617. Are You Really Allergic to Penicillin?
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Freakonomics Radio
01-10 19:0037
全文概览
The dialogue delves into the prevalent issue of misdiagnosed penicillin allergies, a misunderstanding that has led many to avoid a critical antibiotic. It opens with a personal anecdote that evolves into a broader discussion with medical professionals about the widespread nature of this misdiagnosis and its consequential costs. The narrative emphasizes the groundbreaking discovery of penicillin by Alexander Fleming, highlighting its revolutionary role in medicine and its continued relevance despite the development of newer antibiotics. The core of the conversation is the paradox of people believing they are allergic to penicillin, a condition that research shows is inaccurately diagnosed in the majority of cases. This misdiagnosis restricts treatment options for individuals and incurs significant economic and medical expenses due to the unnecessary avoidance of a safe and effective antibiotic. The dialogue extends the discussion to other areas of allergy misdiagnosis, such as food and environmental allergies, suggesting that these issues are exacerbated by factors including pharmaceutical marketing and a lack of diagnostic tools and awareness. It touches on efforts to address these problems, including advancements in penicillin allergy testing and the potential for future technologies to transform allergy diagnosis and management. The conversation underscores the importance of critical thinking in healthcare, the necessity for improved diagnostic methods and increased awareness, and the potential benefits of rectifying these issues to enhance patient outcomes and reduce healthcare costs.
The dialogue delves into the prevalent issue of misdiagnosed penicillin allergies, a misunderstanding that has led many to avoid a critical antibiotic. It opens with a personal anecdote that evolves into a broader discussion with medical professionals about the widespread nature of this misdiagnosis and its consequential costs. The narrative emphasizes the groundbreaking discovery of penicillin by Alexander Fleming, highlighting its revolutionary role in medicine and its continued relevance despite the development of newer antibiotics. The core of the conversation is the paradox of people believing they are allergic to penicillin, a condition that research shows is inaccurately diagnosed in the majority of cases. This misdiagnosis restricts treatment options for individuals and incurs significant economic and medical expenses due to the unnecessary avoidance of a safe and effective antibiotic. The dialogue extends the discussion to other areas of allergy misdiagnosis, such as food and environmental allergies, suggesting that these issues are exacerbated by factors including pharmaceutical marketing and a lack of diagnostic tools and awareness. It touches on efforts to address these problems, including advancements in penicillin allergy testing and the potential for future technologies to transform allergy diagnosis and management. The conversation underscores the importance of critical thinking in healthcare, the necessity for improved diagnostic methods and increased awareness, and the potential benefits of rectifying these issues to enhance patient outcomes and reduce healthcare costs.
00:00
00:00
The Misconception of Penicillin Allergy
A personal recovery story leads to discussing penicillin's significance and the widespread, possibly mistaken belief of penicillin allergy in a significant portion of the population. Highlighting penicillin's historical discovery and its continued importance as an antibiotic, the dialogue raises questions about the accuracy of self-reported penicillin allergies and the potential implications of such misconceptions.
02:49
02:49
Addressing Misdiagnoses and Allergy Controversies
The dialogue touches on concerns about misdiagnosed allergies and broader controversies surrounding food and environmental allergies, highlighting the difficulty in accurately determining the prevalence of allergies due to these issues.
03:10
03:10
The Penicillin Allergy Myth: Exploring the Gap Between Perception and Reality
The episode delves into the surprising fact that a significant discrepancy exists between the number of Americans who believe they are allergic to penicillin and those who actually are. This discrepancy raises questions about the medical, economic, and social implications of this widespread misconception.
04:08
04:08
Exploration of Allergy and Immunology: A Journey Through Medical Interest
Drawn to medicine from a young age due to family influence and supported by mentors, an individual's early interest in hematology and oncology evolved during residency towards allergy and immunology. Fascination with the immune system's complexities, its crucial role in protecting against diseases, and the intriguing challenges of autoimmune and allergic diseases drove this shift. The allure of making a significant impact on patients' quality of life by understanding and treating conditions related to immune system dysfunctions underscores the appeal of this medical specialty.
05:30
05:30
The Role of Immunoglobulin E and Allergies in Modern Medicine
Immunoglobulin E, produced by B cells, played a crucial evolutionary role against parasites but now triggers allergic reactions to harmless substances like peanuts and pollens in some individuals. With tens of millions affected, the demand for allergists is high, yet they are significantly outnumbered by other specialists, highlighting a gap in medical specialization for allergies.
06:43
06:43
Exploring the Misconception of Penicillin Allergy
A patient discusses their long-held belief of being allergic to penicillin, based on family history, until their doctor suggests getting tested to potentially 'delabel' this allergy. Despite the advice, the patient initially dismisses it due to the perceived inconvenience and cost. Years later, after failing to find relief from a persistent cough with alternative antibiotics, the patient considers the possibility of using penicillin. The dialogue touches on the severity of anaphylaxis, a concern for those who suspect they might have a severe allergy to medications like penicillin.
09:28
09:28
Misconceptions About Penicillin Allergy and the Dangers of Anaphylaxis
Anaphylaxis leads to airway constriction and potential cardiac arrest due to blood pressure drop from vessel dilation. Surprisingly, studies reveal that 90% of individuals in the U.S. who think they have a penicillin allergy can actually tolerate it.
09:59
09:59
Misconceptions About Penicillin Allergy and Its Impact on Medical Treatment
Many people wrongly believe they are allergic to penicillin, based on childhood reactions or assumptions, leading to potential health risks and higher costs due to opting for alternative medications with harsher side effects. Contrary to this widespread belief, most individuals deemed penicillin-allergic could benefit from the drug without adverse effects. The dialogue highlights the importance of conducting prick tests, including controls like saline and histamine, to accurately diagnose penicillin allergy, potentially saving lives and reducing healthcare expenses.
12:06
12:06
Understanding Penicillin Allergy Testing and Challenges
The dialogue explains the process of testing for penicillin allergy, starting with skin prick tests using saline, histamine, and penicillin to observe for reactions. If these tests are negative, an intradermal test is performed to confirm. If both tests are negative, a penicillin challenge, typically with amoxicillin, is conducted to conclusively determine allergy status. The oral challenge, considered the gold standard, involves administering a dose of penicillin and monitoring for reactions to confirm non-allergy.
13:27
13:27
Overcoming Misdiagnosed Penicillin Allergy and Managing Thyroiditis
The individual recounted their experience of discovering they were not allergic to penicillin after undergoing tests recommended by a doctor, including a skin prick test and taking a dose of penicillin under observation. This realization allowed them to treat a subsequent health issue, non-group A strep throat and thyroiditis, with amoxicillin, leading to significant improvement in their condition. The thyroiditis, an inflammation of the thyroid gland, was a new concern for the individual, highlighting the gland's crucial role in the body's immune response and overall health regulation.
15:53
15:53
The Potential of Penicillin in Preventing Suffering
Discussed is the possibility that early use of penicillin could have prevented significant suffering. An allergist and immunologist from Mass General Hospital and Harvard Medical School emphasizes the effectiveness of antibiotics against bacteria.
16:25
16:25
Penicillin's Dual-Edged Sword: Effectiveness vs. Allergy
Penicillins are highlighted for their minimal adverse effects and superior efficacy against susceptible infections, although the potential for allergic reactions poses a significant drawback. The dialogue notes that antibiotic allergies are often misdiagnosed, with the occurrence of rashes during infections sometimes leading to confusion about allergy status.
17:08
17:08
Misdiagnosis of Allergy in Children with Infections
Children often develop rashes due to infections, which are sometimes misattributed as allergic reactions to antibiotics. These infections might not have been bacterial but viral, leading to a misattribution of allergy.
17:24
17:24
The Evolution of Antibiotic Use and Patient Treatment
The dialogue reflects a shift in perspective on antibiotic use, highlighting the growing concern over antibiotic resistance. It underscores the importance of not rushing to treat illnesses with antibiotics immediately, suggesting a more cautious approach to healthcare. The conversation also touches on the variability of patient outcomes based on treatment methods, emphasizing the benefits of delayed antibiotic treatment unless absolutely necessary. This approach includes initial management with rest, hydration, and over-the-counter remedies, with antibiotics reserved for cases where symptoms persist or worsen.
18:39
18:39
The Misconception of Medication Allergies and Side Effects
The dialogue explores the confusion between medication allergies and side effects, highlighting the importance of choosing the right drug for a patient. It questions the conventional two-tier system of treatment based on allergy listings and suggests that what is often labeled as an allergy is actually a side effect. The comparison between penicillin and a non-penicillin antibiotic for patients suspected of penicillin allergy illustrates the complexities of pharmaceutical care and the need for a nuanced understanding of medication effects.
20:03
20:03
Penicillin Allergy Misdiagnosis and Clinical Insights
A clinician discusses their extensive experience with patients who believe they are allergic to penicillin, noting that a significant majority turn out not to be. Over a career of testing nearly 3000 patients, only 20 were actually found to have an allergy, with most reactions being mild rashes and only two severe. This observation contrasts sharply with published estimates suggesting that only a small fraction of those who think they're allergic actually are, hinting at a broader issue of penicillin allergy misdiagnosis.
21:20
21:20
The Critical Issue of Misdiagnosis in Medicine
The dialogue highlights the significant problem of misdiagnosis within the medical field, emphasizing the alarming rate of false positives and incorrect information in patients' charts. It points out the common issue of unreconciled medication lists and the failure to address erroneous medical records, which can lead to serious health consequences. Additionally, it mentions the challenges surrounding the diagnosis of food allergies, illustrating the broader concern of diagnostic accuracy in healthcare.
22:15
22:15
Exploring the Rise of Allergies Through Medical Anthropology
The dialogue discusses the increasing prevalence of allergies, expected to rise from 40% to 50% of the human population by the next decade. It suggests that understanding the social, cultural, and economic factors influencing healthcare and individual health choices, as studied by medical anthropology, is crucial to addressing this growing issue.
23:16
23:16
Exploring the Mysteries of Allergies: A Personal and Professional Journey
The dialogue discusses the associate professor's interest in allergies, sparked by a personal tragedy involving her father's fatal anaphylactic reaction to bee venom. Despite having allergies herself, she presents a unique case of not reacting to standard allergy tests, leading to a personal investigation into her allergens, suspected to include grass, ragweed, and possibly more. Her work highlights the complexities of understanding allergies and their impact on human health.
25:04
25:04
Understanding Allergies and Intolerances
An allergy is distinguished by an immune response to a harmless substance, unlike intolerance, which involves digestive issues without immune involvement. The dialogue highlights the confusion between mild allergies and intolerances, using milk allergy and intolerance as examples. It points out that while both can have similar symptoms, an allergy can escalate into severe reactions like anaphylaxis, whereas intolerance symptoms are limited to digestive discomfort. The importance of consulting an allergist for accurate diagnosis is emphasized, noting the challenge of access due to the limited number of specialists.
26:51
26:51
The Complex Rise of Allergy Rates and the Pharmaceutical Response
The incidence of asthma, hay fever, and food allergies has seen significant changes over time, with rates rising post-World War 2 until the 1990s before stabilizing, while food allergy rates continue to rise. Evidence from emergency visits and EpiPen prescriptions, which saw a substantial increase from the 1990s to 2018-2019, suggests a growing allergy issue. However, the substantial growth in the allergy market, influenced by aggressive pharmaceutical campaigns and lobbying, complicates understanding the actual increase in allergy prevalence versus the impact of heightened awareness and treatment options. The global market for epinephrine and allergy remediation is substantial, raising questions about the drivers behind the allergy boom.
29:38
29:38
Exploring the Drivers Behind the Rise in Allergies
The discussion highlights how reduced exposure to environmental pathogens and allergens, particularly in children, may contribute to the increase in allergies. It references the hygiene hypothesis's evolution into the old friends hypothesis, suggesting that early exposure to certain bacteria, viruses, and fungi could train the immune system, preventing allergic diseases. This theory implies that modern lifestyles might disrupt the immune system's training, leading to a rise in allergies. The conversation also touches on the noticeable increase in inquiries about food allergies in restaurant settings, indicating the broader awareness and prevalence of allergic conditions.
32:24
32:24
The Evolution of Food Allergy Research and Advocacy
A group named Fair, funded by parents, emerged to combat the rising rates of food allergies and support research due to the lack of attention it received initially. Dr. Hugh Sampson, a pioneer in the field, noted the shift from convincing people of food allergies' existence to the challenge of false positives in diagnostic tests. These tests, based on outdated methods, highlight the ongoing struggle in accurately diagnosing food allergies.
34:52
34:52
The Significance of False Negatives in Diagnostic Testing
The dialogue emphasizes concern over false negatives in diagnostic tests, highlighting their reliability in almost confirming non-responsiveness. Despite this, the tests are valued for their ability to eliminate certain possibilities, acting as an effective tool for differential diagnosis.
35:15
35:15
The Serious Implications of Misdiagnosed Penicillin Allergies
The dialogue discusses the potential severe consequences of mislabeling someone as having a penicillin allergy without proper testing. It highlights a case where a pregnant woman, presumed to be allergic to penicillin, was given vancomycin, leading to red man syndrome, a wound infection, and subsequently, C diff. The narrative emphasizes the importance of accurate allergy testing to prevent such adverse outcomes, illustrating how misdiagnoses can lead to serious health complications.
38:13
38:13
The Dangers of Misdiagnosed Penicillin Allergy
The dialogue discusses the challenges of identifying and treating pregnant women with a mislabeled penicillin allergy. It highlights the reliance on obstetricians to identify potential penicillin allergy mislabeling, the risks of not testing due to concerns of inducing anaphylaxis, and the advice given to pregnant women to get cleared of their penicillin allergy before conceiving again. Furthermore, it points out the serious implications of mislabeled penicillin allergies, including higher risks of post-surgical infection and mortality, referencing a study that found a 14% increase in all-cause mortality among patients with a penicillin allergy in their medical records compared to those without.
39:27
39:27
The Cost of Misdiagnosed Penicillin Allergies
The dialogue discusses the severe consequences and additional costs associated with misdiagnosed penicillin allergies. It highlights how these misdiagnoses lead to the use of more toxic antibiotics, causing adverse events like renal failure and diarrhea, and potentially resulting in more severe medical conditions and economic burdens. Through the hypothetical comparison of two patients—one with a penicillin allergy and one without—it illustrates the direct impact on health outcomes and the healthcare system. The conversation points out the lack of action against this issue due to the influence of grant funding decisions on medical research priorities.
41:54
41:54
Addressing Misdiagnosed Penicillin Allergy: A Cost-Saving Opportunity
The dialogue highlights the financial and health implications of misdiagnosed penicillin allergies, affecting one in ten people. It advocates for widespread testing to correct these misdiagnoses, suggesting that initial costs could lead to significant savings by reducing unnecessary healthcare expenditures. A specialist from Mass General Harvard underscores the potential benefits of evaluating penicillin allergies through simple tests, aiming to educate non-specialist health workers and improve medical billing practices.
43:12
43:12
The Economic Impact of Delabeling Penicillin Allergy in Healthcare Systems
Evaluating and delabeling penicillin allergy could save healthcare systems billions by reducing antibiotic expenditure, adverse effects, and costs associated with surgical infections. This approach not only leads to significant savings on antibiotics, which are more expensive than penicillins, but also avoids the costly consequences of adverse effects, such as emergency room visits and hospitalizations. Efforts are underway in the Mass General hospital system to realize these cost savings.
44:01
44:01
Managing Allergy Risks in Hospital Settings
In hospital settings, a protocol resembling algorithmic care helps identify and manage allergy risks without direct involvement from allergists. This approach involves observing vital signs to determine allergy likelihood and possibly conducting challenge testing for infections when allergies complicate care. A two-step drug challenge process is utilized to safely administer necessary medications like penicillin, under close observation. Despite the effectiveness of this strategy, there's concern about potentially harmful outcomes if the default was to administer penicillin to patients suspected of having an allergy, due to the risk of accidental fatalities.
45:28
45:28
The Ethical Dilemma of Allergy Labels and Medical Oaths
Concerns about the morality of disregarding allergy labels are expressed, highlighting the conflict with the medical principle of 'first, do no harm' from the Hippocratic Oath. This situation presents an ethical dilemma, emphasizing the importance of avoiding harm to others.
45:40
45:40
Revolutionizing Allergy Care: Blumenthal's Strategy to Decrease Delabeling Rates and Improve Patient Access
Blumenthal's hospitals have significantly reduced the delabeling rate for penicillin allergies, contrasting with the national rate. Instead of increasing the power of allergists as gatekeepers, Blumenthal seeks to empower more patients through advancements in technology, training, and regulation. The approach includes enabling pharmacists in certain states to conduct penicillin allergy skin tests and advocating for the PAVE Act to integrate allergy awareness into routine medical visits. Despite these efforts, the issue of false positives in penicillin allergy tests remains underfunded and overlooked, highlighting the challenges of addressing a cross-disciplinary problem in the medical field.
47:26
47:26
The Evolution and Funding of Allergy Research
Allergic disease research, often undervalued, has seen significant advancements and funding improvements. Initially, allergy researchers received minimal support from their institutions but relied on NIH funding. A breakthrough in the field involved discovering the link between tick bites and meat allergies, which has sparked increased interest and funding, including a notable grant from Congress. This development underscores the unpredictable nature of medical research funding and the importance of persistent, innovative research in uncovering new understandings of diseases.
49:12
49:12
The Plague of Ticks and Their Impact on Public Health and Wildlife
Ticks are discussed as a significant issue for both humans and wildlife, with deer particularly affected. The dialogue humorously suggests ticks were the devil's addition to Earth, highlighting their widespread infestation. Furthermore, it touches on the serious topic of the alpha-gal red meat allergy linked to tick bites, hinting at skepticism faced by researchers studying this condition.
49:56
49:56
The Complex Interplay Between Allergy Treatment and Research
The dialogue highlights concerns about the pharmaceutical industry's focus on selling allergy treatments over investing in robust research and public health measures. It criticizes the influence of drug companies on medical guidelines and the lack of studies on non-drug interventions due to funding constraints. Additionally, it explores theories on the increase in specific types of food allergies and asthma, linking them to environmental and behavioral changes. The discussion emphasizes the need for more comprehensive understanding and approaches to allergy management beyond pharmaceutical solutions.
54:41
54:41
Exploring Misconceptions and Breakthroughs in Allergy Research
The dialogue discusses research into celiac disease and gluten allergy, highlighting efforts to understand if early exposure to wheat could prevent celiac disease, drawing parallels with the Leap study on peanut allergy. It reflects on changing perspectives in allergy treatment, citing personal experiences with penicillin allergy misdiagnosis, and advocating for a reevaluation of long-held beliefs about allergies.
56:48
56:48
Challenges and Solutions for Scalability in Diagnostic Testing
One speaker discusses their experience with a two-day diagnostic process involving an initial test and a subsequent challenge test, highlighting the current unsustainability of the approach. They seek suggestions for addressing scalability issues in testing methodologies.
57:02
57:02
Challenges in Developing a Reliable Penicillin Allergy Test
Despite advances in medical technology, creating a simple, accurate blood test for penicillin allergy remains challenging. The difficulty lies in the unreliability of blood tests for this purpose, complicating efforts to develop a cheaper, faster, and more scalable solution to penicillin allergy diagnosis.
57:55
57:55
Challenges in Developing a Penicillin Allergy Blood Test
Despite efforts with Thermo Fisher Scientific to validate a blood test panel for penicillin allergy on American individuals, preliminary results from a study in the Boston area showed low detection rates. The difficulty in accurately identifying penicillin allergic reactions highlights the challenges in developing effective diagnostic tools.
58:37
58:37
Addressing Misdiagnosed Penicillin Allergies: A Systematic Approach
The dialogue discusses the challenge of identifying and retesting patients previously diagnosed as penicillin allergic to confirm their current allergy status. It highlights the painstaking process of searching through records to find such patients and the necessity of retesting to ensure accurate diagnosis. The speaker reflects on the slow progress being made in correcting these misdiagnoses.
59:14
59:14
Addressing Misdiagnosed Penicillin Allergy in Healthcare
A mentor emphasized the importance of accuracy in work to ensure job security, leading to a discussion on improving diagnostic tests for penicillin allergy. The conversation highlighted efforts in primary care to delabel patients wrongly identified as allergic to penicillin, showcasing a measure developed to track the success of interventions in various clinics. This initiative aims to correct misdiagnoses and improve patient care by identifying and reducing the number of patients unnecessarily labeled with a penicillin allergy.
59:58
59:58
Future of Personalized Medicine and Allergy Management
The dialogue anticipates significant advancements by 2030 in gene sequencing, machine learning, and AI, suggesting these technologies could enable a comprehensive understanding of an individual's allergy susceptibilities at birth or even correct them. Additionally, it's proposed that future drug formulations could be modified to be less allergenic, highlighting a shift towards more personalized and effective medical treatments.
01:00:26
01:00:26
Deciphering Drug Allergens: A Collective Intelligence Effort
Identifying the specific metabolite of a drug that forms allergenic bonds in the body necessitates collaborative expertise from various individuals.
01:00:42
01:00:42
Vision for Reducing Medication Errors and Allergies Through Technology
One expresses optimism about technological solutions to identify drug allergies and prevent medication mislabeling, reducing the number of errors significantly. Despite concerns about rendering certain jobs obsolete, the speaker emphasizes the potential benefits and personal satisfaction such advancements could bring, even humorously suggesting a career shift for those affected.
01:01:08
01:01:08
Gratitude for Medical Help and Conversations
The speaker expresses appreciation to Kimberly Blumenthal and others for a good conversation, and thanks medical professionals, including Dr. Resnick, for their assistance, particularly for addressing a penicillin allergy and improving the speaker's health.
01:01:42
01:01:42
Exploring the Ethical and Financial Complexities of Real Estate
The upcoming show episode delves into the often controversial world of real estate, examining the perceptions surrounding realtors' professional conduct and the high costs of agent commissions. Highlighting a lawsuit against the National Association of Realtors for allegedly inflating these commissions, the dialogue sets the stage for a critical exploration of real estate practices and the comparison of the realtor profession to a contentious hybrid of monopoly and mafia. Despite the contentious description, the episode aims to offer a balanced view, suggesting that not all within the profession adhere to these problematic practices.
01:02:42
01:02:42
Behind the Scenes of Freakonomics Radio
The dialogue provides a brief overview of the production team and contributors involved in creating Freakonomics Radio, highlighting the roles and efforts of various staff members. It also mentions where listeners can access the show's content and acknowledges the theme song and composer.
01:03:31
01:03:31
Exploring the Hidden Side of Everything with Freakonomics Radio on Stitcher
Discover the unseen facets of various topics through the engaging discussions on Freakonomics Radio Network, available on Stitcher, shedding light on the less obvious aspects of life and economics.
发言人 100:04
They say that the new year is a good time to express gratitude. So here's what I am most grateful for right now.
发言人 100:10
My health. For much of last year, I was sick. It started in the spring with a cough that turned into a respiratory infection that turned into a whole other thing, and for a few months I was miserable. It hurt to talk or swallow. Every time I laughed, it would trigger a coughing fit, which is a problem because I like to laugh. Thanks to the cough, I couldn't sleep through the night. I also had some ferocious night sweats and crazy dreams during the day, my entire body ached like I'd been hit by a car. Also, no appetite, Worst energy. Physically, it was the worst few months of my life, but at least I got a story out of it.
发言人 100:55
This one, Today's episode is about penicillin. You may remember the famous story of how penicillin was discovered accidentally nearly 100 years ago by Alexander Fleming. This was at Saint Mary's Hospital in London, Fleming was just returning from holiday. In his lab, he had left behind a petri dish where he had been culturing bacteria, and he found some mold growing in the dish. Interestingly, where the mold grew, the bacteria did not. It turned out that this mold juice, as Fleming called it, could kill many types of bacteria, not just the 1 growing in that petri dish.
发言人 101:34
Penicillin was eventually used to treat strep throat, meningitis, dental infections, gonorrhea, and much more. It came to be thought of as something like a miracle drug. The penicillins are in fact a family of antibiotics, including maicillo, ampicillin, methicillin, and several others. All these years later, they are still among the safest, cheapest and most reliable drugs around. They have saved hundreds of millions of lives, even with all the new antibiotics since then, penicillin is still prescribed at the highest rate of any antibiotic.
发言人 102:11
But there's one big problem. 10% of Americans, more than 30 million people are allergic to it. At least that's what the conventional wisdom says. But the new year is also a good time to tear down conventional wisdoms, especially if they are disastrously wrong. This one is so today on Freakonomics Radio. Why do so many of us think we have this allergy.
发言人 202:39
This patient told me they were allergic to penicillin. Oh, it's that your mom told you when you were a kid, Well, what happened? Oh, you don't even know what happened.
发言人 102:46
what should be done about all these false positives .
发言人 302:49
we should be screaming from the rooftops. This is a misdiagnosis.
发言人 102:53
And what about all the other allergy controversy we hear about, like food and environmental allergies? How bad is the .
发言人 403:01
it's one of the reasons I can't tell you how many people actually have an allergy.
发言人 103:06
can we tell you a lot starting now?
发言人 203:22
This is Freakonomics Radio, the podcast that explores the hidden side of everything with your host, Stephen dubner.
发言人 103:38
Okay, here is the startling fact that I recently learned. While it is true that around 10% of Americans believe they are allergic to penicillin, fewer than 1% actually are. How can there be such a huge gap? And what are the costs of that gap, The medical and economic and social costs? Those are some of the questions we will try to answer today, starting with this new friend of mine.
发言人 204:04
Elena Resnick. All are just an immunologist.
发言人 104:08
And how does one get interested in allergy and immunology?
发言人 204:12
I always knew I wanted to be a doctor. My dad's a doctor, and there was never any doubt about that. I was lucky to have a lot of great mentors along the way. My mentor in college, Jerry g-man, who's up at Harvard, was very instrumental in my choices. I worked in his lab for four years, applied to medical school, thought I wanted to be a hematologist, oncologist like him, explored that field, and later into my residency, I explored allergy immunology, which has fascinating medicine and amazing potential to make people feel better.
发言人 104:44
Give me a little bit of fascinating medicine. I find almost every branch of medicine pretty fascinating, in part because there's so much mystery still. I mean, as much as we've learned, there's still so much that we don't know. So what was it that really got you hooked there?
发言人 204:58
The immune system in particular is fascinating because we know so little about it. It's so important, right? We need our immune system to protect us from disease and to fight things off. When it goes haywire, we can end up with autoimmune disease, which is where our own antibodies attack us, or we can end up with allergic disease, which is when different types of antibodies, Ige antibodies, react against substances that are harmless, But if we make antibodies against them, we can run into big trouble.
发言人 105:30
Define Ige for me.
发言人 205:31
Ige is immunoglobulin E, it's an immunoglobulin that's made by B cells. It probably had more of a function evolutionarily in terms of fighting off parasitic disease etc. It certainly was not evolutionarily made to react to peanuts and pollens, but we don't know why in some people those types of antibodies are made that are specific against harmless substances.
发言人 106:01
Peanuts and pollens, milk and eggs, soybeans and shellfish. These are just a few of the most prominent allergies that tens of millions of people report today. Like Resnick says, harmless substances for most people that cause allergic reactions in some, given the magnitude of allergies, especially in the us, you might think that there are a million Elena resnicks out there, but she is one of just 5000 allergists in the us.
发言人 106:30
If you need an anesthesiologist, there are more than 40000. If you need a pediatrician, there are 60000, but I needed an allergist and Elena Resnick was the one that my primary doctor sent me to.
发言人 106:43
Here's what happened, like I said earlier, I got sick last year. It started with a dry cough, wouldn't go away. So I went to my primary doctor, who I've been seeing for years. Her name is Rebecca Kurth. I love Doctor Kurth, she is very smart, a true scientist, she's determined and methodical, but also a friend and an ally. She's taught me to be vigilant about my health without being paranoid, which I think is a good middle ground. There was one thing she had been wanting me to take care of for a while, but I never did.
发言人 107:18
My medical history says that I'm allergic to penicillin. The first time I saw her, she asked, how do you know, and I told her the story that lives in my memory that I've been allergic since I was a little kid. Based on what my mother told me, which was based on what our family doctor told her. And that's when Kurt told me that this kind of story is very common, but that the vast majority of people who think they are allergic to penicillin are in fact. So at some point, this was still years ago.
发言人 107:51
Dr Kth told me I should try to get my penicillin allergy cleared. This was the first I'd ever heard of being cleared of an allergy. It's also called being delabel. The way back then she gave me Elena resnick's phone number, but I never called. It just seemed like a hassle, time consuming and expensive, and I didn't see why getting cleared for penicillin was a big deal since her so many modern antibiotics. So I did not go see the allergists back then.
发言人 108:22
Fast forward to 2024 and here I was sick with a cough that wouldn't go away. Doctor Kurth gave me what's called a zpaq or azithromycin. That's a short course of antibiotic that's used in a variety of cases, especially for patients allergic to penicillin. The ZPC didn't help, I got sicker, the cough got worse. I went to a radiologist and had a lung scan to look for cancer, no cancer. I began to wonder what would happen if I could take penicillin, would it fix me or would it maybe kill me? There is a scary sounding word we all think of when we think about allergies, anaphylaxis. Here is Elena Resnick again.
发言人 209:09
It's the most serious type of Ige mediated allergic reaction where the allergy cells explode. They release all sorts of mediators, histamine, tryptase, cetera, and that causes your vessels to vasodilate, fluid runs in, people get hives, people get swelling, people's throat closes up, or you have difficulty breathing.
发言人 109:28
So what's happening when you die from anaphylaxis? Your airway is basically constricted.
发言人 209:33
Exactly, your airway is constricted. And because the vessels all over the body are dilating, your blood pressure drops. You can't get blood back up to your heart and you have a cardiac arrest.
发言人 109:45
So what share of people in the us, let's say, who believe that they are allergic to penicillin, are in fact allergic to penicillin?
发言人 209:53
The studies show that 90% of people who believe that they are allergic to penicillin actually can tolerate it.
发言人 110:00
So that sounds absurd, obviously, that so many people are walking around with this false belief about themselves. Are there any similar wrongly held beliefs in medicine that you can think of.
发言人 210:11
oh my gosh, I don't know that I can think of any. I think that the vast majority of people either have or were told that they had some sort of reaction in childhood. So that is the most common history.
发言人 110:24
the story that I told myself my whole life when I was thought to be allergic to penicillin was, well, you know, medical research has been so amazing that there are all these other drugs and like penicillin or the class of drugs called penicillin, it doesn't really matter if I can't have access to them. How wrong was I in that assessment?
发言人 210:45
I think you were 100% wrong. I'm sorry to say the other drugs were so lucky to have them, but many of them have much more severe side effect profiles than penicillin does. They can have more serious complications. They're much more expensive. And in certain cases, for example, vancomycin, they can actually increase the risk of drugs-related bacteria.
发言人 111:15
So you can see the problem here. A lot of people who would benefit from penicillin think they are allergic to it and that they might die if they take it. The vast majority of them are not allergic, but many of them don't even think to get cleared, and doing so takes some effort. It starts with what's called a prick test. Elena Resnick again.
发言人 211:37
How do we do that? So every good experiment has a control, and the controls that we use are saline, which is salt water, nobody's allergic to that, and histamine, which is the body's allergic chemical, so we prick you, and when I say prick, I mean we clean off the forearm, and then we use tiny needles to introduce just under the surface of the skin, saline, histamine, and our penicillin agents. So it's 4 small pricks under the surface of the skin.
发言人 112:03
so you're not giving me enough to hurt me if I am allergic.
发言人 212:06
exactly.
发言人 112:07
but if I am allergic, then what happens?
发言人 212:09
If you are allergic, we would expect that where we pricked you with the saline, nothing would happen. Where we pricked you with the histamine, you'll a red itchy bump. And where we prick you with the penicillin, you will also get a red itchy bump. That's considered a positive test.
发言人 212:22
We say you've tested positive for penicillin allergy, that's it, go home, continue to avoid penicillins. If it's negative, we go on and do the intradermal test, which hurts a little bit more. We're using the same reagents and we're putting them just under the surface of the skin. And again, we look to see, did those bumps get any bigger during the waiting period? And we're comparing them again against saline. If that test is positive, again, you go home, that's it, you're allergic, but if that test is negative, we now have a skin prick and intradermal tests that are both negative. And the studies show that in those cases, it's 95% likely that you'll then pass a penicillin challenge. I think in real life, it's probably much, much higher than that, but we go ahead and we do an oral challenge, which is just what it sounds.
发言人 213:10
We give you a dose of a penicillin. We use amoxicillin, which is a common oral penicillin. We give you that dose. We have you wait in the office for about 2 hours just to make sure that you're fine. And that's the gold standard, right? Tests are tests, but if you take the medication and you're fine, then we know you're not allergic.
发言人 113:31
This clearing process that Dr Resnick just described, that's what I did in her office a few months ago. I did the skin prick test. I did the intradermal test, both negative. And then at a later visit, I took a dose of penicillin and I waited in her office for a couple hours to see if I had an allergic response. I did not, I could now definitively say that I am not allergic to penicillin, probably never was, although it is true that some people grow out of allergies over time, just as some people grow into them. But whatever childhood rash or temperature spike had led our family doctor to declare me allergic to the penicillin he gave me was likely due to something else, perhaps a viral infection rather than a bacterial one. Now I could take penicillin if I needed it, and it appeared I might.
发言人 114:25
Because my illness deepened. I went back to doctor kth's office for another round of tests, and we turned up some interesting evidence. This time. By now I had something called non groups, a strep throat, which seemed to be responsible for some of my symptoms, but I also had thyroiditis, an inflamed thyroid gland.
发言人 114:46
This was the first time in my life I'd ever thought about my thyroid gland. I didn't even know where it is. It turns out it's in the front of the neck and it's shaped like a butterfly. It is also a quiet superstar of the immune. The thyroid produces hormones that help regulate everything from brain and muscle function to body temperature and heart rate. It can also pitch in when your immune system is already under attack.
发言人 115:12
And that's probably what happened to me.
发言人 115:14
The strep got so bad that the thyroid marched in like some auxiliary army, but without any specific orders, it just started shooting out hormones. So I was a mess, but I was no longer allergic to penicillin, so I swallowed as much amoxicillin as Dr Kurth would while, and even though it took a while they healing began. My cough gradually died down, my voice started to come back, and then my energy to I started sleeping through the night. That was probably the biggest thing. For the first time in months, I felt human.
发言人 115:53
Could all that suffering have been prevented if I had taken penicillin back when the trouble started? It's hard to say for sure, but it's quite possible. Here is another physician who specializes in allergy.
发言人 316:11
Nothing kills bacteria better than these drugs.
发言人 116:16
This is Kimberly Blumenthal.
发言人 316:18
I'm an allergist, immunologist and clinical population level researcher at Mass General Hospital and Harvard Medical School.
发言人 116:25
Blumenthal has written dozens of papers about penicillins, not just about the allergy confusion, but about their effectiveness.
发言人 316:33
If your infection is sensitive to these drugs, they are the best drugs out there from an adverse effect profile. There are also much more benign than other antibiotics.
发言人 116:47
unless you happen to be allergic.
发言人 316:49
Unless you happen to be allergic, Penicillin allergy was described immediately after penicillin was released, and it's the same with all drugs. You release new drugs and we find patients that are allergic, but antibiotic allergy is misdiagnosed most of the time. Why is that when we have infections, we get rashes?
发言人 117:08
It's really as simple as that.
发言人 317:09
Yeah, especially in children, children get rashes when they have infections, those infections are treated with antibiotics, there's misattribution of allergy.
发言人 117:19
so often it might even not have been a bacterial infection, it might have been a viral infection.
发言人 317:24
absolutely for years and years, we have had this idea that an infection requires antibiotics and only like past 5, 10 years, we've tried to pull back on that because of antibiotic resistance.
发言人 117:35
So the moral of the story is if your kid is really sick, just let him stew, is that the moral of the story you're not quite.
发言人 317:43
don't act too fast, right? I think it's good to be a really busy parent and not be all on top of it and rushing them in right away.
发言人 117:52
But to be fair, when the parent rushes them in, then it's the physician's opportunity to slow things down.
发言人 317:58
Yeah, and some people do it better than others. There are these fantastic discharge prescriptions that aren't actual prescriptions, things like rest and drink plenty of water and Nana's chicken soup, take Tylenol or Motrin fever and then if things a week later are still in the same place or things worsen, then call me back. And then we treat with antibiotics.
发言人 118:28
When Blumenthal was in medical school, she became fascinated by the idea that two patients with the same infection could have entirely different outcomes depending on how they were treated.
发言人 318:39
I really was drawn to the idea of how important the choice of what drug was the key decision, what drug is right for this patient? I pretty immediately realized that regardless of what non-fissionable garbage was listed on the allergy list, it really changed care and I just got totally distracted as to like, does it need to drain care? Why is there a two tier system? If you have an allergy, you treat with this, but everyone else who doesn't have an allergy gets this? I realized that what we were calling allergy was mostly side effects.
发言人 119:20
So if we're drawing a kind of Sat style analogy, and penicillin is to these bacterial infections as a hammer is to a nail, let's say it's the right tool for the right moment. What would the typical non penicillin antibiotic, what would that be if one suspects that a patient is allergic to penicillin?
发言人 319:44
Something way too big to hammer in the nail. Some sort of mallet is like, you know I'm not, I don't do tools and hardware.
发言人 119:53
Would it be like a leg of lamb perhaps?
发言人 319:57
Sure, maybe could get the job done, but by kind of making a mess.
发言人 120:03
So talk about your own practice as a clinician and tell me roughly if you can, how many people have you tested over your career who thought they were allergic to penicillin? And what share of them actually were.
发言人 320:18
If I were to see something like 5 patients for this a week myself, and I've been doing it for over a decade, where near 3000 patients I've seen probably 20 allergic.
发言人 120:34
And when you say you've seen 3000, those are 3000 who are suspected of being penicillin allergic.
发言人 320:40
Yeah, they present to my clinic at the suggestion of their primary or their surgeon or themselves. Yeah, I would say it's probably been 3000 patients that I've seen myself. I no, and remember two severe reactions, that's it, the rest have been rash.
发言人 121:00
it's even worse than most of the published numbers I've seen. Most of the published numbers say that roughly 10% of the us population is thought to be penicillin and allergic, but if that 10%, roughly 90%, are not, according to you, it sounds like it's more like 99% that are not .
发言人 321:17
99 in my practice.
发言人 121:20
Can you think about another area of medicine where that rate of false positives exists?
发言人 321:26
No, and this is why we should be screaming from the rooftops is misdiagnosis. This is a missed diagnosis. Everyone has something on their chart that's wrong and nobody is screaming about taking it off. We reconcile medicines every visit. I'm taking this I'm not taking this, we try to take care to make sure what is in the chart is correct. This is something that is not ever addressed and is incorrect in the majority of people.
发言人 121:56
Coming up after the break, we take a look at misdiagnosis around 2 food allergies.
发言人 422:01
He used to fight with people to get them to recognize that their issue is food allergy, and now he fights with people to get them to recognize that their issue is not food allergy.
发言人 122:12
I'm Stephen dubner, this is Freakonomics Radio. We'll be right back.
发言人 122:24
You could imagine that artificial intelligence will soon be helpful in sorting out things like who's allergic to what, but we're not there yet. For now, allergy is often a guessing game, a bit of grasping in the dark. It's estimated that roughly 40% of humans have some kind of allergy that's expected to rise to 50% by the next decade. Why? We've already heard from a couple of allergists, but to answer this question, we need someone with a broader view. We need a medical anthropologist.
发言人 422:56
Medical anthropology is looking at all the social and cultural factors involved in healthcare systems. We think about how all those beliefs and politics and economics, how all of that factors into the choices people make about their health and how they view their health.
发言人 123:16
This is Teresa McPhail.
发言人 423:18
I'm associate professor of science and technology studies at Stevens Institute of Technology.
发言人 123:24
McPhail recently published a book called Allergic Our Irritated Bodies in a Changing World. She writes that roughly half a billion people suffer from food allergies alone.
发言人 423:35
That's been a puzzle as to why an immune cell. We'll take a look at something that is otherwise harmless and decide that it's not and do it after sometimes years of tolerating it just fine, and suddenly now it's a problem.
发言人 123:51
Just tell me why and how you became interested in the notion, the big notion of allergy.
发言人 423:57
My father died of a beating, he died from an anaphylactic reaction to be venom. He had had a reaction in the past, but it was fairly mild, just swelling at the site. That's mostly what happens to anyone who gets stung by a venomous insect, and he died on the second sting. We really don't know how many times he was stung because he was a Vietnam vet, so there's a chance that he was stung prior to that. And I got curious about my own susceptibility to such things. Years later, I was diagnosed with allergies, but I am one of the rare people that do not react to skin or blood tests. I have low levels of Ige, the antibody that is driving the allergic response, so there's no way to tell what I'm allergic to except that clinically you can see the signs and symptoms that I am allergic to something.
发言人 124:53
So what are you allergic to.
发言人 424:55
I think based on my years of detective work, that I am am allergic to grass and probably ragweed and maybe MS.
发言人 125:05
Can you just say what an allergy is and what an allergy is not?
发言人 425:08
Oh boy, how much time do we have? This is part of the problem. There's a lot of confusion about what an allergy is and isn't. The easiest answer I can give you is that an allergy is when your body responds to something that is otherwise harmless and triggers an immune response. If your immune cells are not involved in the response, then it is not an allergy.
发言人 425:39
The classic example is milk allergy versus milk intolerance. On the surface, if you have a mild milk allergy, it's going to look the same. Perhaps an upset stomach feeling kind of gross and gassiness. But the difference is with the intolerance, there's something else going on in this. You're not able to digest lactose because you lack an enzyme, but it's producing symptoms that would seem familiar to someone whose immune cells, whose T cells and B cells are producing anti bodies and attacking that milk protein, except that the allergy can, you know, escalate. You can get a skin rash, you can get wheezing, and you can end up in the Er with a full ofon anaphylactic event. That's not going to happen with intolerance, but if you have mild forms of this, you're going to be confused. And you might just assume that you have an allergy.
发言人 426:38
And the only way to know for certain is to see an allergist. The problem there is we don't really have enough of them. They're specialists and you need a referral to see one. And so a lot of people are out there self diagnosing .
发言人 126:51
or allergic rates rising, or is there just more awareness and or diagnosis and or treatment?
发言人 426:56
We think, as far as we can tell, that they are rising, but it's complicated. We know that rates of asthma and hay fever started to rise post World War 2, late 1950s, 1960s, and continued right up until the 1990s, and now they seem to have been flattened. But what has been rising in the wake of that are rates of food allergies. We know this because of several reasons. One is you can look at Er visits, you can see when someone is showing up with asthma or with a rash like a very bad eczema eruption or they are having anaphylaxis, the other thing that we can track is EpiPen or adrenaline prescriptions. Those raised 3, four times from the 1990s to around 2018, 2019.
发言人 127:53
As with penicillin, the discovery and isolation of adrenaline is another great story for medical history. I won't go into the details here, but it's worth reading about if you're so inclined. A dose of adrenaline or epinephrine administered in an EpiPen, for instance, is the first line treatment for anaphylaxis, when Teresa McPhail cites the huge spike in EpiPen prescriptions as evidence of a huge spike in allergies, well, she also points out that much of the demand was driven by the supplier. Myelin Pharmaceuticals marketed the EpiPen aggressively across many channels over one 10 year period. McPhail writes they hired more lobbyists than any other us company. This led to a relabeling of the drug by the FDA, which made more people eligible to take it. Milan also lobbied state legislators as a means to get more EpiPens into schools. They also partnered with Disney to produce children's books about allergy sufferers.
发言人 128:58
So how big is the allergy market? The global market for epinephrine is about $2 billion a year, with 60% of that sold in the us. If you look at hay fever, one recent study put the cost of treating Americans at over $4 billion a year, more than a billion of which goes to medication. If you look at the entire category of allergy remediation, the global sales of tests and treatments is around $40 billion a year. So how much of the allergy boom has been driven by more allergies versus well-run pharmaceutical campaigns? It's hard to say.
发言人 129:38
There are a variety of factors that may be driving allergy increase. Some research shows that environmental and chemical disruption may play a big role. I asked Teresa McPhail about some other potential drivers. Many, many, many people have by now heard or read about the notion allergy rising because we, especially we of the children variety, are not exposed to enough things, pathogens or allergens or whatnot that we don't roll around in the dirt and so on.
发言人 430:11
right? So in the 1980s, this is after the massive rise of asthma, we're starting to see food allergies. An epidemiologist was curious about this and started collecting data on families and realized that older siblings seem to have more allergic disease than younger siblings. The theory was that older siblings bring home colds and track in bugs to expose their younger siblings. And there was something about that earlier exposure that had somehow protected these younger siblings. It was called the hygiene hypothesis.
发言人 430:56
That is morphed over the years to what is now called the old friends hypothesis, which is nice, isn't it? That's a nicer way to put it, that there's something about getting the right exposures to the right bacteria or the right viruses and fungi that will help train our immune system. You're born with a novice and naive immune system that hasn't seen anything, and you're born with an innate immune system, which means there are things online from the very beginning that just act as a brute force response to anything that threatens the individual. And then you have an adaptive immune system which involve your T cells and your B cells, antibodies that remember the things that you've been exposed to. And so the theory is those have to be trained and they have to be trained in the right order, and they have to be exposed to the same type of bugs, microbes that they would have been evolving with for millennia. The theory is that we've changed so much that some of those are missing, it has confused our immune system to the extent that you're seeing more allergic disease because you're not getting the training.
发言人 132:14
It feels as though every time I go to a restaurant these days, the server will ask, is anyone allergic to anything? Do you know anything about that?
发言人 432:24
It's basically advocacy, and at the forefront of that is a group called Fair, which is Food Allergy Research and Education. They're privately funded and run by a group of parents.
发言人 432:38
When I started researching the book, one of the first people I sat down with was Helen Jaffe. Her and her husband, David, are some of the founding members of Fair, and they also have helped to fund the Jaffe research at Mount Sinai for Food Allergy Research. When they started the foundation, it was because two of their children had quite severe food allergies. But it was at a time where no one was doing this. They live here in New York City and they had to take the train down to Johns Hopkins to see Doctor Hugh Sampson. He's a renowned food allergist and researcher, and he has been doing this for over 40 years. But at the time, there were maybe half a dozen people focused on food allergy. So initially, Helen told me that their focus was really on education and research funding to try to figure out what was going on, why the rates seemed to be rising, figure out more about the biological mechanism that drove this response.
发言人 433:45
I spoke with Dr Hugh Samson. Now we're talking about years later. And he said he used to fight with people to get them to recognize that their issue is food allergy. And now he fights with people to get them to recognize that their issue is not food out.
发言人 134:01
Can you explain? I do see on the fair website that 50% to 60% of all blood tests and skin prick tests for food allergy testing will yield a false positive result, correct? So that sounds absurdly bad. Is it not as bad as it sounds, or is it that bad?
发言人 434:21
No, it's bad, it's bad. I mean, diagnostics are one of the sticking points, it's one of the reasons I can't tell you how many people actually have an allergy because we're stuck with primarily the skin tests, which were invented in the late 18 hundreds by a UK physician, doctor Charles Blackley.
发言人 134:43
Wait, the late 18 hundreds? Yes.
发言人 434:46
and if I exhumed him and revived him, he would have no problem giving a skin test today.
发言人 134:52
What about false negative? That's what we should be really concerned about.
发言人 434:55
that is the better situation, It's around 9 95 certain if you do not respond, that you are not going to respond in real life.
发言人 135:06
So that's good news at least.
发言人 435:07
Yes, that's good news, that's why we still use them because it's almost like a differential diagnosis, we can rule some things out.
发言人 135:15
So you mentioned in the book that your aunt and your grandmother were allergic to penicillin? Yes, given everything we've discussed about testing or the lack of great testing and the murkiness surrounding this area, do you think that they actually were allergic to penicillin? Or maybe .
发言人 435:33
in my grandmother's case, we know because she was in the hospital and had an actual skin eruption and reaction to penicillin. I honestly don't know about my aunt, sorry if she's listening to this because to my knowledge, she's never been tested. So I don't know. She does avoid them though. At the end of the day, I suppose it doesn't matter.
发言人 136:00
I suppose it doesn't matter, Teresa McPhail says. That's what I used to think, that a penicillin allergy is no big deal since there are other newer antibiotics that do the same thing. But the allergists we heard from earlier, Elena Resnick and Kimberly Blumenthal, they told me that that is simply not accurate. Resnick told me about a pregnant patient of hers who showed up with a penicillin allergy on her chart.
发言人 236:26
Penicillins are an amazing drug also because we know them to be safe and effective in pregnancy. When a pregnant woman goes in to deliver liver, if she is colonized with group B strep, which is a very common vaginal infection, she must be given antibiotics before delivery to ensure that the baby is not exposed to the group B strep. So the antibiotic of choice for group B strep is in the penicillin family.
发言人 236:51
Mom comes in, she's ready to deliver, she gets a dose of penicillin, she gets her second dose, four hours later, she delivers the baby, everything is fine. If she is thought to be penicillin allergic, instead she's given vancomycin. Vancomycin dosing interval is every 12 hours. So if she's not dosed appropriately, the baby can be considered inadequately treated. And that leads to all sorts of other potential decisions, maybe getting put on antibiotics, maybe going to the NICU.
发言人 237:19
Again, the complications just from this penicillin label, our intense. So in this particular scenario, this mom went in to deliver. She was thought to be penicillin allergic. They gave her vancomycin. She developed red man syndrome from the vancomycin, which is just what it sounds like, where the body becomes completely red and flushed and other medications have to be given. And then she had a wound infection from her ce-series because she was still thought to be penicillin allergic. They gave her clindamycin to treat the wound infection, and she developed C diff from the clindamycin.
发言人 137:57
And how did that play out?
发言人 237:59
So when you develop C diff, then you have to be put on oral vancomycin and then treated usually for two weeks. It's just a nightmare, one thing after another. And then she came to see me and we were able to clear her of that penicillin allergy.
发言人 138:13
Why did she come to you in the first place?
发言人 238:15
So her ob-gyn, we also rely on the ob-gyns to find people who in their charts have this penicillin allergy. The problem with that is we're not going to test a pregnant woman just on the off chance that she does end up being one of these rare people who's truly allergic. Obviously, we don't want to put a pregnant woman into anaphylaxis. So we're sort of stuck with that label, which is hard for the OB because then their patient gets a simple infection. They can't use a penicillin, so a lot of the obese will say to their patients before you get pregnant again, better go get cleared of your penicillin allergy.
发言人 138:51
The fact is that a mislabeled penicillin allergy, and as we've established, the vast majority of penicillin allergies are mislabeled. This is a serious thing. The risk of post-surgical infection is much higher, so are your chances of dying. Kimberly Blumenthal from Mass General Harvard published a study comparing the long term outcomes of 60000 patients with a penicillin allergy in their medical record versus more than 200000 patients without.
发言人 339:20
We did an all cause mortality study in a very nicely controlled observational study, 14% increased all cause mortality.
发言人 139:30
Sillin allergic is producing that many more deaths. What exactly are the adverse outcomes that you're avoiding? If you're able to take penicillin.
发言人 339:39
there's avoiding antibiotic resistance, C diff colitis, avoiding too long of hospital stays, avoiding surgical infections if you had needed an operation, and then there's avoiding other adverse events that result from a choice of antibiotic that is just more toxic, sick, and by its nature, caused more renal failure or caused more diarrhea or whatnot.
发言人 140:06
This may be impossible to say, but let's say there are two observationally equivalent patients. Let's say me, and let's say I have a twin, okay? And one of us has been labeled penicillin allergic, the other hasn't. We have the same medical problem come up. I'll let you pick the problem. One of us receives a penicillin drug. The other is not eligible to do so. Even if his allergy isn't real, we think it's real. How would you think about comparing the medical and economic outcomes of person A and person B?
发言人 340:40
It's such a noob iner I mean, when you give me this description, what comes to mind is two people who have strep throat, strep throat and a penicillin allergy. One person gets penicillin, that's indicated for penicillin, strep throat goes away, no long term sequelae, they're fine, it was cheap, and then the other person gets a ZPC azithromycin, and it doesn't fully go away. Then they call back and they get another antibiotic, Maybe this time they get a bigger antibiotic and that causes some problem. They might get a tonsler abscess, they get aquinaldo ciprofloxacin unnecessarily or some other medication.
发言人 141:18
And I mean, I don't know what any of those are, but all those syllables sound bad to me.
发言人 341:23
Yeah, there's no rule like the more syllables, the antibiotic has its worst, I wish it were that simple.
发言人 141:32
Okay, that's not simple, but this is misdiagnosed. Penicillin allergies are costing all of us a lot of suffering and dollars, so why isn't more being done to solve this problem?
发言人 541:46
Because the public doesn't decide which grants get funded.
发言人 141:50
That's coming up after the break. This is Freakonomics Radio, and I'm Stephen dubner.
发言人 142:06
Once you know about the benefits of penicillin and how millions of people wrongly believe they are allergic, you can't help but think about the costs of this misdiagnosis, not just the bad health outcomes and the complications, but the financial costs, too. That's why some specialists are pushing for more testing and delabel in of people who think they are allergic. That might cost a lot up front, but when one in 10 people think they have a medical handicap and they don't, this actually presents an opportunity to save money. It might even be worth testing every single person whose medical history says they are allergic. Here again is Kimberly Blumenthal from Mass General Harvard.
发言人 342:49
We can evaluate for penicillin allergy with simple tests, and these simple tests need to be delivered to that 10% of America and reimbursed appropriately and taught to a non specialist onist workforce could be welcome to college visit. Welcome to Medicare visit .
发言人 143:10
How much money could you save by doing this?
发言人 343:13
Just my healthcare system would be millions if we evaluated penicillin allergy delabel of the appropriate ones, we would save millions of dollars. Just my healthcare system. So it must be in the billions.
发言人 143:26
You'd save it how .
发言人 343:28
you save on antibiotic expenditure .
发言人 143:31
just because penicillins are cheaper than the other antibiotics.
发言人 343:34
yes, you'd save on adverse effect avoidance.
发言人 143:38
meaning penicillins don't cause as many adverse effects as other .
发言人 343:42
thats. Yes, in some of these adverse effects lead you to the emergency room and another hospitalization you would save on surgical infections, a tremendously costly thing.
发言人 143:55
Blumenthal is trying to make these cost savings a reality in the Mass General hospital system.
发言人 344:01
In our hospitals, without an allergist involved, there's sort of algorithmic care that can clear allergy and low risk situations with just a protocol. Just a little bit more observation, you're ready in the hospital, you're being observed.
发言人 144:14
your vital signs are already on record there. Yeah, and is the idea as simple as you feed the key vital signs into the allergy algorithm and see if indeed there's a likelihood that that person is not allergic and then maybe do some challenge testing, is that the way it works?
发言人 344:31
We do it when patients have infections, so we don't do it electively, like if you're there for something not related, but if you have an infection, that and allergy is getting in the way of best care. We have a two step drug challenge process and as long as the patient's healthy enough to do that, we do it. So we give a small amount, watch the patient, give a full amount, watch the patient, and then if that's the drug that they need to be treated with, they just continue that drug right then and there.
发言人 144:58
Since there is a treatment for the allergic response. But the default is to not give penicillin if there's a suspicion of allergy. What would happen if you just flipped the default and said, no, no, we're just going to give penicillin and if they happen to be in the small group of people who are allergic, then we'll watch and we're it. Is that such a terrible idea? Would you kill a bunch of people by accident that way?
发言人 345:22
You would kill some people by accident and in America, it's just a non starter .
发言人 145:28
because we don't want to kill anybody. You're saying, well.
发言人 345:30
there's also this doctor first, do no harm like the oath we take. And it feels wrong to just disregard allergy labels entirely.
发言人 145:43
The hospitals where Blumenthal works have achieved a 9% delabel in rate over a decade. The national delabel in rate is less than 1%.
发言人 145:52
There's something interesting to notice about Blumenthal's approach. Many specialists in many industries always trying to grow their leverage to become ever more powerful gatekeepers. Blumenthal is moving in the opposite direction. She wants to shift leverage away from the allergists in order to help more patients. This would happen through better technology, better training, and better regulation.
发言人 146:18
In some states, pharmacists are now allowed to perform the skin tests for penicillin allergy. Last year, a Republican congressman with Democratic support introduced the Pave act that stands for penicillin allergy verification and evaluation. It would fold allergy awareness into annual wellness visits and preventive welcome to Medicare visits that Blumenthal mentioned earlier. So that all sounds good, but let's not get too excited. Overall, the false positive problem in penicillin is under examined and underfunded.
发言人 346:53
I can tell you with confidence that I was the first penicillin allergy grant that the NIH funded 30 years, whose area is it? Is infectious disease, is it allergy, it's multidisciplinary, is it surgery, is it obstetrics? Because penicillins are used by everybody, dentists, it was very hard to know who takes ownership of something that crosses every single discipline .
发言人 147:15
and when disciplines cross disciplines compete. Given the cost of medical research, these can be multi billion dollar competitions.
发言人 547:24
there's a pecheur in medicine.
发言人 147:26
this is Thomas platts-mills Tom.
发言人 547:29
a professor of medicine at the University of Virginia, and I've been studying allergic disease for a long time.
发言人 147:37
And where does allergic disease fall in the pecking order of medical research?
发言人 547:42
It's actually much worse than anything you imagine. Neurosurgeons are at the top, cardiac surgeons, all these people fight with each other, but they know that at the bottom there are dermatologists and psychiatrists and allergists. I got very little from the university, a little bit in the first few years, but then basically in the last years, nothing. We've always had to get our own money, and I was getting NIH money, and the NIH has been very generous this last time I actually got a one on a grant, it actually means you're in the top 1%. And then I got a merit award. And the merit award is absolutely wonderful because from 18 to 28 I'm funded by the NIH 10 years instead of 5 tick bite. Research is hot.
发言人 148:32
Platts Mills is a giant in the field of allergy research, some of his early work was on the connection between asthma and dust mites. More recently, he and his team have found that getting bitten by the Lone Star kick can trigger an allergy to a sugar molecule called Alpha Gal, which is found in the blood of mammals, which means the tick bite can therefore render a person allergic to red meat. As Platts Mill said tick-bite research is hot.
发言人 549:00
the Congress voted $100 million for it so that we can get tick bite related grants for different aspects of our research. And that's been tremendously helpful.
发言人 149:12
Why do you think ticks are such a good selling point for voters, Congress etc? Just because it's relatable?
发言人 549:19
Oh come on God had finished making the earth and then the devil reached over and sprinkled ticks all over it. You know that no ticks are very interesting. The deer are absolutely infested with ticks. It is not unusual for hunters to shoot one of our deer and find the thing with so many ticks, they couldn't possibly count them .
发言人 149:44
when you were embarking on the research about the alpha gal red meat allergy related to ticks, did your colleagues think or maybe even say that you were bonkers?
发言人 549:56
They always say. No, no I've got away with murder several times. My father taught us that if we think A and the rest of the world thinks B, that is formal proof that A is correct. Being educated in an environment like that is really extraordinary.
发言人 150:19
It does strike me and I'd love you to tell me if I'm wrong, but my sense is that when it comes to allergy, the pharmaceutical side of the equation is doing very well. There's a lot of money being made selling treatments that may or may not work. But on the research and the public health side of the equation, plainly not nearly as robust. And I'm curious why it would be in a case where if you think of just supply and demand, there's plainly a lot of demand for allergy remediation and so on. The public would like to no more, to suffer less, and so on. If the split I'm describing is accurate, why do you think there is such a big split?
发言人 551:00
Because the public doesn't decide which grants get funded. The trouble is that the drug companies are so powerful and they advertise so much that people just get the idea that that's what it is. And actually, the guidelines are warped. I've been on a guideline panel for asthma where we were told that we should focus on large controlled trials published in the last five years. Well, that basically means drug studies, the number of large controlled trials of tick avoidance that are being done, 0, no one could afford to do them. Companies have a lot of money and they do big, well controlled trials, some of which are really important, but many of which are me too, or trying a new drug, which is a very tiny variant of the previous, It's much more important to try and understand what's happened.
发言人 551:56
I've written a history of food allergy and the three forms of food allergy, which are peanut and the other allergens that cause immediate hypersensitivity, eosinophilic esophagitis, and the alpha-gal syndrome. And why I pull those apart is because they're mechanistically completely different, causally different, and the reasons why they've increased are different peanut is probably ridiculous washing of the skin with detergents. Eoe, we've just published a hypothesis that the processing of milk is a major part of that. Instead of pasteurizing milk at 84 degrees centigrade, all the milk you drink, it's heated to 135 degrees centigrade, it's dead, and it's homogenized, which means the particles are all changed, so they're much smaller, and we say weaponized to immunize the esophagus. And the third one, the alpha girl syndrome, we believe, is primarily due to the loss of dogs in the suburban areas. What happened in the early 80s is leash laws, and now the dogs can't get together to drive the deer out, and so we all have a herd of deer on our lawn and the deer are covered with ticks.
发言人 153:18
This connection that Platt's Mills has drawn between leash laws and the boom in the tick population is not his only unusual theory.
发言人 553:27
I was very well known in the 70s for saying that television had had a major effect on asthma. We published a paper in which we showed that if people watched a screen they took less deep breaths if they're reading a book, they still breathe normally. If your child is watching television and you touch their shoulder, they actually jump slightly because they're in a trance. They're not unconscious, they're not asleep, but they're in a trance. And during that time, the hypothesis was that that prevents their breathing, and the deep breaths are a better broncho D later than albertoi what's happened since then? If you want something really chilly, it's the children no, no longer watching television because they've got cell phones and the cell phones don't put them into a trance. And asthma has actually become less of a problem. The asthma doctors will be horrified if they hear anyone suggesting that asthma is anything but a total problem, but actually pinot allg has become more of a problem than asthma.
发言人 154:37
but a totally different causal mechanism. Yes.
发言人 554:39
totally different, yes.
发言人 154:41
What are your views on celiac disease and gluten allergy?
发言人 554:45
Yeah, Gideon Lack, who did the Leap study, has been looking at celiac and seeing whether natural exposure to wheat in early childhood would prevent celiac disease, and I think he's got some evidence, but it's not of a level comparable to the Leap study. The Leap study was a tremendous breakthrough.
发言人 155:09
This leap study that stands for Learning Early about peanut allergy was published in 2015 by the pediatric allergist Gideon Le. It argued that feeding peanuts to babies will actually reduce their risk of a peanut allergy of the evidence came from Israel, where babies routinely eat Baa, a puffy peanut butter flavored snack. Full disclosure, some adults also love Bamba. Given what we've been hearing about allergies these past few decades, especially peanut allergies, you can imagine that many parents would be terrified to let their baby get anywhere near a peanut snack. Once a conventional wisdom is established, it can be hard to dislodge, which gets us back to the allergy with which we began this episode.
发言人 556:01
A whole generation of doctors were trained thinking that penicillin allergy was very dangerous and very common and very common. And it isn't. When I got here in 82, I already was saying things that, no, you don't need to worry about it as much as this. You need to ask the question and take precautions and be sensible. If someone had no history in 15 years, the chances that their penicillin logic are very small.
发言人 156:27
So what are some solutions? Can you talk about clearing people of penicillin allergy, for instance? By the way, the reason we're doing this episode is this is something that happened with me. I was told as a child I was allergic to penicillin, I avoided it for approximately 50 years. My current doctor, she said, you know, we should test, so I did.
发言人 556:48
You were negative.
发言人 156:49
I was negative, but I had to go through this, you know, two day first the test and then the challenge test, where you actually get a little bit of it. And it's plainly something that's not scalable right now. So I'm curious what you think are solutions.
发言人 557:03
I'm waking my head. People have been trying for a long time. I can't tell you how many of the residents who apply for a fellowship have been doing a study on the labelling penicillin. So this is not something that people are ignoring.
发言人 157:18
Can you explain why it's so difficult? Because as much as medical technology has changed, I mean, everything from time release medicines to the mrna vex. I mean, there's so much technology that is accelerated discovery in medicine. Why is it so hard in this case to come up with a, let's say, cheaper, faster, more scalable way to clear people?
发言人 557:41
Well, there's quite a lot of literature that says you can't quite rely on a blood test. And that's what we should have is a simple blood test for I to eat penicillin. That absolutely solves the problem.
发言人 158:00
Kimberly Blumenthal is one of the people who has been working on a better blood test for penicillin allergy.
发言人 358:06
We were trying so hard. I was working with Thermo Fisher Scientific. They have developed a blood test panel and they wanted to see if it worked in allergic individuals from America. We identified in the Boston area everyone that reacted to penicillin in front of our faces in the last few years. We sent them the blood of these individuals. And I think I picked up like 3, it was like three of 20, it didn't pick it up yet.
发言人 158:36
What makes it so hard?
发言人 358:37
The conclusion was, well, they were allergic in the last 5, 10 years, maybe they weren't allergic now. So I have to bring them back, retest them. And then these patients, they're like needles in haystacks, right? We combed the records of all Mass General Brigham to find these 22 penicillin allergic to. We really need to say, okay, you reacted to penicillin in front of my face today, grab your blood and then send it to be able to know that they were true positives.
发言人 159:06
but you're making progress. It sounds like slowly, I mean, by the time you're 600 years old, this problem will be solved.
发言人 359:14
One of my mentors said to me, if you do your job well, you have no job. And I'm like, I just don't think that's gon na happen, there's always something else. We need better tests. Now back to the basic science in the La. And then on the population level, we're thinking about implementing penicillin allergy. But in primary care, we just created a measure of delabel the patients in our healthcare system. And even just now that I can measure it, I can measure it in this clinic, in that clinic, and I can see what types of interventions move the needle towards a higher percentage of delabel the patients.
发言人 159:51
So what would your message be to anyone who believes that they are allergic to penicillin?
发言人 359:58
Now get tested, Get tested.
发言人 101:00:00
If we were to jump ahead 2030, 50 years or something, I would imagine that given the benefits of gene sequencing and machine learning and artificial intelligence, it would be pretty simple at birth to either understand everything that a given person might be susceptible to allergy wise or just correct it.
发言人 301:00:21
I think it's possible. And it's also possible that we could alter our drugs to be less allergenic.
发言人 101:00:27
How would you do that?
发言人 301:00:28
Oh goodness, we'd have to know what metabolite of the drug is forming bonds in our body to make the allergen. And so it requires a lot of combined intelligence from different people.
发言人 101:00:42
I realize, though, as I asked that question, that it's a little touchy for you because I'd be putting you out of business. You okay with that?
发言人 301:00:48
Yeah, I would stop happy if we have some sort of way that like everybody knows if they can or can not have penicillin or any drug or they're going to be allergic or not. If we were able to, the 30 million miss labels in just America. I'm happy I'm retired .
发言人 101:01:05
and you just open a florist shop or something like that. Be okay.
发言人 301:01:08
I do like floral design.
发言人 101:01:09
Well, there you go. I would like to thank Kimberly Blumenthal for the good conversation today, as well as Thomas Platts Mills, Theresa McPhail and Elena Resnick. Thanks also to Dr Resnick for clearing my stupid penicillin allergy label. And thanks to Becky Kurth. Dr Deb Jones, doctor leney hust and all the other medical professionals who helped turn me from a bone tired coughing machine into, well, beckon to me. I am grateful.
发言人 101:01:43
Making this episode was a good reminder of how much I love physicians drive, their curiosity, their willingness to admit what they don't know yet, and then to work ridiculously hard to find out more coming up next time on the show, there is another group of professionals out there who may not be quite as beloved as doctors. Their professional association has been described as somewhere between a monopoly and a mafia. Yeah, I take great offense at that characterization. The National Association of Realtors was recently sued for conspiring to inflate agent commissions, it's just hard not to say that man, these prices just seem way higher than they need to be to get the job done. That's next time on the show. And remember, our episodes now come out on Friday morning East Coast time. Until then, take care of yourself and if you can, someone else too.
发言人 101:02:42
Freakonomics Radio is produced by Stitcher and Redbud Radio, you can find our entire archive on any podcast app also at Freakonomics dot com where we publish transcripts and show notes that this episode was produced by Davin avala the freakons the radio network staff also includes Alina Cole, Augusta Chapman, Eleanor Osborne, Ellen frankman Elsa Hernandez, Gabriel Roth, Greg Ripon, jasmine Klinger, Jason Gabriel, Jeremy Johnston, John schnat Lear Bait, Morgan Levy, Neal Carruth, Sarah Lilly Teo Jacobs and Zack lepinski Our theme song is Mr Fortune by the Hitchhikers and our composer is Luis garra As always, thank you for listening. Is that far side? Far side? It sounds like you spend as much time with comics as you spend in the lab.
发言人 501:03:31
Of course that's true.
发言人 401:03:37
The Freakonomics radio network, the hidden side of everything.
发言人 101:03:45
Stitcher.
Like tens of millions of people, Stephen Dubner thought he had a penicillin allergy. Like the vast majority, he didn’t. This misdiagnosis costs billions of dollars and causes serious health problems, so why hasn’t it been fixed? And how about all the other things we think we’re allergic to?
- SOURCES:
- Kimberly Blumenthal, allergist-immunologist and researcher at Mass General Hospital and Harvard Medical School.
- Theresa MacPhail, associate professor of science and technology studies at Stevens Institute of Technology.
- Thomas Platts-Mills, professor of medicine at the University of Virginia.
- Elena Resnick, allergist and immunologist at Mount Sinai Hospital.
- RESOURCES:
- Allergic: Our Irritated Bodies in a Changing World, by Theresa MacPhail (2023).
- "Evaluation and Management of Penicillin Allergy: A Review," by Erica S. Shenoy, Eric Macy, and Theresa Rowe (JAMA, 2019).
- "The Allergy Epidemics: 1870–2010," by Thomas Platts-Mills (The Journal of Allergy and Clinical Immunology, 2016).
- "Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy," by George Du Toit, Graham Roberts, et al. (The New England Journal of Medicine, 2015).
- EXTRAS: