Linda Cox

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

Update on allergy immunotherapy: American Academy of Allergy, Asthma & Immunology/European Academy of Allergy and Clinical Immunology/PRACTALL consensus report

Allergy immunotherapy (AIT) is an effective treatment for allergic asthma and rhinitis, as well as venom-induced anaphylaxis. In addition to reducing symptoms, AIT can change the course of allergic disease and induce allergen-specific immune tolerance. In current clinical practice immunotherapy is delivered either subcutaneously or sublingually; some allergens, such as grass pollen, can be delivered through either route, whereas others, such as venoms, are only delivered subcutaneously. Both subcutaneous and sublingual immunotherapy appear to have a duration of efficacy of up to 12 years, and both can prevent the development of asthma and new allergen sensitivities. In spite of the advances with AIT, safer and more effective AIT strategies are needed, especially for patients with asthma, atopic dermatitis, or food allergy. Novel approaches to improve AIT include use of adjuvants or recombinant allergens and alternate routes of administration. As part of the PRACTALL initiatives, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma & Immunology nominated an expert team to develop a comprehensive consensus report on the mechanisms of AIT and its use in clinical practice, as well as unmet needs and ongoing developments in AIT. This resulting report is endorsed by both academies.

Sub-lingual immunotherapy: World allergy organization position paper 2009

Co-Authors: Wahiduzzaman Akhanda, Raul Castro Almarales, Ignacio Ansotegui, Floriano Bonifazi, Jan Ceuppens, Tomás Chivato, Darina Dimova, Diana Dumitrascu, Luigi Fontana, Constance HKatelaris, Ranbir Kaulsay, Piotr Kuna, Dèsirée Larenas-Linnemann, Manolis Manoussakis, Kristof Nekam, Carlos Nunes, Robyn O’Hehir, José M Olaguibel, Nerin Bahceciler Onder, JungWon Park, Alfred Priftanji, Robert Puy, Luis Sarmiento, Glenis Scadding, Peter Schmid-Grendelmeier, Ester Seberova, Revaz Sepiashvili, Dirceu Solé, Alkis Togias, Carlo Tomino, Elina Toskala, Hugo Van Beever, Stefan Vieths*

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

Pearls and pitfalls of allergy diagnostic testing: report from the American College of Allergy, Asthma and Immunology/American Academy of Allergy, Asthma and Immunology Specific IgE Test Task Force.

The intended purpose of this monograph is to provide a general overview of allergy diagnostics for health care professionals who care for patients with allergic disease. For a more comprehensive review of allergy diagnostic testing, readers can refer to the Allergy Diagnostic Practice Parameters. A key message is that a positive allergy test result (skin or blood) indicates only the presence of allergen specific IgE (called sensitization). It does not necessarily mean clinical allergy (ie, allergic symptoms with exposure). It is important for this reason that the allergy evaluation be based on the patients history and directed by a health care professional with sufficient understanding of allergy diagnostic testing to use the information obtained from his/her evaluation of the patient to determine (1) what allergy diagnostic tests to order, (2) how to interpret the allergy diagnostic test results, and (3) how to use the information obtained from the allergy evaluation to develop an appropriate therapeutic treatment plan.

Multiple-allergen and single-allergen immunotherapy strategies in polysensitized patients: Looking at the published evidence

In allergen immunotherapy there is debate as to whether polysensitized patients are best treated with many allergens simultaneously (chosen according to the sensitization profile, a predominantly North American approach) or a single allergen (chosen according to the most clinically problematic allergy, a predominantly European approach). In patients seeking treatment for moderate-to-severe respiratory allergies, polysensitization is more prevalent (range, 50% to 80%) than monosensitization in both the United States and Europe. Safe, effective, single-allergen preparations will most likely have been tested in polysensitized patients. In robust, large-scale clinical trials of grass pollen sublingual tablets, polysensitized patients benefited at least as much from allergen immunotherapy as monosensitized patients. A recent review of multiallergen immunotherapy concluded that simultaneous delivery of multiple unrelated allergens can be clinically effective but that there was a need for additional investigation of therapy with more than 2 allergen extracts (particularly in sublingual allergen immunotherapy). More work is also required to determine whether single-allergen and multiallergen immunotherapy protocols elicit distinct immune responses in monosensitized and polysensitized patients. Sublingual and subcutaneous multiallergen immunotherapy in polysensitized patients requires more supporting data to validate its efficacy in practice.

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

Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study

BACKGROUND Children with allergic rhinitis (AR) often experience significant impairment in quality of life and health, which increases health care utilization. OBJECTIVE To determine whether allergen immunotherapy reduces health care utilization and costs in children newly diagnosed as having AR using a retrospective matched cohort design. METHODS Among children (age <18 years) with a Florida Medicaid paid claim between 1997 and 2007, immunotherapy-treated patients were selected who had newly diagnosed AR, who had not received immunotherapy before their first (index) AR diagnosis, who had received at least 2 immunotherapy administrations after their index AR diagnosis, and who had at least 18 months of data after their first immunotherapy administration. A control group of patients with newly diagnosed AR who had not received immunotherapy either before or subsequent to their index AR diagnosis also were identified, and up to 5 were matched with each immunotherapy-treated patient by age at first AR diagnosis, sex, race/ethnicity, and diagnosis of asthma, conjunctivitis, or atopic dermatitis. RESULTS Immunotherapy-treated patients had significantly lower 18-month median per-patient total health care costs (

International Consensus on Allergen Immunotherapy II: Mechanisms, standardization, and pharmacoeconomics

3,247 vs

Allergy immunotherapy: Reduced health care costs in adults and children with allergic rhinitis

4,872), outpatient costs exclusive of immunotherapy-related care (