Allergies with Dr Richard Nolan

PASSION: The study and mastery of allergic conditions.
PURPOSE: Investigating, managing and relieving allergy symptoms through his practice Perth Allergy so people can live healthier, happier lives.

Is hay fever your nemesis in the Springtime or maybe the sentence “may contain traces of nuts” gets your heart racing. Allergies have become a common companion for many and so often they rob us of our energy levels, concentration and wellbeing … and of course sometimes they can be life threatening. 

Dr Richard Nolan – allergy specialist and immunologist – is our guest around the warm table today and he shares his passion for understanding the causes and cures for allergies and the purpose behind his life’s work. 

There’s no one better to talk about this topic with us today! 

Warm thanks to:
Sponsor: Females Over Forty-five Fitness in Victoria Park
Sound Engineering: Damon Sutton
Music: William A Spence
... and all our generous and inspiring guests around the warm table this season!

Transcript

Sonia Nolan: 0:00

Welcome to My Warm Table. I'm Sonia Nolan and season two of this podcast about passion and purpose is brought to you by Females Over 45 Fitness, or FOFF in Victoria Park.

Introductory Voice Over of Previous Guests: 0:13

My name is Kate Chaney. My name is Bonnie Davies. My name is Madeleine King. My name is Valerio Fantinelli. My name is Lyn Beazley. My name is Alexandra Helen Flanagan Hi, my name is Sharon Todd. My name is Lucy Cooke and I'm the CEO of SpaceDraft. I'm the first Aboriginal female funeral director. CEO and founder of Motion by the Ocean. I'm a psychologist and a professor in psychology at Curtin University. CEO and founder of Lionheart Camp for Kids. Around My Warm Table. Or listening on Sonia Nolan's My Warm Table. Just sharing a yarn with her.

Sonia Nolan: 0:36

Is hay fever your nemesis in the springtime? Or maybe the sentence "may contain traces of nuts" gets your heart racing. Allergies have become a common companion for many Western Australians. And so often they rob us of our energy levels, concentration and general wellbeing. And of course, sometimes they can be life threatening. Dr. Richard Nolan, allergy specialist and immunologist is our guest around the Warm Table today. And he shares his passion for understanding the causes and cures for allergies and the purpose behind his life's work. Richard grew up in Greenwood, he studied medicine at the University of Western Australia. And he's dedicated his career to working and researching in the field of allergy. He's published and presented on allergic rhinitis, immunotherapy, peanut allergy, insect venom allergies, drug, and skin allergies. He's sat on pharmaceutical advisory boards, and he's also actively contributed to the development of treatment guidelines for the Australasian Society of Clinical Immunology and Allergy. There's no one better to talk about this topic with us today. And before we launch into our Warm Table conversation, there's just one more important introduction, you might have recognised his surname. Dr. Richard Nolan is of course my fabulous brother in law. Dr. Richard Nolan, thank you so much for joining me today.

Richard Nolan: 2:05

My pleasure.

Sonia Nolan: 2:06

Richard, we've talked about allergies over many years. So full disclaimer, Richard is my brother in law. So we're going to start with that premise that we know each other pretty well. And we've sat around a warm table together on many, many occasions over many years, which is a delight.

Richard Nolan: 2:22

Absolutely.

Sonia Nolan: 2:23

But we don't always talk about allergies. So today, I'm going to ask you a whole bunch of questions that are probably storing up that haven't made the dinnertime conversations over the years. And I'd like to start with what is our immune system? So can you give us a bit of a 101 on what an immune system is?

Richard Nolan: 2:41

So allergies, and immune system are all part of it. And our training revolves predominantly around the immune system. So our immune system is supposed to protect us from infections. And in some people, rather than protecting infections, they actually make an abnormal immune response to things which actually ends up in an allergy, and several different types of allergic reactions you can have, but the one that we're most familiar with is what we call our IgE system, which is the typical food allergies and hay fever and reactions like that. And that's mainly what we deal with as allergy specialists.

Sonia Nolan: 3:17

And I want to go right into food allergies in a moment, but I'd love you to explain to me, Richard, what is the difference between an intolerance, an allergy, and anaphylaxis? Like, can you- some people are like "oh, I'm allergic to that," and I actually "no, it's just that you don't like that?" Or you're intolerant to it, but it's not necessarily an allergy. So can you run me through what that what they actually mean?

Richard Nolan: 3:39

Yeah, so the best example, or the one that I use mostly is probably milk, right? If you have a milk allergy, you're usually allergic to the protein in milk. And so for example, if you eat milk, within a few minutes, you'll get a immediate reaction, which is our IgE are our allergy reaction, which happens within-

Sonia Nolan: 3:57

The evil one.

Richard Nolan: 3:58

The evil one. Within 10-15 minutes and you'll get itching in your mouth, you'll feel sick, you'll vomit, you might get some swelling of your lips, your hives around your lips. And that can go on to anaphylaxis. We call it anaphylaxis if it also affects your breathing or your blood pressure.

Sonia Nolan: 4:11

Okay, right.

Richard Nolan: 4:12

That's- anaphylaxis is a severity of an immediate allergic reaction. If we're taking milk again, and intolerance is when you get a reaction that's not quite immediate, but it can be a bit more delayed. And it's more sort of bloating or some abdominal discomfort and some diarrhoea, loose stools. And often if we're talking milk, and there's obviously several things, is going to be the sugar component in the milk. So the lactose in the milk. And when you have the lactose, what happens that goes into your gut, and sitting in your gut, if you can't absorb it, then the bacteria in your gut feed off that which then makes more gas makes more distension. And that's when you sort of start to get those symptoms from that. So it's sort of a different mechanism that causes that reaction. And that's a typical example of intolerance, although there are several other types of. And then obviously anaphylaxis, you said, it's just a degree of severity.

Sonia Nolan: 5:04

Are our immune systems pretty much set in utero or at birth? Or do they evolve and change throughout our lifespan?

Richard Nolan: 5:12

Good questions, and yes, to all of those, all of those things. So you're originally given an immune system from your parents, if your parents suffer from allergies, then you have a much greater chance of developing allergies. After you're born, the environment that you're exposed to then has some impact on your immune system. And then for those next couple of years, you progressively develop your immune system. And there's lots of different things that go into that. Part of it is reflected by whether your parents have had lots of infections or not, if you come from an infection prone area, you're going to be less likely to have allergies. We know that there are other things that are linked with allergies. So for example, if there's- you're from a low sunlight area, and you have low vitamin D levels, that sort of seems to increase allergies, if you've got eczema, so if you could develop eczema early on that seems to really develop allergies beyond that. So there's a lot of things that we know in your environment that will make it more likely. If you're born into a house where there's lots of livestock or cattle, or a rural area that's less likely compared to metropolitan areas, there's a lot of factors that we know that sort of will contribute to that.

Sonia Nolan: 6:17

Richard, what are the most common types of allergies?

Richard Nolan: 6:21

So in my work that the three most common things that I see is, one is hay fever. And I call it hay fever, but the common things people can be allergic to is dust mite, grasses, animals, moulds, tree pollen, so it depends. So we'll see people to try and work out which things they're allergic to, and what we can do about them.

Sonia Nolan: 6:44

And just before you jump on to the next one, how do you do that is that the skin prick?

Richard Nolan: 6:48

Yeah, that's the skin prick test. So basically, the way I describe it to kids is you've got like some glad wrap on your skin, which stops any water from going into the skin. And you just do a little scratch, just take that glad wrap off.

Sonia Nolan: 6:59

And you draw a little grid, don't you?

Richard Nolan: 7:01

Yeah, and I've got all the different things that people can be allergic to. So some we've had to make ourselves and some we buy in. And then we can work out which things, so I usually do a profile of a whole heap of different allergies. And I go, well, actually, it's this, this, this this that we're allergic to, and we go "Oh, actually, that's in the front yard, we can get rid of that. Or we can do this. And we can do this." And then we can work out what's the best treatment for someone going forward. So that's how we investigate a hay fever. It's also we investigate food allergies in the same way. And so they're common, and the three most common foods we see is milk, egg, and nuts. And then the other things we see lots of is skin rashes. So as an allergy specialist, there's a couple of things you can see causing skin rashes. So a lot of people think they're allergic to dust or grasses, and sometimes they can be allergic to that or to animals. And usually that's pretty obvious if that's the case. But there's a lot of immunology here. So there's a lot of autoimmune type reactions that will cause skin rashes. And you can also get skin rashes to environmental things. But usually it's like creams and moisturisers and things and hair dyes and things like that, that people can react to. And that sort of causes a slightly different rash. But they all get called hives, and they all come to us and we sort out which ones they are.

Sonia Nolan: 8:15

And is there like, does the body build up a resistance like hair dyes, for example, you've just mentioned, you know, could it be that you know, you're great using hair dyes for the first five years and then all of a sudden it causes a reaction. Does that happen?

Richard Nolan: 8:29

Yes, absolutely. That's exactly what happens. So it's very rare in terms of if we've moved to sort of talking, this one's called allergic contact dermatitis. Over the years people get ongoing exposure to it. And the typical allergic contact dermatitis we'll see is to nickel where someone reacts with some costume jewellery. And that's usually the nickel component in that and the stainless steel ones or the low allergen ones avoid nickel.

Sonia Nolan: 8:54

Now is this true? Or is this a myth, Richard, that if you pierce your ears before the age of 8 or 10, you are more likely to be allergic to the costume jewellery. Is that myth or fact?

Richard Nolan: 9:09

Well, so this is one of those dinner table conversations.

Sonia Nolan: 9:12

You're around the Warm Table Richard, you're around the warm table.

Richard Nolan: 9:15

We've actually had this conversation in the past, because it's come from me.

Sonia Nolan: 9:20

Because neither of us wanted our daughters to get their ears pierced at the age of 8 or 10.

Richard Nolan: 9:25

I have not looked it up. So I don't know for sure. And I was told that by a dermatologist. So I haven't investigated.

Sonia Nolan: 9:30

Look, I'm gonna go with fact on that one.

Richard Nolan: 9:33

But back to your question about hair dye, same thing happens. So basically, as you're exposed to it going on further, probably when you need the hair dye the most as the hair gets grey, that's when you start to develop reactions to it. So what we'd see is you've got the hair dye on and usually sort of within a day you'd start getting a reaction to it, that's a dermatitis. And that usually lasts for about a week or so after exposure which is very different to that immediate reaction and this is where the immune system seeing it as like a virus or an infection, so the immune system is now going to try and kill that and it takes like a week or so for it to do what it determines to be killing it, even though they don't need to kill it. So they're killing skin cells that have seen that allergen.

Sonia Nolan: 10:17

Continuing on then down the food allergy track, which I know is something that people are really interested in, because, you know, everyone wants everyone likes to eat. And also everyone's if they have got a, an allergy to a nut, or milk or eggs, particularly nuts, because they seem to be sort of around a lot. And in things that you may not suspect have nuts or traces of nuts. There's a fear factor as well. So can you tell me more about if people can outgrow their nut allergies?

Richard Nolan: 10:54

So there's a couple of things. So there's a heap of work happening in desensitisation for foods. So we now often are able to descend, so someone with milk or an egg allergy.

Sonia Nolan: 11:04

Can you tell me how that works.

Richard Nolan: 11:06

We start with tiny amounts, and get them to

Sonia Nolan: 11:06

Hard if your immune systems already been progressively eat more and more. And then in doing that, we can compromised. usually induce what we call tolerance being you're able to have it. Sometimes if you have massive amounts, you'll still have reactions. And there are certain side effects that we see. But we're able to often guide someone through that process and be able to do that. There's two main lessons it's taught us number one is that if we do it, so for example, for peanuts, and we do the same thing with peanuts, we know that if someone's been having it, and they've been having it basically every day for three years, once they stop having it a month later, 10% allergic and six months later, 50% are allergic, is that wrong, so it doesn't last. So it's got to be something they can keep having ongoing, and they're trying to work out ways to tweak it. And there's lots of research happening in that area, which I'm hoping is going to come through soon. But for milk and egg, it's much easier to do it regularly. Right. The second issue is we know that if so for example, peanuts, we can get someone who would normally react with a 10th of a peanut after eating five or six peanuts every day. And they're fine, fine, fine. And one day out of the blue, they have a bad anaphylaxis reaction. Even though they had it the day before, and they were fine. And we've known for many years that just having a positive test doesn't mean you're going to have a severe anaphylaxis. So we know there are six risk factors that we've been identifying, or that I've sort of focused on that could potentially make reactions much worse. So those six are number one, the amount of food you eat, logically, if you eat like a bucket full of peanuts compared to one peanut, it's going to be much worse. Whether you've got a cold or a flu, where you run down, that seems

Richard Nolan: 12:42

Absolutely. Any exercise, which will often be if someone's had a reaction they don't have their EpiPen, they have to go and run to the car or run home or whatever then that can make it worse. If they've had any anti inflammatories, for women around the time of their period, and any alcohol, all of those things will make reactions much worse. And so we sort of guide people to say, well, you know, there's a potential that it could be worse, it won't necessarily be but often several of those factors will be there at once. And so the idea of having an EpiPen and things like that is just in case, that would happen. Obviously that's the emergency treatment. So if it's a mild reaction, we just get them have antihistamines, if it's severe, then they've got the EpiPen there ready to go.

Sonia Nolan: 13:21

So tell me about the EpiPen. What is it? And how should you administer it?

Richard Nolan: 13:25

So an EpiPen has got epinephrine in it, which is the American name for adrenaline. Right. So it's an American device, which just basically has adrenaline and our bodies release adrenaline, when fight and flight and all that sort of stuff. In terms of what adrenaline does is, when someone has anaphylaxis, the two major problems is your airways constrict, and that's what causes wheezing and trouble breathing and your blood vessels dilate, meaning get bigger. And that means all the blood goes elsewhere rather than go into your brain. So adrenaline turns both of those off. So it makes your blood vessels tighten, and your airways relax, which actually turns the process off. Problem being it only lasts for 45 minutes to an hour. Okay? So if you've had a substantial amount of food or whatever that's caused a reaction and you have the adrenaline and you're better. That doesn't necessarily mean you're going to now be fixed going forward. So everyone that uses the adrenaline we say you need to get to hospital afterwards. So if it wears off, you can have more drilling at that stage.

Sonia Nolan: 14:24

And I've heard of people having to have more than one EpiPen administered at a time or within a certain amount of time. So is that a regular occurrence that they have a couple of EpiPens to keep them going with that until they get to the hospital? Oh, that's a lot.

Richard Nolan: 14:37

Yeah, so everyone gets two and again, we're just talking personal experience here. Sometimes people have used many when it hasn't actually been anaphylaxis. So like for I think its ridiculous. But in that same study which set up to a third of the people need a second dose, example, if anxiety is in there or something else so that they'll often keep using it because I think that is, but all those second doses were given in hospital. So the from what the studies show is that about a third of the people from a food allergic reaction will need a second dose. So that's why people are given two EpiPens. And in America adrenaline for the most part is going to be okay. If you're a sometimes they will carry around six EpiPens or eight EpiPens together. larger person like me, you might need two doses. If you're a smaller person, the likelihood you're gonna need a second dose is not very high. Fortunately, in Australia, in Perth, or the ambulances have adrenaline on board, so there's easy access to adrenaline if needed. So, usually, I'd give one EpiPen to someone who's in high school. And they the school has one, they have one. If they want one at the parents house and other other places, then they can buy as many as they like, but the government will give two per person. Per year, yep. Well, unless it's used, and then

Sonia Nolan: 15:47

Per year? for older adults we will usually give them two and get them to make sure they've got to with them, so that they can use a second dose if they need it. More than two doses is not very common. And it's a numbers game. It's what I say. So number one, the chances you're going to eat peanuts, if that's what you're allergic to is low. Number two, the chance you're going to eat, eat enough to actually cause a severe allergic reaction is low, usually a bit of itching and vomiting, which goes to antihistamines. And then number three, the chance that one EpiPen won't work, you're getting to reducing small risks in time, and it's all about managing risk. Tell me about the peanut challenge. Because that's another thing that, you know, I've certainly heard about with friends, having their children go through the peanut challenge because they've been allergic to peanuts, and then they're building up their tolerance to the point where they have a day of challenge. What happens?

Richard Nolan: 16:38

Well, there's two separate ways of doing that. One is you can just have a flat out challenge where you go into hospital and you're given a graduated amount, we know that a reaction happens within 15 minutes or every 15 minute intervals, you have increasing amounts, starts with a tiny amount, you just get a bit on the lip, and then we start with like a fraction of a teaspoon and then get progressively larger amounts until you eat probably the equivalent of a bit of peanut butter, peanut butter on a slice of bread. So 11 grammes of peanuts your final challenge. So over the course of the day, you probably have 20 grammes of peanuts, which is probably equivalent to a tablespoon of peanut butter. And then, you know, we see if there's a reaction on the way through, so that's one of them. That's what we've been doing the whole time. And that's what we still do in hospital, when we think someone might not have an allergy and carry forward. What also happens, sometimes they say, Well, you know, you know, your allergy tests have been coming down, you know, I think your reaction is actually quite low, we can do that. Or we can use that as an opportunity to go and try some desensitisation and sort of do a more rapid onset of that. So sometimes we'll do that sometimes we do the challenge. And different doctors will have different strategies in terms of which one they do based on what their experience has been. And obviously, as part of that challenge, that means that there is a chance they can have a reaction. And it's not uncommon for someone who's still allergic to have anaphylaxis with those challenges. And so they need to be aware that that's going to be one of the potential risks, but obviously on the upside is that they pass through it, then they're not allergic to peanuts, so they can eat peanuts whenever they want.

Sonia Nolan: 18:05

Which is exciting. When you've had to limit that in the house. Yeah, from a parent point of view. Knowing that your child is going through a challenge can be a little bit anxiety building for parents, do you spend a lot of time explaining and helping to calm the nerves of the parents before you go into that challenge environment because they would have been told for so long, you need to stay away from peanuts.

Richard Nolan: 18:29

So I don't work in the hospital. So I don't do those challenges. When I do do a challenge in my rooms, in general, I give it to someone who's of low risk. So where I'm confident that it's very unlikely they're going to react. So that's the first thing so I choose the right people, and everyone will do different things. And then I know there's always a massive amount of anxiety. So upfront, I flag that. And so that everyone who I give peanuts to gets an itchy mouth. So that doesn't mean there's an allergic reaction. But everyone gets an itchy mouth because as soon as I give it to you, your whole being is focused on your mouth and is there a reaction there or not? And so and once they kind of know that, and I say that's why I'm doing it here, so I'm going to give it to you. And then we're going to have a look and see if there's a reaction. If there's a reaction, that's fine, we stop if there's nothing there at all, then we can go a bit further and bit further. And the idea of going small doses sort of infrequently means that hopefully we'll have a mild as possible reaction.

Sonia Nolan: 19:28

So Richard, the other food allergy, which he said was quite common, was we talked about a bit about milk. We've talked about nuts. Tell me about eggs.

Richard Nolan: 19:38

Egg allergy is very common, particularly in young kids with eczema.

Sonia Nolan: 19:42

So there's a correlation between eczema and eggs.

Richard Nolan: 19:44

Well, eczema and food allergies, actually. Eczema is probably the start of food allergies. And there's some theories around that which we could talk about. In terms of with egg it's very common for people to have an allergy to raw egg and sometimes to cooked egg and often their first reaction will be like when they're having a little bit of scrambled eggs sort of thing. And often it's quite mild early on. So it's a bit of lip swelling and things. We know that a lot of those people can actually tolerate cooked egg. Okay, but not so correct. And so often if they can eat cooked eggs, so like egg that's cooked in cakes and biscuits and things like that, then there's two parts of your immune system. So there's the allergic part, which we talked about before. And there's a rest of your immune system that helps you learn what to cope with, and what to tolerate and what not to tolerate with. So if you actually, and that, and those two parts of the immune system see different parts of egg. So when the egg is cooked, the allergic part often can't see the bit that it's supposed to be allergic to, but the bit that can tolerate it can still see it. So you're tolerating it. And so that then turns down the bit that reacts to it, if that makes sense. So that's a way that you sort of develop a tolerance to it so often we'll encourage people to keep eating food in cakes and biscuits.

Sonia Nolan: 20:59

Cakes. Finally some good news, Richard, right.

Richard Nolan: 21:01

If you have an egg allergy. And if you're not allergic to cooked egg.

Sonia Nolan: 21:06

It's not actually helping me justify my eating of cakes.

Richard Nolan: 21:09

No. So but often, like, you know, once we've tested someone's we know, then we'll sometimes get them to have that going forward.

Sonia Nolan: 21:16

Okay, let's-

Richard Nolan: 21:18

Lets go back to-

Sonia Nolan: 21:19

I want to go back to eczema, is that what you were going back to?

Richard Nolan: 21:21

Yes, so eczema is very common in childhood. And we now know that lots of people who have eczema go on to get food allergies. And in the past, there's been lots of theories about why food allergies develop. And so one of the main things was that initially, it was like the guts immature, and the gut can't handle these foods. Now, why after 100 years, the guts now immature, not sure. And there's lots of thoughts about you know, additives and foods and all this stuff, tributing to immature guts. But the advice was that you shouldn't feed highly allergic food before a certain age. And you should delay and delay and delay and be very cautious when you choose it. We now actually know you've got these specialised allergy cells under your tongue that teach your body that it should actually be tolerating these foods. So what was happening is by delaying the onset of eating the food, obviously, these children were still loved. And so people still ate the food around them. But it would actually come in contact with this skin and often with eczema. And so the immune systems going crazy with the eczema on the skin and now started seeing this food on their skin as well. And then its thinking, well, maybe that's what's contributed my eczema and all of a sudden they eat it and they have a reaction. So what they've done is they've tried to undo a lot of that advice and say, well, in fact, we'd prefer you do feed the food. And we know that it's best done, at sort of age appropriate times. So sort of once they can start to eat solids and things like that, it's when they should start eating peanuts. They've also done a big study where they actually took kids from, I think it was about one year of age, who had tiny positive skin test to peanut, so they excluded those that have big reactions. But those that had tiny positive reactions, they split them into two, they said, right, you guys, we're going to feed you peanuts, we know there's a risk, we're going to feed your peanuts, the other guys, we're not going to feed you peanuts, because we don't want to cause a reaction. The ones that weren't fed it had a far far greater risk of actually having a proper peanut allergy, ones that were fed it, it all seemed to vanish away. So we're really encouraging people in terms of when they are trying to introduce food to, to infants to actually do it an age appropriate time rather than trying to delay it. And with eczema, we don't know the best strategy for that. But obviously, we think the more aggressively you can treat the eczema and the better control you have, we would hope that would translate into less chance of the food allergies.

Sonia Nolan: 23:38

I'm really intrigued by what you've just said about the under the tongue. Can you explain that one to me? Because that sounds really interesting that, so we're born with these special enzymes, or I don't know, give me the language, Richard, going on under the tongue for us?

Richard Nolan: 23:57

We're getting a lot into immunology here, but it makes sense.

Sonia Nolan: 24:01

It does make sense.

Richard Nolan: 24:02

So you've got area dendritic cells. So dendritic cells are cells, if you just imagine like, it's a person and I've got like 20,000 hands, and I'm just grabbing everything that's coming through, and then I'm taking it back to the immune system and the immune systems assessing it going, okay, yep, fine, fine, fine, fine, fine.

Sonia Nolan: 24:21

Doing a filter.

Richard Nolan: 24:21

And developing, you know, being able to tolerate all those things. And your immune system needs that tolerance to know that it's something that's fine. So if you haven't actually had that tolerance built up, and all of a sudden you're bombarded with it. But in fact, you've had the opposite happen. So you've had exposure through your skin or something else that that and you've developed an allergy to it, then all of a sudden, bang, you're out. So, we actually harness those same cells in terms of when we start to do the food desensitisation, harnesses those, when we sometimes desensitise people for their hay fever and things like that we actually often harness those as well and we can do some drops under the tongue to actually try and turn down people's allergies. as well. So there's some specialised allergy cells there, which are called dendritic cells or allergen presenting cells that are at the forefront about teaching the immune system what it can tolerate.

Sonia Nolan: 25:10

So can I just unpack some of what you've said? And just make sure I understand it, right. So if we are not feeding young children aged appropriately, and introducing them via eating to some of the allergies, what could be an allergen like nuts, or eggs or milk. And because they're exposed to it in the home, and they may, they may, I don't know, have that on their skin instead of via their mouth and tasting and eating it. They may possibly think-

Richard Nolan: 25:43

That contributes a lot to it.

Sonia Nolan: 25:44

That contributes to it. Okay. Yeah, I thought that's what I understood. I just find that really fascinating. Okay.

Richard Nolan: 25:49

We think that's a major driver. But again, how do you test that? How do you test it? You can't. So there's no set, diagnostic or no set research that will give you all those answers, except for what we call epidemiological. So it's population studies. But from everything we understand, we go well, irrespective, it doesn't matter, what we really want to do is get people eating those foods. And we know that if you're eating it, then that should translate into a lesser risk of that. And the advice before was probably harmful. And I think that's sort of because we've seen so much food allergies, now everyone's super anxious about it, which makes it much harder to introduce those foods. So undoing some of that and getting people to eat. Getting kids to eat more early on, I'm hopeful will actually translate into less food allergy.

Sonia Nolan: 26:37

So we're sort of myth busting with the fact that our stomachs are able to cope with these proteins and enzymes and all the things that we're giving them through.

Richard Nolan: 26:48

Yeah so, I think there's a there's...

Sonia Nolan: 26:50

I want to be careful with this.

Richard Nolan: 26:52

That's okay. I think that we're probably going to see a decade of understanding guts much more. Yeah, there's a lot happening in the gut, there's a lot to unravel, as we've talked about before, and there's things like faecal transplants, there's a whole lot of stuff that's happening in the guts.

Sonia Nolan: 27:07

We weren't going to talk about fecal transplants.

Richard Nolan: 27:08

Yeah, we weren't gonna talk a lot about it. But there's a whole lot of stuff happening in people's guts that we don't have a good handle on yet. And it's been sort of managed at arm's length in the past, and it's sort of been a bit of "oh, we don't really understand." So I'm hoping over the next sort of 10 years or so we're going to start to get a lot more information from that feed through. I expect the guts fine, it is immature, but it will develop maturity and eating the food early isn't going to upset that.

Sonia Nolan: 27:41

Richard, we've talked a lot about the more known allergies, can you tell us a bit about some of the lesser known allergies that you might-

Richard Nolan: 27:50

Some weird stuff?

Sonia Nolan: 27:50

Some weird stuff, what's some weird stuff that you might treat?

Richard Nolan: 27:54

So there's a lot of weird stuff out there that...there's three unusual ones. So there's one you might have heard of, you can have like a an allergy to mammalian meat, it's called. Mammalian meat anaphylaxis, it's being allergic to red meat. And so that's beef or lamb and basically you can eat the food. And often actually, several hours later, like four to six hours later, you can have an episode of anaphylaxis so often that's overnight that will happen.

Sonia Nolan: 28:22

And is that something that you're born with, or you just happens at one point in your life?

Richard Nolan: 28:27

Yeah, so population studies. And there's certain pockets of the world where this seems to be really common, including on the east coast. So in Perth, we have a very infrequently, and what they found out is this particular tick. And if you're bitten by a tick, the saliva of that tick you develop an allergic reaction to, and then the proteins in that saliva are very similar to the food- the protein in the in the beef. It's called Alpha gal. And then once you eat that, then you have anaphylaxis. And so it seemed to be a tick bite. So kudos for those that have discovered it because it's amazing. But a couple of different pockets. So we have one over in the eastern states. So I've seen a couple of times, but usually it's in someone who's been on the eastern states.

Sonia Nolan: 29:07

And then other places in the world, is it?

Richard Nolan: 29:09

And in the US, there's a couple of pockets as well. So that's one unusual one. My favourite one...

Sonia Nolan: 29:17

Your favourite weird one.

Richard Nolan: 29:18

Favourite weird one is one that everyone thinks I'm very clever when I diagnose it, but it's all patent.

Sonia Nolan: 29:23

But you're very clever, Richard. Don't underestimate yourself.

Richard Nolan: 29:26

It's called Food Dependent Exercise Induced Anaphylaxis.

Sonia Nolan: 29:30

Oh, I like the exercise induced bit.

Richard Nolan: 29:32

I know. So if you don't exercise, you're fine!

Sonia Nolan: 29:35

Now we're talking. No, I actually love exercising now, Richard, I'm a new person. I just need to throw that in

Richard Nolan: 29:41

So in these people there, you can eat wheat there. without problems. You can exercise without problems. But if you eat wheat within four hours of exercise, and you can have anaphylaxis. And bizarrely, and I don't know how it was discovered, you actually have an allergy to one of the metabolites of wheat. So you eat it. And then once you've absorbed it, it actually metabolises. And then you could actually develop an allergy to that, which is bizarre.

Sonia Nolan: 30:08

That is bizarre.

Richard Nolan: 30:08

Yeah. But we can pick it up, we can pick it up in the blood tests. And we can say, that's what it is. And there'll be, you know, go through periods where there's lots of people that have it, and they're not very many and up and down. But once you know what it is, all of a sudden, this random episodes of anaphylaxis all vanish away, and it's, it's a lot better in terms of clarity going forward.

Sonia Nolan: 30:26

And the trick is to stop eating wheat, not to stop exercising, yes?

Richard Nolan: 30:29

The trick is to stop eating wheat within a few hours of exercise.

Sonia Nolan: 30:33

Okay so you can still eat wheat...

Richard Nolan: 30:35

Potentially, yeah.

Sonia Nolan: 30:36

...When not within the time of exercising.

Richard Nolan: 30:39

Potentially, yes. And some people can't because they react with very small amounts of exercise, but some people can. And the most well, there's, and there's a couple of other unusual ones. So I've seen someone allergic to marijuana, okay. And so, I don't stock marijuana in the room, so they had to bring it in. So I could do some testing, just in case anyone's wondering that.

Sonia Nolan: 31:00

Did you need to get a special permit or anything? Or?

Richard Nolan: 31:04

I hope not. And another one, so I've seen-

Sonia Nolan: 31:08

Wait go back to marijuana. I want to know more about the marijuana. What happened? Like what was the reaction?

Richard Nolan: 31:13

So a bit of- seeing people with hay fever when they're smoking it, or when they're rolling up particularly. And that sort of comes into the air and they can smell that. And then when they sort of drank it, then they had anaphylaxis when they drank it.

Sonia Nolan: 31:27

Can you drink marijuana?

Richard Nolan: 31:29

You can do lots of things with marijuana. So I'm told! So I'm told.

Sonia Nolan: 31:33

So we're told.

Richard Nolan: 31:34

And another one so I've seen some chefs that have been allergic to spices.

Sonia Nolan: 31:40

Oh, oh, that's unfortunate. That's a workplace hazard.

Richard Nolan: 31:43

Very unfortunate. Yeah. So that's a career change, unfortunately.

Sonia Nolan: 31:46

Right, okay. So what sort of spices, are there particular spices more allergenic?

Richard Nolan: 31:51

Well, it's not common to be allergic to spices. One was aniseed. Another one was cumin. So it's, you know, they're not - not common things to have. But yeah, so they're obviously unusual workplace based things that you can get. Yeah. So there's some unusual ones that we see.

Sonia Nolan: 32:06

They are amazing. So is everyday different for you, Richard? Or do you tend to see, you know, similar patterns in who presents to you? Oh, that's really unfortunate.

Richard Nolan: 32:16

Well, the common things is hay fever, food allergies and rashes. But then we'll often see some random But in fact, it ended up being a cream that things come. Yeah, so everything's interesting. When I do a skin test, I never actually know what the results are going partner was using, and they were allergic to a chemical in that to be. So I can guess, but I'm never sure about it. So and I'm always a bit surprised. You know, like, you know, I've seen cream. And then once they stopped using that it all people that are like "I'm sure I'm allergic to my cat." You know, like, since I've had the cat I've been really- I'm like,"you might be But do you realise that? You know, this is what's coming up, you're actually- the dust mites much worse than the cat" its that, oh, well, maybe this, this this, all the things that I've got with dust and doing this. And so again, go into other things. So skin rashes, I've seen people - I saw someone they were allergic to their partner. vanished away.

Sonia Nolan: 33:08

Uh-huh, yeah. It's, it really is a bit of a treasure hunt sometimes, isn't it?

Richard Nolan: 33:12

Very much so.

Sonia Nolan: 33:15

So Richard, is there a pattern in regards to Australia's allergy rates compared to internationally? Like, do we have more allergies in Australia? Are we better at identifying it than other countries?

Richard Nolan: 33:33

Yeah, we got lots in Australia. Which is good for me. But so I think it relates to our, our environment, so our humidity, it relates and so you know, the types of allergies I'm talking about, is we have a lot of food allergies, and we've had a lot of research go into food allergens, if we're thinking that relates to how far away we are from the sun and things of that sort of vitamin D levels, a whole lot of those sort of things lead into it. So all of those things could have some contribution for the food allergies. For hay fever, again, our environment. So we know that in Perth and Melbourne, we have lots and lots of hay fever. In other parts of Australia, there's also a lot - it's not quite as much in Perth, Melbourne and in other parts of the world like in more humid environments. So like Singapore and Malaysia, their dust mite levels are less than ours, they don't have the grasses pollinating. So the chances of being allergic to those things, it's going to be much less than what it is where we are.

Sonia Nolan: 34:28

And that all makes sense environmentally and yeah.

Richard Nolan: 34:31

But we get the trade off of living in a great place.

Sonia Nolan: 34:34

Oh, absolutely. What are the questions that people ask you the most, Richard, when they come to see you about allergies? What what do they want to know more about?

Richard Nolan: 34:44

Yeah, so it's good. So mostly, they want to know what they can do to fix it. And they also often intrigued about why they've got an allergy and why that's all happened. And unfortunately, we don't always know the answer to that, we know population data, but we don't know in an individual why. So if you came to see me and said,"Oh, look, I've started reacting to hair dye, why am I reacting to hair dye?" I don't have a simple answer, except that we know the immune system learns in time. And so if you're using it over time, then you're more likely to develop an allergy to it. But exactly which triggers happen along the way, we don't quite have clarity around that. They want to know what they can do to try and reduce their allergies. So from that side of things, we can put in some medications, which we haven't talked much about. And we can also offer advice about how you can avoid these things. So like with dust mites, or with the, say, moulds or things like that we can sort of offer those things. And then treatment wise, we can do some desensitisation. I guess. The question is when people are seeing me as they have often done quite a lot of research themselves about some of these allergies. And they're sort of looking to say, well, what can we do to sort of try and fix this and what can I do going forward?

Sonia Nolan: 35:57

So let's talk about the medications. What is available to people?

Richard Nolan: 36:01

Oh, there's heaps. So most medications are available just over the counter. So if we're talking, we've talked about food allergies, so the EpiPens, obviously through specialists and through GPS and the antihistamines, the other ones, so my favourite anti histamine for a food allergy, I think the one that works the quickest is Cetirizine. So I get everyone to use that one. In terms of hay fever, I don't mind which anti histamine, I think they're all pretty similar. And so if it's just mild, they do some intermittent antihistamines. If it becomes more severe, then you can use nasal steroids. So that's things like Mometasone nasal spray, I'm being careful not to say trade names. And they can get all those through their chemist. So and there are some other different sprays. There's some new ones, which is a combination of steroids and antihistamines in the same spray, and they actually work better. That's available on script. So this is a wide variety of things that often pharmacies are a good place to start. But if they're not getting a benefit, I really don't like it when I've seen someone, they've been for five years, trying a 1000 things for five years, nothing's been happening. And then I'd much rather see them much sooner and go, well actually, this is what we can do bang, bang, bang. And then obviously, desensitisation works quite well, in most people, but not everyone. And the number is probably about 70% of people notice a big improvement for like for their hay fever, for dust and grasses, they can sort of give treatment for those things. And that often works very well. And we can do that in two ways. So injections or sometimes some drops or tablets under your tongue, which are now available, and they will often work quite well in that area as well.

Sonia Nolan: 37:35

And desensitisation. Does that take a couple of years? Or is it a faster process?

Richard Nolan: 37:40

So it works within a few months.

Sonia Nolan: 37:42

Oh, right. Okay.

Richard Nolan: 37:43

So they get improved within a few months, but the treatment is usually three years in total. And the reason it's three years in total is the longer you do it for the longer it lasts. So we get people to it for three years.

Sonia Nolan: 37:52

And is there like we talked about earlier, where when you stop doing something, and then it might like- eating nuts for example. It came back.

Richard Nolan: 38:00

There's two, two things. So I'm talking with desensitisation more about inhaled allergens, so dust and grass and things. And we know that actually lasts for several years after you stop it. Not forever. But for several years. The foods, we had hoped that would be the case. But it hasn't borne out yet. So that seems to be different in terms of the way that someone develops their allergy to that and the way that it needs to be treated might be a different scenario rather than the the other ones, the airborne allergens.

Sonia Nolan: 38:30

Can we talk very quickly about insect bites and bees, being allergic to bees? Because that's again, a pretty concerning-

Richard Nolan: 38:38

Animals at the zoo as well. Right?

Sonia Nolan: 38:40

Yeah, right. Okay. So tell me about-

Richard Nolan: 38:42

It's always bizarre when you get a phone call from someone from the zoo.

Sonia Nolan: 38:46

So the animals are actually allergic to the bees?

Richard Nolan: 38:48

Yeah.

Sonia Nolan: 38:49

Oh, okay. So how did you treat that? What did you do?

Richard Nolan: 38:52

I can't do much, can I? They're an animal. They're a little tiny animal and I can give them some advice. And they've got you know, the vets there that give us a call and ask about those things. But I don't think in that setting, we couldn't really give any desensitisation or anything. And they were just wondering about EpiPens and right doses and all that sort of stuff. So it was that sort of conversation. But in terms of insect stings, so for bees and wasps, we can certainly do desensitisation for that. And that actually works really well.

Sonia Nolan: 39:17

Oh, good.

Richard Nolan: 39:17

So it's only available through injections, and it's quite a lot of them. But that actually is very helpful. And often people that have had reactions to bees will get quite fearful around them and stuff like that so it helps with anxiety sort of things and also reduces their risk. There's two things I see with bee allergies. So one is like people that say, "Oh, my reaction is getting worse. You know, last time I didn't get a reaction. This time I got stung on my arm, my whole arm swelled up and I'm worried the next time we're gonna get anaphylaxis." The likelihood of that is actually quite low.

Sonia Nolan: 39:47

Okay, that's reassuring.

Richard Nolan: 39:49

It was probably about one in 50 to 100 stings will sort of evolve into anaphylaxis. Whereas the people who actually do have anaphylaxis, their risk is much higher for getting that going forward. So in those people that have had anaphylaxis. They're the ones that would give the desensitisation to.

Sonia Nolan: 40:03

And this is possibly a really silly question. But if you're allergic to bees, it doesn't mean that you would be allergic to honey or any bee products.

Richard Nolan: 40:11

Not silly.

Sonia Nolan: 40:12

No, is that a good question?

Richard Nolan: 40:13

That's a great question.

Sonia Nolan: 40:14

Excellent.

Richard Nolan: 40:15

But no.

Sonia Nolan: 40:15

Oh, okay.

Richard Nolan: 40:17

Although I've seen a lot of people allergic to royal jelly, which is actually the honey pollen propolis, which is actually what the queen bees usually feed off so people can have that for vitality or for other things. I've seen quite a few episodes of anaphylaxis from that.

Sonia Nolan: 40:33

If they are allergic to bees. Beestings?

Richard Nolan: 40:36

No, no, no. You're not allergic to beestings. So there's not much cross reactivity between the honey. So the honey is what is made from the pollen, which is very different to where the venom is. So it's different proteins in both, so it's unlikely you're allergic to both. Medications are good to talk about. So the other thing which has been unusual is medication allergies. So there's a lot of people that can react to medications. So the typical ones are antibiotics, so the amoxicillin stuff, and we've actually changed a lot in the way we manage that. So we now recognise that if you've had anaphylaxis, which is like an immediate reaction, so within half an hour of having it, and you've either had hives or anaphylaxis, that you're a very high risk of having that same reaction the future. Most people, about 90% of people with a penicillin allergy have often had a reaction a couple of days into the course it lasts for about three or four days. In that setting, they've always been told they were allergic to it and avoid it. But we now know that the vast majority those people aren't actually allergic to it, it's probably the virus they had as well as the penicillin at the time that caused it. And so we will often now just challenge those people by giving them some penicillin in a graded way. And then often those people are fine to have it in the future. So it's worthwhile people know about that, because a lot of people with penicillin allergies won't necessarily happen. The other medications that are very common that people don't often think about is anti inflammatories, people can develop reactions to anti inflammatories in two ways. One is they can be allergic to anti inflammatory. And the second is they can actually be allergic to a food that's contributed to by the anti inflammatory like we talked about before. And the third one, which we've been seeing buckets of lately.

Sonia Nolan: 42:12

Oh, what's that?

Richard Nolan: 42:13

So it's a combination of Echinacea, Andrographis, Astragalus and olive leaf extract, which is supposed to boost your immune system. And I've frequently seen anaphylaxis with that.

Sonia Nolan: 42:24

And so this is like a vitamin supplement?

Richard Nolan: 42:27

Yeah, it just over the counter and people take it for their immune system to boost it. In fact, I've had one person that took it had anaphylaxis went into hospital. And the next morning, took another dose. Because they didn't - and the hospital didn't know either. Right? So no one knew and because they just thought it was a vitamin and natural and healthy, but it actually, so it now comes with a warning, say it might have it, no one will read it but in fact, it scares me.

Sonia Nolan: 42:54

And Richard, what excites you most about immunology?

Richard Nolan: 42:58

I think this next- I'm actually quite excited for the next couple of years. So firstly, I think food allergies hopefully going to get, we're going to have big leaps and strides for that. The other thing is there's all these new medicines, these biologic medicines that are manipulating the immune system. And I think that's actually super exciting, in that if we think the problem is that there's one of these aspects which has gone a bit offline and caused an immune reaction that way, we can then sort of potentially just turn that off and get everything back in line again. And we're seeing that across the board. So we've seen that we've now got some really good medicines for severe eczema. For this autoimmune urticaria, we're about to get some hopefully for sinus problems. For asthma, we've got some for all of these sort of really difficult to control medicines, we can actually reduce a lot of the steroids that we've been giving people by just targeting particular parts of the immune system. So I think there's just an explosion of those medicines and trying to sort of get a better handle and trying to be able to almost personalise the immune problems, like treating that immune problem to get someone back to health, I think its very exciting.

Sonia Nolan: 44:07

Richard, thank you so much for your time.

Richard Nolan: 44:10

My pleasure.

Sonia Nolan: 44:10

I've really enjoyed unpacking a lot of those things that we probably haven't really needed to talk around the dinner table about, but it's been an absolute delight to have you on my podcast. So thank you for your time.

Richard Nolan: 44:21

Thank you, my pleasure.

Sonia Nolan: 44:25

Thanks for joining me Sonia Nolan around the Warm Table. Let's grow the community. Please follow my warm table podcast on socials and like and share this episode with your family and friends. My Warm Table is brought to you by Females Over 45 Fitness. Keep listening now for a health tip from FOFF head coach Kelli Reilly.

Kelli Reilly FOFF: 44:46

Hi, it's Kelli Reilly, founder and head coach of Females Over 45 Fitness or FOFF. Did you know that during menopausal years you can suffer from night sweats and hot flashes and you need even more water intake to make up for the losses from those horrible sweating episodes dehydration can also create joint inflammation or pain, skin changes, mood swings brain function, forgetfulness, energy level changes, headaches, irritation to your bladder, and even night palpitations. So try to drink at least 1.5 to 2 litres of water per day, on top of your tea and coffee of course. Remember ladies, it's your time to shine.