Our next episode of the “Allergy, Asthma & Immunology Innovations Podcast” focuses on anxiety and anaphylaxis. This podcast is a collaboration between Allergy & Asthma Network and The Itch Podcast. It is hosted by The Itch Podcast’s Kortney Kwong Hing and allergist/immunologist Payel Gupta, MD.

In this episode, Kortney and Dr. Gupta discuss how to balance anxiety and fear with the reality of anaphylaxis treatment. They are joined by David Golden, MD, a board-certified allergist and immunologist in Owings Mills, Maryland, associate professor of medicine at Johns Hopkins, and expert in anaphylaxis and insect sting allergy.

Allergy & Asthma Network thanks Aquestive for their sponsorship of this podcast.

You can listen to or download the podcast on ItchPodcast.com for listening anytime, anywhere. The podcast can also be downloaded at:

Timestamp overview

  • 1:35 – Balancing fear and reality in anaphylaxis treatment
  • 3:30 – The mind-body connection and reassurance training
  • 4:46 – Can environmental allergies cause anaphylaxis?
  • 6:12 – Stress-related responses, or panic attacks
  • 8:45 – Risk factors and co-factors for severe anaphylaxis

Full Transcript

Kortney Kwong Hing: You’re listening to The Itch, a podcast exploring all things allergy, asthma and immunology. I’m your co-host Kortney, a real-life allergy, asthma and eczema girl.

Payel Gupta, MD: And I’m your second host, Dr. Payel Gupta, a board-certified allergy, asthma and immunology doctor. Kortney and I hope to balance each other out so that we get you all the information that you want and need about allergies, asthma and immunology.

Kortney: Anxiety, anaphylaxis, co-factors and risk factors of a severe reaction, and why epinephrine is not prescribed for mental allergens. Yes, my friends. We get into these topics and a few more in the last of our 3-part anaphylaxis and epinephrine special series as part of our Allergy, Asthma, and Immunology Innovations podcast series in collaboration with Allergy & Asthma Network.

Dr. David Golden joins us once again as he did in our other two episodes. If you missed part 1 and part 2, in part 1 we dive into what anaphylaxis is and why epinephrine is the only treatment for it. In our second episode, Dr. Golden walks us through all of the new methods being developed to administer epinephrine. To learn more about Dr. Golden, check out our show notes, and, of course, check out the other two episodes we have with him if you haven’t yet.

Before we jump in, we want to thank Aquestive for sponsoring this episode.

There’s this fine balance of rhetoric using fear and reality. And I think that I was told my next reaction is going to be worse. And I think it was because I was a teenager, and they were just trying to instill in me that I need to use my epi when I have a reaction. And I think there’s that fine balance of making it reality and making, like, what the worst outcome could be in putting it in my head.

But then as patients, we can take it too far. And we can take it into a paralyzing fear that we can’t even look at our allergen because it’s going to kill us by just being in the same room. So, there’s that fine balance of what our doctors tell us to motivate us to actually do what is necessary to be done, but then to also not live in a complete state of fear.

Dr. Golden: That’s so important. I agree. And it’s difficult. I think you’re very perceptive and that’s very true that as doctors, we’re not sure sometimes how to balance that and how to get people to do the right thing. If they’re not scared enough of anaphylaxis, then maybe they won’t do the right thing. But the fear of anaphylaxis is debilitating in many people, either in adults or in caregivers, and we have to deal with that, too. So, there’s a lot of balance going on between reassurance, on the one hand, that no, the next one’s not going to kill you.

The epinephrine is not dangerous. There’s a lot we need to understand what their concerns and fears are so that we can work around that and have that discussion so that maybe they will carry it and will use it, but not be afraid to even look at a peanut or go into a room where there’s a peanut. And, yes, there’s reflex reactions, if you will. I tell a story, and it’s very true of a patient who confided in me that if she saw a peanut on TV, her throat would close. Is she crazy? No. This is the result of having been almost scared to death about what her reactions would be, and we had to go through a lot of reassurance training, if you will, to get that to calm down.

Dr. Gupta: I think the mind-body connection – it plays such an important role in medicine, and we, I think, undermine that connection. So, yes, when you’re so fearful and then you think something’s going to happen, then your body can feel a certain way, and you can start feeling that throat closure. You can start feeling that heart racing, the difficulty breathing, the shortness of breath, all of those symptoms start becoming very real.

And there is also that parallel between an anxiety attack versus is it asthma versus is it my throat closing? So, again, I think that mind-body connection is something that I point out to a lot, for patients, that I know that fear is playing a big role in their symptoms. And maybe for that patient that you were talking about using their epinephrine device 20 or 30 times in a year, that patient really needs that extra reassurance and extra reassurance training, as you called it, to help them kind of calm their fears and to really understand and take that moment.

Again, we talk about using epinephrine fast, but we also can take a moment to do some techniques to relax and see if it is an anxiety attack versus is it a true anaphylactic reaction.

And I also just wanted to mention, because I think we’ve talked about the mechanism of action in the context also of environmental allergens and, you know, environmental allergens do not cause anaphylaxis. It’s really food allergens or insect venom that causes anaphylaxis, because I know I do have patients sometimes that say, ‘Oh, I have a cat allergy. Can I have an epinephrine device?’ And, no, we don’t give epinephrine devices for environmental allergies because thankfully, we don’t have anaphylactic reactions to those allergens. We have anaphylactic reactions to venom. And we have anaphylactic reactions to food, and that’s probably the way that it’s ingested. Venom literally is injected into our body by the insect. And so, the way that your body is getting those allergens is causing that anaphylactic reaction. So environmental allergens, or inhalant allergens, do not cause the same type of reaction.

Dr. Golden: So true. And yet they can cause severe allergic reactions. So, we get into a definition thing, but I have to agree that I can’t imagine a patient that I would want to prescribe an epinephrine treatment because of environmental allergies. Almost epidemics of asthma for … I don’t know if you’ve heard of thunderstorm asthma, but that’s a case of severe and potentially life-threatening asthma occurring because of a bizarre kind of grass exposure.

I totally agree with what you said, but there was something as part of what was being said that made me want to come back to the reported anaphylactic reactions to COVID vaccine. This is where we saw – I don’t want to put a percentage on it – I’d be guessing at no more than 50%, possibly 80%, of the reported anaphylactic reactions to COVID vaccines were not anaphylaxis. They were what is now called immunization stress-related responses. I don’t like that term either, and it’s unpredictable. We see it in food challenges, for example, or in drug challenges. People who were given placebo can have a reaction. And it’s not just, ‘Oh, I feel funny. I feel bad. I feel like my throat’s closing.’ They can literally break out in hives even though they’re really not having anaphylaxis. It’s a form of stress-related response and anxiety, or panic attack would be another term for some of those, because that’s how it feels.

People who’ve had panic attacks, if they describe it, you could say, ‘Wow, that sounds like anaphylaxis.’ And it’s very tricky and this is something we’re now recognizing better. So, there’s no easy answer. People have tried to construct charts and tables of, how do you tell the difference between true anaphylaxis and these other reactions. And you know what? We can make charts and tables, but when a patient’s reacting in front of me, I’m probably going to give them epinephrine because I’m not sure I can tell the difference.

So, there’s more to it, with the evaluation and management of anaphylaxis. And when I explained to people about the Benadryl thing about the fact that they got better not because of the Benadryl, but because – I try to phrase it in a way that your reaction at this time, got better by itself – and then I’ll go on to say, you know, maybe that won’t happen next time. You really have to treat it appropriately.

Dr. Gupta: Yes. And that every reaction is going to be different, and that the way that your body – if you’re sick with a cold, if you’re already having asthma issues, if there’s other things that are already going on in your body, that can also put you at higher risk of that anaphylactic reaction potentially being more life-threatening. And so that’s why it’s even more important for you.

Dr. Golden: Like during your allergy season.

Dr. Gupta: Exactly. Like, during your allergy season, if you’re reacting. And then, on all of those school forms, we do get asked, ‘Does this patient have asthma?’ when they have a food allergen, for example. And the reason for that is that we do know that patients with asthma and food allergies, that if they’re going to react, we have to be more careful with those patients because they’re at higher risk of having a more dangerous reaction.

Dr. Golden: One of the things that we focus on, that we’ve seen be a focus of research in the past few years and that we dwell on in the upcoming Practice Parameters, are the risk factors and co-factors for severe anaphylaxis. And some of those risk factors are previous severe reactions. So, what you’ve had before is very important in how we’re going to discuss your future management. Because if you’ve had a really severe reaction, you’re at risk for another severe reaction. That sounds like common sense, but it’s an important point.

As I was saying earlier, people who have had reactions, two or three or more, but it’s never been really severe. Odds are that it won’t be in the future. But age, usually meaning older adults because of underlying medical conditions for example, and co-factors – exercise, stress, active viruses or colds, active allergies, active asthma – there are a lot of co-factors that can turn a reaction from just mild to moderate anaphylaxis into severe life-threatening anaphylaxis.

Dr. Gupta: And just another plug for why it’s important to keep your asthma under control, this is another reason. Because if you have uncontrolled asthma and then you have an anaphylactic reaction to a food you’re allergic to, then that puts you at higher risk.

Dr. Golden: Incidentally, it’s neither here nor there, but just because we’re talking about it, people don’t know this, and doctors don’t know this, but epinephrine is a recommended treatment for severe asthma. It’s in the National Asthma Education and Prevention Program, the NAEPP. But in the schools, if asthma is severe and not responding to inhaled medications, and besides calling 911, it’s like anaphylaxis. Epinephrine as an injection is a recommended treatment for that. Now I go back to an era when that was routine. We gave epinephrine for asthma routinely.

Kortney: That’s something you don’t hear very often, actually. I have to say, on my side as a patient, I’ve never heard that. When I have both asthma and I’ve had anaphylactic reactions in the past, no one’s ever told me that.

Dr. Gupta: Thank you for listening to today’s episode. Remember that all information you hear today is for informational purposes only and are not intended to serve as a substitute for the consultation, diagnosis, and or medical treatment of a qualified physician or healthcare provider. And also, don’t forget to subscribe to our podcast.

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