Episode #31: Where Allergy and Asthma Intersect with Dr. Payel Gupta

Dr. Albert Rizzo:
Welcome back to Lungcast, the monthly respiratory health podcast series from the American Lung Association and the medical news site HCP Live. I'm your host, Dr. Albert Rizzo, the chief medical officer of the American Lung Association. Before we introduce our guest today, just a reminder that Lungcast is available on all your favorite streaming platforms. Subscribe to @Lungcast on YouTube to get new and archived episodes, as well as interview segments and episode highlights as they come out. A link to the show page, as well as the American Lung Association and HCP Live home pages for Lungcast, can be found in each episode description.

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Speaking of podcasts, today's episode is something of a crossover. Dr. Payel Gupta, medical director of Allergy, Asthma, Immunology, and ENT for LifeMD.com and co-host of the Itch Podcast, joins us to discuss the intersections of allergy and asthma, as well as advances in research and our understanding of the allergic march.

Dr. Albert Rizzo:
Dr. Gupta, thank you for joining me for today's discussion on aspects of asthma care. To start, will you please tell our listeners what your current role is in your practice and at your institution?

Dr. Payel Gupta:
Thank you so much, Dr. Rizzo, for having me today. I'm looking forward to this discussion. As you mentioned, I am the current medical director for the allergy space at LifeMD, which is a primary care telemedicine platform. We also have a dedicated allergy platform called Cleared. I am also the owner of Ease Allergy, a small practice in Brooklyn, where I see adult and pediatric patients. Additionally, I'm a clinical instructor at Mount Sinai Hospital, where I help see patients at the allergy fellows clinic once a month.

Dr. Albert Rizzo:
Sound well-prepared for today's talk. Before we speak about the clinical presentation of asthma, I would appreciate you level-setting for our audience some of the terms used to classify asthma over the years—childhood, adult-onset, intrinsic, extrinsic—or terms used to describe asthma. Now we talk about phenotypes: allergic, eosinophilic, T2, non-T2 asthma. Can you give us a little understanding of these terms and how they may help in management decisions?

Dr. Payel Gupta:
That's a great question. The model of asthma as a single entity is now actually obsolete due to an increased understanding of its underlying heterogeneity. Traditionally, asthma was thought to be caused by an excessive Th2 cell response and specific IgE driving airway hyperresponsiveness. While this is still accurate for allergic asthma, asthma is now considered an umbrella term for a collection of distinct diseases or endotypes with varying phenotypes or clinical presentations.

Young atopic patients, obese middle-aged patients, elderly patients—these are all clinical phenotypes that manifest with the familiar symptoms of asthma: wheezing, shortness of breath, cough, and chest tightness, accompanied by variable airflow obstruction. Historically, treatments were applied universally to all patients, but now we know asthma responds differently to different therapies. Precision medicine—targeting treatment based on endotypes and phenotypes—is the way forward.

The two overarching endotypes are Th2-high, which includes atopic, weight-onset, eosinophilic asthma (with or without chronic rhinosinusitis with nasal polyps and aspirin-exacerbated respiratory disease, typically adult-onset), and non-Th2 asthma, which includes non-atopic asthma, smokers, obesity-related, and elderly-onset asthma. Exercise-induced asthma is another category. Each has molecular mechanisms and biomarkers that guide treatment options.

Dr. Albert Rizzo:
Very comprehensive answer. Before we get into specifics, we keep running across the term "allergic march." Can you tell our listeners what that means and how it plays a role in treating asthma?

Dr. Payel Gupta:
The allergic march, or atopic march, describes the natural progression of allergic diseases from infancy to adulthood. Atopic conditions include food allergy, allergic rhinitis, asthma, and atopic dermatitis. Children with a family history of any allergic disease are at higher risk.

From birth to one year, children might show signs of skin irritation, such as hives or eczema. Between ages one to three, food allergies often appear, involving common allergens like peanuts, tree nuts, cow’s milk, egg, wheat, soy, shellfish, fish, and more recently, sesame. From ages four to six, seasonal environmental allergies emerge, such as allergic rhinitis and conjunctivitis. Finally, between five to seven years, asthma can present, though it may appear earlier as reactive airways disease. Essentially, the atopic march is the progression from one allergic disease to the next.

Dr. Albert Rizzo:
Thank you. I also wanted to focus a bit on food allergies, whether pediatric or adult. How much is the interaction between food allergies and asthma?

Dr. Payel Gupta:
Not every asthma patient needs to be tested for food allergies. Food allergy presents with immediate symptoms within 30 minutes of exposure, such as facial swelling, hives, vomiting, or nausea. Food allergy alone rarely triggers asthma exacerbations, but patients with both food allergy and asthma are at higher risk for severe reactions with higher morbidity and mortality.

Dr. Albert Rizzo:
You also explain the role of allergy testing, such as skin prick and IgE-specific blood testing, in diagnosing and managing asthma. How does testing impact recommendations for immunotherapy?

Dr. Payel Gupta:
Allergic asthma, triggered by environmental allergens like pollen, dust mites, and pet dander, is the most common type of asthma. Skin prick testing is rapid, sensitive, and cost-effective but requires trained personnel. IgE blood tests are an alternative. Clinical history must correlate with test results—if someone tests allergic to dogs but doesn’t live with one, allergy immunotherapy isn’t indicated.

Immunotherapy is contraindicated in moderate to severe uncontrolled asthma due to the risk of anaphylaxis. Interpretation of allergy testing must always consider patient history.

Dr. Albert Rizzo:
Can you discuss other testing helpful for initial asthma evaluation, such as pulmonary function testing, bronchoprovocation studies, and biomarkers like eosinophils, IgE, and FeNO?

Dr. Payel Gupta:
Pulmonary function testing confirms diagnosis, especially when history is unclear. A 12% improvement in FEV1 post-bronchodilator confirms asthma. Fractional exhaled nitric oxide (FeNO) monitors eosinophilic inflammation and response to inhaled corticosteroids, but variables like meals can skew results. Blood eosinophil counts indicate eosinophilic asthma (150–300+), guiding steroid and biologic therapies. Bronchoprovocation studies are more academic.

Dr. Albert Rizzo:
Most asthma is treated first-line with inhaled corticosteroids. How do you decide when to add therapies?

Dr. Payel Gupta:
We start with monotherapy, then add long-acting beta-agonists (LABA) if needed, followed by inhaled antimuscarinic agents. Step-up or step-down therapy is individualized. Montelukast may help in allergic asthma. Biologics are reserved for moderate to severe uncontrolled asthma.

Dr. Albert Rizzo:
How do you decide on biologics?

Dr. Payel Gupta:
We assess adherence first. Biologics target eosinophilic or non-eosinophilic inflammation for patients with moderate to severe disease not controlled on maximal therapy. Choice depends on eosinophilic status, steroid dependence, and comorbidities such as eczema, eosinophilic esophagitis, or nasal polyps. Early referral to a specialist is crucial. Even one oral corticosteroid dose can be harmful long-term. Breaking the cycle of ER visits is vital to reducing asthma mortality.

Dr. Albert Rizzo:
Can you touch on guideline updates, including SMART therapy?

Dr. Payel Gupta:
SMART—single maintenance and reliever therapy—uses inhaled steroid + LABA as both controller and reliever, reducing overuse of short-acting beta-agonists. Insurance coverage remains a challenge.

Dr. Albert Rizzo:
How do you assess adherence and self-management?

Dr. Payel Gupta:
Shared decision-making is critical. Tools include the Asthma Control Test (ACT) and the AIRQ questionnaire. We discuss inhaler frequency, create individualized asthma action plans, and review treatment every six months. This helps avoid ER visits and ensures ongoing management.

Dr. Albert Rizzo:
You are active with the American Lung Association. Can you discuss health disparities in asthma?

Dr. Payel Gupta:
Asthma disparities stem from limited access, financial barriers, and environmental exposures. In NYC, patients often face mold, rodents, poor heating, and inadequate air conditioning. Advocacy programs, including home interventions from the American Lung Association, help address these challenges.

Dr. Albert Rizzo:
Where do you see asthma research heading?

Dr. Payel Gupta:
Towards precision medicine—understanding diverse patient populations, genetics, and responses to therapy. Research aims to improve severe asthma management and reduce the 11 daily asthma deaths in the U.S.

Dr. Albert Rizzo:
Thanks again to Dr. Payel Gupta for joining us. For more information, check past episodes on pediatric asthma care, disparities, and asthma biologics therapy review. Subscribe and rate Lungcast, and visit Lung.org and HCP Live.com for resources. Until next time, I’m Dr. Albert Rizzo reminding you: you can’t breathe, nothing else matters.