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This week's topic: MCAS Overview
Test your knowledge on MCAS!
- Which 3 systems are particularly sensitive to mast cell degranulation?
- When anti-histamines don't help in a patient with persistent flushing, what common over-the-counter treatment can you try before a prescription?
- You suspect a patient has MCAS, but all diagnostic testing comes back normal. What are 4 plausible reasons for the normal results?
Overview of today's email:
- MCAS Overview
- Resources for taking a deeper dive into MCAS
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MCAS Overview
MCAS, or mast cell activation syndrome, occurs when mast cells become hyperactive and degranulate in response to factors that normally shouldn't trigger their degranulation. Unlike mastocytosis (a rare abnormal accumulation of mast cells), those with MCAS have a normal number of mast cells, but they are not reacting appropriately.
Symptoms:
Since MCAS can impact any system, it can lead to a collection of seemingly unrelated symptoms, and is thus not often on the radar of diagnoses for clinicians. The top 3 systems particularly sensitive to mast cell degranulation include the skin (e.g. flushing), the brain (e.g. brain fog, anxiety), and the gut (e.g. IBS-symptoms).
Diagnosis:
There are different opinions on the diagnosis of MCAS:
- The strict approach favored by many allergists and immunologists, who aim to avoid overdiagnosis, is the "Consensus-1" that requires 3 criteria for diagnosis (episodic symptoms, positive testing, and response to treatments).
- The "clinical" approach, or "Consensus-2", focuses on the complex nature of how mast cell degranulation can impact patient symptoms and quality of life. Having symptoms and responding to treatments is adequate for diagnosis - no positive testing required.
Of note, obtaining a positive test result is difficult. Why?
- Testing often has to be done during a flare (and flares are often unpredictable), due to the very short half lives of the mediators we can test
- The test handling specifications are highly susceptible to error (especially with temperature and pH)
- We can't test for all mast cell mediators
- Some patients metabolize mediators within minutes of release
Treatments:
Most patients end up with a treatment "cocktail" before we can start taking a deeper dive into triggers and root causes. We generally start with H1 and H2 blockers (which, due to the long half life of mast cells, often have to be trialed for 4-6 weeks before we see a consistent response).
After anti-histamines, we layer in mast cell stabilizers, pharmaceutical or nutraceutical leukotriene or prostaglandin inhibitors, and a plethora of supplements that can alleviate variouos symptoms. We can even trial other over-the-counter medications such as low dose aspirin for those with flushing (flushing is associated with the release of the mediator prostaglandin D2).
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Resources for taking a deeper dive into MCAS
The following can help you learn more about the complex world of MCAS:
And we will take a very deep dive into MCAS - and explore a LOT more literature resources - in the MCAS Intensive Workshop that starts tomorrow!
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Interested in journeying through the practical review of MCAS with me?
Join me for the MCAS Intensive "Workshop"!
Instead of passively watching lectures and taking notes, you'll collaborate with fellow clinicians to create a comprehensive, practical MCAS guide tailored for real-world clinical application.
What you'll get:
- Expert guidance on MCAS diagnosis, pathophysiology, and management (guest expert speakers included!)
- Support and inspiration for creating a complete, organized clinical reference document you can use in clinic
- Peer insights and discussions with other clinicians on managing MCAS
- Quizzes to test your knowledge
Dates: March through May, with March 1-14 focused on live reviews of MCAS biology, triggers, diagnosis, testing, and treatments; the remaining time will involve tips from guest speakers, open office hours, and collaboration with colleagues!
Days and Times: Live review webinars, from March 1-14th, on Sunday, Tuesday, and Thursday at 3pm MST; periodic Open Office Hours through April and May
**Note, all review webinars will be recorded and materials/discussion space will be accessible for 3 months
Cost: $99
Bonus: Sign up by Sunday, March 1st, and receive a 1:1 call with me to chat about anything related to the practice of medicine, go over a case, or just "pick my brain"!
Hope to see you on Sunday!
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I hope this was clinically useful!
Stay safe and healthy,
Meg
Additional resources that may be helpful:
New resource - A 2-page clinical reference document on Leaky Gut Syndrome ($49). Code LGS10 for $10 off through March! I am creating a series of these and have been calling them my "back up brain" (BUBs), but am professionally calling these Evidence Essentials :)
Every time one of you chooses to support me financially, it tells me my effort and words matter. It’s validation. It’s fuel.
Thank you for believing in this work — and in me.
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