Transcript Slide 1

When to refer your patient to an
allergist/immunologist
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing
the Evidence
Background
•Allergic diseases affect more than
56,000,000 Americans
•There are only 5400 Board-Certified
Allergist-Immunologists in the country, but
their services are often underused
•Allergist-immunologist care improves
outcomes, and optimal use of their services
should improve the public health
Purpose:
How the Allergist/Immunologist Can Help: Consultation
and Referral Guidelines Citing the Evidence was
designed to assist patients and health care professionals
in determining when referral to an allergist/immunologist
is needed.
What is an allergist/immunologist?
An allergist/immunologist is a physician certified in either
internal medicine or pediatrics, who has completed an
additional two years of training in allergy and immunology
at an accredited training program and passed the
examination given by the American Board of Allergy and
Immunology (ABAI).
The allergist/immunologist is uniquely trained in:
•Allergy testing (skin, in-vitro)
•History-allergy test correlation
•Bronchoprovocation testing (e.g. exercise, methacholine)
•Environmental control instructions
•Inhalant immunotherapy
•Immunomodulator therapy (e.g. anti-IgE, IVIG)
•Venom immunotherapy
•Food and drug challenges
•Drug desensitization
•Evaluation of immune competence
•Education (disease, medications, monitoring)
•Management of chronic or recurrent conditions where
allergy is not always identified: rhinosinusitis, conjunctivitis,
asthma, cough, urticaria/angioedema, eczema, anaphylaxis
Types of Evidence Used For These
Guidelines
•Diagnostic: Tests performed or interpreted by
allergist-immunologists facilitate diagnosis
•Direct outcome evidence: Evidence that
intervention by an allergist-immunologist improves
outcomes
•Indirect outcome evidence: Evidence that
interventions performed by allergist-immunologists
improve outcomes
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Urticaria/Angioedema
Who to refer to an allergist/immunologist:
•Patients with chronic urticaria or angioedema, i.e..those with
lesions recurring persistently over a period of six weeks or
more.
•Patients who may have urticarial vasculitis or urticaria with
systemic disease (vasculidities, connective tissue disease,
rarely malignancies).
Why an allergist/immunologist:
•Allergist/immunologist training and expertise should allow
appropriate differential diagnosis, determination of the need for
biopsy, elimination of a specific inciting agent and optimal
pharmacotherapy.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Occupational Asthma
Who to refer to an allergist/immunologist:
•Patients with a history suggesting occupational asthma should
undergo testing to confirm the diagnosis of asthma and referral to an
allergist/immunologist for evaluation to establish that the asthma is
caused by or triggered by agents at the workplace and to initiate
appropriate avoidance therapy.
Why an allergist/immunologist:
•Allergist/immunologists can outline an algorithm for the clinical
investigation of suspected occupational asthma. Allergists can
arrange and interpret studies to confirm bronchial
hyperresponsiveness and workplace challenges.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Rhinitis
Who to refer to an allergist/immunologist:
•Patients with prolonged or severe manifestations of rhinitis with co-morbid
conditions (e.g. asthma, recurrent sinusitis, nasal polyps); with symptoms
interfering with quality of life and/or ability to function; or who have found
medications to be ineffective or have had adverse reactions to medications.
Why an allergist/immunologist:
•Allergist/immunologist care for rhinitis is associated with improved quality of life,
compliance and satisfaction with care.
•Allergist/immunologists have familiarity with the wide variety of both indoor and
outdoor aeroallergen exposures that have been shown to impact on the upper
respiratory tree and have the expertise to provide avoidance education and
immunotherapy when indicated.
•Allergist/immunologists are specifically trained and experienced in the medical
management of nasal polyps, including intranasal steroids, oral steroids
and treatment of complication sinusitis.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Food Allergy
Who to refer to an allergist/immunologist:
•Persons who have limited their diet based upon perceived adverse reactions
to foods or additives.
•Persons who have experienced allergic symptoms (urticaria, angioedema, itch,
wheezing, gastrointestinal responses) in association with food exposure.
Why an allergist/immunologist:
•Following allergy evaluation, an estimated one third of perceived adverse
reactions to foods and a small fraction of adverse reactions to additives are
verified.
•Evaluation by an allergist/immunologist is likely to result in an individual’s
ability to liberalize their diet (thereby likely improving nutrition and quality of
life).
•The allergist/immunologist can perform diagnostic tests such as skin tests,
serum IgE tests and oral food challenges to determine the cause of
the reaction so that necessary avoidance can be instituted.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Anaphylaxis
Who to refer to an allergist/immunologist:
•Individuals with a severe allergic reaction (anaphylaxis) without an
obvious or previously defined trigger.
•Persons with anaphylaxis attributed to food or drugs.
Why an allergist/immunologist:
•After a severe allergic reaction without a known cause, a trigger
should be identified if at all possible. Suspected food and drug
allergy should be confirmed if possible so that necessary avoidance
can be instituted. An allergist/immunologist is the most appropriate
medical professional to perform this evaluation, which may include
skin testing, in vitro tests and challenges when indicated.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Insect Hypersensitivity
When to refer to an allergist/immunologist:
•Consider referral of patients with systemic reactions suspected or possibly
due to insect for accurate identification of specific allergen and
consideration for venom immunotherapy (or whole body extract in case of
fire ant).
Why an allergist/immunologist:
•Allergy testing and history-test correlation can more accurately identify
specific insects responsible for an allergic reaction and may be helpful in
diagnosis, treatment and avoidance recommendations.
•Skin testing is generally preferred over in vitro testing for the initial
evaluation of venom-specific IgE antibodies.
•Venom immunotherapy (or fire ant whole body extract) greatly reduces the
risk of systemic reactions in stringing insect-sensitive patients.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Asthma Treatment: Adherence
Who to refer to an allergist/immunologist:
•Patients with asthma in whom adherence problems may be limiting optimal
control.
Why an allergist/immunologist:
•Patients who have visited an allergist/immunologist in the prior year were
significantly more likely to have been dispensed an optimally effective
number of inhaled steroid canisters.
•Specialty care is associated with more refills of anti-inflammatory
medications.
•After visiting an allergist/immunologist, patient compliance with national
asthma guidelines was higher
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Asthma Diagnosis
Who to refer to an allergist/immunologist:
•Patients with respiratory symptoms suggestive of asthma but with normal
PFT and no significant reversibility.
•Exercise-induced symptoms that are atypical or do not respond well to pretreatment with albuterol.
Why an allergist/immunologist:
•Allergist/immunologists perform methacholine challenges, which have a high
sensitivity for current asthma.
•Further objective evaluation and confirmation with pulmonary function testing
(including exercise challenge) in conjunction with appropriate
allergist/immunologist evaluation will define diagnosis or differential diagnosis.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Allergic bronchopulmonary aspergilllosis (ABPA)
Who to refer to an allergist/immunologist:
•Patients with suspected/proven asthma or cystic fibrosis who have
pulmonary infiltrates and peripheral blood eosinophilia.
•Patients with known ABPA for management.
Why an allergist/immunologist:
•Allergen skin testing and in vitro tests, when correlated with history, can
establish the diagnosis of ABPA
•Allergist/immunologists are specifically trained to manage this disease, and
positive outcomes of such management have been reported by
allergist/immunologists.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Primary Immune Deficiency
Who to refer to an allergist/immunologist:
•Patients with any of the following warning signs:
•Frequent or severe infections (8 total or 2 serious)
•Two or more months on antibiotic with little or no effect or need for IV
antibiotics to clear infections.
•Failure of an infant to gain weight or grow normally
•Persistent thrush in mouth or elsewhere on skin
•Family history of immune deficiency.
Why an allergist/immunologist:
•Allergist/immunologists are trained to diagnose and treat primary
immunodeficiency. Immunologic therapy reduces infections, prevents
complications and improves the quality of life in patients with primary
immune deficiencies.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Drug Allergy
Who to refer to an allergist/immunologist:
•Patients with a history of penicillin allergy who have a significant probability of
requiring future antibiotic therapy or have an infection in which a penicillinclass antibiotic is the drug of choice.
•Patients with histories of multiple drug allergy/intolerance.
•Patients with a history of possible allergic reactions to biotherapeutics,
NSAIDS, chemotherapy medications, local anesthetics, or other drugs they
may need.
Why an allergist/immunologist:
•Allergist/immunologists provide a comprehensive plan to evaluate the
historical adverse drug reactions and provide suggestions on future therapies
to minimize risks.
•Allergist/immunologists perform skin testing using appropriate concentrations
and techniques to determine current sensitivity
•Allergist/immunologists perform desensitization and
incremental drug challenges when necessary
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Asthma Treatment: Immunotherapy
Who to refer to an allergist/immunologist:
•There is a clear relationship between asthma and exposure to an
unavoidable aeroallergen to which specific IgE antibodies have been
demonstrated and any of the following:
•Poor response to pharmacotherapy or avoidance measures
•Unacceptable side effects of medications
•Desire to avoid long-term pharmacotherapy .
•Coexisting allergic rhinitis.
Why an allergist/immunologist:
•The efficacy of immunotherapy for allergic asthma has been demonstrated
in many studies. Immunotherapy may also prevent the development of new
allergen sensitivities.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Asthma Treatment: Prevention of Morbidity
Who to refer to an allergist/immunologist:
•Patients with uncontrolled asthma.
•Patients who use excessive amounts of reliever medications
•Patients with who require emergency department care for asthma.
•Patients with moderate or severe persistent asthma.
Why an allergist/immunologist:
•Allergist/immunologist care reduces subsequent asthma emergency department
visits, hospitalizations, asthma symptoms, overuse of short acting beta agonists
and cost of care for asthma.
•Allergist/immunologist care improves physical functioning and asthma related
quality of life.
•Allergist/immunologist care results in improved patient self-management
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Asthma: Environmental diagnosis and management
Who to refer to an allergist/immunologist:
•Patients with a history of seasonal or persistent asthma for evaluation of
inhalant sensitization.
•Patients who need management and education concerning environmental
triggers.
Why an allergist/immunologist:
•Exposure to indoor and outdoor allergens may worsen asthma.
Allergist/immunologists have familiarity with the wide variety of both indoor and
outdoor aeroallergen exposures that have been shown to impact on asthma
and respiratory function. Allergist/immunologists are specifically trained to
identify relevant environmental triggers and provide education regarding
appropriate avoidance measures. Allergen avoidance can improve asthma.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Asthma: Preventing mortality
Who to refer to an allergist/immunologist:
•Patients with potentially fatal asthma (prior severe, life threatening episode or
prior intubation).
Why an allergist/immunologist:
•Allergist/Immunologists prescribe inhaled and oral steroids more frequently
than primary care physicians, and these medications reduce the risk of fatal
asthma.
•Allergist/Immunologists perform objective measures of pulmonary function
more frequently than other physicians, and this may identify “poor perceivers”
who are at risk of dying from asthma
•Allergist/immunologists are more likely to provide action plans to their
patients, and action plans can reduce asthma mortality
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Conjunctivitis
Who to refer to an allergist/immunologist:
•Patients with prolonged or recurrent manifestations of allergic conjunctivitis.
•Patients with co-morbid conditions such as asthma, rhinitis or recurrent
sinusitis.
•Patients with symptoms interfering with quality of life and/or ability to function.
•Patients who have found medications to be ineffective or have had adverse
reactions to previously prescribed medications.
Why an allergist/immunologist:
•Allergy cannot be diagnosed on the basis of history alone. Diagnosis is
derived from a correlation of clinical history and diagnostic tests, with which
allergist/immunologists are experienced. Allergist/Immunologists can provide
environmental control advice and immunotherapy that can lead to reduced
symptoms and need for medications
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Cough
Who to refer to an allergist/immunologist:
•Patients with chronic cough of 3-8 weeks or more.
•Patients with coexisting chronic cough and asthma.
•Patients with coexisting chronic cough and rhinitis.
•Patients with chronic cough and tobacco use or exposure.
Why an allergist/immunologist:
•Allergist/immunologists have extensive training to evaluate the upper as well as
lower airway in a patient with chronic cough.
•The allergist/immunologist can both provide expert consultation to ensure the
diagnosis of asthma is correct and maximize therapy in the asthmatic patient.
•Allergist/immunologists are specifically trained and experienced in the
management of rhinitis which can cause cough.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Atopic Dermatitis
Who to refer to an allergist/immunologist:
•To confirm the diagnosis of atopic dermatitis in a patient with dermatitis.
•To identify the role of dust mite allergy in patients with atopic dermatitis.
•To identify the role of food allergy in patients with atopic dermatitis.
•Patients whose atopic dermatitis responds poorly to treatment.
Why an allergist/immunologist:
•Defining IgE-mediated sensitivity (by skin or in vitro testing) is useful in the
differential diagnosis.
•Avoidance of relevant mite or food allergens improves atopic dermatitis
•Allergist/immunologists are specifically trained and experienced in managing
atopic dermatitis in both children and adults.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Contact Dermatitis
Who to refer to an allergist/immunologist:
•To confirm the diagnosis of contact dermatitis and identify the etiology.
Why an allergist/immunologist:
•Allergist/immunologists are specifically trained to diagnose contact
dermatitis.
•More allergist/immunologists than dermatologists currently perform
patch testing.
• If an etiology is defined, avoidance therapy can be initiated.
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Sinusitis
Who to refer to an allergist/immunologist:
•Patients with chronic or recurrent Infectious rhinosinusitis.
•Patients with chronic eosinophilic rhinosinusitis.
•Patients with Allergic Fungal Rhinosinusitis.
Why an allergist/immunologist:
•Allergist/immunologist care is associated with improved outcomes in
patients with rhinosinusitis.
•Allergy immunotherapy is demonstrated to improve outcomes in patients
with concomitant allergic rhinitis.
•Many patients with infectious rhinosinusitis have humoral immunodeficiency,
cystic fibrosis, fungal sinusitis or granulomatous diseases that
allergist/immunologists are trained to identify.
•Allergy testing aids in the diagnosis of Allergic Fungal
Rhinosinusitis, and immunotherapy has been reported to
improve outcomes
How the Allergist/Immunologist Can Help:
Consultation and Referral Guidelines Citing the Evidence
Hypersensitivity Pneumonitis
Who to refer to an allergist/immunologist:
•To confirm the diagnosis is suspected cases.
•To rule out hypersensitivity pneumonitis in patients with interstitial
pneumonitis
•For management of patients with known hypersensitivity pneumonitis
Why an allergist/immunologist:
•Early accurate diagnosis and removal from further exposure carries the
best medical prognosis for hypersensitivity pneumonitis
•.Allergist/Immunologists are specifically trained in the diagnosis of
hypersensitivity pneumonitis
•Allergist/Immunologists are specifically trained in the
management of hypersensitivity pneumonitis