Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
How long do you try an inhaler before increasing the dose because it was inadequate/failed to control the patients asthma?
ICS inhalers should improve asthma control in weeks, not months, especially in steroid naive patients.
In patients with a confirmed allergy to one tree nut, do you recommend continued ingestion of other tree nuts that they tolerate in an effort to increase the likelihood of outgrowing the allergy?
I tailor this approach to the individual patient and their family. I try to balance maintaining tolerance to nuts that are tolerated with prioritizing keeping the patient safe from reactions to the nut(s) to which they are allergic. Often, I will advise families of young children to continue consump...
What is your approach to inhaler therapy in a patient with asthma who cannot be on an inhaled corticosteroid due to ocular disease?
I use LABA/LAMA combination.
How have the 2026 CHEST clinical practice guidelines for biologic management in severe asthma affected your management of these patients given the conditional strength of recommendations and very low certainty supporting evidence using the GRADE approach?
I applaud the panel for their objective, comprehensive analysis of these questions. The recommendations that they made for the 7 clinically relevant questions are sensible and actionable. The challenge, even using GRADE-based recommendations, is that (appropriately based upon existing evidence) the ...
How do you assess for sustained unresponsiveness in a patient who has completed OIT and wishes to discontinue maintenance dosing?
One approach is to stop OIT for 4–8 weeks and then perform a supervised oral food challenge to a meaningful serving, such as 4 g of the relevant food protein. If the patient tolerates the challenge after this period without dosing, this demonstrates sustained unresponsiveness.After a successful chal...
Does baseline facial dermatitis in a patient with AD cause hesitation when starting Dupixent due to conjunctivitis-related complications, especially when there are many available options?
Yes, I definitely do consider this. Not necessarily because of conjunctivitis but because I’ve seen a significant number of patients with “dupilumab facial redness or reaction” with out-of-proportion head/neck flaring in AD patients. In patients with significant facial involvement at baseline, I pre...
How do you select your first line therapy in patients with CSU?
My basic first-line strategy does not change with severity; what changes is the speed with which I optimize and escalate therapy. For example, with a patient in whom I am confident the diagnosis is CSU, I begin with a second-generation H1 antihistamine at the standard approved dose, taken regularly-...
In patients with severe asthma who are candidates for biologics, do you put them on an ICS/LABA/LAMA rather than high dose ICS/LABA?
I have done both. Once I need to go to high-dose ICS/LABA or ICS/LABA/LAMA, I start looking at options for biologics. I work exclusively with children, so it depends on the age of the child and what is approved for their age. It is easier to add a LAMA under age than a biologic.
What is your approach for female patients with severe atopic dermatitis well controlled on Dupixent planning to conceive or already pregnant?
Based on published data, I have a few concerns. However, the clinical trials of Dupixent failed to study effects on learning and memory.IL-4 and IL-13 are known to be important for learning and memory in mice. IL-4-producing T cells accumulate in the meningeal spaces, and acute depletion of these ce...
How do you approach monitoring of specific antibody titers in pediatric patients with 22q11.2 deletion syndrome with normal T cells?
I would start with quantitative immunoglobulin levels (IgG, M, A and E) annually. I'm assuming that the lymphocyte phenotyping has been done and is normal. B cell phenotyping to assess switched memory B cells and transitional B cells could be helpful. It's most important to assess specific antibody ...