Tuesday, November 30, 2010

Immunotherapy: a history of histamines

"Winter" here in the San Francisco Bay Area may not be severe by anyone's standards, but there's a definite change in the air that has flipped some sort of switch for me and Voov. It's always been this way, mysterious: changing weather makes eczema worse. Toward winter, it's probably reduced humidity in the air; in spring, there's probably pollen. Can't do much about either! Slather on more moisturizer after November, maybe, but it's not a 100% remedy. And as far as antihistamines go for pollen: completely useless, in my experience.

So here we are, skin suddenly tighter and drier, the red excoriations on our hands and wrists. But neither of us is going through an extreme flare.

I ran out of Eucerin on the weekend, and picked up a jar of generic moisturizer at CVS. You know the kind. It's the store brand stuff stacked next to the Eucerin, and the price tags read "Eucerin: $15.99" "CVS Moisturizing Creme: $9.99." You get what you pay for. The problem is, the cheap stuff may LOOK the same as Eucerin, but it sucks. It's thinner and slippery and wears off fast. I have to relearn this the hard way every six months or so.
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I want to share this review with you. It covers the history of our understanding of how immunotherapy works. The senior author is Mitchell Grayson, the scientist from the Medical College of Wisconsin who gave a presentation on eosinophils at the recent annual meeting of the American College of Allergy, Asthma, and Immunology.

The review is only eight pages including two of references, but it's encyclopedic. It follows immunotherapy all the way from its inception in 1911 (Leonard Noon's paper in the Lancet on injecting hay fever patients with grass pollen extract) to the current day. The authors explain how the therapy has remained essentially the same, but our understanding of how it works has evolved to become ever more complex as scientists have laid bare the secrets of the immune system.

In short: in the 1930s, scientists realized that patients given immunotherapy develop "blocking antibodies" that hinder the overeager allergic response. In the late 1960s, they learned that immunotherapy stabilizes mast cells and basophils and reduces the quantity of histamine released when patients encounter allergenic triggers. In the 1990s, after the discovery that there are at least two subtypes of helper T cells, scientists realized that immunotherapy partially shifts the T cell population in allergic patients from the allergy-related type 2 to the infection-related type 1. And in the mid-2000s, regulatory T cells were discovered; immunotherapy apparently increases the number of regulatory T cells that inhibit type 2 helper T cells.

Over time,  immunotherapy has been refined. With greater understanding of how the mucosal membranes process allergens, scientists developed sublingual immunotherapy, in which the allergens are placed under the tongue and absorbed into the tissue, where they are taken up by dendritic cells. (Straight-up oral immunotherapy, where the patient swallows the substances, is a bust.)

And, for asthma patients at risk of severe allergic reactions, doctors now administer immunotherapy along with the monoclonal anti-IgE antibody "omalizumab." Which is produced by Genentech, naturally, and costs $10,000 to $30,000 a year. I wonder, within the US, which insurance plans cover this, and whether the product is available outside the US. It's relevant to eczema because it appears to be quite effective-- it might become cheaper over time (e.g. after the patent expires) or other companies might develop alternatives to take excess IgE out of our systems.

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