caps contain a small amount and then, you know, heparin.

13:36
And as we go up, it's also can you know, we mentioned cetuximab at the top of that list, right?

13:42
That's where alpha gel was initially identified from.

13:47
And remember, there isn't typically a delay with, with some of these medication products because we're not ingesting them.

13:54
So the delay is typically thought to be the way that the fats and the oligosaccharide is actually digested and expressed into the system.

14:02
When it's a food, when it's a medication or a therapy, it can sometimes, you know, BIV and you'll see instant symptoms.

14:10
Heparin is typically safe for, for alpha gal syndrome patients, but IV heparin, you know, such as for cardiothoracic procedures, you know, could be a, a pretty severe risk.

14:23
And we've, we've seen severe reactions with that.

14:26
And then finally, you know, with all food allergies and, and allergies in general, we know the cofactors can sometimes magnify the risk.

14:34
And that's definitely the case with alpha gal.

14:37
And probably the number one cofactor with alpha gal is actually alcohol.

14:41
We often see that patients can tolerate say you know, as a steak, especially a lean steak like a, you know, a filet and, but if they have that with a glass of alcohol, they may express symptoms.

14:51
So, so cofactors and asking about cofactors is a very important when we make the diagnosis and how do we diagnose it, right.

14:59
So Quest offers an alpha gal profile that contains the alpha gal specific IGESA as well as assays for protein mediated allergy of beef, mutton or lamb and pork.

15:11
You know, that allows us to get a kind of a good idea if this is truly an alpha gal sensitization or if it potentially because they're having reactions to meat, maybe a protein mediated meat allergy.

15:22
Along with that, it's a good idea to order a total Ige, which we'll see in a second.

15:27
Why when we're looking at ratios of alpha Alto total IG, it can be very important.

15:32
And also, if someone has had severe, so anaphylaxis or pretty severe reactions, you know, it's not a bad idea to get a tryptase.

15:40
So we can look at mast cell disorders, potentially mastocytosis.

15:43
And that's, you know, an elevated tryptase is one of the criteria for that.

15:48
Why it's important to look at total Ige along with specific IGE alpha gal is that sometimes even very low levels of alpha gal can be significant.

15:58
So Tom Pletz Mills, you know, the researcher from the University of Virginia who actually is kind of the father of alpha gal, kind of put a lot of these pieces together to identify the syndrome has seen through his experience that, you know, an absolute level of two or greater.

16:15
So kilo units allergen per liter of alpha gal is pretty diagnostic to having alpha gal syndrome or alpha gal allergy.

16:23
But in someone who has a really low total Ige even 2% or greater of the total Ige being alpha gal can be diagnostic.

16:31
In this case the .9 is 3% of the total Ige which is 30 definitely a diagnostic you know parameter strong diagnostic parameter for that.

16:43
So with that, I'd like to see if we have any questions and then we'll turn things over to Doctor Tejwani to talk about heaters measures and COPD and asthma.

16:54
Great.

16:55
Thank you, Gary.

16:56
And yes, I just echo that please in within the chat or the Q&A feature, either is great for questions.

17:03
And perhaps as we're waiting, Gary, I'll just make a comment and a question for you.

17:08
1 is comment.

17:09
I mean, and I've seen this before with the IV Hepburn is always striking.

17:12
And I think really just underscores the importance of making the diagnosis in the outpatient setting.

17:17
Because if somebody's getting admitted to a hospital, whether it's for a cardiothoracic surgery, as you alluded to, or getting treated for a pulmonary embolism, getting that IV Hepburn in the hospital is not a good time to to find out about this allergen reaction.

17:32
And then the question for you, it's really fascinating that this is on every continent.

17:37
I'm glad the ticks probably like me, don't like the climate of Antarctica.

17:40
So that's been that's been safe so far.

17:43
How reliable?

17:44
I mean, you talked about the itchiness at the tick bite, but in terms of the diagnosis, how much of the absence of a remember take by presence or absence and form our diagnostic suspicion and our decision to pursue testing for this condition?

18:01
Yeah, I think that's a great question, right?

18:03
Because we always want to have a, you know, a strong history before we perform a diagnostic test.

18:09
But I think we do have to be kind of open minded, right, because we know that exposure to not just adult forms of ticks, but larval ticks, sometimes known as seed ticks or, you know, kind of referred to as chiggers in some areas of the country have been associated with transmission of alpha gal syndrome.

18:28
So it does not need to be an adult tick.

18:31
And, you know, often a patient may not remember that exposure and remember the exposure can happen, you know, even a year prior, right, and especially during travel.

18:42
And that does bring to the point that it really should be in our differential no matter where we are in the country because of the mobility of populations, even when the, you know, the tip population in that area isn't necessarily, you know, an Amplium Americanum of the Lone Star tick.

18:57
Yeah, I know that that's great.

18:58
It's certainly reminiscent of Lyme disease.

19:00
Sometimes it's a clean story, but often patients that get diagnosed don't necessarily remember the tech and there it's a closer relationship.

19:10
I'm going to think what you said is certainly striking, that the tick bite for this and the sensitization could have been months or even a year ago.

19:16
It really, it makes it very challenging, I think to rely on that history and recollection of the tick bite.

19:21
Absolutely.

19:22
And you actually just reminded me of another kind of point to remember is that, you know, with Lyme disease, we typically hear you need about a 24 hour or greater attachment of the tick to transmit, right?

19:34
The causative Organism.

19:36
With alpha gal, we're not seeing that.

19:38
So it can happen in as little as 15 minutes if it's, you know, long enough to cause itching.

19:44
From what I hear from, you know, some of the alpha gal researchers, it's long enough to transmit and cause alpha gal syndrome and alpha gal allergy.

19:51
Yeah, that's great.

19:53
Perfect.

19:53
Well, I don't see any.

19:54
But please, even as if things strike you all later, for those attending for Alpha Galler, as I kind of change gears here a little bit speaking about asthma and COPD, don't hesitate to put them in either the chat or the Q&A.

20:07
Jasmine and the Quest team, as well as myself and Gary are monitoring that.

20:11
So asthma certainly like alpha perhaps a little more than alpha, we're certainly well known to the lay or in mainstream media populations because it's just a very common condition unfortunately.

20:23
So for me as I was choosing what to focus on with my life, the reason I really settled on asthma and show similar slide for COPD is unfortunately the burden of these conditions just remains very high.

20:34
So for asthma just domestically we have nearly one in 10 individuals across adult and pediatric populations affected from this.

20:43
It continues to increase.

20:45
And then there's a huge healthcare burden both in terms of time away from school for children, which impacts their parents, their ability to learn and develop and grow work days, both for adults themselves or again, if they're caretaking.

20:58
And then a number of emergency department and hospitalization visit, sadly, which lead to again, most importantly, a huge impact on the patient.

21:07
But Alton laws me also also ultimately, excuse me, lead to a very significant burden of financially on our healthcare system.

21:14
And we'll see some very similar data for COPD.

21:18
So this we kind of framed this earlier, which is that all of us in healthcare systems and healthcare practice are kind of navigating quality measures, which aren't a bad thing.

21:28
I think they are metrics and milestones for us to kind of make sure that we're meeting certain bench points.

21:32
And I think appropriately the one for asthma has recently changed.

21:36
So before going over the current one, which is the third bullet, the AAF Dash E and how we are trying within the context of this talk to framing more as an opportunity for intervention.

21:47
Just to briefly mention, the old one is around this idea of like controller and maintenance medication or rescue medications.

21:53
Excuse me, so that both the asthma medication ratio and medication management for people with asthma have to do with how often are patients using controller medications or their controller medications?

22:04
More than 50% of their medications and I think that these have appropriately been retired 14 patients with milder spectrum of asthma.

22:14
There's a scientific and medical argument to be made of if they need to be adherent on, you know, for if it's example in ICS lab or two puffs twice a day and how critical it is that they're very stringent up to that.

22:25
The other probably more important, and I think that's kind of subjective and or philosophical discussion to some degree.

22:30
But I think the other part that's a little bit more clear and objective is this transition to a type of therapy called smart therapy, which stands for single maintenance and reliever therapy.

22:40
And it's this idea that if you have a four motorol containing inhaled corticosteroid inhaler that that can actually be used as your maintenance medication and your rescue medication.

22:50
So they're the kind of line between the controller slash maintenance medications and rescue medication is continuing to be blurred.

22:57
So it really makes it challenging to use these metrics that kind of rely on our measurements that rely on this kind of older definition of the way we approach inhalers.

23:06
And I think the new one, which is the third bull is really the right approach as far as the healthcare metric goes.

23:12
So it's really saying that if you have basically an unanticipated or unscheduled visit related to an asthma exacerbation and I'll show these in more detail on the next slide, but whether that's emergency department, urgent care, observation, etcetera and they're not and they're within 5 and 6464.

23:28
This has to do with the those being less than 5 approached a little bit differently.

23:31
And 65 and above is 1 approach a little bit differently and two more in the realm of Medicare in a different population that they really just need to be seen within 30 days.

23:41
So this is ultimately the new window is basically this idea that if you have one of these events and it could be any one of these four listed here, that the patient needs to have an outpatient follow up visit.

23:52
And this could be with the physician with an AP or an APP, meaning a PA or an NP.

23:58
The one thing I will say in this is sometimes a challenge for us when we set this up for patients, particularly in the context of social determinants of health and access to healthcare, is that the patient does need to attend the visit for this to count.

24:10
So if they're discharged from your health system and you schedule something two weeks from now, the patient's aware that it's scheduled two weeks from now when leaving the hospital there.

24:18
Yes, I have this appointment, you know, on October 22nd at 4:00 PM or 3:00 PM.

24:24
But then they don't come to that appointment for whatever the reason may be.

24:28
That would not count as a successful achievement of this measure.

24:32
And framing is in a positive way.

24:34
And I think I love Gary's framing around this as an opportunity.

24:38
It's really this idea where you have a patient that's sensitized, meaning they just had this event.

24:42
They had to have their life disrupted either by going to an urgent care or an emergency department or even worse, getting hospitalized.

24:49
And so generally, this is a very good window to revisit with that patient what went wrong here?

24:54
What was the trigger for that episode, which is where we're going to really honing on today?

24:59
And are you using the medications the right way?

25:01
Did it turn out the medication I prescribed to you 6 months ago had a $400.00 out of pocket cost, So you understandably didn't fill it and we never had a chance to revisit it.

25:10
So it really provides this window right after this episode to revisit these things.

25:15
And, and fundamentally, this is a little bit of a simplification, but to some degree, there are 4 main pillars of asthma care, which is assessment and monitoring.

25:23
So things like pulmonary function tests, peak expertory flow control of environmental triggers, which in the vein of kind of alpha gal syndrome, allergen testing that's available within Quest Diagnostics, we're really going to hone it on today.

25:34
And pharmacologic therapy and education, I really think underpins all of these cuz it's important that a patient understands what the peak expertory flows for.

25:43
They understand and Quest has some specific tools around this, around education, around environmental triggers.

25:49
And then for inhalers particularly, which one should they be using on a regular day-to-day basis or as a rescue medication?

25:55
There still is a component of that.

25:57
Are they using it the right way?

25:58
It's very different than prescribing somebody, for example, a Staten or a beta blocker.

26:03
It's just take one of these pills a day and it's kind of a very easily and more readily defined thing.

26:08
And again, you're dealing with people across education levels, across ages.

26:13
So trying to make this as simple as possible is really critical.

26:16
And just that the inhaler is being timed the right way so that it's being sprayed and actually getting into the lungs as opposed to the back of the throat.

26:23
And then in terms of we'll spend the next few slides for asthma, again really keying on this second bullet of this or the second pillar of this that they control the environmental triggers and this manner is a lot for asthma matters for COPD also as we'll learn about.

26:36
But for asthma, really over half of adult patients with asthma have atopia or some type of allergic predisposition.

26:43
And for the pediatric population, it's even higher.

26:45
At least three sports or 75% if not more have an allergic or atopic predisposition and that the way that we cover or treat asthma.

26:54
This is not intended to be gone through in detail, but it's really this idea of step up and step down therapy.

27:00
Basically in a very simplistic way, a patient is you visit with them, you assess and monitor them.

27:06
If they're doing well, you just hang tight.

27:08
Consider actually stepping down treatment, reducing treatments, pharmacologic treatments and if they're not doing well, you step up treatments.

27:15
And that's essentially what's shown here.

27:17
Really across all of these levels though, there's two things that affect all or impact all patients.

27:22
One is education.

27:23
Do they have an asthma action plan?

27:25
Do they understand burden of disease rescue, maintenance, etcetera, inhalers and that it is an episodic condition that has triggers.

27:32
And the other one is kind of in that same vein of triggers is understanding for a given patient, what is the trigger?

27:39
I kind of joke it's not exactly half of my practice, but I've half my practice roughly where cold weather is a trigger for them and half for its humidity.

27:46
And you know, they kind of flip every season.

27:48
So one of 1/2 is looking forward to March and April for the winter to let up, at least here in in the Midwest, probably closer to April.

27:56
And then the other half is looking forward to winter to start because the humidity is so troubling to them.

28:02
So providing that education around them is key.

28:05
And those are environmental controls and something that can be addressed.

28:09
The other one is allergy testing, so something more specific, for example, are they allergic to house dust mites, pollen, cockroach exposure, etcetera, where it's a year-round or potentially only matters in the high pollen season and then they can again avoid this.

28:23
And what I often find is, you know, you might have a patient that, for example, is on Step 3 or step four of the pharmacologic therapy.

28:30
But as you address education and self-empowerment and then identify these triggers, you can actually move them down on the pharmacologic therapy by addressing these non-pharmacologic approaches.

28:41
And patients love that.

28:42
I think many of us that have to be on medications and certainly my patients would prefer not to be.

28:47
So if there's a way for them to kind of tweet their lifestyle a little bit with awareness around what they might be allergic to, to be able to avoid it and then come off of medications, they're always really pleased.

28:57
It's a win.

28:57
I look great because, you know, I know they think I know what I'm talking about and then they're happy because they get to use less medication.

29:03
So it's a win all the way around.

29:05
It really is preventative medicine right at its best.

29:08
Yeah, exactly.

29:09
Yeah, I know.

29:10
I think that's exactly right.

29:11
And unlike, you know, alpha gal where it's in perhaps steaks and I think things that people enjoy.

29:17
So it's a little bit more of a restriction for their lifestyle.

29:19
Most people don't necessarily enjoy breathing in pollen or anything like that.

29:23
So they're exactly, to your point, they're kind of happy to, to be doing it for the most part, except for pets as we'll talk about it in a few slides.

29:30
But so an example and Gary and I both seen different iterations of this patient over our careers.

29:36
But I, I typically would see this patient's mother or uncle etcetera, as an adult pulmonologist.

29:41
But the pearls really translate well into the pediatric population, which is you're seeing a young girl, she has a 10-year-old female.

29:48
The kind of story or chief complaint is that she's coming in with a persistent cough and wheeze.

29:53
And when you hear the history, you hear this persistent wheeze, shortness of breath.

29:57
And this is really important that she's also got these upper airway symptoms.

30:00
So we'll talk later about the one airway hypothesis and then this is a story.

30:04
I, I get a lot this episodic bronchitis and sinusitis.

30:08
Sometimes you hear, oh, I get a pneumonia every spring or I get a pneumonia every winter.

30:13
And then they just get these antibiotics, sometimes steroids and do better and that's it's being treated as an infection when it's really there's an underlying Airways disease, either asthma or COPD.

30:23
And then unfortunately here and and I think this is kind of a line to concording with that he dis measurement is you're seeing a lot of urgent care visits, emergency department visits, these unscheduled visits that are, are going to be important to make sure she's checked in, you know, within the 30 days of that.

30:38
And then from a healthcare perspective, she's having these flares and getting steroids, which I'm sure are necessary during those acute episodes, but we really want to anchor and on scary order preventing those episodes and not and having her get to the point where she needs corticosteroids where we're increasingly learning even just one burst a year can have really long-term consequences.

30:58
And particularly this young girl who might be experiencing this for several decades.

31:03
And then on further history, you hear, and this is a common theme as well, the mother has allergic rhinitis and asthma.

31:09
So this kind of idea of the atopic March and the genetic predisposition lives with the mother and two dogs, busy household, young girl, couple dogs.

31:17
So there's been some kind of question about, you know, what medication is controller, should we use it regularly, etcetera.

31:24
And then fortunately no cigarette smoke exposure.

31:27
And on medication review you hear she's having an inhaled corticosteroid.

31:32
By report she's using it twice a day and rinsing her mouth out after you.

31:35
It's also important to prevent the risk of thrush Montelukast, which is an allergy pill.

31:39
But disconcertingly, she has an albuterol as needed rescue inhaler, but she's needing it almost every day.

31:45
So this kind of suggests that either this isn't enough or that that's what's 1 possibility.

31:50
But also we should explore further into her environment to understand, you know, is it the dogs, is it something else in the house environment that's driving these symptoms or pollen count, etcetera to see if we can mitigate this use of the albuterol without further escalating for other medications.

32:06
On examination, her peak expiratory flow is reduced.

32:09
She's usually around 2:15 and she's 195 on visit with you.

32:13
Vitals are normal and then her mucosa are swollen, suggesting some allergies there.

32:18
And then Denny's lines as well, which you often see with atopy.

32:21
And then although she does not have wheezing on examination, she's got prolonged expiration kind of demonstrating that there's some issues with expiratory flow.

32:29
And so one of the things to do certainly is go over the medications, make sure she's taking the inhalers the right way.

32:34
But as as we drive into triggers, you know, it's really to understand.

32:38
So she's having these episodes of bronchitis or sinusitis and these steroid exposure.

32:44
So often I'll just start by saying what happened a few days leading up to this?

32:48
Was there travel change in home environment, etcetera.

32:51
And then once you get this idea that there's something, the environment driving it, the next step is really to confirm this with objective testing that can be used to inform you treating the patient as well as the patient themselves.

33:03
So similar to alpha gal where you're getting an IG E, this is a kind of generic allergy blood test.

33:09
So just tells you, does this patient have an allergic predisposition?

33:13
So whether it's alpha gal asthma, being atopic or other conditions, all of them will have an elevated IG E.

33:19
The thing that is really kind of takes it to the next level beyond just that overall IG E is this ability to do specific IG E testing, kind of similar to what Gary's saying, where you could test specifically for those beef and lamb proteins.

33:32
You could do the same thing with respiratory allergens.

33:35
And importantly, unlike skin testing, there's no interference from antihistamines.

33:39
Patients do need to be off steroids, systemic steroids for this testing, but they are able to perform the testing while on antihistamines and then they don't need to have, it doesn't need to be like a morning blood draw like cortisol or something like that.

33:52
It's really just at any point during the day and it really is kind of a bespoke panel.

33:57
So the allergens based on where you are in the United States are going to be different.

34:03
So I am in Northeast Ohio.

34:04
I frequently have patients that I'm seeing from Michigan, Pennsylvania, Virginia, West Virginia, sometimes, you know, the West Coast come and travel for patient care.

34:14
So it's really nice to basically get the region and we'd be in region 5 for, for Northeast Ohio if they're local patient.

34:22
But you can look at wherever you're stationed, you know, here, and you can identify basically what allergens are unique to your area.

34:29
Some of those will be universal.

34:31
So for example, dog dander allergens are going to be the same whether you're in, you know, here or California or Washington state or Florida.

34:38
But other ones in terms of pollen and other dust and tree exposures are going to be unique to specific regions and what they're actually testing for.

34:48
This is just an example of 1 is that they're testing for different allergens like cat, like dog, Aspergillus importantly, and you could double check, but most of them actually will include a total IG E.

35:00
There are some historically that did not, but sometimes as long as it includes a total IG E, you don't need to order that separately.

35:07
But that might I believe for a quest.

35:09
My recollection was that it does.

35:10
So I think as long as this is within the quest system, you don't need to separately order a total IG E because it'll be a part of your antibody testing and what that ultimately looks like.

35:19
And if we circle back to our 10-year-old patient, so reassuringly, she's not allergic to dog.

35:26
And this is important.

35:27
I've had some tough conversations with patients about letting go of pets or transitioning them to different households.

35:33
And it's a very challenging conversation.

35:35
They are, as many of us can empathize with a part of the family.

35:40
And then what we see here with this young girl is that she has housed dust mite and those are both highlighted in blue because these are indoor allergens.

35:47
So this suggests, but you know, I this is at this point and I usually do this in the history as well, but certainly if I hadn't at this point, I would ask, you know, is there central heating and cooling?

35:57
Are you changing the filters on the furnace at a good frequency?

36:00
And if they're able to afford potentially the higher strength filters that can be helpful.

36:05
Is there a lot of carpeting that's not perhaps being vacuumed enough?

36:09
Or can the carpeting be changed to vinyl or hard work plank?

36:13
And you know, Gary and I in a previous iteration of this had talked about the value of negative testing.

36:17
And so the other value of negative testing is I don't need to bring those things up if this isn't there.

36:22
I don't need to have them think about oh, what is my home environment and these things they're easy to talk about, but they all have expense attached to them and so and financial implications.

36:33
So if I don't have to bring them up, that's better because then a person could decide to do that or not just in terms of what they want for the environment.

36:41
But there's not this added stress or pressure that this also could be impacting my health.

36:46
And then in terms of some other allergens that are positive here, we have June grass, ragweed.

36:51
And so these are highlighted a little separately here because these are outdoor allergens.

36:56
So this is these are patients where I would say on your weather app on your phone, which to give them credit has really been reported very nicely across platforms.

37:05
There's usually an AQI or an air quality index as well as a pollen count reported.

37:09
So now that I'm seeing these and say, OK, if there's, you know, you're at elementary school or middle school and there's a high pollen count, that might be a day for a recess where you're not playing outside as long or even potentially doing an indoor activity during those days or taking your inhaler before you go outside to avoid the risk of the exposure activating your symptoms.

37:30
And then we kind of talked, touched upon this already, but reassuringly the dog one was negative.

37:34
And that is a pretty good negative predictive value.

37:36
And I think it's about 90%.

37:38
So you could always consider skin testing the future.

37:40
But more than likely, I think you can reasonably rely on this unless there's a very strong story that, you know, every time she stays at someone else's house where there's no dog symptoms get better than she comes back and then the symptoms worsen.

37:52
But for the most part, this provides a lot of reassurance as a negative test.

37:56
And then this is a great resource that Quest offers.

38:00
And again, not intended to go over in detail, but just kind of at a high level as you would write the patient's name, you would write the triggers on this.

38:07
And this is really good educationally to show that all of us, you know, the idea is not to take grass exposure to 0.

38:13
That's not going to be possible and that'll be very limiting in terms of lifestyle and being a particular for a 10-year-old or really anyone to be able to do the things they want to do.

38:22
The goal is really just to keep those exposures below this threshold here.

38:26
And so as long as you can reduce them with some of the features we talked about, and this one is what this is showing is if you can reduce this background of the dust mites and molds which are in the house, then the pollen over here shouldn't be as much of an issue.

38:39
Whereas if you already have a lot of background, then that little bit of pollen pushes you over it.

38:44
And this isn't just to show that it does separate indoor and outdoor, which we kind of talked about already.

38:49
And that's important because the lifestyle implications there are very different.

38:53
And just an example, this is an older study from 2004, but a great one, which is showing in an urban environment that if you take children and you just, and they're allergen or have allergic sensitization with serologic testing and then you just do bedroom only intervention.

39:09
So basically just make sure the blankets, etc, don't have a lot of allergens.

39:14
And particularly for children, the bedroom is where they spend most of their time at home.

39:18
You see a huge improvement of symptom, less symptoms day per year less miss school.

39:23
Again, this is really important at this age or really at all ages, but particularly for the pediatric population.

39:29
And then importantly, both from a Heatus measure perspective and you know, this basically, if they're less of these, you're having to do less of those 30 days, you know, follow-ups within because they're not having as many unscheduled visits.

39:42
And then also from a patient, of course, it, this is a huge outcome, all of these really, but to basically be able to live your life in a more meaningful way with less disruption from the asthma, which is the goal.

39:54
And then one such way to adapt this.

39:56
This is not, it does for systems that haven't been necessarily having a process for this 30-day codified follow up.

40:04
It does create a need to do this.

40:08
And depending on where and how the system functions and may not make sense for a full FTE or a full clinician to be fully focused on this.

40:16
So one such example and that there's nothing.

40:19
That's super unique about this is just one example of a way to do it is that you could have somebody there that is in a multi-specialty clinic, but just on a Monday, Tuesday, for example, they're there.

40:29
And their main focus on those Mondays and Tuesdays are just capturing these post discharge or post Ed or post urgent care visits to really one, make sure that this doesn't continue to happen.

40:41
But to make sure that that box is checked for the heaters measure that there is an opportunity in a landing spot for these patients within that 30 days, which might be if you don't have that allocated can be challenging because many people are already having very busy practices.

40:54
So fitting more into that on short notice can be challenging.

40:57
And as a part of this within that clinic, they didn't, they really addressed all four of those pillars that we talked about.

41:02
They did the assessment monitoring.

41:04
They talked about environmental triggers, which is shown here in green.

41:07
They did education and titrated pharmacologic therapy as effective as indicated, excuse me.

41:13
And that just showed a huge improvement.

41:15
Not surprising that if you get these touch points for these patients that you're going to see an improvement in symptoms.

41:21
And so with that, I'll conclude on asthma and I'll spend a few minutes as well on COPD.

41:26
And then again, we'll open the floor really now at any point between the end for questions on asthma and COPD.

41:34
But again, if anything struck you for Alpha Gal syndrome as well, please, we'd invite those questions as well.

41:42
So for COPDI alluded to this already, but basically similar to asthma, a huge health and economic burden of COPD.

41:50
Really the big difference with COPD is sadly, it's still a more likely to be a cause of death.

41:55
It kind of vacillates up and down between the 3rd and 4th leaning cause of death in the United States as well as globally.

42:01
And this is really continued despite we've been fortunate domestically that smoking rates have gone down, but at that same time, other exposures and other effects have gone up.

42:09
And then actually globally, it's really a disease of biomass exposure from things like wood stove and other and tuberculosis as opposed to tobacco smoke.

42:19
So this is just the United States numbers.

42:21
Globally, the impact is really, really massive.

42:25
And then within the United States, it can lead to a huge number of hospitalizations and those hospitalizations have again, huge financial implications.

42:33
And then although it's not as allergic as a condition of asthma, I think most people kind of think of asthma as an allergic condition.

42:40
We are definitely finding and I'll show some data to support it that COPD is more allergic than we thought.

42:46
So I think it's close to at least conservatively 20%.

42:51
Some data shows that it's closer to 30 or 40%.

42:54
So even whether it's one in five, one in three, one in four, that's quite a bit.

42:59
And it's worth getting a history for and then doing testing when you find that out.

43:04
And then the heat is measure for COPD is a little less of an adjustment, I think for healthcare systems.

43:11
So the old one was about doing spirometry, which I still think is a critical measure.

43:16
So I, I think it still needs to be performed, but I think it's similar to the heat is measure transition for asthma.

43:23
It was kind of this idea that let's really key in on patients that are having these really acute episodes.

43:30
So for COPD, the idea is really to avoid rehospitalization within 30 days and, and this is has been a quality measure and including for Medicare.

43:40
So I think this for most health systems will be a little bit of an easier transition because most places it's hard to do well on this, but most places at least have this on their radar.

43:50
And it's something that they're already thinking about, but it's just kind of codified here now in another metric as a heat is quality measure.

43:56
And basically the idea is similar to asthma, once they leave the hospital, it's not necessarily getting them a visit, although that is one way to try to reduce the likelihood that they are re-hospitalized is to have an outpatient visit.

44:08
But it's really to make sure that everything is kind of tucked in the best you can.

44:11
They've got the right medications.

44:13
They're on a good Prednisone taper heart disease or other comorbidities, allergic disease is all addressed so that they're less likely to kind of quote bounce back.

44:22
And then and within those 30 days, which again, none of us want, most of all, the patient does not want to come back.

44:28
I don't think I've ever heard anyone enjoy hospital food.

44:30
So, you know, they certainly would rather be somewhere else.

44:34
Alpha gal or not, I don't think they would enjoy the hospital.

44:36
So and, and basically the, the general idea is that you just don't want, it's not a COPD specific.

44:43
And that does make it a little challenging because often these patients are advanced stage.

44:47
There's comorbid heart disease, comorbid allergic disease, comorbid asthma.

44:51
So even if they come back 20 days later for a heart failure exacerbation, that's still kind of counts as a readmission for this particular metric, as well as the health, Medicare and other quality metrics as well.

45:03
And so I alluded to this earlier when we were talking about our 10-year-old with allergic rhinitis.

45:09
And it's really, and we switched, we did a precision Airways course here in August and we had one of our best talks was from a sinus surgeon actually.

45:18
And that was for our Airways talk, which was focused on asthma and COPD.

45:22
And that's actually a new feature we've incorporated.

45:24
It's really around this recognition of this idea that the airway doesn't just magically start, you know, in your chest.

45:30
It's actually going all the way from the tip of your nose down to your alveoli.

45:34
And we see that here both for asthma and COPD, that when patients have allergic rhinitis, they're much more likely to get readmitted, which is what you're seeing here for the, sorry, the box was going to pop up.

45:44
But for the asthma, you could see here if they have allergic rhinitis, much more likely to get readmitted.

45:48
And same for COPD if they have allergic rhinitis that has ratios actually over 2.

45:52
So it's like over twice the likelihood of a readmission within 30 days.

45:56
So it's a critical thing to identify.

45:58
And then it's also kind of a sign that there's probably an allergic feature going on.

46:04
I mean, if you have allergic rhinitis.

46:06
So it again drives you into that thing of, OK, what are some triggers, allergic type triggers that are causing the flares that I can test for and potentially are avoidable for the patient.

46:16
And then this is just alluding to this idea or referencing this idea that you need to identify the allergic rhinitis.

46:22
And once you identify it, that's great.

46:24
You know, they're at higher risk, but now you also need to figure out what are they allergic to?

46:29
Is this something that can be avoidable or mitigated in terms of risk exposure?

46:33
And then this is a great paper by colleagues of mine, collaborators of mine actually at Johns Hopkins that shows that as you get more sensitization, so more of these allergic sensitizations, you're much more likely to have to go to the emergency department.

46:47
Even with one to two, you know, so you really for three, you see everything start to go up.

46:51
But for emergency department visits, even just one or two, you start to see those go up in this to me makes sense.

46:57
It's certainly something that needs to be proven at which it is here.

47:00
But it makes sense in the sense that these patients just they, there's much more things in the environment that they're sensitized to that kind of quote, UN quote, set them off to where they have to go to the emergency department.

47:10
So it's incumbent on us to take the history and story about this and then identify it.

47:17
And a lot of the same, we're not talking about it again because we covered it within the asthma section.

47:22
But once you identify that predisposition, then you clarify what the specific allergic triggers are.

47:30
And then the next step is avoidance of that, whether that's through indoor risk mitigation with some ways we talked about or monitoring pollen counts, limiting times outdoors, using masks as appropriate to really minimize breathing in exposures.

47:46
And then, you know, just to, to conclude the idea is really, and, and I know I just want to echo what Gary said about this.

47:51
This is really an opportunity for COP.

47:55
The biggest opportunity is really at discharge.

47:57
I mean, you can still schedule an appointment within the 1st 30 days.

48:01
We do because we just find that it's a very high-risk window for symptoms to get worse, particularly as the steroids are tapering in to come back.

48:09
And then asthma, this new idea, really novel in terms of a quality metric for asthma, just recognizing that now this is any unscheduled visit.

48:17
So even if they weren't hospitalized but went to an urgent care, that they really need this formal touch point within 30 days of that to revisit everything.

48:25
And that's all across those 4 pillars, the medications, the monitoring, the exposures, which we spent a lot of time talking about today.

48:32
And then really making sure that we are providing kind of more personalized and targeted treatment for particular patients, including preventative, which I, I think we're really moving toward as a house, hopefully moving toward as a healthcare field more, more globally.

48:46
So I think this is a good opportunity, an example to do that.

48:49
And then I also, this is a nice, you could see not to, not to forget about our friend here, the Lone Star take on the leaf.

48:56
But so with that we'll, we'll formally conclude and just thank everyone for attention then open it up for questions as well that might have come through.

49:06
Yeah, while while we're waiting for that, I want to first of all, thank you.

49:09
That was a, a great presentation.

49:11
And I think, you know, really covered right, why airway inflammation from any 'cause right, can can really add to the disease burden.

49:21
You know, you mentioned this on a in a few different areas, but I'd love you to talk a little bit more about phenotyping and the ability to, you know, use allergic sensitizations to say allergic versus non allergic.

49:32
And then, you know, kind of how that directs us down to a clinical pathway.

49:36
Yeah, Yeah, it's a great question.

49:38
So I think if we look at and if I may get it might zoom out just since we have a couple moments.

49:43
But if we look at the history of asthma and COPD, and when I say history, I mean, you know, if we take a zoomed out lens 30 to 40 years, it's really been a graveyard of failed studies and over it's really over the last 10 to 15 years, probably the last 15 to 20 in asthma and five to 10 in COPD, we're really seeing an explosion of FDA approved treatments and effective treatments.

50:07
And I think you hit the nail on the head.

50:09
The reason we had this long period of dormancy, I'll say is that we were just looking at every COPD patient and every asthma patient the same way and using this one-size-fits-all approach.

50:19
So we were doing these big trials where everyone got treated with, you know, all the COPD patients got lumped together and we were seeing a lot of negative studies.

50:28
But as we phenotype them more specifically, for example, the eosinophils with IGE, we're really identifying, okay, these are patients with elevated IGN allergen sensitization where some of these triggers are unavoidable.

50:43
So let's use something like omalizumab, which is an Ige targeting antibody to treat that specifically and that's FDA approved for asthma in that context.

50:52
And then there are studies looking at that in COPD and allergic sensitized as well.

50:56
So I think it's really A2 fold.

50:58
One is phenotyping and understanding the heterogeneity of these diseases is really standard of Care now I would say.

51:08
And then that has non pharmacologic implications like we spent a lot of time talking about in terms of lifestyle adjustments but does down feed downstream as well into some actual pharmacologic decisions as well.

51:20
And then tells you what not to use.

51:22
Also if it's negative, right, it tells you, OK, let me look for some alternative explanations and alternative possibilities also.

51:28
Exactly.

51:29
And sometimes the therapeutics as you alluded to, right, are, are different if we don't have that predominant TH2 allergic phenotype.

51:36
So yeah, it helps be, it helps us be more personalized for sure.

51:43
And see if there's any other questions.

51:53
Yeah, Jasmine, I don't, I see Jasmine, I see Jasmine's comment, but I don't see anything in the Q&A, nothing in the chat guys.

52:03
OK, great.

52:04
Thank you, Frank.

52:04
So I think with that, we'll, we'll conclude, we'll give everyone a few minutes back before they get to their next commitment.

52:11
And on behalf of Gary myself and we'll thank everyone for attending and again Quest for for hosting us.

52:18
Yeah, I would echo that.

52:19
Thanks so much.

52:20
And yeah, we'll see you the next time.