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Fragrance allergy

Public understanding of allergy pathology is often inaccurate and can create dangerous misunderstandings. The most common is that you must ingest a protein in order to have an anaphylactic reaction. Another is that inhalation or skin contact cannot cause severe reactions.

Both of these are inaccurate, especially, but not only, for people with mast cell disease. People without mast cell disease have severe reactions to IV contrast without having allergy antibodies to the protein (Singh, 2008). Inhalation can cause anaphylaxis. There are even cases of patients who can tolerate ingestion of a food but not inhalation, such as seen in Baker’s asthma, the second highest cause of occupational asthma in the UK (Ramirez, 2009). While ingestion of protein is the most common mechanism for severe allergic reactions, it is certainly not the only one.

Fragrance allergy is a growing problem worldwide. Fragrance is now one of the top five allergens in North American and European countries and can cause skin, eye and respiratory problems (Jansson, 2001). At least 100 chemicals commonly used in fragrances can cause contact allergies when applied to skin, even passively (Johansen, 2003). European Commission’s Scientific Committee on Cosmetic Products and Non-Food Products’ 1999 list of allergenic substances contained 24 chemicals and 2 botanical preparations, all used as scents (European Parliament and Council Directive 2003/15/EC, 2003).

Though the exact mechanism is not clear, perfume is known to cause asthma and other respiratory problems (Elberling J, 2009). A Dutch study found that isoeugenol, a common component of fragrances, can cause increased proliferation of cells in respiratory tract lymph nodes when inhaled (Ezendam J, 2007). However, more research is needed in this area.

A significant portion of the population also reports adverse reactions to scented products in general, even when worn by others. Products like scent lotions, perfumes, soaps and air fresheners are all cited as problematic. A 2009 paper reported on the results of two surveys of over 1000 people. 30.5% of the general population found scented products on other people to be irritating. 19% reported health effects from air fresheners, and 10.9% reported the venting of scented laundry products as causing symptoms. Percentages were higher among asthma patients and those with chemical sensitivity (Caress SM, 2009).

Symptoms reported from exposure to fragrances on others includes: headaches, chest tightness, wheezing, diarrhea, vomiting, mucosal irritation, reduced pulmonary function, asthma, asthmatic exacerbation, rhinitis, irritation of the airway, nose and mouth, and dermatitis (Caress SM, 2009).

Many of you are aware of the recent dispute over whether or not essential oils can be dangerous. They can. Even in the absence of known chemical triggers, the oils themselves can be triggering to many. As an example, clove oil, which has a large eugenol component, has been tied to severe allergic reactions (A.O. Nwaopara, 2008). Oils of citrus fruits are known to liberate histamine and make it more available to cause mast cell symptoms (Novak, 2007). Furthermore, while the reaction profile of each mast cell patient is unique, the hallmark of mast cell disease is anaphylactic reactions to seemingly harmless substances. Mast cell patients are increasingly being viewed as “canaries in the coal mine” for their ability to detect minute quantities of offensive components. While mastocytosis is rare, affecting about 0.3-13/100000 patients, some level of mast cell activation syndrome (MCAS) is thought to affect a much larger percentage of the population, in the neighborhood of 5% (Molderings, 2014).

Fragrances, from essential oil or otherwise, can cause contact allergies, headaches and respiratory symptoms. In mast cell patients, scents can cause severe full body reactions that are potentially life threatening or fatal.

MCAS: Pain

Pain is an unfortunate fact of life with MCAS. Muscle fatigue and weakness are common complaints, but myositis and rhabdomyolysis are rare. Some patients have elevated creatine kinase and/or aldolase, but have no related symptoms.

Bone pain is frequently reported with MCAS. Osteopenia and osteoporosis are common findings. Focal osteosclerosis is also sometimes found, but less frequently. Joints are often painful, which can lead to diagnoses of osteoarthritis, seronegative rheumatoid arthritis, fibromyalgia and polymyalgia rheumatica. Pain can migrate and is often poorly localized. Patients often feel pain in joints, bones and soft tissues, sometimes inconsistently.

Mast cells have been implicated in several pain disorders. Chronic lower back pain has been hypothesized to be related to mast cell activation for over a decade. Complex regional pain syndrome Type I, formerly known as reflex sympathetic dystrophy (RSD) and reflex neurovascular dystrophy (RND), is the most painful long term condition described. It is marked by neurogenic inflammation (nervous system swelling), sensitization of pain receptors and circulatory problems that cause swelling and color changes. It can affect any part of the body. Mast cells have been linked to the inflammatory response seen in CRPS patients.

Neurons with noradrenaline, serotonin and opioidergic receptors inhibit transmission of pain signals. (This is why taking opiates works for pain – it binds to these opioidergic receptors and suppresses the pain signals.) In the spinal cord, pain signals from the peripheral pathways meet up with the spinal pain signals to send to the brain. Here is where molecules like GABA, opioids made in the body and serotonin control pain transmission.

In chronic pain, serotonin acts to amplify the peripheral pain signals instead of suppress them. Increased serotonin levels and mast cell counts are found in many patients with chronic abdominal pain. About 95% of serotonin in the body is found in the peritoneal cavity, which explains the chronic pain many people feel in this region. Mediators released from colon biopsies in IBS patients were proven to excite the local nerves and activate pain receptors. Serotonin is one of these mediators.

Some antidepressants are known to affect serotonin secretion from mast cells. In particular, tricyclic antidepressants inhibit serotonin release in a dose dependent manner at higher concentrations. Clomipramine was seen to be the most effective, with amitriptyline and doxepin inhibiting release of serotonin and histamine at higher doses. All three were found to affect both uptake and reuptake of serotonin by mast cells and therefore lowering the relative concentration of serotonin in the local environment.

MCAS pain is often difficult to treat with typical pain medications. Antihistamines and cromolyn should be used to manage pain where possible. For bone related pain, bisphosphonates are usually effective. There is some data to suggest hydroxyurea can help manage pain in MCAS patients.

 

References:

Xinning Li, MD; Keith Kenter, MD; Ashley Newman, BS; Stephen O’Brien, MD, MBA. Allergy/ Hypersensitivity Reactions as a Predisposing Factor to Complex Regional Pain Syndrome I in Orthopedic Patients. Orthopedics 2014: Volume 37 · Issue 3: e286-e291

Giovanni Barbara, et al. Mast Cell-Dependent Excitation of Visceral-Nociceptive Sensory Neurons in Irritable Bowel Syndrome. Gastroenterology Volume 132, Issue 1, January 2007, Pages 26–37.

Ferjan, F. Erjavec . Changes in histamine and serotonin secretion from rat peritoneal mast cells caused by antidepressants. Inflammation Research 1996, Volume 45, Issue 3, pp 141-144.

Barbara, V. Stanghellini, R. De Giorgio et al. Activated mast cells in proximity to colonic nerves correlate with abdominal pain in irritable bowel syndrome. Gastroenterology, vol. 126, no. 3, pp. 693–702, 2004.

Barbara, B. Wang, V. Stanghellini et al. Mast cell-dependent excitation of visceral-nociceptive sensory neurons in irritable bowel syndrome. Gastroenterology, vol. 132, no. 1, pp. 26–37, 2007.

Afrin, Lawrence B. Diagnosis, presentation and management of mast cell activation syndrome. 2013. Mast cells.

Language matters: Mast cell terminology

This is by no means a comprehensive list – just a review on definitions of some commonly confused terms.

Acute: This word gets used a lot when people mean “severe.” Acute does not mean severe. It means sudden onset or having a short, limited course. For example, stage III anaphylaxis is an acute complication of mast cell disease. Its symptoms come on suddenly, require immediate treatment, and once treated, resolves. (I am not referring to the after effects of anaphylaxis – just the emergency and treatment.) In a medical sense, acute is the opposite of chronic.

Chronic: Long term, occurs all the time, is expected to occur forever. I have mast cell disease and am chronically ill. I have acute anaphylactic emergencies.

Progressive: Getting worse or will get worse. This term gets used loosely by patients to mean that their symptoms get worse. Medically speaking, this generally refers to progression of disease from one stage to the next, like SM to ASM. SM and MCAS are not inherently progressive diseases. People who have progressed from SM to SSM or ASM have progressive disease.

 

Systemic symptoms: Any symptoms that do not involve the skin. Can be present in cutaneous mastocytosis or MCAS. So diarrhea is a systemic symptom. Tachycardia is a systemic symptom. Systemic symptoms do not mean you have SM.

Systemic mastocytosis: the diagnosis you receive if you meet either the major criterion listed subsequently and at least 1 of the 4 minor criteria, or at least 3 minor criteria if the major criterion is not met:

Major criterion

Multifocal, dense infiltrates of mast cells (≥15 mast cells in aggregates) detected in sections of bone marrow and/or other extracutaneous organ(s)

Minor criteria

In biopsy sections of bone marrow or other extracutaneous organs, >25% of the mast cells in the infiltrate are spindle-shaped or have atypical morphology, or, of all mast cells in bone marrow aspirate smears, >25% are immature or atypical

Detection of an activating point mutation at codon 816 of KIT in bone marrow, blood, or other extracutaneous organ

Mast cells in bone marrow, blood, or other extracutaneous organ express CD2 and/or CD25 in addition to normal mast cell markers

Serum total tryptase persistently exceeds 20 ng/mL (unless there is an associated clonal myeloid disorder, in which case this parameter is not valid)

The diagnosis of SM is unrelated to the symptoms the patient experiences. Some SM patients have no symptoms. Some have severe symptoms.

Systemic symptoms ≠ systemic disease (SM)

 

Aggressive symptoms: Frequent or severe symptoms, which may be life threatening.

Aggressive disease: Doctors sometimes use this term to mean a quick progression of symptoms or rapid change in quality of life.

Aggressive systemic mastocytosis: A diagnosis that indicates multiple organ infiltration and damage by mast cells. Lifespan is significantly shortened in many patients. It is diagnosed by already meeting the criteria for SM and then also having at least one C finding, listed here:

Bone marrow dysfunction manifested by one or more cytopenia (ANC < 1.0 × 109/l, Hb < 10 g/dl, or platelets < 100 × 109/l), but no frank non-mast cell haematopoietic malignancy

Palpable hepatomegaly with impairment of liver function, ascites and/or portal hypertension

Skeletal involvement with large-sized osteolysis and/or pathological fract

Palpable splenomegaly with hypersplenism

Malabsorption with weight loss due to GI mast cell infiltrates

Aggressive symptoms and aggressive disease ≠ aggressive systemic mastocytosis (ASM)

 

Smoldering systemic mastocytosis (SSM): A progression from SM with markers that indicate likelihood of developing ASM. Diagnosed if two or more of the following B findings are present with previous diagnosis of SM:

Bone marrow biopsy showing > 30% infiltration by mast cells (focal, dense aggregates) and/or

serum total tryptase level > 200 ng/ml

 

Signs of dysplasia or myeloproliferaion in non-mast cell lineage, but insufficient criteria

for definitive diagnosis of a haematopoietic neoplasm by WHO, with normal or only slightly

abnormal blood counts

 

Hepatomegaly without impairment of liver function, and/or palpable splenomegaly without

hypersplenism, and/or palpable or visceral lymphadenopathy

 

MCAS: Differing criteria among experts

What criteria you have to meet to be diagnosed with MCAS depends on which doctor you see – even the experts don’t agree.

Molderings, Afrin 2011 Akin, Valent, Metcalfe 2010 Valent, Akin, Castells, Escribano, Metcalfe et al 2012
MCAD (umbrella term including both MCAS and SM) diagnosed if both major criteria, or one major criterion and one minor criterion, are present; following bone marrow biopsy, diagnosis is narrowed down to either SM or MCAS MCAS diagnosed if all criteria are met MCAS diagnosed if all criteria are met

Major Criteria
Multifocal of disseminated dense infiltrates of mast cells in bone marrow biopsies and/or in sections of other extracutaneous organ(s) (GI tract biopsies; CD117-, tryptase- and CD25- stained)
Episodic symptoms consistent with mast cell mediator release affecting ≥2 organ systems evidenced as follows:
  1. Skin: urticaria, angioedema, flushing
  2. Gastrointestinal: nausea, vomiting, diarrhea, abdominal cramping
  3. Cardiovascular: hypotensive syncope or near syncope, tachycardia
  4. Respiratory: wheezing
  5. Naso-ocular: conjunctival injection, pruritus, nasal stuffiness
Typical clinical symptoms
Unique constellation of clinical complaints as a result of a pathologically increased mast cell activity (mast cell mediator release symptom) A decrease in the frequency or severity or resolution of symptoms with antimediator therapy: H1– and H2-histamine receptor inverse agonists, antileukotriene medications (cysteinyl leukotriene receptor blockers or 5-lipoxygenase inhibitor), or mast cell stabilizers (cromolyn sodium) Increase in serum total tryptase by at least 20% above baseline plus 2 ng/ml during or within 4 h after a symptomatic period
  Evidence of an increase in a validated urinary or serum marker of mast cell activation: documentation of an increase of the marker to greater than the patient’s baseline value during a symptomatic period on ≥2 occasions or, if baseline tryptase levels are persistently >15 ng, documentation of an increase of the tryptase level above baseline value on 1 occasion. Total serum tryptase level is recommended as the marker of choice; less specific (also from basophils) are 24-hour urine histamine metabolites or PGD2 or its metabolite 11-β-prostaglandin F2. Response of clinical symptoms to histamine receptor blockers or MC-targeting agents e.g. cromolyn
  Rule out primary and secondary causes of mast cell activation and well-defined clinical idiopathic entities

Minor Criteria
Mast cells in bone marrow or other extracutaneous organ(s) show an abnormal morphology (>25%) in bone marrow smears or in histologies
Mast cells in bone marrow express CD2 and/or CD25
Detection of genetic changes in mast cells from blood, bone marrow or extracutaneous organs for which an impact on the state of activity of affected mast cells in terms of an increased activity has been proved
Evidence of a pathologically increased release of mast cell mediators by determination of the content of:

  1. Tryptase in blood
  2. N-methylhistamine in urine
  3. Heparin in blood
  4. Chromogranin A in blood
  5. Other mast cell specific mediators (leukotrienes, PGD2)

MCAS: GI Symptoms and Liver Abnormalities

MCAS patients suffer a variety of GI ailments, which are largely in common with SM.

Aerophagia, excessive swallowing of air, is very common. It is not entirely obvious why this occurs. In other patient populations, aerophagia is usually due to poor coordination between swallowing and respiration. Severe cases can lead to abdominal distention, aspiration of stomach contents into the lungs and esophageal rupture.

Chest discomfort is common in MCAS. Cardiac issues should be ruled out, but in most people, it is due to esophagitis. Some patients have a previous diagnosis of reflux but it is refractory to all relevant treatments.

Diarrhea and constipation, sometimes alternative, are very common. In one study, 89% of MCAS patients studied had frequent nausea, 100% had abdominal pain of some nature, and 69% had noncardiac chest pain. Partial bowel obstructions are uncommon, but do occur in MCAS. They are thought to be due to focal dysmotility or focal edema.

IBS is a frequent previous diagnosis in MCAS. The GI tract often looks normal by eye and typical H&E staining shows mild inflammation. Staining for mast cells often shows they are increased. Of note, there is not a universal consensus on what is considered “increased mast cells” in GI samples. Generally, above 20 cells per hpf is marked as high by pathologists. Presence of the D816V CKIT mutation is rare in GI biopsies of MCAS patients.

Selective malabsorption of certain nutrients is often seen in MCAS. Iron malabsorption is by far the most common. Copper and B vitamins are often poorly absorbed as well. Protein calorie malabsorption is rare, but leads to weight loss and wasting.

Pancreatic enzyme supplementation can be helpful in treatment of diarrhea, weight loss and malabsorption. The fact that this often works suggests that MCAS driven inflammation or fibrosis causes pancreatic exocrine deficiency, a condition in which the pancreas does not make enough digestive enzymes. Mast cells have a known link to painful chronic pancreatitis. In patients with painful vs painless chronic pancreatitis, mast cell density is 3.5X higher in pancreas biopsy.

About half of MCAS patients have some kind of liver abnormality. Fibrosis (obliterative portal venopathy) is the most common. However, fatty metamorphosis, sinusoidal dilatation, venoocclusive dilatation, nodular regenerative hyperplasia and cirrhosis have also been seen. Sterile (non-infectious) inflammation of the liver and portal trial infiltration by lymphocytes and eosinophils has also been identified in a number of patients. In particular, these patients often have a 2-3X elevation in transaminases and/or alkaline phosphatase, determinants of liver function. Impeded flow of bile from the liver is usually absent. Portal hypertension is unusual but has occurred, causing swelling of the spleen and varices in the esophagus. Rarely, free fluid in the abdomen (ascites) has occurred in MCAS patients.

One study found that 75% of MCAS patients tested had high cholesterol levels. Importantly, 79% of patients had “normal” BMI or were underweight, so the high cholesterol was not correlated to weight. 44% had a twofold or greater elevation of liver enzymes. 36% had increased bilirubin in the blood. 15% had fatty liver; 13% had swelling of the liver; 4% had cysts; 4% had adenomas; 2% had hemangiomas. 14% of patients had pancreatic involvement with elevated lipase or amylase.

 

References:

Kirsten Alfter, Ivar von Ku gelgen, Britta Haenisch, Thomas Frieling, Alexandra Hu lsdonk, Ulrike Haars, Arndt Rolfs, Gerhard Noe, Ulrich W. Kolck, Jurgen Homann and Gerhard J. Molderings. New aspects of liver abnormalities as part of the systemic mast cell activation syndrome. 2009 Liver International 29(2): 181-186.

Afrin, Lawrence B. Presentation, diagnosis and management of mast cell activation syndrome. 2011. Mast Cells.

Happy Halloween

Happy Halloween from MastAttack!

Hope you and your family stay safe and reaction free.

halloween-mastattack

MCAD: General information for public

Mast Cell Activation Disorders (MCAD): Frequently Asked Questions

What are mast cell activation disorders?

They are a group of conditions  in which the mast cells in the body do not function correctly.  MCAD includes systemic mastocytosis, urticaria pigmentosa and mast cell activation syndrome, among other conditions. Mast cells are responsible for allergic responses. In MCAD, patients can have allergic type reactions to things they are not allergic to. These reactions can be very severe and even life threatening.

What are mast cell reactions?

These are reactions caused by mast cells being improperly activated. These reactions vary from person to person. Symptoms can include, but are not limited to, nausea, vomiting, hives, rashes, itching, flushing (turning red), dizziness, confusion and irritability. Symptoms are caused by the chemicals released by the mast cells.

What causes mast cell reactions?

Triggers vary from person to person. More common triggers include heat, cold, friction (especially on the skin), sunlight, foodstuffs, physical exertion, stress, dyes and fragrances. Triggers can also change over time, with new triggers presenting.

Are mast cell reactions dangerous?

YES. Many MCAD patients will experience uncomfortable reactions throughout their lives. However, every reaction carries the risk of anaphylaxis, a life threatening, severe allergic reaction. Therefore, avoiding reactions as much as possible is very important for mast cell patients. Each patient has an individualized response plan. For many, it involves removal of trigger and administration of medication, such as antihistamines or inhalers.

What is anaphylaxis?

Anaphylaxis is a severe allergic reaction affecting multiple organ systems in the body. These are the kinds of reactions observed in patients with bee sting allergies. Anaphylaxis can be fatal. It is a medical emergency requiring immediate treatment, usually epinephrine (Epipen.) Please receive guidance from treating physician on when to use an Epipen.

How are mast cell anaphylaxis and mast cell reactions different from normal allergies (like food allergies?)

With allergies, your body reacts by a specific method that involves ingesting and recognizing the allergen. In MCAD patients, the mast cells incorrectly think many things are allergens. Since mast cells are so sensitive in these people, ingestion of an allergen is NOT necessary to cause mast cell reactions or anaphylaxis. Smelling a perfume or breathing in very hot, humid air is enough to cause a reaction in many MCAD patients.

What causes MCAD?

Genetic mutations cause different kinds of MCAD. Recent studies have shown that mast cell disease can affect multiple members of the same family.

Why do some MCAD patients have spots?

These spots occur in locations where there are more mast cells than usual in the skin. These are NOT contagious rashes. In addition, MCAD patients who do not have permanent spots often have very sensitive skin, which may cause temporary marks or rashes.

How can I help an MCAD patient be safe?

By not being afraid of their disease. Respect their triggers and help them work around these limitations. Reactions can be painful and very scary, especially for kids. Learn the symptoms associated with reactions and be ready to help with a response plan.

 

Is there more information you feel should be included here?  Let me know in the comments and I can add it in.

Lost in space

One of my most deep seated irrational fears is being lost in outer space. Being lost, alone, surrounded by this vast expanse of loneliness – that is the fabric of my nightmares.

“If you die in space, your body just keeps moving until something hits it. Then the pieces keep moving. It doesn’t decompose,” I remember my middle school science teacher telling me. My revulsion was immediate and visceral. It seemed so unkind that space didn’t even offer this last kindness, the ability to disappear and be forgotten. You would be all alone, with no chance of help, and when you die, your body will memorialize this helplessness and despair, forever.

It feels hollow and soundless when I think about space – the ultimate loneliness. Sometimes when masto is too much and I am tired of living in a world that isn’t safe for me, I hide in bed with my feelings, and they are hollow and soundless, too.

A woman I sort of knew killed herself this morning. She had a young son with mastocytosis, and I knew her in the way I know many masto parents – I answered questions for her. I knew very little about her or her family or her own poor health. But her death has started a larger conversation about support that I think needs to be had, and I think we owe it to this woman to have it now. Because even if lack of support was not the reason she ended her life, it is definitely the reason many people in our community have contemplated doing the same.

Let’s pretend that you, my audience, are healthy. Let’s pretend you don’t have any chronic health issues. You’re walking down the sidewalk one day, listening to music on your Iphone and get hit by a car. You are taken by ambulance to the hospital and are relieved to find out that while your leg is broken, you are otherwise okay. Your leg needs some surgery and a cast and you will be good as new soon. You have your surgery and you go home.

Except what if eight doctors looked at your xray and told you your leg wasn’t broken but you could feel the bones shifting? What if you couldn’t bear weight on it, if your pain was excruciating, but they insisted you were fine? What then? What if you went home and stayed off your leg until you could figure out why it hurt only to be called lazy and lucky to be able to stay in bed all day? What if your spouse was upset that your leg hurt too much to move around the kitchen and cook dinner? What if your family members told your kids that your house was dirty because you were lazy and making up the pain in your leg? And what if you find a doctor who sees something on your xray and agrees to work with you, but your family tells people this was all your fault for going for a walk that day or listening to music or being outside? What if the people around you not only denied your condition, but actively refused to support you? What if they made you feel guilty not being unwell as if your sickness was your fault?

This is what life is like for a lot of mast cell patients. I hear from patients all the time that their spouse doesn’t believe they are really sick. I hear that their mother told their kids that they are lying. And for parents of sick kids, I often hear that one parent won’t acknowledge or learn about their kids’ disease. It is discouraging and horrifying and dangerous. Because just like ignoring a broken leg won’t make it heal, pretending someone doesn’t have mast cell disease won’t make them any less sick. It will just make them more alone.

I’m fed up with watching people I care about struggle with family members, friends, coworkers, etc, who feel that acknowledging and accommodating their disease is too much to ask for. I’m tired of my friends crying for support when they are alone in the ICU, going into shock in their home, because their family members won’t help them. This is abuse. No one deserves this.

To everyone who has a chronically ill person in their lives: If you are not helping, you are hurting. When you tell us we are faking or being dramatic or exaggerating, you are chiseling off little slivers of our being that we will never get back. You remind us that we are not worthy of help and sympathy in your eyes. You force us to stop asking for your support, until sometimes it becomes too much. Sometimes when you scream for so long and no one cares, suicide can seem like a relief.

I am very lucky to be well supported now, but I know the pain of begging someone to take care of you. It feels like a great dark expanse, weightless, silent and endless.

 

MCAS: Treatment

This post discusses medications used to treat MCAS. Doses listed are taken directly from “Presentation, diagnosis and management of mast cell activation syndrome” by Lawrence B. Afrin. These doses are general recommendations. Medication should always be taken under the direction of a provider who knows you and your case personally.

MCAS is generally treated identically to ISM, with the medications that block the action of released mediators, that prevent the release of mediators or that prevent the production of mediators. As a reminder, any medication that causes a reaction should be evaluated to see if it is truly caused by the drug or by a dye or inert ingredient. Medications compounded without dyes or noxious fillers can be truly life changing for mast cell patients. Generally, new medications for be trialed for 1-2 months to determine if they are effective.

Antihistamines are first line medications for both acute and chronic management of MCAS (but not for anaphylaxis – epinephrine is first line medication for anaphylaxis.) Most currently available antihistamines either block the histamine 1 (H1) receptor or the histamine 2 (H2) receptor and are referred to by the receptors they block. It is generally recommended for MCAS patients to take medication to block H1 and H2 receptors daily as baseline medications.

Loratadine is a common H1 starting medication. It has low anticholinergic activity and is not sedating. Dosing usually starts at 10mg daily and may be increased to 10mg 2-3 times a day. Fexofenadine starting dose in MCAS is usually 180mg every 12 hours; cetirizine 10mg every 12 hours; levocetirizine 5mg every 12 hours. Loratadine, fexofenadine and cetirizine are all available without prescription in the US. Of note, none of these medications are available for IV administration, so Benadryl should be used for emergency management of severe MCAS symptoms.

There are several H2 blockers available in the US, most over the counter. Cimetidine and ranitidine have more drug-drug interactions than famotidine and nizatadine. Famotidine, which is also readily sourced for IV administration, is usually dosed at 20-40mg every 12 hours, though in severe cases, doses of 80mg every 12 hours may be used. (This dosing is also seen in Zollinger-Ellison Syndrome patients.) Ranitidine starts at 75mg every 12 hours, increasing to 300mg every 12 hours. Nizatadine (Axid) is dosed at 150-300mg every 12 hours, and cimetidine at 400mg every 12 hours.

There are several other medications with H1 antihistamine effect. Tricyclic antidepressants, phenothiazine antiemetics (like promethazine) and quetiapine, an antipsychotic, are all H1 blockers. Addition of these medications often helps even when another H1 blocker is being taken by the patient. In particular, use of doxepin has been well described. It is usually started at 10mg twice daily and can be increased by 10mg twice daily to doses of 40-50mg twice daily. Beyond this, exhaustion and grogginess are often intolerable.

Ketotifen is a medication with both antihistamine and mast cell stabilizing properties, meaning it interferes with the release of mediators. The oral use of this medication for mast cell disease management is not well described, in part due to the oral formulation not being available in the US. Dosing is usually started at 1mg twice daily and increased in increments of 1mg twice daily until desired effects are noted and balanced with an acceptable side effect profile. As described by Afrin, single dosing is usually 6mg or less, and can be taken up to four times a day.

Benzodiazepines are often helpful in MCAS, due both to its action on mast cells and also directly on organs, particularly GI organs. Lorazepam, clonazepam and alprazolam are preferred due to their shorter window of action. All can be dosed beginning at 0.25mg every 12 hours, increasing by 0.25mg twice daily every week. Flunitrazepam has been described in treatment of mast cell disease. This medication has a longer halflife and is generally dosed at 0.5-2mg once a day.

Imidazopyridine medications like zolpidem (Ambien) also act on the benzodiazepine receptors of the body. Though usually taken for insomnia, some MCAS patients report relief of other symptoms. Whether or not these medications work in a patient seems independent of whether benzodiazepines are currently being taken by the patient or have worked or failed in the past.

Non-steroidal anti-inflammatory drugs (NSAIDS) can be helpful in MCAS patients who tolerate them. In particular, use of aspirin to bind prostaglandins has been very well described. A common starting dose is 325mg twice daily, with dosing up to 650-1300mg twice daily seen. Some patients take as much as 1300mg four times a day, but doses higher than 2600mg/day are unhelpful in most patients. Non enteric coated aspirin seems to be better tolerated and more effective at relieving symptoms in MCAS than enteric coated. In MCAS patients for whom aspirin is inappropriate (such as those with low platelets or decreased kidney function), COX2 inhibitors like Celebrex are sometimes used. Celebrex dosing in these patients usually begins at 100mg twice daily and increases up to 400mg twice daily.

Leukotriene inhibitors are frequently used in MCAS patients. Montelukast is the most common, being dosed as 10mg once to twice a day. Zafirlukast is dosed at 20mg twice daily. Doses should be decreased appropriately if liver dysfunction is also present.

Cromolyn is the most well known mast cell stabilizer, despite the fact that the mechanism by which it acts is still unclear. More recently, it has been noted to block mast cell receptor 35, which is increased when IgE is present. Cromolyn has extremely poor absorption, with 98% of oral doses being excreted unchanged. When inhaled, absorption increases to around 5%. Oral dosing is from 100-200mg 2-4 times daily. When nebulized, dosing is usually 20mg 2-4 times daily. Of note, patients usually experience a resurgence of symptoms when first starting the medication that may last 3-4 days. In my experience, this symptom increase is sometimes observed when increasing the dose. It can take several weeks to determine if cromolyn is truly effective in patient, with some people only seeing serious gains after four months.

Pentosan is less well known mast cell stabilizer whose mechanism is likewise unknown. This medication is commonly used in interstitial cystitis, a mast cell disorder that affects the genitourinary tract. Though Pentosan seems to be most effective in the GU tract, some patients report decrease in other symptoms while on this medication. It is usually dosed at 100mg every 8-12 hours.

Quercetin is commonly mentioned as a natural/homeopathic mast cell stabilizer. After much research on the topic, I have to say that I agree. It has been found to inhibit lipoxygenase and cyclooxygenase, which in turn decreases production of leukotrienes and histamine. It is usually dosed starting at 500-2000mg per day, divided up into 2-4 doses. For example, a daily dose of 500mg may be taken as 125mg four times a day. A newer form, quercetin chalcone, is usually taken at 250mg three times a day.

Pancreatic enzymes, like Creon, are sometimes helpful in MCAS patients who have pancreatitis symptoms, even if they are not having pancreatic type pain. It sometimes helps with chronic diarrhea, weight loss and malabsorption.

Corticosteroids like prednisone are sometimes used to manage MCAS symptoms.  These medications can prevent mast cells from producing mediators and as such can be very effective.  However, long term use can have severe side effects and as such is discouraged.

Omaluzimab (Xolair) is an anti-IgE antibody. It is not clear exactly how this stabilizes mast cells reacting by a non-IgE mechanism. Xolair is injected subcutaneously at doses of 150-300mg every 2-4 weeks. It should be trialed for at least 3-4 months before determining if it is effective. Interestingly, whether or not a patient responds and how well seems to be independent of their pretreatment IgE level.

The successful use of chemo medications for severe MCAS cases has been described in literature. In particular, hydroxyurea can be effective, though rapid onset and severe low blood cell counts are a real risk. It is usually started at 500mg daily and increased up to 2000mg daily as needed. Blood counts should be monitored weekly for four weeks at the onset of treatment and after any dosage increase. Tyrosine kinase inhibitors, like imatinib and dasatinib, have also been used as last resorts in MCAS patients. Imatinib is usually dosed at 100-200mg daily and dasatinib at 20-50mg daily. Patients on these medications require careful monitoring for pulmonary and renal issues. All chemo patients are at increased risk of infection.

IV hydration is being used more frequently to manage baseline symptoms of MCAS patients. TNF-alpha inhibitors have been suggested to help mast cell symptoms, but there have been no symptoms. (I take a TNF-alpha inhibitor for autoimmune issues and do find it helps to relieve some of my mast cell symptoms.) Other possible avenues include IL-1 and IL-1b inhibitors and kinin-b2 receptor blockers. Tryptase inhibitors continue to be in development.

 

Reference:

Afrin, Lawrence B. Presentation, diagnosis and management of mast cell activation syndrome. 2013. Mast cells.

 

Bone manifestations of SM: Part Two

SM patients frequently experience bone pain, with one study finding 54% reporting it, with 18% reporting it as severe or intolerable. Another study (Barete 2010) of 75 mastocytosis patients found that 49% had bone involvement, 23% had osteoporosis (with 17% having vertebral fracture), 8% had osteosclerosis and 4% had a mixed pattern. When considering just ISM patients, 51% had osteoporosis with or without fracture. Fracture was more likely in older patients, male patients, and in patients with urinary n-methylhistamine levels above the normal cutoff (160 umol/mol creatinine.) A 2002 study on men with osteoporosis also found that men with osteoporosis and above normal n-methylhistamine levels were found to have bone marrow infiltration by mast cells.

One study (Guillaume 2013) looked at not only radiographic markers of bone abnormalities, but also at how serum markers associated with bone metabolism correlated to findings. In this study, bone mineral density was abnormal in 63% of patients, with 9/24 patients having osteoporosis and 15/24 having osteopenia. There was not found to be any relationship between the lesions seen or BMD alterations and age, sex, WHO mastocytosis type, tryptase level, serum parathyroid hormone level or serum 25-hydroxyvitamin D3 level.

However, levels of c-telopeptide, deoxypyridinoline and osteoprotegerin were highly associated with mastocytosis severity and tryptase level. C-telopeptides of type I collagen and deoxypyridinoline are markers of bone resorption, osteoprotegerin is a marker of osteoclast differentiation, and bone specific alkaline phosphatase is a marker of bone formation. Additionally, bone specific alkaline phosphatase was found to be correlate with tryptase level. In particular, higher levels of c-telopeptide and osteoprotegerin are associated advanced SM and high baseline tryptase levels. This study found that SM patients with c-telopeptide level above 2800 pmol/L had advanced disease 77% of the time; with deoxypyridinoline above 5.9 nmol/L had advanced disease 67% of the time; and osteoprotegerin above 5.5 pmol/L had advanced disease 67% of the time. Furthermore, all SM patients had higher levels of these markers when compared to healthy controls, regardless of WHO variant (SM vs ASM.)

A different study (Rossini 2011) found that bone turnover markers in serum did not correlate well with BMD or serum tryptase in ISM patients with osteoporosis. However, they were found to correlate well with bone turnover levels and serum tryptase in ISM patients with osteosclerosis. In particular, osteosclerosis was associated more with high baseline tryptase and high bone turnover markers. Osteosclerosis is more closely associated with aggressive forms of SM, including ASM and SM-AHNMD, and has been reported in 8-19% of patients with various forms of SM in multiple studies. Scattered sclerotic lesions have been noted in smoldering systemic mastocytosis (SSM) patients.

Previous studies had reported 3-8% of SM patients having an “osteopetrosis-like abnormality,” which has since been described as “skeletal disease caused by increased bone turnover.” The exact reason for this finding is unclear, but mast cells are known to stimulate osteoblast proliferation and activation. This increases production of osteoprotegerin, which in turn limits bone resorption.

In evaluating the WHO diagnostic criteria for mastocytosis, Escribano et al evaluated parameters found in ASM patients. 8/11 of them had C-findings that did not involve pathologic fracture. 7/8 of these patients had low LDH and increased B2 microglobulin, both of which are unusual in ISM. The other 3 patients met the criteria for ASM only because of their bone lesions. These patients first experienced pathologic fracture from lesions 18, 8 and 5 years after diagnosis with ASM, and 39, 34 and 15 years from SM diagnosis, respectively. All three patients had normal LDH and B2 microglobulin levels, with only 1/3 patients having progression of other disease parameters.

Bisphosphonate therapy is usually recommended for any SM patient with osteoporosis. It increases vertebral BMD and prevents osteoporotic fractures, but is less effective at increasing hip and femoral neck BMD. Dr. Pardanini recommends following guidelines for bisphosphonate use in multiple myeloma as a guide for use in SM. Interferon-a is the next line therapy for treating mastocytosis related bone pain and osteoporosis, particularly in patients who have new vertebral fractures despite bisphosphonate therapy. In severe cases, radiation therapy can help manage pain and bone loss.

 

References:

Rossini M, Zanotti R, Bonadonna P, et al. Bone mineral density, bone turnover markers and fractures in patients with indolent systemic mastocytosis. Bone. 2011;49(4):880-885.

Barete S, Assous N, de Gennes C, et al. Systemic mastocytosis and bone involvement in a cohort of 75 patients. Ann Rheum Dis. 2010; 69(10):1838-1841.

Biosse-Duplan M, Baroukh B, Dy M, de Vernejoul MC, Saffar JL. Histamine promotes osteoclastogenesis through the differential expression of histamine receptors on osteoclasts and osteoblasts. Am J Pathol. 2009;174(4):1426-1434.

Brumsen C, Papapoulos SE, Lentjes EG, Kluin PM, Hamdy NA. A potential role for the mast cell in the pathogenesis of idiopathic osteoporosis in men. Bone. 2002 Nov;31(5):556-61.

Nicolas Guillaume, et al. Bone Complications of Mastocytosis: A Link between Clinical and Biological Characteristics. The American Journal of Medicine, Vol 126, No 1, January 2013

Reinacher-Schick, S. Petrasch, B.J. Longley, C. Teschendorf, U. Graeven, W. Schmiegel. c-Kit mutation and osteopetrosis-like osteopathy in a patient with systemic mast cell disease. Ann Hematol, 77 (1998), pp. 131–134

van der Veer, W. van der Goot, J. G. R. de Monchy, H. C. Kluin-Nelemans, J. J. van Doormaal. High prevalence of fractures and osteoporosis in patients with indolent systemic mastocytosis. Allergy 67 (2012) 431–438.

Peter Valent, Wolfgang R. Sperr and Cem Akin. How I treat patients with advanced systemic mastocytosis. December 23, 2010; Blood: 116 (26.)

Laura Sánchez-Muñoz, Ivan Alvarez-Twose, Andrés C García-Montero, Cristina Teodosio, María Jara-Acevedo, Carlos E Pedreira, Almudena Matito, Jose Mario T Morgado, Maria Luz Sánchez, Manuela Mollejo, David Gonzalez-de-Olano, Alberto Orfao and Luis Escribano. Evaluation of the WHO criteria for the classification of patients with mastocytosis. Modern Pathology (2011) 24, 1157–1168.

Pardinini, Animesh. How I treat patients with indolent and smoldering mastocytosis (rare conditions but difficult to manage). April 18, 2013; Blood: 121 (16.)