Circa 2008
Asthma is a chronic condition involving the respiratory system in which the airways occasionally constrict, become inflamed, and are lined with excessive amounts of mucus, often in response to one or more triggers. These episodes may be triggered by such things as exposure to an environmental stimulant such as an allergen, environmental tobacco smoke, cold or warm air, perfume, pet dander, moist air, exercise or exertion, or emotional stress.
In this pair of interviews, ABILITY Magazine’s Chet Cooper speaks with Bobby Lanier MD, who is championing a promising new treatment for allergic asthma. But first Cooper talks with Jeanette Bolden, who won a gold medal as part of the 4×100 meter relay team during the 1984 Summer Olympics, and is coach of the 2008 U.S. Women’s Olympic Track and Field team. She grew up with allergic asthma, improved her self-esteem by running track, and went to the Olympics in Beijing, China, fortified by the medication Lanier recommends.
Chet Cooper: As a child growing up in Compton, CA, you were an athlete, and yet you had issues getting out there and runing around?
Jeanette Bolden: I was born with asthma. I’ve had it all my life. Not really knowing much about asthma, my parents and I just went back and forth to the emergency room numerous times throughout my childhood, due to various allergies. My asthma was so severe that when I was in the sixth grade, I was taken out of my home and placed in Sun Air Home for Asthmatic Children.
Cooper: I’ve never heard of that happening before. Were those kind of places common? Are they still around?
Bolden: A lot of large cities had residential homes for kids with asthma. The one I went to was a dormitory, and they kept you for six to nine months. You stayed to get more of a grasp on your asthma, and to educate you and your parents about the condition. My mother learned about giving injections while I was there, such as epinephrine for when I had really bad attacks. One of the physical activities that everyone had to participate in was learning how to swim. So that’s when I got introduced to a physical activity. It didn’t cure my asthma, but it helped me to not be afraid of it, and not put limits on myself.
Cooper: What was the trigger for you?
Bolden: There were so many different triggers for me: Dust, mold, mildew, pet dander. My food allergy is fish. The people at the home helped me identify my different triggers. When I came back home to Compton, I took my sister to the local park to join the track team. I asked the coach if I could join, too. He said yes. When I told him about my asthma he said, “If it doesn’t bother you, it will not bother me.” So I started running track. I used to hide my inhaler in my sock, because kids can be cruel. One little boy found my inhaler and started throwing it in the air, calling me names like, “Asthma Face” and “Spasma Girl.” But I built up my self-esteem running track. It was almost like I’m running track and I have asthma and I’m winning. Asthma made me a more determined athlete.
Cooper: So did you get the inhaler and spray it in his face and run?
Bolden: (laughs) I hadn’t thought about doing that.
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Cooper: He deserved it. (laughs) So your life basically revolved around athletics and sports at that point?
Bolden: From then on. In high school I ran track. I was hospitalized for the last time when I was a junior in high school, coming from a meet. After that I knew how to manage it better.
Cooper: When you say “manage” your asthma, were you doing anything specific?
Bolden: I took my medication and, to the extent that I knew what they were, I stayed away from things that would cause me to wheeze. For example, when I was running track at UCLA in the early ‘80s, I would wake up in the mornings wheezing; I had tightness of breath and I was coughing a lot. Come to find out, I was allergic to feather pillows.
Cooper: Did you do the allergy tests? Were you taking shots?
Bolden: I was always so busy that I didn’t take the allergy shots regularly. I definitely took the allergy tests, though. Cooper: You won the gold, and then came to coach the Olympics? What was your path?
Bolden: I’ve just finished my 15th season at UCLA. There are certain criteria that you have to fulfill in terms of being an Olympic coach. You get voted in by a committee of your peers, which includes some administrators, some UCLA track and field officials, and also elite athletes. One of the criteria, but certainly not the only one, is that you have to have gone to the Olympic games or been a world-class athlete, having coached a worldclass athlete or been coaching for a significant amount of time, which I have. I’ve been blessed to have very good years at UCLA. We won two national indoor titles and one national outdoor title. So that really helped my “status” in terms of USA track and field. I’m thrilled to be an Olympic coach. When we finished the U.S. Olympic trials in Eugene, OR, I knew we had a great, great team.
Cooper: Had you been to Beijing before?
Bolden: No.
Cooper: Had you heard about the air quality there?
Bolden: Oh, definitely, I know the local organizing committee did all they could prior to the games to reduce the amount of air pollution. More than anything it’s the heat and the humidity that the athletes had to contend with. We talked with them about dehydration. Our Olympic trials in Oregon were hot, too, so they got a taste of the heat, and still gave it their all.
Cooper: Have you coached any athletes that have allergies or asthma?
Bolden: I’ve coached some at UCLA. Asthma is the leading cause of absenteeism among school-age kids, so a lot of people have it. A lot have allergic asthma. So I think a number of Olympians on the team may have exercise-induced asthma, and not know it.
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Cooper: So a part of what you’re doing now is promoting the treatment you’re receiving?
Bolden: Yes. I’m associated with a fantastic website called AsthmaOnTrack.com, which is really a resource where people can learn more about asthma and more importantly, allergic asthma. They can go to the website and learn more about my story, and what type of asthma they have. they can find out about specialists in their area, about the IgE tests, and really educate themselves on allergic asthma. It wasn’t until recently, when I found out about allergic asthma, that I began taking Xolair, and now, it’s under control. Managing it is one thing, under control is another. I really want people to know that with asthma, you don’t have to sit on the sidelines and let life pass you by. You can get engaged in the things that you are passionate about.
Cooper: Xolair is taken once a month, right?
Bolden: Yeah. I’ve been taking it about nine months.
Cooper: How soon did you notice a difference in your quality of life?
Bolden: Within about five months. One of the biggest things for me is, a couple years ago we adopted a pet from the pound, and she had to stay outside. Now she can come in and join the family.
Cooper: So you were allergic to dogs before, or just the dander?
Bolden: Really the dander, especially from cats.
Cooper: So what happens after Beijing?
Bolden: School starts at UCLA the last Thursday in September, so I’ll go back to being a regular old college coach. Also, my family owns the 27th Street Bakery in Los Angeles. It’s been in my family since 1956. We ship pies all around the country. We serve sweet potato pie, pecan pie, sweet potato pecan pie, and I’ll go back to doing that and raising my kids.
Cooper: Anything else you can think of that you would want to share?
Bolden: I don’t think I would have accomplished as much as I have in athletics if I didn’t have asthma. But it really comes to the point where you have to believe that life is worth living and get your health in check.
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Interview with Bobby Lanner, MD
Cooper: How does air quality affect athletes?
Lanier: Athletes are like everybody else: They’re affected to a certain extent. How much is always the issue. Beijing is foggy like San Francisco, add to that 100- plus-degrees heat and tons of humidity and boy, you’ve got a soupy mess! I was certain that the athletes were going to be shocked for a moment when they got off the plane in Beijing, but I think the Chinese government took steps to make the best of it.
I’ve gone there pretty frequently, and my sense was that it wasn’t going to be nearly as severe as what we thought initially. China has gone through unbelievable construction in the last 10 years. Last year about half the world’s concrete went to China, most of it to Beijing. And the construction dust was horrible. It’s better now. I think that the government put a moratorium on construction, and allowed driving only on alternate days. I think people with severe emphysema have it a lot worse than people with asthma. A lot of times people with asthma are affected more by what’s in the air from an allergic standpoint, pollens, molds, things of that nature, and it turns out a lot of times that people are more involved with allergy than almost anything else.
Cooper: So let’s talk about that. I’ve heard that 90 percent of people with asthma have allergic reactions?
Lanier: I think that probably 60 percent of asthma is allergic in nature. Maybe as many of 90 percent of asthmatics have some level of allergy. So it’s real common. It’s part of a genetic trifecta here. Allergy, asthma and eczema all kind of go together. There’s a genetic link, and people who have asthma usually have one of the others as well. The most common combination is allergy and asthma, and the overlap’s pretty brutal. I think that people will get tolerant of it after a period of time. Yet there’s a huge misconception about who has allergy and what it is.
If you look at the ads on TV, you’d think everybody’s got an allergy. But in truth, only about 30 percent of people in the world do. Boy, when they have it though, they’ve got it big. A lot of times people come to me and say, “I just feel so bad; I’m always so sickly. Can you give me something to build up my immune system?” Of course my response is, “You’ve got a high functioning immune system. That’s your trouble!” And in particular, the problem is the allergic antibody, which is called IgE. Ig is the prefix that implies immunoglobulin, so this immunoglobulin E or the allergic antibody is at the root of the evil here. That’s a relatively recently discovery, by the way. I think the antibody was only really discovered around 1970. So we’d gone hundreds of years really not knowing what allergy and asthma is about. In the last 30 or 40 years, we’ve come to understand a lot more about it, and a lot of it has to do with immunoglobulin E.
So the Holy Grail for us, and for me as a physician in particular, is to look for a way to cripple that one particular antibody without hurting everything else. If we do that with steroids, it’s like using a shotgun. Sometimes you take out a lot more things than you want. You need a rifle. The new research and development has gone toward targeting a new class of drugs that really gets to the antibody itself. And that makes a huge difference.
Cooper: Where do trials stand now with this new rifle approach?
Lanier: Well, the anti-IgE antibody has been accepted now for about four or five years, while research on it has been going on for as long as 12 years. I’ve been involved with it from the beginning because it’s an incredible concept. It was approved for adults about five years ago, and in the next year or so it will be approved for people 12 and over, maybe even younger. It’s called Xolair or Omalizumab and it’s designed as an injection. The names sound like something from an alien planet. When injected, it seeks out every allergic antibody you’ve got and ties it up.
This is different from allergy shots, which are kind of the time-honored way to deal with allergic disease, because those things are highly specific. For example, if you are being given an allergy shot for your sensitivity to oak, it doesn’t help you with ragweed. But in the case of Omalizumab or Xolair, it doesn’t matter if it’s carrots or avocados or ragweed, it gets to them all. It diminishes the level of reactivity or allergic disease quite a bit. What we’re hoping, Chet, is that we’re actually moving past an era of chemical pharmaceuticals. Most of the drugs we have to treat asthma right now are sort of like giant paper towels: They wipe up the mess once it’s occurred, but there’s still a mess. What we’re trying to do is get deeper and deeper into the root of this thing to get at what causes the disease. So this anti-IgE for allergic asthma actually may get more to the root of the disease than any of the chemicals that we now use, and it may even have some hope about changing the whole course of the disease. That’s what we’re hoping for.
Cooper: So it would not allow a trigger response to occur in the first place?
Lanier: Exactly. When injected, it seeks out allergic antibody, ties it up, and that takes away the fuel for the allergic process. Without the allergic antibody to fuel the disintegration of what’s known as mass cells, then the process theoretically should cease altogether. It looks like that’s going to be the primary mechanism, tying up the antibody that produces allergy.
Cooper: You said only 30 percent of people actually have allergies. What’s going on with the other 70 percent who think they have allergies?
Lanier: It’s almost as if anything above the navel that is uncharacterized is called an allergy. In truth, there are lots of things that can affect both the nose and the lungs other than an allergic antibody. About half the people who have nasal dripping, running and sneezing will have allergy, and the other half will have something called vasomotor rhinitis. It’s more of a hormonal issue. So there are people who experience the symptoms of allergy, but they don’t have one.
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For example, if you take a handful of pepper and throw it in someone’s face, they’ll sneeze, because that releases the chemical histamine, which is a normal body chemical. So while it’s possible to simulate allergy, you could continue to throw pepper in someone’s face and they would get very tolerant to it after a couple of hours, and you wouldn’t produce that initial reaction again. But if you’ve got ragweed sensitivity, or if you’ve got peanut sensitivity, for example, and you get exposed to that, that problem is going to get worse with repeated exposure. So allergy involves a defensive antibody in the immune system that probably had a terrific reason for being there, but there are a lot of things that probably had a reason for being there that don’t have a reason any more. For example, the appendix, what’s that about? We don’t know why you still have that extra organ. It may have had a function some time in history.
We think that the allergic antibody probably did have a function some time in evolution. We think that the allergic antibody protects people from being infected with parasites, with roundworms, flatworms, tapeworms, lungworms, that type of thing. It used to be that that was an extremely common and very important public-health problem. But you know, we haven’t had that in almost 200 years, yet some people have this hereditary ability to defend themselves that now has got nothing to fight. And the allergic antibody, if it doesn’t have what it was designed to fight, finds something else: grass, ragweed, pollen, house dust. And probably the reason is that those things bear a similarity to some of the parasitic protein. The immune system gets confused, makes a mistake and defends you against something that you really don’t need to be defended against at all.
People with the combination of allergy-asthma-eczema have some advantages, even today. They may live longer. They may have better resistance against some forms of cancer. I mean, this is not altogether negative. So I tell them, “You’re going to live a long time, but man, you’re going to pay a tax.”
Cooper: Some of these allergies, let’s say peanuts or bee stings or something, could cause death to a person. Where do you think that was coming from as a defense mechanism? What was that about?
Lanier: What the antibody was designed to do is attach to a basic cell that exists throughout the lungs, nose, skin, blood vessels, etc. called mass cells. These cells can take granules of chemicals like histamine. Now, the issue was that the antibody was maybe misdirected, but it still goes back to its original host, which is the mass cell, and with re-exposure can cause those mass cells to explode. It then releases histamine, and that’s what you’d think of as an allergic event. As long as the histamine is released in some confined area, like, say, the nose with pepper, that’s not anything worse than cosmetic. But when histamine begins to be released at distant sites, like lungs, liver, kidney, blood vessels, then you have a tremendous dilation of those blood vessels, leading to such things as shock and death.
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So it’s an extension of what used to be protection, but carried to an extreme. Probably anaphylactic reactions, or allergic reactions, have existed forever. We know that a couple of the pharaohs died from bee stings. So we know that is not a new phenomenon.
Cooper: What are your thoughts about exerciseinduced asthma?
Lanier: Exercise-induced asthma is part of a bigger picture, usually. Asthma has to do with bronchial constriction, with the muscles around the lung tubes squeezed down, and you produce that funny sound. Sometimes swelling occurs inside the lung, too. So when people have the basic condition, various triggers can set it off. For example, if you put somebody with asthma in a very cold room, on occasion that’s enough right there to make them wheeze. So people who have certain types of asthma know that they just can’t ski. They can’t tolerate a really cold climate. You may see people with asthma walking around New York City or Chicago during the wintertime with scarves around their face or mufflers because they need to have the warm air. If they don’t, it’ll set off their asthma. So heat, cold and general irritation can trigger a bronchial spasm.
With exercise-induced asthma, of course, exercise is one of the triggers. Generally what happens is that people learn to live with their asthma. But if you have exerciseinduced asthma and you know that it’s gonna give you difficulty if you run, then you don’t run. Kids in school, in many cases will opt out of PE, or they’ll become a bookworm, because they know they can’t run.
Cooper: How do they get around this?
Lanier: They can do short exercises without problems. But when you get people’s muscles warmed up, big muscles, like legs, for example, for more than three or four minutes, if they have asthma, that’s a powerful stimulus for exercise to produce bronchospasm. There are ways to prevent that and ways to treat it, to make it more manageable. In fact, in the Olympics, you’ll probably see the use of common inhalers prior to exercise. What that does is stop the bronchospasm, but it doesn’t stop the swelling in the lung tubes.
It’s real noticeable in young people, especially track and field people who can really be bugged by this, or a basketball player sometimes. It doesn’t prevent you from being able to compete at Olympic levels. Obviously Jeanette Bolden won a gold medal.
As time has gone by and the technology has improved, we’ve been able to control most people’s conditions and keep them out of the emergency room—if they’ll take medication. But as with everything, now that we have control of it, the goal is to find some way to stop it from happening, to get more to the root of it. That’s where these new biological therapies come in. Those things may actually—I don’t use the word “cure” very often, but it may really put these diseases into remission, which is important, because nothing right now will stop the disease progression. Even steroids won’t stop the disease progression. We’re hoping anti-IgE will actually stop it.
Cooper: How does this relate, then, in the exerciseinduced asthma when there’s evidence that high-intensity warm-ups help people with asthma?
Lanier: By staying warm, you deliberately invoke what would be an allergic stimulus, and once you get to that level, you keep it there. I think that a couple of NBA athletes and some NFL athletes have kind of pioneered that concept. They discovered it themselves. Basketball’s Dennis Rodman, who was kind of a wacky guy in a lot of ways, had really bad asthma. When he played a game, especially toward the end of his career, he would ride the exercise bicycle on the sidelines, even when he wasn’t playing. People thought that looked odd, but he recognized that if he could get warm and stay warm, he didn’t have difficulties with his asthma.
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Jimmy Smith from the Carolina Panthers does the same thing, pedaling an exercise bike on the sidelines, to keep his muscles in motion and desensitize himself to the affects of exercise. But people go to extraordinary lengths to prevent their asthma, and we’re just basically looking for a better way.
Cooper: Talk a little bit about the role of diet.
Lanier: We look for ways to improve people’s diets and make a difference in asthma, but when I see somebody with allergy and asthma, the first thing I say is, “You didn’t pick your parents very carefully.” This is a genetic issue, and you can’t really affect it much. You can make it worse if you gain weight, and exercise may make it easier to tolerate, but the issue is still there.
This new therapy we’re doing is different than the old, time-honored allergy shot. As I mentioned, it gets everything. It has an advantage in that people don’t take medicine very well. If you look at the number of times people refill their asthma medicines every year, some of the statistics are startling. Even people with moderate to severe asthma may only refill their medicines two or three times a year, which is really bothersome. So the idea of a treatment like the new one, which is given by injection once a month, is kind of exciting. We think people will follow through with that. Whereas getting them to continuously take a medication when they’re feeling OK, is hard. All of us tend to stop taking medication when we’re feeling well. That’s especially true for people with asthma. but then it catches up to them and they crash.
Cooper: When will the new treatments be available?
Lanier: Now. But so far only for people 12 and older. It will be available hopefully within the year to younger children. Xolair, or Omalizumab, its generic name, is a serum injection and really simple to administer. Virtually any doctor can do it. What we’re trying to do is get the word out to people, particularly older people, who may not really realize that there have been some huge breakthroughs just in the last couple years. This may especially help people who take heavy amounts of inhaled or oral steroids, which is pretty hazardous in the long run. I hear every once in a while somebody telling me, “I go see my doctor and I get my allergy shot twice a year.” What they’re really talking about is, they’re going in and getting a whopping dose of cortisone, which suppresses the immune responses, but is not very helpful long-term because of the bothersome side effects.
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Cooper: Is there perhaps an oral application you could use instead of a needle?
Lanier: The problem with that is that stomach acid is a huge barrier to absorption of certain proteins. What the digestive system is all about is breaking down proteins. That’s the way you live, the way you survive. Your gastrointestinal system has been designed by the good Lord to break down anything you eat, from soup to nuts. The only way to circumvent that at this moment is by doing the injection.
Cooper: What about inhalers?
Lanier: Tried that. They don’t seem to work well with this particular drug. Proteins have to be delivered into muscles or directly into the bloodstream. But the Xolair shots are relatively small, and the material is two or three cc’s, which is not too bad. It goes directly into a muscle or into the bloodstream to get the level of drug needed to control the system.
Cooper: It’s by prescription?
Lanier: Yes, and it’s not cheap. All of these new biotech treatments for arthritis, asthma and other immunologic disease are expensive. It’s because they’re new and require a level of manufacturing that goes beyond the chemical process of just punching out pills according to a big formula that you mix up. This is actually biologically produced, so if people don’t have insurance that covers it, it makes it costly to use. In many cases, though, the trade-off for insurance carriers is that they have a more expensive drug than is currently used for asthma, the results can be so good that the savings in a year make it worth it. It doesn’t take long to know if this medication works well, by the way, just two or three shots, maybe as many as four.
Cooper: After a couple years of using it, it is possible that something might occur within the system that makes the drug less necessary?
Lanier: Good insight. That’s what we’re hoping for, Chet. Right now, the protocol is for this drug to be used for long periods of time. As part of my clinical research, I’ve made it a habit to discontinue people after a certain period of time, usually about two years. But I have a number of women—because it’s mostly women who have this issue—who have been off this medication after using it for a couple of years, and they look really good overall. We think this may be the beginning of a new thinking about the whole process. It’s conceivable, but not proven, that it may change the immune system itself.
