Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
When a patient has CVID and is then diagnosed with lymphoma receiving ongoing chemotherapy, how do you manage the trough levels?
Assuming the patient is already on replacement therapy, I would make sure that at trough (if on IVIG, or steady state if on SCIG), the patient has protective levels against pneumococcal polysaccharides. If not, I would increase the dose and/or shorten the interval to achieve that, and record the tot...
How are you diagnosing chronic FPIES in adults?
Primarily through patient history; delayed onset of GI symptoms, shellfish is a common culprit in adults with acute FPIES. It is hard to differentiate chronic FPIES from intolerance since there is limited pathophysiology on non-IgE mediated mechanisms. Limited role for challenge if history is convin...
Do you recommend patients try antihistamines such as oral ketotifen that are not approved in the US but are approved in the EU for MCAS if currently available formulations have not been effective?
Oral ketotifen is a mast cell stabilizer as well as an antihistamine that targets the H1 histamine receptor. In patients with mast cell activation syndrome that have not had complete symptom relief with second-generation H1 antihistamines at higher doses, including 4 tablets a day, I will consider o...
When would you consider initiating antibiotic sinus rinses for recurrent sinus infections, assuming no other underlying pathology and normal infunction?
Antibiotic sinus rinses are a great alternative to antibiotics by mouth. If indicated, I would favor the rinses after sinus surgery when there is better access to the sinuses. One commonly used preparation is Bactroban or bacitracin in a 45 ml Ocean nasal spray bottle.
When do you consider extending the dosing interval for patients on biologics with CRSwNP?
In patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) who are on biologics, I would wait four (4) symptom-free months before considering extending the dose interval. I can only cite personal experience and not evidence in the medical literature.
Does gastric bypass increase the risk of developing food allergies?
Not in the development of new/de novo food allergies. However, procedure can increase the sensitivity and/or severity of existing food allergies.
Should in-office oscillometry for lung function measurements be utilized in pediatric patients who are unable to reliably perform spirometry?
We don't use oscillometry right now in our office, but the current issue of Annals has several outstanding editorials and reviews looking at oscillometry and how to implement it in your practice. I highly recommend looking at these papers:Link to whole issueEditorials: Oscillometry-determined small ...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
Can Xolair (omalizumab) be safely used in combination with biologics for patients with rheumatic disease?
Ghazanfar & Thomsen, PMID 30132352 The above article addresses combined Xolair and Enbrel. Keep in mind, if RA flares or worsens after starting Xolair, it could be SE as it is well known to have a polyarticular small joint pattern similar to RA. So, the timing of Xolair initiation to RA loss of cont...
How do you approach patients who develop eczema flare after food exposure?
It depends on the timing of the eczema flare; if there are other immediate symptoms, it could be an IgE-mediated reaction. But if it is an isolated, delayed flare of eczema, it is a rare association; management depends on how reproducible the association is and the severity of the eczema. The age of...