All that wheezes is not asthma: Doctor uses YouScript to solve puzzling patient case

Dr_Mark_PamerAs cardiopulmonologist Mark Pamer, DO, goes about his day at his South Florida practice, one adage from medical school that sticks in his mind is: “All that wheezes is not asthma.”

“[As doctors], we probably all heard that. Did we understand it? You know, probably not,” said Dr. Pamer. “We understood it later on in residency or fellowship or in life.”

This adage proved itself during Dr. Pamer’s treatment of a puzzling patient case involving a 59-year-old man who came into his practice with all the classic signs of asthma. It was worse in the winter and around animals, and included nasal congestion. The patient also had history of gastroesophageal reflux disease (GERD) also known as acid reflux, hypertension, irritable bowel syndrome and tremors.

The patient was on multiple medications, including fluticasone/ salmeterol (Advair) for asthma, dexlansoprazole (Dexilant) for GERD and primidone (Mysoline) for tremors, in addition to a rescue inhaler.

The patient came to Dr. Pamer complaining of worsening asthma symptoms, so the dose of Advair was increased. A month later, the asthma symptoms had not changed. Pulmonary function tests and chest x-rays simply did not point to asthma.

Dr. Pamer stopped the Advair and had the patient evaluated for asthma-mimicking states, which can include acid reflux. These tests showed the patient’s reflux was not being controlled by the Dexilant, which is metabolized by the highly variable CYP2C19 enzyme pathway.

Fortunately, Dr. Pamer knew the value of the YouScript Personalized Prescribing System in figuring out tough cases. Genotyping and YouScript analysis revealed the patient to be a CYP2C19 rapid metabolizer, which was predicted to decrease the blood levels of Dexilant.

Primidone, being an inducer of both CYP2C19 and CYP3A4, was likely decreasing Dexilant blood levels even more. Together, these factors resulted in a clinically significant increase in Dexilant metabolism and a decrease indrug effectiveness.

This analysis, in combination with a 24-hour pH probe on the patient, revealed his asthma symptoms were actually a result of acid reflux. The reflux, in turn, was the result of both the patient’s genetics and a drug-drug interaction that was drastically reducing the blood levels of Dexilant.

“I wouldn’t have learned any of this from talking to him,” Dr. Pamer explained. “It just seemed that he had horrible asthma.”

After Dr. Pamer consulted with the patient’s neurologist, the 59-year-old was titrated off primidone. Additionally, his Dexilant was replaced with rabeprazole (Aciphex), which is not as dependent on the CYP2C19 pathway for drug metabolism. The patient’s “asthma” was controlled, and his cough went away.

“I’ll tell you that your knowledge base improves exponentially once you start to use this test,” Dr. Pamer said of YouScript.

2 Comments on “All that wheezes is not asthma: Doctor uses YouScript to solve puzzling patient case”

  1. Another thing to keep in mind/check: A person with “asthma” or wheezing might actually have a casein or whey protein allergy. That was my issue. I was on Advair, and as the years went by, the Advair wasn’t controlling my symptoms, I coughed uncontrollably in the winter time, I eventually started having wheezing episodes–in summer–and I was testing horribly via the spirometer. Then I had an IgA Food Intolerance Panel taken–I was positive to milk casein, soy protein, and gliadin. I went off these foods and particularly all cow dairy and blew the best spirometer test I’d ever done the next time I went to the doctor. (I have found that I can have goat and sheep products in moderation; I usually use coconut milk and nut milks. Ghee also works.) I have been without cow dairy now for 6 years and have never had any signs or problems with asthma or wheezing again, even in the winter, which is when I usually had all my symptoms. If I consume anything with cow dairy, I can tell because I instantly become phlegmy and develop a cough.

    IMPORTANT NOTE: Just putting patients on Advair without checking to see if they have issues with whey or casein protein is NOT a good idea. The information packet for Advair specifically states that patients with a milk protein allergy SHOULD NOT use Advair. My doctor never tested me before putting me on Advair. A lot of unnecessary problems could have been avoided if he had done so.

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