Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
With the difficulty in access to PPSV23 as the new pneumonia vaccine is now standard (non polysaccharide vaccine), have you used MPSV4 (meningococcal) vaccine for evaluation of response to polysaccharide vaccine?
No, but there is good data on using Typhim Vi vaccine, which is also polysaccharide and MCW has a good lab to evaluation for polysaccharide vaccine response.
When would you recommend prescribing an asthmatic patient budesonide/salbutamol rather than budesonide/formoterol?
This is another example of two approaches to the same issue (i.e. adding inhaled steroid to a rescue B2 adrenergic agent) which is actually more theoretical than practical since no head-to-head studies have been reported. For me, there is an intrinsic value to using a rapid onset LABA (i.e. formoter...
Do you favor 24 hour urinary metabolites over random urine collection when screening for MCAS?
In my practice, I currently use 24-hour urine metabolites. The 24-hour urine collection has been extensively validated and its use is supported by the literature (see review: Butterfield et al, PMID 35346887).That being said, a spot urine collection is now available and this is far more convenient f...
Do you cycle through topical steroids in patients with CHE, and should the approval of delgocitinib change our approach on this?
In practice, I do often cycle topical steroids in chronic hand eczema to balance access, efficacy, and safety. Patients are often referred from primary care already having tried multiple topical steroids. Potent topical steroids can help with acute control, but long-term use is problematic. The avai...
Do you diagnose MCAS if a patient is concurrently on drugs known to cause non-specific mast cell degranulation?
Yes, MCAS may be diagnosed if a patient is on drugs known to cause non-specific mast cell activation.The reason for this answer requires a better understanding of MCAS criteria and etiology. In 2022, an expert consortium proposed revisions to the classification of mast cell activation disorders. (Va...
Are there certain clinical features that help you choose between benralizumab and mepolizumab for EGPA in clinical practice?
Given, as noted above, no significant clinical differences between benralizumab and mepolizumab, assuming there are no specific insurance differences between the two, I preferentially prescribe benralizumab because of the 8-week dosing frequency after the first three 4-week loading doses. For a few ...
Do you scale up 2nd generation anti-histamines to 4x daily in acute urticaria in the pediatric population as you do in adults?
Severe urticaria is certainly a therapeutic challenge. Updosing 2nd generation antihistamines in children has been studied, more trials need to be done. For refractory urticaria in children, I will often recommend 2X the recommended dose of a 2nd generation antihistamine in the morning and maximize ...
When would you suspect an allergy to the dialysis membrane in patients who complain of pruritis during dialysis?
The short answer is no. Pruritus is so common with renal disease, and allergic reactions to dialyzers are uncommon. If the pruritus can confidently be documented to be only during dialysis and not at any other time, then it may be worth trying a different dialyzer but it would take a lot for me to b...
Are you increasing the dose and/or frequency of Xolair administration if patients have failed standard dosing for CSU?
The data with omalizumab is clear that updosing is safe and effective. Dupilumab, omalizumab, and remibrutinib are all about equally effective (about 60%), but updosing omalizumab to 300 every 2 weeks and even to 600 every 2 weeks gives a 60% benefit to the 40% that fail 300 a month.
Do you continue to check tryptase levels in your patients with idiopathic anaphylaxis despite normal levels >5 on repeated checks?
Baseline serum tryptase levels have been reported to be quite stable in the vast majority of patients, but can vary more in people with HaT or mastocytosis. With a bST <8 ng/ml, there is no obvious reason to continue to check it. However, even with normal bST, the Practice Parameters recommend furth...