Richard Jacobs: Hello. This is Richard Jacobs with the Finding Genius podcast. I have Lahari Rampur, she’s a clinical assistant professor in the department of medicine, division of allergy and infectious diseases at the University of Washington and we are going to talk about allergies and immune disorders. Lahari specializes in treating disorders like food allergies, drug allergies, seasonal allergies, asthma, insect allergies, et cetera. Lahari, thanks for coming.
Lahari Rampur: Thanks for inviting me, Richard.
Richard Jacobs: Is your work mostly clinical seeing patients or are you doing research as well?
Lahari Rampur: I do mostly clinical work but I also do some research in terms of antibiotic energies and helping the institution coming up with the right protocol to treat patients with antibiotic allergies.
Richard Jacobs: So these are antibiotics you’d take when you get sick and people develop allergies to them?
Lahari Rampur: Yes. Many people who have a history of allergic reactions to penicillin and various antibiotics. What happens is when they get hospitalized because of their history people need to get alternative antibiotics, which may not be the best thing to do because they’re more expensive at times. They can cause side effects. So it’s important to really choose to identify who is actually allergic and who is not. So in those situations, we need certain types of protocols and guidelines and to see who is really allergic. This is part of antimicrobial stewardship where infectious disease specialists and pharmacists get involved. And I also have a role to help develop guidelines and protocols and the institution. That’s what I meant when I said the research.
Richard Jacobs: Okay. So what happens when somebody gets an allergy to an antibiotic? I mean, is it a real serious acute type of thing where they have to quickly help the person or what happens to people in general?
Lahari Rampur: So there are different types of allergic reactions. Yes, people can have severe reactions like anaphylaxis. People can get HIAs and swelling, swelling of their throat, and breathing difficulty and people can even die. Fortunately, mortality is not very high, but people can have a severe reaction. The other types of severe reactions have blistering skin reactions that sometimes it can also affect your organs like kidney and liver. Those types of reactions that rare as well. But for the most common type of reactions are rashes and flushing and itching type of reactions, they’re pretty common into different medications.
Richard Jacobs: So what’s to be learned about these allergies so far? Are there commonalities or does it seem to be very person-specific?
Lahari Rampur: They are person-specific, but in my experience, most of the people who had specific allergy many years ago to any antibiotic are eventually able to take it. About 10% of the population in our patients that we see reports, some type of drug allergies. But more than 90% are able to take it. So most are mild, and they can eventually introduce the same antibiotics that they were allergic to sometimes after testing and sometimes even without testing, just based on the history of mild or minor reactions.
Richard Jacobs: Are you correlating let’s say someone’s microbiome with an allergic reaction? Is that being studied?
Lahari Rampur: Yes, there are a lot of studies on the microbiome and how having a certain type of microbiome predisposes you to develop allergic conditions that may not be specific allergy-like keen a turn other foods and specific drug allergies. But overall, the tendency to develop allergies in the future like eczema, asthma, and seasonal energies. This is called the allergic March. So people have studied about the microbiome, which influences one’s tendency to develop allergies in their life.
Richard Jacobs: Alright. So what other kinds of allergies you run into most of all? Is it asthma or food allergies?
Lahari Rampur: Yes. I do see different types of food allergies whether it’s a minor allergy or a severe type of anaphylaxis to various types of food. Drugs that I already discussed. We also treat patients with beasting allergies. Do skin testing and evaluate them further. And we do see seasonal allergies and environmental allergies. Like pollen, mold, dust, cat, dog. How this also affects asthma and we treat patients with asthma. And we also treat patients with skin disorders like contact allergy. We can do patch testing to help them to find out contact allergens and we treat patients with asthma. So these are the type of allergic conditions we treat.
Richard Jacobs: So what’s the new science saying about some of these allergic conditions? Where do they come from? What modulates?
Lahari Rampur: Your genetics. If you have a family history, if your parents have allergies or asthma you’re much more likely to develop allergies, but there is also environmental influence on a genetically predisposed person. Let’s say you’re exposed to a lot of dust mites and maybe pollution, smoking. Maternal smoking has also been studied as a correlating factor for the development of allergies in kids. So there are various factors. Gene is number one of the reasons. You have genetically predisposed but there are also environmental influences.
Richard Jacobs: Well, if genetics is the main reason why would people develop allergies or over time lose their allergies? That would be epigenetics at best. Right?
Lahari Rampur: Yes, yes. That’s what I meant to say. Environmental influence on genetically predisposed people. Epigenetics also plays a huge role.
Richard Jacobs: So what are the most urgent allergies to look at? Which ones are either on the rise or really prevalent that needs to be addressed?
Lahari Rampur: So these days the food allergies becoming more common for reasons which are not very clear. Maybe it’s a hygiene hypothesis. But people studied kids in Europe, people who were living in the farm. They have a lesser amount of allergies compared to people who are living in urban areas. I don’t know whether it is the hygiene hypothesis that has been studied whether it’s the microbiome so food allergies have been on a race and severe asthma is another allergic condition that needs to be addressed, especially in inner-city population.
Richard Jacobs: So what’s being done? Is it really important therefore to sequence someone’s genetics when they have an allergic reaction and then maybe sequence their whole family or like what’s the protocol where you can quickly figure out what might be going on with someone, what to do?
Lahari Rampur: So typically we don’t go into genetics when it comes to allergic reactions. We simply try to find out what they might be allergic to so that we can help them better. Maybe to avoid or even to desensitize our recommend immunotherapy to certain environmental allergens that they have. We typically don’t test the genetics because even if you find out where it is coming from or why they’re having you’re not able to change that part. Hence, we don’t typically do a genetic analysis in people with allergies. It’s for immune deficiency and immunological disorders. We consider genetic studies not so much for allergies,
Richard Jacobs: But if someone has allergies, what are you doing to treat them then? If genetics play a big role and then look at their genes, I mean, how do you treat them effectively?
Lahari Rampur: Okay, so let’s say somebody went to a restaurant, had an allergic reaction immediately, like hives and lip swelling. They’re not able to breathe. They ate 10 different types of things. We ask them what exactly they ate and we test them for those things that they ate. And if something stands out or comes back significantly positive, we can tell them you came back positive to fish or shelter. So something that they need to avoid so they can be careful and look for ingredients. So when it comes to pollen and dust mites, some people really do suffer and have a poor quality of life in this season or throughout the year with headaches and sinus issues and whatnot. If we find out that they’re positive too, let’s say pollen or dust mites, pet dander, we can give them allergy shots. So we can mix the things that they’re allergic to and we keep giving in the form of shots to reduce their sensitivities. We train their immune system not to react the way it was reacting. Or we can also recommend some dust mite control measures, which are proven to be beneficial in patients who suffer from dust mite allergies. So each person is different when it comes to anaphylaxis to bee stings or any type of insect stings. The chances of having this severe life-threatening reaction in the future in a patient who has had a history of severe systemic reaction are very high. So in those patients, we test them if they’re positive, we can also give allergy shots, which significantly reduces their chances for the future reaction if we start them on the shots.
Richard Jacobs: Oh, why the allergy shots work, how do they work and what do they do?
Lahari Rampur: So allergy shots are a way of training your immune system, converting them from allergic to non-allergic types of cells through the release of various types of chemicals called cytokines. So that are energy causing molecules. They are molecules or cells that build tolerance. So it’s slowly deviating the immune system from being allergic to non-allergic.
Richard Jacobs: So I’m not saying to do this, but if you’re allergic to something, could you expose yourself to like a minute amount of it every day and slowly build up more and more of it until you’re immune to it?
Lahari Rampur: If you had a real significant allergic reaction to something, we wouldn’t advise doing that because there is a risk of developing an allergic reaction. We sort of doing it in a controlled setting and with precisely calculated doses of allergens, since you cannot control that at home, I wouldn’t do that. But for pollen allergies, I know people talk about local honey and things like that. I think it’s one way of developing tolerance to pollens if you are allergic to any. People do that. But for food allergies, I wouldn’t necessarily recommend doing that at home.
Richard Jacobs: Well, it could be so dangerous that you could easily knock yourself off. Okay. Got you. So what’s the difference between a pollen response or a dust mite mold and a food allergy? Why do food allergies seem to be so acute and so strong?
Lahari Rampur: So there are different types of cells that are involved, whether its airway or in the gut. So when you’re eating an allergen the way it is processed and when it went to the immune system is different compared to weight as processed and even to the immune system in the airway and the cells that cause an allergic reaction like mast cells and basophils, they are also a little bit different when it comes to airway and the gut. And that’s why it can be a different type of reaction.
Richard Jacobs: Okay. So do people tend to have allergic reactions both ways? I mean, you’re not eating pollen, but in a way, maybe even minute amount I guess, or not. But what if you have a food allergy? Let’s say it’s the peanuts. Could you smell some volatilized peanut essence and build up a tolerance that way? Would that be a safer way of getting used to it instead of like eating a minute bit of peanut? Like how of a protocol has been developed to get people over really bad allergies, if at all?
Lahari Rampur: Well for peanuts we have peanut patches and sublingual tablets. They are extensively studied these days. And people are using these to develop tolerance to peanut allergies, but I’m not aware of anything that can cost tolerance through inhalation. I don’t think that’s been studied.
Richard Jacobs: Well I guess it wouldn’t be the primary mechanism in which you experienced the allergy. So maybe it makes no sense. I just wonder if there’s a way to do that. Could you inject yourself with something related to peanuts, for instance, and do it that way. Could it be administered that way? But you’re saying sublingual is what the preference is right now since it’s similar to the route by which we get the allergy.
Lahari Rampur: Okay. The chance of having a reaction to any food on anything by injecting is a lot more compared to taking it orally. Even if it’s an IV antibiotic or an oral antibiotic, the chance of having a reaction when you’re receiving IV is higher compared to taking it orally, and also tolerance to food or anything can be let’s say you’re inhaling something pollen allergies. So we don’t necessarily do the immunotherapy through inhalation mode because that can build allergy. As opposed to that if you inject the allergen, the immune system perceives it in a different way so that it can build a tolerance. It can train a totally different set of senses to develop tolerance. And that’s what the idea is.
Richard Jacobs: Forget my bad idea of injecting. [Chuckles]
Lahari Rampur: [Chuckles] No that’s a good question. You are asking smart questions.
Richard Jacobs: But beyond that which cells in the body tend to be the best reporters to other cells and to help build immunity to a give an insult? There are certain cell types identified or does it just depend on the allergy?
Lahari Rampur: So there are cells, antigen-presenting cells, they are called dendritic cells. Anything that we eat they are presented to the immune system. So create the amount of detail reactions happening in the immune system. It depends on what kind of chemicals are released, cytokines are released. Cytokines are some kind of messengers depending on what type of messenger is released after you ingest something. Specific cells are attracted to the area to cause an allergic reaction. So to answer your question, there are different types of cells that present the allergens or an antigen to the immune system. But having a reaction on not is genetically predisposed and epigenetics also playing into play the role. Like at the molecular level, the crazy amount of things happening in the immune system.
Richard Jacobs: Right. That’s true. Any breakthroughs that are being tested right now that seem to hold a lot of promise that we may see clinically soon that you think are important and why?
Lahari Rampur: In terms of allergies more and more things that are coming these days are biologic medications. These are the medications that specifically act on certain molecules. For example, asthma. There are different types of asthma phenotypes. Whether it is one type of cells called eosinophilia pathway, which causes asthma or allergy pathways. Allergy antibodies are IgE antibodies.
So we have antibodies that block the IgE antibodies. For example, an injection called Xolair. This is designed to block IgE antibodies. There are wide varieties of anti-eosinophilic antibodies that are being developed. The exciting thing is that we classify as asthma into different phenotypes, whether it’s an allergic, non-allergic, eosinophilic, non- eosinophilic. And we can pick and do the monoclonal antibodies or biologic medications. So that’s actually exciting. And we have more to come in the next few years. And that’s exciting about treating allergic disorders. And when it comes to immune deficiencies there are other cool things that are being developed as well. We haven’t talked much about immune deficiency, but for so far for allergy advances and understanding the molecular basis of how the immune system reacts to various allergens and specifically targeting certain molecules is the exciting part right now.
Richard Jacobs: Well, what happens typically in an immune reaction right now, let’s say food allergy, why would someone’s throat swell closed? Why would they have this such severe reaction like what’s going on biologically with them that causes these problems?
Lahari Rampur: So when you’re having an allergic reaction, to overly simplify mast cells and basophils are the energy causing cells. They store different types of chemicals. Most commonly histamine and Tripp days. And these are the chemicals that are released. And various types of prostaglandins are released from the mast cells and basophils. These chemicals have various functions. They enlarge the blood vessels, they make the blood vessels more permeable that is losing of liquid from the blood vessels. So these are the things that give rise to flushing and itching and swelling of the local area. If the swelling occurs on the skin it’s called angioedema or skin and the underlying tissue you can get hide. So angioedema is the same thing happening in your throat. Which causes swelling. I mean it may cause swelling and sensation of throat closing and shortness of breath.
Richard Jacobs: Lahari what do you think is going to be possible in the next few years? I mean, do you think that yes, maybe there are new treatments coming, but is the allergy situation worsen or is it kind of the same as it always was? I mean, I know it’s probably changing, but do you see that we have to hurry up and get some better science to treat these things because they’re growing or what’s your overall feel?
Lahari Rampur: So overall the allergies have increased. Whether it is because we are diagnosing and are able to find more patients or whether it is climate change leading to more energies or hygiene hypothesis. We don’t know. But allergies are on the ray. I think scientifically in terms of finding treatment and understanding the pathways people are doing amazing jobs. But I think one of the biggest challenges is that it’s impossible to prevent or completely stop the allergies from occurring. It’s important to understand the molecular basis to treat them better, but I don’t think you can completely prevent allergy. There are certain measures that you can take that there are also studies to show that by early introduction of food in infants you can actually prevent allergies, especially in hiatus children. Those are the things that we are able to better understand, but I don’t know if that is a way to completely prevent, treat, or resolve the allergy once it’s developed.
Richard Jacobs: Yeah. And should I have asked you at the beginning, why is this important to you? Why do you study allergies and things like this? Is there any like an unfortunate personal circumstance that’s governing this?
Lahari Rampur: So when I studied in India, I went to med school in India before coming to the US. So I worked in an underserved area. Where I used to come across a lot of allergies and immune disorders, kids with immune deficiencies, but we didn’t have any resources to treat them, diagnose them or do further. But when I was doing my residency in New York, I had a chance to rotate in the Albert Einstein University allergy department where I came across a wide variety of complex cases of allergies and immune deficiency. It was fascinating to me. I was totally blown away by the kind of variety and complexity and that’s how I got interested in allergies and immune deficiencies.
Richard Jacobs: Okay, great. Well, how do people find out more about you and your work? Where can they go? Is there a website or they Google you?
What’s best?
Lahari Rampur: They Google me. I’m associated with the University of Washington and there are things that we do. It’s there in the website and that’s how people get to know me overall.
Richard Jacobs: Okay, well, very good. Lahari thanks for coming. I appreciate it. And I know this is a problem and I have asthma myself and I’ve experienced allergies and probably everyone listening either has or knows someone that has experienced this stuff. So it’s not alien. It’s very pervasive. So thank you for being here. I appreciate it.
Lahari Rampur: Thank you for inviting me and for giving me this opportunity Richard. Happy to be here.
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