Monday, January 28, 2019

Another option for life-threatening allergic reactions

It’s a new year, the gyms are unusually busy, and many of us started a new physical activity. Several health clubs are offering fun, interactive, and dynamic exercises such as whole-body workouts, functional training, CrossFit, high-intensity interval training, spinning, etc.

Some of these classes are incorporating intense workouts, which was a hot topic in exercise physiology in 2017. There is significant enthusiasm around these programs among my friends, family, and patients. Some of these classes have loud music, lights, and trainers whose job is to push you to a new level. Increasing the intensity of a workout may bring significant health benefits for some; however, lately we are starting to see cases of a potentially life-threatening disease as a result of these activities. It’s called rhabdo.

The other day I saw someone wearing a shirt that said “Pushing until Rhabdo.” That made me cringe. And I realized that, although rare, some people do not understand how serious rhabdo can be.
What is rhabdo?

Rhabdo is short for rhabdomyolysis. This rare condition occurs when muscle cells burst and leak their contents into the bloodstream. This can cause an array of problems including weakness, muscle soreness, and dark or brown urine. The damage can be so severe that it may lead to kidney injury. Intense physical activity is just one of the causes. Others include medication side effects, alcohol use, drug overdose, infections, and trauma/crush injury. Fortunately, most people who have rhabdo do not get sick enough to require hospitalization. But if you develop any of these symptoms after a hard workout, it’s a good idea to set up an appointment with your doctor. A simple blood and urine test could help establish the diagnosis.
How to avoid rhabdo

I know you are probably excited about your new exercise program, and you want to excel. And that’s great. But take it easy, especially if this is a new exercise routine. You want to challenge your body, but avoid extremes. If you are working with a trainer, make sure you tell him/her where you stand in terms of fitness level and health concerns. In addition:

    Drink lots of water. That will help prevent problems and help flush your kidneys.
    Avoid using anti-inflammatory medications such as ibuprofen and naproxen. These drugs may worsen kidney function.
    Avoid drinking alcohol. Alcohol is a diuretic, which means it will make you more dehydrated. You need more fluids in your system, not the opposite.

If you experience intense pain and fatigue after your workout, you should call your doctor. Most cases of rhabdo are treated at home simply by increasing fluid intake. If muscle enzyme levels are high, or if there are signs of kidney problems, IV fluids may be needed. In some cases, we have to admit patients to the hospital and even to the ICU for close monitoring and further treatment.
Ramping up safely

Be smart and train your muscles to adapt to new activity. Exercise is better if it is enjoyable and entertaining, and I have to say that some of these classes are incredibly fun. But make sure that you listen to your body. Watch out for trainers who may push you too hard to the point of exhaustion. That should not be your goal when you are first starting a brand-new routine, especially if you haven’t been active for a while. A good trainer should get to know you and will tailor the exercise routine to your level of fitness. Adding a new workout to your day is probably one of the healthiest habits you can incorporate in 2018, but don’t “push until rhabdo.” Instead push slowly but consistently, challenging your body toward wellness and better function. Attention deficit hyperactivity disorder, or ADHD, is very common — according to the most recent statistics, one in 10 children between the ages of 4 and 17 has been diagnosed with this problem. So it’s not surprising that when parents notice that their child has trouble concentrating, is more active or impulsive than other children, and is having trouble in school, they think that their child might have ADHD.

But ADHD isn’t the only problem that can cause a child to have trouble with concentration, behavior, or school performance. There are actually lots of problems that can cause symptoms that mimic ADHD, which is why it’s really important to do a careful evaluation before giving that diagnosis. Here are five common problems that parents and doctors should always think about:

1.  Hearing problems. If you can’t hear well, it’s hard to pay attention — and easy to get distracted. Now that more newborns are being screened for hearing problems before leaving the hospital, we are able to catch more cases early, but some slip through the cracks, and children can also develop hearing problems from getting lots of ear infections. Any child with behavioral or learning problems should have a hearing test to be sure their hearing is normal.

2.  Learning or cognitive disabilities. If children don’t understand what’s going on around them, it’s hard for them to focus and join in classwork. Children who have trouble understanding may also have difficulty with social interactions, which can be very quick, complex, and nuanced. Any child who is doing poorly in school should be evaluated and given the help they need. All public schools have a process for evaluating children and creating an Individualized Education Program, or IEP, for those who need help. Even if a child goes to an independent school, they can still get an evaluation through the public schools. Parents should talk to their child’s teacher and their pediatrician for guidance.

3.  Sleep problems. Children who don’t get enough sleep, or whose sleep is of poor quality, can have trouble with learning and behavior. Any child who snores regularly (not just with a bad cold) should be evaluated by their doctor, especially if there are any pauses in breathing or choking noises during sleep. Parents of teens should be sure that their children are getting at least eight hours of sleep and aren’t staying up doing homework or on their phones. In general, any time a diagnosis of ADHD is being considered, it’s important to take a close look at a child’s sleep and make sure there aren’t any problems.

4.  Depression or anxiety. It is hard to concentrate when you are sad or worried, and it’s not uncommon for a depressed or anxious child to act out and get in trouble. More than one in 10 adolescents has suffered from depression, and the numbers are higher for anxiety. Even more alarming, both depression and anxiety often go undiagnosed — and untreated — among children and adolescents. As part of any evaluation for ADHD, a child should also be evaluated for other mental health issues, not just because they can mimic ADHD, but because other mental health issues can occur with, or because of, ADHD.

5.  Substance abuse. This is something that should always be considered in an adolescent, especially if the ADHD symptoms weren’t present earlier in childhood (by definition, you have to have the symptoms before age 12 to get the diagnosis). Nobody wants to think that their child could be using drugs or alcohol, but by 12th grade about half of youth have tried an illicit drug at least once, and for some, it can turn into a habit — or worse. For some people, many foods, medicines, and bee stings mean life-threatening allergic reactions that require immediate treatment with injectable epinephrine. For many people, January means the start of a new drug deductible to be met. In June 2017 the FDA approved a new form of emergency epinephrine called Symjepi, which may be good news for people who must be prepared in the event of a life-threatening allergic reaction.
The seriousness of a severe allergic reaction

Severe allergic reactions affect anywhere from 5% to 70% of persons, depending on age and prior exposure. Anaphylactic or “type 1” (immediate hypersensitivity) reactions are the most severe forms of allergic reaction to a substance: insect venom, foods, or some drugs. People who have had prior exposure to an allergic substance are “sensitized” and when they are re-exposed, can have a reaction within seconds to minutes. Anaphylactic reactions are caused by the release of histamine and other chemicals throughout the body, resulting in leaky blood vessels that contribute to swelling of tissues in the mouth and airway and very low blood pressure. These symptoms can lead to difficulty swallowing and speaking, wheezing and severe shortness of breath, and death.
Treating severe allergic reactions

The treatment for severe allergic reactions is the administration of epinephrine (adrenaline) at the first sign of symptoms. Epinephrine is one of the chemicals in the body that raises blood pressure and heart rate. Epinephrine can be administered through an IV in the hospital, but since the 1980s, epinephrine has been available as a pre-filled syringe that can be obtained with a prescription and immediately injected into the thigh muscle when severe allergic symptoms are recognized.

The prevalence of severe allergies has been increasing since 2000. Anaphylaxis to some external chemical or allergen occurs in 2% of the population, and it is estimated that approximately 500 people die from anaphylactic reactions per year in the US. Because of this, more and more people need to have epinephrine available wherever they are (home, school, when traveling). So it is no surprise that the manufacture and marketing of pre-filled epinephrine syringes has been big news in the last two years.
Keeping epinephrine at the ready

Spring-loaded autoinjectors that contain epinephrine have been manufactured by several companies since 1987. In the last 30 years, changes in pharmaceutical companies and patent transfers resulted in a near-monopoly in the production of pre-filled epinephrine products. From 2009 to 2016, one company with a 90% market share dramatically increased the consumer cost for epinephrine injectors, resulting in an investigation and eventual settlement with the US Department of Justice.

Although not a spring-loaded autoinjector, Symjepi consists of two single-dose, pre-filled syringes of epinephrine, for the emergency treatment of anaphylactic and severe allergic reactions in adults. Each pre-filled syringe contains 0.3 mg epinephrine, the recommended initial dose for emergency treatment of anaphylaxis.

At an anticipated lower cost and small size, Symjepi could be an attractive addition to this slice of the pharmaceutical world. In November 2017, the company also submitted a second new drug application to the FDA for a junior version (0.15 mg dose for children between 33 and 65 pounds).

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