Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
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...
Has the tolerance induction program been beneficial in allowing patients with multiple food allergies to freely eat all their food allergens?
There is no published data on the, so called, Tolerance Induction Program (TIP). Without any data, even for a single food allergy, I choose to stick with immunotherapy and desensitization. If the oral route is chosen, then it is OIT. This has been shown to be effective for multiple single food aller...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
Do you favor skin testing over direct oral challenge when the penicillin reaction history is remote but poorly characterized in a hospitalized adult?
Both the fact that the reaction was remote and poorly characterized support direct amoxicillin challenge (rather than skin testing). According to the 2022 Drug Allergy Practice Parameter Update, direct oral amoxicillin challenge may be considered in adults with distant mild reactions, and since that...
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...
Do you routinely recommend peak flow meters for asthma in your practice?
Always helpful for engaging patient in their own care, and managing exacerbations or fluctuations. Even if patient does not "need" it at first, good to have one on hand, have been trained, and establish good habit.
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
How do you approach treating patients who develop psoriasis while on Dupixent?
Stop the Dupixent. These patients likely had a non-Th2 driven type of dermatitis e.g. Malassezia yeast hypersensitivity, which is Th17 driven, or stasis dermatitis with autoeczematization, or eczematous drug reaction. Revisit the Diagnostic Checklist for Generalized Dermatitis.
What therapies would be considered safe and effective in pregnant patients with EoE?
Management of EoE during pregnancy should be individualized using a shared decision-making model. Food elimination can lead to remission, but some patients have difficulty following the diet. Proton pump inhibitors, such as omeprazole and esomeprazole, and swallowed budesonide are safe during pregna...
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...