Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Do you de-escalate back to medium-dose ICS after starting dupilumab in a patient whose uncontrolled severe asthma had not responded adequately to high-dose ICS?
Yes, I will often de-escalate if patients are well controlled after adding a biologic. In fact, I have had times when patients decrease the frequency of their dose or even stop their controller inhalers (on their own) after a good response to biologic therapy. In these cases, it can sometimes be a c...
How do you manage atopic dermatitis in pediatric patients who have failed dupilumab?
If dupilumab fails a preschool-aged patient, I consider UVB, methotrexate, or cyclosporine.
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
In a young patient who was vaccinated to chickenpox as a child (no previous varicella infection) should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
How do you approach tapering medications in patients with CSU who are stable on both antihistamines and biologics?
Consensus is to taper the antihistamines first, and if stability is sustained, then we space out the biologic by increasing the time between injections (for example, from every four weeks to six weeks, then to eight weeks), maintaining each new frequency for a few months to ensure stability. Detail:...
How do you determine which patients to continue VIT beyond 5 years?
For those without ongoing risk factors, 5 years of maintenance VIT provides effective long-term protection, and treatment can generally be discontinued after shared decision-making with the patient. However, extended or indefinite VIT is recommended for patients with a history of, or ongoing, factor...
Have you observed adverse mental health side effects in patients who start montelukast?
A female patient with anxiety but no history of depression or suicidal tendencies developed suicidal ideation with intrusive thoughts while taking montelukast. These were resolved within days of stopping the medication. I also treated a child brought in by his parents for extreme and sometimes viole...
How do you counsel a patient on returning to the care of their PCP when a workup for MCAS has been unrevealing, but the patient insists that they have a mast cell disorder because they respond to antihistamine therapy?
At the end of the day, the treatment approach is the same as with mast cell activation syndrome (MCAS). There are additional relevant codes that can be helpful for these patients including 'mast cell activation, unspecified', and 'other mast cell activation disorders'.
Is there a role for phenotyping patients with CSU outside of a research setting by ordering IgG-anti-TPO, IgG anti-FceRI, total IgE, total IgA, etc.?
I do think it can be helpful in patients who have difficult-to-control disease. Many of these (e.g. IgG-anti-TPO, total IgE, anti-thyroglobulin antibody) have been shown to help predict responsiveness to omalizumab treatment or have been associated with disease activity (Højgaard Pedersen et al., PM...