AAAI/WAO 2018 Perspectives - Episode 14
Jonathan Spergel, MD, PhD, a professor of pediatrics at the Children’s Hospital of Philadelphia, sat down with MD Magazine after the AAAAI/WAO Joint Congress in Orlando, Florida, to discuss the issue of personalized medicine in the treatment of allergy and asthma, and how most allergic diseases need an interdisciplinary approach to achieve proper treatment.
Jonathan Spergel, MD, PhD:
I think one of the biggest issues in the future, when we think about clinical care, is this issue of personalized medicine because not every patient is the same. We know the difference between mild patients, moderate patients, and severe patients. The mild patients—some can be treated with sort of as-needed medicines and really aren't at risk to progress to more severe disease, while other patients are, if we don't treat them aggressively with [regard to] the mild symptoms—they're going to progress to more severe disease.
But then, even with the severe diseases, some severe patients will work well to this treatment and some other ones will work well to that treatment, and some severe patients will end up developing this complication while some of them will not. I think that's going be one of the key things when we think about in the future in terms of therapy and the diagnosis, is deciphering that out—understanding these, what we call endotypes and phenotypes—who is sick, who is at risk.
So if you're at risk for, say for food allergy, you are at risk for a severe life-threatening reaction and we need for you to be really careful, avoid the food, and always carry your epinephrine devices with you. [Meanwhile,] you, yeah, if you eat a little bit of a food by mistake, you break out in hives, but we don't need to worry about it with you too much. [It’s] understanding that difference.
Same thing for asthma. You have mild intermittent asthma, you can take medicine as needed. You're a severe dependent asthmatic, and you are at risk for complications, so I need to put you on a biologic—or you're a severe asthmatic, but you’re really controlled with just a combination therapy. So separating that and understanding that, early on, understanding the response to the therapies would be one of the key things I’ll think about in the future.
For treating most allergic diseases, it is often better to do it with an interdisciplinary approach, whether it's asthma, atopic dermatitis, eosinophilic esophagitis. The advantage of this multidisciplinary approach is, depending on each individual disease, you can look at each thing [individually].
For example, for atopic dermatitis or eczema, having an allergist and dermatologist and a psychologist really will help the different aspects of disease. A lot of patients with atopic dermatitis have a lot of anxiety [and] behavior issues. You have a rash that's very visible. They have very low self-esteem. They're up at night scratching and itching, so they don't sleep well. They get depressed. So, having a psychiatrist to work with those issues, and working on those things really will help [the] patient’s overall health, and having an allergist and dermatologist—there's slight [differences and it’s] 2 different windows looking at the same disease.
Classically, the dermatologist will focus more on contact dermatitis—a little more so like, “hey, maybe this moisturizer is really causing the problem because he's reacting to the moisturizer,” while the allergist might say, “maybe it's actually that cat in the house” or “they’re allergic to egg, that’s triggering the problem.” Using that multidisciplinary approach, and having multiple people looking at the window, you can make people better.
You can see the same thing with asthma using multiple physicians or having other providers, such as a psychiatrist, or a social worker. Working on compliance, looking at the home. For asthma, sometimes we can think about the home environment, [and] what you can do for home environment, what things you can do inside the home. You can have someone who's an expert in that [come in] to really look at that, while maybe the physician is more focused on the medical aspects, [and can say,] “hey, this is the right medication.”
So using that interdisciplinary approach, you can really, not just treat the 1 disease, but the whole person and figure out what's best for that 1 person, and to truly treat them as an individual.