Mast Cell Activation Syndrome with Dr. Tania Dempsey: Rational Wellness Podcast 303
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Dr. Tania Dempsey discusses Mast Cell Activation Syndrome with Dr. Ben Weitz.
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Podcast Highlights
0:30 Mast cell activation syndrome. Mast cells are immune cells found throughout the body that contain granules that contain various chemical mediators, including histamine and heparin. Mast cells are involved in allergies and in various inflammatory and immune functions, including wound healing, angiogenesis, immune tolerance, and defense against pathogens. In mast cell activation syndrome, mast cells are inappropriately and excessively release chemical mediators, resulting in a range of symptoms that are grouped into cardiovascular, dermatological, GI, neurological, and respiratory in nature. These include flushing, hives, a reddish complexion, itchiness, burning, lightheadedness, dizziness, arrhythmia, diarrhea or constipation, stomach pain, nausea, acid reflux, difficulty swallowing, headaches, fatigue, lack of concentration, and other cognitive problems, congestion, coughing, and even anaphylaxis.
2:47 Dr. Dempsey first started to focus on mast cell activation syndrome (MCAS) when researching trying to understand a patient who had a flare of this condition. She spoke with Dr. Lawrence Afrin, who was a recognized expert on mast cell activation syndrome, who explained the mechanism for this condition. She recognized that patients she had treated in the past probably had some elements of this condition as well.
12:05 MCAS is a multisystemic process and the most common symptoms include genital urinary complaints, hormonal complaints like endometriosis, painful periods, and excessive bleeding, migraines, interstitial cystitis, pain syndromes, high or low blood pressure, etc..
13:36 Diagnosis of MCAS. One test that Dr. Dempsey will do with patients is to take a tongue depressor and scrape it across the back of the patient. If there is a skin reaction, that indicates that mast cells are releasing histamine and that the patient may have MCAS. This is called dermatographism. The lab testing for MCAS is tricky, since some of the mediators that can be measured are very short lived, so she has a refrigerated centrifuge in her lab to be able to specially process the samples. There are a number of markers but there is no one marker that is definitive for making a diagnosis. Tryptase, histamine plasma or whole blood, chromagranin A, and C-reactive protein are markers that can be measured. If the patient has had an endoscopy or colonoscopy, we can biopsy a sample of the intestinal mucosa and see if there are more than 20 mast cells in the field. You may see elevated eosinophils.
21:52 The QEESI is a validated questionaire that Dr. Dempsey recommends, that stands for The Quick Environmental Exposure and Sensitivity Inventory that is available here: QEESI.
Dr. Tania Dempsey is an internationally recognized expert in chronic disease, autoimmune disorders and mast cell activation syndrome. Dr. Dempsey received her MD from Johns Hopkins and she is Board Certified in Internal Medicine and a Diplomate of the American Board of Integrative and Holistic Medicine. Dr. Dempsey is the founder of the AIM Center for Personalized Medicine, in Purchase, New York, where she practices with Dr. Lawrence Afrin. Her website is DrTaniaDempsey.com.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.
Hello, Rational Wellness Podcasters. Today we’re going to be speaking about mast cell activation syndrome with Dr. Tania Dempsey. What are mast cells? Well, mast cells are immune system cells found throughout the body that contain granules that contain various chemical mediators, including histamine and heparin and a bunch of others. Mast cells are best known for their role in allergies, but they’re involved in various inflammatory and immune functions, including wound healing, angiogenesis, immune tolerance, and defense against pathogens. In mast cell activation syndrome, mast cells are inappropriately and excessively release chemical mediators, resulting in a range of symptoms that are grouped into cardiovascular, dermatological, GI, neurological, and respiratory in nature. These include, among many others, flushing, hives, a reddish complexion, itchiness, burning, lightheadedness, dizziness, arrhythmia, diarrhea or constipation, stomach pain, nausea, acid reflux, difficulty swallowing, headaches, fatigue, lack of concentration, and other cognitive problems, congestion, coughing, and even anaphylaxis.
Dr. Tania Dempsey is an internationally recognized expert in chronic disease, autoimmune disorders, and mast cell activation syndrome. Dr. Dempsey received her medical degree from Johns Hopkins, and she’s board certified in internal medicine and a diplomat of the American Board of Integrative and Holistic Medicine. Dr. Dempsey is the founder of the AIM Center for Personalized Medicine in Purchase, New York, where she practices with Dr. Lawrence Afrin. Dr. Dempsey, thank you so much for joining us.
Dr. Dempsey: Thank you for having me.
Dr. Weitz: Great. Let’s jump into how did you first get involved in mast cell activation syndrome as an area of focus for you?
Dr. Dempsey: My interest was always in understanding patients whole being, right, and I always looked at patients in a holistic manner, and I always spent time with patients, even when I was doing straight internal medicine, and I was always interested in the why, why a patient had this symptom, why a patient had that symptom, how these different symptoms fit together. And the more that you think about those things, and the more time I spent with patients, trying to understand how all the pieces fit, the more you start to question, is there some root cause that we haven’t thought about before? Is there something that could explain these constellation of symptoms that are multisystemic? And what was that? So I was on a hunt. I had one patient in particular who really sort of had what I would call a major flare. I started seeing her when she was relatively well, and then she had a flare, which we then later realized was consistent with past flares, but it was before I knew her, but all we always saw was an acute episode of her getting worse and not understanding how all the different symptoms she had fit together. And so one day, I just spent hours, like I typically do, I’m very invested in my patients and I will research until the nth degree to figure out what’s wrong with them. And so I was on PubMed, I was on Google, I’ll admit it. I was trying to figure out how I can put this together, and I remember seeing something about this condition, this relatively new condition at the time, mast cell activation syndrome. So some of the publications about it were coming out around 2012, when it was really starting to be recognized and there were people looking at how to diagnose it. So this was, this patient, it was about 2014, 2015. And so there was stuff, just new stuff, the buzzwords. And I remember talking to her and saying, “I think this could be this mast cell activation syndrome, and in fact, if this is what you have, then I think a lot of my other patients probably have this, too. So let’s figure this out.” And so it was sort of serendipity. She somehow knew someone who knew Dr. Afrin and he was in Minnesota at the time, Lawrence Afrin and I got on the phone with him and I said, “I want to hear everything about mast cell activation syndrome. How can I help my patients?” And I think we spent an hour on the phone and I was hooked because everything he said just resonated with me, made me understand that these patients, that some things help. There are different modalities that we’ve tried and they get better, but they don’t fully get better. That’s where I started thinking about, okay, I think this is the tip of the iceberg. I think this is a bigger issue than we’ve ever recognized. And I think what’s really interesting for me is that I really started my career in the women’s health arena, looking at polycystic ovarian syndrome and the like.
And what I was noticing, back then, 20 years ago, that these women also very often had allergic-like phenomena. They could have asthma, eczema, they often had things like irritable bowel syndrome or interstitial cystitis, endometriosis. So I always understood that these women had this collection of other disorders that were being affected, but I didn’t understand what the connection was. And then once I started to understand MCAS, then I was able to look back at my career of 20 years and saying, “Oh, intuitively, I’ve known this all along, but now I understand that the root is really in this dysfunctional mast cell.”
Dr. Weitz: So I just wanted to point out, you mentioned MCAS, and that’s an abbreviation for Mast Cell Activation Syndrome, M-C-A-S.
Dr. Dempsey: Thank you. Yes.
Dr. Weitz: So how would you describe, I know I gave a definition, but how would you describe what mast cell activation syndrome is?
Dr. Dempsey: Yeah, I think you did a great job. That was perfect.
Dr. Weitz: Okay.
Dr. Dempsey: Yeah. Mast cell activation syndrome is a syndrome of abnormal mast cells that are reacting at baseline abnormally. So they are releasing these various mediators abnormally, and then when there’s additional triggers, there’s more activation, more release of mediators. So everyone has mast cells, everybody has mast cells that respond to infections or other triggers. If someone gets COVID or the flu or something, the mast cells get activated. It’s part of your innate, your primitive immune system, but the problem really is in patients who at baseline, their mast cells are already not working well, they’re maybe more reactive in releasing some of these inflammatory mediators, these chemicals at baseline. So they’re inflamed at baseline, and then they’re faced with an infection or a trauma or some other stressor, toxin, mold, and then their already-dysfunctional mast cells become more reactive, releasing more chemicals, and then they go into a bigger flare. So that’s essentially what MCAS is, and it’s really a multi-system disorder. It’s not, and I think this is important to note that it’s not the patient who has allergy, let’s say, and only has allergy, but has nothing else. They don’t have mast cell activation syndrome. So it has to be multiple organs, at least two different systems involved. And so the mast cells can be reactive in different ways in different parts of the body.
Dr. Weitz: And so is mast cell activation syndrome something they just had, or it sounds like you’re saying that they got an infection or they got exposed to some toxins or mold and that triggered this over-activation. Is that what happens?
Dr. Dempsey: Well, it could be either, actually, or both. And so the vast majority of people who have this syndrome, MCAS, have a genetic potential. I would put these people in what I would call like an idiopathic, this is idiopathic MCAS. Primary MCAS is that if there’s a genetic vulnerability, and then there’s some process trigger that makes it evident in them. And then that’s all they have. And so yes, they can have other triggers, but their root cause, the root problem is that they were born with dysfunctional mast cells, and that’s primary. Secondary is when someone has normal mast cells, but then they have a major trigger that makes their mast cells react, and then their mast cells continue to react, and they don’t reset until you take away that trigger. That’s what we call secondary. And theoretically, in secondary MCAS, when you take away that trigger, the mast cells go back to normal. Idiopathic is like that combination probably of both, where there’s a genetic vulnerability, there’s a trigger, but even if you remove the trigger fully, they won’t return to normal. They’ll return to a different baseline because their mast cells were already, I use the term mutated. In a sense, that’s what happens.
Dr. Weitz: So a percentage of these patients, and I don’t know if we know what percentages-
Dr. Dempsey: Yeah.
Dr. Weitz: … likely will never have normal mast cell reactivity.
Dr. Dempsey: Well, look, the number I can give you was based on some literature, some publications out of Germany in 2013. Gerhard Molderings published on the fact that the German population had about 17% incidents of mast cell activation syndrome. And if we assume that their population is similar to our population, 17%, which probably is an underestimate, so let’s say it’s maybe even closer to 20%. So one in five people have MCAS in some form. At one end of the spectrum, they may not even know they have this. They have mild symptoms that they’ve lived with. Maybe they have migraines, maybe they have and they deal with it. They take a pill. Maybe they have women suffering from painful periods, but they go to the gynecologist and they get a birth control pill. But underlying it is probably mast cell activation syndrome. On the other hand of the spectrum are people who are really debilitated from it. So the reality is it’s hard to know how many people are really sitting at the mild end and how many are at the more severe end, but one in five people have the potential and possibly even the full spectrum of this disorder.
Dr. Weitz: So what are the most common symptoms that alert you to the fact that this patient sitting before you may have MCAS?
Dr. Dempsey: For me, it’s really not just about a particular symptom. It’s about a multisystemic process. So if I’m talking to the patient and I’m getting a sense that there are multiple organ systems involved, they have GI complaints, they may have respiratory complaints, they may have genital urinary complaints, they may have endocrine hormonal complaints. And once I start to see that it’s multisystemic, then this is going to be on my radar. Women’s health issues, certainly there are some buzzwords. I hear endometriosis, I hear painful periods, I hear excessive bleeding, things like that. They sort of make me K kind of go in this direction. Migraines, interstitial cystitis, pain syndromes in general, people with pain and sometimes with unknown origins to me, always make me think that this could be it. But really it’s about the fact that these patients often have multiple things going on. They might have high blood pressure and they don’t know why. Sometimes it’s high, sometimes it’s low, sometimes it’s dizzy. Sometimes their heart rate goes up. And then when they say that these are the patients that come in and say that no one else can figure them out, then I know that this is one area that I have to look at.
Dr. Weitz: So in terms of trying to diagnose patients with MCAS, I saw some doctor on YouTube and he took a tongue depressor and rubbed it on this guy’s back and it was a profound skin reaction and that he felt was an indicator that the patient might have MCAS. Is that something that makes sense?
Dr. Dempsey: It’s not diagnostic for MCAS.
Dr. Weitz: Right.
Dr. Dempsey: It’s diagnostic, it’s a called dermatographism. That’s what the dermatologist would call it. And that reaction basically is stimulating mast cells in the skin to release histamine. So if you can see it in other mast cell issues like allergy and eczema, you can see it in mast cell activation syndrome. So when I do that test in patients, and I do it when I see new patients-
Dr. Weitz: Okay.
Dr. Dempsey: … if they don’t have this reaction, it doesn’t mean they don’t have MCAS. And if they have the reaction, I’m thinking it could be MCAS, but I might think allergy, I might think other things as well. So it’s an interesting response. It does suggest that the mast cells are releasing histamine, but not everybody with MCAS has a histamine problem, so you may not see it.
Dr. Weitz: So what’s the best way to diagnose mast cell activation syndrome?
Dr. Dempsey: Yeah, that’s the million-dollar question, actually, because it’s a little complicated.
Dr. Weitz: Yeah, the lab testing seems to be very problematic.
Dr. Dempsey: It can be. I mean, the good news is that we have figured out, Dr. Afrin and myself, we have figured out how to get the testing done. We have found the labs that need to be used for this. We have a refrigerated centrifuge in our lab that we’re able to process the samples specially. So we have, we’re in a very good position, but I think for a lot of others who are out there trying to do testing, it can be problematic. The way, basically, what you’re doing for MCAS is you’re trying to find the mediators that the mast cells make. That’s how you’re trying to justify the diagnosis. Mast cell activation syndrome means that the mast cells are activated. So in order to have this syndrome, you have to have an abnormal level of those mediators, either in the urine or the blood.
Dr. Weitz: But there’s a number of these, so you know, you can test for histamine and that may not be the mediator that they have.
Dr. Dempsey: Correct. Correct. So you test for what we know you can test. And there’s several in the urine. There’s several in the blood. And the other thing we should mention is that there really are kind of two schools of thought on the diagnostic criteria. So I published, along with I think it was like 41 other co-authors, on the diagnosis of cell activation syndrome using a consensus criteria that we put together called the consensus-2. So what I’m talking about is based on what we’ve published, but there are other publications on other ways that others use to diagnose it. So it’s still not quite clear. We don’t use tryptase as the only mediator to diagnose MCAS. And there are groups out there that are using tryptase as one of the mediators to identify activation. And unfortunately, it’s not a great measure, so we do measure it. We just don’t rely on it fully for the diagnosis. And then lastly, quite honestly, probably the best way to make the diagnosis is so many of our patients have had endoscopies or colonoscopies. So you can look for mast cells on biopsy samples, and if they have more mast cells in certain areas on these biopsies, then that is a very good indicator that they may have mast cell activation syndrome. So if I can get a biopsy sample, they’ve already had had biopsies, if I can get them stained in a certain way, we call it CD117 staining, and if we can see that there’s more than 20 mast cells in this field, then we can use that as one point of support for the diagnosis.
Dr. Weitz: I’m assuming your typical gastroenterologist is not looking for mast cells.
Dr. Dempsey: Correct. They’re not. So they’re doing these biopsies and they’re looking-
Dr. Weitz: And what happens when you ask them to do it?
Dr. Dempsey: Well, it depends. So the GI docs that we work with, we have a form that we usually give them, and they’re already aware that they’re going to talk to the pathologist. It’s really not up to the GI doctor. They’ll do the biopsies, but the pathologist has to be the one, they’re the one that stains it. So we have a form that we usually give our patients that if they’re going to go for a procedure, we want to make sure that they can do the staining right away. But let’s say the patients already have done the testing, the GI doctor said everything looked great. What we do is we request the slides, they have to be unstained, and we have a pathologist we work with, we’ll send her the slides, and we’ll say, “Now stain them for CD117 and see if you find mast cells.” And then these are normal results that they’ve gotten from their GI doctor. And then we get it back and we see, with a special stain, we see all the mast cells light up.
Dr. Weitz: Cool. Okay. So are there any, for a conventional doctor who doesn’t want to try to do these complicated labs that require having a centrifuge in the refrigerator and getting these samples to the lab chilled and kept chilled the whole time, and the likelihood of a conventional lab actually handling it in the right way is not that great?
Dr. Dempsey: Correct. Correct.
Dr. Weitz: Are there any just conventional indicators on labs that might give you an idea? Like does a CBC tell you anything?
Dr. Dempsey: Yeah. Yeah. So again, it wouldn’t maybe give you the full diagnosis, but could it give you a picture? Absolutely. You can see hemoglobin’s high, hemoglobin is low. You can see eosinophils. Sometimes they have eosinophillia. If they don’t, it doesn’t mean that they don’t have MCAS, but these are some things that I could look at. You could check out plasma histamine. That’s a really easy test. You can even do a whole blood histamine. Yeah, if histamine is one of their issues, you might find it. Chromogranin A also is a very-
Dr. Weitz: But the plasma histamine, the sample has to be kept cold, right?
Dr. Dempsey: It does, but it’s not as sensitive as some of the other-
Dr. Weitz: Oh, okay. Okay.
Dr. Dempsey: So it’s still worth testing.
Dr. Weitz: Right.
Dr. Dempsey: Heparin in the blood is more problematic. That’s going to be really another conversation, but histamine, chromogranin A, and tryptase, just in case the tryptase comes back, that you can look at the blood counts. I think C-reactive protein is not specific for MCAS, but we certainly see in some patients because they have inflammation, sometimes the inflammation translates to an elevation in inflammation markers, sometimes it doesn’t, surprisingly.
Dr. Weitz: Okay.
Dr. Dempsey: But those are some things that I think, look, there we have an MCAS questionnaire that’s been validated in the literature. So docs can give the patients the questionnaire or fill the questionnaire out with the patient, and it asks specific questions about certain types of symptoms and certain types of testing that they may have had done. And then they can do some of this rudimentary testing so they have an understanding of the patient’s symptoms, where they fall on the questionnaire. I also encourage the use of the QEESI questionnaire, the Q-E-E-S-I questionnaire, which is a chemical sensitivity questionnaire that’s also been validated. And since we’ve published on the association between mast activation syndrome and chemical intolerance, you can give them this chemical intolerance questionnaire, you can give them the MCAS questionnaire, you could use some blood work, and then sure, you could do that scratch test on their back and see if they get a red line. And then I think you can make a case for whether they have this or not.
Dr. Weitz: So this MCAS questionnaire has been validated?
Dr. Dempsey: Yeah, it was published. Gerhard Molderings published this along with Dr. Afrin in 2015, I believe.
Dr. Weitz: Okay.
Dr. Dempsey: And it is in the literature. We’ve taken it, we produced it for our patients. It’s easier.
Dr. Weitz: Would you be willing to share that with me that I can put in the show notes?
Dr. Dempsey: Absolutely.
Dr. Weitz: Sure. That’d be great.
Dr. Dempsey: Absolutely. Yeah, of course. And the QEESI questionnaire, which people can get at queesi.com, I think, or qeesi.org. Oh, it’s qeesi.org. And that questionnaire is readily available and I encourage people to take that one as well.
Dr. Weitz: And that you said is for chemical toxicity.
Dr. Dempsey: Correct.
Dr. Weitz: What kind of chemical toxins do you find that are most associated or that come up a lot?
Dr. Dempsey: Yeah-
Dr. Weitz: Obviously we’re in a society awash with chemicals.
Dr. Dempsey: We certainly are. Claudia, Dr. Claudia Miller, who has really done, has been a pioneer in this realm, she has published on the association between organo phosphate pesticides and the impact on the development of chemical intolerance, and then really what we now understand is mast cell activation syndrome, so I think that’s a huge problem. But all the petroleum stuff, all the plastics, all the stuff that people are exposed to at some point, I think the fragrances, the scents, the disinfectants, we saw an uptick in chemical intolerance and mast cell activation syndrome during COVID, I think, partially, from COVID, like I think people, we were seeing that association between MCAS and COVID.
So maybe people who had COVID or long haul COVID might have had underlying MCAS, but also because of the amount of disinfecting solutions that were used, people were more heightened. People were noticing they were going to the grocery store. Even with the masks, they were still being exposed. So it’s a problem. And for people who don’t have any issues with their mast cells, they might smell it, it may not be great, but when the mast cells are already probably at baseline, a little dysfunctional, but maybe they’re still okay, exposure to these chemicals can certainly bring it out fully.
Dr. Weitz: So you’re saying that drinking bleach probably wasn’t good for their health.
Dr. Dempsey: Right. No comment.
Dr. Weitz: Just kidding. Let’s get into some of the treatments-
Dr. Dempsey: Sure.
Dr. Weitz: … for MCAS.
Dr. Dempsey: Yeah.
Dr. Weitz: I know that I’ve heard Dr. Afrin in talks talk a lot about the use of antihistamines. Do you tend to use antihistamines as part of your treatment approach? Do you tend to use natural supplements or diet or a combination of all of the above?
Dr. Dempsey: Usually a combination because my background is integrative medicine, but I think the number one thing, and he’ll say, Dr. Afrin will say this as well, the number one thing is to eliminate the triggers. So if you are being exposed to something, if you have an infection and that’s run your mast cell, you’ve got to peel that layer away.
Dr. Weitz: Treat that infection.
Dr. Dempsey: You got to treat the infection. Or let’s say you’re taking a medication that has a dye in it and you’re dye-sensitive, and maybe that’s kicking things up, that has to be eliminated. So there’s a process that we go through with patients to educate them about their different triggers and what may be continuously making them sick. So that’s first, before you even treat them, you need to eliminate the triggers. Then we go through a process of going through what makes the most sense for the patient. Sometimes it makes sense to try Vitamin C or quercetin. Sometimes it makes sense to go right to an over-the-counter H1 blocker, antihistamine, and sometimes it makes sense then to go onto the H2 blockers that we use.
Dr. Weitz: Let me just point out. Vitamin C is often considered a natural antihistamine. Quercetin is considered a natural mast cell stabilizer.
Dr. Dempsey: Correct. Correct. They don’t always work for everyone. Some patients react to it, sometimes they react to something mixed in it in a supplement. So I want to be very clear that my suggestions have to be really personalized and individualized. Every patient is different. So what I’m starting with is going to depend on what I think they may react better to initially. Honestly, I think the antihistamines are a great way to start, a little bit more bang for the buck, the way I look at it. They usually do respond, especially if I know there’s histamine involved. It might take some trial and error to go through the different antihistamines to find the one that’s right for them, but I think it’s absolutely a great way to calm things down for some patients.
Dr. Weitz: And are you typically using one or several different antihistamines?
Dr. Dempsey: I’ll start with one. There’s a trial period, so they’re going to start one. They may increase the dosage depending on how they do. If they don’t do well with that, they go on to the next one. So we have four, let’s say, main ones over the counter, Loratadine, Zyxel, Zyrtec, Allegra, those are the brands. And then we have Benadryl. This is a fifth one, which is a more short-acting type of antihistamine. And then there are prescription ones available, too. But you could start with what’s over the counter, one at a time, trial them. Do I have patients who wind up needing two different antihistamines at the same time? Yes, but rare. Usually we try to find one antihistamine that’s going to accomplish the job. Adding an H2 blocker, so this is essentially an antihistamine that works in the gut, but by binding the H1 receptors from the regular antihistamines and then binding the H2 receptors with these other drugs, doing that together has a synergistic effect. So an example of an H2 blocker would be something like Pepcid or the old Zantac when it was on the market, Tagamet.
So we can use them together to help to provide even better stabilization of the mast cell, but that doesn’t always work. And so then we have next in line and lots of different things to try. And what I’ve learned is that you have to keep going because you never know when you’re going to find the thing that’s going to help. And at the same time, I’m always looking at other root causes. I’m looking at their gut microbiome, which is a huge potential trigger for MCAS. We see so much candida in the gut, parasites, just dysbiosis, just bad bugs in the wrong place, not enough good bugs. We have tons of mast cells in our GI tract, so they’re going to be alerted to the mess that’s going on. And so, yeah, I can give all the mast cell drugs in the world, it’s not going to get better.
Dr. Weitz: So a lot of us who are treating these functional gut disorders, like SIBO and acid reflux and some of these other conditions, and most of us have found that some of the conditions resolve very well to simple treatment programs. Others are more complicated and take a long period of time and continue to recur. And that’s where we might start wondering, could mast cells be a factor in this functional gut disorder? And if that’s the case, what would be our first step? And then, how would we want to change our treatment plans?
Dr. Dempsey: Yeah, it’s a great question. Well, I think everything has to be happening almost simultaneously, but-
Dr. Weitz: Let’s say I have a patient with SIBO. I’ll just make up an example.
Dr. Dempsey: Yeah, give me an example.
Dr. Weitz: Patient saw a GI doctor, tested positive on a SIBO breath test, did two weeks of rifaximin, didn’t really help that much, came to see me. We also did a functional stool analysis and I put her on a protocol for reducing the bacterial overgrowth and, in my case, using basically herbal supplements, maybe some other digestive support, a natural prokinetic, maybe a digestive enzyme, a few things like that. And maybe they got better and they recurred in a month. And now I’m wondering, could mast cells be a problem? Because I think a lot of us are looking for the answer. Is it really fungal overgrowth? Did I miss the fungus? Is it just that there’s layers of bacteria and we got through one layer and we got to get through the next layer? Maybe the bacteria are encased in a plaque and we’ve got to break through that. What is the thing I’m missing? When would we think, okay, this might be mast cells and if we do think it’s mast cells, what do we do next?
Dr. Dempsey: So with that patient, right, I would’ve already screened for other symptoms because these patients are not just having gut symptoms. They’re also potentially having other symptoms. So if I already know that I’m treating SIBO and I’m treating their gut issues like you are, but I also know that they have other systems involved, so I’m going to be alerted already and I’m going to still do-
Dr. Weitz: So if they’re not having a lot of other symptoms, you would be less likely to think that this might be a mast cell issue, right?
Dr. Dempsey: Yeah, less likely, but sometimes I think patients underestimate what their symptoms are or they don’t feel like they’re that important or they’ve had them for so long, so they’ve really not even thought to talk to a doctor about it. And this happens all the time, which is why, with my patients, often I will repeat their history with them over and over and over again, especially if I haven’t figured out what’s going on. And I’ll say to them, “I know. I know you told me this whole story, but we’re going to do it again because I feel like we’re missing something.” And sometimes the truth really does come out, things that they hadn’t thought about because it’s been such a part of them. So my guess is that if they’re having SIBO that recurs or symptoms that recur, more likely than not, there’s something else going on elsewhere in the body that they haven’t mentioned. But let’s just say that-
Dr. Weitz: That’s an interesting clinical pearl. I remember being at a Institute of Functional Medicine seminar and one of the older doctors who started the Institute of Functional Medicine talked about how sometimes he would leave the room and come in and say, “Now I’m Doctor Somebody-Different,” and go through their history again and would end up with different answers.
Dr. Dempsey: Yes, yes, and I see this all the time. And so I have history, history, history. I cannot emphasize that enough because I have taken that same history on the same patient for a year until I figured out something that they didn’t say. This happens unfortunately more often than you would think. So the point being is that I would bet money that if they have recurrency that there’s something else there that they’re not talking about or that’s not in the front of their mind. They have so much discomfort from their GI tract, they’re not even thinking about the neuropathy or the migraines or visual issues or skin rashes. They’re not thinking about it because they’re just so focused here.
So that’s the first step, is just to understand what else is going on elsewhere, and then understanding what else is going on there I think is important. I think I have a very similar approach to you. We’re thinking about, yes, did we miss the fungus? Did we miss the biofilms? Did we miss that… Absolutely. I do that all the time. But also the other part of it is that if I think there’s MCAS and I’ve, let’s say, I’ve diagnosed it or I’m close to diagnosing it, I might start a more mast cell targeted therapy regimen while I’m also trying to fix the other things because I might get further along with that approach.
Dr. Weitz: So how about diet? How often do you use specific dietary approaches considering that food sensitivities may also be triggers? Do you typically use a low histamine diet, another type of diet, and when in your protocols do you approach diet?
Dr. Dempsey: So, look, I think diet is critical. I think that food is medicine. There are lots of cliches about it, but I really think you are what you eat, that kind of stuff. So I think food is important, but I don’t think there’s one diet that works for everybody. And so I’m very always a little reluctant to say to patients, “You need to be on the low histamine diet. You need to be on the low FODMAP diet. You need to be on this diet,” because every patient’s going to be different and some patients are going to respond really well to one diet or another, and some patients are going to need some combination of them. So it’s a very personalized approach.
Dr. Weitz: So do you try the low histamine diet, see how that works? If not, try the low FODMAP diet or-
Dr. Dempsey: Sometimes, sometimes, but probably not alone. I usually don’t say, “Here’s a low histamine diet and you’re going to do that for a month and then we’re going to follow up.” Usually what I’m doing is saying, “Let’s go through your diet that you’re eating now. Let’s figure out if there are potential triggers in what you’re eating.” If the diet already is low histamine, then lowering it even more is not going to help. But if I think that too many carbs, if I think that they have insulin resistance, which we see quite frequently in MCAS, and I think it’s MCAS driving insulin resistance in insulin resistance in insulin issues, metabolic issues driving MCAS. So for them, it may not be the specific food, but it may be a food group, like carbohydrates, simple carbohydrates are not good for their body, or gluten or something else.
So again, I take a very, very, very personalized approach, and it’s really trying to understand for the patient what is really going to be best to eliminate or to eat more of for that matter. Sometimes, and I’ll tell you, sometimes it’s not elimination. Sometimes it’s you’re not eating enough protein. Protein’s the number one thing that patients don’t eat enough of. They need it as they get older. They need it for their skeletal muscle, they need it for lots of enzymes and lots of metabolic functioning, fat also, but fat often you can get when you eat protein. So sometimes it’s just like you’re not getting enough nutrition. Let’s just get more food into you. And sometimes, and I’ll make a point, there are definitely patients who are exquisitely sensitive. They might only be able to eat three foods. That’s what their mast cells are allowing them to do, right? That’s a different scenario. I’m not going to eliminate anything. I’m going to try to figure out how to calm things down so that I can introduce more foods. So again, every patient is going to be very, very different.
Dr. Weitz: Let’s go through some of the natural strategies that might help move the needle. I’m just going to throw some out there. What about using DAO, which is a enzyme that helps to break down histamine?
Dr. Dempsey: Right, diamine oxidase-
Dr. Weitz: Right.
Dr. Dempsey: … is one of the ways that the body processes histamine and absolutely can be a great tool, especially if I think histamine is an issue for them. You lower the histamine load a little bit and yes, for some patients, I had one patient whose interstitial cystitis got better with DAO enzyme. It’s beautiful when it works like that, but the patients who don’t tolerate it for various reasons, and it doesn’t always work, especially if histamine is not their issue.
Dr. Weitz: What about some of the natural antihistamines? You mentioned Vitamin C, I know there’s stinging nettle, I know people have used bromine. Are there any natural antihistamines that you find can be helpful?
Dr. Dempsey: Well, in addition to the ones you mentioned, resveratrol, skullcap.
Dr. Weitz: Okay.
Dr. Dempsey: There are different types of skullcap, but sometimes it’s the Chinese skullcap, sometimes it’s-
Dr. Weitz: Right.
Dr. Dempsey: … the other one. Then ,off the top of my head, I mean they’re just like, I use a lot of herbs in general.
Dr. Weitz: Right, okay.
Dr. Dempsey: Some of these herbs have very, very-
Dr. Weitz: I think in one of your articles you mentioned ginger, thyme watercress, turmeric.
Dr. Dempsey: Correct.
Dr. Weitz: And then, of course, we got mast cell stabilizers, like quercetin and I think resveratrol would fit into there, too. What about Vitamin D? Is that something that can be helpful for mast cell patients?
Dr. Dempsey: Yeah. I’m so glad you brought that up because I think that’s really important. It’s probably my number one. Actually, I should say, “What do you do for your mast cell? Number one, vitamin D.” Because mast cells have the Vitamin D receptor on their surface and that’s part of what they react to. Those receptors help them read the environment. And so if they don’t have enough Vitamin D, that can be a trigger, absolutely. And you give them Vitamin D, you get them to good levels. And that alone could be mast cell stabilizing for some patients.
Dr. Weitz: I was just at a Chris Shade seminar and he happened to mention that mast cells express endocannabinoid receptors. So what about CBD?
Dr. Dempsey: CBD, PEA.
Dr. Weitz: Right.
Dr. Dempsey: Palmitoylethanolamide. Palmitoylethanolamide also binds the endocannabinoid receptor. So yes, sometimes the CBD seems to be better with THC. Sometimes it’s better without. It really depends on the patient’s mast cells. But yeah, the expression of a lot of these receptors really can change and dictate what direction you go to for treatment.
Dr. Weitz: What about LDN, low dose naltrexone?
Dr. Dempsey: Yeah. Yeah. And actually, LDN probably works through a few different mechanisms, and it may be modulating the immune system outside of its interaction with the mast cell. But yes, for some patients, it can be helpful. Yeah, there’s a whole host of natural and synthetic things that we use to-
Dr. Weitz: What are some of the other synthetic things you use? We went through the antihistamines.
Dr. Dempsey: Yeah, well, ketotifen is an interesting drug. It’s a partial H1 blocker. So it has some antihistamine properties, but it is also a mast cell stabilizer and it’s available, it has to be compounded to take it orally, but that can be a very helpful for a subset of patients. Cromolyn is another one, which is not absorbed, actually. It’s taken orally, usually in a liquid form or compounded in a capsule, and it works in the gut, so it can be helpful for the gut mast cells. But interestingly, I think the gut mast cells are talking to other mast cells and so many of these patients also have a reduction in some of their neurologic symptoms. So those are some quick go-tos that are pretty easy to get.
And then yes, they’re a host of these other, I’ll call them a little more heavy duty. I don’t love to use these drugs, but some of my patients needed and have done well. Benzodiazepines, those are tranquilizers essentially, but the mast cell has receptors for them. And very small dosages can be helpful to stabilize things. And again, I can keep going. There are lots of things that we can try that, again, very often it’s about either blocking the things that are its making. So another example would be Singulair, which is a drug used for asthma. Ziflo is another drug, Accolade. There are few of them that block leukotriene. That’s another mediator that mast cells make.
So if you test, the reason to test is that if you can measure and you know they have high leukotrienes or they have high prostaglandins, then you might target their treatment a little bit differently. Mast cells have COX receptors, COX-2 receptors, and COX-1 actually. So NSAIDs, anti-inflammatory drugs, can help. I think there should be some research, not yet, but I’m suspecting that it will be helpful, specialized pro-resolving mediators, SPMs, probably have some role here. Things like the drug formulation, Celebrex, Mobic, these are COX-2 inhibitors, they may have an effect as well. So again, the list goes on. And ideally, I’m working on the root causes and maybe I’m using herbs, maybe I’m using supplements. For some patients, maybe I can’t even do those things yet because they’re so sensitive now. And others, I’m combining.
Dr. Weitz: And maybe if patients, you mentioned chemicals, toxins playing a role in being triggers, maybe putting them on a detox to get rid of some of those chemicals might help reduce the mast cell over-activation.
Dr. Dempsey: I think you have to be careful with the term detox with these patients, especially the patients that I’m seeing.
Dr. Weitz: Okay.
Dr. Dempsey: Detoxing them could actually make their mast cells worse, could introducing that process. It’s a stressful process, detox, depending on what kind of detox you’re doing. So I’m always a little cautious about saying detox. There may be things that I’m doing that are in a way I know are helping with detoxification, but I’m also trying to understand how that particular patient is going to react to that. So they’re going to be patients who they cannot tolerate any C, glutathione, any of the phase one or two supplements, you’re just not going to get them that way. But maybe you can get a binder into them if they have molds, maybe. Right? Or there are patients who thrive on glutathione and actually they feel like it helps their mast cells and they feel like when they detox with it, it’s better, but they may not tolerate something else. So yeah, it’s very complex.
Dr. Weitz: Interesting. What about the use of sauna or even exercise?
Dr. Dempsey: Yeah, well, theoretically, and I’m a big proponent of those things, and I’ve written articles on infrared saunas and things like that, but the problem is that some of these patients have heat intolerance. Their mast cells actually get worse with heat. Some patients it gets worse with cold, so they may not be at a stage where they’re ready to tolerate that. Or maybe they start with a minute, maybe they go to two minutes, maybe they do it slowly. Maybe they realize that it is helpful, but for some patients it’s going to take a long time to get them to the point where they could do that. Some of these patients have post-exertional malaise. They may have an overlap of ME/CFS, chronic fatigue. So post-exertional malaise, if I push them too much, if I say, “You know, you need to get outside and get vitamin D and walk,” but then the next day they spend the whole day in bed and they feel awful, then I’m not getting anywhere with them. So again, figuring out where they’re coming from, you know, you have to meet the patient where they are really and understand when you can really pull out the big guns, I call them.
Dr. Weitz: So now most of the patients that you put on antihistamines, are they eventually able to get off these or do they end up having to take these for their long periods of time?
Dr. Dempsey: Yeah, I think it depends. There are certainly patients that are in a flare, an MCAS flare, at a particular time in their life. And I think women are great examples because it does seem to be a little more prominent in women. And women have a cyclical nature to their life cycle. They get their period at a certain time, let’s say, then they may get pregnant, they go through menopause. So there are these certain time periods where the hormones are involved and we know mast cells actually have receptors for estrogen and progesterone, testosterone. So the changes in the hormones may trigger women more. So let’s just say that in a particular time in a women’s life, let’s say, at 13 when she gets her period, she is more reactive and she needs antihistamines and maybe she needs some other things to control her.
She may actually get to a point where she has a good portion of her life where she’s fine. Again, maybe it’s 10 years, maybe it’s more or less, and maybe she doesn’t need anything. And then maybe she goes into another flare. Maybe she still hasn’t figured out she has MCAS, but she realizes some of these things work. So some of the patients have figured it out over time that there’s some things that they need. There are other patients where the flares are going to be longer and they’re never really going to go out of a flare 100%.
They come down to a lower baseline, but they’re never back to their full lower baseline. So they might still need some support. They may need more support during a flare. So I never like to think that patients have to stay on medications for the rest of their lives. And then that’s not how we go about this, but if I think that staying on this medication is going to reduce their risk of going into a major flare, if I think it’s going to help them deal with their life and their environment better, then I say, yeah, maybe they do need it. But again, I think it needs to be looked after each patient.
Dr. Weitz: That’s great. So I think that those are the questions that I had prepared. Are there any other things you want to tell our audience about? Any thoughts you have about mast cell activation syndrome?
Dr. Dempsey: I think the most important thing really is just generally that patients listen to their body and they advocate as much as they can for themselves. And if they’re not getting the answers, I mean, that’s why people are listening to you. You’re putting out this information, which is amazing. It’s about people should try to educate themselves as best they can and try to find practitioners that will work with them to really get to the root cause and not accept the conventional way, which is sort of like, I don’t know how to help you. This is what a lot of these patients are told, that the doctors don’t have answers and they don’t know what to do with them.
There’s always an answer. It may take a long time to figure it out. We may not have all the answers with our current medical technology, but we’re going to get there. But I think finding the help and continuing to look and trust your gut about your own health, I think is critical. And that’s the one thing that I see so much that patients need to be validated. I hate how some patients are treated in the medical profession.
Dr. Weitz: That’s great.
Dr. Dempsey: [inaudible 00:51:31] medical profession.
Dr. Weitz: Thank you. Okay, thank you, Dr. Dempsey. And how can listeners find out more about you and what you have to offer, your programs, et cetera?
Dr. Dempsey: Yeah, so I’m on social media, Facebook, Dr. Tania Dempsey, Instagram, drtaniadempseymd. Twitter, I think is DrTaniaDempsey. I don’t do a lot of tweeting, but I have a couple of websites, drtaniadempsey.com. And then my center, AIM Center for Personalized Medicine, is aimcenterpm.com. And what else? We’re in Purchase, New York.
Dr. Weitz: Okay. And I’m assuming you see patients remotely as well?
Dr. Dempsey: Yeah, we do. I mean, we do prefer to see patients for the first visit in person and then continue telemedicine after that. So we see patients from all over the world and country, and we’ve built a really nice center here. I’m really proud of what I’ve done. I have Dr. Lawrence Afrin with me, and we’ve been publishing papers. We have another publication about to hopefully be accepted and we’re going to be doing some research, maybe some phase two trials here. And I have another colleague that joined me two years ago, Dr. Colin Renaud. He’s a PA, but also a chiropractor by training, and he is doing good work here, too, so.
Dr. Weitz: That’s great.
Dr. Dempsey: [inaudible 00:53:06]
Dr. Weitz: Sounds good. Thank you.
Dr. Dempsey: Thank you. Thanks for having me.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues, like gut problems, autoimmune diseases, cardio-metabolic conditions, or for an executive health screen and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111 and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
