John Oppenheimer

Allergy diagnostic testing: an updated practice parameter.

I. Leonard Bernstein, MD; James T. Li, MD, PhD; David I. Bernstein, MD; Robert Hamilton, PhD, DABMLI; Sheldon L. Spector, MD; Ricardo Tan, MD; Scott Sicherer, MD; David B. K. Golden, MD; David A. Khan, MD; Richard A. Nicklas, MD; Jay M. Portnoy, MD; Joann Blessing-Moore, MD; Linda Cox, MD; David M. Lang, MD; John Oppenheimer, MD; Christopher C. Randolph, MD; Diane E. Schuller, MD; Stephen A. Tilles, MD; Dana V. Wallace, MD; Estelle Levetin, PhD; and Richard Weber, MD

Food allergy: a practice parameter

TABLE OF CONTENTS I. Preface S1 II. Glossary S2 III. Executive Summary S3 IV. Summary Statements S6 V. Classification of Major Food Allergens and Clinical Implications S11 VI. Mucosal Immune Responses Induced by Foods S12 VII. The Clinical Spectrum of Food Allergy S15 VIII. Algorithm and Annotations S18 IX. Prevalence and Epidemiology S21 X. Natural History of Food Allergy S22 XI. Risk Factors and Prevention of Food Allergy S23 XII. Cross-reactivity of Food Allergens S24 XIII. Adverse Reactions to Food Additives S30 XIV. Genetically Modified Foods S32 XV. Diagnosis of Food Allergy S33 XVI. Food-Dependent Exercise-Induced Anaphylaxis S39 XVII. Differential Diagnosis of Adverse Reactions to Foods S40 XVIII. General Management of Food Allergy S44 XIX. Management in Special Settings and Circumstances S45 XX. Future Directions S47 XXI. Appendix: Suggested Oral Challenge Methods S48 XXII. Acknowledgments S49 XXIII. References S50

Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter

Chief Editors: John M. Weiler, MD, MBA, President, CompleWare Corporation, Professor Emeritus, University of Iowa, Iowa City, Iowa; Sandra D. Anderson, PhD, DSc, Clinical Professor, Sydney Medical School, Royal Prince Alfred Hospital, Department of Respiratory and Sleep Medicine, Camperdown NSW 2050, Australia; Christopher Randolph, MD, Clinical Professor of Pediatrics, Yale Affiliated Programs, Waterbury Hospital, Center for Allergy, Asthma and Immunology, Waterbury, Connecticut

Anaphylaxis--a practice parameter update 2015.

Phillip Lieberman, MD; Richard A. Nicklas, MD; Christopher Randolph, MD; John Oppenheimer, MD; David Bernstein, MD; Jonathan Bernstein, MD; Anne Ellis, MD; David B.K. Golden, MD; Paul Greenberger, MD; Steven Kemp, MD; David Khan, MD; Dennis Ledford, MD; Jay Lieberman, MD; Dean Metcalfe, MD; Anna Nowak-Wegrzyn, MD; Scott Sicherer, MD; Dana Wallace, MD; Joann Blessing-Moore, MD; David Lang, MD; Jay M. Portnoy, MD; Diane Schuller, MD; Sheldon Spector, MD; and Stephen A. Tilles, MD Chief Editors: Phillip Lieberman, MD; Richard A. Nicklas, MD; John Oppenheimer, MD; Christopher Randolph, MD Members of the Joint Task Force: David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Jay M. Portnoy, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; Dana Wallace, MD Practice ParameterWorkgroup: David Bernstein, MD; Jonathan Bernstein, MD; Anne Ellis, MD; David B.K. Golden, MD; David Khan, MD; Dennis Ledford, MD; Jay Lieberman, MD; Dean Metcalfe, MD; Dana Wallace, MD

A double-blind, placebo-controlled evaluation of sublingual immunotherapy with standardized cat extract

BACKGROUND In light of the controversial status of sublingual immunotherapy in patients with allergic rhinitis, we undertook a double-blind study of this form of treatment. METHODS Forty-one subjects with cat allergy presenting as rhinoconjunctivitis underwent 105 days of sublingual immunotherapy, with 20 subjects receiving a standardized cat extract (total dose approximately 4,500,000 allergy units) and 21 a matching placebo. Effectiveness of treatment was assessed by changes in symptoms and nasal-blockage index during 90 minutes of exposure in an apartment containing cat dander, which was performed before and after the course of treatment. Changes in cat-specific IgG and IgE levels and skin-test reactions were also monitored. RESULTS Although there were fewer symptoms and less nasal obstruction on cat dander exposure at the end of the study the changes were not significantly different in those receiving active or placebo treatment. Specific IgG and IgE levels and prick skin test results did not change significantly during the course of the study. CONCLUSIONS We conclude that sublingual immunotherapy with high-dose standardized cat extract was no more effective than placebo in reducing symptoms or affecting immunologic measures of cat sensitivity.

Adverse reactions to vaccines practice parameter 2012 update

Mild local reactions and fever after vaccinations are common and do not contraindicate future doses. Anaphylactic reactions to vaccines are rare and should be evaluated with skin tests to the vaccine and its components. If the skin test results are negative, subsequent doses can be administered in the usual manner but under observation. If the skin test results are positive and the patient requires subsequent doses, the vaccine can be administered in graded doses under observation. Some nonanaphylactic reactions to vaccines might also require evaluation, but only a few are contraindications to future doses. Pregnant women and persons who are immune compromised should generally not receive live vaccines. Purported long-term sequelae of vaccination, such as autism, are not supported by epidemiologic studies. Patients with egg allergy of any severity should receive annual influenza vaccinations because studies have demonstrated a very low rate of reactions. Studies to date have evaluated the injectable trivalent influenza vaccine (TIV), and thus TIV, rather than the live attenuated influenza vaccine (LAIV), should be used for recipients with egg allergy. All influenza vaccines available in the United States contain low amounts of ovalbumin. Neither skin testing with the vaccine nor dividing the dose is required; however, the vaccine should be administered in a setting in which anaphylaxis can be recognized and treated. EXECUTIVE SUMMARY Mild local reactions and constitutional symptoms, such as fever, after vaccinations are common and do not contraindicate future doses. Rarely, delayed-type hypersensitivity to a vaccine constituent can cause an injection-site nodule, but this is not a contraindication to subsequent vaccination. Anaphylactic reactions to vaccines are estimated to occur at a rate of approximately 1 per million doses. There are approximately 220million doses of vaccines distributed in the United States each year. All serious events occurring after vaccine administration should be reported to the Vaccine Adverse Event Reporting System (VAERS), even if it is not certain that the vaccine was the causal agent. Measuring levels of IgG antibodies to the immunizing agents in a vaccine suspected of causing a serious adverse reaction to determine whether they are at protective levels can help determine whether subsequent doses are required. All suspected anaphylactic reactions to vaccines should ideally be evaluated in an attempt to determine the culprit allergen. IgE-mediated reactions to vaccines are more often caused by additive or residual vaccine components, such as gelatin, rather than the microbial immunizing agent itself. Patients who have had an apparent anaphylactic reaction after immunization should undergo immediate-type allergy skin testing to help confirm that the reaction was IgE mediated and to determine the responsible component of the vaccine. If the intradermal skin test result is negative, the chance that the patient has IgE antibodies to any vaccine constituent is negligible, and the vaccine can be administered in the usual manner. Nonetheless, it is prudent in a patient with a history suggestive of an anaphylactic reaction to administer the vaccine under observation with epinephrine and other treatment available. In a patient with a history and skin test results consistent with an IgE-mediated reaction to a vaccine who requires additional doses of the suspect vaccine or other vaccines with common ingredients, consideration can be given to administering the vaccine in graded doses under observation. Some nonanaphylactic reactions to vaccines might also require evaluation, but only a few are absolute contraindications to future doses. Pregnant women should not be vaccinated with live vaccines. However, pregnant women should be given inactivated influenza vaccine, as well as tetanus and hepatitis B vaccine, if otherwise indicated. In general, live vaccines should not be given to persons who are immune compromised because of a risk of generalized infection with the immunizing agent. Specific vaccines or vaccination in general have been purported to have long-term consequences, including atopy, autism, and multiple sclerosis. Epidemiologic studies have not supported such associations. Patients with egg allergy should receive influenza vaccinations (TIV) because the risks of vaccinating are outweighed by the risks of not vaccinating. Persons with a history of suspected egg allergy should be evaluated by an allergist to determine the status of their egg allergy, but this should not delay their influenza vaccination. A growing number of studies suggest that influenza vaccines can be safely administered even to patients with a history of anaphylaxis to egg ingestion. Skin testing (prick, intradermal, or both) with the influenza vaccine itself in subjects with egg allergy (but without a history of reacting to the vaccine itself) does not reliably identify patients who are at increased risk of reacting to the vaccine and is not recommended. Influenza vaccine can be administered as a single dose to patients with egg allergy. Patients with egg allergy should receive influenza vaccines in a setting in which clinicians experienced in recognizing and treating anaphylaxis and equipment to manage anaphylaxis are immediately available and should be observed for 30minutes after vaccination. Patients with egg allergy with a history of only hives after egg ingestion can receive influenza vaccine in a primary care provider’s office provided the appropriate personnel and equipment are available, whereas those with a history of more severe reactions to egg ingestion should receive their vaccine in an allergist’s office. All influenza vaccines available in the United States contain low amounts of ovalbumin. Although the intranasally administered LAIV contains a low amount of ovalbumin, all published studies to date have evaluated the injectable TIV, and thus TIV rather than LAIV should be used for recipients with egg Category of evidence: Ia Evidence from meta-analysis of randomized controlled trials Ib Evidence from at least 1 randomized controlled trial IIa Evidence from at least 1 controlled study without randomization IIb Evidence from at least 1 other type of quasiexperimental study III Evidence from nonexperimental descriptive studies, such as comparative studies IV Evidence from expert committee reports or opinions or clinical experience of respected authorities or both Strength of recommendation: A Directly based on category I evidence B Directly based on category II evidence or extrapolated from category I evidence C Directly based on category III evidence or extrapolated from category I or II evidence D Directly based on category IV evidence or extrapolated from category I, II, or III evidence E Based on consensus of the Joint Task Force on Practice Parameters J ALLERGY CLIN IMMUNOL VOLUME nnn, NUMBER nn KELSO ET AL 3

Safety and efficacy of oral immunotherapy with standardized cat extract

Fifty-three subjects with positive skin prick test results to cat extract and rhinoconjunctival symptoms on exposure to cat dander were enrolled in a double-blind, placebo-controlled study of oral cat immunotherapy. Responses were assessed by development of symptoms and nasal blockage on exposure to an apartment contaminated with cat dander, by titrated skin prick tests, and by cat-specific IgG and IgE. A total cumulative dose of 2.5 x 10(6) allergy units or 436 U Fel d I were administered over a period of 3 months. Both groups of subjects had significantly fewer symptoms on exposure to cat dander during the course of the study, but there was no significant difference between active and placebo groups. There were no significant changes in either group in nasal blockage, skin prick test results, or specific IgG levels. Both groups had significant increases in cat-specific IgE, but there were no differences between groups. Subjects receiving active treatment had a slight excess of gastrointestinal complaints. Two subjects receiving active treatment experienced systemic symptoms: one had pulmonary edema, and the other had persistent asthma and urticaria, which may have represented reactions to the treatment. We conclude that oral cat immunotherapy with the preparation and doses used in this study is not effective.

Environmental assessment and exposure control of dust mites: a practice parameter

Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD *; J. David Miller, PhD; Fares Zaitoun, MD; Wanda Phipatanakul, MD, MS; Kevin Kennedy, MPH; Charles Barnes, PhD; Carl Grimes, CIEC; Desiree Larenas-Linnemann, MD; James Sublett, MD; David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; and Dana Wallace, MD Chief Editors: Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD* Members of the Joint Taskforce on Practice Parameters: David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Jay Portnoy, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; Dana Wallace, MD

Environmental assessment and exposure control: a practice parameter—furry animals

Members of the Joint Task Force onPractice Parameters:David Bernstein,MD, Joann Blessing-Moore,MD, Linda Cox,MD, David Khan,MD, David Lang,MD, RichardNicklas, MD, John Oppenheimer, MD, Jay Portnoy, MD, Christopher Randolph, MD, Diane Schuller, MD, Sheldon Spector, MD, Stephen A. Tilles, MD, Dana Wallace, MD Practice ParameterWork Group: James Sublett, MD, cochair, Kevin Kennedy, MPH, cochair, Charles Barnes, PhD, David Bernstein, MD, Jonathan Bernstein, MD, Carl Grimes, Elizabeth Matsui, MD, Jeffrey D. Miller, MD, J. David Miller, PhD, Wanda Phipatanakul, MD, MS, James Seltzer, MD, P. Brock Williams, PhD Invited Reviewers: Jack Armstrong, Hans Gr×nlund, PhD, Kraig W. Jacobson, MD, Jill A. Poole, MD, Matthew A Rank, MD, Megan Taylor, MD This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthmaand Immunology, and the Joint Council of Allergy, Asthmaand Immunology. The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing “Environmental Assessment and Remediation: A Practice Parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changingenvironment, andnotall recommendationswillbeappropriate forallpatients.Because thisdocument incorporatedtheeffortsofmanyparticipants,nosingle individual, including thosewhoservedontheJointTaskForce, isauthorizedtoprovideanofficialAAAAIorACAAIinterpretationofthesepracticeparameters.Anyrequestforinformationaboutoraninterpretation of these practice parameters by the AAAAI or ACAAI should be directed to the executive offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use bypharmaceutical companies in drugpromotion. Reprints: Joint Council of Allergy, Asthmaand Immunology, 50NBrockway St, #3-3 Palatine, IL 60067. Disclosures: The following is a summaryof interests disclosedonWorkGroupmembers’ Conflict of InterestDisclosure Statements (not including information concerning familymember interests). Completed Conflict of Interest Disclosure Statements are available on request. Dr. Sublett is the owner of AllergyZone. Dr. Portnoy is a speaker and consultant for ThermoFisher (Phadia). Dr. Barnes is a consultant for and has received research funding from Clorox Corporation. Mr. Grimes is the owner of Healthy Habitats LLC. Dr. Matsui is speaker for Indoor BioTechnologies.Dr.Miller is theownerofMission:Allergy Inc.Dr. Seltzer is thePresident of JamesM. Seltzer, Assoc. TheotherWorkGroupmembershaveno conflicts todisclose. The Joint Task Force recognizes that experts in a field are likely to have interests that could come into conflictwith development of a completely unbiased and objective practice parameter. To take advantage of that expertise, a process has beendeveloped to prevent potential conflicts from influencing thefinal document in a negativeway. At theworkgroup level,memberswhohaveapotential conflictof interest eitherdonotparticipate indiscussions concerning topics related to thepotential conflictor, if theywrite a section onthattopic, theworkgroupcompletelyrewritesitwithouttheir involvementtoremovepotentialbias. Inaddition,theentiredocumentisreviewedbytheJointTaskForce,andanyapparent bias is removedat that level. Finally, thepracticeparameter is sent for reviewbothby invited reviewersandbyanyonewithan interest in the topicbyposting thedocumenton thewebsites of theACAAI and theAAAAI. In particular, the 2 owners of companies that produce products discussed in this practice parameter are Jeffrey D. Miller, MD, and James Sublett, MD. DrMiller wrote an initial section on mattress encasings. This section was then completely rewritten by other members of the work groupwithout his participation. Dr Sublett wrote a preliminary draft of the section on air filtration. That sectionwas also subsequently rewritten by othermembers of thework groupwithout his participation. Neither participant provided subsequent input into those sections. The Joint Task Force has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the Task Force will ensure that appropriate recognition of such contributions ismade subsequently. Work Group Cochairs: James Sublett,MD, FamilyAllergy andAsthma, Louisville, Kentucky; KevinKennedy,MPH, Center for EnvironmentalHealth, Children’sMercyHospitals C JointTaskForceLiaison:JayM.Portnoy,MD,SectionofAllergy,Asthma& Immunology, TheChildren’sMercyHospitalsC JointTaskForceMembers:David I. Bernstein,MD,DepartmentofClinical,MedicineandEnvironmentalHealth,Division ofAllergy/Immunology,UniversityofCincinnati,CollegeofMedicine,Cincinnati,Ohio; JoannBlessing-Moore,MD,Departmentof Immunology,StanfordUniversityMedicalCenter,PaloAlto, California; Linda Cox, MD, Department of Medicine, Nova Southeastern University College of Osteopathic Medicine, Davie, Florida; David A. Khan, MD, Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, Texas; David M. Lang, MD, Allergy/Immunology Section, Division of Medicine, Allergy and Immunology Fellowship Training Program, Cleveland Clinic Foundation, Cleveland, Ohio; Richard A. Nicklas, MD, Department of Medicine, George Washington Medical Center, Washington, DC; John Oppenheimer, MD, Departmentof InternalMedicine,NewJerseyMedicalSchool,PulmonaryandAllergyAssociates,Morristown,NewJersey; JayM.Portnoy,MD,SectionofAllergy,AsthmaI Christopher C. Randolph, Department of Pediatrics,YaleAffiliatedHospitals,Center forAllergy,Asthma,IDianeE.Schuller,MD,DepartmentofPediatrics,PennsylvaniaStateUniversityMilton S.HersheyMedical College,Hershey, Pennsylvania; SheldonL. Spector,MD,DepartmentofMedicine,UCLASchool ofMedicine, LosAngeles, California; StephenA. Tilles,MD,Departmentof Medicine,UniversityofWashington,SchoolofMedicine,Redmond,Washington;DanaWallaceMD,DepartmentofMedicine,NovaSoutheasternUniversityCollegeofOsteopathicMedicine, Davie, Florida;ParameterWorkGroupMembers:CharlesBarnes,PhD,AllergyResearch,TheChildren’sMercyHospitalsCDavid I.Bernstein,MD,Department of Clinical Medicine, Division of Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Jonathan A. Bernstein, MD, Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio; Carl Grimes, CIEC, Healthy Habitats LLC, Denver, Colorado; Elizabeth Matsui, MD, MHS, Department of Pediatrics, Johns Hopkins School ofMedicine, Baltimore,Maryland; Jeffrey D.Miller, MD, Department of Pediatrics, NewYorkMedical College, Valhalla, NewYork; J. David Miller,PhD,DepartmentofBiochemistry,CarltonUniversity,Ottawa,Ontario,Canada;WandaPhipatanakul,MD,MS,DepartmentofPediatrics,DivisionofAllergyandImmunology,Harvard Medical School, Children’s Hospital Boston, Boston, Massachusetts; JamesM. Seltzer, MD, RelianceMedical Group, Department of Allergy and Immunology,Worcester, Massachusetts; P. BrockWilliams,PhD,DepartmentofAllergy/Immunology,UniversityofMissouri–KansasCitySchoolofMedicineandTheChildren’sMercyHospitalsC Invited Reviewers: Jack Armstrong, MD, Medical Arts Allergy, P.C., Carlisle, Pennsylvania; Hans Gr×nlund, PhD, Department of Immunology, Clinical Immunology and Allergy Unit Karolinska Institute,Stockholm,Sweden;KraigW.Jacobson,MD,CPI,OregonAllergyAssociates,AllergyandAsthmaResearchGroup,Eugene,Oregon;JillA.Poole,MD,DepartmentofMedicine,Division ofAllergy, Asthma& Immunology,University ofNebraskaMedical Center,Omaha,Nebraska;MatthewARank,MD,DivisionofAllergicDiseases,MayoClinic, Rochester,Minnesota;Megan Taylor,MD, Allergy&AsthmaCare, Jenkintown, Pennsylvania.

Practice parameterEnvironmental assessment and exposure control of dust mites: a practice parameter

Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD *; J. David Miller, PhD; Fares Zaitoun, MD; Wanda Phipatanakul, MD, MS; Kevin Kennedy, MPH; Charles Barnes, PhD; Carl Grimes, CIEC; Desiree Larenas-Linnemann, MD; James Sublett, MD; David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; and Dana Wallace, MD Chief Editors: Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD* Members of the Joint Taskforce on Practice Parameters: David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Jay Portnoy, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; Dana Wallace, MD