Newsletter Edition № 3 — December 27, 2020
On December 22, 2020, my friend David Carter, PT, DPT, and owner of Apogee Physical Therapy in Greenville, SC, released an episode of his podcast in which he and his co-host interview me. David gets me to talk about the decisions that led me to emergency medicine and private practice. After that, I’m grilled on a multitude of popular health topics including sleep, nutrition, cholesterol, and hydration. He also has me on the record talking about some of the challenges that patients and doctors face in the healthcare system. I’m very grateful to David for having me on. You can listen to the podcast on several podcasting platforms.
Several days ago, I read with interest this report from sciencemag.org that discusses the possibility that the half-dozen or so severe allergic reactions to the Covid-19 mRNA vaccine may be due to a component of the vaccine called polyethylene glycol. To understand what’s happening with this, it’s important to understand the composition and function of the vaccine.
According to this information sheet from the FDA, “The Moderna COVID-19 Vaccine contains the following ingredients: messenger ribonucleic acid (mRNA), lipids (SM-102, polyethylene glycol [PEG] 2000 dimyristoyl glycerol [DMG], cholesterol, and 1,2-distearoyl-sn-glycero-3-phosphocholine [DSPC]), tromethamine, tromethamine hydrochloride, acetic acid, sodium acetate, and sucrose.” The Pfizer vaccine has similar components.
Messenger ribonucleic acid, or mRNA for short, is a template molecule that allows a cell to construct a particular protein. Under normal circumstances, mRNA is formed in the nucleus of a cell by a process called DNA transcription. Once the mRNA is created, it leaves the nucleus and enters the cytoplasm of a cell to serve as a template for protein synthesis before being degraded and recycled.
One challenge with the development of the Covid-19 mRNA vaccine, as I understand it, was to figure out how to reliably deliver intact mRNA into a cell from the outside-in. To accomplish this, scientists enclosed the mRNA within a lipid vehicle (a sphere of fat - like a droplet of oil). This “synthetic” fat droplet is able to fuse with a human cell membrane and deliver mRNA into the cytoplasm of the cell where it serves as the template for the synthesis of the SARS-CoV-2 spike protein.
The scientists and engineers who designed the lipid vehicle added a chemical group to the lipid particles called polyethylene glycol (PEG for short), in a process appropriately called “pegylation.” This is a technique that has been used for several purposes in various pharmacologic applications. In the case of the Covid-19 mRNA vaccine, pegylation may have been used to stabilize the lipid vehicle. It’s possible that some severe reactions to the vaccine are due to PEG.
To my knowledge, though some of these reactions have been severe and have even required hospitalization, all have been temporary and treatable with typical medications: epinephrine, antihistamines, and steroids.
So, what to do?
It might be reasonable if you’ve had a severe allergic reaction to PEG, or to another component of the vaccine (listed above), to await confirmation of the source of these reactions, or to avoid the vaccine altogether. This decision of course has to be balanced with your risk of contracting and becoming severely ill with, or dying from, Covid-19 itself. This calculation must be done on an individual basis. For those with known anaphylaxis, or severe allergic reactions, but without known reactions to specific components of the vaccine, it’s likely just as safe to receive the vaccine as it is to be exposed to many other unfamiliar medications, foods, or chemicals.
I’ve yet to see expert commentary on preventive measures such as pre-medication with antihistamines (e.g. diphenhydramine) or steroids (e.g. prednisone). But, I think that pre-medication could theoretically be a viable strategy for at-risk vaccine recipients as long as those medications don’t blunt the immunogenic response to the vaccine.
If you do have a history of allergic reactions, you should have at least one, but probably two or more epinephrine auto-injectors in your possession, and one on your person (or at least nearby) at all times. You should also know how and when to use one.
Even those without a history of allergic reactions can save a life with an epinephrine auto-injector. It’s a good idea to ask your doctor for a prescription for one of these regardless of your allergy history.
At this point, the vaccines still appear extremely safe and effective. Keep in mind that despite headlines, only 5-10 severe reactions have been reported in over one-half million doses given thus far. Stay tuned for another update in two weeks.
The Squatty Potty (a toilet stool that helps you assume a squatting position) has made a difference for me and many of my friends and clients with regard to ease of moving the bowels and maintaining regularity. The human body is designed to expel waste while in the squatting position. Watch any animal go to the bathroom - they squat; babies squat too. Not only is squatting a mechanically advantageous position for generating intra-abdominal pressure, it also straightens the otherwise kinked rectum so that you’re driving down a straight road rather than around a narrow hair-pin bend. Using a Squatty Potty, along with following two very other simple rules: i) staying well hydrated ii) refusing to hold your bowels for anything or anyone (with some notable exceptions), can help with regularity. I have found the Squatty Potty to be incredibly beneficial. I have one in front of every toilet in my house.
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Happy Christmas and New Year!
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