Michael S. Tankersley

Perception and practice of sublingual immunotherapy among practicing allergists in the United States: a follow-up survey

BACKGROUNDnLimited information regarding current trends of sublingual immunotherapy (SLIT) use, perception, and prescribing patterns among allergists in the United States is available.nnnOBJECTIVEnTo obtain information about current allergist perception and practice of SLIT compared with 2007.nnnMETHODSnOn behalf of the American College of Allergy, Asthma and Immunology (ACAAI) Immunotherapy and Diagnostics Committee, an electronic survey was sent to all practicing allergists of the ACAAI in August 2011.nnnRESULTSnFifty-nine of 519 US respondents (11.4%) reported experience using SLIT compared with 45 of 766 (5.9%) in 2007 (P < .001). Lack of Food and Drug Administration (FDA) approval was the primary barrier in using SLIT in the United States among 469 of 520 respondents (90.2%), which was increased from 471 of 763 (61.7%) in 2007 (P < .001). Among US respondents, 344 of 516 (66.7%) believed that SLIT was safer than subcutaneous immunotherapy (SCIT) compared with 554 of 755 (73.4%) in 2007 (P < .01). In total, 22 of 51 SLIT users (43.1%) reported SLIT efficacy equal to or even greater than SCIT, which was similar to 21 of 38 (55.3%) reported in 2007 (P < .36).nnnCONCLUSIONnRates of SLIT use reported by US respondents have nearly doubled in the last 4 years, with 11.4% of US respondents reporting SLIT use. Because the greatest barrier to SLIT use in the United States is the lack of FDA approval, it is anticipated that once an FDA-approved product is available, there will be widespread use of SLIT in the United States. Practice guidelines, which include effective dosages and schedules, will be critical to the broad implementation of SLIT in the United States.

Stinging insect hypersensitivity: A practice parameter update 2016

Reprints: David B. K. Golden, MD, Department o dbkgolden@gmail.com. Disclaimer: The American Academy of Allergy, A accepted responsibility for establishing “Stinging I time. The medical environment is a changing envi of many participants, no single individual, includ practice parameters. Any request for information a the AAAAI or the ACAAI. These parameters are no Disclosures: The following is a summary of inter family member interests). Completed Conflict of In its website. Dr Golden has served on the speaker’s witness for & Trifrolis, PC, and is a section editor UptoDate. The other Work Group members have n conflict with development of a completely unbiase conflicts from influencing the final document in discussions concerning topics related to the poten remove potential bias. In addition, the entire docu sent for review both by invited reviewers and by Chief Editor: David B. K. Golden, MD Practice Parameter Work Group: David B.K. Gold Allergy, Asthma & Immunology Center of Alaska, Allergy Clinic, San Antonio, Texas; David Graft, MD Minneapolis, Minnesota; Michael Tankersley, MD, of Nebraska College of Medicine, and Allergy, Asth University Medical Center, Palo Alto, California. Membersof theJointTaskForceonPracticeParame of Cincinnati CollegeofMedicine,Cincinnati, Ohio; Joa Department of Pediatrics, University ofMissouri-Kan City,Missouri;MatthewGreenhawt,MD,AllergySect of InternalMedicine, University of Texas Southweste Institute, ClevelandClinic, Cleveland,Ohio; RichardN Internal Medicine, New JerseyMedical School, Pulmo Mercy Hospital, and Department of Pediatrics, Unive AffiliatedHospitals, Center for Allergy, Asthma, & Imm Medical College, Hershey, Pennsylvania; and DanaW InvitedReviews(inalphabeticalorder):WesleyBurk Columbia, Maryland; AndrewMurphy, MD, Downin All published practice parameters are available at htt The Joint Task Force hasmade a concerted effort to ac appropriate recognition of such contributions is mad

Practice ParameterStinging insect hypersensitivity: A practice parameter update 2016

Reprints: David B. K. Golden, MD, Department o dbkgolden@gmail.com. Disclaimer: The American Academy of Allergy, A accepted responsibility for establishing “Stinging I time. The medical environment is a changing envi of many participants, no single individual, includ practice parameters. Any request for information a the AAAAI or the ACAAI. These parameters are no Disclosures: The following is a summary of inter family member interests). Completed Conflict of In its website. Dr Golden has served on the speaker’s witness for & Trifrolis, PC, and is a section editor UptoDate. The other Work Group members have n conflict with development of a completely unbiase conflicts from influencing the final document in discussions concerning topics related to the poten remove potential bias. In addition, the entire docu sent for review both by invited reviewers and by Chief Editor: David B. K. Golden, MD Practice Parameter Work Group: David B.K. Gold Allergy, Asthma & Immunology Center of Alaska, Allergy Clinic, San Antonio, Texas; David Graft, MD Minneapolis, Minnesota; Michael Tankersley, MD, of Nebraska College of Medicine, and Allergy, Asth University Medical Center, Palo Alto, California. Membersof theJointTaskForceonPracticeParame of Cincinnati CollegeofMedicine,Cincinnati, Ohio; Joa Department of Pediatrics, University ofMissouri-Kan City,Missouri;MatthewGreenhawt,MD,AllergySect of InternalMedicine, University of Texas Southweste Institute, ClevelandClinic, Cleveland,Ohio; RichardN Internal Medicine, New JerseyMedical School, Pulmo Mercy Hospital, and Department of Pediatrics, Unive AffiliatedHospitals, Center for Allergy, Asthma, & Imm Medical College, Hershey, Pennsylvania; and DanaW InvitedReviews(inalphabeticalorder):WesleyBurk Columbia, Maryland; AndrewMurphy, MD, Downin All published practice parameters are available at htt The Joint Task Force hasmade a concerted effort to ac appropriate recognition of such contributions is mad

The sting of the honeybee: an allergic perspective

OBJECTIVEnTo provide a focused understanding of the uniqueness and special considerations of honeybee allergy.nnnDATA SOURCESnA PubMed search using the keywords honeybee, allergy, and hypersensitivity yielded the initial relevant articles. Additional significant sources cited in the reference lists of the initial articles were also used.nnnSTUDY SELECTIONnMore than 130 articles were reviewed, and the most relevant references were selected for inclusion in this article.nnnRESULTSnThe honeybee differs from other flying Hymenoptera from both an entomologic and allergic standpoint. The entomology literature is not often consulted by the allergist when addressing avoidance of honeybees. Beekeepers are a particular population at risk for honeybee exposure and allergy. Venom composition, sting mechanism, diagnostic evaluation, and immunotherapy efficacy and safety all have unique considerations specific to the honeybee.nnnCONCLUSIONSnHoneybee is a significant cause of venom hypersensitivity. By understanding unique behaviors of honeybees, proper avoidance measures may be addressed with patients. Honeybee venom is complex, and the delivery mechanism provides for a large but often variable amount of injected venom. Diagnosis of honeybee allergy by imperfect skin and serologic testing further complicated by cross-reactivity is often difficult. Generally, honeybee immunotherapy is less safe and less effective than for other flying Hymenoptera. Efforts to improve testing and immunotherapy are under way.

IMPORTED FIRE ANT HYPERSENSITIVITY: A 1-DAY RUSH IMMUNOTHERAPY SCHEDULE WITHOUT PREMEDICATION

Imported fire ants (IFAs), which now reside in much of the southern part of the United States, are a frequent cause of hypersensitivity reactions, being the reason for 42% to 54% 1,2 of insect hypersensitivity evaluations performed in these endemic areas. Conventional IFA immunotherapy (IT) schedules, given in the insect hypersensitivity practice parameter, comprise 25 to 28 injections to reach the maintenance dose, which could take more than 3 to 6 months. 3 Unique to IFAs is the difficulty with practicing effective avoidance measures, 4 with annual sting rates up to 58% in people residing in endemic areas. 5 Patients sensitive to IFAs are, therefore, at considerable risk of continued systemic reactions to stings during the months of IT buildup by conventional schedules. We believe these issues, which are unique to IFAs, make rush IT schedules an important option to consider for those patients allergic to IFA stings. In the only published trial of IFA rush IT, Tankersley et al 6 reported on a highly successful and safe 2-day IFA rush IT regimen. After continuing to experience ongoing success with this 2-day regimen, we attempted to shorten the rush period to a single day. We believed this could lessen patient inconvenience and time away from work, reduce costs, and make it a more attractive option for more patients. Because a significant benefit to medication pretreatment was not found using the prior 2-day IFA rush protocol, it was not used in the current protocol. The inclusion criteria for enrollment into the study were patients aged 18 to 65 years, those with a history consistent with a systemic reaction to an IFA sting, and either a positive result to an IFA skin test or an IFA ImmunoCAP (Phadia AB, Uppsala, Sweden) specific IgE test. The protocol was approved by the Wilford Hall Medical Center (San Antonio, Texas) institutional review board. The rush protocol consisted of 10 injections being given during the

Perceptions regarding injection number and technique

Local cutaneous reactions are a common occurrence during allergen immunotherapy.1e4 Patients can experience pain and discomfort from the immunotherapy injections. Because of this pain and discomfort, physicians may attempt to limit the number of injections per visit. Published data are lacking to support the practice of minimizing the number of immunotherapy injections for patient comfort or therapy adherence. The goals of this study were to survey patients and learn their perceptions with regard to the number of immunotherapy injections received per visit. A survey was provided to all patients on allergen immunotherapy at the Wilford Hall Ambulatory Surgical Center Allergy Clinic. The parents of patients younger than 18 years were asked to complete the survey for their child. The survey was approved by the Wilford Hall Ambulatory Surgical Center Institutional Review Board. The survey consisted of 12 questions (Table 1). A total of 344 of 363 immunotherapy patients (94.8%) completed surveys (363 was the total number of patients receiving immunotherapy). The age range of the patients of the study population was 4 to 80 years, which is the age range of our immunotherapy population. Of the 338 patients (6 of the 344 patients did not respond), 276 (81.7%) were receiving aeroallergen immunotherapy, 51 (15.1%) were receiving venom immunotherapy, and 11 (3.2%) were receiving both. Patients were receiving 1 (135/341 [39.6%]), 2 (143/341 [41.9%]), 3 (57/341 [16.7%]), or more than 3 (6/ 341 [1.8%]) injections at each visit (3 of the 344 patients did not respond). Of the 343 patients who answered the question regarding length of immunotherapy, 103 (30.0%) had been receiving immunotherapy for less than 12 months, 76 (22.2%) for 12 to 23 months, 52 (15.2%) for 24 to 35 months, 40 (11.7%) for 36 to 47 months, 19 (5.5%) for 48 to 59 months, and 53 (15.5%) for more than 59 months. Of the 323 patients who responded to the question regarding improvement of symptoms since starting immunotherapy, 36 (11.1%) believed that their symptoms had not improved at all, 40 (12.4%) had slightly improved symptoms, 71 (22.0%) had moderately improved symptoms, 113 (35.0%) had mostly improved symptoms, and 63 (19.5%) reported completely improved symptoms with immunotherapy. Most patients (218/312 [70.0%]) surveyed were receiving immunotherapy in the red 1:1 vol/vol (maintenance) vial.

Pruritus, papules, and perspiration

BACKGROUNDnThe development of pruritus and papules with increased body temperature is a common clinical scenario seen in allergy practice, often leading to a diagnosis of cholinergic urticaria.nnnOBJECTIVEnTo describe an unusual case of miliaria and its significance in the evaluation of patients with pruritic papular eruptions that occur with increased body temperature.nnnMETHODSnAn 18-year-old woman was referred to a local allergist for the evaluation of cholinergic urticaria. For the preceding 6 months, she had experienced a facial burning sensation along with diffuse pruritus accompanied by water-filled pinpoint bumps on her abdomen and extremities during exercise and with hot tub use. The lesions appeared anytime she exercised, and she reduced her workouts because of the associated discomfort. An exercise challenge was performed given the atypical description of her cutaneous symptoms.nnnRESULTSnAfter indoor aerobic exercise on a treadmill, physical examination revealed facial flushing and numerous pinpoint translucent vesicles covering her abdomen. The diagnosis of miliaria crystallina was made. Given the intense pruritus she experienced with the lesions, she was prescribed cetirizine, 10 mg once daily. However, she noted no improvement with her exercise-induced miliaria. At follow-up 1 year later, her miliaria symptoms had spontaneously resolved with no sequelae observed.nnnCONCLUSIONnIntermittent, pruritic, papular eruptions that occur with perspiration can provide a diagnostic challenge when not present on initial examination. Although this presentation often leads to a diagnosis of cholinergic urticaria, our case illustrates that other disorders must be considered in the differential diagnosis. In these situations, exercise challenge is a valuable adjunct.

EMPOWER YOUR PATIENTS : SAVE LIVES

cessfully desensitized to aspirin despite a history of CIU. The patient is a 49-year-old man with a history of diabetes mellitus, childhood asthma, hypertension, gastroesophageal reflux disease, myocardial infarction, and intermittent hives. He first noticed the hives when he was 16 years old. He developed generalized pruritic lesions that lasted 24 hours and spontaneously disappeared. At the age of 33 years, he was prescribed an adult dose of a nonsteroidal anti-inflammatory drug (NSAID) for a leg injury. A few days later, he noticed hives that began on his legs and spread upward 10 to 15 minutes after taking the NSAID. He took diphenhydramine, and the hives resolved. A few months later, the patient was having mild arthritic pain and took an adult dose of aspirin. Ten minutes later he began to develop hives. The hives again were relieved by oral diphenhydramine treatment. Since that time, despite avoiding NSAIDs and aspirin, the patient reports having outbreaks of hives 5 to 6 times per year with no apparent triggers. He had no respiratory complaints, swelling of eyes or lips, or gastrointestinal problems associated with the hives. The patient was referred to us for aspirin desensitization because of his history of myocardial infarction. Physical examination findings were normal. There were no hives or evidence of dermographism. Spirometry showed normal lung function, and autologous serum skin test results were negative. The patient was diagnosed as having CIU and aspirin sensitivity. He was advised of the risks of desensitization and agreed to the procedure. Aspirin desensitization treatment began with 40 mg given at 10 AM. The patient had some mild itching of his ears, but this spontaneously abated. At 11:30 AM, he was given aspirin, 81 mg. He was observed for 2 hours and had no reaction. Later that afternoon, 3.5 hours after the aspirin administration, the patient had a severe flare-up of generalized urticaria. He took diphenhydramine, 25 mg, and the hives subsided. The next day, he was given aspirin, 81 mg, at 8:30 AM. He had no reaction after 2 hours and was given aspirin, 162 mg, at 10:30 AM. At 12:30 PM, the patient began to have a mild flare of hives, with a few lesions seen on his neck. He was given cetirizine, 10 mg, and the hives resolved in 30 minutes. The next day he was given aspirin, 162 mg, at 8:30 AM. At 11:15 AM he was given aspirin, 325 mg, and remained asymptomatic. The patient was advised to continue with the aspirin, 325 mg/d, and cetirizine, 10 mg nightly. Since the patient’s desensitization, his dose of aspirin was reduced from 325 to 81 mg/d after 2 months by his cardiologist, and he is taking cetirizine only as needed. In the 5 months after his desensitization, he had 2 mild urticarial outbreaks that readily resolved with cetirizine treatment. Aspirin desensitization has been proved to be a safe and effective office procedure,4 but its use in patients with aspirin-induced urticaria remains controversial. Grzelewska-Rzymowska et al5 and Asad et al6 demonstrated that patients with urticaria or angioedema reactions solely related to aspirin could be desensitized in a few days. Wong et al2 studied 11 patients, most of whom had acute coronary syndrome and a history of aspirin-induced urticaria and angioedema. They underwent a rapid desensitization protocol, which was successful in 9 patients. This illustrates the possibility that desensitization is possible in single drug–induced urticaria/ angioedema. Simon3 studied aspirin desensitization in patients with a history of chronic urticaria. He desensitized 25 patients to aspirin, 650 mg. However, within 1 day of desensitization, the hives flared. This outbreak was severe, and prednisone was administered to adequately control it. Further aspirin desensitization attempts after the initial trial only triggered more exacerbations of the hives. Our patient experienced acute urticaria with desensitization but was controlled with oral antihistamines. The present case demonstrates that aspirin desensitization may be possible in patients with a history of aspirin sensitivity and CIU. We should emphasize that this patient may represent the milder end of the spectrum in that he was responsive to a histamine1 antihistamine and the autologous serum skin test result was negative. Further studies with more patients are needed to better characterize the possibility of aspirin desensitization in this difficult-to-treat population.

The dry needle technique

Abbreviation: MOAHLFA, Male, Occupational dermatitis, Atopic dermatitis, Hand dermatitis, Leg ulcers, Facial dermatitis, and Age older than 40 years. For this data analysis, patch test reactions at day 3 were selected. Statistical analyses were performed using SAS statistical software, version 9.3 (SAS Institute Inc, Cary, North Carolina). Letters / Ann Allergy Asthma Immunol 113 (2014) 114e121 120