Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Which patient characteristics or scenarios drive you to choose tezepelumab over dupilumab for asthma?
I typically put adult patients with T2 high, and allergic phenotype on dupilumab whereas those that are T2 high only or T2 low are on tezepelumab. Additionally, if the patient has nasal polyps or AD, then I would prefer dupilumab over tezepelumab. I always have a discussion with the patient regardin...
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...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
How would you approach a patient without a history of chronic urticaria who presents with urticaria to multiple antibiotics of different classes (penicillin, cephalosporins, TMP/sulfa, azithromycin)?
While theoretically you could formally evaluate (and try to delabel) all 4 classes of antibiotics, generally it makes sense to focus on the ones that are clinically most useful - which are 1) the beta-lactams, 2) macrolides, and 3) sulfonamides. For a typical patient with a history of only urticaria...
How do you choose amongst first line advanced systemic therapies in a patient with antihistamine refractory CSU?
This has become one of the most interesting questions in CSU because the therapeutic landscape has changed substantially.For a typical antihistamine-refractory adult in 2026, I think about three licensed targeted approaches (Also alluded to in my initial responses re: CSU) anti-IgE → omalizumab (mor...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
When a patient with a known venom allergy reports a sting during immunotherapy but before reaching maintenance dose, do you accelerate the build-up schedule or restart from the beginning?
It usually would not change my approach. However, if close to maintenance and had a significant reaction, I would consider trying to achieve a higher maintenance dose. Not enough details here to fully answer.
What clinical features do you value most when evaluating a patient in whom you suspect CSU?
For me, I think/ask myself: “Does the morphology and behavior of this eruption actually fit the diagnosis of CSU?” vs., sometimes our colleagues may be thinking first -- ?? Are these “hives”? “What laboratory tests and panels should I order?” CSU is defined by spontaneous recurrent wheals, angioedem...
Do you perform a bone marrow biopsy in all patients with grade 5 anaphylaxis to stinging insects and negative workup for HAT, MCAS, c-KIT?
Before saying that bone marrow biopsy is the next step (which it is), we must be certain that we are correctly assessing the situation. Was there documented hypotensive shock (and not just subjective light-headedness or brief vasovagal syncope? Were there other objective signs like urticaria (althou...
Should thunderstorm asthma be incorporated into asthma action plans?
Thank you for the ongoing dialogue around thunderstorm-associated respiratory events. These episodes represent not just allergen exposure but a combined aeroallergen–irritant phenomenon involving pollen fragmentation, fungal spore surges, PM2.5 downdrafts, ozone shifts, and the priming effects of pr...