How the 4Ps of precision medicine can help you break free, not breakout.

Nowadays, there are a very high number of allergic patients not just in this country, but in the world. I treat over 100 patients a day in Bangkok alone,” Prof. Dr. Orapan ‘Ann’ Poachanukoon tells me as we sit down to talk about her lifelong passion to improve peoples’ quality of life. “The problem we allergists face is how to decrease this number, and the answer is always: lifestyle, diet, and environment.”

Treating both children and adults, Dr. Ann not only works in the Bumrungrad Allergy Centre as an allergist, but also in an academic position and as a researcher, to find medical solutions for the allergies that are increasingly in high prevalence in Thailand. “To fully help my patients, I need to be a role model for medical students, and to research the development of new drugs or medical devices,” she explains.

“Innovation is very important in taking care of patients – I’ve developed over five patents in technologies to help asthma patients, and in Thai herbal medicines. I also do a lot of research on the impact of pollution, especially in the northern parts of Thailand. Through this research, we’ve developed the 4Ps of precision medicine to better treat our patients.”

Masala asked Dr. Ann to give more insight into Bumrungrad’s focus on precision medicine, and how we can overcome everyday allergies, especially considering the prevalence of allergens such as the ongoing PM2.5 crisis, and recent stressors that can affect our immune system.

Tell us a little more about the 4Ps of precision medicine.

Precision medicine means that we don’t use the same treatment on all our patients, because they are all so different.

Prevention: We teach lifestyle modification to our patients, and in Bumrungrad, we also have an ‘Allergy Prevention in Pregnancy’ programme to teach pregnant women how to prevent allergies that might develop in their children, often due to certain medical drugs or lifestyle choices.

Predictive: Allergies usually come from either genetics, the environment, or your lifestyle. If you have a family history of allergic disease, that means your children have an increased risk of allergies, so we’ve developed genetic testing to predict this. This can be both preventative and predictive, as if the test is positive, we may suggest an intervention to prevent these allergies from developing in the future.

Personalised: It’s important to choose the right medicine for the right person. These days, there are a lot of allergy medicines available as well as biological treatments and immunotherapy. We choose the right medicine by looking at your cytokines and cells, and making a selection according to your phenotypes and endotypes.

Participatory: The most important part, it means we share decision-making between healthcare professionals – the doctors, the nutritionists, and the rest of the medical team – and the patient. We take a lot of time to discuss and offer the patient a range of treatment options that they can choose from. The doctors’ decisions are always made together with the patient.

How can we discover what allergens we might have, and why is it so important to do so?

The most urgent situation is of course allergic reactions that lead to death, so you will need to find triggers for any allergies that are that severe. In Bumrungrad, we provide a lot of allergen investigation tests, such as skin prick tests, or blood tests. We can test for more than 100 allergens because we have so many international patients, with different lifestyles in each country, and thus exposure to different allergens. We also have an ‘Allergy at Home’ kit for prevention purposes. In our

‘Home Lovers’ service, our team will test your home and environment for different possible allergens; we also have a ‘Pet Lovers’ kit for pet owners and a ‘Food Lovers’ kit for foodies. We also do online consultations, and an official LINE account.

What can we do to help overcome our allergies?

Education is very important for allergic patients. They will need to do environmental controls and lifestyle modifications once we know what their allergens are, so we teach the patients how to modify themselves and their home. For those who don’t want to rely on medicines their whole life, we also provide the option of allergy vaccines, immunotherapy, or desensitisation so that they can enter remission. This consists of exposing the patient to the allergen via injection or sublingual methods, and can induce antibodies to the allergens. However, this only helps those with allergic rhinitis and asthma, not food allergies.

Most allergies depend on your lifestyle, exercise, and environment, so I’ve created the 4Es model, which consists of non- pharmacological treatments for each patient:

Environment: Avoid allergen triggers, including PM 2.5, which can induce allergies in people.

Eating: Obesity can increase the risk of allergies such as asthma and allergic rhinitis. You need to have a balanced diet and not eat too much. Vitamin D is very important for allergies because there is data that shows that Vitamin D deficiencies can increase allergic symptoms or allergies. For pregnant women, a Vitamin D deficiency can increase the risk of allergies in their children.

Exercise: This helps a lot for respiratory allergies, like allergic rhinitis and asthma because it can improve your quality of life and increase lung function.

Emotion: Maintaining your mental health is very important because stress, depression and anxiety can induce allergic inflammation and can increase asthma or allergy symptoms.

Some people can also develop spontaneous allergies as adults – what causes them, and how do we prevent it from happening?

Allergies in adults mostly occur because of their behaviour or lifestyle. Some patients may have a genetic predisposition towards certain allergies, and if they end up eating too much of a certain type of food, such as seafood, it can induce allergies. Allergies are all about balancing your lifestyle and your immune system – too much of anything isn’t good for your body. While some food allergies can be cured, it’s quite difficult to enter remission for seafood allergies, so you’ll have to avoid that food for a long time.

What are some common healthcare misconceptions that you’d like to address when it comes to allergy prevention?

Firstly, it’s a misconception that you’ll be ok as long as you take antihistamines before eating food that you’re allergic to. Antihistamines can reduce skin lesions, but won’t reduce the effects of food allergies. Secondly, it’s not true that if you’re allergic to certain foods, you can increase your tolerance by eating a little more of that food each time. Don’t do that – many patients end up with a severe allergic reaction and can even die because of that.

Another misconception is that if you have asthma, you can’t exercise. Exercise can help improve your lung function, but you have to use certain medications, like bronchodilators, before you do anything too strenuous.

As a paediatric allergist, what is your recommendation for parents on how they can help prevent their children from developing allergies?

Firstly, your environment is very important. Pregnant women should avoid pollution and smoking. If the family has any smokers, it creates a high risk of allergies for your kids in the future. Stop smoking in the family, and use air filters if you’re exposed to PM 2.5. Secondly, dust mites in your house lead to an increased risk of allergies. Thirdly, we call this the ‘hygiene hypothesis,’ which is that too much cleaning can actual induce allergies. Over- cleaning can kill good bacteria, which we need to increase our immune system. For some children who are at high risk of allergies, you can give them probiotic supplements as a preventative measure. In that vein, don’t take too many antibiotics, because that can also kill probiotics, and we also recommend natural childbirth, as that can pass on good probiotics to your child, as opposed to caesarian delivery. In the end, the most important aspect of preventing allergies is your overall wellbeing and lifestyle. Take care of yourself, and take care of your mind.